Sleep in the elderly : experiences, expectations, and adaptations

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Sleep in the elderly : experiences, expectations, and adaptations
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Thesis (Ph. D.)--University of Florida, 1988.
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Includes bibliographical references (leaves 103-107).
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SLEEP IN THE ELDERLY:
EXPERIENCES, EXPECTATIONS, AND ADAPTATIONS










by

RUTH ANN MOONEY


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN
PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE DEGREE OF DOCTOR OF PHILOSOPHY



UNIVERSITY OF FLORIDA


1988











ACKNOWLEDGMENTS


Appreciation is expressed to the members of the

dissertation committee: Dr. Marjorie White, Chair, Dr.

Molly Dougherty, and Dr. Melody Marshall from the

College of Nursing, Dr. Wilse Webb, from Psychology, and

Dr. Gordon Streib, form Sociology for their tireless

effort and expert guidance. I am grateful to Dr.

Margaret Wilson for her assistance in data analysis.

Appreciation is further expressed to Dr. William Hale,

M.D. and the staff of the Dunedin Clinic for their

invaluable assistance in data collection. Appreciation

is extended to Dr. Frank May for his assistance and

advice in retrieving background data. Thanks are

especially given to the subjects for their time, effort,

and interest in completing the questionnaire.

Special thanks are extended to my parents and son

for their support, cooperation, assistance and

understanding.









TABLE OF CONTENTS


Page


ACKNOWLEDGMENTS . . . . . . .

ABSTRACT . . . . . . . . ..


* . ii

* . V


CHAPTERS


I INTRODUCTION . . . . . ..

Problem Statement . . . . .
Objective Behavioral Theory of Sleep.
Adaptive Theory of Sleep ......
Restorative Theory of Sleep . .
The Sick Role . . . . . .
Operational Definitions . . . .
Summary . . . . . . . .

II REVIEW OF LITERATURE . . . ..


7

7
. . 10
. . 16
. . 19
. . 21

* . 22


Sleep Behavior Changes With Age . . .
Sleep Patterns. ... . . . . .....
Subjective Response to Sleep. .. ......
Developmental Changes in Sleep Patterns
Organic States that Affect Sleep . .
Individual Differences . . . ..


Behavioral Facilitators


of Sleep. .
Self-Rating of Health .

III MATERIALS AND METHODS .


and


Inhibitors
. . . 29
. . . 32


. . . . . 36


Methodology
Subjects . .
Setting . .
Instruments . .
Procedure . .
Pilot . . .
Power analysis. .
Main study . ..
Data Analysis . .


IV RESULTS AND DISCUSSION.

Subject Characteristics
Sleep Behavior . ....
Sleep latency. . .
Sleep length . .
Sleep continuity .
Sleep evaluation .
Circadian tendencies
Sleep disturbances .
Help-seeking . ..
Behavioral inhibitors


. . . . . 47


sleep .


. . 83


i i i









Behavioral facilitators and inhibitors
of sleep . . . . . . . 87
Affective response to sleep disturbances 89

Summary . . . . . . . . . 92

V SUMMARY AND RECOMMENDATIONS . . . .. 95
Implications for Nursing . . . ... 99
Recommendations for Research . . .... 102

REFERENCES . . . . .... . . . ... 103

APPENDICES

A SLEEP QUESTIONNAIRE . . . . . .. 108

B FREQUENCY OF USE OF SLEEP FACILITATORS AND
INHIBITORS AND THEIR EFFECTIVENESS. . 117

BIOGRAPHICAL SKETCH . . . . . . .. 124
















Abstract of Dissertation Presented to the Graduate
School of the University of Florida in Partial
Fulfillment of the Requirements for the Degree of
Doctor of Philosophy

SLEEP IN THE ELDERLY:
EXPERIENCES, EXPECTATIONS, AND ADAPTATIONS

By

Ruth Ann Mooney

August, 1988

Chairman: Marjorie White
Major Department: College of Nursing


The purpose of this research is to determine the

relationship between self-report of sleep behavior among

non-institutionalized elderly and their expectations

regarding sleep. Sleep facilitators utilized to manage

sleep disturbances and affective responses to sleep

behavior changes are also explored. It is important

that nurses understand sleep behavior changes

experienced by non-institutionalized elderly so that

effective nursing care can be planned and implemented

for clients in the community, hospitals, and

institutions. Findings from this research help to

validate the objective behavioral theory of sleep

proposed by Webb.

The sample consisted of 282 subjects over the age

of 65 who reported to the Dunedin Program clinic from










September 28, 1987, to November 25, 1987. Subjects took

the Sleep Questionnaires home to complete after

consenting to participate.

Subjects consistently rated their sleep as having

been better when they were younger. Subjects reported

having slept better, gotten enough sleep, felt more

rested upon awakening, enjoyed sleep more, and

experienced deeper sleep when they were younger.

Emotional stress was the most frequently selected

behavioral inhibitor of sleep. A disproportion was

found between the number of subjects who identified

emotional stress as a factor in sleep disturbance (n=67)

and the number of subjects who found relieving

emotional stress to be an effective sleep facilitator

(n=24).

Behavioral facilitators employed when sleep

disturbances occurred included relaxing, reading,

and praying. Few subjects (6%) sought help from health

care professionals or family and friends for sleep

disturbances. When asked how they feel when they

experience sleep disturbances, the most frequent

response indicated they accept the disturbance.

Implications for nursing include utilizing this

information to assess sleep patterns of the elderly, to

plan and implement nursing care, and to educate clients

experiencing sleep disturbances. Gerontological nurses,

as experts on normal age related changes, educate










other health care providers regarding age related

changes in sleep patterns and sleep facilitators the

elderly find useful in dealing with sleep disturbances.

Longitudinal research is needed to substantiate age

related sleep behavior changes. Further research is

also needed to determine the generalizability of sleep

facilitators to larger numbers of the elderly.


vii













CHAPTER I
INTRODUCTION

Problem Statement

In 1980 25.5 million (11.7%) Americans were over

the age of 65 (Atchley, 1985), compared to approximately

50,000, or 2.5% of the population, in 1790. It has been

projected that, based on low birth rates and stable

death rates, in the year 2030, 51.6 million Americans

(20.9% of the population) will be over age 65.

The over-65 population is itself growing older. In

1960 almost 66% of the over 65 population was under 75

years old. Six percent of the over 65 year age group

was over 85 in 1960. By the year 2000, the young-old

(65 to 74 years) will represent 55.7% of the over 65

population, while the proportion of the over 85 year age

group will have risen to 10.4% of the over 65

population. Because of the differences in mortality

rates between males and females, this growing elderly

population will be predominantly female.

An increase in sleep disturbances has been found in

elderly subjects over that reported in other age groups

(McGhie & Russell, 1962). The elderly experience more

difficulty getting to sleep, a decreased ability to

sustain sleep and more early morning wakening than

younger persons (Webb, 1983). Women report sleep












difficulties more frequently and report more frequent

use of sleeping medications than men. Of those elderly

individuals habitually taking sedatives, a large

proportion started taking sedatives while hospitalized

(Lamberg, 1984). Since these medications are usually

ordered as needed, the nurse has a very important role

in assisting elderly clients in decision making

regarding the management of sleep behavior patterns.

Nationally, the elderly comprise 12% of

the population yet account for 31.2% of the total health

care expenditure. (Wolinsky, Mosely, and Coe, 1986).

The cost of care for persons with sleep disturbances

contributes to health care expenditure both directly and

indirectly. Direct costs are incurred for sedatives.

Indirect costs result from the side effects of

sedatives. Side effects of sedatives, including

confusion and incontinence, leading factors in nursing

home admission, are more prevalent and more serious in

the elderly than in younger persons. Decreasing the use

of sedatives in the elderly could substantially decrease

health care expenditures by decreasing the direct and

indirect costs related to the treatment of sleep

disturbances.

Little is known about what the elderly expect of

sleep patterns as they age. Sleep facilitators utilized











by the elderly when they experience sleep disturbances

and the attitudes of elderly subjects to sleep pattern

changes they experience have not been explored. It is

important to discover the normal sleep patterns of the

elderly who reside in the community so that the nurse

will understand when deviations from normal occur in

clients she or he is caring for. Nurses are responsible

for individualizing care for elderly when they are

hospitalized or institutionalized. It is important to

base that plan of care on a sound scientific base. This

includes knowledge of normal age related changes as well

as responses of the elderly to changes they experience.

Nurses play a very active role in educating elderly and

often instruct clients regarding normal age related

changes. In the area of sleep disturbances the nurse is

in a key role to acquaint elderly clients with normal

age related changes and strategies employed and found

effective by other elderly persons. Nurses employed in

the expanded role of nurse practitioner are able to

prescribe medications for the elderly. It is important

to understand sleep related sleep behavior changes in

order to develop protocols that are effective in helping

elderly clients deal with sleep disturbances.

Gerontological nursing is a new specialty area, and

the gerontological clinical specialist often assumes the












function of educating other members of the health care

team regarding normal age related changes and strategies

for dealing with these changes. It is important,

therefore, to determine what these changes are, their

prevalence, and effective strategies being utilized by

elderly living in the community.

This research is undertaken to determine the

relationship between self-report of sleep behavior among

well elderly living in the community as it may be

affected by expectations regarding sleep, sleep

facilitators utilized by elderly who experience sleep

disturbances, and sleep inhibitors common to the

elderly. These data are vital for nurses to develop

nursing interventions to assist the elderly in managing

sleep pattern changes. Physicians who are responsible

for a medical plan of care that includes large numbers

of sleeping medications for elderly clients can also use

these data. Elderly also need to have this information

for better management of sleep pattern changes they

experience.

Research to date has focused on sleep behavior

patterns experienced by the elderly. Several surveys

have been conducted (Domino, Blair, & Bridges, 1984;

Hayter, 1983; McGhie, & Russell, 1962; and Tune, 1969).

Electroencephalogram sleep recordings have also been






5




utilized in the study of sleep of the elderly (Agnew, &

Webb, 1971; Bixler, Kales, Jocoby, Soldatas, & Vela-

Bueno, 1984; Blois, Feinberg, Gaillard, Kupfer, & Webb,

1983; Carskadon, Brown, & Dement, 1982; Karacan,

Thornby, Anch, Holzer, Warheit, Schwab, & Williams,

1979; Roehrs, Zorick, Sicklesteel, Wittig, & Roth,

(1983); Reynolds, Coble, Black, Holzer, Carroll, &

Kupfer, 1980; Webb, & Schneider-Helmert, 1984; Webb,

1982). Webb (1983) conducted a study of sleep patterns

of elderly subjects which included sleep diaries, post-

sleep inventories, EEG recordings, and sleep

questionnaires. Observational studies of sleep in the

elderly have also been conducted (Webb & Swineburne,

1971; and Gress, Bahr, & Hassanein, 1981).

Expectations have been shown to be a factor in

defining a condition as a problem. Further,

expectations are developed based on previous personal

experience and in comparison with what others are

experiencing (Blau, 1964). Although elderly subjects

have been found to experience sleep disturbances, they

often do not report sleep complaints. It has been

suggested (Carskadon, VanDenHoed, & Dement, 1980) that

the elderly may accept the stereotyped view of sleep in

the elderly and believe that their disturbed sleep is

normal for people their age.











Sleep facilitators and inhibitors common to the

elderly, with the exception of sedative use, have not

been explored. Decreasing the amount of time spent in

bed at night to consolidate sleep for individuals who

perceive their sleep as disturbed and taking a nap

during the day if day tiredness is a problem have been

suggested (Carskadon, Brown, & Dement, 1982). The

relationship between expectations about sleep, and the

facilitators and inhibitors the elderly employ in

dealing with sleep pattern disturbances has also not

been explored.

