The utilization of health services and self-care by older women with sleeping problems: results from a nationally representative sample of 9,110 women
S Meredith, J Frawley, J Adams, D Sibbritt
Journal of Health and Ageing, 2017
INTRODUCTION
Across the globe, sleeping problems - a group of complaints indicated by symptoms of insomnia including trouble with initiating sleep, trouble with maintaining sleep and poor quality sleep (Ohayon, 2002) - are a burgeoning, modern encumbrance. Recent international studies amongst adult populations show an elevated prevalence of sleeping problems with one large international study reporting 56% of adults in the US, 31% in Western Europe and 23% in Japan (Léger, Poursain, Neubauer, & Uchiyama, 2007).
Research has found associations between the existence of sleeping problems and chronic illnesses, obesity, lower income, being separated/divorced/widowed, lower level of education and being retired (Liu, Hay, & Faught, 2013; Ohayon, 2002). However, the clearest associations reported are with older age and being female (Leigh, Hudson, & Byles, 2015; Ohayon, 2002). One large-scale American study has shown 60% of women suffer from insomnia or trouble sleeping in contrast with just 39% of men (Pearson, Johnson, & Nahin, 2006) and large, nationally representative Australian studies have found between 50 – 72% of older women have trouble sleeping (Byles, Mishra, & Harris, 2005; Leigh et al., 2015). In contrast, only around 10% of younger women (Jackson, Sztendur, Diamond, Byles, & Bruck, 2015) suffer with sleeping problems. While research suggests sleeping problems increase in mid-age women to 15-25% (Kline et al., 2014), before a sharp rise in women over 65 (Byles et al., 2005; Leigh et al., 2015) , there is a gap in the literature at the cross-section between mid-age and older women.
Research indicates greater risks for older age cohorts with sleeping problems such as falls, injuries and early aged-care (Stone et al., 2008). Although this cohort is a ‘younger’ older age group (62-67 years), longitudinal research suggests sleeping problems persist and are even exacerbated with age (Leigh et al., 2015). Without successful intervention, it is possible that older adults with sleeping problems may be at increased risk of falls, injury and early age-care. It is therefore important to understand the current health-seeking behaviors of women in their early to mid sixties in order to better determine appropriate treatments.
The frontline conventional medical response for sleeping problems is usually prescribed medications such as benzodiazepines which can have detrimental side-effects (Wang, Bohn, Glynn, Mogun, & Avorn, 2014). Medications upheld as safer alternatives such as zolpidem and zopiclone, have equally become associated with side effects such as headaches, dizziness and falls (Leach & Page, 2015) particularly in older people (Wang et al., 2014).
Complementary and alternative medicine (CAM) – a diverse array of health care systems, products and practices that exist outside of the dominant health care model (Adams, Andrews, Barnes, Broom, & Magin, 2012) – has been promoted as potentially providing a safer alternative to conventional treatments for insomnia, with fewer or no side-effects(Fernández-San-Martín et al., 2010). CAM self-care products such as herbal medicines, especially chamomile and valerian, have attracted some evidence supporting their efficacy in the improvement of sleep quality (Fernández-San-Martín et al., 2010) although such evidence is still scarce (Leach & Page, 2015). Mind-body therapies (such as relaxation therapies, yoga and mindfulness), and cognitive behavioral therapy (CBT) have also been recommended to improve sleep quality and to reduce sleep onset latency time (Halpern et al., 2014; Morin, 2010).
From the available evidence, CAM has been shown to be popular in the treatment of insomnia, with a recent study reporting that CAM is used by 45% of American adults who suffer from insomnia (Bertisch, Wells, Smith, & McCarthy, 2012). However, use of CAM for sleeping problems has been significantly lower amongst older populations (Bliwise & Ansari, 2007) No studies have investigated the prevalence of CAM use for sleeping problems in older women and there remains a significant absence of large studies in the research literature evaluating the use of health services- both conventional and CAM – and CAM self-care by women with sleeping problems (Sivertsen, Krokstad, Øverland, & Mykletun, 2009). This paper aims to provide a first step towards filling this literature gap, by analyzing health service use (both conventional and CAM) and CAM self-care by women in their early to mid sixties with sleeping problems. We also seek to explore key drivers and characteristics for this use, reporting analyses from an examination of a large nationally representative sample of women aged 62-67 years.
