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Factors contributing to poor satisfaction with sleep and healthcare seeking behavior in older adults

Open AccessPublished:December 09, 2016DOI:https://doi.org/10.1016/j.sleh.2016.11.004

      Abstract

      Objective

      To identify factors influencing older adults' poor satisfaction with sleep and their current healthcare seeking behaviors.

      Design

      Cross-sectional study.

      Setting

      Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry.

      Participants

      Individuals aged 60 or older enrolled in the registry that completed a cross-sectional mailed survey (N = 1026).

      Measurements

      Participant demographics (age, gender, marital status, race, education), overall health (self-rated health, pain, and comorbidities), and health behaviors (physical activity, smoking, drinking behaviors) were collected from the registry database. A mail survey was used to collect self-report on sleep problems and their current healthcare seeking behaviors. Simple and multiple logistic regression models were used to evaluate associations between variables.

      Results

      A total of 19.3% of participants reported being “dissatisfied” or “very dissatisfied” with their overall sleep quality. Participants who reported poor sleep satisfaction were more likely to be single and report poorer overall health compared to participants who were satisfied with their sleep quality. They were also more likely to report using over-the-counter (OTC) and prescription sleep medications, discuss sleep problems with a healthcare provider, and use strategies to improve their sleep (P < .05). A higher proportion of participants with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) or prescription (20.1%) sleep aids.

      Conclusions

      These results underscore the possible linkage between poor satisfaction with sleep and older adults' current healthcare seeking behaviors and self-treatment methods, particularly using OTC medications to cope with sleep problems without consulting a healthcare provider.

      Keywords

      Introduction

      Sleep is an integral part of maintaining physical, cognitive, and emotional health and well-being
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      National Sleep Foundation's sleep time duration recommendations: methodology and results summary.
      ; however, poor sleep health is a common problem among the elderly in the United States.
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      National Sleep Foundation's sleep time duration recommendations: methodology and results summary.
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      We are chronically sleep deprived.
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      Association between osteoporosis and sleep duration in healthy middle-aged and elderly adults: a large-scale, cross-sectional study in Japan.
      The National Sleep Foundation recommends that older adults (aged 65 and older) obtain 7 to 8 hours of sleep each night to avoid compromising their health.
      • Hirshkowitz M.
      • Whiton K.
      • Albert S.M.
      • et al.
      National Sleep Foundation's sleep time duration recommendations: methodology and results summary.
      Despite this recommendation, 25% to 32% of older adults in the United States get fewer than 7 hours of sleep.
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      Unhealthy sleep-related behaviors - 12 states, 2009.
      • Centers for Disease Control and Prevention (CDC)
      Effect of short sleep duration on daily activities - United States, 2005–2008.
      Furthermore, 15% to 50% of older adults reported that they have experienced sleep difficulties.
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      Associations of frequent sleep insufficiency with health-related quality of life and health behaviors.
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      Sleep complaints among elderly persons: an epidemiologic study of three communities.
      Potential contributing factors to decreased sleep quality in the elderly include changes in chronic conditions, medication use, circadian rhythms, and sleep patterns.
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      Subjective and objective sleep quality and aging in the sleep heart health study.
      Additionally, older adult women in particular report significantly more sleep problems than men.
      • Strine T.W.
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      Associations of frequent sleep insufficiency with health-related quality of life and health behaviors.
      Many older adults often have one or multiple chronic diseases or comorbidities, which may further increase the risk for adverse health effects and symptoms associated with sleep difficulties.
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      • Walsh J.
      Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation sleep in America survey.
      Poor sleep health may impact several domains in older adults such as difficulty sustaining attention, slowed response time, impairments in memory and concentration, decreased ability to accomplish daily tasks, and increased risk of falls.
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      • et al.
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      In order to improve sleep quality in older adults, there must be a better understanding of the multitude of factors impacting their sleep satisfaction.
      Despite the growing literature on sleep disturbance and prevalence in the elderly population, sleep difficulties in older adults are under-recognized and undertreated; one study found that many elderly patients often do not disclose sleep difficulties to their healthcare providers.
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      Untreated sleep problems in older adults may result in decreased health-related quality of life, loss of independence due to functional limitations, multiple chronic conditions, cardiovascular disease, obesity, and diabetes.
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      Sleep and the epidemic of obesity in children and adults.
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      Further study is needed to better understand the association between sleep satisfaction and healthcare seeking behaviors in older adults. With a greater awareness and establishment of these issues, healthcare providers, older adults in the general public, and researchers can begin to treat satisfaction with sleep as an indicator of overall health, alongside other standard indicators such as blood pressure and quality of life.
      Hence, the objective of this study was to elucidate factors including demographics, overall health, and health behaviors that may be associated to poor satisfaction with sleep in older adults. The associations between satisfaction with sleep, reported sleep problems, and healthcare seeking behaviors were also explored. We hypothesized that individual characteristics, such as being a female and self-rated poorer overall health are associated with poor satisfaction with sleep. In addition, poor satisfaction with sleep is associated with increasing underlying sleep problems and healthcare seeking behaviors.

