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J Sleep Med Disord. Author manuscript; available in PMC 2015 May 24. Published in final edited form as: J Sleep Med Disord. 2014 ; 1(2): .

Relationship between Visual Impairment, Insomnia, Anxiety/ Depressive Symptoms among Russian Immigrants Azizi Seixas1,*, Alberto R. Ramos2, Georgiana M Gordon-Strachan3, Vilma Aparecida da Silva Fonseca4, Ferdinand Zizi1, and Girardin Jean-Louis1

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1Department

of Population Health, New York University School of Medicine, USA

2Department

of Neurology, University of Miami, USA

3The

University of the West Indies, Jamaica

4Universidade

Federal Fluminense, Brazil

Abstract Background—Little is known about the association between visual impairment and insomnia symptoms in elderly populations. The purpose of this study was to ascertain associations between self-reported visual impairments and insomnia symptoms in a community-based sample of Russian immigrants.

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Method—Sample consisted of 307 community-residing Russians (ages: 25–95 years, mean=72.64 ± 9.62; women=54% and men=46%). Semi-structured interviews assessed healthcare needs and physical health characteristics. Collected demographic and health-related data were analyzed using SPSS 19.0. Results—Overall, 93% reported at least one of several major health problems: visual impairment (48.4%), hypertension (53%), diabetes (25.7%), arthritis (52.8%), cancer (10.5%), weight problems (34.1%), and anxiety/depressive symptoms (43%), 62% had an insomnia diagnosis. Unadjusted logistic regression analysis showed that individuals with visual impairment were nearly three times as likely as those without to report insomnia symptoms [OR = 2.73, p < 0.01; 95% CI = 1.68–4.48]. Adjusting for the presence of socio demographic variables reduced the odds to 2.68; further adjustment for social isolation and anxiety and depressed symptoms reduced the odds to 2.20.Anxiety/depression mediated the relationship between visual impairment and insomnia.

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Conclusion—Individuals with visual impairment have twice the odds of reporting insomnia independent of anxiety/depression and social isolation, two common problems affecting quality of life in that population. Keywords Insomnia; Visual impairment; Anxiety and Depression

Copyright © 2014 Seixas et al. Corresponding author: Azizi Seixas, Center for Healthful Behavior Change, Department of Population Health, New York University School of Medicine, 550 First Avenue, VZ30 6th Floor, 629D, New York, 10016. Tel: 646-501-2672; Fax: 212.263.4201; [email protected].

*

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INTRODUCTION

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Individuals with visual impairment are at risk for sleep disturbances and sleep-disordered breathing [1]. Specifically, studies indicate that individuals with central serous chorio retinopathy (CSC) [2], sleep depth changes [3], and glaucoma [4, 5] are at risk for obstructive sleep apnea (OSA). Other visual impairments such as glaucoma, blindness, non arteritic anterior ischemic optic neuropathy, poor ocular health [6] and diabetic retinopathy [7] are associated with sleep-disordered breathing and circadian rhythm disruptions. Recent studies have shown that sleep problems, due to visual impairment such as complete blindness, can lead to more debilitating conditions (e.g., delayed or advanced sleep-phase syndrome and irregular sleep-wake cycles), which can lead to insomnia and circadian rhythm disorders [8]. Although progress has been made in understanding associations between visual impairment and insomnia symptoms among individuals with blindness, very little research has been done evaluating potential effects of visual impairment on circadianrelated sleep disturbances. Worse yet, little have been done to delineate the role of psychological well-being on those relationships.

