Yang HY, Li L, Yu LJ, Bian GL. Associations of social isolation with sleep duration and sleep quality in the elderly: Mediating influence of depression. World J Psychiatry 2025; 15(4): 102447 [DOI: 10.5498/wjp.v15.i4.102447]
Corresponding Author of This Article
Guo-Lin Bian, MD, Professor, Department of Psychiatry, The Affiliated Kangning Hospital of Ningbo University, No. 1 Zhuangyu South Road, Zhuangshi Street, Zhenhai District, Ningbo 315000, Zhejiang Province, China. biangl123@163.com
Research Domain of This Article
Geriatrics & Gerontology
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Hong-Ying Yang, Lian Li, Lu-Jie Yu, Guo-Lin Bian, Department of Psychiatry, The Affiliated Kangning Hospital of Ningbo University, Ningbo 315000, Zhejiang Province, China
Author contributions: Bian GL conceived the project; Li L and Yu LJ collected and analyzed the data; Yang HY and Li L wrote the first draft of the manuscript; Bian GL provided expert suggestions and revised the manuscript; All authors contributed to the article and approved the submitted version.
Supported by Ningbo Medical and Health Brand Discipline, No. PPXK2024-07; and Ningbo Top Medical and Health Research Program, No. 2022030410.
Institutional review board statement: Ethics approval was obtained from the Ethics Committee of Affiliated Kangning Hospital of Ningbo University, No. NBKNYY-2023-LC-29.
Informed consent statement: Written informed consent was obtained from all participants.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Data cannot be made available online due to legal and ethical restrictions and are available from the corresponding author upon reasonable request at biangl123@163.com.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Guo-Lin Bian, MD, Professor, Department of Psychiatry, The Affiliated Kangning Hospital of Ningbo University, No. 1 Zhuangyu South Road, Zhuangshi Street, Zhenhai District, Ningbo 315000, Zhejiang Province, China. biangl123@163.com
Received: October 18, 2024 Revised: December 25, 2024 Accepted: February 7, 2025 Published online: April 19, 2025 Processing time: 158 Days and 19.6 Hours
Abstract
BACKGROUND
Sleep disorders are common health problems in the elderly. The effect of social isolation on sleep duration and sleep quality remains unclear in the Chinese community-dwelling elderly.
AIM
To explore the associations of social isolation with sleep duration and sleep quality in community-dwelling elderly people.
METHODS
A total of 7762 community-dwelling elderly people aged 60 years and older in Ningbo were recruited from June 2022 to August 2022. Data were collected using a questionnaire. Multivariate logistic regression was used to analyze the associations of social isolation with sleep duration and sleep quality. The KHB mediating effect model was used to test the mediating effect of depression and anxiety on these associations.
RESULTS
Among the participants, 2656 (34.2%) had abnormal sleep duration (< 6 hours or > 8 hours), 1115 (14.4%) had poor sleep quality, and 917 (11.8%) had social isolation. After adjusting for confounding factors, compared with the elderly without social isolation, the odds ratios (95%CI) of abnormal sleep duration and poor sleep quality in the elderly with social isolation were 1.49 (1.29-1.73) and 1.32 (1.09-1.59), respectively. Depression partially mediated the associations of social isolation with sleep duration and sleep quality, accounting for 5.68% and 9.87% of the mediating effect, respectively.
CONCLUSION
Social isolation was found to be associated with sleep duration and sleep quality in community-dwelling elderly people. More attention should be paid to social isolation in the elderly.
Core Tip: Sleep disorders are common health problems in the elderly. Social isolation was found to be associated with sleep duration and sleep quality in community-dwelling elderly people. This study aims to explore the associations of social isolation with sleep duration and sleep quality, and the mediating effect of depression.
Citation: Yang HY, Li L, Yu LJ, Bian GL. Associations of social isolation with sleep duration and sleep quality in the elderly: Mediating influence of depression. World J Psychiatry 2025; 15(4): 102447
Sleep disorders are common health problems in the elderly. In 2019, the prevalence of sleep disorders in the elderly aged 60 years and older in China was approximately 41.2%[1]. Sleep plays an important role in maintaining mental health, cognitive processing, memory consolidation, and neuroprotection[2]. Sleep disorders mainly include a series of sleep-related clinical syndromes such as difficulty in falling asleep and maintaining sleep, abnormal sleep structure and rhythm, and decreased sleep quantity, quality, and efficiency[3]. Abnormal sleep duration and poor sleep quality have a certain impact on cardiovascular diseases[4], stroke[5], mental diseases[6], and dementia[7] in the elderly.