Several study questions were posed. What is the

sleep behavior reported by persons 65 and older residing

in the community? How do the elderly perceive their

sleep to have changed? What is the relationship between

sleep behaviors reported by the elderly and their views

of sleep in others their age? What is the relationship

between current sleep behavior reported by the elderly

and self-report of their previous sleep behavior? What

types of sleep facilitators do the elderly use to deal

with sleep pattern disturbances they experience? What

types of sleep inhibitors do the elderly exhibit? How

effective are sleep facilitators employed by the elderly

in dealing with sleep pattern disturbances? What are

the subjective reactions of the elderly to sleep pattern











disturbances? What is the affective response reported

by the elderly to sleep disturbances they experience?

Objective Behavioral Theory of Sleep

The objective behavioral theory of sleep developed

by Webb (in press) includes behavioral, adaptive, and

restorative components. Two theories of sleep, the

restorative theory and the adaptive theory, were in

existence prior to the development of the objective

behavioral theory of sleep. The objective behavioral

model of sleep is an attempt to reconcile the

differences between the two preexisting theories.

The behavioral component of the objective

behavioral theory of sleep (Webb, in press) consists of

modulating, intervening, and dependent variables.

Sleep behavior is the dependent variable and consists of

the presence or absence of sleep (sleep latency and

sleep length), sleep structure (sleep stages and

continuity of sleep), and subjective responses to sleep

(sleep evaluations and thresholds and dreams) (see

Figure 1-1).

Adaptive Theory of Sleep

The adaptive theory of sleep proposed by Webb

(1974) is a precursor to the objective behavioral theory

of sleep. In the adaptive theory of sleep (Webb, 1974,

p. 1023) sleep is considered to be an adaptive














MODULATING VARIABLES


Species Differences

Developmental Stages

Organismic States

Individual Differences


INTERVENING VARIABLES


Sleep Demand

Behavioral Facilitators
or Inhibitors

Circadian Tendencies


DEPENDENT VARIABLE


Sleep Behavior

Presence or Absence of
Sleep (Sleep Patterns)

Sleep latency

Sleep length

Sleep Structure

Sleep stages

Continuity

Subjective Responses to
Sleep

Sleep evaluation

Thresholds and Dreams


Adapted from Webb (in press)

Figure 1-1. Diagram of the Behavioral Component Within
the Objective Behavioral Theory of Sleep











non-responding and the particular characteristics of the

sleep of each species evolved from the adaptive role of

this process in the ecological niche of each species.

Webb addresses the semantic problem related to

describing sleep. Webb asks, "Is sleep behaving or not

behaving? If an animal is required to avoid continuing

a behavior, is this avoidance behavior or non-behavior?"

Webb resolves this issue by using the term non-

responding defined as "qualitatively minimal behavioral

engagement with the surround" (Webb, 1974, p. 1023) in

describing sleep behavior.

The primary postulate of the adaptive theory of

sleep is that survival requires periods of non-

responding. Secondly, sleep is an active process

controlling the behavior of the animal, resulting in

nonresponding. According to the adaptive theory of

sleep (Webb, 1974), three critical variables associated

with sleep of all species within each twenty-four hour

period are diurnal placement, intermittentcy, and total

amount. Diurnal placement refers to the time of day

sleep usually takes place. Some animals are nocturnal,

sleeping during the day and searching for food at night

while others sleep during the night and are awake during

daylight hours. Intermittentcy refers to the

continuity of sleep. Some species, for example cats,











sleep for short intervals several times during the 24

hour cycle. Total amount of sleep is the total number

of hours the animal sleeps. The primary correlates of

these variables are the search for food, and the

position on the predatory hierarchy of the particular

species.

Species differences are further addressed in the

adaptive theory of sleep in that precocial animals,

those animals that are highly independent at birth, vary

little in the total amount of sleep time from birth to

adulthood. Altricial animals, those animals that are

highly dependent at birth and for a long time afterward,

including humans, vary greatly developmentally, with

infants sleeping much longer than adults.

Restorative Theory of Sleep

The restorative theory of sleep holds that

wakefulness causes a depletion or build up of some

substance that causes sleep to occur (Dann, Beersma, &

Borbely, 1984). Sleep serves to dissipate or buildup

whatever it is that either becomes depleted or increases

to an excess. The theory developed by Dann, et al.

(1984) is based on the presence of a sleep-regulating

variable (S) which increases during wakefulness and

decreases during sleep. Sleep onset is initiated when S

reaches an upper threshold (H) and awakening occurs when











the lower threshold is reached (L). The restorative

theory of sleep further holds that the thresholds

display a circadian rhythm that is controlled by a

single circadian pacemaker. The major shortcoming of

this theory is that S has not been found and cannot be

measured (Webb, in press).

The common elements of adaptive models of sleep and

restorative models of sleep are an interaction of sleep

demand and circadian tendencies and facilitators and

inhibitors of sleep (Webb, in press). Sleep demand

(Webb, in press) is the amount of time the individual is

awake preceding sleep. Prior wakefulness represents

sleep demand in the restorative theory of sleep (Dann et

al., 1984). Sleep demand is solely a time variable and

does not include activity or behavior within that time.

Time asleep decreases sleep demand (Dann, et al., 1984;

Webb, in press). Sleep latency, the time it takes to

get to sleep, has been found to be affected by prior

wakefulness (Webb & Agnew, 1971). The circadian

tendency of sleep behavior is the time of occurrence of

sleep within a twenty-four cycle. Circadian tendencies

have been described in both the adaptive theory of sleep

(Webb, in press), and in the restorative theory of sleep

(Dann et al., 1984).











External stimuli enhance or interfere with the

circadian tendency of the sleep-wake cycle (Webb, 1982).

Behavioral facilitators and inhibitors are behaviors of

the individual which make sleep more or less likely to

occur (Webb, in press). Anything that makes sleep more

likely to occur such as lying down is a sleep

facilitator. A sleep inhibitor is anything that keeps

the individual from falling asleep, for example,

standing upright. Behavioral facilitators and

inhibitors may be voluntary or involuntary. Behavioral

facilitators and inhibitors are complex and multiple and

include such things as body temperature, light, noise,

and stress level. External conditions described by

Dann, et al., 1984, are analogous to behavioral

inhibitors and facilitators (Webb, in press) and can

affect the threshold of S. The upper threshold has been

demonstrated to be altered in sleep deprivation studies.

Such environmental factors as darkness, warmth, and lack

of social stimulation can lower the threshold so that

sleep onset occurs. Naps can cause a depression of the

upper threshold. The ringing of an alarm clock may

precipitate a sudden rise in the lower threshold,

causing awakening (Dann et al., 1984).

The three intervening variables (Webb, in press),

sleep demand, circadian tendencies, and behavioral











facilitators and inhibitors, are modulated by four

additional variables (Webb, in press). These four

modulating variables are species differences,

developmental stages, organismic states, and individual

differences. These modulating variables affect the

intervening and dependent variables. Species

differences have been discussed under the adaptive

theory of sleep. Sleep behavior changes with

developmental stages in humans. Infants sleep a greater

proportion of the 24 hour cycle than adults. Naps are a

part of the infant's sleep cycle and are not a part of

the adult sleep cycle. Nap patterns seem to emerge

again in the elderly. Sleep demand, circadian

tendencies, and behavioral facilitators and inhibitors

change from infancy to old age (Webb, in press).

Organismic states are physiological characteristics

including such things as pain, medications, sedation,

stimulants, sleep apnea, and nocturnal myoclonus (Webb,

in press). Painful conditions such as arthritis are

more prevalent in the elderly than in younger adults.

The use of sedatives is higher in the elderly. Sleep

apneas and nocturnal myoclonus increase in incidence

with age. Individual differences occur within any

species, developmental stage or organismic state (Webb

in press). Some individuals require as little as 4











hours of sleep to function well, while others require

more than the average 8 hours to function well.

The behavioral component of the objective

behavioral theory of sleep (Webb, in press) is selected

for further study in the current project (see Figure

1-2). The intervening variables described in the

objective behavioral theory of sleep addressed in this

study are sleep facilitators and inhibitors and

circadian tendencies. Dependent variables described in

the objective behavioral theory of sleep addressed in

this study include (1) the presence or absence of sleep

as measured by sleep latency and length of sleep

episodes; (2) subjective responses to sleep consisting

of sleep evaluations; and (3) sleep structure limited to

continuity of sleep. Sleep stages, generally measured

using EEG, are not measured in this study. Sleep

thresholds and dreams are not addressed in this study.

The modulating variable species differences is not

dealt with in this research. Only humans are studied.

Individual differences are not dealt with in this study.

The design used provides some information regarding

developmental stages, and organismic states, the two

remaining modulating variables described by Webb (in

press). If sleep behavior changes are developmental,

one would expect to detect changes in all subjects with















Intervening Variables Dependent Variable

Behavioral Facilitators-4 --- Sleep Behavior

or Inhibitors Sleep patterns

Sleep latency

Circadian Tendencies Sleep length

Sleep structure

Sleep continuity

Subjective Response

Sleep evaluation


Modulating Variables

Developmental Stages Organismic States









Figure 1-2. Objective Behavioral Theory of Sleep:
Schema of Selected Components












aging. Asking subjects questions about their sleep when

they were younger should shed some light on the

developmental nature of sleep patterns. Data obtained

from the retrospective portion of the questionnaire must

be interpreted with caution. Individuals are being

asked to recall sleep patterns experienced when they

were younger and their responses may be influenced by

memory as well as events that have occurred in the time

interval between then and now.

Organismic states are addressed by reviewing data

from elderly individuals living in a community to

determine the relationship between recent major illness

and sleep behavior. Self-ratings of health are

available for a segment of the population and these will

be utilized in relating organismic differences to sleep

patterns.

The Sick Role

Although sleep disturbances are not illnesses,

elderly individuals often think of them as illness, and

seek help in the same manner individuals experiencing

other illnesses seek help. The sick role as described

by Parsons (1951) allows a framework for explaining this

perspective. Parsons defines illness as:

a state of disturbance in the "normal" functioning
of the total human individual, including both the
state of the organism as a biological system and of











his personal and social adjustments. It is partly
biologically and partly socially defined. (p. 431).

Parsons describes four aspects of the

institutionalized expectation system related to the sick

role. The first aspect is that the sick individual is

excused from normal social role responsibilities. The

excuse is related to the nature and severity of the

illness. Second, the individual is helpless to "will"

himself well. Third, the individual has an obligation

to get well. Fourth, the individual is expected to seek

competent help and to cooperate in trying to get well.

The urgency of the need for help varies with the

severity of the disability, suffering, and risk of death

or serious, lengthy, or permanent disability. The

situation of illness places the patient and those close

to the patient in a situation of strain.

Sleep disturbances can be discussed within the

framework of Parson's sick role. The person

experiencing sleep disturbances may be excused from

social roles because of being perceived as too tired to

perform these roles adequately. This judgement is

directly related to the severity and length of the sleep

disturbance. Granting of sick role status is related to

the degree of responsibility for the sleep disturbance

assessed to the individual. If the individual does such

things as consume caffeineated drinks immediately prior












to retiring, that individual will less likely be granted

the privileges of the sick role. The individual is

expected to try to help him/herself by reducing caffeine

intake, decreasing stress, and using remedies such as

drinking milk before retiring. If the sleep disturbance

persists the individual is expected to seek competent

help, usually from a physician. The individual is then

expected to cooperate with the physician and carry out

the prescribed therapy. Death or permanent disability

are not expected to be caused by sleep disturbances.

