Effects of resistance and all-round, functional training on quality of life, vitality and depression of older adults living in long-term care facilities: a 'randomized' controlled trial [ISRCTN87177281]

Wellbeing consists of many different aspects, such as bodily wellbeing (e.g. pain, energy/fatigue, sleep disturbance), emotional wellbeing (e.g. depression, anxiety, positive affect), self-concept (e.g. self-esteem), and global perceptions of health. It is assumed that habitual exercise may improve subjective wellbeing in older people. However, there is little experimental evidence to support this assumption. Few randomized controlled trials studied the effects of exercise on wellbeing of older people and results are inconsistent. There is no standardized method to measure wellbeing, and all studies focus on different aspects of wellbeing. Peel et al. [1] reported a significant improvement in two out of eleven aspects of wellbeing (perceptions of limitations in physical function and emotional problems) after 8 weeks brisk walking and resistance exercise. Two other recent studies [2, 3] found no improvement in their measures of well-being after 8 weeks resistance training or 17 weeks all-round, functional training, respectively.

It is also not clear what type and intensity of activity is most effective for wellbeing. Previously, it was believed that psychological change required high-intensity endurance training. King et al. [4] observed a significant decline in anxiety, stress and ratings of perceived change but not in depressive symptoms after 12 months higher intensity group endurance training, higher intensity home endurance training and lower intensity home endurance training. Strength training also seems of benefit for certain measures of well-being. Tsutsumi et al. [5] observed that both high and low intensity strength training improved mood and self-efficacy in older adults. However, Penninx et al. [6] found a significant beneficial effect of endurance training on depressive feelings and behavior of older women, but not from resistance training. Fewer research is available on other types of training such as functional training or ADL training.

Well-being is a subjective measure and refers to the way people feel about their life. The question is whether exercise and/or physical activity can contribute to an enhanced well-being of older adults, and if so, what type of exercise is most effective. Few studies compared different exercise formats with a social control program, and even fewer studies involved the less mobile and less healthy older population. Therefore, the aim of the present study was to examine the effectiveness of three different group-based moderate-intensity exercise protocols on different aspects of wellbeing, i.e. perceived health, quality of life, vitality and depression of older people, living in long-term care facilities.

Recruitment of participants and baseline measurements were conducted from August to November 2000. Follow-up measurements were conducted from March to May 2001. A total of 251 subjects were visited at home and screened to determine eligibility. Of these, 17 did not meet the inclusion criteria, five declined to participate and five died or became ill before the baseline measurements were completed. The 224 remaining subjects were randomly assigned to the four intervention groups (Figure 1). Mean age of these subjects was 81.7, ranging form 64 to 94. Of the 224 randomized participants, 173 (78%) completed the study (i.e. agreed with the final data collection visit). General characteristics of this group are shown in Table 1. Their mean age was 81 (± 5.4) years old and the majority (86%) lived in a residential care facility. Subjects reported problems with on average three of 17 ADL activities. Dropout of participants was not significantly different among the four groups (strength training 28%, all-round, functional training 20%, combined training 22% and control group 31%). The study participants who dropped out were slightly older (83 versus 81 years), and were more often male (20 versus 15%) and living in nursing homes (23 versus 14%).

Of the 173 subjects who completed the study, the median attendance to the strength training was 78% (range: 0–100), to the all-round, functional training 70% (range: 0–100) and to the combined training 73% (range: 7–100). Attendance to the control program was slightly lower (70%, range: 0–96). No participant was withdrawn for adverse effects, but eight study participants discontinued the intervention because they found that the exercise program was 'too intensive'. From the exercise logs it appeared that compliance to the strength training protocol appeared difficult. Subjects often trained at a lower intensity and increased the intensity at a lower rate than prescribed.

