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Department of Medical-Surgical Nursing, Sri Ramachandra Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai, India
Department of Medical Education, College of Medicine and Health Sciences, National University of Science and Technology, OmanDepartment of Microbiology, Melaka Manipal Medical College, Manipal Academy of Higher Education, Manipal, India
Corresponding author. Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India.
Affiliations
Department of Medical-Surgical Nursing, Manipal College of Nursing, Manipal Academy of Higher Education, Manipal, India
Pharmacologic methods to relieve stress can have side effects on the caregiver's health.
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Practicing yoga helps in reducing the caregiving burden and improving mental health.
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It is cost-effective management as it is a type of non-pharmacological treatment method.
Abstract
Introduction
Yoga is a type of practice with numerous benefits for health. This systematic review aimed to synthesize evidence on yoga therapy and determine its effects on caregiver stress and mental health among those who provide care for people with dementia.
Methods
The Cochrane methodological guidelines were adopted and reported using the PRISMA statement. MEDLINE, Cochrane Central, CINAHL, EMBASE, PROQUEST, Scopus, and Web of Science were among the seven online databases searched between January 2010 and October 2021 for randomized controlled trials. The risk of bias in the trials was evaluated using the Cochrane risk of bias tool. Meta-analysis was done using Revman software 5.4 version.
Results
Thirteen randomized controlled trials consisting of 522 research participants assessed the impact of yoga on caregiver stress, burden, mental health, and depression. A random effects model on the effect of yoga revealed that yoga is beneficial in caregiver stress reduction and enhancing the psychological well-being of caregivers of people with dementia with statistical significance (95%CI: 0.64–0.89, p < 0.05). It was statistically significant that caregiver stress was reduced among the caregivers of people living with dementia.
Discussion
The practice of yoga decreases caregiver stress with a positive impact on caregiver mental health. Additionally, yoga plays a vital role in bringing down caregiver burden and depression. However, considering the heterogeneity among the included studies, additional research with larger sample size and rigorous randomized controlled trials must be conducted to generate a higher quality of evidence.
Yoga is a holistic approach to health and an ancient practice that is classified as a form of complementary and alternative medicine in western culture.
Continuous yoga practice improves self-awareness, enables traits of affability, compassion, and self-control, enriches a sense of serenity and well-being, and enhances the sensation of strength to live fully with genuine happiness.
Its practice is linked with many health enhancements, including reduced risk of cardiovascular diseases, blood pressure control and body mass index, improved respiration, psychological well-being, pain management, and in the management of stress.
By boosting flexibility and muscular strength, yoga supports and improves respiratory and cardiovascular function, supports the treatment of addiction and recovery, reduces stress, anxiety, and depressive symptoms, enhances sleep quality, and generally improves well-being.
One important yogic practice is pranayama which is a Sanskrit name made up of the words “prana,” which refers to the breath of life or vital force, and “Ayama,” which denotes expansion, regulation, and control.
Practicing Pranayama regularly increases the expansion of the chest wall and other lung functions and utilizes abdominal and diaphragmatic muscles efficiently by improving the respiratory system.
While meditation lowers stress by balancing the hypothalamic-pituitary-adrenal axis, asana and pranayama enhance the passage of oxygenation to the cells and increase the amount of oxygen in the blood. The practice of asana, pranayama, and meditation are of crucial significance to an individual's health and lifestyle problems.
To combat stress, Dr. Jon Kabat-Zinn developed the Mindfulness-Based Stress Reduction (MBSR) program in 1979 which is a highly developed psycho-educational and skill-based treatment program that combines hatha yoga and mindfulness meditation.
It is employed for individuals with various chronic illnesses such as depression, anxiety, skin and immune disorders, chronic pain, cancer, diabetes mellitus, hypertension, and those looking to improve coping and reduce stress.
A yoga-based intervention could increase a caregiver's mental health by reducing caregiver stress, burden, and depression. Mixed effects on the interventions were noted. There were no reports of significant adverse effects.
