Yoga-Based Interventions For Improving Balance Among Elderly Residents In A Residential Care Unit

400418 Health Advancement and Health Promotion

Background, Brief Literature and Rationale:

Fall related injuries are one of the most significant contributors towards morbidity and mortality among the elderly. According to Alshammari et al. (2018) fall related injuries are the second biggest cause of accidental deaths after road accidents. The risks of falling have been found to be higher among elderly people with problematic gait and balance. Studies have shown that elderly patients who have poor gait and balance caused due to musculoskeletal disorders, arthritis, reduction of lower body strength, muscular atrophy, obesity as well as mental health problems such as dementia, Multiple/Lateral Sclerosis, Parkinson’s disease and Alzheimer’s.

According to the World Health Organization, every year approximately 646,000 people die every year due to accidental fall related injuries, a majority of whom are elderly people, and the risks of falls are highest among adults above 65 years of age (who.int, 2018). According to the Australian Institute of health and Welfare, more than 1000 elderly people (above 65 years age) die every year in Australia due to fall related injuries and is the cause of 45,000 hospitalizations, representing 54% of all injury related hospitalizations in the country. The statistics also show that elderly people above the age of 85 years have 40 times the risk of fall related injuries compared to individuals between 65 to 69 years of age. Moreover, 48% of the fall related accidents occur at homes and residential setups (aihw.gov.au, 2018). It has been suggested by many authors that increase in the risks of falling and fall related injuries is correlated with a reduction in the muscular tone, strength and fitness among the elderly and a corresponding physical inactivity. Inactivity also leads to muscular degeneration which can further affect the movement of the people. Moreover due to musculoskeletal disorders and arthritis, the elderly people might experience painful joints that can significantly inhibit their movement. Another factor that can also increase the risks of injuries such as fractures due to accidental falls is osteoporosis which can generally occurs among elderly people and affects their bone density thereby making them more brittle and prone to breakage. Falls among the elderly has been related to a reduction in the quality of life and functionality and can impair the ability of the elderly patients to conduct their activities of daily living, all of which can increase the risks of depressive symptoms and mental health problems. It can also be added that these fall related injuries resulted in the expenditure of AUD 498.2 million in Australia (as of 2001) and is estimated to increase to AUD 1375 million by 2051. This shows how fall related injuries are a significant stressor on the health and wellbeing of the elderly people as well as lead to a significant financial burden on both the patients as well as Australian healthcare (safetyandquality.gov.au, 2009).

Statement of Need

According to the Australian Commission on Safety and Quality of care, the main reasons for fall among the elderly includes postural instability and muscular weakness due to which it is important to improve the gait and balance of the elderly to reduce the risks of falling (safetyandquality.gov.au, 2009). Several studies show that interventions such as yoga can improve the functional gait and balance among the elderly. Studies by Phillips et al. (2016) show that an eight week yoga session can significantly improve the functional gait of elderly residents and their health related quality of life. This has also been supported by Youkhana et al. (2015) who proposed that exercise routines based on yoga can improve the balance and mobility among individuals over the age of 60 years and thus help in the reduction in the risks of falls among them. According to the authors, yoga can help to improve muscle strength and joint flexibility which helps in the improvement of balance and mobility and prevent several co morbidities associated with old age such as arthritis, musculoskeletal problem and anxiety. Similarly, according to Nick et al. (2016), yoga can also help to reduce the fear of falling among the elderly people, which in turn can help to improve their quality of life and anxiety levels. Spiewak et al. (2017) also opined that therapeutic yoga not only helps to reduce the risks of falling, but also helps to reduce anxiety and improve sleep quality among elderly. Impact of yoga therapy and meditation on the mental health of people due to the reduction of anxiety and depressive disorders have also been proposed by Klatte et al. (2016) and de Manincor et al. (2016) which clearly shows that yoga and meditation are effective strategies not only to improve gait and balance but also mental health of elderly residents. Hegde et al. (2017) further pointed out that individuals living with chronic aimlemts such as osteoarthritis, diabetes, musculoskeletal disorders, cardiovascular diseases, dementia and hypertension not only affects the physical wellbeing but also impacts their mental health being, quality of life and impairs their ability to socialize with others. Their studies also supported that yoga can help to improve their mental health condition and quality of life.

