TITLE

Assumptions about older good and poor sleepers

ABSTRACT

The ubiquity of chronic sleep complaints, even in the "well elderly," has prompted a variety of explanations related to lifestyle factors. The following have all been proposed: irregular schedules permitted by retirement, napping, early bedtimes, overly long periods spent in bed, unrealistic expectations about sleep needs, and erroneous beliefs about how well comparable age peers sleep, as well as major life stresses such as death or illness in a loved one. Given the pervasiveness of such beliefs and the numerous successful treatment programs which focus on changes in these realms, the lack of confirmatory data for these assumptions is truly astounding. Therefore, the goal here is to report on data concerning some of these widely held - but poorly documented - assumptions about sleep, aging, lifestyle and insomnia in aging individuals.

116 older individuals (mean age = 70, range = 55 to 87), who were participating in a larger investigation (Fichten, Creti, Amsel, Brender, Weinstein, & Libman, 1994), were assigned to 3 groups: good sleepers, high distress poor sleepers (poor sleepers who were greatly troubled by their sleep problem), and low distress poor sleepers (poor sleepers who were minimally troubled by their sleep problem). The sex ratio was 1/3 male and 2/3 female in all groups.

Lifestyle and demographic factors. Our results show consistently negative findings on lifestyle and demographic factors; these show that the three groups of older individuals closely resembled each other in virtually all aspects of lifestyle. For example, there were no differences in the diversity of activities engaged in or in perceptions about how fully one's time was occupied. Nor did the three groups differ on education or on either income level or adequacy. Our findings support other investigators who have shown economic dissatisfaction to be unrelated to sleep quality in older individuals (Frisoni et al., 1993). Epidemiological surveys have found that people with low incomes were considerably more likely to experience poor sleep than people with higher incomes (e.g., Tait, 1992). Here, however, other health and psychosocial variables related to poverty must be taken into consideration.

Major Life Events. Exposure to stressful life events (such as the death of a loved one) was also similar in our three groups. While major negative life events have been implicated in the onset of insomnia (Healey et al., 1981; Kales, et al., 1984), it seems that large, but infrequent stressors are not involved in the maintenance of chronic sleep problems.

While negative findings can never be conclusive, our results add to the growing body of evidence (e.g., Gourash-Bliwise, 1992; Morin & Gramling, 1989) which highlights the absence of differences in lifestyle in older individuals with and without insomnia.

Unrealistic expectations. It has been suggested that older individuals complaining of insomnia have unrealistic beliefs and expectations which, when not met, increase anxiety and distress, thereby perpetuating and aggravating the sleep problem (Morin & Gramling, 1989). Our data do not support the hypothesis that older poor sleepers have unreasonable expectations. For example, poor sleepers in our study were surprisingly optimistic about how their sleep experience compared to that of others. Although they were definitely in the minority, approximately 50% of both the low and high distress poor sleeper groups indicated that their sleep was much the same as that of others their age. Also, good sleepers and highly distressed poor sleepers wanted similar amounts of sleep - approximately 7 hours - the amount actually obtained by our good sleepers. It is the low distress poor sleepers who had particularly modest expectations - ones which were more consistent with their more modest actual sleep times. While low distress poor sleepers may have adjusted their standards to fit their own realities, it is also possible that they are naturally short sleepers who do not need - or desire - the 7 hours obtained by their good sleeper peers. As do older good sleepers, this interesting category of low distress poor sleepers deserves further examination.

Maladaptive sleep lifestyle factors and erratic daytime and sleep schedules. The popular and highly effective stimulus control treatment for insomnia (Bootzin, 1985, Bootzin & Nicassio, 1978) is based on the assumption that the bed and bedroom have become conditioned to sleep incompatible behaviors such as reading, worrying, or tossing and turning. In keeping with this formulation, it is commonly believed that people with primary insomnia, "may fall asleep more easily when not trying to do so (e.g., while watching television, reading,..." and that, "they sleep better away from their own bedrooms" [DSM-IV, p. 553 (American Psychiatric Association, 1994)]. Our data provide no support for the hypothesis that older poor sleepers fall asleep more easily away from their bedrooms; in this regard they were no different from good sleepers. Approximately 20% of individuals in all three groups indicated it was easier for them to fall asleep outside their bedroom. And when this did happen, it occurred with similar frequency in the three groups.

There are suggestions and assertions in the literature that poor sleep in older individuals is associated with maladaptive sleep lifestyle practices and poor "sleep hygiene," such as spending excessive amounts of time in bed, going to bed too early, taking frequent naps, and erratic bedtimes and arising times (Hoelscher & Edinger, 1988; Marchini et al., 1983). Our data show that the three groups were very similar on these dimensions. First, they experienced similarly regular lifestyles; they did not differ on variability in meal times or in the times they went to bed or got up in the morning. As demonstrated by others (Monk, et al., 1992), the hypothesis that impaired sleep in older individuals stems from an irregular lifestyle was not supported by our data. Second, all three groups spent similar amounts of time in bed - an average of approximately 8 hours. They also had similar bed times and arising times and they napped equally frequently; these, too, are findings similar to those reported by others (Gourash-Bliwise, 1992; Morgan et al., 1989; Morin & Gramling, 1989). All suggest that neither sleep lifestyle factors nor faulty sleep hygiene play a role in the poor sleep experienced by many older individuals.

The efficacy of aspirin in alleviating headaches is never used to infer that lack of aspirin causes headaches. Evidence on the effectiveness of lifestyle changes in alleviating sleep complaints (e.g., Edinger et al., 1992) should not be used to justify the assumption that older poor sleepers' maladaptive sleep hygiene and lifestyle practices cause either poor sleep or the complaint of insomnia.

Research supported by the Conseil québécois de la recherche sociale, Health and Welfare Canada, and the Direction générale de l'enseignement collégial.

AUTHOR

Catherine S. Fichten, Laura Creti, Nettie Weinstein, Vicki Tagalakis, Rhonda Amsel, William Brender, and Eva Libman

SOURCE

Proceedings: 9th Annual Meeting of the Association of Professional Sleep Societies, 1995, p. 69. Reprinted in Sleep Research, 24, 94.