Prevalence of Insomnia and its Association with Chronic Morbidities among BRICS Countries Older Adults

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1 Prevalence of Insomnia and its Association with Chronic Morbidities among BRICS Countries Older Adults Kanchan Negi Doctoral Fellow International Institute for Population Sciences Mumbai, India Abhishek Saraswat Doctoral Fellow International Institute for Population Sciences Mumbai, India ABSTRACT Insomnia among the elderly is an important health issue as it has been associated with a higher risk for poorer overall health, lower quality of life, and morbidity including falls and institutionalization, and cognitive impairment. Due to rapidly ongoing population aging researchers have begun to pay attention to the sleep quality among elderly in developing countries. This study aims to assess the association between chronic conditions and insomnia among older adults in BRICS countries (China, India, Russia and South Africa). Severe sleep disorder was considered as an indicator of insomnia. Results from logistic regression indicated that angina and depression were most significant predictors of insomnia in all BRICS countries. In Asian countries insomnia was associated with arthritis and stroke and in South Africa it was significantly associated with chronic lung diseases. Our study suggests that insomnia is a major health problem in BRICS countries, elderly people slept poorly and the prevalence rate increased rapidly with aging. Identifying co-existing sleep problems among patients with chronic conditions and treating them simultaneously may lead to better treatment outcome. Clinicians should be aware of the high risk for sleep problems among patients with multi-morbidity to combat the problem at first hand.

2 I. INTRODUCTION Sleep is an imperative biological necessity and an extremely systematic procedure. It plays a vital role in regulating physiologic, metabolic, thermal and nervous functions of the body. However, sleep is very vulnerable to internal and external disruptions (Jones, 2005). Certain events in life may cause occasional insomnia in a person who otherwise sleeps well. Insomnia is a symptom that arises from multiple environmental, medical, and psychological and mental disorders (Kupfer and Reynolds, 1997). Insomnia can be temporary, short-term, or chronic in its presentation where sleeplessness recurs over an extended period lasting from some days to months or even years (Smith et al., 2002; Ohayon, 2002). There is growing evidence which shows declining trend in average sleep duration and increasing the prevalence of sleep disorders (Bonnet and Arand, 1995; Sutton et al., 2001). The prevalence of insomnia increases with age and the studies in the Western countries have documented that its prevalence is fifty percent higher among older adults (Monane, 1992). Insomnia among elderly is a crucial health issue as it leads to poorer overall health (Newman et al., 1997), lower quality of life (Schubert et al, 2002; Reid et al, 2006) and welcomes other morbidities (Hale, 2005; Ferrie et al, 2011; Stone et al, 2014). Majority of insomnia patients have been reported to have comorbid physical and psychological issues such as mood disorders, cardiovascular disorders and respiratory diseases, hypertension, and diabetes (Neubauer, 2009; Roth, 2009). Changes associated with the older age make elderly more susceptible to comorbid insomnia (McCrae and Lichstein, 2001). Despite this, data on comorbid insomnia among elderly in developing countries is scarce and symbolize an undermined emerging global epidemic and an unmet public health issue (Colten and Altevogt, 2006; Stranges et al., 2012). The scarcity of literature on insomnia is a significant research gap given the fact that in 2010, 65% of the world's population of 60 years and older is residing in the developing nations; this figure is projected to increase to 80% by 2050 (Kinsella and Wan, 2009). Also, there is a rapid increase in chronic diseases in developing countries (Beaglehole et al., 2011). Therefore, the present study aims to assess the association between sleep disorder and chronic problems among older adults in China, India, Russia, and South Africa (S. Africa) for global comparisons. Understanding the epidemiology of comorbid insomnia is crucial to understand its effects on quality of life and well-being and thus guiding interventions to combat the public health issue.

