The Effects of Acupressure Training on

Sleep Quality and Cognitive Function of

Older Adults: A 1-Year Randomized
Controlled Trial
Hui Zeng, Mengjiao Liu, Ping Wang, Jiaxun Kang, Fenghua Lu, Lu Pan

Correspondence to: Hui Zeng
E-mail: zenghui@csu.edu.cn
Hui Zeng
Professor
Xiangya School of Nursing
Central South University
172 Tong Zipo Road
Changsha, Hunan 410013, China
Mengjiao Liu
The Second Xiangya Hospital
Central South University
Changsha, Hunan Province, China
Ping Wang
Lecturer
Hunan Traditional Chinese Medical College
Zhuzhou, Hunan Province, China
Abstract: We explored the effects of acupressure training on older adults’ sleep
quality and cognitive function. Ninety older adults with impaired sleep quality were
selected from screened volunteers and randomly divided into equal control and
experimental groups; 82 completed the 1-year follow-up. Participants in the control
group were given instructions on sleep health, while those in the experimental
group received sleep health instructions plus individual and small group acupres-
sure training sessions and support to practice the intervention on their own each
day. All participants were assessed by trained assistants blind to study group allo-
cation using Chinese versions of the Pittsburgh Sleep Quality Index, the Epworth
Sleepiness Scale, the Mini-Mental State Examination, and four subscales from the
revised Chinese version of the Wechsler Memory Scale, at baseline and at 3, 6,
and 12 months. Repeated measures analysis of variance showed that acupressure
training improved older adults’ sleep quality and cognitive function, but the mediat-
ing effect of sleep on the relationship between acupressure training and cognitive
function was not supported. Given the ease, simplicity, and safety of acupressure
training observed with community-dwelling older adults in China, attempts should
be made to replicate these preliminary positive findings with larger samples.
ß 2016 Wiley Periodicals, Inc.

Keywords: older adults; sleep quality; cognitive function; acupressure

Jiaxun Kang
Lecturer Research in Nursing & Health
School of Nursing Accepted 6 June 2016
Zhengzhou University DOI: 10.1002/nur.21738
Zhengzhou, Henan Province, China Published online in Wiley Online Library (wileyonlinelibrary.com).

Fenghua Lu
Postgraduate Student
Xiangya School of Nursing
Central South University
Changsha, Hunan Province, China

Lu Pan
The Second Xiangya Hospital
Central South University
Changsha, Hunan Province, China

Given the projected increase in number of older adults with
cognitive impairment, especially among those past the age
of 80 years, researchers and clinicians have sought to apply
interventions that might slow the decline of cognitive func-
tion. Cognitive impairment in older adults can decrease their
ability to take care of themselves and adapt to social roles
and circumstances. It affects older adults’ overall quality of
life and that of their family members and caregivers (Garc
ıa-
Alberca et al., 2012). Aging is a main cause of cognitive
impairment, as it can reduce cerebral cortex neurons,

