The elderly are part of the process of growth and development [1]. Humans do not suddenly grow old but develop from babies, children, adults and eventually become old [2]. In this period where a person experiences a physiological, mental and gradual decline in the elderly [1]. The limit for the elderly category based on age level according to WHO is middle age 45–59 years old, elderly 60–74 years, old 75–90 years and very old more than 90 years. World Health Organization (WHO) in 2015, the number of elderly people in the world reached 18.0% of the total world population, in developed countries the number of elderly people has increased, including Japan (17.2%), Singapore (8.7%), Hong Kong (12.9%) and South Korea (7.5%), the World Health Organization (WHO) has calculated that in years [3]. Indonesia is currently entering an aging population, experiencing an increase in the number of elderly people from 18 million (7.56%) in 2010, to 25.9 million (9.7%) in 2019, it is estimated that it will continue to increase in which in 2035 it will be 48.2 million people (15,77%). According to the Central Bureau of Statistics (BPS) of South Sulawesi Province, the number of elderly people reached 721,353 people (9.19%) of the total population of South Sulawesi.

Progressive muscle relaxation is therapy reduce insomnia levels in the elderly. The research was conducted at the Graha Kasih Ayah Nursing Home, Kubu Raya Regency with a sample size of 10 elderlies. The results of the statistical test used were paired samples t-test with p-value <0.05. Result: In the paired t-test, the mean value was obtained at the pretest 14.80 with a standard deviation of 3.327 and on the post-test, that was transformed the mean value was 0.7993 with a standard deviation of 0.18398, with a result value of p = 0.001. The conclusion in this research is that there is an effect of progressive muscle relaxation therapy on the level of insomnia in the elderly [4].

Data from the Bantaeng Regency Health Office 2019, the number of elderly people suffering from insomnia is 8,843 people. The results of observations made in Bajiminasa Village, Gantaran Keke regency, the population consists of 447 people and in it and there are 50 elderly people. Of the 50 elderly, 30 people experience insomnia.

Sleep is a process of changing consciousness that occurs repeatedly over a certain period [5]. The purpose of sleep is to maintain mental-emotional balance and health [5,6]. Another theory about the use of sleep is that the body stores energy during sleep [6]. The ideal time for the elderly to sleep is 6–7 hours, less than 6 hours per day affects the health of the elderly [6,7]. Sleep quality is very important for the elderly, sleep quality is a state of sleep that individual experiences to generate freshness and fitness. Sleep quality–everyone's ability to maintain a sleep state and to get the appropriate REM and NREM stages. Sleep quality includes quantitative aspects of sleep, such as sleep duration, sleep latency and subjective aspects of sleep [5,7]. The need for sleep in the elderly depends on the level of development [8]. An elderly person will take longer to initiate sleep and have less time to sleep well [9]. Along with the decline in body function concerning sleep physiology, the amount of sleep needed in the elderly has decreased. The older a person is, the fewer hours of sleep are needed [10,11].

Insomnia is a nocturnal hyperarousal disorder which is a cause of insomnia that affects cognitive and emotional and physiological effects in the elderly [10,12]. The elderly most often experiences sleep disturbances or insomnia [13]. The symptoms of insomnia are more common in the elderly than in adults, because the diagnosis of insomnia is more common in the elderly [9]. Signs and symptoms of insomnia are difficulties sleeping regularly, feeling tired during the day waking up many times during sleep, difficulty sleeping again [9]. Several causes of insomnia in the elderly, namely mood disorders or major depressive disorders, anxiety disorders and various medical ailments are also associated with insomnia, especially those that cause shortness of breath, pain, nocturia, indigestion, or limited mobility [9].

Study Design

This research was conducted using a pre-experimental design, which reveals the effect of the implementation of progressive muscle relaxation therapy by involving one group of subjects. The sample in this research was 30 elderly people with a purposive sampling technique. Subject groups were observed before the intervention, then observed again after the intervention. This research used a quantitative pre-experimental method without a control group with the One Group pre-test-post-test design approach. This design uses two sample groups which are interviewed twice, namely the interview before the experiment (01) which is called the pretest and the interview after the experiment (0₂) which is called the post-test. The pre- & post-test was carried out using a predefined questionnaire.

