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EFFECTS OF STRUCTURED SLEEP EDUCATION ON BLOOD PRESSURE CONTROL AMONG ADULT HYPERTENSIVES ATTENDING JOS UNIVERSITY TEACHING HOSPITAL GENERAL OUT PATIENT CLINIC, JOS.
Summary
Background: Sleep is one of the most basic elements of human lives. It improves physical and mental abilities. Sleep related problems are important public health concerns and there exists growing evidence that poor sleep quality is associated with increased cardiovascular complications of which hypertension is one.66,83,93 There is a downward trend in sleep quality; and poor sleep quality has been noticed to be more common among hypertensive patient than the general population. 94 This study was therefore, designed to look at the effect of improving sleep quality on blood pressure.
Objective: To determine the effects of structured sleep education on blood pressure control among adult hypertensive patients.
Study design/Setting: A randomized controlled trial involving 212 patients with hypertension, aged 18 years and above presenting in the General Outpatient Clinic of the Jos University Teaching Hospital.
Method: Participants were randomly allocated to the control and the intervention groups. The intervention groups were offered structured sleep education on sleep hygiene that was delivered in a structured format to the participants. Data collected from the participants include socio-demographic data, medical and family history, sleep quality was assessed using the Pittsburg’ sleep quality index (PSQI) questionnaire. Focused physical examination was done. Participants were followed up monthly over 12 weeks during which measurements were repeated.
Results: Majority (64.6%) of the participants had poor sleep quality with PSQI score of
6.86±3.52. Most (75.9%) of them had short sleep and slept less than seven hours per night.
The mean systolic and diastolic blood pressure in the intervention group reduced from 145.19±21.00mmHg to 127.50±16.19mmHg and 91.66±11.66mmHg to 80.00±6.76mmHg
respectively after intervention. This was statistically significant. (p=0.001). This study found a positive relationship between sleep quality and hypertension.
Conclusion: Structured sleep education administered along with routine medical care for hypertension led to reduction in blood pressure and improvement in the quality of sleep.
TABLE OF CONTENTS
Title page---------------------------------------------------------------------------------------- i
Declaration-------------------------------------------------------------------------------------- ii
Certification------------------------------------------------------------------------------------- iii
Dedication--------------------------------------------------------------------------------------- iv
Acknowledgement----------------------------------------------------------------------------- v
Table of contents------------------------------------------------------------------------------ vi
List of figures----------------------------------------------------------------------------------- x
List of table ----------------------------------------------------------------------------------- xi
List of Abbreviations-------------------------------------------------------------------------- xii
Summary---------------------------------------------------------------------------------------- 1
CHAPTER ONE: INTRODUCTION
1.1 Background Information ---------------------------------------------------- 3
1.2 Statement of the problem -------------------------------------------------- 9
1.3 Objectives of the study-------------------------------------------------------- 13
1.4 Significance of the study -------------------------------------------------- 13
CHAPTER TWO: LITERATURE REVIEW
2.1 Introduction ----------------------------------------------------------------------- 14
2.2 Epidemiology----------------------------------------------------------------------- 15
2.3 Pathophysiology of hypertension --------------------------------------------- 22
2.3.1 Pathophysiology of sleep and hypertension---------------------------------- 23
2.4 Cardiovascular and hypertension risk factors----------------------------------- 25
2.5 Subclinical disease and cardiovascular markers------------------------------------- 27
2.6 Cardiovascular morbidity and mortality---------------------------------------- 28
2.7 Sleep quality------------------------------------------------------------------------ 30
2.7.1 Sleep and cardiovascular risk------------------------------------------------- 33
2.7.2 Sleep quality and hypertension----------------------------------------------- 36
2.7.3 Sleep duration and hypertension---------------------------------------------- 38
2.7.4 Effects of sleep on blood pressure control---------------------------------- 40
2.8 Treatment of hypertension----------------------------------------------------- 43
