Gender Differences in Self-Perceptions About Aging and Sleep Among Elderly Chinese Residents in Taiwan

Abstract

Background: 

Previous research has revealed the existence of gender differences in sleep patterns among older adults from various ethnic groups. Data on how gender affects the sleep patterns of Taiwanese are limited.

Purpose: 

The purposes of the current study were to (a) describe perceptions about aging and the influence of these perceptions on sleep in elderly men and women, respectively, and (b) determine whether there are gender differences in perceptions and appraisal of sleep.

Methods: 

A mixed method design was used. In-depth interview data from 23 men and 27 women were integrated with data from the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI).

Results: 

The mean CPSQI score for the entire sample was 6.1 ± 3.5 (men: 4.8 ± 1.6, women: 7.1 ± 4.3). Participants who held negative attitudes about aging were more likely to report poor sleep quality, short sleep duration, and difficulty in falling asleep than those who did not hold negative attitudes. Women had more negative perceptions about aging (e.g., feelings of powerlessness) and more sleep complaints than men. Furthermore, women reported significantly poorer sleep quality (p = .02) and lower sleep efficiency (p = .03) on the CPSQI than men.

Conclusions/Implications for Practice: 

Negative perceptions about aging are associated with reports of poor sleep quality. There are gendered differences in perceptions about aging and appraisals of sleep. As the process of aging and patterns of sleep change over time, longitudinal research designs are recommended for future studies.

Introduction

Self-reported disturbed sleep is common among older adults (^{BaHammam & Pandi-Perumal, 2010}). The prevalence of self-reported disturbed sleep increases with age, ranging from 6% to 50% in adults over the age of 60 years (^{Li et al., 2013}; ^{Yang & Chiou, 2012}). Sleep research has revealed gender differences in various aspects of sleep across countries and cultures (^{Woosley, Lichstein, Taylor, Riedel, & Bush, 2012}), including the differences in subjective and objective sleep measures. Researchers have found that women are more likely to report disturbed sleep than men (^{Jung, Song, Ancoli-Israel, & Barrett-Connor, 2013}; ^{Yoshioka et al., 2012}). For example, a meta-analysis of 29 studies revealed that women are 40% more likely to report disturbed sleep than men, with this trend most common among older adults (^{Zhang & Wing, 2006}). A study conducted in Hong Kong indicated that Chinese women aged 18–65 years faced an approximately 1.6 times higher risk of disturbed sleep than men and that the prevalence of disturbed sleep increased with age (^{Li, Wing, Ho, & Fong, 2002}). A question that remains unanswered is why women are more likely to complain about disturbed sleep than men. Aging research often sheds light on the needs, health problems, and adjustment issues that are faced by aging populations. However, fewer reports describe the potential differences between men and women in self-perceptions about aging and about sleep.

Aging is associated with disturbed sleep. Whereas older adult men show more objective measures of poor sleep such as sleep fragmentation than women (^{Knutson, 2013}), women complain more about poor sleep quality than men (^{Unruh et al., 2008}). Older women complain of the relatively long time needed to fall asleep, difficulties in staying asleep, waking up too early without being able to fall back to sleep, and longer times in bed, whereas men often report daytime sleepiness and frequent daytime napping (^{Jung et al., 2013}; ^{Unruh et al., 2008}).

Gender inequalities in self-reported disturbed sleep may be explained, in part, by gender-related social roles such as gender differences in paid work, the multiplicity of roles, and family responsibilities that are carried out as part of daily life (^{Yoshioka et al., 2012}). The more roles an individual plays in life, the greater the potential for sleep disturbance (^{Moser, Spagnoli, & Santos-Eggimann, 2011}). In many societies, the life course for women is ordered by marriage status and motherhood (^{Lehr, Seiler, & Thomae, 2000}). Women have a greater share of household responsibilities, especially time-consuming activities such as child-rearing, food preparation, and housekeeping, which may lead to increased problems in falling or staying asleep (^{Yoshioka et al., 2012}). Marriage has been suggested as particularly disadvantageous to Chinese women because of gender-specified roles, demands, and burdens (^{Li et al., 2002}). ^{Chen, Kawachi, Subramanian, Acevedo-Garcia, and Lee (2005)} associated being a housewife or being divorced or widowed with a higher risk of insomnia in women and associated being retired with a higher risk of insomnia in men.

