doi:10.1111/psyg.
12190
ORIGINAL ARTICLE
Prevalence and correlates of sleep problems among elderly
Singaporeans
Vathsala SAGAYADEVAN, Edimansyah ABDIN, Saleha BINTE SHAFIE, Anitha JEYAGURUNATHAN,
Rajeswari SAMBASIVAM, Yunjue ZHANG, Louisa PICCO, Janhavi VAINGANKAR, Siow A. CHONG and
Mythily SUBRAMANIAM
Research Division, Institute of Mental Health, Sin-
gapore, Singapore
Correspondence: Miss Vathsala Sagayadevan, Institute
of Mental Health, 10 Buangkok View, Singapore
539747, Singapore. Email: vathsala_sagayadevan@
imh.com.sg
Received 4 November 2015; revision received 9 December
2015; accepted 21 December 2015.
Disclosure statement: The authors have no potential
conflicts of interest to disclose.
Key words: Asia, elderly, mental health, physical
health, sleep difculties.
INTRODUCTION
Sleep-related problems have become pervasive in
modern society given the increasing work-related
demands and lifestyle changes.1 Leger et al. found
prevalence rates of sleep problems among indivi-
duals aged 15 years and above across the USA,
Western Europe, and Japan to be 56%, 31%, and
23%, respectively,2 while epidemiological surveys
have shown that approximately 1333% of Australian
adults have reported frequent difculties in initiating
or maintaining sleep.3
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society
PSYCHOGERIATRICS 2016; 17: 4351
Abstract
Background: The current study examined the prevalence and correlates of
sleep problems among elderly Singaporeans.
Methods: Data were taken from the Well-being of Singapore Elderly study,
a cross-sectional, epidemiological survey conducted among Singapore resi-
dents aged 60 years and above (n = 2565). Respondents were screened for
sleep problems through a series of questions in the Geriatric Mental State
examination. Details on sociodemographic characteristics, physical activity,
cognition, disability, chronic physical conditions, and depression were also
collected. Logistic regression analysis was used to explore signicant asso-
ciations between sleep problems, sociodemographic characteristics, physi-
cal activity, cognition, disability, chronic physical conditions, and
depression.
Results: Overall, 13.7% (n = 341) of older adults reported at least one sleep
problem. Of those who reported sleep problems, 69.4% experienced sleep
interruption at night, 48.9% reported having difculty falling asleep, 22.3%
reported early morning awakening, and 11.4% had all three problems. Eld-
erly with sleep problems were signicantly more likely to have a range of
chronic physical conditions and depression and were also signicantly less
likely to be physically active. Older adults with at least one sleep problem
reported signicantly greater disability compared to those with no sleep
problems.
Conclusion: The high probability of comorbid chronic conditions as well as
higher disability among those with sleep problems makes this an important
area of research.
Although evident among young and middle-aged
adults, sleep problems are particularly common
among the elderly,4 with a large majority reporting
sleep to be shallow and fragmented.5,6 In a review by
Ohayon,7 difculties initiating sleep were reported in
1545% of non-institutionalized elderly, disrupted
sleep in 2065%, early morning awakening in
1554%, and non-restorative sleep in about 10%. As
opposed to being an inevitable part of ageing, sleep
problems among the elderly are often attributed to
underlying physical and mental health conditions,
43
V. Sagayadevan et al.
medications used to treat these conditions, sleep
disorders, and circadian rhythm changes.5,6
Past studies have examined an array of factors in
relation to sleep problems, with these problems
being higher among women, unemployed indivi-
duals, those of older age, those who are widowed,
separated, divorced, or single, those with a low level
of education, and those of low socioeconomic
status.711 The use of medication,6 chronic physical
conditions,1,11 depression,1,6,9,10,12 and low physical
activity have also been identied as potential risk
factors for sleep problems.11
Sleep problems pose signicant economic and
social burden on society.2,11 Daley et al. found the total
annual cost of insomnia among Canadian individuals
aged 18 years and above to be approximately $6.6 bil-
lion Canadian dollars.13 In Australia, sleep disorders
accounted for 1.4% of the total burden of disease, with
an associated economic cost of $10.3 billion Australian
dollars in 2004.14 The literature has linked sleep distur-
bances to several negative outcomes including day-
time drowsiness, fatigue, cognitive decits,1,12
increased likelihood of accidents, mortality,11 reduced
physical and mental health, lower quality of life,9 and
decreased productivity.8 Sleep problems often go
unrecognized among the elderly, as many disregard
them as a problem and consider them to be a part of
normal ageing.15 However, sleep deprivation has been
associated with an increased risk of falls among the
elderly,5,6 which threatens their mobility and independ-
ence.6 Furthermore, the increasing incidence of
chronic physical and mental illnesses with age and the
pre-existing evidence linking sleep problems with
chronic illnesses warrant sleep problems among eld-
erly an important area of research.5,16
Previous studies conducted in Singapore have pri-
marily focused on specic sleep disorders and less
so on the prevalence and correlates of general sleep
problems among the elderly. Ng et al. found the
prevalence rate of snoring and sleep breathing-
related disorders among the general population in
Singapore (aged 2074 years) to be 0.43%,17
whereas, Lee et al. noted the prevalence of obstruc-
tive sleep apnoea among Singaporean patients seek-
ing bariatric surgery to be 72%.18 The current study
therefore aimed to address this gap in knowledge by
examining the prevalence and correlates of sleep
problems among elderly Singaporeans aged 60 years
and above.
44
METHODS
Sample
Singapore is a 712.4-km2 city-state in South-East
Asia with a population of 5 million. Of its residents,
74.2% are of Chinese descent, 13.4% are Malay,
and 9.2% are of Indian descent.19 Data for the cur-
rent study were extracted from the Well-being of Sin-
gapore Elderly (WiSE) study, a cross-sectional,
epidemiological survey conducted between August
2012 and November 2013 among a nationally repre-
sentative sample of Singapore residents aged
60 years and above (n = 2565). Disproportionate stra-
tied sampling was used to obtain equivalent propor-
tions of the three main ethnic groups in Singapore.
As part of the WiSE study, trained lay interviewers
conducted face-to-face household interviews with
the participants. Participants or their legally accepta-
ble representatives provided written informed con-
sent prior to study participation. The study was
approved by the relevant ethics committees: the
National Healthcare Group Domain Specic Review
Board and the Centralised Institutional Review Board
(SingHealth). The detailed methodology of the WiSE
study was described in a previous article.20
Measures
Sleep problems
The respondents were screened for sleep problems
through a series of questions in the sleep module of
the Geriatric Mental State examination, which was
part of the 10/66 Dementia Research Groups ques-
tionnaires.21 Individuals were rst asked if they had
experienced any sleep problems over the past month
(i.e. Have you had trouble sleeping recently?). Those
who provided a positive answer were assessed to
determine if they faced difculty falling asleep
(i.e. Have you had any difculty falling asleep?),
sleep interruption (i.e. Is your sleep interrupted dur-
ing the night?), and/or early morning awakening
(i.e. Have you recently been waking up early in the
morning and found it impossible to get back to
sleep?). These three questions were chosen to
assess sleep problems based on past studies that
have used similar criteria.11,12
Cognitive functioning
Cognitive functioning was measured by the Commu-
nity Screening Instrument for Dementia,21 a 32-item
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society

