Evaluation of the Clinical Effects of Insomnia and Excessive Daytime Sleepiness in Older Adults

Saadet Koç Okudur; Pinar Soysal; Lee Smith; Burcu Akpınar Söylemez; Merve Aliye Akyol

doi:10.46483/deuhfed.969583

Research Article

Yaşlı Bireylerde Uykusuzluk ve Gündüz Aşırı Uykululuk Halinin Klinik Etkilerinin Değerlendirilmesi

Year 2021, Volume: 14 Issue: 4, 433 - 441, 15.10.2021

Saadet Koç Okudur Pinar Soysal Lee Smith Burcu Akpınar Söylemez Merve Aliye Akyol

https://doi.org/10.46483/deuhfed.969583

Cited By: 1

Abstract

Giriş: Uykusuzluk ve gündüz aşırı uykululuk (GAU), yaşlı hastalarda sık görülen uyku bozukluklarındandır. Her ikisi de çok sayıda olumsuz sağlık durumlarıyla ilişkilidir. Amaç: Uykusuzluk ve/veya GAU’nun yaşlılarda fonksiyonellik, yürüme-denge fonksiyonları, kognisyon, duygu durum, düşme ve düşme korkusu (DK) üzerine etkilerini değerlendirmek, hemşirelik pratiği açısından önemini belirlemek ve konuyla ilgili farkındalık yaratmaktır. Yöntem: Kesitsel araştırma tasarımı kullanıldı. Çalışmaya ≥ 65 yaş, 661 ayaktan hasta dahil edildi. Tüm hastalara ayrıntılı geriatrik değerlendirme yapıldı. Komorbiditeler, son bir yıldaki düşmeler ve kullanılan ilaçlar kaydedildi. DK' nu belirlemek ve sınıflandırmak için Uluslararası Düşme Etkinliği Ölçeği (UDEÖ), nörokognitif değerlendirme için Standardize Mini Mental Test (SMMT) ölçeği, günlük yaşam aktivitelerini değerlendirmek için Temel Günlük Yaşam Aktiviteleri (TGYA) ve Enstrümental Günlük Yaşam Aktiviteleri (EGYA) kullanılmıştır. Uykusuzluk Şiddet İndeksinin ≥ 8 puan olması uykusuzluk, Epworth Uykululuk Skalasının ≥ 11 puan olması GAU olarak değerlendirildi. Bulgular: Yaş ortalaması 77.78 ±7.73 yıldı. GAU, uykusuzluk ve GAU ve uykusuzluk halinin prevalansları sırasıyla %5.45, %50.38 ve %12.56 idi. İki değişkenli ve çok değişkenli lojistik regresyon analizi sonucunda; GAU ve uykusuzluk ile orta ve yüksek DK (OR=2.24, %95 CI: 1.74-2.89), polifarmasi (OR=1.20, %95 CI: 1.09-1.30), TGYA (OR=0.94, %95 CI: 0.93-0.96), EGYA (OR=0.87, %95 CI: 0.84-0.91) ve SMMT (OR=0.91, %95 CI: 0.86-0.98) arasında anlamlı ilişki saptanmıştır (p<.05). Sonuç: Yaşlı yetişkinlerde GAU ve uykusuzluk ile DK, polifarmasi, günlük yaşam aktiviteleri ve kognisyon arasında yakın ilişki vardır. Yaşlı bireylerle çalışan sağlık çalışanlarının uyku alanını değerlendirirken bu parametreleri göz önünde bulundurmaları önerilmektedir.

Keywords

Uykusuzluk, Gündüz Aşırı Uykululuk, Yaşlı Birey.

