Journal of Gerontological Nursing

Exercise and Quality of Life in Elderly Individuals

Tammie Ellingson, MSN, RN, CS, M-SCNS; Vicki S Conn, PHD, RN

Abstract

TABLE 1

DIMENSIONS OF QUALITY OF LIFE

TABLE 2

DESCRIPTIVE RESEARCH STUDIES ABOUT QUALITY OF LIFE AND EXERCISE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE…

Less than one third of older adults exercise regularly, and less than 10% exercise vigorously (Barry & Eathorne, 1994). Exercise is important for older adults for several reasons. Exercise is a recommended behavior to prevent, delay, and manage many chronic illnesses common with advancing age (Clark, 1996; Lowenthal, Kirschner, Scarpace, Pollock, & Graves, 1994; O'Brien & Vertinsky, 1991). Increased exercise may result in health care cost savings (Clark, 1996; Shephard, 1993). Shephard (1993) noted that while the typical sedentary individual experiences 10 years of partial dependency, active individuals are less likely to become reliant on institutional support. Although considerable emphasis has been placed on the health care economics and physical health consequences of increased exercise, issues of quality of life are equally important. Quality of life is a complex multidimensional evaluation of life experience (George & Bearon, 1980). Benefits of exercise such as increased mobility and energy could contribute to enhanced perceived quality of life. Individual studies and reviews of the empirical literature have documented the physical benefits of exercise. The purpose of this article is to review the empirical evidence that older adults who exercise regularly have improved quality of life.

POTENTIAL QUALITY OF LIFE OUTCOMES OF EXERCISE

Any effort to examine the association between exercise and quality of life requires some conceptualization of quality of life. There have been many definitions of quality of life (Aaronson, 1988; Burgener & Chiverton, 1992; Caiman, 1987; Ferrans, 1990; George & Bearon, 1980; Grant, Padilla, Ferrell, & Rhiner, 1990; Patrick & Erickson, 1988). The lack of consensus regarding quality of life in part reflects the different views about what is important to different individuals. George and Bearon's (1980) definition is useful because it is a broad definition developed specifically for the elderly population. According to George and Bearon (1980), quality of life is defined in terms of four underlying dimensions, two of which are objective conditions (general health/functional status and socioeconomic status) and two of which reflect the personal judgment of the individual (self-esteem and life satisfaction/ well-being). Table 1 presents George and Bearon's (1980) dimensions of quality of life.

Table

TABLE 1DIMENSIONS OF QUALITY OF LIFE

TABLE 1

DIMENSIONS OF QUALITY OF LIFE

Exercise may affect quality of life by influencing the two predominant components of health-related quality of life - physical functioning and well-being (Stewart & King, 1991). Exercise may enhance quality of life through well-documented physical beneficial effects such as increased resistance to illness, enhanced functional independence, reduced mortality risk, and delayed or prevented hypertension, diabetes, and ischemic heart disease (Clark, 1996; Lowenthal et al, 1994; O'Brien & Vertinsky, 1991). Other potential specific benefits include improving muscle strength, joint flexibility, balance, and general endurance, as well as weight reduction (Stewart & King, 1991). Potential influences of exercise on quality of life are portrayed in the Figure.

Multifaceted possible effects on well-being have been attributed to exercise. Psychosocial benefits of exercise and activity include shortterm enhancement of social and emotional well-being (O'Brien & Vertinsky, 1991; Travis, Duncan, & McAuley, 1996). The modest social encounters combined with mild exercise, such as walking, can improve an older adult's happiness, subjective health, and well-being (Travis et al., 1996). Exercise also could enhance an individual's ability to participate in social activities by improving physical and cognitive functioning (Stewart & King, 1991).

Exercise also may affect healthrelated quality of life through effects on self-esteem. Many people who experience major changes in health status experience a decline in perceived self-worth. Activity or exercise can maintain a sense of selfworth for those who have experienced changes in physical abilities, such as the elderly population in general (Zimmer, Hickey, & Searle, 1995). Elderly individuals who participate in exercise programs may have an increase in self-esteem through establishing friendships with other elderly exercisers.

