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  • 學位論文

癌症病人睡眠品質的評估與其光暴露之相關性

Assessment of Sleep Quality and It’s Relationship to Light Exposure Among Cancer Patients

指導教授 : 林佳靜
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摘要


本研究為探討睡眠的相關研究,分成四個階段進行,第一至第三階段研究以癌症病人為主,探討睡眠困擾原因,建立以癌症病人為對象之阿森斯失眠量表台灣版(Athens Insomnia Scale-Taiwan version, AIS-T)信效度,並以AIS-T測量其失眠程度與瞭解睡眠與光暴露之相關性。第四階段為先驅研究,測試穴位指壓改善失眠之效果,以機構住民為對象,AIS-T做為失眠測量工具,瞭解失眠改善之成效。 癌症末期病人,以緩解疼痛做為目標,睡眠不佳被視為理所當然的自然現象,常被忽略。但積極處理病人困擾的症狀是醫療人員責無旁貸的責任,故研究之初,以質性研究方式,以癌末睡眠品質差的病人為對象,探究其睡眠不佳的原因及處理方式,所獲結果有助於未來工具的修訂及臨床實務上之建議。 由於睡眠障礙常使用匹茲堡睡眠品質量表評估主觀睡眠品質,但其計分方式較為繁瑣,無法測量是否失眠,故第二階段研究為建立台灣版阿森斯(AIS-T)失眠量表之信效度。過去許多研究雖使用AIS測量失眠,但卻未施行於台灣的癌症病人,故建立台灣版AIS信效度於癌症族群,所獲結果有利於迅速篩檢失眠癌症病人,儘早給予合適處置。 光為影響睡眠之生物節率的線索,故進一步研究即是瞭解光暴露在癌症病人睡眠上扮演的角色,並運用先前已建立完成之AIS-T問卷,瞭解癌症病人失眠的程度,建立光暴露與睡眠之關係,做為未來運用光治療促進睡眠的理論基礎。 最後,失眠改善是重要的課題,穴位指壓為其中的一種輔助醫療方式,本研究之最後階段則使用AIS-T測量穴壓改善失眠之成效。由質性研究結果得知,睡眠會受環境因素影響,且癌症病人因醫療因素住院,干擾變項較多,例如:化學治療、症狀困擾等,使得穴壓效果受到威脅,故此先驅研究,以機構住民為對象,瞭解神門穴改善失眠之效用,在印證效用後,可推廣於癌症病人,改善其失眠的現象。 本論文為四個子研究項目所串連,研究項目間有彼此之關連性,故分別敘述四個子研究項目之摘要。 一、癌症末期病人睡眠困擾的主觀經驗 研究背景:睡眠困擾是癌症病人症狀困擾之一,然而過去很少文獻以末期癌症病人的觀點來瞭解睡眠困擾及處理的方法。故本研究之目的在探討癌症末期病人對導致其睡眠困擾原因及其處理方法之主觀經驗。 研究方法:研究設計採用半結構訪談指引,於台灣北部某教學醫院的腫瘤病房進行收案,共有12位癌症病人參與30分鐘的個別訪談,所獲得相關資料以內容分析法加以分析歸納。 研究結果:影響睡眠的因素有受疾病折磨、擔心與放不下以及生活改變等,其主題(theme)包括症狀困擾、治療副作用、病情變差、心中的擔心、不能控制的思考、環境的變動、生活不規律以及探訪的干擾。在處理睡眠困擾上有求助醫療專業人員、自我尋求有效的方法及靈性的安撫支持等,其主題包括醫療藥物處方、輔助醫療及親友安慰及宗教幫忙等。