A Thesis Submitted to the Graduate Faculty of The University of Georgia in ..... community-based physical activity program that leads to meaningful gains in ...
IMPROVED PHYICAL FUNCTION AND PHYSICAL ACTIVITY IN DEPRESSED AND NON-DEPRESSED OLDER ADULTS FOLLOWING A COMMUNITY-BASED INTERVENTION IN GEORGIA SENIOR CENTERS By KATHRYN N. PORTER (Under the Direction of Mary Ann Johnson) ABSTRACT The purpose of this study was to explore the relationship of depression with physical activity and physical function before and after a physical activity intervention of congregate meal participants in senior centers from all 12 Georgia Area Agencies on Aging (AAA). Participants were a convenience sample of older adults (n = 614, mean age = 75 years, 81% female, 62% Caucasian, 38% African American, 23% depressed). The physical activity intervention included educator-led chair exercises that incorporated balls and bands. Pre- and post-tests assessed physical activity and physical function. At the pre-test, depression was related to less moderate physical activity, but was not related to physical function. Following the intervention there were increases in physical activity and physical function. Contrary to expectations, depression was a positive predictor of improvement in physical function following the intervention. These results provide an evidence base for the effectiveness of this intervention in improving physical activity and physical function in a community setting. Moreover, the relatively high prevalence of depression in this sample was not a barrier to these improvements.
INDEX WORDS:
Older Americans Act Program, Community-based intervention, Depression, Physical Activity, Physical Function, Short Physical Performance Battery (SPPB)
IMPROVED PHYICAL FUNCTION AND PHYSICAL ACTIVITY IN DEPRESSED AND NON-DEPRESSED OLDER ADULTS FOLLOWING A COMMUNITY-BASED INTERVENTION IN GEORGIA SENIOR CENTERS
by
KATHRYN N. PORTER B.S.ED, The University of Georgia, 2006
A Thesis Submitted to the Graduate Faculty of The University of Georgia in Partial Fulfillment of the Requirements for the Degree
MASTER OF SCIENCE
ATHENS, GEORGIA 2009
© 2009 Kathryn N. Porter All Rights Reserved
IMPROVED PHYICAL FUNCTION AND PHYSICAL ACTIVITY IN DEPRESSED AND NON-DEPRESSED OLDER ADULTS FOLLOWING A COMMUNITY-BASED INTERVENTION IN GEORGIA SENIOR CENTERS
by
KATHRYN N. PORTER
Electronic Version Approved: Maureen Grasso Dean of the Graduate School The University of Georgia May 2009
Major Professor:
Mary Ann Johnson
Committee:
Joan G. Fischer Jung Sun Lee
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DEDICATION This work is dedicated to my great grandmother, Pearl Porter for her instilment of hard work, dedication and perseverance. To my grandfather, Paul Porter for continuously reminding me that education is one thing no one can take away. To my parents, David and Kathy Porter for their unending love, support and encouragement; this is for you.
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ACKNOWLEDGEMENTS First and foremost I would like to thank my major professor, Dr. Mary Ann Johnson for her endless support, patience, encouragement, and invaluable advice. Her unending passion for others is inspiring; her humanitarianism and selflessness is something we should all aspire to attain. Dr. Johnson thank you for your inspiration and drive to make the world a better place, I have been blessed to have you as my mentor and friend. I am forever indebted. I would also like to thank my advisory committee, Dr. Joan Fischer and Dr. Jung Sun Lee, for their guidance, professional expertise, and support throughout my scholastic journey. I would like to thank Dr. Johnson’s laboratory staff and fellow graduate students for all of their hard work from beginning to end to successfully complete this study. I would like to extend a special thanks to Christina Catlett and Dawn Penn for their unending support and encouragement. I couldn’t have done this without you. Finally, I would like to thank my family for their love and support throughout my entire education. There are no words to explain my gratitude for you. God has truly blessed me.
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TABLE OF CONTENTS Page ACKNOWLEDGEMENTS.........................................................................................................v LIST OF TABLES ...................................................................................................................viii CHAPTER 1
INTRODUCTION .....................................................................................................1
2
LITERATURE REVIEW...........................................................................................4 The Older Adult Population...................................................................................4 Older Americans Act Nutrition Program................................................................5 Older Adults and Depression .................................................................................6 Physical Inactivity, Poor Physical Function, and Depression .................................9 Physical Activity As a Supplemental Treatment for Depression...........................11 The Health Belief Model .....................................................................................13 Previous Successful Interventions........................................................................14 Rationale, Specific Aims, and Hypotheses ...........................................................16
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IMPROVED PHYSICAL FUNCTION AND PHYSICAL ACTIVITY IN DEPRESSED AND NON-DEPRESSED OLDER ADULTS FOLLOWING A COMMUNITY-BASED INTERVENTION IN GEORGIA SENIOR CENTERS 18 Abstract...............................................................................................................19 Introduction.........................................................................................................20 Methods and Design ............................................................................................21
vii Results.................................................................................................................25 Discussion ...........................................................................................................27 Acknowledgements ............................................................................................33 4
CONCLUSIONS .....................................................................................................44
REFERENCES .........................................................................................................................48 APPENDICES ..........................................................................................................................56 A
Power Analysis ........................................................................................................57
B
Physician’s Clearance ..............................................................................................59
C
Intervention Pre-test/Post-Test .................................................................................61
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LIST OF TABLES Page Table 3.1: Characteristics of Participants in Georgia Senior Centers, 2007-2008 .......................35 Table 3.2: Physical Activity and Depression in Georgia Senior Centers, 2007-2008..................36 Table 3.3: Physical Function and Depression in Georgia Senior Centers, 2007-2008.................37 Table 3.4: Changes in Physical Activity Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008..........................................................................................38 Table 3.5: Changes in Physical Function Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008..........................................................................................40 Table 3.6: Regression Models Exploring Predictors of Physical Activity at Pre-test and Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008...41 Table 3.7: Regression Models Exploring Predictors of Physical Function at Pre-test and Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008...43
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CHAPTER 1 INTRODUCTION The older adult population in the US is growing at a rapid rate. In 2007, the US Census Bureau estimated that 37.9 million people were aged 65 and older, accounting for 13% of the total population (US Census Bureau, 2008). This population continues to grow by 500,000 people each year and is expected to reach approximately 90 million by 2050, making up nearly one-fourth of the entire US population (US Census Bureau, 2008; USDHHS, AoA, 2007). As with most states, Georgia has also experienced an increase in the number of older adults. Ten percent of Georgia’s population is 65 and older, and is estimated to reach 13% by 2020, ranking Georgia’s elderly population as the eleventh largest in total number of older adults in the United States (US Census Bureau, 2008; AoA, 2006). Furthermore, life expectancy is also increasing. In 2004, men and women aged 65 and older averaged an additional 18.7 years of life (USDDHS, AoA, 2007). However, longer life does not always equate to better health; research shows that even though the quantity of years has increased, the quality of life for many seniors has not improved (Merck Institute, 2004). It is estimated that up to 80% of adults 65 and older have at least one chronic disease (Center for Disease Control and Prevention and The Merck Foundation, 2007). Major contributors to the increased prevalence of disease include poor nutritional habits and physical inactivity (Division of Adult and Community Health, National Center for Chronic Diseases Prevention and Health Promotion, 2008). Decreased quality of life in this population is also associated with poor mental health (Chapman et al., 2008). Depression in older adults is associated with physical inactivity, poor physical function, and often appears concurrently with
2 chronic diseases. Depression creates a continuous cycle of physical, emotional, and psychological disorders (Paluska et al., 2000; NCCDPHP, Chapman et al., 2008) that is detrimental to well-being. Up to 20% of community-dwelling older adults may be depressed (Beyer et al, 2007; Palmer, 2005; USDHHS, 1999) and the CDC estimates that among adults 50 and older the prevalence of a lifetime diagnosis of depression is 15.7% nationally and 18% for Georgia (Center for Disease Control and Prevention and National Association of Chronic Disease Directors, 2008). Nutritional, mental, and physical health are related to overall quality of life and wellbeing in older adults. The Older Americans Act Nutrition Program (OAANP), under the Older Americans Act (OAA), is a federal program that provides nutritional services, community interactions, and social support networks for older adults, and targets their services to seniors living in rural areas, seniors with high socioeconomic needs, and minority seniors with lowincome levels (AoA, 2008). These programs are offered throughout the US and administered through State Units on Aging, Area Agencies on Aging (AAA), and local providers to improve the overall well-being of this high risk population (AoA, 2008; Millen et al., 2002). Due to the high prevalence of depression and physical inactivity in Georgia, and their negative impact on the health of older adults, the purpose of the current study was to evaluate the influence of depression on physical activity and physical function before and after an intervention designed to improve nutrition, physical activity, and physical function in older adults. The study was conducted in senior centers throughout Georgia in all 12 AAA, and this convenience sample was largely composed of participants of the Older Americans Act programs. The intervention was developed using the Health Belief Model (Stretcher and Rosenstock, 2007) and focused on nutrition, health, physical activity, and physical function. The study included a
3 pre-test evaluation, implementation of an intervention that had 12 sessions, each with a physical activity component, and a post-test evaluation. The intervention used in the current study was similar to a previously successful interventions that focused on physical activity (Fitzpatrick et al., 2008; Bell et al., 2009), with the exception that we included more chair exercises (a total of 32), incorporated both exercise balls and bands to enhance interest and flexibility, and assessed history of depression (BRFSS, 2006). The important contribution of this study is that it provides evidence of the benefits of a community-based physical activity program that leads to meaningful gains in physical activity and physical function in older adults at senior centers, and provides information on the potential role that depression may play in physical activity and physical function in the target population. Chapter 2 is a review of the literature outlining the prevalence of depression, the impact is has on physical activity, physical function, and overall quality of life, and a review of the successful programs targeted to improve, prevent, and manage these issues in the older adult population. The frame-work of this and previous successful interventions is based on the Health Belief Model in hopes to instill self-sustaining impacts on the target population. Chapter 3 is a manuscript to be submitted to the journal of Nutrition for the Elderly. This chapter includes the methods, results, discussion of the outcomes from the physical activity intervention, and data tables. Chapter 4 presents a summary of the major findings and conclusions for this study.
