As the age of the Korean population increases rapidly, the health of older women is a major concern because of high disability and comorbidity rates in this population. As older women have 4.5 years longer to live compared with older men, there are 1.5 times more women than men older than 65 years and 3 times more women than men older than 85 years.1 About 87% of elders have at least one chronic disease that usually includes cardiovascular disease,2 and 14.8% do not have the functional ability to accomplish necessary daily activities.3 Therefore, many older women with disabilities and chronic diseases depend on long-term assisted living facilities, and about 76% of patients in long-term assisted living facilities are women.1
It has been reported that older women in long-term assisted living facilities have very limited access to physical fitness or exercise programs.4,5 Older women's most serious problem is the overall decline of functional status that most face.6 Poor functional status makes daily activities difficult for older people. Furthermore, Korean elders prefer sedentary lifestyles and hesitate to participate in physical activities.7 Thus, physical deterioration with aging and cultural lifestyles discourages many elders from participating in exercise. Together, these forces increase risk for cardiovascular disease. There are virtually no studies reporting exercise interventions tested in older women in institutional settings in Korea, a nation noted for the sedentary status of its older people.
Appropriate physical exercise interventions in older people can reverse functional limitations, help them maintain independent living by improving muscle strength and balance, and decrease risk of cardiovascular disease. Physical exercise increases muscle strength,8,9 reinforces joint flexibility,10,11 and increases balance.12,13 Physical activity and exercise offer the greatest opportunities for older people to extend the period of active independence and reduce functional limitations, but older women in institutional settings are a particularly high-risk group for sedentary lifestyles.14
Physical exercise may play an important role in treating mental health disorders, especially depression.15 Although depressed individuals tend to be less physically active than nondepressed ones,16 increased regular exercise significantly reduces depressive symptoms in older people.15-17 Moreover, increased regular exercise improves quality of life for sedentary older people8,17 and self-esteem in frail elders.18
Physiological, biological, and psychological mechanisms explain the antidepressive effects of exercise.19 Regular exercise may decrease depression levels because it is effective in enhancing specific mood-enhancing neurotransmitters in the brain, such as serotonin. In addition, exercise decreases cortisol and increases endorphins; both can improve mood. Regular exercise may increase self-esteem because it helps older individuals gain confidence in their physical capacity by fortifying physical abilities. This last point is important since lack of confidence in physical abilities is a major barrier to physical activities in older people.
Despite the many benefits of exercise, only 10% to 30% of older people participate in regular exercise programs.20 Although there are studies of the impact of exercise in the oldest of older women,9,12,21 the results of these studies are inconsistent and have not provided information about the types of exercise that might be effective in very sedentary older women. Because the vulnerability of older women in institutional settings rapidly increases functional disability and sedentary lifestyles, an exercise program was specifically designed to overcome these barriers by setting an appropriate intervention in this age group.
The purpose of this study was to determine whether a 16-week group exercise program improved physical function and mental health in an intervention compared to a usual care control group. Because we were also interested in the effects of the intervention in younger elderly women (aged 65-74 years) and in older elderly women (older than 75 years) who lived in long-term assisted living facilities, the sample was stratified by age. Physical function was defined as lower body strength, flexibility, and balance. Mental health was defined as self-esteem and depressive symptoms. The specific aims were to examine group (intervention and control) and age (aged <75 and ≥75 years) differences in intervention effects on the physical function and the mental health.
Study Design, Sample, and Setting
This study was a randomized controlled trial conducted from June 2006 to October 2006. Four long-term assisted living facilities drawn from 14 long-term assisted living facilities in Kyungpook, South Korea, were selected using random cluster sampling. Two of the randomly selected long-term assisted living facilities were assigned to intervention groups, and other 2 were control groups. Twenty older people were randomly selected from each long-term assisted living facility. The sample size was decided using Cohen's method,22 with an effect size = 0.50, power = 0.70, α = .05, and 4 groups. Given these criteria, the total sample size suggested was 40, or 10 in each group. Forty older people were included in the study, who satisfied the following inclusion criteria: (1) older than 65 years, (2) physically able to walk alone, (3) have not participated in any regular exercise programs within the previous 6 months, and (4) no cognitive impairment (ie, had a cognitive score greater than 23 on the Mini-Mental State Examination Korean version, which has different cut points from the US version to account for differences in education level). Older women were excluded if they had (1) a stroke or cardiovascular events within the past 6 months, (2) unstable chronic or terminal illnesses (eg, diabetes mellitus, hepatic cancer, liver cirrhosis), or (3) severe cognitive impairment or major depression. Severe cognitive impairment was defined as having a Mini-Mental State Examination Korean version score of lower than 24. Elders with severe depressive symptoms were excluded from this study. Severely depressed elders were defined by a Geriatric Depression Scale (GDS) score of greater than 20. After eligible women agreed to participate, they were randomly assigned by identification numbers allocated by a random number generator to the intervention and control group. The control group received usual care.
