Aging is a gradual and continuous process of natural change in all the beings, during which the capacity for cell division, growth, and performance decreases, and finally it leads to death.1 One of the challenges for the elderly, in particular, is living with various health problems.2 Of the common problems in aging is sleep disorder that affects the quality of life of the elderly.3 Sleep is considered as a basic human need and is included in the Maslow's needs gradation in physiological needs and provides the human's body with an opportunity to reenergize and get rid of tension.4 Researches showed that aging is associated with a decrease in the quality and quantity of sleep5 , 6 because age-related changes lead to a lighter sleep and decrease in the sleep efficiency.7 According to Wu et al,8 49% of the elderly residing in China had a weak quality of sleep.8 In Iran, 67% of the elderly have sleep disorders, and 61% of these people suffer from insomnia.9 The most common sleep complaints in the elderly include difficulty falling asleep, waking up during the night, waking too early, and daily drowsiness.10
The real amount of sleep decreases as the age goes up.11 In the elderly persons, the delta phase (deep sleep stage) duration decreases, as they spend about 10% of their night sleep in this phase. So, in ageing, sleep is light, and the elderly wake up frequently during the night. Common physical conditions of the ageing also disturb the quality of sleep. For instance, many elderly people suffer from sleep disorders due to the night pain resulting from arthritis, or using diuretic drugs to control high blood pressure causes frequent night wakes to urinate.12
The desirable sleep increases the physical health, decreases the dullness and anxiety, and strengthens the ability to adapt and concentrate.13 On the contrary, lack of sleep brings a sense of tiredness, headache, concentration deficit disorder, day narcolepsy, weak perception, susceptibility to infection, and even cancer and cardiovascular diseases.13 , 14 Helbig et al15 showed a high relationship between low quality of sleep and the risk of falling among the elderly older than 75 years.15 Among the reasons of low sleep quality in the elderly are the external factors such as lighting, noise, environment temperature, and nursing care, and internal factors such as pain, illness, drugs, and anxiety and its related psychological changes.16 , 17
Irrespective of suffering from different chronic conditions, the crisis of losing the spouse or friends, loneliness, retirement, a decrease in the functional abilities, appearance changes, fall income, decrease of social security, and negative social attitudes affect the elderly's quality of sleep.18
There are various methods to deal with sleep disorders.19 The elderly usually use soporific drugs in such a way that 39% of these drugs are used by the elderly older than 60 years.12 , 20 However, these drugs alleviate sleep disorders temporarily and most of them cause drug interference and also lead to many side effects.21 Hence, using supplementary methods such as relaxation, considered nonpharmaceutical method, is essential.22 Among the relaxation methods are Benson's relaxation technique, progressive muscular relaxation, relaxation using mental imagery, and mediation.23 , 24 But Benson's relaxation technique, which was introduced by Dr Herbert Benson in 1970, is more popular than the other relaxation methods due to its easy way of learning.
Based on the high prevalence of sleep disorders and its physical and psychological consequences in the elderly, the need to apply easy, appropriate, and cost-effective approach to improve the quality of sleep among this vulnerable group is vital. So, this study examines the effect of Benson's relaxation technique on the elderly's quality of sleep in order to take some steps to reduce the elderly's sleep disorders and subsequently their quality of life.
INSTRUMENTS AND PROCEDURE
This randomized controlled trial study used a pretest-posttest control group design. It was registered in the Iranian Registry of Clinical Trials with the following identification: IRCT2016071228891N1. This study was in agreement with the principles of the Helsinki Declaration and it was approved by the Medical Research Ethics Committee of the Qazvin University Medical Sciences (IR.QUMS.REC.1395.114).
