衰弱為身體各器官衰退，進而影響健康狀態。國外研究顯示，透過運動、營養、認知訓練等多元介入模式，可有效延緩長者衰弱之發生，甚至改善其衰弱程度。目前國內外對於衰弱的介入研究多只針對社區老人，而未有針對住院老人。巴式呼吸是瑜伽練習重要的快速呼吸方式之一，老年人可以輕鬆進行。我們假設巴式呼吸可以有效改善衰弱指標，並延緩老年人衰弱的發生。本研究在國立成功大學附設醫院老年科病房招募住院衰弱老年人，共接觸113位住院老年人。住院期間，72名老年人接受衰弱及心率變異評估，發現時域參數隨衰弱程度越高有下降之趨勢。頻域分析參數發現交感神經活性指標 (percentage of low frequency power, LF%) 隨衰弱程度下降，副交感神經活性指標 (percentage of high frequency power, HF %) 隨衰弱程度上升。衰弱指標之評估，包括步行速度、平衡控制、手握力、老年憂鬱程度。發現衰弱程度越嚴重者，運動控制較差及老年憂鬱分數越高。14名衰弱老年人住院期間介入單次巴式呼吸練習後，心率 (heart rate, HR) 顯著下降；頻域參數LF %數值上升，HF %數值下降，LF/HF的比值上升。三名衰弱老年人出院後，介入一個月的巴式呼吸練習，發現時域分析參數顯示HR下降，短期時間心跳間期平均標準差 (root mean square of successive NN intervals differences, RMSSD) 上升；頻域分析參數，顯示高頻功率 (high frequency power, HFP) 上升。衰弱指標的部分，介入一個月的巴式呼吸練習後，衰弱老年人手握力及步態功能有改善趨勢。兩名對照組衰弱老人無介入巴式呼吸練習，則無明顯改善。因此，希望能藉此提供住院老年人衰弱預防及延緩衰弱介入措施之參考。

SUMMARY
Frailty is the decline of various organs of the body which affects the state of health. Previous studies have shown that frailty of elders can be effectively delayed and even improved through multiple interventions such as exercise, nutrition, and cognitive training. Bhastrika Pranayama (BP) is an energizing breathing exercise in yoga, which is easily performed by elders. We hypothesized that BP can improve frailty indicators, autonomic nervous tone, and brain activity effectively and delay the occurrence of frailty in elders. We have contacted 113 inpatients in the division of geriatric the National Cheng Kung University Hospital, 41 of them were excluded. The remaining 72 elders were categorized according to clinical frailty scale (CFS) into vulnerable (n = 22), mildly frail (n = 20), moderately frail (n = 25), and severely frail (n = 5). Heart rate variability (HRV) parameters were evaluated by ANSWeatch and Comprehensive Geriatric Assessment (CGA) was used to evaluate different domain of frailty. Time for up and go test is significantly increased in moderately and severely frail elders and grip strength is significantly decreased in mildly, moderately and severely frail elders. Most of the time domain parameters (SDNN, RMSSD and pNN50) and frequency domain parameters (LF%, HF power, and total power) decreased according to the severity of frailty. However, HF% is increased according to the severity of frail. Fourteen hospitalized frail elders were taught one episode of Bhastrika breathing. Results showed significantly decrease in heart rate and HF%, but increase in LF% and LF/HF ratio. After the subjects were discharged, BP intervention continued for a month at home. Resting-state functional magnetic resonance imaging (rs-fMRI) was arranged to record the brain activity on the day of discharge and one month later. Photoplethysmography (PPG) was used to evaluate the HRV during brain imaging. Three of them completed one month of Bhastrika intervention (4-7 times /week) at home. Two of them perform daily routine and served as controls. The elders who have finished the Bhastrika intervention showed a decrease of frailty, increase of RMSSD and increase of the activity in occipital superior gyrus. However, the two controls showed a decrease of frailty, increase of RMSSD and decrease of the activity of cerebellum anterior lobe and frontal lobe. Our results demonstrate that both short-term and long-term practicing of Bhastrika breathing significantly changes the parameters of HRV in frail elders, and long-term practicing of Bhastrika breathing not only improve frailty but also parameters of HRV and regional activity of brain areas involved in motor and visual functions.