Social isolation is an objective state of lack of social contact or insufficient social interaction with others, which can be measured using indicators such as whether or not one is living alone; frequency of social interactions with friends, relatives, and others; and frequency of participation in social activities. Social isolation is common in the elderly[8,9]. One study estimated that 24.0% of the community-dwelling elderly aged over 65 in the United States were socially isolated[10]. Studies in Qingdao[11] and Shanghai[12] found that 29.7% and 28.9% of the community-dwelling Chinese elderly were socially isolated. Previous studies have shown a positive correlation between objective social isolation and sleep disorders[13,14]. However, the effect of social isolation on sleep duration and sleep quality remains unclear in the Chinese community-dwelling elderly. Therefore, this study aimed to analyze the effect of social isolation on sleep duration and sleep quality in the community-dwelling elderly aged 60 years and older in Ningbo and to provide a scientific basis for the prevention and management of sleep disorders in this population.
MATERIALS AND METHODS
Study design
A multi-stage cluster random sampling method was used to conduct a face-to-face questionnaire survey among elderly participants aged ≥ 60 years in Ningbo from June 2022 to August 2022. We first randomly selected two towns or streets in each district (county or city) in Ningbo and then randomly selected one community/village in each town or street. All of the participants who met the inclusion criteria in the selected communities/villages were included in our study. The inclusion criteria were as follows: (1) Age ≥ 60 years and a resident of Ningbo for more than 1 year; (2) Voluntary participation in the study; (3) Having the ability to understand our questionnaires; and (4) No history of serious mental illness. A total of 7840 elderly people aged 60 years and older were surveyed, of whom 78 people who did not complete the questionnaire were excluded. Finally, 7762 elderly people were included in the study. This study was reviewed by the Ethics Review Board of Ningbo Kangning Hospital (approval number: NBKNYY-2023-LC-29). All of the participants or their guardians signed the informed consent before the investigation.
A self-administered paper questionnaire was used to collect data on socio-demographic characteristics, namely, age, gender, education level (< 8 or ≥ 8 years), marital status (married or other), residential location (urban or rural), and pension (< 2000, 2000-5000, or > 5000 China yuan per month); data on lifestyle characteristics, namely, regular diet (yes or no), sedentary time (< 3, 3-5, or > 5 hours per day), physical exercise (< 3 or ≥ 3 times per week), smoking history and drinking history, chronic disease history, and self-rated health (good, intermediate, or poor); and data on psychological problems (depression and anxiety), social isolation, and sleep status (sleep duration and quality). The investigators were all uniformly trained before the survey.
Definitions of variables
Social isolation was assessed using three questions as follows: “Do you live with other people?”, “Do you visit a friend or family member at least once a month?”, and “Do you participate in social activities at least once a week, such as parties, public welfare activities, or volunteer work?” The response options for these questions were “Yes” and “No”. If the participants had negative responses to two or three questions, they were considered to be socially isolated[15,16]. The remaining participants who were not socially isolated were deemed as the reference group in this study.
Depressive symptoms were assessed using the validated 9-item Patient Health Questionnaire (PHQ-9). The scale includes nine items, each of which is scored on a range of 0 (not at all) to 3 (nearly every day), with a total score ≥ 5 points suggesting the presence of depressive symptoms[17]. Anxiety symptoms were assessed using the validated 7-item Generalized Anxiety Disorder questionnaire (GAD-7). The scale has seven items, each of which is scored on a range of 0 to 3, with a total score ≥ 5 points suggesting the presence of anxiety symptoms[17]. Cronbach's alpha for the PHQ-9 and GAD-7 was calculated as 0.87 and 0.90, which shows that have good internal consistency.
Sleep duration was assessed using the question “In the past month, how many hours (not equivalent to bedtime) did you usually sleep per day?” The possible answers were “6 hours”, “6-8 hours” and “> 8 hours”, following large cohort studies such as the United Kingdom Biobank[2], the NHANES[18], and the China Kadoorie Biobank[19]. Those who answered “6 hours” or “> 8 hours” comprised the abnormal sleep duration group, while those who answered “6-8 hours” comprised the normal sleep duration group[19]. Sleep quality was assessed using the question “How many days in a week do you often find it difficult to fall asleep at night or wake up”? The possible answers were “sleep well every day”, “1-2 days per week”, “3-4 days a week”, and “5-7 days a week”. Those who answered “sleep well every day” or “1-2 days per week” comprised the good sleep quality group, while those who answered “3-4 days per week” or “5-7 days per week” comprised the poor sleep quality group[20].
