Whole home exercise intervention for depression in older care home residents (the OPERA study): a process evaluation

BMC Medicine

Stephanie JC Taylor¹  Clive Seale⁴  Martin Underwood²  Margaret Thorogood³  David R Ellard² 

[1] Blizard Institute, Queen Mary, University of London, Barts and the London School of Medicine and Dentistry, London, UK;Warwick Clinical Trials Unit, Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK;Division of Health Sciences, Warwick Medical School, The University of Warwick, Coventry CV4 7AL, UK;Brunel University, Uxbridge, London UB8 3PH, UK

关键词: Cluster randomised controlled trial;    Culture change;    Depression;    Exercise;    Process evaluation;    Elderly residential care;   

Others  :  855207
DOI  :  10.1186/1741-7015-12-1

 received in 2013-10-01, accepted in 2013-12-06,  发布年份 2014

【 摘 要 】

Background

The ‘Older People’s Exercise intervention in Residential and nursing Accommodation’ (OPERA) cluster randomised trial evaluated the impact of training for care home staff together with twice-weekly, physiotherapist-led exercise classes on depressive symptoms in care home residents, but found no effect. We report a process evaluation exploring potential explanations for the lack of effect.

Methods

The OPERA trial included over 1,000 residents in 78 care homes in the UK. We used a mixed methods approach including quantitative data collected from all homes. In eight case study homes, we carried out repeated periods of observation and interviews with residents, care staff and managers. At the end of the intervention, we held focus groups with OPERA research staff. We reported our first findings before the trial outcome was known.

Results

Homes showed large variations in activity at baseline and throughout the trial. Overall attendance rate at the group exercise sessions was low (50%). We considered two issues that might explain the negative outcome: whether the intervention changed the culture of the homes, and whether the residents engaged with the intervention. We found low levels of staff training, few home champions for the intervention and a culture that prioritised protecting residents from harm over encouraging activity. The trial team delivered 3,191 exercise groups but only 36% of participants attended at least 1 group per week and depressed residents attended significantly fewer groups than those who were not depressed. Residents were very frail and therefore most groups only included seated exercises.

Conclusions

The intervention did not change the culture of the homes and, in the case study homes, activity levels did not change outside the exercise groups. Residents did not engage in the exercise groups at a sufficient level, and this was particularly true for those with depressive symptoms at baseline. The physical and mental frailty of care home residents may make it impossible to deliver a sufficiently intense exercise intervention to impact on depressive symptoms.

