INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, VOL. 4: 125-1 27 (1989)

EDITORIAL

Trial and error: evaluating the psychological benefits of physical activity

It would not be false modesty to admit that psycho- geriatrics currently faces a growing number of clinical problems with an as yet limited number of therapeutic solutions. Even so, new approaches to the management of dementing illnesses, particularly non-pharmacological approaches, are often re- garded with more suspician than interest. Perhaps with good reason. Those concerned with the psycho- logical wellbeing of elderly people have, in recent years, seen their fair share of unsuccessful or simply overrated therapeutic innovations. Such experi- ences are not unique to psychiatry. As Hanley and Gilhooly (1986) comment ‘the wayside of the psychology of ageing is littered with the abandoned remains of bandwagons of past decades’. Practi- tioners, then, are apt to be cautious, and occasionally over-cautious. If, as a result of this circumspection innovative non-pharmacological treatment strategies occasionally fail to receive the attention they deserve, then some measure of responsibility should be accepted by those who conduct and report research.

Experienced clinicians are unlikely to adopt a new practice unless convinced of its efficacy. It is important to recognise, therefore, that the credibi- lity of a promising therapeutic intervention is rarely made or broken in a single study. It is more usual for an idea to evolve through a series of reported observations, controlled evaluations, and, wherever possible, clinical trials. Ideally, each individual study should interlock with relevant work already done, and leave a legacy of data for future research. If this procedure is observed, then evidence grows in a systematic way, researchers waste less time re- inventing therapeutic wheels, and practitioners are better able to judge the value of new treatment approaches. All too often, however, the procedure is not observed, and the growth of evidence is far from systematic. An interesting case in point is provided by the small but growing literature on the value of physical activity in combating mental health problems in old age.

Physical activity has been associated with a

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variety of cognitive and behavioural changes which allow the conclusion that, at least in younger individuals, regular exercise can contribute to psychological wellbeing and mental health (Folkins and Sime, 1981; Veale, 1987). Thus, while concern has not entirely moved away from whether certain types of exercise have psychological benefits (e.g. Hughes, 1984) attention is increasingly being paid to how these benefits are mediated, and at whom they might best be targeted. On theoretical grounds, institutionalised elderly people with some degree of cognitive impairment appear to be a particularly appropriate target group. If, for example, cognitive losses are exacerbated by the inactivity which can accompany institutionalisation, then formal exer- cise programmes may help to restore aspects of cognitive function.

The hypothesis is well suited to the clinical trial format in which a treatment (activity) group is compared with a control (non activity group) on relevant outcome measures. But there are prob- lems. In particular there is the need to distinguish between those effects due to exercise per se and those confounding effects due to the social or personal consequences of participating in super- vised activities. In practical terms it is a problem which emphasises the need to include contol inter- ventions which mimic the ‘treatment’ in everything bar activity. (Of course, whether or not social participation has clinical benefits is not irrelevant - but that’s another research issue.)

Some well designed studies conducted in the mid nineteen seventies provided a foundation of both methodology and data. Powell (1974) reported a study in which ‘geriatric mental patients’ engaged in either 12 weeks of physical activity (the treatment group), or 12 weeks of ‘social therapy’(the control group). A second (no-treatment) control group received no special therapeutic attention. While the treatment condition included mild exercise training, the social therapy control condition included ‘. . . arts and crafts work, social interaction, music therapy, and game playing with no accompanying

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physical activity’. The results were encouraging. Relative to both the no-treatment, and the social therapy groups, the exercisers showed significiant improvements on Raven’s Progressive Matrices and the Wechsler Memory Scale.

The limitations of exercise therapy among elderly psychiatric patients were also noted at this time. Clark et al. (1975), in a similarly well designed study, assessed the physiological and social impact of exercise using three groups of elderly, mainly schizophrenic, inpatients (one treatment group and two control groups). While the treatment condition included 12 weeks of regular light exercise, the two control conditions comprised social activities or routine ward activities respectively. Formal psycho- metric assessments were not included in this study. Rather, the authors hypothesised that exercise would lead to a general increase in customary activity levels and, as a result, would ‘. . . upgrade patient self-care’. In the event, levels of daily physical activity did increase in the exercise group, but this increase was not associated with any improvement in personal maintenance (i.e. neat- ness, etc.).

Both Powell (1974) and Clark et al. (1975) used diagnostically heterogeneous patient groups (Clark et al., for example, included patients with personality disorders, and ‘central nervous system syphilis’ in their treatment group). There is no reason to suppose, however, that in combination with institutionalisation, all psychological disorders produce similar, potentially reversible losses. Nevertheless, the feasibility, and some possible effects, of such activity trials had been established. Other studies could now develop these findings, and focus on more homogeneous patient groups.

This need to define more narrowly the patient group was recognised by Diesfeldt and Diesfeldt- Groenendijk (1977) who assessed the impact of a four week activity programme on patients with the single diagnosis of organic brain syndrome. In this study the treatment condition consisted of super- vised light gymnastic exercises ‘. . . executed by the subjects while sitting on a chair’. When compared with carefully matched controls, a significant improvement in memory performance (as measured by a test of free-recall) was noted in the exercise group. But here there is a problem of interpretation. The control group in this study received no special attenion throughout the trial and simply continued to engaged in ward activities. So, was the improve- ment in the activity group due to activity, or some

other factor or factors associated with the activity condition?