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CHAPTER 2 LITERATURE REVIEW
The Older Adult Population The older adult population in the US is growing at a rapid rate. In 2007, the US Census Bureau estimated that 37.9 million people were 65 and older, accounting for 13% of the total population (US Census Bureau, 2008). This population continues to grow by 500,000 each year and is expected to reach approximately 90 million by 2050, making up nearly one-fourth of the entire US population (US Census Bureau, 2008; USDHHS, AoA, 2007). As with most states, Georgia has also experienced an increase in the number of older adults. Ten percent of Georgia’s population is 65 and older, and it is estimated that it will reach 13% by 2020, ranking Georgia’s elderly population as the eleventh largest in the total number of older adults in the United States (US Census Bureau, 2008; AoA, 2005). Life expectancy is increasing as well. In 2004, men and women aged 65 and older averaged an additional 18.7 years of life (USDDHS, AoA, 2007). However, longer life does not always equate to better health; research shows that even though the quantity of years has increased, the quality of life for many seniors has not (Merck Institute, 2004). It is estimated that up to 80% of older adults have at least one chronic disease (Center for Disease Control and Prevention and The Merck Foundation, 2007). Major contributors to the increased prevalence of disease include poor nutritional habits and physical inactivity (Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion, 2008). Decreased quality of life in this population is also associated with poor mental health (Chapman et al., 2008). Depression in older adults is
5 associated with physical inactivity, poor physical function, and often appears concurrently with chronic diseases. Depression creates a continuous cycle of physical, emotional, and psychological disorders (Paluska et al., 2000; NCCDPHP, 2008, Chapman et al., 2008) that is detrimental to well-being. Older Americans Act Nutrition Program The nutritional status of older adults is one aspect of aging that is directly related to their overall quality of life and health. The Older Americans Act Nutrition Program (OAANP) established in 1972, under Title III of the Older American Act (OAA), provides federal grants to state Agencies on Aging (AoA, 2008). This program supports the distribution of congregate and home-delivered meals, nutrition education, health screening, and other nutrition-, health-, and wellness-related services to aid adults aged 60 and older. The OAANP works to improve dietary intake, establish social interactions, and provide support networks that empower and enable older adults to delay their loss of independence. The population that the OAANP and other OAA programs target are seniors living in rural areas, seniors with high socioeconomic needs, and minority seniors with low-income levels. Targeting those with financial needs is important because in 2007 about 17.3% of adults 65 and older were under 130% of the poverty line (U.S. Bureau of Census, 2008). In 2003, the OAANP congregate nutrition services reported that 43% of participants were at high nutritional risk, 58% received half or more of their daily food intake from the provided meal, and 11% reported not having enough money or food stamps to buy food (AoA, 2008). These alarming statistics show that many of these seniors have poor nutritional status and heavily rely on this program for daily meals (AoA, 2008). While this federal program covers the United States through 57 State Units on Aging, 655 Area Agencies on Aging (AAA), and approximately 4,000 local providers, it only reaches approximately 7% of the older
6 population and 20% of the poor older population annually (AoA, 2008; Millen et al., 2002). However, evaluations of this program have shown it to be effective and efficient in providing services for older adults, and in improving dietary intake and social contacts in participants as compared to seniors not involved in these programs (AoA, 2008). As the number of older adults continues to grow it is essential that these supportive programs continue to be created and implemented for this high risk population. Older Adults and Depression In addition to concerns regarding poor nutritional status, many older adults are also dealing with depression. Depression is considered to be one of the five major health problems afflicting older adults (Moore et al., 1999). It is estimated that by 2020, depression, measured as disability-adjusted age, will be the second leading burden of disease among older adults (Murray et al., 1996). Depression in older adults has recently been reviewed (Beyer 2007; Palmer, 2005). One to 4% of older adults experience major depressive disorders, defined in the Diagnostic and Statistical Manual, Fourth Edition (DSM-IV, American Psychiatric Association, 2004), that are characterized by having at least one of the following: a persistent depressed mood or loss of interest or pleasure of activities that were previously pleasurable, along with four or more of the following symptoms: significant weight gain or loss, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of worthlessness or inappropriate guilt, impaired concentration, and recurrent thoughts of death during the same 2-week interval (Blazer et al., 2003; Beyer et al., 2007). Significant depressive symptoms (e.g., minor depression) occur in 5% to 25% of the older adult population, depending on living situation (Beyer et al., 2007). Beyer et al. (2007) and Palmer (2005) reported that 8% to 20% of seniors living in communities report minor depressive disorders, while the prevalence of depressed seniors in nursing homes can
7 range from 17% to 37%. In 2006, 15% of adults 65 and older nation-wide reported having a history of depression, while 18% of Georgia’s older adults reported a history of depression (Centers for Disease Control and Prevention and National Association of Chronic Disease Directors, 2008). These high prevalence of depression and depressive symptoms are a major concern in Georgia and throughout the US. Identification and treatment of depression has been identified as a key priority in the Healthy People 2010 Objectives (USDHHS, 2000) and the White House Conference on Aging (USDHHS, 2006). The loss of a loved one is common among older adults. A depressed mood would be a typical emotion felt in the grieving process. However, there is a difference between a depressed mood and clinical depression. Depression is a recurrent illness that plagues individuals throughout their entire life. Ninety percent of individuals who undergo a depressive episode will experience one or more recurrent episodes within three years (Glass, 1999; Reynolds et al., 1999). This is typically the reason why depression in later life is one of the major contributors to overall healthcare costs and is associated with 50% to 70% higher healthcare expenses (Chapman et al., 2008; Katon et al., 2003; Luppa et al., 2007). Depression and Health Care Costs Annually, the United States spends 43 billion dollars in indirect and direct healthcare costs for depression. Individually, the additional health care cost for a depressed person of any age compared to a non-depressed person ranges from $1400 to $6195 extra per year. Costs for depressed adults aged 65 and older are even higher, averaging an additional $324 dollars, and increase the total health care costs for older adults by one-third (Luppa et al., 2007; Chisholm et al., 2003). Additionally, a recent study indicated that depressed older adults averaged $763 to $979 more in ambulatory costs and $1045 to $1700 more in ambulatory and inpatient cost
8 compared to non-depressed older adults, resulting in 50% higher medical costs (Katon et al., 2003). Depression and Chronic Disease Seniors with depression often have one or more chronic diseases (Chapman et al., 2008; Alexopoulos, 2005). More than 80% of older Americans, 65 and older, have at least one chronic disease, and of those seniors, 25% have diagnosed depressive symptoms (Division of Adult and Community Health, NCCDPHP, 2008). Outcomes of medical illnesses are significantly affected by depression (Alexopoulos, 2005). Depressed older adults were four times more likely to die four months following a myocardial infarction compared to non-depressed older adults (Alexopoulos, 2005). Furthermore, 50% of older adults who have a myocardial infarction have a depressive disorder (Carney et al., 2003; Romanelli et al., 2002). Consequently, like chronic disease, depression significantly affects a senior’s physical function, overall well-being, and quality of life (Gallo et al., 1997; Bruce et al., 1994; CDC, 2002; NIMH, 2008). Treatment of Depression in Older Adults Late-life depression is often under-diagnosed and under-treated. Prospective studies demonstrated that depression is under-diagnosed in nearly half of all elderly patients (Kaplan et al., 1999;Dantz et al., 2003). Even when the patient is accurately diagnosed, pharmacological therapy is the typical outcome; however, compliance with antidepressant medication is low. A meta-analysis and scientific review estimated that up to 59% of elderly patients prescribed antidepressant medication stop taking it within the first three weeks, resulting in no sustained treatment for these individuals (Lawlor and Hopker, 2001). Furthermore, older adults maintain the highest suicide rates in the United States, and 80% of these suicides have been associated with having depressive symptoms (Montano et al., 2003; Alexopoulos et al., 1999). These
9 statistics illustrate the immense need for finding ways to manage and prevent depressive disorders among this population. Physical Inactivity, Poor Physical Function and Depression Americans, especially older adults, are far from meeting the recommended guidelines for physical activity. The 2005 Dietary Guidelines recommend that older adults engage in regular physical activity to reduce the risk of functional decline and obtain benefits from the overall effects of physical activity (USDHHS and USDA, 2005). However, in 2007, 32.7% of the nations’ seniors and 35.2% of Georgia’s seniors 65 and older reported participating in no “leisure-time” physical activity. Additionally, nationwide 36.9% of older adults and 39.4% of older Georgians do not meet the USDA guidelines for physical activity (NCCDPHP, 2007; USDHHS and USDA, 2005). Physical inactivity accounts for 10% of the direct heath care costs in the United States with an estimated 77 billion dollars that could be saved annually by physically inactive adults becoming active (Centers for Disease Control and Prevention, 2002; Colditz et al., 1999). In one study comparing medical costs of active and inactive women 65 to 74 and 75 + , inactive women 65 to 74 years of age had an average of $500 more in health care costs, whereas women 75 and older averaged more than $1000 in additional health care costs, per year (Pratt et al., 2000). Depression in the elderly has also been associated with physical inactivity and decreased physical function, with affected individuals being more de-conditioned as compared to their nondepressed peers (Paluska et al., 2000). Individuals with little or no physical activity had increased depressive symptoms, higher mortality rates, and lower self-worth (O’Connor et al., 1993; King et al., 1993). Similar to physical inactivity, both physical disability and poor physical function are significantly associated with a higher prevalence of depressive symptoms and