Attitudes about aging are believed to be a reflection of societal expectations (^{Li et al., 2013}). The perception of aging in this study refers to an older adult’s attitude toward aging that he or she experiences. One’s attitude toward aging may influence self-reports of physical and psychological states (^{Low, Molzahn, & Schopflocher, 2013}), including sleep. Self-perception of aging has been found to influence mental health, preventive health behaviors, cognitive and physical functioning, and longevity (^{Lai, 2009}).

Information regarding self-perception is subjective, and qualitative inquiry approaches provide more details about the perspectives of older adults on sleep and aging. ^{Bliwise (2008)} responded to the complexity of the sleep issue by suggesting that both quantitative and qualitative approaches be used to better describe sleep patterns and correlates of disturbed sleep. On the basis of these recommendations, this study used in-depth interviews to depict perceptions about aging and the influences of the perceptions on sleep in elderly Chinese men and women. Gender differences in the perceptions and appraisal of sleep were also explored. Data from a standardized and well-established questionnaire of sleep habits and disturbances were integrated with content analyses of the interview data to help interpret the findings.

Methods

Design

A mixed method design (^{Creswell & Zhang, 2009}) was utilized to collect qualitative and quantitative data simultaneously, with both types of data integrated in the interpretation of study results. In-depth interview was the primary approach that was used to gather data on self-perceptions of aging, whereas interviews and a valid questionnaire were used to gather data on sleep. “Naturalistic inquiry” (^{Lincoln & Guba, 1985}) served as the philosophical framework that guided the in-depth interviews. Naturalistic inquiry is “a special form of inquiry” that emphasizes the natural integrity of the phenomenon under study and addresses the need to study a phenomenon in its “natural ongoing character without imposing a fixed preconceived order on it” (^{Athens, 2010}, p. 94). A separate survey was completed to collect the demographic characteristics of the participants.

Ethical Considerations

The human subjects institutional review board of the University of Washington approved the present study (#41924). The participants were given detailed study information and asked to sign a written consent form. All data were stored securely, and pseudonyms were used to de-identify all personal information in tape transcripts.

Sample

Convenience sampling was used to recruit the participants from northern (n = 35) and southern (n = 15) Taiwan. Recruitment flyers were initially distributed in city parks in the Taipei area, where elderly Chinese gather to do morning exercises and socialize. Potential participants could contact the investigator at the telephone number shown on the flyer. A brief telephone-screening interview was conducted to determine the eligibility of the potential participants. However, cold temperatures and frequent rain rendered this sampling plan unsatisfactory, as the target population tends to stay at home rather than congregate in city parks under these weather conditions. For this reason, the researchers resubmitted their institutional review board application to include new research sites, including city or town parks in southern Taiwan, which had generally better weather conditions. To improve recruitment, the researcher lowered the minimum age of participants from 65 to 60 years. Inclusion criteria were as follows: participants had to (a) be ethnically Chinese who could speak Taiwanese or Mandarin, (b) be able to reflect on their lives, and (c) have a score of more than 24 on the Mini-Mental Status Examination (^{Folstein, Folstein, & McHugh, 1975}). Recruitment efforts were supplemented by snowball sampling. Sampling was terminated when no new information was revealed in the interviews with participants.

Data Collection

Procedure

During data collection, each participant was asked to fill out two questionnaires, including the Chinese version of the Pittsburgh Sleep Quality Index (CPSQI; ^{Buysse, Reynolds, Monk, Berman, & Kupfer, 1989}) and a demographic questionnaire. An in-depth interview was conducted at the participant’s home immediately after the completion of the questionnaire.

