Iran Journal of Nursing

1. Introduction
The elderly population in the world as well as in Iran has a growing trend, which can indicate a significant increase in chronic diseases, especially renal failure in the elderly and its associated complications, including sleep disorders, which cause trouble in daily activities and quality. Life goes down in these patients. Also in Iran, only two interventional studies have investigated the effect of exercise on sleep quality in patients undergoing hemodialysis or have been made available to the researcher. However, no research has been done in the elderly population undergoing hemodialysis, or at least no study has been found in this field. Therefore, have been decided to conduct a study using exercise and its effect on sleep quality in elderly patients undergoing hemodialysis with Permicat.
2. Material and Method
The present study is an experimental study that was conducted to investigate the effect of exercise on sleep quality in the elderly with Sheldon venous catheter undergoing hemodialysis referred to Ghiasi Charity Center in Tehran in 2020. This center covers 200 patients, of which 40 are active elderly patients over 60 years of age, 30 of whom met the inclusion criteria, which were randomly selected by lottery method (writing their names on paper) into two groups,the intervention and control groups (15 people in each group) were assigned. Research criteria include was being over sixty years old, ability to answer the questioner’s questions, physical ability to participate in sports activities at the decision of the physician. Also, having the cognitive health of participating in the group, which is assessed using a short cognitive test tool, if the test score is higher than 7, they were eligible to enter the study.Besides, six months of dialysis history, dialysis at least twice a week, no history of surgery in the last three months, constant blood pressure (according to the conditions of each elderly in their file), have a Permicat to access the arteries (hands free to do exercise).Initially, the cognitive health of the elderly was assessed using a short cognitive test tool, all of them had cognitive health. In the experimental group, one of sample was hospitalized and two were transferred to another dialysis center, thus, they were removed from the samples. Finally 12 samples were in expremental group and 15 samples in control group. Research tools included demographic information form, Abbreviated Mental Test and Sleep Quality questionnaire. The Abbreviated Mental Test(AMT) tool, developed by Hodkinson in 1972 to screen for cognitive disorders such as dementia and delirium in the elderly, to identify the elderly with dementia and remove them from the study.The tool includes 10 short and simple questions to measure orientation, focus and attention, short-term and long-term memory of the elderly, each item of which has 1 point and the sum of the resulting scores is 10. The cut-off point for distinguishing cognitive status is 7 out of 10, which normalizes status from abnormal. Foroughan et al. (2014) in Iran have translated this tool into Persian. The validation and internal reliability of the Persian version of this tool with Cronbach’s alpha coefficient of 0.76 has been acceptable.
The Pittsburg Sleep Quality Index (PSQI) was developed by Buysse et al in 1989 and has 9 items, of which 5 questions contain 10 sub-items, so the whole questionnaire has 18 items. These questions are in seven components :Subjective sleep quality,Sleep latency, Sleep duration, sleep efficiency, Sleep disturbance, Use of sleep medication, Daytime dysfunction.The score of each question is between 0 to 3 scores of the questionnaire from 0 to 21. The higher the score, the lower the quality of sleep. Dr. Buysse et al. Obtained the internal consistency of the questionnaire using Cronbach’s alpha of 0.83. Farahi Moghadam et al. (2012) have also confirmed the validity and reliability of this questionnaire in Iran; Cronbach’s alpha coefficient of this questionnaire was 0.78 to 0.82.
All instruments were completed by asking the elderly at two times, before the start of the study and in the eighth week of the study. In order to intervention in the experimental group, the elderly performed a sports activity protocol designed by a sports physiologist with the help of a researcher and under the supervision of the center’s physiotherapist for 8 weeks and 3 times a week during dialysis. Exercises were performed due to the age of the samples in bed and during dialysis. In the first week, because the exercises were light and it was not possible to warm up and cool down in the real sense, the time to start the first exercise activity was 30 minutes in the first week.Then, 35 minutes in the second week, 40 minutes in the third week, 45 minutes in the fourth week, week. The fifth and sixth week were considered 50 minutes.One-half of the exercise time was devoted to aerobic exercise with a minibike (small bike) with arms and legs, and the rest of the time was equally devoted to other resistance exercise. In the first session, the method of conducting research, the rules of participating in the sessions, the impact of exercises on the body and how to do exercises were presented. 
