The relationship between sleep health and multimorbidity in community dwelling populations: Systematic review and global perspectives

Sleep Problems and Sleep Quality in the General Adult Population Living in South Tyrol (Italy): A Cross-Sectional Survey Study

It remains unclear how sleep health has developed in the general population after the COVID-19 pandemic. This study aimed to (1) investigate the prevalence of sleep problems and poor sleep quality and (2) explore the associated sociodemographic and health-related factors in South Tyrol, Italy. A cross-sectional, population-based survey was conducted with a stratified probabilistic sample of 4000 adults aged ≥ 18 years. Sleep quality was assessed using the brief version of the Pittsburgh Sleep Quality Index. Descriptive and logistic regression analyses were performed to analyze the data. A total of 2090 adults (53%) completed the survey. Poor sleep quality was reported by 17.8%, with 28.2% of participants reporting insufficient sleep duration (i.e., six hours or less), 12.7% having problems staying asleep (i.e., waking up to 3-4 times a week and unable to fall asleep again), and 8.7% having problems falling asleep (i.e., >30 min). Sleep problems and poor sleep quality were associated with sociodemographic and health-related factors, including gender, age, mother tongue, chronic disease, and sleep hygiene. Notably, Italian-speaking participants reported poorer sleep quality and greater difficulty staying asleep compared to German-speaking participants, highlighting potential sociocultural influences on sleep health. This study contributes to understanding the unique sleep health challenges in a multilingual region, highlighting the role of sociocultural factors in sleep quality differences between language groups.

Negative Aging Stereotypes and Clinical Insomnia in Older U.S. Military Veterans

BACKGROUND AND OBJECTIVES

Insomnia symptoms are more prevalent in older age and may be impacted by negative perceptions of aging; however, more research is needed. The present study characterizes the relationship between negative aging stereotypes and clinical insomnia symptoms in a nationally representative sample of older U.S. veterans.

RESEARCH DESIGN AND METHODS

Data were analyzed from 3,000 U.S. veterans (aged 60-99) who participated in the National Health and Resilience in Veterans Study (NHRVS). Multivariable regression analyses were conducted to examine associations between negative aging stereotypes (assessed with the Expectations Regarding Aging scale) and clinical insomnia (assessed with the Insomnia Severity Index).

RESULTS

A total of 213 veterans (7.1%) screened positive for clinical insomnia and scored significantly higher on measures of negative emotional (p < .001), physical (p = .003), and cognitive (p = .013) aging stereotypes relative to veterans without clinical insomnia. Multivariable regression analyses revealed that, after adjusting for covariates, greater endorsement of negative stereotypes regarding emotional aging was associated with significantly greater odds of screening positive for clinical insomnia (OR = 1.56, 95%CI = 1.26-1.95, p < .001), sleep disturbance (OR = 1.49, 95%CI = 1.25-1.77, p < .001) and daytime dysfunction (OR = 1.58, 95%CI = 1.34-1.88, p < .001). Veterans who "somewhat" and "fully" endorsed these negative stereotypes were 3- and 6 times more likely to screen positive for clinical insomnia, respectively (probabilities = 0.110 and 0.246 vs 0.040).

DISCUSSION AND IMPLICATIONS

Negative aging stereotypes, particularly those related to emotional aging, are independently associated with clinical insomnia in older U.S. veterans. Efforts to modify these stereotypes in older veterans may help improve overall sleep quality.

Global Perspectives on Sleep Health: Definitions, Disparities, and Implications for Public Health

Sleep health is a multidimensional construct encompassing sleep quality, duration, efficiency, regularity, and alignment with circadian rhythms, playing a crucial role in overall well-being. Sleep health remains inconsistently defined across research and clinical settings despite its importance, limiting the ability to standardize assessments and interventions. Recent studies have emphasized the significance of defining sleep health beyond the absence of sleep disorders, integrating subjective and objective measures to assess its impact on physical and mental health outcomes. Disparities in sleep health exist across gender, socioeconomic status, and geographic regions, particularly in low- and middle-income countries where inconsistent work schedules, economic stress, and healthcare access influence sleep patterns. Poor sleep health is associated with increased risks of cardiovascular disease, obesity, metabolic dysfunction, and mental health disorders, reinforcing its role as a modifiable risk factor in public health. Lifestyle factors such as caffeine consumption, physical activity, and irregular eating patterns also contribute to sleep disturbances, highlighting the need for behavioral interventions. This narrative review aims to synthesize the current knowledge on sleep health, focusing on its definitions, measurement tools, global disparities, and associations.

