Running Head: PHYSICAL PERFORMANCE AND QUALITY OF LIFE

Physical Performance and Health Related Quality of Life in Older Adults Wendy Santos-Modesitt, BA CSPP-Alliant International University San Francisco March 31, 2011

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Physical Performance and Health Related Quality of Life in Older Adults As of the 2009 Census, almost 40 million adults are 65 years and older. It is estimated that by the year 2020 the number of Americans who will be 65 years or older is estimated to be 55 million and about 72 million by 2030 (A Profile of Older Americans: 2008). The 2009 Profile of Older Americans stated that only 39% of older persons reported being in excellent or very good health, suggesting that approximately 60% of the older adult population suffers from at least one (or more) of the most prevalent health conditions affecting older adults. As the older adult population increases, so does the number of individuals reporting less than favorable health, thus reflecting a need for exploring efficacious physical and mental health interventions. In an attempt to understand how to reduce the risks of poor health in older adults, prior studies have consistently found that physical activity and better physical performance are associated with better health outcomes in older adults (Seeman et al., 1994; Nelson et al., 2007). A 2007 report by the American College of Sports Medicine and the American Heart Association suggests (based on their study of the literature) that regular and increased physical activity has a whole host of beneficial implications. The report states that physical activity plays a role in reducing the risk of many of the most prevalent ailments and diseases suffered by older adults including physical and mental health complaints. In addition to the beneficial effects to physical and mental health, physical activity has also been found to improve health related quality of life (HRQoL) (Abell, Hootman, Zack, Moriarty & Helmick, 2005; Park, Park, Shephard & Aoyagi, 2010). In order to develop and test effective intervention strategies, it is crucial to develop a detailed understanding of the associations between aspects of physical performance and quality of life outcomes, specifically the mental health and physical health aspects of quality of life.

PHYSICAL PERFORMANCE QUALITY OF LIFE 3 Physical activity refers to any activity that causes the body to exert itself above and beyond what is typical for an individual, including aerobic and muscle strengthening activities not necessarily done in a gym or as part of an exercise program (e.g., hiking or strenuous gardening) ( Physical Activity Guidelines Advisory Committee, U.S. Department of Health and Human Services, 2008). Physical performance, often referred to as physical fitness, describes, objectively, an individuals ability to perform a desired task or the safety and speed at which tasks can be completed (Resnik, Baker, Holmquist, & Ntuen, 2002). Measured performance includes walking speed, chair stand, grip strength, postural balance, etc. In a randomized control trial (RCT), Pahor et al (2006) found that 70- to 89-year-old subjects, at risk for disability based on sedentary lifestyles, in a structured physical activity intervention group significantly improved their physical performance scores compared to the control group. In addition those in the physical activity group showed a decrease in mobility disability, suggesting a beneficial improvement of physical performance across time. Another assessment of the same cohort found a relationship between subjects who engaged in more vigorous physical activity and their physical performance scores (Chale-Rush, et al. 2010). Thus older adults who engage in more intense physical activity show better performance or score better on physical performance measures. Physical performance has been found to have direct benefits on individuals reports and perceptions of HRQoL. Wolin, Glynn, Coditz, Lee and Kawachi (2007) explored data collected by the Nurses Health Study (data from 121,700 female registered nurses, started in 1976) and found that, when comparing women who had maintained a stable physical activity regimen across time to those who had increased their level of physical activity, the latter group reported higher HRQoL. In a RCT, Groessl (2007) found that physical performance was more strongly associated with HRQoL than was subjects index of co-morbidity (e.g., having diabetes and

