Upsala J Med Sci 102: 185-198, 1997 

A Survey of Sleep Habits and Sleeping Difficulties in 
an Elderly Swedish Population 

Lena Mallon', and Jerker Hetta' 
'Sleep Disorders Unit, Department of Psychiatry, University Hospital, Uppsala, Sweden and 

'Psychiatric Clinic, Falun Hospital, Falun, Sweden 

ABSTRACT 

A random sample of 876 subjects aged 65-79 years were investigated by means of a questionnaire 
concerning sleep and related factors. Sleep problems were reported by 23.8% of females and 13.3% 
of males.Moderate or major complaints of maintaining sleep were reported by 43.5% of subjects, 
early morning awakening 33.4% and difficulties falling asleep 31.4%. Daytime sleepiness was more 
common among males, and a relationship between daytime sleepiness and perceived poor sleep was 
found. Daytime napping was common, but not related to poor sleep. The prevalence of regular 
sleeping pill users was 7.6% for females and 3.0% for males and a relationship between sleep 
problems, sleeping pill usage and psychiatric symptoms was established. Among the regular sleeping 
pill users 39.1% had possible depression (PD) and 63.0% had possible anxiety disorder (PA). 
Among respondents with sleep complaints 29.8% had PD and 48.7% had PA. Sleep problems were 
also related to impaired physical health. Various medical illnesses contributed to sleep complaints 
among males, and depression affected sleep the most among females. 

INTRODUCTION 

During the last century there has been a progressive increase in the number of aged people in the 
community. This change in the demographic pattern will have profound medical consequences 
because a large proportion of these elderly suffer from chronic, disabling health problems, one of 
which is sleep disturbances. 

Several community based surveys of sleep disturbances have compared the prevalence of insomnia 
across age and demonstrated that sleep disturbances are common and that the prevalence of insomnia 
increases with age, especially among women (2, 11-16, 18, 19,26, 27). 

Karacan (1 1) conducted an interview survey in Houston USA of 2347 subjects aged 18 years and 
older. Difficulties initiating sleep did not appear to be age related, whereas difficulty maintaining 
sleep, early morning awakenings and use of hypnotic medication all increased with age both for 
females and males. Welstein (26) published results from a telephone survey in San Francisco USA, 
where 6340 respondents aged 6 to 103 years of age answered questions about sleeping habits. The 
age effect in the material was significant, supporting the finding of increasing sleep disturbances with 

15-980 148 185 



increasing age. In Lugaresis study (16) from San Marino where 5713 subjects aged between 3 and 94 
years were interviewed, reports of insomnia increased progressively after the 20th year. Mellinger 
(19) interviewed 3161 adults aged between 18 to 79 years in the National Survey of 
Psychotherapeutic Drug Use, a cross national survey in USA, and the prevalence of "trouble falling 
asleep or staying asleep a lot the past year" was 15% in the age group 35 to 49 years and 25% in the 
age group 65 to 79 years. One third of those with serious insomnia were characterized by syndromes 
resembling either depression or generalised anxiety. 

Recently more interest has been directed on providing information on sleep disturbances in the 
elderly population and some studies have specifically surveyed sleep disturbances among elderly 
subjects (3-5, 7, 8, 22). 

Data derived from the Activity and Ageing Survey in Nottinghamshire England, an interview study 
of 1023 subjects aged over 65 years published by Morgan ( 2 2 ) ,  reported prevalence of "current 
insomnia often or all the time", 22.5%, significantly more among women. Symptoms of anxiety 
rather than depression emerged out as a the more important predictor of poor sleep quality. From an 
interview survey in Canberra Australia of 874 elderly aged over 70 years Henderson (8) reported 
population prevalence of "trouble sleeping last two weeks", 18.0% for women and 12.6% for men. 
Gisalson (5) found that the most commonly reported insomnia complaint of 430 subjects aged over 
65 years on Iceland was habitual difficulties maintaining sleep, 37% of men and 30% of women. 
Occasional or habitual complaints of both difficulties initiating sleep, difficulties maintaining sleep and 
early morning awakenings was reported by 10.4% of subjects. In a study on the effects of exercise 
on cardiovascular function in Sunnyvale USA Bliwise (3) had the opportunity to study sleep habits in 
a group of 357 healthy adults aged 50 to 65 years. The results of the questionnaire study showed low 
prevalence of poor sleep. The prevalence of "trouble falling asleep every night or almost every night" 
was 2.6% for females and 1.1% for males, and "trouble awakening and returning back to sleep" was 
3.3% for females and 4.4% for males. Despite these low prevalences, about a third of the population 
reported not well-rested andor not getting the sleep they required. 

