Alzheimer’s disease (AD)-type dementia affects more than 5.4 million Americans and ranks as the most common type of dementia (Thies & Bleiler, 2011). Currently, there are few effective long-term treatment options for AD. Managing symptoms and limitations that stem from AD is important and can lead to a better quality of life. Substantial evidence indicates that physical activity enhances balance, strength, learning, and memory for people of all ages, including those with cognitive impairment such as AD (Liang et al., 2010; McCall, 2013; Oken et al., 2006)
One activity that may be beneficial to those with cognitive impairment is yoga. Yoga is a mind-body therapy (Wang & Feinstein, 2011) that involves a combination of physical activity or postures (asanas), breathing (pranayama), deep relaxation (savasana), and meditation. The mechanisms that underlie the benefits of the physical activity aspects of yoga for those with cognitive impairment are hypothesized to involve the simple, repetitive movements in yoga practice that provide a sense of familiarity and the active attentional and mindfulness components that are inherent within yoga practice (Oken et al., 2006; Wiltermuth & Heath, 2009). Oken et al. (2006) studied 135 healthy older adults and found that those randomized into the yoga group had improved scores on quality of life and physical measures compared to participants in the exercise and control groups. These researchers found that the mindfulness aspects of yoga helped the participants feel calmer and focus on their surroundings and fellow participants. Wiltermuth and Heath (2009) studied participants of yoga programs and compared those to a control group who did not participate in yoga. The 52 yoga participants reported the repetitive yoga movements to be comforting and allowed them to connect with others in the group and feel reduced levels of distress and stress.
A few studies have demonstrated that yoga can be a beneficial type of physical activity for individuals with AD. In a qualitative study (Litchke, 2013), 39 participants who were diagnosed with AD were studied during a 10-week adaptive yoga program. After the program, the participants had increased eye contact, decreased physical limitations, increased language repetition, and increased sense of humor. Caregivers for the participants noted uplifted mood, increased alertness, and more social interactions. Litchke, Hodges, and Reardon (2012) found that a 10-week chair yoga intervention had a significant benefit in slowing the progression of AD among those with early dementia (n = 7, p = 0.001) and that the yoga group had significantly less depression (n = 19, p = 0.01). This study did not find any benefits from the yoga sessions on balance but found an increase in participants’ ability to perform activities of daily living. One limitation of this study is the small sample of 19 participants. The researchers recommend further study in the area of chair yoga.
Changes in cognitive ability and function, osteoarthritis (OA), sensorineural ear dysfunction, and dizziness can make standing physical activities dangerous in older adults (Chen et al., 2010; Sollito, n.d.). Many older adults with moderate to severe AD are at higher risk for problems associated with standing exercises due to risk of balance, fatigue, confusion, or fear of falling (Ryan, McCloy, Rundquist, Srinivasan, & Laird, 2011). Promoting the health of these frail older adults by means of a sitting yoga exercise program may improve overall health and well-being and reduce health care expenditures caused by chronic health problems.
Chair yoga is safe, easy to learn, and well suited to older adults with OA (Froeliger, Garland, & McClernon, 2012; Litchke et al., 2012). There are several mechanisms that may be responsible for the improvements in physical function and quality of life among older adults who participate in yoga, including chair yoga. Improving mood through physical activity, even in small amounts, has been associated with improved cognitive function (Barbour & Blumenthal, 2005). Yoga emphasizes body awareness and involves focusing one’s attention on breathing or specific muscles or parts of the body, which increases mental alertness (Gothe, Pontifex, Hillman, & McAuley, 2013). Finally, several studies have demonstrated the ability of yoga to increase physical function through muscle strengthening and stretching (DiBenedetto et al., 2005; Oken et al., 2006; Tran, Holly, Lashbrook, & Amsterdam, 2007).
The Sit ‘N’ Fit Chair Yoga Program was created to be used with older adults who are unable to participate in standing physical activity programs. This yoga program uses the underlying principles of hatha yoga, adapted for use while sitting in a chair. Hatha yoga stretches muscle groups to increase strength, flexibility, and physical balance. In this type of yoga, a person assumes a series of stationary positions that use isometric contraction and relaxation of different muscle groups to create specific body alignments (Oken et al., 2006). Hatha yoga is amenable to easy adaptation for older adults through modifications of the poses and the use of props, such as blankets and chairs (Litchke, 2013). The mechanisms of focusing attention, physical activity, strengthening, and stretching may also apply to the Sit ‘N’ Fit Chair Yoga Program, as it works every muscle group in both the upper and lower body to strengthen and stretch these muscles.
