my topic is: the bereaved individual

Background Biological and social changes Sleep disturbances in older people are well documented and include shorter sleep duration, increased time spent awake at night and an increase in the number of daytime naps (Li et al 2018). Citation Godzik C (2020) Sleep disturbances in bereaved older people: a review of the literature.

Mental Health Practice.

doi: 10.7748/mhp.2020.e1492 Peer review This article has been subject to external double-blind peer review and has been checked for plagiarism using automated sof tware Correspondence cassandra.m.godzik@hitchcock.

org Conflict of interest None declared Accepted 4 May 2020 Published online October 2020 Why you should read this article:

●To increase your understanding of the physical and mental health consequences of bereavement in old age ●To learn about interventions that may improve sleep in older people before and after the death of a loved one ●To gain awareness of the gaps in the literature on sleep disturbances in bereaved older people Sleep disturbances in bereaved older people:

a review of the literature Cassandra Godzik Abstract Sleep disturbances are often seen in older people who have recently experienced the death of a loved one, such as a partner or spouse. Older family carers are particularly at risk of mood and sleep disturbances, not only after the death of the person they were caring for but also beforehand. Sleep disturbances can be treated with psychotropic medicines, but these are not adequate in older people because of the risk of falls, fractures and road accidents. Cognitive behavioural therapy for insomnia is a non-pharmacological intervention that has been found to be beneficial in bereaved older carers.

This article offers a systematic review of the literature on sleep disturbances in bereaved older people. One of the main findings is that sleep disturbances may begin before the loved one’s death, during the caregiving period. More research is needed on sleep disturbances in bereaved older people – notably in those aged ≥85 years, in partners or spouses from same-sex couples, into long-term symptoms post-bereavement, and into sleep interventions provided before the loved one’s death.

Author details Cassandra Godzik, Geisel School of Medicine, Dartmouth Centers for Health and Aging, Hanover, New Hampshire, US; and Department of Psychiatry, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, US Keywords bereavement, bereavement support, carers, clinical, end of life care, grief, patient experience, patients, professional, sleep mentalhealthpractice.com | PEER≥REVIEWED | evidence & practice / bereavement PermissionTo reuse this article or for information about reprints and permissions, please contact [email protected] 16 / March 2021 / volume 24 number 2 Older people are unique in terms of their sleep for several reasons. In advanced age, the circadian rhythm (temporal body clock) shifts to a new schedule (Chen et al 2016). Why this occurs is still not known, but it appears that the sleep-wake cycle biologically changes with age.

Beyond this biological shift, sleep may also be affected by life events that occur in old age.

For example, older people no longer have the daytime work requirements that warrant getting up early in the morning and staying awake for the whole day (Ohayon and Vecchierini 2005).

They can take daytime naps that reduce their sleep pressure ( time needed to rest) during the night hours (Häusler et al 2019).

Sleep practices in older people can affect markers of inflammation (Okun et al 2011) and this can be an issue in those who are bereaved (Seiler et al 2018). Seiler et al (2018) found that fatigued individuals who had recently been bereaved had increased levels of C-reactive protein (CRP) compared with non-fatigued bereaved individuals. Similarly, Chirinos et al (2019) found an association between elevated CRP levels and sleep disturbances in those who had been recently bereaved.

Effects on physical and mental health Research has found that inadequate sleep can have an adverse effect on people’s health (Cappuccio and Miller 2017, Itani et al 2017).

For example, people who report chronically sleeping less than required experience more complications from diabetes and coronary issues (Cappuccio and Miller 2017). This could be explained by the metabolic processes that are thought to take place during sleeping hours (Chirinos et al 2019). Quality and amount of sleep are associated with mood symptoms.

Research has indicated that people with impaired sleep – which includes being unable to fall asleep and/or remain asleep through the night – report more depressive symptoms (Tanimukai et al 2015). Seiler et al (2018) found that fatigued bereaved individuals reported higher levels of stress and depressive symptoms than non-fatigued bereaved individuals.

Bereavement has been shown to affect people’s physical and mental health. One study in 389,316 bereaved individuals found that they had excess mortality and an increased number of physical diseases compared with non-bereaved individuals (Prior et al 2018).

Spousal bereavement has been associated with higher rates of conditions such as cirrhosis (Erlangsen et al 2017). In a study that looked at 432 bereaved carers, researchers found that sleep and mood disturbances were significant in that population (Chiu et al 2011). Effects on cognition It is recognised that cognitive issues can be present in individuals who are unable to obtain adequate sleep. The process of memory consolidation has been shown to be related to sleep (Gildner et al 2014) and a review of observational studies found that, among older people, those with extreme sleep durations, whether long or short, had worse cognition (Devore et al 2016). Cognition has also been researched in bereaved people, for example by Pérez et al (2018), who found that prolonged grief disorder was associated with reduced cognitive function. Another study found changes in memory consolidation related to sleep fragmentation in older people (Pace- Schott and Spencer 2015), while widowhood has been found to be associated with cognitive decline (Lyu et al 2018).

