The effect of group exercise frequency on health related quality of life in institutionalized elderly

Introduction The study aimed to determine the effect of group exercise frequency on health related quality of life in institutionalized elderly. Methods One hundred participants were recruited for voluntary participation from five aged care facilities, with inclusion being based on the outcome of a medical assessment by a sports physician. A quasi-experimental design was used to compare the effect of a 12 week group exercise programme on two groups of participants using pre-test and post-test procedures. Results A significant difference was noted in social function post training 2X/week (MD = -13.85, 95% CI [-24.66, -3.38], p = 0.017, d = 0.674) and 3X/week (MD = -13.30, 95% CI [-21.81, -5.59], p = 0.003, d = 0.712) a week. Training 3X/week a week provided an additional benefit in vitality (MD = -7.55, 95% CI [-13.16, -1.91], p = 0.018, d =0. 379). Improvements in mental component summary scale post training 2X/week (MD = -4.08, 95% CI [-7.67, -0.42], p = 0.033, d = 0.425) and 3X/week (MD = -6.67, 95% CI [-10.92, -2.33], p = 0.005, d = 0.567) a week was further noted. Conclusion Mental health and social health benefits can be obtained irrespective of exercise frequency 2X/week or 3X/week. The exercise intervention at a frequency 3X/ week was more effective in improving mental component summary due to a larger effect size obtained compared to the exercise frequency of 2X/week. Additional benefits in vitality were achieved by exercising 3X/week. This may assist the elderly in preserving their independence.


Introduction
Aging is a complex and inevitable process, which leads to a decline in the body's physiological system and physical capacity [1]. The process of aging may increase the occurrence of chronic diseases and conditions such as hypertension, cardiovascular disease, diabetes, cancer and osteoporosis [2]. Aging is commonly characterized by a progressive and general impairment of function, resulting in vulnerability to environmental challenges, and a growing risk of disease and disability [3]. To combat the challenges experienced due to aging, the World Health Organization initiated the 'Active Aging' policy to reduce inactivity and improve health related quality of life. "Active aging is the process of optimizing opportunities for health, participation and security in the elderly, to enhance quality of life as people age" [4].
There is compelling scientific evidence worldwide, which suggests that a structured exercise programme can improve the physiological functioning, health related quality of life and functional ability of older persons [1,[5][6][7]. Despite the benefits of structured exercise, many older persons lead sedentary lifestyles [8]. Persons over the age of 55 years have the lowest reported moderate to vigorous physical activity levels globally, with an increase in age being associated with increased inactivity [8].
In an urban South African study, 49.7% of elderly persons did not meet the minimum guideline of 150 min of physical activity a week [8]. Inactivity is associated with increased risk of heart disease, type 2 diabetes, hypertension and osteoporosis [9,10].
Health related quality of life (HRQoL) is a state of wellbeing or happiness experienced by an individual despite the presence of illness or disability [11]. In the elderly, it is best described in relation to functional status, independence and the ability to perform activities of daily living efficiently [12]. The Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) is a widespread, reliable and valid instrument that is used to measure HRQoL in the elderly [11]. It consists of eight subscales namely: role physical (RP), bodily pain (BP), general health (GH), physical functioning (PF) vitality (VT), role emotional (RE), social functioning (SF), and mental health (MH). The scores range from 0 to 100 for each subscale, with higher scores closer to 100 indicating a better HRQoL [13,14]. The eight subscales are encapsulated into physical component summary (PCS) and mental component summary (MCS) respectively [15].
A lack of physical stimulation results in functional and health disorders, which negatively affects HRQoL [16], while physical activity promotes independence by improving functional capacity and physical health. A systematic review assessing physical activity and quality of life, found that, physical activity had a positive effect on physical [17], psychological [18] and emotional wellbeing [19].
Physical activity is reported to improve vitality, mental and psychological health, and to support moderate improvements in emotional , physical, overall health, social relationships and pain [7]. A number of cross sectional studies concluded that moderate or high intensity exercises were associated with improvements in the following scales of pain [20,21], physical [22], vitality [20,21,23], mental health [20] and general health [24]. Another study conducted in Japan, concluded that HRQoL was associated moderate physical activity in elderly men [25]. A frequency of at least five times a week was associated with better social and physical domains of HRQoL [22].
A systematic review postulated, to achieve benefits in health indicators and quality of life, a multicomponent exercise program is preferred, and should consist of aerobic, muscular endurance, stability/balance and flexibility exercises [5]. Most studies in the elderly implemented exercise programmes with a frequency of two and three times a week, ranging in duration from 3-12 months [5].
In the community dwelling elderly a multicomponent exercise programme resulted in significant improvements in mobility and balance [26]. A high frequency intervention (≤3X/week) in institutionalized elderly resulted in fewer hospital visits and lower risk of mortality [27]. Moderate frequency (2X/week) interventions had a desirable effect on balance in "pre-frail" elderly, substantially reducing the risk of falling at 1-year follow-up [28].
The inability to perform activities of daily living can be a major problem for people living in aged care facilities, either due to a loss of functioning or independence [29,30]. An international study showed that those who are physically active have a better quality of life and mental health than those with sedentary lifestyles [31]. A lack of independence and inactivity predisposes such persons to chronic disease, particularly those living in aged care facilities. While the above finding is well documented internationally in community dwelling elderly, little research has been conducted in institutionalized homes globally and in the South African context. Therefore, the study aimed to investigate the effect of group exercises 2X/week and 3X/week on HRQoL ininstitutionalized elderly.

