ORI GI NAL ARTI CLE: EPI DEMI OLOGY,

CLI NI CAL PRACTI CE AND HEALTH

Effects of laughter therapy
on depression, cognition
and sleep among the
community-dwelling elderlyggi_680 267..274
Hae-Jin Ko
1
and Chang-Ho Youn
2
1
Department of Family Medicine, Kyungpook National University Hospital, and
2
Department of Family
Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
Aim: To investigate the effects of laughter therapy on depression, cognitive function,
quality of life, and sleep of the elderly in a community.
Methods: Between July and September 2007, the total study sample consisted of 109
subjects aged over 65 divided into two groups; 48 subjects in the laughter therapy group
and 61 subjects in the control group. The subjects in the laughter therapy group under-
went laughter therapy four times over 1 month. We compared Geriatric Depression Scale
(GDS), Mini-Mental State Examination (MMSE), Short-Form Health Survey-36 (SF-36),
Insomnia Severity Index (ISI) and Pittsburgh Sleep Quality Index (PSQI) between the two
groups before and after laughter therapy.
Results: There were no signicant differences in baseline characteristics between the
two groups. Before laughter therapy, the GDS scores were 7.98 1 3.58 and 8.08 1 3.96;
the MMSE scores were 23.81 1 3.90 and 22.74 1 4.00; total scores of SF-36 were
54.77 1 17.63 and 52.54 1 21.31; the ISI scores were 8.00 1 6.29 and 8.36 1 6.38; the PSQI
scores were 6.98 1 3.41 and 7.38 1 3.70 in laughter therapy group and control groups,
respectively. After laughter therapy, the GDS scores were 6.94 1 3.19 (P = 0.027) and
8.43 1 3.44 (P = 0.422); the MMSE scores were 24.63 1 3.53 (P = 0.168) and 23.70 1 3.85
(P = 0.068); total scores of SF-36 were 52.24 1 17.63 (P = 0.347) and 50.32 1 19.66
(P = 0.392); the ISI scores were 7.58 1 5.38 (P = 0.327) and 9.31 1 6.35 (P = 0.019); the PSQI
scores were 6.04 1 2.35 (P = 0.019) and 7.30 1 3.74 (P = 0.847) in both groups, respectively.
Conclusion: Laughter therapy is considered to be useful, cost-effective and easily-
accessible intervention that has positive effects on depression, insomnia, and sleep quality
in the elderly. Geriatr Gerontol Int 2011; 11: 267274.
Keywords: cognitive function, depression, insomnia, laughter therapy, sleep quality.
Introduction
The degenerative changes of biological and psychologi-
cal functions of elderly people come with age. In Korea,
the population of those over 65 years was 9.1% in 2005
1
and diseases of the elderly became a central issue.
Depression is a common condition in the elderly
that negatively affects numerous parts of their lives. The
prevalence of depressive disorder among those over
65 years was 10.99% to 16.7% in Korea,
2,3
approxi-
mately 2.3% to 15.8% in the USA.
4,5
Recent studies
have reported that untreated depression is related to
the increase of illness and disability, suicide and mor-
tality.
6
It also places a substantial burden on family
caregivers as well as health and social services.
Accepted for publication 1 November 2010.
Correspondence: Dr Chang-Ho Youn MD PhD, Department of
Family Medicine, School of Medicine, Kyungpook National
University, 101 Dongin-dong 2Ga Jung-gu, Daegu 700-422,
Korea. Email: ychfm@knu.ac.kr
Geriatr Gerontol Int 2011; 11: 267274
2011 Japan Geriatrics Society doi: 10.1111/j.1447-0594.2010.00680.x 267
The decline of cognitive functions is a primary
symptom of dementia, one of the most important dis-
eases aficting elderly people. It begins with memory
disturbances, miscalculations, disorientation and even-
tually results in a total loss of self-care and social func-
tions. In Korea, the prevalence of dementia was 8.3%
in the elderly over the age of 65 years in 2005, and it
is predicted to increase up to 9.0% in 2020, according
to the National Statistical Ofce. Dementia may accom-
pany other psychiatric symptoms like depression, sleep
disorder, personality changes, delusions and hallu-
cinations. Because of these degenerative changes and
chronic comorbidities, elderly people are at a higher risk
of living a diminished quality of life.
