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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Review
Physical activity in caregivers: What are the psychological benefits? Samantha M. Loi a,b,*, Briony Dow b,2, David Ames a,b,2, Kirsten Moore b,2, Keith Hill c,3, Melissa Russell d,4, Nicola Lautenschlager a,b,1,2 a
Academic Unit for Psychiatry of Old Age, St. Vincent’s Health, Department of Psychiatry, University of Melbourne, Normanby House, St. George’s Hospital, 283 Cotham Road, Kew, Victoria 3101, Australia b National Ageing Research Institute, 34-54 Poplar Road, Parkville, Victoria 3052, Australia c School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Western Australia 6845, Australia d Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Level 3, 207 Bouverie Street, Parkville, Victoria 3010, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 February 2014 Received in revised form 3 April 2014 Accepted 5 April 2014 Available online xxx
Previous research demonstrates that physical activity has psychological benefits for people of all ages. However, it is unclear whether people caring for a frail or ill relative would derive similar psychological benefits, considering the potentially stressful caregiver role. This article reviews the current literature describing the effect of physical activity interventions on the psychological status of caregivers. A search from January 1975 to December 2012 identified five intervention studies investigating physical activity and psychological status in caregivers. These focused on female Caucasian caregivers who were older than 60 years. The physical activity interventions improved stress, depression and burden in caregivers, but small sample sizes, short-term follow up and varying results limited the generalizability of the findings. There were few trials investigating male caregivers, and most carerecipients were people with dementia. Studies with caregivers of different ages and gender, with a range of physical activity interventions, are needed to clarify whether physical activity has psychological benefits for caregivers. ß 2014 Published by Elsevier Ireland Ltd.
Keywords: Physical activity Caregivers Exercise Psychological health
Contents 1. 2.
3.
4. 5.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search strategy and selection criteria . . 2.1. Types of studies . . . . . . . . . . . . . . . . . . . 2.2. Types of participants . . . . . . . . . . . . . . . 2.3. Types of interventions . . . . . . . . . . . . . . 2.4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical trials (see Table ?1) . . . . . . . . . 3.1. Published trial protocols (see Table ?2) 3.2. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: Academic Unit for Psychiatry of Old Age, St. Vincent’s Health, Department of Psychiatry, University of Melbourne, Normanby House, St. George’s Hospital, 283 Cotham Road, Kew, Victoria 3101, Australia. Tel.: +61 3 9816 0485/3 8387 2305; fax: +61 3 9816 0477/3 8387 4030. E-mail addresses: [email protected], [email protected] (S.M. Loi), [email protected] (B. Dow), [email protected] (D. Ames), [email protected] (K. Moore), [email protected] (K. Hill), [email protected] (M. Russell), [email protected] (N. Lautenschlager). 1 Tel.: +61 3 9816 0485; fax: +61 3 9816 0477. 2 Tel.: +61 3 8387 2305; fax: +61 3 8387 4030. 3 Tel.: +61 8 9266 3618; fax: +61 8 9266 3699. 4 Tel.: +61 3 8344 0736; fax: +61 3 9349 5815. http://dx.doi.org/10.1016/j.archger.2014.04.001 0167-4943/ß 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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1. Introduction In the last decade there has been an expansion of research on the benefits associated with physical activity in adults of all ages. Physical activity (PA) has both physical and psychological health benefits. Studies have demonstrated that PA reduces the risk of cardiovascular disease (Dubbert, 2002) and some cancers, improves pulmonary function, reduces the risk of some chronic diseases, minimizes falls and improves pain management (Warburton, Nicol, & Bredin, 2006). PA has been found to decrease morbidity and mortality (Warburton et al., 2006). Psychological benefits include stress reduction and prevention and improvement of depressive symptoms (Castro, Wilcox, O’Sullivan, Baumann, & King, 2002) and improved sleep (King, Baumann, O’Sullivan, Wilcox, & Castro, 2002). There is also evidence to suggest that PA can improve cognition (Lautenschlager, Cox, & Cyarto, 2012). In studies focusing on older people, PA improves balance, strength and gait, endurance and general quality of life (Blake, Mo, Malik, & Thomas, 2009). It may also delay mobility limitations and further disability so that independent living can continue (Bennett & Winters-Stone, 2011). Psychological benefits of PA in older people include improvements in cognitive function, mood and well-being (Kerse et al., 2010). The term ‘‘carer’’ or ‘‘caregiver’’ is commonly defined as someone who provides care to another person who is dependent on the caregiver for help (Oyebode, 2003). Informal caregivers are unpaid, and are usually spouses or other family members. They are a vulnerable group of people (Oyebode, 2003) who play an important role in providing practical help and support, which enables people with chronic conditions to remain living in the community. Although there are positive aspects to providing care, the physical and psychological effort required to provide ongoing care can impact significantly on caregivers’ well-being. Caregivers have been shown to be at increased risk of stress and depression, to experience sleep problems more often, and have poor physical health (Oyebode, 2003). They often do not have the time to engage in preventive health behaviors such as regular PA, and studies have found that caregivers participate in less formal PA compared to non-caregivers (Fredman, Bertrand, Martire, Hochberg, & Harris, 2006; Hirano et al., 2011). There have been numerous interventions aimed at improving the psychological health of caregivers such as education, counseling and respite. However, these have had conflicting results (Pinquart & Sorensen, 2006; Sorensen, Pinquart, & Duberstein, 2002). Due to benefits PA has in the general population, interventions aiming to increase PA have also been trialed in the caregiver population. However, it is less clear whether the psychological benefits seen in the general population also extend to the caregiver population, at least one third of whom experience significant impact on their wellbeing due to their caring role (Oyebode, 2003). This review provides an overview of the literature reporting on PA in caregivers and its effect on their psychological health, from the period of January 1975 to December 2012. The purpose of this review is to examine the psychological benefits of PA in caregivers, what types of PA interventions have resulted in psychological benefits, and the limitations of study results obtained to date. The potential caregiver-specific barriers will also be highlighted. This review will present an overview of this topic, clarify in which psychological domains PA may be useful, and help guide future directions in this area. 2. Methods 2.1. Search strategy and selection criteria The scientific databases MEDLINE, PsycINFO, PubMed and Google Scholar were searched using the terms: exercise, physical
activity, motor activity, physical exertion, physical fitness, caregivers, carers and caring. References listed in articles were also followed up. Limits of English language and human studies were used. Studies published between 1975 and 2012 were included. These dates were selected as caregiver literature dates approximately from the mid 1970s, and we wished to capture as many articles as possible, since there has been no previously published review. 2.2. Types of studies Only studies in which caregivers were allocated to either a PA program, or usual care (control group) were included. Observational studies were excluded because these studies do not contribute to evidence-based practice in this area. Study quality was assessed using criteria following Peacock and Forbes (2003). It was coded whether participants were randomly allocated to intervention or control group (yes = pass; no/not reported = fail), whether these groups were comparable in terms of study characteristics (yes = pass; no = fail), whether these groups had at least 10 participants as studies with smaller sample sizes are at risk of errors (yes = pass; no = fail), the attrition rate (20% or not reported, fail), whether validated outcome measures were used (yes = pass, no = fail), and whether there was blinding of assessors (yes = pass; no/not reported = fail). A study was rated strong if it had no fail ratings and no more than one moderate rating; moderate if it had no fail ratings and more than one moderate rating; weak if it had one or two fail ratings; and poor if it had more than two fail ratings. 2.3. Types of participants Studies included informal caregivers of any age, and there was no restriction on the illness or diagnosis of care-recipient (CR). Only studies in which the major focus was the caregiver psychological outcome were included. 2.4. Types of interventions Interventions included any type of physical activity training. This could range from general walking, to specific programs such as Tai Chi, or yoga. The intervention could take place in any setting, including at home, in the community, or hospital-based. Group and individual PA, as well as types, frequencies, and duration of PA programs were described. 3. Results There were a total of 750 published articles found by the search. All 750 abstracts were reviewed using a standard evaluation form by SL, with consultation with other authors (NL, BD, KM), and checked if these fit the criteria for inclusion. Although this review was not specifically focusing on older caregivers, all of the eligible studies investigated outcomes in caregivers who were over 60 years of age. Fig. 1 shows the flow chart of the search. There were a total of fifteen studies found investigating PA in caregivers. Of these, there were five clinical trials using PA as an intervention which were included in this review (Castro et al., 2002; Connell & Janevic, 2009; Hill, Smith, Fearn, Rydberg, & Oliphant, 2007; King et al., 2002; King & Brassington, 1997; Marsden et al., 2010); four of these were randomized controlled trials (RCTs). There were three studies using PA as an intervention which focused primarily on outcomes for the CR (Molloy et al., 2006; Teri et al., 2003; Vreugdenhil, Cannell, Davies, & Razay, 2012), rather than the caregiver, hence these studies were excluded. Three observational studies were also
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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Search of databases (January 1975 to December 2012) Strategy: [exercise OR physical acvity OR motor acvity OR physical exeron OR physical fitness] AND [caregivers OR carers OR caring]
750 arcles (excluding duplicates) idenfied, abstracts reviewed
15 studies reviewed in full-text
11 studies invesgang PA in carers
4 RCT PA protocol found
3 studies excluded because of observaonal nature of study
2 PA protocols excluded because outcome of PA focused on CR, rather than carers
3 studies excluded because outcome of PA focused on CR, rather than carers
4 RCT studies included
2 RCT PA protocols included
1 study using PA as an intervenon in carers Fig. 1. Flow chart of search results.
