JAMDA 20 (2019) 822e829

JAMDA
journal homepage: www.jamda.com

Original Study

Effects of Acupressure on Sleep Quality and Psychological Distress in

Nursing Home Residents: A Randomized Controlled Trial
I-Hui Chen RN, PhD a, Tzu-Pei Yeh RN, PhD b, c, Yueh-Chen Yeh RN, PhD d,
Mei-Ju Chi PhD a, e, Mei-Wen Chen RN f, Kuei-Ru Chou RN, PhD g, h, i, Yin-Yi Lien BS a,
Chih-Fen Yuan RN, PhD j, *
a
Master Program in Long-Term Care, Taipei Medical University, Taipei, Taiwan
b
School of Nursing, China Medical University, Taichung, Taiwan
c
Department of Nursing, China Medical University Hospital, Taichung, Taiwan
d
Department of Nursing, National Taichung University of Science and Technology, Taichung, Taiwan
e
School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
f
Lee General Hospital affiliated Chunghwa Nursing Home, Taiwan
g
School of Nursing, Taipei Medical University, Taipei, Taiwan
h
Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
i
Department of Nursing, Taipei Medical University- Shuang Ho Hospital, Taipei, Taiwan
j
Yuanli Lee’s General Hospital, Lee’s Medical Corporation, Taiwan

a b s t r a c t

Keywords: Objective: To compare the efficacy of acupressure with sham acupressure in older-adult nursing home
Alternative therapy residents presenting with poor sleep quality and psychological distress.
sleep quality Design: Prospective, randomized, double-blind, sham-controlled trial.
psychological distress
Setting and participants: Sixty-two nursing home residents with poor sleep quality and psychological
residential facilities
distress participated in this study. Participants were randomly assigned to an experimental group (n ¼ 31)
older adults
receiving acupressure at true acupoints (Baihui, Juque, Neiguan, Tianzhu, and Yongchung) or control group
(n ¼ 31) receiving acupressure at sham points. All participants received 20 minutes of acupressure before
sleeping 3 times a week for 8 weeks. All participants were blinded to group allocation.
Measures: Sleep quality and psychological distress were measured using the Pittsburgh Sleep Quality
Index and the Kessler Psychological Distress scale, respectively. Both groups’ outcomes were assessed by
assessors blinded to group allocation at the baseline, the end of the intervention, and 1 month after the
intervention.
Results: The experimental group demonstrated significantly more improvement in sleep quality than did
the control group at the end of the intervention (10.5 vs 13.3) and 1 month after the intervention (8.3 vs
14.2; both P  .001). Moreover, the experimental group had lower psychological distress levels than did
the control group at 1 month after the intervention (14.6 vs 17.9, P ¼ .05). Furthermore, significant
differences in mean sleep quality (F ¼ 60.8, P < .001) and psychological distress (F ¼ 24.6, P < .001) were
observed in the experimental group between the measurements at baseline and after the intervention.
Conclusions: Acupressure at true acupoints improves sleep quality, reduces psychological distress, and
provides more clinically beneficial effects compared with that at sham points. Future studies should
examine whether these effects are maintained in the long term.
Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.

Poor quality and quantity of sleep is attributable to insomnia and

The authors declare no conflicts of interest.
* Address correspondence to Chih-Fen Yuan, RN, PhD, Yuanli Lee’s General
Hospital, Lee’s Medical Corporation, 168, Heping Rd, Yuanli Township, Miaoli
County 358, Taiwan.
E-mail address: yuanhsc@livemail.tw (C.-F. Yuan).
correlated with high risks for morbidity and mortality1 and relatively
low quality of life.2 Poor sleep quality is a common health problem
among older adults,2 with approximately 29% of them suffering from
insomnia.3 The problem is relatively more severe among older adults
living in long-term care (LTC) settings, where its prevalence rate is 46%
to 70%.4,5 Insomnia is globally recognized as a crucial public health

