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 Table of Contents  
REVIEW ARTICLE
Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 38-47

Evidence-based yoga and ayurveda lifestyle practices for the geriatric population during Coronavirus Disease 2019 pandemic: A narrative


1 Department of General Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Kayachikitsa, Sri Sri College of Ayurvedic Science and Research Hospital, Bengaluru, Karnataka, India
3 Department of Pediatrics, Vir Chandra Singh Garhwali Government Institute of Medical Science and Research, Srinagar, Uttarakhand, India

Date of Submission14-Mar-2021
Date of Decision11-Apr-2021
Date of Acceptance05-May-2021
Date of Web Publication09-Jun-2021

Correspondence Address:
Dr. Monika Pathania
Department of General Medicine, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jopcs.jopcs_4_21

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  Abstract 


Coronavirus disease 2019 has had a devastating impact on global health-care systems and the economy. Scientists and medical professionals worldwide are striving to provide for vaccine cures, while the deadly virus continuously mutates and thrives. Immunity being directly co-related to multiple factors such as diet, sleep, lifestyle, and stress; elderly people are at high risk due to factors such as immunosenescence, weakened metabolism, micro-nutrient deficiency, immobility, chronic stress, and comorbidities. The elderly has had the highest morbidity and mortality rates during the pandemic and is the most neglected in general. Holistic and integrative approaches need to be researched for finding safe and risk-free ways that may help counter immune suppression and prevent the vulnerable from getting infected. Yoga and Ayurveda have shown promising results in this regard, although among populations varying in age and health status. However, good-quality clinical trials are needed to strengthen the evidence of yoga for geriatric immunity as online databases of PubMed, Cochrane Library, and Embase showed a paucity of studies when searched for related keywords. Similarly, several aspects of Ayurveda, especially Ahara/food, have vast yet unexplored applications in immune strengthening and developing physical and mental resilience. Primary care physicians can utilize these time-tested techniques as lifestyle modifications along with the standard pharmacological treatment for fulfilling the health-care needs of their patients, especially for the vulnerable elderly, which is the pressing need during this pandemic.

Keywords: Ayurveda, coronavirus disease 2019, geriatrics, immunity, lifestyle, yoga


How to cite this article:
Bhardwaj P, Pathania N, Pathania M, Rathaur VK. Evidence-based yoga and ayurveda lifestyle practices for the geriatric population during Coronavirus Disease 2019 pandemic: A narrative. J Prim Care Spec 2021;2:38-47

How to cite this URL:
Bhardwaj P, Pathania N, Pathania M, Rathaur VK. Evidence-based yoga and ayurveda lifestyle practices for the geriatric population during Coronavirus Disease 2019 pandemic: A narrative. J Prim Care Spec [serial online] 2021 [cited 2021 Aug 5];2:38-47. Available from: http://www.jpcs.com/text.asp?2021/2/2/38/317999




  Introduction Top


Older adults are at high risk of getting infected with coronavirus disease 2019 (COVID-19). Yoga, in adjunct to Ayurveda, is a safe and risk-free way of living that has shown promising results for boosting immunity. This narrative review throws light on the health benefits of yoga practices suitable for the elderly while strengthening the evidence base available on the internet. Dietary recommendations, lifestyle habits, medicinal plants and herbal formulations, useful for strengthening the immune system and building overall strength and resilience of the elderly as per classical texts of Ayurveda, have also been mentioned.


  Methodology Top


Online databases of PubMed, Cochrane Library, and Embase were searched for clinical trials having a yoga and meditation-based intervention for populations >60 years of age and assessing parameters of immunity or inflammation conducted in the past 10 years using keywords yoga, meditation, pranayama, mindfulness, elderly, old age, geriatrics, and immunity, used interchangeably with Boolean operators “AND” and “OR.” After applying the eligibility criteria to the search results, hardly any studies were left for review. Subsequently, an internationally recognized systematic yoga manual[1] was referred to for identifying easy to do Yoga practices that are safe for senior citizens, while backing up the evidence base on good quality studies on well-known yoga and meditation techniques. This being a narrative review, any institutional and/or ethical permissions were not required.


