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<front>
<journal-meta>
<journal-id journal-id-type="publisher-id">Front. Public Health</journal-id>
<journal-title-group>
<journal-title>Frontiers in Public Health</journal-title>
<abbrev-journal-title abbrev-type="pubmed">Front. Public Health</abbrev-journal-title>
</journal-title-group>
<issn pub-type="epub">2296-2565</issn>
<publisher>
<publisher-name>Frontiers Media S.A.</publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id pub-id-type="doi">10.3389/fpubh.2025.1664136</article-id>
<article-version article-version-type="Version of Record" vocab="NISO-RP-8-2008"/>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Systematic Review</subject>
</subj-group>
</article-categories>
<title-group>
<article-title>Prevalence of sleep disorders among older adults in Chinese older adults care institutions: a systematic review and meta-analysis</article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author"><name><surname>Bai</surname> <given-names>Xiaodi</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<uri xlink:href="https://loop.frontiersin.org/people/3131061"/>
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</contrib>
<contrib contrib-type="author"><name><surname>Liu</surname> <given-names>Shulan</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="Formal analysis" vocab-term-identifier="https://credit.niso.org/contributor-roles/formal-analysis/">Formal analysis</role>
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</contrib>
<contrib contrib-type="author"><name><surname>Lv</surname> <given-names>Yanxin</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
<role vocab="credit" vocab-identifier="https://credit.niso.org/" vocab-term="methodology" vocab-term-identifier="https://credit.niso.org/contributor-roles/methodology/">Methodology</role>
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<contrib contrib-type="author"><name><surname>Luo</surname> <given-names>Yuling</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref>
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<contrib contrib-type="author" corresp="yes"><name><surname>Jiang</surname> <given-names>Yunlan</given-names></name><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="corresp" rid="c001"><sup>&#x002A;</sup></xref>
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<aff id="aff1"><label>1</label><institution>School of Nursing, Chengdu University of Traditional Chinese Mdeicine</institution>, <city>Chengdu</city>, <country country="cn">China</country></aff>
<aff id="aff2"><label>2</label><institution>Hospital of Chengdu University of Traditional Chinese Medicine</institution>, <city>Chengdu</city>, <country country="cn">China</country></aff>
<author-notes>
<corresp id="c001"><label>&#x002A;</label>Correspondence: Yunlan Jiang, <email xlink:href="mailto:jiangyunlan1234@163.com">18980880152@163.com</email></corresp>
</author-notes>
<pub-date publication-format="electronic" date-type="pub" iso-8601-date="2025-12-03">
<day>03</day>
<month>12</month>
<year>2025</year>
</pub-date>
<pub-date publication-format="electronic" date-type="collection">
<year>2025</year>
</pub-date>
<volume>13</volume>
<elocation-id>1664136</elocation-id>
<history>
<date date-type="received">
<day>12</day>
<month>07</month>
<year>2025</year>
</date>
<date date-type="rev-recd">
<day>08</day>
<month>11</month>
<year>2025</year>
</date>
<date date-type="accepted">
<day>17</day>
<month>11</month>
<year>2025</year>
</date>
</history>
<permissions>
<copyright-statement>Copyright &#x00A9; 2025 Bai, Liu, Lv, Luo and Jiang.</copyright-statement>
<copyright-year>2025</copyright-year>
<copyright-holder>Bai, Liu, Lv, Luo and Jiang</copyright-holder>
<license>
<ali:license_ref start_date="2025-12-03">https://creativecommons.org/licenses/by/4.0/</ali:license_ref>
<license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="https://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License (CC BY)</ext-link>. The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</license-p>
</license>
</permissions>
<abstract>
<sec>
<title>Objective</title>
<p>To systematically evaluate the prevalence characteristics of sleep disorders among older adults residents in Chinese nursing homes and the differences among various subpopulations, providing evidence for promoting healthy aging.</p>
</sec>
<sec>
<title>Methods</title>
<p>Search formulas were developed to systematically retrieve literature from the CNKI, VIP, Wan fang Data, CBM, PubMed, Web of Science, and Cochrane Library databases. Cross-sectional studies published from the inception of each database until May 2025 on the incidence of sleep disorders among older adults individuals in Chinese nursing homes were collected. Meta-analysis was performed using Stata 15.1 and R language (version 4.3.2).</p>
</sec>
<sec>
<title>R<bold>esults</bold></title>
<p>A total of 35 articles were finally included, involving 15,996 older adults individuals residing in nursing homes. Meta-analysis revealed a pooled detection rate of sleep disorders of 43% (95% CI: 38&#x2013;48%) among this population. Temporal trend analysis indicated significant fluctuations in the incidence of sleep disorders from 2008 to 2024, coupled with an overall downward trend. Subgroup analyses revealed statistically significant differences (<italic>p</italic>&#x202F;&#x003C;&#x202F;0.05) based on geographic region, sample size, gender, and the sleep disorder assessment tool used.</p>
</sec>
<sec>
<title>Conclusion</title>
<p>The detection rate of sleep disorders among older adults residents in Chinese nursing homes is relatively high, with marked disparities across different groups. Significant attention should be directed toward the sleep health of this population. Comprehensive preventive and intervention measures tailored to the characteristics of different subpopulations should be developed and implemented to effectively improve sleep quality and reduce the risk of sleep disorders.</p>
</sec>
<sec>
<title>Systematic review registration</title>
<p><uri xlink:href="https://crd.york.ac.uk/prospero/">https://crd.york.ac.uk/prospero/</uri>, identifier (CRD420251056822).</p>
</sec>
</abstract>
<kwd-group>
<kwd>China</kwd>
<kwd>older adults care institutions</kwd>
<kwd>aged</kwd>
<kwd>sleep disorders</kwd>
<kwd>prevalence</kwd>
<kwd>meta-analysis</kwd>
</kwd-group>
<funding-group>
<funding-statement>The author(s) declare that financial support was received for the research and/or publication of this article. This work was supported by the Sichuan Healthcare Research Project, grant number: ChuanJianYan 2025-504.</funding-statement>
</funding-group>
<counts>
<fig-count count="4"/>
<table-count count="2"/>
<equation-count count="0"/>
<ref-count count="61"/>
<page-count count="11"/>
<word-count count="6497"/>
</counts>
<custom-meta-group>
<custom-meta>
<meta-name>section-at-acceptance</meta-name>
<meta-value>Aging and Public Health</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
</front>
<body>
<sec sec-type="intro" id="sec1">
<title>Introduction</title>
<p>With the accelerating pace of population aging, the demand for older adults care is growing rapidly. According to World Health Organization estimates, by 2050, 60% of the older adults population in China will require daily care and assistance (<xref ref-type="bibr" rid="ref1">1</xref>). Consequently, the number of older adults choosing to reside in nursing homes is steadily increasing (<xref ref-type="bibr" rid="ref2">2</xref>). Among the health-related issues they face, sleep problems are becoming particularly prominent.</p>