In-depth interviews

An in-depth interview lasting approximately 60 minutes was utilized to gather qualitative data. The interview was digitally audio-recorded and initiated with the “grand tour” question: “Tell me about how you spend your day.” Probing questions and follow-up questions were asked to expand upon specific topics. These questions included (a) “How do you rate your sleep quality during the past month?”, (b) “In your opinion, how do you define good sleep and poor sleep?”, and (c) “How does getting older influence your sleep?” Throughout the interview process, nonaudible vocal intonations, physical expressions, and gestures during the recorded interview were described in field notes.

Questionnaire

The CPSQI was used to gather the quantitative data on sleep quality. The questionnaire consists of 19 self-rated questions that are grouped into seven subscale components: sleep quality, sleep latency, sleep duration, habitual sleep efficiency, daytime dysfunction, sleep disturbances, and use of sleep medications. Each component score is weighed equally on a Likert scale of 0 (no difficulty) to 3 (severe difficulty). The seven component scores are then summed to yield a global CPSQI score, which has a range of 0–21. A score of 5 or above indicates poor sleep quality (^{Buysse et al., 1989}). The Cronbach’s alpha of the CPSQI was reported as .78 in a randomized trial that assessed the effects of yoga exercises on 128 Chinese older adults aged 60 years or older (^{Chen et al., 2009}). The Cronbach’s alpha in this study sample was .71. Interview texts were the primary source of data that were used in this study, and the statistical data generated from the CPSQI were used to interpret the interview data. The interview data showed that the vast majority of the participants of this study described sleep quality, sleep time, and the time they spent on the bed. Thus, this study focused on the three component scores of the CPSQI: sleep quality, sleep duration, and habitual sleep efficiency.

Data Analysis

Qualitative content analysis

The approaches of content analysis (^{Graneheim & Lundman, 2004}) were adopted to sort the interview texts. The texts were divided into “meaning units,” abstracted, and labeled with a code. The initial codes were compared, and similar codes were sorted into 11 categories. The principal investigator and two experts in qualitative research discussed the tentative categories and codes. Codes with similar meanings were grouped together as themes. All meaning units, codes, categories, and themes were merged into a codebook.

Quality criteria

Four techniques were followed to assess the trustworthiness of the qualitative inquiry: peer debriefing, member checking, intercoder agreement, and audit trail (^{Lincoln & Guba, 1985}). An American anthropologist who is knowledgeable about Chinese culture served as a peer debriefer to evaluate the accuracy of data integration along with interpretations. The meaningful findings derived from one interview were tested on subsequent interviewees. Twenty percent of the interview transcripts were randomly coded by the principal investigator and a Chinese PhD student. All codes were then compared to assess agreement on the codes that were assigned to the texts. The student also served as the auditor who scrutinized the authenticity of the data.

Statistical Analysis

Quantitative data were analyzed using IBM SPSS Statistics Version 19 (IBM, Armonk, NY, USA). Descriptive analyses included calculations of variable means, standard deviations, and frequency of demographic characteristics. The Pearson product–moment partial correlation (r) was used to explore the association between age and sleep duration. Independent sample t test (α = .05) was performed to test the differences in subjective ratings of sleep quality, sleep efficiency, and sleep duration between women and men.

Data Integration

Integrating interview and questionnaire data for this study took place in four steps (^{Creswell & Zhang, 2009}). First, the interview and questionnaire data sets were independently analyzed. Second, the meaningful themes and quotes of the interview data were integrated to establish a codebook at the end point of the study. Third, when the codebook of interview texts was developed, statistical data from the questionnaires were embedded into the codebook to confirm or contradict the qualitative findings if they were applicable. Finally, a convergence or a divergence of the findings was determined, and then the findings were interpreted. For example, when interview texts indicated that some participants reported poor sleep quality, those participants’ global scores of sleep quality generated from the CPSQI were added in red into the interview texts in the codebook. Afterward, the researcher interpreted both types of data together to see if these data were convergent or divergent. The researcher reviewed the literature and consulted with an experienced anthropologist who is familiar with Chinese culture and sleep research to determine the possible causes of the respective convergence or divergence.