So far, numerous researches on non-pharmacological
treatments for those degenerative changes have been
published. Among those non-pharmacological treat-
ments, laughter therapy is a noticeable psychotherapeu-
tic intervention for depression and dementia of the
elderly. Takeda et al.
7
mentioned that laughter can be a
good and effective complementary and alternative inter-
vention in the treatment of dementia patients because
laughter is preserved in dementia patients. Laughter
therapy provides information on various ways of making
humor. It is cost-effective and it does not need any
special space nor special preparations. Freud (1905)
8
mentioned that humor can be seen as a specic defense
mechanism, by which positive emotions can overcome
the undesirable negative emotions involved in a stressful
situation. One very early report by Paskind et al.
9
exam-
ined the impact of laughter upon muscle tone. It was
demonstrated that intense laughter led to decreased
skeletal muscle tone or relaxation of muscle groups.
This report was the rst research on the physiology of
laughter. Since then, several studies concerning laugh-
ter in the treatment of patients who are suffering from
psychiatric and physical diseases have been published;
improving of quality of life in patients with depression
or dementia,
10
decreasing stress and increasing natural
killer cell activity
11
and acting as moderator of stress
for depressive symptoms
12
as examples. However, most
studies on laughter therapy are limited to disabled
patients with psychiatric diseases or cancer; there is a
lack of studies on community-dwelling elderly people in
spite of the effects of laughter.
Therefore, the purpose of this study was to investigate
the effects of laughter therapy on depression, cognitive
function decline, sleep quality and quality of life for
community-dwelling elderly people.
Methods
Subjects
Between July and September 2007, we recruited the
study participants by free health consultation through
a community center in Daegu, South Korea. The eli-
gibility criteria included: (i) age of 65 years or older; (ii)
no history of admission within 1 month; and (iii)
no involvement in other research studies. The total
number of participants who agreed to the study and
satised the inclusion criteria was 200 initially. We
explained the purposes of this study and then inter-
viewed participants to gain data from a questionnaire
for 2 weeks. After the rst interviews, the subjects were
divided randomly into two groups of 100: 100 partici-
pants in the laughter therapy group and 100 partici-
pants in the control group. The subjects in the laugh-
ter therapy group underwent laughter therapy once a
week, totally four times during 1 month; 1 month after
its completion, they lled out the follow-up question-
naire with the help of research assistants. The 100
subjects in the control group did not receive any inter-
vention and were shielded from laughter therapy;
2 months after the rst interviews, they also lled out
the follow-up questionnaire with the help of research
assistants in the same week as the laughter therapy
group.
The total study participants, who fullled the initial
questionnaire sincerely, consisted of 83 subjects in the
laughter therapy group and 91 in the control group.
We excluded 35 subjects in the laughter therapy
group, who had received laughter therapy less than
three times or answered the questionnaire insincerely;
and 30 subjects in the control group, who answered
the follow-up questionnaire insincerely or were lost to
follow up. Therefore, we analyzed 109 participants as
nal subjects, 48 in the laughter therapy group and 61
in the control group.
Laughter therapy
Laughter therapy was performed by a nurse, who had
been certied in laughter therapy by the Laughter-
Therapy Professional Association, a private agency in
Korea. The nurse planned the programs of laughter
therapy, and carried out the programs with the partici-
pants in the laughter therapy group. The laughter
therapy group received 1 h of laughter therapy once a
week for 4 weeks. The participants in the laughter
therapy group gathered in a community center while
those participating in the blind study were contacted
individually. During the programs, we restricted partici-
pation of other people to prevent the spread of inter-
vention to the control group.
