Depressive symptoms moderate the relationship between sleep quality and cognitive

functions among the elderly

Junhong YU*1,, Iris Rawtaer1, Rathi Mahendran1,2, Simon L Collinson3, Ee-Heok Kua1,2, Lei FENG*2

Department of Psychological Medicine, National University Hospital, Singapore

Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of

Singapore
3

Department of Psychology, National University of Singapore

*Correspondence to be directed to:

Mr. Junhong Yu, Institute of Clinical Neuropsychology, Room 309, 3/F, The Hong Kong Jockey Club
Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong. Email:
gerardyu87@gmail.com
Or
Dr. Lei Feng, Department of Psychological Medicine, National University of Singapore, NUHS Tower
Block, 1E Kent Ridge Road, Singapore 119228, Singapore.
Email: pcmfl@nus.edu.sg
Acknowledgments
The authors would like to thank Fadzillah Nur d/o Mohd Abdullah for her kind assistance in preparing the
data. This research was supported by the Virtual Institute for the Study of Aging, National University of
Singapore (grant number VG-8); the Alice Lim Memorial Fund, Singapore (Alice Lim Award 2010); the
Training and Research Academy at Jurong Point (TaRA@JP), Singapore; the Lee Kim Tah Holdings Ltd.,
Singapore; the Kwan Im Thong Hood Cho Temple, Singapore; and the Presbyterian Community Services,
Singapore

Accepted for publication in Journal of Clinical and Experimental Neuropsychology

on 7th June 2016

ABSTRACT
Objective: The co-occurrence of sleep problems, cognitive impairment and depression among the
elderly suggest that these three conditions are likely to be interrelated. Recent findings suggest
depressive symptoms moderate the relationship between sleep problems and cognitive
impairment in elderly people but methodological problems have led to inconsistent conclusions.
The present study aims to better understand the relationship between sleep quality, depressive
symptoms and cognitive function. Method: We administered the Repeatable Battery for the
Assessment of Neuropsychological Status and self-report measures of sleep quality and
depression to 380 elderly participants (Mage =68, SD=5.7). Bootstrapped moderation analyses
were conducted to examine the role of depressive symptoms in the relationship between sleep
and various aspects of cognitive function. Results: This moderation effect was significant in the
domains of delayed memory (R2 = .01, F = 4.5, p =.04), language (R2 = .01, F = 4.6, p =.035)
and general cognitive status (R2 = .01, F = 5.3, p =.02). However, unlike previous studies,
higher sleep quality corresponded to better outcomes in delayed memory, language abilities and
general cognitive status in participants with low levels of depressive symptoms. No significant
relationship between sleep quality and any cognitive function was observed among participants
with high levels of depressive symptoms. Conclusions: Among individuals who reported low
levels of depressive symptoms, sleep quality was positively related to cognitive performance in
the domains of delayed recall, language, and general cognitive status. However, sleep quality
was not significantly associated with cognitive abilities in these domains among participants with
elevated levels of depressive symptoms; participants had relatively poor outcomes in these
cognitive domains regardless of their sleep quality.
Keywords: sleep problems, cognitive impairment, cognitive function, elderly, depression

INTRODUCTION
Sleep problems are common among the elderly; as much as 77% of the elderly population were
reported to be poor sleepers (Lo & Lee, 2012). Explanations for this phenomenon include
changes in sleep architecture as a result of the aging process, such as decreased proportion of
rapid eye movement sleep and sleep efficiency and increased sleep latency (Ohayon, 2004).
These changes when combined with the health problems commonly associated with old age,
result in frequent sleep problems observed among the elderly (Ancoli-Israel, Ayalon, & Salzman,
2008).
Sleep problems are implicated in many mental health-related outcomes in the elderly
populations. For instance, longitudinal evidence shows that sleep problems, among other noncognitive psychopathological symptoms, significantly predict mild cognitive impairment (MCI)
in the elderly. Furthermore, these sleep problems have the highest odd ratio among all other
symptoms in predicting MCI (Lobo et al., 2008). Associations have been reported between sleep
problems and multiple neurocognitive domains (Blackwell et al., 2011; Tworoger, Lee,
Schernhammer, & Grodstein, 2006), although most studies in this area have focused on
executive functions (Bastien et al., 2003; Lambiase, Gabriel, Kuller, & Matthews, 2014; Nebes,
Buysse, Halligan, Houck, & Monk, 2009) and memory (Mazzoni et al., 1999; Westerberg et al.,
2012; Xu et al., 2011, 2014). Nevertheless, a number of studies have reported negative findings
in these cognitive domains (Schmutte et al., 2007; Vignola, Lamoureux, Bastien, & Morin, 2000)
and so the relationship between sleep and cognition in the elderly remains unclear.
Sleep problems are also commonly related to depression among the elderly (Chang et al.,
2014; Paudel et al., 2008; Yu et al., 2016). This relationship may be bidirectional as sleep