<p>Sleep health is a crucial component of the &#x201C;Healthy China Action (2019&#x2013;2030)&#x201D; plan (<xref ref-type="bibr" rid="ref3">3</xref>). Sleep disorders refer to conditions characterized by frequent and persistent difficulties in falling asleep and/or maintaining sleep, leading to dissatisfaction with sleep quality (<xref ref-type="bibr" rid="ref4">4</xref>). Studies indicate that the overall detection rate of sleep disorders among older adults in China is approximately 46% (<xref ref-type="bibr" rid="ref5">5</xref>, <xref ref-type="bibr" rid="ref6">6</xref>). Globally, the reported detection rate of sleep disorders among older adults residents in nursing homes is even higher, reaching about 65% (<xref ref-type="bibr" rid="ref7">7</xref>). Adequate sleep is essential not only for maintaining normal physiological functions, such as immune system regulation and metabolic balance, but also significantly impacts mental health, including emotional stability and cognitive function preservation (<xref ref-type="bibr" rid="ref8">8</xref>). However, sleep disorders not only significantly reduce the quality of life for older adults but also substantially increase their risk of falls (<xref ref-type="bibr" rid="ref9">9</xref>) and limitations in activities of daily living (<xref ref-type="bibr" rid="ref10">10</xref>), thereby further increasing the burden on both individuals and society.</p>
<p>Older adults residents in nursing homes often present unique characteristics, including older age, higher rates of disability, more complex comorbidities, and distinct psychosocial environments. Consequently, the mechanisms underlying sleep disorders and their epidemiological patterns may differ from those observed in community-dwelling or hospitalized populations. Large-scale, multi-center epidemiological studies focusing specifically on sleep disorders among older adults in Chinese nursing homes remain relatively scarce, and existing survey results exhibit a degree of heterogeneity.</p>
<p>Therefore, a systematic evaluation and synthesis of existing research are necessary to clarify the prevalence and trends of sleep disorders among older adults in Chinese nursing homes. This will provide an evidence-based foundation for healthcare professionals to enhance awareness and develop targeted prevention and intervention strategies. Simultaneously, it will offer scientific support for nursing home policy-makers in optimizing resource allocation, promoting the transition toward precision management of chronic diseases and care models for the older adults, and advancing from the goal of &#x201C;healthy aging&#x201D; to &#x201C;active aging.&#x201D;</p>
</sec>
<sec sec-type="materials|methods" id="sec2">
<title>Materials and methods</title>
<p>This systematic review was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement (PRISMA) guidelines and the detailed study protocol was registered on PROSPERO (CRD420251056822).</p>
<sec id="sec3">
<title>Inclusion and exclusion criteria</title>
<sec id="sec4">
<title>Inclusion criteria</title>
<p>(1) Study type: Observational studies, including cross-sectional studies, case&#x2013;control studies, and cohort studies; (2) Participants: Older adults individuals aged &#x2265;60&#x202F;years residing in nursing homes. Outcome; (3) Measures: Reported the incidence/prevalence of sleep disorders among older adults residents in nursing homes or provided data sufficient for calculation. Sleep disorders were defined using validated instruments or criteria such as the Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), Insomnia Severity Index (ISI), Sleep Disorders Rating Scale (SDRS), or the International Classification of Sleep Disorders, Third Edition (ICSD-3). Publication; (4) Type: Peer-reviewed journal articles.</p>
</sec>
<sec id="sec5">
<title>Exclusion criteria</title>
<p>(1) Duplicate publications; (2) Studies from which required data could not be extracted or that provided incomplete information; (3) Studies published in languages other than Chinese or English; (4) Reviews, conference abstracts, and proceedings. (5) Studies assessed as having critically low quality.</p>
</sec>
</sec>
<sec id="sec6">
<title>Literature search strategy</title>
<p>Computerized searches will be conducted across the following databases: CNKI, WanFang Data, VIP, CBM, PubMed, Embase, Web of Science, and the Cochrane Library. The search will target studies reporting the prevalence/incidence of sleep disorders among older adults residents in nursing homes within China. The search strategy will combine Medical Subject Headings (MeSH)/Emtree terms and free-text keywords. To ensure comprehensiveness, supplementary manual searches of reference lists (backward citation tracking) and citation tracking (forward citation tracking) of included articles will be performed (&#x201C;snowballing&#x201D; method). The search timeframe will span from the inception of each database up to May 2025. Key search terms include: &#x201C;China,&#x201D; &#x201C;Chinese&#x201D;; &#x201C;older adults homes,&#x201D; &#x201C;aged care homes,&#x201D; &#x201C;nursing homes&#x201D;; &#x201C;Sleep Wake Disorders,&#x201D; &#x201C;Sleep Disorders, Intrinsic,&#x201D; &#x201C;Dyssomnias,&#x201D; &#x201C;Sleep Disorders,&#x201D; etc. The detailed search strategy for PubMed is provided as an example.</p>
</sec>
<sec id="sec7">
<title>Literature screening and data extraction</title>
<p>Literature screening will be managed using EndNote X9 software, utilizing its duplicate detection function for initial deduplication. Two reviewers, trained in systematic review methodology, will independently screen titles and abstracts against the predefined inclusion/exclusion criteria. Full texts of potentially eligible studies will then be retrieved and assessed independently. Any discrepancies during screening will be resolved through discussion with a third, senior reviewer. Data extraction will be performed using a standardized form, capturing the following information: first author, publication year, study design, study region/location, sample size, mean age, relevant outcome measures (e.g., prevalence/incidence of sleep disorders, diagnostic criteria/instrument used).</p>
</sec>
<sec id="sec8">
<title>Risk of bias assessment of included studies</title>
<p>The methodological quality of included cross-sectional studies will be assessed using the Agency for Healthcare Research and Quality (AHRQ) tool (<xref ref-type="bibr" rid="ref11">11</xref>). Studies will be categorized as low quality (score 0&#x2013;3), moderate quality (score 4&#x2013;7), or high quality (score 8&#x2013;11). The Newcastle-Ottawa Scale (NOS) (<xref ref-type="bibr" rid="ref12">12</xref>) will be used to assess the risk of bias in included case&#x2013;control and cohort studies. The NOS evaluates studies across three domains, with a maximum score of 9; studies scoring &#x2265;6 will be considered high quality. Two reviewers will independently conduct the risk of bias assessments. Disagreements will be resolved through discussion or consultation with a third reviewer.</p>
</sec>
<sec id="sec9">
<title>Statistical analysis</title>
