ROL1

The effect of exercise on depression and quality of life
among the institutionalised elderly
Thesis
Submitted to
SAVEETHA
Institute of Medical and Technical Sciences
For the award of degree of

DOCTOR OF PHILOSOPHY
(Faculty of Medicine)
In
Medical Community Medicine
By
Dr. Theingi Maung Maung
Under the Guidance of

Dr. Timsi Jain
DEPARTMENT OF RESEARCH AND DEVELOPMENT

SIMATS, CHENNAI – 602105
October - 2022
DECLARATION BY THE CANDIDATE
I declare that the thesis entitled “The effect of exercise on depression
and quality of life among the institutionalised elderly” submitted by me for the
degree of Doctor of Philosophy is the record of work carried out by me under
the guidance of Dr. Timsi Jain and has not formed the basis for the award of
any degree, diploma or associateship in Saveetha Institute of Medical and
Technical Sciences or any other University or similar Institutions of Higher
learning.
Signature of the Candidate

(Dr.Theingi Maung Maung)
CERTIFICATE FROM THE SUPERVISOR/CO-SUPERVISOR
We certify that the thesis entitled “The effect of exercise on depression
and quality of life among the institutionalised elderly” submitted for the degree
of Doctor of Philosophy by Dr.Theingi Maung Maung is the record of research
work carried out by her under our guidance and supervision, and that this
work has not formed the basis for the award of any degree, diploma or
associateship in Saveetha Institute of Medical and Technical Sciences or any
other University or other similar Institutions of Higher learning.
Dr. J. Madhanagopal, Dr. Timsi Jain,

Deputy Dean, Former Professor & HOD,
School of Physiotherapy, Department of Community Medicine,
Faculty of Allied Health Professions, Saveetha Medical College & Hospital
AIMST University, SIMATS, Thandalm,
Bedong- 08100, Malaysia. Chennai - 602 105.
Co – Guide Guide
Acknowledgement
First and foremost, I thank the Almighty for giving me this chance and
conceding me the ability to progress effectively.
I would like to express my sincere and genuine, eternal gratitude to my

guide Prof. Timsi Jain, Former Professor and HOD, Department of
Community Medicine, SMCH, SIMATS for her guidance and unwavering
support throughout my research. Madam has given excellent guidance in
writing the thesis.
I would like to express my gratitude to my co-guide Dr. Madhanagopal,

School of Physiotherapy, AIMST University, for his excellent guidance,
valuable support and development of exercise protocol for research work. I
cannot have imagined having a better guide, better advisor, and mentor for
my PhD research work.
I would like to thank Dr. R. Vijayaraghavan, former Director, and

Dr. E. Sukumar, former Professor, Department of Research and
Development, SIMATS for their insightful comments and encouragements. I
would like to thank the Chancellor, Vice- chancellor, and Registrar of SIMATS
for permitting me to register for Ph.D. degree.
I also provide a genuine thanks to Dr. R Archana, Professor,

Department of Physiology, SMCH, SIMATS, PhD coordinator for her
relentless support and encouraging guidance.
I would like to thank Ministry of Higher Education, Malaysia for

providing funding to conduct my research under the Fundamental Research
Grant Scheme (FRGS/1/2020/SKK04/AIMST/02/1).
I would like to express my special appreciation to AIMST university,

Malaysia, human and animal ethics committee for allowing me to carry out
this project. I also thank Unit of Community Medicine, AIMST for moral
support. I would like to thank all respondents from old age homes in Kedah
and Penang States of Malaysia for taking part in this study.
I am extremely grateful to my colleagues Dr.Sherly, Dr.Harini,

Dr.Jeggadesh and Dr.Aswin for always being there for me and encouraging
my research.
A special thanks to my family for their unwavering support and belief in
me. My beloved mother Ms. Lucy Hla, sister Ms.Grace ,my brother-in-law
Mr.L Seng Li and my nephew Brian ,your prayer for me was what sustained
me thus far. My dear daddy in heaven, your love is still my guide. Thank you
for your guiding hand on my shoulder which will remain with me forever.
Dr.Theingi Maung Maung

LIST OF TABLES
S. No Title Page No.

4.1 Characteristics of the respondents 23
4.2 Age and BMI of the respondents 24
4.3 The respondents’ scores on QOL by each domain and 25
overall
4.4 Pairwise correlation analysis of different domains 26
4.5 Overall quality of life among the elderly inmates 27
4.6 Multiple linear regression to identify the determinants of 28
Physical Health (Domain1)
psychological domain (Domain2)
4.8 Multiple linear regression to identify the determinants of 30-31
social relationship (Domain3)
Environmental Domain (Domain4)
5.1 Exercise protocol for elderly 39
5.2 Score criteria for DASS-21 40
5.3 Prevalence of depression, anxiety, and stress among 41
elderly in old age homes
5.4 Distribution of mean and standard deviation of different 42
SPBB total scores
5.5 ANOVA test based on the different total scores of SPBB 43
among elderly inmates
5.6 Pairwise comparisons of different SPBB total scores 44
5.7 Results of paired differences in depression, anxiety, and 45
stress scores before and after exercise intervention
6.1 Background characteristics of the depressed elderly 60
6.2 QOL of the depressed respondents 61
6.3 Frequency distribution of QOL score among different 62
domains
6.4 Frequency distribution of QOL score among different 63
domains
6.5 Comparison of scores related to QOL domains among 64
respondents with depression before and after exercise
intervention
6.6 Score differences of Depression, Anxiety and Stress 65
before and after exercises
LIST OF FIGURES

5.1 Strengthening exercises (Brisk walking,heel raise,sit to 46
stand) A -Brisk walking, B-Heel raise, C-Sit to stand
5.2 Strengthening exercise (Step up and down stool) 47
5.3 Mean score differences of balance test in week 1,6,9 48
and 12
5.4 Mean score differences of chair stand test in week 1,6,9 49
and 12
5.5 Mean score differences of gait speed test in week 1,6,9 50
and 12
5.6 Estimated means of SPPB total score in week1,6,9 and 51
12
6.1 Study flow chart 59
ABBREVIATIONS
ADL Activities of Daily Living

AIMST Asian Institute of Medicine, Science and Technology
BMI Body Mass Index
COVID-19 Coronavirus disease 2019
DASS Depression, Anxiety and Stress Scale
MCO Movement Control Order
QOL Quality of life
SPPB Short Physical Performance Battery
WHO World Health Organization
An abbreviated generic Quality of Life Scale developed

WHOQOL-BREF
through the World Health Organization.
CONTENTS

1 Introduction 1-5
2 Aim and Objectives 6
3 Review of literature 7-15
4 The quality of life (QOL) among elderly in old age 16-32
homes and associated sociodemographic determinants
5 The prevalence of depression and the effect of exercise 33-51
on mental health of the respondents
6 The effect of Aerobic and Strengthening exercises on 52-65
QOL of depressed elderly
7 Summary and conclusions 66-69
8 References 70-92
9 List of Publications 93
Abstract
Useful in-sights should be provided to the government, private sectors and charitable
individuals regarding the psychological and emotional needs of elderly people who are
either from the underprivileged category or being unfortunate enough to be living apart
from their families. Providing better care for the elderly has become public health
challenges especially for those who stayed in institutionalised dwellings. There is limited
scientific evidence reporting the experiences of elderly to date and QOL of elderly residing
in old age home was not explored enough in Malaysia. Malaysia government is
developing programs that are focusing on the special needs of citizens aged 60 years
and above. Moreover, one of the main agendas in the 11th Malaysia Plan 2016-2020 was
improving the quality of life (QOL) of the citizen. Very limited research has been done
concerning depression in Malaysia older adults residing in old age homes and further
exploration is urgently needed. To seal the considerable research gap and in line with the
government policy, the study population in this study will be focusing on older adults
residing at old folk home and depression and quality of life among the respondents will
be assessed. Since the study was carried out during COVID-19 pandemic period, findings
can be related pandemic situation of Malaysia. This study is also in line with the National
Priority Area (NPA) to improve medical and healthcare practices/policy and United
Nation's Sustainable Development Goal (SGD) number 3, Good and health and wellbeing
(Home | Sustainable Development, n.d.). Findings from this study may help to develop
the necessary guidelines for the old age homes. Outcomes from this study can increase
the public awareness of depression and QOL and findings can highlight the importance
of exercise among the older adults residing at old age homes.
1. Introduction
1.1. Ageing population worldwide
Ageing population and related problems are emerging over the past
few years and it is expected to be a major issue in the near future. Proportion
of older people around the world are increasing dramatically aging population
in many countries would have 30% of total population by the middle of the
century and the population aged 60years and more will double by 2050
according to WHO (Ageing and Health, n.d.).
Aging can be defined as the time-related deterioration of the

physiological functions necessary for survival and fertility(Aging: The Biology
of Senescence - Developmental Biology - NCBI Bookshelf, n.d.)As per the
norm, old age people used to occupy the position of power and prestige in the
family. With aging, they became inactive, dependent, sick, and weak in terms
of economically, physically and psychologically all these phenomena lead to
several social economic problems. Because of technological advancement in
field of health, education, medical facilities and due to other national schemes
or programs for elderly, there was a decline in the death rate of older people
resulting in increased older people population globally (Problems Faced By
Old Age People, n.d.).
Functional decline was part of the aging and disorders such as tooth
loss, increased forgetfulness may happen because of changes in normal
aging. However, people can take actions to compensate for those changes.
Postponement of or reduction in the undesired effect of aging was considered
as healthy aging. Following a balanced diet, avoidance of risk behaviour like
cigarette smoking, alcohol drinking, engage in regular exercise, staying
mentally active can maintain good health in many people(Overview of Aging -
Older People’s Health Issues - MSD Manual Consumer Version, n.d.).
Age 65 was chosen as age of retirement in economically advanced

society like the United States and Germany. In many Asian countries,
minimum retirement age was 60 where as some countries like Indonesia
showed 57 and Israel showed 67 as the retired age(Retirement Age Men -
Countries - List | Asia, n.d.).Better health care, heathier lifestyles, sufficient
nutrition, reduced child mortality contributed to increase in life expectancy.
However, higher risk of getting diseases, disability, dementia, and advanced
1
aging prior to death were challenging problems along with increase in life
expectancy. All these problems were affecting not only quality of life of elderly
but also affecting social and economic systems(Brown, 2015).
1.2. Ageing population in Malaysia
In Malaysia, old age is defined as those who are 60 years old and
above, just as the cut-off age adopted by the United Nations and the minimum
retirement age of an employee is also 60 years(Laws Of Malaysia Online
Version Of Updated Text Of Reprint Minimum Retirement Age Act 2012, n.d.).
Malaysia can be regarded as ―ageing nation‖ and 7% of Malaysia‘s population
were 65 and above in 2020.This can be projected to double to 14% by 2044
and 20% by 2056. In next years, Malaysia may be transformed into ―aged
nation‖(Department of Statistics Malaysia Official Portal, n.d.). Therefore,
special needs and challenges for the aging population such as aged care,
employment and income security are nowadays prioritized by the Malaysia
government(A Silver Lining: Productive and Inclusive Aging for Malaysia, n.d.;
De Medeiros et al., 2020)
The number of old age homes all over Malaysia were increasing and
the institutions were either run by the Department of Social Welfare, non-
governmental organizations or private sectors. According to the Department
of Social Welfare, there were 1473 registered care centres all over Malaysia
in 2015 of which 454 are NGOs and 1,019 are private establishments.
Increasing demands were noticed in urban areas like Kuala Lumpur,
Selangor, Johor and Penang from working adults who are unable to provide
caregiving to their elderly parents(Jabatan Kebajikan Masyarakat, 2014). Lack
of family care, not having home or partner, low educational level, sedentary
lifestyle, poor health, functional and cognitive impairments were contributory
factors leading to elderly institutionalization(De Medeiros et al., 2020)
To meet the needs of elderly, types of senior care were differed in

Malaysia. Companion home care was the one that offered non-medical
services like housekeeping, meal preparation. Nursing care provided services
such as wound care, respiratory care for elderly and it was done by trained
nurse team. Nursing homes were for those elderly who did not need to admit
to hospital and who cannot be cared at home. Speech therapy, occupational
therapy, medical care services were offered by trained health staff and
nurses. Old folks‘ home was a special place to host the destitute and
homeless and different homes in Malaysia ranging from economy to premium.
2
Adult day care centres for seniors to socialize others and health monitoring.
Based on the Japanese concept, there were also retirement villages which
include medical facilities and recreational facilities such as movie theatre,
library and café (Types of Senior Care in Malaysia - Elder Elite, n.d.).
1.3. The concept of Quality of life (QOL)
The term QOL meant ‗the good life‖ at first like having a car or a house
or commodities. The concept gradually evolved and satisfaction of life,
realisation of one‘s needs was later considered. According to De Walden-
Gałuszko 1997, QOL was defined as an individual‘s appraisal of his/her own
life situation within a specific time(Sosnowski et al., 2017). The quality of life
referred as the degree to which an individual is healthy, comfortable, and able
to participate in or enjoy life event by Crispin J 2022. The term quality of life
was highly subjective measure of happiness. A disabled person may report a
high quality of life, whereas a healthy person who recently lost a job may
report a low quality of life(Definition, Measures, Applications, & Facts |
Britannica, n.d.).Depends on the types of profession, definition of QOL
became different. Physicians paid more attention to somatic and physical
complaints whereas psychologists paid more attention to psychosocial
domains. A more holistic understanding of human nature and subjective
states should be considered for QOL in the medical sciences(The Concept of
Quality of Life, n.d.).
Quality of Life is an individual‘s perception of their position in life in the

context of culture and value systems in relation to their goals, expectations,
standards and concerns according to World Health Organization (WHOQOL -
Measuring Quality of Life| The World Health Organization, n.d.).There were
various assessments to measure the quality of life. Based on cross-cultural
comparisons of QOL and a multidimensional concept, world health
organization developed the WHOQOL-BREF questionnaire to measure quality
of life. It was available in more than 40 languages and one of the best known
assessment tools for QOL (Noerholm et al., 2004; Vahedi, 2010).Bahasa
Malaysia version was also proved to be a reliable assessment of quality of life
(Hasanah et al., n.d.).Both English and Malay versions of WHOQOL-BREF
were used in this study.
3
1.4. Role of elderly in society
Increased in the number of older people was associated with increased

in the number of abused, harassed, and abandoned cases of elderly in the
modern society. Many people failed to understand the importance of elderly
who were like the roots of the tree. They made family strong by holding them
firmly. Elderly people played important roles in solving family problems,
providing safe and loving environments for younger generation. They were
ideal mentors and able to give constructive advice with their experiences and
wealth of skills(Importance of Elderly People in Life | LinkedIn, n.d.).
Older people had contributed to the workplace, local community and

individual networks for many decades which was often forgotten. It was
important to balance intergenerational relationships by mutual respect. Elderly
were vulnerable to exclude to integrate into social network because of
poverty, poor health, lack of transport, access to services and age
discrimination. Rights and responsibilities should be in equal basis regardless
of age, race, religion. Integration and participation of older persons in society
were important elements and exclusion should be eliminated. Environment
should be elderly friendly to take part in the communities. Providing smart
cards for elderly to slow down the speed of traffic lights for road crossings ,
well-placed benches for those who were not able to walk well, lighting and
colour to help those with dementia were good examples (How Can Older
People Play a Bigger Role in Society? | Society | The Guardian, n.d.; United
Nations Economic Commission for Europe, 2009)
1.5. The need of the study
Useful in-sights should be provided to the government, private sectors

and charitable individuals regarding the psychological and emotional needs of
elderly people who are either from the underprivileged category or being
unfortunate enough to be living apart from their families. Providing better care
for the elderly has become public health challenges especially for those who
stayed in institutionalised dwellings. There is limited scientific evidence
reporting the experiences of elderly to date and QOL of elderly residing in old
age home was not explored enough in Malaysia.
Malaysia government is developing programs that are focusing on the

special needs of citizens aged 60 years and above. Moreover, one of the
main agendas in the 11th Malaysia Plan 2016-2020 was improving the quality
4
of life (QOL) of the citizen. Very limited research has been done concerning
depression in Malaysia older adults residing in old age homes and further
exploration is urgently needed. To seal the considerable research gap and in
line with the government policy, the study population in this study will be
focusing on older adults residing at old folk home and depression and quality
of life among the respondents will be assessed. Since the study was carried
out during COVID-19 pandemic period, findings can be related pandemic
situation of Malaysia.
This study is also in line with the National Priority Area (NPA) to
improve medical and healthcare practices/policy and United Nation's
Sustainable Development Goal (SGD) number 3, Good and health and
wellbeing (Home | Sustainable Development, n.d.). Findings from this study
may help to develop the necessary guidelines for the old age homes.
Outcomes from this study can increase the public awareness of depression
and QOL and findings can highlight the importance of exercise among the
older adults residing at old age homes.
5
2 Aim and Objectives
2.1. Aim of the study
The present study aimed to determine the effect of exercise on quality

of life (QOL) of depressed elderly residing at old age homes of Malaysia.
2.2. Objectives of the study
1. To identify the quality of life (QOL) and associated sociodemographic

determinants among respondents.
2. To explore the prevalence of depression and the effect of exercise on

mental health of the respondents.
3. To find out the effect of Aerobic and Strengthening exercises on quality

of life (QOL) of depressed elderly.
2.3. Hypothesis
Research Hypothesis: Exercise may be effective in improving

depression and quality of life (QOL) among older adults.
Null Hypothesis: Exercise may not be effective in improving depression

and quality of life (QOL) among older adults.
2.4. Ethical Consideration
Informed consent was distributed and explained in detail to the

participants. Approval was obtained from all respondents before beginning of
the study. Two researchers had undergone training in administering
questionnaire to avoid the observer bias. The study was conducted in
accordance with the standard of deceleration of Helsinki and AIMST university
human and animal ethics committee (Ref: AUHEC/FOM/2020/03).
6
3 Review of literature
3.1. Quality of Life in elderly
It is important to maintain active ageing to enhance quality of life. This

highlights the goal of ensuring that older persons remain a resource to their
family and society. Quality of life (QOL) among the older people is important
as it is strongly associated with the health status and well-being among this
vulnerable population. Overall quality of life can affect either physical or
mental health of an individual. Quality means ―the degree to which a set of
characteristics meets the demands‖(Quality of Life in the Urban Environment
of Bratislava: Two Time-Spatial Perspectives, n.d.)
Traditional health indicators like morbidity and mortality are no longer

sufficient to reflect the measurement of health. The impact of disease and
impairment on daily activities and behavior, perceived health measures and
disability / functional status measures are included to measure broaden area
of health. However, these measures do not include quality of life and it has
been described as "the missing measurement in health" till19th century.
Therefore, World Health Organization‘s initiative to develop a quality-