At the rst meeting, the moderator explained the
effects of laughter and showed a video of practical
laughter therapy that the participants could understand
easily. Then, the moderator directed them to relax their
facial muscles, clap their hands, say hello to each other
and laugh aloud clapping their hands. The meeting
nished off with a laughter meditation session.
H-J Ko and C-H Youn
268 2011 Japan Geriatrics Society
The subjects re-gathered after 1 week; the moderator
made them laugh through dancing and singing. Then,
the moderator led them in exercises training pelvic
muscles with Kegels exercise. They also watched the
video of laughter therapy again and laughed aloud clap-
ping their hands as with the last meeting. The second
meeting nished off with singing a trot song and
dancing.
The third meeting started with the singing of a
song. The moderator taught them the effects of posi-
tive thinking and strategies on how to think positively;
repeating positive words like good, happy, delightful,
nice, and so on. As before, they watched the video of
laughter therapy and then laughed aloud clapping their
hands. The meeting nished off with a laughter medi-
tation session like in the rst meeting.
The fourth and nal meeting also started with the
singing of a song, and then they laughed while trying
to pronounce Ah-E-I-Oh-Woo with a large gape.
The moderator taught them how to express their own
laughs; loquacious laughs, laughing with clapping,
laughing like a lion, laughing like a balloon, laughing
like a ne lady, and so on. They massaged each others
shoulders and said I love you to each other. They
sang songs loudly while laughing and nished off the
meeting with a laughter meditation session.
Psychometric assessment instruments
All questionnaires were examined by two researchers,
who were expert doctors belonging to one university
hospital. The researchers assessed the results of the
psychometric assessment instruments.
For the evaluation of depressive moods, the 15-item
Geriatric Depression Scale (GDS-15)
13
was used. The
GDS is a 15-item questionnaire, scoring from 115.
The higher the score in GDS, the more depressive ten-
dencies subjects might have. The Korean version of
the Mini-Mental State Examination (MMSE-K)
14,15
was
used to evaluate the grade of cognitive impairment.
Scores on the MMSE-K range 030, and scores lower
than 23 indicate cognitive impairment. For functional
evaluation, the Korean Activities of Daily Living
(K-ADL) scale
16
ranging 721, and the Korean Instru-
mental Activities of Daily Living (K-IADL) scale,
17
ranging 1032, were used, respectively. In principle, the
lower the scores in K-ADL and K-IADL, the better
biological function subjects have.
Health-related quality of life (HRQOL) was assessed
by means of Medical Outcomes Research 36-item
Short-Form Health Survey (SF-36), which has been
certied as a valid and reliable means of measuring
physical and mental health constructs.
18
The SF-36
survey consists of 36 questions integrating eight
multi-item scales: 10 questions on physical function
(PF); two questions on social function (SF); four ques-
tions on role limitations caused by physical problems
(RP); three questions on role limitations cased by
emotional problems (RE); ve questions on general
mental health (MH); four questions on vitality, energy
and fatigue (VT); two questions on bodily pain (BP);
ve questions on general health perceptions (GH);
and one question about changes of health status. The
scales and summary components ranged 0100,
with higher values denoting better function and fewer
limitations.
The Insomnia Severity Index (ISI),
19
a brief instru-
ment measuring insomnia, was used to evaluate per-
ceived sleep difculties. The ISI comprises seven
items; each item is rated on a 04 scale and the total
score ranges 028. A higher score suggests more
severe insomnia. The Pittsburgh Sleep Quality Index
(PSQI),
20
a self-rated questionnaire which assesses
sleep quality and disturbances, was used. The PSQI
consisted of seven components; each component is
rated 03 and the sum of scores for these seven com-
ponents range 021. A higher score suggests poorer
sleep quality.
Statistical analysis
Statistical analyses were performed with SPSS ver. 14.0
for Windows. We used an independent Students t-test
and Pearsons c
2
-test to compare each of the baseline
characteristics between the laughter therapy group and
control group. Paired-samples Students t-test and
ANCOVA were used to clarify the effects of laughter
therapy in GDS and MMSE. P < 0.05 was considered
statistically signicant.
