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Insomnia and depressive symptoms in patients with Parkinson's disease
Archives of Gerontology and Geriatrics 32 (2001) 23 – 33 www.elsevier.com/locate/archger
Insomnia and depressive symptoms in patients with Parkinson’s disease Relationship to health-related quality of life. An interview study of patients living at home Marianne Caap-Ahlgren *, Ove Dehlin Department of Community Medicine, Malmo¨ Uni6ersity Hospital, Lund Uni6ersity, 20502 Malmo¨, Sweden Received 12 September 2000; received in revised form 25 October 2000; accepted 26 October 2000
Abstract The objectives of this study were to describe the prevalence of insomnia and depressive symptoms in patients with Parkinson’s disease (PD) and to relate those symptoms to health-related quality of life. A total of 102 patients living at home, most of them moderately to severely disabled, were interviewed. Of them 43 patients were women with a mean age of 70 (range 58–79). The mean age for the men was 71 (range 56 – 80). Time since diagnosis was B2 years for 57%, 2–10 years for 31% and \ 10 years for 12%. The geriatric depression scale (GDS) and Livingston’s insomnia scale were used. The results were related to quality of life as measured with the SF-36 health survey. The prevalence of insomnia was 80%. Moderate depressive symptoms were found in 47% and severe depressive symptoms in 5%. Patients with insomnia or with depressive symptoms had a significantly impaired quality of life on all eight scales of the SF-36. In a stepwise regression analysis the presence of pain and ache and depressive symptoms were significantly related to insomnia. The variables most related to depressive symptoms were Hoehn and Yahr group and insomnia. Hoehn and Yahr groups (more disability) were significantly related to insomnia and depressive symptoms. Thus, insomnia and depressive symptoms are prevalent in PD and influence quality of life and should, therefore, be considered when evaluating patients with PD. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Depression; Geriatric depression scale; Insomnia; Parkinson’s disease; Quality of life * Corresponding author. Tel: +46-40-336878; fax: +46-40-336215. E-mail address: [email protected] (M. Caap-Ahlgren). 0167-4943/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 7 - 4 9 4 3 ( 0 0 ) 0 0 0 8 7 - X
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1. Introduction Parkinson’s disease (PD) is the second most prevalent neurodegenerative disorder after Alzheimer’s disease. In addition to motor disturbances, patients with PD also experience emotional, cognitive, sensorial and autonomic disorders that entail functional and psychosocial impairment (Martinez-Martin and Frades Payo, 1998). All these symptoms have a negative effect on the patients’ quality of life (Henneberg, 1998), and dissatisfaction with quality of life in PD has been attributed to locomotor disability, insomnia, depressive symptoms and a low degree of independence (Askenasy, 1993; Karlsen et al., 1999). Insomnia in a broad sense, including difficulties in falling asleep, disturbed sleep and early morning awakening, has been reported to have a high prevalence in population studies of old age groups, from about 30% to more than 50%, depending on definitions, types of instruments used and populations studied (Ganguli et al., 1996; Jensen et al., 1998; Maggi et al., 1998). Sleep in PD patients has been reported to be light and fragmented due to increased skeletal muscle activity, disturbed breathing and an impaired biological rhythm (Askenasy, 1993) and insomnia prevalence rates have varied from 18–88% depending on definitions and populations (Factor et al., 1990; Wagner et al., 1996). Depressive disorders in elderly non-PD populations have been reported in 9–19% (Jensen et al., 1994) and in 13 – 90% of PD patients (Mindham, 1970; Hoogendijk et al., 1998). This study is part of a larger investigation about health-related quality of life in PD patients using the SF-36 health survey (Sullivan et al., 1995). While depressive symptoms and insomnia are important aspects of quality of life, those aspects are not included in the SF-36 instrument. Therefore, interviews concerning those symptoms were added to widen the concept of health-related quality of life in PD patients.
2. Subjects and methods
2.1. Sample Every third patient registered between 1 January and 31 December, 1997 at the outpatient department of the neurology clinic at Lund University Hospital was invited to take part. In this way 124 patients were recruited. Only patients who lived at home were included, as patients living in nursing homes or other types of sheltered housing were treated by their GPs and were, therefore, not in the registry. A total of 20 patients refused to participate, mainly because they considered themselves too tired or too sick to take part. They did not differ from the participants regarding age, gender or duration of illness. Upon further investigation it was found that two of the patients did not have PD, and they were excluded. Thus, 102 patients remained; patient characteristics are shown in Table 1.