The X residential care setting has 200 elderly residents, 120 of which had been determined to be at risk of slips and falls for a variety of needs including the gait impairment, side effects of the medications, neuromuscular weaknesses, joint pain and more. Based on the secondary research that has already been conducted, it can be anticipated that Yoga programs would help in improving the gait impairments. Hence, in order to conduct a Yoga program for 10 months and for evaluating the effectiveness of the program a funding of about $ 48000 will be required. Hence an amount of $ 48000 is requested for the purchasing the required yoga equipment, fees of the trainers and arrangement of a yoga room.

Aims and Objectives:

The intervention that has been chosen for the program has been done on the basis of a literature research that has already been conducted. Based on those evidences, it has been planned to conduct a yoga program for the elderly patients of a residential care center. 

The main aims and objectives of the intervention of providing yoga and meditation for the elderly patients in a residential care are:

Improving Balance and Gait: By addressing this objective it can be possible to reduce the risks of falling and fall related injuries which as prevalent among elderly residents and thereby helping to improve their health and wellbeing.

Improving the health of the joints and flexibility: This can help to improve the mobility of the elderly residents as well as improve their ability to perform the various ‘activities of daily living’. By increasing flexibility, problems related to musculoskeletal disorders and musculoskeletal degenerative diseases can also be overcome.

The intervention also has two additional objectives which are:

Reduction of anxiety: Through meditative techniques, the intervention will aim to reduce stress and anxiety levels among the residents and reduce the risks of depressive symptoms and anxiety disorders. Since anxiety has been identified to be the cause of several mental health problems, it can be assumed that by reducing anxiety the risks of these diseases can be reduced too.

Improving memory: Medication will also aim to improve memory of the residents, thereby helping to overcome the effects of dementia which is prevalent among elderly people. By improving memory, the ability of the residents to take care of themselves can also develop.

Initially a secondary literary reach has already been conducted based upon which an intervention has been planned. The study is intended to be conducted in a residential care center in Australia, providing shelter to about 200 elderly residents. The main reason for the selecting this age group and this facility is that a high rate of the mortality and morbidity is found among the elderly people in this residential care due to fall due to gait disturbances. Furthermore as per the secondary research that has already been conducted, it has been found the Yoga and the other physical exercises improves the physical and the mental health of the elderly (DiBenedetto et al., 2015). Results presented in an articles shows that most of the health care professionals in the residential care units are poorly acquainted with the occupational therapy.

Study Method

This study will be a primary research where some physical interventions will be administered on a group of elderly individuals followed by a recording of the subsequent outcome of the interventions.

An estimation of about 100 elderly patients of a residential care should be chosen for the study. The choice of the institution will be done by the conduction of an internal survey to find out the average occurrence of the slips and falls occurring some of the chosen residential care and one name of the residential care has been chosen for the study among the probable names. Before the starting of the interventions, permission should be obtained from the institution regarding the initiation of the study informing them about all the pros and the cons.

Elderly residents within the age group 55- 69 will be considered for this program. The rationale for choosing this age group is due to the fact that most of the studies have reported this age group to be vulnerable to slips and falls and a growing body of researches have supported the fact that regular yoga based interventions are readily accepted by the older adults of this age group and has been found to improve a wide range of the health outcomes in the older population. Yoga programs have been found to improve the mood, quality of life, sleep disturbances, metabolic profiles, balance and mobility.

Eligibility to participate in the yoga program will be determined by screening questionnaires and physical assessment. The exclusion criteria for the study should include asymmetric gait, evidence of congestive heart failure, one with a hip, knee or shoulder injury or with the one with replacement, major orthopedic diagnosis in the pelvis or the lower extremities, acute medical illness or some form of osteoarthritis that might cause discomfort while the yoga exercises.  Frail elderly adults above the age of 85 would not be considered for this intervention. There would be other mild exercise regimen for them which will not be considered in this program.

