Relating Factors of Insomnia among Haemodialysis Patients

Background: Insomnia is a sleep disturbance which commonly occurs in haemodialysis patients. Some factors contribute to insomnia in dialysis patients such as demographic, biological, psychological, lifestyle, and dialysis factors. However, there are limited studies which investigate the relating factors of insomnia in haemodialysis patients in Indonesia. Purpose: This study aimed to analyze the relating factors of insomnia in haemodialysis patients in Semarang, Central Java, Indonesia. Methods: This study was a cross-sectional study which involved 102 samples recruited by consecutive sampling technique from two dialysis units in Semarang, Central Java. Data were collected by questionnaires and analyzed using Chi-square and multiple logistic regression to know the most relating factors of insomnia. Results: The result showed that insomnia occurred in 63 respondents (61.8%). Further analysis indicated that insomnia was related to anxiety (p=0.034, OR=2.36) and age (p=0.049; OR=1.75). There was no relationship between insomnia and the other factors such as gender, education level, occupation status, marital status, haemoglobin level, smoking and coffee consumption habit, and dialysis factor (period of dialysis). Moreover, anxiety was the most relating factors of insomnia among haemodyalsis patients. Conclusion: This study concluded that anxiety and age were independent factors related to insomnia. This study recommends that anxiety screening should be performed on haemodialysis patients. Anxiety in haemodialysis patients needs to be treated properly so that it will not develop into insomnia.


BACKGROUND
Patients with End-Stage Renal Disease (ESRD) will lose 85% of kidney function or more, and therefore, the body's function to maintain fluid and electrolyte balances will be altered.The function of excretion will not be adequate, hormonal function will be altered as well, and this will lead to uremic and azotemia (Smeltzer & Bare, 2002).Patients with ESRD need to follow kidney replacement therapies.One of the most common kidney replacement therapies is haemodialysis.
Dialysis is a process to filter metabolism waste in the body using a semi-permeable membrane (dialyzer) which functions as an artificial kidney (Thomas, 2002).The therapy is to promote alteration of fluid and electrolyte, and also to eliminate The normal sleeping pattern will also change individuals who get older (Merlino et al., 2006;Ohayon & Roth, 2003).This condition happens because there is a reduction of central nervous system function which cause the loss of reaction towards extrinsic, biorhythm, and decrease of relation substance (Ohayon & Roth, 2003).However, some previous studies showed that age was not related to insomnia (Al-Jahdali et al., 2010;Chen et al., 2006;Mucsi et al., 2004;Rosdiana, 2011).Furthermore, gender can also be a factor that contributes to insomnia (Al-Jahdali et al., 2010;Elder et al., 2008;Pai et al., 2007;Paparigopoulus et al., 2010).Female patients usually have multi-roles in their lives.When they are diagnosed with ESRD and have to undergo dialysis, their functional status decreases significantly causing insomnia (Al-Jahdali et al., 2010;Elder et al., 2008;Pai et al., 2007).On the other hand, the other studies showed different results (Mucsi et al., 2004;Rosdiana, 2011;Sabry et al., 2010).Another demographic factor such as education level was also generally related to insomnia but it was not in dialysis patients (Paparrigopoulos et al., 2010;Rosdiana, 2011).Such demographic factors which were not related to insomnia in dialysis patients are marital status and occupation (Rosdiana, 2011).Overall, there were different results related to the correlation between demographic factors and insomnia among haemodialysis patients.
Insomnia also mostly occurrs in patients with smoking and coffee consumption habit (Merlino et al., 2006).Smoke in cigarette contains nicotine which is a stimulant to keep the smokers awake and alert.Moreover, caffeine is related to prevent the release of adenosine.Caffeine causes an increase in norepinephrine, epinephrine, dopamine, and serotonin which keep individuals alert (Chen et al., 2006).However, some studies showed that these habits were not related to insomnia (Al-Jahdali et al., 2010;Rosdiana, 2011;Sabbatini et al., 2002;Sabry et al., 2010).Moreover, anemia is a possible condition that will cause patients to get sleepy feeling and fatigue during the day (Danielle et al., 2017;Pai, et al., 2007;Sabry et al., 2010) though some studies showed different results (Al-Jahdali et al., 2010;Mucsi et al., 2004;Rosdiana, 2011).Period of dialysis also contributed to insomnia among dialysis patients (Ahmed & Gehan, 2014;Rosdiana, 2011;Sabbatini et al., 2002).These studies showed that patients with more than 12 months on dialysis were at risk to have sleep disturbance such as insomnia.Other studies showed that period of dialysis was not related to insomnia (Chen et al., 2006;Mucsi et al., 2004).From the various findings above, it can be concluded that the correlation between lifestyle, anemia, a period of dialysis, and insomnia still lacks of evidence.
