Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Behav Sleep Med. 2020 Feb 29;19(2):243–254. doi: 10.1080/15402002.2020.1732981

Sleep Disruption due to Stress in Women Veterans: A Comparison Between Caregivers and Noncaregivers

Yeonsu Song 1,2,3, Gwendolyn C Carlson 4, Sarah Kate McGowan 2, Constance H Fung 2,3, Karen R Josephson 2, Michael N Mitchell 2, Susan M McCurry 5, Edmond Teng 6, Michael R Irwin 7, Cathy Alessi 2,3, Jennifer Martin 2,3
PMCID: PMC7483161  NIHMSID: NIHMS1568268  PMID: 32116050

Abstract

Objective/Background:

Sleep problems are common in women and caregiving for an adult is a common role among women. However, the effects of caregiving on sleep and related daytime impairment are poorly understood among women veterans. This study compared stress-related sleep disturbances, insomnia symptoms, and sleep-related daytime impairment between women veterans who were caregivers and those who did not have a caregiving role.

Participants:

Of 12,225 women veterans who received care in one Veterans Administration Healthcare System, 1,457 completed data on a postal survey (mean age=51.7±15.9 years). Two hundred forty three (17%) respondents (mean age 53.8±12.7 years) were caregivers for an adult, predominantly for a parent, providing transportation.

Methods:

The survey included items that addressed insomnia symptoms, total sleep time, sleep-related daytime impairments, caregiving characteristics, self-rated health, pain, stress, body mass index, and demographic information.

Results:

In adjusted analyses, caregiver status did not directly predict sleep complaints alone. However, in multiple regression analyses, being a caregiver (odds ratio 1.7, p=0.001) significantly predicted stress-related sleep disturbance, even after adjusting for age, pain, self-rated health, and other characteristics. Furthermore, being a caregiver (β=3.9, p=0.031) significantly predicted more symptoms of sleep-related daytime impairment after adjusting for age, pain, self-rated health, and other factors.

Conclusions:

Compared to noncaregivers, women veterans who were caregivers for an adult were more likely to report stress causing poor sleep, and more daytime impairment due to poor sleep. These findings suggest the need to target stress and other factors when addressing sleep disturbance among women veterans who are caregivers.

Keywords: sleep, daytime impairment, stress, caregiving, women veterans

INTRODUCTION

According to the National Alliance for Caregiving, roughly 60% of caregivers in the United States are women (National Alliance for Caregiving, 2015). Female caregivers provide the majority of care to a parent or a spouse, spend more time on caregiving (National Alliance for Caregiving, 2015) and on average, are involved in more caregiving tasks and personal care activities (e.g., bathing, dressing) than male caregivers (del-Pino-Casado, Frias-Osuna, Palomino-Moral, & Ramon Martinez-Riera, 2012; Dwyer & Coward, 1991; Navaie-Waliser, Spriggs, & Feldman, 2002; Tennstedt, Crawford, & McKinlay, 1993). These situations may lead to increased burden (Chou, Fu, Lin, & Lee, 2011; del-Pino-Casado et al., 2012; Swinkels, Tilburg, Verbakel, & Broese van Groenou, 2019) and negative health issues such as stress (Fredman, Cauley, Hochberg, Ensrud, & Doros, 2010), depression (Friedemann & Buckwalter, 2014; Pinquart & Sorensen, 2006), sleep problems (Castro et al., 2009; Song et al., 2017; Willette-Murphy, Todero, & Yeaworth, 2006), and increased risk of mortality (Fredman et al., 2010), which may disproportionately impact women’s health.

Sleep problems are common experience for caregivers (Beaudreau et al., 2008; Peng, Lorenz, & Chang, 2019; Taylor et al., 2015; Willette-Murphy et al., 2006). These problems include nighttime awakenings, shorter sleep duration, and lower sleep efficiency and are significantly associated with other characteristics of caregivers (e.g., depression, stress) and care recipients (e.g., behavioral problems) (Beaudreau et al., 2008). Studies identified caregivers are at risk of developing sleep problems similar to those with high levels of depression or stress (Fredman et al., 2010; Kochar, Fredman, Stone, & Cauley, 2007). This suggests a critical need to identify caregiver subgroups that may experience sleep problems and benefit from treatment.

Sleep issue and related factors specifically among women veterans who are caregivers have received less attention. Women veterans, especially those who are caregivers, may be at high risk of poor sleep. In general, women veterans have higher rates of poor sleep and other negative health issues (e.g., posttraumatic stress disorder, depression) than women who are not veterans (Martin et al., 2017; Rissling et al., 2016). Additionally, women veterans report more lifetime trauma events than non-veteran women, and more past-year stressful life events than both men veterans and non-veteran women (Lehavot et al., 2018). Although evidence is limited, prior studies of women veteran caregivers found more days of sleep problems or more symptoms of daytime impairment that resulted from poor sleep than non-veteran caregivers or veterans without caregiving responsibilities (Lavela, Etingen, & Louise-Bender Pape, 2013; Song et al., 2018).

Unfortunately, prior studies of women veteran caregivers generally have not defined “caregiving” in a precise way; most simply asked participants if they provided care to a friend or family member, or had no definition at all for the term, “caregiver” (Lavela et al., 2013; Song et al., 2018). This limits the ability to extrapolate from research findings into clinical interventions for caregivers. Our current study used an explicit definition of “caregiver” (described below) and collected information on whether caregivers actually helped with activities of daily living (ADLs; i.e., basic self-care tasks) or instrumental activities of daily living (IADLs; i.e., activities related to independent living) (Brown et al., 2009; Fredman et al., 2010; Schulz & Beach, 1999). Another limitation in the literature relates to how the care recipient is defined. In this study we have defined the care recipient as an adult for whom the caregiver provides assistance with ADL or IADL activities. This approach allowed for a more thorough understanding of how specific caregiving roles and activities may impact sleep and stress-related poor sleep.

