Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older...

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




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: [email protected]



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



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).



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,



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.



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,



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



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



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



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



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



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



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).



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



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.



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.



References

Acree, L. S., Longfors, J., Fjeldstad, A. S., Fjeldstad, C., Schank, B., Nickel, K. J., . . . Gardner, A. W.

(2006). Physical activity is related to quality of life in older adults. Health and Quality of Life

Outcomes, 4, 37-43.

Alley, D. E., Koster, A., Mackey, D., Cawthon, P., Ferrucci, L., Simonsick, E. M., . . . Harris, T. (2010).

Hospitalization and change in body composition and strength in a population-based cohort of

older persons. Journal of the American Geriatric Society, 58(11), 2085-2091.

Ashe, M. C., Eng, J. J., Miller, W. C., & Soon, J. A. (2007). Disparity between physical capacity and

participation in seniors with chronic disease. Medicine and science in sports and exercise, 39(7),

1139-1146.

Balboa-Castillo, T., Leon-Munoz, L. M., Graciani, A., Rodriguez-Artalejo, F., & Guallar-Castillon, P.

(2011). Longitudinal association of physical activity and sedentary behavior during leisure time

with health-related quality of life in community-dwelling older adults. Health Quality of Life

Outcomes, 27(9), 1-10.

Bergland, A., & Wyller, T. (2006). Construct and criterion validity of a norwegian instrument for health

related quality of life among elderly women living at home. Social Indicators Research, 77(3),

479-497.

Boyd, C. M., Landefeld, C. S., Counsell, S. R., Palmer, R. M., Fortinsky, R. H., Kresevic, D., . . .

Covinsky, K. E. (2008). Recovery of activities of daily living in older adults after hospitalization

for acute medical illness. Journal of American Geriatric Society, 56(12), 2171-2179. doi:

10.1111/j.1532-5415.2008.02023.x

Boyd, C. M., Xue, Q. L., Guralnik, J. M., & Fried, L. P. (2005). Hospitalization and development of

dependence in activities of daily living in a cohort of disabled older women: the Women's Health

and Aging Study I. The Journals of Gerontology A Biological Medicine Sciences, 60(7), 888-

893.



Brovold, T., Skelton, D. A., & Bergland, A. (2012). The Efficacy of counseling and progressive

resistance home-exercises on adherence, health-related quality of life and function after discharge

from a geriatric day-hospital. Archives of Gerontology and Geriatrics, 55(2), 453-459. doi:

10.1016/j.archger.2012.01.015

Buttery, A. K., & Martin, F. C. (2009). Knowledge, attitudes and intentions about participation in

physical activity of older post-acute hospital inpatients. Physiotherapy, 95(3), 192-198. doi:

10.1016/j.physio.2009.03.002

Chodzko-Zajko, W. J., Proctor, D. N., Fiatarone Singh, M. A., Minson, C. T., Nigg, C. R., Salem, G. J., &

Skinner, J. S. (2009). American College of Sports Medicine position stand. Exercise and physical

activity for older adults. Medicine and science in sports and exercise, 41(7), 1510-1530. doi:

10.1249/MSS.0b013e3181a0c95c

Courtney, M., Edwards, H., Chang, A., Parker, A., Finlayson, K., & Hamilton, K. (2009). Fewer

Emergency readmissions and better quality of life for older adults at risk of hospital readmission:

a randomized controlled trial to determine the effectiveness of a 24-week exercise and telephone

follow-up program. Journal of American Geriatric Society, 57(3), 395-402. doi: 10.1111/j.1532-

5415.2009.02138.x

Covinsky, K. E., Pierluissi, E., & Johnston, C. B. (2011). Hospitalization-associated disability: "She was

probably able to ambulate, but I'm not sure". The Journal of the American Medical Association,

306(16), 1782-1793. doi: 10.1001/jama.2011.1556

Cress, M. E., Buchner, D. M., Prohaska, T., Rimmer, J., Brown, M., Macera, C., . . . Chodzko-Zajko, W.

(2005). Best practices for physical activity programs and behavior counseling in older adult

populations. Journal of Aging and Physical Activity, 13(1), 61-74.

de Morton, N. A., Keating, J. L., & Jeffs, K. (2007). Exercise for Acutely Hospitalised Older Medical

Patients. Cochrane Database Systematic Reviews(1), CD005955. doi:

10.1002/14651858.CD005955.pub2



Dogra, S. (2011). Better self-perceived health is associated with lower odds of physical inactivity in older

adults with chronic disease. Journal of Aging & Physical Activity, 19(4), 322-335.

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). "Mini-Mental State". A practical method for

grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3),

189-198.

Groessl, E. J., Kaplan, R. M., Rejeski, W. J., Katula, J. A., King, A. C., Frierson, G., . . . Pahor, M.

