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Sleep Breath (2012) 16:10591067 DOI 10.

1007/s11325-011-0601-2

ORIGINAL ARTICLE

Relationship between sleep quality and depression among elderly nursing home residents in Turkey
Fatma zlem Orhan & Deniz Tuncel & Filiz Ta & Nermin Demirci & Ali zer & Mehmet Fatih Karaaslan

Received: 28 June 2011 / Revised: 13 September 2011 / Accepted: 21 September 2011 / Published online: 27 November 2011 # Springer-Verlag 2011

Abstract Objectives Epidemiological studies indicate that more than half of the elderly population suffers from chronic sleep disturbances. Therefore, this descriptive study was conducted to examine sleep quality, excessive daytime sleepiness, daytime napping, and depression among a population of nursing home residents. Methods The studys sample included 73 elderly people living in a nursing home in Turkey. Geriatric Depression Scale, the
F. . Orhan (*) : M. F. Karaaslan Department of Psychiatry, Kahramanmaras Sutcuimam University Faculty of Medicine, 46100 Kahramanmaras, Turkey e-mail: fozlemorhan@yahoo.com M. F. Karaaslan e-mail: mf_karaaslan@hotmail.com D. Tuncel Department of Neurology, Kahramanmaras Sutcuimam University Faculty of Medicine, 46100 Kahramanmaras, Turkey e-mail: tuncedeniz@yahoo.com F. Ta : N. Demirci Kahramanmaras Sutcuimam University, Higher Vocational School of Health Services, 46100 Kahramanmaras, Turkey F. Ta e-mail: filiztas@ksu.edu.tr N. Demirci e-mail: nermindemirci@ksu.edu.tr A. zer Department of Public Health, Malatya Inonu University Faculty of Medicine, Malatya, Turkey e-mail: aliozer91@hotmail.com

Pittsburgh Sleep Quality Index, the Epworth Sleepiness Scale, and a sleep diary were used. Results The participants mean age was 74.0 years (standard deviation (SD)=6.7). Forty-four of the individuals had a poor sleep quality prevalence of 60.3%; and the mean global PSQI score was 6.6 (SD=3.6). Their mean ESS score was 5.9 (SD=4.6) and 14 participants (19.2%) had daytime sleepiness. The mean daytime napping duration was 1.0 h (SD=1.3) according to the participants sleep diaries. The study found that 60.3% of the participants were depressed, furthermore the mean depression score was 15.9 (SD=7.0). There was a significant correlation between the PSQI subscores; subjective sleep quality, the sleep latency, and sleep disturbances scores and depression scores. Also, daytime napping frequency and daytime napping duration, according to the sleep diary, were correlated positively with depression scores. Conclusions The current studys results confirm the previously reported high prevalence of poor sleep quality and depression in this nursing home population. Clinicians need to assess patients appropriately to identify high prevalence of sleep problems and depression in nursing home patients and initiate appropriate referrals and interventions. Keywords Nursing home . Sleep quality . Depression . Napping

Introduction The percentage of geriatric people is increasing in the Turkish population, as well as all over the world [1]. Sleep problems have emerged as critical issues arising among elderly populations [2]. Epidemiological studies indicate that more than half of the elderly population suffers from chronic sleep disturbances [36], most of which can be

