Purpose of research of the study is the impact of a three-month program of yoga exercises performed in seating position on a standard chair with a backrest and armrests on depression in elderly people with an inactive lifestyle.
Thirteen people, aged 69—89 (12 women and one man, 79.8 years average age) permanently living in a retirement home have been investigated. They have been asked to do some yoga exercises for three months, three times per week (amount 39 yoga classes), 30 minutes per class. Before starting and after ending the yoga program they were examined by the Geriatric Depression Scale of Sheikh & Yesavage (1986).
The results show a statistically significant reduction of depression by Geriatric Depression Scale (GDS) in the subjects we studied.
The quarterly program of yoga exercises significantlyreduced the level of depression among the elderly people we studied.
The world population is ageing: practically every country in the world is experiencing an increase in the number and proportion of older people in its population. The ageing of the population, including growing share of elderly people in the population, is about to become one of the largest and most significantsocial transformations of the twenty-firstcentury. Globally, the number of old people is growing faster than the number of people in any other age group. The number of people in the world who are 60 and above, is expected to grow by 56% between 2015 and 2030*16.
The ageing process is most advanced in high-income countries. By 2030, adults are expected to be more than 25% of the population in Europe and North America*16. The statistics at present show that the Republic of Bulgaria has an ageing population*4.
Elderly population in many developing countries today is growing significantlyfaster than in the developed countries in the past. Consequently, today, developing countries need to adapt much more quickly to the elderly population and use the experience of countries that have developed much earlier*16.
Diseases among elderly people have generally increased during the time*9. Depression is usually seen among old people. However, doctors tend to underestimate or ignore the presence of these symptoms and do not accept them as part of the normal ageing process*7. The prevalence of depressive symptoms in the general population is lowest in the middle age, and then increases in late mature years and reach the highest level in adults over 80*13. Depression could be seen approximately twice more often among women than men.
During ageing, experiences of depressive nature can be conditioned by a number of factors: social, material, medical, or individual. In some cases, the changes and vulnerability to economic or health status of the elderly are the reason for lasting anxiety and uncertainty that are experienced as depressive states or manifest themselves as depressive illnesses. In other cases, the individual model to deal with specific circumstances and events adversely affects the development of depression*2.
Common chronic illnesses during late age associated with loss of function also lead to serious adverse psychosocial consequences, thus contributing to the origin of depressive disorders*2.
Depression is a mental disorder that is characterized by a depressed (lowered) mood and lack of interest, joy and pleasure. The depressed (lowered) mood is expressed in sadness, misery, hopelessness. There are other symptoms of depression that are in line with depressed mood and lack of interest*3.
Depression can be described as major or minor, depending on the number of symptoms (fiveand more in the major depression and less than fivein the minor depression). Also depression may be of different types, depending on the type of symptoms. Besides the two mandatory symptoms, as additional symptoms depression may reduce appetite and decrease body weight, can cause insomnia, slow down motor activity, decrease concentration, memory disturbance and decrease energy. Low self-esteem, thoughts of mistakes that require punishment, lack of desire to continue life, suicidal thoughts, etc. could also be included in the group of depression symptoms*3.
In 2005, there were 68 retirement homes for elderly people in Bulgaria, where about 4,600 persons were accommodated*1. During the years old people become increasingly inactive physically*12. It is important to offer to these people appropriate and effective group psychophysical exercises and practices that at the same time have no undesirable additional effects and improve psychophysical health and/or social well being.
Current depression treatment strategies are not effective enough for many people, and patients have a number of concerns about existing treatments*18. On the one hand, the results of eight meta-analyses show that physical exercise has a moderate to large anti-depressant effect. Exercise, of course, is not the only and universal solution to the growing problem with depression and this type of treatment will not be appropriate for all depressed people. On the other hand, this limitation is equally important for traditional treatments of depression. This means that neither medication nor psychotherapy is appropriate for all*11.
It is also necessary to test non-pharmacological methods to improve the mental health of old people, which promote interaction between the mind and the body without additional effects*7. Yoga is one of these non-medication methods which adapted to respective age and condition can be used to reduce depressive symptoms in the elderly. Hatha yoga can be an attractive alternative for mild depression or a good complement to current depression treatment strategies*18.
This study is to determine the impact of a three-month yoga exercises program performed in seated position on a standard chair with a backrest and armrests on depression in elderly people with an inactive lifestyle.