The group exercise intervention was conducted at 2 facilities, and participants were randomized by cluster sampling to avoid contamination and to enhance feasibility. Randomization was stratified by age (<75 or ≥75 years). Data were collected at baseline and again 4 months later.
The approval of the Medical Ethical Committee of the University Medical Center was obtained. Written and informed consent was obtained from all participants. First, we conducted a pilot study with 5 older women to determine the feasibility of this study. The results of the pilot study demonstrated that the planned exercise program was feasible. Thus, we implemented the exercise program without modification. We recruited eligible patients from long-term assisted living facilities, where they completed the baseline assessment. Each baseline test included measurements of physical function (ie, lower body strength, flexibility of hip and shoulder, and static balance) and mental health (ie, self- esteem and depressive symptoms). The women were divided into 2 age groups (the younger old, who were <75 years, or the older old, who were ≥75 years). Participants in the intervention group completed a 16-week group exercise program with a series of 8 health education sessions. The control group was asked not to initiate any exercise and education program during the 16-week period. They received usual health services in the long-term assisted living facilities. Three patients dropped out during the posttest period, citing health concerns as their reason. All participants in the intervention and control groups received exercise clothing as an incentive for participating in this study.
This group exercise program included 2 parts: functional exercise and health education. The functional exercise included low- to moderate-intensity activity (Table 1), for a total of 40 minutes per day and 3 times per week for 16 weeks. The group exercise program was based on guidelines from the American Alliance for Health Physical Education, Recreation, and Dance (AAHPERD).23 A physical therapist supervised and 2 research assistants led the functional exercise component. Functional exercise consisted of a 10-minute warm up, a 10-minute muscle strengthening, a 20-minute exercise performed with music, and a 10-minute cooldown.
The warm-up consisted of gentle stretching and large body movements designed to increase heart rate gradually. Muscle strengthening was chosen to provide support for daily activities performed by older women and were focused on increasing older women's ability to perform functional activities while targeting use of muscles that maintain posture. These exercises included squats, side leg raises, inner thigh lifts, wall push ups, and triceps press. Music exercise consisted of continuous rhythmical movements with music. Participants performed all exercises at their own pace. All movements were low impact. Intensity was increased by including large arm movements and a gradual increase in tempo. Cooldown consisted of stretching the major joints and walking. The level of exercise was gradually increased through the warm-up phases.
In the first week of this program, participants started at 40% of their maximum heart rate (220 − age = maximum heart rate), and every week, a 5% increase was made. By the fourth week, participants were able to maintain 50% to 55% of their maximum heart rate. To confirm heart rate, women wore Sports tester PE-3000 (Polar Electro, Finland) while exercising.
The health education component of this intervention was constructed based on social cognitive theory24 and was delivered during a 30-minute period every 2 weeks for 16 weeks by 2 research assistants (Table 2). Social cognitive theory explains how people acquire and maintain certain behavioral patterns, and the theory suggests that environmental factors and others affect uptake of learned material and behavioral patterns. The theory suggests that benefits and barriers to implementing a behavior should be taken care of to increase uptake of the behavior. The theory provided a framework for implementing the health education programs.24
The health education program consisted of describing the benefits to activities of daily living for older women of exercise, how to promote safety in the facility, prevention of chronic diseases (ie, diabetes, hypertension, arthritis, and dementia), and healthy aging (ie, drugs, nutrition, alcohol and tobacco, sleep, and rest).25 PowerPoint presentations, physical models, and other educational materials were used to convey the health education topics. Educational level was adjusted to be suitable for participants with low literacy (ie, elementary/middle school level).
Lower Body Strength
Lower body strength was measured using the 30-second chair test recommended by AAHPERD.23 This test includes counting the number of times that one stands from a sitting position on a chair without using the arms during 30 seconds. Trained research assistants demonstrated how to perform the test to obtain accurate test results. The research assistants observed all test processes and assisted all participants for safety. All participants performed two repeated tests, and the mean score of the two tests was used to reflect lower body strength.
