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Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from

Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Note: This article will be published in a forthcoming issue of the Journal of Aging and Physical Activity. This article appears here in its accepted, peer-reviewed form; it has not been copy edited, proofed, or formatted by the publisher.

Section: Original Research Article Title: Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital Authors: Therese Brovold1, Dawn A Skelton2, and Astrid Bergland1 Affiliations: 1Oslo and Akershus University College of Applied Sciences Institute of Physical Therapy, Norway. 2School of Health and Life Sciences, Glasgow Caledonian University, UK. Running Head: quality of life and activity in seniors leaving hospital Journal: Journal of Aging and Physical Activity Acceptance Date: August 13, 2013
2013 Human Kinetics, Inc.

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Running head: QUALITY OF LIFE AND ACTIVITY IN SENIORS LEAVING HOSPITAL

Association between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital Therese Brovold, Oslo and Akershus University College of Applied Sciences Institute of Physical
Therapy, Norway

Dawn A Skelton, School of Health and Life Sciences, Glasgow Caledonian University, UK Astrid Bergland, Oslo and Akershus University College of Applied Sciences Institute of Physical
Therapy, Norway This research was supported from Oslo and Akershus University College for Applied Sciences Correspondance concerning this article should be addressed to: Therese Brovold, HIOA, Institute of Physical Therapy, P 50 Pb 4 St Olavspl 0130 Oslo, Norway Contact: Therese.Brovold@hioa.no

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Abstract The purpose of this study was to determine the relationship between Health-Related Quality of Life (HRQOL), physical fitness and physical activity, in older patients after recent discharge from hospital. One hundred and fifteen independent living older adults (70-92 yrs) were included. HRQOL (Short-Form Health Status SF-36), physical activity (Physical Activity Scale for Elderly) and physical fitness (Senior Fitness Test) was measured 2-4 weeks after discharge. Higher levels of physical activity and higher levels of physical fitness were correlated with higher self-reported HRQOL. Although this study cannot determine cause and effect, the results suggest that particular focus on the value of physical activity and physical fitness while in hospital and on discharge from hospital may be important in order to encourage patients to actively preserve independence and HRQOL. It may be especially important to target those with lower levels of physical activity, poorer physical fitness and multiple co-morbidities. Key Words: Health-Related Quality of Life, Physical Fitness, Physical Activity, Older People, HospitalAssociation between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

The prevention of functional decline and preservation of independence with aging have been recognised as major clinical policy priorities for the health care of older adults (Wallace et al., 1998). The need to improve the quality of life (QOL) of older people is increasingly acknowledged. Thus, identification of variables related to QOL amongst older people is important (Bergland & Wyller, 2006). QOL is defined by the World Health Organization (WHO) quality of life group as: individuals perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns (WHO, 1995). To distinguish between QOL in its more general sense and QOL associated with health, the term Health-Related Quality of Life (HRQOL) is frequently used (Bergland & Wyller, 2006). Health-related quality of life (HRQOL) is defined as a persons perceived physical and mental health over time (Kelley, Kelley, Hootman, & Jones, 2009). Previous studies have shown an association between physical activity, physical fitness and HRQOL among older people (Acree et al., 2006; Wang, Beyer, Gensichen, & Gerlach, 2008) and higher levels of physical activity and higher fitness status are related to HRQOL in older people (Horder, Skoog, & Frandin, 2012). Hospitalization and chronic disease, such as osteoarthritis and heart disease, are known risk factors for impaired HRQOL among older people (Helvik, Engedal, & Selbaek, 2010; Orwelius et al., 2010; Ozturk, Simsek, Yumin, Sertel, & Yumin, 2011; Rosenberg, Bombardier, Hoffman, & Belza, 2011; Wang et al., 2008). Loss of function is common both during and after hospitalization (Boyd et al., 2008; Volpato et al., 2007) and previous research indicates that hospitalization due to acute illness can increase dependence in activities of daily living (ADL) and decrease HRQOL in the post-discharge period (Boyd, Xue, Guralnik, & Fried, 2005; de Morton, Keating, & Jeffs, 2007; Haines et al., 2009).