INTRODUCTION
In recent years, the rapid increase in the elderly population has led to an increase in the number of hospitalized elderly patients. Frailty in hospitalized elders is more serious than healthy elders, which results in the functional decline of various organs and affects the state of health. Frailty indicators in elders include a decline in the autonomic nervous system (ANS), slow speed, limb weakness, negative emotions, and deterioration of functional networks in the brain. Among them, gait speed and gait variability are associated with the strength of resting-state functional connectivity of the frontoparietal control network and dorsal attention network. Bhastrika Pranayama (BP) is an energizing breathing exercise in yoga, which is easily performed by elders. BP involves a rapid and forceful process of inhalation and exhalation powered by the movement of the diaphragm. Multiple studies have shown that yoga has positive impacts on our body in many ways, including an increase of cardiac sympathovagal balance, improved gait speed, postural control, improved negative emotion, and mobility. We hypothesized that BP can improve frailty indicators, autonomic nervous tone, and brain activity effectively and delay the occurrence of frailty in elders.

MATERIALS AND METHODS
Hospitalized elderly patients over 65 years old were recruited in the division of geriatric, National Cheng Kung University Hospital. BP was taught during hospitalization and heart rate variability (HRV) parameters were collected by ANSWeatch. Clinical frailty scale (CFS) was used to evaluate frailty level. After the subjects were discharged, BP intervention continued for a month at home. Resting-state functional magnetic resonance imaging (rs-fMRI) was arranged to record the brain activity on the day of discharge and one month later. Photoplethysmography (PPG) was used to evaluate the HRV during brain imaging.

RESULTS AND DISCUSSION
One hundred and thirteen elderly inpatients were contacted, 41 were excluded, and the remaining 72 elders were categorized according to clinical frailty scale (CFS) into vulnerable (n = 22), mildly frail (n = 20), moderately frail (n = 25), and severely frail (n = 5). Time for up and go test is significantly increased in moderately and severely frail elders and grip strength is significantly decreased in mildly, moderately and severely frail elders. Most of the time domain parameters (SDNN, RMSSD and pNN50) and frequency domain parameters (LF%, HF power, and total power) decreased according to the severity of frailty. However, HF% is increased according to the severity of frail. Fourteen hospitalized frail elders were taught one episode of Bhastrika breathing. Results showed significantly decrease in heart rate and HF%, but increase in LF% and LF/HF ratio. Seven (3 vulnerable and 4 mildly frail) elders were invited for fMRI study. Whole brain regional homogeneity (ReHo) analyses showed that regional activity of the left supplementary motor area and the cerebellum posterior lobe is decreased in the mildly frail elders. Three of them completed one month of Bhastrika intervention (4-7 times /week) at home. Two of them perform daily routine and served as controls. Three of the elders who have finished the Bhastrika intervention showed a decrease of frailty, increase of RMSSD and increase of the activity in occipital superior gyrus. However, the two controls showed a decrease of frailty, increase of RMSSD and decrease of the activity of cerebellum anterior lobe and frontal lobe.
CONCLUSION
Both short-term and long-term practicing of Bhastrika breathing significantly changes the parameters of HRV in frail elders, and long-term practicing of Bhastrika breathing not only improve frailty but also parameters of HRV and regional activity of brain areas involved in motor and visual functions.