Results
Sample characteristics
The demographic characteristics are summarized in
Table 1. Their mean ages were 76.33 in the laughter
therapy group and 73.92 in the control group. In
general terms, in the laughter and control groups,
there was a high rate of women (79.2% and 70.5%,
respectively), the majority of them had no formal edu-
cation (66.7% and 55.7%, respectively), most of them
were in a poor economic state (85.4% and 83.6%,
respectively) and most had one or more physical dis-
eases (95.8% and 91.8%, respectively). Including prior
characteristics, there were no signicant differences in
other demographic characteristics between the two
groups.
As shown in Table 2, there were also no signicant
differences in GDS, MMSE, ADL, IADL and SF-36
between the two groups before laughter therapy.
Effects of laughter therapy among the elderly
2011 Japan Geriatrics Society 269
Effects of laughter therapy on depression and
cognitive function
Mean GDS score was signicantly decreased from
7.98 1 3.58 to 6.94 1 3.19 in the laughter therapy group
after laughter therapy (P = 0.027). There was, on the
contrary, no signicant change of mean GDS scores in
the control group before and after laughter therapy
(from 8.08 1 3.96 to 8.43 1 3.44, P = 0.422). ANCOVA,
controlling for pre-experimental GDS scores and other
variables, showed statistical signicance in the effect of
laughter therapy on GDS (P = 0.011).
Mean MMSE scores were increased 0.81 in the
laughter therapy group and 0.97 in the control group,
which were not signicant in both groups. ANCOVA,
controlling for pre-experimental MMSE scores and
other variables, did not show statistical signicance
either (P = 0.071; Table 3).
Effects of laughter therapy on HRQOL
Mean HRQOL scores were decreased 2.56 in the laugh-
ter therapy group and 2.22 in the control group, which
were not signicant (P = 0.347 and P = 0.392, respec-
tively). In the laughter therapy group, the MH, VT and
GH scales were signicantly increased (7.00, 8.85 and
6.50, respectively). In the control group, however, there
were no signicant differences in all HRQOL scales
Table 1 Baseline demographic data and clinical characteristics of the subjects
Variables Laughter therapy group
(n = 48)
Control group
(n = 61)
P*
Age (years) 76.33 1 6.44 73.92 1 7.79 0.086
Sex
Male 10 (20.8) 18 (29.5) 0.303
Female 38 (79.2) 43 (70.5)
Educational status
Illiteracy 32 (66.7) 34 (55.7) 0.246
Above Elementary 16 (33.3) 27 (44.3)
Cohabitant
Alone 25 (52.1) 24 (39.3) 0.184
Present 23 (47.9) 37 (60.7)
Smoking
Smoker 7 (14.6) 15 (24.6) 0.422
Ex-smoker 3 (6.3) 4 (6.6)
Non-smoker 38 (79.2) 42 (68.9)
Alcohol
Regular 3 (6.3) 4 (6.6) 0.949
Under once/week 9 (18.8) 10 (16.4)
None 36 (75.0) 47 (77.0)
Regular exercise

Yes 15 (31.3) 12 (19.7) 0.165

No 33 (68.8) 49 (80.3)
Economic status
Fair 7 (14.6) 10 (16.4) 0.796
Poor 41 (85.4) 51 (83.6)
Physical disease
Absent 2 (4.2) 5 (8.2) 0.394
Present 46 (95.8) 56 (91.8)
Bodyweight loss

Absent 44 (91.7) 57 (93.4) 0.724

Present 4 (8.3) 4 (6.6)
Religion
Absent 8 (16.7) 12 (19.7) 0.687
Present 40 (83.3) 49 (80.3)
*Independent Students t-test for continuous variables, and Pearsons c
2
-test for discrete variables.

Regularly exercised for
more than 30 min and more than three times a week.

