Aging & Mental Health

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Comparing sleep quality in institutionalized and

non-institutionalized elderly individuals

Raquel Martins da Silva, Pedro Afonso, Miguel Fonseca & Tomás Teodoro

To cite this article: Raquel Martins da Silva, Pedro Afonso, Miguel Fonseca & Tomás Teodoro
(2019): Comparing sleep quality in institutionalized and non-institutionalized elderly individuals,
Aging & Mental Health, DOI: 10.1080/13607863.2019.1619168

To link to this article: https://doi.org/10.1080/13607863.2019.1619168

Published online: 17 May 2019.

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AGING & MENTAL HEALTH
https://doi.org/10.1080/13607863.2019.1619168

Comparing sleep quality in institutionalized and non-institutionalized elderly

individuals
Raquel Martins da Silvaa, Pedro Afonsoa, Miguel Fonsecab and Tomas Teodoroc,d
a
Department of Psychiatry, Faculty of Medicine, University of Lisbon, Lisbon, Portugal; bCenter for Mathematics and Applications,
Faculty of Sciences and Technology, New University of Lisbon, Lisbon, Portugal; cDepartment of Psychiatry, Lisbon Psychiatric Hospital
Centre, Lisbon, Portugal; dChronic Diseases Research Center, NOVA Medical School, New University of Lisbon, Lisbon, Portugal

ABSTRACT ARTICLE HISTORY

Objectives: Sleep is a physiological function essential to general health and well-being. Insomnia Received 15 February 2019
is a sleep disorder frequently reported by older adults. Institutionalization in nursing care homes Accepted 7 May 2019
may contribute to increase the risk of sleep disorders in this population. The aim of this explora-
KEYWORDS
tory study was to compare sleep quality among a group of institutionalized (GI) and a group of
Aging; sleep; sleep quality;
non-institutionalized (GNI) elderly individuals. institutionalization; psycho-
Method: We selected 100 individuals over 65 years of age. Participants were divided into two social factors
groups (N ¼ 50 in each group) according to their institutionalization status (GI and GNI). The fol-
lowing assessment instruments were used: Pittsburgh Sleep Quality Inventory (PSQI), Epworth
Sonolence Scale (ESS) and Geriatric Depression Scale (GDS). Study groups were compared in their
sociodemographic, social and clinical characteristics with statistical analysis performed to detect
correlations between variables.
Results: GI elderly presented worse overall sleep quality and higher levels of daytime somnolence
and depressive symptoms. A positive correlation was found between sleep quality, daytime sleepi-
ness (ESS) (p < 0.01) and depressive symptoms (GDS) (p < 0.01).
Conclusions: Our results are consistent with the possibility that elderly individuals admitted to
long-term care and residential institutions present with worse sleep quality. Higher levels of
depressive symptoms, lower occupational activity and sunlight exposure are specifically associated
with a worse sleep quality. Further studies with larger and more diverse samples, including com-
munity-dwelling individuals, may be important to consolidate these findings.