Exercise may even have the potential to affect the fourth dimension of quality of life, socioeconomic status. Exercise may influence socioeconomic status indirectly through its potential influence on health state which influences health care expenditures. Older adults who spend less on health care will have more disposable income.

This discussion of exercise and quality of life has used a broad definition of exercise. For this review, exercise is defined as physical activity that is planned, structured, repetitive, and purposive in improving or maintaining physical fitness (Melillo et al., 1996). This definition includes formal or organized activities such as calisthenics, dance, games such as racquet games, and individual or team sports; and includes informal activities such as walking, jogging, swimming, or gardening (Melillo et al., 1996; O'Brien & Vertinsky, 1991). This definition of exercise is consistent with older adults' descriptions of their exercise (MeIIiIo et al., 1996).

REVIEW OF EMPIRICAL STUDIES LINKING EXERCISE AND QUALITY OF LIFE

Many descriptive and experimental studies have attempted to link exercise with components of quality of life. The studies contained a variety of designs and ways of measuring aspects of quality of life. They included direct and indirect measures of quality of life. This review included studies with sample mean ages of at least age 60. Some samples were specific to populations having chronic illnesses such as cancer and arthritis (Young-McCaughn & Sexton, 1991; Zimmer et al, 1995).

Table

TABLE 2DESCRIPTIVE RESEARCH STUDIES ABOUT QUALITY OF LIFE AND EXERCISE

TABLE 2

DESCRIPTIVE RESEARCH STUDIES ABOUT QUALITY OF LIFE AND EXERCISE

Descriptive Studies Addressing the Relationship Between Exercise and Quality of Life

Relatively few descriptive studies were found linking exercise and quality of life (Dómelas, Swencionis, & Wylie-Rosett, 1994; Ruuskanen & Parkatti, 1994; Ruuskanen & Ruoppila, 1995; Young-McCaughn & Sexton, 1991; Zimmer et al., 1995) Table 2 summarizes the descriptive studies.

Five descriptive studies (Dornelas et al., 1994; Ruuskanen & Parkatti, 1994; Ruuskanen & Ruoppila, 1995; Young-McCaughn & Sexton, 1991; Zimmer et al., 1995) explicitly examined the relationship between exercise and quality of life. Four of the five studies documented a positive relationship between physical activity or exercise and dimensions of quality of life (Dornelas et al., 1994; Ruuskanen & Parkatti, 1994; Ruusakanen & Ruoppila, 1995; Young-McCaughn & Sexton, 1991). The fifth study found minimal association between exercise and quality of life (Zimmer et al., 1995). The findings of the studies generally confirm a relationship between quality of life and exercise. This relationship may be bi-directional. One possible explanation for the association between quality of life and exercise is that people who exercise more experience higher quality of life. It is also possible that people with higher life satisfaction are more likely to exercise. For example, Dornelas et al. (1994) found older women with greater psychological well-being were more likely to exercise. Limitations of these studies were the sample characteristics and sizes. Instrumentation remains problematic, with instruments often measuring limited components of quality of life (Zimmer et al, 1995).

Table

TABLE 3EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

Table

TABLE 3EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

Table

TABLE 3EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

Experimental Studies Addressing the Relationship between Exercise and Quality of Lite

Several experimental design studies were found linking quality of life and exercise (Blumenthal et al., 1989. Dungan, Brown, & Ramsey, 1996 Elward, Wagner, & Larson, 1992 Gitlin et al., 1992; Lavie & Milani, 1996; MacRae et al., 1996; McMurdo & Burnett, 1992; Noble, Salcido, Walker, Atchinson, & Marshall, 1994; Singh, Clements, & Fiatarone, 1997; Topp & Stevenson, 1994; Whitlatch & Adema, 19%). Not surprisingly, definitions of quality of life varied greatly, and most studies examined limited dimensions of quality of life. Experimental studies are presented in Table 3.