癌症末期個案睡眠困擾原因多層面,處理睡眠困擾方式不理想。 研究結論:本研究可瞭解影響癌症末期病人對睡眠困擾的看法及處理經驗,可提供醫護人員對協助癌症末期病人睡眠症狀困擾照顧的參考。 二、阿森斯失眠量表台灣版於癌症病人的信效度建立 研究背景:過去研究顯示癌症病人失眠比例很高。雖阿森斯量表(Athens Insomnia Scale, AIS)已廣泛用於測量失眠,但尚未使用於癌症族群。故本研究目的為建立用於癌症病人的台灣版阿森斯量表信效度(reliability and validity of the Taiwanese AIS version, AIS-T)。 研究方法:使用橫斷式研究設計,於北部某一教學醫院放射腫瘤科門診進行收案,共收集195位癌症病人。 研究結果:顯示AIS-T的內在一致性(Cronbach’s alpha)為 .83,30位病人的再測信度為.94。以匹茲堡睡眠品質量表(r=.82, p<.001)及Actiwatch的睡眠效度(sleep efficiency)(r=-.54, p<.001)做效標,有高度相關,具有同時效度。使用簡明疲憊量表(Brief Fatigue Inventory-Taiwan Form)(r=.56, p<.001)及健康相關生活品質量表(Medical Outcomes Study Short Form-36 )(PCS: r=-.52, p<.001; MCS: r=-.53, p<.001)做建構效度,也呈現高度相關。以匹茲堡睡眠品質量表分為品質好與品質差兩組,AIS-T具有既知組別效度。AIS-T與Actiwatch的睡眠參數也具有高度之相關性。 研究結論:AIS-T為一簡單篩檢失眠的量表,其良好的信度與效度,可推廣運用於癌症病人,篩檢其失眠情形。 三、癌症病人光暴露、症狀困擾與生活品質之間的關係 研究背景:睡眠與生活品質為癌症病人的健康指標,已有許多措施被證實可以改善病人之症狀困擾、睡眠或生活品質。雖然光為矯正生物節率之一重要線索,但是尚未有任何證據顯示癌症病人之光暴露、症狀困擾、睡眠品質與生活品質間之關係。因此本研究之目的為探討癌症病人之光暴露、症狀困擾、睡眠品質與生活品質間之關係。故本研究之目的為探討光暴露與睡眠、症狀困擾及生活品質之間的關係。 研究方法:本研究採橫斷性設計,在北部某教學醫院腫瘤科門診進行收案,共計收集163位癌症病人。使用問卷收集主觀的睡眠品質(Pittsburgh Sleep Quality Index-Taiwan Form, PSQI-T)、失眠(Taiwanese AIS version, AIS-T)、疲憊(Brief Fatigue Inventory-Taiwan Form)、憂鬱(Beck Depression Inventory-II)及健康相關生活品質(Medical Outcomes Study 36-Item Short-Form Health Survey-Taiwan Version, SF-36-T)程度,使用Actiwatch收集病人客觀睡眠參數及光暴露值(light exposure),客觀睡眠參數包括睡眠潛伏期(sleep onset latency, SOL)、睡眠效率(sleep efficiency, SE)、夜間醒來時間(waking after sleep onset, WASO)、睡眠總時數(total sleep time, TST)等,光暴露值以大於1000 lux的時間及活動時平均光暴露強度做為光暴露參數。 