Clinical Question: A PA working in a geriatric clinic presents to her supervising physician to discuss a 79 y/o patient that presents with generalized fatigue and sadness. The patient describes that all her friends are slowly passing away and she feels that her quality of life is slowly decreasing. She wants to know if there are non-pharmacologic measures to try to improve the patient’s quality of life. The physician offers laughter therapy as a suggestion.

Does laughter therapy help to improve the quality of life in geriatric patients?

PICO Question:

Identify the PICO elements (Recalling that some questions do not have all the elements)

P  Geriatrics patients, elderly, older adults  

I  laughter therapy  

C  Lack of laughter therapy  

O  Increased happiness, less suicidal, improved quality of life

Search Strategy:

Terms Used: geriatric patients, older adults, elderly patients, laughter therapy, improved quality of life, suicidal, happiness,  results within the last 5 years

Databases:

Database	Terms	Filter	Articles
Pubmed	Laughter therapy in geriatric patients, quality of life, happiness	5 years	3
Up-to-date	Laughter therapy in geriatric patients, quality of life, happiness	5 years	1,233
Google Scholar	Laughter therapy in geriatric patients, quality of life, suicidal, happiness	4 years	1,340

Reason for chosen articles:   I chose these articles because I believe that in addition to answering my question they provided me with a good clinical understanding on how to implement the therapy. The articles were each recently published and were all had proper research. I was able to learn about the positive effects of laughter therapy and learn more about the benefits that it would have on the geriatric population specifically.  

Articles Chosen for Inclusion (please copy and paste the abstract with link):

ABSTRACT (#1)

– Background: Mental disorders are common among the elderly with serious symptoms of depression and social isolation. This study was conducted to investigate the effect of laughter therapy (LT) on depression and quality of life (QOL) of the elderly living in Abadeh nursing homes. Methods: This is a controlled semi-experimental study with a pre-test, post-test design. Ninety eligible ones of the elderly living in the Abadeh nursing homes and from July to September 2017, entered the study. Some of the criteria for entering the study include being over 60 years old, orientation, not having blindness and deafness, lack of physical and mental problems. After determining the intervention and control groups, the scale of depression and QOL was administered to the subjects and their scores were collected in the pre-test. Results: Most of the study samples were in the intervention (35.55%) and control (37.77%) group in the age range of 60–69 years. In both intervention and control groups, respectively, 31.11% and 68.88% elderly were males and females. The mean scores of depression in the intervention group after LT (M = 2.57) were lower than those before the intervention (M = 6.87) [CI = −5.58–(–3.02)] and also the results of independent t-test showed a statistically significant difference before and after the intervention between the two groups (P < 0.001). The mean score of dimensions of QOL after LT was higher than that before in the intervention and there was a statistically significant difference in all dimensions with paired t-test (P < 0.001). Conclusion: Since the implementation of this programme could improve the mental status and QOL of the elderly, this method of therapy can be used as an alternative or complementary model to enhance the health of the elderly.

LINK/PDF

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7444838/

ABSTRACT (#2)

Aim: In the present study we investigated the effect of laughter therapy on physio‐ logical and psychological function in older people. Design: An open‐label trial. Methods: Seventeen older people who regularly attended an elderly day care centre were recruited. Stand‐up comedy as laughter therapy was performed once a week for 4 weeks. Parameters of physiological and psychological function were evaluated before and after laughter therapy. Results: Laughter therapy intervention resulted in a significant reduction in systolic blood pressure and heart rate, accompanied by a significant increase in plasma con‐ centration of serotonin and a significant decrease in salivary concentration of chro‐ mogranin A. Questionnaire surveys of SF‐8, GDS‐15, and Vitality Index demonstrated alleviation of depression and improvement of sociability and activity in older people. Laughter therapy could be expected to become a practical treatment to improve quality of life of older people in an elderly day care centre

LINK/PDF

– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6279721/

ABSTRACT (#3)