These are precisely the issues which, in a healthy research culture, can be taken up in subsequent investigations. However, by the late nineteen seventies psychogeriatrics appears to have had enough of exercise intervention trials, and the topic remained fallow for some time. While experimental interest waned, theoretical interest persisted. Inge- bretsen (1982) carefully analysed ‘the relationship between physical activity and mental factors in the elderly’, and provided several pointers for future research. This important review goes well beyond the experimental studies considered here, and is recommended reading for anyone interested in the topic.

After a long period of relative neglect, two recent studies seem to have put exercise and cognitive per- formance in old age back on the therapeutic agenda. In the first (Molly et al., 1988a), the impact of a single 45 minute dose of exercise was measured in 15 elderly outpatients who were ‘. . . physically active and complained of memory loss of cognitive impairment’ (sic). Using a design in which the participants acted as their own controls, the authors report slight but significant improvements in logical memory and MMSE test scores immediately (not more than 35 minutes) after excercise. The improve- ments were slight indeed and appear to have been influenced, perhaps as much as anything by variable MMSE baselines, and a control condition which seems actually to have impaired logical memory.

In a subsequently reported study Molloy et al. (1988b) examined the effects of a 3 month light exercise programme on the cognitive test perform- ance of elderly women (aged 73-90 years) living in a nursing home. The two participating groups (the exercise group and a ‘control intervention’ group) were assessed only twice, immediately before, and 3-7 days after the exercisers had completed their 12 week programme. From a total of eight different assessments (including WAIS subtests and the MMSE) the authors report that the activity group improved on only one - a word fluency test.

This study is certainly not without merit, but again, there are problems of interpretation. As in the Diesfeldt and Diesfeldt-Groenendijk (1977) study, Molley el a1.k control group was simply identified, then left alone. If, relative to these passive controls, the exercisers had shown a uniform improvement in test performance, it would

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have been a matter of conjecture whether such improvements were due to exercise, or t o a host of other factors associated with group activities. There are other problems with this report. Molloy et al. insist on using the terminology of absolute differences to describe relative differences. Thus, while the authors note ‘. . . a significant improve- ment in the World Fluency Test in the exercise group compared to the control group’, closer scrutiny shows this ‘improvement’ to be more apparent than real. In fact over the 3-month study period, mean word fluency deteriorated in both groups but, from a significantly higher baseline, the deterioration was greater in the control group - which isn’t quite the same as saying that per- formance significantly ‘improved’ in the exercisers.

Hopefully, this welcome revival of research interest will promote not only further studies, but also further debate of important methodological issues. And this interaction of experiment and constructive discussion can only produce better quality data, and hence better quality evidence. Reflecting on the value, and the limitations of their own experimental results Diesfeldt and Diesfeldt- Groenendijk (1977) concluded that ‘the search for circumstances which positively influence perform- ance levels will finally result in increased thera- peutic possibilities’. I agree. Ideally, however, this search should proceed through studies which build on, develop, and test earlier findings, and not through a series of trials which don’t so much re- invent the wheel as re-design the puncture.

KEVIN MORGAN University of Nottingham

Medical School

REFERENCES

Clark, B. A., Wade, M. G., Massey, G. H. and Van Dyke, R. (1975) Response of institutionalized geriatric mental patients to a twelve-week program of regular physical activity. J. Gerontol. 30, 565-573.

Diesfeldt, H. F. A. and Diesfeldt-Groenendijk, H. (1977) Improving cognitive performance in psychogeriatric patients: the influence of physical exercise. Age and Ageing, 6, 58-64.

Folkins, C. H. and Sime, W. E. (1981) Physical fitness training and mental health. Amer. Psychol. 36, 373-389.

H a n k y , I . and Gilhooly, M. (1986) Psychological therapies for the elderly (preface). Croom-Helm, London.

Hughes, J. R. (1984) Psychological effects of habitual aerobic exercise: a critical review. Prev. Med. 13, 66-78.

Ingebretsen, R. (1982) The relationship between physical activity and mental factors in the elderly. Scand. J. SOC. Med. Supp. 29, 153-159.

Molloy, D. W., Beerschoten, D. A,, Borrie, M. J., Crilly, R. G. and Cape, R. D. T. (1988a) Acute effects of exercise on neuropsychological function in elderly subjects. J. Amer. Ger. SOC. 36, 29-33.

Molloy, D. W., Richardson, L. D. and Crilly, R. G. (1988b) The effects of a three-month exercise pro- gramme on neuropsychological function in elderly institutionalized women: a randomized controlled trial. Age and Ageing, 17, 303-310.

Powell, R. D. (1974) Psychological effects of exercise therapy up o n i ii s t i t u t i o n a1 ize d geriatric men t a I patients. J. Gerontol. 29, 157-161.

Veale, D. M. W. de C. (1987) Exercise and mental health. Acta Psychiat Scand. 76, 1 13- 120.