Effectiveness of acupressure for residents of long-term care facilities with insomnia: A randomized controlled trial

International Journal of Nursing Studies 47 (2010) 798–805

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Effectiveness of acupressure for residents of long-term care facilities with insomnia: A randomized controlled trial Jia-Ling Sun a,b, Mei-Sheng Sung c, Mei-Yu Huang a, Guang-Chih Cheng d, Chia-Chin Lin e,f,* a

Department of Nursing, Yuanpei University, Hsinchu, Taiwan Graduate Institute of Nursing, Taipei Medical University, Taiwan c General Education Center, Chunghua University, Hsinchu, Taiwan d Department of Rehabilitation Medicine, St. Mary’s Hospital, Lotung, I-Lan, Taiwan e School of Nursing, Taipei Medical University, Taiwan f Wan-Fang Hospital, Taiwan b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 31 May 2009 Received in revised form 29 November 2009 Accepted 5 December 2009

Background: Acupressure on the Shenmen point (indexed as HT7) can improve insomnia, but there has been no longitudinal study to evaluate its efficacy for residents of long-term care facilities. No evidence from the existing literature indicates how long its efficacy can be maintained after stopping acupressure. Objective: The aim of this study was to evaluate the effectiveness of acupressure on the Shenmen point for residents of long-term care facilities with insomnia. Methods: Fifty residents with insomnia in long-term care facilities were enrolled in a randomized controlled trial, with 25 participants allocated to the experimental group and 25 participants to the control group. For a 5-week period, the experimental group received standard acupressure on the HT7 points of both wrists, whereas the control group received only light touch on the same places. Insomnia was measured with the Athens Insomnia Scale-Taiwan form (AIS-T). Participants’ self-reported scores were done at baseline, during the 5-week period, and after intervention. This study was analyzed on an intention-totreat procedure. Results: The experimental group has significantly better scores on the AIS-T compared to the control group, not only during the intervention period, but also extending after intervention, as shown by generalized estimating equations (p < 0.05). Conclusions: Offering acupressure on a regular basis has the potential to improve insomnia in residents of long-term care facilities. Acupressure on the HT7 point may improve insomnia for up to 2 weeks after the intervention. ß 2009 Elsevier Ltd. All rights reserved.

Keywords: Acupressure Athens Insomnia Scale Insomnia

What is already known about the topic?  Insomnia is a common distress symptom among residents in long-term care facilities and severely impacts quality of life.

* Corresponding author at: School of Nursing, Taipei Medical University, 250 Wu-Hsing Street, Taipei 110, Taiwan. Tel.: +886 2 23776229; fax: +886 2 23772842. E-mail address: [email protected] (C.-C. Lin). 0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2009.12.003

 Previous studies have indicated that acupressure may improve sleep quality in hemodialysis and stroke patients. What this paper adds  Acupressure on the HT7 point may improve insomnia among residents in long-term care facilities.  Acupressure is an intervention, which could be incorporated into routine practice in residents of long-term care facilities with insomnia, although further evidence is required to fully establish its effectiveness.