However, individual suffering from severe and prolonged

sleep disturbances may fear that their mental health

will be affected. Side effects of medications used to

treat sleep disturbances may be severe.

Sleep disturbances experienced by one member of the

family may place other members of the family under a

strain. Family members may be asked to alter their

routines to accommodate the sleep disturbed individual.

The sleep disturbed individual may be excused from

family roles which need to be adopted by other family

members. It seems relevant to address help-seeking

behavior of the elderly with regard to sleep

disturbances from the perspective of Parson's sick role.












Operational Definitions

Several operational definitions are utilized in

this research. They are as follows:

Sleep behavior. Sleep behavior is comprised of

sleep patterns, sleep structures, and subjective

responses to sleep.

Sleep Pattern. Sleep pattern is the presence or

absence of sleep as identified by sleep latency and

length of sleep episode.

Sleep latency. Sleep latency is the length of time

subjects report it takes them to get to sleep.

Length of sleep episode. The length of the sleep

episode is the duration of sleep as measured by the

average number of hours subjects report sleeping at

night.

Sleep structure. Sleep structure is limited to

continuity of sleep and omits sleep stages in this

study.

Continuity of sleep. Continuity of sleep consists

of the number of awakenings, the length of time awake

after falling asleep, and the frequency and length of

naps.

Subjective response to sleep. Subjective response

to sleep is limited to sleep evaluations and eliminates

thresholds and dreams in this study.












Sleep evaluations. Sleep evaluations include the

subject's estimate of how well they sleep; self-rating

of the amount of sleep they get; how rested they feel

when they wake up; how much they enjoy sleep; and how

light or deep they report their sleep.

Circadian tendency. Circadian tnedency is the

placement of sleep within a 24 hour cycle as measured by

the time subjects report as their bedtime and time of

getting out of bed on weekdays and on weekends.

Circadian tendency also includes the reported weekday

bedtime of subjects compared to their average weekend

bedtime; the average weekday time of awakening compared

to their average weekend time of awakening; the use of

an alarm clock; the number of days per week subjects

report going to bed more than one hour earlier or later

than their average bedtime.

Sleep disturbance. Sleep disturbances include the

reported frequency of; (1) difficulty getting to sleep;

(2) awakening during the night without being able to

return to sleep: and (3) awakening earlier than expected

without being able to return to sleep.

Behavioral facilitators. Behavioral facilitators

are strategies elderly subjects identify as those they

use to help them when they experience sleep disturbances













and which are considered effective in dealing with sleep

disturbances.

Behavioral inhibitors. Behavioral inhibitors are

those variables identified by subjects as possible

causes of overall sleep problems; and strategies elderly

subjects employ which have been shown to have a

detrimental effect on sleep (i.e. alcohol or

sedatives).

Affective responses to sleep disturbances.

Affective responses to sleep disturbances are the

reported reactions to sleep pattern disturbances.

Elderly. Elderly are individuals age 65 or older.

Summary

The objective behavioral theory of sleep as

described by Webb (in press) is used as the foundation

for this research with the focus on exploring the

behavioral components of the theory. This research is

undertaken to determine the relationship between sleep

behavior of the elderly and expectations regarding

sleep. Sleep facilitators employed by the elderly as

they encounter sleep disturbances are also investigated.

Affective reactions to sleep disturbances experienced by

elderly subjects are also explored. Help-seeking

behavior for sleep disturbances will be examined within

the framework of Parson's sick role.













CHAPTER II
REVIEW OF LITERATURE

Sleep Behavior Changes With Age

Research findings related to sleep pattern changes

in the elderly suggest that there is a great variability

in sleep behavior in elderly subjects (Hayter, 1983).

As clients age, changes in sleep behavior are reported

in subjects over age 75 with still greater changes seen

in subjects over 85 year of age (Hayter, 1983; McGhie &

Russell, 1962). The primary sleep related changes that

occur with aging are difficulty getting to sleep,

awakening within sleep, sleep stage liability, longer

time to return to sleep following arousal and early

awakenings. (Webb, 1983).

Sleep Patterns

Sleep latency, the time it takes to fall asleep, is

longer in older subjects (Agnew and Webb, 1971; Hayter,

1983; and Webb and Schneider-Helmert, 1984). Agnew and

Webb (1971) compared the sleep latencies of seven age

groups and found that subjects aged 16 to 69 had sleep

latencies of one to five minutes. The oldest age group,

60 to 69 years, exhibited the longest sleep latencies

with a mean of 15 minutes to fall asleep. More frequent

night awakenings occur in those over 85 (Hayter, 1983;

Tune, 1969; Webb, 1982a). Sleep patterns were evaluated












in the laboratory and total wake time was found to be

correlated positively with age (Bixler, et al., 1984).

This difference was due primarily to an increase in the

number and duration of night awakenings in subjects in

the 50 to 80 year group. Webb and Swineburne (1971)

observed night awakenings in subjects ranging from two

to five per night. Awakening during the night increased

with age (Tune, 1969) with subjects over 50 having the

most disturbed sleep.

Differences in sleep behavior changes between men

and women have not been found to be significant

(Carskadon, et al., 1982; Webb & Schneider-Helmert,

1984; Webb, 1982c). Women report more pre-sleep

difficulties (McGhie & Russell, 1962) including longer

sleep latency (Hayter, 1983; Webb & Schneider-Helmert,

1984). A greater number of awakenings for men has been

reported (Bixler, et al., 1984; Reynolds, Kupfer, Taska,

Hoch, Sewitch, & Spiker, 1985; and Webb, & Schneider-

Helmert, .1984).

An increase in the number of naps has been found in

those over 75 years of age (Hayter, 1983) In subjects

over 85, the total amount of nap time increases with no

increase in the number of naps (Hayter, 1983). Tune

(1969) reported an increase in the number and duration

of naps in older subjects. Webb and Swineburne (1971)












observed the sleep of 19 elderly subjects for two 36

hour periods and found that almost all of the subjects

took one or more naps. Great variability was found with

one subject not taking any naps while four subjects took

three naps a day. The length of naps was not related to

night sleep and was judged to be neither compensatory

nor limiting relative to night sleep.

Webb and Agnew (1974) studied 14 subjects for 14

days in a time-free environment to determine if sleep

patterns were dependent on exogenous or endogenous

factors. All subjects displayed a rhythm greater than

24 hours. Large individual difference in the amount of

variance from 24 hours were seen. The overall

distribution of sleep stages did not differ from

baseline recordings. Webb and Agnew (1974) concluded

that overall sleep patterns remain stable in a time-free

environment. Prior wakefulness, length of sleep, and

sleep onset time continue to affect sleep. This is

taken as-evidence for the stability of the structure of

the sleep process.

Subjective Response to Sleep

Karakan, et al., (1979) studied 1645 subjects

ranging in age from 18 to over 70. A steady increase in

the percentage of subjects reporting trouble sleeping

occurred with age. Seventy-five percent of the 18-19












year age group reported never or seldom having trouble

sleeping while 50% of those over 70 reported never or

seldom having trouble sleeping. Twenty-five percent of

subjects over 70 reported having trouble sleeping often

or all the time. In the 18-19 year age group, 6% of the

subjects reported trouble sleeping often or all of the

time. Females in the older age ranges reported more

difficulty sleeping than males. When asked what kind of

sleep problems they experienced, a higher percentage of

respondents over age 40 indicated trouble staying

asleep or waking too early.

McGhie and Russell (1962) found that despite sleep

changes, the aged tended to complain less of morning

tiredness until age 75 when there was a significant

increase in the incidence of reports of day tiredness.

Carskadon, et al., (1982) reported that only transient

arousal and respiratory events had a statistically

significant relationship to daytime sleep tendency.

Continuity of sleep was of greater significance to

daytime well-being than total sleep time.

Webb and Levy (1982) found that older subjects were

affected more by acute sleep deprivation than younger

subjects. Although many sleep pattern changes occur

with aging, few are related to daytime tiredness (McGhie

& Russell, 1962). Day tiredness does not significantly












increase until age 75. Women and those over 75 are more

likely to take sedatives. This is of great importance

because the over 75 age group is the most rapidly

growing cohort, and women constitute a high percentage

of that cohort.

Webb and Schneider-Helmert (1984) use the terms

"disturbance" rather than disease and "category" rather

than symptom when describing sleep changes. This

reflects their belief that sleep changes are associated

with the aging process.

Developmental Changes in Sleep Patterns

Webb (1982b) was able to study a second time the

sleep of five subjects who had undergone sleep

recordings of four nights 15 years earlier. The

recordings at an older age showed a sharp increase in

awakenings. Rank order correlations for time one and

time two resulted in .55 correlation on number of

awakenings.

Organic States That Affect Sleep

Organic states that affect the sleep of the elderly

include sleep apnea, nocturnal myoclonus, arthritis,

heart disease, respiratory disease, Alzheimer's disease,

blindness, and nocturia. (Milne, 1982; Quan, et al.,

1984; and Schirmer, 1983). Roehrs, Zorick, Sicklesteel,

Wittig, and Roth (1983) conducted a study of 562












patients referred to a sleep disorder clinic because of

sleep disorders. Of those patients seen, 97 were in the

61 to 81 year age group, 264 were in the 41 to 60 year

age group and 202 were in the 20 to 40 year age group.

Nocturnal myoclonus was the most frequent problem of the

elderly. Sleep disturbances related to drug and alcohol

use were higher in the oldest age group than in the

other two groups. Other disorders that contributed to

sleep disorders included sleep apnea, psychophysiologic

and psychiatric disorders, medical disorders and

circadian rhythm disturbance.

Sleep apnea is a condition in which the individual

experiences episodes of apnea throughout the night

(Quan, et al., 1984). Sleep is interrupted by apneic

episodes that are often followed by loud snoring. Sleep

apnea is often most apparent to the bed partner, and may

go unrecognized by the individual experiencing sleep

apnea. Because of the sleep fragmentation, the

individual often experiences daytime hypersomnolence.

Nocturnal myoclonus is a condition in which the

individual experiences periodic leg movements throughout

the night that result in sleep fragmentation (Quan, et

al., 1984). Excessive daytime hypersomnia may result.

Arthritis and other painful conditions may prevent

the elderly individual from getting to sleep easily or












awaken the individual during the night. (Quan, et al,

1984). Arthritis is more frequent in the elderly than

in younger age groups. Elderly individuals with heart

disease may be awakened from sleep because of pain or

because of difficulty breathing (Quan, et al., 1984).

Respiratory disorders, Alzheimer's disease, and

blindness may also lead to sleep fragmentation and

increased daytime somnolence (Quan, et al., 1984).

Nocturia, getting out of bed at night to void,

is more common in the elderly than in younger

individuals (Schirmer, 1983). This may be due to

prostatism in males or to an increased use of diuretics

in either males or females.

Individual Differences

Great variations in sleep behaviors are seen

between individuals. The average number of hours adults

sleep is 7.5 with a standard deviation of one hour

(Webb, 1983). This means that an individual may sleep

6.5 to 8.5 hours and be within one standard deviation of

the norm for sleep. Ninety-nine percent of individuals

will sleep between 5.5 and 9.5 hours. Webb and

Swineburne (1971) observed the sleep of nine men and 10

women. They found great variability between subjects.

Hayter (1983) studied sleep of 212 noninstitutionalized

subjects aged 65 to 93 and found great variability even












among subjects in the same age group. Hayter found

variability in time spent in bed, sleep latency, number

and amount of time awake after sleep onset, number and

length of daytime naps, time going to bed, and time

getting up.

