Informal Care and Sleep Disturbance Among Caregivers in Paid Work: Longitudinal Analyses From a Large Community-Based Swedish Cohort Study

Sleep, Feb 2018

Sacco, Lawrence B, Leineweber, Constanze, Platts, Loretta G

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Informal Care and Sleep Disturbance Among Caregivers in Paid Work: Longitudinal Analyses From a Large Community-Based Swedish Cohort Study

Informal Care and Sleep Disturbance Among Caregivers in Paid Work: Longitudinal Analyses From a Large Community-Based Swedish Cohort Study Lawrence B. Sacco Emalila: Constanze Leineweber 0 Loretta G. Platts 0 S,UtrKe,ss Research Institute, Stockholm University, Stockholm, Sweden Work performed: Stress Research Institute, Stockholm University , Stockholm , Sweden 1 Department of Global Health and Social Medicine, Institute of Gerontology, King's College London , London Study Objectives: To examine cross-sectionally and prospectively whether informal caregiving is related to sleep disturbance among caregivers in paid work. Methods: ParticipantsN( = 21604) in paid work from the Swedish Longitudinal Occupational Survey of Health. Sleeping problems were measured with a validated scale of sleep disturbance (Karolinska Sleep Questionnaire). Random-effects modeling was used to examine the cross-sectional association between informal caregiving (self-reports: none, up to 5 hours per week, over 5 hours per week) and sleep disturbance. Potential sociodemographic and health confounders were controlled for and interactions between caregiving and gender included. Longitudinal random-effects modeling of the effects of changes in reported informal caregiving upon sleep disturbance and change in sleep disturbance was performed. Results: In multivariate analyses controlling for sociodemographics, health factors, and work hours, informal caregiving was associated cross-sectionally with sleep disturbance in a dose-response relationship (compared with no caregiving, up to 5 hours of caregivingβ: = 0.03; 95% CI: 0.01, 0.06, and over 5 hours:β = 0.08; 95% CI: 0.02, 0.13), results which varied by gender. Cessation of caregiving was associated with reductions in sleep disturbanβce=(−0.08; 95% CI: −0.13, −0.04). Conclusions: This study provides evidence for a causal association of provision of informal care upon self-reported sleep disturbance. Even low-intensity care provision was related to sleep disturbance among this sample of carers in paid work. The results highlight the importance of addressing sleep disturbance in caregivers. carer; cohort study; epidemiology; informal care; Karolinska Sleep Questionnaire; SLOSH; sleep disturbance - Sleep disturbances are a common health problem. One likely cause of sleep disturbance is provision of informal care to an elderly, ill, or disabled person. In this prospective analysis of 21 604 participants in paid work, caregiving was -associ ated with self-reported sleep disturbance, particularly at higher numbers of hours of informal care. The effects of -provid ing informal care at different intensities varied between women and men. In analyses of change in caregiving, providing caregiving at the first but not the second wave was associated with reduction in sleep disturbance. These findings support the hypothesis that provision of informal care affects the carer’s sleep quality. Further large-scale studies to examine the mechanisms of sleep disturbance among in-work carers are required. Introduction and longitudinal associations of caregiving with sleep -dis turbance. Important health and demographic confounders of Sleeping problems are common: in Swedish adults aged 18–84, the caregiving-sleep relationship are controlled for. Firstly, we insomnia disorder, that is, insomnia symptoms and daytime examine whether greater intensity of caring, operationalized consequences, has an estimated prevalence of around 10.5% and using weekly hours of care provided, is associated with sleep symptoms of insomnia are reported by one-quarter of the pop-u disturbance in cross-sectional analyses. We hypothesize that lation[ 1 ]. Evidence is growing that people with insomnia sym-p providing informal care will be associated with sleep distu-rb toms have a raised risk of developing physical illnes[2s], specific- ance, although the benefits of “role enhancement” may mean ally cardiometabolic disease, occupational injuries, and all-cause that carers providing low-intensity caregiving experience lower mortality[3, 4]. In terms of mental illness, disturbed sleep and levels of sleep disturbance than noncaregivers. Since women tiredness are common symptoms of mood disorders such as tend to provide more informal care than me[n7], and reports depression [5]. Consequently, addressing the causes of insomnia of insomnia symptoms are more frequent for women than for may contribute to improvements in population heal[t6h]. men [ 1 ], gender