Abstract of thesis entitled. Evidence-based guideline for increasing physical activity among Chinese. older adults with depressive symptoms

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1 Abstract of thesis entitled Evidence-based guideline for increasing physical activity among Chinese older adults with depressive symptoms Submitted by Lau Siu In for the degree of Master of Nursing at the University of Hong Kong in July 2013 Depression has become a medical condition that affects more and more of the aged Hong Kong population, yet this condition is often overlooked. Depression is a treatable condition. Nevertheless, the current practice in Hong Kong relies heavily on medication and cognitive-behavioural therapy. The i

2 effectiveness of these two types of therapy is limited by the side-effects of the medications and the accessibility to medical facilities for cognitive-behavioural therapy. Physical activity is suggested by many studies to be effective in managing depressive symptoms in the population. Physical exercise is a relatively economic and convenient activity that can be self-administered for health. Some studies have suggested that physical activity is effective for managing depression, yet the number of theses on this topic for the aged population is limited. In this thesis, studies related to the effectiveness of physical activity on depressive symptoms alleviation among older adults were reviewed and critically appraised. The potential to apply the findings of these studies to the aged Chinese population in Hong Kong is discussed and presented. Studies were searched using the databases Pubmed and CINAHL, and a total of 15 relevant studies were found. The 15 studies were analyzed and listed as tables of evidence and appraised with the SIGN checklist for their quality. The results of these studies and the quality of the papers were summarized. Regarding the physical activity types examined in these studies, aerobic exercise involving controlled-breathing or deep-breathing (e.g. TaiChi) and ii

3 activities to promote posture including flexibility and balance (e.g. Yoga) were found to be effective for alleviating depressive symptoms among the aged population. The feasibility and transferability of the desired intervention to the target population and setting were discussed. An evidence-based guideline with 8 recommendations was also developed. Finally, a plan for communication with different parties (e.g., administrators, users and staff) to administer the intervention was devised. A pilot test was also planned, with and evaluation plan for the pilot test to allow for adjustments to the intervention. This thesis discussed an alternative to treatment of depressive symptoms among the aged population. With the practice of physical activity effective in managing depressive symptoms in this population, it gave rise to the possibility that to promote the innovation to all of this population. iii

4 Evidence-based guideline for increasing physical activity among Chinese older adults with depressive symptoms By Lau Siu In BNURS, HKU, RN For Master of Nursing The University of Hong Kong A thesis submitted in partial fulfillment of the requirements for the Degree of Master of Nursing at the University of Hong Kong. July 2013 iv

5 Declaration I declare that this thesis represents my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications. Signed... Lau Siu In v

6 Contents ABSTRACT... Error! Bookmark not defined. DECLARATION... v CONTENTS... vi CHAPTER 1: INTRODUCTION BACKGROUND AFFIRMING THE NEED OBJECTIVES AND SIGNIFICANCE... 5 CHAPTER 2: CRITICAL APPRAISAL SEARCH AND APPRAISAL STRATEGIES RESULTS...11 Participants...12 Intervention and Control...12 Outcome SUMMARY AND SYNTHESIS...14 Randomization...15 Concealment...16 Blinding...17 Baseline characteristics...17 Outcome measure...19 Drop-out rate...19 Intention to treat...20 Multisite comparisons...21 Grading of studies...22 Application to the designated population...23 Findings...24 Conclusion...29 CHAPTER 3: TRANSLATION AND APPLICATION IMPLEMENTATION POTENTIAL...31 Target population and setting...32 Transferability of the findings...33 vi

7 Feasibility...37 Cost / Benefit ratio of the innovation EVIDENCE-BASED PRACTICE GUIDELINE...49 NAME...49 PURPOSE...49 TARGET GROUP...50 THE GUIDELINE...50 Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation Recommendation CHAPTER 4: IMPLEMENTATION PLAN COMMUNICATION PLAN...58 GOVERNMENT DEPARTMENT OFFICER...59 DISTRICT ELDERLY COMMUNITY CENTRE MANAGER 60 DISTRICT ELDERLY COMMUNITY CENTRE STAFF...60 PROGRAMME STAFF...61 DEPRESSED ELDERLY...62 INITIATION OF THE CHANGE PILOT STUDY PLAN...67 Pilot testing or other plans to try out the guideline EVALUATION PLAN...68 Outcomes to be achieved...68 CONCLUSION...76 Appendix A Table 1: Table of evidence of 15 reviewed studies...78 Appendix B Table 2: Critical Appraisal of the reviewed studies using SIGN checklist...92 Appendix C Results...97 vii

8 Appendix D Quality of paper by physical activity type...99 Appendix E Flow Chart of the Programme Appendix F Exercise Protocol Reference viii

