Material throughout this chapter has been reproduced from Tew et al.1
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Burden of multimorbidity in older people
Multimorbidity, often defined as the co-existence of two or more chronic medical conditions,2 is a major challenge for health and care systems worldwide and of particular relevance for older adults. In 2015, 54% of people aged 65 years or older in England exhibited multimorbidity; this percentage is projected to increase to 68% by 2035.3 Multimorbidity is associated with poorer outcomes such as reduced quality of life, impaired functional status, worse physical and mental health and premature death.4,5 Multimorbidity also increases healthcare utilisation and associated costs.6,7
Interventions for improving outcomes for people with multimorbidity
There has been limited exploration of the effectiveness of interventions to improve outcomes for people with multimorbidity. A 2021 systematic review identified 16 randomised controlled trials (RCTs) with 4753 participants that had evaluated a range of complex interventions for people with multimorbidity in primary care and community settings.8 Eight studies examined multifaceted interventions that targeted the co-ordination of care and healthcare providers while also providing self-management support for patients. Four studies reported on self-management support interventions that did not have a clear link to the patients’ healthcare provision. The other four studies focused primarily on medication management. The results suggested that all intervention types probably make little or no difference to health-related quality of life (HRQoL) or mental health outcomes. Five of the 10 studies with HRQoL outcomes reported EuroQoL 5 Dimensions (EQ-5D) (a generic measure of health utility) scores that could be included in a meta-analysis, with a mean difference (MD) of 0.03 [95% confidence interval (CI) −0.01 to 0.07], consistent with the overall effect suggesting no difference in this outcome. There was also little or no effect on clinical, psychological or medication outcomes or healthcare utilisation. There were mixed effects on function, activity and patient health behaviours, and limited data on costs. There was a low risk of bias overall; however, the evidence for all outcomes was downgraded to low certainty due to serious concerns about inconsistency and imprecision. This review highlighted the need for further research to determine the clinical and cost-effectiveness of interventions that are ideally simple, generalisable and which can address several medical conditions simultaneously. Yoga is a potential candidate intervention.
Yoga as an intervention for improving health and well-being
Yoga originated thousands of years ago in India as an integrated mind–body practice based on ancient Vedic philosophy. During the 20th century, yoga became increasingly recognised outside India, and over the past decades, it has continued to grow in popularity worldwide as a practice for improving health and well-being. While modern yoga often focuses primarily on physical poses and is sometimes thought of as a type of exercise, the practice usually incorporates one or more of the mental or mindful elements that are traditionally part of yoga, such as relaxation, concentration or meditation. There are currently many different styles or schools of yoga, each with a variable emphasis and approach to practice. Research evidence suggests that some of these yoga practices may help to prevent and treat various physical and mental illnesses and improve HRQoL.9,10
In November 2017, the Cochrane Library published a special collection of 14 systematic reviews that focused on the effectiveness of yoga for improving physical or mental health symptoms and quality of life in a range of health conditions, including musculoskeletal, pulmonary, cancer, cardiovascular, neurological and mental health. A summary of four diverse but pertinent reviews is as follows:
Yoga for chronic non-specific low back pain:
11 For yoga compared to non-exercise controls (9 trials; 810 participants), there was moderate-certainty evidence that yoga produced small-to-moderate improvements in back-related function [standardised mean difference (SMD) −0.44, 95%
CI −0.66 to −0.22] and pain (
MD −7.81, 95%
CI −13.37 to −2.25) at 6 months. The authors recommended additional high-quality research to improve confidence in estimates of effect and to evaluate long-term outcomes.
Yoga for asthma:
12 There was some evidence that yoga may improve quality of life (
MD in Asthma Quality of Life Questionnaire score per item 0.57 units on a 7-point scale, 95%
CI 0.37 to 0.77; five studies;
n = 375) and symptoms (
SMD 0.37, 95%
CI 0.09 to 0.65; three studies;
n = 243) and reduce medication usage (risk ratio 5.35, 95%
CI 1.29 to 22.11; two studies) in people with asthma. The authors concluded that large, high-quality trials are needed to confirm the effects of yoga on asthma.
Yoga for improving
HRQoL, mental health and cancer-related symptoms in women diagnosed with breast cancer:
13 Seventeen studies that compared yoga versus no therapy provided moderate-quality evidence showing that yoga improved
HRQoL (
SMD 0.22, 95%
CI 0.04 to 0.40; 10 studies,
n = 675), reduced fatigue (
SMD −0.48, 95%
CI −0.75 to −0.20; 11 studies,
n = 883) and reduced sleep disturbances in the short term (
SMD −0.25, 95%
CI −0.40 to −0.09; six studies,
n = 657). No serious adverse events (SAEs) were reported. Additional research was recommended to assess medium- and longer-term effects.
