The Association of Physical-Performance Level With Attitude Toward Exercise in Older Adults

Transcription

1 254 Chang et al. Journal of Aging and Physical Activity, 2003, 11, Human Kinetics Publishers, Inc. The Association of Physical-Performance Level With Attitude Toward Exercise in Older Adults Milan Chang, Suzanne Leveille, Jiska Cohen-Mansfield, and Jack M. Guralnik The Hebrew Home Study of Impairment and Exercise is a cross-sectional community-based study of nondisabled adults age years that assessed attitude toward exercise by asking level of agreement with four statements evaluating participants perceptions of the health benefits and personal rewards of exercise. A physical-performance battery evaluated lower extremity function on a scale of 0 to 12. Attitude toward exercise was compared across 4 groups: non vigorous exercisers with scores of 4 6 (n = 21), 7 9 (n = 90), or (n = 113) and vigorous exercisers (n = 71). Vigorous exercisers had a significantly better attitude toward exercise than the reference group did, with odds ratios of in all attitude statements. The lowest and moderateperformance groups had less positive attitudes toward exercise than the reference group did, with odds ratios of for all statements. There was a highly significant gradient with better attitude toward exercise and higher functional-status level. Future work in improving older adults compliance with exercise should take into account the less positive attitude of those with functional limitations toward the benefits of exercise. Key Words: vigorous exercisers, physical performance, elderly, disability, fitness How best to maintain the health and quality of life of older adults is a critical public health issue, given the increasing number of elderly (Kinsella & Velkoff, 2001). It has been shown that daily exercise can protect older adults from further decline in fitness (King et al., 2000; Worm et al., 2001). Thus, an increase in activity level has the potential to have a major impact on their health and well-being and a positive effect on morbidity and mortality rates (Blair et al., 1995; Lachman et al., 1997; Shephard, 1997). The general benefits of regular physical activity and exercise are well documented (Blair & Connelly, 1996; Chang et al., 2001; Dishman, Sallis, & Orenstein, 1985; Ettinger et al., 1997, King, Oman, Brassington, Chang and Guralnik are with the Laboratory of Epidemiology, Demography and Biometry, Natl. Institute on Aging, Natl. Institutes of Health, Bethesda, MD, Leveille is with the Hebrew Rehabilitation Center for Aged, Research and Training Institute, 1200 Centre St., Boston, MA, Cohen-Mansfield is with the Hebrew Home of Greater Washington Research Institute, 6121 Montrose Rd., Rockville, MD,

2 Physical-Performance Level and Attitude Toward Exercise 255 Bliwise, & Haskell, 1997; Maroulakis & Zervas, 1993; Shephard). Knowledge of the benefits of daily physical activity does not always lead older adults to exercise more, however, and it is still unclear why inactivity is common in the elderly despite increasing scientific evidence and widening public acceptance of the benefits of exercise. A number of investigations have examined the barriers and reasons that older adults do not engage in regular exercise (Ebrahim & Rowland, 1996; Marcus et al., 1992; McAuley, Lox, & Duncan, 1993; Rich & Rogers, 2001), concluding that the attitudes and beliefs they have about exercise play a strong role in influencing their activity level and behavior. Among moderately physically impaired people living in the community, attitudes toward exercise might be influenced by their functional limitations and experience they have recently had with exercise. Jette et al. (1998) found that a positive attitude toward exercise was significantly associated with higher adherence to a home exercise program, and people who perceived exercise as more desirable and beneficial for their health and felt they had greater control over their exercise behavior were more likely to meet their exercise goals. Nonetheless, the question of whether attitude toward exercise is associated with actual level of functional capacity remains unclear because it has not been directly examined, especially in those at risk for future disability. The purpose of this study was to examine the association between objectively measured physical-performance level and attitude toward exercise among a population of older adults who represent a wide spectrum of health and functional status. We hypothesized that those who engage in vigorous exercise would have a more positive attitude toward exercise than would those who do not. We further hypothesized that even within the nondisabled subset of the older population that does not exercise vigorously, those with lower levels of physical performance would have a less positive attitude toward exercise than would those with higher levels of performance. PARTICIPANTS Methods The study participants were from the Hebrew Home Study of Impairment and Exercise, a cross-sectional community-based study of men and women age years who are mobile but at increased risk for future disability. In collaboration with the Laboratory of Epidemiology, Demography and Biometry of the National Institute on Aging, the Hebrew Home of Greater Washington Research Institute on Aging conducted the investigation with older adults living in Maryland. The recruiting process is described in detail in the accompanying article by Marx et al. (2003). Using information from telephone interviews, we categorized participants into two groups based on their participation in strenuous sport and recreational activities such as jogging, cycling, tennis, aerobic dance, or other similar activities. Individuals who reported that they engaged in the activities at least once a week were defined as vigorous exercisers. Those who reported that they did not engage in these activities were defined as non vigorous exercisers. The non vigorous exercisers who reported not being disabled in mobility (walking 2 3 blocks and climbing stairs) received a home visit. They were administered the short physicalperformance battery developed for the Established Populations for Epidemiologic