J.-L. Sun et al. / International Journal of Nursing Studies 47 (2010) 798–805

1. Background Insomnia is a symptom of unsatisfactory sleep quantity and/or sleep quality for a period of time. The criteria for a diagnosis of insomnia, according to the International Classification of Disease (ICD-10) (World Health Organization, 1992), is a series of complaints, including difficulty in falling asleep or maintaining asleep, and poor sleep quality. Besides, sleep disturbance should have occurred at least three times per week and lasted for at least 1 month. Insomnia is a major problem for residents in long-term care facilities (Dornberger, 2008; Hsu, 2001; Voyer et al., 2006). The prevalence of insomnia in residents of longterm care facilities ranges from 6.2% to 39% (Scherer et al., 2007; Voyer et al., 2006). Insomnia accompanies aging, cognitive impairment, and changes to environment or living patterns (Alessi et al., 2005; Voyer et al., 2006). Poor sleep quality among residents in long-term care facilities contributes to many other problems, such as attention deficit, falls, and frequent requests for evening nursing care (Avidan et al., 2005; Voyer et al., 2006). Insomnia is common in long-term care settings but there is no standard ways of assessing and managing sleep disturbance (Scherer et al., 2007). If it continues for a long time, it results in poor quality of life for the residents (Dornberger, 2008). For such reasons, insomnia has become an important issue that caregivers must address. In traditional Chinese medicine, normal physiological functioning of the human body is generated from the harmonious opposition of tendencies called Yin and Yang. A normal sleeping pattern is the result of the mutual transformation between Yin and Yang (Chen, 2003; Liu et al., 2006). Chinese medicine holds that if the elements, such as the Qi, blood, Yin, Yang, and Zang-Fu (internal organs), are not properly functioning and in harmonious relation with each other, abnormalities in consciousness may occur, including mental illness, insomnia, excessive dreaming, mental restlessness, delirium, and even susceptibility to illness (Liu et al., 2006; Sierpina and Frenkel, 2005). Han’s (2004) report supports that Chinese acupuncture and electroacupuncture can produce an analgesic effect by releasing endogenous opiate peptides in the central nervous system and increasing the pain threshold. The release of neurotransmitters, such as endorphins, encephalin, dopamine, and serotonin during acupuncture, has analgesic effects and may cause sedation (Cabyoglu et al., 2006; Lin and Chen, 2008). Like acupuncture, acupressure can release endorphins in the brain to relax muscles, reduce pain, and enhance comfort (Yang and Lin, 2007). It regulates physical mechanisms that may induce the body to relax and may improve sleep quality. Gooneratne (2008) focused on researches of sleep disturbances for older adults from publications of complementary and alternative medicine literature. He found that more evidences about acupressure are needed to prove its efficacy. Cheuk et al. (2007) reviewed existing researches to evaluate the efficacy and safety of acupuncture for people with insomnia. Only seven trials were included in the analysis. They were with a small number of randomized controlled trials, poor methodological quality, and significant heterogeneity. The evidence was not

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sufficient to prove acupressure for improving insomnia. Chen et al. (2007) reviewed researches on the efficacy of auricular acupuncture (AA) treatment for insomnia. Only six trials met the inclusion criteria and were retrieved. Those trials found that the Shenmen auricular acupoint was effective for improving insomnia. There has been a systematic review (Huang et al., 2009) to explore the studies of effects on acupuncture for insomnia. Its results indicated that acupuncture can ameliorate insomnia and is a safe treatment. However, those studies did not have adequacy sham procedure groups to be compared with treatment groups. Because acupuncture is invasive, requiring an acupuncture needle to be inserted into an acupoint on the body, only a trained physician or a qualified acupuncturist is allowed to perform such procedures (Cabyoglu et al., 2006; Sierpina and Frenkel, 2005). Besides, participants are easily withdrawable during the treatment period because of pain by acupuncture (Kim et al., 2004). This is a common adverse event frequently reported. In contrast, acupressure is a noninvasive procedure that consists of applying only finger pressure at the same acupoint. Nurses or staff members may be qualified to carry out such a treatment. In addition, as many residents are nervous about needles, acupressure is a more comfortable alternative. Meeks et al. (2007) reviewed the databases of PubMed (1966-September 2006) and PsycINFO (1984-September 2006) on depression, anxiety, and sleep status among the elderly. Results show that acupressure is beneficial for reducing sleep disturbance and anxiety among senior citizens. Previous studies also have indicated that acupressure may improve sleep quality in hemodialysis and stroke patients (Kim et al., 2004; Tsay et al., 2004). The Shenmen (indexed as HT7) is an acupoint located on the Heart Meridian of Hand-Shaoyin. It is also called the ‘‘spirit gate,’’ a pathway that is related to vitality and that controls mood, consciousness, and thought. Many studies indicate that acupuncture or acupressure can improve sleep quality (Kim et al., 2004; Nordio and Romanelli, 2008; Tsay and Chen, 2003; Tsay et al., 2004), but there are few studies which investigate treatment performed at the HT7 point (Tsay and Chen, 2003; Cerrone et al., 2008). In the study of Cerrone et al., they applied acupressure on the HT7 point for patients with insomnia by at least two consecutive weeks. Based on the above reviews, we concluded that acupressure has the effect of ameliorating their insomnia and requires a period of time to achieving efficacy, but there has been no study to confirm how long the efficacy can be even lasted. Moreover, we found that these clinical trials are deficient in terms of treatment duration and follow-up period for acupressure on the HT7 point. Also, they were only focused on sleep quality. Therefore, we proceeded to investigate the efficacy of the HT7 point acupressure on improving the sleep quality among longterm care residents by using the Pittsburgh Sleep Quality Index-Taiwan form (PSQI-T) (Hsu et al., 2006). Furthermore, we aimed to document the efficacy of the HT7 acupressure for improving insomnia using the Athens Insomnia Scale-Taiwan form (AIS-T) and evaluating the duration of its effect after treatment stopped.

