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Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Note: This article will be published in a forthcoming issue of
the Journal of Aging and Physical Activity. This article appears
here in its accepted, peer-reviewed form; it has not been copy
edited, proofed, or formatted by the publisher.
Section: Original Research
Article Title: Association Between Health-Related Quality of Life, Physical Fitness and
Physical Activity in Older People Recently Discharged from Hospital
Authors: Therese Brovold1, Dawn A Skelton
2, and Astrid Bergland
1
Affiliations: 1Oslo and Akershus University College of Applied Sciences Institute of Physical
Therapy, Norway. 2School of Health and Life Sciences, Glasgow Caledonian University, UK.
Running Head: quality of life and activity in seniors leaving hospital
Journal: Journal of Aging and Physical Activity
Acceptance Date: August 13, 2013
2013 Human Kinetics, Inc.
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Running head: QUALITY OF LIFE AND ACTIVITY IN SENIORS LEAVING HOSPITAL
Association between Health-Related Quality of Life, Physical Fitness and Physical Activity in
Older People Recently Discharged from Hospital
Therese Brovold, Oslo and Akershus University College of Applied Sciences Institute of Physical
Therapy, Norway
Dawn A Skelton, School of Health and Life Sciences, Glasgow Caledonian University, UK
Astrid Bergland, Oslo and Akershus University College of Applied Sciences Institute of Physical
Therapy, Norway
This research was supported from Oslo and Akershus University College for Applied Sciences
Correspondance concerning this article should be addressed to: Therese Brovold,
HIOA, Institute of Physical Therapy, P 50 Pb 4 St Olavspl 0130 Oslo, Norway
Contact: Therese.Brovold@hioa.no
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Abstract
The purpose of this study was to determine the relationship between Health-Related Quality of
Life (HRQOL), physical fitness and physical activity, in older patients after recent discharge
from hospital. One hundred and fifteen independent living older adults (70-92 yrs) were
included. HRQOL (Short-Form Health Status SF-36), physical activity (Physical Activity Scale
for Elderly) and physical fitness (Senior Fitness Test) was measured 2-4 weeks after discharge.
Higher levels of physical activity and higher levels of physical fitness were correlated with
higher self-reported HRQOL. Although this study cannot determine cause and effect, the results
suggest that particular focus on the value of physical activity and physical fitness while in
hospital and on discharge from hospital may be important in order to encourage patients to
actively preserve independence and HRQOL. It may be especially important to target those with
lower levels of physical activity, poorer physical fitness and multiple co-morbidities.
Key Words: Health-Related Quality of Life, Physical Fitness, Physical Activity, Older People,
HospitalAssociation between Health-Related Quality of Life, Physical Fitness and Physical
Activity in Older People Recently Discharged from Hospital
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
The prevention of functional decline and preservation of independence with aging have
been recognised as major clinical policy priorities for the health care of older adults (Wallace et
al., 1998). The need to improve the quality of life (QOL) of older people is increasingly
acknowledged. Thus, identification of variables related to QOL amongst older people is
important (Bergland & Wyller, 2006). QOL is defined by the World Health Organization (WHO)
quality of life group as: individuals perceptions of their position in life in the context of the
culture and value systems in which they live and in relation to their goals, expectations,
standards, and concerns (WHO, 1995). To distinguish between QOL in its more general sense
and QOL associated with health, the term Health-Related Quality of Life (HRQOL) is
frequently used (Bergland & Wyller, 2006). Health-related quality of life (HRQOL) is defined as
a persons perceived physical and mental health over time (Kelley, Kelley, Hootman, & Jones,
2009).