found (Fredman et al., 2006; Gusi, Prieto, Madruga, Garcia, & Gonzalez-Guerrero, 2009; Hirano et al., 2011), which were excluded, two were of cross-sectional (Gusi et al., 2009; Hirano et al., 2011), and one was of longitudinal design (Fredman et al., 2006). Two PA RCT protocols were also identified (Dow et al., 2013; Prick, de Lange, Scherder, & Pot, 2011). A further two PA RCT protocols focusing on outcomes for the CR were found which were excluded (Cerga-Pashoja et al., 2010; James et al., 2011). A summary of the studies included is listed in Table 1 (studies reporting results) and Table 2 (protocol only – no results published). Table 3 describes the quality of the study, as per Peacock and Forbes (2003). 3.1. Clinical trials (see Table 1) There were five trials reviewed, of which were four were RCTs. These were carried out between 1997 and 2007, and occurred in the United States (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; King & Brassington, 1997) and in Australia (Marsden et al., 2010). There was one RCT whose results were reported in two papers (Castro et al., 2002; King et al., 2002). The majority of caregivers were female, with two studies focusing on female carers only (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002). The mean age of the carers was 64.78 years old. The majority of carers were of Caucasian ethnicity. CRs had diagnoses of dementia in three studies (Castro et al., 2002; Connell & Janevic,
2009; King et al., 2002; King & Brassington, 1997), stroke in one study (Marsden et al., 2010), and the CR diagnosis was not specified in one study (Hill et al., 2007). Sample sizes varied from 17 participants (Marsden et al., 2010) to 137 participants (Connell & Janevic, 2009). Types of PA varied from brisk walking on a treadmill (Castro et al., 2002; King et al., 2002; King & Brassington, 1997), strength training (Connell & Janevic, 2009) and other types such as tai chi and hatha yoga (Hill et al., 2007). Control groups included usual care (Connell & Janevic, 2009; King & Brassington, 1997; Marsden et al., 2010) and a nutritional program (Castro et al., 2002; King et al., 2002). The duration of the trials ranged from 7 weeks (Marsden et al., 2010) to 12 months (Castro et al., 2002; King et al., 2002), with varying frequencies from one hour once-to-twice a week (Hill et al., 2007), to 30–40 min four times a week (Castro et al., 2002; King et al., 2002; King & Brassington, 1997). One study was not a RCT, but had a variety of group-based PA which included Tai Chi, Hatha yoga and circuit training (Hill et al., 2007). Three studies had additional unique characteristics. Telephone contact rather than face-to-face contact was used for monitoring and motivating in the Connell & Janevic (2009) and King et al. (2002) and Castro et al. (2002) trials. The Mardsen et al. trial (2010) included an educational component as well as the PA. These were sessions given by a MDT such as a physiotherapist and dietician which supplemented the PA. Two studies conducted follow up measures, which also ranged from 12 weeks (Marsden et al., 2010) to 12 months (Connell & Janevic, 2009). Attrition rates
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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Table 1 Characteristics of trials which had PA as an intervention for caregivers (results reported). Study
Number of caregivers who completed (female). Mean age (years)
Care-recipient diagnosis; Involved in study?
PA intervention type
King & Brassington (1997)
24 (21) Controls 63.2; PA 60.2
Alzheimer’s dementia; No
King et al. (2002), and Castro et al. (2002)
85 (85) 63
Study
PA adherence
Duration; Follow up
Caregiver outcome measures
Outcomes (NS = non significant); Attrition
RCT: PA – brisk Home; walking (30– individual 40 min 4/week) vs usual activity
Rate Perceived Exertion (RPE); Casio computer diary; activity log
4 months; No follow up
PA group – improved anger expression (mean score 7.6, compared to 9.2, p < 0.03) Drop out rate 4.1%
Dementia; No
RCT: PA – brisk Home; individual walking (30– 40 min 4/wk) vs nutrition program
Heart rate 12 months; No monitor; follow up activity log; microprocessor; diary; RPE
Anger Expression; Screen for Caregiver Burden; Beck Depression Inventory (BDI); Perceived Stress Scale (PSS); Total Manifest Anxiety Scale (TMAS) BDI; PSS; Screen for Caregiver Burden; TMAS
Number of caregivers who completed (female); Mean age, years 137 (137) 66.8
Care-recipient diagnosis; Involved in trial?
PA intervention type
Setting
PA adherence
Duration; Follow up
Caregiver outcome measures
Dementia; No
RCT: PA plus education vs usual activity
Home; individual
Activity log
6 months. 12 month follow up.
Centre for Epidemiological StudiesDepression scale; PSS
Marsden et al. (2010)
17 (15) Controls 69.6; PA 66.3
Stroke survivors; Yes
Hill et al. (2007)
88 (75) 64.4
Not specified; No
Attendance roll HospitalRCT: PA plus based education vs usual activity (group) once weekly for 7 weeks (2.5 h) Attendance roll Group class PA – Tai Chi, Hatha yoga, 1 h/1–2 strength week training, circuit
Connell & Janevic (2009)
Setting
ranged from 4.1% (King & Brassington, 1997) to 24% (Hill et al., 2007). Psychological outcomes were varied and included measures of depression (using different scales such as the Beck Depression Inventory and Geriatric Depression Scale), burden (using Screen for Caregiver Burden and Zarit Burden Inventory), stress (Perceived Stress Scale), anxiety (Total Manifest Anxiety Scale), strain (Caregiver Strain Index) and anger (Anger Expression). PA was found to improve caregiver depression (Castro et al., 2002; Connell & Janevic, 2009; Hill et al., 2007; King et al., 2002), stress (Marsden et al., 2010), anger (King & Brassington, 1997) and burden (Castro et al., 2002). 3.2. Published trial protocols (see Table 2) Prick et al. (2011) are conducting a RCT in people with dementia and their caregivers in the Netherlands. They aim to recruit 156 pairs. The intervention group will receive an integrated home-based exercise and support program, while the control
7 weeks. 12 Caregiver Strain week follow up. Index
6 months. No follow up.
Zarit Burden Inventory, Geriatric Depression Scale-15
Improved depression – PA 3.2 points, nutrition 4.3 points, NS Improved stress – PA 3.3 points, nutrition 2.7 points, NS Both groups – Improved subjective burden (# 41.6–38.2, p < 0.007) Drop out rate 15% Outcomes (NS = nonsignificant) Attrition
PA group – improved depressive and stress scores (# 0.16 points, p < 0.05) at 6 months (no change at 12 months) Drop out rate 15.9% PA group – decreased caregiver stress (# 1.2 points, NS) Drop out rate 15% All PA groups – decreased depressive symptoms (26.3% change, p < 0.00) No change in burden (p > 0.05) Drop out rate 24%
group will receive usual care. Psychological measures such as mood and burden are being assessed in caregivers, as well as the impact of the intervention on the quality of the relationship between the care-recipient and their carer. The PA consists of an exercise component, aimed at improving flexibility, strength and endurance, where the pairs complete 30 min of active exercise at least three times a week. This is a home-based intervention lasting for three months, with follow up three months (six months) and then six months (one year) later. In Australia, Dow et al. (2013) are recruiting for a RCT for older caregivers (over 55 years) and older care-recipients (over 60 years), hypothesizing that the home-based, physiotherapist prescribed, individualized PA program will improve depressive symptoms in caregivers. To account for the potential confounder of the social component improving caregiver mood, a social control will also be included. A total of 273 pairs are required, with 117 pairs in both the PA and social program, and 39 in the usual care group. A qualitative component exploring the effect of exercising together is also part of the study. The intervention will last for six months,
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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Table 2 Characteristics of protocol trials (all involving caregiver and care recipient) – all randomized controlled trials. Study
Numbers
Care-recipient diagnosis
PA intervention
Duration
Caregiver outcome measures
Other
Prick et al. (2011)
156 dyads
Dementia
PA (30 min 3/week) vs usual activity
6 months. 12 month follow up.