Treatments for sleep disturbances Short-term insomnia, defined as sleep disturbances lasting between a few days and a few weeks, can lead to chronic or long-term insomnia (Griffiths and Peerson 2005). Sleep disturbances are often treated, and may be temporarily resolved, with prescribed psychotropic medicines, notably benzodiazepines such as temazepam or zolpidem tartrate (Pillai et al 2017). However, the long-term risks associated with these medicines are well documented, particularly in older people (Kaufmann et al 2018, Kim et al 2019). Studies have found an increased risk of falls and fractures with benzodiazepines (Tinetti and Kumar 2010, Bakken et al 2014), which can also cause morning drowsiness and reduce co-ordination, with a potential risk of road accidents if patients are still driving (Booth et al 2016). Even over-the-counter medicines used for sleep contain ingredients that may increase the risk of falls, cognitive impairment and dizziness. Common over-the-counter sleeping aids include diphenhydramine and doxylamine, which are both listed as potentially inappropriate medicines in the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (American Geriatrics Society Beers Criteria Update Expert Panel 2019).

Sleep disturbances can also be managed with non-pharmacological methods, such as sleep hygiene strategies and cognitive behavioural therapy (CBT). Sleep hygiene strategies usually involve education about lifestyle and how the environment affects sleep, including information about fluid intake, exercise restrictions, night- time routines and adherence to a predetermined bedtime (Irish et al 2015). CBT for insomnia (CBT-I) is a psychotherapy programme designed mentalhealthpractice.com | PEER≥REVIEWED | evidence & practice / bereavement volume 24 number 2 / March 2021 / 17 to support individuals who struggle to initiate and maintain sleep, and has been delivered in a variety of ways ranging from in-person group sessions to individual online sessions (Taylor and Pruiksma 2014). Research has found the treatment to be acceptable and to reduce sleep disturbances and depressive symptoms in bereaved older carers (Carter et al 2009).

Findings about CBT-I have generally been positive, with one study (Currie et al 2004) showing that participants recovering from alcohol dependence who received a CBT-I intervention had a significantly improved sleep efficiency compared with controls. However, the number of CBT-I therapists is limited.

Method For this systematic literature review, four major health and psychology online databases were searched: PubMed, Cumulative Index of Nursing and Allied Health Literature, OVID with PsychInfo, and Scopus. Medical subject headings (MeSH) used included: ‘ bereavement’, ‘sleep initiation and maintenance disorders’, ‘spousal’, ‘caregivers’, ‘aged’ and ‘middle aged’. Search strings using these MeSH were used to locate relevant articles. Once relevant articles had been identified, their abstracts were examined by the author. Articles deemed to be of interest were retrieved in their entirety for further reading. Those meeting the inclusion criteria were retained for inclusion in the literature review. The inclusion criteria were:

»Peer-reviewed content.

»Original research.

»Articles published between 2008 and 2018.

»Articles written in English.

»Study participants aged ≥50 years and bereaved in the previous decade.

»Measurement of sleep disturbances.

The database search produced a total of 153 non-duplicate articles. Reviewing the abstracts left 59 articles, which were read in their entirety; 51 of them were excluded because they did not fulfil all inclusion criteria. Eight articles were therefore included in the literature review. They are described in detail in Table 1.

All eight articles reported quantitative studies, two of which were behavioural interventions; the remaining six were descriptive studies. The quality of the eight articles was evaluated using the Quality Assessment Tool for Quantitative Studies (Effective Public Health Practice Project 1998) and rated. The ratings are shown in Table 1.

Findings The findings of the literature review are summarised under four themes: »Gender differences in symptomatology.

»Carer versus non-carer responsibilities and dying process experience.

»Sleep disturbances beginning during the caregiving period.

»Benefits of sleep interventions.

Gender differences in symptomatology Women made up the largest group of study participants in four of the eight studies (Monk et al 2008, Carter et al 2009, Pfoff et al 2014, Lerdal et al 2016). In one study, only widowers had been recruited (Jonasson et al 2009). In Tanimukai et al (2015), no statistically significant differences between genders were found for insomnia symptoms, but women had significantly more depressive symptoms than men during the bereavement period.

The age of the bereaved played a role in the number of insomnia symptoms reported.

Insomnia symptoms significantly increased in women aged 50-59 years and in men aged 65-70 years in the first year of bereavement (Simpson et al 2014). None of the studies had collected longitudinal data beyond a year for women. In their study population of widowers, Jonasson et al (2009) determined that sleep disturbances continued for four to five years after the death of the spouse (Jonasson et al 2009).

Carer versus non-carer responsibilities and dying process experience The involvement of the surviving partner or spouse in the care of their partner or spouse before death appears to be a critical component in understanding sleep disturbances in bereaved older people. The role of the surviving spouse can be categorised as either ‘carer’ or ‘non- carer’ (Carter et al 2009). A spousal carer is the person who primarily supports their partner at the end of life; the care provided typically involves dressing, cleaning, feeding and administering medicines. A spousal non-carer may still provide some care to their partner but they are not the sole or main carer; there may be a round-the-clock paid carer in the home, or the partner may live in a hospice or be hospitalised.