To understand how caregiving may impact sleep among women veterans, the aims of the current study were as follows: 1) to test whether poor sleep due to stress could be explained by caregiver status (i.e., caregivers versus noncaregivers). 2) to test whether caregiver status would be a significant predictor for self-reported sleep complaints and sleep-related daytime impairment. We hypothesized that women veteran caregivers are more likely to experience poor sleep due to stress than those who are not caregivers. We also hypothesized that being a caregivers among women veterans is a significant factor for sleep complaints and daytime impairment due to poor sleep.

This study was guided by the modified Stress Process Model (Pearlin, Mullan, Semple, & Skaff, 1990) and Spielman’s 3P model (Spielman et al., 2000) adapted to chronic sleep problems among caregivers (McCurry, Song, & Martin, 2015). The modified Stress Process Model explains how background factors (e.g., age, caregiving history), stressors (e.g., care recipient factors, caregiving overload), and mediators of stress (e.g., coping, social support, resources) can impact each other and ultimately caregivers’ health (e.g., sleep, daytime impairment) and wellbeing. In the modified Spielman’s 3P model, a combination of three factors (i.e., predisposing, precipitating, and perpetuating factors) causes insomnia. For example, older age and female sex are viewed as predisposing factors of insomnia, precipitating factors include stressors related to caregiving situation or other life events, and perpetuating factors include inadequate sleep hygiene and social isolation. The goal of this work was to inform future caregiver support interventions focused on improving both sleep problems and stress.

METHODS

Study Design

Our study used a cross-sectional design and involved secondary data analysis. Data were obtained from a regional postal survey of women veterans completed during the screening phase of a randomized controlled trial on insomnia treatments in woman veterans (ClinicalTrials.gov Identifier: NCT02076165). The survey was designed for use with women veterans and the core items addressed the diagnostic criteria for insomnia disorder (Martin et al., 2017). That survey’s original goals were to understand the participants’ sleep habits and types of sleep problems, and to identify individuals likely to have insomnia disorder for the trial. The version of the survey that included caregiving items had a total of 48 questions. Those questions consisted of items addressing the diagnostic criteria for insomnia disorder (Martin et al., 2017), caregiving variables, demographics, and health-related factors (described below). Overall, the survey questionnaire was mailed in 31 batches of approximately 350 per batch from October 2014 through June 2017.

Study Sample

Survey recipients were identified in two ways. First, a database of women who had at least one health care visit in the past 6 months and resided within 50 miles of one Veterans Administration (VA) Healthcare System site was obtained from the VA Health Eligibility Center. Second, women who had been referred for clinical insomnia treatment within the sleep disorders center at this healthcare system were added to the dataset, even if they did not meet the above criteria (i.e., lived more than 50 miles away or had not been seen within the past 6 months) since they were likely to receive care at the study clinical site.

In total, 12,225 women veterans with valid addresses were mailed the survey, which included a preaddressed, postage-paid envelope for completed survey return. The total response rate was 21.8% (2,669 surveys returned). Of the 2,669 who responded, 1,522 had a valid response to the caregiving question on whether the veteran was a caregiver or not (the caregiving items were removed during the final year of the survey). Out of the 1,522, an additional 65 surveys were omitted because the caregiving relationship did not meeting our definition (e.g., the respondent was a paid caregiver or was caring only for an infant or child younger than 18 years of age). The decision of excluding those for caring a child was based on findings that the effects of the caregiving experience of health and sleep differed between caregivers of adults and caregivers of children (Song et al., 2018). A final sample of 1,457 women provided complete data on the survey for variables included in the current analyses.

In our study, a caregiver was defined as a person who (1) regularly provides unpaid care for another person (e.g., a spouse, parent, adult child, friend) because of physical illness, memory disorder, psychological disorder, or physical health decline, and (2) helps with at least one of the ADLs (i.e., eating, dressing, bathing) or IADLs (i.e., housework, managing money, preparing meals, taking medication, transportation, communicating with others, learning or remembering, seeing or hearing, moving around at home, getting along with people, relieving/decreasing anxiety or depression) (U.S. Centers for Disease Control and Prevention (CDC), 2009–2010).

The study was approved by the Institutional Review Board at the VA Greater Los Angeles Healthcare System. A waiver of documentation of informed consent was granted for the postal survey.

Measures

Demographic characteristics included age, race/ethnicity, marital status, and employment status. Self-rated health was obtained from the single item on the Short Form-12 Health Survey (Jenkinson et al., 1997). A single question rating pain was obtained from the Geriatric Pain Measure (Ferrell, Stein, & Beck, 2000). Body mass index was also calculated based on self-reported weight and height.

Sleep complaints were measured with the following instruments. Six items of the Insomnia Severity Index (adapted for use in a postal survey) were used, including whether the respondent was satisfied with sleep; had difficulty falling asleep, trouble staying asleep, or waking up too early; had sleep problems interfering with daily functioning; and was worried or distressed about sleep (Morin, Belleville, Belanger, & Ivers, 2011). Severity of each symptom ranged from 0 (none) to 4 (very severe). A total score of the six items (range 0–24) was calculated for this study to assess severity of insomnia symptoms.

The Pittsburgh Sleep Quality Index measured bed time, rising time, and estimated total sleep time (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989). Sleep efficiency was calculated as a percentage of total sleep time in bed. Questions addressing the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) diagnostic criteria for insomnia (American Psychiatric Association, 2013; Martin et al., 2017) were also included in the postal survey. A dichotomous variable of insomnia disorder was created based on the DSM-5 criteria.

Finally, the International Classification of Sleep Disorders - Third Edition (ICSD-3) was used to define 11 items listed as symptoms of daytime impairment due to poor sleep, including feeling tired or fatigued; having trouble paying attention, concentrating, or remembering things; having difficulty with daily activities; having difficulty with social life; feeling irritable, depressed, or anxious; feeling sleepy; having less motivation, energy or drive; making mistakes or errors; having accidents or mishaps; feeling hyperactive, impulsive, or aggressive; and having concerns about or dissatisfaction with sleep (American Academy of Sleep Medicine, 2014). The percent of the 11 items endorsed was used to indicate the overall endorsement of daytime impairment symptoms (0–100% of symptoms).