https://doi.org/10.1016/j.jamda.2019.01.003
1525-8610/Ó 2019 AMDA e The Society for Post-Acute and Long-Term Care Medicine.
 I.-H. Chen et al. / JAMDA 20 (2019) 822e829
concern; for instance, the total annual insomnia-related costs incurred
in the United States is approximately $100 billion.6 In nursing homes
(NHs), sleep medication is often prescribed to reduce insomnia in
residents. Approximately 15% to 41% of NH residents have a long
history of taking sleep medication.7,8 Although medication may
rapidly alleviate poor sleep quality, it often has significant side
effects, such as falling, dependency syndrome, confusion, daytime
drowsiness, and cognitive impairment.2,9
The causes of insomnia in older adults include various medications
as well as medical and psychiatric illnesses.10 Psychological distress is
highly and bidirectionally correlated to insomnia in older adults.11,12 In
particular, older adults living in LTC settings exhibit an increased risk
of psychological distress, such as anxiety, anger, loneliness, and social
isolation.13e15 These risks are evidenced by high prevalence rates of
psychological distress among NH residents of up to 85%.13,16 Psycho-
logical distress, a psychological disease,17 may be a crucial factor un-
derlying the sleep problems of NH residents. Accordingly, the safer
approach of nonpharmacologic intervention designs for reducing
insomnia and psychological distress among NH residents would be of
great value.
Although interventions using physical activities, social activities,
bright lights, and music to reduce sleep problems among NH residents
have been developed,18e21 those focusing on insomnia and psycho-
logical distress among NH residents are lacking. Acupressure, a com-
plementary therapy, has attracted attention as a strategy for
improving sleep quality or reducing psychological distress22,23 and
potentially has no associated side effects.23
Acupressure is a massage technique in which a certain amount of
force is applied using the fingers and palms to stimulate acupoints
along the meridian lines on the surface of the skin to open block-
ages.4,24,25 According to traditional Chinese medicine, an acupoint is a
location where qi and blood from the viscera and meridian infuse into
the body surface.26,27 The diameter of each acupoint is 0.3 to 1.2 cm.
Meridians constitute unique pathways for the circulation of qi and
blood, connecting the organs and extremities and linking the exterior
with the interior and the upper with the lower parts of the body.28,29
Balanced energy (yang and yin) can help maintain health and prevent
diseases.28 The disruption of this network by blocked meridians af-
fects overall health. The current study investigated the effects of
acupressure on sleep quality and psychological distress in older NH
residents, with the hypothesis that acupressure improves sleep
quality and reduces psychological distress.
Methods
Study Design
This study was approved by the ethics committee of the university
of the principal investigator (PI). Moreover, an NH in Central Taiwan
provided permission to conduct this study at the NH. This was a
double-blind, randomized, controlled trial with repeated measures.
Written consent was obtained from participants after the researchers
had fully informed them of the details of the study.
Before group assignment, participants took a pretest assessing
their sleep quality by using the Chinese version of Pittsburgh Sleep
Quality Index (C-PSQI) and their psychological distress by using the
Kessler Psychological Distress scale (K-10)dthe results of both of
which constituted the baseline values (T0). A random distribution
was used to assign participants to an experimental group (n ¼ 31)
and control group (n ¼ 31). A statistician not involved in the study
randomly allocated participants into the acupressure or the sham
group using a computer software program that generated the
random sequence. The sequence was concealed until assignment was
completed. Both groups accepted interventions at bedtime 3 times a
week for 8 weeks; each session was of 20 minutes, involving 3 to 5 kg
823
force. The posttest and follow-up test were conducted at the end of
the intervention (T1) and at 1 month after the intervention (T2),
respectively. The study flow is presented in Figure 1. Neither the
participants nor the 2 outcome assessors knew the group allocation.
The research assistants who implemented the interventions knew
which group each participant belonged to but were blinded to all
measurements at the baseline and follow-ups; furthermore, they
were not permitted to inform participants of this or interact with
them in any way.
Participants
To be eligible for participation, individuals were required to meet
the following criteria: age of 65 years; living in an NH for at least
3 months; ability to communicate with the research teams; normal
cognitive function (ie, a Mini-Mental State Examination score of
25)30; a C-PSQI score of >531; a K-10 score of 2232; and absence of
any problems, such as a fracture, ulcer, skin disease, or inflammation,
at the locations of the pressure points. Individuals were excluded if
they presented with major organ failure, tuberculosis, burns, tumors,
injuries, hemorrhagic disorders, or local infections. Participants were
not excluded for using hypnotics or antidepressants, provided that the
dose was stable over the 6 weeks before the start of the trial. Sample
size calculations were based on previous C-PSQI research.33 A sample
size of 60 participants was required to verify significant intervention
effects at a statistical power of 80% at the end of an 8-week inter-
vention, a significant level of 0.05, 2-sided, a medium effect size of 0.5,
and a presumed dropout rate of 10%. In total, 62 residents participated
in this study (Figure 1).
During the study period, participants were requested to not
practice other forms of intervention for promoting sleep or reducing
psychological distress (eg, tai chi and mindfulness practices); more-
over, a physician with a license for traditional Chinese medicine
reviewed participants’ medical statuses and medications each week. If
changes were observed in a participant’s medical status (eg, unstable
chronic illness or infection around the acupoints) or medications (eg,
new hypnotic type or dose) that could influence the results, then the
physician would inform the PI, who decided whether the participant
should be withdrawn from the study. One researcher collected data on
medication changes from medical records each week. During the
entire research period, no changes in the medical statuses or medi-
cations of participants were observed.
Interventions
The researchers and a senior licensed Chinese medicine expert
with clinical acupressure experience selected the acupoints for the
interventions and developed the instructions. Interventions were
administered by 2 assistantsdone for the experimental group and
the other for the sham-controlled group. These assistants had
received 62 hours of training in the concepts of acupressure as well
as in true acupoint and sham point identification and acupressure
skills (eg, implementing uniform pressure in a rotary motion with
the pressure on the tips of the fingers) from the senior Chinese
medicine expert, who repeatedly confirmed the accuracy of the
implementation. Before the experiment, the PI used a platform scale
of 0.02 to 6 kg to measure the force of the finger pressure applied by
the assistants to ensure intrarater reliability. To pass this test, correct
pressure was required to be achieved 9 of 10 times. The reliability of
the pressure level was confirmed after 50 practice trials with a mean
of 3.4 to 4.9 kg on the scale for both hands of the assistants. The
experimental group received acupressure and usual care, whereas
the control group received sham acupressure and usual care. The
true and sham acupressure protocols were the same, with the only
difference being the selected acupoints. The interventions were
824 I.-H. Chen et al. / JAMDA 20 (2019) 822e829