Introduction Aging-related sleep architecture changes result in a glo-

Sleep is a basic physiological need, essential for health and
well-being. In the elderly population, sleep disorders
are influenced by several factors, including primary
sleep disturbances (such as sleep apnea, periodic sleep
movements and restless legs syndrome) or secondary to
physical illness, psychiatric conditions, pharmacological
interactions or psychosocial factors (Ancoli-Israel et al.,
1991; Crowley, 2011).
Insomnia is a sleep disorder frequently reported by
older adults. The prevalence of insomnia is higher in eld-
erly individuals compared to younger adults. Over 50% of
adults aged 65 and above present with complaints of sleep
disturbances, and this is typically undervalued by health
professionals (Kamel & Gammack, 2006).
In older adults the circadian rhythm also changes and
there is a tendency for an advanced sleep-wake phase (fall-
ing asleep earlier and waking up earlier) (Carrier, Monk,
Buysse, & Kupfer, 1997; Roenneberg et al., 2007). A disrup-
tion in daily routines due to retirement along with low lev-
els of physical activity and reduced sunlight exposure are
some factors that may contribute to changes in circadian
sleep rhythm (Campbell, Dawson, & Anderson, 1993; Duffy,
Kronauer, & Czeisler, 1996; Neikrug & Ancoli-Israel, 2010a;
Stoica, 2015; Vitiello & Borson, 2001).
bal reduction of sleep efficiency with less total sleep time,
reduced amount spent in deeper non-rapid-eye-movement
(NREM) sleep stages and rapid-eye-movement (REM) sleep.
On the other hand, there is a higher number of nocturnal
awakenings resulting in an increased sleep fragmentation
(Chokroverty, 2017; Jagus & Benbow, 1999; Mander, Winer,
& Walker, 2017).
These age-related sleep changes can lead to the emer-
gence of clinical complaints, translating a significative
negative impact on quality of life and overall negative
health outcomes. Possible effects may include an increase
in excessive daytime sleepiness, poorer physical perform-
ance, cognitive impairment, and increased risk of psychi-
atric and medical illness (Blackwell et al., 2006; Dam et al.,
2008; Neikrug & Ancoli-Israel, 2010a). In addition, sleep dis-
orders in the elderly are associated with an increased risk
of falls, substance abuse, negative self-health assessment
and quality of life (Bloom et al., 2009; Foley, Ancoli-Israel,
Britz, & Walsh, 2004; Ong et al., 2016).
Sleep deprivation and insomnia are associated with a
higher risk of metabolic syndrome, hypertension and myo-
cardial infarction (Laugsand, Vatten, Platou, & Janszky,
2011; Palagini et al., 2013, Troxel et al., 2010; Vgontzas,
Liao, Bixler, Chrousos, & Vela-Bueno, 2009). Chronic