Finally, a single item asked whether stress was a contributing factor to poor sleep over the past month, (i.e., “Did you have trouble sleeping because of stress, yes/no?”).

Questions on caregiving included caregiver status (i.e., caregiver vs. noncaregiver), relationship to care recipient, care recipient’s age, whether the caregiver lived with the care recipient, and caregiving tasks such as ADLs and IADLs performed by the caregiver (U.S. Centers for Disease Control and Prevention (CDC), 2009–2010). The total number of caregiving tasks was calculated to indicate intensity of caregiving responsibility.

Data analyses

Descriptive statistics with means, standard deviations (SD), frequencies, and percentages were used to analyze the total population and subgroups (caregivers vs. noncaregivers). Student’s t-test (for continuous outcomes) and the chi-square test (for categorical outcomes) were used to compare symptoms of sleep complaints and daytime impairment between caregivers and noncaregivers; and to test differences in sleep and daytime impairment by caregiving characteristics (i.e., living situation, relationship to a care recipient). Our statistical approaches were developed, based on the two conceptual frameworks described above (McCurry et al., 2015; Pearlin et al., 1990; Spielman et al., 2000).

Logistic regression was used to test whether caregiving status predicted poor sleep due to stress, after adjusting for age, pain, and self-rated health. Multiple regression models were also used to test whether caregiving status predicted sleep complaints and sleep-related daytime impairment, adjusting for age, pain, self-rated health, and other demographic characteristics (i.e., marital status, race, employment status) as covariates. The covariates in the regression models were selected based on prior literature on factors related to sleep (Adenekan et al., 2013; Finan, Goodin, & Smith, 2013; Ford et al., 2014; Lallukka et al., 2012; Ohayon, Carskadon, Guilleminault, & Vitiello, 2004; Shankar, Charumathi, & Kalidindi, 2011; Troxel et al., 2010). To provide a measure of effect size when the caregiving status variable was significant, we included a measure of effect size (R2 change) reflecting the increase in R2 comparing a model with and without the hypothesized predictor (i.e., caregiving status).

For all analyses, P< .05 was considered statistically significant. Since the main hypothesis-driven analysis included only two statistical tests, we did not employ type 1 error adjustment. The additional statistical comparisons (e.g., bivariate comparisons) are provided as context to facilitate interpretation of the main findings. The analyses were performed using Stata statistical software (version 15.0, StataCorp LLC, College Station, Texas, USA).

RESULTS

Respondent characteristics

Of the 1,457 respondents (mean age = 51.7 ± 15.9 years), 441 women veterans (30%) were married or living as married, and 568 (39%) were employed for wages. Two hundred forty-three respondents (17%) reported serving as caregivers for adults. Table 1 compares characteristics of caregivers and noncaregivers. Women veteran caregivers were significantly older (53.8 ± 12.7 vs. 51.2 ± 16.4 years old), had higher body mass indices (29.1 ± 6.8 vs. 27.9 ± 6.4), and reported more with having stress as a cause of their poor sleep (67.8% vs. 57.6%) than noncaregivers (P < .05).

Table 1.

Characteristics of women veteran caregivers and noncaregivers (N = 1,457)

Respondent characteristics Caregivers (n = 243) Noncaregivers (n = 1,214) p value
Age in years, M (SD) 53.8 (12.7) 51.2 (16.4) 0.021
Race/ethnicity, n (%)
 African American 76 (31.5) 316 (26.3) 0.092
 Hispanic/Latina 44 (18.3) 266 (22.1) 0.185
 White/Caucasian 120 (49.8) 588 (48.8) 0.787
 Asian or Asian American 13 (5.4) 66 (5.5) 0.956
 Native Hawaiian/Pacific Islander 6 (2.5) 19 (1.6) 0.322
 American Indian/Alaskan Native 14 (5.8) 46 (3.8) 0.158
 Other 9 (3.8) 48 (4.0) 0.862
Employment status, n (%)
 Employed for wages 96 (39.8) 472 (39.1) 0.840
 Unable to work 46 (19.2) 226 (18.7) 0.877
 Unemployed 46 (19.1) 198 (16.4) 0.312
 Retired 69 (28.6) 308 (25.5) 0.318
 Student 28 (11.6) 160 (13.3) 0.487
 Homemaker 27 (11.2) 87 (7.21) 0.036
Marital status, n (%)
 Married or living as married 82 (34.0) 359 (29.8) 0.198
 Divorced 77 (32.0) 383 (31.8) 0.973
 Separated 12 (5.0) 49 (4.1) 0.523
 Widowed 11 (4.6) 91 (7.6) 0.097
 Never married 60 (24.9) 329 (27.4) 0.434
General health, n (%) 0.051
 Poor 18 (7.4) 55 (4.6)
 Fair 67 (27.7) 324 (26.9)
 Good 103 (42.6) 467 (38.8)
 Very good 47 (19.4) 285 (23.7)
 Excellent 7 (2.9) 74 (6.1)
Self-reported cognitive function, n (%) 0.081
 Poor 24 (9.9) 113 (9.4)
 Fair 56 (23.1) 238 (19.7)
 Average 83 (34.2) 350 (29.0)
 Good 61 (25.1) 350 (29.0)
 Excellent 19 (7.8) 155 (12.0)
Pain (0–10) 4.75 (2.9) 4.38 (3.0) 0.085
Body mass index 29.1 (6.8) 27.9 (6.4) 0.013
Stress as a cause of poor sleep 164 (67.8) 694 (57.6) 0.003
Open in a new tab

Note: n = 1,431 for body mass index; n = 1,440 for pain; n = 1,444 for age, marital status; n = 1,447 for employment status and general health; n = 1,449 for self-reported cognitive function.

