Correlates and influences of taking an afternoon nap on nocturnal sleep in Chinese elderly: A qualitative study 中国老年人午睡与夜间睡眠的相关性及影响:一项定性研究 ABSTRACT Objective Taking afternoon naps is common among elderly people, but the information about napping from qual- itative viewpoints is limited. This study aimed to describe napping experience from the perspectives of Chinese elderly, specifically on nap taking correlates and its influences on nocturnal sleep. Design A qualitative study Setting Taiwan Population and Methods Data were gathered via individual in-depth interviews with 50 Chinese elderly in Taiwan. Results The majority of the nappers napped for 1–2 hours between 12 PM and 1 PM. Nap promoting factors included “belief in afternoon nap taking benefits,” “nothing to do,” “low energy level,” “compensation -for disturbed sleep” and “extreme weather.” Nap taking (>1 hr.) was found to be associated with delay of the onset of sleep, reduction of sleep duration, and light sleep.Short afternoon napping (<1 hour) is recommended for the elderly. Conclusion Future research should determine the direction of the causative association between afternoon nap-taking and nocturnal sleep. Key words: Napping Older adult Sleep 摘要 目的 午睡在老年人中很常见，关于午睡定性研究的信息很少。这项研究旨在从中国老年人的角度来描述午睡经验，特别是关于午睡的相关因素及其对夜间睡眠的影响。 设计 一项定性研究 地点 台湾 研究对象及方法 通过对台湾50名中国老年人的个人深入访谈收集数据。 结果 发现午睡时间大于1小时的老年人与夜间睡眠开始的延迟，睡眠时间减少和浅睡眠有关。建议老年人午睡时间少于1小时。 结论 未来的研究方向应该确定午睡和夜间睡眠之间的因果关系。 关键词：午睡；老年人；睡眠 Introduction Afternoon nap-taking is common among older adults, and its prevalence rate varies from 25% to 60%, with a wide range of nap duration (0-240 mins) in different countries. Could such a difference in the prevalence and nap duration be explained, in part, on the basis of personal prospectives about napping and the changes in daily life routine after retirement? What encourages older adults to take a nap? Thus far, there a lackof information that can answer these questions. Most of existing literature focuses on the association between day time napping and health factors.For example, in a study that investigated the relationship of mortality with day time nap duration in older adults who were followed for up to 19 years. found that napping ≥30 minutes was associated with not only prevalent depressed mood, coronary heart disease, and cancer, but also with the mortality of such problems. Leng and colleagues also reported that both subjective and objective napping were significantly related to age and comorbidities, such as heavily drinking alcohol, smoking, depression, diabetes, dementia, obesity, stroke, and myocardial infarction. However, these studies did not provide a definitive explanation for the causal relationship between napping and health factors. 前言 老年人中约有25%到60%的老年人午睡，不同国家的午睡时间(0-240分钟)差异很大。午睡发生率和午睡时间的这种差异，是否与个人对午睡的看法以及退休后日常生活规律的变化有关呢?又是什么促使老年人的午睡习惯呢？到目前为止，对这些问题没有明确的研究数据来解释。大多数现有的文献多集中于午睡和健康因素之间的相关性研究。例如，一项研究中，作者跟踪调查老年人19年，研究其死亡率与午睡时间的关系，发现午睡时间超过30分钟不仅与抑郁情绪，冠心病和癌症有关，而且还与其引发的死亡率有关。Leng和同事指出，主观和客观的午睡均与年龄和共病有显著相关，如酗酒，吸烟，抑郁，糖尿病，痴呆，肥胖，中风和心肌梗塞。然而，这些研究并未对午睡和健康因素之间的因果关系提供明确的解释。 There is no consensus about the relation between afternoon napping and nocturnal sleep. The pros and cons of afternoon napping in older adults are uncertain, and whether they should nap or avoid napping is debatable. Some researchers have reported that napping often is used to compensate for poor nocturnal sleep as people age.However, Leland et al. contended that excessive daytime napping can have a negative impact on nocturnal sleep and give rise to a cycle of poor sleep.Daytime napping not only reduces sleep efficiency and total nocturnal sleep