Impact of PA on dyad
Dow et al. (2013)
273 dyads
Any illness
PA (30 min + walking 5/week) vs usual activity
6 months. 6 month follow up.
Centre of Epid Studies-Depression; General Health Questionnaire; Self-Perceived Pressure from I nformal Care ZBI, Geriatric Depression Scale, Carer Assessment of Satisfaction
with an additional six month follow up. An economic analysis will also be completed to evaluate the cost-effectiveness of the program. 4. Discussion Previous observational studies investigating levels of PA in caregivers consistently demonstrated that caregivers were less physically active compared to non-caregivers, and caregivers who did less PA had more depressive symptoms (Fredman et al., 2006), burden (Hirano et al., 2011) and generally worse psychological health (Gusi et al., 2009) compared to caregivers who did more PA. This literature review extends the knowledge in this area, seeking to evaluate the psychological benefit of PA in caregivers. There were five intervention trials of PA involving caregivers and psychological benefits, described in the literature to date. The number of studies which fulfilled criteria was small, and although it was not limited to older caregivers, all the studies included caregivers who were in the older age range. There were both heterogeneity of outcome measures and limitations with regards to type of PA, type of caregiver, CR disorder and small sample sizes. Table 3 demonstrates that overall, the quality of these studies were weak, due to lack of blinding and moderate attrition rates. In general, the studies found that PA (mostly consisting of walking) in caregivers can improve depression (Castro et al., 2002; Connell & Janevic, 2009; Hill et al., 2007; King et al., 2002), stress (Marsden et al., 2010), anger (1997) and burden (Castro et al., 2002). The most commonly utilized form of PA was brisk walking (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; King & Brassington, 1997; Marsden et al., 2010). Two of these trials had additional exercises to improve flexibility and stretching (Connell & Janevic, 2009; Marsden et al., 2010). There was only one trial using a variety of PA, such as yoga and Tai Chi (Hill et al., 2007), and excluded walking. The potential strength of this approach was that it provided options and choice to participants, rather than being constrained to a single PA. However due to the small numbers of participants in these types of PA, comparisons between
Social control Impact of PA on dyad Economic evaluation
each were not conducted, and hence it is unclear which of these PA had the most effect on caregivers’ psychological health. Due to the majority of studies only using walking as the most common PA studied, there is insufficient research using other PA approaches to determine whether other types of PA may result in psychological benefits in caregivers. There was one RCT which used a nutritional program as the comparison to the PA intervention (Castro et al., 2002; King et al., 2002), rather than a control or waitlist group (Connell & Janevic, 2009; King & Brassington, 1997; Marsden et al., 2010). One study (Hill et al., 2007) did not have a comparison control group. One study only had a sample size of 17, and none of the results were statistically significant (Marsden et al., 2010) and there was only one trial with a sample size larger than 100 (Connell & Janevic, 2009). About half the trials were home-based PA programs, which required consideration for monitoring and adherence to the PA. Diaries, and activity logs were frequently utilized, but have the limitation of recall bias, or socially desirable over-reporting. Studies which used more objective and sophisticated measures, such as a heart rate monitor (Castro et al., 2002; King et al., 2002; King & Brassington, 1997) may have more accurate recordings of home-based PA. Attendance rolls were used for group-based PA (Hill et al., 2007; Marsden et al., 2010). Connell & Janevic (2009) utilized telephone contact, rather than face-to-face contact, which the authors stated was effective for motivating and encouraging participants. The samples in the RCTs were predominantly older female caregivers, who were of Caucasian background, with sample sizes ranging from 17 (Marsden et al., 2010) to 137 caregivers (Connell & Janevic, 2009). Outcomes included measures of anger expression (King & Brassington, 1997), depression (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002), anxiety (Castro et al., 2002; King & Brassington, 1997), burden (Connell & Janevic, 2009; King & Brassington, 1997) and stress (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; Marsden et al., 2010). The results of three of the four RCTs showed that the caregivers who participated in the PA intervention had improved psychological health – significantly decreased anger (King & Brassington, 1997), depression and burden (Castro et al., 2002; Connell & Janevic, 2009; King
Table 3 Study quality (attrition rate 21% fail. N/A = not applicable). Study
Random allocation
Groups comparable
Sample size > 10
Attrition rate
Validated outcomes
Blinding of assessors
King & Brassington (1997) King et al. (2002) and Castro et al. (2002) Connell & Janevic (2009) Marsden et al. (2010)
Pass Pass Pass Pass
Pass Pass Pass Pass
Pass Moderate Moderate Moderate
Pass Pass Pass Pass
Fail Fail Fail Fail
Hill et al. (2007)
N/A
N/A
Pass Pass Pass Pass (less than 10 in each group) Pass
Fail
Pass
N/A
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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et al., 2002), compared to control groups. The results of these small number of studies is suggestive that walking as a PA can improve the psychological health in caregivers. However, there were also equivocal results in two of the RCTs which may imply that there are additional barriers which preclude this statement. King and Brassington (1997) and Connell & Janevic (2009) did not find any significant improvements in depression or burden, and King et al. (2002) and Castro et al. (2002) found improvements in stress and depression occurred in both the PA and nutritional control groups, so drawing conclusions about whether PA was more effective than nutrition are problematic. Connell & Janevic (2009) found that the improvements in depression (non-significant) and stress which occurred during the intervention period (6 months) were no longer evident at 12 months. The caregivers in the intervention group also declined in their levels of PA during the follow up period. Cessation of the regular monitoring may mean that caregivers cease the PA due to lack of structured motivation and encouragement. This suggests the need for sustained participation in PA long-term by caregivers if psychological benefits are to be maintained. Does the inclusion of an educational/behavioral component in addition to the PA contribute to improving the psychological state in caregivers? There were only two studies using this combination (Connell & Janevic, 2009; Marsden et al., 2010). Connell & Janevic (2009) found an improvement in stress scores during the intervention which were not sustained in the follow up period. Due to the small sample size and short duration of the intervention, it is difficult to assess the combination in Mardsen et al. trial (2010). None of the RCTs reported on whether the researchers were blinded to whether participants were in the intervention or control group, which means that interviewer bias could influence results. The protocol by Dow et al. (2013) seeks to address this by blinding of researchers. It is also unclear whether the social contact which participants received as monitoring, or the actual PA which contributes to improving depression, stress and burden in caregivers. The study without a control group found an improvement in psychological symptoms (Hill et al., 2007), however studies with a control group activity (i.e. the nutritional control) did not find a difference between the intervention and the control. It is possible that the benefit seen in the studies without the comparison was simply the effect of having a social aspect, or having ‘‘something’’ done. In studies that have investigated the effect of PA interventions in noncaregivers, it has been found that the social component of PA could also be contributing to the alleviation of depressive symptoms (Kerse et al., 2010). The protocol by Dow et al. (2013) attempts to control for this potential confounder. Most of the studies reviewed focused on older female spousal caregivers. This is of concern, as the ratio of older male to older female caregivers is almost 50:50 (Australian Bureau of Statistics, 2012). There is good evidence to indicate that male caregivers may approach and react to caring differently, and it has been reported that they have lower levels of depression compared to female caregivers (Pinquart & Sorensen, 2003). Additionally, although many of the caregivers involved in these studies have been classified as ‘‘older’’ (that is, their mean age is approximately 60 years), it can be expected that due to the increasing age of populations in most countries, proportions and numbers of caregivers will be substantially older than 60 years in the future. There were no studies looking at caregivers whose age was in a higher age range. Nearly all the care-recipients in the studies had dementia, which is particularly challenging for caregivers due to its deteriorating and fluctuating nature (Pinquart & Sorensen, 2003). The majority of studies used a graduated PA program
