Sleep Breath (2007) 11:187–194
DOI 10.1007/s11325-006-0097-3
ORIGINAL ARTICLE
Insomnia symptoms and their correlates among the elderly in
geriatric homes in Alexandria, Egypt
Mohamed M. Makhlouf & Abla I. Ayoub &
Moataz M. Abdel-Fattah
Published online: 19 January 2007
# Springer-Verlag 2007
Abstract The prevalence of sleep complaints increases
steadily with age. Studies investigating insomnia among
elderly people living in geriatric homes, especially among
Egyptians, are scarce. This study aimed to determine the
prevalence of insomnia symptoms among the elderly living in
geriatric homes in Alexandria and their correlates. A cross-
sectional survey of a representative sample of elderly
population of geriatric homes in Alexandria was imple-
mented. A total of 177 persons aged 60 years or older
participated. Difficulty initiating sleep was reported by 65%
of the participants. Approximately half of them had difficulty
maintaining their sleep (50.8%) or had non-restful sleep
(51.4%). Short sleep was reported by 43.5% of the
participants, while early morning awakening was reported by
28.2%. Advanced age (≥75 years) was significantly associated
with increased risk for early morning awakening, non-restful
sleep and short sleep. Women had approximate-ly a fourfold
risk of non-restful sleep as opposed to men. Short stay in
geriatric homes (<1 year) was associated with 2.5-fold
increased risk of non-restful sleep. Unmarried status was
strongly and positively related to difficulty to maintain sleep
and non-restful sleep. Depressive status was
: consequence of getting older [2, 3].
M. M. Makhlouf A. I. Ayoub
Geriatric Health Department, High Institute of Public Health,
Alexandria University,
Alexandria, Egypt
M. M. Abdel-Fattah
Medical Statistics Department, Medical Research Institute,
Alexandria University,
Alexandria, Egypt
M. M. Abdel-Fattah (*)
Chief and Consultant of Preventive Medicine Department,
Al-Hada Armed Forces Hospital,
P.O. Box 1347, Taif, Kingdom of Saudi Arabia
e-mail: mezo106@yahoo.com
significantly associated with an increased risk of difficulty
to maintain sleep and decreased risk of early morning
awakening. Conclusively, the present study showed that
insomnia symptoms are highly prevalent among the elderly
living in geriatric homes. It also revealed that although age,
gender, and other socio-demographic factors are correlated
with insomnia symptoms, other factors are highly impor-
tant. Health care providers should take these factors in
consideration when dealing with elderly patients who
complain of insomnia.
. .
Keywords Insomnia Elderly Egypt
Introduction
Getting a good night’s sleep is essential for feeling
refreshed and alert during the day. Unfortunately, not
everyone is able to get the restorative sleep they need [1].
Older adults often experience sleep disturbances, but most
of them fail to mention these disturbances to their
physician out of a false belief that sleep troubles are just a
It has been estimated that sleep disturbances affect more
than 50% of community dwelling individuals more than 65
years of age and an estimated two-thirds of institution-
alized elderly persons [4].
Insomnia can be simply defined as difficulty initiating
sleep (DIS), difficulty maintaining sleep (DMS), early
morning awakening (EMA), short sleep (SS), or non-restful
sleep (NRS) [5, 6]. Insomnia can be classified according to
the part of sleep cycle most affected, that is, sleep initiation,
sleep maintenance (frequent awakening), or early awaken-ing
(terminal insomnia). Classifying insomnia in this way may
give clues to the underlying cause [5].
188 Sleep Breath (2007) 11:187–194