2.8.1 Non-pharmacologic treatment of hypertension----------------------------- 43
2.8.1.1 Lifestyles measures-------------------------------------------------------------- 43
2.8.1.2 Sleep education------------------------------------------------------------------- 43
2.8.2 Pharmacologic treatment--------------------------------------------------------- 44
2.9 Prevention-------------------------------------------------------------------------- 46
CHAPTER THREE: METHODOLOGY
3.1 Study setting-------------------------------------------------------------------------- 48
3.2 Study population--------------------------------------------------------------------- 48
3.3 Study period-------------------------------------------------------------------------- 48
3.4 Eligibility ------------------------------------------------------------------------------ 49
3.4.1 Inclusion criteria-------------------------------------------------------------------- -- 49
3.4.2 Exclusion criteria--------------------------------------------------------------------- 49
3.5 Sampling size determination------------------------------------------------------- -- 49
3.6 Ethical consideration----------------------------------------------------------------- 50
3.7 Instrument of data collection------------------------------------------------------- -- 50
3.8 Study design-------------------------------------------------------------------------- -- 51
3.9 Study protocol------------------------------------------------------------------------- 51
3.10 Method of data analysis------------------------------------------------------------- -- 53 CHAPTER FOUR: RESULTS
4.1 Introduction---------------------------------------------------------------------------- 56
4.2 Baseline characteristics of the study participants-------------------------------- --- 58
4.3 Personal characteristics of the study participants-------------------------------- 61
4.4 Family characteristics---------------------------------------------------------------- 62
4.5 Sleep quality before and after intervention among the study group---------- 63
4.6 Assessment of sleep quality in study groups--------------------------------- 64
4.7 Participants mean blood pressure changes before and after intervention----- -- 68
4.8 Report of the mean blood pressure changes over the study period---------------- 69
4.9 Reduction in blood pressure---------------------------------------------------------- 70
4.10 Logistic regression analysis of the association between PSQI, Systolic BP
and Diastolic BP in relation to study group------------------------------------- ---- 72
CHAPTER FIVE:
Discussion
5.1 Socio-demographic characteristics of the participant------------------------------ 74
5.2 Sleep quality------------------------------------------------------------------------------ 77
5.3 Sleep duration---------------------------------------------------------------------------- 79
5.4 Effect of structured sleep education on blood pressure-------------------------- 80
5.5 Strength of the study ------------------------------------------------------------------- 82
5.6 Limitations of the study----------------------------------------------------------- --- 82
5.7 Relevance of the study to family medicine---------------------------------------- 83
5.8 Conclusion----------------------------------------------------------------------------- 83
5.9 Recommendations---------------------------------------------------------------------- 84
5.10 Suggestion for further studies-------------------------------------------------------- 86
References------------------------------------------------------------------------------------ ---- 86
Appendix ---------------------------------------------------------------------------------------- 102
CHAPTER ONE
INTRODUCTION
1.1 BACKGROUND INFORMATION
Hypertension (HTN) is the most common cardiovascular disease and one of the reasons patients visit Family Physicians.1 It is defined as systolic blood pressure greater than or equal
to 140 mm Hg or diastolic blood pressure greater than or equal to 90 mmHg.2
The World Health Organization(WHO)’s report on non-communicable diseases in 2008 showed that approximately 40% of adults aged 25 and above had been diagnosed with hypertension globally; the number of people with the condition rose from 600 million in 1980 to one billion in 2008.3 By 2025, the number of people with hypertension(HTN) will increase by about 60% to a total of 1.56 billion as the proportion of elderly people will increase
significantly.1
