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Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults
Sleep Health xxx (2016) xxx–xxx
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Sleep Health Journal of the National Sleep Foundation journal homepage: sleephealthjournal.org
Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults☆ Olufunmilola Abraham, PhD, MS, BPharm a,⁎, Jia Pu, PhD b, Loren J. Schleiden, BS a, Steven M. Albert, PhD c a b c
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA, 15261, USA Mathematica Policy Research, 505 14th Street, Suite 800, Oakland, CA, 94612, USA Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
a r t i c l e
i n f o
Article history: Received 6 January 2016 Received in revised form 11 November 2016 Accepted 11 November 2016 Available online xxxx Keywords: Poor sleep satisfaction Sleep health Sleep disturbance Sleep complaints Healthcare seeking behaviors Older adults
a b s t r a c t Objective: To identify factors influencing older adults' poor satisfaction with sleep and their current healthcare seeking behaviors. Design: Cross-sectional study. Setting: Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry. Participants: Individuals aged 60 or older enrolled in the registry that completed a cross-sectional mailed survey (N = 1026). Measurements: Participant demographics (age, gender, marital status, race, education), overall health (selfrated health, pain, and comorbidities), and health behaviors (physical activity, smoking, drinking behaviors) were collected from the registry database. A mail survey was used to collect self-report on sleep problems and their current healthcare seeking behaviors. Simple and multiple logistic regression models were used to evaluate associations between variables. Results: A total of 19.3% of participants reported being “dissatisfied” or “very dissatisfied” with their overall sleep quality. Participants who reported poor sleep satisfaction were more likely to be single and report poorer overall health compared to participants who were satisfied with their sleep quality. They were also more likely to report using over-the-counter (OTC) and prescription sleep medications, discuss sleep problems with a healthcare provider, and use strategies to improve their sleep (P b .05). A higher proportion of participants with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) or prescription (20.1%) sleep aids. Conclusions: These results underscore the possible linkage between poor satisfaction with sleep and older adults' current healthcare seeking behaviors and self-treatment methods, particularly using OTC medications to cope with sleep problems without consulting a healthcare provider. © 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Introduction Sleep is an integral part of maintaining physical, cognitive, and emotional health and well-being 1; however, poor sleep health is a common problem among the elderly in the United States. 1–4 The National Sleep Foundation recommends that older adults (aged 65 and older) obtain 7 to 8 hours of sleep each night to avoid compromising their health. 1 Despite this recommendation, 25% to 32% of older
☆ Funding: This research was supported by the Inaugural AcademyHealth New Investigator Small Grant Program (NISGP). ⁎ Corresponding author at: Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 639 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261. Tel.: +1 412 648 1982; fax: +1 412 624 1850. E-mail address: [email protected] (O. Abraham).
adults in the United States get fewer than 7 hours of sleep.5,6 Furthermore, 15% to 50% of older adults reported that they have experienced sleep difficulties.7,8 Potential contributing factors to decreased sleep quality in the elderly include changes in chronic conditions, medication use, circadian rhythms, and sleep patterns. 9 Additionally, older adult women in particular report significantly more sleep problems than men.7 Many older adults often have one or multiple chronic diseases or comorbidities, which may further increase the risk for adverse health effects and symptoms associated with sleep difficulties.3 Poor sleep health may impact several domains in older adults such as difficulty sustaining attention, slowed response time, impairments in memory and concentration, decreased ability to accomplish daily tasks, and increased risk of falls.10–12 In order to improve sleep quality in older adults, there must be a better understanding of the multitude of factors impacting their sleep satisfaction.
http://dx.doi.org/10.1016/j.sleh.2016.11.004 2352-7218/© 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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Despite the growing literature on sleep disturbance and prevalence in the elderly population, sleep difficulties in older adults are under-recognized and undertreated; one study found that many elderly patients often do not disclose sleep difficulties to their healthcare providers. 13 Untreated sleep problems in older adults may result in decreased health-related quality of life, loss of independence due to functional limitations, multiple chronic conditions, cardiovascular disease, obesity, and diabetes. 14,15 Further study is needed to better understand the association between sleep satisfaction and healthcare seeking behaviors in older adults. With a greater awareness and establishment of these issues, healthcare providers, older adults in the general public, and researchers can begin to treat satisfaction with sleep as an indicator of overall health, alongside other standard indicators such as blood pressure and quality of life. Hence, the objective of this study was to elucidate factors including demographics, overall health, and health behaviors that may be associated to poor satisfaction with sleep in older adults. The associations between satisfaction with sleep, reported sleep problems, and healthcare seeking behaviors were also explored. We hypothesized that individual characteristics, such as being a female and self-rated poorer overall health are associated with poor satisfaction with sleep. In addition, poor satisfaction with sleep is associated with increasing underlying sleep problems and healthcare seeking behaviors. Participants and methods Study participants Study participants were members of the Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry of community-dwelling persons in the Pittsburgh, Pennsylvania region aged 60 or older. Registry members previously consented to being contacted for participation in Pepper-approved research studies, and are followed yearly to update their contact and basic health information. Data collection Survey packets containing an introduction to the study, consent form, mail survey, and a pre-addressed stamped return envelope were sent via the United States Postal Service (USPS) to 2064 Pepper registrants in February 2015. The survey was created based upon prior research and the objectives of this study using investigator developed questions and adapted items from validated sleep health questionnaires.16–18 Survey questions were designed to collect information on older adults' perceptions of sleep quality, satisfaction with sleep, and approaches used to alleviate sleep problems. Survey questions were vetted by the research team and piloted with multiple older adults in the community to ensure they were clear to study participants. Follow-up reminder postcards were sent out after the initial survey packet mailing and surveys were returned through April 2015. Surveys were returned by 1026 participants with a response rate of 49.7%. Eleven of the returned surveys were excluded from analyses due to missing information regarding sleep satisfaction, resulting in a final sample of 1015 participants. This study was approved by the Institutional Review Board at the University of Pittsburgh. Measures Overall satisfaction with sleep. Overall satisfaction with sleep quality was measured on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied) with the following survey item: “please rate your overall satisfaction with your sleep quality.” We classified participants into two groups based on their reported overall satisfaction with sleep quality. A participant was defined as “satisfied or neutral” (Group 1) if he/she reported being very satisfied, satisfied, or neutral