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2.2. Instruments Insomnia was diagnosed using Livingston’s questionnaire (Livingston et al., 1993). It comprises eight ‘yes/no’ questions about the following; difficulty falling asleep, taking or being dependent on medication to help one sleep, sleep interrupted during the night, difficulty sleeping owing to moods or tension, difficulty sleeping owing to pain or itching, inability to return to sleep after waking at night, waking early, feeling tired and sleeping more than 2 h during the day. Caseness is two or more positive answers. The scale has been shown to have construct validity (Livingston et al., 1993). Patients with no sleep problems (0–1 positive answers) were compared to patients with moderate and severe sleep problems (2–8 positive answers) with regard to the eight scales in the SF-36. Depressive symptoms were rated with the short, 15-item version of the geriatric depression scale (GDS). The scale has been shown to have satisfactory validity (Sheikh and Yesavage, 1986) and positive answers to 39 2 items is considered as normal, positive answers to 79 3 items as equivalent to slight depression, and positive answers to 1292 items as equivalent to a major depression (Sheikh and Yesavage, 1986). In this study patients with no or few depressive symptoms (0–4 positive answers) were compared with patients with moderate depressive symptoms (5– 9 positive answers) and to patients with severe depressive symptoms (10 –15 positive answers) with regard to the eight scales in the SF-36. Table 1 Demographic characteristics of the patients (N =102) Percent women Mean age, women Mean age, men Percent co-habiting with spouse or child Percent living alone in own home Time since diagnosis
Diagnosis before age 60 Classification according to Hoehn and Yahr
Drugs
43 70 (range 58–79) 71 (range 56–80) 90 10 B2 years 57% 2–10 years 31% \10 years 12% 11 women 18 men Group 1: 19% Group 2: 25% Group 3: 28% Group 4: 18% Group 5: 10% Levodopa 98% Apomorphine pump 2% Other anti-Parkinson drugs 20% Hypnotics 25% Anti-depressants 11% Cardiovascular drugs 39% Other drugs 35%
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The SF-36 is a health status survey instrument that was constructed to measure eight of the most important areas of health. A total of 35 items make up eight scales; physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. These eight areas are assumed to be universal and to represent basic human function and well being (Sullivan et al., 1995). Moreover, there is one item about changes in health over the past year. The SF-36 has been satisfactorily validated (Sullivan et al., 1995). Data about pain and ache were taken from the SF-36 instrument and related to insomnia and depressive symptoms. The patients were classified in five groups according to the degree of disability (Hoehn and Yahr, 1967). Patients in group 1 have minimal or no functional impairment, in group 2 patients have bilateral or midline involvement, but with no impairment of balance. In group 3 patients have significant tremor, rigidity and/or bradykinesia and mobility problems. In group 4, the patients have more pronounced disability, but are still mobile and able to function independently. In group 5, the patients are confined to bed or wheelchair unless aided. All interviews were carried out in the patients’ own homes by an experienced PD nurse (MCA).
2.3. Statistical methods Spearman’s r was used for correlation analysis. The Mann –Whitney U-test was used to compare patients with and without insomnia, and the Jonckheere –Terpstra test was used to compare patients with no or few depressive symptoms to those with moderate and severe depressive symptoms in relation to the eight scales in the SF-36. ANOVA was used to compare different Hoehn and Yahr groups with respect to insomnia and depressive symptoms. A stepwise regression analysis was performed with insomnia or depressive symptoms as dependent variables and age, time since diagnosis, magnitude of pain or ache over the last 4 weeks, Hoehn –Yahr group and depressive symptoms/insomnia as independent variables. A P-value of B 0.05 was considered statistically significant. Reliability was calculated according to Cronbach’s a.
2.4. Ethics The study was approved by the ethics committee of the University of Lund, LU 255-97.
3. Results Only a very few single answers were missing in the interviews. All patients (102) answered the sleep questions, but four patients were unable to take part in the whole interview with the depression questionnaire and were thus excluded.
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Table 2 Stepwise regression analysis of different variables on the presence of insomnia and depressive symptoms Variable
i
t
P-value
Insomnia Pain and ache Depressive symptoms Time since diagnosis Age Hoehn and Yahr group
0.40 0.28 0.11 0.01 0.10
4.3 3.1 1.2 0.012 1.0
0.000 0.003 ns ns ns
Depressi6e symptoms Hoehn and Yahr group Insomnia Pain and ache Time since diagnosis Age
0.39 0.27 0.05 −0.04 0.008
4.2 2.9 0.43 0.4 0.08
0.000 0.005 ns ns ns
The reliability of the insomnia scale as assessed with Cronbach’s a was 0.56. Using the criteria for insomnia as proposed by Livingston (two or more positive answers), 80% had insomnia. On the insomnia scale, 90% reported that their sleep was interrupted during the night and 68% reported waking early. There was a strong correlation between insomnia and depressive symptoms (PB 0.0003) and between insomnia and pain and ache (PB 0.0001). In the stepwise regression analysis with age, time since diagnosis, Hoehn and Yahr group, pain and ache and depressive symptoms, pain and ache and depressive symptoms were significantly correlated to insomnia (Table 2). Frequent, spontaneously reported reasons for the sleeping problems were stiffness/akinesia with difficulty in changing position in bed, pain, nycturia, sweating dreams/nightmares/hallucinations, anxiety and restless legs.