A 10 month yoga program specifically tailored for the elderly patients will be designed for improving the lower body strength and the flexibility. Based on the assessment each of the participants will be attending two 60 minutes yoga classes each week and will be instructed to complete at least twenty minutes of yoga practice within the residential care under the surveillance of the nurses. Each group session would include a standard yoga session of gentle and supervised yoga postures and relaxation techniques that has been designed for the beginners and specifically tailored for the older patients. Props like chairs, blankets, yoga mats would be provided to all the elderly patients for supporting them in any yoga positions that were difficult or uncomfortable for them and to minimize the risk of this injuries due to over stretching. Each of the yoga session would begin with a yoga warm up session and centering poses, which will be followed by more active yoga exercises. Yoga postures that will be included in the program are – Centering (cross legged position), tadasana (mountain pose), vajrasana( thunderbolt pose), table pose ( with the leg lifting), virasana ( the hero pose), padangithasana ( holding the big toe). Each of the yoga sessions would initiate with breathing yoga exercises (pranayama) and every session of the yoga would be terminated by the corpse pose: the sabasana. Poses that specifically targeted the pelvic region were included in yoga regimen.

Sampling Methods

The home practice sessions would alternate between 2 standard beginner’s yoga regimens, each consisting of a subset of the group sessions. All the patient taking part in the yoga program would receive a complete and illustrated homework assignments after each yoga sessions. A daily log will also be maintained by the participants for monitoring the duration and the frequency of the practice and for the documentation of the problems, progress, deterioration or the other experiences.

Ethical approval is an important part of the any interventions applied to a target group and generally involves informing the participants about all the outcomes of the research such that they can contribute to the program without any bias (Hariprasad et al., 2013).  At first consent should be taken from the authority of the residential care center officially for the conduction of such a health promotion program.   All the residents of the residential care will be invited verbally as well as in writing to participate in the program informing about the advantages and the disadvantages of the program. Sealed envelope should be sent to each of the participants.  Each of the participants will be allowed to leave the intervention program as per their wish and their health conditions.  Furthermore, ethical approval should also be taken from the ethics approval committee or the institutional review board, before the conduction of the Yoga based interventions.

Data analysis is the step that helps in inspecting, clean and transform the remodeled data in order to reach a certain conclusion for a given intervention (Brannen, 2017). It is mainly of two kind, the qualitative and the quantitative. The QOL and the perception of the patients and the caregivers that has been found out by the help of the interviews will be analyzed thematically. The interview texts will be coded for generating broader themes relevant to the topic (Hariprasad et al. 2013). Furthermore, the  data will be analyzed by the use of SPSS, version 11.2 (Brannen, 2017). The potential differences in the baseline data will be measured by using the student t tests.  The instruments that will be used for measuring the outcomes are Geriatric anxiety scale (GAS), Quality of life questionnaire (QOL), and KATZ index for measuring the ADL, dynamic gait index (DGI), Short physical performance battery and the Berg scale. The data will be analyzed by comparing the baseline data obtained before the starting of the interventions and the commencement of the interventions.

Sample Size and Power

In order to conduct a comprehensive yoga program for the elderly people, there has to be an effective planning before the implementation of the interventions. Planning would include choosing of suitable yoga postures as per the age group chosen for this interventions. The yoga postures will be approved by a registered occupational expert before their implementation.

This should be followed by buying of the equipment needed for the conduction of the yoga classes such as yoga mat, a yoga mat towel, comfortable and stretchable clothing for the participants ,blankets and mattresses, a weighing machine for assessing the loss in weight especially in the obese patients.  Some modifications should be done for the yoga room, such as provision of wide space to accommodate 100 patients, with effective lighting and audible sound system. Two instructors will be present at the time of the yoga training. 

Warm up session- Free hand stretches and breathing exercises [ 10 minutes]

Asanas-

• Centering
• Virasana
• Vajrasana
• Padangusthasana
• Tadasana
• Parvotasana
• Sun salutation (using a chair)
• Modified sun salutation (using a prop)

[ Each postures to be maintained for 2 minutes ]

 3 minutes rest will be given after the conduction of three asana at a time and the entire asana cycle is repeated twice in each sessions.

• Salabhasana (locust pose)
• uttitha hasta padangustasana (extended holding
• the big toe pose)
• eka pada bhekasana (1-leg frog pose)
• supta baddha konasana (lying down bound
• angle pose)

[Each of the asana for two minutes each and repeated twice within the session]

At the end of the sessions sabasana (corpse pose) will be repeated.