CONTACT Tomas Teodoro tomasteodoro@chpl.min-saude.pt

Supplemental data for this article is available online at here.
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 R. MARTINS DA SILVA ET AL.
insomnia can lead increased use of healthcare services and
an increased risk of institutionalization (National Institutes
of Health, 2005).
Sleep can be influenced by a disruption in a series of
biopsychosocial factors associated with the transition to
institutionalization (Fiorentino & Ancoli-Israel, 2006). These
factors may influence sleep quality and lead to various
sleep disorders (Azri, Dahlan, Masuri, & Isa, 2016).
Considering that sleep disorders may increase the risk for
various medical illnesses and psychiatric conditions, it is
important to identify modifiable behavioral and environ-
mental factors making it possible to adopt strategies that
can contribute to prevent a decline and improve the qual-
ity of sleep in the elderly.
The main goal of this study is to compare the quality of
sleep between institutionalized and non-institutionalized
elderly individuals. In addition, we searched for possible vari-
ables that might be associated with a lower sleep quality.
Through the identification of contributing factors, we intend
to contribute to the future proposal of potential measures
to reduce the impact of institutionalization on sleep.
Methods
Study design and setting
The study was designed as a cross-sectional observational
study. It was conducted in residential care and day care
units belonging to a Portuguese private institution of social
rdia de Lisboa) located in
solidarity (Santa Casa da Miserico
Lisbon. In our study institutionalization status was defined
as admission to a residential care unit for at least 6 months
and non-institutionalization status was defined as attend-
ance of a day care unit. A convenience sample of 100 indi-
viduals was obtained from individuals older than 65 years.
The study was submitted and approved by the Ethics
Committee of Faculty of Medicine, University of Lisbon,
Portugal. The procedures followed were in accordance to
the Declaration of Helsinki. All selected participants were
informed about the study and their written signed consent
was obtained.
Participants
Participants had to be at least 65 years old and have the
necessary cognitive, interpretative and communication
skills, as assessed by the researchers (taking into account
factors that adversely influence an individual’s capacity to
consent and participate in this study, including aspects of
comprehension, decision-making or communication).
Exclusion criteria included individuals with known diagnosis
of primary sleep disorders (obstructive sleep apnea, for
example), severe neurological diseases (dementia, degenera-
tive diseases, for example), substance use disorders and
severe communication impairment. A convenience sample
of a total of 100 individuals was selected and divided in two
groups: institutionalized (GI) and non-institutionalized (GNI).
Data sources
Data were collected through a questionnaire and the
application of several instruments (Pittsburgh Sleep
Quality Index, Epworth Sonolence Scale and Geriatric
Depression Scale).
Sociodemographic, clinical, environment and quality of
life questionnaire
A questionnaire was designed to collect general sociode-
mographic data (age, gender, marital status, number of
children), health history (including psychiatric disorders,
respiratory and cardiac disorders, hip/knee arthrosis and
cancer), occupational/environmental factors (including per-
formance of occupational activities, exposure to natural
sunlight, room air temperature, room noise level) and qual-
ity of life.
Pittsburgh sleep quality index (PSQI)
PSQI evaluates sleep quality and sleep patterns during the
previous month (Buysse, Reynolds, Monk, Berman, &
Kupfer, 1989). This self-report instrument assesses sleep
quality through the evaluation of seven domains: subject-
ive sleep quality, sleep latency, total sleep duration, habit-
ual sleep efficiency, sleep disturbances, medication use and
daytime dysfunction. Items are scored on a scale of 0–3,
with 3 as the negative extreme on the Likert scale. A total
score of 5 or higher indicates “poor” sleep.
Epworth sonolence scale (ESS)
ESS is a self-report scale that evaluates the level of daytime
sleepiness. It provides a report on the perceived changes
of falling asleep while engaged on 8 different activities.
(Johns, 1991). Each item is scored on a scale of 0–3, in
which 0 means the individual “would never doze off” and 3
would mean a “high chance of dozing off”. Total scores
range from 0 to 24 and can be interpreted as follows: 0–5
lower normal daytime sleepiness, 6–10 higher normal day-
time sleepiness, 11–12 mild excessive daytime sleepiness,
13–15 moderate excessive daytime sleepiness and 16–24
severe excessive daytime sleepiness.
Geriatric depression scale (GDS)
GDS is a brief screening instrument used to evaluate
and to monitor the presence of depressive symptoms in
older adults (Yesavage et al., 1982). There are two versions
(30-item and 15-item). In the original 30-item version indi-
viduals are asked to answer to 30 dichotomous (yes/no)
questions referring to how they felt on the past week. Each
positive answer on items 2–4, 6, 8, 10–14, 16–18, 20, 22–26
and 28 is allocated one point. Each negative answer on
items 1, 5, 7, 9, 15, 19, 21, 27, 29 and 30 is also scored one
point. Scores 0–9 are considered normal, 10–19 indicate
mild depression and 20–30 indicate severe depression.
Statistical analysis
GI and GNI were compared using the following tests chi-
square test, Fisher’s exact test and T-test for independent
variables or the Mann-Whitney U test when there was not
a normal distribution. Correlations between sociodemo-
graphic variables and PSQI, ESS and GDS scores were
tested using the Spearman correlation coefficient (rs).
 AGING & MENTAL HEALTH 3

Table 1. Clinical and sociodemographic characteristics of study participants.