9 CHAPTER 1: INTRODUCTION 1.1 BACKGROUND Depression is a type of mental disorder characterized by prolonged low mood, loss of interests and lack of energy. If symptoms persist or worsen, the daily life of depressed patients is affected (Hospital Authority, 2012). One cause of depression is bio-chemical changes in the brain. Certain neurotransmitters such as serotonin, noradrenaline and dopamine in depressive individuals, may be out of balance in depressive individuals, causing changes in mood, thinking and behaviour (APA, 2012). According to the American Psychiatric Association (2012), depression is common in the aged population. A study of non-demented Chinese elderly in Hong Kong found that depressive symptoms were associated with functional disability (as cited in Tam & Lam, 2012). Physical disability is prominent in the aged population. Often, the disabilities affecting the quality of life of the population are closely related to depression (Chan, Chiu, Chien, Thompson, & Lam, 2006). Therefore, the population is more prone to depression. Depression in the aged population is often overlooked. According to the National Institute of Mental Health (NIMH) in 2011, when elderly suffer from depression, they may show less obvious symptoms than the younger 1

10 population. Depression is diagnosed using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). In addition, there are commonly used scales for rating depressive symptoms such as the Geriatric Depression Scale (GDS) by Yesavage developed in 1982, the Beck Depression Inventory (BDI) developed in 1960 and the Hamilton Depression Rating Scale (HDRS) developed by Hamilton in For these scales, a higher the score indicates more depressive symptoms. The DSM-IV is used mainly by highly trained professionals to assess depressive symptoms, while the GDS is a relatively simple tool that enables self report of the individual and is widely used in clinical settings. Because symptoms of depression are not obvious in the aged population, some people may falsely regard the symptoms as a normal process of aging (NIMH, 2011) and miss the opportunity for elderly to receive appropriate treatment. In the US, the suicide rate is the highest among the age group of 85 years or older, and many of these individuals did not receive appropriate treatment (NIMH, 2011). Though treatment of depression is effective, but many elderly patients refuse treatment because of the side-effects or low accessibility of resources (Blake, Mo, Malik, & Thomas, 2009). 2

11 1.2 AFFIRMING THE NEED Depression is the most prevalent mental disorder among the aged population. The World Health Organization in 2004 projected that depression would be the second leading cause of disability world wide in 2020 (Chan, Chiu, Chien, Thompson, & Lam, 2006). In an interview with the elderly individuals (Chi, Yip, Chiu, Chou, Chan, & Kwan, 2005), for the population in Hong Kong aged 65 years or older, 10.2% of male and 14.8% of female respondents presented with significant depressive symptoms. In a study of depression in Chinese elderly (Chan et al., 2006), a high level of depression was associated with a poor perception of quality of life. Moreover, if depression is left untreated, the risk of morbidity and mortality increases (as cited in Blake, Mo, Malik & Thomas, 2009), and depression and its impacts become a burden to the economy and society. Depression and other mental health disorders are placing increasing demand on government resources. In , government expenditure on mental health services just in the Hospital Authority was HKD 3.92 billion, and the amount is expected to rise to an additional HKD 210 million for the following year according to the figures from the legislative council (Legislative Council Secretarist, 2011). To an individual sufferer of 3

12 depression, the cost of the treatment of depression, including medication and therapy, is USD 1,500-4,500 in the United States (NAMI, 2006). As the WHO projected, the number of depressive individuals will continue to increase, resulting in increases in the costs related to management and treatment. Exploring alternative treatment that may be as effective as usual treatment and with a lower cost may help to ease the burden on the economy. Depression in the elderly is closely related to cognitive impairment, lowered physical functioning and dementia which are major challenges to the quality of life in elderly individuals. In a study of the relationship between depression and cognitive function of Hong Kong Chinese, it was found that the higher the level of depressive symptoms, the greater the decline of cognitive functioning that was observed (Chi & Chou, 2000). According to research published in 2012 by the Hong Kong College of Psychiatrists, the severity of depression was found to be correlated to impairment in cognitive function in elderly in Hong Kong (Tam & Lam, 2012). Though depression is not yet proven to be a risk factor for dementia, causative factors for depression in the aged population may be the same as the causative factors for dementia (Panza et al., 2010). Depression and dementia exhibits similar symptoms, such as loss of memory, a decrease in interests and slow motion 4

13 (Panza et al., 2010). Certain symptoms co-exist in both depression and dementia and hence may lead to confusion in physicians and care givers for the during diagnosis (Evers & Marin, 2002). Depressive symptoms in the aged population are easily overlooked (NIMH, 2011), which increases the likelihood of the under-diagnosis of dementia and could affect the elderly in their cognitive and physical functions and hence lower their quality of life. 1.3 OBJECTIVES AND SIGNIFICANCE Because of the aging of the population in Hong Kong, it is estimated that the number of sufferer of late-life depression will increase. Depression is a treatable condition (Blake et al., 2009). Currently in Hong Kong, depression in the elderly is mainly managed by pharmacological means, accompanied by cognitive-behavioural therapy (CBT) (Hospital Authority, 2012). However, common anti-depressive drugs can lead to significant side-effects such as dry mouth, agitation and weight-gain (Evers & Marin, 2002), that are undesirable to many depressive patients. Additionally, in elderly with depression, their symptoms usually co-exist with other medical problems such as cerebral vascular diseases; consequently this population has a lower response to psychological and pharmacological 5