      Participants and methods

      Study participants

      Study participants were members of the Pittsburgh Claude D. Pepper Older Americans Independence Center Community Registry of community-dwelling persons in the Pittsburgh, Pennsylvania region aged 60 or older. Registry members previously consented to being contacted for participation in Pepper-approved research studies, and are followed yearly to update their contact and basic health information.

      Data collection

      Survey packets containing an introduction to the study, consent form, mail survey, and a pre-addressed stamped return envelope were sent via the United States Postal Service (USPS) to 2064 Pepper registrants in February 2015. The survey was created based upon prior research and the objectives of this study using investigator developed questions and adapted items from validated sleep health questionnaires.
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      Insomnia and health services utilization in middle-aged and older adults: results from the health and retirement study.
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      Survey questions were designed to collect information on older adults' perceptions of sleep quality, satisfaction with sleep, and approaches used to alleviate sleep problems. Survey questions were vetted by the research team and piloted with multiple older adults in the community to ensure they were clear to study participants. Follow-up reminder postcards were sent out after the initial survey packet mailing and surveys were returned through April 2015. Surveys were returned by 1026 participants with a response rate of 49.7%. Eleven of the returned surveys were excluded from analyses due to missing information regarding sleep satisfaction, resulting in a final sample of 1015 participants. This study was approved by the Institutional Review Board at the University of Pittsburgh.

      Measures

      Overall satisfaction with sleep

      Overall satisfaction with sleep quality was measured on a 5-point Likert scale (1 = very dissatisfied to 5 = very satisfied) with the following survey item: “please rate your overall satisfaction with your sleep quality.” We classified participants into two groups based on their reported overall satisfaction with sleep quality. A participant was defined as “satisfied or neutral” (Group 1) if he/she reported being very satisfied, satisfied, or neutral (neither satisfied nor dissatisfied) with sleep quality. Participants that reported being “dissatisfied” or “very dissatisfied” were classified as “dissatisfied” (Group 2).

      Participant characteristics: Demographics, overall health, and health behaviors

      Participant characteristics that were potentially associated with poor satisfaction with sleep, which included demographics, overall health, and health behaviors, were collected by the Pepper registry database and linked to survey responses. Participant demographics included age, gender, marital status, race, and educational attainment. To assess overall health, participants' self-rated health (excellent, very good, good, fair/poor), pain (never, sometimes, or often/always have pain), and number of reported comorbidities were used from the registry database. Health behaviors were assessed by participants' reported participation in physical activity (daily, >3 times a week, <3 times a week, or none), and smoking (not at all, some days, and every day) and drinking (not at all or yes) behaviors in the past 30 days.

      Sleep problems

      Problems with sleep were assessed with three survey items. To assess sleep problems, participants were asked “how often do you have trouble sleeping at night?” Responses included a range from 1 to 3 nights per week to 1 to 2 nights per year, or never. Participants were asked to select troublesome aspects of sleep, with responses such as trouble falling asleep, excessively sleepy during the day, or other with the request to specify if not listed. To assess the potential causes of sleep problems, participants were asked “do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months?” Participants were asked to select from responses that included work hours and/or demands of work, emotional stress from work-related activities, family commitments, changing circadian rhythms, or another specified reason.

      Healthcare seeking behaviors

      Participants' healthcare seeking behaviors and coping strategies to address sleep problems were assessed using five survey items. Participants were asked to answer yes or no to the following questions to assess healthcare seeking behaviors regarding sleep problems: “have you ever been diagnosed with a sleep condition by a doctor”; “have you ever discussed sleep problems with a health care provider?”; “have you ever used OTC sleep aid medication?”? and “have you ever used prescription sleep aid medication?” To assess coping strategies for sleep problems, participants were asked “do you use any of the following methods regularly to help you fall sleep?” Examples of responses included reading, watching TV, or taking an over-the-counter (OTC) or prescription medication.