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Engagement in physical activity is recognized to play an important role in preventing or postponing functional decline and in the development and progression of many chronic conditions (Dogra, 2011; Rasinaho, Hirvensalo, Leinonen, Lintunen, & Rantanen, 2007). Leisure time physical activity can also prevent loss of function associated with hospitalization and inactivity, maintaining independence in activities of daily living and increasing HRQOL (Balboa-Castillo, Leon-Munoz, Graciani, Rodriguez-Artalejo, & Guallar-Castillon, 2011; Hill et al., 2011; Landi et al., 2007; Nelson et al., 2007). The WHO recommends that older adults perform 150 minutes of moderate intensity physical activity a week, alongside strength and balance activities and the minimization of sitting for long periods, for substantial public health effect (WHO, 2010). Most of the previous studies regarding HRQOL, physical fitness and physical activity have focused on healthy older people (Olivares, Gusi, Prieto, & Hernandez-Mocholi, 2011), older people in primary care settings (Ozturk et al., 2011; Wang et al., 2008) or older people living in the community with existing mobility problems after a long hospital stay (Hill et al., 2011). The information is sparse regarding the association between the level of physical activity, physical fitness and HRQOL amongst older people recently discharged from hospital. It may be of importance to evaluate HRQOL, physical fitness and physical activity in the group of independent recently hospitalized older patients because previous studies indicate that they are at risk for inactivity, functional decline and decreased HRQOL after discharge from hospital. (Boyd et al., 2008; Nilsson, Westheim, & Risberg, 2008; Wolinsky et al., 2011). Thus, the purpose of this study was to describe the HRQOL, physical fitness and physical activity of patients after recent discharge from hospital and to compare their HRQOL with the general population of older people in Norway. A second objective was to explore which, if any,

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

variables (physical fitness, physical activity, demographics, reason for hospital admission, and number of chronic diseases) were independently associated with HRQOL. To the authors knowledge, no other study has examined these associations within a population of recently discharged patients before. Methods This study has a cross sectional design and forms the baseline data from a one-year randomized controlled aerobic exercise intervention trial.(Brovold et al 2013, in press) Participants The study group comprised older people aged > 70 admitted to hospital because of an acute medical event. Participants were initially recruited whilst resident in the hospital. The participants were included in the study if they lived independently in the community (they were allowed some domestic help or help from a nurse with medication), consented to participate in the aerobic exercise program twice a week, were able to manage the Timed Up and Go test in less than 20 seconds without the use of an assistive device, and assessed by a doctor as able to tolerate aerobic exercise. They were excluded if they had any cognitive disorder (Score on Mini Mental State Examination less than 24) (Folstein, Folstein, & McHugh, 1975), if they had a chronic disease with expected lifespan < 1 year, or if they exercised regularly more than twice a week at a fitness centre or in a structured exercise program. Those who reported regular or occasionally engagement in physical activities like walking, cycling or skiing were included. The Regional Ethics Committee for Medical Research and the Data Inspectorate at Oslo University Hospital approved the study.

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Measures Measurement of HRQOL occurred at baseline, 2-4 weeks after discharge from hospital, by a research assistant (physical therapist). The time-point was not standardized because the study participants had to finish their medical treatment at home before they could be tested and included in the study. This time-point was based on recommendation that rehabilitation should start within the first month after discharge (Boyd et al., 2008). Prior to test day, the questionnaires was sent by mail so the participants could fill in the forms at home. The research assistant checked the questionnaire for completeness. Where necessary, the questions left blank were filled in by interviewing the subject. Demographic variables Age (years), gender, household composition (defined as living alone or living with someone), use of outdoor walking aid (yes/no), hospital admission diagnosis and number and type of co-morbidities at the time of admission were recorded from the participants hospital notes and by asking the participants. Health-related quality of life (HRQOL) HRQOL was measured using the Medical Outcome Study 36 Item Short-Form Health Survey (SF-36) version 2 (Ware, 2000; Ware & Sherbourne, 1992). SF-36 is a generic and validated questionnaire, which is also translated into Norwegian (Loge & Kaasa, 1998). The 36 items in SF-36 are grouped into eight health status scales: physical functioning, role limitations due to physical problems and due to emotional problems, bodily pain, general health perception, vitality, social functioning and mental health (Ware, 2000; Ware & Sherbourne, 1992). Each subscale score were transformed according to the manual from 0 (worst) to 100 (best) (Ware,

