Journal of Aging and Physical Activity, 2015, 23, 120-127 http://dx.doi.org/10.1123/JAPA.2013-0164 © 2015 Human Kinetics, Inc.
Official Journal of ICAPA www.JAPA-Journal.com ORIGINAL RESEARCH
Impact of Psychosocial Factors on Functional Improvement in Latino Older Adults After Tai Chi Exercise Ka-Chun Siu, Shireen S. Rajaram, and Carolina Padilla Increasing evidence underscores the health benefits of Tai Chi (TC), although there is limited evidence of benefits among racial and ethnic minorities. This study investigated the impact of psychosocial status on balance among 23 Latino seniors after a twice-a-week, 12-week TC exercise program. Functional status was measured at baseline, immediately after, and three months following the TC exercise program, using the Timed Up and Go Test and Tinetti Falls Efficacy Scale. Psychosocial status was measured at baseline by the Center for Epidemiologic Studies Depression Scale and Norbeck Social Support Questionnaire. Both measures of functional status improved and were sustained after three months of TC. Greater improvement was significantly related to a higher level of baseline social support. More depressed seniors reported less fear of falling after TC. Depression and social support are important moderators of functional improvement after TC among Latino seniors. Keywords: balance, depression, social support
A growing body of evidence demonstrates the effectiveness of Tai Chi exercise in preventing falls among older adults (Li, Hong, & Chan, 2001; Li et al., 2008; Low, Ang, Goh, & Chew, 2009; Wu, 2002; Yan & Downing, 1998). Tai Chi, a traditional Eastern exercise, has more than a thousand years of history. It is an engaging, evidence-based intervention that consists of a number of exercise modules focusing on stability, mobility, flexibility, and sustainability, all of which are key components to maintaining balance. Tai Chi has been shown to decrease rates of falls among older adults by improving balance while also encouraging healthy, noninjurious activity in a safe social atmosphere that builds confidence and mastery (Costello & Edelstein, 2008; Kutner, Barnhart, Wolf, McNeely, & Xu, 1997; Rand, Miller, Yiu, & Eng, 2011; Yan, 1998). Studies on the effectiveness of Tai Chi have mainly focused on Chinese and non-Latino White older adults. There is limited research that examines the effectiveness of this exercise on balance among different racial and ethnic minority older adults. More specifically, there is a paucity of data on the effectiveness of a Tai Chi exercise program among Latino older adults, a population that has high rates of health disparities, including falls. Indeed, a recent report from the Centers for Disease Control and Prevention showed that Latino older adults reported the greatest percentage of fall-related injuries (Stevens, Mack, Paulozzi, & Ballesteros, 2008). In a study by Thomson, Nuru-Jeter, Richardson, Raza, and Minkler (2013), both immigrants and foreign-born Mexican and Cuban older adults had higher self-reported functional limitations compared with both immigrants and U.S.-born, non-Latino Whites. The odds for functional limitations were significantly higher for those who could not speak English compared with those who spoke English at home and for the increasing length of stay in the United States. The prevalence of functional limitation ranged from one in four for Mexican American immigrants to one in three for Cuban Americans born in the United States.
Siu is with the Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha, NE. Rajaram is with the College of Public Health, University of Nebraska Medical Center, Omaha, NE. Padilla is with the Intercultural Senior Center, Omaha, NE. Address author correspondence to Ka-Chun Siu at [email protected]. 120
Latinos are the fastest growing ethnic population in the United States and will compromise a third of the population by 2050 (Passel & Cohn, 2008). As the population ages, the proportion of Latino older adults is expected to increase steadily. By 2019, the Latino population aged 65 and older is projected to be the largest ethnic minority in this age group (Department of Health and Human Services, Administration on Aging, 2010). Hayes-Bautista, Hsu, Perez, and Gamboa (2002) have referred to this as the “browning of the graying” of the United States. In addition, Latino older adults have higher rates of poverty and lower educational attainment compared with non-Latino Whites (Department of Health and Human Services, Administration on Aging, 2010; Thomson et al., 2013). As reflective of the “Latino paradox,” despite their relative disadvantaged social position (including education and income), Latinos have better than expected life expectancy and lower mortality rates compared with non-Latino Whites (Markides & Eschbach, 2005; Thomson et al., 2013). A part of the lifestyle explanation of the “Latino paradox” includes the fact that Latinos have social and cultural factors such as stronger social ties and larger social networks compared with non-Latinos, which provide a protective effect with regards to mortality (Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999; Palloni & Arias, 2004; Thomson et al., 2013; Vega, Rodriguez, & Gruskin, 2009). Familismo, or the importance of kin, is an important institution for Latinos, and emphasizes family solidarity and an obligation to care for the older adults in multigenerational households (de Vos & Arias, 2003; Ruiz, 2007). A study by Ruiz (2007) showed that as Latinos age they report a decrease in support from kin. Interestingly, this has resulted in a reframing of the concept of family to go beyond bloodlines to include a social network of neighbors and friends. Emerging evidence shows that psychological factors such as social support and depression impact the functional status of older adults. For example, social support has been shown to have a positive effect on functional capacity and overall health of older adults (Beyene, Becker, & Mayen, 2002; de Brito & Pavarini, 2012; Golden, Conroy, & Lawlor, 2009; Stuck et al., 1999). A longitudinal epidemiological study with ~2,800 older adults revealed a significant association between social engagement and disability; more socially engaged participants had less physical disability in activities of daily living. This research underscores the important