C 2016 Wiley Periodicals, Inc.
2 RESEARCH IN NURSING & HEALTH
damage synapses, and decrease levels of neurotransmitters
such as acetylcholine (Ebersole, Hess, & Luggen, 2004).
Considerable manpower and materials are spent addressing
cognitive issues in older adults (McKibbin et al., 2005).
Aging also affects sleep quality. Approximately 75%
of older adults report sleep problems (Johar, Kawan,
Emeny, & Ladwig, 2016), including trouble falling asleep,
awakening too early and more often, and other problems
(Santos, Mansano-Schlosser, Ceolim, & Pavarini, 2013). A
reduction in deep sleep influences memory conversion and
information extraction, resulting in impairment of memory
and study abilities in older adults, which can further accel-
erate cognitive damage (Liao, Chiu, & Landis, 2008). Sleep
quality and cognitive function are closely related (Kang,
Zeng, & Wang, 2011; Nebes, Buysse, Halligan, Houck, &
Monk, 2009), suggesting that interventions aimed at
improving sleep quality might also help improve cognitive
function in older adults.
Individuals with normal cognition may be at risk of cog-
nitive impairment if they experience difficulties in maintaining
sleep (Johar et al., 2016). Sleep allows the brain to rest,
recover functionality, and reserve energy to prepare for opti-
mal performance on wakening (Kerkhof & Dongen, 2011).
Adequate sleep is necessary to ensure optimal use of salient
functions of the cerebral cortex, such as attention, reason-
ing, verbal ability, and the ability to plan and execute various
behavioral sequences, adapt to environmental change, and
respond rapidly to stimuli (Kopp, Longordo, Nicholson, &
Luthi, 2006; Nguyen, Tucker, Stickgold, & Wamsley, 2013).
Implementing safe, cost-effective interventions such as acu-
pressure might enhance sleep quality in older adults and
protect or delay the decline of their cognitive functions.
Given the Chinese belief in “getting old before getting
rich” and China's growing population, interventions to pre-
serve older adults’ well-being are sought that are safe,
effective, and simple. Acupressure, the application of physi-
cal pressure on acupuncture points, may be such an inter-
vention. He, Huang, Lai, Li, and Tang (2009) have
observed that acupressure can improve patients’ sleep
quality; however, whether acupressure can improve cogni-
tive function while promoting sleep in older adults has not
been investigated. In the present study we explored the
effects on cognitive function of an acupressure intervention
to improve sleep quality in older adults.
Sleep in Traditional Chinese Medicine
The mechanisms underlying the relationship of sleep and
cognition are not fully understood. According to the theories
of traditional Chinese medicine (Li, 2008), sleep function is
managed by the brain, driven by the heart, and aided by the
coordination of multiple organs. Sleep quality is thus highly
dependent on the proper functioning of internal organs and
blood circulation. Dysfunctional organs, especially the heart,
liver, spleen, and kidneys, can decrease sleep quality. Acu-
pressure is thought to stimulate relevant acupoints and
Research in Nursing & Health
indirectly stimulate meridians to promote energy flow, which
improves blood circulation. Acupressure is also believed to
affect the internal organs through the transmission and
reflection of the meridians. Gently massaging the head and
face, for example, using the hands to produce face friction,
scrape around the eyes, and massage acupoints on the
head, may stimulate the peripheral nerves and increases
blood circulation to the head and face. Through various com-
plex reflexes, neural activity becomes more consistent,
which balances both excitatory and inhibitory brain mecha-
nisms to promote better sleep quality.
In the present study (see Fig. 1), special acupoints
were chosen: Anmian, Shenmen, Neiguan, and Sanyinjiao
(Li, 2008). The Anmian acupoint is the main acupoint for
sedation (Dong, 2010). It treats insomnia by helping the
heart and the brain rest. The heart is believed to control
blood circulation as well as the spiritual and emotional state
of an individual—both believed to be strongly related to
sleep quality. Shenmen is the original acupoint of the heart
meridian that passes through and ends in the heart; it is
believed to ease the mind and calm the nerves. Neiguan is
an important acupoint of the Pericardium Channel of Hand-
Jueyin, another acupoint that relaxes the heart and calms
the nerves (Tian, Li, & Wang, 2011). In addition, insomnia
is believed to have a close relationship with the activities of
the liver, spleen, and kidneys. The Sanyinjiao acupoint is at
the intersection of the Kidney Channel of Foot-Shaoyin, the
Spleen Channel of Foot-Taiyin, and Liver Channel of Foot-
Jueyin. Massage applied to Sanyinjiao can calm an
individual's agitated temper and help to treat insomnia.
Massaging the Sanyinjiao acupoint can activate the frontal
temporal lobe and cingulate gyrus, helping to regulate
mood and sleep (Chen, Shou, Li, Xu, & Liu, 2007).
In summary, massaging these acupoints is believed to
adjust the functions of the heart, brain, liver, spleen, kidneys,
FIGURE 1. Acupoints.
 ACUPRESSURE EFFECT ON SLEEP AND COGNITION/ ZENG ET AL.
and these organs are most related to insomnia. Massaging
these acupoints also helps to nourish the heart and spleen,
adjust the functions of many internal organs, balance yin