14 treatment (Spoelhof, Davis, & Licari, 2011). Therefore, pharmacological treatment, though effective, may not be the best treatment for the elderly. Moreover, the adherence to CBT is associated with the accessibility to the service, which is closely related to resources and limited by its inconvenience for elderly patients. Due to the undesirable factors of both pharmacological intervention and CBT, the adherence of the elderly to treatment may be lowered (Chan et al., 2006). As a result, there is a need to explore alternative treatment to manage depression in the aged population. Physical activity was found to be effective in managing depression in adults (Sjosten & Kivela, 2006). It is widely proposed that physical activity could diverse individuals from negative thoughts, and the knowledge of a new skill may improve mood. According to Rimer, Dwan, Lawlor, Greig, McMurdo, Morley and Mead (2012), physical activity can reduce the stress hormone cortisol and change endorphin monoamine levels in body, which may explain the biological significance of depressive symptoms. In the aged population, evidence has shown that physical activities improve depressive symptoms (Blake et al., 2009). Exercising may also benefit cognitive function and physical function (Nied & Franklin, 2002). Exercising is associated with other health benefits such as improved balance, strength and 6

15 gait endurance, and it may also positively affect the quality of life among older people (as cited in Blake et al., 2009). Physical activity, when compared with CBT, is more preferable because it is less expensive and more convenient (Chou, 2008). Moreover, there is no identified direct side-effect of physical activity (Chou, 2008). Despite various published research, no guideline for a physical activity programme for depressed aged individuals in Hong Kong has been developed. After a search for previous studies, two systematic reviews related to physical activity and depression in the elderly were found. Sjosten and Kivela (2006) found that physical exercise was effective for reducing depressive symptoms among the elderly in the short term. Blake et al. (2009) also concluded that a short-term positive outcome for depressive symptoms was found by engaging in physical activity. Nevertheless, the systematic reviews request that more high quality controlled trials be conducted to develop recommendations. The objectives of this study were to gather evidence about the effectiveness of physical activity for depressive symptoms in elderly to develop recommendations. The PICO and research question of the review are listed as follows: 7

16 P: Older adults I: Physical activity C: No physical activity O: Depressive symptoms Research Question: Is physical activity engagement more effective at alleviating depressive symptoms in older adults compared to no regular physical activity? 8

17 CHAPTER 2: CRITICAL APPRAISAL 2.1 SEARCH AND APPRAISAL STRATEGIES To locate relevant articles in this review, strategies were designed; these strategies are discussed in the following paragraphs. The databases used in the search were Pubmed which is a free database of life sciences and biomedical topics maintained by the National Institute of Health of the US and CINAHL via EBSCO publishing which is an index of journals about nursing, allied health, biomedicine and healthcare. Inclusion criteria were all studies concerning the aged that were randomized control trials (RCTs), containing a physical activity intervention, written in English, with full-text available and human species related. A study was excluded if it focused on a programme containing additional non-exercise components. Then both a pilot study and a related larger scale study exsited, the pilot study was excluded because it provided a lower power of effect. Lastly, articles included in previous systematic review (on or before the year of 2008) were excluded because the findings were already known. A variety of keywords were used in searching for relevant articles in the databases. Keywords set for the search were be divided into two categories, 9

18 one category was outcome related (depressive symptoms) and the other category was intervention-related (physical activity). For the depressive outcome category, the keywords used were depressive, depression and depressed. For the intervention, the keywords exercise, physical exercise, physical activity, aerobic, ROM, range of motion, muscle strengthening, breathing, balancing, yoga, dance, dancing, run, running, walk, walking, jog, jogging, swim, swimming, Qigong, Qi Gong, Chi Gong, Tai Chi, Tai Qi and Tai Ji were searched in an attempt to include all possible type of physical activity for the elderly. For within one category, keywords were linked by the operation OR.For the search for terms between categories of keywords, AND was used to represent the relationship between the two categories. After the steps mentioned above, a search was performed in the two database mentioned previously. As of August 2, 2012, 799 articles from PubMed and 15 articles from CINAHL were found. To trim down the number of journals found to suit the criteria of this review, limitations were set. First, only journal articles concerning the aged were included. Second, journal articles were limited to 10

19 randomized-controlled trials only because they provide a higher level of evidence. Then, only journal articles that were written in English were chosen. Last, only papers from 2009 and onwards would be included. After these limitation criteria, 396 articles from PubMed and 3 articles from CINAHL were remained. Then, exclusion criteria were applied, and duplicated journals were excluded. The result was 15 articles from PubMed but no articles from CINAHL. Therefore, 15 articles were included in this review. The results of the studies were included in the table of evidence attached in the appendix. 2.2 RESULTS Fifteen papers from 2009 to 2012 were included from two databases after the searching strategies. Further searches using the reference lists of those papers resulted in no additional papers. Details of the strategies are shown in Appendix C. All of these papers were RCTs. A table of evidence of the evidence from the identified studies is shown in Appendix A. Three studies were studies from Asia, one was from Australia, and the others were from western countries or the US. All of these papers adequately addressed or well-covered the research question. Some studies clearly 11