Behavioral Facilitators and Inhibitors of Sleep

Organic disease such as arthritis, sleep apnea,

nocturnal myoclonus, cardiac disease, respiratory

conditions have been indicated in sleep disturbances.

Treating the underlying cause of the sleep disturbance

may be all that is necessary to restore adequate sleep

(Quan, et al., 1984). Exercise programs and relaxation

training have also been suggested (Milne, 1982; Quan, et

al., 1984, Schirmer, 1983). Praying may be a soothing

activity for some individuals (Schirmer, 1983).

Education regarding normal sleep pattern changes that

occur with age has also been recommended (Milne, 1982;

Quan et al., 1984, Schirmer, 1983). Eating a light

snack or drinking a glass of milk before retiring have

been suggested (Milne, 1982; Schirmer, 1983). Drinks

which contain caffeine should not be ingested within two

hours of bedtime (Milne, 1982). A regular sleep

schedule to regulate the biological clock has been

recommended (Schirmer, 1983). For difficulty getting to












sleep, getting out of bed and listening to music or

reading may be helpful (Schirmer, 1983).

Older subjects were more likely to report sedative

use than younger subjects (McGhie & Russell, 1962;

Hayter, 1983; Karacan, et al., 1979). In 1981, twenty-

one million prescriptions were written for sleeping

pills (Lamberg, 1984). An increase in the use of

sedatives has been found in the 85-year-old age group

(Hayter, 1983). Many people who report habitually

taking sleeping pills state that they began taking

sleeping pills while they were in the hospital (Lamberg,

1984). Sedatives are usually ordered as needed,

therefore the nurse has great latitude in administering

these medications. Sedative use can result in side

effects such as ataxia, paradoxical excitement,

confusion, incontinence, and even death in individuals

with sleep apnea (Quan, Bamford, & Beutler, 1984).

Confusion and incontinence are leading factors in

nursing home admissions of the elderly. Nurses play a

pivotal role in sedative use among the elderly.

Lamberg (1984, p.139) advises against the use of

sleeping pills if one is "middle-aged" or older because

of the increased incidence of ataxia, the decreased

ability of the liver to detoxify the drug and the

incidence of interaction with other drugs. Other












conditions frequent to the elderly in which the authors

warn the use of sleeping pills include the presence of

respiratory disease, liver or kidney disorders, alcohol

consumption, and a history of having taken sleeping

pills before without improvement in sleep.

Problems associated with sedative use include

confusion, paradoxical excitement, morning "hangover"

perhaps accompanied by ataxia, interactions with other

drugs, dangers in specific illness such as sleep apnea,

and distortion of natural sleep patterns (Hartman,

1980). Because of decreased ability to adapt, and

increased incidence of chronic illness, the elderly are

more likely to experience adverse effects from sedatives

(Quan, et al., 1984).

Most sleep inducing agents lose their effectiveness

within a week or two and influence sleep stage pattern

during their administration (Borkovec and Fowles, 1973).

Many cases of insomnia do not involve physiological

causes such as pain but are caused by psychological or

environmental factors. (Borkovec and Fowles, 1973).

Psychological factors include such things as stress,

anxiety, and fear, while environmental factors include

such things as noise, light, and temperature. The most

important biological cause of insomnia has been

identified as drugs (Borkovec et al., 1973). Sedatives












are of questionable value in the elderly and may

contribute to a reduced quality of sleep rather than

improved sleep (Colling, 1983). In 1974, one-third of

all prescriptions for secobarbital and diazepam were for

patients over 60 years of age (Quan, et al., 1984).

Excessive use of alcohol is associated with the

same kind of sleep problems associated with sedatives

(Milne, 1982; Quan, et al., 1984). Individuals may fall

asleep more readily after consuming alcohol, but are

likely to awaken and be unable to return to sleep (Quan

et al., 1984).

In this research, sleep facilitators employed by

the elderly when they experience disruptions of sleep

patterns are explored. Sleep inhibitors exhibited by

the elderly are also explored.

Self-Rating of Health

An older person with a given set of health status

characteristics is more likely than a younger person

with similar characteristics to rate his/her health

better than that of peers the same age (Stoller, 1984).

Older persons are more likely to rate their health

positively than younger persons (Cockerham, Sharp, &

Wilcox, 1983). The old-old, those over age 75, assess

their health at a higher level than do the young-old












exhibiting similar health characteristics (Linn, & Linn,

1980).

Symptoms themselves do not define a person as sick,

but rather serve as "triggers that raise questions for

further exploration" (Zola, 1966). Self-assessments of

health among older people seem to be influenced by

comparisons with their peers (Cockerham, et al., 1983).

In a study conducted by Stoller (1984) most older

respondents rated their health on the upper (positive)

rungs of the Cantril ladder (Cantril, 1965). In this

study subjects were presented with a picture of a ladder

with the rungs numbered from zero on the bottom rung to

nine on the top rung. Subjects were asked where they

would place themselves, where they would place others

their age, and where they thought they would be in five

years. The majority (63.8%) of the elderly subjects in

this study (Stoller, 1984) rated their own health better

than they rated the health of other people their own

age. Stoller concludes that self-assessments of health

by the elderly as better than others of the same age may

reflect misconceptions about health by the elderly. The

elderly may believe that a marked decrease in level of

health and functional decline are inevitable with aging.

Because of these misconceptions, when the elderly do not

experience the declines they expect with aging, they












consider themselves the exception and rate their health

better than they rate the health of their peers.

It can be concluded, therefore, that expectations

of health influence the way the elderly describe their

health. In this research, it is anticipated that

expectations regarding sleep disturbances in aging will

correlate with self-rating of sleep by the elderly. It

is anticipated that elderly individuals experiencing

sleep disturbances will rate their sleep more poorly

than they rate the sleep of others their age.

Some elderly persons may accept sleep pattern

changes as part of aging and not define sleep changes

they are experiencing as problems (Quan, et al., 1984).

Other elderly individuals interpret sleep pattern

changes as being abnormal and define changes as problems

(Quan, et al., 1984). Lack of knowledge on the part of

the elderly concerning age related sleep changes

(Hayter, 1983; and Quan, et al., 1984) and the great

variability of sleep patterns exhibited by the elderly

(Hayter, 1983) contribute to the confusion. This

research is undertaken to further elucidate the

behavioral aspects of Webb's Objective behavioral Theory

of Sleep (in press) by describing sleep behaviors

experienced by the elderly, their expectations regarding

sleep behavior, help-seeking for sleep disturbances,






35





sleep facilitators and inhibitors common to the elderly

and affective responses to sleep behavior changes.













CHAPTER III
MATERIALS AND METHODS

Methodology

Subjects

Using a survey design, 336 subjects from the

Dunedin Clinic, Dunedin, Florida were given

questionnaires to complete. All eligible clients of the

Dunedin Clinic who had their annual health assessment

during the period from September 28, 1987 to November

25, 1987 were invited to participate in the main study.

Subjects ranged in age from 65 to 94 with a mean age of

78.3. A total of 282 subjects returned the sleep

questionnaire in a useable form. One hundred sixty-five

(57.9%) respondents were female and 87 (35.4%) were

male. Demographic data was not available for 33

subjects. All subjects were living in the community.

Setting

The Dunedin Program is a longitudinal study of 4200

elderly residents of Dunedin, Florida, funded in part by

the James Hilton and Emma Austin Manning Foundation

since 1975. The Dunedin Program is conducted at the

Dunedin Clinic. The sole function of the Dunenin Clinic

is to conduct the Dunedin Program. The purpose of the

Dunedin Program is to study healthy elderly individuals

living in the community for unidentified health












disorders. The study is also conducted to generate

information about the prevalence of disease, signs and

symptoms, and to determine biochemical norms for this

age group. (Hale, Marks, & Stewart, 1980).

Each year subjects complete a detailed

questionnaire about their health including a detailed

medication assessment. Subjects then report to the

Dunedin Clinic where an electrocardiogram is performed,

and biochemical analysis of a blood sample is conducted.

Each subject's blood pressure is assessed. Subjects are

referred to their private physician for treatment if

health problems are discovered.

The Dunedin Clinic provides access to a readily

available subject pool from which subjects can be drawn.

All subjects are over the age of 65, and are living

independently in the community. Longitudinal data are

available on subjects and it may be possible to continue

to study subjects in this project in the future.

Dunedin, Florida is located on the western coast of

Florida. Dunedin is located in Pinellas county, the

most densely populated county in Florida with 4.4

persons per acre. The economy of Dunedin is dependent

on tourism and retirement living. According to the

Chamber of Commerce (1986) the permanent population

estimate of Dunedin is 35,292. Approximately 43 percent












of Dunedin's population is sixty years of age or older

with females making up approximately 54.7% of the total

population and 58.1% of the over sixty population.

White persons constitute 98.7% of the population.

Educational information indicates that 72.4 percent of

the Dunedin residents 25 years of age and older are high

school graduates. Eighteen percent have had some

college and 16 percent have had at least 4 years of

college.

Instruments

The Sleep Questionnaire developed by White (1975)

(See Apprendix A) was utilized to assess subjects'

current sleep patterns, their previous sleep patterns,

and their thoughts about the sleep patterns of others

their age. Items were added to the Sleep Questionnaire

to determine mechanisms employed by the elderly when

they encounter sleep disturbances of sleep onset

latency, awakening during the night, and early morning

awakening. The frequency of the use of these

mechanisms, and the subjects' perception of the

effectiveness of these mechanisms were assessed.

Subjects' affective responses to sleep disturbances were

also assessed. The final questionnaire consisted of 94

items. Webb and Stone (1963) administered a

questionnaire related to sleep to 104 undergraduate












students over a two year period. Test-retest

reliability was .82 for the first class and .83 for the

second class for length of sleep. Sample two was asked

a question regarding length of time to function at full

capacity upon awakening. Test-retest reliability was

.63.

Reliability of the Sleep Questionnaire used in this

study has been established in an investigation which

compared the measurement of sleep behavior using this

questionnaire versus using a daily diary (White, 1975).

Subjects were asked to complete the Sleep Questionnaire

as a pre-log and as a post-log. Subjects were asked to

maintain a sleep diary for two or four weeks. Sleep

length had a correlation of .70 between the pre-log

questionnaire and the diary. Average weekday bedtime

correlated .78 between the pre-log questionnaire

estimate and the diary. Average weekend bedtime

correlated .66 between pre-log questionnaire and diary.

Sleep diary mean weekday wake-up time and questionnaire

correlated .74. Average weekend wake-up time and

questionnaire estimate correlated .58. Post-log

questionnaire and diary correlations were also reported.

These correlations tended to be higher, presumably

because subjects had been paying attention to their

sleep behaviors for two or four weeks. The more












conservative pre-log questionnaire correlations were

selected for this study because they more accurately

correspond to the method used in this study.

Webb, Bonnet, and Blume (1976) tested a post-sleep

inventory to determine construct validity. The

researchers found that subjects rated their sleep "good"

or "bad" by comparing their sleep with their "usual"

night, their sleep over a few weeks or several years, or

by comparing their sleep to the way they thought others

slept. The scale developed was found to have high

construct validity.

Content validity was claimed for the instruments.

The Sleep Questionnaire was developed by an expert in

the field of sleep research. The questionnaire reflects

the literature of sleep research. Following a study of

102 college students, White (1975) concluded that

estimates of the expected range of average sleep

behavior for a group utilizing the Sleep Questionnaire

was valid.

Items related to adaptations to sleep disturbances

were developed in consultation with two sleep research

experts. Literature was reviewed to determine

recommendations for improving sleep. Items which could

be used in the questionnaire were then developed. Sleep

difficulties were divided into difficulties getting to












sleep, difficulty staying asleep and awakening earlier

than desired. Subjects were asked to indicate which

measures they used when they had difficulty at any or

all of the three times. Subjects were also asked to

rate the effectiveness of strategies they employ when

they encounter sleep difficulties.