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There is a paucity of data evaluating the associations of visual impairment with insomnia, anxiety, and depression. There is strong evidence that visual impairment is independently linked to anxiety and depression [9]; insomnia itself is linked to anxiety and depression [10]. In a sample of 900 participant’s ages 75 years or older, researchers found that 13.5% of individuals with visual impairment, compared with 4.6% of those with good vision, were two and a half times more likely to report depressive symptoms. These investigators argued that people with visual impairment are more likely to experience impairment in activities of daily living and functioning, which may increase risk for depression. Investigators found that visual impairment mediated the relationship between ambient illumination and depression. Specifically, lower exposure to ambient illumination due to visual impairment caused reduced melatonin levels, thus potentially increasing risk for depressive symptoms [11]. The relationship of insomnia to anxiety and depression is bidirectional [12]. Some studies indicate that insomnia is a risk factor for anxiety and depression symptoms [13], while others suggest that individuals suffering from anxiety and depression are at an increased risk for insomnia symptoms partly because they form part of the diagnostic symptomatology of anxiety and depression [14]. One epidemiological study found that individuals with insomnia were nine times more likely to report depression and seventeen times more likely to report anxiety, compared with those without insomnia [15]. The purpose of this study was to ascertain associations between self-reported visual impairment and insomnia symptoms in a community-based sample of Russian immigrants. We also explored whether anxiety and/ or depression (as a single variable) mediated the relationship between visual impairment and insomnia symptoms.

MATERIALS AND METHODS Participants (N= 307) were urban Russian immigrants residing in Brooklyn, NY (age range = 25 to 95 years, mean= 72.5, SD = 9.6). We assessed the health characteristics of sample of Russian immigrants through semi-structured interviews. Surveys were conducted in English

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and Russian by bilingual social workers (English and Russian) in various community centers. Procedures and measures We ascertained information about age, sex, marital status, education, and spoken language. In addition, information about history of hypertension, diabetes, stroke, snoring, cancer, pain, arthritis, anxiety and/or depression (as a single variable), visual impairment and insomnia were provided by participants.

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Self-reported visual impairment was obtained based on the following question “do you have vision problems”. Categorical responses were obtained (yes=1 versus no=0). Insomnia was defined as difficulty initiating sleep, difficulty maintaining sleep, or early morning awakenings [16] and was converted into a binary variable (yes/no). Social Isolation was measured by a question about whether the individual lived alone (yes=1 versus no=0). Statistical analysis

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Frequency and measures of central tendency were used for sample description. All variables were examined for normality and tested for co linearity. Fisher’s Exact Test was employed to assess differences in categorical variables. Insomnia was categorized based on the participant’s reports of any of the three insomnia complaints. Participants with no insomnia complaints were used as the reference. We performed multivariate logistic regression with insomnia as the outcome, adjusting for socio demographic measures (i.e., age, sex, marital status, education, and language) and medical factors (i.e., depression, pain, and arthritis). All explanatory factors were simultaneously adjusted in the model, providing independent estimates of the strength of the associations between candidate predictors and the dependent measure. Sobel mediation analysis was conducted using β coefficients and standard errors for independent variable (visual impairment) and mediation variable(anxiety and depression) based on the following equation: Y= B0 + B1X+ B2M + e.

RESULTS AND DISCUSSION

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Eighty-nine percent of the volunteers had an education of High School or more than high school; 27% were married and 73% were single, divorced, or separated. Forty-one percent lived alone, whereas 59% lived either with a spouse, their children, a family member, or a friend. Overall, 93% reported at least one of several major health problems: vision (48%), hearing (26%), breathing (13%), hypertension (53%), snoring (28%), diabetes (25.7%), arthritis (52.8%), cancer (10.5%), weight problems (34.1%), anxiety and depression (68.1%). Approximately sixty-two percent reported insomnia symptoms (Table 1). Individuals who were: obese (65.4%), hypertensive (74.2%), suffered from arthritis (72.2%), reported anxiety and depression symptoms (72.2%), pain (64.1%), and visual impairment (73%) all had an insomnia diagnosis (Table 2). Unadjusted logistic regression analysis showed that individuals with visual impairment were nearly three times as likely than those without to report insomnia symptoms [OR = 2.73, p < 0.01; 95% CI = 1.68–4.48]. Further adjustments for age, gender, language, and marital status revealed a 6% reduction in the odds ratio (OR =2.68, p < .001, 95% CI =1.58–4.53] (Model J Sleep Med Disord. Author manuscript; available in PMC 2015 May 24.

