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1 | INTRODUCTION
The world’s population has been rapidly ageing in recent decades.
The United Nations reported that the population aged 60 or above
comprised 12% of the global population in 2015 and is growing at
a rate of 3.26% a year. Under this situation, some developed coun‐
tries are already reaching a super‐ageing society. Because ageing is
associated with progressive degenerative changes in not only organ
function but also both physiological and psychological function, re‐
sulting in a decline in quality of life (QOL), promotion of the physical
and mental health of older people to improve QOL is becoming a
more important issue in an ageing society. From the viewpoint of
controlling the escalating healthc are/medical cost associated with
an increasing elderly population, cost‐free and practical treatment
is sought, in addition to established conventional therapies. Various
strategies for health promotion of older people have already been
investigated, among which laughter therapy has been evaluated in
many studies and is expected to be effective.
Laughter (or humour) therapy has been focused on as an eas‐
ily accessible, noninvasive, nonpharmacological treatment and
has been performed in various groups of participants and as a
part of various programmes all over the world (Arrick & Mayhan,
2010; Averill, 1969; Bennet t, Zeller, Rosenberg, & McCann, 2003;
Berk, Tan, & Nehlsen‐Cannarella, 1988; Bhagat & Vallance, 1987;
Broadley et al., 2005; Bush, Krukowski, Eddy, Janusek, & Mathews,
2012; Cardillo, Kilcoyne, Quy yumi, Cannon, & Panza, 1997; Cha &
Hong, 2015; Eriksson, Johansson, Sarabi, & Lind, 2007; Ghiadoni
et al., 2000; Ghodsbin, Sharif, Jahanbin, & Sharif, 2015; Gottdiener
Received:9March2018
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Accepted :21June2018
DOI: 10.1002/nop2.190
RESEARCH ARTICLE
Beneficial effect of laughter therapy on physiological and
psychological function in elders
Yuki Yoshikawa1 | Etsuko Ohmaki1 | Hirohisa Kawahata1 | Yoshihiro Maekawa1 |
Toshio Ogihara1 | Ryuichi Morishita2 | Motokuni Aoki1
This is an op en acces s article unde r the terms of the Cre ative Commons At tribu tion License, which permits use, distr ibutio n and reproduc tion in any medium,
provide d the original wor k is prope rly cite d.
© 2018 The Aut hors. Nursing Open publishe d by John Wiley & Sons Ltd.
1Graduate School of Health
Sciences, Morinomiya University of Medical
Sciences, Suminoe‐ku, Japan
2Department of Clinical Gene Therapy,
Gradu ate School of Medicine, Osaka
University, Suita, Japan
Correspondence
Motokuni Aoki, Graduate School of Health
Sciences, Morinomiya University of Medical
Sciences, Suminoe‐ku, Japan.
Email: aoki@morinomiya‐u.ac.jp
Present address
Yuki Yoshikawa, Faculty of Nursing,
Setsunan University, Hirakata City, Japan
Abstract
Aim: In the present study we investigated the effect of laughter therapy on physio‐
logical and psychological function in older people.
Design: An open‐label trial.
Methods: Seventeen older people who regularly attended an elderly day care centre
were recruited. Stand‐up comedy as laughter therapy was performed once a week
for 4 weeks. Parameters of physiological and psychological function were evaluated
before and after laughter therapy.
Results: Laughter therapy inter vention resulted in a significant reduction in systolic
blood pressure and heart rate, accompanied by a significant increase in plasma con‐
centration of serotonin and a significant decrease in salivary concentration of chro‐
mogranin A . Questionnaire sur veys of SF‐8, GDS‐15, and Vitality Index demonstrated
alleviation of depression and improvement of sociability and activity in older people.
Laughter therapy could be expected to become a practical treatment to improve
quality of life of older people in an elderly day care centre.
