Correlation between Physical Activity and Depression in Community-Dwelling Older Adult Palestinians

As individuals age, they are more likely to confront multiple health conditions simultaneously [1], and among older adults, the susceptibility to mental disorders and other ailments such as diabetes, sensory impairment, and age-related decline is heightened [2]. Engaging in physical activity (PA) has been shown to significantly contribute to the overall physical and mental well-being of older adults. Physically active older adults experience a reduced risk of limitations in daily activities, cognitive decline, and depression [3‒5]. Furthermore, PA plays a critical role in the primary prevention of various chronic diseases, including diabetes, osteoporosis, rheumatoid arthritis, anxiety, and depression [3, 4, 6]. Specifically, regular moderate-intensity PA can effectively prevent a decline in health-related quality of life (HRQoL) [7].

To promote health, the World Health Organization (WHO) recommends that older adults engage in at least 150 min of moderate-intensity aerobic exercise per week [8]. However, despite the well-established benefits of PA, the majority of older people fail to meet the recommended levels of PA. Popular and feasible approaches to be physically active include moderate-intensity PA (e.g., walking, cycling, and swimming) which can be practiced at different capabilities as well as for enjoyment by different age groups [8]. Walking is one of the most common physical activities among older adults, and it is simple to incorporate into daily life. Daily walks of at least 30 min have been shown to be associated with improved physical and mental health status [8‒10].

Mental health is conceptualized as a “a state of mental well-being that enables people to cope with the stresses of life, realize their abilities, learn well and work well, and contribute to their community” [11]. However, mental health can be adversely impacted by symptoms of depression, leading to considerable suffering and disruptions in one’s daily life [1, 12].

Regular PA has been shown to help prevent anxiety and depression symptoms in older adults, and can be a beneficial lifestyle intervention for reducing depression [13, 14]. This might be related to the antidepressant effect of exercise which is believed to be multifaceted, with a potential mechanism involving the increase of brain-derived neurotrophic factor levels in the brain, blood, and muscles as a result of regular PA [15, 16]. This biological process may serve as a link between PA and depressive symptoms, and higher brain-derived neurotrophic factor levels have been associated with a reduced risk of major depressive disorder [16].

With the increasing proportion of older adults worldwide, older adults face significant challenges in maintaining physical and mental health. Depressive symptoms are prevalent among older adults [1], having a detrimental effect on their mental and physical well-being and leading to considerable disruptions in their daily lives. Thus, investigating potential factors contributing to depressive symptoms in older adults has become a vital area of research. To the best of our knowledge, this study is the first in Palestine aimed at highlighting the association between PA and depression among community-dwelling older adult Palestinians, a marginalized growing population age group with a high rate of poverty, unemployment, and chronic diseases that necessitate additional research and studies.

A cross-sectional study was conducted in the West Bank/Palestine.

A total of 266 community-dwelling older adults were included in the study. The participants were selected through a voluntary sampling method, with recruitment facilitated in collaboration with various community and health centers in the West Bank. The inclusion criteria required participants to be females or males aged 55 years or above and willing to participate. Older adults with neurological diseases, walking disabilities, or communication deficits that would hinder data collection were excluded from the study.

A questionnaire was administered to collect demographic and clinical information from the participants. This included data on age, sex, marital status, diagnosed diseases (such as cardiovascular, musculoskeletal, hypertension, and others), sensory functions (visual, hearing, and speech), and anthropometric measurements (such as weight and height).

The participants’ PA levels were assessed using a PA socio-cultural adapted questionnaire (PA-SCAQ) [10]. The PA-SCAQ is a validated and reliable tool that aligns with the global recommendations of the World Health Organization [8]. Based on the total number of minutes spent on moderate-intensity aerobic exercise during the week, the participants were categorized into three levels: low PA (less than 150 min per week), moderate PA (between 150 and 300 min per week), and high PA (more than 300 min per week).

The Short Portable Mental Status Questionnaire was utilized to evaluate the cognitive status of the older adults. It assesses their orientation regarding place, personal information, and time. The SPMSQ has been described as a valid and reliable measure for assessing cognitive status in older adults [17].

The EuroQuol-5Dimensions-5Levels (EQ-5D-5L) is a non-disease specific standardized instrument for describing and valuing HRQoL. The validated and reliable Arabic version of the EQ-5D was used in this study [18]. The EQ-5D-5L consists of five dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each with five coding levels ranging from 1 (no problems) to 5 (extreme problems). In addition, participants used the Euro Quality-Visual Analogue Scale (EQ-VAS) to assess their own health. The EQ-VAS is a visual scale on which respondents express their health status by marking a point on a scale ranging from 0 (worst possible health) to 100 (best possible health).

The Arabic Geriatric Depression Scale (GDS-15) is a reliable and valid measure [19] used to assess depression in older adults residing in the community. It consists of 15 items and is specifically designed for Arabic-speaking individuals. A positive response to ten or more items indicates the presence of depressive symptoms. Scores between 0–4 are considered normal, 5–8 indicate mild depression, 9–11 indicate moderate depression, and 12–15 indicate severe depression.

Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 26. Descriptive and inferential analyses were conducted, with continuous variables presented as mean ± standard deviation, and categorical variables reported as frequencies and percentages. Independent sample t tests and ANOVA tests were employed to determine mean differences between groups based on age and sex for PA and GDS-15 scores. Multiple linear regression analysis was used to assess the association between study variables and examine the effects of the independent variable (level of PA) on depressive symptoms. Three models were developed: Model 1 assessed the relationship between PA and depressive symptoms, model 2 adjusted for participants’ age, and model 3 further adjusted for age and sex. The regression coefficient (β), p values, and 95% confidence intervals (95% CIs) were reported. Statistical significance was set at p < 0.05.

A total of 266 older adults were recruited in this study (138 women and 128 men; mean age = 65.01 ± 8.02 years, range: 55–86). Of the participants, 213 (82%) were married, and 241 (90.6%) lived with their families. Regarding work status, the results revealed that 101 (38%) were employed or had a private job, 80 (30%) were housewives, and 85 (32%) were either not working or retired. Furthermore, 170 (63.9%) participants had a diagnosed disease, with hypertension in 118 (44.4%), diabetes in 84 (31.6%), bone and muscle disease in 74 (27.8%), hyperlipidemia in 58 (21.9%), and rheumatic disease accounting for 31 (11.7%).

Results of PA level indicated that 82 (59.4%) of the women and 58 (45.3%) of the men were classified as low physically active. The demographic and clinical characteristics of the participants are illustrated in Table 1.

Results of the quality-of-life measure (EQ-5D-5L) showed that 130 (48.9%) of the participants had no mobility problems; 61 (22.9%) recorded slight problems; 44 (16.5%) had moderate problems; 31 (11.7%) recorded severe problems. In the pain/discomfort domain, a number of 159 (59.8%) participants reported minor to moderate problems, 82 (30.8%) reported no pain or discomfort problems, and 25 (9.4%) reported severe problems. Among the participants, 136 (51%), constituting 73 (57%) of the men, and 63 (45%) of the women recorded no anxiety or depression; 105 (39.6%) recorded slight to moderate anxiety and depression problems, and 25 (9.4%) had severe anxiety and depression problems. In addition, the mean value of the EQ-VAS was recorded as 70.6 ± 16.3, and 68.7 ± 16.9 for men and women, respectively, with no significant difference (p = 0.367). However, a significant association was recorded between the EQ-VAS and GDS-15 score (r = −0.556, p = 0.00), and PA level (r = 0.315, p = 0.00).

Results of the GDS-15 indicated that 109 (41%) of the participants recorded having depressive symptoms ranging from mild to severe, 44 (34.4%) of the men and 65 (47%) of the women. The mean score of the GDS-15 was higher among women compared to men (p = 0.024) with values of 4.96 ± 3.17 and 4.13 ± 2.78, respectively. ANOVA tests’ results showed that there were significant differences in the mean of the GDS-15 scores in both sexes according to GDS categories, PA categories, and EQ-5D-5L (anxiety/depression) domain (p < 0.05) as shown in Table 2.

The independent sample t test results of PA level showed a significant difference according to age and sex, where women and participants ≥65 years old recorded lower scores of PA and higher GDS-15 score (p < 0.05), as shown in Figures 1, 2. Also, the results indicated that participants <65 years old recorded significantly lower GDS-15 and higher EQ-VAS scores (p < 0.05) (Table 3).

The results of t tests comparing PA levels and GDS-15 scores based on diagnosed diseases revealed significant differences. Among the participants, those who had a diagnosed disease (n = 170) exhibited lower levels of PA (p = 0.009) and higher GDS-15 scores (p = 0.003) compared to participants without a diagnosed disease (n = 96). Specifically, individuals with musculoskeletal disorders such as osteoporosis, rheumatoid arthritis, and bone and muscle diseases showed lower levels of PA and higher GDS-15 scores when compared to individuals with hyperlipidemia, diabetes, and hypertension (Table 4).

As shown in Table 5, a series of linear regression models were conducted to examine the relationships among the variables in the study, as presented in Table 5. In model 1, a significant negative association was found between PA and depression (β = −0.235, 95% CI = −0.010, −0.003, p = 0.00). After adjusting for age in model 2, a significant negative association between PA and depression (p = 0.002) was observed, along with a significant positive association between age and depression (β = 0.192, 95% CI = 0.027, 0.117, p = 0.002). Upon including sex in model 3, the results indicated a significant correlation among PA, age, female sex, and depression (p = 0.015).

