Page 218 - Cardiac Nursing

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194 PA R T I I / Physiologic and Pathologic Responses
internal clock and the external schedule. Delayed sleep phase dis- conducted for sleep disorders in infants and children. Studies in
order, when sleep time is delayed in relation to the desired clock adult populations are limited and focus on patients with comor-
time, and advanced sleep phase disorder, when the patient goes to bid medical conditions. One study examined aromatherapy mas-
sleep in the early evening and wakes up earlier than desired in the sage for hospice patients using self-report measures of sleep. Al-
morning are two common circadian sleep-related distur- though this study reported no benefits in quality of life or pain
bances. 285,286 Patients with a delayed sleep phase have been re- control, there were statistically significant improvements in self-
ported to benefit from early morning light exposure. This requires reports of sleep and depression. 295 Another randomized study
bright light exposure to be given in the morning as close to the pa- compared therapeutic massage and relaxation tapes in the man-
tient’s scheduled arising time as possible. Light therapy delays the agement of stress with both modalities showing improvements in
shift toward a later phase and may be useful in sustaining a sleep, but no significant benefit of one over the other. 296 Among
24-hour circadian period. Evening bright light exposure is useful patients with cardiovascular disease, massage therapy and its ef-
for treating advance sleep phase disorders by impeding the circa- fects on sleep have received little attention.
dian sleep phase. 287 Another form of manipulative therapy is acupressure, a nonin-
Natural sunlight or artificial light, using a light box, can be vasive technique that involves stimulation of meridian or acu-
used to administer light therapy. Artificial light requires using points on the body using finger pressing movements. It can be ad-
10,000 lux for 30 to 40 minutes upon awakening. Evening light ministered by nursing staff or by family members of a patient.
exposure is decreased to attain positive results in those with de- Acupressure in end-stage renal patients has shown improvements
layed phase sleep disorders. Blue-blocking sunglasses may be worn in self-reported sleep quality, sleep latency, and sleep efficiency. 297
to counter the phase-delaying effect of evening light exposure. Re- Acupressure has had limited use in cardiac patients for sleep, re-
sponse is usually seen in 2 to 3 weeks and often requires indefinite quires further study, and has exhibited little effectiveness for low-
treatment. Advanced phase disorder patients require a light box in ering nausea and vomiting following cardiac surgery. 298
the evenings. The use of sun glasses that block blue light in the
morning may also be beneficial. 41,286,288,289 Meditation. While there are several forms of meditation, one
of the most commonly studied for insomnia is mindfulness med-
Complementary and Alternative Therapies itation. Stress reduction may be one of the mechanisms by which
One of the most frequent uses of complementary and alternative meditation can exert a beneficial effect on sleep and most of the
medicines (CAM) is in the treatment of sleep disturbances. While studies that have demonstrated improved sleep during meditation
the terms are often used synonymously, a more accurate statement therapy have been conducted as stress reduction studies. In this re-
is the National Institutes of Health—National Center for Com- gard, it can be used as part of a cognitive therapy approach. In ad-
plementary and Alternative Medicine (NCCAM) definition that dition to stress reduction, there may also be differences in slow-
complementary medicines are “used together with conventional wave sleep as a result of meditation. Few studies have used
medicine,” while alternative medicines are “used in place of con- meditation as a method to improve sleep in patients with cardio-
ventional medicine.” The NCCAM lists five broad categories of vascular disease but recent data from a yoga intervention, which
CAM therapies including: (1) alternative medical systems. These included posture, breathing, and meditation, suggests it may im-
299
include acupuncture, Ayurveda, or homeopathy; (2) biologically prove autonomic function.
based practices, such as herbal products; (3) mind-body medicine, Yoga. Yoga incorporates the holistic components of physical
meditation, Tai Chi, yoga, and biofeedback; (4) manipulative and activity, specific postures, breathing exercises, and a philosophic
body-based practices, massage-based therapies; and (5) energy attitude toward life. It has been shown to reduce anxiety levels and
medicine that focuses on the use of energy fields, including bio- physiological arousal in cardiac patients. 300 A randomized, paral-
electromagnetic-based therapies.
lel group study conducted over a 6-month treatment period com-
Melatonin. Melatonin is a hormone produced by the pineal pared yoga (60-minute session 6 days a week, with a 15-minute
gland that is thought to play an important role in regulating the evening session), Ayurvedic therapy, and wait-list control in 69
sleep–wake cycle. During the daytime, circulating levels are low older adults. Self-reported sleep measures were assessed and
with nocturnal levels becoming elevated, which coincide with the demonstrated a 1-hour increase in total sleep time relative to pre-
sleep phase. Melatonin can alter the timing of the circadian treatment in the yoga group that was significantly higher than
sleep–wake cycle. 290 Melatonin also has sedative effects, possibly changes in the wait-list or Ayurveda groups. 301
by inhibiting the suprachiasmatic nucleus. Melatonin has exhib-
ited positive effects on the cardiovascular system. 291,292 Studies of Tai Chi. Tai chi is a low- to moderate-intensity traditional
Chinese exercise that includes a meditational component. Previ-
the effectiveness of melatonin have been inconsistent using both
ous findings supports that Tai chi enhances aerobic capacity,
wrist-worn actigraphy and PSG to document sleep parameters.
muscular strength, endothelial function and psychological
Melatonin is well tolerated by most individuals in the dose range 302
of 0.1 to 10 mg with few reported adverse events. 293 However, wellbeing. A study of the effects of tai chi (three 60-minute ses-
sions for 24 weeks) in older adults, in comparison to low-impact
melatonin may reduce the antihypertensive effectiveness of cal-
exercise, noted that Tai chi improved self-reported sleep duration
cium channel blockers to a mild degree. Patients taking nifedip- 303
by 48 minutes. General health-related quality of life and day-
ine, who were treated with melatonin, showed a mean increase in
time sleepiness levels also improved. Tai chi appears to be safe and
systolic blood pressure of 6.5 mm Hg, and in diastolic blood pres-
sure of 4.9 mm Hg. 294 effective for patients with MI and HF, and post-CABG surgery.
304
Yeh et al reported improved sleep time in patients receiving
Manipulative and Body-Based Practices. The manipula- 12 weeks of Tai chi training compared to controls. Therefore, Tai
tive and body-based practices include a wide range of hands-on chi may be viewed as an alternative exercise program that may
interventions. Massage therapy studies have primarily been enhance sleep for selected patients with cardiovascular diseases.