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Functional Improvement in Latino Older Adults 121
impact of social support on physical health and the prevention of physical disability (Mendes de Leon, Glass, & Berkman, 2003). A study of 83 Latino elders showed that the quality of social support influenced a sense of emotional well-being despite challenges in physical functional capacity and chronic health conditions (Beyene, Becker, & Mayen, 2002). Similarly, a recent study to promote successful aging evaluated over 1,000 community-dwelling older adults and found an association between depression and successful aging. They concluded that reducing depression might lead to successful aging by reducing physical disability (Jeste et al., 2013). Of note, limited studies explored the interaction between functional status and psychosocial factors among Latino older adults. Given the high rates of functional limitation in the Latino population compared with the non-Latino White population (Stevens et al., 2008), and the growing proportion of Latino older adults, there is an urgent need to better understand the interaction between functional ability and psychosocial factors affecting balance–both strong indicators of quality of life (Thomson et al., 2013). The purpose of this study was to: (a) investigate the impact of a Tai Chi exercise program on functional status in Latino older adults and (b) to examine if psychosocial factors such as social support and depression mediate changes in functional status following a 12-week Tai Chi program. We hypothesized that the functional status (e.g., balance) would be improved and psychosocial factors would be associated with improvements in functional status among Latino older adults after the Tai Chi program. Furthermore, we expected that the benefits would be sustained three months after completion of the exercise program.
Method Participants We recruited 23 Latino adults (7 males and 16 females) with an average age of 65 years (ranging from 51 to 91 years) from the Intercultural Senior Center, a local senior center in a Midwestern metropolitan city. All participants lived in the community, either independently or with their family. They were able to follow instructions and had normal or corrected vision and hearing. They did not have a diagnosis of cognitive disturbances, neurological, affective, orthopedic, vascular, or other comorbidities that are likely to impact balance or the ability to stand without support. The project was approved by the institutional review board of the University of Nebraska Medical Center for human subject compliance.
Materials After completion of the informed consent process, data were collected from participants using the following set of established and validated functional and psychosocial assessments at three points in time: (1) at baseline before the program (pre); (2) immediately after the 12-week program (post); and (3) three months following completion of the program (3M). Timed Up and Go (TUG) Test. This test measures balance and is administered by a trained physical therapist. It requires participants to stand up from a chair with arms, walk 3 m to a line marked on the floor, turn and walk back, and sit down. Participants who performed the TUG within a shorter time have better balance (Shumway-Cook, Brauer, & Woollacott, 2000). Tinetti’s Fall Efficacy Scale (FES). This self-report questionnaire measures level of confidence in performing 10 daily activities,
such as taking a bath or shower and getting on and off of the toilet. Scores range from 10 to 100. Lower scores indicated a higher level of confidence to perform all activities (Tinetti, Richman, & Powell, 1990). The Center for Epidemiologic Studies Depression Scale (CESD). This psychosocial self-report questionnaire, administered
only at baseline, measures depressive symptoms. It is a 4-factor, 20-item questionnaire. Participants who received 16 points or more were considered depressed (Andresen, Malmgren, Carter, & Patrick, 1994). The Norbeck Social Support Questionnaire (NSSQ). This self-
report questionnaire, administered only at baseline, measures several dimensions of social support, including social function, social network, social aid, and loss (Norbeck, Lindsey, & Carrieri, 1981).
Procedure All participants first completed the functional assessments and psychosocial evaluation. Next, they began a “Moving for Better Balance (MBB)” Tai Chi program. This program was developed from a randomized, controlled trial for community-based use and significantly improved health-related outcomes among older adults, including reducing the number of falls and the fear of falling. This Tai Chi program was chosen since it is practical to disseminate and can be effectively implemented and maintained in various community settings (Li et al., 2008). Participants practiced eight forms of Tai Chi movement that engaged the core and promoted stability, beginning with the basic level of “hold the ball” exercise to the advanced level of “Repulse Monkey” (Figure 1). They attended the MBB program two times a week for 12 weeks, and were led by a Latino Tai Chi Instructor from the community who was trained and certified in Tai Chi instruction by the local chapter of the National Safety Council. Upon the completion of the 12-week MBB program, the second set of functional assessments was conducted to examine the immediate effect of the Tai Chi exercise program on participants’ balance performance. The third set of functional assessments was performed three months after the Tai Chi program to examine the long-term sustained effect of Tai Chi exercise on participants’ balance performance.
Statistical Analysis One-way ANOVA with repeated measures was used to examine the immediate (post) and long-term (3M) effects of Tai Chi exercise on functional status of all participants. The differences of functional assessments between pre and post, as well as pre and 3M, were calculated. Pearson’s correlation coefficient was used to examine the relationship between functional changes after the Tai Chi exercise program and baseline psychosocial status. Partial correlations were performed to adjust for confounding factors such as age and sex. The significant level was set as alpha = .05.
