The relationship between pain, sleep quality, and care dependency in older adults living in a long-term care facility

Abstract

Background

Due to the frequency of pain, sleep disorders and the complexity of their associated factors, the diagnosis of these disorders may be of great importance in identifying factors linked to care dependency in older people staying in long-term care facilities. The aim of the study was to investigate the relationship between pain, sleep quality, and care dependency in older adults living in a long-term care facility.

Methods

The study was conducted among older people staying in a long-term care facility between October 2022 and September 2023. The study used a survey questionnaire including questions about demographic and social characteristics, clinical condition and the following scales: ADL, IADL, GSD-15, GPM-24, CDS, PSQI.

Results

The analysis showed a statistically significant relationship between the deterioration of sleep quality by 1 unit and: an increase in the level of pain (B = 0.68; SE = 0.17; 95% CI [0.38; 1.10]), dependency in ADL (B = -0.09; SE = 0.04; 95% CI [-0.17; -0.02]), feeling depressed (B = 0.18; SE = 0.06; 95% CI [0 0.06, 0.31]) and care dependency (B = -0.78, SE = 0.24, 95% CI [-1.25, -0.31]). A statistically significant effect was noted between: pain level (B = -0.18; SE = 0.06; 95% CI [-0.30; -0.05], dependency in ADL (B = 1.98; SE = 0.35; 95% CI [1.28; 2.68]), instrumental activities of daily living (B = 1.86; SE = 0.28; 95% CI [1.30; 2.42]], feelings of depression (B = -0.96; SE = 0.17; 95% CI [-1.30; -0.62]) and care dependency.

Conclusions

The study is a valuable addition to research showing a strong link between pain, sleep quality and care dependency. The results support the need for a holistic approach in assessing pain, sleep quality, care dependency in older adults living in a long-term care facility.

Introduction

The aging of society results in a dynamic increase in the share of older people in the population and in an increased demand for long-term care facilities (LTCF). In the population of older people, especially those who suffer from loneliness, for whom the family cannot provide care, long-term care has become particularly important. That is because in the course of natural ageing the body’s efficiency gradually decreases, resulting in deficits in psychophysical fitness, which is further aggravated by co-existing diseases [1].

Long-term care provides support and care to people who require constant assistance and who, due to illness or disability, are unable to perform activities of daily living (ADL) on their own [1, 2]. Care dependency for ADL for people living in LTCF negatively affects their quality of life, health care costs and the workload of staff [1, 2]. Care in LTCF should focus on maintaining as high a degree of independence as possible, and studies of older adults should include care dependency as an outcome measure [3]. Identifying risk factors for care dependency in older adults living in LTCF is important for targeted interventions.

Pain in older people staying in LTCF is of importance because of the negative subjective experience and because of its objective consequences [4]. The consequence of pain is that the ability to perform everyday activities is limited or impossible. This leads to higher levels of care dependency and health care costs [3, 5,6,7,8]. Research on the perception of pain shows that from 25 to 80% of older people living in LTCF experience pain [6, 9,10,11]. The experience of pain may be compounded by the accumulation of many pain conditions [12, 13]. Additionally, evidence shows that pain has a strong association with conditions such as anxiety, depression, social isolation, loss of appetite [8], cognitive disorders, falls and sleep disorders [6, 13,14,15,16]. There is likely a bidirectional relationship between pain and sleep quality [17], as evidence confirms that pain can generate sleep disturbances, and sleep disturbances can be a predictor of experienced pain [18,19,20,21,22,23].

According to the literature, 20–73% of older adults living in LTCF report poorer sleep quality than those living in the community [24, 25]. Sleep disorders among older people staying in LTCF are most often the result of the simultaneous action of many risk factors and the activation of mutually overlapping pathogenetic mechanisms. Physiological changes in sleep architecture and pattern coexisting with multi-morbidity and adverse effects of drugs predispose to sleep disorders [26]. Moreover, older people staying in LTCF are additionally exposed to unfavourable environmental stimuli. Noise, night care practices, lack of privacy, and dormitories are factors contributing to sleep problems. Psychosocial factors, such as a sense of loneliness, lack of physical activity, and spending most of the day in bed, also predispose older people living in LTCF to sleep disorders [2, 24]. Recognizing these factors and managing sleep disturbances in long-term care residents is an important aspect of providing high-quality care [2, 26].