Table 3 Both patients with insomnia (Mann–Whitney U-test) and patients with moderate or severe depressive symptoms (Jonckheere–Terpstra test) had a significantly impaired quality of life in all the eight scales in the SF-36 SF-36 scale
Insomnia P
Depressive symptoms P
Physical function Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health
0.013 0.000 0.000 0.000 0.000 0.001 0.003 0.000
0.000 0.000 0.004 0.000 0.000 0.000 0.000 0.000
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Patients with insomnia had, compared with patients without sleep problems, a significantly impaired quality of life as measured with the SF-36 (Table 3). There was a significant difference in insomnia in different Hoehn and Yahr groups (P= 0.009), with higher groups reporting more insomnia. The reliability of the GDS scale as assessed with Cronbach’s a was 0.78. The prevalence of moderate depressive symptoms was 47%, and the prevalence of severe depressive symptoms was 5%. About 48% were considered to be non-depressed. Depressive symptoms were not related to pain and ache (P= 0.07). In the stepwise regression analysis with age, time since diagnosis, Hoehn and Yahr group, pain and ache and insomnia, Hoehn and Yahr group and insomnia were significantly correlated to depressive symptoms (Table 2). Frequent, spontaneously reported reasons for the depressive symptoms were that the spouse had not accepted the patient’s disease and wanted the patient to be more active, neighbours’ negative attitudes, the withdrawal of friends, and feelings of loneliness and isolation. Patients with depressive symptoms had, compared with those with no such symptoms, a significantly impaired quality of life as measured with the SF-36 (Table 3). There was a significant difference in depressive symptoms in different Hoehn and Yahr groups (P=0.000), with higher groups reporting more depressive symptoms.
4. Discussion This study has limitations. Only patients who lived at home were studied, and the most disabled PD patients, those living in sheltered housing or nursing homes, were, therefore, not included. Moreover, of the 124 patients invited, 20 patients refused to take part, mainly because they considered themselves too tired or too sick and two were misclassified. Many of the participating patients were, however, moderately or severely disabled and 28% belonged to groups 4 and 5 in the Hoehn and Yahr classification. A limitation of this classification is that it does not capture the fluctuations in functioning that many PD patients experience daily and hourly (Habermann, 1996). The GDS is a much used instrument with satisfactory validity (Sheikh and Yesavage, 1986), and the 15-item version was chosen because of the patients’ relatively high age and advanced disabilities. The reliability in this study, 0.78, was quite similar to that found in another study of PD patients (Jenkinson et al., 1995). The insomnia questionnaire was very simple to use, but the reliability was only 0.56. The SF-36 is a generic — not a disease-specific — instrument, and does not take into consideration specific parkinsonian symptoms. On the other hand, such an instrument makes comparisons with other patient populations possible. A diseasespecific PD quality-of-life instrument, such as the PDQ-39, has just one question about depression (felt depressed?) and one about sleep (had distressing dreams and hallucinations?) (Peto et al., 1998). Almost all (98%) of the patients were on levodopa drugs, which as a common side effect has confusion, hallucinations and insomnia. The 80% prevalence rate of
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Table 4 Prevalence of insomnia in PD patients in various studies Prevalence of insomnia
Study
66–88%
Factor et al. (1990) Starkstein et al. (1991) Wagner et al. (1996) Smith et al. 1997 Tandberg et al. (1998) Chrischilles et al. (1998) Stocchi et al. (1998) Karlsen et al. (1999) Present study
78–89% in patients with major depression, 31–100% in patients with minor depression, 23–68% in patients without depression 18% (in patients aged \65), 58% (in patients aged 41–64) Sometimes (men 41%, women 35%), often/always (men 25%, women 41%) 60% 57% 23% 73% 80%
insomnia found in this study can be compared with the original study using this sleep questionnaire with older non-PD individuals living at home in central areas of London (Livingston et al., 1993). In that study, the prevalence of insomnia was 33% in 1 particular year and 43% 2 years later in the same population. The prevalence of insomnia in older non-PD populations has been reported to be from about 30% to more than 50%, depending on definitions, types of instruments used and populations studied (Ganguli et al., 1996; Jensen et al., 1998; Maggi et al., 1998). The prevalence of insomnia is thus markedly higher in PD patients as compared with figures found in ‘normal’ elderly populations. Our prevalence of insomnia is comparable or slightly higher than that found in most other studies of PD patients (Table 4). When examining patients with PD, Starkstein found, in a stepwise regression analysis of the effect of depression scores on numerous clinical variables, that depression scores had the greatest effect on sleep disorders (Starkstein et al., 1991). In our study, however, the presence of pain and ache was even more strongly related to insomnia than depressive symptoms (Table 2). In an overview, Askenasy (1993) pointed out various factors that could negatively influence sleep in PD patients. These comprised muscle events, an imbalance between REM- and non-REM sleep, altered biological rhythms, altered breathing during sleep, and the effect of anti-parkinson medication on sleep. Motor disturbances and emotional, cognitive, sensorial and autonomic impairments can influence the patients’ quality of life in a negative way (Henneberg, 1998). Stiffness, pain, an inability or difficulty in turning over in bed during the night could also impair sleep.