Spousal carers had high levels of depression in bereavement. Carter et al (2009) found that primary carers had scores ranging from 4 to 45 (mean 17) on the Center for Epidemiologic Studies – Depression scale. The spousal carer is a witness to the dying process of their spouse or partner, which can be life-altering.

In Jonasson et al (2009), men who had witnessed their wives experiencing unresolved pain had an increased risk of sleep-related issues for four to five years after their loss; men whose wives had experienced anxiety in Key points ●Sleep disturbances are often seen in older people who have recently experienced the death of a loved one, such as a partner or spouse ●Among bereaved older people, those who were the main carers of the deceased are particularly at risk of mood and sleep disturbances ●Sleep disturbances in older carers may start before the death of their loved one, during the caregiving period ●Psychotropic medicines such as benzodiazepines are not adequate to treat long- term insomnia in older people because of the risk of falls, fractures and road accidents ●Cognitive behavioural therapy for insomnia has been shown to reduce sleep disturbances and depressive symptoms in bereaved older carers mentalhealthpractice.com | PEER≥REVIEWED | Table 1. Detailed description of the eight studies included in the systematic literature review Citation Purpose Measurement of variables Population Primary findings Strengths and limitations Rating* Carter P, Mikan S, Simpson C (2009) A feasibility study of a two-session home-based cognitive behavioral therapy-insomnia intervention for bereaved family caregivers. Palliative and Supportive Care. 7, 2, 197-206.

doi: 10.1017/S147895150900025X To investigate the implementation of a cognitive behavioural therapy for insomnia (CBT-I) intervention for treating insomnia and depressive symptoms in bereaved family carers »Sleep quality:

–19-item Pittsburgh Sleep Quality Index –Sleep diaries –Actigraph worn for three 72-hour periods »Goal attainment: Goal Attainment Scaling Measure »Depression: 20-item Center for Epidemiologic Studies – Depression scale 11 bereaved primary carers recruited through flyers at oncology centres in Texas Statistically significant improvement in sleep disturbance from baseline to five weeks (total length of study). No statistically significant improvement in depressive symptoms »Strengths: minimal resources needed for the intervention, optimal participant retention »Limitations: no control group, small sample size, heterogeneity of sample 1 Jonasson J, Hauksdóttir A, Valdimarsdóttir U et al (2009) Unrelieved symptoms of female cancer patients during their last months of life and long-term psychological morbidity in their widowers: a nationwide population- based study. European Journal of Cancer. 45, 10, 1839- 1845. doi: 10.1016/j.ejca.2009.02.008 To examine surviving widowers’ mental health and sleep status four to five years after their wives’ deaths from cancer »Depression and anxiety: Hospital Anxiety and Depression Scale »Wife’s death and other information: 69-item survey developed by the research team 691 men enrolled through Sweden national registries participated in the final study Men who had observed their wives having depression in the last three months of life had an increased risk of waking up at night with anxiety. Men who had observed their wives experiencing unrelieved pain were at increased risk of being unable to fall asleep »Strengths: large databases used, three periods of participants’ lives captured »Limitations: recall biases, no significant difference in the demographic characteristics between participants and non-participants 2 Lerdal A, Slåtten K, Saghaug E et al (2016) Sleep among bereaved caregivers of patients admitted to hospice: a 1-year longitudinal pilot study. BMJ Open. 6, 1, e009345.

doi: 10.1136/bmjopen-2015-009345 To measure sleep changes in bereaved family members before and after the death of a relative »Sleep quality:

»19-item Pittsburgh Sleep Quality Index »Actigraph worn for four nights and three days »Sleep diaries Sixteen family members recruited in a hospice centre Bereaved spousal carers experienced significantly worse sleep quality than bereaved carers who were not the deceased person’s partner or spouse. Older carers (>65 years) had longer sleep durations than younger carers (<65 years) »Strengths: objective and subjective measures of sleep, sleep measures collected before and after death »Limitations: small sample size, 20% attrition rate, relatives were in a hospice and not at home 1 Monk T, Begley A, Billy B et al (2008) Sleep and circadian rhythms in spousally bereaved seniors. Chronobiology International. 25, 1, 83-98.

doi: 10.1080/07420520801909320 To examine circadian rhythms in partners experiencing spousal bereavement »Sleep quality:

–Pittsburgh Sleep Quality Index –Sleep diaries –17-item Social Rhythm Metric –Actigraph worn for two weeks »Grief:

–Composite Scale of Mourningness –Texas Revised Inventory of Grief –Index of Complicated Grief »Biomarkers: core body temperature 28 spousally bereaved older people recruited via word of mouth and advertisements Higher levels of grief were associated with less sleep.

