Sleep Poverty in Caregivers of Individuals with Alzheimer’s Disease
Abstract
Nocturnal disturbance in care recipients with Alzheimer’s disease (AD) has been one of the most
difficult behaviors with which caregivers cope, resulting in decisions to transfer the AD patients to formal
care facilities (Pollak & Stokes, 1997). The purpose of this study was to investigate how sleep perceptions
of a sample of caregivers who take care of individuals with AD differs from a sample of non-caregivers
within the same age range. Convenience samples of 103 non-caregivers and 55 caregivers of individuals
with Alzheimer’s disease filled out sleep logs for seven consecutive days, and rated their sleepiness and
fatigue for that week. Caregivers described a significantly higher amount of time awake after sleep onset,
approximately half an hour more, than their non-caregiver counterparts (t(df=127) = -3.99, p<0.05). On
the whole, caregivers perceived themselves to be sleeping less, sleeping much more poorly, and staying
awake much longer with a greater number of nighttime awakenings. Using a simple sleep diary to assess
caregiver sleep may be a beneficial application to the nursing care process for this particular population of
care-providers.
Review of Literature
The informal (unpaid) caregiving of an individual with Alzheimer’s disease (AD) can involve a highly
strained 24-hour work shift, spanning years after the care recipient’s diagnosis. People suffering from AD
commonly exhibit changes in their sleep-wake cycle (Moran et al., 2005), with increases in time awake at
night (Ancoli-Israel, Klauber, Gillin, Campbell, & Hofstetter, 1994; Klein et al., 1999; Logsdon et al.,
1998; McCurry et al., 1999)and sleep propensity and napping during the day (McCurry et al.,
1999).Deficiency of caregiver sleep, or sleep poverty, suggests poor or interrupted patterns of sleep, not
only throughout the year but for the duration of years from diagnosis until the caregiver can leave the role.
This type of sleep deprivation may contribute to the mental strains and physiological pathologies that are
a part of the wear and tear of informal caregiving. The care recipient’s nocturnal disturbances often
require the caregiver’s aid and/or attention, such as help with toileting, or may involve unpredictable
behaviors like wandering (Flaskerud, Carter, & Lee, 2000; Pollak & Stokes, 1997). Because of cognitive
impairments and memory loss related to the disease, wandering may lead to potentially dangerous
situations in which the care recipient becomes lost (Rowe, 2003). Providing care for this population is
a complex matter involving emotional, physical, and mental stress (Haley, 1997; McConaghy &
Caltabiano, 2005).
Nocturnal disturbance in care recipients with AD has been one of the most difficult behaviors with
which caregivers cope, resulting in decisions to transfer the AD patients to formal care facilities (Pollak &
Stokes, 1997). The purpose of this study was to investigate how the sleep perception of a sample of
caregivers of individuals with AD differs from a sample of non-caregivers within the same age range. It
was hypothesized that the caregiver group would report significantly inferior daytime functioning (higher
sleepiness and fatigue scores) and sleep disturbances, with shorter total sleep time, lower sleep
efficiencies, greater number of wake bouts during the night and longer total wake time (including longer
sleep onset latency, wake after sleep onset, and snooze time) than the non-caregiver group.
Methods
Caregiver Sample
A convenience sample of 55 adult caregivers, aged 38 to 86 years old, was recruited through
advertisements via resources like local chapters of the Alzheimer’s Association and senior retirement
communities in the North Central Florida region. IRB approval was obtained through the University of
Florida, and those interested were screened for eligibility. All participants were primary informal
caregivers (spouses or adult children) of care recipients with AD, living in a home setting without
provisions for professional care at night. They had not been undergoing active treatment for sleep
disorders, such as taking prescription sleep medications nightly. They had also no cognitive impairments,
as assessed by a Mini-Mental Status Exam score greater than 27 (Folstein, Folstein, & McHugh, 1975).
Non-caregiver Sample
The normative group was a convenience sample of 103 adults residing in North Central Florida, also
aged 60 years or older, recruited through flyers, the media, and announcements by community groups.
IRB approval was obtained through the University of Florida, and those interested were screened for
eligibility. All lived in a home setting, and they had not been undergoing active treatment for sleep
disorders, such as taking prescription sleep medications nightly. Participants with cognitive impairments,
those scoring in the impaired range on three or more subtests of the Cognistat, were excluded from the
study (Mueller, Kiernan, & Langston, 2001).