and yang energies, and promote the body's coordination,
which could improve daytime functioning and sleep quality.
Methods
Design
Ninety older adults with impaired sleep quality were ran-
domly divided into equal control and experimental groups.
Participants in the control group were given instructions on
sleep health, while those in the experimental group
received sleep health instructions plus individual and small
group acupressure training sessions and support to prac-
tice the intervention on their own each day. Data were col-
lected at baseline and at 3, 6, and 12 months.
Recruitment and Sample
The study was conducted between July 2010 and
June 2011. Prior to the initiation of the study, the primary
investigator carried out training with the research team
members on all measures and implementation procedures.
With the permission and support of community lead-
ers, older adults with impaired sleep were targeted in
Wang Yuehu community in Changsha, China, via adver-
tisements and posters. Two hundred volunteers were
screened to determine their eligibility based on the follow-
ing criteria: (a) aged 60 years or older with no hearing or
visual dysfunction; (b) a Pittsburgh Sleep Quality Index >5
points; and (c) normal mental status with no dementia
(MMSE score 17 in the illiteracy, 20 in the elementary
educated, 24 in the middle education levels). Those with
prior experience of acupressure, yoga, or meditation, who
had experienced a recent serious family disruption, or who
expected to have difficulty completing the acupressure
training, were excluded.
A study of acupressure on sleep quality (Shariati,
Jahani, Hooshmand, & Khalili, 2012) provided the basis to
estimate the sample size. According to the formula of com-
paring two means (Sun, 2010), a sample size of 26 partic-
ipants per group was necessary to detect statistically
significant differences (two-tailed a of .05, with power of
.90, d ¼ m1–m2 ¼ 10.90–5.90 ¼ 5.00, s ¼ 5.45). Allowing for
a 20% dropout rate, 90 participants were selected and ran-
domly divided using a table of random numbers into two
groups by the primary investigator.
Ethical Considerations
Ethics committee approval for this study was obtained from
Central South University. Before the intervention, all partic-
ipants were introduced to the content and methods of the
research and written informed consent was obtained from
each participant by the investigators. During the study, all
Research in Nursing & Health
3
participants’ information was kept strictly confidential. Per-
sonal information was replaced with codes during data
entry to prevent any information exposure.
Measures
General information questionnaire. A general
information questionnaire included sex, age, marriage, liv-
ing situation, education, occupation, income, chronic dis-
ease, drug use, smoking, history of drinking, family history,
and exercise.
Pittsburgh Sleep Quality Index (PSQI). The
PSQI (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989)
is a self-rated measure of sleep quality, including subjective
sleep quality, sleep latency, sleep time, sleep efficiency,
sleep disturbances, hypnotic drug usage, and daytime dys-
function. In this study, we used the 10-item Chinese ver-
sion of the PQSI (Liu, Tang, & Hu, 1996). Possible scores
range from 0 to 21, with higher scores indicating worse
sleep quality. An overall PSQI score >5 can be used to
identify sleep problems. In Liu et al.'s study, construct valid-
ity of the above seven domains was .60–.80, Cronbach a
was .84, split-half reliability .87, and test-retest reliability
.81. In the present study, Cronbach a was .79.
Epworth Sleepiness Scale (ESS). The ESS
(Chen et al., 2002) is a self-report questionnaire used to
evaluate the extent of daytime sleepiness under eight dif-
ferent conditions. Possible scores for the ESS with eight
items range from 0 to 24; the higher the score, the more
severe the sleepiness. A score >10 is regarded as
“sleepy,” and a score 18 as “very sleepy.” Chen et al.
(2002) found the reliability and validity of the Chinese
version of ESS to be acceptable, reporting coefficients of
.81 and .74, respectively. In the present study, Cronbach a
of the Chinese version was .81.
Mini-mental state examination (MMSE; He
et al., 2005). The MMSE was used to evaluate the sub-
jects’ cognitive function in five areas: orientation, memory,
attention and calculation, language, and graphic simulation.
MMSE has 30 items, and scores range from 0 to 30, with
higher scores indicating better cognition. Based on educa-
tional level, primary school, middle school, and above, the
cut-off scores of cognitive dysfunction in the Chinese ver-
sion are 17, 20, and 24, respectively. The reliability of .91
and validity of .99 of the MMSE have been widely accepted
(Zhang, 1993). In this study, the Cronbach a of the MMSE
was .92.
Wechsler Memory Scale revised, Chinese
version (WMS-RC; Gong, Xie, Jiang, Dai, &
Zhou, 1981). Gong et al. (1981) translated and revised
the Wechsler Memory Scale, originally developed by
Wechsler and Stone, into the WMS-RC. The test-retest reli-
ability of WMS-RC was .82. The WMS-RC has 10 sub-
scales, evaluating remote memory, short-term memory,
and transient memory. However, to avoid fatigue of the
older adults, we used only the four subscales assessing
4 RESEARCH IN NURSING & HEALTH
memory function: number memory (20 items, score range
0–20), picture memory (20, 0–20), associative memory (10,
