Sleep disturbances in bereaved older people: a review of the literature
Intended for healthcare professionals
Evidence and practice    

Sleep disturbances in bereaved older people: a review of the literature

Cassandra Godzik Geisel School of Medicine, Dartmouth Centers for Health and Aging, Hanover, New Hampshire, US; and Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, US

Why you should read this article:
  • To increase your understanding of the physical and mental health consequences of bereavement in old age

  • To learn about interventions that may improve sleep in older people before and after the death of a loved one

  • To gain awareness of the gaps in the literature on sleep disturbances in bereaved older people

Sleep disturbances are often seen in older people who have recently experienced the death of a loved one, such as a partner or spouse. Older family carers are particularly at risk of mood and sleep disturbances, not only after the death of the person they were caring for but also beforehand. Sleep disturbances can be treated with psychotropic medicines, but these are not adequate in older people because of the risk of falls, fractures and road accidents. Cognitive behavioural therapy for insomnia is a non-pharmacological intervention that has been found to be beneficial in bereaved older carers.

This article offers a systematic review of the literature on sleep disturbances in bereaved older people. One of the main findings is that sleep disturbances may begin before the loved one’s death, during the caregiving period. More research is needed on sleep disturbances in bereaved older people – notably in those aged ≥85 years, in partners or spouses from same-sex couples, into long-term symptoms post-bereavement, and into sleep interventions provided before the loved one’s death.

Mental Health Practice. 24, 2, 15-21. doi: 10.7748/mhp.2020.e1492

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

cassandra.m.godzik@hitchcock.org

Conflict of interest

None declared

Godzik C (2020) Sleep disturbances in bereaved older people: a review of the literature. Mental Health Practice. doi: 10.7748/mhp.2020.e1492

Published: 04 March 2021

Published online: 06 October 2020

Clinicians often encounter sleep disturbances in older people who have recently experienced the death of a partner or spouse (Li et al 2018). Bereavement is particularly challenging for those who are physically and emotionally closest to the deceased individual, and studies have found that family carers experience mood and sleep disturbances after the person they were caring for has died (Jonasson et al 2009, Lerdal et al 2016). The reasons for this are numerous and include grief about the loss, departures from daily routine and changes in identity as partner and carer (Tang and Chow 2017). Older people might have spent much of their life with their partner and are then expected to adjust to daily life without that person. Bereavement is different for each individual, with some studies finding that consequences of the loss include symptoms of anxiety, depression and sleep disturbances (Jonasson et al 2009). Although bereavement has been studied thoroughly in the literature, there is still much to understand about this developmental transition and the effect it can have on the body and mind, particularly on sleep. This article offers a systematic review of the literature on sleep disturbances in bereaved older people.

Key points

  • Sleep disturbances are often seen in older people who have recently experienced the death of a loved one, such as a partner or spouse

  • Among bereaved older people, those who were the main carers of the deceased are particularly at risk of mood and sleep disturbances

  • Sleep disturbances in older carers may start before the death of their loved one, during the caregiving period

  • Psychotropic medicines such as benzodiazepines are not adequate to treat long-term insomnia in older people because of the risk of falls, fractures and road accidents

  • Cognitive behavioural therapy for insomnia has been shown to reduce sleep disturbances and depressive symptoms in bereaved older carers

Background

Biological and social changes

Sleep disturbances in older people are well documented and include shorter sleep duration, increased time spent awake at night and an increase in the number of daytime naps (Li et al 2018).

Older people are unique in terms of their sleep for several reasons. In advanced age, the circadian rhythm (temporal body clock) shifts to a new schedule (Chen et al 2016). Why this occurs is still not known, but it appears that the sleep-wake cycle biologically changes with age.

Beyond this biological shift, sleep may also be affected by life events that occur in old age. For example, older people no longer have the daytime work requirements that warrant getting up early in the morning and staying awake for the whole day (Ohayon and Vecchierini 2005). They can take daytime naps that reduce their sleep pressure (time needed to rest) during the night hours (Häusler et al 2019).

