The Effect of Chair-Supported Yoga on Sleep Quality and Pain Level in Elderly Individuals Living in Nursing Homes

Study Rationale

The proportion of the older population in Türkiye has been steadily increasing over the years. The proportion of the older population increased from 9.1% in 2019 to 10.6% in 2024. As of 2024, women accounted for 55.4% of the older population, while men accounted for 44.6%. The proportion of the older population in Türkiye is above the global average.

Aging is an inevitable biological process accompanied by progressive functional declines in physiological systems over time. This process leads to various changes in the physiological, psychological, and social aspects of individuals' lives. The individual aging process can be described as the inability to perform activities of daily living adequately due to declines in physiological, psychological, and biological capacity.

With the increasing number of older adults, identifying the characteristics of this vulnerable population and understanding the most common diseases and health problems are important for preventing emerging problems and diseases and for managing existing conditions appropriately.

In older adults, sleep may become lighter and more fragmented, nighttime awakenings may increase, and early morning awakening may occur. In addition, the prevalence of primary sleep disorders, such as sleep apnea and REM sleep behavior disorder, may increase with age.

Sleep is essential for both physical and mental health. Adequate and good-quality sleep helps individuals recover physically and mentally, cope with stressors, and feel refreshed for daily activities.

Deterioration in sleep quality and sleep patterns may negatively affect the metabolic, cardiovascular, and neurological systems. Sleep disturbances may be associated with various health problems, including type 2 diabetes, hypertension, stroke, coronary artery disease, obesity, increased inflammatory symptoms, reduced immune system function, and cognitive impairment.

Chronic conditions such as osteoarthritis-related pain, asthma, obesity, chronic obstructive pulmonary disease, depression, and diabetes, as well as some medications used to treat these conditions, may make it difficult to initiate and maintain sleep.

Fatigue resulting from sleep disturbances and other causes may make it difficult for older adults to maintain their activities of daily living. Among older adults living in nursing homes, reduced social interaction may increase feelings of loneliness and may subsequently have negative physical and psychological effects.

Changes occurring during aging may result in weakening of the musculoskeletal system, alterations in hormonal balance, and slowing of nervous system functions. Consequently, health problems such as decreased sleep quality and increased pain levels are frequently observed in older adults. An association between increased pain levels and poorer sleep quality has also been reported among older adults living in nursing homes.

Pharmacological approaches are commonly used to manage health problems in older adults. However, as medication use increases, the risks of toxicity, drug-drug interactions, and adverse effects also increase. These risks become particularly important among individuals exposed to polypharmacy.

Therefore, non-pharmacological approaches such as exercise, meditation, and relaxation techniques have gained increasing importance in improving the quality of life of older adults. Among these approaches, yoga is considered a low-risk, easy-to-implement, and relatively low-cost intervention.

Previous studies have reported that yoga may improve sleep quality and reduce pain levels in older adults. Randomized controlled studies conducted among older adults have demonstrated improvements in sleep-related parameters following yoga interventions. Pilot studies have also indicated that yoga may contribute to reductions in pain levels.

Accordingly, evaluating chair-supported yoga among older adults living in nursing homes is considered important for improving quality of life and supporting psychophysiological health outcomes. Since research on this subject in Türkiye is limited, further studies are needed to evaluate chair-supported yoga as an evidence-based complementary approach in elderly care.

### 1.1. Study Objective

The aim of this study is to evaluate the effects of chair-supported yoga on sleep quality and pain levels among individuals aged 65 years and older living in a nursing home.

No biological materials will be used under any circumstances in this study. The study will examine the effects of a low-risk relaxation exercise that may improve the quality of life of older adults.

It is hypothesized that regular chair-supported yoga exercises will improve sleep quality and reduce pain levels among older adults.

• 1.2. Research Hypotheses

• H1:** Chair-supported yoga significantly reduces pain levels among older adults living in a nursing home compared with the control group.
• H2:** Chair-supported yoga significantly improves sleep quality among older adults living in a nursing home compared with the control group.
• Study Population and Sample

The study population will consist of individuals aged 65 years and older living in Maltepe Nursing Home.

A power analysis was conducted to determine the required sample size. The power analysis was performed using G*Power 3.1 software. Based on the findings of a previous study, the effect size was determined as 1.6115849. With a 95% confidence level and 99% statistical power, a total of 32 older adults, including 16 participants in the intervention group and 16 participants in the control group, were determined to be required.

### Randomization

Older adults who meet the eligibility criteria and agree to participate in the study will be randomly assigned to the intervention or control group using a simple randomization method.

The randomization process required for group allocation will be performed using a random number table generated through an online randomization tool.

### Preparation and Use of Chair-Supported Yoga Intervention Videos

Chair-supported yoga instructional videos will be prepared based on training and experience obtained through 200-hour Basic Yoga Training and 250-hour Yoga Therapy Instructor Training. The videos will be presented to the participants by the study researchers.

The chair-supported yoga movements included in the intervention will be structured according to the principles of posture, breathing control, joint range of motion, and safe mobility for older adults.

In addition to routine nursing home care, participants in the intervention group will receive chair-supported yoga twice a week for 8 weeks, with each session lasting approximately 30-40 minutes.

To ensure the safety of the intervention, the movements included in the program will be adapted according to the physical capacity and tolerance level of each participant.

Two separate instructional videos have been prepared for use in the study.

• Video 1 (Weeks 1-4):** This video includes appropriate chair positioning, breathing awareness, basic stretching, and posture correction exercises. It consists of slow and controlled exercises designed to support participants' adaptation to the program.
• Video 2 (Weeks 5-8):** This video includes preparation for balance, controlled standing exercises with chair support, slow and safe stepping, and coordination exercises. It is designed to support progression during the second half of the program and to enable participants to integrate the movements more smoothly.

The videos were recorded from a fixed camera angle using a tripod in a simple environment without distracting elements. Audio commands and instructions were prepared using slow, clear, and easily understandable language appropriate for the auditory and cognitive needs of older adults.

The two prepared videos will be projected in an appropriate setting using a projector, and the intervention will be performed according to the videos. Participants will perform the intervention twice a week.

Participants will be able to communicate any questions arising during the intervention to the researchers.

### Data Collection and Assessment

The Pittsburgh Sleep Quality Index and a Pain Assessment Scale will be used to evaluate the effectiveness of the intervention.

Measurements will be performed at baseline, at the end of Week 4, and at the end of Week 8.

During the assessments, attention will be paid to the participants' level of participation and comfort.

With this structured approach, the intervention is intended to be accessible, safe, sustainable, and supportive of individual participation.

Inclusion criteria

• Aged 65 years or older
• Resident of a nursing home
• Voluntarily agreed to participate in the study
• Able to communicate in Turkish
• No diagnosed psychiatric disorder (e.g., dementia or major depression)
• No antidepressant medication change within the last 3 months
• No physical impairment preventing participation in chair-supported yoga
• Pittsburgh Sleep Quality Index (PSQI) score ≥5
• Numeric Rating Scale (NRS) pain score ≥5

Exclusion criteria

• Younger than 65 years
• Refused to participate or withdrew consent
• Diagnosed dementia or major depression
• Antidepressant medication change within the last 3 months
• Unable to communicate in Turkish
• Physical impairment preventing participation in chair-supported yoga
• PSQI score <5
• Numeric Rating Scale (NRS) pain score <5