Objectives: To assess the potential of laughter and humour interventions to increase well-being in a general population of adults aged 60 plus; and to develop a classification to compare approaches and potential benefits of different intervention types. Design: A systematic search of Web of Science, PubMed/MEDLINE, PsychInfo, AMED, and PsychArticles used inclusive terms relating to laughter and humour interventions. A realist synthesis approach enabled hetero- geneous interventions to be compared pragmatically.Setting: Five laughter interventions, and one humour intervention, using one or more outcome related to well- being, were considered for inclusion after screening 178 primary research papers. The five laughter interven- tions, representing a sample of 369 participants, were retained. Main outcome measures: Well-being related outcome measures reported in each intervention informed efficacy; Joanna Briggs Institute tools appraised design; and a realist approach enabled heterogeneous interventions to be measured on their overall potential to provide an evidence base.Results: Well-being related measures demonstrated at least one significant positive effect in all interventions. Confounding factors inherent in the intervention types were observed. Individual participant laughter was not reported. Conclusions: Laughter and humour interventions appear to enhance well-being. There is insufficient evidence for the potential of laughter itself to increase well-being as interventions contained a range of confounding factors and did not measure participant laughter. Interventions that isolate, track, and measure the parameters of in- dividual laughter are recommended to build evidence for these potentially attractive and low-risk interventions. The classification proposed may guide the development of both evidence-oriented and population-appropriate intervention designs.

LINK/PDF

https://www.sciencedirect.com/science/article/abs/pii/S0965229918302358?via%3Dihub

ABSTRACT (#4)

Purpose: This study examined the effects of laughter therapy on life satisfaction and loneliness in older adults living in nursing homes.Design: A single-blind, parallel-group, randomized controlled trial (ClinicalTrials NCT03687788) with a pretest-posttest design was conducted.Methods: There were 31 experimental participants and 31 controls. The experimental group received laughter therapy twice a week for 6 weeks, along with usual care. The control group received usual care only. Loneliness was measured with the De Jong Gierveld Loneliness Scale, and life satisfaction was measured with the Satisfaction With Life Scale.Findings: After 6 weeks, there was a statistically significant difference in De Jong Gierveld Loneliness Scale total score between the two groups, and the subscale scores of the experimental group decreased.Conclusions: Laughter therapy may reduce loneliness in older adults.Clinical relevance: Healthcare professionals, especially nurses, can potentially use laughter therapy to reduce loneliness in older adults.

LINK/PDF

–  https://www.nursingcenter.com/wkhlrp/Handlers/articleContent.pdf?key=pdf_00006939-202103000-00007

ABSTRACT (#5)

Rationale: Laughter-inducing therapies are being applied more regularly in the last decade, and the number of scientific reports of their beneficial effects is growing. Laughter-inducing therapies could be cost-effective treatments for different populations as a complementary or main therapy. A systematic review and meta-analysis has not yet been performed on these therapies for different populations and outcomes, but is needed to examine their potential benefits. This research aims to broadly describe the field of laughter-inducing therapies, and to estimate their effect on mental and physical health for a broad range of populations and conditions. Method: A systematic review of the field was undertaken, followed by a meta-analysis of RCTs and quasi-experimental studies. The systematic review included intervention studies, one-session therapies, lab studies and narrative reviews to provide a broad overview of the field. The meta-analysis included RCTs or quasi-experimental studies that assessed multi-session laughter or humor therapies compared to a control group, performed on people of any age, healthy or with a mental or physical condition. English and non-English articles were searched using PubMed, Web of Science, EBSCO and EMBASE. Search terms included laugh(ing), laughter, humo (u)r, program, therapy, yoga, exercise, intervention, method, unconditional, spontaneous, simulated, forced. Studies were classified as using humor (‘spontaneous’ laughter) or not using humor (‘simulated’ laughter). Results: This systematic review and meta-analysis suggests that (1) ‘simulated’ (non-humorous) laughter is more effective than ‘spontaneous’ (humorous) laughter, and (2) laughter-inducing therapies can improve depression. However, overall study quality was low, with substantial risk of bias in all studies. With rising health care costs and the increasing elderly population, there is a potential for low-cost, simple interventions that can be administered by staff with minimal training. Laughter-inducing therapies show a promise as an addition to main therapies, but more methodologically rigorous research is needed to provide evidence for this promise.

