Associations of objective and subjective sleep disturbance with cognitive function in older men with comorbid depression and insomnia

Published:April 10, 2017DOI:



      To examine whether poor objective and subjective sleep quality are differentially associated with cognitive function.




      Participants were recruited from primary and secondary care, and directly from the community, in Sydney, Australia.


      The sample consisted of 74 men 50 years and older (mean [SD], 58.4 [6.2] years), with comorbid depression and above-threshold insomnia symptoms, participating in a trial of online cognitive behavioral therapy for insomnia.


      Insomnia severity and depression severity were assessed via self-report. Objective sleep efficiency and duration were measured using actigraphy. Objective cognitive function was measured using 3 subtests of a computerized neuropsychological battery.


      Poor objective sleep efficiency was associated with slower reaction time (r = −0.249, P = .033) and poorer executive functioning (odds ratio, 4.14; 95% confidence interval, 1.35-12.69), but not memory. These associations remained after adjusting for age, education, depression severity, cardiovascular risk, and medication. Subjective sleep quality was not related to cognitive function.


      Among older men with depression and insomnia, objectively measured poor sleep efficiency may be associated with worse cognitive function, independent of depression severity. Objective poor sleep may be underpinned by neurobiological correlates distinct from those underlying subjective poor sleep and depression, and represent a potentially effective modifiable mechanism in interventions to improve cognitive functioning in this population. This supports the use of objective measures of sleep in diagnostic assessments and care.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Sleep Health: Journal of the National Sleep Foundation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dias V.V.
        • Brissos S.
        • Frey B.N.
        • Kapczinski F.
        Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder.
        J Affect Disord. 2008; 110: 75-83
        • Tolman A.W.
        • Kurtz M.M.
        Neurocognitive predictors of objective and subjective quality of life in individuals with schizophrenia: a meta-analytic investigation.
        Schizophr Bull. 2012; 38: 304-315
        • Fortier-Brochu É.
        • Beaulieu-Bonneau S.
        • Ivers H.
        • Morin C.M.
        Insomnia and daytime cognitive performance: a meta-analysis.
        Sleep Med Rev. 2012; 16: 83-94
        • Hammar Å.
        • Årdal G.
        Cognitive functioning in major depression—a summary.
        Frontiers in human neuroscience. 2009; 3: 26
        • Cricco M.
        • Simonsick E.M.
        • Foley D.J.
        The impact of insomnia on cognitive functioning in older adults.
        J Am Geriatr Soc. 2001; 49: 1185-1189
        • Shekleton J.A.
        • Flynn-Evans E.E.
        • Miller B.
        • et al.
        Neurobehavioral performance impairment in insomnia: relationships with self-reported sleep and daytime functioning.
        Sleep. 2014; 37: 107-116
        • Nissen C.
        • Kloepfer C.
        • Nofzinger E.A.
        • Feige B.
        • Voderholzer U.
        • Riemann D.
        Impaired sleep-related memory consolidation in primary insomnia-a pilot study.
        Sleep. 2006; 29: 1068-1073
        • Morin C.M.
        • Jarrin D.C.
        Epidemiology of insomnia: prevalence, course, risk factors, and public health burden.
        Sleep Med Clin. 2013; 8: 281-297
        • Vgontzas A.N.
        • Fernandez-Mendoza J.
        • Liao D.
        • Bixler E.O.
        Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder.
        Sleep Med Rev. 2013; 17: 241-254
        • Fernandez-Mendoza J.
        • Calhoun S.
        • Brixler E.O.
        • et al.
        Insomnia with objective short sleep duration is associated with deficits in neuropsychological performance: a general population study.
        Sleep. 2010; 33: 459-465
        • Naismith S.L.
        • Norrie L.M.
        • Mowszowski L.
        • Hickie I.B.
        The neurobiology of depression in later-life: clinical, neuropsychological, neuroimaging and pathophysiological features.
        Prog Neurobiol. 2012; 98: 99-143
        • Naismith S.L.
        • Longley W.A.
        • Scott E.M.
        • Hickie I.B.
        Disability in major depression related to self-rated and objectively-measured cognitive deficits: a preliminary study.
        BMC Psychiatry. 2007; 7: 32
        • Lee R.
        • Hermens D.
        • Naismith S.
        • et al.
        Neuropsychological and functional outcomes in recent-onset major depression, bipolar disorder and schizophrenia-spectrum disorders: a longitudinal cohort study.
        Transl Psychiatry. 2015; 5: e555
        • McDermott L.M.
        • Ebmeier K.P.
        A meta-analysis of depression severity and cognitive function.
        J Affect Disord. 2009; 119: 1-8
        • Gallagher D.
        • Savva G.M.
        • Kenny R.
        • Lawlor B.A.
        What predicts persistent depression in older adults across Europe? Utility of clinical and neuropsychological predictors from the SHARE study.
        J Affect Disord. 2013; 147: 192-197
        • Sivertsen B.
        • Salo P.