Nurses' understanding regarding insomnia in patients undergoing haemodialysis is an important factor for effective nursing care.Unluckily, some contributing factors such as demographic factors (age, gender, education level, occupation status, marital status), biological factor (haemoglobin level), psychological factor (anxiety), lifestyle factors (smoking and coffee consumption habit), and dialysis factor (dialysis period) are lack of evidence to be related to insomnia.Nurses need to asses other factors as a routine screening of nursing care in dialysis patients.Therefore, it is important to investigate the relating factors of insomnia among patients with dialysis in Semarang, Central Java.The results of this study will help the health professionals provide the best nursing care to reduce insomnia.

PURPOSE
This study aimed to analyze the relating factors of insomnia among dialysis patients.In particular, the study aimed to: (1) identify insomnia in haemodialysis patient, (2) analyze the correlation between such potential factors as demographic factors (age, gender, education level, occupation status, and marital status), biological factor (haemoglobin level), psychological factor (anxiety), lifestyle factors (smoking and coffee consumption habit), and dialysis factor (period of dialysis) and insomnia, and (3) analyze the most relating factors of insomnia among haemodialysis patients.This research had obtained approval from the Ethics Committee of Dr. Kariadi Hospital and Faculty of Medicine, Diponegoro University.All respondents had signed an informed consent after receiving a clear explanation regarding this study.

The most relating factors of insomnia among haemodialysis patients
The results of this study showed that anxiety was more significant to yield insomnia than age in haemodialysis patients.Table 3 describes that anxiety was a dominant factor related to insomnia (OR=2.363)compared to age (OR=1.75).This meant that haemodialysis patients who suffered from severe anxiety had 2.36 times of risk to get insomnia compared to patients suffering from mild anxiety.Also, haemodialysis patients in the late adulthood had 1.75 times higher risk to get insomnia than patients in the other age groups.

DISCUSSION
The result of this study showed that more than a half of total respondents experienced insomnia (61.8%).It was similar with some previous studies which reported that the occurrence of insomnia among ESRD patients was high such as Sabry et al. (2010) and  2010) who found that about 65.9% and 60.8% of patients with kidney failure respectively experienced insomnia.The incident of insomnia in this study was higher than the previous studies (Rosdiana, 2011;Sabbatini et al., 2001).The high incidence rates of insomnia in this study are likely to be associated with nearly half of respondents experiencing severe anxiety and in late adulthood, where these conditions were reported to have a significant association with incidence of insomnia (Merlino et al., 2006;Ohayon & Roth, 2003;Paparrigopoulos et al., 2010;Rosdiana, 2011;Sabry et al., 2010).
Insomnia highly occurred among dialysis patients because most patients have some syndromes of sleep disturbance related to their health conditions (uremia, excessive fluid intake, imbalanced electrolytes, and hypoalbuminemia) such as restless leg syndrome, obstructive sleep apnea syndrome, and shift-wake sleep disorder (Szentkiralyi et al., 2009).Being unable to maintain sleep and inadequate sleep will cause dialysis patients to wake up early before having enough sleep.This condition will cause patients to get some consequences such as sleepy feeling during the day, depression, lack of energy, cognitive disturbance, memory disturbance, cranky, psychomotor disturbance, alert and decreased concentration (Szentkiralyi et al., 2009;Unruh et al., 2011).Therefore, the quality of life among ESRD patients with insomnia will also decrease (Elder et al., 2008;Ishak et al., 2012;Novak et al., 2006;Szentkiralyi et al., 2009;Unruh et al., 2011).However, assessment of sleep quality, preferably with polysomnography, is necessary to confirm our results.Interventional studies for the management of sleep disorders in haemodialysis patients are recommended to do in the next study.This result also implies that routine screening of insomnia in nursing care in haemodialysis patients need to be regularly applied so that nurses can provide appropriate interventions directly to patients.
The results indicated that anxiety and age were related to insomnia while the other factors such as gender, education, occupation, marital status, life Style, hemoglobin level, and period of dialysis were not related to insomnia.Furthermore, anxiety was the most significant factor relating to insomnia.