questionnaire incorporating the modied Consortium
to Establish a Registry of Alzheimers Diseases 10-
word list learning task with delayed recall, and the
Consortium to Establish a Registry of Alzheimers
Diseases animal naming verbal uency task. A cog-
nitive score based on an item-weighted total score of
each participant was obtained based on the number
of correct answers (0 = cognitively impaired, 32 = no
cognitive impairment).21
Sociodemographic information
Sociodemographic information obtained included age
at interview (6074, 7584, or 85 years), gender, eth-
nicity (Chinese, Malay, Indian, or other), marital status
(never married, married/cohabiting, divorced or sepa-
rated, or widowed), educational level (primary and
below, secondary, or tertiary) and employment status
(employed, homemaker, retired, or unemployed).
Disability
Disability was assessed with the World Health Organ-
ization Disability Assessment Schedule II. The modi-
ed World Health Organization Disability Assessment
Schedule II evaluates ve domains of functioning:
(i) understanding and communicating; (ii) self-care;
(iii) mobility; (iv) getting along with people; and (v) life
activities. Each of the items yield severity ratings indi-
cating the extent of difculty individuals faced in per-
forming these activities.22
Physical activity, chronic physical conditions,
and depression
The level of physical activity was assessed through
the following question: Taking into account both
work and leisure, would you say that you are very
physically active, fairly physically active, not very
physically active, or not at all physically active?
Those who reported being very/fairly physically active
were grouped as being physically active, whereas
those who were not very/not at all physically active
were grouped as not physically active. Details
regarding the presence of chronic medical conditions
(i.e. high blood pressure, heart problem, stroke, dia-
betes, arthritis or rheumatism, persistent cough,
asthma, stomach or intestine problems, fainting/
blackouts, paralysis, pain, and cancer) were also
obtained via self-report. The presence or absence of
depression was assessed via the following question:
Has there been a time or times in your life when you
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society
Sleep problems among the elderly
felt sad, empty, depressed, or lost interest in most
things like work, hobbies, and other things which
lasted at least two weeks?
Statistical analyses
Statistical analyses were carried out with SAS version
9.2 (SAS Institute, Cary, NC, USA). To ensure that
the survey ndings were representative of the Singa-
pore population, the data were weighted to adjust for
oversampling and post-stratied by age and ethnicity
between the survey sample and the Singapore resi-
dent population in 2010. Descriptive analyses were
performed to establish the prevalence of sleep pro-
blems. Logistic regression analysis was used to
explore signicant associations between sleep pro-
blems, sociodemographic characteristics, physical
activity, cognition, disability, chronic physical condi-
tions, and depression. Statistical signicance was
evaluated at the 0.05 level with two-sided tests.
RESULTS
Prevalence of sleep problems
Of the 2565 respondents who were interviewed for
the WiSE study, 2382 individuals responded to the
questions on sleep problems and were included in
this study. Overall, 13.7% (n = 341) of the older
adults in the current sample reported at least one
sleep problem (i.e. difculty falling asleep, sleep inter-
ruption, or early morning awakening). Of those who
had trouble sleeping, 69.4% experienced sleep inter-
ruption at night, 48.9% reported having difculty fall-
ing asleep, 22.3% reported early morning awakening,
and 11.4% had all three sleep problems. A break-
down of prevalence of sleep problems by sociode-
mographic correlates are presented in Table 1.
Sociodemographic correlates of sleep
problems
Logistic regression was used to determine the socio-
demographic correlates of sleep problems. Women
(versus men), Indians (versus Chinese), those who
had completed secondary education (versus tertiary
education), and retirees (versus those with full- or
part-time paid work) were signicantly more likely to
report any one of the sleep problems. In particular,
elderly women were 1.7 times more likely than men
(odds ratio (OR): 1.7, 95% condence interval (CI):
1.12.7; P = 0.02) to report any one of the sleep pro-
blems; those who completed secondary education
45
V. Sagayadevan et al.

