Physical functioning and risk for sleep disorders in US adults: results from the National Health and Nutrition Examination Survey 2005–2014

doi:10.1016/j.puhe.2017.07.030

Public Health

Volume 152, November 2017, Pages 123-128

https://doi.org/10.1016/j.puhe.2017.07.030 Get rights and content

Highlights

•
Sleep and physical functioning are associated.
•
Patients with significant functional disability should be screened for sleep disorders.
•
Adults with cognitive and cardiovascular dysfunction are at greater risk for being diagnosed with a sleep disorder.
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Men with functional disability are at greater odds of being diagnosed with a sleep disorder when compared to women.

Abstract

Objectives

Sleep disorders (SDs), particularly problems with falling asleep or daytime sleepiness, have negative impact on health and longevity. Sleep deprivation is also associated with a decline in physical functioning (PF) that mediates the ability to perform activities of daily living. But it remains unknown if deterioration in PF can predict the risk of having a SD. Therefore, the purpose of the present study is to assess the risk of SD associated with PF status in the US adult population.

Study design

Cross-sectional study design with data from the National Health and Nutrition Examination Survey from year 2005 to year 2014.

Methods

PF limitation is assessed by reported difficulty in performing 10 tasks selected from PF questionnaire. SD is identified by subjective description of presence of doctor diagnosed SD. Also, five categories of comorbidities that caused difficulty in carrying out these tasks were created.

Results

The adults with self-reported PF limitation have 41% higher odds of having a SD (odds ratio [OR] = 1.41, 95% confidence interval [CI] = 1.22–1.59). Moreover, participants having cognitive problems and cardiovascular and pulmonary disorders as secondary conditions that cause difficulty in PF have 145% and 28% higher odds (OR = 2.45 and 1.28; 95% CI = 2.01–3.01 and 1.08–1.53, respectively) of having a SD. Also, females have a 27% lower odds of having a SD than males (OR = 0.73, 95% CI = 0.63–0.83).

Conclusion

Risk for SD is associated with increasing level of functional disability. We advocate the importance of engagement in physical activities to prevent or delay the onset of SD.

Introduction

Sleep is one of the essential human physiological processes and is vital for physical and cognitive well-being and resurgence. Any sort of disturbance in sleep is therefore detrimental for health.¹ Epidemiologic studies have shown that presence of a clinically significant sleep disorder (SD) affects at least 10% of the population in the United States causing deleterious effects on overall wellness.² Insomnia is the most common SD, followed by sleep apnea and restless legs syndrome.² Daytime sleepiness or difficulty in falling asleep are reported by approximately 35–40% of US adults annually and are a major cause of occurrence of health-related secondary complications and deaths.³ Despite the significant health implications it has been reported that the presence of SD often remains undiagnosed or overlooked by individuals and physicians.⁴ The mounting effects of untreated SD with sleep deprivation or poor quality sleep lead to the development of ‘sleep debt’. The cumulative long-term effects of chronic sleep debt may lead to a number of comorbidities including cardiovascular disease, obesity, diabetes, and even early mortality.⁵

The Patient Reported Outcomes Measurement Information System defined physical function as ‘self-reported capability to perform a host of activities ranging from self-care (instrumental activities of daily living) to more vigorous activities that require increasing degrees of dexterity and mobility’.⁶ Physical functioning (PF) is important to provide for the necessities of life to meet basic needs and fulfill one's usual societal roles to maintain health and well-being. It can be classified into ‘basic actions and complex tasks; tasks that are obligatory for sustaining independence as well as those that are not essential for an independent living but may have an impact on overall quality of life’.⁷ The subclinical limitation in physical function has been found to predict the risk of disability within 1 to 2 years.⁸ Therefore, limitations in PF may exacerbate a functional decline leading to a loss of physical independence, functional disability, and reduction in quality of life. Moreover, given that sleep problems are an intrinsic part of the aging process,⁹ it becomes critical to address the influence of limitations of functional performance on sleep in an aging society with increased life expectancy.

Sleep disorders have major effects on overall health and safety and have great economic impact on both an individual and on society.¹⁰ They often lead to mental and/or physical fatigue in adolescents as well as adults.¹¹ Sleep deprivation can be a major cause of physical disability resulting in problems in effectively performing daily functional activities. This hypothesis is supported by previous studies in patients with hemodialysis,¹² in older veterans in an adult day healthcare program,¹³ and in family caregivers of older adults with a memory impairment¹⁴ that showed that sleep disturbance is associated with poor self-reported physical function.

Given that poor sleep is associated with functional decline, it remains unknown if the presence of functional disability can predict the risk of having a SD. This information is important for expanding our knowledge in sleep medicine and for the identification of patients with lower functioning who would benefit from restorative therapies to improve sleep quality and quantity and prevent the health consequences related to SD. Furthermore, SDs are commonly associated with other major health problems such as cardiovascular disease, dementias, cognitive impairment, and metabolic disorders. Past researchers12, 14 have not accounted for any of these coexisting secondary conditions that may contribute to the development or worsening of sleep deprivation. Therefore, the aim of this secondary data analysis was to examine the risk of having a SD in individuals with PF limitation in a large representative sample of community dwelling adults in the United States. We also determined the impact of comorbidities on the relationship between SDs and difficulty in physical function.

