Introduction
Human health is related to the quantity and quality of sleep [1]. Insomnia, high blood pressure, improper heart rate and breathing problems are among the types of disorders in old age. Elderly people with insomnia face low quality of sleep on the one hand and physiological fluctuations (blood pressure, heart rate and oxygen saturation in the blood) on the other hand. There is scientific evidence of a relationship between sleep quality and physiological condition [2]. All behavioral therapies that have a fruitful research background are good, but not every person is suitable for them. Combined treatments that can cover more dimensions (physical, psychological and social) of the problem need scientific evaluations, and this cannot be achieved without conducting controlled (interventional-comparative) studies. This study aims to compare the effects of acceptance and commitment therapy (ACT), sleep hygiene education (SHE), and their combination on sleep quality and physiological indicators of the elderly.
Methods
The is a quasi-experimental study with a pre-test/post-test/follow-up design using a control group. The study population consists of the elderly members of Jahandidegan center in Shiraz, Iran. Of these, 80 older adults (Mean±SD age=70.41±4.5 years) were selected using a convenience sampling method and based on the entry and exit criteria. They were randomly divided into four groups (three experimental groups and one control group). The entry criteria included: reading and writing literacy, age over 60 years, getting a periodic insomnia diagnosis based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders- 5th edition [3], not having insomnia caused by medical problems, not having an acute condition of blood pressure (systolic and diastolic pressures >90 and >140, respectively), heart rate (>100) and oxygen saturation in the blood (<90), willingness to cooperate, not smoking, Pittsburgh sleep quality index (PSQI) score >5, and not receiving psychological interventions in the last three months. The exclusion criteria were: Absence from more than one session in experimental groups and willingness to continue cooperation.
The ACT group received the intervention based on the protocol proposed by Fletcher [4] at 8 sessions of 90 minutes, two times per week. The SHE group received the intervention based on the protocol proposed by Espie [5] at 4 sessions of 30 minutes, and the combined group received both ACT and SHE, while the control group received no intervention. Data were collected by using the PSQI, a mercury sphygmomanometer, and a pulse oximeter at pretest, post-test, and follow-up phases.
Results
In this study, the number of female participants was more than males (80% vs. 20%). There was no significant difference between the groups in terms of gender, educational level, employment status, marital status and age (P>0.05). Most of the participants had high school education, were retired and living alone. The mean and standard deviation of the score of sleep quality, heart rate, oxygen saturation in blood, and systolic and diastolic blood pressures in pre-test, post-test and follow-up phases are presented in Table 1.


Two-way mixed ANOVA was used to assess the effect of each intervention. The results showed that the interaction between intervention and time factor was significant (F=15.34, P<0.001). To assess the difference in the sleep quality among the pre-test, post-test and follow-up phases, one-way repeated measure ANOVA was used, which was reported significant (P<0.05). The results of Tukey’s post hoc tests showed a significant difference in the sleep quality of the experimental groups (SHE, ACT and SHE+ACT) between the post-test and pre-test phases, but not between the post-test and follow-up phases. The effect size of intervention in the combined group (0.83) was higher than in the SHE (0.67) and ACT (0.60) groups (Table 1).
To determine the effect of interventions on physiological parameters (blood oxygen level, heart rate, and systolic and diastolic blood pressures) of the elderly, multivariate analysis of covariance was used. According to the obtained results, Wilks’s lambda, which shows the effect of group type in the post-test (F=5.68, P<0.001) and follow-up (F=4.28, P<0.001) phases, was significant. The statistics of univariate analysis of covariance for each dependent variable showed that the group effect was significant on the post-test scores of all variables (P<0.005) except for diastolic blood pressure. However, in the follow-up phase, its effect was significant only on oxygen saturation in blood and systolic blood pressure (P<0.001). The greatest effect of interventions on reducing systolic blood pressure was related to the combined intervention, followed by SHE. Regarding the effect on blood oxygen saturation, the greatest effect was related to the combined intervention, followed by ACT. Regarding the effect on heart rate, the greatest effect was in the post test phase related to the combined intervention, followed by ACT.
Conclusion
All three treatment methods (ACT, SHE, and combined treatment) can improve the sleep quality and consequently systolic blood pressure and oxygen saturation in the blood of the elderly. Each of these methods are useful according to the mental and behavioral capacity of the elderly, where the combined treatment has superiority. Treatment centers for the elderly can implement these methods by employing mental health specialists along with other specialists in the medical field. With psychological investigations about the underlying factors and screening people prone to insomnia, high blood pressure and lack of dissolved oxygen in the blood entering old age, they can be targeted for ACT, SHE, or both. This can improve their psychological and physical health. Drug therapy is not the only and the best possible solution for the elderly; it is better to combine this treatment with proposed methods.

Ethical Considerations
Compliance with ethical guidelines
All ethical principles in this study were according to the guidelines of the ethics committee Islamic Azad University of Yasouj branch (Code: 12020706972007).

Funding
The current research is taken from the doctoral dissertation of Reza Motaghi, Department of Psychology, Faculty of Humanities, Islamic Azad University of Yasouj.

Authors' contributions
Conceptualization of research: Alireza Mardpour, Shirali Khoramin; Research design: Alireza Mardpour; All authors discussed the results and contributed to the final writing.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The researchers of this study would like to thank all elder members of Jahandedhgan center in Shiraz who participated and helped us in this study, Yasooj University of Medical Sciences Management, Vice-chancellor for research of Islamic Azad University of Yasooj branch.
 

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