Fig. 1. Flow chart of the study.

conducted at night 3 times a week for 8 weeks, beginning on the Acupressure

second day after participants were randomly allocated to the
experimental and sham groups. Adverse events, if any, were recor- Pressure on the Baihui, Juque, Neiguan, Tianzhu, and Yongchung
ded weekly. acupoints effectively ameliorates poor sleep and psychological
 I.-H. Chen et al. / JAMDA 20 (2019) 822e829 825

Fig. 2. Locations of selected acupoints.

distress.4,28,29,34 Baihui (governing vessel 20) is located at the inter-
section of the line connecting the apexes of the 2 auricles and the
median line of the head (Figure 2A). Juque (conception vessel 14) is on
the midline between the umbilicus and sternum (Figure 2B). Neiguan
(pericardium 6) is on the palmar side of the forearm, approximately
the width of 3 middle fingers up from the wrist line, between the
flexor carpi radialis and palmaris longus tendons (Figure 2C). Tianzhu
(bladder 10) is within the posterior hairline in the trapezius muscle
(Figure 2D). Yongchung (kidney 1) is on the sole of the foot, in the
depression that forms when the foot is in plantar flexion, at the
junction of the anterior one-third and posterior two-thirds of the line
connecting the base of the second and third toes with the heel
(Figure 2E). Each of the 5 selected acupoints on the bodies of the
participants were treated for 4 minutes in every session. Acupressure
for an interval of 3 seconds with a feeling of soreness, numbness,
distension, and ache (de qi) was followed by 3 seconds of rest.
Sham Acupressure
The control group received sham acupressure at nonacupoints.
Nonacupoints were 0.5 cun (half width of the thumb) away from the
targeted active acupoints and avoided being on the same meridian as
the true acupoint. Acupressure was performed for intervals of 3 sec-
onds followed by 3 seconds of rest at the same frequency as it was
826 I.-H. Chen et al. / JAMDA 20 (2019) 822e829

