Correlation Between Sleep Disorders and Mental Health in Elderly Women

Review Paper 3 Thomas, K.M., Redd, L.A., Wright, J.D., & Hartos, J.L. (2017). Sleep and Mental Health in the General Population of Elderly Women. J Primary Prevent, 38, 495–503. DOI 10.1007/s10935-017-0484-5. See Link http://ezproxy.lib.swin.edu.au/login?url=https://search.proquest.com/docview/1 943871364?accountid=14205

This article evaluates the elderly people, who suffer from sleep disorders in view of finding a correlation between insomnia and mental health problems, while evaluating the common factors. The research examines the relationship between sleep and mental health in three representative’s samples of older women while evaluating several common risk factors.

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The key points, presented in this paper, are that sleep and mental health problems, which are common among the elderly, of whom up to 70% report is related to some sleep problems, and 20% have some mental concern.Research shows that, mental health outcomes in the elderly are related to sleep quality. However, the research also shows that, mental and sleeps health share common risk factors.

For elderly females, sleep disorders are more common than in older males. However, physical health problem such as general health, chronic illness, disability, obesity, drug consumption, tobacco use and levels of activity contribute negatively in mental health and sleep.

The study was to assess the relationship between sleep and mental health in a representative sample of US elderly women, while controlling the risk factors common to both. This analysis was carried out in 2015 using data from the Behavioural Risk Factor Surveillance System (BRFSS) for women aged 65 years and older from California, Florida and Pennsylvania for assessing the relationship between short, moderate or long sleep periods, and mental health problems in elderly females over 30 days, while monitoring multiple characteristics

Overall, 25% of participants reported having mental health problems over the past month. It is also noted that, elderly female participants reported average or poor health, inactivity, overweight or obese, activity restrictions and three or more health conditions. Almost 70% registered two or more health conditions.

The results indicated that 66% of women, who reported short sleep durations of 5 or fewer hours of sleep per day and suffered from mental health issues and that 26% of women, had long sleep duration of 9 hours and more per day and also suffered mental health issues. Moreover, the following participants were less likely to report mental health issues in the past 30 days as compared to the other groups were those who reported being retired, having $50,000 or higher annual income, and being 70 years of age or older.

The findings are similar to those of other studies by using national surveys around the world, which found that, sleep could play an essential role in the mental health, but findings also indicated that, mental health problems in elderly women are also linked to physical health issues. The aim was to highlight whether elderly females, who are a common group seen in general practice, when present with sleep issues, physical health conditions, and mental health concerns, should be assessed by health practitioners in all three areas.

The limitations of the study were that, no data was present to establish the pattern and interaction of sleep, physical health, and mental health over time, so the pattern of causality is not known. The mental health assessment does not include the type, extent and length of any particular mental health problems or difficulties. Also, sleep measurements did not indicate the types of sleep disorders or whether participants were taking any drugs that might affect sleep.

In conclusion, the purpose of the study was to investigate the correlation between mental health and sleep in representative samples of elderly females while monitoring the risk factors specific to both. The results indicated that, mental health and sleep disorders might be prevalent in the general elderly female population, with about 25 per cent reporting mental health problems and 20 per cent reporting sleep length issues. The evidence gathered suggests that, the practitioners should be aware of the relationship between mental health and sleep and identify issues related to both during the consultation.

Case Study Group: Jennifer Wheeler, Radmila Badzoka, Karissa Beale, Sarah D’Mello, and Tina LaRocca

Referral Information

Betty, a 75 year old woman, was referred to the local mental health centre by her GP due to issues she is experiencing relating to her sleep patterns.

Presenting Problem

Betty presented with a history of sleep issues that she stated had increased in the last 2-3 years. Betty described terminal insomnia, waking early and unable to return to sleep. She stated that she generally slept for approximately 4 hours, between 10pm and 3am without naps during the day. She described feelings of fatigue, which has been occurred most days, even if she was not participating in any physical activity.

Betty described that, she is feeling sad and lonely “most of the time”. Betty stated that she felt “useless” and believed she was “a burden to [her] family”. She described having a poor appetite and often being unable to concentrate. Betty also described feeling anxious when in social settings or when faced with new or unfamiliar situations. She stated that, she has been experienced tightness in her chest, a racing heart, and an overall tense feeling. Betty stated that she often stayed home due to these anxious feelings.