Our study population consists of all the elderly suffering from sleep disorder referring to the health centers of the city of Qazvin, Iran. During 6 months from the beginning of September 2016 to the end of March 2017, 80 qualified elderly were randomly selected from among the elderly referring to 10 health centers using random cluster sampling method. They were randomly assigned into the control and intervention groups. The inclusion criteria of this study consisted of age range of 60 years or older, suffering from sleep disorder based on Petersburg's Sleep Scale, able to comprehend the study procedures and instructions and to follow the relaxation program, and having necessary facilities to use the training file. Participants were excluded if they suffered from psychological disorders (schizophrenia, dementia, anxiety, and depression), had mental disabilities and chronic illnesses (cancer, musculoskeletal disorders), used sedative drugs aside from soporific drugs, did not complete the relaxation program, died, or were hospitalized for any reason during the study. All the elderly participating in this study signed the written consent form after they were informed about the purpose of the study. Then, the participants in the intervention group were trained on Benson's relaxation technique one by one. After that, the subjects in the intervention group participated in the group relaxation program (4 elderly in each group) twice a week for 20 minutes, and in other days of the week they performed the practices individually at homes using the compact disk in the morning after sleep and in the evening before the bedtime. To perform the exercises correctly, Benson's relaxation in the visual form with the film was taught to the experimental group, and the elderly performed it practically. Finally, they were given a copy of this film along with a pictorial pamphlet to use it at home. This treatment lasted 4 weeks and the follow-up session was administered in person (face-to-face) and by phone. After 1 month of treatment (60 sessions), quality of sleep questionnaire was again administered by the researcher to the control and experimental groups. Filling out the questionnaire took 20 minutes for each participant.
In Benson's relaxation, the participants were asked to be in comfortable position with the eyes closed, relax their muscles of the body from the sole of their feet and progressing up to their face gradually, keep them relaxed, breathe through their nose, be aware of their breathing, exhale orally and gently, and when they breath out, they say number 1 and breathe naturally and easily. They continue these practices for 20 minutes and try to relax their muscles. After finishing the duration, they sit quietly for several minutes with eyes closed and later with eye opened.
A demographic questionnaire and the Petersburg's quality of sleep questionnaire were used for data collection. The data were evaluated twice (baseline, week 6) by face-to-face interview. Demographic questionnaire consisted of the subjects' personal information including age, gender, weight, body mass index, lifestyle, economical status, and medical history. Petersburg's quality of sleep questionnaire was used to assess the quality of sleep and the sleep disorders diagnosis of the participants. It included 18 items and 7 subscales including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction. Each item was scored on a 4-point Likert scale from 0 to 3. Sum of the 7 subscales scores is the total score that ranges from 0 to 21. The higher amount indicates a lower quality of sleep. In fact, achieving the total score of 5 or more indicates sleep disorder.25 Buysse et al25 reported the Cronbach α for the questionnaire equal to 0.83.25 In the study by Spira et al,26 the internal consistency of the questionnaire was 74.6 for elderly men. Furthermore, Hoseinabadi et al27 in their study on Iranian elderly estimated the reliability of this questionnaire using κ's coefficient equal to 0.87.
Descriptive statistics was used to calculate mean, standard deviation, frequency, and percentage. Normal distribution of the data was checked using Kolmogorov-Smirnov, skewness, and kurtosis. Dependent and independent-samples t tests were run for within and between groups comparison. All statistical analyses were conducted by SPSS software, version 19 (SPSS IBM, New York) for Windows. The level of significance was set at P < .05.
Of the original participants, 80 elderly met the study inclusion criteria. They were allocated to either the intervention (N = 40) group or the control (N = 40) group randomly. At the end of the study, there were 2 dropouts in the intervention group and 3 dropouts in the control group (Figure).
The participants of the current study were 38 people in the intervention group with the mean age of 67.95 ± 5.24 years and 37 people in the control group with the mean age of 66.89 ± 4.10 years. More than half of the participants were female (54.7%) and married (68%). The majority of the elderly were under diploma, economically independent (82.7%), physically active (78.7%), and did not smoke (86.7%). At baseline, the intervention and control groups did not statistically differ with respect to demographic data, economic status, physical activity, and smoking behavior (Table 1).
Based on the elderly's medical history, more than half of them suffered from high blood pressure (54.7%) or joint pain (50.7%). Furthermore, number of them reported to have heart problems (34.8%), diabetes mellitus (28%), digestive disorders (22.7%), respiratory problems (16%), and kidney problems (10.7%). Eight percent of them also had other health conditions. The results of χ2 showed that there were no significant differences between the groups in terms of their medical history.
Based on the results of the statistical tests, both of the groups were homogenous in the 7 subscales of the quality of sleep before the treatment. The changes in the total score of the elderly's quality of sleep in the intervention and control groups indicated that the score of the quality of sleep in 5 subscales including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, and the daytime dysfunction improved significantly (P < .000). Moreover, the find of independent-samples t test showed significant differences between the intervention and the control group in the total score of the quality of sleep, subjective sleep qual sleep latency, sleep duration, and sleep sufficiency (P < .000) (Table 2).
As depicted in Table 3, taken from item 9 of the questionnaire, about 96% of the elderly in the intervention and the control groups suffered from a very bad or fairly bad quality of sleep before the relaxation program. After the treatment, only 18% of the elderly in the intervention group versus 93% in control group complained about a very bad or fairly bad quality of sleep.
Sleep disorders cause many physical and mental consequences such as decreased concentration, memory disorder, and general weakness in the elderly.28 Therefore, the current study was conducted to examine the efficacy of a cognitive-behavioral method called “Benson's relaxation technique” on the quality of sleep of the elderly. The findings from the present study indicated that Benson's relaxation technique can result in improvement of the quality of sleep in general and in some of its subscales (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, and the daytime dysfunction) among community-dwelling elderly adults.
In this study, the mean score of the subjective sleep quality in the intervention group improved significantly after the relaxation program. The results of the study were in line with the studies conducted by Rambod et al29 and Akbarzadeh et al,30 who showed the efficacy of Benson's relaxation technique on the subjective sleep quality in dialysis and chronic heart patients, respectively. A possible explanation for this result might be that the use of Benson's relaxation technique could reduce anxiety among the elderly as the elderly people have different levels of anxiety due to age-related conditions such as loss of the spouse or children, retirement, and facing with illnesses that can lead to poor quality of sleep.
In this study, Benson's relaxation technique could improve the elderly's sleep duration and sleep latency. These findings are consistent with those of Halpern et al,21 who found the effectiveness of yoga as a kind of relaxation training in sleep duration and sleep latency.21 Furthermore, a great deal of the previous works in this field support the efficacy of the relaxation exercises on the sleep duration of the patients.10 , 29 , 31 , 32 These results may be explained by the fact that Benson's relaxation is the most common method that is effective in pain,33 anxiety,34 and depression35 that are the important factors of poor quality of sleep among the elderly.
The findings of the study showed that relaxation was effective in the habitual sleep efficiency. Likewise, Orsal et al36 and Rambod et al29 showed the effect of relaxation exercises on improvement of the sleep efficiency.29 , 36 But Hariprasad et al37 did not support the effect of yoga on the elderly's quality of sleep and quality of life.37 This inconsistency may be due to the differences in the methods used. Benson's relaxation is effective on the reduction of the muscular tension, heartbeat, cortisol level, breath rate, and blood lactate that result in the sleep adequacy improvement.35
Benson's relaxation exercises did not significantly reduce the use of sleeping medications in this study. The results of the study were in line with the findings of the study conducted by Hoseinabadi et al27 and Saeedi et al.38 However, Orsal et al36 indicated the effect of relaxation technique on the reduction of sleeping medications use.36 This difference is probably due to the fact that the participants of the current study did not receive any advice on the reduction or disuse of the sleeping medications in the case of the feeling of improvement in their quality of sleep, and the elderly used their medications as usual.
Relaxation program did not improve the sleep disturbances in this study. Sebnem and Ismet39 also could not show the effect of massage as a kind of relaxation exercise on the sleep disorders.39 However, Akbarzadeh et al30 and Rambod et al29 reported the effect of relaxation practice on the sleep disorders. It can be considered that the items in the Petersburg's questionnaire related to the sleep disorders such as shortness of breath, a feeling of heat and cold can be affected by the elderly's medical history. The controversy may be the average age of the participants.
The other finding of this study was the effectiveness of relaxation technique on the elderly's daily function in the intervention group. These results are in agreement with those reported by Rambod et al29 and Akbarzadeh.30 It seems possible that these results are due to effect of the relaxation exercise on improvement of adequacy and duration of sleep by reducing the level of stressors of the elderly as more adequate night sleep and less stress and anxiety in the elderly would result in better ability for daily activities performance.
The main limitation of the study was the relatively small and the individual differences. The participants of this study were community-dwelling elderly adults, which could limit the generalization of the results to the institutionalized elderly adults.
The results of the present study indicated that Benson's relaxation exercises can serve as a practical and effective way for eliciting quality of sleep improvement among community-dwelling elderly. These positive effects could have an important role in increasing quality of life among this vulnerable group of people. Therefore, this cost-effective and simple technique can be used by the elderly along with the soporific drugs for improvement of their quality of sleep and then their quality of life.
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