(2007). Health-related quality of life in older adults at risk for disability. American journal of

preventive medicine, 33(3), 214-218. doi: 10.1016/j.amepre.2007.04.031

Haines, T. P., Russell, T., Brauer, S. G., Erwin, S., Lane, P., Urry, S., . . . Condie, P. (2009). Effectiveness

of a video-based exercise programme to reduce falls and improve health-related quality of life

among older adults discharged from hospital: a pilot randomized controlled trial. Clinical

Rehabilitation, 23(11), 973-985. doi: 10.1177/0269215509338998

Harvey, I. S., & Alexander, K. (2012). Perceived social support and preventive health behavioral

outcomes among older women. Journal of Cross Cultural Gerontolology, 27(3), 275-290. doi:

10.1007/s10823-012-9172-3

Haywood, K. L., Garratt, A. M., & Fitzpatrick, R. (2005). Quality of life in older people: a structured

review of generic self-assessed health instruments. Quality of Life Research, 14(7), 1651-1668.

Helvik, A. S., Engedal, K., & Selbaek, G. (2010). The quality of life and factors associated with it in the

medically hospitalised elderly. Aging Mental Health, 14(7), 861-869. doi:

10.1080/13607861003801003

Hill, A. M., Hoffmann, T., McPhail, S., Beer, C., Hill, K. D., Brauer, S. G., & Haines, T. P. (2011).

Factors associated with older patients' engagement in exercise after hospital discharge. Archives

of Physical Medicine and Rehabilitation, 92(9), 1395-1403. doi: 10.1016/j.apmr.2011.04.009



Hirvensalo, M., Heikkinen, E., Lintunen, T., & Rantanen, T. (2005). Recommendations for and warnings

against physical activity given to older people by health care professionals. Preventive Medicine,

41(1), 342-347. doi: 10.1016/j.ypmed.2004.11.020

Horder, H., Skoog, I., & Frandin, K. (2012). Health-related quality of life in relation to walking habits

and fitness: a population-based study of 75-year-olds. Quality of Life Research. doi:

10.1007/s11136-012-0267-7

Kelley, G. A., Kelley, K. S., Hootman, J. M., & Jones, D. L. (2009). Exercise and health-related quality

of life in older community-dwelling adults. Journal of Applied Gerontology, 28(3), 369-394. doi:

10.1177/0733464808327456

Landi, F., Onder, G., Carpenter, I., Cesari, M., Soldato, M., & Bernabei, R. (2007). Physical activity

prevented functional decline among frail community-living elderly subjects in an international

observational study. Journal of Clinical Epidemiology, 60(5), 518-524. doi:

10.1016/j.jclinepi.2006.09.010

Latham, N. K., Mehta, V., Nguyen, A. M., Jette, A. M., Olarsch, S., Papanicolaou, D., & Chandler, J.

(2008). Performance-Based or Self-Report Measures of Physical Function: Which Should Be

Used in Clinical Trials of Hip Fracture Patients? Archives of Physical Medicine and

Rehabilitation, 89(11), 2146-2155. doi: http://dx.doi.org/10.1016/j.apmr.2008.04.016

Lobo, A., Carvalho, J., & Santos, P. (2011). Comparison of functional fitness in elderlies with reference

values by Rikli and Jones and after one-year of health intervention programs. The Journal of

Sports Medicine and Physical Fitness, 51(1), 111-120.

Loge, J. H., & Kaasa, S. (1998). Short form 36 (SF-36) health survey: normative data from the general

Norwegian population. Scandinavian Journal of Social Medicine, 26(4), 250-258.

Loland, N. W. (2002). Reliability of the Physical Activity Scale for the Elderly (PASE). European Journal

of Sport Science, 2(5), 1-12.



Motl, R. W., & McAuley, E. (2010). Physical activity, disability, and quality of life in older adults.

Physical Medicine Rehabilitaion Clinics North America, 21(2), 299-308. doi:

10.1016/j.pmr.2009.12.006

Murphy, C. L., Sheane, B. J., & Cunnane, G. (2011). Attitudes towards exercise in patients with chronic

disease: the influence of comorbid factors on motivation and ability to exercise. Postgraduate

Medical Journal, 87(1024), 96-100. doi: 10.1136/pgmj.2010.105858

Nelson, M. E., Rejeski, W. J., Blair, S. N., Duncan, P. W., Judge, J. O., King, A. C., . . . Castaneda-

Sceppa, C. (2007). Physical activity and public health in older adults: recommendation from the

American College of Sports Medicine and the American Heart Association. Medicine and

Science in Sports and Exercise, 39(8), 1435-1445. doi: 10.1249/mss.0b013e3180616aa2

Newman, A. B., Simonsick, E. M., Naydeck, B. L., Boudreau, R. M., Kritchevsky, S. B., Nevitt, M. C., . .

. Harris, T. B. (2006). Association of long-distance corridor walk performance with mortality,

cardiovascular disease, mobility limitation, and disability. Journal of the American Medical

Association, 295(17), 2018-2026. doi: 10.1001/jama.295.17.2018

Nilsson, B. B., Westheim, A., & Risberg, M. A. (2008). Long-term effects of a group-based high-

intensity aerobic interval-training program in patients with chronic heart failure. Amercian

Journal of Cardiology, 102(9), 1220-1224. doi: 10.1016/j.amjcard.2008.06.046

Olivares, P. R., Gusi, N., Prieto, J., & Hernandez-Mocholi, M. A. (2011). Fitness and health-related

quality of life dimensions in community-dwelling middle aged and older adults. Health and

Quality of Life Outcomes, 9, 117. doi: 10.1186/1477-7525-9-117

Orwelius, L., Nordlund, A., Nordlund, P., Simonsson, E., Backman, C., Samuelsson, A., & Sjoberg, F.