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2. Methods

2.4. Interventions

2.1. Participants and settings

Four trained assistants administered the intervention to participants before bedtime every night. The experimental group received the HT7 acupressure on both wrists with an interval of five-second pressure followed by one-second rest for 5 min. To avoid strong placebo effects, the control group only received a light touch on the same acupoints by the same setting. Only assistants accompanied them and touched their acupoints with no pressure. The interventions were performed for five continuous weeks. Four assistants were trained to ensure the accuracy of the HT7 acupoint location and the pressure amount. The HT7 acupoint is located at the ulnal end of the crease of the wrist, and in the depression on the radial side of the tendon of the wrist’s ulnal flexor muscle (Shao et al., 2006). The exerted pressure should have been within 3–5 kg, using a standard scale. After the training was finished, all assistants were required to demonstrate the technique to confirm the accuracy of their performance. In order to assure intra-rater reliability, a registered nurse used the same standard to monitor the assistants’ technique prior to the experiment. The correct pressure had to be achieved at least 8 out of 10 times.

Participants were recruited from two long-term care facilities in Northern Taiwan. Both facilities have the same routine and similar environments. Characteristics of residents and staff arrangements are much alike, too. All subjects were screened based on the following criteria: (1) they resided in the same facility for at least 3 months. (2) We administered both PSQI-T and AIS-T questionnaires to them. They had self-reported PSQI-T scores greater than or equal to five over the past 3 weeks, and AIS-T scores greater than or equal to six. (3) They could communicate well with researchers in verbally. Residents were excluded if they had heart diseases, acute diseases (e.g. inflammation or upper respiratory disease), trauma, wounds on both wrists, or regularly took hypnotics more frequently than four times per week. The PSQI-T (Wang et al., 2007), which was translated from the PSQI (Buysse et al., 1989), uses scores ranging from 0 to 21. When the score is greater than or equal to five, it indicates poor sleep quality. The AIS-T scores equal to or more than six indicates insomnia. Two nurses at each work unit performed data collection. They asked residents about their feelings corresponding to items in the AIS-T and PSQI-T over the past 3 weeks before starting the intervention. Then, the nurses recorded the answer and the score was individually calculated to obtain the total score. 2.2. Research design A randomized controlled trial with pre- and posttesting was adopted for this study. Twenty-five participants in each facility were assigned with sequential numbers after recruitment, and were randomly assigned to the experimental or control group by a computergenerated random function of the statistics program, Statistical Package for the Social Sciences (SPSS). The processes were not disclosed until separation allocation was assigned. In the experimental group, 13 residents came from one facility and 12 residents from the other. A single blind method was adopted with the following protocols: (1) the day-shift nurses did not know which group each resident had been assigned to. They were only responsible for collecting questionnaires. (2) The residents were not informed of which group they were in, but we were not sure if the residents knew the differences between two interventions or not. (3) The assistants who performed the intervention were the only people who knew which group each resident belonged to; however, they were not permitted to inform the residents of this. 2.3. Sample size Based on repeated measured data to estimate sample size, the effect size was assigned to be 5.0 as a significant difference based on the Athens Insomnia Scale score (Sun et al., 2005) with a standard deviation equal to 6.20 under a of 0.05 and b of 0.2. The minimum sample size was therefore estimated to be at least 14 for each group.

