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Sleep Breath (2007) 11:187–194

DOI 10.1007/s11325-006-0097-3

ORIGINAL ARTICLE

Insomnia symptoms and their correlates among the elderly in


geriatric homes in Alexandria, Egypt
Mohamed M. Makhlouf & Abla I. Ayoub &
Moataz M. Abdel-Fattah

Published online: 19 January 2007


# Springer-Verlag 2007

Abstract The prevalence of sleep complaints increases significantly associated with an increased risk of difficulty
steadily with age. Studies investigating insomnia among to maintain sleep and decreased risk of early morning
elderly people living in geriatric homes, especially among awakening. Conclusively, the present study showed that
Egyptians, are scarce. This study aimed to determine the insomnia symptoms are highly prevalent among the elderly
prevalence of insomnia symptoms among the elderly living in living in geriatric homes. It also revealed that although age,
geriatric homes in Alexandria and their correlates. A cross- gender, and other socio-demographic factors are correlated
sectional survey of a representative sample of elderly with insomnia symptoms, other factors are highly impor-
population of geriatric homes in Alexandria was imple- tant. Health care providers should take these factors in
mented. A total of 177 persons aged 60 years or older consideration when dealing with elderly patients who
participated. Difficulty initiating sleep was reported by 65% complain of insomnia.
of the participants. Approximately half of them had difficulty
maintaining their sleep (50.8%) or had non-restful sleep . .
Keywords Insomnia Elderly Egypt
(51.4%). Short sleep was reported by 43.5% of the
participants, while early morning awakening was reported by
28.2%. Advanced age (≥75 years) was significantly associated Introduction
with increased risk for early morning awakening, non-restful
sleep and short sleep. Women had approximate-ly a fourfold Getting a good night’s sleep is essential for feeling
risk of non-restful sleep as opposed to men. Short stay in refreshed and alert during the day. Unfortunately, not
geriatric homes (<1 year) was associated with 2.5-fold everyone is able to get the restorative sleep they need [1].
increased risk of non-restful sleep. Unmarried status was Older adults often experience sleep disturbances, but most
strongly and positively related to difficulty to maintain sleep of them fail to mention these disturbances to their
and non-restful sleep. Depressive status was physician out of a false belief that sleep troubles are just a
: consequence of getting older [2, 3].
M. M. Makhlouf A. I. Ayoub
It has been estimated that sleep disturbances affect more
Geriatric Health Department, High Institute of Public Health,
Alexandria University, than 50% of community dwelling individuals more than 65
Alexandria, Egypt years of age and an estimated two-thirds of institution-
alized elderly persons [4].
M. M. Abdel-Fattah Insomnia can be simply defined as difficulty initiating
Medical Statistics Department, Medical Research Institute,
Alexandria University, sleep (DIS), difficulty maintaining sleep (DMS), early
Alexandria, Egypt morning awakening (EMA), short sleep (SS), or non-restful
sleep (NRS) [5, 6]. Insomnia can be classified according to
M. M. Abdel-Fattah (*) the part of sleep cycle most affected, that is, sleep initiation,
Chief and Consultant of Preventive Medicine Department,
Al-Hada Armed Forces Hospital, sleep maintenance (frequent awakening), or early awaken-ing
P.O. Box 1347, Taif, Kingdom of Saudi Arabia (terminal insomnia). Classifying insomnia in this way may
e-mail: mezo106@yahoo.com give clues to the underlying cause [5].
188 Sleep Breath (2007) 11:187–194