LINK/PDF

https://reader.elsevier.com/reader/sd/pii/S0277953619300851?token=A44178ABB3881582D1706952A3D8B82EEA0EB5F577DE30E25F2C00ABB200B684E4DD3560C7759562F54F24A24851F273&originRegion=us-east-1&originCreation=20210709195522

Summary of the Evidence:

Author (Date)	Level of Evidence	Sample/Setting(# of subjects/ studies, cohort definition etc. )	Outcome(s) studied	Key Findings	Limitations and Biases
Heidari, M., Borujeni, M. G., Rezaei, P., Abyaneh, S. K., & Heidari, K(2020)	Controlled semi-experimental study	90 participants	Investigate the effect of laughter therapy on depression and quality of life of the elderly population.	The elderly population is plagued with serious issues of depression due to their social isolation. The study included 90 elderly patients that were living in a nursing home. The patients were given a pretest to determine their quality of life and scale of depression. The patients needed to be patients that had no previous diagnosis of a physical or mental problem. There were two questionnaires used to assess. One of them was the SF-36 QOL questionnaire. It consisted of 36 questions that assessed physical functioning, social functioning, mental health, vitality and physical pain. The study showed that before laughter therapy was implemented the majority of the subjects had a mild depression, which was treated by the time the laughter therapy had been completed. Ultimately, it showed that laughter enhances the physical, mental, and emotional health of geriatric patients. It is a cost effective, safe and non-invasive way to treat geriatric patients and try to improve their quality of life.	The limitation of the study could be that the sample size is relatively small. Additionally, there was no control group and the study did not have a blinded design.
Yoshikawa Y, Ohmaki E, Kawahata H, Maekawa Y, Ogihara T, Morishita R, Aoki M(2018)	Open label trial	Seventeen patients	Laughter therapy as an easy and accessible way to improve the quality of life of elderly patients.	Every year the age of elderly patients around the world is increasing. As the population increases we need to adjust the way we treat them and think about health care for the elderly. Laughter therapy is an easily accessible and noninvasive way to treat patients who are looking for a way to help improve the quality of life for elderly patients. Seventeen participants, aged 60 and older, were recruited from people who attended an elderly day care center. Stand-up comedy was used as the laughter therapy. It was carried out once a week at a fixed time for 30 minutes, for four consecutive weeks. Measurements taken one day before the first show and at the same time on the day after each of the shows. Blood pressure, levels of plasma concentration of serotonin, and HR were used to evaluate the effect of the laughter therapy. Additionally, they used questionnaires to determine the effect of laughter therapy. Laughter therapy helped to significantly reduce the levels of systolic BP as well as HR when compared to those before the intervention. Also, plasma serotonin concentration was significantly increased after repeated therapy when compared to the participants prior to the LT. LT also significantly improved the psychological function of the patients. Ultimately, this study showed that LT is a safe, cost-effective and easily accessible way to help improve the quality of life and health of geriatric patients. depression	The limitation of the study is that the use of self-reporting tools and so the subjects may not be completely honest in expressing their problems and responses. They also have very different cultural and social backgrounds and it does not create a uniform group of which the study was based off of.   Small sample size.
F.N. Gonot-Schoupinsky, G. Garip,(2018)	Systematic Review and meta-analysis	178 primary research papers that consisted of 369 participants.	To assess the potential of laughter and humour interventions to increase well-being in a general population of adults aged 60 plus; and to develop a classification to compare approaches and potential benefits of different intervention types.	Six papers were ultimately selected for the study. The majority of the sample sizes were small. 369 participants were split in between experimental group and the control group. The samples were almost evenly split between patients that lived in communities and patients that lived in residential care. The Geriatric Depression Scale was used to compare the results. The study searched to see if laughter and humor interventions would increase the well-being in older adults. Ultimately, the study showed that laughter therapy can have a positive effect on the well-being of geriatric patients. However, this study found that there were too many confounding factors and not being able to truly measure the laughter that make the study inconclusive.	Methodological limitations, mainly resulting from convenience sampling, prevented the possibility of generalizing results.It was also a small sample size.
Kuru Alici N, Zorba Bahceli P.(2021)	A single-blind, parallel-group, randomized controlled trial	31 experimental participants and 31 controls.	This study examined the effects of laughter therapy on life satisfaction and loneliness in older adults living in nursing homes.	Laughter therapy that includes yoga breathing techniques and laughter exercises are a positive method in promoting laughter. This study was an experimental study that divided the participants into two groups. The experimental group and the control group. It was a single-blinded, parallel-group randomized control trial. A total of 68 adults that were randomly selected from among patients that were 60 and above were included in the study. The experimental group received laughter therapy twice a week for 6 weeks.  Each session consisted of a warm up exercise, deep breathing and hand clapping, children’s games and laughter exercises. Lastly, meditation was applied for 10 minutes. The control group did not participate in the laughter therapy. The results showed that there was a significant decrease in the loneliness scale (measured using the De Jong Gierveld Loneliness Scale) in the experimental group when compared to the control group. The study did not find any statistically significant difference between the two groups when using the Satisfaction With Life Scale. The study notes that the quality of life for the experimental group was conducted as a group and therefore requires the adults to participate with one another. The group may have felt like they were a part of something and  therefore give the participants a sense of happiness and purpose. Ultimately, the study found that laughter therapy can reduce loneliness in older adults and therefore increase their quality of life.	First, the study was carried out at a single institution. Second, the study population was composed of older adults, and some of the participants did not finish the study due to unforeseen reasons such as illness and death.
C. Natalie van der Wala,b,c,∗ , Robin N. Kokb, (2019)	Systematic review and meta-analysis	33 articles were included in the study.	The risks for women in developing postpartum depression.	Depression, anxiety and stress were measured across each of the studies. In 26 studies depression significantly decreased in the elderly the to the laughter therapy. In 18 studies stress was shown to decrease due to LT. Anxiety was measured and in 14 studies anxiety was significantly reduced due to the laughter therapy. In 21 different studies there was a positive effect of both the mental and physical health of the elderly after LT. These studies have defined elderly as 65 and above.	low quality of studies and high risk of bias in the included studies. Many studies in the meta-analysis had a very low sample size (average n = 68) with one distinctive outlier, a multi-site randomized controlled trial (Low et al., 2013; Low et al., 2014, n = 398). Twelve studies had 20 or fewer participants per condition, and they could perhaps more accurately be described as pilot studies unsuitable for reliable effect size estimations.