Student’s t-test and chi-square test were used.

Caregiving characteristics

Of 243 caregivers, 42% (n=102) were providing care for parent(s) or parent(s)-in-law, and 68% of caregivers provided care for persons aged 65 years or older. Sixty-three percent of the caregivers lived with the care recipients. On average, caregiver respondents endorsed providing assistance with 38% (SD= 21) of caregiving tasks, the most common being helping with transportation (n = 165, 69%), housework (n = 133, 56%), preparing meals (n = 132, 55%), managing money (n = 121, 51%), and overseeing medication use (n = 120, 50%).

Characteristics of sleep

Only 20% of respondents reported no sleep problems, meaning no difficulty falling asleep, staying asleep, or waking up too early, during the past month. Roughly 70% (n = 1,018) met insomnia criteria as defined by the DSM-5. More than 80% of the respondents worried or were distressed about their sleep or believed that their sleep problems interfered with their daily functioning. Only half of the women veterans were satisfied with their sleep over the past month. On average, women veterans endorsed 61% (SD 30.9) of the daytime impairment symptoms due to poor sleep at night during the past month, and experienced at least one symptom for an average of 4.8 days (SD 2.4) per week. Among the caregiver subgroup, caregivers living together with the care recipient experienced fewer daytime impairments related to sleep (60.1±29.9% vs 70.9±27.2%, p=0.0085). However, there were no differences when we compared the two groups in terms of the actual sleep variables. No significant relationships were also found in sleep variables or daytime impairments related to sleep with other caregiving characteristics (e.g., numbers of ADL/IADL tasks, relationship to a care recipient).

Factors associated with poor sleep due to stress

In a logistic regression model, the probability of experiencing poor sleep due to stress was associated with being a caregiver, after adjusting for age, self-rated health status, pain, and others (e.g., marital status, employment). The odds for reporting stress as a cause of poor sleep was 1.7 times greater for caregivers versus noncaregivers (odds ratio 1.7, 95% confidence interval=1.2, 2.4, p=0.001: Table 3A).

Table 3A.

A multiple logistic regression model predicting stress as a cause of poor sleep among women veterans (N=1,382)

Independent variables Poor sleep due to stress
OR (95% CI) P value
Age (years)
 ≤ 30 Reference
 30–40 0.6 (0.4–1.1) 0.078
 40–50 0.4 (0.2–0.7) <0.001
 50–60 0.3 (0.2–0.5) <0.001
 60–70 0.2 (0.1–0.3) <0.001
 >70 0.1 (0.1–0.2) <0.001
Caregiving status 1.7 (1.2, 2.4) 0.001
Married 1.1 (0.8, 1.4) 0.637
White vs. others 1.7 (1.2, 2.2) 0.001
African Americans vs. others 1.3 (0.9, 1.8) 0.101
Employed 1.1 (0.8, 1.4) 0.656
Pain scale 1.2 (1.1, 1.2) <0.001
Self-rated health 1.3 (1.1, 1.5) <0.001
Body mass index −0.2 (−0.4, −0.1) 0.035
 >18.5 Reference
 18.5–24.9 1.3(0.6–3.0) 0.478
 25–29.9 1.1(0.5–2.6) 0.737
 ≥30 0.9 (0.4–2.0) 0.782
Open in a new tab

P < .001

Sleep complaints and symptoms of daytime impairment between caregivers and noncaregivers

Caregivers reported significantly shorter total sleep time (5.5± 1.7 hours vs. 5.7± 1.8 hours) than noncaregivers (P < .05; Table 2). No significant differences in other sleep measures (i.e., severity of insomnia symptoms, sleep efficiency) were found between the two groups. The average daytime impairment rate was greater for caregivers than noncaregivers (64.8± 28.9 % vs. 60.2± 31.2 %; P < .05). Compared with noncaregivers, caregivers were more likely to experience more tiredness or fatigue during the day (88.4% vs. 82.9%), more likely to feel hyperactive, impulsive or aggressive (44.8% vs. 37.3%), and more likely to feel concerned about or dissatisfied with their sleep because of poor sleep at night (77.0% vs. 70.4%; all P<.05).

Table 2.

Sleep problems and daytime impairment in women veteran caregivers and noncaregivers (N = 1,457)

Types of sleep problem and daytime impairment Caregivers (n = 243) Noncaregivers (n = 1,214) p value
Total score of insomnia severity symptoms (0–24), M (SD) 12.4 (0.4) 11.6 (0.2) 0.086
Total sleep time, hours, M (SD) 5.5 (1.7) 5.7 (1.8) 0.047
Sleep efficiency, %, M (SD) 71.2 (21.3) 72.7 (20.1) 0.320
DSM-5 defined insomnia (yes/no), n (%) 177 (72.8) 841 (69.3) 0.269
Daytime impairment due to poor sleep, n (%)
 Feeling tired or fatigued during the day (yes/no) 214 (88.4) 1,000 (82.9) 0.034
 Trouble paying attention, concentrating, or remembering things 176 (73.0) 831 (69.3) 0.243
 Difficulty with daily activities (work, school, other responsibilities) 151 (63.2) 689 (57.6) 0.107
 Difficulty with social life 123 (51.5) 564 (47.1) 0.219
 Feeling irritable, depressed or anxious 178 (74.5) 821 (68.4) 0.061
 Feeling sleepy during the day 199 (82.2) 978 (81.2) 0.715
 Having less motivation, energy, or drive 197 (81.4) 908 (75.9) 0.062
 Making mistake or errors 137 (57.3) 634 (53.1) 0.237
 Having accidents or mishaps (e.g., car crashes, falls, other injuries) 48 (20.1) 223 (18.6) 0.596
 Feeling hyperactive, impulsive, or aggressive 108 (44.8) 448 (37.3) 0.028
 Having concerns about or dissatisfaction with sleep 181 (77.0) 836 (70.4) 0.039
% of endorsed rate of daytime impairment symptoms above 64.8 (28.9) 60.2 (31.2) 0.035
Open in a new tab

Note: n = 1,436 for satisfaction with sleep; n = 1,453 for trouble falling asleep; n = 1,451 for trouble staying asleep; n = 1,442 for waking up too early; n = 1,348 for sleep problems interfering with daily functioning; n = 1,350 for sleep as worried or distressed; n = 1,414 for self-reported total sleep time; n = 1,355 for sleep efficiency; n = 1,449 for daytime impairment symptoms; DSM-5, Diagnostic and statistical manual of mental disorders-5th edition.