20 presented background information. Two studies were part of a larger study. Participants All papers recruited participants from the aged population Two out of fifteen focused on Alzheimer s patients. All of the papers conducted their studies in community settings. Either community-dwelling individuals or residents in residential care facilities were recruited. Five studies included participants from residential-care facilities. Three papers of the fifteen recruited only women as the sample. The sample size ranged from 30 to 900. However in nine studies, the sample size was approximately in each experimental arm. All studies only excluded participants if they had a disability or medical condition that would prevent them from performing physical activity. Intervention and Control A variety of activity types were included in those studies such as aerobic, resistance, muscle strengthening, posture-related, ROM and combined physical exercise. All papers compared physical activity intervention with a control as no-exercise intervention in four studies, usual care in one study 12

21 and the attention control group in nine studies except for one study that compared combine exercise with jumping with combine exercise alone. Because of setting and resources, most interventions were delivered in groups. In each of the studies, the control group was scheduled for attention control activity with the same duration and frequency as the intervention in the intervention group if possible. Outcome There were 7 types of measurement scales used for depressive outcome measures. Ten papers used the Geriatric Depression Scale (GDS); others used the Taiwanese Depression Questionnaire (TDQ), Hospital Anxiety and Depression Scale for Depression (HADS-D) with Stroke Aphasic Depression Questionnaire (SAD-Q), Patient Health Questionnaire-9 (PHQ-9), Hamilton rating scale for Depression (HAM-D) and Cornell Scale for Depression in Dementia (CSDD). All scales were tested for validity and reliability. Pre- and post-testing were conducted, and the differences in scores were compared, except for one study that compared the change in percentage of depressive, borderline depressive and non-depressive subjects. All studies measured their outcome before and after the intervention. Two studies had depressive 13

22 outcome measured at various occasion during the intervention, while three studies had another depressive outcome measured after the post-intervention measure to examine the long-term effect of the intervention. All of the papers except one compared the change in mean depressive score of participants; the other study presented the data as 95% CI. Depressive scores of individuals in the experimental group were compared with their score before the intervention and with the score of the control group. Due to the different scoring of the instruments used, the effect sizes could not be compared directly. Among all of those papers, the Geriatric Depression Score (GDS) was the most commonly-used measuring instrument and was included in ten studies; the change in depressive score ranged from no change to -6. During data analysis, improvement in depressive symptoms was stated as 5% of the level of significance in the observed change of depressive score. Therefore in this paper, those studies with an intervention effect significance of p<0.05 were considered as effective. 2.3 SUMMARY AND SYNTHESIS In five of those studies, a significant change in depressive outcome was found. While in two of the remaining studies, a significant change in the 14

23 experimental group was found when comparing pre- and post-intervention results; however the change in score was not significant when compared to the change in score in the control group. Consequently, those interventions were considered as not effective. The remainder of the studies showed no significant results with their intervention. The tables listing out the results are shown in Appendix C. In this thesis, the studies were appraised using the Scottish Intercollegiate Guidelines Network (SIGN) checklist. Checklist 2 was used because the studies in this review were randomized-controlled trials. The result of the appraisal is shown in Appendix B. Randomization All studies claimed that they were randomized control trials. Randomization is a crucial element in RCTs to minimize bias and to generate two similar groups at the start of the study. However, only six of the studies clearly stated the mechanism of randomization, while the others only mentioned that participants were randomized but no details of the randomization process were provided. Of the studies a randomization mechanism provided, sealed envelope, drawing lots and computer-generated 15

24 groups were used which as the accountable methods of randomization, thus giving these paper higher quality. Papers with clearly stated randomization mechanisms were graded as well covered for this item, while the nine studies that did not provide this information were graded as poorly addressed. Concealment Not all studies had the allocator concealed to the randomization. Concealment describes a situation where an allocator is unaware of the assignment of subjects to the study groups. If concealment is inadequate, it may cause over-estimation or under-estimation of the effect of the study. Only five of the fifteen papers described a convincing way for concealment; these papers were graded as well covered for this item. One paper reported concealment but did not describe the process was graded adequately addressed. Examples of concealment methods used included a computer-generated group assignment, or the preparation of sealed envelopes by someone other than the allocator. 16