Measures
Demographics. Demographic and health data was collected via a questionnaire consisting of items
about paticipants’ age, gender, race, and education. As shown in Table 1, the majority of participants
were females and white in both non-caregiver (64.1% and 96.1%, respectively) and caregivers (80% and
100%, respectively). Contrary to having no statistically significant difference in age (t(df=131) = 1.83,
p>0.05), in gender (χ2=2.692, p>0.05), or in race (χ2=1.201, p>0.05), statistical computations showed a
significant difference between the two groups in educational level (χ2=15.416, p<0.05). Most of the noncaregiver participants had 17 years or more of education (40.8%), but the majority of caregivers had some
college or technical education (51.1%). This may be a function of most non-caregivers living in a
university-based community.
Table 1.
Demographic Comparison of Non-Caregivers and Caregivers
Demographic Characteristic
Non-Caregiver
Age (M ± SD)
72.90 ± 6.86
Gender n(Valid %)
Female
66 (64.1)
Male
37 (35.9)
Race (Valid %)
White
99 (96.1)
African American
3 (2.9)
Other
1 (1)
Education
Less than 7 years
--Junior High School (7-9 years)
--Some High School (10-11 years)
4 (3.9)
High School Graduate (12 years)
12 (11.07)
Some college or technical (13-15 years)
21 (20.4)
College graduate (16 years)
24 (23.3)
Graduate School (17 or more years)
42 (40.8)
Caregiver
70.73 ± 7.55
t
1.83
χ2
2.692
df
131
1
p-value
0.07
0.101
1.201
2
0.548
15.416
4
0.004
24 (80)
8 (20)
30 (100)
----------6 (20)
15 (50.0)
5 (16.7)
4 (13.3)
Subjective sleep. Each morning upon awakening, participants completed a sleep diary (Lichstein,
Riedel, & Means, 1999), giving approximations of the following: bedtime; sleep onset latency; number of
wake bouts during the night; wake after sleep onset; final wake-up time; out of bed time; and sleep quality
on a 1-5 scale (1 = very poor, 2 = poor, 3 = fair, 4 = good, 5 = excellent). From the sleep diary entries, the
following sleep parameters were calculated: 1. time in bed, the time between bedtime and getting out of
bed; 2. snooze time, time between final wake-up time and getting out of bed; 3. total sleep time, time in
bed minus sleep onset latency, wake after sleep onset and snooze time; and 4. sleep efficiency, the
percentage of the time in bed that was spent asleep. A recent study concluded that sleep diaries
sufficiently measure sleep among caregivers of individuals with AD without the cost of actigraphy (Rowe,
M. A., Campbell, J., McCrae, C. S., & Pe Benito, A. J., unpublished raw data).
Daytime sleepiness. Based on their past week of sleep activity, the Epworth Sleepiness Scale (ESS;
Johns, 1991) was used to ask participants about their likeliness to doze off (1 = would never doze, 2 =
slight chance of dozing, 3 = moderate chance of dozing, and 4 = high chance of dozing) in eight daytime
situations, like sitting and reading, or watching TV. The totaled sum of the ratings can range from 8 to 32.
Lichstein et al. (2003) suggested that persons who score greater than 7.4 have excessive daytime
sleepiness. Among an adult sample, the ESS has presented sufficient reliability in quantifying daytime
sleepiness (Johns, 1992).
Daytime fatigue. To measure daytime tiredness, participants responded to the Fatigue Severity Scale
(FSS; Krupp, LaRocca, Muir-Nash, & Steinberg, 1989) by indicating their degree of agreement with 9
statements on a scale from 1 to 7 (1=strongly disagree to 7=strongly agree). Scores are averaged to render
a result between 1 and 7. Those who scored greater than or equal to 5.5 are considered to have excess
daytime fatigue (Lichstein, Durrence, Taylor, Bush, & Riedel, 2003). The FSS has been documented to
have adequate test-retest reliability and validity (Dittner, Wessely, & Brown, 2004).
Procedure
Both caregiver and non-caregiver participants completed sleep diaries upon awakening for seven
consecutive days. On the first day, they filled out demographic information, the ESS, and the FSS. Out of
the 55 caregiver participants, only those aged 60 years or older were included in the comparison analyses
to control for age (N=30).