of-life assessment to the continued promotion of a holistic approach to health
and health care. The multi-dimensional nature of quality of life is reflected in
the WHOQOL by assessing four major domains: physical health,
psychological, social relationships and environment (Beard et al., 2016;
Quality of Life (QOL) among People between 30 to 60years of Age with Acute
Arthralgia | Request PDF, n.d.)
3.2. The need of old age home and elderly care in Malaysia
Nuclear families became more common than joint families in current

days and a traditional way of taking care of one another in a family became
less popular. Due to changing lifestyle, older adults preferred more
independent lifestyle after their retirement. However, nursing homes or day-
care centres were necessary for those elderly who stayed alone or needed
special care(Care Homes - Solution to Your Aging Care| Ashiana Housing
Ashiana, n.d.).
7
In Malaysia, different types of service for elderly were available based
on their requirements and affordability which were assisted living, nursing
home, home health nursing and old aged care. Assisted living was suitable for
elderly with basic ADL and the residences could have as much
independences as they desire. The personal care and support services were
available when they needed. Nursing homes had 24 hours nursing aids and it
was suitable for those who did not need hospital care and not able to receive
home care. Home health nursing is the most cost-effective way to deliver
quality care in patient‘s home by certified nurse. Old aged care provided
accommodation and support like living assistance, intensive care for frail to
old aged residents(Old Aged Care | Assisted Living Malaysia, n.d.).
In 2020, Malaysia reported only 39 geriatricians in both private and

public sector and in some part of Malaysia like Perlis, Terengganu, Kelantan,
there was no geriatrician. Geriatric care is the most needed thing in Malaysia
since 14.5% of total population will be 65 years and older by 2040. Old age
homes with basic facilities in the city area of Malaysia cost from RM1,200 to
RM3,500 per month. The bottom 40 % (B40) and middle 40%(M40) earning
group could not afford to go to quality nursing home. Most of the senior living
facilities in Malaysia were run by private, government and non-profit
organizations and they had long waited lists of applicants. These highlighted
the need of more nursing homes for elderly(Cover Story: Senior Living
Facilities Catching on in Malaysia | The Edge Markets, n.d.; What Malaysia
Needs For Healthy Ageing And Care - CodeBlue, n.d.)
3.3. People residing in old age homes
Contemporary society find caring for the elderlies a lot harder due to
family and work demand. Many families consider institutional care for their
aging family members to ensure they receive proper care in this phase of their
life. One of the advantages of staying in old age home was preventing
isolation and loneliness by social interaction among people of the same age
group. On the other hand, the scarcity of geriatrician and trained personal for
elderly care was a major weakness in many countries including
Malaysia(What Malaysia Needs For Healthy Ageing And Care - CodeBlue,
n.d.).
Older people residing in nursing home did not need to struggle for day
to day living like dressing, bathing as staff on hand usually assist with
everyday tasks. Medical problems of elderly were taken care by assigned
8
nurse or health personal. Older people were prone to become victims of
violence and crime especially when they forgot to lock their doors. Safety and
security were better in old age home than those stayed alone at home.
Sharing life experiences and interacting with peers in residential homes could
reduce the chance of loneliness among elderly. Proper meals were served at
regular intervals for residents. Old folk homes were the best choice for those
family who did not have sufficient time to look after older people throughout
the day(What Are The Benefits Of Nursing Homes? | Balcombe Care Homes,
n.d.).
However, there were some drawbacks to nursing homes. Many homes

were expensive and difficult to access to trained health personnel on site.
Many seniors feared to move into old age homes from comfortable place
where they stayed for years and many of them depressed because of a huge
change. Trying to adjust a new schedule in old age home caused loss of
freedom among elderly inmates. Many of them felt a lack of family presence
which eventually led to loneliness and depression. Increased risks of
accidents among elderly inmates because of poor quality care and
supervision in some residential homes(Disadvantages of Nursing Homes for
Seniors | Family Matters, n.d.).
Many studies carried out to assess the quality of life among elderly in
old age homes. A study among Cypriot elderly people reported that the elderly
living in their own home showed significantly happier than those who stayed in
old age homes(Neocleous & Apostolou, 2016). A research conducted in Brazil
found that the subjects felt abandonment, loneliness, anger, ingratitude, living
with chronic pain and satisfaction of facilities in the nursing home(Syed-Abdul
et al., 2019).Another study in Finland found that residents felt loneliness due
to lack of communication with one another in the nursing homes and they also
have poor relationships with the caregivers as they are too busy to talk to
them. Strict rules control the life of residents making them feel disconnected
with the outside world. Some residents felt lacking purpose to look forward in
life(Teeri et al., 2006)
3.4. Depression in elderly and their Quality of Life
Due to the changes in the life situations like retirement or poor health,
the life domains contribute to happiness may change with age. Two health
aspects that are prone to age-related decline are cognitive and sensory
health. Cognitive impairment tends to exhibit higher rates of loneliness and
9
anxiety and increased difficulty in performing daily activities, causing poor
quality of life among the older aged group(Lam et al., 2014). Evidence
suggests that people who had experienced depression had more extensive
cognitive decline later in life than people who had not experienced
depression(Nandam et al., 2020).Depression can increase risk for late-life
dementia, influencing cognitive decline, these can eventually lead to poor
quality of life (John et al., 2019; Khaje-Bishak et al., 2014).
In Malaysia, overall prevalence of cognitive impairment among elderly

people was 68% and prevalence in day care centres in Klang Valley was
59%(Khairiah et al., 2016; The Prevalence of Cognitive Disorder and Its
Associated Socio- Demographic Factors in Elderly from Assisted Living
Residences, KlangValley.Malaysia, n.d.).Different studies in Malaysia
revealed that prevalence of depression in Malaysia varied from 3.9 to 4.6%
and overall prevalence of depression in the general population in Malaysia is
about 8 to 12 %.A study in University Malaya in 2014 stated that the rate of
depression in the rural community was 11.3%(A Review of Depression
Research in Malaysia | Request PDF, n.d.).The prevalence of severe
depression among the elderly Malaysians was 19.2 % according to another
study done in Malaysia(Rashid & Tahir, 2015).
According to a review article based on 953 studies revealed that

significant association between severity of depression and poor QoL in older
people. This association was found to be stable over time regardless of
different assessment pattern of QoL(Sivertsen et al., 2015).This finding was
supported by another cross-sectional study in Greece and secondary data
analysis of the adolescent Syrian Refugees(Andriopoulos et al., 2013;
Kazandjian et al., 2020).
3.5. Economic and Pscychosocial impact of COVID-19 Pandemic
The COVID-19 outbreak was first identified in Wuhan, China, in

December 2019 and the World Health Organization (WHO) declared it as a
pandemic on 11 March(WHO Director-General’s Opening Remarks at the
Media Briefing on COVID-19 - 9 March 2020, n.d.; Y. Yao et al., 2020). It
affected globally with alarming rate of morbidity and mortality leading to mass
panic situation. The first case of COVID-19 was detected in Malaysia on 25th
January 2020. In response to the COVID-19 pandemic, government of
Malaysia and Ministry of Health (MOH) implemented a Movement Control
Order (MCO) on March 18, 2020 which was a lockdown approach to prevent
10
the disease spread. (3 Coronavirus Cases Confirmed in Johor Baru,
n.d.).MCO was continued till 1st November 2021 and restrictive mass
quarantine lasted for nearly two years.Fear of infection, insufficient income,
duration of quarantine, fears of infection, boredom, unable to communicate
with family, inadequate supplies and information, stigma created anxiety and
stress among many Malaysians during MCO(Bunyan, 2020; Nasaruddin et al.,
2022) .
Findings from a cross sectional study among 400 Malaysians reported
that some people were unable to get basic needs and medical care
(Nasaruddin et al., 2022). The longer the lockdown period, more people lost
their jobs. Closure of industries or economic activities had significantly
affected economic health of the country. Increased unemployment and
reduced income were leading causes of suicide during MCO(266 Commit
Suicide during Movement Restrictions (One Everyday) | Daily Express Online
- Sabah’s Leading News Portal, n.d.; Habibullah et al., 2021). As an impact of
pandemic, Malaysia lost RM 2.4 billion a day during MCO period(Hashim et
al., 2021).
World Health Organization (WHO) reported that prevalence of anxiey

and depression globally increased by 25% because of COVID-19
pandemic(COVID-19 Pandemic Triggers 25% Increase in Prevalence of
Anxiety and Depression Worldwide, n.d.).Findings from a nationwide survey
showed alarming prevalence of 59.2% depression, 55.1% anxiety and 30.6%
stress among Malaysian adults(Wong et al., 2021).Pandemic may intensified
psychological disorder, anxiety, stress, alcohol misuse, obsessive compulsive
behaviour and paranoia. Depression, aggressiveness, and domestic violence
were noticed during stay home. Certain groups like health professionals,
elderly, children, students were more vulnerable to greater psychological
impact during pandemic. Health care personals showed higher perceived
stress, insomnia, depression, anxiety, burn out during pandemic. Long term
school closure disrupted children‘s psychosocial development and learning
losses in many students who had insufficient access to internet.Social
disconnection and self-isolation during pandemic contributed to increased
anxiety ,depression ,neurodegenerative disorders and suicidal behaviour
among older adults(Stuijfzand et al., 2020; The Impact of COVID-19 on
Education and Socioeconomic Mobility | Astro Awani, n.d.).
11
3.6. Mental well-being of elderly during COVID-19 pandemic
COVID-19 pandemic had a negative impact on the well being of

elderly.Severity and fatality of COVID-19 was directly related to age and frail
elderly had high risk of getting infection.Disruptions to their daily routines,
inable to access care,difficulty to adapt technologies like telemedicine and
isolation affected significantly to elderly mental health during pandemic. Older
adults usually had lower stress reactivity and better emotional regulation than
young people, however,a mental health crisis was identified among older
adults during pandemic. Social distancing during the pandemic was a major
cause of loneliness especially for those who were dependent on others for
their basic needs, those who were living alone and those who resided in
institutional care fascilities.Less contact with friends, family, and
caregivers,changes in social and medical support , feeling of negligence might
lead to stress related mental health disorder among older people (Banerjee,
2020; Vahia et al., 2020).
Based on the survey done by University of Michigan, more than one in

four older adults expressed that they felt hopeless, one in three reported
feeling anxious and stressed, more than one in three revealed that a lack of
companionship and they felt isolated from others during the COVID-19
pandemic. Once in five older adults reported that overall mental health was
worse since the pandemic started(Mental Health Among Older Adults Before
and During the COVID-19 Pandemic | National Poll on Healthy Aging, n.d.).
Another study done in the United State showed that nearly half of the older
adults felt that their mental health was influenced by worries of getting COVID
19 infection(One in Four Older Adults Report Anxiety or Depression Amid the
COVID-19 Pandemic | KFF, n.d.). Rates of depression and anxiety were
reported more among elderly patients during the pandemic as compared to
data before pandemic based on the study carried out in China(Meng et al.,
2020).
Reports of anxiety and depression were slightly more in elderly who

lived alone compared to those who loved with at least one other person. It
was also noticed that depression was associated to those who lived alone,
had a poor relationship with co inhabitants and those who did not have a pet.
Moreover, underlying psychiatric condition was a favourable factor to develop
mental illness among elderly during pandemic. Patients with schizophrenia
were at risk for having paranoid interpretations of events and elderly with
obsessive‐compulsive disorder are at higher risk of obsessive worries about
12
the virus. Older adults with depression were more likely to have functional
impairment and prone to slow recovery from medical illnesses and disorders.
They were also at higher risk for death from illness or by suicide(Di Santo et
al., 2020; Webb & Chen, 2022).
Long-term care facilities in Malaysia were managed by the government

as well as private. Many facilities were largely dependent on donations.
Insufficient trained staff, limited funding and resources were major concerns
during COVID-19 pandemic. In Malaysia, nursing homes were usual place of
admission for those who were abandoned at hospitals and pick up cases who
were found on the streets. More social problems were noticed among elderly
Malaysians with increasing age, female or unmarried, poverty and those with
existing co-morbidity. Elderly with one or more co-morbidities and chronic
diseases were associated with high risk of malnutrition. It was important to
ensure older people to receive adequate nutritional support while they
followed social distancing during movement control order period(Momtaz et
al., 2011; Mustaffa et al., 2020)
3.7. Benefits of exercise in mental health
Research showed that regular exercise was good for better mental
health, and it could be as effective as cognitive behavioural therapy or
antidepressants in mild to moderate depressive cases. The valuable
advantages of doing exercise were releasing endorphins in the brain,
improving sense of control and self-esteem, and reduced in muscle tension.
People with mental health issues were associated with more chronic physical
problems like heart disease and arthritis and physical benefit of exercise could
improve their overall health. Stress release, memory improvement and better
sleep were positive impact of regular exercise(The Effect of Physical Exercise
on Our Mental Health | Employment Hero, n.d.).
According to WHO ,exercise supports nerve cell growth in the

hippocampus, improving nerve cell connections, which helps relieve
depression(Doing What Matters in Times of Stress, n.d.). A rise in core body
temperature following exercise was associated with reduction in depressive
symptoms. Moreover, exercise can increase brain neurotransmitters like
serotonin, dopamine, and norepinephrine that are diminished with
depression(Craft & Perna, 2004).According to a systematic review in 2008
revealed that physical exercise programmes obtained clinically relevant
13
outcomes in the treatment of depressive symptoms in depressed older people
(Blake et al., 2009; Blumenthal et al., 1999a).
Silva et al., 2020 reported that increased level of depression, anxiety

and stress were noticed in those who were physically inactive. Compared to
those who engaged in regular exercise,118% higher risk of increased
anxiety,152% higher risk of having increased depression and 75% higher risk
of having increased stress among those who were lack of exercise. Sedentary
lifestyle also increased the risk of dementia and regular exercise can reduce
the risk of cognitive impairment. Increased body temperature by doing
exercise can also relax the mind .All forms of physical activity can improve
self-esteem and confidence although an ideal dose of exercise was not yet
revealed(Elwood et al., 2013; L. R. B. Silva et al., 2020).
3.8. Importance of exercise in elderly
The risk of behavioural and physical problem could be increased if

elderly people were not able to handle daily challenges. It was important to
encourage seniors to practise healthy habits like exercise. Exercise helped to
reduce the risk of obesity by burning calorie. A positive body image motivated
older people to socialise more by building self-esteem. Vitamin D sunshine
and refreshing nature during outdoor exercises helped to boost quality of life
in elderly.
A senior admitted to hospital due to fall-related injury in every 11

seconds and an older adult died from a fall in eery 19 minutes based on
sobering statistics. Most falls were preventable and Brad, 2019 reported that
likelihood of fall could be reduced 23% by regular exercise. Common non-
communicable diseases like heart disease, diabetes, osteoporosis,
depression could be prevented by active lifestyle. Regular exercise helped to
improve cognitive health and it was found that the risk of developing
Alzheimer or dementia was reduced approximately 50% by engaging
exercise(Can Alzheimer’s Be Prevented? | Alzheimer’s Association, n.d.;
Preventing Falls in Older Adults: Multiple Strategies Are Better - Harvard
Health, n.d.; Gomez-Pinilla & Hillman, 2013).
The World Health Organization suggested that 150 minutes of exercise

per week in 10 to 30 minutes interval. Aerobic, strength training, balance and
flexibility were recommended exercises for elderly. General fitness and
endurance were trained by Aerobic exercises, strength training helped muscle
14
and bone growth, muscles responsible for balance were strengthen by
balance exercises and flexibility exercises reduced stiffness and improved
mobility. Depends on existing fitness level and physical condition, suitable
exercise protocol for elderly can be developed by an expert advice(9 Best
Exercises for the Elderly, n.d.).
15
4 The quality of life (QOL) among elderly in
old age homes and associated socio-
demographic determinants
4.1. Introduction
Old age or elderly consists of ages surpassing the average lifespan of

an individual. As per the norm, old age people used to occupy the position of
power and prestige in the family. But nowadays they are becoming inactive,
dependent, sick and weak in terms of economically, physically and
psychologically all these phenomena lead to several social economic
problems. Because of technological advancement in field of health, education,
medical facilities and due to other national schemes or programs for old age
people, there is a decline in the death rate of old age people resulting in
continuous incline in population of 60 years and above aged people
globally(Problems Faced by Old Age People, n.d.).
Old age home is becoming a preferred choice for many contemporary

nuclear families to send their elderly parents or relatives to during their old
age when they are sickly or when no one is available at home to perform
caregiving duties. This is especially so when the primary caregiver, which is
usually women, are working and have lesser time to care for the children and
elderly in the family. These sociodemographic and socioeconomic changes
raise the demand on institutional care for elderly people(Choo et al., 2018).
It is common for elderly people to feel helpless and unproductive when

they become frail, not only because of loss of functional systems but by how
they are being regarded by their own family and society at large. The onset of
old age; presence of diseases and inability to perform daily living activities
increase the likelihood of the elderlies ending up in old age homes.
Additionally, contemporary society find caring for the elderlies a lot harder due
to family and work demand. Hence, many families will consider institutional
care for their aging family members to ensure they receive proper care in this
phase of their life(Alessandra Evangelista et al., 2014). Elderly people who
are sickly or with reduced mobility will find difficulty in caring for themselves.
Family members mostly do not have the skills to care for the sick elderly and
this may jeopardize their life if they are not properly cared for. Apart from
16
health issues, elderly people are sent to old age homes for various other
reasons, such as, lower fertility rate resulting in having lesser children to give
caregiving to them in their old age; adult children leaving home to work far
away and worry about living aged parents alone at home; changing mindset of
the younger generation where they prefer staying apart rather than together
with the elderly parents, and transformation of family structure from nuclear to
pluralistic society(Y. Huang et al., 2019).
A study conducted by Custers, Westerhof, Kuin & Riksen-Walraven

found out the relation between need fulfilments in a caring relationship with
levels of depression and life satisfaction. It was found that caring relationship
is related to lower level of depression and higher life satisfaction among the
elderly in the old age home (Custers et al., 2010).There are many challenges
faced by elderlies staying at old age homes which directly effects their quality
of life. A study conducted in Sweden found that the main concerns of the
elderlies staying at home is the lack of autonomy (Anderberg and Berglund,
2010). This was due to the reason that they have no control over their own
activities. Lack of privacy was also another common challenge faced by the
occupants at old age home. Since most of the old age homes offer dormitory-
type sleeping arrangement, this offers limited personal space. Moreover, high
partition walls were associated with poor physical and mental health of elderly
inmates based on a study in Hong Kong(Tao et al., 2018).
Longevity should come along with the quality. Number of elderly homes
are increasing day by day in Malaysia and providing better care for the elderly
has become public health challenges. However, there is a paucity of
knowledge on QOL of older people residing at old age home in northern
Malaysia. Research in this field would be helpful to know the exact status of
the quality of lives of the elderly people by exploring the associated factors.
The first objective of the current study was to determine quality of life of the
elderly people residing in old age home and its associated factors.
4.2. Materials and Methods
4.2.1. Study design and selection criteria for participants: A cross

