發展非藥物性措施用於老年人睡眠困擾臨床照護指引

Development of clinical practice guideline for nonpharmacological interventions on clinical management of sleep disturbance in older adults

陳嬿今(Yen-Chin Chen)；陳佳德(Chia-Te Chen)；呂宗樺(Tsung-Hua Lu)；陳昶濬(Chang-Chun CHEN)；林政佑(Cheng-Yu Lin)；張瑩如(Ying-Ju Chang)；柯乃熒(Nai-Ying Ko)

老年人 ； 睡眠困擾 ； 非藥物性措施 ； 穴位按摩 ； 音樂治療 ； 照護指引 ； sleep disturbance ； older adults ； nonpharmacological interventions ； acupressure ； music therapy ； clinical guideline

嘉基護理

21卷1期（2021 / 06 / 01）

12 - 33

繁體中文

睡眠困擾是臨床上老年人常見的症狀，不僅對其生活品質、認知、情緒等造成負面的影響，長期的失眠更會加速老年人身體功能衰退及增加發生意外事件的風險。本文以實證為基礎發展非藥物性措施於住院老年人睡眠困擾照護指引，於南部某醫學中心成立指引發展小組，分析現有老年人睡眠困擾非藥物處置措施及建構臨床問題，進行系統性文獻回顧與文獻評析，共納入12篇非藥物治療於睡眠品質之系統性文獻及統合分析，包括：按摩3篇、音樂治療1篇、光照治療6篇及2篇臨床照護指引，透過GRADE評核系統之方法學進行證據品質評估與建議，初擬非藥物性措施於老年人睡眠困擾照護指引。經由修正型德菲法專家共識決策後，完成指引適用範圍及2個議題非藥物性被動式介入措施，內容包含穴位按摩（每一個穴位點按壓約1～4分鐘，一次完整按摩時間約5～20分鐘，一周三次持續4周；強度建議，中度證據品質）及音樂治療（睡前聽音樂20分鐘持續2天或3周；強度建議，中度證據品質）。至於光照治療對於老年人的睡眠困擾改善上需要進一步評估（弱建議，低度證據品質）。最後由2位外部及2方法學專家對於非藥物性措施於老年人睡眠困擾照護指引評價為建議使用；同時調查30位一般內科醫護同仁本指引之臨床適用性，均為可行且容易做到。期以此臨床照護指引提供醫護人員，讓睡眠困擾的老年人能優先考慮非藥物性的介入措施，進而降低鎮靜安眠藥物的使用。

Sleep disturbance is a common problem among older adults. It leads to poor quality of life as well as cognitive and emotional impairments. Additionally, it increases the risks of functional decline and fall-related injuries. The aim of this study was to develop evidence-based clinical practical guidelines for nonpharmacological interventions for older adults with sleep disturbances. A panel was formed at a medical center in southern Taiwan, and a systematic review of existing evidence-based nonpharmacological strategies for the evaluation and management of sleep disturbances in older adults was conducted. In total, 12 systematic reviews and a meta-analysis of randomized controlled trials, including acupressure (n=3), music therapy (n=1), bright light therapy (n= 6), and clinical practice guidelines (n=2), were analyzed. The grading of recommendations, assessment, development, and evaluation was used to evaluate the quality of evidence and guide recommendations. A modified Delphi method was used to develop guidelines for the applicability of different nonpharmacological interventions, such as acupressure (1-4 minutes at each point for 5-20 minutes, thrice a week for 4 weeks; strong recommendation, moderate-quality evidence) and music therapy (20 minutes before sleep and 2 days per week for 3 weeks; strong recommendation, moderate-quality evidence). The efficacy of bright light therapy for older adults with sleep disturbances requires further evaluation (weak recommendation, low-quality evidence). There were two clinical and two methodological experts in the panel, who recommended the application of nonpharmacological intervention guidelines in clinical practice. Thirty health care providers also opined that the guidelines were feasible for implementation. The efficacy of nonpharmacological strategies to resolve sleep disturbances in older adults were defined in the guidelines. The implementation of these guidelines might reduce the demand of sedatives and sleep medications.

