Sleep patterns in older bereaved spouses

The study examined the prevalence and pattern of reports of sleep disturbance over two years in a group of 296 adults aged 50 years and over, and assessed the relationship between patterns of sleep disturbance and bereavement adjustment over time. A sample of 192 widows and widowers were compared to a matched sample of 104 non-bereaved persons. About half of the bereaved respondents experienced sleep disruption in the first month following their loss. Regardless of bereavement status, one-third of the sample experienced ongoing sleep disruption, and 10% consulted a physician for difficulty sleeping. Persons with a pattern of consistent sleep disturbance showed statistically significant differences in grief outcomes that persisted over time and tended to be female, older,with poor health, and taking more medications.

OMEGA, Vol. 47(4) 361-383, 2003 SLEEP PATTERNS IN OLDER BEREAVED SPOUSES STEPHANIE J. RICHARDSON DALE A. LUND MICHAEL S. CASERTA WILLIAM N. DUDLEY SARAH JANE OBRAY University of Utah, Salt Lake City ABSTRACT The study examined the prevalence and pattern of reports of sleep disturbance over two years in a group of 296 adults aged 50 years and over, and assessed the relationship between patterns of sleep disturbance and bereavement adjustment over time. A sample of 192 widows and widowers were compared to a matched sample of 104 non-bereaved persons. About half of the bereaved respondents experienced sleep disruption in the first month following their loss. Regardless of bereavement status, one-third of the sample experienced ongoing sleep disruption, and 10% consulted a physician for difficulty sleeping. Persons with a pattern of consistent sleep disturbance showed statistically significant differences in grief outcomes that persisted over time and tended to be female, older, with poor health, and taking more medications. The adjustment process accompanying grief and bereavement can impact virtually every aspect of a person's life. Particularly in the case of spousal bereavement in later life, many married persons develop long-standing patterns of behavior that are disrupted by their spouse's death. Research over the past 25 years has contrib­uted a great deal to our understanding of how the bereaved and widowed experi­ence a roller-coaster like process of adjustment including changes in emotions, © 2003. Baywood Publishing Co.. Inc. 361 362 / RICHARDSON ET AL. attitudes, motivations, interests, spirituality, identity, social interactions, work productivity, financial stability, and physical and mental health. Much of the past research, however, has focused on broad outcome measures such as life satisfaction, morale, social participation, depression, wellness, or self-reported ratings of physical health along with indicators of difficulties such as doctor visits, use of medications and the onset of physical health problems (Lund, Caserta, & Dimond, 1993). Frequently, when many research studies conclude that the bereaved have worsened physical and mental health outcomes, the investigators often did not examine the daily life experiences that might help to explain and better understand why the adjustment outcomes changed. It is not sufficient to simply know that recently widowed persons are likely to be less healthy and/or more depressed than others without knowing more about why this happens. In other words, we need to more carefully examine selected aspects of the daily lives of those who are grieving. This article explores some of the data from a previous longitudinal study of bereavement among spouses over the age of 50 and specifically highlights the potential importance that the quality of sleep might have on the coping process. Sleep is particularly relevant because many previous studies of bereavement have mentioned descriptively that sleep is frequently cited as a problem, yet it has been largely ignored as a primary area of investigation. It is quite likely that those who are grieving and experience significant problems with their daily lives are also having great difficulty sleeping at night. "Difficulty sleeping" at night can be expressed in several ways and in various levels of intensity. In order to better understand why a focus on sleep disturbances is relevant to the grief process, we need to know the features of healthy sleep, negative consequences of sleep disturbances, and what is known about sleep in older adults. CHARACTERISTICS OF SLEEP AND AGING Healthy sleep is characterized as efficient, lasting six to eight hours with little time in bed awake. Falling asleep occurs within 5-15 minutes of going to bed, and one does not awaken in the morning prematurely and lay in bed trying to achieve more sleep. Efficient sleep also is not fragmented, meaning that one does not awaken one or more times during the night. Healthy sleep is also characterized as being deep, without awareness of noise and activity in one's environment, and with a refreshing quality, so that one wakens feeling rested and ready for the day. Healthy sleep generally occurs at night, and may or may not be supplemented with one or two daytime naps. The length, efficiency, fragmentation, depth, quality, and supplementation of sleep all combine to form a sleep pattern. Sleep