Insomnia can be due to medical conditions, chronic dis- Table 1 Demographic and medical characteristics of the participants
eases, psychiatric disorders, and medications. In addition, the (n=177)
circadian rhythm advances that accompany aging can cause Variables Percentage
early evening lethargy and early morning awakenings [7].
Gender
The inability to have restful sleep at night results in
Men 39.5
excessive daytime sleepiness, attention and memory prob-
Women 60.5
lems, depressed mood, falls and lowered quality of life. It is Geriatric home category
also evident that disturbances in sleep can also lead to adverse
changes in functioning of number of body systems [8]. In Private 45.2
addition to affecting the quality of life in the aged, problems Public 54.8
with sleep have been associated with increased risk of nursing Education
home placement and increased mortality [7].
Illiterate or read and write 39.5
Studies investigating insomnia among elderly people
Primary 18.1
living in geriatric homes, especially among Egyptians, are Preparatory or secondary 26.6
scarce. So, this study aimed to determine the prevalence of University 15.8
insomnia symptoms among Egyptian elderly living in Marital status
geriatric homes in Alexandria and their correlates.
Married 12.8
Divorced 9.6
Materials and methods Widowed 62.1
Single 15.8
Current job Status
Study design
Working 3.4
A cross-sectional survey of a representative sample of Not working 96.6
elderly population of geriatric homes in Alexandria was Previous Job
implemented. Three geriatric homes (two representing
public and one representing private geriatric homes) were Manual 9.0
randomly selected from 15 located in Alexandria (three Skilled 13.6
Professional 30.5
private and 12 public).
Free 4.5
Housewife 42.4
Participants History of chronic diseases

All residents of the selected homes were eligible to participate No 9.6


in the study provided that they were: (a) 60 years of age or One disease 23.2
older; (b) free from communication problems; and Two diseases 33.3
Three diseases or more 33.9
(c) free from dementia (absence of established diagnosis in
Hypertension 48.6
their medical records and/or a score of 24 or more in Diabetes mellitus 20.3
MMSE [9]). Those who did not meet the inclusion criteria Cardiac diseases 26.0
were excluded from the study (n=32). The study was Chest diseases 7.3
carried out between May 2003 and June 2004. Neurological diseases 18.6
Of those eligible, 177 completed the questionnaire Osteoarthritis 31.1
(response rate 95.6%). The sample constituted approxi- Medication use 89.3
mately 25% of the elderly population in all the geriatric Taking diuretics 26.0
Taking antihypertensive
homes in Alexandria.
ACE inhibitors 22.6
Measures Beta-Blockers 5.6
Others 4.0
All eligible participants (n=185) were invited to complete Taking analgesics 19.8
a structured questionnaire, filled in by trained physicians, Taking tricyclic drugs 2.8
and covering the following: Taking antihistaminic 5.6
Taking benzodiazepines 11.3
Socio-demographic characteristics and environmental
factors that could affect sleeping such as excessive light,
sound, and temperature variation.
Sleep Breath (2007) 11:187–194 189

Table 2 Distribution insomnia


symptoms among participants Insomnia symptoms Females (n=107) Males (n=70) Total (n=177) P value
according to their gender No. (%) No. (%) No. (%)

Number of symptoms
No 25 (23.4) 20 (28.6) 45 (25.4)
One symptom 49 (45.8) 27 (38.6) 76 (42.9)
Two or more symptoms 33 (30.8) 23 (32.8) 56 (31.7) 0.601
Type of symptoms

Difficulty initiating sleep 77 (72.0) 38 (54.3) 115 (65.0) 0.024


Difficulty maintaining sleep 61 (57.0) 29 (41.4) 90 (50.8) 0.047
Early morning awakening 29 (27.1) 21 (30.0) 50 (28.2) 0.734
Non-restful sleep 71(66.4) 20 (28.6) 91 (51.4) 0.000
Short sleep 48 (44.9) 29 (41.4) 77 (43.5) 0.757

