Journal of Gerontological Nursing

Feature Article 

Insomnia and Daily Function in Older Adults With Asthma

Faith S. Luyster, PhD; Xiaojun Shi, BSN; Lynn M. Baniak, PhD, RN; Jonna L. Morris, PhD, RN; Kyeongra Yang, PhD, MPH, RN; Eileen R. Chasens, PhD, RN, FAAN

Abstract

The current study examined the prevalence of insomnia and its relationship with daily function in older adults with asthma. Data on 278 older adults with asthma (aged ≥60 years) from the 2005–2008 National Health and Nutrition Examination Survey were analyzed. Insomnia was present in 40% of the study sample and was associated with a greater number of activities of daily living (ADL) and instrumental ADL (IADL) limitations. In multivariate analyses accounting for covariates including depressive symptoms, insomnia was not associated with having at least two ADL/IADL limitations. However, those with co-occurring insomnia and depressive symptoms were more likely to have at least two ADL/IADL limitations compared to those with either condition singly. Insomnia in the presence of depressive symptoms may impede one's ability to perform ADL/IADL. Current findings suggest that assessment and treatment of insomnia and depression in older adults with asthma may be important for maintaining active, independent living. [Journal of Gerontological Nursing, 46(11), 28–36.]

Abstract

The current study examined the prevalence of insomnia and its relationship with daily function in older adults with asthma. Data on 278 older adults with asthma (aged ≥60 years) from the 2005–2008 National Health and Nutrition Examination Survey were analyzed. Insomnia was present in 40% of the study sample and was associated with a greater number of activities of daily living (ADL) and instrumental ADL (IADL) limitations. In multivariate analyses accounting for covariates including depressive symptoms, insomnia was not associated with having at least two ADL/IADL limitations. However, those with co-occurring insomnia and depressive symptoms were more likely to have at least two ADL/IADL limitations compared to those with either condition singly. Insomnia in the presence of depressive symptoms may impede one's ability to perform ADL/IADL. Current findings suggest that assessment and treatment of insomnia and depression in older adults with asthma may be important for maintaining active, independent living. [Journal of Gerontological Nursing, 46(11), 28–36.]

Although asthma is often perceived as a young person's disease, the prevalence of asthma in adults age >65 years has been reported to be between 4% and 13% (Dunn et al., 2018). Compared to younger adults with asthma, older adults experience more severe asthma and are at a higher risk for asthma-related mortality and morbidity (Boulet, 2016; Zein et al., 2015), which has been attributed to under-diagnosis, tendency to minimize symptoms, diagnostic difficulties, presence of comorbidities, and age-related changes in the lungs (Bellia et al., 2000; Boulet, 2016; Dunn et al., 2018; Loth et al., 2013; Quadrelli & Roncoroni, 2001; Zein et al., 2015).

Sleep difficulties, including insomnia (i.e., difficulty initiating and maintaining sleep despite adequate opportunity for sleep) and poor sleep quality, are commonly reported by adults with asthma (Braido et al., 2009; Luyster et al., 2012; Mastronarde et al., 2008; Sundbom et al., 2013). In a sample of primarily young and middle-aged adults with asthma, the prevalence of insomnia was estimated to be 37% (Luyster et al., 2016). Although the prevalence of insomnia is known to increase with age, with approximately one half of all community-dwelling adults aged >65 years reporting insomnia symptoms (Dzierzewski et al., 2010; Morin et al., 2006; Ohayon, 2002), the prevalence in older adults with asthma is unknown. Studies that examined the relationship between asthma and insomnia have historically focused on middle-aged adults and/or only reported older adults with asthma as “more likely” to report insomnia symptoms, without age-specific prevalence (Luyster et al., 2016; Sundberg et al., 2010; Sundbom et al., 2013; Sundbom et al., 2020).

With advancing age, the likelihood of limitations in physical functioning and performing activities of daily living (ADL) increases (Chatterji et al., 2015). In the general older adult population, subjective and objective measures of disturbed sleep are associated with greater ADL (e.g., eating, dressing, getting in and out of bed) and instrumental ADL (IADL) (e.g., housework, shopping, preparing meals, handling money), and limitations and poorer physical function leading to increased risk for falls (Goldman et al., 2007; Song et al., 2015; Spira et al., 2012). Functional limitations are frequently experienced by adults with asthma; in particular older adults with asthma (Chen et al., 2008; Gazzotti et al., 2013; Haselkorn et al., 2010; Player et al., 1994; Woods et al., 2016). In a sample of 452 older adults with asthma, 31% had difficulty performing at least one of six basic ADL (Woods et al., 2016). Although ADL limitations are frequently reported among older adults with asthma, it is unclear whether insomnia may further impact daily function in this vulnerable population.