Family System

Betty and her late husband Geoff had three adult children and seven grandchildren from the ages 11 – 24 years. Her two sons Harry and Tom live interstate with their families – one in Perth and one in Adelaide, and her daughter Suzanne lives close by.

Betty grew up in a small house in Melbourne with her parents and younger brother Wilfred, who she is quite close to despite him now living in QLD. She reported a traditional upbringing in a low-socio economic family. Her father Theodore passed away 20 years ago from heart failure and Betty’s mother Gertrude died shortly after from pneumonia.

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Before Geoff died, five years ago from a stroke, Betty would see her daughter and granddaughters quite frequently, now only seeing them on birthdays and other occasions due to their busy schedules. Suzanne is recently divorced and shares custody of her two children with her ex-partner Richard. She was closer to her father growing up and experienced bouts of depression after his death and her divorce.

Betty would like her relationship with Suzanne to improve. Betty keeps in contact with both her sons and their families by phone, though hasn’t seen either of them in a few years. She is reluctant to travel interstate to visit them, as she doesn’t have much confidence travelling.

There is a history of long-standing conflict between Tom and Harry, which was exacerbated by the death of their father. Since Betty shares a close relationship with both her sons, she believes if they resolved their conflict they would visit her more often and she would not feel as isolated as she now reports.

Developmental History

Betty reported that, she was born as a happy and healthy baby and recalls a happy childhood despite her family’s low socioeconomic status. She enjoyed a close relationship with her younger brother Wilfred (born 4 years her junior). Betty described herself as being shy and prone to playing imaginative games on her own. She said she loved being in the garden and learning all the plant names as a child but did not get much opportunity to do so. Betty was frequently required to look after her brother, when her mother was busy.

Betty achieved average grades at school and left at the end of year ten, when she commenced work. She recalled being sad to leave her friendship circle, but understood the financial need to earn money. After two years Betty left her job, married Geoff and proceeded to have three children (all pregnancies being unproblematic). Betty said she enjoyed being a mother and looks back on these years with her husband and children as her happiest. She described missing her children, especially since her husband passed away and a sense of feeling lost. She wished she had more friends.

Betty experienced menopause at age 50. She reported getting a bout of bronchitis every winter in recent years. She wears multi focal glasses due to declining eyesight and reported her hearing to have also worsened. Betty has arthritis in her hands and feet. She walks daily, but felt she has gained weight in the last few years.

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Educational and work history

Betty was educated to fourth year of high school only, as family of origin was poor. She began work at age 16, as a filing clerk in a government office. She met Geoff at 19, left her job at 20 and married Geoff. Betty was a housewife and mother until her third child reached high school, when she worked as a school receptionist. She enjoyed the social aspect of this role, and talking to the children.

Relationship and sexual history

Betty was living with her husband for 51 years until he passed away 5 years ago. They lived, where Betty remains to live, in a quiet suburban home in Melbourne. Betty and her husband met at a social function; they courted for one year, became engaged and married six months later. Betty has had no other sexual partners, but she reported to have been courted by some men before she met her husband and also since he had passed.

Betty and her husband lived with their three children, who have since moved out. Her daughter lives nearby. She reported that she spends most evenings watching television from 7 p.m. until bedtime, around 10.30 p.m. Betty further stated that she has two close friends that she socialises semi-regularly with, once a fortnight, and since her husband passed away, she did not feel overly confident socialising. Betty walks for 30 minutes most days, slowly around the block.

Psychiatric and medical history

Betty went through menopause age 50. She has some arthritis in her hands and feet, and has had cataracts removed age 71, some sign of return. Betty has her flu shots every year, with some bronchitis recurring each winter. Her pregnancies (aged between 26 and 32) were all to term and unproblematic. Betty takes PanadolOsteo for arthritis and calcium supplements.

Treatment History

Betty had no prior experience of counselling. Before presenting to her GP regarding her current symptoms, she attended for acupuncture without success. Betty bought a new mattress and pillow, which did not appear to have helped.