A large number of literary resources have proved that that yoga based interventions improves balance and mobility in older people and have been found to be one of the precursor to prevent falls. This done by increasing the muscular strength, flexibility and balance, reduction of the stressors, anxiety and depression and overall enhancement of the well-being and the quality of life (Gothe, Kramer & McAuley, 2014). Hence some of the anticipated outcomes after the interventions are –

• Improvement in the quality of life (QOL)
• Improvement in the mobility of the adults
• Improvement in the balance
• Reduction of age related anxiety stressors

In order to evaluate the outcome of the 12 month intervention of yoga and meditation for elderly residents, the following measures can be used to understand whether the intervention was able to achieve the objectives of the study. These measures include:

Dynamic gait Index: This measure is used to assess the likelihood of falling among elderly people through an eight item test that measures the dynamic balance of the people and identify whether an individual has normal gait or are experiencing mild, moderate or severe impairment of gait.

Short Physical Performance battery (SPPB): This measure combines tests on gait speed, chair stand and balance of the individual through a series of activities one has to conduct in a given time and thus help to assess the mobility of the person.

Intervention

Berg Balance Scale (BBS): This measure assesses the ability of elderly patients to balance them while conducting a series of predetermined activities and measures the standing balance, sitting balance and dynamic balance of the patients.

Quality Of life Questionnaire (WHOQOL-100): This questionnaire has been developed by the World Health Organization that helps to measure the Quality Of Life among elderly people through 24 Quality of Life related questions.

Geriatric Anxiety Scale (GAS 10): This scale can be used to measure anxiety levels among the elderly people through 10 questions.

These values will be collected first during the baseline measurement and then compared with the measures taken at the final evaluation. Comparison between the baseline data and final data can help to understand if the intervention was able to improve the gait, mobility, balance, quality of life and anxiety levels among the participants and thus understand if the intervention was successful or not to achieve its objectives.

The study will be conducted for 12 month during which data collection will be done on the residential care setting to identify the potential participants and residents who are in need of this particular intervention in the first two weeks of the month. After this the rest of the month will be used to seek for the grant for the study. Baseline measures will be taken from the participants using the evaluation metrics on the second month which can be compared to the final evaluation data collected at the end of the month 12. From month 3 to month 12 for a total of 10 months the intervention will be conducted for the selected residents in the aged care setup. The Gantt chart below shows the proposed timelines for the project.

                     

Elements	Price	Quantity	Total (AUD)
Yoga Mats	AUD 5.00	100	500
Yoga Blankets	AUD10.00	100	1000
Computer	AUD 1000.00	1	1000
Home Modifications	AUD 500.00	1	500
Yoga Instructors	AUD 150 per hour	100 hours	15000
Visiting Nurses	AUD 100 per hour	100 hours	10000
Training Costs	AUD 200 per hour	100 hours	20000
Total Cost in AUD	48000

Equipments such as yoga mats and blankets would be needed for every participant on whom they can practice yoga and meditation daily. Since the intervention does not necessary depend upon the need of many equipment, it can be assumed that the mattress and blankets would suffice the needs. A computer is required for maintenance and computation of the data generated during the study and thus helps in its final evaluation using data processing software. Home modifications are needed to ensure the area where the intervention will be conducted in properly ventilated, has adequate lighting and is safe for the participants. Yoga Instructors will be hired for 100 hours (10 hours per month for 10 months) who would help the residents to follow the Yoga and Meditation routines. Visiting nurses would also visit the facility every week to assess changes in the health and wellbeing of the participants and understand if they are facing any troubles with the program.

Data Collection Methods

The future implication for such a study and the such a program is that yoga interventions can be actively introduced in the treatment regimen of most of the residential care as, that would improve the quality of life of these people and the would encourage them in carrying out their daily chores of life (Patel et al., 2012) . Additionally such yoga programs are likely to facilitate social interactions among the members of the residential care that again might prove to be refreshing for this elderly people as most of them are susceptible to depression due to isolation and loneliness (Gothe,  Kramer & McAuley, 2014).