It is important to understand the relationship between insomnia and ADL/IADL limitations in older adults with asthma as insomnia is a modifiable factor with known effective nonpharmacological treatments. The objectives of the current study were to examine the extent to which (a) insomnia is present in older adults with asthma; (b) demographic and clinical patient characteristics correlate with insomnia; and (c) the association between insomnia and daily function. In addition to potentially relevant demographic and clinical characteristics, analyses will also control for depressive symptoms given that insomnia increases the risk for, and perpetuates, depression in older adults (Bao et al., 2017).

Method

Design and Sample

The current study sample comprised participants evaluated in the 2005–2006 and 2007–2008 National Health and Nutrition Examination Survey (NHANES), a cross-sectional, nationwide survey of the noninstitutionalized U.S. civilian population. A stratified multistage probability design was used to select a sample that was representative of the U.S. population. There was planned oversampling of persons aged ≥60 years and ethnic minorities (e.g., African American, Hispanic). Data were collected through face-to-face interviews and health measurements were conducted in participants' homes or mobile assessment units located throughout the country. The study protocol was approved by the National Center for Health Statistics Research Ethics Review Board. Further information on NHANES can be obtained on the website (access https://www.cdc.gov/nchs/nhanes/index.htm).

For the purpose of the current study, older adults (aged ≥60 years) with current asthma as defined by positive answers to the following questions: (1) “Has a physician or other health profession ever told you that you have asthma?” and (2) “Do you still have asthma?” were included in the analyses.

Measures

Demographic Variables. Demographic variables included age (60 to 64 years, 65 to 69 years, ≥70 years), sex, self-identified race/ethnicity (Non-Hispanic White, Non-Hispanic Black, or Other [including Asian, Mexican American/other Hispanic, and Other/Multiple Races]), education (less than high school, high school or General Educational Development [GED], some college or associate's degree, or college degree or higher), and marital status (married/partnered or not). Participants aged ≥80 years were reported as “80” to reduce the risk of identification. Income level was defined by the poverty income ratio, the ratio of income to the family's appropriate poverty threshold and presented as four levels (≤133%, 134% to 299%, 300% to 499%, and ≥500%). Smoking status was categorized as nonsmoker, former smoker, or current smoker.

Clinical Variables. Body mass index (BMI) (kg/m2) was calculated from height and weight measurements. The presence of an asthma attack in the past 12 months was classified as a positive response to the questionnaire item asking if participants had an episode of asthma or an asthma attack (i.e., asthma symptoms that have become worse than usual) in the past 12 months. The presence of sleep apnea was determined by either self-reported physician diagnosis of sleep apnea or subjective symptoms assessed by questionnaire items asking about the frequency of snoring, snorting, or stopping breathing while asleep, and being overly sleepy during the day. Participants with positive responses (occasionally or often) to questionnaire items referring to snoring and snorting during sleep, and responses of often or almost always to the questionnaire item about daytime sleepiness were classified as having high risk for sleep apnea. The presence of medical conditions (e.g., arthritis, congestive heart failure, cancer, emphysema, chronic bronchitis, diabetes) was assessed by asking participants if they had been told by a physician or other health professional that they had each condition.

Depressive Symptoms. The Patient Health Questionnaire (PHQ-9) (Kroenke et al., 2001) assessed depressive symptoms. Participants were asked to rate the frequency of specified symptoms (e.g., “Feeling tired or having little energy”) over the past 2 weeks as: 0 (not at all), 1 (several days), 2 (more than half of the days) and 3 (nearly every day). Total score ranges from 0 to 27, with a higher score indicating more severe symptoms. Severity of symptoms was defined as minimal (scores 0 to 4), mild (scores 5 to 9), moderate (scores 10 to 14), moderately severe (scores 15 to 19), and severe (scores ≥20) (Kroenke et al., 2001). The PHQ-9 is a reliable measure for assessing major and sub-threshold depression in population samples (Kroenke & Spitzer, 2002). In the current study, the PHQ-9 severity categories were dichotomized into “minimal or mild” versus “moderate to severe.”

