- Email: [email protected]
Sleepiness and sleep in elderly persons with tinnitus
Arch. Gerontol. Geriatr. 37 (2003) 139 /145 www.elsevier.com/locate/archger
Sleepiness and sleep in elderly persons with tinnitus R. Asplund a,b,* b
a Family Medicine Stockholm, Karolinska Institutet, SE-141 57 Huddinge, Sweden ¨ stersund, Sweden The Research and Development Unit, Ja¨mtland County Council, SE-831 25 O
Received 10 October 2002; received in revised form 6 March 2003; accepted 10 March 2003
Abstract The aim of this study was to evaluate the relation of tinnitus to sleep and daytime sleepiness (DS) in a group of elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects in northern Sweden. The mean (9/s.d.) ages of the men and women were 73.09/6.0 and 72.69/6.7 years, respectively. Tinnitus was reported by 14.9% of the men and 12.0% of the women. The relative number with tinnitus was not related to age in men, but increased with age in women. Poor sleep was reported by 14.4% of the men and 27.9% of the women. Among subjects with tinnitus poor sleep and frequent waking were more common in both sexes, while difficulties in falling asleep after awakening at night were reported more often by women. DS was more common in subjects with tinnitus and the frequency was even more increased in those with both tinnitus and poor sleep. There was no further increase in DS in men and women on sleep medication. Thus, DS in elderly persons with tinnitus may due both to tiring effect of the annoying sound itself but also the negative effect by tinnitus on sleep. # 2003 Published by Elsevier Science Ireland Ltd. Keywords: Health; Hypnotics; Sleep; Sleepiness; Tinnitus
* Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: /46-670-100-07; fax: /46-63165626. E-mail address: [email protected] (R. Asplund). 0167-4943/03/$ - see front matter # 2003 Published by Elsevier Science Ireland Ltd. doi:10.1016/S0167-4943(03)00028-1
140
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
1. Introduction Tinnitus, the perceived sensation of sound in the absence of acoustic stimulation, is a common complaint. In a study of tinnitus among men aged 63 years (range 53 / 75), Parving et al. (1993) found that 17% had tinnitus episodes of more than 5 min and in 3% the tinnitus was so annoying that it interfered with sleep, reading and/or concentration. There is an age-related increase in the prevalence of tinnitus in both sexes at least up to the age of 70, and this increase is reported to be most pronounced in women (Abutan et al., 1993; Parving et al., 1993). Tinnitus exerts profound influence on the sense of well-being and quality of life. Among 20 elderly tinnitus sufferers, Sourgen and Ross (1998) found that a majority had difficulty in relaxing and following conversations and suffered feelings of frustration, feelings of tenseness, irritability and depression associated with the tinnitus. One common consequence of tinnitus is disturbance of sleep (Parving et al., 1993; Sanchez and Stephens, 1997; Folmer et al., 2001). Depression, a common disorder in association with sleep impairment, is a significant correlate in the tinnitus-related need of absence from work among gainfully employed individuals (Holgers et al., 2000). Sleep complaints, sleepiness and tinnitus are all common in the elderly and all these conditions increase with age (Asplund, 1996; Hoch et al., 1997; Morgan and Clarke, 1997). The present study was undertaken in order to make a close assessment of the interrelationship between tinnitus, sleep and sleepiness.
2. Subjects and methods
2.1. Current study group All 10,216 members of the pensioners’ association SPF in the Swedish counties of Va¨sterbotten and Norrbotten were asked to participate in a questionnaire survey. A further questionnaire was sent to those who did not respond within 1 month.
2.2. The questionnaire The questionnaire included questions on age, civil status, the general state of health, diseases and medication. To evaluate tinnitus, the subjects were asked to respond to the statement ‘‘I am often troubled by disturbing sounds in my head’’. Sleep was analysed from the responses to the three statements: ‘‘I have a good night’s sleep’’; ‘‘I often wake up at night’’; and ‘‘I easily fall asleep again after waking up at night’’; and daytime sleepiness (DS) from those to the statement ‘‘I am often sleepy in the daytime’’, all with the alternative answers ‘‘yes’’ or ‘‘no’’.
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
141
2.3. Statistical methods Standard methods were used for calculating mean values and standard deviations. Group comparisons of non-numerical data were made with the x2-test. For comparing frequencies, odds ratios (OR) with a 95% confidence interval were calculated. For simultaneous evaluation of the influence of more than one independent variable on a dependent variable, logistic regression analysis (StatView 5.0 for the Macintosh) was performed.