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exacerbated by institutional settings [7, 8]. Sleep problems are more common and more severe in nursing home residents than increased age alone would indicate, with a prevalence of approximately 70% [9]. Daytime sleepiness and difficulties initiating and maintaining sleep are the sleep disturbances that elderly people most commonly report [10, 11]. Also, elderly people generally spend more time in bed (sleep latency), but less time asleep, and are more easily aroused from sleep, than younger persons [12]. In fact, polysomnographic recordings have shown that sleep deteriorates with age; in particular, frequent and long-lasting nighttime awakenings disrupt sleep among those whose internal organization has been altered [13, 14]. Partly as a consequence of poor night sleep quality, aging also has been associated with increased daytime napping [15, 16]. Depression is a common psychiatric disorder among elderly adults. The literature and clinical evidence suggest that the institutionalized elderly experience a higher prevalence of depression than the community-dwelling elderly. Researchers have found that relocation to an institution might result in adjustment problems in elderly individuals, such as depression [17, 18]. These studies use a variety of diagnostic criteria and depression rating scales to define depression; their cited prevalence of major depression in nursing homes ranges from 5% to 25% [19, 20], with a median prevalence of 10%; and the cited prevalence of depressive symptoms, meanwhile, ranges from 14% to 82% [21, 22], with a median prevalence of 29%. The reported prevalence rates of depression in institutions vary widely in different localities, which might reflect variations in the diagnostic criteria and scales utilized, sampling differences, and demographic differences in the characteristics of the nursing home populations studied [19, 21, 2326]. A study in Turkey reported that 34.3% of community-dwelling elderly people, as well as 48.1% of elderly people living in a nursing home, exhibited depressive symptoms [27]. Sleep disturbances and depression are the mental disorders that the elderly in various countries most commonly report [2830]. Reports of poor sleep quality correlate strongly with both health complaints and depressive symptoms [31]. The association between sleep disturbances and depressive symptoms is complex, bidirectional in nature, and not thoroughly understood [32]. Elderly people with chronic insomnia have a higher level of depression than other people [31, 33]; insomnia, meanwhile, increases the risk for depressive onset and relapse [34], and otherwise depressed patients report poor sleep quality [31]. Previous studies have reported a relationship between sleep complaints and depressive symptoms in the elderly [35, 36], however there is no study regarding this

relationship in a nursing home population. This descriptive study was conducted to fill that research gap.

Methods Study setting and participants Of the 100 older adult residents of the nursing home in Kahramanmaras, the research population included 73 older adult residents who met the research criteria and agreed to participate in the study. Those included in the study were aged 60 years or older, could communicate verbally, and were not residing in the long-term care unit. Residents who were younger than age 60 years had dementia, had communication difficulties, or did not agree to participate were excluded. Seventeen older adult residents who had dementia, as well as ten older adult residents who did not agree to participate were excluded from the study. Residents fulfilling the inclusion criteria were invited to participate in the study, and informed consent was obtained from them. All measurements were obtained during face-toface interviews, each of which lasted between 1 and 3 h and were, spread over one to three interview sessions. Data concerning physical illness and disability were also obtained from the attending physician and the nursing staff. In addition, medical records were reviewed for disease information. The demographic questionnaire obtained information on the participants' age, gender, marital status, and education, as well as the presence of comorbid conditions. Personal interviews facilitated the participants' completion of the questionnaires. The researcher stayed with the participants, who were elderly and had difficulty reading and completing the questionnaires, to assist them and clarify questions for them. In view of the high prevalence of illiteracy and reading/writing difficulties among the local elderly, the research assistant administered the scales verbally to all the recruited participants. The research assistant was trained by a psychiatrist to administer the Geriatric Depression Scale (GDS), the Pittsburgh Sleep Quality Index (PSQI), and the Epworth Sleepiness Scale (ESS), and each participant kept a sleep diary. Ethical considerations This study was approved by the ethics committee of Kahramanmaras Sutcu Imam University, Faculty of Medicine. The researcher obtained written permission to conduct the research, from both the aforementioned ethics committee and the nursing home. Furthermore all eligible patients were informed both verbally and in writing, informed consent was obtained from all participants prior to inclusion.

