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Sleep Misperception in Caregiving and Noncaregiving Older Adults

Permanent Link: http://ufdc.ufl.edu/UFE0022032/00001

Material Information

Title: Sleep Misperception in Caregiving and Noncaregiving Older Adults
Physical Description: 1 online resource (54 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: caregivers, older, sleep
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study examined sleep misperception--the discrepancy between subjective total wake time (TWTs) and objective total wake time (TWTo)--in older adult dementia caregivers and older adult noncaregivers. Thirty-one caregiving (mean age=70.48 years, SD=7.55) and 103 noncaregiving (mean age=72.90 years, SD=6.86) older adults completed one week of sleep diaries and actigraphy. Participants were defined as good or poor sleepers, resulting in 4 groups: good sleeping noncaregivers, poor sleeping noncaregivers, good sleeping caregivers, and poor sleeping caregivers. Due to the small number of good sleeping caregivers (n=4), they were excluded from further analyses. Sleep misperception was defined as (TWTS-TWTO)/TWTO*100. Wilcoxon Signed-Rank tests were conducted for each group and revealed significant differences between TWTs and TWTo for good sleeping noncaregivers and poor sleeping noncaregivers, but not for poor sleeping caregivers. Poor sleeping caregivers' data, however, were reaching significance (p = 0.06). Chi-square analyses revealed group differences in the proportion of misperceivers with 100.00% of poor sleeping noncaregivers misperceiving compared to 55.90% of good sleeping noncaregivers and 50.00% of poor sleeping caregivers. The Kruskal-Wallis test revealed significant between group differences in misperception. Specifically, poor sleeping noncaregivers exhibited more sleep misperception than both good sleeping noncaregivers and poor sleeping caregivers. Good sleeping noncaregivers and poor sleeping caregivers were statistically similar (p > 0.05). According to the Harvey model of insomnia maintenance, poor sleeping caregivers should be experiencing the most sleep misperception of the three groups. The literature indicates that dementia caregivers experience high levels of cognitive arousal, physiological arousal, and anxiety during the night in comparison to the other groups. This arousal and anxiety, according to the Harvey model, should induce sleep misperception. These results, however, indicate that this is not the case. One hypothesis for these results is that some of the cognitive and physiological arousal these caregivers experience aid in time estimation instead of sleep misperception. Specifically, arousal related to nightly chores may help with total wake time estimation. Since the caregivers are focused on the chores and not their sleep, they may be able to estimate better. These chores, instead of creating anxiety about not sleeping, distract the caregiver from negative thoughts about sleep and focus more on the activity. This focus and attention on the chores may aid in consistent total wake time estimates. Poor sleeping noncaregivers in turn may only experience the anxiety-inducing and sleep misperception-causing cognitive and physiological arousal. Since noncaregivers are most likely not performing planned activities during the night, they may be lying awake in bed and focusing their attention on not sleeping, which induces sleep misperception. These data suggest that poor sleeping caregivers may have tools to help them report consistent total wake time events and therefore have similar amounts of sleep misperception in comparison to good sleeping noncaregivers.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: McCrae, Christina S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022032:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022032/00001

Material Information

Title: Sleep Misperception in Caregiving and Noncaregiving Older Adults
Physical Description: 1 online resource (54 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: caregivers, older, sleep
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: This study examined sleep misperception--the discrepancy between subjective total wake time (TWTs) and objective total wake time (TWTo)--in older adult dementia caregivers and older adult noncaregivers. Thirty-one caregiving (mean age=70.48 years, SD=7.55) and 103 noncaregiving (mean age=72.90 years, SD=6.86) older adults completed one week of sleep diaries and actigraphy. Participants were defined as good or poor sleepers, resulting in 4 groups: good sleeping noncaregivers, poor sleeping noncaregivers, good sleeping caregivers, and poor sleeping caregivers. Due to the small number of good sleeping caregivers (n=4), they were excluded from further analyses. Sleep misperception was defined as (TWTS-TWTO)/TWTO*100. Wilcoxon Signed-Rank tests were conducted for each group and revealed significant differences between TWTs and TWTo for good sleeping noncaregivers and poor sleeping noncaregivers, but not for poor sleeping caregivers. Poor sleeping caregivers' data, however, were reaching significance (p = 0.06). Chi-square analyses revealed group differences in the proportion of misperceivers with 100.00% of poor sleeping noncaregivers misperceiving compared to 55.90% of good sleeping noncaregivers and 50.00% of poor sleeping caregivers. The Kruskal-Wallis test revealed significant between group differences in misperception. Specifically, poor sleeping noncaregivers exhibited more sleep misperception than both good sleeping noncaregivers and poor sleeping caregivers. Good sleeping noncaregivers and poor sleeping caregivers were statistically similar (p > 0.05). According to the Harvey model of insomnia maintenance, poor sleeping caregivers should be experiencing the most sleep misperception of the three groups. The literature indicates that dementia caregivers experience high levels of cognitive arousal, physiological arousal, and anxiety during the night in comparison to the other groups. This arousal and anxiety, according to the Harvey model, should induce sleep misperception. These results, however, indicate that this is not the case. One hypothesis for these results is that some of the cognitive and physiological arousal these caregivers experience aid in time estimation instead of sleep misperception. Specifically, arousal related to nightly chores may help with total wake time estimation. Since the caregivers are focused on the chores and not their sleep, they may be able to estimate better. These chores, instead of creating anxiety about not sleeping, distract the caregiver from negative thoughts about sleep and focus more on the activity. This focus and attention on the chores may aid in consistent total wake time estimates. Poor sleeping noncaregivers in turn may only experience the anxiety-inducing and sleep misperception-causing cognitive and physiological arousal. Since noncaregivers are most likely not performing planned activities during the night, they may be lying awake in bed and focusing their attention on not sleeping, which induces sleep misperception. These data suggest that poor sleeping caregivers may have tools to help them report consistent total wake time events and therefore have similar amounts of sleep misperception in comparison to good sleeping noncaregivers.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: McCrae, Christina S.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022032:00001


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SLEEP MISPERCEPTION IN CAREGIVI NG AND NONCAREGIVING OLDER ADULTS By PAMELA DUBYAK A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008 1

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2008 Pamela Dubyak 2

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To my Mom and Dad 3

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ACKNOWLEDGMENTS I want to thank several people for helping me to ge t to this point in my life. First, I wish to thank my parents for their continuous love and encouragement. Second, I wish to thank my comentors, Dr. Christina McCrae and Dr. Meredeth Rowe for their support during the masters process. Third, I wish to thank all of my fr iends for their cheerleading when I needed it. 4

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TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF ABBREVIATIONS.......................................................................................................... 8 ABSTRACT.....................................................................................................................................9 CHAPTER 1 INTRODUCTION................................................................................................................. .11 2 REVIEW OF THE LITERATURE........................................................................................12 Sleep and Older Adults......................................................................................................... ..12 Poor Sleep and Older Adults..................................................................................................13 Sleep and Physical Health...................................................................................................... 13 Sleep Misperception...............................................................................................................14 Harvey Model of Insomnia Maintenance........................................................................15 Role of Sleep Misperception in Poor Sleep.....................................................................16 Time Estimation..............................................................................................................16 Reporting Sleep...............................................................................................................17 Total Wake Time.............................................................................................................17 Sleep and Caregivers........................................................................................................... ...18 Effect of the Care Recipient on Sleep.............................................................................18 Effect of Psychologica l Distress on Sleep.......................................................................19 Effects of Poor Sl eep in Caregivers.................................................................................20 Sleep Misperception in Caregivers..................................................................................20 3 STATEMENT OF THE PROBLEM......................................................................................23 Aim 1......................................................................................................................................24 Hypothesis 1................................................................................................................... ........24 Aim 2......................................................................................................................................25 Hypothesis 2................................................................................................................... ........25 Aim 3......................................................................................................................................26 Hypothesis 3................................................................................................................... ........26 4 METHODS AND MATERIALS...........................................................................................27 Participants.............................................................................................................................27 Noncaregiving Older Adults............................................................................................27 Caregiving Older Adults..................................................................................................27 Measures.................................................................................................................................28 5

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Sleep Measures................................................................................................................2 8 Subjective sleep measure.........................................................................................28 Objective sleep measure...........................................................................................29 Sleep Misperception........................................................................................................30 Group Classifications......................................................................................................30 Background Information.................................................................................................31 Analyses..........................................................................................................................31 5 RESULTS...................................................................................................................... .........34 Demographic, Health, and Sleep -Related Characteristics......................................................34 Main Analyses........................................................................................................................35 Aim 1: Differences between Subjective a nd Objective Total Wake Times within Groups..........................................................................................................................35 Aim 2: Estimation of Perceived Total Wake Time within Groups.................................35 Aim 3: Differences in the Amount of Sleep Misperception between Groups.................35 6 DISCUSSION................................................................................................................... ......41 Discussion of the Findings..................................................................................................... .41 Aim 1: Differences between Subjective a nd Objective Total Wake Times within Groups..........................................................................................................................41 Aim 2: Estimation of Perceived Total Wake Time within Groups.................................42 Aim 3: Differences in the Amount of Sleep Misperception between Groups.................44 Limitations.................................................................................................................... ..........46 Future Directions....................................................................................................................47 Summary.................................................................................................................................49 LIST OF REFERENCES...............................................................................................................50 BIOGRAPHICAL SKETCH.........................................................................................................54 6