研究結果:結果顯示光暴露≧1000 lux的時間對數(r=-.60, p<.001)、平均光暴露強度對數 (r=-.59, p<.001)與主觀睡眠品質成負相關;結果顯示光暴露≧1000 lux的時間對數(r=-.24, p=.002)、平均光暴露強度對數(r=-.28, p<.001)與Actiwatch睡眠潛伏期成負相關,亦即光暴露≧1000 lux的時間越長或光暴露強度越大,主觀睡眠品質分數越低,睡眠品質越佳、Actiwatch睡眠潛伏期越短。光暴露≧1000 lux的時間對數 (r=.28, p<.001)與平均光暴露強度對數(r=.30, p<.001)與Actiwatch睡眠效率成正相關,亦即光暴露≧1000 lux的時間越長、平均光暴露強度越大,睡眠效率越佳。光暴露≧1000 lux的時間對數與Actiwatch醒來時間成負相關(r=.17, p=.03),亦即光暴露≧1000 lux的時間越長,夜間醒來時間越短。將AIS-T以6分或7分為界線、PSQI-T以5分做界線、Actiwatch睡眠潛伏期以30分為界線、睡眠效率以80%為界線分別對睡眠品質分成兩組,其顯示對光暴露≧1000 lux的時間對數與平均光暴露的強度對數皆具有統計意義。光暴露≧1000 lux的時間對數分別與疲憊嚴重度、疲憊影響以及憂鬱成負相關,亦即時間越長,疲憊與憂鬱皆越低。同樣地,平均光暴露的強度對數也分別與疲憊影響及憂鬱成負相關,亦即強度越高,疲憊影響與憂鬱皆越低。 研究結論:光暴露與睡眠品質之間有關係,光暴露時間越長或平均光暴露強度越大者,癌症病人睡眠品質越佳。此結果可作為未來癌症病人光暴露量之參考。 四、應用穴壓改善機構住民失眠成效之先驅研究 研究背景:神門穴位指壓(標記為HT7)可以改善失眠,然而至今尚未有縱貫性之研究探討其對長期照顧機構住民的效益。從現存之文獻中亦無證據顯示出在停止穴位指壓後其效益可以維持多久。本研究之目的為檢測以神門穴指壓來改善患有失眠之長期照顧機構住民的成效。 研究方法:招募50位患有失眠之長期照顧機構住民,以隨機分派之方式分成25位於實驗組與25位於控制組。實驗組接受標準之HT7穴位指壓於手腕上,控制組僅接受於相同位置之輕觸,共為期5週,以AIS-T作為失眠之量測工具。住民自我陳述前測、在五週期間、以及介入措施停止後之分數。 研究結果:實驗組的AIS-T分數相對於控制組有顯著較好之分數,以廣義估算方程式(Generalized estimating equations, GEE)所示,不僅於介入措施期間,甚至延伸到停止介入措施之後(p<.05)。 研究結論:施以穴位指壓具有改善長期照顧機構住民失眠之潛力,在HT7之穴位指壓可以改善失眠至介入措施之後的兩週。 癌症末期病人失眠原因複雜,除醫療協助睡眠品質外,病人對失眠處理有獨特方式。本第二子研究驗證阿森斯量表中文版為有信效度之量表,可測量癌症病人失眠之程度,可運用在臨床及研究中。癌症病人光暴露與睡眠品質、失眠、疲憊、憂鬱皆有相關,穴位指壓也可改善機構住民之失眠,未來可進一步驗證光治療及穴位指壓對癌症病人失眠改善之效果。

