1. IFA 11th Global Conference on Ageing 28 May – June 1 2012, Prague
SLEEP PROBLEMS OF
SERVICE USERS OF ELDER
CARE IN HONG KONG -
THE USE OF THE
CANTONESE VERSION
PITTSBURGH SLEEP QUALITY
INDEX
Alice M.L. Chong, PhD.
City University of Hong Kong,
Hong Kong, China
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2. Table of Content
1. Brief introduction to Hong Kong
2. Introduction
3. Methods: Overall
4. Stage 1: Scale Validation – Methods
5. Stage 1: Scale Validation – Results
6. Stage 2: Main Survey – Methods
7. Stage 2: Main Survey – Results
8. Discussion
9. References
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3. 1. Hong Kong (HK) in a glance
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Table 1: Hong Kong as an aging society
Figure 1: Increasing percentage of Figure 2: Life expectancy from 1981 to
60+/total population from 1981 to 2050 2030
Source: Census & Statistics Department. (2011). http://www.censtatd.gov.hk
US Bureau of Census, International Data Base.(2011). http://www.census.gov/population/international/data/idb/informationGateway.php
香港人口推算2004-2003. (2004). http://www.info.gov.hk/gia/general/200406/30/0630091.htm
Alice Chong Gap Model 3

4. 2. Introduction
2.1 Sleep problems
a. Sleep problems increase with age and constitutes some of the most
difficult afflictions in late life (Cuellar, Rogers, Hisghman & Volpe, 2007;
McCall, 2005).
b. Patients with insomnia report difficulty in initiating sleep, difficulty in
maintaining sleep, or early morning awakening (Ohayon, Caulet, Priest,
& Guilleminault, 1997).
c. Possible causes of sleep problems
 Sleep disorders (e.g., narcolepsy or sleep apnea)
 Physical illnesses and medication (e.g., chronic infections and sleep
allergy)
 Emotional factors (e.g., anxiety, depression or stress)
 Lifestyle factors, such as too much coffee and decreased activity levels
 Environmental factors, such as noise, and overcrowding (Bootzin & Engle-
Friedman, 1987).
 Among all factors, depression is the psychiatric diagnosis most commonly
associated with insomnia (Ancoli-Israel, 2004; Pigeon et al., 2008).
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5. 2. Introduction
2.2 Study objectives
a. Translate and validate a widely-used measure on sleep
quality, namely the Pittsburgh Sleep Quality Index (PSQI),
for use with older Chinese.
b. Explore the sleep problems of Chinese users of elder care
in Hong Kong using the Chinese version PSQI (C-PSQI)
c. Identify demographic and psycho-social factors
associated with sleep problems.
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6. 3. Methods: Overall
3.1 Two stages
Stage 1: Scale validation
Stage 2: A cross-sectional survey exploring the
prevalence of sleep problems and their predictors.
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7. 3. Methods: Overall
3.2 Measures
a. PSQI (Buysse, Reynolds, Monk, Berman & Kupfer, 1989)
 A 19-item self-rating tool designed to assess the sleep quality and
pattern of sleep during the past month
 Seven components: subjective sleep quality, sleep-onset latency, sleep
duration, sleep efficiency, sleep disturbances, use of sleeping
medications, and daytime dysfunction
 Each component score ranges from 0 to 3, yielding a global score of
sleep quality ranging from 0 to 21, higher scores indicate poorer sleep
quality.
 A PSQI global score of 5 or above is an indicator of poor quality sleep.
 Widespread application in a variety of populations and validated in
many different languages
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8. 3. Methods: Overall
3.2 Measures
b. Geriatric Depression Scale Short Form (GDS-SF; Lee et al.,
1993)
 15 items
 Total score ranged from 1 to 15
 The higher the score, the higher is the level of depression.
 In this study, >7 will be used as the cut-of score (Lee, Chiu, & Kwong,
1994).