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

2000). The SF-36 has high validity and reliability among older people (Haywood, Garratt, & Fitzpatrick, 2005; Latham et al., 2008). Population means of SF-36 v2 are equivalent to 50 10 and normal limits are considered to be within 1 (Ware et al 2000). The study sample was compared to an age-and sex matched Norwegian sample (Loge & Kaasa, 1998). This sample consists of 2323 Norwegian citizen aged 19-80 and 10 percent of the sample was aged between 70-80 years. In this study SF-36 v1 was used. However, the data from Loge and Kaasa (1998) was used as there are no norm-based data from v2 in Norway. Physical Fitness Physical fitness was defined as the capacity to perform daily activities safely and independently without fatigue and was measured by the Senior Fitness Test (SFT) (Rikli & Jones, 1999). The test consists of: number of Chair Stands in 30 seconds, number of Arm Curls in 30 seconds, Chair-Sit-and-Reach-Test (CSRT) (cm), Back Scratch Test (cm), 2.45 m Up-andGo test (seconds) and 6 min walk test 6 MWT and BMI (weight/height2). All of the tests have high reliability and validity and the procedures for administering SFT are standardized and described in detail (Rikli & Jones, 1999, 2013). The test has no reported floor or ceiling effect and is translated into Danish (Rikli, Jones, & Hanson, 2004) with normative values for the Norwegian older population provided by Langhammer and Stanghelle (2011). Physical Activity The level of physical activity (PA) was assessed using the Physical Activity Scale for the Elderly (PASE) which is a questionnaire developed for persons over 65 years with and without disabilities and systematically developed for epidemiological and clinical research (Washburn, McAuley, Katula, Mihalko, & Boileau, 1999). The PASE is translated into Norwegian and

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

slightly adjusted for use among Norwegian older people. The Norwegian version has been shown to have high and moderate reliability (Loland, 2002; Svege, Kolle, & Risberg, 2012). The PASE questionnaire comprises of self-reported household and leisure-time activities in the previous week. The leisure-time activities are divided into light, moderate or strenuous physical activity or muscle strength/endurance exercises. There are also six items concerning light or heavy housework, home repairs, lawn work or yard care, outdoor gardening and caring for another person. Those items are answered by yes or no. The last item is about work for pay or as a volunteer. The total PASE score is computed by multiplying time spent in each activity (hours per day) (for leisure and work-related activities) or participation (yes/no) in an activity (for household-related activities), by empirically derived weighting, and then summarizing all items. The total PASE score is derived from weights and frequency values for each activity and represent the overall activity level (Loland, 2002; Svege et al., 2012; Washburn et al., 1999). Statistical analysis The normality of the distribution was examined graphically by histograms and Q-Q plots and by using the Kolmogorov-Smirnov statistic. Data are described as means and standard deviations (SD) for normally distributed variables and median and quartiles (25,75) when variables did not reach normality. Categorical variables are described with proportions and percentages. Descriptive data for the SFT are given as mean and standard deviation (SD) and for PASE median (25,75 quartiles). Descriptive data for the different domains of SF-36 are presented as mean (SD), and 95 % Confidence Intervals (CI) to compare normative standards for gender and age. The student T-test for independent samples (or when data did not reach normality, the Mann- Whitney U-test) was used to identify significant differences in subject characteristics, HRQOL and physical fitness between the genders. Student T-test and chi-square

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

test was used to identify differences in age and genders in participants who were included in or excluded from the study. To evaluate the univariate associations between the demographics (age, household composition, hospital admission diagnosis and number of co-morbidities), SFT, BMI and PASE and each of the SF-36 scales univariate linear regression analyses were used (student T-test or Spearmans rank correlation). Further, to adjust for possible confounding variables with the strongest association with the outcome (p< .05) from the crude analyses were fitted into multiple linear regression models. Regression model assumptions were examined graphically and analytically. Statistical analysis was performed with the IBM SPSS Statistics 20.0. (SPSS Inc., Chicago, IL). P-values < .05 were considered statistically significant and all tests were twosided. Results A total of 115 participants were included in the study. Four hundred and ninty-six participants were screened and found eligible for the study. Forty-three percent were screen failures and thirty-four percent refused to participate. The participants who were excluded or refused to participate were significantly older than the participants who were included, mean age (SD) 79.6 (5) vs 78.0 (5) p< .001. No difference in gender was found amongst those who were included or excluded. Descriptive data and baseline score for SFT and PASE for all the participants are shown in Table 1. The participants ranged from 70-92 years, mean (SD) age was 78.0 (5.2) years. Descriptive data for HRQOL and the comparison of the SF-36 scores from the study-group and the reference-group are presented in Table 2 (Loge & Kaasa, 1998). There were differences between the genders in HRQOL on the subdomain SF-36 physical functioning, SF-36 bodily