Insomnia can be due to medical conditions, chronic dis- Table 1 Demographic and medical characteristics of the participants
eases, psychiatric disorders, and medications. In addition, the (n=177)
circadian rhythm advances that accompany aging can cause Variables Percentage
early evening lethargy and early morning awakenings [7].
Gender
The inability to have restful sleep at night results in
Men 39.5
excessive daytime sleepiness, attention and memory prob-
Women 60.5
lems, depressed mood, falls and lowered quality of life. It is Geriatric home category
also evident that disturbances in sleep can also lead to adverse
changes in functioning of number of body systems [8]. In Private 45.2
addition to affecting the quality of life in the aged, problems Public 54.8
with sleep have been associated with increased risk of nursing Education
home placement and increased mortality [7].
Illiterate or read and write 39.5
Studies investigating insomnia among elderly people
Primary 18.1
living in geriatric homes, especially among Egyptians, are Preparatory or secondary 26.6
scarce. So, this study aimed to determine the prevalence of University 15.8
insomnia symptoms among Egyptian elderly living in Marital status
geriatric homes in Alexandria and their correlates.
Married 12.8
Divorced 9.6
Materials and methods Widowed 62.1
Single 15.8
Current job Status
Study design
Working 3.4
A cross-sectional survey of a representative sample of Not working 96.6
elderly population of geriatric homes in Alexandria was Previous Job
implemented. Three geriatric homes (two representing
public and one representing private geriatric homes) were Manual 9.0
randomly selected from 15 located in Alexandria (three Skilled 13.6
Professional 30.5
private and 12 public).
Free 4.5
Housewife 42.4
Participants History of chronic diseases

All residents of the selected homes were eligible to participate No 9.6

in the study provided that they were: (a) 60 years of age or One disease 23.2
older; (b) free from communication problems; and Two diseases 33.3
Three diseases or more 33.9
(c) free from dementia (absence of established diagnosis in
Hypertension 48.6
their medical records and/or a score of 24 or more in Diabetes mellitus 20.3
MMSE [9]). Those who did not meet the inclusion criteria Cardiac diseases 26.0
were excluded from the study (n=32). The study was Chest diseases 7.3
carried out between May 2003 and June 2004. Neurological diseases 18.6
Of those eligible, 177 completed the questionnaire Osteoarthritis 31.1
(response rate 95.6%). The sample constituted approxi- Medication use 89.3
mately 25% of the elderly population in all the geriatric Taking diuretics 26.0
Taking antihypertensive
homes in Alexandria.
ACE inhibitors 22.6
Measures Beta-Blockers 5.6
Others 4.0
All eligible participants (n=185) were invited to complete Taking analgesics 19.8
a structured questionnaire, filled in by trained physicians, Taking tricyclic drugs 2.8
and covering the following: Taking antihistaminic 5.6
Taking benzodiazepines 11.3
Socio-demographic characteristics and environmental
factors that could affect sleeping such as excessive light,
sound, and temperature variation.
Sleep Breath (2007) 11:187–194 189

Table 2 Distribution insomnia

symptoms among participants Insomnia symptoms Females (n=107) Males (n=70) Total (n=177) P value
according to their gender No. (%) No. (%) No. (%)

Number of symptoms
No 25 (23.4) 20 (28.6) 45 (25.4)
One symptom 49 (45.8) 27 (38.6) 76 (42.9)
Two or more symptoms 33 (30.8) 23 (32.8) 56 (31.7) 0.601
Type of symptoms

Difficulty initiating sleep 77 (72.0) 38 (54.3) 115 (65.0) 0.024

Difficulty maintaining sleep 61 (57.0) 29 (41.4) 90 (50.8) 0.047
Early morning awakening 29 (27.1) 21 (30.0) 50 (28.2) 0.734
Non-restful sleep 71(66.4) 20 (28.6) 91 (51.4) 0.000
Short sleep 48 (44.9) 29 (41.4) 77 (43.5) 0.757

