Assessing Sleep Quality in Older Adults: A Comparison of Three Measurement Approaches.

Discrepancies between subjective and objective sleep measures have been reported for some time; however, it is critical to consider the implications of inaccurate or incomplete sleep assessment for frail older adults who are struggling to maintain independence. To compare sleep assessment methods, we collected objective sleep measurements, subjective measures via self-report sleep surveys, and qualitative data through semi-structured audio-recorded interviews, from five older adults who self-reported sleep problems while living in a retirement community in the southwestern US. Participants' objective sleep and qualitative narratives were congruent, but self-report measures failed to capture several unique sleep problems identified in the sample. A sleep assessment tool specifically designed to measure older people's sleep experiences could provide more accurate and sensitive data.

The effects of insomnia on older adults' quality of life and daily functioning: A mixed-methods study.

Insomnia in older adults has been linked to increased incidence of falls, depression and anxiety, cognitive impairment, institutionalization, and mortality, but traditional sleep assessment instruments, designed for the general adult population, fail to capture many of the experiences and causes that are unique to older adults. This mixed methods study elicited open narratives from 18 older adults (6 men,12 women, mean age 84, SD= 7.62, range 67-96) who reported chronic insomnia or disrupted sleep to learn how poor sleep affected their quality of life and daily functioning. The interviews were supplemented with three widely used self-report sleep instruments to provide baseline sleep quality and hygiene scores. Content analysis of the participants' narratives revealed the overriding theme of Insomnia Is Exhausting, which exemplifies the physical and emotional strain this chronic condition creates, and four categories: A Bad Night, Self-Management, Stoicism and Consequences. The narratives revealed severe, negative effects on quality of life, including reduced functional capacity and increased stress, anxiety, and social isolation. The results of this study can be used as a foundation for interventions to enhance sleep quality for this population.

Health Literacy in Adolescents With Sickle Cell Disease.

PURPOSE: To evaluate health literacy in a cohort of 75 adolescents with sickle cell disease (SCD). DESIGN AND METHODS: This cross-sectional, descriptive correlational study included assessment of demographic measures and appraisal of data resulting from completion of the REALM-Teen and Newest Vital Sign (NVS) instruments by 75 Black, non-Hispanic adolescents with SCD. Convenience sampling was utilized. Inclusion criteria were a diagnosis of one of the four primary genotypes of SCD and age 10-19years. RESULTS: Thirty-seven males and 38 females were recruited for the study. Their mean age was 14.7years (SD=2.2; range 8.1). Their grade level ranged from 4 to 12 (mean 8.7; SD=2.2). Scores on the REALM-Teen ranged from 12 to 66 (mean 53.7; SD=12.8). Scores on the NVS ranged from 0 to 6 (mean 2.37; SD=1.33). These health literacy scores were lower using both the REALM-Teen and the NVS instruments when compared to scores in all healthy adolescents and adults. Current grade level and health literacy scores showed a moderately high positive correlation (r=0.52, p<0.01). Health literacy scores were also significantly positively correlated with age (r=0.49, p<0.01) and income (r=0.37, p<0.01). CONCLUSIONS: Health literacy in adolescents with SCD is suboptimal. Future research should include identifying facilitators and barriers to health literacy levels in a larger cohort of adolescents with SCD. PRACTICE IMPLICATIONS: Health literacy is a potential facilitator of successful health outcomes for all adolescents. This study lays a solid foundation for future adolescent health literacy initiatives.

Sleep disturbance, chronic stress, and depression in hospice nurses: testing the feasibility of an intervention.