  Old-Age, Health and Immunity Top


Old age exposes one to a wide array of health-related complications and may bring upon grave physical and mental health challenges.[2] Moreover, the immune system gets weakened with age, which is normally referred to as “Immunosenescence.”[3] With weakened adaptive immunity due to reduction in both counts and potency of naïve T- and B-cells, along with an increase in nonspecific innate immunity, elderly people are more prone to chronic tissue inflammation, developing autoimmune disorders and cancers, and catching immune-related infections such as COVID-19.[4]

A wholesome diet rich in essential micronutrients and full of fresh fruits, vegetables, nuts and grains is essential to strengthen and maintain immunity for combating COVID-19.[5],[6] Micro-nutrient deficiencies (esp. for Vitamin B12, D, and Calcium) are common among the elderly due to impaired digestion and lack of exposure to sunlight.[7] Regular moderate exercise affects every individual differently and acts as a promoter of immunity.[8] However, there is a lacuna of evidence for its efficacy in reducing the frequency of infectious diseases.[3] Elders are prone to stress, anxiety, and depression due to factors such as loneliness/isolation, lack of purpose, and loss of independence.[9] Stress deregulates many components of innate and adaptive immunity among older adults,[9] resulting in poor response to vaccines, improper control of latent viruses, hyperproduction of inflammatory markers, and rapid cellular ageing.[10]


  The Pandemic and Risk for Elderly Top


The COVID-19 spread has one phenomenon in common globally, i.e., older adults and those with chronic health conditions are the most affected and make up a majority of the total COVID-19-related deaths.[11],[12],[13],[14] Moreover, the course of disease tends to be much severe and difficult for older adults in comparison to young and healthy individuals.[13] The presence of chronic diseases and comorbidities in seniors, low levels of immunity and body reserves, makes them vulnerable to getting infected.[15],[16],[17] Scientists mapping the course of patient recovery suggest that a robust immune response across different cell types is associated with clinical recovery in an otherwise healthy person affected with mild-to-moderate symptoms of COVID-19, something similar to what is seen in patients of influenza and earlier in patients of severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS).[18],[19] Considering that elderly people lack both good health and strong immunity essential to fight viral infections,[20] there is a dire need to search for holistic therapeutic interventions and to develop targeted therapies to combat this deadly virus that affects the geriatric populations most.


  How Can Yoga Help? Top


Although originally intended as preparatory practices for Meditation, Self-Mastery, and God-Realization, Yoga asana and pranayama are a great way to be physically fit and healthy. Airway maneuvers, posture correction, breathing exercises, stretching, and physical activity, etc., are suggested to aid the rehabilitation of COVID-19 patients.[21] Yoga holds the potential for the prevention and complementary treatment of inflammation-associated diseases by down-regulating pro-inflammatory markers and by optimizing immune function (previously impaired due to stress).[22] Yoga might help to reduce the symptoms of distress and improve cellular immunity and functional performance in patients with chronic diseases.[16] Evidence suggests that regular Yoga practice can have manifold benefits for the health of older adults on their physical, mental, emotional, social, and vital planes.[23],[24] Yoga, as a conjunct to standard treatment, has benefitted patients of communicable diseases such as flu,[25],[26] tuberculosis,[27] and human immunodeficiency virus (HIV) infection[28],[29],[30] all of which involve the immune system status playing a vital role in disease progression.

Like SARS and MERS, the COVID-19 patients show a rise in the Cytokine levels Interleukin-6 (IL-6), IL-10, tumor necrosis factor-alpha (TNF-α), lymphocytopenia (in CD4+ and CD8+ T-cells), and decreased interferon-gamma expression in CD4+ T-cells.[31],[32] Yoga helps in diseases involving a chronic inflammatory state[22] and has shown reductions in stress markers plasma Cortisol[33],[34] and b-endorphin[26] and inflammatory markers Interleukin IL-1a,[27] IL-6,[26],[27],[28] TNF-a,[33],[34],[35] erythrocyte sedimentation rate (ESR),[35] C-reactive protein,[35] and anti-cyclic citrunillated peptide.[35] This makes yoga and other mind body-based interventions worth investigating, as a preventive measure and as an adjunct to the treatment of COVID-19, which is trending nowadays in alternative and complementary medicine research these days.[36],[37],[38] [Table 1] depicts the evidence base from research studies conducted among various populations, assessing change in levels of immune markers, stress markers, and inflammatory markers before and after yoga interventions.
Table 1: Evidence base for yoga/meditation and mindfulness