Even though these studies show an increase in sleeping difficulties with age, the prevalence figures 
show considerable variation, and only a few of the studies have investigated health status in relation 
to sleep. The principal aim of the present study was to investigate sleep habits, the prevalence and 
types of sleeping difficulties and related symptoms in a geographically-defined population of elderly 
in Sweden. 

MATERIAL AND METHODS 

Subjects 
The investigation was performed during the month of December 1995. A randomly selected sample 

of 1228 elderly inhabitants, 65-79 years, in the county of Dalarna in Sweden were asked to 
participate in a questionnaire survey. 

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Sleep questionnaire 

sleep behaviours and certain variables that might affect sleep. 
1. Demographic variables (age, gender, residential status, marital status). 
2. Questions about life style variables (smoking habits, alcohol drinking habits, coffee and tea 
consumption, car driving). 
3. Sleep habits. Questions about time for going to bed, time to fall asleep, number of nocturnal 
awakenings, total sleep time, time for arising, day time napping and sleep-requirement expectations. 
4. Questions adopted from the Uppsala Sleep Inventory (USI) (13-15) concerning the severity of 
various sleeping difficulties on a five-point 1. 1. scale (1= no problems, 2= small problems, 3= some 
problems, 4= great problems, 5= very great problems). In the subsequent statistical analysis scores 1 
and 2 were considered to represent "no complaints", score 3 "moderate complaints" and scores 4 and 
5 "major complaints". 
5. Questions adopted from Uppsala Sleep Inventory (USI) concerning how often a symptom 
occurred on a five-point scale (1= never, 2= seldom, 3= sometimes, 4= often, 5= very often). In the 
subsequent statistical analysis scores 1 and 2 were considered to represent "never", score 3 
"occasionally" and scores 4 and 5 "habitually". 
6. Questions adopted from the Basic Nordic Sleep Questionnaire (BNSQ) (23) concerning the 
frequency of a symptom during the last three months on a five-point scale. occurred ( I =  never or less 
than once a month, 2= less than once per week, 3= once or twice per week, 4= three to five times per 
week, 5= every night or almost every night). 
7. Questions about physical illness (medical history, hospital admissions, number of illnesses). 
Physical health status was to be rated on a six-point scale (l=excellent, 2=good, 3=quite good, 4= 
fairly good, 5=poor, 6=very poor). 
8. Questions about medication (medication currently used, past and present sleep medication usage). 
9. Measure of mood. The Hospital Anxiety and Depression Scale (HAD Scale) (28) consists of 14 
questions in which the overall severity of anxiety and depression is rated on a four point scale (0 to 
3). Seven questions are related to anxiety and seven to depression. It is recommended that scores of 8 
or more on a subscale are taken to indicate possible pathology. 

The survey sleep questionnaire contained 89 questions designed to supply information about typical 

Procedure 
Each subject was mailed a questionnaire, a pre-stamped envelope and a letter explaining the purpose 

of the study. Subjects were encouraged to call the investigator if they had any questions. Full 
anonymity protection was ensured. One month later a follow up letter, along with duplicates of all 
material, was sent to all non respondents. 

The study protocol was approved by the Ethics Committee of the Faculty of Medicine at Uppsala 
University in- Sweden. 

