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Combination Of Autogenic And Progressive Muscle Relaxation To Reduce Blood

Pressure Among Elderly With Hypertension In A Nursing Home

Article · August 2021

DOI: 10.36295/AOTMPH.2021.7302

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 Annals of Tropical Medicine and Public Health
Volume 7, Issue 3, 2021
Print ISSN: 1755-6783
Online ISSN: 0974-6005

Combination Of Autogenic And Progressive Muscle

Relaxation To Reduce Blood Pressure Among Elderly With
Hypertension In A Nursing Home
Sri Widiyati, Sugih Wijayati , Sukma Diyanatul Faikha, Muhamad Jauhar

Nursing Department, Health Polytechnic of Ministry of Health Ministry of Semarang, Jl. Tirto Agung, Pedalangan,
Banyumanik, Semarang, 50268

Corresponding author: Sugih Wijayati, Jl. Tirto Agung Pedalangan Banyumanik Semarang,
sugihwijayasam@gmail.com

Abstract

Background: Hypertension is a non-communicable disease that is still become a significant health problem in developing
countries, and its steady increasing cases happens each year. Hypertension was caused by lack of physical activity and
unhealthy nutrition therefore it’s threatening for all age populations, especially the high-risk age group, including the
elderly. Hypertension in the elderly can cause multiple complications; consequently, complementary therapies are needed to
counterbalance the medication and lifestyle modification. One of which can reduce blood pressure in the elderly was a
combination of autogenic and progressive muscle relaxation.

Objective: This study aimed to identify the effectiveness of the combined autogenic and progressive muscle relaxation in
reducing blood pressure in the elderly.

Methods: This study of quasi-experimental pre-test and post-test type with control group involved 23 elderly for each
intervention and control group selected by purposive sampling based on inclusion and exclusion criteria. The tool for
measuring the blood pressure in this study was an aneroid sphygmomanometer and a stethoscope. The intervention was
given two times a week for three weeks long, with a duration of 15-20 minutes per session. The data found was analyzed
using paired t-test and independent t-test.

Results: The results showed that there was a significant effect of the combination of autogenic and progressive muscle
relaxation on lowering blood pressure in the elderly with p-value = 0.037 (p <0.05) in systolic blood pressure and p-value =
0.033 (p <0.05) in diastolic blood pressure.

Conclusion: There is a decrease in systolic and diastolic blood pressure in the elderly after taking the therapy. These
intervention can be integrated in non-communicable disease control programs in primary health care facilities.

Keyword: Hypertension, elderly, autogenic relaxation, progressive muscle relaxation