(neither satisfied nor dissatisfied) with sleep quality. Participants that reported being “dissatisfied” or “very dissatisfied” were classified as “dissatisfied” (Group 2). Participant characteristics: Demographics, overall health, and health behaviors. Participant characteristics that were potentially associated with poor satisfaction with sleep, which included demographics, overall health, and health behaviors, were collected by the Pepper registry database and linked to survey responses. Participant demographics included age, gender, marital status, race, and educational attainment. To assess overall health, participants' self-rated health (excellent, very good, good, fair/poor), pain (never, sometimes, or often/always have pain), and number of reported comorbidities were used from the registry database. Health behaviors were assessed by participants' reported participation in physical activity (daily, N3 times a week, b3 times a week, or none), and smoking (not at all, some days, and every day) and drinking (not at all or yes) behaviors in the past 30 days. Sleep problems. Problems with sleep were assessed with three survey items. To assess sleep problems, participants were asked “how often do you have trouble sleeping at night?” Responses included a range from 1 to 3 nights per week to 1 to 2 nights per year, or never. Participants were asked to select troublesome aspects of sleep, with responses such as trouble falling asleep, excessively sleepy during the day, or other with the request to specify if not listed. To assess the potential causes of sleep problems, participants were asked “do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months?” Participants were asked to select from responses that included work hours and/or demands of work, emotional stress from work-related activities, family commitments, changing circadian rhythms, or another specified reason. Healthcare seeking behaviors. Participants' healthcare seeking behaviors and coping strategies to address sleep problems were assessed using five survey items. Participants were asked to answer yes or no to the following questions to assess healthcare seeking behaviors regarding sleep problems: “have you ever been diagnosed with a sleep condition by a doctor”; “have you ever discussed sleep problems with a health care provider?”; “have you ever used OTC sleep aid medication?”? and “have you ever used prescription sleep aid medication?” To assess coping strategies for sleep problems, participants were asked “do you use any of the following methods regularly to help you fall sleep?” Examples of responses included reading, watching TV, or taking an over-the-counter (OTC) or prescription medication. Statistical data analysis Based on findings from previous research and our study objectives, we hypothesized that participants less satisfied with sleep would report poorer overall health, unfavorable health behavior, more sleep problems, and healthcare seeking behaviors such as consulting a healthcare provider or using various strategies (eg, OTC or prescription medications, reading before bed) to help improve sleep. We also investigated gender differences in poor satisfaction with sleep, sleep disturbances, and healthcare seeking behaviors. In order to provide meaningful comparison and to identify factors associated with poor satisfaction with sleep, the responses to the question of sleep quality were collapsed into two groups: Group 1 Satisfied or neutral about their sleep quality, included very satisfied, satisfied, and neutral (neither satisfied nor dissatisfied); and Group 2 – Dissatisfied, included dissatisfied and very dissatisfied (see Table 1). To test our first hypothesis, descriptive and bivariate analyses were used to describe the characteristics of the sample in the two groups. Multiple logistic regression models were used to
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
O. Abraham et al. / Sleep Health xxx (2016) xxx–xxx
examine the associations between sleep satisfaction and participants' characteristics, including demographics, overall health status, and health behaviors (see Table 2). To test our second hypothesis, descriptive analyses were conducted to assess the association between sleep problems, healthcare seeking behaviors, and sleep satisfaction (see Tables 3 and 4). P b .05 was considered to be evidence of a statistical trend, and 95% confidence intervals were calculated. Sensitivity analyses were conducted using sequential imputations to account for missing data from survey responses. All survey items had a missing rate of no more than 5%. Statistical analyses were performed using
Table 1 Participants' Characteristics
Total number (N, %) Demographics (N, %) Age (year) 60–69 70–7 80–89 90+ Female Marital status Married Single (never married) Widowed Divorced/separated Missing/skipped Race Non-hispanic white Non-hispanic Black Other race (includes those of hispanic ethnicity) Missing/skipped Education More than 4-year college degree Some college/4-year college degree HS degree/GED or less Missing/skipped Overall health (N, %) Self-rated health Excellent Very good Good Fair/poor Missing/skipped Pain Never have pain Sometimes have pain Often/always have pain Missing/skipped Number of comorbidities (mean, SD) Health behavior (N, %) Participation in physical activity Daily N3 times a week b3 times a week No Missing/skipped Smoking Not at all Every day & some days Missing/skipped Drinking Not at all Yes Missing/skipped
Group 1 Satisfied or neutral
Group 2 Dissatisfied
819 (80.7)
196 (19.3)
115 (14.0) 390 (47.6) 274 (33.5) 40 (4.9) 480 (58.6)
30 (15.3) 92 (46.9) 57 (29.1) 17 (8.7) 130 (66.3)
490 (59.8) 78 (9.5) 175 (21.4) 68 (8.3) 8 (1.0)
93 (47.5) 28 (14.3) 51 (26.0) 24 (12.2) 0 (0.0)
747 (91.2) 50 (6.1) 15 (1.8)
175 (89.3) 15 (7.7) 5 (2.6)
7 (0.9)
1 (0.5)
399 (48.7) 287 (35.0) 126 (15.4) 7 (0.9)
105 (53.6) 67 (34.2) 20 (10.2) 4 (2.0)
88 (10.7) 343 (41.9) 300 (36.6) 68 (8.3) 20 (2.4)
17 (8.7) 50 (25.5) 90 (45.9) 32 (16.3) 7 (3.6)
121 (14.8) 464 (56.7) 221 (27.0) 13 (1.6) 1.87 (1.18)
24 (12.2) 100 (51.0) 72 (36.7) 0 (0.0) 2.13 (1.22)
192 (23.4) 211 (25.8) 189 (23.1) 197 (24.1) 30 (3.7)
32 (16.3) 54 (27.6) 45 (23.0) 49 (25.0) 16 (8.2)
759 (92.7) 21 (2.6) 39 (4.8)
174 (88.8) 9 (4.6) 13 (6.6)
262 (32.0) 528 (64.5) 29 (3.5)
73 (37.2) 116 (59.2) 7 (3.6)
P
0.16
0.05 b0.01
0.59
0.15
3
Table 2 Factors Associated with Poor Satisfaction: Multiple Logistic Regression (Reference Group = Satisfied/Neutral)
Demographics Age (year) 60–69 70–79 80–89 90+ Female Marital status Married Single (Never married) Widowed Divorced/separated Race Non-hispanic white Non-hispanic black Other Education More than 4-year college degree Some college/4-year college degree HS degree/GED or less Overall health Self-rated health Excellent Very good good Fair/poor Pain Never have pain Sometimes have pain Often/always have pain Health behavior Participation in physical activity Daily N3 times a week b3 times a week No Current smoking Not at all Every day and some days Current drinking Not at all Yes
Adjusted odds ratio
95% Confidence interval
Ref 0.97 0.81 1.41 1.34
Ref 0.59–1.58 0.46–1.41 0.64–3.12 0.92–1.94
Ref 1.80 1.74 1.33
Ref 1.07–3.04 0.99–3.05 0.85–2.08
Ref 0.85 1.23
Ref 0.43–1.66 0.43–3.58
Ref 0.48
Ref 0.27–0.84
0.81
0.57–1.17
Ref 0.68 1.54 2.26
Ref 0.36–1.27 0.82–2.86 1.05–4.85
Ref 1.03 1.34
Ref 0.62–1.74 0.76–2.35
Ref 1.63 1.39 1.15
Ref 0.99–2.66 0.84–2.29 0.68–1.94
Ref 1.85
Ref 0.78–4.42
Ref 0.96
Ref 0.66–1.39
b0.01
0.03
Stata statistical software (version 13; Stata Corp, College Station, TX) and SAS (version 9.3; SAS Institute, Inc, Cary, NC).
Results b0.01 0.30
0.12
0.16
Table 1 describes the characteristics of survey respondents. Study participants were well-educated and reported healthy lifestyles, more than 80% having a college degree or higher and the majority (N90%) being non-smokers. A total of 819 (80.7%) participants indicated they were “satisfied or neutral” when asked to rate their overall sleep quality (Group 1), while 196 (19.3%) reported they were “dissatisfied” (Group 2). There were statistical trends towards differences in gender, marital status, self-rated health, pain, and number of comorbidities between the groups. Dissatisfied participants were more likely to not be married (52.5% vs. 40.2%, P b .01). These participants also reported poorer overall health status compared to participants who were satisfied with their sleep quality (self-rated poor health: 16.3% vs. 8.3%, P b .01; always have pain: 36.7% vs. 27.0%, P = .03; number of comorbidities: 2.13 vs. 1.87, P b .01).