3 256 Chang et al. Studies of the Elderly study (Guralnik, Simonsick, et al., 1994) and the Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). This article reports on 295 participants (125 men and 170 women) who received a screening evaluation and provided questionnaire data on attitudes toward exercise. MEASUREMENT All participants completed an extensive questionnaire on health, exercise habits, and attitude toward exercise. Attitude statements were used to assess whether exercise was seen as desirable and beneficial for health (Jette et al., 1998). The questionnaire assessed attitude toward exercise from responses to four statements: S1 Doing an exercise routine is satisfying and rewarding to me, S2 Doing an exercise routine is good for me, S3 There is little I can do to make up for the physical losses that come with age, and S4 Exercising regularly can be helpful to my health. Participants reported whether they strongly agreed, slightly agreed, were unsure, slightly disagreed, or strongly disagreed with each statement. S1, S2, and S4 indicated a positive attitude about the value of exercise. An affirmative response to S3 indicated a negative attitude toward exercise. The physical-performance battery used in the study has previously been described in detail (Guralnik, Ferrucci, Simonsick, Salive, & Wallace, 1995; Guralnik, Seeman, Tinetti, Nevitt, & Berkman, 1994; Guralnik, Simonsick, et al., 1994). The test battery evaluated lower extremity function using tests of gait speed, standing balance, and time required to rise from a chair five times. For each test, a categorical score of 0 to 4 was assigned using cut points developed from a large, population-based study (Guralnik, Simonsick, et al., 1994). Assessments by trained interviewers were done only for participants not reporting vigorous physical exercise (n = 224). A summary performance score was created by adding up the individual test scores, with 12 being the best performance. Participants with a summary performance score less than 4, indicating severe functional limitation, were excluded from the study population. The presence of specific diseases was assessed in the questionnaire, which asked whether a physician had ever told the participant he or she had any of the following conditions: heart attack or myocardial infarction, angina, high blood pressure, congestive or chronic heart failure, broken or fractured hip, arthritis or rheumatism, intermittent claudication, hip or knee replacement, compression fracture or collapsed or crushed vertebra, Parkinson s disease, cancer, emphysema or chronic bronchitis, diabetes, cataract, stroke, chronic nervous or emotional problems, and chronic foot trouble. ANALYSIS We studied the association of participant characteristics and the responses to each attitude statement and functional status, as represented by four groups (summary performance score of 4 6, n = 21; 7 9, n = 90; 10 12, n = 113; and vigorous exercisers, n = 71). The associations of participant characteristics with functional status were assessed using chi-square tests for categorical variables and analysis of variance for continuous variables. Chi-square tests were used to test the associations of the groups with the attitude scale. Logistic-regression models for each attitude question were used to examine the odds ratio of having a positive attitude toward