3. Results 3.1. General The questionnaire was completed initially by 4544 persons. After a reminder, a further 1559 answers were received. Thus there were 6103 evaluable questionnaires, of which 39.5% were from men. The response rate was 61.3%. The ages (mean9/standard deviation) of the male and female participants were 73.09/6.0 and 72.69/6.7 years, respectively. Tinnitus was reported by 14.9% of the men and 12.0% of the women. The prevalence of tinnitus was unrelated to age in men but was twice as high in women aged ]/80 years than in those aged B/70 years (P B/ 0.0001) (Table 1). Poor health was reported by 16.8% of the men and 18.7% of the women. Health deteriorated with increasing age (Table 1). Tinnitus was not associated with negative health perception in men, but was 2.0 (1.6 /2.5) times more common in women with poor health. 3.2. Tinnitus and sleep Poor sleep was reported by 14.4% of the men and 27.9% of the women (P B/ 0.0001). Compared to subjects without tinnitus poor sleep and frequent awakenings were more common in tinnitus sufferers of both sexes, while difficulties in falling
Table 1 The percentage proportions of elderly men and women of different ages in poor health and of those suffering from tinnitus Age (years)
B/70 70 /79 ]/80
Poor health
Tinnitus
Men
Women
Men
Women
14.6 17.6 18.6
18.2 17.4 23.2
15.7 14.9 13.3
8.2 12.5 16.0
142
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
Fig. 1. The occurrence of poor sleep (%) in men and women without (white bars) and with tinnitus (black bars) (left group of bars; men P B/0.05, women P B/0.001); frequent awakenings (middle group of bars; men P B/0.001, women P B/0.0001); and difficulty in falling asleep again after nocturnal awakening (right group of bars; men NS, women P B/0.0001).
asleep after waking at night were more common only in women with tinnitus (Fig. 1). A multiple logistic regression analysis with tinnitus, health and age as independent variables revealed an increase in poor sleep and in frequent awakenings in tinnitussuffering men independently of age and health. In tinnitus-suffering women, poor sleep, frequent awakenings and difficulties in falling asleep after nocturnal awakenings were all increased, again independently of age and health (Table 2). 3.3. Sleep medication Sleep medication was used by 13.6% of the men and 22.3% of the women (P B/ 0.0001). The use of sleep medication was 1.4 (1.0/1.9) times more common in men with tinnitus and 1.8 (1.3 /2.5) times more common in women with tinnitus than in men and women without tinnitus, respectively. 3.4. DS, tinnitus and sleep DS was reported by 33.0% of the men and 34.7% of the women (NS). DS was more common in subjects suffering from tinnitus than in those without tinnitus and was even more increased in subjects with both tinnitus and poor sleep (Fig. 2). There was no further increase in DS in men and women on sleep medication.
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
143
Table 2 The occurrence of a poor night’s sleep, frequent awakenings and difficulty in falling asleep again after nocturnal awakening in relation to tinnitus, age and health. Poor night’s sleep Frequent awakenings Difficulty in falling asleep again Variables
OR
(CI)
OR
(CI)
OR
(CI)
Tinnitus (No /1.0) Yes
1.4
(1.0 /2.0)
1.4
(1.1 /1.9)
1.2
(0.9 /1.7)
Age ( B/70 years /1.0) 70 /79 years ]/80 years
1.1 1.4
(0.8 /1.5) (0.9 /2.1)
1.2 1.4
(0.9 /1.5) (1.0 /2.0)
1.8 2.8
(1.3 /2.5) (1.9 /4.2)
Health (Good health /1.0) Poor 2.5
(1.9 /3.4)
2.5
(1.9 /3.2)
2.0
(1.5 /2.7)
Men
Women Tinnitus (No /1.0) Yes
1.4
(1.1 /1.8)
1.5
(1.1 /1.9)
1.5
(1.2 /1.9)
Age ( B/70 years /1.0) 70 /79 years ]/80 years
1.1 1.2
(0.9 /1.3) (0.9 /1.6)
1.2 1.4
(1.0 /1.4) (1.1 /1.8)
1.2 1.9
(1.0 /1.4) (1.5 /2.4)
Health (Good health /1.0) Poor 3.1
(2.5 /3.8)
2.7
(2.2 /3.3)
2.2
(1.8 /2.7)
OR and 95% confidence intervals, (CI) for each of the variables included in the logistic model
4. Discussion In the present study, the frequency of sleep complaints was 40% higher in men and women with tinnitus than in those without when the influence of age and health had been taken into account. The severity of tinnitus is highly correlated with the degree of sleep disturbance (Folmer et al., 2001). It is therefore, surprising that sleep complaints seldom seem to be attributed to tinnitus by the patient. Parving et al. (1993) found that only about one out of five tinnitus sufferers stated that their tinnitus was so annoying that it interfered with sleep, reading and/or concentration. One important question in the interpretation of these data concerns the reliability of the reports of tinnitus. The similarity between the frequency figure for tinnitus in the present study and those given in other reports (17% in Parving et al., 1993, 14.5% in Quaranta et al., 1995) supports the view that the answers on tinnitus are reliable. Another issue in the interpretation of the findings concerns the validity of sleep data from a questionnaire. However, consistent correspondence has been found between reports on poor sleep and different sleep measurements (Morgan et al., 1989). There was only a slight sex difference in the occurrence of tinnitus in the whole group of men and women, although there was an age-related increase in the women, which was not seen in the men (Table 1). Other authors have also found similar prevalence figures in men and women (Rosenhall and Karlsson, 1991).