sectional descriptive study was conducted at two government home and eight
private homes in Northern Malaysia by purposive sampling. This study
included consented 178 inmates, aged 60 and above from private homes.
Those who were younger than 60, ill or mentally unstable, respondents from
homes other than northern Malaysia were excluded from the study. Two
17
researchers had undergone training in administering questionnaire to avoid
the observer bias.
The proportion of depressive adults in old age home based on the

study done among institutionalised elderly in Malayisa was 70%(Normala et
al., 2014). By considering 95% confidence interval with 7% error of margin,
the minimal sample size was 165. In the current study,178 respondents were
taken as study sample. The formula used was given below:
N=Z2p(1-p)/d2
4.2.2. Quality of Life assessment: WHOQOL-BREF questionnaire was used

for the assessment of quality of life(WHOQOL-BREF - Physiopedia, n.d.). The
questionnaire consists of four domains (Physical, Psychological, Social and
Environment). The Physical domain consists of seven questions, the
psychological domain consists of six questions, the social domain consists of
three questions and the Environment domain consists of eight questions with
a scoring system. Cronbach‘s alpha coefficient was more than 0.7 for each
domain of WHOQOL-BREF, showing acceptable evidence of internal
consistency(Kim et al., 2013).
4.2.3. Statistical Analysis: Data entry and data analysis were done by
SPSS version 23. Pearson correlation was carried out to find out the
relationship between one domain and another domain. Determinants for each
domain were identified by multiple logistic regression. P-value smaller than
0.05 was considered as significant relationship.
4.3. Results
4.3.1. Sociodemographic background of the respondents: The socio-

demographic information obtained from 178 inmates were shown in Table 4.1.
The respondents were majority males (51.1%), Chinese(62.9%), unmarried
(41.6%), with primary education (36.5%), stayed alone (64.6%), with income
less than or equal RM600 (52.2%), without disability (65.7%),could not
receive visits by friends or relatives (61.8%), not having role in family decision
(73.6%),without caretaker (61.8%) ,from private home (85.4%) and those with
comorbidity (83.7%). (Table 1)
18
According to Table 4.2, the age of the respondents ranged between 60
to 96 years where the mean age was 69 years (±8.6) whereas BMI ranged
between 16 to 28, showing an average BMI as 22.9 (±3.2).
4.3.2. Quality of Life of the respondents at the old age homes: The average
QOL score was 58.7(SD=12.9) among the elderly respondents at old age
home, ranged in between 26.5 and 89.3.In physical domain, the score ranged
between 38 to 94, with a mean of 62.6(SD=12.5).The score for psychological
domain ranged from 31 to 81with a mean of 57.2(SD=11.7).The score ranged
from 0 to 100 for social relationships, showing an average of 44(SD=29.9).In
environmental domain, the score ranged from 31 to 94, with a mean of
71.1(SD=14.3). In this study, the environmental domain showed the highest
score, and the social domain showed the lowest score among all four
domains of QOL(Table 4.3).
4.3.3. The relationships among different domains: The relationships

among different domains were identified by pairwise Pearson‘s correlations.
All domains are positively correlated to each other with significant p-values.
Correlation coefficients and respective p-values were shown in Table 2,
showing moderate strength of correlation between environment and
psychological domains and weak correlations between other pairs of domains.
(Table 4.4)
4.3.4. Overall quality of life among elderly inmates: Quality of life among
the respondents was assessed by WHOQOL-BREF questionnaires. The
respondents were categorized into poor and satisfactory QOL based on 60%
cut-0ff point (Monteiro Silva et al., n.d.; S. M. Silva, Santana, Silva, et al.,
2019). Those with less than 60 percent of total score were considered as
unsatisfactory QOL whereas those with score 60 or more were considered as
satisfactory QOL. Out of 178 respondents, 56.7% presented with satisfactory
QOL whereas 43.3% showed unsatisfactory QOL (Table 4.5).
4.3.5. Factors influencing each domain of the QOL: Multiple linear

regression analysis with stepwise approach was done to identify the
significant determinants of each domain of QOL.
4.3.5.1. Determinants of Physical domain: Table 4.6. Multiple linear

regression to identify the determinants of Physical Health (Domain1).
19
Based on Table 4.6, physical health (Domain1) of the respondents was
influenced by gender(p=0.024), existing disability(p=0.012), role in decision
making in the family (p=0.027). Weak association was noticed in between
physical health and visit paid by friend or family (p=0.06).
4.3.5.2. Determinants of Psychological domain: For psychological domain,

underlying non-communicable diseases (NCDs) was identified as a significant
determinant (p=0.019). Weak associations were noticed in between
psychological domain and existing disability as well as role in family decision
(p=0.054). The remaining variables did not have any association (Table 4.7.).
4.3.5.3. Determinants of Social Relationship: Table 4.8. showed the results

of multivariate analysis for social relationships (domain 3). Income(p=0.044),
and role in family decision(p=0.047) were identified as determinants of social
relationships among the elderly respondents.
4.3.5.4. Determinants of Environmental Domain: Table 4.9. Multiple linear

regression to identify the determinants of Environmental Domain (Domain4).
According to Table 4.9, gender(p=0.031), living condition(p=0.017) and

BMI(p=0.043) were found to have significant associations with environmental
domain.
4.4. Discussion
In this study, the environmental domain showed the highest mean

score 58.7(SD=12.9) while the lowest mean score 44.0(SD=29.9) was noticed
in the social domain. Most of the homes had nice gardens and residents got
opportunities to involve in garden related activities so that they were more
physically engaged and active, showing the highest score of environmental
health. However, many inmates were abandoned by their families or relatives
and many of them could not catch up their loved ones, explaining the low
score in the social domain. The score of each domain in this study was higher
than the study done by Onunkwor et al. in Kuala Lumpur. Homes in Kedah
State were more spacious and able to allocate a greater number of inmates
than homes in big city like Kuala Lumpur, contributing better environmental
situation and meaningful social interaction among the inmates. The lowest
score in social domain was also noticed in that study (Onunkwor et al., 2016).
20
Current findings showed all four domains of QOL were positively
related to each other‘s and similar findings were seen in a study carried out in
India by Thresa and S (Thresa & S., 2020a). Well balanced in physical health,
psychological health, social relationships, and environmental health were
important to maintain better QOL. It was demonstrated that an individual‘s
perception of their wellbeing and life satisfaction contributed more to QOL
than objective measures of life condition(González-Blanch et al., 2018). To
assess the better QOL, it is needed to consider several domains as in a
holistic approach.
Approximately 60% of the respondents perceived themselves as poor

QOL and 40% perceived as satisfactory QOL in our study. Financial,
infrastructure, professionalism, collaboration and supports, living
arrangements, emotional, cultural, and psychological needs of the elderly
people should be improved for better services in old age homes(Meriam Syed
Akil & Abdullah, n.d.).
4.4.1. Physical Domain of QOL: Gender, disability, and role in decision making in
the family were associated to physical health in our study. Gender was associated to
physical health and males showed better physical health than females. The results
from our study corresponded with the results of research conducted by Onunkwor et
al.(Onunkwor et al., 2016) and Lepsy et al.(Lepsy et al., 2021). Disability like loss or
limited use of limbs could affect the daily living activities of elderly which in turn could
affect the physical health(Ageing with Physical Disabilities and/or Long-Term Health
Conditions, n.d.).Shared decision making could allow older people to feel that they
are respected and understood(Bunn et al., 2018). Psychological well-being could
reduce the risk of serious health conditions like heart disease and good mental state
could keep them physically fit. It was supported by the findings from this study.
4.4.2. Psychological Domain and associated factors: Underlying co-morbid

disease, role in family decision were statistically related to psychological health in our
study. A study done by Sartorious highlighted that psychological symptoms were
associated to physical illness and distress occurred because of chronic diseases
(Sartorious, 2013). Appropriate management of a disease can help to disappear
associated psychological problems. Elderly people were encouraged to be actively
involved in decision making process so that they perceived themselves as having a
role in their family. According to research done by Bunn et al., elderly people
preferred to make decisions for themselves and some of them wanted to share the
responsibility with others. This could enhance their self-confidence to cope up with
the challenges (Bunn et al., 2018).
21
4.4.3. Social Domain and associated factors: Income and role in family decision
were associated to social relationships in our study. Income was identified as a
determinant of health in studies done by Onunkwor et al. (Onunkwor et al., 2016) and
Chandra et al. (Acharya Samadarshi et al., 2022). Successful decision-making
needed ability to understand the intentions, emotions and beliefs of others (Frith &
Singer, 2008). A person who had empathy could maintain better social relationships
with people around him and it was supported by our results.
4.4.4. Environmental Domain and related factors: Male respondent

showed higher score of environmental domain and this finding supported the
findings from the previous studies (Onunkwor et al., 2016; Tesfay et al.,
2015).
Moreover, living condition was a determinant factor for environmental

health based on the research done by Tesfay et al.(Tesfay et al., 2015) and
Lai and Tey(Lai & Tey, 2021).30The condition of toilets and bathrooms,
kitchen, dining area, sleeping condition, privacy, a gathering place for
recreational and leisure activities in residential home were important for the
quality of life of the elderly.
Current study found that higher BMI was associated to better QOL.
Many studies indicated that those with lower BMIs had better QOL than those
with higher BMIs (Apple et al., 2018; Pimenta et al., 2015; The Association of
Obesity and Quality of Life in the Dutch Province Flevoland in 2016,
n.d.).Negative association between BMI and QOL could be true for healthy
people. According to the research done by Zawisza et al., reverse finding was
noticed in sick people and whose weight loss was identified as an indicator of
poor QOL(Zawisza et al., 2021).Majority of our respondents had underlying
co-morbidity, and this might be an explanation for positive association in
between BMI and QOL.
22
Table 4.1: Characteristics of the respondents
S.No Variables Frequency Percent
1 Gender
Females 87 48.9
Males 91 51.1
2 Race
Malay 31 17.4
Indian 35 19.7
Chinese 112 62.9
3 Marital status
Unmarried 74 41.6
Married 46 25.8
Single/Divorce/Widow 58 32.6
4 Education
Primary 65 36.5
Secondary 54 30.3
Tertiary 16 9.0
No formal education 43 24.2
5 Living condition
Alone 115 64.6
With family 63 35.4
6 Income
Less than or equal RM 93 52.2
600 85 47.8
More than RM 600
7 Disability
Present 61 34.3
Absent 117 65.7
8 Visit by friends & relatives
Present 68 38.2
Absent 110 61.8
9 Role in family decision
Present 47 26.4
Absent 131 73.6
10 Caretaker
Present 68 38.2
Absent 110 61.8
11 Type of home for aged
Government 26 14.6
Private 152 85.4
N= 178
23
Table 4.2. Age and BMI of the respondents
S. No Variables Mean (SD) Minimum Maximum
1 Age (years) 68.8 (8.5) 52.0 96.0
2 BMI 23.0 (3.2) 16.0 28.6
N=178
24
Table 4.3: The respondents‘ scores on QOL by each domain and
overall
Variables Mean (SD) Minimum Maximum
Domain 1 62.6 (12.5) 38.0 94.0
Domain 2 57.2 (11.7) 31.0 81.0
Domain 3 44.0 (29.9) 0.0 100.0
Domain 4 71.1 (14.3) 31.0 94.0
Overall 58.7 (12.9) 26.5 89.3

(Average)
Domain 1 – Physical health; Domain 2 – Psychological; Domain 3 – Social

relationships; Domain 4 – Environment
25
Table 4.4. Pairwise correlation analysis of different domains
Domains Domain 1 Domain 2 Domain 3
Domain 1
Domain 2 0.4658 (<0.001)
Domain 3 0.2216 (0.044) 0.3930 (<0.001)
Domain 4 0.4193 (<0.001) 0.5980 (<0.001) 0.4016 (<0.001)
Domain 1 – Physical health; Domain 2 – Psychological; Domain 3 –
Social relationships; Domain 4 – Environment
26
Table 4.5: Overall quality of life among the elderly inmates
QOL Frequency Percent (95% CI)
(n=178)
Unsatisfactory 77 43.3 (35.9, 50.5)
Satisfactory 101 56.7 (49.5, 64.1)
27
Table 4.6. Multiple linear regression to identify the determinants of Physical
Health (Domain1)
S.No Variables Univariate analysis Multivariate analysis
β p-value β p-value
1 Age - 0.32 0.045 **
2 Gender
Females Reference Reference
Males 5.78 0.034 5.77 0.024
3 Race*
Malay Reference
Indian 2.49 0.566
Chinese - 1.03 0.776
4 Marital status*
Unmarried Reference
Married 2.34 0.499
SDW 1.76 0.591
5 Education*
Primary Reference
Secondary 2.35 0.495
Tertiary - 1.63 0.749
No formal - 0.1 0.978
education
6 Occupation*
Working Reference
Retired - 1.88 0.519
Never employed - 4.55 0.418
7 Income (Ringgit)
≤600 Reference
>600 4.19 0.128 **
8 Living condition*
Alone Reference
With family 0.01 0.996
9 Disability
Dependent Reference Reference
Independent 5.85 0.043 6.95 0.012
10 Visit by friends &
relatives
Present Reference Reference
Absent - 5.07 0.070 - 5.02 0.064
11 Role in family
decision
Absent - 7.05 0.020 - 6.55 0.027
12 Caretaker
Present Reference
Absent - 3.55 0.210 **
13 BMI 0.58 0.185 **
14 NCDs*
Present 2.13 0.451
Absent Reference
N=178
28
Table 4.7. Multiple linear regression to identify the determinants of
psychological domain (Domain2)
S. No Variables Univariate analysis Multivariate analysis
β p- β p-value
value
1 Age* - 0.08 0.622
2 Gender
Females Reference
Males 4.38 0.089 **
3 Race*
Malay Reference
Indian 2.70 0.501
Chinese 5.77 0.089
4 Marital status*
Unmarried Reference
Married 3.16 0.331
SDW 1.37 0.655
5 Education*
Primary Reference
Tertiary - 0.98 0.837
No formal education 1.97 0.571
6 Occupation*
Working Reference
Retired 3.95 0.141
7 Income (Ringgit)*
≤600 Reference
>600 - 0.72 0.781
8 Living condition*
Alone Reference
With family - 2.53 0.341
9 Disability
Dependent Reference Reference
Independent 4.42 0.104 5.09 0.054
relatives*
Present Reference
Absent - 0.15 0.954
Present
Absent Reference Reference
- 4.50 0.118 - 5.13 0.065
12 Caretaker*
Present Reference
Absent 0.77 0.772
13 BMI 0.61 0.135 **
14 NCDs
Present 5.98 0.022 5.98 0.019
Absent Reference
N=178
29
Table 4.8: Multiple linear regression to identify the determinants of
social relationship (Domain3)
S. Variables Univariate analysis Multivariate analysis
No β p-value β p-value
1 Age* 0.10 0.804
2 Gender
Males 10.66 0.105 11.22 0.079
3 Race*
Malay Reference
Indian - 18.29 0.073
Chinese - 0.35 0.967
4 Marital status*
Unmarried Reference
Married 9.67 0.238
SDW - 4.29 0.579
5 Education*
Primary Reference
Tertiary 7.72 0.525
No formal 7.79 0.379
education
6 Occupation*
Working Reference
Retired 7.97 0.253
Never employed 2.09 0.876
7 Income
(Ringgit) Reference Reference
≤600 - 10.73 0.103 -13.11 0.044
>600
8 Living condition
Alone Reference
With family - 9.03 0.183 **
9 Disability
Dependent Reference
Independent 8.39 0.230 **
30
10 Visit by friends
& relatives*
Present Reference
Absent - 6.87 0.309
11 Role in family
decision
Absent - 12.10 0.100 - 14.37 0.047
12 Caretaker*
Present Reference
Absent - 1.24 0.855
13 BMI* 0.58 0.577
14 NCDs*
Present - 1.79 0.792
Absent Reference
N=178
31
Table 4.9. Multiple linear regression to identify the determinants of Environmental
Domain (Domain4)
S.No Variables Univariate analysis Multivariate analysis
β p-value β p-value
1 Age - 0.26 0.167 **
2 Gender
Males 7.90 0.011 6.55 0.031
3 Race*
Malay Reference
Indian 0.59 0.906
Chinese 2.19 0.600
4 Marital status*
Unmarried Reference
Married 3.55 0.369
SDW 1.11 0.767
5 Education*
Primary Reference
Secondary - 1.38 0.726
Tertiary - 5.04 0.387
No formal - 1.61 0.703
education
6 Occupation
Working Reference **
Retired 4.83 0.134
7 Income (Ringgit)*
≤600 Reference
>600 - 3.47 0.272
8 Living condition
Alone Reference Reference
With family - 6.18 0.055 - 7.56 0.017
9 Disability*
Dependent Reference
Independent 3.40 0.309
relatives* Reference
Present 0.13 0.968
Absent
11 Role in family
decision* Reference
Present - 2.68 0.449
Absent
12 Caretaker*
Present Reference
Absent 0.23 0.944
13 BMI 0.92 0.063 1.00 0.043
14 NCDs
Present 6.72 0.035 **
Absent Reference
N=178
32
5 The prevalence of depression and the
effect of exercise on mental health of
the respondents
5.1. Introduction
Proportion of older people, those aged 60 or above, around the world is