Sleep: The silent hero in cardiometabolic health

The essential role of sleep in overall health is increasingly recognized, yet it remains underemphasized in both clinical and public health contexts. Despite extensive research linking poor sleep health to chronic conditions such as cardiovascular disease, type 2 diabetes, and cognitive decline, sleep health is not routinely assessed or integrated into standard care practices. Sleep problems, including insomnia, sleep apnea, and poor sleep quality, are prevalent globally, affecting over 30 % of the population and contributing to significant public health burdens like cardiometabolic disease, mental health disorders and multimorbidity. The economic implications are substantial, with insufficient sleep imposing significant societal and financial costs worldwide. Recognizing this, recent initiatives like the American Heart Association's inclusion of sleep in the Life's Essential 8 framework highlight the importance of sleep in cardiometabolic health. Integrating sleep into clinical and public health strategies is crucial, due to the wide-ranging impact of sleep on cardiometabolic health. Social, environmental, and demographic factors also play significant roles in sleep health, with lower socioeconomic groups and women often experiencing poorer sleep, further exacerbating health disparities. Adopting a life course approach and promoting healthy sleep behaviors early in life are essential for mitigating long-term cardiometabolic risks. Effective evidence-based strategies for improving sleep behaviors and cardiometabolic health, beyond addressing sleep disorders, include prioritizing sleep hygiene, managing stress, promoting physical activity, maintaining a healthy diet, and reducing substance use, all of which contribute to overall well-being. In conclusion, incorporating sleep health into routine cardiometabolic risk stratification, prevention, and management is essential for improving overall health outcomes.

The Role of Nutrition and Other Lifestyle Patterns in Mortality Risk in Older Adults with Multimorbidity

Background: Limited research has examined how older adults' lifestyles intersect with multimorbidity to influence mortality risk. Methods: In this community-dwelling prospective cohort, the Sydney Memory and Ageing Study, principal component analysis was used to identify lifestyle patterns using baseline self-reported data on nutrition, lifestyle factors, and social engagement activities. Multimorbidity was defined by self-reported physician diagnoses. Multivariable logistic regression was used to estimate odds ratios (ORs) for multimorbidity cross-sectionally, and Cox proportional hazards models were used to assess hazard ratios (HRs) for mortality risk longitudinally. Results: Of 895 participants (mean age: 78.2 years; 56.3% female) with complete lifestyle data, 597 had multimorbidity. Two distinct lifestyle patterns emerged: (i) a nutrition pattern characterised by higher intakes of protein, fibre, iron, zinc, magnesium, potassium, and folate, and (ii) an exercise-sleep-social pattern marked by weekly physical activities like bowling, bicycling, sleep quality (low snoring/sleepiness), and high social engagement. Neither pattern was associated with multimorbidity cross-sectionally. Over a median 5.8-year follow-up (n = 869; 140 deaths), participants in the upper tertiles for combined lifestyle pattern scores had a 20% lower mortality risk than those in the lowest tertile [adjusted HR: 0.80 (95% CI: 0.65-0.97); p-trend = 0.02]. This association was stronger in participants with multimorbidity, with a 29% lower risk [0.71 (0.56-0.89); p-trend = 0.01], likely due to multimorbidity modifying the relationship between nutrition and mortality risk (p-interaction < 0.05). While multimorbidity did not modify the relationship between the exercise-sleep-social pattern and risk of mortality, it was consistently associated with a 19-20% lower risk (p-trend < 0.03), regardless of the multimorbidity status. Conclusions: Older adults with multimorbidity may particularly benefit from adopting healthy lifestyles focusing on nutrition, physical activity, sleep quality, and social engagement to reduce their mortality risk.

