Sleeping dif culties in relation to depression and anxiety in elderly adults

LENA MALLON, JAN-ERIK BROMAN, JERKER HETTA

Mallon L, Broman J-E, Hetta J. Sleeping dif culties in relation to depression and anxiety in elderly adults. Nord J Psychiatry 2000;54:355 360. Oslo. ISSN 0803-9488. This study examines the prevalence of sleeping dif culties and their relationship to depression and anxiety in 1328 subjects aged 57 79 years by means of a questionnaire. Dif culties initiating sleep (DIS), dif culties maintaining sleep (DMS), early morning awakenings (EMA), and nightmares were assessed with The Uppsala Sleep Inventory (USI) and depression and anxiety with The Hospital Anxiety and Depression Scale (HAD scale). A total of 20.4% reported severe sleeping dif culties (DIS, DMS, or EMA), with a female preponderance. On the basis of the HAD scale we found that 3.4% ful lled the criteria for de nite depression and 10.1% ful lled the criteria for possible depression. The prevalence of de nite and possible pure anxiety (anxiety without depression) was 2.7% and 8.1%, respectively. There was no sex difference in reports of depression, but women more often reported pure anxiety. Altogether, 24.3% of the sample had either depression or anxiety. Nightmares were reported by 2.2% of the sample and associated with both depression and anxiety. We found that 39% of respondents with de nite depression and 45.2% with de nite pure anxiety reported sleeping dif culties. Depression emerged as the variable most consistently associated with sleeping dif culties when depression, pure anxiety, age, and sex were considered simultaneously. Habitual sleeping pill use was reported by 31.1% of the subjects with de nite depression, whereas only 24.4% received antidepressive medication. These ndings indicate that sleeping dif culties often are associated with psychiatric symptoms, especially depression. Anxiety, Depression, Elderly, Epidemiology, Sleeping dif culties. Lena Mallon, Psychiatric Clinic, Falun Hospital, SE-791 82 Falun, Sweden; Accepted: 19 July 1999.

ith advancing age there is an increase in sleeping dif culties and in the use of sleep medication, especially among women (1 3). Overall, from epidemiological surveys 15% 35% of elderly subjects report sleep problems (4 6). Sleeping dif culties are traditionally classi ed as dif culties initiating sleep (DIS), dif culties maintaining sleep (DMS), or early morning awakenings (EMA). Sleeping dif culties and nightmares have been found to be associated with both depression and anxiety (6 10). Estimates of the prevalence of depression among the elderly have been the focus of many studies, but there is a considerable variation in reported prevalence rates. In community-based surveys using different screening instruments the prevalence of depression generally varies between 10% and 17% (7, 11), whereas studies using the DSM criteria for major depression report lower prevalence rates, about 2% 8% (12 14). Anxiety has been thought to be less common among the elderly (15), but surveys (16 18) have found that anxiety disorders have a preva 2000 Taylor & Francis

lence rate of about 13% 18% among the elderly, similar to the rates of depression in the same populations. Methodological differences such as survey methods and diagnostic criteria may account for some of the variability in reported prevalence rates of depression and anxiety. One factor relevant to this discrepancy in the prevalence is the overlap between the two conditions. If a clinical state is characterized by both depression and anxiety, it is classi ed as depression, and anxiety is only diagnosed when depression is absent, the so-called hierarchical approach to diagnosis. Consequently, using the hierarchical approach in diagnosing will yield lower prevalence rates for anxiety than a non-hierarchical approach. It is still not clear how advancing age, sex, depression, and anxiety together might affect sleep. The aim of the present study was to assess the prevalence of sleeping dif culties and nightmares in elderly adults and investigate their association with depression and anxiety.

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Materials and Methods

Subjects
From the population register 1792 elderly adults, aged 57 79 years, were randomly selected from the County of Dalarna, Sweden, and asked to participate in a questionnaire survey. The study was performed in December 1995. The questionnaire was initially completed by 1117 subjects, and one reminder resulted in another 211 questionnaires. No signi cant differences were found in age, demographic characteristics, symptoms of depression, anxiety, or sleeping dif culties between early and late responders. The total response rate was 74.1%, and of the 1328 responders 623 were men and 705 were women. The mean age was about the same for men and women, 67 9 6 years versus 68 9 6 years.

