Neuropathic Pain Correlated With Poor Sleep Quality in The Elderly in Banjar Tegallulung Bon Biu Village Kecamatan Blahbatuh Kabupaten Gianyar***
Widiastuti, M*, Budiarsa, IGN **, Widyadharma PE** , Utami DKI**, Adnyana IMO** Neurology Department, Faculty of Medicine, Udayana University/Sanglah General Hospital
Denpasar, Bali
ABSTRACT
BACKGROUND
The incidence of pain increases with age. Neuropathic pain are common in elderly patient. Neuropathic pain and poor sleep quality is a common complaint reported in elderly patients. At the community as much as 5-50% of the elderly suffer from chronic pain, while in the nursing home the prevalence is 45-85%. The prevalence of sleep disorders in the elderly quite high, about 67%. A person with neuropathic pain affects the quality of sleep.
PURPOSE
To dermine neuropathic pain correlated with poor sleep quality in the elderly in Banjar Tegalulung, Desa Bon Biu Kecamatan Blahbatuh Kabupaten Gianyar.
METHOD
This study was a cross-sectional study. Sampling was carried out on all elderly in Banjar Tegallulung Desa Bon Biu Kecamatan Blahbatuh Kabupaten Gianyar using consecutive method. Leeds Asseement of Neuropathic Symptoms and Signs (LANSS) was applied to measure neuropathic pain and the Pittsburgh Sleep Quality Index (PSQI) to determine the quality of sleep. Descriptive analysis and lambda test to determine the correlation between neuropathic pain and quality of sleep in elderly. Data analised using SPSS 16.0 for windows.
RESULTS
Fifty samples were recruited with the proportion of 66% woman with a mean age of 67,40 ± 6,80 years. The proportion of neuropathic pain was 44% and poor sleep quality as much as 58%. Subjects who had neuropathic pain with poor sleep quality was 42%. There is a significant correlation (p = 0.010) and (r = 0.571), between neuropathic pain with poor sleep quality in the elderly.
CONCLUSION
Neuropathic pain has significant corelation with poor sleep quality in the elderly.
Keywords: sleep quality, elderly, neuropathic pain.
===================================================================== *Resident of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General Hospital Denpasar
**Lecturer of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General Hospital Denpasar
INTRODUCTION
The changes in demographic characteristics of the world population serves as critical challenge for clinicians. The number of population aged >65 years is increasing rapidly.
In developing countries, the number of elderly population is increasing rapidly. By 2050, the ratio of population aged 65 years to 15-64 years would be three times bigger.1,2,3 The number of elderly in the world is increasing as a result of increased life expectancy and decreased mortality rate. In 2006, the number of elderly citizens in Indonesia was ± 19 millions with life expectancy of 66.2 years. This number was estimated to reach 23.9 millions (9.77%) by 2010, with life expectancy of 67.4 years and in 2020 it is estimated to have achieved 28.8 millions (11.34%), with life expectancy of 71.1 years. From those numbers, in 2010, the number of elderly who live in cities were 12.380.321 (9.58%) and in rurals were 15.612.232 (9.97%).3 By 2020 the number of elderly in Indonesia is estimated to rank as the fourth after China, India, and the USA.1
Vitality and health start to decline middle age. Degenerative diseases start to develop during this period. However, vitality and health in elderly are highly varied. Statistics show that elderly with severe health problems are only about 15-25%, and this percentage increases as they’ re getting older. Also, the elderly who aren’ t able to carry out the Activities of Daily Living (ADL) are only 5-15%, depends on the age.1
Most elderly are at high risk of experiencing sleeping disorders due to aging and other etiological factors such as neurologic and vascular disorders, depression, and diabetes melitus. During the process of aging, physical and mental changes take place, followed by changes in sleep pattern that are different from people of younger age.4
The incidence of pain increases as the aging process continues. Pain is suffered by a quarter of elderly. In the community, 25-50% of elderly have chronic pain, while in nursing homes, the prevalence is estimated to be 45-85%.6 The condition of patients with chronic neuropathic pain is often worsened by the existence of insomnia and sleeping disorders.
The research about neuropathic pain and its correlation to sleep quality in elderly is scarce in Indonesia. This research was therefore initiated to determine the correlation between neuropathic pain to poor sleep quality in elderly in Banjar Tegalulung, Bon Biu Village, Blahbatuh Sub-district, Gianyar.
METHODS
This research was an analytic observational research with cross sectionaldesign conducted in Banjar Tegalulung, Bon Biu Village, Blahbatuh Sub-district, Gianyar district in July 31st 2014.
Samples were obtained with non-random consecutive sampling method. The inclusion criteria for this research were age of ≥ 60 years, cooperative, and provided consent to participate in the research. Elderly who were unable to do their daily activities independently and had severe psychiatric disorders (schizophrenia) were excluded in this research. All elderly who came to Banjar Tegalulung, Bon Biu Village, Blahbatuh Sub-district, Gianyar district were screened for their demographic data. The sexes of the research subjects were determined to male and female based on interview with nominal measurement scale. The educational level was defined as the educational stage that was able to be experienced, and was categorized as no school, elementary school, junior high school, senior high school, and higher education. The data were obtained from the interview.
The Pittsburgh Sleep Quality Index (PSQI) was used to measure subjective sleep quality. This scale consisted of 7 domains of latency, duration, quality, efficiency of sleep habit, sleep disorder, the use of sleep-inducing medications, and disturbance of bodily functions at day time.