increasing dramatically and 30% of population in many countries will be
occupied by aging population by the middle of the century. Issues related to
elderly were often overlooked although they made important contribution to
the society. Many of them were vulnerable to different types of abuse,
negligence and they were at risk of developing mental disorders. According to
WHO, mental or neurological disorder was noticed in 20% of elderly which
could account for 17.4% of Years Lived with Disability (YLDs). Experiencing
different life stressors, functional disabilities, and reduced capacities among
elderly can lead to physical injuries as well as psychological problems like
depression and anxiety(Mental Health of Older Adults, n.d.).
Mental health was the second biggest health problem after heart
diseases in Malaysia. Based on the national survey, it was found that one in
three Malaysian adults had a mental health condition in 2020(Faizul bin
Hassan et al., 2018). Moreover, Malaysia can be regarded as ―ageing nation‖
and aging population can be projected to double to 14% by 2044 and 20% by
2056 (“Super-Aged” Malaysia by 2056: What We Need to Do, n.d.). Healthy
aging was prioritised by the Malaysian government in National Health Policy
by improving facilities and providing health care for older people(Aziz &
Ahmad, 2019).
Increasing demands of old age homes were noticed in urban areas like
Kuala Lumpur, Selangor, Johor, and Penang from working adults who are
unable to provide caregiving to their elderly parents (Statistik & Kebajikan
Malaysia, n.d.). However, the quality of life in home dwelling elderly was
better than those who stayed in nursing home(Olsen et al., 2016). The empty
nest syndrome was a common trigger for depression and anxiety among
elderly when children left home and migrated to other places for their future.
Those in nursing homes might have a higher risk of mental health problems
33
compared to those who stayed with the family(The Invisible Mental Health
Issues Of Older Malaysians - CodeBlue, n.d.).
Research showed that regular exercise was good for better mental
health, and it could be as effective as cognitive behavioural therapy or
antidepressants in mild to moderate depressive cases. The valuable
advantages of doing exercise were releasing endorphins in the brain,
improving sense of control and self-esteem, and reduced in muscle tension.
People with mental health issues were associated with more chronic physical
problems like heart disease and arthritis and physical benefit of exercise could
improve their overall health(Exercise and Mental Health - Better Health
Channel, n.d.) Stress release, memory improvement and better sleep were
positive impact of regular exercise(Syed-Abdul et al., 2019).
Elderly should avoid the sedentary lifestyle and regular physical activity
was important for healthy aging. It was well established that overall quality of
life and general health of elderly were improved by doing any amount of
aerobic exercise, strength, or resistance training, stretching exercise and
balance training(O‘Donovan et al., 2010).Strengthening exercises were
recommended to elderly people by focusing on balance, mobility, and posture.
Weight-bearing exercise was one form of strengthening exercise and
respondents needed to bear their own weight. Both bone health and general
health could be benefited by doing weight-bearing exercises like brisk
walking, stair walking and jogging(Strengthening Exercises for Bones and
Health for Seniors | Australian Seniors, n.d.).
Very limited research has been done concerning mental health among
institutionalised elderly Malaysians and there was no structured exercise
programme in most of the old age homes in northern Malaysia. To seal the
considerable research gap and in line with the government policy, the second
objective of current study was to find out the prevalence of depression and the
effect of exercise on mental health among institutionalised elderly.
5.2. Materials and methods
5.2.1. Study design and selection of participants: Older adults who were
residing at 1 government home and 9 private homes in Northern Malaysia
(Penang and Kedah) were screened using DAS scale. Two homes from
Penang and 8 homes from Kedah State were involved in our study. The study
participants were recruited using convenience sampling, The adopted study
34
design was single group pre-test and post-test design. The status of physical
performance and mental health among the respondents was assessed before
and after exercise programme.
5.2.2. Prevalence of depression, anxiety, and stress (Phase I): Phase I of

this study was to find out the prevalence of depression, anxiety, and stress
among the respondents. Mental health was assessed among consented 178
inmates, aged 60 and above from homes. Those who were younger than 60,
respondents from homes other than northern Malaysia, those who were
suffering from Psychosis, Dementia, severe decompensation and those on
any psychotic medication were excluded from the study. Two researchers had
undergone training in administering questionnaire to avoid the observer bias.
5.2.3. Pre and Post -test mental health assessment (Phase II): Phase II of
the study was to assess the mental health status of the selected participants
before and after exercise programme. In this phase, strengthening and
aerobic exercises were introduced to 39 respondents with mild to moderate
degree of depression. Two researchers from the team were trained by
geriatric physiotherapist for a period of two weeks to assess the mental health
and implementation of exercise training among study participants. The
assessors were competent in data collection and implementing the exercise
training. The Short Physical Performance Battery (SPPB) scores were
assessed at week 1, week 6, week 9 and week 12. Mental health
reassessment was done at week 12 of exercise intervention.
5.2.4. Exercise protocol for elderly: Strengthening and Aerobic exercises

were introduced to depressed elderly at week 1,6,9 and 12 according to Table
5.1. The exercise protocol was developed by well-experienced geriatric
physiotherapist, and it was shown in Table.2. The exercise protocol was
developed based in the earlier literature(Hewitt et al., 2018; S. M. Silva,
Santana, da Silva, et al., 2019; Watanabe et al., 2015). It was developed for
the following reasons: 1) It was easy to administer in any residential and
clinical settings without any need of resistance band/dead weights 2) minimal
supervision was needed during exercise training and 3) this exercise may be
performed by themselves without supervision once they have become
master‘s in it.
5.2.5. Mental health assessment: Depression, Anxiety and Stress Scale

(DASS-21) was used to assess the mental health among the inmates which
consisted of 21 questions (Depression Anxiety and Stress Scale 21 (DASS-
35
21) – Healthfocus Clinical Psychology Services, n.d.). It was recognised as an
effective screening tool and scoring criteria were described in Table 5.2. (All
About DASS-21: The Depression, Anxiety & Stress Scale, n.d.).It was a
reliable tool with good internal consistency and validity especially for
screening of depression among the elderly(Gloster et al., 2008).
5.2.6. The Short Physical Performance Battery (SPPB): SPBB consisted of

the combined results of the gait speed, chair stand and balance tests. The
lowest score was 0 (worst performance) and the highest was 12 (best
performance). The SPBB was reliable and valid tool to assess the physical
performance of elderly people, showing high test-retest reliability value of
0.87(Gómez Montes et al., 2013). It was used to assess the lower extremity
function in the respondents by checking at week 1,6,9 and 12 after introducing
exercise programme(Guralnik et al., 1995).
5.2.7. Statistical Analysis: Data entry and data analysis were done by SPSS
version 23. Descriptive statistics was used to identify the prevalence of DASS
among study participants. Repeated measures ANOVA was used to identify
the SPBB score differences among different exercise sessions. Paired sample
t test was performed to compare the mental health status before and after
exercise programme. P-value<0.05 was considered as significant difference.
5.3. Results
5.3.1. Prevalence of Depression, Anxiety and Stress among elderly

inmates: The sample comprised of 178 inmates from old age homes from
Northern Malaysia. Mental well-being was assessed by DASS-21
questionnaire and results can be seen in Table 5.3. Findings indicated that
27(15.2%) respondents had mild depression and 15(8.4%) had moderate
depression. In addition, 31(17.4%) had mild anxiety and 2(1.1%) had
moderate anxiety. Moreover, 14(7.9%) respondents had mild stress.
5.3.2. Comparison of SPBB scores in week1,6,9 and 12 of exercise: The

exercise was introduced to the respondents with mild to moderate depression.
Out of 42 respondents with depression, 39 respondents compliance with
exercise and 2 respondents dropped out of study. SPBB was assessed by
balance test, chair stand test, gait speed test and combined total score at
week1, week 6, week 9 and week 12. The improvement in physical
performance can be noticed in Figure 5.3. to 5.6. The average total scores of
36
SPBB were described in Table 5.4., showing 3.512, 4.846,5.615 and 6.205 at
week 1,6,9 and 12 respectively.
5.3.3. Pair-wise comparison of SPBB score: A repeated measures ANOVA

was performed to compare the effect of exercise on SPBB total score.
According to table 5.5, our data had not met the assumption of sphericity and
Greenhouse-Geisser showed F=85.953, p=0. 000.Bonferroni test was carried
out in Table 5.6. for pairwise comparisons based on the average total score of
SPBB in week 1,6,9 and 12. There was a statistically significant difference in
SPBB total score between each pair of exercise sessions. Highest score of
SPBB was noticeable at week 12 of exercise intervention compared to week
1,3 and 6 and significant improvement of physical performance was noticed
among the respondents (p=0.000).
5.3.4. Impact of exercise on Depression, Anxiety and Stress: Paired

sample t test was performed to identify the impact of exercise on depression,
anxiety, and stress (Table 5.7). The average score related to mental health
were assessed at week1 and week 12 of exercise programme. The results
revealed the significant decrease in depression scores before exercise
(M=6.179, SD=1.121) to after exercise (M=4.359, SD=1.459), t (38) =12.439,
p=0.000. Significant decrease in anxiety scores before exercise (M=3.461,
SD=1.393) to after exercise (M=2.205, SD=1.174), t (38) =7.023, p=0.000 and
decrease in stress scores before exercise (M=4.589, SD=2.863) to after
exercise (M=2.846, SD=1.785), t (38) = 6.944, p=0.000.
5.4. Discussion
The prevalence of depression, anxiety and stress can be assessed by

different measurements definitions and socio-economic backgrounds. In the
current study, assessment was done by DASS-21 survey and 23.6% of the
respondents had depression, 18.5% had anxiety and 7.9% had stress. The
prevalence of depression was ranging from 11% to 35.5% based on the
findings from the different studies(Munirah & Elias, 2018).The prevalence of
depressive symptoms among institutionalised elderly Malaysians was noticed
as 16.5% in the studies done by Vanoh et al.in 2016 and the prevalence was
high in the current study(Vanoh et al., 2016).COVID-19 pandemic affected the
mental health of elderly population and it was reported by Okruszek et al. and
Clair et.al. that many elderly experienced psychological burdens because of
less social contact and loneliness during pandemic. Fear of contracting
COVID-19 and death also contributed to decompensation(Clair et al., 2021;
37
Okruszek et al., 2020). The prevalence of anxiety in this study was 18.5% and
majority of them were mild conditions which was in concordance with the
study by Yong et al in which it was found that 15.2% of the admitted cases in
Hospital Tapah, Malaysia were mild condition in anxiety(Yong et al., 2022). In
this study, 7.9% of elderly experienced stress and similar finding was noticed
among Malay elderly in rural community of Perak State(Abdul Manaf et al.,
2016).
According to Centre of Disease Control and Prevention (CDC), it was

recommended minimum 150 minutes per week for moderate intensity and 2
days per week for strengthening exercise for those 65 years and older.
Strengthening exercise and brisk walking were introduced to elderly inmates 3
days per week for 12 weeks and significant improvement in physical activity
was noticed in the current study. Physical activity was essential for healthy
aging by preventing health problems and making muscles stronger(How Much
Physical Activity Do Older Adults Need? | Physical Activity | CDC, n.d.).
Significant reduction in depression score was identified after 12 weeks

of exercise programme in our study. A study done by Blumenthal et al. found
that 16 weeks of aerobic exercise was equally effective as antidepressant
among patients with major depressive disorder(Blumenthal et al.,
1999b).Anxiety score was significantly reduced after the exercise programme
among elderly in old age homes. Our findings supported findings from the
systematic review in which anxiety score was reduced after exercise
intervention based on 19 studies(Kazeminia et al., 2020a). According to
Boston University, lower anxiety in older adults was noticed after regular
leisure time exercise 30 minutes for three time per week(Aguiñaga et al.,
2018). One study in Brazil by de Oliveira et al. had revealed that physical
activity was a protective factor for anxiety and depression among elderly(de
Oliveira et al., 2019). It was interesting to find that exercise was associated
with lower score of perceived stress in the studies done among the older
population by Krause et al. and McHugh and Lawlor(Krause et al., 1993;
McHugh & Lawlor, 2012).It was found that aerobic exercise could reduce the
stress hormone and stimulate the endorphin production which can create the
feeling of relaxation and optimism. Stress reduction could be benefited by
strengthening and stretching exercise two to three times per week as reported
by Havard Medical School(Exercising to Relax - Harvard Health Publishing -
Harvard Health, n.d.). It was supported by reduction in stress score after 12
weeks of aerobic and strengthening exercise in our study.
38
Table 5.1: Exercise protocol for elderly
S.No Exercise Protocol Duration
1 Warm up Strengthening exercise 12 weeks
Marching and brisk 4 sets per day, each set
walking for 2 minutes at consists of 10
very low intensity of Borg repetitions, 1 minute rest
scale (7-8 in scale) between each set and 3
days per week.
Aerobic exercise
2 Strengthening exercise
Intensity of exercise:
Stepping on stool (14-
somewhat hard in borg
inch stool) in forward and
scale (13 in scale), 3
sideways direction
days per week
Basic chair squat
Progression of exercise:
Heel rising by holding a
Strengthening and
stable object
aerobic exercise will be
Heel walking
progressed to every 2
Aerobic exercise
weeks by varying the
Brisk walking
intensity of exercise.
3 Cool down
Marching and brisk
walking for 2 minutes at
very low intensity of Borg
scale (7-8 in scale)
39
Table 5.2: Score criteria for DASS-21
Depression Anxiety Stress
Normal 0-5 0-4 0-7
Mild 6-7 5-6 8-9
Moderate 8-10 7-8 10-13
Severe 11-14 9-10 14-17
Very Severe 15+ 11+ 18+
40
Table 5.3: Prevalence of depression, anxiety, and stress among elderly in
old age homes
Total (N=178)
Severity level Depression Anxiety Stress
N % N % N %
Normal 136 76.4 145 81.5 164 92.1
Mild 27 15.2 31 17.4 14 7.9
Moderate 15 8.4 2 1.1 0 0
Severe 0 0 0 0 0 0
Extremely severe 0 0 0 0 0 0
41
Table 5.4: Distribution of mean and standard deviation of different
SPBB total scores
SPBB total score Mean Std. Deviation N
Week 1 3.512 2.126 39
Week 6 4.846 2.084 39
Week 9 5.615 1.786 39
Week12 6.205 2.117 39
42
Table 5.5: ANOVA test based on the different total scores of SPBB
among elderly inmates
Tests of Within-Subjects Effects
Measure: MEASURE_1
Source Type III df Mean F p-
Sum of Square value
Squares
factor1 Sphericity 158.276 3 52.759 85.953 0.000
Assumed
Greenhouse- 158.276 1.840 86.035 85.953 0.000
Geisser
Huynh-Feldt 158.276 1.929 82.058 85.953 0.000
Lower-bound 158.276 1.000 158.276 85.953 0.000
Error Sphericity 69.974 114 .614
Assumed
(factor1) Greenhouse- 69.974 69.908 1.001
Geisser
Huynh-Feldt 69.974 73.296 .955
Lower-bound 69.974 38.000 1.841
43
Table 5.6: Pairwise comparisons of different SPBB total scores
(I) (J) Mean Std. Sig.b 95% Confidence
factor1 factor1 Difference Error Interval for Differenceb
(I-J) Lower Upper
Bound Bound
1 2 -1.333* 0.185 .000 -1.848 -0.819
*
3 -2.103 0.204 .000 -2.670 -1.535
4 -2.692* 0.244 .000 -3.372 -2.013
*
2 1 1.333 0.185 .000 .8190 1.848
*
3 -0.769 0.124 .000 -1.115 -0.423
4 -1.359* 0.166 .000 -1.822 -0.896
*
3 1 2.103 0.204 .000 1.535 2.670
*
2 0.769 0.124 .000 0.423 1.115
4 -0.590* 0.102 .000 -0.874 -0.306
*
4 1 2.692 0.244 .000 2.013 3.372
*
2 1.359 0.166 .000 0.896 1.822
3 0.590* 0.102 .000 0.306 0.874
Based on estimated marginal means
*. The mean difference is significant at the .05 level.
b. Adjustment for multiple comparisons: Bonferroni.
44
Table 5.7: Results of paired differences in depression, anxiety, and stress scores before
and after exercise intervention
Mental Exercise Mean Std. Mean Std. Std. 95% t df p-
Health value
variables Dev. Devi Error Confidence
ation Mean Interval of the
Difference
Lower Upper
Depression Before 6.174 1.121 1.821 0.914 0.146 1.524 2.117 12.43 38 0.000
After 4.359 1.459 9
Anxiety Before 3.461 1.393 1.256 1.117 0.179 0.894 1.619 7.023 38 0.000
After 2.205 1.174
Stress Before 4.589 2.863 1.744 1.570 0.251 1.235 2.252 6.944 38 0.000
After 2.846 1.785
45
A B C
Figure 5.1.Strengthening exercises (Brisk walking,heel raise,sit to stand) A -

Brisk walking, B-Heel raise, C-Sit to stand
46
a b c
Figure 5.2: Strengthening exercise (Step up and down stool)
47
Figure 5.3: Mean score differences of balance test in week 1,6,9 and 12
48
Figure 5.4: Mean score differences of chair stand test in week 1,6,9 and 12
49
Figure 5.5: Mean score differences of gait speed test in week 1,6,9 and 12
50
Figure 5.6: Estimated means of SPPB total score in week1,6,9 and 12
51
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Journal of Positive School Psychology http://journalppw.com
2022, Vol. 6, No. 5, 6681–6691
Prevalence of Depression, Stress and Anxiety and Impact of Exercise

on Mental Health and Physical Performance among Institutionalised
Older Adults of Northern Malaysia
Theingi Maung Maung 1*, Timsi Jain 2, Madhanagopal Jagannathan 3,

Nurhazrina Binti Noordin 4, Vincent Chung Yi Zhen 5, Win Myint Oo 6,
Sukumaran Sudarsanan 7
1
* PhD Scholar, Saveetha Institute of Medical and Technical Sciences, Chennai. India.
Associate Professor, Unit of Community Medicine, Faculty of Medicine,
AIMST University. Malaysia.
2
Community Medicine Department, Saveetha Institute of Medical and Technical Sciences,
Chennai, Tamil Nadu, India.
3,4,5
School of Physiotherapy, FAHP, AIMST University. Malaysia.
6
Faculty of Medicine, SEGi University, Malaysia.
7
Psychiatry Unit, AIMST University. Malaysia.
Email: 1* drtheingi68@gmail.com
Abstract
Ageing population around the world is increasing dramatically and mental health is the second biggest
health problem in Malaysia. Avoiding sedentary lifestyle and regular physical activity were important
for healthy ageing. This study aimed to determine the exercise and mental health among Malaysian
elderly in old age homes. Single group pre-test and post-test design was chosen. Status of mental
health was assessed before and after exercise programme by using DASS-21 questionnaire. Single
group pre-test and post-test study was conducted among old age homes of northern Malaysia and
prevalence of mental health was assessed among 178 elderly and strengthening and aerobic exercises
were introduced to 39 respondents with mild to moderate depression. The prevalence of depression
was 23.6%, anxiety was 18.5% and stress was 7.9%. Significant improvement in physical
performance was identified by the Short Physical Performance battery (SPBB) score at week1,6,9 and
12 of the exercise programmes (p=0.000). Depression, anxiety, and stress scores were significantly
reduced after the exercise intervention as compared to scores before the exercise (p=0.000). Social
support and emotional support are required to promote the better exercise habits among the elderly.
Regular review of the elderly home facilities and exercise activities will help to support healthy aging
and active lifestyle among Malaysian elderly residing in old age homes.
Keywords : Exercise, Mental Health, Elderly, Old age home
I. INTRODUCTION Many of them were vulnerable to different

Proportion of older people, those aged 60 or types of abuse, negligence and they were at risk
above, around the world is increasing of developing mental disorders. According to
dramatically and 30% of population in many WHO, mental or neurological disorder was
countries will be occupied by aging population noticed in 20% of elderly which could account
by the middle of the century. Issues related to for 17.4% of Years Lived with Disability
elderly were often overlooked although they (YLDs). Experiencing different life stressors,
made important contribution to the society. functional disabilities, and reduced capacities
© 2022 JPPW. All rights reserved