Hip flexibility was measured by trained research assistants using the Sit-And-Reach test based on the AAHPERD manual. The Sit-And-Reach test was conducted using equipment designed specifically for this purpose (Scientific Instruments Co, Korea, No. m1-385-s61). Participants sat on the equipment with straight knees and then extended their arms as far forward as possible. Reached distance was assessed in centimeter. Each participant conducted this test twice, and the mean score was chosen to reflect the flexibility of the hip.26
Static balance was measured by 2 trained research assistants using the one-legged stand with eyes open and closed.27 The time of one-legged standing with eyes open or closed was counted separately, and then the 2 results, in seconds, were added. The research assistants measured this test in each participant, and the mean time of these tests was chosen for the static balance.
Self-esteem was measured using the Rosenberg Self-esteem Scale.28 This instrument consisted of 10 items that assessed global self-esteem. Each item had 4 response options ranging from 1 to 4. The total score was calculated by adding the ratings after reversing the scoring for 5 items, so the total score ranged from 4 to 40. Higher scores mean better self-esteem. Acceptable reliability and validity of this instrument were demonstrated.29 Cronbach α in the current study was .72.
The GDS developed by Yesavage et al30 was used to assess the level of depressive symptoms. The GDS is a valid and reliable scale in geriatric populations. It consists of 30 items with a yes (1) or no (0) response option. The possible scores range from 0 to 30. A score between 0 and 9 indicates no depression, whereas 10 to 19 indicates borderline depression. A score of 20 or greater reflects depression. This instrument has been used for healthy older people and older people with several diseases.31 Several studies have demonstrated acceptable internal consistency and construct validity of this instrument among geriatric populations.17 The GDS Korean version is commonly used in Korea to assess the level of depressive symptoms in Korean geriatric populations.32 Cronbach α of this instrument in the current study was .79.
The data were analyzed using the SPSS version 14.0 (SPSS Inc, Chicago, Illinois) software system for Windows. Descriptive analyses were used to describe sociodemographic characteristics. To compare outcomes between the intervention and control groups and the 2 age groups, a 2-way analysis of variance was used to test for group main effects, age main effects, and the interaction of group by age. We used mean differences as posttest scores minus pretest scores for the 2-way analysis of variance test. Values of P < .05 were considered statistically significant.
The mean (SD) age of the participants in this study was 75.8 (5.6) years. The mean (SD) period of institutionalization in the long-term assisted living facilities was 30.6 (18.4) months. A total of 40.5% of the participants completed no education or only elementary school courses, and 24.3% completed middle school courses only, whereas 35.1% completed high school courses or greater. The mean (SD) body mass index of the sample was 24.1 (3.6) kg/m2. Of the participants, 75.7% had a chronic condition such as hypertension, arthritis, or diabetes mellitus (Table 3).
At baseline, there were no differences between the 2 age groups (≤75 and >75 years) or between the intervention and control groups in lower body strength (F = 3.535, P = .069; F = .200, P = .658), hip flexibility (F = 1.204, P = .280; F = .978, P = .330), static balance (F = 4.138, P = .058; F = 2.148, P = .152), self-esteem (F = .535, P = .469; F = .014, P = .906), and depressive symptom scores (F = 1.899, P = .177; F = .860, P = .360) (Table 4).
After training, there were no differences between the age groups (<75 and ≥75 years) in lower body strength (F = 1.351, P = .254), hip flexibility (F = 1.142, P = .293), static balance (F = .016, P = .091), and depressive symptom scores (F = .717, P = .403). Participants aged 75 years or older had significantly higher self-esteem score at baseline than participants younger than 75 years (F = 4.484, P = .042).
On follow-up, participants in the intervention group demonstrated significant improvement in several parameters compared to the control group. All participants in the intervention group showed a significant improvement in lower body strength (F = 7.431, P = .011), flexibility of hip (F = 5.306, P = .028), static balance (F = 5.591, P = .024), and self-esteem (F = 18.269, P = .000) compared to the control group. There was no change in depressive symptom scores (F = 1.164, P = .289). There was no age-by-treatment group interaction (Table 5).
There are few programs that promote activity in long-term assisted living facilities in Korea. When older people are increasingly sedentary, it is difficult for them to remain independent and active, particularly when they develop chronic illnesses. In addition, the provision of health education is not the cultural norm in Korea. As a consequence, older individuals have difficulty improving their health status as they do not have the opportunity to receive health education supporting self-management strategies. Thus, we devised a program specifically for older women, the majority in assisted care environments in Korea. The program included both group-based exercise and health education. We found that the group-based exercise program, which was performed regularly, led to improvements in their physical function and self-esteem. These improvements occurred regardless of age, with women older than 75 years realizing benefits comparable to those seen by women aged 65 to 74 years.