Habits Information regarding the frequency and timing of
drinking caffeinated beverages (tea, coffee, and soft
drinks) and history of practicing aerobic exercise on a
regular basis has been determined.
The activities of daily living of the participants were
assessed using the Katz index [10] and instrumental
activities of daily living [IADL] [11].
Data about number and type of chronic diseases and
medication use were obtained.
Depression status The following National Health Interview
Survey (NHIS) [12] question was used to measure depression:
“Over the past year, have you had 2 consecu-tive weeks or
more during which you felt sad, blue, or depressed, or lost
pleasure in things you usually cared about or enjoyed?”
(Yes/no). The depression item from the NHIS has been shown
to be useful in discriminating medical health care utilization
and costs as well as risk of all-cause mortality among men and
women [13].
Insomnia symptoms Detailed sleeping history during the last
month was assessed including the frequency of the common types
of insomnia symptoms including: DIS—“prolonged sleep onset
latency >0.5 hours”, DMS—“frequent awakening after sleep”,
EMA— “waking up before or at 5 o’clock in the morning”, SS
“sleep at night equal or less than 6 hours,” and NRS—“not
feeling rested upon awakening in the morning”.
Outcome variables
DIS, DMS, EMA, NRS, SS (no vs yes for all the variables).
Independent variables
Age in years (<75 vs ≥75), gender (male vs female),
geriatric home category (public vs private), room type
(single vs shared), duration of geriatric home stay (<1 year
vs >1 year), educational level (illiterate or read and write
vs primary, preparatory or secondary, and university),
marital status (married vs unmarried), daily activity
(independent for all activities vs partially or completely
dependent), time of drinking caffeinated beverages (not al
all vs yes not evening and yes evening), depression status
(no vs yes), history of chronic diseases (no vs one, two and
three or more diseases), hypertension (no vs yes), diabetes
mellitus (no vs yes), cardiac diseases (no vs yes), chest
diseases (no vs yes), neurological diseases (no vs yes),
osteoarthritis (no vs yes), medication use (no vs one or two
and three or more drugs), benzodiazepines (no vs yes),
environmental factors (no. vs yes), and time of going to
bed (<9 P.M. vs 9–12 P.M. and >12 P.M.).
Statistical analysis
Analyses were performed using the Statistical Package for
Social Science (SPSS), version 11.0. The differences between
men and women in different studied insomnia symptoms were
2
tested by X test. For each of the independent variables, the
crude odds ratio (OR) and 95% confidence interval (CI)
associated with each category were computed. Multivariate
associations were evaluated in a multiple logistic regression
model, including only significant variables in univariate
analyses, based on the backward stepwise selection. This
procedure allowed the estimation of the association between
each independent variable and the dependent variable, taking
into account the potential confounding effect of other
independent variables. Separate models have been constructed
for each insomnia symptom entity. The covariates were
removed from the model if the likelihood ratio statistic based
on the maximum likelihood estimates had a probability of
more than 0.10. Each category of the predictor variables was
contrasted with the initial category “reference category.” An
adjusted OR with 95% CI that did not include 1.0 was
considered significant. All models were tested for significant
possible interactions.
190 Sleep Breath (2007) 11:187–194
Table 3 Risk factors for different forms of insomnia symptoms among participants: multivariate analysis