Eleven experimental studies evaluated an exercise intervention. Seven of the 1 1 studies found improvement in quality of life dimensions in response to the exercise intervention. Of these, five studies were conducted comparing an exercise intervention that consisted of aerobic exercise, walking, bicycle exercise group, or structured exercise group with a control group (Blumenthal et al., 1989; Gitlin et al., 1992; MacRae et al., 1996; McMurdo et al., 1992; Singh et al., 1997). Two studies compared two exercise groups with each other (Lavie & Milani, 1996; Topp & Stevenson, 1994). One examined two groups of men in a cardiac rehabilitation program (Lavie & Milani, 1996), and one examined two groups with differing exercise intensities (Topp & Stevenson, 1994).

Many measurement tools for quality of life were used. Three of the five studies that measured life satisfaction found within group changes of improved aspects of quality of life (Blumenthal et al., 1989; Dungan et al., 1996; McMurdo & Burnett, 1992; Noble et al., 1994; Topp & Stevenson, 1 994). For example, in a single-group pretestposttest design, Dungan et al. (1996) found improved life satisfaction scores. One of the two studies that measured self-esteem found a differenee in self-esteem after the exercise intervention (Dungan et al., 1996). One of the two studies that used the Medical Outcomes Survey (MOS) Short Form found an improvement in well-being in the exercise group (Singh et al., 1997). The other study with a single-group pretest-posttest design found no significant change with seven of the eight (MOS) subscales (Whitlatch & Adema, 1996). One study measured parameters such as mental health, energy, general health, pain, function, well-being, and total quality of life (Lavie & Milani, 1996). This study found a statistically significant improvement in the total quality of life· score and well-being score for the older group after the cardiac rehabilitation program (Lavie & Milani, 1996). The study that measured affect, pain, and physical functioning as quality of life parameters found no significant changes in these measurements after exercise (MacRae et al., 1996). The two studies that used instruments specifically designed to measure perceived quality of life found no significant differences in quality of life scores after exercise (Elward et al., 1992; Gitlin et al, 1992).

Most of the studies included small samples. Measurement of quality of life varied greatly. Some studies used well-developed instruments that clearly addressed major dimensions of quality of life (Blumenthal et al., 1989; Dungan et al., 1996; Lavie & Milani, 1996; McMurdo & Burnett, 1992; Noble et al., 1994; Topp & Stevenson, 1994). Other investigators used newly developed instruments lacking validity and reliability documentation (Ruuskanen & Ruoppila, 1995). Some studies used instruments that measured very restricted components of quality of life, such as positive and negative feelings (Zimmer et al., 1995). The interventions used may be questionable tests of the hypothesis that increased exercise will increase quality of life. For example, the pool exercise may have resulted in limited increased exercise (Whitlatch & Adema, 1996). The reported duration of the studies was typically short (i.e., 9 months or less). The effects of exercise on quality of life may require a longer duration to accumulate. Longer longitudinal studies may show a more consistent statistical improvement in quality of life parameters.

RESEARCH IMPLICATIONS

Measurement of quality of life is a challenge. The subjective components of quality of life are difficult to assess. Considerable research has purported to examine quality of life but has not used measures that address aspects commonly thought to be dimensions of quality of life. Many of these studies were excluded from this review because they lacked measures of dimensions of quality of life. Continued use of valid and reliable quality of life instruments will increase confidence in the findings. The recent move toward instruments designed to measure health-related quality of life, such as the Medical Outcomes Study instruments, needs to continue.

Generalizability of findings has been limited by the preponderance of White subjects. Future research should include more minority subjects (Melillo et al., 1996). Research examining the effect of exercise on quality of life of cognitively impaired elderly individuals would provide valuable information.

