CHAPTER – 1

INTRODUCTION

The world is currently experiencing demographic revolution in which the number of elderly is
increasing. Elderly is defined as the age of 60 or more as defined by the World Health
Organization that consists of (1) elderly 60-74 years, (2) old elderly 75-90 years, (3) very old
elderly above 90 years. Currently population age 60 years or more is a tenth of total population,
and by 2050 it is estimated to become a fifth and in 2150 it is estimated to be a third. More than
half of them live in developing countries. In Indonesia, in 1999, the proportion of population
aged 60-64 years is 2,9 %, the group age 65-69 years of 2,3%, the group age 70-74 years 1,4%,
and population aged 75 years or more are 1,4% 1. According to the estimation from United
State Bureau of Census 1993, the population of elderly in Indonesia is projected to
increase 414% during the years 1990-2023, he number that is highest in the world. In 2020 the
number of elderly in Indonesia will rank the fourth after China, India and the United States.
In a community based-study, it was found that the prevalence of mild to severe cognitive
impairment to be 17-34% of elderly population3. More than 80% elderly suffered from physical
diseases that interfere with their independence in carrying out daily functions. A number of 30%
patients who have physical diseases have psychiatric comorbidities, especially depression and
anxiety. Most elderly with physical diseases and mental disorders have sleeping disorders.
Sleep and its stages is correlated to the process of consolidation of declarative and procedural
memories5. REM (Rapid Eye Movement) sleep is beneficial for restoring the ability of learning,
consolidation of memory, restoration of adrenergic system and restoration od reticular system to
make ready for arousal6. Zimmerman et al,2006 stated that memory impairment is a cognitive
impairment that is commonly found in patients with Obstructive Sleep Apnea (OSA)7. The
existence of cognitive impairment might interfere in conducting the Activities of Daily Living-
ADL, and this might decrease the quality of life of elderly which implies interference in
independence in carrying out the activity of daily living. The lost of social function and the
function of independence in elderly will lead to problems with family members. The research
concerning sleep quality which are specifically correlated to cognitive function disturbances in
elderly is rarely found in Indonesia.
Sleep disorder is a common complaint among the general populations of western countries, with
rates of self-reported insomnia ranging between 10% and 48% Sleep disorder has a significantly
negative impact on morbidity and mortality, particularly in the elderly population . Inability to
sleep can lead to difficulty sustaining attention, a slowed response time, impairments in memory
and concentration, and decreased performance. These symptoms are of particular concern in
older people, because they may be misinterpreted as symptoms of dementia or mild cognitive
impairment. Slowed response time is particularly important because it can affect driving ability
and increase the risk of falls Perhaps most startling is that insomnia is also associated with
shorter survival. Mortality due to common causes of death (e.g., heart disease, stroke, cancer,
suicide) is up to two times higher in elderly with sleep disorders than in those who sleep well.
Sleep quality is an important clinical construct and essential part of quality of life. It includes
quantitative aspects of sleep, eg. sleep duration, sleep latency, or number of arousals as well as
more pure subjective aspects, such as "depth" or "restfulness" of sleep Most previous studies in
China only used simple unstructured questions like “how many hours on average do you sleep
every day”, “have you had trouble sleeping recently”, or “how do you rate your sleep quality
recently”. These questions may be insufficient to deliver valid assessment of sleep quality. The
Pittsburgh Sleep Quality Index (PSQI) was designed to evaluate sleep quality through 19 items
on multiple dimensions of sleep over a 1-month period The Chinese version of Pittsburgh Sleep
Quality Index (CPSQI) has been validated. It can be a sensitive, reliable, and valid outcome
assessment tool for use in population-based studies of primary insomnia It has been used in
several studies in Taiwan and Hongkong Chinese, and resulted the prevalence of poor sleep
quality ranging from 6% to 78%. In mainland China, there was only one epidemiological study
using CPSQI, reporting that 50% of elderly aged 60 or older had poor sleep quality in a sample
population in rural area. Data in urban China is still lacking. In this study, we aimed to fill this
knowledge gap.
Independence of elderly can be achieved through their abilities to perform Activities of Daily
Livings (ADLs). ADLs is the term used to refer to the basic daily activities of self-care of an
individual such as taking bath, ability to self dress, eating, control over urination and defecation,
going to toilet and moving inside house and intermediate activities which includes ability to use
phone, to take self medication and to do simple house hold activities and going outside house or
abilities to perform basic and intermediate activities both (Shelley, 2012). Inability to perform
basic and instrumental activities of daily living is known as functional impairment which affects
the wellbeing in elderly (Mohanty, et al., 2012). It is a fact that threat to functional independence
in elderly arises as a result of physiological changes from the ageing process and effect of
chronic diseases, psychological problems as depression and cognitive impairment which demand
for long term health care cost and support from society (Hudakova, & Hornakova, 2011; Tripathi
& Tripathi, 2012). Research studies have revealed that functional limitations are associated with
different socio-demographic factors like increased age, female sex, illiteracy, non communicable
