Review article
Prevalence, associated factors and treatment of sleep problems in adults with intellectual disability: A systematic review

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Abstract

In people with intellectual disability (ID), impaired sleep is common. Life expectancy has increased in this group, and it is known that in general population sleep deteriorates with aging. Therefore the aims of this systematic review were to examine how sleep problems are defined in research among adults and older people with ID, and to collect information on the prevalence, associated factors and treatment of sleep problems in this population. PubMed, EMBase, PsycINFO and Web of Science were searched for studies published between January 1990 and August 2011. All empirical studies covering sleep problems in adults with ID were included, and assessed on quality (level of evidence), using a slightly modified version of the SIGN-50 methodology checklist for cohort studies. Of 50 studies that were included for systematic review, one was of high quality, 14 were well conducted, 14 were well conducted but with a high risk of bias, and 21 were non-analytical. The reported estimated prevalence rates of sleep problems in adults with ID ranged from 8.5% to 34.1%. A prevalence of 9.2% was reported for significant sleep problems. Sleep problems were associated with the following factors: challenging behavior; respiratory disease; visual impairment; psychiatric conditions; and using psychotropic, antiepileptic and/or antidepressant medication. Little information was found on older people specifically. Two studies reported treatment effects on sleep problems in larger populations; their findings suggest that non-pharmaceutical interventions are beneficial. Research on the prevalence, associated factors and treatment of sleep problems in adults and older people with ID has mainly focused on subjectively derived data. The definitions used to describe a sleep problem are not uniform, and associations are mainly described as correlations. In order to give recommendations for clinical practice further research is needed, involving objective measurements and multivariate analysis.

Highlights

► The estimated prevalence of sleep problems in adults with ID ranges from 8.5% to 34.1%. ► Challenging behavior, dementia, respiratory disease, visual impairment, psychiatric conditions and medication use are associated with sleep problems. ► Research on sleep problems in adults with ID has mainly focused on subjectively derived data. ► The definitions used to describe a sleep problem are not uniform, and associations are mainly described as correlations.

Introduction

Sleep problems are common in the aging general population. Foley, Monjan, Brown, Simonsick, Wallace, & Blazer (1995) interviewed 9282 community-living persons aged 65 years and over and reported that 43% experience difficulties initiating or maintaining sleep (Foley et al., 1995). Meta-analyses of the change in sleep patterns during the lifespan demonstrate an increase in sleep latency and night waking frequency, and a decrease in total sleep time and sleep efficiency (ratio of time spent asleep to the amount of time spent in bed) with aging (Floyd et al., 2000, Ohayon et al., 2004). Symptoms of insomnia can lead to poorer quality of life, cognitive decline, depression, disability in instrumental activities of daily living (ADLs) and institutionalization (Vaz Fragoso & Gill, 2007). In contrast, a cohort study of 3820 persons aged 60 years and over showed that self-reported long sleep duration was associated with higher mortality rates, even in those with better health status (Mesas, Lopez-Garcia, Leon-Munoz, Guallar-Castillon, & Rodriguez-Artalejo, 2010).

For people with intellectual disability (ID), previous reviews on sleep problems indicate that disruptions of sleep and sleep–wake rhythms are common (Espie, 2000), and the prevalence of sleep problems is higher than in the general population (Doran, Harvey, & Horner, 2006). The estimated prevalence of sleep problems in people with ID varies from 13% to 86%, depending on the age of the studied participants, used diagnostic method and definitions used for a sleep problem (Didden & Sigafoos, 2001). Although these reviews are valuable, they were not done systematically and cover both children and adults (Didden and Sigafoos, 2001, Doran et al., 2006, Espie, 2000).

A criterion to diagnose a sleep problem is that the individual experiences his sleep quality as a burden (ICSD-R, 2001). However, for people with ID it is often hard to communicate their personal sleep experience, and professional caregivers may selectively report problems that disturb themselves or other clients (Brylewski & Wiggs, 1998). This may complicate the detection and subsequent treatment of sleep problems. People with ID nowadays live longer than previously expected, and aging in people with a mild level of ID is even similar to that in the general population (Patja, Livanainen, Vesala, Oksanen, & Ruoppila, 2000). Accordingly, a better insight into sleep problems in adults and older people with ID is first important for optimal care, and second important for working towards a unified and broadly accepted definition for sleep problems in this population.

Therefore, the aim of this systematic review is first to examine how sleep problems are defined in research among this population. Secondly we aim to give an overview of existing literature on sleep problems in adults and older people with ID, in order to investigate the prevalence rate, associated factors (e.g. personal characteristics, medical history) and treatment of sleep problems, taking methodological quality into account.

Section snippets

Search strategy

A systematic literature search was conducted using the electronic databases Medline/PubMed, EMBase, PsycINFO and Web of Science. We selected various different search terms, in order to reduce the chance of missing important information.

Terms for intellectual disability were: mental retardation, intellectual disability, intellectually retarded, intellectually disabled, mental disability, mentally disabled, idiocy, mental deficiency, learning disability, learning disorder, learning disturbance,

Results

The initial search resulted in 1217 studies. Finally, fifty studies met the inclusion criteria.

Fig. 1 shows the flow chart of data selection.

Searching the bibliographies of included studies did not result in additional relevant references that met the selection criteria.

Fifty studies were included for the systematic review. Two studies described the same study population (Brylewski and Wiggs, 1999, Brylewski and Wiggs, 1998). In six studies a clear definition of a sleep problem in the studied

Discussion

This is the first systematic review on the prevalence, associated factors and treatment of sleep problems in adults and older people with intellectual disability (ID). Fifty studies matched the inclusion criteria, of which one study was of high-quality, 14 were well conducted, 14 well conducted but with a high risk of bias and 21 were non-analytical. Informant-based interviews were the most frequently used research method. Sleep problems were most often named as settling problem, night waking

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