patterns vary between individuals, and vary within individuals from one night, week, year, or decade to the next, according to circumstances and age. Age is an important factor affecting sleep patterns. Newborn infants' and young children's sleep is dramatically different from that of adults. During adolescence,SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 363 deep sleep decreases by approximately 40% (Carskadon & Dement, 1994). Deep and dream sleep decline with aging, though controversy exists regarding the age of onset, magnitude of decline, and importance of decline in these sleep characteristics in older adults (Bliwise, 1994; Ilayashi & Endo, 1982; Webb, 1982). Opposing evidence exists regarding older adults' use of naps, their sleep latency, sleep efficiency, and awakenings (Iloch et al., 1997; Middlekoop, Smilde-van den Doel, Neven, Kamphuisen, & Springer, 1996). The depth of sleep may decrease with age, as a significantly higher noise intensity threshold is necessary to awaken younger subjects compared with older persons (Zepelin, McDonald, & Zammit, 1984). The effects of inadequate or ineffective sleep are cumulative, with sequellae worsening as deprivation is prolonged (Dinges et al., 1997; Home, 1985; Lorenzo, Ramos, Arce, Guevera, & Corsi-Cabrera, 1995; Luby, Frohman, Grisell, Lenzo, & Gottleib, 1960; Pilcher & Iluffcutt, 1996). There are many physical consequences of sleep loss. Deprived of sleep for varying lengths of time, healthy adults may suffer from gastrointestinal upset, visual changes, large and fine motor disrup­tions, changes in hormone regulation, and both mild and serious neural difficulties (Baumgartner et al., 1993; Chen & Tang, 1989; Dinges et al., 1997; Fountain, Kim, & Lee, 1998; Lai et al., 1997; Landis, Savage, Lentz, & Brengelmann, 1997; Morriss, Wearden, & Battersby, 1997; Mullington, Hermann, Holsboer, & Pollmacher, 1996; Phillips, Cooper, & Burke, 1987; Rogers et al., 1995; Seifritz et al., 1997). Disrupted sleep also may adversely affect the immune system (Irwin et al., 1994; Irwin et al., 1996; Palmblad, Petrini, Wasserman, & Akcrstcdt, 1979). Reduced efficacy of the respiratory system, including weakening muscles and reduced air movement, have been documented following sleep loss (Chen & Tang, 1989; Cooper & Phillips, 1982; Mcuricc, Marc, & Series, 1995; Phillips et al., 1987; Schiffman, Trontcll, Mazar, & Edelman, 1983; Series, Roy, & Marc, 1994; White, Douglas, Pickett, Swilich, & Weil, 1983). Finally, any adult experiencing infection and fever may be particularly affected by the disrupted thermoregulation that follows sleep disruptions (Landis et al., 1997). Many healthy adults also are familiar with the mental and emotional con­sequences of sleep disturbances. Disrupted sleep may lead to depression, weepiness and emotional lability, loss of anger control, difficulty processing logical functions (e.g., math problems), and experiencing illusions (Aeschbach, Cajochen, Landolt, & Borbcly, 1996; Dinges et al., 1997; Hill, Welch, & Godfrey III, 1995; Lorenzo et al., 1995; Morriss et al., 1997; Pilcher & Iluffcut, 1996; Richardson et al., 1996). In healthy volunteers, mental and emotional diffi­culties following sleep deprivation are transient, yet represent abnormalities that are uncomfortable for the individual (and for those around him or her) (Chokroverty, 1999). Such mental and emotional difficulties may at least affect the ability to participate meaningfully in his or her own life activities. At worst, mental and emotional difficulties following disrupted sleep represent suffering and distress.364 / RICHARDSON ET AL. Sleep disturbances affect a significant portion of the general population, ranging from 15% to 35% of healthy adults (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989; Kales, Kales, & Soldatos, 1982; Mant & Eyland, 1988). Beginning with the work of Lindemann (1944), sleep disturbances are frequently mentioned in the bereavement studies and reports that have since been published (Bowlby, 1980; Caserta, Lund, & Dimond, 1990; Clayton, Desmarais, & Winokur, 1968; Glick, Weiss, & Parkes, 1974; Hall & Irwin, 2001; Osterweis, Solomon, & Green, 1984; Shuchter & Zisook, 1993; Stroebe & Stroebe, 1987; Thompson, Breckenridge, Gallagher, & Peterson, 1984). Bereaved respondents often reported having diffi­culty falling asleep, staying asleep, waking too early, and/or increased use of sleep aid medications. Tn some studies sleep disturbances were among the most commonly experienced if not the most problematic of the physical symptoms that were published (Bowlby, 1980; Caserta et al., 1990; Clayton et al., 1968; Glick et al., 1974; Hall & Irwin, 2001; Osterweis et al., 1984; Shuchter & Zisook, 1993; Stroebe & Stroebe, 1987; Thompson et al., 1984). There is some evidence that sleep disruption is an indicator for either dysfunctional grief or complicated grief disorders (Horowitz et al., 1997; Jacobs, Mazure, & Prigerson, 2000; McDermott et al., 1997; Prigerson et al., 1995). Although spousal loss has been suggested as one potential factor associated with sleep problems among older adults, the nature of the problem as well as its relationship with other commonly examined bereavement outcomes, has not been the primary focus of most bereavement studies. Some