Applied Nursing Research xxx (2014) xxx–xxx
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Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of randomized controlled trials Seong-Hi Park, PhD, RN a, Kuem Sun Han, PhD, RN b,⁎, Chang-Bum Kang, PhD c a b c
School of Nursing, Pai Chai University, Daejeon 155-40, Korea College of Nursing, Korea University, Seoul 136-701, Korea Research Development Team, Korea Health Promotion Foundation, Seoul 150-868, Korea
a r t i c l e
i n f o
Article history: Received 25 June 2013 Revised 16 January 2014 Accepted 16 January 2014 Available online xxxx Keywords: Exercise Depressive symptoms Quality of life Self-esteem
a b s t r a c t Objective: This study attempted to show evidence of exercise programs as intervention to decrease depressive symptoms and to improve quality of life and self-esteem in older people. Design: Systematic review of randomized controlled trials. Data sources: Electronic databases of KoreaMed, Korea Scientific and Technological Intelligence Center, Korean Society of Nursing Science, Korean Academy of Psychiatric Mental Health Nursing, Ovid-Medline and Embase were searched up to May 25th, 2012 for relevant articles. Review: We searched studies of randomized controlled trials involving exercise programs administered to participants aged 65 years or over. Of 461 publications identified, 18 met the inclusion criteria for the meta-analysis. Quality assessment of the studies utilized Cochrane's Risk of Bias. Results: Exercise therapy in older people was effective, as evidenced by a decrease in depressive symptoms [standardized mean difference (SMD) − 0.36; 95% confidence interval (CI) − 0.64, − 0.08], and improvements in quality of life (SMD 0.86; 95% CI 0.11, 1.62) and self-esteem (SMD 0.49; 95% CI 0.09, 0.88). The changes were significant statistically, with no heterogeneity. Conclusions: Exercise programs in older people are effective in improving depressive symptoms, quality of life and self-esteem. Development and efficient use of tailored exercise programs for elderly people is a prudent strategy. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Advances of science and medicine resulted in an increase of life expectancy and consequent increase in the proportion of older people (Eyigor, Karapolat, Durmaz, Ibisoglu, and Cakir, 2009). This is one of global phenomenon, and in case of Korea, already became an aging society with 7.1% in the proportion of the elderly population in 2001 and, also, as Korea will be predicted to be an aged society by 2018 and a super aging society in 2026 (Statistics Korea, 2012). In case of UK, the projected rise in the proportion of population over 65 from 16% in 2001 to 21% in 2026 will increase this number (Brittle et al., 2009). An aging society is a problem all over the world. These demographic changes of the social structure have increased the needs for elderly population-associated social interests. The life expectancy among the phenomenon of social interests became important because of the quality of life in the extended life time especially after retirement. According to the U.S. National Center for Health Statistics (1993), about 15 percent of human life stays unhealthy, and the causing factors are age-associated dysfunction, injury, disease and so on. What elderly people really want is spending the rest of their ⁎ Corresponding author at: Korea University, College of Nursing, AnAmDong, SungbukGu, Seoul, Korea, 136-705. Tel.: +82 2 3290 4919; fax: +82 2 927 4676. E-mail address: [email protected] (K.S. Han).
lives to stay healthy, and one of the most important requirements is regular, active, and physical activity in order to maintain independent lives. The definition of health for the older individuals is, in general, the maintenance of functional independence until death. The exercise may promote physical function which is a key factor for daily healthy life and prevent chronic disease and a fall for older people (Shon, 2010; Sattin, Easley, Wolf, Chen, & Kutner, 2005; Sjosten et al., 2008). Regular exercise increases the social contact, improves the physical and mental health, and plays the important role to diminish chronic disease risk factors and to maintain body functions for older people (Ko and Lee, 2012). It also prevents physical exhaustion by enhancing cardiovascular function, central nervous system, immune system, and the endocrine system. And in spiritual element, it reduces depressive symptoms and promotes self-efficacy (Chung, 2008). It is reported that there are effects on the immune system against disease, psychological well-being, self-respect, and sense of accomplishment (Tsang, Fung, Chan, Lee, and Chan, 2006). The goal of regular daily exercise is to promote older people's stamina, to reduce depressive symptoms and anxiety from disease associated with aging by aging prevention, and to have positive thinking about their own aging process (Cho and Rho, 2009). However, there were some studies suggested that exercise had no direct effects on depressive symptoms (Brenes et al., 2007;
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Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
Conradsson et al., 2010). Thus, studies of the effects of physical exercise on depressive symptoms, quality of life, and self-esteem have reported conflicting results, considering these discrepancies in the literature the need of the present study was to examine these researches critically and to validate practical application. Recently, discussion for evidence based practice discussions are activated in healthcare setting, and the examination of practical application through the systematic review is suggested (Kim et al., 2011). Therefore, this study is conducted to suggest evidence for the exercise programs as nursing intervention to reduce depressive symptoms and to improve the quality of life and self-esteem from a systematic review based on the results of randomized controlled trials (RCTs). 2. Methods 2.1. Research design This study was a systematic review and meta-analysis of RCTs examining the effects of exercise programs on the depressive symptoms, quality of life and self-esteem of elderly patients 65 years and greater (Lee, 2008). 2.2. Search strategy 2.2.1. Key question ▪ Participants: Elderly people are aged 65 years or over who did not have disorders of orientation and who were capable of independent living.
▪ Interventions: Any type of exercise program designed for the elderly defined as muscle strengthening training, walking, qigong physical exercise, tai chi and dance etc. ▪ Comparisons: Routine conservative treatment such as no treatment/placebo or any other type of non-exercising intervention including routine nursing care, counseling and health education (Pakkala et al., 2008). ▪ Outcomes: The main outcomes were measured depression symptom level, quality of life and self-esteem. ▪ Types of studies: RCTs were only included. 2.2.2. Data sources and study selection The literature review utilized Internet-based electronic databases. Ovid-Medline and Embase, KoreaMed, and the National Discovery for Science Leaders (NDSL) were used as the main search database (Bidwell & Jensen, 2004). Additionally, the websites of the Korean Society of Nursing Science and the Korean Academy of Psychiatric Mental Health Nursing were searched to include all Korean academic journals that deal with associated fields. The data were retrieved in May 25th, 2013. The keywords were derived from participants and interventions which were components of key question. The keywords for the search in Korean DBs (KoreaMed and NDSL) were selected in consideration of the search function of each DB. Mainly, ‘depression’ and ‘exercise’ were used integrated with ‘the elderly with age over 65 years old’ (Kim & Park, 2011). Studies search in KoreaMed were limited to randomized controlled trials. The search terms for the international databases were those used in the systematic review on the depression and exercise program by the Cochrane Collaboration (Dong et al.,
Fig. 1. Flow chart of study selection.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
22.20–23.10
≥24.00
N21.00 27.00 27.60
N23.00
21.00
Sweden France France New Zealand UK Turkey Korea New Zealand USA Finland Finland Australia Hong Kong USA the Netherland Finland the Netherland Korea 2005 2004 2002 2001 2000
2006
2008 2007
2009
Conradsson et al. Dechamps et al. Dechamps et al. Kerse et al. Brittle et al. Eyigor et al. Sung Kerse et al. Brenes et al. Pakkala et al. Sjösten et al. Sims et al. Tsang et al. Sattin et al. Chin et al. Timonen et al. Wolf et al. Jang30 2010
Notes: MMSE = Mini mental state examination; Exp. = Experimental group; Cont. = Control group; DS = Depressive symptoms; QOL = Quality of life; SE = Self-esteem; GDS-15 = 15-item Geriatric depression scale; PGCMS = Philadelphia geriatric center morale scale; GDS = Geriatric depression scale; SF-36 = Short form (36) health survey; AM-PAC = Activity measure for post-acute care; HAD-S = Hospital anxiety and depression scale; RSES = Rosenberg self-esteem scale; EuroQol = EuroQol instrument and the life satisfaction index; CES-D = Center for epidemiological studies depression scale; WHO-QOL = The World Health Organization quality of life assessment; ASSEI = Adult sources of self-esteem instrument; DQoL = Dementia quality of life instrument; ZSDS = Zung self-rating depression scale.
DQoL
WHO- QOL
RSES EuroQol SF-36
SF-36
AM-PAC SF-36
PGCMS
GDS-15 GDS GDS GDS-15 HAD-S GDS GDS GDS GDS-15 CED-S GDS GDS GDS-15 CES-D GDS ZSDS HAD-S GDS 3,6 6,12 3 6,12 3,6 2 4 6,1 4 24 12 3, 6 6 4,8,12 6 3,9 1 5 45 min, 29 sessions, 13 weeks 40 min twice a week for 6 months 50 min a week for 6 weeks N30 min, 6 months 40–60 min, twice a week for 5 weeks 180 min a week for 8 weeks 30 min, twice a week for 16 weeks 6 months 60 min, 3 days a week for 16 weeks 60 min, 24 months 3 times a week for 12 months 3 session a week for 10 weeks 30–45 min, 16 weeks 10–50 min, 48 weeks 45–60 min a week for 6 months 90 min, 10 weeks 2–3 times a week for 4–6 weeks N60 min 20 weeks weight bearing etc. muscular reinforcement etc. balance exercise etc. limb-strengthening, walking etc. muscular reinforcement etc. dance based exercise functional exercise walking etc. facility base exercise walking etc. physical activity group based exercise limb-strengthening, walking etc. Qigong Tai chi group based exercise group based exercise balance exercise etc. aquatic exercise 17.80 ± 5.10 14.20–17.20 10.60
N80 N80 N80 N80 N80 N70 N75 N80 N70 N70 N70 N70 N80 N80 N80 N80 N80 N65
191 109 49 193 56 37 21 682 26 632 591 32 82 303 107 68 77 41
MMSE
Exp. Sample
Total
Participants
Age
Country Author Year
Table 1 Characteristics of the selected studies.