METHODS
Sample
This research was conducted as part of the Australian Longitudinal Study on Women’s Health (ALSWH): a prospective, population-based survey, funded by the Australian government. The study assesses multiple factors of women’s health and their use of health services. For the baseline survey in 1996, women in three age cohorts aged 18-23 (born 1973-1978), 45-50 (1946-1951) and 70-75 (1921-1926), were randomly selected from the national Medicare database and invited to take part in the survey. (The Medicare database contains contact details of all Australian citizens and permanent residents).Respondents were shown to be largely representative of Australian women in these target age groups (Brown, Dobson, Bryson, & Byles, 1999). Women in the three age cohorts completed surveys on a variety of health and social issues approximately every three years. More details of the recruitment and survey process were published in 1999 (Brown et al., 1999) and updated in 2015 (Dobson et al., 2015). This paper reports on the analyses of the most recent survey (Survey 7) conducted in 2013, for the cohort born 1946-1951, when the women were aged 62-67 years. These women were originally selected to examine menopausal transitions and the social and personal changes associated with middle age. Now (from Survey 7), this cohort provides us with information on predictors of various health issues as women transition into older adult life. From survey 7 (n=9,151), 9,110 (99.6%) women responded to the question about sleeping problems.
Ethics
Ethics approval for the study was gained from the relevant ethics committees at the University of Newcastle (#H-2010_0031), University of Queensland (#2010000411) and the University of Technology Sydney (#2011-174N).
Measure of health status
Women were asked if they currently had any of the following sleeping problems: lying awake for most of the night, taking a long time to get to sleep or sleeping badly at night. If they indicated that they had one or more of these problems they were classified as having a sleeping problem.
Existence of other medical conditions
Women were asked if they had been diagnosed or treated for a series of chronic medical conditions over the last 3 years, including diabetes, osteoarthritis, rheumatoid arthritis, other arthritis, osteoporosis, heart disease (including heart attack and angina), hypertension, low iron level (iron deficiency or anemia), asthma, bronchitis/emphysema, cancer (not including skin cancer), depression, anxiety/nervous disorder and chronic fatigue syndrome).
Demographic characteristic measures
Residential status (urban or non-urban) was classified using residential postcode (participants were asked ‘what is your residential postcode?).Codes were then classified as ‘urban’, ‘rural’ or ‘remote’ defined according to Rural, Remote and Metropolitan Areas (RRMA) classification. Urban includes ‘Capital City’ and ‘Other Metropolitan Areas’; rural captures ‘Large Rural Centres’, ‘Small Rural Centres’ and ‘Other Rural Areas’; and remote includes ‘Remote Centres’ and ‘Other Remote Areas’. We then collapsed the rural and remote variables leaving two groups: urban and rural/remote.
Women were asked questions relating to marital status (the question was ‘what is your present marital status? (Mark one only): married, de facto relationship (opposite sex), de facto relationship (same sex), separated, divorced, widowed, never married’). Variables were collapsed to leave three groups: married/defacto, separated/divorced/widowed and never married.
Participants were also asked about their ability to manage on their income: (the survey asked ‘how do you manage on the income you have available? (mark one only): it is impossible, it is difficult all of the time, it is difficult some of the time, it is not too bad, it is easy’). These variables were also collapsed into three groups: impossible/difficult all of the time, difficult some of the time and not too bad/it is easy.
Self-reported measures of weight and height were used to calculate BMI. Based on the WHO classification of BMI, responses were divided into four groups: BMI <18.5 kg/m2 (underweight), BMI 18.5 – 24.99 kg/m2 (healthy weight), BMI 25 – 29.99 kg/m2 (overweight) and BMI >30 kg/m2 (obese).