involving brisk walking, and only one non-randomized study investigated non-aerobic types of PA such as Tai Chi and yoga (Hill et al., 2007). There were also different measures of depression (Beck Depression Inventory, Geriatric Depression Scale, Hospital Anxiety and Depression Scale) and burden (Zarit Burden Interview, Screen for Caregiver Burden), which add to the heterogeneity of results. Previous studies indicate that caregivers of people with dementia prefer PA programs that are simple, convenient and inexpensive (Farran et al., 2008). Home-based, rather than groupbased programs also appear to be preferred (King, Rejeski, & Buchner, 1998), however most caregivers found the social aspect of group PA programs enjoyable (Marsden et al., 2010; Vreugdenhil et al., 2012), and enjoyed exercising with the care-recipient (Marsden et al., 2010; Vreugdenhil et al., 2012). Using caregivers’ preferences to formulate PA programs is worth investigating in more detail (Cerga-Pashoja et al., 2010). The caregiver group may also have other characteristics which limit the translation of benefits of physical activity. The positive psychological effects attributed to PA in the general population may not be found amongst caregivers, as the burden and stress of this role may make PA an additional load. Caregivers have stated that participating in such programs interfered with their caring role and other responsibilities, and they worried about being away from the CR (Farran et al., 2008; Hill et al., 2007). Caregivers’ concern about their own health has also been cited as a barrier to maintaining PA (Connell & Janevic, 2009). Table 3 shows that except for the King and Brassington (1997) program, attrition rate was problematic. Reasons for dropping out of the study were attributed to high levels of caregiving responsibilities (King & Brassington, 1997) and being too busy (Connell & Janevic, 2009). The CRs whose caregivers were involved in one study were able to be cared for during the PA program, which attempted to address the caregivers’ concern about leaving their CR alone (Hill et al., 2007). Further research is required to investigate if these barriers can be overcome through finding the most acceptable method of assisting caregivers to undertake PA. Comparing the benefits of PA in caregivers who have varying levels of psychological distress may help clarify this. Most PA interventions have targeted the individual, and there have been limited studies to date exploring the potential benefits of PA in the caregiver/CR dyad. Prick et al. (2011) and Dow et al. (2013) both aim to address this gap in their studies by investigating the impact of the intervention on the caregiver dyad. Due to the small number of studies, which mostly used walking as PA, there is not yet conclusive evidence that PA can improve psychological health in caregivers. The paucity of RCTs, varying activity dosages, insufficient sample sizes and short follow-up periods limit the generalizability of results to older female caregivers of people with dementia. The results in this review are limited by the study parameters which only included studies involving informal, unpaid caregivers as participants. This review also did not access non-English language studies. Future directions for research that would improve generalizability of results and help clarify benefits, should include studies specifically focussing on older male caregivers, caregivers of a younger age (this age group has its own particular characteristics), and caregivers who are older than 70 years, all of whom have been little studied to date. Although people with dementia are an increasing group, it is also important to look at caregivers of people with other illnesses (for example, people with stroke and other neurological disorders). Almost all the literature investigates caregivers of Caucasian background and the cultural aspects of caring are an important consideration. For example, some cultures (e.g. Italian, Greek, Chinese) are particularly reluctant to have a family member transferred to residential care and may continue
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caring for an extended period of time with few external supports. Home-based individual PA programs versus community group programs have been evaluated, with different results. 5. Conclusions Physical activity, that is, walking, appears to have some benefit for caregivers, in that it can decrease levels of stress, depression and burden. However, the small number of trials, the heterogeneity of physical activity interventions and outcome measures, and limited sample sizes, restrict the generalizability of results. Providing care can be a stressful and time-consuming task which may be one of the reasons why the positive psychological effects of physical activity interventions are not as strong in this population. Further randomized controlled trials including samples with older male caregivers, with different levels of psychological distress, and a variety of PA modalities may help answer these questions. Conflicts of interest There are no conflicts of interest. All authors disclose that there is no financial and personal relationships with other people or organizations that could inappropriately influence the work. References Australian Bureau of Statistics. (2012). Australian Social Trends – Older carers. http:// www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4102.0Main+Features40Dec+2012 Retrieved 26.01.13. Bennett, J., & Winters-Stone, K. (2011). Motivating older adults to exercise: What works? Age and Ageing, 40, 148–149. Blake, H., Mo, P., Malik, S., & Thomas, S. (2009). How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clinical Rehabilitation, 23(10), 873–887. Castro, C. M., Wilcox, S., O’Sullivan, P., Baumann, K., & King, A. C. (2002). An exercise program for women who are caring for relatives with dementia. Psychosomatic Medicine, 64(3), 458–468. Cerga-Pashoja, A., Lowery, D., Bhattacharya, R., Griffin, M., Iliffe, S., Lee, J., et al. (2010). Evaluation of exercise on individuals with dementia and their carers: A randomised controlled trial. Trials, 11, 53. Connell, C. M., & Janevic, M. R. (2009). Effects of a telephone-based exercise intervention for dementia caregiving wives: A randomized controlled trial. Journal Applied Gerontology, 28(2), 171–194. Dow, B., Moore, K., Russell, M., Ames, D., Cyarto, E., Haines, T., et al. (2013). Improving mood through physical activity for carers and care recipients (IMPACCT): Protocol for a randomised trial. Journal of Physiotherapy, 59(2), 125. Dubbert, P. M. (2002). Physical activity and exercise: Recent advances and current challenges. Journal Consulting and Clinical Psychology, 70(3), 526–536. Farran, C., Staffileno, B., Gilley, D., McCann, J., Li, Y., Castro, C., et al. (2008). A lifestyle physical activity intervention for caregivers of persons with Alzheimer’s disease. American Journal of Alzheimers Disease and Other Dementia, 23(2), 132–142. Fredman, L., Bertrand, R. M., Martire, L. M., Hochberg, M., & Harris, E. L. (2006). Leisuretime exercise and overall physical activity in older women caregivers and noncaregivers from the Caregiver-SOF Study. Preventive Medicine, 43(3), 226–229.
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Gusi, N., Prieto, J., Madruga, M., Garcia, J. M., & Gonzalez-Guerrero, J. L. (2009). Healthrelated quality of life and fitness of the caregiver of patient with dementia. Medicine and Science in Sports and Exercise, 41(6), 1182–1187. Hill, K., Smith, R., Fearn, M., Rydberg, M., & Oliphant, R. (2007). Physical and psychological outcomes of a supported physical activity program for older carers. Journal of Aging and Physical Activity, 15(3), 257–271. Hirano, A., Suzuki, Y., Kuzuya, M., Onishi, J., Hasegawa, J., Ban, N., et al. (2011). Association between the caregiver’s burden and physical activity in community-dwelling caregivers of dementia patients. Archives of Gerontology and Geriatrics, 52(3), 295–298. James, E. L., Stacey, F., Chapman, K., Lubans, D. R., Asprey, G., Sundquist, K., et al. (2011). Exercise and nutrition routine improving cancer health (ENRICH): The protocol for a randomized efficacy trial of a nutrition and physical activity program for adult cancer survivors and carers. BMC Public Health, 11, 236. Kerse, N., Hayman, K. J., Moyes, S. A., Peri, K., Robinson, E., Dowell, A., et al. (2010). Home-based activity program for older people with depressive symptoms: DeLLITE – a randomized controlled trial. Annals of Family Medicine, 8(3), 214–223. King, A. C., Baumann, K., O’Sullivan, P., Wilcox, S., & Castro, C. (2002). Effects of moderate-intensity exercise on physiological, behavioral, and emotional responses to family caregiving: A randomized controlled trial. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 57(1), M26–M36. King, A. C., & Brassington, G. (1997). Enhancing physical and psychological functioning in older family caregivers: The role of regular physical activity. Annals Behavioural Medicine, 19(2), 91–100. King, A. C., Rejeski, W. J., & Buchner, D. M. (1998). Physical activity interventions targeting older adults. A critical review and recommendations. American Journal Preventative Medicine, 15(4), 316–333. Lautenschlager, N. T., Cox, K., & Cyarto, E. V. (2012). The influence of exercise on brain aging and dementia. Biochimica et Biophysica Acta, 1822(3), 474–481. Marsden, D., Quinn, R., Pond, N., Golledge, R., Neilson, C., White, J., et al. (2010). A multidisciplinary group programme in rural settings for community-dwelling chronic stroke survivors and their carers: A pilot randomized controlled trial. Clinical Rehabilitation, 24(4), 328–341. Molloy, G. J., Johnston, D. W., Gao, C., Witham, M. D., Gray, J. M., Argo, I. S., et al. (2006). Effects of an exercise intervention for older heart failure patients on caregiver burden and emotional distress. European Journal of Cardiovascular Prevention and Rehabilitation, 13(3), 381–387. Oyebode, J. (2003). Assessment of carers’ psychological needs. Advances in Psychiatric Treatment, 9, 45–53. Peacock, S., & Forbes, D. (2003). Interventions for caregivers of persons with dementia: A systematic review. Canadian Journal of Nursing Research, 35(4), 88–107. Pinquart, M., & Sorensen, S. (2003). Associations of stressors and uplifts of caregiving with caregiver burden and depressive mood: A meta-analysis. Journal Gerontology. Series B. Psychological Sciences and Social Sciences, 58(2), P112–P128. Pinquart, M., & Sorensen, S. (2006). Helping caregivers of persons with dementia: Which interventions work and how large are their effects? International Psychogeriatrics, 18(4), 577–595. Prick, A. E., de Lange, J., Scherder, E., & Pot, A. M. (2011). Home-based exercise and support programme for people with dementia and their caregivers: Study protocol of a randomised controlled trial. BMC Public Health, 11, 894. Sorensen, S., Pinquart, M., & Duberstein, P. (2002). How effective are interventions with caregivers? An updated meta-analysis. Gerontologist, 42(3), 356–372. Teri, L., Gibbons, L. E., McCurry, S. M., Logsdon, R. G., Buchner, D. M., Barlow, W. E., et al. (2003). Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial. Journal American Medical Association, 290(15), 2015– 2022. Vreugdenhil, A., Cannell, J., Davies, A., & Razay, G. (2012). A community-based exercise programme to improve functional ability in people with Alzheimer’s disease: A randomized controlled trial. Scandinavian Journal Caring Science, 26(1), 12–19. Warburton, D. E., Nicol, C. W., & Bredin, S. S. (2006). Health benefits of physical activity: The evidence. Canadian Medical Association Journal, 174(6), 801–809.