Previous studies have shown an association between physical activity, physical fitness
and HRQOL among older people (Acree et al., 2006; Wang, Beyer, Gensichen, & Gerlach,
2008) and higher levels of physical activity and higher fitness status are related to HRQOL in
older people (Horder, Skoog, & Frandin, 2012). Hospitalization and chronic disease, such as
osteoarthritis and heart disease, are known risk factors for impaired HRQOL among older people
(Helvik, Engedal, & Selbaek, 2010; Orwelius et al., 2010; Ozturk, Simsek, Yumin, Sertel, &
Yumin, 2011; Rosenberg, Bombardier, Hoffman, & Belza, 2011; Wang et al., 2008). Loss of
function is common both during and after hospitalization (Boyd et al., 2008; Volpato et al.,
2007) and previous research indicates that hospitalization due to acute illness can increase
dependence in activities of daily living (ADL) and decrease HRQOL in the post-discharge period
(Boyd, Xue, Guralnik, & Fried, 2005; de Morton, Keating, & Jeffs, 2007; Haines et al., 2009).
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Engagement in physical activity is recognized to play an important role in preventing or
postponing functional decline and in the development and progression of many chronic
conditions (Dogra, 2011; Rasinaho, Hirvensalo, Leinonen, Lintunen, & Rantanen, 2007).
Leisure time physical activity can also prevent loss of function associated with hospitalization
and inactivity, maintaining independence in activities of daily living and increasing HRQOL
(Balboa-Castillo, Leon-Munoz, Graciani, Rodriguez-Artalejo, & Guallar-Castillon, 2011; Hill et
al., 2011; Landi et al., 2007; Nelson et al., 2007). The WHO recommends that older adults
perform 150 minutes of moderate intensity physical activity a week, alongside strength and
balance activities and the minimization of sitting for long periods, for substantial public health
effect (WHO, 2010).
Most of the previous studies regarding HRQOL, physical fitness and physical activity
have focused on healthy older people (Olivares, Gusi, Prieto, & Hernandez-Mocholi, 2011),
older people in primary care settings (Ozturk et al., 2011; Wang et al., 2008) or older people
living in the community with existing mobility problems after a long hospital stay (Hill et al.,
2011). The information is sparse regarding the association between the level of physical activity,
physical fitness and HRQOL amongst older people recently discharged from hospital. It may be
of importance to evaluate HRQOL, physical fitness and physical activity in the group of
independent recently hospitalized older patients because previous studies indicate that they are at
risk for inactivity, functional decline and decreased HRQOL after discharge from hospital. (Boyd
et al., 2008; Nilsson, Westheim, & Risberg, 2008; Wolinsky et al., 2011).
Thus, the purpose of this study was to describe the HRQOL, physical fitness and physical
activity of patients after recent discharge from hospital and to compare their HRQOL with the
general population of older people in Norway. A second objective was to explore which, if any,
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
variables (physical fitness, physical activity, demographics, reason for hospital admission, and
number of chronic diseases) were independently associated with HRQOL. To the authors
knowledge, no other study has examined these associations within a population of recently
discharged patients before.
Methods
This study has a cross sectional design and forms the baseline data from a one-year
randomized controlled aerobic exercise intervention trial.(Brovold et al 2013, in press)
Participants
The study group comprised older people aged > 70 admitted to hospital because of an
acute medical event. Participants were initially recruited whilst resident in the hospital.
The participants were included in the study if they lived independently in the community
(they were allowed some domestic help or help from a nurse with medication), consented to
participate in the aerobic exercise program twice a week, were able to manage the Timed Up and
Go test in less than 20 seconds without the use of an assistive device, and assessed by a doctor as
able to tolerate aerobic exercise. They were excluded if they had any cognitive disorder (Score
on Mini Mental State Examination less than 24) (Folstein, Folstein, & McHugh, 1975), if they
had a chronic disease with expected lifespan < 1 year, or if they exercised regularly more than
twice a week at a fitness centre or in a structured exercise program. Those who reported regular
or occasionally engagement in physical activities like walking, cycling or skiing were included.
The Regional Ethics Committee for Medical Research and the Data Inspectorate at Oslo
University Hospital approved the study.