The questionnaire

The questionnaire Sleep and Health consisted of 89 questions that covered demographic characteristics, sleep habits, sleeping dif culties, physical illnesses, symptoms of depression and anxiety, and medication. A description of the questionnaire has been published previously (19). In the present paper we investigated data concerning sleeping dif culties, depression, anxiety, and related medication usage. Sleeping dif culties were assessed by using questions from The Uppsala Sleep Inventory (USI), which has previously been used in studies to assess sleeping dif culties (20 22). Subjects were asked about dif culties initiating sleep (DIS), dif culties maintaining sleep (DMS), and early morning awakenings (EMA), and the questions were to be answered on a ve-point scale (1 no problems, 2 minor problems, 3 moderate problems, 4 severe problems, and 5 very severe problems). For the current analyses scores of 4 and 5 were considered to represent complaints, and sleeping dif culties were de ned as complaints of DIS, DMS, or EMA. Subjects were asked about nightmares and sleeping pill usage, and these questions were also to be answered on a ve-point scale (1 never, 2 seldom, 3 sometimes, 4 often, and 5 very often). Responders were classi ed as having nightmares or being habitual sleeping pill users if they reported nightmares or usage often or very often (scores of 4 and 5). There was also an open-ended question about the use of medication. Depression and anxiety were assessed by using the Hospital Anxiety and Depression Scale (HAD scale). This is a self-rating scale in which the overall severity of depression and anxiety is rated on a four-point scale (0 to 3). Seven questions are related to depression (HADD) and seven to anxiety (HAD-A), both with a score range of 0 21. The items of the scale have been chosen so as to be in uenced as little as possible by concomi-

tant physical illness, and the depression subscale does not include sleeping dif culties. Zigmond & Snaith (23) have recommended two cut-off points: 8 for possible cases and 11 for de nite cases. The HAD scale has been shown to be a reliable instrument for screening depression and anxiety (24 26). When assessing the prevalence of depression and anxiety, scores of 8 10 on either subscale were de ned as possible cases of depression or anxiety, and scores of 11 and more on either subscale as de nite cases of depression or anxiety. We also assessed the prevalence of anxiety without depression, so-called pure anxiety and de ned this as having scores of 0 7 on the HAD-D and scores of 8 10 (possible cases of pure anxiety) or ] 11 (de nite cases of pure anxiety) on the HAD-A. To test the validity of the two HAD subscales, factor analysis was conducted. The analysis yielded two factors (eigenvalue \ 1.0), corresponding to the HAD-A and HAD-D. All items were loading on the appropriate factor, except one item, which was found to load on both factors. The Cronbach alpha was 0.83 for HAD-A and 0.73 for HAD-D.

Procedure

A questionnaire, a stamped, addressed envelope, and a letter explaining the purpose of the study were mailed to each subject. Subjects were encouraged to call the investigator if they had any questions. Full anonymity protection was ensured. The study protocol was approved by the Ethics Committee of the Faculty of Medicine at Uppsala University in Sweden.

Statistical analysis

The statistical analyses were performed on a Macintosh computer, using the statistical analysis program SPSS 6.1. Standard methods have been used to calculate mean values and standard deviations. For comparison between categorical variables the chi-square test was used. The in uence of multiple variables was analysed using multiple logistic regression analysis, and the results are presented as an adjusted odds ratio (OR) with 95% con dence interval (95% CI). The P B0.05 level was adopted as a reference point for considering results to be statistically signi cant.

Results

Prevalence of sleeping dif culties, depression, and anxiety

Table 1 presents the prevalence of sleeping dif culties, nightmares, depression, and anxiety by sex. Of the total sample 8.0% reported DIS, 10.4% DMS, and 12.1% EMA. Altogether, 20.4% reported sleeping dif culties de ned as having DIS, DMS, or EMA. There was a female preponderance in reports of DIS and in having sleeping dif culties. Having nightmares was reported by
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2.2% of the respondents, with no sex difference. The criterion level indicating de nite depression was ful lled by 3.4% of the sample, and that of possible depression by 10.1%. The corresponding gures for de nite and possible anxiety were 6.6% and 11.6%, respectively. We also investigated the prevalence of pure anxiety and included only subjects with anxiety but without depression. In accordance with these criteria, 2.7% ful lled the criteria for de nite pure anxiety and 8.1% the criteria for possible pure anxiety. There was no sex difference in reports of depression, but women more often reported both anxiety and pure anxiety.

15.3% had sleeping dif culties, and the corresponding gure for de nite cases of pure anxiety was 45.2% (chi-square 31.8; PB 0.001). Table 3 summarizes the results of multiple logistic regression analyses to determine the independent association of de nite depression, de nite pure anxiety, sex, and age with sleeping dif culties and nightmares. The data showed that de nite depression was signi cantly and independently associated with DIS, DMS, EMA, and nightmares, whereas de nite pure anxiety was associated with DIS and nightmares. Female sex was a signi cant predictor of DIS, whereas older age did not give rise to increased odds in any of the variables.

