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Revista da Escola de Enfermagem da USP

Print version ISSN 0080-6234

Rev. esc. enferm. USP vol.47 no.6 São Paulo Dec. 2013

http://dx.doi.org/10.1590/S0080-623420130000600014 

Original Article

Profile of the elderly who naps

Ariene Angelini dos Santos 1  

Simone Camargo de Oliveira 2  

Denise Cuoghi de Carvalho Veríssimo Freitas 3  

Maria Filomena Ceolim 4  

Sofia Cristina Iost Pavarini 5  

Maria Cecília Pires da Rocha 6  

ABSTRACT

This study aimed to characterize the elderly who naps according to sociodemographic characteristics and frailty. A descriptive, cross-sectional study part of the multicenter project Frailty in the Elderly Brazilians. We evaluated 1,866 elderly people using a sociodemographic questionnaire. The frailty was assessed using the phenotype proposed by Fried. The data were analyzed with descriptive statistics. The results showed that the profile of the elderly who naps consists predominantly of women, married, retired, pre-frail, with an average age of 73 years, four years of study, with monthly family income of 3.9 minimum salary, with 4,4 children who were living with them only. The elderly reported napping on average 5.9 days per week, lasting 53.5 minutes per nap. Knowing the profile of the elderly who naps contributes to health professionals in the development of actions in relation to sleep problems of the frail/pre-frail elderly, preventing, minimizing or solving these problems.

Key words: Aged; Sleep; Geriatric nursing

INTRODUCTION

The increase of the elderly population has resulted in greater numbers of long-term problems, either for individual or for society. Among them, we highlight the changes in the pattern of habitual sleep ( 1 ) . The mortality due to common causes in the elderly, such as cardiovascular disease, stroke and cancer, for example, is about twice higher in people with sleep disorders than those with good sleep quality ( 2 ) .

Changes in sleep patterns associated with aging may correspond to sleep disorders or impairment of its quality. Among them, we emphasize: quantitative reduction of deep sleep stages; reduction of the threshold for waking up due to noise associated with the quantitative increase in the superficial sleep; higher latency to sleep onset, increased daytime naps; reduction of the total nocturnal sleep duration; high number of transitions from one stage to another and to wakefulness; higher frequency of respiratory disturbances during sleep ( 3 ) .

Researches suggests that the main factors related to daytime napping in the elderly are nocturnal sleep disturbances, changes in the sleep-wake cycle related to age, comorbidities and mental illness ( 4 ) . Studies have suggested that the usual nap can be beneficial, depending on the time of day and duration of the nap ( 5 ) .

When assessing healthy elderly without complaints related to nocturnal sleep, authors found that 90 minutes naps between 13h30 and 15h00, established in the study protocol, although it resulted in lower efficiency of nocturnal sleep, it also positively influenced psychomotor performance after the period of the nap ( 6 ) .

In a cohort study conducted in the United States, the results were opposite to the referred study above. In order to assess the independent association of mortality causes with duration of daytime napping, researchers followed-up residents of a small community located in Southern California for a period of 19 years. The results showed that in men, mortality was associated with nap lasting more than 30 minutes per day, and these results were significant after adjusting for multiple covariates such as greater age ( 7 ) . The literature shows that the greatest frequency of occurrence and timing of daytime naps are associated with higher incidence of cardiovascular disease and type 2 diabetes ( 8 - 9 ) .

There is also evidence that sleep disorders are independently associated with frailty in the elderly. Proving this hypothesis, a research conducted in the U.S.A, with 3,133 men with age equal or higher than 67 years, showed that complaints of poor sleep quality, excessive daytime sleepiness, short sleep spans, prolonged sleep latency and sleep fragmentation were more prevalent in the frail elderly. The authors concluded that sleep complaints such as poor self-reported quality, efficiency and prolonged latency are independently associated with greater evidence of frailty ( 10 ) .

Given the above, knowing the profile of the elderly who naps is essential to support health services in planning care on the quality of their sleep. Researches, which characterize the profile of the elderly who naps, are scarce in our context, therefore, there is a gap in the Brazilian literature. Thus, this study aimed to characterize the elderly who naps, according to sociodemographic and frailty characteristics.

METHOD

This is a descriptive, transversal study using a quantitative approach. It was developed from data belonging to the electronic database of the Multicenter Study on Frailty in the Elderly Brazilians (FIBRA), conducted by researchers from four universities in the country (UFMG, USP-RP, UNICAMP, UERJ) and conducted in order to study the health and well-being conditions of men and women aged 65 years old and older living in the community.