All other associations with sleep were not statistically significant »Strengths: objective and subjective measures of sleep »Limitations: small sample size, mean age of participants (72.3 years) younger compared with other studies, older people aged ≥85 years not represented 1 Monk T, Germain A, Buysse D (2009) The sleep of the bereaved. Sleep and Hypnosis. 11, 1, 219 To compare self-reported sleep measures in a group of bereaved partners, a group of non-bereaved adults with insomnia, and a group of controls »Sleep quality:

»18-item Pittsburgh Sleep Quality Index »Two-week Pittsburgh Sleep Diary »Actigraph worn for two weeks 47 bereaved partners recruited by advertisements, oral presentations, and word of mouth Sleep quality of bereaved partners found to be somewhere between the sleep qualities of ‘good sleeper ’ controls and of non-bereaved adults with insomnia. In diaries, sleep latency values were similar for bereaved partners and non-bereaved adults with insomnia »Strengths: bereavement period clearly defined as being between four and 19 months »Limitations: objective data collected using an actigraph but no effect size observed, which could be due to the fact that actigraphy is less reliable in older people 2 Pfoff M, Zarotney J, Monk T (2014) Can a function- based therapy for spousally bereaved seniors accrue benefits in both functional and emotional domains? Death Studies. 38, 6-10, 381-386. doi:

10.1080/07481187.2013.766658 To compare the effectiveness of functional therapy versus control therapy for sleep and mood »Grief: 21-item Texas Revised Inventory of Grief »Depression: 21-item Hamilton Rating Scale for Depression »Objective sleep: Pittsburgh Sleep Diary »Sleep quality: 18-item Pittsburgh Sleep Quality Index 38 participants at least two months after loss of a partner, recruited from senior centres, funeral homes and churches Grief, mood and sleep improved in both the functional therapy group and the control therapy group. The functional therapy group, who received sleep education, showed greater improvements »Strengths: significant health screenings to rule out organic sleep disorders, long period of intervention (ten weeks) »Limitations: small sample size, no blinding of participants 2 Simpson C, Allegra J, Ezeamama A et al (2014) The impact of mid- and late-life loss on insomnia:

findings from the Health and Retirement Study, 2010 cohort. Family and Community Health. 37, 4, 317-326.

doi: 10.1097/FCH.0000000000000039 To examine the association between loss and insomnia symptoms in different age cohorts and genders »Insomnia: four-question insomnia measure »Depression: eight-item Center for Epidemiologic Studies – Depression scale »Losses: number of losses in participant’s life »Lifestyle: physical activity, body mass index, smoking, alcohol consumption Data from 12,759 participants in the Health and Retirement Study There was a positive relationship between the number of insomnia symptoms and the number of losses experienced. Loss was associated with predictive increase of insomnia symptoms in women aged 50-59 years and men aged 65-70 years »Strengths: large sample size »Limitations: many potential covariates not explored, including the amount of time that had passed since the loss and the relationship of participants with the person who had died (for example, participants could have lost a partner or a child) 2 Tanimukai H, Adachi H, Hirai K et al (2015) Association between depressive symptoms and changes in sleep condition in the grieving process. Supportive Care in Cancer. 23, 7, 1925-1931. doi: 10.1007/s00520-014-2548-x To clarify the prevalence of insomnia symptoms and to explore associations between present depressive state and changes in sleep condition in the grieving process in bereaved Japanese families »Insomnia: four-question insomnia measure »Psychological status: 11-item Center for Epidemiologic Studies – Depression scale »Attribution of symptoms to bereavement: one-item question 561 bereaved families recruited from 103 certified palliative care units in Japan Depressive symptoms were highest in women and in spouses. Insomnia symptoms were highest in participants aged ≥65 years and in spouses. 81% of all participants experienced insomnia symptoms »Strengths: large sample size »Limitations: self-reported questionnaires, recalling past sleep conditions, simpler version of insomnia questionnaire than is typically used in research, treatment interventions possible but not evaluated 2 * Ratings obtained by using the Quality Assessment Tool for Quantitative Studies: 1 = strong; 2 = moderate; 3 = weak 18 / March 2021 / volume 24 number 2 mentalhealthpractice.com | PEER≥REVIEWED | evidence & practice / bereavement Table 1. Detailed description of the eight studies included in the systematic literature review Citation Purpose Measurement of variables Population Primary findings Strengths and limitations Rating* Carter P, Mikan S, Simpson C (2009) A feasibility study of a two-session home-based cognitive behavioral therapy-insomnia intervention for bereaved family caregivers. Palliative and Supportive Care. 7, 2, 197-206.

doi: 10.1017/S147895150900025X To investigate the implementation of a cognitive behavioural therapy for insomnia (CBT-I) intervention for treating insomnia and depressive symptoms in bereaved family carers »Sleep quality:

–19-item Pittsburgh Sleep Quality Index –Sleep diaries –Actigraph worn for three 72-hour periods »Goal attainment: Goal Attainment Scaling Measure »Depression: 20-item Center for Epidemiologic Studies – Depression scale 11 bereaved primary carers recruited through flyers at oncology centres in Texas Statistically significant improvement in sleep disturbance from baseline to five weeks (total length of study). No statistically significant improvement in depressive symptoms »Strengths: minimal resources needed for the intervention, optimal participant retention »Limitations: no control group, small sample size, heterogeneity of sample 1 Jonasson J, Hauksdóttir A, Valdimarsdóttir U et al (2009) Unrelieved symptoms of female cancer patients during their last months of life and long-term psychological morbidity in their widowers: a nationwide population- based study. European Journal of Cancer. 45, 10, 1839- 1845. doi: 10.1016/j.ejca.2009.02.008 To examine surviving widowers’ mental health and sleep status four to five years after their wives’ deaths from cancer »Depression and anxiety: Hospital Anxiety and Depression Scale »Wife’s death and other information: 69-item survey developed by the research team 691 men enrolled through Sweden national registries participated in the final study Men who had observed their wives having depression in the last three months of life had an increased risk of waking up at night with anxiety. Men who had observed their wives experiencing unrelieved pain were at increased risk of being unable to fall asleep »Strengths: large databases used, three periods of participants’ lives captured »Limitations: recall biases, no significant difference in the demographic characteristics between participants and non-participants 2 Lerdal A, Slåtten K, Saghaug E et al (2016) Sleep among bereaved caregivers of patients admitted to hospice: a 1-year longitudinal pilot study. BMJ Open. 6, 1, e009345.