problems may both precede (Baglioni et al., 2011) and occur as a consequence of depression
(Costa, Carvalho, & Fernandes, 2013). Furthermore, the prevalence of sleep problems among the
elderly is at least three times higher among depressed, relative to non-depressed individuals
(Roberts, Shema, Kaplan, & Strawbridge, 2000). This link between sleep and depression, taken
together with the fact that depression can also lead to cognitive deficits (Jorm, 2001) suggests
that sleep problems, cognitive impairment and depression tend to co-occur together and are interrelated (Guarnieri & Sorbi, 2015). This is supported by the observation that MCI subjects,
relative to controls, are more likely to report higher levels of sleep problems (Dlugaj et al., 2014)
and depression (Panza et al., 2010). Individuals with insomnia, relative to controls, were also
found to have significantly lower scores on measures of general cognition, semantic fluency and
auditory-verbal learning, and also report significantly higher levels of depressive symptoms
(Naismith et al., 2009).
Nevertheless, such findings may not fully characterize the relationship between sleep,
cognition and depression. A study by Sutter, Zllig, Allemand and Martin (2012) revealed a
more complex relationship between these three variables. They showed depressive symptoms
had a moderating influence on the relationship between sleep quality and performance in certain
cognitive domains. Specifically, in individuals who reported high levels of depressive symptoms,
performance on executive functions tests was positively related to self-reported sleep quality. In
contrast, no significant relationship between sleep and executive functions was found in those
who reported low levels of depressive symptoms. Sutter et al.s results were largely restricted to
the executive domain; negative findings were reported in the memory and inhibition domains.
These findings, though preliminary in nature, suggests the possibility that individual differences
in levels of depressive symptoms may account for some of the inconsistent findings on the

relationship between sleep and cognition, especially since that most of such studies had not
accounted for the possible depression interaction effects. Furthermore, other methodological
issues, such as the failure to control for other confounding factors such as gender and education
levels (Sutter et al., 2012) and the use of a relatively small sample (Bastien et al., 2003; Mazzoni
et al., 1999; Vignola et al., 2000; Westerberg et al., 2012) or a sample that consist of only males
or females(Blackwell et al., 2011; Lambiase et al., 2014; Tworoger et al., 2006), may have also
led to inconsistent results. Taken together, there is a need to relook at the relationship between
sleep and cognition, while taking into account of the possible moderation effect of depression.
For the present study, depression was operationalized in terms of depressive symptoms
among individuals who are not clinically diagnosed with depression; our participants are
recruited from the community rather than from clinical settings. Furthermore, participants who
have any previous or pre-existing clinical diagnoses of depression were excluded from this study.
The present study aims to clarify the relationship between sleep, depressive symptoms
and cognition. Using a large sample, and the Repeatable Battery for the Assessment of
Neuropsychological Status (RBANS) to assess specialized/narrowly-defined domains of
cognitive functioning, we examined a moderation model similar to that of Sutter et al. Based on
their findings, we hypothesized that depressive symptoms would have a moderating effect on the
relationship between sleep quality and neuropsychological tests scores, or at least in those that
relate to executive functions. Specifically, we predicted that poor sleep quality would be related
to low level cognitive function among participants with high levels of depressive symptoms ,
whereas among participants with low levels of depressive symptoms, we do not expect a
significant relationship between sleep quality and cognitive function.

METHODS
Participants and procedures
The studys sample came from the Aging in a Community Environment Study (ACES). The
inclusion criteria were: 1) aged 60 years and 2) residing within geographically defined districts
in Jurong (a western part of Singapore). Recruitment of elderly participants in the ACES was
carried out via door to door visits by nurses. Interested participants were subsequently invited to
a community research center where written informed consent was obtained from them and
trained research nurses would administer the RBANS, GDS, PSQI and a demographics
questionnaire to the participants. These nurses were present the entire time during the
administration of the questionnaires to provide assistance or clarifications to the participants if
they needed any. The ACES was approved by a universitys Institutional Review Board. Each
participant was assigned a unique code number for identification; no personal identifiers were
used in the data entry.
Measures
A local adaptation (Collinson, Fang, Lim, Feng, & Ng, 2014; Lim, Collinson, Feng, & Ng, 2010)
of the RBANS (Randolph, 1998) was administered to the participants. The RBANS took
approximately 30 minutes to administer and consisted of 12 subtests that assessed cognitive
functions in the domains of Immediate Memory, Delayed Memory, Language, Attention and
Visuospatial/Construction. Index scores for each of these domains were derived from their
respective subtests scores via age-specific norms. The Total scale index- a measure of overall
cognitive functioning, was then computed by summing up the five index scores. The local
adaptation is largely similar to the original RBANS with the exception that a few certain