Insomnia and Female Reproductive Diseases: A Cross-Sectional and Mendelian Randomization Study

Background

Insomnia is increasingly emerging as a significant concern in public health, with a longstanding emphasis on its relationship with overall well-being. Nevertheless, few research has been devoted to investigating the relationship between insomnia and female reproductive health.

Methods

In our study, we conducted a Mendelian randomization (MR) study to estimate the causal relationship between insomnia and female reproductive diseases. A total of 268 independent genetic variants associated with insomnia at the genome-wide significance level (P < 5×10-8) were used as instrumental variables. Summary-level data were obtained from the UK Biobank and Finn Gen study, including ovarian cysts, polycystic ovarian syndrome (PCOS), endometriosis, premature ovarian insufficiency (POI), ovarian cancer (OC), uterine fibroids, endometrial cancer (EC) and female infertility. We performed logistic regression to assess the associations between insomnia and the risk of OC and EC by using data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014.

Results

Our research reveals that genetic liability to insomnia constitutes a risk factor for ovarian cysts (odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.21-1.72, P< 0.05), PCOS (OR: 1.67, 95% CI: 1.44-1.94, P< 0.05), and endometriosis (OR: 1.43, 95% CI: 1.16-1.76, P< 0.05). However, we found no statistically significant associations between insomnia and POI, OC, uterine fibroids, EC, or female infertility. Additionally, body mass index (BMI) was found to mediate about 10% of the effect of the insomnia on ovarian cysts and PCOS. Moreover, in cross-sectional study, insomnia was not associated with OC and EC.

Conclusion

Our study provides causal evidence that genetically predicted insomnia increases the risk of ovarian cysts, PCOS, and endometriosis. Accordingly, the potential significance of weight control and good sleep in keeping fit need to be emphasized.

Insight into potential long COVID effects: Antidepressant use in post SARS-CoV-2 Infection scenarios. A multiregional nested case-control study

This study aimed to investigate the impact of previous SARS-CoV-2 infection and the role of vaccination in the onset of neuropsychiatric conditions, evaluated through antidepressant prescriptions. This case-control study evaluated the risk of new antidepressant prescriptions in relation to previous exposure to SARS-CoV-2 infection and vaccination. It was conducted in three Italian Regions on adults who did not receive antidepressant prescriptions in the year preceding the study period. Individuals with newly prescribed antidepressants (cases) were matched by sex and age to non-users of antidepressants (controls). Pooled estimates of regional Odds Ratios (ORs) were obtained through a meta-analysis. Findings showed that individuals previously infected with SARS-CoV-2 had a higher risk of receiving a new prescription of antidepressants. Moreover, this association was stronger among subjects hospitalized due to infection, and SARS-CoV-2 vaccination may have acted as an effect modifier by reducing that risk. In fact, the pooled OR for receiving a new antidepressant prescription was higher for unvaccinated individuals than for those vaccinated. The results of this study confirm the role of SARS-CoV-2 infection as a risk factor for the onset of neuropsychiatric symptoms. Antidepressant treatment initiation was much more likely after severe COVID-19 infection but vaccination reduced such a risk.

Impact of Overactive Bladder and Dry Mouth on Subjective and Comprehensive Sleep Quality in Older Adults With Nocturia

BACKGROUND

Nocturia is among the most common and bothersome urinary tract symptoms in older adults. While sleep quality is key to nocturia management, there is little information on the impact of nocturia itself on sleep quality. We investigated the impacts of nocturia on sleep quality and quality of life and explored factors contributing to reduced sleep quality.

METHODS

A total of 186 men, aged 42-88 years (patients with nocturia and a control group), were evaluated using the Pittsburgh Sleep Quality Index, the Nocturia Quality-of-Life questionnaire, a visual analog scale measurement of dry mouth, and the Overactive Bladder Symptom Score, among other tools. Patients were graded into four categories of nocturia severity based on 3-day frequency volume charts. Factors associated with reduced subjective and comprehensive sleep quality were investigated using multiple regression analysis.

RESULTS

Initial undisturbed sleep duration was negatively associated with nocturia frequency. Subjective and comprehensive sleep quality, overactive bladder scores, sleep efficiency and oral dryness were significantly associated with nocturia-related quality of life, when controlled for both age and nocturia severity. Sleep efficiency was a major predictor of reduced subjective and comprehensive sleep quality; overactive bladder scores and oral dryness were also independently significantly associated with reduced subjective and comprehensive sleep quality on multiple regression analysis, although nocturia frequency and initial undisturbed sleep duration were not.

CONCLUSIONS

It may be beneficial to conduct a comprehensive assessment for overactive bladder and dry mouth when managing nocturia in older adults with poor sleep quality.

Socioeconomic status and sleep duration among a representative, cross-sectional sample of US adults

BACKGROUND

Sleep is a crucial determinant of physical and mental health outcomes, and insufficient sleep is highly prevalent among United States adults. Although some risk factors of poor sleep have been extensively studied, including substance use, age, health behaviors, and others, the associations between socioeconomic status (SES) and sleep remain inconclusive. There is limited evidence on SES and sleep duration among the US adult population. This study analyzed the relationships between three SES indicators (poverty, education, and food security), and sleep duration.

METHODS

We used responses from the 2017-March 2020 National Health and Nutrition Examination Survey (NHANES). Respondents younger than 25 years old were excluded. Sleep duration was classified using self-reported sleep time and stratified by work vs. non-workdays. SES was operationalized using three indicators: poverty-income ratio, educational attainment, and food security status. We imputed missing data for socioeconomic status and outcome variables using multiple imputation. Weighted Poisson regression models with robust standard errors were used to calculate the crude and adjusted prevalence ratios for insufficient sleep duration (< 7 h of self-reported sleep) on workdays and non-workdays separately by each of the three SES indicators.

RESULTS

We included a total of 8,457 individuals. In the adjusted model, participants with lower income, educational status, and food security had significantly higher prevalence of insufficient sleep duration on both workdays and non-workdays. For example, low-income individuals (poverty-income ratio < 1) had 1.22 (95% CI 1.04-1.44) and 2.08 (95% CI 1.61-2.67) higher prevalence of insufficient sleep as compared to high income individuals on workday and non-workdays, respectively. In general, we found larger differences by level of SES indicator for the non-workday than for the workday outcome. There were no major differences in gender-stratified analysis. We also found that lower SES was associated with higher prevalence of excessive sleep (≥ 9 h).

CONCLUSION

Socioeconomic status indicators are significantly associated with sleep duration in the US adult population. Lower SES correlates with increased prevalence of insufficient sleep duration, which has implications for the overall wellbeing of US adults with lower SES. Targeted interventions and further research are needed to reduce this disparity.

Cross-sectional and prospective associations between sleep health and multimorbidity in middle to older-aged adults: Results from the Canadian Longitudinal Study on Aging (CLSA)

OBJECTIVE

Middle-aged to older adults often exhibit the co-existence of poor sleep health and multimorbidity. We examined cross-sectional and prospective associations of pooled index of sleep health with prevalent and incident multimorbidity in the framework of an ongoing cohort study in Canada.

METHODS

Data were from approximately 24,000 individuals from the Canadian Longitudinal Study on Aging (CLSA), an ongoing national study of community-dwelling adults aged 45-85 years at baseline. Multimorbidity was defined as two or more chronic conditions out of five major condition categories. Sleep variables included sleep duration, quality, initiation, maintenance, and excessive daytime sleepiness, which were combined into an index using pooled approaches. Weighted logistic regression models were computed for each index with additional age- and sex-stratified analyses.

RESULTS

Higher sleep index scores, indicating poorer sleep health, were observed in females and younger age groups (ages 45-54 and 55-64). In cross-sectional analysis, the fully adjusted model showed that a 1-unit increase in pooled scores was significantly associated with 1.48 higher odds (95 % CI = 1.38, 1.58; p < 0.001) of prevalent multimorbidity at baseline. Similarly, the prospective analysis indicated significant changes in incident multimorbidity with pooled index scores in the fully adjusted model (OR = 1.33; 95 % CI = 1.20, 1.48; p < 0.001).

