Physical Activity, Sleep Quality and Physical Fitness of the Elderly

Who Live in Nursing Homes

Elida Ulfiana, Dyah Priyantini and Rista Fauziningtyas

Fakultas Keperawatan, Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia

Keywords: Physical Activity, Sleep Quality, Physical Fitness, Elderly.

Abstract: The aging process can cause a reduction in physiological function. Being older means a 30-50% decrease in

physical fitness for the elderly. Factors related to elderly fitness are associated with the Giant Geriatric

Syndrome including physical activity and sleep quality. This research is intended to explain the relationship

of physical activity and sleep quality with the level of physical fitness of the elderly who live in nursing

homes. This research used a descriptive correlational design with a cross-sectional approach. The population

was the elderly with a Barthel score > 60. Sample size was 102 respondents with total sampling. The

variables were physical activity, sleep quality and physical fitness. The instrument used was a 24 hours

activity recall questionnaire, Pittsburg Sleep Quality Index. Physical fitness was measured using a six

minutes walking test, five times sit to stand test, chair sit and reach test and body mass index. Data analysis

used chi square α ≤ 0,05. The results showed that there was a significant correlation between physical

activity and sleep quality and physical fitness (p=0,001). Physical activity in the category of moderate to

hard activity and good sleep quality can improve physical fitness in the elderly because the physical fitness

results from metabolism that occurs in the sleep cycle. It can be concluded that physical activity and sleep

quality had the effect of maintaining physical fitness.

1 BACKGROUND

The aging process causes changes in the

physiological condition of the body and affects

physical fitness. Physical fitness is the body’s ability

to perform daily activities without causing excessive

fatigue, and still have the energy reserves to rest or

do the work suddenly (Francesco Landi, Riccardo

Calvani, Anna Picca, Matteo Tosato & Emanuela

D’Angelo, Elisabetta Serafini, Roberto Bernabei,

2018; Junaidi, 2011). The elderly are said to

demonstrate fitness if they have strong muscles so

that the risk of falls can be reduced, the

cardiopulmonary ability is good and be marked with

VO2. Max height and pulse breakdown, body

flexibility is good, body composition is ideal, they

are able to perform physical activity independently,

the body’s endurance is good and they have

adequate sleep (Afriwardi, 2008; Nugraheni, 2013).

The elderly aged > 60 years old who are still fit will

improve their physiological capabilities and can

retard the degenerative process. However, the fact is

that in the community the age increase can reduce

the body’s physical fitness by 30%-50% (Akmal,

2012).

The factors causing impaired fitness in the

elderly include a problem related to the Giant

Geriatric Syndrome, namely immobility, inanition

(malnutrition), instability (imbalance),

immunodeficiency (decreased endurance), and

insomnia (sleep disorder) (Darmojo, 2015). The

previous study on the physical fitness of the elderly

by Zelvya (2014) showed that nutrition, health status

and also exercise have a strong relationship with the

physical fitness of the elderly who live in nursing

homes. The study related to other factors such as

physical activity and the need to sleep, but to

achieve a good quality of life the elderly need three

components, namely activities, food, and rest.

The eldery population in Indonesia ranked fifth

in the world in 2015, which increased 15.5% from

2014 and is estimated to reach 35 million in 2035

(Ministry of Health of the Republic of Indonesia,

2016). An increasing elderly population will impact

on the health status of the country. Based on

physical fitness indicators proposed by Afriwardi

(2008) and Nugraheni (2013) it is shown that the

388

Ulﬁana, E., Priyantini, D. and Fauziningtyas, R.

Physical Activity, Sleep Quality and Physical Fitness of the Elderly Who Lived in Nursing Home.

DOI: 10.5220/0008325703880393

In Proceedings of the 9th International Nursing Conference (INC 2018), pages 388-393

ISBN: 978-989-758-336-0

physical fitness of the elderly in Indonesia is still

lacking, as evidenced by morbidity still being high.

Elderly morbidity in 2012 was 24.77% in urban and

28.62% in rural areas. This is supported by the

percentage of elderly who have health complaints

during the years 2012 – 2015, the everage reached

47.17% of the total elderly in Indonesia (Ministry of

Health of the Republic of Indonesia, 2016). The

morbidity among the elderly in East Java reached

26.93% with a top rank in Surabaya city reaching

35,99% in 2015 (Health Office of Surabaya). The

condition of the less fit made 11.90% of elderly in a

state of complete dependence (total care). The

American Community Survey also supports that

28% of the elderly aged > 65 years have limitation

in activities so they need full assistance (total care)

(Administration of Aging, 2013).