10 disorders (Blazer et al., 1991; Hays et al., 1997). Two recent publications in older communitydwelling adults found that depressed older adults were three times more likely to develop a disability as compared to their non-depressed peers, indicating that depression predicts a decline in physical performance (Dunlop et al., 2005; Pennix et al., 1998). Similarly, a longitudinal study over six years revealed that depressed community dwellers were up to 73% more likely to develop poor physical function and disabilities in mobility and activities of daily living compared to non-depressed older adults (Pennix et al., 2000). In 1994, Guralnik et al. validated the Short Physical Performance Battery (SPPB) that measures lower extremity function in older adults. This performance score is highly associated with increased risk of mortality, nursing home placement, and disability in older adults (Guralnik et al., 1994). Poor physical function, as defined by the SPPB, is also associated with physical inactivity and frailty (Ferrucci et al., 2000). An inverse relationship has been established between physical function and depressive symptoms, indicating that as physical function declines, depressive symptoms increase (Guralnik et al., 1994; Guralnik et al., 1995; Kerse et al., 2008). The relationship of depression with poor physical function is a consistent finding in the literature (Ostir et al., 2007). For example, older women with poor physical function were more likely to have less social participation and have higher depressive symptoms compared to participants who had a good SPPB score (Ostir et al., 2007). Similarly, another study reported that older adults with physical impairments were four times more likely to have depressive symptoms compared to those with good physical function (Strawbridge et al., 2002). The causal relationship between impaired physical function, independent of chronic disease (e.g., cardiovascular, pulmonary, and metabolic) status, and depression is not clear because it is unknown whether or not depression leads to poor physical function or poor physical function is
11 the cause of depression (Zeiss et al., 1996). The research illustrates the interrelationships of poor physical function and depression, potentially leading to psychological and physical decline in the older adult population. Physical Activity as a Supplemental Treatment for Depression While physical inactivity is a predictor for depressive disorders, physical activity also has been associated with decreasing the number of depressive moods (Paluska et al., 2000). As mentioned before, up to 20% of the general older adult population experienced an episode of depression in their lifetime (CDC, 2008). In conjunction with the high prevalence of depressive disorders among this population, depression continues to be under-diagnosed and treated, and patients are often non-compliant with their antidepressant treatment regimens (Guralnik et al., 1994; Lawlor et al., 2001; Kaplan et al., 1999; Dantz et al., 2003). Regular physical activity, as defined by the 2005 Dietary Guidelines as engaging in at least 30 minutes of moderate physical most days of the week, improves mood, decreases depressive symptoms, improves function, and lowers the risk of developing chronic disease (USDHHS and USDA, 2005; CDC, 2002). Additionally, the reduction in depressive symptoms does not appear to be dependent on the duration and intensity of exercise; however, the greatest improvements were seen in the highly depressed groups (North et al., 1990; Craft et al., 1998). Strawbridge et al. found a significant reduction in the risk for developing depression among individuals who participated in higher levels of physical activity (Strawbridge et al., 2002). This protective relationship was consistent with similar studies that reported dose-response relationships of increases in physical activity and less risk of developing depression (Goodwin et al., 2003; Dunn et al., 2001).
12 The American College of Sports Medicine’s expert panel reported that physical activity and psychological function in older adults are related (ACSM, 1998, Nelson et al., 2007). This is supported by evidence that has shown exercise to improve physical function, emotional wellbeing, and social support among older adults (Taylor et al., 2004). Recently, a critical review examined the role of exercise as a treatment for depression among older adults by comparing different benefits of physical activity, social interaction, and pharmacotherapy as treatments for depression (Brosse et al., 2002). Researchers found that depressive symptoms significantly decreased in older adults who participated in exercise walking conditions or who had social contact conditions compared to control groups. Individuals in the exercise group who maintained the exercise program after the completion of the study reported lower depression scores, illustrating the continued benefits of exercise over time (Brosse et al., 2002). Interestingly, in some circumstances exercise treatment has proven to be more beneficial than no treatment and is just as effective as pharmacotherapy in significantly decreasing depressive symptoms. Along with reduction of symptoms, the physically active groups showed evidence of lower recurrence of depressive episodes compared to the pharmacologically treated groups (Blumenthal et al., 1999; Lawlor and Hopker et al., 2001; Brosse et al., 2002). In summary, several studies support the value of physical activity in reducing depressive symptoms and improving physical performance in all populations, especially older adults 65 years old and older. However, due to inconsistencies in measurements of physical activity, physical function, and depression, at this time physical activity interventions are not recognized as a primary treatment for depression (Steinman et al., 2007).
13 The Health Belief Model Since its development in the 1950’s, the conceptual framework of the Health Belief Model has been incorporated in many educational interventions to predict health behaviors (Stretcher and Rosenstock, 2007). The core framework for the model is based on an individual’s readiness to respond when a health-related action outweighs the perceived threat. The readiness of action is based on six key concepts that have been used in previous physical activity interventions conducted by this research team (McCamey et al., 2003; Fitzpatrick et al., 2008; Bell et al., 2009): perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Perceived susceptibility is the risk of developing a condition. For example, it is the likelihood of developing health conditions by being physical inactive. Perceived severity is how an individual views the risks and consequences of the behavior, meaning how severe the consequences of remaining physically inactive are. Perceived benefits are the belief that the preferred action will reduce the severity and risk of the health condition. That is, an individual believes that being physically active will reduce the risk of health conditions that result from a sedentary lifestyle. Perceived barriers are the physical and psychological costs of adopting the preferred action. This would entail the overall physical, psychological, and economical costs of being physically active. Cues to action refers to readiness to adopt the preferred action or how ready an individual is to begin being physically active. Finally, self-efficacy is the confidence in the ability to begin and sustain the preferred action. An individual must believe that being physically active is achievable and can be included on a dayto-day basis (Stretcher and Rosenstock, 2007). Overall, the health belief model posits that once an individual is aware that a negative health behavior can be avoided, accepts that a positive alternative has substantial benefits, and is confident that a change in behavior will have a
14 successful outcome, and then the individual will avoid the negative health behavior and choose a positive alternative. Previous Successful Interventions Previous research conducted by the Department of Foods and Nutrition at the University of Georgia and the Division of Aging Services in the Georgia Department of Human Resources has illustrated significant benefits of physical activity on physical function in older adults in a state-wide community-based intervention. Three recent studies, McCamey et al. (2003), Fitzpatrick et al. (2008), and Bell et al. (2009) established a foundation for demonstrating improvement in senior’s ability to move better and be more active through the participation of physical activity programs conducted at senior centers in Georgia. The research by McCamey et al. was based on the Health Belief Model and included a twelve-lesson educational intervention program that promoted nutrition and physical activity in 501 older adults throughout Georgia. The physical activity intervention included five leg exercises that were done at each lesson, and it also included a placemat that illustrated how to perform each exercise in an effort to help seniors complete the exercises at home and at the senior centers. Measurements of the participants’ physical function were determined at pre- and post-test by the use of the SPPB (Guralnik et al., 1994). Participants’ physical activity and knowledge were assessed by answering questions from the validated Behavioral Risk Factor Surveillance System questionnaire (BRFSS, 2002). McCamey et al. (2003) reported significant increases in duration, knowledge, and behavior of physical activity in the older participating adults following the statewide intervention. Physical activity participation, defined as participation in any physical activity in the past month, increased from 82% to 87%. Knowledge of the recommended 30 minutes of
15 moderate physical activity most days of the week was reported by 68% at post-test compared to only 53% at pre-test. Finally, a positive but non-significant trend was evident in the physical function measurement assessed by the SPPB. Fitzpatrick et al. (2008) and Bell et al. (2009) also examined the change in physical function and physical activity in older adults following a statewide physical activity intervention conducted at senior centers. Similar to McCamey, most participants were a part of the Title III congregate meals program, were given a pre-test, participated in a statewide intervention, and then completed a post-test. However, these physical activity interventions included additional chair exercises (16 to 24 different exercises), emphasized the importance of walking, and promoted the use of pedometers in the program. Bell et al. (2009) also incorporated exercise balls. Measurements of physical activity and physical function were assessed using the same measures as the McCamey report. Following the intervention, physical function, several measures of physical activity, and/or step counts all increased significantly. Significant improvements in physical function scores were seen in these interventions, unlike McCamey et al. (2003). Perhaps the increase was related to the additional chair exercises that were included. Results from Bell et al. (2009), Fitzpatrick et al. (2008) and McCamey et al. (2003) provide evidence of the significant benefits to older adults of physical activity intervention programs implemented at senior centers throughout Georgia. Recently, Kerse and colleagues (2008) began a randomized controlled intervention trial called DeLLITE (Depression in late life: an Intervention Trial of Exercise) designed to increase functional status and improve mood and quality of life in older adults with depressive symptoms. This 12 month physical activity intervention included validated measures of physical function (SPPB), depressive symptoms (Geriatric Depression Scale), and physical activity (AHS Physical