PHYSICAL PERFORMANCE QUALITY OF LIFE 4 hypertension). Takata et al. (2009) found that among 80- and 85-year-old Japanese older adults, those who performed better in measures of physical performance also reported higher HRQoL. Specific aspects of physical performance, including muscle strength and body flexibility, are associated with HRQoL. A few studies have found relationships between specific aspects of physical performance, such as muscle strength, and benefits or improvements in HRQoL. Tomas-Carus, et al. (2009), in a RCT of 30 women with fibromyalgia, found that women in the intervention group, with improved lower body muscle strength, predicted improvements in HRQoL. Eyigor, Karapolat and Durmanz (2007) found that women, 65 years and over, who participated in an 8-week exercise group, designed to improve muscle strength, not only significantly improved in physical performance scores but also significantly improved in HRQoL at follow-up compared to baseline. Finally, another RCT (King, Pruitt, Phillips, Oka, Rodenburg & Hasken. 2000) investigating the effects of different types of physical activity revealed different aspects of physical performance being associated with different aspects of quality of life. Subjects in this study were randomly assigned to one of two exercise groups; either a Fit and Firm class, focusing on aerobic, muscle strength and toning or a Stretch and Flex class, focused on stretching and flexibility exercises. A main effect for group found a relationship between improvements in body flexibility (an aspect of physical performance) and reported improvements in bodily pain (an aspect of quality of life). HRQoL improvements over time included, significant improvements at 12-month follow-up in the energy/fatigue scale of their HRQoL measure in the Fit and Firm group. And significant improvements in the emotional well-being scale at 12-month follow-up for the Stretch and Flex group (King, Pruitt, Phillips, Oka, Rodenburg & Hasken. 2000). Physical performance has also been found to be associated with mental health. Depression and anxiety are among the more prevalent

PHYSICAL PERFORMANCE QUALITY OF LIFE 5 mental health concerns among older adults. Prior studies have suggested that physical activity is related to a decreased risk of mental health issues (Nelson, et al., 2007). Deschamps, Onifade, Decamps and BuordelMarchasson (2009) compared two different types of exercise interventions, Tai Chi vs. Cognitive Action Exercise, in which frail institutionalized older adults were randomly assigned. While there were no significant differences between the two groups, at follow up the researchers found all subjects showed significant improvements in physical performance, HRQoL and depression. A RCT, studying the effects of aerobic exercise on sedentary males aged 60-75, found significantly decreased scores in depression and anxiety and significantly improved HRQoL at six-month follow-up as compared to the control group (Atunes, Stell, Santos, Bueno & de Mello, 2004). A review of the literature conducted by Fox (1999) found that there was a significant amount of evidence suggesting that physical activity improves depression, anxiety and mental wellbeing. An alternative explanation may be that poor physical performance may increase dependence on others which may increase symptoms of depression and anxiety and decrease HRQoL; however, existing literature has not adequately addressed this. While there are many studies exploring physical activity and its influence on health and quality of life, to date, there are not many randomized control trials (Atuens, Stell, Santos, Bueno & de Mello, 2004; Devereux, Robertson, & Briffa, 2005; King, et al., 2002) exploring these relationships, particularly effects of physical performance on HRQoL. In order to explore causal effects, more RCTs are needed. In addition, the majority of studies are long term studies ranging from six months to three years. With the number of older adults predicted to benefit from exercise treatment programs increasing, shorter term programs will be more efficient and cost effective. Finally, understanding the relationship between aspects of physical performance and how these might differently influence aspects of quality of life will help

PHYSICAL PERFORMANCE QUALITY OF LIFE 6 clinicians design more effective exercise programs that more accurately target specific impairments. The objective of this study was to determine whether an intervention designed to improve physical performance was associated with improvements in health-related quality of life in a relatively shorter period of time compared to other studies and to examine the crosssectional correlations between specific aspects of physical performance (strength vs. flexibility) and health-related quality of life (mental vs. physical) in older adults. Studies tend to simply explore the relationship between physical performance and HRQoL as a single variable. While other studies have explored the various domains of quality of life, very few have associated these with aspects of physical performance. Other studies might explore physical performance and dichotomize HRQoL to further explore the relationship to physical and mental quality of life. This study further explores which aspects of physical performance (upper body strength vs. flexibility) might influence mental health aspects of quality of life. In other words, would individuals who might have difficulty getting up out of a chair have lower score in the mental health quality of life vs. an individual who has more difficulty with touching his/her toes? We were interested to see:
1. In this 12-week intervention, was there a significant improvement in

