Introduction
Falling is one of the most common problems related to health in old age. Loss of balance is one of the most important factors causing falls in the elderly [4]. Deficit in cognitive function is other risk factor of falling in the elderly [7]. Since most falls occur as a result of the interaction between physical and cognitive risk factors, exercises that include all risk factors should be used to prevent and reduce falls. Therefore, it seems to be beneficial to use mind-body exercises that can affect the mind and body at the same time [8]. Studies have shown the positive effects of yoga and square-stepping exercise (SSE) on improving balance and cognitive functions of the elderly [8, 21]. The purpose of this study is to investigate the difference between the effects of yoga and SSE on memory quotient, static and dynamic balance and fear of falling in older women.

Methods
This is a quasi-experimental study. Participants were 20 older women aged 60-70 years from Isfahan, Iran, who were selected purposefully, and randomly divided into two groups of SSE (n=10) and yoga (n=10). To measure the cognitive functions, Wechsler memory scale and mini-mental state examination were used. Physical functions were measured by the Berg balance scale, timed up and Go test and stork test. The fear of falling was measured by the fall efficacy scale-International.
The exercises were performed for three months. Participants in the yoga group performed stretching and breathing exercises for the first 15 minutes to warm up. The next 40 minutes were devoted to yoga exercises. At the end, a 15-min cooling down phase was included, focusing on performing low-intensity stretching movements. The SSE program also lasted for 70 minutes. In the first 15 minutes, exercises such as slow walking and simple stretching exercises were performed to warm up. The next 40 minutes were devoted to the main exercises performed on a 100×250 cm mat that was divided into 40 identical squares. The SSE consist of 196 step patterns, which are categorized according to the increasing level of complexity into eight levels (elementary, 1–2; intermediate, 1–3; and advanced, 1–3). In this study, a total of 140 step patterns were performed at six levels: Elementary 1-2, intermediate 1-3 and advanced 1). Analysis of variance with repeated measures (2×2) was conducted to analyze the collected data.

Results
In the examination of memory quotient, the within-group effect of time (F(1, 18)=32.692, P<0.001, η2=0.645) was significant and the mean score after training was significantly more than the pretest score. Regarding the static balance, the between-group effect (F(1, 18)=34.039, P<0.001, η2=0.582) and the within-group effect (F(1, 18)=148.041, P<0.001, η2=0.892) of time as well as the interaction effect of time and group (F(1, 18)=60.755, P<0.001, η2=0.771) was significant. According to the results of Bonferroni post hoc test, in the yoga group (P<0.001) and SSE group (P=0.006), the mean static balance score after the exercise was significantly higher than before the exercise. After performing the exercises, the mean score of static balance was higher in the yoga group than in the SSE group (P<0.001).
Regarding the dynamic balance, the within-group effect of time (F(1, 18)=21.429, P<0.001, η2=0.543) and the interaction effect of time and group (F(1, 18)=7.714, P=0.012, η2=0.300) was significant. According to the results of Bonferroni post hoc test, in the yoga group, the mean score of dynamic balance was not significantly different before and after the exercise (P=0.207), but it was significant in the SSE group (P<0.001). After performing the exercises, the mean score of dynamic balance was higher in the SSE group than in the yoga group (P<0.033).
Regarding the fear of falling, the within-group effect of time (F(1, 18)=32.715, P<0.001, η2=0.645) and the interaction effect of time and group (F(1, 18)=11.777, P= 0.003, η2=0.396) was significant. According to the results of Bonferroni post hoc test, in the yoga group, the mean score of fear of falling was not significantly different before and after the exercise (P=0.123) but it was significant in the SSE group (P<0.001). After performing the exercises, the mean score of fear of falling was lower in the SSE group than in the yoga group (P<0.045).

Conclusion
The results of the current study showed the beneficial effects of yoga on memory quotient and static balance, and the effect of SSE on improving dynamic and static balance and reducing the fear of falling in older women after performing 12 weeks of exercises. Since most falls in older adults occur as a result of the interaction between multiple physical and cognitive risk factors, to prevent and reduce falls, methods must be used that include all risk factors. From this point of view, it seems that the use of mind-body exercises that can simultaneously affect the mind and body and improve physical and cognitive functions are beneficial in older women.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the University of Isfahan (Code: IR.UI.REC.1400.048). Written informed consent was obtained from all participants.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Study design, supervision and data analysis: Maryam Nazakat Al-Hosseini, and Sheila Safavi Hamami; Implementation of exercise protocol: Marzie Eskandari.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
The authors would like to thank Isfahan Mohabbate Foundation Association, the yoga instructors, and all senior women participated in this study for their cooperation.


