Evidence-Based Yoga Therapy for Older Adults (page 3)

Mental Health Considerations in Older Adults

Mental health is a particularly critical issue within the elderly population. Depression is a common psycho­logical impairment in advanced age and mental health plays a large role in determining both quality of life and physical health. For example, anxiety and depression are important risk factors for pain and it estimated that 70% to 80% of modern illnesses and 90% of doctor’s visits are stress-related.

Stress refers to the consequence of the failure of an organism — human or other animal — to respond adequately to mental, emotional, or physical demands, whether actual or imagined. Signs of stress may be cognitive, emotional, physical, or behavioral. Signs include poor judgment, a general negative outlook excessive worrying, moodiness, irritability, agitation, inability to relax, feeling lonely, isolated or depressed, acne, aches and pains, diarrhea or constipation, nausea, dizziness, chest pain, rapid heartbeat, eating too much or not enough, sleeping too much or not enough, social withdrawal, procrastination or neglect of responsibilities, increased alcohol, nicotine or drug consumption, and nervous habits such as pacing about, nail-biting, and knuckle-cracking. Chronic stress can significantly affect many of the body's immune systems, as can an individual's perceptions of, and reactions to, stress. 
Although the basic neurochemistry of the stress response is now well understood, much remains to be discovered about how the components of this system interact with one another, in the brain, and throughout the body. In response to a stressor, neurons with cell bodies in the paraventricular nuclei (PVN) of the hypothalamus secrete corticotropin-releasing hormone (CRH) and arginine-vasopressin(AVP) into the hypophyseal portal system.
The locus ceruleus and other noradrenergic cell groups of the adrenal medulla and pons also become active and use brain epinephrine to execute autonomic and neuroendocrine responses, serving as a global alarm system.
The autonomic nervous system provides the rapid response to stress commonly known as the fight-or-flight response, engaging thesympathetic nervous system and withdrawing the parasympathetic nervous system, thereby enacting cardiovascular, respiratory, gastrointestinal, renal, and endocrine changes. The hypothalamus-pituitary axis, a major part of the neuroendocrine system involving the interactions of the hypothalamus, the pituitary gland, and the adrenal glands, is also activated by release of CRH and AVP.
This results in release of adrenocorticotropic hormone (ACTH) from the pituitary into the general bloodstream, which results in secretion of cortisol and other glucocorticoids from the adrenal cortex. The related compound cortisone is frequently used as a key anti-inflammatory component in drugs that treat skin rashes and in nasal sprays that treat asthma and sinusitis. Recently, scientists realized the brain also uses cortisol to suppress the immune system and reduce inflammation within the body. These corticoids involve the whole body in the organism's response to stress and ultimately contribute to the termination of the response via inhibitory feedback.

Conventional Treatment for Stress
One promising intervention for older adults that tar­gets both mental and physical health is physical exercise. The American College of Sports Medicine guidelines now recommend physical activity for older adults to manage depression and anxiety disorders and improve overall men­tal health.(19) Research has verified the beneficial effects of exercise on psychological health and well-being across different popula­tions including the elderly.(20) Regular physical activity is associated with reduced symptoms of anxiety and depression and per­ceived stress.(21)

Alternative treatments for Stress
Researchers have identified the potential benefits of mindful exercise (Tai Chi and Qigong) in older adults. A single session of mindful exercise has been demonstrated to have immediate effects on well-being, increasing one’s sense of tranquility (22) and reducing depressive mood and state anxiety. (23) Research also shows longer-term benefits. Tsang, Mok, Yeung, and Chan (24) demonstrated that elderly adults with chronic physical illnesses (mean age = 72.9 years) showed perceived improvement in physical health, psycho­logical health, social relationships, and health in general (as reflected by scores on the Perceived Benefits Questionnaire and informal feedback) after 12 weeks of Qigong practice. Another study (25) showed similar results in a Tai Chi inter­vention in which 98 individuals (mean age = 73.2 years) either participated in a Tai Chi exercise class or continued their daily routine activities for six months. At post-test, the Tai Chi participants had higher levels of health percep­tions, life satisfaction, positive effect, and well-being and lower levels of depression, negative effect, and psychologi­cal