Risk factors Difficulty initiating a b

Difficulty maintaining Early morning Non-restful sleep Short sleep (<6 h)
sleep Cases/controls sleep cases/controls awakening Cases/ Cases/controls Cases/controls
115/62 90/87 controls 50/127 91/86 77/100
Age in years
c 62/43 49/56 23/82 47/58 38/67
<75 (105)
≥75 (72) 53/19 41/31 27/45 44/28 39/33
d e 1.83 (0.90–3.90) Not included 2.41 (1.16–5.26)* 3.81 (1.53–8.61)* 2.30 (1.17–4.31)*
Adjusted OR (95% CI)
Gender
c 38/32 29/41 21/49 20/50 29/41
Male (70)
Female (107) 77/30 61/46 29/78 71/36 48/59
Adjusted OR (95% CI) Removed Removed Not included 3.69 (1.42–8.40)* Not included
Duration of home stay
c 91/47 66/72 37/101 64/74 22/17
≥1 year (138)
<1 year (39) 24/15 24/15 13/26 27/12 55/83
Adjusted OR (95% CI) Not included Not included Not included 2.49 (1.11–5.38)* Not included
Marital status
c 11/11 4/18 3/19 4/18 7/15
Married (22)
Unmarried (155) 104/51 86/69 47/108 87/68 70/85
Adjusted OR (95% CI) 2.05 (0.76–5.57) 5.15 (1.55–17.11)* Not included 4.58 (1.20–17.42)* Not included
Environmental factors
c 41/40 37/44 32/49 27/54 38/43
No (81)
Yes (96) 74/22 53/43 18/78 64/32 39/57
Adjusted OR (95% CI) 3.17 (1.61–7.03)* Not included 0.36 (0.21–0.73)* 5.16 (2.30–11.56)* 0.77 (0.43–1.41)
Depression status
c 18/13 10/21 14/17 8/23 14/17
No (31)
Yes (146) 97/49 80/66 36/110 83/63 63/83
Adjusted OR (95% CI) Not included 2.67 (1.09–5.88)* 0.36 (0.13–0.91)* Removed Not included
Educational level
c 46/24 43/27 21/49 49/21 34/36
Illiterate or read and write (70)
Primary (32) 18/14 15/17 11/21 17/15 17/15
Preparatory or 2ry (47) 32/15 18/29 9/38 18/29 12/35
University (28) 19/9 14/14 9/19 7/21 14/14
f 0.49 (0.17–1.42) 1.39 (0.61–3.62)
Adjusted OR (95% CI)
g
Adjusted OR (95% CI) 0.32 (0.13–0.91)* 0.40 (0.17–0.94)*
h Not included Removed Not included 0.26 (0.08–0.94)* 1.40 (0.57–3.54)
Adjusted OR (95% CI)
Chronic diseases
c 10/7 3/14 5/12 3/14 5/12
No (17)
One (41) 25/16 25/16 17/24 20/21 19/22
Two (59) 39/20 23/36 12/47 31/28 24/35
3 41/19 39/21 16/44 37/23 29/31
Three or more (60)
i
Adjusted OR (95% CI) 5.30 (1.46–27.27)* 6.95 (1.24–38.7)*
j
Adjusted OR (95% CI) 3.04 (0.74–12.16) 4.51 (0.75–28.62)
k Not included 8.28 (2.04–34.44)* Not included 9.02 (1.44–53.52)* Not included
Adjusted OR (95% CI)
Cardiac diseases
c 93/48 70/71 40/101 56/85 56/85
No (141)
Yes (36) 22/14 20/16 10/26 21/15 21/15
Adjusted OR (95% CI) Not included Not included Not included Not included 2.34 (1.07–5.38)*
Osteoarthritis
c 71/51 57/65 38/84 56/66 52/70
No (122)
Yes (55) 44/11 33/22 12/43 35/20 25/30
Adjusted OR (95% CI) 2.31 (1.01–5.17)* Not included Not included Removed Not included
Body pain during sleep
c 66/54 46/74 48/72 42/78
No (120)
Yes (57) 49/8 44/13 43/14 35/22
Adjusted OR (95% CI) 4.82 (2.16–10.49)* 5.14 (2.51–11.15)* Not included 4.43 (2.16–8.32)* 2.55 (1.59–5.71)*
Sleep Breath (2007) 11:187–194 191
Table 3 (continued)

Risk factors Difficulty initiating a b

Difficulty maintaining Early morning Non-restful sleep Short sleep (<6 h)
sleep Cases/controls sleep cases/controls awakening Cases/ Cases/controls Cases/controls
115/62 90/87 controls 50/127 91/86 77/100
Time of going to bed
c 7/7 5/9 3/11 5/9 4/10
<9 P.M. (14)
9–12 P.M. (141) 90/51 69/72 39/102 72/69 58/83
>12 P.M. (22) 18/4 16/6 8/14 14/8 15/7
l 2.02 (0.60–6.8) 1.86 (0.55–6.27) 2.48 (0.72–9.17)
Adjusted OR (95% CI)
m 7.17 (1.35–38.09)* 5.48 (0.78–19.92) Removed Removed 6.92 (1.51–33.56)*
Adjusted OR (95% CI)

*P<0.5
aVariables of daily activity and medication use have been removed from the final model.
b Variables of room type, daily activity, and medication use have been removed from the final model.
cReference category
d Odds ratio
eConfidence interval
f Primary vs c
g Preparatory or 2ry vs c
h University vs c
i One vs c
j Two vs c
k Three or more vs c
l 9–12 P.M. vs c
m >12 P.M. vs c