Table 1 Data Analysis

Participant Characteristics

Variable Experimental Control Group c2 P Demographic data were compared using a c2 test and Fisher exact
Group (n ¼ 31) (n ¼ 31) Value test. If significant results were produced, a post hoc test with the Sidak
Frequency % Frequency % correction was used to assess pairwise comparisons of the C-PSQI and
K-10 within a group. Independent t test was used to compare the
Gender 1.2 .3
Male 12 38.7 8 25.8 mean C-PSQI and K-10 scores between the 2 groups. Data were
Female 19 61.3 23 74.2 analyzed using PASW (version 22.0 for Windows; SPSS, Chicago, IL).
Age, y 2.1 .6 All statistical tests were 2-tailed; a P value of <.05 was considered
65-70 7 22.6 3 9.7
statistically significant.
71-75 8 25.8 8 25.8
76-80 5 16.1 7 22.6
81 11 35.5 13 41.9 Results
Education 3.0 .4
Uneducated 7 22.6 3 9.7 Both groups comprised more women than men. Those aged
Primary school 12 38.7 18 58.1
81 years, who had a primary school education, who were widowed,
Junior high school 8 25.8 7 22.6
Senior high school 4 12.9 3 9.7 who had experienced cardiovascular accidents, and whose children
Marital status 5.5 .1 paid the expenses for living at the NH constituted the highest pro-
Married 4 12.9 1 3.2 portion in both groups (Table 1). No significant differences were
Divorced 3 9.7 0 0
observed between the demographics of the 2 groups. Furthermore, no
Widowed 23 74.2 29 93.5
Unmarried 1 3.2 1 3.2
participant reported any adverse effects of the intervention (eg,
Source of funding 1.0 .6 dizziness, headache, muscle ache, or muscle cramps).
Government 1 3.2 2 6.5
Children 26 83.9 27 87.1 Group Comparisons
Self-pay 4 12.9 2 6.5
Medical condition 5.7 .8
Heart disease 0 0 2 6.5 No significant differences were observed between the experi-
Hypertension 7 22.6 7 22.6 mental and control groups at T0 for sleep quality (t ¼ 1.5, P ¼ .1) or
Diabetes mellitus 10 32.3 9 29.0 psychological distress (t ¼ 1.6, P ¼ .1; Table 2). A significant differ-
Cardiovascular accident 10 32.3 10 32.3
ence in global C-PSQI scores was observed between the experimental
Mental disease 4 12.9 3 9.7
Medications taken 5.0 .4
and control groups at T1 (t ¼ 5.2, P < .001). However, a nearly sig-
None 11 35.5 9 29.0 nificant difference was observed between the experimental and
Hypnotic drugs 5 16.1 5 16.1 control groups regarding K-10 scores (t ¼ 2.0, P ¼ .054). At T2, the
Cardiovascular drugs 10 32.3 11 35.5 global C-PSQI and K-10 scores significantly differed between the
Antidepressant drugs 5 16.1 6 19.4
experimental and control groups (t ¼ 11.5, P < .001 and t ¼ 2.00,
P ¼ .05, respectively). As for the components of the C-PSQI, significant
differences in sleep latency, sleep duration, habitual sleep efficiency,
and sleep disturbance were noted between the experimental and
performed in the experimental group. According to traditional Chi-
control groups at T1 and T2. Furthermore, significant differences in the
nese medicine, the manipulation of nonacupoints should not produce
use of sleep medications and sleep sufficiency were observed between
a feeling of de qi.
the experimental and control groups at T2 (Table 2).