In multiple regression, being a caregiver was significantly associated with daytime impairment rate, even after adjusting for other variables such as age, self-rated health status, and pain (Table 3B). Being a caregiver corresponded to a 3.9% increase in daytime impairment (P = .031). Compared to a model including all variables except caregiver status, the addition of caregiver status increased the variance explained by 0.23%. In a regression model predicting total sleep time, this variable was no longer significant after accounting for other factors (results not shown).

Table 3B.

A multiple linear regression model predicting sleep-related daytime impairment among women veterans (N=1,391)

Independent variables Daytime impairment
β (95% CI) P value
Age −0.6 (−0.7, −0.5) <0.001
Caregiving status 3.9 (0.3, 7.6) 0.031
Married −1.6 (−4.6, 1.4) 0.290
White vs. others 3.6 (0.3, 6.9) 0.031
African Americans vs. others 1.5 (−2.1, 5.1) 0.427
Employed −1.9 (−4.8, 1.1) 0.208
Pain scale 3.0 (2.5, 3.5) <0.001
Self-rated health 8.6 (6.9, 10.2) <0.001
Body mass index −0.3 (−0.5, −0.1) 0.004
Open in a new tab

F(9,1381) = 70.94; P < .001; R2 = 31.6%; Adjusted R2= 31.7%

DISCUSSION

We found that, among women veterans, caregiving for an adult was a significant risk factor for having poor sleep due to stress, over and above known risk factors for poor sleep. Women veteran caregivers were nearly twice as likely to report poor sleep due to stress compared to noncaregivers. Group differences in daytime impairment remained significant after controlling for other known risk factors for poor sleep (e.g., pain, health status); however, no significant group differences were observed for insomnia symptom severity or sleep efficiency.

Stress-related sleep disturbances

Previous studies have found stress levels serve a critical role on mortality rate both in caregivers and noncaregivers among women (Fredman et al., 2010). High-stress caregivers and noncaregivers have higher mortality than low-stress noncaregivers. Prior work has demonstrated the impact of stress (Song et al., 2017) and depression (Carter & Chang, 2000; Kochar et al., 2007; von Kanel et al., 2012) on sleep is significant among caregivers in the general population. Studies have also found that women veterans experience a variety of unique traumatic and stressful life events (Lehavot et al., 2018). Thus, stress-related sleep problems experienced by women veterans in the current study cannot be exclusively attributed to caregiver-related stress. It is possible that other events or psychological distress symptoms (e.g., posttraumatic stress disorder, depression) contribute to stress among women veteran caregivers. Future studies should explore how caregiver status contributes to the development of new stressors and/or exacerbates existing stressors.

Daytime impairment related to poor sleep

The current findings regarding elevated daytime impairment among women veteran caregivers build upon the results of previous studies. A cross-sectional study found that caregivers reported shorter sleep time and more functional consequences of daytime sleepiness than noncaregivers (McKibbin et al., 2005). Associations between caregiving status and sleep-related daytime impairment were also consistent with the findings of another survey of women veterans which found that those who had trouble sleeping because of caring for a sick or disabled adult experienced greater impairment in daytime function due to their poor sleep than other groups of veterans who had trouble sleeping because of caring for an infant or child or all other respondents (e.g., noncaregivers)(Song et al., 2018). Collectively, these findings suggest that caregiving status is a major risk factor for sleep-related daytime impairment, and interventions aimed at improving sleep are highly relevant to the caregiver population.

Sleep complaints and other sleep characteristics

An unexpected finding in the current study was the lack of significant difference in sleep complaints alone, reported total sleep time, or sleep efficiency, between women veteran caregivers and noncaregivers, after controlling for other known risk factors for poor sleep. Possible reasons for these findings might be explained by pre-existing poor sleep or medical conditions that our women veteran respondents may have had at the time of the survey. For example, both caregivers and noncaregivers reported less than six hours of total sleep time and low sleep efficiency (less than 80%). BMI of both groups was high especially among the caregivers, which increases risk of sleep disorders (e.g., sleep apnea) leading to sleep disruption due to arousal. Additionally, certain care-recipient medical conditions may affect caregivers’ experiences more adversely, leading to more sleep problems (Clipp & George, 1993; Flaskerud, Carter, & Lee, 2000). For example, studies reported poorer sleep quality and more stress among caregivers of patients with frontotemporal dementia compared to those caring for patients with Alzheimer’s disease (Merrilees, Hubbard, Mastick, Miller, & Dowling, 2014; Uflacker, Edmondson, Onyike, & Appleby, 2016; Wong et al., 2012). Unfortunately, we did not ask about the medical condition of care recipients in the survey.

Although caregivers may not perceive their sleep to be worse in terms of falling or staying asleep, sleep may be affecting daytime function more negatively, perhaps through increased stress. Differences in caregiver and noncaregivers’ sleep are not necessarily reflected in the severity of sleep complaints, but in their abilities to cope with disturbed sleep. Caregiving status is associated with increased stress levels and decreased coping resources (Gilhooly et al., 2016). Veteran caregivers may experience greater functional impairment than noncaregivers who report similar insomnia symptoms. Thus, caregivers without a formal diagnosis of insomnia may still benefit from behavioral strategies to improve sleep, prevent further deterioration of daily function and improve quality of life.