3 II. METHODS Data: The data for the present study come from the WHO Study on global AGEing and adult health (SAGE) survey wave 1 ( ). Sage is a part of global longitudinal study implemented in six countries namely China, India, Ghana, Mexico, Russia and S. Africa. Our analysis is confined to BRICS countries, including China, India, Russia and S. Africa. Brazil could not be included in the analysis because the SAGE survey was not conducted in Brazil. Dependent variable: Sleep disorder is taken as an indicator of insomnia, which was assessed by single item question. The question covered three dimensions of sleep disorder, i.e., problem in falling asleep, walking up frequently during the night or waking up too early in the morning. A reference period of 30 days was taken for evaluating the prevalence of sleep disorder. Those who had severe or extreme problems were considered to have insomnia. Independent variables: The inclusion of morbidities in our analysis is based on two criteria first, the morbidities must be influenced by insomnia; and second, information on the morbidities was collected by the SAGE survey. Accordingly, we included Angina, Arthritis, Asthma, Depression, Chronic lung disease, Diabetes, Hypertension, and Stroke in our analysis. Body mass index (BMI) was calculated as the ratio of weight and height in kg/m 2, and obesity was defined as BMI 30 kg/m2. Sample: We restricted the analysis to those 50 years or older since sleep problems and chronic morbidities are more prevalent in this age group. Hence, the analytical sample of China 13175, India 6560, Russia 3938, and, South Africa 3838 was considered, totaling to the sample size of Statistical analysis: Country-wise analyses were conducted as one of our prime objectives was to assess the inter-country differentials in the association between chronic conditions and sleep problems. Characteristics of the study sample are shown for each country using descriptive analysis in Table 1. Associations between insomnia and the presence of chronic morbidity and number of chronic conditions are shown using logistic regression with multiple variables in Table 2 and 3. In the analysis assessing the association between the individual chronic health conditions and sleep problems, nine chronic problems namely, angina, arthritis, asthma, chronic

4 lung disease, depression, diabetes, hypertension, obesity, and stroke were considered. Sampling weights were used to generate nationally-representative estimates. III. RESULTS Table 1 illustrates the characteristics of study sample in country-wise format. The median age ranged from 60 years (India, Mexico, and South Africa) to 65 years. In all the countries, the majority of respondents belonged to the age group of years. Proportion of females was highest in the Russian sample. Also, in terms of education more than ninety percent of sample from Russia was well educated. On the contrary, in remaining three countries, percent of the sample attained education of primary level or less. The major proportion of sample population from S. Africa had the low physical activity. Fifty percent of sample population from India was current smoker. As compared to other countries, Russian sample had the highest proportion of current drinkers. In table 2 logistic regression has been used to assess the association between chronic morbidities and insomnia among older adults in BRICS Countries. Angina was significantly associated with 2 times higher odds for insomnia in all BRICS countries (Odds ratio, OR ). Similarly, arthritis was significantly associated with times higher odds for insomnia in all BRICS countries with an exception of S. Africa (OR, ). The likelihood for insomnia was significantly higher among asthmatics in India (OR, 2.2). As for chronic lung disease, significantly higher odds for insomnia were observed in S. Africa (OR, 3.5). Depression had higher odds for insomnia in all BRICS countries (OR, ). Diabetes was significantly associated with insomnia problems only in India (OR, 2.0). Hypertension and obesity were not associated with insomnia in any of the countries. A significant association between stroke and insomnia was observed in China and India (OR, 2.1 & 2.4). Table 3 represents odds ratio from logistic regression showing the association between number of chronic conditions and insomnia among older adults in BRICS countries. Presence of 1 chronic condition was not associated with insomnia any of the BRICS nations. In all the BRICS countries except S. Africa, odds of insomnia was significantly higher among older adults with 2 chronic conditions (OR, ) than their counterparts without chronic problems. As compared to those with no chronic problems, insomnia was significantly higher among older adults having

