Mature Women Sex Sleep
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In addition, it has been observed that the modifying role of sex on the association between sleep and frailty might mainly occur among women older adults. Previous studies indicated that sleep complaint, sleep duration, and sleep-breathing disorders were only associated with frailty in older women but not in men.11,14,15 However, it is non-conclusive since men and women sleep differently. For instance, women tend to self-report less sleep duration; insomnia is more commonly reported by women than men, while the risk of obstructive sleep apnea (OSA) predominates in men.17 Results from observational studies comprised of men participants have shown that prolonged sleep latency, poor subjective sleep quality, and nocturnal hypoxemia were associated with frailty/or mortality.18,19 In light of these facts, it seems that the variability of the association between sleep and frailty regarding sex difference needs to be addressed.
Table 1 shows the distribution of the characteristics of men and women with or without frailty. In both men and women, participants with frailty were older, less educated, had a higher percentage of clinically significant depression symptoms and cognitive decline, a lower proportion of alcohol consumption, and a higher percentage of comorbidities than older adults in the non-frail group. Use of medications related to nervous system was more frequent in frail women than in non-frail (33.7% vs 16.9%, p < 0.001) but not in men. Regarding sleep disorders, the report of insomnia was significantly higher in older adults with frailty in men (47.1% vs 25.6%, p < 0.001) and in women (54.8% vs 30.0%, p < 0.001). The percentage of somnolent men was higher among frail than non-frail (33.8% vs 17.2%, p = 0.001). It seems that the percentage of high risk of OSA was higher among frail men than non-frail men but there was no statistical difference (35.3% vs 25.7%, p= 0.08). In contrast, frail women were more likely to have high risk of OSA compared to non-frail women, and a higher reported sleepiness, although this was not significant. Sleep duration and the report of naps were not different according to frailty condition, neither in men nor in women.
Table 2 shows the results of the logistic regression models for the association between sleep disorders and frailty. In the entire study sample, unadjusted and adjusted model show that having prior diagnosis of OSA was not associated with frailty. In contrast, the unadjusted model shows that compared to older adults without risk of OSA, people with risk of OSA were 76% more likely to present frailty (95% CI: 1.26, 2.46). This association remained significant in the model adjusted for sex, age, education, marital status, insomnia, sleepiness, sleep duration, napping, current alcohol consumption, tobacco use, clinically significant depression symptoms, cognitive decline, comorbidities, and use of nervous system medications (OR = 1.59, 95% CI: 1.07, 2.38). The presence of insomnia increased the odds of frailty in the unadjusted (OR = 2.79, 95% CI: 2.03, 3.85) and adjusted (OR = 2.11, 95% CI: 1.41, 3.16) logistic regression analysis. In the unadjusted model, sleepiness was significantly associated with a greater possibility of frailty (OR = 1.91, 95% CI: 1.34, 2.72); however, when controlling for the covariates, the association did not maintain statistical significance (OR = 1.38, 95% CI: 0.90, 2.12). Self-assessed sleep duration was not associated with frailty.
Regarding the stratified analysis by sex, neither having prior diagnosis of OSA nor risk of OSA were associated with frailty in men (Table 2). Having insomnia significantly increased the chances of frailty both in the unadjusted (OR = 2.59; 95% CI: 1.56, 4.28) and adjusted models (OR = 1.88; 95% CI: 1.01, 3.52). Table 2 shows sleepiness as a possible variable related to frailty (OR = .46, 95% CI: 1.44, 4.20) but after the adjusted analysis, the association lost statistical significance (OR = 1.51, 95% CI: 0.79, 2.88). Regarding self-assessed sleep duration, no association with frailty was observed in any model.
In the case of women, participants with prior diagnosis of OSA were significantly more likely to have frailty (unadjusted OR = 3.90; 95% CI: 1.17, 13.03). Although no significant association was seen when the model was controlled for covariates (OR = 4.02; 95% CI: 0.99, 16.22). It was observed that the participants with risk of OSA were more likely to be frail in the unadjusted (OR = 1.99; 95% CI: 1.29, 3.08) and in the adjusted model (OR = 1.84; 95% CI: 1.05, 3.22) compared to women with no OSA. Women with insomnia faced greater chances of frailty (adjusted OR: 2.38; 95% CI: 1.35, 4.20) compared to women without insomnia. Neither sleepiness nor self-assessed sleep duration was associated with frailty in women.
