The review of literature in a research report is a summary of current knowledge about a particular practice-problem.(Nancy & Burns 2002). A literature review is an organized writer’s presentation of what has been published on a topic by the scholars. The task of reviewing literature involves the identification, selection, critical analysis and reporting of existing information on the topic of interest.

The literatures found relevant and useful for the present study have been organized under the following headings

A) Literature related to psycho social wellbeing of elderly people

B) Literature related to quality of sleep among elderly people

C) Literature related to the benefit of relaxation therapy

A) Literature related to psycho social wellbeing of elderly people

Thailand, Ingersoll-Dayton et al (2009), conducted a community survey of 1147 older parents aged 60 years and over in rural Thailand with the aim of finding out their level of psychological well being in relation to their physical illness by using the Thai Psychological Wellbeing Scale and the brief WHO Disability Assessment Schedule. They rated received and perceived social support separately from children and from others and rated support to children. Results has shown that Impairments due to arthritis, pain, paralysis, vision, stomach problems or breathing were all associated with lower wellbeing. After adjusting for disability, only impairment due to paralysis was independently associated with lowered wellbeing. The effect of having two or more impairments compared to none was associated with lowered wellbeing. The parsimonious model for wellbeing included age, wealth, social support, disability and impairment due to paralysis (the effect of paralysis was -2.97, p = 0.001. In their setting, most of the association between physical impairments and lower wellbeing is explained by disability. Disability is potentially mediating the association between impairment and low wellbeing. Received support may buffer the impact of some impairment on wellbeing in this setting. The study recommended that improving community disability services for older people and optimizing received social support will be vital in rural areas in developing countries.

Martin Pinquart and Silvia Sorensen (2009) conducted a Meta analysis on gender differences in self concept and Psychological wellbeing in old age. Meta-analysis was used to synthesize findings from 300 empirical studies on gender differences in life satisfaction, happiness, self-esteem, loneliness, subjective health, and subjective age in late adulthood. Older women reported significantly lower Subjective Wellbeing and less positive self-concept than men on all measures, except subjective age, although gender accounted for less than 1% of the variance in well-being and self-concept. Smaller gender differences in Subjective wellbeing were found in younger than in older groups.

K Morgan, HM Dallosso, T Arie, EJ Byrne, R Jones and J Waite, Activity and Ageing Research Group (2008), conducted a comparative descriptive study on assessing mental health and psychological well-being among the old and the very old living at home in Nottingham. 507 old (aged 65-74 years) and 535 very old (aged 75+) individuals randomly sampled from the community. They used four brief assessment scales to collect the data on mental health and psychological well-being. Assessments of dementia and depression were subsequently validated against diagnostic ratings made by experienced psycho geriatricians. Levels of agreement between psychometric and clinical ratings of dementia (kappa = 0.83) and depression (kappa = 0.66) were satisfactory. The old and very old groups reported similar levels of anxiety and personal disturbance, and showed a similar prevalence of depression. However, those aged 75+ showed higher levels of dementia and significantly lower level of social involvement and morale.

A study done on recently retired people was published by Susan A (2009) in The Journal of Gerontology. The author reported that retirement provides a sense of psychological well-being in the short term. However when longer times are considered, retirement does not provide a sense of purpose and psychological well-being goes down rather quickly after the first few months of retirement.

Laura E. Middleton, Arnold Mitnitski, Nader Fallah, Susan A. Kirkland, Kenneth Rockwood (2008), Geriatric Medicine Research Unit, Centre for Health Care of the Elderly, conducted a population based study to assess Changes in Cognition and Mortality in Relation to Exercise in Late Life. 8403 people who had baseline cognition measured were included in this study. The study was conducted by using parametric Markov chain model to estimate the probabilities of cognitive improvement, decline, and death, adjusted for age and education, from any cognitive state as measured by the Modified Mini-Mental State Examination. Result showed that exercise is strongly associated with improving cognition. As the majority of mortality benefit of exercise is at the highest level of cognition, and declines as cognition declines, the net effect of exercise should be to improve cognition at the population level, even with more people living longer.