Long-term facilities provide patients with around-the-clock health services including nighttime nursing care and medical treatment. Nighttime care is managed according to human resources requirements and labour standards. In compliance with minimum standards of employment, the level of nursing staff cannot be lower than 40% of the total employment rate. Employment standards of medical assistants are determined taking into account daily working time required by each individual patient (i.e. his/her level of self care). These rates are recognised together with nurses’ employment rates and they vary from 0.6 of total working time per patient (i.e. 0 points according to Barthel scale) to 0.5 of total/full working time per patient (i.e. 5–40 points according to Barthel scale). What is more, a doctor is also available when called by a nurse in each long-term facility [27].

Improving pain treatment and sleep quality should be considered a priority. A better understanding of the relationship between pain, sleep quality, and care dependency could improve interventions to prevent and manage care dependency. The aim of the study was to investigate the relationship between pain, sleep quality, and care dependency in older adults living in a LTCF.

Methods

A prospective study was conducted among older people staying in a long-term care facility located in southern Poland between October 2022 and September 2023. The facility manager authorised the research and medical documentation analysis. The study was conducted by the coordinator or a member of the research team after analysing the medical documentation and the subject meeting the criteria for inclusion in the study, on the premises of the facility in conditions convenient for the examined person (time and place, in the absence of other people). After obtaining the patient’s written consent to analyse/view the medical records and the study was conducted, those who met the inclusion criteria were informed about the purpose of the study, as well as the opportunity to ask questions at each stage. The research tools used were also described in oral form. The participants of the study were aware that they would be able to withdraw at any stage of the study without suffering any consequences. The task of each respondent was to choose one answer from the distractors assigned to a given question. The duration of the study was approximately 15–20 min. The coordinator and/or a member of the research team stayed with the examined person throughout the study, providing assistance. Due to the need to access the documentation, the studies were not anonymous. The data has been anonymised. It is impossible for the Project Coordinator or any member of the research team to identify the respondent on the basis of given answers. The analysis of medical records was aimed at determining the date of admission to a LTCF, getting to know the medical diagnosis and medications. The inclusion criteria for the study were: age ≥ 60 years, duration of stay in a LTCF – one month or more; no serious cognitive impairment (MMSE ˂ 10 points); no visual impairment (‘I can’t see at all’) and/or hearing (‘I can’t hear at all’) that could prevent data collection; subject being in a period of stable health; subject giving informed written consent to participate in the study. Previous research has shown that people with mild to moderate cognitive impairment are able to answer questions about their health [28,29,30].

Initially, 256 patients age ≥ 60 years were supposed to take part in the research. However, medical condition of 14 patients (5.47%) deteriorated and 16 patients (6.25%) refused to participate in the study. Thus, the research included 226 (88.28%) elderly patients.

The collected data were subjected to statistical analysis. Only complete data/questionnaires were included in the statistical analysis. The sample size was calculated using G*Power 3.1.9.2, which showed that for linear regression, mediation and correlation analyses with a moderate effect, the power of the test was 1.00, while for correlation analyses with a weak effect, the power of the test decreased to 0.32 (below the satisfactory threshold). The results were coded, preventing the recognition of the subject. The collected data were collected in an Excel sheet of the MS Office package. The collected data was collected in an Excel spreadsheet of the MS Office package and processed using statistical analysis.

Ethics statement

The Bioethics Committee of the Jagiellonian University approved the study (no. 1072.6120.34.2022 of February 23, 2022).

General characteristics

The study used a survey questionnaire that included questions regarding demographic and social characteristics and assessment of the clinical condition.

Activities of Daily Living (ADL)

The assessment of functional ability in performing ADL was carried out using the ADL scale by Katz. A score above 5 points indicates a fully functional person (5–6 points), scores in the range of 3–4 indicate moderate disability, a score below 2 points indicates severe impairment of functional ability in everyday activities [31]. The Cronbach’s alpha internal consistency coefficient for ADL was 0.865.

Instrumental Activities of Daily Living (IADL)

The assessment of functional ability in the field of IADL was performed using the Lawton scale. The possible scoring range is 9–27 points. A decrease in points indicates a deterioration of functional ability [32]. The standardized Cronbach’s alpha coefficient value was 0.772.