interactions are included in these analyses in One likely important cause of sleep disturbance is provision case the relationship between caregiving and sleep disturbance of informal care to an elderly, ill, or disabled person. Informal differs by gender. Secondly, in longitudinal analyses, we exa-m care is assistance provided by people from the intimate envir-on ine the effects of changes in caregiving upon sleep disturbance ment of the dependent person, who do not receive any training and upon change in sleep disturbance. We hypothesize that or economic compensation. It is common: in the United States, commencing informal caregiving will be associated with greater 16.6% of adults[ 7 ] and in Sweden, 10.9% of adults[8] are cur- sleep disturbance and cessation of caregiving with reduced rently informal carers, rates that are expected to increase in linesleep disturbance. To the best of our knowledge, only one study with population aging and cut-backs in publicly funded ca[r9e]. has previously examined the relationship between starting and Informal caregiving has been associated, albeit inconsistently, stopping provision of informal care on sleeping problems, in a with a range of poor health outcomes among carers in large small sample of spousal Alzheimer caregiver[2s6]. In short, the cross-sectional and prospective studie[s10–13], depending on longitudinal analyses performed in this study may offer a-dd the characteristics of the carer and person cared for, type of itional evidence for a causal relationship between informal c-are health outcome, type of care provided, and duration of follow- giving and sleep disturbance in a large sample of in-work carers. up [14, 15]. However, some studies find that caregiving may be neutral or benefit carers’ health, e.g., by providing an additional rewarding role r(ole enhancement) and improving the quality of family relationships[ 16–20 ]. Among other factors, it is pro-b METHODS able that the intensity and duration of care provision determine whether and to what degree caring has a positive or negative Study Population impact on the caregiver. Participants in the Swedish Longitudinal Occupational Survey Although it has been argued that various aspects of the care-giv of Health (SLOSH) formed the study population. SLOSH is a ing role impact on sleep specificall[y21], recent reviews of the ev-i biennial postal survey, which follows a subsample of gainfully dence note that few adequately powered, community-based, lon-gi employed people aged 16–64 from the Swedish Labour Force tudinal studies have examined the impacts of caregiving on sleep Survey who were recruited into the Swedish Work Environment [ 22–24 ]. Existing studies point to poorer sleep among caregivers, Surveys (SWES) 2003–2011 [ 31 ]. Both SLOSH and the present but apart from certain exceptions, tend to be cross-sectional, use study have been approved by the Regional Research Ethics Board small samples which make effects hard to detect, or only examine in Stockholm. All participants provided informed consent. specific groups of carers without comparing them to the general SLOSH participants respond to one of the two versions of population. Important confounders such as the caregiver’s edu-ca the postal questionnaire: an in-work questionnaire for those tion level or health may not be controlled for, factors which lead tocurrently in paid work at least 30% of full-time and another for both selection into the caregiving role and sleep disturban[1c7e]. those working less or who are outside the labor force whether Stronger evidence would also be provided by prospective designs permanently or temporarily. The present study is based on linking changing provision of care to changes in sleep, but almost information provided in the in-work questionnaires only from no research has so far done so[25, 26]. 2010, 2012, 2014, and 2016. Response rates to the SLOSH que-s Although recent reviews have argued for greater focus on tionnaires were 57% in 2010 and 2012, 53% in 2014, and 51% in subpopulations of carers in terms of factors such as ag[2e7], 2016. In total, 21604 participants responding to at least one inor care recipient characteristic[s28], to the best of our know- work questionnaire were included in the study, providing 42928 ledge, prior research has not examined the impact of ca-re observations for the analysis. The change analyses required p-ar giving on sleep in the important and large population of -car ticipants to respond to the in-work questionnaire in at least two egivers who are simultaneously engaged in paid work. This is consecutive waves, a requirement which reduced the sample to despite evidence that difficulties combining work tasks with 12253 people. family obligations can generate stress and health proble[m29s, 30], Specifically, the demands of paid work may conflict with requirements to provide informal care, which