References

Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med 2018;34(2):205-216.
2. Littner MR, Kushida C, Wise M, Davila DG, Morgenthaler T, Lee-Chiong T, et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep 2005;28(1):113-121.
3. Chasens ER, Williams LL UM. Excessive sleepiness. In: Capezuti E, Zwicker D MM, editor. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer: Publishing Company; 2008. p. 459–76.
4. Simonson W, Bergeron CA, Crecelius CA, Murphy R, Roth Maguire S, Osterweil D, Clinical Professor C, et al. Improving sleep management in the elderly. [online] 2007;1-17. URL: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.468.1446&rep=rep1&type=pdf. 10.07.2021.
5. Flores S. Sleepiness or excessive daytime somnolence. Geriatr Nurs 2009;30(1):53–60.
6. Gulia KK, Kumar VM. Sleep disorders in the elderly: A growing challenge. Psychogeriatrics 2018;18(3),155-165.
7. Lopes JM, Dantas FG, Medeiros JLA de. Excessive daytime sleepiness in the elderly: Association with cardiovascular risk, obesity and depression. Rev Bras Epidemiol 2013;16:872-879.
8. Gooneratne NS, Weaver TE, Cater JR, Pack FM, Arner HM, Greenberg AS, et al. Functional outcomes of excessive daytime sleepiness in older adults. J Am Geriatr Soc 2003;51(5):642-649.
9. Luck KE, Doucet S. A rapid review exploring nurse-led memory clinics. Nursing Open 2021;8:1538-1549.
10. Mozo-Alonso F, Novalbos-Ruiz JP, Duran-Alonso JC, Rodríguez-Martin A. Nutritional status of non-institutionalized adults aged over 65. Study of weight and health in older adults (PYSMA). Nutrients 2021;13(5),1561.
11. Chidume T. Promoting older adult fall prevention education and awareness in a community setting: A nurse-led intervention. Appl Nurs Res 2021;57:151392.
12. Kulakci Altintas H, Korkmaz Aslan G. Incidence of falls among community-dwelling older adults in Turkey and its relationship with pain and insomnia. Int J Nurs Pract 2019;25(5):e12766.
13. Piamjariyakul U, Shapiro AL, Wang K, Zulfikar R, Petitte T, Shafique S, et al. Impact of Sleep Apnea, Daytime Sleepiness, Comorbidities, and Depression on Patients’ Heart Failure Health Status. Clin Nurs Res 2021:1-9.
14. Unutmaz GD, Soysal P, Tuven B, Isik AT. Costs of medication in older patients: Before and after comprehensive geriatric assessment. Clin Interv Aging 2018;13:607-613.
15. Ates Bulut E, Soysal P, Isik AT. Frequency and coincidence of geriatric syndromes according to age groups: Single-center experience in Turkey between 2013 and 2017. Clin Interv Aging 2018;13:1899–905.
16. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci 2011 Jun;66(6):674–680.
17. Rivasi G, Kenny RA, Ungar A, Romero-Ortuno R. Predictors of Incident Fear of Falling in Community-Dwelling Older Adults. J Am Med Dir Assoc 2019;21(5):615-620.
18. Bloem BR, Marinus J, Almeida Q, Dibble L, Nieuwboer A, Post B, et al. Measurement instruments to assess posture, gait, and balance in Parkinson’s disease: Critique and recommendations. Movement Disorders 2016;31(9):1342-1355.
19. Durmaz B, Soysal P, Ellidokuz H, Isik AT. Validity and reliability of geriatric depression scale-15 (Short Form) in Turkish older adults. North Clin Istanbul 2018;5(3):216-220.
20. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 34(5):601-608.
21. Bastien CH, Vallières A, Morin CM. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med 2001;2(4):297–307.
22. Johns MW. Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth sleepiness scale: Failure of the MSLT as a gold standard. J Sleep Res 2000;9(1):5–11.
23. Miner B, Kryger MH. Sleep in the Aging Population. Sleep Med Clin. 2020;15(2):311-318.