Participant

The research population was all research subjects. The population in this research were 30 elderly people who experienced insomnia who lived in Moti, Bajiminasa Village, Gantaran Keke regency, Bantaeng Regency. A research sample is several members who are selected or taken from a population.

Respondents with inclusion and exclusion criteria, namely that these are elderly aged 45–90 years, can hear and see, experience mild/moderate/severe/very severe insomnia levels, live in the Motif Village environment of Bajiminasa, Gantaran Keke regency, Bantaeng Regency, are willing to be respondents and follow research procedures up to the final stage. The exclusion criteria were elderly who were not cooperative, did not participate fully in activities, took sleeping pills in the last 1 week, under special care, experienced limb limitations or paralysis had mental disorders and experienced other comorbidities such as diabetes mellitus, rheumatism and gout.

Instruments

The instrument used to measure the incidence of insomnia in the elderly is a measuring tool for the Jakarta Psychiatric Biology Study–Insomnia Rating Scale (KSPBJ–IRS). This questionnaire consists of 8 question indicators. This measuring tool uses an ordinal scale, where answers are given a value of 1,2,3,4. Where the total number can be categorized as follows: no complaints of insomnia if the score is <8, mild insomnia if the score is 9–13, moderate insomnia if the score is 14–18 and severe insomnia if the score is >187. Researchers also used the observation sheet for the regularity of the elderly in implementing progressive muscle relaxation therapy for 21 days. Observation sheet for the implementation of progressive muscle training.

Questions based on a standardized insomnia scale, namely the insomnia rating scale limitation or insomnia indicators can be determined including the following parameters, namely difficulty starting to sleep, suddenly waking up at night, being able to wake up early in the early morning, feeling sleepy during the day, headaches during the day, feeling unsatisfied with sleep, feeling uncomfortable or restless while sleeping, having nightmares, lack of energy after sleeping, irregular sleep and wake schedules and sleeping for 6 hours a night.

Intervention

Data collection on elderly insomnia before and after progressive muscle relaxation therapy exercises. The sampling technique is the purposive sampling technique using structured interviews using measuring instruments for the Jakarta Biology Psychiatric Study Group–Insomnia Rating Scale (KSPBJ–IRS). The pre-test by measuring respondents' insomnia with the insomnia rating scale (IRS) questionnaire, after measuring insomnia, a progressive muscle relaxation therapy was carried out which consisted of 11 light muscle movements with a duration of 15 minutes, for three weeks which is held every day according to the respondent's time both morning, afternoon and evening. Posttest is done after progressive muscle training by re-measuring respondents' insomnia.

Procedure data Including IRB

Respondents were informed about the purpose of the research and the length of time it would take while maintaining the privacy of respondents. Respondents have distributed an informed consent sheet as a consent form to be used as a respondent.

Data Analysis

Analysis of the data used in this research using the t-test with SPSS data analysis to test the significance level with the criteria Ha accepted if the value of p-value <α 0.05. This means that there is a significant difference in the level of insomnia in the elderly before and after progressive muscle relaxation exercises.

Research Result

Univariate Analysis (Table 1).

Primary Data Source

Based on Table 2 shows that the demographic data of respondents based on age are as many as 7 (23.3%) of respondents aged 45–49 years, as many as 18 (60.0%) respondents aged 60–74 years and as many as 5 (16.7%) respondents aged 75–90 respondents. Gender 6 (20.0%) respondents with male gender and 24 (80.0%) respondents with female gender. Education data 18 (60.0%) respondents did not go to school and 12 (40.0%) respondents with primary education. Job data shows that from 30 respondents, 14 (46.7%) did not work, 1 (3.3%) traders, 14 (46.7%) farmers, 1 (3.3%) self-employed.