The outcomes of a feasibility study on the ability of older adults to complete the Sit ‘N’ Fit Chair Yoga Program determined that those who were unable to attempt more strenuous activity could safely participate in Sit ‘N’ Fit Chair Yoga (Park & McCaffrey, 2012). After participants in this study completed the twice-weekly 8-week yoga program, they were more relaxed because they felt secure in a chair. At the end of the study, the participants were given a booklet with pictures and written instructions to guide them in continuing the program. Many of the participants stated they used the booklet and continued the practice at home when they had pain or trouble sleeping. Focus group data showed that Sit ‘N’ Fit Chair Yoga provided security so that participants could complete the stretching, breathing, and bending activities that comprise yoga postures, while sitting in a chair. Study participants stated that the yoga had helped them become stronger physically, to sleep better, and to complete activities of daily living with reduced pain.
There are few studies on the use of chair yoga programs and the benefits of chair yoga on physical function in older adults with moderate to severe AD. The purpose of this study was to determine the feasibility of the Sit ‘N’ Fit Chair Yoga Program among older adults with AD. We theorized that the Sit ‘N’ Fit Chair Yoga Program could be a form of seated physical and mental activity to improve physical function in older adults diagnosed with moderate to severe AD who were unable to participate in standing activity.
Sit ‘N’ Fit Chair Yoga was developed by an experienced yoga instructor who has worked extensively for more than 20 years with older adults in chair-based yoga. The program incorporates the four aspects of regular yoga using the support of a chair at all times. It was designed to be presented in 45-minute classes twice weekly for at least 8 weeks. Table 1 presents the components and desired outcomes of the program. Each section of the program is completed identically at each of the 16 sessions.
Components of Sit ‘N’ Fit Chair Yoga Program Sessions
In a systematic review of yoga research (Park & McCaffrey, 2012), a lack of standardization of yoga programs was noted as a deficit in fully explicating evidence of the potential benefits of yoga. The Sit ‘N’ Fit Chair Yoga Program is specifically designed for older adults who are unable to participate in regular yoga or physical activity programs due to weakness, fatigue, or fear of falling. One of the benefits of using the Sit ‘N’ Fit Chair Yoga Program is that it is standardized for use with older adults and after study can be a model for an evidence-based yoga program.
This study used a quasi-experimental single-group design. Multiple data collection points provided for a repeated measures analysis of outcome measures. The study was funded by a Faculty Research Seed Grant Program from the participating university’s Division of Research.
The research question posed by the authors was “What is the effect of the 8-week Sit ‘N’ Fit Chair Yoga Program on the gait and balance in older adults with moderate to severe AD?” The three measures of physical function were the Six-Minute Walk Test (6MWT), the Gait Speed Test (GST), and the Berg Balance Scale (BBS).
Nine older adults (ages ≥65) with a diagnosis of moderate to severe dementia, who were cared for in an AD day care center in Deerfield Beach, Florida participated in the study. The center cares for a total of approximately 20 older adults (attendance varies) with a diagnosis of moderate to severe dementia from 8 a.m. to 4 p.m. each weekday.
After approval from the participating university Institutional Review Board, a request for participation was sent home with each of the older adults at the center; nine caregivers indicated interest. Those caregivers who indicated interest were contacted to discuss the program, and all nine sign informed consent. Those older adults with informed consent from caregivers were asked for their assent to participant in the program, and all nine agreed to participate in the study. All nine had a note on file at the center from their physician that indicated the diagnosis of AD and the level to which the disease had progressed, which ranged from moderate to severe. The mean age of participants was 83; 66% were women and 34% were men. One participant was in a wheelchair, and five routinely used walkers.
All participants were non-Hispanic White, whose place of residence was with family members who acted as caregivers. Nurses, aides, and activities personnel serve as staff at the center, and participants receive breakfast and lunch as well as participate in activities. No exercise activities are conducted at the center, and the participants were described as sedentary by their family members, as most of the patients were unable to participate in standing activities. None of the nine participants dropped out of the study, and there were no adverse events during the study period.
Two yoga instructors were hired and trained by the developer of the Sit ‘N’ Fit Chair Yoga Program. They also attended a 2-hour safety lecture that prepared them to work with individuals with dementia. Twice each week, the yoga instructors and the researcher (R.M.) went to the day care center to meet with the participants. The researcher monitored the instructors’ fidelity to the Sit ‘N’ Fit Chair Yoga Program. Prior to leaving the day care room, the participants ate breakfast and were toileted so they would not be distracted during the class. The day care center also provided one aide and one nurse to accompany the group to the activity room. The activity room was well lit with ambient light from windows and overhead lighting. The temperature in the room was set at 74 °F. Stiff backed chairs without arm rests were placed in a semicircle facing the front of the room.