Click here to view



  Asana for Seniors Top


Asana practices have been proven as time-tested ways to achieve robust health among people of all ages coming from all walks of life. Many of the hatha yoga techniques are simple and easy to learn and practice, are not strenuous, are physically relaxing, and can be done in a self-paced manner, indoors at home, justifying the term asana in its literal form, i.e., “Sthiram Sukham Asanam” (Patanjali Yoga Sutras [PYS] 2.46) meaning what is stable and comfortable is asana. A famous set of yoga asana known as Pawanmuktasana series-one (Anti-Rheumatic Group of Asana/PM-1)[48] has been described as suitable for seniors. These should be practiced slowly and gracefully with full awareness of the bones, joints, ligament, and muscles involved in the movement in coordination with the flow of breath.[49] These activate the body and the mind and help develop focus, objectivity, and a witnessing attitude.[50] The PM-1 is recommended for people having rheumatism, arthritis, high blood pressure, and heart problems.[48] These easy to do asana have been shown to significantly increase flexibility and strength of the muscles of the abdomen and back[51] and significantly reduce ESR and rheumatoid factor levels and improve the physical and mental well-being of rheumatoid arthritis patients.[35],[52] Regular practice of PM-1 might help maintain muscle tone, strengthen the joints, counter/prevent chronic inflammation responsible for immobility, arthralgia and arthritis, making it a contemporary way, if not an alternative to an active lifestyle for the elderly. More details are as per [Table 2].
Table 2: Asana for the Elderly (Pawanmuktasana-One Series)

Click here to view



  Pranayama for Seniors Top


Pranayama plays an immense role in Yoga practice. As per the yogic text of Hatha Yoga Pradipika, when Prana (breath) is disturbed, the mind gets disturbed, therefore by restraining or controlling Prana, the Yogi gets steadiness of mind.[53] Pranayama can act as an effective intervention that can be included by people of all ages in their daily regimen due to its simplicity and cost-effectiveness.[30] Consistent Pranayama practice has been shown to improve respiratory/ventilatory functions[54],[55],[56],[57] and improve cardiorespiratory strength,[58] cardiac sympathovagal balance[51] and increase parasympathetic activity.[58] Pranayama practices such as Bhastrika, Kapalbhati, Ujjayi, Naadi Shodhana, and Bhrahmari[59] are suitable for older adults and their regular practice might help achieve good health and resilience while boosting host immunity. [Table 3] provides further details in this regard.
Table 3: Pranayama for the elderly

Click here to view


Sudarshan Kriya Yoga (SKY) is one popular breathing technique, notable for its mental and physical health benefits, and involves three-stage Ujjayi Pranayama, Bhastrika Pranayama, Om chanting, and rhythmic breathing. Regular practice of SKY has shown significant reductions in counts of neutrophils and platelets (as markers of stress),[46] downregulation of oxidative stress markers like blood lactate and plasma malondialdehyde, a significant increase in the levels of antioxidants such as glutathione peroxidase, superoxide dismutase[60] and catalase,[61] and natural-killer (NK) cell counts,[47] suggesting SKY as a potential tool for preventing many serious diseases[62] and effective in promoting overall health and wellness.[63] SKY practice is hypothesized to stimulate the Vagus nerve by harmonizing the HPA axis and related psycho-neuro-endo-immunological pathways while balancing the sympathetic and parasympathetic activity of the central nervous system.[64] Regular SKY practice might be useful in improving cardiovascular health by significantly increasing cardiac autonomic tone, cardiorespiratory coupling, and inducing psychophysiological relaxation.[65],[66] SKY practice is speculated to benefit host immunity at a molecular level by significantly improving the expression of AVIL gene and nuclear factor erythroid 2 gene, which are associated with increased cytotoxicity of the NK cells and benefiting platelet production and megakaryocyte maturation respectively.[67] SKY increases antioxidant status at the RNA level and enzyme activity, thus enhancing immune status by upregulating antiapoptotic genes and prosurvival genes and further prolonging lymphocyte lifespan.[60]