Habits Information regarding the frequency and timing of vs >1 year), educational level (illiterate or read and write
drinking caffeinated beverages (tea, coffee, and soft vs primary, preparatory or secondary, and university),
drinks) and history of practicing aerobic exercise on a marital status (married vs unmarried), daily activity
regular basis has been determined. (independent for all activities vs partially or completely
The activities of daily living of the participants were dependent), time of drinking caffeinated beverages (not al
assessed using the Katz index [10] and instrumental all vs yes not evening and yes evening), depression status
activities of daily living [IADL] [11]. (no vs yes), history of chronic diseases (no vs one, two and
Data about number and type of chronic diseases and three or more diseases), hypertension (no vs yes), diabetes
medication use were obtained. mellitus (no vs yes), cardiac diseases (no vs yes), chest
diseases (no vs yes), neurological diseases (no vs yes),
Depression status The following National Health Interview osteoarthritis (no vs yes), medication use (no vs one or two
Survey (NHIS) [12] question was used to measure depression: and three or more drugs), benzodiazepines (no vs yes),
“Over the past year, have you had 2 consecu-tive weeks or environmental factors (no. vs yes), and time of going to
more during which you felt sad, blue, or depressed, or lost bed (<9 P.M. vs 9–12 P.M. and >12 P.M.).
pleasure in things you usually cared about or enjoyed?”
(Yes/no). The depression item from the NHIS has been shown Statistical analysis
to be useful in discriminating medical health care utilization
and costs as well as risk of all-cause mortality among men and Analyses were performed using the Statistical Package for
women [13]. Social Science (SPSS), version 11.0. The differences between
men and women in different studied insomnia symptoms were
Insomnia symptoms Detailed sleeping history during the last 2
tested by X test. For each of the independent variables, the
month was assessed including the frequency of the common types crude odds ratio (OR) and 95% confidence interval (CI)
of insomnia symptoms including: DIS—“prolonged sleep onset associated with each category were computed. Multivariate
latency >0.5 hours”, DMS—“frequent awakening after sleep”, associations were evaluated in a multiple logistic regression
EMA— “waking up before or at 5 o’clock in the morning”, SS model, including only significant variables in univariate
“sleep at night equal or less than 6 hours,” and NRS—“not analyses, based on the backward stepwise selection. This
feeling rested upon awakening in the morning”. procedure allowed the estimation of the association between
each independent variable and the dependent variable, taking
into account the potential confounding effect of other
Outcome variables independent variables. Separate models have been constructed
for each insomnia symptom entity. The covariates were
DIS, DMS, EMA, NRS, SS (no vs yes for all the variables). removed from the model if the likelihood ratio statistic based
on the maximum likelihood estimates had a probability of
Independent variables more than 0.10. Each category of the predictor variables was
contrasted with the initial category “reference category.” An
Age in years (<75 vs ≥75), gender (male vs female), adjusted OR with 95% CI that did not include 1.0 was
geriatric home category (public vs private), room type considered significant. All models were tested for significant
(single vs shared), duration of geriatric home stay (<1 year possible interactions.
190 Sleep Breath (2007) 11:187–194
Table 3 Risk factors for different forms of insomnia symptoms among participants: multivariate analysis