Results

Twenty-three men and 27 women participated in the current study. The mean age of the participants was 76.3 ± 11 years (men: 76.4 ± 9.4 years, women: 76.2 ± 12.4 years). The mean global score of the CPSQI was 6.1 ± 3.5 (men: 4.8 ± 1.6, women: 7.1 ± 4.3). As shown in Table 1, most of the participants were married or widowed and lived with their children. Educational levels for 72% of the participants were at or below the elementary school level. Twenty-eight percent of the participants worked full time or part time.

TABLE 1.: Sociodemographic and Sleep-Related Characteristics of the Participants (N = 50)

The most significant themes of self-perceptions about aging that were generated from the interview data included powerlessness and the influence of aging on sleep. The theme of powerlessness was divided into three subthemes: “worthlessness,” “counting days,” and “lack of control.” The subthemes of the influences of aging on sleep consisted of “difficulty in falling asleep,” “changes in sleep duration,” and “poor sleep quality.”

Powerlessness

As shown in Table 2, the participants perceived their later life as “worthlessness,” “counting days,” and “lack of control.” They stated that “there is no way to avoid growing old” and “when a baby is born, we are happy for that, but we are not delighted about growing old.” They, especially the female participants, also believed that it is important to rear children for self-protection in old age.

TABLE 2.: Summary of Themes/Subthemes by Gender

Worthlessness

Four female participants viewed themselves as “worthless persons” who were dependent on other people to handle mundane tasks. They felt sad about their inability to make contributions to their families. These women had trouble falling asleep when they thought about their self-perceived worthlessness. For example, Jane, a 64-year-old single mother, tried to learn how to email her daughter in the United States, but she only knew how to turn her computer on and off after taking a computer class. She was extremely upset with herself for being a “worthless person” who was not sharp enough to learn something new. These thoughts of worthlessness interrupted her sleep (CPSQI = 16, sleep efficiency = 61%, sleep duration = 5 hours).

Counting days

On the basis of the perspectives on aging of seven women and three men, “the elderly are counting their days regardless of what their life is like.” “No matter what will happen to them and no matter how bad their sleep is, their days continue to fly by until they die.” They believed that it is normal for older adults to count their days. They sometimes had trouble falling asleep because they felt upset about being unable to stop their days “flying by.” Linda, a 77-year-old retired farmer, stated:

I am going to be 80 years old…. Like other people, I am counting my days. It is inevitable for everyone to have their days pass by…I sometimes tossed and turned because of thinking…my days are passing by…I cannot stop it.

Lack of control

Ten participants reported that it is inevitable for human beings to grow old and undergo a series of life events. They also believed that aging causes loss of control over life. The 10 participants felt helpless, as there was no effective way for them to deal with the influence of growing old. This discovery is explained through the story told by Sandra, a 100-year-old widow living alone (CPSQI = 14, sleep efficiency = 50%, sleep duration = 5 hours).

I sometimes think about how old I am now…I am a very old and lonely woman…. I felt sad about my friend who became a disabled and dependent person…. There is no way for me to avoid being sick and control my life when I become older (sighing) like my friend…. I realize that it is useless to be upset about it…It is my destiny…. I am still growing older even though I cannot sleep well.