Yoga for primary prevention of cardiovascular disease:
14 Yoga was found to produce reductions in diastolic blood pressure (
MD −2.90 mmHg) and triglycerides (
MD −0.27 mmol/l) and increase high-density lipoprotein cholesterol (
MD 0.08 mmol/l). There was no clear evidence of a difference between groups for low-density lipoprotein cholesterol, although there was moderate statistical heterogeneity. Adverse events (AEs), occurrence of type 2 diabetes and costs were not reported in any of the studies. No study reported cardiovascular mortality, all-cause mortality or non-fatal events, and most studies were small and short term.
Elsewhere, studies have sought to determine the effects of yoga in older populations. For example, a 2012 systematic review of 16 studies (n = 649)15 and a more recent trial of 118 participants16 demonstrated that yoga may provide greater improvements in physical functioning and self-reported health status than conventional physical activity interventions in older adults. More recently, a systematic review of six trials (n = 307) of relatively high methodological quality reported that yoga interventions had a small beneficial effect on balance (SMD 0.40, 95% CI 0.15 to 0.65, six trials) and a medium effect on physical mobility (SMD 0.50, 95% CI 0.06 to 0.95, three trials) in people aged 60 and over.17
In summary, these data offer support for the beneficial effects of yoga in older adults and for several chronic conditions. However, many of the previous studies had limitations, including small sample sizes, a single yoga teacher delivering the programme and short-term follow-up. Robust economic evaluations of yoga are also limited, although a recent systematic review concluded that ‘medical’ yoga is likely to be a cost-effective option for low back pain.18 Very little research has specifically focused on older people with multimorbidity.
In 2009, the Gentle Years Yoga© (GYY) programme was developed by the Yorkshire Yoga and Therapy Centre to cater specifically to the needs of older adults, including those with conditions common to an older cohort such as osteoarthritis, hypertension and cognitive impairment. As part of the pilot research study conducted at Yorkshire Yoga in 2016, a standardised GYY teacher training programme was manualised with the creation of a quality-assured teacher training course which became the British Wheel of Yoga (BWY) GYY programme that is being delivered by the BWY. British Wheel of Yoga is the National Governing Body of Yoga in Great Britain, with a nationwide network of over 5000 qualified yoga teachers. Gentle Years Yoga is based on standard Hatha Yoga, incorporating traditional physical poses and transitions as well as breathing, concentration and relaxation activities. Adaptations to challenging Hatha Yoga poses have been made so that older adults can participate safely while still obtaining the fitness, health and well-being benefits of yoga. Each programme involves one group-based session per week for 12 weeks (each session includes a 75-minute chair-based yoga class and after-class social time) and promotion of regular self-managed yoga practice at home.
In a pilot trial of the GYY programme,19 82 older adults expressed an interest within a 2-month recruitment period, of which 52 (mean age 75 years) were recruited and randomised. Participants had up to six chronic conditions, the most common of which were osteoarthritis, hypertension and depression. Trial yoga courses were delivered across four community venues by four yoga teachers. Two-thirds of participants had an acceptable attendance of ≥ 80%. The study demonstrated feasibility of evaluating the GYY programme in a fully powered RCT and the potential for a positive clinically important effect on health status [EuroQol-5 Dimensions, five-level version (EQ-5D-5L) utility index score] at 3 months after randomisation (MD 0.12, 95% CI 0.03 to 0.21).
Consequently, we conducted a larger trial – The GYY Trial – to establish the clinical and cost- effectiveness of the GYY programme in older adults with multimorbidity. If this intervention was shown to be clinically effective and cost-effective, it could be implemented more widely, leading to improved outcomes for this population.
Research aims and objectives
The GYY Trial was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) Programme in response to a themed call on complex health and care needs in older people. The aim of the trial was to establish the clinical and cost effectiveness of the GYY programme in addition to usual care versus usual care alone in community-dwelling older adults with multimorbidity.
The primary objective was to establish if the offer of a 12-week GYY programme in addition to usual care is more effective compared with usual care alone in improving HRQoL (EQ-5D-5L utility index score) over 12 months in people aged 65 years or over with multimorbidity.
Secondary objectives were as follows:
to explore the effect of the
GYY programme on
HRQoL, depression, anxiety and loneliness at 3, 6 and 12 months after randomisation
to explore the effect of the
GYY programme on the incidence of falls over 12 months from randomisation
to explore the safety of the
GYY programme relative to control in terms of the occurrence of AEs over 12 months after randomisation
to assess if the
GYY programme is cost-effective, measured using differences in the cost of health resource use between the intervention and usual care groups and the incremental cost-effectiveness ratios (ICER) using quality-adjusted life-years (QALYs) derived from the
EQ-5D-5L measured at 3, 6 and 12 months after randomisation
to undertake a qualitative process evaluation to describe the experience of the intervention, explain the determinants of delivery (including treatment fidelity) and identify the optimal implementation strategies for embedding and normalising the
GYY programme in preparation for a wider roll-out.