time but also de- creases sleep quality.Goldman et al. administered actigraphy and sleep diaries to measure nocturnal and daytime napping in a sample of 235 older adults. They found that the possibility of daytime nap-taking was higher for older adults with higher levels of nocturnal sleep fragmentation. In an analysis of data (n = 2001), Jung and colleagues reported that older adults sleeping less than 6 hours per night napped longer during the day. Nevertheless, Li et al. found that older adults who reported less napping tended to have less nocturnal sleep duration. The findings of a few studies indicate no association between napping and nocturnal sleep. Can qualitative inquiry help fill the gap in understanding the association between afternoon napping and nocturnal sleep? 关于午睡和夜间睡眠之间的关系，业内目前还没有形成共识。老年人午睡的好处和坏处还不确定，他们是否应该午睡还存在争议。一些研究人员说,随着人们年龄的增长，午睡经常被用来弥补夜间睡眠不足。然而，Leland等人认为午睡时间过长会对夜间睡眠产生负面影响，并导致循环性的不良睡眠。午睡不仅会降低睡眠效率和夜间睡眠时间，还会降低睡眠质量。Goldman等人使用管理活动记录和睡眠日记，评估以235名老年人为样本的夜间和白天的睡眠状况。他们发现，夜间睡眠零碎程度较高的老年人白天午睡的可能性较高。在数据分析（n = 2001）中，Jung及其同事据报道，白天睡眠时间少于6小时的老年人白天打盹时间更长。尽管如此，Li等人研究发现，午睡时间越短的老年人，夜间睡眠时间越短。一些研究的结果表明，午睡和夜间睡眠之间没有关联。定性调查是否有助于理解午睡和夜间睡眠之间的联系呢？ Cultural norms and rituals play a role in shaping sleep habits and account for variability among cultures in regard to sleep-patterns.An afternoon nap is considered part of a healthy lifestyle from a cultural perspective in many countries. It is a tra- ditional practice common in Taiwan, China, and Mediterranean countries, to name a few. Chinese view an afternoon nap as complementary sleep and a healthy activity that is especially beneficial to older adults who may have nocturnal sleep problems.Many Chinese older adults believe that it is important to maintain whole- ness and congruity among all parts of the human body by balancing Yin and Yang forces, and that regular daily sleep is a significant method to maintain the balance of the two forces.Daytime napping between 11 AM and 1 PM and going to bed by 11 PM are encouraged to benefit human health because these two periods are considered critical for the exchange of Yin and Yang forces.Nowadays is afternoon napping still considered by older adults a traditional practice? This question remains unanswered. 文化规范和仪式在形成睡眠习惯方面发挥了重要作用，并解释了不同文化在睡眠模式方面的差异。从许多国家的文化角度来看，午睡是一种健康的生活方式。以中国包括台湾地区和地中海国家常见的传统做法为例。中国人认为午睡是一种补充性的睡眠和健康行为，对于可能有夜间睡眠问题的老年人来说尤其有益。许多中国老年人认为，通过平衡阴阳力来维持人体各部位的整体性和一致性是很重要的，而有规律的常规睡眠是维持两种力量平衡的重要方法。我们鼓励在上午11点到下午1点之间以及晚上11点之前上床睡觉，因为这两个时期对于阴阳力量的交换至关重要。如今午睡是否仍被老年人视为传统习俗？这个问题仍然没有解答。 Based on the aforementioned information and the questions raised by the author, this study aimed to use qualitative inquiry to gain a comprehensive understanding of napping behaviors, correlates of napping, and how afternoon nap-taking relates to nighttime sleep. The reasons for utilizing qualitative inquiry in this study are as follows: First, napping behaviors are individually associated with certain correlates and are affected by the personal perspectives of a variety of ethnic groups of older adults.These older adults may have different cultural beliefs and practices pertaining to napping. Under these circumstances, quantified measurements are not efficient to gather the information on napping from personal perspectives. Second, napping research has traditionally emphasized quantitative methods, especially self-reported questionnaires, of data collection. It is questioned whether quantified measurements alone can gather ample information to understand napping behaviors under various circumstances for different ethnic groups.According to Bliwise’s recommendation, researchers should utilize