      Statistical data analysis

      Based on findings from previous research and our study objectives, we hypothesized that participants less satisfied with sleep would report poorer overall health, unfavorable health behavior, more sleep problems, and healthcare seeking behaviors such as consulting a healthcare provider or using various strategies (eg, OTC or prescription medications, reading before bed) to help improve sleep. We also investigated gender differences in poor satisfaction with sleep, sleep disturbances, and healthcare seeking behaviors.
      In order to provide meaningful comparison and to identify factors associated with poor satisfaction with sleep, the responses to the question of sleep quality were collapsed into two groups: Group 1 - Satisfied or neutral about their sleep quality, included very satisfied, satisfied, and neutral (neither satisfied nor dissatisfied); and Group 2 – Dissatisfied, included dissatisfied and very dissatisfied (see Table 1). To test our first hypothesis, descriptive and bivariate analyses were used to describe the characteristics of the sample in the two groups. Multiple logistic regression models were used to examine the associations between sleep satisfaction and participants' characteristics, including demographics, overall health status, and health behaviors (see Table 2). To test our second hypothesis, descriptive analyses were conducted to assess the association between sleep problems, healthcare seeking behaviors, and sleep satisfaction (see Table 3, Table 4). P < .05 was considered to be evidence of a statistical trend, and 95% confidence intervals were calculated. Sensitivity analyses were conducted using sequential imputations to account for missing data from survey responses. All survey items had a missing rate of no more than 5%. Statistical analyses were performed using Stata statistical software (version 13; Stata Corp, College Station, TX) and SAS (version 9.3; SAS Institute, Inc, Cary, NC).
      Table 1Participants' Characteristics.
      Group 1 Satisfied or neutralGroup 2 DissatisfiedP
      Total number (N, %)819 (80.7)196 (19.3)
      Demographics (N, %)
      Age (year)0.16
       60–69115 (14.0)30 (15.3)
       70–7390 (47.6)92 (46.9)
       80–89274 (33.5)57 (29.1)
       90+40 (4.9)17 (8.7)
      Female480 (58.6)130 (66.3)0.05
      Marital status<0.01
       Married490 (59.8)93 (47.5)
       Single (never married)78 (9.5)28 (14.3)
       Widowed175 (21.4)51 (26.0)
       Divorced/separated68 (8.3)24 (12.2)
       Missing/skipped8 (1.0)0 (0.0)
      Race0.59
       Non-hispanic white747 (91.2)175 (89.3)
       Non-hispanic Black50 (6.1)15 (7.7)
       Other race (includes those of hispanic ethnicity)15 (1.8)5 (2.6)
       Missing/skipped7 (0.9)1 (0.5)
      Education0.15
       More than 4-year college degree399 (48.7)105 (53.6)
       Some college/4-year college degree287 (35.0)67 (34.2)
       HS degree/GED or less126 (15.4)20 (10.2)
       Missing/skipped7 (0.9)4 (2.0)
      Overall health (N, %)
      Self-rated health<0.01
       Excellent88 (10.7)17 (8.7)
       Very good343 (41.9)50 (25.5)
       Good300 (36.6)90 (45.9)
       Fair/poor68 (8.3)32 (16.3)
       Missing/skipped20 (2.4)7 (3.6)
      Pain0.03
       Never have pain121 (14.8)24 (12.2)
       Sometimes have pain464 (56.7)100 (51.0)
       Often/always have pain221 (27.0)72 (36.7)
       Missing/skipped13 (1.6)0 (0.0)
      Number of comorbidities (mean, SD)1.87 (1.18)2.13 (1.22)<0.01
      Health behavior (N, %)
      Participation in physical activity0.30
       Daily192 (23.4)32 (16.3)
       >3 times a week211 (25.8)54 (27.6)
       <3 times a week189 (23.1)45 (23.0)
       No197 (24.1)49 (25.0)
       Missing/skipped30 (3.7)16 (8.2)
      Smoking0.12
       Not at all759 (92.7)174 (88.8)
       Every day & some days21 (2.6)9 (4.6)
       Missing/skipped39 (4.8)13 (6.6)
      Drinking0.16
       Not at all262 (32.0)73 (37.2)
       Yes528 (64.5)116 (59.2)
       Missing/skipped29 (3.5)7 (3.6)
      Table 2Factors Associated with Poor Satisfaction: Multiple Logistic Regression (Reference Group = Satisfied/Neutral).
      Adjusted odds ratio95% Confidence interval
      Demographics