Risk factors Difficulty initiating a b


Difficulty maintaining Early morning Non-restful sleep Short sleep (<6 h)
sleep Cases/controls sleep cases/controls awakening Cases/ Cases/controls Cases/controls
115/62 90/87 controls 50/127 91/86 77/100
Age in years
c 62/43 49/56 23/82 47/58 38/67
<75 (105)
≥75 (72) 53/19 41/31 27/45 44/28 39/33
d e 1.83 (0.90–3.90) Not included 2.41 (1.16–5.26)* 3.81 (1.53–8.61)* 2.30 (1.17–4.31)*
Adjusted OR (95% CI)
Gender
c 38/32 29/41 21/49 20/50 29/41
Male (70)
Female (107) 77/30 61/46 29/78 71/36 48/59
Adjusted OR (95% CI) Removed Removed Not included 3.69 (1.42–8.40)* Not included
Duration of home stay
c 91/47 66/72 37/101 64/74 22/17
≥1 year (138)
<1 year (39) 24/15 24/15 13/26 27/12 55/83
Adjusted OR (95% CI) Not included Not included Not included 2.49 (1.11–5.38)* Not included
Marital status
c 11/11 4/18 3/19 4/18 7/15
Married (22)
Unmarried (155) 104/51 86/69 47/108 87/68 70/85
Adjusted OR (95% CI) 2.05 (0.76–5.57) 5.15 (1.55–17.11)* Not included 4.58 (1.20–17.42)* Not included
Environmental factors
c 41/40 37/44 32/49 27/54 38/43
No (81)
Yes (96) 74/22 53/43 18/78 64/32 39/57
Adjusted OR (95% CI) 3.17 (1.61–7.03)* Not included 0.36 (0.21–0.73)* 5.16 (2.30–11.56)* 0.77 (0.43–1.41)
Depression status
c 18/13 10/21 14/17 8/23 14/17
No (31)
Yes (146) 97/49 80/66 36/110 83/63 63/83
Adjusted OR (95% CI) Not included 2.67 (1.09–5.88)* 0.36 (0.13–0.91)* Removed Not included
Educational level
c 46/24 43/27 21/49 49/21 34/36
Illiterate or read and write (70)
Primary (32) 18/14 15/17 11/21 17/15 17/15
Preparatory or 2ry (47) 32/15 18/29 9/38 18/29 12/35
University (28) 19/9 14/14 9/19 7/21 14/14
f 0.49 (0.17–1.42) 1.39 (0.61–3.62)
Adjusted OR (95% CI)
g
Adjusted OR (95% CI) 0.32 (0.13–0.91)* 0.40 (0.17–0.94)*
h Not included Removed Not included 0.26 (0.08–0.94)* 1.40 (0.57–3.54)
Adjusted OR (95% CI)
Chronic diseases
c 10/7 3/14 5/12 3/14 5/12
No (17)
One (41) 25/16 25/16 17/24 20/21 19/22
Two (59) 39/20 23/36 12/47 31/28 24/35
3 41/19 39/21 16/44 37/23 29/31
Three or more (60)
i
Adjusted OR (95% CI) 5.30 (1.46–27.27)* 6.95 (1.24–38.7)*
j
Adjusted OR (95% CI) 3.04 (0.74–12.16) 4.51 (0.75–28.62)
k Not included 8.28 (2.04–34.44)* Not included 9.02 (1.44–53.52)* Not included
Adjusted OR (95% CI)
Cardiac diseases
c 93/48 70/71 40/101 56/85 56/85
No (141)
Yes (36) 22/14 20/16 10/26 21/15 21/15
Adjusted OR (95% CI) Not included Not included Not included Not included 2.34 (1.07–5.38)*
Osteoarthritis
c 71/51 57/65 38/84 56/66 52/70
No (122)
Yes (55) 44/11 33/22 12/43 35/20 25/30
Adjusted OR (95% CI) 2.31 (1.01–5.17)* Not included Not included Removed Not included
Body pain during sleep
c 66/54 46/74 48/72 42/78
No (120)
Yes (57) 49/8 44/13 43/14 35/22
Adjusted OR (95% CI) 4.82 (2.16–10.49)* 5.14 (2.51–11.15)* Not included 4.43 (2.16–8.32)* 2.55 (1.59–5.71)*
Sleep Breath (2007) 11:187–194 191
Table 3 (continued)

Risk factors Difficulty initiating a b


Difficulty maintaining Early morning Non-restful sleep Short sleep (<6 h)
sleep Cases/controls sleep cases/controls awakening Cases/ Cases/controls Cases/controls
115/62 90/87 controls 50/127 91/86 77/100
Time of going to bed
c 7/7 5/9 3/11 5/9 4/10
<9 P.M. (14)
9–12 P.M. (141) 90/51 69/72 39/102 72/69 58/83
>12 P.M. (22) 18/4 16/6 8/14 14/8 15/7
l 2.02 (0.60–6.8) 1.86 (0.55–6.27) 2.48 (0.72–9.17)
Adjusted OR (95% CI)
m 7.17 (1.35–38.09)* 5.48 (0.78–19.92) Removed Removed 6.92 (1.51–33.56)*
Adjusted OR (95% CI)