Nurse Media Journal of Nursing, 8(1), 2018, This study found that almost half of respondents experienced severe anxiety.This result was a little higher than Lee et al. (2013) which reported that 27.6% of patients with dialysis felt anxious.However, this result was lower than Vasilopoulou et al. (2015) which reported that 47.8% of patients with haemodialysis had high anxiety levels.Stress and anxiety are parts of daily life.According to Reinhardt (2001), well adaptation towards stress would decrease anxiety.On the contrary, patients who are not able to manage their stress would find difficulty in their daily function.Patients with long term dialysis used to feel worried regarding the uncertainty of their condition in the future.They also face a financial problem, unable to maintain their job, loss of sexual desire, impotence, depression, and fear of death (Coccossis et al., 2008).
Feroze et al (2010) reported that more than 70% of patients with dialysis experienced depression or anxiety.However, they were not aware to seek for medical help for their condition.Physicians and nurses in the dialysis unit, who are not experts in mental health, often failed to recognize the signs and symptoms, including somatic complaints related to psychological distress (anxiety and depression).Thus, those conditions went undiagnosed.A study reported that anxiety is one of the factors which causes suicide attempt in patients with dialysis and is closely related to physical comorbidity such as low quality of life and weakness (Lee et al., 2013).Stress or anxiety in patients with dialysis would initiate the sympathetic nervous system to release catecholamine, glucagon, and cortisol-steroid hormones (Feroze et al., 2010).These hormones would alter center nervous system and can cause frustration, shortness of breath, hypertension, and muscle strain.Furthermore, those hormones would stimulate reticular activating system (RAS) function which manages all body cycles, i.e., sleep pattern, sleep latency, and sleep efficiency (Krystal, 2012;Paparrigopoulos et al., 2010).
This study also indicated that anxiety was the most significant factor relating to insomnia in which haemodialysis patients who suffered from severe anxiety had 2.36 times of risk to get insomnia compared to patients suffering from mild anxiety.This result is in accordance with many studies showing that anxiety as a psychological problem which can cause insomnia in haemodialysis patients (Elder et al., 2008;Rosdiana, 2011;Sabry et al., 2010).The relationship between anxiety and insomnia is reciprocal, in which patients who have insomnia would have anxiety.On the other hand, those who feel anxious would get insomnia or sleep disturbance.Krisytal (2012) supported this result, saying that the increase in anxiety is two times higher than those who obtain enough sleep.On the other hand, it was reported that a sleep disturbance (difficulty of sleeping or staying asleep) affected over half of those with generalized anxiety disorder (Krisytal, 2012).
Anxiety is a trigger of chronic insomnia.There are many patients who feel anxious before they get to sleep since they are afraid of being unable to sleep.They will get the consequence in the following day when they do not get enough sleep.The increase of anxiety will decrease "arousal" when "arousal state" should have decreased, and this will decrease the chance to sleep, hence it will create a loop or cycle of insomniaanxiety (Nutt, Wilson, & Paterson, 2008).Based on the phenomena, it is very crucial for nurses in the dialysis unit and medical team to perform a screening regarding anxiety and insomnia, because these two things influence each other and will decrease patients' Nurse Media Journal of Nursing, 8(1), 2018, quality of life in general.Nurses can detect anxiety and insomnia by performing a comprehensive assessment, not only covering the patients' biological factor, but also the psychological, social, and spiritual aspects.After a diagnosis is determined, professional nurses should be able to perform anxiety management and constructive coping development to prevent psychological disturbance and to prevent insomnia.
The result showed that insomnia highly occurred in late adulthood patients.This finding is in line with some previous studies which reported that insomnia was experienced by elderly patients (Merlino et al., 2006;Ohayon & Roth, 2003).This study also reported that age was related to insomnia.This result is in line with a study by Merlino et al. (2006) which reported that age was a significant independent predictor for patients with ESRD who have insomnia condition (p=0.001).However, some previous studies showed that age was not related to insomnia among haemodialysis patients (Al-Jahdali et al., 2010;Chen et al., 2006;Mucsi, et al., 2004;Rosdiana, 2011).Normal sleep pattern would also change especially in individuals who get older (Merlino et al., 2006;Ohayon & Roth, 2003).This condition happens because there is a reduction of central nervous system function which is caused by the loss of reaction towards extrinsic, biorhythm, and decrease of relation substance (Ohayon & Roth, 2003).