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The 47% prevalence of moderate depressive symptoms and the 5% prevalence of severe depressive symptoms in PD patients are considerably higher than figures reported in ‘normal’ elderly populations, where prevalences from 9 to 20% are often found (Jensen et al., 1994). It is important, however, to point out that these figures need not be equivalent to moderate or severe depression as a clinical diagnosis based on an psychiatric interview was not performed. Our data are nevertheless, in agreement with findings in other studies of PD patients, where prevalence figures of up to 90% have been found (Table 5). In the stepwise regression analysis, in our study the significant variables for depressive symptoms were Hoehn and Yahr group and insomnia (Table 2). Martinez-Martin and Frades Payo (1998) found a strong relationship in PD patients between mood as measured with the 15-item version of the GDS and bodily pain, which was not found in this study. Our patients with insomnia or depressive symptoms had a significantly impaired quality of life on all eight scales in the SF-36 questionnaire (Table 3), i.e. poorer physical function, emotional function and general health as experienced by the patients. Hobson found a strong relationship between depressive symptoms in PD patients as measured with the GDS 15 and a poorer quality of life using a specific instrument, the Parkinson Disease Quality of Life Measure (PDQL), (Hobson et al., 1999). Likewise, Karlsen et al. (1999) found in their study of PD patients that of the variables studied, depressive symptoms and self-reported insomnia most strongly predicted impaired quality of life as studied with the Nottingham Health Table 5 Prevalence of depression in PD patients in various studies Prevalence of depression
Study
20% 40% 63% 90% 52% 37% (varying from 18–50% depending on disease stage)
Patrick and Levy (1922) Mjones (1949) Warburton (1967) Mindham (1970) Brown and Wilson (1972) Celesia and Wanamaker (1972) Mindham et al. (1976) Lieberman et al. (1979) Mayeux et al. (1981) Mayeux et al. (1984) Starkstein et al. (1990) Cummings (1992) Wagner et al. (1996) Hoogendijk et al., (1998) Starkstein et al. (1998) Chrischilles et al., (1998) Aarsland et al. (1999) Meara et al. (1999) Present study
48% 29% 49% 14% (dysthymia), 27% (major depression) 20% (minor depression), 21% (major depression) 40% 37% (patients aged \65), 73% (patients aged 41–64) 13–23% (major depression) 31% (dysthymia), major depression 15% and 38%a 26–60% 38% 64% Moderate depressive symptoms 47%, severe depressive symptoms 5% a
Akinetic-rigid PD 38%; classic PD 15%.
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Profile, but nevertheless only explained a fraction of the total variance. Thus, irrespective of the type of quality of life instrument used in PD patients — either disease-specific instruments or, as in this study, generic health-related instruments — the negative correlation between insomnia and depressive symptoms and quality of life remains. The prevalence of insomnia and depressive symptoms found in this study was not lower, but fairly similar to earlier findings, Table 4 and Table 5. Better drug treatment during later years and an increased awareness of physiotherapy for the maintenance of mobility might change the disease process and decrease the patients’ disabilities. This was not, however, reflected in a lower prevalence of insomnia and depressive symptoms in this study as compared with older ones. The neurologic symptoms in PD might predominate to a large extent over other symptoms, such as depressive symptoms and insomnia, and there could be a risk that those symptoms are overlooked when the patients are examined. Level of disability as measured with the Hoehn and Yahr classification was strongly related to more insomnia and more depressive symptoms in this study. Therefore, to influence on those symptoms optimal treatment of the disease is of utter importance. In conclusion, this study has shown a high prevalence of insomnia and depressive symptoms in PD patients, and that those symptoms have a negative influence on health-related quality of life. Consequently, insomnia and depressive symptoms should be taken into consideration, when evaluating patients with PD.
Acknowledgements This study was supported by Va˚rdalstiftelsen (project no. V97/192) and Ra˚det fo¨r Ha¨lso-och sjukva˚rdsforskning (project no. 146/1997).
