Association Between Level of Sleep Quality and Demographic Variables among Older Persons in Pusat Aktiviti Warga Emas (PAWE) Selangor

Association Between Level of Sleep Quality and Demographic Variables among Older Persons


Introduction
Ageing is the process of becoming older. According to the Social and Welfare Malaysia portal, older person is a person who is 60 years old and above (JKM, 2017). Ageing refers to a gradual and time related to a biological process that takes place such as degenerative processes which overtake regenerative or growth processes (Rattan, 2006).
Preparing for an ageing population in Malaysia, the government takes action to create Pusat Aktiviti Warga Emas (PAWE) as a medium to occupy them with daily activities.
According to the goal National Health Policy of Older Person, the purpose of PAWE is to obtain maximum health for the older person through integrated and comprehensive health and health-related services. PAWE is designed to give older persons opportunities to involve in social participation and continue the role as part of the community. PAWE was established up to 60 centres covering each parliamentary area in Malaysia. The ultimate purpose of PAWE is to improve the quality of life.
Sleep is a natural resting period in order to recuperate after daily exhaustion. Good sleep is essential for both physical and mental health (Asghari, Farhadi, Kamara and et al., 2012). The benefit of good sleep leads to the optimal level of occupational performance, participation and engagement in everyday life.
Sleep is essential for the functioning and quality of life. Insufficient sleep can lead to metabolic dysfunction, obesity, hypertension, heart attack, stroke (Altman et al., 2012). Deep sleep is defined as a habitual sleep length of at least 9 hours (Frange et al., 2014).
According to Occupational Therapy Practice Framework 4th edition (2020), sleep and rest are components from the performance area that are evaluated and implemented to produce good quality of life. Previous studies about sleep quality among older person are still limited and scarce. Thus, the result of this study will provide information to care provider about level of sleep quality amongst this population. Therefore, this information is useful to it provide a better picture about relationship between sleep quality and demographic variables of older persons. This paper is aimed to identify the association between the level of sleep quality and demographic data among older persons in PAWE in Selangor.

Literature Review
Sleep is the behavioural action show by the level of arousal, cognitive and sensory with is unresponsiveness with the surrounding. The sleep process involves behavioural and physiologic process. Usually, alternate changing between rapid eye movement (REM) and non-REM (NREM) are cycling for the sleep episode. When a person is sleeping, it will be showing some characteristics such as a postural recline, no volunteer physical or behavioural movement and closed both eyes, (Carscadon et al., 2011).

The Sleep Cycle
A study conducted by Carscadon et al (2011) has mentioned that sleep has four-stage cycles to complete. In stage one, the onset of sleep for healthy adults usually only a few minutes around one to seven-minute. At this stage, calling a person's name, a light touch, a slow sound like quietly closing the window, making the person who sleeps been easily awake. At this stage, sleep has easily been a disturbance and easily awake because stage one is to have a relationship with a low arousal threshold. Furthermore, to its role in the initial waketo-sleep transition, stage one sleep occurs as a transitional stage throughout the night. A common sign of severely sleep disturbance is increased at stage one.
In stage two are known-rapid eye movement (REM), continues sleep from stage one is around ten to twenty-five minutes. This stage required more stimuli to awake. Sleep is continuous, progressive and high-voltage slow-wave activity increase.
In stage three, it is carry on activity from stage one which non-rapid eye movement (NREM) have high voltage (at least 75 µV) slow-wave. The high voltage slow-wave activity at this stage is more progressive. The action takes a few minutes in the first cycle before the transition to stage four.
In stage four, 50% high voltage slow-wave activity of NREM around 20 to 40 minute occurs. In this stage, a broad stimulation is required to make a person awake and arousal from sleep compared in an early stage at one and two. The person in this stage four is achieved deep sleep or know as delta sleep. Delta sleep is a slow wave from combination stage three and four.