qualitative inquiries to gain a better insight about napping and its correlates due to the complexity of napping behaviors. Although sleep diaries, which can provide qualitative data, have been utilized in few studies, the use of sleep diaries can be influenced by educational levels and physical functions, such as vision and ability in hand movements. Taiwanese older adults who are especially older than 70 years have lower educational levels than younger adults, and they may have hard time keeping a sleep diary. Thus, this qualitative study employed in-depth interviews to collect data. 基于上述信息和作者提出的问题，本研究旨在使用定性研究来全面了解午睡行为，午睡的相关性，以及午睡与夜间睡眠的关系。在本研究中使用定性研究的原因如下：首先，午睡行为与某些相关因素单独相关，并受到各种老年人群体的个人观点的影响。这些老年人可能有不同的文化信仰和个人习惯。 在这些情况下，量化测量不能有效地从个人角度收集关于午睡的信息。其次，午睡研究传统上强调数据收集的定量方法，尤其是自我报告的问卷。有人质疑量化测量是否可以收集足够的信息，来理解不同种族群体在不同情况下的午睡行为。根据Bliwise的建议，由于午睡行为的复杂性，研究人员应利用定性研究来更好地了解午睡及其相关性。尽管睡眠日记可以提供定性数据，且已在少数研究中应用，但是睡眠日记的使用会受到教育水平和身体功能的影响，例如视力和手的灵活性。特别是70岁以上的台湾老年人的教育水平低于年轻人，并且他们可能很难保持书写睡眠日记。因此，这项定性研究采用深度访谈来收集数据。 Methods Setting and participants The recruitment flyers were initially distributed in city parks of the Taipei region, where older adults frequent for socializing with people. The study information was also explained by using a Chinese consent form approved by the Human Subjects Institutional Review Board of the University of Washington ( 41924). However, cold temperatures and frequent rain rendered this recruitment plan not completely practical as Chinese elderly tended to stay at home rather than congregating in city parks under these weather conditions. Thus, new research sites were added including city or town parks in south- ern Taiwan where there was sunnier weather. Eighty older adults aged 60–104 years were approached and 51 of them gave their consent to participate in this study. One interview was dropped because the participant had a hearing problem and as a result, one of his family members became too involved in the interview. Of the entire valid sample (N = 50), 35 participants were recruited from northern Taiwan, and 15 were recruited from southern Taiwan. 方法 地点与研究对象 参与者的招募分布开始定在台北地区内的城市公园，因为老年人经常在此与人交往。研究信息也通过使用华盛顿大学人类参与者机构审查委员会批准的中国同意书来阐述（41924）。然而，因为天气寒冷和经常下雨的缘故，中国老年人不会聚集在公园而情愿呆在家里，使得这项招聘计划不能完全实用。故增加了新的研究地点，包括台湾南部的城市或城镇公园，这里有阳光明媚的天气。接触了80名年龄在60-104岁的老年人，其中51人同意参加本研究。因为一个参与者有听力问题，并且他的一个家庭成员过于参与了访谈，此次采访被撤销。在整个有效样本中（N = 50），从台湾北部招募了35名参与者，从台湾南部招募了15名参与者。 Convenience sampling was the major method to recruit the participants. The recruitment efforts were supplemented by snowball sampling. Inclusion criteria were: participants had to (1) be ethnically Chinese who could speak Taiwanese or Mandarin; (2) be able to reflect on their lives; and (3) have a score > 24 on the mini-mental status exam.The exclusion criteria were: (1) individuals who were receiving oxygen treatment (e.g., the use of portable oxygen); (2) wheelchair bound individuals; (3) individuals with medical problems that disturb sleep, e.g., pain, congestive heart failure, Parkinson’s disease, obstructive sleep apnea, multiple sclerosis, chronic obstructive pulmonary disease, stroke, cancer under treatment; and (4) individuals with psychiatric disorders, e.g., depression and dementia. 便利抽样是招募参与者的主要方法，滚雪球抽样补充了招募工作。纳入标准是：参与者必须（1）成为中国人，可以说台语或普通话;（2）能够反思自己的生活;（3）在简易的心理状态考试中得分> 24。排除标准是：（1）接受氧气治疗的个体（例如，使用便携式氧气）;（2）使用轮椅的老年人;（3）患有睡眠障碍类的医疗问题，例如疼痛，充血性心力衰竭，帕金森病，阻塞性睡眠呼吸暂停，多发性硬化症，慢性阻塞性肺病，中风，接受治疗的癌症;（4）患有精神疾病的人，例如抑郁症和痴呆症。 Data collection An in-depth interview, lasting approximately 60 minutes, was utilized to gather the data.