Prevalence and Contributing Factors of Insomnia among Elderly of Pashupati Old Aged Home (Briddhashram)

Sushila Shrestha¹, Tara Roka², Sunil Shrestha ^3*, Sujyoti Shakya⁴

¹Registered Nurse, Manmohan Cardiothoracic Vascular and Transplant Centre, TUTH Complex, Maharjgunj, Kathmandu.

²Associate Professor, Nepalese Army Institute of Health Sciences, Kathmandu

³Lecturer, Medical Biochemistry Department, Nobel College, Sinamangal, Kathmandu

⁴Market Planning Department, Everest Pharmaceuticals Pvt. Ltd, Tinkune, Koteshwor, Nepal.

Corresponding Author: Sunil Shrestha, Lecturer, Medical Biochemistry Department, Nobel College, Sinamangal, Kathmandu, Nepal, Tel +977-11-661399; E-Mail:[email protected]

Received Date: 21 Mar 2017  
Accepted Date: 10 Apr 2017  
Published Date: 11 Apr 2017  

Copyright � 2017 Shrestha S

Citation:Shrestha S, Roka T, Shrestha S and Shakya S. (2017). Prevalence and Contributing Factors of Insomnia among Elderly of Pashupati Old Aged Home (Briddhashram). M J Psyc. 2(2): 014.

Ageing is a natural phenomenon and an inevitable process. Every living being born, develops, grows old and dies. With the increase in age, people lose their creativity level, problem solving ability and learning skills as well as short-term memory. All the people of the world - be they rich or poor and learned or uneducated - have to pass through this cyclical process in their lives, irrespective of their present state of strength or merit or weakness [1].

Sleep is a vital physiological process with important restorative functions. Sleep disorders and sleeping difficulties are among the most pervasive and poorly addresses problems of aging

Getting enough sleep can have a significant impact on daily function, alertness and overall quality of life [2].

Insomnia or sleeplessness, is a sleep disorder in which there is an inability to fall asleep or to stay asleep as long as desired. This sleep disorder is often practically defined as a positive response to either of two questions: �Do you experience difficulty sleeping?� or �Do you have difficulty falling or staying asleep?� [3].

With age, several changes occur that can place one at risk for sleep disturbances including increased prevalence of medical condition, increased medications use, age related changes in various circadian rhythms, and environmental and life style changes. Insomnia is generally classified as primary or secondary to some underlying cause. Primary insomnia is usually not associated with a medical or psychiatric condition. Secondary insomnia occurs most frequently in the older adult with medical or psychiatric disorders. The causes of insomnia in the elderly are divided into four groups: (1) physical diseases or symptoms, such as long-term pain, bladder or prostate problems, joint diseases such as arthritis or bursitis, and gastroesophageal reflux; (2) environmental/behavioral factors; (3) use of drugs, such as caffeine, alcohol, or prescription medications for chronic diseases; and (4) mental diseases or symptoms, such as anxiety, depression, loss of personal identity, or perceived poor health status [2, 4].

Insomnia affects almost half of adults 60 and older. Many factors can cause insomnia. However, the most common reason older adults wake up at night is to go to the bathroom. Prostate enlargement in men and continence problems in women are often the cause. As a person ages, sleep becomes more fragmented [5, 6].

In a previous study from Thailand, nearly 50% of patients over the age of 60 years had insomnia; the factors most strongly associated with insomnia were poor perceived health status and the presence of depression. Somatic comorbidities associated with aging are known to be risk factors for insomnia and depression. Given these facts, insomnia in elderly patients merits clinical attention and research [4].

Like in other developing countries, Nepal�s elderly population is increasing and facing many health problems. The increasing growth and demand of elderly people urges the active involvement of health personnel from different faculty in providing quality services to them.

This study will show the prevalence of insomnia and its associated factors among the elderly people of Pashupati Briddhashram. The findings will help in making the people aware about the possible causes of insomnia; which later on can be used in the management of insomnia at both hospital and community level.

In Nepal, very few studies are reported on insomnia among elderly people. Nepal Health Research Council (NHRC) has enlisted areas of elderly health issues in its short term research priority area. Studies on insomnia and its contributing factors in elderly are necessary to aid health planners and care professional in planning and providing appropriate promotive, preventive, curative and rehabilitative services related to insomnia to the elderly

Research DesignObservational cross-sectional study was applied in the study.

Study SiteThis study site was Pashupati Briddhashram (Old Aged Home).

Study PopulationAll the elderly people who resided in Pashupati Briddhashram (Old Aged Home).