As yogic practice improves well-being by lowering stress and boosting mental health, it can be used as a diversion for those who care for persons with severe mental illnesses.
Yoga is effective at reducing stress in those who care for people with schizophrenia, as evidenced by considerable improvements in overall quality of life and total psychological distress' mental health component score.
Dementia is a condition normally chronic and progressive, where there is a decline in cognitive function beyond the anticipation of the usual effect of normal aging. It is a significant contributor to older dependency and incapacity, and it has negative physical, psychological, social, and economic repercussions for those who care for them, their families, and society as a whole.
Memory, learning ability, reasoning, direction, learning capacity, judgment, behaviour, and daily living tasks are just a few of the areas of the brain that are affected due to dementia.
Hence, people suffering from dementia require comprehensive care based on the stage of dementia. The majority of them are taken care of at home by their family or relatives.
Caregiver stress is an unrecognized and untreated health risk resulting in bad consequences for both caregivers and individuals with dementia, including increased morbidity and mortality rates.
Caregivers of people with dementia tend to sacrifice their leisure time and hobbies. They frequently lack social interaction and support, which leaves them feeling lonely.
Hence, the caregivers are often at high risk for various health problems especially poor immunity, cardiovascular problems, chronic conditions such as diabetes, hypertension, anaemia, arthritis, etc.
Mindfulness training for psychological stress in family caregivers of persons with dementia: a systematic review and meta-analysis of randomized controlled trials.
Caregiving for someone with dementia puts a strain on the caregivers, which can lead to a higher level of stress, depression, and health problems for both carers as well as care recipients.
Numerous studies are being conducted using different approaches to reduce caregiver strain and burden and enhance the quality of life for people taking care of dementia patients.
Effectiveness of educational interventions for informal caregivers of individuals with dementia residing in the community: systematic review and meta‐analysis of randomized controlled trials.
Effectiveness of a psychoeducational intervention for caregivers of people with dementia with regard to burden, anxiety, and depression: a systematic review.
Holistic health practices encourage people to consider all aspects of their health, including their physical, emotional, spiritual, intellectual, and mental well-being. Implementation of holistic nursing practices such as yoga helps to improve an individual's quality of life. Health professionals such as doctors, nurses, and counsellors can teach yoga techniques to the caregivers of people living with dementia to enhance their well-being.
1.1 Rationale
Numerous systematic reviews and meta-analyses have examined the effectiveness of interventions like MBSR, educational interventions, support groups, psychoeducational interventions, etc. in reducing caregiver burden among dementia carers to date.
Effectiveness of educational interventions for informal caregivers of individuals with dementia residing in the community: systematic review and meta‐analysis of randomized controlled trials.
Effectiveness of a psychoeducational intervention for caregivers of people with dementia with regard to burden, anxiety, and depression: a systematic review.
It is still challenging to draw firm results on yoga's efficiency in lowering caregiver stress and enhancing the quality of life. Most of the earlier published reviews comprised heterogeneous interventions and examined the effectiveness of physical exercise, occupation therapy, kirtan kriya yoga, mindfulness meditation, etc.
Trials are being done to determine whether yoga is useful for helping dementia caregivers. However, there is no evidence of systematic reviews being published in this field, and this is the first systematic review to examine the impact of yoga therapy on those who care for dementia patients. The evidence compiled here could provide insight for future clinical trials and research projects. It is crucial to collect evidence on the effect of yoga treatments on caregiver stress and quality of life.
1.2 Objective
To synthesize evidence on yoga therapy and determine its effects on caregiver stress and mental health among those who provide care for people with dementia.