Statistical Analysis. Descriptive statistics were done for the demographic and clinical variables. To
compare the two groups, Chi-square (c2) was done for the categorical data, and t-tests for the ages and
clinical variables.
Results
As illustrated in Table 2, non-caregivers sleep nearly a half-hour (M = 26.69 minutes) longer per night
than caregivers(t(df=127) = 2.11, p<0.05) (Table 2). The normative group had significantly higher sleep
efficiency than the caregiver group, t(df=127) = 3.80, p<0.05, indicating a greater percentage of time in
bed spent asleep. This is partially due to the fact that non-caregivers have significantly less time awake
after sleep onset (t(df=127) = -3.99, p<0.05) than their caregiver counterparts. However, the amount of
time in bed was not significantly different between the two groups (t(df=131) = -1.28, p>0.05). Noncaregiver participants scored their sleep quality significantly higher (M=3.60) than age-matched
caregivers (M=3.10), (t(df=131) = 4.10, p<0.05), and caregivers’ estimations of number of nighttime
awakenings (M=2.77) were significantly higher (t(df=19) = -3.99, p<0.05) than non-caregivers’ (M=2.19).
But there was no significant difference in sleep onset latency (t(df=131) = -1.06, p>0.05) and snooze time
(t(df=131) = -1.44, p>0.05).
Table 2.
Results of Daytime Functioning Variables and Sleep Parameters for Non-caregivers and Caregivers
Non-caregiver
Caregiver
Measure M
Mean
t
df
pSD
Range
M
SD
Range
Difference
value
ESS
8.05
3.36
0.0020.00
15.66
3.60
10.0027.00
-7.61
10.59
130
0.00
FSS
3.47
1.41
1.007.00
3.69
1.35
1.386.44
-0.22
-0.76
131
0.45
TST
414.37
59.74
170.00536.43
386.68
64.17
215.71480.00
26.69
2.11
127
0.04
SE
0.85
0.09
0.410.98
0.78
0.11
0.490.93
0.08
3.80
127
0.00
SOL
24.27
20.86
2.17132.86
28.80
20.21
5.7187.86
-4.53
-1.06
131
0.29
WASO
28.81
28.15
0.00137.14
53.38
33.99
10.00136.43
-24.57
-3.99
127
0.00
TIB
485.31
53.91
275.29572.14
499.80
56.40
415.71595.71
-14.49
-1.28
131
0.20
ST
22.39
27.64
0.00242.83
30.38
23.06
1.4389.29
-7.99
-1.44
131
0.15
SQ
3.60
0.57
1.715.00
3.10
0.64
1.864.29
0.50
4.10
131
0.00
NWB
2.19
1.15
0.002.77
1.40
0.33-0.58
-2.30 131 0.02
6.43
6.33
Note. ESS= Epworth Sleepiness Scale; FSS = Fatigue Severity Scale; TST = total sleep time; SE = sleep
efficiency; SOL = sleep onset latency; WASO = wake after sleep onset; TIB = time in bed; ST = snooze
time; SQ = sleep quality; NWB = number of wake bouts.
Discussion
On the whole, findings indicated that caregivers sleep less, their sleep is interrupted by more frequent
awakenings, and there is greater total time awake at night than for non-caregivers. Averaging about six
and a half hours of total reported sleep time, the caregiver group reported approximately a half hour less
sleep than the normative group. Shorter total sleep time and lower sleep efficiency among caregivers is in
line with past research findings (Willette-Murphy, Todero, & Yeaworth, 2006). Antithetical to the half
hour of lost sleep by the caregivers is approximately a half hour of logged wake after sleep onset, which
may be explained by the greater number of wake bouts during the night. Furthermore, poor sleep quality
ratings by caregivers is in accordance with the literature (Brummett et al., 2006; Carter & Acton, 2006;
McCurry, Vitiello, Gibbons, Logsdon, & Teri, 2006; Teel & Press, 1999).