Table 1 Prevalence of sleep problems by sociodemographic characteristics

At least one Difculty
sleep problem falling asleep Sleep interruption Early morning All three sleep
(n = 341) (n = 185) (n = 225) awakening (n = 97) problems (n = 59)
n (%) n (%) n (%) n (%) n (%)
Overall 341 (13.7) 185 (48.9) 225 (69.4) 97 (22.3) 59 (11.4)
Age group
6074 204 (13.9) 116 (49.8) 130 (67.6) 56 (22.5) 36 (11.7)
7584 89 (12.6) 42 (43.4) 63 (81.4) 29 (24.1) 15 (12.2)
85 48 (15.0) 27 (53.6) 32 (56.1) 12 (10.8) 8 (4.0)
Sex
Men 109 (10.0) 46 (37.7) 72 (62.6) 31 (13.9) 17 (8.4)
Women 232 (16.6) 139 (54.2) 153 (72.7) 66 (25.8) 42 (12.9)
Ethnicity
Chinese 129 (13.9) 60 (46.6) 90 (70.5) 20 (18.3) 11 (9.5)
Malay 85 (11.3) 47 (56.2) 60 (68.0) 41 (59.7) 23 (25.8)
Indian 124 (16.5) 75 (61.7) 73 (58.8) 36 (38.6) 25 (20.6)
Others 3 (8.7) 3 (100) 2 (66.9)
Marital status
Never married 21 (19.7) 11 (55.1) 17 (83.4) 5 (25.3) 4 (22.6)
Married/cohabiting 184 (12.6) 95 (44.8) 118 (67.6) 55 (25.3) 34 (11.4)
Widowed 117 (14.8) 70 (55.3) 78 (71.2) 33 (17.8) 20 (8.6)
Divorced/separated 19 (14.5) 9 (53.4) 12 (54.1) 4 (7.0) 1 (1.2)
Education
None 74 (17.5) 38 (42.9) 54 (77.0) 25 (21.8) 12 (9.6)
Some but did not complete primary 86 (13.4) 46 (39.0) 59 (66.4) 29 (25.9) 20 (14.0)
Completed primary 85 (11.2) 45 (48.6) 48 (63.8) 22 (27.3) 12 (8.3)
Completed secondary 73 (17.2) 44 (61.4) 47 (70.0) 15 (16.2) 11 (11.0)
Completed tertiary 23 (8.5) 12 (48.7) 17 (71.9) 6 (22.4) 4 (18.1)
Employment
Paid work (part time and full time) 66 (9.8) 36 (40.4) 39 (58.9) 16 (14.8) 12 (4.4)
Unemployed 5 (16.9) 2 (46.7) 5 (100) 2 (10.8)
Homemaker 125 (16.1) 77 (57.1) 78 (69.9) 38 (28.7) 23 (13.1)
Retired 141 (15.5) 68 (47.2) 102 (75.5) 39 (22.6) 23 (15.2)

