Journal of Gerontological Nursing

Feature Article 

Feasibility and Effects of Tai Chi for the Promotion of Sleep Quality and Quality of Life: A Single-Group Study in a Sample of Older Chinese Individuals in Hong Kong

Catherine Mei-Han Lo, RN, BN; Paul H. Lee, PhD

Abstract

Poor sleep in later life is a global issue that reduces many individuals’ quality of life (QOL). The purpose of this pilot study was to test the feasibility and effects of a simplified tai chi exercise intervention on sleep quality and QOL among Chinese community-dwelling older adults with poor sleep quality. This single-group, descriptive feasibility study included 34 individuals with poor sleep quality who agreed to participate in a 12-week tai chi intervention. Twenty-six individuals completed the program (23.5% dropout rate). Older adults with poor sleep quality who completed the intervention showed significant improvement in the Medical Outcomes Study Short Form-36 mental component and the Pittsburgh Sleep Quality Index global and component scores. The low recruitment and attendance and high dropout rates might be associated with participants’ age, gender, and sleep quality. Further long-term studies are required to examine the potential effects of the tai chi intervention. [Journal of Gerontological Nursing, 40(3), 46–52.]

Ms. Lo is former Assistant Professor, and Dr. Lee is Postdoctoral Fellow, School of Public Health, Department of Community Medicine, The University of Hong Kong, Hong Kong.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Catherine Mei-Han Lo, RN, BN, Flat D, 8/F Wah Kay House, 11 Yuk Wah Crescent, Kowloon, Hong Kong; e-mail: melo2963@yahoo.com.

Received: January 08, 2013
Accepted: June 07, 2013
Posted Online: November 07, 2013

Abstract

Poor sleep in later life is a global issue that reduces many individuals’ quality of life (QOL). The purpose of this pilot study was to test the feasibility and effects of a simplified tai chi exercise intervention on sleep quality and QOL among Chinese community-dwelling older adults with poor sleep quality. This single-group, descriptive feasibility study included 34 individuals with poor sleep quality who agreed to participate in a 12-week tai chi intervention. Twenty-six individuals completed the program (23.5% dropout rate). Older adults with poor sleep quality who completed the intervention showed significant improvement in the Medical Outcomes Study Short Form-36 mental component and the Pittsburgh Sleep Quality Index global and component scores. The low recruitment and attendance and high dropout rates might be associated with participants’ age, gender, and sleep quality. Further long-term studies are required to examine the potential effects of the tai chi intervention. [Journal of Gerontological Nursing, 40(3), 46–52.]

Ms. Lo is former Assistant Professor, and Dr. Lee is Postdoctoral Fellow, School of Public Health, Department of Community Medicine, The University of Hong Kong, Hong Kong.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Catherine Mei-Han Lo, RN, BN, Flat D, 8/F Wah Kay House, 11 Yuk Wah Crescent, Kowloon, Hong Kong; e-mail: melo2963@yahoo.com.

Received: January 08, 2013
Accepted: June 07, 2013
Posted Online: November 07, 2013

Global aging has prompted examination of sleep problems, which reduce quality of life (QOL) in many older individuals (Fok, Stewart, Besset, Ritchie, & Prince, 2010) and increase health care utilization. Up to 75% of older Asians experience sleep disturbance (Su, Huang, & Chou, 2004). The multifactorial (medical, psychological, sociodemographic, lifestyle) etiology of later-life poor sleep results in poor sleep initiation, maintenance, and increased daytime napping (Wong & Fielding, 2011). However, evidence for the predictive nature of these factors is heterogeneous.

Poor later-life sleep quality has negative physical and psychological effects, increasing the risk of respiratory symptoms, physical disability, falling, mortality, and suicide (Morphy, Dunn, Lewis, Boardman, & Croft, 2008). Insomnia is highly comorbid with later-life depression and other psychiatric disorders (Fok et al., 2010). Although sleep problems are effectively managed pharmacologically, long-term use of benzodiazepine agents in older adults is associated with increased falling risk, drug intolerance, and adverse central nervous system effects (van den Berg et al., 2009). Nonpharmacological approaches have reduced benzodiazepine agent use among older adults with insomnia (Kirkwood, 1999), but are expensive. Cost-effective alternatives, such as simple tai chi, should be explored.