Anne Case and Christina Paxson (2008) conducted an analysis on Height, Health, and Cognitive Function at Older Ages. Their analysis was based on a longitudinal study sponsored by the National Institute on Aging, which is carried out by the Institute for Social Research at the University of Michigan. Since 1992, the researchers has been following a cohort of men and women in the United States over the age of 50, in order to better understand the physical and mental health, quality of life, and life circumstances of older Americans. They collected a variety of measures of cognitive function, health and mental health status, and difficulties with daily life that can be used to examine the extent to which height is protective of well-being at older ages. Mainly three measures of cognitive function (word recall, counting backward, knowing the day and date), and self-reports of health status, depression, and difficulties with activities of daily living. The analyses shown that early life experiences as summarized by height have important consequences for well-being at older ages. Height is associated with better mental and physical health and cognitive function in late life. Research on the determinants of both height and cognitive ability suggests that health and nutrition in early childhood may be a key factor in the association between height and cognitive ability.

Robert M. Hauser, Tatyana Pudrovska. Center for Demography of Health and Aging, University of Wisconsin-Madison (2005) conducted a longitudinal study based on three large data sets: the Wisconsin Longitudinal Study (WLS), Midlife Development in the United States (MIDUS), and the National Survey of Families and Households (NSFH); explored cross-sectional and longitudinal age Differences in the six dimensions (autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance) of Ryff’s scales of Psychological wellbeing. This was the first Study to use longitudinal data to examine changes in psychological wellbeing among real cohorts over approximately a 10-year period. In addition to longitudinal analysis, they also looked at cross-sectional age patterns to assess the extent to which their cross-sectional findings were consistent with previous studies on age variation conducted based on cross-sectional data. Results of this study revealed that there is a tendency for autonomy and environmental mastery to increase with age, and for personal growth and purpose in life to decline with age, while positive relations with3 others and self-acceptance do not show any specific pattern. In terms of environmental mastery and positive relations with others start to decline in late midlife and continue to decrease after that. This is consistent with some previous cross-sectional studies.

Geritol (2010) stated that old age as an anti depressant based on the telephonic survey of 340,000 people aged 18 to 85 conducted by the Gallup organization, in which older people scored much higher than younger people on global well being. In this study, each person who was called ranked overall life satisfaction on a 10-point scale, as well as answered questions about their recent experience of enjoyment, happiness, stress, worry, anger, and sadness. Contra stereotypes, 85 year olds were more satisfied with life than 18 year olds or 50 year olds.

Elliott AF, McGwin G Jr, Owsley C. (2009) conducted a descriptive study to assess the Health-related quality of life and visual and cognitive impairment among nursing-home residents. The result showed that the deleterious impact of vision impairment on Health Related Quality Of Life in nursing-home residents was not exacerbated by the co-occurrence of cognitive impairment. Age-related visual impairment in nursing-home residents is often reversible through treatment leading to improved HRQoL, and thus it is clinically important to know that cognitive impairment is unlikely to interfere with this benefit.

Prieto-Flores ME, Fernández-Mayoralas G, Rojo-Pérez F (2005), conducted a study to analyze the relationships of emotional wellbeing with socio demographic and health factors. A survey on QoL among older people living in family housing of Madrid province (CadeViMa-2005) was used in this study. . Multivariate analyses were applied for generating an indicator of emotional wellbeing which integrated positive and negative affects, as well as personal coping resources. A logistic regression model was created to explain a positive emotional wellbeing, according to socio demographic and health characteristics. Results showed that people without anxiety or depression problems were around three times more likely to evaluate their emotional wellbeing positively than those who had problems. Older adults whose health was better than in the previous 12 months, seemed to be five times more likely to report a high emotional wellbeing, compared to those who experienced a health decline. Individuals with a very good perceived health status were 26 times more likely of having a high emotional wellbeing than people with a negative health perception. Those with middle and upper social class were three times more likely to experience a positive emotional wellbeing than those belonging to a low social class.

Phillips CJ, Henderson AS conducted a descriptive study to assess the prevalence of depression among Australian nursing home residents. The aims of this study were, to estimate the prevalence of depressive disorders in Australian nursing home residents using international diagnostic criteria, and to explore environmental determinants of such disorders. Residents of 24 nursing homes were surveyed using the Canberra Interview for the Elderly (CIE) and a range of environmental measures was also taken. Of 323 residents who were screened for cognitive impairment, 165 (51%) scored 18 or above on the Mini-Mental State Examination and were interviewed. According to this study the prevalence of major depressive episode was 9.7%. 6.1% of residents suffered from a severe depressive episode, 6.7% from a moderate depressive episode and 6.7% from a mild depressive episode. Some measures of the social environment were significantly related to depressive symptoms.