144
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
Fig. 2. The occurrence of DS (%) in men (white bars) (P B/0.0001) and women (black bars) (P B/0.0001) without tinnitus and with good sleep, with tinnitus and good sleep, without tinnitus and with poor sleep and with tinnitus and poor sleep.
Although poor sleep was twice as common in women as in men, the influence of tinnitus on sleep was the same in the two sexes (Table 2). Men and women with tinnitus were also troubled by frequent awakenings to the same extent as those without tinnitus, while difficulties in falling asleep after nocturnal awakenings occurred to a higher extent only in women with tinnitus (Table 2, Fig. 1). The subjects with tinnitus were more troubled by DS than those without tinnitus (Fig. 2). It has been reported that many patients are annoyed by their tinnitus during substantial parts of their time, which makes them tired and impairs their quality of life (Alster et al., 1993; Parving, et al., 1993). Another common cause of DS is a poor night’s sleep (Asplund, 1996). More than half of the men and women of the present study who suffered from both tinnitus and poor sleep reported DS (Fig. 2). As elderly tinnitus sufferers are more inclined to have sleep problems than elderly persons in general, tinnitus seems to cause DS both directly and through its detrimental effect on sleep. Sleep medication was used 40% more frequently in men and 80% more frequently by women suffering from tinnitus than by non-sufferers. It could therefore be expected that the prevalence of DS would to some extent have been increased in tinnitus sufferers by the increased use of sleeping pills. No such increase in DS that could be attributed to sleep medication was found, however, after the influence of sleep deterioration had been taken into account. Thus, the increased use of hypnotics corresponds to an increase in sleep complaints among the tinnitus sufferers. Hypnotics use reflects decreasing somatic and mental health, and many diseases and symptoms are associated with increased use of such drugs, such as cardiac
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
145
diseases and musculoskeletal pain (Asplund, 1995, 2000a). Functional loss in the sensory organs, such as visual or hearing impairment is also associated with increased prevalence of poor sleep and, accordingly, increased sleep medication (Asplund, 2000b, 2002). To summarize, in these elderly subjects tinnitus was associated with an increased frequency of sleep deterioration, independently of health and age. DS was increased by tinnitus and poor sleep but not by sleep medication.