An evidence table basic form prepared for the extraction of all data required for evaluation without omission was used after the examination of pilot form as a demonstration. The evidence table was independently prepared by reviewers so that the articles' results would be accurately stated. The results were cross-checked, and this process was repeated three times. Meta-analyses were performed mainly using Review Manager ver. 5.1 (RevMan). For all statistical comparisons, differences with a p b 0.05 were considered significant. We used a random-effects model based on DerSimonian and Laird's method to calculate the pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) for the effects of exercise programs. The inverse variance method was used because most intervention results were reported as continuous variables. Since various measuring tools were used the average effect was stated as SMD. The chi-squared (χ 2) test detected statistical heterogeneity. When heterogeneity was present (p b 0.1), the data were analyzed using the random effects model. The I-squared (I 2) test was used to identify heterogeneity. I 2 statistics are the form of statistics quantifying inconsistency. I 2 ranged from 0% to 100%. Presently, values between 0% and 40% indicated unimportant heterogeneity, values up to 60% as moderate heterogeneity and values over 60% as considerable heterogeneity (Higgins and Green, 2011). When heterogeneity did not exist, it was analyzed as a fixed effect model. A funnel plot was designed to check the existence of publication bias.
Cont.
2.4. Data extraction and analysis
100 60 25 96 28 18 10 352 12 310 298 18 34 153 51 34 40 17
Exercise intervention
The methodological quality of selected studies was undertaken using the Cochrane's tool for assessing risk of bias (RoB) developed by Cochrane Collaboration. Two review authors assessed it independently, and any disagreements or unclear parts were resolved by discussion and consensus agreement.
Type
2.3. Risk of bias in included studies
91 49 24 97 28 19 11 330 14 314 293 14 48 158 56 34 37 24
Depressive symptoms Period for exercise
Follow-up (months)
Outcome measures
Quality of life
Self-esteem
2009). Before the search, the MeSH terms, synonyms and related terms expressing ‘the elderly’, ‘depression’ and ‘exercise’ were checked through the MeSH database at PubMed, and the search sensitivity of each database was confirmed. In the Ovid-Medline and Embase databases, searching was integrated by exercise, fitness, kinesiotherapy, depression, anxiety disorder, dysthymic disorder and neurosis, while the search was limited to those over 65-years-of-age and to literature published after 2000 by using limiting function. The using search filter for RCTs was the search strategy which was proposed by SIGN (Scottish Intercollegiate Guidelines Network). The selection criteria were as follows: (a) studies performed exercise therapy as main intervention on elderly (≥ 65 years), (b) intervention studies including randomized clinical trials comparing routine conservative treatment or no intervention, (c) studies with reported more than one main outcome, and (d) studies published in English and Korean. Studies with any of the following criteria were excluded: (a) subjects had specific diseases, such as hypertension or diabetes, which could affect the intervention results; (b) studies including subjects b 65-years-of-age; and (c) studies that were not original articles (e.g., editorials, opinion pieces, reviews, and notes). Studies were selected in accordance with the inclusion and exclusion criteria with reviewing of the title and abstract of each study after duplicated journals were removed from the primary search. The remaining studies were confirmed with the original one and validated by applying the inclusion and exclusion criteria. Two independent authors reviewed the results of the searches, and the papers that met the inclusion criteria were selected. Any disagreement between authors was resolved by discussion and consensus agreement after another review of the research. If consensus cannot be reached, a final decision was made by the third author, but there was no conflicting opinion between the authors.
3
ASSEI
S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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difficult to blind participants and researchers because of the prolonged length of the exercise program (3–6 months) and because of study characteristics.
3. Results 3.1. General characteristics of selected studies Our initial literature search yields 461 references (84 Korean and 377 international studies). After 47 duplicated studies (3 Korean and 44 international studies) were excluded according to the inclusion and exclusion criteria, a total of 414 randomized controlled trials were included. The titles and abstracts were reviewed, and 396 studies were extracted based on the selection criteria, of which 18 were finally identified relevant in our review. A detailed flowchart of the literature search and study selection is presented in Fig. 1. Eighteen trials involving 3,297 participants were identified by evidence-based evaluation on exercise programs for elderly Koreans (≥ 65-years-of-age). The 18 studies were from New Zealand, Australia, United States, Turkey, various countries in Europe including Finland, France and Netherlands and Asia (Korea, Hong Kong). Eleven trials (61%) involved subjects N80-years-of-age. Ten trials (56%) performed mini-mental state examination (MMSE) to identify the absence/presence of cognitive impairment. Six of these 10 studies documented normal cognition or mild cognitive decline. There was no case of serious symptoms of dementia (MMSE ≤ 9). The study subjects were mainly residents of eight care facilities. Exercise programs were mainly walking, muscle strengthening, balance-keeping, qigong physical exercise, tai chi, dance and other programs (Wolf et al., 2001). Exercise sessions were 30–60 minutes long and were done one-to-three times each week. In 12 of the 18 trials, the sessions continued for 3 months or more. Effects of the exercise programs were measured by depressive symptoms, quality of life and selfesteem. Four tools measured depressive symptoms: most studies used the long form Geriatric Depression Scale (GDS) developed by Yesavage et al. (1983) (Lee, Choi, Jung, & Kwak, 2000). Fifteen studies used the short version of the GDS. Other tools used were the Hospital Anxiety and Depression Scale (HAD-S), Center for Epidemiological Studies Depression Scale (CES) and Zung Self-Rating Depression Scale (ZSDS). Each study used a different tool in the measurement of quality of life and self-esteem. The tracking observation period was more than 3 months, except in two studies. Depressive symptoms and quality of life measurements were done repeatedly. Therefore, the analyses involved grouping measurement timings and various factors depending on study object characteristics (Table 1).
3.2. Assessing risk of bias The result of quality evaluation suggested that the risks of selection bias relevant to random allocation sequence generation, allocation sequence concealment, attrition bias and reporting bias were low in almost all articles. However, bias did exist concerning blinding of study participants and result evaluation (Fig. 2). It is
3.3. Effects of exercise programs 3.3.1. Depressive symptoms All included studies reported the level of depressive symptoms in subjects engaging in exercise programs. Sixteen trials (2,594 participants) reported average and standard deviation using measuring tool for depressive symptoms. Two trials (Eyigor et al., 2009; Kerse et al., 2008) were excluded because they reported results as the number of patients with depressive symptoms. As a whole, exercise programs significantly decreased depressive symptoms. The pooled SMD calculated using the random-effects model was − 0.36 (95% confidence interval (CI) − 0.64 to 0.08) but heterogeneity was high (I 2 = 93.0%, p b 0.001) (Fig. 3A). Regarding the change in depressive symptoms depending on measurement timing, there was a statistically significant difference after 3 months (Z = 2.09, p = 0.04). At that time, the depressive symptoms also decreased while the heterogeneity among the studies increased. 3.3.2. Quality of life The change in quality of life by exercise programs was measured in eight trials (Brenes et al., 2007; Conradsson et al., 2010; Dechamps et al., 2009; Eyigor et al., 2009; Kerse et al., 2010, 2008; Sims et al., 2006). Collectively, exercise programs (1,317 participants) improved the quality of life of the elderly participants (Z = 2.23, p = 0.03). The pooled SMD calculated using the random-effects model was 0.86 (95% CI 0.11 to 1.62). There was substantial heterogeneity (I2 = 98.0%, p b 0.001). The result by measurement timing was that the quality of life point improved by SMD 0.57 (95% CI −0.82 to 1.97) after 3 months, SMD 0.67 (95% CI −0.24 to 1.57) after 6 months and SMD 1.96 (95% CI −2.78 to 6.71) after 12 months. Though they did not have statistical significance, they showed the pattern that quality of life improved as time passed after commencing an exercise program (Fig. 3B). 3.3.3. Self-esteem The change in self-esteem by an exercise program was measured in two trials (Sung, 2009; Tsang et al., 2006). Both studies (103 participants) measured self-esteem at 16 weeks after exercise in elderly participants (Fig. 3C). The study by Sung (2009) included only the result with subjects N 75-years-of-age. There was no heterogeneity (I2 = 0%, p = 0.400) among the trials. Exercise programs improved self-esteem (Z = 2.39, p = 0.020); SMD 0.49 (95% CI 0.09 to 0.88). 3.4. Publication bias Funnel plot analysis demonstrated a mild publication bias (Fig. 4).
Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other bias 0% Low risk of bias
Unclear risk of bias
25%
50%
75%
100%
High risk of bias
Fig. 2. Risk of bias graph.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
indicated no bias caused by random allocation sequence, concealment or selective reporting 65 and greater. The study population comprised subjects aged 65 years and over, who were capable of independent daily living without disorientation disorder or cognitive impairment or dementia. Eighteen studies were finally included in the meta-analysis as the result of searches on electronic Korean and international databases. Some identified studies were not included in the meta-analysis because they did not provide standard deviations or standard errors of intervention results. Thirteen of the 18 studies were published after 2005, exemplifying the recently increased interest on the depressive symptoms of the
4. Discussion This study was a systematic review and meta-analysis of RCTs regarding the effect of exercise program on depressive symptoms, quality of life and self-esteem of the elderly (≥65-years-of-age). The study design – which consisted of systematic and comprehensive literature search, literature inclusion by inclusion/exclusion criteria, evaluation of selected literatures and summarization/synthesis of evaluation results in accordance with the method suggested by Cochrane Collaboration – provided the highest evidence level. Cochran's risk bias on the quality evaluation of included literature Exercise Study or Subgroup
Mean
Control
SD Total Mean
5
Std. Mean Difference
SD Total Weight
Std. Mean Difference
IV, Random, 95% CI
IV, Random, 95% CI
1.1.1 Depression_3months Brenes 2007
4.5
2.9
14
6.1
3.2
12
3.5%
-0.51 [-1.30, 0.28]
Brittle 2009
3.4
2.2
11
5.4
3.3
10
3.3%
-0.69 [-1.58, 0.20]
4.35
2.08
75
4.25
2.09
90
4.6%
0.05 [-0.26, 0.35]
5.9
3.7
24
8.6
3.5
25
4.0%
-0.74 [-1.32, -0.16]
58.1 25.64
106
53.5 19.96
0.20 [-0.08, 0.48]
Conradsson 2010
Dechamps 2010_1 Sattin 2005
93
4.6%
Sims 2006
12.23
5.22
14
12
4.26
16
3.7%
0.05 [-0.67, 0.76]
Sung 2009
17.82
2.16
11 17.93
2.06
10
3.3%
-0.05 [-0.91, 0.81]
Timonen 2002
44.7
7.7
34
51.6
9.7
34
4.2%
-0.78 [-1.27, -0.28]
Tsang 2006
3.4
2.46
48
5.68
1.53
34
4.3%
-1.06 [-1.53, -0.59]
Wolf 2001
5.3
3.87
37
5.5
4.62
40
4.3%
-0.05 [-0.49, 0.40]
364
39.8%
-0.34 [-0.65, -0.02]
-0.68 [-1.56, 0.21]
Subtotal (95% CI)
374
Heterogeneity: Tau² = 0.17; Chi² = 34.62, df = 9 (P < 0.0001); I² = 74% Test for overall effect: Z = 2.09 (P = 0.04) 1.1.2 Depression_6months
Brittle 2009
3.6
2
10
6
4.3
11
3.3%
Conradsson 2010
4.5
2.3
73
4.25
2.3
83
4.6%
0.11 [-0.21, 0.42]
Dechamps 2010_2
4.7
3
45
5
3.3
54
4.4%
-0.09 [-0.49, 0.30]
Jang 2000
6.3
3.2
24
8.6
5.59
17
3.9%
-0.52 [-1.15, 0.11]
Kerse 2010
2.4
0.2
94
3.1
0.3
92
4.4%
-2.74 [-3.14, -2.34]
6.3
5.4
6.11
35
4.3%
0.12 [-0.31, 0.56]
51.4 20.66
80
4.6%
0.43 [0.13, 0.73]
18
3.7%
-0.06 [-0.76, 0.63]
Marijke 2004
8.01
49
Sattin 2005
60.1 19.98
95
Sims 2006
11.5
6.66
14 11.88
Timonen 2002
46.4
10.8
24
Subtotal (95% CI)
50.1
4.88 9.6
428
28
4.1%
-0.36 [-0.91, 0.19]
418
37.3%
-0.42 [-1.12, 0.28]
Heterogeneity: Tau² = 1.08; Chi² = 176.53, df = 8 (P < 0.00001); I² = 95% Test for overall effect: Z = 1.17 (P = 0.24) 1.1.3 Depression_12months
Dechamps 2010_2 Kerse 2010 Pakkala 2007 Sattin 2005
5
3
41
6.3
3.3
51
4.4%
-0.41 [-0.82, 0.01]
2.4
0.2
94
2.8
0.3
87
4.5%
-1.57 [-1.91, -1.24]
11.21
7.53
307 10.93
7.82
302
4.8%
0.04 [-0.12, 0.20]
50.3 19.19
82
4.6%
0.49 [0.18, 0.80]
261
4.7%
-0.05 [-0.23, 0.12]
783
23.0%
-0.29 [-0.82, 0.24]
100.0%
-0.36 [-0.64, -0.08]
59.6 18.65
Sjosten 2007
3.1
82
3.8
251
Subtotal (95% CI)
775
3.3
3.9
Heterogeneity: Tau² = 0.34; Chi² = 93.51, df = 4 (P < 0.00001); I² = 96%
Test for overall effect: Z = 1.08 (P = 0.28) Total (95% CI)
1577
1565
Heterogeneity: Tau² = 0.43; Chi² = 308.87, df = 23 (P < 0.00001); I² = 93% Test for overall effect: Z = 2.50 (P = 0.01)
-2
-1
0
1
2
Favours experimental Favours control
Test for subgroup differences: Chi² = 0.08, df = 2 (P = 0.96), I² = 0%
A) Depressive symptoms Fig. 3. Comparison outcomes of exercise versus control. A. Depressive symptoms. B. Quality of life. C. Self-esteem.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
Experimental
Study or Subgroup
Mean
Control
SD Total Mean
Std. Mean Difference
SD Total Weight
Std. Mean Difference
IV, Random, 95% CI
IV, Random, 95% CI
2.1.1 Quality of Life_3months Brenes 2007
31.3 13.5
Conradsson 2010
11.52 0.28
Dechamps 2010_1
49.9 21.2
Eyigor 2009
28
79 10.95
81.01 18.2
Subtotal (95% CI)
50.7 25.01
28
9.0%
-0.95 [-1.51, -0.40] 2.11 [1.73, 2.48]
0.26
91
9.2%
24 36.01 26.01
25
8.9%
0.57 [0.00, 1.15]
19
18
8.8%
0.53 [-0.13, 1.19]
162
35.9%
0.57 [-0.82, 1.97]
71.7
16.1
150
Heterogeneity: Tau² = 1.95; Chi² = 84.46, df = 3 (P < 0.00001); I² = 96% Test for overall effect: Z = 0.80 (P = 0.42) 2.1.2 Quality of Life_6months Conradsson 2010
Kerse 2008 Kerse 2010
Marijke 2004 Sims 2006
11.56 0.29
73 10.92
0.28
83
9.2%
2.24 [1.83, 2.64]
9.9 3.26
266 10.01
3.41
290
9.4%
-0.03 [-0.20, 0.13]
54.7
0.7
94
53.7
0.9
92
9.3%
1.24 [0.92, 1.55]
3.5 1.04
49
3.6
0.87
35
9.1%
-0.10 [-0.54, 0.33]
14 13.37
2.09
18
8.7%
-0.06 [-0.75, 0.64]
518
45.7%
0.67 [-0.24, 1.57]
13.26 1.69
Subtotal (95% CI)
496
Heterogeneity: Tau² = 1.01; Chi² = 139.94, df = 4 (P < 0.00001); I² = 97% Test for overall effect: Z = 1.45 (P = 0.15) 2.1.3 Quality of Life_12months
Kerse 2008
10.01
0.2
225
10.1
0.2
248
9.4%
Kerse 2010
55.4
0.7
94
52.7
0.5
87
9.0%
4.39 [3.85, 4.93]
335
18.4%
1.96 [-2.78, 6.71]
Subtotal (95% CI)
319
-0.45 [-0.63, -0.27]
Heterogeneity: Tau² = 11.68; Chi² = 274.80, df = 1 (P < 0.00001); I² = 100% Test for overall effect: Z = 0.81 (P = 0.42) 965
Total (95% CI)
1015 100.0%
0.86 [0.11, 1.62]
Heterogeneity: Tau² = 1.58; Chi² = 532.66, df = 10 (P < 0.00001); I² = 98%
-10
Test for overall effect: Z = 2.23 (P = 0.03)
-5
0
5
10
Favours experimental Favours control
Test for subgroup differences: Chi² = 0.30, df = 2 (P = 0.86), I² = 0%
B) Quality of life Experimental
Control
Std. Mean Difference
Std. Mean Difference
Study or Subgroup
Mean
Sung 2009
25.55 3.59
11 22.51 3.42
10
19.5%
0.83 [-0.07, 1.73]
Tsang 2006
16.85 3.86
48 15.44 2.84
34
80.5%
0.40 [-0.04, 0.85]
59
44 100.0%
0.49 [0.09, 0.88]
Total (95% CI)
SD Total Mean
SD Total Weight
Heterogeneity: Chi² = 0.70, df = 1 (P = 0.40); I² = 0%
IV, Fixed, 95% CI
IV, Fixed, 95% CI
-4
Test for overall effect: Z = 2.39 (P = 0.02)
-2
Favours experimental
0
2
4
Favours control
C) Self-esteem Fig. 3 (continued).
elderly. Various initiatives in practical healthcare have sought to decrease the depressive symptoms and improve the quality of life of the elderly. Sixteen of the 18 studies involved subjects in United States and Europe, while two studies (Jang, 2000; Sung, 2009) were conducted and published in Korea. This may indicate the need for more active studies concerning exercise and elderly depressive symptoms in Korea. This need could be especially pressing, given the increasing prevalence of both the elderly population and the elderly with depressive symptoms in Korea.
Eleven studies involved subjects N 80-years-of-age, and one Korean study involved subjects 65–69-years-of-age. Especially, most studies published after 2009 involved subjects over 80-years-of-age. This may reflect the extended age distribution of the elderly, as average life expectancy continues to increase due to advancements in medical treatment/prevention and health care, and increased personal interest in health. The increasing emphasis on subjects N 80-years-of-age may also reflect the increased prevalence of depressive symptoms and quality of life in this segment of the population. There were 26–682
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
A) Depressive symptoms 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-4
-2
0
2
4
B) Quality of life 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-10
-5
0
5
10
-2
0
2
4
C) Self-esteem 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-4
Fig. 4. Funnel plot of selected studies for effect size extraction. A. Depressive symptoms. B. Quality of life. C. Self-esteem.
