Better sleep quality in chronic haemodialyzed patients is associated with morning-shift dialysis: A cross-sectional observational study
Introduction
Sleep disturbance is common in end-stage renal disease patients who are maintained by long-term haemodialysis. The most frequently reported sleep complaints in haemodialysis patients are insomnia, restless leg syndrome, sleep apnea, and excessive daytime sleepiness (Kosmadakis and Medcalf, 2008). Poor sleep quality was associated with reduced quality of life (Turkmen et al., 2012), increased morbidity (Hanly, 2004), and mortality (Elder et al., 2008).
Pathophysiological factors including comorbidities (De Santo et al., 2006), uremia-related factors (i.e., uremic toxins or acid-base disturbance) (Chiu et al., 2009, Molnar et al., 2005), anemia (Pai et al., 2007), and altered melatonin metabolism (Novak et al., 2006) were reported to be associated with poor sleep in haemodialyzed patients. Medications commonly prescribed for patients with chronic kidney disease may also interfere with sleep (Novak et al., 2006). Moreover, there is a relatively well-documented association between psychological factors, including depression (Afsar and Elsurer, 2012, Feroze et al., 2012, Guney et al., 2010), anxiety (Feroze et al., 2012, Paparrigopoulos et al., 2009, Violani et al., 2006), and sleep disturbance in haemodialyzed patients. Lifestyle-related factors including sedentary lifestyles (Novak et al., 2006), time of the day of haemodialysis (Novak et al., 2006), and the habit of stimulant beverage drinking (Chen et al., 2006) may also interfere with sleep in haemodialyzed patients.
The impact of time of the day when dialysis is administered (i.e., dialysis shift) on sleep quality in haemodialyzed patients has been previously investigated. As patients often napped during the treatment due to limited mobility and increased body temperature (Parker et al., 2000), dialysis treatment itself may predispose patients to sleepiness. The repeated experience of these changes in sleep patterns during the normal waking phase may lead to disruption of the sleep-wake circadian rhythm (Parker et al., 2003), consequently resulting in disturbed nocturnal sleep. However, there exist conflicting results regarding the relationship between dialysis shift and sleep disturbances. Compared with haemodialyzed patients on the other shifts, those on the morning shift had more daytime sleepiness as measured by the Epworth Sleepiness Scale (Hsu et al., 2008). Complaints of insomnia including difficulty in falling sleep, difficulty in maintaining sleep, or early morning awakening were more common in patients receiving morning-shift dialysis than those who dialyzed later in the day (Merlino et al., 2006). Others reported no difference in subjective sleep quality among haemodialyzed patients on different dialysis shifts (Bastos et al., 2007, Hsu et al., 2008). Previous studies typically included small sample sizes (Bastos et al., 2007, Hsu et al., 2008). One study included a sample with a wide age range (17–95) (Merlino et al., 2006), thus, the confounding effect of age on the association between dialysis shift and sleep quality could not be removed.
In this study, we sought to determine whether dialysis shift may impact sleep quality in haemodialyzed patients. Therefore, the aim of this study was to investigate the association between dialysis shift and subjective sleep quality in haemodialyzed patients as determined by the Pittsburgh Sleep Quality Index (PSQI) adjusting for comorbidities, depression, anxiety, and stimulant beverage consumption.
Section snippets
Participants
This study was a secondary analysis of data from a previous instrument validation study (Chan et al., 2012). The research protocol was approved by the Institutional Review Board of the participating institution and all participants gave informed consent. Participants were recruited from a dialysis center in a university-affiliated medical centre in northern Taiwan using a convenience sampling method. Participants were eligible for participation if he/she was older than 18 years of age,
The Pittsburgh Sleep Quality Index (PSQI)
The Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire consisting of 19-individual items which assess multiple dimensions of sleep quality during the previous month (Buysse et al., 1989). The PSQI has been widely used to assess sleep quality in patients with ESRD (Bastos et al., 2007, Chen et al., 2006, Hsu et al., 2008). A Chinese version of the PSQI has previously been developed and validated (Tsai et al., 2005).
The Beck Depression Inventory (BDI)-II
The Beck Depression Inventory (BDI)-II is a 21-question
Results
Participants ranged from 22 to 71 years of age with a mean age of 52.4 years. The proportion of participants in the morning-shift group and other-shifts group was 44.7%, and 55.3%, respectively. Most of the participants (95.7%) received dialysis three times a week. As can be seen in Table 1, participants in the morning-shift group were significantly older (p = 0.003) and had a higher percentage of persons who are married (p = 0.003) than those in the other-shifts group. In terms of the distribution
Discussion
Lifestyle-related factors, pathophysiological factors, and psychological factors have been suggested to explain poor sleep reported by haemodialyzed patients (Novak et al., 2006). Our data add information to the literature and support the role of dialysis shift in affecting quality of sleep in haemodialysis patients. In this study, we found that morning dialysis shift was significantly associated with better subjective sleep quality. A possible explanation for this result is that patients
Conclusion
Our data revealed that dialysis shift was associated with subjective sleep quality in chronic haemodialyzed patients after adjusting for confounding variables. Morning dialysis shift was significantly associated with better subjective sleep quality in chronic haemodialyzed patients.
Conflict of interest: All authors have no conflict of interest to declare.
Funding: None.
Ethical approval: Institutional Review Board of Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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Location of work: College of Nursing, Taipei Medical University, Taipei, Taiwan.