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Measures Depression status The participants' depressive symptoms were evaluated using the Turkish version of the GDS [37, 38], a 30-item questionnaire specifically developed for elderly individuals. Researchers have found this instrument to be reliable and valid in multiple settings and have recommended it for use in nursing home populations [39 41]. Ertan et al. tested the validity and reliability of GDS scoring in the Turkish population and found it to be valid and reliable [42]. In accordance with the original cutoff point, this study considered a score 14 to indicate clinically relevant depression. The Pittsburgh Sleep Quality Index Sleep quality was measured using the PSQI. This 19-item questionnaire includes seven component scores, including (1) subjective sleep quality, (2) sleep onset latency, (3) sleep duration, (4) habitual sleep efficiency, (5) sleep disturbance, (6) use of sleep medications, and (7) daytime functioning. The PSQI refers to the majority of days and nights over the previous month. The seven component scores are summed to provide a global score that ranges from 0 to 21, with higher scores indicating worsequality sleep. A global PSQI score >5 indicates a significant level of sleep disturbance [43]. This questionnaire's significance is that it provides a reliable, valid, and standardized measure of sleep quality and its ability to distinguish between good and poor sleepers. The PSQI has good internal consistency ( =0.83) and testretest reliability (r = 0.85) [44]. Agargn, et al. tested the PSQI's validity and reliability for Turkey (Cronbach's alpha=0.80) [45]. Sleep diary The participants kept a sleep diary (subjective estimate of the sleep/wake cycle) for 14 consecutive days. They recorded, in the morning immediately upon awakening, the number of times they had awakened during the night, the duration of each awakenings (wake after sleep onset), and the total amount of time they had slept (total sleep time). One advantage of this measure over other measures is that it constitutes an index of the considerable night-to-night variability in sleep [46]. Epworth Sleepiness Scale The ESS consists of eight items, and it measures a participant's self-reported daytime sleepiness. The instrument focuses on the expectation of dozing in a variety of situations. The probability ratings in hypothetical situations are zero (0), slight (1), moderate (2), or high (3). The ratings can be summarized to a total score of 24, with a cutoff value of >10 indicating excessive daytime sleepiness [47]. Several studies have used the ESS and it is a well-validated questionnaire. Izci et al. [48] tested the ESS's validity and reliability for Turkey (Cronbach's alpha 0.86).

Data analysis Data were computerized using the Statistical Packages for the Social Sciences (SPSS v.15.0; SPSS Inc., Chicago, IL, USA).The independent samples t test, Kruskal Wallis test, and Pearson correlation were used in statistical analysis. Values are presented as meanstandard deviation (SD) and as percentages. p values<0.05 (two-tailed) were considered statistically significant. Sleep parameters were expressed as dichotomous outcomes (i.e., ESS, >10 vs. 10; PSQI, >5 vs. 5; and GDS, 14 vs. <14), based on a consideration of the values' clinical relevance vis--vis elderly adults and the availability of a sufficient number of participants in each category.

Results The response rate for patients invited to participate was 73% (total number was 100). Thirty-three (45.2%) were aged 75 years or above, 27 (37%) were female, and 58 (79.5%) were divorced or widowed. The participants' mean age was 74.0 years (SD=6.7), and their average time living in the institution was 30.8 months (SD=29.9). Forty-four of the individuals scored >5 on the PSQI, indicating a poor sleep quality prevalence of 60.3%; the mean global PSQI score was 6.6 (SD=3.6). In addition, the mean values for the PSQI score components revealed that the highest subscale scores were for sleep latency and sleep disturbances while the lowest subscale scores were for sleep medication and daytime functioning (Table 1). Their mean ESS score was 5.9 (SD=4.6); 14 participants (19.2%) had ESS scores >10, indicating daytime sleepiness. The mean daily sleep duration was 7.8 h (SD=2.1 h), the mean daytime napping frequency was 0.7 times (SD=0.8), and the mean daytime napping duration was 1.0 h (SD=1.3 h), all according to the participants' sleep diaries. The study found that 60.3% of the participants were depressed, according to the Turkish GDS's cutoff point; and the mean depression score was 15.9 (SD=7.0). Sociodemographic characteristics (except marital status) did not influence the participants' sleep quality, as Table 2 shows. The married group had the highest mean PSQI score (11.02.5) and the difference between married and single or widowed/divorced patients was statistically significant (p <0.05). Table 3 summarizes the differences between good and poor sleepers, in terms of demographic and clinical characteristics. Their marital status differed significantly (p <0.05). In the current study, the percentage of poor sleepers was significantly higher among the married elderly than among single or widowed/divorced elderly people (p =0.04).

1062 Table 1 Mean scores (meanSD) of sleep and depression scales Variables Age Average living time in the nursing home (months) Geriatric Depression Scale Total sleep time Number of wake-ups per night Nap frequency Nap duration Epworth Sleepiness Scale PSQI global score Subjective sleep quality Sleep latency Sleep duration Habitual sleep efficiency Sleep disturbances Use of sleeping medication Daytime disfunction MeanSD Descriptive variables 74.06.7 30.829.9 15.97.0 7.82.1 0.30.6 0.70.8 1.01.3 5.94.6 6.63.6 1.20.9 1.51.1 0.91.1 0.71.0 1.50.6 0.40.9 0.40.6