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Introduction
Elderly was one of the vulnerable groups that is prone to
degenerative diseases such as coronary heart disease,
diabetes mellitus, rheumatism, cancer, and hypertension.
Hypertension is known as "The Silent Killer" because it
typically does not show signs and symptoms on the
client; however this leads to a serious awareness to battle
this disease. Blood pressure mostly will increase with
age, therefore it is more common to find the case in the
adult and middle-aged groups. Despite the complications
it brings, hypertension was often neglected even though
data stated that it is the most common disease found in
the community. Hypertension is a big challenge in
Indonesia to date because of the constant increasing of
morbidity and mortality observed every year [1].
[2] noted that there are 1.13 billion people with
hypertension worldwide and as many as 1 in 3 people in
the world are diagnosed with hypertension, but only
36.8% of patients consume anti-hypertensive drugs. The
prevalence of hypertension globally reaches 42% which
affects the death rate due to hypertension by 13%. Based
on the 2018 Indonesia Basic Health Research Report, it
was found that hypertension was the number one disease
found in the elderly group (63,5%). The prevalence of
hypertension cases in Indonesia is 34.11% with the
proportion of cases in women at 36.85% and men at
31.34% [3]. Hypertension was ranked first on the list of
non-communicable diseases (NCDs) in Central Java
Province with a case prevalence of 57.1% with a
proportion of cases in women at 15.84% higher than
cases in men at 14.15% [4]. The prevalence of
hypertension cases in Semarang City in 2018 increased
in the elderly group by 161,283 cases. In addition, the
underlying factor of this phenomenon was the poor
healthy lifestyles, such as: healthy food consumption,
regular health checks, exercising promptly, avoiding
smoking habits and exposure to cigarette smoke [5].
Hypertension that often found in the elderly associates
with the physiological changes such as decreased
immune response, thickening and stiffy heart valves,
decreased cardiac contractility, reduced blood vessels
elasticity, and lack of effective oxygenation in the
peripheral blood vessels. Consequently, these changes
cause an increase in vascular resistance and finally leads
to higher risk of hypertension in the elderly. In addition,
Page: 09
Annals of Tropical Medicine and Public Health
study found several underlying factors such as genetic,
race, gender, smoking habits, obesity and psychological
stress that contribute to hypertension. Furthermore,
hypertension attacks various organs of the body and
causes complications in the form of other diseases such
as heart attacks, strokes, kidney disorders, even
blindness. According to the previous research results, it
is known that uncontrolled hypertension will increase the
risk of stroke by 7 times and heart attack by 3 times if
not handled properly [6]. Strategic steps need to be taken
to manage hypertension in accordance with community
needs.
Pharmacological therapy and non-pharmacological
therapy had been used to manage hypertention of the
clients. Clients must take anti-hypertensive medication
regularly that often cause a weary which results in
treatment non-compliance. Nurses are expected to
provide nursing care to hypertensive patients one of
which is the non-pharmacological management of
through modification of a healthy lifestyle also stress
management. The relaxation method becomes a
complementary intervention that aims to avoid stress by
creating a pleasant atmosphere for hypertensive clients.
Relaxation methods can control the nervous system
thereby it can lower blood pressure and also reduce
anxiety through exercising the muscles of the body [7,8].
Relaxation methods have various techniques, one of
which is autogenic relaxation.
Autogenic relaxation is proven to have a positive impact
on changes in blood pressure, easy, inexpensive, and can
be done anywhere and anytime. Autogenic relaxation
puts the client in a hypnotized state through
concentration training exercises, gives rise to a sense of
comfort and enhances the body's ability to fight disease.
As with auto-hypnosis and meditation, the goal is for the
patient to learn how to bring himself to a relaxed state by
releasing muscle tension, overcoming anxiety, and other
psychosomatic conditions without the help of a coach or
therapist [9]. Based on research conducted [10] that there
is an influence of autogenic relaxation on blood pressure
reduction in hypertensive clients. Besides interventions
with autogenic relaxation techniques, there are other
forms of relaxation interventions, namely progressive
muscle relaxation (PMR). According to [11], PMR is a
http://doi.org/10.36295/AOTMPH.2021.7302
 Annals of Tropical Medicine and Public Health