187 



Statistical methods 
The statistical analysis was performed on a Macintosh computer with the StatView software 

package. The results are presented as means 5 SD. A chi-squared test was used for categorical 
variables and unpaired t-test for continuous scales. For all results ~ 0 . 0 5  was required for statistical 
significance. 

RESULTS 

General results 
In all 876 subjects answered the questionnaire after one reminder giving a response rate of 71.3%. 

Respondents were 405 men and 471 women and their mean age was 71.2 years (SD=4.0 years, 
range 65 to 79 years). Table 1 gives the age and sex distribution of respondents in the study and the 
population in the county of Dalarna at the time of the study. The younger age groups were slightly 
overrepresented in the study and the age group of 75 years and older underrepresented. Of the males 
79.3% lived with someone else compared to 59.6% of females (x2=37.5; p<O.OOl), and 26.0% of 
females were widowed versus 9.1% of males (x2=40.8; p<O.OOI). 

Table 1. Age and sex distribution of respondents in the statistical analysis and the population in the 
county of Dalarna at the time of the study. 

Respondents in study Population of Dalarna county* 
Men (%) Women (%) Total Men (%) Women (%) Total (%) 

\ ’-/ 

Age group 
(in years) 
65-69 162 (40) 183 (39) 345 (39) 6 569 (35) 7 454 (33) 14 023 (34) 
70-74 140 (35) 156 (33) 296 (34) 6 510 (35) 7 542 (34) 14 052 (34) 
75-79 103 (25) 132 (28) 235 (27) 5 740 (30) 7 463 (33) 13 203 (32) 

*Source: Swedish Central Bureau of Statistics, Yearbook 1995, Stockholm 1996. 

Sleep habits 
Time for going to bed was similar between sexes, 10.32f 0.77 hours, but males woke up earlier, 

06.74f1.01 hours versus 07.04f 0.86 hours for females ( t =  4.6; p<O.OOI). Sleep latencies was 
significantly longer for females, 41.7+ 59.0 min versus 27.95 36.6 min (t=4.1; p<O.OOl), and 
females also reported a shorter total sleep time 398.8+ 81.5 min versus 416.2f 71.5 min ( k 3 . 3 ;  

The estimated need for sleep in the total sample was equal between males and females, 434.4f 59.0 
min. The ratio of amount of habitual sleep to the amount of estimated need for sleep expressed in 

p<O.OOl). 

188 



percent (called Sleep Sufficiency Index, SSI), was 91.4% for females and 95.7% for males ( ~ 4 . 2 ;  
p<O.OOl). The number of reported nocturnal awakenings ranged from 0 to 16, with a mean number 
of 1.9f 1.3 awakenings per night. No difference between sexes was found (Table 2). Of the study 
population 47.7% reported waking up at least twice per night and 19.5% reported waking up at least 
3 times per night, equal between sexes. 

Table 2. Sleep variables (means f S D )  according to gender. 

Variables Females Males t - value 

Time for going to bed 10.27f 0.76 10.37f 0.77 1.9 
(hours) 
Time for waking up (hours) 07.04f 0.86 06.74f l.O1 4.6*** 
Sleep latency (minutes) 41.7f 59.0 27.9f 36.6 4.1*** 

(minutes) 

(minutes) 
Sleep Sufficiency Index (%) 91.4f 14.6 95.7+ 13.2 4.2*** 
No of awakeningstnight 1.9f 1.4 1.8f 1.2 1.5 
*p<0.05, **p<O.Ol, ***p<O.OOl 

(n=47 1) (n=405) 

Total night sleep time 398.8f 81.5 416.2f 71.5 3.3*** 

Estimated sleep need 434.1f 61.0 434.8f 56.8 0.1 

Sleep complaints 
In a categorical (yes-no) question (CSP), 18.9% stated that they had sleep problems. Females more 

often than males, 23.8% versus 13.3% (x2=15.1; p<O.OOl). Subjects living alone did not report 
sleep problems more frequently than those living with someone else, and no relationship was found 
between reported sleep problems and coffee or tea consumption, smoking habits or body mass index 
(BMI). 
Table 3 shows the reported severity of sleeping difficulties according to the USI-question. The most 
commonly reported sleep complaints were difficulties maintaining sleep (DMS). Moderate complaints 
of DMS were reported by 34.2% of subjects, followed by moderate complaints of difficulties 
initiating sleep (DIS) 22.9% and moderate complaints of early morning awakenings (EMA) 21.7%. 
The only gender difference was a female preponderance in reports of major complaints of DIS, 
12.0% versus 4.5% (x2=19.2; p<O.OOl). 