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Measures
Measurement of HRQOL occurred at baseline, 2-4 weeks after discharge from hospital,
by a research assistant (physical therapist). The time-point was not standardized because the
study participants had to finish their medical treatment at home before they could be tested and
included in the study. This time-point was based on recommendation that rehabilitation should
start within the first month after discharge (Boyd et al., 2008). Prior to test day, the
questionnaires was sent by mail so the participants could fill in the forms at home. The research
assistant checked the questionnaire for completeness. Where necessary, the questions left blank
were filled in by interviewing the subject.
Demographic variables
Age (years), gender, household composition (defined as living alone or living with
someone), use of outdoor walking aid (yes/no), hospital admission diagnosis and number and
type of co-morbidities at the time of admission were recorded from the participants hospital
notes and by asking the participants.
Health-related quality of life (HRQOL)
HRQOL was measured using the Medical Outcome Study 36 Item Short-Form Health
Survey (SF-36) version 2 (Ware, 2000; Ware & Sherbourne, 1992). SF-36 is a generic and
validated questionnaire, which is also translated into Norwegian (Loge & Kaasa, 1998). The 36
items in SF-36 are grouped into eight health status scales: physical functioning, role limitations
due to physical problems and due to emotional problems, bodily pain, general health perception,
vitality, social functioning and mental health (Ware, 2000; Ware & Sherbourne, 1992). Each
subscale score were transformed according to the manual from 0 (worst) to 100 (best) (Ware,
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
2000). The SF-36 has high validity and reliability among older people (Haywood, Garratt, &
Fitzpatrick, 2005; Latham et al., 2008). Population means of SF-36 v2 are equivalent to 50 10
and normal limits are considered to be within 1 (Ware et al 2000). The study sample was
compared to an age-and sex matched Norwegian sample (Loge & Kaasa, 1998). This sample
consists of 2323 Norwegian citizen aged 19-80 and 10 percent of the sample was aged between
70-80 years. In this study SF-36 v1 was used. However, the data from Loge and Kaasa (1998)
was used as there are no norm-based data from v2 in Norway.
Physical Fitness
Physical fitness was defined as the capacity to perform daily activities safely and
independently without fatigue and was measured by the Senior Fitness Test (SFT) (Rikli &
Jones, 1999). The test consists of: number of Chair Stands in 30 seconds, number of Arm Curls
in 30 seconds, Chair-Sit-and-Reach-Test (CSRT) (cm), Back Scratch Test (cm), 2.45 m Up-and-
Go test (seconds) and 6 min walk test 6 MWT and BMI (weight/height2). All of the tests have high
reliability and validity and the procedures for administering SFT are standardized and described
in detail (Rikli & Jones, 1999, 2013). The test has no reported floor or ceiling effect and is
translated into Danish (Rikli, Jones, & Hanson, 2004) with normative values for the Norwegian
older population provided by Langhammer and Stanghelle (2011).
Physical Activity
The level of physical activity (PA) was assessed using the Physical Activity Scale for the
Elderly (PASE) which is a questionnaire developed for persons over 65 years with and without
disabilities and systematically developed for epidemiological and clinical research (Washburn,
McAuley, Katula, Mihalko, & Boileau, 1999). The PASE is translated into Norwegian and
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
slightly adjusted for use among Norwegian older people. The Norwegian version has been shown
to have high and moderate reliability (Loland, 2002; Svege, Kolle, & Risberg, 2012). The PASE
questionnaire comprises of self-reported household and leisure-time activities in the previous
week. The leisure-time activities are divided into light, moderate or strenuous physical activity or
muscle strength/endurance exercises. There are also six items concerning light or heavy
housework, home repairs, lawn work or yard care, outdoor gardening and caring for another
person. Those items are answered by yes or no. The last item is about work for pay or as a
volunteer. The total PASE score is computed by multiplying time spent in each activity (hours
per day) (for leisure and work-related activities) or participation (yes/no) in an activity (for
household-related activities), by empirically derived weighting, and then summarizing all items.
The total PASE score is derived from weights and frequency values for each activity and
represent the overall activity level (Loland, 2002; Svege et al., 2012; Washburn et al., 1999).