The staffs for this study and the yoga based interventions would include investigators with special degree in Yoga and physical education having an extensive experience working with the elderly people having gait impairments and has played a pioneering role in the conduction of several yoga programs before. The investigators are proficient with the physical activities and occupational therapies.

References

Australian Institute of Health and Welfare (2018). Deaths from falls in the elderly top 1,000 a year – Australian Institute of Health and Welfare. Retrieved from https://www.aihw.gov.au/news-media/media-releases/2001-1/nov/deaths-from-falls-in-the-elderly-top-1-000-a-year

Alshammari, S. A., Alhassan, A. M., Aldawsari, M. A., Bazuhair, F. O., Alotaibi, F. K., Aldakhil, A. A., & Abdulfattah, F. W. (2018). Falls among elderly and its relation with their health problems and surrounding environmental factors in Riyadh. Journal of family & community medicine, 25(1), 29.

Brannen, J. (2017). Mixing methods: Qualitative and quantitative research. Routledge.

de Manincor, M., Bensoussan, A., Smith, C. A., Barr, K., Schweickle, M., Donoghoe, L. L., … & Fahey, P. (2016). Individualized yoga for reducing depression and anxiety, and improving well?being: A randomized controlled trial. Depression and anxiety, 33(9), 816-828.

DiBenedetto, M., Innes, K. E., Taylor, A. G., Rodeheaver, P. F., Boxer, J. A., Wright, H. J., & Kerrigan, D. C. (2015). Effect of a gentle Iyengar yoga program on gait in the elderly: an exploratory study. Archives of physical medicine and rehabilitation, 86(9), 1830-1837.

Gothe, N. P., Kramer, A. F., & McAuley, E. (2014). The effects of an 8-week Hatha yoga intervention on executive function in older adults. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 69(9), 1109-1116.

Hariprasad, V. R., Varambally, S., Varambally, P. T., Thirthalli, J., Basavaraddi, I. V., & Gangadhar, B. N. (2013). Designing, validation and feasibility of a yoga-based intervention for elderly. Indian journal of psychiatry, 55(Suppl 3), S344.

Hegde, A., Metri, K., Chwadhary, P., Babu, N., & Nagendra, H. R. (2017). Effects Of Yoga On Cardiac Health Sleep Quality, Mental Health And Quality Of Life Of Elderly Individuals With Chronic Ailments: A Single Arm Pilot Study (No. 2017-06-07).

Klatte, R., Pabst, S., Beelmann, A., & Rosendahl, J. (2016). The Efficacy of Body-Oriented Yoga in Mental Disorders: A Systematic Review and Meta-Analysis. Deutsches Ärzteblatt International, 113(12), 195.

Nick, N., Petramfar, P., Ghodsbin, F., Keshavarzi, S., & Jahanbin, I. (2016). The effect of yoga on balance and fear of falling in older adults. PM&R, 8(2), 145-151.

Patel, N. K., Newstead, A. H., & Ferrer, R. L. (2012). The effects of yoga on physical functioning and health related quality of life in older adults: a systematic review and meta-analysis. The journal of alternative and complementary medicine, 18(10), 902-917.

Phillips, C., Schmid, A., & Willis, L. (2016). Effects of Yoga on Functional Gait and Health-Related Quality of Life for Adults With Diabetic Peripheral Neuropathy. American Journal of Occupational Therapy, 70(4_Supplement_1), 7011515269p1-7011515269p1.

ACSQHC (2009). Preventing Falls and Harm From Falls in Older People. Retrieved from https://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-HOSP1.pdf

Spiewak, C., Steffen, S., Hicks, B., Little, K., & Pickett, K. (2017). A Systematic Review of the Outcomes of Therapeutic Yoga With Older Adults. American Journal of Occupational Therapy, 71(4_Supplement_1), 7111505134p1-7111505134p1.

WHO (2018). Falls. Retrieved from https://www.who.int/news-room/fact-sheets/detail/falls

Youkhana, S., Dean, C. M., Wolff, M., Sherrington, C., & Tiedemann, A. (2015). Yoga-based exercise improves balance and mobility in people aged 60 and over: a systematic review and meta-analysis. Age and ageing, 45(1), 21-29.