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LIST OF TABLES Table page 4-1 Normality Test Results.................................................................................................... ..33 5-1 Demographic Characteristics for the Sample....................................................................36 5-2 Sleep Characteristics for the Sample.................................................................................37 5-3 Results for Aim 1: Differences between Subjective and Objective Total Wake Times within Groups.....................................................................................................................38 5-4 Results for Aim 2: Estimation of Pe rceived Total Wake Time within Groups.................39 5-5 Results for Aim 3: Differences in the Amount of Sleep Misperception between Groups................................................................................................................................40 7

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LIST OF ABBREVIATIONS NREM Non-rapid eye movement REM Rapid eye movement SOLo Objective sleep onset latency SOLs Subjective sleep onset latency TSTo Objective total sleep time TSTs Subjective total sleep time TWAKo Objective terminal wakefulness TWAKs Subjective terminal wakefulness TWTo Objective total wake time TWTs Subjective total wake time WASOo Objective wake after sleep onset WASOs Subjective wake after sleep onset 8

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Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science SLEEP MISPERCEPTION IN CAREGIVI NG AND NONCAREGIVING OLDER ADULTS By Pamela Dubyak May 2008 Chair: Christina McCrae Major: Psychology This study examined sleep misperception the discrepancy between subjective total wake time (TWTs) and objective total wake time (TWTo) in older adult dementia caregivers and older adult noncaregivers. Thirty-one caregivi ng (mean age=70.48 years, SD=7.55) and 103 noncaregiving (mean age=72.90 years, SD=6.86) ol der adults completed one week of sleep diaries and actigraphy. Participants were defined as good or poor sl eepers, resulting in 4 groups: good sleeping noncaregivers, poor sleeping noncaregivers, good sl eeping caregivers, and poor sleeping caregivers. Due to the small number of good sleeping car egivers (n=4), they were excluded from further analyses. Slee p misperception was defined as [(TWTSTWTO)/TWTO*100]. Wilcoxon Signed-Rank tests were c onducted for each group and revealed significant differences between TWTs and TWTo for good sleeping noncaregivers and poor sleeping noncaregivers, but not fo r poor sleeping caregivers. P oor sleeping caregivers data, however, were reaching significance ( p = 0.06). Chi-square analyses revealed group differences in the proportion of misperceivers with 100.00% of poor sleeping noncar egivers misperceiving compared to 55.90% of good sleeping noncaregiver s and 50.00% of poor sleeping caregivers. The Kruskal-Wallis test revealed significan t between group differences in misperception. Specifically, poor sleeping noncaregivers exhib ited more sleep misperception than both good 9

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10 sleeping noncaregivers and poor sleeping caregivers. G ood sleeping noncaregivers and poor sleeping caregivers were statistically similar ( p > 0.05). According to the Harvey model of insomnia maintenance, poor sleeping caregivers should be experiencing the most sleep misperception of the three groups. The literature indicates that dementia caregivers experience high levels of cognitive arousal, physiological arousal, and anxiety during the night in comparison to the other groups. This arousal and anxiety, according to the Harvey model, should induce sleep misperception. These results, however, indicate that this is not the case. One hypothesis for these results is that some of the cognitive and physiological arousal these caregivers experience aid in time estimation instead of sl eep misperception. Specifically, arousal related to nightly chores may help with total wake time estim ation. Since the caregivers are focused on the chores and not their sleep, they may be able to estimate better. These chores, instead of creating anxiety about not sleeping, distract the car egiver from negative thoughts about sleep and focus more on the activity. This focus and attention on the chores may aid in consistent total wake time estimates. Poor sleeping noncaregivers in turn may only experience the anxiety-inducing and sleep misperception-caus ing cognitive and physiological arousal. Since noncaregivers are most likely not performing pl anned activities during th e night, they may be lying awake in bed and focusing their attent ion on not sleeping, which induces sleep misperception. These data suggest that poor sleeping caregivers may have tools to help them report consistent total wake time events a nd therefore have similar amounts of sleep misperception in comparison to good sleeping noncaregivers.

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CHAPTER 1 INTRODUCTION The current study examines sleep mispercepti on in older adult careg ivers of dementia patients and older adult noncaregivers. Sleep mi sperception is defined as the difference between a subjectively measured sleep variable and an objective measure of that same sleep variable (Tang & Harvey, 2004). This study will investigate whether misp erception of total wake time occurs in older adult caregivers of dementia pa tients, and whether this groups amount of sleep misperception differs significantly in comp arison to older adult noncaregivers. There has been a large contri bution of research looking at the lives of dementia caregivers and their qua lity of life. However, even within the vast amount of research in this area, there has been a paucity of research on caregivers. Currently, 5.8 to 7 million adults are informal caregivers to adults over the age of 65 (U.S. Department of Health and Human Services, 1994). In addition, about 30 % of thes e caregivers are over the age of 65 themselves (U.S. Department of Health and Human Services, 2001). Older adult caregivers constitute a large portion of the population. In addition, although po or sleep is a common complaint within both the caregiving and older adult communities, sleep misperception has not been fully investigated in either group (McCurry, Logsdon, Teri, & Vitiello, 2007; National Sleep Foundation, 2003). This is unexpected since research ers have noted that sleep complaints in dementia caregivers are multifaceted and objective sleep findings do not match these caregivers sleep complaints (McCurry et al., 2007). A better understanding of sleep misperception in older adult caregivers of dementia patients may contribute to a better understanding of their poor sleep complaints. 11

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CHAPTER 2 REVIEW OF THE LITERATURE Sleep and Older Adults As individuals age, their sleep patterns cha nge. Babies enter sleep with REM (rapid eye movement) sleep as opposed to NREM (non-rapi d eye movement) sleep and have short NREMREM cycles (approximately 50 minutes in le ngth; Carskadon & Deme nt, 2005). Over time, individuals begin to enter sl eep through stage I of NREM sl eep and their NREM-REM sleep cycles lengthen to 90 minutes (Carskadon & Dement, 2005). During adolescence, NREM stage III and IV sleep decrease by 40% (Carskadon & Dement, 2005). As individuals enter older adulthood, these changes to their sleep continue. Firs t, their quality of sleep begins to decrease (Morgan, 2000). Second, average total sleep time decreases from seven hours per night to six hours per night (Nau, McCrae, & Lichstein, 2005). Third, sleep efficiency (percentage of time spent asleep divided by time spent in bed) decreases from an average of 90% to 70-80% (Bliwise, 2005). This means that older adults sp end more time awake in be d than asleep. Fourth, daily total sleep time is more vari able in older adults in comparis on to younger adults (Nau et al., 2005). Fifth, as people age, the number of nighttime arousals increase (Morgan, 2000). Specifically, older adults report an average of eight awakenings per night (Nau et al., 2005). Sixth, the length of the sleep stages changes w ith age. The length of NREM (non-rapid eye movement) stages I and II (often referred to as light sleep) in crease, while NREM stages III and IV (often referred to as deep sleep) de crease (Morgan, 2000; Nau et al., 2005). Individuals are more easily aroused during NREM stages I a nd II. Seventh, older adu lts shift between sleep stages more frequently than younger adults (Morgan, 2000). Although thes e changes in sleep architecture occur in both men and women, the deterioration is significantly worse in men (Morgan, 2000). It is important to note, however, that women are more likely to complain about 12

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their sleep and seek help for their poor sleep than men (Bliwise, 2005; Morgan, 2000). Finally, older adults spend more time napping than younge r adults, which can cr eate a reduction in the homeostatic drive for sleep at night (Nau et al., 2005). Poor Sleep and Older Adults According to the National Sleep Foundation (2003), 48% of older adults complain of at least one insomnia symptom three times or more per week. About 30% of a dults over the age of 65 report sleep maintenance difficulties and 15% report problems at sleep onset (Bliwise, 2005). In a study with over 9,000 participants aged 65 and older, 57% complained of one or more sleep disturbance occurring most of the time, 29% stated that they had difficult y falling asleep or woke up too early in the morning, and 13% reported ra rely waking up feeling rested (Foley, Monjan, Brown, Simonsick, Wallace, & Blazer, 1995). Although some of these sleep complaints may be related to the change in sleep architecture duri ng the aging process, these sleep complaints are related to multiple factors. In a study by V itiello, Moe, and Prinz (2002), it was found that geriatric sleep complaints were primarily associated with medical and psychiatric disorders and other health factors. In their study, they analyzed sleep data fro m two groups of older adults. In the first group of 1619 older adults only 3.14% repor ted sleep complaints that were not related to health factors (Vitiello et al., 2002). In the second group of 1335 older adults, 1.35% reported sleep complaints not related to health factors (Vitiello et al., 2002). These data suggest that not only is poor sleep a common complain t in older adults, but it is also associated with their health. Sleep and Physical Health Health status does not only act upon sleep quality in older adu lts; there is a strong relationship between health and sleep. In a study by Ohayon and Vecchierini (2005), the researchers looked at participan ts reported sleep accounts (sleep diaries) and health status. Ohayon and Vecchierini (2005) found a link between poor sleep and poor health status. Poor 13