<p>Statistical analyses will be performed using Stata 15.0 and R software (version 4.3.2). For meta-analysis of proportions (prevalence/incidence), the raw proportions are transformed using the Freeman-Tukey double arcsine transformation method (<xref ref-type="bibr" rid="ref13">13</xref>) to stabilize variances, especially when data are non-normally distributed or proportions are near 0 or 1. The primary pooled outcome will be the prevalence/incidence rate with its corresponding 95% confidence interval (<italic>CI</italic>). Heterogeneity among studies will be evaluated using the Cochran&#x2019;s Q test and quantified using the <italic>I</italic><sup>2</sup> statistic. A fixed-effects model will be employed if heterogeneity is low (<italic>p</italic>&#x202F;&#x003E;&#x202F;0.1 for Q test and <italic>I</italic><sup>2</sup> &#x003C;&#x202F;50%); otherwise, a random-effects model will be used. Potential publication bias will be assessed visually using funnel plots and statistically using Egger&#x2019;s test. <italic>p</italic>&#x202F;&#x003C;&#x202F;0.05 indicates a statistically significant publication bias. Sensitivity analyses will be conducted using the leave-one-out method to evaluate the robustness of the results. Alternatively, subgroup analyses based on characteristics such as geographic region, sample size, gender, assessment tool, duration of nursing home residence, and depressive status were conducted to explore the sources of heterogeneity.</p>
</sec>
</sec>
<sec sec-type="results" id="sec10">
<title>Results</title>
<sec id="sec11">
<title>Literature screening process and results</title>
<p>A comprehensive search of relevant databases initially retrieved 1,494 records. Through a rigorous screening process, 35 studies ultimately met the inclusion criteria and were selectedfor this review. The flow diagram detailing the screening process is presented in <xref ref-type="fig" rid="fig1">Figure 1</xref>.</p>
<fig position="float" id="fig1">
<label>Figure 1</label>
<caption>
<p>Flow chart for screening included literature.</p>
</caption>
<graphic xlink:href="fpubh-13-1664136-g001.tif" mimetype="image" mime-subtype="tiff">
<alt-text content-type="machine-generated">Flowchart illustrating the study selection process for a systematic review. Identification phase: 1,489 records found in databases such as CNKI, Wanfang Data, VIP, CBM, PubMed, Embase, Web of Science, and Core China Library, with 5 more identified from other sources. Screening phase: 556 duplicates removed, leaving 938 records for title and abstract screening. 845 records are excluded for reasons like irrelevance and non-nursing home population. Full-text eligibility assessment includes 93 articles, excluding 58 for unusable data and other issues. 35 studies are included in the systematic review.</alt-text>
</graphic>
</fig>
</sec>
<sec id="sec12">
<title>Characteristics and quality assessment of included studies</title>
<p>A total of 35 studies were included in this systematic review. The quality assessment scores ranged from 4 to 9 points. Twenty-five studies were rated as moderate quality, and 10 studies were classified as high quality. These studies encompassed 17 provincial-level regions in China. Detailed characteristics are presented in <xref ref-type="table" rid="tab1">Table 1</xref>.</p>
<table-wrap position="float" id="tab1">
<label>Table 1</label>
<caption>
<p>Basic characteristics of the included literature.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="left" valign="top">First author</th>
<th align="center" valign="top">Year</th>
<th align="left" valign="top">Region</th>
<th align="center" valign="top">Mean age</th>
<th align="center" valign="top">Questionnaire</th>
<th align="center" valign="top">Sample size (cases)</th>
<th align="center" valign="top">Sleep disorders (cases)</th>
<th align="center" valign="top">Prevalence rate</th>
<th align="center" valign="top">Quality assessment</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="middle">Hao, 2023 (<xref ref-type="bibr" rid="ref27">27</xref>)</td>
<td align="center" valign="middle">2021&#x2013;2023</td>
<td align="left" valign="middle">Beijing</td>
<td align="center" valign="middle">74.8&#x202F;&#x00B1;&#x202F;8.4</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">203</td>
<td align="center" valign="middle">97</td>
<td align="center" valign="middle">47.78</td>
<td align="center" valign="middle">6</td>
</tr>
<tr>
<td align="left" valign="middle">Han, 2023 (<xref ref-type="bibr" rid="ref28">28</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Changchun</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">411</td>
<td align="center" valign="middle">201</td>
<td align="center" valign="middle">48.91</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Zhu, 2022 (<xref ref-type="bibr" rid="ref29">29</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Hangzhou</td>
<td align="center" valign="middle">80.80&#x202F;&#x00B1;&#x202F;7.35</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">402</td>
<td align="center" valign="middle">160</td>
<td align="center" valign="middle">39.8</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Wu, 2016 (<xref ref-type="bibr" rid="ref30">30</xref>)</td>
<td align="center" valign="middle">2014&#x2013;2015</td>
<td align="left" valign="middle">Fuzhou</td>
<td align="center" valign="middle">83.52&#x202F;&#x00B1;&#x202F;6.97</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">176</td>
<td align="center" valign="middle">96</td>
<td align="center" valign="middle">54.5</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Gong, 2012 (<xref ref-type="bibr" rid="ref31">31</xref>)</td>
<td align="center" valign="middle">2010</td>
<td align="left" valign="middle">Tangshan</td>
<td align="center" valign="middle">79.29&#x202F;&#x00B1;&#x202F;7.04</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">409</td>
<td align="center" valign="middle">211</td>
<td align="center" valign="middle">51.59</td>
<td align="center" valign="middle">4</td>
</tr>
<tr>
<td align="left" valign="middle">Zhu, 2015 (<xref ref-type="bibr" rid="ref32">32</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Chongqing</td>
<td align="center" valign="middle">82.01&#x202F;&#x00B1;&#x202F;8.22</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">123</td>
<td align="center" valign="middle">53</td>
<td align="center" valign="middle">43.0</td>
<td align="center" valign="middle">6</td>
</tr>
<tr>
<td align="left" valign="middle">Huang, 2019 (<xref ref-type="bibr" rid="ref33">33</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Shanghai</td>
<td align="center" valign="middle">80.66&#x202F;&#x00B1;&#x202F;7.61</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">410</td>
<td align="center" valign="middle">259</td>
<td align="center" valign="middle">63.17</td>
<td align="center" valign="middle">5</td>
</tr>
<tr>
<td align="left" valign="middle">Yu, 2011 (<xref ref-type="bibr" rid="ref34">34</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Siping</td>
<td align="center" valign="middle">74.5&#x202F;&#x00B1;&#x202F;8.76</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">100</td>
<td align="center" valign="middle">61</td>
<td align="center" valign="middle">61.0</td>
<td align="center" valign="middle">5</td>
</tr>
<tr>
<td align="left" valign="middle">Liu, 2023 (<xref ref-type="bibr" rid="ref35">35</xref>)</td>
<td align="center" valign="middle">2022&#x2013;2023</td>
<td align="left" valign="middle">Weifang</td>