“Naturalistic inquiry” was used as a philosophical framework to guide in-depth interviews. Naturalistic inquiry, “a special form of inquiry,” stresses the natural integrity of a phenomenon under study; the phenomenon should be studied in its “natural ongoing character without imposing a fixed preconceived order on it” (pp.94).The in-depth interviews primarily were initiated with the question:“Do you take naps regularly, at least 3 times per week?”Those who answered in the affirmative were asked: “Tell me about your naps and night time sleep.”Probing questions and follow-up questions were asked to expand upon specific topics. The questions included: (1) on average, how many hours do you nap each time?; (2) in your opinion, how are your naps and nighttime sleep related?; (3) why do you take a nap during the day? Throughout the interview process, vocal intonations, physical expressions, and gestures that could not be audible in the recorded interview were described in field notes. 数据收集 采用持续约60分钟的深度访谈来收集数据。采用“自然式探究”作为指导深度访谈的哲学框架。自然式探究是一种特殊的探究形式，它强调了对正在研究现象的自然完整性;研究这种现象应该以其“自然持续的特征而不对其强加先发制人的命令”进行研究。深入访谈主要是以下问题开始的：“你是否经常午睡，每周至少3次？”那些持肯定回答的人接着会被问到：“请介绍一下你的午睡和夜间睡眠的情况。”探讨问题并且要求后续问题扩展特定主题。过程中会问及调查性问题和后续问题以对特定的话题进行详细论述。问题包括：（1）平均而言，每次午睡多少小时？（2）在您看来，您的午睡与夜间睡眠有何关系？（3）你为什么白天午睡？在整个采访过程中，录音采访中听不到的语调、身体表情和手势都在现场笔记中加以说明。 Coding and data analysis The approaches of content analysis were used to sort the interview texts.The texts were divided into “meaning units,” (meaningful statements) that were labeled with a code. The initial codes were compared, and similar codes were sorted into catego- ries. The tentative categories and codes were analyzed by the principal investigator and two qualitative researchers. Codes with similar meanings were categorized together and developed into a theme. All meaning units, codes, categories, and themes, were integrated into a codebook. 程序和数据分析 采用内容分析法对访谈文本进行排序。文本分为“意义单位”（有意义的语句），用代码标注。对初始码进行比较，并将相似码进行分类。主要研究者和两名定性研究人员分析了暂定类别和代码。具有相似含义的代码被分类在一起并发展成为一个主题。所有含义单位，代码，类别和主题都集成到码本中。 Trustworthiness Four techniques were followed to assess the trustworthiness of this qualitative inquiry: peer debriefing, member checking, inter-coder agreement, and audit trail.Peer debriefing was conducted by an American anthropologist who is proficient in Chinese to exam the accuracy of text translation and data interpretations. The meaningful findings generated from one interview were tested with subsequent interviewees. Two coders coded the interview text in-dependently and then discussed the results to reduce coding bias and to come to a consensus on the findings. The authenticity of the data was scrutinized by discussing codes of interview text and developing themes during the ongoing data analysis. 可信度 遵循四种方法来评估此次定性研究的可信度：同行汇报，成员检查，一致性和审计跟踪。同行汇报由一名美国人类学家以中文的方式，检查文本翻译和数据解释的准确性。一次采访产生的有意义的结果也会对随后的受访者进行测试。两位编码员独立编码了访谈文本，然后讨论了结果，以减少编码偏差，并对结果达成共识。在进行数据分析的过程中，通过讨论访谈文本代码和研究的主题来审查数据的真实性。 Results Participants Twenty-three Chinese men and 27 Chinese women took part in the study. The mean age of the participants was 76.3 ± 11. As indicated in Table 1, the vast majority of the participants were married or widowed and lived with their offspring. Educational levels for 72% of the participants were at or lower than elementary school. Twenty-eight percent of the participants worked full time or part time. 结果 参与者 23名中国男性和27名中国女性参加了这项研究。参与者的平均年龄为76.3±11。如表格1所示，绝大多数参与者都是已婚、丧偶或与后代一起生活。72％的参与者的教育水平等于或低于小学。28%的参与者要全职或兼职工作。 The prevalence rate of napping was 54% (n = 27) in all participants. The vast majority of the nappers took a nap for 1–2 hour in the afternoon, most often between 12 PM and 1 PM. 在所有参与者中，午睡的发生率为54％（n = 27）。绝大多数的午睡者在下午小睡1-2小时，最常见的是在下午12点到下午1点之间。 