Unintended loss of bodyweight of more than 10% over 6 months. Data
is presented as mean 1 standard deviation or number (%).
H-J Ko and C-H Youn
270 2011 Japan Geriatrics Society
before and after laughter therapy. ANCOVA, controlling
for each of the HRQOL scales of pre-experiment and
other variables, showed statistical signicance in BP
(P = 0.028); whereas other factors did not show signi-
cance (Table 4).
Effects of laughter therapy on sleep
The total ISI scores were decreased from 8.00 1 6.29 to
7.58 1 5.38 in the laughter therapy group (P = 0.327)
and increased from 8.36 1 6.38 to 9.31 1 6.35 in
the control group (P = 0.019) after laughter therapy.
ANCOVA, controlling for pre-experimental ISI and other
variables, showed statistical signicance in the effect of
laughter therapy on ISI (P = 0.015).
The total PSQI scores were decreased from
6.98 1 3.41 to 6.04 1 2.35 in the laughter therapy group
(P = 0.019). In the control group, however, there was
no signicant change of total PSQI scores (P = 0.847).
ANCOVA showed statistical signicance after controlling
for pre-experimental PSQI scores and other variables
(P = 0.047; Table 5).
Discussion
This study is a randomized, prospective, experi-
mental research designed to determine the effects of
laughter therapy on depression, cognition, sleep and
quality of life among elderly people. Our study dem-
onstrated that depression, insomnia and sleep quality
improved in the laughter therapy group, while they
worsened or showed no signicant change in the
control group.
Table 2 Baseline psychometric test results of the subjects
Variables Laughter therapy group
(n = 48)
Control group
(n = 61)
P*
GDS 7.98 1 3.58 8.08 1 3.96 0.889
MMSE 23.81 1 3.90 22.74 1 4.00 0.163
ADL 7.13 1 0.39 7.36 1 1.10 0.159
IADL 11.06 1 2.02 12.11 1 3.33 0.057
SF-36
Mean 54.77 1 17.63 52.54 1 21.31 0.560
PF 47.81 1 20.13 44.43 1 28.00 0.482
SF 78.79 1 22.87 70.92 1 25.49 0.097
RP 51.56 1 42.96 38.52 1 43.44 0.121
RE 75.00 1 41.55 76.49 1 40.09 0.850
MH 58.92 1 16.25 59.87 1 19.83 0.788
VT 39.58 1 19.29 38.44 1 20.18 0.766
BP 54.04 1 25.99 57.20 1 26.53 0.535
GH 32.38 1 20.39 33.61 1 25.10 0.783
*Pearsons c
2
-test. All data is presented as mean 1 standard deviation. ADL, activities of daily living; BP, body pain; GDS,
Geriatric Depression Scale; GH, general health; IADL, instrumental activities of daily living; MH, mental health; MMSE,
Mini-Mental State Examination; PF, physical function; RE, role limitations emotional; RP, role limitations physical; SF,
social function; SF-36, 36-item Short Form health survey; VT, vitality.
Table 3 Differences of mean values for depression and cognitive function between two groups after laughter
therapy
Pre-test Post-test P* R
2
P**
GDS
Laughter therapy group 7.98 1 3.58 6.94 1 3.19 0.027 0.364 0.011
Control group 8.08 1 3.96 8.43 1 3.44 0.422
MMSE
Laughter therapy group 23.81 1 3.90 24.63 1 3.53 0.168 0.319 0.071
Control group 22.74 1 4.00 23.70 1 3.85 0.068
*Paired Students t-test; **ANCOVA adjusted for age, sex, educational status, cohabitation, smoking, alcohol, exercise, economic
status, physical disease, pre-test GDS, and pre-test MMSE. All data is presented as mean 1 standard deviation. GDS, Geriatric
Depression Scale; MMSE, Mini-Mental State Examination.
Effects of laughter therapy among the elderly
2011 Japan Geriatrics Society 271
The results of depression in this study are similar
to previous studies that demonstrated that a sense of
humor is correlated with increased self-esteem and
decreased depressive features.