關鍵字

癌症 睡眠 光暴露

並列摘要


This dissertation is a study of sleep consisting of four parts. Based on the cancer patients, the first to the third parts discussed the factors that cause the sleep disturbance. The Athens Insomnia Scale-Taiwan version was used as an instrument to be validated for cancer patients and to realize the relationship between sleep and light exposure. In the fourth part, it is a pilot study to evaluate the effectiveness of acupressure for residents of long-term care facilities with insomnia. Generally, to relief pain was the main issue for advanced cancer patients. Therefore, the sleep disturbance was regarded as a normal phenomenon and often ignored. It is the duty of health professionals to aggressively manage patients’ symptoms distresses. The first part of this research adopted qualitative design to explore the factors causing poor sleep quality and strategies for advanced cancer patients. The results could be the reference of the instrument revision and the practical suggestions in the future. The Pittsburg Sleep Quality Index (PSQI) was often used to evaluate the sleep disturbances for cancer patients. However, its scoring was too complex to calculate and too hard to measure the insomnia status. The aims of the second part of the study were to establish the reliability and validity of Athens Insomnia Scale-Taiwan (AIS-T) version. Although many researchers used the AIS to measure insomnia for various populations, there was no researcher applying it to evaluate insomnia for cancer patients in Taiwan. As a result, to establish the reliability and validity of AIS-T is important for rapidly screening the insomnia of cancer patients and giving them suitable treatment by the health professionals as soon as possible. Light is the cue of circadian rhythm that affects sleep in nature. We further investigated the role of light on sleep and to evaluate the insomnia severity based on the already created AIS-T for cancer patients in the third part of the study. The results could be applied to the improvement of sleep quality for cancer patients in the future. Finally, improving insomnia is an important issue. Acupressure is one of the complementary and alternative medicines. The last part of the study was to explore the effectiveness of the acupressure by the AIS-T. From the results of qualitative study, we knew that the sleep was influenced by the environmental factors and was made complicated by variables, including chemotherapy, symptoms distress, others treatments etc., for cancer patients in hospital. They would threaten the effects of acupressure. The residents of long term facility were adopted as subjects and evaluated for the effects of acupressure of the Shenmen point on the insomnia improvement in the study. It was a pilot research. Once being proved as a positive effect, it could be extended to cancer patients for improving their insomnia in the further.. The dissertation composed of four sub-studies. There were correlations among each others. Therefore, four abstracts were individually described as the below. Sub-study 1 Experiences of approach and self-management sleep disturbance among advanced cancer patients: a qualitative study Background: Sleep disturbance is a common symptom of distress for cancer patients, yet few studies have been conducted on understanding sleep disturbance and self-management from the perspectives of advanced cancer patients. The purpose of this study was therefore to explore the experiences of advanced cancer patients, with attention to causes of sleep disturbance and patients’ manner of self-management. Methods: Semi-structured interviews were adopted with participants recruited from an oncology ward of the teaching hospital in northern Taiwan. Twelve advanced cancer patients participated in the individual interviews, which lasted for 30 minutes. Content analysis was used to define domains and themes from the data. Results: The explorations that were attributed to sleep disturbance fell into the categories of “suffering from the disease”, “fear and reluctance to let go”, and “changes in life pattern”. The themes embraced “symptom distress”, “side effects from treatment”, “anxiety about worsening of the disease”, “unwillingness to leave loved ones”, “lack of self control”, “changes in surroundings”, “disruptions of regular life pattern”, and “disturbance from the visitors”. The domains of self-management with sleep disturbance were divided into “seeking medical treatment”, “discovering other effective methods”, and “spiritual support”. Themes related to self-management with sleep disturbance were “prescriptions hypnotics”, “symptom control”, “tolerance and adaptation”, “complementary medicines”, “religious belief”, and “consolation from family and friends”. Conclusions: Advanced cancer patients suffered from physical symptoms, psychological distress, and disruptions of daily rhythms. Therefore, there were various causes of sleep disturbance in advanced cancer patients. However, patients’ ways of self-management with sleep disturbance were non-systematic and of limited effectiveness. Bedsides, this study provides a reference for healthcare professionals on assisting and caring for advanced cancer patients suffering from sleep disturbance. Sub-study 2 Validation of the Taiwanese Version of the Athens Insomnia Scale and Assessment of Insomnia for Taiwanese Cancer Patients Background: It is well known that a high prevalence of insomnia exists in cancer patients. Although there are various studies using the Athens Insomnia Scale (AIS) for insomnia assessment in the literature, it has never been applied to cancer patients with insomnia. The purposes of this study were to establish the reliability and validity of the Taiwanese AIS version (AIS-T) and evaluate the severity of insomnia for cancer patients in Taiwan. Methods: A cross-sectional research design was conducted and one hundred and ninety-five cancer patients (n=195) were recruited from outpatient oncology clinics. Results: The results show that the