Demographic data as well as information regarding

current health status, recent illnesses, and recent

hospitalizations were obtained from the Dunedin Program

Questionnaire. This questionnaire is completed annually

by all clients of the Dunedin Clinic.

Procedure

Pilot. A pilot study was conducted during the week

of September 7, 1987 to test the use of the Sleep

Questionnaire with the participants enrolled in the

Dunedin Program. All subjects (n=24) who visited the

Dunedin Clinic for their annual assessment were asked to

complete the questionnaire and mail it to the

investigator within two weeks. Fourteen of the subjects

who returned the questionnaire to the researcher were

interviewed by telephone. Subjects were asked to

describe any difficulties they had with the

questionnaire, how they rate their sleep, how they

compare their sleep to others their age, what they do if

they have trouble sleeping, how they define "younger",












and what additional questions they might have asked.

Data obtained in the questionnaires and the telephone

interviews were compared to determine consistency.

Methodological problems encountered in conducting

the pilot study were corrected before the main study

began. One question was added to the questionnaire and

several questions were modified as a result of this

pilot study.

The added question required subjects to indicate

whether or not they have a friend or relative who

experiences trouble sleeping. Many of the subjects in

the pilot did not answer questions about sleep of other

elderly persons. This question was added to provide a

focus for subjects related to sleep of other elderly

persons. It was hoped that this would increase the

number of responses to questions about sleep of other

elderly. Questions about sleep of others were changed

from comparative questions to questions requiring a

numeric answer. For example, in the pilot questionnaire

subjects were asked "Do you think others your age sleep

better, worse, or the same as you do?". This question

was changed to "How well do you think others your age

sleep?" The choices for responses were; 1) very well,

2) satisfactorily, 3) some problems, 4) poorly, and 5)

don't know. This was to increase the consistency of the











questions and to increase the response rate of those

items. A "don't know" response was included in all

questions related to sleep of others.

Power analysis. A power analysis as described by

Marks (1982) and Cohen (1977) was conducted to determine

the required number of subjects for this study. A pilot

study was conducted on 24 subjects and from the data

obtained in the pilot study, it was determined that 39%

of the pilot sample chose the response "very well" to

describe their sleep at the present time. The value 39

was used as the estimated P (the percentage of

observations that fall into a particular category) to

determine the number of subjects required for the main

study. The confidence coefficient of .95 was chosen.

The confidence coefficient "reflects our confidence that

the computed interval will contain the parameter of

interest" (Marks, 1982, pg. 122). In this study it is

95% probable that the estimated sleep length obtained,

for example, will fall within the true, unknown, average

sleep length. A bound on error of .06 was selected. To

continue with the previous example, a bound on error of

.06 means that the estimate of sleep length obtained

will be within 6% of the true sleep length. A sample

size of 257 was estimated to be needed for the study











(Marks, 1982, pg. 132) based on the return rate

experienced in the pilot study.

Main study. The 336 subjects attending the clinic

during the time of this study represent 14% of the 2400

subjects currently being seen at the Dunedin Clinic.

Clients with physical or psychological problems such as

blindness or Alzheimer's disease were excluded. All

other clients who presented at the clinic during the

time period of the study were invited to participate in

this study. The time period was defined to end prior to

Thanksgiving and the beginning of the Christmas holidays

because of the increased incidence of depression during

the Christmas holiday. The relationship between

depression and sleep disturbances is well documented.

The Sleep Questionnaire was given to each subject

who consented to be included in the study at the

completion of his/her annual visit. A total of 336

questionnaires were distributed over a six week

interval. The nurse who gave the questionnaire to

subjects described the purpose of the study, and

encouraged the subject to complete and mail the

questionnaire to the researcher within two weeks.

Subjects were asked to sign a consent form permitting

access to data from their most recent Dunedin Program

Questionnaire. Questionnaires for this study were











identified using the same subject number that is used in

the Dunedin Program. The subject number was known only

to the researcher and the research team of the Dunedin

Clinic. Subjects were advised that the same subject

number was being used for this study as is used in the

main Dunedin Program study. A stamped, addressed

envelope was given to subjects for returning the

questionnaire to the investigator at her home.

Telephone calls were made as reminders to subjects who

had not returned their questionnaires within two weeks.

A total of 285 questionnaires were returned for a return

rate of 84.8%.

Data Analysis

Much of the data are presented using descriptive

techniques. The number of subjects who responded to

each item is different. The highest number of subjects

responded to questions regarding their sleep patterns at

present, with fewer subjects responding to questions

about their sleep when they were younger, and still

fewer subjects responded to items about the sleep of

others. Of the 336 questionnaires distributed, 282 were

completed and returned in a useable form. Frequencies

and percentages of subjects responding are reported.

Several subscales exist within the Sleep

Questionnaire. These subscales were used to assess the






46





rhythmic quality of sleep, sleep patterns, behavioral

facilitators or inhibitors of sleep, and affective

responses to sleep disorders. These subscales were

utilized in making comparisons in data analysis.












CHAPTER IV
RESULTS AND DISCUSSION

A pilot study was conducted at the Dunedin Clinic

from September 8, 1987 to September 11, 1987. All of

the 24 subjects who reported to the clinic were

considered for inclusion in the pilot study. Of the 24

subjects who visited the clinic during the time of the

pilot study, all but two were given the questionnaire to

take home and complete. One blind subject and one

subject with Alzheimer's disease were not asked to

participate. Eighteen (81.8%) of the 22 subjects who

were invited to participate returned the completed

questionnaire. The researcher was able to contact 14 of

these subjects by telephone.

Subject's self-rating of sleep at time of interview

was consistent for 13 of the 14 subjects. One subject

rated her sleep as satisfactory on the questionnaire and

good during the interview. When asked what they do when

they have trouble sleeping, 13 of the 14 subjects

interviewed answered the same as they had answered the

questionnaire. One subject indicated on the

questionnaire that she never had trouble sleeping but in

the interview, she answered that when she has trouble

sleeping she stays in bed until she falls asleep.












Subjects were less consistent in their rating of

others' sleep. Seven subjects rated the sleep of others

as compared to their own sleep consistently and five

were not consistent in their replies.

Based on the pilot, it was decided to include a

question to determine if subjects had a friend who had

sleep problems. This was done to provide a focus for

subjects and provide a basis for comparison of subjects

in the main study. Items about the sleep of others were

changed to be consistent with items which immediately

preceded them regarding subject's current and past sleep

patterns.

Subject Characteristics

A convenience sample of the subjects of the Dunedin

Clinic was obtained. A total of 285 subjects returned

the questionnaire. Of these, three subjects had not

answered any questions and returned blank questionnaires

leaving 282 usable questionnaires. Subjects who

reported to the Dunedin Clinic during the time of the

study ranged in age from 65 to 94 with a mean of 78.1

(SD=5.1). The mean age of subjects who returned the

completed questionnaire was 78.1 (SD=5.4) (see Table 1).

The mean age of subjects who did not return the

questionnaire was 78.1 (SD=5.4) There was a higher

percentage of females in both the subjects who returned











Table 1

Aae and


Gender of Respondents and Non Respondents


Respondents Non respondents Total



Age n Mean(SD) n Mean(SD) n Mean(SD)



Female 165 77.4(5.7) 70 78.1(5.9) 235 77.6(5.7)

Male 87 79.4(4.9) 36 78.2(5.6) 123 79.1(5.0)

Total 252 78.1(5.4) 106 78.1(5.4) 358 78.1(5.1)



Gender n % n % n %



Female 165 46.1 70 19.6 235 65.7

Male 87 24.3 36 10.1 123 34.4

Total 252 60.4 106 29.7 358 100.1a


aTotal is greater than 100% due to rounding.












the questionnaire and the subjects who did not return

the questionnaire. Of the subjects reporting to the

Dunedin Clinic at that time for whom demographic data is

known, 235 (65.7%) were female and 123 (34.4%) were

male.

Fifty (14.0%) of the subjects reporting to the

Dunedin Clinic during the time of the study had been

hospitalized at least once during the previous year (see

Table 2). Three subjects had been hospitalized twice,

and one subject had been hospitalized three times within

the last year.

The total number of subjects who indicated that

they had experienced a heart attack within the last year

was 20 (5.6 %). Fifteen (4.2%) of the subjects

indicated they had experienced a cerebrovascular

accident within the past year. No statistically

significant differences were found between those who

responded to the Sleep Questionnaire and those who did

not on any of the demographic variables evaluated.

Subjects who reported to the Dunedin Clinic during

the time of the study included 41 who were entering the

study for the first time. Subjects complete a different

questionnaire each year they are a part of the Dunedin

Program. On questionnsires eight through twelve an

item is included in which subjects are asked to rate











Table 2

Illness Related Variables of Respondents and Non
Respondents by Gender



Respondents Non respondents Total


Subjects Hospitalized

n %


12.7

16.1

13.9


17.1

8.3

14.2


Heart Attacks


% n %

3.6 7 10.0

6.9 1 2.8

4.8 8 7.5

Cerebrovascular Accidents


%

4.9

2.8

3.6


%

7.1

1.2

5.7


%

14.0

13.8

14.0


%

5.5

5.7

5.6


%

5.5

1.6

4.2


Gender

Female

Male

Total


Female

Male

Total





Female

Male

Total


%











their health. In this subsample of 160 subjects, 23

(6.4%) rated their health excellent; 131 (36.6%) rated

their health good; 66 (18.4%) rated their health fair;

and 6 (1.7%) rated their health poor (see Table 3).

Statistically significant differences existed between

respondents and nonrespondents to the questionnaire (chi

square=14.3 df=2, p=.007). Nonrespondents were more

likely to rate their health as fair or poor than

respondents. Significant differences existed between

male respondents and nonrespondents (chi square=15.7

df=3, p=.004) with a higher percentage of male

respondents rating their health as good, while a greater

proportion of male nonrespondents rated their health as

fair or poor. No differences were found between female

respondents and nonrespondents or between male and

female respondents or nonrespondents.

Average daily coffee consumption was reported by

subjects. The amount of coffee consumption ranged from

none to eight cups per day. The modal response was 1 to

2 cups of coffee per day. Subjects were also asked how

much alcohol they ingest. Responses available were

none; occasionally; 2-3 cocktails weekly; 1-2 cocktails

nightly; three or more cocktails nightly; wine

occasionally; and wine daily. One hundred thirteen

subjects denied alcohol consumption; 114 indicated they











Table 3

Self Rating of Health by Gender for Respondents and
Non Respondents



Excellent Good Fair Poor



Gender n % n % n % n %



Respondents

Female 12 7.3 58 35.2 31 18.8 1 .6

Male 6 6.9 44 50.6 12 13.8 -

Total 18 7.1 102 40.5 43 17.1 1 .4

Non respondents

Female 1 1.4 23 32.9 16 22.9 3 4.3

Male 4 11.1 6 16.6 7 19.4 2 5.6

Total 5 4.7 29 27.4 23 21.7 5 4.7

Total Sample

Female 13 5.5 81 34.5 47 20.0 4 1.7

Male 10 8.1 50 40.1 19 15.5 2 1.6

Total 23 6.4 131 36.6 66 18.4 6 1.7



Chi square for respondents vs non respondents =14.3
df=3 p=.007. Chi Square for male respondents vs male
nonrespondents =15.7 df=3 p=.004.











use alcohol occasionally; 27 indicated they drink 2-3

cocktails weekly; 44 indicated they consume 1-2

cocktails nightly; 4 selected three or more cocktails

nightly; 39 drink wine occasionally; and 16 drink wine

daily.

