The Effect of Benson's Relaxation Technique on Anxiety, Depression and Sleep Quality of Elderly Patients Undergoing Hemodialysis

Abstract

Background: Chronic kidney disease (CKD) is the most important cause of morbidity and mortality among elderly. Hemodialysis is the most commonly applied method for treatment, and is accompanied by a high incidence of psychological problems such as anxiety, depression, and sleep disturbance, which are having a negative impact on one's life. Benson's relaxation technique (BRT) is an effective technique used to reduce stress, anxiety, depression, and enhance sleep quality in elderly patients undergoing hemodialysis. Aim: determine the effect of Benson's relaxation technique on anxiety, depression, and sleep quality among elderly patients undergoing hemodialysis. Design: Quasi-experimental, pre and post intervention design was used. Setting: The study was carried out in the hemodialysis unit affiliated to Mansoura University Hospital, Mansoura, Egypt. Subjects: A purposive convenience sample of 92 elderly patients scheduled for maintenance hemodialysis. Tools: Five tools were used: interview schedule-mini-mental state examination (MMSE)-study subject's relaxation technique knowledge-hospital anxiety and depression scale (HADS) and Pittsburgh sleep quality index (PSQI). Results: The age of the studied subjects ranged from 60 to 92 years with mean ± SD = 66.256± 6.78 years, 70.9% are males, all mean total scores of hospital anxiety scale, depression scale, and Pittsburgh sleep quality index for elderly patients improved significantly after applying Benson's relaxation technique. Conclusion: Benson's relaxation technique (BRT) is an effective technique to reduces level of anxiety, depression, and improve sleep quality in elderly patients undergoing hemodialysis. Recommendation: Hospitals are recommended to use the Benson's relaxation technique for the management of anxiety, depression and sleep disturbance associated with hemodialysis for elderly patients.

Full text

International Journal of Nursing Didactics, 9: (02) February (2019).
Contents lists available at www.innovativejournal.in
INTERNATIONAL JOURNAL OF NURSING DIDACTICS
Homepage: http://innovativejournal.in/index.php/ijnd
23
The Effect of Benson's Relaxation Technique on Anxiety, Depression and Sleep Quality
of Elderly Patients Undergoing Hemodialysis
1 Eman Baleegh Meawad Elsayed, 1 Eman Hassan Mounir Radwan, 1 Neamit Ibrahim Elemam Ahmed Elashri, 2Abdel-
Hady El-Gilany
1 Lecturer of Gerontological Nursing, Faculty of Nursing, Mansoura University
2 Professor of Public Health, Faculty of Medicine, Mansoura University
DOI: https://doi.org/10.15520/ijnd.v9i02.2443
Abstract: Background: Chronic kidney disease (CKD) is the most important cause of morbidity and mortality among elderly. Hemodialysis is
the most commonly applied method for treatment, and is accompanied by a high incidence of psychological problems such as anxiety,
depression, and sleep disturbance, which are having a negative impact on one’s life. Benson’s relaxation technique (BRT) is an effective
technique used to reduce stress, anxiety, depression, and enhance sleep quality in elderly patients undergoing hemodialysis. Aim: determine the
effect of Benson's relaxation technique on anxiety, depression, and sleep quality among elderly patients undergoing hemodialysis. Design:
Quasi- experimental, pre and post intervention design was used. Setting: The study was carried out in the hemodialysis unit affiliated to
Mansoura University Hospital, Mansoura, Egypt. Subjects: A purposive convenience sample of 92 elderly patients scheduled for maintenance
hemodialysis. Tools: Five tools were used: interview schedule-mini-mental state examination (MMSE) - study subject's relaxation technique
knowledge-hospital anxiety and depression scale (HADS) and Pittsburgh sleep quality index (PSQI). Results: The age of the studied subjects
ranged from 60 to 92 years with mean ± SD = 66.256± 6.78 years, 70.9% are males, all mean total scores of hospital anxiety scale, depression
scale, and Pittsburgh sleep quality index for elderly patients improved significantly after applying Benson's relaxation technique. Conclusion:
Benson’s relaxation technique (BRT) is an effective technique to reduces level of anxiety, depression, and improve sleep quality in elderly
patients undergoing hemodialysis. Recommendation: Hospitals are recommended to use the Benson's relaxation technique for the management
of anxiety, depression and sleep disturbance associated with hemodialysis for elderly patients.
Keywords: Elderly, Hemodialysis, Benson's Relaxation Technique, Depression, Anxiety, Sleep quality.
INTRODUCTION
Aging population is a worldwide phenomenon so the
number of elderly people is growing faster than any other
age group, as a result of both longer life expectancy and
declining fertility rates (1). Currently, life expectancy of
Egyptian males and females at birth is 70.82 years and 76.2
years, respectively (2). Moreover, aging is a fundamental risk
factor for the development of many chronic disease
especially kidney disease, which is considered a complex
disease with an increasing incidence in the elderly people (3).
Chronic kidney disease (CKD) is a progressive, irreversible
reduction in renal function (4). It is recognized as one of the
most important cause of morbidity and mortality (5). The
incidence of this condition is increasing, worldwide, and the
number of individuals diagnosed with it doubles every seven
years (4). It is likely to increase further as a consequence of
aging populations and a complication to type II diabetes
mellitus. The median prevalence of chronic kidney disease
(CKD) in the elderly population in Europe, America, Asia,
and Australia varies between 23.4% to 35.8 %( 5).
Common treatment methods for CKD include renal
replacement therapy, hemodialysis, peritoneal dialysis and
kidney transplant; among which hemodialysis is the most
commonly applied method, with major impacts on patient
health(6). Depression prevalence in patients with advanced
renal failure is estimated to be 20-70% (6). Anxiety and
depression are the most common and important mental
disorders among hemodialysis patients, with adverse effects
on the course of disease and treatment process and are
recognized as an independent risk factor for mortality in
elderly patients (7).