Health service (conventional and CAM practitioner) and CAM self-care use
The women were asked about their use of conventional medical and allied health care providers i.e. general practitioner, specialist (specialization unspecified), counselor/psychologists/social worker, dietician. In addition, women were asked if they had consulted with a range of CAM practitioners (i.e. massage therapist, naturopath/herbalist, chiropractor, osteopath). They were also asked about their use of CAM self-care products and services such as vitamins/minerals, yoga/meditation, herbal medicines, aromatherapy oils and Chinese medicines over the last 12 months.
Statistical analysis
The associations between the characteristics of women with sleeping problems and their use of health services were examined using a chi-square test. All health service and CAM self-care variables were entered into a logistic regression model. The model was adjusted for the demographic measures listed in table 1 and all 14 chronic health conditions listed in table 3. The 14 chronic health conditions were combined into a single variable that represented the count of the number of chronic health conditions each individual woman had been diagnosed with. That is, women could have a minimum of zero or a maximum of 14 chronic health conditions. Then a backward stepwise elimination process - using all health service and CAM self-care variables - was undertaken applying a likelihood ratio test to determine the most parsimonious model. Statistical analyses were conducted using statistical software program STATA 13.1 (StataCorp LP, College Station, TX, USA). Due to the large sample size, a p<0.001 was used for statistical significance.
RESULTS
Of the 9,110 women who responded to the question regarding sleeping problems, 48.2% (n= 4,394) indicated that they had a sleeping problem. Specifically, 34.7% of respondents indicated that they slept badly at night, 33.36% reported taking a long time to get to sleep and 16.09% had the problem of lying awake for most of the night. Associations between sleeping problems and demographic characteristics are presented in Table 1. Women were significantly more likely to be obese or have financial difficulties if they had sleeping problems compared to those without sleeping problems (p<0.001).”
Table 1: Comparison of sleeping problems and demographic characteristics
Table 2 compares health service use and use of CAM self-care practices/productsbetween women who had sleeping problems and those that did not. Women with sleeping problems consulted conventional healthcare providers more frequently than those without sleeping problems, including GP (75% vs. 63%), specialist doctor (38% vs. 30%), counselor/ psychologist (9% vs. 5%) (all p<0.001). Women with sleeping problems were also more likely to see a dietician although this was not statistically significant (7% vs. 6%) (p<0.022). Women with sleeping problems in this sample were not significantly more likely to consult a CAM practitioner than those without sleeping problems. However, women with sleeping problems were significantly more likely (p<0.001) to use CAM self-care products, including vitamins/minerals (83% vs. 80%) and/or herbal medicines (38% vs. 33%) than those without sleeping problems.
Table 2: Comparison of sleeping problems and health service use and self-care
The associations between sleeping problems and comorbid chronic illnesses are presented in Table 3. Women with sleeping problems were more likely than those who did not experience sleeping problems to suffer from a number of specific chronic illnesses including - in order of prevalence - hypertension, osteoarthritis, depression, asthma, other arthritis, anxiety/nervous disorder, diabetes, osteoporosis, bronchitis/emphysema, iron deficiency/anemia, heart disease, rheumatoid arthritis, and/or chronic fatigue syndrome (all p<0.001).
Table 3: Comparison of sleeping problems and chronic illnesses
When all health care variables were considered together, using a multiple logistic regression modeling (Table 4), the health service and CAM self-care options positively associated with sleeping problems were higher frequency of GP use and higher use of herbal medicines compared with women without sleeping problems. Specifically, GPs were considerably more likely to be consulted by women with sleeping problems 1-2 times (OR=1.20; 95% CI: 1.08, 1.35; p<0.0001), 3-6 times (OR=1.48; 95% CI: 1.31, 1.67; p<0.0001) or more than 7 times (OR=1.70; 95% CI: 1.34, 2.15; p<0.0001) than by women without sleeping problems. Women with sleeping problems were more likely to use herbal medicines (OR=1.25; 95% CI: 1.14, 1.37; p<0.0001) than women without sleeping problems. All results were statistically significant (p<0.001).