Chi square statistics were computed for all

variables obtained from the Dunedin Program

Questionnaire and self-rating of sleep. The only

statistically significant relationship was between use

of medications that effect sleep and self-rating of

sleep. Twenty-two (8.9%) of the subjects for whom

background data were available reported using

medications that would affect sleep, including sedatives

and pain medications used at bedtime (see Table 4). A

higher percentage of subjects who reported taking

medications which affect sleep also rated their sleep as

poor (chi square=10.71, df=3, p=0.013).

Sleep Behavior

Findings are reported within the framework of the

objective behavioral theory of sleep. Sleep behavior

consists of sleep patterns (sleep latency and length of

sleep), sleep structure limited to continuity of sleep,

and subjective response to sleep confined to sleep

evaluation. Continuity of sleep includes awakenings

within sleep and naps.











Table 4

Quality of Sleep and Use of Medications That Affect
Sleep



Use of Medications

Yes No Total



Quality of n % n % n %
Sleep


Very Well 3 13.6 65 28.9 68 27.5

Fairly Well 5 22.7 84 37.3 89 36.0

Poorly 14 63.6 67 29.8 81 32.8

Some Problems -- 9 4.0 9 3.6

Total 22 8.9 225 91.1 247 99.9


Note. Does not equal 100% due to rounding.













Sleep latency. In response to an item regarding

sleep latency, subjects reported an average length of

time to get to sleep as 26.2 (SD=25.7) minutes. Great

variability is seen in this response with a range from

one to 150 minutes to get to sleep (see Table 5). The

mean sleep latency reported by Webb and Schneider-

Helmert (1984) for subjects 60 to 69 years of age was 15

minutes.

The mean sleep latency subjects reported when they

were younger was much shorter with a mean of 10.6

minutes (SD=8.5). Sleep latency subjects reported for

their younger years was also less variable. The mean

sleep latency of peers was very similar to the subjects'

current sleep latency with a mean of 28.7 minutes

(SD=24.1). It must be noted however that far fewer

subjects estimated sleep latency of peers than reported

their own present or past sleep latency. The finding of

differences between now and younger supports earlier

findings (Agnew & Webb, 1971; Hayter, 1983; and Webb &

Schneider-Helmert, 1984) that sleep latency is longer in

the elderly.

Sleep length. The average sleep length reported by

subjects was 7.1 hours (see Table 5). This varied

little from the report of sleep length when younger

(7.5) and the sleep length of peers (7.0).












Sleep continuity. In addressing the concept of

continuity of sleep, subjects were asked the frequency

and duration of awakenings within sleep and the

frequency and duration of naps. Subjects reported

awakening 0 to 10 times per night with an average of 2.1

(SD=1.3) (see Table 6). Subjects reported fewer

awakenings when they were younger (Mean=.4, SD= 1.0).

Previous studies (Hayter, 1983; Tune, 1969; and Webb

1982a) have reported an increase in the number of

wakenings during the night in elderly subjects. In an

observational study of elderly subjects, Webb &

Swineburne (1971) found that elderly subjects awoke 2 to

5 times per night. Those subjects who reported the

number of times awake for peers estimated a mean of 2.1

awakenings (SD =1.9), which is very similar to the

mean number of times awake per night as subjects

reported for themselves.

Subjects report a mean time awake after sleep onset

of 30.4 minutes (SD=39.4). Again a large variability is

seen with a range from no time awake after sleep onset

to a total of 3 hours spent awake after sleep onset.

Subjects recalled an average of 4.2 minutes awake after

sleep onset when they were younger (SD=19.1). Thirty-

one subjects estimated the amount of time peers spend

awake after sleep onset as 50.2 minutes (SD=40.1).












Table 5

Sleep Patterns Now, When Younger, and of Peers



Age Group n Mean(SD) Range



Sleep latency (minutes)

Now 269 26.2(25.7) 1-150

Younger 187 10.6( 8.5) .5-60

Peers 64 28.7(24.1) 1-120

Sleep length (hours)

Now 279 7.1(1.2) 4-10

Younger 235 7.5(0.9) 4-12

Peers 71 7.0(2.1) 4-10.5












Great variability is observed in estimates of the length

of time awake after sleep onset when subjects were

younger as well as estimates of wake time for peers.

Time awake after sleep onset was reported as shorter

when younger and longer for peers. Bixler et al.,

(1984) report an increase in both the frequency of night

awakenings and the total time awake after sleep onset.

The frequency and length of naps was explored.

Subjects were also asked to indicate the number of hours

per week they spent taking naps. Two hundred sixty-

seven subjects answered the item related to length of

current naps (see Table 6). The mean number of hours

spent taking naps was 3.4 hours per week (SD=3.8). The

mean number of hours reported by subjects when they were

younger was .7 hours per week (SD=2.9). The finding of

an increased number of naps is consistent with findings

of a study conducted by Hayter (1983). Tune (1969)

reported an increased number of naps in older subjects.

In an observational study of elderly subjects Webb &

Swineburne (1971) found that all subjects took naps.

More subjects responded to items regarding current

naps than responded to items dealing with past nap

patterns or nap patterns of others their age. One

hundred ninety-four subjects (71.6%) reported that

currently take naps (see Table 7). Forty-two (17.1%











Table 6

Continuity of Sleep Now, When Younger, and of Peers



Age Group n Mean(SD) Range



Times per night awake

Now 277 2.1(1.3) 0-10

Younger 178 .4(1.0) 0-10

Peers 69 2.1(1.9) 0-15

Minutes awake after sleep onset

Now 228 30.4(39.4) 0-180

Younger 140 4.2(19.1) 0-210

Peers 31 50.2(40.1) 0-120

Hours of naps per week

Now 267 3.4(3.8) 0-21

Younger 185 .7(2.9) 0-21

Others 81 6.2(4.9) 0-21












reported having taken naps when they were younger, and

98 (86.0%) indicated that others their age take naps.

Sleep evaluation. To explore the concept of

subjective response to sleep behavior subjects were

asked to evaluate how well they sleep now, the amount of

sleep they get now, how rested they feel when they

awaken, how much they enjoy sleep, and how light or deep

they consider their sleep. Overall, 76 (27.4%) subjects

indicated that they sleep very well, 99 (35.7%)

satisfactorily, 91 (32.9%) some problems, and 11 (4.0%)

indicated that they sleep poorly (see Table 8). When

asked how well they slept when they were younger, 190

asked to indicate how well they felt others their age

sleep, and 141 (50.2%) indicated that others their age

have some problems sleeping. Statistically significant

differences were found between self-ratings of current

and former sleep (chi square=90.7, df=3, p=0.0002) and

between ratings of current sleep and sleep of peers (chi

square=44.6, df=3, p=0.000). The tendency of subjects

to report better sleep when they were younger is

consistent with findings reported by Karakan, et al.,

(1979) from a study which involved subjects ranging in

age from 18 to over 70. In that study, subjects in the












Table 7

Subjects Taking Naps Now, When younger, and Peers



no naps naps



Age Group n % n %



Now 77 28.4 194 71.6

Younger 204 82.9 42 17.1

Peers 6 5.2 98 86.0



Chi Square now vs younger=209.5 df=l p=0.0000.
Chi Square now vs others=21.8 df=l p=0.0000.












Table 8

Evaluations of Sleep Now, When Younger, and


of Peers


now younger others



Response n % n % n %


Quality of Sleep


Very Good

Satisfactory

Some Problems

Poor

Total



About Enough

Not Enough

Too Much

Total


76

99

91

11

277



245

25

9

279


27.4

35.7

32.9

4.0

100.0

Amount

87.9

8.9

3.2

100.0


190 67.4

71 25.2

8 2.8

4 1.4

273 96.8a

of Sleep

226 81.6

27 9.7

1 .4

254 91.7c


Note. Does not equal 100% because don't know and don't
remember responses not shown, aChi square now vs
younger=90.7 df=3 p=0.0000. bchi square now vs others=
44.6 df=3 p=0.0000. Cchi square=20.2 df=2 p=0.0000.
dchi square=38.3 df=2 p=0.0000.


6

42

141

10

199



88

16

15

119


2.1

14.9

50.2

3.6

70.8b



31.9

5.7

5.4

43. 0d












Table 8--continued


now younger others



Response n % n % n %


Feel rested upon awakening


Almost Always


Often


Occasionally

Almost Never


Total


164


58.8


71 25.4

35 12.5

9 3.2

279 100.0


205

29


73.0

10.3


9 3.2

7 2.5


250


25 8.9

47 16.7

39 13.9

4 1.4


89.0e 115 40.9f


Enjoyment of sleep


Much

Moderately

A Little

Not At All


Total


166

104


59.3

37.1


190


67.9


44 15.7


9 3.2


280 100.0


236 84.3g


41 14.7

47 16.8

3 1.1

1 .4

92 33.0h


Note. Does not equal 100% because don't know and don't
remember responses not shown, eChi square now vs
younger=19.5 df=3 p=0.0002. fChi square now vs
others=46.5 df=3 p=0.0000. gChi square=163.9 df=3
p=0.0000. hchi square=46.0 df=3 p=0.0000.











Table 8--continued


now younger others



Response n % n % n %



Depth of Sleep

Very Deep 12 4.3 46 16.6 1 .4

Deep 145 52.2 152 54.9 9 3.3

Light 113 40.6 45 16.2 55 20.0

Very Light 8 2.9 4 1.4 3 1.1

Total 278 100.0 247 89.1i 68 24.8J



Note. Does not equal 100% because don't know and don't
remember responses not shown.. -Chi square now vs
younger=46.0 df=2 p=0.0000. JChi square now vs
others=59.8 df=2 p=0.0000.











older age groups tended to report more frequent problems

with sleep.

An original question in this research, addressing

the issue of whether subjects who experienced sleep

disturbances when younger continue to exhibit sleep

disturbances when they are older was not answered. Only

12 subjects (4.2%) were found to have experienced sleep

problems when they were younger. The more significant

finding was the increased number of subjects who

reported sleep problems now (n=102, 36.9%).

In response to questions about the amount of sleep

they get, 245 (87.9%) reported getting enough sleep, 25

(8.9%) indicated they do not get enough sleep, and 9

(3.2%) reported getting too much sleep. Subjects were

asked about the amount of sleep they got when they were

younger. Two hundred twenty-six (81.6%) indicated they

got about enough and 27 (9.7%) indicated they had not

gotten enough sleep when they were younger. Fewer

subjects answered the item regarding sleep of others.

Of those who answered, 88 (31.9%) selected about enough.

Statistically significant differences were found between

evaluation of the amount of current sleep and the amount

of sleep when younger (chi square=20.2, df=2, p=0.0000).

Significant differences were found between ratings of











amount of sleep subjects got and the amount of sleep

others obtained (chi square=38.3, df=2, p=0.0000).

One hundred sixty-four subjects (58.8%) indicated

they almost always feel rested when they awaken, 71

(25.5%) indicated they often feel rested when they

awaken, 35 (12.5%) chose occasionally, and 9 (3.2%)

indicated that they almost never feel rested when they

awaken. Two hundred five subjects (73.9%) indicated

they almost always felt well rested upon awakening when

they were younger. Analysis of data revealed

statistically significant differences between self-

report of feeling rested upon awakening now and when

younger (chi square =19.5, df=3, p=0.0002). Twenty-five

subjects (8.9%) indicated that others their age feel

rested upon awakening. Significant differences were

found between self-rating of feeling rested upon

awakening and rating of others on this item (chi square=

46.5, df=3, p=0.0000).