翁菁甫、林坤霈、詹鼎正 (2014)。老人憂鬱與認知功能障礙。內科學誌，25：158-164。
Afonso, R. F., Balardin, J. B., Lazar, S., Sato, J. R., Igarashi, N., Santaella, D. F., Lacerda, S. S., Amaro Jr., E., & Kozasa, E. H. (2017). Greater Cortical Thickness in Elderly Female Yoga Practitioners—A Cross-Sectional Study. Frontiers in Aging Neuroscience, 9(201).
AM, N. M., Fan, C. W., Romero-Ortuno, R., Cogan, L., Cunningham, C., Kenny, R. A., & Lawlor, B. (2012). Frailty, depression, and anxiety in later life. Int Psychogeriatr, 24(8), 1265-1274.
Apóstolo, J., Cooke, R., Bobrowicz-Campos, E., Santana, S., Marcucci, M., Cano, A., Vollenbroek-Hutten, M., Germini, F., D'Avanzo, B., Gwyther, H., & Holland, C. (2018). Corrigendum: Effectiveness of interventions to prevent pre-frailty and frailty progression in older adults: a systematic review. JBI Database System Rev Implement Rep, 16(5), 1282-1283.
Bernard, J. A., & Seidler, R. D. (2013). Relationships between regional cerebellar volume and sensorimotor and cognitive function in young and older adults. Cerebellum, 12(5), 721-737.
Bohannon, R. W. (2019). Grip Strength: An Indispensable Biomarker For Older Adults. Clin Interv Aging, 14, 1681-1691.
Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: part I-neurophysiologic model. J Altern Complement Med, 11(1), 189-201.
Buccelletti, E., Gilardi, E., Scaini, E., Galiuto, L., Persiani, R., Biondi, A., Basile, F., & Silveri, N. G. (2009). Heart rate variability and myocardial infarction: systematic literature review and metanalysis. Eur Rev Med Pharmacol Sci, 13(4), 299-307.
Buchner, D. M., & Wagner, E. H. (1992). Preventing frail health. Clin Geriatr Med, 8(1), 1-17.
Buta, B. J., Walston, J. D., Godino, J. G., Park, M., Kalyani, R. R., Xue, Q. L., Bandeen-Roche, K., & Varadhan, R. (2016). Frailty assessment instruments: Systematic characterization of the uses and contexts of highly-cited instruments. Ageing Res Rev, 26, 53-61.
Chang, Y. M., Huang, Y. T., Chen, I. L., Yang, C. L., Leu, S. C., Su, H. L., Kao, J. L., Tsai, S. C., Jhen, R. N., & Shiao, C. C. (2020). Heart rate variability as an independent predictor for 8-year mortality among chronic hemodialysis patients. Sci Rep, 10(1), 881.
Chen, S., Honda, T., Chen, T., Narazaki, K., Haeuchi, Y., Supartini, A., & Kumagai, S. (2015). Screening for frailty phenotype with objectively-measured physical activity in a west Japanese suburban community: evidence from the Sasaguri Genkimon Study. BMC Geriatr, 15, 36.
Dedeyne, L., Deschodt, M., Verschueren, S., Tournoy, J., & Gielen, E. (2017). Effects of multi-domain interventions in (pre)frail elderly on frailty, functional, and cognitive status: a systematic review. Clin Interv Aging, 12, 873-896.
Dent, E., Morley, J. E., Cruz-Jentoft, A. J., Woodhouse, L., Rodríguez-Mañas, L., Fried, L. P., Woo, J., Aprahamian, I., Sanford, A., Lundy, J., Landi, F., Beilby, J., Martin, F. C., Bauer, J. M., Ferrucci, L., Merchant, R. A., Dong, B., Arai, H., Hoogendijk, E. O., Won, C. W., Abbatecola, A., Cederholm, T., Strandberg, T., Gutiérrez Robledo, L. M., Flicker, L., Bhasin, S., Aubertin-Leheudre, M., Bischoff-Ferrari, H. A., Guralnik, J. M., Muscedere, J., Pahor, M., Ruiz, J., Negm, A. M., Reginster, J. Y., Waters, D. L., & Vellas, B. (2019). Physical Frailty: ICFSR International Clinical Practice Guidelines for Identification and Management. J Nutr Health Aging, 23(9), 771-787.