culturally foreign items were replaced with a local equivalent. The RBANS had demonstrated
good test-retest reliability (rTotal scale index = .80) and convergent validity (r=.61 correlation with a
formal neuropsychological battery) in the local population (Dong et al., 2013).
The 15-item version (Sheikh & Yesavage, 1986) of the Geriatric Depression Scale (GDS)
was used to index the level of depressive symptoms. This scale consisted of 15 yes/no questions,
each worth a point, giving a maximum total score of 15. This version of the GDS had
demonstrated good psychometric validity in the local context (Nyunt, Fones, Niti, & Ng, 2009)
and had been used in several Asian cohorts (Feng et al., 2013; Liang Feng, Nyunt, Feng, Yap, &
Ng, 2014). The Pittsburgh Sleep Quality Index (PSQI; Buysse et al. 1989) was used to assess
sleep quality. This index consisted of 19 items that assessed sleep duration, latency, disturbance,
efficiency and quality, daytime dysfunction and use of sleep medications. Each of these
components was scored from 0 to 3, and a global score was obtained by adding up the
components scores. This global score was used as the measure of sleep quality in the present
study. The PSQI had demonstrated good psychometric properties in a similar Asian population
(Tsai et al., 2005). For both of these questionnaires, higher scores corresponded to worse
outcomes.
Statistical Analysis
To test for the moderating effects of depression, we used bootstrapped regression analyses
(Hayes, 2013) as implemented in the Statistical Package for the Social Sciences (SPSS) macro of
Hayes (2012). Bootstrapping is a non-parametric approach to estimating effect-sizes and testing
hypotheses; it makes no inherent assumptions on the distribution of the data (Preacher, Rucker,
& Hayes, 2007). Separate models with each of the index scores as the outcome variables were

analyzed. In these models, PSQI was entered as the predictor and GDS scores as the moderator.
Additionally, gender and years of education were included as covariates. Age was not included
as a covariate because it was already accounted for when the index scores were derived via agespecific norms. Bootstrapping was carried out using a bias-corrected approach with 5000
samples. Statistical significance was set at p < .05. All analyses were carried out using the SPSS
(version 22) software.

RESULTS
Participants demographic characteristics
In the current study, after excluding participants (N=15) who had pre-existing or previous
neurological conditions (which includes dementia) and those with a pre-existing or previous
diagnosis of depression (N=7), a total of 373 (99 males and 274 females) participants were
included the current analyses. They were predominantly Chinese (362 Chinese, 7 of other Asian
ethnicities and 4 prefer not to disclose their ethnicity). The mean age of these participants was 68
years (SD = 5.7) and their age ranged from 60 to 89 years. They had approximately an average of
5.9 years of education (SD = 4.4) and their years of education ranged from 0 to 22 years. Most of
the participants were married (N= 253), the rest were widowed (N= 83), divorced/separated (N=
21) or single (N= 14). Two participants did not want to disclose their marital status. The majority
of the participants were retired (N= 204) or housewives (N= 104), the rest (N= 62) were
employed in full-time or part-time jobs. Three participants did not want to disclose their
employment status. These participants reported a number of different medical conditions in the
demographics questionnaire, the most common included high cholesterol (N =189), high blood
pressure (N =187) and cataracts/glaucoma (N =132).

INSERT TABLE 1 AND FIGURE 1 HERE

Descriptive statistics
The participants have a mean GDS score of 1.7 (SD = 1.7) and mean PSQI score of 4.3 (SD =
3.4). Their mean scores on the RBANS immediate memory, visuospatial/construction, language,
attention and delayed memory indices were 104 (SD = 18.4), 102 (SD = 15.6), 94 (SD = 7.2),
102 (SD = 15.3) and 109 (SD = 14.6) respectively. They have a mean RBANS Total scale score
of 512 (SD = 50.7).
Total scale index
The predictors for the total scale index scores accounted for 17% of the variance and the overall
regression equation for Total scale was significant; F(5, 341) = 13.6, p <.001. All the predictors
except gender significantly predicted Total scale scores. GDS and PSQI scores were negatively,
and years of education were positively related to Total scale scores (see Table 1). Additionally,
the interaction term of GDS*PSQI yielded significance; R2 = .01, F(1, 341) = 5.3, p =.022. The
conditional effects of GDS scores on Total scale scores (see figure 1) revealed that among low
GDS scorers, PSQI scores were negatively related to Total scale scores; t = -2.54, B = -2.7, p
=.012. However, PSQI scores were unrelated to Total scale scores among high GDS scorers,
p > .05.
Language index
The overall regression equation was significant for the language index and the predictors
explained 7% of the variance; F(5, 354) = 5.1, p <.001. All of the predictors except gender
scores were significantly related to language Index scores. PSQI scores were negatively