Measures
Quality of Sleep
The C-PSQI is a self-rating questionnaire assessing sleep quality,
with a total score range of 0 to 21. The individual 19 items are used to
generate 7 component scores: subjective sleep quality, sleep latency,
sleep duration, habitual sleep efficiency, sleep disturbances, use of
sleep medications, and sleep sufficiency. Items are scored from 0 (no
difficulty) to 3 (severe difficulty). A score of >5 indicates poor sleep
quality.31 A global score of >5 on the C-PSQI yields a diagnostic
sensitivity of 98% and specificity of 55%.35 Cronbach’s alpha for the
scale was 0.82 in this study.
Psychological Distress
K-10 is a 10-item scale for nonspecific psychological distress.32,36
The measured dimensions include feelings of depression, restless-
ness, anxiety, hopelessness, and worthlessness. Items are scored from
1 (none of the time) to 5 (all of the time). The total score range is 10 to
50. A score of 22 indicates worse levels of psychological distress. The
Chinese version of K-10 is reliable and valid.37 Cronbach’s alpha for the
scale was 0.89 in this study.
Acupressure Evaluation
Global C-PSQI scores of the experimental group at T0, T1, and T2
differed significantly (F ¼ 60.8, P < .001). Sleep latency, sleep duration,
habitual sleep efficiency, sleep disturbance, sleep medication use, and
sleep sufficiency scores on the C-PSQI in the experimental group
exhibited significant differences at T0, T1, and T2 (Table 2). K-10 scores
of the experimental group differed significantly at T0, T1, and T2
(F ¼ 24.6, P < .001). Although scores for psychological distress in the
control group exhibited a decline during treatment, the differences
were nonsignificant (Table 2).
Discussion
This study determined whether acupressure on the Baihui, Juque,
Neiguan, Tianzhu, and Yongchung points can decrease the occurrence
of insomnia and the level of psychological distress. The findings of this
study suggested that acupressure can promote sleep quality and
reduce psychological distress in older-adult NH residents with
insomnia, who experience psychological distress.
Effectiveness of Acupressure in Improving Sleep Quality
Before the intervention, older adults in both groups generally
experienced severe sleep problems (C-PSQI scores of >13), suggesting
 I.-H. Chen et al. / JAMDA 20 (2019) 822e829 827