24. Oliveira BHD, Yassuda MS, Cupertino APFB, Neri AL. Relations between sleep patterns, perceived health and socioeconomic variables in a sample of community resident elders - PENSA Study. Ciencia e Saude Coletiva 2010;15(3):851–860.
25. Su TP, Huang SR, Chou P. Prevalence and risk factors of insomnia in community-dwelling chinese elderly: A Taiwanese urban area survey. Aust New Zeal J Psychiatry 2004;38(9):706–713.
26. Honig E, Green A, Dagan Y. Gender differences in the sleep variables contributing to excessive daytime sleepiness among patients with obstructive sleep apnea. Sleep Breath 2021:1-6.
27. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: Results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res 2004;56(5):497–502.
28. Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult-A mini-review. Gerontology 2010;56(2):181-189.
29. Spiegel K, Knutson K, Leproult R, Tasali E, Van Cauter E. Sleep loss: A novel risk factor for insulin resistance and Type 2 diabetes. J Appl Physiol 2006;99(5):2008-2019.
30. Strand LB, Carnethon M, Biggs M Lou, E LD, Kaplan RC, Siscovick DS, et al. Sleep disturbances and glucose metabolism in older adults: The cardiovascular health study. Diabetes Care 2015;38(11):2050–2058.
31. Holingue C, Wennberg A, Berger S, Polotsky VY, Spira AP. Disturbed sleep and diabetes: A potential nexus of dementia risk. Metabolism 2018;84:85–93.
32. Bargiotas P, Schuepbach MWM, Bassetti CL. Sleep-wake disturbances in the premotor and early stage of Parkinson’s disease. Curr Opin Neurol 2016;29(6):763-772.
33. Xu Z, Anderson KN, Saffari SE, Lawson RA, Chaudhuri KR, Brooks D, et al. Progression of sleep disturbances in Parkinson’s disease: A 5-year longitudinal study. J Neurol 2021;268(1):312–320.
34. Feng F, Cai YY, Hou YB, Ou R, Jiang Z, Shang HF. Excessive daytime sleepiness in Parkinson’s disease: A systematic review and meta-analysis. Parkinsonism Relat Disord 2021;85:133-140.
35. Dokuzlar O, Koc Okudur S, Soysal P, Kocyigit SE, Yavuz I, Smith L, et al. Factors that Increase Risk of Falling in Older Men according to Four Different Clinical Methods. Exp Aging Res. 2020;46(1):83–92.
36. Dokuzlar O, Koc Okudur S, Smith L, Soysal P, Yavuz I, Aydin AE, et al. Assessment of factors that increase risk of falling in older women by four different clinical methods. Aging Clin Exp Res 2020;32(3):483–490.
37. Soysal P, Smith L, Tan SG, Capar E, Veronese N, Yang L. Excessive daytime sleepiness is associated with an increased frequency of falls and sarcopenia. Exp Gerontol 2021;150:111364.
38. Unsal P, Sengul Aycicek G, Deniz O, Esme M, Dikmeer A, Balcı C, et al. Insomnia and falls in older adults: Are they linked to executive dysfunction? Psychogeriatrics 2021;21(3):359–367.
39. Malhotra RK, Desai AK. Healthy brain aging: What has sleep got to do with it? Clin Geriatr Med 2010;26(1):45-56.
40. Tworoger SS, Lee S, Schernhammer ES, Grodstein F. The association of self-reported sleep duration, difficulty sleeping, and snoring with cognitive function in older women. Alzheimer Dis Assoc Disord 2006;20(1):41–48.
41. Nutt DJ, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci 2008;10(3):329–336.
42. Vance DE, Heaton K, Eaves Y, Fazeli PL. Sleep and cognition on everyday functioning in older adults: Implications for nursing practice and research. J Neurosci Nurs 2011;43(5):261–271.
43. Jiang HX, Xie X, Xu Y, Wang R, Lei X, Yu J. Older Adults’ Subjective Cognitive Decline Correlated with Subjective but Not Objective Sleep: A Mediator Role of Depression. Int J Aging Hum Dev 2021;1-15.
44. Suzuki K, Miyamoto M, Hirata K. Sleep disorders in the elderly: Diagnosis and management. J Gen Fam Med 2017;18(2):61-71.
45. Neubauer DN. A review of ramelteon in the treatment of sleep disorders. Neuropsychiatr Dis Treat 2008;4(1):69-79.