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Contents lists available at ScienceDirect
Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger
Review
Physical activity in caregivers: What are the psychological benefits? Samantha M. Loi a,b,*, Briony Dow b,2, David Ames a,b,2, Kirsten Moore b,2, Keith Hill c,3, Melissa Russell d,4, Nicola Lautenschlager a,b,1,2 a
Academic Unit for Psychiatry of Old Age, St. Vincent’s Health, Department of Psychiatry, University of Melbourne, Normanby House, St. George’s Hospital, 283 Cotham Road, Kew, Victoria 3101, Australia b National Ageing Research Institute, 34-54 Poplar Road, Parkville, Victoria 3052, Australia c School of Physiotherapy and Exercise Science, Faculty of Health Sciences, Curtin University, Perth, Western Australia 6845, Australia d Centre for Epidemiology and Biostatistics, School of Population and Global Health, University of Melbourne, Level 3, 207 Bouverie Street, Parkville, Victoria 3010, Australia
A R T I C L E I N F O
A B S T R A C T
Article history: Received 18 February 2014 Received in revised form 3 April 2014 Accepted 5 April 2014 Available online xxx
Previous research demonstrates that physical activity has psychological benefits for people of all ages. However, it is unclear whether people caring for a frail or ill relative would derive similar psychological benefits, considering the potentially stressful caregiver role. This article reviews the current literature describing the effect of physical activity interventions on the psychological status of caregivers. A search from January 1975 to December 2012 identified five intervention studies investigating physical activity and psychological status in caregivers. These focused on female Caucasian caregivers who were older than 60 years. The physical activity interventions improved stress, depression and burden in caregivers, but small sample sizes, short-term follow up and varying results limited the generalizability of the findings. There were few trials investigating male caregivers, and most carerecipients were people with dementia. Studies with caregivers of different ages and gender, with a range of physical activity interventions, are needed to clarify whether physical activity has psychological benefits for caregivers. ß 2014 Published by Elsevier Ireland Ltd.
Keywords: Physical activity Caregivers Exercise Psychological health
Contents 1. 2.
3.
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Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Search strategy and selection criteria . . 2.1. Types of studies . . . . . . . . . . . . . . . . . . . 2.2. Types of participants . . . . . . . . . . . . . . . 2.3. Types of interventions . . . . . . . . . . . . . . 2.4. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Clinical trials (see Table ?1) . . . . . . . . . 3.1. Published trial protocols (see Table ?2) 3.2. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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* Corresponding author at: Academic Unit for Psychiatry of Old Age, St. Vincent’s Health, Department of Psychiatry, University of Melbourne, Normanby House, St. George’s Hospital, 283 Cotham Road, Kew, Victoria 3101, Australia. Tel.: +61 3 9816 0485/3 8387 2305; fax: +61 3 9816 0477/3 8387 4030. E-mail addresses: [email protected], [email protected] (S.M. Loi), [email protected] (B. Dow), [email protected] (D. Ames), [email protected] (K. Moore), [email protected] (K. Hill), [email protected] (M. Russell), [email protected] (N. Lautenschlager). 1 Tel.: +61 3 9816 0485; fax: +61 3 9816 0477. 2 Tel.: +61 3 8387 2305; fax: +61 3 8387 4030. 3 Tel.: +61 8 9266 3618; fax: +61 8 9266 3699. 4 Tel.: +61 3 8344 0736; fax: +61 3 9349 5815. http://dx.doi.org/10.1016/j.archger.2014.04.001 0167-4943/ß 2014 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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1. Introduction In the last decade there has been an expansion of research on the benefits associated with physical activity in adults of all ages. Physical activity (PA) has both physical and psychological health benefits. Studies have demonstrated that PA reduces the risk of cardiovascular disease (Dubbert, 2002) and some cancers, improves pulmonary function, reduces the risk of some chronic diseases, minimizes falls and improves pain management (Warburton, Nicol, & Bredin, 2006). PA has been found to decrease morbidity and mortality (Warburton et al., 2006). Psychological benefits include stress reduction and prevention and improvement of depressive symptoms (Castro, Wilcox, O’Sullivan, Baumann, & King, 2002) and improved sleep (King, Baumann, O’Sullivan, Wilcox, & Castro, 2002). There is also evidence to suggest that PA can improve cognition (Lautenschlager, Cox, & Cyarto, 2012). In studies focusing on older people, PA improves balance, strength and gait, endurance and general quality of life (Blake, Mo, Malik, & Thomas, 2009). It may also delay mobility limitations and further disability so that independent living can continue (Bennett & Winters-Stone, 2011). Psychological benefits of PA in older people include improvements in cognitive function, mood and well-being (Kerse et al., 2010). The term ‘‘carer’’ or ‘‘caregiver’’ is commonly defined as someone who provides care to another person who is dependent on the caregiver for help (Oyebode, 2003). Informal caregivers are unpaid, and are usually spouses or other family members. They are a vulnerable group of people (Oyebode, 2003) who play an important role in providing practical help and support, which enables people with chronic conditions to remain living in the community. Although there are positive aspects to providing care, the physical and psychological effort required to provide ongoing care can impact significantly on caregivers’ well-being. Caregivers have been shown to be at increased risk of stress and depression, to experience sleep problems more often, and have poor physical health (Oyebode, 2003). They often do not have the time to engage in preventive health behaviors such as regular PA, and studies have found that caregivers participate in less formal PA compared to non-caregivers (Fredman, Bertrand, Martire, Hochberg, & Harris, 2006; Hirano et al., 2011). There have been numerous interventions aimed at improving the psychological health of caregivers such as education, counseling and respite. However, these have had conflicting results (Pinquart & Sorensen, 2006; Sorensen, Pinquart, & Duberstein, 2002). Due to benefits PA has in the general population, interventions aiming to increase PA have also been trialed in the caregiver population. However, it is less clear whether the psychological benefits seen in the general population also extend to the caregiver population, at least one third of whom experience significant impact on their wellbeing due to their caring role (Oyebode, 2003). This review provides an overview of the literature reporting on PA in caregivers and its effect on their psychological health, from the period of January 1975 to December 2012. The purpose of this review is to examine the psychological benefits of PA in caregivers, what types of PA interventions have resulted in psychological benefits, and the limitations of study results obtained to date. The potential caregiver-specific barriers will also be highlighted. This review will present an overview of this topic, clarify in which psychological domains PA may be useful, and help guide future directions in this area. 2. Methods 2.1. Search strategy and selection criteria The scientific databases MEDLINE, PsycINFO, PubMed and Google Scholar were searched using the terms: exercise, physical