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1), while the model adjusting for social isolation, anxiety and depressed moods showed a 48% reduction in these odds ratios [OR = 2.198, p < 0.01; 95% CI = 1.26–3.84], (Table 3). Sobel mediation analysis indicated that anxiety and depression (as a combined binary variable, no=0 yes=1) significantly mediated the relationship between visual impairment and insomnia Y= −1.67(constant) + 0.79 visual impairment + 1.45 Anxiety/Depression + e, p=. 016 (Figure 1). We observed a significant association between visual impairment and insomnia symptoms in a sample of Russian immigrants living in Brooklyn, NY. This association remained significant even after adjustment for known covariates. Our models showed that socio demographic variables including age, gender, language and marital status minimally attenuated the odds ratio, but social isolation and anxiety and depressive symptoms substantially reduced the odds ratio.

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While social isolation is an important variable to consider in such analyses, in our study anxiety/depressive symptoms mediated the relationship between visual impairment and insomnia. Our findings are consistent with studies showing that comorbid visual impairment and anxiety/depressive symptoms are associated with insomnia symptoms [9–10, 12–15].

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Additionally, these individuals with visual impairment and insomnia symptoms are at risk for impaired social functioning [17–19]; anxiety [20]; cognitive deficits [21]; depression [22–28]; Type 2 Diabetes [29]; circadian disruption potentially leading to sleep problems [30]; lower quality of life [19]. They often incur high healthcare costs [30], are less likely to seek, be referred to, or use rehabilitation services, and have poor rehabilitation outcomes [31, 32]. Perhaps, rehabilitation programs should include activities of daily living (ADL) and psychosocial interventions when treating individuals with comorbid visually impairment and insomnia symptoms. Although the homogeneity of our sample limits our ability to generalize our findings, we believe our finding that visual impairment and insomnia symptoms are highly comorbid can be replicated in other groups. Future studies should investigate: a) the prevalence of circadian rhythm disorder and insomnia among the visually impaired; b) whether circadian rhythm de-synchronization causes insomnia; and c) which biological and psychological mechanisms necessitate the relationship between visual impairment and insomnia and circadian rhythm disorder.

CONCLUSION

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Our study showed that visual impairment was associated with anxiety, depression, and insomnia symptoms in a sample of Russians from Central Brooklyn. Those with visual impairment had twice the odds of reporting insomnia symptoms. This association was mediated by symptoms of anxiety and depression.

Acknowledgments SUPPORT This work was supported by funding from the NIMHD (R01MD007716) and the NINDS (U54NS081765).