research and clinical reports suggest that sleep problems could be symptomatic of the presence of depression, stress, or anxiety, which may or may not be related to loss (Hall et al., 1997; Lankford, 1994; McDermott et al., 1997; Nakra, Grossberg, & Peck, 1991; Reynolds et al., 1992). The death of a husband or wife also can alter the surviving spouse's sleeping environment, which could precipitate difficulties with sleep, especially among those who are older (Nakra et al., 1991). Understanding the prevalence of sleep disturbances among older bereaved spouses is important because the relationship of bereavement to sleep problems may become recursive (Hall & Irwin, 2001). As noted, prolonged periods of inadequate sleep can suppress the immune system's ability to fight infections and disease, can alter respiratory function, and can decrease thermoregulation. Tt also potentially impairs an individual's level of functioning and their capacity to effectively cope with stressors, including bereavement. Consequently, from a clinical perspective, sleep problems among the bereaved can be an indicator for underlying psychological and physiological difficulties that may require inter­vention and treatment (Hall & Trwin, 2001). This study examines: 1) prevalence and pattern of reports of sleep disturbance over time in a group of recently bereaved adults aged 50 years and over; and 2) assesses the relationship between patterns of sleep disturbance and indicators of SLEEP AND BEREAVEMENT SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 365 bereavement over time. The following specific research questions guided this study: 1. What are the prevalence and patterns of reported sleep disturbance over time in a group of bereaved and non-bereaved adults aged 50 years and over? 2. What factors are most common among adults over age 50 who report having disturbed sleep, either episodically or consistently? 3. What is the relationship over time between patterns of sleep disturbance and global measures of bereavement adjustment (bereavement-related feelings and behaviors and depression)? CLARIFICATION OF TERMS For the purposes of this study, we focused on three components of sleep disturbances: presence or absence of difficulty sleeping, seeking help from a professional, and the frequency of occurrence of trouble sleeping. Presence or absence of difficulty sleeping was a judgment made by each respondent. People usually know when they are not sleeping well (exceptions include some few sleep difficulties that do not result in awakening or other noticeable symptoms). These self-reports of having sleep difficulty may be attributed to frequent awakenings, difficulty initiating sleep, sleep that is not deep and refreshing, or excessively early awakening. Seeking help from a professional, for this study, indicated a quantitative self­assessment of the sleep disturbance as being from mild to disruptive enough of daily life that professional assistance was sought. Mild sleep disturbance may be noticed but not reported, dismissed as not worth mentioning to a health care professional. Moderate to excessive sleep disturbance is distressing enough to be noticed and reported to a health care professional. Frequency of occurrence is a report of the repetitive nature of the disturbance, within a proscribed period of time. Symptoms of sleep disturbance increase as frequency increases and the effects of sleep disturbances are cumulative. To achieve the goals of the study, the prevalence and pattern of sleep com­plaints over two years in a sample of widows and widowers, aged 50 and over, were compared to that reported by a matched sample. A comparison group was used in order to determine if sleep problems were more common or pat­terned differently in older adults experiencing spousal loss, compared to older adults in general reporting high levels of sleep disruption (Statement, 1990). To achieve the second goal, patterns of sleep difficulties were correlated to indicators of grief. These grief indicators were chosen based on a review of the literature and previous research regarding the more common indicators of bereavement adjustment.366 / RICHARDSON ET AL. METHODS The data used in this report were part of a longitudinal descriptive study of spousal bereavement in later life that took place in the Salt Lake metropolitan area (The University of Utah Bereavement Study ). Numerous reports were published from this data (cf. Lund et al., 1993), however, none focused on the prevalence of sleep disturbances among the participants or its correlates. Most of the studies published by others that examined the relationship between sleep problems and bereavement were either exploratory with small samples or were laboratory-based (Hall & Irwin, 2001). This data provided us with the opportunity to examine longi­tudinally the impact of spousal loss on sleep disturbances using a community- based sample of bereaved older adults and a matched comparison group of married nonbereaved controls. Although detailed descriptions of the study design have been published elsewhere (Lund, Caserta, & Dimond., 1989; Lund et al., 1993), features of the project most salient to this report are presented below. Sample Recently bereaved spouses aged 50 and over were identified