CONCLUSION

The pooled sleep index introduced in this study may offer a novel, concise, and comprehensive approach to assessing sleep health among middle-aged and older adults. Those in these age groups experiencing poorer sleep health are at a greater risk of prevalent multimorbidity, as well as of developing multimorbidity over time.

Care models for individuals with chronic multimorbidity: lessons for low- and middle-income countries

BACKGROUND

Patients with multiple long-term conditions requires understanding the existing care models to address their complex and multifaceted health needs. However, current literature lacks a comprehensive overview of the essential components, impacts, challenges, and facilitators of these care models, prompting this scoping review.

METHODS

A scoping review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis Extension for Scoping Reviews guideline. Our search encompassed articles from PubMed, Web of Science, EMBASE, SCOPUS, and Google Scholar. The World Health Organization's health system framework was utilized to synthesis the findings. This framework comprises six building blocks (service delivery, health workforce, health information systems, access to essential medicines, financing, and leadership/governance) and eight key characteristics of good service delivery models (access, coverage, quality, safety, improved health, responsiveness, social and financial risk protection, and improved efficiency). Findings were synthesized qualitatively to identify components, impacts, barriers, and facilitators of care models.

RESULTS

A care model represents various collective interventions in the healthcare delivery aimed at achieving desired outcomes. The names of these care models are derived from core activities or major responsibilities, involved healthcare teams, diseases conditions, eligible clients, purposes, and care settings. Notable care models include the Integrated, Collaborative, Integrated-Collaborative, Guided, Nurse-led, Geriatric, and Chronic care models, as well as All-inclusive Care Model for the Elderly, IMPACT clinic, and Geriatric Patient-Aligned Care Teams (GeriPACT). Other care models (include Care Management Plus, Value Stream Mapping, Preventive Home Visits, Transition Care, Self-Management, and Care Coordination) have supplemented the main ones. Care models improved quality of care (such as access, patient-centeredness, timeliness, safety, efficiency), cost of care, and quality of life for patients that were facilitated by presence of shared mission, system and function integration, availability of resources, and supportive tools.

CONCLUSIONS

Care models were implemented for the purpose of enhancing quality of care, health outcomes, cost efficiency, and patient satisfaction by considering careful recruitment of eligible clients, appropriate selection of service delivery settings, and robust organizational arrangements involving leadership roles, healthcare teams, financial support, and health information systems. The distinct team compositions and their roles in service provision processes differentiate care models.

Healthier Dietary Patterns Are Associated with Better Sleep Quality among Shanghai Suburban Adults: A Cross-Sectional Study

BACKGROUND

More is to be explored between dietary patterns and sleep quality in the Chinese adult population.

METHODS

A cross-sectional study including 7987 Shanghai suburban adults aged 20-74 years was conducted. Dietary information was obtained using a validated food frequency questionnaire. Adherence to a priori dietary patterns, such as the Chinese Healthy Eating Index (CHEI), Dietary Approaches to Stop Hypertension (DASH) diet and Mediterranean diet (MD), was assessed. Sleep quality was assessed from self-reported responses to the Pittsburgh Sleep Quality Index (PSQI) questionnaire. Logistic regression models adjusting for confounders were employed to examine the associations.

RESULTS

The overall prevalence of poor sleep (PSQI score ≥ 5) was 28.46%. Factor analysis demonstrated four a posteriori dietary patterns. Participants with a higher CHEI (ORQ4 vs. Q1: 0.81, 95% CI: 0.70-0.95), DASH (ORQ4 vs. Q1: 0.70, 95% CI: 0.60-0.82) or MD (ORQ4 vs. Q1: 0.75, 95% CI: 0.64-0.87) had a lower poor sleep prevalence, while participants with a higher "Beverages" score had a higher poor sleep prevalence (ORQ4 vs. Q1: 1.18, 95% CI: 1.02-1.27).