doi: 10.1136/bmjopen-2015-009345 To measure sleep changes in bereaved family members before and after the death of a relative »Sleep quality:

»19-item Pittsburgh Sleep Quality Index »Actigraph worn for four nights and three days »Sleep diaries Sixteen family members recruited in a hospice centre Bereaved spousal carers experienced significantly worse sleep quality than bereaved carers who were not the deceased person’s partner or spouse. Older carers (>65 years) had longer sleep durations than younger carers (<65 years) »Strengths: objective and subjective measures of sleep, sleep measures collected before and after death »Limitations: small sample size, 20% attrition rate, relatives were in a hospice and not at home 1 Monk T, Begley A, Billy B et al (2008) Sleep and circadian rhythms in spousally bereaved seniors. Chronobiology International. 25, 1, 83-98.

doi: 10.1080/07420520801909320 To examine circadian rhythms in partners experiencing spousal bereavement »Sleep quality:

–Pittsburgh Sleep Quality Index –Sleep diaries –17-item Social Rhythm Metric –Actigraph worn for two weeks »Grief:

–Composite Scale of Mourningness –Texas Revised Inventory of Grief –Index of Complicated Grief »Biomarkers: core body temperature 28 spousally bereaved older people recruited via word of mouth and advertisements Higher levels of grief were associated with less sleep.

All other associations with sleep were not statistically significant »Strengths: objective and subjective measures of sleep »Limitations: small sample size, mean age of participants (72.3 years) younger compared with other studies, older people aged ≥85 years not represented 1 Monk T, Germain A, Buysse D (2009) The sleep of the bereaved. Sleep and Hypnosis. 11, 1, 219 To compare self-reported sleep measures in a group of bereaved partners, a group of non-bereaved adults with insomnia, and a group of controls »Sleep quality:

»18-item Pittsburgh Sleep Quality Index »Two-week Pittsburgh Sleep Diary »Actigraph worn for two weeks 47 bereaved partners recruited by advertisements, oral presentations, and word of mouth Sleep quality of bereaved partners found to be somewhere between the sleep qualities of ‘good sleeper ’ controls and of non-bereaved adults with insomnia. In diaries, sleep latency values were similar for bereaved partners and non-bereaved adults with insomnia »Strengths: bereavement period clearly defined as being between four and 19 months »Limitations: objective data collected using an actigraph but no effect size observed, which could be due to the fact that actigraphy is less reliable in older people 2 Pfoff M, Zarotney J, Monk T (2014) Can a function- based therapy for spousally bereaved seniors accrue benefits in both functional and emotional domains? Death Studies. 38, 6-10, 381-386. doi:

10.1080/07481187.2013.766658 To compare the effectiveness of functional therapy versus control therapy for sleep and mood »Grief: 21-item Texas Revised Inventory of Grief »Depression: 21-item Hamilton Rating Scale for Depression »Objective sleep: Pittsburgh Sleep Diary »Sleep quality: 18-item Pittsburgh Sleep Quality Index 38 participants at least two months after loss of a partner, recruited from senior centres, funeral homes and churches Grief, mood and sleep improved in both the functional therapy group and the control therapy group. The functional therapy group, who received sleep education, showed greater improvements »Strengths: significant health screenings to rule out organic sleep disorders, long period of intervention (ten weeks) »Limitations: small sample size, no blinding of participants 2 Simpson C, Allegra J, Ezeamama A et al (2014) The impact of mid- and late-life loss on insomnia:

findings from the Health and Retirement Study, 2010 cohort. Family and Community Health. 37, 4, 317-326.