through the use of local newspaper obituaries in order to complete the first interview or questionnaire as early as three weeks following the spouse's death. Official mortality data obtained later from the State Department of Health Statistics revealed that this procedure missed only 9% of the actual deaths for those in the same age category. No significant gender, age, or socioeconomic differences were found between those who had a published obituary and those who did not. All potential bereaved participants (N= 192) were randomly assigned to either a home interview group (N= 104) or a mailed questionnaire group (N = 88) in order to test for an interview effect. No major interviewer effect was observed regarding most psychosocial bereavement outcomes (Caserta, Lund, & Dimond, 1985) but the two groups were treated separately for some of the analyses regarding sleep problems because of the differences in the number of sleep difficulties reported between the two bereaved samples. Due to the early assess­ment and the longitudinal design, 61% of the potential bereaved respondents refused to participate. The most common reasons for refusal were extreme busyness, extreme upset, poor health, and advice from adult children not to participate. A one-year follow-up telephone interview with a random sample of those who had refused to be in the study (N = 111) indicated that their self­reported health was slightly lower than those who had participated. They did not differ, however, in age, gender, socioeconomic status, perceived coping, perceived stress, and rate of remarriage. This does not suggest that the participants and the refusals were experiencing the bereavement process in the same way but that they were similar with respect to several important considerations. Nonbereaved older adults were identified for the control group through the use of public voter registry data and were selected on the basis of sex, age, andSLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 367 socioeconomic area of residence. In order to reduce the number of matching procedures, a matched nonbereaved person was selected only for each of the 104 bereaved respondents in the interview group. The refusal rate for this sample was 50% and the major reasons for refusal were busyness and lack of interest. The first two questionnaires for each of the nonbereaved participants were delivered by a research assistant according to the same procedures as those used for the mailed questionnaire group of bereaved participants. In both samples, the respondents completed them without the assistance of an interviewer and returned them by mail. The mean age for the bereaved sample at the beginning of the study was 67.6 years (SD = 8.2), with a range of 50 to 93 years, and they had been married an average of 39.7 years (SD = 13.6). The majority was female (74%), white (97%), and had graduated from high school (78%). The mean age of the non­bereaved control participants was 66.8 years (SD = 7.9), with a range of 51 to 85 years, and they had been married an average of 38.1 years (SD = 12.8) at the time they entered the study. Similar to the bereaved sample, most were female (73%), white (99%), and had graduated from high school (78%). Procedures All of the 192 bereaved persons were interviewed (BI) or completed question­naires (BC) at six times during the first two years of bereavement: three to four weeks (Tj), two months (T2), six months, (T3), one year (T4), 18 months (T5), and two years (T^) after the death. With the exception of the demographic variables, all six questionnaires were essentially the same. The survey instruments took approximately 1.5 to 2 hours to complete. The 104 nonbereaved controls completed similar questionnaires at the same six times. Because their ques­tionnaires did not include the items pertaining to specific aspects of bereave­ment (e.g., cause of death, coping, etc.), they required only 45 minutes to com­plete them. While the bereaved interview participants and bereaved controls had different data completion strategies, most of our research reports have not found significant differences between the groups. In most cases, we have combined them into one bereaved sample. Measures In addition to demographic data, the respondents were asked at each data point questions about sleep problems, grief related feelings and behaviors, and completed a standardized scale that measured depression. Baseline health data also were collected, including the number of chronic conditions and medications taken on a regular basis as well as an item in which the respondents rated their health on a scale ranging from 1 (poor) to 7 (excellent).368 / RICHARDSON ET AL. Sleep Items Three sleep variables were extracted from the larger data set to reflect the conceptual definitions of the terms presence or absence of difficulty sleeping, seeking help from a professional, and the frequency of occurrence of the disorder. The first two, labeled difficulty and MD visit, respectively, were taken from a two-part question on a health and illness symptom scale. The first part of the question asked the respondent if he/she "has had difficulty sleeping during the past several weeks?" (1 = yes, 0 = no), and the follow-up question asked if he/she "has visited a