Roy P.C. Kassel, Roel P.L.M. Hoogma, Johanna M.L. Henselmans (2008) conducted a study to assess the Cognitive Performance, Psychological Well-Being, and Brain Magnetic Resonance Imaging in Older Patients With Type 1 Diabetes in Department of Neurology, University Medical Center, Utrecht, the Netherlands . Forty type 1 diabetic patients (age >50 years) and 40 age-matched control subjects were included. Neuropsychological assessment included all major cognitive domains, and psychological well-being was assessed with questionnaires. Atrophy, white-matter abnormalities, and infarcts were rated on MRI scans. Type 1 diabetic patients performed slightly (effect sizes <0.4) worse on cognitive tasks, but only “speed of information processing” reached statistical significance. No significant between-group differences were found on any of the MRI parameters. Type 1 diabetic patients tended to report more cognitive and depressive problems than control subjects, but this did not correlate with the performance on cognitive tests. They concluded that cognition in older type 1 diabetic patients is only mildly disturbed.

Literature related to quality of sleep among elderly people

Newman AB, Unruh ML, University of Pittsburgh Medical Center,(2008), conducted a cross sectional study to examine the extent to which subjective and objective sleep quality are related to age independent of chronic health conditions. Five thousand four hundred seven community-dwelling adults were participated in this study (mean age 63, range 45-99). Results shown that older age was associated with shorter sleep time, diminished sleep efficiency, and more arousals in men and women. In men, age was independently associated with more Stage 1 and Stage 2 sleep and less slow-wave (Stage 3 to 4) and rapid eye movement sleep. In women, older age was less strongly associated according to linear trend with sleep stage. Conversely, poor subjective sleep quality was not associated with older age in men, but older women had more trouble falling asleep, and there was a trend toward older women having more problems with waking up during the night and waking up too early. Associations between self-report and directly measured sleep time and sleep latency were low to moderate across age groups (correlation coefficient=0.06-0.32). The researcher concluded that older age was more strongly associated with poorer sleep according to direct observation in men than women, yet the subjective report of poor sleep with older age was stronger in women.

Newman AB, Enright PL, Manolio TA, Department of Medicine, University of Pittsburgh (2004) conducted a Cross-sectional study of sleep disturbance, CVD, general health, psychosocial factors, physical function, and use of psychotropic medications. 5201 adults aged 65 and older recruited from a random sample of no institutionalized Medicare enrollees in four US communities. Results shown that Women were twice as likely as men to report difficulty falling asleep (30% vs. 14%). Daytime sleepiness, difficulty falling asleep, and frequent awakenings increased in prevalence with age. All symptoms were related strongly to depression. Symptoms of daytime sleepiness were also related strongly to poor health and limitations in activities of daily living in men and women. In multivariate analysis, men taking benzodiazepines were likely to report difficulty falling asleep and daytime sleepiness, whereas women taking benzodiazepines reported difficulty falling asleep and waking up too early. The study concluded that Sleep disturbances are relatively common in older men and women and are associated with poor health, depression, angina, limitations in activities of daily living, and the use of benzodiazepines.

Haimov I, Vadas L (2009), conducted a study to analyze whether insomnia is associated with changes in cognitive functioning among elderly people. The study population comprised two groups: 64 older adult subjects without sleep disorders, and 48 older adult insomniacs. All subjects were living independently in the community and were in good clinical condition. The cognitive capacity of each subject was tested at the subject’s home using the computerized “Mind Fit” test. The results demonstrate that chronic insomnia in older adults is associated with impairment in cognitive functioning. Specifically, we found that older people suffering from late-life insomnia exhibit significantly reduced performance in memory span, allocating attention to a target, time estimation, working memory and integration of two dimensions. The present findings suggest that late-life insomnia may be one of the factors contributing to the decline in cognitive functioning seen among older people.