correlated to, whereas years of education was positively correlated to language index scores (see
Table 1). The interaction between GDS and PSQI scores was significant R2 = .01, F(1, 354) =
4.6, p =.035. The conditional effects of GDS scores on the language scores (see figure 1)
showed that PSQI scores were negatively associated with language scores among low GDS
scorers ; t = -2.9, B = -.45, p =.005. However, there was not a significant association between
these two variables among high GDS scorers, p> .05.
Delayed memory index
The overall regression equation for the delayed memory index was significant and the predictors
explained 6% of the variance; F(5, 349) = 5.0, p <.001. All of the predictors were significantly
related to Delayed Memory Index scores. PSQI and GDS scores were negatively related to,
whereas years of education was positively related to Delayed memory index scores (see Table 1).
The interaction between GDS and PSQI scores reached significance R2 = .01, F(1, 349) = 4.5, p
=.035. The conditional effects of GDS scores on the Delayed Memory Index scores (see figure 1)
showed that PSQI scores were negatively associated with Delayed Memory Index scores among
low GDS scorers ; t = -2.3, B = -.74, p =.023. However, there was not a significant association
between these two variables among high GDS scorers, p> .05.
INSERT TABLE 2 HERE
Other indices
The overall regression equations in the other three indices (i.e., immediate memory,
visuospatial/construction, and attention) were also significant; 3.2 F 18.3, all ps .008. Years
of education were significantly and positively related to these index scores. The interaction

between GDS and PSQI scores was not significant in any of the regression equations for these
three index scores (see Table 2).

DISCUSSION
We sought to investigate the potential moderating effect of depression in the relationship
between subjective sleep quality and cognition. Among participants with low levels of
depression, the results showed that poorer sleep quality corresponded to poorer cognitive
abilities in terms of delayed recall, language abilities and general cognition. In contrast, among
those with high levels of depression, sleep quality was unrelated to any of the RBANS indices.
These findings suggest that poor sleep quality was associated with cognitive impairment in
certain cognitive domains. However, this relationship between sleep quality and cognitive status
was not observed when elevated levels of depressive symptoms were present.
These present findings have yet to be documented in the literature and are substantially
different from those of earlier studies. Sutter et al. previously reported a moderation effect of
depressive symptoms on the relationship between subjective sleep quality and cognition,
specifically in the domain of executive functions. In the present study, we found moderation
effects in delayed recall, general cognition and language domains. However, the direction of
these moderation effects was different as compared to Sutter et al.s study. Sleep quality was
only significantly related to cognitive functioning among the participants with high levels of
depressive symptoms in their study; we found the opposite- sleep quality was significantly
related to cognitive functioning among participants with low levels of depressive symptoms.
Such differences may stem from variations in methodology and sample characteristics. Firstly,
the cognitive domains examined in Sutter et al.s study could not be perfectly mapped on to

those examined in the present study; these domains may not be directly comparable between
studies. For instance, Sutter et al.s operationalization of executive function was derived via
reducing tests scores of the digit symbol substitution, verbal fluency and reasoning, and trail
making tests into a single factor. While participants were administered the verbal fluency test in
the current study, these test scores were combined with those of the picture naming tests to form
a composite language index. Furthermore, Sutter et al. reduced immediate recall, delayed recall
and recognition test scores into a single memory factor, whereas the RBANS which was used
in the present study had separate domains for immediate and delayed recall. In general, the
cognitive domains assessed in the current study were more specialized/narrowly defined. This,
taken together with the control for gender and education by including them as covariates and a
bigger sample may have enabled greater sensitivity to pick up significant effects. In addition to
these methodological differences, differences in education levels could also account for the
inconsistent findings. For example, Western studies such as Sutter et al., tend to have samples
with higher mean education levels than Asian studies (Collinson et al., 2014) which may result in
greater cognitive reserve to buffer against the detrimental effects of depression on cognition
(Butters et al., 2000). Such a relationship may not exist in those with high levels of depression
who show low levels of cognitive functioning regardless of their sleep quality.
A few other significant results were observed relating to subjective sleep quality and
cognitive functioning. Firstly, sleep quality significantly predicted delayed recall ability, but not
immediate recall. While it is generally known that sleep plays an important role in memory
consolidation (Stickgold, 2005), the current report is perhaps the first to note a dissociation
between immediate and delayed memory in relation to sleep quality. Such a preliminary finding
awaits further replication. Secondly, subjective sleep quality was also a significant predictor of