doctor for this problem?" (1 = yes, 0 = no). The third sleep variable, a measure of the frequency of occurrence of the sleep disorder, labeled frequency, was a specific question on the Zung Depression Scale (Zung, 1965). This question asked the respondent if he/she "has trouble sleeping at night?" Five response categories were possible but our coding pro­cedures followed the recommendation of the scale authors by scoring "never" and "a little of the time" as the same response; therefore, only four responses are coded on a 1-4 scale: (Never = 1, A little of the time = 1, Some of the time = 2, Good part of the time = 3, Most of the time = 4). Bereavement-Related Feelings and Behaviors Those in the bereaved samples were asked to indicate to what extent they experienced both the presence and intensity of 26 bereavement related feelings. Their responses were recorded on a 5-point Likert scale from "never had" (1) to "very strong" (5). A series of 16 bereavement-related behaviors also were presented in a similar Likert format with response categories ranging from "never did this" (1) to "most of the time" (5). Items included on these two checklists were generated primarily from the classic Harvard bereavement study (Glick et al., 1974). The items ranged from such early grief characteristics as shock, confusion, crying, and a review of the death event, to other experiences that might include confidence, pride, learning to do new things, and making new friends. In addition to these checklists, each questionnaire obtained self-reported ratings for perceived stress, coping ability and self-esteem measured by 7-point single-item statements. To make all these unstandardized measures more meaningful and statistically more manageable, they were factor analyzed into five global scales (see Caserta et al., 1985, for a detailed description of the item-factor loadings.) The five global scales and their corresponding alpha coefficients are: emotional shock (.82); helplessness/avoidance (.77); psychological strength and coping (.78); anger/guilt/confusion (.66); and grief-related behaviors (.64). The possible ranges for each scale are as follows: emotional shock (9-47); helpless/avoidance (9-45); psychological strength and coping (7-39); anger/guilt/confusion (6-30); and grief-related behaviors (7-35). In each instance a higher score represents a greater level of the bereavement-related response being measured.SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 369 Depression Depression was measured using the Zung (1965) Self-Rating Scale, which consists of 20 items scored in a Likert format ranging, from 1 to 4 where a higher rating indicates a more depressive response. The item pertaining to "having trouble sleeping at night" was omitted from the total score in this report so the possible total score for any respondent ranged from 19 to 76. This item was omitted because our analyses examine sleep as both an independent and dependent variable. We could not use sleep as an indicator of depression and as a cause. This depression scale was used widely with older populations at the time the data for this study were gathered (Kitchell, Barnes, Veith, Okimoto, & Raskind, 1982). We acknowledge that a greater variety of depression scales have since been developed but are confident that the Zung (1965) scale has sufficient psychometric properties for the puiposes of this study. It continues to be used in studies using older samples although it is understood that the presence of items inquiring into somatic complaints could overestimate the prevalence of depressive symptoms (Kane & Kane, 2000). In this study, however, it was not our intent to discriminate between those who were clinically depressed and those who were not, but to treat the measure as one of several indicators of bereavement adjustment. RESULTS To answer the first research question regarding prevalence of self-reported sleep disturbances in bereaved adults, all sleep items were subjected to descriptive analysis (Table 1). These analyses show how the participants in each of the three study groups (bereaved interview, bereaved controls, and nonbereaved controls) varied on each of the sleep measures at all six time periods. Although the number of bereaved interview, bereaved survey, and control were 104, 88, and 104 respectively, data are missing on individual items in a sporadic fashion, thus the iV used for the denominator in the calculation of the percent varies over time for each group and may differ across each variable. The bereaved interview group reported significantly more difficulty sleeping, (56.7%) at Time 1 than did the bereaved (43.4%) and nonbereaved (38.6%) controls. At all other time points, the percentage of subjects in any group reporting difficulty sleeping did not fall below 38.6% (nonbereaved control Time 1) and was as high as 62.7% (bereaved interview Time 5). There were no significant differences between the three study groups, even though the bereaved participants had higher percentages of difficulty sleeping than did the nonbereaved controls. For all subjects reporting difficulty sleeping, the percentage ranged from 46.1% at Time 2 to 54.5% at Time 5. Among those subjects reporting difficulty sleeping, the bereaved interview group reported