5 3 chronic conditions in all BRICS nations except China (OR, ). Presence of 4 or more chronic conditions among older adults was significantly associated with insomnia in all the BRICS nations (OR, ) as compared to those having no chronic conditions. IV. DISCUSSION The present study showed that insomnia among older adults is common in India (15.0%), and Russia (9.0%), and it is associated with chronic conditions even after adjusting for confounders. A large and nationally representative sample from varied settings is the strength of our study. However, several limitations of the present study shall also be kept in mind. Firstly, there is no standard definition of insomnia in epidemiological research (Roth, 2007) and secondly, we did not consider the type, sternness, or persistence of insomnia in our analyses. Many studies have reported the association of insomnia with angina and depression. All the countries showed the significant association between insomnia and presence of angina (Grandner et al., 2012; Sivertsen et al., 2014) and depression (Roth, 2009). Except for S. Africa all three countries China, India, and Russia showed significant association with arthritis. Other studies (Power et al., 2005; Budhiraja et al., 2011) have also reported a similar relationship between sleep problems and arthritis. Many researchers around the world have reported the presence of chronic conditions like asthma (Budhiraja et al., 2011) and diabetes (Vgontas et al., 2009; Plantinga et al., 2012) alongside sleep disorders. However, we found the association of insomnia with diabetes and asthma only for India. Data from other studies have reported associations between sleep disturbance chronic lung disease (Ohayon, 2014; Budhiraja et al., 2011), but in our results, except for S. Africa, none of the countries showed an association of insomnia with lung disorders. Studies have globally documented the association between hypertension (Vgontas et al., 2009; Spiegelhalder et al., 2010) and obesity (Hargens et al., 2013; Cappuccio et al., 2008). However, unlike them, our study did not establish any significant association of insomnia to any of them. In the present study, angina, arthritis, and, depression was significantly associated with sleep problems in the majority or all of the countries. In line with the findings of Koyanagi et al. (2015), we found that in all the countries studied; insomnia had a highly significant association with the presence of four or more chronic conditions.

6 Our study suggests that insomnia is emerging as a major public health problem in BRICS countries. Older adults living in the countries studied, slept poorly, and the prevalence increased rapidly with aging. Earlier, it was believed that treating the comorbid chronic condition would relieve insomnia and improve sleep conditions. However, the growing number of research has suggested that insomnia is a growing global epidemic and should be given separate attention and treatment. Not only it hampers the day-to-day functioning but also increases the risk of other chronic disorders (Colten and Altevogt, 2006; Sivertsen et al., 2014). Currently, there is no specific treatment available for comorbid insomnia, but following healthy and active lifestyle along with relaxation techniques. Also, clinicians and health providers should be aware of the epidemiology of insomnia. Future studies are needed to explicate the best treatment options for sleep disorders and co-existing chronic conditions, especially in the developing country settings. V. REFERENCES 1. Jones BE. Basic mechanism of Sleep-Wake States. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 4th ed. Philadelphia: Saunders; pp Kupfer DJ, Reynolds CF., 3rd Management of Insomnia. New England Journal of Medicine. 1997;336: Smith MT, Perlis ML, Park A, et al. Comparative meta-analysis of pharmacotherapy and behavior therapy for persistent insomnia. American Journal of Psychiatry Jan 1;159(1): Ohayon MM. Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews May 31;6(2): Bonnet MH, Arand DL. We are chronically sleep deprived. Sleep Dec 1;18(10): Sutton DA, Moldofsky H, Badley EM. Insomnia and health problems in Canadians. Sleep Sep 1;24(6): Monane M. Insomnia in the elderly. Journal of Clinical Psychiatry Jun;53 Suppl: Newman AB, Enright PL, Manolio TA, et al. Sleep disturbance, psychosocial correlates, and cardiovascular disease in 5201 older adults: the Cardiovascular Health Study. Journal of the American Geriatrics Society Jan 1;45(1): Schubert CR, Cruickshanks KJ, Dalton DS, et al. Prevalence of sleep problems and quality of life in an older population. Sleep Dec 1;25(8): Reid KJ, Martinovich Z, Finkel S, et al. Sleep: a marker of physical and mental health in the elderly. American Journal of Geriatric Psychiatry Oct 31;14(10):860-6.