Tai Chi

Tai chi, a traditional Chinese exercise with physical and meditational components involving slow movement and deep breathing, reduces mental stress and facilitates energy flow and balance. Tai chi is usually performed daily in the long term to improve health. It may alleviate sleep problems by improving stress-related factors (e.g., bodily pain, depression), improving QOL (Li et al., 2001; Song, Lee, Lam, & Bae, 2003; Su et al., 2004). Tai chi interventions have been used to improve older adults’ balance, flexibility, strength, and endurance to prevent falls (Taylor-Piliae, Haskell, Stotts, & Froelicher, 2006), alleviating depression, and indirectly improving sleep quality (Ni Mhaoláin et al., 2012). However, tai chi’s indirect physiological and psychological effects on sleep quality have not been fully examined. Randomized controlled trials among U.S. older adults found that 16- and 24-week tai chi interventions improved sleep quality more effectively than low-impact stretching (Wolf et al., 1996) and health education (Irwin, Olmstead, & Motivala, 2008). However, given previous studies’ small samples, differences in tai chi style and practice length, failure to examine ethnic and cultural differences, and inconclusive results, further research is required.

Despite tai chi’s popularity among Chinese older adults, its effects on sleep problems have not been reported. This low-cost, convenient exercise can be practiced independently, without equipment, after brief training. Its group nature is also socially beneficial. Tai chi is more culturally appropriate than Western physical exercise styles for Chinese older adults, which should increase its acceptability, efficacy, and cost effectiveness. The purpose of this pilot study was to test the feasibility and potential effects of a simplified tai chi exercise intervention on sleep quality and QOL among Chinese community-dwelling older adults with poor sleep quality.

Method

Design

A single-group descriptive approach was used in this study. All participants in this study received tai chi training for 12 consecutive weeks.

Sample

The participating university’s institutional review board approved this study. The first author (C.M.-H.L.) and three trained research assistants recruited older adults with poor sleep quality over a 4-month period in 2010 through community centers in Hong Kong. Once an individual expressed willingness to participate, his or her eligibility was assessed and a written consent was obtained. A total of 318 older adults were approached and 301 agreed to take part in the study. Using the following criteria, 234 (77.7%) eligible volunteers were identified: age 60 or older, living at home, without cognitive impairment, and global Pittsburgh Sleep Quality Index (PSQI) (Irwin et al., 2008) score ⩾5. Individuals with sleep apnea or receiving treatment for sleep disorders, including prescription medications, were excluded to avoid confounding effects. Only 34 (15%) older adults with poor sleep quality agreed to participate in the tai chi intervention; 26 completed the entire study period (12-consecutive-week intervention and 4-week follow-up assessment). These 26 participants comprised our final sample.

Tai Chi Intervention

In a community center accessible to the public, two certified instructors led the group exercise (12 weeks; three 1-hour sessions per week) based on 10-form easy tai chi (Wolf et al., 1996) following 10 to 15 minutes of low-intensity exercise. A research assistant kept attendance and watched for adverse effects.

Measures

Baseline data collected on all participants included demographics (age, gender, marital status, educational level, occupation, financial status [sufficient funds to meet daily expenses], and health history (number of chronic illnesses and perceived health).

The 19-item PSQI includes seven components: subjective quality, latency, duration, efficiency, sleep disturbances, sleep medication use, and daytime dysfunction (Irwin et al., 2008). Component (0 to 3) and global (0 to 21) scores were calculated; higher scores indicated poorer sleep quality (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989).

The well-validated Chinese (HK) version of the Medical Outcomes Study Short Form-36 (SF-36) has been used to examine QOL in Hong Kong (Lam, Gandek, Ren, & Chan, 1998). Its eight domains (physical functioning, role: physical [limitations due to physical health problems], bodily pain, general perceived health, vitality, social functioning, role: emotional [limitations due to emotional problems], mental health) are summarized by physical and mental component subscales (PCS and MCS).

Data Collection

Sleep quality and QOL were measured at baseline, 6 and 12 weeks, and 4 weeks postintervention using the PSQI and Chinese (HK) version of SF-36, respectively. Due to the low educational level among most of the participants, the nurse researcher and three trained research assistants helped fill out the questionnaires during the entire study period.

Data Analysis

Kolmogorov-Smirnov tests were performed to examine normality assumptions for PSQI and SF-36 domain scores. Because these assumptions were rejected for several variables, general estimating equation was used to measure tai chi’s effects on sleep quality and health-related QOL (SPSS version 19). P values ⩽0.05 indicated significance in all two-tailed tests. Cohen’s d coefficient was used to assess the intervention effect size (0.2 = small; 0.5 = medium; 0.8 = large).

