Mental wellbeing in over 65s: occupational therapy and physical activity interventions

Evidence statement 1 (Mixed exercise)

Two meta-analyses (Arent et al. 2000, MA+; Netz et al. 2005, MA+), together comprising 68 controlled trials from many developed countries, since augmented by four other rigorous trials in the Netherlands (2), Norway and the USA, together provide strong evidence that mixed exercise programmes generally have small-to-moderate effects on mental wellbeing. As the reported exercise programmes cover a range of types, settings and countries, firm conclusions about the duration of programmes and the frequency of sessions are difficult. It is clear, however, that exercise of moderate intensity (not well defined in the meta-analyses) has beneficial effects on physical symptoms and psychological wellbeing.

The programmes evaluated were generally community-based, well organised and run by trained instructors. The findings apply to similar populations (relatively healthy and independent, and motivated to take exercise) in similar community settings in the UK. The sole qualitative study (Hardcastle and Taylor 2001, Q+) highlights the importance of appropriate facilities and good supervision.

Evidence statement 2 (Strength and resistance exercises)

Meta-analysis of four US trials that included a total of 1733 independent frail older people aged 65+ living in the community. Four of the SF-36 scales were used to evaluate similar resistance exercise interventions. A significant small-to-moderate improvement in emotional health was reported (Schechtman and Ory 2001, MA+). The findings are likely to be broadly applicable to frail older people in a range of settings in the UK.

Of six smaller controlled studies evaluating the benefit of resistance exercise for older people in general, five reported significant positive effects, mostly on the Profile of Mood States (POMS) measure (a self-reported measure of general mood over the past week). As all six were of poor quality, this finding should not be considered robust.

Evidence statement 3 (Aerobic exercise)

A medium-sized RCT in the US showed that both interventions – supervised aerobic brisk walking and 'toning and stretching' – generated similar trajectories of Memorial University of Newfoundland Scale of Happiness (MUNSH) and Satisfaction with Life Scale (SWLS) scores over 12 months in sedentary adults aged 60 to 75. These trajectories showed significant growth in happiness and satisfaction over the six-month exercise period, followed by a significant decrease at 12 months (McAuley et al. 2000, RCT+). The findings are likely to be broadly applicable to similar populations in the UK.

Evidence statement 4 (Walking interventions)

A walking programme delivered to older people in 28 heterogeneous neighbourhoods in Portland, Oregon by trained leaders three times a week over six months improved SF-12 mental health and SWLS scores relative to control neighbourhoods (Fisher and Li 2004, Cluster RCT+). This cluster randomised trial recruited 279 people to the intervention group (of whom 156 completed the intervention) and compared them with 303 controls who received education only. Though recruitment and retention of participants is important for such programmes, the results are likely to be broadly applicable to similar populations in the UK.

Evidence statement 8 (Group-based health promotion)

There is evidence from one well-designed longitudinal trial (Clark et al. 1997, RCT++; Clark et al. 2001, RCT++) that weekly educational sessions led by occupational therapists promoted and maintained positive changes in the SF‑36 mental health score in participants recruited from two federally-subsidised apartment complexes for older adults in the US. Though the findings are likely to be broadly applicable to a similar population in the UK, the findings may not generalise to those in other circumstances (for example, owner–occupiers and nursing home residents). A small pilot study adapted the intervention for the UK context (Mountain et al. 2006, Q+). The findings indicate that the intervention 'Lifestyle Matters' is acceptable to older people with diverse health status living in private housing, and a range of positive benefits were reported.

Evidence statement 17 (Cost-effectiveness review)

Two studies provided good evidence about the cost-effectiveness of interventions to improve the mental wellbeing of older people. First, Hay and coworkers (2002, RCT+) showed that a 2-hour group session of preventive advice from an occupational therapist per week is cost effective in the USA with an incremental cost per QALY of $10,700 (95% CI, $6700 to $25,400). Second, Munro et al. (2004, RCT+) showed that twice-weekly exercise classes led by qualified instructors are probably cost effective in the UK with an incremental cost per QALY of £12,100 (95% CI, £5800 to £61,400). While both studies are sound, one cannot be confident that such sparse findings will apply to similar populations (relatively healthy, living independently, and motivated to take advice and exercise) in similar community-based settings in the UK.

Evidence statement 18 (Cost-effectiveness analyses)

There are only two published economic analyses of interventions to improve the mental wellbeing of older people (evidence statement 16). To complement these sparse data economic modelling based on the integration of existing studies of effectiveness and existing sources of data about patient utilities and resource costs was needed. The most cost-effective intervention was a thrice-weekly community-based walking programme, delivered to sedentary older people who are able to walk without assistance (Fisher and Li 2004, Cluster RCT+). Modelling yielded an incremental cost per QALY of £7400 after 6 months, which is comparable with the two published economic analyses. Modelling was also used to enhance three RCTs of advice about physical activity. Such advice had an estimated incremental cost per QALY of £26,200 when modelled from Kerse and coworkers (2005, NCT+), who estimated the effects of the primary care 'green prescription' counselling programme in New Zealand. The estimated incremental cost per QALY rose to £45,600 when modelled from Markle-Reid and coworkers (2006, RCT++), who evaluated proactive health promotion by nurses in Canada in addition to usual home care for people over 75, and to £106,232 based on the modelling of the Norwegian physiotherapist-led exercise programme described by Helbostad et al. (2004, RCT+). However, Halbert and coworkers (2000, RCT+) reported decreased mental wellbeing in response to 20 minutes of individual advice on physical activity by an exercise specialist in general practice in Australia. Thus the advice was dominated by the control group to whom no advice was given.