were 2.2 times more likely than those who completed
tertiary education (OR: 2.2, 95%CI: 1.14.4; P = 0.03)
to report any one of the sleep problems; and retirees
were 1.8 times more likely than those employed in
paid work (OR: 1.8, 95%CI: 1.12.9; P = 0.01) to
report any one of the sleep problems.
The individual subtypes of sleep problems (i.e. sleep
interruption at night, difculty falling asleep, and early
morning awakening) were further examined in relation
to sociodemographic correlates. In comparisons of the
three subtypes of sleep problems, both difculty falling
asleep and early morning awakening yielded signicant
ndings. Marital status and ethnicity were found to be
signicantly associated with early morning awakening.
Those who were divorced or separated (OR: 0.1, 95%
CI: 0.030.6; P = 0.01) were signicantly less likely to
report early morning awakening than those who were
married/cohabiting, whereas Indians (OR: 3.5, 95%CI:
1.67.8; P < 0.01) and Malays (OR: 11.7, 95%CI:
4.530.5; P < 0.01) were signicantly more likely to
report early morning awakening than Chinese respon-
dents. Indians (OR: 2.1, 95%CI: 1.23.9; P = 0.01) were
also more likely than the Chinese to report difculty
sleeping (Table 2).
Relationship between sleep problems and
physical activity, chronic physical conditions,
and depression
After adjustment for sociodemographic variables,
individuals who reported sleep problems were signi-
cantly more likely to have a range of chronic physical
and mental conditions including pain, heart pro-
blems, arthritis/rheumatism, persistent cough,
asthma, stomach or intestine problems, fainting/
blackouts, paralysis, and depression. Those with
sleep problems were also signicantly less likely to
be physically active compared to those who did not

46 2016 The Authors

Psychogeriatrics 2016 Japanese Psychogeriatric Society
 Table 2 Sociodemographic correlates of sleep problems
Any one of the sleep problems Difculty falling asleep Sleep interruption Early morning awakening
95%CI 95%CI 95%CI 95%CI

Odds Lower Upper Odds Lower Upper Odds Lower Upper Odds Lower Upper
ratio limit limit P-value ratio limit limit P-value ratio limit limit P-value ratio limit limit P-value

2016 The Authors

Age group
6074
7584 0.8 0.5 1.2 0.25 0.8 0.3 2.1 0.72 1.9 0.7 5.0 0.18 0.7 0.2 2.0 0.46
85 0.9 0.5 1.6 0.78 1.3 0.4 4.1 0.65 0.5 0.2 1.4 0.17 0.3 0.1 1.4 0.13
Sex
Male
Female 1.70* 1.1 2.7 0.02 2.5 1.0 6.3 0.06 1.5 0.6 3.9 0.39 3.0 0.9 9.7 0.06
Marital status
Married/cohabiting
Divorced/separated 1.0 0.5 2.0 0.90 0.7 0.1 3.2 0.61 0.4 0.1 2.5 0.35 0.10 0.03 0.6 0.01
Never married 1.7 0.9 3.1 0.10 1.8 0.5 7.1 0.40 1.9 0.4 9.7 0.43 1.4 0.3 6.1 0.68
Widowed 0.9 0.6 1.5 0.76 1.5 0.6 3.7 0.35 0.9 0.4 2.3 0.85 0.4 0.1 1.2 0.10
Employment status
Paid work (part time and