significantly more visits to an MD for difficulty sleeping at Time 3 (41.4%) and at Time 4 (52.2%) than did the bereaved and nonbereaved controls.Table 1. Prevalence of Difficulty Sleeping and Visiting an MD for Help, and Frequency of Occurrence of Sleep Disorders Over Time Variables/group 3-4 Weeks N (%) 2 Months N (%) 6 Months N (%) 1 Year N (%) 18 Months N (%) 2 Years N (%) Difficulty sleeping® Bereaved interview Bereaved controls Non bereaved Total 55 (56.7)* 36 (43.4) 39 (38.6) 130(46.3) 41 (47.1) 38 (50.0) 40 (42.1) 119 (46.1) 45 (54.9) 38 (53.5) 44 (50.0) 127 (52.7) 40 (49.4) 33 (46.5) 42 (46.2) 115 (47.3) 47 (62.70) 38 (53.5) 42 (48.3) 127 (54.5) 37 (48.7) 29 (47.5) 40 (47.10) 106 (47.7) MD visit® Bereaved interview Bereaved controls Nonbereaved Total 11 (23.4) 4 (11.4) 5(12.8) 20 (16.5) 5 (17.2) 4 (20.0) 3 (12.0) 12 (16.2) 12 (41.4)* 5 (26.3) 3(12.0) 20 (27.4) 12 (52.2)* 2 (11.8) 4 (14.3) 18 (26.5) 13 (44.8) 6 (35.3) 4(16.0) 23 (32.4) 8 (36.4) 3 (17.6) 3 (11.5) 14 (21.5) Frequency6 Bereaved interview Never or little of time 6(12.6) 15 (34.1) 16(37.2) 19 (46.3) 11 (29.7) 15 (39.5) Some of the time 14(29.8) 11 (25.0) 11 (25.6) 12 (29.3) 16 (43.2) 9 (23.7) Good part of the time 13(27.7) 8(18.2) 8(18.6) 3 (7.3) 3 (8.1) 5(13.2) Most of the time 14(29.8) 10 (22.7) 8(18.6) 7 (17.1) 7(18.9) 9 (23.7) 370 / RICHARDSON ETAL.Bereaved controls Never or little of time 5 (14.7) 10 (33.3) 8 (32.0) 13 (44.8) 14(53.8)* 11 (44.0) Some of the time 16 (47.1) 12 (40.0) 11 (44.0) 10 (34.5) 7 (26.9) 8 (32.0) Good part of the time 6 (17.6) 3 (10.0) 3 (12.0) 3 (10.3) 5 (19.2) 5 (20.0) Most of the time 7 (20.6) 5 (16.7) 3 (12.0) 3 (10.3) 0 (0) 1 (4.0) Nonbereaved Never or little of time 10 (25.6) 9 (23.7) 12 (34.3) 9 (25.7) 11 (31.4) 9 (26.5) Some of the time 13 (33.3) 14(36.8) 8 (22.9) 9 (25.7) 9 (25.7) 10 (29.4) Good part of the time 10 (25.6) 12 (31.6) 12 (34.3) 12 (34.3)* 9 (25.7) 8 (23.5) Most of the time 6 (15.4) 3 (7.9) 3 (8.6) 5 (14.3) 6(17.1) 7 (20.6) aReporting "Yes." 6The frequency item was coded with four possible responses, as recommended by scale authors, thus Never = 1, A little of the time = 1, Some of the time = 2, Good part of the time = 3, and Most of the time = 4. *p < .05 (according to Chi-square tests). **p < .005 (according to Chi-square tests). SLEEP PATTERNS IN OLDER BEREAVED SPOUSES372 / RICHARDSON ET AL. At all other time points, the percentage of subjects in any group reporting visits to an MD for difficulty sleeping did not fall below 11.4% (bereaved control Time 1). For all subjects reporting difficulty sleeping, the percentage reporting a visit to an MD for this problem ranged from 16.2% at Time 2 to 32.4% at Time 5. Both the bereaved interview and bereaved control groups reported the highest frequency of trouble sleeping at Time 1 (29.8% and 20.6%, respectively). Numbers of those reporting trouble sleeping a good part or most of the time drop off over time, so that at Time 5 a significant percentage of bereaved control subjects (53.8%) reported trouble sleeping never or a little of the time. However, trouble sleeping remained a frequent problem for a number of respondents regard­less of bereavement status (group membership), such that at Time 4 a significant percentage of nonbereaved control subjects reported trouble sleeping a good part of the time (34.3%). In an attempt to determine patterns of sleep disturbance over time, data for difficulty sleeping, a dichotomous variable reported as "yes" or "no," was anal­yzed on the basis of time, using Chi-square (Table 2). Data from Times 1, 2, or 3 were classified as "early" and data from Times 4, 5, or 6 were classified as "late." Thus, each subject could have a score for early difficulty sleeping ranging from 0 (never reported difficulty sleeping at early time points) to 3 (reported difficulty sleeping at each early time point). Similarly, each subject could have a score for late difficulty sleeping ranging from 0, no reports, to 3, reports at each late time point. Results showed three clear patterns of sleep. The most common pattern, reported by 114 subjects (45.4% of the total sample), was Pattern 1, no or little difficulty sleeping either early or late. Pattern 1 was indicated by scores of 0 or 1, both early and late. The next most common pattern, reported by 84 subjects Table 2, Prevalence of Difficulty Sleeping among Elderly Reported Early in the Study Compared to Late in the Study 3 weeks to 6 months (early) 12 to 24 months (late) No difficulty N (%) Difficulty once N (%) Difficulty twice N (%) Difficulty thrice N (%) Total N (%) No difficulty 60 (23.9) 26 (10.3) 4 (1.6) 3 (1.2) 93 (37.1) Difficulty once 11 (4.4) 17 (6.8) 10 (4.0) 5 (2.0) 43 (17.1) Difficulty twice 4 (1.6) 11 (4.4) 12 (4.8) 13 (5.2) 40 (15.9) Difficulty thrice 4 (1.6) 12 (4.8) 26 (10.4) 33 (13.2) 75 (29.9) Total 79 (31.5) 66 (26.3) 52 (20.7) 54 (21.5) 251 (100.0) Note: Pearson Chi-square value = 110.1. p < .000.SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 373 (33.5% of the sample), was Pattern 2, difficulty sleeping both early and late. Pattern 2 was indicated by scores of 2 or 3, both early and late. The differences between distributions in Patterns 1 and 2 were significant at a p-value of less than .0001. A smaller number of 53 subjects (21%) experienced episodic