        • Mykletun A.
        • et al.
        The bidirectional association between depression and insomnia: the HUNT study.
        Psychosom Med. 2012; 74: 758-765
        • Naismith S.L.
        • Norrie L.M.
        • Lewis S.J.
        • Rogers N.L.
        • Scott E.M.
        • Hickie I.B.
        Does sleep disturbance mediate neuropsychological functioning in older people with depression?.
        J Affect Disord. 2009; 116: 139-143
        • Naismith S.L.
        • Rogers N.L.
        • Lewis S.J.
        • et al.
        Sleep disturbance relates to neuropsychological functioning in late-life depression.
        J Affect Disord. 2011; 132: 139-145
        • Scullin M.K.
        • Bliwise D.L.
        Sleep, cognition, and normal aging: integrating a half century of multidisciplinary research.
        Perspectives Psychol Sci. 2015; 10: 97-137
        • Cockayne N.L.
        • Christensen H.M.
        • Griffiths K.M.
        • et al.
        The sleep or mood novel adjunctive therapy (SOMNA) trial: a study protocol for a randomised controlled trial evaluating an internet-delivered cognitive behavioural therapy program for insomnia on outcomes of standard treatment for depression in men.
        BMC Psychiatry. 2015; 15: 16
        • Rush A.J.
        • Trivedi M.H.
        • Ibrahim H.M.
        • et al.
        The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), clinician rating (QIDS-C), and self-report (QIDS-SR): a psychometric evaluation in patients with chronic major depression.
        Biol Psychiatry. 2003; 54: 573-583
        • Bastien C.H.
        • Vallières A.
        • Morin C.M.
        Validation of the Insomnia Severity Index as an outcome measure for insomnia research.
        Sleep Med. 2001; 2: 297-307
        • Allen R.P.
        • Burchell B.J.
        • MacDonald B.
        • Hening W.A.
        • Earley C.J.
        Validation of the self-completed Cambridge-Hopkins Questionnaire (CH-RLSq) for ascertainment of restless legs syndrome (RLS) in a population survey.
        Sleep Med. 2009; 10: 1097-1100
        • Netzer N.C.
        • Stoohs R.A.
        • Netzer C.M.
        • Clark K.
        • Strohl K.P.
        Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome.
        Ann Intern Med. 1999; 131: 485-491
        • First M.B.
        • Spitzer R.L.
        • Gibbon M.
        • Williams J.B.W.
        Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research Version, Patient Edition (SCID-I/P).
        Biometrics Research, New York State Psychiatric Institute, New York2002
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Radloff L.S.
        The CES-D scale: a self-report depression scale for research in the general population.
        Appl Psychol Measur. 1977; 1: 385-401
        • Philips
        Equivalence of Activity Recordings and Derived Sleep Statistics.
        (accessed 31.03.16)
        • Naismith S.L.
        • Rogers N.L.
        • Hickie I.B.
        • Mackenzie J.
        • Norrie L.M.
        • Lewis S.J.
        Sleep well, think well: sleep-wake disturbance in mild cognitive impairment.
        J Geriatr Psychiatry Neurol. 2010; 23: 123-130
        • Sahakian B.
        • Owen A.
        Computerized assessment in neuropsychiatry using CANTAB: discussion paper.
        J R Soc Med. 1992; 85: 399-402
        • Carpenter J.S.
        • Robillard R.
        • Lee R.S.
        • et al.
        The relationship between sleep-wake cycle and cognitive functioning in young people with affective disorders.
        PLoS One. 2015; 10e0124710
        • Edinger J.D.
        • Means M.K.
        • Carney C.E.
        • Krystal A.D.
        Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia.
        Sleep. 2008; 31: 599-607
        • Winkelman J.W.
        • Buxton O.M.
        • Jensen J.E.
        • et al.
        Reduced brain GABA in primary insomnia: preliminary data from 4T proton magnetic resonance spectroscopy (1H-MRS).
        Sleep. 2008; 31: 1499-1506
        • Vgontzas A.N.
        • Bixler E.O.
        • Lin H.M.
        • et al.
        Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications.
        J Clin Endocrinol Metab. 2001; 86: 3787-3794
        • Drummond S.P.
        • Walker M.
        • Almklov E.
        • Campos M.
        • Anderson D.E.
        • Straus L.D.
        Neural correlates of working memory performance in primary insomnia.
        Sleep. 2013; 36: 1307-1316
        • Stoffers D.
        • Altena E.
        • van der Werf Y.D.
        • et al.
        The caudate: a key node in the neuronal network imbalance of insomnia?.
        Brain. 2014; 137: 610-620
        • Haimov I.
        • Shatil E.
        Cognitive training improves sleep quality and cognitive function among older adults with insomnia.
        PLoS One. 2013; 8e61390
        • Sadeh A.
        The role and validity of actigraphy in sleep medicine: an update.
        Sleep Med Rev. 2011; 15: 259-267
        • Kaplan K.A.
        • Talbot L.S.
        • Gruber J.
        • Harvey A.G.
        Evaluating sleep in bipolar disorder: comparison between actigraphy, polysomnography, and sleep diary.
        Bipolar Disord. 2012; 14: 870-879
        • McCall C.
        • McCall W.V.
        Comparison of actigraphy with polysomnography and sleep logs in depressed insomniacs.
        J Sleep Res. 2012; 21: 122-127