As shown in Table 2, three themes were identified from the interview data: (1) viewpoints about napping; (2) nap promoting factors, with subthemes of “belief in napping benefits”, “nothing to do”, “low energy level”, “compensation of disturbed sleep”, and “extreme weather”; (3) influences of napping, including subthemes of “disturbed nighttime sleep patterns”, and“no change in night time sleep patterns”. 如图所示表2，从访谈数据中确定了三个主题：（1）关于午睡的观点;（2）午睡发生因素，包括“相信午睡有益”，“没事做”，“精神不佳”，“补偿夜间睡眠不足”和“极端天气”;（3）午睡的影响，包括“夜间睡眠模式紊乱”以及“夜间睡眠模式没有变化”。 Viewpoints about napping All participants call napping “kun dao” in Taiwanese (Kun means “sleep” and “dao” refers to“afternoon”). Napping was viewed by most participants as a “habit,” “policy,” and “cultural tradition.” They described that they usually felt sleepy and needed to nap between 12 PM and 1 PM, but the feeling of sleepiness tended to disappear after 1 PM if they did not nap. Furthermore, napping was a cultur- al tradition in former times and is a school policy for younger students nowadays. 关于午睡的观点 所有参与者都称午睡为“kun dao”（Kun表示“睡觉”，“dao”表示“下午”）。大多数参与者认为午睡是一种“习惯”，“政策”和“文化传统”。他们描述他们通常感到困倦，需要在下午12点到下午1点之间打盹，如果他们没有午睡，困意会在下午一点之后消失。此外，午睡在以前是文化传统，现今对于中小学生而言也是一项学校政策。 Look back at people in the olden days. The older generation took a nap in the afternoon. People that worked for the government napped in their offices after lunch. It was a social and cultural tradition. This is different from American culture. I worked for a company in the US when I was young. I only had a 45 minute break at noon. So, I did not have time to nap…In Taiwan students are asked to nap after lunch in their schools…The schools have their reasons for this policy. 回顾往日的人们，老一辈的人们会在午后小睡。午餐后，政府工作人员会在他们的办公室打盹，这是一种社会文化传统习惯。美国文化不同，我小时候在美国的一家公司工作过。我中午只有45分钟的休息时间，所以，我没有时间午睡；在台湾，学校要求学生们在学校午餐后小睡。 Nap promoting factors Belief in napping benefits Thirty-seven percent of the nappers believed that afternoon napping could improve their energy level and benefit their health. They felt refreshed without a feeling of tiredness, and their brain became sharper after napping. They also assumed an afternoon nap is necessary when they got up in the early morning. 促进午睡的因素 相信午睡有益 37％的午睡者认为午睡可以提高他们的精神水平并对自身健康有益。他们感到神清气爽，没有疲倦感，午睡后他们的大脑变得更加敏锐。他们还坚称对于早晨过早起床的自己，午睡是非常必要的。 I usually feel sleepy after lunch because I get up at 5 AM…so I nap for one hour. It is good to take a nap at 12:30 -1:00 PM. If I take a nap in the afternoon, I will be refreshed and energetic. If I do not do it, I will feel listless. If my energy level is high, I can exercise…so, I can maintain my health. 我经常在午饭后感到困倦，因为我早上5点起床...所以我午睡了一个小时。最好在12:30 -1:00 PM小睡一下。如果我午睡，在下午会精神焕发，精力充沛。如果中午不休息，我会感到无精打采。如果我的精神水平很高，我还可以参加运动......所以，通过午睡，会有益于我的健康。 Nothing to do Five participants napped due to nothing to do after lunch. They tended to switch on their TV sets when they napped. They teased themselves for that by saying that “the television set watches me when I am napping.” 无事可做 5名参与者在午餐后因无所事事而午睡。当他们午睡时，往往喜欢打开电视机。他们常常自嘲道“电视机在我打盹时看着我”。 “I think that it is a habit that I snooze when I have nothing to do. After lunch if I do not have something to do, I usually turn on my TV set and nap when I watch a TV program. My daughter teased me for that by saying that the television set watches me rather than I watch TV. I feel “bian shui bian xing” (half asleep and half awake) when I nap. If I see my neighbors sitting in their yards, I will go to chat with them and do not nap that afternoon. “我觉得这是一种习惯，当我无事可做时，我会打瞌睡。午饭后，如果我没有事情要做，我通常在看电视节目时打开电视机和午睡。我的女儿会和我开玩笑说：电视机看着你而不是你在看电视。我午睡的时候感觉“半睡半醒”。如果我看到我的邻居坐在他们的院子里，我会去和他们聊天，那天下午就不会午睡了。 