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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1328-1332
The impact of guided mental imagery on the sleep quality of the elderly after having heart attack


1 Student Researcher, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran
2 Department of Critical Care Nurses, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
3 Department of Community Health Nursing, Nursing and Midwifery Care Research Center, Isfahan University of Medical Sciences, Isfahan, Iran

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Date of Web Publication6-Nov-2017
 

   Abstract 


Background: There are numerous factors such as cardiovascular diseases which cause sleep problems for the elderly. Relaxation is one of the components of cognitive behavioral therapy which refers to the practice of relaxation solutions to improve the sleep quality. Objectives: This paper aims to examine the impact of guided mental imagery on the sleep quality of the elderly after having heart attack. Patients and Methods: This study is considered to be a two-group random clinical trial that was carried out on sixty elderly patients suffering heart attack who have been discharged with sleep problems from selected teaching hospitals of Isfahan University of Medical Sciences. Participants were placed in intervention and control groups through random allocation method. Two training sessions of calm making and guided imagery protocols were applied to the intervention group. The sleep quality in research units was examined before and after the intervention using Pittsburgh sleep quality questionnaire. Data analysis was carried out by the statistical software SPSS version 16 through paired and independent t-tests. Results: The mean sleep quality score in the intervention group was significantly lower after intervention (2.6 ± 2.3) (P < 0.001). Furthermore, the mean of changes in sleep quality score after intervention was significantly greater in the case group (−7.9 ± 2.3) compared to the control group (−2.9 ± 2.2) (P < 0.001). Conclusion: The guided mental imagery program was found to be effective in improving the sleep quality of the elderly suffering heart attack. The guided mental imagery is, therefore, recommended to be considered as a part of rehabilitation care for the elderly having heart attack with sleep disorders.

Keywords: Elderly, guided imagery, heart attack, sleep quality

How to cite this article:
Aghababaei S, Yazdannik AR, Keshvari M. The impact of guided mental imagery on the sleep quality of the elderly after having heart attack. Ann Trop Med Public Health 2017;10:1328-32

How to cite this URL:
Aghababaei S, Yazdannik AR, Keshvari M. The impact of guided mental imagery on the sleep quality of the elderly after having heart attack. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Dec 11];10:1328-32. Available from: http://www.atmph.org/text.asp?2017/10/5/1328/217504



   Introduction Top


Sleep is considered to be an important and necessary part of daily life.[1] Lack of sleep has negative adverse effects on physical, mental health, and cardiovascular performance.[2] Numerous factors cause sleep problems in the elderly such as cardiovascular diseases.[3],[4] Research indicates that the prevalence of sleep problems in cardiac patients is high, and it was shown in the Nielsen study that 68.3% of the cardiac patients have inappropriate sleep quality.[2],[5],[6] There are various solutions to improve sleep quality including pharmaceutical and nonpharmaceutical methods.[7] Although studies show that pharmaceutical therapy leads to induction and prolongation of sleep and also effective in insomnia, there were no effective impacts on sleep quality and were not found any convincing evidence regarding its continuous effect.[8] Furthermore, chronic use of sleep medicines causes drug resistance, physical dependence, drowsiness and decreased mental alertness, depression and changes in balance, and memory which are very important considering special conditions of elderly people.[9]

One of the nonpharmaceutical methods to improve sleep quality is cognitive behavioral therapy. Relaxation practice is a part of cognitive behavioral therapy and includes progressive muscle relaxation, imaginary relaxation, hypnotism, and coordinated breathing. Imagery is based on the belief that imagination of a relaxing scene can make the person feel more relaxed.[10] This method is included in complementary medicine and can be learned through books, self-studying, or an instructor.[11] It is also a simple, inexpensive method without any side effects. Various studies have investigated the effect of mental imagery on sleep quality in different patients. Golmakani et al. in their study among primigravida women showed that mental imagery was more effective in improving sleep quality compared to muscle relaxation technique.[12] Nielsen and Germain also examined the effect of imagery on nightmare, psychological distress, and sleep quality in 18 years and older nightmare patients and found out that this method leads to decreased frequency of disturbing dreams, and psychological distress and sleep improvement may occur later in the recovery process.[13] Kwekkeboom et al. compared both methods of guided imagery and progressive muscle relaxation on the pain severity of cancer patients in a relaxation period of 2 days and found no significant difference between these two methods and they decided to use patient's preference to choose one of the two methods based on the physical ability, energy level, type, and pain severity.[14] On the whole, evidence shows no positive impacts of this method on sleep quality according to the high prevalence of sleep problems as age increases and its negative effects on life quality and the elderly performance, the negative effects on cardiac patients, lack of long-term efficiency, the side effects of sleep medicines, and also the researcher's experience in the field of sleep problems and the nurses role of the elderly patients in improving sleep quality.

Objectives

This study aims to determine the impact of guided mental imagery method on sleep quality of the elderly after having heart attack.