PURPOSE/OBJECTIVES: To test the feasibility of a cognitive-behavioral therapy for an insomnia (CBT-I) intervention in chronically bereaved hospice nurses. DESIGN: Five-week descriptive correlational. SETTING: Nonprofit hospice in central Texas. SAMPLE: 9 agency nurses providing direct patient and family care. METHODS: Direct care nurses were invited to participate. Two intervention group sessions occurred at the hospice agency and included identification of dysfunctional thoughts and beliefs about sleep, stimulus control, sleep hygiene, and relaxation techniques to promote sleep. Measurements were taken at baseline and three and five weeks postintervention. MAIN RESEARCH VARIABLES: Sleep quality, depressive symptoms, and narrative reflections on the impact of sleep quality on self-care. FINDINGS: Participants reported moderate-to-severe sleep disturbances and moderate depressive symptoms. The CBT-I intervention was well accepted by the participants, and on-site delivery increased participation. CONCLUSIONS: Additional longitudinal study is needed to investigate the effectiveness of CBT-I interventions to improve self-care among hospice nurses who are at high risk for compassion fatigue and, subsequently, leaving hospice care. IMPLICATIONS FOR NURSING: Hospice nurses are exposed to chronic bereavement that can result in sleep disturbances, which can negatively affect every aspect of hospice nurses' lives. Cognitive-behavioral sleep interventions show promise in teaching hospice nurses how to care for themselves by getting quality sleep. KNOWLEDGE TRANSLATION: Identifying the risks for sleep disturbances and depressive symptoms in hospice nurses will allow for effective, individualized interventions to help promote health and well-being. If hospice nurses achieve quality sleep, they may remain in the profession without suffering from chronic bereavement, which can result in compassion fatigue. A CBT-I intervention delivered at the agency and in a group format was feasible and acceptable by study participants.

Pilot study of a brief behavioral sleep intervention for caregivers of individuals with dementia.

Informal caregivers of individuals with dementia experience higher rates of poor sleep quality and depression than the general population. Short-term behavioral interventions have been shown to improve sleep quality in other caregiver populations. The purposes of this study were to determine the feasibility of the CAregiver Sleep Intervention (CASI) in a small sample of caregivers of both community-dwelling and institutionalized individuals with dementia. The caregivers were given CASI, a 5-week behavioral sleep intervention combining relaxation, stimulus control, and sleep hygiene with personal goal setting, delivered at the caregiver's convenience. Caregivers reported no increased burden with CASI. The intervention was well received, and sleep quality and depression trended toward improvement. CASI appears to be feasible and beneficial in this small sample and warrants further study in caregivers of individuals with dementia.

A feasibility study of a two-session home-based cognitive behavioral therapy-insomnia intervention for bereaved family caregivers.

OBJECTIVE: In 2008 over two million family caregivers will become bereaved. The vast majority of these caregivers have provided 'round-the-clock care for a period ranging from months to years. Bereaved family caregivers report insomnia symptoms that persist beyond 1 year, longer than what is seen in bereaved noncaregivers, placing them at increased risk of depression and complicated grief. Despite some rewarding elements, caregiving is a stressful and exhausting role that often requires the caregiver to restructure his or her life around the needs of the patient. Once the patient dies, the structure is lost. Cognitive behavioral therapy interventions are effective in providing structure. This pilot study explored the feasibility of a two-session home-based cognitive behavioral therapy-insomnia (CBT-I) intervention for bereaved family caregivers. METHOD: A 5-week longitudinal descriptive study design was used with 11 adult primary family caregivers of patients who died from cancer. A master's prepared nurse delivered two CBT-I intervention sessions in participant homes. Data collection sessions occurred at baseline, 3, and 5 weeks. A debriefing session was held at Week 6. RESULTS: Participant evaluations of the intervention indicated that it was feasible and acceptable (e.g., 100% would recommend it to others); objective data further supported its feasibility (e.g., 100% completed the trial). In addition, when comparing baseline with Weeks 3 and 5, participants demonstrated improvement in insomnia and depressive symptoms. SIGNIFICANCE OF RESULTS: The results of this pilot study suggest that the intervention is feasible and acceptable and produces promising effects on insomnia and depressive symptoms in bereaved family caregivers.

A brief behavioral sleep intervention for family caregivers of persons with cancer.

Behavioral interventions that support caregivers' restful sleep may delay the onset or decrease the severity of debilitating depressive symptoms. This, in turn, may increase caregivers' physical and psychological health and wellbeing. A repeated-measures experimental design was used to test the feasibility and effectiveness of a brief behavioral sleep intervention for family caregivers of persons with advanced stage cancer. The CAregiver Sleep Intervention (CASI) includes stimulus control, relaxation, cognitive therapy, and sleep hygiene elements. CASI is individualized and delivered to accommodate caregiver burden. Thirty adult caregivers participated. The Pittsburgh Sleep Quality Index (PSQI), Center for Epidemiological Studies-Depression scale (CES-D), and Caregiver Quality of Life-Cancer scale (CQOLC) were used to measure self-reported sleep quality, depressive symptoms, and quality of life. Actigraphs measured latency, duration, efficiency, and wake after sleep onset (WASO) scores. Data were collected at baseline, 3 and 5 weeks, 2, 3, and 4 months post baseline. Improvement was seen across groups; however, intervention caregivers showed more improvement in PSQI and CES-D scores than control caregivers. The CASI appears to be effective in improving sleep quality and depressive symptoms in caregivers of persons with cancer. Improvements in quality of life scores were similar across groups. Sample size and homogeneity limit generalizability.