Low energy level Eight participants reported that they needed to nap due to the feelings of sleepiness and tiredness in the afternoon. 精神不佳 8名参与者说道，他们午睡是因为下午会困倦并有疲倦感。 I nap almost every afternoon because I feel tired easily and have no energy owing to swimming in the early morning. It is ideal to nap for one hour when I am not energetic. It is easy for me to feel sleepy at 1 - 2 PM or so after my lunch, thus I usually nap around that time. 我几乎每天下午都会打盹，因为我很容易感到疲倦，因为清晨游泳而没有精力。当我精力不足时，最好是午睡一小时。在午饭后1-2点左右，我很容易感到困倦，因此，我通常会在这个时间段打盹。 Compensation of disturbed sleep Four participants reported that the main reason for them to nap in the afternoon was to compensate for poor night time sleep due to work and restless mind. 补偿夜间睡眠不足 4名参与者在报告中说，他们下午午睡的主要原因，是为了弥补因工作和心神不安而导致的夜间睡眠不佳。 If I do not sleep well at night, I will catch up on sleep the next day. I will take a nap in the afternoon. Even though I only nap for 10 - 20 minutes, it helps me catch up on sleep that I have lost. In this way, my sleep is enough. I think napping helps one catch up on sleep that one has lost at night. 如果我晚上睡不好，我会在下午小睡一会进行弥补。虽然我只睡10-20分钟，但它补充我的睡眠不足。所以，我认为午睡可以帮助人们弥补晚上的睡眠不足。 Extreme weather Seven participants reported that weather was associated with napping behaviors, and they were more likely to nap when the weather was extreme, either when it was very hot or when it was very chilly. 极端天气 7名参与者报告说，午睡行为与天气情况有关。当有极端天气时，无论是天气是非常热还是非常寒冷，他们都更容易打盹。 I am an orchardist. I grow different fruits in a mountainous area. In the summer, the daytime is longer. If it is too hot to work in the afternoon or if it rains, I nap until it is not too hot. I cannot tolerate working in extremely hot weather. I eat my lunch at about 12:30 PM. After lunch, I nap about 10–20 minutes. I nap only if the sunlight is too strong and the weather is extreme. 我是一名果园主。我在一个山区种植不同的水果。在夏天，白天时间更长。如果下午工作太热或下雨而不能工作，我会小睡一会直到天气不很热。因为我无法接受在炎热的天气里工作。我在12:30左右吃午饭，午饭后，我小睡大约10-20分钟。但只有在阳光太强或其他极端天气的情况下我才会打盹。 The influences of napping Disturbed nighttime sleep patterns Sixteen participants reported that they would “toss and turn”,“have difficulty falling asleep,” and “do not fall asleep easily” at night if they took a nap for more than one hour in the afternoon. They needed to spend an additional 20–30 minutes to fall asleep those nights. According to eight participants’ perspectives, napping disturbed nocturnal sleep and resulted in light sleep. Their wakefulness after sleep onset increased. They reported “felt half asleep and half awake” during their sleep. Furthermore, napping shortened their sleep duration and postponed their bedtime. 夜间睡眠模式紊乱 16名参与者报告，如果他们午睡时间超过一个小时，晚上便会“辗转反侧”，“难以入睡”和“不能很快入睡”。他们需要多花20-30分钟才能入睡。根据8位参与者的观点，午睡打扰了夜间睡眠并会导致浅睡眠。他们在入睡后的清醒程度增加。在睡觉时总会有“半睡半醒”的状态。总之，午睡缩短了他们的睡眠时间，并且延长了他们的入睡时间。 If I “kun dao,” I will not fall asleep easily at night. I feel that I seem to be awake during my sleep. If I nap in the afternoon, I will be more likely to have diverse dreams… If I do not work in my store, and I nap too long during the day time, I will not feel sleepy and will go to sleep later than the nights I do not nap. 如果我白天午休，我晚上不会轻易入睡。我觉得我在睡觉时似乎很清醒。如果午睡，我将更有可能做各种各样的梦，而白天不午睡则不会做各种梦。如果我不在商店工作，且在白天睡得太久，我不会感到困倦，晚上也会睡的比较晚。 No change in nocturnal sleep patterns As opposed to the aforementioned results, seven participants reported that their sleep patterns had nothing to do with napping status. Their sleep patterns were the same whether or not they napped in the afternoon because they believed that the older adults’ biological clock was fixed and sleep was habitual. 夜间睡眠模式没有变化 与上述结果相反，7名参与者报告他们的睡眠模式与午睡习惯无关。无论他们是否午睡，他们的睡眠模式是相同的。因为他们认为睡眠时间已经养成了生物钟，不会因此改变。 