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Insomnia and depressive symptoms in patients with Parkinson’s disease Relationship to health-related quality of life. An interview study of patients living at home Marianne Caap-Ahlgren *, Ove Dehlin Department of Community Medicine, Malmo¨ Uni6ersity Hospital, Lund Uni6ersity, 20502 Malmo¨, Sweden Received 12 September 2000; received in revised form 25 October 2000; accepted 26 October 2000
Abstract The objectives of this study were to describe the prevalence of insomnia and depressive symptoms in patients with Parkinson’s disease (PD) and to relate those symptoms to health-related quality of life. A total of 102 patients living at home, most of them moderately to severely disabled, were interviewed. Of them 43 patients were women with a mean age of 70 (range 58–79). The mean age for the men was 71 (range 56 – 80). Time since diagnosis was B2 years for 57%, 2–10 years for 31% and \ 10 years for 12%. The geriatric depression scale (GDS) and Livingston’s insomnia scale were used. The results were related to quality of life as measured with the SF-36 health survey. The prevalence of insomnia was 80%. Moderate depressive symptoms were found in 47% and severe depressive symptoms in 5%. Patients with insomnia or with depressive symptoms had a significantly impaired quality of life on all eight scales of the SF-36. In a stepwise regression analysis the presence of pain and ache and depressive symptoms were significantly related to insomnia. The variables most related to depressive symptoms were Hoehn and Yahr group and insomnia. Hoehn and Yahr groups (more disability) were significantly related to insomnia and depressive symptoms. Thus, insomnia and depressive symptoms are prevalent in PD and influence quality of life and should, therefore, be considered when evaluating patients with PD. © 2001 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Depression; Geriatric depression scale; Insomnia; Parkinson’s disease; Quality of life * Corresponding author. Tel: +46-40-336878; fax: +46-40-336215. E-mail address: [email protected] (M. Caap-Ahlgren). 0167-4943/01/$ - see front matter © 2001 Elsevier Science Ireland Ltd. All rights reserved. PII: S 0 1 6 7 - 4 9 4 3 ( 0 0 ) 0 0 0 8 7 - X
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1. Introduction Parkinson’s disease (PD) is the second most prevalent neurodegenerative disorder after Alzheimer’s disease. In addition to motor disturbances, patients with PD also experience emotional, cognitive, sensorial and autonomic disorders that entail functional and psychosocial impairment (Martinez-Martin and Frades Payo, 1998). All these symptoms have a negative effect on the patients’ quality of life (Henneberg, 1998), and dissatisfaction with quality of life in PD has been attributed to locomotor disability, insomnia, depressive symptoms and a low degree of independence (Askenasy, 1993; Karlsen et al., 1999). Insomnia in a broad sense, including difficulties in falling asleep, disturbed sleep and early morning awakening, has been reported to have a high prevalence in population studies of old age groups, from about 30% to more than 50%, depending on definitions, types of instruments used and populations studied (Ganguli et al., 1996; Jensen et al., 1998; Maggi et al., 1998). Sleep in PD patients has been reported to be light and fragmented due to increased skeletal muscle activity, disturbed breathing and an impaired biological rhythm (Askenasy, 1993) and insomnia prevalence rates have varied from 18–88% depending on definitions and populations (Factor et al., 1990; Wagner et al., 1996). Depressive disorders in elderly non-PD populations have been reported in 9–19% (Jensen et al., 1994) and in 13 – 90% of PD patients (Mindham, 1970; Hoogendijk et al., 1998). This study is part of a larger investigation about health-related quality of life in PD patients using the SF-36 health survey (Sullivan et al., 1995). While depressive symptoms and insomnia are important aspects of quality of life, those aspects are not included in the SF-36 instrument. Therefore, interviews concerning those symptoms were added to widen the concept of health-related quality of life in PD patients.
2. Subjects and methods
2.1. Sample Every third patient registered between 1 January and 31 December, 1997 at the outpatient department of the neurology clinic at Lund University Hospital was invited to take part. In this way 124 patients were recruited. Only patients who lived at home were included, as patients living in nursing homes or other types of sheltered housing were treated by their GPs and were, therefore, not in the registry. A total of 20 patients refused to participate, mainly because they considered themselves too tired or too sick to take part. They did not differ from the participants regarding age, gender or duration of illness. Upon further investigation it was found that two of the patients did not have PD, and they were excluded. Thus, 102 patients remained; patient characteristics are shown in Table 1.