Bivariate Analysis

Based on the analysis Table 3 of the effect of progressive muscle relaxation therapy in the elderly with statistical tests with paired T-test on pre-test and post-test with 30 Pre-intervention respondents with a mean value of 17.53 and Post-test intervention with a mean value of 8.43.

The results of statistical tests with paired t-test in the pre-test and post-test showed that the value of p = 0.000 or <α 0.05, there is a significant difference, there is an effect on the decrease in the level of insomnia before and after progressive muscle relaxation therapy.

Demographic data of respondents explain that the number of elderly women is more than that of men. The age factor is a factor that affects the quality of sleep in the elderly. In the elderly, there is a change in physiological function, especially in the elderly, namely the excretion hormone cortisol and GH (Growth Hormone), which affects changes in body temperature. Melatonin is a hormone that is excreted at night and is associated with decreased sleep quality with increasing age in the elderly (Table 1). The elderly is prone to insomnia because of changes in sleep patterns [9]. Post-menopausal women affect the quality of sleep which usually affects sleep stage IV (Sleep at night) in which the elderly experience inability to sleep which is often experienced compared to men [9]. The decrease in the rate of insomnia is an effect of implementing progressive muscle relaxation therapy [14]. This is in line with the theory of progressive muscle relaxation techniques, namely progressive muscle relaxation techniques whose movements include light and easy movements.

Table 1: Distribution of Respondents Based on Demographic Data on Elderly People Who Experience Insomnia 

The results of the study (Table 2) showed that the distribution data of insomnia levels before and after progressive muscle relaxation therapy, there was a significant change in the level of insomnia after progressive muscle relaxation therapy intervention. There are still two respondents with severe insomnia levels. Research data and interview results indicate that the respondent is a single family with no immediate family (spouse). In theory, it is explained that one of the factors causing insomnia is stress and psychological factors. The level of insomnia in the elderly is influenced by several factors that cause insomnia, namely stress, anxiety, physical condition and lifestyle of the elderly. Stress is a trigger factor for insomnia, the more stressed the elderly, the worse the quality of sleep will cause insomnia in the elderly. Besides, the elderly spends more time in bed to start sleeping. The frequency of awakening increases so that the poor quality of sleep due to frequent waking has increased. Physical condition and lifestyle factors of the elderly also tend to experience fatigue, drowsiness, decreased sleep efficiency and easily fall asleep during the day. The results showed that there was a significant relationship between anxiety and the incidence of insomnia in the elderly [9].

Table 2: Distribution of Insomnia Levels Before and After (Pre-Test and Post Test) Progressive Muscle Relaxation Therapy in the Elderly

Progressive muscle relaxation therapy, namely therapy by stretching the muscles then relaxing the muscles to relax the muscles [14]. There was a significant change in insomnia in the level of insomnia before and after progressive muscle relaxation therapy [14-18]. The results of the analysis of the effect of progressive muscle relaxation therapy before (pre-test and post-test) explain the changes in the level of insomnia before and after progressive muscle relaxation therapy. Research data with a decrease in the insomnia score (IRS-Insomnia Rating Scale). Where the results of progressive muscle relaxation analysis in the elderly was showed at table 3 with statistical tests with paired T-test on pre-test and post-test with 30 Pre-intervention respondents with a mean value of 17.53 and Post-test intervention with a mean value of 8.43. The results of statistical tests with paired T-test on the pre-test and post-test, it was found that the value of p = 0.000 or p < 0.05 means that there is a significant difference and there is an effect on decreasing the level of insomnia before and after progressive muscle relaxation therapy, there is a significant difference in the level of insomnia before and after progressive muscle relaxation therapy. In the Systematic Review or Meta-Analysis research, it explains the effectiveness of non-pharmacological uses for insomnia or sleep disorders experienced by the elderly [19]. Explained in the research that about 50% of the elderly complain about the symptoms of insomnia. Insomnia can reduce the quality of life with various disorders of psychosocial and cognitive functions, other mental disorders such as depressive disorders. Untreated insomnia increases the risk of cardiovascular disease and metabolic disorders. Non-pharmacological treatment options include progressive muscle relaxation techniques, or cognitive behavioral therapy, acupuncture, music therapy, bright light therapy, or yoga to reduce insomnia levels in the elderly. The results of the study of fifty-three RCT respondents (mean age 75 years) with a case-control study method, 43 respondents with pharmacological therapy experienced a reduction in insomnia with various side effects of insomnia drugs. Meanwhile, 10 respondents of whom experienced a decrease with non-pharmacological therapy, including progressive muscle relaxation therapy, yoga, acupuncture, music therapy without adverse side effects to the health of the elderly. The decrease in the level of insomnia is due to the effect of progressive muscle relaxation therapy, which states that the effect of progressive muscle relaxation helps the elderly in increasing their need for sleep and reduces sleep disorders which tend to increase in the elderly. This relaxation is better done than acupuncture or meditation techniques [20]. 