Fried, L. P., Ferrucci, L., Darer, J., Williamson, J. D., & Anderson, G. (2004). Untangling the Concepts of Disability, Frailty, and Comorbidity: Implications for Improved Targeting and Care. The Journals of Gerontology: Series A, 59(3), M255-M263.
Fried, L. P., Tangen, C. M., Walston, J., Newman, A. B., Hirsch, C., Gottdiener, J., Seeman, T., Tracy, R., Kop, W. J., Burke, G., & McBurnie, M. A. (2001). Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci, 56(3), M146-156.
Gandelman, J. A., Newhouse, P., & Taylor, W. D. (2018). Nicotine and networks: Potential for enhancement of mood and cognition in late-life depression. Neurosci Biobehav Rev, 84, 289-298.
GÓMEZ-ANGULO, C., & CAMPO-ARIAS, A. (2011). Escala de Yesavage para Depresión Geriátrica (GDS-15 y GDS-5): estudio de la consistencia interna y estructura factorial. Universitas Psychologica, 10, 735-743.
Gothe, N. P., Khan, I., Hayes, J., Erlenbach, E., & Damoiseaux, J. S. (2019). Yoga Effects on Brain Health: A Systematic Review of the Current Literature. Brain Plast, 5(1), 105-122.
Hedman, A. M., van Haren, N. E., Schnack, H. G., Kahn, R. S., & Hulshoff Pol, H. E. (2012). Human brain changes across the life span: a review of 56 longitudinal magnetic resonance imaging studies. Hum Brain Mapp, 33(8), 1987-2002.
Holtzer, R., Epstein, N., Mahoney, J. R., Izzetoglu, M., & Blumen, H. M. (2014). Neuroimaging of Mobility in Aging: A Targeted Review. The Journals of Gerontology: Series A, 69(11), 1375-1388.
Huikuri, H. V., & Stein, P. K. (2013). Heart rate variability in risk stratification of cardiac patients. Prog Cardiovasc Dis, 56(2), 153-159.
Katayama, P. L., Dias, D. P. M., Silva, L. E. V., Virtuoso-Junior, J. S., & Marocolo, M. (2015). Cardiac autonomic modulation in non-frail, pre-frail and frail elderly women: a pilot study. Aging Clinical and Experimental Research, 27(5), 621-629.
Kleiger, R. E., Miller, J. P., Bigger, J. T., & Moss, A. J. (1987). Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol, 59(4), 256-262.
Kuo, T. B., Lin, T., Yang, C. C., Li, C. L., Chen, C. F., & Chou, P. (1999). Effect of aging on gender differences in neural control of heart rate. Am J Physiol, 277(6), H2233-2239.
Kwok, J. Y. Y., Kwan, J. C. Y., Auyeung, M., Mok, V. C. T., Lau, C. K. Y., Choi, K. C., & Chan, H. Y. L. (2019). Effects of Mindfulness Yoga vs Stretching and Resistance Training Exercises on Anxiety and Depression for People With Parkinson Disease: A Randomized Clinical Trial. JAMA Neurol, 76(7), 755-763.
Liu, Y., Li, M., Chen, H., Wei, X., Hu, G., Yu, S., Ruan, X., Zhou, J., Pan, X., Li, Z., Luo, Z., & Xie, Y. (2019). Alterations of Regional Homogeneity in Parkinson's Disease Patients With Freezing of Gait: A Resting-State fMRI Study. Front Aging Neurosci, 11, 276.
Marsh, A. P., Wrights, A. P., Haakonssen, E. H., Dobrosielski, M. A., Chmelo, E. A., Barnard, R. T., Pecorella, A., Ip, E. H., & Rejeski, W. J. (2015). The Virtual Short Physical Performance Battery. J Gerontol A Biol Sci Med Sci, 70(10), 1233-1241.