<td align="center" valign="middle">79.84&#x202F;&#x00B1;&#x202F;7.71</td>
<td align="center" valign="middle">AIS&#x003E;6</td>
<td align="center" valign="middle">453</td>
<td align="center" valign="middle">106</td>
<td align="center" valign="middle">23.4</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Wang, 2019 (<xref ref-type="bibr" rid="ref36">36</xref>)</td>
<td align="center" valign="middle">2017&#x2013;2018</td>
<td align="left" valign="middle">Nanjing</td>
<td align="center" valign="middle">83.1&#x202F;&#x00B1;&#x202F;6.0</td>
<td align="center" valign="middle">AIS&#x003E;6</td>
<td align="center" valign="middle">516</td>
<td align="center" valign="middle">222</td>
<td align="center" valign="middle">43.0</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Yang, 2021 (<xref ref-type="bibr" rid="ref37">37</xref>)</td>
<td align="center" valign="middle">2018&#x2013;2019</td>
<td align="left" valign="middle">Jinan</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">AIS&#x003E;6</td>
<td align="center" valign="middle">353</td>
<td align="center" valign="middle">78</td>
<td align="center" valign="middle">22.0</td>
<td align="center" valign="middle">9</td>
</tr>
<tr>
<td align="left" valign="middle">Wu, 2020 (<xref ref-type="bibr" rid="ref38">38</xref>)</td>
<td align="center" valign="middle">2016</td>
<td align="left" valign="middle">Jinan</td>
<td align="center" valign="middle">77.45&#x202F;&#x00B1;&#x202F;9.05</td>
<td align="center" valign="middle">AIS&#x003E;6</td>
<td align="center" valign="middle">296</td>
<td align="center" valign="middle">112</td>
<td align="center" valign="middle">38.1</td>
<td align="center" valign="middle">9</td>
</tr>
<tr>
<td align="left" valign="middle">Wang, 2024 (<xref ref-type="bibr" rid="ref39">39</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Changchun</td>
<td align="center" valign="middle">82.28</td>
<td align="center" valign="middle">PSQI&#x2265;8</td>
<td align="center" valign="middle">87</td>
<td align="center" valign="middle">36</td>
<td align="center" valign="middle">41.4</td>
<td align="center" valign="middle">6</td>
</tr>
<tr>
<td align="left" valign="middle">Cai, 2022 (<xref ref-type="bibr" rid="ref40">40</xref>)</td>
<td align="center" valign="middle">2020</td>
<td align="left" valign="middle">Fuzhou</td>
<td align="center" valign="middle">77.67&#x202F;&#x00B1;&#x202F;8.39</td>
<td align="center" valign="middle">PSQI&#x2265;5</td>
<td align="center" valign="middle">275</td>
<td align="center" valign="middle">189</td>
<td align="center" valign="middle">68.73</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Li, 2012 (<xref ref-type="bibr" rid="ref41">41</xref>)</td>
<td align="center" valign="middle">2011</td>
<td align="left" valign="middle">Beijing</td>
<td align="center" valign="middle">82.48&#x202F;&#x00B1;&#x202F;6.85</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">107</td>
<td align="center" valign="middle">35</td>
<td align="center" valign="middle">32.71</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Gao, 2023 (<xref ref-type="bibr" rid="ref42">42</xref>)</td>
<td align="center" valign="middle">2021</td>
<td align="left" valign="middle">Weifang</td>
<td align="center" valign="middle">82.08&#x202F;&#x00B1;&#x202F;8.13</td>
<td align="center" valign="middle">PSQI&#x2265;11</td>
<td align="center" valign="middle">381</td>
<td align="center" valign="middle">135</td>
<td align="center" valign="middle">35.43</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Zhao, 2025 (<xref ref-type="bibr" rid="ref43">43</xref>)</td>
<td align="center" valign="middle">2019</td>
<td align="left" valign="middle">Shanghai</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">ASI&#x202F;&#x003E;&#x202F;6</td>
<td align="center" valign="middle">739</td>
<td align="center" valign="middle">307</td>
<td align="center" valign="middle">41.54</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Xia, 2018 (<xref ref-type="bibr" rid="ref44">44</xref>)</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Wenzhou</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">100</td>
<td align="center" valign="middle">39</td>
<td align="center" valign="middle">39.0</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Chen, 2014 (<xref ref-type="bibr" rid="ref45">45</xref>)</td>
<td align="center" valign="middle">2012</td>
<td align="left" valign="middle">Wuhan</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">151</td>
<td align="center" valign="middle">98</td>
<td align="center" valign="middle">64.9</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Wu, 2021 (<xref ref-type="bibr" rid="ref46">46</xref>)</td>
<td align="center" valign="middle">2019</td>
<td align="left" valign="middle">Chengdu, Deyang</td>
<td align="center" valign="middle">73.67&#x202F;&#x00B1;&#x202F;7.75</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">351</td>
<td align="center" valign="middle">114</td>
<td align="center" valign="middle">32.4</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Nie, 2020 (<xref ref-type="bibr" rid="ref47">47</xref>)</td>
<td align="center" valign="middle">2018</td>
<td align="left" valign="middle">Changsha, Hengyang, Yiyang</td>
<td align="center" valign="middle">79.10&#x202F;&#x00B1;&#x202F;8.71</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">817</td>
<td align="center" valign="middle">550</td>
<td align="center" valign="middle">67.3</td>
<td align="center" valign="middle">8</td>
</tr>
<tr>
<td align="left" valign="middle">Zhang, 2020 (<xref ref-type="bibr" rid="ref48">48</xref>)</td>
<td align="center" valign="middle">2017</td>
<td align="left" valign="middle">Shenyang, Anshan, Tieling, Benxi</td>
<td align="center" valign="middle">71.9&#x202F;&#x00B1;&#x202F;4.8</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">553</td>
<td align="center" valign="middle">254</td>
<td align="center" valign="middle">31.1</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Gao, 2023 (<xref ref-type="bibr" rid="ref49">49</xref>)</td>
<td align="center" valign="middle">2021&#x2013;2022</td>
<td align="left" valign="middle">Weifang</td>
<td align="center" valign="middle">77.43&#x202F;&#x00B1;&#x202F;9.96</td>
<td align="center" valign="middle">PSQI&#x2265;11</td>
<td align="center" valign="middle">645</td>
<td align="center" valign="middle">214</td>
<td align="center" valign="middle">33.2</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Wang, 2022 (<xref ref-type="bibr" rid="ref50">50</xref>)</td>
<td align="center" valign="middle">2019&#x2013;2020</td>
<td align="left" valign="middle">Xuzhou</td>
<td align="center" valign="middle">80.8&#x202F;&#x00B1;&#x202F;6.3</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">228</td>
<td align="center" valign="middle">88</td>
<td align="center" valign="middle">38.6</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle">Liu, 2022 (<xref ref-type="bibr" rid="ref51">51</xref>)</td>
<td align="center" valign="middle" rowspan="2">2021</td>
<td align="left" valign="middle" rowspan="2">Huaihua, Shaoyang<break/>Changde, Xiangtan</td>
<td align="center" valign="middle" rowspan="2">77.32&#x202F;&#x00B1;&#x202F;8.87</td>
<td align="center" valign="middle" rowspan="2">PSQI&#x003E;7</td>
<td align="center" valign="middle" rowspan="2">1,206</td>
<td align="center" valign="middle" rowspan="2">735</td>
<td align="center" valign="middle" rowspan="2">60.9</td>
<td align="center" valign="middle" rowspan="2">7</td>
</tr>
<tr>
<td/>
</tr>
<tr>