language-related functions that were assessed via semantic fluency and picture naming tests in
the RBANS. This is largely consistent with reports suggesting an association between sleep
problems and language-related functions (Ferrie et al., 2011; Naismith et al., 2009). Functional
neuroimaging studies have shown that these tests elicited task-related activity in the frontal lobe,
specifically in the lateral inferior frontal gyrus (Birn et al., 2010; Kan & Thompson-Schill, 2004)
in line with the frontal lobe hypothesis of sleep and cognition, which predicts impaired frontal
lobe functioning following sleep deprivation (Jones & Harrison, 2001). It should be noted from
the size of the coefficients that a drop in sleep quality was related to a smaller decrease in
language index scores, relative to the other index scores. This may be due to the fact that
language functions, relative to the other cognitive functions, are usually more resilient to
impairments in the elderly (Wingfield & Grossman, 2006).
These findings are subjected to a number of limitations. Firstly, there is a lack of
objective sleep measurements, such as polysomnography, to corroborate subjective reports of
sleep quality. Secondly, the RBANS which was used in the current study does not have a varied
selection of tests that assess executive function adequately. Other important cognitive abilities
that relate to executive functions such as set-shifting, decision making and sequencing were not
assessed. Thirdly, this is a cross-sectional study, hence no causal inferences can be made. Next,
there might be some concerns relating to the generalizability of the present findings in the
clinical context since the current report studied depressive symptoms in a non-clinical population
instead of actual clinically depressed patients. Fourthly, participants responses on the
questionnaires may be subjected to social desirability biases. As a result, they may downplay
their level of sleep-related problems and depressive symptoms. Finally, the amount of variance
explained by the predictors appeared to be relatively small. We believe this might be due to the

fact that medical conditions and medications which could potentially influence sleep problems
and cognition in our participants were not accounted for in the analyses. These factors were not
included in the regression equations due the practical limitations/difficulties of accounting for
medical conditions (i.e., different types, number of and severity) and medications (i.e. different
types, number of and dosage) in a systematic manner.
In conclusion, the findings of the current report revealed a complicated relationship
between subjective sleep quality, depressive symptoms and cognitive status. Among individuals
who reported low levels of depressive symptoms, there exists a significant positive relationship
between sleep quality and cognitive performance in the domains of delayed recall, language, and
general cognitive status. However, no such association was observed among participants with
elevated levels of depressive symptoms; in general, participants had relatively poor outcomes in
these cognitive domains regardless of their sleep quality. Consequently, these findings
highlighted the need to address both sleep problems and depressive symptoms in the elderly
population to better cognitive outcomes, especially since previous longitudinal research have
emphasized the importance of managing depression (Jorm, 2001) and sleep problems (Lim,
Kowgier, Yu, Buchman, & Bennett, 2013) to prevent further cognitive decline.

DISCLOSURE STATEMENT
The authors declare that there is no conflict of interests regarding the publication of this paper

REFERENCES
Ancoli-Israel, S., Ayalon, L., & Salzman, C. (2008). Sleep in the elderly: normal variations and
common sleep disorders. Harvard Review of Psychiatry, 16(5), 27986.
doi:10.1080/10673220802432210
Baglioni, C., Battagliese, G., Feige, B., Spiegelhalder, K., Nissen, C., Voderholzer, U.,
Riemann, D. (2011). Insomnia as a predictor of depression: A meta-analytic evaluation of
longitudinal epidemiological studies. Journal of Affective Disorders, 135(1-3), 1019.