Geriatric Depression Scale (GDS)

Depression was assessed using the Geriatric Depression Scale – 15 points (GSD-15) by J. A. Yesavage. A score of 0–5 points indicates a normal condition, 6–10 points indicate a moderate mood disorder, and 11–15 points indicate a severe mood disorder [33, 34]. The assessment of internal validity is confirmed by the Cronbach’s alpha coefficient value, which was 0.755.

Geriatric Pain Measure-24 (GPM-24)

Pain was assessed using the Polish version of the Geriatric Pain Measure-24 (GPM-24) scale [35, 36]. GPM-24 is a multidimensional scale for assessing pain in older people and consists of five subscales: disengagement because of pain (items 6, 17,18, 19, 20, 21, 24), pain intensity (items 1, 2, 3, 4, 5, 22, 23), pain with ambulation (items 9, 10, 11, 12), pain with strenuous activities (items 8, 13, 14), and pain with other activities (items 7, 15, 16, 17, 22). GPM-24 contains 22 dichotomous questions and 2 questions assessing the intensity of pain on a scale from 0 to 10. The total score (0–42) is obtained by summing each ‘yes’ answer (1 point) along with the pain intensity rating (0–10 points). Adjusted Score (0–100) is the total score multiplied by 2.38. A score below 30 indicates mild pain, a score of 30 to 69 indicates moderate pain, and a score greater than or equal to 70 indicates severe pain [35, 37, 38]. The internal consistency of the scale was confirmed by the Cronbach’s alpha coefficient value of 0.841.

Care Dependency Scale (CDS)

The degree of care dependency was assessed using the Care Dependency Scale (CDS). This scale includes questions about nutrition, control of physiological activities, body posture, ability to move, day and night rhythm, dressing and undressing, body temperature, personal hygiene, avoiding dangers, communication, social contacts, adherence to rules and values, daily activities, leisure, and learning abilities. Each category is assessed individually using a 5-point scale. The scale score: 15–44 indicates a high level of dependence on care, 45–59 – a medium level of dependence on care, 60–75 – a low level of dependence on care [39]. The reliability of the discussed scale was assessed based on the Cronbach’s alpha internal consistency coefficient, which was 0.939.

Pittsburgh Sleep Quality Index – PSQI

Sleep quality was assessed using the most commonly used method in clinical and research studies: Pittsburgh Sleep Quality Index – PSQI [40]. The global PSQI score for these components ranges from 0 to 21 points, a higher score means worse sleep quality. A score above 5 points means sleep disorders and a score below 5 points means no sleep disorders [41, 42]. The assessment of the internal validity of the scale is confirmed by the Cronbach’s alpha coefficient value, which was 0.636.

Statistical analysis

To answer the research questions and test the hypotheses, statistical analyses were carried out using the IBM SPSS Statistics version 29 package. It was used to analyse basic descriptive statistics, correlation analysis with Pearson’s r coefficient and linear regression analysis. Additionally, mediation analysis was performed using the PROCESS v3.4 macro. The classic threshold of α = 0.05 was assumed as the level of statistical significance.

Results

Among the 226 people (219 women, 123 men) over 60 years of age included in the presented analysis, the percentage of surveyed women was higher compared to men (64% vs. 36%). The mean age was 78.44 (± SD 9.06). The sociodemographic and clinical characteristics are presented in Table 1.

Table 1 Sociodemographic and clinical characteristics of older people staying in long-term care facilities

Descriptive statistics of measured quantitative variables

In the first step of the analysis, basic descriptive statistics were calculated along with the Kolmogorov-Smirnov (K-S) test examining the normality of the distribution of all measured variables on a quantitative scale. Outliers (with a value greater than |3SD|) were removed before analysis. The analysis of variables was statistically significant – the exception was the level of care dependence assessed by CDS. This means that only the distribution of this variable is similar to the normal distribution. In the case of the remaining variables, the distributions do not resemble a normal distribution, but at the same time their skewness does not exceed |2|, which indicates a slight level of asymmetry [43] which allows for the use of parametric tests.