Although 36.9% of respondents reported having some

problems with sleep or sleeping poorly, only 15.7% of

respondents indicated they occasionally or almost never

felt rested upon awakening. This supports findings

reported by McGhie and Russell (1962) that the elderly

did not report morning tiredness despite sleep changes.











When asked how much they enjoy sleep, 166 (59.3%)

of subjects selected much, 104 (37.1%) chose moderately

9 chose a little, and only one subject replied not at

all. When asked how much they enjoyed sleep when they

were younger, 190 (67.9%) chose much. When asked how

much others their age enjoy sleep, 41 (14.7%) indicated

much, and 47 (16.8%) selected moderately. Statistically

significant differences were found between reports of

enjoyment of sleep now as compared to younger (chi

square=163.9, df=3, p=0.0000) and between subjects' own

enjoyment sleep and others enjoyment of sleep (chi

square=46.5, df=3, p=0.0000)

The concept of depth of sleep was explored by

asking subjects to rate the depth of their sleep now,

when they were younger, and of others their age. Twelve

subjects (4.3%) rated their sleep as very deep, 145

(52.2%) rated their sleep deep, 113 (40.6%) indicated

that they consider their sleep light, and 8 (2.9%) rated

their sleep as very light. When asked how deep their

sleep was when they were younger, 152 (54.9%) selected

deep. When asked to indicate how deep the sleep of

others their age is, 55 (20.0%) selected light.

Data analysis revealed statistically significant

differences between self-report of depth of sleep now

and depth of sleep when younger (chi square=46.0, df=2,











p=0.0000) and depth of sleep now and depth of sleep of

peers (chi square=59.8, df=2, p=0.0000). Statistically

significant relationships were found between all

variables related to subjective response to sleep using

Spearman's rho (see Table 9).

Subjects consistently rated their sleep as having

been better when they were younger. Subjects reported

having slept better, gotten enough sleep, felt rested

upon awakening, enjoyed sleep more, and experienced

deeper sleep. These findings lend support to the

developmental aspect of the Objective Behavioral Theory

of Sleep (Webb, in press) just as the findings of sleep

pattern changes lend support to this aspect of the

theory.

The pattern of self-evaluation of current sleep and

the sleep of peers was less clear when considering

subjective evaluation of sleep. Many subjects chose the

don't know response in relation to the sleep of others

their age. Statistically significant differences were

found, but they must be interpreted with caution. Fifty

percent of subjects who responded to the item regarding

how well others their age sleep at night responded that

their peers have some problems. This is a higher rate

than subjects indicated that they themselves have











Table 9

Correlations Matrix for Subjective Responses to Sleep
and Circadian Subscale



Sleep Feeling Enjoy Sleep Circadian
Subscale Rating Rested Sleep Depth Tendency



Sleep 1.000*
Rating .000**

Feeling .429 1.000
Rested .000 .000

Enjoy .147 .156 1.000
Sleep .014 .009 .000

Sleep .433 .344 .161 1.000
Depth .000 .000 .007 .000

Circadian .218 .226 .112 .150 1.000
Tendency .008 .000 .180 .071 .000


*Spearman's rho
**Significance












problems sleeping. This adds more evidence that the

elderly expect sleep problems as they age.

Circadian tendencies. In order to evaluate

circadian tendencies, the placement of sleep within the

twenty four hour cycle, subjects were asked to respond

to items regarding their usual bedtime and wake up time.

Subjects reported going to bed from 1800 (6:00 P.M.) to

0100 (1:00 A.M.) with an average bedtime of 2246 (10:46

P.M.) (see Table 10). This also varied little from the

estimated bedtime of peers and bedtime when they were

younger. Subjects report an average weekday wake up

time of 0651 (6:51 A.M.) an average weekend wake up time

of 0709 (7:09 A.M.). There is little difference

reported between average weekday and weekend wake up

time now, however there is a difference between weekend

wake up time now and weekend wake up time when younger.

To further assess circadian tendencies, questions

were asked to determine if subjects go to sleep at the

same time, wake up at the same time, and use an alarm

clock. In response to the item dealing with going to

sleep at the same time, 44 (15.7%) indicated they always

go to bed at the same time and 195 (11.8%) stated they

usually go to sleep at the same time (see Table 11).

Twenty-six subjects (9.3%) indicated that they always

went to sleep at the same time when they were younger,












Table 10

Circadian Tendencies Now, When Younger, and of Peers



Age Group n Mean(SD) Range


Weekday bedtime

269 2246(1.7)

176 2242(1.3)

92 2209(1.6)

Weekend bedtime

260 2224(2.0)

148 2200(3.3)

77 2154(2.0)

Weekday wake up time

269 0651(1.0)

200 0629(0.7)

76 0709(0.7)

Weekend wake up time

273 0657(1.0)

180 0842(1.1)

53 0724(0.9)


1800-0100

1930-0100

2000-0100



1800-0200

2000-0200

1800-2400



0230-0930

0500-0900

0530-0845



0300-1000

0500-1200

0530-0930


Now

Younger

Peers



Now

Younger

Peers


Now

Younger

Peers


Now

Younger

Peers











Table 11

Circadian Tendency of Sleep of Elderly Subjects Now,
When Younger, and Others


now younger others

Frequency n % n % n %


Going to sleep at the same time


Yes


44 15.7


Usually

Sometimes


Never


195


69.6


33 11.8

8 2.9


Total 280 100.0


26 9.3


108


38.6


91 32.5

32 11.4


257


21 7.5

92 32.9

17 6.1

1 .4

131 46.9b


Awakening at the same time


Yes


61 22.0


Usually

Sometimes


Never


169


61.0


43 15.5

4 1.5


Total 277 100.0


66 23.9


122


44.2


30 10.9


3.6


228


19 7.0

65 23.8

21 7.7

2 .7

107 39.2d


Note. Columns do not equal 100% because don't know and
don't remember responses have not been included.
aChi Square now vs younger=48.8 df=3 p=0.000. bChi
Square now vs others=28.5 df=3 p=0.000. cChi Square
now vs younger=9.7 df=3 p=0.02. dChi Square now vs
others=37.3 df=3 p=0.000.











Table 11--continued


now younger others

Frequency n % n % n %



Using an alarm clock or radio to help wake up

Almost Always 24 8.7 139 50.1 8 2.9

Often 15 5.4 42 15.2 21 7.7

Occasionally 84 30.4 26 9.4 47 17.2

Almost Never 153 55.4 59 21.3 23 8.4

Total 276 99.9 266 96.0a 99 36.2b



Note. Columns do not equal 100% due to rounding and
omitting don't know and don't remember responses.
aChi Square now vs younger=142.5 df=3 p=0.000. bChi
Square now vs others=285.5 df=3 p=0.000.











while 108 (38.6%) indicated they usually went to sleep

at the same time when they were younger. Chi square

analysis of data revealed statistically significant

differences between present and previous sleep patterns

with subjects reporting more consistency in going to bed

at the same time now than when they were younger.

Subjects were also asked if they always awaken at

the same time. Sixty-one subjects (22%) indicated they

always awaken at the same time; 169 (61.0%) indicated

they usually awaken at the same time; 43 (15.5%) stated

they sometimes awaken at the same time, and 4 (1.5%)

indicated they never awaken at the same time (see Table

11).

Sixty-six subjects (23.9%) indicated they always

got up at the same time when they were younger, and 122

(44.2%) indicated they usually got up at the same time

when they were younger. Chi Square analysis reveals

statistically significant differences for this item

between now and younger. The greatest difference is

evident between the percentage of subjects who reported

that they usually awaken at the same time now than when

they were younger, with a higher percentage of subjects

reporting they usually awaken at the same time now.

Large differences are seen in the rate of use of an

alarm clock or radio to awaken between what subjects











reported they were doing at the time of the study and

what they reported doing when they were younger. One

hundred fifty-three subjects (55.4%) reported they

almost never used an alarm clock or radio to help them

awaken now, while 139 (50.1%) indicated that they had

almost always used an alarm clock when they were younger

(chi square=142.5, df=3, p=.000). Differences between

what subjects report they are doing versus what they

think others their age are doing are not so dramatic,

however, differences between both of these categories

are statistically significant (chi square=285.5, df=3,

p=.000).

The concept of circadian tendencies was further

explored by utilizing the circadian subscale imbedded

within the Sleep Questionnaire to make comparisons with

other items. Data from the items regarding bedtime,

wake up time, and use of an alarm clock comprised the

circadian subscale. This subscale included items

related to bedtime (Do you go to bed at the same time

now? and How many days per week do you go to bed more

than one hour earlier or later then your usual

bedtime?); wake up time (Do you always awaken at the

same time now? How many days per week do you awaken

more than one hour earlier or later then usual?); and

the regularity of the use of an alarm. All items











comprising the circadian subscale were found to

significantly correlated with the circadian score on the

circadian subscale (see Table 12). The score obtained

on the circadian subscale was also found to be

significantly related to several other items on the

Sleep Questionnaire. It is of interest to note that

this score is related to current and past sleep patterns

as well as to ratings of sleep of others.

The score on the circadian subscale was used to

investigate the relationship between circadian

tendencies and quality of sleep variables. The

circadian quality of sleep was found to be significantly

related to rating of sleep and the reported frequency of

feeling rested upon awakening (see Table 9).

Sleep disturbances. Several items addressed the

issue of sleep disturbances directly. Subjects were

asked how often they have trouble getting to sleep as

quickly as they would like, how many days per week the

usually wake up earlier than they expect and are unable

to return to sleep, and if they have sought help from

either a health care professional or a friend or

relative for sleep problems. In response to the item

which addressed trouble getting to sleep as quickly as

they would like, 71 subjects (25.6%) indicated they

almost never have difficulty getting to sleep, 137












Table 12

Relationship Between Circadian Tendencies of Sleep
and Quality of Sleep and Other Variables


r

.21

.31

.30

.48

.77

.65


.67


.36


Variable

Going to bed at same time

Waken at the same time

Frequency of use of alarm clock

Going to bed earlier or later

Waking up earlier then expect

Going to bed earlier or later
(younger)

Others going to bed earlier
or later

Waking up earlier then expect
(younger)

Others waking up earlier than
expect

Frequency of trouble getting to
sleep

Times awaken per night

Minutes awake per night


.52


p n

.05 87

.004 87

.004 87

.0001 87

.0001 87

.0001 87


.009 14


.002 71


.004 14


.0001 85


.37 .0004

.29 .02












(49.5%) stated they occasionally have trouble getting to

getting to sleep, and 19 (6.9%) indicated they always

have trouble getting to sleep (see Table 13).

Subjects were also asked how often they had trouble

getting to sleep when they were younger and how often

they think others their age have trouble getting to

sleep. One hundred sixty-six (60.8%) replied they

almost never had trouble getting to sleep when they were

younger. The most frequent responses given in relation

to others their age were occasionally (n=38, 14.1%) and

often (n=43, 16.0%). Statistically significant

differences were found between responses to items about

trouble sleeping now and trouble sleeping when younger

(chi square=203.7, df=3, p=0.0000) as well as trouble

sleeping now and others their age experiencing trouble

(chi square=51.1, df=3, p=0.0000).