16 Activity Questionnaire) that were attained at baseline, 6, and 12 months. The results of this study should be available in the next year. If this study is effective in improving functional status and decreasing depressive symptoms it will reinforce the physical, mental, and economical benefits of physical activity in this high risk older adult cohort (Kerse et al., 2008). Rationale, Specific Aims, and Hypotheses This study builds upon and enhances community-based physical activity interventions conducted previously in the target population of older adults at Georgia senior centers (McCamey et al., 2003; Fitzpatrick et al., 2008; Bell et al., 2009) by incorporating a more extensive physical activity program to improve flexibility, strength, and functional movement. Previously, McCamey et al. (2003) assessed the benefits of 5 educator-led chair exercises in 12 sessions during a 6-month period. Fitzpatrick et al. (2008) assessed the benefits of 16 educatorled chair exercises in 16 sessions during a 4-month period and Bell et al. (2009) reported the benefits of 24 educator-led chair exercises in 16 sessions during a 4-month period; together these studies demonstrated improvements in objective measures of physical function, self-reported daily physical activity, and step counts, as well as decreased barriers to physical activity. The present intervention had a total of 32 exercises that were demonstrated in 12 sessions during a 3month period. Similar to the previous studies (McCamey et al., 2003; Fitzpatrick et al., 2008; Bell et al., 2009), participants were encouraged to do the exercises at the senior centers and at home most days of the week. Research has shown significant benefits of chair-exercises in older adults in improving physical function and neuromuscular response, along with increasing strength, and improving flexibility (Hauiter et al., 2007). Additional physical and psychological benefits have also been seen with the use of resistance bands and balls. Thus, it is expected that this new physical activity intervention will significantly increase physical activity and improve
17 physical function and flexibility in the older adult participants. Along with the improvements in the physical activity program, the current study will explore the relationship of depression with physical activity and physical function before and after the physical activity intervention. The first specific aim of the study is to determine the initial daily physical activity and physical function scores in depressed and non-depressed older adults. The first hypothesis is that older adults diagnosed with a depressive disorder will participate in less physical activity and will have lower physical function scores compared to non-depressed older adults. The second specific aim is to compare the impact of the physical activity intervention on improving physical activity and physical function. The second hypothesis is that depression will be associated with a lower amount of improvement in physical activity and physical function following the physical activity intervention.
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CHAPTER 3 IMPROVED PHYSICAL ACTIVITY AND PHYSICAL FUNCTION IN DEPRESSED AND NONDEPRESSED OLDER ADULTS FOLLOWING A COMMUNITY-BASED INTERVENTION1
1
Porter, K. N., Johnson, M. A., Fischer, J. G., Lee, J. S., Reddy, S., & Lommel, T. S. To be submitted to Journal of Nutrition for the Elderly.
19 Abstract The purpose of this study was to explore the relationship of depression with physical activity and physical function before and after a 3-month physical activity intervention in Georgia senior centers. Participants were a convenience sample from all 12 Georgia Area Agencies on Aging (AAA) that completed a pre-test (n = 811, mean age= 75 years, 81% female, 62% Caucasian, 38% African American, 23% depressed) or the pre-test, the intervention, and the post-test (n = 614). The physical activity intervention was based on the Health Belief Model and included 12 sessions with educator-led chair exercises that incorporated balls and bands. Preand post-tests assessed moderate physical activity and physical function using the Short Physical Performance Battery. At the pre-test those reporting a history of depression, measured using a question from the 2006 BRFSS’s Anxiety and Depression module, participated in less moderate physical activity [mean (SD): 3.7 (2.7) vs. 4.2 (2.6) days/week, P ≤ 0.01], but depression was not related to physical function. Following the intervention there were increases in physical activity (pre- vs. post-test: 52% vs. 61%, respectively, participated in 5 or more days per week of moderate physical activity, P ≤ 0.001) and in physical function (pre- vs. post-test: 25% vs. 32%, respectively, had good physical function, P ≤ 0.01). In a series of multivariate regression analyses, a history of depression was an independent and positive predictor of change in physical function (P ≤ 0.01), and there was a trend for history of depression being a negative predictor of improvements in moderate physical activity (P ≤ 0.09). These results provide an evidence base for the effectiveness of this intervention in improving physical activity and physical function in a community setting. Moreover, the relatively high prevalence of a history of depression in this sample was not a barrier to these improvements. KEYWORDS: Intervention, older adults, depression, physical activity, and physical function.
20 Introduction Regular physical activity provides one of the greatest opportunities to extend years of active independent life, improve quality of life, improve physical function, and reduce disability and functional limitations. Engaging in physical activity by older adults is strongly endorsed by the Older Americans Act (Public Law 109–365, 2006), the Administration on Aging (2004), the National Institute on Aging (2001), AARP (2004), the Dietary Guidelines for Americans (US Department of Health and Human Services (USDHHS), US Department of Agriculture (USDA), 2005), Healthy People 2010 (USDHHS, 2000), the American College of Sports Medicine and American Heart Association (ACSM/AHA, 2004; Cress et al., 2004; Nelson et al., 2007), and the American Dietetics Association (2005). The 2005 Dietary Guidelines for Americans recommends that adults, including older adults, “engage in at least 30 minutes of moderateintensity physical activity on most, preferably all, days of the week” (USDHHS & USDA, 2005). However, in the 2007 Report Card on Healthy Aging, 40% of Georgians aged 65 and older were physically inactive, participating in no “leisure-time” physical activity, ranking Georgia 49th out of fifty states for having the most inactive older adults (Center for Disease Control and Prevention and The Merck Company Foundation, 2007). Depression in older adults is associated with low physical activity, low physical function, increased risk of other health conditions and mortality (Paluska et al., 2000; Strawbridge et al., 2002; Baldwin et al., 2003) and is considered one of the five major health problems faced by older people (Moore et al., 1999). Up to 20% of community-dwelling older adults may be depressed (Beyer et al, 2007; Palmer, 2005) and the CDC estimates that among adults 50 and older the prevalence of a lifetime diagnosis of depression is 15.7% nationally and 18% for
21 Georgia (Center for Disease Control and Prevention and National Association of Chronic Disease Directors, 2008). Given the high prevalence of depression and physical inactivity in Georgia, we conducted a study to evaluate the impact of depression on physical activity and physical function before and after a physical activity intervention conducted in senior centers with Older Americans Act programs. A theory-driven nutrition, health, and physical activity intervention was developed, implemented and evaluated with a pre-test, a series of 12 sessions, each with a physical activity component, and a post-test for older adults at senior centers in all 12 Georgia Area Agencies on Aging (AAA). The intervention was similar to previously successful interventions (Fitzpatrick et al., 2008; Bell et al., 2009) except that we included more chair exercises (32 vs 16 to 24), incorporated exercise balls and bands to enhance interest and flexibility, and assessed depression (BRFSS, 2006). The important contribution of this study is that it provides evidence of the benefits of a community-based physical activity program that leads to meaningful gains in physical activity and physical function in older adults at senior centers, and provides information on the potential role that a history of depression may play in physical activity and physical function in this population. Methods Sample Questionnaires and procedures were approved by the Institutional Review Boards on Human Subjects of the University of Georgia and the Georgia Department of Human Resources. Participants were a convenience sample of people aged 50 (2% were under 60) and older recruited from 40 senior centers in the fall of 2007, similar to previous studies (Fitzpatrick et al., 2008, Bell et al., 2009). Briefly, each of the 12 AAA’s in Georgia were asked to recruit about 70
22 people from senior centers in their area. Senior centers were selected based on the support of the senior center director and interest of the participants. Most participants received congregate meals. Procedures were explained and the consent forms were read to participants, and written informed consent was obtained from participants. People were excluded if they were homebound or when the interviewer determined that the individual may be unable to understand the informed consent and/or answer questions. These recruitment procedures yielded 815 participants of whom 811 were included in the analyses of this study following the exclusion criteria for missing responses for depression and/or physical activity, total score for physical function, and sit-andreach questions (n = 4). Participants (n = 614) who completed both the pre- and post-test questionnaires by answering pre- and post-test questions for moderate physical activity, total physical function score, or chair-sit-and-reach; and had the same response to the depression question at the pre- and post-test,were included in analyses assessing the influence of the intervention in improving physical activity and physical function; some of these analyses have fewer individuals because of incomplete responses to questions. One hundred and ninty three participants who were not included in the pre- and post-test comparison had missing or incomplete for the following reasons: death (n = 10), hospitalization/sickness (n = 25), homebound (n = 4), no longer attending the senior center (n = 23), moved or traveling (n = 3), work (n = 3), refusal (n = 12), unavailable (n = 53), or no reason given (n = 50). The final regression analyses were conducted in 376 participants who met these inclusion criteria: had pre-test responses for chronic conditions, height and weight; had pre- and post-test responses for moderate physical activity, defined as 5 or more days of 30 minutes of moderate physical activity, and total physical function score; and had the same response to the depression question at the pre- and post-test (n = 376).