The Importance to Study Sleep Quality
Some mental, behaviour and physical are a major issued in public. Usually, the issued have related to sleep quality. Bad mood, easily angry, confused, weakness and not alert are some symptom that shows if a person lack in sleep. Sometimes, we can't differentiate between sleep quality symptoms related to the significant issued. There are limited studies about the relationship between the role of Occupational Therapy with sleep. The important to studying about sleep can help occupational therapy to understand more about sleep, especially in the elderly. Poor sleep quality can lead to a mental symptom (Augner, 2011).

How the Issues/variables Lead to a Research Problem
In Pittsburgh Sleep Quality Index (PSQI), question number 5a until 5j are assets sleep disturbance. From this study, we can find the most sleep disturbance in the elderly. Environment, pain, snoring, coughs, wake up in the middle night, used bathroom, and difficulty to initial sleep is a possible factor of sleep disturbance. Hock set al (1988), stated from his survey 100 participants were involved, and the result show majority sleep disturbance is nocturia which is 59 %, factor cough and breathing issued are respectively 16%, and pain is 12% and other reason such as environment, dreaming and muscle cramps. The elderly who have a chronic illness can lead to insomnia, especially some elderly who taking medication. Some medication can have disturbed sleep quality. Thus, the result from the study can arrange the proper intervention for the elderly due to the sleep pattern of the elderly.
According to Wolkove et al. (2007), ageing has related to the level of sleep quality. Sustain in staying sleep until morning is some issued in the elderly. Usually, almost the elderly have insomnia that disturbed in falling sleep in the early stage and maintained the sleep (Neubauer, 1999). Madrid-Valero et al (2017) Stated age is related to poor sleep quality. He also noted that females have poor sleep quality compare to the man. This is because the female always has secondary issued like menopause, stress, depression, and anxiety.

Research Method Study Design
This is a quantitative research survey using a cross-sectional approach, which is a type of observational study design. Quantitative studies are analyzed using statistics (mathematic method) of numeric data to explain particular questions or phenomena (Muijs, 2011). Descriptive research or cross-sectional is to determine the characteristics in population like social demographic data (age, weight, marital status). It cannot describe cause, effect, and relationship between different variables. It recorded by the population but not change the variable (Song & Chung, 2010).

Study Setting
The study setting refers to the location where data are collected; for this study, data were collected at seven (7)

Sampling Design
Selection of sample to fit in the study called a purposive sample. A purposive sample is researching selected for their sample in specific criteria.

Inclusion Criteria of Sampling
1. Age 65 and above.

Literate with good command in English and Malay language.
Exclusion Criteria of Sampling 1. The elderly have a severe physical impairment. 2. Elderly people dependent on Activity Daily Living 3. Elderly need assistance in Insrustment Activity Daily Living

Instruments
Self-administered questionnaires that are valid and reliable are chosen and be using for this data collection. Two assessment used are: 1. Demographic Form 2. Pittsburgh Sleep Quality Index (PSQI)

Statistical Methods
Data collection from the questionnaire is filled to the Microsoft Excel spreadsheet. The item is categorized by theme. Next, date in excel was imported into the Statistical Package for Social Sciences (SPSS, version 21.0 (SPSS Inc. Chicago IL, USA) use to analyze all data. The data will generate output, such as in tables, graphs, and statistics. The descriptive statistical analysis was used to calculate variables such as weight, age, gender, educational level, working status, number of being taking care, marital status, living with family members and number of illnesses.

Level of Sleep Quality
Based on the result in Table 3 show p-value is 0.008 means there is a significant association between level sleep quality with gender among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, an accepted alternative hypothesis. Based on graph one show frequency sleep quality and gender on 180 subjects. Elderly who in poor sleep quality 56.3 % (40) are male and 75.2 % (82) are female. In good sleep quality, 43.7% (31) are male, and 24.8% (27) are female. H0: There is no association between sleep quality and age Ha: There is an association between sleep quality and age