Group
Characteristics Institutionalized (N ¼ 50) Control (N ¼ 50) P value
Gender, n (%)
Men 18 (36.0%) 8 (16.0%) 0.039a
Woman 32 (64.0%) 42 (84.0%)
Age 0.274b
Mean (SD) 82.24 (8.98) 80.42 (8.07)
Marital status, n (%) 0.001a
Married 2 (4.0%) 9 (18.0%)
Single 25 (50.0%) 7 (14.0%)
Widower 19 (38.0%) 27 (54.0%)
Divorced 4 (8.0%) 7 (14.0%)
Number of children, n (%) < 0.001a
None 36 (72.0%) 12 (24.0%)
1–5 children 14 (28.0%) 35 (70.0%)
6–11 children 0 (0.0%) 3 (6.0%)
Psychiatric disorders, n 0.379a
Depression 14 8
Anxiety 3 2
Bipolar disorder 2 1
Medical conditions, n (%)
Respiratory disease Yes 13 (26.0%) 12 (24.0%) 1.000a
No 37 (74.0%) 38 (76.0%)
Hypertension and heart disease Yes 26 (52.0%) 26 (52.0%) 1.000a
No 24 (48.0%) 24 (48.0%)
Hip and knee arthrosis Yes 43 (86.0%) 43 (86.0%) 1.000a
No 7 (14.0%) 7 (14.0%)
Cancer Yes 9 (18.0%) 9 (18.0%) 1.000a
No 41 (82.0%) 41 (82.0%)
Others Yes 14 (28.0%) 9 (18.0%) 0.342a
No 36 (72.0%) 41 (82.00%)
aChi-square test.
bMann-Whitney test.