7
4–12 weeks after commencing exercise. The effects of exercise on depressive symptoms are not expected in the short-term, but are achieved over the longer-term when subjects are empowered to continue exercise on their own initiative (Brenes et al., 2007). Exercises included muscle strengthening, balancing, walking, back stretching, qigong physical exercise and dance. Some studies reported on exercise programs combined with counseling and education, consistent with reports that exercise programs for the elderly should be designed for self-learning and health promotion without exhausting the body, given that elderly people can experience difficulty in doing aerobic exercise because of physical weakness and lower resistance (Cho and Rho, 2009; Kerse et al., 2008). The meta-analysis indicated that, overall, exercise programs decreased the depressive symptoms of the elderly by an SMD − 0.36. Significant benefits were apparent by 3 months (p = 0.040). Practicing continuous exercise program beyond 3 months would likely be effective (Brittle et al., 2009; Chin, Van Poppel, Twisk, and Van Mechelen, 2004; Seo, 2011). The present findings are also consistent with prior reports that exercise programs are effective in decreasing chronic depression in patients (including the elderly) (Lorrant, Delige, Eaton, Robert, & Ansseau, 2003). This result supports the results that an exercise program is helpful in improving cognitive– behavioral, socio-psychological and medical health (Chung, 2008; Conradsson et al., 2010). This study is a similar finding to the Cochrane review (Mead et al., 2009) that for the 23 trials (907 participants, aged 18 and over) comparing exercise with no treatment or control intervention, on the reducing effect of depressive symptoms, pooled SMD was −0.82 (95% CI −1.12, − 0.51), and there was significant heterogeneity (I 2 = 77.0%). Although it was not possible to make a conclusion because of the heterogeneity among the literatures, it seems likely that an exercise program improves the quality of life of the elderly by decreasing depressive symptoms and increasing self-esteem. Indeed, studies have reported that exercise programs are effective in the quality of life and sense of happiness of chronic disease patients and therapy participants of various ages (Cho and Rho, 2009; Dechamps et al., 2010; Timonen et al., 2002). Presently, exercise programs were effective in improving the self-esteem of the elderly (p = 0.020). Self-esteem can diminish with deteriorated cognitive and physical functions, and is bolstered by exercise-related improvements in physical function (Seo, 2011; Sung, 2009). Most of the 18 studies used the GDS as the measurement tool, given its suitability for elderly subjects. It was difficult to interpret and integrate test results concerning the quality of life because various types of measurement tools measured sense of well-being and related symptoms. A measurement tool for quality of life considering the characteristics and function level of the elderly population should be developed in future studies (Littbrand et al., 2011). However, this study has some limitations. First, there may be a publication bias although we tried to minimize it in the process of article selection. Publication bias shown by a funnel plot (Fig. 4) may alter the results of this review. In general, a positive result of trials may usually be easier to report than a negative one. Second, our result in overall depressive symptoms and quality of life revealed heterogeneity despite the inclusion of 18 RCTs with 3297 patients, which limits drawing a general conclusion and providing any recommendation. Third, although in case of self-esteem, there had been no heterogeneity on the result of the meta-analysis, but the number of studies combined was very small. So, there is some problem for generalization. Finally, there is some possibility of bias. At the domain of blindness, only 8 studies satisfied the criteria, and 10 studies did not. 5. Conclusion
subjects in the studies. The duration of exercise intervention was 4– 48 weeks. Twelve studies applied an exercise program for a minimum of 3 months. All 18 studies tracked and observed depressive symptoms for
This study is to examine the effects of exercise programs on depressive symptoms, quality of life, and self-esteem in older people
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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with a systematic review and meta-analysis. The present study proved the positive effects of exercise programs on depressive symptoms, quality of life, and self-esteem in older people because this result of the study is based on systemic review and meta-analysis of the 18 randomized controlled trials although it was difficult to interpret the results of researches due to the heterogeneity among studies. However, there is limitation in interpretation because the result of the quality of life is from two studies out of 18 randomized controlled trials performed. In order to reduce depressive symptoms and to improve quality of life and health promotion in older people, I suggest multi-faceted researches to develop the easier exercise programs which older people can participate in and to examine the effects of exercise programs.
References Bidwell, S., & Jensen, M. F. (2004). Chapter 3: Using a search protocol to identify sources of information: The COSI model in topfer L-A. In I. auston (Ed.), A Text on Health Technology Assessment (HTA) Information Resources. Bethesda, MD: National Information Center on Health Services Research and Health Care Technology (NICHSR), US National Library of Medicine. Brenes, G. A., Williamson, J. D., Messier, S. P., Rejeski, W. J., Pahor, M., Ip, E., et al. (2007). Treatment of minor depression in older adults: A pilot study comparing sertraline and exercise. Aging & Mental Health, 11, 61–68. Brittle, N., Patel, S., Wright, C., Baral, S., Versfeld, P., Sackley, C., et al. (2009). An exploratory cluster randomized controlled trial of group exercise on mobility and depression in care home residents. Clinical Rehabilitation, 23, 146–154. Chin, A. P., Van Poppel, M. N. M., Twisk, J. W. R., & Van Mechelen, W. (2004). Effects of resistance and all-round, functional training on quality of life, vitality and depression of older adults living in long-term care facilities: A 'randomized' controlled trial [ISRCTN87177281]. BioMed Central Geriatrics, 4, 1–9. Cho, Y. H., & Rho, B. I. (2009). The effect of geriatric health exercise on depression with special reference to naegong gymnastics. Korean Journal of Care Work, 12, 5–12. Chung, H. A. (2008). A literature review a program of intervention of patient geriatric depression. Society of Occupational Therapy for the Aged and Dementia, 2(1), 59–67. Conradsson, M., Littbrand, H., Lindelof, N., Gustafson, Y., Rosendahl, E., Conradsson, M., et al. (2010). Effects of a high-intensity functional exercise program on depressive symptoms and psychological well-being among older people living in residential care facilities: A cluster-randomized controlled trial. Aging & Mental Health, 14, 565–576 (http://dx.doi.org/10.1080/13607860903483078). Dechamps, A., Diolez, P., Thiaudiere, E., Tulon, A., Onifade, C., Vuong, T., et al. (2010). Effects of exercise programs to prevent decline in health-related quality of life in highly deconditioned institutionalized elderly persons: A randomized controlled trial. Archives of Internal Medicine, 170, 162–169. Eyigor, S., Karapolat, H., Durmaz, B., Ibisoglu, U., & Cakir, S. (2009). A randomized controlled trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Archives of Gerontology and Geriatrics, 48, 84–88. Higgins, J., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration (Retrieved March 30, 2011, from http://www.cochrane-handbook.org). Jang, S. (2000). The effects of aquatic exercise program on the physical function and depression in community elderly. Journal of Korea Community Health Nursing Academic Society, 14, 122–130. Kerse, N., Hayman, K. J., Moyes, S. A., Peri, K., Robinson, E., Dowell, A., et al. (2010). Home-based activity program for older people with depressive symptoms: DeLLITE–a randomized controlled trial. Annals of Family Medicine, 8, 214–223 (http://dx.doi.org/10.1370/afm.1093).
Kerse, N., Peri, K., Robinson, E., Wilkinson, T., von Randow, M., Kiata, L., et al. (2008). Does a functional activity program improve function, quality of life, and falls for residents in long term care? Cluster randomised controlled trial. British Medical Journal, 337, a1445 (http://dx.doi.org/10.1136/bmj.a1445). Kim, K. W., & Park, J. H. (2011). A review of the epidemiology of depression in Korea. Journal of the Korean Medical Association, 54(4), 362–369. Kim, S. Y., Park, H. J., Seo, H. J., Lee, Y. J., Jang, B. H., Son, H. J., et al. (2011). NECA's guidance for undertaking systematic reviews and meta-analyses for intervention. : National Evidence-based Healthcare Collaborating Agency. Ko, J. E., & Lee, S. H. (2012). A multilevel modeling of factors affecting depression among older Korean adults. Mental Health & Social Work, 40(1), 322–351. Lee, J. (2008). Meta-analysis. Journal of Korean Endocrine Society, 23, 361–378 (http:// dx.doi.org/10.3803/jkes.2008.23.6.361). Lee, M. S., Choi, Y. K., Jung, I. K., & Kwak, D. I. (2000). Epidemiological study of geriatric depression in a Korea urban area. Journal of Korean Geriatric Psychiatry, 4(2), 154–163. Littbrand, H., Carlsson, M., Lundin-Olsson, L., Lindelof, N., Haglin, L., Gustafson, Y., et al. (2011). Effect of a high-intensity functional exercise program on functional balance: Preplanned subgroup analyses of a randomized controlled trial in residential care facilities. Journal of the American Geriatrics Society, 59, 1274–1282 (http://dx.doi.org/10.1111/j.1532-5415.2011.03484.x). Lorrant, V., Delige, D., Eaton, W., Robert, P., & Ansseau, M. (2003). Socioeconomic inequalities in depression. American Journal of Epidemiology, 157, 98–112. Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A. (2009). Exercise for depression. Cochrane Database Systematic Review, 3, 1–62. Pakkala, I., Read, S., Leinonen, R., Hirvensalo, M., Lintunen, T., Rantanen, T., et al. (2008). The effects of physical activity counseling on mood among 75- to 81-year-old people: A randomized controlled trial. Preventive Medicine, 46, 412–418. Sattin, R. W., Easley, K. A., Wolf, S. L., Chen, Y., & Kutner, M. H. (2005). Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults. Journal of the American Geriatrics Society, 53, 1168–1178 (http://dx.doi.org/10. 1111/j.1532-5415.2005.53375.x). Seo, E. H., 2011. Effects of the Behas exercise program on physical strength, depression and life satisfaction in the institutionalized elderly. Unpubished doctoral dissertation, Chonnam University, Gwangju. Shon, J. H., 2010. Effects of chronic combined exercise on cognitive function, depression and life satisfaction in elderly women. Unpublished doctoral dissertation, Yeungnam University, Gyeongbuk. Sims, J., Hill, K., Davidson, S., Gunn, J., Huang, N., Sims, J., et al. (2006). Exploring the feasibility of a community-based strength training program for older people with depressive symptoms and its impact on depressive symptoms. BioMed Central Geriatrics, 6, 18. Sjosten, N. M., Vahlberg, T. J., Kivela, S. L., Sjosten, N. M., Vahlberg, T. J., & Kivela, S. L. (2008). The effects of multifactorial fall prevention on depressive symptoms among the aged at increased risk of falling. International Journal of Geriatric Psychiatry, 23, 504–510. Statistics Korea. (May 1, 2012). Statistics for the future population. retrieved July 20, 2012, from. http://www.kostat.go.kr Sung, K. (2009). The effects of 16-week group exercise program on physical function and mental health of elderly Korean women in long-term assisted living facility. Journal of Cardiovascular Nursing, 24, 344–351. Timonen, L., Rantanen, T., Timonen, T. E., Sulkava, R., Timonen, L., Rantanen, T., et al. (2002). Effects of a group-based exercise program on the mood state of frail older women after discharge from hospital. International Journal of Geriatric Psychiatry, 17, 1106–1111. Tsang, H. W. H., Fung, K. M. T., Chan, A. S. M., Lee, G., & Chan, F. (2006). Effect of a qigong exercise program on elderly with depression. International Journal of Geriatric Psychiatry, 21, 890–897. Wolf, B., Feys, H., De Weerdt, W., Van der Meer, J., Noom, M., & Aufdemkampe, G. (2001). Effect of a physical therapeutic intervention for balance problems in the elderly: A single-blind, randomized, controlled multicentre trial. Clinical Rehabilitation, 15, 624–636. Yesavage, J., Brink, T., Rose, T., Lum, O., Huang, V., Adey, M., et al. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49.