The incidence of sleep disturbance in the patients on
maintenance hemodialysis (HD) ranges from 40 to 85%. It
is one of the most physiological problems associated with
hemodialysis. Previous studies reported that most patients
with chronic renal failure are poor sleepers as a result of
increase toxins concentrations of plasma (creatinine and
urea), anemia, nocturnal hypoxia, and co-morbidities (8, 9).
Moreover anxiety, worry, sadness, and depression are
among the major factors significantly associated with sleep
disturbance in the elderly patients with end stage renal
disease. Poor sleep in these patients has a negative impact
on the physical and mental components of one’s life and
leads to a decrease in their performance as well as cognitive
and memory dysfunction (10, 11).
Management of anxiety, depression, and sleep disturbance
among hemodialysis elderly patients includes
pharmacological and non-pharmacological interventions.
Considering the complications associated with
pharmacological treatments, the use of non-pharmacological
methods seems reasonable. Common non-pharmacological
interventions include biofeedback, music therapy, yoga,
mind distraction techniques, relaxation, time control,
lifestyle changes, cognitive restructuring and guided
imagery. Relaxation is an effective nursing intervention,

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
24
which has been introduced as useful non pharmacological
method (12) which decreases stress over its effect on mental,
physical conditions, depression, anxiety, self-steam, enhance
sleep and improves the quality of life of hemodialysis
patients (9, 13, 14). It acts by balancing the posterior and
anterior hypothalamic regions, dropping the activities of
sympathetic nervous system and inducing catecholamine
secretion leads to reduced muscle tension, alleviation of
adverse physiological effects, reduced blood pressure and
regular breathing, pulse rate and muscle spasms induced by
stress (15, 16). There are many types of relaxation technique.
Benson’s relaxation technique (BRT) is one of these
techniques which is better tolerated by hemodialysis
patients. This technique was identified by Benson (1975) (17).
It is the most effective and easy nursing intervention method
to use. It include mindfulness techniques that are affected on
wide range of physical and psychological signs and
symptoms such as anxiety, pain, depression, mood and self-
esteem, reduced stress and enhance sleep quality in elderly
patients on hemodialysis through its effect of complete
relaxation of all the muscles (9, 15, 18, 19). Thus, the necessity
of application of Benson's relaxation technique according to
elderly patients’ condition seems to be necessary to reduce
their level of anxiety, depression, improve their quality of
sleep and overall sense of wellbeing.
Aim of the study: To determine the effect of Benson's
relaxation technique on anxiety, depression, and sleep
quality among elderly patients undergoing hemodialysis.
Research hypothesis:
Hemodialysis elderly patients who apply Benson's
relaxation technique (BRT) will report low anxiety,
depression, and better quality of sleep.
SUBJECTS AND METHOD
Design: Quasi- experimental, pre and post intervention
research design was used in this study.
Setting: This study was conducted in the hemodialysis unit
affiliated to Mansoura University Hospital, Mansoura
Egypt.
SUBJECTS
A convenience sample of 92 elderly patients who scheduled
for maintenance hemodialysis in the above mentioned
setting, and fulfilling the following criteria:
 Aged 60 years and above, of both sexes.
 Able to communicate effectively.
 Undergoing hemodialysis for at least six months, and
scheduled for maintenance hemodialysis 2 or 3 times
per week.
 Elderly people with normal cognitive ability (score of
24-30), and free from severe physical disabilities (e.g.
paralysis, coma).
 Accept to participate in the study.
 Patients with kidney transplant or peritoneal dialysis
were excluded.
TOOLS:
Tool I: Mini – Mental State Examination (MMSE):
This scale was designed by Folstien 1975 (Folstien, 1999)
(20).It was translated into Arabic language by Elokl, 2008 (21),
validated and tested for its reliability (r =0.93) by (Abd El
Moniem, 2012) (22). It was designed for assessing the elder's
cognitive function. It includes 11 items that examine the
memory, orientation to time and place, attention, calculation
naming, repetition, registration, language, praxis and
copying of a design. This was used to exclude elders with
moderate and severe degree of cognitive impairment. The
MMSE scale score is 30 points and classified as follows:
 Sore of 24-30 indicates normal cognitive function.
 Score of 18-23 indicates mild cognitive impairment.
 Score of 0-17 indicates severe cognitive impairment
Tool II: Socio demographic and Clinical Data Structured
Interview Schedule: as age, sex, income, religion,
educational level, marital status, presence of chronic illness
as diabetes mellitus, hypertension, duration of disease and
family history, habits of sleep, factor that interfere with
sleep (factors related to haemodialysis session , factors
unrelated to haemodialysis session).
Tool III: Study Subject's Relaxation technique
Knowledge: It was developed by the researcher after
reviewing of current literature to assess patients' knowledge
about Benson's relaxation technique (9, 15, 17). It included a set
of questions about the following:
 Definition of Benson's relaxation technique
 Benefits of Benson's technique and its effect on,
anxiety, depression, and sleep quality.
 Benson's relaxation technique instructions
Scoring system of patients' knowledge about Benson's
relaxation technique was done as follows, each question
had a group of answer points, each correct answer take a
score of one grade, while no answer or did not know take a
score of zero. The scores obtained for each set of questions
was summed up to get the total score for patient's
knowledge. The total score was computed out of 28.
Tool IV: Hospital anxiety and depression scale: (HADS)
It was developed by Zigmond and Snaith (1983) (23). It is a
self-report questionnaire commonly used to assess levels of
anxiety and depression. This scale was translated into
Arabic and tested for its validity and reliability by Abd
Elhameed, 2010 (24). The Arabic version was used in the
present study. The reliability of this tool was tested using
test retest reliability Spearman's correlation coefficient r =
0.861. The scale comprises statements which the patient
rates based on their experience over the past week. It
consists of 7 questions relating to anxiety are marked "A",
and 7 questions relating to depression and marked "D".