1. 楊秋月, C. Y.,邱愛富, A. F.(2012)。北台灣地區社區老年人的睡眠品質預測因子。護理研究，20(4)，249-260。
   連結：
2. AGREE Collaboration(2003).Development and validation of an international appraisal instrument for assessing the quality of clinical practice guidelines: the AGREE project.Quality and Safety in Health Care,12(1),18-23.
3. Alessi, C.,Vitiello, M. V.(2011).Insomnia (primary) in older people.British Medical Journal Clinical Evidence,2011,2302.
4. Andrade, C.(2018).Sedative hypnotics and the risk of falls and fractures in the elderly.Journal of Clinical Psychiatry,79(3)
5. Balshem, H.,Helfand, M.,Schünemann, H. J.,Oxman, A. D.,Kunz, R.,Brozek, J.,Guyatt, G. H.(2011).GRADE guidelines: 3. Rating the quality of evidence.Journal of Clinical Epidemiology,64(4),401-406.
6. Boubekri, M.,Cheung, I. N.,Reid, K. J.,Wang, C.-H.,Zee, P. C.(2014).Impact of Windows and Daylight Exposure on Overall Health and Sleep Quality of Office Workers: A Case-Control Pilot Study.Journal of Clinical Sleep Medicine,10(06),603-611.
7. Bowker、 R.,Lakhanpaul, M.,Atkinson, M.,Armon, K.,MacFaul, R.,Stephenson, T.,林菁華（譯）, J. H.(Trans.),蔡伶觀（譯）, L. K.(Trans.)(2009).如何撰寫臨床指引：從開始到完成.台北市=Taipei City, Taiwan, ROC:台灣愛思唯爾=Elsevier Taiwan.
8. Chang, M. Y.,Chen, C. H.,Huang, K. F.(2008).Effects of music therapy on psychological health of women during pregnancy.Journal of Clinical Nursing,17(19),2580-2587.
9. Chate, S.,Nayak, R.,Patil, N.,Chattopadhyay, S.(2013).Zolpidem induced delirium.Journal of The Scientific Society,40(3),164-165.
10. Chen, M. C.,Yang, L. Y.,Chen, K. M.,Hsu, H. F.(2019).Systematic review and meta-Analysis on using acupressure to promote the health of older adults.Journal of Applied Gerontology
11. Chesson, A. L., Jr.,Littner, M.,Davila, D.,Anderson, W. M.,Grigg-Damberger, M.,Hartse, K.,Wise, M.(1999).Practice parameters for the use of light therapy in the treatment of sleep disorders. standards of practice committee, american academy of sleep medicine.Sleep,22(5),641-660.
12. Crowley, K.(2011).Sleep and sleep disorders in older adults.Neuropsychology Review,21(1),41-53.
13. De Niet, G.,Tiemens, B.,Lendemeijer, B.,Hutschemaekers, G.(2009).Music-assisted relaxation to improve sleep quality: meta-analysis.Journal of Advanced Nursing,65(7),1356-1364.
14. Düzgün, G.,Durmaz Akyol, A.(2017).Effect of Natural Sunlight on Sleep Problems and Sleep Quality of the Elderly Staying in the Nursing Home.Holistic Nursing Practice,31(5),295-302.
15. Figueiro, M. G.,Hunter, C. M.,Higgins, P.,Hornick, T.,Jones, G. E.,Plitnick, B.,Brons, J.,Rea, M.(2015).Tailored lighting intervention for persons with dementia and caregivers living at home.Sleep Health,1(4),322-330.
16. Forbes, D.,Blake, C. M.,Thiessen, E. J.,Peacock, S.,Hawranik, P.(2014).Light therapy for improving cognition, activities of daily living, sleep, challenging behaviour, and psychiatric disturbances in dementia.Cochrane Database of Systematic Reviews,2,CD003946.
17. Forbes, D.,Culum, I.,Lischka, A. R.,Morgan, D. G.,Peacock, S.,Forbes, J.,Forbes, S.(2009).Light therapy for managing cognitive, sleep, functional, behavioural, or psychiatric disturbances in dementia.Cochrane Database of Systematic Reviews,4,CD003946.
18. Forbes, D.,Morgan, D. G.,Bangma, J.,Peacock, S.,Pelletier, N.,Adamson, J.(2004).Light therapy for managing sleep, behaviour, and mood disturbances in dementia.Cochrane Database of Systematic Reviews,2,CD003946.
19. Harris, M.,Richards, K. C.(2010).The physiological and psychological effects of slow-stroke back massage and hand massage on relaxation in older people.Journal of Clinical Nursing,19(7-8),917-926.
