Sleep quality and related factors in hemodialysis patients

(1)

in Hemodialysis Patients

1

_{Fang-Yu Lin MS, RN}

2

_{Kwua-Yun Wan PhD, RN, Professor}

*

3

_{Tso-Hsiao Chen PhD, MD, Associate Professor}

4

_{Kuan-Chia Lin, PhD, Associate Professor,}

5

_{Wu-Chang Yang, BS,MD, PhD, Associate Professor}

1_{Department of Nursing, Wan Fang Hospital,}_{Taipei Medical University}

and Graduate Institute of Nursing, National Defense Medical Center

2_{Deputy Director, Department of Nursing,}_{Taipei Veterans General Hospital,}

School of Nursing, National Defense Medical Center

3_{Department of Nephrology, Wan Fang Hospital, Taipei Medical University} 4_{School of Nursing, National Taipei University of Nursing and Health Science}

5 _{Department of Nephrology, Taipei Veterans General Hospital}

July 2012

(2)

Outline

v

Introduction

v

Research Purpose

v

Research Framework

v

Material and Methods

v

Results

v

Conclusion

(3)

Introduction

Sleep Quality and Related Factors

in Hemodialysis Patients

(4)

Introduction

v

Sleeping problems affect

50%~80%

in hemodialysis patients.

(Basto et al., 2007; Chen et al., 2006)

v

Sleep quality is an important predictor

of health status, quality of

life and survival rate.(Elder et al., 2008)

v

There were few research

showing the influential factors related to

(5)

United States Renal Data System.(2011).Annual Data Report Retrieved May 21,2012, From http://www.usrds.org/atlas.aspx

Prevalence & incidence worldwide

Taiwan

Taiwan has the

highest prevalence

of ESRD in the world

Taiwan has the second highest incidence rate of ESRD in the world

(6)

Research Purpose

Sleep Quality and Related Factors

in Hemodialysis Patients

(7)

Sleep Quality and Related Factors

in Hemodialysis Patients

The purpose of the study was to investigate

sleep quality and related factors

in hemodialysis

(8)

Research Framework

Sleep Quality and Related Factors

in Hemodialysis Patients

(9)

Definition of Terms

v

Hemodialysis Patients

ì

Diagnosed

ESRD

by a nephrology doctor and receiving

hemodialysis therapy

v

Regular Use Hypnotic Agents

ì

Participants who had regular

regularly used hypnotics

more than

3 times per week

to aid sleep.

.

v

Physical Status

ì

RLS, EDS, high risk of SA and laboratory data

(BUN,

Creatinine,Albumin, Hb, Phosphate)

v

Mental Status

(10)

Mental status Depression Demographics Age (years) Sex Smoking Drinking Hypnotic agents Illness Characteristics Hemodialysis duration Dialysis shift Kt/V Comorbidity

Sleep Quality and Related Factor

in Hemodialysis Patients Framework

Essential Attributes

Physical Status

RLS, EDS, high risk of SA

Laboratory data

(BUN, Creatinine, albumin, Hb, P)

Sleep quality

(11)

Material and Methods

Sleep Quality and Related Factors

in Hemodialysis Patients

(12)

Material and Methods

Study Design

v

Cross-sectional, purposive

and

correlation

design.

v

Sample Size:

n=170

(01/03/2011~30/04/2011)

ì

Subject were recruited from

outpatient

hemodialysis centers of

2 medical centers in Taipei City.

v

Ethical considerations

ì

Before starting this study, researchers obtained

IRB approvals

from the administrative departments of both medical centers.

ì

Participants signed a written

consent form

and

(13)

Material and Methods

Participants population (

Inclusion Criteria

)

þ

Diagnosed with ESRD

by nephrologist.

þ

Hemodialysis patient

20 years of age or

older

and

mentally competent

.

þ

Every week receives

two or three convention hemodialysis

treatments for three or more months.

þ

Can communicate in

Mandarin or Taiwanese languages

.

þ

Patient or caregiver

is willing to participate

in the

study and

sign the

consent form

.

(14)

Material and Methods

Participant Population (

Exclusion Criteria

)

ý

Hospitalized

hemodialysis patient

within the past month

.

ý

Hemodialysis patient had

mental disturbance, blindness or

dementia.