Theingi Maung Maung, et. al. 6682
among elderly can lead to physical injuries as sleep were positive impact of regular
well as psychological problems like depression exercise.(The Mental Health Benefits of
and anxiety.(Mental Health of Older Adults, Exercise - HelpGuide.Org, n.d.)
n.d.) Elderly should avoid the sedentary lifestyle and
Mental health was the second biggest health regular physical activity was important for
problem after heart diseases in Malaysia. Based healthy aging. It was well established that
on the national survey, it was found that one in overall quality of life and general health of
three Malaysian adults had a mental health elderly were improved by doing any amount of
condition in 2020. (Hassan et al., 2018) aerobic exercise, strength, or resistance training,
Moreover, Malaysia can be regarded as “ageing stretching exercise and balance training. (Lee et
nation” and aging population can be projected al., 2017) Strengthening exercises were
to double to 14% by 2044 and 20% by recommended to elderly people by focusing on
2056.(“Super-Aged” Malaysia by 2056: What balance, mobility, and posture. Weight-bearing
We Need to Do, n.d.) Healthy aging was exercise was one form of strengthening exercise
prioritised by the Malaysian government in and respondents needed to bear their own
National Health Policy by improving facilities weight. Both bone health and general health
and providing health care for older people.(Aziz could be benefited by doing weight-bearing
& Ahmad, 2019) exercises like brisk walking, stair walking and
Increasing demands of old age homes were jogging.(Strengthening Exercises for Bones and
noticed in urban areas like Kuala Lumpur, Health for Seniors | Australian Seniors, n.d.)
Selangor, Johor, and Penang from working Special needs for the aging population are
adults who are unable to provide caregiving to prioritized by the Malaysia government for
their elderly parents.(JKM, 2014) However, the ageing country status by 2030. Very limited
quality of life in home dwelling elderly was research has been done concerning mental
better than those who stayed in nursing home. health among institutionalised elderly
(Olsen et al., 2016) The empty nest syndrome Malaysians and there was no structured exercise
was a common trigger for depression and programme in most of the old age homes in
anxiety among elderly when children left home northern Malaysia.To seal the considerable
and migrated to other places for their future. research gap and in line with the government
Those in nursing homes might have a higher policy, this study aimed to determine the
risk of mental health problems compared to exercise and mental health among Malaysian
those who stayed with the family.(The Invisible elderly in old age homes.
Mental Health Issues Of Older Malaysians -
II. MATERIAL AND METHODS
CodeBlue, n.d.)
Older adults who are residing at 1 government
Research showed that regular exercise was
home and 9 private homes in Northern
good for better mental health, and it could be as
Malaysia (Penang and Kedah) were screened
effective as cognitive behavioural therapy or
using DAS scale. Two homes from Penang and
antidepressants in mild to moderate depressive
8 homes from Kedah State were involved in our
cases. The valuable advantages of doing
study. The study participants were recruited
exercise were releasing endorphins in the brain,
using convenience sampling, The adopted study
improving sense of control and self-esteem, and
design was single group pre-test and post-test
reduced in muscle tension. People with mental
design. The status of physical performance and
health issues were associated with more chronic
mental health among the respondents was
physical problems like heart disease and
assessed before and after exercise programme.
arthritis and physical benefit of exercise could
Informed consent was distributed and explained
improve their overall health.(Exercise and
in detail to the participants. The privacy and
Mental Health - Better Health Channel, n.d.)
confidentiality of the collected data were
Stress release, memory improvement and better
maintained. The study was conducted in

6683 Journal of Positive School Psychology
accordance with the standard of deceleration of Phase II of the study was to assess the mental
Helsinki and AIMST university human and health status of the selected participants before
animal ethics committee (Ref: and after exercise programme. In this phase,
AUHEC/FOM/2020/03). strengthening and aerobic exercises were
introduced to 39 respondents with mild to
Phase I of this study was to find out the moderate degree of depression. Two researchers
prevalence of depression, anxiety, and stress from the team were trained by geriatric
among the respondents. Mental health was physiotherapist for a period of two weeks to
assessed among consented 178 inmates, aged assess the mental health and implementation of
60 and above from homes. Those who were exercise training among study participants. The
younger than 60, respondents from homes other assessors were competent in data collection and
than northern Malaysia, those who were implementing the exercise training. The Short
suffering from Psychosis, Dementia, severe Physical Performance Battery (SPPB) scores
decompensation and those on any psychotic were assessed at week 1, week 6, week 9 and
medication were excluded from the study. Two week 12. Mental health reassessment was done
researchers had undergone training in at week 12 of exercise intervention.
administering questionnaire to avoid the
observer bias.
Table 1. Exercise protocol for elderly respondents
Exercise Protocol Duration
Warm up Strengthening exercise

Marching and brisk walking for 2 4 sets per day, each set consists of
1 10 repetitions, 1 minute rest
minutes at very low intensity of
Borg scale (7-8 in scale) between each set and 3 days per
week.
Strengthening exercise Aerobic exercise
Stepping on stool (14 inch stool) in Intensity of exercise: somewhat
forward and sideways direction hard in borg scale (13 in scale), 3
Basic chair squat days per week
2 Heel rising by holding a stable Progression of exercise: 12 weeks
object Strengthening and aerobic
Heel walking exercise will be progressed to
Aerobic exercise every 2 weeks by varying the
Brisk walking intensity of exercise.
Cool down
Marching and brisk walking for 2
3
minutes at very low intensity of
Borg scale (7-8 in scale)
were described in Figure 1.(Depression Anxiety

III. MENTAL HEALTH ASSESSMENT
and Stress Scale 21 (DASS-21) – Healthfocus
Depression, Anxiety and Stress Scale (DASS-
Clinical Psychology Services, n.d.) It was a
21) was used to assess the mental health among
reliable tool with good internal consistency and
the inmates which consisted of 21
validity especially for screening of depression
questions.(Depression Anxiety Stress Scale
among the elderly.(Gloster et al., 2008)
(DASS 21) Form, n.d.) It was recognised as an
effective screening tool and scoring criteria

2022, Vol. 6, No. 5, 6681–6691
Figure 1. Scoring criteria for DASS-21
The Short Physical Performance Battery caretaker (61.8%) and those residing in private
(SPPB) homes (85.4%).
SPBB consisted of the combined results of the
Table 2. Characteristics of the respondents
gait speed, chair stand and balance tests. The
lowest score was 0 (worst performance) and the Frequency
No. Variables Percent
highest was 12 (best performance). The SPBB (n=178)
was reliable and valid tool to assess the physical 1 Gender
performance of elderly people, showing high Females 87 48.9
test-retest reliability value of 0.87.(Gómez Males 91 51.1
Montes et al., 2013) It was used to assess the 2 Race
lower extremity function in the respondents by Malay 31 17.4
checking at week 1,6,9 and 12 after introducing Indian 35 19.7
exercise programme.(Guralnik et al., 1995) Chinese 112 62.9
3 Marital status
IV. STATISTICAL ANALYSIS
Unmarried
Data entry and data analysis were done by 74 41.6
Married
SPSS version 23. Descriptive statistics was 46 25.8
Single/Divorce
used to identify the prevalence of DASS among 58 32.6
/Widow
study participants. Repeated measures ANOVA
4 Education
was used to identify the SPBB score differences
Primary
among different exercise sessions. Paired 65 36.5
Secondary
sample t test was performed to compare the 54 30.3
Tertiary
mental health status before and after exercise 16 9.0
No formal
programme. P-value<0.05 was considered as 43 24.2
education
significant difference.
7 Living
V. RESULTS condition
115 64.6
The sample comprised of 178 inmates from old Alone
63 35.4
age homes and general characteristics of them With family
were shown in Table 2. Majority of the 8 Income
respondents were males (51.1%), Chinese Less than or
(62.9%), unmarried (41.6%), those with equal RM 600 93 52.2
primary education level (36.5%), those who More than RM 85 47.8
stayed alone (64.6%), income less than or equal 600
RM 600, those without disability (65.7%), those 9
Disability
who did not get visit by friends (61.8%), no role 34.3
Present 61
in family decision (73.6%), those having no 65.7
Absent 117

10 Visit by friends
& relatives
68 38.2
Present
110 61.8
Absent
11 Role in family
decision
47 26.4
Present
131 73.6
Absent
12 Caretaker
Present 68 38.2
Absent 110 61.8
13 Type of home
for aged
26 14.6
Government
152 85.4 Figure 2: Mean score differences of balance
Private
test in week 1,6,9 and 12
Mental well-being was assessed by DASS-21
questionnaire and results can be seen in Table
3. Findings indicated that 27(15.2%)
respondents had mild depression and 15(8.4%)
had moderate depression. In addition,
31(17.4%) had mild anxiety and 2(1.1%) had
moderate anxiety. Moreover, 14(7.9%)
respondents had mild stress.
Table 3. Prevalence of depression, anxiety, and

stress among elderly in old age homes
Figure 3: Mean score differences of chair stand

test in week 1,6,9 and 12
The exercise was introduced to the respondents

with mild to moderate depression. Out of 42
respondents with depression, 39 elderly
compliance with exercise and 2 respondents
dropped out of study. SPBB was assessed by
balance test, chair stand test, gait speed test and
combined total score at week1, week 6, week 9
and week 12. The improvement in physical Figure 4: Mean score differences of gait speed
performance can be noticed in Figure 2 to 5. test in week 1,6,9 and 12

The average total scores of SPBB were

described in Table 4, showing 3.512,
4.846,5.615 and 6.205 at week 1,6,9 and 12
respectively. A repeated measures ANOVA was
performed to compare the effect of exercise on
SPBB total score. According to table 5, our data
had not met the assumption of sphericity and
Greenhouse-Geisser showed F=85.953, p=0.
000.Bonferroni test was carried out in Table 6
for pairwise comparisons based on the average
total score of SPBB in week 1,6,9 and 12. There
was a statistically significant difference in
SPBB total score between each pair of exercise
Figure 5: Estimated means of SPPB total score sessions. Highest score of SPBB was noticeable
in week1,6,9 and 12 at week 12 of exercise intervention compared to
week 1,3 and 6 and significant improvement of
Table 4. Distribution of mean and standard physical performance was noticed among the
deviation of different SPBB total scores respondents (p=0.000).
SPBB Total Std.

Mean N
Score Deviation
Week 1 3.512 2.126 39
Week 6 4.846 2.084 39
Week 9 5.615 1.786 39
Week12 6.205 2.117 39
Table 5. ANOVA test based on the different total scores of SPBB among elderly inmates
Tests of Within-Subjects Effects

Measure: MEASURE_1
Type III
Mean
Source Sum of df F p-value
Square
Squares
Sphericity Assumed 158.276 3 52.759 85.953 0.000
Greenhouse-Geisser 158.276 1.840 86.035 85.953 0.000
factor1
Huynh-Feldt 158.276 1.929 82.058 85.953 0.000
Lower-bound 158.276 1.000 158.276 85.953 0.000
Sphericity Assumed 69.974 114 .614
Error Greenhouse-Geisser 69.974 69.908 1.001

(factor1) Huynh-Feldt 69.974 73.296 .955
Lower-bound 69.974 38.000 1.841

Table 6. Pairwise comparisons of different SPBB total scores

95% Confidence Interval for
Mean
(I) factor1 (J) factor1 Std. Error Sig.b Differenceb
Difference (I-J)
Lower Bound Upper Bound
2 -1.333* 0.185 .000 -1.848 -0.819
*
1 3 -2.103 0.204 .000 -2.670 -1.535
4 -2.692* 0.244 .000 -3.372 -2.013
*
1 1.333 0.185 .000 .8190 1.848
*
2 3 -0.769 0.124 .000 -1.115 -0.423
*
4 -1.359 0.166 .000 -1.822 -0.896
1 2.103* 0.204 .000 1.535 2.670
*
3 2 0.769 0.124 .000 0.423 1.115
*
4 -0.590 0.102 .000 -0.874 -0.306
*
1 2.692 0.244 .000 2.013 3.372
*
4 2 1.359 0.166 .000 0.896 1.822
3 0.590* 0.102 .000 0.306 0.874
Based on estimated marginal means
*. The mean difference is significant at the .05 level.
b. Adjustment for multiple comparisons: Bonferroni.
Paired sample t test was performed to identify anxiety scores before exercise (M=3.461,
the impact of exercise on depression, anxiety, SD=1.393) to after exercise (M=2.205,
and stress (Table 7). The average score related SD=1.174), t (38) =7.023, p=0.000 and
to mental health were assessed at week1 and decrease in stress scores before exercise
week 12 of exercise programme. The results (M=4.589, SD=2.863) to after exercise
revealed the significant decrease in depression (M=2.846, SD=1.785), t (38) = 6.944, p=0.000.
scores before exercise (M=6.179, SD=1.121) to Table 7. Results of paired differences in
after exercise (M=4.359, SD=1.459), t (38) depression, anxiety, and stress scores before
=12.439, p=0.000. Significant decrease in and after exercise intervention
Table 7. Results of paired differences in depression, anxiety, and stress scores before and after
exercise intervention

2022, Vol. 6, No. 5, 6681–6691
Significant reduction in depression score was

VI. DISCUSSION
identified after 12 weeks of exercise
The prevalence of depression, anxiety and
programme in our study. A study done by
stress can be assessed by different
Blumenthal et al. found that 16 weeks of
measurements definitions and socio-economic
aerobic exercise was equally effective as
backgrounds. In the current study, assessment
antidepressant among patients with major
was done by DASS-21 survey and 23.6% of the
depressive disorder.(Blumenthal et al.,
respondents had depression, 18.5% had anxiety
1999)Anxiety score was significantly reduced
and 7.9% had stress. The prevalence of
after the exercise programme among elderly in
depression was ranging from 11% to 35.5%
old age homes. Our findings supported findings
based on the findings from the different
from the systematic review in which anxiety
studies.(Syed, 2018)The prevalence of
score was reduced after exercise intervention
depressive symptoms among institutionalised
based on 19 studies.(Kazeminia et al., 2020)
elderly Malaysians was noticed as 16.5% in the
According to Boston University, lower anxiety
studies done by Vanoh et al.in 2016 and the
in older adults was noticed after regular leisure
prevalence was high in the current
time exercise 30 minutes for three time per
study.(Vanoh et al., 2016)COVID-19 pandemic
week.(Aguiñaga et al., 2018)One study in
affected the mental health of elderly population
Brazil by de Oliveira et al. had revealed that
and it was reported by Okruszek et al. and Clair
physical activity was a protective factor for
et.al. that many elderly experienced
anxiety and depression among elderly.(de
psychological burdens because of less social
Oliveira et al., 2019) It was interesting to find
contact and loneliness during pandemic. Fear of
that exercise was associated with lower score of
contracting COVID-19 and death also
perceived stress in the studies done among the
contributed to decompensation.(Clair et al.,
older population by Krause et al. and McHugh
2021; Okruszek et al., 2020) The prevalence of
and Lawlor.(Krause et al., 1993; McHugh &
anxiety in this study was 18.5% and majority of
Lawlor, 2012) It was found that aerobic
them were mild conditions which was in
exercise could reduce the stress hormone and
concordance with the study by Yong et al in
stimulate the endorphin production which can
which it was found that 15.2% of the admitted
create the feeling of relaxation and optimism.
cases in Hospital Tapah, Malaysia were mild
Stress reduction could be benefited by
condition in anxiety.(Yong et al., 2022) In this
strengthening and stretching exercise two to
study, 7.9% of elderly experienced stress and
three times per week as reported by Havard
similar finding was noticed among Malay
Medical School.(Exercising to Relax - Harvard
elderly in rural community of Perak
Health Publishing - Harvard Health, n.d.) It
State.(Abdul Manaf et al., 2016)
was supported by reduction in stress score after
According to Centre of Disease Control and
12 weeks of aerobic and strengthening exercise
Prevention (CDC), it was recommended
in our study.
minimum 150 minutes per week for moderate
intensity and 2 days per week for strengthening VII. LIMITATIONS
exercise for those 65 years and older. Due to the travel restriction and infection
Strengthening exercise and brisk walking were among the elderly at the old age homes during
introduced to elderly inmates 3 days per week COVID-19 pandemic, we could not get the
for 12 weeks and significant improvement in required sample during the limited time frame.
physical activity was noticed in the current Convenience sampling was used as the sample
study. Physical activity was essential for obtained was only from the homes that gave
healthy aging by preventing health problems permission and only one government home took
and making muscles stronger.(How Much part in the current study. The sample may not
Physical Activity Do Older Adults Need? | reflect the overall inmates at the old age home
Physical Activity | CDC, n.d.)

of northern Malaysia and there can be Health Problems among Malay Elderly
possibility of selection bias. Residing in a Rural Community: A
Cross-Sectional Study. PLoS ONE,
VIII. CONCLUSION
11(6). https://doi.org/10.1371/JOU
The mental health situation among the elderly
RNAL.PONE.0156937
inmates in old age homes were quite alarming
2. Aguiñaga, S., Ehlers, D. K., Salerno, E.
and depression was identified in approximately
A., Fanning, J., Motl, R. W., &
one forth of the elderly inmates. Regular
McAuley, E. (2018). Home-based
screening of mental health should be done
physical activity program improves
among institutionalised elderly to get the early
depression and anxiety in older adults.
diagnosis and timely referral. Our study found
Journal of Physical Activity and Health,
that severity of depression, anxiety, and stress
15(9), 692–696. https://doi.org/10.11
were significantly reduced after 12 weeks of
23/JPAH.2017-0390
strengthening and aerobic exercises. Social
3. Aziz, N. A. binti, & Ahmad, Y. binti.
support and emotional support are required to
(2019). The Evolution of Government’s
promote the better exercise habits among the
Attention Towards Older Person: a
elderly. Moreover, the close cooperation among
Critical Review of Malaysia 5 Years
government, NGOs, health personal,
Plan. Ageing International, 44(4), 319–
physiotherapist, caretaker and elderly is
330. https://doi.org/10.1007/S12126-
important for the better understanding of their
019-09347-9
requirements and constraints. Regular review of
4. Blumenthal, J. A., Babyak, M. A.,
the elderly home facilities and exercise
Moore, K. A., Craighead, W. E.,
activities will help to support healthy aging and
Herman, S., Khatri, P., Waugh, R.,
active lifestyle among Malaysian elderly
Napolitano, M. A., Forman, L. M.,
residing in old age homes.
Appelbaum, M., Doraiswamy, P. M., &
IX. ACKNOWLEDGEMENT Krishnan, K. R. (1999). Effects of
We would like to thank all respondents from Exercise Training on Older Patients
old age homes for taking time to answer the With Major Depression. Archives of
questionnaire. We are grateful to the Malaysian Internal Medicine, 159(19), 2349–2356.
Ministry of Education for financing this work https://doi.org/10.1001/ARCHINTE.15
under the Fundamental Research Grant Scheme. 9.19.2349
X. DECLARATION OF CONFLICTING 5. Clair, R., Gordon, M., Kroon, M., &
INTERESTS Reilly, C. (2021). The effects of social
The author(s) declared no potential conflicts of isolation on well-being and life
interest with respect to the research, authorship, satisfaction during pandemic.
and /or publication of this article. Humanities and Social Sciences
Communications 2021 8:1, 8(1), 1–6.
FUNDING https://doi.org/10.1057/s41599-021-
The author(s) disclosed the receipt of the 00710-3
following financial support for the research, 6. de Oliveira, L. D. S. S. C. B., Souza, E.
authorship, and/or publication of this article: C., Rodrigues, R. A. S., Fett, C. A., &
Ministry of Higher Education, Malaysia. Piva, A. B. (2019). The effects of
(FRGS/1/2020/SKK04/AIMST/02/1) physical activity on anxiety, depression,
and quality of life in elderly people
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Article
Impact of Aerobic and Strengthening Exercise on Quality of