0–10), and understanding memory (50, 0–25), with higher
scores indicating better memory function. Cronbach a of
these four subscales in the present study were .78, .84,
.82, and .77, respectively.
Procedures
Both groups: sleep health instructions. Both
groups received sleep health instructions in three sessions
over 3 consecutive weeks by a community health staff. The
session topics included how to maintain good sleep habits,
bedtime toileting, doing nothing in one's bedroom other
than sleeping, and promoting a good sleep environment.
Intervention group: acupressure training.
Subjects randomized to the experimental group also partici-
pated in an intensive 90-minute training session once a
week over 3 consecutive weeks, during which the
researchers explained and demonstrated acupressure
techniques, ensuring that older adults mastered the correct
acupoint selection and massage methods. Acupressure
training was as follows: To massage the face with both
hands: rubbing the hands, placing the middle fingers near
the nose, moving up beside the nose to the brow and the
forehead, and then moving from the front of the ear back to
the nose area. The subjects were told that it was important
to use gentle, even, coordinated movements and a consis-
tent speed, which helped maintain the continuity of motion
and strength during massage.
To press the Anmian acupoint, subjects were shown
and instructed to use the middle finger pad. To rub the Nei-
guan acupoint, massage was clockwise using the thumb.
To press the Shenmen acupoint, instruction was to use the
end of the thumb. To rub the Sanyinjiao acupoint, the
thumb was used. Each action was repeated at least 50
times by each participant. The precision of acupressure
was confirmed if participants felt sore, numb, heavy, dis-
tended, or warm (Ma, Chang, & Lin, 2007).
After these training sessions, the acupressure group
was subdivided into five groups, and participants who exhib-
ited skillful use of the techniques and organizational ability
were selected to lead their “team” to exercise five mornings
a week. To increase the team leaders’ sense of responsibil-
ity, compensation was provided on a monthly basis.
In addition to the group practice, the participants in
the experimental group were required to continue their acu-
pressure exercises at home for at least two 30-minute ses-
sions daily. Moreover, they were asked to record their
practice after each session in a diary using a template
(date and time of the exercise, effects).
During the study, five assistants telephoned the par-
ticipants every week and conducted home visits every
other week. They checked the subjects’ practice diaries
and communicated with the subjects in the experimental
group and their families to determine the subjects’
Research in Nursing & Health
adherence with the home program and to supervise those
who neglected the daily acupressure training. A pamphlet
explaining the mechanism and benefits of acupressure and
an acupressure video offering guidelines for training at
home were also given to the participants.
Data collection. Standardized training for the
data collectors was conducted. Each data collector was
required to complete five qualified administrations of the
general questionnaire survey before the formal study
began. To avoid bias in data collection, all the data collec-
tors were blind to study group allocation of participants.
Data were collected on participants’ sleep quality and
cognitive function before the intervention and at 3, 6, and
12 months of the intervention. Data were collected individu-
ally and face-to-face, as most of the subjects had limited
education. The data collectors asked questions one-by-one
and verified the information with the subjects, checking the
quality of their data immediately after the survey. If errors,
omissions, or illogical answers were found, the data collec-
tors asked the question again and corrected the answer.
Statistical Analyses
Before carrying out data analysis, troubleshooting and logic
checks were completed to check all data entry and coding.
A database was established using the statistical software
SPSS version 17.0.
Groups were compared before the intervention on
demographic features, sleep quality, and cognitive function
using t-tests or chi-square tests. The relationship between
sleep quality and cognition was tested by Pearson correla-
tion. Repeated measures analysis of variance (ANOVA)
was used to determine the effects of acupressure training.
Mediation analysis was conducted to explore the possible
mediating effect of sleep by applying multiple regression
analysis combining with the Sobel test. For the mediation
analysis, the PSQI was used as the measure of sleep qual-
ity and the MMSE was used to measure cognitive function.
The a value was set at .05, and p values were two-tailed.
Results
Description of Groups
There were no significant group differences in socio-
demographic variables, PSQI, ESS, MMSE, or any
WMS-RC subscale scores before the intervention, as
shown in Table 1.
Adherence
Three participants in the acupressure training group and
five in the control group dropped out, due to being hospital-
ized (one from each group), moving away (n ¼ 3), or loss
to follow-up at the beginning of the intervention (n ¼ 3).
No significant differences in variables at baseline were
observed between dropouts and completers. In all, 82
 ACUPRESSURE EFFECT ON SLEEP AND COGNITION/ ZENG ET AL. 5