This study used data regarding UNICAMP, which covers the following cities: Belem (PA), Pocos de Caldas (MG), Parnaiba (PI), Campinas (SP), Ivoti (RS), Ermelino Matarazzo (district of SP) and Campina Grande (PB) (n=3,478). The recruitment of the elderly occurred at home in urban census sectors randomly selected.

Inclusion criteria for the elderly were: age equal or higher than 65 years, be able to understand instructions, agree to participate and be a permanent resident in the household and in the census sector. Exclusion criteria were: a) elderly with severe cognitive impairment, suggestive of dementia, evidenced by problems with memory, attention, spatial and temporal orientation, and communication, or observed by recruiters; b) elderly who were using a wheelchair or in temporary or permanently bedridden c) carriers of serious sequelae of stroke, with localized loss of strength and/or aphasia; d) carriers of Parkinson’s disease in severe or unstable stage, with severe impairment of motor skills, speech or affectivity; e) carriers of severe deficits in hearing or vision, which would greatly hinder communication and; f) elderly in terminal stage.

The study sample was composed by all elderly from the Database of the FIBRA Project UNICAMP, except those who did not have data on the nap (occurrence, weekly frequency and duration). Thus, the final sample consisted of 1,866 elderly, 53.6% of the overall sample.

Data collection occurred in a single session and began after reading and signing the Consent Form. The elderly participants were subjected to measures of frailty and sociodemographics characteristics.

The following variables were used to their sociodemographic characteristics: gender, age, marital status, education, family income in minimum salary, family structure, current work and retirement.

For the assessment of frailty, we adopted the definition proposed by Linda Fried ( 11 ) . There are five elements of the operational definition of the syndrome or frailty phenotype: 1) unintentional weight loss equal or higher than 4.5 kg; 2) weakness assessed by self-reports; 3) low grip strength measured with a portable hydraulic dynamometer in dominant hand; 4) low energy expenditure measured in kilocalories assessed from self-reported exercise and housework; 5) low gait velocity indicated by the average time taken to cover the distance of 4.6 m. For the last three criteria, frailty is scored for individuals that obtained results located between the lowest 20% of the sample. The presence of three or more of the five characteristics of the phenotype mean frailty, one or two means pre-frailty and no characteristic indicates a non-frail elderly.

All ethical principles ruling research with human subjects were observed. The use of data belonging to UNICAMP FIBER Project was authorized by the study coordinator. This investigation was approved by the Ethical Research Committee as an addendum to the study FIBRA (protocol 208/2007) in 27/09/2011.

Data were coded and entered into an electronic spreadsheet and analyzed with SPSS software, version 17.0. Data were analyzed with descriptive statistics and presented in tables, with absolute numbers and percentages for categorical variables, means, standard deviations and medians for numerical variables.

RESULTS

The sample for this study consisted of 1,866 elderly. Table 1 shows the distribution of the elderly according to sociodemographic characteristics and levels of frailty.

Table 1 – Distribution of elderly who naps according to sociodemographic and frailty levels – UNICAMP, Campinas, 2008-2009. 

Variable (n) * N %
Gender (1,866)    
  Male 680 36.4
  Female 1186 63.6
Age group (1,866)    
  65 to 69 years 634 34.0
  70 to 74 years 555 29.7
  75 to 79 years 390 20.9
  80 years or more 287 15.4
Marital status (1,862)    
  Married or living with partner 925 49.7
  Single 153 8.2
  Separated 107 5.7
  Widow 677 36.4
Education (1,864)    
  0 353 18.9
  1 to 4 years 932 50.0
  5 to 8 years 335 18.0
  9 years or more 244 13.1
Family income† (1,566)    
  0 to 1.0 minimum salary 173 11.1
  1.1 a 3.0 minimum salary 750 47.9
  3.1 a 5.0 minimum salary 353 22.5
  5.1 a 10.0 minimum salary 185 11.8
  >10.0 minimum salary 105 6.7
Family structure (1,862)    
  Alone 226 12.2
  Only with partner 359 19.3
  Ancestry 517 27.7
  Partner + ancestry 484 26.0
  Other family members and externs 97 5.2
  Other structure mixed 179 9.6
Work (1,855)    
  Yes 265 14.3
  No 1590 85.7
Retired (1,854)    
  Yes 1426 76.9
  No 428 23.1
Frailty (1,838)    
  Not frail 708 38.5
  Pre-frail 952 51.8
  Frail 178 9.7

Table 2 shows the measures of position and dispersion of numerical variables.