Approximately 30% of adult Americans have hypertension and 7% of adults with HTN have not been told by their physician that they have high blood pressure(HBP).4 The National Health and Nutrition Examination Survey(NHANES) report of 2005 in the United States found that in the population aged 20 years or older, the prevalence of prehypertension[Systolic Blood Pressure(HBP), 120-139 mm Hg; Diastolic Blood Pressure(DBP), 80-99 mm Hg] , is 41.9 million in men and 27.8 million women. For stage 1 hypertension (SBP, 140-159 mm Hg; DBP, 90-99 mm Hg), it is12.8 million men and 12.2 million women while in stage 2 hypertension (SBP ≥160 mm Hg; DBP ≥100 mm Hg) the prevalence for men and women are 4.1 million and 6.9 million respectively.4
According to the Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7 ), systolic blood pressure of greater than 140 mm Hg is a more important cardiovascular disease risk factor than diastolic blood pressure in individuals older than 50 years of age.2 But current reports by the Eighth report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-8) states that systolic blood pressure of greater than 150 mmHg is an important cardiovascular risk factor in persons aged 60 years or older, and DBP of >90 mmHg in those less than 60 years.5 Black individuals have a higher prevalence and incidence of hypertension than white persons.6 The World Health Organization (WHO) 2010 Global report on non-communicable diseases showed that the prevalence of hypertension was highest in the African region.3 They reported a prevalence of 46% for both sexes in those aged 25years and above, while the lowest prevalence of raised blood pressure was in the Americans, with 35% for both sexes.3 The reason for the high prevalence in Africa is due to the influence of the low income and socioeconomic status.3 The report also showed that age is an important risk factor for hypertension.3 Reports by the National Centre for Health and Statistic in the United State of America(USA), JNC-7, JNC-8 and WHO confirms this with
advancing age.2, 3, 5, 7
In the West African sub-region, the prevalence of hypertension between 1970 and 2009 in Ghana was in the range of 19% to 48%, and in 2007, hypertension was said to be the second
leading cause of outpatient morbidity in the Greater Accra region.8, 9 In Nigeria and other developing countries there has been an increase in the prevalence of hypertension. A 2010 report by WHO put the prevalence of high blood pressure in Nigeria at 42.8% in both sexes.3 A study in South-South semi-urban Nigeria showed that 47.0% of the study population had a raised BP >140/90mmHg.10 In a meta analysis in South-West Nigeria the prevalence of hypertension ranged from a minimum of 12.4% to a maximum of 34.8%.11 In Jos, NorthCentral, the prevalence of hypertension was 36.6%.12 The rising prevalence of hypertension in Nigeria and other developing countries is due to change in diet and lifestyles and improved access to health facilities for early screening and detection of hypertension and due to adoption of western lifestyle and diet.12
Because of the increasing prevalence of hypertension, the World Health Organization declared April 7, 2013 as a year of hypertension with the theme "silent killer, global public health crisis." with the slogan "healthy heart beat, healthy blood pressure, while the World Health Day for hypertension is celebrated on the 17th of May annually."3 Report by WHO,
2010 showed that high-income countries have a lower prevalence of hypertension which was 35% as compared to that of low-income countries which was 40%.3
The classification of blood pressure is the same both in JNC-7 and JNC-8 as shown in appendix A. The only difference is that in JNC-8 the definition of pre-hypertension and
hypertension were not addressed.2, 5
The risk factors for high blood pressure are classified into modifiable and non-modifiable. The non-modifiable factors include advancing age, genetic predisposition and race, while the modifiable risk factors include obesity, excessive alcohol consumption, psychological stress,
short sleep duration, sedentary lifestyle, unhealthy diet.2, 3, 6
Worldwide hypertension has been estimated to cause 7.5million deaths, about 12.8% of the total of all annual death in adults.3 It is a major risk factor for coronary heart disease and ischaemic as well as haemorrhagic stroke.3 The report by JNC-7 showed that in some age groups, the risk of cardiovascular disease doubles for each incremental increase of 20/10mmHg of blood pressure, starting as low as 115/75mmHg.2
In treating high blood pressure, a study by Egan showed that maintaining systolic blood pressure and diastolic blood pressure so that they are below 140/90mmHg is associated with a reduction in cardiovascular complications.13 Treatment of high blood pressure using the JNC7 algorithm involves both lifestyle modifications and the use of right combination of drugs.2
This algorithm is similar to JNC-8, except that drug therapy for JNC-7 is from five classes while for JNC-8 is from four classes.3, 5 A population based policy and systems change approach which involves lifestyle changes in population, that decreases the BP level in the general population by even modest amounts has the potential to substantially reduce