Table 1. Comparison of Control and Experimental Groups at Baseline (N ¼ 82)

Overall Sample Control (n ¼ 40) Experimental (n ¼ 42)

n (%) n (%) n (%) Chi-Squarea p

Gender 1.728 .229

Male 24 (29.3) 9 (22.5) 15 (35.7)
Female 58 (70.7) 31 (77.5) 27 (64.3)
Marital status 2.466 .535
Married 44 (53.7) 18 (45.0) 26 (61.9)
Divorced 2 (2.4) 1 (2.5) 1 (2.4)
Widowed 34 (41.5) 20 (50.0) 14 (33.3)
Single 2 (2.4) 1 (2.5) 1 (2.4)
Living status .017 1.000
Live alone 18 (22.0) 9 (22.5) 9 (21.4)
Couple 27 (32.9) 13 (32.5) 14 (33.3)
Live with children 35 (42.7) 17 (42.5) 18 (42.9)
Other 2 (2.4) 1 (2.5) 1 (2.4)
Education 4.004 .263
None 16 (19.5) 10 (25.0) 6 (14.3)
Primary school 33 (40.2) 18 (45.0) 15 (35.7)
Middle school 24 (29.3) 8 (20.0) 16 (38.1)
High school and above 9 (11.0) 4 (10.0) 5 (11.9)
Occupation .784 .376
Employed 11 (13.4) 4 (10.0) 7 (16.7)
Unemployed 71 (86.6) 36 (90.0) 35 (83.3)
Income (RMB) 2.933 .071
<300 14 (17.1) 9 (20.4) 5 (13.2)
300–1,000 33 (40.2) 16 (36.4) 17 (44.7)
1,000–2,000 31 (37.8) 18 (40.9) 13 (34.2)
>2,000 4 (4.9) 1 (2.3) 3 (7.9)
Chronic disease .391 .532
Yes 54 (65.9) 25 (62.5) 29 (69.0)
No 28 (34.1) 15 (37.5) 13 (31.0)
Drug use .109 .742
Yes 42 (51.9) 20 (50.0) 22 (53.7)
No 39 (48.1) 20 (50.0) 19 (46.3)
Smoking .151 .697
Yes 20 (24.4) 9 (2.5) 11 (26.2)
No 62 (75.6) 31 (77.5) 31 (73.8)
History of drinking .237 .626
Yes 14 (17.1) 6 (15.0) 8 (19.0)
No 68 (82.9) 34 (85.0) 34 (91.0)
Family history 2.753 .360
No 76 (92.7) 38 (95.0) 38 (90.5)
Dementia 1 (1.2) 1 (2.5) 0 (.0)
Others 5 (6.1) 1 (2.5) 4 (9.5)
Regular exercise .005 1.000
Yes 74 (90.2) 36 (90.0) 38 (90.5)
No 8 (9.8) 4 (10.0) 4 (9.5)

M  SD M  SD M  SD tb

Age 70.74  7.31 70.78  7.26 70.07  7.42 .434 .666

PSQI 8.96  3.98 9.10  4.09 8.83  3.91 .302 .764
ESS 4.70  3.80 4.53  3.97 4.86  3.67 .394 .695
MMSE 23.83  3.64 23.38  3.99 24.36  3.23 1.354 .180
Number memory 9.27  1.83 9.20  1.84 9.33  1.83 .329 .743
Picture memory 7.84  3.28 7.51  3.79 8.14  2.73 .868 .388
Associative memory 2.17  1.32 2.05  1.63 2.28  0.94 .807 .422
Understanding memory 5.13  3.01 5.03  3.33 5.24  0.42 .318 .751

Notes. PSQI, Pittsburgh Sleep Quality Index; ESS, Epworth Sleepiness Scale; MMSE, Mini-Mental State Examination.
a
Independent chi-square test.
b
Independent two-sample t-test or independent Fisher’s exact test.

Research in Nursing & Health

6 RESEARCH IN NURSING & HEALTH

Table 2. Intervention Effects on Sleep Quality and Cognitive Function in Repeated Measures ANOVA

Time Main Effect Intervention Main Effect Interaction Effect

F p Partial h2 F p Partial h2 F p Partial h2

PSQI 10.638 .002 .117 16.398 <.001 .170 85.442 <.001 .516
ESS .511 .477 .006 8.589 .004 .097 72.902 <.001 .477
MMSE 12.619 .001 .136 14.038 <.001 .149 41.051 <.001 .339
Number memory 1.843 .178 .230 41.320 <.001 .341 191.083 <.001 .705
Picture memory 31.448 <.001 .282 28.186 <.001 .261 94.637 <.001 .548
Associative memory 53.879 <.001 .402 32.773 <.001 .291 98.524 <.001 .552
Understanding memory 98.238 <.001 .551 12.520 .001 .135 28.314 <.001 .261

Notes: PSQI, Pittsburgh Sleep Quality Index; ESS, Epworth Sleepiness Scale; MMSE, Mini-Mental State Examination.