References Abutan, B.B., Hoes, A.W., Van Dalsen, C.L., Verschuure, J., Prins, A., 1993. Prevalence of hearing impairment and hearing complaints in older adults: a study in general practice. Fam. Pract. 10, 391 / 395. Alster, J., Shemesh, Z., Ornan, M., Attias, J., 1993. Sleep disturbance associated with chronic tinnitus. Biol. Psychiatry 34, 84 /90. Asplund, R., 1995. Sleep and hypnotics among the elderly in relation to body weight and somatic disease. J. Int. Med. 238, 65 /70. Asplund, R., 1996. Daytime sleepiness and napping among the elderly in relation to somatic health and medical treatment. J. Int. Med. 239, 261 /267. Asplund, R., 2000a. Sleep and hypnotics use in relation to perceived somatic and mental health among the elderly. Arch. Gerontol. Geriatr. 31, 199 /205. Asplund, R., 2000b. Sleep, health and visual impairment in the elderly. Arch. Gerontol. Geriatr. 30, 7 /15. Asplund, R., 2002. Sleepiness and sleep in elderly with hearing complaints. Arch. Gerontol. Geriatr. 36, 93 /99. Folmer, R.L., Griest, S.E., Martin, W.H., 2001. Chronic tinnitus as phantom auditory pain. Otolaryngol. Head Neck Surg. 124, 394 /400. Hoch, C.C., Dew, M.A., Reynolds, C.F., Buysse, D.J., Nowell, P.D., Monk, T.H., Mazumdar, S., Borland, M.D., Miewald, J., Kupfer, D.J., 1997. Longitudinal changes in diary- and laboratory-based sleep measures in healthy ‘old old’ and ‘young old’ subjects: a three-year follow-up. Sleep 20, 192 /202. Holgers, K.M., Erlandsson, S.I., Barrenas, M.L., 2000. Predictive factors for the severity of tinnitus. Audiology 39, 284 /291. Morgan, K., Clarke, D., 1997. Longitudinal trends in late-life insomnia: implications for prescribing. Age Ageing 26, 179 /184. Morgan, K., Healey, D.W., Healey, P.J., 1989. Factors influencing persistent subjective insomnia in old age: a follow up study of good and poor sleepers aged 65 /74. Age Ageing 2, 117 /122. Parving, A., Hein, H.O., Suadicani, P., Ostri, B., Gyntelberg, F., 1993. Epidemiology of hearing disorders. Some factors affecting hearing. The Copenhagen Male Study. Scand. Audiol. 22, 101 /107. Quaranta, A., Assennato, G., Sallustio, V., 1995. Epidemiology of hearing problems among adults in Italy. Scand. Audiol. Suppl. 42, 9 /13. Rosenhall, U., Karlsson, A.K., 1991. Tinnitus in old age. Scand. Audiol. 20, 165 /171. Sanchez, L., Stephens, D., 1997. A tinnitus problem questionnaire in a clinic population. Ear Hear 18, 210 /217. Sourgen, P.M., Ross, E., 1998. Perceptions of tinnitus in a group of senior citizens. S. Afr. J. Commun. Disord. 45, 61 /75.
Sleepiness and sleep in elderly persons with tinnitus R. Asplund a,b,* b
a Family Medicine Stockholm, Karolinska Institutet, SE-141 57 Huddinge, Sweden ¨ stersund, Sweden The Research and Development Unit, Ja¨mtland County Council, SE-831 25 O
Received 10 October 2002; received in revised form 6 March 2003; accepted 10 March 2003
Abstract The aim of this study was to evaluate the relation of tinnitus to sleep and daytime sleepiness (DS) in a group of elderly men and women. A questionnaire survey was undertaken among 10,216 elderly subjects in northern Sweden. The mean (9/s.d.) ages of the men and women were 73.09/6.0 and 72.69/6.7 years, respectively. Tinnitus was reported by 14.9% of the men and 12.0% of the women. The relative number with tinnitus was not related to age in men, but increased with age in women. Poor sleep was reported by 14.4% of the men and 27.9% of the women. Among subjects with tinnitus poor sleep and frequent waking were more common in both sexes, while difficulties in falling asleep after awakening at night were reported more often by women. DS was more common in subjects with tinnitus and the frequency was even more increased in those with both tinnitus and poor sleep. There was no further increase in DS in men and women on sleep medication. Thus, DS in elderly persons with tinnitus may due both to tiring effect of the annoying sound itself but also the negative effect by tinnitus on sleep. # 2003 Published by Elsevier Science Ireland Ltd. Keywords: Health; Hypnotics; Sleep; Sleepiness; Tinnitus
* Present address: Tallva¨gen 3, S-833 34 Stro¨msund, Sweden. Tel.: /46-670-100-07; fax: /46-63165626. E-mail address: [email protected] (R. Asplund). 0167-4943/03/$ - see front matter # 2003 Published by Elsevier Science Ireland Ltd. doi:10.1016/S0167-4943(03)00028-1
140
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
1. Introduction Tinnitus, the perceived sensation of sound in the absence of acoustic stimulation, is a common complaint. In a study of tinnitus among men aged 63 years (range 53 / 75), Parving et al. (1993) found that 17% had tinnitus episodes of more than 5 min and in 3% the tinnitus was so annoying that it interfered with sleep, reading and/or concentration. There is an age-related increase in the prevalence of tinnitus in both sexes at least up to the age of 70, and this increase is reported to be most pronounced in women (Abutan et al., 1993; Parving et al., 1993). Tinnitus exerts profound influence on the sense of well-being and quality of life. Among 20 elderly tinnitus sufferers, Sourgen and Ross (1998) found that a majority had difficulty in relaxing and following conversations and suffered feelings of frustration, feelings of tenseness, irritability and depression associated with the tinnitus. One common consequence of tinnitus is disturbance of sleep (Parving et al., 1993; Sanchez and Stephens, 1997; Folmer et al., 2001). Depression, a common disorder in association with sleep impairment, is a significant correlate in the tinnitus-related need of absence from work among gainfully employed individuals (Holgers et al., 2000). Sleep complaints, sleepiness and tinnitus are all common in the elderly and all these conditions increase with age (Asplund, 1996; Hoch et al., 1997; Morgan and Clarke, 1997). The present study was undertaken in order to make a close assessment of the interrelationship between tinnitus, sleep and sleepiness.