difficulty over time in varying ways, indicated by early scores of 0 or 1 combined with late scores of 2 or 3 (31 subjects), and early scores of 2 or 3 combined with late scores of 0 or 1 (22 subjects). The disorganization and variance of the sleep of these subjects contrasted conceptually with the more fixed, long-term sleep patterns seen in Patterns 1 and 2. Since the effects of sleep difficulty are cumulative and symptoms of sleep deprivation increase with the frequency of occurrence, we decided to combine those with episodic sleep difficulties (early problems but not later or later problems but not early) into one group rather than separating them into two different groups. We refer to these persons in Pattern 3 as "episodic pattern." Combining these two subtypes into one group allowed us to maintain our analysis focus on comparing those with clear established sleep patterns with those who have more episodically disorganized sleep. In order to describe the elderly adult experiencing either Pattern 1, 2, or 3 type of sleep disturbance during bereavement, patterns of difficulty sleeping were subjected to group analysis, again using Chi square. There were no differences in patterns of difficulty sleeping on the basis of bereavement. Bereaved (both interview and control) and nonbereaved control respondents were proportionately distributed across all patterns, thus we combined bereaved interview and control groups for subsequent analysis. Specifically, subjects with no or little difficulty with early sleep tended to report no or little difficulty with late sleep, regardless of bereavement status, and subjects with early difficulty sleeping also tended to report later difficulty sleeping, regardless of bereavement status. However, when patterns of difficulty sleeping were analyzed to help identify early indicators of problems on the basis of socio-demographic variables measured at Time 1, significant differences were found on the basis of sex with females having more difficulty than men (Chi square = 18. 31, p < .000), age with older adults having more difficulty than younger persons (F = 4.96, p < .008), health rating at Time 1 with adults in poor health having more difficulty than adults in good health (Chi square 23.49, p < .000), and number of medications taken at Time 1 with adults taking more medications having more difficulty than adults taking fewer medications (Chi square 11.14, p < .004). A trend toward significance was found on the basis of number of chronic illnesses found at Time 1 with adults reporting more chronic illnesses having more difficulty sleeping than adults with fewer chronic illnesses (Chi square = 5.02, p < .081). Therefore, those experiencing the greatest difficulty sleeping were those who were older, female, in poorer health, and taking more medications. Research question three examined the relationship over time between patterns of sleep disturbance and global measures of bereavement adjustment by usingFigure 1, Repeated measures analysis of variance for patterns of sleep and emotional shock, helplessness/avoidance, self-esteem/coping, grief-related behaviors, anger/guilt/confusion, and depression. 374 / RICHARDSON ETAL.Figure 1. (Cont'd.) SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 375Figure 1. (Cont'd.) 376 / RICHARDSON ETAL.SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 377 a repeated measures ANOVA procedures (Figure 1). Specific global measures of bereavement adjustment included emotional shock, helplessness and avoidance, self-esteem and coping, grief-related behaviors, anger and guilt and confusion, and finally, depression. All relationships were in the expected direction with sleep being problematic in grief. On all six indicators, those with the least difficulty sleeping on a consistent basis (Pattern 1) had the most favorable bereavement outcomes through nearly every time period. Conversely, those with persistent sleep disturbance (Pattern 2) had the most negative scores over time (with only minor exceptions at some time periods) on all six bereavement outcome measures. While there were changes over time for most outcomes, the differences between the three groups persisted over time. Of all six outcome measures, the one that revealed the most distinct differences among the three groups was "Helplessness/ Avoidance." This subscale may reflect feeling a lack of control that persists over time and includes not wanting to be among others (Lund, Caserta, & Dimond, 1986). Those with the greatest sleep difficulty may have been con­sistently troubled by feelings of helplessness and avoidance in the two years following bereavement. DISCUSSION What are the prevalence and patterns of reports of sleep disturbance over time in a group of bereaved and nonbereaved adults aged 50 years and over? About half of bereaved elderly subjects experienced sleep disruption in the initial (one month) period following their loss. These results are congruent with initial difficulty many bereaved adults have soon after the loss, and this percentage approximates the percentage of people, identified by other researchers, as having major difficulty coping with their grief, particularly in the early stages (Lund et al., 1993). A large portion of the elderly, bereaved or not, evidenced