Table 2 that health professionals should focus on developing effective in-

Independent t Test Analysis of Effects of the Intervention on Sleep Quality and terventions to promote healthy sleep habits and patterns in this
Psychological Distress
population.
Variable Experiment Control t P The results revealed that the overall scoring for sleep quality in the
Group Group Value experimental group demonstrated significant improvement. By
(n ¼ 31) (n ¼ 31)
contrast, the control group exhibited no such change. In terms of the
Mean SD Mean SD effectiveness of the intervention, the sleep latency, sleep duration,
Subjective quality habitual sleep efficiency, sleep disturbances, sleep medication use, and
T0 2.2 0.4 2.2 0.4 0.3 .8 sleep sufficiency all exhibited significant differencesdin agreement
T1 2.2 0.4 2.2 0.4 0.3 .8
with the results reported by numerous studies on the effectiveness of
T2 2.2 0.4 2.2 0.4 0.3 .8
F(P) 0.0 (1.0) 0.0 (1.0) acupressure on sleep quality.4,27,29,38,39 By applying pressure to acu-
Sleep latency points, acupressure may release neurotransmitters that relay signals
T0 2.2 0.8 2.4 0.7 1.2 .2 along neurons or activate the hypothalamic-pituitary-adrenal axis to
T1 1.4 0.6 2.2 0.7 4.7 <.001 regulate endocrine function, thereby causing muscles to relax and
T2 1.1 0.4 2.2 0.7 8.4 <.001
making it easier to fall asleep and remain asleep.4,24,29,40e42 Further-
F(P) 26.5 (<.001) 1.2 (.3)
Post hoc T0 > T1 more, acupressure is believed to function by harmonizing qi and blood,
(Sidak) T0 > T2 relieving muscle rigidity, activating collaterals, warming meridians,
Sleep duration and dispersing cold sensations while also clearing meridians and col-
T0 1.5 1.2 1.4 1.1 0.2 .8
laterals, dispersing accumulations, and freeing stasis,26e29 all of which
T1 0.5 0.9 2.1 0.9 7.1 <.001
T2 0.6 0.9 2.0 0.9 6.3 <.001
improve sleep quality.
F(P) 9.5 (<.001) 4.5 (.013) Notably, the use of sleep drugs significantly decreased in the
Post hoc T0 > T1 T0 < T1 experimental group until the end of the study. The reduction in sleep
(Sidak) T0 > T2 T0 > T2 medications was further confirmed by reviewing medical records. The
Habitual sleep
frequency of drug administration in the experimental group was
efficiency
T0 2.1 0.9 1.2 0.8 4.0 <.001 5.5  0.6, 5.2  0.8, and 4.5  0.5 nights/wk at T0, T1, and T2,
T1 1.9 0.9 1.4 0.8 2.4 .019 respectively; by contrast, the frequency remained stable in the sham
T2 0.6 0.7 1.9 1.8 4.0 <.001 group (5.6  0.8 nights/wk). This indicates that acupressure can be
F(P) 32.6 (<.001) 2.8 (.1)
used as a nonintrusive method for reducing the number of sleep
Post hoc T0 > T2
(Sidak) T1 > T2
medications taken by residents, which would in turn influence care
Sleep disturbance quality.
T0 2.1 0.8 1.7 0.9 2.0 .052
T1 1.3 0.5 1.7 0.9 2.1 .045 Effectiveness of Acupressure in Reducing Psychological Distress
T2 1.1 0.3 1.8 0.9 4.0 <.001
F(P) 24.7 (<.001) 0.1 (.9)
Post hoc T0 > T1 Improvements in the psychological health status of participants
(Sidak) T0 > T2 was more remarkable at the 1-month follow-up after the intervention
Use of sleep than at the endpoint. It is postulated that acupressure can produce
medications
long-term effects on reducing psychological distress. Furthermore,
T0 2.2 0.7 2.5 0.7 1.5 .1
T1 2.0 0.8 2.4 0.9 1.7 .1
acupressure was more effective than sham pressure. These results are
T2 1.7 0.8 2.5 0.8 3.7 .001 similar to the findings of other studies that reported that acupressure
F(P) 9.0 (<.001) 0.1 (1.0) reduced psychological distress and depression, promoted well-being,
Post hoc T0 > T1 and increased comfort.43e45 Modern medicine has proven that
(Sidak) T0 > T2
acupressure can regulate the activation of neural circuits during
Sleep sufficiency
T0 1.8 0.8 1.8 0.8 0.2 .9 anxiety and nervousness and maintain homeostasis of neurochemical
T1 1.2 0.5 1.5 0.7 1.6 .1 mechanisms to promote psychological healing. One probable mech-
T2 1.1 0.3 1.6 0.8 3.2 .002 anism of acupressure involves the adjustment of neurotransmitters
F(P) 12.5 (<.001) 1.5 (.2) (eg, serotonin) in the central nervous system, affecting the comfort
Post hoc T0 > T1
(Sidak) T0 > T2
experienced by individuals.39 Other studies have reported that certain
Global PSQI peptides are set free during the process of acupressure and produce
T0 14.1 2.8 13.1 1.9 1.5 .1 the same effects as painkillers in response to reduced function of the
T1 10.5 2.0 13.3 2.3 5.2 <.001 sympathoadrenal system during periods of anxiety.46,47 Second,
T2 8.3 1.8 14.2 2.3 11.5 <.001
acupressure can increase C-tactile afferents, creating a privileged pe-
F(P) 60.8 (<.001) 2.1 (.1)
Post hoc T0 > T1 ripheral pathway for pleasant tactile stimulation, thus promoting
(Sidak) T0 > T2 positive psychological feelings.48 Other probable mechanisms under-
T1 > T2 lying acupressure are that it employs gentle massage techniques,
K-10 stimulates alpha waves in the brain, and has an excellent sedative
T0 24.8 7.8 22.0 6.6 1.6 .1
T1 14.6 6.0 17.9 7.3 2.0 .054
effect of relieving tension and mental and physical fatigue as well as
T2 14.6 6.0 17.9 6.9 2.0 .05 reducing stress and psychological distress.33,49
F(P) 24.6 (<.001) 0.8 (.5)
Post hoc T0 > T1 Limitations
(Sidak) T0 > T2

