Original Study| Volume 21, ISSUE 10, P1458-1463.e2, October 2020

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The Role of Cognitive Impairment, Physical Disability, and Chronic Conditions in the Association of Sleep Duration With All-Cause Mortality Among Very Old Adults



      This study aimed to examine the relationship between sleep duration and all-cause mortality, and to assess the role of cognitive impairment, physical disability, and chronic conditions on this association among very old adults.


      A prospective cohort study.

      Setting and Participants

      Within the Chinese Longitudinal Healthy Longevity Surveys, 17,637 oldest-old aged 80-105 years were followed up to 10 years (2005- 2014).


      Data on sleep duration at baseline were based on self-report and were categorized as short (<7 hour), moderate (7-9 hours), and long sleep (>9 hours). Information on cognitive function using the Mini-Mental State Examination (MMSE), physical disability using Activities of Daily Living (ADL), and chronic conditions including diabetes, heart disease, stroke, asthma, and cancer were collected at baseline based on a structured questionnaire. Information about vital status was ascertained and confirmed by a close family member or village doctor of the participant during the follow-up. Data were analyzed using Cox proportional hazards models, with adjustment for potential confounders.


      During the follow-up of 10 years, 11,067 (62.7%) participants died. The multivariate-adjusted hazard ratios (HRs) with 95% confidence interval (CI) for mortality were 1.03 (0.98-1.09) for short sleep and 1.13 (1.08-1.18) for long sleep compared with moderate sleep duration. In stratified analysis by cognitive impairment, physical disability, and chronic conditions, the risk of morality was present only among people with MMSE scores ≤24 but did not differ much when stratified by physical disability and chronic conditions. There was a statistically significant interaction between long sleep and cognitive impairment on mortality (P for interaction = .002).

      Conclusions and Implications

      Long sleep duration is associated with higher risk of mortality in very old adults independently of health conditions. Cognitive impairment may enhance this association. These findings suggest that health practitioners and families should be aware of the potential adverse prognosis associated with long sleep.