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Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of randomized controlled trials Seong-Hi Park, PhD, RN a, Kuem Sun Han, PhD, RN b,⁎, Chang-Bum Kang, PhD c a b c
School of Nursing, Pai Chai University, Daejeon 155-40, Korea College of Nursing, Korea University, Seoul 136-701, Korea Research Development Team, Korea Health Promotion Foundation, Seoul 150-868, Korea
a r t i c l e
i n f o
Article history: Received 25 June 2013 Revised 16 January 2014 Accepted 16 January 2014 Available online xxxx Keywords: Exercise Depressive symptoms Quality of life Self-esteem
a b s t r a c t Objective: This study attempted to show evidence of exercise programs as intervention to decrease depressive symptoms and to improve quality of life and self-esteem in older people. Design: Systematic review of randomized controlled trials. Data sources: Electronic databases of KoreaMed, Korea Scientific and Technological Intelligence Center, Korean Society of Nursing Science, Korean Academy of Psychiatric Mental Health Nursing, Ovid-Medline and Embase were searched up to May 25th, 2012 for relevant articles. Review: We searched studies of randomized controlled trials involving exercise programs administered to participants aged 65 years or over. Of 461 publications identified, 18 met the inclusion criteria for the meta-analysis. Quality assessment of the studies utilized Cochrane's Risk of Bias. Results: Exercise therapy in older people was effective, as evidenced by a decrease in depressive symptoms [standardized mean difference (SMD) − 0.36; 95% confidence interval (CI) − 0.64, − 0.08], and improvements in quality of life (SMD 0.86; 95% CI 0.11, 1.62) and self-esteem (SMD 0.49; 95% CI 0.09, 0.88). The changes were significant statistically, with no heterogeneity. Conclusions: Exercise programs in older people are effective in improving depressive symptoms, quality of life and self-esteem. Development and efficient use of tailored exercise programs for elderly people is a prudent strategy. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Advances of science and medicine resulted in an increase of life expectancy and consequent increase in the proportion of older people (Eyigor, Karapolat, Durmaz, Ibisoglu, and Cakir, 2009). This is one of global phenomenon, and in case of Korea, already became an aging society with 7.1% in the proportion of the elderly population in 2001 and, also, as Korea will be predicted to be an aged society by 2018 and a super aging society in 2026 (Statistics Korea, 2012). In case of UK, the projected rise in the proportion of population over 65 from 16% in 2001 to 21% in 2026 will increase this number (Brittle et al., 2009). An aging society is a problem all over the world. These demographic changes of the social structure have increased the needs for elderly population-associated social interests. The life expectancy among the phenomenon of social interests became important because of the quality of life in the extended life time especially after retirement. According to the U.S. National Center for Health Statistics (1993), about 15 percent of human life stays unhealthy, and the causing factors are age-associated dysfunction, injury, disease and so on. What elderly people really want is spending the rest of their ⁎ Corresponding author at: Korea University, College of Nursing, AnAmDong, SungbukGu, Seoul, Korea, 136-705. Tel.: +82 2 3290 4919; fax: +82 2 927 4676. E-mail address: [email protected] (K.S. Han).
lives to stay healthy, and one of the most important requirements is regular, active, and physical activity in order to maintain independent lives. The definition of health for the older individuals is, in general, the maintenance of functional independence until death. The exercise may promote physical function which is a key factor for daily healthy life and prevent chronic disease and a fall for older people (Shon, 2010; Sattin, Easley, Wolf, Chen, & Kutner, 2005; Sjosten et al., 2008). Regular exercise increases the social contact, improves the physical and mental health, and plays the important role to diminish chronic disease risk factors and to maintain body functions for older people (Ko and Lee, 2012). It also prevents physical exhaustion by enhancing cardiovascular function, central nervous system, immune system, and the endocrine system. And in spiritual element, it reduces depressive symptoms and promotes self-efficacy (Chung, 2008). It is reported that there are effects on the immune system against disease, psychological well-being, self-respect, and sense of accomplishment (Tsang, Fung, Chan, Lee, and Chan, 2006). The goal of regular daily exercise is to promote older people's stamina, to reduce depressive symptoms and anxiety from disease associated with aging by aging prevention, and to have positive thinking about their own aging process (Cho and Rho, 2009). However, there were some studies suggested that exercise had no direct effects on depressive symptoms (Brenes et al., 2007;
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Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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Conradsson et al., 2010). Thus, studies of the effects of physical exercise on depressive symptoms, quality of life, and self-esteem have reported conflicting results, considering these discrepancies in the literature the need of the present study was to examine these researches critically and to validate practical application. Recently, discussion for evidence based practice discussions are activated in healthcare setting, and the examination of practical application through the systematic review is suggested (Kim et al., 2011). Therefore, this study is conducted to suggest evidence for the exercise programs as nursing intervention to reduce depressive symptoms and to improve the quality of life and self-esteem from a systematic review based on the results of randomized controlled trials (RCTs). 2. Methods 2.1. Research design This study was a systematic review and meta-analysis of RCTs examining the effects of exercise programs on the depressive symptoms, quality of life and self-esteem of elderly patients 65 years and greater (Lee, 2008). 2.2. Search strategy 2.2.1. Key question ▪ Participants: Elderly people are aged 65 years or over who did not have disorders of orientation and who were capable of independent living.
▪ Interventions: Any type of exercise program designed for the elderly defined as muscle strengthening training, walking, qigong physical exercise, tai chi and dance etc. ▪ Comparisons: Routine conservative treatment such as no treatment/placebo or any other type of non-exercising intervention including routine nursing care, counseling and health education (Pakkala et al., 2008). ▪ Outcomes: The main outcomes were measured depression symptom level, quality of life and self-esteem. ▪ Types of studies: RCTs were only included. 2.2.2. Data sources and study selection The literature review utilized Internet-based electronic databases. Ovid-Medline and Embase, KoreaMed, and the National Discovery for Science Leaders (NDSL) were used as the main search database (Bidwell & Jensen, 2004). Additionally, the websites of the Korean Society of Nursing Science and the Korean Academy of Psychiatric Mental Health Nursing were searched to include all Korean academic journals that deal with associated fields. The data were retrieved in May 25th, 2013. The keywords were derived from participants and interventions which were components of key question. The keywords for the search in Korean DBs (KoreaMed and NDSL) were selected in consideration of the search function of each DB. Mainly, ‘depression’ and ‘exercise’ were used integrated with ‘the elderly with age over 65 years old’ (Kim & Park, 2011). Studies search in KoreaMed were limited to randomized controlled trials. The search terms for the international databases were those used in the systematic review on the depression and exercise program by the Cochrane Collaboration (Dong et al.,
Fig. 1. Flow chart of study selection.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
22.20–23.10
≥24.00
N21.00 27.00 27.60
N23.00
21.00
Sweden France France New Zealand UK Turkey Korea New Zealand USA Finland Finland Australia Hong Kong USA the Netherland Finland the Netherland Korea 2005 2004 2002 2001 2000
2006
2008 2007
2009
Conradsson et al. Dechamps et al. Dechamps et al. Kerse et al. Brittle et al. Eyigor et al. Sung Kerse et al. Brenes et al. Pakkala et al. Sjösten et al. Sims et al. Tsang et al. Sattin et al. Chin et al. Timonen et al. Wolf et al. Jang30 2010
Notes: MMSE = Mini mental state examination; Exp. = Experimental group; Cont. = Control group; DS = Depressive symptoms; QOL = Quality of life; SE = Self-esteem; GDS-15 = 15-item Geriatric depression scale; PGCMS = Philadelphia geriatric center morale scale; GDS = Geriatric depression scale; SF-36 = Short form (36) health survey; AM-PAC = Activity measure for post-acute care; HAD-S = Hospital anxiety and depression scale; RSES = Rosenberg self-esteem scale; EuroQol = EuroQol instrument and the life satisfaction index; CES-D = Center for epidemiological studies depression scale; WHO-QOL = The World Health Organization quality of life assessment; ASSEI = Adult sources of self-esteem instrument; DQoL = Dementia quality of life instrument; ZSDS = Zung self-rating depression scale.
DQoL
WHO- QOL
RSES EuroQol SF-36
SF-36
AM-PAC SF-36
PGCMS
GDS-15 GDS GDS GDS-15 HAD-S GDS GDS GDS GDS-15 CED-S GDS GDS GDS-15 CES-D GDS ZSDS HAD-S GDS 3,6 6,12 3 6,12 3,6 2 4 6,1 4 24 12 3, 6 6 4,8,12 6 3,9 1 5 45 min, 29 sessions, 13 weeks 40 min twice a week for 6 months 50 min a week for 6 weeks N30 min, 6 months 40–60 min, twice a week for 5 weeks 180 min a week for 8 weeks 30 min, twice a week for 16 weeks 6 months 60 min, 3 days a week for 16 weeks 60 min, 24 months 3 times a week for 12 months 3 session a week for 10 weeks 30–45 min, 16 weeks 10–50 min, 48 weeks 45–60 min a week for 6 months 90 min, 10 weeks 2–3 times a week for 4–6 weeks N60 min 20 weeks weight bearing etc. muscular reinforcement etc. balance exercise etc. limb-strengthening, walking etc. muscular reinforcement etc. dance based exercise functional exercise walking etc. facility base exercise walking etc. physical activity group based exercise limb-strengthening, walking etc. Qigong Tai chi group based exercise group based exercise balance exercise etc. aquatic exercise 17.80 ± 5.10 14.20–17.20 10.60
N80 N80 N80 N80 N80 N70 N75 N80 N70 N70 N70 N70 N80 N80 N80 N80 N80 N65
191 109 49 193 56 37 21 682 26 632 591 32 82 303 107 68 77 41
MMSE
Exp. Sample
Total
Participants
Age
Country Author Year
Table 1 Characteristics of the selected studies.
An evidence table basic form prepared for the extraction of all data required for evaluation without omission was used after the examination of pilot form as a demonstration. The evidence table was independently prepared by reviewers so that the articles' results would be accurately stated. The results were cross-checked, and this process was repeated three times. Meta-analyses were performed mainly using Review Manager ver. 5.1 (RevMan). For all statistical comparisons, differences with a p b 0.05 were considered significant. We used a random-effects model based on DerSimonian and Laird's method to calculate the pooled standardized mean difference (SMD) and 95% confidence intervals (CIs) for the effects of exercise programs. The inverse variance method was used because most intervention results were reported as continuous variables. Since various measuring tools were used the average effect was stated as SMD. The chi-squared (χ 2) test detected statistical heterogeneity. When heterogeneity was present (p b 0.1), the data were analyzed using the random effects model. The I-squared (I 2) test was used to identify heterogeneity. I 2 statistics are the form of statistics quantifying inconsistency. I 2 ranged from 0% to 100%. Presently, values between 0% and 40% indicated unimportant heterogeneity, values up to 60% as moderate heterogeneity and values over 60% as considerable heterogeneity (Higgins and Green, 2011). When heterogeneity did not exist, it was analyzed as a fixed effect model. A funnel plot was designed to check the existence of publication bias.