Evaluation of the Clinical Effects of Insomnia and Excessive Daytime Sleepiness in Older Adults

Year 2021, Volume: 14 Issue: 4, 433 - 441, 15.10.2021

Saadet Koç Okudur Pinar Soysal Lee Smith Burcu Akpınar Söylemez Merve Aliye Akyol

https://doi.org/10.46483/deuhfed.969583

Cited By: 1

Abstract

Background: Insomnia and excessive daytime sleepiness (EDS) are common sleep disorders in older adults. Both are associated with numerous adverse health conditions.
Objectives: The aim of our study is to evaluate the effects of insomnia and/or EDS on functionality, gait-balance functions, cognition, mood, falls and fear of falling (FoF) in older adults, to determine its importance in terms of nursing practice and to raise awareness on the subject.
Methods: A cross-sectional study design was used. A total of 661 outpatients were included, aged ≥ 65 years. All patients underwent comprehensive geriatric assessment. Comorbidities, falls in the last year and drugs used were recorded. The Falls Efficacy Scale–International (FES-I) was used to determine and classify FoF. MMSE was applied to all patients for neurocognitive evaluation. Activities of daily living were assessed by Basic Activities of Daily Living Scale (BADL) and Instrumental Activities of Daily Living (IADL) scales. Insomnia Severity Index (ISI) with scores of 8 and over indicated insomnia. The Epworth Sleepiness Scale score of ≥ 11 points indicated EDS.
Results: The mean age was 77.78 ± 7.73 years. The prevalences of EDS, insomnia, and EDS+insomnia were 5.45%, 50.38%, and 12.56%, respectively. As a result of bivariate and multivariate logistic regression analysis, there was a significant relationship between EDS+insomnia with moderate and high FoF (OR=2.24, 95% CI: 1.74 to 2.89), polypharmacy (OR=1.20, 95% CI: 1.09 to 1.30), BADL (OR=0.94, 95% CI: 0.93 to 0.96) ), IADL (OR=0.87, 95% CI: 0.84 to 0.91) and MMSE (OR=0.91, 95% CI: 0.86 to 0.98) (p<.05).
Conclusions: There is a close relationship between EDS+insomnia and FoF, polypharmacy, activities of daily living and cognition in older adults.