Table 2 – Descriptive analysis of numerical variables age, number of children, frequency of naps, duration of naps, family income and years of education – UNICAMP, Campinas, 2008-2009. 

Variable N Mean Standard-deviation Minimum Q1 Median Q3 Maximum
Age 1,866 73.0 5.9 65.0 68.0 72.0 77.0 101.0
Nap days * 1,811 5.9 1.9 1.0 5.0 7.0 7.0 7.0
Nap hours† 1,797 53.5 42.7 1.0 30.0 40.0 60.0 360.00
Income‡ 1,566 4.0 4.9 0.0 1.9 2.4 4.3 72.3
Education years 1,864 4.3 3.9 0.0 1.0 4.0 5.0 22.0

DISCUSSION

The results show that there was a female predominance (63.6%), which is corroborated by both the national ( 12 - 16 ) and international ( 17 ) literature. The high number of female participation in studies with elderly reflects the greater longevity of women with higher chances of survival. This phenomenon is known as feminization of old age.

This fact might be understood given their lower exposure to certain occupational risk factors, given that in the past, men’s activities were focused on the labor market and women were supposed to care for the home. In addition, women use health services more often when compared to men ( 12 - 16 ) . Note that they also have lower prevalence of smoking and alcohol consumption ( 14 - 16 ) and are less exposed to mortality from external causes (violence and car accidents, for example) when compared to young men ( 16 ) .

In relation to gender, some studies have found higher rates of napping among elderly men compared with elderly women ( 8 , 18 ) . However, there is controversy in the literature about it ( 19 ) .

In the present study, there was a prevalence of the age group 65 to 69 years (34.0%). The average age of the elderly was 73.0 years (SD=5.9), varying between 65 and 101 years. These data are consistent with both international ( 17 ) and national studies ( 20 - 21 ) . The prevalence of participants in the age group of young elderly in research demonstrates the characteristic of recent aging of the Brazilian context, unlike developed countries, where there is a prevalence of older elderly, ie, 80 years and over ( 22 ) .

Regarding marital status, the majority of the elderly in this study were married or living with a partner (49.7%), followed by widowed (36.4%). Researchers claim that having a companion to perform daily activities is important for the health of the elderly, contributing to self-esteem and autonomy ( 16 ) . Male individuals seem to have more benefits in relation to marriage than females. This is because men are more likely to stay married, whereas women are more likely to become widows due to greater longevity. This difference in relation to marital status reflects widespread cultural aspects between generations. When they become widowed, men tend to remarry, while widows women usually remain without a partner, assuming mourning for the rest of their lives, exclusively dedicated to their children and their home ( 14 ) .

Regarding education, most elderly presented one to four years of study (50.0%) and the average education was 4.3 years (SD=3.9), ranging between zero and 27 years of study. These results were also confirmed by the census conducted with Brazilian elderly: 50.2% with less than four years of education, 32.3% with four to eight years and 17.4% with nine or more years of education ( 23 ) .

Low education can be explained by the time these elderly were born and raised. There was no appreciation for formal education and socioeconomic conditions were precarious, reflecting problems in accessing education, especially in rural areas, as these were located in closer villages ( 20 ) . Children’s education was privilege of a minority: the boys were responsible for the cultivation of the land, while the girls helped their mothers with household activities ( 14 , 20 - 21 ) .

Authors state that low education may be associated with negative health-related outcomes of the elderly, such as mental health problems, frailty and chronic conditions ( 16 ) . Elderly with low education may have a precarious state of health resulting from bad lifestyles, greater social exclusion, lower level of information and poor socioeconomic conditions for free access to health services as early as possible. In contrast, access to literacy can foster greater participation of the elderly in health promotion programs ( 16 ) .

Education may be seen as a categorical variable to health conditions, since the higher the education, the healthier the lifestyle will be and the greater demand for services of disease prevention and health promotion will be ( 24 ) . The chances for a better health status report from elderly is higher among those with more years of education ( 12 ) .

In this study, most of the elderly (85.7%) did not work at the time of the research and they were retired (76.9%). The average monthly family income was 4.0 times the minimum salary (SD=4.9), with prevalence of the range from 1.1 to 3.0 minimum salary per month (47.9%).