【 授权许可】

   
2014 Ellard et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Llewellyn-Jones RH, Baikie KA, Smithers H, Cohen J, Snowdon J, Tennant CC: Multifaceted shared care intervention for late life depression in residential care: randomised controlled trial. BMJ 1999, 319:676-682.
• [2]Mann AH, Graham N, Ashby D: Psychiatric illness in residential homes for the elderly: a survey in one London borough. Age Ageing 1984, 13:257-265.
• [3]Parmelee PA, Katz IR, Lawton MP: Incidence of depression in long-term care settings. J Gerontol 1992, 47:M189-M196.
• [4]Katz IR, Simpson GM, Curlik SM, Parmelee PA, Muhly C: Pharmacologic treatment of major depression for elderly patients in residential care settings. J Clin Psychiatry 1990, 51:41-47.
• [5]Schreiner AS, Yamamoto E, Shiotani H: Positive affect among nursing home residents with Alzheimer’s dementia: the effect of recreational activity. Aging Ment Health 2005, 9:129-134.
• [6]Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A, Spencer A, Thorogood M, Atherton N, Bremner SA, Devine A, Diaz-Ordaz K, Ellard DR, Potter R, Spanjers K, Taylor SJ: Exercise for depression in care home residents. A randomised controlled trial with cost-effectiveness analysis (OPERA). Health Technol Assess 2013, 17:1-281.
• [7]Underwood M, Eldridge S, Lamb S, Potter R, Sheehan B, Slowther AM, Taylor S, Thorogood M, Weich S: The OPERA trial: protocol for a randomised trial of an exercise intervention for older people in residential and nursing accommodation. Trials 2011, 12:27. BioMed Central Full Text
• [8]Underwood M, Lamb SE, Eldridge S, Sheehan B, Slowther A, Spencer A, Thorogood M, Atherton N, Bremner SA, Devine A, Diaz-Ordaz K, Ellard DR, Potter R, Spanjers K, Taylor SJ: Exercise for depression in older care home residents. A cluster randomised controlled trial. Lancet 2013, 382:41-49.
• [9]Oakley A, Strange V, Bonell C, Allen E, Stephenson J: Process evaluation in randomised controlled trials of complex interventions. BMJ 2006, 332:413-416.
• [10]Ellard D, Taylor S, Parsons S, Thorogood M: The OPERA trial: a protocol for the process evaluation of a randomised trial of an exercise intervention for older people in residential and nursing accommodation. Trials 2011, 12:28. BioMed Central Full Text
• [11]Sheikh J, Yesavage J: Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clin Gerontol 1986, 5:165-173.
• [12]Folstein MF, Folstein SE, McHugh PR: “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975, 12:189-198.
• [13]EuroQol: EQ-5D: A Standardised Instrument For Use As A Measure Of Health Outcome. http://www.euroqol.org/eq-5d/eq-5d-products/eq-5d-3l-translations/alternative-modes-3l.html#c337 webcite
• [14]Guralnik JM, Simonsick EM, Ferrucci L, Glynn RJ, Berkman LF, Blazer DG, Scherr PA, Wallace RB: A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol 1994, 49:M85-M94.
• [15]Guralnik JM, Ferrucci L, Pieper CF, Leveille SG, Markides KS, Ostir GV, Studenski S, Berkman LF, Wallace RB: Lower extremity function and subsequent disability: consistency across studies, predictive models, and value of gait speed alone compared with the short physical performance battery. J Gerontol A Biol Sci Med Sci 2000, 55:M221-M231.
• [16]Fetterman DM: Ethnography Step by Step. 2nd edition. Thousand Oaks, CA: Sage Publications; 1998.
• [17]Reeves S, Kuper A, Hodges BD: Qualitative research methodologies: ethnography. BMJ 2008, 337:a1020.
• [18]McKee KJ, Houston DM, Barnes S: Methods for assessing quality of life and well-being in frail older people. Psychol Health 2002, 17:737-751.
• [19]Parker C, Barnes S, McKee K, Morgan K, Torrington J, Tregenza P: Quality of life and building design in residential and nursing homes for older people. Ageing Soc 2004, 24:941-962.
• [20]Ritchie J, Spencer L: Qualitative data analysis for applied policy research. In Analysing Qualitative Data. Edited by Bryman A, Burgess R. London, UK: Routledge; 1994.
• [21]Pope C, Ziebland S, Mays N: Qualitative research in health care: analysing qualitative data. BMJ 2000, 320:114-116.
• [22]Logghe IHJ, Verhagen AP, Rademaker ACHJ, Zeeuwe PEM, Bierma-Zeinstra SMA, Van Rossum E, Faber MJ, Van Haastregt JCM, Koes BW: Explaining the ineffectiveness of a Tai Chi fall prevention training for community-living older people: a process evaluation alongside a randomized clinical trial (RCT). Arch Gerontol Geriatr 2011, 52:357-362.
• [23]Jonkers C, Lamers F, Bosma H, Metsemakers J, Kempen G, Van Eijk J: Process evaluation of a minimal psychological intervention to reduce depression in chronically ill elderly persons. Patient Educ Couns 2007, 68:252-257.
• [24]Jansen APD, van Hout HPJ, Nijpels G, Rijmen F, Dröes RM, Pot AM, Schellevis FG, Stalman WAB, van Marwijk HWJ: Effectiveness of case management among older adults with early symptoms of dementia and their primary informal caregivers: a randomized clinical trial. Int J Nurs Stud 2011, 48:933-943.
• [25]Skoro-Kondza L, Tai SS, Gadelrab R, Drincevic D, Greenhalgh T: Community based yoga classes for type 2 diabetes: an exploratory randomised controlled trial. BMC Health Serv Res 2009, 9:33. BioMed Central Full Text
• [26]Braun SM, van Haastregt JC, Beurskens AJ, Gielen AI, Wade DT, Schols JM: Feasibility of a mental practice intervention in stroke patients in nursing homes; a process evaluation. BMC Neurol 2010, 10:74. BioMed Central Full Text
• [27]Potter R: Does the Physical Environment Predict Depressive Symptoms in Older People Living in Care Homes?. Coventry UK: The University of Warwick; 2013.
• [28]British Geriatrics Society: Quest for Quality An Inquiry into the Quality of Healthcare Support for Older People in Care Homes: A Call for Leadership, Partnership and Improvement. http://www.bgs.org.uk/index.php?option=com_content&view=article&id=1487&Itemid=719 webcite
• [29]BBC News: Southern Cross set to shut down and stop running homes. http://www.bbc.co.uk/news/business-14102750 webcite
• [30]Conradsson M, Littbrand H, Lindelof N, Gustafson Y, Rosendahl E: Effects of a high-intensity functional exercise programme on depressive symptoms and psychological well-being among older people living in residential care facilities: a cluster-randomized controlled trial. Aging Ment Health 2010, 14:565-576.
• [31]Kerse N, Hayman KJ, Moyes SA, Peri K, Robinson E, Dowell A, Kolt GS, Elley CR, Hatcher S, Kiata L, Wiles J, Keeling S, Parsons J, Arroll B: Home-based activity program for older people with depressive symptoms: DeLLITE - a randomized controlled trial. Ann Fam Med 2010, 8:214-223.
• [32]Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE: Exercise for depression. Cochrane Database Syst Rev 2013, 9:CD004366.