12,21
Though laughter
therapy had a positive effect on depression and sleep, it
is unclear whether improvement of depression led to
improvement of sleep or laughter therapy inuenced
depression and sleep independently. In our study, being
Table 4 Differences of mean values for health-related quality of life between two groups after laughter therapy
SF-36 Pre-test Post-test P* R
2
P**
Mean
Laughter therapy group 54.77 1 17.63 52.24 1 20.89 0.347 0.257 0.728
Control group 52.54 1 21.31 50.32 1 19.66 0.392
PF
Laughter therapy group 47.81 1 20.13 42.08 1 25.11 0.136 0.250 0.381
Control group 44.43 1 28.00 38.20 1 27.46 0.058
SF
Laughter therapy group 78.79 1 22.87 73.63 1 24.97 0.201 0.059 0.940
Control group 70.92 1 25.49 72.72 1 24.94 0.673
RP
Laughter therapy group 51.56 1 42.96 38.02 1 45.54 0.089 0.145 0.728
Control group 38.52 1 43.44 32.54 1 40.80 0.265
RE
Laughter therapy group 75.00 1 41.55 54.85 1 49.82 0.006 0.097 0.270
Control group 76.49 1 40.09 65.59 1 45.13 0.123
MH
Laughter therapy group 58.92 1 16.25 65.92 1 21.29 0.020 0.150 0.227
Control group 59.87 1 19.83 61.97 1 21.27 0.455
VT
Laughter therapy group 39.58 1 19.29 48.44 1 26.68 0.017 0.169 0.146
Control group 38.44 1 20.18 43.69 1 21.95 0.065
BP
Laughter therapy group 54.04 1 25.99 56.06 1 17.86 0.550 0.168 0.028
Control group 57.20 1 26.53 49.66 1 23.31 0.050
GH
Laughter therapy group 32.38 1 20.39 38.88 1 21.60 0.042 0.153 0.836
Control group 33.61 1 25.10 37.18 1 20.83 0.247
*Paired Students t-test; **ANCOVA adjusted for age, sex, educational status, cohabitation, smoking, alcohol, exercise, economic
status, physical disease, pre-test geriatric depression scale, pre-test Mini-Mental State Examination, and each pre-test SF-36
scales. All data is presented as mean 1 standard deviation. BP, body pain; GH, general health; MH, mental health; PF, physical
function; RE, role limitations emotional; RP, role limitations physical; SF, social function; SF-36, 36-item Short Form
health survey; VT, vitality.
Table 5 Differences of insomnia severity index and sleep quality between two groups after laughter therapy
Pre-test Post-test P* R
2
P**
ISI
Laughter therapy group 8.00 1 6.29 7.58 1 5.38 0.327 0.775 0.015
Control group 8.36 1 6.38 9.31 1 6.35 0.019
PSQI
Laughter therapy group 6.98 1 3.41 6.04 1 2.35 0.019 0.403 0.047
Control group 7.38 1 3.70 7.30 1 3.74 0.847
*Paired Students t-test; **ANCOVA adjusted for age, sex, educational status, cohabitation, smoking, alcohol, exercise, economic
status, physical disease, pre-test geriatric depression scale, pre-test Mini-Mental State Examination; and pre-test ISI for ISI,
pre-test PSQI for PSQI. All data is presented as mean 1 standard deviation. ISI, Insomnia Severity Index; PSQI, Pittsburgh Sleep
Quality Index.
H-J Ko and C-H Youn
272 2011 Japan Geriatrics Society
incompletely blind to laughter therapy for the control
group, may have had an inuence on low compliance
and high complaints with the study. It may have led to
slight increases of the depression scale in the control
group. Moreover, we did not exclude positive effects of
the group meeting themselves; thus, the effects of group
meeting may have contributed to the improvement of
depression in the laughter therapy group.
In general, scores higher than or equal to 6 in GDS
are used to judge whether depressive symptoms are
present.