Statistical analysis
The normality of the distribution was examined graphically by histograms and Q-Q plots
and by using the Kolmogorov-Smirnov statistic. Data are described as means and standard
deviations (SD) for normally distributed variables and median and quartiles (25,75) when
variables did not reach normality. Categorical variables are described with proportions and
percentages. Descriptive data for the SFT are given as mean and standard deviation (SD) and for
PASE median (25,75 quartiles). Descriptive data for the different domains of SF-36 are
presented as mean (SD), and 95 % Confidence Intervals (CI) to compare normative standards for
gender and age. The student T-test for independent samples (or when data did not reach
normality, the Mann- Whitney U-test) was used to identify significant differences in subject
characteristics, HRQOL and physical fitness between the genders. Student T-test and chi-square
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
test was used to identify differences in age and genders in participants who were included in or
excluded from the study.
To evaluate the univariate associations between the demographics (age, household
composition, hospital admission diagnosis and number of co-morbidities), SFT, BMI and PASE
and each of the SF-36 scales univariate linear regression analyses were used (student T-test or
Spearmans rank correlation). Further, to adjust for possible confounding variables with the
strongest association with the outcome (p< .05) from the crude analyses were fitted into multiple
linear regression models. Regression model assumptions were examined graphically and
analytically. Statistical analysis was performed with the IBM SPSS Statistics 20.0. (SPSS Inc.,
Chicago, IL). P-values < .05 were considered statistically significant and all tests were two-
sided.
Results
A total of 115 participants were included in the study. Four hundred and ninty-six
participants were screened and found eligible for the study. Forty-three percent were screen
failures and thirty-four percent refused to participate. The participants who were excluded or
refused to participate were significantly older than the participants who were included, mean age
(SD) 79.6 (5) vs 78.0 (5) p< .001. No difference in gender was found amongst those who were
included or excluded.
Descriptive data and baseline score for SFT and PASE for all the participants are shown
in Table 1. The participants ranged from 70-92 years, mean (SD) age was 78.0 (5.2) years.
Descriptive data for HRQOL and the comparison of the SF-36 scores from the study-group and
the reference-group are presented in Table 2 (Loge & Kaasa, 1998). There were differences
between the genders in HRQOL on the subdomain SF-36 physical functioning, SF-36 bodily
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
pain and SF-36 social functioning, with women reporting significantly lower HRQOL than men
(Table 2). No difference in HRQOL was seen between those who lived alone and those who
lived with someone.
Men had better physical fitness than women (see Table 1). Forty-one % of the women
and 18 % of the men scored below 400 meters on 6 MWT. No difference in functional fitness
was found between those who lived alone and those who lived with someone.
The distribution of PASE was skewed and median and quartiles are presented in Table 1.
The study sample scored lower than the Norwegian sample, median 59 (min, max) 0-268) vs.
median 121 range 0-436 (Loland, 2002). However, unlike the sample from Loland, there were no
differences in total PASE score between the men and women in the present study (p= .16, Mann
Whitney U-test). There were no differences in PASE score between those who lived alone or
lived with someone. Thirty-two % of the participants reported engagement in light leisure time
activities, like walking 5-7 times per week, while 13 % reported engagement in moderate
physical activity, like cycling or skiing 5-7 times per week.