The effect of progressive muscle relaxation therapy on the reduction of insomnia levels in the elderly at the Darma Bakti Kasih Nursing Home, Surakarta. Based on the results of research before or pre-test, progressive muscle relaxation therapy was carried out, there were 22 (73%) mild insomnia levels of respondents and 8 (73%) respondents with severe insomnia levels. Meanwhile, the level of insomnia after being given progressive muscle relaxation therapy showed no complaints about insomnia by 25 (83%) respondents and mild insomnia levels by 5 (17%) respondents. The results of the paired t-test with p-value = 0.001, it can be concluded that the effect of progressive muscle relaxation therapy on the decrease in the level of insomnia at Panti Werdha Bakti Kasih Surakarta [20]. 

The results of research on changes in the level of insomnia in the elderly at Panti Werdha Manado. A total of 36 respondents with the results of research conducted before progressive muscle relaxation therapy with mild insomnia levels as much as 24 (66.7%), severe insomnia as much as 9 (25.0%) and very severe insomnia as much as 3 (8.3%). Meanwhile, after progressive muscle relaxation therapy there was no insomnia as much as 29 (80.5%), mild insomnia as much as 5 (13.9%) and severe insomnia (5.6%). The results of the Wilcoxon test statistical test obtained p-value = 0.000. There is an effect of progressive muscle relaxation therapy on changes in insomnia in the elderly [16-19].

Table 3: Analysis of the Effects of Progressive Muscle Relaxation Therapy Before and After (Pre-Test and Post Test) in the Elderly

By using the pretest-posttest model used on the same subjects, namely, the elderly, respondents felt a significant reduction in sleep time, calmer sleep and feeling more refreshed when they woke up, respondents felt more satisfied with their sleep after using progressive muscle relaxation techniques. Polysomnography (Electroencephalogram (EEG), Electromyogram (EMG) and Electrooculogram (EOG)) indicates a significant reduction in sleep time, reduced frequency of waking at night, less time to sleep lightly during the first 3 hours of sleep and more time to sleep with slow waves during the first 3 hours of sleep experienced by respondents. Changes in the level of insomnia before and after progressive muscle relaxation therapy in the elderly, is a therapy that helps the elderly in overcoming insomnia, does not have side effects and does not require expensive costs, with progressive muscle relaxation therapy, it is hoped that the elderly will be able to do it independently so that the respondent's sleep quality increases as an effort to improve the quality of life of the elderly [21].

• Before progressive muscle relaxation therapy, most of the elderly experienced severe levels of insomnia and a small proportion with mild and moderate insomnia

• After progressive muscle relaxation therapy, the rate of insomnia in the elderly has decreased, namely most of the elderly have no insomnia, mild insomnia is moderate insomnia and the least is severe insomnia

• There is an effect on the significant changes in insomnia on insomnia levels before and after progressive muscle relaxation therapy

• There are no harmful side effects to progressive muscle movements, it is easier to use and costs nothing