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TitleInsomnia symptoms in elderly persons
File Size2.5 MB
Total Pages103
Table of Contents
Abbreviations and definitions
Original papers
	Defining insomnia
		Prevalence of insomnia symptoms in the general population
	Defining old age
	Normal sleep
		Sleep stages and diurnal rhythms
	Sleep in the elderly
		Insomnia in the elderly
	The concept of sleep quality
	Factors affecting sleep
	Sleep assessment
	Management of sleep disturbances
		Pharmacological methods
		Non-pharmacological methods
			Self-care for sleep disturbances
			Cognitive behavioural therapy
			Activity as a form of sleep management
	Scientific outline for the thesis
	Samples and context
	Data collection
		Literature search
			Critical Appraisal Skills Programme (CASP)
			Uppsala Sleep Inventory 25
			Minimal Insomnia Symptom Scale
			Sleep disturbances
			Leisure activities
			Functional status
			General health
			Mini Mental State Examination
		Evidence strength
		Statistical analysis
		Qualitative content analysis
	Ethical considerations
	Evaluation of the effects of non-pharmacological nursing interventions
		Music/natural sounds or viewing instrumental music videos
		Acupunctural stimulation
		Sleep hygiene
	Measuring insomnia symptoms in the elderly
	Activities linked to sleep disturbances
	Gender differences in relation to sleep
	Methodological considerations
	General discussion of the results
Conclusions and clinical applications
Further research
Summary in Swedish/ Svensk sammanfattning
Document Text Contents
Page 1


PO Box 117
221 00 Lund
+46 46-222 00 00

Insomnia symptoms in elderly persons - assessment, associated factors and non-
pharmacological nursing interventions

Hellström, Amanda


Link to publication

Citation for published version (APA):
Hellström, A. (2013). Insomnia symptoms in elderly persons - assessment, associated factors and non-
pharmacological nursing interventions. Division of Nursing, Lund University.

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Page 2


Insomnia symptoms in elderly persons

Assessment, associated factors and
non-pharmacological nursing interventions

Amanda Hellström

by due permission of the Faculty of Medicine, Lund University, Sweden.

To be defended at SSSH-salen, Health Science Center, Baravägen 3 Lund

the 17th of December 2013 at 1.00 pm .

Faculty opponent

Associate Professor David Edvardsson,

Umeå University

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RCTs, which is why other methods also need to be considered for gathering evidence
(Taylor & Muncer, 2000). In their note, Polit and Beck (2008) suggested a hierarchy
of evidence, topped by systematic reviews of RCTs and non-randomised trials. These
are followed by RCTs and non-randomised single studies (Polit & Beck, 2008).
According to the British Medical Journal (BMJ) Group, the instigators of the
GRADE system, the next key element is the quality of the study. In the systematic
review (Study I), CASP templates for RCTs were used when judging the quality of
the studies. Consistency refers to similarity of the effects across studies investigating
the same intervention/treatment. Attention should be paid to unexplained
inconsistency and difference in the direction of the effect. Lastly, the directness
should be considered. Directness is the extent to which the study sample, the
interventions/treatments and the outcome measures are similar to those in focus, i.e.
if the findings of a study are transferable to your group of patients (BMJ Group,
2004). For Study I, a minor modification of the GRADE system was made. The
possibility of increasing the grade if there is evidence of a dose response gradient was
found irrelevant when evaluating the effects of nursing interventions and was omitted.
Reliability increases if the results of several studies point in the same direction.
However, it is important that the inclusion criteria for the individual studies are clear
and that the study samples are comparable. Furthermore, the intervention and
outcome measures should also be comparable between the studies. If this is
accomplished, a meta-analysis of the studies can be performed (Polit & Beck, 2008).

Cohen’s d was used in order to estimate the effects of the interventions. However, due
to the heterogeneity of the studies, effects were calculated for each study. Cohen’s d is
calculated by subtracting one mean value from the other and then dividing the
difference by the standard deviation (SD) of the control group or a pooled standard
deviation (Taylor & Muncer, 2000). A pooled standard deviation is the average
variation of subgroups. However, if the SD of the two groups differs, the
homogeneity of variance assumption is violated. In such a case, pooling of the
standard deviation should be avoided. Instead, the SD of the control group is inserted
as the denominator in the equation. The SD of the control group is not contaminated
by the treatment and will reflect the standard deviation of the population from which
the sample was drawn. The larger the control group, the more likely it is to resemble
the population (Ellis, 2009). An effect of 0.2 is considered small, an effect of 0.5 is
considered to be of moderate importance and an effect of 0.8 is considered to be of
clinical importance (Norman & Streiner, 2008).