Results All 23 Latino older adults completed the 12-week MBB Tai Chi program. No injury occurred during the sessions. Demographical information and initial results of functional status are presented in Table 1.
122 Siu, Rajaram, and Padilla
Table 1 Demographics and Initial Clinical Assessments Demographics Participants (N) Age (mean ± SD)
23 65.22 ± 10.22
Gender (% female)
69.57
Latinos
100%
Initial Clinical Assessments
(Mean ± SD)
CESD
16.52 ± 10.20
NSSQ—Social function
113.00 ± 71.51
NSSQ—Social network
54.70 ± 30.81
NSSQ—Loss
2.83 ± 2.85
TUG (in second)
13.46 ± 4.21
FES
17.43 ± 13.18
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Note. CESD = Center for Epidemiologic Studies Depression Scale; NSSQ = Norbeck Social Support Questionnaire; TUG = Timed Up and Go Test; FES = Tinetti’s Falls Efficacy Scale.
Changes in Functional Status Timed Up and Go Test (TUG). A significant main effect of time on the changes in TUG was found (P = .003). The time to complete TUG was reduced significantly in pre–post (P = .048), and no change was found in post–3M (P = .745; Figure 2). Reduction in time to complete TUG indicates that participants’ balance improved and TUG performance was sustained after three months of the Tai Chi exercise program. Tinetti’s Fall Efficacy Scale (FES). A significant main effect of
time on the changes in FES was found (P = .038). Participants’ self-reported scores of FES improved between pre–post, but the differences did not reach a level of significance (P > .05). However, there was a significant linear trend (P = .027) from pre to 3M post MBB Tai Chi program, indicating an improvement in fear of falling over a three-month period following completion of the Tai Chi program (Figure 3).
Associations Between Psychosocial Factors and Changes in Functional Status Timed Up and Go Test (TUG). Psychosocial factors (social support and depression) were assessed at baseline before the start of the Tai Chi program. Significant associations were found between the NSSQ (social function) and changes in TUG (Figure 4) as well as between the NSSQ (social network) and changes in TUG (Figure 5). Particularly, significant positive and strong associations were shown between social function and changes in TUG in both pre–post (r = .606, P = .002) and pre–3M (r = .547, P = .008). Significant positive and moderate to strong associations were shown between social network and changes in TUG in both pre–post (r = .618, P = .002) and pre–3M (r = .520, P = .013). Partial correlation coefficient revealed that all significant associations remained after adjusting for age and sex. However, nonsignificant and very weak associations were found between CESD (depression) and changes in TUG. Figure 1 — Eight forms of Tai Chi movement in the “Moving for Better Balance” program.
Tinetti’s Fall Efficacy Scale (FES). A significant association was found between CESD (depression) and changes in FES (Figure 6). Particularly, a significant positive and strong association
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Functional Improvement in Latino Older Adults 123
Figure 2 — Timed Up and Go Test performance at three time points (pre, at baseline before program; post, immediately after program; 3M, three months after program completion).
Figure 3 — Scores for Tinetti’s Fall Efficacy Scale at three time points (pre, at baseline before program; post, immediately after program; 3M, three months after program completion).
was shown between CESD and changes in FES in pre–3M (r = .588, P = .004), but not in pre–post. Partial correlation coefficient revealed that the significant association remained after adjusting for both age and sex. In addition, nonsignificant and very weak associations were found between the NSSQ (social network) and changes in FES.
Discussion This study focused on the impact of Tai Chi exercise on the functional ability among Latino older adults and also examined the interaction of psychosocial factors (e.g., social support and depression)
following a 12-week Tai Chi exercise program. We hypothesized that functional status (e.g., balance) would be improved immediately after the program, and improvements would be sustained three months following completion of the program. In addition, such improvements would be mediated by the psychosocial status of the Latino older adults. All Latino participants improved their functional status (reduced the time to complete the Timed Up and Go test) and sustained the improvement three months following completion of the program. These results support our hypothesis that practicing Tai Chi can improve balance among Latino older adults. Although previous research studies in Tai Chi have shown similar physical
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124 Siu, Rajaram, and Padilla
Figure 4 — Associations between TUG and social function. TUG = timed up and go; NSSQ = Norbeck Social Support Questionnaire; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
Figure 5 — Associations between TUG and social network. TUG = timed up and go; NSSQ = Norbeck Social Support Questionnaire; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
benefits, there is a paucity of research on underrepresented populations, particularly Latino older adults (Li, Hong, & Chan, 2001; Li et al., 2008; Low et al., 2009; Wu, 2002; Yan & Downing, 1998). This study focused on Latino older adults and found similar improvements compared with non-Latino White older adults. Especially important, this study also provided evidence of the long-term effects of Tai Chi on functional status, and demonstrated that improvements in balance were sustained three months following the Tai Chi program. Previous studies indicated Tai Chi could increase
muscle strength and postural stability (Li, Hong, & Chan, 2001; Li et al., 2008; Low et al., 2009), which may explain why Latino older adults in this study sustained improvements in functional status as measured by TUG and FES. In addition to increasing physical strength, studies have shown that factors, such as self-confidence, play a key role for older adults to maintain their balance and perform daily activities (Beyene et al., 2002; Li, McAuley, Harmer, Duncan, & Chaumeton, 2001; Stuck et al., 1999). Older adults with a higher level of confidence
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Functional Improvement in Latino Older Adults 125
Figure 6 — Associations between FES and CESD. FES = fall efficacy scale; CESD = Center for Epidemiologic Studies Depression Scale; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
