Physical exercise and mental health among older people : measurement methods and exercise effects focusing on people living in residential care facilities

Abstract: The aim of this thesis was to study the effects of exercise on mental health among older people living in residential care facilities. The aim was also to study the reliability of an assessment scale for balance function and the usefulness of an assessment scale for depressive symptoms among older people, including people with cognitive impairments. The Berg Balance Scale (BBS) is frequently used to assess balance in older people, but knowledge is lacking about its absolute reliability. The BBS (0-56 points) was assessed twice among older people living in residential care facilities by the same assessor, at approximately the same time of day, and with 1-3 days in between. The absolute reliability was calculated as being 7.7 points, using 95% confidence level, and the Intra Class Correlation coefficient (ICC) was calculated to 0.97. Depression is common among older people and is often not detected and not treated adequately. The Geriatric Depression Scale 15-item version (GDS-15) was designed to assess depressive symptoms among older people, but there is limited knowledge about the usefulness of the scale among people with varying degree of cognitive impairment. A sample of people aged 85 years and over was divided into groups according to cognitive function using their Mini-Mental State Examination (MMSE) scores; 0-4, 5-9, 10-14, 15-19, 20-24, 25-27, and 28-30. In total, 650 (78%) of the 834 participants completed the GDS-15. The lower the cognitive function, the smaller the proportion who completed the GDS-15 assessment; for the two MMSE groups with scores of < 10, the proportions who completed the GDS-15 were 1% and 42%, respectively, compared to 64–95% in people with MMSE scores of ≥ 10. The level of correlation between the GDS-15 and a scale of psychological wellbeing, the Philadelphia Geriatric Center Morale Scale (PGCMS), did not differ between MMSE groups with scores of ≥5 compared to people in the group with the highest scores (MMSE 28–30). Exercise has been suggested as effective in influencing mental health among community-dwelling older people, but there is a need for a well-designed study to establish the effects among older people living in residential care facilities. A high-intensity functional exercise programme was evaluated for effects on depressive symptoms and psychological wellbeing among older people dependent in activities of daily living (ADL) and living in residential care facilities. The study was a cluster-randomised controlled study. Participants were randomised to either a high-intensity functional weight-bearing exercise program (HIFE Program) or a control activity. Sessions were held in groups, for approximately 45 minutes, five times over each two-week period for three months, a total of 29 times. The outcome measures, the GDS-15 and the PGCMS, were blindly assessed at baseline, 3- and 6-month follow-up.  There were no differences between the groups at the 3- or 6-month follow-ups in the total sample. However, sub-groups analyses showed a difference in PGCMS scores in favor of the exercise group among people with dementia at the 3-month follow-up. Regarding older people living in residential care facilities, including people with cognitive impairments, there is a lack of evidence showing that exercise has a positive influence on mental health. This may either be due to a lack of effect, or an insufficient amount of effect of exercise on physical capacity or dependence in ADL, which could be two important mediating factors for influencing mental health. The association between changes in physical capacity (BBS) or dependence in ADL (Barthel ADL Index) and changes in mental health (GDS-15 and PGCMS) was evaluated. The results showed no significant associations between change in physical capacity or dependence in ADL, and change in depressive symptoms or psychological well-being. Further, interaction analyses showed no moderating effects for dementia disorder. In conclusion, despite a high ICC value, the result of the absolute reliability evaluation shows that a change of 8 BBS points is required to reveal a genuine change in function among older people who are dependent in ADL and living in residential care facilities. This knowledge is important in the clinical setting when evaluations are made of an individual’s change in balance function over time in this group of older people. The GDS-15 seems useful in assessing depressive symptoms among very old people with MMSE scores of ten or above. More studies are needed to strengthen the validity among people with MMSE scores of 10-14, and for people with lower MMSE scores than ten there may be a need to develop and validate other measurements. Furthermore, a high-intensity exercise programme offered 2-3 times/week seems not to generally influence mental health among older people living in residential care facilities. However, the exercise programme may have a short-term effect on well-being among people with dementia. A change in physical capacity or dependence in ADL does not appear to be associated with a change in depressive symptoms or psychological well-being among older people who are living in residential care facilities. These results may explain why studies of using exercise to influence mental health have not shown effects in this group of older people. In future research, there is a need for studies that evaluate whether exercise offered more frequently, or interventions that aim to increase the level of physical activity in daily life, can influence mental health among older people living in residential care facilities.