may lead troole Sleep Disturbance overload, in which an individual with a finite amount of time and Self-reported sleep disturbance was measured at each wave energy experiences strain from trying to fulfil multiple ro[1l6e]s. using a validated measure of disturbed sleep composed of four Consequently, this study focuses on caregivers and no-n questions from the Karolinska Sleep Questionnair[e32–34]. The caregivers who are in paid work, and uses a large community- measure contains the core symptoms of insomnia; specifically based prospective dataset to examine both the cross-sectional participants were asked how often they had been disturbed in the previous 3  months by difficulties falling asleep, repeated the previous 3 months (specifically headache, pain in the neck awakenings with difficulties going back to sleep, premature or shoulders, pain in the lower back, or other pain). For both (final) awakening, or disturbed or restless sleep, with response variables, participants could respond: no; yes, but this does not options ranging from 0 (“never”) to 5 (“always/five times a affect their life at all; yes, this affects their life a little; or yes, this week”). Item nonresponse rates were low: 1.1% for one missing affects their life a lot. The two variables were dichotomized such item, 0.2% for each of two and three missing items, and 1.1% that reports that chronic disease or pain/discomfort affected the for four missing items. An average sleep disturbance score was participant’s life either a little or a lot were coded as 1, otherwise calculated for participants who provided responses to at least they were coded as 0. three of the four items. Change in sleep disturbance from one Self-rated health and reports of depressive symptoms were wave to the next was calculated by subtracting the score in the included in the analyses as both potential confounders and earlier wave from the score in the next wave. mediators of the relationship between informal caregiving and sleep disturbance. To measure self-rated health, respondents were asked: “How would you rate your general state of health” Provision of Informal Care with the responses: very good, good, neither good nor bad, quite At each study wave, questions about participants’ time use in poor, or very poor, a single-item measure of general physical a typical work week were used to identify how much care in and mental health which predicts mortali[t3y9, 40]. A brief sixhours participants provided for a relative other than a child or item version of the Symptom Checklist Core Depression Scale grandchild. Original response categories were 0 hour (85.8% of (SCL-CD6) was used to measure depressive symptomatology sample members), 1–5 hours (12.4%), 6–10 hours (1.2%), 11–15 [41–43]. Questions in this scale evaluate how much (from 0 = not hours (0.3%), and >15 hours (0.4%). The last three categories were at all to 4 = very much) participants were troubled by lethargy collapsed into >5 hours per week since relatively few respo-nd or low energy, feeling blue, blaming oneself, excessive wor-ry ents provided high numbers of hours of informal care. A dich-ot ing, feelings of no interest in things, and feeling that everything omized variable of caregiving was used in analyses examining is an effort. An overall score (0–24) was obtained by summing change between consecutive waves: no care-giving and prov-i responses to all items. sion of any care (at least 1 hour per week). This generated the Self-rated health and depressive symptoms were considered combinations: no caregiving at either wave; no caregiving at the to be potential confounders of the informal caring–sleep r-ela first wave, caregiving at the second wave; caregiving at the first tionship because poor self-rated health and depressive sym-p wave but not at the second; and caregiving at both waves. toms might prevent carers from providing help to relatives and also be likely to increase sleep disturbance. However, self-rated health and depressive symptoms might also mediate the re-la Covariates tionship from informal caregiving to sleep disturbance; i.e., they may be on the causal path. Previous research has highlighted Selection of covariates was performed by drawing directed ac-yc the importance of physical fatigue and tiredness to how p-eo lic graphs based on existing knowledge of factors which might ple evaluate their self-rated healt[4h0, 44]. Furthermore, fatigue affect both sleep disturbance and possibilities to provide in-for and sleep disturbance are common symptoms of depressive mal care[ 35 ]. The sociodemographic variables of gender, age, episodes in the ICD-10 classification of mental and behavioral marital status, and education were included in the analyses as disorders. possible confounders of the relationship between caring and Paid work intensity was measured in four categories indic-at sleep disturbance. Information