Sample Size The sample size of the study was
n = z²p(1-p) for finite population of size N
d² + z²p (1-p )/N
Where, p = proportion; d = sampling error that can be tolerated; z = 1.96; confidence level; N = size of population.

The total elderly population in the Pashupati Bridhashram (Old Aged Home) was 235.
Taking the value of p=49.3 %, the sample size calculated was; 145.7~148.

Sampling Method
Probability; simple random sampling method was used for sampling. The lottery method was implied for the sampling process.

Data Collection Techniques and Tools

Data Collection Technique

• Interview by the researcher self Data Collection Tools
• Semi-structured questionnaire
• Athens Insomnia Scale:
  Insomnia was diagnosed with the use of Athens Insomnia Scale; which assessed eight different sleep factors (rated on a 0-3 scale) among the respondents. The sleep factors are sleep induction, awakenings during night, final awakening, total sleep duration, sleep quality, well-being during the day, and functioning capacity during the day and sleepiness during the day. Elderly subject who had a total score 6 points or higher was considered as a positive case for insomnia.
• Geriatric Depression Scale (Short Form)
  This scale was developed by Sheikh and Yesavage as a basic screening measure for depression in older adults. This consists of 15 questions requiring �yes� or �no� answers. Of the 15 items, 10 indicate the presence of depression when answered positively, while the rest indicate depression when answered negatively. A score higher than five suggests depression.
  1-5: no depression
  6-10: mild depression
  11-15: severe depression

Criteria for Selection of Patients

Inclusion Criteria
� All the elderly people living in the Pashupati Briddhashram were included in the study.

Exclusion Criteria
� Elderly people who were not interested in the study were excluded.

Validity and Reliability
Pre-testing was done for validating the tools. Necessary changes were done on the basis of results obtained from pre-testing and final set of questionnaire had been prepared by accommodating necessary changes under the advice of research guide and other related expertise. Standard valid tools were also used for measuring insomnia and depression. The questionnaire was pre-tested for the reliability as well. Corrective actions were taken to remove the gaps found in the tools. Pre-testing was done among the elderly of Nijananda Briddhashram (Old Aged Home), Taudaha; constituting about 10 percent of the total sample population of the study.
Socio-demographic characteristics.

Table 1: shows socio-demographic characteristics.

n = 148
S.N.	Socio-demographic variables	Frequency	Percentage
1	Age
	60-69 years	45	30.4	Mean: 73.64
	70-79 years	60	40.5	S.D.: �8.16
	80 years and above	43	29.1
2	Sex
	Male	70	47.3
	Female	78	52.7
3	Marital status
	Married	27	18.2
	Unmarried	29	19.6
	Divorced	7	4.7
	Widowed	85	57.4
4	Duration of widowhood
	1-10 years	49	57.6	Median: 10.00
	11-20 years	19	22.8	IQR: 5.00- 19.00
	21 years and above	17	20
5	Number of children
	No children	43	29.1	Median: 2.00
	01-May	86	58.1	IQR: 0.00- 5.00
	More than 5	19	12.8
6	Ethnicity
	Brahmin	60	40.5
	Chhetri	43	29.1
	Janajat	44	29.7
	Dalit	1	0.7
7	Religion
	Hindu	141	95.3
	Buddhist	7	4.7
8	Educational status
	Illiterate	7	4.7
	Informal education	32	21.6
	Primary level	5	3.4
	Secondary level	2	1.4

Ethical Consideration
The objectives of the study were clearly explained to the respondents as well as the concerned authority of the Briddhashram, before data collection. A letter from college was submitted to the concerned authority and permission for data collection was taken from the Briddhashram (Old Aged Home). Letter of approval was obtained from the review committee of the campus. Informed consent was taken from respondents. No one was forced to give their consent or participate in the study. Respondents were free to withdraw participation at any point during the interview. Privacy, confidentiality and anonymity were maintained.

Table 2: shows that majority of the respondents (60.1%) stated lack of care taker as being the reason for leaving home, followed by personal wish (25.7%). About two fifth (43.9%) of the respondents were living in the Briddhashram (Old Aged Home) since more than 5 years. Around three fourth of the respondents (71.6%) said that their family members didn�t visit them. All of the respondents didn�t have any kind of financial support from the family.