7 11. Hale L. Who has time to sleep? Journal of Public Health Mar 7;27(2): Ferrie JE, Shipley MJ, Akbaraly TN, et al. Change in sleep duration and cognitive function: findings from the Whitehall II Study. Sleep May 1;34(5): Stone KL, Blackwell TL, Ancoli Israel S, et al. Sleep disturbances and risk of falls in older community dwelling men: the outcomes of Sleep Disorders in Older Men (MrOS Sleep) Study. Journal of the American Geriatrics Society Feb 1;62(2): Neubauer DN. Current and new thinking in the management of comorbid insomnia. American Journal of Managed Care Feb;15:S Roth T. Comorbid insomnia: current directions and future challenges. American Journal of Managed Care Feb;15:S McCrae CS, Lichstein KL. Secondary insomnia: diagnostic challenges and intervention opportunities. Sleep Medicine Reviews Feb 28;5(1): Altevogt BM, Colten HR, editors. Sleep disorders and sleep deprivation: an unmet public health problem. Washington: National Academies Press; 2006 Oct Stranges S, Tigbe W, Gómez-Olivé FX, et al. Sleep problems: an emerging global epidemic? Findings from the indepth WHO-SAGE study among more than 40,000 older adults from 8 countries across Africa and Asia. Sleep Aug 1;35(8): Kinsella K, Wan H. An aging world: U.S. Census Bureau, International Population Reports, P95/09-1, Washington, DC: U.S. Government Printing Office, Beaglehole R, Bonita R, Horton R, et al. Priority actions for the non-communicable disease crisis. Lancet Apr 29;377(9775): Roth T. Insomnia: definition, prevalence, etiology, and consequences. Journal of Clinical Sleep Medicine Aug 15;3(5 Suppl):S Grandner MA, Jackson NJ, Pak VM, et al. Sleep disturbance is associated with cardiovascular and metabolic disorders. Journal of Sleep Research Aug 1;21(4): Sivertsen B, Lallukka T, Salo P, et al. Insomnia as a risk factor for ill health: results from the large population based prospective HUNT Study in Norway. Journal of Sleep Research Apr 1;23(2): Power JD, Perruccio AV, Badley EM. Pain as a mediator of sleep problems in arthritis and other chronic conditions. Arthritis Care & Research Dec 15;53(6): Budhiraja R, Roth T, Hudgel DW, et al. Prevalence and polysomnographic correlates of insomnia comorbid with medical disorders. Sleep Jul 1;34(7): Vgontzas AN, Liao D, Pejovic S, et al. Insomnia with objective short sleep duration is associated with type 2 diabetes. Diabetes Care Nov 1;32(11): Plantinga L, Rao MN, Schillinger D. Prevalence of self-reported sleep problems among people with diabetes in the United States, Preventing Chronic Disease. 2012;9: E76.

8 28. Ohayon MM. Chronic obstructive pulmonary disease and its association with sleep and mental disorders in the general population. Journal Of Psychiatric Research Jul 31;54: Spiegelhalder K, Scholtes C, Riemann D. The association between insomnia and cardiovascular diseases. Nature and Science of Sleep. 2010;2: Hargens TA, Kaleth AS, Edwards ES, et al. Association between sleep disorders, obesity, and exercise: a review. Nature and science of sleep. 2013;5: Cappuccio FP, Taggart FM, Kandala NB, et al. Meta-analysis of short sleep duration and obesity in children and adults. Sleep May 1;31(5): Koyanagi A, Garin N, Olaya B, et al. Chronic conditions and sleep problems among adults aged 50 years or over in nine countries: a multi-country study. PloS One Sep;10(9):e VI. TABLES Table 1. Country-wise distribution of study sample by various characteristics. Characteristics China India Russia S. Africa Age (years) Sex Female Male Education Primary or less Secondary Above secondary Married/Cohabiting Physical activity Low Moderate High Current smoker Current alcoholic

9 Table 2. Odds ratios from logistic regression assessing the association between chronic morbidities and insomnia among older adults in BRICS Countries. Chronic morbidities China India Russia S. Africa Angina 1.72** 1.92*** 2.50*** 2.20** Arthritis 1.37* 1.45** 1.96** 1.27 Asthma *** Chronic lung disease *** Depression 4.67*** 1.97*** 3.13*** 3.45* Diabetes ** Hypertension Obesity Stroke 2.15* 2.36*** Notes: *** p< 0.001; ** p< 0.01; * p< 0.05; Odds Ratio (95% Confidence Intervals). Table 3. Odds ratios from logistic regression assessing the association between number of chronic conditions and insomnia among older adults in BRICS Countries. Number Of chronic conditions China India Russia S. Africa * 2.86*** 5.07* *** 8.55** 3.01* *** 7.73*** 19.24*** 7.10*** Notes: *** p< 0.001; ** p< 0.01; * p< 0.05; Reference category

Study on sleep quality and associated psychosocial factors among elderly in a rural population of Kerala, India

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