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9. 4. Stage 1: Scale Validation - Methods
4.1 Pre-test
a. Conducted in September to October 2005
b. PSQI was translated into Chinese and then back-translated into English by two
different translation experts.
c. Participants (N = 17): ageing 60 or above, including 9 women and 8 men, 10
physically healthy and 7 frail.
d. Face-to-face interviews by trained interviewers were adopted for data
collection.
e. The wordings and presentation of the C-PSQI were then revised according to
the participants’ responses.
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10. 4. Stage 1: Scale Validation - Methods
4.2 Validation survey
a. Selection criteria for participants:
-older people aged 60 or over
-cognitively intact
-able to communicate verbally with the interviewers
-using either community or residential services of the largest NGO serving
older people in Hong Kong.
b. The staff members of the service units were asked to identify
service users who met the sampling criteria.
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11. 4. Stage 1: Scale Validation - Methods
4.2 Validation survey
c. Individual participants’ consent to participate in the study was
then sought by the interviewers who were social sciences
undergraduates.
d. To establish the C-PSQI’s reliability over time, the participants
were interviewed again one week later.
e. Seventy-five participants were successfully interviewed twice.
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12. 5. Stage 1: Scale Validation - Results
The reliability and validity of C-PSQI
a. SPSS was used.
b. Internal consistency: moderate, with crobach’s alpha of .68
c. Test re-test reliablity & inter-rater reliability established
e. Convergent validity: positive but moderate, with the Pearson
Correlation coefficient between PSQI and the GDS as .32 (p < .01)
 C-PSQI was moderately reliable and valid for use with older
Chinese.
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13. 6. Stage 2: Main Survey - Methods
6.1 The Sample
a. The sampling criteria were similar to the validation survey
b. The sampling frame: all service users from the largest NGO in
elder care in Hong Kong.
c. The study participants were recruited from all its 8 community
centres and 4 residential care homes, which were located in all
five geographic regions of Hong Kong, thus included older
people of various socio-economic statuses.
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14. 6. Stage 2: Main Survey - Methods
6.1 The Sample
d. A sample size of 400 was planned, with three-quarter from
community care units and one-quarter from residential care homes.
e. The participants were randomly selected from a list of all service
users meeting the sampling criteria in each centre and care home.
f. Finally, 420 older people were contacted, and 406 (97%) were
successfully interviewed.
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15. 6. Stage 2: Main Survey - Methods
6.2 Data collection method
a. After getting informed consent, face-to-face interviews were
carried out by trained interviewers who were social sciences
undergraduates in service units of the NGO in a room free
from disturbances, e.g. interview room, conference room or
nursing room.
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16. 7. Stage 2: Main Survey - Results
7.1 Participant characteristics
Table 1: Demographical characteristics of participants (N = 406)
Sex Male Female
33.3% 66.7 %
Age 60 – 69 70 – 79 >80
6.5% 44.3% 39.2%
Marriage
Married Widowed Never got married Divorced or separated
Status
48.5% 40.9% 5.4% 5.2%
Residence Community Aged care home
77.3% 22.7%
Educational
No formal education Primary education Secondary education Tertiary education
Status
34.7% 26.6% 7.2% 4.0%
Depressiona Not depressed Depressed
80.2% 19.8%
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Note. a The GDS cutoff score of more than 7 was used.

17. 7. Stage 2: Main Survey - Results
7.2 Sleep quality
a. The mean C-PSQI scores was 8.28 (SD=4.11).
b. Principal Component Analysis found the 7 components clustered
into 3 domains, which can be classified as perceived sleep quality,
daily disturbances and sleep medication.
c. Their mean scores were 1.42 (SD=.73), .93 (SD=.88) and .29
(SD=.85) respectively.
 The participants had more problems with perceived sleep quality,
followed by daily disturbances, and there was a low use of sleep
medication.