KEY WORDS
blood pressure, geriatric depression scale (GDS), laughter therapy, quality of life (QOL),
serotonin, SF‐8
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YOSHIK AWA et Al.
et al., 2003; Hayashi et al., 2007). It is possible that the pleasurable
feeling induced by laughter or humour could reduce stress and
anxiety and have an ef fect on psychological function of patients
with dementia or depression. In fact, some previous clinical stud‐
ies demonstrated that psychotherapeutic inter vention of laughter
resulted in beneficial effects on stress, dementia, and depression
(Arrick & Mayhan, 2010; Averill, 1969; Bennet t et al., 2003; Berk
et al., 1988). Also, two reports investigating the ef fect of laugh‐
ter therapy on community‐dwelling older people demonstrated
that laughter therapy significantly increased self‐rated health
(Bhagat & Vallance, 1987) and that it had positive effects on de‐
pression and insomnia assessed by GDS, SF‐36, and PSQI scores
(Broadley et al., 2005). Moreover, another randomized controlled
trial showed that laughter therapy significantly improved general
health, somatic symptoms, insomnia, and anxiety, although it did
not improve social dysfunction and depression (Bush et al., 2012).
In addition, laughter therapy is strongly suggested to have ef fects
on physiological and biological functions. Laughter was reported
to influence the immune system and to induce natural killer cell
(NK) activity, accompanied by reduction in stress (Bennett et al.,
2003; Bhagat & Vallance, 1987; Cardillo et al., 1997; Cha & Hong,
2015). Also, it was demonstrated that a 3‐month consecutive pro‐
gramme of laughter and exercise in older people resulted in a sig‐
nificant increase in bone mineral density and a significant decrease
in haemoglobin A1c (Bhagat & Vallance, 1987). Moreover, happy
laughter, joyful music, and hobbies are suggested to improve en‐
dothelial function (Hirosaki et al., 2013). These findings obtained
from previous studies suggest that laughter therapy has a benefi‐
cial effect on not only psychological function but also physiolog‐
ical function and could be a practical treatment to improve QOL
of older people with deterioration of activities of daily living (ADL)
and a decline in mental health due to depressive feelings, impaired
cognitive function, reduced vitality, and poor social activit y.
Here, we inve stigated the ef fects of laug hter therapy on p hysiolog‐
ical and psychological function in older pe ople who regularl y attended
an elderly day care centre because of impaired ADL or cognitive dis‐
order. A unique point of the present study is that the Japanese style
of stand‐up comedy performed by professional comedians was em‐
ployed as stimulation to cause laughter or a pleasant feeling. St and‐up
comedy was used as laughter therapy once a week for 4 weeks in an
elderly day care centre. Changes in blood pressure, heart rate, NK ac‐
tivity, plasma concentration of serotonin, and salivary concentration
of chromogranin A (CgA) were measured as biological/physiological
parameters, in addition to psychological parameters such as the geri‐
atric depression scale, QOL scale, and vitality scale.
2 | METHODS
2.1 | Participants and study design
Seventeen participants aged 60 years and older were recruited
from people who regularly at tended an elderly day care centre,
“Gashu‐en”, because of impaired motor or cognitive function. Stand‐
up comedy was used as laughter therapy and participants with suf‐
ficient cognitive function to enjoy and respond to stand‐up comedy
were recruited. Stand‐up comedy, which was performed by a profes‐
sional Japanese comedian from Yoshimoto Kogyo Co., Ltd. (Osaka,
Japan), was carried out once a week at a fixed time in the morning
in the presence of par ticipants for 30 min and run for four consecu‐
tive weeks. The content of stand‐up comedy was different each time
and each comedy session was performed by a different comedian.
Stand‐up comedy consisted of comical per formances that were sim‐
ple, visual and participatory, so as to be easily understandable, such
as comical magic, joking, impersonation, and so on.
2.2 | Parameters for assessment
Measurements taken one day before the first show and at the same
time on the day after the last show included NK activity, plasma con‐
centration of serotonin, blood pressure (BP), and heart rate (HR), to
evaluate the effec t of laughter therapy on physiological functions.
As one participant did not provide a blood sample, blood analysis
was performed in the remaining 16 participant s. Extracted blood
samples (Eriksson et al., 20 07) were immediately placed on ice and
stored at 4°C until just before measurement. Measurements were
performed within a day.
In additi on, the effect s of laughter ther apy on psychologic al func‐
tion were ev aluated by questio nnaire surveys . Health‐related Q OL of
the participants was inves tigated using the 8‐item Short Form (SF‐8).