Statistical analysis
The participants’ baseline characteristics were compared using the t-test for continuous variables and the χ2 test for categorical variables. Multivariate logistic regression analysis was used to analyze the associations of social isolation with sleep duration and sleep quality. The mediating effects of depression and anxiety were measured using the KHB mediating effect model. An α value of 0.05 with a two-sided P value < 0.05 was considered statistically significant. EpiData 3.1 software was used to establish the database. SPSS 22.0 and STATA 15.0 were used for statistical description and analysis.
RESULTS
A total of 7762 elderly people aged 60 years and older (mean age: 71.1 years) were included in the study. Of these, 3486 (44.9%) were men and 4276 (55.1%) were women; 2656 (34.2%) had abnormal sleep duration (< 6 hours or > 8 hours); 1115 (14.4%) had poor sleep quality; and 917 (11.8%) were socially isolated (Table 1).
The female participants were statistically significantly younger than the male participants (70.9 years vs 71.4 years, P < 0.05). The proportions of participants who lived in urban areas, had a high level of education, were married, had a high pension income, had a low frequency of physical exercise, were smokers, drank alcohol, and had self-rated health were higher among men than among women (all P < 0.05). The proportions of participants who had a history of chronic disease, abnormal sleep duration, poor sleep quality, and social isolation were lower among men than among women (all P < 0.05). No significant differences were observed in sedentary time, regular diet, depression, and anxiety between men and women (all P > 0.05). All results are provided in Table 1.
Multivariate logistic regression analysis showed that social isolation was significantly associated with sleep duration and sleep quality in all three models. Moreover, in model 3, which was adjusted for age, gender, residence location, education level, pension, sedentary time, physical exercise, regular diet, self-rated health, depression, and anxiety as the confounding factors, the odds ratios (ORs) (95%CI) of abnormal sleep duration and poor sleep quality in the elderly with social isolation were 1.49 (1.29-1.73) and 1.32 (1.09-1.59), respectively (Table 2).
Table 2 The association of social isolation with sleep duration and sleep quality.
In the gender subgroups, the results showed that after adjusting for confounding factors, social isolation was associated with both abnormal sleep duration and poor sleep quality in female participants, with ORs (95%CI) of 1.54 (1.28-1.85) and 1.33 (1.06-1.68), respectively. However, in male participants, social isolation was significantly associated with abnormal sleep duration (OR = 1.36, 95%CI: 1.06-1.74, P < 0.05) but not with poor sleep quality (OR = 1.25, 95%CI: 0.88-1.76, P > 0.05; Table 3).
Table 3 The association of social isolation with sleep duration and sleep quality in different age and sex.
In the age subgroups, as shown in Table 3, social isolation was associated with abnormal sleep duration (OR = 1.56, 95%CI: 1.32-1.84) and poor sleep quality (OR = 1.42, 95%CI: 1.15-1.76) in the elderly aged < 80 years (P < 0.05). However, no significant association was observed between social isolation and sleep duration or sleep quality in the elderly aged ≥ 80 years (P > 0.05).
Depression partially mediated the associations of social isolation with sleep duration and sleep quality, with the ORs (95%CI) for its indirect effect being 1.02 (1.01-1.04) and 1.03 (1.01-1.05) for the respective associations, accounting for 5.68% and 9.87% of the mediating effect, respectively. Anxiety had no mediating effect on the associations of social isolation with sleep duration and sleep quality (Table 4). Table 5 shown the mediating effects of depression on social isolation, sleep behaviors in different age and sex.
Table 4 The mediating effects of depression and anxiety on social isolation, sleep behaviors.
Of the community-dwelling elderly in Ningbo recruited in our study, 11.8% had social isolation, 34.2% had abnormal sleep duration, and 11.4% had poor sleep quality. Social isolation was associated with sleep duration and sleep quality in our elderly participants, and depression was found to partially mediate these associations.