School Information

Betty completed year 10 of high school. Due to poor family of origin, she did not continue with education. Betty enjoyed the social aspect of school, but was not highly academic and achieved average marks at school.

Individual Assessment

Betty was dressed in a casual, well groomed manner. She appeared anxious about the interview process and talking about her feelings. Upon questioning Betty presented as fatigued, flat in affect and low in mood. At times, her ability to think clearly seemed diminished. A risk assessment was conducted with a low risk of harm outcome. Betty expressed her wishes for improved sleep and to feel happy again.

Case Formulation

Betty was referred to counselling by her GP, because of the issues she is experiencing relating to her sleep patterns. The referral was made due to her insomnia, which has lead to the feelings of fatigue. Betty’s presenting the issues appear to have occurred after her husband passed away, with an increase in isolation from her family, feeling like a burden, and also feelings of sadness and loneliness.

Possible factors underlying Betty’s presentation may include grief, the transition to becoming a widow, transition into old age, and confronting one’s mortality. Betty has described feeling “useless” and a burden to her family. Betty also describes feeling anxious when in social settings or when faced with new or unfamiliar situations. She reported that, this anxiety is new and has not experienced it in the past and states feeling distressed, when experiencing tightness in her chest, a racing heart and anoverall tense feeling.

She described feelings of fatigue, which occurs most days, even if she was not participating in any physical activity. Betty stated that, there was no familial depression or anxiety, but that her daughter has experienced bouts of depression after her father’s death and the divorce.

There are possible unresolved grief issues, following the death of her husband, with secondary grief issues related to social changes, with Betty stating that, she often stays at home due to social anxiety.

An additional familial issue that may be impacting on Betty includes, the conflict between her sons Tom and Harry, which was exacerbated by the death of their father. Together with the divorce and subsequently the distance she is now experiencing with her daughter with who lives nearby and was once a close relationship.

Using the 4-P model to conceptualise Betty’s insomnia problem and to inform treatment, presenting the predisposing, precipitating, perpetuating, and protective causes for Betty’s insomnia is effective. Predisposing issues may include shyness in childhood with possible untapped feelings of anxiety. The need for close family relationships that could account for preoccupied attachment style. The decrease in circadian rhythm city, (one is sleepier as some times of the day than others), which may partly explain the physical response of insomnia. Responsibility of having to care for her brother when parents were busy, and dropping out of school and her social network to work due to the family’s poor social demographic. The precipitating issues, as in why she is presenting to counselling now, are, persistently feeling fatigued and wanting to sleep better. Feeling isolated, lonely, and anxious, having less social interactions than before her husband passed away. The perpetuating concerns are social anxiety with the feeling of tightness in her chest, a racing heart and an overall tense feeling. She is not seeing her children and grandchildren as much as she would like, with reluctance to travel, due to the anxiety, which results in fewer family visits. Another perpetuating factor is the strained relationship with her daughter Suzanne, and the ongoing discord with her two sons. Betty experiences low moods and believes that, she is a burden to her family. The protective insights are her close relationship with her sons and two close friendships. Betty does regular exercise, walking thirty minutes most days. She is in good general health and only experience a mild form of arthritis for which she takes PanadolOsteo. Betty also shows a willingness to engage in therapy, having tried other health modalities, such as acupuncture.

Treatment goals

The treatment goals for Betty would be to return her to a regular sleep pattern, which would combat her complaints of fatigue. The use of BBTI rational would address her sleep cycle and circadian rhythm. The goal would also be to support Betty with her anxiety and work on how to improve her socializing, by considering to volunteer in reading program at her local primary school and joining a short course, through her council, such as pottery, to promote social activity. This may address her issue of feeling isolated and lonely.

Given the perpetuating factors of social anxiety with the feeling of tightness in her chest, a racing heart and an overall tense feeling, using Progressive Muscle Relaxation, PMR, would improve her anxiety. Another perpetuating factor is that, Betty is experiencing low moods and believes she is a burden to her family. The use of CBT would support Betty’s mental health and address her depression.

Outline of treatment

A phone call would be made to her local primary school to organise involvement in the reading program for children, which will include a regular weekly visit to read the children of age prep and grade one. Information will be shared with Betty about her local council and programs they are running, times and dates of the programs and how to enrol in a program that would interest her.