concentrated muscle activity by identifying tense An enumerator that fit the requirement criteria of this
muscles and then reducing the tension by using study were involved and were specifically given the
relaxation techniques for relaxing sensation. [11] also essential steps of the study. Furthermore, the researchers
further explained that PMR is effective in lowering gave the explanation about the study procedures and
blood pressure in hypertensive clients. Previous study informed consent as the preparation. Researchers
also states that the combination of PMR and autogenic measured blood pressure before and after the session
relaxation is effective for lowering blood pressure in using an aneroid type sphygmomanometer, a stethoscope
hypertensive clients. with dual head chest and ear type plug specifications,
and filling out the measurement into a blood pressure
Based on the results of a preliminary study at the observation sheet. Univariate data analysis consisted of
research site, it was found that hypertension is the most age and sex variables in the form of frequency and
common disease experienced by the elderly (56.7%). percentage distributions, duration of illness and blood
One of the existing program that deals with hypertension pressure are presented in the form of mean and standard
in the elderly is PROLANIS (Indonesia Program of NCD deviation. Bivariate analysis uses paired t-test and
Management); however the low number of elderly have independent t-test. This study has passed ethical tests
BPJS (Indonesia National Health Insurance) hinders from the Medical/Health Research Bioethics
them to participate in the program. Furthermore, other Commission Sultan Agung Islamic University with the
non-pharmacological interventions also have been approval number No.055/I/2020/Bioethics Commission.
carried out in nursing homes but the sustainability of the
program is still lacking from various reasons: costs, Results
facilities, and human resources. The combination of
autogenic relaxation and PMR is expected to be an Table 1. Characteristics of the elderly with
effective and efficient complementary intervention to hypertension by sex (n = 46)
reduce blood pressure in the elderly as it offers a simple,
low cost, minimum facilities to carry out and monitor as
needed. This non-pharmacological interventions denote Characteristics of Intervention Control
the independence of nurses in providing nursing f % F %
intervention. The purpose of this study was to determine Gender
the effectiveness of a combined autogenic relaxation and Male 11 47.8 8 34.8
PMR on blood pressure in the elderly with hypertension.
Women 12 52.2 15 65.2
Method Age
This quasi-experimental pre and post-test with control Elderly (60-74) years 14 60.9 11 47.8
group study involved a population of elderly with Old (75-90) years 9 39.1 12 52.2
hypertension who live in nursing homes. The number of
research samples were 23 people for each intervention Total 23 100 23 100
and control group that met the inclusion criteria of:
elderly people aged ≥ 60 year, blood pressure ≥ 140/90
mmHg, and lastly not experiencing hemiplegia and
hemiparesis. The study was conducted in January- Based on table 1. It was found that half of the elderly
February 2020 in one of the elderly social service houses with hypertension were female on both of the study
in Central Java Province. The independent variable is a groups that was 52.2% and 65.2% in the intervention and
combination of autogenic relaxation and progressive the control group respectively. Most of the elderly with
muscle tone. The dependent variable is blood pressure in hypertension in the intervention group was aged 60-74
the elderly with hypertension. The intervention was (60.9%) and half of the elderly with hypertension in the
carried out 2 times per week for 3 weeks with a duration control group aged 75-90 year (52.2%).
of 15-20 minutes per session.

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 Annals of Tropical Medicine and Public Health

Table 2. Characteristics of the elderly with hypertension based on the duration of the disease (n = 46)

Characteristics of Interventions Control

Mean SD 95% CI Mean SD 95% CI

Duration of Disease 8.65 2.187 7.71-9.60 8.17 3,200 6.79-9.56

Based on table 2 it is explained that the average duration of hypertension experienced by the elderly in the
intervention group which is 8.65 years with a standard deviation of 2.187 and in the control group that is 8.17
years with a standard deviation of 3.20. Based on this, it was concluded that the average duration of hypertension
experienced by the elderly> 8 years

Table 3. Blood pressure in the intervention and control groups before and after intervention

Pre-Test Post-Test

group Blood Pressure Mean SD Mean SD

Systolic 147.78 4.805 141.61 3.940

Intervention
Diastolic 90.65 3.157 87.74 3.441

Systolic 147.22 5.477 144.43 4.897

Control
Diastolic 91.39 3.327 90.30 4.384

Furthermore, Table 3 explains that the mean systolic
blood pressure of elderly with hypertension in the
intervention group before intervention was 147.78
mmHg (SD=4,805) and after the intervention of 141.61
mmHg (SD=3.94). The mean diastolic blood pressure of
the elderly with hypertension in the intervention group
before the intervention was 90.65 mmHg (SD=3.157)
and after the intervention of 87.74 mmHg (SD= 3.441).
The mean systolic blood pressure of elderly with
hypertension in the control group before the intervention
was 147.22 mmHg (SD=5.477) and after the intervention
of 144.43 mmHg (SD=4.897). The mean diastolic blood
pressure of the elderly with hypertension in the control
group before the intervention was 91.39 mmHg
(SD=3,327) and after the intervention of 90.3 mmHg
(SD= 4,384)