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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Table 3 Sleep Problems and Healthcare Seeking Behaviors by Sleep Satisfaction
Total Number (N, %) Sleep problems (N, %) How often do you have trouble sleeping at night? Every Night 4–6 Nights Per Week 1–3 Nights Per Week 2–3 Nights Per Month 1 Nights Per Month b1 Nights Per Month 1–2 Nights Per Year Never missing/skipped Troublesome aspects of sleep: Trouble falling asleep Trouble sleeping throughout the night Wake up too early in the morning Nightmares Excessively sleepy during the day Other No trouble sleeping at night Do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months? Work hours and/or demands of work Emotional stress from work-related activities Family commitments Changing circadian rhythms Other Healthcare seeking behavior and coping strategy Ever been diagnosed with a sleep condition by a doctor: Yes No Missing/skipped Have you ever discussed sleep problems with a healthcare provider Yes No Missing/skipped OTC sleep aids (ever use) Yes No Missing/skipped Prescription sleep aids (ever use) Yes No Missing/skipped Do you use any of the following methods regularly to help you fall asleep? (Top three) Reading Taking OTC or prescription Watching TV
Group 1, not dissatisfied (satisfied or neutral)
Group 2, dissatisfied
n = 819 (80.7)
n = 196 (19.3)
25 (3.1) 25 (3.1) 123 (15.0) 201 (24.5) 121 (14.8) 121 (14.8) 110 (13.4) 87 (10.6) 6 (0.7)
63 (32.1) 46 (23.5) 53 (27.0) 13 (6.6) 5 (2.6) 5 (2.6) 4 (2.0) 4 (2.0) 2 (1.0)
157 (19.2) 343 (41.9) 173 (21.1) 29 (3.5) 62 (7.6) 109 (13.3) 214 (26.1)
97 (49.5) 153 (78.1) 73 (37.5) 12 (6.1) 28 (14.3) 36 (18.4) 12 (6.1)
b0.01 b0.01 b0.01 0.16 0.01 0.09 b0.01
45 (6.0) 33 (4.4) 95 (12.6) 55 (7.5) 69 (16.7)
18 (10.7) 20 (11.8) 38 (22.8) 35 (22.3) 33 (34.4)
0.06 b0.01 b0.01 b0.01 b0.01
104 (12.7) 698 (85.2) 17 (2.1)
30 (15.3) 164 (83.7) 2 (1.0)
196 (23.9) 620 (75.7) 3 (0.4)
107 (54.6) 88 (44.9) 1 (0.5)
145 (17.7) 674 (82.3) 0 (0.0)
70 (35.7) 126 (64.3) 0 (0.0)
79 (9.7) 734 (89.6) 6 (0.7)
43 (21.9) 153 (78.1) 0 (0.0)
339 (41.4) 119 (14.5) 233 (28.5)
90 (45.9) 66 (33.7) 72 (36.7)
P
b0.01
0.36
b0.01
b0.01
b0.01
0.04 b0.01 b0.01
Participants' characteristics and satisfaction with sleep quality
Sleep problems, healthcare seeking behaviors and coping strategy
Based on the multiple logistic regression results shown in Table 2, the likelihood of reporting poor satisfaction with sleep was higher among single (never married) compared with married participants (Adjusted odds ratio/AOR: 1.80, 95% confidence interval/CI: 1.07–3.04) and self-rated fair/poor health status compared to excellent health status (AOR: 2.26, 95% CI: 1.05–4.85), and lower among participants with some college/4-year college degree compared to more than 4 year college degree (AOR: 0.48, 95% CI: 0.27–0.84). There were no statistical trends in differences between age, gender, race, health behaviors, or experience of pain between the two groups, and thus our hypothesis regarding the association between these demographic variables and poor satisfaction with sleep was not supported. The count of comorbidities variable was excluded from the multiple logistic regression model due to its collinearity with selfrated health status.
Participants that reported poor satisfaction with sleep were more likely to state they had sleep problems, including trouble sleeping at night (Table 3). These participants reported greater frequency of all aspects of troublesome sleep except “nightmares” (P b .05). Most reported trouble sleeping throughout the night (78.1%), half trouble falling asleep (49.5%), and more than one third “waking up too early in the morning” (37.5%). Similarly, participants that reported poor satisfaction with sleep were also more likely to report they had used OTC and prescription sleep medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to help improve sleep quality (P b .05). There was no statistical trend in “diagnosed with a sleep condition by a doctor” between participants who were satisfied/neutral or dissatisfied regarding their sleep quality. The most frequently reported sleep problem was trouble sleeping throughout the night (N = 496). Among participants with sleep
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
O. Abraham et al. / Sleep Health xxx (2016) xxx–xxx
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Table 4 Healthcare seeking behaviors by sleep problem. Trouble sleeping throughout the night (n = 496) Have discussed sleep problems with a healthcare provider (N, %) Have been diagnosed with a sleep condition (N, %) Ever uses OTC sleep aids (N, %) Uses prescription sleep aids (N, %)
120 (47.2) 41 (16.1) 98 (38.6) 51 (20.1)
problems, a higher proportion with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) and prescription (20.1%) sleep aids, while participants with trouble falling asleep had a higher proportion of being diagnosed with a sleep condition (28.9%). These results are shown in Table 4. Sensitivity analysis was conducted to test the impact of missing data by comparing the multiple logistic regression results using multiple imputations to complete case analysis and we found no significant difference in study results. Discussion Study findings indicate that a number of community-dwelling older adults have poor satisfaction with their sleep quality. This has important implications for healthcare providers caring for older adult patients. Participants in this study who reported poor satisfaction with sleep were more likely to be single and have poorer overall health compared to participants who were satisfied with their sleep. Additionally, participants who were less satisfied with sleep and those who reported trouble sleeping throughout the night were more likely to report they had used OTC and prescription medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to improve sleep. A total of 19.3% of survey respondents reported being “dissatisfied” with their overall sleep quality; which is consistent with previous research involving older adults on self-reported sleep disturbance or tiredness.19 Participants who were less satisfied with their sleep were more likely to be single and reported poorer overall health status. This finding is consistent with previous research which suggests that older adults often have chronic health conditions which prevent them from getting a good night's sleep. 13 Healthy older adults experience much less sleep disturbance than those with comorbidities,20 and individuals with more severe chronic conditions often report worse sleep health. 21 Since single older adults with poorer overall health are more likely to report poor satisfaction with sleep, such individuals can be targeted for educational interventions that improve sleep hygiene. When seeking to improve sleep quality, many older adults may overlook behavioral and environmental interventions and instead seek to address their sleep difficulties with prolonged use of OTC medications. As buttressed by findings from this study, participants that reported poor satisfaction with sleep were more likely to have used OTC and prescription sleep medications and report poorer overall health. Previous research has shown that as many as 5.5% of adults age 60 to 69 and 7% of adults age 80 and older are taking a prescription sleep aid. 22 About 17% of older adults who reported regular sleeplessness symptoms are taking an OTC sleep medication containing diphenhydramine or doxylamine, which are not recommended for use by the elderly and may increase the risk of anticholinergicrelated adverse events.13,23,24 OTC sleep medications can be especially problematic in the elderly because they may cause prolonged sedation effects resulting in increased risk of impaired cognition and falls. 25 Consequently, education and policy initiatives that promote appropriate sleep hygiene behaviors and safe use of OTC sleep
Wake up too early in the morning (n = 246) 199 (40.1) 70 (14.1) 140 (28.2) 76 (15.3)
Nightmares (n = 41) 102 (41.5) 39 (15.9) 70 (28.5) 41 (16.7)
Excessively sleepy during the day (n = 90) 17 (41.5) 4 (9.8) 10 (24.4) 10 (24.4)
Trouble falling asleep (n = 254) 38 (42.2) 26 (28.9) 26 (28.9) 18 (20.0)