Cont.
2.4. Data extraction and analysis
100 60 25 96 28 18 10 352 12 310 298 18 34 153 51 34 40 17
Exercise intervention
The methodological quality of selected studies was undertaken using the Cochrane's tool for assessing risk of bias (RoB) developed by Cochrane Collaboration. Two review authors assessed it independently, and any disagreements or unclear parts were resolved by discussion and consensus agreement.
Type
2.3. Risk of bias in included studies
91 49 24 97 28 19 11 330 14 314 293 14 48 158 56 34 37 24
Depressive symptoms Period for exercise
Follow-up (months)
Outcome measures
Quality of life
Self-esteem
2009). Before the search, the MeSH terms, synonyms and related terms expressing ‘the elderly’, ‘depression’ and ‘exercise’ were checked through the MeSH database at PubMed, and the search sensitivity of each database was confirmed. In the Ovid-Medline and Embase databases, searching was integrated by exercise, fitness, kinesiotherapy, depression, anxiety disorder, dysthymic disorder and neurosis, while the search was limited to those over 65-years-of-age and to literature published after 2000 by using limiting function. The using search filter for RCTs was the search strategy which was proposed by SIGN (Scottish Intercollegiate Guidelines Network). The selection criteria were as follows: (a) studies performed exercise therapy as main intervention on elderly (≥ 65 years), (b) intervention studies including randomized clinical trials comparing routine conservative treatment or no intervention, (c) studies with reported more than one main outcome, and (d) studies published in English and Korean. Studies with any of the following criteria were excluded: (a) subjects had specific diseases, such as hypertension or diabetes, which could affect the intervention results; (b) studies including subjects b 65-years-of-age; and (c) studies that were not original articles (e.g., editorials, opinion pieces, reviews, and notes). Studies were selected in accordance with the inclusion and exclusion criteria with reviewing of the title and abstract of each study after duplicated journals were removed from the primary search. The remaining studies were confirmed with the original one and validated by applying the inclusion and exclusion criteria. Two independent authors reviewed the results of the searches, and the papers that met the inclusion criteria were selected. Any disagreement between authors was resolved by discussion and consensus agreement after another review of the research. If consensus cannot be reached, a final decision was made by the third author, but there was no conflicting opinion between the authors.
3
ASSEI
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difficult to blind participants and researchers because of the prolonged length of the exercise program (3–6 months) and because of study characteristics.
3. Results 3.1. General characteristics of selected studies Our initial literature search yields 461 references (84 Korean and 377 international studies). After 47 duplicated studies (3 Korean and 44 international studies) were excluded according to the inclusion and exclusion criteria, a total of 414 randomized controlled trials were included. The titles and abstracts were reviewed, and 396 studies were extracted based on the selection criteria, of which 18 were finally identified relevant in our review. A detailed flowchart of the literature search and study selection is presented in Fig. 1. Eighteen trials involving 3,297 participants were identified by evidence-based evaluation on exercise programs for elderly Koreans (≥ 65-years-of-age). The 18 studies were from New Zealand, Australia, United States, Turkey, various countries in Europe including Finland, France and Netherlands and Asia (Korea, Hong Kong). Eleven trials (61%) involved subjects N80-years-of-age. Ten trials (56%) performed mini-mental state examination (MMSE) to identify the absence/presence of cognitive impairment. Six of these 10 studies documented normal cognition or mild cognitive decline. There was no case of serious symptoms of dementia (MMSE ≤ 9). The study subjects were mainly residents of eight care facilities. Exercise programs were mainly walking, muscle strengthening, balance-keeping, qigong physical exercise, tai chi, dance and other programs (Wolf et al., 2001). Exercise sessions were 30–60 minutes long and were done one-to-three times each week. In 12 of the 18 trials, the sessions continued for 3 months or more. Effects of the exercise programs were measured by depressive symptoms, quality of life and selfesteem. Four tools measured depressive symptoms: most studies used the long form Geriatric Depression Scale (GDS) developed by Yesavage et al. (1983) (Lee, Choi, Jung, & Kwak, 2000). Fifteen studies used the short version of the GDS. Other tools used were the Hospital Anxiety and Depression Scale (HAD-S), Center for Epidemiological Studies Depression Scale (CES) and Zung Self-Rating Depression Scale (ZSDS). Each study used a different tool in the measurement of quality of life and self-esteem. The tracking observation period was more than 3 months, except in two studies. Depressive symptoms and quality of life measurements were done repeatedly. Therefore, the analyses involved grouping measurement timings and various factors depending on study object characteristics (Table 1).
3.2. Assessing risk of bias The result of quality evaluation suggested that the risks of selection bias relevant to random allocation sequence generation, allocation sequence concealment, attrition bias and reporting bias were low in almost all articles. However, bias did exist concerning blinding of study participants and result evaluation (Fig. 2). It is
3.3. Effects of exercise programs 3.3.1. Depressive symptoms All included studies reported the level of depressive symptoms in subjects engaging in exercise programs. Sixteen trials (2,594 participants) reported average and standard deviation using measuring tool for depressive symptoms. Two trials (Eyigor et al., 2009; Kerse et al., 2008) were excluded because they reported results as the number of patients with depressive symptoms. As a whole, exercise programs significantly decreased depressive symptoms. The pooled SMD calculated using the random-effects model was − 0.36 (95% confidence interval (CI) − 0.64 to 0.08) but heterogeneity was high (I 2 = 93.0%, p b 0.001) (Fig. 3A). Regarding the change in depressive symptoms depending on measurement timing, there was a statistically significant difference after 3 months (Z = 2.09, p = 0.04). At that time, the depressive symptoms also decreased while the heterogeneity among the studies increased. 3.3.2. Quality of life The change in quality of life by exercise programs was measured in eight trials (Brenes et al., 2007; Conradsson et al., 2010; Dechamps et al., 2009; Eyigor et al., 2009; Kerse et al., 2010, 2008; Sims et al., 2006). Collectively, exercise programs (1,317 participants) improved the quality of life of the elderly participants (Z = 2.23, p = 0.03). The pooled SMD calculated using the random-effects model was 0.86 (95% CI 0.11 to 1.62). There was substantial heterogeneity (I2 = 98.0%, p b 0.001). The result by measurement timing was that the quality of life point improved by SMD 0.57 (95% CI −0.82 to 1.97) after 3 months, SMD 0.67 (95% CI −0.24 to 1.57) after 6 months and SMD 1.96 (95% CI −2.78 to 6.71) after 12 months. Though they did not have statistical significance, they showed the pattern that quality of life improved as time passed after commencing an exercise program (Fig. 3B). 3.3.3. Self-esteem The change in self-esteem by an exercise program was measured in two trials (Sung, 2009; Tsang et al., 2006). Both studies (103 participants) measured self-esteem at 16 weeks after exercise in elderly participants (Fig. 3C). The study by Sung (2009) included only the result with subjects N 75-years-of-age. There was no heterogeneity (I2 = 0%, p = 0.400) among the trials. Exercise programs improved self-esteem (Z = 2.39, p = 0.020); SMD 0.49 (95% CI 0.09 to 0.88). 3.4. Publication bias Funnel plot analysis demonstrated a mild publication bias (Fig. 4).