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18. 7. Stage 2: Main Survey - Results
7.2 Sleep quality
Table 2: Factor Matrix for the 3-Domains of C-PSQI (N=406)
Domains of C-PSQI
Perceived Sleep Daily Disturbances Sleep Medication
Quality
1. Subjective sleep quality 0.70 0.30 0.05
2. Sleep latency 0.69 0.07 0.06
3. sleep duration 0.76 -0.53 0.03
4. Habitual sleep efficiency 0.81 -0.46 -0.05
5. Sleep disturbances 0.57 0.40 0.00
6. Use of sleep 0.11 0.18 0.95
medications
7. Daytime dysfunction 0.47 0.57 -0.34
Extraction Method: Principal Component Analysis.
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19. 7. Stage 2: Main Survey - Results
7.2 Sleep quality
e. With the PSQI global score 5 or above as the cutoff point,
68.81% of the participants would be seen as having some sleep
problems.
f. Only 34.7 % of the participants self-reported to be suffering
from insomnia. Among them, 78% had it for more than one year,
51.0% did not seek help, and 16.5% could not find any suitable
persons to help.
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20. 7. Stage 2: Main Survey - Results
7.3 Factors associated with insomnia
c. There were significant difference of the means C-PSQI scores
Table 4: Differences in C-PSQI scores
M SD df t
Male 7.22 3.95
Sex 392 -3.62***
Female 8.78 4.07
Community 7.87 4.05
Residence
Aged care 392 -3.87***
home
9.75 3.99
Self-reported
Not reported 6.64 3.50
insomnia
393 -12.87***
Reported 11.33 3.37
* p<0.05 **p<0.01 ***p<0.001
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21. 7. Stage 2: Main Survey - Results
7.3 Factors associated with insomnia
Table 4: Standardized Regression Coefficients of Demographic and
Personal Variables on C-PSQI (N=406)
Model 1 Model 2
Age 0.116* 0.079
Gender (Female) 0.105* 0.023
Education level -0.143** -0.068
Perceived health^ 0.146***
Perceived financial adequacy 0.033
Depression (Geriatric Depression 0.218***
Scale)
Living in institution 0.114**
Self-reported insomnia 0.416***
Adjusted R² 0.059 0.435
* p<0.05 **p<0.01 ***p<0.001
Dependent variable: C-PSQI
^ 5 point scale with 1 being very good to 5 being very bad 21

22. 7. Stage 2: Main Survey - Results
7.4 Reliability and validity of PSQI
a. Internal consistency: satisfactory, with crobach’s alpha of .71
b. Convergent validity: positive but moderate, with the Pearson
Correlation coefficient between PSQI and the GDS as .49 (p <
.001)
 Together with the findings of the pilot study and the
validation survey, C-PSQI was found to be moderately reliable
and satisfactorily valid for use with the Chinese elders.
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23. 8. Discussion
a. Sleep problems in late-life are common
 At least one-third of the participants reported having insomnia at
the time of the study.
 C-PSQI revealed that the participants had the greatest problems
with perceived sleep quality, including taking long time to fall
asleep, poor assessment of sleep quality, short sleep duration, low
sleep efficiency, and various sleep disturbances (e.g. early
awakening or frequent waking-up during the night to go to the
bathroom, feeling too hot/cold or having pain).
 The participants might have trouble staying awake while engaging
in social activities or eating meals; and might have problem keeping
up enthusiasm to get things done in the last month before the time
of the study.
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24. 8. Discussion
b. More sleep problems among institutionalized elders
 To the best of our knowledge, this study was the first one to find
living in institutions predicts sleep problems, possibly due to the
following reasons.
-Severe lack of land in Hong Kong: Noise, lack of privacy and other
environmental disturbances might affect the residents’ sleep quality.
-Physical and mental illnesses: Older residents usually suffer more
physical and mental illnesses (Census and Statistics, 2005) which might
bring about sleep disturbances.