Subjects
The study population comprised of individuals who were 60 years of age and older residing in an aged care facility within a 30 kilometre radius of the Durban central business district (CBD). A listing of all government supported elderly care facilities located within a 20 km radius of the Durban CBD was obtained from the Department of Social Development, from which five elderly care homes were randomly selected. All residents who were interested in participating in the study were invited to be assessed to establish whether they met the inclusion criteria. The outcome of a physical assessment conducted by a sports medicine physician, determined, participation in the intervention. From the eligible participants, 20 were randomly selected in each aged care facility, with a total of 100 for the study.
They were randomly all allocated numbers from 1 to 20, and the fish bowl technique was used to identify ten participants for Group A (all odd numbers) and ten for Group B (all even numbers). Group B exercised two times a week and group A exercise three times a week for 12 weeks. Individuals were excluded if they were < 60 years of age, had undergone hormone supplementation, were unable to participate based on a medical assessment and were participating in other research/clinical trials. The study was designed as a three-month (12 week) intervention, exercise frequency was three times a week, two sessions per week was introduced as a control arm into the quasi-experimental design, and to establish any difference in effect between the two groups. Participants had to attend 80 % of the exercise sessions. However, as a result of hospital visits and illness during the exercise intervention, 83 participants completed the study (Group A = 47 and Group B = 37) The warm-up included progressive exercises that involve dynamic stretching, continuous rhythmic endurance activities such as easy walking, light marching, toe and heel presses and low knee lifts. The warm-up included rehearsal (step by step but slower tempo) of exercise sequences, as well as specific joint mobility exercises (e.g. arms overhead and circles along with low intensity endurance exercise). Intensity was monitored using Borg's Rating of Perceived Exertion (RPE) 6 -20 point scale [32]. Accordingly, the RPE for this population was maintained between 9 and 10.

Study design and procedure
Endurance training involved walking, which required using the larger muscle groups, and requires rhythmic and continuous movement.
Intensity for the first 3 weeks was equivalent to 10 to 11 on the RPE scale (light), while during weeks 4 to 9 the intensity was increased to 12 to 13 on the RPE scale (somewhat hard) and maintained for weeks 10 to 12. However, the duration of exercise was increased over the 12 week exercise programme from three bouts of 5 minutes (week 1 to 3), to two bouts of 10 minutes (weeks 4 to 9), and finally two bouts of 15 minutes (weeks 10 to 12).
The study incorporated resistance exercises for developing muscle endurance, strength and power. The following 10 exercises are deemed appropriate for the elderly and was used to train the entire body: Leg press or squat; Knee extension; Knee curl; Calf raise; Chest press; Seated row; Upright row; Arm curl; Shoulder press; Abdominal/core exercise. Ten repetitions per set of exercise were performed over the 12 week program. The number of sets increased from one in the first 4 weeks to two sets during weeks 5 to 8, and to three sets from weeks 9-12. Abdominal strengthening exercises were used to develop the core and abdominal muscles. Cohen (1988), who proposed that an ES of 0.2 represents a small effect, 0.5 a medium effect and 0.8 a large effect. A p value of <0.05 was considered statistically significant [33].

Results
The study consisted of 79% females and 21% males, with a mean age of 73 years (SD 7.57) ( Table 1). A large percentage of the participants in the study were of Indian ethnicity (72%). Over half of the participants were widowed (53%) and had a mean body mass index of 28.07 kg/m 2 .
The mean age of participants who exercised twice and thrice a week were 71 and 72 years respectively (  (Figure 3).

Discussion
There was a significant difference in social functioning, vitality and Exercise has recently been found to preserve the functioning of the aging brain [34] and increases brain derived neurotrophic factors in the hippocampus [35]. Brain derived neurotrophic factors may be an important mediators in reducing cognitive decline, which effects a persons' autonomy [36]. an international study reported that supervised group exercise twice a week for 45 minutes improved the mental HRQoL [37]. In the current study, the frequency of the exercise (2X/week and 3X/week) resulted in elevated mental component summary, hence, group exercise had a desirable effect on mental health in the elderly residing in long-term care facilities.
There was a significant difference in mental health in the group that