Table 2. Occupational activity and daylight exposure. day. Exposure to daylight was considered when individuals
Group were exposed to natural light for a minimum of 30 minutes
Institutionalized n, % Control n, % P value
per day in an open-air space or, alternatively, in another
Occupational activity
location with sufficient light exposure.
Yes 11 (22.0%) 34 (68.0%) < 0.001a Results showed that GI individuals had significantly less
No 39 (78.0%) 16 (32.0%) occupational activities in comparison to GNI individuals (p
Daylight exposure
Yes 11 (22.0%) 32 (64.0%) < 0.001a < 0.001) (see Table 2). In relation to daylight exposure, the
No 39 (78.0%) 18 (36.0%) results revealed that 78% of the GI participants (n ¼ 39) do
aChi-square test. not have enough exposure to natural light during the day.
GNI participants exposure to natural light is significantly
Statistical significance was defined as a p-value < 0.05. higher with approximately 64% (n ¼ 32) having daily
Data statistical analysis was performed using IBM SPPS exposure to natural light (p < 0.001) (see Table 2).
StatisticsV
R version 24.0 for Windows. GI presented an overall worse sleep quality (mean 12.86;
SD 3.87) when compared to GNI (mean 10.84; SD 4.63).
This difference in sleep quality between groups proved to
Results be statistically significant (p ¼ 0.026). GI presented worse
A sociodemographic and clinical profile of participants in results in all seven domains of PSQI, except for sleep dur-
both GI and GNI is presented in Table 1. The only sociode- ation and habitual sleep efficiency. Daytime sleepiness, as
mographic variables that presented statistically significant assessed through the use of ESS, revealed that GI pre-
differences were gender, marital status and number of chil- sented significant greater daytime sleepiness (6.02; SD 5.35)
dren. In terms of gender differences were found in the compared to GNI (3.18; SD 4.25) (p ¼ 0.004). In the evalu-
homogeneity of the variable in both groups (p ¼ 0.039), ation of depressive symptoms on the GDS, we observed
with more females in both groups. Marital status and num- that GI had a higher score (12.32; SD 6.25) in comparison
ber of children also presented statistically significant differ- to GNI (9.90; SD 7.21). These results indicate a statistically
ences in their homogeneity in both groups, GI (p ¼ 0.001) significant increased presence of depressive symptoms in
and GNI (p < 0.001). Age differences were not statistically the group of institutionalized elderly (p ¼ 0.033) (see
significant (p ¼ 0.274). Table 3).
Performance in occupational activities and exposure to In our study, we found a positive correlation between
daylight were other variables studied. Occupational activ- the PSQI score and the ESS score in GI (rs ¼ 0.697; p <
ities included personal education, volunteer work, leisure 0.001) and GNI (rs ¼ 0.497; p < 0.001). This means that the
activities, participation in other organized activities that worse the sleep quality, the greater the level of daytime
provide enjoyment or entertainment. In order to be consid- sleepiness. In addition, there was also a positive correlation
ered relevant activities should be performed with a min- between the PSQI score and the GDS score in GI (rs ¼
imum frequency of twice a week for at least one hour per 0.722; p < 0.001) and in GNI (rs ¼ 0.712; p < 0.001), which
4 R. MARTINS DA SILVA ET AL.
Table 3. PSQI, ESS, GDS and sleep schedules results.
Institutionalized Mean (SD)
PSQI – Sleep Quality
Subjective sleep quality 1.66 (0.77)
Sleep latency 1.88 (1.17)
Sleep duration 1.28 (0.94)
Sleep efficiency 2.84 (0.46)
Sleep disturbances 1.20 (0.49)
Use of sleep medication 2.52 (1.11)
Daytime dysfunction 1.48 (1.14)
Global PSQI score 12.86 (3.87)
ESS – Daytime sleepiness 6.02 (5.36)
GDS – Geriatric depression 12.32 (6.25)
Bedtime (in minutes) 1136.10 (350.79) (18:54H)
Waketime (in minutes) 419.10 (59.49) (06:59H)
bMann-Whitney test.
reveals that increased symptoms of depression are associ-
ated with a worse sleep quality.
From the data obtained through the application of the
PSQI scale, we were able to extract information related to
the usual time that individuals went to bed at night and
got out of bed in the morning. These results are also pre-
sented in Table 3, showing the results of the means of
these variables, as well as a comparison between the two
groups. Thus, significant differences were found between
the two groups. GI tend to go to bed earlier at nigh
(18 h54; SD 350.79), relative to GNI (21 h21; SD 268.46)
There were no significant differences between the two
groups in the time individuals usually got out of bed in
the morning (p ¼ 0.969).
Discussion
