ORIGINAL PAPER Nagoya J. Med. Sci. 71. 115 ~ 126, 2009 CHANGES IN ACTIVITIES OF DAILY LIVING, PHYSICAL FITNESS, AND DEPRESSIVE SYMPTOMS AFTER SIX-MONTH PERIODIC WELL-ROUNDED EXERCISE PROGRAMS FOR OLDER ADULTS LIVING IN NURSING HOMES OR SPECIAL NURSING FACILITIES PEI OUYANG, HIROSHI YATSUYA, HIDEAKI TOYOSHIMA, REI OTSUKA, KEIKO WADA, KUNIHIRO MATSUSHITA, MIYUKI ISHIKAWA, LI YUANYING, YO HOTTA, HIROTSUGU MITSUHASHI, TAKASHI MURAMATSU, NORIKATSU KASUGA and KOJI TAMAKOSHI Department of Public Health/Health Information Dynamics, Field of Social Life Science, Nagoya University Graduate School of Medicine ABSTRACT A 6-month, twice weekly, well-rounded exercise program (47 sessions in total) comprised of a combination of aerobic, resistance and flexibility training was provided for institutionalized older adults aged 60 to 93. We analyzed the data of 18 older adults who could stand and had attended more than 10% of the classes (mean participation rate: 54%) to examine changes in activities of daily living (ADL), physical fitness tests and depressive moods. The mean (± standard deviation, range) age of the participants was 71.3 (±15.6, 60–93) in men and 85.9 (±5.8, 72–93) in women. Significant improvement in ADL of the hand manipulation domain and borderline significant improvement in ADL of the mobility domain were observed (McNemar test p=0.011 and 0.072, respectively). A 6-minute walk distance increased significantly from 151.6 m to 236.6 m (p=0.01, paired t-test), and the result of the Soda Pop test, which tests hand-eye coordination, also improved significantly from 35.2 sec to 25.3 sec (p=0.01, paired t-test). These findings suggest that such a program could be effective in improving the ADL and physical fitness of the elderly. Key Words: Older adults, Well-rounded exercise program, Activities of daily living, Physical fitness INTRODUCTION Japan is facing severe and rapid population aging such as no country has ever experienced.1) The current social security scheme that financially depends on the younger generation would not be sustainable if the number of frail elderly continues to rise as steeply as we have already experienced.2,3) It has been realized that reducing the need for long-term care by targeting the elderly with a strategy to strengthen and maintain their residual functions is important.4) Corresponding author: Hiroshi Yatsuya Department of Public Health/Health Information Dynamics, Field of Social Life Science, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya 466-8550, Japan Phone: +81-52-744-2128, Fax: +81-52-744-2131, E-mail: [email protected] 115 116 Pei Ouyang et al. Preventing elderly people from becoming limited in performing activities of daily living (ADL) is also an important health objective for maintaining their quality of life.5) More and more attention has been paid to devising measures for preventing a decline in muscle strength in an attempt to reduce the burden of long-term care since muscular atrophy due to disuse, a consequence of an inactive life, plays an important role in the progression of frailness.6) Recently, multifactorial intervention that targets balance, strength, endurance, or flexibility was reported to be highly effective for the prevention of falls and injuries in older adults.7) Concurrent aerobic and resistance or flexibility exercises, i.e. a well-rounded exercise program (WREP), were reported in Japan to improve the fitness of the elderly.8) There is relatively limited evidence regarding the late elderly or institutionalized elderly,9-12) especially in Japan where preventive programs targeting the pre-frail elderly to maintain their independence have been promoted by the nursing care insurance system. There are also uncertainties regarding the ideal duration, frequency, or content of such programs.7,13) Furthermore, the prospective association between WREP and depression is unresolved. In this study, we attempt to address some of these issues by assessing differences in ADL, physical fitness and depressive symptoms before and after periodic WREP classes to infer whether combined exercise intervention may be effective in improving physical performance and mental well-being in the elderly living in nursing homes or special nursing facilities. METHODS Participants The present study utilized the data collected during exercise programs conducted as part of the activities of a social welfare enterprise. In 2003, 28 elderly, aged 60 to 93, who could stand and who had lived or been institutionalized either in a nursing home (n=11) or in a special nursing facility for the frail elderly (n=17), were included in the study. Both facilities were located in the same building and owned by a social welfare enterprise. Participation in the classes was