This study has several strengths. To our knowledge, it is the first study to explore types of sleep complaints and related daytime impairment between caregivers and noncaregivers in a large survey of women veterans. We also explored sleep disruption specifically caused by stress, which is highly relevant to the health of caregivers. We used a robust definition of caregiver that captured those who assisted family members and/or friends with ADLs and IADLs.

Despite our study’s strengths, it had several limitations. The response rate to our postal survey was only 22 %. However, completion of postal surveys has fallen in recent years possibly due to methodology issue of the postal survey (Czajka & Beyler, 2016). Other reasons included failure of our survey delivered to some women veterans who frequently relocated and lack of follow-ups (e.g., by telephone) due to resource limitations. We also did not attempt to obtain complete survey data for those whose response indicated ineligibility for our clinical trial. Our sample of women veteran caregivers largely provided assistance with IADLs, so we are less able to address caregiving that focuses on assisting with ADLs, which may be associated with even higher levels of burden and stress. However, our finding that transportation was the most frequent caregiving task was similar to the type of caregiving activities in prior studies of the general population (AARP Public Policy Institute & National Alliance for Caregiving, 2015).

Due to space limitations on the postal survey, we also did not measure some important variables. They included time spent completing nighttime caregiving activities, caregiving burden, whether caregivers shared a bed/room with the care recipient, care recipients’ characteristics and type of support received (e.g., respite care), history and treatment of post-traumatic stress disorder, military sexual trauma, depression, anxiety, history of sleep disorders (e.g., sleep apnea) or snoring, and whether caregivers were VA service connected disability themselves. Our measures of sleep complaints (i.e., the Insomnia Severity Index and the Pittsburgh Sleep Quality Index) included only selected items from the original instruments due to the need to limit the length of the survey. We measured symptoms related to daytime impairment that were derived from items of daytime consequences of insomnia disorders in the ICSD-3, and although our previous study demonstrated face validity of the items (Song et al., 2018), its psychometric validation may need to be established further. Information on self-rated health, pain, and stress contributing poor sleep was obtained from a single item each. Finally, because our survey was conducted among women who received care within one VA healthcare system, our findings may not be generalizable to women veterans in other VA settings, women veterans who do not use VA services, or men veterans.

The current findings demonstrate women veteran caregivers are at an increased risk of experiencing sleep-related daytime impairment and highlight the need for sleep interventions within this rapidly growing population. Cognitive behavioral sleep interventions focusing on reducing daytime symptoms may benefit those women veteran who are caregivers. Specific components would include management of caregiver stress and teaching coping skills, fatigue management, and time management skills. Further research on women veterans is needed to understand the relationship between complex caregiving experiences, levels of stress, and symptoms resulting from disturbed sleep. Additional research is also warranted to develop sleep interventions accounting for stress to address the needs of this growing population.

Acknowledgements:

Dr. Song had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Work was presented in part at the American Professional Sleep Societies Annual Meeting, Baltimore, Maryland, June 2018.

This study was supported by the Veterans Affairs Health Services Research and Development Service (HSR&D IIR 13-058-2 PI: Martin). Additional support includes VA Greater Los Angeles Healthcare System, Geriatric Research, Education, and Clinical Center (GRECC); Office of Academic Affiliations, Department of Veterans Affairs; National Institute on Aging (Song K23AG055668, Fung K23AG045937), and the National Heart Lung and Blood Institute (Martin K24HL143055) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs, National Institutes of Health, or the U.S. Government.

Footnotes

Conflict of Interest: No conflicts of interest have been declared by the authors.

Data Availability Statement: Derived data supporting the findings of this study are available from the corresponding author [JM] on request.