physical performance as measured by the Senior Fitness Test among the four MAX Trial physical activity and mental activity groups?
2. Was there a significant improvement in physical performance as

measured by the Senior Fitness Test among the physical activity intervention and control group? 3. Which aspects of physical functioning (upper body strength, lower body strength, upper body flexibility, lower body flexibility, endurance and agility/balance) are related to HRQoL, specifically the mental vs. physical aspect of quality of life?

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4. Does a 12-week physical and mental activity intervention result in

improvements in physical performance and health related quality of life among all participants?
5. Are changes/improvements in physical performance related to

change/improvements in HRQoL at follow up? Methods: Procedures Intervention. The Mental Activity and Exercise (MAX) Trial study is a randomized control trial (RTC) in which older adults (65 and over), who selfreported a recent decline in memory or thinking, were randomly assigned into one of four possible groups. Recent decline in memory and thinking was assessed by self report. The potential participant was asked: Do you feel your memory and thinking have recently gotten worse? If the potential participant did not perceive having some difficulty in these aspects of cognition, the individual would not be eligible for the study. If participant self-reported having been diagnosed with Alzheimers disease or any other form of dementia or neurological disorder, the participant was excluded from participating in the study (e.g. Has a doctor ever told you that you have). To confirm this report, the Telephone Interview for Cognitive Status-modified (TICS-m) was administered as the last step in the telephone screening process. Potential participants who scored in the dementia range, 0-18 points, would not be eligible to participate in the study. For the purposes of this study, recent decline in memory and thinking may include forgetting names, word finding difficulties, and difficulty with concentrating and organization. The primary goal of the larger study was to explore the impact of a physical and mental activity intervention on the primary outcome of cognitive functioning. This secondary data analysis reports on the outcomes of physical performance, health-related quality of life and their associations with each other.

PHYSICAL PERFORMANCE QUALITY OF LIFE 8 Eligible participants were randomly assigned to one of four groups in a two-by-two design: (1) mental activity control + physical control group, (2) mental activity control + physical intervention group, (3) mental activity intervention + physical control group, or (4) a mental activity intervention + physical intervention group, resulting in approximately equal number of participants in each group. Participants in the mental activity intervention group used the Posit Science Brain fitness program, installed on computers and laptops assigned to participants, for one hour a day, three days a week, for twelve weeks. Participants in the mental activity control group were asked to view educational DVDs one hour a day, three days a week, for twelve weeks. The physical activity intervention consisted of participants enrolling in a structured aerobics and strength building class, while the physical activity control group consisted of a structured stretching and toning class. Both physical activity regimens were designed for this age group. Participants commitment consisted of attending classes held at a local YMCA for one hour a day, three days a week, for twelve weeks. Subjects/Participants: Study participants were recruited primarily through direct mailing to older adults in the zip codes surrounding the local YMCA. Additional strategies included recruitment from databases of several university memory clinics and from other medical clinics, advertisement in local newspapers, postings in various sites including places of worship, pharmacies and shopping centers, and referrals from current study participants. Individuals who showed interest in participating in the study, by either calling the MAX Trial phone line or mailing back a post card attached to a study brochure, were first screened for eligibility over the phone by a research assistant. Inclusion criteria stated individuals had to be 65 years or older, inactive, endorse self reported recent decline in memory or thinking, able to commit to the time restrictions of the study and able to get permission to participate in the study from a physician or general practitioner. Exclusion criteria