Insomnia. The presence of insomnia was determined by either self-reported physician diagnosis of insomnia or subjective symptoms assessed by three questionnaire items. These items asked about the frequency of difficulty falling asleep, difficulty maintaining sleep, and early morning awakenings. Participants with an item response of often or almost always for any one of the three insomnia symptom questionnaire items were classified as having insomnia. These criteria for insomnia have been used in previous studies (Chung, 2005; Krell & Kapur, 2005).

Daily Function. ADL and IADL limitations were assessed by asking participants about level of difficulty in performing six activities (i.e., ADL: transferring or getting in and out of bed, dressing, eating; IADL: housekeeping, meal preparation, managing finances). Response options were no difficulty, some difficulty, much difficulty, unable to do, and do not do this activity. Those reporting some difficulty, much difficulty, or unable to do were considered to have a limitation in the ADL or IADL. Categorization of ADL and IADL limitations followed previously published definitions (Kuo et al., 2006).

Statistical Analysis

All analyses included the complex multistage sampling and sampling weights provided by NHANES. Data analyses were conducted with SAS version 9.4. Simple descriptive statistics were used to describe the study population. Univariate analyses (SURVEYMEANS and SURVEY FREQ) using Student's t test for continuous variables and Pearson chi-square test for categorical variables were conducted to explore the association among demographic characteristics, daily function, and insomnia. Multivariate analysis (SURVEYLOGISTIC) using stepwise logistic regression was conducted. The selection of covariates was based on clinical and statistical significance in previous analyses. The model was minimally adjusted for demographics (age, sex, race, education, marital status, and poverty level) and BMI, then further adjusted for depressive symptom severity. Estimated crude odds ratio (OR) and adjusted ORs with their corresponding 95% confidence interval (CI) were calculated. Less than 10% of missing data was observed on the variables of interest, thus missing data were ignored.

Results

Sample Characteristics

The current study sample (N = 278) included participants aged ≥60 years with self-reported physician diagnosis of asthma from NHANES. Weighted population demographic and medical characteristics for the total sample and insomnia status are presented in Table 1. The sample was primarily female (62%), Non-Hispanic White (79%), had a poverty level >133% (72%), former smokers (46%), and had high school/GED or less education (53%). Mean age of participants was 69.9 (SD = 7.2 years). More than one third of the sample reported having an asthma attack in the past 1 year. The most common comorbid medical conditions were arthritis (71%), chronic bronchitis (41%), and moderate to severe depression (29%).

Characteristics of Participants (N = 278) by Insomnia StatusaCharacteristics of Participants (N = 278) by Insomnia Statusa

Table 1:

Characteristics of Participants (N = 278) by Insomnia Status

A total of 40% (n = 112) were categorized as having insomnia. There were no statistically significant differences in demographic and most medical characteristics, including asthma attack and sleep apnea (Table 1). However, individuals with insomnia were significantly more likely to have moderate to severe depressive symptoms (51%) than individuals without insomnia (17%) (p < 0.001).

Associations Between Insomnia and Daily Function

Overall, 53% of participants had one or more ADL/IADL limitations (Table 2). Those with insomnia were more likely than those without to report having four or more ADL/IADL limitations (p < 0.05), with a proportion four times higher among those with insomnia (20%) compared to those without insomnia (5%). Individuals with insomnia were significantly more likely to report limitations in dressing (p < 0.05) and transferring or getting in or out of bed (p < 0.001) (Table 2). There is also a trend toward older adults with insomnia being more likely to have limitations with food preparation (p = 0.08).

Activities of Daily Living (ADL) and Instrumental ADL (IADL) Limitations According to Insomnia Status

Table 2:

Activities of Daily Living (ADL) and Instrumental ADL (IADL) Limitations According to Insomnia Status

Table 3 shows results of the regression models examining the association of insomnia and having at least two ADL/IADL limitations. There was no significant association between insomnia and having at least two or more ADL/IADL limitations when controlling for demographics and BMI. With additional adjustment for depressive symptoms, the association between insomnia and ADL/IADL limitations remained nonsignificant; however, moderate to severe depression symptoms were associated with having at least two ADL/IADL limitations (OR = 3.47, 95% CI [1.27, 9.51], p < 0.05) (Table 3).