Table 4. Differences in blood pressure in the intervention and control groups before and after intervention

Pre-Test Post-Test
Group Blood Pressure Mean SD Mean SD MD p-value
Systolic 147.78 4.805 141.61 3.940 6.17 0.000
Intervention
Diastolic 90.65 3.157 87.74 3.441 2.91 0.000
Systolic 147.22 5.477 144.43 4.897 2.79 0.000
Control
Diastolic 91.39 3.327 90.30 4.384 1.09 0.028

Table 4 explains that there are significant differences in
systolic blood pressure in the elderly with hypertension
in the intervention group before and after the
intervention with a p-value of = 0.000 (p <0.05) and in
the control group with p-value = 0.000 (p <0.05).
There were significant differences in elderly diastolic
blood pressure with hypertension in the intervention
group before and after the intervention with a value of p
= 0.000 (p <0.05) and in the control group with a value
of p = 0.028 (p <0.05). Based on this it can be concluded
that statistically, there are differences in both systolic

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 Annals of Tropical Medicine and Public Health

and diastolic blood pressure in elderly with hypertension Lipoprotein (HDL). Low HDL levels and high levels of
found in the both two study groups. Low Density Lipoprotein (LDL) can affect the
atherosclerosis process and induce high blood pressure
Table 5. Effects of a combination of autogenic [15].
relaxation and progressive muscles on blood pressure
There are slight differences in the age category of the
group Mean SD p elderly with hypertension in our study. According to
[16], age constributes to the change in the body systems
Systolic such as reduced elasticity of blood vessels and decreased
kidney function as a counterweight to blood pressure.
Intervention 141.61 3940
The incidence of hypertension increases with age due to
Control 144.43 4,897 physiological changes in the body that affect the heart,
0037 blood vessels and hormones. This causes blood pressure
Difference 2.82 0.957 to increase with age [13]. In the elderly there is a change
in physical condition due to the process of cell
Diastolic degeneration, causing decreased function and endurance
and also a change in psychological conditions that can
Treatment 87.74 3441
cause the elderly prone to loneliness, anxiety and
Control 90.30 4,384 depression.
0.033
Our participants have the average duration of
Difference 2:56 0943
hypertension more than 8 years. This study is in
accordance with [16] states that the average duration of
hypertension client disease is more than 7 years (57.9%).
Table 5 shows a significant effect of the combined
The longer a person experiences hypertension, the lower
autogenic relaxation and PMR in decreasing systolic
the level of medication adherence, this is because the
blood pressure in elderly hypertensive, with p-value =
clients feel bored. According to [18], there is a
0.037 (p <0.05). Also, there was also a significant effect
relationship between the duration of hypertension and
of the therapy above in decreasing diastolic blood
compliance with hypertension treatment with a value of
pressure in the elderly with hypertension with a value of
p = 0.005 (p <0.05). This is in line with research that
p = 0.033 (p <0.05). It can be concluded that the
stated that the longer the patient has hypertension, the
combined autogenic relaxation and PMR have
lower medication adherence level [19].
statistically proven to be able to reduce both systolic and
diastolic blood pressure in the elderly with hypertension. Both systolic and diastolic blood pressure in the elderly
with hypertension in this study proven to be lower after
Discussion the intervention. Elderly blood pressure is categorized as
hypertension if the systolic is more than 140 mmHg and
Our study found that the majority of elderly with
the diastolic is more than 90 mmHg. This study is in line
hypertension involved are women. This study is in
with [20] that there are a lower blood pressure among 15
accordance with [12] that 80% elderly people with
elderly with hypertension who are given the intervention
hypertension are women so it can be interpreted that
of autogenic relaxation techniques.
elderly women have a higher risk on hypertension than
elderly men. According to [13], woman will usually There are significant differences in both systolic and
experience an increased risk of high blood pressure diastolic blood pressure in the elderly with hypertension
during menopause as women begin to lose estrogen before and after the combined autogenic and PMR is
slowly at the age of 45 year or over as known as pre- given. The results of this study indicate that the
menopausal stage. [14] explained that this lower
estrogen levels in menopausal women can cause intervention significantly influences the decrease in
systolic and diastolic blood pressure in the elderly with
narrowing of blood vessels and atherosclerosis which hypertension. The results of this study are in accordance
results in an increase of blood pressure. In addition, with [20] that concluded autogenic relaxation therapy
estrogen plays a role in increasing levels of High Density can reduce blood pressure in the elderly with