*P<0.5
aVariables of daily activity and medication use have been removed from the final model.
b Variables of room type, daily activity, and medication use have been removed from the final model.
cReference category
d Odds ratio
eConfidence interval
f Primary vs c
g Preparatory or 2ry vs c
h University vs c
i One vs c
j Two vs c
k Three or more vs c
l 9–12 P.M. vs c
m >12 P.M. vs c

Results related to DMS and NRS. Depressive status was signifi-


cantly associated with an increased risk of DMS and a
Table 1 provides a summary of socio-demographic and lower risk of EMA.
medical characteristics for participants. A total of 177 Participants with a history of three or more of chronic
persons (their age ranged between 60 and 92, with a mean diseases had an increased risk of DMS and NRS compared
of 72.53 and standard deviation of 7.64 years) participated to those with no history of chronic diseases. History of
in the study. Their insomnia symptoms are presented in cardiac diseases was found to be a significant risk factor
Table 2. Of all the subjects, 74.6% reported at least one for SS, while history of osteoarthritis was found to be a
insomnia symptom. The most common insomnia sig-nificant risk factor for DIS. Regarding exposure to
symptoms were DIS (65%), followed by NRS (51.4%) and envi-ronmental factors, those reported history of exposure
DMS (50.8%). Twenty-eight percent of the participants to these factors were more liable to develop problems of
gave a history of EMA. The median value of the total DIS and NRS and less liable to develop a problem of
duration of night sleep was 6 h. SS was reported by 43.5% EMA. DIS and SS symptoms were significantly associated
of the participants. DIS, DMS, and NRS were more with going to bed after 12 P.M. as opposed to before 9 P.M.
significantly reported by females (p values <0.05, <0.05, History of body pain during sleep was significantly
and <0.001, respectively). associated with all studied sleep symptoms except EMA.
Advanced age (≥75 years) was significantly associated
with increased risk for EMA, NRS, and SS. Females had
approximately a fourfold significant risk of NRS as opposed Discussion
to males. Short staying in geriatric homes (<1 year) was
significantly associated with 2.5-fold increased risk of NRS. The present study revealed that insomnia symptoms were
On the other hand, relatively higher educational level highly prevalent among the elderly in geriatric homes
(preparatory or secondary) was significantly associated with a (74.6%). The most common insomnia symptom among the
lower risk of NRS and SS as compared to lower educational elderly was DIS (65%), followed by NRS (51.4%), DMS
level (illiterate or just able to read and write) and university (50.8%), and SS (43.5%). EMA was reported by 28.2%.
level was significantly associated with lower a risk of NRS. These figures are somewhat higher than those found in
Unmarried status was strongly and positively other studies. However, it is difficult to make direct
192 Sleep Breath (2007) 11:187–194