Multiple Logistic Regression Analyses for the Association Between Insomnia and Having Two or More Activities of Daily Living (ADL) or Instrumental ADL (IADL) LimitationsMultiple Logistic Regression Analyses for the Association Between Insomnia and Having Two or More Activities of Daily Living (ADL) or Instrumental ADL (IADL) Limitations

Table 3:

Multiple Logistic Regression Analyses for the Association Between Insomnia and Having Two or More Activities of Daily Living (ADL) or Instrumental ADL (IADL) Limitations

We conducted additional post-hoc analyses to determine whether daily function differed between individuals with comorbid insomnia and moderate to severe depressive symptoms, with insomnia only, and depressive symptoms only. Persons with comorbid insomnia and depressive symptoms (27%) were significantly more likely to report having two or more ADL/IADL limitations than those with insomnia only (7%) and those with depressive symptoms only (9%) (χ2 = 4.75, p < 0.001).

Discussion

The current study investigated the prevalence of insomnia and its association with daily function, in particular limitations in ADL/IADL among older adults with asthma. Insomnia was common and associated with moderate to severe depression symptoms. Those with insomnia were more likely to report four or more ADL/IADL limitations, with particular limitations in transferring or getting in and out of bed and dressing. Insomnia was not significantly associated with having at least two ADL/IADL limitations after controlling for demographics, BMI, and depressive symptoms. However, it was found that those with comorbid insomnia and moderate to severe depressive symptoms were more likely to report having at least two ADL/IADL limitations compared to individuals who had only one of the conditions. This finding suggests that the coexistence of insomnia and depression may significantly impair ability to perform ADL and IADL among older adults with asthma.

The current study findings extend those of previous work examining insomnia in adults with asthma by focusing on older adults (aged ≥60 years). Forty percent of our sample reported insomnia, which is similar to rates (37%) found in prior studies of primarily middle-aged adults with asthma (mean ages ranging from 42 to 53 years) (Andenæs & Schwartz, 2016; Luyster et al., 2016; Sundberg et al., 2010; Sundbom et al., 2013). Despite the similarity in insomnia prevalence, insomnia is more likely to be reported among older adults with asthma (Andenæs & Schwartz, 2016; Sundberg et al., 2010; Sundbom et al., 2013). Differences in the assessment of insomnia may partly account for the comparable rates of insomnia found in our sample of older adults and other studies of primarily middle-aged adults (Andenæs & Schwartz, 2016; Luyster et al., 2016; Sundberg et al., 2010; Sundbom et al., 2013). The correlates of insomnia have varied across previous studies, yet as found in our study, depression is a consistent factor associated with insomnia (Andenæs & Schwartz, 2016; Luyster et al., 2016).

Older adults with asthma frequently experience limitations in ADLs (Woods et al., 2016). We found more than one half of our sample of older adults with asthma reported ADL/IADL limitations. Our findings support prior studies that have primarily focused on the impact of asthma control on activity limitations in adults with asthma and have found limitations in ADLs among those with not well-controlled or uncontrolled asthma (Gazzotti et al., 2013; Haselkorn et al., 2010; Woods et al., 2016). The current study did not enable assessment of asthma control, thus the absence of association between insomnia and ADL/IADL limitations could be confounded by asthma control. Of note, we did not find a significant difference in the proportion of older adults reporting having an asthma attack in the previous 1 year between those with and without insomnia.

Our findings suggest that comorbid insomnia and depression may have a greater impact on ADL/IADL limitations than either condition singly. Previous research has demonstrated a bidirectional relationship between insomnia and depression in older adults (Bao et al., 2017; de Paula et al., 2015). Studies in older adult populations have shown associations between poor sleep and ADL/IADL limitations while controlling for depression (Goldman et al., 2007; Song et al., 2015; Spira et al., 2014). In addition, depression has been shown to be a predictor of activity limitations in older adults (de Paula et al., 2015; Sin et al., 2015). Interestingly, one study found that ability to complete ADLs in older adults mediated the relationship between insomnia and depression; however, depression failed to mediate the relationship between insomnia symptoms and ADLs (Webb et al., 2018). More research is needed to better elucidate the relationships between insomnia, depressive symptoms, and ADL/IADL limitations in older adults with asthma.