Patients are asked to choose one response from the four
given for each item. Scores ranged from 0 to 3 and the total
score is 21 is divided into four ranges: normal (0-7), mild
(8-10), moderate (11-15), and severe (16-21).
Tool V: The Pittsburgh Sleep Quality Index (PSQI):
This scale was developed by Buysse, et al, 1989 (25). It is an
effective instrument used to measure the quality and patterns
of sleep in the older adult. It was translated into Arabic

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
25
language and approved to be valid and reliable by (Asaad
and Kahla, 2009) (26). It differentiates ―poor‖ from ―good‖
sleep by measuring seven domains: subjective sleep quality,
sleep latency (i.e., how long it takes to fall asleep), sleep
duration, habitual sleep efficiency (i.e., the percentage of
time in bed that one is asleep), sleep disturbances, use of
sleeping medication, and daytime dysfunction. In scoring
the PSQI, seven component scores are derived, each score
ranged from 0 (no difficulty) to 3 (severe difficulty). The
component scores are summed to produce a global score
(range 0 to 21), lower scores denote a healthier sleep quality
while higher scores indicate worse sleep quality.
METHOD
1. An official letter was issued from the responsible
authorities of faculty of nursing Mansoura University.
2. The head of hemodialysis unit in Mansoura university
hospital were informed by the researcher about the
purpose of the study and the time of data collection in
order to obtain approval to carry out the study
3. The study tool II (socio demographic and clinical data
structured interview schedule), and tool III (study
subject's relaxation technique knowledge) were
developed by the researchers after thorough review of
current literature.
4. The Arabic version of tool IV, and V (Hospital anxiety
and depression scale, and The Pittsburgh Sleep Quality
Index (PSQI) was used by the researchers. The reliability
was assured by means of r coefficient (r= 0.86, and 0.85
respectively).
5. All study tools II, III, and IV, V were tested for its
content validity by 7 experts in the related fields of
gerontological nursing, medical–surgical nursing,
psychiatric and mental health nursing, and geriatric
medicine. The necessary modifications were done
consequently.
6. A pilot study carried out on 10 of elderly patients
undergoing hemodialysis from specialized medical
hospital, Mansoura University. These patients were
excluded from the study sample.
7. The studied elderly patient was interviewed individually
by the researchers to collect the necessary data using
study tools, give simple information about the definition,
benefits, of the technique and then apply the relaxation
technique, three times per week ( Sunday, Tuesday, and
Thursday), for a period of two months.
8. The researchers applied a Benson's relaxation technique
after reviewing of the related literature (9, 27, 28).
9. The patients and their care givers take information about
the benefits of technique and learned about the relaxation
technique through colored booklet, demonstration and re
demonstration, and asked care giver to observe and guide
patients to practice correctly twice a day in morning and
evening for 20 min, for two months in their homes.
10. During session the researcher ask the patient to perform
Benson's relaxation technique in front of him to ensure
that the patient done it correctly.
11. The instruction of the Benson’s relaxation technique
included the following steps:
 Sit in a comfortable position
 Close the eyes.
 Relax all muscles beginning from the soles for the feet to
the top of the head moving forward up, and relax all
parts of the body.
 Take a breath from the nose. Exhale from the mouth
whenever exhaling, repeat one word or number (as God),
inhale, and exhale with comfort and confidence.
 Do this for 20 minutes. Try to keep the body and muscles
relaxed, and repeat the desired word in their mind. Then
open the eyes slowly and do not move for few minutes.
12. Evaluation of the technique was done after two months
using study tools (study subject's relaxation technique
knowledge, hospital anxiety and depression scale, the
Pittsburgh sleep quality index).
13. The study was conducted over a period of 7 months
beginning at June 2018 till the end of December 2018.
14. Six elderly patients were excluded from data analysis
because four of them not compliant with dialysis and two
elderly were died.
ETHICAL CONSIDERATIONS
Ethical approval was taken from Mansoura University
Faculty of Nursing Ethic Committee. An official permission
was obtained from the director of Mansoura university
hospital. Verbal consent was obtained from elderly persons
after complete explanation of the study purpose. The elderly
were informed that their participation is voluntary and that
they can withdraw from the study at any time. Anonymity,
privacy of the study subjects and confidentiality of the data
collected were assured.
DATA ANALYSIS
Data was analyzed using SPSS (Statistical Package for
Social Sciences) version 16. Qualitative variables were
presented as number and percent. Quantitative variables
were tested for normality distribution by Shapiro test. Non-
parametric variables were presented as median (minimum-
maximum) and Wilcoxon sign test were used for paired
comparison. Normally distributed variables were presented
as mean and standard deviation and paired t-test was used
for pre-post comparison. P0.05 was considered statistically
significant.
RESULTS
Table (1) shows the distribution of older adults' patients
undergoing hemodialysis according to their socio-
demographic characteristics. It was observed from the table
that the studied subjects age ranged from 60 to 92 years with
mean ± SD = 66.256± 6.78 years, older adults aged 60<75
constituted 88.4% of the studied subjects. Males were more
prevalent in the studied subjects they constituted 70.9% of
the patients, while 29.1% of them were females. The
majority (66.3%) of the studied subjects were married.
Regarding the level of education and living condition,
52.3% of the patients had primary and secondary education,
while 30.2% of them were illiterate and 17.4% of them were
university degree. Regarding income about 70.9% of studied
subjects reported had not enough income and only 29.1% of
them reported had enough income and 69.8% living with
their family.