<td align="left" valign="middle">Hu, 2023 (<xref ref-type="bibr" rid="ref52">52</xref>)</td>
<td align="center" valign="middle">2020&#x2013;2021</td>
<td align="left" valign="middle">Guangzhou</td>
<td align="center" valign="middle">70.56&#x202F;&#x00B1;&#x202F;7.58</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">259</td>
<td align="center" valign="middle">136</td>
<td align="center" valign="middle">52.5</td>
<td align="center" valign="middle">7</td>
</tr>
<tr>
<td align="left" valign="middle" rowspan="2">Liu, 2019 (<xref ref-type="bibr" rid="ref53">53</xref>)</td>
<td align="center" valign="middle" rowspan="2">-</td>
<td align="left" valign="middle">Xining</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">207</td>
<td align="center" valign="middle">86</td>
<td align="center" valign="middle">41.54</td>
<td align="center" valign="middle" rowspan="2">6</td>
</tr>
<tr>
<td align="left" valign="middle">Guangzhou</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="top">437</td>
<td align="center" valign="top">82</td>
<td align="center" valign="top">18.76</td>
</tr>
<tr>
<td align="left" valign="top">Jiang, 2019 (<xref ref-type="bibr" rid="ref54">54</xref>)</td>
<td align="center" valign="top">-</td>
<td align="left" valign="top">Shanghai</td>
<td align="center" valign="top">84.33&#x202F;&#x00B1;&#x202F;6.9</td>
<td align="center" valign="top">ASI&#x003E;6</td>
<td align="center" valign="top">605</td>
<td align="center" valign="top">120</td>
<td align="center" valign="top">19.83</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Sun, 2024 (<xref ref-type="bibr" rid="ref55">55</xref>)</td>
<td align="center" valign="top">2023</td>
<td align="left" valign="top">Jilin, Liaoning Heilongjiang Provinces</td>
<td align="center" valign="top">76.79&#x202F;&#x00B1;&#x202F;8.56</td>
<td align="center" valign="top">PSQI&#x003E;5</td>
<td align="center" valign="top">574</td>
<td align="center" valign="top">127</td>
<td align="center" valign="top">22.1</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Wang, 2021 (<xref ref-type="bibr" rid="ref56">56</xref>)</td>
<td align="center" valign="top">2018</td>
<td align="left" valign="top">Shanghai</td>
<td align="center" valign="top">86.40&#x202F;&#x00B1;&#x202F;5.27</td>
<td align="center" valign="top">AIS&#x003E;6</td>
<td align="center" valign="top">218</td>
<td align="center" valign="top">56</td>
<td align="center" valign="top">25.7</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Tsai, 2008 (<xref ref-type="bibr" rid="ref57">57</xref>)</td>
<td align="center" valign="top">-</td>
<td align="left" valign="top">Taiwan Province</td>
<td align="center" valign="top">79.0&#x202F;&#x00B1;&#x202F;6.7</td>
<td align="center" valign="top">PSQI&#x003E;5</td>
<td align="center" valign="top">196</td>
<td align="center" valign="top">91</td>
<td align="center" valign="top">46.4</td>
<td align="center" valign="top">8</td>
</tr>
<tr>
<td align="left" valign="top">Wen, 2024 (<xref ref-type="bibr" rid="ref58">58</xref>)</td>
<td align="center" valign="top">2021</td>
<td align="left" valign="top">Hunan Province</td>
<td align="center" valign="top">77.52&#x202F;&#x00B1;&#x202F;9.16</td>
<td align="center" valign="top">PSQI&#x003E;7</td>
<td align="center" valign="top">3,356</td>
<td align="center" valign="top">1,035</td>
<td align="center" valign="top">30.8</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Hou, 2024 (<xref ref-type="bibr" rid="ref59">59</xref>)</td>
<td align="center" valign="top">2021&#x2013;2022</td>
<td align="left" valign="top">Changsha</td>
<td align="center" valign="top">-</td>
<td align="center" valign="top">PSQI&#x003E;7</td>
<td align="center" valign="top">172</td>
<td align="center" valign="top">108</td>
<td align="center" valign="top">62.8</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Zhu, 2024 (<xref ref-type="bibr" rid="ref60">60</xref>)</td>
<td align="center" valign="top">2023</td>
<td align="left" valign="top">Chongqing</td>
<td align="center" valign="top">81.54&#x202F;&#x00B1;&#x202F;7.94</td>
<td align="center" valign="top">PSQI&#x003E;7</td>
<td align="center" valign="top">127</td>
<td align="center" valign="top">71</td>
<td align="center" valign="top">55.96</td>
<td align="center" valign="top">7</td>
</tr>
<tr>
<td align="left" valign="top">Mou, 2020 (<xref ref-type="bibr" rid="ref61">61</xref>)</td>
<td align="center" valign="top">2018</td>
<td align="left" valign="top">Jinan</td>
<td align="center" valign="top">78.81&#x202F;&#x00B1;&#x202F;8.90</td>
<td align="center" valign="top">PSQI&#x003E;7</td>
<td align="center" valign="top">353</td>
<td align="center" valign="top">221</td>
<td align="center" valign="top">62.6</td>
<td align="center" valign="top">8</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>&#x201C;-&#x201D; Indicates that the item was not reported in the study. Assessment tools: Pittsburgh Sleep Quality Index (PSQI); Athens Insomnia Scale (AIS).</p>
</table-wrap-foot>
</table-wrap>
</sec>
<sec id="sec13">
<title>Prevalence of sleep disorders in nursing home residents</title>
<p>A total of 35 studies involving 15,996 older adults residents in nursing homes were included in this meta-analysis. Among them, 6,583 individuals were identified as having sleep disorders. Due to significant heterogeneity among the included studies, a random-effects model was employed to pool the effect sizes. The meta-analysis revealed that the pooled prevalence of sleep disorders among older adults residents in nursing homes in China was 43% (95% CI: 38 to 48%), as illustrated in <xref ref-type="fig" rid="fig2">Figure 2</xref>.</p>
<fig position="float" id="fig2">
<label>Figure 2</label>
<caption>
<p>Forest plot of the prevalence of sleep disorders among older adults residents in nursing homes in China.</p>
</caption>
<graphic xlink:href="fpubh-13-1664136-g002.tif" mimetype="image" mime-subtype="tiff">
<alt-text content-type="machine-generated">Forest plot displaying the effect sizes (ES) and ninety-five percent confidence intervals (CI) for multiple studies, along with their corresponding weights. Studies are listed on the left, with ES values, CIs, and weights on the right. The overall random effect is marked at ES 0.40 with CI 0.39 to 0.41, and heterogeneity is indicated as ninety-seven point sixty-nine percent.</alt-text>
</graphic>
</fig>
</sec>
<sec id="sec14">
<title>Temporal trends in sleep disorder prevalence</title>
<p>Analysis of temporal trends demonstrated significant fluctuations in the prevalence of sleep disorders among nursing home residents in China between 2008 and 2024. Despite these fluctuations, a general downward trend was observed. Notably, a transient increase in prevalence occurred in 2022. The temporal trend is detailed in <xref ref-type="fig" rid="fig3">Figure 3</xref>.</p>
<fig position="float" id="fig3">
<label>Figure 3</label>
<caption>
<p>Temporal trend in the prevalence of sleep disorders among older adults residents in nursing homes in China (2008&#x2013;2024).</p>
</caption>
<graphic xlink:href="fpubh-13-1664136-g003.tif" mimetype="image" mime-subtype="tiff">
<alt-text content-type="machine-generated">Line graph showing percentage change from 2008 to 2024. Fluctuations occur, with peaks at 64.9% in 2014 and 52% in 2021, and a low of 22.7% in 2020. A red dashed trend line indicates an overall decline.</alt-text>
</graphic>
</fig>
</sec>
<sec id="sec15">
<title>Subgroup analyses</title>
<sec id="sec16">