regarding gender, age, education, ing time spent weekly in paid work created from participants’ and marital status (0 = married/cohabiting and 1 = nonmarried/ reports (<10 hours, 10–19 hours, 20–29 hours, and ≥30 hours). This divorced/widowed/single) was obtained through linkage using covariate could be both a confounder or mediator of the in-for individual person numbers to Statistics Sweden’s Longitudinal mal caring–sleep relationship: a confounder because time in paid Individual Data Base (LISA) administrative register. Age was c-en work could affect both the number of hours dedicated to informal tered at its mean of 50 years. In order to model nonlinear r-ela caregiving and sleep disturbance, and a mediator because hours tionships between age and sleep disturbance, squared and cubic spent providing informal care could lead to a decrease in hours functions of age were generated. Highest education level was of paid work, which in turn may affect sleep disturbance if, for grouped into the following categories: compulsory schooling; example, this generated financial difficulti[e4s5]. 2  years upper secondary/vocational training or 4  years upper secondary; university or equivalent shorter than 3 years; and at least 3 years of university or equivalent. Two variables recorded participants’ perceptions of whether Statistical Methods their lives were affected by (1) any of a range of chronic co-n Statistical analysis was carried out in Stata 14.2 (Stata ditions and (2) physical pain or discomfort. These variables Corporation, College Station, TX, USA). We performed r-an were included as confounders because such health problems dom intercept (random effect) modeling, which allows the might prevent carers from providing help to relatives and are use of full information provided by longitudinal data, while also likely to increase sleep disturbanc[e36–38]. Specifically, accounting for the dependency of repeated measures within participants indicated whether they had any of the foll-ow individuals [46]. These models use both the between- and ing chronic conditions (hypertension, cardiovascular disease, within-subject components of the variability that are present diabetes, rheumatic disorder, musculoskeletal disorder, m-en in longitudinal data. tal illness, asthma, obstructive pulmonary disease, migraine, Two main analyses were performed, which both present physical disability, cancer, and other illness) and in a separate results from the random intercept models as regression c-oef question whether they had experienced pain or discomfort over ficients with 95% confidence intervals. First, cross-sectional associations between intensity of informal caregiving (no ca-re disturbance even after controlling for the average older age of giving, up to 5 hours, and over 5 hours) and sleep disturbance caregivers. were examined. The reference group contained participants In the random effects model, presented inTable 2, informal who provided no informal care. These bivariate associations are care provision was associated with sleep disturbance before presented as Model 1. In Model 2, variables were included that (Model 1) and after adjustment for possible socioeconomic and were considered to be potential confounders (sociodemograp-h health confounders (Model 2). Specifically, after adjustment, ics, physical pain, and chronic disease) because they might affect compared with participants who were not providing informal both sleep disturbance and possibilities to provide informal care, those who were providing care up to 5 hours per week care. In Model 3, additional variables (self-rated health, dep-res reported higher levels of sleep disturbancβe =( 0.07; 95% CI: 0.04, sive symptoms, and hours in paid work) were included which 0.09), whereas those who were providing over 5 hours of care might be both confounders and mediators of the informal c-ar reported highest levels of sleep disturbanceβ (= 0.17; 95% CI: ing–sleep relationship. In other words, in addition to being likely 0.11, 0.23). In Model 3, we adjusted for depressive symptoms, confounders, these factors may also lie on the causal pathway self-rated health and hours in paid work, and variables which from informal caregiving to sleep disturbance. Consequently, could be both confounders and mediators of the association adjusting on them may remove part or all of any effect of in-for between caregiving and sleep. Following this adjustment, ca-re mal caregiving on sleep disturbance (overadjustment). Potential giving was still associated with higher levels of reported sleep interactions between gender and care-giving intensity were also disturbance (up to 5 hours of careβ: = 0.03; 95% CI: 0.01, 0.06 and examined (Model 4). over 5 hours of care:β = 0.08; 95% CI: 0.02, 0.13). Second, we examined changes in informal caregiving Gender interacted significantly with carinTgab(le 2, Model 4 (whether providing any care or not) between two consecutive and Figure 1). Men who did not provide care and who provided waves in relation to sleep disturbance at the second of the up to 5 hours of care had similar levels of sleep disturbance. two waves, as well as in relation to change in sleep distu-rb Both groups had significantly lower sleep disturbance than men ance between the waves. All of the changes between the four who provided over 5 hours of care. Women who provided up to available waves were simultaneously modeled in random int-er 5 hours of informal care weekly reported slightly more sleep cept models. Covariates were taken from the second of the two disturbance than women who provided no care; differences waves. The reference group contained participants providing no between those groups and women providing more than 5 hours informal care in either of the two waves. of care were not discernibleF(igure 1). In Table  3, random effects models of change in caregiving on both sleep disturbance and change in sleep disturbance are RESULTS presented. The left-hand set of analyses present change in ca-re Descriptive and bivariate statistics of the total study sample giving from one wave to the next on sleep disturbance at the (N = 21604)  are presented inTable  1 using information from second of the two waves. Compared with participants who did the baseline survey year for each individual. Although most of not provide informal care in either wave, those who provided the sample (18531 participants) did not report providing in-for care during at least one time point had greater sleep dist-urb mal care at baseline, 2675 participants (12.4%) reported pro-vid ance both before (Model 1) and after adjustment (Model 2) for a ing informal care up to 5 hours per week, and 398 participants range of possible confounders at the current wave. Specifically, (1.8%) reported higher number of hours of care. Caregivers were compared with participants who did not provide informal care more likely to be female, be older, have a lower education level, in either wave, those who provided care at both waves had s-ig report that their life was affected by physical pain or discomfort nificantly greater sleep disturbancβe =( 0.10; 95% CI: 0.04, 0.15), or by chronic illness, report poorer self-rated health, depressive as did those who provided care only at the second of the two symptoms, and sleep disturbance, and be in paid work under 20 waves (β = 0.07; 95% CI: 0.03, 0.12), and those who provided care hours per week. In sensitivity analyses (not shown), caregivers at the first, but not at the second wavβe =( 0.05; 95% CI: 0.00, had poorer physical and mental health as well as greater sleep 0.10). Results from Wald tests showed that differences in sleep Caregiving > 5 h per week 1.8% disturbance among these three categories in which participants at both waves:χ2: 4.45, p = .035). Performing caregiving in both provided care in at least one wave were not significant at the 5% waves and providing care only at the current wave were not level. Only the coefficient for high sleep disturbance for those associated with change in sleep disturbance compared with the who were caring in both waves remained significant at the 95% reference group composed of participants who did not provide level after including variables in Model 3 (self-rated health, care at either wave. depressive symptoms, and time spent in paid work), which may be both confounders and mediators of the caregiving–sleep relationship. Discussion The right-hand set of analyses present change in caregiving In this large sample of Swedish people in paid work, prov-id from one wave to the next upon change in sleep disturbance ing informal care predicted higher levels of self-reported sleep over the same period. Compared with participants who did not disturbance, particularly when more than 5 hours of care per provide informal care in either wave, providing caregiving at the week were provided, associations which were robust to incl-u previous but not the current wave was associated with a red-uc sion of demographic and health covariates as well as time in tion in sleep disturbance over the same time period, results paid work. These results correspond to previous research su-g which changed little after adjustment for possible confounders gesting that informal caregiving impacts on self-reported and and mediators (Model 2:β = −0.07; 95% CI: −0.12, −0.02 and Model objective sleep[ 22–24, 47 ]. and that providing informal care for a 3: β = −0.08; 95% CI: −0.13, −0.04). Results from Wald tests showed higher number of hours is more strongly associated with sleep that this group who provided care only at the first wave also disturbance[48, 49], Studies have shown that provision of nigh-t reported a reduction in sleep disturbance in comparison to the time care is associated with poorer self-reported