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CHAPTER I
THE PROBLEM AND ITS SETTING

Introduction
The prevalence of depression in older adults in the world ranging from 815 percent and the results of a meta-analysis of the reports of countries in the
world to get the average prevalence of depression in the older adults is 13.5
percent with female -to-male ratio of 14.1 : 8.6. The prevalence of depression in
the older adults undergoing treatment in hospitals and nursing homes by 30-45
percent. More women are suffering from depression. 10-15 Depression hit the
older adults at age 65 or older who live in the family and the rates of depression
increased dramatically in the older adults living in institutions, with approximately
between 50-75 % of occupants, long-term care have symptoms of mild to
moderate depression ( Azizah 2011).
According to Nugroho ( 2012) Depression is a feeling of sadness,
helplessness, and pessimistic, which is associated with an affliction, can be an
attack that aimed to yourself or feeling angry inside. And there are those who
define Depression is a mood disorder that is marked by sadness, low self-esteem,
guilt , despair, empty feeling ( Azizah, 2011).

Depression can be treated and cured. Many people feel better within a
few weeks after undergoing serious treatment with prescribed treatment. There are
some treatments that are usually made to people with depression, among others:
the form of medical treatment, psychotherapy and electroshock therapy. Besides
depression, can be prevented in several ways such as by going to the doctor for a
check-up, a break from routine, talking about ( sharing) of each issue to the trust,
as well as the management of depression by means of relaxation ( Mufti, 2010).
Many techniques in overcoming psychological problems in addition to the
older adults, especially medical depression is by way of relaxation for example
relaxation with singing , praying and listening to music. The relaxation technique
is a technique to overcome fears or feelings of anxiety through relaxation of the
muscles of the nerve ( Aziz, 2009).
Relaxation is a state of rest on the physical and mental aspects of man,
while the spiritual aspects remain employed. Relaxation techniques in not the
same as for everyone. As for the types of relaxation techniques that include deep
breathing techniques, imagery, stretching, calisthenics, yoga therapy, dancing and
one of them can be done with music therapy ( Kirana, 2008).
Music therapy is an attempt to improve the physical and mental qualities
for sufferers of depression, especially older music therapy is very beneficial for
physical and mental health. Music has the power to cure disease and improve one's

mind. When applied to become a music therapy, music can enhance, restore and
maintain physical, mental, emotional, social and spiritual ( Erwin, 2011).
Listening to music can help relax the mind and body and restore energy
becomes more powerful. Even when listening to music regularly at the right time
it can become a therapy that brings greater benefits to health. One of them
removes depression, especially for the older adults ( admid, 2008).
As is known, keroncong music is music that can train the muscles and
mind are relaxed. By listening to music, older adults are feeling relaxed and
feeling comfortable. Langgem Java music therapy aims to entertain the older
adults thereby increasing passion for life and can remember the past to provide a
sense of relaxation in the older adults. Some experts advise not to use certain types
of music such as pop , disco, rock and roll , and rhythmic music loud ( anapestic
beat) more, because this type of music with anapestic beat ( 2 beat the short, 1 beat
long and then pause) is the rhythm of the opposite with the heart rhythm. Soft
music and regularly as intrumentalia and classical music is music that is often used
for music therapy ( Potter, 2005).
In psychological testing found that patients every day for 12 weeks
stimulated by music , levels of depression and a sense of anxiety is reduced
making it easier to work with than those getting the same treatment facility but
without music (Djohan, 2009).

Music therapy is designed with in-depth introduction to the circumstances

and problems of the client, so there will be different for everyone. No clients are
more in line used certain music model, but there is also much helped by the other
models. Each music therapy will also be different meanings for different people
but every music therapy have same goal, namely to help express feelings, help
physical rehabilitation, influence pisitif on the condition of mood and emotion,
enhance memory, and provides a unique opportunity to interact da build emotional
closeness. Thus the music therapy are also expected to help overcome depression
(Djohan, 2006).
Music has the secret power of which music is able to relieve the sadness,
or always immersed in depression, music can provide tremendous help for mental
health, and if you combine the right type of music and imagination are directed or
meditation, its impact on people suffering from depression is fabulous. Music as a
spiritual vitamin that fills the soul with strength, confidence, and hope (Djohan,
2006).
The music greatly affect human life. Music has three important parts of
beat, rhythm, and harmony. Beat affect the body, affecting the rhythm of the soul,
while the harmony affects the spirit. Music therapy is an effective use of music
with the right composition between the beat, rhythm and harmony that adjust with