doi:10.1016/j.jad.2011.01.011
Bastien, C. H., Fortier-Brochu, E., Rioux, I., LeBlanc, M., Daley, M., & Morin, C. M. (2003).
Cognitive performance and sleep quality in the elderly suffering from chronic insomnia.
Relationship between objective and subjective measures. Journal of Psychosomatic
Research, 54(1), 3949. doi:10.1016/S0022-3999(02)00544-5
Birn, R. M., Kenworthy, L., Case, L., Caravella, R., Jones, T. B., Bandettini, P. A., & Martin, A.
(2010). Neural systems supporting lexical search guided by letter and semantic category
cues: a self-paced overt response fMRI study of verbal fluency. NeuroImage, 49(1), 1099
107. doi:10.1016/j.neuroimage.2009.07.036
Blackwell, T., Yaffe, K., Ancoli-Israel, S., Redline, S., Ensrud, K. E., Stefanick, M. L., Stone,
K. L. (2011). Association of Sleep Characteristics and Cognition in Older CommunityDwelling Men: the MrOS Sleep Study. Sleep. doi:10.5665/sleep.1276
Butters, M. A., Becker, J. T., Nebes, R. D., Zmuda, M. D., Mulsant, B. H., Pollock, B. G., &
Reynolds, C. F. (2000). Changes in Cognitive Functioning Following Treatment of LateLife Depression. American Journal of Psychiatry, 157(12), 19491954.
doi:10.1176/appi.ajp.157.12.1949
Buysse, D., III, C. R., & Monk, T. (1989). The Pittsburgh Sleep Quality Index: a new instrument
for psychiatric practice and research. Psychiatry Research, 28(2), 193213. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/2748771
Chang, K. J., Son, S. J., Lee, Y., Back, J. H., Lee, K. S., Lee, S. J., Hong, C. H. (2014).
Perceived sleep quality is associated with depression in a Korean elderly population.
Archives of Gerontology and Geriatrics, 59(2), 46873. doi:10.1016/j.archger.2014.04.007
Collinson, S. L., Fang, S. H., Lim, M.-L., Feng, L., & Ng, T.-P. (2014). Normative Data for the
Repeatable Battery for the Assessment of Neuropsychological Status in Elderly Chinese.
Archives of Clinical Neuropsychology, 29(5), 442455. doi:10.1093/arclin/acu023
Costa, I., Carvalho, H., & Fernandes, L. (2013). Aging, circadian rhythms and depressive
disorders: a review. American Journal of Neurodegenerative Disease, 29(2), 228246.
Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3852564/
Dlugaj, M., Weinreich, G., Weimar, C., Stang, A., Dragano, N., Wessendorf, T. E., Jckel,
K.-H. (2014). Sleep-Disordered Breathing, Sleep Quality, and Mild Cognitive Impairment
in the General Population. Journal of Alzheimers Disease: JAD, 41, 479497.
doi:10.3233/JAD-132132
Dong, Y., Thompson, C. L., Huey Joanne Tan, S., Ben Swie Lim, L., Pang, W., & Li-Hsian
Chen, C. (2013). Test-Retest Reliability, Convergent Validity and Practice Effects of the
RBANS in a Memory Clinic Setting: A Pilot Study. Open Journal of Medical Psychology,
02(04), 1116. doi:10.4236/ojmp.2013.24B003
Feng, L., Nyunt, M. S. Z., Feng, L., Yap, K. B., & Ng, T. P. (2014). Frailty predicts new and
persistent depressive symptoms among community-dwelling older adults: Findings from
singapore longitudinal aging study. Journal of the American Medical Directors Association,
15(1), 76.e776.e12. doi:10.1016/j.jamda.2013.10.001

Feng, L., Yan, Z., Sun, B., Cai, C., Jiang, H., Kua, E.-H., Qiu, C. (2013). Tea consumption
and depressive symptoms in older people in rural China. Journal of the American Geriatrics
Society, 61(11), 19431947. doi:10.1111/jgs.12496
Ferrie, J. E., Shipley, M. J., Akbaraly, T. N., Marmot, M. G., Kivimki, M., & Singh-Manoux, A.
(2011). Change in Sleep Duration and Cognitive Function: Findings from the Whitehall II
Study. Sleep, 34(5), 565573. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079935/
Guarnieri, B., & Sorbi, S. (2015). Sleep and Cognitive Decline: A Strong Bidirectional
Relationship. It Is Time for Specific Recommendations on Routine Assessment and the
Management of Sleep Disorders in Patients with Mild Cognitive Impairment and Dementia.
European Neurology, 74(1-2), 4348. Retrieved from
http://www.karger.com/DOI/10.1159/000434629
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation,
moderation, and conditional process modeling [White paper]. Retrieved from
http://www.afhayes.com/
Hayes, A. F. (2013). Introduction to Mediation, Moderation, and Conditional Process Analysis A
Regression-Based Approach. New York: Guilford Press.
Jones, K., & Harrison, Y. (2001). Frontal lobe function, sleep loss and fragmented sleep. Sleep
Medicine Reviews, 5(6), 463475. doi:10.1053/smrv.2001.0203
Jorm, A. F. (2001). History of Depression as a Risk Factor for Dementia: An Updated Review.
Australian and New Zealand Journal of Psychiatry , 35 (6 ), 776781. doi:10.1046/j.14401614.2001.00967.x
Kan, I. P., & Thompson-Schill, S. L. (2004). Effect of name agreement on prefrontal activity
during overt and covert picture naming. Cognitive, Affective, & Behavioral Neuroscience,
4(1), 4357. doi:10.3758/CABN.4.1.43
Lambiase, M. J., Gabriel, K. P., Kuller, L. H., & Matthews, K. a. (2014). Sleep and Executive
Function in Older Women: The Moderating Effect of Physical Activity. The Journals of
Gerontology. Series A, Biological Sciences and Medical Sciences, 69(9), 11701176.
doi:10.1093/gerona/glu038
Lim, A. S. P., Kowgier, M., Yu, L., Buchman, A. S., & Bennett, D. A. (2013). Sleep
Fragmentation and the Risk of Incident Alzheimers Disease and Cognitive Decline in
Older Persons. Sleep, 36(7), 10271032. doi:10.5665/sleep.2802
Lim, M.-L., Collinson, S. L., Feng, L., & Ng, T.-P. (2010). Cross-cultural application of the
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS):
performances of elderly Chinese Singaporeans. The Clinical Neuropsychologist, 24(5),
811826. doi:10.1080/13854046.2010.490789
Lo, C. M., & Lee, P. H. (2012). Prevalence and impacts of poor sleep on quality of life and
associated factors of good sleepers in a sample of older Chinese adults. Health and Quality
of Life Outcomes, 10(1), 72. doi:10.1186/1477-7525-10-72
Lobo, A., LPez-Antn, R., De-La-Cmara, C., Quintanilla, M., Campayo, A., & Saz, P. (2008).