The results that emerge from this research concur with other studies that have shown a relationship between sleep and frailty.10 Although it is still not entirely conclusive, some previous research suggests that the association of sleep complaints, sleep quality, and insomnia on frailty may be differentiated according to sex.6,15,29
In the particular case of sleep breathing disorders, Endeshaw et al reported that the apnea-hypopnea index >30 significantly increased the chances of being frail only in the group of women and not in the group of men.14 In a cross-sectional study made up of men, Ensrud et al showed that an index of respiratory events (RDI > 15) was associated with frailty.19 However, after studying the same cohort of men for 3.4 years, Ensrud et al observed that OSA did not increase the incidence of frailty, but it did increase the risk of death and the only respiratory disorder related to frailty and death was hypoxemia during sleep defined with 10% of the recording time with saturation less than 90%.18 On the other hand, in a cohort of women, Spira et al found no effect between the apnea-hypopnea index and the incidence of difficulty in moving (a criterion that may be similar to the walking speed of frailty).30 Because there are few investigations that have addressed the relationship between OSA (either measured with a questionnaire or with polysomnography) and frailty,14,18,19 it is important that other studies resume this issue and confirm the phenomenon, as well as the pathophysiological mechanisms involved in these apparent differences between men and women.
The association between insomnia and frailty has scarcely been explored with non-conclusive findings. A previous cross-sectional study in this cohort had also reported sex differences with respect to the association between insomnia and frailty, showing that insomnia is an independent factor for frailty in women.29 However, it missed to consider other co-occurring sleep disturbances such as risk of OSA or daytime sleepiness. In the study by Vaz Fragoso et al where insomnia was defined based on the insomnia severity index, an association with frailty was found to loses statistical significance when adjusting for comorbidities and use of medications.16 A recent study that investigated the association between insomnia symptoms and frailty found that sleep-onset insomnia but no sleep-maintenance explained frailty through reduced physical performance.31 In our study, the association between insomnia and frailty was significant globally and in women even in the model adjusted for comorbidities and medication use; the existence of an ethnic or cultural factor that explains this discrepancy cannot be ruled out and further studies are required in this regard.
As diseases are not mutually exclusive in real life, insomnia co-exists with OSA in a group of patients,25 thus, we assessed its association with frailty. First, results revealed that the prevalence of co-morbid insomnia and risk of OSA in older adults was 1.8%. As far as we know, there is no report of COMISA in older adults but this value is similar to the prevalence reported in an Australian population-based study which found 1.5% of adults with COMISA evaluated at disorder level.32 Second, in line to what we found analyzing the risk of OSA and insomnia as independent variables, when we took into account COMISA, we found that older adults who faced OSA-alone, insomnia alone or co-morbid insomnia and OSA had greater chances of frailty than older adults with no such sleep disorders. The association between COMISA and frailty, although imprecise due to small sample size, appears to be more than the simple additive effect of each factor and this finding suggests that COMISA is relevant not only to clinical settings but also in the general population.32 However, further studies to assess this association are warranted.
The fact that insomnia, risk of OSA and COMISA explained frailty may be expected as they have been related to hyperactivity of the adrenocortical axis. OSA is characterized by repeated interruptions of breathing during sleep, with consequent nocturnal hypoxemia and sleep fragmentation. Apneas markedly disrupt Phase 3 of sleep and REM sleep.33 Since it has been suggested that hypoxia could be a pathway that promotes sympathetic activation, it could be thought that such activation could promote oxidative stress34 which has been previously related with frailty.35 For their part, sleep fragmentation and insomnia promote a state of hypervigilance that is also associated with an increase in sympathetic activity and the adrenocortical axis36 derived from which the levels of inflammatory molecules such as interleukin-6 and C-reactive protein as well as catabolic processes, increase the deterioration of the organism, affect the immune system that would lead to frailty in older adults.37 Given that prevalence of insomnia and risk of OSA in this study sample were high and being disorders for which there is an effective pharmacological and non-pharmacological treatment, screening of older adults should be part of a routine health assessment in this age group.
In this study, we observed a significant association between sleepiness and frailty in the unadjusted statistical analysis for the whole sample and in men, but it was lost in the adjusted analysis. This differs from the work of Vaz Fragoso et al who found a strong association between sleepiness and frailty.16 This discrepancy, despite the use of the same instrument and cut-off point to define sleepiness, could be due to older age, schooling and a higher percentage of women in the study by Vaz Fragoso; additionally, the study by Vaz Fragoso et al did not include any OSA assessment tool. In contrast, Ensrud et al reported, for a male cohort, that both in the cross-sectional and longitudinal analysis, the association between daytime sleepiness and frailty is lost in the adjusted statistical models, while the perception of poor sleep quality as well as nocturnal hypoxemia increased the risk of frailty or death.18,19 Given the discordant results, more studies are required on the relation between excessive sleepiness and frailty. 59ce067264