<title>Region</title>
<p>Studies were stratified according to China&#x2019;s six major administrative regions. Meta-analysis results indicated the highest prevalence of sleep disorders in nursing homes was in Central China (57%), while the lowest prevalence was found in South China. The East China region contributed the largest number of included studies (<italic>n</italic>&#x202F;=&#x202F;16), with a pooled prevalence of 40%. The Northwest China and Taiwan/Hong Kong/Macau regions were analyzed separately due to limited included studies (<italic>n</italic>&#x202F;=&#x202F;1). Hence, these findings have limited reliability and generalizability and are not suitable for independent interpretation or extrapolation (See <xref ref-type="table" rid="tab2">Table 2</xref>).</p>
<table-wrap position="float" id="tab2">
<label>Table 2</label>
<caption>
<p>Subgroup analysis of sleep disorder prevalence among older adults residents in nursing homes in China.</p>
</caption>
<table frame="hsides" rules="groups">
<thead>
<tr>
<th align="left" valign="top" rowspan="2">Subgroup</th>
<th align="center" valign="top" rowspan="2">Included studies</th>
<th align="center" valign="top" colspan="2">Heterogeneity test</th>
<th align="left" valign="top" rowspan="2">Effect model</th>
<th align="center" valign="top" rowspan="2">Prevalence rate (95% CI)</th>
</tr>
<tr>
<th align="center" valign="top">
<italic>I<sup>2</sup></italic>
</th>
<th align="center" valign="top">
<italic>p</italic>
</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" valign="middle" colspan="6">Region</td>
</tr>
<tr>
<td align="left" valign="middle">North China</td>
<td align="center" valign="middle">3</td>
<td align="center" valign="middle">85</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">45% (34%, 55%)</td>
</tr>
<tr>
<td align="left" valign="middle">Northeast China</td>
<td align="center" valign="middle">5</td>
<td align="center" valign="middle">97</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">44% (31%, 56%)</td>
</tr>
<tr>
<td align="left" valign="middle">East China</td>
<td align="center" valign="middle">16</td>
<td align="center" valign="middle">98</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">40% (33%, 38%)</td>
</tr>
<tr>
<td align="left" valign="middle">Central China</td>
<td align="center" valign="middle">5</td>
<td align="center" valign="middle">99</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">57% (44%, 71%)</td>
</tr>
<tr>
<td align="left" valign="middle">South China</td>
<td align="center" valign="middle">2</td>
<td align="center" valign="middle">99</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">28% (25%, 31%)</td>
</tr>
<tr>
<td align="left" valign="middle">Southwest China</td>
<td align="center" valign="middle">3</td>
<td align="center" valign="middle">91</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">43% (30%, 57%)</td>
</tr>
<tr>
<td align="left" valign="middle">Northwest China</td>
<td align="center" valign="middle">1</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">-</td>
<td/>
<td align="char" valign="middle" char="(">42% (35%, 49%)</td>
</tr>
<tr>
<td align="left" valign="middle">Taiwan/Hong Kong/Macao</td>
<td align="center" valign="middle">1</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">-</td>
<td/>
<td align="char" valign="middle" char="(">46% (39%, 54%)</td>
</tr>
<tr>
<td align="left" valign="middle" colspan="6">Sample size</td>
</tr>
<tr>
<td align="left" valign="middle">&#x2264;150</td>
<td align="center" valign="middle">6</td>
<td align="center" valign="middle">81</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">46% (37%, 54%)</td>
</tr>
<tr>
<td align="left" valign="middle">150&#x2013;300</td>
<td align="center" valign="middle">11</td>
<td align="center" valign="middle">94</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">49% (41%, 57%)</td>
</tr>
<tr>
<td align="left" valign="middle">300&#x2013;500</td>
<td align="center" valign="middle">10</td>
<td align="center" valign="middle">98</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">40% (30%, 50%)</td>
</tr>
<tr>
<td align="left" valign="middle">500&#x2013;1,000</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">99</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">39% (27%, 51%)</td>
</tr>
<tr>
<td align="left" valign="middle">&#x003E;1,000</td>
<td align="center" valign="middle">2</td>
<td align="center" valign="middle">100</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">48% (37%, 40%)</td>
</tr>
<tr>
<td align="left" valign="middle" colspan="6">Duration of residence</td>
</tr>
<tr>
<td align="left" valign="middle">&#x003E;1&#x4E2A;&#x6708;</td>
<td align="center" valign="middle">4</td>
<td align="center" valign="middle">95</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">42% (26%, 58%)</td>
</tr>
<tr>
<td align="left" valign="middle">&#x2265;3&#x4E2A;&#x6708;</td>
<td align="center" valign="middle">12</td>
<td align="center" valign="middle">99</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">41% (32%, 50%)</td>
</tr>
<tr>
<td align="left" valign="middle">&#x2265;6&#x4E2A;&#x6708;</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">91</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">44% (35%, 52%)</td>
</tr>
<tr>
<td align="left" valign="middle">&#x2265;12&#x4E2A;&#x6708;</td>
<td align="center" valign="middle">2</td>
<td align="center" valign="middle">96</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">56% (32%, 79%)</td>
</tr>
<tr>
<td align="left" valign="middle" colspan="6">Diagnostic criteria</td>
</tr>
<tr>
<td align="left" valign="middle">PSQI&#x003E;7</td>
<td align="center" valign="middle">23</td>
<td align="center" valign="middle">98</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">49% (43%, 54%)</td>
</tr>
<tr>
<td align="left" valign="middle">PSQI&#x2265;8</td>
<td align="center" valign="middle">1</td>
<td align="center" valign="middle">-</td>
<td align="center" valign="middle">-</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">41% (31%, 52%)</td>
</tr>
<tr>
<td align="left" valign="middle">AIS&#x003E;6</td>
<td align="center" valign="middle">3</td>
<td align="center" valign="middle">96</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">30% (23%, 38%)</td>
</tr>
<tr>
<td align="left" valign="middle">PSQI&#x2265;11</td>
<td align="center" valign="middle">2</td>
<td align="center" valign="middle">0</td>
<td align="center" valign="middle">0.46</td>
<td align="left" valign="middle">Fixed</td>
<td align="char" valign="middle" char="(">34% (31%, 37%)</td>
</tr>
<tr>
<td align="left" valign="middle">PSQI&#x003E;5</td>
<td align="center" valign="middle">3</td>
<td align="center" valign="middle">99</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">46% (19%, 72%)</td>
</tr>
<tr>
<td align="left" valign="middle" colspan="6">Gender</td>
</tr>
<tr>
<td align="left" valign="middle">Male</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">96</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">37% (27%, 46%)</td>
</tr>
<tr>
<td align="left" valign="middle">Female</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">95</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">41% (32%, 50%)</td>
</tr>
<tr>
<td align="left" valign="middle" colspan="6">Depression status</td>
</tr>
<tr>
<td align="left" valign="middle">Yes</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">92</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">53% (40%, 66%)</td>