Random sequence generation (selection bias) Allocation concealment (selection bias) Blinding of participants and personnel (performance bias) Blinding of outcome assessment (detection bias) Incomplete outcome data (attrition bias) Selective reporting (reporting bias) Other bias 0% Low risk of bias
Unclear risk of bias
25%
50%
75%
100%
High risk of bias
Fig. 2. Risk of bias graph.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
indicated no bias caused by random allocation sequence, concealment or selective reporting 65 and greater. The study population comprised subjects aged 65 years and over, who were capable of independent daily living without disorientation disorder or cognitive impairment or dementia. Eighteen studies were finally included in the meta-analysis as the result of searches on electronic Korean and international databases. Some identified studies were not included in the meta-analysis because they did not provide standard deviations or standard errors of intervention results. Thirteen of the 18 studies were published after 2005, exemplifying the recently increased interest on the depressive symptoms of the
4. Discussion This study was a systematic review and meta-analysis of RCTs regarding the effect of exercise program on depressive symptoms, quality of life and self-esteem of the elderly (≥65-years-of-age). The study design – which consisted of systematic and comprehensive literature search, literature inclusion by inclusion/exclusion criteria, evaluation of selected literatures and summarization/synthesis of evaluation results in accordance with the method suggested by Cochrane Collaboration – provided the highest evidence level. Cochran's risk bias on the quality evaluation of included literature Exercise Study or Subgroup
Mean
Control
SD Total Mean
5
Std. Mean Difference
SD Total Weight
Std. Mean Difference
IV, Random, 95% CI
IV, Random, 95% CI
1.1.1 Depression_3months Brenes 2007
4.5
2.9
14
6.1
3.2
12
3.5%
-0.51 [-1.30, 0.28]
Brittle 2009
3.4
2.2
11
5.4
3.3
10
3.3%
-0.69 [-1.58, 0.20]
4.35
2.08
75
4.25
2.09
90
4.6%
0.05 [-0.26, 0.35]
5.9
3.7
24
8.6
3.5
25
4.0%
-0.74 [-1.32, -0.16]
58.1 25.64
106
53.5 19.96
0.20 [-0.08, 0.48]
Conradsson 2010
Dechamps 2010_1 Sattin 2005
93
4.6%
Sims 2006
12.23
5.22
14
12
4.26
16
3.7%
0.05 [-0.67, 0.76]
Sung 2009
17.82
2.16
11 17.93
2.06
10
3.3%
-0.05 [-0.91, 0.81]
Timonen 2002
44.7
7.7
34
51.6
9.7
34
4.2%
-0.78 [-1.27, -0.28]
Tsang 2006
3.4
2.46
48
5.68
1.53
34
4.3%
-1.06 [-1.53, -0.59]
Wolf 2001
5.3
3.87
37
5.5
4.62
40
4.3%
-0.05 [-0.49, 0.40]
364
39.8%
-0.34 [-0.65, -0.02]
-0.68 [-1.56, 0.21]
Subtotal (95% CI)
374
Heterogeneity: Tau² = 0.17; Chi² = 34.62, df = 9 (P < 0.0001); I² = 74% Test for overall effect: Z = 2.09 (P = 0.04) 1.1.2 Depression_6months
Brittle 2009
3.6
2
10
6
4.3
11
3.3%
Conradsson 2010
4.5
2.3
73
4.25
2.3
83
4.6%
0.11 [-0.21, 0.42]
Dechamps 2010_2
4.7
3
45
5
3.3
54
4.4%
-0.09 [-0.49, 0.30]
Jang 2000
6.3
3.2
24
8.6
5.59
17
3.9%
-0.52 [-1.15, 0.11]
Kerse 2010
2.4
0.2
94
3.1
0.3
92
4.4%
-2.74 [-3.14, -2.34]
6.3
5.4
6.11
35
4.3%
0.12 [-0.31, 0.56]
51.4 20.66
80
4.6%
0.43 [0.13, 0.73]
18
3.7%
-0.06 [-0.76, 0.63]
Marijke 2004
8.01
49
Sattin 2005
60.1 19.98
95
Sims 2006
11.5
6.66
14 11.88
Timonen 2002
46.4
10.8
24
Subtotal (95% CI)
50.1
4.88 9.6
428
28
4.1%
-0.36 [-0.91, 0.19]
418
37.3%
-0.42 [-1.12, 0.28]
Heterogeneity: Tau² = 1.08; Chi² = 176.53, df = 8 (P < 0.00001); I² = 95% Test for overall effect: Z = 1.17 (P = 0.24) 1.1.3 Depression_12months
Dechamps 2010_2 Kerse 2010 Pakkala 2007 Sattin 2005
5
3
41
6.3
3.3
51
4.4%
-0.41 [-0.82, 0.01]
2.4
0.2
94
2.8
0.3
87
4.5%
-1.57 [-1.91, -1.24]
11.21
7.53
307 10.93
7.82
302
4.8%
0.04 [-0.12, 0.20]
50.3 19.19
82
4.6%
0.49 [0.18, 0.80]
261
4.7%
-0.05 [-0.23, 0.12]
783
23.0%
-0.29 [-0.82, 0.24]
100.0%
-0.36 [-0.64, -0.08]
59.6 18.65
Sjosten 2007
3.1
82
3.8
251
Subtotal (95% CI)
775
3.3
3.9
Heterogeneity: Tau² = 0.34; Chi² = 93.51, df = 4 (P < 0.00001); I² = 96%
Test for overall effect: Z = 1.08 (P = 0.28) Total (95% CI)
1577
1565
Heterogeneity: Tau² = 0.43; Chi² = 308.87, df = 23 (P < 0.00001); I² = 93% Test for overall effect: Z = 2.50 (P = 0.01)
-2
-1
0
1
2
Favours experimental Favours control
Test for subgroup differences: Chi² = 0.08, df = 2 (P = 0.96), I² = 0%
A) Depressive symptoms Fig. 3. Comparison outcomes of exercise versus control. A. Depressive symptoms. B. Quality of life. C. Self-esteem.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
Experimental
Study or Subgroup
Mean
Control
SD Total Mean
Std. Mean Difference
SD Total Weight
Std. Mean Difference
IV, Random, 95% CI
IV, Random, 95% CI
2.1.1 Quality of Life_3months Brenes 2007
31.3 13.5
Conradsson 2010
11.52 0.28
Dechamps 2010_1
49.9 21.2
Eyigor 2009
28
79 10.95
81.01 18.2
Subtotal (95% CI)
50.7 25.01
28
9.0%
-0.95 [-1.51, -0.40] 2.11 [1.73, 2.48]
0.26
91
9.2%
24 36.01 26.01
25
8.9%
0.57 [0.00, 1.15]
19
18
8.8%
0.53 [-0.13, 1.19]
162
35.9%
0.57 [-0.82, 1.97]
71.7
16.1
150
Heterogeneity: Tau² = 1.95; Chi² = 84.46, df = 3 (P < 0.00001); I² = 96% Test for overall effect: Z = 0.80 (P = 0.42) 2.1.2 Quality of Life_6months Conradsson 2010
Kerse 2008 Kerse 2010
Marijke 2004 Sims 2006
11.56 0.29
73 10.92
0.28
83
9.2%
2.24 [1.83, 2.64]
9.9 3.26
266 10.01
3.41
290
9.4%
-0.03 [-0.20, 0.13]
54.7
0.7
94
53.7
0.9
92
9.3%
1.24 [0.92, 1.55]
3.5 1.04
49
3.6
0.87
35
9.1%
-0.10 [-0.54, 0.33]
14 13.37
2.09
18
8.7%
-0.06 [-0.75, 0.64]
518
45.7%
0.67 [-0.24, 1.57]
13.26 1.69
Subtotal (95% CI)
496
Heterogeneity: Tau² = 1.01; Chi² = 139.94, df = 4 (P < 0.00001); I² = 97% Test for overall effect: Z = 1.45 (P = 0.15) 2.1.3 Quality of Life_12months
Kerse 2008
10.01
0.2
225
10.1
0.2
248
9.4%
Kerse 2010
55.4
0.7
94
52.7
0.5
87
9.0%
4.39 [3.85, 4.93]
335
18.4%
1.96 [-2.78, 6.71]
Subtotal (95% CI)
319
-0.45 [-0.63, -0.27]
Heterogeneity: Tau² = 11.68; Chi² = 274.80, df = 1 (P < 0.00001); I² = 100% Test for overall effect: Z = 0.81 (P = 0.42) 965
Total (95% CI)
1015 100.0%
0.86 [0.11, 1.62]
Heterogeneity: Tau² = 1.58; Chi² = 532.66, df = 10 (P < 0.00001); I² = 98%
-10
Test for overall effect: Z = 2.23 (P = 0.03)
-5
0
5
10
Favours experimental Favours control
Test for subgroup differences: Chi² = 0.30, df = 2 (P = 0.86), I² = 0%
B) Quality of life Experimental
Control
Std. Mean Difference
Std. Mean Difference
Study or Subgroup
Mean
Sung 2009
25.55 3.59
11 22.51 3.42
10
19.5%
0.83 [-0.07, 1.73]
Tsang 2006
16.85 3.86
48 15.44 2.84
34
80.5%
0.40 [-0.04, 0.85]
59
44 100.0%
0.49 [0.09, 0.88]
Total (95% CI)
SD Total Mean
SD Total Weight
Heterogeneity: Chi² = 0.70, df = 1 (P = 0.40); I² = 0%
IV, Fixed, 95% CI
IV, Fixed, 95% CI
-4
Test for overall effect: Z = 2.39 (P = 0.02)
-2
Favours experimental
0
2
4
Favours control
C) Self-esteem Fig. 3 (continued).
elderly. Various initiatives in practical healthcare have sought to decrease the depressive symptoms and improve the quality of life of the elderly. Sixteen of the 18 studies involved subjects in United States and Europe, while two studies (Jang, 2000; Sung, 2009) were conducted and published in Korea. This may indicate the need for more active studies concerning exercise and elderly depressive symptoms in Korea. This need could be especially pressing, given the increasing prevalence of both the elderly population and the elderly with depressive symptoms in Korea.
Eleven studies involved subjects N 80-years-of-age, and one Korean study involved subjects 65–69-years-of-age. Especially, most studies published after 2009 involved subjects over 80-years-of-age. This may reflect the extended age distribution of the elderly, as average life expectancy continues to increase due to advancements in medical treatment/prevention and health care, and increased personal interest in health. The increasing emphasis on subjects N 80-years-of-age may also reflect the increased prevalence of depressive symptoms and quality of life in this segment of the population. There were 26–682
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
A) Depressive symptoms 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-4
-2
0
2
4
B) Quality of life 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-10
-5
0
5
10
-2
0
2
4
C) Self-esteem 0
SE(SMD)
0.1
0.2
0.3
0.4
0.5
SMD
-4
Fig. 4. Funnel plot of selected studies for effect size extraction. A. Depressive symptoms. B. Quality of life. C. Self-esteem.
7
4–12 weeks after commencing exercise. The effects of exercise on depressive symptoms are not expected in the short-term, but are achieved over the longer-term when subjects are empowered to continue exercise on their own initiative (Brenes et al., 2007). Exercises included muscle strengthening, balancing, walking, back stretching, qigong physical exercise and dance. Some studies reported on exercise programs combined with counseling and education, consistent with reports that exercise programs for the elderly should be designed for self-learning and health promotion without exhausting the body, given that elderly people can experience difficulty in doing aerobic exercise because of physical weakness and lower resistance (Cho and Rho, 2009; Kerse et al., 2008). The meta-analysis indicated that, overall, exercise programs decreased the depressive symptoms of the elderly by an SMD − 0.36. Significant benefits were apparent by 3 months (p = 0.040). Practicing continuous exercise program beyond 3 months would likely be effective (Brittle et al., 2009; Chin, Van Poppel, Twisk, and Van Mechelen, 2004; Seo, 2011). The present findings are also consistent with prior reports that exercise programs are effective in decreasing chronic depression in patients (including the elderly) (Lorrant, Delige, Eaton, Robert, & Ansseau, 2003). This result supports the results that an exercise program is helpful in improving cognitive– behavioral, socio-psychological and medical health (Chung, 2008; Conradsson et al., 2010). This study is a similar finding to the Cochrane review (Mead et al., 2009) that for the 23 trials (907 participants, aged 18 and over) comparing exercise with no treatment or control intervention, on the reducing effect of depressive symptoms, pooled SMD was −0.82 (95% CI −1.12, − 0.51), and there was significant heterogeneity (I 2 = 77.0%). Although it was not possible to make a conclusion because of the heterogeneity among the literatures, it seems likely that an exercise program improves the quality of life of the elderly by decreasing depressive symptoms and increasing self-esteem. Indeed, studies have reported that exercise programs are effective in the quality of life and sense of happiness of chronic disease patients and therapy participants of various ages (Cho and Rho, 2009; Dechamps et al., 2010; Timonen et al., 2002). Presently, exercise programs were effective in improving the self-esteem of the elderly (p = 0.020). Self-esteem can diminish with deteriorated cognitive and physical functions, and is bolstered by exercise-related improvements in physical function (Seo, 2011; Sung, 2009). Most of the 18 studies used the GDS as the measurement tool, given its suitability for elderly subjects. It was difficult to interpret and integrate test results concerning the quality of life because various types of measurement tools measured sense of well-being and related symptoms. A measurement tool for quality of life considering the characteristics and function level of the elderly population should be developed in future studies (Littbrand et al., 2011). However, this study has some limitations. First, there may be a publication bias although we tried to minimize it in the process of article selection. Publication bias shown by a funnel plot (Fig. 4) may alter the results of this review. In general, a positive result of trials may usually be easier to report than a negative one. Second, our result in overall depressive symptoms and quality of life revealed heterogeneity despite the inclusion of 18 RCTs with 3297 patients, which limits drawing a general conclusion and providing any recommendation. Third, although in case of self-esteem, there had been no heterogeneity on the result of the meta-analysis, but the number of studies combined was very small. So, there is some problem for generalization. Finally, there is some possibility of bias. At the domain of blindness, only 8 studies satisfied the criteria, and 10 studies did not. 5. Conclusion
subjects in the studies. The duration of exercise intervention was 4– 48 weeks. Twelve studies applied an exercise program for a minimum of 3 months. All 18 studies tracked and observed depressive symptoms for
This study is to examine the effects of exercise programs on depressive symptoms, quality of life, and self-esteem in older people
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
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S-H. Park et al. / Applied Nursing Research xxx (2014) xxx–xxx
with a systematic review and meta-analysis. The present study proved the positive effects of exercise programs on depressive symptoms, quality of life, and self-esteem in older people because this result of the study is based on systemic review and meta-analysis of the 18 randomized controlled trials although it was difficult to interpret the results of researches due to the heterogeneity among studies. However, there is limitation in interpretation because the result of the quality of life is from two studies out of 18 randomized controlled trials performed. In order to reduce depressive symptoms and to improve quality of life and health promotion in older people, I suggest multi-faceted researches to develop the easier exercise programs which older people can participate in and to examine the effects of exercise programs.