25 Blinding The blinding process is important in randomized controlled trials. However in studies where physical activity is the intervention, it is quite impossible to keep participants unaware that they were allocated to the exercise group. In view of this issue, the blinding of the data collector was the main consideration. In six of the fifteen studies, the data collector was blinded to the grouping of the study subjects, and these papers were rated as well covered for this item. Blinding strategies included randomization after initial data collection and asking subjects not to reveal their grouping to the data collector. One study checked the blinding of the data collector by asking the collector to guess the grouping of the subjects after final data collection which acted as a good way in checking the blinding of the blinding process. Two papers mentioned that blinding was used, but they did not give the mechanism and were graded as adequately addressed. Baseline characteristics All studies intended to have similar treatment and control group in terms of depressive outcome related aspects at the start of the trial, such as baseline depressive state, age and sex. This effect was accomplished through 17

26 randomization, as discussed before. Baseline characteristics were listed as tables in all these fifteen studies. However, only six studies commented on the similarity of the two groups at baseline, these papers were rated as well covered. In four studies, only figures of baseline characteristics and significance levels were provided. Some studies had two unequal groups at the baseline either in age, MMSE or depressive score. Differences in these variables may have affected the outcome, yet only an adjustment for MMSE score was made in analysis. These studies were rated as adequately addressed. Those remaining studies provided only primary data but no comparison, significance or comments, and these studies were rated as poorly addressed. All studies had one intervention, which was the physical activity intervention, as the only difference between the treatment group and control group. However, only those reports in which the authors commented on this issue were rated as well covered. For those studies with unequal groups generated after randomization, controlling could have been applied in the analysis using statistical method to minimize the effect caused by the difference. However, few studies addressed the issue. 18

27 Outcome measure All of studies had a section listing the outcome measures used in their studies. All depressive outcomes were measured with suitable tools, but not every paper provided details of the tool. Ten studies rated as well covered in this item explained the scoring of the tool and the internal consistency of the questionnaire in the various formats given. Other papers that only stated the tool were rated as adequately addressed. All studies investigated the effect of physical activity on depressive symptoms in elderly individuals. However, only nine of those studies had depressive symptoms as their primary outcome, while the other studies had depressive symptom measures as secondary outcomes. Among those non-depressive related outcomes, oter common outcomes related to depressive symptoms were included, such as anxiety in three studies, cognitive functions in three studies and reaction and balance score in five studies. It may be a suggestion to the association between physical activity and the reduction of depressive symptoms. Drop-out rate The dropout rate represents the percentage of participants who discontinued their intervention after being randomized to either group. A 19

28 higher dropout rate may lead to bias. In all of these studies, the dropout rate was less than 20%. However, in four of the studies, the dropout rate was relatively higher as 13-18%. The authors provided reasons for the dropout (e.g. medical reasons) and compared the drop-out subjects with the remaining subjects. No significant differences in characteristic were found. No obvious correlations were found between lengths of intervention with dropout rate; for example, one study with more than 800 participants (Walker et al., 2010) had similar drop out rate to another study with only 80 participants (Cakar et al., 2010). Studies that were conducted at residential care facilities had higher dropout rates than studies with community-dwelling individuals. This may due to the fact that residential care residents have worse medical condition than community-dwelling older adults that did not allow them to complete the full course of the intervention. This finding may also indicate that the activity interventions suggested in this study would not be suitable for effectively reducing depressive symptoms in residential care residents. Intention to treat Only five studies stated clearly that intention-to-treat analysis was used. 20

29 Intention-to-treat is a strategy in which all subjects were considered in the same group to which they were initially allocated. This approach is often applied by assigning the same final value of the outcome as the same as the initial value for the drop-out subjects. Intention-to-treat can minimize the possibility of Type I error. In five of the studies, the drop-out subjects were analysed at the end of the studies with the completed subjects. These studies were rated as well covered for this aspect. The three studies that did not address the issue of intention-to-treat were rated as not addressed. The studies that excluded drop-out subjects in their final analysis (so-called per-protocol analysis) may have a higher chance of committing Type I error; these two studies were rated as poorly addressed for this item. In these two studies, the drop-out rate was relatively low at approximately 7% to 11%. For studies with no drop out subjects, this item was not applicable. Multisite comparisons None of the studies had multi-site comparisons because the interventions were only conducted at a single site or assessed individual physical activity at home. The three studies with no sites of intervention described in the text were rated as not mentioned because there were no 21

30 details given for the assessment. Another three studies with several sites for intervention did not mention information related to the existence of a multi-site arrangement, so data were analyzed as one large group only. If the proposed intervention was conducted in several separated sites, the results of participants from difference sites could be compared to look for factors causing differences. However, of all the studies included, no studies addressed this element. Grading of studies After appraising for important components in the study, the methodological quality of the study was be rated as 1++, 1+ or 1-. After summarizing all of the items in the critical appraisal described above, the possibility of the outcome as being related to the intervention alone was determined. A paper with high certainty of effect was graded as 1++. A paper with some aspect needing improvement and some uncertainty of effect due to the methodology was given a 1+. Studies for which the relationship of the intervention to the outcome was unclear because of the poor methodology were given a 1-. In this review, one paper (Lavretsky et al., 2011) was graded as 1++. Six papers (Gutierrez et al., 2012, Lincoln et al., 22