Keywords

Insomnia, Excessive Daytime Sleepiness, Older Adults

References

Yaremchuk K. Sleep disorders in the elderly. Clin Geriatr Med 2018;34(2):205-216.
2. Littner MR, Kushida C, Wise M, Davila DG, Morgenthaler T, Lee-Chiong T, et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep 2005;28(1):113-121.
3. Chasens ER, Williams LL UM. Excessive sleepiness. In: Capezuti E, Zwicker D MM, editor. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York: Springer: Publishing Company; 2008. p. 459–76.
4. Simonson W, Bergeron CA, Crecelius CA, Murphy R, Roth Maguire S, Osterweil D, Clinical Professor C, et al. Improving sleep management in the elderly. [online] 2007;1-17. URL: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.468.1446&rep=rep1&type=pdf. 10.07.2021.
5. Flores S. Sleepiness or excessive daytime somnolence. Geriatr Nurs 2009;30(1):53–60.
6. Gulia KK, Kumar VM. Sleep disorders in the elderly: A growing challenge. Psychogeriatrics 2018;18(3),155-165.
7. Lopes JM, Dantas FG, Medeiros JLA de. Excessive daytime sleepiness in the elderly: Association with cardiovascular risk, obesity and depression. Rev Bras Epidemiol 2013;16:872-879.
8. Gooneratne NS, Weaver TE, Cater JR, Pack FM, Arner HM, Greenberg AS, et al. Functional outcomes of excessive daytime sleepiness in older adults. J Am Geriatr Soc 2003;51(5):642-649.
9. Luck KE, Doucet S. A rapid review exploring nurse-led memory clinics. Nursing Open 2021;8:1538-1549.
10. Mozo-Alonso F, Novalbos-Ruiz JP, Duran-Alonso JC, Rodríguez-Martin A. Nutritional status of non-institutionalized adults aged over 65. Study of weight and health in older adults (PYSMA). Nutrients 2021;13(5),1561.
11. Chidume T. Promoting older adult fall prevention education and awareness in a community setting: A nurse-led intervention. Appl Nurs Res 2021;57:151392.
12. Kulakci Altintas H, Korkmaz Aslan G. Incidence of falls among community-dwelling older adults in Turkey and its relationship with pain and insomnia. Int J Nurs Pract 2019;25(5):e12766.
13. Piamjariyakul U, Shapiro AL, Wang K, Zulfikar R, Petitte T, Shafique S, et al. Impact of Sleep Apnea, Daytime Sleepiness, Comorbidities, and Depression on Patients’ Heart Failure Health Status. Clin Nurs Res 2021:1-9.
14. Unutmaz GD, Soysal P, Tuven B, Isik AT. Costs of medication in older patients: Before and after comprehensive geriatric assessment. Clin Interv Aging 2018;13:607-613.
15. Ates Bulut E, Soysal P, Isik AT. Frequency and coincidence of geriatric syndromes according to age groups: Single-center experience in Turkey between 2013 and 2017. Clin Interv Aging 2018;13:1899–905.
16. Delbaere K, Smith ST, Lord SR. Development and initial validation of the Iconographical Falls Efficacy Scale. J Gerontol A Biol Sci Med Sci 2011 Jun;66(6):674–680.
17. Rivasi G, Kenny RA, Ungar A, Romero-Ortuno R. Predictors of Incident Fear of Falling in Community-Dwelling Older Adults. J Am Med Dir Assoc 2019;21(5):615-620.
18. Bloem BR, Marinus J, Almeida Q, Dibble L, Nieuwboer A, Post B, et al. Measurement instruments to assess posture, gait, and balance in Parkinson’s disease: Critique and recommendations. Movement Disorders 2016;31(9):1342-1355.
19. Durmaz B, Soysal P, Ellidokuz H, Isik AT. Validity and reliability of geriatric depression scale-15 (Short Form) in Turkish older adults. North Clin Istanbul 2018;5(3):216-220.
20. Morin CM, Belleville G, Bélanger L, Ivers H. The insomnia severity index: Psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 34(5):601-608.
21. Bastien CH, Vallières A, Morin CM. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med 2001;2(4):297–307.
22. Johns MW. Sensitivity and specificity of the multiple sleep latency test (MSLT), the maintenance of wakefulness test and the Epworth sleepiness scale: Failure of the MSLT as a gold standard. J Sleep Res 2000;9(1):5–11.
23. Miner B, Kryger MH. Sleep in the Aging Population. Sleep Med Clin. 2020;15(2):311-318.
24. Oliveira BHD, Yassuda MS, Cupertino APFB, Neri AL. Relations between sleep patterns, perceived health and socioeconomic variables in a sample of community resident elders - PENSA Study. Ciencia e Saude Coletiva 2010;15(3):851–860.
25. Su TP, Huang SR, Chou P. Prevalence and risk factors of insomnia in community-dwelling chinese elderly: A Taiwanese urban area survey. Aust New Zeal J Psychiatry 2004;38(9):706–713.