in balance to perform daily tasks were less likely to trip and fall when unexpected perturbation occurred in their surrounding environment (Jeste et al., 2013; Portegijs et al., 2012). In this study, scores on the self-report of the fall efficacy scale improved, suggesting that Latino participants gained confidence in performing certain daily activities without assistance from family members or friends. Practicing Tai Chi not only improved the functional status of the older adults, but also enhanced their independence. Participants became more confident in maintaining their balance and accomplishing daily routine by themselves, both immediately and three months following the 12-week Tai Chi program. Improvements in functional status and internal confidence were closely associated with psychosocial factors such as depression or social support. For example, older adults with higher social support (larger social function and network) had greater improvements in balance after the Tai Chi program (Figures 4 and 5). Studies have indicated that older adults with a higher level of social support (i.e., larger social function or networks) can be easily motivated by peers to be active and perform daily tasks compared with those with lower levels of social support (Golden et al., 2009; Mendes de Leon et al., 2003; Stuck et al., 1999). It should be noted that our sample of Latino older adults might represent a self-selected group with higher levels of social support compared with the general population of older adults. To participate in the 12-week Tai Chi program, Latino participants required assistance with transportation from family members to attend the classes held twice a week at the Intercultural Senior Center. It is likely that improvements in functional status in our sample are reflective of older adults with a solid level of social support. This study also investigated the association between depression and changes in functional status after the Tai Chi exercise program. Interestingly, our data indicated that participants with baseline higher level of depression had larger changes in confidence to perform daily activities. The association only showed significance between baseline testing and three months after the Tai Chi program. These results demonstrate that older adults with
depressive symptoms (scores 16 or higher on CESD) gain more confidence in performing daily activities after Tai Chi exercise. However, it is possible that the older adults with no depression already had strong confidence to perform daily tasks, and hence did not show significant improvements following the Tai Chi program. It also suggests that the lack of improvement in functional status among nondepressed Latino older adults might be limited by the possible floor effects of FES. In other words, older adults who initially self-report a higher level of confidence to perform daily tasks (e.g., score of 10 on the FES) do not gain further changes after the Tai Chi program. Nonetheless, a significant association between depression and changes in physical status was found three months after the Tai Chi program (Figure 6). The findings suggest that practicing Tai Chi could provide benefits for depressed Latino older adults to regain their self-esteem and confidence to encounter daily activities by themselves and be more independent. Overall, the findings from this study underscore that regardless of race or ethnicity, older adults can practice Tai Chi and improve their functional status, which can be sustained for a minimum of three months following the training period. These improvements in functional status can help prevent fall incidence, a serious problem among older adults. This study has a few limitations. First, this is a self-selected sample, which can introduce selection bias and restricts the generalizability of the findings to the general population of communitydwelling older adults. Second, the study design does not have a randomized control group and, therefore, it is not possible to definitively attribute improvements in functional ability to the Tai Chi exercise program. Third, psychosocial variables were measured only at baseline, before the exercise program. Hence, changes in psychosocial status immediately after and three months following the program and possible interactions with functional status are not discernible. Fourth, this study did not monitor whether participants participated in any other exercise program during or after the 12-weeks Tai Chi program. Finally, all participants in
126 Siu, Rajaram, and Padilla
this study were Latino older adults. It is likely that sociocultural factors such as familismo might restrict the generalizability of the findings to other racial or ethnic senior populations.
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Implications and Conclusions This study demonstrates that a Tai Chi exercise program could be a simple and useful exercise program for community-dwelling Latino older adults to improve their functional status and decrease their risk for falls. It is important to examine psychosocial factors such as social support and depression in Latino older adults when testing the impact of exercise interventions. It is likely that psychosocial factors function as critical mediators that determine the effectiveness of an exercise intervention program among Latinos and other racial or ethnic groups of older adults. With the growing proportion of Latino older adults, and given the high rates of functional limitation in this population, there is an urgent need to better understand the interaction between functional ability and psychosocial factors affecting balance, both strong indicators of the quality of life (Thomson et al., 2013). As the population ages nationally and globally, it is important to determine a best practice that takes into account low-cost and low-impact exercise modalities such as Tai Chi, and the mediating effect of key psychosocial variables, such as depression and social support on functional status. While this study focused on Latino older adults in the United States, the findings from this study are generalizable to diverse public health practice contexts across the globe to ensure healthy aging for all. Acknowledgments The project was supported by the Mutual Fund from the College of Public Health at the University of Nebraska Medical Center. Authors would like to thank the two Hispanic Tai Chi Instructors, Ms. Teresita Ayala and Ms. Ilda Vazqves, for teaching the Tai Chi program, and the student researcher, Kelsey Wilhelm, for data collection at the Intercultural Senior Center.