activity, motor activity, physical exertion, physical fitness, caregivers, carers and caring. References listed in articles were also followed up. Limits of English language and human studies were used. Studies published between 1975 and 2012 were included. These dates were selected as caregiver literature dates approximately from the mid 1970s, and we wished to capture as many articles as possible, since there has been no previously published review. 2.2. Types of studies Only studies in which caregivers were allocated to either a PA program, or usual care (control group) were included. Observational studies were excluded because these studies do not contribute to evidence-based practice in this area. Study quality was assessed using criteria following Peacock and Forbes (2003). It was coded whether participants were randomly allocated to intervention or control group (yes = pass; no/not reported = fail), whether these groups were comparable in terms of study characteristics (yes = pass; no = fail), whether these groups had at least 10 participants as studies with smaller sample sizes are at risk of errors (yes = pass; no = fail), the attrition rate (20% or not reported, fail), whether validated outcome measures were used (yes = pass, no = fail), and whether there was blinding of assessors (yes = pass; no/not reported = fail). A study was rated strong if it had no fail ratings and no more than one moderate rating; moderate if it had no fail ratings and more than one moderate rating; weak if it had one or two fail ratings; and poor if it had more than two fail ratings. 2.3. Types of participants Studies included informal caregivers of any age, and there was no restriction on the illness or diagnosis of care-recipient (CR). Only studies in which the major focus was the caregiver psychological outcome were included. 2.4. Types of interventions Interventions included any type of physical activity training. This could range from general walking, to specific programs such as Tai Chi, or yoga. The intervention could take place in any setting, including at home, in the community, or hospital-based. Group and individual PA, as well as types, frequencies, and duration of PA programs were described. 3. Results There were a total of 750 published articles found by the search. All 750 abstracts were reviewed using a standard evaluation form by SL, with consultation with other authors (NL, BD, KM), and checked if these fit the criteria for inclusion. Although this review was not specifically focusing on older caregivers, all of the eligible studies investigated outcomes in caregivers who were over 60 years of age. Fig. 1 shows the flow chart of the search. There were a total of fifteen studies found investigating PA in caregivers. Of these, there were five clinical trials using PA as an intervention which were included in this review (Castro et al., 2002; Connell & Janevic, 2009; Hill, Smith, Fearn, Rydberg, & Oliphant, 2007; King et al., 2002; King & Brassington, 1997; Marsden et al., 2010); four of these were randomized controlled trials (RCTs). There were three studies using PA as an intervention which focused primarily on outcomes for the CR (Molloy et al., 2006; Teri et al., 2003; Vreugdenhil, Cannell, Davies, & Razay, 2012), rather than the caregiver, hence these studies were excluded. Three observational studies were also
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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3
Search of databases (January 1975 to December 2012) Strategy: [exercise OR physical acvity OR motor acvity OR physical exeron OR physical fitness] AND [caregivers OR carers OR caring]
750 arcles (excluding duplicates) idenfied, abstracts reviewed
15 studies reviewed in full-text
11 studies invesgang PA in carers
4 RCT PA protocol found
3 studies excluded because of observaonal nature of study
2 PA protocols excluded because outcome of PA focused on CR, rather than carers
3 studies excluded because outcome of PA focused on CR, rather than carers
4 RCT studies included
2 RCT PA protocols included
1 study using PA as an intervenon in carers Fig. 1. Flow chart of search results.
found (Fredman et al., 2006; Gusi, Prieto, Madruga, Garcia, & Gonzalez-Guerrero, 2009; Hirano et al., 2011), which were excluded, two were of cross-sectional (Gusi et al., 2009; Hirano et al., 2011), and one was of longitudinal design (Fredman et al., 2006). Two PA RCT protocols were also identified (Dow et al., 2013; Prick, de Lange, Scherder, & Pot, 2011). A further two PA RCT protocols focusing on outcomes for the CR were found which were excluded (Cerga-Pashoja et al., 2010; James et al., 2011). A summary of the studies included is listed in Table 1 (studies reporting results) and Table 2 (protocol only – no results published). Table 3 describes the quality of the study, as per Peacock and Forbes (2003). 3.1. Clinical trials (see Table 1) There were five trials reviewed, of which were four were RCTs. These were carried out between 1997 and 2007, and occurred in the United States (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; King & Brassington, 1997) and in Australia (Marsden et al., 2010). There was one RCT whose results were reported in two papers (Castro et al., 2002; King et al., 2002). The majority of caregivers were female, with two studies focusing on female carers only (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002). The mean age of the carers was 64.78 years old. The majority of carers were of Caucasian ethnicity. CRs had diagnoses of dementia in three studies (Castro et al., 2002; Connell & Janevic,
2009; King et al., 2002; King & Brassington, 1997), stroke in one study (Marsden et al., 2010), and the CR diagnosis was not specified in one study (Hill et al., 2007). Sample sizes varied from 17 participants (Marsden et al., 2010) to 137 participants (Connell & Janevic, 2009). Types of PA varied from brisk walking on a treadmill (Castro et al., 2002; King et al., 2002; King & Brassington, 1997), strength training (Connell & Janevic, 2009) and other types such as tai chi and hatha yoga (Hill et al., 2007). Control groups included usual care (Connell & Janevic, 2009; King & Brassington, 1997; Marsden et al., 2010) and a nutritional program (Castro et al., 2002; King et al., 2002). The duration of the trials ranged from 7 weeks (Marsden et al., 2010) to 12 months (Castro et al., 2002; King et al., 2002), with varying frequencies from one hour once-to-twice a week (Hill et al., 2007), to 30–40 min four times a week (Castro et al., 2002; King et al., 2002; King & Brassington, 1997). One study was not a RCT, but had a variety of group-based PA which included Tai Chi, Hatha yoga and circuit training (Hill et al., 2007). Three studies had additional unique characteristics. Telephone contact rather than face-to-face contact was used for monitoring and motivating in the Connell & Janevic (2009) and King et al. (2002) and Castro et al. (2002) trials. The Mardsen et al. trial (2010) included an educational component as well as the PA. These were sessions given by a MDT such as a physiotherapist and dietician which supplemented the PA. Two studies conducted follow up measures, which also ranged from 12 weeks (Marsden et al., 2010) to 12 months (Connell & Janevic, 2009). Attrition rates
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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Table 1 Characteristics of trials which had PA as an intervention for caregivers (results reported). Study
Number of caregivers who completed (female). Mean age (years)
Care-recipient diagnosis; Involved in study?
PA intervention type
King & Brassington (1997)
24 (21) Controls 63.2; PA 60.2
Alzheimer’s dementia; No
King et al. (2002), and Castro et al. (2002)
85 (85) 63
Study
PA adherence
Duration; Follow up
Caregiver outcome measures
Outcomes (NS = non significant); Attrition
RCT: PA – brisk Home; walking (30– individual 40 min 4/week) vs usual activity
Rate Perceived Exertion (RPE); Casio computer diary; activity log
4 months; No follow up
PA group – improved anger expression (mean score 7.6, compared to 9.2, p < 0.03) Drop out rate 4.1%
Dementia; No
RCT: PA – brisk Home; individual walking (30– 40 min 4/wk) vs nutrition program
Heart rate 12 months; No monitor; follow up activity log; microprocessor; diary; RPE
Anger Expression; Screen for Caregiver Burden; Beck Depression Inventory (BDI); Perceived Stress Scale (PSS); Total Manifest Anxiety Scale (TMAS) BDI; PSS; Screen for Caregiver Burden; TMAS
Number of caregivers who completed (female); Mean age, years 137 (137) 66.8
Care-recipient diagnosis; Involved in trial?
PA intervention type
Setting
PA adherence
Duration; Follow up
Caregiver outcome measures
Dementia; No
RCT: PA plus education vs usual activity
Home; individual
Activity log
6 months. 12 month follow up.