Table 4: Health service use and CAM self-care for sleeping problems
DISCUSSION
This large, nationally representative study of health service utilization and CAM self-care amongst women in their early to mid sixties with sleeping problems fills a gap in the sleep literature in the continuum between ‘mid-age’ and ‘older women’. While other studies have highlighted the magnitude of sleeping problems as an issue for women over 70 (Leigh et al., 2015), this study suggests that even from 62 years, nearly 50 percent of women will have sleeping problems.
While the prevalence of sleeping problems in our study is higher than many other large studies examining the general population (Bertisch et al., 2012; Bin, Marshall, & Glozier, 2012; Léger & Poursain, 2005; Pearson et al., 2006), these results are broadly inline with other studies on older adults (Roepke & Ancoli-Israel, 2010). They are further corroborated by Australian studies, which consistently find a higher prevalence (50 – 72%) of sleeping problems amongst older women (Byles et al., 2005; Hasan, Byles, Mishra, & Harris, 2001; Leigh et al., 2015). Knowledge of important characteristics such as health service use and CAM self-care in this large proportion of older women with sleeping problems, is important to help health professionals improve health outcomes before associated events occur such as early aged-care, injuries and falls (Stone et al., 2008). Our analysis reveals a number of significant findings:
Co-morbid chronic illnesses
This study shows a strong association between sleeping problems and chronic illnesses, consistent with other epidemiological studies (Ancoli-Israel, 2006; Foley, Ancoli-Israel, Britz, & Walsh, 2004; Pearson et al., 2006; Smagula, Stone, Fabio, & Cauley, 2015; Taylor et al., 2007). The chronic illnesses highlighted in this study are partly those affecting older women disproportionately such as osteoarthritis (Allen & Golightly, 2015) and other arthritis (Affleck et al., 1999; Theis, Helmick, & Hootman, 2007). It is likely that chronic pain associated with these complaints in part lead to, or result from, sleeping problems, contributing to an increased use of health services (Blyth, March, Brnabic, & Cousins, 2004).
Currently, conventional treatment tends to focus on the ‘primary’ underlying chronic causes of insomnia symptoms (Billiard & Bentley, 2004; Léger & Poursain, 2005), assuming it will automatically resolve sleeping problems (Morin, 2010). However, sleeping problems can be both a prodromal symptom and a precursor to chronic conditions (Byles et al., 2005; Eaton, Badawi, & Melton, 1995). The treatment of sleeping problems as a specific condition therefore, rather than a secondary symptom or inevitable part of ageing, could also be helpful in preventing, or alleviating symptoms of, other chronic illnesses. Health professionals should actively enquire as to the existence of sleeping problems in older women reporting chronic illnesses to make sure they are being effectively treated. Further clinical research is also required to ascertain the relationships between pain medication and treatments used for different chronic conditions and their effects on sleep.
Conventional health service use
This study found sleeping problems were significantly associated with an increase in GP visits, in line with other recent studies (Byles et al., 2005; Sivertsen, Krokstad, Mykletun, & Øverland, 2009). Although it is likely some of the visits will have been for the treatment of other chronic conditions, studies from Australia have shown extra GP visits for older women with sleeping problems frequently result in prescribed medications (Byles et al., 2005) which are often limited to potentially harmful drugs such as benzodiazepines which have been associated – especially in older people - with harmful consequences despite short-term efficacy (Wang et al., 2014).
As this study shows, nearly 50% of women are suffering from sleeping problems; the consequent social and economic costs are likely significant (Moloney, Konrad, & Zimmer, 2011; Sarsour, Kalsekar, Swindle, Foley, & Walsh, 2011). Alternative, long-term frontline treatment options for sleeping problems could reduce the disproportionate healthcare costs ensuing from the increase in GP consultations by women with sleeping problems. Morin suggests for example, despite an increase in initial time treatment, (compared to drug prescription), CBT can provide long-term results in the treatment of sleeping problems (Morin, 2010), whereby reducing the long-term economic costs and associated public health burden that sleeping problems currently represent. After logistic regression modeling, women with sleeping problems in this study were not seeing a significantly greater number of medical specialists than women without sleeping problems. This could be because specialist sleep clinics tend to focus on non-insomnia based sleeping problems such as sleep apnea (Morin, 2010). A widening of the specialization to effectively treat sleeping problems, such as insomnia, could also help reduce costs and suffering.