Yoga for Stress
Yoga can be wisely applied in old age care and there is no age restriction to practice yoga, however, the effect may differ by age. One study was conducted in Japan to find the effect of yoga on mental health between young and senior people. Twenty-five normal healthy volunteers of both sexes were divided into two groups according to age. Fifteen participants of the age group between 65 to 75 years and 10 participants of the age group between 20 to 30 years were selected. Selected individuals were subjected to 90 min of yoga classes once or twice a week for a month. Salivary amylase activity was assessed before and after yoga practice.(26) State Trait Anxiety Inventory (STAI) was given before yoga on the first day and after one month of practice to assess the change in State anxiety and Trait anxiety. Decrease in Salivary amylase activity may be due to reduction in sympathetic response. Reduction in State and Trait anxiety score signifies that yoga has both immediate as well as long-term effect on anxiety reduction. Thus yoga helps to improve the mental health in both the groups. Stress is a major factor affecting the mental health of a person irrespective of age. Presentation of the stress may vary from that of fight to flight phenomenon. Chronic stress is the major cause of many physical and mental disorders. Yoga has been effectively used in the management of stress. It has been observed that the practice of yoga decreases verbal aggressiveness compared to physical exercise. (27) It is also useful against physical stress like cold exposure(28) and stress due to diseases like epilepsy.(29) Yoga has been found useful for mental disorders like depression.(30) In a study conducted by Oken et al., on healthy seniors participants were divided into three groups as yoga, exercise and control. The yoga group showed significant improvement in quality of life and physical measures compared to the exercise and the control group. (31) Yoga helps to improve the mental health of both the young and seniors by reducing stress. Yoga can be wisely applied in welfare programs to improve the Quality of Life in all age groups.

Dementia is a serious loss of cognitive ability in a previously unimpaired person, beyond what might be expected from normal aging. It may be static, the result of a unique global brain injury, or progressive, resulting in long-term decline due to damage or disease in the body. Although dementia is far more common in the geriatric population, it can occur before the age of 65, in which case it is termed "early onset dementia". Dementia is not a single disease, but rather a non-specific illness syndrome (i.e., set of signs and symptoms) in which affected areas of cognition may be memory, attention, language, and problem solving. It is normally required to be present for at least 6 months to be diagnosed; cognitive dysfunction that has been seen only over shorter times, in particular less than weeks, must be termed delirium. In all types of general cognitive dysfunction, higher mental functions are affected first in the process. Dementia, though often treatable to some degree, is usually due to causes that are progressive and incurable. Symptoms of dementia can be classified as either reversible or irreversible, depending upon the etiology of the disease. Less than 10% of cases of dementia are due to causes that may presently be reversed with treatment. There are many specific types (causes) of dementia, often showing slightly different symptoms. However, the symptom overlap is such that it is impossible to diagnose the type of dementia by symptomatology alone, and in only a few cases are symptoms enough to give a high probability of some specific cause. Diagnosis is therefore aided by nuclear medicine brain scanning techniques. Dementia is not merely a problem of memory. It reduces the ability to learn, reason, retain or recall past experience and there is also loss of patterns of thoughts, feelings and activities (32). Additional mental and behavioral problems often affect people who have dementia, and may influence quality of life, caregivers, and the need for institutionalization. As dementia worsens individuals may neglect themselves and may become disinhibited and may become incontinent. (32) Depression affects 20–30% of people who have dementia, and about 20% have anxiety. Psychosis (often delusions of persecution) and agitation/aggression also often accompany dementia.

Conventional Treatment for Dementia
There is no cure for dementia. Although there are no medications that are clinically proven to be preventative or curative of dementia, cholinesterase inhibitors are often used early in the disease course. Cognitive and behavioral interventions may also be appropriate. Educating and providing emotional support to the caregiver is of importance as well.  Adult daycare centers as well as special care units in nursing homes often provide specialized care for dementia patients. Adult daycare centers offer supervision, recreation, meals, and limited health care to participants, as well as providing respite for caregivers. In addition, Home care can provide one-on-one support and care in the home allowing for more individualized attention that is needed as the disease progresses.