comparisons between our findings and other studies as they that women significantly reported more DIS [21, 25], both
were dealing with different cohorts, living in different DIS and DMS than men [27]. Other studies [24, 29]
settings, questions about insomnia symptoms were asked revealed that female gender was not an independent risk
differently, and frequency response options vary. Most of factor for sleep disturbances. It was concluded that the
these studies were dealing with community-dwelling elderly clear gender difference in the prevalence of insomnia is
with lower prevalence of insomnia symptoms. For example, caused by gender difference in the prevalence of anxiety
estimates of DIS ranged from 10 to 37%, DMS ranged from and depression [29].
14 to 65%, and EMA from 17 to 30% [14–19]. In a study done in non-institutionalized elderly in US
Higher rates of DMS (81%) and EMA (51%) in elderly communities [17], all symptoms of sleep disturbances were
patients with knee pain were found in USA [20]. Also, high strongly related to depression. In many other studies [30– 33],
prevalence of sleep disturbances (69%), close to that found depression was one of the strongest risk factors for current
in the present study was found among elderly people living insomnia Table 3. There is also epidemiological evidence that
in assisted living facility in Maryland, USA [21]. The high the relationship between depression and insomnia is bi-
prevalence of sleep disturbances among the elderly living directional [34]. The present study also revealed that
in these facilities or in geriatric homes may be associated depressed mood is significantly associated with DMS.
with unfamiliar environment especially in the early period However, depressed mood in the present study was protective
after admission, lower social support, higher prevalence of from early morning awakening. This may be explained by the
chronic illnesses, and depressive symptoms among the fact that depressed elderly, having interrupted sleep (DMS),
residents. Environmental factors, mainly excessive noise may at the late hours of the night become tired and fall asleep
and light, were significantly associated with DIS and NRS and hence may not complain of EMA.
in the present study and with sleep disturbances in other Apart from depression, perceived poor health, and the
studies [22, 23]. actual health status of the elderly as predicted by the
Also, shorter duration of the elderly in the geriatric home number of current diseases, were strongly associated with
was associated with NRS in the present study. This may be insomnia in different studies [26, 31, 33]. The present
related to being unfamiliar with the new environment, or the study also revealed that the number of chronic diseases the
development of depressive symptoms that may accom-pany elderly have was strongly associated with DMS and NRS.
admission to geriatric homes. The last reason may also A higher number of chronic diseases may lead to occur-
explain the higher and significant prevalence of insomnia rence of insomnia among the elderly in two ways. First, an
symptoms (DMS, NRS) among unmarried than married indirect way, through the higher prevalence of depression
elderly. Being unmarried was also found to be associated with among the elderly with multiple chronic illnesses. Second,
insomnia among Chinese elderly men [24]. through a direct way, by the symptoms of these chronic
In addition to marital status, educational level also illnesses or due to side effects of the drugs used to manage
appeared to be significantly associated with insomnia in them, which may disturb sleep.
the present study. Although those with higher educational Several drugs have been implicated in the occurrence of
level appeared to sleep shorter time than those with lower insomnia including antihypertensive agents, corticosteroids,
educational level, they appeared to have less NRS. Other diuretics, sympathomimetics, antihistaminics, and many
studies also showed significant association between lower others [6]. However, none of these drugs showed a sig-
educational level and increased risk of insomnia [23–25]. nificant association with insomnia symptoms in the present
Increasing age in the present study was a significant study. Moreover, the use of benzodiazepines was not
predictor of all forms of insomnia symptoms, except DMS significantly associated with insomnia in the present study.
and DIS. Significant association between age and insomnia This was not the case in other studies [17, 21, 33] Smaller
was also found in several studies [17, 26–27]. On the other sample size and lower utilization rate of some of these drugs
hand, age was not associated with increased rate of may partially explain difference in results of our study and
insomnia in Taiwan [24]. There is epidemiological those of other studies.
evidence demonstrating that the bulk of sleep complaints Depressed mood and coexisting arthritis were the most
and disorders is not the result of age per se, but rather co- relevant independent correlates of sleep disturbances
segregate with medical and psychiatric disorders and among the elderly in Italy [35]. Also among the elderly
related health burdens [28]. Japanese, history of cardiovascular disease, arthritis or
Concerning gender, the present study revealed that joint pain and prostatic hypertrophy, and lower subjective
women significantly reported higher DIS, DMS, and NRS well-being among men and depression among women
than men. However in multivariate analysis, NRS was the were associated with sleep disturbances [25]. Moreover,
only insomnia symptom that remained significantly elderly patients with confirmed angina were 1.6 times
different between both sexes. Several studies also showed more likely to report DIS [17].
Sleep Breath (2007) 11:187–194 193

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