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health was commonly associated with a shorter total sleep time, increased sleep onset latency, late bedtime, and early wake-up time (Ohayon and Vecchierini, 2005). Ohayon and Vecchierini (2005) also noted an association between obesity and a low total sleep time and a late bedtime. Ohayon and Vecchierini (2005) postu lated that sleep deprivation ma y be associated with changes in metabolism which are in turn related to weight gain. There is an associ ation between a lack of physical exercise and people who sleep between 4 to 6 hours per night (Ohayon & Vecchierini, 2005). In another study, a link between insomnia and a decrease in health-r elated quality of life (according to the SF-36) was noted (Schubert Cruickshanks, Dalton, Klein, & Nondahl, 2002). Foley and colleagues found a relationship betwee n poor sleep and heart disease, incident diabetes, stroke, and respiratory problems (Foley et al., 1999). This research suggests a strong relationship between chronic poor sleep and physical health. Sleep Misperception Sleep misperception is defined as the difference between a subjectively measured sleep variable and an objective measure of that sa me sleep variable (Tang & Harvey, 2004). Sleep misperception can have serious consequences. An individual who mispercei ves her sleep at night may react to situations differently during the day. Specifically, the misperception of sleep can play a significant role in a pe rsons perception of her ability to function during the day. For example, an individual who perceives her sleep as poor may report poor daytime functioning even though there is no object ive evidence to explain the daytime dysfunction (Semler & Harvey, 2005). In addition, the perception of po or sleep can negativel y impact ones physical health. One study noted that thos e who perceived their sleep as poor reported significantly more chronic health conditions and daytime fatigue th an those who did not (McCrae, Rowe, Tierney, Dautovich, DeFinis, & McNamara, 2005). 14

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Harvey Model of Insomnia Maintenance In addition to negatively impacting ones health and daytime functioning, sleep misperception plays a central role in the mainte nance of insomnia. Acco rding to the Harvey model of insomnia maintenance, sleep mispercep tion initially occurs after an individual has become cognitively and physiologically aroused (Means, Edinger, Glenn, & Fins, 2003; Tang & Harvey, 2004). Tang and Harvey (2005) found that individuals in an anxiously aroused group reported significantly longer sleep onset latenc y periods. Interestingly, Tang and Harvey (2005) also found that participants who were in a neutrally aroused group also reported perceiving a significantly shorter total sleep time than they actually experienced (Harvey & Tang, 2004). This data suggests that although anxiety arousing cognitions can play a large role in sleep misperception, neutral cognitions ca n also play a role in sleep misperception. Tang and Harvey (2004) also noted that their phys iologically aroused group reported a shorter total sleep time in comparison to the non-physiologically aroused group. It is important to note that both the anxious-cognitively aroused group and the physiologically-aroused group described their sleep as poorer than the non-aroused group (Harvey & Tang, 2004). Harvey suggests that after the individual begins to experience the cognitive and physiological arousal, sleep misperception occurs. Specifically, sleep misperception encourages additional anxiety related to not sleeping (Tang & Harvey, 2004). This anxiety then leads to worse sleep. At this point the anxiety is arousing the individual out of th e state of relaxation and possible sleep (Tang & Harvey, 2004). For exam ple, an individual may be worried about speaking at a presentation the next day. This ap prehension may lead to an increased heart rate. This cognitive and physiological arousal may begi n to lead to sleep misperception. At this time the individual may believe he has been awake in bed for 30 minutes, when in fact he has been awake for 10 minutes. This sleep misperception can then lead to additional arousal and 15

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cognitions including the belief that he will never fall asleep. These new cognitions lead to further sleep misperception. Thus, according to the Harvey model, the flow of arousal is cyclical and quickly creates a state of chronic poor sleep. Role of Sleep Misperception in Poor Sleep It should be noted that the Harvey model of insomnia maintenance and sleep misperception does not create poor sleepers. Behaviors (e.g., inc onsistent sleep schedule, caffeine in the late afternoon, and napping) and cogniti ons (e.g., thoughts regarding an acute stress) begin the poor sleep cycle. The Harvey model suggests that these behaviors a nd cognitions begin the insomnia cycle. Specifically, these cogniti ons and behaviors increase arousal which in turn induces sleep misperception. This sleep misperception genera tes additional arousal and anxiety, which maintains the insomnia. Time Estimation It is important to note that although sleep misp erception is defined as individuals not being able to accurately estimate time, these individuals are not overall poor estimators of time. Individuals who misperceive their wake time duri ng the night are typically able to estimate time in other situations. Tang and Harvey (2005) found that poor sleep ers and good sleepers were not significantly different at estimating time when they were not tr ying to sleep. In addition, the location of the experiment did not contribute to poor time estimation. The participants in this study estimated time accurately in their bedroom environments (Tang & Harvey, 2005). Although poor sleepers (according to the Harvey m odel of insomnia maintenance) may be more likely to overestimate wake time in their bedrooms, they did not overestimate in this experiment (Tang & Harvey, 2005). The poor sleepers did no t overestimate time more in their bedrooms than in the laboratory even when the experime nt was posed 30 to 40 minutes prior to their bedtimes (Tang & Harvey, 2005). Tang and Ha rvey (2005) proposed that the poor time 16

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estimation primarily occurs at bedtime when arousal related to prior poor sleeping experiences increases. They hypothesized that the poor sleepe rs inaccurate estimations only occur once they become distressed and aroused at bedtime due to th eir concerns regarding not being able to sleep (Tang & Harvey, 2005). When thes e poor sleepers are estimating tim e that is not related to sleeping, they are able to perfor m the task easily. It is important to note that the time estimation tests were relatively short (5 seconds, 15 seconds, 35 seconds, 1 minute, and 15 minutes; Tang & Harvey, 2005). It is possible that these time periods were too shor t to observe inaccurate time estimation by poor sleepers. Reporting Sleep Although several studies do not refer to the Ha rvey model by name, they do reinforce the concept that poor sleepers commonl y over-report their wake time. Studies indicate that selfdescribed poor sleepers commonly over-report their perception of wake time in comparison to good sleepers (Carskadon, Dement, Mitler, Guille minault, Zarcone, & Spiegel, 1976; Borkovec, Lane, & VanOot, 1981). Specifically, insomnia studies have shown that poor sleepers significantly misperceive their length of sleep onset latency and their total sleep time (Means, Edinger, Glenn, & Fins, 2003). In addition, in polysomnography studies, patients misreported being awake during REM sleep and Stage II of NREM sleep (Borkovec et al., 1981; Sewitch, 1984). These studies indicate that poor sleepers for unknown reasons misperceive some aspects of their sleep time as wake time. The Harvey model of insomnia maintenance suggests that higher arousal levels in these poor sleepers promote their misperceptions. Total Wake Time This study examines the misperception of a speci fic sleep variable, total wake time. Total wake time is the total time spent awake in bed from bedtime to final wake up time. Total wake time was chosen in lieu of total sleep time, because wake time during the night is one of the 17

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primary complaints of individuals with poor sleep (Bliwise, 2005; Foley et al., 1995; McCurry et al., 2007; McCurry & Teri, 1995; National Sl eep Foundation, 2003; Wilcox & King, 1999). In addition, most sleep misperception researchers examine on how much individuals misperceive the time they spend awake during the night (Borkovec et al., 1981; Mean s et al., 2003; Sewitch, 1984). By understanding whether indi viduals misperceive their wake time, future research can focus on treatments for poor sleep that take this information into account. Sleep and Caregivers Effect of the Care Recipient on Sleep Due to the nature of the dementia caregiver role, sleep problems often occur (Creese, Bedard, Brazil, & Chambers, 2008; Teel & Pr ess, 1999; Wilcox & King, 1999). Specifically, dementia caregivers report planned awakeni ngs (i.e. handle medi cation) and unplanned awakenings throughout the night (i .e. the care recipient wandered outside the home; McCurry et al., 2007). Creese and colleagues (20 08) noted that 63% of spousal caregivers reported disturbed sleep due to the nocturnal activ ity of their dementia patients. This constant awakening throughout the night can lead to poor sleep patte rns and compensation techniques, for example, late afternoon napping and caffeine use, which can further hinder sleep (McCurry et al., 2007). One study noted that when respite care becam e available, the caregivers sleep improved significantly (Lee, Morgan, & Li ndesay, 2008). Caregivers reported increased total sleep time, improved sleep quality, and increased time in be d (Lee et al., 2008). Lee and colleagues also noted that when respite care was terminated the caregivers total sleep ti me during the night and sleep quality ratings returned to baseline levels (Lee et al., 2008). These data suggest that in some cases of poor sleep in caregivers, th e causal factor is the care recipient. 18

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Effect of Psychological Distress on Sleep In addition to care recipient-induced sleep problems in dementia caregivers, the emotional burden of the caregiving role can ne gatively impact caregivers sleep. Dementia caregivers experience a higher prevalence rate of depressi on and anxiety than noncaregivers (McCurry et al., 2007). Dementia caregivers are also under a signifi cant amount of distress including physical, psychologica l, emotional, social, and fi nancial (George & Gwyther, 1986; McCurry et al., 2007). It is for many of these reasons that care givers often report having difficulty obtaining sleep that is both satisfying and of sufficient duration. Recent studies indicate that 33% of older adult caregivers of dementia patients report sl eep disturbances (Creese et al., 2008; McCurry et al., 2007; McCurry & Teri, 1995; Lee et al., 200 7; Pruchno & Potashnik, 1989; Wilcox & King, 1999). Several studies have looked at the effects of sleep problems in dementia caregivers (Lee, Morgan, Lindesay, 2007; McKibbin et al., 2005; T eel & Press, 1999). Lee and colleagues noted that dementia caregivers reporte d higher levels of fatigue than age-matched noncaregivers (2007). McKibbin and colleagues (2005) found that caregivers of patients with Alzheimers disease had significantly worse sleep than noncaregivers. Specifical ly, caregivers reported lower total sleep times and significant daytime dysfunction, including daytime sleepiness (McKibbin et al., 2005). It is important to note, however, that these caregivers did not have more nighttime disruptions in comparison to noncaregivers; onl y fewer hours of sleep (M cKibbin et al., 2005). Teel and Press (1999) found that dementia caregivers had more fatigue, less energy, and more sleep difficulties in comparison to noncaregiv ers. These studies highl ight the difficulties dementia caregivers experience regarding sleep. 19