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2.2. Instruments Insomnia was diagnosed using Livingston’s questionnaire (Livingston et al., 1993). It comprises eight ‘yes/no’ questions about the following; difficulty falling asleep, taking or being dependent on medication to help one sleep, sleep interrupted during the night, difficulty sleeping owing to moods or tension, difficulty sleeping owing to pain or itching, inability to return to sleep after waking at night, waking early, feeling tired and sleeping more than 2 h during the day. Caseness is two or more positive answers. The scale has been shown to have construct validity (Livingston et al., 1993). Patients with no sleep problems (0–1 positive answers) were compared to patients with moderate and severe sleep problems (2–8 positive answers) with regard to the eight scales in the SF-36. Depressive symptoms were rated with the short, 15-item version of the geriatric depression scale (GDS). The scale has been shown to have satisfactory validity (Sheikh and Yesavage, 1986) and positive answers to 39 2 items is considered as normal, positive answers to 79 3 items as equivalent to slight depression, and positive answers to 1292 items as equivalent to a major depression (Sheikh and Yesavage, 1986). In this study patients with no or few depressive symptoms (0–4 positive answers) were compared with patients with moderate depressive symptoms (5– 9 positive answers) and to patients with severe depressive symptoms (10 –15 positive answers) with regard to the eight scales in the SF-36. Table 1 Demographic characteristics of the patients (N =102) Percent women Mean age, women Mean age, men Percent co-habiting with spouse or child Percent living alone in own home Time since diagnosis
Diagnosis before age 60 Classification according to Hoehn and Yahr
Drugs
43 70 (range 58–79) 71 (range 56–80) 90 10 B2 years 57% 2–10 years 31% \10 years 12% 11 women 18 men Group 1: 19% Group 2: 25% Group 3: 28% Group 4: 18% Group 5: 10% Levodopa 98% Apomorphine pump 2% Other anti-Parkinson drugs 20% Hypnotics 25% Anti-depressants 11% Cardiovascular drugs 39% Other drugs 35%
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The SF-36 is a health status survey instrument that was constructed to measure eight of the most important areas of health. A total of 35 items make up eight scales; physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health. These eight areas are assumed to be universal and to represent basic human function and well being (Sullivan et al., 1995). Moreover, there is one item about changes in health over the past year. The SF-36 has been satisfactorily validated (Sullivan et al., 1995). Data about pain and ache were taken from the SF-36 instrument and related to insomnia and depressive symptoms. The patients were classified in five groups according to the degree of disability (Hoehn and Yahr, 1967). Patients in group 1 have minimal or no functional impairment, in group 2 patients have bilateral or midline involvement, but with no impairment of balance. In group 3 patients have significant tremor, rigidity and/or bradykinesia and mobility problems. In group 4, the patients have more pronounced disability, but are still mobile and able to function independently. In group 5, the patients are confined to bed or wheelchair unless aided. All interviews were carried out in the patients’ own homes by an experienced PD nurse (MCA).
2.3. Statistical methods Spearman’s r was used for correlation analysis. The Mann –Whitney U-test was used to compare patients with and without insomnia, and the Jonckheere –Terpstra test was used to compare patients with no or few depressive symptoms to those with moderate and severe depressive symptoms in relation to the eight scales in the SF-36. ANOVA was used to compare different Hoehn and Yahr groups with respect to insomnia and depressive symptoms. A stepwise regression analysis was performed with insomnia or depressive symptoms as dependent variables and age, time since diagnosis, magnitude of pain or ache over the last 4 weeks, Hoehn –Yahr group and depressive symptoms/insomnia as independent variables. A P-value of B 0.05 was considered statistically significant. Reliability was calculated according to Cronbach’s a.
2.4. Ethics The study was approved by the ethics committee of the University of Lund, LU 255-97.
3. Results Only a very few single answers were missing in the interviews. All patients (102) answered the sleep questions, but four patients were unable to take part in the whole interview with the depression questionnaire and were thus excluded.
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Table 2 Stepwise regression analysis of different variables on the presence of insomnia and depressive symptoms Variable
i
t
P-value
Insomnia Pain and ache Depressive symptoms Time since diagnosis Age Hoehn and Yahr group
0.40 0.28 0.11 0.01 0.10
4.3 3.1 1.2 0.012 1.0
0.000 0.003 ns ns ns
Depressi6e symptoms Hoehn and Yahr group Insomnia Pain and ache Time since diagnosis Age
0.39 0.27 0.05 −0.04 0.008
4.2 2.9 0.43 0.4 0.08
0.000 0.005 ns ns ns
The reliability of the insomnia scale as assessed with Cronbach’s a was 0.56. Using the criteria for insomnia as proposed by Livingston (two or more positive answers), 80% had insomnia. On the insomnia scale, 90% reported that their sleep was interrupted during the night and 68% reported waking early. There was a strong correlation between insomnia and depressive symptoms (PB 0.0003) and between insomnia and pain and ache (PB 0.0001). In the stepwise regression analysis with age, time since diagnosis, Hoehn and Yahr group, pain and ache and depressive symptoms, pain and ache and depressive symptoms were significantly correlated to insomnia (Table 2). Frequent, spontaneously reported reasons for the sleeping problems were stiffness/akinesia with difficulty in changing position in bed, pain, nycturia, sweating dreams/nightmares/hallucinations, anxiety and restless legs.