morbidity and mortality or at least delay the onset of hypertension.2, 14 For instance, it has been estimated that a 5mmHg reduction of SBP in the population would result in a 14 percent overall reduction in mortality due to stroke, a nine percent reduction in mortality due to coronary heart disease (CHD), and a seven percent decrease in all-cause mortality.2
When high blood pressures are not controlled, complications such as coronary heart diseases, stroke, heart failure, peripheral vascular disease, renal impairment, retinal haemorrhage and visual impairment can occur.3
One of the risk factors for poor BP control in hypertension is insufficient sleep and poor sleep quality.15, 16 Sleep is one of the most important elements of human lives and improves the physical and mental abilities.17 Sleep quality is one of the dimensions of sleep, other dimensions include sleep duration, which is the total amount of sleep obtained per 24hours; sleep efficiency or continuity which is the ease of falling asleep and returning to sleep.18 Others include timing of sleep, ability to maintain attentive wakefulness (alertness/sleepiness)
and satisfaction.18 Sleep quality is the assessment of sleep as either good or poor.18 It measures both the quantitative and the qualitative component of sleep.19 Using the Pittsburg Sleep Quality Index (PSQI), good sleep is defined as PSQI score of five or less, while poor sleep is defined as score of greater than five.19 Sleep duration is also used to define sleep quality. Normal sleep is defined as sleeping between six to eight hours, while sleeping less than six or more than eight hours is referred to as short and long sleep respectively and
represent poor sleep quality.19, 20, 21 Complaints about sleep quality are common in epidemiological surveys and indicate that 15-35% of adult population complain of frequent
sleep quality disturbance.19
Study by Bruno and colleagues, showed that resistant hypertension is associated with poor sleep quality, increased sleep latency and reduced sleep efficiency.22 Short sleep duration is
associated with elevated blood pressure and the risk of other cardiovascular diseases.13, 20, 22, 24 Insufficient sleep may increase the risk of hypertension and cardiovascular disease through effects on sympathetic nervous system activation by alteration of the hypothalamus-pituitaryadrenal axis leading to secretion of cortisol and renin-angiotensin system and augmented
systemic levels of inflammation such as elevation of C-reactive protein levels.3, 20 However, there are evidences that a good night sleep is associated with better control of blood
pressure.19,22-24 Blood pressure declines to its lowest levels during nighttime sleep when the parasympathetic activity is highest. Consequently, the arteries of people with short sleep duration benefit the least from this positive effect. Indeed, part of the association was explained by adjusting for BMI, total HDL cholesterol ratio, systolic blood pressure, and prevalence of type 2 diabetes.25, 26 Therefore, there is the need to establish the relationship between sleep quality and blood pressure control in hypertensive patients.
Sleep is increasingly recognized as important to public health, with sleep insufficiency linked to motor vehicle crashes, industrial disasters, and medical and other occupational errors27 It can even contribute to cardiovascular disorders and mortality.28 Activation of the sympathetic nervous system is an important mechanism that links sleep disorders with combined systolic and diastolic hypertension, which is common in the middle-aged hypertensive patients.29 Individuals with both shorter and longer sleep had an increased risk of hypertension.20, 21 Short sleep and long sleep duration are also associated with weight gain, obesity, type 2
diabetes, cardiovascular disease, and premature mortality.13, 21
Technological advancements have afforded modern society with 24-hour work operations, trans-meridian travel and exposure to a myriad of electronic devices such as televisions, computers and cellular phones that keep people awake most of the times leading to shorter sleep duration.30 There is a growing evidence which suggests that these advancements take their toll on human functioning and health through their damaging effects such as increase in
sedentary lifestyle and its effect on sleep quality, quantity and timing.30
The factors that affect sleep duration are socio-economic, occupation and race/ethnicity.13 Studies showed that usual sleep duration above or below the median of seven to less than eight hours per night is associated with an increased prevalence of hypertension, particularly at the extreme of less than six hours per night indicating the effect of sleep duration on blood