Results from multivariate regression analyses are listed in Table 3. There were no
significant differences between the different hospital admission diagnoses, except that
participants with a diagnosis of a transient ischemic attack (TIA) scored significantly higher on
SF-36 vitality, bodily pain, general health and role physical than participants with other
cardiopulmonary diseases. In univariate analysis there was a significant correlation between
number of chronic disease and all of the subdomains of SF-36 except for role physical and
vitality. All tests of SFT were positively associated with all subdomains of SF-36. The Chair
Stand and the Arm Curl tests within SFT were highly correlated with each other and with the 6
Minute Walk Test (6MWT) (R > .6). Since the 6MWT was the main variable of interest only
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
6MWT was included in the final model to avoid multicollinearity. The univariate analyses
showed that a number of chronic diseases were significantly associated with all of the
subdomains of SF-36 except for role physical. One model was created for each subdomain of SF-
36 and was adjusted for possible confounders (Table 3). After controlling for confounders such
as number of chronic disease, age and gender, significant associations remained between 6 MWT
and all of the domains of SF-36 and between PASE and SF-36 physical functioning, role
physical and general health. For instance, when all other variables in the model are held constant,
for every fifty meter increase in 6 MWT, SF-36 physical functioning increases by 7.5 points (95
% CI 5.5, 9.5) (Table 4). For the models, the adjusted explained variance (adjusted R2) varied
from 49.5 % (physical functioning) to 11.2 % (mental health).
Discussion
The purpose of this study was to describe and explore the associations between the
HRQOL, physical fitness and physical activity of independent living older people after recent
discharge from hospital. The results have been compared to HRQOL within the Norwegian age-
and gender match population (Loge & Kaasa, 1998) and show that the participants discharged
from hospital scored significantly lower on SF-36 than the age-matched Norwegian population.
The difference observed is beyond the minimal important difference (MID) of 5-10 points
reported in earlier studies (Wang et al., 2008). Pre-existing disease and comorbidity are major
factors affecting HRQOL (Orwelius et al., 2010; Wang et al., 2008). This study included a group
of participants who had a wide range of pre-existing conditions and who, therefore, were likely
to already have lower HRQOL than age-matched norms without such co-morbidities. The results
from this study showed a significant relationship between SF-36 and number of chronic diseases,
however, in a multiple regression model, only 6 MWT remained significantly associated with all
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
of the subdomains of SF-36 after controlling for age, gender and number of chronic diseases.
This result is consistent with previous literature (Groessl et al., 2007; Horder et al., 2012) and
indicates that declining physical fitness may have greater negative impact on HRQOL than many
distinct diseases for older people being discharged from hospital.
Maintaining adequate physical fitness and walking endurance are important to preserve
independence in activities of daily living and HRQOL among older people (Acree et al., 2006;
Lobo, Carvalho, & Santos, 2011). Physical fitness is especially crucial to continue with interests
such as going to the theatre, taking a walk in the park, shopping for groceries, meeting friends or
be able to travel (Cress et al., 2005; Lobo et al., 2011). As already mentioned, for older people,
hospitalization is associated with an increased risk of loss of function and reduced HRQOL
(Alley et al., 2010; Covinsky, Pierluissi, & Johnston, 2011; Helvik et al., 2010; Wolinsky et al.,
2011). Inactivity, in the post-discharge period especially, is hypothesized to be closely related to
this decline. In the present study, higher levels of physical activity were independently associated
with better HRQOL (physical functioning, general health and vitality) and better physical fitness.
Although several studies have shown that physical activity plays a critical role in promoting
perceived HRQOL (Kelley et al., 2009; Motl & McAuley, 2010) and on the management of
illness among adults (Chodzko-Zajko et al., 2009; Murphy, Sheane, & Cunnane, 2011), the level
of physical activity in this population is very low. In the present study, participants were
excluded if they exercised regularly at a fitness center, but the participants were included if they
reported physical activities such as walking and cycling. Thirteen percent of the study
participants reported engagement in moderate physical activity in line with recommendations of
>150 min/week (WHO, 2010), while 32 % of the study participants reported engagement in
physical activities with lower intensities like walking. This result indicates that increased focus
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
on physical activity while resident in hospital may be of importance, because inactivity in
combination with acute hospitalization and comorbidities is associated with increased risk for
functional decline and further disease progression (Covinsky et al., 2011). Poor self-perceived
health (Dogra, 2011) and low self-efficacy, fear of falling and fear of injury during the activity
are also associated with low levels of physical activity (Ashe, Eng, Miller, & Soon, 2007; Hill et
al., 2011). None of the participants included in this study had any activity restrictions due to their
acute illness or co-morbidities, furthermore, they were functionally independent, indicating that
participants should be motivated to engage in moderate intensity physical activities to improve
their physical fitness and their disease treatment (Dogra, 2011; Nelson et al., 2007). It is also
important for older people with chronic disease to engage in physical activity as much as
possible as they are at risk of developing a reduced tolerance to activity, further sedentary
lifestyle behaviour and compromised health (Ashe et al., 2007). In the present study 41 % of the
women and 18% of the men scored below 400 m on 6 MWT, the threshold associated with
higher risk of mobility limitations and disability (Newman et al., 2006).