REFERENCES

  1. AARP Public Policy Institute, & National Alliance for Caregiving. (2015). Caregiving in the U.S Retrieved from https://www.aarp.org/content/dam/aarp/ppi/2015/caregiving-in-the-united-states-2015-report-revised.pdf
  2. Adenekan B, Pandey A, McKenzie S, Zizi F, Casimir GJ, & Jean-Louis G (2013). Sleep in America: role of racial/ethnic differences. Sleep Med Rev, 17(4), 255–262. doi: 10.1016/j.smrv.2012.07.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. American Academy of Sleep Medicine. (2014). International Classification of Sleep Disorders-Third Edition (ICSD-3) (3rd ed). Darien, IL: American Academy of Sleep Medicine. [Google Scholar]
  4. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) (5th ed). Arlington, VA: American Psychiatric Association. [Google Scholar]
  5. Beaudreau SA, Spira AP, Gray HL, Depp CA, Long J, Rothkopf M, & Gallagher-Thompson D (2008). The relationship between objectively measured sleep disturbance and dementia family caregiver distress and burden. Journal of Geriatric Psychiatry and Neurology, 21(3), 159–165. doi: 10.1177/0891988708316857 [DOI] [PubMed] [Google Scholar]
  6. Brown SL, Smith DM, Schulz R, Kabeto MU, Ubel PA, Poulin M, … Langa KM (2009). Caregiving behavior is associated with decreased mortality risk. Psychol Sci, 20(4), 488–494. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, & Kupfer DJ (1989). The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213. doi:0165-1781(89)90047-4 [pii] [DOI] [PubMed] [Google Scholar]
  8. Carter PA, & Chang BL (2000). Sleep and depression in cancer caregivers. Cancer Nurs, 23(6), 410–415. [DOI] [PubMed] [Google Scholar]
  9. Castro CM, Lee KA, Bliwise DL, Urizar GG, Woodward SH, & King AC (2009). Sleep patterns and sleep-related factors between caregiving and non-caregiving women. Behav Sleep Med, 7(3), 164–179. doi: 10.1080/15402000902976713 [DOI] [PubMed] [Google Scholar]
  10. Chou YC, Fu LY, Lin LC, & Lee YC (2011). Predictors of subjective and objective caregiving burden in older female caregivers of adults with intellectual disabilities. International Psychogeriatrics, 23(4), 562–572. doi: 10.1017/s1041610210001225 [DOI] [PubMed] [Google Scholar]
  11. Clipp EC, & George LK (1993). Dementia and cancer: a comparison of spouse caregivers. Gerontologist, 33(4), 534–541. doi: 10.1093/geront/33.4.534 [DOI] [PubMed] [Google Scholar]
  12. Czajka JL, & Beyler A (2016). Declining Response Rates in Federal Surveys: Trends and Implications. Retrieved from Washington, DC: [Google Scholar]
  13. del-Pino-Casado R, Frias-Osuna A, Palomino-Moral PA, & Ramon Martinez-Riera J (2012). Gender differences regarding informal caregivers of older people. J Nurs Scholarsh, 44(4), 349–357. doi: 10.1111/j.1547-5069.2012.01477.x [DOI] [PubMed] [Google Scholar]
  14. Dwyer JW, & Coward RT (1991). A multivariate comparison of the involvement of adult sons versus daughters in the care of impaired parents. J Gerontol, 46(5), S259–269. doi: 10.1093/geronj/46.5.s259 [DOI] [PubMed] [Google Scholar]
  15. Ferrell BA, Stein WM, & Beck JC (2000). The Geriatric Pain Measure: validity, reliability and factor analysis. J Am Geriatr Soc, 48(12), 1669–1673. [DOI] [PubMed] [Google Scholar]
  16. Finan PH, Goodin BR, & Smith MT (2013). The association of sleep and pain: an update and a path forward. J Pain, 14(12), 1539–1552. doi: 10.1016/j.jpain.2013.08.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Flaskerud JH, Carter PA, & Lee P (2000). Distressing emotions in female caregivers of people with AIDS, age-related dementias, and advanced-stage cancers. Perspectives in Psychiatric Care, 36(4), 121–130. doi: 10.1111/j.1744-6163.2000.tb00600.x [DOI] [PubMed] [Google Scholar]
  18. Ford ES, Li C, Wheaton AG, Chapman DP, Perry GS, & Croft JB (2014). Sleep duration and body mass index and waist circumference among U.S. adults. Obesity (Silver Spring), 22(2), 598–607. doi: 10.1002/oby.20558 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Fredman L, Cauley JA, Hochberg M, Ensrud KE, & Doros G (2010). Mortality associated with caregiving, general stress, and caregiving-related stress in elderly women: results of caregiver-study of osteoporotic fractures. Journal of the American Geriatrics Society, 58(5), 937–943. doi: 10.1111/j.1532-5415.2010.02808.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Friedemann ML, & Buckwalter KC (2014). Family Caregiver Role and Burden Related to Gender and Family Relationships. J Fam Nurs, 20(3), 313–336. doi: 10.1177/1074840714532715 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Gilhooly KJ, Gilhooly ML, Sullivan MP, McIntyre A, Wilson L, Harding E, … Crutch S (2016). A meta-review of stress, coping and interventions in dementia and dementia caregiving. BMC Geriatr, 16, 106. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Jenkinson C, Layte R, Jenkinson D, Lawrence K, Petersen S, Paice C, & Stradling J (1997). A shorter form health survey: can the SF-12 replicate results from the SF-36 in longitudinal studies? J Public Health Med, 19(2), 179–186. [DOI] [PubMed] [Google Scholar]
  23. Kochar J, Fredman L, Stone KL, & Cauley JA (2007). Sleep problems in elderly women caregivers depend on the level of depressive symptoms: results of the Caregiver--Study of Osteoporotic Fractures. Journal of the American Geriatrics Society, 55(12), 2003–2009. doi: 10.1111/j.1532-5415.2007.01434.x [DOI] [PubMed] [Google Scholar]
  24. Lallukka T, Sares-Jaske L, Kronholm E, Saaksjarvi K, Lundqvist A, Partonen T, … Knekt P (2012). Sociodemographic and socioeconomic differences in sleep duration and insomnia-related symptoms in Finnish adults. BMC Public Health, 12, 565. doi: 10.1186/1471-2458-12-565 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Lavela SL, Etingen B, & Louise-Bender Pape T (2013). Caregiving experiences and health conditions of women veteran and non-veteran caregivers. Womens Health Issues, 23(4), e225–232. doi: 10.1016/j.whi.2013.04.001 [DOI] [PubMed] [Google Scholar]