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Effects of Poor Sleep in Caregivers As addressed, caregivers face numerous difficulties that impede their quality and quantity of sleep. Poor sleep can lead to a multitude of problems including daytime dysfunction (McKibbin et al, 2005) and changes in the care giver-care recipient rela tionship. In one study, poor sleep was the primary reason caregivers in stitutionalized their care recipients (Pollak & Perlick, 1991). Institutionaliz ation can negatively affect the care recipients and their caregivers. Many care recipients find the transition to a nursing home to be very difficult. Some care recipients develop symptoms of anxiety and/or depression with the transition (Blenkner, 1967; Thorson & Davis, 2000). The decisi on to institutionalize a family me mber can be very emotional for the caregiver. Many caregivers report increased stre ss, anger, and depression prior to the placement (Gaugler, Zarit, & Pearlin, 1999). One study showed that husbands who were caring for their spouses reported increased family conf lict prior to the placement (Gaugler et al., 1999). Additionally, decreased socioemo tional support and family conf lict prior to the placement predicted anger and/or depression in the former caregivers (Ga ugler et al., 1999). Sleep Misperception in Caregivers Although there have been no studies looking specifically at sleep misperception in dementia caregivers, it is possible to make some inferences. Since sleep misperception is based primarily on arousal, dementia caregivers may experience a greater degree of sleep misperception in comparison to noncaregivers. De mentia caregivers report more anxiety and depression than noncaregivers, and therefore may experience more arousal and sleep misperception (Thommessen, Aarsland, Braekhus, Oksengaard, Engedal, & Laake, 2002; Brummett, Babyak, Siegler, Vitaliano, Ballard, Gwyther, et al., 2006). Caregivers frequently report high levels of distressing emotions due to the multiple chores related to caring for their care recipients and the concerns that come along with caregiv ing (Flaskerund, Carter, & Lee, 20

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2001). This stress is also infl uenced by the limited amount of social resources and depression that can occur because of limited social rela tionships and a highly stressful life (Brkhus, ksengard, Engedal, & Laake, 1998). This chronic anxiety may induce cognitive and physiological arousal during the night, which in turn can create sleep misperception, according to the Harvey model. In addition to the increased anxiety, dementia caregivers report arousal during the night related to their care recipients nocturnal awakenings (Creese et al., 2008). Many caregivers have planned awakenings throughout the night in order to manage their care recipients (i.e. handle medication). However, many caregivers also ha ve unplanned awakenings throughout the night, because their care recipients may wander from the house or injure themselves. One may hypothesize that these awakenings may increase th e likelihood of sleep mi sperception, according to the Harvey model. Planned awakenings increase wake time, decrease sleep time, and force the individual to become cognitively and physiologi cally aroused during the night. This type of arousal does not necessarily contain the level of anxiety that the Harvey model of insomnia maintenances cognitive and physiological arousal assume; however, this arousal does involve the caregiver becoming cognitively and physiological ly more aware than when they were asleep. Unplanned awakenings also increase wake time, d ecrease sleep time, and create anxiety-related cognitive and physiological arousal If the care recipien t is prone to leaving his bed during the night, it may be hypothesized that the caregiver is hyperaroused and is prone to awakening during the night to check on the care recipient. This uncontrollable and stressful possible event may lead to cognitive and physiological arousal throughout the night, which may be similar in intensity to that anxiety-inducing cognitive and physiological arousal described in the Harvey model of insomnia maintenance. 21

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Due to increased levels of anxiety related to being a caregiver and the multiple arousals during the night related to both planned and unpl anned awakenings, dementia caregivers may possibly report higher levels of sleep misperception than noncaregivers. In addition, one may propose that poor sleeping caregiver s may misperceive their sleep to a greater extent than do noncaregivers, since their arousal levels and lik elihood for sleep misperception may be greater. 22

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CHAPTER 3 STATEMENT OF THE PROBLEM Evidence suggests that the misperception of wa ke time during the sleep period is a major contributor to the promotion of poor sleep in individuals. Many re searchers have investigated the causal factors of sleep mispercep tion and its relationship with poor sleep (Means & Fins, 1995; Tang & Harvey, 2004). Specifically, the Harvey mode l of insomnia maintenance suggests that sleep misperception increases the level of arousal in an individual which later leads to chronic poor sleep (Tang & Harvey, 2004). In previous sleep misperception studies, the primary distinguishing variable in part icipant groups has only been qual ity of sleep (good versus bad; Borkovec, Lane, & VanOot, 1981; Carskadon, Deme nt, Mitler, Guilleminault, Zarcone, & Spiegel, 1976). Although these studies have led to a better understanding of sleep misperception, the difference in sleep misperception between ca regiving and noncaregiving older adults remains unknown. This study addresses this question. Better understanding of sleep misperception in both caregiving and noncaregiving older adults is impor tant, because poor sleep is a major concern for both groups (Nau et al., 2005; Mc Curry et al., 2007; Pollak & Pe rlick, 1991). In addition, this study endeavors to address the arousal component of the Harvey model of insomnia. Due to dementia caregivers increase in arousal in co mparison to noncaregivers, sleep misperception may play an even greater role in the maintenance of poor sleep in dementia caregivers than it does in noncaregiving older adul ts (McCurry et al., 2007). This study investigates the misperception of wa ke time in three distinct groups of older adults: good sleeping n oncaregivers, poor sleeping noncaregiv ers, and poor sleeping dementia caregivers. Good sleeping dementia caregivers were not studied because there were not enough participants for analysis ( n = 4). The small number of good sleep ing caregivers was due to the 23

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study recruiting caregivers who complained of ni ghttime activity by their care recipients. This study criterion most likely ruled out most good sleeping caregivers. The noncaregivers and caregivers were divided into good sleeping nonc aregiving, poor sleep ing noncaregiving, and poor sleeping caregiving groups. This was done to fit with the current sleep misperception literature. Previous research has focused on identifying differences between good sleepers and poor sleepers. Three hypot heses will be tested. Aim 1 The first aim of this study examines the di fference between objectiv e and subjective total wake times within each of the three groups : good sleeping noncareg ivers, poor sleeping noncaregivers, and poor sleeping dementia caregivers. Hypothesis 1 There will be a significant total wake time disparity (subjective versus objective) in the poor sleeping caregiver and the poor sleeping noncaregiver groups. These two groups will have larger subjective total wake times in comparison to their objective total wake times. The significant discrepancy w ill be found within these two groups, because they maintain a heightened level of disparity-i nduced arousal. The poor sleeping noncaregivers will maintain a high level of ar ousal due to their cognitive and physiological anxiety regard ing not sleeping (Tang & Harvey, 2004). The poor sleeping caregivers will maintain their hi gh level of arousal due to multiple factors including (1) cognitive and phys iological anxiety regarding not sleeping, (2) cognitive and physiological anxiety rega rding whether their care recipients may wander during the night or hurt themselves, and (3) non-anxiety related cognitive and physiological arousal related to scheduled awakenings for nightly chores (Lee et al., 2008; McCurry et al., 2007, Tang & Harvey, 2004). In these two group s, arousal will promote the disparity 24

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between objective and subjectiv e total wake times. Good sl eeping noncaregivers will not have a significant discrepancy, because they do not have this chronic arousal. Aim 2 The first aim examines whether there is an overall discrepancy be tween subjective and objective total wake times within each of th e three groups. Aim 2 assesses the percentage of individuals within each of the three groups who under-estimate, have a consistent estimate, and over-estimate their perceived total wake time (sleep misperception). Since perfect perception of total wake tim e is unlikely, a subjective total wake time estimate within 30% of the objective total wa ke time will be considered consistent. Previous sleep misperception research has only looked at whether i ndividuals overor under-estimated their perceived wake time or the number of minutes that individuals overor under-estimated thei r perceived wake time (Carskadon et al., 1976; Tang & Harvey, 2005). There is no precedent for choos ing a margin of error for consistent estimation of sleep misperception. A 10% marg in of error would have suggested that individuals who reported 11 minutes of total wake time and objectively had 10 minutes of total wake time were considered over-estimat ors of their total wake time. A 30% margin of error allows for some discrepancy betw een the subjective and objective total wake times, without eliminating the possibility of individuals overor under-estimating their perception of total wake time. Hypothesis 2 Poor sleeping caregiving older adults and poor sleeping noncaregiving older adults will over-report their percepti on of total wake time during the night due to their increased arousal during the sleep period as described in the first aims hypothesis (Tang & Harvey, 2004). Good sleeping noncaregiving older adults will not exhibit a significant objective/subjective 25

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26 discrepancy in total wake time, because they do not experience this chronic arousal during the night. Aim 3 This third aim addresses whether the three gr oups display significan tly different amounts of sleep misperception from one another. Hypothesis 3 All three groups will have significantly diffe rent amounts of sleep misperception from one another. According to the Harvey model of in somnia maintenance (Tang & Harvey, 2004), poor sleep and arousal play a major role in sleep misperception. Poor sleeping caregivers will report the largest amount of sleep misperception. They w ill report this, because they will experience the following (1) cognitive and physio logical anxiety regarding not sleeping, (2) cognitive and physiological anxiety regarding whether their ca re recipients may wande r during the night or hurt themselves, and (3) non-anxiety related c ognitive and physiological arousal related to scheduled awakenings for nightly chores (L ee et al., 2008; McCurry et al., 2007, Tang & Harvey, 2004). Poor sleeping noncaregivers will report the second highest amount of sleep misperception, because of their cognitive and phys iological anxiety regarding not sleeping (Tang & Harvey, 2004). Since good sleepin g noncaregivers do not experien ce the previously described levels of anxiety and arousal, they will report the least amount of sleep misperception.

