Laughter Therapy as a Psychosocial Intervention for Empty Nest Syndrome Among Older Adults: A Pilot Study

Population ageing is a major demographic transition worldwide, driven by increasing life expectancy, declining fertility and mortality and advances in healthcare. India is also experiencing rapid population ageing, with a considerable increase in the elderly population projected over the coming years. Kerala is among the more rapidly ageing states in India, with longer lifespans [1,2]. At the same time, large-scale migration of younger adults has increased geographical separation between older parents and their children. The Kerala Migration Survey reported approximately 4 million non-resident Keralites in 2023 [3].

The departure of adult children from the household for education, employment, marriage or migration may create an empty-nest situation for parents. However, geographical separation or migration alone does not necessarily result in empty nest syndrome. Empty nest syndrome may occur when parents experience difficulties adjusting to the absence of their children and changes in their parental roles, which may be associated with feelings of loneliness, sadness, anxiety, stress and challenges in adapting to changing family circumstances. Huang et al. [4] reported depressive symptoms among empty-nest older adults in China and identified several factors associated with depression. In India, Sunidhi [5] reported the psychological challenges experienced by parents following children's departure from home.

Social isolation and loneliness may further affect the psychological health of older adults. Rakesh et al. [6] highlighted the importance of social care services in addressing loneliness among older adults residing in old-age home. Stojanović et al. [7] also identifiedlack of social interaction as important concerns among elderly individuals, emphasizing the need for interventions that promote social connection and well-being. These concerns are particularly relevant in settings where ageing is accompanied by family separation and migration.

Laughter therapy is a complementary psychosocial intervention incorporating laughter, breathing, relaxation and playful activities. Systematic reviews, reported beneficial effects of laughter and humour interventions on well-being among older adults [8,9].

However, there is limited evidence on the effectiveness of laughter therapy specifically for addressing empty nest syndrome among the elderly population, particularly in the Indian and Kerala contexts. Therefore, this pilot study was undertaken to assess the preliminary effectiveness of laughter therapy on empty nest syndrome and selected psychological outcomes among elderly individuals in selected community areas. The novelty of the study lies in applying laughter therapy specifically to address empty nest syndrome and its associated psychological outcomes.

Aim and Objectives

The study aimed to evaluate the effect of laughter therapy on empty nest syndrome among elderly population in selected community areas of Kottayam, Kerala.

A quasi-experimental design was adopted. The pilot study was conducted during July-August 2023 in selected community areas of Kottayam district, Kerala. Twenty elderly participants aged 60-75 years were recruited through purposive sampling from selected community areas of Kottayam, Kerala. The study and comparison groups consisted of 10 participants each and were selected from two different Panchayats to minimize contamination between groups.

Eligible participants were selected based on the screening assessment. Participants with severe cognitive impairment, mental illness, terminal illness, inability to communicate in English or Malayalam or unwillingness to participate were excluded.

Data Collection

After obtaining ethical and administrative permissions, eligible participants were identified and written informed consent was obtained. Baseline assessment was conducted in both groups using the study instruments. The study group received structured laughter therapy for 20 minutes per session, four days per week, for one month, conducted in the morning. The control group did not receive the intervention during the study period. Following completion of the intervention, posttest assessment was conducted in both groups using the same study instruments. Ethical approval was received from the Bhaarat Institutional Ethics Committee (BIEC-094-24). Permission was obtained from the District Medical Officer, Kottayam and the concerned Grama Panchayat authorities.

A total of 20 elderly participants were included in the pilot study, with 10 participants each in the study and control groups.

Table 1 shows that the two groups consisted of 10 participants each. In the study group, most participants were aged 60-65 or 71-75 years (40% each), male (70%), had high-school education (90%), were married (90%) and lived with their spouse (90%).

Table 2 indicates that during the pretest, 90% of individuals in the study group and every participant in the control group had average levels of empty nest syndrome. At the posttest, the percentage of individuals exhibiting low levels rose to 40% in the study group, in contrast to 10% in the control group. The average empty nest syndrome score in the study group diminished from 129.10±23.17 to 91.70±17.45 (p = 0.0003), whereas the control group exhibited no statistically significant variation from 118.40±17.10 to 116.78±19.85 (p = 0.34).

Table 3 showed the statistically significant reductions in depression, anxiety and stress in the study group following laughter therapy, whereas no statistically significant changes were observed in the control group. Table 4 shows that the study group demonstrated statistically significant improvement in psychological health and environment domains following laughter therapy. In the control group, significant changes were observed in psychological health and social relationships. No statistically significant changes were observed in physical health, overall quality of life or general health in either group.

Table 5 reveals statistically significant study-control group differences at posttest for empty nest syndrome, depression, anxiety, stress, loneliness, psychological health, social relationships and environment. The study group had lower posttest scores for empty nest syndrome, depression, anxiety, stress and loneliness and higher scores in the significant quality-of-life domains.