the objective of music therapy. So it is indeed an effective music therapy can not
use any music (Djohan, 2006).
Background of the Study
Geriatrics is the branch of science of gerontology and medicine that studies
the health of the older adults in various aspects , namely promotive, preventive ,
curative , and rehabilitative services . In principle geriatrics old to seek a happy
and useful ( MOH, 2000). While feriatri derived from the word " Geros " which
means the older adults and " eatriea " which means health (Nugroho, 2012 ).
According to the law No. 13 of 1998 on the welfare of usian further in
chapter 1 of Article 1, paragraph 2, which referred to the older adults is a person
who reached the age of 60 years and older. According to the law No. 4 1965
Article 1 stated older adults person or older adults after the horse reaches the age
of 55 years, does not have the power on their own earnings or for the purposes of
everyday life and receive sustenance from others (Azizah , 2012).
This time around the world , the number of older adults is estimated that
more than 629 million people (one in ten people over the age of 60 years), and in
2005, the older adults will reach 1.2 billion. In developed countries the increase of
population / older adults population has been anticipated since the beginning of the
20th century. The Central Bureau of Statistics in 2010, data showed Indonesia's
population is 237.5 million. The composition of the number of older adults over 75

years of age 59- as much as 23,190,345 people. Bojonegoro province there are
8.026.191 people and has a number of older adults people over the age of 59- 75
years as many as 613.325

people. (Central Bureau of Statistics,2014).

Based on the survey in barangay Karang Sari in Bojonegoro , have a total

population 2.596 people and has 566 families and 243 older adults. Not
surprisingly, people in developed countries have been more prepared for the
increase of the older adults population with a variety of challenges. But this time,
developing countries are beginning to face the same problem. This phenomenon is
clearly bring a number of consequences, such as the onset of physical problems,
mental, social, as well as the needs of degenerative (Nugroho, 2008).
Often the presence of the older adults is considered negative, is considered
a burden on families and the surrounding communities. This realization led to the
growing notion that being old is synonymous with the increasing number of health
problems experienced by the older adults. Older adults people tend to be seen as
no more than a group of people who get sick. Not only is it an old man too many
who thought it could not be anything, or had no hope of living better. Considered
This perception arises because looking at the older adults only case that is very
dependent older adults and sickly. The negative perception like that of course is
not all true. Many of the older adults people who actually play an active role, not
only in his family, but also in the surrounding community. Therefore, older people

should be seen as individuals who have a need, intellectual, emotional, and

spiritual, in addition to the biological needs (Nugroho, 2008).
Social problems facing the older adults is a break kinship, decreased
ability to adapt psychologically to himself, nor anyone else who marked also by
the disruption mood characterized by sadness, low self-esteem , feelings of guilt
often appears, and then shut himself in the room, desperate, a blank look and no
passion or enthusiasm of the high life for himself. Symptoms of depression often
associated with adjustments that hampered loss of life and stressors. Precipitating
stressors such as retirees who are forced, death of a spouse, deterioration of ability
or physical strength and decline of strength as well as physical ailments, social
standing , financial, income and residence thereby affecting the older adults a
sense of security and cause a depression on him (Azizah, 2011).
Based on the researchers observation, most of depression patients in
Indonesia seldom monitored their health condition. They assumed that the
conditions that they experienced were a natural thing to older patients. They
consulted doctors only when they manifested signs and symptoms of deases. They
had no enough strength to travel because of inaccessible location of health care
facilities.
This situation leads to the searching of non-pharmacological methods to treat the
depression, in other word, to prevent the elevation of depression level. Related to

this, the use of music therapy. Music therapy has become one of the complement
in the treatment of mental disorders such as schizophrenia, violent behavior, mood
disorders such as mania and depression, emotional disorders, stress and anxiety
(MacKay,2002).
Music therapy is helpful to provide comfort, reduce stress, depression,
anxiety and nervousness, releasing emotional stress experienced, improve selfcontrol and sense of worth clients. These objectives can be achieved through a
variety of activities that can be done in music therapy, such as singing , playing
music, listening to music, watching music videos, writing songs or musical
arrangements, and discuss music (Halim , 2007).
The available researches separately indicate possibilities for the use of
Music therapy in treating many varied phychological problems including
depression. However, there is limited research to document theeffect of music
theraphy for reducing depression level, especially inIndonesia since in this country
has high prevalence of depression. In thispoint, the researcher become interested to
explore the inexpensive alternative nursing interventions that will help decrease
the depression level on older adults patients.
Theoretical Framework