completely voluntary, and verbal informed consent was obtained from both participants and their families. Ten subjects who attended the classes 10% of the time or less were excluded, leaving 18 subjects for the present analysis (mean participation rate: 54%) including 11 elderly institutionalized in the special nursing facility. All 18 subjects had answered both the baseline and post-WREP ADL questionnaire-based interviews; however, four did not undergo post-WREP physical fitness tests. The study procedure, including the use of secondary data for epidemiologic research, was approved by the Ethics Review Committee of the Nagoya University School of Medicine. Exercise program A well-rounded exercise program (WREP) consists of resistance, aerobic and flexibility train- ing. In the present WREP, to ensure the safety of the elderly, exercises were designed that could be performed while seated and at 30–50% of maximum heart rate, which had been estimated from baseline physical fitness test result. One interventionist (licensed exercise trainer), one chief care worker, one clerk, one to two care workers or nurses, and one to two volunteers were involved in the program. We had also prioritized low-cost exercises as well as those that were fun. The class was held twice a week over a period of six months (47 sessions in total). The duration of each class began at 30 minutes, but was gradually increased based on improvements in physical strength and endurance (120 minutes maximum). Activities such as participating in games were included in each session aimed at producing beneficial psychological effects. The 117 COMBINED EXERCISE AND ADL AMONG ELDERLY Table 1 Baseline characteristics of participants according to types of facility and age groups Types of facility Age groups Special nursing Total (n=18) Nursing homes 75 years or older 60~74 years old facilities for elderly (n=7) (n=14) (n=4) Variables (n=11) M/F (n) 4/14 4/7 0/7 1/13 3/1 Age (years old) 82.7 ± 10.4 82.3 ± 12.4 83.3 ± 7.2 87.4 ± 4.6 66.0 ± 6.9 Height (cm) 145.2 ± 10.2 147.5 ± 12.0 141.6 ± 5.6 140.6 ± 4.5 161.1 ± 8.1 Weight (kg) 49.2 ± 7.7 50.4 ± 9.0 47.0 ± 5.0 48.1 ± 7.5 53.8 ± 8.2 Body mass index (kg/m2) 23.4 ± 3.1 23.6 ± 3.5 23.2 ± 2.8 24.1 ± 3.1 20.6 ± 1.0 ADL score 17.1 ± 7.0 16.1 ± 7.5 18.6 ± 6.3 15.6 ± 5.7 22.3 ± 9.6 CES-D score 8.8 ± 8.1 10.5 ± 8.4 6.3 ± 7.4 6.9 ± 6.5 15.8 ± 10.3 n indicates number; M, male; F, female; ADL, Activities of Daily Living; CES-D, Center for Epidemiologic Studies Depression scale. Values are presented as means±standard deviation. Body mass index is calculated as weight (kg) divided by (height (m))2. types of exercise were selected according to the following considerations. (1) Dance, cycle ergometers and walking were included for endurance improvement. (2) Resistance training, elastic band-based training, and dumbbell training were aimed at increasing the muscular strength of limbs. (3) Flexibility exercises, stretching, rhythmic exercises, Proprioceptive Neuromuscular Facilitation (PNF), Tai Ji Quan (Tai Chi Chuan), and finger exercises were performed for the improvement of flexibility and adjustment ability. (4) The control of small joints was stimulated through participation in games. Activities of daily living (ADL) questionnaire The ADL level was assessed by a structured interview using a 12-item questionnaire, which had originally been introduced by the Japanese Ministry of Education, Culture, Sports, Science and Technology for the assessment of the elderly, with minor modifications (Table 2).14) A single examiner (a care worker of the facility) assessed all the participants to avoid evaluation differences between testers. In this study, four domains of ADL were defined: (I) mobility and walking assessed by items Q1, Q2, Q3, Q4 and Q11, (II) hand manipulation assessed by items Q9 and Q10, (III) balance assessed by items Q6, Q7 and Q8, and (IV) changing posture by items Q5 and Q12. Each item uses three or four ordinal scales, and we assigned a score ranging from 1 to 4 according to the response. The composite score for each domain was then calculated as the sum of each item score. Anthropometry and blood analysis Height and body weight were obtained, and the percentage of body fat was estimated by an impedance method (body fat analyzer, TBF-305; Tanita, Tokyo, Japan). Body mass index (BMI) was calculated as the weight (kg) divided by the square of height (m). Blood pressure was measured in a sitting position by an automatic sphygmomanometer by the oscillometric method. We have acquired blood analysis data that were obtained as a part of the participants’ health check-up by the facility. Thus, post-WREP blood analyses were not actually carried out right after the class. Physical fitness tests 1.