2. Subjects and methods
2.1. Current study group All 10,216 members of the pensioners’ association SPF in the Swedish counties of Va¨sterbotten and Norrbotten were asked to participate in a questionnaire survey. A further questionnaire was sent to those who did not respond within 1 month.
2.2. The questionnaire The questionnaire included questions on age, civil status, the general state of health, diseases and medication. To evaluate tinnitus, the subjects were asked to respond to the statement ‘‘I am often troubled by disturbing sounds in my head’’. Sleep was analysed from the responses to the three statements: ‘‘I have a good night’s sleep’’; ‘‘I often wake up at night’’; and ‘‘I easily fall asleep again after waking up at night’’; and daytime sleepiness (DS) from those to the statement ‘‘I am often sleepy in the daytime’’, all with the alternative answers ‘‘yes’’ or ‘‘no’’.
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
141
2.3. Statistical methods Standard methods were used for calculating mean values and standard deviations. Group comparisons of non-numerical data were made with the x2-test. For comparing frequencies, odds ratios (OR) with a 95% confidence interval were calculated. For simultaneous evaluation of the influence of more than one independent variable on a dependent variable, logistic regression analysis (StatView 5.0 for the Macintosh) was performed.
3. Results 3.1. General The questionnaire was completed initially by 4544 persons. After a reminder, a further 1559 answers were received. Thus there were 6103 evaluable questionnaires, of which 39.5% were from men. The response rate was 61.3%. The ages (mean9/standard deviation) of the male and female participants were 73.09/6.0 and 72.69/6.7 years, respectively. Tinnitus was reported by 14.9% of the men and 12.0% of the women. The prevalence of tinnitus was unrelated to age in men but was twice as high in women aged ]/80 years than in those aged B/70 years (P B/ 0.0001) (Table 1). Poor health was reported by 16.8% of the men and 18.7% of the women. Health deteriorated with increasing age (Table 1). Tinnitus was not associated with negative health perception in men, but was 2.0 (1.6 /2.5) times more common in women with poor health. 3.2. Tinnitus and sleep Poor sleep was reported by 14.4% of the men and 27.9% of the women (P B/ 0.0001). Compared to subjects without tinnitus poor sleep and frequent awakenings were more common in tinnitus sufferers of both sexes, while difficulties in falling
Table 1 The percentage proportions of elderly men and women of different ages in poor health and of those suffering from tinnitus Age (years)
B/70 70 /79 ]/80
Poor health
Tinnitus
Men
Women
Men
Women
14.6 17.6 18.6
18.2 17.4 23.2
15.7 14.9 13.3
8.2 12.5 16.0
142
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
Fig. 1. The occurrence of poor sleep (%) in men and women without (white bars) and with tinnitus (black bars) (left group of bars; men P B/0.05, women P B/0.001); frequent awakenings (middle group of bars; men P B/0.001, women P B/0.0001); and difficulty in falling asleep again after nocturnal awakening (right group of bars; men NS, women P B/0.0001).
asleep after waking at night were more common only in women with tinnitus (Fig. 1). A multiple logistic regression analysis with tinnitus, health and age as independent variables revealed an increase in poor sleep and in frequent awakenings in tinnitussuffering men independently of age and health. In tinnitus-suffering women, poor sleep, frequent awakenings and difficulties in falling asleep after nocturnal awakenings were all increased, again independently of age and health (Table 2). 3.3. Sleep medication Sleep medication was used by 13.6% of the men and 22.3% of the women (P B/ 0.0001). The use of sleep medication was 1.4 (1.0/1.9) times more common in men with tinnitus and 1.8 (1.3 /2.5) times more common in women with tinnitus than in men and women without tinnitus, respectively. 3.4. DS, tinnitus and sleep DS was reported by 33.0% of the men and 34.7% of the women (NS). DS was more common in subjects suffering from tinnitus than in those without tinnitus and was even more increased in subjects with both tinnitus and poor sleep (Fig. 2). There was no further increase in DS in men and women on sleep medication.