Socio-demographic characteristics

n = 148
S.N.	Socio-demographic variables	Frequency	Percentage
1	Reasons for leaving home*
	Low economy	15	10.1
	Family conflict	22	14.9
	Lack of care taker	89	60.9
	Loss of spouse	9	6.1
	Personal wish	38	25.7
2	Duration of stay in ashram*
	Upto 5 years	83	56.1	Median: 5.00
	More than 5 years	65	43.9	IQR: 2.00- 10.00
3	Frequency of family visit in past 6 months*
	No
	1-5 times	106	71.6	Median: 3.00
	More than 5	32	21.6	IQR: 2.00- 5.25
	10	6.8

^*Multiple Response

Data Analysis Procedure
After the collection of data, it was overviewed, checked and verified checked for completeness, consistency and accuracy. The raw data collected was processed, analyzed and interpreted using the SPSS 17.0 version software. The data were analyzed by using different statistical technique. The findings were interpreted through frequency table.

Table 3: shows that among the respondents, three fifth (61.5%) of them had insomnia. Insomnia was diagnosed with the use of Athens Insomnia Scale which assessed eight different factors (rated on a 0-3 scale) among the respondents.

Assessment of insomnia.

n = 148
Insomnia	Frequency	Percentage
Yes	91	61.5
No	57	38.5

Data was obtained from 148 elderly people, yielding a 100% response rate. The elderly people included in the study were 60-94 years of age. The mean age was 73.64 years and the Standard Deviation (S.D.) was 8.167.

This study was conducted in order to find out the prevalence of insomnia and identify its contributing factors among elderly people of Pashupati Briddhashram (Old Aged Home).

Table 4: shows that majority of the respondents had the physical symptom of pain i.e. 75.0%. Around two third (65.5%) of them had weakness of extremities, followed by problem of blurred vision (54.1%). Each 8.8% of them had diarrhea and skin itching, and 4.7% had constipation.

n = 148
S.No	Name of symptoms	Yes	No
1	Pain	111 (75.0)	37 (25.0)
2	Shortness of breath	53 (35.8)	95 (64.2)
3	Weakness of extremities	97 (65.5)	51 (34.5)
4	Fatigue and malaise	54 (36.5)	94 (63.5)
5	Poor appetite	28 (18.9)	120 (81.1)
6	Skin itching	13 (8.8)	135 (91.2)
7	Dizziness	25 (16.9)	123 (83.1)
8	Diarrhea	13 (8.8)	135 (91.2)
9	Constipation	7 (4.7)	141 (95.3)
10	Urinary frequency	36 (24.3)	112 (75.7)
11	Urinary incontinence	18 (12.2)	130 (87.8)
12	Urinary difficulty	16 (10.8)	132 (89.2)
13	Blurred vision	80 (54.1)	68 (45.9)
14	Difficulty hearing	29 (19.6)	119 (80.4)
15	Dry mouth	28 (18.9)	120 (81.1)

Prevalence of Insomnia
This study has revealed that the prevalence of insomnia among elderly of Pashupati Briddhashram (Old Aged Home) is three fifth (61.5%). This finding is similar to a study conducted in three French cities [7], where more than 70% of the elderly reported at least one insomnia symptom. The finding is also similar to the study conducted in Panchthar district of Nepal [6]; which reported that difficulty maintaining sleep was the most common form of insomnia among the elderly i.e. 61.3% and 49.3% had difficulty initiating sleep. Moreover, the finding is similar to the study conducted in Northern Taiwan [4], where insomnia criteria were met for 41.4% individuals. The finding is in contrast with the finding of the study done in Hong Kong [8], where the prevalence of insomnia was reported to be 11.9% respectively. The finding is also in contrast with the study conducted in long-term care residents of Canada [9], where the prevalence of insomnia was 6.2%

Table 5: shows that most of the respondents had the physical symptoms for more than 6 months. Majority of them had difficulty hearing (96.6%) and blurred vision (93.8%) for more than 6 months. Similarly, 92.6% of them had fatigue; 91.8% had weakness of extremities; 90.6% had shortness of breath; 89.3% had dry mouth; 88.9% had urinary incontinence; 88.3% had pain; for more than 6 months.
Duration of physical symptoms.

S.No	Name of symptoms	Yes	No
1	Pain	111 (75.0)	37 (25.0)
2	Shortness of breath	53 (35.8)	95 (64.2)
3	Weakness of extremities	97 (65.5)	51 (34.5)
4	Fatigue and malaise	54 (36.5)	94 (63.5)
5	Poor appetite	28 (18.9)	120 (81.1)
6	Skin itching	13 (8.8)	135 (91.2)
7	Dizziness	25 (16.9)	123 (83.1)
8	Diarrhea	13 (8.8)	135 (91.2)
9	Constipation	7 (4.7)	141 (95.3)
10	Urinary frequency	36 (24.3)	112 (75.7)
11	Urinary incontinence	18 (12.2)	130 (87.8)
12	Urinary difficulty	16 (10.8)	132 (89.2)
13	Blurred vision	80 (54.1)	68 (45.9)
14	Difficulty hearing	29 (19.6)	119 (80.4)
15	Dry mouth	28 (18.9)	120 (81.1)