26. Honig E, Green A, Dagan Y. Gender differences in the sleep variables contributing to excessive daytime sleepiness among patients with obstructive sleep apnea. Sleep Breath 2021:1-6.
27. Foley D, Ancoli-Israel S, Britz P, Walsh J. Sleep disturbances and chronic disease in older adults: Results of the 2003 National Sleep Foundation Sleep in America Survey. J Psychosom Res 2004;56(5):497–502.
28. Neikrug AB, Ancoli-Israel S. Sleep disorders in the older adult-A mini-review. Gerontology 2010;56(2):181-189.
29. Spiegel K, Knutson K, Leproult R, Tasali E, Van Cauter E. Sleep loss: A novel risk factor for insulin resistance and Type 2 diabetes. J Appl Physiol 2006;99(5):2008-2019.
30. Strand LB, Carnethon M, Biggs M Lou, E LD, Kaplan RC, Siscovick DS, et al. Sleep disturbances and glucose metabolism in older adults: The cardiovascular health study. Diabetes Care 2015;38(11):2050–2058.
31. Holingue C, Wennberg A, Berger S, Polotsky VY, Spira AP. Disturbed sleep and diabetes: A potential nexus of dementia risk. Metabolism 2018;84:85–93.
32. Bargiotas P, Schuepbach MWM, Bassetti CL. Sleep-wake disturbances in the premotor and early stage of Parkinson’s disease. Curr Opin Neurol 2016;29(6):763-772.
33. Xu Z, Anderson KN, Saffari SE, Lawson RA, Chaudhuri KR, Brooks D, et al. Progression of sleep disturbances in Parkinson’s disease: A 5-year longitudinal study. J Neurol 2021;268(1):312–320.
34. Feng F, Cai YY, Hou YB, Ou R, Jiang Z, Shang HF. Excessive daytime sleepiness in Parkinson’s disease: A systematic review and meta-analysis. Parkinsonism Relat Disord 2021;85:133-140.
35. Dokuzlar O, Koc Okudur S, Soysal P, Kocyigit SE, Yavuz I, Smith L, et al. Factors that Increase Risk of Falling in Older Men according to Four Different Clinical Methods. Exp Aging Res. 2020;46(1):83–92.
36. Dokuzlar O, Koc Okudur S, Smith L, Soysal P, Yavuz I, Aydin AE, et al. Assessment of factors that increase risk of falling in older women by four different clinical methods. Aging Clin Exp Res 2020;32(3):483–490.
37. Soysal P, Smith L, Tan SG, Capar E, Veronese N, Yang L. Excessive daytime sleepiness is associated with an increased frequency of falls and sarcopenia. Exp Gerontol 2021;150:111364.
38. Unsal P, Sengul Aycicek G, Deniz O, Esme M, Dikmeer A, Balcı C, et al. Insomnia and falls in older adults: Are they linked to executive dysfunction? Psychogeriatrics 2021;21(3):359–367.
39. Malhotra RK, Desai AK. Healthy brain aging: What has sleep got to do with it? Clin Geriatr Med 2010;26(1):45-56.
40. Tworoger SS, Lee S, Schernhammer ES, Grodstein F. The association of self-reported sleep duration, difficulty sleeping, and snoring with cognitive function in older women. Alzheimer Dis Assoc Disord 2006;20(1):41–48.
41. Nutt DJ, Wilson S, Paterson L. Sleep disorders as core symptoms of depression. Dialogues Clin Neurosci 2008;10(3):329–336.
42. Vance DE, Heaton K, Eaves Y, Fazeli PL. Sleep and cognition on everyday functioning in older adults: Implications for nursing practice and research. J Neurosci Nurs 2011;43(5):261–271.
43. Jiang HX, Xie X, Xu Y, Wang R, Lei X, Yu J. Older Adults’ Subjective Cognitive Decline Correlated with Subjective but Not Objective Sleep: A Mediator Role of Depression. Int J Aging Hum Dev 2021;1-15.
44. Suzuki K, Miyamoto M, Hirata K. Sleep disorders in the elderly: Diagnosis and management. J Gen Fam Med 2017;18(2):61-71.
45. Neubauer DN. A review of ramelteon in the treatment of sleep disorders. Neuropsychiatr Dis Treat 2008;4(1):69-79.

There are 45 citations in total.

Details

Primary Language	English
Subjects	Nursing
Journal Section	Research Articles
Authors	Saadet Koç Okudur 0000-0001-5034-3720 Pinar Soysal 0000-0002-6042-1718 Lee Smith This is me 0000-0002-5340-9833 Burcu Akpınar Söylemez 0000-0002-9643-0325 Merve Aliye Akyol 0000-0001-5107-266X
Early Pub Date	October 15, 2021
Publication Date	October 15, 2021
Published in Issue	Year 2021 Volume: 14 Issue: 4

Cite

APA	Koç Okudur, S., Soysal, P., Smith, L., Akpınar Söylemez, B., et al. (2021). Evaluation of the Clinical Effects of Insomnia and Excessive Daytime Sleepiness in Older Adults. Dokuz Eylül Üniversitesi Hemşirelik Fakültesi Elektronik Dergisi, 14(4), 433-441. https://doi.org/10.46483/deuhfed.969583

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