doi: 10.1097/FCH.0000000000000039 To examine the association between loss and insomnia symptoms in different age cohorts and genders »Insomnia: four-question insomnia measure »Depression: eight-item Center for Epidemiologic Studies – Depression scale »Losses: number of losses in participant’s life »Lifestyle: physical activity, body mass index, smoking, alcohol consumption Data from 12,759 participants in the Health and Retirement Study There was a positive relationship between the number of insomnia symptoms and the number of losses experienced. Loss was associated with predictive increase of insomnia symptoms in women aged 50-59 years and men aged 65-70 years »Strengths: large sample size »Limitations: many potential covariates not explored, including the amount of time that had passed since the loss and the relationship of participants with the person who had died (for example, participants could have lost a partner or a child) 2 Tanimukai H, Adachi H, Hirai K et al (2015) Association between depressive symptoms and changes in sleep condition in the grieving process. Supportive Care in Cancer. 23, 7, 1925-1931. doi: 10.1007/s00520-014-2548-x To clarify the prevalence of insomnia symptoms and to explore associations between present depressive state and changes in sleep condition in the grieving process in bereaved Japanese families »Insomnia: four-question insomnia measure »Psychological status: 11-item Center for Epidemiologic Studies – Depression scale »Attribution of symptoms to bereavement: one-item question 561 bereaved families recruited from 103 certified palliative care units in Japan Depressive symptoms were highest in women and in spouses. Insomnia symptoms were highest in participants aged ≥65 years and in spouses. 81% of all participants experienced insomnia symptoms »Strengths: large sample size »Limitations: self-reported questionnaires, recalling past sleep conditions, simpler version of insomnia questionnaire than is typically used in research, treatment interventions possible but not evaluated 2 * Ratings obtained by using the Quality Assessment Tool for Quantitative Studies: 1 = strong; 2 = moderate; 3 = weak volume 24 number 2 / March 2021 / 19 mentalhealthpractice.com | PEER≥REVIEWED | 20 / March 2021 / volume 24 number 2 the three months before death had unresolved issues falling asleep and frequent night-time awakenings with anxiety during bereavement (Jonasson et al 2009). These various findings could indicate that more contact with one’s partner at the end of life may result in worse outcomes for the surviving partner.

When sleep was assessed using objective measures, such as an actigraph – a wearable device that detects activity through light and movement (Scarlett et al 2020) – it did not appear to be affected by spousal death.

However, subjective measures of sleep, obtained for example through sleep diaries, were significantly different in the bereaved, who reported more sleep disturbances than controls (Monk et al 2009). Even when no sleep disturbances were recorded by the actigraph, participants continued to report suboptimal sleep quality.

Sleep disturbances beginning during the caregiving period Several studies found that sleep disturbances had begun before the death of the loved one.

Stressors associated with death and dying begin once death starts to be anticipated and can therefore start to affect carers’ sleep during the caregiving period (Tanimukai et al 2015, Lerdal et al 2016). Sleep quality may remain stable during the transition period into bereavement, so when sleep quality is suboptimal before the relative’s death, it remains suboptimal after their death. Tanimukai et al (2015) found that the prevalence of insomnia in bereaved families was stable between six weeks before and six months after the death of their relative. In the weeks before death, the prevalence of insomnia was 86.5% and after death it was 84.5% (Tanimukai et al 2015).

Benefits of sleep interventions Two out of the eight studies included in the literature review had tested interventions, including CBT-I and sleep hygiene strategies, to manage sleep disturbances in their respective populations. Their findings suggest that sleep interventions in the bereavement period are possible and can be beneficial.

Carter et al (2009) used a CBT-I intervention administered over two sessions in the home of participants (who were bereaved family carers). When comparing baseline and five- week measurements, sleep measures had significantly improved in terms of self-reported duration, sleep efficiency and Pittsburgh Sleep Quality Index (PSQI) scores (Carter et al 2009).

Pfoff et al (2014) used a function-based therapy modality intervention over ten individual sessions. The intervention comprised teaching healthy sleep practices and education about factors that can affect sleep. Sleep and mood improved between baseline and end-of-study assessment in both the treatment group and the control group, but improvements were greater in the treatment group (Pfoff et al 2014).

Discussion Sleep disturbances in bereaved older people are an important clinical problem that has not been studied thoroughly. Not adequately addressing this health concern has individual and societal consequences. Medicines such as benzodiazepines are not adequate to treat long-term insomnia in older people because of the risk of falls, fractures and road accidents (Tinetti and Kumar 2010, Bakken et al 2014, Booth et al 2016).

Studies in this literature review suggest that sleep disturbances may start before the death of the loved one, so there may be scope in researching the risk characteristics of those vulnerable to sleep disturbances (Lerdal et al 2016), as well as sleep interventions provided during the caregiving period. Clinicians and relatives need to be aware that older carers need support before and after the death of their loved one.

The findings of this literature review emphasise that more research is needed in the field of sleep disturbances in bereaved older people. Specific gaps in the literature identified are described below.

»Long-term symptoms such as insomnia and low mood in both genders at two, three and four years after the death of a loved one and beyond are not thoroughly understood. Data about the long-term experiences of older men post-bereavement are limited, while the long-term experiences of older women post- bereavement have not yet been explored.

»Sleep disturbances among bereaved partners or spouses from same-sex couples have not yet been explored.

»Older people aged ≥85 years are rarely represented in study samples, so more research is needed in that age group.

»Sleep interventions provided during the caregiving period need be further explored – for example, there is scope for investigating whether sleep disturbances can be prevented or limited by early CBT-I.