4 Physical-Performance Level and Attitude Toward Exercise 257 exercise, looking at lower performers (4 6 or 7 9 scores) and vigorous exercisers versus the reference group high performers (10 12 scores) who do not engage in vigorous exercise. Covariates included in the models were age, gender, marital status, education, living status, and number of diseases. The three positive-attitude statements (S1, S2, and S4) were dichotomized by the response of strongly agree versus other responses, and the statement indicating a negative attitude (S3), by the response of strongly disagree versus other responses. The trend in the relationship between functional-status categories and exercise attitude was evaluated in separate, fully adjusted models that employed an ordinal variable (scored 1 4) for functional category. Results Participant characteristics were examined according to summary performance scores and exercise status (Table 1). We found significant differences among the groups for all factors (age, gender, marital status, living situation, and number of Table 1 Participant Characteristics by Summary Performance Score and Exercise Status, n (%) Summary Performance Score (No Vigorous Exercise) Vigorous exercisers Characteristic (n = 21) (n = 90) (n = 113) (n = 71) p Age (mean) Gender.001 male 9 (42.9) 22 (24.4) 52 (46.0) 42 (59.2) female 12 (57.1) 68 (75.6) 61 (54.0) 29 (40.9) Marital status.008 married or living 8 (38.1) 34 (37.8) 63 (55.8) 50 (70.4) as married widowed 10 (47.6) 42 (46.7) 36 (31.9) 19 (26.8) separated 1 (4.8) 2 (2.2) 1 (0.9) 0 divorced 1 (4.8) 11 (12.2) 9 (8.0) 1 (1.4) never married 1 (4.8) 1 (1.1) 4 (3.5) 1 (1.4) Education.319 less than college 3 (14.3) 22 (24.4) 16 (14.2) 7 (9.9) college 11 (52.4) 43 (47.8) 51 (45.1) 35 (49.3) graduate school 7 (33.3) 25 (27.8) 45 (39.8) 29 (40.9) Living situation.002 lives alone 12 (57.1) 53 (58.9) 50 (44.3) 21 (29.6) lives with others 9 (42.9) 37 (41.1) 63 (55.8) 50 (70.4) Number of diseases

5 258 Chang et al. diseases) except education. Nearly 84% of the entire sample had an education level beyond high school over 75% of each functional-status group. Lower performance scores were associated with older age and a greater number of chronic conditions. The vigorous exercisers and high performers were more likely to be male and married and were less likely to live alone. Figures 1a and 1b show the distribution of the five responses to each attitude statement (strongly agree, slightly agree, unsure, slightly disagree, and strongly disagree) among the four groups. In all statements, the lowest performance group had the lowest proportion of individuals reporting the most positive attitude, and vigorous exercisers had the highest proportion reporting the most positive attitude. The proportion of participants who responded strongly agree to three statements (S1, S2, and S4) gradually increased as physical-performance levels rose. S2 and S4 were similar questions (S2 for overall benefits of exercise and S4 for health benefits), and, in fact, the percentages of participants who strongly agreed with these two statements were very similar for each of the functional-status categories. For S1, which assessed level of agreement on exercise being rewarding and satisfying, the lowest and moderate-performance groups had fewer than 40% of participants who strongly agreed. This percentage was 20% higher in those with a performance score of and about 40% higher in the vigorous-exercisers group. For S3 ( There is little I can do to make up for the physical losses that come with age ), none of the participants in the lowest performance group responded strongly disagree, whereas 54% of the vigorous exercisers did. The results of four separate logistic-regression models that assessed the associations between physical-performance level and attitude are shown in Table 2. All models were adjusted for age, gender, marital status, education, living status, Figure 1a Degree of agreement/disagreement with Statements 1 and 2 about exercise according to functional-status category.

6 Physical-Performance Level and Attitude Toward Exercise 259 Figure 1b Degree of agreement/disagreement with Statements 3 and 4 about exercise according to functional-status category. Table 2 Odds Ratios (95% CI) for Strongly Agreeing (S1, S2, S4) and Strongly Disagreeing (S3) With Statements on Attitude Toward Exercise Summary Performance Score (No Vigorous Exercise) Vigorous exercisers Characteristic (n = 21) (n = 90) (n = 113) (n = 71) p S1. Doing an exercise routine is satisfying ( ) ( ) ( ) and rewarding to me. S2. Doing an exercise routine is good for me. ( ) ( ) ( ) S3. There is little I can b do to make up for the ( ) ( ) physical losses that come with age. S4. Exercising regularly can be helpful to my ( ) ( ) ( ) health. Note. All models adjusted for age, gender, marital status, living status, and number of diseases. a Reference group. b No one in this category strongly disagreed with the statement.