Cronbach’s alpha for internal consistency is .83 and the test-retest reliability is .94 over an interval of three days by a sample of 30 patients. Moreover, the concurrent validity could be supported by significant correlations of the AIS-T with the Pittsburgh Sleep Quality Index-Taiwan form (PSQI-T) (r=.82, p<.001), and sleep efficiency of Actiwatch parameters (r=-.54, p<.001). The construct validity could be established by the Brief Fatigue Inventory-Taiwan form (r=.56, p<.001) and the Medical Outcomes Study Short Form-36 (PCS: r=-.52, p<.001; MCS: r=-.53, p<.001). The AIS-T could detect significant known-group validity from sleep quality (PSQI-T ≥ 5 or < 5, respectively). The Actiwatch parameters are consistent with the results of the AIS-T, and both data indicate that patients experienced sleep disturbances. The prevalence of insomnia was 22.56% according to the DSM-IV; 49.2% subjects had significant insomnia at the score ≥6 at AIS-T. Conclusion: This study concludes that the AIS-T is a reliable and valid instrument for assessing insomnia among cancer patients in Taiwan. Sub-study 3 Relationship among Light Exposure, Symptom Distress, Sleep Quality, and Life Quality for Cancer patients Background: Sleep and life qualities are health indexes for cancer patients. Many interventions have been demonstrated to promote their level of symptom distress, sleep, or life quality. Although light is an important cue to entrainment circadian rhythm, there has been not any evidence revealing the relationship among light exposure, symptom distress, sleep quality, and life quality for cancer patients. As a result, the purpose of this study was to explore the relationship among light exposure, symptom distress, sleep quality, and life quality for cancer patients. Methods: This was a cross-sectional research design. 163 cancer patients were recruited from a teaching hospital in northern Taiwan. The questionnaires included the Taiwanese AIS version (AIS-T), the Pittsburgh Sleep Quality Index-Taiwan form (PSQI-T), the Brief Fatigue Inventory-Taiwan Form (BFI-T), the Beck Depression Inventory-II (BDI-II), and the Medical Outcomes Study 36-Item Short-Form Health Survey-Taiwan version (SF-36-T). Patients were requested to wear the Actiwatch, an actigraphic instrument for measuring the activity and light, for a 3-day period. It could offer objective data, including light exposure, sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), and total sleep time (TST). The light parameters were adopted by using the time (in logarithm scale) of light exposure≧1000 lux and the intensity (in logarithm scale) of light exposure under average activity. Results: The results indicated that there were negative relationships among the time of light exposure≧ 1000 lux (r=-.61, p<.001), the intensity of light exposure under average activity (r=-.59, p<.001) and the sleep quality. There were negative relationship among the time of light exposure≧ 1000 log lux (r=-.24, p=.002), the intensity of light exposure under average activity (r=-.28, p<.001), and the sleep latency. There were positive correlations between the time of light exposure≧ 1000 lux (r=.17, p=.03), the intensity of light exposure under average activity (r=.18, p.02), and the sleep efficiency. Longer time of light exposure≧ 1000 lux and more intensity of light exposure under average activity could improve the sleep quality, sleep latency, and sleep efficiency. There was negative relationship between the time of waking after sleep onset (WASO) and the time of light exposure≧ 1000 lux . It meant that the longer the time of light exposure≧ 1000 lux was, the shorter that of WASO would be. The sleep quality was divided into two groups according to the AIS-T (with the cut-point of 6 or 7), the PSQI-T (with the cut-point of 5), sleep latency (with the cut-point of 30 minutes), and sleep efficiency (with the cut-point of 80%), respectively. They showed statistic significance on both the time of light exposure≧ 1000 and the intensity of light exposure under average activity. The time of light exposure≧ 1000 lux was negatively correlated to the fatigue severity, fatigue effect, and depression, respectively. The longer the time was, the less the fatigue and depression would be. Similarly, the intensity of light exposure under average activity was also negatively correlated to the fatigue effect and depression, respectively. The higher the intensity was, the less the fatigue effect and depression would be. Conclusion: There were relationships between light exposure and sleep quality. The sleep quality of patients could be better if the time of light exposure was longer or the intensity of light exposure was higher. The results provided references of light exposure for the cancer patients in the future. Sub-study 4 The Effectiveness of Acupressure for Residents of Long-Term Care Facilities with Insomnia: A Randomized Controlled Trial 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. 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 five-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 five-week period, and after intervention. 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<.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 can improve insomnia for up to two weeks after the intervention. The reasons for insomnia are complexes among cancer patients. They seek to medical treatment for insomnia. Besides, they have special method to manage insomnia. The second study concludes that the AIS-T is a reliable and valid instrument for assessing insomnia among cancer patients in Taiwan. Therefore, the AIS-T can measure insomnia of cancer patients. Moreover, it can apply to clinical practice and furture study. Light exposure is related to sleep quality, insomnia, fatigue, and depression for cancer patients and acupressure can improve insomnia for residents of long-term care facilities. Light therapy and acupressure can be verified to improve insomnia for cancer patients in next study.

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