Yoga classes were offered on Tuesday and Thursday from approximately 10 to 11 a.m. Each class lasted approximately 50 minutes with 10 minutes for participants to get settled in their seats and prepare for the class. Soft, calming music was played during the yoga sessions at a level that allowed participants to clearly hear the instructor’s directions. The nine participants in the study were the only yoga participants in the class. The yoga instructor sat at the front of the semicircle while giving directions and physically demonstrating postures and stretches. All participants were asked to sit up in the chair, leaning against the chair’s back with feet flat on the floor. Any of the participants who could not reach the floor were provided with a pillow on which to place their feet. From the chair, participants accomplished the poses and breathing exercises demonstrated by the instructor. During the meditation portion of the class, participants sat quietly and continued to breathe as instructed. The researcher observed every yoga session to determine the fidelity of each instructor to the Sit ‘N’ Fit Chair Yoga Program. Fidelity was measured by following the Sit ‘N’ Fit Chair Yoga guide to assure that each posture, meditation, and breathing exercise was consistently completed as described in the book.
Demographic data were collected from the participants with the assistance of the day care staff; data included age, gender, residence, living partner, and confirmation of AD. The diagnosis of AD was confirmed via a physician’s note in the participant’s chart at the center. The researcher attended each of the yoga group sessions and took attendance and monitored the accuracy of participants’ completion of all parts of the Sit ‘N’ Fit Chair Yoga Program.
Three measures were used to ascertain changes in participants’ balance and gait before, during, and after the intervention. The BBS was developed to measure balance among older adults with impairment in balance function by assessing performance of functional tasks (Berg, Wood-Dauphinee, Williams, & Gayton, 1989). The BBS contains 14 items; it is performance based and uses a 5-point scale (0 = lowest level of function to 4 = highest level of function; score range = 0 to 56). The BBS is considered the gold standard assessment of balance, with good to excellent intrarater reliability (intraclass correlation coefficient [ICC] = 0.68 to 0.99), excellent interrater reliability (ICC = 0.88 to 0.98), and good internal validity (Bennie et al., 2003).
The 6MWT is a good measure of physical function in community-dwelling adults (Troosters, Gosselink, & Decramer, 1999). The test measures exercise tolerance by measuring the maximum distance a person can walk in 6 minutes—self-paced with the ability to rest as needed—on a 30-meter track. A Cronbach’s alpha coefficient of 0.98 has been reported for individuals with muscular problems. Some studies have shown good test-retest reliability, with ICCs ranging from 0.94 to 0.96 (Pankoff, Overend, Lucy, & White, 2000).
The GST requires the participant to negotiate a standard distance (e.g., 20 feet or 6 meters) between markers. Gait speed is calculated using distance in meters and time in seconds (Kuo et al., 2006). Gait speed measurement is considered highly reliable in older adults without known impairments that could affect gait (r = 0.89 to 1.00; Pearson correlation coefficient, r = 0.93, ICC = 0.78). In Cress et al.’s (1995) study of 417 community-dwelling older adults and 200 nursing home residents (mean age = 79), gait speed was the strongest independent predictor of self-reported physical function in both groups.
Data Collection and Analysis
Over the 8-week period of the yoga program, measurement tools were administered four times: prior to the intervention, after 4 weeks, after 8 weeks, and at 1 month after conclusion of the program. Under the direction of the two study researchers (R.M., J.P.), a research assistant (D.H., who had been trained in data collection techniques, the specific tools used in the study, and safety in working with AD patients) collected and recorded all data. The same research assistant collected all of the BBS data at all four data collection points. The two researchers collected all of the demographic data. One researcher and one research assistant collected all of the GST and 6MWT data at each data collection point; these data were collected on one day. All of the participants completed all measurement tools at each data collection point. Participants received gift cards as a reward for participation, and the day care center received compensation for participation in the study.
A repeated measures analysis of variance (RMANOVA) was performed to analyze the data collected via the three measurement tools. Although the sample of nine was small for parametric analysis, repeated measures and the underlying normal distribution of the data allow for the use of the RMANOVA in this case.
The fundamental finding from this study was that older adults with moderate to severe AD could complete a twice-weekly chair yoga program. During the 8 weeks, the participants did not miss any of the sessions and did not lose interest in participation. The participants were able to accurately complete all of the postures, breathing, and meditative aspects of the program. This is consistent with the findings of the study by Litchke et al. (2012). However, the Sit ‘N’ Fit Chair Yoga Program was able to accommodate those participants who could not participate in standing exercises.