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        • Shan Z.
        • Ma H.
        • Xie M.
        • et al.
        Sleep duration and risk of type 2 diabetes: A meta-analysis of prospective studies.
        Diabetes Care. 2015; 38: 529-537
        • Nakakubo S.
        • Doi T.
        • Makizako H.
        • et al.
        Sleep duration and excessive daytime sleepiness are associated with incidence of disability in community-dwelling older adults.
        J Am Med Dir Assoc. 2016; 17: 768.e1-768.e5
        • Jike M.
        • Itani O.
        • Watanabe N.
        • et al.
        Long sleep duration and health outcomes: A systematic review, meta-analysis and meta-regression.
        Sleep Med Rev. 2018; 39: 25-36
        • Cappuccio F.P.
        • D'Elia L.
        • Strazzullo P.
        • Miller M.A.
        Sleep duration and all-cause mortality: A systematic review and meta-analysis of prospective studies.
        Sleep. 2010; 33: 585-592
        • Morgan K.
        • Hartescu I.
        Sleep duration and all-cause mortality: Links to physical activity and prefrailty in a 27-year follow up of older adults in the UK.
        Sleep Med. 2019; 54: 231-237
        • Wang C.
        • Bangdiwala S.I.
        • Rangarajan S.
        • et al.
        Association of estimated sleep duration and naps with mortality and cardiovascular events: A study of 116 632 people from 21 countries.
        Eur Heart J. 2019; 40: 1620-1629
        • Akerstedt T.
        • Ghilotti F.
        • Grotta A.
        • et al.
        Sleep duration, mortality and the influence of age.
        Eur J Epidemiol. 2017; 32: 881-891
        • Zhang J.
        • Jin X.
        • Li R.
        • et al.
        Influence of rapid eye movement sleep on all-cause mortality: A community-based cohort study.
        Aging (Albany NY). 2019; 11: 1580-1588
        • Liu F.
        • Zhang H.
        • Liu Y.
        • et al.
        Sleep duration interacts with lifestyle risk factors and health status to alter risk of all-cause mortality: The Rural Chinese Cohort Study.
        J Clin Sleep Med. 2018; 14: 857-865
        • Zhu Q.
        • Fan H.
        • Zhang X.
        • et al.
        Changes in sleep duration and 3-year risk of mild cognitive impairment in Chinese older adults.
        Aging (Albany NY). 2020; 12: 309-317
        • Friedman E.M.
        Self-reported sleep problems prospectively increase risk of disability: Findings from the Survey of Midlife Development in the United States.
        J Am Geriatr Soc. 2016; 64: 2235-2241
        • Zeng Y.
        • Feng Q.
        • Hesketh T.
        • et al.
        Survival, disabilities in activities of daily living, and physical and cognitive functioning among the oldest-old in China: A cohort study.
        Lancet. 2017; 389: 1619-1629
        • Lv Y.B.
        • Liu S.
        • Yin Z.X.
        • et al.
        Associations of body mass index and waist circumference with 3-year all-cause mortality among the oldest old: Evidence from a Chinese community-based prospective cohort study.
        J Am Med Dir Assoc. 2018; 19: 672-678.e4
        • Lv Y.B.
        • Gao X.
        • Yin Z.X.
        • et al.
        Revisiting the association of blood pressure with mortality in oldest old people in China: Community based, longitudinal prospective study.
        BMJ. 2018; 361: k2158
        • Lv X.
        • Li W.
        • Ma Y.
        • et al.
        Cognitive decline and mortality among community-dwelling Chinese older people.
        BMC Med. 2019; 17: 63
        • Suarez E.C.
        Self-reported symptoms of sleep disturbance and inflammation, coagulation, insulin resistance and psychosocial distress: Evidence for gender disparity.
        Brain Behav Immun. 2008; 22: 960-968
        • Cai H.
        • Shu X.O.
        • Xiang Y.B.
        • et al.
        Sleep duration and mortality: A prospective study of 113 138 middle-aged and elderly Chinese men and women.
        Sleep. 2015; 38: 529-536
        • Katzman R.
        • Zhang M.Y.
        • Qu O.Y.
        • et al.
        A Chinese version of the Mini-Mental State Examination; impact of illiteracy in a Shanghai dementia survey.
        J Clin Epidemiol. 1988; 41: 971-978
        • Mungas D.
        In-office mental status testing: A practical guide.
        Geriatrics. 1991; 46 (63, 6): 54-58
        • Katz S.
        • Ford A.B.
        • Moskowitz R.W.
        • et al.
        Studies of illness in the aged: The index of ADL, a standardized measure of biological and psychosocial function.
        JAMA. 1963; 185: 914-919
        • Angleman S.B.
        • Santoni G.
        • Von Strauss E.
        • Fratiglioni L.
        Temporal trends of functional dependence and survival among older adults from 1991 to 2010 in Sweden: Toward a healthier aging.
        J Gerontol A Biol Sci Med Sci. 2015; 70: 746-752
        • Rutten-Jacobs L.C.
        • Larsson S.C.
        • Malik R.
        • et al.
        Genetic risk, incident stroke, and the benefits of adhering to a healthy lifestyle: Cohort study of 306 473 UK Biobank participants.
        BMJ. 2018; 363: k4168
        • Kripke D.F.
        • Garfinkel L.
        • Wingard D.L.
        • et al.
        Mortality associated with sleep duration and insomnia.
        Arch Gen Psychiatry. 2002; 59: 131-136
        • Lam T.H.
        • Xu L.
        • Schooling C.M.
        • et al.
        Smoking and mortality in a prospective cohort study of elderly Chinese in Hong Kong.
        Addiction. 2015; 110: 502-510
        • Tamakoshi A.
        • Ohno Y.
        Self-reported sleep duration as a predictor of all-cause mortality: Results from the JACC study.
        Japan. Sleep. 2004; 27: 51-54
        • Castro-Costa E.
        • Dewey M.E.
        • Ferri C.P.
        • et al.
        Association between sleep duration and all-cause mortality in old age: 9-year follow-up of the Bambui Cohort Study, Brazil.
        J Sleep Res. 2011; 20: 303-310
        • Grandner M.A.
        • Hale L.
        • Moore M.
        • Patel N.P.
        Mortality associated with short sleep duration: The evidence, the possible mechanisms, and the future.
        Sleep Med Rev. 2010; 14: 191-203
        • Cheng G.H.
        • Malhotra R.
        • Ostbye T.
        • et al.
        Changes in nocturnal sleep and daytime nap durations predict all-cause mortality among older adults: The Panel on Health and Ageing of Singaporean Elderly.
        Sleep. 2018; 41
        • Soh A.Z.
        • Chee M.W.L.
        • Yuan J.M.
        • Koh W.P.
        Sleep lengthening in late adulthood signals increased risk of mortality.
        Sleep. 2018; 41
        • Hall M.H.
        • Smagula S.F.
        • Boudreau R.M.
        • et al.
        Association between sleep duration and mortality is mediated by markers of inflammation and health in older adults: The Health, Aging and Body Composition Study.
        Sleep. 2015; 38: 189-195
        • Kurina L.M.
        • McClintock M.K.
        • Chen J.H.
        • et al.
        Sleep duration and all-cause mortality: A critical review of measurement and associations.
        Ann Epidemiol. 2013; 23: 361-370
        • Lee J.S.
        • Auyeung T.W.
        • Leung J.
        • et al.
        Long sleep duration is associated with higher mortality in older people independent of frailty: A 5-year cohort study.
        J Am Med Dir Assoc. 2014; 15: 649-654
        • Fujisawa C.
        • Umegaki H.
        • Nakashima H.
        • et al.
        Complaint of poor night sleep is correlated with physical function impairment in mild Alzheimer's disease patients.
        Geriatr Gerontol Int. 2019; 19: 171-172
        • Mesas A.E.
        • Lopez-Garcia E.
        • Leon-Munoz L.M.
        • et al.
        Sleep duration and mortality according to health status in older adults.
        J Am Geriatr Soc. 2010; 58: 1870-1877
        • Sabeti S.
        • Al-Darsani Z.
        • Mander B.A.
        • et al.
        Sleep, hippocampal volume, and cognition in adults over 90 years old.
        Aging Clin Exp Res. 2018; 30: 1307-1318
        • Youngstedt S.D.
        • Kripke D.F.
        Long sleep and mortality: Rationale for sleep restriction.
        Sleep Med Rev. 2004; 8: 159-174
        • Grandner M.A.
        • Kripke D.F.
        Self-reported sleep complaints with long and short sleep: A nationally representative sample.
        Psychosom Med. 2004; 66: 239-241
        • Dantzer R.
        Cytokine-induced sickness behavior: Mechanisms and implications.
        Ann N Y Acad Sci. 2001; 933: 222-234
        • Lockley S.W.
        • Skene D.J.
        • Arendt J.
        Comparison between subjective and actigraphic measurement of sleep and sleep rhythms.
        J Sleep Res. 1999; 8: 175-183
        • Van Den Berg J.F.
        • Van Rooij F.J.
        • Vos H.
        • et al.
        Disagreement between subjective and actigraphic measures of sleep duration in a population-based study of elderly persons.
        J Sleep Res. 2008; 17: 295-302

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