20. Hmwe, N. T. T.,Browne, G.,Mollart, L.,Allanson, V.,Chan, S. W. C.(2018).An integrative review of acupressure interventions for older people: A focus on sleep quality, depression, anxiety, and agitation.International Journal of Geriatric Psychiatry,34(3),381-396.
21. Huang, W. F.,Lai, I. C.(2006).Potentially inappropriate prescribing for insomnia in elderly outpatients in Taiwan.International Journal of Clinical Pharmacology and Therapeutics,44(7),335-342.
22. Kao, Y. H.,Huang, Y. C.,Chung, U. L.,Hsu, W. N.,Tang, Y. T.,Liao, Y. H.(2017).Comparisons for effectiveness of aromatherapy and acupressure massage on quality of life in career women: A randomized controlled trial.The Journal of Alternative and Complementary Medicine,23(6),451-460.
23. Kim, H. J.,Lee, Y.,Sohng, K. Y.(2016).The effects of footbath on sleep among the older adults in nursing home: A quasi-experimental study.Complementary Therapies in Medicine,26,40-46.
24. Lai, F. C.,Chen, I. H.,Chen, P. J.,Chen, I. J.,Chien, H. W.,Yuan, C. F.(2017).Acupressure, sleep, and quality of life in institutionalized older adults: A randomized controlled trial.Journal of the American Geriatrics Society,65(5),e103-e108.
25. Langevin, H. M.,Yandow, J. A.(2002).Relationship of acupuncture points and meridians to connective tissue planes.The Anatomical Record,269(6),257-265.
26. MacLeod, S.,Musich, S.,Kraemer, S.,Wicker, E.(2018).Practical non-pharmacological intervention approaches for sleep problems among older adults.Geriatric Nursing,39(5),506-512.
27. Makramalla, A.,Zuckerman, D. A.(2011).Nephroureteral stents: principles and techniques.Seminars in Interventional Radiology,28(4),367-379.
28. McFeeters, S.,Pront, L.,Cuthbertson, L.,King, L.(2016).Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: A review of the literature.International Journal of Older People Nursing,11(4),266-283.
29. Mofredj, A.,Alaya, S.,Tassaioust, K.,Bahloul, H.,Mrabet, A.(2016).Music therapy, a review of the potential therapeutic benefits for the critically ill.Journal of Critical Care,35,195-199.
30. Mok, E.,Woo, C. P.(2004).The effects of slow-stroke back massage on anxiety and shoulder pain in elderly stroke patients.Complementary Therapies in Nursing and Midwifery,10(4),209-216.
31. Montgomery, P.,Dennis, J.(2002).Bright light therapy for sleep problems in adults aged 60+.Cochrane Database of Systematic Reviews,2002(2),CD003403.
32. Mottaghi, R.,Kamkar, A.,Maredpoor, A.(2016).Effectiveness of Targeted Musical Therapy on Sleep Quality and Overcoming Insomnia in Seniors.Yektaweb Journals,11(2),348-357.
33. Ohayon, M. M.,Carskadon, M. A.,Guilleminault, C.,Vitiello, M. V.(2004).Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: developing normative sleep values across the human lifespan.Sleep,27(7),1255-1273.
34. Olfson, M.,King, M.,Schoenbaum, M.(2015).Benzodiazepine use in the United States.Journal of the American Medical Association Psychiatry,72(2),136-142.
35. Patel, D.,Steinberg, J.,Patel, P.(2018).Insomnia in the Elderly: A Review.Journal of Clinical Sleep Medicine,14(6),1017-1024.
36. Paterniti, S.,Dufouil, C.,Alperovitch, A.(2002).Long-term benzodiazepine use and cognitive decline in the elderly: the Epidemiology of Vascular Aging Study.Journal of Clinical Psychopharmacology,22(3),285-293.
37. Petit, L.,Azad, N.,Byszewski, A.,Sarazan, F.F-A,Power, B.(2003).Non-pharmacological management of primary and secondary insomnia among older people: review of assessment tools and treatments.Age Ageing,32(1),19-25.
