Exercise for depression in elderly residents of care homes: a cluster-randomised controlled trial
Open accessAbstract
Background Depression is common and is associated with poor outcomes among elderly care-home residents. Exercise is a promising low-risk intervention for depression in this population. We tested the hypothesis that a moderate intensity exercise programme would reduce the burden of depressive symptoms in residents of care homes.Methods We did a cluster-randomised controlled trial in care homes in two regions in England; northeast London, and Coventry and Warwickshire. Residents aged 65 years or older were eligible for inclusion. A statistician independent of the study randomised each home (1 to 1·5 ratio, stratified by location, minimised by type of home provider [local authority, voluntary, private and care home, private and nursing home] and size of home [<32 or ≥32 residents]) into intervention and control groups. The intervention package included depression awareness training for care-home staff, 45 min physiotherapist-led group exercise sessions for residents (delivered twice weekly), and a whole home component designed to encourage more physical activity in daily life. The control consisted of only the depression awareness training. Researchers collecting follow-up data from individual participants and the participants themselves were inevitably aware of home randomisation because of the physiotherapists' activities within the home. A researcher masked to study allocation coded NHS routine data. The primary outcome was number of depressive symptoms on the geriatric depression scale-15 (GDS-15). Follow-up was for 12 months. This trial is registered with ISRCTN Register, number ISRCTN43769277.Findings Care homes were randomised between Dec 15, 2008, and April 9, 2010. At randomisation, 891 individuals in 78 care homes (35 intervention, 43 control) had provided baseline data. We delivered 3191 group exercise sessions attended on average by five study participants and five non-study residents. Of residents with a GDS-15 score, 374 of 765 (49%) were depressed at baseline; 484 of 765 (63%) provided 12 month follow-up scores. Overall the GDS-15 score was 0·13 (95% CI -0·33 to 0·60) points higher (worse) at 12 months for the intervention group compared with the control group. Among residents depressed at baseline, GDS-15 score was 0·22 (95% CI -0·52 to 0·95) points higher at 6 months in the intervention group than in the control group. In an end of study cross-sectional analysis, including 132 additional residents joining after randomisation, the odds of being depressed were 0·76 (95% CI 0·53 to 1·09) for the intervention group compared with the control group.Interpretation This moderately intense exercise programme did not reduce depressive symptoms in residents of care homes. In this frail population, alternative strategies to manage psychological symptoms are required.Funding National Institute for Health Research Health Technology Assessment.
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The review team used an ICC of 0.03 for cluster-RCTs because none reported an ICC and estimates from other cluster-RCTs of depression interventions in LTC suggested this value, consistent with typical values lower than 0.05.
“We decided to use an ICC of 0.03, based on estimates from other cluster-RCTs of interventions to reduce symptoms of depression in LTC (Davison 2021b; Underwood 2013).”
From Psychological therapies for depression in older adults residing in long-term care settings (2024) · cites this paper as Underwood 2013
The Discussion (page unavailable) says the trial’s intracluster correlation coefficients were mostly close to zero, supporting the use of this care-home depression trial as a source of low-ICC estimates. It does not report an ICC of 0.03; Methods > Statistical analysis instead says the trial assumed 0.05 for sample-size planning. The review team’s choice of 0.03 is therefore not established by this source alone. (LLM, conf=0.86)
Experimental — accuracy not yet measuredSample sizes were recalculated to account for error in cluster RCTs by determining a design effect with a conservative intracluster correlation coefficient of 0.05.
“Thus, sample sizes were recalculated to account for error in cluster RCTs by determining a design effect 128 with a conservative intracluster correlation coefficient of 0.05, in accordance with past studies 46, 129 .”
Some large, multisite trials have failed to find a benefit of exercise in late-life depression samples.
“The effects of exercise training in this population have been heterogeneous; some large, multisite trials have failed to find a benefit of exercise in LLD samples (23).”
From The Role of Exercise in Management of Mental Health Disorders: An Integrative Review (2021) · cites this paper as [23]
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- Authors
- Underwood, M., Lamb, S. E., Eldridge, S., Sheehan, B., Slowther, A.-M., Spencer, A., Thorogood, M., Atherton, N., Bremner, S. A., Devine, A., Diaz-Ordaz, K., Ellard, D. R., Potter, R., Spanjers, K., & Taylor, S. J.
- Affiliations
- University of Warwick (GB)
- Queen Mary University of London (GB)
- University of Exeter (GB)
- Corresponding author
- Underwood, Martin
- ORCID
- Venue
- The Lancet
- Publisher
- Elsevier BV
- Published
- 2013-07
- Volume
- 382
- Issue
- 9886
- Pages
- 41-49
- ISSN
- 0099-5355 (ISSN-L)
- 0140-6736
- PMC
- PMC3919159
- OpenAlex
- W2169679525
- Cited by
- 135
- References
- 39
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 6 · 2023: 7 · 2022: 9 · 2021: 11 · 2020: 13 · 2019: 8 · 2018: 14 · 2017: 9 · 2016: 16 · 2015: 15 · 2014: 12 · 2013: 5
- FWCI
- 11.11
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- The Lancet (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- LSHTM Research Online (London School of Hygiene and Tropical Medicine) (acceptedVersion)
- Sussex Research Online (University of Sussex) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Funders
- Advantage West Midlands
- National Institute for Health and Care Research (06/02/01, NF-SI-0512-10103)
- Health Technology Assessment Programme (06/02/01)
- Topics
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Aging, Health, and Disability
- Keywords
- depression, older adults, nursing home residents, exercise intervention, group exercise, employee training, physical activity, Geriatric Depression Scale, nursing homes, long-term care, cluster randomization, home-based exercise, employee attitudes
- MeSH terms
- Aged, Aged, 80 and over, Cross-Sectional Studies, Depression, England, Exercise Therapy, Female, Homes for the Aged, Humans, Male, Nursing Homes, Cluster Analysis, Treatment Outcome
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