2. Methods
Utilizing the Cochrane Handbook for Systematic Reviews of Interventions, this systematic review and meta-analysis were conducted. It was then described following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.
in: Higgins J.P.T. Thomas J. Chandler J. Cochrane Handbook for Systematic Reviews of Interventions. second ed. Wiley-Blackwell,
Chichester UK2019: 205-228
The study's eligibility criteria were: (a) Types of participants: participants were caregivers of individuals living with dementia; (b) Types of interventions: interventions that include yoga in any form to reduce caregiver stress and enhance caregiver wellbeing; (c) Types of comparators: comparators with no intervention or intervention other than yoga; (d) Types of outcomes: primary outcomes were: caregiver stress, caregiver mental health, caregiver burden, and caregiver depression; secondary outcomes were (1) heart rate; (2) blood pressure; (3) sleep quality; (4) self-efficacy; (5) quality of life.
The studies were excluded if the RCTs included a dyadic group (i.e., caregivers and people living with dementia), study subjects utilizing numerous programs simultaneously, research studies with an unclear explanation of intervention contents, or feasibility studies were also excluded.
2.1.1 Information sources
To identify all the potential research studies, a rigorous search method was formulated using the keywords associated with PICO (Population or patient, Intervention, control/comparator, and Outcomes). The following are the search terms combined to recognize the related studies: yoga, asana, pranayama, yogic practices, meditation, mindfulness meditation, effects, dementia, caregivers, Alzheimer's, caregiver burden, and quality of life. The databases were explored independently by the two authors for the qualified studies published between January 2010 - October 2021 which included the MEDLINE, Cochrane library, CINAHL, EMBASE, PROQUEST, Scopus, and Web of Science. Based on the inclusion criteria, references from pertinent studies were manually searched by limiting the language to English exclusively.
2.1.2 Search strategy
((((dementia OR Alzheimer's OR Alzheimer's disease OR cognitive impairment OR cognitive decline OR memory loss OR mild cognitive impairment OR people with dementia OR dementia patients) AND (Caregiver OR Caregivers OR Care giver OR Family OR Family caregiver OR Family caregivers OR Carer OR Carers OR Spouse caregiver OR Spouse care giver OR Relatives OR Informal caregivers OR dementia carers OR dementia caregivers)) AND (Yoga OR Yoga therapy OR Yoga exercise OR Yoga asana OR Yoga asanas OR Pranayama OR Asana OR Meditation OR Mindfulness meditation OR Yogic practices)) AND (Caregiver burden OR Caregiver stress OR Caregiver fatigue OR Caregiver burnout OR Caregiver strain OR Caregiver role strain OR Family burden OR Family stress OR Quality of life OR Well being OR Well-being OR Health-related quality of life OR Life satisfaction OR QOL OR Lived experience OR Satisfaction OR Caregiver satisfaction OR Caregiver wellbeing OR Caregiver well being OR Caregiver well-being)) AND (Randomized controlled trial OR Randomized controlled trial OR Clinical trial OR Clinical trials OR Controlled clinical trials).
2.1.3 Selection process
One reviewer executed a search from each electronic database, scrutinized titles, and abstracts for their eligibility, and retrieved the studies that achieved the pre-established eligibility criteria and involved only those research studies that were published in the electronic databases. In addition, the reviewer also cross-referenced other studies that evaluated the effectiveness of yogic practices.
2.1.4 Data collection process
By using a standard data extraction form, two independent reviewers were able to obtain the study's data. This data extraction form included details of the study (year, authors, and country), features of intervention (type of yoga, methods, duration, frequency, mode), control, outcome measurements (key outcome variables and instruments used to measure them), duration of follow up and engagement evaluation. For any vital information regarding the study that was left out, the original author(s) of the study were contacted. The data was then checked for accuracy and inconsistencies. Any discrepancy between the two researchers was settled by a third reviewer through discussion or agreement.
After removing duplicates, two reviewers separately looked at the titles and abstracts to assess whether the research was eligible. Both researchers further obtained and read through the entire text of research studies that any of them believed would be relevant. Additional discussion was held to clarify any disagreements or ambiguity regarding the inclusion of trials. If an agreement could not be reached, disputes were settled by a senior reviewer in the team.
Using the Cochrane Collaboration risk of bias tool, two independent authors assessed the quality of the included trials.