Results related to DMS and NRS. Depressive status was signifi-

Table 1 provides a summary of socio-demographic and
medical characteristics for participants. A total of 177
persons (their age ranged between 60 and 92, with a mean
of 72.53 and standard deviation of 7.64 years) participated
in the study. Their insomnia symptoms are presented in
Table 2. Of all the subjects, 74.6% reported at least one
insomnia symptom. The most common insomnia
symptoms were DIS (65%), followed by NRS (51.4%) and
DMS (50.8%). Twenty-eight percent of the participants
gave a history of EMA. The median value of the total
duration of night sleep was 6 h. SS was reported by 43.5%
of the participants. DIS, DMS, and NRS were more
significantly reported by females (p values <0.05, <0.05,
and <0.001, respectively).
Advanced age (≥75 years) was significantly associated
with increased risk for EMA, NRS, and SS. Females had
approximately a fourfold significant risk of NRS as opposed
to males. Short staying in geriatric homes (<1 year) was
significantly associated with 2.5-fold increased risk of NRS.
On the other hand, relatively higher educational level
(preparatory or secondary) was significantly associated with a
lower risk of NRS and SS as compared to lower educational
level (illiterate or just able to read and write) and university
level was significantly associated with lower a risk of NRS.
Unmarried status was strongly and positively
cantly associated with an increased risk of DMS and a
lower risk of EMA.
Participants with a history of three or more of chronic
diseases had an increased risk of DMS and NRS compared
to those with no history of chronic diseases. History of
cardiac diseases was found to be a significant risk factor
for SS, while history of osteoarthritis was found to be a
sig-nificant risk factor for DIS. Regarding exposure to
envi-ronmental factors, those reported history of exposure
to these factors were more liable to develop problems of
DIS and NRS and less liable to develop a problem of
EMA. DIS and SS symptoms were significantly associated
with going to bed after 12 P.M. as opposed to before 9 P.M.
History of body pain during sleep was significantly
associated with all studied sleep symptoms except EMA.
Discussion
The present study revealed that insomnia symptoms were
highly prevalent among the elderly in geriatric homes
(74.6%). The most common insomnia symptom among the
elderly was DIS (65%), followed by NRS (51.4%), DMS
(50.8%), and SS (43.5%). EMA was reported by 28.2%.
These figures are somewhat higher than those found in
other studies. However, it is difficult to make direct
192
comparisons between our findings and other studies as they
were dealing with different cohorts, living in different
settings, questions about insomnia symptoms were asked
differently, and frequency response options vary. Most of
these studies were dealing with community-dwelling elderly
with lower prevalence of insomnia symptoms. For example,
estimates of DIS ranged from 10 to 37%, DMS ranged from
14 to 65%, and EMA from 17 to 30% [14–19].
Higher rates of DMS (81%) and EMA (51%) in elderly
patients with knee pain were found in USA [20]. Also, high
prevalence of sleep disturbances (69%), close to that found
in the present study was found among elderly people living
in assisted living facility in Maryland, USA [21]. The high
prevalence of sleep disturbances among the elderly living
in these facilities or in geriatric homes may be associated
with unfamiliar environment especially in the early period
after admission, lower social support, higher prevalence of
chronic illnesses, and depressive symptoms among the
residents. Environmental factors, mainly excessive noise
and light, were significantly associated with DIS and NRS
in the present study and with sleep disturbances in other
studies [22, 23].
Also, shorter duration of the elderly in the geriatric home
was associated with NRS in the present study. This may be
related to being unfamiliar with the new environment, or the
development of depressive symptoms that may accom-pany
admission to geriatric homes. The last reason may also
explain the higher and significant prevalence of insomnia
symptoms (DMS, NRS) among unmarried than married
elderly. Being unmarried was also found to be associated with
insomnia among Chinese elderly men [24].
In addition to marital status, educational level also
appeared to be significantly associated with insomnia in
the present study. Although those with higher educational
level appeared to sleep shorter time than those with lower
educational level, they appeared to have less NRS. Other
studies also showed significant association between lower
educational level and increased risk of insomnia [23–25].
Increasing age in the present study was a significant
predictor of all forms of insomnia symptoms, except DMS
and DIS. Significant association between age and insomnia