Researcher utilized two theories in this study that are Neuman

SystemsModel by Betty Neuman (1995) and Self-Care Theory by Dorothea
Orem(1995).
The Neuman Systems Model defines clients as open systems consistingof a
central core protected by lines of resistance and flexible and normal linesof
defense. Within each client system, there are five variable areas:physiological,
psychological, sociocultural, developmental, and spiritual (Masters, 2014).
Environment is identified as all internal and external forcesthat influence or are
influenced by the client. Health is viewed on awellness/illness continuum that is
dynamic in nature. Wellness is a conditionin which each of the parts of the client is
in harmony within the largersystem. Illness, as the antithesis of wellness, can be
identified as a lack ofharmony within the system. As humans are open systems in
continualinteraction with their environment, the state of health of an individual
iscontinually subject to change (Johnson & Webber, 2015). The role of nursingis
identified in the Neuman model as assisting the client to attain or maintainsystem
stability. Nurses accomplish this by using interventions that willstrengthen and
support the lines of defense and resistance (Neuman &Fawcett, 2011). Neuman
identifies stressors as having the potential to disturb anindividuals lines of defense
causing system instability. As stressors make animpaction the client, the flexible
lines of defense are employed to protect theindividuals normal or stable state.

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Ideally this line of defense keeps theclient system free of symptomatology

(Neuman & Fawcett, 2011). If theflexible lines of defense are penetrated, the
normal line of defense is calle into action. This line of defense is identified as
adaptation and developingover time. The normal line of defense is identified as a
standard againstwhich the wellness state of the individual can be determined.
When the normal line of defense is penetrated illness results, and lines of
resistance areactivated to protect the basic integrity of the client. Penetration of
stressorsthrough the lines of resistance to the core, results in death (Smith &
Parker,2015).Neuman's

model

categorizes

nursing

interventions

as

primary,secondary or tertiary preventive actions. Primary preventive actions

involve reducing the possibility of a client's encounter with stressors or to
decreasethe

possibility

of a

reaction when a

stressor

is

confronted.

Secondaryprevention is used when a reaction to a stressor has already

occurred.Interventions are directed at reducing existing symptoms and
strengtheningthe lines of resistance. Tertiary preventive actions strive to maintain
stabilityby promoting adaptive processes (Snowden, Donnell, & Duffy,
2014).Within Neuman's model, secondary preventive actions are required
tosupport the internal lines of resistance and to reduce the reaction to thestressors
responsible for producing the hypertension (Neuman & Fawcett,2011). The music

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therapy believed to foster the relaxation response resulting in aprevention of

depression.
Orems self-care theory has two strong concepts that are associated
withsuccessful self-care. These are therapeutic self-care demand and selfcareagency. Therapeutic self-care is a summation of the measure of ones abilityto
perform the demands of self-care in relation to his/heirs life condition (Johnson &
Webber, 2015). Self-care agency is an individuals ability toperform self-care
activities, or health endorsing behaviors, on ones ownbehalf to maintain a healthy
lifestyle. It is a complex phenomenon anddevelops through day-to-day practices.
Also, it can be adapted through thehelp and guidance of health professionals. This
could incorporate self careability and is mostly to be applied and developed in
mature people to control,manage and regulate decision making surrounding their
own health(Alligood, 2014).Self-care agency constitutes three concepts: 1) The
capability to engagein estimative and productive activities of self-care; 2) The
estimativeactivities of self-care; 3) the productive activities of self-care.
Thesecomponents are integrated with each other, and none of them can
standalone.In general, estimative activities of an individual are the action
systemsaccomplished with a purpose of determining what is to be achieved
withrespect to self-care. Productive activities are accomplished with the

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objectiveof meeting existing and known self-care requirements by using

particulartechnologies (Smith & Parker, 2015).
Conceptual Framework
The Neumans Systems Model of Betty Neuman and Self-CareTheory of
Dorothea Orem served as underpinning theories of the study in determining the
effects of music therapy on depression level on older adults patients. The
participants of the study were older adult patients with. The self-care agency was
ability of these older patients to perform self-care activity to enhance/ maintain
good health condition. The older adults were mature individuals. They were
capable to control, manage and regulate decision making surrounding their own
health.
The music therapy used as an alternative non-pharmacological intervention
selfcare activity. It also utilized as secondary preventive nursing action to
lowerdepression level. The music therapy was easy to perform, has no significant
side effects, and inexpensive.The study also determined the significant difference
in the effect ofMusic therapy between male and female older adults patients
depression level before and after implementation. The independent variable is the
music therapy and the dependent variable is depression level of the study. It was
further illuminated in Figure 1.

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Conceptual Paradigm
Gender :
Male and Female

Music Therapy

Depression Level

FIGURE 1. The Effect of music therapy on dpression level on older adults

Research Paradigm
This study utilized single group pre-test post-test quasi-experimental. The twelve
(12) male and twelve (12) female older patients implemented the music therapy in
two weeks .