Following that, each study trial was rated according to the Cochrane Handbook for Systematic Reviews of Interventions as having a high, unclear, or low risk of bias. The study's quality was assessed separately by two reviewers, and any disagreements were settled with the help of a senior reviewer (Fig. 2).
2.2 Data items
The primary outcomes were (i) caregiver stress; (ii) caregiver mental health; (iii) caregiver burden; (iv) caregiver depression.
The secondary outcomes were heart rate, systolic blood pressure, diastolic blood pressure, sleep quality, quality of life, serum cortisol, fatigue, life satisfaction, and self-efficacy.
2.3 Study risk of bias assessment
The risk of bias in the trials was evaluated using the Cochrane risk of bias tool. Fig. 2 & Fig. 3 explains the risk of bias evaluation.
2.3.1 Effect measures
The effect of each outcome measure(s) (e.g., risk ratio, mean difference) used in the synthesis or presentation of results is explained in the results section.
2.4 Synthesis methods
To summarise the effect of yoga on caregiver outcomes, meta-analyses were conducted by using Review Manager 5.4 by the statistical principles specified in the Cochrane Handbook for Systematic Reviews of Interventions. When doing the meta-analysis, a random effects model was adopted because the studies used various scales. To determine the difference between continuous outcomes evaluated using the same scale and other scales, the standardized mean difference (SMD) was determined.
The statistical significance of heterogeneity was determined by the Q test with a p-value of >0.10, which was used to calculate heterogeneity. Following that, the level of heterogeneity was determined using the I2 statistics. If heterogeneity was significant, statistical pooling was done using a random effects model (p-value of Q test > -0.10 and I2<50%).
When quantitative synthesis was inappropriate, narrative synthesis was executed. To deliver the strength and quality of the evidence and outcome measurements, the GRADE approach guidelines and recommendations were implemented.
Table 3 describes the summary of evidence synthesis. Overall, the estimated primary outcomes had low-quality evidence because the risks of bias were unclear, there was significant heterogeneity, and inconsistent data. No higher quality evidence on the primary outcome caregiver burden was noted (Table 3).
2.4.1 Reporting bias assessment
Bias in reporting is mentioned in the results section.
3. Results
3.1 Study selection
The PRISMA flow graphic illustrates the wide search approach (Fig. 1). A preliminary pool of 150 trials was found, and 132 further records were examined for eligibility. After reviewing a total of 13 trials, nine research, totalling 323 participants, were comprised in the meta-analysis. Table 1 provides a summary of all the pertinent information about the included research. Each included study had a sample size ranging from 9 to 145. The participants' ages ranged from 34 to 66.12 years old with an average of 57.01 years. The length of the intervention ranged from three weeks to twelve weeks. Among the 13 studies, one study used multi-center RCT.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
IG: Yoga & compassion meditation CG: No intervention
1 h 15 min per week for 3 weeks
Quality of life
WHO-QOL-BREF
NR
A significant increase in quality of life (p < 0.05)
*IG- Intervention group, CG-Control group, MBSR – Mindfulness Based Stress Reduction, MBCT-Mindfulness-based cognitive therapy, NR- Not recorded, QOL-Quality of life.
All included studies were carried out in various nations, with the USA accounting for the majority of them (n = 7). These are the countries where studies have been carried out.: USA (7),
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
did not blind the study participants or research team. Due to the lack of implementation of outcome blinding among outcome assessors, five (38.46%) trials were evaluated to have a low risk of detection bias.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
All included studies were carried out in various nations, with the USA accounting for the majority of them (n = 7). These are the countries where studies have been carried out.: USA (7),
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.
The use of modified mindfulness-based stress reduction and mindfulness-based cognitive therapy program for family caregivers of people living with dementia: a feasibility study.
Meditation program enhances self-efficacy and resilience of home-based caregivers of older adults with Alzheimer's: a five-year follow-up study in two South Asian cities.
