Benefits of relaxation techniques in the elderly : a systematic review

Recebido em: 24 ago. 2017. Aceito em: 6 mai. 2018. Publicado em: xx xxx. 2020. Abstract: The goal of this Clinical Psychology study was to present the possible therapeutic effects of Relaxation Techniques in elderly people. The systematic review was conducted by two researchers who performed inquiries independently in the following databases: PubMed, PsycInfo, Scopus and Lilacs in June 2015 using the string: “relaxation” OR “relaxation therapy” AND “elderly people.” The initial selection resulted in 244 articles and, from the criteria for inclusion and exclusion, 11 studies were analysed for this review as of May 2017. This research found evidence of the effectiveness of Relaxation Techniques in elderly populations, especially in reducing symptoms of anxiety, related cognitive difficulties, physical symptoms, especially tension headaches and increasing immunity through the diminishment of stress.

Relaxation began to be studied in 1908 at the Harvard Laboratory of Experimental Psychology.
Later the method was brought to other universities, more extensively developed in research at the Human Physiology laboratory at Chicago University (Jacobson, 1925). Progressive Relaxation appeared from the observation of relaxation as a natural physiological function of the body, but the goal of the research was to develop control of this function to benefit the organism. It was discovered that if it were possible to calm the sensory impulses through a gradual and generalized relaxation, the mind would correspond, quieting down as well (Jacobson, 1924).
Later, Benson (Benson & Stark, 1998) studied the answer to "fight or flight," described by Cannon, and the "general adaptation answer to stress", described by Selye, as well as physiological reactions resulting from stressful situations. As a rebuttal to these physiological changes from stress came the "Relaxation Response," in which the heart beat reduces, breathing rhythm, metabolic rate and brain waves slow and the blood pressure decreases.
Within the study of body-mind incorporation, we find the field of Psychoneuroimmunology that has been applying an integrative concept of human beings since the 70's. This approach embraces the vision of preserving health in diverse human dimensions: physical, emotional, mental and spiritual. In this understanding of a person as an unit, it is the human that is healthy or sick and not one of his parts (Azambuja, 2000). In this sense, relaxation techniques bring this experience of incorporation, since it is in the physiological response resulting from this technique that the stress reduction occurs (Epstein, 2009 In particularly, populations that are especially vulnerable to symptoms of stress, such as in grief, terminal patients, and elderly people can greatly benefit from these techniques (Chang et al., 2010).
According to the World Health Organization (WHO), between 1970 and 2025 there will be an increase of around 223% in the age range of 60 years or higher (WHO, 2005). And by 2050, 80% of this population, around 2 billion people over the age of 60, will be in the developing countries.
This data shows that global population aging will be a great global challenge with a considerable increase in social and economic demands.
The changes that occur in the aging process, such as physical and cognitive decline, appearance of diseases, modifications in financial and social condition due to retirement, loss of loved ones, family distance and isolation may be experienced as stress causing situations (Vivian & Bicca, 2015).
On the other hand, the concept of old age is changing in that in this phase of live, we can have personal accomplishments, higher maturity and wisdom. However, to many elderly, life quality means the ability to take care of yourself independently, which still represents a challenge (Argimon, Stein, Xavier, & Trentini, 2004). Therefore, promotion of health and quality of life in old age becomes indispensable as an answer to the elderly population increase, helps to face stressful situations and develop certain abilities.
Aiming to promote health in this population, we can use preventive and/or therapeutic interventions, such as Relaxation Techniques (Argimon, Esteves & Wendt, 2015;Burmeister, Argimon, & Cataldo Neto, 2016). With that in mind, we performed a systematic review with the aim of presenting the "State of the Art" therapeutic effects of Relaxation Techniques for the elderly population.

Method
The present systematic review was conducted by two researchers (LA and AS), who independently Together, the same researchers (LA and AS), included articles in the study according to the following criteria: empirical studies that had original data, specifically including elderly population (59 years or older) and that presented relaxation techniques as a therapeutic tool. Duplicate works, philosophical essays or revisions, editor's letters, works including other age groups or that did not specify age group of the subjects and works which methods could produce as an effect some sort of relaxation, not focusing on relaxation as a technique, but using the word itself associated with other practices, for instance: mindfulness, dance, music, massage, biofeedback, etc. were excluded.
After the articles were filtered through the reading of titles and abstracts according to the criteria for inclusion and exclusion, manual searches in the articles' bibliographic references commenced with the intent of identifying other articles that fit in the parameters established for this research. Then, the following data was extracted from the articles and compiled in the results section: authors, year, publication country, used technique, type of study and results. All of the authors of the present study decided to organize the papers according to its main issue and describe it in sub-sections along results.