My night time sleep is not related to napping in the afternoon. Unlike other old people, my sleep at night is the same whether or not I nap in the afternoon because my night time sleep patterns are fixed. 我的夜间睡眠不受午睡习惯影响。与其他老人不同，无论我是否午睡，我夜间睡眠总是相同的，因为我的夜间睡眠模式是固定的。 Discussion Compatible with the findings of the foregoing Taiwan researchers,all nappers in this study reported that they regularly napped after lunch between 12 PM and 3 PM. This indicates that afternoon nap-taking is still a common practice for older adults nowadays as it was in the olden days. “After-lunch napping,” is traditionally believed to be common and an element of a good lifestyle for the older adults in Taiwan.Historically, agriculture was a central practice in Taiwan where the heat and humidity are very high in the summer. Working on agricultural lands in the afternoon was discouraged because heat and humidity are thought to be harmful to the harmony of human organs.Thus, the high preference for afternoon naps by the participants of this study may be associated with this traditional belief and heritage. However, these notions contradict Yoon et al.’s (2003)report that older adults are more likely to nap in the evening, especially within two hours before bedtime, compared to their young counterparts. They speculated that evening naps may be associated with advances of circadian rhythms that promote early bedtimes and shorten sleep latencies. 讨论 与上述中国台湾研究人员的结果相符，本研究中的所有午睡者在访谈中都说他们经常在午餐后12点到3点之间午睡。这表明，就像在过去那样，现在午睡对于老年人来说仍然是一种常见的做法。传统认为“午餐后午睡”是台湾老年人常见的一种生活方式。从历史上看，台湾的支柱产业是农业，夏季温度和湿度都很高。因为考虑到高温高湿的环境，不鼓励下午在农田上劳作，因为会对人体器官产生危害。因此，本研究的参与者对午睡的高度偏好可能与这种传统的生活方式有关。然而，Yoon等人（2003）的报告与这些观点相矛盾，他们提出与年轻人相比，老年人更有可能在晚上，特别是在睡前两小时内进行小睡。他们推测，晚上小睡可能与昼夜节律的改善有关，而昼夜节律的改善会促进早睡和缩短睡眠延迟。 Could the differences in the prevalence and nap duration be explained on the basis of the changes in daily life routine of older adults after retirement? The finding of this study still could not provide a definitive answer to this question. The main reason for the participants to take a nap was their belief in napping benefits, as only a few participants (n = 5) napped due to nothing to do after retirement. This might be due to the fact that 28% of the participants still worked full time or part time during the study. Those participants had a regular life routine. Cheng and colleagues (2017) specu- lated that working increases the development of social networks with friends and colleagues outside of the household. Retired older adults have weaker social networks and fewer social engagements, which increase the opportunity for napping. 是否可以根据退休后老年人日常生活常规的变化，来解释发生率和午睡时间的差异呢？这项研究的结论，仍无法为这个问题提供一个确切的答案。参与者午睡的主要原因是他们相信午睡是有益的，因为只有少数参与者（n = 5）因退休后无事可做而午睡。这可能是因为28％的参与者在研究期间仍然全职或兼职工作。这些参与者均有一个规律性的生活方式。Cheng及其同事（2017）研究指出工作会增加与家庭以外的朋友和同事的社交网络的发展。退休的老年人社交网络较弱，社交活动较少，这也增加了午睡的发生率。 The gap in knowledge as to what specific effect napping has on nocturnal sleep and whether napping should be recommended or not is still undetermined in this study. The qualitative inquiry helped the author gain insight into how the different length of daytime napping and nighttime sleep are related to the personal perspectives of older adults. Most participants in this study reported that napping in the midday for more than one hour contributes to difficulty falling asleep, a decrease in sleep duration, poor quality of sleep, and an increase in wakefulness after sleep onset (WASO). These findings are in agreement with Monk et al.’s finding (2001) that a 90-minute afternoon nap significantly caused a reduction of 2.4% in nocturnal sleep efficiency, a diminution of 48–51 minutes in total nocturnal sleep time, and