Results

Participants

All participants (mean age = 73.45, SD = 6.43 years, age range = 62 to 85) were retired and most were women (82.4%), single/divorced/widowed (58.8%), with 0 to 6 years of education (70.6%), sufficient finances (94.1%), two or more chronic illnesses (55.9%), and fair or better perceived health (76.5%; Table 1). Participants were younger (p = 0.046) and had lower global PSQI scores (p < 0.01) than nonparticipants. Demographic characteristics, baseline sleep quality, and QOL among those who completed and dropped out of the intervention were similar.

Baseline Characteristics of the Sample (N = 34)

Table 1:

Baseline Characteristics of the Sample (N = 34)

Intervention Effects

No injuries or adverse effects of the intervention were reported. The intervention effects reported below are for the 26 participants who completed the entire study period.

The upper half of Table 2 presents the effects of the tai chi intervention on sleep quality. Global PSQI scores of participants with poor sleep quality ranged from 1 to 16 during the entire study period (0 to 16 weeks). It was observed that the global PSQI scores and most of the subscales scores had decreased from baseline to 12-week intervention and 4-week follow-up assessment period, but not all reached significant levels. Only the subscale “Sleep medication use” had slightly increased, and “Sleep disturbance” maintained the same level during the study period.

Participants’ Sleep Quality and Health-Related Quality Of Life (N = 26)

Table 2:

Participants’ Sleep Quality and Health-Related Quality Of Life (N = 26)

After 6 weeks of the tai chi intervention, only subjective sleep quality and global PSQI scores improved significantly. After 12 weeks of the intervention, in addition to the above scores, habitual sleep efficiency had also improved significantly compared with baseline values, and the effect of PSQI score improvement was large (Cohen’s d = 1.13). All improvements were maintained at the 4-week follow-up assessment. It was also observed that the greatest improvement of the global and most of the subscales scores (except “Sleep medication use” and “Sleep disturbance”) were found between baseline and 6-week intervention period. Then the improvements of the scores slowed down, maintained the same level, and even dropped slightly between 6-week and 12-week intervention and 4-week follow-up period.

The lower half of Table 2 presents the effects of the tai chi intervention on health-related QOL. The SF-36 domain scores of the sample indicated moderate levels of QOL. Similar to the sleep quality scores, PCS, MCS, and most of the SF-36 subscales improved during the study period but not all reached significant levels.

After 6 weeks of the tai chi intervention, physical functioning, social functioning, and PCS improved significantly, with improvement in PCS and MCS showing effect sizes of 0.33 (small effect) and 0.27 (small effect), respectively. After 12 weeks of the intervention, physical functioning, vitality, social functioning, mental health, and MCS improved significantly, but PCS no longer differed significantly from baseline. At 12 weeks, improvement in PCS and MCS showed effect sizes of 0.18 (approaching small effect) and 0.49 (approaching medium effect), respectively. At the 4-week follow-up, role: physical and all MCS domain scores had improved significantly. However, physical functioning no longer differed significantly from baseline. It was also observed that the greatest improvement on PCS, MCS, and all of the subscales, except vitality, were found between baseline and the 6-week intervention period. Then the improvements of the scores slowed down, maintained the same level, and even dropped slightly between 6-week and 12-week intervention and 4-week follow-up period.

Feasibility

Intervention feasibility was influenced by low recruitment (15%) and attendance (37% to 100%; mean = 68.5%) and high dropout (23.5%) rates. Major reasons for unwillingness to attend were poor health, venue distance, and program length. Reasons for withdrawal included family and personal reasons, hospitalization, and physical health problems.

Discussion

This preliminary study showed that the tai chi intervention was influenced by low recruitment and attendance and high dropout rates. On the other hand, this short intervention also demonstrated potential effects on sleep and QOL.

First, we believed that participants’ baseline characteristics (e.g., age, gender, PSQI scores) compromised tai chi implementation feasibility in a community setting. Our low recruitment rate (15%) may have been due to age-related perceived attendance barriers (poor health, inconvenient venue, program duration), which participants’ poorer baseline sleep quality (compared to eligible nonparticipants) may have motivated them to overcome. The PSQI score has not been reported as a health-related determinant of exercise participation; further studies should compare sleep quality between intervention participants and eligible nonparticipants, including the definition of cut-off values to predict exercise participation among older adults with poor sleep quality.