Psychogeriatrics 2016 Japanese Psychogeriatric Society

full time)
Homemaker 1.4 0.8 2.5 0.21 1.4 0.5 4.3 0.56 1.4 0.4 4.3 0.60 2.3 0.5 11.4 0.31
Retired 1.80 1.1 2.9 0.01 1.1 0.4 2.9 0.92 2.2 0.8 6.0 0.12 3.1 0.8 12.5 0.11
Unemployed 1.9 0.5 7.3 0.35 1.0 0.1 12.5 0.99 0.4 0.04 4.3 0.48
Education
Completed tertiary
Completed primary 1.4 0.7 2.8 0.40 0.6 0.1 2.6 0.46 0.6 0.1 3.1 0.57 0.7 0.1 5.2 0.75
Completed secondary 2.2 1.1 4.4 0.03 1.1 0.2 5.3 0.90 1.1 0.2 5.2 0.91 0.4 0.1 2.8 0.37
None 2.1 0.9 4.5 0.06 0.3 0.1 1.7 0.18 1.3 0.2 6.7 0.79 0.7 0.1 5.4 0.73
Some, but did not 1.6 0.8 3.4 0.18 0.4 0.1 1.9 0.25 0.7 0.1 3.5 0.67 1.0 0.1 7.4 0.97
complete primary
Ethnicity
Chinese
Indian 1.40 1.03 1.9 0.03 2.10 1.2 3.9 0.01 0.6 0.3 1.2 0.17 3.50 1.6 7.8 <.01
Malay 0.8 0.6 1.1 0.17 1.9 0.9 3.9 0.07 1.1 0.5 2.5 0.83 11.70 4.5 30.5 <.01
Others 0.7 0.2 2.3 0.52 0.9 0.0 29.4 0.93

Referent group.
CI, condence interval.
* OR in bold represent those with p-values <.05.

47
Sleep problems among the elderly
V. Sagayadevan et al.

Table 3 Relationship between sleep problems* and physical activ- Although it is possible that the prevalence of sleep
ity, chronic physical conditions, and chronic mental conditions
problems is truly low among the elderly in Singapore,
95%CI methodological differences between studies
Odds Lower Upper (e.g. different instruments, varying denitions of sleep
Criterion variable ratio limit limit P-value problems)7,24 preclude direct comparison of results.
Chronic conditions Low prevalence of sleep problems in the current pop-
Depression 1.9* 1.1 3.3 0.02 ulation could also be due to underreporting of symp-
High blood pressure 0.9 0.7 1.3 0.71
Heart problems 2.1 1.4 3.4 <0.01 toms. In comparing sleep problems across various
Stroke 0.9 0.5 1.9 0.94 countries (the USA, France, Germany, Italy, Spain,
Diabetes 1.1 0.8 1.7 0.56 the UK, and Japan), Leger et al. attributed the low
Arthritis/rheumatism 1.5 1.1 2.2 0.02
Persistent cough 3.0 1.5 6.0 <0.01
prevalence of sleep problems in Japan to possible
Asthma 2.4 1.5 4.1 <0.01 cultural reticence and reluctance among Japanese
Stomach or intestine 2.6 1.7 4.0 <0.01 people to associate sleep problems with psychiatric
problems
disorders.2 Similarly, given that the current study was
Faints or blackouts 2.6 1.5 4.6 <0.01
Paralysis 2.2 1.4 3.4 <0.01 part of a larger survey aimed at examining the preva-
Cancer 1.3 0.5 3.4 0.58 lence of dementia and depression among older
Pain 3.2 2.2 4.8 <0.01 adults in Singapore, it is possible that individuals
Physical activity 0.5 0.3 0.7 <0.01
might have associated the presence of sleep symp-
Presence of sleep problems was the predictor variable in all regression ana-
toms with these disorders and consequently chose
lyses reported in this table.
CI, condence interval. to minimalize or deny these symptoms.
* OR in bold indicate p-values <.05. With regard to the prevalence of individual sleep
complaints, our ndings were similar to those of
report such problems (OR: 0.5, 95%CI: 0.30.7; Foley et al.,9 who noted the highest prevalence for
P < 0.01) (Table 3). difculty maintaining sleep (29%) (equivalent to sleep
interruption in our study), followed by difculty initiat-
ing sleep (19%) (equivalent to difculty falling asleep
Sleep problems, cognition, and disability
in our study), and early morning awakening (18%)
Older adults who had at least one sleep problem
among elderly aged 65 years and above in a multi-
(mean  SEM: 14.4  1.2) reported signicantly
centre study.
greater disability than those without sleep problems
Consistent with previous ndings, women,7,911
(7.6  0.4, P < 0.001). However, cognitive scores
those with lower education,7,11 and retirees were
between those with sleep problems (28.9  0.1) and
found to be more likely to report any one of the sleep
those without sleep problems (28.7  0.2, P = 0.635)
problems.7,11 Leng et al.,10 for instance, found that
were not statistically different.
only 39.6% of women reported never experiencing
difculty falling asleep, whereas 63.3% of men never
had difculty. The study also found the decrease in
DISCUSSION sleep efciency to be greater among older women
Overall, 13.7% of elderly in the current sample than in men. Those of Indian ethnicity were also sig-
reported having experienced at least one sleep prob- nicantly more likely than those of Chinese ethnicity
lem in the month prior to being interviewed. The to report sleep problems in this study. This nding
majority experienced sleep interruption at night concurred with the study by Ng et al.,17 which found
(69.4%), followed by difculty falling asleep (48.9%), snoring and sleep breathing-related disorders to be
and early morning awakening (22.3%). The overall more prevalent among Indians (and Malays) than
prevalence was generally lower than those reported among Chinese. Age and marital status did not
in past studies.8,23,24 Li et al., for instance, found emerge as signicant correlates.
49.7% of elderly in China reported poor sleep In further examining the individual subtypes of
quality,24 whereas Eser et al. reported a prevalence sleep problems in relation to sociodemographic cor-
rate of 60.9% among Turkish elderly residing in nurs- relates, we noted a signicant association between
ing homes.8 early morning awakening and marital status; those