  Meditation Practices for Seniors Top


Dhyana (Meditation), the seventh limb of sage Patanjali's Ashtanga Yoga (the eightfold path of yoga) is described as an uninterrupted connection between the mind and the object of meditation (PYS: 3.2), which is preceded by Dharana, i.e., confining the mind to a chosen region/space/object of focus (whether inside or outside the physical body) (PYS: 3.1).[69] Several new meditation techniques have evolved over the years, revolving around this central concept. Transcendental Meditation (TM) has been researched extensively, producing robust evidence for its effects on psychiatric disorders.[70] TM practitioners have been shown to have higher levels of CD3+ CD4-CD8+ lymphocytes, B-lymphocytes, and NK cells.[39] Similarly, Mindfulness-based stress reduction (MBSR) has been used for coping up with varied physical and mental health issues[71] and day-to-day stress.[72] MBSR practice shows a significant increase in NK cell count[40] and activity[40],[41] and cytokine levels,[41] increased insulin growth factor-1 levels, and reduced Immunoglobulin-M and Immunoglobulin-G response.[42] Similarly, Mindfulness Awareness Practices showed significant reductions in pro-inflammatory gene expression and perceived stress.[45]

COVID-19 infection induces an intense and widespread inflammatory response known as “Cytokine Storm”[31],[32] that causes massive tissue damage further leading to acute respiratory distress syndrome, pulmonic aspiration, septic shock, and death.[73] Meditating regularly has been shown to significantly improve vagal tone,[74],[75] besides showing improvements in inflammatory markers, cell-mediated immunity, and biological aging,[76] suggesting it to be a potent preventive measure and an effective adjunct for treating inflammatory-based diseases[22],[37] and COVID-19.[37]

It is worth mentioning that SKY practice also leads to a meditative state of mind, in addition to the multiple benefits from the breath work, thus serving a dual purpose. A recent comparative study shows that participants in the SKY group improved the most on mental health outcomes when compared to MBSR and Foundations of Emotional Intelligence.[77] SKY is available through online medium and has helped uplift the mental, physical and social health of people from all walks of life during lockdowns.[63]


  Ayurveda's Dietary and Lifestyle Recommendations Top


Human life comes across the three main stages, namely balya avastha (16–30 years), madhyavastha (30–60 years), and jeerana avastha (>60 years). The description of the jeerna avastha is given as where shareera dhatus (body tissues), indriya (sense organs), bala (strength), grahana shakti (retention), smarana shakti (recollection), vachana shamata (speech), and vigyan shamata (understanding) gradually degenerate (Charaka Samhita: Vimana Sthana 8/112)[78] all due to the predominance of vata dosha.

To restore health, Trayo-upasthambha or the three important pillars of health need to be strengthened, which include ahara (food), nidra (sleep) and brahmacharya (abstinence) (Charaka Samhita: Sutra Sthana-11/34).[78] Acharaya Charaka has described ahara as one which is the vital force for all living beings constituting varna (color), gandha (smell), rasa (taste) which is according to the liking of the person. Food acts as a fuel for the agni (metabolic fire), improves the sattva (positive state of mind), assimilates various dhatus of the body and provides strength, color and nourishment to the sense organs (Charaka Samhita: Sutra Sthana 27/3)[78] when consumed as per Ahara vidhi vishesha aayatanaani, i.e., special guidelines regarding food (Charaka Samhita: Sutra Sthana 1/22).[78] Following are Ayurveda'a dietary recommendations in line with the modern perspective of nutrition:

  • Shashtika/Rakta shali (red rice) which has a red bran layer is considered the best among cereals. Its color varies from light to dark red and is rich in polyphenols and anthocyanin, possessing antioxidant properties, with two to three times higher zinc and iron contents than white rice[79]
  • Millets such as Yava (barley), Raagi (finger millet), Jowar (sorghum), and Bajra (pearl millet) should be consumed regularly for they are superior to wheat and rice in terms of carbohydrate and energy levels[80] and are a great source of protein high dietary fiber, vitamins, minerals, antioxidants, and micro-nutrients[81]
  • Ksheera (milk) obtained from indigenous cows is considered to be jivaniya (restorative) and rasayana (regenerative) and should form an integral part of an elderly person's daily diet. (Ashtanga Hhridaya of Vaghbhatta: Sutra Sthana 5/42)[82]
  • Regular use of ghrita (clarified butter) is indicated to achieve dhi (intellect), smriti (memory), medha (discriminative ability), bala (strength), ayu (longevity), shukra (virility), and chakshu (vision) (Ashtanga Hhridaya of Vaghbhatta: Sutra Sthana 5/52)[82]
  • Mudga (green gram), Saindhava lavana (rock salt), Madhu (honey), and Amalaki (Emblica Officinalis) should also be consumed regularly
  • Rasayana (Rejuvenating foods) such as Chyavanprasha and Medhya Rasayana:
  • Antioxidant-rich foods are essential for boosting immunity and fighting COVID-19.[83] Chyavanprasha is composed of many medicinal plants and herbs, of which Amlaki (Phyllanthus Emblica), a rich source of Vitamin C and antioxidants, is the main ingredient. Its regular intake helps strengthen the tracheal bronchial tree, improves respiratory functions,[84] digestion and metabolism
  • The use of Medhya Rasayana which comes under the umbrella of nootropic drugs like Mandukaparni (Centella asiatica Linn.), Yastimadhu (Glycirrhiza glabra Linn.), Guduchi (Tinospora cordifolia (Wild) Miers), and Shankhapushpi (Convovulus pleuricaulis Chois) and has memory-enhancing, antidepressant, anti-stress, and anxiolytic qualities, might be helpful for senile memory impairment.[85]


