Progressive Muscle Relaxation, Aromatherapy, and Combination of Aroma Therapy on Depression for Elderly People

Introduction

Depression is a common problem in the elderly. Depression is associated with poor outcomes with increased risk of disability, slow recovery from illness and death. Approximately 12%-20% of the elderly population has symptoms of depression. Depressed elderly have poorer health status, higher prevalence of disability, and more severe comorbidities and even increased mortality [1].

Depression in the elderly is a serious public health problem, resulting in impaired physical, mental, and social functioning that places a burden on families and communities. The National Institute of Mental Health Epidemiologic Catchment Area Study reported the prevalence of major depression in those aged 65 years or older to be around 1% (0.4% in men, 1.4% in women). Steffens and colleagues found a 15.8% prevalence of major depression in the elderly of all age groups in Cache County, Utah, higher than previously reported [2]. Wirasto, et al., (2007) stated that overall sociodemographic factors contributed to depression in the elderly by 19.2%. Sociodemographic factors associated with depression in the elderly who were respondents were not married, female and the number of dependent children [3].

The World Health Organization data shows that at the end of the 20^th century, the increase in the world's population led to an increase in the number of senior citizens aged 65 years or older. The number of elderly population in Indonesia in 2020 will be the 4th largest in the world after China, India, and the United States [4].

Nursing interventions that can be given to patients with depression are individual therapies such as cognitive therapy, behavioral therapy, thought stopping, Progressive Muscle Relaxation (PMR), and other relaxation methods such as lavender aroma therapy [5].

Progressive Muscle Relaxation is a form of muscle relaxation therapy through two steps, namely by applying tension to a muscle group and stopping the tension and then focusing on how the muscle relaxes, feels a relaxed sensation, and the tension disappears. Progressive Muscle Relaxation (PMR) can stimulate the release of endorphin and enkephalin chemicals that cause a sense of calm (relax), happiness (euphoria) and are able to stimulate brain signals that cause muscles to relax and increase blood flow to the brain [6]. According to Purwanto (2007), PMR can provide a smooth massage on various glands in the body, reduce the production of cortisol in the blood, restore the release of hormones in moderation so as to provide emotional balance and peace of mind [7].

Several studies reveal the benefits of PMR therapy, such as research conducted by Resti (2014) proving that it can reduce stress and stress symptoms in asthma sufferers [8]. Rahman (2014) [9] reported that PMR therapy has a significant effect on the quality of elderly sleep. Furthermore, Supriati, et al., (2014) proved that PMR therapy with a combination of thought stopping can reduce anxiety in clients with physical disorders compared to groups that are only given therapy alone [10]. Tobing (2012) reported that PMR therapy with a combination of logotherapy can reduce anxiety, depression and increase relaxation and the ability to make meaning of life compared to groups that are only given logotherapy therapy alone in cancer clients [6].

Lavender aromatherapy is a form of relaxation therapy. Lavender aroma therapy is an ancient healing process that uses pure lavender aroma therapy plant essence that aims to improve the health and well-being of the body, mind, and spirit [11]. Based on research, various aroma oils from flowers and woods have therapeutic and psychotherapeutic properties [12]. Lavender aroma therapy works by stimulating olfactory nerve cells and affecting the work of the limbic system by increasing positive and relaxed feelings [13]. Some of the essential oils that are commonly used in lavender aroma therapy because of their versatility are geranium, Eucalyptus (Eucalyptus), and Eucalyptus (Eucalyptus).

Some essential oils that are commonly used in lavender aroma therapy because of their versatility are geranium, eucalyptus (eucalyptus oil), lavender, and rose essentials [11]. According to Merdikawati, et al., (2012) Lavender aroma can increase the frequency of alpha waves in the back of the head, and this state is associated with relaxation [12].

Laura, et al., (2015) proved that lavender aroma therapy has a significant effect on sleep quality in post partum mothers [14]. Furthermore, Merdikawati, et al., (2012) stated that lavender aroma therapy can reduce anxiety in adolescent girls who experience Premenstrual Syndrome [12]. Arwana, et al., (2013) [15] confirmed that the administration of lavender aroma therapy can reduce the anxiety of patients before spinal anesthesia surgery. [The results of a preliminary study conducted in December 2016 through interviews with 20 elderly people at the UPT Social Services for the Elderly and Toddler Children in Gowaand Bone, found that some elderly people complained of insomnia, despair, sadness, laziness, lack of appetite and lack of concentration].

Based on this background, research related to PMR therapy, lavender aroma therapy and their combination on reducing depression in the elderly has never been carried out at UPT. Social services for the elderly and children under five in the Gowaand Bone regions. Therefore, researchers are interested in examining the effectiveness of PMR and lavender aroma therapy and the combination of both on reducing depression in the elderly at the UPT of Social Services for the Elderly and Toddler Children.

Conceptual Framework

(Figure 1)

Method of Research

This research type is a quasi experiment, with a pre-post-test control-group design, namely by comparing pretest and posttest values in the intervention group. In this study there were four groups, namely the first group, namely the control group (without treatment), the second group with PMR treatment, the third group with lavender aromatherapy treatment, and the fourth group with PMR-lavender aromatherapy combination treatment.

Gambar 1: Conseptual framework research.

This study aims to determine the effectiveness of Progressive Muscle Relaxation (PMR) therapy and aroma therapy on depression in the elderly at the UPT social services for the elderly and children under five. This research was conducted at the UPT Social Services for the Elderly and Toddler Children in the Gowa and Bone Regions. The research time started on August 18 to September 27, 2023.The population in this study were all elderly people at the UPT Social Services for the Elderly and Toddler Children in Gowaand Bone as many as 180 people.

Research Sampling is using purposive sampling technique, a sample of 72 respondents was obtained, all of which were used as samples and divided into four groups, each group totaling 18 people. The first group is a control group, the second group of elderly people by getting Progressive Muscle Relaxation (PMR) therapy, the third group gets lavender aromatherapy therapy, and the fourth group gets a combination therapy, namely Progressive Muscle Relaxation (PMR) exercise and lavender aromatherapy. The treatment was carried out for 6 consecutive days. At the beginning of the treatment, namely before the therapy, depression was measured and at the end of the treatment, namely after the therapy, depression was measured again.

Analysis of data is using univariate and bivariate analysis. Univariate analysis is used to analyze the frequency distribution of the measurement results of a data by describing each data. In this study, the results of depression measurements are displayed in the form of a mean and then analyzed on the data display. While bivariate analysis aims to prove the truth of the hypothesis that has been formulated using the SPSS version 19 program. Wilcoxon test is used to determine the effect of treatment in one group with pre-test and post-test as well as comparing between groups, namely to determine the intervention that has the most effect on reducing depression with Kruskal Wallis analysis. If there is a difference, the Post-Hoc test is continued, namely the Mann Whitney test. The difference is declared significant if P<0.05.

Result Research

(Table 1) Based on the table above, it is known that the characteristics of respondents in this study are mostly female, Makassarness ethnicity, Muslim religion, and age range 61-65.

Table 1: Characteristics of Respondents at the UPT Social Services for the Elderly and Toddler Children in the GowaRegion.

(Table 2) The table above shows that the level of depression at the end of the measurement compared to the beginning of the measurement obtained a P value of 0.317 (P>0.05). This indicates that there is no significant difference in the level of depression between the beginning of the measurement and the end of the measurement in the control group.

Table 2: Depression Level of the Control Group in the elderly at the UPT Social Services for the Elderly and Toddler Children GowaRegion.

Progressive Muscle Relaxation (PMR) Therapy Group

(Table 3) Based on the table above, after PMR therapy, a P value of 0.003 (P<0.05) was obtained, which means that there is a significant difference in the level of depression between before and after PMR therapy.

Table 3: Effect of Progressive Muscle Relaxation (PMR) Therapy on Depression Levels in the elderly at the UPT Social Services for the Elderly and Toddler Children GowaRegion.

Lavender Aroma Therapy Group

(Table 4) Based on the table above, it shows that the level of depression after lavender aromatherapy therapy compared to before aromatherapy therapy obtained a P value of 0.003 (P <0.05), which means that there is a significant difference in depression levels between before and after lavender aromatherapy therapy.

Table 4: The Effect of Lavender Aroma Therapy on Depression Levels in the elderly at the UPT Social Services for the Elderly and Toddler Children in the GowaRegion.

Combination therapy group of Progressive Muscle Relaxation (PMR) and Lavender Aroma

(Table 5) The table above shows that the level of depression after combined PMR-aromatherapy lavender therapy compared to before combined PMR-aromatherapy lavender therapy obtained a P value of 0.000 (P <0.05), which means that there is a significant difference in depression levels between before and after combined PMR-aromatherapy lavender therapy.

(Table 6) The table above shows that the comparison of depression levels at the end of the measurement of the four groups obtained a P value of 0.003 (P<0.05), which means that there is a difference in depression levels between the control group, the group with PMR therapy, lavender aromatherapy therapy, and combined PMR¬ lavender aromatherapy therapy. Furthermore, a post-hoc test was conducted, namely the Mann¬ whitney test to determine the therapy that had the most effect on reducing the level of depression.

Table 5: The effect of PMR-Aromatherapy lavender combination therapy on depression levels in the elderly at the UPT Social Services for the Elderly and Toddler Children GowaRegion.

Table 6: The The Effectiveness of PMR Therapy, Lavender Aromatherapy Therapy, and Combination PMR-Aromatherapy Lavender Therapy in Reducing Depression Levels Compared to the Control Group in the Elderly at the UPT Social Services for the Elderly and Toddler Children GowaRegion.

Discussion

The research results obtained the majority of elderly people in UPT Pelayanan. Social Services for the Elderly and Toddler Children in the GowaRegion at the beginning of the measurement experienced mild depression. Muna (2013) states that 60% of elderly people living in nursing homes experience depression [16]. Siboro and Rusdi (2012) state that of the 76 elderly who were sampled 35 of them suffered from depression, even 40% of them, suffered from severe depression [17]. Meanwhile, Pradnyandari and Diniari (2013), stated that the proportion of depression in the elderly, who live with their families is greater than those who live in Nursing Homes, however, based on the level of depression, elderly with severe depression are more in Nursing Homes than those who live with their families, although this difference is not statistically significant [18].

Muna, et al., (2013) state that older age, female gender, and basic education factors affect the incidence and level of depression [16]. According to Siboro and Rusdi (2012), family communication factors, greatly affect the incidence of depression, the worse the family communication pattern, the incidence of depression increases in the elderly. This communication pattern factor is also very influential on the elderly who live in Werda Nursing Homes, elderly who feel lonely will be very susceptible to depression [17].

Based on the results of the study after giving progressive muscle relaxation therapy, it was found that there was a decrease in the level of depression in the elderly and statistically there was a significant difference between the level of depression before and after giving progressive relaxation therapy. This research is in line with research conducted by Palupi (2015) which states that progressive relaxation techniques have an effect on the level of depression in the elderly, at the Tresna Werdha Unit Abiyoso Pakem Sleman Social Home Yogyakarta [19]. Research conducted by Windarwati, et al., (2011) also obtained similar results, namely progressive muscle relaxation therapy has a significant effect on. The occurrence of a decrease in the depression score of the elderly at the Pandaan Social Elderly Social Service Unit [20]. Sholihah (2015) confirms that there is an effect of progressive muscle relaxation therapy on reducing depression levels in the elderly [21].

Progressive muscle relaxation therapy is a technique that focuses on a muscle activity by identifying tense muscles and then reducing tension by performing relaxation techniques to get a feeling of relaxation.

In progressive muscle relaxation exercises the elderly are asked to tense the muscles with a certain tension and then relax them. Before being relaxed, the tension is felt first so that individuals can distinguish between tense and limp muscles (Setyohadi and Kushariyadi, 2011).

Relaxation can affect the hypothalamus and parasympathetic nerves for metabolism and respiration to reduce oxygen consumption and muscle tension. This is to maintain health and mental balance. According to Jacob, relaxation can reduce neural reflexes that can reduce skeletomuscular neural input and activity output. Furthermore, according to Jacob, neuroanatomic activity will be lowered. This muscle relaxation will inhibit the hypothalamus to stop the secretion of CRH, so that the secretion of ACTH and cortisol also decreases. This will have an impact on reducing the level of depression (Amila 2014).

In this research, there was a significant decrease in depression levels after being given aromatherapy therapy. Based on the literature search conducted by researchers, there has been no similar research, but aromatherapy therapy has been widely used in handling insomnia and lowering blood pressure in the elderly. Adiyati (2010) stated that aromatherapy therapy can significantly reduce the degree of insomnia in the elderly [22]. Kurnia, et al., (2009) [23] and Foerwanto, et al., (2016) [24] stated that aromatherapy can improve sleep quality in the elderly. Furthermore, Marina and Kulsum (2017) [25] and Soraya, et al., (2014) [26] state that the administration of rose and lavender aromatherapy in the elderly with hypertension has a significant effect on reducing high blood pressure. Insomnia and high blood pressure are one of the characteristics of depression. Improving sleep quality and reducing blood pressure in the elderly will have an effect on reducing depression in the elderly.

The scent of fragrances such as lavender scent has a sensitive effect on the limbic system in the brain, which is associated with emotional and memory in humans. The molecules released into the air are as water vapor. When water vapor containing these chemical components is inhaled, it is absorbed by the body through the nose and lungs and then enters the bloodstream. When aromatherapy vapor is inhaled, the vapor molecules will affect the limbic system of the brain which is responsible for the integration and expression of feelings, learning, memory, emotions, physical stimulation, and provide a feeling of relaxation [27] (Taylor, et al., 2005).

In this research, giving a combination therapy of progressive muscle relaxation therapy and aromatherapy can significantly reduce depression levels in the elderly. Progressive muscle relaxation therapy can work together with aromatherapy therapy in reducing depression. Relaxation can change the brain rhythm from beta (alert) to alpha (relaxed) which can reduce anxiety by activating parasympathetic nerves and also inhibiting the secretion of the hormone cortisol which plays a role in stress conditions. The decrease in depression levels will be strengthened by aromatherapy therapy which according to the literature, aromatherapy can increase the production of endorphin hormone. Hormone endorphin is a hormone that provides a sense of happiness [22] (Adiyati, 2010 and Maghfirah, et al., 2015).

This research also examines the therapy that has the most effect on reducing depression. Based on the Kruskal Wallis test, the p value <0.05 was obtained so that there were differences in the four treatments in reducing the level of depression in the elderly. Furthermore, the Post Hoc test found that PMR therapy and PMR-aromatherapy combination therapy can significantly reduce depression levels compared to the control group.

The statistical results show that the level of depression in the aromatherapy group is still the same as the control group, which means that when compared to the control group, lavender aromatherapy therapy has not been able to reduce the level of depression in the elderly.

However, the results will be different if aromatherapy becomes a complementary therapy to PMR therapy, namely the level of depression will be lower when compared to the control group. The main key in reducing depression is to provide a relaxing and pleasant effect, so that the brain can reduce tension so that it will have an effect in reducing depression. PMR therapy and PMR-aromatherapy combination therapy are able to relax the brain and have a positive effect on reducing depression levels (Setyohadi and Kushariyadi and Maghfirah, et al., 2015).

Acknowledgments

This research received no external funding.

Conflict of interest

The authors declare no conflict of interest.

References

• Onder G, Penninx BWJH, Cesari M, Bandinelli S, Lauretani F, Bartali B, et al. (2005) Anemia Is Associated With Depression in Older Adults: Results From the InCHIANTI Study. Journal of Gerontology: MEDICAL SCIENCES 60(9): 1168-1172.
• Lapid MI, Rummans TA (2003) Evaluation and Management of Geriatric Depression in Primary Care. Mayo Clin Proc 78: 1423-1429.
• Wirasto R, Mukhlas M dan Moetrarsi (2007) TESIS: Bobot Pengaruh Faktor¬faktor Sosiodemografis Terhadap Depresi Pada Usia lanjut di Kota Yogyakarta. Bagian Ilmu Kedokteran Jiwa RS DR Sardjito/Fakultas Kedokteran Universitas Gadjah Mada Yogyakarta.
• Darmojo B (2001) Problema Kesehatan Para Lanjut Usia di Indonesia, dalam Wasilah-Rochmah, I.P.D. Pramantara, Probosuseno (Eds): Seminar Successful Aging (Tua Berguna), hal:5-10, ed. 1, cetakan 1, Yogyakarta.
• Stuart GW (2009) Principles and practice of psychiatric nursing (9h Edition). St. Louis: Mosby.
• Tobing DL (2012) Pengaruh Progressive Muscle Relaxation dan Logoterapi terhadap perubahan Ansietas, Depresi, Kemampuan Relaksasi dan Kemampuan Memaknai Hidup Klien Kanker di RS Kanker Dharmais Jakarta. Fakultas Ilmu Keperawatan Universitas Indonesia.
• Purwanto (2007) Mengatasi Insomnia Dengan Terapi Relaksasi. Jurnal Kesehatan I (2): 141-147.
• Resti IB (2014) Teknik Relaksasi Otot Progresif Untuk Mengurangi Stres Pada Penderita Asma. Jurnal Ilmiah Psikologi Terapan, 2(1): 1-20.
• Rahman A (2014) Pengaruh Terapi Relaksasi Otot Progresif Terhadap Kualitas Tidur pada Lansia di Panti Sosial Tresna Wredha Unit Abiyoso Pakem Sleman Yogyakarta. Skripsi Program Studi Ilmu Keperarawatan Sekolah Tinggi Ilmu Kesehatan Aisyiah Yogyakarta.
• Supriati L, Keliat BA, Nuraini T (2014) Pengaruh Terapi Thought Stopping dan Progresive Muscle Relaxation Terhadap Ansietas pada Klien dengan Ganguan Fisik. Jurnal Ilmiah Keperawatan 3(3): 191-203.
• Sharma S (2009) Aromaterapi lavender lavender Tangerang: Karisma.
• Merdikawati A, Wihastuti TA, Yuliatun L (2012) Aromaterapi Lavender Bunga Lavender dengan Tingkat Kecemasan Remaja Putri Saat Pre Menstrual Syndrome, Jurnal Keperawatan 3(2): 133-140.
• Kristanti ee (2010) Pengaruh aromaterapi lavenderterhadap penurunan derajat kecemasan pada lansia di panti wredha st. Yoseph Kediri. Jurnal STIKES RS. Baptis Kediri 3(2): 94-100
• Laura DD, Misrawati Woferst R (2015) Efektivitas Aromaterapi Lavender Terhadap Kualitass Tidur Ibu Pospartum. JOM, 2(2): 1024-1031. Mashudi. 2011. Pengaruh Progressive Muscle Relaxation terhadap Kadar Glukosa Darah Pasien Diabetes Melitus Tipe 2 di Rumah Sakit Umum Daerah Raden Mattaher Jambi. Universitas Indonesia Depok: Tesis yang tidak dipublikasikan.
• Arwana Sriningsih I, Hartono R (2013) Pengaruh Pemberian Aromaterapi lavender Terhadap Tingkat Kecemasan Pasien Sebelum Operasi Dengan Anestesi Spinal Di RS Tugu Semarang. Jurnal Keperawatan Jiwa 1(2): 129-134.
• Muna N (2013) Hubungan Antares Karakteristik dengan Kejadian Depresi Pada lansia di Panti Werda Pelkris Pengayoman Kota Semarang. Skipsi. Program Studi S1 Ilmu Keperawatan STIKES Telogorejo.
• Siboro EN dan Rusdi I (2012) Pola Komunikasi Keluarga dan Tingkat Depresi Lansia di Kelurahan Padang Bulan Bone. Fakultas Keperawatan Universitas Sumatera, Utara.
• Pradnyandari NKD, dan Diniari NKS (2013) Perbandingan Kejadian dan Status Depresi Lansia yang Tinggal Bersama Keluarga dengan yang Tinggal di Panti Sosial Tresna Werdha Wanes Seraya Denpasar Bali. Program Studi Pendidikan Dokter Fakultas Kedokteran Universitas Udayana.
• Palupi NWN (2015) Pengaruh Tekhnik Relaksasi Otot Progresif terhadap Tingkat Depresi Pada Lanjut Usia (Lansia). Jurnal Kesehatan 3(1): 35
• Windarwati HD, Chuluq A, Putri GN (2011) Pengaruh Terapi Relaksasi Otot Progresif Jenis Tension Relaxation terhadap Penurunan Skor Depresi pada Lansia di UPT Pelayanan Sosial Lanjut Usia Pandaan Kabupaten Pasuruan. Seminar Nasional Keperawotan PPNI Jawa Tengah.
• Sholihah S (2015) Pengaruh relaksasi otot progresif terhadap tingkat depresi Lansia di desa turigede kec. Kepohbaru kab. Bojonegoro. Surya 8(2): 1-6.
• Adiyati S (2010) Pengaruh Aromaterapi terhadap Insomnia pada Lansia di PSTW Unit Budi Luhur Kasongan Bantul Yogyakarta. Jurnal Kebidanan 2(2): 21-28.
• Kurnia AD, Wardhani V, Rusca KT (2009) Lavender Aromatherapy Improve Quality of Sleep in Eldery People. Jurnal Kedokteran Brawyaya 25(2): 83-86.
• Foerwanto, Noviyanti M, Prabowo T (2016) Pengaruh Aromaterapi Mawar terhadap Kualitas Tidur Lansia di Panti Sosial Tresna Werdha Unit Budi Luhur Kasongan Bantul Yogyakarta. Media Ilmu Kesehatan 5(1): 14-22.
• Marina A, Kalsum AU (2017) Pemberian Aromaterapi Bunga Mawar terhadap Penurunan Tekanan Darah pada Wanita Lanjut Usia di UPTD Panti Sosial Lanjut Usia Tresna Werdha Natar Lampung Selatan. Jurnal Kesehatan 8(1): 30-35.
• Soraya (2014) Pengaruh Aromaterapi Lavender terhadap Penurunan Tekanan Darah pada Lansia dengan Hipertensi di Kelurahan Siantan Hulu Pontianak Utara. Skripsi. Program Studi Keperawatan Fakultas Kedokteran Universitas Tanjungpura.
• Taylor C, Lilis C, More P (2005) Fundamental of Nursing. Philadelphia: Lippincot William & Wilkins.