We assume that a three-month practice of a session of yoga exercises will reduce depression in elderly people permanently living in retirement homes.
The study includes 13 elderly people (12 women and 1 man) aged 69—89 year (average age 79.8 years) living in the retirement home 'Longevity', Sofa, Bulgaria. The persons have not practised yoga until the present study. Criteria for including people in the study: they have to live permanently in this home, to have desire for participation in yoga classes, to be able to understand instructions of the yoga teacher, and not to have chronic illnesses that make participation in the survey contra-indicative (this has been confirmedby a doctor from the retirement home ('Longevity'). Regarding the need to use a walking aid, the people surveyed are classifiedas follows: 4 people with independent gait, 6 people using a walking stick and 3 people moving with a walking frame. The investigated per sons have several different diseases, which were treated according to the current medical practice and are listed in Table 1.
|Disease||Number of persons|
|Arthrosis (gonarthrosis and/or coxarthrosis, spondyloarthrosis etc.)||9|
|Chronic arterial insufficiency of the limbs||1|
|Ischaemic heart disease||1|
Research shows that there is an increased risk of deep depression in people with one or more chronic diseases. Also, people with chronic diseases such as diabetes and arthrosis have an increased risk of developing a major depression compared to the general population*14. It has been found that among the elderly Americans (≥65 years), depressive symptoms are an independent risk factor for the development of ischaemic heart disease and death for any reason. Among investigated people with the highest average level of depression, the risk of ischaemic heart disease increased by 40% and the risk of death by 60% compared to those with the lowest average scores*5.
Some of the persons included in this study have chronic diseases that are associated with a higher risk of depression. The level of depression for tested persons prior to the application of the yoga exercise program is described in Table 2.
|GDS-15 results||Number of persons||Percent|
|Average level of depression||5-9||7||54%|
|High level of depression||1-15||3||23%|
In the above table it can be seen that before starting the yoga program, for 23% of the group tested normal (no depression), 54% have an average depression level and 23% had a high depression level.
The study was conducted on the territory of the Retirement home 'Longevity' starting on 15th January and ending on 15th April 2017 (3 months). Three times weekly (Monday, Wednesday and Friday) 30-minute group exercises including yoga exercises appropriate for this age group were held during this period. Altogether 39 classes were conducted, with 11 of the participants attending 100% and the other two attending 95% of the classes. There were no dropouts during the study. During the study, participants did not take anti-depressant medications. They shared that they were glad to attend classes, because they like it very much. They also like to meet with the teachers, as outsiders, who bring to them new useful information and activities. We assume that communication in the group and with teachers has also influencedtheir mental state.
The series of exercises performed by the participants in the study were appropriate to their physical and mental capabilities, the illnesses they had and the basic requirements for conducting a group procedure with this group of people. The participants were motivated to be more active. During the exercises precise, complete and comprehensible instructions were given. The exercises were arranged starting with the easier and gradually followed by the more difficultones. An individual approach was always applied when the exercises were done.
The research is based on practices from the firstgroup of the pawanmuktasana series â€“ the anti-rheumatic group (6). All exercises were performed from an initial seated position on a chair. During the class, movements were made up to 5 times for each type of movement for each joint. The goal for each participant was to perform the movement in the largest possible painless manner for each joint.
Yoga exercises included appropriate coordinated exercises for upper limbs, including physiological movements (such as folding, unfolding and rotation) with fingers, elbows, shoulder joints, toes, ankles, knee joint, and cervical spine. Typical in the performance of the exercises was the very slow speed of their performance, with the exercises executed at a very slow speed. The speed of movement is the one that can be used to fold and unfold the fingersfor 15 seconds. This slow speed is encouraged by Satyananda Yoga as it enhances awareness and better control over execution.
In connection with the well-known positive effect of breathing exercises on the psyche we specify that as part of the program of yoga exercises we applied a kind of breathing technique, which took into consideration the possibilities and physical condition of the persons under study and also according to the teacher's assessment.
This type of breathing is part of the practice kriya pranayama. Its description is as follows: Inhalation is very slow — as much as possible for the practitioner. Once inhalation is done, one must swallow and then allow the air to come out of the lung by itself, very slowly. It should not be driven out by the diaphragm. The air must go so slowly that if one places the index fingernear the nostrils, one will feel only the warmth, but not the movement of the air. The rule is that the duration of breathing in and breathing out is the same, but it may not be strictly observed because we believe that this is achieved by itself when the body is cleaner and the lungs begin to use a greater part of their volume. Practitioners focus their attention on the area of the entrance of the nostrils, and watch the air as it moves in and out at that point. Inhalation and exhalation is only through the nose. The mouth is closed. The position of the body is comfortable, seated on a chair. The back is as straight as possible for the body.