38. Praharaj, S. K.,Gupta, R.,Gaur, N.(2018).Clinical practice guideline on management of sleep disorders in the elderly.Indian journal of psychiatry,60(l3),383-396.
39. Sargazi, M.,Salehi, S.,Naji, S. A.(2012).An investigation on sleep behaviors of the elderly hospitalized in Zahedan.Iran Journal of Nursing and Midwifery Research,17(1),58-63.
40. Shang, B.,Yin, H.,Jia, Y.,Zhao, J.,Meng, X.,Chen, L.,Liu, P.(2019).No pharmacological interventions to improve sleep in nursing home residents: A systematic review.Geriatric Nursing,40(4),405-416.
41. Silva, A. A.,de Mello, R. G.,Schaan, C. W.,Fuchs, F. D.,Redline, S.,Fuchs, S. C.(2016).Sleep duration and mortality in the elderly: A systematic review with meta-analysis.British Medical Journal Open,6(2),e008119.
42. Smagula, S. F.,Stone, K. L.,Fabio, A.,Cauley, J. A.(2016).Risk factors for sleep disturbances in older adults: Evidence from prospective studies.Sleep Medicine Reviews,25,21-30.
43. Soldatos, C. R.,Dikeos, D. G.,Paparrigopoulos, T. J.(2000).Athens Insomnia Scale: validation of an instrument based on ICD-10 criteria.Journal of Psychosomatic Research,48(6),555-560.
44. Suzuki, K.,Miyamoto, M.,Hirata, K.(2014).Neurological common diseases in the super-elder society. Topics: V. Dizziness, faintness, numbness and insomnia: 3. Characteristics and treatment of sleep disorders in the elderly.Nihon Naika Gakkai zasshi,103(8),1885-1895.
45. Van Someren, E. J.,Kessler, A.,Mirmiran, M.,Swaab, D. F.(1997).Indirect bright light improves circadian rest-activity rhythm disturbances in demented patients.Biological Psychiatry,41(9),955-963.
46. Vanderlinden, J.,Boen, F.,van Uffelen, J. G. Z.(2020).Effects of physical activity programs on sleep outcomes in older adults: A systematic review.International Journal of Behavioral Nutrition and Physical Activity,17(1),11.
47. Waits, A.,Tang, Y. R.,Cheng, H. M.,Tai, C. J.,Chien, L. Y.(2018).Acupressure effect on sleep quality: A systematic review and meta-analysis.Sleep Medicine Reviews,37,24-34.
48. Walker, W. D. Hall,Hurst, J. W.(1990).Clinical methods: The history, physical, and laboratory examinations.Boston:Butterworths.
49. Wang, Q.,Chair, S. Y.,Wong, E. M.,Li, X.(2016).The Effects of Music Intervention on Sleep Quality in Community-Dwelling Elderly.Journal of Alternative and Complementary Medicine,22(7),576-584.
50. Wu, C. R.,Chen, P. Y.,Hsieh, S. H.,Huang, H. C.,Chen, Y. T.,Chen, T. J.,Chiu, H. Y.(2019).Sleep mediates the relationship between depression and cognitive impairment in older men.American Journal of Men's Health,13(1),1557988319825765.
51. Yeung, W. F.,Chung, K. F.,Yung, K. P.,Ho, F. Y.,Ho, L. M.,Yu, Y. M.,Kwok, C. W.(2014).The use of conventional and complementary therapies for insomnia among Hong Kong chinese: A telephone survey.Complementary Therapies in Medicine,22(5),894-902.
52. 國家發展委員會（2018，8 月）‧中華民國人口推估 2018 至 2065 年。https://www.ndc.gov.tw/Content_List.aspx?n=84223C65B6F94D72 [National development council (2018, August). Population projections for the republic of china (Taiwan):2018-2065.] https://www.ndc.gov.tw/Content_List.aspx?n=84223C65B6F94D72
53. 陳可欣, K. H.,蔣立琦, L. C.(2016)。實證護理新趨勢：GRADE 的變革與新證據金字塔。全聯護訊，109，13-18。
54. 陳杰峰, C. F.,邱文達, W. T(2008)。AGREE臨床指引之評估工具。台灣醫學，12(5)，584-590。
55. 鐘威昇, W. S.,李鳳群, F. C.,何豐名, F. M.(2013)。失眠的分類及治療。臺灣醫界，56(12)，19-22。

1. (2024)。團體音樂治療對改善急性精神病房住院病人憂鬱及焦慮之成效。志為護理-慈濟護理雜誌，23(2)，71-84。
2. (2024)。重度失智併呼吸衰竭個案之護理經驗。若瑟醫護雜誌，18(1)，87-98。