Experimental research is essential. More randomized trials are needed to establish cause and effect between exercise and quality of life. Longer duration longitudinal research is needed, with at least 1-year follow up. Shorter duration studies may conclude incorrectly that exercise is not beneficial if insufficient time accrues prior to measurement of dependent variables. The existing literature has been largely limited to single-group pretest-posttest designs or comparisons of one experimental group with a control group.

Experimental studies comparing types of exercise, such as waterbased exercise compared to walking exercise, would provide useful information. Studies examining the influence of exercise intensity on quality of life would be helpful. Finally, research that determines the frequency and duration of exercise necessary to achieve improvements in quality of life would provide valuable knowledge. This determination of the minimal dose required to achieve optimal outcomes is necessary to determine appropriate goals of programs to motivate older adults to exercise.

NURSING PRACTICE IMPLICATIONS

Patients' quality of life is of central importance to nursing practice. Nurses are dedicated to designing interventions to improve not only health but also well-being (Burgener & Chiverton, 1992; Ferrans, 1990; Orem, 1995). Nurses traditionally have provided considerable patient education. Much of the patient education is focused on teaching patients how to provide optimal care for themselves. The evidence that exercise is associated with quality of life is generally positive. Certainly, there is no evidence that increased exercise is associated with lower quality of life. In addition, at least moderate and light exercise and physical activity are generally safe for older adults. These factors combine to make interventions that increase exercise among appropriate older adults reasonable in most situations.

Exercise prescription elderly individuals should include activities of low impact for the musculoskeletal system and joints. Low impact activities prevent joint trauma especially for older adults who have arthritis. Low impact exercises to which older adults are especially receptive include walking and exercise biking. Older adults with significant joint disease may prefer water exercise to reduce weight bearing during the exercise. The intensity should be moderate, and the progression of the exercise should be slow to allow more gradual adaptation. Most older adults can safely begin with 5 minutes of exercise per day. Often they can add 5 minutes every other week until they reach 30 minutes of exercise. Recent evidence that lifestyle physical activity (i.e., accumulating 30 minutes of physical activity during the day instead of 30 minutes of continuous exercise) may be attractive for older adults. There should be strong emphasis on warming up and cooling down activities (Pollock, Graves, Swart, & Lowenthal, 1994).

Nurses practice in ideal settings to influence exercise among older adults. Travis et al. (1996) suggest nurses in the community or clinic settings are in ideal positions to facilitate older adults' participation in exercise programs. Elderly patients in clinic settings often are seen for chronic illnesses. This may be a valuable window of opportunity to teach about exercise because many chronic illnesses are improved with exercise. Nurses who routinely counsel patients about medications could add some information about increasing older adults' exercise. Community-based nurses can design programs that reach older adults. Older adults usually are attentive to possible ways to improve their health. Community-based programs linking socialization with exercise may meet multiple valuable goals for older adults' social needs. More advanced practice nurses are becoming nurse case managers. Nursing case management focuses on quality of care, cost, and patient outcomes. Documented benefits of exercise suggest case managers attempt to increase exercise among older adults. Nurses practicing in long-term care should emphasize exercise. Delaying the progression of functional decline is an important component of effective long-term care nursing practice. Facility-wide policies to increase ambulation by residents can have diverse health effects, besides those typically associated with exercise.

Specific interventions to motivate older adults to exercise are not suggested in this article because a review of the research literature examining the efficacy of interventions to increase exercise among older adults is beyond the scope of this article. Interested readers can find several extensive literature reviews, including a strong meta-analysis of exerciseenhancing interventions (Dishman & Buckworth, 1996). The evidence linking exercise and quality of life suggests that familiarity with interventions to promote exercise is an important aspect of nursing knowledge.

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TABLE 1

DIMENSIONS OF QUALITY OF LIFE

TABLE 2

DESCRIPTIVE RESEARCH STUDIES ABOUT QUALITY OF LIFE AND EXERCISE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

TABLE 3

EXPERIMENTAL STUDIES EXAMINING THE INFLUENCE OF EXERCISE ON QUALITY OF LIFE

10.3928/0098-9134-20000301-06

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