Gras CB, Hidalgo JL, Garcia YD (2004-2005), conducted a cross sectional study to assess the prevalence and characteristics of insomnia and its relationship to other health problems, medication, socio-health status and sleep hygiene in the elderly over 65 years of age in Albacete. Semi-structured interview method was used to collect the data from the participants. Semi-structured interview. Study variables were: sleep characteristics, socio-familial repercussions, sleep hygiene, health problems, medication, health care utilization and socio-demographic variables. The result shown that 34.2% of the participants had sleeping difficulties, 95.7% the sleep disturbance was chronic. The most frequent repercussions were sensation of insufficient night-time sleep (62.1%) and daytime tiredness or sleepiness (52.2%). 20.3% of the participants met the criteria of primary insomnia. Insomnia rates were significantly higher in females and in subjects maintaining irregular hours and expressing dissatisfaction with bedroom environmental conditions.

Whitney CW, Enright PL (2008) conducted a Cross-sectional survey and clinical exam to describe the prevalence of self-reported daytime sleepiness in older men and women and to describe their relationships with demographic factors, nocturnal complaints, health status, and cardiovascular diseases. 4578 adults aged 65 and older, recruited from a random sample of non-institutionalized Medicare enrollees in four U.S. communities participated in this survey. The study concluded that Daytime sleepiness is common in the elderly, probably due to nocturnal disturbances such as frequent awakenings and snoring. The occasional use of sleeping pills for insomnia is associated with reduced daytime sleepiness in the elderly, while the use of medications for congestive heart failure is associated with daytime sleepiness. Surprisingly, anatomic abnormalities such as evidence of previous strokes and brain atrophy (as seen on brain MRI scans) were not associated with daytime sleepiness in these non-institutionalized elderly persons.

Haponik EF, Boyle PJ (2004) conducted a descriptive study to assess the prevalence of snoring, observed apneas, and daytime sleepiness in older men and women, and to describe the relationships of these sleep disturbances to health status and cardiovascular diseases. 5,201 adults, aged 65 and older, who were recruited from a random sample of Medicare enrollees in four U.S. communities participated in this study. The study reported that Observed apneas were reported much less frequently (13% of men and 4% women) than snoring, Thirty-three percent of the men and 19% of the women reported loud snoring. In both men and women, daytime sleepiness was associated with poor health, advanced age, and ADL limitations.

Kim JM, Stewart R (2008), conducted a community based longitudinal study to investigate prevalence, incidence, and persistence of insomnia, and their bidirectional longitudinal associations with depression and physical disorders. 1204 people > or = 65 years of age were evaluated at baseline; 909 of them (75%) were re-interviewed after 2 years. Of those (27%) with insomnia at baseline, 40% had insomnia at follow-up. Of those without insomnia at baseline, 23% had insomnia at follow-up. Baseline depression was significantly associated with prevalence and incidence of insomnia. Baseline number of physical disorders was significantly associated with prevalence, incidence, and persistence of insomnia. Baseline insomnia was independently associated with incident depression and an increase in reported physical disorders. The study concluded that Insomnia was common and often persistent in this population. Insomnia was closely and reciprocally related to depression and physical disorders.

Gentile A, Weiner DK, Kuchibhatil M, Edinger (2004), conducted a cross sectional study to identify the Factors that disturb sleep in nursing home residents. The purpose of this cross-sectional survey was to examine subjective sleep quality, and identify factors that disturb sleep in cognitively intact nursing home (NH) residents. They interviewed 51 cognitively intact NH residents using a validated instrument, the Pittsburgh Sleep Quality Index (PSQI). The report showed that Seventy-three percent of the subjects were identified as “poor” sleepers based upon a total PSQI score > 5. Factors that disturbed the residents’ sleep three or more times a week were: nocturia (71%), environment-related noise or light (38%), pain (33%), feeling too hot (6%) and leg cramps (6%). On multiple regression analysis, poor sleep correlated with depressive symptoms and co morbidity, not with age or gender. Poor sleep quality is common among cognitively intact NH residents. In this study, nocturia, environmental factors and pain were the most commonly perceived causes of sleep disturbance. Poor sleep independently correlated with depressive symptoms and co morbidity

Schnelle JF, Ouslander JG (2009), conducted a Cross-sectional survey to evaluate the association between noises, light, nursing care practices, and nighttime awakenings in incontinent nursing home residents. One hundred eighteen incontinent nursing home residents participated in this study. The data reported that general environmental noise and incidents of nursing care practices, particularly those related to incontinence care are responsible for a substantial amount of the sleep fragmentation that is common among nursing home residents.