Influences of Aging on Sleep

As shown in Table 2, the vast majority of the participants reported that their sleep patterns had changed in terms of falling asleep, sleep duration, and sleep quality as they grew old, but no one was aware of the mechanisms that were causing these changes. Seventeen of them viewed their bodies as “an old machine” that did not function well. As the “machine” was used over a long period, damage and wear to the machine were inevitable. This might influence sleep patterns. Only a few participants felt that their sleep had not changed much since their younger years although they perceived changes in their physical condition since growing older.

Difficulty in falling asleep

Eleven female participants reported experiencing difficulties falling asleep and a sleep latency ranging from 1.5 to 2 hours. They conjectured that it was a common problem for most older adults to toss and turn before falling asleep and that “irritated brain nerves” contributed to the problem. Linda, a 77-year-old woman, reported a relatively long sleep latency (>60 minutes). She teased herself, saying that she acted as a patrol for her neighbors when she was awake during the night (CPSQI = 10, sleep efficiency = 73%, sleep duration = 5.5 hours). She said:

When I was young, I slept well and did not have such a problem. I fell asleep as soon as I lay down on my bed…but now…it takes me at least one hour to fall asleep. I sometimes toss and turn and need a long period of time to fall asleep. I cannot fall asleep as soon as I lie on my bed. I do not have the ability to do that.... I do not sleep well.... I have had this problem since I grew old. So, I think it is because I grew old….

Changes in sleep duration

Approximately 42% of the participants believed that their sleep duration had declined with increasing age. Nevertheless, there was no consensus about quantifying sleep duration as being appropriate for older adults. Seven male and 14 female participants consistently reported that they slept about 1–2 hours less than they did in their younger years. Their mean sleep duration was 6.5 hours (n = 21). They assumed that sleep accounted for a smaller proportion of their life and was not very important to them because of age-related decreases in physical needs. Doris, a 78-year-old woman (CPSQI = 6, sleep efficiency = 92%, sleep duration = 6.0 hours), articulated:

Compared to my younger years, I sleep 2 hours less now…youths may sleep for more than 5–6 hours, but it may be enough for older adults to sleep only for 4–5 hours. It is probably because they do not work….

In contrast, four male participants stated that the amount of time spent in sleep had increased as they had grown older (sleep duration = 6–9 hours). They slept 2–3 hours longer than they had in their younger years. They explained that it was probably because their physical conditions had worsened with age, which required more sleep. They teased themselves that sleeping longer was to compensate for the insufficient sleep that they had in their younger years.

The interview data indicated that age may be associated with changes in sleep duration. However, this is incongruent with the statistical analysis of the questionnaire data, indicative of no statistically significant correlation between age and sleep duration (r = .20, p = .17). The mean number of sleep hours for the “young old” group (60–79 years old; n = 30, 6.4 ± 1.2) was not strikingly different than the mean for the “old old” group (80–104 years old; n = 20, 7.2 ± 1.6).

Poor sleep quality

Nine male and 18 female participants reported that aging made people lose their ability to sleep well and that there is no way to improve age-related poor sleep. Marilyn, a 64-year-old amateur writer, described (CPSQI = 7.0, sleep efficiency = 93%):

When I was young, I slept very well despite having a heavy workload. I do not have many things to do now, but I cannot sleep well. I think it is because of the age-related physical changes….

The 27 participants also complained about sleeping lightly. This complaint may best be explained by Sandra, a 100-year-old widow.

During the night…I do not sleep deeply. I slept soundly when I was young…I seem to feel “semi-sleep” or “half asleep and half awake” because I cannot totally fall asleep…I am a light sleeper…. I am usually aware of different noises....

Gender Differences in Self-Perception About Aging and Sleep

Qualitative Analysis

Compared with men, women in this study were more likely to have a stronger sense of family responsibilities and expectations about their family caregiver roles. For example, several female participants put an emphasis on a traditional grandmother’s role by stating an old Taiwanese saying, “Di ai jia pun, a ma ai chua sun” which stresses that grandmothers caring for grandchildren are as common as pigs eating leftovers. However, more than 70% of the female participants reported that aging had caused them to lose their ability to carry out their responsibilities and become dependent on family members to deal with an increasing number of mundane tasks that they were no longer able to handle. The aging-related inability influenced their mood and consequently disrupted their sleep.