Sleep practices in older people can affect markers of inflammation (Okun et al 2011) and this can be an issue in those who are bereaved (Seiler et al 2018). Seiler et al (2018) found that fatigued individuals who had recently been bereaved had increased levels of C-reactive protein (CRP) compared with non-fatigued bereaved individuals. Similarly, Chirinos et al (2019) found an association between elevated CRP levels and sleep disturbances in those who had been recently bereaved.

Effects on physical and mental health

Research has found that inadequate sleep can have an adverse effect on people’s health (Cappuccio and Miller 2017, Itani et al 2017). For example, people who report chronically sleeping less than required experience more complications from diabetes and coronary issues (Cappuccio and Miller 2017). This could be explained by the metabolic processes that are thought to take place during sleeping hours (Chirinos et al 2019). Quality and amount of sleep are associated with mood symptoms. Research has indicated that people with impaired sleep – which includes being unable to fall asleep and/or remain asleep through the night – report more depressive symptoms (Tanimukai et al 2015). Seiler et al (2018) found that fatigued bereaved individuals reported higher levels of stress and depressive symptoms than non-fatigued bereaved individuals.

Bereavement has been shown to affect people’s physical and mental health. One study in 389,316 bereaved individuals found that they had excess mortality and an increased number of physical diseases compared with non-bereaved individuals (Prior et al 2018). Spousal bereavement has been associated with higher rates of conditions such as cirrhosis (Erlangsen et al 2017). In a study that looked at 432 bereaved carers, researchers found that sleep and mood disturbances were significant in that population (Chiu et al 2011).

Effects on cognition

It is recognised that cognitive issues can be present in individuals who are unable to obtain adequate sleep. The process of memory consolidation has been shown to be related to sleep (Gildner et al 2014) and a review of observational studies found that, among older people, those with extreme sleep durations, whether long or short, had worse cognition (Devore et al 2016). Cognition has also been researched in bereaved people, for example by Pérez et al (2018), who found that prolonged grief disorder was associated with reduced cognitive function. Another study found changes in memory consolidation related to sleep fragmentation in older people (Pace-Schott and Spencer 2015), while widowhood has been found to be associated with cognitive decline (Lyu et al 2018).

Treatments for sleep disturbances

Short-term insomnia, defined as sleep disturbances lasting between a few days and a few weeks, can lead to chronic or long-term insomnia (Griffiths and Peerson 2005). Sleep disturbances are often treated, and may be temporarily resolved, with prescribed psychotropic medicines, notably benzodiazepines such as temazepam or zolpidem tartrate (Pillai et al 2017). However, the long-term risks associated with these medicines are well documented, particularly in older people (Kaufmann et al 2018, Kim et al 2019). Studies have found an increased risk of falls and fractures with benzodiazepines (Tinetti and Kumar 2010, Bakken et al 2014), which can also cause morning drowsiness and reduce co-ordination, with a potential risk of road accidents if patients are still driving (Booth et al 2016). Even over-the-counter medicines used for sleep contain ingredients that may increase the risk of falls, cognitive impairment and dizziness. Common over-the-counter sleeping aids include diphenhydramine and doxylamine, which are both listed as potentially inappropriate medicines in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (American Geriatrics Society Beers Criteria Update Expert Panel 2019).

Sleep disturbances can also be managed with non-pharmacological methods, such as sleep hygiene strategies and cognitive behavioural therapy (CBT). Sleep hygiene strategies usually involve education about lifestyle and how the environment affects sleep, including information about fluid intake, exercise restrictions, night-time routines and adherence to a predetermined bedtime (Irish et al 2015). CBT for insomnia (CBT-I) is a psychotherapy programme designed to support individuals who struggle to initiate and maintain sleep, and has been delivered in a variety of ways ranging from in-person group sessions to individual online sessions (Taylor and Pruiksma 2014). Research has found the treatment to be acceptable and to reduce sleep disturbances and depressive symptoms in bereaved older carers (Carter et al 2009). Findings about CBT-I have generally been positive, with one study (Currie et al 2004) showing that participants recovering from alcohol dependence who received a CBT-I intervention had a significantly improved sleep efficiency compared with controls. However, the number of CBT-I therapists is limited.