The objective of this study was to compare the sleep qual-
ity of institutionalized and non-institutionalized older
adults. The use of self-report instruments and the necessary
cognitive abilities to complete them results in that current
findings are only applicable to a subset of institutionalized
individuals with relatively intact cognitive functioning.
The two groups did not present significant differences
in age, medical conditions and psychiatric disorders (Table
1). However, statistically significant differences were found
in gender, marital status and number of children. GI has a
higher number of single, widowed and childless individuals
compared to GNI. Marital status can play a key role in the
risk of institutionalization. In this case, those who have
never been married or are divorced are at greater risk,
since living alone increases significantly the risk of institu-
tionalization (Hays, Pieper, & Purser, 2003). On the other
hand, the lack of offspring or a weak family network might
be factors that contribute to future institutionalization
(Fekih-Romdhane, Ouanes, & Melki, 2014).
In our study, GI presented an overall worse sleep quality
when compared to GNI. There are several factors that may
help explain these observed differences, including the daily
exposure to natural daylight. GI presented a daily sunlight
exposure lower than GNI (Table 2). Sunlight is an important
synchronizer of the internal biological clock (zeitbergers),
helping to fine-tune the sleep-wake cycle (Klein et al.,
1993). Lack of adequate sun exposure may contribute to a
desynchronization of the circadian rhythm of sleep.
Increased appropriate sunlight exposure is associated with
Group
Control Mean (SD) P value
1.00 (1.06) < 0.001b
1.72 (1.19) 0.521b
1.52 (1.11) 0.262b
3.00 (0.00) 0.012b
1.04 (0.66) 0.146b
1.86 (1.44) 0.010b
0.74 (1.12) < 0.001b
10.84 (4.63) 0.026b
3.18 (4.25) 0.004b
9.90 (7.21) 0.033b
1281.30 (268.46) (21:21H) < 0.001b
417.80 (65.29) (06:57H) 0.969b
improved sleep quality and reduced daytime sleepiness
(Benca, 2005; Bloom et al., 2009; Duzgun & Akyol, 2017).
Institutionalized elderly individuals usually have less nat-
ural light exposure contributing to changes in the circadian
rhythm of sleep (Shochat, Martin, Marler, & Ancoli-Israel,
2000). In addition, the transmission of light through the
lens to the retina is reduced due to age-related changes.
These aspects associated with the eventual development of
cataracts, highly prevalent, may contribute to a decrease in
the effect of light as a synchronizer of the sleep wake cycle
at the level of the suprachiasmatic nucleus (Asplund &
Lindblad, 2004). Long-term care and residential institutions
should routinely provide the means for an adequate expos-
ure to sunlight, thus providing normal sleep-wake syn-
chronization and an improvement in sleep quality.
GI presented greater daytime sleepiness. Poor sleep
quality in the elderly contributes to increased daytime
drowsiness and decreased daytime functioning, leading the
elderly to less involvement in daytime occupational activ-
ities and reduced levels of physical activity (Galimi, 2010;
Kamel & Gammack, 2006; Martin & Ancoli-Israel, 2008).
The elderly tend to spend a large part of their daily life
inactive and deprived of meaningful social activity. They
tend to spend many hours in bed with frequent naps dur-
ing the day and this can be explained by the absence of
involvement in occupational or physical activities (Azri
et al., 2016; Ibrahim & Dahlan, 2015; Mozley, 2001). The
results of our study revealed that institutionalized elderly
individuals presented a lower participation in several occu-
pational activities. This lack of occupational activities may
contribute to greater daytime sleepiness (Chuang & Abbey,
2009; Neikrug & Ancoli-Israel, 2010b). For this reason, insti-
tutions should actively promote the participation of the
elderly in occupational activities, favoring cognitive, motor
and sensorial stimulation, reducing idleness and drowsi-
ness, helping to improve the sense of self-satisfaction
(Ibrahim & Dahlan, 2015).
Changes in the circadian rhythm of sleep may also con-
tribute to poorer sleep quality. The advanced sleep phase
pattern, daytime sleepiness, and insomnia often present in
institutionalized elderly (Foley et al., 1995; Jaussent et al.,
2012). As previously reported, our results showed that insti-
tutionalized individuals tend to go to bed much earlier
than non-institutionalized individuals. These differences
may be partially explained by the rules governing the oper-
ation of the institutions. Bedtime, if it occurs too early, may
lead to an internal biological time-lag, increasing sleep