Limitations and Strengths

The current study has several limitations. First, data were analyzed in a cross-sectional manner that precludes making causal inferences about the relationship between insomnia and daily function. Second, several important confounders, including lung function, asthma control, and comorbidities, such as gastroesophageal reflux disease or chronic sinusitis, that could influence the results were not examined because of lack of assessment or due to a high proportion of missing data. Finally, assessment of ADLs or IADLs may not have fully captured all aspects of limitations that one may face.

Strengths of this study include use of the 2005–2008 NHANES data, which enabled evaluation of insomnia and daily function in a nationally representative sample of older adults with asthma. In addition, the current study evaluated the prevalence of insomnia and daily function, including ADL/IADL among community-dwelling older adults with asthma, for whom these topics are of importance but have received little attention.

Conclusion

The current study found insomnia to be a common complaint among older adults with asthma. Insomnia in the presence of depressive symptoms may impede one's ability to perform ADLs or IADLs. The identification of modifiable factors most strongly associated with reduced daily function has important nursing implications in the context of safety and self-management for older adults with asthma. Increased risk for falls is a primary concern for older adults, especially in relation to impairment in the ability to perform ADL/IADL. Impaired ability to ambulate, toilet, and bathe can lead to accidental falls. Likewise, inability to prepare proper meals or adequately manage medications can adversely impact disease self-management. Insomnia and depression are commonly observed in older adults with asthma but are not part of the routine clinical evaluation and management of asthma (Luyster et al., 2016; Patel et al., 2009; Quadrelli et al., 2001). Potential adverse effects from symptoms of insomnia and depression on daily function illustrate the importance of evaluation, especially for the coexistence of these symptoms in older adults with asthma (de Paula et al., 2015; Patel et al., 2009; Sin et al., 2015; Spira et al., 2014; Webb et al., 2018). Geriatric practitioners must be aware of these links and take into account sleep and mental health to identify interventions that could help maximize independent living in the community in older adults with asthma. Cognitive-behavioral therapy for insomnia has been shown to treat both insomnia and depression in patients with comorbid insomnia and depression, including older adults and thus should be considered in addition to pharmacological or psychological treatments for depression (Blom et al., 2017; Manber et al., 2008; Tanaka et al., 2019). Adequately treated insomnia and depression in older adults with asthma may help preserve daily function.

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Characteristics of Participants (N = 278) by Insomnia Statusa

Characteristicn (Weighted %)p Value
All ParticipantsInsomnia (n = 112)No Insomnia (n = 166)
Age (years)0.87
  60 to 6484 (29.3)38 (29.7)46 (29.1)
  65 to 6958 (24.2)25 (26.3)33 (22.9)
  ≥70136 (46.5)49 (44)87 (48)
Gender0.58
  Female157 (62)65 (63.8)92 (61)
  Male121 (38)47 (36.2)74 (39)
Race0.14
  White155 (78.8)55 (75.3)100 (80.9)
  Black65 (10.3)32 (13.6)33 (8.4)
  Other58 (10.9)25 (11.2)33 (10.7)
Educational level0.11
  <High school105 (30.3)53 (42.8)52 (23.1)
  High school or GED59 (22.5)21 (20.4)38 (23.8)
  Some college62 (23.2)23 (18.8)39 (25.8)
  >College graduate51 (23.9)15 (18)36 (27.3)
Poverty level0.24
  ≤133%98 (27.7)44 (34.4)54 (23.9)
  134% to 299%77 (31.4)29 (30.2)48 (32.1)
  300% to 499%46 (23.4)16 (23.9)30 (23.2)
  ≥500%32 (17.4)9 (11.5)23 (20.8)
Marital status0.18
  Single127 (58)58 (46.8)69 (39.1)
  Married/partnered150 (42)54 (53.2)96 (60.9)
Smoking status0.20
  Never112 (41.9)44 (41.2)68 (42.3)
  Former127 (45.7)46 (42.1)81 (47.8)
  Current38 (12.4)22 (16.7)16 (9.8)
Medical conditions
  Arthritis193 (70.8)87 (75.8)106 (67.9)0.15
  Asthma attack in previous 1 year102 (38.8)44 (45.8)58 (34.6)0.18
  Chronic bronchitis98 (41.1)45 (40.6)53 (41.4)0.92
  Diabetes77 (20.1)35 (20.9)42 (19.5)0.74
  Moderate to severe depressive symptoms73 (29.2)43 (50.5)30 (17.1)<0.001
  Cancer66 (22.8)26 (26.6)40 (20.6)0.47
  Emphysema66 (24.2)25 (23)41 (24.9)0.83
  Congestive heart failure42 (14.6)22 (17)20 (13.2)0.39
  Sleep apnea40 (17.8)22 (19)18 (17.1)0.73
Mean (SD)
Age (years)69.9 (7.2)69.1 (6.5)70.3 (7.4)0.21
BMI (kg/m2)b30.4 (7.8)30.6 (8.6)30.3 (7.3)0.77