  26. Lehavot K, Goldberg SB, Chen JA, Katon JG, Glass JE, Fortney JC, … Schnurr PP (2018). Do trauma type, stressful life events, and social support explain women veterans’ high prevalence of PTSD? Soc Psychiatry Psychiatr Epidemiol, 53(9), 943–953. doi: 10.1007/s00127-018-1550-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Martin JL, Schweizer CA, Hughes JM, Fung CH, Dzierzewski JM, Washington DL, … Alessi CA (2017). Estimated Prevalence of Insomnia among Women Veterans: Results of a Postal Survey. Womens Health Issues, 27(3), 366–373. doi: 10.1016/j.whi.2016.12.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. McCurry SM, Song Y, & Martin JL (2015). Sleep in caregivers: what we know and what we need to learn. Curr Opin Psychiatry, 28(6), 497–503. doi: 10.1097/yco.0000000000000205 [DOI] [PubMed] [Google Scholar]
  29. McKibbin CL, Ancoli-Israel S, Dimsdale J, Archuleta C, von Kanel R, Mills P, … Grant I (2005). Sleep in spousal caregivers of people with Alzheimer’s disease. Sleep, 28(10), 1245–1250. [DOI] [PubMed] [Google Scholar]
  30. Merrilees J, Hubbard E, Mastick J, Miller BL, & Dowling GA (2014). Sleep in persons with frontotemporal dementia and their family caregivers. Nursing Research, 63(2), 129–136. doi: 10.1097/nnr.0000000000000024 [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Morin CM, Belleville G, Belanger L, & Ivers H (2011). The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep, 34(5), 601–608. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. National Alliance for Caregiving. (2015). Caregiving in the U.S. 2015. Retrieved from Bethesda: MD: [Google Scholar]
  33. Navaie-Waliser M, Spriggs A, & Feldman PH (2002). Informal caregiving: differential experiences by gender. Medical Care, 40(12), 1249–1259. doi: 10.1097/01.mlr.0000036408.76220.1f [DOI] [PubMed] [Google Scholar]
  34. Ohayon MM, Carskadon MA, Guilleminault C, & Vitiello MV (2004). Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan. Sleep, 27(7), 1255–1273. [DOI] [PubMed] [Google Scholar]
  35. Pearlin LI, Mullan JT, Semple SJ, & Skaff MM (1990). Caregiving and the stress process: an overview of concepts and their measures. Gerontologist, 30(5), 583–594. [DOI] [PubMed] [Google Scholar]
  36. Peng HL, Lorenz RA, & Chang YP (2019). Factors associated with sleep in family caregivers of individuals with dementia. Perspectives in Psychiatric Care, 55(1), 95–102. doi: 10.1111/ppc.12307 [DOI] [PubMed] [Google Scholar]
  37. Pinquart M, & Sorensen S (2006). Gender differences in caregiver stressors, social resources, and health: an updated meta-analysis. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 61(1), P33–45. doi: 10.1093/geronb/61.1.p33 [DOI] [PubMed] [Google Scholar]
  38. Rissling MB, Gray KE, Ulmer CS, Martin JL, Zaslavsky O, Gray SL, … Weitlauf JC (2016). Sleep Disturbance, Diabetes, and Cardiovascular Disease in Postmenopausal Veteran Women. Gerontologist, 56 Suppl 1, S54–66. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Schulz R, & Beach SR (1999). Caregiving as a risk factor for mortality: the Caregiver Health Effects Study. JAMA, 282(23), 2215–2219. [DOI] [PubMed] [Google Scholar]
  40. Shankar A, Charumathi S, & Kalidindi S (2011). Sleep duration and self-rated health: the national health interview survey 2008. Sleep, 34(9), 1173–1177. doi: 10.5665/sleep.1232 [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Song Y, Harrison SL, Martin JL, Alessi CA, Ancoli-Israel S, Stone KL, & Fredman L (2017). Changes in Caregiving Status and Intensity and Sleep Characteristics Among High and Low Stressed Older Women. J Clin Sleep Med, 13(12), 1403–1410. doi: 10.5664/jcsm.6834 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Song Y, Washington DL, Yano EM, McCurry SM, Fung CH, Dzierzewski JM, … Martin JL (2018). Caregiving-Related Sleep Problems and Their Relationship to Mental Health and Daytime Function in Female Veterans. Behav Sleep Med, 16(4), 371–379. doi: 10.1080/15402002.2016.1228640 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Spielman A, Yang C, Glovinsky P, Kryger M, Roth T, & Dement W (2000). Assessment techniques for insomnia Principles and practice of sleep medicine (pp. 1239–1250). Philadelphia: Saunders. [Google Scholar]
  44. Swinkels J, Tilburg TV, Verbakel E, & Broese van Groenou M (2019). Explaining the Gender Gap in the Caregiving Burden of Partner Caregivers. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 74(2), 309–317. doi: 10.1093/geronb/gbx036 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Taylor BJ, Irish LA, Martire LM, Siegle GJ, Krafty RT, Schulz R, & Hall MH (2015). Avoidant Coping and Poor Sleep Efficiency in Dementia Caregivers. Psychosomatic Medicine, 77(9), 1050–1057. doi: 10.1097/psy.0000000000000237 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Tennstedt SL, Crawford S, & McKinlay JB (1993). Determining the pattern of community care: is coresidence more important than caregiver relationship? J Gerontol, 48(2), S74–83. doi: 10.1093/geronj/48.2.s74 [DOI] [PubMed] [Google Scholar]
  47. Troxel WM, Buysse DJ, Matthews KA, Kravitz HM, Bromberger JT, Sowers M, & Hall MH (2010). Marital/cohabitation status and history in relation to sleep in midlife women. Sleep, 33(7), 973–981. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. U.S. Centers for Disease Control and Prevention (CDC). (2009–2010). Behavioral Risk Factor Surveillance System Survey, Survey Data. Retrieved from Atlanta, Georgia: [Google Scholar]
  49. Uflacker A, Edmondson MC, Onyike CU, & Appleby BS (2016). Caregiver burden in atypical dementias: comparing frontotemporal dementia, Creutzfeldt-Jakob disease, and Alzheimer’s disease. International Psychogeriatrics, 28(2), 269–273. doi: 10.1017/s1041610215001647 [DOI] [PubMed] [Google Scholar]
  50. von Kanel R, Mausbach BT, Ancoli-Israel S, Dimsdale JE, Mills PJ, Patterson TL, … Grant I (2012). Sleep in spousal Alzheimer caregivers: a longitudinal study with a focus on the effects of major patient transitions on sleep. Sleep, 35(2), 247–255. doi: 10.5665/sleep.1632 [DOI] [PMC free article] [PubMed] [Google Scholar]
  51. Willette-Murphy K, Todero C, & Yeaworth R (2006). Mental health and sleep of older wife caregivers for spouses with Alzheimer’s disease and related disorders. Issues in Mental Health Nursing, 27(8), 837–852. [DOI] [PubMed] [Google Scholar]
  52. Wong C, Merrilees J, Ketelle R, Barton C, Wallhagen M, & Miller B (2012). The experience of caregiving: differences between behavioral variant of frontotemporal dementia and Alzheimer disease. American Journal of Geriatric Psychiatry, 20(8), 724–728. doi: 10.1097/JGP.0b013e318233154d [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES