As per National Policy on Older Persons, ‘elderly’ are persons above 60 years of age. Elderly population is predicted to account for one sixth of the total globally by 2030 and by 2050 one in every five persons would be above 60 years of age (World Population Ageing Highlights, 2020). The elderly are more vulnerable especially to mental health issues. Prevalence studies have reported that the mental health problems among elderly are on much higher scale. Stress is more subtle, but if chronic, the eventual consequences are harmful. Stressed-out brains sound an alarm that releases potentially harmful hormones such as cortisol and adrenaline (Wilson, 2011). Causative factors include stressors as environmental, physiological, social and life style changes. Outcome can be a feeling of insecurity, rejection, need for approval/inability to cope with changed circumstances. Quality of life (QOL) of the elderly at old age homes is different from those living with families. Dimensions like physical, psychological, social and environment affect their lives. WHO (2020) defines Quality of Life as an individual’s perception of their position in life in context of their culture and value systems. Laughter therapy has gone beyond the one-on-one relationship between a therapist and elderly, helps minimise stress and improve quality of life.

Need of the study:
The elderly need care, attention, affection and mind diversion with various techniques and therapies. Studies indicate that laughter therapy creates marked difference in life; assessing it needs implementation and adequate analysis.

Review of Literature
Elahai & Sharma (2023) conducted a pilot study with quantitative research approach. They used pre-experimental design and non-probability convenient sampling technique for the research. The study was conducted for 3 weeks on 40 senior citizens at old age home. The tools consisting of demographic data and standardised DASS 21 stress scale were used. Laughter therapy was administered to the senior citizens. The data was collected, organised and analysed in terms of both descriptive and inferential statistics. The mean score of the senior citizens for stress was 21.65 with 34.36 percent before intervention while mean score of stress was 18.22 with 28.92 percent mean percentage. The pre-test median and SD of stress was 21 and 4.67 while the post-test median and SD was 18 and 4.02. The t test value for stress was 7.07. The calculated value i.e. 7.07 was more than tabulated value i.e. 1.96 at 39 df on 0.05 level of significance. So, the laughter therapy is effective to reduce the stress level among the senior citizens.

Objectives
The study was conducted with three objectives.
1. To assess the level of stress and quality of life among the elderly residing at old age home.
2. To compare the impact of laughter therapy on level of stress and quality of life among elderly residing at old age home.
3. To find association of level of stress and quality of life with selected demographic variables among elderly residing at old age home.

Hypothesis
H1-There will be significant difference between pretest and post-test scores of stress among the elderly at p ≤ 0.05 level.
H01-There will be no significant difference between pre-test and post-test scores of stress among elderly at ≤ 0.05 level.
H2- There will be significant difference between pre-test and post-test score of quality of life among elderly at ≤ 0.05 level.
H02- There will be no significant difference between pre-test and post-test score of quality of life among elderly at ≤ 0.05 level.

Methodology
One group pre-test post-test interventional pilot study was conducted on total of 19 elderly subjects at selected old age homes of Amritsar (Punjab). Out of the total 24 elderly only 19, who were eligible as per inclusion and exclusion criteria of nonprobability convenient sampling were selected for the study conducted during time period of March to April 2023. Pre-test was conducted to assess the level of stress and quality of life. Laughter therapy were conducted in 16 sessions for one month (weekly 4 days), on 4-6 elderly at one time. Post-test was conducted on day 30 after therapy to assess the level of stress and quality of life. Data was collected by using part A: socio-demographic profile, part B: standardised Perceived Stress Scale-14, three tools: and part C: standardised WHO quality of life (BREFF) scale with Interview technique. Ethical permission was taken from the concerned authorities and written informed consent was taken from each participant.

The study protocol is laid in Table 1.

Inclusion criteria :
The elderly who are (a) residing in old age home from minimum six months; (b) at minimum 60 years of age; (c) able to understand English, Punjabi and Hindi; and (d) willing to participate in research project.

Exclusion criteria:
The elderly who (a) have hearing or speaking disabilities; (b) have history of mental illness; and (c) are sufferings from severe stress.

Results
Percentage Distribution of Socio-Demographic Variables of the Elderly

Most of the elderly were in the age group of 60-70 years. Out of 19, 13 were male, 8 elderlies had completed only secondary education. Nine were widow and duration of stay in old age home ranged between 6 months to 3 years; 11 elderlies belonged to nuclear families and were having no source of income. More than half (10) elderlies came voluntarily to stay in old age home. Almost every one (15) did physical activity daily; 11 elderlies had physical illness.