pressure.21, 23, 27 Short sleepers according to Knutson et al were defined as those reporting < 6 hours of sleep in their time diary. They also showed that percentages of short sleepers ranged from 7.6% in 1975 to 9.3% in 2006.31 The study showed that the highest proportion of short sleepers was observed in the 1998-99 data, which had the smallest sample size.31 A Study by Egan and the report by the National Sleep Foundation in US showed that sleep duration has decreased in the general population over the last 30 years.22, 32 It also reported an increase from 12% to 16% of subjects sleeping less than 6 hours on workdays confirming the reduction in the sleep duration among the general population.32 Other studies also showed
that poor sleep quality and sleep disorders can affect blood pressure and vice versa.13, 32 This is because decrease sleep duration and sleep quality leads to prolonged exposure to activated sympathetic nervous system which could accentuate structured remodeling and augment renal sodium retention.22 Sleep restriction and sleep disorders are both associated with increased prevalence and incidence of hypertension.32 Sleep deprivation studies in normotensive
subjects have demonstrated that BP was increased after nights of sleep restriction.32
All the major physiological changes are influenced by sleep.33 There are two stages of sleep: the non rapid eye movement(NREM) and the rapid eye movement(REM),each marked by
characteristic physiologic changes.33, 34 The Non rapid eye movement(NREM) sleep
constitutes about 75 to 80% of total sleep time in adults.34 It consists of 4 stages in increasing depth of sleep.34 Stage one is the state between wakefulness and sleep, the muscle are active and the eye roll around slowly. It is the period of transition from a relatively unsynchronized beta and gamma brain waves to more synchronized but slower alpha and then to theta
waves.22, 33, 34 Stage two is characterized by further decrease in muscle activity and conscious awareness of the outside world, the theta waves predominate and is characterised by sleep spindles and k- complexes. In stage three, the individual is less responsive to the outside environment and unaware of any sound or stimuli and blood pressure, neuronal activity, temperature, heart and respiratory rates are all at their lowest level. This stage is characterised by delta brain wave or slow wave sleep with some sleep spindles fewer than in stage two.
Stage four is characterized by delta wave that exceed more than 50% of the total wave. Stages three and four are referred to as deep or delta sleep because arousal threshold is high;
people may perceive these stages as high-quality sleep.28, 33
Cardiovascular changes, which include the decrease in blood pressure and heart rate, occur during the NREM particularly during the slow-wave sleep.33 The REM sleep follows each cycle of NREM sleep. It is characterized by low-voltage fast activity on the EEG and postural muscle atonia. Respiratory rate and depth fluctuate dramatically. Most dreams occur during REM sleep. Most adults sleep 7–8 hours per night, although the timing, duration, and internal structure of sleep vary among healthy individuals and as a function of age.33 Report by European Society of Hypertension said that Blood pressure (BP) and heart rate (HR) decrease throughout NREM sleep, particularly during slow-wave sleep (dipping pattern).34 However, good sleep hygiene has been found to reduce blood pressure.35 The move toward the use of non-drug approach to improved sleep is due to the unwanted side effects of drugs.17
1.2 STATEMENT OF THE PROBLEM
It is worthy of note that not all hypertensive patients who are on drugs have achieved blood pressure control. In a study on prevalence of hypertension in Lagos, it was found that control of hypertension was poor in 78.79% of the subjects possibly because of low earning capacity of these subjects.36 and the prevalence was put at 25%.36 A study in Zaria, North Western Nigeria showed that only 12.4% of patients attending Tertiary Health Centre had their blood pressure controlled while only 67.3% reported compliance with their medication.37 In Ilorin, North Central Nigeria Blood Pressure control is still unacceptably poor among hypertensive Nigerians. This may not be unconnected with the poor knowledge of high blood pressure and adverse practices by the patients.38 Because of these, many studies have been carried out to find ways of improving blood pressure control. These include lifestyle modifications and
improving quality of sleep.2, 39, 40 Sleep plays an important role in the life of human being, and that is why the National Sleep Foundation suggested that most adults need 7–9 hours of sleep per night, although individual variations exist.41 It also reported that 35.3% of Americans are having less than 7 hours of sleep on average during a 24-hour period. Studies have shown a relationship between sleep duration and hypertension.27 In Japan both long and short habitual sleep duration were significantly associated with high blood pressure values and hypertension occurrence in Japanese male subjects.34 Other studies showed that sleeping 5hours or less per night was associated with a 60% increased risk of incident hypertension and subjects sleeping more than 9 hours per night had 30% higher prevalence of