   Patients and Methods Top


Design and samples

This study is considered to be a two-group clinical trial which was conducted in two stages of before and after intervention on sixty elderly patients suffering heart attack discharged with sleep problems selected from teaching hospital of Isfahan Medical Sciences University. Samples were selected through simple random selection method then placed in two groups of intervention and control using random allocation. Entry criteria into the study are the elderly aged above 60 suffering heart attack, understanding ability, score 5 or higher on Pittsburgh sleep quality scale, not using relaxation techniques or nervous system stimulators, no smoking and no diagnosis of depression, mental retardation, or chronic pain with effect on sleep at night. Excluding criteria were disability and not willing to take part, death of patient before cessation of intervention, and crisis creation for elders (for example, partner and darling).

Data collection instruments

The questionnaire was divided into three different sections including demographic data, Pittsburgh sleep quality index (PSQI), and a sheet for recording the results of the intervention.

PSQI is a global self-report questionnaire for measuring the person's approach to the sleep quality in the past 4 weeks. It includes nine questions in seven components of subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction. The items are scored using a Likert scale, ranging from 0 to 3 (3 = the highest negative score). The total score is calculated by summing the scores of components, ranging from 0 to 21; scores ≥5 indicates undesirable sleep quality.[15] This questionnaire has good sensitivity (89.6%), internal validity α = 0.83 and r = 0.85.[16] Hossein-Abadi et al.[17] also confirmed test–retest reliability of this questionnaire (r = 0.84).

The procedure

The aim of the study was explained to the participants, and informed consent was obtained from the participants. The demographic and Pittsburgh sleep quality questionnaires were completed through interviews, then samples through random allocation method were placed into two groups of intervention and control using envelopes which were already filled with cards associated with intervention and control groups by asking elderly to choose one of them. Guided mental imagery instruction was performed through two 45 min sessions consisting of groups of 4–7 people in each unit's health education center. The relaxation file was of 10 min duration including a background music with an audio file to guide relaxation and asking for imagination of beautiful sceneries to deepen the relaxation which all produced by researcher in a sound recording studio. Afterward, a booklet containing all the materials and an MP3 relaxation file were provided to the participants of the intervention group to use and to practice at home. An MP3 player was also provided if necessary. Participants were asked to use this program every night before sleep and mark the relaxation paper for a month. Control group was also provided with a file without audio texts. Researcher was in contact with participants through phone calls every other day, and after 1 month, the sleep quality questionnaire was again completed for all participants by the researcher in [Table 1].
Table 1: Method

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It was used the following formula to determine sample size; therefore, the sample size was found to be sixty patients considering 20% as sample falling.

Z1: Reliance factor of 95% equals 1.96

Z2: Power factor of 80% equals 0.84

S: Estimate of standard deviation of mental imagery score variation after intervention in each group.

D: Minimum difference in the mean score variation of sleep quality after intervention between two groups which shows a significant difference and considered to be 0.8 s in this paper.



Ethical considerations

This study, which was registered in IRCT (code: IRCT2016062128568N1), is the result of a M. Sc. thesis of nursing, approved by the Vice-Presidency for Research at Isfahan University of Medical Sciences (IUMS) (approval code: 394582).

The relative clearance and code of ethics were obtained from the Ethics Committee of Isfahan Medical Sciences University to comply with the ethical considerations of intervention. With permission of School of Nursing and Midwifery, IUMS, the researcher attended the research units, and participants were selected with cooperation of authorities. Informed written consent was gained from the survey individuals. Participants were allowed to leave the research at every stage, and the required reliance was given to the authorities and the elderly to be informed of the research results if they desire.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics 13 software and paired and independent t-tests were used. Independent t-test was used to compare the mean score of sleep quality in the two groups and the mean score variation of sleep quality, and it was also used paired t-test to compare the mean score of sleep quality before and after intervention [Figure 1].
Figure 1: Consort diagram

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   Results Top


The study showed [Table 2] that the majority of participants were male (81.05%), married (96.75%), and unemployed (59.15%). The mean age was 63.2 ± 6.8 and 64.1 ± 5.9 in control and intervention groups, respectively.
Table 2: Comparison of demographic characteristics at baseline

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The mean sleep quality score improved significantly after the intervention (P < 0.001) [Table 3].
Table 3: The mean score of sleep quality in two groups before and after the intervention

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   Discussion Top


The survey results showed that guided mental imagery resulted in the improvements of the total score of sleep quality and its components in the elderly diagnosed with heart attack. Since the quality of sleep is influenced by the intermediary individual factors such as gender, marital status, education, illness, and other factors,[7] two groups of intervention and control were compared to each other regarding these factors which were observed no significant difference between them.