Our attendance rates (mean = 68.8%) were lower than in Western studies (Irwin et al., 2008; Wolf et al., 1996), perhaps related to the predominance (82.4%) of women (more likely than men to face family- and health-related barriers). Our high dropout rate (23.5%) is consistent with other reports (Lee et al., 2010).

To increase feasibility in future studies, perceptual factors might be improved by increasing participants’ self-efficacy (e.g., providing transportation to venues, recruiting only participants able to walk without assistance) (Loeb, O’Neill, & Gueldner, 2001). A more gender-balanced sample and randomization to minimize age effects might also enhance response and attendance rates. However, evidence from this and previous studies suggests that high dropout rates typify tai chi programs, especially among older adults with poor physical health, which should be considered during future sample size determination.

The other aim of this study was to describe the potential effectiveness of the tai chi intervention on sleep quality and QOL. Although this study used a shorter (12-week) intervention than Western studies, results were similar: sleep quality and QOL improved (Song et al., 2003; Wolf et al., 1996). However, our intervention did not significantly improve the PCS, whereas Wolf et al. (1996) found significant improvements in PCS and MCS after 24-week and 1-year tai chi programs, respectively. Such results might be due to the fact that tai chi’s physical benefits may develop over the long term as practitioners’ skills improve (Wayne & Kaptchuk, 2008), whereas social benefits may appear in the short term. The effects of the tai chi intervention were still inconclusive, as this study was limited by the small sample, lack of a control group, and no physiological measure of sleep quality. The effects of the tai chi intervention on sleep and QOL are worthwhile to be studied further, given the increasing trends of PSQI and SF-36 scores during the study period. In particular, the greatest improvements of PSQI and QOL were observed between baseline and 6-week intervention level, and then the improvements slowed down, which might suggest the participants had reached the exercise plateau after 6 weeks of intervention. The insignificant results might be due to the small sample and short-term tai chi intervention. Thus, further repeated-measures prospective cohort studies of long-term tai chi practice should be conducted to understand its multicomponent effects on sleep and QOL, including addressing exercise plateau for older adults with poor sleep quality. In particular, objective physiological sleep measurements such as actigraphy should be used to measure the effects of tai chi on sleep quality.

Nursing Implications

Healthy, independent living provides better QOL for older adults. Therefore, nursing strategies must address primary health care, promoting independent lifestyles through aspects such as sleep quality maintenance. Further studies of the feasibility and effects of tai chi should be conducted to explore its potential as an integrated community-setting intervention to promote sleep quality. At the same time, nurses can be trained as tai chi instructors to teach simple exercises, such as the 10-form easy tai chi for both healthy and frail community-dwelling older adults. This would be a potential cost-effective health care strategy to promote exercise programs in aging societies. With respect to this, an exercise course should be included in future gerontological nursing curriculum.

Conclusion

This study demonstrated the potential effects of tai chi on sleep quality and QOL in Chinese community-dwelling older adults. However, the program’s feasibility was significantly influenced by participants’ characteristics (i.e., age, gender, sleep quality). The major limitations of this feasibility study include lack of a control group, a small sample, and no physiological measure of sleep quality. More robust long-term studies including an objective sleep measurement should be conducted to improve intervention feasibility and explore whether this safe, simple, cost-effective exercise can be implemented in community settings to improve sleep quality and QOL in older adults.

References

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Baseline Characteristics of the Sample (N = 34)