Late adulthood is generally considered to begin at about old age.Furthermore, National Sleep Foundation (2005) found that the majority of older people reported that they wake up a lot during the night and feeling fatigue in the morning.It becomes harder for men and women with ages more than 50 years to stay asleep throughout the night.In other words, aging seems to make certain aspects of sleep more difficult.There are certain biological changes that make sleep more difficult as getting older.For example, older adults can experience a shift in the circadian rhythm that causes them to become sleepy in the early evening and to wake up too early in the morning.Indeed, the 2005 NSF poll found that 64% of adults over 65 consider themselves a "morning person."Medical conditions and other sleep disorders can also cause insomnia such as gastrointestinal and respiratory problems.Patients ESRD with ascites mostly feel heavy breath when they sleep (Merlino et al., 2006).Sleep apnea in which a person briefly but repeatedly stops breathing during sleep can also cause insomnia.
The result of this study showed that insomnia occurred among the majority of female respondents.Al-Jahdali (2010) reported that female patients have a higher risk (1.5 times) to get insomnia compared to male patients.This probably happens because female patients have more emotions in dealing with situations.Female patients also usually have multi-roles in their lives.Therefore, when they are diagnosed with ESRD, physical alteration and have to undergo dialysis, their functional status decrease significantly (Elder et al., 2008;Pai et al., 2007).Guilt and threaten in self-esteem could be the results of the alteration in roles and responsibility in female patients with ESRD (Elder et al., 2008;Paparigopoulus et al., 2010).Female patients usually have multiroles in their lives, and when they are diagnosed with ESRD, physical alteration and have to undergo dialysis, their functional status decrease significantly and can cause insomnia.These conditions lead to anxiety and moreover to depression.Thus, it is understandable that almost half of female respondents suffered from severe anxiety (Al-Jahdali et al., 2010;Elder et al., 2008;Pai et al., 2007;Sabry et al., 2010).Although the Nurse Media Journal of Nursing, 8(1), 2018, early test showed that insomnia often happened in female patients, a further statistical test yielded that there was no relationship between insomnia and gender.This result was supported by two previous studies which found no significant relationship between gender and insomnia (Mucsi, et al., 2004;Sabry et al., 2010;Rosdiana, 2011;).In this study, there was evidence that anxiety was the most significant factor related to insomnia.Not only women but also men can have a bad feeling caused by their health condition and maybe change their lives a lot, such as loss of job, divorce, etc.
The result showed that insomnia occurred in more than a half of respondents with high education level.However, this factor was not related to insomnia in dialysis patients.Education level is generally related to insomnia as a coping source and possible condition but it was not in dialysis patients (Paparrigopoulos et al., 2010;Rosdiana, 2011).It is in contrast with the health behaviors in which patients with high education level can obtain information for self-care management to prevent insomnia (Notoatmojo, 2014).This phenomenon happens because it is not only education level which supports capability of health care behaviors but also motivation (Lee et al., 2013).Patients with chronic kidney disease can be getting bored to manage their self-care even they have high education level.As a result, they can experience insomnia.Furthermore, insomnia may also due to the complexity of life in people with high education level, and sometimes it can cause stress and not enough time for sleep.The quality of their activities might be lower than they usually expect.Many patients with high education level have to cease their job since they experience much physical distress and have to adapt with dialysis schedule.The situation will make them bored, helpless, feel useless and then lead to anxiety and insomnia.
The result of this study showed that insomnia mostly occurred in unemployed respondents.In other words, occupation was not related to insomnia among dialysis patients in this study.It is congruent with the result of a previous study which found no significant correlation between occupation and insomnia (Rosdiana, 2011).If ESRD patients are still doing their work, it can make them exhausted and have a high risk to get insomnia.Also, insomnia may be caused by the complexity of life among employed people which can lead to stress and inadequate sleep.However, if haemodialysis patients are not doing some work for their lives, it also can also make them frustrated and have high risk to get insomnia (Ahmed & Gehan, 2014;Elder et al., 2008;Vasilopoulou et al., 2015).