7 260 Chang et al. and number of diseases. Overall, vigorous exercisers had a significantly better attitude toward exercise than did the reference group. Results of each model for the four attitude statements showed that vigorous exercisers had significantly higher odds ratios for having a strong positive attitude toward exercise than those of the reference group S1: 3.6, 95% confidence interval (CI) ; S2: 5.5, 95% CI ; and S4: 3.1, 95% CI For S3, vigorous exercisers were 1.8 times as likely to strongly disagree with this negative statement as the reference group was, although this effect only approached statistical significance (p =.06). In these models, the lowest and moderate-performance groups had less positive attitudes toward exercise than the reference group did, with odds ratios ranging from 0.27 to 0.62 for all attitude statements. The strongest relationships were seen for the S1 statement. The odds ratio for strongly agreeing with S1 for the lowest performance group was 0.27 (95% CI ) and for the moderateperformance group was 0.30 (95% CI ) compared with the reference group. For all four statements about exercise, there was a highly significant trend in the overall relationship between higher functional-status category and more positive attitude toward exercise. Discussion We evaluated the association between attitude toward exercise and physicalperformance level and exercise status among older adults of varying health status living in the community. Unlike previous studies based on self-report evaluations (Lee, 1993; Sallis, Hovell, & Hofstetter, 1992), in the present study we measured the actual physical performance of the participants. We were able to examine differences in attitudes toward exercise across a wide range of functional status, including older adults without disability but with functional limitations, who have been shown in epidemiologic studies to be at increased risk for future disability (Guralnik et al., 1995). Vigorous exercisers had the most positive attitude toward exercise. This can be seen in Figures 1a and 1b, which show that the proportions of participants who strongly agreed with S1, S2, and S4 and strongly disagreed with S3 were highest in the vigorous exercisers. The proportion of people having the most positive response to each statement gradually decreased as the physical-performance level decreased in the non vigorous exercisers, which indicates that older adults with low performance levels have a less positive attitude toward exercise than do people with high performance levels. Therefore, the hypotheses that vigorous exercisers would have a more positive attitude toward exercise than non vigorous exercisers would and that those with a low physical-performance level would have a less positive attitude toward exercise were strongly supported. There was clear evidence (Table 2) that vigorous exercisers had a more positive attitude than did the reference group, who were not functionally impaired but did not exercise vigorously. The findings agree with those of previous research that found that active older adults believed more strongly than inactive older adults that physical activity would lead to health benefits (Booth, Owen, Bauman, Clavisi, & Leslie, 2000; Resnick & Spellbring, 2000). The results also clearly show that among non vigorous exercisers, the lower his or her performance score the less