Centre for Epidemiological StudiesDepression scale; PSS
Marsden et al. (2010)
17 (15) Controls 69.6; PA 66.3
Stroke survivors; Yes
Hill et al. (2007)
88 (75) 64.4
Not specified; No
Attendance roll HospitalRCT: PA plus based education vs usual activity (group) once weekly for 7 weeks (2.5 h) Attendance roll Group class PA – Tai Chi, Hatha yoga, 1 h/1–2 strength week training, circuit
Connell & Janevic (2009)
Setting
ranged from 4.1% (King & Brassington, 1997) to 24% (Hill et al., 2007). Psychological outcomes were varied and included measures of depression (using different scales such as the Beck Depression Inventory and Geriatric Depression Scale), burden (using Screen for Caregiver Burden and Zarit Burden Inventory), stress (Perceived Stress Scale), anxiety (Total Manifest Anxiety Scale), strain (Caregiver Strain Index) and anger (Anger Expression). PA was found to improve caregiver depression (Castro et al., 2002; Connell & Janevic, 2009; Hill et al., 2007; King et al., 2002), stress (Marsden et al., 2010), anger (King & Brassington, 1997) and burden (Castro et al., 2002). 3.2. Published trial protocols (see Table 2) Prick et al. (2011) are conducting a RCT in people with dementia and their caregivers in the Netherlands. They aim to recruit 156 pairs. The intervention group will receive an integrated home-based exercise and support program, while the control
7 weeks. 12 Caregiver Strain week follow up. Index
6 months. No follow up.
Zarit Burden Inventory, Geriatric Depression Scale-15
Improved depression – PA 3.2 points, nutrition 4.3 points, NS Improved stress – PA 3.3 points, nutrition 2.7 points, NS Both groups – Improved subjective burden (# 41.6–38.2, p < 0.007) Drop out rate 15% Outcomes (NS = nonsignificant) Attrition
PA group – improved depressive and stress scores (# 0.16 points, p < 0.05) at 6 months (no change at 12 months) Drop out rate 15.9% PA group – decreased caregiver stress (# 1.2 points, NS) Drop out rate 15% All PA groups – decreased depressive symptoms (26.3% change, p < 0.00) No change in burden (p > 0.05) Drop out rate 24%
group will receive usual care. Psychological measures such as mood and burden are being assessed in caregivers, as well as the impact of the intervention on the quality of the relationship between the care-recipient and their carer. The PA consists of an exercise component, aimed at improving flexibility, strength and endurance, where the pairs complete 30 min of active exercise at least three times a week. This is a home-based intervention lasting for three months, with follow up three months (six months) and then six months (one year) later. In Australia, Dow et al. (2013) are recruiting for a RCT for older caregivers (over 55 years) and older care-recipients (over 60 years), hypothesizing that the home-based, physiotherapist prescribed, individualized PA program will improve depressive symptoms in caregivers. To account for the potential confounder of the social component improving caregiver mood, a social control will also be included. A total of 273 pairs are required, with 117 pairs in both the PA and social program, and 39 in the usual care group. A qualitative component exploring the effect of exercising together is also part of the study. The intervention will last for six months,
Please cite this article in press as: Loi, S.M., et al., Physical activity in caregivers: What are the psychological benefits? Arch. Gerontol. Geriatr. (2014), http://dx.doi.org/10.1016/j.archger.2014.04.001
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Table 2 Characteristics of protocol trials (all involving caregiver and care recipient) – all randomized controlled trials. Study
Numbers
Care-recipient diagnosis
PA intervention
Duration
Caregiver outcome measures
Other
Prick et al. (2011)
156 dyads
Dementia
PA (30 min 3/week) vs usual activity
6 months. 12 month follow up.
Impact of PA on dyad
Dow et al. (2013)
273 dyads
Any illness
PA (30 min + walking 5/week) vs usual activity
6 months. 6 month follow up.
Centre of Epid Studies-Depression; General Health Questionnaire; Self-Perceived Pressure from I nformal Care ZBI, Geriatric Depression Scale, Carer Assessment of Satisfaction
with an additional six month follow up. An economic analysis will also be completed to evaluate the cost-effectiveness of the program. 4. Discussion Previous observational studies investigating levels of PA in caregivers consistently demonstrated that caregivers were less physically active compared to non-caregivers, and caregivers who did less PA had more depressive symptoms (Fredman et al., 2006), burden (Hirano et al., 2011) and generally worse psychological health (Gusi et al., 2009) compared to caregivers who did more PA. This literature review extends the knowledge in this area, seeking to evaluate the psychological benefit of PA in caregivers. There were five intervention trials of PA involving caregivers and psychological benefits, described in the literature to date. The number of studies which fulfilled criteria was small, and although it was not limited to older caregivers, all the studies included caregivers who were in the older age range. There were both heterogeneity of outcome measures and limitations with regards to type of PA, type of caregiver, CR disorder and small sample sizes. Table 3 demonstrates that overall, the quality of these studies were weak, due to lack of blinding and moderate attrition rates. In general, the studies found that PA (mostly consisting of walking) in caregivers can improve depression (Castro et al., 2002; Connell & Janevic, 2009; Hill et al., 2007; King et al., 2002), stress (Marsden et al., 2010), anger (1997) and burden (Castro et al., 2002). The most commonly utilized form of PA was brisk walking (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; King & Brassington, 1997; Marsden et al., 2010). Two of these trials had additional exercises to improve flexibility and stretching (Connell & Janevic, 2009; Marsden et al., 2010). There was only one trial using a variety of PA, such as yoga and Tai Chi (Hill et al., 2007), and excluded walking. The potential strength of this approach was that it provided options and choice to participants, rather than being constrained to a single PA. However due to the small numbers of participants in these types of PA, comparisons between
Social control Impact of PA on dyad Economic evaluation
each were not conducted, and hence it is unclear which of these PA had the most effect on caregivers’ psychological health. Due to the majority of studies only using walking as the most common PA studied, there is insufficient research using other PA approaches to determine whether other types of PA may result in psychological benefits in caregivers. There was one RCT which used a nutritional program as the comparison to the PA intervention (Castro et al., 2002; King et al., 2002), rather than a control or waitlist group (Connell & Janevic, 2009; King & Brassington, 1997; Marsden et al., 2010). One study (Hill et al., 2007) did not have a comparison control group. One study only had a sample size of 17, and none of the results were statistically significant (Marsden et al., 2010) and there was only one trial with a sample size larger than 100 (Connell & Janevic, 2009). About half the trials were home-based PA programs, which required consideration for monitoring and adherence to the PA. Diaries, and activity logs were frequently utilized, but have the limitation of recall bias, or socially desirable over-reporting. Studies which used more objective and sophisticated measures, such as a heart rate monitor (Castro et al., 2002; King et al., 2002; King & Brassington, 1997) may have more accurate recordings of home-based PA. Attendance rolls were used for group-based PA (Hill et al., 2007; Marsden et al., 2010). Connell & Janevic (2009) utilized telephone contact, rather than face-to-face contact, which the authors stated was effective for motivating and encouraging participants. The samples in the RCTs were predominantly older female caregivers, who were of Caucasian background, with sample sizes ranging from 17 (Marsden et al., 2010) to 137 caregivers (Connell & Janevic, 2009). Outcomes included measures of anger expression (King & Brassington, 1997), depression (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002), anxiety (Castro et al., 2002; King & Brassington, 1997), burden (Connell & Janevic, 2009; King & Brassington, 1997) and stress (Castro et al., 2002; Connell & Janevic, 2009; King et al., 2002; Marsden et al., 2010). The results of three of the four RCTs showed that the caregivers who participated in the PA intervention had improved psychological health – significantly decreased anger (King & Brassington, 1997), depression and burden (Castro et al., 2002; Connell & Janevic, 2009; King
Table 3 Study quality (attrition rate 21% fail. N/A = not applicable). Study
Random allocation
Groups comparable
Sample size > 10
Attrition rate
Validated outcomes
Blinding of assessors
King & Brassington (1997) King et al. (2002) and Castro et al. (2002) Connell & Janevic (2009) Marsden et al. (2010)
Pass Pass Pass Pass
Pass Pass Pass Pass
Pass Moderate Moderate Moderate
Pass Pass Pass Pass
Fail Fail Fail Fail
Hill et al. (2007)
N/A
N/A
Pass Pass Pass Pass (less than 10 in each group) Pass
Fail
Pass
N/A