189 



Table 3. Prevalence of sleeping difficulties according to gender (%). 

% females % males % total x2 value 
(n=471) (n=405) (n=876) 

Dificulties initiating sleep 

Moderate complaints 24.6 20.8 22.9 NS 
(DIS) 

Major complaints 12.0 4.5 8.5 19.2, 

Dificulties maintaining sleep 

33.9 34.6 34.2 NS 
(DMS) 
Moderate complaints 
Major complaints 10.0 8.5 9 . 3  N S  

Early morning awakenings 

20.1 23.5 21.7 N S  
(EMA) 
Moderate complaints 
Major complaints 12.0 11.3 11.7 NS 

p<O.OOl 

Pain was the most commonly reported complaint during initiation of sleep. Among females 18.8% 
and of males 10.0% reported this as a major complaint ( x 2 =  12.9; p<O.Ol), followed by major 
complaints of tension, 11.7% of females and 6.3% of males (x2=7.2; p<O.Ol). 

How many nights per week a sleeping difficulty occurred was measured by using BNSQ. Fig. 1 
shows that more than three out of four elderly, 78.3%, reported waking up at least one night per 
week and 60.7% reported waking up at least 3 nights per week. No difference between sexes was 
found. Of females 18.1% reported DIS at least 3 times per week versus 7.6% of males (x2=19.7; 
p<O.OOl) and 20.1% of females versus 13.8% of males reported EMA at least 3 times per week 
(x2=5.8; p<0.05). 

190 



Fig 1. Frequency of sleeping difficulties according to gender (%) 

m f m  f m f  
DIS DMS EMA 

Daytime symutoms 
Females reported more often than males "never" or only "occasionally" feeling well rested after 

sleep, 34.4% versus 23.5% (x2=12.0 p<O.OOI). Of the males, 26.0% had moderate complaints of 
daytime sleepiness compared to 17.5% of females ( x 2 =  8.2; peO.Ol), and 5.8% of males and 5.1% 
of females considered this a major problem. 

Subjects with moderate or major complaints of daytime sleepiness had shorter total night sleep time 

Of subjects reporting moderate or major complaints of daytime sleepiness 37.1% reported sleep 
problems in the categorical item (CSP) compared to 13.7% of those reporting no complaints of 
daytime sleepiness (x2=49.6; peO.001). 

Some 69.5% of males and 50.5% of females reported daytime napping at least occasionally 
(x2=31.8; peO.OOl), and 29.4% of males and 14.7% of females reported napping habitually 
(x2=21.1; peO.001). There was no difference in total night sleep time or sleep problems (CSP) 

between subjects napping and subjects not napping. 

368.4+ 84.8 min versus 418.1+ 69.8 min (t=8.2; peO.001). 

Sleeping pill usage 
There was a female preponderance in both past and present sleeping pill usage. Almost three times 

as many females as males used sleeping pills at least once per week, 14.7% versus 5.5% (x2=19.4; 
peO.001). The prevalence of regular sleeping pill users (every night or almost every night) was 7.6% 
of females and 3.0% of males (x2=8.7; p<0.05). Almost twice as many females compared to males 
had previously used sleeping pills, 19.2% versus 10.4% (x2=12.7; pe0.001). Females had also 

consulted a physician because of sleeping difficulties more often than males, 15.7% versus 9.3% 
(x2=7.6; pe0.01). (Table 4). 

191 



Table 4. Prevalence of sleeping pill usage and physician consultations because of sleeping difficulties 
according to gender (%). 