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Official Journal of ICAPA www.JAPA-Journal.com ORIGINAL RESEARCH
Impact of Psychosocial Factors on Functional Improvement in Latino Older Adults After Tai Chi Exercise Ka-Chun Siu, Shireen S. Rajaram, and Carolina Padilla Increasing evidence underscores the health benefits of Tai Chi (TC), although there is limited evidence of benefits among racial and ethnic minorities. This study investigated the impact of psychosocial status on balance among 23 Latino seniors after a twice-a-week, 12-week TC exercise program. Functional status was measured at baseline, immediately after, and three months following the TC exercise program, using the Timed Up and Go Test and Tinetti Falls Efficacy Scale. Psychosocial status was measured at baseline by the Center for Epidemiologic Studies Depression Scale and Norbeck Social Support Questionnaire. Both measures of functional status improved and were sustained after three months of TC. Greater improvement was significantly related to a higher level of baseline social support. More depressed seniors reported less fear of falling after TC. Depression and social support are important moderators of functional improvement after TC among Latino seniors. Keywords: balance, depression, social support
A growing body of evidence demonstrates the effectiveness of Tai Chi exercise in preventing falls among older adults (Li, Hong, & Chan, 2001; Li et al., 2008; Low, Ang, Goh, & Chew, 2009; Wu, 2002; Yan & Downing, 1998). Tai Chi, a traditional Eastern exercise, has more than a thousand years of history. It is an engaging, evidence-based intervention that consists of a number of exercise modules focusing on stability, mobility, flexibility, and sustainability, all of which are key components to maintaining balance. Tai Chi has been shown to decrease rates of falls among older adults by improving balance while also encouraging healthy, noninjurious activity in a safe social atmosphere that builds confidence and mastery (Costello & Edelstein, 2008; Kutner, Barnhart, Wolf, McNeely, & Xu, 1997; Rand, Miller, Yiu, & Eng, 2011; Yan, 1998). Studies on the effectiveness of Tai Chi have mainly focused on Chinese and non-Latino White older adults. There is limited research that examines the effectiveness of this exercise on balance among different racial and ethnic minority older adults. More specifically, there is a paucity of data on the effectiveness of a Tai Chi exercise program among Latino older adults, a population that has high rates of health disparities, including falls. Indeed, a recent report from the Centers for Disease Control and Prevention showed that Latino older adults reported the greatest percentage of fall-related injuries (Stevens, Mack, Paulozzi, & Ballesteros, 2008). In a study by Thomson, Nuru-Jeter, Richardson, Raza, and Minkler (2013), both immigrants and foreign-born Mexican and Cuban older adults had higher self-reported functional limitations compared with both immigrants and U.S.-born, non-Latino Whites. The odds for functional limitations were significantly higher for those who could not speak English compared with those who spoke English at home and for the increasing length of stay in the United States. The prevalence of functional limitation ranged from one in four for Mexican American immigrants to one in three for Cuban Americans born in the United States.
Siu is with the Division of Physical Therapy Education, University of Nebraska Medical Center, Omaha, NE. Rajaram is with the College of Public Health, University of Nebraska Medical Center, Omaha, NE. Padilla is with the Intercultural Senior Center, Omaha, NE. Address author correspondence to Ka-Chun Siu at [email protected]. 120
Latinos are the fastest growing ethnic population in the United States and will compromise a third of the population by 2050 (Passel & Cohn, 2008). As the population ages, the proportion of Latino older adults is expected to increase steadily. By 2019, the Latino population aged 65 and older is projected to be the largest ethnic minority in this age group (Department of Health and Human Services, Administration on Aging, 2010). Hayes-Bautista, Hsu, Perez, and Gamboa (2002) have referred to this as the “browning of the graying” of the United States. In addition, Latino older adults have higher rates of poverty and lower educational attainment compared with non-Latino Whites (Department of Health and Human Services, Administration on Aging, 2010; Thomson et al., 2013). As reflective of the “Latino paradox,” despite their relative disadvantaged social position (including education and income), Latinos have better than expected life expectancy and lower mortality rates compared with non-Latino Whites (Markides & Eschbach, 2005; Thomson et al., 2013). A part of the lifestyle explanation of the “Latino paradox” includes the fact that Latinos have social and cultural factors such as stronger social ties and larger social networks compared with non-Latinos, which provide a protective effect with regards to mortality (Abraido-Lanza, Dohrenwend, Ng-Mak, & Turner, 1999; Palloni & Arias, 2004; Thomson et al., 2013; Vega, Rodriguez, & Gruskin, 2009). Familismo, or the importance of kin, is an important institution for Latinos, and emphasizes family solidarity and an obligation to care for the older adults in multigenerational households (de Vos & Arias, 2003; Ruiz, 2007). A study by Ruiz (2007) showed that as Latinos age they report a decrease in support from kin. Interestingly, this has resulted in a reframing of the concept of family to go beyond bloodlines to include a social network of neighbors and friends. Emerging evidence shows that psychological factors such as social support and depression impact the functional status of older adults. For example, social support has been shown to have a positive effect on functional capacity and overall health of older adults (Beyene, Becker, & Mayen, 2002; de Brito & Pavarini, 2012; Golden, Conroy, & Lawlor, 2009; Stuck et al., 1999). A longitudinal epidemiological study with ~2,800 older adults revealed a significant association between social engagement and disability; more socially engaged participants had less physical disability in activities of daily living. This research underscores the important