23 Pre-tests Participants were interviewed as previously described (Fitzpatrick et al., 2008). Assessments included demographic information; general health, including current chronic conditions; and height and weight (measured or self-reported). Body mass index was calculated (BMI = (weight (pounds)/height (inches)2) x 703). History of depression was assessed with one question, “Has a doctor or other heath care provider ever told you that you have a depressive disorder?” from the 2006 Behavior Risk Factor Surveillance System’s Anxiety and Depression Module (BRFSS, 2006). Physical activity measures were similar to a previous study (Fitzpatrick et al., 2008), and were adapted from Toobert et al. (2000) and the BRFSS questionnaire (BRFSS, 2006): “How many days of the week do you participate in any physical activity?”, “How many minutes of physical activity (light or moderate) do you do on the days you are active?”, “On how many of the days of the last seven days did you participate in at least 30 minutes of moderate physical activity?”, and “How many days of the last week did you participate in a specific exercise session other than what you do around the house or as part of your daily activities.” The overall physical activity measure used was moderate physical activity defined as 30 minutes of moderate physical activity five or more days of the week. Participant’s physical function was assessed using the Short Physical Performance Battery (SPPB) (Guralnik et al., 1994). Increased risk for future nursing home placement, disability, and death has been associated with a poor score on this performance battery (Guralnik et al., 1994). This test assesses older adults’ mobility by measuring the three categories of balance, strength, and gait speed as an individual performs a standing balance, chair stands, and an 8-foot walk, respectively, with performance in each category scored on a scale of zero to four.
24 A summary performance score was calculated by summing each of the three category scores to give a final score ranging from zero to twelve, where higher scores indicate higher performance: poor function (zero to five), moderate function (six to nine), and good function (10 to 12). Exlusion criteria included participants reporting a time of ≤ 2.0 seconds on the 8-foot walk (Fitzpatrick et al., 2008). Flexibility was measured using the validated chair-sit-and reach (Jones et al., 1998). This test entails participants sitting in a stable chair with knees straight, and then bending over to reach their toes with arms extended. The distance, either to the toes or beyond the toes, is measured with a ruler. Intervention Upon completing the pre-test questionnaires, the educational and physical activity intervention, “Seniors Taking Charge of Your Health!” was initiated at the senior centers (available at http://www.livewellagewell.info/study/materials.htm). The complete intervention consisted of 12 lessons (January through April 2008). Each lesson was given one time and lasted 45 to 60 minutes. The physical activity part of each lesson lasted up to 30 minutes, included demonstrations by the educator, and participation by the older adults in chair exercises that incorporated exercise balls and resistance bands (adapted from other sources: NIA, 2001; CDC, 2002). Participants were encouraged to walk and to do the chair exercises at home. The conceptual framework for the physical activity intervention was based on the health belief model (Stretcher and Rosenstock, 1997) in a manner similar to that described by Fitzpatrick et al. (2008).
25 Post-test The post-test was administered within one to two months following the last lesson of the intervention to allow participants time to make behavioral changes. The post-test was identical to the pre-test, with the addition of questions for the participants to describe changes in their physical activity as well as their satisfaction with the lessons and overall program. Statistical Analyses Questionnaires, consent forms, and physicians’ clearance forms were sent to The University of Georgia for analyses (SAS, Version 9.1, SAS Institute, Cary, NC). Descriptive statistics, including frequencies, means, and standard deviations were calculated. Spearman correlations were used to determine the relationship between physical activity and physical function. Differences in physical activity and physical function between people with and without a history of depression were assessed with Mann-Whitney U test for non-normally distributed data, and chi-square analyses for dichotomous physical activity and physical function variables. Changes in physical activity and physical function in the sample were assessed using Wilcoxon Signed-Rank test. Regression analyses were used to identify independent factors that influenced physical activity and physical function at the pre-test and following the intervention. Variables included in these models were pre-test demographics, depression, self-reported health, health conditions, physical activity, and total physical function score. P < 0.05 was considered statistically significant. Results Of the 811 participants who completed the pre-test, 75% were age 70 and older, 81% were female, 38% were black, mean years of education was 10, mean self-reported health was in
26 the “fair” range, the prevalence of health conditions was high (31% to 73%), BMI averaged 29.5 kg/m2, and 23% (n = 184) reported a history of depression (Table 1). Compared to those without depression, those with a history of depression were significantly younger, more likely to be white than black, had lower self-reported health, had a higher prevalence of most health conditions, and had higher BMI, but did not differ in gender, education, or prevalence of diabetes. For the final regression models, 376 participants were included who completed the pre-test and post-test measures of depression (same answer at the pre- and post-test), days of moderate physical activity, total score for physical function, and all co-variates (demographics and health). Compared to the excluded participants (n = 435), those included (n = 376) were older (76 vs. 75 years, P ≤ 0.01), but did not differ in depression, gender, race, education, days of moderate activity, total physical function score, self-reported health, prevalence of health conditions, or BMI (data not shown). The program was highly rated as good (27%), very good (33%), or excellent (35%) by participants at post-test (n = 614), and 74% of the participants reported improving their physical activity following the intervention (“yes” in response to “After attending the health, nutrition, and physical activity education programs at your senior center, have you …. Increased your physical activity?” n = 452). All measures of physical activity participation (i.e., days of physical activity, minutes of daily physical activity, days of moderate physical activity, and days of exercise session participation) at the pre-test were significantly lower in those with a history of depression compared to those without depression, except for minutes of physical activity on the days participants reported being physically active (Table 2). Having a history of depression was significantly associated with poorer standing balance score, higher time to complete chair stands, and less flexibility (Table 3). Following the intervention, there were significant
27 improvements in all measures of physical activity (Table 4) and several measures of physical function [total physical function score, chair stands (seconds and score), and flexibility, Table 5]. Regression analyses were conducted to identify predictors of moderate physical activity participation at the pre-test and following the intervention (Table 6). At the pre-test, logistic regression analyses indicated that history of depression was independently associated with fewer days of moderate physical activity when controlled for demographic variables (P ≤ 0.001) and when controlled for demographic variables and health-related variables (P ≤ 0.05). In the second pre-test model, logistic regression analyses were used and moderate physical activity was coded as a dichotomous dependent variable (0 = < 5 days/week, 1 = ≥ 5 days/week); in these models, the relationship of depression with moderate physical activity was attenuated when controlled for both demographic and health-related variables. In both pre-test models (linear and logistic), physical function was significantly and positively associated with moderate physical activity. Following the intervention, change in moderate physical activity was not associated with depression, but was positively and significantly associated with being female vs. male, higher physical function score at pre-test, and lower body mass index at pre-test. Linear regression analyses were conducted to identify predictors of the total physical function score at the pre-test and following the intervention (Table 7). At the pre-test, physical function was not associated with depression, but was significantly and negatively associated with age, being black vs. white, and having joint pain, and was significantly and positively associated with higher moderate physical activity and self-reported health. Following the intervention, improved physical function was significantly associated with reporting a history of depression when controlled for other factors in both the demographic model and in the demographic and
28 health model. Other statistically significant and independent predictors of improved physical function were lower physical function at the pre-test and not having joint pain at the pre-test. Discussion The purpose of this study was to explore the relationship of depression with physical activity and physical function before and after a 3-month physical activity intervention conducted in Georgia senior centers. To our knowledge, this is the first study to examine the effects of depression on the ability to improve physical activity and physical function in a senior center setting. One of the major findings was that the prevalence of a history of depression was higher than reported for older adults in Georgia and nationally (BRFSS, 2008). Also, before the intervention depression was associated with less physical activity, but was not related to physical function. However, following the intervention depression was not associated with changes in physical activity, but those reporting a history of depression had larger increases in physical function compared to those without depression. Lastly, despite these relationships of depression with physical activity and physical function, this physical activity intervention was associated with increases in both physical activity and physical function. Depression was assessed with one question from the BRFSS (2006), “Has a doctor or other heath care provider ever told you that you have a depressive disorder?” At the pre-test, 23% of these older adults reported a history of depression (Table 1) compared to 18% in Georgia and 15% nationally in 2006 (CDC and Prevention and National Association of Chronic Disease Directors, 2006). The higher prevalence of depression in our sample may be related to purposeful targeting by senior center programs of older adults with high social and economic needs and/or who live in rural areas (AoA, 2008; Department of Human Resources-Division of Aging Services, 2007), which are factors associated with depression (Blazer et al., 2003).