hypertension.20, 23, 34
Further studies carried out establish the relationship between sleep and hypertension.20, 23, 27, 32, 33 These studies showed that usual sleep duration above or below the median of 7 to less than 8 hours per night is associated with an increased prevalence of hypertension, particularly
at the extreme of less than 6 hours per night.20, 23 Short term experimental sleep restriction for as little as one night has been reported to increase blood pressure in both healthy and hypertensive subjects.23 In a natural experiment of sleep deprivation occurring in Japanese workers intermittently exposed to long shifts, in which sleep duration was curtailed to 3.6 hours compared to nights when sleep was reported to be 8 hours was associated with an average increase in systolic and diastolic blood pressure of 6 and 3mmHg respectively.20 Redline reported that after adjusting for numerous confounders, the odds of hypertension increased by approximately 70% and 20% for those reporting sleep duration of less than 6 hour and between 6 and 7 hour per night respectively.20 Those reporting more than 9 hours of sleep per night had an approximately 30% increased odds of hypertension.20 A decreased odds of hypertension was also observed in association with improved sleep efficiency.20 Intervention studies are therefore needed to assess whether improving the quality of sleep will help to reduce blood pressure since in Nigeria there is no study on the effect of sleep on blood pressure control. Increasing evidence have suggested that adequate duration and quality
of sleep are important for overall health.42
A structured sleep education is aimed at improving the quality of sleep by educating the patients to practice good sleep hygiene. Sleep hygiene has been defined as those behaviors that are believed to promote and improve quantity and quality of sleep.43 This can be achieved by keeping a regular sleep schedule; avoiding stimulating activities (e.g., vigorous exercise) within 2 hours of bedtime; avoiding caffeine, nicotine, and alcohol in the evening; avoiding going to bed on a full or empty stomach; and sleeping in a dark, quiet, well-
ventilated space with a comfortable temperature.34, 44
Because chronic sleep loss has a cumulative effect on mental and physical well-being, potentially exacerbating depression, obesity, diabetes, and other chronic conditions, treatment of patients with chronic diseases might benefit from counseling about the importance of sufficient sleep.41
Several studies have been carried out on the relationship between sleep duration, sleep disorders and hypertension in other countries but only little is known about the effect of sleep on blood pressure control in my institution; the Jos University Teaching Hospital. 14, 15,
1.3 OBJECTIVES OF THE STUDY
General Objectives
To assess the effect of structured sleep education on blood pressure control with the view of incorporating it in the management of adult hypertensive patients attending the general outpatient clinic (GOPC) of the Jos University Teaching Hospital (JUTH)
Specific objectives
1.To determine the socio-demographic characteristics of the adult hypertensives presenting at GOPC of JUTH.
- To determine the sleep quality in the study population using the Pittsburg sleep quality index.
- To compare the blood pressure changes from baseline in the group of hypertensive patients who had structured sleep education and those without structured sleep education.
1.4 SIGNIFICANCE OF THE STUDY
This study is worth carrying out because studies in Zaria, Nsukka, Ilorin and Ife showed that
most hypertensive patients have not achieved good blood pressure control.36, 45, 46, 47 Hypertension has been shown to affect sleep quality and vice versa.16,22,32 Several studies have linked insufficient sleep and poor sleep quality to development of hypertension and their
effect on quality of life.14,16,24,27 Therefore, this research if found significant will help in the reduction of blood pressure among hypertensive patients by improving the quality of sleep among them and thereby improving their quality of life. Information from this study would be utilized in providing care and management of hypertensive patients. It will be incorporated into the lifestyle modifications approach in the management of high blood pressure in hypertensive patients to reduce the burden and cost of treating hypertension.
EFFECTS OF STRUCTURED SLEEP EDUCATION ON BLOOD PRESSURE CONTROL AMONG ADULT HYPERTENSIVES ATTENDING JOS UNIVERSITY TEACHING HOSPITAL GENERAL OUT PATIENT CLINIC, JOS.