Transcendental Meditation for the improvement of health and wellbeing in community-dwelling dementia caregivers [TRANSCENDENT]: a randomised wait-list controlled trial.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
A considerable reduction in caregiver stress, statistically (SMD, −0.13%; 95% CI; −0.51 to −0.23; p = 0.38; I2 = 3%) was seen in favour of the intervention group in the meta-analysis utilizing the random effects model (Fig. 4).
Using a random effects model to analyze pooled data, it was found that the intervention group's mental health scores had improved statistically significantly (SMD, 0.06%; 95% CI; 0.12 to 0.65; p = 0.07; I2 = 50%) (Fig. 5).
The analysis of the random effects model revealed that the caregiver burden was statistically significantly lower in the intervention group. (SMD, −1.07%; 95% CI; 0.05 to −0.23; p < 0.00001; I2 = 98%) (Fig. 6).
When the random effects model was examined, it was found that the intervention group saw a statistically significant reduction in depression. (SMD, −0.33%; 95% CI; −0.27 to −0.65; p = 0.54; I2 = 0%) (Fig. 7).
The secondary outcomes in this study were comprised of heart rate, anger, confusion, fatigue, cognition, medical burden, anxiety, diurnal cortisol level, life satisfaction, and self-efficacy. To evaluate the impact of yoga treatment on secondary outcomes, a narrative synthesis was conducted. Five of the 13 trials examined the impact of yoga therapy on ancillary results.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
HR: Heart rate, SBP: Systolic blood pressure, DBP: Diastolic blood pressure, SQ: Sleep quality, QOL: Quality of life, ↑: Significant increase in the scores, ↓: Significant decrease in the scores, = : Not included as a study outcome in the analyzed trials.
The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardized mean difference.
(95% CI)
Relative effect (95% CI)
№ of participants (studies)
Certainty of the evidence (GRADE)
Comments
Risk with [Stress]
Risk with [Yogic Practices]
Caregiver Stress
–
SMD 0.13 lower (0.42 lower to 0.16 higher)
–
189 (4 RCTs)
⨁⨁◯◯ Low
Mental Health Functioning
–
SMD 0.13 higher (0.12 lower to 0.39 higher)
–
192 (4 RCTs)
⨁⨁◯◯ Low
Caregiver Burden
–
SMD 0.96 lower (1.23 lower to 0.69 lower)
–
323 (5 RCTs)
⨁⨁◯◯ Low
Caregiver Depression
–
SMD 0.33 lower (0.57 lower to 0.08 lower)
–
267 (7 RCTs)
⨁⨁⨁⨁ High
GRADE Working Group grades of evidence.
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
a The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: confidence interval; SMD: standardized mean difference.
Asymmetry in funnel plots suggests that the included research may have publication bias. This could be due to the study effect sizes and the level of heterogeneity. These indications imply that there is evidence of publication bias.
4. Discussion
Dementia is prevalent among older adults and is associated with frequent episodes of memory loss. The person with dementia may not be able to carry out everyday tasks at the advanced stage, may need to be continually watched, and may need full-time care. This will result in increased stress and burden in giving care affecting the caregiver's mental health and leading to depression. Numerous research has shown that yoga is beneficial for improving quality of life and reducing burden, stress, and depression. The effectiveness of yoga therapy as a caregiver intervention for those with dementia was examined in this current study using meta-analysis.
In this systematic review, we sought to determine whether yoga therapy may enhance caregivers’ mental health by lowering stress, burden, and depression. An extensive systematic review of studies published from January 2021 to October 2021 was carried out to analyze the current evidence regarding the effect of yoga therapy on caregiver outcomes among caregivers of people living with dementia. The RCTs that were used in this meta-analysis were conducted in both middle-income and high-income nations.
A total of 13 randomized controlled trials were included and reviewed, of which nine were used in the meta-analysis and four trials were used in the narrative synthesis. According to this meta-analysis, yoga therapy benefits caregivers of people with dementia by enhancing their mental health and by reducing caregiver stress, burden, and depression. Among the four studies included in narrative synthesis, one single study concluded that yoga therapy improves life satisfaction and self-efficacy,
Effects of integrated yoga intervention on psychopathologies and sleep quality among professional caregivers of older adults with Alzheimer's disease: a controlled pilot study.