Statistical analysis

Analyses in Study II were conducted using PASW Statistics 17.0 (SPSS Inc. Chicago,
IL.). To investigate the measurement properties, assumptions concerning adding up
item scores into a total score were tested. All items on a scale should be correlated

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positively with the construct. This was considered to be supported if corrected item-
total correlations were ≥0.4 (Ware & Gandek, 1998). Continuing this line of
argument, all items must be correlated with each other, rendering a high degree of
internal consistency of scale as measured by coefficient alpha (Streiner, 2003a;
Streiner & Norman, 2008). When comparing groups for research purposes, an alpha
of 0.7 – 0.8 is regarded as satisfactory. However, when conducting clinical
investigations, a value of 0.9 – 0.95 is desirable (Bland & Altman, 1997). Floor and
ceiling effects on the scale (i.e. the proportion of persons with minimum and
maximum scores respectively) were also investigated. Floor and ceiling effects should
not exceed 15% (McHorney & Tarlov, 1995).

The discriminating ability of the MISS, i.e. the scale’s ability to distinguish good
sleepers from poor sleepers, was examined. A receiver operating characteristic (ROC)
curve was drawn and the area under the ROC curve (AUROC) was calculated. The
ROC curve is an illustration of the discriminating abilities of a test at different cut-off
values (Goutham, 2003). Based on the ROC curve, sensitivity and specificity can be
calculated for various cut-off scores. Sensitivity is the ability to diagnose a condition
correctly, while specificity measures the ability to accurately identify non-cases. These
values provide an indication of the discriminatory abilities of the scale (Bring &
Taube, 2006). In Study II, sensitivity and specificity were considered equally
important. Youden’s index was therefore used to decide an appropriate cut-off value:

((sensitivity + specificity) -1)

Since the maximum value of Youden’s index is 1, indicating a perfect test, the cut-off
value associated with the highest Youden’s index (J) is considered optimal (Bewick et
al., 2004). Results were reported as frequencies, percentages and confidence intervals.
P-values <0.05 were considered statistically significant.

For comparison of the prevalence of insomnia symptoms found using MISS, a proxy
gold standard was constructed. This proxy consisted of three items extracted from
USI-25: experiencing severe or very severe difficulties with daytime sleepiness,
physical tiredness after sleep and admitting to having sleep difficulties (yes/no). The
items capture possible daytime symptoms of insomnia and the diagnosis of insomnia
implies a presence of both nocturnal and daytime symptoms (Lichstein et al., 2011).
Furthermore, a drop-out analysis was performed on non-respondents using available
data from the SNAC-B study concerning age, gender and reported diseases.

The data in Study III were analysed using PASW Statistics 21.0 (SPSS Inc. Chicago,
IL., USA). Descriptive analyses and group comparisons were made using the Chi-
squared test and the Mann-Whitney U-test. Yates’ continuity correction was used in
four field tables (Altman, 1999). Associations between variables were calculated by
means of Spearman’s rho and multiple logistic regressions. Age, gender, general
health, functional status, mood and cognitive function were considered to be possible

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Tononi, G. & Cirelli, C. (2012). Time to be SHY? Some comments on sleep and synaptic
homeostasis. Neural Plastisity, 2012, 415250.

Tsai, J.-F., Wong, T.K.S. & Ku, Y.-C. (2008). Self-care management of sleep disturbances
and risk factors for poor sleep among older residents of Taiwanese nursing homes.
Journal of Clinical Nursing, 17, 1219-1226.

Wade, A.G. (2010). The societal costs of insomnia. Neuropsychiatric Disease and Treatment, 7,

van den Heuvel, W.J.A. & van Santvoort, M.M. (2011). Experienced discrimination amongst
European old citizens. European Journal of Ageing, 8, 291-299.

van Someren, E.J. (2000). Circadian and sleep disturbances in the elderly. Experimental
Gerontology, 35, 1229-1237.

Vance, D.E., McNees, P. & Meneses, K. (2009). Technology, cognitive remediation, and
nursing: directions for successful cognitive aging. Journal of Gerontological Nursing, 35,

Vandekerckhove, M. & Cluydts, R. (2010). The emotional brain and sleep: an intimate
relationship. Sleep Medicine Reviews, 14, 219-226.