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

pain and SF-36 social functioning, with women reporting significantly lower HRQOL than men (Table 2). No difference in HRQOL was seen between those who lived alone and those who lived with someone. Men had better physical fitness than women (see Table 1). Forty-one % of the women and 18 % of the men scored below 400 meters on 6 MWT. No difference in functional fitness was found between those who lived alone and those who lived with someone. The distribution of PASE was skewed and median and quartiles are presented in Table 1. The study sample scored lower than the Norwegian sample, median 59 (min, max) 0-268) vs. median 121 range 0-436 (Loland, 2002). However, unlike the sample from Loland, there were no differences in total PASE score between the men and women in the present study (p= .16, Mann Whitney U-test). There were no differences in PASE score between those who lived alone or lived with someone. Thirty-two % of the participants reported engagement in light leisure time activities, like walking 5-7 times per week, while 13 % reported engagement in moderate physical activity, like cycling or skiing 5-7 times per week. Results from multivariate regression analyses are listed in Table 3. There were no significant differences between the different hospital admission diagnoses, except that participants with a diagnosis of a transient ischemic attack (TIA) scored significantly higher on SF-36 vitality, bodily pain, general health and role physical than participants with other cardiopulmonary diseases. In univariate analysis there was a significant correlation between number of chronic disease and all of the subdomains of SF-36 except for role physical and vitality. All tests of SFT were positively associated with all subdomains of SF-36. The Chair Stand and the Arm Curl tests within SFT were highly correlated with each other and with the 6 Minute Walk Test (6MWT) (R > .6). Since the 6MWT was the main variable of interest only

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

6MWT was included in the final model to avoid multicollinearity. The univariate analyses showed that a number of chronic diseases were significantly associated with all of the subdomains of SF-36 except for role physical. One model was created for each subdomain of SF36 and was adjusted for possible confounders (Table 3). After controlling for confounders such as number of chronic disease, age and gender, significant associations remained between 6 MWT and all of the domains of SF-36 and between PASE and SF-36 physical functioning, role physical and general health. For instance, when all other variables in the model are held constant, for every fifty meter increase in 6 MWT, SF-36 physical functioning increases by 7.5 points (95 % CI 5.5, 9.5) (Table 4). For the models, the adjusted explained variance (adjusted R2) varied from 49.5 % (physical functioning) to 11.2 % (mental health). Discussion The purpose of this study was to describe and explore the associations between the HRQOL, physical fitness and physical activity of independent living older people after recent discharge from hospital. The results have been compared to HRQOL within the Norwegian ageand gender match population (Loge & Kaasa, 1998) and show that the participants discharged from hospital scored significantly lower on SF-36 than the age-matched Norwegian population. The difference observed is beyond the minimal important difference (MID) of 5-10 points reported in earlier studies (Wang et al., 2008). Pre-existing disease and comorbidity are major factors affecting HRQOL (Orwelius et al., 2010; Wang et al., 2008). This study included a group of participants who had a wide range of pre-existing conditions and who, therefore, were likely to already have lower HRQOL than age-matched norms without such co-morbidities. The results from this study showed a significant relationship between SF-36 and number of chronic diseases, however, in a multiple regression model, only 6 MWT remained significantly associated with all