PSQI consists of 9 item of questions with each question being scored as 0-3. The score 3 showed extreme negative value in Likert scale.7 The total PSQI scores were obtained by summing up the scores from 1-7 with a range of 0-21. The instrument validity of PSQI in the research conducted by Cunha et al. (2008) was 0.89, while its reliability was 0.88 as measured by Cueller et al. (2008).7
Sleep quality was considered as good if total score (global score) ≤ 5 and it was poor if the total value (global score) > 5.8 The scores were then dichotomized to good and poor sleep quality.
items of examination of sensory dysfunction.9 The LANSS scale in Indonesian language was able to be used as a believable research instrument with kappa coefficient agreementof 0.76.10 Scores of 12 or more were classified as neuropathic pain while scores of under 12 were classified as nociceptive pain. The scores were then dichotomized to yes/no.
Statistical analysis was conducted with SPSS16.0 for windows. Descriptive analysis was used to determine the characteristics of sleep quality in elderly. To determine the correlation of poor sleep quality with cognitive function impairment, Lambda correlation test was used.
RESULTS
A number of 50 subjects participated, consisted of 17 (34%) males and 33 (66%) females with mean age of 67.40 ± 6.80. Most research subjects (n=14; 28%) experienced elementary school, and most of them (n=21; 42%) worked as farmers (table 1).
[image:3.595.117.477.292.613.2]The proportion of neuropathic pain was 44%, and the proportion of good sleep quality was 44% and poor sleep quality was 58% (table 1).
Table 1. Characteristics of the research subjects
Variables Numbers %
Age Age (mean± SD) 67,40 (± 6,80)
Sex Male
Female 17 33 34 66 Educational achievement No school Elementary school Junior high school Senior high school Higher education 13 14 8 9 6 26 28 16 18 12
Occupation Civil public employee Private employee Entrepreneur Labor Farmers Others 5 6 3 8 21 7 10 12 6 16 42 14 Neuropathic pain Yes No 22 28 44 56 Sleep quality Good Bad 21 29 42 58
Table 2 showed that most subjects (n=21; 95.45%) suffered from neuropathic pain and had poor sleep quality. Lambda correlation test revealed value of r=0.571. This showed moderate correlation between neuropathic pain and sleep quality with significance of p=0.010.
Table 2
Group
Sleep quality
Total N(%)
r p
Good N(%)
Poor N(%)
Neuropathic pain
Yes 1 (4.55%) 21(95.45%) 22(100%)
0.571 0.010
No 20 (71.43%) 8(28.57%) 28 (100%)
Total 21(42.0%) 29(58.0% ) 50(100%)
DISCUSSSION
The proportion of poor sleep quality in this research was 58% (N=29), with 95.45% (N=21) subjects who had neuropathic pain complained about poor sleep quality. The proportion of neuropathic pain in research subjects was high (42%). Neuropathic pain often happens in elderly. The research obtained a prevalence of joint diseases in age of 55 of more than 40%. They usually come to the public health center with complaints of back pain, dizziness, joint pain, abdominal pain, or waist pain. No different results were observed in developed countries in terms of pain due to musculoskeletal problems and physical disability in elderly.
Pain is defined as a sensory experience of discomfort and is correlated to potential of tissue damage. Pain is a symptom commonly experienced by a person, and it has diverse causes and symptoms, location, quality, frequency, nature, and co-occurring symptoms. The pain in elderly is a complaint that is commonly encountered in the primary health care. The complaint of pain might affect one’ s health status and quality of life, especially in elderly. Inadequate pain management has been correlated to the feeling of being depressed, isolation from social relationship, disability, and the development of sleeping problems.11
Chronic pain in elderly might render them highly dependent to other people, feeling depressed, losing confidence, and this condition is often followed by sleep disorders. Often, patients with chronic neuropathic pain has their conditions worsened by insomnia and sleep disorders. In the United States, it is reported that the occurrence of chronic pain is 15% in the population, in which 50% happens in elderly. Many studies have demonstrated positive correlation between pain intensity and sleep quality. It was stated that 65% patients with chronic pain had poor sleep quality. Sleep disorders can take the form of being easily awaken at night, waking up too early in the morning, having trouble to initiate sleeping, or trouble to maintain sleep. 12,13,14
Among the patients who come to pain clinics, 50-70% report the development of sleep disorder and 20% is accompanied by severe depression. An epidemiologic study showed that these patient also showed higher level of anxiety compared to people without pain. Other research have observed the existence of positive correlation between pain intensity and poor sleep quality.5
Poor sleep quality is frequently found in elderly, and it affects about 50% elderly, compared to 20% in young adults. This high percentage of poor sleep quality is in concordance with the result of the research conducted by Khusnul Khasanah and Wahyu Hidayati in 2012.
chronic pain such as neuropathic pain can be a significant cause of impaired sleep quality and it might interfere with normal sleeping stages.14
This descriptive research had some weaknesses. This research only observed the existence of neuropathic pain without further classification of the etiology of pain or duration of pain. Sleep quality was only differentiated to good sleep quality and poor sleep quality, without any differences between insomnia or hypersomnia. This research was a descriptive one with cross sectional data collection so it wasn’ t able to determine the degree of correlation between the two variables, and this research didn’ t use randomization, and had small sample size. However, this research had some strength due to its nature as a community based study. In the future, it is warranted to conduct a cohort research with bigger sample size, along with good assessment of variables of neuropathic pain and sleep quality using more specific instruments.
CONCLUSION
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