Ward, T.M., (2011). Conducting sleep assessment, In N.S. Redeker & G.P. McEnany (Eds.),
Sleep disturbances and sleep promotion in nursing practice (pp. 53-71). New York:
Springer Publishing.

Ware, J., Jr., Kosinski, M. & Keller, S.D. (1996). A 12-Item Short-Form Health Survey:
construction of scales and preliminary tests of reliability and validity. Medical Care, 34,

Ware, J.E. & Gandek, B. (1998). Methods for testing data quality, scaling assumptions and
reliability: The IQOLA Project Approach. Journal of Clinical Epidemiology, 51, 945-952.

Waterhouse, J., Fukuda, Y. & Morita, T. (2012). Daily rhythms of the sleep-wake cycle.
Journal of Physiological Anthropology, 31, 5.

Venn, S. & Arber, S. (2012). Understanding older peoples' decisions about the use of sleeping
medication: issues of control and autonomy. Sociology of Health and Illness, 34, 1215-

Vetenskapsrådet, (2013). CODEX - regler och riktlinjer för forskning.
WHO, (1983). Health Education in Self-care: Possibilities and Limitations Report of a

Scientific Consultation, Geneva, pp. 1-20.
WHO, (2013a). Older adult health and ageing in Africa.
WHO, (2013b). Global strategy in diet, physical activity and health. World Health

Wijk, H. (2004). Goda miljöer och aktiviteter för äldre [Swedish]. Lund:Studentlitteratur.
Williamson, J.W. (1992). The effect of ocean sounds on sleep after coronary artery bypass

graft surgery. American Journal of Critical Care 1, 91-97.

Page 103


Willman, A., Forsberg, A. & Strömberg, A., 2003. Metoder i omvårdnad och i
sjuksköterskans arbete [Swedish], Stockholm.

Wills, E., (2007). Grand nursing theories based on human needs, In M. McEwen & E. Wills
(Eds.), Theoretical basis for nursing (pp. 132-161). Philadelphia: Lippincott Williams &

WMA, (2008). WMA Declaration of Helsinki: Ethical priciples for medical research involving
human subjects. 59th WMA General Assembly, Seul.

Wolkove, N., Elkholy, O., Baltzan, M. & Palayew, M. (2007). Sleep and ageing:1. Sleep
disorders commonly found in older people. Canadian Medical Association Journal, 176,

Voyer, P., Verreault, R., Mengue, P.N. & Morin, C.M. (2006). Prevalence of insomnia and
its associated factors in elderly long-term care residents. Archives of Gerontology and
Geriatrics, 42, 1-20.

Ye, L., Keane, K., Hutton Johnson, S. & Dykes, P.C. (2013). How do clinicians assess,
communicate about, and manage patient sleep in the hospital? Journal of Nursing
Administration, 43, 342-347.

Yngman-Uhlin, P. & Edéll-Gustafsson, U. (2006). Self-reported subjective sleep quality and
fatigue in patients with perioneal dialysis treatment at home. International Journal of
Nursing Practice, 143-152.

Yokoyama, E., Kaneita, Y., Saito, Y., Uchiyama, M., Matsuzaki, Y., Tamaki, T., Munezawa,
T. & Ohida, T. (2010). Association between depression and insomnia subtypes: a
longitudinal study on the elderly in Japan. Sleep, 33, 1693-1702.

Zilli, I., Ficca, G. & Salzarulo, P. (2009). Factors involved in sleep satisfaction in the eldely.
Sleep Medicine, 10, 233-239.

Zimmerman, L., Nieveen, J., Barnason, S. & Schmaderer, M. (1996). The effects of music
interventions on postoperative pain and sleep in coronary artery bypass graft (CABG)
patients. Sholary of Inquiry Nursing Practice, 10, 153-170.

Zisberg, A., Young, H.M., Schepp, K. & Zysberg, L. (2007). A concept analysis of routine:
relevance to nursing. Journal of Advanced Nursing, 57, 442-453.

Åkerstedt, T. (2002). [We need our sleep!]. Läkartidningen, 99, 150-152.
Åkerstedt, T., Perski, A. & Kecklund, G., (2011). Sleep, stress and burnout, In M.H. Kryger,

T. Roth & W.C. Dement (Eds.), Priciples and practice of sleep medicine (pp. 814-821).
St Louis: Elsevier Saunders.

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