% females % males x 2  value 
Sleeping pill usage>l/week 14.7 5.5 19.4*** 
Sleeping pill usage regularly 7.6 3.0 8.7** 
Previous sleeping pill usage 19.2 10.4 12.7*** 
Consulted physician because 15.5 9.3 7.6** 
of sleeping difficulties 
*p<0.05 , **p<O.Ol, ***p<O.OOl 

(11471) (11405) 

Psvchological status 
On the HAD-scale, scores of 8 or more on a subscale was used as an indicator of depression and 

anxiety respectively. The criterion level indicating possible depression was exceeded by 13.3% of the 
total sample, equally between sexes. A significant difference between sexes was calculated for 
anxiety, 23.5% for females and 10.9% for males had scores of 8 or more on the anxiety subscale 
( x 2 =  23.8; p<O.OOl). 

As seen in Table 5, almost one-third of subjects stating sleep problems i n  the categorical item 
(CSP), 29.8%, scored 8 or more on the depression subscale versus 9.4% of subjects without sleep 
problems (x2=46.6; p<O.OOl). Almost one-half of subjects with sleep problems, 48.7%, scored 8 or 
more on the anxiety subscale versus 10.5% of subjects without sleep problems (x2=128.6; p<O.OOl). 

Among the regular sleeping pill users (every night or almost every night) 39.1 % exceeded the cut- 
off point indicating possible depression versus 1 1.9% of respondents not using sleeping pills 
regularly (x2=27.8; p<O.OOl). The cut-off point for possible anxiety disorder was exceeded by 
63.0% of subjects using sleeping pills regularly versus 15.1% of subjects not using sleeping pills 
regularly (x2=68.7; p<O.OOl). 

Table 5 .  Prevalence of HAD score 28 on depression or anxiety subscale (%) among respondents 
with and without sleep problems (CSP) and among respondents using and not using sleeping pills 
regularly. 

Sleep No sleep X2value Regular N o  x2 value 
problems problems sleeping regular 

(%.> (%I pill usage sleeping 
(%) pill usage 

(%I 
HAD 29.8 9.4 46.6*** 39.1 11.9 28.7*** 
depression 
score 28 
HAD 48.7 10.5 128.6*** 63.0 15.1 68.7*** 
anxiety 
score 28 
*p<0.05 , **p<O.Ol, ***p<O.OOl 

192 



Physical health status 
Subjects stating sleep problems in the categorical item (CSP) rated their physical health as being 

poor more often than subjects without sleep problems. Only 19.4% of subjects reporting sleep 
problems in the categorical item (CSP) rated their physical health as being excellent or good compared 
to 52.3% of subjects without sleep problems (x2=83.5; p<O.OOl). 

Table 6. Prevalence of any major sleep comlaint (ASC) among females and males with and without 
medical health problems (%). 

~ 

ASC" ASC" 
Males % In) Males % Females % In) Females O/o 

Hyper- 
tension 
N o  
Yes 
Cardiac 
disease 
N o  
YeS 
Angina 
No 
Yes 
Diabetes 
N o  
Yes 
Joint 
pain 
N o  
Yes 
Asthma 
No 
YeS 
Gastric 
symptoms 
N o  
Yes 
Depression 
N o  
YeS 
Urinary tract 
symptoms 
No 
YeS 
Prostate 
problems 
N o  

