@phdthesis{oai:niigata-u.repo.nii.ac.jp:02000938,
 author = {池, 睦美},
 month = {2023-04-24, 2023-04-24},
 note = {【背景と目的】適切な睡眠は心身の疲労を回復させ，量的な不足や質的な悪化は日常生活に支障をもたらし生活習慣病リスクを高める．透析患者は睡眠に関する訴えが多いが，睡眠障害の実態は十分に明らかにされていない．本研究では透析患者の睡眠の特徴を主観的，客観的に明らかにし，睡眠と自己管理行動との関連性を明らかにすることを目的とした．【方法】透析患者41名(以下，対象者)にピッツバーグ睡眠質問票(Pittsburgh Sleep Quality Index：以下，PSQI)を使用し主観的睡眠評価とアクチグラフを使用し客観的睡眠状態を調査した．さらに血液透析患者自己管理行動尺度(以下，自己管理行動尺度)を使用し基本的属性，検査データなどから自己管理行動と睡眠との関連性を分析した．【結果】1）対象者の睡眠の特徴：PSQI総合得点は平均6.80，対象者の56%がcut off point 5.5を超えていた．アクチグラフの測定結果は平均で総睡眠時間が277.35分(4時間37分)と短く，入眠潜時は62分，覚醒時間は64分といずれも長く，5分以上の覚醒回数は3.79回と多かった．対象者の睡眠薬服用は26.8%と多く，服用の有無で比較すると「有」は睡眠の主観的評価が不良で入眠障害を強く自覚しており，「無」では客観的評価の覚醒時間が長く，5分以上の覚醒回数に有意な差がみられた．またPSQI総合得点と「家族構成」「体重増加率」には相関がみられ，同居者がいる者，体重増加率の低い者には睡眠評価に良い傾向がみられた．2）対象者の自己管理行動：自己管理行動尺度の総得点は平均86.28であった．自己管理行動尺度の総得点と「心胸比」「家族構成」などの変数には相関がみられた．自己管理行動と睡眠との関連を分析するため，自己管理行動に影響を与える因子を分析すると自己管理行動尺度の総得点は「PSQI総合得点」「心胸比」とともに体重増加に影響を及ぼしていた．3）対象者の中から自己管理行動尺度の総得点が高く，体重増加率が少ない，自己管理行動が良好と推察される6名にインタビューを実施すると(1)発症からの経過と透析療法に対する思いには【不安への抵抗】【困難との遭遇】【就労継続による幸福】の3つのカテゴリー，(2)透析療法の継続のための工夫と自己管理行動には【自己管理による自己の肯定】【現在を感謝】【透析スタッフからの自立】【治療の抑圧】の4つのカテゴリー，(3)睡眠についての自己管理行動には【質の変化の受容】【睡眠量の調整】の2つのカテゴリーが抽出された．対象者は就労を継続しながら夜間透析を受けており慢性的な睡眠不足がみられたが，職場で午睡をとり，透析中も仮眠をとることで睡眠量を補い，睡眠時間を透析スケジュールに合わせて捻出しながら体調管理と生活の再構築に繋げていた．【考察】対象者の主観的睡眠評価は一般人と比べて悪く，客観的評価からも重度の入眠障害，中途覚醒が存在し，総睡眠時間も短く，睡眠薬の効果もあまりみられなかった．また自己管理行動尺度と血液データとの相関もみられなかったことから，適切な自己管理行動ができているか否かは検査データと照合して評価する必要がある．自己管理行動の指標の1つである体重増加率に影響する因子としてPSQI総合得点が抽出され，睡眠が自己管理行動に影響を及ぼすことが示された．対象者が良質な睡眠をとることは自己管理行動の改善に繋がると考えられる．インタビューの対象者は就労を継続し，家族機能と社会的役割を維持していた．こうしたことは自己に対する肯定的な受け止めや自己管理行動への自信に繋がっていると考えられる．対象者の語りからは，透析導入によって睡眠の質は変化し，疾病の経過の中で睡眠障害の状態も変化していた．体重増加による呼吸困難，便秘による腹満感，原疾患がもたらす腰痛などの身体的苦痛，副甲状腺機能亢進症による掻痒感や足のイライラ感が睡眠障害の原因になっていることがわかった．自己管理行動が良好な者でも加齢に伴う睡眠の質の変化や身体機能の低下を感じており，適正体重の変更に戸惑いつつも加齢に伴って派生する危機に対応していた．【結論】透析患者(対象者)の睡眠には入眠障害，中途覚醒がみられ，総睡眠時間が短く，主観的かつ客観的にも不良であった．睡眠状態は体重の自己管理行動に影響を与えていた．自己管理行動が良好な者では，睡眠の質の変化を自覚しつつも睡眠量を確保するために時間管理を行っていた．透析療法に携わる医療スタッフは睡眠状態や日中の覚醒困難を確認し，年齢に応じて派生し得る諸課題を予測しながら危機回避の介入を行い，良好な睡眠が獲得できるように援助する必要がある．, 【Background and Purpose】Adequate sleep helps patients recover from mental and physical exhaustion. Qualitative insufficiency and deterioration of sleep interfere with daily life and increase the risk of lifestyle-related diseases. Patients undergoing dialysis often complain of sleep disorders. However, sleep disorders have not yet been fully elucidated. This research sheds light on the subjective and objective characteristics of sleep in patients on dialysis, clarifying the relationship between sleep and self-management behavior during dialysis. 【Methods】Subjective sleep evaluation in 41 patients on dialysis was performed using the Pittsburgh Sleep Quality Index (PSQI). Actigraphy was used to investigate the objective sleep state. Additionally, using a self-management behavior scale for patients on hemodialysis, the relationship between self-management behavior and sleep was analyzed based on basic attributes and test data of these patients. 【Results】1) Characteristics of sleep in patients on dialysis: the PSQI total score average of patients on dialysis was 6.80, and 56% of the patients exceeded the cut-off point of 5.5. The average actigraphy measurement results were as follows: the total sleep time (TST) was short, 277.35 minutes (4 hours 37 minutes). Sleep onset latency (SOL) and wake after sleep onset (WASO) were long, 62 minutes and 64 minutes, respectively. The number of awakenings longer than 5 minutes (NA>5) was high, 3.79 times. Many patients (26.8%) were taking sleep medications. When comparing patients with or without sleep medication, those who took sleep medication had a poor subjective sleep evaluation and were intensely aware of the disturbance of sleep induction. WASO was longer in objective evaluations by patients who did not take sleep medication, and a significant difference was found in NA>5. PSQI total scores were correlated with "family structure" and "weight increase rate." Patients living with someone or those with a low rate of weight increase were likely to show good sleep evaluation. 