-Chinese culture: For Chinese older people, admission to residential
care homes might imply a sense of parental failure and loss of respect.
The feelings of abandonment and distress might affect their sleep
quality.
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25. 8. Discussion
c. Depression predicted sleep problems
 Similar to other studies (Staner, 2010; Vollrath, Wicki & Angst,
1989), depression was found to predict sleep problems, as the
second most powerful predictor, after self-reported insomnia.
 A vicious cycle of mood and sleep: Depressed mood reduces
sleep quality and sleep quantity. On the other hand, adverse
effect of poor sleep (e.g. daytime fatigue) causes
psychological distress.
 Intervention on sleep problems is recommended to tackle
both the sleep disturbances and depression simultaneously.
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26. 8. Discussion
d. Low level of help-seeking
 The present study found that a high percentage (78%) of respondents with
self-reported insomnia had been suffering from the problem for one year or
above
 Half (51.0%) of them never sought help.
 Only 10% of the participants took any medications to help them sleep.
 Possible reasons
 The respondents might feel that sleep problems were just phenomena of the
normal aging process.
 It might reflect the stigmatization associated with mental health and
psychiatric treatment (Chiu et al., 1999).
 The percentage of participants using of sleep medications was low.
 A possible reluctance of the Chinese elders to the use of pharmacological
interventions in sleep disturbances
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27. 8. Discussion
e. Insufficient service available
 16.6% of the participants had tried to seek help but could not
find a suitable service or person
 Insufficient treatment opportunities or a lack of knowledge
about how to get help
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28. 8. Discussion
f. PSQI cutoff score
 A discrepancy was found between self-report and C-PSQI scores
 About one-third (34.7 %) of the participants perceived themselves
as suffering from insomnia, which was much lower than the rate of
68.81% if PSQI global score of 5 was used as the cutoff score
 Such discrepancy might reflect a under-report due to misguided
association of sleep disturbances with advancing age (Chiu et al.,
1999), or might be because PSQI assessed not just insomnia but a
lot of sleep related behaviors.
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29. 8. Discussion
f. PSQI cutoff score
 The discrepancy may suggest a need to adjust the PSQI
cutoff score for older Chinese.
 No consensus about the PSQI cutoff score was found in
previous studies.
 Buysse et al. (1989) recommended a global sum of 5 and above.
 Carpenter and Andrykowski (1998) proposed a score of 8 to
indicate poor sleep quality since their four patient groups with
sleep problems had mean scores greater than 8.0.
 Another suggestion was a global score of 6 (Backhaus, Junghanns,
Broocks, Riemann & Hohagen, 2002).
 A cutoff score of 10 or above appeared to be more
appropriate for our participants, and would result in 39.8%
of them classified as having some sleep problems. 29

30. 8. Discussion
g. Limitations
 The sampling frame was service users of the largest NGO serving
older people in Hong Kong.
 The findings could only be generalized directly to service users of
elder care of this NGO, and indirectly to all service users of elder
care in Hong Kong.
 Another limitation is the reliance on self-report.
 Triangulation of study methods which include both subjective and
objective measures, as well as clinical and laboratory confirmation, is
recommended for future research in this area.
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31. 8. Discussion
h. Recommendations for further studies
 The association between institutionalization and sleep quality
and what could be done to promote sleep quality within the
environmental constraints of communal living
 The relationship between depression and sleep disturbances,
and the reasons behind the low level of help-seeking and low
use of sleep medications
 It is important to cross-validate the exact cutoff score for
older Chinese in Hong Kong as well as in other Chinese
societies such as Singapore, Taiwan, and cities in Mainland
China.
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32. 8. Discussion
i. Recommendations for service
 The C-PSQI is recommended for initial screening of sleep-
related problems by human service professionals.
 Community education on causes, symptoms and intervention
options (both pharmacological and non-pharmacological) of
sleep problems is strongly recommended to the general
public and the older population, especially those living in
residential care homes.