After adjusting for confounding factors, the likelihood of abnormal sleep duration and poor sleep quality was respectively 1.49 times and 1.32 times higher in the elderly with social isolation than in those without social isolation, which is consistent with previous studies[9,13,14]. After adjusting for confounding factors, the high prevalence of social isolation in the elderly at baseline was associated with poor sleep quality 6 years later, with an incidence rate ratio (95%CI) of 1.13 (1.04-1.24)[21]. Another large-sample study[22] found that compared with the elderly living alone, those living with relatives or friends had better sleep quality, with an OR (95%CI) of 1.17 (1.05-1.30). Chen et al[23] also found that lower levels of social participation were associated with worse sleep outcomes. Specific aspects and outcome of social isolation, such as lack of social support[24] and loneliness[25] may have an impact on sleep quality. Studies have found that social isolation has adverse effects on the neuroendocrine system, the cardiovascular system, the central nervous system, and mental health[26]. Biologically, social isolation and sleep may be linked through their shared relationship with the hypothalamic-pituitary-adrenal (HPA) axis[14,27]. Studies have shown that social isolation increases the activation of the HPA axis in humans[26] and that insomnia and wakefulness are also associated with increased HPA axis activity[28]. Therefore, social isolation may affect sleep in the elderly by activating the HPA axis.
In the present study, social isolation was found to be associated with both sleep duration and sleep quality in women, but only with sleep duration in men. Gender differences in work of social isolation may be partially attributable to sexually dimorphic reactions. In social isolated male mice, increased dopamine release was observed during subsequent social interactions, leading to enhanced pleasure and fostering a strong desire for social participation[29]. However, this phenomenon was not observed in female mice. Thus, this could explain why the effects of social isolation appear to be mitigated in men[30]. In our study, both sleep duration and sleep quality were associated with social isolation in the elderly aged < 80 years, but no significant association was found between social isolation and sleep duration or sleep quality in the elderly aged ≥ 80 years. The possible reason is that younger elderly people have more unhealthy lifestyles[31], such as a higher prevalence of smoking[32] and a lower intake of vegetables[33]. These results suggest that the main target population of interventions for social isolation should be the younger elderly.
Social isolation was associated with sleep duration and sleep quality, objective social isolation in the elderly can be improved by implementing relevant policies and measures. Therefore, early identification of and intervention for social isolation in the elderly may be an important measure to improve their abnormal sleep duration and poor sleep quality. Interventions for decreasing social isolation among the elderly include: (1) Social skills training: Improving the interpersonal communication skills of the elderly; (2) Strengthening social support: Providing regular contact, care, or companionship for the elderly; (3) Increasing social contact: Increasing opportunities for the elderly to participate in social interactions, such as organizing social welfare activities; and (4) Social cognition training: Changing the social cognition of the elderly[34].
In addition, depression was found to partially mediate the associations between social isolation and sleep duration and sleep quality. Social isolation may affect sleep in the elderly by activating the HPA axis[26], which was a major stress-depression response system in the human body. The result suggested the need to pay more attention to depression in the elderly. Previous studies have shown that anxiety mediates the relationship between social isolation and sleep problems in young adults[35,36]. However, anxiety was found to have no significant mediating effect in our study. This inconsistency in the results may be due to the age and racial differences between the two study populations, In Chinese elderly, social isolation was not associated with anxiety score at 6-month follow-up[12], we got the same result. Thus, further research is needed to explore the specific reasons.
In this study, we quantified the extent to which social isolation was associated with abnormal sleep duration and poor sleep quality after controlling for various confounding factors. However, this study still has some limitations. First, this was a cross-sectional study, and the strength and direction of the causal associations were insufficient, so they can only provide theoretical support for intervention studies. Thus, future longitudinal studies of the relationships of social isolation with sleep will be needed to infer causality. In addition, the sleep duration and sleep quality of the elderly were self-reported; hence, potential information bias, relative to objective measurements, cannot be ruled out. Finally, although self-reported loneliness variables are known to be correlated with social isolation, they were not adjusted as confounding factors in this study. Considering that they are both objective and subjective manifestations of loneliness, the self-reported loneliness variables are not expected to have any influence on the conclusion.
CONCLUSION
In conclusion, more attention should be paid to the status of social isolation of the elderly in Ningbo, and relevant measures should be taken to reduce their social isolation and improve their sleep duration and sleep quality.
ACKNOWLEDGEMENTS
The authors express their gratitude to the doctors from the Office of Mental Health and the Community Health Service Center who were involved in the data collection.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: China
Peer-review report’s classification
Scientific Quality: Grade C, Grade C, Grade D
Novelty: Grade B, Grade B, Grade C
Creativity or Innovation: Grade C, Grade C, Grade C
Scientific Significance: Grade B, Grade B, Grade C
P-Reviewer: Wang T; Zhang XD S-Editor: Li L L-Editor: A P-Editor: Zhang XD
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