48 2016 The Authors

Psychogeriatrics 2016 Japanese Psychogeriatric Society

who were divorced or separated were signicantly
less likely to report early morning awakening than
those who were married/cohabiting. This nding,
however, failed to support past literature, which has
generally found those who are widowed, separated,
divorced, or single to be more likely to report sleep
problems.711 While there may have been other
underlying factors (e.g. previous relationship pro-
blems, household commitments) for this association
between marital status and early morning awakening,
we are unable to fully account for this nding.
With respect to ethnicity, Malays and Indians were
signicantly more likely than the Chinese to report
early morning awakening; Indians were also more
likely to report difculty falling asleep. This result par-
tially supports past studies that have found ethnic
differences in sleep complaints.25 However, given
that most studies have mainly focused on Western
populations, direct comparison of results across
studies is limited.
As in past literature, individuals who reported
sleep problems were more likely to have a range of
chronic physical and mental conditions (i.e. pain,
heart problems, arthritis/rheumatism, persistent
cough, asthma, stomach or intestine problems, faint-
ing/blackouts, paralysis, or depression).1,11,12 While
Foley et al. found sleep complaints among older
adults aged 65 years and above to be associated
with having heart disease, a history of stroke, or
depression,16 a longitudinal study among Korean eld-
erly aged 65 years and above found baseline insom-
nia to be independently associated with depression
and an increase in reported physical disorders.23
Those with sleep problems were also signicantly
less likely to be physically active and more likely to
report disability than those who did not report such
problems. In Australia, the National Survey of Mental
Health and Wellbeing, which used an equivalent criteria
for assessing sleep problems (indicators of insomnia:
difculty falling asleep, difculty staying asleep, and
early morning awakening) among individuals aged
1685 years old, found individuals with insomnia to
have a higher median World Health Organization Disa-
bility Assessment Schedule score (i.e. greater disabil-
ity) than those without insomnia.11 Likewise, Strine and
Chapman found those with insufcient sleep to be
more likely to report activity limitation and physical
inactivity than those without these problems among a
US population aged 18 years and above.26
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society
Sleep problems among the elderly
The difference in cognitive scores between those
with and without sleep problems was not statistically
signicant in the current sample. This was surprising
given that past studies have found sleep problems to
be associated with poorer cognition. In examining
sleep quality and cognitive decits, Amer et al. found
24% of good sleepers to have cognitive decits com-
pared to 52% of poor sleepers on the Mini-Mental
State Examination.4 This effect of sleep on cognition
was evident even when comparing individuals with
mild cognitive impairment (MCI) with sleep disorders
to MCI patients without sleep disorders, whereby the
latter had signicantly higher scores in domains such
as attention, visuo-spatial/executive function com-
pared to the former.27
One possible reason for the insignicant nding in
this study might be due to the limited number of cog-
nitive domains that were examined in relation to
sleep problems. Past studies, such as that by Black-
well et al.,28 have found sleep disruptions at different
sleep stages to be associated with decits in various
cognitive domains, particularly executive functioning.
For instance, a lower proportion of time spent in the
rapid eye movement sleep stage was associated with
measures of executive functioning and attention,
whereas a higher percentage of time spent in stage
1 sleep was associated with executive functioning,
attention, and a global measure of cognition among
community-dwelling older men in the USA. Likewise,
Naismith et al. have suggested that sleep problems
may have a greater impact on cognition among those
who already have existing memory impairments,29
with sleep disruptions being especially associated
with executive functioning including attention, con-
cept formation, and problem-solving. Therefore, it
might be important to look into a range of cognitive
domains, particularly executive functioning, rather
than specic domains such as memory
(e.g. immediate and delayed recall).
Other studies have attributed lower cognition to
both short and long sleep duration.30 In comparing
sleep duration and cognition in community-dwelling
elderly individuals, Benito-Len et al. found baseline
cognitive scores in both short (5 h) and long sleepers
(9 h) to be lower than the reference group (68 h).31
It is possible that despite the report of sleep pro-
blems, both groups (with and without sleep problems)
may be getting an adequate 68-h sleep, thus
accounting for the lack of signicant difference in