Life (QOL), Mental Health and Physical Performance of Elderly
People Residing at Old Age Homes
Theingi Maung Maung 1,2,*, Timsi Jain 3, Jagannathan Madhanagopal 4, Sawri Rajan L. Rajagopal Naidu 5,
Hnin Pwint Phyu 6 and Win Myint Oo 7
1 Saveetha Institute of Medical and Technical Sciences, Chennai 602105, India

2 Unit of Community Medicine, AIMST University, Bedong 08100, Kedah, Malaysia
3 Community Medicine Department, Saveetha Institute of Medical and Technical Sciences,
Chennai 602105, India

4 School of Physiotherapy, FAHP, AIMST University, Bedong 08100, Kedah, Malaysia
5 Unit of Family Medicine, AIMST University, Bedong 08100, Kedah, Malaysia
6 Preclinical Department, Universiti Tunku Abdul Rahman, Sungai Long, Kajang 43000, Selangor, Malaysia
7 Faculty of Medicine, SEGi University, Petaling Jaya 47810, Selangor, Malaysia
* Correspondence: drtheingi68@gmail.com or theingi@aimst.edu.my; Tel.: +91-6014-594-792
Abstract: Background: The COVID-19 infection spread rapidly in Malaysia, and elderly people with
underlying comorbidities were affected most. The study aimed to determine the effect of exercise
on QOL and mental health among elderly people residing in old age homes during the COVID-19
Citation: Maung, T.M.; Jain, T.;
pandemic. Methods: Out of 178 older adults from old age homes in Kedah and Penang States, 39
Madhanagopal, J.; Naidu, S.R.L.R.;
respondents undertook aerobic and strengthening exercises. A single group pre-test and post-test
Phyu, H.P.; Oo, W.M. Impact of
study was conducted in one government home and nine private homes in the northern region of
Aerobic and Strengthening Exercise
Malaysia. The DASS-21 scale was used to assess mental health, and the WHOQOL-BREF question-
on Quality of Life (QOL), Mental
Health and Physical Performance of
naire was used to evaluate QOL. Results: After 12 weeks of the exercise programme, scores for the
Elderly People Residing at Old Age physical domain increased from 53.1 to 61.8, for the psychological domain from 51.8 to 59.3, for the
Homes. Sustainability 2022, 14, 10881. social domain from 53.2 to 60.5 and for the environmental domain from 67.2 to 72.1. Moreover, there
https://doi.org/10.3390/su141710881 was a significant reduction in the depression score from 6.2 to 4.4, the anxiety score from 3.5 to 2.2
and the stress score, from 4.6 to 2.8. Conclusion: Performing aerobic and strengthening exercises for
Academic Editors: Roy Rillera
a minimum of 12 weeks may have helped to improve mental health among the elderly during the
Marzo, Yulan Lin, Edlaine Faria de
Moura Villela, Sudip Bhattacharya
COVID-19 pandemic, and it may also improve the quality of life for those who are residing in old
and Kittisak Jermsittiparsert age homes.
Received: 21 July 2022

Keywords: exercise; elderly; quality of life; mental health
Accepted: 26 August 2022
Published: 31 August 2022
Publisher’s Note: MDPI stays neu-

tral with regard to jurisdictional 1. Introduction
claims in published maps and institu-
Coronavirus disease 2019 (COVID-19) affected millions of people worldwide, and
tional affiliations.
was officially declared a pandemic by the World Health Organization on 11 March 2020
[1,2]. The first case of COVID-19 was detected in Malaysia on 25 January 2020, and the
government implemented the Movement Control Order (MCO) from 18 March 2020 to 31
Copyright: © 2022 by the authors. Li-
December 2021 in order to reduce disease transmission [3].
censee MDPI, Basel, Switzerland.
During the MCO period, the movement of people was restricted, and this caused a
This article is an open access article strong impact on the economy, sport and tourism. The COVID-19 infection spread rap-
distributed under the terms and con- idly, and people with underlying comorbidities and the elderly were affected most [4–6].
ditions of the Creative Commons At- Fear and worry related to COVID-19, as well as social isolation because of nationwide
tribution (CC BY) license (https://cre- lockdown, caused negative emotions among people [7–9]. Different countries adopted
ativecommons.org/licenses/by/4.0/). quarantine successfully in order to contain the rapid spread of the coronavirus. Separation
Sustainability 2022, 14, 10881. https://doi.org/10.3390/su141710881 www.mdpi.com/journal/sustainability

Sustainability 2022, 14, 10881 2 of 12
from family or friends, disturbances in sleeping and eating, worsening chronic conditions,
increased alcohol consumption and substance use, worry and stress over the coronavirus,
and fear of uncertainty were associated with poor mental health and well-being for pa-
tients as well as the general population [10,11].
QOL can be subjectively considered as a measure of happiness; however, a multidi-
mensional view of the quality of life was proven to be important, especially in health
[12,13]. According to the WHO, quality of life can be defined as an individual’s perception
of their position in life based on culture and value systems, and it is related to their goals,
expectations, standards and concerns [14]. Physical health, psychological state, personal
beliefs, social relationships and relationship with the environment were identified as im-
portant determinants for QOL in [15]. Changes in lifestyle, inadequate physical activity,
consuming insufficient fruit and vegetables, wearing a face mask, delay in obtaining med-
ical care and social isolation were shown to have huge effects on QOL for older adults
during the pandemic [16]. Many elderly people were not able to access adequate food due
to functional limitations, transportation issues, fear of COVID-19 exposure and poor
knowledge relating to technology [17]. One study found that elderly individuals in nurs-
ing homes and care homes had a higher risk of COVID-19 infection, as these homes acted
as incubators of infection [18]. Moreover, many homes were faced with financial difficul-
ties during the pandemic, causing an increased burden on elderly care [19–21].
Physical activity is important for maintaining fitness, and exercise plays an essential
role in promoting health-related quality of life for the elderly. Exercise was shown to im-
prove emotional functioning and mental wellbeing in [22]. A study conducted by Hu et
al., 2020, found a reduction in anxiety and depression even after a single session of exer-
cise, and significant improvement was reported after engaging in rhythmic aerobic exer-
cise of low-to-moderate intensity. Exercising for 15 to 30 min, at least three times a week
for 10 weeks was also recommended [23]. Those who engaged in exercise showed better
QOL than those who did not engage. A study conducted in Korea reported that those who
performed resistance, flexibility and walking exercises attained better QOL scores than
non-exercisers; it was noted that older people preferred to engage in walking exercise,
followed by flexibility and resistance exercise [24]. Another study in Romania found that
participants who engaged in aerobic exercise displayed positive effects in aspects of both
physical and mental health, such as weight loss, higher self-esteem, improved sleep qual-
ity and higher confidence [25].
Aerobic and strength exercises are recommended to reduce the risk of falling for
older people, according to the WHO [26].Nonetheless, older adults with comorbid dis-
eases considered themselves handicapped, and became physically inactive and more de-
pendent on caregivers during the COVID-19 pandemic [27]. Based on data from previous
studies, the quality of life of the elderly in old age homes was significantly poorer than
that of the elderly living with family. A study carried out in Indonesia reported that the
elderly living in the community displayed higher QOL scores than those in nursing
homes, showing significant differences in mobility and daily activities [28]. Fiorelli De
Almeida et al. reported that the QOL of the elderly who attended day care centres attained
better QOL scores than those in nursing homes [29]. Many elderly individuals felt left
alone unsatisfied with life in old age homes [30]. Malaysia may be transformed into an
‘aged nation’ in the near future, and the government is faced with special needs and chal-
lenges for the ageing population [31].
The psychological impact of COVID-19 was reported as significantly high in re-
spondents with depression and anxiety [23]. Comprehensive care, which includes lifestyle
modifications by engaging in regular exercise, should be considered for elderly individu-
als with mental health problems, especially during a pandemic. In this study we aimed to
determine whether exercise can improve mental wellbeing and QOL among the elderly
during the COVID-19 pandemic. Developing exercise which is easy to administer in resi-
dential settings may help to improve the wellbeing of elderly residents in old age homes.
The mental-health-related information in this study may help to improve public aware-
ness of the emotional needs of elderly people who are either from an underprivileged
category or are unfortunate enough to be living apart from their families. Moreover, find-
ings may provide useful information for the Malaysian Government in developing pro-
grammes for the special needs of citizens aged 60 years and above. This exercise protocol
can also be used as an easily accessible measure for individuals with mental disorders
during the COVID-19 pandemic. There is limited scientific evidence of the experiences of
the elderly to date, and of the QOL of the elderly residing in old age homes in Malaysia.
Results may help to fill the research gap by providing information on QOL among de-
pressed elderly individuals residing in old age homes.
2. Materials and Methods

Older adults above the age of 60 years residing in old age homes in northern Malaysia
from Penang and Kedah States were selected as participants in this study. A total of 39
respondents with depression undertook exercise. This research used a single-group pre-
test and post-test design, and respondents were recruited by convenience sampling from
one government home and nine private homes in the northern region, from December
2020 to April 2022. Those who were younger than 60, ill, or mentally unstable, as well as
terminally ill respondents, were excluded from the current study. QOL and mental health
were assessed among the participants before and after the exercise programme. Partici-
pants were screened by a psychiatrist, and were included in the study after obtaining a
green light to participate in the study. Informed consent information was distributed and
explained in detail to the participants. Approval was obtained from all respondents before
beginning the study. Two researchers had undergone training in administering question-
naires to avoid observer bias. The study was conducted in accordance with the standards
of the Declaration of Helsinki and the AIMST University Human and Animal Ethics Com-
mittee (Ref: AUHEC/FOM/2020/03).
Exercise was introduced to 39 depressed elderly people from old age homes. The
majority of respondents were females (53.8%), unmarried and single/divorced/widowed
(61.8%), with primary education (30.8%), living alone (66.7%), without disability (51.3%),
unable to receive visits from friends or relatives (61.5%), with no role in family decisions
(69.2%), without a caretaker (59%), from a private home (71%) and with a comorbidity
(94.9%). The age of the respondents ranged from 60 to 90, with a mean age of 70.5 years ±
8.3. while BMI ranged from16 to 28, showing an average BMI as 22.9 ± 3.1). Those with
mild and moderate depression accounted for 61.5% and 38.5% of participants, respec-
tively; 41% and 5.1% reported mild and moderate anxiety, respectively; and 20.5% of re-
spondents reported experiencing mild stress. The detailed characteristics of depressed re-
spondents are shown in Table 1.
Table 1. Characteristics of the depressed respondents.
Variables Frequency (n = 39) Percent

Gender
Females 21 53.8
Males 18 46.2
Marital status
Unmarried 14 35.9
Married 11 28.2
Single/Divorced/Widowed 14 35.9
Education
Primary 12 30.8
Secondary 9 23.1
Tertiary 3 7.7
Living condition
Alone 26 66.7
With family 13 33.3
Disability
Present 19 48.7
Absent 20 51.3
Visit by friends and relatives
Present 15 38.5
Absent 24 61.5
Role in family decision
Present 12 30.8
Absent 27 69.2
Caretaker
Present 16 41
Absent 23 59
Type of home for aged
Government 11 28.2
Private 28 71.8
Comorbidity
Present 37 94.9
Absent 2 5.1
Depression
Mild 24 61.5
Moderate 15 38.5
Anxiety
Normal 21 53.8
Mild 16 41
Moderate 2 5.1
Stress
Normal 31 79.5
Mild 8 20.5
Mental health and QOL were assessed among residents of old age homes using the
Depression, Anxiety and Stress Scale (DASS-21) and the WHOQOL-BREF questionnaire,
respectively. Post-test data were collected at weeks 1, 6, 9 and 12 of exercise.
By considering the confidence interval ((Z) as 95%, effect size (Δ) as 1.5, and standard
deviation (σ) as 3, the minimal sample requirement was 32 depressed patients [32]. The
formula used is given below:
n = (Z1−α/2 + Z1−β)2 σ2/Δ2
In this study, 42 respondents were screened by DASS-21 for depression. Three indi-
viduals dropped out of the study, and exercise was ultimately introduced to 39 elderly
people with depression.
Depression, Anxiety and Stress Scale (DASS-21): Respondents were asked to com-
plete 21 questions on the DASS-21 scale based on their last two weeks’ experience [33].
The respondents who scored marked evidence of depression were recorded for intro-
duced exercises and follow-up. DASS-21 is a reliable screening tool for mental health, es-
pecially for depression among the elderly [34]. It uses a 4-point Likert scale from 0 to 3
based on the severity of depression, anxiety and stress. The cut-off scores are presented in
Table 2 [35]. Cronbach’s alpha of 0.926 for the overall score of DASS-21 showed excellent
reliability for its use as a screening tool in [36].
Table 2. Score criteria for DASS-21.
Depression Anxiety Stress

Normal 0–5 0–4 0–7
Mild 6–7 5–6 8–9
Moderate 8–10 7–8 10–13
Severe 11–14 9–10 14–17
Very Severe 15+ 11+ 18+
WHOQOL-BREF Questionnaire: To assess quality of life, the WHOQOL-BREF ques-

tionnaire was used, and respondents answered questions related to four domains (physi-
cal, psychological, social and environmental) [37]. There were seven questions for the
physical domain, six questions for the psychological domain, three questions for the social
domain and eight questions for the environmental domain. The WHOQOL-BREF ques-
tionnaire exhibited acceptable evidence of internal consistency, showing a Cronbach’s al-
pha coefficient of 0.896 in [38]. Both English and Malay versions of the questionnaire were
used in this study, based on respondent preference. The respondents were categorized
into poor and satisfactory QOL, based on a 60% cut-off point [39,40]. Those with a total
score of less than 60 percent were considered as unsatisfactory QOL, whereas those with
a score of 60 or more were considered as satisfactory QOL.
Exercise Protocol: Strengthening and aerobic exercises were introduced to 39 re-
spondents with mild to moderate depression. The exercise protocol was developed by an
experienced geriatric physiotherapist, and is shown in Table 3. The exercise protocol was
developed based on the earlier literature [41–43]. It was developed for the following rea-
sons: (1) It was easy to administer in any residential and clinical settings without the need
of resistance bands/dead weights, (2) minimal supervision was needed during exercise
training and (3) this exercise can be performed by the elderly people themselves without
supervision once they have mastered. In addition, two researchers from the team were
trained by a geriatric physiotherapist for a period of two weeks to assess the mental health
and implementation of exercise training among study participants. The assessors were
competent in data collection and the implementation of the exercise training.
Table 3. Exercise protocol for elderly respondents.
Exercise Protocol Duration

Warm up
1
min at very low intensity on Borg
scale (7–8 on scale).
Strengthening exercise
Strengthening exercise
Four sets per day, each set consisting of 10
Stepping on a stool (14 inch stool)
repetitions; 1 min rest between each set; 3
in forward and sideways
days per week.
directions.
Aerobic exercise
Basic chair squat.
2 Intensity of exercise: somewhat hard on Borg 12 weeks
Heel raising by holding a stable
scale (13 in scale); 3 days per week.
object.
Progression of exercise
Heel walking.
Strengthening and aerobic exercise will be
Aerobic exercise.
progressed every 2 weeks by varying the
Brisk walking.
intensity of exercise.
Cool down
3
min at very low intensity on Borg
scale (7–8 on scale).
Statistical Analysis: Data obtained from the study were analyzed using SPSS version
23. Descriptive statistics were used to identify the prevalence of DASS among study par-
ticipants. The normality distribution of obtained data was analysed using the Shapiro–
Wilk test. A Wilcoxon signed-rank test was carried out to compare mental health status
and QOL before and after the exercise programme. A p-value < 0.05 was considered a
significant difference.
3. Results
Among the respondents, 62.9% expressed their QOL as unsatisfactory and 30.8% ex-
pressed it as satisfactory (Table 4).
Table 4. Overall quality of life among depressed elderly participants.
QOL Frequency (n = 39) Percent (95% CI)