72.0 (275) 14.6 
28.0 (107) 21.5 

77.5 (289) 14.2 
22.5 (84) 26.2** 

82.5 (312) 14.4 
17.5 (66) 28.8** 

89.4 (339) 14.4 
10.6 (40) 37.5*** 

74.2 (279) 11.5 
25.8(97) 29.9*** 

93.1 (352) 16.8 
6.9 (26) 19.2 

76.7 (289) 15.2 
23.3 (88) 22.7 

95.4 (357) 15.4 
4.6 (17) 29.4 

84.3 (316) 15.7 
15.7 (59) 17.1 

73.3 (277) 15.9 

69.0 (309) 21.0 
31.0 (139) 22.3 

85.1 (378) 20.6 
14.9 (66) 27.3 

87.9 (392) 19.4 
12.1 (54) 35.2** 

92.1 (408) 20.3 
7.9 (35) 31.4 

64.2 (281) 18.9 
35.8 (157) 26.1 

92.3 (408) 20.3 
7.7 (34) 32.4 

78.6 (348) 19.8 
21.4 (95) 26.3 

89.4 (390) 16.4 
10.6 (46) 56.5*** 

79.1 (352) 19.9 
20.9 (93) 28.0 

Yes 26.7 ( i o i j  19.8 
' A X =  any major sleep complaint (DIS, DMS or EMA) 

*p<0.05, **p<O.Ol, ***p<O.OOl 

193 



As can be seen in Table 6, among males any major sleep complaint (DIS, DMS or EMA) was related 
to joint pain, diabetes, cardiac disease and angina. Among females any major sleep complaint was 
more commonly reported by females with depression and angina. 

DISCUSSION 

The results of our study demonstrate that sleep disturbances are common among elderly subjects. 
Almost one-fifth, 18.9%, of subjects reported sleep problems in a categorical (yes-no) question. 
Other surveys have reported prevalence of insomnia from 10-40%, possibly due to various 
populations and various definition of investigated sleep problem. For example Brabbins (4) reported 
that 35% of persons over the age of 65 living in Liverpool reported trouble sleeping the last 4 weeks, 
Weyerer (27) reported 23.3% prevalence of moderate or severe insomnia among persons aged 60-69 
years in the Upper Bavarian Field Survey and Henderson (8) reported the prevalence of insomnia 
15.8% in a sample of people aged 70 years and over in Canberra and Queanbeyan in Australia. 

Like previous investigations, females in our sample reported sleep problems more frequently than 
males, 23.8% versus 13.3%. Females went to bed at the same time as males, but waking up time was 
later. Despite this, females rated their total sleep time as shorter than males. These findings indicate 
that females spend more time awake in bed. Females also complained of never or only occasionally 
feeling well rested after sleep more often than males, 34.3% versus 23.5%. 

The most commonly reported sleeping difficulty was DMS. Moderate or major complaints of DMS 
was reported by 43.5% of subjects. The reports of major complaints of DIS, DMS and EMA was 
rather uniform (8.5%, 9.3% and 11.7% respectively) and the only gender difference was that females 
reported major complaints of DIS more often than males. 

Reports of sleep continuity disturbances were very common in our study. Almost one-half of 
subjects, 47.7%, reported waking up at least twice per night and 19.5% reported waking up at least 3 
times per night. Nocturnal awakening occurred for over one-half of subjects, 60.7%, at least 3 nights 
per week. However, only 9.3% of subjects reported major complaints of DMS and our interpretation 
is that these nocturnal awakenings were not always perceived as a sleep disturbance for many of the 
elderly subjects. These findings underline the importance of distinguishing between the severity and 
the frequency of a sleep complaint before interpretations are made. 

We found a male preponderance in reports of daytime symptoms. Moderate or major complaints of 
daytime sleepiness was reported by 3 1.8% of males versus 22.6% of females, which is in agreement 
with others. For example, Asplund (1) reported that of pensioners in northern Sweden 32.0% of 
males and 23.2% of females were often sleepy during the day and Schmitt (24) reported that 37.2% 
of subjects aged 70-79 years in Kentucky, USA, complained of excessive daytime somnolence. 

194 



Schmitt found daytime somnolence to be associated with snoring, and we found, like Asplund, that 
daytime sleepiness was related to poor sleep. 

In our survey we found that daytime napping was not related to sleep problems. This finding 
supports the hypothesis that napping is an effect of changed distribution of sleep wakefulness in 
elderly and that it is not necessarily related to sleep disturbances (9, 20). Like previous investigators, 
we found that napping is a common phenomenon. In our sample 69.5% of males and 50.5% of 
females reported napping at least occasionally. Metz (20) reported that 72.7% of males and 56.3% of 
females reported taking naps among subjects aged 58-95 years, and Gislason (5) reported that 50% of 
males and 3 I % of females aged 65-84 years on Iceland slept during the day for an average of 28 min. 