2.5. Ethical considerations The study was approved by the institutional review board of Yuanpei University and the two facilities. After a verbal explanation, all participants and their families agreed to join this research. Written informed consent was signed by residents or their legal guardians. 2.6. Outcome measures and follow-up procedures The AIS-T, a structured questionnaire translated from the Athens Insomnia Scale (AIS), was used for collecting data, because the AIS had been developed to assess insomnia severity based on ICD-10 diagnosis of nonorganic insomnia (Soldatos et al., 2000, 2003). It meets the definitions of insomnia and has good validity. The AIS component consists of eight items, including: difficulty with sleep induction, awakenings during the night, early morning awakening, total sleep time, overall sleep quality, well-being during the day, functioning capacity during the day, and sleepiness during the day. Each item was scored from zero (no problem) to three (very much). A total score of six or higher indicated insomnia, with a total range between 0 and 24; the higher the score, the worse the indicated insomnia. In this study, the AIS-T scale was adopted on a weekly basis for 7 weeks to examine the effect of acupressure on insomnia severity. The AIS applied in various studies to measure insomnia and had been widely used in different populations and translated into many languages, including Spanish, Korean, and Japanese. Its psychometric properties have been established in the literature (Portocarrero and Jime´nezGenchi, 2005; Soldatos et al., 2000, 2003). It has a cutoff score of six based on the balance between sensitivity (93%) and specificity (85%). The instrument also has a good predictive value of 99% (Soldatos et al., 2000, 2003).

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Because participants were Chinese, the AIS had to be translated into Mandarin in this study. The AIS-T was developed by a translation and back-translation process. The first step was to translate the scale from English into Chinese via a translator, then, reverse-translate it from Chinese into English with a different translator. Finally, a third translator verified the accuracy of the translations. The process was repeated until congruence was achieved. Internal consistency was measured by calculating Cronbach’s alpha coefficient for the HT7 acupressure process, which was 0.92 at baseline. Content validity was established by a panel featuring five experts. Based on the definition of insomnia from ICD-10, they constructed the score. The content validity index (CVI) was used to represent the AIS-T. The experts were asked to rate each item based on clarity, relevance, simplicity and ambiguity under a four-point scale ranging from one (not relevant) to four (very fit). The CVI was measured according to the proportional agreement of experts on each item. The average CVI was 0.95 for the AIS-T. We used the PSQI-T to establish the criterion-related validity. The AIS-T score was significantly correlated with the PSQI-T and the correlation coefficient was 0.75 (p-value <0.001) at baseline. Each participant’s weekly insomnia severity was measured by the AIS-T for 7 weeks, starting from the first week of intervention until 2 weeks after intervention. Two nurses at each work unit performed data collection. The morning timing was set to be after getting up and the nurses asked participants’ feelings corresponding to items in the AIS-T over the whole week. The participants’ responses were recorded by every week. The items evaluated the feeling intensity of every week and the recordings were performed for seven times after starting intervention. When the data were recorded, the staff assured that participants were alert enough to answer questions. During intervention, we continued to measure insomnia severity weekly and labeled the results from ‘‘Week 1’’ to ‘‘Week 5.’’ After the intervention was completed, the AIS-T was performed for another 2 weeks, labeled as ‘‘Week 6’’ and ‘‘Week 7.’’ The data analyses from baseline to each follow-up were documented under an intention-to-treat procedure. 2.7. Data analysis The presented analyses used intention-to-treat, with missing data being substituted by the last-observationcarried-forward procedure. The SPSS (ver. 15.0) was used for data analysis. The descriptive statistics, t-tests, and Chisquare tests (x2) were used for evaluating differences between the two groups in terms of demographic data. Generalized estimating equations (GEE) were performed to examine the longitudinal dependent data of the HT7 acupressure effects on insomnia severity. All p-values were set to be smaller than 0.05 for statistical significance. 3. Results 3.1. Participants’ enrolment and their characteristics The data were collected from a total of 106 residents in two Northern Taiwan long-term care facilities. Fifty