latency, and inducing “behavioral insomnia”. The scarcity of
studies comparing sleep quality and sleep schedules in
institutionalized and non-institutionalized Portuguese
older adults limits the possibility of comparison and con-
firmation of our results.
Total sleep time decreases with normal aging.
Considering the age of participants, their sleep needs are
on average 6–7 hours. Since institutionalized individual’s
bedtime schedules are usually inadequately early, after
sleeping the necessary age-adjusted sleeping hours, the
wake-up time will be from 03 h00 to 04 h00 AM. That is,
the wakening occurs at a socially undesirable time. In add-
ition, the fact that bedtime occurs too early contributes to
increased sleep latency, since bedtime does not coincide
with the endogenous circadian rhythm of sleep. This aspect
alerts us to the importance of creating behavioral rules
(bedtime) that respect the natural circadian rhythm of
sleep of the elderly, avoiding behavioral desynchrony with
the internal biological clock. This situation may contribute
to explain the poorer sleep quality noticed in institutional-
ized elderly since circadian rhythm sleep disorders typically
develop when there is a gap between endogenous circa-
dian stimulus and the external environmental requirements
(Cooke & Ancoli-Israel, 2011).
Nursing homes and other long-term care residential
units should provide education to their staff and try to
comply with basic requirements for a good sleep hygiene.
By doing that it would be possible to respect circadian
sleep-wake rhythms, avoiding behavioral disruptions that
may result in severe sleep disturbances (Morin et al., 2006).
We identified a positive correlation between total scores
in ESS and GDS. This is in line with other studies, in which
daytime sleepiness and depressive symptoms have been
shown to be two strongly associated factors (Bixler et al.,
2005; Jaussent et al., 2011). Individuals with a depression
diagnosis are more likely to experience fatigue and diurnal
somnolence (Bixler et al., 2005; Lopes, Dantas, & Medeiros,
2013). Depression and sleep quality have a bidirectional
relationship. On the one hand, one domain of symptoms in
depressive disorders is related to sleep changes (insomnia/
hypersomnia) therefore increasing the risk of development
of sleep disturbances. On the other hand, poor sleep qual-
ity strongly contributes to the onset of depression in the
elderly (Azri et al., 2016; Lessov-Schlaggar et al., 2008; Wu,
Su, Fang, & Chang, 2012).
Our study did not show any significant differences
between groups in terms of psychiatric disorders between
the two groups. However, the fact that we obtained signifi-
cantly higher GDS scores in institutionalized individuals
may reveal that in that group depression is probably
underdiagnosed (Damian, Pastor-Barriuso, & Valderrama-
Gama, 2010). Bearing in mind the relationship between
sleep and depression, this may be a contributing factor
explaining differences found in the sleep quality scores
between institutionalized and non-institutionalized
individuals.
This study presents some limitations. The first concerns
the sample size and its representativeness. A larger and
more representative sample of each group would allow a
greater validation and possibility of generalization of our
results. Another limitation refers to the fact that no object-
ive measurement methods were used in the evaluation of
AGING & MENTAL HEALTH 5
sleep, such as actigraphy or polysomnography. The use of
such methods would be important to allow a more
accurate evaluation of sleep quality, achieving a reduc-
tion of possible biases associated with the use of self-
report subjective instruments. The cross-sectional nature
of our study might also be considered a limitation since
it hinders the establishment of causal relationships. Also,
sleep is a variable process over time and a longitudinal
study of would possibly allow more accurate and con-
solidated data on the evaluation of sleep quality. None
of the participants suffered from dementia or severe
cognitive impairment. Despite that, we didn’t evaluate
cognition (using for example, The Mini-Mental State
Examination - MMSE) and this can be considered a bias
of this study.
Finally, for ethical reasons, some potential confounding
factors were not controlled, including medication use.
Many individuals presented several diseases requiring
pharmacological treatment that might interfere with sleep
and associated symptoms, creating a possible bias.
Conclusion
Sleep disorders are highly prevalent in the elderly. This age
group shows a trend towards an overall decrease in sleep
quality. This phenomenon is in part due to physiological
changes related to the normal aging process, which may
impact the quality of sleep. However, there are several
potentially modifiable contributing factors including psy-
chosocial, environmental, medical, pharmacological and
behavioral aspects.
This study revealed that institutionalized individuals had
a lower participation in occupational activities, less daytime
sun exposure, greater daytime sleepiness, more depressive
symptoms, and poorer sleep quality. We also found a nega-
tive association between sleep quality and depressive
symptoms. Additionally, more studies should be performed
in order to support the likely cross-cultural generalizability
of these conclusions.
Institutions should adopt measures that may contribute
to reducing excessive daytime sleepiness and improving
sleep quality, such as: encouraging adequate daily sunlight
exposure, promoting occupational activities, and adopting
behavioral rules of sleep schedules that allow for an
adjusted sleep-wake synchronization. On the other hand,
the presence of greater depressive symptomatology in GI
reveals that depression may be underdiagnosed in this
population. More attention is needed for the diagnosis and
treatment of depression in the elderly population, since
this psychiatric disorder is associated with an increased risk
of sleep disorders. Furthermore, clinicians must be aware of
age-related sleep changes in elderly individuals. They
should actively explore potential sleep complaints in eld-
erly people, since these often negatively interfere with
overall quality of life and increase the risk of development
of several medical illnesses.
Sleep and aging-related sleep changes are important
areas of research. Future studies with more representative
samples of the population should be able to assess and
identify measures that could be implemented to improve
sleep quality in the elderly, as this is an emerging public
health issue with a significant impact on health outcomes.
6 R. MARTINS DA SILVA ET AL.
Disclosure statement
The authors report no conflict of interest.
ORCID
Tomas Teodoro http://orcid.org/0000-0002-4603-3946
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