medications, particularly for older adults with comorbidities, are critically needed. Older adults should receive education regarding different non-pharmacological methods to improve their sleep quality, which include physical therapy, mindfulness interventions, yoga, therapeutic massage, and acupuncture.26 It is important to note that sleep hygiene modifications and other approaches, such as the use of OTC medications, may not address the underlying causes of insomnia, which is distinguished from sleep disturbance or general poor sleep quality. 13 The potential for insomnia disorder in individuals who report sleep disturbances and the need for appropriate treatment for this condition are important considerations for healthcare providers when discussing sleep quality with older adult patients. It is imperative for healthcare providers to address poor satisfaction with sleep with elderly patients because they rarely discuss sleep complaints during routine clinic visits, and may inappropriately use OTC or prescription sleep medications. 13,27 In this study, nearly half of participants who had trouble sleeping throughout the night reported seeking consultation from their healthcare provider (47.2%), and a similar rate was reported by those who reported having trouble falling sleep (42.2%). Previous research found that only 58% of patients told their physicians about their recent and past OTC medication use.28 Discussions about the use of OTC medications with healthcare providers can facilitate conversations about common sleep disturbances to determine more safe and effective approaches to improve older adults' sleep quality. Findings from this study highlight the associations between reported poor satisfaction with sleep and healthcare seeking behaviors of older adults. Future studies should examine how to proactively identify older adults with sleep problems and increase awareness of recommended non-pharmacological approaches to improve sleep quality. This study has several study limitations. This was a crosssectional study, and data were limited to members of the Pepper Community Registry which is not a representative sample of older adults living in the United States. Registry participants had relatively high level of education and were primarily white, thus results are not generalizable to the overall older adult population in the United States. The results are also subject to the inherent limitation of selfreported data (recall bias), which relied on respondents to complete the surveys accurately. Future research can utilize not only selfreport but also objective measures of sleep such as polysomnography or actigraphy—a method of measuring sleep by recording wrist movement.29 It has been indicated that older adults may underreport the severity of sleep disturbances compared to objective methods using polysomnography, and use of this tool may provide a more accurate assessment of sleep quality.30 Conclusions In conclusion, our findings underscore the possible linkage between sleep satisfaction and older adults' healthcare seeking behaviors including the use of self-care methods, particularly OTC medications to cope with sleep problems, and the need for additional research. It is important that healthcare providers, such as physicians and pharmacists, discuss sleep health with older adult patients and
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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provide education on appropriate sleep hygiene behaviors to improve sleep satisfaction. Author contributions All authors have contributed to this manuscript, revised and edited the manuscript, and approved the final version. Olufunmilola Abraham: study concept and design, acquisition of data, analysis and interpretation of data. Jia Pu: data analysis and interpretation and preparation of the manuscript. Loren J. Schleiden: data collection, analysis and interpretation and preparation of the manuscript. Steve M. Albert: study concept and design, data interpretation and analysis, and preparation of the manuscript. All authors state that they had complete access to the study data that support this publication. Sponsor's role None. Disclosure Dr Abraham has nothing to disclose. Dr Pu has nothing to disclose. Dr Schleiden has nothing to disclose. Dr Albert has nothing to disclose. Acknowledgments We acknowledge Amanda Brothers, Research Specialist, University of Pittsburgh, School of Pharmacy for editorial assistance in revising the final manuscript for publication. This research was supported by the AcademyHealth New Investigator Small Grant Program (NISGP). Results from this study were presented as a podium presentation at the AcademyHealth annual meeting on June 2016. The Pepper Community Registry is supported by the Pittsburgh Claude D. Pepper Older Americans Independence Center, NIH P30 AG024827. References 1. Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1:40–43. 2. Bonnet MH, Arand DL. We are chronically sleep deprived. Sleep. 1995;18:908–911. 3. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation sleep in America survey. J Psychosom Res. 2004;56:497–502. 4. Kobayashi D, Takahashi O, Deshpande GA, Shimbo T, Fukui T. Association between osteoporosis and sleep duration in healthy middle-aged and elderly adults: a large-scale, cross-sectional study in Japan. Sleep Breath. 2012;16:579–583. 5. Centers for Disease Control and Prevention (CDC). Unhealthy sleep-related behaviors - 12 states, 2009. MMWR Morb Mortal Wkly Rep. 2011;60:233–238.
6. Centers for Disease Control and Prevention (CDC). Effect of short sleep duration on daily activities - United States, 2005–2008. MMWR Morb Mortal Wkly Rep. 2011; 60:239–242. 7. Strine TW, Chapman DP. Associations of frequent sleep insufficiency with healthrelated quality of life and health behaviors. Sleep Med. 2005;6:23–27. 8. Foley DJ, Monjan AA, Brown SL, et al. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18:425–432. 9. Unruh ML, Redline S, An MW, et al. Subjective and objective sleep quality and aging in the sleep heart health study. J Am Geriatr Soc. 2008;56:1218–1227. 10. Cricco M, Simonsick EM, Foley DJ. The impact of insomnia on cognitive functioning in older adults. J Am Geriatr Soc. 2001;49:1185–1189. 11. Ancoli-Israel S, Cooke JR. Prevalence and comorbidity of insomnia and effect on functioning in elderly populations. J Am Geriatr Soc. 2005;53:S264–S271. 12. Stone KL, Ancoli-Israel S, Blackwell T, et al. Actigraphy-measured sleep characteristics and risk of falls in older women. Arch Int Med. 2008;168:1768–1775. 13. Albert SM, Roth T, Toscani M, Vitiello MV, Zee P. Sleep health and appropriate use of OTC sleep aids in older adults—recommendations of a Gerontological Society of America workgroup. Gerontologist. 2015 [Epub ahead of print]. 14. Van Cauter E, Knutson KL. Sleep and the epidemic of obesity in children and adults. Eur J Endocrinol. 2008;159:S59–S66. 15. Institute of Medicine, Committee on Sleep Medicine and Research. Sleep disorders and sleep deprivation: an unmet public health problem. Washington: National Academies Press; 2006. 16. Morin CM, LeBlanc M, Daley M, Gregoire JP, Mérette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7:123–130. 17. Kaufmann CN, Canham SL, Mojtabai R, et al. Insomnia and health services utilization in middle-aged and older adults: results from the health and retirement study. J Gerontol A Biol Sci Med Sci. 2013;68:1512–1517. 18. Pillitteri JL, Kozlowski LT, Person DC, Spear ME. Over-the-counter sleep aids: widely used but rarely studied. J Subst Abuse. 1994;6:315–323. 19. Grandner MA. Age and sleep disturbances among American men and women: data from the U.S. behavioral risk factor surveillance system. Sleep. 2012;35: 395–406. 20. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep. 2004;27: 1255–1273. 21. Zee PC, Turek FW. Sleep and health: everywhere and in both directions. Arch Int Med. 2006;166:1686–1688. 22. Chong Y, Fryer CD, Gu Q. Prescription sleep aid use among adults: United States, 2005-2010. NCHS Data Brief. 2013;127:1–8. 23. American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63:2227–2246. 24. Gross HJ, O'Neill G, Toscani M, Chapnick J. Sex Differences in over-the-Counter Sleep Aid Use in Older Adults. International Society for Pharmacoeconomics and Outcomes Research (ISPOR) 20th Annual International Meeting, Philadelphia, PA; 2015. 25. Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med. 2008;168: 508–513. 26. Nicolau ZF, Andersen ML, Tufik S, Hachul H. Can sleep hygiene behaviors improve sleep quality in midlife women? J Women’s Health. 2015;24:252–253. 27. Jacobs JM, Cohen A, Hammerman-Rozenberg R, Stessman J. Global sleep satisfaction with older people: the Jerusalem cohort study. J Am Geriatr Soc. 2006;54: 325–329. 28. Sleath B, Rubin RH, Campbell W, Gwyther L, Clark T. Physician-patient communication about over-the-counter medications. Soc Sci Med. 2001;53:357–369. 29. Spira AP, Covinsky KR, Stone KL, et al. Objectively measured sleep quality and nursing home placement in older women. J Am Geriatr Soc. 2012;60:1237–1243. 30. Vitiello MV, Larsen LH, Moe KE. Age-related sleep change: gender and estrogen effects on the subjective–objective sleep quality relationships of healthy, noncomplaining older men and women. J Psychosom Res. 2004;56:503–510.