Page: 12 http://doi.org/10.36295/AOTMPH.2021.7302

hypertension with a value of p = 0.001 (p <0.05).
Autogenic therapy can improve vascular blistering in
hypertension by decreasing cerebral vascular resistance
[21]. PMR therapy can also reduce blood pressure in the
elderly with hypertension with a value of p = 0.005 (p
<0.05).
Progressive muscle relaxation therapy is a relaxation
technique that can be performed in the elderly with
hypertension by alternately tensing and relaxing the
muscles that when performed, the parasympathetic
nervous system releases acetylcholine which functions to
inhibit the activity of the sympathetic nerves. When the
activity of the sympathetic nervous system decreases due
to the relaxing effect, the production of catecholamine is
reduced therefore causes blood vessel dilatation and
decreased blood pressure [11]. This therapy can be done
lying down or sitting as needed 2 times a week for 3
weeks with a duration of 15-20 minutes per session
[22,23].
Based on the results of this study, most of the elderly
with hypertension feel more relaxed and calm after doing
the teraphy. This happens because the elderly with
hypertension who implemented PMR feel a relaxing
state so that the tension in the body decreases. In
addition, autogenic relaxation can make the mind of
elderly people with hypertension become more calm,
mood in good condition, and eliminate unpleasant
feelings. So that the elderly with hypertension can feel
the state of the body really relaxed and blood pressure
becomes decreased. The research by [11] stated that
progressive muscle relaxation is effective in lowering
blood pressure in hypertensive clients. Other research
conducted by [24] states that the combination of
progressive muscle training and autogenic relaxation is
effective for lowering blood pressure in hypertensive
clients. These results are in line with previous studies
that show that the administration of the combined
autogenic relaxation and PMR had been shown to be
effective in reducing blood pressure in the elderly with
hypertension.
Our modification of non-pharmacological therapies such
as autogenic relaxation and PMR can be used as
complementary therapies for patients with hypertension 4.
including the elderly. Nurses as healthcare workers must
be able to provide quality nursing care to the elderly that
refers to how the elderly are able to carry out their daily
lives independently. Nurses need to modify 5.
complementary therapies that can improve the health
status of the elderly according to the needs of the elderly
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Annals of Tropical Medicine and Public Health
that can also reflect the nurse's ability to provide nursing
actions independently. The limitation of this study is that
the researcher did not take measurements of blood
pressure every session but only did it at the beginning
and end of the session.
Conclusion
Based on the results of this study it can be concluded
that there is a significant influence of the combined
autogenic relaxation and PMR on reducing blood
pressure in the elderly with hypertension. This
combination therapy can be done in the elderly group
because it is easy, inexpensive, can be done anytime and
anywhere. This combination therapy becomes
complementary therapy which is proven to reduce blood
pressure in the elderly with hypertension. This
combination therapy can be integrated with the
PROLANIS program at a primary health care facility or
an independent program by a nursing home.
Acknowledgments
Special thanks to Nursing Department, Health
Polytechnic of Ministry of Health Semarang, Central
Java Province Social Service, and Wening Wardoyo
Ungaran Elderly Social Service House for valuable
support.
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