ý

Hemodialysis patient

refuses

to be interviewed or to fill out

(15)

Material and Methods

v

Participants answered structured questionnaires

including

:

ì

Demographic questionnaire

ì

International restless legs scale (IRLS):

RLS (

Yes/No

)

ì

Epworth sleepiness scale (ESS) :

EDS (

Yes/No

)

ì

Berlin’s Questionnaire:

Risk for sleep apnea (

Yes/No

)

ì

The Beck depression inventory-II (BDI-II):

Depression (

Yes/No

)

ì

Chinese version of the Pittsburgh sleep quality index (CPSQI):

Sleep quality (

Good /Poor

)

vv

Illness characteristics

and

laboratory data

from dialysis centers

(16)

Material and Methods

v

Statistical Analysis:

SPSS, version 18.0

ì

A

p value

of

< 0.05

was considered statistically significant.

v

Descriptive statistic (frequency/percentage/mean± SD)

v

Inferential statistic

ì

Chi-square (χ

2

_{) test or independent t-test}

ì

Stepwise regression

:

Find the most important

sleep quality

variables

in hemodialysis patients

ì

Hierarchical logistic regression (combined with stepwise

regression procedure)

:

find out

the most important independent

(17)

Results

Sleep Quality and Related Factors

in Hemodialysis Patients

(18)

Results

v

 

Demographic characteristics of participants

ì

Data was collected from March 2011 to April 2011(N=170)

1)

The mean

age

of the participants was

62.6 years (SD, 14.56

years)

2)

The sample consisted of 88

men (51.2%)

and

82 women (48.2%

)

3)

10.6% of the participants smoked cigarettes

4)

Alcohol consumption was extremely low (5.9%)

5)

35.3%

of participants had

regularly used hypnotics

to aid sleep

(Table1)

(19)

Characteristic Category n % Range Mean SD Age(years) 20~30 5 2.9% 20-91 62.58 14.56 31 ~40 6 3.5% 41~50 24 14.1% 51~60 46 27.1% 61~70 37 21.8% 71~80 32 18.8% ≧81 20 11.8% Sex Female 82 48.2% male 88 51.2% Smoking No 152 89.4% Yes 18 10.6% Drinking alcohol No 160 94.1% Yes 10 5.9% Hypnotic No 110 64.7% Yes 60 35.3%

Elderly person

1/3

Hypnotic

(20)

Table 2 illness characteristics of the sample (n=170)

Characteristic Category n % Range Mean SD

Dialysis duration 0.25-23.25 5.13 4.44 3 months~1year 30 17.6% >1 year~10years 113 66.5% >10years 27 15.9% Dialysis shifts Morning 53 31.2% Afternoon 57 33.6% Evening 60 35.3% Kt/V index 0.65~2.63 1.65 0.33 Comorbidity 0 23 13.5% 1 44 25.9% 2 60 35.3% ≥3 43 25.3%

dialysis shifts

(morning, afternoon

and evening)

are

(21)

Results

vClinical manifestations of hemodialysis patients

ì

 

41.8%

of participants had

high risk for sleep apnea

ì

 

34.1%

of participants had

daytime sleepiness

ì

 

19.4%

of participants had

restless legs syndrome

(Table 3)

vDistribution of participant characteristics by laboratory data

The mean

BUN

of the participants was

82.3 (SD, 20.7)mg/dl

The mean

creatinine

of the participants was

11.21 (SD, 2.8)mg/dl

The mean

hemoglobin

of the participants was

10.31(SD, 1.8)g/dl

The mean

albumin

of the participants was

4.1 (SD,0.7 )g/dl

The mean

phosphate

of the participants was

5.3 (SD,1.7)mg/dl

(Table4)

vDistribution of participant characteristics by mental status

(22)

Table 3 Clinical manifestation of hemodialysis patients

(N=170)

Variables

Category N

%

Rank

Risk for sleep apnea

No

99 58.2%

Yes

71 41.8%

1 Daytime sleepiness

No

112 65.9%

Yes

58 34.1%

2 Restless legs

No

137 80.6%

(23)

Table 4

Laboratory data distribution (N=170)