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
26
Table (1): The distribution of older adults' patients undergoing hemodialysis according to their socio-demographic characteristics
Characters
Category
No (86)
%
Age (years)
60 <75
>75
76
10
88.4
11.6
Range: 60.0 – 92.0 years, Mean ± SD = 66.256± 6.78 years
Sex
Males
Females
61
25
70.9
29.1
Marital status
Single
Married
Widow
5
57
24
5.8
66.3
27.9
Education
illiterate
primary & Secondary
University
26
45
15
30.2
52.3
17.5
Income
Not Enough
Enough
61
25
70.9
29.1
Living condition
Family (Wife/ husbands)
Siblings
Alone
60
22
4
69.8
25.6
4.6
Table (2) shows the distribution of older adults' patients
according the duration of dialysis, and number of session. It
was found that 47.7% of the patients undergo for
hemodialysis since less than 5 years and 31.4% of them
since 5 to less than 10 years and 20.9% of them since 10
years and more. Most of the studied subjects undergo for
dialysis three sessions per week and only 7% of them twice
per week, and 88.4% of the patients reported the duration of
each session lasts 4 hours, and only 9.3% of them reported
the session last for three hours.
Table (2): The distribution of older adults' patients according to the duration of dialysis and number of session
Medical history
Items
No (86)
%
Duration of dialysis
< 5 years
5 to < 10 years
≥ 10 years
41
27
18
47.7
31.4
20.9
Number of session per week
Two
Three
6
80
7.0
93.0
Duration of session
3 hours
4 hours
5 hours
8
76
2
9.3
88.4
2.3
Table (3) shows the effect of acquiring knowledge and
application of Benson's relaxation technique, on mean score
of anxiety, depression and sleep quality of the studied
elderly. It appears from the table that the total mean score
of knowledge increased, and the total mean scores for
hospital anxiety, depression, and Pittsburgh sleep quality
index for elderly patients were decreased (improved)
significantly after applying Benson's relaxation technique (P
≤ 0.01).
Table (3): Effect of acquiring knowledge and application of Benson's relaxation technique, on mean score of anxiety, depression and sleep quality of the
studied elderly
Characters
Before the technique
Mean ± SD
After the technique
Mean ± SD
significance test
Median score of knowledge
(min -max)
0 (0-7)
28 (20-28)
z=8.2
P= 0.001*
Mean score of hospital anxiety
scale (HADS)
12.941±2.829
6.255±2.175
t=18.163
P= 0.001*
Mean score of hospital
depression scale (HADS)
18.430±3.230
6.627±2.029
t=27.799
P= 0.001*
Mean score of Pittsburgh sleep
quality index (PSQI
18.395±1.374
12.267±1.676
t=26.036
P= 0.001*
Z of Mann-Whitney test
Table (4) shows the effect of the Benson’s relaxation
technique on mean score of sleep quality index subscales.
The table demonstrated a significant difference was found
before application of the technique and after application of
the technique concerning the mean score of the global PSQI,
and its subscales (subjective sleep quality, sleep latency,
sleep duration, sleep efficiency, sleep disturbance, use of
sleep medication, and daytime dysfunction).

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
27
Table (4): The effect of the Benson’s relaxation technique on mean score of sleep quality index subscales
PSQI subscales
Before the technique
Mean ± SD
After the technique
Mean ± SD
Paired t-test & P-value
Subjective sleep quality
2.613±0.489
1.093±0.292
t= 22.517
P= 0.001*
Sleep latency
2.709±0.456
1.546±0.500
t= 18.882
P= 0.001*
Sleep duration
2.883±0.322
1.965±0.416
t= 15.277
P= 0.001*
Sleep efficiency
2.965±0.184
1.941±0.386
t= 20.648
P= 0.001*
Sleep disturbance
2.965±0.184
1.907±0.475
t= 19.880
P= 0.001*
Use of sleep medication
1.255±0.799
0.988±0.711
t= 5.267
P= 0.001*
Daytime dysfunction
3.000±0.000
2.825±0.439
t= 3.684
P= 0.001*
Table (5) shows the relation between socio demographic
characteristics, and the mean score of anxiety, depression,
and quality of sleep after implementation of Benson's
technique. The table revealed that, there are a significant
relationship between socio demographic characteristic of the
studied elders, and the mean score of anxiety, depression,
and sleep quality index (p≤ 0.01)
Table (5): The relation between socio-demographic characteristics of the studied elders and mean score of anxiety, depression, and sleep quality index
after implementation of Benson's relaxation technique
Character
s
Mean score of anxiety
Mean ± SD
Mean score of depression
Mean ± SD
Mean score of Sleep Quality Index
Mean ± SD
Before the
technique
After the
technique
Significan
ce test
Before the
technique
After the
technique
Significanc
e test
Before the
technique
After the
technique
Significance
test
Sex:
Male
12.557±3.138
6.147±2.279
t= 13.552
P=0.001*
18.016±3.593
6.508±2.134
t=-20.591
P=0.001*
18.409±1.464
12.229±1.637
t=23.985
P=0.001*
Female
13.880±1.563
6.520±1.917
t= 14.445
P=0.001*
19.440±1.781
6.920±1.754
t= 24.535
P=0.001*
18.360±1.150
12.360±1.800
t=16.230
P=0.001*
Age
60->75
13.105±2.705
6.171±2.199
t=17.621
P=0.001*
18.618±3.136
6.460±2.081
t=27.402
P=0.001*
18.389±1.350
12.276±1.709
t=28.243
P=0.001*
75-<85
11.700±3.560
6.900±1.969
t=5.538
P=0.001*
17.000±3.741
7.900±.875
t=8.125
P=0.001*
18.900±1.523
12.200±1.475
t=8.199
P=0.001*
Marital
status
Single
13.400±0.894
6.800±2.774
t=7.117
P=0.002*
20.200±0.836
6.800±2.774
t=13.015
P=0.001*
18.400±0.894
12.000±0.707
t=26.128
P=0.001*
Married
12.684±3.065
6.017±2.318
t=13.212
P=0.001*
17.982±3.603
6.368±2.192
t=19.861
P=0.001*
18.403±1.521
12.280±1.698
t=23.315
P=0.001*
Widow
13.458±2.466
6.708±1.627
t=12.518
P=0.001*
19.125±2.271
7.208±1.284
t=20.321
P=0.001*
18.375±1.374
12.291±1.805
t=14.026
P=0.001*
Education
illiterate
13.346±2.382
5.730±2.358
t=11.559
P=0.001*
18.961±2.505
6.192±2.498
t=15.202
P=0.001*
18.576±1.301
12.730±1.866
t=13.418
P=0.001*
Prim &Sec
12.688±2.786
6.355±2.035
t=13.229
P=0.001*
18.155±3.336
6.711±1.791
t=21.422
P=0.001*
18.177±1.511
12.022±1.725
t=20.088
P=0.001*
University
& post
13.000±3.683
6.866±2.199
t=5.969
P=0.001*
18.333±4.047
7.133±1.767
t=10.097
P=0.001*
18.733±0.961
12.200±0.941
t=27.640
P=0.001*
DISCUSSION
End stage renal disease (ESRD) is the most serious
consequence of kidney diseases. In that case renal
replacement therapies as hemodialysis, peritoneal dialysis