participants (mean age 70.74  7.31 years) completed the
1-year study. All 42 completers in the experimental group
attended the intensive training sessions. The average
adherence rate across these 42 subjects was 96.5% for
the small group practice and 88.6% for the home sessions,
based on the team leaders’ reports, the participants’ prac-
tice diaries, and the researchers’ monitoring records.
The Relationship Between Sleep Quality,
Sleepiness, and Cognition
Sleep quality (PSQI) was negatively related to cognitive
function (MMSE), with r ¼ .368. Daytime sleepiness
(ESS) also was negatively related to cognitive function,
r ¼ .370, (both p < .01).
in Table 2 and Figure 2, the main effect of time on sleep
quality (PSQI) and the main effects of the acupressure
intervention on PSQI and daytime sleepiness (ESS) were
statistically significant (p < .01). The interaction effect of
time  intervention was significant for PSQI and ESS
(p < .001), indicating that the intervention group scores on
the sleep measures showed more improvement over time
than did the control group.
As seen in Figure 2, over 1 year of acupressure train-
ing and practice, sleep quality, particularly as measured by
the PSQI, improved in the experimental group. The average
score on PQSI decreased 35%, from 8.8  3.9 to 5.7  2.3,
while sleep quality worsened in the control group, with an
increase in PQSI of 16%, from 9.1  4.1 to 10.6  3.9.

Effects of Acupressure Training and Time on

Effects of Acupressure Training and Time on Cognitive Function
Sleep Quality In repeated measures ANOVA as shown in Table 2
PSQI and ESS scores before and after the intervention and Figure 3, the main effects of time on MMSE and all
were used for the repeated measures ANOVA. As shown WMS-RC subscales but number memory, and the main

FIGURE 2. Repeated measures ANOVA results: intervention effects on sleep quality.

Research in Nursing & Health

 ACUPRESSURE EFFECT ON SLEEP AND COGNITION/ ZENG ET AL. 7

FIGURE 3. Repeated measures ANOVA results: intervention effects on cognitive functions.

effects of the intervention on MMSE and all four WMS-RC
subscales, were statistically significant (p < .01). The inter-
action of time  intervention was significant for MMSE and
the four WMS-RC subscales (p < .001), indicating that the
intervention group scores improved over time more than
did those of the control group.
Sleep as Mediator of the Effect of
Acupressure on Cognitive Function
We further explored the possible mediating effect of sleep
on the relationship between acupressure training and cog-
nitive function. In multiple regression, the direct effect of