      Age (year)
       60–69RefRef
       70–790.970.59–1.58
       80–890.810.46–1.41
       90+1.410.64–3.12
      Female1.340.92–1.94
      Marital status
       MarriedRefRef
       Single (Never married)1.801.07–3.04
       Widowed1.740.99–3.05
       Divorced/separated1.330.85–2.08
      Race
       Non-hispanic whiteRefRef
       Non-hispanic black0.850.43–1.66
       Other1.230.43–3.58
      Education
       More than 4-year college degreeRefRef
       Some college/4-year college degree0.480.27–0.84
       HS degree/GED or less0.810.57–1.17
      Overall health
      Self-rated health
       ExcellentRefRef
       Very good0.680.36–1.27
       good1.540.82–2.86
       Fair/poor2.261.05–4.85
      Pain
       Never have painRefRef
       Sometimes have pain1.030.62–1.74
       Often/always have pain1.340.76–2.35
      Health behavior
      Participation in physical activity
       DailyRefRef
       >3 times a week1.630.99–2.66
       <3 times a week1.390.84–2.29
       No1.150.68–1.94
      Current smoking
       Not at allRefRef
       Every day and some days1.850.78–4.42
      Current drinking
       Not at allRefRef
       Yes0.960.66–1.39
      Table 3Sleep Problems and Healthcare Seeking Behaviors by Sleep Satisfaction.
      Group 1, not dissatisfied (satisfied or neutral)Group 2, dissatisfiedP
      Total Number (N, %)n = 819 (80.7)n = 196 (19.3)
      Sleep problems (N, %)
      How often do you have trouble sleeping at night?<0.01
       Every Night25 (3.1)63 (32.1)
       4–6 Nights Per Week25 (3.1)46 (23.5)
       1–3 Nights Per Week123 (15.0)53 (27.0)
       2–3 Nights Per Month201 (24.5)13 (6.6)
       1 Nights Per Month121 (14.8)5 (2.6)
       <1 Nights Per Month121 (14.8)5 (2.6)
       1–2 Nights Per Year110 (13.4)4 (2.0)
       Never87 (10.6)4 (2.0)
       missing/skipped6 (0.7)2 (1.0)
      Troublesome aspects of sleep:
       Trouble falling asleep157 (19.2)97 (49.5)<0.01
       Trouble sleeping throughout the night343 (41.9)153 (78.1)<0.01
       Wake up too early in the morning173 (21.1)73 (37.5)<0.01
       Nightmares29 (3.5)12 (6.1)0.16
       Excessively sleepy during the day62 (7.6)28 (14.3)0.01
       Other109 (13.3)36 (18.4)0.09
       No trouble sleeping at night214 (26.1)12 (6.1)<0.01
      Do any of the following cause you difficulty initiating sleep more than 4 times a month for at least 2 consecutive months?
       Work hours and/or demands of work45 (6.0)18 (10.7)0.06
       Emotional stress from work-related activities33 (4.4)20 (11.8)<0.01
       Family commitments95 (12.6)38 (22.8)<0.01
       Changing circadian rhythms55 (7.5)35 (22.3)<0.01
       Other69 (16.7)33 (34.4)<0.01
      Healthcare seeking behavior and coping strategy
      Ever been diagnosed with a sleep condition by a doctor:0.36
       Yes104 (12.7)30 (15.3)
       No698 (85.2)164 (83.7)
       Missing/skipped17 (2.1)2 (1.0)
      Have you ever discussed sleep problems with a healthcare provider<0.01
       Yes196 (23.9)107 (54.6)
       No620 (75.7)88 (44.9)
       Missing/skipped3 (0.4)1 (0.5)
      OTC sleep aids (ever use)<0.01
       Yes145 (17.7)70 (35.7)
       No674 (82.3)126 (64.3)
       Missing/skipped0 (0.0)0 (0.0)
      Prescription sleep aids (ever use)<0.01
       Yes79 (9.7)43 (21.9)
       No734 (89.6)153 (78.1)
       Missing/skipped6 (0.7)0 (0.0)
      Do you use any of the following methods regularly to help you fall asleep? (Top three)
      Reading339 (41.4)90 (45.9)0.04
      Taking OTC or prescription119 (14.5)66 (33.7)<0.01
      Watching TV233 (28.5)72 (36.7)<0.01
      Table 4Healthcare seeking behaviors by sleep problem.
      Trouble sleeping throughout the nightWake up too early in the morningNightmaresExcessively sleepy during the dayTrouble falling asleep
      (n = 496)(n = 246)(n = 41)(n = 90)(n = 254)
      Have discussed sleep problems with a healthcare provider (N, %)120 (47.2)199 (40.1)102 (41.5)17 (41.5)38 (42.2)
      Have been diagnosed with a sleep condition (N, %)41 (16.1)70 (14.1)39 (15.9)4 (9.8)26 (28.9)
      Ever uses OTC sleep aids (N, %)98 (38.6)140 (28.2)70 (28.5)10 (24.4)26 (28.9)
      Uses prescription sleep aids (N, %)51 (20.1)76 (15.3)41 (16.7)10 (24.4)18 (20.0)