The Japanese version of SF‐8, which is a questionnaire survey of
self‐rated health, consists of eight items; Physical Function, Physical
Roles (limitation of roles due to physical problems), Bodily Pain,
General Health, Vitality, Social Function, Emotional Roles (limitation
of roles due to emotional problems), and Mental Health (Ko & Youn,
2011). Mental health was also assessed using the Japanese version
of the Geriatric Depression Scale 15 (GDS‐15), which consist s of 15
questions addressing self‐reported feelings in daily life and various
depressive symptoms (Kuru & Kublay, 2017). GDS‐15 is commonly
used as a screening tool for depression in older people. A higher total
score indicates more severe depressive symptoms. Moreover, daily
activities and vitalit y were evaluated by Vitality Index (Lebowitz,
Suh, Diaz, & Emery, 2011; Meguro, Ouchi, Akanuma, Meguro, &
Kasai, 2014). This questionnaire is not self‐rated and is completed
by the participant’s family who live with the par ticipant. It consists
of five items; Waking pattern, Communication, Feeding, On and off
toilet, and Rehabilitation/Activity. Each item is rated as three grades
(Arrick & Mayhan, 2010; Averill, 1969). One participant declined to
answer SF–8 and GDS–15; thus, assessment by these two question‐
naires was performed in the remaining 16 participants.
2.3 | Saliva analysis
Whole saliva samples (200 µl) were collected from each participant
using a soft syringe immediately before and after the last show.
Extracted saliva samples were immediately placed on ice and stored
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YOSHIK AWA et Al.
at 4°C until just before measurement. Measurements were per‐
formed within a day. Saliva samples were immediately centrifuged at
13,00 0rpm for 2min, followedbystorage at −20°C. The concentra‐
tion of CgA in saliva was measured using an enzyme‐linked immuno‐
sorbent a ssay (ELISA) kit, ac cording to the manufacture r’s instructions.
2.4 | Ethics statement
The stu dy protocol was appr oved by the Ethics Com mittee for Clinic al
Investigation of Morinomiya University of Medical Sciences (Permit
Number: 2011–020). The study was performed in compliance with
these institutional guidelines. All of the participants and their fami‐
lies gave written informed consent before entering the study, which
was conduc ted in accordance with the Declaration of Helsinki.
2.5 | Statistical analysis
All numerical values are expressed as mean ± SD in the tables. In
the figures, values are expressed as mean ± SEM. Dataset s were
analysed by paired t test. Differences with p < 0.05 were considered
statistically significant.
3 | RESULTS
3.1 | Baseline clinical characteristics of participants
The baseline clinical characteristics of the participant s in this study
are presented in Table 1. All participants at tended a facilit y for el‐
derly day care three times a week on a regular basis. There were 17
participants (Bennet t et al., 20 03; Hayashi et al., 2007). The partici‐
pants’ age was 77.0 ± 9.1 years. As the MMSE score of each partici‐
pant was 19 or higher (23.9 ± 3.2), participants with normal cognitive
function or mild cognitive impairment were included. Five partici‐
pants had been receiving antihypertensive medication and BP was
well controlled in these participants. No participant was prescribed
medication for dementia or antidepressant agents, which affect psy‐
chological func tion, or any drugs that act on the immune function.
3.2 | Effects of laughter therapy on physiological
function of participants
As shown in Figure 1a,b, after repeated laughter therapy for
4 weeks, systolic BP and HR were signific antly reduced compared
with those before the intervention. In addition, plasma serotonin
concentration was significantly increased after repeated laugh‐
ter therapy compared to that before laughter therapy (Figure 1c).
Moreover, a signif icant decrease i n salivary Cg A concentration w as
observed immediately after the last stand‐up comedy show com‐
pared to that immediately before the show (Figure 1d). Although
there was no significant difference in NK activity between before
and after laughter therapy (dat a not shown), the increase in sero‐
tonin concentration by laughter therapy was positively correlated
with the increase in NK activity after the intervention (Figure 1e).
3.3 | Effects of laughter therapy on psychological
factors of participants
Questionnaire surveys using SF‐8 and GDS‐15 in this study demon‐
strated that laughter therapy also significantly improved psychologi‐
cal func tion. A s shown in Table 2, total SF‐8 score was significantly
reduced af ter four interventions of laughter therapy compared to that
before intervention. Among the eight items comprising SF‐8, a signifi‐
cant improvement in score was observed for “Bodily Pain” and “Social
Function” (Table 2). Also, the GDS‐15 score after four inter ventions of
laughter therapy was significantly decreased in comparison with that
before laughter therapy (Table 2). Not only self‐rated scales but also an
objective parameter assessed by the participant’s family, Vitality Index,
was improved. Total Vitality Index score was significantly increased by
laughter therapy, as shown in Table 3. Especially, a significant increase
in the score of motivation for rehabilitation and other activities was ob‐
served (Table 3). All five participants who originally scored 0 or 1 for
this item showed improvement.