31 2011, Walker et al., 2010, Kerse et. al., 2010, Conradsson et al., 2010 and Chen et al., 2009) were graded as 1+. The other eight papers were graded as 1-. The effects in the conclusions of papers graded as 1- were uncertain to be due to the intervention because of the relatively lower quality of the studies. In those studies graded as 1++ and 1+, the positive effects were certain to be due to the intervention, which would be strong evidence in the synthesis of the conclusion in this study. Application to the designated population In all these studies, the intervention could be applied to the patient group of the guideline which would be older adults. All participants in these studies were from the same population as the population of this review, and all of the studies contained a physical activity as the intervention. Three studies had female participants, but the physical activity programmes were not designed for the female population only, so the intervention could be generalized to males. However, in studies focusing on demented subjects, no significant reduction in depressive symptoms was found (Conradsson et al., 2010, Eggermont et al., 2009, Brittle et al., 2009 and Steinberg et al., 2009). Physical activity conducted in residential care facilities was also found to be 23

32 ineffective (Cakar et al., 2010, Conradsson et al., 2010, Eggermont et al., 2009), Brittle et al., 2009 and Brown et al. 2009). Findings Among all fifteen randomized-controlled trials, five concluded that there was evidence that the physical activity intervention could significantly reduce depressive symptoms when compared to no physical activity intervention. The quality and type of physical activity were important elements and are discussed in the following sections. Of the five studies with positive findings, one study was graded as 1++ (Lavretsky et al., 2011), three were graded as 1+ (Gutierrez et al., 2012, Lincoln et al., 2011 and Chen et al., 2009) and one was graded as 1- (Shahidi et al., 2011). The other ten papers among the fifteen had no significant reduction in depressive symptoms after their intervention. Among those ten papers, only three were graded as 1+, the others were graded as 1- (as in Appendix C). More of the good quality studies had positive findings, so there is evidence that physical activity had an effect on the reduction in depressive symptoms among the aged population. 24

33 Physical activity type When considering only studies with a higher quality and positive outcome (Lavretsky et al., 2011, Lincoln et al., 2011, Gutierrez et al., 2012 and Chen et al. 2009), aerobic exercise (e.g. walking, Tai Chi and yoga ) together with resistance training was found as intervention effective in reducing depressive symptoms. When the studies were grouped by intervention type, aerobic activity and posturing (flexibility and balancing) types of exercise were more effective in reducing depressive symptoms than other types of physical activity (as shown in Appendix D). Five studies suggested that aerobic exercise was effective, with four of these studies graded as 1+ or 1++; while only three studies (with one graded with 1+) regarded aerobic exercise as non-effective. Aerobic exercises suggested by these studies were Tai Chi (Lavretsky et al., 2011 and Chen et al., 2009), yoga (Shahidi et al., 2011) and walking or jogging (Shahidi et al., 2011). However, walking was suggested as not effective in two other studies (Maki et al., 2012 and Conradsson et al., 2012), and also dancing was also not found to be more effective than the control (Eyigor, Karapolat, Durmaz, Ibisoglu, & Cakir, 2009). 25

34 In the posturing sub-group, Tai Chi (Lavretsky et al., 2011 and Chen et al., 2009) and yoga (Shahidi et al., 2011) were found to be effective. There were two studies (Brittle et al., 2009 and Brown et al., 2009) that found flexibility and balancing exercises only were ineffective for reducing depressive symptoms. Overall, physical activity that involved muscle or strength training only was not shown to be as effective in reducing depressive symptoms, which may due to the higher physical demand on the participants. On the other hand, the physical activity interventions that involved aerobic exercise, such as deep breathing or controlled breathing, together with posturing, including components of flexibility of joints and balancing, were found to be effective in reducing depressive symptoms. Tai Chi or yoga was suggested by the evidence to be effective (Lavretsky et al., 2011, Chen et al., 2009 and Shahidi et al., 2011). Because Tai Chi or yoga would have to be conducted by a leader for most participants, these activities were generally performed in groups. Duration of physical activity The duration of the intervention in the fifteen studies ranged from 30 26

35 minutes to 120 minutes, and the frequency of the intervention ranged from once per week to five times per week. The interventions lasted from 10 weeks to as long as 24 months, depending on the type of physical activity intervention delivered. It was suggested by studies with effective outcomes that the duration should be 120 min to 210 min per week (Lavretsky et al., 2011, Lincoln et al., 2011, Gutierrez et al., 2012, Shahidi et al., 2011 and Chen et al., 2009). Some studies suggested two times per week while others suggested three times per week. To improve the adherence of the intervention, it is recommended for a 60-minute physical activity intervention to be administered two times per week. In three of these studies, a 6-month intervention was used (Lavretsky et al., 2011, Shahidi et al., 2011 and Chen et al., 2009), while in the other two, 10 sessions over 10 weeks were conducted. When the proposed physical activity type was an exercise which required training for steps and postures, it was recommended as the three studies as an intervention period lasting for 6 months (Lavretsky et al., 2011, Shahidi et al., 2011 and Chen et al., 2009) in the proposed guideline. Number of participants to be recruited For group size, evidence suggested approximately 30 participants in the 27