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Functional Improvement in Latino Older Adults 121
impact of social support on physical health and the prevention of physical disability (Mendes de Leon, Glass, & Berkman, 2003). A study of 83 Latino elders showed that the quality of social support influenced a sense of emotional well-being despite challenges in physical functional capacity and chronic health conditions (Beyene, Becker, & Mayen, 2002). Similarly, a recent study to promote successful aging evaluated over 1,000 community-dwelling older adults and found an association between depression and successful aging. They concluded that reducing depression might lead to successful aging by reducing physical disability (Jeste et al., 2013). Of note, limited studies explored the interaction between functional status and psychosocial factors among Latino older adults. Given the high rates of functional limitation in the Latino population compared with the non-Latino White population (Stevens et al., 2008), and the growing proportion of Latino older adults, there is an urgent need to better understand the interaction between functional ability and psychosocial factors affecting balance–both strong indicators of quality of life (Thomson et al., 2013). The purpose of this study was to: (a) investigate the impact of a Tai Chi exercise program on functional status in Latino older adults and (b) to examine if psychosocial factors such as social support and depression mediate changes in functional status following a 12-week Tai Chi program. We hypothesized that the functional status (e.g., balance) would be improved and psychosocial factors would be associated with improvements in functional status among Latino older adults after the Tai Chi program. Furthermore, we expected that the benefits would be sustained three months after completion of the exercise program.
Method Participants We recruited 23 Latino adults (7 males and 16 females) with an average age of 65 years (ranging from 51 to 91 years) from the Intercultural Senior Center, a local senior center in a Midwestern metropolitan city. All participants lived in the community, either independently or with their family. They were able to follow instructions and had normal or corrected vision and hearing. They did not have a diagnosis of cognitive disturbances, neurological, affective, orthopedic, vascular, or other comorbidities that are likely to impact balance or the ability to stand without support. The project was approved by the institutional review board of the University of Nebraska Medical Center for human subject compliance.
Materials After completion of the informed consent process, data were collected from participants using the following set of established and validated functional and psychosocial assessments at three points in time: (1) at baseline before the program (pre); (2) immediately after the 12-week program (post); and (3) three months following completion of the program (3M). Timed Up and Go (TUG) Test. This test measures balance and is administered by a trained physical therapist. It requires participants to stand up from a chair with arms, walk 3 m to a line marked on the floor, turn and walk back, and sit down. Participants who performed the TUG within a shorter time have better balance (Shumway-Cook, Brauer, & Woollacott, 2000). Tinetti’s Fall Efficacy Scale (FES). This self-report questionnaire measures level of confidence in performing 10 daily activities,
such as taking a bath or shower and getting on and off of the toilet. Scores range from 10 to 100. Lower scores indicated a higher level of confidence to perform all activities (Tinetti, Richman, & Powell, 1990). The Center for Epidemiologic Studies Depression Scale (CESD). This psychosocial self-report questionnaire, administered
only at baseline, measures depressive symptoms. It is a 4-factor, 20-item questionnaire. Participants who received 16 points or more were considered depressed (Andresen, Malmgren, Carter, & Patrick, 1994). The Norbeck Social Support Questionnaire (NSSQ). This self-
report questionnaire, administered only at baseline, measures several dimensions of social support, including social function, social network, social aid, and loss (Norbeck, Lindsey, & Carrieri, 1981).
Procedure All participants first completed the functional assessments and psychosocial evaluation. Next, they began a “Moving for Better Balance (MBB)” Tai Chi program. This program was developed from a randomized, controlled trial for community-based use and significantly improved health-related outcomes among older adults, including reducing the number of falls and the fear of falling. This Tai Chi program was chosen since it is practical to disseminate and can be effectively implemented and maintained in various community settings (Li et al., 2008). Participants practiced eight forms of Tai Chi movement that engaged the core and promoted stability, beginning with the basic level of “hold the ball” exercise to the advanced level of “Repulse Monkey” (Figure 1). They attended the MBB program two times a week for 12 weeks, and were led by a Latino Tai Chi Instructor from the community who was trained and certified in Tai Chi instruction by the local chapter of the National Safety Council. Upon the completion of the 12-week MBB program, the second set of functional assessments was conducted to examine the immediate effect of the Tai Chi exercise program on participants’ balance performance. The third set of functional assessments was performed three months after the Tai Chi program to examine the long-term sustained effect of Tai Chi exercise on participants’ balance performance.
Statistical Analysis One-way ANOVA with repeated measures was used to examine the immediate (post) and long-term (3M) effects of Tai Chi exercise on functional status of all participants. The differences of functional assessments between pre and post, as well as pre and 3M, were calculated. Pearson’s correlation coefficient was used to examine the relationship between functional changes after the Tai Chi exercise program and baseline psychosocial status. Partial correlations were performed to adjust for confounding factors such as age and sex. The significant level was set as alpha = .05.