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

of the subdomains of SF-36 after controlling for age, gender and number of chronic diseases. This result is consistent with previous literature (Groessl et al., 2007; Horder et al., 2012) and indicates that declining physical fitness may have greater negative impact on HRQOL than many distinct diseases for older people being discharged from hospital. Maintaining adequate physical fitness and walking endurance are important to preserve independence in activities of daily living and HRQOL among older people (Acree et al., 2006; Lobo, Carvalho, & Santos, 2011). Physical fitness is especially crucial to continue with interests such as going to the theatre, taking a walk in the park, shopping for groceries, meeting friends or be able to travel (Cress et al., 2005; Lobo et al., 2011). As already mentioned, for older people, hospitalization is associated with an increased risk of loss of function and reduced HRQOL (Alley et al., 2010; Covinsky, Pierluissi, & Johnston, 2011; Helvik et al., 2010; Wolinsky et al., 2011). Inactivity, in the post-discharge period especially, is hypothesized to be closely related to this decline. In the present study, higher levels of physical activity were independently associated with better HRQOL (physical functioning, general health and vitality) and better physical fitness. Although several studies have shown that physical activity plays a critical role in promoting perceived HRQOL (Kelley et al., 2009; Motl & McAuley, 2010) and on the management of illness among adults (Chodzko-Zajko et al., 2009; Murphy, Sheane, & Cunnane, 2011), the level of physical activity in this population is very low. In the present study, participants were excluded if they exercised regularly at a fitness center, but the participants were included if they reported physical activities such as walking and cycling. Thirteen percent of the study participants reported engagement in moderate physical activity in line with recommendations of >150 min/week (WHO, 2010), while 32 % of the study participants reported engagement in physical activities with lower intensities like walking. This result indicates that increased focus

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

on physical activity while resident in hospital may be of importance, because inactivity in combination with acute hospitalization and comorbidities is associated with increased risk for functional decline and further disease progression (Covinsky et al., 2011). Poor self-perceived health (Dogra, 2011) and low self-efficacy, fear of falling and fear of injury during the activity are also associated with low levels of physical activity (Ashe, Eng, Miller, & Soon, 2007; Hill et al., 2011). None of the participants included in this study had any activity restrictions due to their acute illness or co-morbidities, furthermore, they were functionally independent, indicating that participants should be motivated to engage in moderate intensity physical activities to improve their physical fitness and their disease treatment (Dogra, 2011; Nelson et al., 2007). It is also important for older people with chronic disease to engage in physical activity as much as possible as they are at risk of developing a reduced tolerance to activity, further sedentary lifestyle behaviour and compromised health (Ashe et al., 2007). In the present study 41 % of the women and 18% of the men scored below 400 m on 6 MWT, the threshold associated with higher risk of mobility limitations and disability (Newman et al., 2006). Several studies have shown that health-care personnel have an opportunity to influence older peoples physical activity (Buttery & Martin, 2009; Hill et al., 2011; Hirvensalo, Heikkinen, Lintunen, & Rantanen, 2005). In a recent study the level of physical activity increased after participating in a combined exercise program consisted of counseling and exercise follow-up from physical therapists at home, among older people recently discharged from a geriatric day-hospital (Brovold, Skelton, & Bergland, 2012). Other studies have shown similar results (Courtney et al., 2009). Hill and colleagues (2011) found that older people increased their participation in exercise if they had been recommended to do so by the hospital physiotherapist (Hill et al., 2011).

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Strength and Limitations The findings from this study have a number of limitations. The cross-sectional design of the study does not allow us to conclude on causality and the total sample size was relatively small. Subjects were enrolled in an intervention trial with an aerobic exercise component, they are more likely to be fitter and perhaps more engaged than those who would not have agreed to be part of the intervention. Those who agreed to participate were significantly younger than those who were excluded or refused to participate. Furthermore, this study did not consider those who did not live independently and those who have a TUG greater than 20 seconds, as this group of patients would require a different approach to exercise. Therefore, the associations seen in this study may not be applicable to the overall population of older people recently discharged from hospital. However, the correlations between HRQOL and physical fitness found in this study, correspond well with results from other studies evaluating HRQOL in a frailer patient group (Helvik et al., 2010), and among healthy older adults (Horder et al., 2012; Olivares et al., 2011). The PASE was used to measure participation in physical activities. This questionnaire asks about activities in the previous week. It is possible that the subjective responses from the participants in this study could have been influenced by their recent hospital stay, the advice received from professionals or other factors. The multivariate models in this study did not fully explain HRQOL indicating that HRQOL is a complex construct. In this study, 6 MWT, PASE, age, gender, BMI and number of chronic diseases accounted for 49.5 % of the variance in SF-36 physical functioning and only 11.2 % in mental health. This means that 50.5 % of the variance in the SF-36 physical functioning and 88.8 % of the variance in the SF-36 mental health remained unexplained by the models. These findings suggest that associations of physical fitness may be stronger with