Variables

Range

Mean

SD

Laboratory data

BUN

26~150

82.34

20.71 Creatinine

1~25

11.21

2.79 Hb

6.9~14.3

10.32

1.79 Albumin

2.7~7.6

4.06

0.65 Phosphate

1.7~10.9

5.29

1.69

(24)

Table 5 Mental status in hemodialysis patients (n=170)

Characteristic Category N % Range Mean SD

Depression scale (BDI-II) 0-56 14.23 13.52

0~13 (Normal) 95 55.9 14~19 (Mild depression) 21 12.4 20~28 (Moderate depression ) 27 15.9 29~63 (Major depression) 27 15.9

44.1% have

depression

(25)

Distribution of Sample

Characteristics by Sleep Status

Sleep Quality and Related Factors

in Hemodialysis Patients

(26)

Results

Good sleepers CPSQI≤5 Poor sleepers CPSQI>5 P-Value N(%) N(%) Age < 64 ≥ 65 24(58.5%) 41(41.5%) 74(57.4%%) 129(42.6%) 0.895 Sex Female Male 20(48.8) 21(51.2%) 62(48.1%) 67(51.9%) 0.936

Don’t smoke cigarettes Smoke cigarettes 38(92.7%) 3(7.3%) 115(89.1%) 14(10.9%) 0.511

Don’t drink alcohol Drink alcohol 38(92.7%) 3(7.3%) 122(94.6%) 7(5.4%) 0.654

Don’t require hypnotics Require hypnotics 34(82.9%) 7(7.3%) 122(94.6%) 7(5.4%) 0.005**

CPSQI = The Chinese version of the Pittsburgh Sleep Quality Index; p<0.001 **p<0.01 *p<0.05

Table 6 : hemodialysis patients’ essential attributes and sleep quality (n=170) The number of hemodialysis

pa3ents who needed hypno3cs to aid sleep was sta3s3cally

(27)

Results

Good sleepers CPSQI≤5 Poor sleepers CPSQI>5 P-Value N(%) /mean± SD N(%) /mean± SD

Hemodialysis duration (year) 5.24±4.79 5.04±4.39 0.803 Dialysis shift Morning Afternoon Evening 13(31.7%) 12(29.3%) 16(39.0%) 40(31.0%) 45(34.9%) 44(34.1%) 0.775 spKt/V 1.69± 0.32 1.64± 0.33 0.442 Comorbidity 1.73±1.21 1.84±1.18 0.594

CPSQI= The Chinese version of the Pittsburgh Sleep Quality Index; p<0.001 **p<0.01 *p<0.05

Table 7: hemodialysis patients’ essential attributes and sleep quality (n=170)

Hemodialysis

dura3on,

dialysis shi;, spKt/V,

comorbidity

were not

(28)

Results

Good sleepers CPSQI≤5 Poor sleepers CPSQI>5 P-Value N(%)/mean± SD N(%) /mean± SD Non RLS RLS 39(95.1%) 2(4.9%) 98(76%) 31(24.0%) 0.006** Non EDS EDS 35(85.4%) 6(14.6%) 77(59.7%) 52(40.3%) 0.002**

Low risk of sleep apnea High risk of sleep apnea

37(90.2%) 4(9.8%)

80(62.0%) 49(38.0%)

<0.001***

Blood urea nitrogen (BUN)mg/dl 87.88±19.40 80.57±20.87 0.049*

Hemoglobin (Hb)g/dl 10.74± 1.06 10.19± 1.19 0.009**

Albumin (g/dl) 4.17±0.71 4.03± 0.62 0.217

Phosphate (mg/dl) 5.11±1.96 5.35±1.60 0.427 Table 8 : hemodialysis patients’ physical status and sleep quality (n=170)

RLS, EDS, risk of sleep apnea,

BUN, Hb

were sta3s3cally

(29)

Results

Good sleepers CPSQI≤5 Poor sleepers CPSQI>5 P-Value N(%) N(%) Non Depression Depression 32(78.0%) 9(22.0%) 63(48.8%) 66(51.2%) <0.001***

Table 9: hemodialysis patients’ mental status and sleep quality (n=170)

CPSQI= The Chinese version of the Pittsburgh Sleep Quality Index; p<0.001 **p<0.01 *p<0.05

The number of hemodialysis

pa3ents who had

depression

(30)

Table 10 Univariable logistic regression of sleep quality

in hemodialysis patients

Predictor Variables (B) S.E. Wald p Exp(β) 95% CI Hypnotic v.s non Hypnotic 1.220 0.452 7.286 0.007** _3.387 _1.397-8.214 RLS vs. non RLS _1.819 _0.754 _5.827 _0.016** _6.168 _1.408-27.024 EDS vs. non-EDS _1.317 _0.477 _8.264 _0.004** _3.939 _1.547-10.032

High risk for SA

VS.