The results of a preliminary study carried out in

one of Surabaya’s nursing homes in April 2017

showed the morbidity of the elderly reaching 85%.

This condition is also accompanied by heavy

dependency of the elderly (40.38%) and total

dependency of elderly 19.23% (Barthel index ≤ 60).

The total of elderly (59.61%) in nursing homes is

not included in the independent category, so it is

difficult to perform activities that improve fitness.

The results of preliminary data obtained from

measurements of fitness that are accumulated based

on the scale of Guttman (Zelvya, 2014), show 20

elderly who lived in nursing homes, 8 elderly in a fit

condition and 12 elderly in un-fit condition. 20

elderly as a whole say they could not sleep soundly

and perform fewer daily activities, so they only sit

and lie down.

The physical fitness will have an impact on the

physiological condition of the elderly. The poor

physical fitness speeds up the degenerative process,

increasing morbidity, increasing fall incidents, and

decreasing life expectancy, with many not reaching

the age of 70 (Junaidi, 2011).

Growing old can not be avoided, but growing old

healthily is a need of everyone. Healthy ageing is the

concept that has a purpose of making the elderly

period healthy. Healthy ageing is influenced by the

endogenous aging factor from the body and the

exogenous aging factor from environment and life

style. The elderly who achieve a healthy ageing

condition will have an old age of higher quality and

free from pathological conditions (Darmojo, 2015).

Healthy ageing will help the elderly become more

able to perform activities, so they become more

healthy, fit, and able to prevent the occurrence of

disease. Based on the existing phenomenon,

researchers consider it necessary to conduct research

on other variables that represent the factor

influencing elderly fitness. In accordance with the

Giant Geriatric Syndrome other factors that need to

be considered are the condition of limited movement

(immobility) and sleep disorders (insomnia), so the

researchers are interested in conducting research on

the relationship of physical activity and sleep quality

with physical fitness of the elderly who live in

nursing homes.

2 METHODS

The design used in this research is correlation

descriptive with a cross-sectional approach. The

overall population of elderly in UPTD Griya Wredha

Jambangan Surabaya, Social Welfare Institution of

Hargo Dedali Elderly and Anugrah’s Nursing Home,

Surabaya is as many as 175 people. The target

population based on elderly characteristics with

Barthel index > 60 is 108 people. The affordable

population who can be reached by researchers is

limited in time to 2017 and place so there are 102

people. This population is in accordance with the

criteria having verbal communication, no psychiatric

disorder, MMSE score (Mini Mental Status

Examination) ≥17 and no heart disease, stroke, and

malignancy. The sample size in this study is 102

elderly obtained with a total sampling technique.

The independent variables in this study are

physical activity and sleep quality, dependent

variable is elderly physical fitness. The instruments

were questionnaires, one 24-hours in activity recall

to measure physical activity and a Pittsburgh Sleep

Quality Index (PSQI) questionnaire to measure sleep

quality of the elderly. The physical fitness variable

of the elderly was measured using six minutes walk

distance test, five times sit to stand test, chair sit and

reach test and bpdy mass index (IMT).

Analysis of data used in this tsudy is Chi Square

(x2) test.

3 RESULTS

A total of 35 respondents (34,3%) had mild physical

activity, 56 respondents (54,9%) had good sleep

quality, and 53 respondents (52%) in fitness

condition (Table 1).

25 respondents (24.6%) did mild physical

activity at the level unfit. While 32 respondents

(31.4%) did moderate physical activity at the level

of fitness (Table 2). The elderly in the category of

Physical Activity, Sleep Quality and Physical Fitness of the Elderly Who Lived in Nursing Home

389

moderate and hard physical activity had higher

physical fitness compared to the elderly in category

of very mild and mild physical fitness. The result of

the analysis of the chi square test showed p = 0.000,

so there is a significant relationship between

physical activity with physical fitness of the elderly

who live in nursing homes.

The elderly with poor sleep quality had more un-

fitness, while the elderly with good sleep had more

fitness. The analysis result of the chi square test

showed p = 0.000 meaning there was a relationship

between sleep quality and physical fitness of the

elderly who live in nursing homes.

4 DISCUSSION

4.1 The Relationship of Physical

Activities and Physical Fitness

Physical activity and physical fitness among those

living in nursing homes had a significant

relationship. Physical activity in the very mild and

mild categories show the elderly to be unfit, and

otherwise physical activity in the moderate and hard

categories made the elderly fit. The regular physical

activity related to FITT (frequency, intensity, type,

and time) will make the body more healthy and fit.

