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Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-036401 on 13 July 2020. Downloaded from Association between poor sleep quality and depression symptoms among the elderly in nursing homes in Hunan province, China: a cross- sectional study Zhao Hu ,1 Xidi Zhu,1 Atipatsa Chiwanda Kaminga,2,3 Tingting Zhu,4 Yu Nie,5 Huilan Xu1 To cite: Hu Z, Zhu X, ABSTRACT Strengths and limitations of this study Kaminga AC, et al. Association Objectives To examine the association between the between poor sleep quality and prevalence of poor sleep quality and depression symptoms ► This is the first study to examine the impact of sleep depression symptoms among among the elderly in the nursing homes of Hunan province the elderly in nursing homes in quality on depression symptoms among the Chinese in China. Hunan province, China: a cross- elderly in nursing homes. Design, Setting and participants This was a cross- sectional study. BMJ Open ► The study provides valuable information on sleep sectional study investigating 817 elderly people from 24 2020;10:e036401. doi:10.1136/ pattern and emotional problems among the elderly nursing homes in China’s Hunan province. bmjopen-2019-036401 in a nursing home setting. Main outcome measures Sleep quality was assessed ► The statistical power was satisfied as the study in- ► Prepublication history for using the Pittsburgh Sleep Quality Index (PSQI) such this paper is available online. cluded adequate samples. that poor sleep quality was defined as PSQI Score >5. To view these files, please visit ► All data were obtained from self-reports, hence re- In addition, depression symptoms were assessed using the journal online (http:// dx. doi. call bias was unavoidable. the Geriatric Depression Scale (GDS). Linear regression org/ 10. 1136/ bmjopen- 2019- ► The cross- sectional study design makes causal re- models and binary logistic regression models were used 036401). lationships undeterminable. to analyse the relationship between the prevalence of poor ZH and XZ contributed equally. sleep quality and depression symptoms. Results The mean PSQI Score was 8.5±4.9, and the Received 13 December 2019 prevalence of poor sleep quality was 67.3%. Additionally, experienced sleep interruption at night and http://bmjopen.bmj.com/ Revised 12 May 2020 the mean GDS Score was 9.8±7.5, and the prevalence Accepted 03 June 2020 48.9% reported having difficulty falling of depression symptoms was 36.0%. Elderly people asleep.2 with poor sleep quality had increased GDS Score (mean In agreement with the foregoing observa- difference=2.54, 95% CI 1.66 to 3.42) and increased risk tions, the prevalence of poor sleep quality of depression symptoms (OR=3.19, 95% CI 2.04 to 4.98) among older adults was also relatively high. after controlling for demographics, chronic disease history, For instance, in China, the prevalence of lifestyle behaviours, social support, activities of daily living poor sleep quality among the elderly was and negative life events. 3 Conclusions The prevalence of poor sleep quality was 41.5% in urban communities and 49.7% in on September 30, 2021 by guest. Protected copyright. 4 relatively high, and this was associated with increased rural areas. However, several studies demon- depression symptoms. Therefore, poor sleep quality strated that most sleep problems can be exac- could be speculated as a marker of current depression erbated by an institutional setting.5–7 In this symptoms in the elderly. regard, Fetveit and Bjorvatn6 found that the prevalence of sleep disturbance was approx- imately 70% among nursing home residents, INTRODUCTION whereas Hoffman7 reported that approxi- Ageing is a challenging problem in China mately two- thirds of older adults living in © Author(s) (or their and all over the world. Research has shown long- term care facilities had some degree of employer(s)) 2020. Re- use that as age increases in old age, the risk of sleep disturbance. In summary, sleep prob- permitted under CC BY-NC. No commercial re- use. See rights problems with sleep also increases, which lems are very common among the elderly in and permissions. Published by is a public health concern for the elderly. nursing homes and pose a great challenge for BMJ. For examples, a cross-sectional investiga- public health. For numbered affiliations see tion conducted among 2398 community- Poor sleep quality has significant nega- end of article. dwelling older persons in Italy indicated that tive effects on physical and mental health, 8–10 Correspondence to 74% of men and 79% of women had sleep and health- related quality of life. Specif- 1 Professor Huilan Xu; complaints. Another cross- sectional study on ically, epidemiological studies suggested xhl6363@ sina. com 2565 elderly Singaporeans showed that 69.4% that poor sleep quality is a strong risk factor Hu Z, et al. BMJ Open 2020;10:e036401. doi:10.1136/bmjopen-2019-036401 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-036401 on 13 July 2020. Downloaded from for suicidal ideation among