Method

For this systematic literature review, four major health and psychology online databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, OVID with PsychInfo, and Scopus. Medical subject headings (MeSH) used included: ‘bereavement’, ‘sleep initiation and maintenance disorders’, ‘spousal’, ‘caregivers’, ‘aged’ and ‘middle aged’. Search strings using these MeSH were used to locate relevant articles. Once relevant articles had been identified, their abstracts were examined by the author. Articles deemed to be of interest were retrieved in their entirety for further reading. Those meeting the inclusion criteria were retained for inclusion in the literature review. The inclusion criteria were:

  • Peer-reviewed content.

  • Original research.

  • Articles published between 2008 and 2018.

  • Articles written in English.

  • Study participants aged ≥50 years and bereaved in the previous decade.

  • Measurement of sleep disturbances.

The database search produced a total of 153 non-duplicate articles. Reviewing the abstracts left 59 articles, which were read in their entirety; 51 of them were excluded because they did not fulfil all inclusion criteria. Eight articles were therefore included in the literature review. They are described in detail in Table 1.

Table 1.

Detailed description of the eight studies included in the systematic literature review

mhp.2020.e1492_0001_tb1.jpg

All eight articles reported quantitative studies, two of which were behavioural interventions; the remaining six were descriptive studies. The quality of the eight articles was evaluated using the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project 1998) and rated. The ratings are shown in Table 1.

Findings

The findings of the literature review are summarised under four themes:

  • Gender differences in symptomatology.

  • Carer versus non-carer responsibilities and dying process experience.

  • Sleep disturbances beginning during the caregiving period.

  • Benefits of sleep interventions.

Gender differences in symptomatology

Women made up the largest group of study participants in four of the eight studies (Monk et al 2008, Carter et al 2009, Pfoff et al 2014, Lerdal et al 2016). In one study, only widowers had been recruited (Jonasson et al 2009). In Tanimukai et al (2015), no statistically significant differences between genders were found for insomnia symptoms, but women had significantly more depressive symptoms than men during the bereavement period.

The age of the bereaved played a role in the number of insomnia symptoms reported. Insomnia symptoms significantly increased in women aged 50-59 years and in men aged 65-70 years in the first year of bereavement (Simpson et al 2014). None of the studies had collected longitudinal data beyond a year for women. In their study population of widowers, Jonasson et al (2009) determined that sleep disturbances continued for four to five years after the death of the spouse (Jonasson et al 2009).

Carer versus non-carer responsibilities and dying process experience

The involvement of the surviving partner or spouse in the care of their partner or spouse before death appears to be a critical component in understanding sleep disturbances in bereaved older people. The role of the surviving spouse can be categorised as either ‘carer’ or ‘non-carer’ (Carter et al 2009). A spousal carer is the person who primarily supports their partner at the end of life; the care provided typically involves dressing, cleaning, feeding and administering medicines. A spousal non-carer may still provide some care to their partner but they are not the sole or main carer; there may be a round-the-clock paid carer in the home, or the partner may live in a hospice or be hospitalised.

Spousal carers had high levels of depression in bereavement. Carter et al (2009) found that primary carers had scores ranging from 4 to 45 (mean 17) on the Center for Epidemiologic Studies – Depression scale. The spousal carer is a witness to the dying process of their spouse or partner, which can be life-altering. In Jonasson et al (2009), men who had witnessed their wives experiencing unresolved pain had an increased risk of sleep-related issues for four to five years after their loss; men whose wives had experienced anxiety in the three months before death had unresolved issues falling asleep and frequent night-time awakenings with anxiety during bereavement (Jonasson et al 2009). These various findings could indicate that more contact with one’s partner at the end of life may result in worse outcomes for the surviving partner.

When sleep was assessed using objective measures, such as an actigraph – a wearable device that detects activity through light and movement (Scarlett et al 2020) – it did not appear to be affected by spousal death. However, subjective measures of sleep, obtained for example through sleep diaries, were significantly different in the bereaved, who reported more sleep disturbances than controls (Monk et al 2009). Even when no sleep disturbances were recorded by the actigraph, participants continued to report suboptimal sleep quality.