Correlation Between Empty Nest Syndrome and Selected Outcomes

Correlation analysis showed no statistically significant relationships between empty nest syndrome and depression (r = 0.2848, p = 0.4252), stress (r = 0.5494, p = 0.1004), anxiety (r = 0.1342, p = 0.7117), loneliness (r = 0.1303, p = 0.7198) or quality of life (r = 0.0419, p = 0.9085).

Association with Demographic Variables

In the study group, age (χ² = 10, df = 2, p = 0.0067) and educational status (χ² = 10, df = 1, p = 0.00157) showed statistically significant associations with empty nest syndrome. In the control group, the number of years since children left home showed a statistically significant association with empty nest syndrome (χ² = 13, df = 3, p = 0.0042). Other demographic variables did not demonstrate statistically significant associations.

Table 1: Demographic Data of the Participants (N = 20)

Table 2: Pretest and Posttest Levels of Empty Nest Syndrome in the Groups (N = 20)

Table 3: Pretest-Posttest Comparison of Depression, Anxiety and Stress in the Groups (N = 20)

Table 4: Comparison of Pretest and Posttest Scores of Quality-of-Life Domains Among Elderly Population in Study and Control Groups

Table 5: Effectiveness of Laughter Therapy on Posttest Outcomes Among Elderly Population by Between the Study and Control Groups

The present pilot study demonstrated a significant reduction in empty nest syndrome following one month of structured laughter therapy. The mean empty nest syndrome score in the study group decreased from 129.10 to 91.70. This finding is consistent with Rana [10], who reported the occurrence of empty nest syndrome among elderly parents in urban communities of North India. Hossen et al. [11] also reported psychosocial impacts among elderly individuals living in empty nest families, highlighting the emotional challenges associated with the absence of adult children. The present findings provide preliminary evidence that a structured community-based laughter intervention may help reduce the severity.

The considerable depression decreased in the study group is consistent with findings reported by Nayak et al. [12], who identified a greater burden of depressive symptoms among elderly empty nesters in India. He et al. [13] similarly reported higher depressive symptoms among empty-nest older adults compared with non-empty-nest older adults in China. These findings indicate the psychological vulnerability associated with the empty-nest experience. In the present study, the significant reduction in depression following laughter therapy suggests that the intervention may have contributed to improved emotional well-being.

A significant reduction in anxiety was observed in the study group. Wang et al. [14] reported the prevalence of anxiety among empty-nest elders in China.

Stress scores also decreased significantly in the study group. The findings aligns with Walke et al. [15], who reported the effectiveness of laughter therapy in reducing stress among elderly individuals residing in old-age homes. The present laughter therapy programme incorporated breathing, playful activities, laughter exercises and laughter meditation, which may have provided opportunities for relaxation and emotional release.

Loneliness showed a significant reduction following laughter therapy, with the mean score decreasing from 25.70-17.60. This finding is particularly relevant because loneliness and social isolation are important concerns among older adults. Studies identified social isolation and loneliness as significant concerns among elderly individuals. It emphasized the importance of social-care services for addressing loneliness among older adults [16,17]. The group-based nature of laughter therapy may have encouraged social interaction and interpersonal engagement, which could partly explain the reduction in loneliness observed in the study group.

Recent studies further support the potential benefits of laughter-based interventions among older adults. Spytska [18] described the potential psychological and physiological benefits associated with laughter therapy. Livingston et al. [19] reported improvement in depression among elderly individuals following laughter therapy [19], while Pertiwi et al. [20] reported a reduction in anxiety among elderly individuals following laughter therapy.

The study also identified significant associations between age and education and empty nest syndrome in the study group, while the number of years since children left home was significantly associated with empty nest syndrome in the control group [21].

Overall, the findings indicate that laughter therapy may be a feasible and potentially useful community-based psychosocial intervention for elderly individuals experiencing empty nest syndrome. Its group-based format, relatively short sessions and combination of laughter, breathing, playfulness and relaxation make it suitable for community settings [22].

This pilot study provides preliminary evidence that structured laughter therapy may help reduce empty nest syndrome, depression, anxiety, stress and loneliness and improve selected quality-of-life domains among older adults. However, these findings should be interpreted cautiously due to the pilot nature and methodological limitations of the study. The results support the feasibility and potential value of laughter therapy and warrant further investigation through adequately powered randomized controlled trials with appropriate control groups and longer follow-up.

Limitations

The small sample size, purposive sampling, non-randomized allocation, single-region setting, different intervention and control communities and baseline imbalance may limit generalizability. The absence of an attention-control group, short follow-up and possible measurement and response bias may also have influenced the findings.

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