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
143
Table 2 The occurrence of a poor night’s sleep, frequent awakenings and difficulty in falling asleep again after nocturnal awakening in relation to tinnitus, age and health. Poor night’s sleep Frequent awakenings Difficulty in falling asleep again Variables
OR
(CI)
OR
(CI)
OR
(CI)
Tinnitus (No /1.0) Yes
1.4
(1.0 /2.0)
1.4
(1.1 /1.9)
1.2
(0.9 /1.7)
Age ( B/70 years /1.0) 70 /79 years ]/80 years
1.1 1.4
(0.8 /1.5) (0.9 /2.1)
1.2 1.4
(0.9 /1.5) (1.0 /2.0)
1.8 2.8
(1.3 /2.5) (1.9 /4.2)
Health (Good health /1.0) Poor 2.5
(1.9 /3.4)
2.5
(1.9 /3.2)
2.0
(1.5 /2.7)
Men
Women Tinnitus (No /1.0) Yes
1.4
(1.1 /1.8)
1.5
(1.1 /1.9)
1.5
(1.2 /1.9)
Age ( B/70 years /1.0) 70 /79 years ]/80 years
1.1 1.2
(0.9 /1.3) (0.9 /1.6)
1.2 1.4
(1.0 /1.4) (1.1 /1.8)
1.2 1.9
(1.0 /1.4) (1.5 /2.4)
Health (Good health /1.0) Poor 3.1
(2.5 /3.8)
2.7
(2.2 /3.3)
2.2
(1.8 /2.7)
OR and 95% confidence intervals, (CI) for each of the variables included in the logistic model
4. Discussion In the present study, the frequency of sleep complaints was 40% higher in men and women with tinnitus than in those without when the influence of age and health had been taken into account. The severity of tinnitus is highly correlated with the degree of sleep disturbance (Folmer et al., 2001). It is therefore, surprising that sleep complaints seldom seem to be attributed to tinnitus by the patient. Parving et al. (1993) found that only about one out of five tinnitus sufferers stated that their tinnitus was so annoying that it interfered with sleep, reading and/or concentration. One important question in the interpretation of these data concerns the reliability of the reports of tinnitus. The similarity between the frequency figure for tinnitus in the present study and those given in other reports (17% in Parving et al., 1993, 14.5% in Quaranta et al., 1995) supports the view that the answers on tinnitus are reliable. Another issue in the interpretation of the findings concerns the validity of sleep data from a questionnaire. However, consistent correspondence has been found between reports on poor sleep and different sleep measurements (Morgan et al., 1989). There was only a slight sex difference in the occurrence of tinnitus in the whole group of men and women, although there was an age-related increase in the women, which was not seen in the men (Table 1). Other authors have also found similar prevalence figures in men and women (Rosenhall and Karlsson, 1991).
144
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
Fig. 2. The occurrence of DS (%) in men (white bars) (P B/0.0001) and women (black bars) (P B/0.0001) without tinnitus and with good sleep, with tinnitus and good sleep, without tinnitus and with poor sleep and with tinnitus and poor sleep.