Several studies have shown that health-care personnel have an opportunity to influence
older peoples physical activity (Buttery & Martin, 2009; Hill et al., 2011; Hirvensalo,
Heikkinen, Lintunen, & Rantanen, 2005). In a recent study the level of physical activity
increased after participating in a combined exercise program consisted of counseling and
exercise follow-up from physical therapists at home, among older people recently discharged
from a geriatric day-hospital (Brovold, Skelton, & Bergland, 2012). Other studies have shown
similar results (Courtney et al., 2009). Hill and colleagues (2011) found that older people
increased their participation in exercise if they had been recommended to do so by the hospital
physiotherapist (Hill et al., 2011).
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Strength and Limitations
The findings from this study have a number of limitations. The cross-sectional design of
the study does not allow us to conclude on causality and the total sample size was relatively
small. Subjects were enrolled in an intervention trial with an aerobic exercise component, they
are more likely to be fitter and perhaps more engaged than those who would not have agreed to
be part of the intervention. Those who agreed to participate were significantly younger than
those who were excluded or refused to participate. Furthermore, this study did not consider those
who did not live independently and those who have a TUG greater than 20 seconds, as this group
of patients would require a different approach to exercise. Therefore, the associations seen in this
study may not be applicable to the overall population of older people recently discharged from
hospital. However, the correlations between HRQOL and physical fitness found in this study,
correspond well with results from other studies evaluating HRQOL in a frailer patient group
(Helvik et al., 2010), and among healthy older adults (Horder et al., 2012; Olivares et al., 2011).
The PASE was used to measure participation in physical activities. This questionnaire
asks about activities in the previous week. It is possible that the subjective responses from the
participants in this study could have been influenced by their recent hospital stay, the advice
received from professionals or other factors.
The multivariate models in this study did not fully explain HRQOL indicating that
HRQOL is a complex construct. In this study, 6 MWT, PASE, age, gender, BMI and number of
chronic diseases accounted for 49.5 % of the variance in SF-36 physical functioning and only
11.2 % in mental health. This means that 50.5 % of the variance in the SF-36 physical
functioning and 88.8 % of the variance in the SF-36 mental health remained unexplained by the
models. These findings suggest that associations of physical fitness may be stronger with
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
HRQOL than mental health components (Takata et al., 2010). Furthermore, previous studies
have identified factors like self-efficacy (Stretton, Latham, Carter, Lee, & Anderson, 2006),
social support (Harvey & Alexander, 2012) and emotional conditions such as anxiety and
depression (Helvik et al., 2010) to be significantly associated with functional and mental health
among older people. Further research is necessary to examine associations between these factors
and HRQOL amongst this population recently discharged from hospital.
The strengths of the study include the use of performance-based tests to objectively
assess physical fitness. Furthermore, the study sample included older people with chronic disease
after recent discharge from hospital. Their hospitalization had been due to acute illnesses like
cerebrovascular disease, cardiopulmonary disease, arrhythmias and infections. This patient group
may be especially amenable for prevention strategies because of the increased risk for future
functional decline and decreased HRQOL.
Considering the possible limitations and the strengths mentioned above, this study
provides important information about the associations between HRQOL, physical activity and
physical fitness in a population of older people recently discharged from hospital. Although pre-
admission co-morbidities and function will have had an effect, in accordance with previous
results in different older populations, this study showed that physical fitness, measured by 6
MWT and physical activity was significantly associated with SF-36 score post-discharge.