Research in Nursing & Health

8 RESEARCH IN NURSING & HEALTH
the training on MMSE (standardized beta ¼ .58) decreased
to .37 when the PQSI was added to the equation, indicating
possible partial mediation. However, the indirect effect of
the intervention on MMSE through PQSI was .21, with a
Sobel test statistic of .70 (one-tailed p ¼ .24), indicating that
the mediating effect of sleep on the relationship between
the intervention and cognitive function did not reach
significance.
Discussion
We studied the effect of a community-based acupressure
training on sleep quality and cognitive function in older
adults during a 1-year period in China and found that acu-
pressure training can improve sleep quality and cognitive
function in older adults. Our participants did not experience
major difficulty in learning and practicing acupressure,
the training cost little, and no undesirable side effects were
reported by any participant. We coupled training with the
establishment of peer team leaders, family members’ sup-
port, and regular supervision visits and other support.
Although the training lasted for 1 year, adherence was
excellent.
In this study, acupressure improved sleep quality
over time. The average sleep score of PQSI for the acu-
pressure training group decreased 35% from 8.8 to 5.7,
bringing the score in the experimental group much nearer
to the commonly used sleep problem cutoff value of 5. In
contrast, the average score for the control group increased
16%, indicating a modest worsening of sleep quality. Simi-
larly, Shariati et al. (2012) concluded that acupressure sig-
nificantly increased sleep quality in end-stage renal
patients. He et al. (2009) reported that the use of acupres-
sure for patients with insomnia improved sleep by 84%.
Another group (Yuan, Luo, & Li, 2012) found that acupres-
sure was more effective than a Chinese medicine footbath
in improving sleep quality in hemodialysis patients. Acu-
pressure can stimulate the release of serotonin, which
helps relaxation and promotes sleep and also can relax the
muscles and relieve fatigue, helping to improve body com-
fort, mood, and sleep.
At the same time, cognitive function as measured by
MMSE and the four WMS-RC subscales was also signifi-
cantly improved by applying acupressure. To our knowl-
edge, no study linking acupressure to both improved sleep
quality and cognition has been reported. Although the
MMSE score change in the experimental group did not
reach a 1.0 standard deviation (SD) increase in all cases,
the memory scores of all four WMS-RC subscale scores
did exceed 1–2 SD, suggesting that acupressure has clini-
cal utility for improving or at least protecting cognition in
older adults (Nasreddine et al., 2005).
It is known that poor sleep is related to cognitive
dysfunction in older adults. Westerbeg et al. (2010) found
that poor sleep influenced the severity of memory disrup-
tion and learning ability in patients with mild cognitive
Research in Nursing & Health
impairment. Sleep deprivation can also lead to a decline
in memory, operating capacity, and attention (Sun, Yin, &
Gao, 2013). The result of our mediation analysis, how-
ever, did not support the possible mediating effect of
sleep on cognition. Further investigation is recommended
with a larger sample providing additional power to repli-
cate these findings and possibly extend them to test other
predictors of cognitive improvement. In summary, we
reported for the first time that acupressure training aimed
at enhancing sleep quality appears to increase sleep
quality and improve or at least maintain cognition in older
adults.
Limitations
Several limitations must be noted. First, we did not con-
tact control group participants as often as experimental
group participants, which may have led to a Hawthorne-
effect-like influence on the experimental group. Second,
because participants came from the same community,
contamination between two groups cannot be ruled
out, but would be expected to narrow differences
between experimental and control group outcomes. Third,
the sample size was insufficient to separate direct from
indirect effects of acupressure on cognitive function.
Therefore, overall, these generally positive findings
should be considered as preliminary. Exploring the mech-
anism behind the effects of acupressure on cognitive
function and including measurement of other variables
(such as depression, vascular health, or pain) appear
worthy of investigation in future studies.
Conclusions
To our knowledge, this was the first study to test whether acu-
pressure training aimed at promoting sleep also could improve
cognitive function in older adults. Our results showed that acu-
pressure may not only improve sleep quality but protect or
improve memory functions as well. The acupressure training
used in this study is a safe, practical intervention, which could
be popularized to promote healthy aging.
References
Buysse, D. J., Reynolds, C. F., Monk, T. H., Berman, S. R., & Kupfer,
D. J. (1989). The Pittsburgh Sleep Quality Index: A new instru-
ment for psychiatric practice and research. Psychiatry Research,
28, 193–213.
Chen, N. H., Johns, M. W., Li, H. Y., Chu, C. C., Liang, S. C., Shu, Y. H.,
. . . Wang, P. C. (2002). Validation of a Chinese version of the
Epworth Sleepiness Scale. Quality of Life Research, 11, 817–821.
Chen, W. J., Shou, Y. Q., Li, J. H., Xu, Z. S., & Liu, H. (2007). Appli-
cation of functional magnetic resonance imaging Sanyinjiao acu-
puncture role in the regulation of brain function. Journal of
Physical Medicine and Rehabilitation, 29, 774–779.
 ACUPRESSURE EFFECT ON SLEEP AND COGNITION/ ZENG ET AL.
Dong, L. Q. (2010). Acupuncture points sleep, sleep points with tra-
ditional Chinese medicine treatment of insomnia 30 cases. Hebei
Traditional Chinese Medicine, 32, 537–538.
Ebersole, P., Hess, P., & Luggen, A. S. (2004). Toward healthy
aging: Human needs and nursing response (6th ed.). St Louis,
MO: Mosby.
Garc
a-Alberca, J. M., Cruz, B., Lara, J. P., Garrido, V., Lara, A., &
Gris, E. (2012). Anxiety and depression are associated with cop-
ing strategies in caregivers of Alzheimer’s disease patients:


Results from the MALAGA-AD study. International Psychogeriat-
rics, 24, 1325–1334. doi: 10.1017/S1041610211002948
Gong, Y. X., Xie, G. R., Jiang, D. W., Dai, Z. S., & Zhou, Q. Z.
(1981). Revised Wechsler Memory Scale. Presentation at Chinese
Psychological Society and the Third Congress of the 60th anni-
versary of its founding Conference (Fourth National Conference
on Psychology).
He, J., Gui, J. H., Yu, W. Z., Zhang, Y. H., Qiu, D. H., Xu, J. T., &
Song, Y. B. (2005). Evaluation of MMSE, HIS, ADL in Alzheimer’s
disease screening. Chinese Journal of Birth Health & Heredity,
13, 28–30.
He, Y. F., Huang, J. J., Lai, Y. M., Li, Y. Y., & Tang, H. L. (2009).
Observation on treatment of sleep disorders using manipulation
maneuver. Jiangsu Journal of Traditional Chinese Medicine,
41, 49.
Johar, H., Kawan, R., Emeny, R. T., & Ladwig, K. H. (2016). Impaired
sleep predicts cognitive decline in older people: Findings
from the prospective KORA Age study. Sleep, 39, 217–226.
doi: 10.5665/sleep.5352
Kang, J. X., Zeng, H., & Wang, P. (2011). Correlation between
sleep quality and cognitive functions of older adults in commu-
nity. Chinese General Practice, 14, 439–441.
Kerkhof, G. A., & Dongen, H. V. (2011). Human sleep and cognition
(volume 185): Basic research. Amsterdam: Elsevier Science.
Kopp, C., Longordo, F., Nicholson, J. R., & Luthi, A. (2006). Insuffi-
cient sleep reversibly alters bidirectional synaptic plasticity and
NMDA receptor function. Journal of Neuroscience, 26, 12456–-
12465. doi: 0.1523/JNEUROSCI.2702-06.2006
Li, J. B. (2008). Traditional Chinese medicine (7th ed.). Beijing:
People’s Medical Publishing House.
Liao, W. C., Chiu, M. J., & Landis, C. A. (2008). A warm footbath
before bedtime and sleep in older Taiwanese with sleep distur-
bance. Research in Nursing & Health, 31, 514–528. doi: 10.1002/
nur.20283
Liu, X. C., Tang, M. Q., & Hu, L. (1996). Study on reliability and
validity of Pittsburgh Sleep Quality Index. Chinese Journal of
Psychiatry, 29, 103–107.
Acknowledgments
This work was funded by Hunan Natural Science Foundation (contract grant number: 11JJ5057) and a grant for masters students from Central
South University, China (contract grant number: 2010ssxt056). Professor Mary-Lynn Brecht from UCLA helped us greatly with the data analysis
and other revisions, and Professor David Cohen (also from UCLA) helped us to edit the paper. We express our deep appreciation to them.
Research in Nursing & Health
9
Ma, H., Chang, M., & Lin, C. (2007). A systematic review of acupres-
sure for the application on nursing practice. Journal of Nursing,
54(4), 35–44.
McKibbin, C. L., Ancoli-Israel, S., Dimsdale, J., Archuleta, C., Kanel,
R. V., Mills, P., . . . Grant, I. (2005). Sleep in spousal caregivers of
people with Alzheimer’s disease. Sleep, 28, 1245–1250.
Nasreddine, Z. S., Phillips, N. A., Bedirian, V., Charbonneau, S.,
Whitehead, V., Collin, I., . . . Chertkow, H. (2005). The Montreal
Cognitive Assessment, MoCA: A brief screening tool for mild
cognitive impairment. Journal of the American Geriatrics Society,
53, 695–699. doi: 10.1111/j.1532-5415.2005.53221.x
Nebes, R. D., Buysse, D. J., Halligan, E. M., Houck, P. R., & Monk,
T. H. (2009). Self-reported sleep quality predicts poor cognitive
performance in healthy older adults. Journals of Gerontology
Series B: Psychological Sciences and Social Sciences, 64,
180–187. doi: 10.1093/geronb/gbn037
Nguyen, N. D., Tucker, M. A., Stickgold, R., & Wamsley, E. J. (2013).
Overnight sleep enhances hippocampus-dependent aspects of
spatial memory. Sleep, 36, 1051–1057. doi: 10.5665/sleep.2808
Santos, A. A., Mansano-Schlosser, T. C., Ceolim, M. F., & Pavarini, S. C.
(2013). Sleep, fragility and cognition: A multicenter study with
Brazilian elderly. Revista Brasileira de Enfermagem, 66, 351–357.
Shariati, A., Jahani, S., Hooshmand, M., & Khalili, N. (2012). The
effect of acupressure on sleep quality in hemodialysis patients.
Complementary Therapies in Medicine, 20, 417–423. doi: 1016/j.
ctim.2012.08.001
Sun, P., Yin, J. B., & Gao, A. M. (2013). Effects of sleep deprivation
at different time during night on serum cortisol and cognition
function of healthy men. Acta Academica Medica, 35, 292–294.
Sun, Z. Q. (2010). Medical statistics (3rd ed.). Beijing: People’s
Medical Publishing House.
Tian, Y., Li, L., & Wang, J. (2011). Effects of acupuncture at points of
pericardium channel of hand-jueyin on myocardium enzymes of
rats with myocardial ischemia reperfusion injury. Chinese Journal
of Traditional Medical Science and Technology, 2, 2.
Westerbeg, C. E., Lundgren, E. M., Florczak, S. M., Mesulam, M. M.,
Weintraub, S., Zee, P. C., & Paller, K. A. (2010). Sleep influences
the severity of memory disruption in amnestic mild cognitive
impairment: Results from sleep self-assessment and continuous
activity monitoring. Alzheimer Disease and Associated Disorders,
24, 325–333. doi: 10.1097/WAD.0b013e3181e30846
Yuan, Y. P., Luo, X. M., & Li, L. (2012). Effect of two Chinese medi-
cine physical therapies on sleep quality of hemodialysis patients
with sleeping disorders. Journal of Nursing, 19, 68–70.
Zhang, M. Y. (1993). Handbook of psycho-department rating scale.
Changsha: Technology Publishing Company in Hunan.