Table 2 shows that more women had a feeling of powerlessness about later life than men. For example, Susan and Roger, a couple, had a schizophrenic son. Susan viewed herself as “a worthless person” who could not take good care of her son. She was extremely pessimistic about her life and growing old. She usually tossed and turned at night (CPSQI = 10, sleep efficiency = 65%). By contrast, most of the time in the interview, Roger excitedly described recent activities that he had participated in rather than complaining about his son. He viewed himself as a good sleeper (CPSQI = 4, sleep efficiency = 98%). He did not report a significant change in his sleep as he grew old.

Quantitative Analysis

As shown in Table 3, the male participants tended to have better sleep quality, greater sleep efficiency, and slightly longer sleep duration than their female counterparts, with a statistically significant difference in the means for CPSQI and sleep efficiency between the genders (p < .05).

TABLE 3.: Summary of Means and Standard Deviation of CPSQI, Sleep Efficiency, Sleep Duration, and Independent Sample t Test by Gender

Discussion

We believe that this study was the first to integrate both qualitative and quantitative data to describe the gender differences in perceptions about aging and sleep. The researcher found that the participants who held negative attitudes about aging tended to report poorer sleep quality, shorter sleep duration, and lower sleep efficiency than those who did not. Possibly, negative perceptions, such as feelings of powerlessness, may produce cognitive arousal at bedtime accompanied by a tumultuous mind, which makes it more difficult to fall asleep. These perceptions may lead to insecurity and psychological distress, which cause older adults to hold less positive outlooks toward their lives, including sleep. Furthermore, these perceptions may undermine self-identity and discourage the individual from engaging in outdoor or social activities, which reduces their levels of exposure to zeitgebers (synchronizing stimuli), which are critical to maintaining normal circadian rhythm (^{Naylor et al., 2000}). Powerlessness is associated with activity limitations and psychological distress and is also a frequent concomitant of poor sleep (^{Phelan, Love, Ryff, Brown, & Heidrich, 2010}).

The result of this study revealed that women were more likely to feel negative about their aging experience and sleep. Possibly, perception of aging reflects cultural values and judgments about the stages of life and major turning points. ^{Nguyen (2012)} argued that the process of aging is dynamic and that perceptions of aging are shaped by social contexts and cultural meanings. For instance, traditional Chinese beliefs about gender roles emphasize that men hold more power in household decision making than women (^{Maume, Sebastian, & Bardo, 2009}). To adjust these traditional expectations, women may view their experience as their destinies and thereby feel powerless. Internalized age stereotypes based on cultural values may also contribute to this finding (^{Moser et al., 2011}). For example, many female participants stressed a cultural belief in “rearing children to protect against aging,” indicating that they would depend more on their offspring as they aged and degenerated physically.

Consistent with this study (^{Wu, Su, Fang, & Yeh Chang, 2012}), women in this study reported poorer sleep quality, longer sleep latency, and less sleep time than men. ^{Knutson (2013)} found that gender roles and expectations contribute to differences in measurements of sleep parameters. Taiwan is a patriarchal society in which men are traditionally expected to be superior to women, and thus, they may be less willing to admit to sleep difficulties than women to “save face.” Men may appraise their sleep as a problem only if poor sleep interferes with their daily activities (^{Venn, Meadows, & Arber, 2013}). Most female participants in this study had a stronger sense of family responsibilities and reported more worries about their children than men. They may be agitated by their responsibilities and worries, which results in sympathetic nervous system activation and then induced physical arousal. Therefore, their propensity to sleep was eliminated (^{Carney, Harris, Moss, & Edinger, 2010}).