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
Contents lists available at ScienceDirect
Sleep Health Journal of the National Sleep Foundation journal homepage: sleephealthjournal.org
Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults☆ Olufunmilola Abraham, PhD, MS, BPharm a,⁎, Jia Pu, PhD b, Loren J. Schleiden, BS a, Steven M. Albert, PhD c a b c
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 3501 Terrace Street, Pittsburgh, PA, 15261, USA Mathematica Policy Research, 505 14th Street, Suite 800, Oakland, CA, 94612, USA Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, 130 De Soto Street, Pittsburgh, PA, 15261, USA
a r t i c l e
i n f o
Article history: Received 6 January 2016 Received in revised form 11 November 2016 Accepted 11 November 2016 Available online xxxx Keywords: Poor sleep satisfaction Sleep health Sleep disturbance Sleep complaints Healthcare seeking behaviors Older adults
a b s t r a c t Objective: To identify factors influencing older adults' poor satisfaction with sleep and their current healthcare seeking behaviors. Design: Cross-sectional study. Setting: Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry. Participants: Individuals aged 60 or older enrolled in the registry that completed a cross-sectional mailed survey (N = 1026). Measurements: Participant demographics (age, gender, marital status, race, education), overall health (selfrated health, pain, and comorbidities), and health behaviors (physical activity, smoking, drinking behaviors) were collected from the registry database. A mail survey was used to collect self-report on sleep problems and their current healthcare seeking behaviors. Simple and multiple logistic regression models were used to evaluate associations between variables. Results: A total of 19.3% of participants reported being “dissatisfied” or “very dissatisfied” with their overall sleep quality. Participants who reported poor sleep satisfaction were more likely to be single and report poorer overall health compared to participants who were satisfied with their sleep quality. They were also more likely to report using over-the-counter (OTC) and prescription sleep medications, discuss sleep problems with a healthcare provider, and use strategies to improve their sleep (P b .05). A higher proportion of participants with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) or prescription (20.1%) sleep aids. Conclusions: These results underscore the possible linkage between poor satisfaction with sleep and older adults' current healthcare seeking behaviors and self-treatment methods, particularly using OTC medications to cope with sleep problems without consulting a healthcare provider. © 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Introduction Sleep is an integral part of maintaining physical, cognitive, and emotional health and well-being 1; however, poor sleep health is a common problem among the elderly in the United States. 1–4 The National Sleep Foundation recommends that older adults (aged 65 and older) obtain 7 to 8 hours of sleep each night to avoid compromising their health. 1 Despite this recommendation, 25% to 32% of older
☆ Funding: This research was supported by the Inaugural AcademyHealth New Investigator Small Grant Program (NISGP). ⁎ Corresponding author at: Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, 639 Salk Hall, 3501 Terrace Street, Pittsburgh, PA, 15261. Tel.: +1 412 648 1982; fax: +1 412 624 1850. E-mail address: [email protected] (O. Abraham).
adults in the United States get fewer than 7 hours of sleep.5,6 Furthermore, 15% to 50% of older adults reported that they have experienced sleep difficulties.7,8 Potential contributing factors to decreased sleep quality in the elderly include changes in chronic conditions, medication use, circadian rhythms, and sleep patterns. 9 Additionally, older adult women in particular report significantly more sleep problems than men.7 Many older adults often have one or multiple chronic diseases or comorbidities, which may further increase the risk for adverse health effects and symptoms associated with sleep difficulties.3 Poor sleep health may impact several domains in older adults such as difficulty sustaining attention, slowed response time, impairments in memory and concentration, decreased ability to accomplish daily tasks, and increased risk of falls.10–12 In order to improve sleep quality in older adults, there must be a better understanding of the multitude of factors impacting their sleep satisfaction.