Sleep Breath (2012) 16:10591067 Table 2 The distribution of the mean PSQI scores (meanSD) of participants of study according to sociodemographic variables PSQI global score Number Gender Female Male Age 6074 75 Marital status Married Single Divorced/widowed MeanSD p value

27 46 40 33 5 10 58

7.33.7 6.23.6 7.24.1 5.82.9 11.02.5 7.73.2 6.03.5 6.33.7 7.03.5 6.63.9 6.83.8 5.92.9 7.03.7 6.63.5 6.33.9 6.53.6 6.83.8 6.2363.914 6.4003.680 7.3503.099 6.1303.805 5.8693.180 8.8573.919 6.1533.210

0.197

0.107

0.005

Pearson's product was computed to evaluate the relationships among sleep quality, depression, and napping. There was a significant correlation between the subscores of PSQI [subjective sleep quality (r =0.298, p =0.01), sleep latency (r =0.380, p =0.001) and sleep disturbances scores (r = 0.261, p =0.026)] and depression scores. Also, daytime napping frequency (r =0.365, p =0.002) and duration (r = 0.280, p =0.017) correlated positively with depression scores, according to the sleep diaries (Table 4).

Discussion The present study's results represent the sleep quality and depressive symptoms of the elderly Turkish people who live in a nursing home in Turkey. Considerable evidence suggests that the elderly experience disrupted sleep patterns and that institutional settings exacerbate this problem [68]. The current study's results confirm the previously reported high prevalence of poor sleep quality in this nursing home population. Overall, 60.3% of the current study's patients experienced poor sleep quality; this finding is similar to those of another study from Turkey, which reported that 60.9% of elderly nursing home residents experienced poor-quality sleep (mean global PSQI score=7.70, SD=4.63) [49]. This number is below the 77%, with a mean sleep quality score of 8.02 2.87, as reported for a sample of nursing home patients in Turkey [50]. In addition, the mean PSQI score component values revealed that the highest subscale scores were for sleep latency and sleep disturbances; this profile suggests

Education Illiterate or read and write 48 Primary school and above 25 Time living in nursing home (months) 011 21 1236 36 >36 16 Number of beds in room 1 15 2 33 3 25 History of chronic disease Yes 55 No 18 Visit frequency of relatives Less than once a year 38 Monthly 20 At least once a week 15 Engagement with activities No Sometimes Often Always 23 23 14 13

0.436

0.710

0.796

0.732

0.537

0.073

that these patients had problems with both initiating and maintaining sleep. The current study's findings are consistent with those of study conducted by Cankurtaran et al. [51] in Turkey, which found that 33.4% of the elderly had difficulty falling asleep and 42% had difficulty staying asleep. Also, similar to other studies in Turkey, the current study's population had minor problems related to sleeping medications or daytime dysfunction. This might be because the use of sleep medications is not widespread in Turkey and because elderly residents of nursing homes are retired and can nap without disrupting their daytime functions [49].

Sleep Breath (2012) 16:10591067 Table 3 Demographic characteristics of poor and good sleepers among elderly residents
Variables Good sleepers (global PSQ 5), N (%) Poor sleepers (global PSQI>5), N (%) Total N (%) Pearson p value

1063 Table 3 (continued)


Variables Good sleepers (global PSQ 5), N (%) Poor sleepers (global PSQI>5), N (%) Total N (%) Pearson p value

Age 6074 75 Marital status Married Single Divorced/widowed Children Yes No Education Illiterate or read and write Primary school and above Social insurance Yes No Time living in nursing home (months) 011 1236 >36 The reason for admission to nursing home Self-care insufficiency Upon the children's wish Voluntarily History of chronic disease Yes No Mobility %Ambulatory with assistance %Ambulatory without assistance Self-care Partial Complete Number of beds in room 1 2 3 Engagement with activities No Sometimes Often Always Visit frequency of 6 (20.7) 12 (41.4) 9 (20.45) 15 (20.5) 33 (45.2) 11 (37.9) 22 (50) 15 (51.7) 20 (45.4) 14 (48.3) 24 (54.6) 35 (47.9) 38 (52.1) 21 (72.4) 27 (61.4) 8 (27.6) 17 (38.6) 48 (65.8) 25 (34.2) 20 (83.3) 24 (75) 4 (16.7) 8 (25) 44 (60.3) 12 (16.4) 0 (0) 2 (6.9) 5 (11.4) 5 (6.8) 8 (18.2) 10 (13.7) 58 (79.5) 13 (44.8) 27 (61.4) 16 (55.2) 17 (38.6) 40 (54.8) 33 (45.2)

1,930 0.165 6,049 0.040

relatives Less than once a year Monthly At least once a week Weekend activities (home visits, outdoor activities, etc.)