PHYSICAL PERFORMANCE QUALITY OF LIFE 9 included self-report diagnosis of any form of dementia or any other neurological disorder; recent brain injury (within the past year); psychiatric disorder such as major depression or bipolar disease; heart disease; lung disease; history of substance or alcohol abuse; physical disabilities such as tremor, hearing or vision impairment; dependence on cane, walker or similar device; or currently enrolled in another study. Eligible participants verbally consented during the telephone screening and were scheduled for a formal consent visit. Participants were also scheduled for a baseline visit, where their mental and physical functioning was evaluated. After the twelve-week intervention, a follow-up visit was scheduled, where mental and physical functioning was re-evaluated. Six hundred and thirty-eight potential participants showed interest. Of this, 360 were found ineligible, typically due to being too active (engaging in moderately intense physical activity at least once per week for one hour or more per week), 151 refused resulting in 127 eligible participants. Of the 127 eligible participants, 31 withdrew (due to either medical reasons or time constraints) after the baseline visit, leaving 96 participants who successfully completed the study, meaning the participants completed baseline evaluations, successfully completed the exercise and mental activity training program and completed follow up evaluations. Of the 31 participants who withdrew, four participants volunteered to undergo 12 week follow up evaluations. The MAX Trial study has been approved by the University of California, San Franciscos Committee on Human Research and by the San Francisco Veterans Affairs Medical Center Research Committee. The secondary data analyses conducted for this study has been approved by the Institutional Review Board of the California School of Professional Psychology at Alliant International University. Measures

PHYSICAL PERFORMANCE QUALITY OF LIFE 10 DemographicsParticipants were asked demographic information such as age, gender, level of education, income, veteran status, race and ethnicity. Physical PerformanceThe Senior Fitness Test (SFT), developed by Rikli and Jones (2001), was used to assess functional fitness of older adults. The SFT measures functional fitness by assessing physical parameters. Lower body strength was measured by counting how many times, in 30 seconds, the participant could stand from sitting position and return to a seated position (Chair Stand); upper body strength was measured by counting how many times, in 30 seconds the participant could lift a weight, do an arm curl, using a five pound weight for women and an eight pound weight for men (Arm Curl). Aerobic endurance was measured by counting how many steps the participant could take in two minutes, while raising both knees to a specified height (the specified height was based on the distance halfway between the participants hip bone and knee bone; 2-Minute Step Test). Lower body flexibility and upper body flexibility were measured by taking distance from the participant middle finger reaching towards or going past their toes (Sit and Reach), and placing their preferred hand over the same shoulder, palms facing down, and the other hand around their back, palms facing out, in an attempt to touch middle fingers and measuring the distance between their middle fingers or overlap (Back Scratch). And motor ability/agility balance were measured by timing how quickly the participant could stand from a chair, walk eight feet, go around a marker (a cone) and walk back another eight feet, returning to the chair and sitting down (8 Foot Up & Go). Norms have been established by assessing over 7,000 men and women ages 60-94 (Jones & Rikli, 2002). Health Related Quality of LifeThe Short Form 12 Health Survey (SF-12; Ware, Kosinski & Keller, 1995; Ware, Kosinski & Keller, 1996) was used to assess HRQoL. The SF-12 was developed from the longer version Short Form 36 Health Survey and measures eight domains resulting in a

PHYSICAL PERFORMANCE QUALITY OF LIFE 11 Mental Component Summary (MCS) Score and a Physical Component Summary (PCS) Score. The specific domains measured include mental health, social functioning, energy/vitality, role emotional, general health, physical functioning, role physical and bodily pain. The scores have been standardized based on general population norms as well as gender and age based norms. These have been established using a US sample of over 2300 subjects, ages 18 to over 75 years (Ware, Kosinski & Keller, 1995). The SF12 has been validated in the US as well as many European countries (Gandek, et al., 1998). All participants were asked to read and answer all questions on the form. The Short Form-12 Health Survey (SF-12) and Senior Fitness Test (SFT) were administered as part of a comprehensive neuropsychological battery administered to MAX Trial participants at baseline and after a twelve-week intervention. The cognitive and physical evaluations were administered according to a protocol, which was developed for the MAX Trial, by a doctorate level graduate student. All interviewers underwent an extensive training prior to administering the battery. Analysis Study data were analyzed using Stata 10.1 statistical software. The distributions of all continuous variables were examined using means, medians, standard deviations (SD) and histograms/box plots. One way ANOVA analyses were used to determine if the difference or change observed in SFT item scores, from baseline to follow up, were significantly different among 1) the four identified groups and 2) more specifically the two physical activity groups (intervention vs. control). In addition, the researchers were interested in exploring which aspects of physical performance correlated with the mental aspects of quality of life versus the physical aspects of quality of life. Pairwise correlations were used to determine relationships among SFT items and PCS and MCS scores.