Yoga for Dementia
One study aimed to test the effects of yoga exercises on the physical and mental health of elderly people with dementia living in long-term care facilities. A quasi-experimental, pretest-post-test design was used. A convenience sample of 68 residents in long-term care facilities aged 60 years and above with mild to moderate dementia, was selected. An experimental group of 33 elders participated in a 12-week yoga training program of three 55-minute sessions a week; a control group of 35 elders maintained their usual daily activities. Data were collected before and after completing the 12-week study. Measurements included body composition, cardiopulmonary functions, body flexibility, muscle strength and endurance, balance, joints motion, depression, and problem behaviors. The yoga-trained participants had better physical and mental health than those who did not participate, including lowered blood pressure, reduced respiration rate, strengthened cardiopulmonary fitness, enhanced body flexibility, improved muscle strength and endurance, improved balance, and increased joints motion (all p values < 0.05). In addition, the depression state (p < 0.001) and problem behaviors (p < 0.001) of these demented elders were significantly reduced. Conclusion: Yoga exercise has positive benefits for both the physical and mental health of elders with dementia living in long-term care facilities. It is recommended that yoga be included as one of the routine activities in these long-term care facilities. (33)

Anxiety is a psychological and physiological state characterized by somatic (body), emotional, cognitive (mental), and behavioral components. Anxiety is considered to be a normal reaction to a stressor. It may help someone to deal with a difficult situation by prompting them to cope with it. When anxiety becomes excessive, it may fall under the classification of an anxiety disorder. Anxiety is a generalized mood condition that can often occur without an identifiable triggering stimulus. As such, it is distinguished from fear, which is an emotional response to a perceived threat. Additionally, fear is related to the specific behaviors of escape and avoidance, whereas anxiety is related to situations perceived as uncontrollable or unavoidable. Another view defines anxiety as "a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events", suggesting that it is a distinction between future vs. present dangers which divides anxiety and fear.
Physical effects of anxiety may include heart palpitations, muscle weakness and tension, fatigue, nausea, chest pain, shortness of breath, stomach aches, or headaches. The body prepares to deal with a threat: blood pressure and heart rate are increased, sweating is increased, blood flow to the major muscle groups is increased, and immune and digestive system functions are inhibited (the fight or flight response). External signs of anxiety may include pale skin, sweating, trembling, and pupillary dilation. Someone who has anxiety might also experience it as a sense of dread or panic. Although panic attacks are not experienced by every person who has anxiety, they are a common symptom. Panic attacks usually come without warning, and although the fear is generally irrational, the perception of danger is very real. A person experiencing a panic attack will often feel as if he or she is about to die or pass out.
Emotional effects may include feelings of apprehension or dread, difficulty concentrating, feeling tense or “on edge,” anticipating the worst, irritability, restlessness,  and/or  feeling like your mind's gone blank.
Cognitive effects of anxiety may include thoughts about suspected dangers, such as fear of dying. For example, you may fear that the chest pains [a physical symptom of anxiety] are a deadly heart attack or that the shooting pains in your head [another physical symptom of anxiety] are the result of a tumor or aneurysm. You may feel an intense fear when you think of dying, or you may think of it more often than normal, or can’t get it out of your mind.
Behavioral effects may include withdrawal from situations where unpleasant effects of anxiety have been experienced in the past. Behavior can also be affected in ways which include changes in sleeping patterns, nail biting and increased motor tension, such as foot tapping, etc.

There are several recognized types of anxiety disorders, including:

Panic disorder: People with this condition have feelings of terror that strike suddenly and repeatedly with no warning. Other symptoms of a panic attack include sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking, which may make the person feel like he or she is having a heart attack or "going crazy."
Obsessive-compulsive disorder (OCD): People with OCD are plagued by constant thoughts or fears that cause them to perform certain rituals or routines. The disturbing thoughts are called obsessions, and the rituals are called compulsions. An example is a person with an unreasonable fear of germs who constantly washes his or her hands.
Post-traumatic stress disorder (PTSD): PTSD is a condition that can develop following a traumatic and/or terrifying event, such as a sexual or physical assault, the unexpected death of a loved one, or a natural disaster. People with PTSD often have lasting and frightening thoughts and memories of the event, and tend to be emotionally numb.
Social anxiety disorder: Also called social phobia, social anxiety disorder involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others, or behaving in a way that might cause embarrassment or lead to ridicule.
Specific phobias: A specific phobia is an intense fear of a specific object or situation, such as snakes, heights, or flying. The level of fear usually is inappropriate to the situation and may cause the person to avoid common, everyday situations.
Generalized anxiety disorder: This disorder involves excessive, unrealistic worry and tension, even if there is little or nothing to provoke the anxiety.


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