Intensity of physical exercise must be considered in providing interventions for older women. Different intensities of physical exercise have very different effects on functional performance in older women.9 Physical exercise with moderate intensity is helpful to prevent deterioration of functional status,9,33 whereas physical exercise with higher intensity fails to prevent falling incidents and increases the risk of exercise-related injury.34 Although there is lack of literature about what duration and frequency are adequate for older women, 30 minutes has been commonly chosen in exercise programs. The current study confirmed that low to moderate exercise of relatively short duration is effective in improving the functional status of Korean older women.
In general, a combined exercise program, which focuses on aerobic effects and muscle strengthening and balance such as the one tested in this study, improves muscle strength, balance, and flexibility and results in better functional performance than an aerobic-only or a resistance training program only.10,35,36 Chronic diseases in older people may make them dependent on others to perform their daily activities. Loss of balance and flexibility is a major risk factor for falls in older people, and physical exercise may improve balance27,37 and flexibility and thus prevent falls.10,11 Although we have not directly tested the impact of our intervention on older people's abilities to perform the activities of daily living, balanced physical activity programs, such as the one tested in our study, may increase ability to perform daily activity and reduce the risks associated with activity in older people by improving overall muscle strength and balance.21 Increased lower extremity muscle strength as a result of exercise improves the ability to perform daily activities such as walking, transferring positions, and stair climbing. In this study, muscle strength was improved by a simple exercise program with low to moderate intensity. In the future, investigators should test older people's ability of performing daily activities to exactly determine what extent improvements in flexibility, balance, and muscle strength translate into the ability to engage in daily activities.
Only a few investigators have evaluated the effects of physical exercise on mental health of older people.8,15,16,38 The effects of exercise on mental health have primarily been studied in patients with coronary heart disease, obesity, and diabetes. Increasing self-esteem is one of the primary goals for health improvement in older people. The group exercise program tested in this study contributed to an increase in older women's self-esteem. It is unclear which component, the exercise or health education (or both), of the intervention contributed to this outcome, so future investigations are needed to resolve this question. However, because self-esteem contributes to improved mental health, self-esteem may be a factor key to improving quality of life. Thus, this program may offer better quality of life for Korean older women who usually have sedentary lifestyles.
Physical exercise programs may assist in depression management in older people.16 It has been reported that people in the 75- to 79-year age group have a high risk of depression.15 One group16 examined the effect of aerobic and resistance exercise on emotional and physical functioning among older people with initially high or low depressive symptoms. Aerobic and resistance exercise significantly reduced disability and increased walking speed, to an equal extent, in older people with high and low depressive symptoms. In the current study, we found that an exercise program of moderate intensity failed to improve depressive symptoms. Recently, 2 groups also reported that group exercise programs did not improve depressive symptoms in older women.8,39 A possible reason that our program failed to decrease depression is that a moderate-intensity exercise program may not be intense enough to decrease high levels of depressive symptoms. It has been reported that the prevalence of depressive symptoms in Korean older women living in long-term assisted living facilities is higher than that of those living in the community. Thus, an exercise program alone may not be sufficient to improve depressive symptoms. Pharmacologic therapy may be an important adjunct to exercise in older women to reduce depression, but the frequency of its use in older people is low, and care providers commonly ignore depressive symptoms in older women because they erroneously consider them as a part of aging.
During our exercise program, none of the participants experienced serious pain or musculoskeletal side effects. There was no negative feedback regarding the intensity or difficulty of the exercises. Therefore, it is reasonable to suggest that the exercise program tested in this study is safe and enjoyable for participants aged 75 years or older and younger than 75 years in long-term assisted living facilities.
Motivation among participants was probably enhanced by social support provided in a group setting.40 Because our study was performed in a group, motivation among the participants was probably increased. In addition, checking attendance at the beginning of the exercise program likely helped to encourage the participants to participate in the program. Without an attention placebo control group, it is difficult to determine to what extent social support alone contributed to the changes seen, although there is evidence from other studies to suggest that this aspect of an exercise program should be capitalized on by those planning similar programs in institutional setting. Our study is also limited by our inability to discern which component of the combined exercise and health education intervention contributed to the effects seen. Given the impact of the intervention on measures of functional status, it seems likely that the exercise component contributed to the outcomes, but it is unclear what role was played by education. Future studies in this and similar populations should focus on unraveling the specific components of multidimensional interventions that are effective.
Summary and Implications
Korean older women living in long-term assisted living facilities can physically benefit from a group exercise program of low intensity. Self-esteem is also enhanced by participation in such program, but depressive symptoms in this population seem to be more resistant to treatment with exercise alone. The group-based exercise seems to be an effective and safe intervention that can be used in elderly women to prevent deterioration of their functional status.
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