Results
The initial selection resulted in 244 articles. Of these, 25 were found in PubMed, 58 in Scopus, 153 in PsycInfo and 8 in LILACS, and no articles were found in Scielo. Afterwards, 30 were removed for being duplicates, leaving a total of 214 for analysis.
A total of 11 studies were selected for this review.

Articles identified through databases (n =244 )
Articles removed for being repeated (n =30)

Eligible articles (n = 50)
Studies included for analysis in the article (n = 6)

Manual search in bibliographical references (n= 5)
Total studies included (n= 11) Excluded articles (n = 164) For not presenting original data, for not dealing with elderly people and for not using relaxation as a therapeutical tool.
It was also observed that the use of Relaxation helped reduce anxiety and memory problems.
Two studies showed anxiety as a cognitive factor, interfering in the performance of memory and attention tasks. Relaxation training seemed to reduce anxiety and consequently to improve elderly people's memory and/or attention (Yesavage & Jacob, 1984;Yesavage et al., 1982).
In four studies, Relaxation was evaluated for the treatment of physical symptoms. It was associated to the improvement of the immunological system, to reduce tension headaches, and it has shown to be beneficial in a general manner to patients with cardiac insufficiency. In addition, the affective states studied as a whole, such as psychological anguish, depression and negative affectation presented significant improvement, which contributes to the increase in quality of life and improvement of physical symptoms (Arena et al., 1988;Galvin et al., 2006;Reig-Ferrer et al., 2014;Yu et al., 2007).
In short, study results point to the effectiveness of the technique, except when relaxation is compared to treatments for insomnia.

Discussion
The aim of this study was to review the academic control groups across studies (Thorp et al., 2009).
In addition, the percentage of female participants was higher than the male percentage, as shown in the previous section. In two studies with elderly women, the number of men that volunteered to participate was so reduced that the researchers opted to carry out the study only with women (DeBerry, 1982;Lichstein & Johnson, 1993). We can infer that elderly men demonstrate less interest in participating in research or that men, statistically, present lower life expectation, making the group of women who reach senility higher (Bebbington, 1988;Bhayat, Das-Gupta, Smith, McKeever, & Hubbard, R, 2009;Camargos & Gonzaga, 2015;García-García et al., 2014;Petrov, 2007).
An issue taken into account was that some elderly people present physical limitations, resulting in difficulties while performing relaxations that involve tensing and relaxing certain muscles.
Thus, the authors suggest that relaxation through imagination can be an alternative to progressive muscular relaxation, and it may have the same clinical use (Scogin et al., 1992).
On the other hand, both studies which analysed the influence of Relaxation Techniques for anxiety and depression symptoms indicated that relaxation can be efficient in reducing traces/states of symptoms, revealing that daily relaxation practice can bring benefits to the elderly population (DeBerry, 1982;Scogin et al., 1992). Based on a wide population sample, a 2015 study shows that the prevalence of anxiety disorders in the world is 33.7% throughout the lifespan (Bandelow & Michaelis, 2015). However, the authors suggest that the elderly population has very specific characteristics and cannot be classified among the criteria of mental disorders manuals. Thus, aging and all aspects related to it presents factors that can lead to what the authors recognize as a "natural anxiety" or expected anxiety (Bandelow & Michaelis, 2015

Final considerations
This systematic review found evidence of the effectiveness of Relaxation Techniques for the elderly population. The main benefits of relaxation in this population are observed in two great areas: 1. reduction of anxiety symptoms, as well as cognitive difficulties related to it (attention and memory); 2. reduction of physical symptoms, especially tension headache and immunity increase through decline of stress consequences.
Since it is a technique with low cost and easy Techniques application in public health systems and that it helps the qualification of professionals, so they can make use of these techniques in the elderly population as an important therapeutic and preventative asset.