Correlation analysis of the relationship between pain and sleep quality

The analysis of the Pearson’s r coefficient showed a significantly positive correlation in the study group between:

• withdrawal due to pain and sleep latency, sleep efficiency (weak relationships) as well as sleep disorders, impaired daytime functioning and overall sleep quality (moderate relationships);

• pain intensity and sleep efficiency, sleep disorders;

• pain associated with walking and subjective sleep quality, taking sleeping pills, impaired functioning during the day, general sleep quality (weak correlations);

• pain resulting from strenuous activities and subjective sleep quality, sleep latency (weak relationships), sleep duration, use of sleeping pills, impaired functioning during the day, overall sleep quality;

• pain resulting from other activities and the subjective quality of sleep, sleep latency, sleep duration, impaired functioning during the day, overall sleep quality (weak relationships);

• general assessment of pain and sleep latency, sleep duration, sleep disorders, use of sleeping pills, impaired functioning during the day, general assessment of sleep quality (weak relationships). This means that as pain increases, sleep quality decreases.

A significantly negative correlation was demonstrated between:

• pain intensity and sleep efficiency, sleep disorders (weak relationships, as the intensity of pain increases, sleep efficiency increases and sleep disorders decrease) – Table 2.

Table 2 Analysis of Pearson’s r correlation between pain perception and sleep quality in older people staying in a LTCF

Analysis of the correlation between pain, sleep quality and dependence on care in older people staying in a LTCF

Correlation analysis of the Pearson r coefficient showed a significantly negative correlation between:

• withdrawal due to pain, intensity of pain, pain associated with walking, pain resulting from strenuous activities, pain from other activities, total pain score and dependence on care (as pain intensity increases, dependence on care increases;

• sleep efficiency, sleep disorders, daytime functioning disorders, general sleep quality and dependence on care (with better sleep quality, dependence on care decreases in the study group) Table 3.

Table 3 Pearson’s r correlation between pain sensation, sleep quality and care dependency in older people living in a LTCF

Predictors of care dependency

To determine variables predicting dependency on care, linear regression analysis was performed using the hierarchical method. Sociodemographic and clinical variables were included in the analysis. First, the model was built from the following predictors: gender, age, BMI, education, marital status, place of residence and structure of residence before admission to a LTCF. Secondly, variables including clinical status (number of diseases and medications taken) and variables related to the length of stay in a LTCF were included. Thirdly, the following variables were included: functional ability in the scope of ADL, functional ability in the scope of IADL, feelings of depression, next the level of pain intensity was added, and finally sleep quality was added.

Given the prior linear relationship between BMI and care dependency, groups were merged for analyses (assuming coding for BMI). Ordinal or multilevel nominal variables were coded using dummy variable encoding, setting the lowest level as the reference point. The variables age, ADL, IADL, GDS, GMP-24, and PSQI were included in the analysis as quantitative variables. The model did not show any outliers based on the values of standardized residuals or the Mahalanobis distance. Within variables, observations exceeding the third standard deviation were removed. Taking into consideration outliers, in the further analysis the number of administered medications was removed for two subjects (0.9%) as well as IADL for one patient (0.4%), while 6 subjects (2.7%) were removed for the PSQI due to missing/incorrect data. Moreover, the remaining assumptions of the analysis were met, the results of which are presented in Table 4.

Table 4 Results of linear regression analysis for care dependency based on sociodemographic and clinical variables

The mediating role of clinical status and pain indicators on the relationship between sleep quality and care dependency

To check the existence of total mediation of the relationship between sleep quality and dependence on care, taking into account functional ability, depression and pain (ADL, IADL, GDS and GPM-24) as mediators, a moderation analysis was performed using the PROCESS v3.4 macro. The following sociodemographic variables were introduced into the model: BMI, place and structure of residence before admission to a LTCF. Figure 1 presents the standardized regression coefficients of the mediation model.

Fig. 1

Standardized coefficients of the mediation model of the relationship between sleep quality and care dependency

In the first step, the relationship between the independent variable (sleep quality) and the mediators was checked. The analysis showed a significant impact of sleep quality on the level of pain: B = 0.68; SE = 0.17;. As sleep quality deteriorates by 1 unit, pain levels increase by 0.68 units. A significant impact of sleep quality on functional ability in everyday activities was also demonstrated: B = -0.09; SE = 0.04;. Deterioration of sleep quality by 1 unit results in functional ability in everyday activities being lower by 0.09 units. In turn, the impact of sleep quality on functional ability in performing IADL turned out to be statistically insignificant: B = -0.07; SE = 0.05. A significant effect was found between sleep quality and depression: B = 0.18; SE = 0.06. As the quality of sleep deteriorates by 1 unit, the level of depression increases by 0.18 units.