(2010). Pre-existing disease: the most important factor for health related quality of life long-term

after critical illness: a prospective, longitudinal, multicentre trial. Critical Care, 14(2), R67. doi:

10.1186/cc8967



Ozturk, A., Simsek, T. T., Yumin, E. T., Sertel, M., & Yumin, M. (2011). The relationship between

physical, functional capacity and quality of life (QoL) among elderly people with a chronic

disease. Archives of Gerontolology and Geriatrics, 53(3), 278-283. doi:

10.1016/j.archger.2010.12.011

Rasinaho, M., Hirvensalo, M., Leinonen, R., Lintunen, T., & Rantanen, T. (2007). Motives for and

barriers to physical activity among older adults with mobility limitations. Journal of Aging &

Physical Activity, 15(1), 90-102.

Rikli, R., & Jones, C. (1999). Functional fitness normative scores for community-residing older adults,

ages 60-94. / Normes pour l ' evaluation de la condition physique fonctionnelle pour des

personnes agees de 60 a 94 ans, residant en maison de retraite. Journal of Aging and Physical

Activity, 7(2), 162-181.

Rikli, R., & Jones, C. (2013). Development and validation of criterion-referenced clinically relevant

fitness standards for maintaining physical independence in later years. Gerontologist, 53(2), 255-

267.

Rikli, R., Jones, C., & Hanson, T. (2004). Senior fitness test: fysisk formen hos ldre : manual og

referencevrdier. Kbenhavn: FADL`s Forlag.

Rosenberg, D. E., Bombardier, C. H., Hoffman, J. M., & Belza, B. (2011). Physical activity among

persons aging with mobility disabilities: shaping a research agenda. Journal of Aging Research,

2011, 708510. doi: 10.4061/2011/708510

Stretton, C. M., Latham, N. K., Carter, K. N., Lee, A. C., & Anderson, C. S. (2006). Determinants of

physical health in frail older people: the importance of self-efficacy. Clin Rehabil, 20(4), 357-

366.

Svege, I., Kolle, E., & Risberg, M. A. (2012). Reliability and validity of the Physical Activity Scale for

the Elderly (PASE) in patients with hip osteoarthritis. BioMedCentral Musculoskeletal Disorders,

13, 26-26.



Takata, Y., Ansai, T., Soh, I., Awano, S., Yoshitake, Y., Kimura, Y., . . . Takehara, T. (2010). Quality of

life and physical fitness in an 85-year-old population. Archives of Gerontology and Geriatrics,

50(3), 272-276. doi: 10.1016/j.archger.2009.04.005

Volpato, S., Onder, G., Cavalieri, M., Guerra, G., Sioulis, F., Maraldi, C., . . . Fellin, R. (2007).

Characteristics of nondisabled older patients developing new disability associated with medical

illnesses and hospitalization. Journal of General Internal Medicine, 22(5), 668-674. doi:

10.1007/s11606-007-0152-1

Wallace, J. I., Buchner, D. M., Grothaus, L., Leveille, S., Tyll, L., LaCroix, A. Z., & Wagner, E. H.

(1998). Implementation and effectiveness of a community-based health promotion program for

older adults. The Journals of Gerontology A Psychology Sciences, 53(4), M301-306.

Wang, H. M., Beyer, M., Gensichen, J., & Gerlach, F. M. (2008). Health-related quality of life among

general practice patients with differing chronic diseases in Germany: cross sectional survey.

BioMedCentral Public Health, 8, 246. doi: 10.1186/1471-2458-8-246

Ware, J. E., Jr. (2000). SF-36 health survey update. Spine (Phila Pa 1976), 25(24), 3130-3139.

Ware, J. E., Jr., & Sherbourne, C. D. (1992). The MOS 36-item short-form health survey (SF-36). I.

Conceptual framework and item selection. Medical Care, 30(6), 473-483.

Washburn, R. A., McAuley, E., Katula, J., Mihalko, S. L., & Boileau, R. A. (1999). The physical activity

scale for the elderly (PASE): evidence for validity. Journal of Clinical Epidemiology, 52(7), 643-

651.

WHO. (1995). The World Health Organization Quality of Life assessment (WHOQOL): position paper

from the World Health Organization. Social Sciences & Medicine, 41(10), 1403-1409.

WHO. (2010). World health organization global recommendations on physical activity for health

Wolinsky, F. D., Bentler, S. E., Hockenberry, J., Jones, M. P., Obrizan, M., Weigel, P. A., . . . Wallace, R.

B. (2011). Long-term declines in ADLs, IADLs, and mobility among older medicare

beneficiaries. BioMedCentral Geriatrics, 11, 43. doi: 10.1186/1471-2318-11-43



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



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)



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.

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older...

Documents

Transcript of Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older...