BBTI will be delivered to Betty over four consecutive weeks, which will include two in-person sessions and two telephone sessions. The first session will include a thorough sleep evaluation by completing a standard sleep daytime sleepiness questionnaire, an insomnia rating scale, a depressive rating scale and two weeks of a sleep diary. The review of her sleep diary will allow discussion in treatment about problems and challenges, which may have occurred in previous weeks as well as to encourage consistency to the prescribed sleep schedule.

Session two will be dedicated to Progressive Muscle Relaxation which will involve tensing muscles for four to seven seconds and then relaxing for twenty to forty-five seconds, starting from the muscles in her forehead, face, jaw, neck, shoulders, arms, hands, abdomen, buttocks, thighs, ankle and feet. This will then be prescribed as a home task for Betty to do during the day and prior to bedtime.

CBT will then follow with a six week treatment plan, in which during the first session the focus will be on building rapport and explaining that Cognitive Behavioural Therapy is a guided program that helps you recognise and replace thoughts and behaviours with patterns which encourage sound sleep, which has triggered or exacerbate the sleeping problems. Together with Betty, we will look at resolving any underlying causes of her sleep problems.

Rational for treatment

CBT is an evidence-based therapy that has proven effective for sleep disorders and in particular insomnia. Within the CBT model, there are other modalities included, such as BBTI and PMR. All three methods will be used in addressing Betty’s presenting issues.

BBTI focuses on altering behaviors in order to improve sleep and is shorter in duration than CBT. BBTI uses two essential principles of behavior: sleep restriction and stimulation regulation, which enables the person to consistently and effectively, produce sleep. The primary reasons for BBTI are that it can have a direct impact on the two main biological processes governing sleep by changing sleeping behaviors: homeostatic and circadian drives.

The design of this therapy is driven by the assumption that for treatment to be applicable to general medical environments, it must be concise, patient-acceptable, deliverable by a nurse or medical professional without a large amount of training, and successful over a short period of time.

Progressive Muscle Relaxation is a combination of the CBT model. This technique is designed to increase awareness of tension throughout the body and allow it to be reduced. Furthermore, PMR counteracts and inhibits physiological responses to anxiety because, at the same time, it is difficult to be nervous or calm. The goal is to increase understanding of stress.

CBT is based on factors that conflict with sleep induction and maintenance. Cognitive Behavioral Therapy treats insomnia with a holistic approach that explores various putative triggers and perpetuators. Insomnia patients also share sleep attitudes and beliefs, which may cause worry and fear about one's ability to sleep. This stress and concern lead to anticipation that interferes with sleep, causing more anxiety and worry, and creating a cycle of self-fulfillment that is difficult to break in the absence of direct intervention. Cognitive therapy focuses on identifying and replacing these beliefs with more adaptive attitudes and beliefs. Sleep awareness (discussed earlier) supports cognitive therapy because of knowing about healthy sleep patterns can help address mistaken beliefs. CBT is designed to reduce sleep-related anxious feelings.

References

Benca, R. M., & Buysse, D. J. (2018). Reconsidering insomnia as a disorder rather than just a symptom in psychiatric practice. J Clin Psychiatry, 79(1).

Buysse, D. J., Rush, A. J., & Reynolds, C. F. (2017). Clinical management of insomnia disorder. Jama, 318(20), 1973-1974.

Fiorentino, L. (2010). Treatment of insomnia with early morning awakenings among older adults. Journal of Clinical Psychology, 66(11), 1161-1174.

Pearson, Q. M. (2017). Challenges and Recommendations for Middle-Aged and Older Adults. Adultspan Journal, 16(1), 1-46.

Troxel, W. M., Germain, A. & Buysse, D. J. (2012). Clinical Management of Insomnia with Brief Behavioral Treatment (BBTI). Behavioral Sleep Medicine., 10(4), 266-279.

Wang, J., Wei, Q., Wu, X., Zhong, Z., & Li, G. (2016). Brief behavioral treatment for patients with treatment-resistant insomnia. Neuropsychiatric disease and treatment, 12, 1967.

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