http://dx.doi.org/10.1016/j.sleh.2016.11.004 2352-7218/© 2016 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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Despite the growing literature on sleep disturbance and prevalence in the elderly population, sleep difficulties in older adults are under-recognized and undertreated; one study found that many elderly patients often do not disclose sleep difficulties to their healthcare providers. 13 Untreated sleep problems in older adults may result in decreased health-related quality of life, loss of independence due to functional limitations, multiple chronic conditions, cardiovascular disease, obesity, and diabetes. 14,15 Further study is needed to better understand the association between sleep satisfaction and healthcare seeking behaviors in older adults. With a greater awareness and establishment of these issues, healthcare providers, older adults in the general public, and researchers can begin to treat satisfaction with sleep as an indicator of overall health, alongside other standard indicators such as blood pressure and quality of life. Hence, the objective of this study was to elucidate factors including demographics, overall health, and health behaviors that may be associated to poor satisfaction with sleep in older adults. The associations between satisfaction with sleep, reported sleep problems, and healthcare seeking behaviors were also explored. We hypothesized that individual characteristics, such as being a female and self-rated poorer overall health are associated with poor satisfaction with sleep. In addition, poor satisfaction with sleep is associated with increasing underlying sleep problems and healthcare seeking behaviors. Participants and methods Study participants Study participants were members of the Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry of community-dwelling persons in the Pittsburgh, Pennsylvania region aged 60 or older. Registry members previously consented to being contacted for participation in Pepper-approved research studies, and are followed yearly to update their contact and basic health information. Data collection Survey packets containing an introduction to the study, consent form, mail survey, and a pre-addressed stamped return envelope were sent via the United States Postal Service (USPS) to 2064 Pepper registrants in February 2015. The survey was created based upon prior research and the objectives of this study using investigator developed questions and adapted items from validated sleep health questionnaires.16–18 Survey questions were designed to collect information on older adults' perceptions of sleep quality, satisfaction with sleep, and approaches used to alleviate sleep problems. Survey questions were vetted by the research team and piloted with multiple older adults in the community to ensure they were clear to study participants. Follow-up reminder postcards were sent out after the initial survey packet mailing and surveys were returned through April 2015. Surveys were returned by 1026 participants with a response rate of 49.7%. Eleven of the returned surveys were excluded from analyses due to missing information regarding sleep satisfaction, resulting in a final sample of 1015 participants. This study was approved by the Institutional Review Board at the University of Pittsburgh. Measures Overall satisfaction with sleep. Overall satisfaction with sleep quality was measured on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied) with the following survey item: “please rate your overall satisfaction with your sleep quality.” We classified participants into two groups based on their reported overall satisfaction with sleep quality. A participant was defined as “satisfied or neutral” (Group 1) if he/she reported being very satisfied, satisfied, or neutral
(neither satisfied nor dissatisfied) with sleep quality. Participants that reported being “dissatisfied” or “very dissatisfied” were classified as “dissatisfied” (Group 2). Participant characteristics: Demographics, overall health, and health behaviors. Participant characteristics that were potentially associated with poor satisfaction with sleep, which included demographics, overall health, and health behaviors, were collected by the Pepper registry database and linked to survey responses. Participant demographics included age, gender, marital status, race, and educational attainment. To assess overall health, participants' self-rated health (excellent, very good, good, fair/poor), pain (never, sometimes, or often/always have pain), and number of reported comorbidities were used from the registry database. Health behaviors were assessed by participants' reported participation in physical activity (daily, N3 times a week, b3 times a week, or none), and smoking (not at all, some days, and every day) and drinking (not at all or yes) behaviors in the past 30 days. Sleep problems. Problems with sleep were assessed with three survey items. To assess sleep problems, participants were asked “how often do you have trouble sleeping at night?” Responses included a range from 1 to 3 nights per week to 1 to 2 nights per year, or never. Participants were asked to select troublesome aspects of sleep, with responses such as trouble falling asleep, excessively sleepy during the day, or other with the request to specify if not listed. To assess the potential causes of sleep problems, participants were asked “do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months?” Participants were asked to select from responses that included work hours and/or demands of work, emotional stress from work-related activities, family commitments, changing circadian rhythms, or another specified reason. Healthcare seeking behaviors. Participants' healthcare seeking behaviors and coping strategies to address sleep problems were assessed using five survey items. Participants were asked to answer yes or no to the following questions to assess healthcare seeking behaviors regarding sleep problems: “have you ever been diagnosed with a sleep condition by a doctor”; “have you ever discussed sleep problems with a health care provider?”; “have you ever used OTC sleep aid medication?”? and “have you ever used prescription sleep aid medication?” To assess coping strategies for sleep problems, participants were asked “do you use any of the following methods regularly to help you fall sleep?” Examples of responses included reading, watching TV, or taking an over-the-counter (OTC) or prescription medication. Statistical data analysis Based on findings from previous research and our study objectives, we hypothesized that participants less satisfied with sleep would report poorer overall health, unfavorable health behavior, more sleep problems, and healthcare seeking behaviors such as consulting a healthcare provider or using various strategies (eg, OTC or prescription medications, reading before bed) to help improve sleep. We also investigated gender differences in poor satisfaction with sleep, sleep disturbances, and healthcare seeking behaviors. In order to provide meaningful comparison and to identify factors associated with poor satisfaction with sleep, the responses to the question of sleep quality were collapsed into two groups: Group 1 Satisfied or neutral about their sleep quality, included very satisfied, satisfied, and neutral (neither satisfied nor dissatisfied); and Group 2 – Dissatisfied, included dissatisfied and very dissatisfied (see Table 1). To test our first hypothesis, descriptive and bivariate analyses were used to describe the characteristics of the sample in the two groups. Multiple logistic regression models were used to
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
O. Abraham et al. / Sleep Health xxx (2016) xxx–xxx
examine the associations between sleep satisfaction and participants' characteristics, including demographics, overall health status, and health behaviors (see Table 2). To test our second hypothesis, descriptive analyses were conducted to assess the association between sleep problems, healthcare seeking behaviors, and sleep satisfaction (see Tables 3 and 4). P b .05 was considered to be evidence of a statistical trend, and 95% confidence intervals were calculated. Sensitivity analyses were conducted using sequential imputations to account for missing data from survey responses. All survey items had a missing rate of no more than 5%. Statistical analyses were performed using
Table 1 Participants' Characteristics
Total number (N, %) Demographics (N, %) Age (year) 60–69 70–7 80–89 90+ Female Marital status Married Single (never married) Widowed Divorced/separated Missing/skipped Race Non-hispanic white Non-hispanic Black Other race (includes those of hispanic ethnicity) Missing/skipped Education More than 4-year college degree Some college/4-year college degree HS degree/GED or less Missing/skipped Overall health (N, %) Self-rated health Excellent Very good Good Fair/poor Missing/skipped Pain Never have pain Sometimes have pain Often/always have pain Missing/skipped Number of comorbidities (mean, SD) Health behavior (N, %) Participation in physical activity Daily N3 times a week b3 times a week No Missing/skipped Smoking Not at all Every day & some days Missing/skipped Drinking Not at all Yes Missing/skipped
Group 1 Satisfied or neutral
Group 2 Dissatisfied
819 (80.7)
196 (19.3)
115 (14.0) 390 (47.6) 274 (33.5) 40 (4.9) 480 (58.6)
30 (15.3) 92 (46.9) 57 (29.1) 17 (8.7) 130 (66.3)
490 (59.8) 78 (9.5) 175 (21.4) 68 (8.3) 8 (1.0)
93 (47.5) 28 (14.3) 51 (26.0) 24 (12.2) 0 (0.0)
747 (91.2) 50 (6.1) 15 (1.8)
175 (89.3) 15 (7.7) 5 (2.6)
7 (0.9)
1 (0.5)
399 (48.7) 287 (35.0) 126 (15.4) 7 (0.9)
105 (53.6) 67 (34.2) 20 (10.2) 4 (2.0)
88 (10.7) 343 (41.9) 300 (36.6) 68 (8.3) 20 (2.4)
17 (8.7) 50 (25.5) 90 (45.9) 32 (16.3) 7 (3.6)
121 (14.8) 464 (56.7) 221 (27.0) 13 (1.6) 1.87 (1.18)
24 (12.2) 100 (51.0) 72 (36.7) 0 (0.0) 2.13 (1.22)
192 (23.4) 211 (25.8) 189 (23.1) 197 (24.1) 30 (3.7)
32 (16.3) 54 (27.6) 45 (23.0) 49 (25.0) 16 (8.2)
759 (92.7) 21 (2.6) 39 (4.8)
174 (88.8) 9 (4.6) 13 (6.6)
262 (32.0) 528 (64.5) 29 (3.5)
73 (37.2) 116 (59.2) 7 (3.6)
P
0.16
0.05 b0.01
0.59
0.15
3
Table 2 Factors Associated with Poor Satisfaction: Multiple Logistic Regression (Reference Group = Satisfied/Neutral)
Demographics Age (year) 60–69 70–79 80–89 90+ Female Marital status Married Single (Never married) Widowed Divorced/separated Race Non-hispanic white Non-hispanic black Other Education More than 4-year college degree Some college/4-year college degree HS degree/GED or less Overall health Self-rated health Excellent Very good good Fair/poor Pain Never have pain Sometimes have pain Often/always have pain Health behavior Participation in physical activity Daily N3 times a week b3 times a week No Current smoking Not at all Every day and some days Current drinking Not at all Yes
Adjusted odds ratio
95% Confidence interval
Ref 0.97 0.81 1.41 1.34
Ref 0.59–1.58 0.46–1.41 0.64–3.12 0.92–1.94
Ref 1.80 1.74 1.33
Ref 1.07–3.04 0.99–3.05 0.85–2.08
Ref 0.85 1.23
Ref 0.43–1.66 0.43–3.58
Ref 0.48
Ref 0.27–0.84
0.81
0.57–1.17
Ref 0.68 1.54 2.26
Ref 0.36–1.27 0.82–2.86 1.05–4.85
Ref 1.03 1.34
Ref 0.62–1.74 0.76–2.35
Ref 1.63 1.39 1.15
Ref 0.99–2.66 0.84–2.29 0.68–1.94
Ref 1.85
Ref 0.78–4.42
Ref 0.96
Ref 0.66–1.39
b0.01
0.03
Stata statistical software (version 13; Stata Corp, College Station, TX) and SAS (version 9.3; SAS Institute, Inc, Cary, NC).