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

HRQOL than mental health components (Takata et al., 2010). Furthermore, previous studies have identified factors like self-efficacy (Stretton, Latham, Carter, Lee, & Anderson, 2006), social support (Harvey & Alexander, 2012) and emotional conditions such as anxiety and depression (Helvik et al., 2010) to be significantly associated with functional and mental health among older people. Further research is necessary to examine associations between these factors and HRQOL amongst this population recently discharged from hospital. The strengths of the study include the use of performance-based tests to objectively assess physical fitness. Furthermore, the study sample included older people with chronic disease after recent discharge from hospital. Their hospitalization had been due to acute illnesses like cerebrovascular disease, cardiopulmonary disease, arrhythmias and infections. This patient group may be especially amenable for prevention strategies because of the increased risk for future functional decline and decreased HRQOL. Considering the possible limitations and the strengths mentioned above, this study provides important information about the associations between HRQOL, physical activity and physical fitness in a population of older people recently discharged from hospital. Although preadmission co-morbidities and function will have had an effect, in accordance with previous results in different older populations, this study showed that physical fitness, measured by 6 MWT and physical activity was significantly associated with SF-36 score post-discharge. Indeed, it seems reasonable to propose that implementation of exercise rehabilitation or promotion of physical activity for older adults recently discharged from hospital could positively influence HRQOL of this population sub-sample, though this needs testing in a future RCT trial.

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Conclusion In conclusion, the results from this study show that engagement in physical activity and higher levels of physical fitness are associated with higher self-reported HRQOL among older people, with a wide range of co-morbidities, recently discharged from hospital after an acute medical illness. The results showed that the participants had lower levels of HRQOL compared to an age-matched Norwegian sample and that the level of physical activity post-discharge was low. This cross-sectional study, although not designed to look at cause and effect, suggests that it would be beneficial for health-care personnels to provide encouragement and opportunity to engage in physical activity and physical fitness for their patients while admitted at hospital. This advice should help patients increase their level of activity after acute illness and hospitalization, in order to help preserve independence and HRQOL. The study implies that it is especially important to target those with lower levels of physical activity, poorer physical fitness and those with multiple co-morbidities. Acknowledgements The authors want to thank physical therapist Ellen Hamre for her valuable contributions to our project.

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

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Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

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Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Table 1 Socio-demographics variables and baseline score for senior fitness test and physical activity of the whole sample
All participants N =115 Age, years, M(SD) Living alone, % Hospital diagnosis Cerebrovascular disease % Heart attack/chest pain % Arrythmias % Infections % Mean number of chronic disease (SD) No.of participants with Cerebral insult Heart disease Arrhythmias Hypertension Chronic lung disease Musculoskeletal disease Osteoporosis Cancer Diabetes type II Other Senior Fitness Test Chair Stand, number, M (SD) Arm Curl, reps, M (SD) Back Scratch, cm M (SD)
Chair sit and reach, cm, M (SD)

Women n= 70 78.3 70* 24 34 21 25 (5.0)

Men n= 45 77.4 31 30 28 12 30 (5.4)

78.0 54 25 32 19 24

(5.2)

2.5

(1.2)

2.7*

(1.1)

2.2

(1.3)

20 63 35 29 17 45 5 18 12 39

12 36 21 19 12 37* 5 10 7 27

8 27 14 10 5 8 0 8 5 12

10.2 13.6
-14.5 -2.9

(3.4) (3.7)
(12.5) (12.4)

9.4 12.7
-11.5 -0.5

(3.3)* (2.8)*
(11.4)* (10.6)*

11.4 15.0
-19.0 -6.3

(3.3) (4.4)
(13.0) (14.1)

2.45 m up and go, s, M (SD) 6.9 (2.1) 7.5 (2.1)* 6.0 (1.6) 6 MWT ,m, M (SD) 452.7 (115) 416.2 (105.3)* 509.4 (106) PASE Median (Quartile 1,Quartile 2) 59 (30,105) 55 (30,86) 85 (32,117) Note. 6 MWT= 6 Minute Walk Test. PASE (Physical Activity Scale for elderly). PASE presented as median (interquartil range) as data not normally distributed. * p< .05 significant difference between men and women