22
In this study, mean GDS score were 7.98 and
8.08 in both groups, respectively, which showed high
tendencies of depression. Considering the factors inu-
encing geriatric depression,
2,3,23
a high rate of women,
poor economic state, single living and the presence of
comorbidities may inuence high GDS scores. The
subjects also showed ISI scores above 8,
19
sub-threshold
insomnia and PSQI scores above 6,
20
each of which
indicate poor sleep quality. It is possible to say that there
must be a correlation between depression and insomnia,
based on the results of research work. Insomnia is a
major risk factor of depression in the elderly,
24
and
depressive mood is associated with development of
insomnia symptoms.
25
The MMSE scores were similarly increased in both
groups after laughter therapy, which was not statistically
signicant. These results are considered to have been
inuenced by two factors: simplication of the follow up
questionnaire and the same items of MMSE that they
had already done during the rst investigation made
them easier to answer the second time. When using
MMSE-K, the threshold of 23 points or less is generally
used to indicate cognitive impairment,
15
mean scores
were 23.81 and 22.74 in both groups, respectively,
which demonstrated mild cognitive impairment. In this
study, there were multiple factors which related to cog-
nitive impairment;
2,26,27
the subjects were relatively
advanced in age, there was a high rate of women, a
majority of them had no formal education and most of
them were of poor socioeconomic status. In addition,
the fact that there is a strong relation between cognitive
function and depression
28,29
could explain how high ten-
dencies of depression might inuence low cognitive
function of the subjects.
Our study did not demonstrate signicant changes
of HRQOL in both groups after laughter therapy
except BP. The BP scores were increased in the laugh-
ter therapy group and decreased in the control
group. This might suggest that the use of laughter
diminishes pain and moderates a patients response to
pain.
30
The study by Walter et al.
10
showed signicant
improvement of quality of life in patients with late-
life depression after humor therapy; the study was of
inpatients with major depressive disorders using
the Anamnestic Comparative Self Assessment Scale
(ACSA) to measure quality of life. On the other hand,
our study was of community-dwelling people using
SF-36 to measure quality of life. These differences are
considered to have inuenced the contrary results
between the studies.
In general, mean HRQOL scores tend to be low
before and after laughter therapy in our study. Consid-
ering the results of recent studies,
31,32
relatively older
age, low socioeconomic status, high depression scores
and presence of comorbid chronic illness may have
inuenced the low HRQOL in this study. According to
Tsai et al.,
33
HRQOL is a predictor of mortality among
the community-dwelling elderly; thus, we must be con-
cerned about the high rate of elderly people in Korea.
We investigated the hypothesis that laughter therapy
may affect depression, cognitive function, sleep and
quality of life of community-dwelling elderly people.
Our study demonstrated that laughter therapy had posi-
tive effects on geriatric depression, insomnia and sleep
quality, but no signicant effects on cognitive function
and HRQOL. There are several limitations of these
results. The sample size was relatively small; initial sub-
jects were 200 but 52 in the laughter therapy group and
39 in the control group were excluded, and the high
ratio of dropout is a signicant limitation. There could
be selection bias because the subjects were all of lower
socioeconomic status, advanced age and their residency
was limited to one city. Incomplete blinding for the
control group may have inuenced the results. We did
not exclude positive effects of the group meetings them-
selves that might have had some affect on the depres-
sion scale. Also, the laughter therapy was performed for
only 1 month, limiting to generalized results. From now
on, further studies are needed that control these limi-
tations and follow up more frequently as well as for a
long-term period.
Laughter therapy provides various methods of and
information on humor, is of low cost, and it can be
easily performed without regard of place and time;
therefore, it is a very effective and practical intervention.
Further studies with higher frequency, long-term
laughter therapy and larger samples may provide better
results in the understanding of therapeutic advantages
of laughter therapy in the treatment and prevention of
depression and cognitive function decline of the elderly.
Acknowledgment
This research was supported by Kyungpook National
University Research Fund, 2007.
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