Table 3 Both patients with insomnia (Mann–Whitney U-test) and patients with moderate or severe depressive symptoms (Jonckheere–Terpstra test) had a significantly impaired quality of life in all the eight scales in the SF-36 SF-36 scale
Insomnia P
Depressive symptoms P
Physical function Role physical Bodily pain General health Vitality Social functioning Role emotional Mental health
0.013 0.000 0.000 0.000 0.000 0.001 0.003 0.000
0.000 0.000 0.004 0.000 0.000 0.000 0.000 0.000
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Patients with insomnia had, compared with patients without sleep problems, a significantly impaired quality of life as measured with the SF-36 (Table 3). There was a significant difference in insomnia in different Hoehn and Yahr groups (P= 0.009), with higher groups reporting more insomnia. The reliability of the GDS scale as assessed with Cronbach’s a was 0.78. The prevalence of moderate depressive symptoms was 47%, and the prevalence of severe depressive symptoms was 5%. About 48% were considered to be non-depressed. Depressive symptoms were not related to pain and ache (P= 0.07). In the stepwise regression analysis with age, time since diagnosis, Hoehn and Yahr group, pain and ache and insomnia, Hoehn and Yahr group and insomnia were significantly correlated to depressive symptoms (Table 2). Frequent, spontaneously reported reasons for the depressive symptoms were that the spouse had not accepted the patient’s disease and wanted the patient to be more active, neighbours’ negative attitudes, the withdrawal of friends, and feelings of loneliness and isolation. Patients with depressive symptoms had, compared with those with no such symptoms, a significantly impaired quality of life as measured with the SF-36 (Table 3). There was a significant difference in depressive symptoms in different Hoehn and Yahr groups (P=0.000), with higher groups reporting more depressive symptoms.
4. Discussion This study has limitations. Only patients who lived at home were studied, and the most disabled PD patients, those living in sheltered housing or nursing homes, were, therefore, not included. Moreover, of the 124 patients invited, 20 patients refused to take part, mainly because they considered themselves too tired or too sick and two were misclassified. Many of the participating patients were, however, moderately or severely disabled and 28% belonged to groups 4 and 5 in the Hoehn and Yahr classification. A limitation of this classification is that it does not capture the fluctuations in functioning that many PD patients experience daily and hourly (Habermann, 1996). The GDS is a much used instrument with satisfactory validity (Sheikh and Yesavage, 1986), and the 15-item version was chosen because of the patients’ relatively high age and advanced disabilities. The reliability in this study, 0.78, was quite similar to that found in another study of PD patients (Jenkinson et al., 1995). The insomnia questionnaire was very simple to use, but the reliability was only 0.56. The SF-36 is a generic — not a disease-specific — instrument, and does not take into consideration specific parkinsonian symptoms. On the other hand, such an instrument makes comparisons with other patient populations possible. A diseasespecific PD quality-of-life instrument, such as the PDQ-39, has just one question about depression (felt depressed?) and one about sleep (had distressing dreams and hallucinations?) (Peto et al., 1998). Almost all (98%) of the patients were on levodopa drugs, which as a common side effect has confusion, hallucinations and insomnia. The 80% prevalence rate of
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Table 4 Prevalence of insomnia in PD patients in various studies Prevalence of insomnia
Study
66–88%
Factor et al. (1990) Starkstein et al. (1991) Wagner et al. (1996) Smith et al. 1997 Tandberg et al. (1998) Chrischilles et al. (1998) Stocchi et al. (1998) Karlsen et al. (1999) Present study
78–89% in patients with major depression, 31–100% in patients with minor depression, 23–68% in patients without depression 18% (in patients aged \65), 58% (in patients aged 41–64) Sometimes (men 41%, women 35%), often/always (men 25%, women 41%) 60% 57% 23% 73% 80%
insomnia found in this study can be compared with the original study using this sleep questionnaire with older non-PD individuals living at home in central areas of London (Livingston et al., 1993). In that study, the prevalence of insomnia was 33% in 1 particular year and 43% 2 years later in the same population. The prevalence of insomnia in older non-PD populations has been reported to be from about 30% to more than 50%, depending on definitions, types of instruments used and populations studied (Ganguli et al., 1996; Jensen et al., 1998; Maggi et al., 1998). The prevalence of insomnia is thus markedly higher in PD patients as compared with figures found in ‘normal’ elderly populations. Our prevalence of insomnia is comparable or slightly higher than that found in most other studies of PD patients (Table 4). When examining patients with PD, Starkstein found, in a stepwise regression analysis of the effect of depression scores on numerous clinical variables, that depression scores had the greatest effect on sleep disorders (Starkstein et al., 1991). In our study, however, the presence of pain and ache was even more strongly related to insomnia than depressive symptoms (Table 2). In an overview, Askenasy (1993) pointed out various factors that could negatively influence sleep in PD patients. These comprised muscle events, an imbalance between REM- and non-REM sleep, altered biological rhythms, altered breathing during sleep, and the effect of anti-parkinson medication on sleep. Motor disturbances and emotional, cognitive, sensorial and autonomic impairments can influence the patients’ quality of life in a negative way (Henneberg, 1998). Stiffness, pain, an inability or difficulty in turning over in bed during the night could also impair sleep.