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CHAPTER 4 METHODS AND MATERIALS This is a secondary data analysis of two research studies. Both studi es collected objective sleep data (actigraphy two-cha nnel Mini-Meter Actiwatch-L), subjective sleep data (sleep diaries), and demographic information. The first se ven days of baseline data from the parent studies were analyzed. Participants Noncaregiving Older Adults The noncaregiving older adults were fr om a community-based sample study ( N = 103) recruited from the North Central Florida area. Th ese participants were recruited through media advertisements and community group meetings. Exclusionary criteria included (1) being under the age of 60, (2) having a sleep disorder othe r than insomnia, (3) having a major psychiatric disorder, (4) having severe cognitive impairment (scoring in the impaired range on 3 or more tests on the Cognistat), and (5) taking psychotro pic or other medications that may alter sleep (such as beta-blockers). Subjective (sleep diarie s) and objective (actigraphy) sleep data were collected for a two-week period. Only the firs t seven days of data are reported herein. Caregiving Older Adults The caregivers data was ta ken from a treatment study ( N = 55) examining an at homebased monitoring system for informal caregivers of patients with dementia. The system alarms the caregiver if the pa tient is attempting to exit the house. The car egiving study recruited informal caregivers from the North Central Fl orida area. The recrui tment methods included media advertisements and talk s at community group meetings including dementia support groups. Exclusionary criteria included (1) inabil ity to speak and read in English, (2) having a Mini-Mental Status Exam score lower than 27, (3) participating in treatmen t for a sleep disorder, 27

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(4) not living with his/ her care recipient, (5 ) the care recipient not having a diagnosis of dementia, and (6) the care recipient not engaging in nocturnal activity. Data was collected on the caregivers and their care recipien ts for a 12-month period. Particip ants met with the researchers at baseline and then 2-, 3-, 4-, 5-, 6-, 8-, 10-, a nd 12-months post-baseline. After each interview, subjective and objective sleep data was collected for seven consecuti ve days. Only the first seven days of baseline data are reported herein. Measures Sleep Measures Total wake time variables were measured c oncurrently with a subjective measure (sleep diary; Lichstein, Riedel, & M eans, 1999) and an objective m easure (actigraphy watch; Mini Mitter Co., 2001). Since the total wake time vari ables were analyzed using both subjective and objective measures, subscripts are utilized to note the type of m easure. An s subscript denotes the variable was measured subjectively and an o subscript denotes the variable was measured objectively. Subjective sleep measure This study utilized the daily sleep diary as it s subjective sleep measur e (Lichstein et al., 1999). Every morning, participants recorded their minutes of napping per day, bedtime, length of time to fall asleep, number of nighttime awakenings minutes awake during the night, final wakeup time, out-of-bed time, and sleep quality rating. Three subjective sleep variables on the sleep diary were analyzed (1) sleep onset latency (time from li ghts out until sleep onset; SOLs), (2) wake after sleep onset (total time spent awake from sleep onset to final wake up time; WASOs), and (3) terminal wakefulness (time spent awake in bed from final wake up time to out of bed time; TWAKs). From these three variables, a total wake time variable (TWTs) was calculated. Subjective total wake time wa s defined as the following TWTs = SOLs + WASOs + TWAKs. 28

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Objective sleep measure This study utilized the two-channel Mini-M eter Actiwatch-L, a wr ist-worn actigraphy device, to record objective sleep (Mini Mitter Co. Inc., 2001). Part icipants wore the Actiwatch-L on their non-dominant wrists for th e course of their pare nt studies. The partic ipants concurrently reported their sleep patterns on their daily sleep diaries, while wearing their actigraphy devices. The Actiwatch-L measures gross motor activity and ambient light exposure and consists of an omnidirectional, piezoelectric acc elerometer with a sensitivity of greater th an or equal to 0.01 gforce and a light sensor with a recording ra nge of 0.1 to 150,000 lux (Mini Mitter Co. Inc., 2001). Actiwatch-L analysis was perf ormed using an epoch length of 30 seconds (Lichstein, et al, 2006; Littner et al., 2003). An epoch length of 30 seconds was used, because it matches the 30 second standard utilized for polysomnography scoring (Rechtshaffen & Kales, 1968). During each epoch, the Actiwatch-L samples movement 32 times per second. The highest activity count is recorded for each second and the highest activity count within e ach epoch is used to describe the epoch. This data was downloaded onto a computer and analyzed using the ActiwareSleep v.3.3 software program. This program uses a validated algorithm to define each epoch as sleep or wake time (Oakley, 1997). Three levels of activity count sensitivity (low, moderate, and high) are available with the Actiware software A moderate level of sensitivity (40 activity counts) was utilized to define the threshold for wake and sleep. Moderate sensitivity was chosen, because it represents the standard used in sl eep research (Morgenthaler et al., 2007). If an epochs activity count is equal to or greater than 40, it is scored as wake. If an epochs activity count is less than 40, the surrounding 2 minutes (4 epochs) are analyzed using the following equation Total Activity Epoch A = EA-4 (0.04) + EA-3 (0.04) + EA-2 (0.20) + EA-1 (0.20) + EA (2) + EA+1 (0.20) + EA+2 (0.20) + EA+3 (0.04) + EA+4 (0.04). When A is the activity count of a given 29

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epoch, EA+/-(1-4) is the activity count of the four adjacen t epochs. If Total Activity Epoch A is less than 40 activity counts, the epoc h in question is scored as slee p. Bedtime and final wake up times were determined by the participants sleep di aries as recommended by the Actiware software. This program defined the start of sleep by the first 10-minute block with one epoch or less of defined wake time. The end of sleep was defined by the first 10-minute block with one epoch or less of defined sleep time. Four sleep variables were analyzed from the actigraphy data (1) sleep onset latency (interval from subjective be dtime to sleep onset; SOLo), (2) wake after sleep onset (sum of all wake epochs from sleep onset to wake time; WASOo), and (3) terminal wakefulness (interval from final wake time to out of bed time; TWAKo). From these three sleep variables, a total wake time variable (TWTo) was calculated. Objective total wake time was defined as the following TWTo = SOLo + WASOo + TWAKo. Sleep Misperception Participants sleep misperception was identified by utilizing both the sleep diary and actigraphy data. The formula to calculate the per centage of sleep misperception (Edinger & Fins, 1995) was defined as follow s Sleep Misperception = [TWTs TWTo] / TWTo 100. A sleep misperception score of 0% indicat es a perfect match between subjective and objective total wake time. A sleep misperception sc ore of 50% indicates the participant reported on her sleep diary being awake 1.5 times longer than her objective total wake time amount. A sleep misperception score of -50% indicates that the participan t reported being awake 1.5 times less than her objective total wake time amount. Group Classifications Participants were classified as poor sleeper s if they reported 31 minutes or more of unwanted wake time (at sleep onset latency or wa ke time after sleep onset) for three or more 30

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days of the one week of analyzed data; otherw ise, they were classifi ed as good sleepers. A 31 minute criterion was used since it is a more rigor ous criterion than the 30 minute criterion, which is common in sleep research (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003). As previously noted, because only 4 good sleep ing caregivers were id entified, this group was not analyzed. Background Information Demographic (age, gender, education, race, a nd marital status) and health-related data were collected during the screening a nd baseline questionnaire process. Analyses SPSS 15.0 was used for data analysis. The Kolmogorov-Smirnov and Shapiro-Wilk tests were performed to test for normality. All sleep data variables were significant, indicating that the data was not normally distributed (Table 4-1 for further information). Thus, non-parametric tests were performed to analyze the data. Demographic differences between the 3 sleep groups were analyzed using analyses of variance (ANOVA; ag e) and Chi-square analyses (gender, race, education, and marital status). Differences between the two poor sleeping groups in regards to subjective total sleep time (TSTs), objective total sleep time (TSTo), subjective total wake time (TWTs), and objective total wake time (TWTo) were analyzed using the Mann-Whitney test, the nonparametric version of the Independent Samples t-Test. For the main analyses of this study, one subjective sleep variable total wake time (TWTs), one objective sleep vari able total wake time (TWTo), and one variable combining both objective and subjective sleep variables sleep misperception were analyzed. For Aim 1, the Wilcoxon-Signed Ranks test, the non-parametric vers ion of the Paired Samples t-Test, was used to analyze differences in subjective versus objec tive total wake times within each of the three groups. For Aim 2, the Chi-square was utilized to analyze the percen tage of consistent 31

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estimation, over-estimation, and under-estimation of total wake time within each of the three groups. For Aim 3, the Kruskal-Wallis test, th e nonparametric version of the ANOVA, was performed to analyze whether the amount of sl eep misperception significantly differed between groups. Post hoc analyses were performed using Mann-Whitney tests. 32

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33 Table 4-1. Normality Test Results Variable KolmogorovSmirnov p WilkShapiro p TWTs a,c 0.14 0.00 0.89 0.00 TWTo b,d 0.14 0.00 0.90 0.00 Sleep Misperception 0.21 0.00 0.76 0.00a TWTs is defined as subjective total wake time. b TWTo is defined as objective total wake time. c A subscript s denotes the vari able was measured subjectively. d A subscript o denotes the va riable was measured objectively.