Section snippets

Methods

For the present study we analyzed the National Health and Nutrition Examination Survey (NHANES) data from year 2005 to year 2014. NHANES is a program of studies conducted in a nationally representative sample of the resident civilian non-institutionalized US population by National Center for Health Statistics (NCHS)—a branch of the Centers for Disease Control and Prevention (CDC). Designed to determine the health and nutritional status of people of all ages, this survey consists of

Results

A total of 50,965 survey participants were interviewed for the NHANES survey. With 49.61% males, the mean age of the survey population was 31.2 (±24.6) years. Out of 50,965 survey participants, 31,284 responded to sleep questionnaire and 9777 persons answered the PF questionnaire. A total of 9618 individuals responded to both sleep and PF questionnaires and became the sample for the present study. The descriptive data of the sample participants is presented in Table 3.

In the logistic regression

Discussion

In this study we assessed the risk of having a SD with subclinical decline in physical function in a nationally representative sample of non-institutionalized adults. We are the first to present a 10-year analysis on this relationship.

Most previous research has examined the impact of poor sleep on physical function12, 13, 14, 15 and has been indicative of sleep as an important factor for preserving functional independence. However our results demonstrate that the limitations in PF pose a higher

Ethical approval

The NCHS Research Ethic Review Board reviews and approves the NHANES protocol annually. The informed consent was obtained from all participants themselves or by their parent/guardian if they were minor or cognitively impaired according to the guidelines of the Declaration of Helsinki.

Funding

None declared

Competing interests

None declared.