CONCLUSIONS

In Shanghai suburban adults, healthier dietary patterns and lower consumption of beverages were associated with better sleep quality.

Bidirectional associations between sleep quality/duration and multimorbidity in middle-aged and older people Chinese adults: a longitudinal study

BACKGROUND

Multimorbidity and sleep disorder possess high incidence rates in the middle-aged and older people populations, posing a significant threat to quality of life and physical and mental health. However, investigators have previously only analysed the unidirectional association between sleep status and multimorbidity. We aimed to investigate bidirectional associations between sleep quality or duration and multimorbidity in middle-aged and older Chinese adults from a longitudinal perspective.

METHOD

We enrolled a total of 9823 participants 45 years and older from the China Health and Retirement Longitudinal Study from 2015 to 2018 in our study. Multimorbidity was defined as two or more coexisting chronic diseases in the same individual based on 14 self-reported disease questions. Sleep quality was classified as "good" (restless < 1 day per week) and "poor" (restless ≥ 1 days per week); and sleep duration was divided into short (< 6 h), medium (6-9 h), and long (> 9 h). The bidirectional association between multimorbidity and sleep condition was examined using multivariate logistic regression models with adjustments for covariates.

RESULTS

Individuals with poor sleep quality showed a significantly higher prevalence of multimorbidity in the future. The adjusted OR (95% CI) values of individuals with poor sleep quality with respect to developing two diseases, three diseases, and ≥ 4 diseases were 1.39 (1.19, 1.63), 1.56 (1.23, 2.03), and 2.36 (1.68, 3.33), respectively. In addition, individuals with multimorbidity exhibited a significantly higher risk of poor sleep quality in the future. Short sleep duration led to multimorbidity in the future (OR = 1.49; 95 CI%, 1.37-1.63), while multimorbidity contributed to short sleep duration (< 6 h) in the future (OR = 1.39; 95% CI, 1.27-1.51) after full adjustment.

CONCLUSIONS

There was a bidirectional association between sleep quality or short sleep duration and multimorbidity in middle-aged and older Chinese adults. We recommend that greater attention be given to clinical management among adults with sleep disorders or physical multimorbidities.

Self-Reported Sleep Duration and Bedtime Are Associated with Dementia Risk in Community-Dwelling People Aged 40-74 Years: The Murakami Cohort Study

Background

Sleep is a potentially modifiable factor associated with dementia, including Alzheimer's disease, but current evidence supporting this is insufficient.

Objective

This study aimed to determine whether sleep duration and bedtime patterns are associated with the risk of dementia among middle-aged and older people.

Methods

This cohort study had an eight-year follow-up period. Participants were 13,601 community-dwelling people aged 40-74 years living in Murakami (Niigata, Japan). Data were collected using a self-administered questionnaire. Predictors were self-reported sleep duration and bedtime, and the outcome was newly-diagnosed dementia determined using the long-term care insurance database. Covariates were demographic characteristics, body mass index, smoking, alcohol consumption, total physical activity, insomnia symptoms, disease history, and either bedtime or sleep duration. Cox proportional hazard models were used to calculate hazard ratios (HRs).

Results

The mean age of participants at baseline was 59.2 years. Over a mean follow-up period of 8.0 years, 319 cases of dementia were observed. A long self-reported sleep duration relative to the reference sleep duration (7 hours) was associated with increased dementia risk, with the "8 hours" group (adjusted HR = 1.30, 95% CI:0.99-1.73) and "≥9 hours" group (adjusted HR = 1.46, 95% CI:1.00-2.15) having an increased risk (marginally significant) relative to the reference group. Early bedtime was associated with increased dementia risk (adjusted p for trend = 0.0010), with the "21 : 00 or earlier" group (adjusted HR = 1.61, 95% CI:1.14-2.28) having an increased risk relative to the reference ("23 : 00").

Conclusions

A long self-reported sleep duration and early bedtime are both associated with increased dementia risk in middle-aged and older people.