was also found in several studies [17, 26–27]. On the other
hand, age was not associated with increased rate of
insomnia in Taiwan [24]. There is epidemiological
evidence demonstrating that the bulk of sleep complaints
and disorders is not the result of age per se, but rather co-
segregate with medical and psychiatric disorders and
related health burdens [28].
Concerning gender, the present study revealed that
women significantly reported higher DIS, DMS, and NRS
than men. However in multivariate analysis, NRS was the
only insomnia symptom that remained significantly
different between both sexes. Several studies also showed
Sleep Breath (2007) 11:187–194
that women significantly reported more DIS [21, 25], both
DIS and DMS than men [27]. Other studies [24, 29]
revealed that female gender was not an independent risk
factor for sleep disturbances. It was concluded that the
clear gender difference in the prevalence of insomnia is
caused by gender difference in the prevalence of anxiety
and depression [29].
In a study done in non-institutionalized elderly in US
communities [17], all symptoms of sleep disturbances were
strongly related to depression. In many other studies [30– 33],
depression was one of the strongest risk factors for current
insomnia Table 3. There is also epidemiological evidence that
the relationship between depression and insomnia is bi-
directional [34]. The present study also revealed that
depressed mood is significantly associated with DMS.
However, depressed mood in the present study was protective
from early morning awakening. This may be explained by the
fact that depressed elderly, having interrupted sleep (DMS),
may at the late hours of the night become tired and fall asleep
and hence may not complain of EMA.
Apart from depression, perceived poor health, and the
actual health status of the elderly as predicted by the
number of current diseases, were strongly associated with
insomnia in different studies [26, 31, 33]. The present
study also revealed that the number of chronic diseases the
elderly have was strongly associated with DMS and NRS.
A higher number of chronic diseases may lead to occur-
rence of insomnia among the elderly in two ways. First, an
indirect way, through the higher prevalence of depression
among the elderly with multiple chronic illnesses. Second,
through a direct way, by the symptoms of these chronic
illnesses or due to side effects of the drugs used to manage
them, which may disturb sleep.
Several drugs have been implicated in the occurrence of
insomnia including antihypertensive agents, corticosteroids,
diuretics, sympathomimetics, antihistaminics, and many
others [6]. However, none of these drugs showed a sig-
nificant association with insomnia symptoms in the present
study. Moreover, the use of benzodiazepines was not
significantly associated with insomnia in the present study.
This was not the case in other studies [17, 21, 33] Smaller
sample size and lower utilization rate of some of these drugs
may partially explain difference in results of our study and
those of other studies.
Depressed mood and coexisting arthritis were the most
relevant independent correlates of sleep disturbances
among the elderly in Italy [35]. Also among the elderly
Japanese, history of cardiovascular disease, arthritis or
joint pain and prostatic hypertrophy, and lower subjective
well-being among men and depression among women
were associated with sleep disturbances [25]. Moreover,
elderly patients with confirmed angina were 1.6 times
more likely to report DIS [17].
Sleep Breath (2007) 11:187–194
The present study also revealed that cardiac diseases
were significantly associated with shorter sleep time, while
osteoarthritis was associated with DIS. On the other hand,
body pain was significantly associated with all symptoms
of insomnia except EMA. Chronic pain, a prominent
feature of knee OA, was found to be a strong correlate of
sleep complaints in community-based samples [14, 36].
Several other types of pain like that of rheumatoid arthritis
and fibromyalgia were also associated with sleep distur-
bances in other studies [37, 38].
The present study revealed that although age, gender,
and other socio-demographic factors are associated with
sleep disturbances, other factors are highly important.
These include health status as predicted by number of
chronic diseases especially cardiac diseases and arthritis,
depressive mood, and body pains. Health care providers
should take these problems into consideration when
dealing with elderly patients who complain of insomnia.
Proper management of these problems may help in
overcoming the problem of insomnia and its sequelae.
Also, handling environmental conditions in geriatric homes
and promotion of sleep hygiene of the elderly may be also
of utmost importance.
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