Both normative and caregiver groups described the same amount of time falling asleep, the same time
getting up, and the same amount of time in bed. However, this emphasizes the ratio of time in bed to
wake after sleep onset, where the caregivers chronicle longer times awake during the night. Albeit sleep
onset latency, snooze time, and time in bed are the same, caregivers report longer wake after sleep onset
and more nighttimewake bouts. While the statistical insignificance of sleep onset latency, snooze time,
and time in bed was unexpected, it further highlights the extent of sleep deprivation in the caregiver
sample.
Caregiver hyper-arousal from care recipient nocturnal disturbances may be the cause of the higher
levels of sleep fragmentation, which may precipitate a high number of micro-arousals, or intrusions of
alpha waves designating wakefulness during non-REM sleep (Rowe, M. A., Campbell, J., McCrae, C. S.,
& Pe Benito, A. J., unpublished raw data). Health implications related to higher numbers of micro-arousal
include elevated levels of low density lipoproteins, cortisol and higher blood pressure (Ekstedt, Akerstedt,
& Soderstrom, 2004).
Although the variables that are statistically significant all describe inferior caregiver sleep and
increased caregiver daytime sleepiness, the other parameters that show no difference between the two
groups challenge past findings and present new questions. Why was there no significant difference in
fatigue, when higher fatigue scores have been related to lower total sleep time (Alapin et al., 2000)?
Additionally, research has presented evidence that because of the longer hours of attention toward another
individual, caregivers of care recipients with AD reported significantly more complaints of fatigue than
non-caregivers (Teel & Press, 1999).
Perhaps relating daytime functioning with sleep variables may explain the discrepancy. Tsukasaki et
al. (2006) found an association between time in bed, number of wake bouts, and fatigue in caregivers by
analyzing their data according to the type of sleep interruption made (voluntary or involuntary awakening,
or none at all). Though compared by different patterns of sleep interruptions and among different types of
caregivers instead of judging the data against caregivers of persons with AD with non-caregivers, their
findings pointed out that the type of number of wake bouts reflected degree of total wake time and fatigue
(Tsukasaki et al., 2006). Higher fatigue ratings, shorter total sleep time, and more time for giving
attention to the care recipient have been related to involuntary awakening for providing care (Tsukasaki et
al., 2006).
Since poorer psychological and physical health on the part of the caregiver has been correlated with
higher levels of the care recipient’s behavioral disturbances (Baumgarten et al., 1994; Hooker et al., 2002;
Lowery et al., 2000), perhaps the type of care and the amount of caregivers’ stress may be a better
measure of nighttime and daytime parameters. Those who have been providing care for a longer period of
time may have adapted to the caregiver stressors and documented fewer sleep complaints because of the
lifestyle to which they have grown accustom (Flaskerud, Carter, & Lee, 2000). Another limitation
concerns the demographics of this study. The group of caregivers may express poorer subjective sleep,
but they are all females, who have been documented to express more sleep complaints than men (Ohayon,
2002). The total duration of caregiving may need to be taken in account also, including specific types of
awakenings and total period of caregiving (instead of only counts of wake bouts) to clarify the
relationship between fatigue and sleep in this particular population of caregivers. The seven-day study
period also provides a narrow representation of caregiver sleep for comparison, thus longer study periods
in future caregiver sleep research are needed.
Conclusion
Sleep deprivation may not necessarily affect the caregiver alone. Particular stressors associated with
the caregiver role may also result in neglect, abuse, abandonment or institutionalization (Coyne,
Reichman, & Berbig, 1993; Nash, 1992). Sleep poverty or sleep deprivation resulting from interrupted
sleep patterns for the duration of years from diagnosis until the caregiver can leave the role, may
contribute to the mental strains and physiological pathologies that are a part of the wear and tear of
informal caregiving. More attention must be given to this population, for their latent impact in society
will become apparent in the near future. As life expectancy increases, so does the percentage of those
diagnosed with AD, as well as the need for those to care for them (Eisdorfer, 1991). In 2000, there were
about 4.5 million Americans with AD, and it was predicted that by 2050, 13.2 million Americans will
have this progressive neurodegenerative disease (Prigerson, 2003). Increased awareness of caregivers’
plight may pave the way for political changes that can provide more support for caregivers of individuals
with dementia. Further, using a simple sleep diary to assess caregiver sleep may be a beneficial
application of nursing care for this particular population of care providers. By mitigating stressors such as
insufficient sleep, caregivers’ coping abilities may improve, helping them continue to provide care.
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