CAM self -care product use
This research found an association between sleeping problems and use of herbal medicines for self-care. Whilst this is the first study focusing on CAM use for older women with sleeping problems, other mixed studies of adults have also found use of herbal medicines to be significant amongst those with sleeping problems (Bliwise & Ansari, 2007; Sánchez-Ortuño, Bélanger, Ivers, LeBlanc, & Morin, 2009). It is possible that women with sleeping problems are more likely to be using herbal medicines than women without sleeping problems because they are not finding long-term relief using current frontline medical solutions such as benzodiazepines which are only recommended for short-term use, especially in older patients (Wang et al., 2014). It may also be due to concerns related to the safety of treatments such as benzodiazepines which have been implicated in causing iatrogenic diseases such as Alzheimer’s (de Gage et al., 2014) and injuries such as hip fractures, resulting from an increased likelihood of falls (Wang et al., 2014). Research has also found that women are frequently motivated to use ‘natural’ CAM self-care products believing them to have minimal adverse effects compared to conventional medicines and frequently then, do not disclose this use to health providers (Peng, Adams, Sibbritt, & Frawley, 2014). While this research was unable to determine what conventional medications were being utilized, further research is warranted to investigate concurrent use with conventional drugs and herbal medicines for sleeping problems.
Whilst there is some evidence for the efficacy of herbal medicine alternatives such as valerian, chamomile and kava, to mainstream frontline hypnotic approaches (Fernández-San-Martín et al., 2010), it is scant (Leach & Page, 2015). There are also concerns about the use of herbal medicines for sleeping problems both with regards to toxicity and safety without expert administration and with regards to concurrent use alongside conventional medical treatments (Leach & Page, 2015). Risks increase because patients (with and without sleeping problems) are unlikely to report using CAM self-care products to their conventional health practitioner (McCaffrey, Pugh, & O’Connor, 2007). The significant use of herbal medicines, in the context of only emerging and inconclusive evidence for their efficacy, prompts a need for further investigation into the motivations accompanying decisions to use herbal medications for people with sleeping problems and into the concurrent use of herbal medicines with hypnotic medications.
As these results indicate women with sleeping problems are likely to be seeing their GP more frequently, a greater communication role for GPs - particularly in regards to CAM self-care consumption - could reduce risks associated with CAM use. It could also help avoid unintended direct adverse affects on sleep from herbal medicines that present stimulant effects (Bliwise & Ansari, 2007) or herbal medicines that are used incidentally to treat a concurrent condition. Research has shown patient-centered communication, including a collaborative approach to treatment and respectful and open communication, can help improve the likelihood of patients disclosing their use of CAM to their health care professional (Sohl et al., 2015). This in turn has a positive affect for both GPs and patients alike, as harmful drug interactions can be identified and avoided. A patient-centered context can keep patients informed of up-to-date evidence of efficacy for herbal - and other relevant alternative - medicine, whilst monitoring possible contraindications. This approach reduces the risk of interactions occurring amongst multiple, concurrent treatments. This is particularly pertinent for older women with sleeping problems, whom, as the results of this study show, are likely to have other comorbid illnesses requiring attention. One obstacle in this approach for health professionals may be the scant and ambiguous literature on the efficacy and safety of herbal medicines for the treatment of sleeping problems. A limited number of studies have also shown certain CAM treatments have a directly detrimental affect on people’s ability to sleep well (Lichstein et al., 2007). More detailed research to examine the prevalence of use of specific CAM treatments for persons with sleeping problems is required in order to identify safety concerns and to better arm health professionals with reliable information for patients.