</tr>
<tr>
<td align="left" valign="middle">No</td>
<td align="center" valign="middle">7</td>
<td align="center" valign="middle">83</td>
<td align="center" valign="middle">0.01</td>
<td align="left" valign="middle">Random</td>
<td align="char" valign="middle" char="(">23% (16%, 31%)</td>
</tr>
</tbody>
</table>
<table-wrap-foot>
<p>&#x201C;-&#x201D; Indicates that the item was not reported in the study.</p>
</table-wrap-foot>
</table-wrap>
</sec>
<sec id="sec17">
<title>Sample size</title>
<p>Subgroup analysis based on sample size revealed that the highest prevalence of sleep disorders (49%) was reported in studies with sample sizes between 150 and 300. Conversely, the lowest prevalence (39%) was observed in studies with sample sizes between 500 and 1,000. These findings suggest a potential influence of sample size on prevalence estimates (See <xref ref-type="table" rid="tab2">Table 2</xref>).</p>
</sec>
<sec id="sec18">
<title>Length of nursing home residence</title>
<p>Stratification by duration of residence in nursing homes showed that the highest prevalence of sleep disorders (56%) occurred among residents with a length of residence &#x2265;12&#x202F;months. In contrast, the lowest prevalence (41%) was found among those with a length of residence &#x2265;3&#x202F;months (See <xref ref-type="table" rid="tab2">Table 2</xref>).</p>
</sec>
<sec id="sec19">
<title>Diagnostic criteria for sleep disorders</title>
<p>Subgroup analysis according to the diagnostic criteria used demonstrated the highest prevalence (49%) when sleep disorders were defined using the criterion PSQI &#x003E;7. The lowest prevalence (30%) was observed when the AIS &#x003E;6 criterion was applied. The widest confidence interval (46%; 95% CI: 19 to 72%) was associated with the PSQI &#x003E;5 criterion (See <xref ref-type="table" rid="tab2">Table 2</xref>).</p>
</sec>
<sec id="sec20">
<title>Gender</title>
<p>Gender-based subgroup analysis indicated a slightly higher prevalence of sleep disorders among female residents (41%) compared to male residents (37%). However, the magnitude of this gender difference was relatively small (See <xref ref-type="table" rid="tab2">Table 2</xref>).</p>
</sec>
</sec>
<sec id="sec21">
<title>Sensitivity analysis</title>
<p>Sensitivity analysis was performed using the leave-one-out method. After sequentially excluding individual studies, the estimated prevalence of sleep disorders among older adults residents in nursing homes in China ranged between 39 and 48%. The pooled prevalence remained stable throughout this process, indicating that the meta-analysis results are robust.</p>
</sec>
<sec id="sec22">
<title>Publication bias assessment</title>
<p>Publication bias was assessed for the included studies. The funnel plot for the prevalence of sleep disorders among nursing home residents demonstrated approximate symmetry (<xref ref-type="fig" rid="fig4">Figure 4</xref>). Egger&#x2019;s linear regression test further confirmed no significant publication bias (<italic>t</italic>&#x202F;=&#x202F;1.36, <italic>p</italic>&#x202F;=&#x202F;0.182). These results suggest the absence of substantial publication bias in the current meta-analysis.</p>
<fig position="float" id="fig4">
<label>Figure 4</label>
<caption>
<p>Assessment of publication bias for sleep disorder prevalence in nursing homes: <bold>(A)</bold> Funnel plot; <bold>(B)</bold> Egger&#x2019;s regression test.</p>
</caption>
<graphic xlink:href="fpubh-13-1664136-g004.tif" mimetype="image" mime-subtype="tiff">
<alt-text content-type="machine-generated">Scatter plot showing SND of effect estimate versus precision with a regression line. Points indicate study data, regression line is in red, and a 95% confidence interval for the intercept is noted.</alt-text>
</graphic>
</fig>
</sec>
</sec>
<sec sec-type="discussion" id="sec23">
<title>Discussion</title>
<p>This systematic review incorporated 35 studies conducted between 2008 and 2024, encompassing 17 provinces (autonomous regions, and municipalities) in China. The results indicate that the prevalence of sleep disorders among older adults residents in Chinese nursing homes is 43%, which is marginally higher than that reported for community-dwelling older adults (41%). This finding aligns with international research indicating poorer sleep quality among residents of long-term care facilities compared to their community-dwelling counterparts (<xref ref-type="bibr" rid="ref14">14</xref>, <xref ref-type="bibr" rid="ref15">15</xref>).</p>
<p>Our analysis revealed a significantly higher prevalence of sleep disorders among nursing home residents in Central China compared to other regions, with the lowest prevalence observed in South China. Prevalence rates in other regions showed minimal variation. This spatial heterogeneity may stem from several factors: the uneven geographical distribution of nursing homes (characterized by a higher concentration in eastern regions compared to western areas), regional disparities in socio-economic development levels, and imbalanced allocation of older adults care service resources (<xref ref-type="bibr" rid="ref1">1</xref>). Research suggests a negative correlation between social support and sleep disorders in the older adults (<xref ref-type="bibr" rid="ref16">16</xref>). Compared to community-dwelling seniors, nursing home residents often experience reduced opportunities for interaction with family members and neighbors, leading to a weakened social support network (<xref ref-type="bibr" rid="ref17">17</xref>). This diminished social engagement reduces emotional support and participation, directly impairing sleep quality.</p>
<p>Our findings indicate that sample size did not significantly influence the estimated prevalence of sleep disorders in this population. Regarding diagnostic tool efficacy, the highest prevalence (49%) was observed when using the PSQI &#x003E;7 cutoff, while the lowest prevalence (30%) was associated with the AIS&#x202F;&#x003E;&#x202F;6 criterion. This discrepancy likely arises from the multidimensional assessment advantage of the PSQI, which comprehensively evaluates seven domains of sleep (quality, latency, duration, efficiency, disturbances, medication use, and daytime dysfunction) and possesses strong psychometric properties. In contrast, while the AIS is simpler and easier to administer, its unidimensional nature, focusing solely on insomnia symptoms, fails to capture information about other types of sleep disorders (<xref ref-type="bibr" rid="ref18">18</xref>).</p>
<p>Subgroup analysis based on the duration of residence in nursing homes revealed the highest prevalence of sleep disorders (56%) among residents with a length of stay &#x2265;12&#x202F;months. This elevated risk is not solely attributable to prolonged residence. Contributing factors include: (1) environmental influences within facilities, such as limited activity space and social isolation (<xref ref-type="bibr" rid="ref19">19</xref>); and (2) age-related factors including declining physiological function, progression or exacerbation of chronic diseases, increased polypharmacy risk (<xref ref-type="bibr" rid="ref20">20</xref>), and the accumulation of psychological burdens such as loneliness, helplessness, and a sense of loss, all of which collectively heighten the risk of sleep disorders (<xref ref-type="bibr" rid="ref21">21</xref>, <xref ref-type="bibr" rid="ref22">22</xref>).</p>