36 experimental group, as suggested by three of the studies that found their intervention to be effective (Lavretsky et al., 2011, Lincoln et al., 2011, Gutierrez et al., 2012). In the other two studies, 60 participants were included in the experimental group (Shahidi et al., 2011 and Chen et al., 2009). Because the papers with higher quality suggested approximately 30 participants in the group, this number would be recommended in the proposed guideline. Proposed elements for the guideline As discussed in the previous sections, the target population would be community-dwelling aged adults who were not severely demented. The upper limit of age would not be set but participants must not be suffering from severe medical condition or disability that would contraindicate physical activity. Aerobic exercise such as Tai Chi or yoga that incorporates components of posturing would be recommended as the intervention. The intervention would be conducted in 60 minute sessions, 2 times per week for 10 weeks in the proposed guideline. 28

37 Conclusion From our review above, it can be seen that aerobic and flexibility types of physical activity were effective in reducing depressive symptoms in community-dwelling older adults. In the search conducted for this study, fifteen RCTs were found. However, when the studies were analyzed, only seven studies were of good quality. In those studies with lower quality, a high portion did not mention the exact mechanism of randomization which is an important element of RCTs. Concealment was only well described in five studies. Some studies did not address the issue of intention-to-treat. These factors lowered the quality of the studies and the findings of those studies could not be proven to be due to the intervention alone. In studies of physical activity, blinding of the participants is quite impossible, as suggested by most researchers. However, good quality studies ensured that the data collector was blinded. Three good quality studies found insignificant results, which may due to the small sample size or poor adherence of the participants to the intervention. Some studies that found insignificant differences between groups had non-comparable groups at baseline or relatively high drop-out rate of 29

38 approximately 15%. The insignificant outcomes may due to poorly designed methodologies, the choice of a non-effective physical activity for the participants or an intervention that was of a weaker intensity. Though most people believe that physical activity is important for health, evidence of its effect on depressive symptoms is still scare. From the currently available, good quality studies, aerobic exercise combined with flexibility was effective in alleviating depressive symptoms, while the other types of exercises showed no significant effect. Though a number of related studies were found, the number of good-quality studies available was relatively small. As a result, the conclusions drawn were limited. More good quality studies related to this topic should be conducted in the future to provide more evidence for the development of recommendations. 30

39 CHAPTER 3: TRANSLATION AND APPLICATION This Innovation is proposed to be a programme running for a year. Each run of the programme would be 10 weeks, with one-hour sessions conducted 2 times per week. Each group would accommodate 30 participants. Participants would be recruited in a District Elderly Community Centre by staff in the centre. Two District Elderly Community Centre staff would be trained to lead the programme for the participants. These staff would be provided with a four-hour long training by a recruited experienced TaiChi trainer and the programme proposer. These individuals would then responsible for leading the programme with the help of a DVD. Participants would be assessed for depression score and balancing score before and after the programme. The details are described below. 3.1 IMPLEMENTATION POTENTIAL In this chapter, the implementation potential of the innovation is introduced. In the following text the benefits, risks, costs and feasibility of the innovation are discussed. The details of the innovation such as target setting and programme structure are also introduced. 31

40 Target population and setting In this section, the target population and the designed setting of implementation of the programme are discussed. The innovation is proposed to be a combined breathing, stretching and balancing programme for community-dwelling older adults who are suffering from depressive symptoms and is to be held in a district community centre to benefiting the target population living in the community. As previously presented, physical activity is an evidence-based intervention for reducing depressive levels among older adults aged 65 years or older who are living in the community. The programme would be promoted in district B, in which participants would be recruited from a District Elderly Community Centre. The programme would last for one year. There would be a group of 30 participants for one hour physical activity sessions held two times per week for 12 weeks. There would be a total 13 groups. Therefore, the programme would accommodate a total of 390 participants. Two leaders for the physical exercise intervention would be recruited from the district elderly community centre staff and given proper training before the commencement of the programme. In addition, one 32

41 part-time physiotherapist would be recruited to assess the eligibility of participants for the programme to assess the balancing ability of the participants during and after the programme. Transferability of the findings Fitness of transferring the programme to the targeted setting The proposed setting is a district elderly community centre in District B. In 10 of the 15 reviewed studies reported in the earlier section, the innovation was conducted in a community centre, and the research team found no complication in this arrangement. The district elderly community centre is operated by a government department of the Hong Kong government and is easily accessible to Hong Kong elderly in district B (Social Welfare Department, 2012). There are a wide variety of services offered at the district elderly community centre to serve and support elderly in the community. There would be a need for the elderly centre to deploy staff to be responsible for the recruitment of potential participants including assistance with filling in the application and the questionnaire for the Geriatric Depression Scale, and serving as the leader of the programme. The district 33