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The purpose of this article is to highlight the importance of considering sleep-disordered breathing (SDB) as a potential confounder to rehabilitation research interventions in spinal cord injury (SCI). SDB is highly prevalent in SCI, with increased prevalence in individuals with higher and more severe lesions, and the criterion standard treatment with continuous positive airway pressure remains problematic. Despite its high prevalence, SDB is often untested and untreated in individuals with SCI. In individuals without SCI, SDB is known to negatively affect physical function and many of the physiological systems that negatively affect physical rehabilitation in SCI. Thus, owing to the high prevalence, under testing, low treatment adherence, and known negative effect on the physical function, it is contended that underdiagnosed SDB in SCI may be confounding physical rehabilitation research studies in individuals with SCI. Studies investigating the effect of treating SDB and its effect on physical rehabilitation in SCI were unable to be located. Thus, studies investigating the likely integrated relationship among physical rehabilitation, SDB, and proper treatment of SDB in SCI are needed. Owing to rapid growth in both sleep medicine and physical rehabilitation intervention research in SCI, the authors contend it is the appropriate time to begin the conversations and collaborations between these fields. We discuss a general overview of SDB and physical training modalities, as well as how SDB could be affecting these studies.
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Citation Excerpt :
These results were based on associations and neither causality nor the direction of relationships can be inferred. Although these relationships may be bidirectional, most past research in other populations has treated lower physical functioning as partial outcome of sleep problems.14,15,36 Logically, people who do not sleep well may not rest adequately, and this may adversely affect their performance in functional tasks.
Sleep quality is associated with physical functioning in adults, but this has not been examined in those with Down syndrome (DS). High body mass index (BMI) and accelerated aging, both common in adults with DS, may alter the relationship between sleep quality and physical functioning in this population.
To examine sleep quality indicators and its association with physical functioning in adults with DS, and whether associations are altered by BMI and age.
Participants were 15 adults with DS (8 women; age 29 ± 14 years). We evaluated sleep quality over seven days with wrist-worn accelerometers and physical functioning with the timed-up-and-go (TUG) and 6-min walk (6 MW) tests. We examined the associations between sleep quality and physical functioning variables using Spearman's rho.
Sleep quality indicators were: total sleep time 407 ± 54 min; latency 26.8 ± 21 min; efficiency 73.9 ± 12 %; wake after sleep onset 122.8 ± 65.2 min; number of awakenings 21.0 ± 6.2; and average length of awakenings 6.1 ± 3 min. Total sleep time and average length of awakenings were significantly associated with 6 MW distances (rho = 0.58 and −0.69; p < 0.05, respectively). After controlling for age and BMI, 6 MW distance was significantly associated with total sleep time, latency, efficiency, and average length of awakenings (rho = 0.56, −0.73, 0.60, and −0.87; p < 0.05, respectively). TUG was significantly associated with total time in bed (rho = 0.71); p < 0.05).
Sleep quality indicators are associated with walking performance in adults with DS. Age and BMI strengthen the relationship between sleep quality and physical functioning.
Sleep and functional capacity in adults: Cross-sectional associations among self-report and objective assessments
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A growing number of studies suggest that poor sleep may be a risk factor for disability in later life. Adults with physician-diagnosed sleep disorders8 and those with poorer sleep, as determined by either self-report9,10 or actigrapy,11,12 are significantly more likely to report functional limitations and/or disability than those with better quality sleep. Collectively, these studies support the possibility that poor sleep may contribute to declines in functional capacity, although the association between sleep and physical disabilities is likely to be bidirectional.
This study examined the relationship between self-reported and objectively measured sleep and functional capacity in adults.
Cross-sectional.
Data were from the Midlife in the United States study. The sample consisted of men and women (n = 664) aged 25-83 who completed telephone interviews, questionnaires, and an overnight clinic stay.
Sleep was assessed by self-report (Pittsburgh Sleep Quality Index [PSQI]) and by objective measures (sleep latency, duration, wake after sleep onset [WASO], and midpoint/midpoint variability) from 7 consecutive days of actigraphy. Functional capacity was assessed by self-report of limitations and measured gait speed, grip strength, and chair stands.
In linear regression models adjusting for demographic and health factors, better self-reported sleep quality predicted fewer reported limitations, stronger grip, quicker gait, and faster chair stands (all P< .01). Greater WASO predicted more self-report limitations and slower gait speed (P< .05). Long (>8 hours) sleep duration and a more variable sleep schedule predicted lower grip strength (p < .05). Finally, after adjustment for objective sleep measures, PSQI remained a significant predictor of functional measures (P< .05) and explained a significant amount of additional variance (change in R²: 0.01-0.05).
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Prevalence of Disability and Disability Types by Urban–Rural County Classification—U.S., 2016
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In a recent population-based study, Matthews and colleagues13 reported the prevalence of having 5 healthy behaviors (sufficient sleep, current nonsmoking, no or moderate drinking, maintaining a healthy body weight, and meeting aerobic physical activity recommendations) was lowest in noncore counties. Evidence has shown that people with disabilities are more likely to have obesity, smoke, be physically inactive, or have sleep-related problems compared with people without disabilities.20–23 However, whether the low prevalence of having 5 healthy behaviors in noncore counties reported by Matthews et al.13 is attributable to a high proportion of adults with disability residing in those areas remains unknown and needs be investigated further.
In the U.S., disability affects approximately 61.4 million (25.7%) adults, with mobility disability being the most prevalent type, affecting about 1 in 7 U.S. adults. However, little is known about the prevalence of disability and functional disability types by urbanization level.
Data from the 2016 Behavioral Risk Factor Surveillance System were analyzed. The prevalences of disability, overall and by functional disability type, were estimated among U.S. adults across 6 levels of urban–rural county categories based on the 2013 National Center for Health Statistics Urban–Rural Classification Scheme for Counties. Adjusted prevalence ratios with 95% CIs were estimated by conducting log-linear regression analyses with robust variance estimator while adjusting for study covariates. Data analyses were conducted in 2018.
The prevalences of having any disability, functional disability type, or multiple disabilities were lowest in large metropolitan centers and fringe metropolitan counties and highest in noncore (rural) counties. After controlling for age, sex, race/ethnicity, education, and federal poverty level, adults living in noncore counties were 9% more likely to report having any disability, 24% more likely to report having 3 or more disabilities, and 7% (cognition) to 35% (hearing) more likely to report specific disability types than the adults living in large metropolitan centers.
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Re: ‘Physical functioning and risk for sleep disorders in US adults: results from the National Health and Nutrition Examination Survey 2005–2014’
2018, Public Health

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Original ResearchPhysical functioning and risk for sleep disorders in US adults: results from the National Health and Nutrition Examination Survey 2005–2014

Highlights

Abstract

Objectives

Study design

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Ethical approval

Funding

Competing interests

Sleep Med

Sleep Med

Adv Ren Replace Ther

Med Clin North Am

J Am Med Dir Assoc

Trends Neurosci

Auton Neurosci

J Adolesc Health

The prevalence, cost implications, and management of sleep disorders: an overview

Sleep Breath

Prevalence and impact of sleep disorders and sleep habits in the United States

Sleep Breath

Attitudes towards treatment among patients suffering from sleep disorders. A Latin American survey

BMC Fam Pract

Further evidence for the importance of subclinical functional limitation and subclinical disability assessment in gerontology and geriatrics

J Gerontol Ser B Psychol Sci Soc Sci

Economic implications of sleep disorders

PharmacoEconomics

Fatigue and mood correlates of sleep length in three age-social groups: school children, students, and employees

Chronobiol Int

Correlation between physical functioning and sleep disturbances in hemodialysis patients

Hemodial Int

Association between sleep and physical function in older veterans in an adult day healthcare program

J Am Geriatrics Soc

Original Research
Physical functioning and risk for sleep disorders in US adults: results from the National Health and Nutrition Examination Survey 2005–2014