References Bidwell, S., & Jensen, M. F. (2004). Chapter 3: Using a search protocol to identify sources of information: The COSI model in topfer L-A. In I. auston (Ed.), A Text on Health Technology Assessment (HTA) Information Resources. Bethesda, MD: National Information Center on Health Services Research and Health Care Technology (NICHSR), US National Library of Medicine. Brenes, G. A., Williamson, J. D., Messier, S. P., Rejeski, W. J., Pahor, M., Ip, E., et al. (2007). Treatment of minor depression in older adults: A pilot study comparing sertraline and exercise. Aging & Mental Health, 11, 61–68. Brittle, N., Patel, S., Wright, C., Baral, S., Versfeld, P., Sackley, C., et al. (2009). An exploratory cluster randomized controlled trial of group exercise on mobility and depression in care home residents. Clinical Rehabilitation, 23, 146–154. Chin, A. P., Van Poppel, M. N. M., Twisk, J. W. R., & Van Mechelen, W. (2004). Effects of resistance and all-round, functional training on quality of life, vitality and depression of older adults living in long-term care facilities: A 'randomized' controlled trial [ISRCTN87177281]. BioMed Central Geriatrics, 4, 1–9. Cho, Y. H., & Rho, B. I. (2009). The effect of geriatric health exercise on depression with special reference to naegong gymnastics. Korean Journal of Care Work, 12, 5–12. Chung, H. A. (2008). A literature review a program of intervention of patient geriatric depression. Society of Occupational Therapy for the Aged and Dementia, 2(1), 59–67. Conradsson, M., Littbrand, H., Lindelof, N., Gustafson, Y., Rosendahl, E., Conradsson, M., et al. (2010). Effects of a high-intensity functional exercise program on depressive symptoms and psychological well-being among older people living in residential care facilities: A cluster-randomized controlled trial. Aging & Mental Health, 14, 565–576 (http://dx.doi.org/10.1080/13607860903483078). Dechamps, A., Diolez, P., Thiaudiere, E., Tulon, A., Onifade, C., Vuong, T., et al. (2010). Effects of exercise programs to prevent decline in health-related quality of life in highly deconditioned institutionalized elderly persons: A randomized controlled trial. Archives of Internal Medicine, 170, 162–169. Eyigor, S., Karapolat, H., Durmaz, B., Ibisoglu, U., & Cakir, S. (2009). A randomized controlled trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Archives of Gerontology and Geriatrics, 48, 84–88. Higgins, J., & Green, S. (Eds.). (2011). Cochrane handbook for systematic reviews of interventions version 5.1.0. The Cochrane Collaboration (Retrieved March 30, 2011, from http://www.cochrane-handbook.org). Jang, S. (2000). The effects of aquatic exercise program on the physical function and depression in community elderly. Journal of Korea Community Health Nursing Academic Society, 14, 122–130. Kerse, N., Hayman, K. J., Moyes, S. A., Peri, K., Robinson, E., Dowell, A., et al. (2010). Home-based activity program for older people with depressive symptoms: DeLLITE–a randomized controlled trial. Annals of Family Medicine, 8, 214–223 (http://dx.doi.org/10.1370/afm.1093).
Kerse, N., Peri, K., Robinson, E., Wilkinson, T., von Randow, M., Kiata, L., et al. (2008). Does a functional activity program improve function, quality of life, and falls for residents in long term care? Cluster randomised controlled trial. British Medical Journal, 337, a1445 (http://dx.doi.org/10.1136/bmj.a1445). Kim, K. W., & Park, J. H. (2011). A review of the epidemiology of depression in Korea. Journal of the Korean Medical Association, 54(4), 362–369. Kim, S. Y., Park, H. J., Seo, H. J., Lee, Y. J., Jang, B. H., Son, H. J., et al. (2011). NECA's guidance for undertaking systematic reviews and meta-analyses for intervention. : National Evidence-based Healthcare Collaborating Agency. Ko, J. E., & Lee, S. H. (2012). A multilevel modeling of factors affecting depression among older Korean adults. Mental Health & Social Work, 40(1), 322–351. Lee, J. (2008). Meta-analysis. Journal of Korean Endocrine Society, 23, 361–378 (http:// dx.doi.org/10.3803/jkes.2008.23.6.361). Lee, M. S., Choi, Y. K., Jung, I. K., & Kwak, D. I. (2000). Epidemiological study of geriatric depression in a Korea urban area. Journal of Korean Geriatric Psychiatry, 4(2), 154–163. Littbrand, H., Carlsson, M., Lundin-Olsson, L., Lindelof, N., Haglin, L., Gustafson, Y., et al. (2011). Effect of a high-intensity functional exercise program on functional balance: Preplanned subgroup analyses of a randomized controlled trial in residential care facilities. Journal of the American Geriatrics Society, 59, 1274–1282 (http://dx.doi.org/10.1111/j.1532-5415.2011.03484.x). Lorrant, V., Delige, D., Eaton, W., Robert, P., & Ansseau, M. (2003). Socioeconomic inequalities in depression. American Journal of Epidemiology, 157, 98–112. Mead, G. E., Morley, W., Campbell, P., Greig, C. A., McMurdo, M., & Lawlor, D. A. (2009). Exercise for depression. Cochrane Database Systematic Review, 3, 1–62. Pakkala, I., Read, S., Leinonen, R., Hirvensalo, M., Lintunen, T., Rantanen, T., et al. (2008). The effects of physical activity counseling on mood among 75- to 81-year-old people: A randomized controlled trial. Preventive Medicine, 46, 412–418. Sattin, R. W., Easley, K. A., Wolf, S. L., Chen, Y., & Kutner, M. H. (2005). Reduction in fear of falling through intense tai chi exercise training in older, transitionally frail adults. Journal of the American Geriatrics Society, 53, 1168–1178 (http://dx.doi.org/10. 1111/j.1532-5415.2005.53375.x). Seo, E. H., 2011. Effects of the Behas exercise program on physical strength, depression and life satisfaction in the institutionalized elderly. Unpubished doctoral dissertation, Chonnam University, Gwangju. Shon, J. H., 2010. Effects of chronic combined exercise on cognitive function, depression and life satisfaction in elderly women. Unpublished doctoral dissertation, Yeungnam University, Gyeongbuk. Sims, J., Hill, K., Davidson, S., Gunn, J., Huang, N., Sims, J., et al. (2006). Exploring the feasibility of a community-based strength training program for older people with depressive symptoms and its impact on depressive symptoms. BioMed Central Geriatrics, 6, 18. Sjosten, N. M., Vahlberg, T. J., Kivela, S. L., Sjosten, N. M., Vahlberg, T. J., & Kivela, S. L. (2008). The effects of multifactorial fall prevention on depressive symptoms among the aged at increased risk of falling. International Journal of Geriatric Psychiatry, 23, 504–510. Statistics Korea. (May 1, 2012). Statistics for the future population. retrieved July 20, 2012, from. http://www.kostat.go.kr Sung, K. (2009). The effects of 16-week group exercise program on physical function and mental health of elderly Korean women in long-term assisted living facility. Journal of Cardiovascular Nursing, 24, 344–351. Timonen, L., Rantanen, T., Timonen, T. E., Sulkava, R., Timonen, L., Rantanen, T., et al. (2002). Effects of a group-based exercise program on the mood state of frail older women after discharge from hospital. International Journal of Geriatric Psychiatry, 17, 1106–1111. Tsang, H. W. H., Fung, K. M. T., Chan, A. S. M., Lee, G., & Chan, F. (2006). Effect of a qigong exercise program on elderly with depression. International Journal of Geriatric Psychiatry, 21, 890–897. Wolf, B., Feys, H., De Weerdt, W., Van der Meer, J., Noom, M., & Aufdemkampe, G. (2001). Effect of a physical therapeutic intervention for balance problems in the elderly: A single-blind, randomized, controlled multicentre trial. Clinical Rehabilitation, 15, 624–636. Yesavage, J., Brink, T., Rose, T., Lum, O., Huang, V., Adey, M., et al. (1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49.
Please cite this article as: Park, S-H., et al., Effects of exercise programs on depressive symptoms, quality of life and self-esteem in older people: A systematic review of rando..., Applied Nursing Research (2014), http://dx.doi.org/10.1016/j.apnr.2014.01.004