42 elderly community centre would be able to support this manpower requirement because there are regular staffs members supporting various types of activity in the centre. The two District Elderly Community Centre staff would only have to provide one to two working hours per day to support the programme. Similarity of proposed population and population from evidence The proposed population is Hong Kong older adults aged 65 or older who are living in the community. Older adults group is the same group of the population were the focus in all of the reviewed studies. Though most of the studies included non-asian participants, they focused on the same age-group of the population. As a result, the studies are directly applicable in the proposed setting. Because physical activity was only found to be effective for alleviating depressive symptoms in non-demented individuals, this innovation would not be suitable for demented individuals. Therefore, the innovation would focus on the group of the population that is the same as those in the published studies that demonstrated a benefit of physical activity useful, i.e. non-demented older adults. 34

43 Philosophy of care of innovation and practice setting The principle of the proposed programme is to promote mental health through physical activity. By promoting the programme, the depressive symptoms of the participants could be alleviated, hence allowing participants to maintain their health. As long as their health status could be maintained, the participants could remain living in the community and would require fewer resources related to medical expenditure. The department to which the district elderly community centre belongs operates under the Hong Kong government and serves the community. The department provides services to the elderly to enable the aged to live in dignity and with a sense of worth by promoting the well-being of the elders (Social Welfare Department, 2012). The Community Support Service in the Social Welfare Department encourages elders living in the community and provides support for their adaptation for living in the community (Social Welfare Department, 2012). The philosophy of care of this innovation is similar to that of the practice setting under that government department; resistance is not expected 35

44 when promoting this innovation in the practice setting. Sufficiency of number of clients in the practice setting In 10 out of 15 of the studies reviewed in the earlier section, the population was community-dwelling older adults. In Hong Kong, there are approximately 30,000 older adults living in residential-care facilities according to 2009 data (Hong Kong Council of Social Service, 2009). However, the 2011 Census indicates that 1 million Hong Kong citizens are aged 65 or older. This report indicated that the majority of Hong Kong older adults are still residing in the community. There is a huge demand for services for this population and the innovation proposed in this thesis is beneficial for this group. In a 2006 survey, an estimated half of the elderly living in the community were registered as members in the district elderly community centre (Social Welfare Department, 2006). The statistical data indicated that the potential client group is large. This innovation would accommodate about 390 community-dwelling older adults. As a result, the number of potential clients would be sufficiently large for the innovation. 36

45 Estimated time for the programme to implement and evaluate The preparation period which includes booking the venue and recruiting the staff, participants and promotion, is estimated to be 12 weeks. The exercising portion of the programme would last for 10 weeks for each group. In total 6-7 groups were planned for each week, each with 10 weeks of exercise. To accommodate 13 groups, 2 cycles would be run, meaning 20 weeks would be needed for the desired number of participants to finish the programme. An immediate evaluation of the effects of physical activity would be conducted at the end of the intervention. The evaluation of the whole innovation would be finished within 4-weeks time after the end of innovation. If the findings are positive, the innovation would continue to run. The whole process including the physical activity programme, would require 36 weeks. Feasibility Staff freedom to try or terminate The programme proposer would closely monitor for any problems. If there is a serious problem, the programme proposer could discuss with 37

46 programme staff to determine if there is a need to terminate the programme. Minor problems would be discussed with the programme proposer and potential modifications to the programme would be considered. Opinions would also be gathered from both participants and staff. If the innovation is indeed unsuitable for the participants, the programme proposer could make the decision to terminate the programme. If the programme is found unsuitable for certain participants, the nurse could also have the freedom to discontinue the programme for that participant. Possibility of interference with current staff functions The programme would be held in the district elderly community centre, and the staff there may experience a greater workload. Staff members would have to be given extra workload to address inquiries, to receive participants, to process applications from potential participants and to conduct activity sections. For most District Elderly Community Centre staff, the main additional workload would be the recruitment of participants and assisting interested participants with the application form. However, two District Elderly Community Centre staff would be dedicated to leading the programme. A four-hour-long training would be provided to the two staff 38

47 members of the Community Centre who would be responsible for collecting applications from potential participants to familiarize them with application procedures and to teach them to lead the programme. Administration support to the innovation, and conductive climate to research utilization The Social Welfare Department is a department that would be supportive of research utilization. This department emphasises empowering and building of an innovative team to provide services to the clients. The District Elderly Community Centre is one of its services that aims to provide services to elders to live a healthy life in the community (Social Welfares Department, 2012). The aim of this programme is to help to alleviate depressive symptoms in community-dwelling elderly, which fits the objectives of the District Elderly Community Centre. The District Elderly Community Centre would most likely be supportive of the programme. Consensus among staff and administrators and pockets of resistance As discussed before, the District Elderly Community Centre has been 39