Next, the influence of mediators on the dependent variable (care dependency) was checked. A statistically significant effect was noted between pain and care dependency: B = -0.18; SE = 0.06. It was shown that with an increase in pain by 1 unit, the dependence on care increases by 0.18. Functional ability in performing everyday activities also influences dependence on care: B = 1.98; SE = 0.35. Higher functional ability in everyday activities by 1 unit results in the level of independence from care being 1.98 units higher. Moreover, a significant impact of functional ability in the field of IADL on dependence on care was observed: B = 1.86; SE = 0.28. If the level of this ability increases, the level of independence from care increases. The last mediator, depression, also significantly changes care dependency: B = -0.96; SE = 0.17. An increase in depression by 1 unit results in an increase in the level of care dependency by 0.96 units.

The total effect of sleep quality when controlling for sociodemographic variables is statistically significant: B = -0.78; SE = 0.24. Without considering mediators, when sleep quality deteriorates by 1 unit, care dependence increases by 0.78 units. The direct effect was checked taking into account mediators in the model. This effect turned out to be statistically insignificant: B = -0.18; SE = 0.15.

Using the 5000 sampling method, the significance of the indirect effect was checked to verify the mediating roles of depression, functional ability and pain in the relationship between sleep quality and care dependency [44]. The total indirect effect was statistically significant (Table 5). This proves the important mediating role of the indicated mediators. To precisely check the effects, each mediator was tested separately. It turned out that pain, functional ability in ADL and depression are mediators of the relationship between sleep quality and dependence on care. In turn, the indirect effect of functional ability in IADL turned out to be insignificant, which proves that this variable does not play a mediating role in this relationship. There were also no differences in indirect effects. Due to the lack of a significant effect of sleep quality on care dependency in the mediation model, there appears to be a complete mediation effect (Table 5).

Table 5 Standardized values of the indirect effects of sleep quality on care dependency

Discussion

The paper presents the results of the relationship between pain, sleep quality and care dependency in older people staying in a LTCF. The total mediating effect in the study showed that pain, functional ability, and depression are mediators of the relationship between sleep quality and care dependency.

The results of the study showed a relationship between pain and care dependency in older people living in a LTCF. The mediation results showed that with an increase in pain by 1 unit (assessed by the GPM-24 scale), care dependency assessed by the CDS scale (within a possible 60-point range) increases by 0.18 units among the study participants. Correlation results also showed that as pain withdrawal, pain intensity, pain associated with walking, strenuous and other activities, and GPM-24 total score increase, care dependency increases as well. The association between pain and care dependency in older people living in a LTCF was also confirmed in a Dutch study [44]. Although a cross-sectional study showed that with an increase in pain by one unit assessed by the Numerical Rating Scale (NRS), the care dependency (assessed by the CDS questionnaire) increased by 0.65 units. However, a higher baseline pain score was not associated with greater care dependency at 2 months of follow-up (for every one unit increase in pain, 0.20% less care dependency was demonstrated with an adjusted regression coefficient of 0.20). As shown in this study, both stable pain and pain with increasing severity were associated with increased progression of care dependency compared to those who experienced a reduction in pain. Longitudinally, a 2-unit increase in care dependency was demonstrated for those with stable or increased pain, while stable care dependency was demonstrated among those with decreased pain. The authors of the study explain that 2 units can be the critical cut-off point between losing or maintaining self-esteem, for example in performing everyday activities. Since as many as 70% of people in this Dutch study were people with stable and severe pain, appropriate pain treatment can have a wide impact on care dependency, the study authors emphasize [45].

The relationship between care dependency (assessed by the CDS questionnaire) and pain (assessed by trained nurses on a 5-point scale) in older people staying in LTCF was also confirmed in an Austrian study. This study found that people experiencing pain were more likely to be dependent on care than people without pain. Moreover, this study showed that pain relief appears to be correlated with varying degrees of care dependency. People who experienced mild/moderate pain and were care-dependent were more likely to receive non-pharmacological interventions than people who were care-dependent with pain [46]. However, in a cross-sectional study by Tabali et al. no relationship was found between care dependency (CDS score) and pain perception. Despite a similar research group, the study covered only 120 people, pain was measured using ‘yes/no’ questions, and the CDS result was divided into 3 categories [47].