18 (62.1) 20 (45.4) 6 (20.7) 9 (20.5) 5 (17.2) 15 (34.1)

38 (52.1) 20 (27.4) 15 (20.5) 1.616 0.254

17 (23.3) Yes 9 (31.0) 8 (47.1) 56 (76.7) 44 (60.3) 29 (39.7) Depression 2.893 14 (31.8) 30 (68.2) 15 (57.1) 14 (48.3) 5 35.7 24 40.7 9 64.3 35 59.3 14 (19.2) 59 (80.8) 0.116 44 (60.3) 29 (39.7) Yes No 20 (69.0) 36 (64.3)

0.204

27 (93.1) 31 (70.4)

0.566 0.452 0.948 0.33

0.089

No Daytime sleepiness Yes

0.733

0.398 17 (58.6) 29 (65.9) 12 (41.4) 15 (34.1) 46 (63) 27 (37) 2.462 7 (24.1) 14 (31.8) 7 (24.1) 6 (13.6) 15 (51.8) 24 (54.6) 21 (28.8) 36 (49.3) 16 (21.9) 0.587 0.292 0.528

No

18 (62.1) 28 (63.6) 5 (17.2) 5 (11.4)

46 (63.0) 10 (13.7) 17 (23.3) 0.007

0.746

6 (20.7) 11 (25)

22 (75.9) 33 (75) 7 (24.1) 11 (25)

55 (75.3) 18 (24.7) 0.275

0.933

0.600

0.003 16 (55.2) 24 (54.6) 13 (44.8) 20 (45.4) 40 (54.3) 33 (45.2) 1.278 0.528 5.416 10 (34.5) 13 (29.5) 12 (41.4) 11 (25) 2 (6.9) 5 (17.2) 12 (27.3) 23 (31.5) 23 (31.5) 14 (19.2) 2.739 0.144 0.958

13(29.55) 25 (34.2)

8 (18.2) 13 (17.8)

The relationship between depressive symptoms and sleep complaints has been described previously. Depressive symptoms have a strong, graded association with subjective sleep disturbances and are moderately associated with objectively measured prolonged sleep latency [32]. Also, the finding of a relationship between the quality of sleep and depression accords with the findings of several previous studies [31, 52, 53]. Similarly, the current study found significant correlations among subjective sleep quality, sleep latency, sleep disturbances scores, and depression scores. Also, according to the participants' sleep diaries, daytime napping frequency, and duration were correlated positively with depression scores. Numerous studies have examined the relationships among sleep quality and other variables, including age [54, 55], gender [3], marital status [55], living arrangements, and health status [56, 57]. In the current study, no sociodemographic characteristic (except marital status) was found to influence the participants' sleep quality. Epidemiological studies have consistently shown that women tend to have more sleep-related complaints and be at higher risk of insomnia than men [5860]; however, in the current sample, gender was found to be unrelated to sleep quality. This difference might be related to the studies' samples; the current study included only institutionalized elderly individuals, but other studies also recruited community-dwelling elderly participants [61]. Additional studies are needed to explore this issue. No statistical significance was found when the mean PSQI score of a patient was examined in terms of the number of days that

1064 Daytime Mean daily Wake-ups Nap Nap disfunction sleep duration per night frequency duration 0.994 0.001 0.000 0.862 1 0.017 0.280 0.987 0.002