Sleep disturbances beginning during the caregiving period

Several studies found that sleep disturbances had begun before the death of the loved one. Stressors associated with death and dying begin once death starts to be anticipated and can therefore start to affect carers’ sleep during the caregiving period (Tanimukai et al 2015, Lerdal et al 2016). Sleep quality may remain stable during the transition period into bereavement, so when sleep quality is suboptimal before the relative’s death, it remains suboptimal after their death. Tanimukai et al (2015) found that the prevalence of insomnia in bereaved families was stable between six weeks before and six months after the death of their relative. In the weeks before death, the prevalence of insomnia was 86.5% and after death it was 84.5% (Tanimukai et al 2015).

Benefits of sleep interventions

Two out of the eight studies included in the literature review had tested interventions, including CBT-I and sleep hygiene strategies, to manage sleep disturbances in their respective populations. Their findings suggest that sleep interventions in the bereavement period are possible and can be beneficial. Carter et al (2009) used a CBT-I intervention administered over two sessions in the home of participants (who were bereaved family carers). When comparing baseline and five-week measurements, sleep measures had significantly improved in terms of self-reported duration, sleep efficiency and Pittsburgh Sleep Quality Index (PSQI) scores (Carter et al 2009). Pfoff et al (2014) used a function-based therapy modality intervention over ten individual sessions. The intervention comprised teaching healthy sleep practices and education about factors that can affect sleep. Sleep and mood improved between baseline and end-of-study assessment in both the treatment group and the control group, but improvements were greater in the treatment group (Pfoff et al 2014).

Discussion

Sleep disturbances in bereaved older people are an important clinical problem that has not been studied thoroughly. Not adequately addressing this health concern has individual and societal consequences. Medicines such as benzodiazepines are not adequate to treat long-term insomnia in older people because of the risk of falls, fractures and road accidents (Tinetti and Kumar 2010, Bakken et al 2014, Booth et al 2016). Studies in this literature review suggest that sleep disturbances may start before the death of the loved one, so there may be scope in researching the risk characteristics of those vulnerable to sleep disturbances (Lerdal et al 2016), as well as sleep interventions provided during the caregiving period. Clinicians and relatives need to be aware that older carers need support before and after the death of their loved one.

The findings of this literature review emphasise that more research is needed in the field of sleep disturbances in bereaved older people. Specific gaps in the literature identified are described below.

  • Long-term symptoms such as insomnia and low mood in both genders at two, three and four years after the death of a loved one and beyond are not thoroughly understood. Data about the long-term experiences of older men post-bereavement are limited, while the long-term experiences of older women post-bereavement have not yet been explored.

  • Sleep disturbances among bereaved partners or spouses from same-sex couples have not yet been explored.

  • Older people aged ≥85 years are rarely represented in study samples, so more research is needed in that age group.

  • Sleep interventions provided during the caregiving period need be further explored – for example, there is scope for investigating whether sleep disturbances can be prevented or limited by early CBT-I.

Limitations

This systematic literature review was limited to research published between 2008 and 2018 and retrieved from four databases. The included articles had important limitations. While the measures used in the studies were reliable and valid, no consistent set of measures was used across studies. Most studies used the PSQI to measure sleep, but the actual questions asked to participants varied: some studies used the 19-item PSQI, others used the 18-item PSQI and others did not specify the number of PSQI items used. Depressive symptoms were measured using a variety of tools, including various forms of the Center for Epidemiologic Studies – Depression scale and the 21-item Hamilton Rating Scale for Depression. This means that it is challenging to compare findings between studies and to discuss mental health conditions other than depression, such as anxiety disorders. Sampling was also quite different between the studies. Lastly, only five of the eight articles described the use of a theoretical framework as part of their design.

Conclusion

Older people who have recently been bereaved are likely to experience sleep disturbances, and sleep disturbances can start before the loved one’s death. Sleep interventions such as CBT-I have been found to be beneficial, but more research is needed to identify ways to improve sleep in the period before the loved one’s death, especially for those who act as the main carer for their partner or spouse, who are particularly at risk. Future studies will need to be more inclusive and extend their populations to partners or spouses of same-sex couples and to older people aged ≥85 years. Finally, few studies have explored the long-term effects of bereavement on sleep in older people, which will need to be addressed in future research.

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