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CHAPTER 5 RESULTS Demographic, Health, and Sl eep-Related Characteristics The three groups did not differ by age ( F( 2, 125) = 69.95, p = 0.24), gender ( X2(2) = 4.19, p = 0.12), marital status ( X2(4) = 2.08, p = 0.72), or race ( p = 0.53). The three groups did differ by education ( X2(8) = 15.81, p = 0.05). Specifically, the thre e groups differed in the number of participants who receive d graduate education (F( 2, 125) = 3.20, p = 0.04). There was no difference between the two noncaregivi ng groups for graduate education, t (101) = -0.59, p = 0.59. The good sleeping noncaregivers reported more graduate sc hool work than the poor sleeping caregivers t (53.01) = 2.71, p = 0.01. The poor sleeping noncaregivers also reported more graduate school work than the poor sleeping caregivers, t (52.90) = 2.68, p = 0.01. To better understand whether health status varied between groups, the number of me dications within each group was analyzed. The three groups did not differ by number of medications ( F( 2, 125) = 0.54, p = 0.58). Table 5-1 has additional informati on on the samples demographic and health characteristics. There was a significant difference between th e poor sleeping caregivers and the poor sleeping noncaregivers for TSTs ( p = 0.01) and TWTo ( p = 0.00), but not for TSTo ( p = 0.378) and TWTs ( p = 0.43). Good sleeping noncaregivers were not included in this analysis. Since good sleeping noncaregivers report less than 31 minutes or more of unwanted awake time, their sleep variables will be significantly different than the two poor sleeping groups who report at least 31 minutes or more of unwanted awake tim e. Table 5-2 has additional information on the samples sleep-related characteristics. 34

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Main Analyses Aim 1: Differences between Subjective and Ob jective Total Wake Times within Groups For good sleeping noncaregivers, TWTs was significantly larger than TWTo, T = 29.00, p = 0.00. For poor sleeping noncaregivers, TWTs was larger than TWTo, T = 0.00, p = 0.00. For poor sleeping caregivers, there was no difference between TWTs and TWTo, T = 3.60, p = 0.06. Table 5-3 has additional information. Aim 2: Estimation of Perceived Total Wake Time within Groups The Chi-square was significant for estimations of perceived total wake times within the three groups, X2(4) = 22.76, p = 0.00. Specifically, 100% of poor sleeping noncaregivers, 55.90% of good sleeping noncaregiver s, and 50.00% of poor sleeping caregivers over-estimated their perception of total wake time. Table 5-4 has additional information. Aim 3: Differences in the Amount of Sleep Misperception between Groups The amount of sleep mispercepti on differed significantly by group, ( H (2) = 21.84, p = 0.00). Poor sleeping noncaregivers reported mo re sleep misperception than good sleeping noncaregivers (U = 490.00, p = 0.00). Poor sleeping noncaregivers also reported more sleep misperception than poor sleeping caregivers (U = 65.00, p = 0.00). There was no difference between good sleeping n oncaregivers and poor sleeping caregivers ( U = 406.00, p = 0.99). Table 5-5 has additional information. 35

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Table 5-1. Demographic Char acteristics for the Sample Noncaregiving Noncaregiving Caregivers Overall Sample Good Sleepers Poor Sleepers Poor Sleepers ( N = 126) ( n = 32) ( n = 71) ( n = 23) M M M M Age (years) 72.43 (6.97)d 73.14 (6.60) d 72.38 (7.50) d 70.30 (7.18)d Education Some High School (%) 4.00 2.80 9.40 0.00 High School Graduate (%) 13.60 9.90 12.50 26.10 Some College/Technical School (%) 28.80 26.80 18.80 47.80 College Graduate (%) 18.40 21.10 15.60 13.00 Graduate School (%) 35.20a 38.00b 43.80c 13.00b, c Race White (%) 96.80 94.40 100.00 100.00 Black (%) 2.40 4.20 0.00 0.00 Other (%) 0.80 1.40 0.00 0.00 Female (%) 66.70 59.20 75.00 78.30 Marital Status Currently Married (%) 63.50 56.30 65.60 82.60 Previously Married (%) 18.30 16.90 25.00 13.00 Never Married (%) 4.80 5.60 3.10 4.30 Other (%) 13.40 21.2 6.3 0.10 Medications (number) 2.99 (2.18)d 3.07 (2.24)d 2.66 (2.03)d 3.22 (2.24)d a The three groups differed in graduate education ( F (2, 125) = 3.20, p = 0.04). b There was a significant difference between good sleeping noncaregiv ers and poor sleeping caregivers, t (53.01) = 2.71, p = 0.01. The good sleeping noncaregiv ers reported more graduate school work than the poor sleeping caregivers. c There was a significant difference between poor sleeping noncaregiv ers and poor sleeping caregivers, t (52.90) = 2.68, p = 0.10. The poor sleeping noncaregiv ers reported more graduate school work than the poor sleeping caregivers. d The number within the parenthesi s is the standard deviation. 36

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Table 5-2. Sleep Characteristics for the Sample Noncaregivers Noncaregivers Caregivers Overall Sample Good Sleepers Poor Sleepers Poor Sleepers Mdn Mdn Mdn Mdn Z U r SleepRelated Variables TSTs (minutes)b, f 408.29 414.79 414.79a 374.00 -2.49 222.00 a -0.26 TSTo (minutes)c, g 425.93 425.21 425.21 420.43 -0.88 230.00 -0.09 TWTs (minutes)d, f 70.07 95.71 95.71 126.43 -0.79 220.00 -0.08 TWTo (minutes)e, g 42.43 43.29 43.29a 86.07 -5.28 33.00 a -0.54 a There was a significant difference (p < 0.01) between poor sleeping noncaregivers and poor sleeping caregivers. b TSTs is defined as subjective total sleep time. c TSTo is defined as objective total sleep time. d TWTs is defined as subjective total wake time. e TWTo is defined as objective total wake time. f A subscript s denotes the vari able was measured subjectively. g A subscript o denotes the va riable was measured objectively. 37

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Table 5-3. Results for Aim 1: Differences between Subj ective and Objective Total Wake Times within Groups Mdn (minutes) Mean Negative Rank Difference Mean Positive Rank Difference Z r TWTs b TWTo c Good Sleeping Noncaregivers 50.13 34.57 36.79 29.00a -3.62 -0.31 Poor Sleeping Noncaregivers 95.71 43.29 16.50 0.00a -4.94 -0.62 Poor Sleeping Caregivers 126.43 86.07 9.13 3.60 -1.92 -0.38 a There was a significant within group difference (p < 0.01) between TWTs and TWTo. b TWTs is defined as subjective total wake tim e. A subscript s denotes the variable was measured subjectively. c TWTo is defined as objective total wake time. A subscript o denotes the variable was measured objectively. 38

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Table 5-4. Results for Aim 2: Estimation of Perceived Total Wake Time within Groups Noncaregivers Noncaregivers Caregivers Good Sleepers Poor Sleepers Poor Sleepers Amount Mdn Amount Mdn Amount Mdn Under-Reporta 16.20% -49.68% 0.00% --8.30% 30.79% Consistent Reportb 27.90% 5.80% 0.00% --41.70% 14.66% Over-Reportc 55.90% 104.85% 100.00% 151.50% 50.00% 92.85%a Under-estimation is defined as the self-report of the total wake time being 30% lower than the objective total wake time. b Consistent estimation is defined as the self-r eport of the total wake time being within 30% of the objective total wake time. c Over-estimation is defined as the self-report of the total wake time being 30% greater than the objective total wake time. 39

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40 Table 5-5. Results for Aim 3: Differences in the Amount of Sleep Misperception between Groups Mdn Mean Rank Difference in Mean Ranks U Test Z r Post Hoc 1 Good Sleeping Noncaregivers 36.45% 41.71 27.48 490.00a -4.42 -0.44 Poor Sleeping Noncaregivers 151.50% 69.19 Post Hoc 2 Good Sleeping Noncaregivers 36.45% 40.53 0.20 406.00 -0.03 0.00 Poor Sleeping Caregivers 32.10% 40.33 Post Hoc 3 Poor Sleeping Noncaregivers 151.50% 26.47 14.55 65.00a -3.35 -0.51 Poor Sleeping Caregivers 32.10% 11.92 a There was a significant difference ( p < 0.01) between groups.

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CHAPTER 6 DISCUSSION Discussion of the Findings Aim 1: Differences between Subjective and Ob jective Total Wake Times within Groups This first aim addressed whether there was a significant discrepancy between objective and subjective total wake times within the three groups. Results from this analysis indicate that both good sleeping and poor sleeping noncar egivers exhibit a si gnificant discrepancy between their subjective and objective total wake times. Poor sleeping caregivers did not exhibit a significant difference between their subjective and objective to tal wake times; however, the group was near significance ( p = 0.06). This non-significant result may be a result of a small sample size of poor sleeping caregivers ( n =23). The hypothesis for this aim was that the two poor sleeping groups would have a significant discrepancy between th eir objective and subjecti ve total wake times, while the good sleeping group would not. This hy pothesis was not fully supported. Specifically, good sleeping noncaregivers reported a significant discrepancy between subjective and objective total wake times and poor sleepi ng caregivers did not. Poor sl eeping noncaregivers reported a significant discrepancy between the variables, as hypothesized. According to the Harvey model of insomnia arousal and chronic poor sleep increase the likelihood of misperceiving wake time (Tang & Harvey, 2004). These results indicate, however, that arousal and poor sleep are not the only two factors in significant discrepancies between subjective and objective total wake times. G ood sleeping noncaregivers had a significant discrepancy between subjective and objective to tal wake times although th ere is no evidence of the cognitive and physiological ar ousal, which Harvey postulates is necessary for sleep misperception (Tang & Harvey, 2004). These resu lts suggest that discrepancies between subjective and objective total wake times ar e common to both good sleeping and poor sleeping 41