More than half of the participants in this study were found to be physically inactive, meaning they did not meet the global recommendation of 150 min of moderate-intensity PA per week [8]. Notably, women outnumbered men in terms of physical inactivity, which is consistent with findings in other countries [20]. This suggests that a variety of personal and environmental factors, such as women’s greater likelihood of devoting time to household tasks and potentially reduced mobility when walking outside [10, 21]. However, despite these differences in PA levels between genders, no significant disparity based on sex was observed in terms of HRQoL as assessed by the EQ-VAS in this study. On the other hand, our research did establish a significant association between EQ-VAS, GDS-15 scores (indicative of depression symptoms), and the level of PA. These findings corroborate existing evidence indicating that regular moderate PA can substantially enhance the HRQoL of older adults [7, 22].

The results of our study revealed a significant negative relationship between PA level and depressive symptoms in older adults. Men and women classified as highly physically active had lower GDS-15 depression scores, indicating milder depressive symptoms. These findings support previous research that links PA to lower levels of depression [7, 23, 24]. This association could be attributed to the biological link between depression and PA. According to several theories, hormonal changes in beta-endorphin and monoamine concentrations during PA can influence mood and depressive symptoms [25]. Exercise also promotes the formation of new nerve cells as well as the release of proteins that improve nerve cell health and survival. Notably, PA may directly benefit the hippocampus volume, which can be reduced by depression. Regular PA appears to increase hippocampal volume, activating extracellular signal-regulated kinase (ERK), and thus alleviating depressive symptoms [15, 16].

In the regression analysis, when accounting for age and gender as controlling variables, we noted that the correlation was impacted by both advanced age and gender (women). In which the decreased level of PA among women and participants aged ≥60 years have been associated with higher depression symptoms. These results align with findings from similar studies revealing that lower PA levels and higher depressive symptoms are more prevalent among women and older age [26, 27]. This may be attributed to various personal and environmental factors that create unfavorable conditions for PA among women and older participants [10, 21].

Furthermore, our findings revealed that a significant majority of the study’s participants had been diagnosed with chronic diseases, which is common in this age group. We noticed a clear pattern among these participants: those with diagnosed diseases had lower levels of PA and higher levels of depressive symptoms. However, depending on the nature of the disease, the impact of disease severity and its effect on PA and depression varied. For example, participants with osteoporosis, rheumatic diseases, and bone and muscle disorders, in particular, had lower levels of PA and higher levels of depressive symptoms when compared to participants with hyperlipidemia, diabetes, and hypertension. This disparity can be attributed to the fact that individuals with musculoskeletal disorders often experience reduced muscle strength and impaired function, which negatively affects their mobility and, consequently, their PA levels [25]. Therefore, physical exercise has been recognized as an important strategy for managing conditions like arthritis [28]. The higher prevalence of depressive symptoms among participants with musculoskeletal disorders, particularly arthritis, can be attributed to the bidirectional relationship between depression and arthritis. Depression is the most common comorbid condition associated with arthritis, and individuals suffering from depression are at a higher risk of developing arthritis [29]. Evidence suggests that inflammatory mechanisms may play a role in explaining the connection between depression and arthritis. Pro-inflammatory cytokines have been implicated in the pathogenesis of both depression and arthritis, highlighting their negative impact [30]. Furthermore, the confounding and contributing effects of pain and discomfort associated with these comorbid conditions may be detrimental to PA [30]. Corresponding to our findings, the majority of participants reported problems ranging from mild to severe on the pain/discomfort domain of the EQ-5D-5L, a factor that may have a negative impact on PA level.

A potential limitation of this study is its cross-sectional design, which hinders the ability to establish a definitive causal association between PA and depressive symptoms among older adults. To confirm a cause-and-effect relationship, additional prospective and intervention studies are needed. It is important to acknowledge that the participants in this study mainly comprised independent, functioning, and community-dwelling older adults. Consequently, further research is warranted to explore the association between PA and depressive symptoms among older age groups and older adults residing in institutions with lower levels of functioning and independence. Examining these populations can provide valuable insights into how PA impacts mental well-being across diverse settings and contexts.

The findings of the study have important clinical implications. Physically active older adults have fewer symptoms of depression; thus, PA interventions can be used as an effective tool to promote mental health in older adults. Based on the findings of the present study, we propose incorporating moderate-intensity aerobic PA for at least 150 min per week into mental health promotion programs in Palestine. Individualized PA interventions for older adults with chronic diseases, particularly musculoskeletal disorders, should be developed.

We thank all the participants and the physiotherapy and community geriatric centers who participated in this study.

This study protocol was reviewed and approved by the Research Ethical Committee at Al-Quds University, Palestine (Approval Number 226/REC/2022), which complies with the Helsinki Declaration. Prior to participating in the study, the participants were informed about the scope and objectives of the study; they had the right to refuse or withdraw from the study at any time. A signed written consent form was obtained.

The authors have no conflicts of interest to declare.

None.

Hadeel Halaweh: conception and design of the work, data analysis and interpretation, drafting the article, and approving of the final version; Amal Al-Khateeb: design of the work, data collection, analysis and presentation design, revision of the article, and approval of the final version; Aya Rasheed, Layth Tomeze, Mohammad Sultan, and Ismail Alqaissi: data collection and interpretation, revision of the article, and approval of the final version.

The data that support the findings of this study are available on request from the corresponding author.