4 | DISCUSSION
With the increase in number of older people in an aged society, it is
becoming critically important to develop new strategies to improve
QOL in older people with impaired physic al and/or cognitive func‐
tion. Day care centres for older people are popular institutions to
care for these people, where they regularly attend to receive reha‐
bilitation, food, bathing, and recreation. This study was designed to
investigate the effects of laughter therapy as recreation performed
in an elderly day care centre and examine the possibility of estab‐
lishing an easily accessible, noninvasive, nonpharmacological, cost‐
free, and practical treatment to improve QOL in older people. No
TABLE 1 Baseline clinical characteristics of subjects
Age 77.0 SD 9.1 years
Male 3/17
MMSE 23.9 SD 3.2
NK activity 28.1 SD 20.2%
Serotonin concentration 124.3 SD 85.9 ng/ml
GDS score 7.0 SD 4.3
Total score of SF‐8 20.4 SD 6. 2
SBP 129.3 SD 14.8 mmHg
DBP 71.3 SD 5.2 mmHg
Heart rate 71.0 SD 4.5 min
Medication
Antihypertensive drugs 5/17
Antidepressant agents none
Drugs for dementia none
Note. N = 17. Values are expressed as mean ± SD.
MMSE: Mini Mental State Examination; NK activity: natural killer activ‐
ity; SBP: systolic blood pressure; DBP: diastolic blood pressure
96
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YOSHIK AWA et Al.
previous report has evaluated the effect of laughter therapy in older
people in an elderly day care centre.
The present study demonstrated that laughter therapy sig‐
nificantly improved some physiological functions. One important
finding of this study was a significant reduction in BP and HR by
regular laughter intervention (Figure 1a,b). This reduction is con‐
sidered to be induced by parasympathetic activation followed by
relaxation and reduced stress by laughter therapy, because early re‐
ports demonstrated that humorous stimulation by a funny movie or
happy laughter had a beneficial influence on physiological responses
determined by BP and HR via autonomic responses (Minami et al.,
2015; Nezu, Nezu, & Blissett, 1988). Reduced stress by laughter
therapy was also confirmed by lowered levels of stress hormones
in this study. The concentration of salivar y CgA , which is a sensitive
stress hormone that responds in a short time period, significantly
decreased immediately after seeing stand‐up comedy, compared
to that before the show (Figure 1d). Moreover, laughter therapy for
four consecutive weeks resulted in a significant increase in plasma
concentration of serotonin, which is known to maintain a stable
mental state (Figure 1c), similarly to a previous repor t (Ghodsbin et
al., 2015). Thus, lowering BP and HR by laughter therapy may be
followed by suppression of sympathetic nervous system ac tivit y via
changes in such hormones. Also, the successful reduction of a stress
hormone and induction of serotonin indicated that stand‐up comedy
could be a useful tool as a method of laughter therapy.
Mental stress is known to affect endothelial function (Hirosaki et
al., 2013; Ryu, Shin, & Yang, 2015; Sanchez et al., 2007; Takahashi et
al., 2001; Takeda et al., 2010; Toba et al., 20 02). It was reported that
psychological stress induced by performing an arithmetic or speech
task inhibited forearm flow response, indicating endothelial dysfunc‐
tion (Takahashi et al., 20 01; Takeda et al., 2010; Toba et al., 2002).
Previous animal experiments partially elucidated its mechanisms,
demonstrating that stress hormones, such as glucocorticoids, endo‐
thelin‐1, and inflammatory cytokines, caused endothelial dysfunction
through the impairment of NO‐dependent vasodilation (Ryu et al.,
2015; Sanchez et al., 20 07; Toda & Nakanishi‐Toda, 2011; Tokuda et
al., 2009). A continuous reduction in stress by laughter therapy may
FIGURE 1 (a) BP before and af ter
intervention. (N = 17). (b) HR before and
after intervention. (N = 17). (c) Percent
change in plasma serotonin concentration
after four performances of laughter
therapy. (N = 16). (d) Concentration of
salivar y CgA before and after laughter
therapy. (N = 16). (e) Correlation of
percent change in plasma serotonin
concentration with percent change in
plasma NK activit y. (N = 16). Values are
expressed as mean ± SEM. *p < 0.05
versus Pre. Pre, the day before the first
laughter therapy. Post, the day after the
last laughter therapy.