Our results suggest that exercise does not affect quality of life, vitality or depression of older adults living in long-term care facilities. After adjustments for baseline score, age, sex and compliance (class attendance), minimal differences in perceived health, quality of life, vitality and depression were observed between the strength training and all-round, functional training group and the non-exercise control group. Noticeable is that the combined training group declined slightly in perceived health, quality of life and vitality compared to the non-exercise controls after 24 weeks. However, in the subgroup that attended at least 75% of all classes no differences between either of the exercise groups and the controls were seen.

Few randomized controlled trials looking at the psychological effects of exercise in older adults have been performed and all looked at different measures [1–6]. Even fewer studies compared the psychological effects of different types of exercise [4, 6]. All looked at different training formats (strength training and endurance training), different durations, as well as different aspects of wellbeing such as depression, mood and anxiety, stress and self-efficacy. Findings on outcome measures were inconsistent.

Most studies used a non-exercise or waiting list control group. To positively rule out social interaction or staff attention as the most important underlying factor of improvement for quality of life, vitality and depression we added a sedentary, social activity control group. This may be one explanation for the lack of effect of the exercise programs in our study. The control program may have lead to improvement. King et al. [4] compared higher intensity group, higher intensity home and lower intensity home endurance exercise. Their results suggest that change in physical fitness and social support from group training was not necessary to achieve psychological change.

Another explanation for the lack of effect may be that some aspects of quality of life, vitality and depression represent stable personality traits rather than modifiable states or that the used measures were insufficiently responsive to change. The quantification of psychological wellbeing is difficult. There are many instruments that measure different aspects of wellbeing, such as bodily wellbeing (e.g. pain, energy/fatigue, sleep disturbance), emotional wellbeing (e.g. depression, anxiety, positive affect), self-concept (e.g. self-esteem), and global perceptions of health. Most instruments are not developed for measuring change over time. Thus, it is important to develop useful instruments in these potentially important areas. The Vitality Plus Scale used in our study was specifically developed to measure perceived psychophysical benefits of exercise participation, but did not indicate any changes in our trial. The responsiveness to change of this scale has been studied insufficiently up till now.

Our study was conducted in the less mobile and less healthy group of older people living in long-term care facilities. This group is likely to experience lower psychological wellbeing because of problems with health, mobility, and autonomy. Therefore, we expected greater gains in wellbeing from exercise. Still, average scores at baseline were not exceptionally low, leaving little room for improvement (ceiling effect). Because of these health and mobility problems, regular exercising at a considerable intensity appeared difficult. Most persons were not used to exercising and afraid to exercise at moderate intensity, which was in some people associated with pain. From the exercise logs it appeared that compliance to the strength training protocol appeared difficult.

The exercise programs showed little improvement in fitness and function (data not shown). In the subgroup of subjects who attended at least 75% of the classes, improvements in some fitness and function measures were observed (reaction time, eye-hand-coordination, chair rise performance) in the functional training group and the combined training group. No effect of strength training was observed. None of the exercise protocols were effecting ADL-disability (manuscript submitted for publication). Despite the lack of functional improvement subjects may still experience psychological benefit from participating in an exercise program, for instance because of hormonal or metabolic adaptations, alterations in brain monoamines or opioid peptides, the opportunity of socializing, enhanced feelings of competency, or distraction of day-to-day stressors. The studies of King et al. [4] and Tsutsumi et al. [5] suggest that neither high intensities, nor substantial fitness changes are essential to achieve positive mental health effects. Though, both studied healthy community-dwelling older people who were much younger (mean age 57 and 68, respectively).

A limitation of this type of study examining the effect of exercise programs in more real-life circumstances is the difficulty in standardizing and measuring the intensity of the training. Therefore, we cannot say whether the lack of effect is due to the insufficient compliance of the participants or due to the insufficient intensity or frequency of the exercise program.

Another limitation is that we used multilevel analysis. This technique is the state of the art for analyzing discrete variables in this type of trials. However, in our study we used ordinal outcome variables. Therefore, the results have to be interpreted with caution.

We conclude that neither strength training nor all-round, functional training of moderate intensity is effective in improving psychological quality of life, vitality and depression of older people living in long-term care facilities.