8 Physical-Performance Level and Attitude Toward Exercise 261 likely an older person would be to have a positive attitude toward exercise. It is also clear that the number of diseases decreases as the functional-performance level goes up. Therefore, the burden of illness among lower performance older adults could be a possible reason that they are inactive. It should be noted, however, that in the recruitment of this cohort, those who were disabled (unable to walk 2 3 blocks or to climb stairs) were excluded at the time of the screening telephone interview. The group that did not qualify as being vigorous exercisers, therefore, comprises older adults who potentially could exercise, even though they have a wide range of diseases and functional performance, as demonstrated by the performance-battery scores. The clear trend in the relationship across the spectrum of performance indicates that people with low performance levels have a less positive attitude toward exercise than do people with higher performance level. O Brien Cousins (2001) analyzed older women s descriptions of motivating triggers for physical activity and found that semiactive and inactive women experienced triggers but had doubts about the usefulness of being active. Our findings show similar results that inactive older adults with a low physicalperformance level believed less in the benefits of regular exercise than did the higher performance group. Although the causal direction cannot be ascertained in this cross-sectional study, it is likely that the belief that exercise is not beneficial would prevent many older, functionally impaired adults from becoming active. Our findings suggest that there is a need to provide older adults with basic information about safe and effective levels of physical activity and to make them aware of the benefits of regular exercise (Lee, 1993; Riebe & Nigg, 1998). Improving attitudes toward exercise might be a necessary step in improving the chances of having inactive older people, especially those with functional limitations, be active and engaged in regular physical activity. The results of this study should be interpreted in the light of certain limitations. First, the data are cross-sectional, which limits our ability to ascertain the causal direction of the associations. Second, our population might not be a representative sample of older adults in the United States. The education level of the study participants was generally high, with at least 75% or more in all groups educated at the college level (Table 1). Several researchers have reported that people with more than a high school education are more likely to engage in medium- or high-intensity physical activity (Kaplan, Lazarus, Cohen, & Leu, 1991; Walsh, Pressman, Cauley, & Browner, 2001). Our low-physical-performance group, however, even though it had high levels of education, similar to the other groups, believed less in the healthful effects of exercise. In addition, the relationship between physical performance and attitude toward exercise did not change substantially after we adjusted for education. Other limitations include the reliance on selfreports of vigorous exercise and the lack of information on the validity and reliability of the attitude scale. Furthermore, it should be emphasized that this study was focused on differences in attitude toward exercise according to functional status and that we used vigorous exercise as a marker for the highest level of functional status. This was not a study of the impact on attitude toward exercise of doing moderate or light exercise. Nonetheless, it is important to consider that any regular exercise will provide benefits if done regularly (Kaplan, Newsom, McFarland, & Lu, 2001).

9 262 Chang et al. In conclusion, older adults who regularly engage in vigorous exercise have a more positive attitude toward exercise than non vigorous exercisers do. Furthermore, within the non vigorous-exercise group, the older adults with low physicalperformance levels were less positive about exercise being good for them than the highest physical-performance group was. This study suggests that low-performing older adults need to have more knowledge about the benefits of exercise and strong support to encourage them to engage in regular physical activity. Providing an exercise program geared to the special needs and knowledge of the population at future risk for disability would give older adults the opportunity to reap the benefits of regular physical activity. To be able to improve the physical fitness of those with low functional status, we need to further investigate environmental and behavioral determinants of inactivity among older adults. References Blair, S.N., & Connelly, J.C. (1996). How much physical activity should we do? The case for moderate amounts and intensities of physical activity. Research Quarterly for Exercise and Sport, 67(2), Blair, S.N., Kohl, H.W., III, Barlow, C.E., Paffenbarger, R.S., Jr., Gibbons, L.W., & Macera, C.A. (1995). Changes in physical fitness and all-cause mortality. A prospective study of healthy and unhealthy men. Journal of the American Medical Association, 273(14), Booth, M.L., Owen, N., Bauman, A., Clavisi, O., & Leslie, E. (2000). Social-cognitive and perceived environment influences associated with physical activity in older Australians. Preventive Medicine, 31(1), Chang, M., Kim, H., Shigematsu, R., Nho, H., Nishijima, T., & Tanaka, K. (2001). Functional fitness may be related to life satisfaction in older Japanese adults. International Journal of Aging and Human Development, 53(1), Dishman, R.K., Sallis, J.F., & Orenstein, D.R. (1985). The determinants of physical activity and exercise. Public Health Report, 100(2), Ebrahim, S., & Rowland, L. (1996). Toward a new strategy for health promotion for older women: Determinants of physical activity. Psychology, Health and Medicine, 1(1), Ettinger, W.H., Burns, R., Messier, S.P., Applegate, W., Rejeski, W.J., Morgan, T., et al. (1997). A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. Journal of the American Medical Association, 27, 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, Guralnik, J.M., Ferrucci, L., Simonsick, E.M., Salive, M.E., & Wallace, R.B. (1995). Lowerextremity function in persons over the age of 70 years as a predictor of subsequent disability. New England Journal of Medicine, 332(9), Guralnik, J.M., Seeman, T.E., Tinetti, M.E., Nevitt, M.C., & Berkman, L.F. (1994). Validation and use of performance measures of functioning in a non-disabled older population: MacArthur studies of successful aging. Aging (Milano), 6(6),