Guided mental imagery, therefore, without any relationship with the mentioned variables causes improvements in the sleep quality of the elderly suffering heart attack. The results also showed that the relaxation file without any audio texts can lead to improvement of sleep quality of the participants in the control group, but the effect is less compared to the intervention group. The findings are in line with other researches related to the effect of cognitive behavioral methods such as guided mental imagery on the sleep quality of patients. In this regard, a study by Golmakani et al. compared the effects of progressive muscle relaxation and guided imagery on sleep quality in primigravida women showed that both methods had positive impacts on the sleep quality of primigravida women, but the effect of guided imagery was more significant.[12] Furthermore, Schaffer et al. showed that guided imagery positively affected the sleep quality of mothers of preterm infants.[15] Richardson indicated that a combination of music and mental imagery affected the sleep quality of critically ill patients.[18] Chen and Francis study also confirmed the effect of guided imagery on sleep quality in patients with chronic pain.[19] Despite these studies, Kwekkeboom et al. compared both methods of guided imagery and progressive muscle relaxation on the pain severity of cancer patients in a relaxation period of 2 days and found no significant difference between these two methods and they decided to use patient's preference to choose one of the two methods based on the physical ability, energy level, type, and pain severity.[14] The results of this study showed that sleep disturbances were lower in the intervention group compared to the controls. It seems that the improvement of sleep quality and reduction of sleep disturbances was due to the relaxation techniques performed including guided imagery. Guided imagery helps the person to move into the alpha level. Alpha is a level of brain waves with half the frequency of brain waves in complete consciousness and is a state of light sleep. In this level, the ability of imagination, focus, and suggestibility is increased, disturbing thoughts decrease, and the person is completely relaxed. Furthermore, the imagery method is based on the notion that thinking of a calming scene helps to feel more relaxed and as a body–mind technique states that mind and body are interconnected and can strengthen each other.[10] The results showed that imagery has positive effects on the sleep quality of elderly. Considering high prevalence of insomnia and associated adverse effects, this study suggests imagery can be used as a nonpharmacological therapy in sleep disturbance management among elderly. Generalizability of the results is limited due to small sample size, and further studies are warranted.

There was no possibility to verify the authentication and completion of relaxation practices checklist and ensure the implementation of these practices by researcher and it is also further research needed to expand the findings of this study in the area.

It is recommended to apply this method to the treatment of sleep disorders in the cardiac elderly.


   Conclusion Top


The guided mental imagery program was found to be effective in improving the sleep quality of the elderly suffering a heart attack. The guided mental imagery is therefore recommended to be considered as a part of rehabilitation care for the elderly having a heart attack with sleep disorders.

Acknowledgments

We thank all staff in health education units in hospitals of Isfahan University of Medical Sciences, authorities, patients, and their families and all those who helped us in conducting this work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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2.
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Aslani Y, Etemadifar S, Ali AF, Heydari A. Sleep disorders in patients with congestive heart failure hospitalized in Hajar hospital, Shahrekord, 2003. J Shahrekord Univ Med Sci 2007;9:44-9.  Back to cited text no. 6
    
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Hajibagheri A, Babaii A, Adib-Hajbaghery M. Effect of Rosa damascene aromatherapy on sleep quality in cardiac patients: A randomized controlled trial. Complement Ther Clin Pract 2014;20:159-63.  Back to cited text no. 7
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Yang PY, Ho KH, Chen HC, Chien MY. Exercise training improves sleep quality in middle-aged and older adults with sleep problems: A systematic review. J Physiother 2012;58:157-63.  Back to cited text no. 8
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Hajian S, Mirzaei KH, Keramat A, Mirzaie HM. A systematic review of the effects of muscle relaxation techniques and guided imagery to reduce pain and distress caused by illness or the effects of treatment in women with breast cancer during the years 2007-1998. Iran J Breast Dis 2008;1:32-44. [In Persian].  Back to cited text no. 11
    
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Golmakani N, Seyed Ahmadi Nejad FS, Shakeri MT, Asghari Pour N. Comparing the effects of progressive muscle relaxation and guided imagery on sleep quality in primigravida women referring to Mashhad health care centers-1393. J Midwifery Reprod Health 2015;3:335-42.  Back to cited text no. 12
    
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Germain A, Nielsen T. Impact of imagery rehearsal treatment on distressing dreams, psychological distress, and sleep parameters in nightmare patients. Behav Sleep Med 2003;1:140-54.  Back to cited text no. 13
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Kwekkeboom KL, Wanta B, Bumpus M. Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. J Pain Symptom Manage 2008;36:604-15.  Back to cited text no. 14
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Schaffer L, Jallo N, Howland L, James K, Glaser D, Arnell K. Guided imagery: An innovative approach to improving maternal sleep quality. J Perinat Neonatal Nurs 2013;27:151-9.  Back to cited text no. 15
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Chan MF, Chan EA, Mok E. Effects of music on depression and sleep quality in elderly people: A randomised controlled trial. Complement Ther Med 2010;18:150-9.  Back to cited text no. 16
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Chen YL, Francis AJ. Relaxation and imagery for chronic, nonmalignant pain: Effects on pain symptoms, quality of life, and mental health. Pain Manag Nurs 2010;11:159-68.  Back to cited text no. 19
    

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Correspondence Address:
Ahmad Reza Yazdannik
School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_204_17

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