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qualified participants were recruited based on specific criteria. Forty-four people, 21 in the control group and 23 in the experimental group, completed all the data (see Fig. 1) and six participants failed to complete the study procedure. They were dropped out because of taking hypnotics more than four times per week at the beginning of the intervention. Their mean age was 68.83 years old (SD = 20.71). There were two persons in the intervention group and the others were in the control group. Four of six dropout participants were female. Four of them had not accepted formal education. Four of them were diagnosed with cerebral vascular accidents and the others had dementia. They had stayed for 1350 days (SD = 1759) in a long-term care facility. The PSQI-T score was 13.17 (SD = 6.08). Participants’ demographic and disease-related characteristics are presented in Table 1. The control group featured ten male participants, with a mean age of 67.76 years (SD = 18.70). Meanwhile, the experimental group featured 17 male participants, with a mean age of 73.20 years (SD = 14.15). The control group’s diseaserelated characteristics included: cerebral vascular accidents (56%), dementia (12%), chronic psychiatric conditions or psychosis (8%), chronic obstructive pulmonary disease (8%), and central nervous system injury (16%). Moreover, the experimental group included: cerebral vascular accidents (72%), dementia (12%), chronic psychiatric conditions or psychosis (8%), chronic obstructive pulmonary disease (4%), and central nervous system injury (4%). The most common diseases were similar in both groups. There was no statistical differences in diagnoses between these groups (Fisher’s exact test, x2 = 2.63, p = 0.66). For both the PSQI-T and AIS-T scores, there were no statistical differences between the control group and the experimental group before the intervention (t = 1.12, p = 0.27 for PSQI-T; t = 0.87, p = 0.39 for AIS-T). 3.2. Effect of acupressure on insomnia severity Because of following the intention-to-treat procedure, all participants were included in the analyses to avoid overestimating effectiveness. We compared differences in the AIS-T scores between the control group and the experimental group. There was no statistically significant difference in AIS-T scores between the control and experimental groups before intervention (t = 0.87, p = 0.39). Subjects in the control group reported higher AIS-T scores than those in the experiment group from ‘‘Week 1’’ to ‘‘Week 6.’’ Furthermore, the AIS-T scores from ‘‘Week 3’’ to ‘‘Week 6’’ were less than six points in the experimental group, which indicated no insomnia during this period (Table 2). The effect of acupressure on insomnia severity was further examined by GEE. After controlling variables of time and group, the interactions between them were analyzed. Results suggest that the AIS-T dropped in the experimental group compared to that in the control group from ‘‘Week 1’’ to ‘‘Week 6.’’ Even in ‘‘Week 7’’, the score was lower than the baseline in the experimental group (Table 3).

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Fig. 1. Participants and study flow.

Results showed that the severity of participants’ insomnia decreased during the course of the experiment. Statistical differences were found between the experimental group and the control group, after controlling for time and group effects. However, insomnia severity returned to its original status in the experimental group after the acupressure treatment had ceased for 2 weeks. But, ‘‘Week 7’’ still showed significant difference between two groups after controlling time and group effects.

4. Discussion Results from this study indicate that the experimental group had significantly better scores on the AIS-T compared to the control group, not only during the intervention period, but also through the second week after intervention completion, based on generalized estimating equations. The second week after acupressure discontinuation, insomnia severity gradually regressed to

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Table 1 Demographic information for the control and the experimental groups (n = 50). Variables

Experimental group (N = 25)

Control group (N = 25)

n (%) or M [SD]

n (%) or M [SD]

Gendera Male Female

17 (68.0) 8 (32.0)

15 (60.0) 10 (40.0)

Educationa No formal education 1–6 grade 37 grade

13 (52.0) 8 (32.0) 4 (16.0)

12 (48.0) 9 (36.0) 4 (16.0)

Diagnosisa Cerebral vascular accidents Dementia Chronic psychiatric condition or psychosis Chronic obstructive pulmonary disease Central nervous system injury

18 3 2 1 1

14 3 2 2 4

Age (years)c Length of stay (days)c PSQI-T scorec AIS-T scorec a b c

(72.0) (12.0) (8.0) (4.0) (4.0)

73.20 [14.15] 760.8 [833.27] 16.12 [2.60] 20.56 [4.28]

t or x2

p

x2 = 3.94

0.09

x2 = 0.09

0.99

x2 = b2.63

0.66

t = 1.16 t = 0.52 t = 1.12 t = 0.87

0.25 0.61 0.27 0.39

(56.0) (12.0) (8.0) (8.0) (16.0)