and renal transplant become necessary to sustain patients'
life. Hemodialysis is a method of removing waste products
such as creatinine and urea, as well as excess water from the
blood when kidneys failed (29). The results of the current
study reported that the majority of the studied elders were
married, in young age group with a mean of 66.256± 6.789
years while their income not enough. More than one half of
the studied elders have basic primary and secondary
education (table 1). The same results were reported by other
studies done in Iran by Rambod, 2013, Otaghi, 2016 stated
that 55.7% of their participants were married, young old and
not have enough income(9, 27).
As for sex, the results of the present study revealed that
males constituted two thirds of the studied subjects (table 1).
This result is congruent with the literature and the same
result was reported by other studies that patients undergoing
hemodialysis are predominantly males (4, 27,30, 31). Other
studies conducted by Heshmatifar, 2015, Otaghi, 2016
supported this result which concluded that the rate of
progression of chronic renal disease is more rapid in men
than in women. The impact of gender on renal disease
progression may reflect both genetically determined
differences between both sexes in renal structure and

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
28
function as well as receptor-mediated effects of sex
hormones (4, 27).
As regards the duration of being on hemodialysis, the
majority of the studied elders were on hemodialysis for less
than 5 years (table 2). This finding is in line with other
studies conducted in Egypt which revealed that around two
thirds of hemodialysis subjects dialyzed for less than 5 years
and one third of them on hemodialysis for more than 5 years
(28, 32,33). Also the same finding was reported by a study
conducted by the Spanish medical institution, 2008 which
reported that mean duration of dialysis among elderly
patients was 4.3 years (34). On opposite side a study
conducted in Hong Kong by Mok, 2001 reported that the
majority of their subjects had been on dialysis for more than
5 years (35).
Hemodialysis elderly patients usually experience high levels
of psychological stress, anxiety, depression, and sleep
disorders. Decreasing these problems, through non-
pharmacological methods like Benson's relaxation technique
can be effective for decreasing and controlling patients’
problems and provides them with more psychological
resources to help them to cope with their physical condition.
Benson's relaxation (RT) include mindfulness techniques
that are affect on wide range of physical and psychological
signs and sleep quality ( 36).
The results of the present study found a significant positive
difference in total mean score of anxiety of the studied
elders after implementation of Benson's relaxation technique
(BRT) (table 3). In this regard, a study conducted in Iran,
2016 by Otaghi found that anxiety in patients undergoing
hemodialysis was reduced after the application of Benson's
relaxation technique (27). On the same line the study done in
Turkey by Yilmaz, 2015, reported that the use of Benson’s
relaxation technique could lower anxiety in patients (37).
Moreover, some studies confirm this result are Mahdavi,
2013(28), reported that application of Benson’s relaxation
method has a positive result in decrease level of stress,
anxiety and pain, and Torabi, 2013, reported that the
significant effect of Benson’s relaxation method and
pressure massage on patients anxiety before kidney
transplantation(38). Also a study done in Iran by Kiani, 2017
(16), and a study done in India by Mahdavi, 2016 reported
decrease level of anxiety with significantly difference after
application of Benson's relaxation technique (28). Also this
result is congruent with the results of many studies (39- 41).
This result may be explained by the Benson's technique is
simple, safe technique, effective, in expensive and easy to
learn by patients, and do not need any equipment or
resources. On opposite side a study done in Yogyakarta by
Kurniasari, 2016 who reported that Benson's relaxation
technique have no effect on anxiety scores of hemodialysis
patients (42).This contradiction may be explained by this
paper apply Benson's relaxation for a period of two weeks
only and this period was not enough to decrease the level of
anxiety while our study conducted for two months.
Depression is the second common psychological effects on
elderly patients undergoing hemodialysis. This disorder has
adverse effects on the course of disease and treatment
process and is recognized as an independent risk factor for
death for hemodialysis elderly patient. The results of the
current study reported that a significant positive
improvement was found in total mean score of depression of
the studied elders after implementation of Benson's
relaxation technique (table 3). On the same line a study done
in Iran by Heshmatifar, 2015 revealed that the mean score of
depression in the intervention group decreased and the
difference was statistically significant and Benson's
relaxation technique (BRT) is effective in reducing
depression in hemodialysis patients (4). Also Lu, 2013
reported that after 10 session of group music therapy, the
groups showed statistically significant differences in
depression status (43). This result is supported also by a study
done in Iran by Barati, 2016, who reported significant
difference in depression level among elderly patient before
and after application of Benson's technique (44). This result is
in the same line with many studies (38, 45-49) .On the opposite
side a study done in Iran by Otaghi, 2016 who found that
Benson's relaxation technique decrease the depression level
but without significant difference found (27). Also Mahdavi,
2013, in India reported that no significant difference
between the mean score of depression value in study group
before and after interventions (28). This contradiction may be
explained by high prevalence of depression among their
participants, and may be due to limited practiced time period
while Benson's technique need prolonged period to be
effective.