illnesses.
Old age is a period of physical decline. Even if one does not become sans eyes, sans teeth, sans
everything, right away, one does begin to slow down physically. The physical condition depends
partly upon hereditary constitution, the manner of living and environmental factors. Vicissitudes
of living, faulty diet, malnutrition, infectious, intoxications, gluttony, inadequate rest, emotional
stress, overwork, endocrine disorders and environmental conditions like heat and cold are some
of the common secondary causes of physical decline. Due to the loss of teeth, the jaw becomes
smaller and the skin sags. The cheeks become pendulous with wrinkles and the eye lids become
baggy with upper lids over hanging the lower. The eyes seem dull and lustreless and they often
have a watery look due to the poor functioning of the tear glands. Loss of dentures affect speech
and some even appear to lisp. The skin becomes rough and looses its elasticity. Wrinkles are
formed and the veins show out prominently on the skin. Perspiration is less profuse and other
skin pigmentation appears as the age advances. The hair becomes thin and grey, nails become
thick and tough. Tremors of the hands, forearms, head and lower jaw are common. Bones harden
in old age, become brittle and are subject to fractures and breaks. Changes in the nervous system
have a marked influence on the brain. Atrophy is particularly marked in the spleen, liver and soft
organs. The ratio of heart weight to body weight decreases gradually. The softness and pliability
of the valves change gradually because of an increase in the fibrous tissue from the deposits of
cholesterol and calcium. The aged are also prone to heart disease, other minor ailments and
chronic diseases. Due to the weakening regulatory mechanism, the body temperature is affected.
Therefore the old persons feel the change in climate more profoundly than others. They suffer
from digestive troubles, insomnia. Due to dental problems they are not able to chew or swallow
well. The old are more accident prone because of their slow reaction to dangers resulting in
malfunctioning of the sense organs and declining mental abilities, the capacity to work decreases.
Eyes and ears are greatly affected Changes in the nerve centre in the brain and retina affect
vision and sensitivity to certain colours gradually decreases. Most old people suffer from
farsightness because of diminishing eye sight. With advancing age, the sexual potency decreases
along with a waning of secondary sex characters. Women go through menopause generally at the
age of 45 – 50 years accompanied by nervousness, headaches, giddiness, emotional instability,
irritability and insomnia. The movements of the aged are fewer co-ordinates. They get fatigued
easily. Due to lack of motivation, they do not take interest to learn new skill and become
lethargic. Above all visits to the doctor becomes a routine work for them. Mental disorders are
very much associated with old age. Older people are susceptible to psychotic depressions. The
two major psychotic disorders of older people are senile dementia (associated with cerebral
atrophy and degeneration) and psychosis with cerebral arterio sclerosis (associated with either
blocking or ruptures in the cerebral arteries). It has been observed that these two disorders
account for approximately 80% of the psychotic disorders among older people in the civilized
societies. Older people suffer from senile dementia. They develop symptoms like poor memory,
intolerance of change, disorientation, rest lessens, insomnia, failure of judgement, a gradual
formation of delusion and hallucinations, extreme-mental depression and agitation, severe mental
clouding in which the individual becomes restless, combative, resistive and incoherent. In
extreme cases the patient become bed ridden and resistance to disease is lowered resulting in his
days being numbered. Decline in mental ability makes them dependent. They no longer have
trust in their own ability or judgements but still they want to tighten their grip over the younger
ones. They want to get involved in all family matters and business issues. Due to generation gap
the youngsters do not pay attention to their suggestion and advice. Instead of developing a
sympathetic attitude towards the old, they start asserting their rights and power. This may create
a feeling of deprivation of their dignity and importance. Loss of spouse during old age is another
hazard. Death of a spouse creates a feeling of loneliness and isolation. The negligence and
indifferent attitude of the family members towards the older people creates more emotional
problems.
Older people suffer social losses greatly with age. Their social life is narrowed down by loss of
work associated, death of relatives, friends and spouse and weak health which restricts their
participation in social activities. The home becomes the centre of their social life which gets
confined to the interpersonal relationship with the family members. Due to loss of most of the
social roles they once performed, they are likely to be lonely and isolated severe chromic health
problem enable them to become socially isolated which results in loneliness and depression.
Retirement from service usually results in loss of income and the pensions that the elderly
receive are usually inadequate to meet the cost of living which is always on the rise. With the
reduced income they are reversed from the state of “Chief bread winner to a mere dependent”
though they spend their provident fund on marriages of children, acquiring new property,
education of children and family maintenance. The diagnosis and treatment of their disease
created more financial problem for old age.
BACKGROUND OF THE STUDY:
Potter and perry(2010):stated that sleep disturbance is common nowadays,its just a move in
laptop or catching thing for the next day,insomnia or a party of the lack of good hours of sleep
increase our risk for various health problems.