Activities of Daily Living (ADL) and Instrumental ADL (IADL) Limitations According to Insomnia Status

Variablen (Weighted %)p Value
All Participants (N = 278)Insomnia (n = 112)No Insomnia (n = 166)
ADL/IADL limitations0.02
  0123 (47.3)40 (41.8)83 (50.5)
  159 (20.9)22 (19.8)37 (21.6)
  2 to 360 (21.6)25 (18.6)35 (23.3)
  ≥436 (10.2)25 (19.7)11 (4.6)
Limitation type
  Housekeeping106 (34.6)54 (42.9)52 (29.6)0.10
  Transferring in/out of bed81 (23.1)47 (36.1)34 (15.4)<0.001
  Dressing63 (19.8)35 (25.8)28 (16.3)0.04
  Meal preparation52 (17.8)29 (24.1)23 (1.2)0.08
  Managing finances41 (16)20 (17.9)21 (14.9)0.55
  Eating30 (9)19 (13.5)11 (6.3)0.11

Multiple Logistic Regression Analyses for the Association Between Insomnia and Having Two or More Activities of Daily Living (ADL) or Instrumental ADL (IADL) Limitations

Demographics and BMI Adjusted
CharacteristicOR [95% CI]
Age (years)
  60 to 641.00
  65 to 691.51 [0.58, 3.96]
  ≥701.70 [0.75, 3.85]
Gender
  Female1.23 [0.55, 2.79]
  Male1.00
Race
  White1.00
  Black1.57 [0.88, 2.82]
  Other1.05 [0.28, 3.91]
Educational level
  <High school4.11 [1.25, 13.51]
  High school or GED2.63 [0.69, 10.01]
  Some college1.80 [0.42, 8.05]
  ≥College graduate1.00
Marital status
  Married/partnered1.00
  Single1.27 [0.67, 2.40]
Poverty level
  ≥500%1.00
  ≤133%1.38 [0.41, 4.68]
  134% to 299%0.68 [0.22, 2.11]
  300% to 499%0.25 [0.08, 0.78]
BMI1.03 [0.98, 1.08]
Insomnia1.53 [0.70, 3.34]
Demographics, BMI, and Depressive Symptoms Adjusted
CharacteristicOR [95% CI]
Age (years)
  60 to 641.00
  65 to 691.69 [0.63, 4.53]
  ≥701.87 [0.71, 4.90]
Gender
  Male1.00
  Female0.90 [0.37, 2.23]
Race
  White1.00
  Black1.43 [0.83, 2.45]
  Other0.96 [0.17, 5.14]
Educational level
  <High school3.50 [0.75, 16.23]
  High school or GED2.73 [0.53, 14.18]
  Some college1.36 [0.24, 7.72]
  ≥College graduate1.00
Marital status
  Married/partnered1.00
  Single1.29 [0.56, 2.95]
Poverty level
  ≥500%1.00
  ≤133%0.94 [0.29, 2.99]
  134% to 299%0.66 [0.22, 1.99]
  300% to 499%0.14 [0.04, 0.57]
BMI1.04 [0.97, 1.11]
Moderate to severe depressive symptoms3.47 [1.27, 9.51]
Insomnia0.97 [0.42, 2.25]
Authors

Dr. Luyster is Assistant Professor, Ms. Shi is Doctoral Student, Dr. Baniak is Adjunct Faculty, Dr. Morris is Assistant Professor, and Dr. Chasens is Professor, Department Chair, Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania; and Dr. Yang is Associate Professor, School of Nursing, Rutgers, The State University of New Jersey, Newark, New Jersey. Dr. Baniak is also Associate Chief Nurse for Research, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Faith S. Luyster, PhD, Assistant Professor, School of Nursing, University of Pittsburgh, 3500 Victoria Street, Room 415, Pittsburgh, PA 15261; email: luysterfs@upmc.edu.

Received: March 28, 2020
Accepted: June 23, 2020

10.3928/00989134-20201012-04

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