SD, standard deviation. The findings of this study should be interpreted with caution.
PSQI total scores ranged from 0 to 21, with lower scores being favorable. K-10 total
The study was limited to 1 NH and a sample size of 62 people;
scores ranged from 10 to 50, with lower scores being favorable.
therefore, the results cannot be inferred as valid in other settings.
828 I.-H. Chen et al. / JAMDA 20 (2019) 822e829
To establish more comprehensive research on this topic, further
studies must be conducted at multiple NHs with larger samples.
This study only included dementia-free participants to obtain ac-
curate results from the self-report measures because the measures
relied on the cognitive ability to reflect on the previous month or
few days. It is suggested that future studies include both subjective
and objective measures when examining sleep quality in older-
adult NH residents as well as involve older adults with dementia.
Furthermore, excessive daytime sleepiness, which has frequently
been associated with insomnia in older adults,50 was not assessed.
Thus, future studies should use validated tools, such as the obser-
vation- and interview-based diurnal sleepiness inventory,51 to
assess excessive daytime sleepiness. Moreover, more studies with
longer intervention periods must be conducted to achieve a clearer
understanding of the effects of acupressure on sleep quality and
psychological distress.
Implications
This study involved the conduction of a long-term follow-up
regarding the influence and effectiveness of acupressure on the sleep
quality and psychological distress experienced by older adults in LTC
settings. The research outcomes may provide new empirical knowl-
edge for the care of older adults in LTC settings, introduce clinical
practices that focus more on the physical and psychological health of
older adults, and improve the quality of care. Further investigation
could benefit from useful information about objective sleep and
wakefulness to determine the effect of acupressure on sleep among
this population or establish physiological indices as scientific evidence
in relation to psychological changes (eg, levels of catecholamine and
cortisol),52 which are less susceptible to the influence of testing and
practice effects.
The research results of this study proved that acupressure is a
simple nonpharmacologic treatment method that improves sleep
quality and reduces psychological distress in older NH residents.
Therefore, health care providers in LTC settings may benefit from
acquiring qualifications for performing this noninvasive method in
their routine clinical care. Moreover, acupressure is safe and harm-
less and can even be performed by the individuals themselves.
Residents and their family members can be trained in this practice,
suggesting that health care providers in LTC settings can incorporate
acupressure into health education programs for residents and their
families.
Medical and nursing schools are advised to incorporate acupres-
sure methods into their curriculums to enable students to learn
the operational guidelines of acupressure and promote clinical
applications.
Conclusions
Few studies have investigated the effectiveness of acupressure on
older adults in LTC settings. Thus, the effects of relevant factors, such
as the duration of acupressure interventions, dosages, and numbers of
acupoints, on the effectiveness of acupressure warrant investigation.
The current study results support the use of acupressure for improving
sleep quality and reducing psychological distress in older-adult NH
residents, in turn improving their quality of life. Thus, the application
of acupressure in combination with medical treatments can improve
sleep quality and reduce psychological distress.
Acknowledgments
The authors thank the NH residents who participated in this study.
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