Sleeping dif culties and their relation to depression and anxiety

In the following analyses we included only subjects with pure anxiety when evaluating anxiety. In Table 2 it can be seen that the most common sleeping dif culty for subjects with de nite depression was EMA, 33.3%, whereas the most common problem for subjects with de nite pure anxiety was DIS, 22.9%. Subjects with possible depression or possible pure anxiety more often reported DIS, DMS, and EMA than non-subjects. However, there was no signi cant difference in any of the sleeping dif culties between possible and de nitive cases of depression and pure anxiety. Having nightmares, habitual use of sleeping pills, and use of antidepressants were all more often reported in de nite cases of depression than in possible cases of depression. De nite cases of pure anxiety reported more often nightmares than possible cases of pure anxiety. Moreover, of the non-depressed, 17.2% reported sleeping dif culties, and of the de nite cases of depression 39.0% reported sleeping dif culties (chi-square 31.1; P B0.001). Of subjects without pure anxiety

Discussion

The rst main nding of the present study was that the prevalence of severe sleeping dif culties was 20.4%, with a female preponderance. The second main nding was that, on the basis of the HAD scale, 24.3% had either depression or anxiety. The third important nding was that depression emerged as the variable most consistently associated with sleeping dif culties. With an almost 75% response rate and with the same age and sex distribution among the responders as in the population in the county of Dalarna at the time of the study (27), we consider our results to be representative and valid with regard to sex and age characteristics. However, it seems quite plausible that the most disabled elderly adults are overrepresented among non-responders. Thus, our reported rates of morbidity may be somewhat underestimated. One main nding in the present study was that the point prevalence of sleeping dif culties was 20.4% when de ning sleeping dif culties as severe or very severe

Table 1. Prevalence (in percentage) of sleeping dif culties, depression, and anxiety in men and women.
Variable* DIS DMS EMA Sleeping dif culties Nightmares Depression De nite Possible Anxiety De nite Possible Pure anxiety De nite Possible Total (n1328) 8.0 10.4 12.1 20.4 2.2 3.4 10.1 6.6 11.6 2.7 8.1 Men (n 623) 4.7 9.4 12.4 17.5 2.0 2.9 8.8 3.4 6.8 1.5 4.9 Women (n705) 10.9 11.3 11.9 23.2 2.4 3.9 11.3 9.4 16.0 4.7 13.6 Chi-square test, P value B0.001 NS NS B0.05 NS NS NS B0.001 B0.001 B0.01 B0.001

* DIS dif culties initiating sleep; DMSdif culties maintaining sleep; EMAearly morning awakenings; Sleeping dif culties DIS, DMS, or EMA; de nite depression HAD-D score ]11; possible depression, HAD-D score 810; de nite anxiety, HAD-A score ]11; possible depression, HAD-A score 810; de nite pure anxiety, HAD-D score 07 and HAD-A ]11; and possible pure anxiety, HAD-D score 07 and HAD-A score 810.
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Table 2. Prevalence (in percentage) of sleeping dif culties and related variables in relation to depression and pure anxiety.
Depression Nondepressed (N) 6.4 8.7 10.0 1.8 4.2 2.5 Possible depression (P) 15.8 18.3 23.4 2.3 15.8 9.7 De nite depression (D) 20.0 28.6 33.3 11.4 31.1 24.4 Nonanxiety (N) 5.0 7.7 8.7 1.2 2.8 1.6 Pure anxiety Possible pure anxiety (P) 14.2 14.7* 17.7 2.8 15.0 9.3 De nite pure anxiety (D) 22.9 18.2 21.9 17.1 11.4 8.3

Variable DIS DMS EMA Nightmares Sleeping pills Antidepressants

Total 8.0 10.4 12.1 2.2 6.3 4.1

Difference between N and P: * PB0.05, PB0.01, P B0.001; difference between P and D: PB0.05, PB0.01, PB0.001. DIS dif culties initiating sleep; DMSdif culties maintaining sleep; EMAearly morning awakenings. Non-depressed HAD-D score 07; possible depression HAD-D score 810; de nite depression HAD-D score ]11. Non- anxiety HAD-D score 07 and HAD-A score 07, possible pure anxiety HAD-D score 07 and HAD-A score 810, de nite pure anxiety HAD-D score 07 and HAD-A ]11.