During pre-test majority (n=17) of the elderly fall in moderate level of stress category, and only 2 elderly had mild level of stress (Fig 1). After the intervention, the strength in mild level of stress increased to 11 and only 8 remained in moderate

level. Fig 2. depicts that 84.2 percent of elderly had fair quality of life whereas 15.8 percent had poor quality of life; none had good and very good quality of life in the pre-test. After the intervention 47.5 percent came in good quality of life category and 52.65 in fair category. Table 2 depicts that there is markable difference between pre-test and post-test level of stress with the laughter therapy so it indicates high effectiveness in reducing stress level. Table 3 shows impact of laughter therapy pre-test and post-valves regarding quality of life measurement, as it have ‘p’ value of 0.00 1 that is highly significant.

*p<0.05 level of significance; NS: Non significance

*p<0.05 level of significance; NS: Non significance

The computed ‘t’ value and ‘p’ value have a significant difference between the pre-test and post-test quality of life score of psychological, social relationship and environmental domain (Table 4).

Data in this Table 5 shows the association of pre-test and post test score of level of stress with socio-demographic variables. Only previous type of family showed significance with ‘p’value 0.001. Table 6 shows the association of pre-test and posttest score of quality of life with socio-demographic variables. Only previous type of family showed significance with ‘p’ value 0.0016.

*p<0.05 level of significance; NS: Non-significance

Discussion
Stress, Quality of Life assessment
In pre-test, majority of the elderly felt moderate stress whereas after post-test, more than half of them experienced mild stress. On the other hand, pre-test revealed that majority of them had fair quality of life however after laughter therapy most of them (n=10) reported fair and good quality of life.

The study concluded that after laughter therapy, level of stress was reduced thus improving quality of life.

Impact of laughter therapy: This study has revealed that laughter therapy had significant impact on both, level of stress and quality of life with p-value 0.006 and 0.001 respectively.

Stress-QOL association: The study undertook several variables to study the association of level of stress and quality of life among elderly. From Table 5, it is clear that, the variable ‘previous type of family’ was found significant with p-value of 0.001 (level of stress) and 0.016 (QOL).

A pre-experimental supportive study was conducted by Walke (2021) to assess the effectiveness of laughter therapy on level of stress and assertiveness among elderly at old age homes in selected Areas Akluj. The results showed that in pre-test, 53.3 percent of the elderly had moderate stress and 46.7 percent had severe stress and after laughter therapy, in post-test, only 41.7 percent of the elderly had mild stress and 58.3 percent had moderate stress. Before laughter therapy, 53.3 percent had difficulty being assertive and 43.3 percent of them were non-assertive and 3.3 percent were naturally assertive (Score 30-40). After laughter therapy, 86.7 percent of them were non-assertive and 13.3 percent of them were naturally assertive.

Nursing Implications: As laughter therapy is cost effective and highly impactable so it can be included in day-to-day schedules of the elderly. It can be used in day care centres.

Recommendations
As this was a pilot study, such studies may be conducted on a large sample sizes.

For better assessment of impact, different variables can also be included in the study.

Conclusion
The study has concluded that the laughter therapy was highly significant in relieving stress and improving quality of life among the elderly residing in old age homes.
 

References

1. India’s Elderly Population: Some Fundamentals. General Knowledge Today - GK Current Affairs & General Studies 2013. Retrieved from: https://www.gktoday.in/gk/indias- el derly-population-some-fundamentals/

2. Kataria M. Laughter Yoga for Health and Happiness. Laughter Yoga International Foundation; Bangalore. 2016; pp8, 39-46, 54, 55, 82-85

3. Elahai MI, Sharma R. A study to assess the effectiveness of laughter therapy in reduction of stress among senior citizens in selected old age homes. Jaipur - pilot study. Journal of Southwest Jiaotong University, 2023; 58 (2): 523-34

4. United Nations Department of Economic and Social Affairs, Population Division. World Population Ageing 2020. Highlights: Living Arrangements of Older Persons (ST/ ESA/SER.A/451)

5. WHOQOL: Programme of Mental Health 2013. User Manual of WHOQOL. Health Statistics and Information SystemsWHO. https://www.who.int/healthinfo/ survey/whoqol-qualityoflife/en/

6. Walke RS, Effectiveness of laughter therapy on level of stress and assertiveness among elderly at old age homes in selected areas. International Journal of Nursing Education and Research 2021; 9 (1): 1-4