Conclusion(s):

1. This controlled semi-experimental study showed that ultimately, it showed that laughter enhances the physical, mental, and emotional health of geriatric patients. It is a cost effective, safe and non-invasive way to treat geriatric patients and try to improve their quality of life.
2. This open label trial showed that LT is a safe, cost-effective and easily accessible way to help improve the quality of life and health of geriatric patients and should be implemented in both elderly day cares and nursing homes as often as possible.
3. This systematic review and metaanalysis showed that laughter therapy can have a positive effect on the well-being of geriatric patients. However, it must be noted that there were too many confounding factors and not being able to truly measure the laughter that make the study inconclusive. 
4. This single-blind, parallel-group, randomized controlled trial showed that laughter therapy can improve the quality of life of elderly patients. It is important to note that they found that the fact that the laughter therapy brought the elderly patients together in a group was one of the main reasons why it was so effective. If this is the case it could be that the true reason why the quality of life was improved was just due to the social aspect and not the laughter therapy. If so, then any activity that created socialization for the elderly could benefit them. Further research would need to be done.
5. This systematic review and metanalysis found that ultimately laughter therapy was beneficial in lowering the rates of depression, stress and anxiety and helped to increase the physical and mental health of elderly patients.

Weighted

5-  Medium number of articles used, systematic review and meta-analysis

3- systematic review and meta-analysis but has a smaller sample size and also note that there were many confounding factors

4- single-blind, parallel group, randomized controlled trial

1- controlled semi-experimental study, small sample size

2- open label trial, very small sample size

Clinical Bottom Line:

The clinical bottom line that is derived from these articles is that laughter therapy is a cost effective way to help improve a geriatric patient’s quality of life. It can improve the quality of life through improving psychosocial aspects of the patients life or actually improving a patient’s physical well-being (HR or BP). Therefore, I believe that laughter therapy should be included in all geriatric patients that have any form of mild depression, sadness, pain or verbalize that they feel they have a decreased quality of life. Just as physical therapy is utilized often in the geriatric population I believe that laughter therapy should as well. Geriatric clinics should be helping to organize events where there patients could come to hear stand-up comedy or other entertaining shows that can be considered laughter therapy. It is important to create social interaction between geriatric patients. As we saw in article #4 the very notion of participating in a group can increase the patient’s sense of purpose and therefore their quality of life!

It is important to realize that this therapy cannot be a single event and needs to take place over time. Laughter therapy as we have seen can increase a patient’s purpose in life and also leads to positive social interactions. It is important that the patients go consistently for weeks at a time to highlight these positive qualities. Although according to the studies, even after one time patients had a higher rate of scored happiness, it was more beneficial and significant when it went over a period of time.