References

1. Sivaramakrishnan D, Fitzsimons C, Kelly P, Ludwig K, Mutrie N, Saunders DH, et al. The effects of yoga compared to active and inactive controls on physical function and health related quality of life in older adults-systematic review and meta-analysis of randomised controlled trials. The International Journal of behavioral Nutrition and Physical Activity. 2019; 16(1):33. [DOI:10.1186/s12966-019-0789-2] [PMID] [PMCID]
2. Joolaei N, Bagherli J, Sanatkaran A. [The effects of regular pilates exercise on long- term and short- term memory of the elderly (Persian)]. Aging Psychology. 2017; 3(2):147-57. [Link]
3. Bhanusali H, Vardhan V, Palekar T, Khandare S. Comparative study on the effect of square stepping exercises versus balance training exercises on fear of fall and balance in elderly population. International Journal of Physiotherapy and Research. 2016; 4(1):1352-59. [DOI:10.16965/ijpr.2015.206]
4. Thomas E, Battaglia G, Patti A, Brusa J, Leonardi V, Palma A, et al. Physical activity programs for balance and fall prevention in elderly: A systematic review. Medicine. 2019; 98(27):e16218. [DOI:10.1097/md.0000000000016218] [PMID] [PMCID]
5. Rubenstein LZ. Falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing. 2006; 35(suppl_2):ii37-41. [DOI:10.1093/ageing/afl084] [PMID]
6. Shirooka H, Nishiguchi S, Fukutani N, Tashiro Y, Nozaki Y, Hirata H, et al. Cognitive impairment is associated with the absence of fear of falling in community‐dwelling frail older adults. Geriatrics & Gerontology International. 2017; 17(2):232-8. [DOI:10.1111/ggi.12702] [PMID]
7. Karimi E, Hassani Mehraban A, Akbar Fahimi M, Maghfouri B, Jamali AR. [A self-report home environment screening tool for determining fall risk in Iranian older people (Persian)]. Salmand: Iranian Journal of Ageing. 2019; 14 (3):272-83. [Link]
8. Edwards E. The effects of a yoga intervention on cognitive function in older adults [MA thesis]. Logan: Utah State University; 2018. [DOI:10.26076/f9d6-e5af]
9. Vaezi A, Tafti AD, Goodari SB, Bidaki R. Effect of yoga on memory in elderly women. Elderly Health Journal. 2020; 6(1):3-8. [DOI:10.18502/ehj.v6i1.3409]
10. Tendulkar SS, Bangad AS, Yeole UL. Effect of square-stepping exercise on Physiological cost index in elderly Population. International Journal of Academic Research and Development. 2018; 3(1):240-4. [Link]
11. De la Torre J, Marin J, Polo M, Marín JJ. Applying the minimal detectable change of a static and dynamic balance test using a portable stabilometric platform to individually assess patients with balance disorders. Healthcare. 2020; 8(4):402. [DOI:10.3390/healthcare8040402] [PMID] [PMCID]
12. Khesali Z, Mohammadi Shahboulaghi F, Khankeh H, Biglarian A. [Effect of "Tai Chi Chuan" on anxiety among elderly women (Persian)]. Journal of Nursing,Midwifery and Paramedical. 2018; 3(4):15-23. [DOI:10.29252/sjnmp.3.4.15]
13. Bademli K, Lok N, Canbaz M, Lok S. Effects of physical activity program on cognitive function and sleep quality in elderly with mild cognitive impairment: A randomized controlled trial. Perspect Psychiatr Care. 2019; 55(3):401-8. [DOI:10.1111/ppc.12324] [PMID]
14. Mokhtari M, Nezakatalhossaini M, Esfarjani F. The effect of 12-week pilates exercises on depression and balance associated with falling in the elderly. Procedia - Social and Behavioral Sciences. 2013; 70:1714-23. [DOI:10.1016/j.sbspro.2013.01.246]
15. Aibar-Almazán A, Martínez-Amat A, Cruz-Díaz D, De la Torre-Cruz MJ, Jiménez-García JD, Zagalaz-Anula N, et al. Effects of Pilates on fall risk factors in community-dwelling elderly women: A randomized, controlled trial. European Journal of Sport Science. 2019; 19(10):1386-94. [DOI:10.1080/17461391.2019.1595739] [PMID]
16. Taylor-Piliae RE, Newell KA, Cherin R, Lee MJ, King AC, Haskell WL. Effects of Tai Chi and Western exercise on physical and cognitive functioning in healthy community-dwelling older adults. Journal of Aging and Physical Activity. 2010; 18(3):261-79. [DOI:10.1123%2Fjapa.18.3.261] [PMID] [PMCID]