Indeed, it seems reasonable to propose that implementation of exercise rehabilitation or
promotion of physical activity for older adults recently discharged from hospital could positively
influence HRQOL of this population sub-sample, though this needs testing in a future RCT trial.
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Conclusion
In conclusion, the results from this study show that engagement in physical activity and
higher levels of physical fitness are associated with higher self-reported HRQOL among older
people, with a wide range of co-morbidities, recently discharged from hospital after an acute
medical illness. The results showed that the participants had lower levels of HRQOL compared
to an age-matched Norwegian sample and that the level of physical activity post-discharge was
low. This cross-sectional study, although not designed to look at cause and effect, suggests that it
would be beneficial for health-care personnels to provide encouragement and opportunity to
engage in physical activity and physical fitness for their patients while admitted at hospital. This
advice should help patients increase their level of activity after acute illness and hospitalization,
in order to help preserve independence and HRQOL. The study implies that it is especially
important to target those with lower levels of physical activity, poorer physical fitness and those
with multiple co-morbidities.
Acknowledgements
The authors want to thank physical therapist Ellen Hamre for her valuable contributions to our
project.
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
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Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Table 1 Socio-demographics variables and baseline score for senior fitness test and physical
activity of the whole sample
All participants
N =115
Women
n= 70
Men
n= 45
Age, years, M(SD) 78.0 (5.2) 78.3 (5.0) 77.4 (5.4)
Living alone, % 54 70* 31 Hospital diagnosis
Cerebrovascular disease % 25 24 30
Heart attack/chest pain % 32 34 28
Arrythmias % 19 21 12
Infections % 24 25 30
Mean number of chronic
disease (SD)
2.5
(1.2)
2.7*
(1.1)
2.2
(1.3)
No.of participants with
Cerebral insult 20 12 8
Heart disease 63 36 27
Arrhythmias 35 21 14
Hypertension 29 19 10
Chronic lung disease 17 12 5
Musculoskeletal disease 45 37* 8
Osteoporosis 5 5 0
Cancer 18 10 8
Diabetes type II 12 7 5
Other 39 27 12
Senior Fitness Test
Chair Stand, number, M (SD) 10.2 (3.4) 9.4 (3.3)* 11.4 (3.3)
Arm Curl, reps, M (SD) 13.6 (3.7) 12.7 (2.8)* 15.0 (4.4)
Back Scratch, cm M (SD) -14.5 (12.5) -11.5 (11.4)* -19.0 (13.0)
Chair sit and reach, cm, M (SD) -2.9 (12.4) -0.5 (10.6)* -6.3 (14.1)
2.45 m up and go, s, M (SD) 6.9 (2.1) 7.5 (2.1)* 6.0 (1.6)
6 MWT ,m, M (SD) 452.7 (115) 416.2 (105.3)* 509.4 (106)
PASE Median (Quartile 1,Quartile 2) 59 (30,105) 55 (30,86) 85 (32,117)
Note. 6 MWT= 6 Minute Walk Test. PASE (Physical Activity Scale for elderly). PASE presented as median (interquartil range) as
data not normally distributed.