Hypothesis two: Sleep quality with age
Based on the result in Table 4 shows p-value is 0.838 means there is no significant association between level sleep quality with weight among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, reject the alternative hypothesis. Based on a graph 4.4.2 to show the frequency of sleep quality and age in 180 subjects. Elderly in poor sleep quality in age 65 to 75 years' old which is 66.9% (101) and 33.1% (50) is good in quality of sleep, follow by 76 to 85 years' old 72% (18) are poor sleep quality and 28% (7) is good sleep quality and supported by 86 to 94 years old is 75% (3) is poor sleep quality and 25% (1) is good sleep quality. There show in the age of 65 to 75 years old commonly have poor sleep quality. H0: There is no association between sleep quality and number of medical illness Ha: There is an association between sleep quality and number of medical illness Based on the result in Table 5 shows p-value is 0.805 means there is no significant association between level sleep quality with the number of medical illnesses among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (twotailed)). Therefore, reject the alternative hypothesis.

Hypothesis three: Sleep quality with a number of medical illness
Based on Table 5, the result shows the frequency of sleep quality and the number of medical illness in 180 subjects. The elderly who have one medical illness is 50% (1) in good sleep quality, and 50% (1) (1) show good sleep quality. For elderly who have six number of medical illness is 100% (1) indicate poor sleep quality and 0% in good sleep quality. Based on the result shows the number of medical illnesses, sleep quality becomes poor. In this study show, four and three number of medical illnesses are higher in poor sleep quality. H0: There is no association between sleep quality and weight Ha: There is an association between sleep quality and weight

Hypothesis four: Sleep quality with weight
Based on the result in Table 6, show the p-value is 0.028 means there is a significant association between level sleep quality with weight among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, an accepted alternative hypothesis.
Based on Table 6, the frequency of sleep quality and weight on 180 subjects. The elderly who weight below 39 is 100% (2) show poor sleep quality and 0%. For the elderly who age 40kg to 50kg is 73.7% (14) represent poor sleep quality, and 26.3% (5) represent good sleep quality. For the elderly who weight 51kg to 60kg is 83.3% (35) represent poor sleep quality, and 32.7% (16) represent good sleep quality. For the elderly who weight 61kg to 70kg is 67.3% (33) represent poor sleep quality, and 32.7% (16) represent good sleep quality. For the elderly who weight 71kg to 80kg is 53.7% (22) represent poor sleep quality, and 46.3% (19) represent good sleep quality. For the elderly who weight 81kg to 90kg is 52.2% (12) represent poor sleep quality, and 47.8% (11) represent good sleep quality. For the elderly who weight 90kg above 100% (4) represent poor sleep quality, and 0% represents good sleep quality. This study show elderly who weight 51kg to 60 kg show the higher poor sleep quality, followed by 61kg to 70kg and followed by 71kg to 80kg. H0: There is no association between sleep quality and working status Ha: There is an association between sleep quality and working status Based on the result in Table 7 show p-value is 0.017 means there is a significant association between level sleep quality with working status among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, an accepted alternative hypothesis.

Hypothesis five: Sleep quality with working status
Based on Table 7, it shows the frequency of working status in 180 subjects. For the elderly who are not working, 77.4%(72) are poor sleep quality, and 22.6%(21) are good sleep quality. For the elderly who are retired 55.9%(38) are poor sleep quality and 44.1%(30) are good sleep quality. For the elderly who are self-employed, 71.4%(10) are poor sleep quality, and 28.6%(4) are good sleep quality. For the elderly who are agricultural, 40%(2) are poor sleep quality, and 60%(3) are good sleep quality. This study show elderly who are not working show an increased in poor sleep quality. H0: There is no association between sleep quality and number of taking care Ha: There is an association between sleep quality and number of taking care