Results All 23 Latino older adults completed the 12-week MBB Tai Chi program. No injury occurred during the sessions. Demographical information and initial results of functional status are presented in Table 1.
122 Siu, Rajaram, and Padilla
Table 1 Demographics and Initial Clinical Assessments Demographics Participants (N) Age (mean ± SD)
23 65.22 ± 10.22
Gender (% female)
69.57
Latinos
100%
Initial Clinical Assessments
(Mean ± SD)
CESD
16.52 ± 10.20
NSSQ—Social function
113.00 ± 71.51
NSSQ—Social network
54.70 ± 30.81
NSSQ—Loss
2.83 ± 2.85
TUG (in second)
13.46 ± 4.21
FES
17.43 ± 13.18
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Note. CESD = Center for Epidemiologic Studies Depression Scale; NSSQ = Norbeck Social Support Questionnaire; TUG = Timed Up and Go Test; FES = Tinetti’s Falls Efficacy Scale.
Changes in Functional Status Timed Up and Go Test (TUG). A significant main effect of time on the changes in TUG was found (P = .003). The time to complete TUG was reduced significantly in pre–post (P = .048), and no change was found in post–3M (P = .745; Figure 2). Reduction in time to complete TUG indicates that participants’ balance improved and TUG performance was sustained after three months of the Tai Chi exercise program. Tinetti’s Fall Efficacy Scale (FES). A significant main effect of
time on the changes in FES was found (P = .038). Participants’ self-reported scores of FES improved between pre–post, but the differences did not reach a level of significance (P > .05). However, there was a significant linear trend (P = .027) from pre to 3M post MBB Tai Chi program, indicating an improvement in fear of falling over a three-month period following completion of the Tai Chi program (Figure 3).
Associations Between Psychosocial Factors and Changes in Functional Status Timed Up and Go Test (TUG). Psychosocial factors (social support and depression) were assessed at baseline before the start of the Tai Chi program. Significant associations were found between the NSSQ (social function) and changes in TUG (Figure 4) as well as between the NSSQ (social network) and changes in TUG (Figure 5). Particularly, significant positive and strong associations were shown between social function and changes in TUG in both pre–post (r = .606, P = .002) and pre–3M (r = .547, P = .008). Significant positive and moderate to strong associations were shown between social network and changes in TUG in both pre–post (r = .618, P = .002) and pre–3M (r = .520, P = .013). Partial correlation coefficient revealed that all significant associations remained after adjusting for age and sex. However, nonsignificant and very weak associations were found between CESD (depression) and changes in TUG. Figure 1 — Eight forms of Tai Chi movement in the “Moving for Better Balance” program.
Tinetti’s Fall Efficacy Scale (FES). A significant association was found between CESD (depression) and changes in FES (Figure 6). Particularly, a significant positive and strong association
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Functional Improvement in Latino Older Adults 123
Figure 2 — Timed Up and Go Test performance at three time points (pre, at baseline before program; post, immediately after program; 3M, three months after program completion).
Figure 3 — Scores for Tinetti’s Fall Efficacy Scale at three time points (pre, at baseline before program; post, immediately after program; 3M, three months after program completion).
was shown between CESD and changes in FES in pre–3M (r = .588, P = .004), but not in pre–post. Partial correlation coefficient revealed that the significant association remained after adjusting for both age and sex. In addition, nonsignificant and very weak associations were found between the NSSQ (social network) and changes in FES.
Discussion This study focused on the impact of Tai Chi exercise on the functional ability among Latino older adults and also examined the interaction of psychosocial factors (e.g., social support and depression)
following a 12-week Tai Chi exercise program. We hypothesized that functional status (e.g., balance) would be improved immediately after the program, and improvements would be sustained three months following completion of the program. In addition, such improvements would be mediated by the psychosocial status of the Latino older adults. All Latino participants improved their functional status (reduced the time to complete the Timed Up and Go test) and sustained the improvement three months following completion of the program. These results support our hypothesis that practicing Tai Chi can improve balance among Latino older adults. Although previous research studies in Tai Chi have shown similar physical
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124 Siu, Rajaram, and Padilla
Figure 4 — Associations between TUG and social function. TUG = timed up and go; NSSQ = Norbeck Social Support Questionnaire; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
Figure 5 — Associations between TUG and social network. TUG = timed up and go; NSSQ = Norbeck Social Support Questionnaire; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
benefits, there is a paucity of research on underrepresented populations, particularly Latino older adults (Li, Hong, & Chan, 2001; Li et al., 2008; Low et al., 2009; Wu, 2002; Yan & Downing, 1998). This study focused on Latino older adults and found similar improvements compared with non-Latino White older adults. Especially important, this study also provided evidence of the long-term effects of Tai Chi on functional status, and demonstrated that improvements in balance were sustained three months following the Tai Chi program. Previous studies indicated Tai Chi could increase
muscle strength and postural stability (Li, Hong, & Chan, 2001; Li et al., 2008; Low et al., 2009), which may explain why Latino older adults in this study sustained improvements in functional status as measured by TUG and FES. In addition to increasing physical strength, studies have shown that factors, such as self-confidence, play a key role for older adults to maintain their balance and perform daily activities (Beyene et al., 2002; Li, McAuley, Harmer, Duncan, & Chaumeton, 2001; Stuck et al., 1999). Older adults with a higher level of confidence
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Functional Improvement in Latino Older Adults 125
Figure 6 — Associations between FES and CESD. FES = fall efficacy scale; CESD = Center for Epidemiologic Studies Depression Scale; pre = at baseline before program; post = immediately after program; 3M = three months after program completion.