PHYSICAL PERFORMANCE QUALITY OF LIFE 12 Significance level was set at .05. Paired T-tests were used to determine significant differences in SFT performance and PCS and MCS scores from baseline and post intervention. Change in performance on the SFT and the change in the MCS and PCS scores was analyzed using pairwise correlations. Results: Table 1 displays a summary of the demographic characteristics of the participants in the Max Trial. A large proportion of the participants identified as non-white, 35.7%, mean age was 73.4 years and 63% were female. The mean level of education or the mean highest grade completed was 16 (graduate degree/some graduate work). Baseline performance on SFT and SF-12 are also reported. The four groups, (1) mental activity control + physical control group, (2) mental activity control + physical intervention group, (3) mental activity intervention + physical control group, or (4) a mental activity intervention + physical intervention group, were compared based on physical performance difference (e.g. T2-T1) on all the SFT items. Oneway ANOVA analyses revealed that improvements in physical performance did not differ by randomization group. The ANOVA analyses yielded the following results: Chair Stand F(3,96)=.63, p=.6, Arm Curl F(3,96)=.31, p=.82, 2-Min Step Test F(3,96)=.30, p=.82, Sit and Reach F(3,96)=1.34, p=.27, Back scratch F(3,96)=.43, p=.73 and 8-Foot Up and Go F(3,96)=.73, p=.54. Oneway ANOVA analyses, comparing all participants assigned to the physical activity control group and the physical activity intervention group, revealed no significant difference among the two groups when comparing the difference on the SFT items: Chair Stand F(1,98)=.13, p=.72, Arm Curl F(1,98)=.46, p=.50, 2-Min Step Test F(1,98)=.04, p=.85, Sit and Reach F(1,98)=.12, p=.73, Back scratch F(1,98)=.58, p=.45 and 8-Foot Up and Go F(1,98)=.35, p=.55. Therefore, all participants were combined in the remaining analyses.

PHYSICAL PERFORMANCE QUALITY OF LIFE 13 Improvements in HRQoL did not differ by randomization group. Oneway Anova analyses of four groups, as described above, found no significant difference among the PCS-12 and MCS-12 change scores, PCS-12 F(3, 96)=2.02, p=.12 and MCS-12 F(3, 96)=.42, p=.74. Likewise, no significance found for HRQoL when comparing participants in the physical activity control versus intervention group F(1, 98)=.30, p=.59, MCS-12 F(1, 98)=.01, p=.93.

Physical Performance and Health Related Quality of Life. Table 2 displays the cross-sectional correlations between measures of physical performance and mental versus physical aspects of quality of life at baseline. The following SFT items were significantly correlated with PCS scores: Chair Stand (r=.32, p<.001), Step Test (r=.38, p<.001), and 8 Foot Up and Go (r=-.36, p<.001). Arm Curl was the only SFT item significantly correlated with MCS (r=.31, p<.001) at baseline. At follow up, results were similar for PCS scores; however Arm Curl was no longer significantly correlated with MCS; no SFT items significantly correlated with MCS scores.

Physical Performance.