Sleep Breath (2012) 16:10591067

the patient had stayed in a nursing home. To the best of our knowledge, no extant study addresses this issue. Previous studies have found that insomnia is more prevalent in those who are divorced and live alone than in those who are married and/or live with others [62, 63]. A study from Turkey found that single elderly people's mean PSQI scores were significantly higher than those of married elderly people (p <0.05) [48]; in that study, the married individuals' sleep quality scores might have been affected positively by the social support provided by spouses, which in turn facilitated coping with psychological stress. However, Martikainen et al. [64] report no correlation between insomnia and marital status. In the current study, the proportion of those experiencing poorquality sleep was significantly higher among the married elderly than among single or widowed/divorced elderly people (p =0.04; Table 3). The reason for the poor sleep quality among married participants may be due to chance or confounded by poorer health quality. Although some controversy exists about the frequency of napping among elderly individuals, the consensus is that napping increases with age. Reported prevalence rates for habitual daytime napping in elderly populations range from 22% to 61% [65, 66]. Most studies have reported average nap durations in the elderly ranging from 28 to 59 min, [6668]. Although longer durations of up to 119 min have also been documented in adults aged 50 to 60 years [67, 69]. In the current study, the napping duration was 1.0 1.3 h, and participants reported taking an average of 1.32 daytime naps per day. As the extent to which napping affects nighttime sleep, daytime functioning or overall wellbeing in the elderly is unclear [70, 71]. Recent sleep studies have debated whether daytime naps influence nocturnal sleep. Several researchers have reported that daytime napping increases nighttime sleep complaints [72, 73]. Chen and Wang [72] found that poor-quality nighttime sleep was significantly related to daytime napping; however, some other researchers have claimed that daytime napping and nocturnal sleep are not significantly related in the elderly population. Abert and Webb [74], for example, report that a nap of about 50 min or less might be beneficial, as it may compensate for nighttime awakening in elderly people. In another study, some participants took naps longer than 60 min, but they still claimed to sleep very well at night [11]. Similar to these results, the findings of the current study show that, the participants' daytime napping did not affect the quality of their nighttime sleep. Healthcare providers may find this information useful, as they can apply it to their practice; the study suggests that there is no need to restrict elderly persons' daytime napping, in order to prevent them from awakening at night. Although findings regarding daytime napping and mood are less clear, studies suggest that among older people,

0.002 0.365 0.706 0.045

Sleep Use of disturbances sleeping medication

0.026 0.261 0.785 0.032

Subjective Sleep Sleep Habitual sleep quality latency duration sleep efficiency

0.926 0.011 0.217 0.146

0.001 0.987 0.380 0.002 0.170 0.000 0.162 0.474

Table 4 Correlation of sleep and depression scores

Statistical Epworth values Sleepiness Scale

PSQI global score

0.05 0.231 0.013 0.29

Mean daily sleep duration Wake-ups per p night r Nap p frequency r Nap duration p r