n (%)
Characteristic Participants Who Completed Intervention (n = 26) Participants Who Dropped Out (n = 8) Nonparticipants (n = 200) Test Statistic (p Value)
Sex χ2 = 1.10 (0.58)
  Female 21 (80.8) 7 (87.5) 176 (88)
  Male 5 (19.2) 1 (12.5) 24 (12)
Age (years) χ2 = 8.79 (0.07)
  61 to 70 10 (38.5) 1 (12.5) 43 (21.5)
  71 to 80 13 (50) 6 (75) 93 (46.5)
  81 to 90 3 (11.5) 1 (12.5) 64 (32)
Years of education χ2 = 3.66 (0.45)
  0 to 6 17 (65.4) 7 (87.5) 161 (80.5)
  ⩾7 9 (34.6) 1 (12.5) 39 (19.5)
Marital status χ2 = 6.64 (0.36)
  Single/divorced/widowed 15 (57.7) 5 (62.5) 138 (69)
  Married 11 (42.3) 3 (37.5) 62 (31)
Financial status χ2 = 3.96 (0.68)
  Sufficient 24 (92.3) 8 (100) 178 (89)
  Insufficient 2 (7.7) 0 (0) 22 (11)
Employment status χ2 = 0.89 (0.93)
  Retired/unemployed 26 (100) 8 (100) 195 (97.5)
  Employed 0 (0) 0 (0) 5 (2.5)
Number of chronic illnesses χ2 = 7.07 (0.72)
  0 5 (19.2) 0 (0) 40 (20)
  1 6 (23.1) 4 (50) 68 (34)
  ⩾2 15 (57.7) 4 (50) 92 (46)
Perceived health χ2 = 7.72 (0.46)
  Fair or better 20 (76.9) 6 (75) 144 (72)
  Bad or worse 6 (23.1) 2 (25) 56 (28)
Mean (SD)
PSQI global score 10.50 (2.91) 9.29 (2.29) 7.24 (3.89) F = 8.42 (<0.001)
SF-36 PCS 43.60 (7.65) 45.14 (7.94) 45.51 (8.12) F = 0.66 (0.52)
SF-36 MCS 48.78 (10.81) 51.55 (4.16) 51.26 (9.61) F = 0.80 (0.45)

Participants’ Sleep Quality and Health-Related Quality Of Life (N = 26)

Mean Score (SD)
Scale/Subscale Baseline 6 Weeks 12 Weeks 16 Weeks Postintervention
PSQI
  Subjective sleep quality 1.46 (0.15) 0.88 (0.11)*** 0.77 (0.12)*** 0.77*** (0.10)
  Sleep latency 1.49 (0.25) 1.18 (0.21) 1.18 (0.19) 1.03 (0.19)
  Sleep duration 1.17 (0.22) 0.75 (0.19) 0.79 (0.17) 0.82 (0.15)
  Habitual sleep efficiency 1.56 (0.29) 1.29 (0.27) 1.06 (0.25)* 0.87 (0.23)**
  Sleep disturbancea 1.00 (1.00) 1.00 (0.00) 1.00 (0.00) 1.00 (0.00)
  Sleep medication use 0.02 (0.24) 0.06 (0.25) 0.06 (0.24) 0.05 (0.24)
  Daytime dysfunction 0.56 (0.19) 0.25 (0.16) 0.21 (0.14) 0.17 (0.14)
  Global PSQI score 8.31 (0.73) 5.36 (0.74)*** 5.04 (0.70)*** 4.78 (0.59)***
SF-36
  Physical functioning 71.40 (2.70) 77.74 (2.34)* 78.90 (2.58)* 76.20 (2.34)
  Role: Physical 78.24 (3.03) 85.21 (3.74) 84.26 (2.91) 90.73 (2.85)***
  Bodily pain 79.82 (7.77) 87.97 (7.59) 81.28 (7.41) 87.55 (6.73)
  General perceived health 49.69 (4.72) 53.69 (5.00) 53.26 (4.77) 52.03 (4.21)
  Vitality 67.93 (4.83) 71.54 (4.86) 76.83 (4.66)** 74.66 (4.56)**
  Social functioning 82.64 (5.96) 94.17 (4.83)* 100.00 (4.46)** 100.00 (6.19)**
  Role: Emotional 88.13 (3.81) 94.54 (3.68) 97.74 (3.73) 98.06 (3.47)**
  Mental health 81.50 (3.23) 85.92 (2.91) 86.50 (2.79)* 88.23 (2.37)**
  Physical component subscale 44.62 (1.78) 47.17 (1.82)* 45.99 (1.71) 46.82 (1.53)
  Mental component subscale 54.05 (1.78) 57.02 (1.64) 59.40 (1.54)** 59.38 (1.63)***

Keypoints

Lo, C.M.-H. & Lee, P.H. (2014). Feasibility and Effects of Tai Chi for the Promotion of Sleep Quality and Quality of Life: A Single-Group Study in a Sample of Older Chinese Individuals in Hong Kong. Journal of Gerontological Nursing, 40(3), 46–52.

  1. This pilot study reported the feasibility and effects of a simplified tai chi exercise intervention on sleep quality and quality of life.

  2. Low recruitment and attendance and high dropout rates of the intervention were associated with participants’ age, gender, and sleep quality.

  3. Quality of life and sleep quality were improved after the intervention.

10.3928/00989134-20131028-08

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