Low risk for SA

1.734 0.557 9.706 0.002** _5.666 _1.903-16.870 BUN _-0.017 _0.009 _3.795 _0.051 _0.983 _0.966-1.000 Hb _-0.419 _0.165 _6.499 _0.011* _0.657 _0.476-0.908 Depression vs. Non- Depression 1.315 0.416 9.974 0.002** _3.725 _1.647-8.425

p<0.001 **p<0.01 *p<0.05

Hemodialysis pa3ents’ sleep quality was

related to hypno3c drug use, RLS, EDS, high risk of SA, HB, depression

(31)

Predictor Model for Sleep Quality

in Hemodialysis Patients

Sleep Quality and Related Factors

in Hemodialysis Patients

(32)

Predictor Variables (B) S.E. Exp(β) （ odd ratio） p Cox& Snell R2 Nagelkerke R2

Model 1 (Essential attribute) Hypontic drug V.S non-Hypontic drug

0.049 _0.073

(χ

2

_{=8.56, p=0.003; Hosmer- Lemeshow=0.000 ,p＜0.001)}

(N=170)

Model 2 ( add

Physical status

)

↑△R

2

_{change 70%}

0.162

0.242 (χ

2

_{=29.96,p＜0.001; Hosmer- Lemeshow=10.75, p=0.216)}

Model 3 (add

Physical status

Mental status

)

↑△R

2

_change12%

0.184

0.275 (χ

2

_{=34.599, p＜0.001; Hosmer- Lemeshow=5.58, p=0.694)}

The increase in R

2

_(△R

2

_{) was computed to determine}

(33)

Predictor Variables (B) S.E. Exp(β) (odd ration) p Cox& Snell R2 Nagelkerke R2

Model 1 (Essential attribute) 0.049 0.073 Hypnotic drug V.S non-hypontic drug

Hypnotic Constant 1.220 0.804 0.452 0.206 3.387 15.199 0.007** <0.001***

Model 2 (Add Physical status) ↑△R2_{change 70%} _0.161 _0.241

Hypnotic drug v.s non-hypontic drug

1.There was a very large R2_change_{when the} RLS, EDS,Hb variables were added to the model. 2. The overall model fit was still good (p<0.05) 3.Physical status and

hypnotic drug use were significant predictors of sleep quality. Hypnotic drug 1.10 0.489 2.996 0.025* RLS vs. non-RLS RLS 1.829 0.776 6.225 0.018* EDS vs. non-EDS EDS 1.048 0.501 2.852 0.037* Hb -0.445 0.183 0.641 0.015* Constant 5.005 1.937 149.19 0.010**

Table12 Predictors of Sleep Quality in Hemodialysis Patients

(34)

Table13 Predictors of Sleep Quality in Hemodialysis Patients

Model 3(Add Mental status)

↑ △R

2

_{change 12%}

0.184

0.275

Hypnotic vs. Non-Hypnotic

Hypnotic 1.084 0.498 2.956 0.030* _1._{27.5%
of
the
model
3}

in sleep quality was explained by all the variables considered. 2. Hypno3c, RLS, EDS, HB, and depression were signiﬁcant predictors of sleep

quality in hemodialysis pa3ents . RLS vs. Non-RLS RLS 1.595 0.790 4.074 0.044* EDS vs. Non-EDS EDS 1.022 0.580 2.779 0.044* Hb -0.397 0.185 0.672 0.032* Depression vs. Non-Depression Depression 0.936 0.448 2.550 0.037* Constant 4.218 1.973 67.931 0.033* Predictor Variables (B) S.E. Exp(β) (odd ratio) p Cox& Snell R2 Nagelkerk R2 p<0.001 **p<0.01 *p<0.05