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Talwadkar S, Jagannathan A, Nagarathna R

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BACKGROUND Aging is associated with a gradual impairment of cognitive functions (Curr Neurol Neurosci Rep, 2004) Cognitive functions most affected by age are Speed of processing Memory Attention Executive function Spatial ability Reasoning (Aging Health, 2010)

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Treatment options for cognitive impairment- Drug Activity Diet Cognitive interventions Tai chi Yoga (Journal of the American Geriatrics Society, 2010; Dementia and Geriatric Cognitive Disorders, 2010; Neurosci Biobehav Rev, 2012; Journal of the South Carolina Medical Association, 2008)

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Trataka is one of the Shatkarmas (six cleansing processes) (HYP) Looking intently with an unwavering gaze at a small point until tears are shed is known as Trataka (HYP)

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Trataka practice makes eyes clear and bright. It improves memory and helps to develop good concentration and strong will power (Yoga publications trust, Munger, 2008) By practicing trataka, all the diseases of eyes are destroyed and clairvoyance is obtained(Gheranda Samhita) Trataka eradicates all eye diseases, fatigue and sloth and closes the doorway creating these problems(Hatha yoga pradipika)

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Combination of focusing and defocusing through yoga reduces optical illusion more than focusing alone (Indian Journal of physiology & Pharmacology, 1997) Jyotritrataka reduces intraocular pressure in normal subjects (Thai Journal of Physiological Sciences, 2008) An increase in the CFF (perceptual accuracy) is seen immediately after Trataka (The Journal of Alternative and Complementary Medicine, 2010)

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LITERATURE REVIEW Numerous studies looking at the effect of yoga on cognition in healthy young subjects (Percept Mot Skills, 2007; Indian J Physiol Pharmacol, 2009; Front Integr Neurosci, 2012 ) Review study-15 studies with cognitively healthy elders, 8 studies with cognitive decline-Improvement in most of the studies (Clin J Sports Med, 2008) Review of nine studies including 3 RCTs, 6 NRCTs-yoga improved cognitive health of older adults (Int J Yoga Therap, 2009)

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Relaxation response training improved attention, memory in healthy elderly (Compl Ther Clin Pract, 2006) Long term practitioners of Vihangam yoga in the geriatric age group- better cognition (Neuropsychol Cogn, 2012) Study in SVYASA-improvement in semantic, primary, and working short term memory in healthy elderly subjects (SVYASA, 2005)

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AIM & OBJECTIVES To study the effect of Trataka in the elderly on: Short term and working memory (digit span forward and backward) Executive functions (Trail making test B)

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METHODOLOGY o Age & gender:- 60 to 80 yrs., Both males and females. o Subjects: Sample size:- n=60 Source of subjects:- Subjects were obtained from Old age homes in Goa and from individuals staying in and around Shantinagar and Margao areas in Goa.

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Inclusion Criteria: Healthy subjects Education: 5 th Std. and above Willing to participate by giving a written informed consent. Those knowing Konkani, Hindi, English, Marathi. Exclusion Criteria : Those having neurological and psychiatric disorders Those who practiced yoga for the last 3 months.

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DESIGN Randomized block design For the convenience of conducting the intervention, each group was not more than 10 members the groups were randomized into Trataka or wait list control group.

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Group A (trataka intervention) Day 30 TMT B, DS-F, DS-B Day1(Immediately after intervention ) TMT B, DS-F, DS-B Day1 TMT B, DS-F, DS-B

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Group B (Wait-list control) Day 30 TMT B, DS-F, DS-B Day 1 (After quiet sitting) TMT B, DS-F, DS-B Day 1 TMT B, DS-F, DS-B

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ASSESSMENT Trail making test B-visual scanning, complex attention, psychomotor speed mental exibility, executive functions, working memory and task-switching ability. Digit Span forward and backward- evaluates short-term memory and working memory.

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DETAILS OF TRATAKA PRACTICE

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DATA ANALYSIS Data was analyzed with the help of Statistical Package for Social Sciences (SPSS) version 16.

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RESULTS Shapiro-Wilk test of normality Trail Making Test Part B (TMT B) for both groups - normally distributed (p > 0.05). Digit span test- not normally distributed (p

Wilcoxon Signed Ranks Test showed that there was no significant change in the digit span test scores from baseline to 1 st follow-up (p=0.06). But significant increase in scores was seen from baseline to 2 nd follow up (p = 0.001) and also from 1 st follow up to 2 nd follow up (p=0.002) in the trataka group. There was no significant changes in the digit span scores from baseline to 1 st follow-up/2 nd follow-up (p>0.05) or from 1 st follow-up to 2 nd follow-up in the control group.