17. Gothe NP, Kramer AF, McAuley E. The effects of an 8-week Hatha yoga intervention on executive function in older adults. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 2014; 69(9):1109-16. [DOI:10.1093/gerona/glu095] [PMID] [PMCID]
18. Taheri M, Irandoust K, Seghatoleslami A, Rezaei M. [The effect of yoga practice based on biorhythms theory on balance and selective attention of the elderly women (Persian)]. Salmand: Iranian Journal of Ageing. 2018; 13(3):312-23. [DOI:10.32598/sija.13.3.312]
19. Bucht H, Donath L. Sauna yoga superiorly improves flexibility, strength, and balance: A two-armed randomized controlled trial in healthy older adults. International Journal of Environmental Research and Public Health. 2019; 16(19):3721. [DOI:10.3390/ijerph16193721] [PMID] [PMCID]
20. Shigematsu R, Okura T. A novel exercise for improving lower-extremity functional fitness in the elderly. Aging Clinical and Experimental Research. 2006; 18(3):242-8. [DOI:10.1007/bf03324655] [PMID]
21. Pereira JR, Gobbi S, Teixeira CVL, Nascimento CMC, Corazza DI, Vital TM, et al. Effects of Square-Stepping Exercise on balance and depressive symptoms in older adults. Motriz. 2014; 20(4):454-60. [DOI:10.1590/S1980-65742014000400013]
22. Pramita I. Square stepping exercise improve short-term memory in elderly. International Conference on Fundamental and Applied Research (I-CFAR). 2020; 225-228. [Link]
23. Gardner MM, Buchner DM, Robertson MC, Campbell AJ. Practical implementation of an exercise‐based falls prevention programme. Age and Ageing. 2001; 30(1):77-83. [DOI:10.1093/ageing/30.1.77] [PMID]
24. Choudhary A, Pathak A, Manickam P, Purohit M, Rajasekhar TD, Dhoble P, et al. Effect of yoga versus light exercise to improve well-being and promote healthy aging among older adults in central India: A study protocol for a randomized controlled trial. Geriatrics. 2019; 4(4):64. [DOI:10.3390/geriatrics4040064] [PMID] [PMCID]
25. Brunner D, Abramovitch A, Etherton J. A yoga program for cognitive enhancement. Plos One. 2017; 12(8):e0182366. [DOI:10.1371%2Fjournal.pone.0182366] [PMID] [PMCID]
26. Wang YY, Chang HY, Lin CY. Systematic review of yoga for depression and quality of sleep in the elderly. Hu Li Za Zhi. 2014; 61(1):85-92. [DOI:10.6224/jn.61.1.85]
27. Ramanathan M, Bhavanani AB, Trakroo M. Effect of a 12-week yoga therapy program on mental health status in elderly women inmates of a hospice. International Journal of Yoga. 2017; 10(1):24-8. [DOI:10.4103/0973-6131.186156] [PMID] [PMCID]
28. Chen KM, Chen MH, Lin MH, Fan JT, Lin HS, Li CH. Effects of yoga on sleep quality and depression in elders in assisted living facilities. The Journal of Nursing Research. 2010; 18(1):53-61. [DOI:10.1097/jnr.0b013e3181ce5189] [PMID]
29. Groessl EJ, Maiya M, Schmalzl L, Wing D, Jeste DV. Yoga to prevent mobility limitations in older adults: Feasibility of a randomized controlled trial. BMC Geriatrics. 2018; 18(1):306.[DOI:10.1186/s12877-018-0988-8] [PMID] [PMCID]
30. Teixeira CV, Gobbi S, Pereira JR, Vital TM, Hernandéz SS, Shigematsu R, et al. Effects of square‐stepping exercise on cognitive functions of older people. Psychogeriatrics. 2013; 13(3):148-56. [DOI:10.1111/psyg.12017] [PMID]
31. Foroughan M, Jafari Z, Shirin Bayan P, Ghaem Magham Farahani Z, Rahgozar M. [Validation of Mini Mental State (MMSE) in the elderly population of Tehran (Persian)]. Advances in Cognitive Sciences. 2008; 10(2):29-37. [Link]
32. Zare H, Siahjani L. [The efficacy of cognitive rehabilitation on mental state and memory function of the elderly with mild Alzheimer's (Persian)]. Advances in Cognitive Sciences. 2018; 20(3):51-66. [Link]
33. Orangi M, Atefvahid MK, Ashayeri H. [Standardization of the Revised Wechsler Memory Scale in Shiraz (Persian)]. Iranian Journal of Psychiatry and Clinical Psychology. 2002; 7(4):56-66. [Link]
34. Riddle DL, Stratford PW. Interpreting validity indexes for diagnostic tests: An illustration using the Berg balance test. Physical Therapy. 1999; 79(10):939-48. [DOI:10.1093/ptj/79.10.939] [PMID]