      Results

      Table 1 describes the characteristics of survey respondents. Study participants were well-educated and reported healthy lifestyles, more than 80% having a college degree or higher and the majority (>90%) being non-smokers. A total of 819 (80.7%) participants indicated they were “satisfied or neutral” when asked to rate their overall sleep quality (Group 1), while 196 (19.3%) reported they were “dissatisfied” (Group 2). There were statistical trends towards differences in gender, marital status, self-rated health, pain, and number of comorbidities between the groups. Dissatisfied participants were more likely to not be married (52.5% vs. 40.2%, P < .01). These participants also reported poorer overall health status compared to participants who were satisfied with their sleep quality (self-rated poor health: 16.3% vs. 8.3%, P < .01; always have pain: 36.7% vs. 27.0%, P = .03; number of comorbidities: 2.13 vs. 1.87, P < .01).

      Participants' characteristics and satisfaction with sleep quality

      Based on the multiple logistic regression results shown in Table 2, the likelihood of reporting poor satisfaction with sleep was higher among single (never married) compared with married participants (Adjusted odds ratio/AOR: 1.80, 95% confidence interval/CI: 1.07–3.04) and self-rated fair/poor health status compared to excellent health status (AOR: 2.26, 95% CI: 1.05–4.85), and lower among participants with some college/4-year college degree compared to more than 4 year college degree (AOR: 0.48, 95% CI: 0.27–0.84). There were no statistical trends in differences between age, gender, race, health behaviors, or experience of pain between the two groups, and thus our hypothesis regarding the association between these demographic variables and poor satisfaction with sleep was not supported. The count of comorbidities variable was excluded from the multiple logistic regression model due to its collinearity with self-rated health status.

      Sleep problems, healthcare seeking behaviors and coping strategy

      Participants that reported poor satisfaction with sleep were more likely to state they had sleep problems, including trouble sleeping at night (Table 3). These participants reported greater frequency of all aspects of troublesome sleep except “nightmares” (P < .05). Most reported trouble sleeping throughout the night (78.1%), half trouble falling asleep (49.5%), and more than one third “waking up too early in the morning” (37.5%). Similarly, participants that reported poor satisfaction with sleep were also more likely to report they had used OTC and prescription sleep medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to help improve sleep quality (P < .05). There was no statistical trend in “diagnosed with a sleep condition by a doctor” between participants who were satisfied/neutral or dissatisfied regarding their sleep quality.
      The most frequently reported sleep problem was trouble sleeping throughout the night (N = 496). Among participants with sleep problems, a higher proportion with trouble sleeping throughout the night reported they had discussions with a healthcare provider (47.2%), and used OTC (38.6%) and prescription (20.1%) sleep aids, while participants with trouble falling asleep had a higher proportion of being diagnosed with a sleep condition (28.9%). These results are shown in Table 4. Sensitivity analysis was conducted to test the impact of missing data by comparing the multiple logistic regression results using multiple imputations to complete case analysis and we found no significant difference in study results.