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SUB GROUP ANALYSIS The elderly from the old age home formed 2 blocks and those from residential localities formed 2 blocks- randomized into any of the 2 interventions (Trtaka or wait list control) Trataka group- 1 block-old age home 1 block- Elderly from Localities Wait-list control group- 1 block-old age home 1 block- Elderly from Localities

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Trataka Group Variable Baseline 1 st follow up 2 nd follow up Fp-value Mean (SD) Digit span Old age home 268.57 (87.042) 228.14 (64.752) 199.29 (77.706) 0.29 Locality 134.47 (65.031) 98.79 (47.989) 78.84 (31.489) TMT B Old age home 15.14 (3.024) 14.14 (1.773) 14.43 (2.070) 8.90.001 Locality 16.32 (4.137) 17.68 (4.877) 19.95 (3.979)

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Wait-List control Group Variable Baseline 1 st follow up 2 nd follow up Fp-value Mean (SD) Digit span Old age home 16.77 (2.555) 15.77 (3.345) 14.69 (3.011) 3.170.06 Locality 17.56 (5.126) 18.44 (4.693) 18.22 (6.667) TMT B Old age home 202.17 (81.658) 217.75 (99.649) 180.08 (85.373) 0.770.48 Locality 149.00 (60.858) 142.67 (68.440) 114.00 (58.643)

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DISCUSSION Subjects were at a stage when cognitive decline was a reality Have never been exposed to Tr aka or any Yog intervention earlier Scales used in this study were sensitive enough to tap the cognitive improvement in the elderly Prolonged duration of practice of Yog/tr aka for desirable effects 1 day of practice was not sufficient to produce changes in the cognitive functions, whereas one month follow up showed significant changes

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Tr aka- involves focusing and defocusing Focusing-Dharana Defocusing-Dhyana Dharana or focusing improves mainly concentrative attention, enhances the stability of attention and reduces the need to invoke executive skills that regulate the focus of attention from moment to moment(decreased cognitive efforts), improves the ability to remain vigilant and monitor distractors without losing focus. Dhyana-the regulative attentional skills are invoked less and less frequently, and the ability to sustain focus thus becomes progressively effortless.

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Relaxation techniques have shown to reduce anxiety and improve memory as well as attention. Reduced anxiety can improve the performance on tasks requiring attention and memory.

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CONCLUSIONS Results establish that Tr aka can be used as a technique to enhance cognition. Tr aka if provided to a group which is prone for cognitive decline and to those who have not been exposed to any cognition improving interventions, it can be helpful in improving their cognition Long term practice of tr aka (according to this study an optimum duration of one month) is needed to bring about the required change in cognition. Tr aka improved memory scores of those living in residences better than those living in old age homes shows that the place where elderly age, has an impact on their cognition.

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STRENGTHS & LIMITATIONS Strengths: Randomized block design (RBD) Standardized neuropsychological tests with high reliability and validity. Intervention was provided to the sample that needed the intervention.

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Limitations: Sampling was done only in 2 old age homes Sample size was small Only three outcome variables

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FUTURE SUGGESTIONS Study with a larger sample Combinations of cognition enhancing Yog techniques Subjects with cognitive deficits Combinations of Yog and other cognitive interventions Mechanism of Tr aka practice

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Panza F, Frisardi V, Capurso C, D'Introno A, Colacicco AM, Chiloiro R, et al. Effect of donepezil on the continuum of depressive symptoms, mild cognitive impairment, and progression to dementia. Journal of the American Geriatrics Society. 2010;58(2):389-90. Simon SS, Yokomizo JE, Bottino CM. Cognitive intervention in amnestic Mild Cognitive Impairment: A systematic review. Neurosci Biobehav Rev. 2012;36(4):1163-1178. Roberts RO, Geda YE, Cerhan JR, Knopman DS, Cha RH, Christianson TJ, et al. Vegetables, Unsaturated Fats, Moderate Alcohol Intake, and Mild Cognitive Impairment. Dementia and Geriatric Cognitive Disorders. 2010;29(5):413-423. Prakash R, Rastogi P, Dubey I, et al. Long-term concentrative meditation and cognitive performance among older adults. Neuropsychol Dev Cogn B Aging Neuropsychol cogn. 2012;19(4):479-94.

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Jennifer AG, Herbert B, et al. The relaxation response: Reducing stress and improving cognition in healthy aging adults. Compl Ther Clin Pract. 2006;3(12):186191. Diller L, Ben YY, Gerstman LJ, Goodin R, Gordon W, Weinberg J. Studies in scanning behavior in hemiplegia. Rehabilitation Monograph No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: New York University Medical Center, Institute of Rehabilitation Medicine; 1974. Reitan RM, Wolfson D. The HalsteadReitan Neuropsycholgical Test Battery: Therapy and clinical interpretation. Tucson, AZ: Neuropsychological Press; 1985. Galante E, Venturini G, Fiaccadori C. Computer-based cognitive intervention for dementia: preliminary results of a randomized clinical trial. G Ital Med Lav Ergon. 2007;29(3 Suppl B):B26-32.

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Larson EB, Wang L, Bowen JD, McCormick WC, Teri L, Crane P, et al. Exercise is associated with reduced risk for incident dementia among persons 65 years of age and older. Annals of Internal Medicine. 2006;144(2):7381. Wechsler DA. Wechsler Adult Intelligence Scale. 3 rd ed. San Antonio: The Psychological Corporation; 1997. Manjunath NK. Yoga and geriatric care: an evaluation of positive health indicators. Phd Thesis:SVYASA University; 2005. Uffelen, Jannique GZ, Chin AP et al. The Effects of Exercise on Cognition in Older Adults With and Without Cognitive Decline: A Systematic Review. Clin J Sports Med. 2008;18(6):486-500. Wang D. The Use of Yoga for Physical and Mental Health Among Older Adults: A Review of the Literature. Int J Yoga Therap. 2009;19(1):91-96.

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Thank you

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Dr Shubhada S. Talwadkar E-mail id-shubhadatalwadkar@gmail.com