29 Among older adults in Georgia’s Older Americans Act programs 46% are living below the poverty line, 37% are minorities, and 28% live in rural areas (AoA, 2007). Depression in older adults has been associated with chronic diseases, poor physical function, isolation, premature death, and suicide (Chapman et al., 2008; Alexopoulos, 2005) and longitudinal studies suggest that older adults with depression may be up to three times more likely to develop poor physical function and disabilities in mobility and activities of daily living (Pennix et al. 2000). Poor physical function also is a predictor of disability, nursing home placement, and death in older adults (Guralnik, 1994). Thus, given the overall negative impact of depression on several healthrelated indices, we conducted the present study to determine the relationship of depression with physical activity and physical function. Before the intervention was initiated a pre-test was conducted and it was found that depression was associated with lower physical activity, but not with poor physical function. In a series of multivariate regression analyses, we explored the relationship of depression with moderate physical activity , which is specifically recommended for older adults (Nelson et al., 2007; USDHHS & USDA, 2005); also bi-variate correlation analyses indicated that depression was somewhat more strongly related to moderate physical activity than to our other measure of physical activity (data not shown). Three of the four regression models confirmed that a history of depression was negatively related to moderate physical activity even when controlled for demographic and health-related factors known to influence physical activity and/or depression (Nelson et al., 2007; Chapman et al., 2008; Taylor et al., 2003, Table 6). Similarly, others have found that depression negatively influences physical activity, even when controlled for other factors (Goodwin et al., 2003; Paluska et al., 2000).
30 Despite the negative impact of a history of depression on physical activity at the pre-test, depression did not appear to significantly interfere with the ability to increase the number of days that respondents reported moderate physical activity following the intervention when controlled for demographic and health-related factors (Table 6). However, these results should be interpreted with caution, because the parameter estimates indicated that the increase in physical activity following the intervention was about 0.5 days per week less in those with depression compared to those without depression (P = 0.09 to 0.12). The potential negative impact of depression on improving physical activity might become statistically significant in a larger sample of participants. The lack of effect of depression on increasing moderate physical activity following the intervention may have been related to the familiar settings where the interventions were held and exercising in groups, as well to our experiences in tailoring physical activity programs to this audience, introduction of chair exercises throughout the intervention, and providing handouts illustrating the exercises for participants (Bell et al., 2009; Cheong et al., 2003; Fitzpatrick et al., 2008; McCamey et al., 2003). The social interaction and support provided at senior centers may have facilitated physical activity, even among those with depression currently or with a history of depression. Social support has been consistently associated with good mental health and group exercise provides positive feedback, social contact, and accomplishment of new tasks that can improve mood and decrease depressive disorders in older adults (Lawlor et al., 2001). Also, participants did not need to expend any additional effort to attend a physical activity program in other settings, because the program was “brought to them” at their senior center. A strength of this study was the objective assessment of physical function with the short physical performance battery (Guralnik et al., 1994, 1995). Poor performance on this measure of
31 physical function has been associated with subsequent morbidity, hospitalization, disability, nursing home placement, and death (Guralnik et al., 1994, 1995). However, the relationship of depression with physical function is somewhat mixed. While several studies show that depression is associated with physical disability, poor physical function status, and disabilities in activities of daily living (Blazer et al., 2003, Chapman et al., 2008), Pennix et al. (1999) reported that objectively measured physical function was not associated with depression. The lack of a relationship between depression and physical function at the pre-test in the present study may have been due to the observation that only about 24% of participants were in the “poor” physical function category and physical function scores averaged 7.4 on the 12 point scale (Table 5). Perhaps a sample that had a larger proportion of participants in the “poor” category might show a significant relationship between physical function and depression. Differences in the methodology used to assess depression may also contribute to these inconsistencies in the literature. Although a history of depression was not associated with physical function at the pre-test, depression did emerge as a significant positive predictor of improved physical function following the intervention when controlled for physical function at the pre-test, physical activity, other health-related factors, and demographics (Table 7). We had predicted that depression would be negatively associated with improvements in physical function following the intervention. As previously discussed, perhaps our experience with designing physical activity programs for older adults at senior centers, the use of chair exercises that incorporated bands and balls, distribution of handouts illustrating the exercise to take home, the familiarity of the older adults with their senior centers, and the social support provided in senior centers facilitated improvements in
32 physical function in response to this intervention – even among those with a history of depression. Overall, the physical activity intervention resulted in meaningful improvements in physical activity and physical function. Using 30 minutes of moderate activity on five or more days of the week as a goal (ACSM/AHA, 2004; USDHHS & USDA, 2005; Nelson et al., 2007), about 52% met this goal prior to the intervention and 61% met it following the intervention (Table 4). Also, participants added an average of about 0.7 more days of moderate physical activity weekly. Overall physical function scores significantly increased following the 12-week physical activity intervention by 0.3 units. Our previous 4-month physical activity interventions in similar target populations were associated with somewhat larger gains in physical function of 0.5 units (Fitzpatrick et al., 2008) and 0.4 units (Bell et al., 2009). The relatively smaller gains in the current study may be because the intervention was somewhat shorter than our previous interventions that lasted 4 months (Fitzpatrick et al., 2008; Bell et al., 2009). There are some limitations to this study. Depression was assessed historically with a single question from the Behavioral Risk Factor Surveillance System that assessed ever having depression (BRFSS, 2006). There is considerable evidence that depression is a recurrent illness that plagues individuals throughout life and it is estimated that about 90% of older adults in remission will have a recurrence of depression within 3 years (Reynolds et al., 1999; Glass et al., 1999). Therefore, the BRFSS question may provide meaningful information about depression in the target population. Future studies could explore depression with instruments designed for use with older adults, such as the Geriatric Depression Scale (Yesavage et al., 1982; Herrmann et al., 1996; Almeida et al., 1999), as well as assessments of type of diagnosed depressive disorder, psychological treatment, and/or medications taken for depression. In this study, concerns about
33 impaired vision and/or hearing were addressed by requiring interviewer-administration of all questionnaires. Potential variability in implementation of the physical activity intervention at the various sites was minimized by holding a statewide training for the educators, provision of printed and online training and educational materials, and technical assistance from the university by phone, email, and site visits. Information concerning attendance and the intensity and types of physical activity in the participants were not recorded and would be important to collect in future studies. Although we have not collected data on the maintenance of this intervention, the materials are accessible online, printed in large fonts, and can be used in a variety of settings to promote physical activity. In summary, this physical activity intervention improved physical activity and physical function in a community setting and the relatively high prevalence of a history of depression in this sample was not a barrier to these improvements. Future studies are needed to more thoroughly assess depression and to determine the benefits of this physical activity intervention in other samples of older adults in similar settings.
34 Acknowledgements We thank the older adults for their participation. This study was a collaborative effect among the Georgia Division of Aging Services, the Georgia Department of Human Resources (DHR), The University of Georgia, and the 12 Georgia Area Agencies on Aging. This project was financially supported by the GA Division of Aging Services (contract #427-93-0606071799), The University of Georgia Experiment Station (HATCH #GEO 00575 and #GEO 00576), and The University of Georgia Department of Foods and Nutrition.
35 TABLE 3.1. Characteristics of Participants in Georgia Senior Centers, 2007-2008 Pre-test
Depressionb Age (years)
N
Mean (SD) or %
N
Mean (SD) or %
811 811
23 75 (8)
184 184
100 73 (8)
Non-depressed
N
Mean (SD) or %
P-valuea
627 627
0 76 (8)
0.0001 0.01
< 60
2
4
1
60-69 70-79
23 44
28 45
22 43
27 4
22 1
29 5
80-89 ≥ 90 Gender Male Female Race/ethnicity White Black Education (years) Self-reported healthc Diabetesd High blood pressured Heart diseased Joint paind Body mass index (kg/m2) a
Depressed
184
811 19 81 811
14 86 183
62 38 796 811 807 809 806 810 771
627
10 (3) 1.7 (0.9) 33 73 31 69 29.5 (6.6)
20 80 619
72 28 182 184 183 184 184 183 176
0.06
11 (3) 1.5 (0.9) 38 80 41 81 31.1 (7.9)
0.01 60 40
614 627 624 625 622 627 595
10 (3) 1.8 (0.9) 31 71 28 66 29.0 (6.1)
0.48 0.001 0.09 0.05 0.001 0.0001 0.01
P-value of depressed compared to non-depressed participants.
b
Depression determined from the response, “Has a doctor or other health care provider ever told you that you have a depressive disorder?” Response categories: no or yes. (BRFSS, 2006) c
Self-reported health coded as 0 = poor, 1 = fair, 2 = good, 3 = very good, 4 = excellent.
d
Diabetes, high blood pressure, heart disease, and joint pain were self-reported, with responses coded as 0 = no and 1 = yes.
36 TABLE 3.2. Physical Activity and Depression in Georgia Senior Centers, 2007-2008a
N
N
Depressed Mean (SD) or %
How many days of the week do you participate in physical activity? (days)
802
183
4.3 (2.5)
619
4.7 (2.4)
0.05
About how many minutes of physical activity do you do on the days you are physically active? (minutes)
772
176
34.5 (26.3)
596
35.8 (26.2)
0.13
766
175
24.6 (25.8) 66 34
591
27.9 (25.9) 58 42
0.01 0.05
766
175
61 39
591
49 51
0.01
803
183
3.7 (2.7) 59 41
620
4.2 (2.6) 46 54
0.01 0.010.
803
183
1.8 (2.0)
620
2.3 (2.2)
0.01
Daily physical activity (= days X minutes/7) (minutes) < 30 minutes ≥ 30 minutes Weekly physical activity (= days X minutes) < 5 days or 150 minutes ≥ 5 days and 150 minutes On how many days of the last seven days did you participate in at least 30 minutes of moderate physical activity? (days) < 5 days ≥ 5 days On how many of the last seven days did you participate in a specific exercise session other than what you do around the house as part of your daily activities? (days) a
Percentages may not add up to 100% because of rounding.