67.76 [18.70] 637.2 [863.0] 14.96 [4.55] 19.44 [4.81]

Results expressed as number and (percent). Fisher’s exact test. Results expressed as mean and [standard deviation].

the original pre-experiment levels. Previous studies have also documented that insomnia could be improved through acupressure on the Yungchuan (KI1) and Shenmen (HT7) acupoints (Sun et al., 2005; Tsay and Chen, 2003). The benefits of performing acupressure on the HT7 point to reduce insomnia can be significant. Sun et al. (2005) showed similar results for improving insomnia through acupressure on the Yungchuan (KI1) point. The study similarly indicated that insomnia gradually returned to its original status after acupressure discontinuation. They applied acupressure on the KI1 point for only 3 weeks. The effect ceased when the acupressure stopped. Based on the intention-to-treat analysis, we applied acupressure on the HT7 point for 5 weeks and found that its effect could last for at least 7 weeks in our study. It is reasonable to suggest that insomnia severity was positively affected by acupressure. Although a few studies (Tsay and Chen, 2003; Cerrone et al., 2008) have explored the acupressure effect of the HT7 point for insomnia, previous studies have not investigated the effect on reducing insomnia severity among long-term care residents. This study is the first to demonstrate positive long-term effect and duration of acupressure for reducing insomnia severity in long-term Table 2 The AIS-T scores of the control and experimental groups (n = 50).

Week Week Week Week Week Week Week

1 2 3 4 5 6 7

Experimental (N = 25)

Control (N = 25)

M  SD

M  SD

16.60  6.04 7.76  5.89 3.88  6.65 3.84  6.30 2.80  6.44 3.52  6.53 15.72  4.01

20.32  4.53 18.04  4.51 19.12  4.59 19.60  4.54 19.96  4.55 19.56  4.56 16.12  2.84

Note: Week 1 to Week 5 = intervention period, Week 6 and Week 7 = postintervention.

care residents. Traditional Chinese medicine has proposed that the HT7 point is an entry point for influencing the mind and Qi. It is the primary acupoint on the HandShaoyin Heart Meridian and functions to stabilize mental states. The results of our study demonstrate significant reduction of insomnia severity by the acupressure on the HT7 point. This finding is consistent with previous reports (Nordio and Romanelli, 2008). Acupressure is a noninvasive treatment involving finger pressure on the meridian or acupoints on the body (Yang and Lin, 2007). It is generally considered safe for elderly people and can be easily administered by nursing staff or a patient’s family (Gooneratne, 2008). There were not any adverse events in either group; therefore, acupressure is appropriate in the elderly. Acupressure can be conveniently and safely used to benefit residents of long-term care facilities. In Avis et al.’s study (2008), they explored the effect of acupuncture for decreasing hot flashes in peri- and postmenopausal women. Their participants were divided into three groups, including usual care, sham acupuncture, and acupuncture. The results showed that hot flashes were decreased in the two acupuncture groups compared to in the usual care group. That showed a strong placebo effect. However, there was no report regarding how long the effect could last. In our study, analyses of demographic data and baseline AIS-T scores showed no statistical difference between the experimental and control groups; the residents were homogeneous before the intervention was adopted. Results from this study indicate that the AIST scores apparently dropped from the baseline to ‘‘Week 6’’ in the experimental group, with insomnia severity improving up to at least the 14th day after cessation of acupressure. For the same time frame, the differences of the AIS-T scores between the experimental and control groups indicate that severity of insomnia could effectively be improved by acupressure rather than light touch.