Limitations
The limitations of our study should be noted. First, no operative definition of sleeping problems was employed in the data collection and thus, subjective interpretations of the terms indicated to denote sleeping problems might affect the reliability of the results. Second, potential for recall bias exists as findings are based on self-report; however, research suggests subjective sleep measures are highly correlated with objective measures of sleep, even in depressed individuals (Armitage, Trivedi, Hoffmann, & Rush, 1997). Third, in the ALSWH study, information on individual herbal medicines and vitamins was not collected and CAM self-care products were not specifically defined. It is thus possible that clearer correlates could emerge if more specific questions were asked. Fourth, although an increased number of GP visits was a stronger predictor of sleeping problems than chronic conditions, the ALSWH data did not reveal the specific reasons women with sleeping problems had for visiting health specialists and so we cannot know how many participants visited health professionals specifically for the treatment of sleeping problems. Fifth, did not collect data on medications used to treat sleeping problems, or any of the other chronic health conditions. However, the limitations of our study are outweighed by the opportunity to draw upon a large nationally representative sample of Australian women aged 62-67 years.
CONCLUSION
A substantial percentage of women aged 62-67 with sleeping problems utilize herbal medicines and it is important for all health professionals to actively enquire with patients about such use to ensure safe patient outcomes and avoid potentially dangerous drug-herb interactions. Further research is needed to investigate the efficacy and safety of herbal medicines, including interactions with conventional medication. This will enable health professionals to advise patients about treatment options that expand beyond conventional medicine and maximize patient care and safety. This need is further underlined by the association of sleeping problems with comorbid chronic illnesses that may be being treated concurrently either by health professionals or by patients themselves. Further research is also needed on decision-making that accompanies the use of herbal medicines for people with sleeping problems, especially given their high proportional use despite minimal evidence for efficacy. In light of research suggesting that women with sleeping problems in this cohort will become increasingly susceptible to falls, injury and possible early age-care, successful intervention is crucial for this age group.
Conflict of interest:
The authors declare no conflict of interest for this research
REFERENCES
Adams, J., Andrews, G., Barnes, J., Broom, A., & Magin, P. (2012). Traditional, complementary and integrative medicine: an international reader. London, United Kingdom: Palgrave Macmillan.
Affleck, G., Tennen, H., Keefe, F. J., Lefebvre, J. C., Kashikar-Zuck, S., Wright, K., . . . Caldwell, D. S. (1999). Everyday life with osteoarthritis or rheumatoid arthritis: independent effects of disease and gender on daily pain, mood, and coping. Pain, 83(3), 601-609.
Allen, K. D., & Golightly, Y. M. (2015). Epidemiology of osteoarthritis: state of the evidence. Current Opinion in Rheumatology, 27(3), 276.
Ancoli-Israel, S. (2006). The impact and prevalence of chronic insomnia and other sleep disturbances associated with chronic illness. The American Journal of Managed Care, 12(8 Suppl), S221-229.
Armitage, R., Trivedi, M., Hoffmann, R., & Rush, A. J. (1997). Relationship between objective and subjective sleep measures in depressed patients and healthy controls. Depression and Anxiety, 5(2), 97-102.
Bertisch, S. M., Wells, R. E., Smith, M. T., & McCarthy, E. P. (2012). Use of relaxation techniques and complementary and alternative medicine by American adults with insomnia symptoms: Results from a national survey. Journal of Clinical Sleep Medicine, 8(6), 681-691.
Billiard, M., & Bentley, A. (2004). Is insomnia best categorized as a symptom or a disease? Sleep Medicine, 5(1), S35-S40.
Bin, Y. S., Marshall, N. S., & Glozier, N. (2012). The burden of insomnia on individual function and healthcare consumption in Australia. Australian and New Zealand Journal of Public Health, 36(5), 462-468.
Bliwise, D. L., & Ansari, F. P. (2007). Insomnia associated with valerian and melatonin usage in the 2002 National Health Interview Survey. SLEEP, 30(7), 881.