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ABBREVIATIONS ADL

Activities of Daily Living

CSC

Central Serous Chorioretinopathy

OSA

Obstructive Sleep Apnea

References

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1. Waller EA, Bendel RE, Kaplan J. Sleep disorders and the eye. Mayo Clin Proc. 2008; 83:1251– 1261. [PubMed: 18990324] 2. Leveque TK, Yu L, Musch DC, Chervin RD, Zacks DN. Central serous chorioretinopathy and risk for obstructive sleep apnea. Sleep Breath. 2007; 11:253–257. [PubMed: 17457629] 3. Saunamäki T, Jehkonen M, Huupponen E, Polo O, Himanen SL. Visual dysfunction and computational sleep depth changes in obstructive sleep apnea syndrome. Clin EEG Neurosci. 2009; 40:162–167. [PubMed: 19715178] 4. Lin CC, Hu CC, Ho JD, Chiu HW, Lin HC. Obstructive sleep apnea and increased risk of glaucoma: a population-based matched-cohort study. Ophthalmology. 2013; 120:1559–1564. [PubMed: 23601803] 5. Chen HY, Chang YC, Lin CC, Sung FC, Chen WC. Obstructive sleep apnea patients having surgery are less associated with glaucoma. J Ophthalmol. 2014; 2014:838912. [PubMed: 25206977] 6. Dhillon S, Shapiro CM, Flanagan J. Sleep-disordered breathing and effects on ocular health. Can J Ophthalmol. 2007; 42:238–243. [PubMed: 17392846] 7. Shiba T, Sato Y, Takahashi M. Relationship between diabetic retinopathy and sleep-disordered breathing. Am J Ophthalmol. 2009; 147:1017–1021. [PubMed: 19268888] 8. US Food and Drug Administration. FDA approves Hetlioz: first treatment for non-24 hour sleepwake disorder in blind individuals [news release]. 2014 9. Evans JR, Fletcher AE, Wormald RP. Depression and anxiety in visually impaired older people. Ophthalmology. 2007; 114:283–288. [PubMed: 17270678] 10. Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, depression, and anxiety. Sleep. 2005; 28:1457–1464. [PubMed: 16335332] 11. Jean-Louis G, Kripke D, Cohen C, Zizi F, Wolintz A. Associations of ambient illumination with mood: contribution of ophthalmic dysfunctions. Physiol Behav. 2005; 84:479–487. [PubMed: 15763587] 12. Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res. 2006; 40:700–708. [PubMed: 16978649] 13. Neckelmann D, Mykletun A, Dahl AA. Chronic insomnia as a risk factor for developing anxiety and depression. Sleep. 2007; 30:873–880. [PubMed: 17682658] 14. Jansson-Fröjmark M, Lindblom K. A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. J Psychosom Res. 2008; 64:443– 449. [PubMed: 18374745] 15. Casimir GJ, Jean-Louis G, Butler S, Zizi F, Nunes J, Brady L. Perceived insomnia, anxiety, and depression among older Russian immigrants. Psychol Rep. 2010; 106:589–597. [PubMed: 20524564] 16. The international classification of sleep disorders: Diagnostic and coding manual. Vol. 18. Westchester, IL: American Academy of Sleep Medicine; 2005. p. 297 17. Desrosiers J, Wanet-Defalque MC, Témisjian K, Gresset J, Dubois MF, Renaud J, et al. Participation in daily activities and social roles of older adults with visual impairment. Disabil Rehabil. 2009; 31:1227–12234. [PubMed: 19802927] 18. Reinhardt JP, Boerner K, Horowitz A. Personal and social resources and adaptation to chronic vision impairment over time. Aging Ment Health. 2009; 13:367–375. [PubMed: 19484600]