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Table 3 GEE Model of the AIS-T scores (n = 50). Variables/tests Intercept Experimental group vs control group Week 1 vs Baseline Week 2 vs Baseline Week 3 vs Baseline Week 4 vs Baseline Week 5 vs Baseline Week 6 vs Baseline Week 7 vs Baseline Week 1  Group Week 2  Group Week 3  Group Week 4  Group Week 5  Group Week 6  Group Week 7  Group

Estimate 19.44 1.12 3.32 0.12 0.52 0.16 0.32 1.40 0.88 1.52 17.16 18.28 16.88 16.36 11.40 4.84

Standard error

95% CI

p

0.94 1.26 0.78 0.60 0.48 0.61 0.56 0.46 0.48 1.02 1.50 1.43 1.45 1.59 1.30 0.89

17.59 to 21.29 1.35 to 3.59 4.85 to 1.79 1.06 to 1.30 0.43 to 1.47 1.04 to 1.36 1.41 to 0.77 2.31 to 0.49 0.06 to 1.82 3.54 to 0.50 20.10 to 14.22 21.09 to 15.47 19.73 to 14.03 19.47 to 13.25 13.96 to 8.84 6.59 to 3.09

<0.001 0.38 <0.001 0.84 0.28 0.79 0.57 0.002 0.065 0.14 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

Note: Week 1 to Week 5 = intervention period, Week 6 and Week 7 = post-intervention. Interaction of Week and Group: differences between experimental and control groups in change from baseline to current week. The change in the experimental group is given by the change in the control group plus the interaction term.

The AIS-T was the first measuring instrument for insomnia developed in Chinese for long-term care facility residents. The internal consistency and reliability of the AIS-T was acceptable and correlations between the AIS-T and the PSQI-T were high and indicated good criterionrelated validity. Not only did this study have an interventional longitudinal design, but also subjects’ characteristic data indicated participants with chronic disease and old age. Therefore, it was necessary to select a brief instrument to follow up on the insomnia severity. The AIS-T was composed of eight items that could be easily used by staff. Furthermore, the AIS-T was an appropriate method to screen the insomnia severity in long-term care facility residents. In spite of these advantages, we must also consider the accuracy of the answers as the sample characteristics. A study with larger population of sample for achieving the stability of an instrument to test the AIS-T is suggested. In this study, several limitations remain. First, research design intended to use one staff person to perform the procedure for all participants and thus avoid data inconsistency. However, the 9 pm curfew at the two institutions and the impossibility of treating more than 13 participants within an hour necessitated two staff members to administer treatment. Discrepancies might occur between their performances. Second, because the AIS-T has not been validated by prior studies, future studies with a larger sample size should be undertaken to properly validate the AIS-T, even our results provided reassurance regarding validity. Third, we did not record the baseline use of hypnotics, duration of insomnia, and other interventions, that might have some impacts on the results of the study. However, participants had stayed in the longterm care facility more than 1 year and were in stable condition with no special events happened during 2 months. Fourth, even though we established procedures, staff, and circumstance nearly the same for each group except pressure on acupoints, nevertheless, contamination between two groups could not be completely eliminated. Fifth, there are insufficient patients for separate subgroup

analyses, e.g. gender, education levels, diagnosis, or individual facility, which might potentially bias the results. The findings of this study might be considered as preliminary results. For generalization, we suggest that further studies are needed in large randomized controlled trials to confirm whether acupressure works better or worse in certain subgroups. Finally, this study only used a self-administered and structured questionnaire as an evaluation tool. Thus, the insomnia severity was a subjective measurement. In addition to using the AIS-T, future studies might be necessary to employ objective measurements of insomnia severity by polysomnography or actigraphy. Although the participants’ insomnia severity was improved, we still do not know how long the effects of the HT7 acupressure can be lasted in the RCT longitudinal study. Thus, we suggest that the duration of the effects after stopping the HT7 acupressure should be further assessed. Besides, Nordio and Romanelli (2008) have suggested that the sleep promotion by the HT7 acupressure could be relative to the melatonin secretion, but its underlying mechanism has not been completely understood. Therefore, exploring other possible mechanisms can be worthy of being investigated in the future study. 5. Conclusion Acupressure offers a safe, efficient, and non-pharmacologic method to relieve insomnia severity. Our study demonstrates that acupressure on the HT7 point may be an effective alternative therapy for residents with insomnia in long-term care facilities and is also without adverse effects. Acupressure on the HT7 point can improve insomnia severity from the first week of treatment and up to 2 weeks after intervention completion. Offering acupressure on a regular basis has the potential to decrease insomnia severity among long-term care facility residents and could be integrated into routine care. However, more researches to evaluate the effectiveness are expected to provide evidences for verifying its operating mechanism.

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