PHYSICAL PERFORMANCE QUALITY OF LIFE 14 Paired t-test analyses were conducted in order to determine improvement in physical performance over time. At baseline participants completed an average of 10.8 (SD=3.8) chair stands in 30 seconds and 12.2 (SD=4.8) arm curls in 30 seconds; took 74.3 (SD=23.3) steps during the 2-Min Step Test; were 1.2 (SD=4.6) inches away from touching their toes and 4.0 (SD=5.0) inches away from touching their fingers behind their backs; and took 6.7 (SD=2.2) seconds to complete the 8 Foot Up and Go task. After the twelve week intervention period, participants could complete 1.7 (SD=3.2, p=<0.001) more chair stands and 2.7 (SD=4.0), p=<0.001) more arm curls; took 5.5 (SD=19.7, p=0.007) more steps during the 2 Minute Step Test; got 1.0 (SD=3.0, p=0.002) inches closer to touching their toes and .4 (SD=2.3, p=.19) inches closer to touching fingers behind their backs; and completed the 8 Foot Up and Go in .24 (SD=1.6, p=0.14) seconds less (Table 3).

Health Quality of Life. Similarly, paired t-tests were also conducted to determine improvement in the subjects scores on the self-report measure of quality of life. At follow up, subjects reported significant improvement in PCS scores [t (99)=-1.998, p=.05], however MCS scores at follow-up were not significantly different from baseline (figure 1).

52.5 52.4 (7.8) (8.6)

P-Value= .99

Finally, changes in SFT scores were not correlated with changes in quality of life, in either MCS or PCS scores (Table 4).

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Discussion: The mean difference, that is the participants performance on a Senior Fitness Test (SFT) items, at follow up, subtracted from their performance at baseline, was compared among the main four groups of the study, as described above. The analysis revealed there was no significant difference in the change (or difference) scores among the four groups. The same mean difference comparison (or mean change) of all the participants in the physical activity control group versus the physical activity intervention group yielded no significance as well. One possible explanation is that the control group was not a true control, as they too received some form of exercise. It is possible that for this sample, both forms of exercise, either aerobic or flexibility and stretching, were equally beneficial in improving physical performance in a 12-week intervention. At baseline several aspects of the physical performance measure, the SFT, were significantly associated with the Physical Component Summary Score (PCS) of our HRQoL measure, the SF-12. These included: Chair Stands, which measures lower body strength; 2-min Step Test, which measures endurance; and 8-foot Up & Go, which measures agility and balance. At baseline we also found that Arm Curl (upper body strength) was significantly related to the Mental Component Summary Score (MCS). While these relationship remain constant at follow-up for PCS, arm curl is no longer associated with MCS at follow up, neither is any other physical performance item of the SFT. We were interested in learning whether or not this 12 week exercise intervention could significantly improve physical performance and HRQoL in

PHYSICAL PERFORMANCE QUALITY OF LIFE 16 community dwelling adults with self-reported cognitive complaints. After analysis, we discovered that this sample did improve significantly in 4 of the 6 physical performance items measured by the SFT, including upper and lower body strength, endurance and lower body flexibility. PCS also significantly improved in the group from baseline to follow up. There were no significant improvements in the MCS, however, this groups MCS mean of 52.5, at baseline ,was higher than that of the general US population mean (51.3; Ware, Kosinski & Keller, 1995). It is possible that this group was relatively well, in terms of mental health factors, as assessed by this measure, thus improvements in HRQoL would more likely load on the PCS. In addition, more SFT items correlated with PCS at baseline than MCS. We also wanted to explore whether or not the physical performance improvements observed would correlate to the improvements observed in HRQoL. For this analysis we found that none of the changes or improvements for the SFT correlated with changes on the MCS or PCS scores. Limitations. This study recruited community dwelling participants living in the Bay Area, thus based on geographical nature of their residence and demographics of this region, study participants were relatively healthy, active and highly educated. Hence this study cannot be generalized to other populations, such as institutionalized or disabled older adults. RCTs with a more representative US sample may yield more improvements in physical performance and HRQoL. Secondly, the intervention was for only twelve weeks. While this was efficacious enough for this sample, in terms of improvements in physical performance and PCS, and may be cost effective for adult treatment programs, exploring longer interventions may also yield significant improvements in all physical functioning domains and HRQoL. It is possible some aspects of physical performance (e.g. upper body flexibility, agility and balance) required a longer intervention to show significant