Yoga and compassion meditation program improves the quality of life and self‐compassion in family caregivers of Alzheimer's disease patients: a randomized controlled trial.
None of the 13 research found any negative effects of yoga therapy on those who care for dementia patients.
This meta-analysis demonstrates that there is evidence of yoga therapy as an intervention is effective in helping caregivers reduce stress, burden, and depression while also enhancing their mental health. The findings provide preliminary support for healthcare professionals such as nurses, physicians, yoga therapists, counsellors, etc to integrate the practice of yoga therapy in reducing stress, burden, and depression among the caregivers and also to improve their mental health and well-being. Table 1 provides an overview of all the included trials, their results, measurements, and conclusions.
One RCT's results were in agreement with the findings about the impact of yoga therapy on the people who care for those with dementia.
, which concludes that yoga is most efficacious in bringing down the symptoms of anxiety, depression, and pain. To generate further evidence for yoga therapy interventions in developing countries, additional studies are required. A meta-analysis reported that yoga is beneficial in improving muscle strength, balance, and flexibility among the elderly and hence yoga should continue as an activity that enhances physical and mental well-being among older adults.
Dementia is a condition that affects people in their old age who are taken care of by either spouses or children who are in their mid-life. As a result, the study suggests that it will be helpful to those who care for people with dementia.
Among the 13 reviewed trials, the majority were conducted in developed countries like USA, and Australia, and hence, results from these studies cannot be directly applied in developing nations like India or other Asian countries as socio-cultural and economic factors may affect the recipient's reaction to the given interventions. Some of the included trials were pilot studies, so, high-quality randomized controlled trials with a larger sample size are necessary to build solid evidence for yoga therapy as an intervention to reduce caregiver stress, caregiver burden, and caregiver depression, as well as to enhance caregiver mental health in developing nations.
The effects of meditation on perceived stress and related indices of psychological status and sympathetic activation in persons with Alzheimer's disease and their caregivers: a pilot study.
There are a few limitations in this systematic review that should be considered while explicating the results. The quality of the evidence was lesser due to the unclear risk of bias, inconsistency, and high heterogeneity among the included studies. The meta-analysis only included a small number of good qualities RCTs. The strength of this systematic review is that this is the first systematic review to examine the impact of yoga therapy on those who care for people with dementia.
4.2 Implications for practice, policy, and future research
The findings of this meta-analysis and systematic review demonstrate that yoga intervention can improve the well-being of people who care for dementia patients. However, given the heterogeneity and the paucity of research that has scrutinized the impact of yoga therapy on carers' stress, to provide a solid scientific basis for the use of yoga among caregivers of people with dementia, higher-quality studies with larger sample sizes are necessary.
Registration and protocol
This systematic review protocol is registered with PROSPERO and the registration number is CRD42020212566.
Funding support
This systematic review did not receive any source of funding from any funding agency.
Availability of data, code, and other materials
No data is available in public domain.
Funding
This systematic review is not funded by any funding agency.
Registration
This review is registered with PROSPERO with registration number CRD42020212566.
CRediT authorship contribution statement
Clarita Shynal Martis: Data curation, Formal Analysis, Data collection, writing the original draft. Elsa Sanatombi Devi: Methodology Supervision, writing – original draft, supervision. Ramesh Chandrababu: Conceptualization, Supervision, writing – original draft. Rajeshkrishna Bhandary: Data Curation, Supervision. Ravishankar N: formal analysis. Ciraj Ali Mohammad: Writing – Review and editing. Debbie Tolson: Visualization, Methodology, Supervision.
Declaration of competing interest
The authors declare there are no conflicts of interest.
Acknowledgement
Ms Clarita Shynal Martis, would like to acknowledge Manipal Academy of Higher Education, Manipal College of Nursing for giving the access to library resources to accomplish this review.
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