49
V. Sagayadevan et al.
cognitive scores between the two groups. However,
this remains inconclusive given that the current study
did not obtain any information on sleep duration.
Limitations
Our ndings should be considered in light of the
studys limitations. Firstly, the prevalence of the three
commonly assessed symptoms of insomnia
difculty falling asleep, sleep interruption, and early
morning awakeningwere assessed through single
questions. While this provides an overview of the
prevalence of sleep problems among the elderly pop-
ulation in Singapore, a more comprehensive tool
such as the Pittsburgh Sleep Quality Index may be
required to develop a better understanding of these
problems in the local population. Further information
regarding sleep habits (e.g. watching television, using
a computer before bedtime),32 sleep duration, and
frequency might also be needed to gain further
insight into the extent of sleep problems in this popu-
lation.3 Future studies might also look into assessing
various cognitive domains, such as attention,
sequencing, immediate and delayed recall, and exec-
utive functioning, in relation to sleep problems to gain
a holistic understanding of the effect of these pro-
blems on cognition. In addition, the cross-sectional
design of this study limited any causal inferences
from being made. Past literature has suggested rela-
tionships between sleep problems and factors such
as chronic conditions, disability, and physical activity
to be bi-directional.3,9 As such, a prospective design
might be useful in examining these associations.
Conclusions
The study ndings offered some insight into the prev-
alence and correlates of sleep problems among the
elderly population in Singapore. While past studies in
the local context focused on specic sleep disorders,
this study provided an overview of sleep problems
present among the Singaporean elderly. Elderly who
reported sleep problems were more likely to have
comorbid chronic conditions, greater disability, and
less physical activity than those without these pro-
blems. Given that a large proportion of sleep com-
plaints are secondary to underlying chronic physical
and mental illnesses, it is imperative that geriatricians
and health-care providers screen the elderly for sleep
problems when they present with chronic conditions
and vice versa. Identifying and addressing these
50
underlying conditions would aid in both increasing
the sleep quality of the elderly and improving their
quality of life.
ACKNOWLEDGMENTS
This work was supported by the Ministry of Health,
Singapore, and the Singapore Millennium Foundation
of the Temasek Trust under the Ministry of Health
Reinvestment Funds, Project No. RF07(2011-02).
The salaries of JV, LP, MS, VS, SBS, AJ, RS, and
YZ were partly funded by the grant.
REFERENCES
1 Banks S, Dinges DF. Behavioral and physiological conse-
quences of sleep restriction. J Clin Sleep Med 2007; 3:
519528.
2 Leger D, Poursain B, Neubauer D, Uchiyama M. An interna-
tional survey of sleeping problems in the general population.
Curr Med Res Opin 2008; 24: 307317.
3 Cunnington D, Junge MF, Fernando AT. Insomnia: prevalence,
consequences and effective treatment. Med J Aust 2013; 199:
S36S40.
4 Amer MS, Hamza SA, El Akkad RM, Abdel Galeel YI. Does self-
reported sleep quality predict poor cognitive performance
among elderly living in elderly homes? Aging Ment Health 2013;
17: 788792.
5 Ancoli-Israel S, Ayalon L, Salzman C. Sleep in the elderly: nor-
mal variations and common sleep disorders. Harv Rev Psychia-
try 2008; 16: 279286.
6 Subramanian S, Surani S. Sleep disorders in the elderly. Geriat-
rics 2007; 62: 1032.
7 Ohayon MM. Epidemiology of insomnia: what we know and
what we still need to learn. Sleep Med Rev 2002; 6: 97111.
8 Eser I, Khorshid L, Cinar S. Sleep quality of older adults in nurs-
ing homes in Turkey: enhancing the quality of sleep improves
quality of life. J Gerontol Nurs 2007; 33: 4249.
9 Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB,
Blazer DG. Sleep complaints among elderly persons: an epide-
miologic study of three communities. Sleep 1995; 18: 425432.
10 Leng Y, Wainwright NW, Cappuccio FP et al. Self-reported
sleep patterns in a British population cohort. Sleep Med 2014;
15: 295302.
11 Yu SB, Marshall NS, Glozier N. The burden of insomnia on indi-
vidual function and healthcare consumption in Australia. Aust N
Z J Public Health 2012; 36: 462468.
12 Jelicic M, Bosma H, Ponds RW, Van Boxtel MP, Houx PJ,
Jolles J. Subjective sleep problems in later life as predictors of
cognitive decline. Report from the Maastricht Ageing Study
(MAAS). Int J Geriatr Psychiatry 2002; 17: 7377.
13 Daley M, Morin CM, LeBlanc M, Grgoire JP, Savard J. The
economic burden of insomnia: direct and indirect costs for indi-
viduals with insomnia syndrome, insomnia symptoms, and
good sleepers. Sleep 2009; 32: 5564.
14 Access Economics. 2004. Wake Up Australia: the value of
healthy sleep. [Cited 03/15/2015.] Available from URL: https://
www.sleep.org.au/documents/item/69
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society