Coping ability and overall wellbeing may be directly
influenced by the amount of restful sleep that they have each
night. Proper management of sleep disorders in patients on
hemodialysis may yield favorable outcomes both
physiologically and psychologically (50).The present study
results revealed a significant improvement regarding the
global quality of sleep, and all sleep subscales after
application of the technique (table 4). On the same line a
study done in in Egypt by Masry , 2017 who stated that an
improvement in sleep quality scores among study group
subjects than control group subjects after implementing of
Benson's relaxation technique (51).The results were similar
also to findings of Tsay, 2003, who stated that relaxation
techniques improve quality of sleep in patients with end
stage renal disease (52), and Field, 2002 in USA, observed
that increased the number of sleep hours in patients with
fibromyalgia after relaxation technique application (53). Other
study congruent with our results indicated that some
relaxation techniques decreased the sleep disturbance
(54).Many studies reported the same finding that Benson's
relaxation technique enhance the global quality of sleep in
the patients on hemodialysis (55- 57). Another study done in
Iran by Rambod, 2013, indicated significant differences
between the two groups regarding the scores of Pittsburgh
sleep quality index subscales, such as sleep disturbance,
daytime dysfunction, the use of sleep medication, and
subjective sleep quality and as well as its global scores at the
8th week of the intervention (p<0.05) (9). This improvement
may be due to Benson’s relaxation response promotes a
relaxation reaction by reducing the activity of the autonomic
nervous system thus promoting better perception of quality
of sleep. And also may be explained by when the level of
anxiety and depression decrease lead to enhancement of
sleep quality.

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
29
The results of the present study revealed that there are a
significant relation between socio demographic
characteristics, and mean score of anxiety, depression, and
sleep quality index (table 5). These results are the same line
with a study done in Egypt by Masry, 2017, who reported
that there was a statistical significant correlation between
ages of their subjects and level of pain, and sleep quality (51).
This result also is congruent with a study done in India by
Mahdavi, 2013, who reported that there were significant
relationships between anxiety, stress, and depression with
demographic characters such as age, gender, marital status,
economic level, and level of education (28). This result may
be contributed to Benson's relaxation technique is simple,
and easy technique to be learned by any person regardless of
age or marital status, or level of education. On the other
hand this result was contradicted with many studies
conducted by Heshmatifar, 2015, Rahimi, 2006, Patten,
2009 and Roykulcharoen, 2004, who reported no correlation
between individual characteristics (patients’ age, gender, or
educational status) and their pain levels, anxiety, depression
level before and after relaxation exercises (4,49,58, 59).
CONCLUSION
Implementation of Benson's relaxation technique was highly
effective in alleviating anxiety, depression, and improving
sleep quality in the elderly patients undergoing
hemodialysis. There was a significant relationship between
socio demographic variables and decrease level of anxiety,
depression, and improve the sleep quality.
RECOMMENDATIONS
Based on the findings of the current study the following
recommendations are suggested:
 In service training program to all health care providers
and elderly care givers about the effects of Benson's
relaxation technique for the reduction of anxiety and
stress in elderly patients undergoing hemodialysis.
 Hospitals are recommended to use the Benson's
relaxation technique for the management of anxiety,
depression and sleep disturbance which accompany
hemodialysis for elderly patients.
 Further studies on the impact of this technique with a
large number of elderly patients with different chronic
illness.
REFERENCES
[1]. World Health Organization. (2013): Health topics: Aging.
Available at http://www.who.int/topics/aging/en/Retrieved
1 June 2018.
[2]. Central intelligence Agency. (2014).The world fact book
[on line], https:/ / www. cia. Gov / library / publications/the
world facebook/goes/eg.html. Accessed on 1 May 2018.
[3]. World Health Organization. (2015). Media center: Fact
sheet No. 297. Available at http://www.who.int/media
center /fact sheets/ fs 297/ en / acc. Acessed on May 2018.
[4]. Heshmatifar, N., Sadeghi, H., Mahdavi, A., Shegarf
Nakhaie, M., Rakhshani, M. H.(2015). The effect of
Benson relaxation technique on depression in patients
undergoing hemodialysis. Journal of Babol University of
Medical Sciences, 17(8), 34-40.
[5]. Tayyebi, A., Babahaji, M., Sadeghi Sherme, M., Ebadi, A.,
Eynollahi, B. (2011).Study of the effect of Hatha Yoga
exercises on stress, anxiety and depression among
hemodialysis . Iran J Crit Care Nurs;4(2):67-72.
[6]. Bossola, M., Ciciarelli, C., Di Stasio, E., Conte, GL.,
Vulpio, C., Luciani, G. (2010). Correlates of symptoms of
depression and anxiety in chronic hemodialysis patients.
Gen Hosp Psychiatry.; 32(2):125-31.
[7]. Mahmoudi, Sh., Salehnegad, G., Nazaryan, S., Yaghobi, M.
(2010). A comparison study of depression between
hemodialysis patients and renal transplant recipients. Iran J
Nurs Res; 5(18):73-80.
[8]. Lima, M.G., Francisco, P., Barros, M.(2012). Sleep
duration pattern and chronic diseases in Brazilian adults
(ISACAMP, 2008/09).Sleep Med; 13(2):139—144.
[9]. Rambod, M., Pourali-Mohammadi, N., Pasyar, N., Rafii, F.,
Sharif, F. (2013). The effect of Benson's relaxation
technique on the quality of sleep of Iranian hemodialysis
patients: A randomized trial. Complementary therapies in
medicine, 21(6), 577-584.