N
Non-depressed Mean (SD) or %
P-value
37 TABLE 3.3. Physical Function and Depression in Georgia Senior Centers, 2007-2008
N
N
Depressed Mean (SD) or %
N
Non-depressed Mean (SD) or %
Pvalue
537
7.4 (2.8)
0.35 0.96
Short Physical Performance Battery (SPPB)a Total score
705
168
7.3 (2.7)
Poor (0-5)
23.2
24.2
Moderate (6-9)
51.8
51.2
Good (10-12)
25.0
24.6
Standing balance scoreb
772
176
2.8 (1.2)
596
3.0 (1.3)
0.05 0.19
Poor (0-2)
40
34
Good (3-4)
60
66
8 foot walk (seconds) c
699
165
3.7 (1.5)
534
3.8 (1.7)
0.23
8 foot walk score
709
169
3.0 (1.1)
540
2.9 (1.1)
0.23 0.14
Poor (0-2)
27
33
Good (3-4)
73
67
Chair stands (seconds) d
597
139
17.2 (6.8)
458
16.3 (6.3)
0.05
Chair stands score
578
177
1.5 (1.3)
401
1.5 (1.2)
0.17 0.05
Poor (0-2)
77
69
Good (3-4)
23
31
Chair Sit and Reach Distance (inches)
754
172
-2.4 (4.2)
582
-1.7 (4.5)
0.01
a
The SPPB total physical function score ranges from 0 to 12 and is calculated from the combined scores of the standing balance (0 to 4), 8 foot walk (0 to 4), and five chair stands (0 to 4) (Guralnik et al., 1994). b
Standing balance is a timed semi-tandem stand, followed by either a timed tandem (completers of semitandem) or side-by-side (non-completers of semi-tandem) stand. c
8 foot walk is a timed walk that can be done with or without an assistive device.
d
Chair stands are five timed chair stands from the seated position.
38 TABLE 3.4. Changes in Physical Activity Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008a
N
Pre-testb Mean (SD) or %
Post-test Mean (SD) or %
Change
P-value
4.6 (2.4)
614
4.7 (2.4)
5.2 (2.1)
0.5 (2.6)
0.0001
772
35.5 (26.2)
563
36.6 (26.1)
41.5 (29.4)
4.8 (32.1)
0.01
766
27.2 (25.9)
560
28.2 (26.0)
34.0 (30.2)
5.8 (32.4)
0.0001 0.01
N
Pre-test Mean (SD) or %
How many days of the week do you participate in physical activity? (days)
802
About how many minutes of physical activity do you do on the days you are physically active? (minutes) Daily physical activity (= days X minutes/7) (minutes) < 30 minutes
60
57
51
-6
≥ 30 minutes
40
43
49
6
49
40
-9
51
60
9
4.2 (2.6)
4.8 (2.3)
0.7 (2.8)
0.0001
49
48
39
-9
00.001
51
52
61
9
2.1 (2.1)
2.6 (2.1)
0.4 (2.4)
Weekly physical activity (= days X minutes) < 5 days or >150 minutes ≥ 5 days and ≥150 minutes On how many days of the last seven days did you participate in at least 30 minutes of moderate physical activity? (days)
766
562
48
805
< 5 days ≥ 5 days On how many of the last seven days did you participate in a specific exercise session other than what you do around the house as part of your daily activities? (days)
52
803
4.1 (2.6)
2.2 (2.2)
608
606
0.001
0.0001
39 a
Percentages may not add up to 100% because of rounding.
b
Completed both the pre-test and post-test.
40 TABLE 3.5. Changes in Physical Function Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008
N
Pre-test Mean (SD) or %
N
Pre-testa Mean (SD) or %
Post-test Mean (SD) or %
Change
P-value
465
7.4 (2.7)
7.7 (2.8)
0.3 (2.3)
0.001 0.01
b
Short Physical Performance Battery (SPPB) Total score
705
7.4 (2.7)
Poor (0-5)
24
24
22
-2
Moderate (6-9)
51
51
46
-5
Good (10-12)
25
25
32
8
2.9 (1.2)
3.0 (1.2)
0.1 (1.2)
0.39
37
36
35
-1
1.00
63
64
65
1
c
Standing balance score
772
Poor (0-2) Good (3-4) 8 foot walk (seconds)
d
8 foot walk score
3.8 (1.7)
475
3.8 (1.7)
3.7 (1.8)
-0.1 (1.3)
0.18
709
3.0 (1.1)
488
3.0 (1.1)
3.0 (1.1)
0.03 (1.0)
0.42
32
32
29
-3
0.70
68
68
71
3
Good (3-4) Chair stands (seconds) Chair stands score
577
699
Poor (0-2) e
2.9 (1.3)
597
16.5 (6.4)
418
16.0 (5.9)
14.7 (5.3)
-1.3 (5.1)
0.0001
771
1.7 (1.3)
561
1.7 (1.3)
2.0 (1.4)
0.2 (1.2)
0.0001 0.05
Poor (0-2)
71
71
62
-9
Good (3-4)
29
29
38
9
-2.0 (4.5)
-1.5 (3.9)
.47 (3.4)
Chair Sit and Reach Distance (inches)
754
-1.8 (4.4)
551
0.01
a
Completed both the pre-test and post-test.
b
The SPPB total score ranges from 0 to 12 and is calculated from the combined scores of the standing balance (0 to 4), 8 foot walk (0 to 4), and five chair stands (0 to 4) (Guralnik et al., 1994). c
Standing balance is a timed semi-tandem stand, followed by either a timed tandem (completers of semitandem) or side-by-side (non-completers of semi-tandem) stand. d
8 foot walk is a timed walk that can be done with or without an assistive device.
e
Chair stands are five timed chair stands from the seated position.
41 TABLE 3.6. Regression Models Exploring Predictors of Physical Activity at Pre-test and Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008a Predictors of change in Predictors of moderate activity at prePredictors of moderate moderate activity test (< 5 vs. ≥ 5 days/week)b activity at pre-test (days/week)c (days/week)d Parameter Parameter OR PEstimates PEstimates Pvalues (SEM) values (SEM) values B (95% CI) Demographic models Intercept 0.46 0.14 4.28 (0.40) 0.0001 3.67 (0.54) 0.0001 Depressed (0 = no, 1 = yes) -0.59 0.55 (0.39, 0.78) 0.001 -0.66 (0.22) 0.01 -0.50 (0.29) 0.09 Age (0 is < 80, 1 is ≥ 80 years) -0.22 0.81 (0.59, 1.10) 0.18 -0.41 (0.20) 0.05 -0.13 (0.25) 0.59 Gender (0 = male, 1 = female) 0.11 1.12 (0.77, 1.62) 0.56 0.13 (0.24) 0.59 0.59 (0.30) 0.05 Race (1 = white, 2 = black) -0.38 0.68 (0.51, 0.93) 0.01 -0.33 (0.20) 0.09 -0.28 (0.25) 0.26 Education (0 is < 8, 1 is ≥ 8 years) 0.26 1.30 (0.92, 1.84) 0.13 0.59 (0.22) 0.01 -0.19 (0.28) 0.50 Physical activity at pre-test (0 is < 5, 1 is ≥ 5 NAe NA NA NA NA -0.72 (0.04) 0.0001 days/week) Demographic and health models Intercept Depressed (0 = no, 1 = yes) Age (0 is < 80, 1 is ≥ 80 years) Gender (0 = male, 1 = female) Race (1 = white, 2 = black) Education (0 is < 8, 1 is ≥ 8 years) Physical activity at pre-test (0 is < 5, 1 is ≥ 5 days/week) Physical function (0 to 12) Change in physical functionf Self-reported health (0 = poor, 1 = fair, 2 = good, 3 = very good, 4 = excellent) Diabetes (0 = no, 1 = yes) High blood pressure (0 = no, 1 = yes) Heart disease (0 = no, 1 = yes) Joint pain (0 = no, 1 = yes) Body mass index (0 is < 30, 1 is ≥30 kg/m2 )
-0.47 -0.38 -0.10 0.20 -0.15 0.08 NA 0.10 NA 0.18 -0.07 -0.15 -0.16 -0.13 -0.13
0.68 (0.47, 0.999) 0.91 (0.63, 1.31) 1.22 (0.81, 1.86) 0.86 (0.61, 1.22) 1.08 (0.75, 1.57) NA 1.11 (1.04, 1.18) NA 1.19 (0.85, 1.67)
0.35 0.05 0.60 0.34 0.39 0.68 NA 0.001 NA 0.30
2.43 (0.62) -0.33 (0.24) -0.13 (0.23) 0.24 (0.26) 0.01 (0.22) 0.30 (0.23) NA 0.20 (0.04) NA 0.23 (0.21)
0.0001 0.16 0.57 0.35 0.94 0.19 NA 0.0001 NA 0.28
2.60 (0.80) -0.46 (0.30) -0.11 (0.27) 0.64 (0.31) -0.10 (0.26) -0.25 (0.28) -0.75 (0.05) 0.12 (0.05) 0.07 (0.06) 0.07 (0.25)
0.001 0.12 0.67 0.05 0.69 0.38 0.0001 0.05 0.24 0.75
0.93 (0.65, 1.67) 0.86 (0.60, 1.24) 0.85 (0.60, 1.20) 0.88 (0.61, 1.26) 0.88 (0.62, 1.24)
0.71 0.42 0.36 0.47 0.46
0.08 (0.22) -0.08 (0.23) -0.26 (0.22) -0.12 (0.23) -0.42 (0.21)
0.70 0.72 0.23 0.59 0.05
0.12 (0.26) 0.16 (0.27) 0.28 (0.26) -0.01 (0.27) -0.58 (0.25)
0.66 0.56 0.29 0.96 0.05
42 a
All independent variables are the pre-test values, unless otherwise indicated. Moderate physical activity estimated from the response to, “How many days of the last week did you participate in at least 30 minutes of moderate physical activity?” (Adapted from Toobert et al., 2000). b
Logistic regression analyses; demographic model n = 783; demographic and health model n = 666.
c
General linear models; demographic model n = 783; demographic and health model n = 666.
d
Both models n=376.
e
NA is not applicable.
f
Change in physical function is calculated from the post-test minus the pre-test values.