sleep difficulty at every time point, with approximately one-third of elderly adults experiencing ongoing sleep disruption, regardless of bereavement status. This high rate of sleep difficulty is similar to that found in multiple populations (Bliwise, 1994; Call-Schmidt & Richardson, 2003; Carskadon & Dement, 1994; Chokroverty, 1999; Iloch et al., 1997; Middlekoop et al., 1996; Richardson, 2003). Although bereave­ment by itself may not be associated with sleep difficulties, those who are bereaved and not sleeping, particularly elderly women in poor health, are at risk for impaired adjustment and all the negative consequences associated with grief and sleeplessness. Over 10% of all elderly in this study reported consulting a physician for difficulty sleeping, regardless of bereavement status. Nonbereaved controls also reported difficulty sleeping, but were not seeing an MD for this, while bereaved interview and control respondents were reporting difficulty and only the bereaved interviews were seeking help from an MD. Bereaved persons may have assumed that everything they initially experienced as negative was grief-related. After one378 / RICHARDSON ET AL. year, however, they may have begun to understand that the real problem was sleep disturbance, and they consulted a physician for this. For the bereaved who visited a physician related to the care of their dying spouse, or for their own chronic conditions, seeing a physician for sleep difficulty may have been more acceptable, easier or less stigmatizing. Finally, some of the bereaved may have been burdened enough with their grief that difficulty sleeping became unbearable and they had to seek assistance. What factors are most common among adults over age 50 who report having disturbed sleep, either episodically or consistently? Persons with consistent sleep disturbance tended to be female, older, with poor health, and were taking more medications. All these results were in the expected direction. Even with the small number of men in our sample, the study had sufficient power to confirm others' objective findings of increased sleep difficulty for women (Call-Schmidt & Richardson, 2003). The oldest respondents reported more sleep disturbance than did younger old adults, confirming others' findings about aging and sleep (Bliwise, 1994; Ilayashi & Endo, 1982; Iloch et al., 1997; Webb, 1982). The relationship between poor health and prolonged difficulty with sleep may be explained in part if one accepts that poor health may be a source of worry, as well as a source of symptoms that disrupt sleep. Increased numbers of medica­tions may disrupt sleep through side effects, as all medications have side effects. While some medications (histamine blockers, beta blockers, and calcium channel blockers, to name only a few) can cause drowsiness and sleepiness, others (e.g., theophylline) increase arousal. Further, taking greater numbers of medications increases the likelihood that one would need to get up in the night to take a scheduled medication, or deal with the expected effects of the medication (e.g., diuresis). Finally, the relationship between stress and disrupted sleep is a common experience, possibly due simply to stress-mediated neurotransmitter release, resulting in increased wakefulness while stressed. What is the relationship over time between patterns of sleep disturbance and global measures of bereavement adjustment (bereavement-related feelings and behaviors)? Persons with consistent sleep disturbance showed statistically sig­nificant differences in grief outcomes that persisted over time. Apparently, if one has an established pattern of poor sleep, adjustment to grief takes longer and will be associated with a less favorable process. It is possible that the effects of prolonged difficulty sleeping are cumulative and additive, affecting grief outcomes as well as health. Implications for practice are, at this point, fairly straightforward. Findings suggest that the elderly female in poor health and taking multiple medications is at risk for difficulty adjusting to bereavement particularly if they report chronic difficulty sleeping. Patients fitting this profile should be carefully assessed upon bereavement for their chronic sleep pattern. Improving sleep in the elderly bereaved may be accomplished with a combination of short-term medication therapy and longer-term cognitive-behavioral sleep counseling (Montgomery,SLEEP PATTERNS IN OLDER BEREAVED SPOUSES / 379 2002). Finally, while our study used spousal bereavement as the model for grief, other losses, such as the death of a pet, grandchild, or friend, a change in work status, loss of independent living, and sensory loss can also precipitate grieving and should be assessed for at each patient-provider contact. SUGGESTIONS FOR FUTURE RESEARCH In terms of future research, we suggest that investigations focused on bereave­ment adjustments include measures of sleep difficulty. We need more in-depth assessments of how these adjustments can be impacted by sleep difficulties. And while we focused on patterns of sleep, future research might explore the relation­ship between sleep and grief in persons with no established pattern of sleep over time, with more power. 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