Limitations This systematic literature review was limited to research published between 2008 and 2018 and retrieved from four databases. The included articles had important limitations. While the measures used in the studies were reliable and valid, no consistent set of measures was used mentalhealthpractice.com | PEER≥REVIEWED | evidence & practice / bereavement References American Geriatrics Society Beers Criteria Update Expert Panel (2019) American Geriatrics Society 2019 Updated AGS beers criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society. 67, 4, 674-694. doi: 10.1111/jgs.15767 Bakken M, Engeland A, Engesæter L et al (2014) Risk of hip fracture among older people using anxiolytic and hypnotic drugs: a nationwide prospective cohort study. European Journal of Clinical Pharmacology. 70, 7, 873-880. doi: 10.1007/s00228-014-1684-z Booth J, Behring M, Cantor R et al (2016) Zolpidem use and motor vehicle collisions in older drivers. Sleep Medicine. 20, 98-102. doi: 10.1016/j.sleep.2015.12.004 Cappuccio F, Miller M (2017) Sleep and cardio-metabolic disease. Current Cardiology Reports. 19, 11, 110. doi: 10.1007/s11886-017-0916-0 Carter P, Mikan S, Simpson C (2009) A feasibility study of a two-session home-based cognitive behavioral therapy-insomnia intervention for bereaved family caregivers. Palliative and Supportive Care. 7, 2, 197-206. doi: 10.1017/S147895150900025X Chen C, Logan R, Ma T et al (2016) Effects of aging on circadian patterns of gene expression in the human prefrontal cortex. Proceedings of the National Academy of Sciences. 113, 1, 206-211. doi: 10.1073/pnas.1508249112 Chiu Y, Yin S, Hsieh H et al (2011) Bereaved females are more likely to suffer from mood problems even if they do not meet the criteria for prolonged grief. Psycho-Oncology. 20, 10, 1061-1068. doi: 10.1002/pon.1811 Chirinos D, Ong J, Garcini L et al (2019) Bereavement, self-reported sleep disturbances, and inflammation. Psychosomatic Medicine. 81, 1, 67-73. doi: 10.1097/PSY.0000000000000645 Currie S, Clark S, Hodgins D et al (2004) Randomized controlled trial of brief cognitive-behavioural interventions for insomnia in recovering alcoholics. Addiction. 99, 9, 1121-1132. doi: 10.1111/j.1360-0443.2004.00835.x Devore E, Grodstein F, Schernhammer E (2016) Sleep duration in relation to cognitive function among older adults: a systematic review of observational studies. Neuroepidemiology. 46, 1, 57-78. doi: 10.1159/000442418 Effective Public Health Practice Project (1998) Quality Assessment Tool for Quantitative Studies. McMaster University, Hamilton ON.

Erlangsen A, Runeson B, Bolton J et al (2017) Association between spousal suicide and mental, physical, and social health outcomes. JAMA Psychiatry. 74, 5, 456-464. doi: 10.1001/jamapsychiatry.2017.0226 Gildner T, Liebert M, Kowal P et al (2014) Associations between sleep duration, sleep quality, and cognitive test performance among older adults from six middle income countries: results from the Study on Global Ageing and Adult Health (SAGE). Journal of Clinical Sleep Medicine. 10, 6, 613-621. doi: 10.5664/jcsm.3782 Griffiths M, Peerson A (2005) Risk factors for chronic insomnia following hospitalization. Journal of Advanced Nursing. 49, 3, 245-253. doi: 10.1111/j.1365-2648.2004.03283.x Häusler N, Marques-Vidal P, Haba-Rubio J et al (2019) Does sleep predict next-day napping or does napping influence same-day nocturnal sleep? Results of a population-based ecological momentary assessment study. Sleep Medicine. 61, 31-36. doi: 10.1016/j.sleep.2019.04.014 Irish L, Kline C, Gunn H et al (2015) The role of sleep hygiene in promoting public health: a review of empirical evidence. Sleep Medicine Reviews. 22, 23-36. doi: 10.1016/j.smrv.2014.10.001 Itani O, Jike M, Watanabe N et al (2017) Short sleep duration and health outcomes: a systematic review, meta-analysis, and meta-regression. Sleep Medicine. 32, 246-256. doi: 10.1016/j.sleep.2016.08.006 Jonasson J, Hauksdóttir A, Valdimarsdóttir U et al (2009) Unrelieved symptoms of female cancer patients during their last months of life and long-term psychological morbidity in their widowers: a nationwide population-based study. European Journal of Cancer. 45, 10, 1839-1845. doi: 10.1016/j.ejca.2009.02.008 Kaufmann C, Spira A, Depp C et al (2018) Long-term use of benzodiazepines and nonbenzodiazepine hypnotics, 1999-2014. Psychiatric Services. 69, 2, 235-238. doi: 10.1176/appi.ps.201700095 Kim H, Gerlach L, Van RT et al (2019) Predictors of long-term and high-dose use of zolpidem in veterans. Journal of Clinical Psychiatry. 80, 2, 18m12149. doi: 10.4088/JCP.18m12149 Lerdal A, Slåtten K, Saghaug E et al (2016) Sleep among bereaved caregivers of patients admitted to hospice: a 1-year longitudinal pilot study. BMJ Open. 6, 1, e009345. doi: 10.1136/bmjopen-2015-009345 Li J, Vitiello M, Gooneratne N (2018) Sleep in normal aging. Sleep Medicine Clinics. 13, 1, 1-11. doi: 10.1016/j.jsmc.2017.09.001 Lyu J, Min J, Kim G (2018) Widowhood status as a risk for cognitive decline among Korean older adults. Innovation in Aging. 2, Suppl 1, 255-256. doi: 10.1093/geroni/igy023.951 Monk T, Begley A, Billy B et al (2008) Sleep and circadian rhythms in spousally bereaved seniors. Chronobiology International. 25, 1, 83-98. doi: 10.1080/07420520801909320 Monk T, Germain A, Buysse D (2009) The sleep of the bereaved. Sleep and Hypnosis. 11, 1, 219.