<p>Consistent with both domestic and international studies (<xref ref-type="bibr" rid="ref23">23</xref>), our results show that the prevalence of sleep problems among female residents was higher than among males, aligning with reports that females experience sleep problems at 1.3&#x2013;1.8 times the rate of males. This gender disparity may be linked to the gradual decline or cessation of endogenous estrogen secretion following menopause due to ovarian function decline (<xref ref-type="bibr" rid="ref24">24</xref>), coupled with women&#x2019;s heightened sensitivity to inflammatory biomarker responses following sleep deprivation (<xref ref-type="bibr" rid="ref25">25</xref>).</p>
<p>Temporal trend analysis demonstrated an overall declining trend in the prevalence of sleep disorders among Chinese nursing home residents from 2008 to 2024. This positive shift may be attributed to three key factors: Policy drivers: Implementation of the &#x201C;Healthy China 2030&#x201D; blueprint has elevated public awareness of holistic health management. Technological innovation: The proliferation of intelligent sleep monitoring devices (e.g., sleep trackers, polysomnography) and digitalized intervention programs has enabled precise sleep assessment and personalized interventions. Social engagement: Collaborative efforts between healthcare institutions, enterprises, and research organizations in conducting sleep health education campaigns and community intervention projects have fostered a multidimensional support system, collectively promoting improved sleep health nationwide. Given the critical importance of sleep health as a core indicator of older adults well-being (<xref ref-type="bibr" rid="ref26">26</xref>), we recommend enhancing the sleep health management system within nursing homes by: Optimizing physical infrastructure: Improving acoustic insulation and lighting conditions in living environments. Enhancing service delivery: Establishing dedicated sleep health management teams. Upskilling nursing staff: Providing specialized training in sleep disorder recognition and non-pharmacological interventions (e.g., music therapy, aromatherapy). Implementing personalized care: Developing tailored intervention plans based on individual characteristics. These measures aim to improve sleep quality, promote functional recovery, and ultimately enhance the quality of life for older adults residents.</p>
<sec id="sec24">
<title>Limitations of this study</title>
<p>(1) The included studies exhibited substantial heterogeneity. Although subgroup analyses were conducted based on factors such as gender, geographical region, and duration of nursing home residence, they failed to significantly reduce the heterogeneity. Consequently, the findings of this study may be subject to a certain degree of bias. (2) Among the included literature, the number of studies from some provinces (autonomous regions, municipalities) was limited or even absent, and some subgroups (e.g., Northwestern China, Taiwan/Hong Kong/Macau) contained only a single study. This limits our ability to obtain stable and reliable effect estimates for these specific populations and affects the generalizability of our findings to these groups. Future research targeting these regions is required to validate our findings. (3) All selected studies were cross-sectional in design, which may introduce biases related to implementation and measurement. Furthermore, the results of this review primarily reflect the sleep status of nursing home residents with basic cognitive and communication abilities. They may not be fully representative of the entire nursing home population, particularly those with moderate to severe dementia, a group in which sleep problems are especially prominent. Future studies should adopt more rigorous designs, incorporate standardized cognitive assessments as a basis for inclusion and stratification, and combine caregiver proxy-reported questionnaires with objective sleep monitoring technologies (e.g., actigraphy) to provide a more comprehensive and accurate understanding of sleep issues among nursing home residents across different cognitive statuses.</p>
</sec>
</sec>
<sec sec-type="conclusions" id="sec25">
<title>Conclusion</title>
<p>The detection rate of sleep disorders among older adults residents in Chinese nursing homes is relatively high (43%), with marked disparities observed across different demographic and geographic groups. Significant attention should be directed toward the sleep health of this vulnerable population. Comprehensive preventive and intervention measures, tailored to the specific characteristics of different subpopulations, must be developed and implemented to effectively improve sleep quality and reduce the burden of sleep disorders.</p>
</sec>
</body>
<back>
<sec sec-type="data-availability" id="sec26">
<title>Data availability statement</title>
<p>Publicly available datasets were analyzed in this study. This data can be found here: All data analyzed during this study are included in this article, and further inquiries can be directed to the corresponding author.</p>
</sec>
<sec sec-type="author-contributions" id="sec27">
<title>Author contributions</title>
<p>XB: Data curation, Methodology, Software, Writing &#x2013; original draft. SL: Formal analysis, Resources, Writing &#x2013; original draft. YanL: Methodology, Visualization, Writing &#x2013; review &#x0026; editing. YuL: Supervision, Visualization, Writing &#x2013; original draft. YJ: Funding acquisition, Supervision, Writing &#x2013; review &#x0026; editing.</p>
</sec>
<sec sec-type="COI-statement" id="sec28">
<title>Conflict of interest</title>
<p>The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p>
</sec>
<sec sec-type="ai-statement" id="sec29">
<title>Generative AI statement</title>
<p>The authors declare that no Gen AI was used in the creation of this manuscript.</p>
<p>Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.</p>
</sec>
<sec sec-type="disclaimer" id="sec30">
<title>Publisher&#x2019;s note</title>
<p>All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.</p>
</sec>
<sec sec-type="supplementary-material" id="sec31">
<title>Supplementary material</title>
<p>The Supplementary material for this article can be found online at: <ext-link xlink:href="https://www.frontiersin.org/articles/10.3389/fpubh.2025.1664136/full#supplementary-material" ext-link-type="uri">https://www.frontiersin.org/articles/10.3389/fpubh.2025.1664136/full#supplementary-material</ext-link></p>
<supplementary-material xlink:href="Table_1.docx" id="SM1" mimetype="application/vnd.openxmlformats-officedocument.wordprocessingml.document" xmlns:xlink="http://www.w3.org/1999/xlink"/>
</sec>
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<fn-group>
<fn fn-type="custom" custom-type="edited-by" id="fn0001">
<p>Edited by: <ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/920027/overview">Lawrence Ejike Ugwu</ext-link>, Renaissance University, Nigeria</p>
</fn>
<fn fn-type="custom" custom-type="reviewed-by" id="fn0002">
<p>Reviewed by: <ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/1384211/overview">Mohammed Abu El-Hamd</ext-link>, Sohag University, Egypt</p>
<p><ext-link ext-link-type="uri" xlink:href="https://loop.frontiersin.org/people/3243899/overview">Santa Pangaribuan</ext-link>, Krida Wacana Christian University, Indonesia</p>
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