Results b0.01 0.30
0.12
0.16
Table 1 describes the characteristics of survey respondents. Study participants were well-educated and reported healthy lifestyles, more than 80% having a college degree or higher and the majority (N90%) being non-smokers. A total of 819 (80.7%) participants indicated they were “satisfied or neutral” when asked to rate their overall sleep quality (Group 1), while 196 (19.3%) reported they were “dissatisfied” (Group 2). There were statistical trends towards differences in gender, marital status, self-rated health, pain, and number of comorbidities between the groups. Dissatisfied participants were more likely to not be married (52.5% vs. 40.2%, P b .01). These participants also reported poorer overall health status compared to participants who were satisfied with their sleep quality (self-rated poor health: 16.3% vs. 8.3%, P b .01; always have pain: 36.7% vs. 27.0%, P = .03; number of comorbidities: 2.13 vs. 1.87, P b .01).
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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Table 3 Sleep Problems and Healthcare Seeking Behaviors by Sleep Satisfaction
Total Number (N, %) Sleep problems (N, %) How often do you have trouble sleeping at night? Every Night 4–6 Nights Per Week 1–3 Nights Per Week 2–3 Nights Per Month 1 Nights Per Month b1 Nights Per Month 1–2 Nights Per Year Never missing/skipped Troublesome aspects of sleep: Trouble falling asleep Trouble sleeping throughout the night Wake up too early in the morning Nightmares Excessively sleepy during the day Other No trouble sleeping at night Do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months? Work hours and/or demands of work Emotional stress from work-related activities Family commitments Changing circadian rhythms Other Healthcare seeking behavior and coping strategy Ever been diagnosed with a sleep condition by a doctor: Yes No Missing/skipped Have you ever discussed sleep problems with a healthcare provider Yes No Missing/skipped OTC sleep aids (ever use) Yes No Missing/skipped Prescription sleep aids (ever use) Yes No Missing/skipped Do you use any of the following methods regularly to help you fall asleep? (Top three) Reading Taking OTC or prescription Watching TV
Group 1, not dissatisfied (satisfied or neutral)
Group 2, dissatisfied
n = 819 (80.7)
n = 196 (19.3)
25 (3.1) 25 (3.1) 123 (15.0) 201 (24.5) 121 (14.8) 121 (14.8) 110 (13.4) 87 (10.6) 6 (0.7)
63 (32.1) 46 (23.5) 53 (27.0) 13 (6.6) 5 (2.6) 5 (2.6) 4 (2.0) 4 (2.0) 2 (1.0)
157 (19.2) 343 (41.9) 173 (21.1) 29 (3.5) 62 (7.6) 109 (13.3) 214 (26.1)
97 (49.5) 153 (78.1) 73 (37.5) 12 (6.1) 28 (14.3) 36 (18.4) 12 (6.1)
b0.01 b0.01 b0.01 0.16 0.01 0.09 b0.01
45 (6.0) 33 (4.4) 95 (12.6) 55 (7.5) 69 (16.7)
18 (10.7) 20 (11.8) 38 (22.8) 35 (22.3) 33 (34.4)
0.06 b0.01 b0.01 b0.01 b0.01
104 (12.7) 698 (85.2) 17 (2.1)
30 (15.3) 164 (83.7) 2 (1.0)
196 (23.9) 620 (75.7) 3 (0.4)
107 (54.6) 88 (44.9) 1 (0.5)
145 (17.7) 674 (82.3) 0 (0.0)
70 (35.7) 126 (64.3) 0 (0.0)
79 (9.7) 734 (89.6) 6 (0.7)
43 (21.9) 153 (78.1) 0 (0.0)
339 (41.4) 119 (14.5) 233 (28.5)
90 (45.9) 66 (33.7) 72 (36.7)
P
b0.01
0.36
b0.01
b0.01
b0.01
0.04 b0.01 b0.01
Participants' characteristics and satisfaction with sleep quality
Sleep problems, healthcare seeking behaviors and coping strategy
Based on the multiple logistic regression results shown in Table 2, the likelihood of reporting poor satisfaction with sleep was higher among single (never married) compared with married participants (Adjusted odds ratio/AOR: 1.80, 95% confidence interval/CI: 1.07–3.04) and self-rated fair/poor health status compared to excellent health status (AOR: 2.26, 95% CI: 1.05–4.85), and lower among participants with some college/4-year college degree compared to more than 4 year college degree (AOR: 0.48, 95% CI: 0.27–0.84). There were no statistical trends in differences between age, gender, race, health behaviors, or experience of pain between the two groups, and thus our hypothesis regarding the association between these demographic variables and poor satisfaction with sleep was not supported. The count of comorbidities variable was excluded from the multiple logistic regression model due to its collinearity with selfrated health status.