15 Hoffman S. Sleep in the older adult: implications for nurses
(CE). Geriatr Nurs 2003; 24: 210216.
16 Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances
and chronic disease in older adults: results of the 2003 National
Sleep Foundation Sleep in America Survey. J Psychosom Res
2004; 56: 497502.
17 Ng TP, Seow A, Tan WC. Prevalence of snoring and sleep
breathing-related disorders in Chinese, Malay and Indian adults
in Singapore. Eur Respir J 1998; 12: 198203.
18 Lee YH, Johan A, Wong KKH, Edwards N, Sullivan C. Preva-
lence and risk factors for obstructive sleep apnea in a multieth-
nic population of patients presenting for bariatric surgery in
Singapore. Sleep Med 2009; 10: 226232.
19 Singapore Department of Statistics. 2011. Census of Popula-
tion 2010, Statistical Release Demographic Characteristics,
Education, Language and Religion. [Cited 03/15/2015.] Availa-
ble from URL: http://www.singstat.gov.sg
20 Subramaniam M, Chong SA, Vaingankar JA et al. Prevalence of
dementia in people aged 60 years and above: results from the
WiSE study. J Alzheimers Dis 2015; 45: 11271138.
21 Prince MJ, de Rodriguez JL, Noriega L et al. The 10/66 Demen-
tia Research Groups fully operationalised DSM-IV dementia
computerized diagnostic algorithm, compared with the 10/66
dementia algorithm and a clinician diagnosis: a population vali-
dation study. BMC Public Health 2008; 8: 112.
22 Rehm J, stn TB, Saxena S et al. On the development and
psychometric testing of the WHO screening instrument to
assess disablement in the general population. Int J Methods
Psychiatr Res 1999; 8: 110122.
23 Kim JM, Stewart R, Kim SW, Yang SJ, Shin IS, Yoon JS. Insom-
nia, depression, and physical disorders in late life: a 2-year
2016 The Authors
Psychogeriatrics 2016 Japanese Psychogeriatric Society
Sleep problems among the elderly
longitudinal community study in Koreans. Sleep 2009; 32:
12211228.
24 Li J, Yao YS, Dong Q, Liu JJ, Yang LS, Huang F. Charac-
terization and factors associated with sleep quality among
rural elderly in China. Arch Gerontol Geriatr 2013; 56:
237243.
25 Jean-Louis G, Magai CM, Cohen CI et al. Ethnic differences in
self-reported sleep problems in older adults. Sleep 2001; 24:
926936.
26 Strine TW, Chapman DP. Associations of frequent sleep insuf-
ciency with health-related quality of life and health behaviors.
Sleep Med 2005; 6: 2327.
27 An C, Yu L, Wang L et al. Association between sleep character-
istics and mild cognitive impairment in elderly people. Neuro-
physiology 2014; 46: 8894.
28 Blackwell T, Yaffe K, Ancoli-Israel S et al. Association of sleep
characteristics and cognition in older community-dwelling men:
the MrOS sleep study. Sleep 2011; 34: 13471356.
29 Naismith SL, Rogers NL, Hickie IB, Mackenzie J, Norrie LM,
Lewis SJ. Sleep well, think well: sleep-wake disturbance in mild
cognitive impairment. J Geriatr Psychiatry Neurol 2010; 23:
123130.
30 Ferrie JE, Shipley MJ, Akbaraly TN, Marmot MG, Kivimki M,
Singh-Manoux A. Change in sleep duration and cognitive func-
tion: ndings from the Whitehall II Study. Sleep 2011; 34:
565573A.
31 Benito-Len J, Louis ED, Bermejo-Pareja F. Cognitive decline
in short and long sleepers: a prospective population-based
study (NEDICES). J Psychiatr Res 2013; 47: 19982003.
32 Bastien CH, Vallieres A, Morin CM. Precipitating factors of
insomnia. Behav Sleep Med 2004; 2: 5062.
51