Physical activity has an impact on physical health by

increasing cardivascular endurance. Cardiovascular

endurance in a well condition will keep the function

of the cardiac muscle, respiratory, and vascular

systems intact. Physical activity also strengthens the

body’s muscles, maintains balance, and body

flexibility of the elderly and maintans body

composition (Francesco Landi, Riccardo Calvani,

Anna Picca, Matteo Tosato & Emanuela D’Angelo,

Elisabetta Serafini, Roberto Bernabei, 2018; Junaidi,

2011).

The fit elderly had a level of activity above that

of the un-fit. The un-fit elderly tend to prefer to

sleep and sit, while the fit elderly will try to perform

independent activities such as household chores

(washing clothes, dishes, cooking, sweeping,

cleaning room), making crafts and performing light

activities (watching TV, listening to the radio,

chatting, leisurely strolling, activities in the hall).

This was in line with a study by Junaidi (2011) which states that people who have a good value VO2

Table 2: Cross Tabulation Physical Activity and Physical Fitness of the Elderly Variables in Nursing Home.

Physical Activity

Physical Fitness

Total

Un-Fitness Fitness

N % N % N %

Ver

Mild 25 24.6 3 2.9 28 27.5

Mild 21 20.6 14 13.7 35 34.3

Moderate 3 2.9 32 31.4 35 34.3

Hard 0 0 4 3.9 4 3.9

Total 49 48,1 53 51.9 102 100

Chi S

uare test

= 0.000

Table 3: Cross Tabulation Sleep Quality and Physical Fitness of the Elderly Variables in Nursing Home.

Sleep Quality

Physical Fitness

Total

Un-Fitness Fitness

N % N % N %

Poo

43 42.2 3 2.9 46 45.1

Good 6 5.9 50 49 56 54.9

Total 49 48,1 53 51.9 102 100

Chi Square test

= 0.000

Table 1: The data of Physical Activity, Sleep Quality

and Physical Fitness of the Elderly in Nursing Homes.

n %

sical Activit

Ver

Mild 28 27.5

Mild 35 34.3

Moderate 35 34.3

Hard 4 3.9

Sleep Quality

Good 56 54.9

Poo

46 45.1

sical Fitness

Fitness 53 52

Un- fitness 49 48

INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research

390

Max (a distance > 320 metres) are able to perform

more physical activity. However, based on the

obtained data some fit elderly could not achive a

distance > 320 metres. The factors causing the

elderly to stop the walking test after 6 minutes

included dizziness, joint pain, and using walking

aids. The elderly who did moderate-hard physical

activity were more active and had more interaction

than the elderly who did less physical activity,

because their physical fitness condition was also

different. This is in accordance with the study by

Akmal (2012) which states that elderly with physical

activity moderate-hard are more likely to participate

in activities such as gymnastics routines. The result

of the study was also consistant with the research by

Alrushud, Rushton AB, Kanavaki AM et al. (2017)

on elderly with obesity, which states that physical

activity has a significant result in weight loss, so that

the body composition remains ideal.

In accordance with the concept of healthy ageing

for the elderly good physical activity will achieve a

state of healthy ageing, which is achieved through

active ageing, in various fields – cultural, economic

determinant, social, spiritual and health. The active

elderly will increase their quality of life, active

participants enjoy well-being and are able to

optimize the healthy body (Darmojo, 2015) Physical

activity has an impact on physical fitness as

evidenced by the significant relationship, in

accordance with the concept of healthy ageing.

According to the reseacher achieving a healthy old

age should be stimulated by factors that influence it,

but the whole of the factors must be optimal in order

to achieve the purpose. All of these factors meant

belonging to endogenous aging and external factors.

Physical activity acts as an external factor and will

make the eldery more active. At the level of physical

activity moderate and heavy the elderly become

more active in moving than the elderly with physical

activity very mild and mild. The increasing

movement of the elderly’s gestures will stimulate the

muscles and they do not atrophy. The habit of

regular activity during old age will maintain the

body systems, ranging from cardiovascular system,

respiration, and neuromuscular.. If all the body

systems are still functioning properly, the body will

remain in a healthy condition and fit.

4.2 Relationship of Sleep Quality and

Physical Fitness

Sleep quality and physical fitness in the elderly

have a significant relationship. This is in accordance

with the results of a study showing that good quality

sleep maintained 50 elderly (49%) in a fit condition,

while for the elderly with poor quality sleep only 3

elderly (2.9%) were in a fit condition. This showed

that good sleep quality has a greater impact on the

elderly’s physical fitness.This is in accordance with

the indicators of elderly physical fitness by

Nugraheni (2013), which were that physical fitness

was good if having good sleep quality and adequate

rest of at least 6-7 hours per day.