40
50
60
70
80
90
Pr
eP
ost
*
40
60
80
100
120
140
160
PrePost
(erusserpdoolB mmHg)
*
Heart rate (/min)
60
80
100
120
140
160
PrePost
niegnahC%
noitartnecnocninotores
%
*
0
5
10
15
20
25
Pr
eP
ost
*
Concentration of
salivary CgA
ng/ml
0
50
100
150
200
250
0100 200300
niegnahC%
noitartnecnocninotores
% Change in NK activity
%
r = 0.5135
p = 0.042
%
(a) (b)
(c) (d)
(e)
TABLE 2 SF‐8 and GDS‐15 score
Pre Post p
SF‐8 (Total score) 20.44 SD 6.22 15.88 SD 4.84 0.008**
Physical
function
3.06 SD 0.68 2.87 SD 0.74 0.255
Physical roles 2.62 SD 1.50 1.60 SD 0.99 0.097
Bodily pain 2.75 SD 1.69 1.67 SD 1.05 0.010*
General health 3.06 SD 0.68 2.87 SD 0.74 0.486
Vitality 2.94 SD 0.68 2.60 SD 0.74 0.136
Social function 2.19 SD 1.42 1.20 SD 0.56 0.034*
Emotional roles 2 .13 SD 1.46 1.33 SD 0.62 0.082
Mental health 2.13 SD 1.31 1.33 SD 0.62 0.334
GD S ‐1 5 7.00 SD 4.05 5.63 SD 4.03 0.038*
Note. N = 16. Values are expressed as mean ± SD.
*p<0.05 versus Pre (paired t test).
**p<0.01 versus Pre.
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97
YOSHIK AWA et Al.
improve endothelial dysfunction in older people via a reduction in
glucocor ticoids, as previous studies showed that serum concentration
of glucocorticoids was significantly decreased in participants who
viewed a humorous video compared to control participants (Eriksson
et al., 20 07; Ryu et a l., 2015; Walter et al., 20 07). Laughter the rapy may
also contribute to preventing stress‐induced cardiovascular events in
older people through not only lowering BP and HR but also improving
endothelial dysfunction mediated by a reduction in glucocorticoids. In
addition, the reduction in the glucocorticoid level by laughter therapy
would affect immune function, because glucocorticoids are immuno‐
suppressive (Yovetich, Dale, & Hudak, 1990). The reported increase
in NK activity by laughter therapy (Bennett et al., 2003; Cardillo et
al., 1997; Cha & Hong, 2015; Ghiadoni et al., 2000) may be mediated
by a reduction in glucocorticoids. Although the level of NK activit y
was not changed by laughter therapy in the present study (data not
shown), the increase in serotonin concentration by laughter therapy
was positively correlated with the increase in NK activity (Figure 1e),
suggesting some effects of laughter therapy on immune function.
In most older people, psychological factors are directly con‐
nected to social activity and loss of QOL, rather than impairment
of physical function. The present study strongly suggests beneficial
effects of laughter therapy on psychological function and mental
health. The results of depressive feelings in older people in this study
were similar to those in previous report s (Broadley et al., 20 05).
Our finding that GDS‐15 score was improved by laughter therapy
once a week for 4 weeks from 7.00 ± 4.05 to 5.63 ± 4.03 (p = 0.038)
(Table 2) is consistent with previous dat a showing that laughter ther‐
apy at the same frequency changed the score from 7.98 ± 3.58 to
6.94 ± 3.19 (Broadley et al., 20 05). The baseline score of participants
and the degree of improvement in score were similar in both studies,
suggesting that the effect is reliable and that laughter therapy would
be useful in older people with a depressive tendency. Moreover, the
questionnaire survey of SF‐8 in this study showed a significant im‐
provement in the total score of SF‐8 (Table 2). It is noteworthy that
the score of “Social Function” was signific antly increased. These data
suggest that laughter therapy would improve sociability, preventing
social isolation and leading to stronger social ties. Also, the score
of “Bodily Pain” was significantly improved in the present study, as
well as in a previous report showing an improvement in the score of
Bodily Pain in SF‐36 (Broadley et al., 2005). Improved sociability and
pain reduction would contribute to improvement of QOL, indicating
the usefulness of laughter therapy. Of importance, in the present
study, the effects of laughter therapy on psychological function
were firstly assessed by the Vitality Index (Table 3), which is not a
self‐rated but an objective scale. An interesting finding was the in‐
crease in score of motivation for rehabilitation and other activities.