[10]. Turkmen, K., Erdur, F.M., Guney, I., Gaipov, A., Turgut,
F., Altin-tepe, L. (2012). Sleep quality, depression, and
quality of life in elderly hemodialysis patients. Int J
Nephrol Renovasc Dis; 5:135—42 [Epub 24.10.2012].
[11]. Kang, E.W., Abdel-Kader, K., Yabes, J., Glover, K.,
Unruh, M. (2012).Association of sleep-disordered
breathing with cognitive dysfunction in CKD stages 4—5.
Am J Kidney Dis; 60(6):949—58 [Epub16.10.2012].
[12]. Heidari Gorji, Yazdani, J., Ardebil, M.D. (2013).
Implementing Benson's Relaxation Training in
Hemodialysis Patients: Changes in Perceived Stress,
Anxiety, and Depression. N Am J Med Sci; 5(9): 536–540.
[13]. Hadadian, F., Ghorbani, A., Falah, H., Latifi, SM. (2011).
The effect of trancscutaneus electrical acupoint stimulation
(TEAS) on fatigue reduction in hemodialysis patients. J
Kermanshah Univ Med Sci; 15(3).
[14]. Elali, E.S., Mahdavi, A., Jannati, Y., Yazdani, J., Setareh, J.
(2012). Effect of Benson relaxation response on stress
among in hemodialysis patients. J Mazandaran Univ Med
Sci; 22(91):61-8.
[15]. Dayapoglu, N., Tan, M. (2012). Evaluation of the effect of
progressive relaxation exercises on fatigue and sleep quality
in patients with multiple sclerosis. J Altern Complement
Med; 18(10): 983-7.
[16]. Kiani, F., Zadeh, M., Shahrakipour, M. (2017). The effect
of Benson's relaxation method on hemodialysis patients'
anxiety. Research Article - Biomedical Research (2017)
Volume 28, Issue 3.
[17]. Benson, H., Klipper, M.Z. (1975).The relaxation response.
New York: HarperCollins.
[18]. Jhangri, G.S., Davison, S.N. (2010): Impact of pain and
symptom burden on the health-related quality of life of
hemodialysis patients. J Pain Symptom Manage 39, 477-
485.
[19]. Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010).
Biophysical and psychological concepts in nursing practice,

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
30
Brunner & suddarths text book of medical surgical nursing.
Philadelphia: Woltres.
[20]. Folstien, M. (1999). Mini-Mental State, a practical method
for grading the cognitive state of patients for the clinician in
clinical Gerontological Nursing: A Guide to Advanced
Practice.2nd.London: WB Saunders company.
[21]. Elokl, M. (2008). Prevalence of Alzheimer disease and
other types of dementia in Egyptian elderly. Thesis, MSc,
Ain Shams: University of Ain Shams, Faculty of medicine.
[22]. Abd El Moniem, M. (2012). Comparative study of the
effect of three types of restorative Nursing Interventions on
the health-related functional status of geriatric patients with
Parkinson's disease. Unpublished doctorate thesis,
Alexandria: university of Alexandria, Faculty of Nursing.
[23]. Zigmond, A., Snaith, R. (1983). The Hospital Anxiety and
Depression Scale. Acta Psychiatrica Scandinavica; 67: 361-
70.
[24]. Abd Elhameed, S.H. (2010). Caregivers training and health
status outcomes in cerebral stroke elder patients. Published
Doctoral Thesis. Faculty of Nursing. Alexandria
University.
[25]. Buysse, D.J., Reynolds III, C.F., Monk, T.H., Berman,
S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality
Index: A new instrument for psychiatric practice and
research. (2), 193-213.
[26]. Asaad, T., Kahla, A. (2009). Sleep problems and diagnosis.
Egypt: Dar Eirtak for Printing, Publishing and Distribution
Co., 169-383-977, p 22-25.
[27]. Otaghi, M., Borji, M., Bastami, S., Solymanian, L. (2016).
The Effect of Benson's Relaxation on depression, anxiety
and stress in patients undergoing hemodialysis. Int J Med
Res Health Sci,5(12), 76-83.
[28]. Mahdavi, A., Gorji, M., Gorji, A., Yazdani, J., Ardebil, M.
(2016). Implementing Benson’s Relaxation Training in
Hemodialysis Patients: Changes in Perceived Stress,
Anxiety, and Depression. North American Journal of
Medical Sciences, September 2013: 5 (9).
[29]. El-Shahed M. (2013).Hemoglobin level, associated co-
morbidities and quality of life among patients undergoing
hemodialysis at one of the university hospitals in Cairo
governorate. World Applied Sciences Journal; 23 (1): 29-
36.
[30]. Tahmasbi, H., Hasani, S. (2016). Effect of Benson’s
relaxation technique on the anxiety of patients undergoing
coronary angiography: A randomized control trial. Journal
of Nursing and Midwifery Sciences: 3(1): 8-14.
[31]. Sankarasubbaiyan, S., Rajkumar, A., Tangalvadi, T. (2007).
Challenges and Limitations of Maintenance Hemodialysis
in Urban South India. Hemodialysis International; 11: 485-
91.
[32]. Abd El-Hamed, H. (2006). Changes in Quality of Life of
Patients with End Stage Renal Disease. Unpublished
Thesis. Master degree. Faculty of Nursing. University of
Zagazig; 77-78.
[33]. Al-Thaifani, A. (2004). Assessment of Self-Care Practices
among Patients on Maintenance Hemodialysis.
Unpublished Thesis. Master degree. Faculty of Nursing.
Alexandria University; 85-87.
[34]. Epidemiological Study on Chronic Renal Failure Elderly
Patients on Hemodialysis. (2008). Nefrologla; 28 (1): 48-
55.