In Brazil, the income for the elderly is until a minimum salary 43.2% or from one to two minimum salary to 29.0% ( 23 ) . The income strongly impact the health of the population and the elderly may also be victims, due to money expenditures with medication in this stage of life. In addition, due to recent change in family structure, many elderly significantly contribute to the family budget. Retirement becomes a fixed guaranteed to meet the basic needs of households of the elderly ( 14 , 20 ) , they often assume financial responsibility and become providers of their unemployed children and grandchildren. Insufficient income situation causes great social vulnerability, exposing the elderly to the risk of aggravation of existing diseases and the emergence of new conditions of illness, so insufficient income do not meet the needs of the elderly and their families ( 14 ) .

Elderly with higher-income are more independent in self-care and make proper use of medications, while elderly with a lower income are more susceptible to diseases and therefore require more health care. However, in a contradictory way, the poor have less use of health services ( 12 ) .

Regarding the family structure, most of the elderly reside only with their children (27.7%), followed by those living with their spouse and children (26.0%). The co-residence may be considered a strategy of families to benefit both the older and younger generations, as it can mean better living conditions. Factors influencing the composition of the households of the elderly depend on: the need of family members, gender, age, marital status, health status, number of elderly children and the degree of dependence ( 25 ) .

In relation to frailty, 51.8% of the elderly showed to be pre-frail, 38.5% non-frail and 9.7% frail, considering the phenotype proposed by Linda Fried. These data corroborate the results of other studies found in the literature. The prevalence of frailty syndrome in research around the world with the use of this phenotype, were found in percentages ranging from 5 to 20% ( 26 - 27 ) . The increasing number of publications concerning the frailty syndrome in recent years refers to the growing interest in the matter, since frailty can be considered a public health problem, although it may be prevented or even reversed when treated early ( 27 ) .

Regarding naps, 61.7% of the elderly reported napping during the day, on average 5.9 days per week (SD=1.9), with an average duration of 53.5 minutes (SD=42.7) per nap. These data are similar to other research ( 19 , 28 ) that indicated variation of 22-61% for prevalence rates in the usual nap. This is depending on the location of the study, the definition of nap that was used and the characteristics of the studied population ( 4 - 5 ) .

Napping among elderly people can be considered a routine habit, especially in places where the climate is warm, such as China, Latin America and the Mediterranean region ( 29 ) . The time spent for daytime naps can both positively and negatively impact the health of the elderly. Authors claim that long naps would be detrimental, resulting in sleep inertia and interfering in the duration and quality of nocturnal sleep. Yet, short naps would be beneficial to increase wakefulness ( 5 ) .

CONCLUSION

Most elderly showed to be pre-frail and reported napping during the day, on average 5.9 days per week, lasting 53.5 minutes per nap. The profile of the elderly who naps constituted predominantly by women, with an average age of 73 years, four years of education, married, and retired with a monthly family income of 3.9 minimum salaries. As it is a multidisciplinary study, the profile presented here, in many aspects, brought us closer to the reality of the elderly who naps and are, in fact, an important cohort for future research in the area of aging.

The results emphasize the need to establish programs in accordance with specific characteristics for the elderly in frailty states or pre-fail who frequently naps.

The health professional must learn about the reality that surrounds him, being aware, and acting in a competent, scientific and technical manner, which requires critical reflection in relation to sleep problems that the elderly population present. Knowing the profile of the elderly who naps can contribute to more appropriate gerontological nursing care, because the professional will have subsidies to implement the best course of care according to their needs.

Even though national and international literature embodies the fact that the elderly is susceptible to the occurrence of sleep-related problems, there is a lack of attention on the part of public health in relation to this issue.

Thus, considering that the structure of public health policies should be grounded in the diagnosis of specific problems, it is expected that the results of this study may support programs of health promotion, health prevention and care for the elderly in a frailty condition and with disturbances related to sleep.

Acknowledgements

We acknowledge the financial support of the Coordination of Improvement of Higher Education Personnel (CAPES) and FIBRA study coordinator, PhD, Professor Anita Liberalesso Neri.

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Received: June 24, 2013; Accepted: August 16, 2013

Correspondence addressed to : Ariene Angelini dos Santos. Rua Luiz Turri, 47 – Jardim Planalto, CEP 37800-000 – Guaxupé, MG, Brazil

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