Age
In this study, about three fourth (76.7%) of the elderly who were 76 years and above had insomnia, whereas around half (51.1%) of the elderly who were 60-75 years had insomnia. There was strong statistical significance between age and insomnia (p=0.002). The finding is similar to the finding of the study in Zagazig city [2], where it was reported that the prevalence of insomnia was higher among the elderly who were above 65 years (63.9%). The finding is consistent with the study in Alexandria, Egypt [10], where it was concluded that advanced age was significantly associated with the insomnia symptoms. The finding is also similar to the study conducted in Hong Kong [8] in which the prevalence of insomnia was shown to increase with age (p<0.001). The finding is also consistent to one of the study done among Greek population [11], where it was found out that insomnia increased with age (p<0.001).

Table 6: shows the total number of physical symptoms present among the respondents. More than half of the respondents (52.7%) had more than 3 physical symptoms. The median of number of physical symptoms is 4.00.

n = 148
Number of physical symptoms	Frequency	Percentage
Up to 3 symptoms	62	41.9	Median: 4.00
More than 3 symptoms	78	52.7	IQR: 2-6

Sex
In this study, more than two third (67.9%) of the females and just more than half (54.3%) of the males had insomnia; but there was no statistical significance between sex and insomnia (p>0.005). The finding is similar to the study by [12] in which it was concluded that men were less likely than female to develop insomnia symptoms. The result is consistent with the result of the study in Zagazig city [2] where females developed insomnia more commonly than males (61.1% vs. 38.9%). Similarly, the study in Hong Kong [8] reported that the insomnia symptoms were more common in females than males (14% vs. 9.3%). Similarly, a study in china [13] showed that women reported more insomnia symptoms than men (36.4% vs. 28.7%, p=0.001). Similarly, according to the study by [7]; women reported more insomnia symptoms than men (75% vs. 70%, p=0.0001). The result is similar to the study by [4] in Northern Taiwan, which concluded that insomnia was more common in women than in men (63.3% vs. 36.7%). The finding is in contrast to the study conducted in Cairo, Egypt [13]; where a significantly higher percentage of males suffered insomnia more than females (45% vs. 22.6%).

Table 7: shows that two fifth of the respondents experienced cough during night (41.2%). About 28.4% of them had the problem of nocturia. Only 1.4% of them had the problem of snoring during sleep.
Presence of problems during night sleep

n = 148
S.N.	Problems	Yes	No
1	Cough	62(41.2)	87 (58.8)
2	Nocturia	42 (28.4)	106 (71.6)
3	Snoring	2 (1.4)	146 (98.6)
4	Bad dreams	15 (10.1)	133 (89.9)
5	Apnea	11 (7.4)

Marital status
In this study, more than two third (72.4%) of the unmarried group of elderly, followed by less than two third (62.0%) of divorced and widowed, and less than half (48.1%) of the married had insomnia. The result is similar to the study done in Zagazig city [2]; where insomnia was found to be highest among divorced, widowed and single group of elderly i.e. 66.7%. The result is in contrast with the study conducted in Cairo, Egypt [13]; where it was reported that married individuals suffered insomnia at a significantly higher percentage than unmarried, divorced, separated and widows. The finding also contrasts with the study done by [7] which concluded that widowed or divorced condition was significantly associated with insomnia symptoms (p<0.0001).

The present study was aimed to explore the relational aspect of mindfulness and psychological distress. Finding of the study confirmed that mindfulness has negative relationship with psychological distress. As mindfulness will increase psychological distress will decrease in depressed patients. Finding showed that mindfulness has negative impact on psychological distress. Gender played a significant role in the identification of mindfulness level in depressed patients. High level of mindfulness showed in male patients than female patients. But no significance difference of psychological distress was found in term of gender.

Limitations also exist when it comes to measures of critical independent variables along with the theoretical frameworks we were looking at intended to stand for. Sample composition is relative small. Current study based on cross-sectional method and longitudinal method is best way to get depth knowledge about depressed patients.

In future researchers must notice these suggestions: Sample size of the research must be increase and across the nation exploration is required. This examination has established the relationship between mindfulness and positive thinking but in future exploration causal relationship highly recommended. More demographic variables like forgiveness, personality and happiness ought to be explored in the role of mental health.

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