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The 47% prevalence of moderate depressive symptoms and the 5% prevalence of severe depressive symptoms in PD patients are considerably higher than figures reported in ‘normal’ elderly populations, where prevalences from 9 to 20% are often found (Jensen et al., 1994). It is important, however, to point out that these figures need not be equivalent to moderate or severe depression as a clinical diagnosis based on an psychiatric interview was not performed. Our data are nevertheless, in agreement with findings in other studies of PD patients, where prevalence figures of up to 90% have been found (Table 5). In the stepwise regression analysis, in our study the significant variables for depressive symptoms were Hoehn and Yahr group and insomnia (Table 2). Martinez-Martin and Frades Payo (1998) found a strong relationship in PD patients between mood as measured with the 15-item version of the GDS and bodily pain, which was not found in this study. Our patients with insomnia or depressive symptoms had a significantly impaired quality of life on all eight scales in the SF-36 questionnaire (Table 3), i.e. poorer physical function, emotional function and general health as experienced by the patients. Hobson found a strong relationship between depressive symptoms in PD patients as measured with the GDS 15 and a poorer quality of life using a specific instrument, the Parkinson Disease Quality of Life Measure (PDQL), (Hobson et al., 1999). Likewise, Karlsen et al. (1999) found in their study of PD patients that of the variables studied, depressive symptoms and self-reported insomnia most strongly predicted impaired quality of life as studied with the Nottingham Health Table 5 Prevalence of depression in PD patients in various studies Prevalence of depression
Study
20% 40% 63% 90% 52% 37% (varying from 18–50% depending on disease stage)
Patrick and Levy (1922) Mjones (1949) Warburton (1967) Mindham (1970) Brown and Wilson (1972) Celesia and Wanamaker (1972) Mindham et al. (1976) Lieberman et al. (1979) Mayeux et al. (1981) Mayeux et al. (1984) Starkstein et al. (1990) Cummings (1992) Wagner et al. (1996) Hoogendijk et al., (1998) Starkstein et al. (1998) Chrischilles et al., (1998) Aarsland et al. (1999) Meara et al. (1999) Present study
48% 29% 49% 14% (dysthymia), 27% (major depression) 20% (minor depression), 21% (major depression) 40% 37% (patients aged \65), 73% (patients aged 41–64) 13–23% (major depression) 31% (dysthymia), major depression 15% and 38%a 26–60% 38% 64% Moderate depressive symptoms 47%, severe depressive symptoms 5% a
Akinetic-rigid PD 38%; classic PD 15%.
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Profile, but nevertheless only explained a fraction of the total variance. Thus, irrespective of the type of quality of life instrument used in PD patients — either disease-specific instruments or, as in this study, generic health-related instruments — the negative correlation between insomnia and depressive symptoms and quality of life remains. The prevalence of insomnia and depressive symptoms found in this study was not lower, but fairly similar to earlier findings, Table 4 and Table 5. Better drug treatment during later years and an increased awareness of physiotherapy for the maintenance of mobility might change the disease process and decrease the patients’ disabilities. This was not, however, reflected in a lower prevalence of insomnia and depressive symptoms in this study as compared with older ones. The neurologic symptoms in PD might predominate to a large extent over other symptoms, such as depressive symptoms and insomnia, and there could be a risk that those symptoms are overlooked when the patients are examined. Level of disability as measured with the Hoehn and Yahr classification was strongly related to more insomnia and more depressive symptoms in this study. Therefore, to influence on those symptoms optimal treatment of the disease is of utter importance. In conclusion, this study has shown a high prevalence of insomnia and depressive symptoms in PD patients, and that those symptoms have a negative influence on health-related quality of life. Consequently, insomnia and depressive symptoms should be taken into consideration, when evaluating patients with PD.
Acknowledgements This study was supported by Va˚rdalstiftelsen (project no. V97/192) and Ra˚det fo¨r Ha¨lso-och sjukva˚rdsforskning (project no. 146/1997).
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