Michael T. Smith (2008) conducted a study to analyze the effect of fragmented sleep on pain perception among healthy young people in a hospital. One group slept normally for eight hours in the hospital. Another was awakened every hour by a nurse and kept up for 20 minutes. Their sleep pattern was meant to mimic the fragmented sleep of elderly people. A third group was allowed four hours of solid sleep. Comparing the second and third groups apart the causes of the problems that arise from fragmented sleep: were they because of the short total sleep time, or because of the disrupted nature of the sleep. Fragmented sleep, resulted in severe impairments the next day in pain pathways. The subjects felt pain more easily, were less able to inhibit pain, and even developed spontaneous pain, like mild backaches and headaches

Chokroverty (2000) conducted an exploratory study to find out altered sleep physiology among elderly nursing home residents. In this study the researcher reported that REM sleep is needed for brain tissue restoration and appears to be important for cognitive restoration. Rem sleep is associated with changes in cerebral blood flow, increased cortical activity, increased O2 consumption, and epinephrine release. This association may assist in memory storage and learning. With ageing episodes of REM sleep tend to shorten. There is a progressive decrease in stage 3 and 4, or deep sleep. An older adult awakens more often during the night, and it may take more time for an older adult to fall asleep

Literature related to the benefit of relaxation therapy

Song RH, Kim DH. (2005), conducted an experimental study to assess the effectiveness of foot reflexion massage on sleep disturbance, depression disorder, and the physiological index of the elderly. The research design was a non-equivalent control group pretest-posttest quasi-experimental study. The subjects in this study were 50 elderly people who resided in two different nursing homes in the same region. An experimental group and a control group were organized with 25 subjects respectively, and foot reflexion massage was provided for 12 sessions, 30 minutes per session. The selected dependent variables were sleep disturbance, depression disorder, and physiological indices (blood plasma serotonin, serum cortisol), which were all measured before and after foot reflexion massage was offered. Results shown that the experimental group improved sleep quality more than the control group; the experimental group had less depression disorder than the control group. The experimental group had higher serotonin levels than the control group. The researcher concluded that foot reflexion massage is a successful nursing intervention to elderly who undergo a change in sleep, and suffer from a depression disorder due to deterioration in sleep.

Melanie K. Means, Kenneth L. Lichstein conducted an experimental study to assess the effectiveness of progressive muscle relaxation technique on insomnia and day time functions among dental college students. They compared day time functioning in college students with and without insomnia and explored changes in day time functioning after progressive relaxation (PR) treatment for insomnia. Students with insomnia (SWI; n=57) were compared to a control group of students not complaining of insomnia (SNI; n=61) on self-reported sleep variables and five questionnaires. To investigate treatment effects on day time functioning, 28 students with insomnia were randomly assigned to PR. Treated students with insomnia were compared to untreated SWI and students not having insomnia at post treatment. Treated participants improved sleep in comparison to untreated SWI, but failed to show significant improvements in day time functioning. Insomnia treatments focused on improving sleep may not improve day time functioning, or day time gains may emerge more slowly than sleep gains.

Mr. piton vutiso (2007), conducted an experimental study to assess the effectiveness of progressive muscle relaxation technique on post operative abdominal surgery pain in the elderly patients. The sample size in this study was 64 elderly patients who underwent abdominal surgery in the surgical department, in Saraburi Hospital. They were enrolled into the study at pre operative period. 32 of them were randomly assigned into the experimental group, while other 32 were in the control group. The experimental group was received progressive muscle relaxation technique along with usual care, while the control group received only the usual care. Pain level was measured by using Numerical rating scale at rest, immediately after the first ambulation, 30 minutes and 90 minutes after the rest. The uses of analgesic drugs required within 12 hours were recorded. Independent “t” test was employed to test the difference of pain level between experimental group and control group. ANOVA was employed to test the difference level of pain pre and post intervention in the experimental group and control group. Chi- square was employed to test the difference between analgesics used in experimental group and in control group. The study revealed that after receiving progressive muscle relaxation technique the mean score of pain level between experimental group and the control group were different. The finding in this study supported the effect of progressive muscle relaxation technique on post operative pain reduction among the elderly patients.