Blyth, F. M., March, L. M., Brnabic, A. J., & Cousins, M. J. (2004). Chronic pain and frequent use of health care. Pain, 111(1), 51-58.
Brown, W., Dobson, A., Bryson, L., & Byles, J. (1999). Women's Health Australia: on the progress of the main cohort studies. Journal of Women's Health & Gender-Based Medicine, 8(5), 681-688.
Byles, J. E., Mishra, G. D., & Harris, M. A. (2005). The experience of insomnia among older women. SLEEP, 28(8), 972.
de Gage, S. B., Moride, Y., Ducruet, T., Kurth, T., Verdoux, H., Tournier, M., . . . Bégaud, B. (2014). Benzodiazepine use and risk of Alzheimer’s disease: Case-control study. BMJ, 349, g5205.
Dobson, A. J., Hockey, R., Brown, W. J., Byles, J. E., Loxton, D. J., McLaughlin, D. P., . . . Mishra, G. D. (2015). Cohort Profile Update: Australian Longitudinal Study on Women’s Health. International Journal of Epidemiology, dyv110.
Eaton, W. W., Badawi, M., & Melton, B. (1995). Prodromes and precursors: epidemiologic data for primary prevention of disorders with slow onset. The American Journal of Psychiatry, 152(7), 967.
Fernández-San-Martín, M. I., Masa-Font, R., Palacios-Soler, L., Sancho-Gómez, P., Calbó-Caldentey, C., & Flores-Mateo, G. (2010). Effectiveness of Valerian on insomnia: A meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 11(6), 505-511.
Foley, D., Ancoli-Israel, S., Britz, P., & Walsh, J. (2004). Sleep disturbances and chronic disease in older adults: results of the 2003 National Sleep Foundation Sleep in America Survey. Journal of Psychosomatic Research, 56(5), 497-502.
Halpern, J., Cohen, M., Kennedy, G., Reece, J., Cahan, C., & Baharav, A. (2014). Yoga for improving sleep quality and quality of life for older adults. Altern Ther Health Med, 20(3), 37-46.
Hasan, S., Byles, J. E., Mishra, G., & Harris, M. A. (2001). Use of sleeping medication and quality of life among older women who report sleeping difficulty. Australasian Journal on Ageing, 20(1), 29-35.
Jackson, M. L., Sztendur, E. M., Diamond, N. T., Byles, J. E., & Bruck, D. (2015). Chronic sleep difficulties in non-depressed young women: A longitudinal population-based investigation| NOVA. The University of Newcastle's Digital Repository.
Kline, C. E., Irish, L. A., Buysse, D. J., Kravitz, H. M., Okun, M. L., Owens, J. F., & Hall, M. H. (2014). Sleep hygiene behaviors among midlife women with insomnia or sleep-disordered breathing: the SWAN sleep study. Journal of Women's Health, 23(11), 894-903.
Leach, M. J., & Page, A. T. (2015). Herbal medicine for insomnia: A systematic review and meta-analysis. Sleep Medicine Reviews, 24, 1-12.
Léger, D., & Poursain, B. (2005). An international survey of insomnia: under-recognition and under-treatment of a polysymptomatic condition. Current Medical Research and Opinion, 21(11), 1785-1792.
Léger, D., Poursain, B., Neubauer, D., & Uchiyama, M. (2007). An international survey of sleeping problems in the general population. Current Medical Research and Opinion, 24(1), 307-317.
Leigh, L., Hudson, I. L., & Byles, J. E. (2015). Sleeping difficulty, disease and mortality in older women: A latent class analysis and distal survival analysis. Journal of Sleep Research.
Lichstein, K. L., Payne, K. L., Soeffing, J. P., Durrence, H. H., Taylor, D. J., Riedel, B. W., & Bush, A. J. (2007). Vitamins and sleep: An exploratory study. Sleep Medicine, 9(1), 27-32.