Personality and coping: predictors of depression and sleep problems among caregivers of individuals who have cancer.

This cross-sectional study described personality and coping and examined their relationships with depression and sleep in 51 adult caregivers of individuals who have cancer. Findings are compared with dementia caregiver literature. Fifty-two percent of caregivers reported Center for Epidemiological Studies-Depression (CES-D) scores greater than 16, and 95% reported Pittsburgh Sleep Quality Index (PSQI) scores greater than 5, indicating risk for clinical depression and severe sleep problems. Less functional coping, optimism, mastery, neuroticism, and sleep predicted 66.4% of the variance in depression. Less functional coping, mastery, neuroticism, and depression predicted 41% of the variance in sleep. Neuroticism and mastery predicted 45.3% of the variance in less functional coping strategies. Caregiver optimism and mastery levels were consistent with levels found in dementia studies. Neuroticism scores were higher than in studies of caregivers of individuals with dementia. Mastery and neuroticism were related to depression, as in other caregiver studies. Findings suggest there are far more similarities than differences between caregivers of individuals who have cancer and caregivers of those who have dementia. Caregiver personality and coping strategies appear to be related to caregiver outcomes similarly in the cancer and dementia populations.

Sleep wake disturbances in people with cancer and their caregivers: state of the science.

PURPOSE/OBJECTIVES: To review the state of the science on sleep/wake disturbances in people with cancer and their caregivers. DATA SOURCES: Published articles, books and book chapters, conference proceedings, and MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and the Cochrane Library computerized databases. DATA SYNTHESIS: Scientists have initiated studies on the prevalence of sleep/wake disturbances and the etiology of sleep disturbances specific to cancer. Measurement has been limited by lack of clear definitions of sleep/wake variables, use of a variety of instruments, and inconsistent reporting of sleep parameters. Findings related to use of nonpharmacologic interventions were limited to 20 studies, and the quality of the evidence remains poor. Few pharmacologic approaches have been studied, and evidence for use of herbal and complementary supplements is almost nonexistent. CONCLUSIONS: Current knowledge indicates that sleep/wake disturbances are prevalent in cancer populations. Few instruments have been validated in this population. Nonpharmacologic interventions show positive outcomes, but design issues and small samples limit generalizability. Little is known regarding use of pharmacologic and herbal and complementary supplements and potential adverse outcomes or interactions with cancer therapies. IMPLICATIONS FOR NURSING: All patients and caregivers need initial and ongoing screening for sleep/wake disturbances. When disturbed sleep/wakefulness is evident, further assessment and treatment are warranted. Nursing educational programs should include content regarding healthy and disrupted sleep/wake patterns. Research on sleep/wake disturbances in people with cancer should have high priority.

Bereaved caregivers' descriptions of sleep: impact on daily life and the bereavement process.

PURPOSE/OBJECTIVES: To describe how sleep and bereavement may be related in family caregivers. DESIGN: Descriptive and qualitative. SETTING: Participants' homes. SAMPLE: 9 adults with no previous diagnoses of clinical depression or sleep disorders who had been providing care to family members who died in the previous six months. METHODS: Participants provided narrative accounts of sleep quality, bereavement, and daily functioning since the death of their family members. Participants' sleep quality and depressive symptoms also were measured with the Pittsburgh Sleep Quality Index (PSQI) and Center for Epidemiological Studies-Depression Scale (CES-D). MAIN RESEARCH VARIABLES: Sleep quality, depressive symptoms, bereavement, and daily functioning. FINDINGS: Narratives revealed five themes: nightmares, wake after sleep onset, scheduling, daily life, and bereavement. Participants scored high on the PSQI and CES-D. CONCLUSIONS: Sleep quality appears to affect bereavement and daily functioning. Participants reported severe levels of sleep disturbance and depressive symptoms. IMPLICATIONS FOR NURSING: Studies are needed to explore sleep quality in bereaved caregivers and to examine the relationship between sleep quality and an individual's ability to accomplish the tasks of bereavement.

A comparison of sleep and daytime sleepiness in depressed and non-depressed mothers during the early postpartum period.