problems with DIS, DMS, or EMA. Studies using relatively narrow criteria in the de nition of sleeping dif culties, like ours, have reported similar prevalence rates: 18% 22% (8, 28, 29). As a screening instrument for depression and anxiety we used the HAD scale, which was developed to detect emotional disturbances among physically ill patients (23). We found that the prevalence of at least possible depression was 13.5%, and the prevalence of at least possible pure anxiety was 10.8%. The prevalence of both disorders together was 24.3% that is, about onefourth of elderly adults had either depression or anxiety. In this study 3.4% ful lled the criteria for de nite depression, and 10.1% the criteria for possible depression, the latter re ecting milder forms of depressive symptoms. Our prevalence rate of de nite depression in accordance with the HAD scale is similar to prevalence rates of depressive disorders based on the DSM classi cation reported from community surveys (13, 14). Studies assessing the prevalence of depression using other screening instruments generally report higher prevalence rates, 10% 39% (7, 11, 18, 30). In our survey 6.6% ful lled the criteria for de nite anxiety, and 11.6% ful lled the criteria for possible anxiety, most common among women. These ndings show that symptoms of anxiety are common among elderly adults. The prevalence rate of at least possible anxiety (18.2%) in the present survey is similar to community surveys among elderly, where anxiety is measured without hierarchical rules (16 18). When we applied a hierarchical procedure and excluded possible cases of depression, the prevalence rates of de nite and possible pure anxiety were 2.7% and 8.1%, respectively. In other studies using hierarchical rules among subjects aged 65 or more, the prevalence of anxiety range between 4% and 10% (31, 32). Disturbed sleep is a core symptom of both depression and anxiety disorders (33, 34), and sleeping dif culties

are common in the depressed elderly (7, 35). In a longitudinal study of elderly subjects (36) depression was related positively to sleep disturbance even when age, sex, and health status were considered simultaneously, and early morning awakening was the sleep symptom most consistently associated with depression. In the present study we found that severe sleeping dif culties were about twice as common in subjects with de nite depression as in the non-depressed. Furthermore, depression was strongly associated with sleeping dif culties and nightmares.
Table 3. Variables related to sleeping dif culties and nightmares, analysed by using multiple logistic regression analyses.
Dependent variable DIS Independent variable* Depression Pure anxiety Female Age Depression Pure anxiety Female Age Depression Pure anxiety Female Age Depression Pure anxiety Female Age OR (95% CI) 3.2 3.4 2.3 1.1 3.7 2.1 1.2 0.9 4.1 2.3 0.9 1.1 8.9 15.0 0.9 0.9 (1.57.1) (1.57.8) (1.43.6) (0.91.4) (1.97.6) (0.85.1) (0.81.7) (0.81.1) (2.18.0) (0.95.5) (0.61.3) (0.91.2) (3.125.4) (5.441.8) (0.42.1) (0.61.2) P value B0.01 B0.01 B0.001 NS B0.001 NS NS NS B0.001 NS NS NS B0.001 B0.001 NS NS

DMS

EMA

Nightmares

DIS dif culties initiating sleep; DMSdif culties maintaining sleep, EMAearly morning awakenings. * The independent variables examined are de nite depression, de nite pure anxiety, female sex, and age (in 5-year strata). The results are presented as an adjusted OR with 95% CI. OR odds ratio; CI con dence interval. OR calculated for a 5-year increase in age.
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Epidemiological data also support linkage between sleep disturbances and anxiety in the elderly (6, 8). In the present study severe sleeping dif culties were about 2.8 times as common in subjects with de nite pure anxiety as in those without anxiety. In our study pure anxiety was related to DIS and nightmares when age, sex, depression, and pure anxiety were considered simultaneously. A considerably high percentage of de nite cases of depression, 31.1%, used sleeping pills habitually. This nding emphasizes the need to keep depression in mind when evaluating sleeping dif culties among elderly adults. Moreover, it is noteworthy that only 24.4% of subjects with de nite depression received antidepressive medication. A similarly low gure has been reported by Skoog et al. (37), who found that among 85-year-olds in Goteborg, Sweden, 19.4% of those with any depres sive disorder received antidepressant medication. Livingston et al. (7) also found that only 13% of depressives were receiving antidepressants of subjects aged 65 and more in London. These ndings indicate that depression, for the most part, is untreated among the elderly. Because our study is cross-sectional we cannot establish any cause-and-effect relationship. It might be argued that it is a shortcoming that our sleep data are based only on self-reports of disturbed sleep. However, subjective data have been found to be largely consistent with polysomnographic ndings (38 40), and subjective complaints are particularly relevant because they re ect the persons beliefs and attitudes about sleep, and these conceptions decide whether the person seeks professional help or advice (41). In conclusion, about one- fth of elderly adults reported severe sleeping dif culties, about one-forth had depression or anxiety, and depression emerged as the variable most consistently associated with sleeping dif culties.
AcknowledgementsThis study was supported nancially by the Swedish Medical Research Council (Project 06869), the Dalarna Research Institute, the Swedish Psychiatric Association, the Marta and Nicke Nasvells Foundation, and the Swedish Lundbeck Foundation.

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Lena Mallon, M.D.; Jan-Erik Broman, Dr. Med. Sci.; and Jerker Hetta, M.D., Ph.D., Sleep Disorders Unit, Department of Neuroscience, Psychiatry, University Hospital, SE-751 85 Uppsala, Sweden.

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