Roosevelt University Stress Institute, Chicago, USA (2005), conducted an experimental study to assess the effectiveness of relaxation techniques on the level of anxiety. Progressive muscle relaxation, yoga stretching and imagery are all methods which used to induce a state of relaxation in this study. They investigated these forms of relaxation by monitoring their effects on 114 men and women. Each participant was treated to 25 minutes of progressive muscle relaxation, yoga stretching and imagery taking the Smith Quick Stress Test (which measures Somatic Stress, Negative Affect, and Worry) and data was recorded before and after the therapies. The exercises concentrated on relaxation, mental relaxation, strength and awareness, joy, love and thankfulness, and prayer. No difference was observed for creativity, but physical relaxation was found to be significantly improved after the yoga stretching and progressive muscle relaxation technique. All those who took part in the relaxation exercises reported that they were calmer and were able to cope better with anxiety. The researchers concluded that the relaxation methods were capable of inducing a deep state of relaxation and that these techniques should be more widely taught to patients who need help controlling stress in their lives

Meeks S, Looney SW, (2006) conducted an experimental study to assess the effectiveness of a staff-assisted Sympathetic Breathing technique for depression in nursing home. The sample size in this study was 80 elderly people in a nursing home. They were enrolled into the study before the intervention. 40 of them were randomly assigned into the experimental group and rest of them was in the control group. Sympathetic breathing technique was administered for experimental group for one month.post assessment done in both group. The result showed that the intervention was well received by residents, family, and staff members. Experience with the intervention and input from staff members resulted in increased overall active participation by the residents, and improved depressive symptoms. Despite low power, statistical and graphical comparisons suggest superiority of the intervention over treatment as usual.

Kwekkeboom KL, Wanta B (2008) conducted a comparative experimental study to examine the Individual difference variables and the effects of progressive muscle relaxation and analgesic imagery interventions on cancer pain. . A crossover design was used in which 40 hospitalized cancer patients received two trials of progressive muscle relaxation technique two trials of analgesic imagery, and two trials of a control condition. In comparing means between treatment and control conditions, both Progressive Muscle Relaxation and analgesic imagery produced greater improvements in pain intensity, pain-related distress, and perceived control over pain than the control condition.

Paul Yung, Peter French and Bartholomew Leung (2005), studied Relaxation training as complementary therapy for mild hypertension control and the implications of evidence-based medicine. The empirical work examined the effects of three relaxation therapies for the reduction of high blood pressure in nine Chinese subjects. Subjects were randomly assigned to three groups: (a) progressive muscle relaxation, (b) stretch release relaxation and (c) cognitive imagery relaxation. Systolic, diastolic blood pressure and heart rate were assessed in a baseline session, the 8th post-treatment session, and a 30 -days follow-up session. Data were analyzed using ANOVA and Paired sample t-test. One-Sample Kolmogorov-Smirnov Tests for the normal distribution were performed among the three groups. Results revealed that in the context of the study all relaxation therapies can reduce blood pressure in Chinese Subjects, but stretch release relaxation and progressive muscle relaxation therapies appeared to be more effective in lowering blood pressure compared to cognitive imagery Relaxation.

Smith MT, Neubauer DN (2006) conducted an experimental study to assess the effectiveness of Cognitive behavior therapy for chronic insomnia. . 300 adults, aged 65 and older, who were recruited from a random sample of Medicare enrollees in four U.S. communities participated in this study. In this study Cognitive-behavioral treatment approaches for chronic insomnia and related sleep disorders have been shown to be effective in various patient populations.

Bumpus M. (2010) published an article on Stress Relief Breathing Exercise. In this article he stated that The Sympathetic Breathing technique reduces stress and promotes natural sleep. Sympathetic Breathing causes a profound calming effect by promoting parasympathetic function. This breathing technique was developed through biofeedback research, and is well documented in Heart Rate Variability research. It is unique in its ability to shift the autonomic nervous system from the “fight or flight” response to the “rest and digest” response. If practiced twice a day f