Participants that reported poor satisfaction with sleep were more likely to state they had sleep problems, including trouble sleeping at night (Table 3). These participants reported greater frequency of all aspects of troublesome sleep except “nightmares” (P b .05). Most reported trouble sleeping throughout the night (78.1%), half trouble falling asleep (49.5%), and more than one third “waking up too early in the morning” (37.5%). Similarly, participants that reported poor satisfaction with sleep were also more likely to report they had used OTC and prescription sleep medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to help improve sleep quality (P b .05). There was no statistical trend in “diagnosed with a sleep condition by a doctor” between participants who were satisfied/neutral or dissatisfied regarding their sleep quality. The most frequently reported sleep problem was trouble sleeping throughout the night (N = 496). Among participants with sleep
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
O. Abraham et al. / Sleep Health xxx (2016) xxx–xxx
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Table 4 Healthcare seeking behaviors by sleep problem. Trouble sleeping throughout the night (n = 496) Have discussed sleep problems with a healthcare provider (N, %) Have been diagnosed with a sleep condition (N, %) Ever uses OTC sleep aids (N, %) Uses prescription sleep aids (N, %)
120 (47.2) 41 (16.1) 98 (38.6) 51 (20.1)
problems, a higher proportion with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) and prescription (20.1%) sleep aids, while participants with trouble falling asleep had a higher proportion of being diagnosed with a sleep condition (28.9%). These results are shown in Table 4. Sensitivity analysis was conducted to test the impact of missing data by comparing the multiple logistic regression results using multiple imputations to complete case analysis and we found no significant difference in study results. Discussion Study findings indicate that a number of community-dwelling older adults have poor satisfaction with their sleep quality. This has important implications for healthcare providers caring for older adult patients. Participants in this study who reported poor satisfaction with sleep were more likely to be single and have poorer overall health compared to participants who were satisfied with their sleep. Additionally, participants who were less satisfied with sleep and those who reported trouble sleeping throughout the night were more likely to report they had used OTC and prescription medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to improve sleep. A total of 19.3% of survey respondents reported being “dissatisfied” with their overall sleep quality; which is consistent with previous research involving older adults on self-reported sleep disturbance or tiredness.19 Participants who were less satisfied with their sleep were more likely to be single and reported poorer overall health status. This finding is consistent with previous research which suggests that older adults often have chronic health conditions which prevent them from getting a good night's sleep. 13 Healthy older adults experience much less sleep disturbance than those with comorbidities,20 and individuals with more severe chronic conditions often report worse sleep health. 21 Since single older adults with poorer overall health are more likely to report poor satisfaction with sleep, such individuals can be targeted for educational interventions that improve sleep hygiene. When seeking to improve sleep quality, many older adults may overlook behavioral and environmental interventions and instead seek to address their sleep difficulties with prolonged use of OTC medications. As buttressed by findings from this study, participants that reported poor satisfaction with sleep were more likely to have used OTC and prescription sleep medications and report poorer overall health. Previous research has shown that as many as 5.5% of adults age 60 to 69 and 7% of adults age 80 and older are taking a prescription sleep aid. 22 About 17% of older adults who reported regular sleeplessness symptoms are taking an OTC sleep medication containing diphenhydramine or doxylamine, which are not recommended for use by the elderly and may increase the risk of anticholinergicrelated adverse events.13,23,24 OTC sleep medications can be especially problematic in the elderly because they may cause prolonged sedation effects resulting in increased risk of impaired cognition and falls. 25 Consequently, education and policy initiatives that promote appropriate sleep hygiene behaviors and safe use of OTC sleep
Wake up too early in the morning (n = 246) 199 (40.1) 70 (14.1) 140 (28.2) 76 (15.3)
Nightmares (n = 41) 102 (41.5) 39 (15.9) 70 (28.5) 41 (16.7)
Excessively sleepy during the day (n = 90) 17 (41.5) 4 (9.8) 10 (24.4) 10 (24.4)
Trouble falling asleep (n = 254) 38 (42.2) 26 (28.9) 26 (28.9) 18 (20.0)
medications, particularly for older adults with comorbidities, are critically needed. Older adults should receive education regarding different non-pharmacological methods to improve their sleep quality, which include physical therapy, mindfulness interventions, yoga, therapeutic massage, and acupuncture.26 It is important to note that sleep hygiene modifications and other approaches, such as the use of OTC medications, may not address the underlying causes of insomnia, which is distinguished from sleep disturbance or general poor sleep quality. 13 The potential for insomnia disorder in individuals who report sleep disturbances and the need for appropriate treatment for this condition are important considerations for healthcare providers when discussing sleep quality with older adult patients. It is imperative for healthcare providers to address poor satisfaction with sleep with elderly patients because they rarely discuss sleep complaints during routine clinic visits, and may inappropriately use OTC or prescription sleep medications. 13,27 In this study, nearly half of participants who had trouble sleeping throughout the night reported seeking consultation from their healthcare provider (47.2%), and a similar rate was reported by those who reported having trouble falling sleep (42.2%). Previous research found that only 58% of patients told their physicians about their recent and past OTC medication use.28 Discussions about the use of OTC medications with healthcare providers can facilitate conversations about common sleep disturbances to determine more safe and effective approaches to improve older adults' sleep quality. Findings from this study highlight the associations between reported poor satisfaction with sleep and healthcare seeking behaviors of older adults. Future studies should examine how to proactively identify older adults with sleep problems and increase awareness of recommended non-pharmacological approaches to improve sleep quality. This study has several study limitations. This was a crosssectional study, and data were limited to members of the Pepper Community Registry which is not a representative sample of older adults living in the United States. Registry participants had relatively high level of education and were primarily white, thus results are not generalizable to the overall older adult population in the United States. The results are also subject to the inherent limitation of selfreported data (recall bias), which relied on respondents to complete the surveys accurately. Future research can utilize not only selfreport but also objective measures of sleep such as polysomnography or actigraphy—a method of measuring sleep by recording wrist movement.29 It has been indicated that older adults may underreport the severity of sleep disturbances compared to objective methods using polysomnography, and use of this tool may provide a more accurate assessment of sleep quality.30 Conclusions In conclusion, our findings underscore the possible linkage between sleep satisfaction and older adults' healthcare seeking behaviors including the use of self-care methods, particularly OTC medications to cope with sleep problems, and the need for additional research. It is important that healthcare providers, such as physicians and pharmacists, discuss sleep health with older adult patients and
Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004
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provide education on appropriate sleep hygiene behaviors to improve sleep satisfaction. Author contributions All authors have contributed to this manuscript, revised and edited the manuscript, and approved the final version. Olufunmilola Abraham: study concept and design, acquisition of data, analysis and interpretation of data. Jia Pu: data analysis and interpretation and preparation of the manuscript. Loren J. Schleiden: data collection, analysis and interpretation and preparation of the manuscript. Steve M. Albert: study concept and design, data interpretation and analysis, and preparation of the manuscript. All authors state that they had complete access to the study data that support this publication. Sponsor's role None. Disclosure Dr Abraham has nothing to disclose. Dr Pu has nothing to disclose. Dr Schleiden has nothing to disclose. Dr Albert has nothing to disclose. Acknowledgments We acknowledge Amanda Brothers, Research Specialist, University of Pittsburgh, School of Pharmacy for editorial assistance in revising the final manuscript for publication. This research was supported by the AcademyHealth New Investigator Small Grant Program (NISGP). Results from this study were presented as a podium presentation at the AcademyHealth annual meeting on June 2016. The Pepper Community Registry is supported by the Pittsburgh Claude D. Pepper Older Americans Independence Center, NIH P30 AG024827. References 1. Hirshkowitz M, Whiton K, Albert SM, et al. National Sleep Foundation's sleep time duration recommendations: methodology and results summary. Sleep Health. 2015;1:40–43. 2. Bonnet MH, Arand DL. We are chronically sleep deprived. Sleep. 1995;18:908–911. 3. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation sleep in America survey. J Psychosom Res. 2004;56:497–502. 4. Kobayashi D, Takahashi O, Deshpande GA, Shimbo T, Fukui T. Association between osteoporosis and sleep duration in healthy middle-aged and elderly adults: a large-scale, cross-sectional study in Japan. Sleep Breath. 2012;16:579–583. 5. Centers for Disease Control and Prevention (CDC). Unhealthy sleep-related behaviors - 12 states, 2009. MMWR Morb Mortal Wkly Rep. 2011;60:233–238.
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Please cite this article as: Abraham O, et al, Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults, Sleep Health (2016), http://dx.doi.org/10.1016/j.sleh.2016.11.004