Positive changes were seen across all of the physical measures; however, only the change in balance was statistically significant. Lack of statistical significance in the other measures may have been due to the small sample. To better determine the overall effect of the Sit ‘N’ Fit Chair Yoga Program, at least 60 participants randomly divided into a yoga group and a control group would be required.
As shown in Table 2, balance improved across all data collection points. Overall, the change in mean score on the BBS from 40.46 at the beginning of the intervention to 45.13 at the 1-month follow up was positive and statistically significant, F = 6.87, p = 0.034, η2 = 0.495. GST measures improved from a mean 10.76 seconds to walk the 20 feet prior to yoga participation to 4.36 seconds at the end of the program and 8.5 seconds at the 1-month follow up, a medium effect size of 0.495. The maximum distance walked in 6 minutes improved from 492.40 feet prior to yoga participation to 516.30 feet after 4 weeks of the chair yoga program. However, from 4 weeks to 8 weeks, the distance decreased from 516.30 to 482 feet. At the 1-month follow up, the distance improved again from 482 to 500 feet. Figure 1, Figure 2, and Figure 3 show changes in overall physical functioning across time.
Measure of Physical Function at Baseline, 4 Weeks, 8 Weeks, and 1-Month Follow Up
Results of the 6-Minute Walk Test.
Results of the Berg Balance Scale.
Results of the Gait Speed Test.
This study was designed to determine the feasibility of older adults with AD-type dementia to complete the 8-week Sit ‘N’ Fit Chair Yoga Program. Important findings were that participants were able to complete all aspects of the program and did not lose interest in participation. Participants completed all yoga sessions without becoming agitated, fatigued, or distracted, as noted by the researcher who attended all yoga sessions. Each time the group was assembled to go to the activity room, participants expressed eagerness to participant in the yoga sessions. Day care workers noted a decrease in overall agitation and wandering on “yoga days.”
The poses in the Sit ‘N’ Fit Chair Yoga program designed to improve balance included the “Body Proper” and “Warrior of the Body” poses, which stretch the legs while sitting in the chair. Bringing attention to the body during the meditation, or “Mind-Body Connection,” component of the program also may have increased balance. The participants had improved balance scores at each data collection point.
Although the 6MWT and GST did not demonstrate statistically significant changes in mean scores, this may have been due to the small sample. There was a steady decrease in mean scores on both measures (Figure 1 and Figure 2). The 6MWT scores decreased from 4 weeks to 8 weeks but returned to baseline scores at the 1-month follow up, leading to the conclusion that, without steady twice-weekly yoga practice, some of the benefits of this program had dissipated.
Limitations of this study include the lack of a control group; the findings cannot be specifically attributed to the yoga program intervention. Another limitation was the small sample (N = 9). Further studies using a randomized control design with a control group and a larger sample would provide a higher level of evidence for the use of the Sit ‘N’ Fit Chair Yoga Program. A power analysis indicates that to achieve statistical significance for this program, a group of 60 individuals divided into two groups (intervention and control) would be required.
The findings of this study support the use of the Sit ‘N’ Fit Chair Yoga Program as an evidence-based intervention for individuals with moderate to severe AD. All of the older adults with AD who participated in this study completed all 16 yoga sessions and the program held their attention and interest for the full 50 minutes per session. Balance was improved and some improvements in gait speed and walking ability were noted in the data analysis. None of the participants dropped out of the study, and there were no adverse events. Participants and their caregivers noted improvement in attention and reduced agitation in participants.
Further study is needed, using a larger sample and including a control group, to fully determine the effect of the Sit ‘N’ Fit Chair Yoga Program on older adults with moderate to severe AD. Outcome measures in future studies might also extend beyond physical function and include attention, agitation levels, sleep, and cognitive performance, all of which have shown positive outcomes in other yoga studies with older adults. The Sit ‘N’ Fit Chair Yoga Program is easy to implement and safe, which makes it a promising intervention to provide movement exercise to older adults with moderate to severe AD.
Exercise has been shown to be beneficial for older adults with AD, but many of these older adults are unable to participate in standing exercise due to lack of balance, confusion, or agitation. The Sit ‘N’ Fit Chair Yoga Program was designed to provide physical and mental activities for older adults in the safety and security of a chair. Nine participants with moderate to severe AD completed the twice-weekly 8-week Sit ‘N’ Fit Chair Yoga Program. There were improvements in balance, as well as slight improvements in gait speed and distance walked in 6 minutes. Further research may provide more evidence of the value of the Sit ‘N’ Fit Chair Yoga Program for older adults with AD.
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|1-month follow up||500.00 (359.00)||8.50 (4.36)||45.13 (14.34)||6.870||0.034||0.495|