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groups. The significant results for the two noncaregiving groups and the near signif icant results for the caregiving group suggest two possible hypotheses. The fi rst is that the discrepancy between subjective and objective total wake times is not necessarily the primary factor in sleep misperception and chronic poor sleep. This hypothesi s would suggest that Harveys theory that sleep misperception is the primar y factor in chronic poor sleep is not accurate. Specifically, cognitive and physiological arousal and anxiety may be more important to chronic poor sleep than the sleep misperception this arousal induces This would explain why three groups have significant or near significant total wake time discrepancies, but not all three groups (good sleeping noncaregivers) report poor sleep. The second hypothesis is that the Harvey model is correct and the discrepancy between subjective and objective total wake time promotes sleep misperception and chronic poor sleep in poor sleepers. This hypothe sis suggests that good sleeping noncaregivers are subject to sleep mispercep tion; however, they are more resilient to it and its effects. For example, although the good sleeping noncaregivers report being awake for longer than their object ive total wake times, they feel th at their sleep is restorative. Aim 2: Estimation of Perceived Total Wake Time within Groups While the first aim addressed whether ther e was a disparity between subjective and objective total wake times within groups, this aim focused on the estimation of perceived total wake times within the three gr oups. All three groups over-estimated their perception of total wake time. Specifically, 100% of poor sleep ing noncaregivers, 55.90% of poor sleeping caregivers, and 50.00% of good sleeping noncaregiver s over-estimated their perception of total wake time. The hypothesis for this aim was that both poor sleeping groups would over-estimate their perceptions of wake time, while good sleeping noncaregivers estimates would be consistent with their objec tive total wake times. This hypothesis was not fully supported. 42

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The over-estimation of subjective total wake time for the two poor sleeping groups is consistent with previous research (Carska don et al., 1976; Borkovec et al., 1981). However, good sleeping noncaregivers did not pr imarily report consistent total wake times as expected (Carskadon et al., 1976; Borkovec et al., 1981). Interestingly, a bout half of the good sleeping noncaregivers and the poor sleeping caregivers ove r-estimated their perceived total wake times. When looking at these first two aims togeth er, these results suggest new information about poor sleeping caregivers. Although ther e was no significant difference between the subjective and objective total wake times for the poor sleeping caregivers (A im 1), only half of poor sleeping caregivers ove r-estimated their subjective total wake times (Carskadon et al., 1976; Borkovec et al., 1981). These results suggest that the Harvey model of insomnia maintenance does not fit with the poo r sleeping caregivers sleep profile The Harvey model suggests that poor sleepers will overestimate their perceived wa ke time, since they are both cognitively and physiologically aroused (Tang & Harvey, 2004). According to the literature, poor sleeping caregivers should experience cogni tive and physiological arousal related to their poor sleep, cognitive and physiological arousal related to unanticipated awak enings (i.e. the care recipient wanders from the home), cognitive and physiologi cal arousal related to anticipated nightly awakenings (i.e. checking on the care recipient or handling a medication) and a high level of anxiety related to their caregiving duties. Accord ing to the Harvey model, this combination of arousal and anxiety should cause most poor sleeping caregivers to misperceive (Tang & Harvey, 2004). In addition, according to the literatu re, the good sleeping noncaregivers should not experience the arousal and anxiety that is required for over-estima ting their total wake times. The only group that continues to fit the Harvey prof ile for chronic poor sleep ers is the poor sleeping noncaregivers. Specifically, this group, according to the literature, expe riences cognitive and 43

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physiological arousal related to their poor sleep, which in turn promotes over-estimation of total wake times (Tang & Harvey, 2004). The similar grouping of estimations between poor sleeping caregivers and good sleeping non caregivers (50.00% versus 55.90%) suggests that sleep misperception may not be the primary factor fo r chronic poor sleep in these caregivers. In addition, these results suggest th at poor sleeping caregivers are more similar to good sleeping noncaregivers than poor sleeping noncaregivers. Aim 3: Differences in the Amount of Sleep Misperception between Groups The third aim addressed how the three gr oups differed in their amount of sleep misperception. There was a significant differe nce between good sleepin g noncaregivers, poor sleeping noncaregivers, and poor sleeping caregivers. Speci fically, poor sleeping noncaregivers reported more sleep misperception than both th e poor sleeping caregiver s and the good sleeping noncaregivers. In addition, there was no significant difference in sleep misperception between poor sleeping caregivers and good sleeping noncar egivers. The hypothesis that poor sleeping caregivers would have the gr eatest amount of sleep misp erception was not supported. These results further reflect what was found in Aim 2: poor sleeping caregivers are more similar to good sleeping careg ivers than poor sleeping noncaregivers. Although the Harvey model suggests that arousal, anxiety, and poor sleep influence the amount of sleep misperception, these data reflect that these factor s need to be examined further and that other factors should be considered as well (Means et al., 2003; Tang & Harvey, 2004). One possible explanation for this phenom enon is that although these poor sleeping caregivers may have the initial high levels of cognitive and physiological arousal and anxiety, they are able to anchor their nighttime estima tes of wake time. Anchoring might allow the poor sleeping caregivers to make subjective total wake time estimates that ma tch their objective total wake times. One possible anchor which poor sleepi ng caregivers may use is caring for their care 44

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recipients (Creese, 2008). Many caregivers pe rform a variety of tasks during the night to maintain their care recipients health and safety. Although orig inally hypothesized that this neutral arousal would induce slee p misperception, it is possible that this arousal aids in anchoring perceived total wake time. By anchori ng their total wake times to their chores, poor sleeping caregivers are not increasing their ar ousal, which is required to sustain sleep misperception according to the Harvey model of insomnia maintenance (Creese, 2008; Tang & Harvey, 2004). Caregivers are focusing on their chores and not worrying about being awake during the night. This hypothesis suggests that some of the arousal that the caregivers are experiencing (specifically the cognitively a nd physiological arousal related to planned awakenings) is not creating anxiety and prompting sleep misperception but instead is helping the caregivers report consistent total wake times. This hypothesis fits with previous time es timation literature. Tang and Harvey (2005) found that poor sleepers were able to estimate ti me accurately even in their bedrooms as long as they were not attempting to sleep. These caregivers may be able to accurately estimate their time, because they are focused on a non-sleep activity, fo r example, checking on their care recipients. Since the caregivers are not activ ely concerned about not sleeping, when they return to bed, they are able to accurately esti mate their wake time. Additi onally, the noncaregivers may be estimating poorly because they are estimating th eir wake times while concentrating on trying to return to sleep. The noncaregivers focus on tr ying to return to sleep may hinder their time estimation skills, while the caregivers focus on non-sleep activities ma y be helping them estimate their wake time (Tang & Harvey, 2005). Th is suggests that not a ll arousal is anxietyinducing but instead is useful fo r consistent time estimations. 45

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These data reflect that although dementia caregivers typically experience more distress and anxiety than noncaregivers, they also may expe rience arousal events that help deter sleep misperception (Brummett et al., 2006; Haape & Berger, 2002; Thommessen et al., & Laake, 2002). Specifically, poor sleeping car egivers had similar over-estimations of perceived total wake time in comparison to good sleeping noncareg ivers (Aim 2), and were not significantly different in the amount of sleep mispercepti on in comparison to good sleeping noncaregivers (Aim 3). In contrast to the Tang and Harvey study (2004), these results suggest that sleep misperception does not automatically occur because individuals are aroused and anxious during the night. Instead, it is possible that some types of arousal (pla nned nighttime activity) may help individuals estimate wake time and not misperceive wake time. These results also suggest that poor sleeping caregivers are more similar to good sleeping n oncaregivers than to other poor sleeping groups (i.e. noncaregivers). Specifically, although poor sleeping caregivers and good sleeping noncaregivers may use di fferent resources and techni ques (for example, plannedawakening arousal versus limited awakenings) to limit the amount of sl eep misperception they experience, they are both able to do so more effectively than poor sleeping noncaregivers. Limitations This study has several limitations. First, two research studies were combined to create this study. The caregivers and the noncaregivers fulfille d two different sets of rule out criteria. Although the criteria were very similar, there is the possibility that a si ngle rule out criteria would have elicited different pa rticipants. Second, this was a secondary data analysis. Only measures that were administered for the a prio ri hypotheses of the two respective studies could be analyzed to understand sleep misperception. Additional measures may have been used to further understand sleep misperception in caregiv ing and noncaregiving older adults. Third, a selection bias for poor sleep in the caregivers may have occurr ed. Caregivers joined the study 46

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because their care recipients e xperienced awakenings during the night. It is possible that caregivers whose care recipients do not awaken du ring the night, and therefore did not join the study, have good sleep. It is for th is reason that there may have been a limited number of good sleeping caregivers recruited (n = 4). Fourth, both studies primarily enrolled Caucasian, female participants. The female gender is representa tive of the caregiving community; however, the caregiving community is ethnically diverse. These results may not necessarily be generalized to the larger dementia caregiving community. Fifth, this study only examined caregivers of dementia patients. These results may not genera lize to the greater careg iving community. Sixth, as noted earlier, poor sleep and health pr oblems are interrelate d. Although there was no difference between groups for the nu mber of medications used, it is possible that the health status of the groups contributed to the results of this study. Future Directions This study suggests two interesting venues for fu ture research. First, this study was unable to analyze good sleeping caregivers due to the small number ( n = 4). Future studies should attempt to actively recruit good sleepi ng caregivers to determine if they exist. If they do, research regarding their ability to accurately perceive th eir sleep and wake time should be investigated. Second, the results of this study suggest that caregivers are ab le to anchor their estimates of wake time, possibly with th e use of nighttime caregiving duties. However, it is unknown whether poor sleeping caregivers (and caregivers in general) are able to estimate accurately all wake time episodes. It is possible that careg ivers may experience two difference types of nighttime awakenings: anchored awakenings and non-anchored awakenings. The non-anchored awakenings involve the cognitive and physiological arousal that Harvey describes as inducing anxiety-related sleep mispercep tion. The anchored awakenings also involve cognitive and physiological arousal; however, this arousal is not anxiety-inducing but instead promotes 47