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MeasurementDepression level older Adults

Male older
patients

Female older
patients

Implementing of Music Therapy 30 minute every

Day during one week and continue one week

Measurement Depression level older Adults

Effect of Music Therapy on Depression Level

FIGURE 2. The quasi experimental single group pre-test and post-test design of
the effect of music therapy on depression level on older adults.
The phases of quasi experimental design, which will followed in the study.In the
phase, the participants will selected. They are male and female older adults

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patients with depression. During the experimental phase, all of participants are
observed by the researcher in two weeks. The depression level measured before
implementing music therapy by the researcher. The music therapy will performed
by all participants once a day in the afternoon for two weeks.The last phase, The
depression level measured after implementing music therapy by the researcher
and then the researcher determined the effect of the music therapy on preventing
the high depression level older adults patients.
Statement of the Problems
This study aim to determine the effects of music therapy on depression
level on older adult patients. Specifically to answer the following questions:
1. What is the demographic profile of participants regarding with the gender?
2. What is the depression level of participants before and after the music
therapy?
3. Is there a significant difference in the depression level of participants before
and after music therapy?
4. Is there a significant difference in the depression level of participants before
and after the music therapy when grouped according to gender?
5. Is there a significant difference in the depression level of participants after
one week and after two week the music therapy?

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Hypotheses
This study tests the following hypothesis at 0.05 level of significance:
Ho1: There is no significant difference in the depression level of participants
before and after music therapy
Ho2: There is no significant difference in the depression level ofparticipants
before and after the music therapy when grouped according to gender.
Ho3 : There is no a significant difference in the depression level of participants
after one week and after two week the music therapy
Significance of the Study
The main significance of this study is to provide non-pharmacological
intervention with the use of music therapyin managing depression level of older
adults patients.The study can be significant to the following groups of individuals:
Older adults persons This study would provide awareness of availability of
practical and effective alternative adjunct non-pharmacological interventionin
managing depression level, decreasing the sign and symptoms of depression and
increasing their overall well being. This technique minimizes exposure of toxicity
from medicine consumption. Health care professionals This study can provide a
vivid view of the effects of non-pharmacological intervention, which can be
utilized to preventfurther complications cause by depression.

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Nursing Practice The findings of the study contribute in evidence

basednursing practice of non-pharmacological nursing strategy. This study proves
the efficacy of combination progressive music therapy techniques as a nonpharmacological nursing intervention and an alternative adjunct therapy to lower
depression level. Nursing research This study can be used as starting point for
future researches pertain to music therapy technique as a non-pharmacological
depression treatment.
Scope, and Limitation
This study aimed will to determine the effects of music therapy on
depression level on older adults patients. This study will conducted May 08, 2016
to May 21, 2016.This study involved twelve (12) male and twelve (12) female of
the member institutions Tresna Werdha Bojonegoro . Purposive sampling
technique will utilized in the selection of the participants based on inclusion and
exclusion criteria. The inclusion criteria were the following: age of 1) Male and
female older patients who are 65 75 years old in age; 2)communicate well; 3)
Able to follow instruction; 4) do not have a hearing loss ; 5) able to read ; and 6)
do not experience psychiatric disorders. If there are subjects who take medication
during the study, they will be excluded from the study.
The exclusion criteria of the subjects are:1 ) the state itself is not stable; 2)
experience discomforts such as headaches; 3)Refuse to become participant.

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The psychological instrument that is geriatric depression scale (GDS) will used to
measure the depression level on older adults participants during this study. The
music therapy checklist is also utilized to ensure the participant follow the correct
steps of music therapy.The researcher cannot fully control the behavior of the
participants. Theresults of the study can be generalized because small number of
participants.
Definition of Terms
Music therapy is Enterprises improve the physical and mental qualities with
sound stimuli consisting of melody, rhythm , harmony , timbre , form and style are
organized in such way to create music that is beneficial for physical health and
mental. Metode music therapy is given in the form of listening to music through
speaker / sound played with mp3 files from a laptop for 30 minutes , 1 times a day
Depression is a natural disorder characterized by feelings of sadness , low
self esteem , guilt and despair . To measure the level of depression using a
questionnaire Geriatric Depression Scale ( GDS ), which consists of 30 questions
with : Statement favorable score on a yes = 1 and a score on the answer does not =
0 and Statement of unfavorable answers yes and no answer = 0 = 1 . Measuring
results of GDS there are three categories of Score 0-10 = no depression , 11-20 =
mild depression score , and a score of 21-30 = moderate severe depression .