Other than diet, the following lifestyle changes may also benefit the elderly:

  • Waking up at brahmo-muhuruta boosts the immune system due to the abundant availability of nascent oxygen in the pre-dawn which easily combines with hemoglobin making oxy-hemoglobin accessible to distant tissues[86]
  • Regular abhyanga (massage) with vatahara taila strengthens and stabilizes the bodily structure. It increases blood circulation, affects the lymphatic system, supplies nourishment to the blood and skin, and soothes the nervous system[87]
  • Nasya, i.e., applying oil in the nostrils,[88] either medicated oils formulated from ghrita (clarified butter) or natural oils obtained from plants such as sesame or coconuts, might protect the respiratory tract from pathogen entry.[89],[90]



  Conclusions Top


Immunity gets worse affected by lack of nutrition, lack of physical activity, chronic mental and emotional stress, and presence of comorbidities. All these, in addition to Immunosenescence, can create havoc for the elderly, making it important to address these to achieve good health and strengthen one's immunity. This article contributes to the current evidence on the use of Yoga and Ayurveda for improving patient health and well-being, and their importance in primary care specialty clinics, geriatrics, in particular. It tries convincing clinicians to develop acceptance toward these alternate systems of medicine and amalgamate these in mainstream medicine by directing patients toward experts in these fields while continuing the standard care.

Primary care specialists, especially gerontologists should endeavor quality research on the efficacy of traditional Indian systems of medicine. Like the Chinese, India needs to strengthen the evidence base for her Integrative medicine systems, as the world looks towards India, not just for vaccines, but for varied solutions on lowering the global impact of the pandemic. Hence, primary care physicians need to consider the vast array of solutions available in the ancient Indian traditions and explore methods for renovating the ways of healthcare delivery in times of social distancing and lockdowns, including the use of evidence-based yoga techniques and Ayurveda-based nutrition and lifestyle approaches for improving mass immunity during this global health crisis.

Limitations of this review include the limited number of studies available online concerning the particular area of interest. Furthermore, in-depth investigation is needed regarding how yoga and mind-body techniques might help combat COVID-19, as their immunomodulatory/anti-inflammatory effects have been studied on varying disease conditions (rheumatoid arthritis, cancer, HIV-AIDS, etc.) the pathology of which might differ from that of an infectious viral disease. For now, evidence from past literature suggests the use of Yoga in conjunct with Ayurveda based lifestyle and nutrition as a potential preventive measure to prepare the body to fight against the deadly virus, giving way to future research prospects.

Key Messages

  • Regular practice of gentle asanas like Pawanmuktasana series-1, pranayamas like Bhastrika, Kapalbhati, Ujjayi, Naadi Shodhana, Bhrahmari and techniques like SKY, TM and MBSR etc., are beneficial for all
  • SKY has multifold physical and mental health benefits, is suitable for all and available for online learning during COVID-19 lockdowns
  • Regular consumption of red bran rice, green gram, rock salt, barley, cow's milk, clarified butter and honey are important for strengthening the body in old age
  • Chayavanprash is a potent source of antioxidants and Medhya Rasayana helps avoid age-associated memory impairment
  • Waking up early at predawn, massaging the body regularly with oil and applying oil in the nostrils are some useful lifestyle habits for people of all ages.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Introduction
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Old-Age, Health ...
The Pandemic and...
How Can Yoga Help?
Asana for...
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