[35]. Mok, E., Tam, B. (2001). Stressors and coping methods
among chronic hemodialysis patients in Hong
Kong. Journal of clinical nursing, 10 (4), 503-511.
[36]. Sahrakhil, M., Nasrabadi, T., Ebrahimi Abyaneh, E. (2017).
Effects of Benson’s relaxation technique on comfort level
of patients before coronary artery bypass grafting (A
clinical trial) Medical - Surgical Nursing Journal; 5(4): 60-
65.
[37]. Yilmaz, S.G., Arslan, S. (2015).Effects of progressive
relaxation exercises on anxiety and comfort of Turkish
breast cancer patients receiving chemotherapy. Asian
Pacific Journal of Cancer Prevention; 16(1): 217-20.
[38]. Torabi, M., Salavati, M., Pourismail, Z., Akbarzade
Baghban, A. (2013).The effects of acupressure and Benson
relaxation interventions on pre operating anxiety in patients
undergoing kidney transplantation. J Complement Med; 2:
13-22. 42.
[39]. Mollahadi M, Tayyebi A, Ebadi A, Daneshmandi M.
(2010). Comparison between anxiety, depression and
stress in hemodialysis and kidney transplantation
patients, Iranian J Crit Care Nurs; 2:9-10.
[40]. Hosseini, S.H., Espahbodi, F., Mirzadeh Goudarzi S. M.
(2012). Citalopram versus psychological training for
depression and anxiety symptoms in hemodialysis
patients. Iran J Kidney Dis; 6:446-51.
[41]. Shafipour V, Jafari H, Shafipour. (2009). The relationship
between stress intensity and life quality in Hemodialysis
patients hospitalized in sari Iran Quartery Journal of
Sabzevar University of Medical Sciences;16:155-60
[42]. Kurniasari, A. N., Kustanti, A., Harmilah, H. (2016). The
Effect Benson Relaxation Technique with Anxiety in
Hemodialysis Patients in Yogyakarta. Indonesian Journal of
Nursing Practices, 1(1), 40-47.
[43]. Lu, S. F., Lo, C. H. K., Sung, H. C., Hsieh, T. C., Yu, S. C.,
Chang, S. C. (2013). Effects of group music intervention on
psychiatric symptoms and depression in patient with
schizophrenia. Complementary therapies in
medicine, 21(6), 682-688.
[44]. Barati, S., Sarjuei, Z. (2016). The effects of Benson &
Jacobson combined relaxation techniques on the elderly’s
depression & life quality. Journal of Chemical and
Pharmaceutical Research, 8(6):100-103.
[45]. Ilali, V. (2012). Mazandaran medical University. 22 (91)
P61-68.
[46]. Dehghan-nayeri, N., Adib-Hajbaghery, M. (2011).
Complementary Therapies in Medicine. 8//; 19(4):194-200.
[47]. Zakerimoghadam, M., Shaban, M., Mehran, A., Hashem S.
(2010). Effect of muscle relaxation on anxiety of patients
under go cardiac catheterization. J Faculty Nurs Midwife;
16: 71-64.

Eman Baleegh Meawad Elsayed, et al, International Journal of Nursing Didactics, 9 (02) February, 2019
31
[48]. Kim, K, B., Lee, M.H., Sok, S.R. The effect of music
therapy on anxiety and depression in patients undergoing
hemodialysis. Taehan Kanho Hakhoe Chi 2006; 36:321-9.
[49]. Rahimi, A., Ahamadi, F., Gholiaf, M. (2006). Effects of
applying continuous care model (CCM) on stress, anxiety
and depression in hemodialysis patients. Res Med;
30(4):361-9.
[50]. Dunn, M.J. (2018). The effect of Benson's Relaxation
Response on Perception of Sleep and Quality of Life in
Patients on Hemodialysis; A pilot Study (Doctoral
dissertation, Carlow University.
[51]. Masry, S. E., Aldoushy, E., Abd El-Mawgoud, N. (2017).
Effect of Benson's Relaxation Technique on Night Pain and
Sleep Quality among Adults and Elderly Patients
Undergoing Joints Replacement Surgery International
Journal of Nursing Didactics, 7: 04 April.
[52]. Tsay, SL., Rong, JR., Lin, PF. (2003). Acupoints massage
in improving the quality of sleep and quality of life in
patients with end-stage renal disease. J Adv Nurs. 42:134–
42.
[53]. Field, T., Diego, M., Cullen, C., Hernandez-Reif, M.,
Sunshine, W., Douglas, S. (2002). Fibromyalgia pain and
substance decrease and sleep improve after massage
therapy. Journal of Clinical Rheumatology: 8 (2); 72-76.
[54]. Harmat, L., Takacs, J., Bodizs, R. (2008). Music improves
sleep quality in students. J Adv Nurs; 62(3):327-35.
[55]. Demiralp, M., Oflaz, F., Komurcu, S. (2010). Effects of
relaxation training on sleep quality and fatigue in patients
with breast cancer undergoing adjuvant chemotherapy. J
Clin Nurs; 19(7-8):1073-83.
[56]. Simeit, R., Deck, R., Conta-Marx, B. (2004). Sleep
management training for cancer patients with insomnia.
Support Care Cancer; 12(3):176-83.
[57]. Tsai, SL. (2004).Audio-visual relaxation training for
anxiety, sleep, and relaxation among Chinese adults with
cardiac disease. Res Nurs Health; 27(6):458-68.
[58]. Patten, S. B., Lavorato, D.H., Metz, L.M. (2009) Clinical
correlates of CES-D depressive symptom ratings in an MS
population. Gen Hosp Psychiatry; 27(6):439-45.
[59]. Roykulcharoen, V., Good, M. (2004). Systematic relaxation
to relieve postoperative pain. Journal of Advanced Nursing,
48(2), 140–148.
.