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consistent estimation. This anchored arousal may be similar to normal day arousal and therefore the individual is able to estimate tim e as accurately during those episodes as during the day. Future research should examine whether caregivers are able to accurately estimate their sleep onset latencies, wake after sleep onset periods and terminal wakefulness. It is possible that caregivers are able to accurately estimate certain periods of the night better than others. For example, nighttime awakenings may be anchored to chores. At the same time, caregivers may misperceive wake time when trying to fall aslee p, because the caregivers may be more focused on trying to sleep than care giving duties (and other time anchoring activities). This investigation of how sleep mispercepti on may vary at sleep onset, during the night, and at final wake up time may also play a major role in future research for sleep treatment plans. Current treatments for insomnia focus on elim inating most wake time during the night. Many caregivers, unfortunately, cannot remove a ll nighttime wakefulness because of required caregiving duties and unexpected nocturnal care recipi ent activity. By better understanding if and when caregivers misperceive their sleep, clinicia ns can focus on limiting that misperception. In addition, future research needs to examine if and when caregivers experience cognitive and physiological arousal and anxiety that induces sleep misperception, as per the Harvey model. For example, if caregivers experience anxiety-induci ng arousal at sleep onset only, clinicians can focus their efforts on that portion of the night. Also, if research indicates that caregivers experience anchoring-induced arousal during their wake after sleep onset period, clinicians may be able to focus their treatment efforts on other ways of increasing sleep quality. Future research should focus on if and when caregivers accurately perceive their wake time and misperceive their wake time to better serve this group in a treatment environment. With additional research in this area, clinicians will be able to tailor insomnia treatments for caregivers to their specific needs. 48

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49 Summary This study suggests that poor sleeping caregivers ar e similar to good sleeping noncaregivers. Specifically, there was a significant difference between subj ective and objective total wake times in the good sleeping and poor sleeping noncaregiving groups. There was no difference between subjective and objective tota l wake times in the poor sleeping caregivers; however, the group almost reached significance ( p = 0.06). This group may have had a significant discrepancy if the sample size had been larger ( n = 23). Both good sleeping noncaregivers and poor sleeping careg ivers reported similar estimat es of perceived total wake times. There was a significant difference in sl eep misperception between groups. Poor sleeping noncaregivers reported a significantl y larger percentage of sleep misperception compared to both good sleeping noncaregivers and poor sleeping caregivers. In addi tion, there was no significant difference in the percentage of sleep misperception between good sleep ing noncaregivers and poor sleeping caregivers. These results suggest that poor sl eeping caregivers are able to estimate total wake time as accurately as good sleeping ca regivers. This result is in conflict with the Harvey model of insomnia maintenance, which links the maintenance of poor sleep with sleep misperception. One possibility for the poor sleeping caregivers being able to accurately estimate their total wake times is that some of thei r arousal during the night does not promote sleep misperception as per the Harvey model. Instead, this arousal (from planned nightly chores) anchors their wake time. Future research studies looking at sleep onset, wake episodes after sleep onset, and wake time prior to exiting bed is warranted. By engaging in research at these specific time points, researchers may be able to bett er understand when dementia caregivers are misperceiving wake time and when they are not.

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McCurry, S., & Teri, L. (1995). Sl eep disturbance in elderly careg ivers of dementia patients. Clinical Gerontologist, 16, 51-66. McKibbin, C., Ancoli-Israel, S., Dimsdale, J., Arc huleta, C., von Kanel, R., Mills, et al. (2005). Sleep in spousal caregivers of people with Alzheimers disease. Sleep: Journal of Sleep and Sleep Disorders Research, 28, 1245-1249. Means, M., Edinger, J., Glenn, D., & Fins, A. (2003). Accuracy of sleep perceptions among insomnia sufferers and normal sleepers. Sleep Medicine, 4, 285-296. Mini Mitter Co. Inc. (2001). Actiwatch 16/Actiwatch 64/Actiwatch-L/Actiwatch-Score instruction manual. Bend, OR: Author. Morgan, K. (2000). Sleep and aging. In K. Lichstein, & C. Morin (Eds.), Treatment of late-life insomnia (pp. 3-26). USA: Sage Publications, Inc. Moregenthaler, T., Alessi, C., Friedman, L., Owe ns, J., Kapur, V., Boeckecke, B., et al. (2007). Practice paramters for the use of actigra phy in the assessment of sleep and sleep disorders: An update for 2007. Sleep: Journal of Sleep and Sleep Disorders Research, 30, 519-529. Nau, S., Cook, K., McCrae, C., & Lichstein, K., ( 2005). Treatment of insomnia in older adults. Clinical Psychology Review, 25 645-672. Oakley, N. R. (1997). Validation with polysomnography of the sleepwatch sleep/wake scoring algorithm used by the Actiwatch activity monitoring system. Bend, OR: Mini Mitter Co. Inc. Ohayon M., & Vecchierini, M. (2005). Normative sleep data, cognitive function and daily living activities in older adults in the community. Sleep: Journal of Sleep and Sleep Disorders Research, 28, 981-989. Pollak, C., & Perlick, D. (1991). Sleep problem s and institutionaliza tion of the elderly. Journal of the Geriatric Psychiatry and Neurology, 4, 204-210. Pruchno, R., & Potashnik, S. (1989). Caregiving spouses: Physical and mental health in perspective. Journal of the American Geriatric Society, 37, 697-705. Rechtschaffen, A., Kales, A. (1968). A manual of standardized terminology, techniques, and scoring system for sleep stages of human subjects. Bethesda, Maryland: U.S. Dept. of Health, Education, and Welfare. Schubert, C., Cruickshanks, K., Dalton, D., Klein, B., Klein, R., & Nondahl, D. (2002). Prevalence of sleep problems and qua lity of life in an older population. Sleep: Journal of Sleep and Sleep Disorders Research, 25, 889-893. 52

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53 Semler, C., & Harvey, A. (2005). Mispercepti on of sleep can adversely affect daytime functioning in insomnia. Behaviour Research and Therapy, 43, 843-856. Sewitch, D. (1984). The perceptual uncertainty of having slept: The inability to discriminate electroencephalgographic sleep from wakefulness. Psychophysiology, 21, 243-259. Tang, N., & Harvey, A. (2004). Effects of cognitive arousal and physiolo gical arousal on sleep perception. Sleep: Journal of Sleep and Sleep Disorders Research, 27, 69-78 Tang, N., & Harvey, A. (2005). Time estimation ability and distorted perception of sleep in insomnia. Behavioral Sleep Medicine, 3, 134-150. Teel, C, & Press, A. (1999). Fatigue among elders in caregiving and noncaregiving roles. Western Journal of Nursing Research, 21, 498-520. Thommessen, B., Aarsland, D., Braekhus, A., Okseng aard, A., Engedal, K., & Laake, K. (2002). The psychosocial burden on spous es of the elderly with stroke dementia and Parkinsons disease. International Journal of Geriatric Psychiatry, 17, 78-84. Thorson, J., & Davis, R. (2000). Reloca tion of the institutionalized aged. Journal of Clinical Psychology, 56, 131-138. U.S. Department of Health and Human Services (2001). The characteristics of long-term care users. Rockville: Agency for Healthcare Research and Quality. U.S. Department of Health and Human Services (1994). National long-term care survey. Vitiello, M., Moe, K., & Prinz, P. (2002). Sleep complaints cosegregate with illness in older adults: Clinical research informed by and informing epidemiological studies of sleep. Journal of Psychosomatic Research, 53, 555-559. Wilcox, S., & King, A. (1999). Sleep complaints in older women who are family caregivers. Journals of Gerontology: Seri es B: Psychological Sciences and Social Sciences, 54B, 189-198.

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BIOGRAPHICAL SKETCH Pamela Dubyaks interest in sleep research began when she was a junior at Brown University. She became engaged in the literature once she disc overed that although people spend one-third of their lives sleeping, no one understa nds fully why people sleep. During the summer of 2003, Ms. Dubyak had the opportunity to work with Dr. Mary Carskadon and learn more about her research in developmen t and sleep. After graduating from Brown with a Bachelor of Arts in American civilizati on and psychology, Ms. Dubyak took a break from sleep research. She worked for two years at the Substance Abuse Research Unit at Rhode Island Hospital. She presented a poster at the Association of Behavi oral and Cognitive Therapies national convention on research on the relationship am ong Hepatitis C, health belief s, and risk behaviors in a substance-using population. In 2006, she returned to academia and sleep research. For the past two years, she has worked in the Sleep Research Laboratory under the supe rvision of mentor Dr. Christina McCrae in the Department of Clinical and Health Psychology at the University of Florida. During her time at the University of Flor ida, she has presented some of her research on objective and subjective differen ces between caregiving and noncar egiving older adults at the annual Sleep Conference. Although her interests within the field of sleep have varied, she continues to be drawn to unders tanding how sleep plays an impor tant role in peoples lives. 54