2) Patients' self-management behavior: The average total score on the self-management behavior scale was 86.28. There were correlations between the total scores on the self-management behavior scale and variables such as "cardiothoracic ratio (CTR)" and "family structure." Factors influencing self-management behavior were examined to analyze the relationship between self-management behavior and sleep. The results revealed that "the total scores on the self-management behavior scale" influenced the increase in weight, along with "PSQI total scores" and "CTR." 3) Interviews were conducted with six patients with a high total score on the self-management behavior scale and low weight increase who were supposed to engage in self-management behavior well. The following categories were extracted from the interview results. (1) Three categories of "resistance to anxiety," "encounter with difficulties," and "happiness from employment continuation" for the course from onset and feelings for dialysis therapy. (2) Four categories of "self-affirmation via self-management," "appreciation for the present," "independence from dialysis staff," and "suppression of treatment" for continuation of dialysis therapy and self-management behavior. (3) Two categories of "acceptance of quality change" and "adjustment for the amount of sleep" for self-management behavior. The patients studied showed a chronic lack of sleep because they had received dialysis while continuing to work. However, they made up for the insufficient amount of sleep by taking a nap at work and during dialysis, and squeezed time to sleep in accordance with their dialysis schedules. Their actions led to health care and reconstruction of life. 【Discussion】The subjective sleep evaluation of patients on dialysis was worse than that of the general population. The objective evaluation showed that they had severe disturbances in sleep induction and intermittent awakenings and that their TST was short. Sleep medication did not have a substantial effect. Since no correlation was found between the self-management behavior scale score and blood sample data, determining whether patients are able to perform appropriate self-management behavior is needed for a comparison with test data. The PSQI total score was extracted as a factor influencing the rate of weight increase; it was one of the indicators of self-management behavior, which indicated that sleep influenced self-management behavior. For patients on dialysis, good sleep quality improves their self-management behavior. The patients who were interviewed continued to work and maintain family functions and social roles, which led to positive acceptance of the self and confidence during self-management of behavior. The patients' narratives revealed that the introduction of dialysis changed the quality of sleep and the clinical status of sleep disorders during the course of illness. Dyspnea due to weight increase, a feeling of fullness due to constipation, lower back pain and other physical pain caused by primary diseases, and feelings of itching and leg irritation caused by hyperparathyroidism were thought to be the causes of sleep disorders. Even patients engaging in self-management behavior experienced age-related changes in sleep quality and decline in physical functions. They dealt with the risks associated with aging while being perplexed by changes in appropriate weight. 【Conclusions】Sleep in patients on dialysis was subjectively and objectively poor because of disturbances in sleep induction and intermittent awakening, and short TST. Their sleep state influenced their weight self-management. Patients who exhibited good self-management behavior underwent time management to secure the amount of sleep while being aware of changes in sleep quality. It is essential for medical staff involved in dialysis therapy to check patients' sleep conditions and daytime dysfunction, undertake interventions to avert a crisis by anticipating problems that could be derived from their age, and help them in attaining a good sleep., 新大院博(保)甲第46号},
 school = {新潟大学, Niigata University},
 title = {維持血液透析患者の睡眠と自己管理行動の関連性に関する研究},
 year = {}
}