In our study population 14.7% of females and 5.5% of males used sleeping pills at least once per 
week, and 7.6% of females and 3.0% males used sleeping pills regularly (every or almost every 
night). Karacan (11) reported that 17% of females and 15% of males aged over 64 years used 
sleeping pills sometimes, and 9% of females and 8% of males were regular users. Morgan (22) 
reported that 22% females and 1 1.1 % of males aged over 65 years used sleeping pills and Gislason 
(5) reported that 16.7% of females and 12.2% of males aged over 65 years on Iceland were habitual 
users of sleeping pills. In view of these results, our study provides similar or lower prevalence rates 
of hypnotic usage. 

There was a relationship between reports of sleep problems and psychological factors. Of subjects 
stating sleep problems in the categorical question, 29.8% scored 8 or more on the HAD depression 
subscale, indicating possible depression, compared to 9.4% of subjects without sleep problems. The 
criterion level indicating possible anxiety disorder was exceeded by 48.7% of subjects reporting sleep 
problems versus 10.5% of those without sleep problems. Sleep disturbances have often been reported 
to be associated with depression and anxiety disorders. Mellinger (19) found that one third of those 
with serious insomnia in a population aged 18 to 79 years were characterized by syndromes 
resembling either major depression or generalised anxiety. Henderson (8) found insomnia associated 
with symptoms of both anxiety and depression in subjects older than 70 years, and Morgan (22) 
found symptoms of anxiety rather than depression as predictor of poor sleep quality in subjects aged 
65 to 74 years. 

Among the regular sleeping pill users in our study there was a high percentage of subjects scoring 8 
or more on the HAD subscales respectively, 63.0% had possible anxiety disorder and 39.1% had 
possible depression. 
Subjects with sleep problems in our study also showed evidence of poor physical health status that 
confirms previous reports of associations between insomnia, self-perceived poor health and physical 
illnesses. Bixler (2), for example, found among adults that subjects with insomnia more frequently 
reported multiple health problems and Bliwise (3) found very low prevalence of poor sleep in his 
sample of subjects aged 50-65 years with relatively good health. Morgan (22) reported from a sample 
of elderly that subjects with insomnia were significantly more likely to rate their health below average. 
From a sample of elderly in Australia Henderson (8) found insomnia to be associated with poor self- 
rated health. In our sample there was a gender difference insofar as medical illnesses among males, 
but depression among females, was related to any major sleep complaint (DIS, DMS or EMA). 

195 



Our results are based on subjective reports of sleep quality, which is not the same as sleep disorders 
of clinical significance. Webb (25) states that self-reports reflect the person’s view about sleep and its 
importance, and these conceptions are important to understand because they will determine if the 
person defines himself as having a sleep problem for which he might seek professional advice or 
treatment. As a clinician, it is important to understand the relationship between self-reported sleep 
problems and general health. The present study shows that sleep problems are common among 
elderly and our data suggest that late life insomnia is not simply due to a normal ageing process. 
Physical and psychiatric disorders must be considered in the evaluation of sleep complaints in the 
elderly patient. 

Because our data is cross-sectional we are not able to make definitive conclusions about causal 
relationships. We therefore intend to continue with longitudinal studies and also make structured 
clinical interviews in an effort to increase knowledge about sleep complaints among elderly. 

ACKNOWLEDGEMENTS 

This study was supported by grants from the Swedish Medical Research Council (Project 06869), the 
Dalarna Research Institute, the Swedish Psychiatric Association, the Marta and Nicke Nasvells 
Foundation and the Swedish Lundbeck Foundation. 

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Correspondence to: 

Lena Mallon 
Sleep Disorders Unit 
Department of Psychiatry 
University Hospital 
S-75 1 85 Uppsala 
Sweden 
Tel+46 18 66 30 00 
F a x + 4 6 1 8 5 1 5 8  10 

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