Non-cognitive psychopathological symptoms associated with incident mild cognitive

impairment and dementia, alzheimers type. Neurotoxicity Research, 14(2-3), 263272.
doi:10.1007/BF03033815
Mazzoni, G., Gori, S., Formicola, G., Gneri, C., Massetani, R., Murri, L., & Salzarulo, P. (1999).
Word recall correlates with sleep cycles in elderly subjects. Journal of Sleep Research, 8(3),
185188. doi:10.1046/j.1365-2869.1999.00154.x
Naismith, S. L., Norrie, L., Lewis, S. J., Rogers, N. L., Scott, E. M., & Hickie, I. B. (2009). Does
sleep disturbance mediate neuropsychological functioning in older people with depression?
Journal of Affective Disorders, 116(1-2), 139143. doi:10.1016/j.jad.2008.11.017
Nebes, R. D., Buysse, D. J., Halligan, E. M., Houck, P. R., & Monk, T. H. (2009). Self-Reported
Sleep Quality Predicts Poor Cognitive Performance in Healthy Older Adults. The Journals
of Gerontology Series B: Psychological Sciences and Social Sciences , 64B (2 ), 180187.
doi:10.1093/geronb/gbn037
Nyunt, M. S. Z., Fones, C., Niti, M., & Ng, T.-P. (2009). Criterion-based validity and reliability
of the Geriatric Depression Screening Scale (GDS-15) in a large validation sample of
community-living Asian older adults. Aging & Mental Health, 13(3), 376382.
doi:10.1080/13607860902861027
Ohayon, M. M. (2004). Meta-analysis of quantitative sleep parameters from childhood to old age
in healthy individuals: developing normative sleep values across the human lifespan. Sleep,
27(7), 12551273.
Panza, F., Frisardi, V., Capurso, C., DIntrono, A., Colacicco, A. M., Imbimbo, B. P.,
Solfrizzi, V. (2010). Late-life depression, mild cognitive impairment, and dementia:
possible continuum? The American Journal of Geriatric Psychiatry: Official Journal of the
American Association for Geriatric Psychiatry, 18(2), 98116.
doi:10.1097/JGP.0b013e3181b0fa13
Paudel, M. L., Taylor, B. C., Diem, S. J., Stone, K. L., Ancoli-Israel, S., Redline, S., Group,
for the O. F. in M. S. (2008). Association Between Depressive Symptoms and Sleep
Disturbances in Community-Dwelling Older Men. Journal of the American Geriatrics
Society, 56(7), 12281235. doi:10.1111/j.1532-5415.2008.01753.x
Preacher, K. J., Rucker, D. D., & Hayes, A. F. (2007). Addressing Moderated Mediation
Hypotheses: Theory, Methods, and Prescriptions. Multivariate Behavioral Research, 42(1),
185227. doi:10.1080/00273170701341316
Randolph, C. (1998). Repeatable Battery for the Assessment of Neuropsychological Status,
manual. San Antonio, TX: Psychological Corporation.
Roberts, R. E., Shema, S. J., Kaplan, G. A., & Strawbridge, W. J. (2000). Sleep complaints and
depression in an aging cohort: A prospective perspective. The American Journal of
Psychiatry, 157(1), 818. doi:10.1176/ajp.157.1.81
Schmutte, T., Harris, S., Levin, R., Zweig, R., Katz, M., & Lipton, R. (2007). The Relation
Between Cognitive Functioning and Self-Reported Sleep Complaints in Nondemented
Older Adults: Results From the Bronx Aging Study. Behavioral Sleep Medicine, 5(1), 39
56. doi:10.1080/15402000709336725

Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and
development of a shorter version. Clinical Gerontologist, 5(1-2), 165173.
doi:10.1300/J018v05n01_09
Stickgold, R. (2005). Sleep-dependent memory consolidation. Nature, 437(7063), 12721278.
Retrieved from http://dx.doi.org/10.1038/nature04286
Sutter, C., Zllig, J., Allemand, M., & Martin, M. (2012). Sleep quality and cognitive function in
healthy old age: The moderating role of subclinical depression. Neuropsychology, 26(6),
768775. doi:10.1037/a0030033
Tsai, P.-S., Wang, S.-Y., Wang, M.-Y., Su, C.-T., Yang, T.-T., Huang, C.-J., & Fang, S.-C.
(2005). Psychometric evaluation of the Chinese version of the Pittsburgh Sleep Quality
Index (CPSQI) in primary insomnia and control subjects. Quality of Life Research: An
International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation,
14(8), 194352. doi:10.1007/s11136-005-4346-x
Tworoger, S. S., Lee, S., Schernhammer, E. S., & Grodstein, F. (2006). The Association of SelfReported Sleep Duration, Difficulty Sleeping, and Snoring With Cognitive Function in
Older Women. Alzheimer Disease & Associated Disorders, 20(1). Retrieved from
http://journals.lww.com/alzheimerjournal/Fulltext/2006/01000/The_Association_of_Self_R
eported_Sleep_Duration,.8.aspx
Vignola, a, Lamoureux, C., Bastien, C. H., & Morin, C. M. (2000). Effects of chronic insomnia
and use of benzodiazepines on daytime performance in older adults. The Journals of
Gerontology. Series B, Psychological Sciences and Social Sciences, 55(1), P54P62.
Westerberg, C. E., Mander, B. a., Florczak, S. M., Weintraub, S., Mesulam, M.-M., Zee, P. C., &
Paller, K. a. (2012). Concurrent Impairments in Sleep and Memory in Amnestic Mild
Cognitive Impairment. Journal of the International Neuropsychological Society, 18(03),
490500. doi:10.1017/S135561771200001X
Wingfield, A., & Grossman, M. (2006). Language and the Aging Brain: Patterns of Neural
Compensation Revealed by Functional Brain Imaging. Journal of Neurophysiology, 96(6),
28302839. Retrieved from http://jn.physiology.org/content/96/6/2830.abstract
Xu, L., Jiang, C. Q., Lam, T. H., Liu, B., Jin, Y. L., Zhu, T., Thomas, G. N. (2011). Short or
Long Sleep Duration Is Associated with Memory Impairment in Older Chinese: the
Guangzhou Biobank Cohort Study. Sleep, 34(5), 575580. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3079936/
Xu, L., Jiang, C. Q., Lam, T. H., Zhang, W. Sen, Cherny, S. S., Thomas, G. N., & Cheng, K. K.
(2014). Sleep Duration and Memory in the Elderly Chinese: Longitudinal Analysis of the
Guangzhou Biobank Cohort Study. Sleep, 37(11), 17371744. doi:10.5665/sleep.4162
Yu, J., Rawtaer, I., Fam, J., Jiang, M.-J., Feng, L., Kua, E. H., & Mahendran, R. (2016). Sleep
Correlates of Depression and Anxiety in an Asian Elderly Population. Psychogeriatrics,
16(3), 191195. doi:10.1111/psyg.12138

Table 1. Predictors of Delayed Memory and Total scale index scores

Delayed Memory

Language

Total scale

SE

SE

SE

GDS

-1.52*

.76

-2.01

-.85*

.35

-2.40

-6.01*

2.49

-2.41

PSQI

-.73*

.32

-2.27

-.45**

-.16

-2.85

-2.68*

1.05

-2.54

Gender

5.11**

1.75

2.93

1.01

.86

1.17

9.32

5.81

1.60

Years of Education

.66***

.18

2.93

.35***

.09

3.99

4.69***

.61

7.72

GDS*PSQI

.27*

.13

2.09

.13*

.06

2.11

.98*

.42

2.31

Note. GDS = Geriatric Depression Scale; PSQI= Pittsburgh Sleep Quality Index.
*p < .05. **p < .01. ***p < .001.

Table 2. Predictors of Immediate memory, Visuospatial/Construction, Language and Attention index scores
Immediate memory

Visuospatial/Construction

Attention

SE

SE

SE

GDS

-1.07

.92

-1.16

-.84

.76

-1.11

-1.39

.73

-1.90

PSQI

-.74

.41

-1.82

.03

.32

.09

-.55

.31

-1.77

Gender

4.13

2.23

1.86

-1.01

1.75

-.58

-1.19

1.69

-.71

Years of education

.80***

.23

3.46

1.39***

.18

7.54

1.57***

.18

8.85

GDS*PSQI

.29

.16

1.80

-.005

.13

-.04

.23

.12

1.89

Note. GDS = Geriatric Depression Scale; PSQI= Pittsburgh Sleep Quality Index.
***p < .001.

Delayed Memory

High cognitive
ability

Low cognitive
ability
PSQI

Language

High cognitive
ability

Low cognitive
ability
PSQI

Total Scale

High cognitive
ability

Low cognitive
ability

Good sleep quality

PSQI
Poor sleep quality

Low GDS scores

High GDS scores

Figure 1. Conditional effects of GDS in the relationship between PSQI and Delayed memory
index scores, and PSQI and Total scale index scores