Taiwanese mothers have identified insufficient sleep as a major manifestation of postpartum depression. Few studies have thoroughly examined the relationship between sleep and depression during the early postpartum period, however. The objectives of this study were to compare the characteristics of both the postpartum sleep and daytime sleepiness of depressed first-time mothers and of their non-depressed counterparts, and to determine the factors that significantly increased mothers' risks of being depressed. A non-probability sample of 163 first-time mothers completed a questionnaire between the 13th and 20th days of the postpartum period. The Center of Epidemiological Studies- Depression and Pittsburgh Sleep Quality Index were used to measure mothers' experiences of depression symptoms and sleep. Daytime sleepiness was estimated in four ways, derived from the Roy Adaptation Model. The results indicated that the depressed mothers had poorer sleep quality than the non-depressed mothers, slept less efficiently, reported more sleep disturbances, and exhibited more daytime dysfunctions. Mothers who frequently perceived their daytime sleepiness to be affected by infant-care performance were more likely to be depressed. The study' s findings support the view that there is a connection between depression and poor sleep among postpartum mothers in Taiwan, and indicate that depressed mothers' experiences of poor sleep are multi-faceted, and not simply a matter of insufficient sleep.

Perceived helpfulness of telephone calls--providing support for caregivers of family members with dementia.

The purpose of this study was to determine the perceived helpfulness of telephone calls to 83 caregivers of family members with dementia. Study participants were assigned by groups to experimental (n = 41) or attention-only control (n = 42) conditions. Initial baseline interview data and narrative transcripts of telephone calls were used in this study. Major perceived reasons for helpfulness were that participants were assisted in sharing thoughts and feelings, expressing feelings of being overwhelmed, discussing physical and psychosocial problems, forgetting the situation, seeking reassurance, and asking for information; several participants perceived the telephone calls to be lacking in helpfulness. Results from this study suggest family caregivers can be helped through a variety of social support mechanisms.

Family caregivers' sleep loss and depression over time.

Depression is a normal response when a family member receives a diagnosis of cancer. However, this response may be exacerbated by other factors such as chronic sleep loss that are amenable to intervention. This pilot study described caregiver sleep and depression patterns over time and explored the feasibility of data collection methods and instruments. The stress and coping framework of Lazarus and Folkman guided this study. A descriptive correlational design was used for this 10-week pilot study. Ten adult family caregivers of patients with cancer were recruited from outpatient oncology clinics. Sleep quality and depression were measured weekly. Actigraphs were worn for 72 hours during weeks 1, 5, and 10. Individual sleep quality and depression scores were generated. Actigraph latency, duration, and efficiency scores were generated. Actigraph and sleep quality scores were compared. Individual caregiver sleep and depression plots show large variance over time. Discrepancies were noted between Actigraph and sleep quality latency, duration, and efficiency scores. Sleep and depressive symptoms fluctuate widely over time. Therefore, accurate assessment and treatment of caregiver problems require repeated assessments. Self-reports of sleep and depression appear to underestimate problems and must be evaluated carefully within this context.

Caregivers' descriptions of sleep changes and depressive symptoms.

PURPOSE/OBJECTIVES: To describe caregiver sleep and depression using caregiver narratives. To compare qualitative descriptions with quantitative scores. DESIGN: Descriptive, one-time, open-ended interview followed by structured sleep and depression questions. SETTING: Interview conducted in person or via telephone at caregiver's preference. SAMPLE: 47 caregivers of patients with advanced stage cancer. Caregivers had a mean age of 54 years, and most were female (81%), Caucasian (82%), and spouses (61%). They provided care for a mean of 24 months. Patients' diagnoses were lung cancer (36%), colorectal cancer (13%), or recurrences (51%). METHODS: Two cancer care sites in southern California provided participants. After consent, the researcher conducted interviews. The Pittsburgh Sleep Quality Index (PSQI) and Center for Epidemiological Studies-Depression (CES-D) instruments were administered following interviews. MAIN RESEARCH VARIABLES: Sleep pattern changes and depression levels over time as defined by caregivers. FINDINGS: Caregivers described severe fluctuations in sleep patterns over time and how these changes affected caregiver depressive symptoms. PSQI and CES-D scores matched narrative comments. CONCLUSIONS: Caregivers' narratives suggest they suffer progressive sleep deprivation that affects their emotions and ability to continue as caregivers. IMPLICATIONS FOR NURSING: Nurses must recognize the severe sleep problems experienced by caregivers and respond with interventions to increase sleep quality and decrease depression.