PHYSICAL PERFORMANCE QUALITY OF LIFE 17 improvement. Perhaps a combination of short-term programs coupled with home based interventions may also yield positive results. Finally, this study does not include a true control group, that is, a group receiving no form of treatment. This studys physical activity control group participated in an exercise program focusing on stretching and flexibility for twelve weeks. It is possible that including a control group that receives no form of exercise may shed some light on whether or not the improvements we see on the SFT items are related to the exercise program or simply being tested twice. In summary, this study found that a short twelve week intervention was sufficient in providing improvements in specific aspects of physical performance, such as lower body strength (standing up out of a chair), upper body strength (carrying/lifting groceries), endurance (walking/climbing stairs) and lower body flexibility (reaching for dropped keys). These are all crucial in an individuals ability to maintain independence as they age. participation in this short intervention also significantly improved participants PCS scores which are related to the physical aspects of quality of life. As the Baby Boomer generation begins to join the current older adult population it is crucial for community centers and agencies, providing services to help reduce risk of disability and to help older adults maintain independence, implement efficacious exercise interventions. In addition,

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References Abell, J. E., Hootman, J. M., Zack, M. M., Moriarty, D., & Helmick, C. G. (2005). Physical activity and health related quality of life among people with arthritis. J Epidemiol Community Health, 59(5), 380-385. Antunes, H. K., Stella, S. G., Santos, R. F., Bueno, O. F., & de Mello, M. T. (2005). Depression, anxiety and quality of life scores in seniors after an endurance exercise program. Rev Bras Psiquiatr, 27(4), 266-271. A profile of older Americans: 2008. Administration on Aging, U.S. Department on Health and Human Services. A profile of older Americans: 2009. Administration on Aging, U.S. Department on Health and Human Services. Chale-Rush, A., Guralnik, J. M., Walkup, M. P., Miller, M. E., Rejeski, W. J., Katula, J. A., et al. Relationship between physical functioning and physical activity in the lifestyle interventions and independence for elders pilot. J Am Geriatr Soc, 58(10), 1918-1924. Deschamps, A., Onifade, C., Decamps, A., & Bourdel-Marchasson, I. (2009). Health-related quality of life in frail institutionalized elderly: effects of a cognition-action intervention and Tai Chi. J Aging Phys Act, 17(2), 236248. Devereux, K., Robertson, D., & Briffa, N. K. (2005). Effects of a water-based program on women 65 years and over: a randomised controlled trial. Aust J Physiother, 51(2), 102-108. Eyigor, S., Karapolat, H., & Durmaz, B. (2007). Effects of a group-based exercise program on the physical performance, muscle strength and quality of life in older women. Arch Gerontol Geriatr, 45(3), 259-271. Fox, K. R. (1999). The influence of physical activity on mental well-being. Public Health Nutr, 2(3A), 411-418. Groessl, E. J., Kaplan, R. M., Rejeski, W. J., Katula, J. A., King, A. C., Frierson, G., et al. (2007). Health-related quality of life in older adults at risk for