Unsatisfactory 27 69.2 (57.1, 84.8)
Satisfactory 12 30.8 (15.2, 42.9)
The average QOL score was 62.1 (SD = 11.2) among the elderly respondents in old
age homes, ranging from a minimum of 34.3 to a maximum of 89.3. The physical domain
showed a high score of 94 and a low score of 36, with a mean of 65.2 (SD = 14.1). The
psychological domain showed a high of 82 and a low of 31, with a mean of 58.3 (SD = 11.8).
The score ranged from 0 to 100 for the social domain, showing an average of 53.3 (SD =
24.1). The environmental domain a high score of 94 and a low of 31, with a mean of 71.6
(SD = 13.5). In this study, the environmental domain showed the highest score, and Social
domain showed the lowest score (71.6 vs. 53.3) among all four domains of QOL (Table 5).
Table 5. Frequency distribution of QOL score among different domains.
Environmenta
Physical Psychological Social Overall QOL
l
Mean 65.2 58.3 53.3 71.6 62.1
Median 63.0 56.0 56.0 75.0 61.8
Mode 63.0 56.0 56.0 75.0 59.5
Std. Deviation 14.1 11.8 24.1 13.5 11.2
Minimum 36.0 31.0 0.0 31.0 34.3
Maximum 94.0 82.0 100.0 94.0 89.3
Domain 1—physical health; Domain 2—psychological; Domain 3—social relation-

ships; Domain 4—environmental.
Exercise was introduced to 39 respondents with mild to moderate depression. Scores
related to QOL and mental health were considered non-normal distributions, since the p-
values of the Shapiro–Wilk test were less than 0.05. Skewness z-values were 0.086, −0.230,
−0.147 and −0.871 respectively for the physical, psychological, social, environmental do-
mains of QOL, and were 0.710, 0.467 and 1.323 respectively for depression, anxiety and
stress scores. Kurtosis z-values were −0.518, −0.082, −0.611 and 1.588 for the physical, psy-
chological, social and environmental domains respectively and −0.715, −1.024 and 0.825
respectively for scores related to depression, anxiety and stress Visual inspection of the
normal Q–Q plots showed data which deviated from the reference lines and non-normal
distributions of QOL scores, as well as mental health scores.
The Wilcoxon signed-rank test was performed to test any significant differences in
the scores related to four domains of QOL and mental health before and after the exercises
[44].
The score for Domain 1 (physical) was statistically improved after exercise (Mdn =
58), as compared to the score before exercise (Mdn = 56) in 36 out of 39 respondents: T =
678.5, Z = −4.937, p = 0.000. For Domain 2 (psychological), the score after exercise (Mdn =
60) was statistically higher than the score before exercise (Mdn = 54) in 31 out of 39 re-
spondents, showing T = 547, Z = −4.764, p = 0.000. Similarly, for Domain 3 (social), 32 out
of 39 depressed elderly people had a higher post-exercise (Mdn = 65) score than pre-exer-
cise score (Mdn = 56); T = 581, Z = −4.360, p = 0.000. Regarding Domain 4 (environmental),
a higher post-exercise score (Mdn = 74) was noticed among 27 respondents, compared to
the pre-exercise score (Mdn = 69); T = 425.5, Z = −4.505, p = 0.000.
Out of 39 respondents, 36 showed a lower depression score (Mdn = 4) after exercise,
as compared to the score before exercise (Mdn = 6). The Wilcoxon signed-rank test indi-
cated that this difference was statistically significant (T = 666, Z = −5.372, p = 0.000). For the
scores related to anxiety, 29 out of 39 were lower after exercise (Mdn = 2) compared to
before exercise (Mdn = 3), and the difference was statistically significant (T = 480, Z =
−4.632, p = 0.000). Similar findings were noted for stress: 31 out of 39 respondents indicated
a statistically lower score (Mdn = 3) after exercise, compared to the score before exercise
(Mdn = 4; T = 546, Z = −4.799, p = 0.000).
Based on these results, exercise can be considered an effective tool to improve QOL
and mental wellbeing in the current study.
4. Discussion
The sociodemographic background of the depressed respondents in the current
study indicated that the majority were women; without family support; were unmarried,
single, divorced, or widowed; lived alone; did not receive visits from families and friends;
had attained a primary education; and had comorbidities. A previous study reported that
the risk of developing depression was 80% higher in individuals who lived alone, com-
pared to those who lived with families or friends. Loneliness could increase the produc-
tion of cortisol, which is also known as the stress hormone, and depression is associated
with long-term loneliness and loss of social support. A study done by Kemal, 2012, indi-
cated that poor education was a common risk factor for depression, especially in females
[45,46]. Kang et al., 2015, and Nguyen et al., 2021, reported that a high risk of depression
and anxiety was noticed in patients with underlying health conditions [47,48]. However,
severe and very severe cases were not detected in our homes, as most residents already
received regular treatment from doctors. The majority of nursing homes in the current
study were run by private companies or individuals, and they offered medical and nurs-
ing care as well as recreational activities based on payment. Medical care can be provided
by the respondents’ GPs or a doctor from the nearest health centre, so that they can receive
early treatment [49].
Life satisfaction has been positively related to socioeconomic status, adequacy of in-
come, perceived health status, engagement in activities and social interaction [50–53]. The
majority of respondents in the current study could not fulfil all these requirements, and
this might have contributed to unsatisfactory quality of life. Compared to the studies done
in Sabah and Sarawak, the average QOL score was lower in the current study. Elderly
people in Sarawak were satisfied with their QOL, showing an average score of 90.17,
whereas elderly people residing in rural areas of Sabah showed an average score of 65.2
[54,55]. The mean QOL score in the current study was 62.1, with the Environmental do-
main the highest and social domain the lowest among all four QOL domains. The higher
QOL score in the other studies was probably due to time differences in study duration
and the fact that findings were based on older people in the general population. The Sabah
and Sarawak studies were carried out in 2015 and 2019, when COVID-19 was either non-
existent or not very prominent in Malaysia. Shrestha et al., 2018, reported that elderly
people living with their families had better QOL than those who lived in care homes, es-
pecially because of low scores in the social domain [56]. The lowest score was in the social
domain in our study, as many elderly people faced social isolation during the Movement
Control Order (MCO) during the COVID-19 pandemic [57]. Our respondents were satis-
fied with their living conditions, showing higher scores in the Environmental domain. The
greener and pollution-free environment in Kedah State might contribute to the favorable
environmental conditions, as compared to urban areas. A similar finding was reported by
a study done in rural populations [54].
All four domains of QOL were significantly improved after 12 weeks of aerobic and
strengthening exercises in this study. Findings from this study supported findings from
another study carried out in Brazil, in which people who engaged in exercise regularly for
16 weeks had higher QOL scores than a control group with sedentary lifestyles [58]. Ac-
tive older people had greater self-efficacy, which was associated with better physical and
mental health. In turn, they became more satisfied with life [59]. Regular exercise can im-
prove outcomes beyond physical health. Greater social interaction and enjoyment in the
performance of activities can enhance the quality of life [60]. Atad and Caspi, 2020, found
that older adults who engaged in a minimum of 2.5 h exercise per week could achieve
better physical health, and a higher level of physical activity was associated with increased
quality of life [61,62].
Yao et al., 2021, suggested that low-frequency, long-term regular exercise was effec-
tive for those aged 60 year or older, in improving mental health [63]. Light physical activ-
ity such as walking, aerobic exercise, strength exercises and gardening was advised dur-
ing the COVID-19 pandemic to reduce depressive symptoms among the elderly, by Cal-
low et al., 2020 [64]. Regular exercise was found to protect against depression and to im-
prove sleep quality among older people [65]. Exercise could reduce stress hormone levels
as well as muscle tension, and could produce an anti-anxiety effect; anxiety scores were
reduced after 12 weeks of the exercise programme, based on a meta-analysis. However,
the score difference before and after exercise was greater in their findings (38.7 ± 5.6 and
33.7 ± 3.4) than in the current study (4.6 ± 2.9 and 2.8 ± 1.8) [66]. The nature of the homes,
the age and sex of the residents, the availability of support, including caregivers, and the
type and duration of the exercise programme may contribute to the differing results be-
tween the current and previous studies. Andréa et al., 2010, stated that stress coping ca-
pacity and daily activities were improved after exposure to aerobic, resistance, breathing
and stretching exercises [67]. Scores related to depression, anxiety and stress were signif-
icantly reduced after a 12 week exercise programme in the current study.
5. Conclusions
The findings indicate that performing aerobic and strengthening exercises for a min-
imum of 12 weeks may help to improve mental health among the elderly, and may also
improve the quality of life for those residing in old age homes. A regular exercise pro-
gramme should be considered an essential component of healthy ageing, not only for
those with depression, but also for every elderly person. A balanced diet, encouragement
and attention should be provided for the elderly, along with exercise, for better outcomes.
A similar study using a randomized controlled trial should be done in order to assess the
effectiveness of the aerobic and strengthening exercises among the elderly living in care
homes or living with their families, irrespective of mental health status.
6. Limitations of the Study

The lack of a control group presents a threat to research validity. However, a separate
control group was not included in this research, as the study was conducted in an institu-
tionalized setting; the elderly people were able to share their exercise protocol (social in-
teraction) and start to introduce the exercise themselves, without our knowledge. Further-
more, a control group was not included in order to obtain an adequate sample size in the
experimental group. It was difficult in practice to assemble a suitable control group, as
many homes did not allow visitors during the COVID-19 pandemic. A future study will
be conducted to explore the effect of exercise upon mental health and QOL among de-
pressed elderly people, including a control group to support our conclusion.
Author Contributions: Conceptualization, T.M.M. and T.J.; methodology, T.M.M. and J.M.; soft-
ware, W.M.O.; validation, T.M.M., J.M. and T.J.; formal analysis, W.M.O.; investigation, T.M.M. and
S.R.L.R.N.; resources, T.M.M.; data curation, W.M.O.; writing—T.M.M.; writing—review and edit-
ing, T.J. and J.M.; visualization, H.P.P.; supervision, J.M.; project administration, T.M.M. and
S.R.L.R.N.; funding acquisition, T.M.M. All authors have read and agreed to the published version
of the manuscript.
Funding: This research was funded by the Malaysian Ministry of Education under the Fundamental
Research Grant Scheme (FRGS/1/2020/SKK04/AIMST/02/1).
Institutional Review Board Statement: The study was conducted in accordance with the Declara-
tion of Helsinki, and approved by the Institutional Review Board (AUHEC) of AIMST University
(Reference number: AUHEC/FOM/2020/03 and date of approval: 11 December 2020).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. Written informed consent to publish this paper was obtained from the respondents.
Data Availability Statement: Not applicable.
Acknowledgments: We are grateful to the Malaysian Ministry of Education for financing this work
under the Fundamental Research Grant Scheme (FRGS/1/2020/SKK04/AIMST/02/1).We would like
to thank all respondents for taking part in this study.
Conflicts of Interest: The authors declare no conflicts of interest. The funders had no role in the
design of the study; in the collection, analysis, or interpretation of data; in the writing of the manu-
script; or in the decision to publish the results.
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63. Yao, L.; Fang, H.; Leng, W.; Li, J.; Chang, J. Effect of Aerobic Exercise on Mental Health in Older Adults: A Meta-Analysis of
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6 The effect of Aerobic and Strengthening
exercises on QOL of depressed elderly
6.1 Introduction
Coronavirus disease 2019 (COVID-19) affected millions of people

worldwide and it was officially declared as pandemic by the World Health
Organization on 11th March 2020 (Yuki et al., 2020)(The World Health
Organization Officially Declared Coronavirus a Pandemic, n.d.).The first case
of COVID-19 was detected in Malaysia on the 25th January 2020 and the
government implemented the Movement Control Order (MCO) from 18th of
March 2020 till 31st December 2021 in order to reduce disease
transmission(COVID-19 Response: FAQs (MCO 2021): Rahmat Lim &
Partners, n.d.).
During MCO period, movement of people were restricted, and it caused

strong impact on the economy, sports, and tourism. The COVID-19 infection
spread rapidly and people with underlying comorbidities and the elderly were
affected most(Elengoe, 2020; C. Huang et al., 2020; Wang et al., 2020).Fear
and worry related to COVID-19 and social isolation because of nationwide
lockdown caused negative emotions among people(Bäuerle et al., 2020;
Musche et al., 2020; Tsamakis et al., 2020).Different countries adopted
quarantine successfully to contain the rapid spread of the coronavirus.
Separation from family or friends, disturbance in sleeping and eating,
worsening chronic conditions, increase alcohol consumption and substance
use, worry and stress over the corona virus and fear of uncertainty were
associated with poor mental health and well-being for patients as well as
general populations(Al Dhaheri et al., 2021; Young et al., 2021). Physical
health, psychological state, personal beliefs, social relationship, and
relationship with the environment were important determinants for QOL
(WHOQOL : Measuring Quality of Life, n.d.).Changes in the lifestyle, getting
inadequate physical activity, consuming insufficient fruits and vegetables,
wearing face mask, delay in obtaining medical care and social isolation
caused huge effect on QOL for older adult during the pandemic(Duan et al.,
2021). Many elderly people were not able to access adequate food due to
functional limitations, transportation issues, fear of COVID-19 exposure and
poor knowledge related to technology (Gruneir et al., 2011).Elderly in nursing
homes and aged care homes had higher risk of COVID-19 infection as these
52
homes acted as an incubator of infection(Chee, 2020). Moreover, many
homes faced with financial difficulties during the pandemic, causing increased
burden to the aged care(Abu et al., 2021; RM25 Million Set aside for
Vulnerable Groups, n.d.; Shah et al., 2020).
Physical activity is important to maintain the fitness and exercise plays

the essential role in promoting a health-related quality of life for elderly.
Exercise improved emotional functioning and mental well-being(5 Ways
Exercise Improves Your Quality of Life - Harvard Health, n.d.). Those who
engaged in exercises showed better QOL than those who did not
engage(Ana-Maria, 2015; Oh et al., 2017a) . A study conducted in Korea
reported that those who performed resistance, flexibility and walking exercises
showed better QOL scores than non-exercisers and it was noticed that older
people preferred to engage in walking exercise, followed by flexibility and
resistance exercises(Oh et al., 2017b). Another study in Romania found that
participants who engaged in aerobic exercises showed positive effect in both
physical and mental health such as losing weight, better opinion of
themselves, sleep quality improvement and more confidence(Ana-Maria,
2015).
Aerobic exercise and strength exercise were recommended for older

people to reduce the risk of fall according to WHO (Langhammer et al., 2018).
However, older adults with comorbid diseases considered themselves as
being handicapped and they became physically inactive and more dependent
on the caregivers during COVID-19 pandemic(Brooke & Jackson, 2020).
Based on the data from the previous studies, quality of life of elderly in old
age homes was significantly poorer than elderly living with family. A study
done in Indonesia reported that elderly living in community showed higher
QOL scores than those stayed in nursing homes, showing significant
differences in mobility and daily activities(Masyarakat et al., 2020). Fiorelli De
Almeida et al. reported that QOL of elderly who attended Day Centre showed
better QOL score than those who residing in nursing homes(Fiorelli De
Almeida et al., n.d.).Many older adults felt left alone and they were not
satisfied with the life in old age homes (Thresa & S., 2020b). The
psychological impact of COVID-19 was reported significantly high in the
respondents with depression and anxiety (Joo et al., 2021b). Comprehensive
care which includes lifestyle modifications by engaging regular exercise
should be considered for elderly with mental health problems especially
during pandemic. The third objective of the current study was to find out
whether exercise can improve mental wellbeing and QOL among depressed
53
elderly. By developing exercise which was easy to administer in residential
setting may help to improve wellbeing of elderly residents in old age homes.
Mental health related information in this study may improve public awareness
towards emotional needs of elderly people who are either from the
underprivileged category or being unfortunate enough to be living apart their
families.
6.2. Materials and Methods
6.2.1 Study design and study duration: This research used a single group
pre-test and post-test design, and respondents were recruited by convenience
sampling from one government home and nine private homes of northern
region of Malaysia. The data were conducted from December 2020 till
December 2021 when Malaysian Government applied Movement Control
Disorder.
6.2.2. Participants selection: Older adults above the age of 60 years

residing in old age homes of northern Malaysia from Penang and Kedah State
were selected as participants in this study. Out of 178 elderly,39 respondents
with depression underwent exercise. Those who were younger than 60, ill or
mentally unstable and terminally ill respondents were excluded from the
current study. Participants were screened by psychiatrist, and they were
included in the study after getting green signal to participate in the study. By
considering the confidence interval (z) as 95%, effect size ( ) as 1.5 and
standard deviation(σ) as 3, the minimal sample requirement was 32
depressed patients (Edimansyah et al., 2008).. The formula used was given
below:
In this study, 42 respondents were screened by DASS-21 as depression. The

dropout of study was 3 and the exercise was introduced to 39 elderly with
depression.6.2.3. Mental Health and QOL Assessment and exercise
protocol: Mental health and QOL were assessed among depressed elderly
from old folk homes by using Depression, Anxiety and Stress Scale (DASS-
21) and WHOQOL-BREF questionnaire. Post test data was collected at 1, 6,
9 and 12 weeks of exercise.
54
6.2.3.1. Mental health assessment: The details of DASS-21 scale was
mentioned in Chapter 5.
6.2.3.2. WHOQOL-BREF questionnaire: To assess the quality of life,

WHOQOL-BREF questionnaire was used, and respondents needed to answer
questions related to four domains (Physical, Psychological, Social and
Environment) (WHOQOL-HIV Bref, n.d.).There were seven questions for
Physical domain, six questions for Psychological domain, three questions for
Social domain and eight questions for Environmental domain. WHOQOL-
BREF questionnaire had acceptable evidence of internal consistency by
showing Cronbach‘s alpha coefficient of 0.896(Ilić et al., 2019). Both English
and Malay version of the questionnaire were used in this study based on the
respondent‘s convenience.
Quality of life among the respondents was assessed by WHOQOL-

BREF questionnaires. The respondents were categorized into poor and
satisfactory QOL based on 60% cut-0ff point (Monteiro Silva et al., n.d.; P. A.
B. Silva et al., 2014). Those with less than 60 percent of total score were
considered as unsatisfactory QOL whereas those with score 60 or more were
considered as satisfactory QOL.
6.2.3.3. Exercise Protocol: Strengthening and aerobic exercises were

introduced to 39 respondents with mild to moderate degree of depression.
Two researchers from the team were trained by geriatric physiotherapist for a
period of two weeks to assess the mental health and implementation of
exercise training among study participants. The assessors were competent in
data collection and implementing the exercise training. Exercise protocol was
as mentioned in Chapter 5.
6.2.4. Flow chart of the study: The study flow chart was explained in the
figure 6.1.
6.3. Results
6.3.1. Characteristics of the depressed elderly: The socio-demographic

information obtained from 39 inmates were shown in Table 6.1. The
respondents were majority females (53.8%), unmarried and
single/divorce/widow(61.8%), with primary education (30.8%), stayed alone
(66.7%), without disability (51.3%),could not receive visits by friends or
relatives (61.5%), not having role in family decision (69.2%),without caretaker
55
(59%) ,from private home (71%) and those with comorbidity (94.9%).The age
of the respondents ranged between 60 to 90 years where the mean age was
70.5 years ±8.3) whereas BMI ranged between 16 to 28, showing an average
BMI as 22.9 ±3.1).
6.3.2. Quality of life and mental health among depressed elderly: Among
the respondents,62.9% expressed their QOL as unsatisfactory and 30.8%
expressed as satisfactory (Table 6.2).
6.3.2. QOL score among different domains : The average QOL score was
62.1(SD=11.2) among the elderly respondents at old age home, ranged in
between minimum 34.3 and maximum 89.3.Physical domain had a high score
of 94 and a low score of 36, with a mean of 65.2(SD=14.1).Psychological
domain had a high of 82 and a low of 31 with a mean of 58.3(SD=11.8).The
score ranged from 0 to 100 for social relationships, showing an average of
53.3(SD=24.1).Environmental domain had a high score of 94 and a low of 31,
with a mean of 71.6(SD=13.5). In this study, the environmental domain
showed the highest score, and the social domain showed the lowest score
(71.6 vs 53.3) among all four domains of QOL (Table 6.3.).
6.4. Discussion
The sociodemographic background of the depressed respondents in

the current study indicated that majority were women, without family support ,
were unmarried, single, divorced or widowed, lived alone, did not receive
visits from families and friends, had attained primary education, and had
comorbidities. A previous study reported that the risk of developing
depression was 80% higher in individuals who lived alone as compared to
those who lived with families or friends. Loneliness could increase the
production of cortisol which was also known as the stress hormone and
depression was associated with long term loneliness and loss of social
support. A study done by Kemal A, 2012 indicated that poor education was a
common risk factor for depression especially in females(Alone at Home:
Depression Is More Common in People Who Live Alone, n.d.; Mushtaq et al.,
2014). Kang et al., 2015 and Nguyen et al., 2021 reported that high risk of
depression and anxiety was noticed in patients with underlying health
conditions(Kang et al., 2015; Nguyen et al., 2021).However, severe and very
severe cases were not detected in our homes as most of them already
received regular treatment from the doctors. Majority of nursing homes in the
current study were run by private and they offered medical and nursing care,
56
recreational activities based on the payment. Medical care can be provided by
respondent‘s family doctor or doctor from nearest health centre so that they
can receive early treatment (Lecadia Primacare Center - Nursing Home Kuala
Lumpur (KL), Malaysia, n.d.).
Life satisfaction has been positively related to socioeconomic status,