Three to fiveinhalations and exhalations have been done after the completion of the yoga exercises for one particular joint or at most for two joints for both limbs. For example: fingerand wrist exercises — then follows breath awareness; practices in the elbows and shoulder joints — breath awareness; ankles and knees — breath awareness; practices in the neck — breathing.
Immediately before and after the mentioned three-month intervention, a Geriatric Depression Scale (GDS-15) of Sheikh & Yesavage, 1986*17 was implemented with a Bulgarian translation of Mehandjiyska, 2014*2. The enquiry consists of 15 questions to which the persons respond with 'yes or 'no. Normal state is estimated if the sum of the points in the replies is 0 to 4 points. Depression is estimated when there are more than 5 points. Scores of 5 to 9 are definedas average depression, and if it is 10 to 15 the depression is at a high level and, respectively, markedly depressed (2; 6).
Other researches carried out with this scale findit reliable for groups of elderly people with physical illnesses and also to those with dementia*2.
The statistical processing of the results was carried out with a specialized statistical program — SPSS.19. Confidence Interval (CI) was determined to be 95%. The normality of the distribution of the primary data from the firstand second tests was determined by the Kolmogorov-Smirnov test. The distribution of the volume of movement of almost all variables was normal in both studies.
Statistic results according to the Geriatric Depression Scale (GDS-15) are presented in Table 3.
|I test||II test||Difference||a|
The results show a statistically significantreduction in the Geriatric Depression Scale on the depression level of the tested people. The true difference between the two studies has a high probability â€“ the significancelevel named with α is less than 0.01, which corresponds to a guarantee probability P = 99%, this means under 1% chance for error in this case.
At the end of the three-month study the average level of depression decreased by 2.16 points. Also, in the second test the highest score was 9 points and this indicates that there were not any persons with a high depression score in the group. Average test values measured before and after the yoga program are shown in Figure 1.
We found a statistically significantdecrease of depression after the implementation of the three-month yoga program. The average of the result on the GDS-15 scale decreased by 2.16 points. In the scientificliterature*19 a clinically meaningful difference is indicated if it is 1.2 points or more according to the Geriatric Depression Scale. The average points of improvement in our investigations is above this value and indicates that improvement obtained is not only statistically significant, but also clinically significantfor that research.
As the study does not have a control group, it can be assumed that there is another factor of influencesuch as the change of the seasons (winter to spring) and the prolongation of the lighter part of the day that affects the depression of the subjects. But a large four-year research of persons over 85 years of age indicates a lack of significantseasonal changes in GDS data*10. Within each of the four years of observation (people of age 85—88 years) and throughout the period of study, there was no significantrelationship between the GDS score and the one-month amount of daytime, daylight, or rain. The authors conclude that estimates of the influenceof seasonality on mood reported in the literature may be overestimated or there is a remarkable difference between the young and the most elderly people in this respect*10. Among the persons surveyed by us, 4 people (30.7%) are aged 85—89 years old, and the rest are below this age. Therefore, we assume that they do not have the seasonal mood changes, which gives us reason to believe that the results obtained in our research are due to the yoga classes.
There are a number of modern studies that show that physical exercises are effective in reducing depressive symptoms. According to Josefsson, Lindwall and Archer*11, physical exercises can be recommended for people with mild and moderate depression who are inclined, motivated, and physically healthy enough to get involved in such a program. A more recent meta-analysis*15 shows that physical exercises have a significantand great anti-depressive effect for people with depression.
Our present study shows a significant reduction in depressive symptoms by yoga exercises program three times a week for three months and is consistent with other similar studies. A study with non-institutionalized individuals over 60 years of age in the experimental (n=62) or control group (n=66) found a decrease in depression in both the third and sixth month of a special yoga program ('silver yoga') three times per week (70 minutes) for six months*7.
The same program applied to people living in homes for elderly people shows a reduction in depressive symptoms and sleep improvement after six months of application*8.
Our three-month program of yoga exercises has significantly reduced the level of depression in the elderly people living in the retirement home.
We do recommend carrying out a larger research in Bulgaria about the influenceon the mental state and in particular on depression by yoga exercises suitable for the elderly.