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PHYSICAL PERFORMANCE QUALITY OF LIFE 20 Taguchi, N., Higaki, Y., Inoue, S., Kimura, H., & Tanaka, K. (2010). Effects of a 12-month multicomponent exercise program on physical performance, daily physical activity, and quality of life in very elderly people with minor disabilities: an intervention study. J Epidemiol, 20(1), 21-29. Takata, Y., Ansai, T., Soh, I., Awano, S., Yoshitake, Y., Kimura, Y., et al. Quality of life and physical fitness in an 85-year-old population. Arch Gerontol Geriatr, 50(3), 272-276. Tomas-Carus, P., Gusi, N., Hakkinen, A., Hakkinen, K., Raimundo, A., & Ortega-Alonso, A. (2009). Improvements of muscle strength predicted benefits in HRQOL and postural balance in women with fibromyalgia: an 8-month randomized controlled trial. Rheumatology (Oxford), 48(9), 1147-1151. Ware, J. E., Jr., Kosinski, M., Bayliss, M. S., McHorney, C. A., Rogers, W. H., & Raczek, A. (1995). Comparison of methods for the scoring and statistical analysis of SF-36 health profile and summary measures: summary of results from the Medical Outcomes Study. Med Care, 33(4 Suppl), AS264-279. Ware, J., Jr., Kosinski, M., & Keller, S. D. (1996). A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care, 34(3), 220-233. Wolin, K. Y., Glynn, R. J., Colditz, G. A., Lee, I. M., & Kawachi, I. (2007). Longterm physical activity patterns and health-related quality of life in U.S. women. Am J Prev Med, 32(6), 490-499.

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Table 1. Table 2. Characteristics of the MAX Trial Study Baseline Relationships among Physical Performance Items and MCS Participants PCS SF-12 scores at Baseline N=127 Gender Baseline MCS-12 Male (r) Female Chair Stand .12 Race/ ethnicity African American Arm Curl .31*** Asian American Latino/a Step Test .05 White Other Sit and Reach -.06 Age Back Scratch -.02 Years of education TICS-ma 8 Foot Up & Go .01 SF-12b PCS-12c *** p <.001 MCS-12d Senior Fitness Test Items: Chair Stand Arm Curl 2-Min Step Test Sit and Reach Back Scratch 8-Foot Up and Go a Telephone Interview of Cognitive StatusModified, b Health Survey Short Form-12, c Physical Component Summary Score for SF-12, d Mental Component Summary Score for SF-12 n (%) PCS-12 48(r) (37) 79 (63) .32*** 11 (9) .16 18 (14) 11 (9) .38*** 81 (64) 5 (4) -.10 Mean (SD) 73.4 (6.0) .13 16.1 (2.4) 35.3 (4.1) -.36*** 46.5 (9.6) 52.1 (8.3) 10.8 (3.8) 12.2 (4.8) 74.3 (23.3) -1.2 (4.6) -4.0 (5.0) 6.7 (2.2)

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Table 3. Comparison of Physical Performance at Baseline and Follow up Paired T-Tests Senior Fitness Test Items Chair Stand Arm Curl Step Test Sit & Reach Back Scratch 8 Foot Up & Go ** p <.01 *** p < .001 Baseline n=100 Mean (SD) 10.8 (3.8) 12.2 (4.8) 74.3 (23.3) -1.2 (4.6) -4.0 (5.0) 6.7 (2.2) Follow-up n=100 Mean (SD) 12.6 (4.3) 14.9 ( 4.0) 79.7 (24.4) -0.38 (4.6) -3.6 (5.2) 6.5 (1.7)

P-value <.001*** <.001*** .007** .002** .07 .14

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Table 4. Relationship among change in physical performance (SFT) and change in MCS and PCS SF-12 scores Change Chair Stand Arm Curl Step Test Sit and Reach Back Scratch 8 Foot Up & Go MCS-12 (r) .19 .12 .05 .03 .11 -.09 PCS-12 (r) -.02 .04 .10 -.11 -.02 -.05

Note: none of the relationships were significant at a p < .05

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Figure 1. Comparison of MCS-12 and PCS-12 at baseline and follow up.

53 52 51 50 49 48 47 46 45 Menta Component l Baseline Phys a Component ic l Follow up

52.5 52.4 (7.8) (8.6)

P-Value= .99 47.5 49.0 (8.8) (8.8) *P-Value= .049

* P value significant at .05

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