43 TABLE 3.7. Regression Models Exploring Predictors of Physical Function at Pre-test and Following the Physical Activity Intervention in Georgia Senior Centers, 2007-2008a Predictors of physical function at pre-testb Parameter Estimates P-values (SEM) Demographic models Intercept Depressed (0 = no, 1 = yes) Age (0 is < 80, 1 is ≥ 80 years) Gender (0 = male, 1 = female) Race (1 = white, 2 = black) Education (0 is < 8, 1 is ≥ 8 years) Physical function at pre-test (0 to 12) Demographic and health modelsa Intercept Depressed (0 = no, 1 = yes) Age (0 is < 80, 1 is ≥ 80 years) Gender (0 = male, 1 = female) Race (1 = white, 2 = black) Education (0 is < 8, 1 is ≥ 8 years) Physical function at pre-test (0 to12) Physical activity (0 is < 5, 1 is ≥ 5 days) Change in physical activitye Self-reported health (0 = poor, 1 = fair, 2 = good, 3 = very good, 4 = excellent) Diabetes (0 = no, 1 = yes) High blood pressure (0 = no, 1 = yes) Heart disease (0 = no, 1 = yes) Joint pain (0 = no, 1 = yes) Body mass index (0 is < 30, 1 is ≥30 kg/m2)
Predictors of change in physical functionc Parameter Estimates P-values (SEM)
9.38 (0.45) -0.35 (0.24) -1.31 (0.22) -0.19 (0.28) -1.13 (0.22) 0.29 ((0.24) NAd
0.0001 0.15 0.0001 0.50 0.0001 0.24 NA
2.53 (0.60) 0.40 (0.26) -0.19 (0.23) 0.01 (0.27) -0.02 (0.23) -0.13 (0.26) -0.29 (0.04)
0.0001 0.05 0.42 0.98 0.93 0.62 0.0001
8.53 (0.55) -0.07 (0.24) -1.11 (.23) -0.22 (.26) -0.98 (.22) 0.14 (0.24) NA 0.21 (0.04) NA 0.58 (0.22)
0.0001 0.77 0.0001 0.40 0.0001 0.56 NA 0.0001 NA 0.01
3.28 (0.72) 0.70 (0.26) -0.38 (0.24) -0.12 (0.27) 0.08 (0.23) -0.15 (0.25) -0.31 (0.04) 0.03 (0.05) 0.06 (0.05) 0.12 (0.13)
0.0001 0.01 0.12 0.65 0.73 0.54 0.0001 0.58 0.23 0.35
0.34 (.23) -0.16 (0.24) -0.11 (0.22) -0.77 (0.23) 0.21 (0.22)
0.13 0.50 0.61 0.001 0.34
-0.35 (0.24) -0.24 (0.24) -0.06 (0.23) -0.60 (0.24) -0.16 (0.22)
0.13 0.31 0.78 0.01 0.47
a
All independent variables are the pre-test values, unless otherwise indicated. Physical function ranges from 0 to 12 (Guralnik et al., 1994). b
General linear models; demographic model n = 685; demographic and health model n = 458.
c
Both models n = 376.
d
NA is not applicable.
e
Change in days of moderate physical activity is calculated from the post-test minus the pre-test values.
44
CHAPTER 4 CONCLUSION
The primary goal of this study was to explore the relationship of a history of depression with physical activity and physical function before and after a physical activity intervention conducted in Georgia senior centers. The first specific aim of the study was to determine the initial daily physical activity and physical function scores in depressed and non-depressed older adults. The first hypothesis was that older adults diagnosed with a history of a depressive disorder will participate in less physical activity and will have lower physical function scores compared to non-depressed older adults. The second specific aim was to compare the impact of the physical activity intervention on improving physical activity and physical function. The second hypothesis was that depression will be associated with a lower amount of improvement in physical activity and physical function following the physical activity intervention. At pre-test, depression, when controlled for demographic variables and demographic and health-related variables, was independently associated with lower participation in 5 or more days of 30 minutes of moderate physical activity (41% in depressed and 54% of non-depressed older adults). These findings support the hypothesis that depression is inversely related to meeting the recommended guidelines of moderate physical activity for older adults (Nelson et al., 2007; USDHHS & USDA, 2005). Unlike physical activity, poor physical function was not independently associated with depression at pre-test, but was significantly and positively associated with moderate physical activity and self-reported health, and negatively associated
45 with age, being black vs white, and having joint pain. The lack of association between depression and poor physical function at pre-test may have been due to the relatively good physical function status among these Georgia senior centers participants (average of 7.4 on the 12-point scale and in the “moderate” category). The program was rated as good, very good, or excellent by 97% of the 614 participants at post-test, and nearly 3/4th of the participants reported improving their physical activity following the intervention. Following the physical activity intervention the participants significantly improved in all measures of physical activity and several measures of physical function. The results showed that this 3-month physical activity intervention significantly improved physical activity and/or function outcomes comparable to 6-month and 4-month interventions conducted in previous years (Bell et al., 2009; Fitzpatrick et al., 2008; McCamey et al., 2003). For example, at pre-test only 52% of the older adults were achieving the recommended 30 minutes of physical activity 5 or more days of the week. Following the intervention 61% of the participants were meeting the recommend physical activity guideline. Their physical function and flexibility scores also significantly improved. Therefore, improvements in physical activity and physical function can be seen using this short community-based intervention program. Despite the negative impact of depression on physical activity at pre-test, depression did not influence the ability of depressed participants to achieve 5 or more days of moderate physical activity as measured at post-test. The significant improvements in physical activity following the intervention were positively associated with being female vs male, having higher physical function score and lower body mass index at pre-test. The success of this community-based physical activity intervention in helping older adults in Georgia senior centers to become more physically active most days of the week was apparent by the significant improvement in the
46 depressed and non-depressed older adult participants. The familiar setting at the senior center with peers may facilitate improved physical activity in these depressed older adults. Future research should be conducted to determine if familiar environments (e.g., senior center vs. gym) and other participants (e.g., familiar peers at the senior center vs. strangers at a gym), facilitates increased physical activity in depressed older adults. Although depression was not associated with physical function at pre-test, it became a significant and positive predictor of improved physical function following the intervention, which is opposite of the hypothesized relationship. Other independent predictors of improved physical function were lower physical function at pre-test and not having joint pain at the pretest. Nearly one in four of the older adults that participated in the physical activity intervention had been diagnosed with depression. The results of this study illustrated that depression was a significant barrier to achieving the moderate physical activity recommendations, but through participation in this physical activity intervention even those with depression made gains towards the goal of 5 or more days of 30 minutes of moderate physical activity. Research has shown that depression and physical function are often highly correlated thereby creating a continuous cycle of disability (Pennix et al., 1998; Bruce et al., 1994). Thus being physical active may be particularly important for older adults with depression. Overall, this study demonstrated that the relationships among depression, physical activity, and physical function are complex and further research is needed to investigate these interactions more thoroughly. Although significant benefits were seen in the intervention there is room for further improvements. Following the intervention one in five older adults still had “poor” physical function, and approximately 40% were still not getting 30 minutes of moderate
47 physical activity 5 days a week. Future studies need to include a validated measure of depression and treatments for depression at pre- and post-test to establish an accurate relationship between current depression, physical function, and physical activity, such as the Geriatric Depression Scale (Yesavage et al., 1982; Herrmann et al., 1996; Almeida et al., 1994). A validated measure of physical activity would also improve the accuracy of the findings, such as the Rapid Assessment of Physical Activity (RAPA) designed to measure physical activity in older adults (Topolski et al., 2006). Additionally, future studies may consider increasing the number of weeks the intervention is conducted. Also varying the intensity and modes of physical activity have shown to increase muscular strength, develop endurance, and improve neuromuscular response in the older adult population (Nelson et al., 2007; Taylor et al., 2003). Therefore, the incorporation of aerobic and resistance training could allow for further physiological and functional improvements in the older adult population. In conclusion, these results provide an evidence base for the effectiveness of this intervention in improving physical activity and physical function in a community setting, regardless of the presence of a history of depression. Moreover, participation in community programs are important to the well-being of older adults as they provide opportunities to be more physically active, gain greater functional abilities, and potentially improve overall health which are all essential for healthful aging.
48
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