      Discussion

      Study findings indicate that a number of community-dwelling older adults have poor satisfaction with their sleep quality. This has important implications for healthcare providers caring for older adult patients. Participants in this study who reported poor satisfaction with sleep were more likely to be single and have poorer overall health compared to participants who were satisfied with their sleep. Additionally, participants who were less satisfied with sleep and those who reported trouble sleeping throughout the night were more likely to report they had used OTC and prescription medications, discussed sleep problems with a healthcare provider, and used a variety of strategies to improve sleep.
      A total of 19.3% of survey respondents reported being “dissatisfied” with their overall sleep quality; which is consistent with previous research involving older adults on self-reported sleep disturbance or tiredness.
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      Participants who were less satisfied with their sleep were more likely to be single and reported poorer overall health status. This finding is consistent with previous research which suggests that older adults often have chronic health conditions which prevent them from getting a good night's sleep.
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      When seeking to improve sleep quality, many older adults may overlook behavioral and environmental interventions and instead seek to address their sleep difficulties with prolonged use of OTC medications. As buttressed by findings from this study, participants that reported poor satisfaction with sleep were more likely to have used OTC and prescription sleep medications and report poorer overall health. Previous research has shown that as many as 5.5% of adults age 60 to 69 and 7% of adults age 80 and older are taking a prescription sleep aid.
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      • Vitiello M.V.
      • Zee P.
      Sleep health and appropriate use of OTC sleep aids in older adults—recommendations of a Gerontological Society of America workgroup.
      • Jacobs J.M.
      • Cohen A.
      • Hammerman-Rozenberg R.
      • Stessman J.
      Global sleep satisfaction with older people: the Jerusalem cohort study.
      In this study, nearly half of participants who had trouble sleeping throughout the night reported seeking consultation from their healthcare provider (47.2%), and a similar rate was reported by those who reported having trouble falling sleep (42.2%). Previous research found that only 58% of patients told their physicians about their recent and past OTC medication use.
      • Sleath B.
      • Rubin R.H.
      • Campbell W.
      • Gwyther L.
      • Clark T.
      Physician-patient communication about over-the-counter medications.
      Discussions about the use of OTC medications with healthcare providers can facilitate conversations about common sleep disturbances to determine more safe and effective approaches to improve older adults' sleep quality.
      Findings from this study highlight the associations between reported poor satisfaction with sleep and healthcare seeking behaviors of older adults. Future studies should examine how to proactively identify older adults with sleep problems and increase awareness of recommended non-pharmacological approaches to improve sleep quality. This study has several study limitations. This was a cross-sectional study, and data were limited to members of the Pepper Community Registry which is not a representative sample of older adults living in the United States. Registry participants had relatively high level of education and were primarily white, thus results are not generalizable to the overall older adult population in the United States. The results are also subject to the inherent limitation of self-reported data (recall bias), which relied on respondents to complete the surveys accurately. Future research can utilize not only self-report but also objective measures of sleep such as polysomnography or actigraphy—a method of measuring sleep by recording wrist movement.
      • Spira A.P.
      • Covinsky K.R.
      • Stone K.L.
      • et al.
      Objectively measured sleep quality and nursing home placement in older women.
      It has been indicated that older adults may underreport the severity of sleep disturbances compared to objective methods using polysomnography, and use of this tool may provide a more accurate assessment of sleep quality.
      • Vitiello M.V.
      • Larsen L.H.
      • Moe K.E.
      Age-related sleep change: gender and estrogen effects on the subjective–objective sleep quality relationships of healthy, noncomplaining older men and women.

      Conclusions

      In conclusion, our findings underscore the possible linkage between sleep satisfaction and older adults' healthcare seeking behaviors including the use of self-care methods, particularly OTC medications to cope with sleep problems, and the need for additional research. It is important that healthcare providers, such as physicians and pharmacists, discuss sleep health with older adult patients and provide education on appropriate sleep hygiene behaviors to improve sleep satisfaction.

      Author contributions

      All authors have contributed to this manuscript, revised and edited the manuscript, and approved the final version. Olufunmilola Abraham: study concept and design, acquisition of data, analysis and interpretation of data. Jia Pu: data analysis and interpretation and preparation of the manuscript. Loren J. Schleiden: data collection, analysis and interpretation and preparation of the manuscript. Steve M. Albert: study concept and design, data interpretation and analysis, and preparation of the manuscript. All authors state that they had complete access to the study data that support this publication.

      Sponsor's role

      None.

      Disclosure

      Dr Abraham has nothing to disclose.
      Dr Pu has nothing to disclose.
      Dr Schleiden has nothing to disclose.
      Dr Albert has nothing to disclose.

      Acknowledgments

      We acknowledge Amanda Brothers, Research Specialist, University of Pittsburgh, School of Pharmacy for editorial assistance in revising the final manuscript for publication. This research was supported by the AcademyHealth New Investigator Small Grant Program (NISGP). Results from this study were presented as a podium presentation at the AcademyHealth annual meeting on June 2016. The Pepper Community Registry is supported by the Pittsburgh Claude D. Pepper Older Americans Independence Center, NIH P30 AG024827.

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