The results of the study also confirm the relationship between sleep quality and dependence on care in older people living in LTCF. The study showed that with the deterioration of sleep quality by 1 unit, the dependence on care assessed by the CDS scale (with a possible 60-point range) decreases by 0.78 units, i.e. the dependence on care among the surveyed people increases. The correlation results also confirmed that with better sleep quality, dependence on care decreases in the study group. Research conducted among older people staying in LTCF shows that the consequences of sleep disorders are daytime symptoms in the form of fatigue and daytime sleepiness, and, as a result, deterioration of ability to perform everyday activities, leading to increased dependency on care [2, 22, 24, 26, 48].

Although pain and sleep quality have a bidirectional relationship, research to date indicates that sleep disorders generally predict pain to a greater extent than pain predicts sleep disorders [22, 23, 49]. The study showed that with the deterioration of sleep quality by 1 unit, the pain level increases by 0.68 units. A bidirectional association between sleep quality and pain in older adults was confirmed in a 6-month observational study in Brazil where pain and sleep were assessed as a continuous measure in a statistical analysis. This study found that baseline sleep quality predicted pain intensity, and baseline pain intensity predicted poor sleep quality. This study showed that for every 1 point increase in sleep quality (i.e. sleep quality assessed by PSQI deteriorates), pain intensity increases by 0.18 points (NRS), while each 1 point increase in pain intensity causes sleep quality to deteriorate by 0.14 points. Although this association appears to be stronger for sleep quality predicting pain intensity, it is still unclear whether pain intensity can be used to predict sleep quality [50]. Nevertheless, numerous studies show that pain is a reliable predictor of poor sleep quality [23, 24, 51]. Our results confirm that as pain increases, sleep quality decreases. Moreover, it was shown that as the intensity of pain increases, sleep latency, sleep duration, sleep disturbances, the frequency of taking sleeping medications, and impaired functioning during the day increases, which emphasizes the need for regular assessment of sleep quality and pain in LTCF.

Due to the frequency of pain, sleep quality disturbances and the complexity of their associated factors, the diagnosis of these disorders may be of great importance in identifying factors of care dependency in older people staying in LTCF. Implementing policies and promoting regular assessment of pain and sleep quality may improve treatment in LTCF. Healthcare professionals’ knowledge and approach to assessing pain and sleep quality in older people may also influence treatment to some extent. Therefore, employees of LTCF must be aware of their responsibility for the correct identification and treatment of these conditions. This is important because this awareness can reduce the negative consequences of pain, sleep disorders such as reduced quality of life, reduced functional ability and increased dependency on care.

It should be emphasized that the presented study has both limitations and strengths. The strength of the study is that it analyses the impact on care dependency of the two most common ailments among older adults in LTCF, and that potential confounders of this dependency were carefully assessed with in-depth statistical analysis. The second advantage of this study is the use of the Polish version of the CDS scale, which considers physical and psychosocial aspects in assessing care dependency, while other scales only take into account physical aspects. Another advantage of this study is the assessment of pain carried out using the multidimensional Polish version of the Geriatric Pain Measure-24 (GPM-24) scale, which takes into account psychological and functional aspects, while other one-dimensional scales only assess the intensity of pain.

The limitation of the study is the prospective nature of the design, which makes it challenging to establish definitive causal relationships. Assessing the care dependency of people with pain would demonstrate improved validity in longitudinal studies, making it a parameter of continuity. Secondly, the presented results are also limited by the fact that they do not take into account the location of pain, which could have a significant impact on care dependency, and the sleep quality assessment did not analyse the impact of environmental factors that may disturb the sleep of older people staying in a LTCF. Third, pain assessment depends on self-esteem and cognitive functions. People with severe cognitive impairment and communication difficulties were excluded from the study, limiting the possibility of obtaining results among people with cognitive impairment. Pain as a risk factor may be particularly important in this group of people because their discomfort is often undiagnosed and poorly treated. Therefore, the results of this study cannot be generalized to all older adults living in a LTCF. The study design could have been improved by assessing the reason for admission to a LTCF and by conducting additional follow-up measures of pain, sleep quality, and care dependency. Repeated measurements at shorter and longer intervals could provide insight into the short- and long-term effects of pain and sleep quality on care dependency.

Conclusions

The study is a valuable addition to research showing a strong link between pain, sleep quality and care dependency. The results of this study support the need for a holistic approach in assessing pain, sleep quality, and care dependency in older adults living in a LTCF. Multidisciplinary assessment of older adults in a LTCF is critical to reducing pain, improving sleep quality, and increasing independence from care.