Hypothesis six: Sleep quality with a number of taking care
Based on the result in Table 8 show p-value is 0.772 means there is no significant association between level sleep quality with the number of taking care among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (twotailed)). Therefore, reject the alternative hypothesis.
Based on Table 8 shows the frequency sleep quality and number of family being take care of 180 subjects. For the elderly who have one family to take care to represent 70.1% (47) indicate poor sleep quality and 29.9%(20) indicate good sleep quality. For the elderly who have two family members to take care to represent 61.3%(38) indicate poor sleep quality and 38.7%(24) indicate good sleep quality. For the elderly who have three family members to take care to represent 75.8%(25) indicate poor sleep quality and 24.2%(8) indicate good sleep quality. For the elderly who have four family members to take care to represent 62.5%(5) indicate poor sleep quality and 37.5% (3) show good sleep quality. For the elderly who have five family members to take care to represent 66.7%(4) indicate poor sleep quality and 33.3% (2) show good sleep quality. For the elderly who have six family members to take care to represent 75%(3) indicate poor sleep quality and 25%(1) indicate good sleep quality. On this study, the small number of family being take care show increase in poor sleep quality. H0: There is no association between sleep quality and marital status Ha: There is an association between sleep quality and marital status Based on the result in Table 9, show the p-value is 0.099 means there is no significant association between level sleep quality with marital status among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, reject the alternative hypothesis.

Hypothesis seven: Sleep quality with marital status
Based on Table 9 shows the frequency of sleep quality and marital status on 180 subjects. For the elderly who are single status represent 71.4%(5) in poor sleep quality and 28.6%(2) in good sleep quality. For the elderly who are married status represents 62.8% (81) in poor sleep quality and 37.2%(48) in good sleep quality. For the elderly who are divorced status represents 75%(15) in poor sleep quality and 25%(5) in good sleep quality. For the elderly who are widow status represent 87.5%(21) in poor sleep quality and 12.5%(3) in good sleep quality. This study shows the elderly who are married status have poor sleep quality. H0: There is no association between sleep quality and stay with family Ha: There is an association between sleep quality and stay with family Based on the result in Table 10, show the p-value is 0.464 means there is no significant association between level sleep quality with stay with family among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, reject the alternative hypothesis.

Hypothesis eight: Sleep quality with stay with family
Based on Table 10 shows the frequency of sleep quality based on stay with family in 180 subjects. For the elderly who are staying with the family show, 66.9%(107) are poor sleep quality, and 33.1%(53) are good in sleep quality. For the elderly who are not stay with the family show, 75%(15) are poor sleep quality, and 25%(5) are good in sleep quality. This study show elderly who are staying with family show poor sleep in quality. Master Degree 2 0 (0) 2 (100%)

Hypothesis nine: Sleep quality with a level of education
H0: There is no association between sleep quality and the level of educational Ha: There is an association between sleep quality and the level of educational Based on the result in Table 11 show p-value is 0.044 means there is a significant association between level sleep quality with the level of education among elderly attending PAWE in Selangor state. The significant value is set as the p-value (Set α=0.05 (two-tailed)). Therefore, accept the alternative hypothesis.
Based on Table 11 shows the frequency sleep quality and level of education based on 180 subjects. For the elderly who are not school show, 78.6% (22) indicates poor sleep quality and 21.4% (6) indicate good sleep quality. For the elderly who are primary school show, 69.6% (39) indicates poor sleep quality and 30.4% (17) indicate good sleep quality. For the elderly who are secondary school show, 70.6% (24) are indicate poor sleep quality and 29.4% (10) indicate good sleep quality. For the elderly who are SPM show, 60.5% (23) are indicate poor sleep quality and 39.5% (15) indicate good sleep quality. For the elderly who are diploma show, 73.3% (11) indicates poor sleep quality and 26.7% (4) indicate good sleep quality. For the elderly who are degree show, 14.3% (1) indicates poor sleep quality and 85.7% (6) indicate good sleep quality. The elderly who are master's degree show 100% (2) indicates poor sleep quality. This study shows that primary school shows an increased in poor sleep quality.

Conclusion
Sleep quality in the elderly based on demographic data shows that the elderly has poor sleep quality even involved in a community activity. The participant was choosing is actively come to Pusat Aktiviti Warga Emas in Selangor.