At the beginning of each exercise session in the intervention group, vital signs were assessed and with the permission of the physician, the patient participated in exercise. Exercise started 30 minutes after the start of dialysis and stabilization of the patient. In the control group, except for routine interventions, no intervention is performed, but they were assured that if the research results are effective in the experimental group, exercise sessions will be held for them.
SPSS v.16 was used to analyze the data. Descriptive statistics were used to describe the contextual variables and sleep quality. Skewness and kurtosis were used to determine the normality of the data. Then, paired t tests (intra group comparison) and univariate covariance (between group comparison) were used. Chi-square and Fisher’s exact tests were used to determine the differences of contextual variables between the experimental and control groups. P less than 0.05 was considered as a significant level.
3. Result
Comparing the quality of sleep between before (14.75±1.91) and after intervention (12.46±2.69) in the experimental group, was found that after exercise, sleep quality improved significantly (P<0.0001) but in control group the sleep quality between the first (10.75±2.17) and eighth week (16.33±1.39) of the study was significant increased (P = 0.001). Comparison of the mean of sleep quality between the experimental and control groups before the study was statistically significant (P=0.035). The control group had better sleep quality but the mean of sleep quality between the two groups in the eighth week of the study was significant (P<0.0001) and sleep quality was better in the experimental group than the control group.
4. Conclusion
By comparing the quality of sleep between the experimental and control groups, it was found that the intervention of exercise program has a significant effect on improving sleep quality in the elderly undergoing hemodialysis. The results of this study showed significant results in improving the overall sleep quality of the elderly in the experimental group after exercise intervention compared to the control group, while in the control group there was a decrease in sleep quality.A study by Cho et al. In 2018 in South Korea on hemodialysis patients in three groups with different exercise methods showed a significant improvement in sleep quality. Leopolido et al. also examined the effect of Pilates exercises on patients with mobility problems in Brazil in 2013 and showed a significant increase in improving the sleep quality of these patients. One of the problems of patients undergoing hemodialysis is the poor quality of sleep of these patients, and now if these patients are in old age, their problems will increase.Because the nature of aging causes sleep disorders and in addition to aging, the presence of chronic kidney disease, the use of various drugs that affect the quality of sleep and also the process of hemodialysis also affects the quality of sleep. In the meantime, the time of hemodialysis, which interferes with the rest time of the elderly patient, and also, the conditions during hemodialysis, which cause short sleep during hemodialysis, double the sleep disturbance in them. Therefore, methods should be taken in the lifestyle of the elderly patient as well as during hemodialysis to improve their quality of life and consequently the quality of sleep. In this regard, exercise interventions during hemodialysis can prevent short sleep in the elderly and on the other hand, prepare the body for a good night’s sleep. Therefore, it is recommended to perform sports interventions during hemodialysis and to encourage the elderly patient to do it at home.It should be noted that the beginning of the intervention concurrent with the onset of the Covid-19 viral disease epidemic. Although at the beginning of the intervention, the researcher thought that the epidemic conditions could affect the results of the study, but it had no effect on the cooperation of the elderly patient and the results of the study. Even the elderly cooperated more with the idea of enhancing the immune system by exercising. The results of this study, in addition to being effective in increasing nursing knowledge, can also be used as a safe and low-cost method to improve sleep quality in the elderly undergoing hemodialysis.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Shahed University (Code: IR.SHAHED.REC.1398.109). Before conducting the study all the necessary explanations about the goals and process of the study were provided to the subjects, and the subjects voluntarily entered the study and signed an informed written consent. They were also assured that they could leave the study at any time as they wish and that all their information would remain confidential.
Funding
The paper was extracted from the MSc thesis in geriatric nursing by Mansour Ali-Mohammadi and funded in part by the Shahed University.
Authors' contributions
Maryam Jadid-Milan and Mansour Ali Mohammadi contributed in conceptualization and supervision. Maryam Jadid-Milan and Ali Samadi contributed in designing the study and methodology. The original draft was prepared by Mansour Ali Mohammadi and Maryam Jadid-Milan, also Ali Samadi contributed in reviewing & editing the draft. All the authors contributed in data collection and/or data analysis. Mansour Ali Mohammadi and Maryam Jadid-Milan contributed in the acquisition of fund and resources.
Conflict of interest
The authors declared no conflict of interest.

We appreciate deputy of research and technology of Shahed University, Shahid Ghiasi Hospital management and hemodialysis section staff, and all the patients for participating in this study. We also thank Mrs Shima Haghani for her technical advice in statistical analysis.