Miller, K. L., Alfaro-Almagro, F., Bangerter, N. K., Thomas, D. L., Yacoub, E., Xu, J., Bartsch, A. J., Jbabdi, S., Sotiropoulos, S. N., Andersson, J. L., Griffanti, L., Douaud, G., Okell, T. W., Weale, P., Dragonu, I., Garratt, S., Hudson, S., Collins, R., Jenkinson, M., Matthews, P. M., & Smith, S. M. (2016). Multimodal population brain imaging in the UK Biobank prospective epidemiological study. Nat Neurosci, 19(11), 1523-1536.
Musselman, D. L., Betan, E., Larsen, H., & Phillips, L. S. (2003). Relationship of depression to diabetes types 1 and 2: epidemiology, biology, and treatment. Biol Psychiatry, 54(3), 317-329.
Park, S. C., Lee, H. Y., Lee, D. W., Hahn, S. W., Park, S. H., Kim, Y. J., Choi, J. S., Lee, H. S., Lee, S. I., Na, K. S., Jung, S. W., Shim, S. H., Kim, K. W., Paik, J. W., & Kwon, Y. J. (2017). Screening for Depressive Disorder in Elderly Patients with Chronic Physical Diseases Using the Patient Health Questionnaire-9. Psychiatry Investig, 14(3), 306-313.
Parmelee, P. A., Harralson, T. L., McPherron, J. A., & Schumacher, H. R. (2013). The structure of affective symptomatology in older adults with osteoarthritis. Int J Geriatr Psychiatry, 28(4), 393-401.
Parmelee, P. A., Lawton, M. P., & Katz, I. R. (1998). The structure of depression among elderly institution residents: affective and somatic correlates of physical frailty. J Gerontol A Biol Sci Med Sci, 53(2), M155-162.
Pliner, E. M., Seo, N. J., Ramakrishnan, V., & Beschorner, K. E. (2019). Effects of upper body strength, hand placement and foot placement on ladder fall severity. Gait Posture, 68, 23-29.
Ponciano, V., Pires, I. M., Ribeiro, F. R., Villasana, M. V., Crisóstomo, R., Canavarro Teixeira, M., & Zdravevski, E. (2020). Mobile Computing Technologies for Health and Mobility Assessment: Research Design and Results of the Timed Up and Go Test in Older Adults. Sensors (Basel), 20(12).
Porges, S. W. (2007). The polyvagal perspective. Biol Psychol, 74(2), 116-143.
Potter, G. G., McQuoid, D. R., Whitson, H. E., & Steffens, D. C. (2016). Physical frailty in late-life depression is associated with deficits in speed-dependent executive functions. Int J Geriatr Psychiatry, 31(5), 466-474.
Quandt, F., Bönstrup, M., Schulz, R., Timmermann, J. E., Mund, M., Wessel, M. J., & Hummel, F. C. (2019). The functional role of beta-oscillations in the supplementary motor area during reaching and grasping after stroke: A question of structural damage to the corticospinal tract. Hum Brain Mapp, 40(10), 3091-3101.
Qureshi, N. A., & Al-Bedah, A. M. (2013). Mood disorders and complementary and alternative medicine: a literature review. Neuropsychiatr Dis Treat, 9, 639-658.
Raghuraj, P., Ramakrishnan, A. G., Nagendra, H. R., & Telles, S. (1998). Effect of two selected yogic breathing techniques of heart rate variability. Indian J Physiol Pharmacol, 42(4), 467-472.
Rockwood, K., Song, X., MacKnight, C., Bergman, H., Hogan, D. B., McDowell, I., & Mitnitski, A. (2005). A global clinical measure of fitness and frailty in elderly people. Canadian Medical Association Journal, 173(5), 489-495.