35. Bird ML, Hill KD, Fell JW. A randomized controlled study investigating static and dynamic balance in older adults after training with Pilates. Archives of Physical Medicine and Rehabilitation. 2012; 93(1):43-9. [DOI:10.1016/j.apmr.2011.08.005] [PMID]
36. Zhou X, Zhang C, Li L, Zhang Y, Zhang W, Yin W, et al. Altered brain function in cerebral small vessel disease patients with gait disorders: A Resting-State Functional MRI Study. Frontiers in Aging Neuroscience. 2020; 12:234. [DOI:10.3389/fnagi.2020.00234] [PMID] [PMCID]
37. Asadi Samani Z, Rahnama N, Reisi J, Lenjan Nejadian Sh. [Effect of 3 months square stepping exercise and resistance training on postural balance and fear of falling in elderly woman (Persian)]. Studies in Sport Medicine. 2019; 11(25):59-80. [DOI:10.22089/smj.2019.7369.1375]
38. Jafari M, SHamshiri M. [Reviewing the static and dynamic balance in predicting the risk of falls in elderly people in Tehran (Persian)]. Nursing and Midwifery Journal. 2015; 12(11):1045-53. [Link]
39. Lipardo DS, Leung AYM, Gabuyo CMA, Escuadra CJT, Leung PA, Aseron AMC, et al. Cross-cultural adaptation and psychometric properties of the Falls Efficacy Scale-International in Filipino community-dwelling older adults. Disability and Rehabilitation. 2020; 42(9):1292-8. [DOI:10.1080/09638288.2018.1519045] [PMID]
40. Khajavi D, MoradiVeghar M. [Investigation of Validity and Reliability of Persian Translation of "Modified Gait Efficacy Scale" in older adults in Qom City (Iran) (Persian)]. Qom University of Medical Sciences Journal. 2017; 11(9):70-8. [Link]
41. Greendale GA, Kazadi L, Mazdyasni S, Ramirez E, Wang MY, Yu SS, et al. Yoga Empowers seniors study (YesS): Design and Asana series.Journal of Yoga & Physical Therapy. 2012; 2(1):107. [PMID]
42. Giannouli E, Morat T, Zijlstra W. A Novel Square-Stepping Exercise Program for Older Adults (StepIt): Rationale and implications for falls prevention. Frontiers in Medicine. 2020; 6:318. [DOI:10.3389%2Ffmed.2019.00318] [PMID] [PMCID]
43. Tait JL, Duckham RL, Milte CM, Main LC, Daly RM. Influence of sequential vs. simultaneous dual-task exercise training on cognitive function in older adults. Frontiers in Aging Neuroscience. 2017; 9:368. [DOI:10.3389/fnagi.2017.00368] [PMID] [PMCID]
44. Chobe S, Chobe M, Metri K, Patra SK, Nagaratna R. Impact of Yoga on cognition and mental health among elderly: A systematic review. Complementary Therapies in Medicine. 2020; 52:102421. [DOI:10.1016/j.ctim.2020.102421] [PMID]
45. PP SJ, Manik KA, Sudhir PK. Role of yoga in attention, concentration, and memory of medical students. National Journal of Physiology, Pharmacy and Pharmacology. 2018; 8(11):1526-8. [DOI:10.5455/njppp.2018.8.0723521082018]
46. Shouhani M, Jalilian M, Parsaei S, Modara F, Seidkhani H. [The effect of unilateral and bilateral electrical stimulation of the brain on improving the balance of the elderly (Persian)]. Salmand: Iranian Journal of Ageing. 2020; 15(3):312-23. [DOI:10.32598/sija.10.15.3.1895.3]
47. Shumway-Cook A, Woollacott M, Kerns KA, Baldwin M. The effects of two types of cognitive tasks on postural stability in older adults with and without a history of falls. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. 1997; 52(4):232-40. [DOI:10.1093/gerona/52a.4.m232] [PMID]
48. Kjaer TW, Bertelsen C, Piccini P, Brooks D, Alving J, Lou HC. Increased dopamine tone during meditation-induced change of consciousness. Brain Research. Cognitive Brain Research. 2002; 13(2):255-9. [DOI:10.1016/S0926-6410(01)00106-9] [PMID]
49. Aftanas LI, Golocheikine SA. Human anterior and frontal midline theta and lower alpha reflect emotionally positive state and internalized attention: High-resolution EEG investigation of meditation. Neuroscience Letters. 2001; 310(1):57-60. [DOI:10.1016/S0304-3940(01)02094-8] [PMID]
50. Aragão FA, Karamanidis K, Vaz MA, Arampatzis A. Mini-trampoline exercise related to mechanisms of dynamic stability improves the ability to regain balance in elderly. Journal of Electromyography and Kinesiology. 2011; 21(3):512-8. [DOI:10.1016/j.jelekin.2011.01.003] [PMID]