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Table 2. Comparison of the SF-36 scale of the study group and those of the an age-and gender matched Norwegian Sample (mean,standard deviation (SD), 95 % Confidence Interval (CI))
Study group Malen= 45 Mean (SD) Physical Functioning Role Physical General Health Vitality Mental Health Bodily Pain Social Functioning Role Emotional Female n= 70 Mean 52.4 38.9 50.4 38.2 64.3 47.6 60.7 49.6 Reference group Age group 70-80 years Male Female (SD) (24)* (20) (16) (19) (25)* (28)* (29) (24)* Mean 75.0 52.5 67.5 61.9 82.7 69.4 82.3 69.7 (SD) (20) (17) (22) (29) (24) (23) (44) (38) Mean 56.1 37.0 62.5 50.6 76.7 59.5 74.1 59.5 (SD) (28) (18) (23) (29) (29) (22) (43) (44) -12.3 -10.5 -15.5 -17.7 -16.9 -10.2 -10.3 -12.1 (-4,-21)* (-23.4,2) (-24,-8)* (-25,-11)* (-22,-11)* (-20,-0.6)* (-19,-2)* (-22,-2)* -3.7 1.9 -12.1 -12.4 -12.4 -11.9 -13.4 -9.9 (-8,0.2) (-9,13) (-20,-5)* (-19,-6)* (-18,-7)* (-20,-4)* (-22,-5)* (-21,1) Mean Difference From Population Norms Male Mean Female Mean

(95 % CI)

(95 % CI)

62.7 42.0 52.0 44.2 65.8 59.2 72.0 57.6

(27) (23) (18) (18) (28) (25) (32) (27)

* p< .05 significant difference between the genders and between the study group and the age-and gender matched Norwegian Sample from Loge and Kaasa(1998) Note: sample size differs in the Norwegian sample from 97-115 participants in each gender group (Loge and Kaasa 1998)

Association Between Health-Related Quality of Life, Physical Fitness and Physical Activity in Older People Recently Discharged from Hospital by Brovold T, Skelton DA, Bergland A Journal of Aging and Physical Activity 2013 Human Kinetics, Inc.

Table 3 Multivariable regression models for the SF-36 scales (unstandardized (95 % confidence interval (CI) )

Physical Functioning (95 % CI)* Age p Gender p Chronic disease p 6 MWT p PASE p 0.54 (-0.2,1.4) .17 3.54 (-4.5,11.6) .39 -0.68 (-2.7,4.1) .69 0.15 (0.11,0.19) .001 0.07 (0.05,0.14) .035

Role Physical (95 % CI)* 0.90 (-0.24,0.20) .12 9.43 (-1.41,20.59) .09 1.95 (-3.02,6.92) .44 0.13 (0.8,1.9) .001 0.09 (-0.12,0.18) .084

General Health (95 % CI)* 0.71 (0.6,1.36) .032 7.24 (-0.05,14.4) 0.048 -0.30 (-3.57,2.96) .85 0.08 (0.05,0.12) .001 0.10 (0.03,0.16) .004

Vitality (95 % CI)* 0.2 (-0.4,0.3) .53 -2.0 (-9.29,5.24) .58 2.0 (-1.30,5.30) .23 0.04 (0.01,0.08) .044 0.83 (0.02,0.15) .013

Mental Health (95 % CI)* 0.13 (-0.46,0.72) .67 .19 (-2.4,10.7) .21 -2.60 (-5.58,0.37) .086 0.05 (0.01,0.08) .008 0.05 (-0.05,0.08) .86

Bodily Pain (95 % CI)* 0.82 (-0.23,1.87) .12 -5.52 (-15.83,4.76) .29 1.03 (-3.62,5.68) .61 0.06 (0.01,0.012) .032 0.69 (-0.02,0.16) .14

Social Functioning (95 % CI)* 0.26 (-0.71,1.23) .59 -3.79 (-14.48,6.98) .48 -1.66 (-6.51, 3.19) .50 0.07 (0.01,0.12) .02 0.04 (-0.05,0.14) .38

Role Emotional (95 % CI)* 0.85 (-0.53,1.74) .065 -0.28 (-10.2,9.62) .95 -0.94 (-5.5,3.5) .68 0.068 (0.02,0.12) .011 0.87 (-0.0,0.02) .0053

Adjusted R2 49.5 24.9 32.3 12.7 12.2 15.3 11.2 16.7 Note. 6 MWT= 6 minute walk test; PASE= Physical activity Scale for Elderly Gender 0= male. 1= female. The models are adjusted for age, sex and number of chronic disease. Significant results are bolded.