Santaella, D. F., Devesa, C. R., Rojo, M. R., Amato, M. B., Drager, L. F., Casali, K. R., Montano, N., & Lorenzi-Filho, G. (2011). Yoga respiratory training improves respiratory function and cardiac sympathovagal balance in elderly subjects: a randomised controlled trial. BMJ Open, 1(1), e000085.
Schwenk, M., Mohler, J., Wendel, C., D'Huyvetter, K., Fain, M., Taylor-Piliae, R., & Najafi, B. (2015). Wearable sensor-based in-home assessment of gait, balance, and physical activity for discrimination of frailty status: baseline results of the Arizona frailty cohort study. Gerontology, 61(3), 258-267.
Shen, Z., Jiang, L., Yang, S., Ye, J., Dai, N., Liu, X., Li, N., Lu, J., Liu, F., Lu, Y., Sun, X., Cheng, Y., & Xu, X. (2017). Identify changes of brain regional homogeneity in early and later adult onset patients with first-episode depression using resting-state fMRI. PLOS ONE, 12(9), e0184712.
Stancák, A., Jr., Kuna, M., Srinivasan, Dostálek, C., & Vishnudevananda, S. (1991). Kapalabhati--yogic cleansing exercise. II. EEG topography analysis. Homeost Health Dis, 33(4), 182-189.
Strawbridge, W. J., Shema, S. J., Balfour, J. L., Higby, H. R., & Kaplan, G. A. (1998). Antecedents of Frailty Over Three Decades in an Older Cohort. The Journals of Gerontology: Series B, 53B(1), S9-S16.
Suttajit, S., Punpuing, S., Jirapramukpitak, T., Tangchonlatip, K., Darawuttimaprakorn, N., Stewart, R., Dewey, M. E., Prince, M., & Abas, M. A. (2010). Impairment, disability, social support and depression among older parents in rural Thailand. Psychol Med, 40(10), 1711-1721.
Telles, S., Singh, N., & Balkrishna, A. (2011). Heart rate variability changes during high frequency yoga breathing and breath awareness. Biopsychosoc Med, 5, 4.
Tew, G. A., Howsam, J., Hardy, M., & Bissell, L. (2017). Adapted yoga to improve physical function and health-related quality of life in physically-inactive older adults: a randomised controlled pilot trial. BMC Geriatr, 17(1), 131.
Thayer, J. F., Yamamoto, S. S., & Brosschot, J. F. (2010). The relationship of autonomic imbalance, heart rate variability and cardiovascular disease risk factors. Int J Cardiol, 141(2), 122-131.
Ugurbil, K. (2016). What is feasible with imaging human brain function and connectivity using functional magnetic resonance imaging. Philos Trans R Soc Lond B Biol Sci, 371(1705).
van Iersel, M. B., Munneke, M., Esselink, R. A., Benraad, C. E., & Olde Rikkert, M. G. (2008). Gait velocity and the Timed-Up-and-Go test were sensitive to changes in mobility in frail elderly patients. J Clin Epidemiol, 61(2), 186-191.
Wai, Y. Y., Wang, J. J., Weng, Y. H., Lin, W. Y., Ma, H. K., Ng, S. H., Wan, Y. L., & Wang, C. H. (2012). Cortical involvement in a gait-related imagery task: comparison between Parkinson's disease and normal aging. Parkinsonism Relat Disord, 18(5), 537-542.
White, O., Davare, M., Andres, M., & Olivier, E. (2014). The Role of Left Supplementary Motor Area in Grip Force Scaling. PLOS ONE, 8(12), e83812.
Zang, Y., Jiang, T., Lu, Y., He, Y., & Tian, L. (2004). Regional homogeneity approach to fMRI data analysis. Neuroimage, 22(1), 394-400.
Zhang, P., Wang, F., Hu, J., & Sorrentino, R. (2013). Exploring the relationship between drug side-effects and therapeutic indications. AMIA Annu Symp Proc, 2013, 1568-1577.