What do older people do during periods of nocturnal wakefulness and how can this be measured?
LIBMAN E, CRETI L, WEINSTEIN N, AMSEL R, BRENDER W, FICHTEN CS
SMBD Jewish General Hospital, McGill University, Concordia University, Dawson College, Montreal, Quebec, CanadaEveryone experiences occasions of undesired wakefulness during the night, and the aging process generally increases the frequency of this experience1. There is ample evidence that CognitiveBehavioral interventions directed at changing sleep lifestyle practices may alleviate sleep complaints and insomnia2,3,4,5. But what do relatively healthy older people do while awake during the night? Do good sleepers and poor sleepers, with and without insomnia complaints, differ in the nature of activities engaged in during periods of nocturnal wakefulness?
The Present Investigation
Since older people often experience disrupted sleep and report lengthy sleep onset and nocturnal awake times, one goal of the present study was to explore what they do during these times. In spite of the prevalence of poor sleep, a substantial number of older people report experiencing good quality sleep and infrequent nocturnal awakenings; others report significant sleep disruption, but experience minimal associated distress. Therefore, we also compared sleep behaviors of good sleepers with those of poor sleepers who experience low or high related distress.
Method
Subjects were 375 community dwelling individuals, 115 men and 260 women (mean age = 68, range 55 to 89). Of these, 163 met our criteria for Good Sleeper and 104 for Poor Sleeper status. Of the Poor Sleepers, 49 met the criteria for Low Distress Poor Sleeper, and 28 for High Distress Poor Sleeper status.
Subjects completed a battery of measures which included a sleep behaviors listing, from which the Sleep Behaviors Scale: 60+ was derived, as well as a demographic measure, evaluations of sleep parameters, sleep quality, anxiety, tension, worry, depression, other cognitive-affective variables and life satisfaction.
Results
The subscale structure for the Sleep Behaviors Questionnaire: 60+ was determined by carrying out a principal components analysis on the scores of the 104 Poor Sleepers. Four relatively independent subscales were identified: Active Behaviors (e.g., listen to radio, watch TV, take a hot bath), Relaxation Behaviors (e.g., think pleasant thoughts, lie very still, imagine a scene), Cognitive /Behavioral Activities (e.g., worry, toss and turn, work on personal problems) and Medication Use. The measure showed good reliability and validity.
The single most frequently reported behavior for Poor Sleepers was "Go to toilet;' this was ranked third for Good Sleepers, who were more likely to "Lie in bed quietly" and "Rest and relax." When Low and High Distress Poor Sleepers and Good Sleepers were compared, results indicate that overall, both groups of Poor Sleepers engaged in more Sleep Behaviors than did Good Sleepers. Relaxation Behaviors were the most popular for all 3 groups, and Good Sleepers and Low and High Distress Poor Distress Sleepers did not differ on this subscale. Medication Use was least popular, and, of course, both groups of Poor Sleepers were equally likely to use sleep medications. Similarly, the two groups of poor sleepers engaged in more Active Behaviors than did Good Sleepers, and, again did not differ significantly from each other. An exception to this pattern on Cognitive/Behavioral Activities, where High Distress Poor Sleepers clearly had substantially larger scores than Low Distress Poor Sleepers. It is noteworthy that only scores on the Cognitive/Behavioral Activities subscale correlate with psychological maladjustment.
Discussion and Implication
The present study provides a reliable and valid measure of sleep behaviors during nocturnal wakefulness in older individuals. Findings on the Cognitive/Behavioral subscale reflect significantly less psychological maladjustment in Low Distress Poor Sleepers than in High Distress Poor Sleepers. This is consistent with our previous reports showing that Low Distress Poor Sleepers manifest significantly less psychological maladjustment than their High Distress counterparts. This also supports our hypothesis that Low Distress Poor Sleepers are generally coping well with their substantial sleep disruption. Moreover, these results provide further support for the notion that cognitive arousal and negative thinking are at the core of the insomnia complaint.
Performance on the Sleep Behaviors Questionnaire: 60+ by Good Sleepers and Poor Sleepers who are or are not distressed by their insomnia suggests more specific and objectively based insomnia intervention strategies. For example, therapeutic efforts should be directed at diminishing the frequency of nocturnal activities represented in the Cognitive/Behavioral Activities subscale (e.g., worrying, tossing and turning, working on personal problems), promoting those incorporated in the Relaxation Activities subscale (e.g., active relaxation, imagery, lying quietly), or in the Active Behaviors subscale (e.g., listening to radio, watching T.V., reading, eating, drinking, out of bed activities); the therapeutic approach would need to be tailored to the individual. In addition, the relationship between Cognitive/Behavioral Activities and psychological maladjustment implicates daytime contributors to the insomnia complaint, such as anxiety, tension, depression, and an anxious, worrying cognitive style. This suggests a therapeutic role for modification of maladaptive daytime thoughts and feelings as well.
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3Bootzin, R.R., & EngleFriedman, M. (1987). Sleep disturbances. In L.L. Carstensen & B.A. Edelstein (Eds.), Handbook of clinical gerontology (pp 238251). New York: Pergamon Press.
4Borkovec, T.D. (1982). Insomnia. Journal of Consulting and Clinical Psychology, 50, 880895.
5Speilman, A. J., Caruso, L. S., & Glovinsky, P. B.(1987).A behavioral perspective in insomnia treatment. Psychiatric Clinics of North America, 10(4), 541553.Research supported by the Conseil quebecois de la recherche sociale and National Health Research and Development Program (Canada).