adequacy of income, perceived health status, engagement in activities and
social interaction(Cutler, 1979; Dickie et al., 1979; Dumitrache et al., 2016;
Vaillant et al., 2006). The majority of respondents in the current study could
not follow all the requirements which might be contributing for unsatisfied
quality of life. As compared to the studies done in Sabah and Sarawak, the
average QOL score was lower in the current study. Elderly people in Sarawak
satisfied their QOL showing an average score of 90.17 whereas elderly
people residing in rural areas of Sabah showed an average score of
65.2(Cosmas & Aren, 2020; Shi Yin et al., 2017). The mean QOL score in the
current study was 62.1 whereby environmental domain was the highest and
the social domain was the lowest among all four domains of QOL. The higher
QOL score in the other studies was probably due to time differences of study
duration and findings were based on the older people in general population.
Both Sabah and Sarawak studies were done in 2015 and 2019 when COVID-
19 was not much affected in Malaysia. Shrestha et al., 2018 reported that
elderly living with their families had better QOL as compared to those who
stayed in the old folk homes especially because of low score in social domain
(Shrestha et al., 2019). The lowest score of social domain was noticed in our
study, as many elderly faced social isolation during movement control
disorder (MCO) during COVID pandemic(Joo et al., 2021a; UM Study: 47% Of
Older Malaysians More Depressed During Pandemic - CodeBlue, n.d.) .Our
respondents satisfied with their living condition by showing higher score of
environmental domain. The greener and pollution free environment in Kedah
State might contribute to the better environmental conditions as compared to
urban area. Similar finding was reported by a study done in rural
populations(Shi Yin et al., 2017).
All four domains of QOL were significantly improved after 12 weeks of

aerobic and strengthening exercises in this study. Findings from this study
supported findings from another study that had been done in Brazil in which
better score in QOL was obtained by the people who engaged exercise
regularly for 16 weeks as compared to control group of sedentary lifestyles
(Soares Pernambuco et al., 2012). Active older people had greater self-
efficacy, which was associated with better physical and mental health. In turn,
57
they became more satisfied with life (McAuley et al., 2006).By doing regular
exercise, outcome achieved can be more than physical health. More social
interaction and enjoyment in the performance activities can enhance the
quality of life (Rejeski & Mihalko, 2001). Atad and Caspi, 2020 found that
older adults who engaged in exercise minimum 2.5 hours per week could
achieve better physical health and higher level of physical activity was
associated with increased quality of life (Atad & Caspi, 2020; Puciato et al.,
2017).
Yao et al., 2021 suggested that low-frequency, long term regular

exercise was effective for 60 years or older to improve mental health (L. Yao
et al., 2021). Light physical activity like walking, aerobic exercise, strength
exercise, gardening was advised during COVID-19 pandemic to reduce
depressive symptoms among elderly by Callow et al., 2020 (Callow et al.,
2020). Regular exercise was found protecting against depression and
improved sleep quality among older people (Kadariya et al., 2019). Exercise
could reduce stress hormone and muscle tension and gave anti-anxiety effect
and anxiety score was reduced after 12 weeks of exercise programme based
on the meta-analysis. However, score difference before and after exercise
was bigger in their findings (38.7 ± 5.6 and 33.7 ± 3.4) as compared to current
study (4.6 ± 2.9 and 2.8 ±1.8)(Kazeminia et al., 2020b). The nature of homes,
age and sex of the residents, available of support, including care givers, the
type and duration of exercise programme may contribute to the differing
results between the current and previous studies. Andréa et al., 2010 stated
that stress coping capacity and daily activities were improved after exposure
to aerobic, resistance, breathing and stretching exercises(Andréa et al.,
2010).Scores related to depression, anxiety and stress were significantly
reduced after 12 weeks of exercise programme in the current study.
58
Figure 6.1: Study flow chart
59
Table 6.1: Background characteristics of the depressed elderly
S. No Variables Frequency Percent
1 Gender
Females 21 53.8
Males 18 46.2
2 Race
Malay 7 17.9
Indian 9 23.1
Chinese 23 59.0
3 Marital status
Unmarried 14 35.9
Married 11 28.2
Single/Divorce/Widow 14 35.9
4 Education
Primary 12 30.8
Secondary 9 23.1
Tertiary 3 7.7
5 Living condition
Alone 26 66.7
With family 13 33.3
6 Income
Less than or equal RM 600 19 48.7
More than RM 600 20 51.3
7 Disability
Present 19 48.7
Absent 20 51.3
8 Visit by friends & relatives
15
Present 38.5
24
Absent 61.5
Present 12 30.8
Absent 27 69.2
10 Caretaker
Present 16 41
Absent 23 59
60
11 Type of home for aged
Government 11 28.2
Private 28 71.8
12 Comorbidity
37 94.9
Present
2 5.1
Absent
13 Depression
Mild 24 61.5
Moderate 15 38.5
14 Anxiety
Normal 21 53.8
Mild 16 41
Moderate 2 5.1
15 Stress
Normal 31 79.5
Mild 8 20.5
N=39
Those with mild to moderate depression were 61.5% and 38.5%, mild to
moderate anxiety were 41%,5.1% whereas respondents with mild stress were
20.5%.
61
Table 6.2: QOL of the depressed respondents
S. No QOL Frequency Percent (95% CI)
1 Unsatisfactory 27 69.2((57.1,84.8)
2 Satisfactory 12 30.8(15.2,42.9)
N=39
62
Table 6.3. Frequency distribution of QOL score among different domains
Physical Psychological Social Environment Overall
Health relationship QOL
Mean 65.2 58.3 53.3 71.6 62.1
Median 63.0 56.0 56.0 75.0 61.8
Mode 63.0 56.0 56.0 75.0 59.5
Std.
14.1 11.8 24.1 13.5 11.2
Deviation
Minimum 36.0 31.0 0.0 31.0 34.3
Maximum 94.0 82.0 100.0 94.0 89.3
N=39
63
Table 6.4: Comparison of scores related to QOL domains among respondents
with depression before and after exercise intervention
N Mean Rank Sum of Media Z p-value

Ranks n
(Mdn)
a
Posttest_Domain1 - Negative 1 24.50 24.50 58 -4.937 0.000*
Pretest_Domain1 Ranks
b
Positive 36 18.85 678.50 56
Ranks
c
Ties 2
Total 39
d
e
Positive 31 17.65 547.00 60
Ranks
f
Ties 6
Total 39
g
h
Positive 32 18.16 581.00 65
Ranks
i
Ties 4
Total 39
j
k
Positive 27 15.76 425.50 74
Ranks
l
Ties 10
Total 39
N=39
a. Posttest_Domain1 < Pretest_Domain1
b. Posttest_Domain1 > Pretest_Domain1
c. Posttest_Domain1 = Pretest_Domain1
d. Posttest_Domain2 < Pretest_Domain2
e. Posttest_Domain2 > Pretest_Domain2
f. Posttest_Domain2 = Pretest_Domain2
g. Posttest_Domain3 < Pretest_Domain3
h. Posttest_Domain3 > Pretest_Domain3
i. Posttest_Domain3 = Pretest_Domain3
j. Posttest_Domain4 < Pretest_Domain4
k. Posttest_Domain4 > Pretest_Domain4
l. Posttest_Domain4 = Pretest_Domain4
64
Table 6.5: Score differences of Depression, Anxiety and Stress before and
after exercises
N Mean Sum of Media Z p-
Rank Ranks n value
(Mdn)
a
Posttest_ Negative 36 18.50 666.00 6 -5.372 0.000
Depression - Ranks *
b
Pretest_ Positive 0 .00 .00 4
Depression Ranks
Ties 3c
Total 39
Posttest_ Negative 29d 16.55 480.00 3 -4.632 0.000
Anxiety - Ranks *
e
Pretest_ Positive 2 8.00 16.00 2
Anxiety Ranks
Ties 8f
Total 39
Posttest_ Negative 31g 17.61 546.00 4 -4.799 0.000
Stress - Ranks *
h
Pretest_ Positive 2 7.50 15.00 3
Stress Ranks
Ties 6i
Total 39
N=39
a. Posttest_Depression < Pretest_Depression
b. Posttest_Depression > Pretest_Depression
c. Posttest_Depression = Pretest_Depression
d. Posttest_Anxiety < Pretest_Anxiety
e. Posttest_Anxiety > Pretest_Anxiety
f. Posttest_Anxiety = Pretest_Anxiety
g. Posttest_Stress < Pretest_Stress
h. Posttest_Stress > Pretest_Stress
i. Posttest_Stress = Pretest_Stress
65
7. Summary and conclusions
7.1. Chapter 1 explains about the introduction to the aging population

worldwide and Malaysia, the concept of Quality of Life (QOL) and the role of
elderly in society and the need of the study. Aging population in many
countries would have 30% of total population and the population aged
60years and more will double by 2050 according to WHO. In many Asian
countries, minimum retirement age was 60. Higher risk of getting diseases,
disability, dementia, and advanced aging prior to death were challenging
problems along with increase in life expectancy. All these problems were
affecting not only quality of life of elderly but also affecting social and
economic systems.
In Malaysia, old age is defined as those who are 60 years old and
above. In next years, Malaysia may be transformed into ―aged nation‖. The
number of old age homes all over Malaysia were increasing and more
demands were noticed in urban areas. The special needs and challenges for
the aging population are nowadays prioritized by the Malaysia government.
A more holistic understanding of human nature and subjective states

should be considered for QOL in the medical sciences. One of the best-known
assessment tools for QOL was WHOQOL-BREF questionnaire which was
developed based on multidimensional concept. Both English and Malay
versions of WHOQOL-BREF were used in this study to assess the quality of
life among elderly.
Providing better care for the elderly has become public health
challenges especially for those who stayed in institutionalised dwellings.
There is limited scientific evidence reporting the experiences of elderly to date
and QOL of elderly residing in old age home was not explored enough in
Malaysia. Outcomes from this study can increase the public awareness of
depression and QOL and finings can highlight the importance of exercise
among the older adults residing at old age homes.
7.2. Chapter 2 explains the aim and objectives of the current study.
The aim of the present study was to determine the effect of exercise on
quality of life (QOL) of depressed elderly residing at old age homes of
Malaysia. The objectives were 1) to identify the quality of life (QOL) and
associated sociodemographic determinants among respondents.2) to explore
66
the effect of exercise on mental health of the respondents.3) to find out the
effect of Aerobic and Strengthening exercises on quality of life (QOL) of
depressed elderly. The study was conducted in accordance with the standard
of deceleration of Helsinki and AIMST university human and animal ethics
committee (Ref: AUHEC/FOM/2020/03).
7.3. Chapter 3 narrates with a detailed literature survey related to QOL

in elderly, the need of old age home and elderly care in Malaysia, people
residing in old age homes, depression in elderly and their QOL, economic and
psychosocial impact of COVID-19 Pandemic, mental well-being of elderly
during COVID-19 pandemic, benefits of exercise in mental health, importance
of exercise in elderly.
7.4. Chapter 4 explains the QOL among elderly in old age homes and
associated sociodemographic determinants. The present study found that
only 41% of the respondents had satisfactory QOL in old age homes of
northern Malaysia. Most of the respondents were satisfied with institutional life
as the environmental domain was identified as the most satisfactory domain.
Emotional challenges among elderly gave social domain as the weakest
result. Gender and role in family decision making were identified as common
determinants for QOL among elderly.
7.5. Chapter 5 reveals the effect of exercise on mental health of the

respondents. Depression, Anxiety and Stress Scale (DASS-21) was used to
assess the mental health among the inmates which consisted of 21 questions.
The lower extremities functions were assessed by The Short Physical
Performance Battery (SPPB).
Findings indicated that 27(15.2%) respondents had mild depression

and 15(8.4%) had moderate depression. In addition, 31(17.4%) had mild
anxiety and 2(1.1%) had moderate anxiety. Moreover, 14(7.9%) respondents
had mild stress. The exercise was introduced to the respondents with mild to
moderate depression at week 1,6,9 and 12. Highest score of SPBB was
noticeable at week 12 of exercise intervention compared to week 1,3 and 6
and significant improvement of physical performance was noticed among the
respondents (p=0.000).
This study found that severity of depression, anxiety, and stress was
significantly reduced after 12 weeks of strengthening and aerobic exercises.
Regular review of the elderly home facilities and exercise activities will help to
67
support healthy aging and active lifestyle among Malaysian elderly residing in
old age homes.
7.6. Chapter 6 stated the effect of Aerobic and Strengthening exercises

on QOL of depressed elderly. Among 39 depressed respondents,62.9%
expressed their QOL as unsatisfactory and 30.8% expressed as satisfactory.
Those with mild to moderate depression were 61.5% and 38.5%, mild to
moderate anxiety were 41%,5.1% whereas respondents with mild stress were
20.5%. After engaging 12 weeks of Aerobic and Strengthening exercises,
score for physical domain increased from 56 to 58, psychological domain from
54 to 60, social domain from 56 to 65 and environmental domain from 69 to
74. Moreover, significant reduction in depression score from 6 to 4, anxiety
score from 3 to 2 and stress score from 4 to 3. The results showed that
exercise can be considered as an effective tool to improve QOL and mental
well-being in the current study.
A regular exercise program should be considered as an essential

component for healthy ageing not only for those with depression but also for
every elderly person. A balanced diet, encouragement and attention should
be provided for the elderly, along with exercise for better outcomes. A similar
study using a randomized controlled trial should be done to assess the
effectiveness of the aerobic and strengthening exercises among the elders
living in care homes or living with their families irrespective of mental health
status. Limitations of the study
The lack of a control group represents a threat to research validity.

However, a separate control group was not included in this research, as a
study was conducted in an institutionalized setting; the elderly people were
able to share their exercise protocol (social interaction) and start to introduce
the exercise themselves, without our knowledge. Furthermore, a control
group was not included in order to obtain an adequate sample size in the
experimental group. It was difficult in practice to assemble a suitable control
group, as many homes did not allow visitors during the COVID-19 pandemic.
A future study will be conducted to explore the effect of exercise among
mental health and QOL among depressed elderly people, including a control
group to support our Conclusion
68
Recommendations
 Regular mental health screening for elderly should be provided in old
age homes to detect the early signs of depression and get help from
doctors.
 Elderly friendly environments like proper lighting, a ramp for
wheelchairs, a raised toilet, handrails and grab bars at the toilet, non-
skid strips in the shower should be strengthened.
 It is important to encourage seniors to incorporate manageable levels
of physical activity into their daily lives.
 Activities such as playing musical instruments, learning a language,
knitting should be encouraged for older adults with limited mobilities to
keep their mind active.
 Older people should be stay connected with their community by
encouraging them to attend religious functions, arranging family and
friends to visit or by getting them involved in their hobbies.
 Local charities or religious organizations can develop projects that
older adults can contribute to. Allowing them to participate in charitable
works will make them feel a sense of purpose and accomplishment.
 Elderly caregiver support groups should be available more to offer
emotional support and advice.
 Family and community values to nurture a caring society should be
strengthened.
 Government should develop mobile nursing care and mobile home
rehabilitation which enable seniors to receive care in the comfort of
their homes.
 More day care centres should be opened where children can send their
elderly parents before going to work and pick them up after work so
that elderly person can interact with others.
 Government should equally pay attention to the long-term care for the
aged as well as curative care.
Necessary to enhance a holistic policy that is geared towards caring for an
ageing society to ensure the well-being of the community.
69

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The effect of exercise on depression and quality of life

among the institutionalised elderly

For the award of degree of

Dr. Theingi Maung Maung

Under the Guidance of

DEPARTMENT OF RESEARCH AND DEVELOPMENT

I declare that the thesis entitled “The effect of exercise on depression

degree of Doctor of Philosophy is the record of work carried out by me under

any degree, diploma or associateship in Saveetha Institute of Medical and

Technical Sciences or any other University or similar Institutions of Higher

Signature of the Candidate

We certify that the thesis entitled “The effect of exercise on depression

of Doctor of Philosophy by Dr.Theingi Maung Maung is the record of research

associateship in Saveetha Institute of Medical and Technical Sciences or any

other University or other similar Institutions of Higher learning.

Dr. J. Madhanagopal, Dr. Timsi Jain,

I would like to express my sincere and genuine, eternal gratitude to my

I would like to express my gratitude to my co-guide Dr. Madhanagopal,

I would like to thank Dr. R. Vijayaraghavan, former Director, and

I also provide a genuine thanks to Dr. R Archana, Professor,

I would like to thank Ministry of Higher Education, Malaysia for

I would like to express my special appreciation to AIMST university,

I am extremely grateful to my colleagues Dr.Sherly, Dr.Harini,

Dr.Theingi Maung Maung

S. No Title Page No.

S. No Title Page No.

ADL Activities of Daily Living

An abbreviated generic Quality of Life Scale developed

S. No Title Page No.

1.1. Ageing population worldwide

Aging can be defined as the time-related deterioration of the

Age 65 was chosen as age of retirement in economically advanced

1.2. Ageing population in Malaysia

To meet the needs of elderly, types of senior care were differed in

1.3. The concept of Quality of life (QOL)

Quality of Life is an individual‘s perception of their position in life in the

Increased in the number of older people was associated with increased

Older people had contributed to the workplace, local community and

1.5. The need of the study

Useful in-sights should be provided to the government, private sectors

Malaysia government is developing programs that are focusing on the

2.1. Aim of the study

The present study aimed to determine the effect of exercise on quality

2.2. Objectives of the study

1. To identify the quality of life (QOL) and associated sociodemographic

2. To explore the prevalence of depression and the effect of exercise on

3. To find out the effect of Aerobic and Strengthening exercises on quality

Research Hypothesis: Exercise may be effective in improving

Null Hypothesis: Exercise may not be effective in improving depression

2.4. Ethical Consideration

Informed consent was distributed and explained in detail to the

3.1. Quality of Life in elderly

It is important to maintain active ageing to enhance quality of life. This

Traditional health indicators like morbidity and mortality are no longer

Therefore, World Health Organization‘s initiative to develop a quality-

Nuclear families became more common than joint families in current

In 2020, Malaysia reported only 39 geriatricians in both private and

3.3. People residing in old age homes

However, there were some drawbacks to nursing homes. Many homes

3.4. Depression in elderly and their Quality of Life

In Malaysia, overall prevalence of cognitive impairment among elderly

According to a review article based on 953 studies revealed that

3.5. Economic and Pscychosocial impact of COVID-19 Pandemic

The COVID-19 outbreak was first identified in Wuhan, China, in