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19. Chai Y, Shao Y, Lin S, Xiong KY, Chen WS, Li YY, et al. Vision-related quality of life and emotional impact in children with strabismus: a prospective study. J Int Med Res. 2009; 37:1108– 1114. [PubMed: 19761693] 20. Cumurcu T, Cumurcu BE, Celikel FC, Etikan I. Depression and anxiety in patients with pseudoexfoliative glaucoma. Gen Hosp Psychiatry. 2006; 28:509–515. [PubMed: 17088167] 21. Ishii K, Kabata T, Oshika T. The impact of cataract surgery on cognitive impairment and depressive mental status in elderly patients. Am J Ophthalmol. 2008; 146:404–409. [PubMed: 18602079] 22. Jampel HD, Frick KD, Janz NK, Wren PA, Musch DC, Rimal R, et al. CIGTS Study Group. Depression and mood indicators in newly diagnosed glaucoma patients. Am J Ophthalmol. 2007; 144:238–244. [PubMed: 17560843] 23. Lundmark PO, Trope GE, Shapiro CM, Flanagan JG. Depressive symptomatology in tertiary-care glaucoma patients. Can J Ophthalmol. 2009; 44:198–204. [PubMed: 19491956] 24. Jones GC, Rovner BW, Crews JE, Danielson ML. Effects of depressive symptoms on health behavior practices among older adults with vision loss. Rehabil Psychol. 2009; 54:164–172. [PubMed: 19469606] 25. Freeman EE, Gresset J, Djafari F, Aubin MJ, Couture S, Bruen R, et al. Cataract-related vision loss and depression in a cohort of patients awaiting cataract surgery. Can J Ophthalmol. 2009; 44:171– 176. [PubMed: 19491951] 26. Fenwick EK, Lamoureux EL, Keeffe JE, Mellor D, Rees G. Detection and management of depression in patients with vision impairment. Optom Vis Sci. 2009; 86:948–54. [PubMed: 19609229] 27. Roy MS, Roy A, Affouf M. Depression is a risk factor for poor glycemic control and retinopathy in African-Americans with type 1 diabetes. Psychosom Med. 2007; 69:537–542. [PubMed: 17634567] 28. Banerjee A, Kumar S, Kulhara P, Gupta A. Prevalence of depression and its effect on disability in patients with age-related macular degeneration. Indian J Ophthalmol. 2008; 56:469–474. [PubMed: 18974517] 29. Robertson N, Burden ML, Burden AC. Psychological morbidity and problems of daily living in people with visual loss and diabetes: do they differ from people without diabetes? Diabet Med. 2006; 23:1110–1116. [PubMed: 16978376] 30. Lockley SW, Arendt J, Skene DJ. Visual impairment and circadian rhythm disorders. Dialogues Clin Neurosci. 2007; 9:301–314. [PubMed: 17969867] 31. Bramley T, Peeples P, Walt JG, Juhasz M, Hansen JE. Impact of vision loss on costs and outcomes in medicare beneficiaries with glaucoma. Arch Ophthalmol. 2008; 126:849–856. [PubMed: 18541852] 32. Horowitz A, Reinhardt J. Adequacy of the mental health system in meeting the needs of adults who are visually impaired. Journal of Visual Impairment and Blindness. 2006; 100:871–874.

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The mediation effect of anxiety and depression on the relationship between visual impairment and insomnia symptoms among Russian immigrants. Note: βVI = Beta coefficient of Visual Impairment from logistic regression model; βAD= Beta coefficient of combined Anxiety and Depression variable from logistic regression model SEVI= Standard Error for Visual Impairment; SEAD= Standard Error for combined anxiety and depression variable.

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Table 1

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Characteristics of adult participants (n= 307). Variables

(%)

Visual Impairment Insomnia Symptoms

48.4 61.9

Age     25–51     51–73     74–95

2.00 48.8 49.2

Sex

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Male

35.9

Female

64.1

High School Education

89.0

Married

27.0

Lives with a spouse, child, or friend

59.0

Single, Divorced or Separated

73.0

Live alone

41.0

Activity

68.4

Anxiety/Depression

68.1

Pain

87.9

Body Mass Index (BMI)-Obese

34.1

Depression

43.0

Hypertension

53.0

Stroke

29.3

Cancer

10.5

Diabetes

25.7

Arthritis

52.8

Note: Visual Impairment = Do you have problems with your vision; Insomnia Symptoms =difficulty staying awake, falling asleep, early morning awakenings; Activity= do you get >30 minutes of moderate to vigorous exercise per day; Anxiety and Depression= “Yes” or “No” ever experienced depressive or anxiety symptoms; Pain= “yes” or “no” ever experience pain; BMI= Obese ≥30kg/m2; Hypertension = ever had diagnosis; Stroke=ever been diagnosed; Cancer = ever had diagnosis; Diabetes =Type 2 Diabetes; Arthritis= ever had condition.

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Table 2

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Participant Characteristics and Insomnia. Insomnia p

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Variable

Yes

No

Female

63.3

36.7

Male

60.0

40.0

Activity

63.3

36.7

Anxiety/Depression

72.2

27.8

Pain

64.1

35.9

Depressive Symptoms among Russian Immigrants.

Little is known about the association between visual impairment and insomnia symptoms in elderly populations. The purpose of this study was to ascerta...
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