* p< .05 significant difference between men and women
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Table 2. Comparison of the SF-36 scale of the study group and those of the an age-and gender
matched Norwegian Sample (mean,standard deviation (SD), 95 % Confidence Interval (CI))
Study group Reference group
Age group 70-80 years
Mean Difference From Population Norms
Malen= 45 Mean (SD)
Female n= 70
Mean (SD)
Male
Mean (SD)
Female
Mean (SD)
Male Mean
(95 % CI)
Female Mean (95 % CI)
Physical Functioning
62.7
(27)
52.4
(24)*
75.0
(20)
56.1
(28)
-12.3
(-4,-21)*
-3.7
(-8,0.2)
Role
Physical
42.0
(23)
38.9
(20)
52.5
(17)
37.0
(18)
-10.5
(-23.4,2)
1.9
(-9,13) General
Health
52.0
(18)
50.4
(16)
67.5
(22)
62.5
(23)
-15.5
(-24,-8)*
-12.1
(-20,-5)*
Vitality 44.2 (18) 38.2 (19) 61.9 (29) 50.6 (29) -17.7 (-25,-11)* -12.4 (-19,-6)* Mental
Health
65.8
(28)
64.3
(25)*
82.7
(24)
76.7
(29)
-16.9
(-22,-11)*
-12.4
(-18,-7)*
Bodily Pain
59.2
(25)
47.6
(28)*
69.4
(23)
59.5
(22)
-10.2
(-20,-0.6)*
-11.9
(-20,-4)*
Social
Functioning
72.0
(32)
60.7
(29)
82.3
(44)
74.1
(43)
-10.3
(-19,-2)*
-13.4
(-22,-5)* Role
Emotional
57.6
(27)
49.6
(24)*
69.7
(38)
59.5
(44)
-12.1
(-22,-2)*
-9.9
(-21,1)
* p< .05 significant difference between the genders and between the study group and the age-and gender matched Norwegian
Sample from Loge and Kaasa(1998)
Note: sample size differs in the Norwegian sample from 97-115 participants in each gender group (Loge and Kaasa 1998)
Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity
2013 Human Kinetics, Inc.
Table 3 Multivariable regression models for the SF-36 scales (unstandardized (95 % confidence interval (CI) )
Physical Functioning
Role Physical
General Health
Vitality
Mental Health
Bodily Pain
Social Functioning
Role Emotional
(95 % CI)*
(95 % CI)*
(95 % CI)*
(95 % CI)*
(95 % CI)*
(95 % CI)*
(95 % CI)*
(95 % CI)*
Age 0.54
(-0.2,1.4) 0.90
(-0.24,0.20)
0.71
(0.6,1.36)
0.2
(-0.4,0.3)
0.13
(-0.46,0.72)
0.82
(-0.23,1.87)
0.26
(-0.71,1.23)
0.85
(-0.53,1.74) p .17 .12 .032 .53 .67 .12 .59 .065
Gender 3.54 (-4.5,11.6)
9.43 (-1.41,20.59)
7.24 (-0.05,14.4)
-2.0 (-9.29,5.24)
.19 (-2.4,10.7)
-5.52 (-15.83,4.76)
-3.79 (-14.48,6.98)
-0.28 (-10.2,9.62)
p .39 .09 0.048 .58 .21 .29 .48 .95
Chronic
disease
-0.68
(-2.7,4.1)
1.95
(-3.02,6.92)
-0.30
(-3.57,2.96)
2.0
(-1.30,5.30)
-2.60
(-5.58,0.37)
1.03
(-3.62,5.68)
-1.66
(-6.51, 3.19)
-0.94
(-5.5,3.5)
p .69 .44 .85 .23 .086 .61 .50 .68
6 MWT 0.15
(0.11,0.19)
0.13
(0.8,1.9)
0.08
(0.05,0.12)
0.04
(0.01,0.08)
0.05
(0.01,0.08)
0.06
(0.01,0.012)
0.07
(0.01,0.12)
0.068
(0.02,0.12) p .001 .001 .001 .044 .008 .032 .02 .011 PASE 0.07
(0.05,0.14)
0.09
(-0.12,0.18)
0.10
(0.03,0.16)
0.83
(0.02,0.15)
0.05
(-0.05,0.08)
0.69
(-0.02,0.16)
0.04
(-0.05,0.14)
0.87
(-0.0,0.02)
p .035 .084 .004 .013 .86 .14 .38 .0053
Adjusted
R2
49.5
24.9
32.3
12.7
12.2
15.3
11.2
16.7
Note. 6 MWT= 6 minute walk test; PASE= Physical activity Scale for Elderly Gender 0= male. 1= female. The models are adjusted for age, sex and number of chronic disease. Significant results are bolded.