Alia Khan Hudson:lack of sleep typically takes the blame for exhaustion,and if you are lagging
less than 7 hours of shut eye each night ,achieving the recommended 7to 9 hours should be your
first step to overcome daytime tiredness.But if you are already getting the target amount and still
feel wiped out,you may have one of the following underlying sleep disorders.

Cathy A.lessi:sleep disturbance is common with advancing age,due to age related changes in
sleep and an increased prevalence of certain sleep disorders,in addition to health
conditions,psychosocial issues,medication effects and a variety of other factors thataffects sleep.

NEED FOR THE STUDY Sleep is one of the essential components in the overall mosaic of
health,and it profoundly affects the subjective sense of the physical and mental well being.sleep
is a subjective feeling and every day is running towards night.sleep energy conservation,rest and
smooth functioning of the organs,we need 7-8 hrs of sleep everyday.
Since the ancient times,sleep has been viwed as and integral part of human life and health,
people were aware of the beneficiary effect of sleep and hypotherapy was among the first
psychotherapeutic procedure used.on the other hand,the sleep disorder is one of the most
effective nayural treatments.some of these methods still applicable to problems of initiating or
sustaining sleep and may be even preferable tp pharmacology,however these practicesb cannot
substitute for a medical treatment.The evidence that insomnia and other sleep problems have
negative effects on health and quality of life(QOL)across the lifespan is convincing,and data
suggest that this relationship is even stronger as people age.several population based studies have
demonstrated an association between impaired sleep and worse performance on global measure
and specific individual domains of QOL in the older adult.In addition,among older
people,excessive day time sleeping may be associated with an increased risk of falls.there is also
evidence that sleeping problems can interfere with an older persons ability to carry out healthy
and stable relationship with their spouse,other family and friens,which likely firther impairs their
QOL.taken together,research evidence is convincing among older adults that the cumulative
effects of sleep disturbance can significantly impair their well being.

STATEMENT OF THE PROBLEM:

A study to assess the quality of sleep and activities of daily living (ADL)
among geriatric population at selected communities in Chennai.

OBJECTIVES:
1) To assess the quality of sleep and activities of daily living of geriatrics population.
2) To correlate the quality of sleep and activities of daily of geriatrics population.
3) To associate the sleep quality and activities of daily living with the selected demographic
variables of geriatrics population.
OPERATIONAL DEFINITION :
Quality of sleep:
Quality of sleep is a subjective expression of individual who had quality sleep without
disturbance and full day time alertness as rated on a pittsburg sleep quality index (pqsi) a score of
5or<5 on pqsi is considered as good sleep quality.

GERIATRICS POPULATION:
In this study geriatrics population refers to the people above the age of 65years
residing in the village of Ayappakam.

HYPOTHESIS:
1) There is no correlation between quality of sleep and Activity of daily living
among geriatrics.
2) There is no significant association between quality of sleep and Activity of daily
living among geriatrics and their selected demographic variable.

ASSUMPTION:
1) Geriatrics population above the age of 60years in the Ayappakam may have sleep
problem
2) The sleep problem of the geriatrics affects the activity of the daily living
3) The geriatric population need to be assessed for the quality of the sleep and how it
affects their activities of daily living.

DELIMINATION:
1.The study is delimited to the sample size of 100.
2.The study is delimited to the geriatric population residing at ayapakkam village.