Spearman's rho correlations were performed to

determine the relationship between sleep latency and

other qualitative sleep variables. A positive

correlation was found between sleep latency and overall

evaluation of sleep, feeling rested upon awakening and

circadian tendencies (see Table 14). When sleep latency

was reported as short, the evaluation of sleep was more

likely to be positive, the score on the circadian

subscale was smaller, and the subject was more likely to












Table 13

Frequency of Trouble Getting to Sleep Now, When
Younger, and Others


n % n % n %

now younger others



Almost Never 71 25.6 166 60.8 5 1.9

Occasionally 137 49.5 59 21.6 38 14.1

Often 50 18.1 7 2.6 43 16.0

Almost Always 19 6.9 2 .7 5 1.9

Total 277 100.0 234 85.7a 91 33.91b



Note. Does not equal 100% because don't know and don't
remember responses not shown.
aChi Square now vs younger =203.7 df=3 p=0.000. bchi
Square now vs others = 51.1 df=3 p=0.000.











Table 14

Relationship Between Sleep Problems and Subjective
Evaluation of Sleep Using Spearman's rho



Subjective evaluation of sleep r p n



Sleep latency

Overall evaluation of sleep .58 .0001 151

Feeling rested upon awakening .43 .0001 153

Depth of sleep -.35 .0001 153

Number of times awake

Overall evaluation of sleep .37 .0001 161

Feeling rested upon awakening -.32 .0001 163

Depth of sleep -.24 .0025 162

Length of time awake

Overall evaluation of sleep .58 .0001 123

Feeling rested upon awakening -.38 .0001 124

Depth of sleep -.23 .0025 162











report feeling rested upon awakening. A negative

correlation was found between sleep latency and depth of

sleep. The longer the sleep latency, the more likely

the subject was to report light sleep.

Subjects were also asked how many times they awaken

during the night and how long it takes them to get back

to sleep. Responses to these items have been addressed

earlier. Positive correlations were found between

both the frequency and duration of night awakening and

overall evaluation of sleep, rhythmic quality of sleep,

and feeling rested upon awakening. Negative

correlations were found between depth of sleep and both

frequency and duration of wakefulness after sleep onset.

Early morning awakening was addressed by asking

subjects how often they wake up earlier than they would

like and are unable to return to sleep. One hundred

thirteen (40.0%) subjects indicated they never have this

problem. Most of those who reported they do wake up

earlier than they would like indicated that this occurs

once or twice a week (n=116, 42.7%). Thirty-five

subjects (12.9%) indicated they have this problem 3 to 4

times per week and 12 subjects (4.4%) experience this

problem 5 to 7 times per week.

Help-seeking. In order to assess help-seeking for

sleep disturbances, subjects were asked if they had











sought help from health care professionals or friends

and relatives for trouble sleeping. Thirteen (4.9%)

indicated they had sought help from a health care

professional and 3 (1.1%) had sought help from family or

friends. One hundred seventeen subjects indicated they

do not have trouble sleeping in response to these items

(see Table 15).

Behavioral inhibitors of sleep. To explore the

concept of behavioral inhibitors of sleep, subjects were

asked to select items they felt might be affecting their

overall sleep. They were then asked to rate the

effectiveness of various items dealing with overall

sleep that they might have tried. Emotional stress,

caffeine intake, pain, going to bed too early, lack of

exercise, and naps were cited as problem areas by

greater than 25% of subjects who responded to that item

(see Table 16). While 67 subjects indicated that

emotional stress may have been affecting their overall

sleep behavior, only 24 indicated that reducing

emotional stress worked very well or fairly well in

improving the quality of their sleep (see Table 17).

Three subjects indicated that reducing emotional stress

worked poorly or was no help. Perhaps subjects who

indicated emotional stress was affecting their sleep,

but did not respond to effectiveness of reducing











Table 15

Frequency of Help Seeking for Sleep Problems From Health
Professionals and Peers



Response n % n %



health peers
professionals


Yes 13 4.9 3 1.1

No (but trouble sleeping) 136 50.7 148 55.4

No (no trouble sleeping) 119 44.4 116 43.4

Total 268 100.0 267 99.9



Note. Totals do not equal 100% due to rounding.











Table 16

Behavioral Inhibitors of Overall Sleep Patterns



Yes No



Inhibitor n % n %



Emotional stress 67 57.3 50 42.7

Caffiene 54 46.2 63 53.8

Pain 52 34.8 58 38.9

Bed too early 44 40.7 64 59.3

Lack of exercise 42 40.4 62 59.6

Naps 38 36.9 65 59.6

Wake up too late 14 11.2 64 51.2

Bed too late 10 13.2 66 86.8











Table 17

Subjects' Evaluations of Effectiveness of Facilitators
for Overall Sleep Patterns



Works well Works poorly



Facilitator n % n %



Decrease caffiene 38 97.4 1 2.5

Relieve pain 32 86.5 3 8.1

Decrease stress 24 88.9 3 11.1

Decrease naps 19 82.6 4 17.4

Increase exercise 19 90.5 2 10.0

Awaken earlier 4 100.0 -

Go to bed earlier 3 75.0 1 25.0

Go to bed later 1 33.3 2 66.6












emotional stress were unable to reduce their levels of

emotional stress, or have not attempted to do so.

Fifty-four subjects indicated that they felt caffeine

intake might be affecting their overall sleep, and 38

subjects indicated that reducing caffeine intake worked

very well or fairly well. One subject indicated that

reducing caffeine intake worked poorly or was no help.

Fifty-two subjects responded they felt pain was

affecting their overall sleep behavior. Thirty-two

subjects indicated that relieving pain worked well

in improving their sleep behavior. Three subjects

indicated that relieving pain worked poorly.

Lack of exercise was indicated as affecting overall

sleep behavior by 42 subjects. Nineteen subjects

indicated that increasing exercise worked well in

helping overall sleep behavior. Two subjects indicated

increasing exercise worked poorly.

Thirty-eight subjects indicated that naps might be

a factor in their overall sleep behavior. Nineteen

subjects stated that decreasing naps worked well in

improving their overall sleep behavior. Four subjects

indicated that decreasing naps worked poorly.

Behavioral facilitators and inhibitors of sleep.

In addition to overall sleep behavior three areas of

difficulty sleeping were assessed separately. These












three areas were (1) difficulty falling asleep; (2)

difficulty staying asleep; and (3) waking up in the

morning earlier than desired and being unable to return

to sleep. Subjects were first asked to respond to an

item that addressed the frequency with which they

employed various facilitators or inhibitors with each

category of disturbance. A second item addressed how

well those facilitators or inhibitors worked.

Behavioral facililatators included in the items were

relax, read, listen to the radio, take a pain pill,

pray, count sheep, and think of something else.

Behavioral inhibitors included get out ot bed and do

something, watch TV, take a sleeping pill, drink

alcohol, and talk to someone.

The faciliitators subjects always use when they

experience difficulty getting to sleep were: try to

relax, read, pray, think of something else, and listen

to the radio (see Appendix B). Seventy subjects

indicated they never have trouble getting to sleep at

night. The facilitatorss most frequently identified as

working well or very well were read, try to relax,

listen to the radio, pray, and think of something else.

When subjects were asked to indicate what they do

when they wake up at night and can't get back to sleep,

ninety-seven responded that they never wake at night












without being able to get back to sleep. The

facilitators most frequently identified as always used

included read, try to relax, listen to the radio, pray,

and think of something else. Inhibitors frequent used

included getting up and do something, and watching

television. The facilitators most often identified as

working well or very well were read, try to relax,

listen to the radio, and pray. The inhibitor of sleep,

getting up and doing something, was also found to be

effective in dealing with waking up at night and being

unable to get back to sleep. Subjects were also asked

to indicate what they do if they wake up in the morning

earlier than they like. Sixty-seven subjects indicated

that they never wake up in the morning earlier than they

like without being able to get back to sleep. The

facilitators used most frequently were try to relax,

read, listen to the radio, and count sheep. The

inhibitor of getting up and doing something was also

frequently used. The facilitators most frequently

indicated as working well or very well included read,

and try to relax. Getting up and doing something was

also found to be an effective strategy.

Affective response to sleep disturbances. To

explore the concept of affective responses to sleep

disturbances, subjects were asked how they feel when












they don't fall asleep as quickly as they would like,

wake up at night and can't get back to sleep, or wake up

in the morning earlier than they would like. Sixty-five

subjects indicated they always fall asleep as quickly as

they like, 50 indicated that they never wake up at night

and are unable to return to sleep, and 52 subjects

indicated that they never wake up in the morning earlier

than they like. As can be seen in Table 18 the most

frequent response in all three instances indicated that

subjects accepted the sleep disturbance. Of those

subjects who reported having difficulty getting to sleep

at night. 114 (42.7%) indicated they accepted the

disturbance. One hundred twenty-one subjects (46.5%) of

those who reported waking up at night and having

difficulty returning to sleep reported they accepted the

disturbance, and 153 (56%) of subjects who reported

awakening earlier in the morning than they would like

reported they accept the disturbance. The next most

frequent response selected by subjects who did not fall

asleep as quickly as they liked at night (n=47, 17.6%)

and those who woke up at night without being able to get

back to sleep (n=50, 19.2%) was that they feel

frustrated. Thirty-two subjects who reported having

difficulty getting to sleep, 32 subjects who wake up at

night and have difficulty returning to sleep, and 20













Table 18

Affective Response to Difficulty Falling Asleep,
Awakening During the Night, and Early Morning Awakening



Falling Asleep Wake during Wake too
the night early



Reactions n % n % n %



Not a 65 50 52
Problem

Accept 114 42.7 121 46.5 153 56.0

Frustrated 47 17.6 50 19.2 9 3.3

Tired 32 11.9 32 12.3 20 7.3

Don't think 31 11.6 27 10.4 45 16.5
about

Depressed 19 7.1 10 3.8 5 1.8

Worried 10 3.7 7 2.7 1 .3

Angry 8 3.0 5 1.9 7 2.5

Happy to have 6 2.2 8 3.1 33 12.1
more time

Total 267 99.8 260 99.9 273 99.3


Note. Columns do not equal


100% due to rounding.












subjects who woke up earlier in the morning than they

liked, indicated that they felt physically tired when

this occurred. Some subjects do not think about their

sleep disturbance. Forty-five subjects reported waking

up in the morning earlier than they would like, 31

subjects who reported having difficulty getting to

sleep, and 27 subjects who woke up at night indicated

they don't think about it. Thirty-three subjects who

reported waking up earlier than they like in the morning

reported they were happy to have more time.


Summary

Data obtained in this research were analyzed to

determine the relationship between current sleep

behavior, recalled sleep behavior when younger, and

perceived sleep behavior of others. Analysis of

background data as related to sleep revealed a

statistically significant relationship between overall

evaluation of sleep and use of medications that affect

sleep. Analysis of overall sleep behavior revealed that

subjects reported their sleep behavior when they were

younger in a more positive light than their current

sleep behavior. Subjective evaluations of sleep

revealed a similar pattern.











Sleep patterns appear to have great variability.

The mean length of time to get to sleep is longer now

(26.2 minutes) than when subjects were younger (10.6

minutes). The number of reported awakenings during the

night increased from an average of .4 times per night to

2.1 times per night. The amount of time spent awake

after sleep onset also increased from a mean of 4.2

minutes awake after sleep onset when younger, to a mean

of 30.4 minutes spent awake now. More subjects report

taking naps now than when they were younger. Naps are

also longer now than when subjects were younger.

In relation to the circadian quality of sleep,

findings indicated that subjects go to bed and get up at

the same time more frequently now than when they were

younger. Differences between alarm clock usage when

younger and now are dramatic with the majority of

subjects reporting frequent use of an alarm clock when

younger and the majority of subjects reporting not using

an alarm clock now. Statistically significant

relationships exist between circadian tendencies and

evaluations of sleep.

Sleep disturbances were approached from a global

perspective as well as from the perspective of specific

problem areas including difficulty getting to sleep,

difficulty maintaining sleep, and early morning