10 Physical-Performance Level and Attitude Toward Exercise 263 Guralnik, J.M., Simonsick, E.M., Ferrucci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G., et al. (1994). A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. Journal of Gerontology, 49(2), M85-M94. Jette, A.M., Rooks, D., Lachman, M., Lin, T.H., Levenson, C., Heislein, D., et al. (1998). Home-based resistance training: predictors of participation and adherence. Gerontologist, 38(4), Kaplan, G.A., Lazarus, N.B., Cohen, R.D., & Leu, D.J. (1991). Psychosocial factors in the natural history of physical activity. American Journal of Preventive Medicine, 7, Kaplan, M.S., Newsom, J.T., McFarland, B.H., & Lu, L. (2001). Demographic and psychosocial correlates of physical activity in late life. American Journal of Preventive Medicine, 21(4), King, A.C., Oman, R.F., Brassington, G.S., Bliwise, D.L., & Haskell, W.L. (1997). Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. Journal of the American Medical Association, 277(1), King, A.C., Pruitt, L.A., Phillips, W., Oka, R., Rodenburg, A., & Haskell, W.L. (2000). Comparative effects of two physical activity programs on measured and perceived physical functioning and other health-related quality of life outcomes in older adults. Journal of Gerontology, 55(2), M74-M83. Kinsella, K., & Velkoff, V.A. (2001). The demographics of aging, In An aging world: 2001, International population reports (pp. 7-21). Washington, DC: U.S. Department of Health and Human Services. Lachman, M.E., Jette, A., Tennstedt, S., Howland, J., Harris, B.A., & Peterson, E. (1997). A cognitive-behavioural model for promoting regular physical activity in older adults. Psychology, Health and Medicine, 2(3), Lee, C. (1993). Attitudes, knowledge, and stages of change: A survey of exercise patterns in older Australian women. Health Psychology, 12(6), Marcus, B.H., Banspach, S.W., Lefebvre, R.C., Rossi, J.S., Carleton, R.A., & Abrams, D.B. (1992). Using the stages of change model to increase the adoption of physical activity among community participants. American Journal of Health Promotion, 6(6), Maroulakis, E., & Zervas, Y. (1993). Effects of aerobic exercise on mood of adult women. Perceptual and Motor Skills, 76(3 pt. 1), Marx, M.S., Cohen-Mansfield, J., & Guralnik, J.M. (2003). Recruiting community-dwelling elderly at risk for physical disability into exercise research. Journal of Aging and Physical Activity, 11(2), McAuley, E., Lox, C., & Duncan, T.E. (1993). Long-term maintenance of exercise, selfefficacy, and physiological change in older adults. Journal of Gerontology, 48(4); P218-P224. O Brien Cousins, S. (2001). Thinking out loud: What older adults say about triggers for physical activity. Journal of Aging and Physical Activity, 9, Resnick, B., & Spellbring, A.M. (2000). Understanding what motivates older adults to exercise. Journal of Gerontological Nursing, 26(3), Rich, S.C., & Rogers, M.E. (2001). Stage of exercise change model and attitudes toward exercise in older adults. Perceptual and Motor Skills, 93(1),

11 264 Chang et al. Riebe, D., & Nigg, C. (1998). Setting the stage for healthy living. ACSM s Health and Fitness Journal, 2(3), Sallis, J.F., Hovell, M.F., & Hofstetter, C.R. (1992). Predictors of adoption and maintenance of vigorous physical activity in men and women. Preventive Medicine, 21(2), Shephard, R.J. (1997). Aging, physical activity, and health. Champaign, IL: Human Kinetics. Walsh, J.M., Pressman, A.R., Cauley, J.A., & Browner, W.S. (2001). Predictors of physical activity in community-dwelling elderly White women. Journal of General Internal Medicine, 16(11), Worm, C.H., Vad, E., Puggaard, L., Stovring, H., Lauritsen, J., & Kragstrup, J. (2001). Effects of a multicomponent exercise program on functional ability in communitydwelling, frail older adults. Journal of Aging and Physical Activity, 9,