In this study, the mean CPSQI global score, which measures overall sleep quality, did not match the mean of the individual items representing sleep efficiency and sleep duration, which are also used as indicators of adequate sleep. Consistent with the result of a Taiwanese study on older adults (^{Wu et al., 2012}), most of the participants reported poor sleep quality, which was indicated by an overall CPSQI score of more than 5, while reporting a sleep efficiency of more than 85%, which is considered adequate, and an average sleep duration of 7 hours. These contradictory findings may be explained by the following. First, the appraisal of sleep quality may result from a memory gap between certain sleep variables such as sleep duration and total time in bed, subsequently affecting the classification of older adults with good or poor sleep quality based on the total score of CPSQI (^{Wu et al., 2012}). Second, the findings of the current study revealed that the older participants, especially the participants older than 80 years, were more likely to spend their days in bed. They reported that they usually fell asleep while watching television and that they were unsure of the specific time. Third, the participants tended to provide numerical ranges rather than exact numbers when they were asked about their sleep parameters, which might influence the estimation of sleep duration and sleep efficiency.

The measure of reliability (Cronbach’s α) of the CPSQI in this study was lower than the criterion level suggested by ^{Buysse et al. (1989)}. However, the reliability was similar to the finding of a previous Taiwanese study (^{Yang & Chiou, 2012}). Because α values of an instrument are affected by sample attributes such as age (^{Streiner, 2003}), a possible explanation for the differences in the reliability values is that the participants in this study (mean age = 76.3 years) and in the study of ^{Yang and Chiou (2012}; mean age = 72. 6 years) were older than the participants in the study that was conducted by Buysse et al. Two additional factors that influenced the reliability of this study were difficulty selecting the answers for the questions in the CPSQI and a recall bias about specific sleep parameters such as falling asleep and waking up times.

Implications

The findings of this study may be applied to future research and clinical practice. Snowball sampling is a useful approach to compensate for weather limitations and worries about being scammed by strangers. It is important to develop social relationships within Chinese social circles through personal referrals. Most of the participants complained about the inconvenience of providing written consent because of vision impairments or reduced hand functions. Therefore, oral consent and the use of stamps or fingerprints are recommended for future research that explores the health issues of Chinese older adults.

The process of aging changes over time (^{Nguyen, 2012}). The appraisal of aging and sleep is linked to the organization of the life course that is shaped by sociocultural factors (^{Jenni & O’Connor, 2005}). Longitudinal and ethnographic approaches are recommended to better understand the roles of self-perception about aging in appraisals of sleep. In-depth studies of self-perceptions about aging may yield more complete information when additional sociocultural correlates such as family and cultural value are included. Health providers need to be aware of the influence of age-related stereotypes when assessing sleep and age-related health problems. According to ^{Lu’s (2014)} findings, helping patients voice their concerns may mitigate feelings of powerlessness. Thus, geriatric health professionals should take time to communicate with older adults and to encourage them to express their negative perceptions about aging and sleep.

Limitations

Several limitations affected the current study. First, word selection for transcribing the interview recordings and translating them from Taiwanese into Chinese and subsequently into English was an issue because Taiwanese has no uniform written characters, and the vast majority of the interviews were conducted in Taiwanese. Second, the scope of data collection may have been limited by internalized age stereotypes. A number of the participants believed growing old to be associated with poor sleep and to lead to loss of control over their lives regardless of what actually happens in their lives. Third, only self-reported measures of sleep were used in this study. The use of actigraphy would have provided a more objective measure of sleep for comparison.

Conclusions

In conclusion, negative perceptions about aging are linked to poor sleep quality. Older adults believe that aging may cause changes in sleep. Gender-based differences in perceptions about aging and appraisals of sleep exist. Women are more likely to feel powerless about aging, to complain about poor sleep quality, and to have low sleep efficiency than men. The aging process and sleep patterns change over time. Thus, longitudinal and ethnographic research designs are recommended for future studies.