The result showed that insomnia occurred more often in respondents who were married compared to those who were not.This result is on the opposite with Paparrigopoulos et al. (2010) which reported that Odd Ratio for insomnia in unmarried patients was high.A spouse will help a patient, and a spouse can be a coping resource in dealing with the stressor.However if the support from a spouse is not adequate and the family initiates conflict related to patient's health problem, anxiety will increase (Xhulia et al., 2015;Reinhardt, 2010).Further analysis revealed that there was no relationship between marriage and insomnia.This result was in line with Al-Jahdali et al. (2010) and Rosdiana, (2011) which reported that insomnia in patients was not related to marital status.Married person may also have problems that can cause them to have insomnia (Al-Jahdali et al., 2010;Rosdiana, 2011) Nurse Media Journal of Nursing, 8(1), 2018, In this study, respondents who did not smoke and have coffee consumption habit experienced severe insomnia higher than those who had those habits.This result was supported by Al-Jahdali et al. (2010) who reported that there was no relationship between smoking-coffee consumption habit and insomnia.This finding was quite surprising because of some previous studies reported differently (Merlino et al., 2006).Insomnia mostly occurred in patients with smoking and coffee consumption habit.Smoke in cigarette contains nicotine which is a stimulant to keep the smokers awake and alert.Moreover, caffeine is related to prevent the release of adenosine.Caffeine causes the increase of norepinephrine, epinephrine, dopamine, and serotonin which keep individuals alert (Mucsi et al., 2014).Merlino et al. (2006) reported that smoking habit has a significant relationship with and an independent predictor of insomnia.However, this study concluded that there were no relationships between smoking habit and coffee consumption with insomnia.This result might be caused by the low sample size of respondents who had smoking and coffee consumption habits.
The number of respondents with anemia in this study was far more than those without anemia.This result is almost the same with a study by Ishak et al. (2012) which reported the number of patients with dialysis who suffered from anemia (Hb<11gr/100ml) was 88.7%.Similar result was also identified in some other studies (Chen et al., 2006;Danielle et al., 2017;Pai et al., 2007;Sabry et al., 2010).Anemia in patients with chronic kidney failure has started since the beginning of the disease process.Anemia is always found in patients with ESRD (80-95%), except in patients with chronic kidney disease because of polycystic.The main factor which causes anemia in patients with ESRD is the deficiency of erythropoietin (EPO).This happens because of the alteration of cells producer of EPO (peritubular cells) in the kidney (Smeltzer & Bare, 2002).However, in further analysis in this study, it was revealed that there was no relationship between hemoglobin level and insomnia.The sample size which was small might be the reason of this insignificant relationship.Although statistically insignificant, the condition might be clinically significant.
The result showed that insomnia mostly occurred in patients who had undergone longterm dialysis than in those who just recently had dialysis.This result is in line with some previous studies (Ahmed and Gehan, 2014;Pai et al., 2007;Sabbatini et al., 2002;Rosdiana, 2011).Sabbatini et al. (2002) reported that the increase of insomnia in patients with long-term dialysis is due to the progressive nature of ESRD's symptoms, disease complications and suffering from other diseases related to the kidney.Patients with long-term dialysis often experience complications from ESRD, for example, cardiovascular and neurological problems.According to Coccossis et al. (2008), patients with long-term dialysis often suffer from insomnia due to increased physical and social deficits.The patients' QoL also decreases along with the alteration of their psychological or mental aspect.Sabbatini et al. (2002) reported that there was a significant increase in insomnia occurrence in patients with long-term dialysis (p<.005).However, this study reported different finding that there was no relationship between insomnia occurrence and the period of dialysis.The sample size which was small might be the reason of this insignificant relationship.Although statistically insignificant, the condition might be clinically significant.The phenomenon showed that the longer the Nurse Media Journal of Nursing, 8(1), 2018, patients undergoing dialysis, the higher the complications and insomnia occurrence would be.

CONCLUSION
Insomnia occurred in many patients undergoing dialysis.Anxiety was a factor which was associated with insomnia.Patients who had severe anxiety had 2.63 times higher risk to get insomnia rather than those with mild anxiety.The age was also related to insomnia occurrence in which patients in late adulthood had 1.75 times higher risk to get insomnia than patients in the other age.Such other factors as gender, education level, occupational status, marital status, lifestyle (smoking and coffee consumption habit), hemoglobin level, and dialysis period were not related to insomnia occurrence.This study recommends that anxiety screening should be performed to patients with dialysis.Anxiety in dialysis patients need to be treated properly so that it will not develop into insomnia.

Table 2 .
Correlation between the relating factors and insomnia (n=102)