Although poor sleep was twice as common in women as in men, the influence of tinnitus on sleep was the same in the two sexes (Table 2). Men and women with tinnitus were also troubled by frequent awakenings to the same extent as those without tinnitus, while difficulties in falling asleep after nocturnal awakenings occurred to a higher extent only in women with tinnitus (Table 2, Fig. 1). The subjects with tinnitus were more troubled by DS than those without tinnitus (Fig. 2). It has been reported that many patients are annoyed by their tinnitus during substantial parts of their time, which makes them tired and impairs their quality of life (Alster et al., 1993; Parving, et al., 1993). Another common cause of DS is a poor night’s sleep (Asplund, 1996). More than half of the men and women of the present study who suffered from both tinnitus and poor sleep reported DS (Fig. 2). As elderly tinnitus sufferers are more inclined to have sleep problems than elderly persons in general, tinnitus seems to cause DS both directly and through its detrimental effect on sleep. Sleep medication was used 40% more frequently in men and 80% more frequently by women suffering from tinnitus than by non-sufferers. It could therefore be expected that the prevalence of DS would to some extent have been increased in tinnitus sufferers by the increased use of sleeping pills. No such increase in DS that could be attributed to sleep medication was found, however, after the influence of sleep deterioration had been taken into account. Thus, the increased use of hypnotics corresponds to an increase in sleep complaints among the tinnitus sufferers. Hypnotics use reflects decreasing somatic and mental health, and many diseases and symptoms are associated with increased use of such drugs, such as cardiac
R. Asplund / Arch. Gerontol. Geriatr. 37 (2003) 139 /145
145
diseases and musculoskeletal pain (Asplund, 1995, 2000a). Functional loss in the sensory organs, such as visual or hearing impairment is also associated with increased prevalence of poor sleep and, accordingly, increased sleep medication (Asplund, 2000b, 2002). To summarize, in these elderly subjects tinnitus was associated with an increased frequency of sleep deterioration, independently of health and age. DS was increased by tinnitus and poor sleep but not by sleep medication.
References Abutan, B.B., Hoes, A.W., Van Dalsen, C.L., Verschuure, J., Prins, A., 1993. Prevalence of hearing impairment and hearing complaints in older adults: a study in general practice. Fam. Pract. 10, 391 / 395. Alster, J., Shemesh, Z., Ornan, M., Attias, J., 1993. Sleep disturbance associated with chronic tinnitus. Biol. Psychiatry 34, 84 /90. Asplund, R., 1995. Sleep and hypnotics among the elderly in relation to body weight and somatic disease. J. Int. Med. 238, 65 /70. Asplund, R., 1996. Daytime sleepiness and napping among the elderly in relation to somatic health and medical treatment. J. Int. Med. 239, 261 /267. Asplund, R., 2000a. Sleep and hypnotics use in relation to perceived somatic and mental health among the elderly. Arch. Gerontol. Geriatr. 31, 199 /205. Asplund, R., 2000b. Sleep, health and visual impairment in the elderly. Arch. Gerontol. Geriatr. 30, 7 /15. Asplund, R., 2002. Sleepiness and sleep in elderly with hearing complaints. Arch. Gerontol. Geriatr. 36, 93 /99. Folmer, R.L., Griest, S.E., Martin, W.H., 2001. Chronic tinnitus as phantom auditory pain. Otolaryngol. Head Neck Surg. 124, 394 /400. Hoch, C.C., Dew, M.A., Reynolds, C.F., Buysse, D.J., Nowell, P.D., Monk, T.H., Mazumdar, S., Borland, M.D., Miewald, J., Kupfer, D.J., 1997. Longitudinal changes in diary- and laboratory-based sleep measures in healthy ‘old old’ and ‘young old’ subjects: a three-year follow-up. Sleep 20, 192 /202. Holgers, K.M., Erlandsson, S.I., Barrenas, M.L., 2000. Predictive factors for the severity of tinnitus. Audiology 39, 284 /291. Morgan, K., Clarke, D., 1997. Longitudinal trends in late-life insomnia: implications for prescribing. Age Ageing 26, 179 /184. Morgan, K., Healey, D.W., Healey, P.J., 1989. Factors influencing persistent subjective insomnia in old age: a follow up study of good and poor sleepers aged 65 /74. Age Ageing 2, 117 /122. Parving, A., Hein, H.O., Suadicani, P., Ostri, B., Gyntelberg, F., 1993. Epidemiology of hearing disorders. Some factors affecting hearing. The Copenhagen Male Study. Scand. Audiol. 22, 101 /107. Quaranta, A., Assennato, G., Sallustio, V., 1995. Epidemiology of hearing problems among adults in Italy. Scand. Audiol. Suppl. 42, 9 /13. Rosenhall, U., Karlsson, A.K., 1991. Tinnitus in old age. Scand. Audiol. 20, 165 /171. Sanchez, L., Stephens, D., 1997. A tinnitus problem questionnaire in a clinic population. Ear Hear 18, 210 /217. Sourgen, P.M., Ross, E., 1998. Perceptions of tinnitus in a group of senior citizens. S. Afr. J. Commun. Disord. 45, 61 /75.