These dat a obtained by questionnaire surveys suggest beneficial
effects of laughter therapy on mental health and QOL through an
improvement of depressive feelings, sociability, and activity. In ad‐
dition, a significant increase in serum concentration of serotonin by
laughter therapy was observed in this study (Figure 1c). Serotonin
is known to ac t as a neurotransmitter in the central nervous system
and to play a major role as a controller of feelings, anxiet y, sleep, and
vitality. As serum serotonin concentration could reflect intracerebral
secretion of serotonin, the effects of laughter therapy observed in
the present study might be mediated by induction of serotonin.
Although this study successfully demonstrated some beneficial
effect of laughter therapy, its mechanism is still unclear. However,
considering the results obtained in this study and previous reports
(Eriksson et al., 20 07; Ghodsbin et al., 2015; Ryu et al., 2015; Walter
et al., 2007), conceivable mechanisms are that changes in physiolog‐
ical parameters are mediated by reduction in stress hormones, such
as CgA and glucocor ticoids, and that improvement in psychologi‐
cal func tion is mediated by an increase in serotonin. We observed
a reduction in the concentration of salivary CgA immediately af ter
stand‐up comedy and an increase in plasma serotonin concentration
after four laughter therapy interventions. However, there are some
points that should be considered study limitations. Cg A was mea‐
sured before and after just one show and reproducibility was not
confirmed in this study. Also, change in glucocorticoids was not mea‐
sured in the present study, although a previous study reported that
serum concentration of glucocorticoids was significantly decreased
in participants who received a laughter therapy programme. In addi‐
tion, plasma concentration of serotonin was measured in this study,
whereas intracerebral secretion of serotonin was not. Moreover, the
present study did not reveal how long the effects are maintained.
Biological parameters, such as CgA and serotonin, physiological, and
psychological parameters should be evaluated in the long term after
laughter therapy in a further study.
TABLE 3 Vitality index score
Pre Post p
Vitality Index (total
score)
9.18 SD 1.38 9.59 SD 1.0 0 0.030*
Waking pattern 1.94 SD 0. 24 1.94 SD 0.24 1
Communication 1.82 SD 0.39 1.94 SD 0.24 0.163
Feeding 2.00 SD 0.00 2.00 SD 0.00 1
On and off toilet 1.76 SD 0.66 1.76 SD 0.66 1
Rehabilitation/
activity
1.65 SD 0.61 1.94 SD 0.24 0.020*
Note. Each item is rated by three grades (2, 1 and 0).
1) Waking pat tern
2: Organ ized pattern of waking, 1: Requires a ca regiver’s aid occa sionally,
0: Never wakes voluntarily
2) Communication
2: Vocalizes reciprocal exchanges at will, 1: Responsive to verbal stimula‐
tion, 0: No cognitive response
3) Feeding
2: Motivated to eat, 1: Passive, but eats with encouragement, 0:
Indifferent to eating
4) On and off toilet
2: Independent or never fails to express micturition need, 1: Does not
express micturition need consis tently, 0: Indifferent to voiding
5) Rehabilitation and other activities
2: Motivated to be rehabilitated or to be involved in other activities, 1:
Passive but tries with encouragement, 0: Refuses or indifferent
N = 17. Values are expressed as mean ± SD.
*p<0.05 versus Pre (paired t test).
98
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YOSHIK AWA et Al.
This study has a few other limitations which should be investi‐
gated in further studies. First, the sample size was relatively small.
Second, there was no control group and this study did not have a
blinded design. Thus, a certain level of bias could not be excluded,
especially in self‐rated data. Fur ther randomized, blinded studies
using a large number of participants are needed to improve the reli‐
abilit y. Third, de spite the impor tance of a control group, it is difficult
to set a rational control group in such studies to clarif y the effect
of laughter therapy. Although another group without intervention
(an untreated group) could be suitable as a control, a different in‐
tervention should be considered to be a suitable control. In studies
to evaluate laughter therapy, a quantitative parameter to assess the
humorousness of various interventions would be needed. Finally,
validation of the procedure of laughter therapy was not sufficient
in this study. It is still unclear how many times intervention should
be provided and for how long it should be continued. The effects of
more frequent laughter therapy and an ex tended period of laugh‐
ter therapy should be evaluated further. Also, the methodology of
causing laughter was not sufficiently evaluated in this study. The
method of stimulation of laughter varies among reported studies.