slee[4p9], as other two caregiving groups ( compared with caregiving only at is (albeit inconsistently) when carers and care recipients are the second wave: χ2: 7.85, p = .005; compared with caregiving coresident[50–52], It might be expected that providing relatively Table 2. Sleep Disturbance in Relation to Level of Informal Caregiving (Swedish Longitudinal Occupational Survey of HeNa l=t h21, 604, Random Effects Models) low intensity of informal care (up to 5 hours a week) would be with little or no choice about engaging in caregivin[5g5]. The associated with better sleep through the mechanism of role impacts of caregiving upon sleep disturbance extend beyond enhancement. However, in this Swedish working sample, even the time taken for care tasks: caregivers may be on 24-hour call low intensity caregiving was associated with self-reported sleep [21, 56] and the emotional labor involved in caregiving can g-en disturbance, suggesting that in-work carers may be experie-nc erate substantial worry and distress. Accordingly, introduction ing stress generated by role overload in managing the comp-et of depressive symptoms and self-rated health into the models ing commitments of paid work and informal caregiving. attenuated the relationship between provision of informal care In terms of the stress process model, in which primary stre-ss and sleep disturbance. This result accords with prior research ors generated by informal caregiving lead to problems in other which has highlighted the comorbidity of insomnia symptoms domains, such as job-caregiving conflicts[ 53 ], such role over- with depression[ 24 ] and self-rated healt h[ 57 ], and found crossload may be generated due to the difficulty of apportioning time sectional and longitudinal associations between sleep and affect and energy to two relatively inflexible activiti[e5s4]. In-work in caregivers[ 25, 58, 59 ]. carers have partial control at best over the timing of car-egiv In contrast to a previous study which failed to find gender ing and paid work activities, leading to scheduling difficulties differences in the impact of caregiving upon sleeping problems (e.g., providing care at unpredictable times, at night, and during [50], we found significant interactions between gender and inf-or the working week), and the difficulty of catching up on sleep mal caring in relation to sleep disturbance, specifically similar during the day due to the fixed timing of most jobs. Informal levels of sleep disturbance in men providing no caregiving and caregiving, unlike other unremunerated activities, is often p-er up to 5 hours of caregiving and much higher sleep disturbance formed out of a sense of moral obligation, particularly when the among men providing more than 5 hours of care. Women had care recipient is a close family member, leaving some caregivers higher levels of sleep disturbance overall; differences among CI = confidence interval. *p < .05; **p < .01; ***p < .001. Model 1 was unadjusted. Model 2 included gender, age, age-squared, age-cubed, education level, marital status, pain, and chronic disease at the second of the two waves. Model 3 additionally contained self-rated health, depressive symptoms, and hours in paid work at the second of the two waves. aThe outcome is sleep disturbance at1.t bThe outcome is change in sleep disturbance between−1tand t1. women by caregiving status were smaller than among men. It of spousal death on nighttime wakening and sleep time (mea-s is possible that gender differences in sleep disturbance at m-od ured with actigraph data), but no effect on self-reported sleep erate levels of caregiving are due to different tasks being p-er complaints. formed by male and female carers, e.g., more personal care and routine tasks being performed by female carer[s60,61]. Higher intensity caregiving is more often spousal care, where gender Strengths and Limitations differences in care tasks are smalle[r60]. It would be valuable for The major strengths of this study are its use of a validated future research to examine gender differences in large samples, measure of sleep disturbance with good measurement pro-p where information about the carer burden, who is cared for and erties in a longitudinal analysis of a large sample with a wide the tasks performed, is available, in order to examine possible range of demographic and health covariates. In addition, the mechanisms generating gendered differences in the impact of random effects model is a robust approach to dealing with caregiving upon sleep disturbance. unbalanced panels and missing data due to attrition, which is Relatively little prior research has examined the relationship generally found in longitudinal analyses. Rather than having to between starting and stopping provision of informal care and assume that data are missing completely at random, random sleep disturbance, an approach which provides