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33. 8. Discussion
i. Recommendations for service
 The use of non-pharmacological and psychological
intervention strategies such as sleep hygiene education,
cognitive therapy, physical exercise, and an active life style
might be more acceptable by the older Chinese than
pharmacological intervention and should be promoted (Petit,
Aza, Byszewski, Sarazan, & Power, 2003).
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34. References
• Ancoli-Israel, S. (2004). Sleep disorders in older adults: A primary care guide to assessing 4 common sleep
problems in geriatric patients. Geriatrics, 59, 37-40.
• Backhaus, J, Junghanns, K, Broocks, A, Riemann, D, & Hohagen, F. (2002). Test-retest reliability and validity
of the Pittsburgh Sleep Quality Index in primary insomnia. Journal of Psychosomatic Research, 2002, 53,
737-740.
• Bootzin, RR, & Engle-Friedman, M. (1987). Sleep disturbances. In: L.L. Carstensen & B.A. Edelstein (Eds).
Handbook of clinical gerontology (pp.238-251). New York: Pergamon Press.
• Buysse, D.J., Reynolds, C.F., Monk., T.H., Berman, S.R., & Kupfer, D,J. (1989). The Pittsburgh Sleep Quality
Index: a new instrument for psychiatric practice and research. Psychiatry Research, 28, 193–213.
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Journal of Psychosomatic Research, 45(1), 5-13.
• Census and Statistics Department, Hong Kong Special Administration Region Government. (2005).
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problems in Chinese elderly in Hong Kong. Sleep, 22(6), 717-726.
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Shanghai. The Journal of Comparative Asian Development, 8(1), 67-104.
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Brisbane: John Wiley & Sons.
• Cuellar, N.G., Rogers, A.E., Hisghman, V., & Volpe, S.L. (2007). Assessment and treatment of sleep disorders
in the older adult. Geriatric Nursing, 28(4), 254-264.
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35. References
• Lee, H.C.B., Chiu, H.F.K., Wing, Y.K., Kwong, P.K., Leung, C.M., & Chung, D.W.S. (1993). The GDS short form
as a screening test for the Chinese elderly: A preliminary study. Clinical Gerontology, 14, 37-41.
• Lee, H.C.B., Chiu, H.F.K., & Kwong, P.P.K. (Jan & July 1994). Cross-validation of the Geriatric Depression
Scale Short Form in the Hong Kong Elderly. Bulletin of the Hong Kong Psychological Society, 32/33, 72-77.
• Li, R.H.Y., Wing, Y.K., Ho, S.C., & Fong, S.Y.Y. (2002). Gender differences in insomnia: A study in the Hong
Kong Chinese population. Journal of Psychosomatic Research, 53, 601-609.
• McCall, W.V. (2005). Diagnosis and management of insomnia in older people. Journal of the American
Geriatrics Society, 53 (Suppl l7), 264–271.
• Ohayon, M.M., Caulet, M., Priest, R.G., & Guilleminault, C. (1997). DSM-IV and ICSD-90 insomnia
symptoms and sleep dissatisfaction. British Journal of Psychiatry, 171, 382-388.
• Petit, L., Aza, N., Byszewski, A., Sarazan, F.F., & Power, B. (2003). Non-pharmacological management of primary and
secondary insomnia among older people: review of assessment tools and treatments. Age and Ageing, 32, 19-25.
• Pigeon, W.R., Hegel, M., Unützer, J., Fan, M.Y., Sateia, M.J., Lyness, J.M., Phillips, C., & Perlis, M.L. (2008). Is
insomnia a perpetuating factor for late-life depression in the IMPACT cohort? Sleep, 31(4), 481-488.
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syndromes, and course of insomnia. European Archives of Psychiatry and Neurological Sciences, 239, 119-124.
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36. Alice M.L. Chong
City University of Hong Kong
Email: Alice.chong@cityu.edu.hk
36