In many cases, laughter was forced under guidance as an exercise
without a t arget of a joy ful feeling. In contrast, laughter in the pres‐
ent study was caused by the emotional response to viewing and
joining in with stand‐up comedy. It is an important point that the
stand‐up comedy performed in the present study was designed by
professional comedians to be simple, visual, and participatory, so
that even older people with somewhat impaired cognitive function
could easily understand it and join in. Our method to induce the
emotion of comfort may have some advantage in relation to sero‐
tonin secretion, different from forced laughter or a laughing exer‐
cise as carried out in previous reports. However, no previous study
has established a procedure for laughter therapy and the present
study did not assess the methodology of laughter therapy.
The type of intervention can be expected to be important.
Although there are various t ypes of intervention for laughter ther‐
apy, such as a humorous video, slapstick comedy etc., it is still un‐
clear which type is preferable in older people, especially in those
with impaired cognitive function. Studies thus far, including the
present study, have failed to evaluate what kind of intervention
is suitable. Although appreciation of the “sense of humor” of par‐
ticipants receiving various interventions and measurement of the
humorousness of each intervention in these studies would help to
reveal what kind of inter vention is suitable as laughter therapy and
to set a rational control group, it is quite difficult to measure and
evaluate them. This point is a study limitation and a future task. In
addition, when considering a programme of laughter therapy, there
may be a difference between spontaneous humour and rehearsed
humour. Our programme of laughter therapy using stand‐up com‐
edy is not spontaneous and is more rehearsed humour. In this study,
we did not compare the effect of laughter therapy by seeing a show
to that of spontaneous humour. As it is difficult to exploit sponta‐
neous humour in participants with impaired cognitive function or
a depressive mood, it would be desirable for laughter therapy for
older people to be provided as passive humour, where a joyful feel‐
ing wells up from seeing a comic show or humorous video.
5 | CONCLUSION
The present study demonstrated that the intervention of laughter
therapy once a week for 4 weeks in an elderly day care centre re‐
sulted in a significant reduction in BP/HR, alleviation of geriatric
depression/bodily pain and improvement of sociability/activity,
accompanied by a significant decrease in salivar y CgA level and a
significant increase in serum serotonin level. These data strongly
suggest beneficial effects of laughter therapy on physiological and
psychological functions, although laughter did not affect cognitive
function. The present study supports the therapeutic advantage of
laughter therapy and raises the opportunit y of a new approach to
promote physical and mental health in older people. In an aged so‐
ciety, where older people with impairment of ADL and QOL are in‐
creasing, laughter therapy could be expected to be a low‐cost, safe,
and prac tical treatment that nurses can use.
ACKNOWLEDGMENTS
We are grateful to the study volunteers and their families for their
participation. We thank Yu Miyake for her excellent advice on the
protocols of laughter therapy. We also thank the staff of “Gashu‐en”
for their su pport of our stu dy and Yoshimoto Kogyo Co., Ltd . for pro‐
viding the comedians. Finally, we especially thank all the comedians
who participated in this study for their wonderful performances.
CONFLICT OF INTEREST
The authors declare no conflict of interest.
AUTHOR CONTRIBUTIONS
YY, RM, and MA: Study concept and design. Y Y, EO, and MA:
Acquisition of participant s and/or data. YY, HK, YM, TO, RM,
and MA: Analysis and interpretation of data. TO, RM, and MA:
Preparation of manuscript.
All authors have agreed on the final version and meet at least one
of the following criteria [recommended by the ICMJE (https://www.
icmje.org/recommendations/)]:
• substantial contributions to conception and design, acquisition of
data, or analysis and interpretation of data;
• drafting the ar ticle or revising it critically for important intellec‐
tual content.
ORCID
Motokuni Aoki http://orcid.org/0000‐0002‐3912‐3222
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YOSHIK AWA et Al.
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How to cite this article: Yoshikawa Y, Ohmaki E, Kawahata H,
et al. Beneficial ef fect of laughter therapy on physiological
and psychological function in elders. Nursing Open.
2019;6:93–99. https://doi.org/10.1002/nop2.190
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