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et al., 2002), compared to control groups. The results of these small number of studies is suggestive that walking as a PA can improve the psychological health in caregivers. However, there were also equivocal results in two of the RCTs which may imply that there are additional barriers which preclude this statement. King and Brassington (1997) and Connell & Janevic (2009) did not find any significant improvements in depression or burden, and King et al. (2002) and Castro et al. (2002) found improvements in stress and depression occurred in both the PA and nutritional control groups, so drawing conclusions about whether PA was more effective than nutrition are problematic. Connell & Janevic (2009) found that the improvements in depression (non-significant) and stress which occurred during the intervention period (6 months) were no longer evident at 12 months. The caregivers in the intervention group also declined in their levels of PA during the follow up period. Cessation of the regular monitoring may mean that caregivers cease the PA due to lack of structured motivation and encouragement. This suggests the need for sustained participation in PA long-term by caregivers if psychological benefits are to be maintained. Does the inclusion of an educational/behavioral component in addition to the PA contribute to improving the psychological state in caregivers? There were only two studies using this combination (Connell & Janevic, 2009; Marsden et al., 2010). Connell & Janevic (2009) found an improvement in stress scores during the intervention which were not sustained in the follow up period. Due to the small sample size and short duration of the intervention, it is difficult to assess the combination in Mardsen et al. trial (2010). None of the RCTs reported on whether the researchers were blinded to whether participants were in the intervention or control group, which means that interviewer bias could influence results. The protocol by Dow et al. (2013) seeks to address this by blinding of researchers. It is also unclear whether the social contact which participants received as monitoring, or the actual PA which contributes to improving depression, stress and burden in caregivers. The study without a control group found an improvement in psychological symptoms (Hill et al., 2007), however studies with a control group activity (i.e. the nutritional control) did not find a difference between the intervention and the control. It is possible that the benefit seen in the studies without the comparison was simply the effect of having a social aspect, or having ‘‘something’’ done. In studies that have investigated the effect of PA interventions in noncaregivers, it has been found that the social component of PA could also be contributing to the alleviation of depressive symptoms (Kerse et al., 2010). The protocol by Dow et al. (2013) attempts to control for this potential confounder. Most of the studies reviewed focused on older female spousal caregivers. This is of concern, as the ratio of older male to older female caregivers is almost 50:50 (Australian Bureau of Statistics, 2012). There is good evidence to indicate that male caregivers may approach and react to caring differently, and it has been reported that they have lower levels of depression compared to female caregivers (Pinquart & Sorensen, 2003). Additionally, although many of the caregivers involved in these studies have been classified as ‘‘older’’ (that is, their mean age is approximately 60 years), it can be expected that due to the increasing age of populations in most countries, proportions and numbers of caregivers will be substantially older than 60 years in the future. There were no studies looking at caregivers whose age was in a higher age range. Nearly all the care-recipients in the studies had dementia, which is particularly challenging for caregivers due to its deteriorating and fluctuating nature (Pinquart & Sorensen, 2003). The majority of studies used a graduated PA program
involving brisk walking, and only one non-randomized study investigated non-aerobic types of PA such as Tai Chi and yoga (Hill et al., 2007). There were also different measures of depression (Beck Depression Inventory, Geriatric Depression Scale, Hospital Anxiety and Depression Scale) and burden (Zarit Burden Interview, Screen for Caregiver Burden), which add to the heterogeneity of results. Previous studies indicate that caregivers of people with dementia prefer PA programs that are simple, convenient and inexpensive (Farran et al., 2008). Home-based, rather than groupbased programs also appear to be preferred (King, Rejeski, & Buchner, 1998), however most caregivers found the social aspect of group PA programs enjoyable (Marsden et al., 2010; Vreugdenhil et al., 2012), and enjoyed exercising with the care-recipient (Marsden et al., 2010; Vreugdenhil et al., 2012). Using caregivers’ preferences to formulate PA programs is worth investigating in more detail (Cerga-Pashoja et al., 2010). The caregiver group may also have other characteristics which limit the translation of benefits of physical activity. The positive psychological effects attributed to PA in the general population may not be found amongst caregivers, as the burden and stress of this role may make PA an additional load. Caregivers have stated that participating in such programs interfered with their caring role and other responsibilities, and they worried about being away from the CR (Farran et al., 2008; Hill et al., 2007). Caregivers’ concern about their own health has also been cited as a barrier to maintaining PA (Connell & Janevic, 2009). Table 3 shows that except for the King and Brassington (1997) program, attrition rate was problematic. Reasons for dropping out of the study were attributed to high levels of caregiving responsibilities (King & Brassington, 1997) and being too busy (Connell & Janevic, 2009). The CRs whose caregivers were involved in one study were able to be cared for during the PA program, which attempted to address the caregivers’ concern about leaving their CR alone (Hill et al., 2007). Further research is required to investigate if these barriers can be overcome through finding the most acceptable method of assisting caregivers to undertake PA. Comparing the benefits of PA in caregivers who have varying levels of psychological distress may help clarify this. Most PA interventions have targeted the individual, and there have been limited studies to date exploring the potential benefits of PA in the caregiver/CR dyad. Prick et al. (2011) and Dow et al. (2013) both aim to address this gap in their studies by investigating the impact of the intervention on the caregiver dyad. Due to the small number of studies, which mostly used walking as PA, there is not yet conclusive evidence that PA can improve psychological health in caregivers. The paucity of RCTs, varying activity dosages, insufficient sample sizes and short follow-up periods limit the generalizability of results to older female caregivers of people with dementia. The results in this review are limited by the study parameters which only included studies involving informal, unpaid caregivers as participants. This review also did not access non-English language studies. Future directions for research that would improve generalizability of results and help clarify benefits, should include studies specifically focussing on older male caregivers, caregivers of a younger age (this age group has its own particular characteristics), and caregivers who are older than 70 years, all of whom have been little studied to date. Although people with dementia are an increasing group, it is also important to look at caregivers of people with other illnesses (for example, people with stroke and other neurological disorders). Almost all the literature investigates caregivers of Caucasian background and the cultural aspects of caring are an important consideration. For example, some cultures (e.g. Italian, Greek, Chinese) are particularly reluctant to have a family member transferred to residential care and may continue
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caring for an extended period of time with few external supports. Home-based individual PA programs versus community group programs have been evaluated, with different results. 5. Conclusions Physical activity, that is, walking, appears to have some benefit for caregivers, in that it can decrease levels of stress, depression and burden. However, the small number of trials, the heterogeneity of physical activity interventions and outcome measures, and limited sample sizes, restrict the generalizability of results. Providing care can be a stressful and time-consuming task which may be one of the reasons why the positive psychological effects of physical activity interventions are not as strong in this population. Further randomized controlled trials including samples with older male caregivers, with different levels of psychological distress, and a variety of PA modalities may help answer these questions. Conflicts of interest There are no conflicts of interest. All authors disclose that there is no financial and personal relationships with other people or organizations that could inappropriately influence the work. References Australian Bureau of Statistics. (2012). Australian Social Trends – Older carers. http:// www.abs.gov.au/AUSSTATS/[email protected]/Lookup/4102.0Main+Features40Dec+2012 Retrieved 26.01.13. Bennett, J., & Winters-Stone, K. (2011). Motivating older adults to exercise: What works? Age and Ageing, 40, 148–149. Blake, H., Mo, P., Malik, S., & Thomas, S. (2009). How effective are physical activity interventions for alleviating depressive symptoms in older people? A systematic review. Clinical Rehabilitation, 23(10), 873–887. Castro, C. M., Wilcox, S., O’Sullivan, P., Baumann, K., & King, A. C. (2002). An exercise program for women who are caring for relatives with dementia. Psychosomatic Medicine, 64(3), 458–468. Cerga-Pashoja, A., Lowery, D., Bhattacharya, R., Griffin, M., Iliffe, S., Lee, J., et al. (2010). Evaluation of exercise on individuals with dementia and their carers: A randomised controlled trial. Trials, 11, 53. Connell, C. M., & Janevic, M. R. (2009). Effects of a telephone-based exercise intervention for dementia caregiving wives: A randomized controlled trial. Journal Applied Gerontology, 28(2), 171–194. Dow, B., Moore, K., Russell, M., Ames, D., Cyarto, E., Haines, T., et al. (2013). Improving mood through physical activity for carers and care recipients (IMPACCT): Protocol for a randomised trial. Journal of Physiotherapy, 59(2), 125. Dubbert, P. M. (2002). Physical activity and exercise: Recent advances and current challenges. Journal Consulting and Clinical Psychology, 70(3), 526–536. Farran, C., Staffileno, B., Gilley, D., McCann, J., Li, Y., Castro, C., et al. (2008). A lifestyle physical activity intervention for caregivers of persons with Alzheimer’s disease. American Journal of Alzheimers Disease and Other Dementia, 23(2), 132–142. Fredman, L., Bertrand, R. M., Martire, L. M., Hochberg, M., & Harris, E. L. (2006). Leisuretime exercise and overall physical activity in older women caregivers and noncaregivers from the Caregiver-SOF Study. Preventive Medicine, 43(3), 226–229.
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