additional e-vi effects models make the less restrictive missing at random dence for the direction of effects. We found that, compared with assumption, i.e., the propensity for data to be missing is not not providing informal care in either wave, patterns of care-giv related to the missing data after accounting for relationships ing between two study waves that would correspond to beg-in with observed data[63–65]. However, the study has certain lim- i ning, terminating, or continuing to provide informal care were tations: first, although the original sample of the SLOSH study associated with higher sleep disturbance at the second of those was drawn from a representative sample of the Swedish pop-u study waves. The finding that reporting providing care only at lation within the age-range 16–64 years (i.e., the Swedish Labour the first wave was associated with sleep disturbance at the -sec Force Survey), the findings are not generalizable to those wo-rk ond wave is in line with qualitative research suggesting that ing less than 30% of full-time or outside this age range. In a-dd sleep disturbance extends beyond the end of informal care p-ro ition, selective attrition from the SLOSH study has taken place, vision [62]. with SLOSH respondents more likely than nonrespondents to In analyses relating changes in sleep disturbance from be older, female, married, Swedish-born, with university qua-li one wave to the next to patterns of caregiving over the same fications, and to work in the government sector. Second, it is period, individuals who provided informal care only at the first possible that individuals with disturbed sleep are less likely to wave (which would correspond to ceasing caregiving) expe-ri provide informal care, as a result of the impact of health c-on enced improved self-reported sleep compared with the ref-er ditions associated with disturbed sleep (e.g., depression and ence group of participants not providing informal care at either chronic pain). Although this would have a conservative effect on wave. These results point to cessation of caregiving generating the results, weakening the caregiving–sleep disturbance ass-oci reductions in sleep disturbance, even if not to the level of those ations, such reverse causation has been reduced by taking such who had not provided informal care at either wave. They stand health variables into account. Third, although we were able to in contrast to the sole earlier study examining transitions out control for a wide range of demographic and health variables, of caregiving, which used a small sample of spousal Alzheimer there may be residual confounding related to unobserved ch-ar caregivers and differentiated caregiving ceasing as a result of acteristics which could generate a spurious positive association spousal institutionalization or deat[2h6]. That study, by von between participation in informal care and sleep disturbance. Känel et al., found no impact on self-reported or objective sleep Consequently, we performed a sensitivity analysis using fixed measures of spousal institutionalization and a negative impact effect modeling, which partials out unobserved time-invariant individual differences as well as baseline differences in sleep supported by FAS (2005-0734) and the Swedish Research Council disturbance by utilizing only information on changes in depe-nd (VR, 2009-6192 and 2013-1645). The work was carried out within ent and independent variables within individuals. The results the framework of the Stockholm Stress Center, a FORTE Centre are presented inSupplementary Table S1and confirm the con- of Excellence (FORTE, 2009-1758). clusions presented in the main analyses. Fourth, measures of care-giving were only provided at each wave; therefore, it was not possible to ascertain what was happening between the Disclosure statement waves, e.g., whether a carer providing care at two consecutive None declared. waves had been providing care continuously during the 2-year period between those waves. Last, it was only possible to exa-m ine associations with weekly hours of care provision because the References SLOSH study lacks information about the nature of tasks -per formed and characteristics of the care recipient (e.g., whether co-resident, nature of disability, or illness), an important avenue for future research in large, community-based samples. 1. Mallon L , Broman JE , Akerstedt T , Hetta J . Insomnia in Sw-e den: a population-based survey . Sleep Disord . 2014 ; 2014: Article ID 843126, 1 - 7 . doi: 10 .1155/ 2014 /843126. 2. Hall MA , Fernandez-Mendoza J , Kline CE , Vgontzas AN . 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Sacco, Lawrence B, Leineweber, Constanze, Platts, Loretta G. Informal Care and Sleep Disturbance Among Caregivers in Paid Work: Longitudinal Analyses From a Large Community-Based Swedish Cohort Study, Sleep, 2018, DOI: 10.1093/sleep/zsx198