Depression

p r p r

0.458 0.08 0.340 0.113 0.153 0.169

0.44 0.091 0.002 0.349

0.248 0.137 0.904 0.014 0.155 0.16

0.627 0.058 0.517 0.077 0.818 0.027

0.01 0.298 0.783 0.033

0.067 0.928 0.216 0.011 0.796 0.476 0.031 0.085 0.443 0.392 0.091 0.102

0.809 0.029 0.574 0.067 0.310 0.12

0.020 0.273 0.374 0.106 0.709 0.04

0.132 0.178 0.222 0.145 0.152 0.169

0.961 0.006 0.077 0.208

0.492 0.082 0.070 0.213 0.101 0.19

0.633 0.057 0.774 0.034

0.028 0.257 0.706 0.045 0.987 0.002

0.424 0.095 1

0.934 0.010 0.994 0.001

0.095 0.197 0.028 0.257

0.000 0.862

0.934 0.010 1

Sleep Breath (2012) 16:10591067

1065 7. Alessi CA, Schnelle JF (2000) Approach to sleep disorders in the nursing home setting. Sleep Med Rev 4(1):4556 8. Erser SJ, Wiles A, Taylor H, Wade S, Walsh R, Bentley T (1999) The sleep of older people in hospital and nursing homes. J Clin Nurs 8(4):360368 9. Fetveit A, Bjorvatn B (2002) Sleep disturbances among nursing home residents. Int J Geriatr Psychiatry 17(7):604609 10. Hoffman S (2003) Sleep in the older adult: mplications for nurses. Geriatr Nurs 24(4):210214 11. Hsu HC (2001) Relationships between quality of sleep and its related factors among elderly Chinese immigrants in the Seattle area. J Nurs Res 9(5):179190 12. Lin CL, Su TP, Chang M (2003) Quality of sleep and its associated factors in the institutionalized elderly. J Formos Med 7:174184 13. Lombardo P, Formicola G, Gori S, Gneri C, Massetani R, Murri L, Fagioli I, Salzarulo (1998) Slow wave sleep (SWS) distribution across night sleep episode in the elderly. Aging 10 (6):445458 14. Salzarulo P, Formicola G, Lombardo P, Gori S, Rossi L, Murri L, Cipolli C (1997) Functional uncertainty, aging and memory processes during sleep. Acta Neurol Belg 97(2):118122 15. Bliwise DL, Ansari FP, Straight LB, Parker KP (2005) Age changes in timing and 24-h distribution of self-reported sleep. Am J Geriatr Psychiatry 13(12):10771082 16. Foley DJ, Vitiello MV, Bliwise DL, Ancoli-Israel S, Monjan AA, Walsh JK (2007) Frequent napping is associated with excessive daytime sleepiness, depression, pain, and nocturia in older adults: findings from the National Sleep Foundation 2003 Sleep in America Poll. Am J Geriatr Psychiatry 15(4):344350 17. Hou HM, Chen YM (2008) Loneliness and related factors among the elderly living in long-term care facilities. J Evidence-Based Nursing 4:212221 18. Hwang YS (2007) Releasing the sense of loss of long-term care institution's residents service quality perspective. J Long-Term Care 11:125131 19. Teresi J, Abrams R, Holmes D, Ramirez M, Eimicke J (2001) Prevalence of depression and depression recognition in nursing homes. Soc Psychiatry Psychiatr Epidemiol 36(12):613620 20. McSweeney K, O'Connor DW (2008) Depression among newly admitted Australian nursing home residents. Int Psychogeriatr 20 (4):724737 21. Parmelee PA, Katz IR, Lawton M (1989) Depression among institutionalized aged: assessment and prevalence estimation. J Gerontol 44(1):2229 22. Lin PC, Wang HH, Huang HT (2007) Depressive symptoms among older residents at nursing homes in Taiwan. J Clin Nurs 16 (9):17191725 23. Kivela SL, Lehtomaki E, Kivekas J (1986) Prevalence of depressive symptoms and depression in elderly Finnish home nursing patients and home help clients. Int J Social Psychiatry 32 (1):313 24. Horiguchi J, Inami Y (1991) A survey of the living conditions and psychological states of elderly people admitted to nursing homes in Japan. Acta Psychiatric Scand 83(5):338341 25. Phillips CJ, Henderson AS (1991) The prevalence of depression among Australian nursing home residents. Results using ICD-10 and DSM-IIIR criteria. Psycholog Med 21(3):739748 26. Brodaty H, Draper B, Saab D, Low LF, Richards V, Paton H, Lie D (2001) Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 16(5):504512 27. Maral I, Aslan S, Ilhan MN, Yldrm A, Candansayar C, Bumin MA (2001) Depression and risk factors: A comperative study on elderly people living in community and in nursing homes. Turk Psikiyatri Derg 12(4):251259

reported daytime napping is associated with more symptoms of depression [73]. This was also true in the current study. Several limitations of this study warrant mention. First, data were obtained from self-reports and physician-diagnosed comorbid conditions, since we did not have objective sleep measures, which might have led to the misclassifications of some of the measurements. Second, the sample was small; therefore, these findings warrant replication with large samples. Third, due to a lack of power, we were limited in the types of analyses that could be performed, and hence results are unadjusted and may be confounded. Finally, data on specific sleep and depression medications used by these patients were unavailable. To our knowledge, this is the first study to evaluate sleep quality and depression in nursing home residents in Turkey. Taken together, and consistent with previous studies' findings, these findings suggest that sleep disturbance is a common problem among nursing home patients. Additionally, the results demonstrate that depression is an important health problem in the elderly nursing home population. The results point to the recommendation to improve psychological counseling services in the institutions and routinely use screening tests to identify high prevalence of sleep problems and depression in nursing home patients and initiate appropriate referrals and interventions. This study provides data to healthcare professionals vis-vis the clinical significance of the relationship between depression and sleep impairment in nursing home residents. Based on this study's results, we recommend replicating the study with a large sample.

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