Liu, J., Hay, J., & Faught, B. E. (2013). The association of sleep disorder, obesity status, and diabetes mellitus among US adults—The NHANES 2009-2010 survey results. International journal of endocrinology, 2013.
McCaffrey, A. M., Pugh, G. F., & O’Connor, B. B. (2007). Understanding patient preference for integrative medical care: Results from patient focus groups. Journal of General Internal Medicine, 22(11), 1500-1505.
Moloney, M. E., Konrad, T. R., & Zimmer, C. R. (2011). The medicalization of sleeplessness: a public health concern. American Journal of Public Health, 101(8), 1429-1433.
Morin, C. M. (2010). Chronic insomnia: Recent advances and innovations in treatment developments and dissemination. Canadian Psychology/Psychologie Canadienne, 51(1), 31.
Ohayon, M. M. (2002). Epidemiology of insomnia: What we know and what we still need to learn. Sleep Medicine Reviews, 6(2), 97-111.
Pearson, N. J., Johnson, L. L., & Nahin, R. L. (2006). Insomnia, trouble sleeping, and complementary and alternative medicine: Analysis of the 2002 national health interview survey data. Archives of Internal Medicine, 166(16), 1775-1782.
Peng, W., Adams, J., Sibbritt, D. W., & Frawley, J. E. (2014). Critical review of complementary and alternative medicine use in menopause: focus on prevalence, motivation, decision-making, and communication. Menopause, 21(5), 536-548.
Roepke, S. K., & Ancoli-Israel, S. (2010). Sleep disorders in the elderly. Indian Journal of Medical Research, 131(2), 301-310.
Sánchez-Ortuño, M. M., Bélanger, L., Ivers, H., LeBlanc, M., & Morin, C. M. (2009). The use of natural products for sleep: A common practice? Sleep Medicine, 10(9), 982-987.
Sarsour, K., Kalsekar, A., Swindle, R., Foley, K., & Walsh, J. K. (2011). The association between insomnia severity and healthcare and productivity costs in a health plan sample. SLEEP, 34(4), 443.
Sivertsen, B., Krokstad, S., Mykletun, A., & Øverland, S. (2009). Insomnia symptoms and use of health care services and medications: The HUNT-2 study. Behavioral Sleep Medicine, 7(4), 210-222.
Sivertsen, B., Krokstad, S., Øverland, S., & Mykletun, A. (2009). The epidemiology of insomnia: Associations with physical and mental health.: The HUNT-2 study. Journal of Psychosomatic Research, 67(2), 109-116.
Smagula, S. F., Stone, K. L., Fabio, A., & Cauley, J. A. (2015). Risk factors for sleep disturbances in older adults: evidence from prospective studies. Sleep Medicine Reviews.
Sohl, S. J., Borowski, L. A., Kent, E. E., Smith, A. W., Oakley‐Girvan, I., Rothman, R. L., & Arora, N. K. (2015). Cancer survivors' disclosure of complementary health approaches to physicians: The role of patient‐centered communication. Cancer, 121(6), 900-907.
Stone, K. L., Ancoli-Israel, S., Blackwell, T., Ensrud, K. E., Cauley, J. A., Redline, S., . . . Cummings, S. R. (2008). Actigraphy-measured sleep characteristics and risk of falls in older women. Archives of Internal Medicine, 168(16), 1768-1775.
Taylor, D. J., Mallory, L. J., Lichstein, K. L., Durrence, H., Riedel, B. W., & Bush, A. J. (2007). Comorbidity of chronic insomnia with medical problems. SLEEP, 30(2), 213.
Theis, K. A., Helmick, C. G., & Hootman, J. M. (2007). Arthritis burden and impact are greater among US women than men: intervention opportunities. Journal of Women's Health, 16(4), 441-453.
Wang, P. S., Bohn, R. L., Glynn, R. J., Mogun, H., & Avorn, J. (2014). Hazardous benzodiazepine regimens in the elderly: Effects of half-life, dosage, and duration on risk of hip fracture. American Journal of Psychiatry, 158(6), 892-898.