Ohayon M, Vecchierini MF (2005) Normative sleep data, cognitive function and daily living activities in older adults in the community. Sleep. 28, 8, 981-989.

Okun M, Reynolds C, Buysse D et al (2011) Sleep variability, health-related practices, and inflammatory markers in a community dwelling sample of older adults. Psychosomatic Medicine. 73, 2, 142-150. doi: 10.1097/PSY.0b013e3182020d08 Pace-Schott E, Spencer R (2015) Sleep-dependent memory consolidation in healthy aging and mild cognitive impairment. Current Topics in Behavioral Neurosciences. 25, 307-330. doi: 10.1007/7854_2014_300 Pérez H, Saavedra M, Ikram A et al (2018) Prolonged grief and cognitive decline: a prospective population-based study in middle-aged and older persons. American Journal of Geriatric Psychiatry. 26, 4, 451-460. doi: 10.1016/j.jagp.2017.12.003 Pfoff M, Zarotney J, Monk T (2014) Can a function-based therapy for spousally bereaved seniors accrue benefits in both functional and emotional domains? Death Studies. 38, 6-10, 381-386. doi: 10.1080/07481187.2013.766658 Pillai V, Roth T, Roehrs T et al (2017) Effectiveness of benzodiazepine receptor agonists in the treatment of insomnia: an examination of response and remission rates. Sleep. 40, 2, zsw044. doi: 10.1093/sleep/zsw044 Prior A, Fenger-Grøn D, Davydow J et al (2018) Bereavement multimorbidity and mortality: a population-based study using bereavement as an indicator of mental stress. Psychological Medicine. 48, 9, 1437-1443. doi: 10.1017/S0033291717002380 Scarlett S, Nolan HN, Kenny RA et al (2020) Discrepancies in self-reported and actigraphy-based sleep duration are associated with self-reported insomnia symptoms in community-dwelling older adults. Sleep Health. S2352-7218(20)30173-X. doi: 10.1016/j.sleh.2020.06.003 Seiler A, Murdock K, Fagundes C (2018) Impaired mental health and low-grade inflammation among fatigued bereaved individuals. Journal of Psychosomatic Research. 112, 40-46. doi: 10.1016/j.jpsychores.2018.06.010 Simpson C, Allegra J, Ezeamama A et al (2014) The impact of mid- and late-life loss on insomnia: findings from the Health and Retirement Study, 2010 cohort. Family and Community Health. 37, 4, 317-326. doi: 10.1097/FCH.0000000000000039 Tanimukai H, Adachi H, Hirai K et al (2015) Association between depressive symptoms and changes in sleep condition in the grieving process. Supportive Care in Cancer. 23, 7, 1925-1931. doi: 10.1007/s00520-014-2548-x Tang S, Chow A (2017) How do risk factors affect bereavement outcomes in later life? An exploration of the mediating role of dual process coping. Psychiatry Research. 255, 297-303. doi: 10.1016/j.psychres.2017.06.001 Taylor D, Pruiksma K (2014) Cognitive and behavioural therapy for insomnia (CBT-I) in psychiatric populations: a systematic review. International Review of Psychiatry. 26, 2, 205-213. doi: 10.3109/09540261.2014.902808 Tinetti M, Kumar C (2010) The patient who falls. JAMA. 303, 3, 258-266. doi: 10.1001/jama.2009.2024 volume 24 number 2 / March 2021 / 21 across studies. Most studies used the PSQI to measure sleep, but the actual questions asked to participants varied: some studies used the 19-item PSQI, others used the 18-item PSQI and others did not specify the number of PSQI items used. Depressive symptoms were measured using a variety of tools, including various forms of the Center for Epidemiologic Studies – Depression scale and the 21-item Hamilton Rating Scale for Depression.

This means that it is challenging to compare findings between studies and to discuss mental health conditions other than depression, such as anxiety disorders. Sampling was also quite different between the studies. Lastly, only five of the eight articles described the use of a theoretical framework as part of their design. Conclusion Older people who have recently been bereaved are likely to experience sleep disturbances, and sleep disturbances can start before the loved one’s death. Sleep interventions such as CBT-I have been found to be beneficial, but more research is needed to identify ways to improve sleep in the period before the loved one’s death, especially for those who act as the main carer for their partner or spouse, who are particularly at risk. Future studies will need to be more inclusive and extend their populations to partners or spouses of same-sex couples and to older people aged ≥85 years. Finally, few studies have explored the long-term effects of bereavement on sleep in older people, which will need to be addressed in future research.

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