Sleep is one of the basic needs for maintaining

health and functioning of the body’s cells (Miller,

2012). According to Mubarak, Indrawati and

Susanto (2015) during sleep regeneration of

damaged cells occurs, with immune enhancement,

repairation of the brain’s neurons and recovery of

the body’s energy that has been used during a full

day. This was consistent with the results of a study

showing that respondents having good quality sleep

also had good fitness. The good sleep quality

increased the cell regeneration activity, resulting in

better fitness when waking the next day.

When an individual sleeps well the body’s

metabolism for repairing damaged cells also occurs

releasing hormones from the pons and brainstem

(Bulbar Syncronizing Regional) (Anita D. Christie,

Seery & Jane A. Kent, 2016). The hormones

released are serotonin, melatonin, endorphin dan

enkephalin. Serotonin hormone functions to regulate

body temperature, appetite, sleep quality, memory,

mood, and circulatory function. Melatonin is

associated with circadian rhythm. Endorphin results

in euphoria, repressing pain so helping in cell

regeneration, and Enkephalin inhibits pain impulse

through a prostaglandin inhibitor (Khasanah &

Hidayati, 2012). When an individual has good

quality sleep, then the stages of the sleep cycle will

be fulfilled both NREM and REM. The hormone

secretion of sleep if occurring properly will impact

to regenerate cells during sleep. The body feels fresh

the next morning if experiencing good sleep quality.

Conversely, poor quality sleep will mean the

elderly’s physical condition is not fresh the next

morning, they will be drowsy interfering with daily

activities. Based on the results of interviews and

recall questionnaire PSQI, the poor sleep quality of

the elderly is caused by unfavorable environment

conditions, frequent wakening, insomnia and not

being able to go back to sleep after wakening in the

night. This is in accordance with the theory that the

elderly’s sleep pattern will change, namely

shortening NREM III and REM, so the elderly will

be easy awakened. If the elderly fail to gain good

sleep quality, hormone secretion will be inhibited

Physical Activity, Sleep Quality and Physical Fitness of the Elderly Who Lived in Nursing Home

391

and the regeneration process will be occur. This

makes the body un-fit the next day.

In accordance with the concept of healthy

ageing, one factor that allows the elderly to achieve

healthy aging is that of endogenous aging, namely

sleep pattern. Elderly sleep patterns consist of

several cycles of NREM and REM. The good sleep

cycle will also allow good sleep quality. During

quality sleep metabolism of cell regeneration will

occur increasing the body’s energy, the damaged

cells will regenerate and hormone secretion will

occur from the bulbar synchronizing region helping

the metabolic process of the body. Cell metabolism

and energy recovery that impact on the elderly’s

bodily health can actualize the healthy ageing

condition (Darmojo, 2015).

The healthy ageing concept can be demonstrated

by the author through two respondents, one has good

sleep quality and is fit (respondent 30H) and the

other one has poor sleep quality and is unfit

(respondent 32H). During interviews respondent

30H had given a greeting first, looked cheerful, did a

lot of activities and did not seem sleepy. Respondent

30H did not have any sleep disorder, so he/she was

subjectively assessing sleep very well. While

respondent 32H looked more lazy, un-cheerful, there

were bags under the eyes, irritability, and

drowsiness. During the interview, the respondent

said that it was difficult to sleep every night because

he was remembering his granddaughter, he often

awakened at night due to frequent dreaming and

wanting to go to the bathroom. Based on these two

examples, it can be proved that there is a significant

relationship between sleep quality and physical

fitness of the elderly. The elderly with good sleep

quality will be more fit, and otherwise the elderly

with poor sleep quality will not be fit. The un-fitness

of the body is due to the process of repairing body

cells while sleeping being impaired causing

difficulty in maintaining physical activity. While

sleeping, the body will work to repair the body’s

energy metabolism, the energy that has been used

during a full long day will be recovered again, the

fatigue will be improved, so that the elderly feel

fresh when waking the next day. The maintaining of

physical activity that stimulates the elderly body

muscles will maintain the ability to still perform

independent activity, so the elderly will become

more healthy and fit.

5 CONCLUSIONS

The physical activity of the elderly who lived in

nursing homes is mostly mild and moderate. The

physical activity and physical fitness of the elderly

have a significant relationship. If physical activity is

in the category level of very mild and mild, the

elderly will be in an unfit condition. But if the

physical activity is moderate and hard, the elderly

are in a fit condition. Sleep quality of the elderly in

nursing homes is mostly shows good. Good sleep

quality will have an impact on repairing the body

systems and restoring the elderly energy. Sleep

quality and physical fitness of the elderly who live in

nursing homes had a significat relationship. The

elderly with good sleep quality will become fit and

the elderly with the poor sleep quality will become

unfit.

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