in balance to perform daily tasks were less likely to trip and fall when unexpected perturbation occurred in their surrounding environment (Jeste et al., 2013; Portegijs et al., 2012). In this study, scores on the self-report of the fall efficacy scale improved, suggesting that Latino participants gained confidence in performing certain daily activities without assistance from family members or friends. Practicing Tai Chi not only improved the functional status of the older adults, but also enhanced their independence. Participants became more confident in maintaining their balance and accomplishing daily routine by themselves, both immediately and three months following the 12-week Tai Chi program. Improvements in functional status and internal confidence were closely associated with psychosocial factors such as depression or social support. For example, older adults with higher social support (larger social function and network) had greater improvements in balance after the Tai Chi program (Figures 4 and 5). Studies have indicated that older adults with a higher level of social support (i.e., larger social function or networks) can be easily motivated by peers to be active and perform daily tasks compared with those with lower levels of social support (Golden et al., 2009; Mendes de Leon et al., 2003; Stuck et al., 1999). It should be noted that our sample of Latino older adults might represent a self-selected group with higher levels of social support compared with the general population of older adults. To participate in the 12-week Tai Chi program, Latino participants required assistance with transportation from family members to attend the classes held twice a week at the Intercultural Senior Center. It is likely that improvements in functional status in our sample are reflective of older adults with a solid level of social support. This study also investigated the association between depression and changes in functional status after the Tai Chi exercise program. Interestingly, our data indicated that participants with baseline higher level of depression had larger changes in confidence to perform daily activities. The association only showed significance between baseline testing and three months after the Tai Chi program. These results demonstrate that older adults with
depressive symptoms (scores 16 or higher on CESD) gain more confidence in performing daily activities after Tai Chi exercise. However, it is possible that the older adults with no depression already had strong confidence to perform daily tasks, and hence did not show significant improvements following the Tai Chi program. It also suggests that the lack of improvement in functional status among nondepressed Latino older adults might be limited by the possible floor effects of FES. In other words, older adults who initially self-report a higher level of confidence to perform daily tasks (e.g., score of 10 on the FES) do not gain further changes after the Tai Chi program. Nonetheless, a significant association between depression and changes in physical status was found three months after the Tai Chi program (Figure 6). The findings suggest that practicing Tai Chi could provide benefits for depressed Latino older adults to regain their self-esteem and confidence to encounter daily activities by themselves and be more independent. Overall, the findings from this study underscore that regardless of race or ethnicity, older adults can practice Tai Chi and improve their functional status, which can be sustained for a minimum of three months following the training period. These improvements in functional status can help prevent fall incidence, a serious problem among older adults. This study has a few limitations. First, this is a self-selected sample, which can introduce selection bias and restricts the generalizability of the findings to the general population of communitydwelling older adults. Second, the study design does not have a randomized control group and, therefore, it is not possible to definitively attribute improvements in functional ability to the Tai Chi exercise program. Third, psychosocial variables were measured only at baseline, before the exercise program. Hence, changes in psychosocial status immediately after and three months following the program and possible interactions with functional status are not discernible. Fourth, this study did not monitor whether participants participated in any other exercise program during or after the 12-weeks Tai Chi program. Finally, all participants in
126 Siu, Rajaram, and Padilla
this study were Latino older adults. It is likely that sociocultural factors such as familismo might restrict the generalizability of the findings to other racial or ethnic senior populations.
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Implications and Conclusions This study demonstrates that a Tai Chi exercise program could be a simple and useful exercise program for community-dwelling Latino older adults to improve their functional status and decrease their risk for falls. It is important to examine psychosocial factors such as social support and depression in Latino older adults when testing the impact of exercise interventions. It is likely that psychosocial factors function as critical mediators that determine the effectiveness of an exercise intervention program among Latinos and other racial or ethnic groups of older adults. With the growing proportion of Latino older adults, and given the high rates of functional limitation in this population, there is an urgent need to better understand the interaction between functional ability and psychosocial factors affecting balance, both strong indicators of the quality of life (Thomson et al., 2013). As the population ages nationally and globally, it is important to determine a best practice that takes into account low-cost and low-impact exercise modalities such as Tai Chi, and the mediating effect of key psychosocial variables, such as depression and social support on functional status. While this study focused on Latino older adults in the United States, the findings from this study are generalizable to diverse public health practice contexts across the globe to ensure healthy aging for all. Acknowledgments The project was supported by the Mutual Fund from the College of Public Health at the University of Nebraska Medical Center. Authors would like to thank the two Hispanic Tai Chi Instructors, Ms. Teresita Ayala and Ms. Ilda Vazqves, for teaching the Tai Chi program, and the student researcher, Kelsey Wilhelm, for data collection at the Intercultural Senior Center.
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