earlier wake times following an afternoon nap in nappers (6:43 AM) versus non-nappers (7:19 AM). An explanation for the inverse relationship between napping and nocturnal sleep is that diurnal napping decreases the homeostatic drive to sleep at the usual bedtime, causing delayed sleep onset and a further reduction in nocturnal sleep. Conversely, the reason for some participants to nap was the feeling of sleepiness and compensation for nocturnal sleep disturbance. Many researchers found that day time sleepiness occurs from fragmented night time sleep, and napping represents an attempt to compensate for this nocturnal sleep deficit. 目前尚不清楚午睡对夜间睡眠的具体影响，以及是否应建议午睡。本次定性研究帮助作者深入了解了不同长度的午睡和夜间睡眠与老年人的个人观点有关。本研究中的大多数参与者报告说，在中午午睡超过一小时会导致难以入睡，睡眠持续时间减少，睡眠质量差以及睡眠起始后觉醒（WASO）增加。这些结果与Monk等人的发现（2001）一致，他们指出90分钟的午睡显著导致夜间睡眠效率降低2.4％，夜间睡眠总时间缩短48-51分钟以及早晨早醒（午睡者 早上6:43；不午睡者 上午7:19）。对午睡和夜间睡眠之间的负相关的解释是，昼夜午睡减少了在通常的就寝时间睡眠的稳态驱动，导致睡眠延迟和夜间睡眠的进一步减少。相反，一些参与者打盹的原因是睡眠的感觉和夜间睡眠障碍的补偿。许多研究人员发现，白天的困倦是由于夜间睡眠不足造成的，而午睡则是为了弥补这种夜间睡眠不足。 The possibilities for no definitive relationship between napping and nocturnal sleep reported by the participants in this study are as follows. First, some older participants may not have been aware of unintentional naps, such as dozing off during solitary activities (e.g., watching television), and thus they may underestimate the association between napping and nocturnal sleep. Second, Martin and Ancoli-Israel found that it is difficult to determine the direction of the causative relationship, and the direction may vary across individuals.Leng and colleagues found that older adults may tend to doze off frequently during the day but may have difficulties recalling these brief napping episodes. Unplanned dozing-off episodes are more likely to be missed by self-report but are captured by actigraphy. Therefore, future research should explore napping behaviors of older adults by using both actigraphy and qualitative inquiry. Clarification of these associations may help health care providers determine whether or not to recommend daytime naps to community-dwelling older adults. 本研究报告体现的参与者的午睡和夜间睡眠之间没有确定关系的可能性如下。首先，一些年长的参与者可能没有意识到无意识的小睡，比如在独自活动时打瞌睡（例如，在看电视时），由此他们可能低估了午睡和夜间睡眠之间的关系。其次，Martin和Ancoli-Israel发现很难确定因果关系，因为这个方向可能因人而异。Leng和同事们发现，老年人可能会在白天经常打瞌睡，但可能难以回忆起这些短暂的午睡事件。计划外的瞌睡发生更有可能被自我报告错过，但却被体动记录仪捕捉到。因此，未来的研究应该通过使用体动记录仪和定性研究来探索老年人的午睡行为。解释这些关联性可能有助于医疗保健工作者，确定是否建议在社区居住的老年人进行午睡。 This work adds the information about napping correlates fromthe personal perspectives of older adults to the literature. It also provides further evidence that afternoon nap taking is a commonpractice of Chinese older adults, and it appears to worsen nocturnal sleep only if Chinese older adults nap for more than one hour. Nap taking behaviors of older adults may be influenced by different factors, including personal beliefs, physical status, and daily life situations. There is no need to restrict older adults’ afternoon napping unless it impedes their nocturnal sleep. It is crucial for health care providers to assess napping behaviors and determine their link with day time sleepiness and nocturnal sleep before making clinical recommendations. To determine the direction of the causative relationship between daytime napping and fragmented nocturnal sleep, longitudinal and causative research is recommended. 这项工作是从老年人个人角度阐释午睡信息的文献。它还提供证据表明午睡是中国老年人常见的做法，中国老年人午睡超过一小时才会影响到夜间睡眠。老年人的午睡行为可能受到不同因素的影响，包括个人信仰，身体状况和日常生活情况。同时，没有必要限制老年人午睡，除非午睡已影响到他们的夜间睡眠。对卫生保健提供者来说，在提出临床建议之前，评估午睡行为并确定其与白天嗜睡和夜间睡眠的关系至关重要。为了确定白天午睡和断续的夜间睡眠之间的因果关系，建议进行纵向和病因研究。 表1：参与者的社会人口学特征 表2：主题/子主题/出现频率
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