the elderly.8 9 Further, in a Study population large population- based cohort study, long sleepers with This cross- sectional study was conducted among the elderly poor sleep quality had a 95% higher risk of cardiovas- living in nursing homes in Changsha, Hengyang and cular disease mortality than those who slept for 7 hours.11 Yiyang cities of Hunan province in China from October Another large cohort study found that poor sleep quality 2018 up until December 2018. A multistage sampling was associated with increased odds of hypertension in a method was used to select a representative sample as Chinese rural population.12 However, despite the signifi- follows. First, three cities Yiyang, Changsha and Hengyang cance of poor sleep quality among the elderly population, were randomly selected from Northern Hunan, Central its prevalence and the underlying effect on their physical Hunan and Southern Hunan, respectively. Then, three and mental functioning are not entirely understood. counties, one from each city; and six districts, two from Depression is a common psychiatric disorder among each city, were randomly selected and this resulted in the the elderly. It contributes not only to mild cognitive following counties and districts chosen: Changsha county, impairment but also to an increased risk of comorbidity Kaifu and Yuelu districts from Changsha city; Hengyang and mortality.13–15 In addition, many studies indicated county, Yanfeng and Shigu districts from Hengyang city that the institutionalised elderly have a higher preva- and Yuanjiang county, Ziyang and Heshan districts from lence of depression than the community- dwelling elderly. Yiyang city. Furthermore, six townships, two from each Notwithstanding, the reported prevalence of depression county, were randomly selected and this resulted in the symptoms in nursing homes varied widely across different following townships chosen: Xingsha and Tiaoma from localities due to differences in diagnostic criteria, assess- Changsha county; Xidu and Jingtou from Hengyang ment tools and sample characteristics. For example, county and Qionghu and Caowei from Yuanjiang county. epidemiological studies indicated that the prevalence Finally, 24 nursing homes were randomly selected, two of depression symptoms among the elderly in nursing from each district and two from each township. homes was 90.2% in Iran,16 81.8% in Taiwan,17 29.6% in The elderly population in the selected nursing homes London18 and 46.1% in the Mainland China.19 formed the sampling frame and participants were The association between sleep quality and depression included in our study if they met the following inclusion symptoms among the elderly is complex, bidirectional criteria: (1) had age 60 years and above and (2) had been and not entirely understood. However, many studies have in the nursing home for more than 1 year. However, partic- suggested that elderly people with some sleep distur- ipants were excluded if they (1) refused to participate in bance are more likely to develop depression symptoms this study and (2) had a severe hearing impairment or a than younger people with some sleep disturbance.20 21 language barrier. A total of 2055 older adults reside in the Conversely, people with depression symptoms reported 24 nursing homes, of which 511 were excluded because 22 a higher prevalence of poor sleep quality. Although of less than 60 years or staying in a nursing home less http://bmjopen.bmj.com/ many previous studies have demonstrated that poor sleep than 1 year. Six hundred and three older adults have quality is positively associated with depression symptoms severe hearing impairment or language barrier and 112 among the elderly, the evidence of this relationship older adults, who did not agree to participate, were also among the elderly in nursing homes was scarce. There- excluded in this study. Of the remaining 829 older adults, fore, the purpose of this study was to examine the associa- 12 were excluded for incomplete data. Finally, a total of tion between poor sleep quality and depression symptoms 817 subjects were included in the data analysis of this among the elderly of nursing homes in China. study. on September 30, 2021 by guest. Protected copyright. Data collection Trained staff collected data through face- to- face inter- METHODS views using a set of structured questionnaires, and each Sample size interview lasted between 1/2 and 1 hour. Demographic To examine the impact of sleep quality on depression information collected included gender, age, education symptoms among the elderly of nursing homes, a sample level, marital status, monthly personal income, dura- size was calculated using the formula as follows: tion of admission, number of living children, a history 2 n=4 µα + µβ /ln 1+ρ / 1 ρ +3 of chronic diseases, a history of smoking tobacco and a − history of alcohol consumption. Marital status was classi- {( ) [( ) ( )]} where μα=1.96 when α=0.05; μβ=0.84 when β=0.80 and fied as either stable or unstable.

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