Appendix C: The evidence

This appendix sets out the evidence statements provided by the review and links them to the relevant recommendations (see appendix B for the key to study types and quality assessments). The evidence statements are presented here without references – these can be found in the full review (see appendix E for details). It also sets out a brief summary of findings from the economic appraisal.

Evidence statement 1 indicates that the linked statement is numbered 1 in the review 'Public health interventions to promote mental well-being in people aged 65 and over: systematic review of effectiveness and cost-effectiveness'.

The review and economic appraisal are available on the NICE website. Where a recommendation is not directly taken from the evidence statements, but is inferred from the evidence, this is indicated by IDE (inference derived from the evidence) below.

Where PHIAC has considered other evidence, it is linked to the appropriate recommendation below. It is also listed in the additional evidence section of this appendix.

Recommendation 1: evidence statements 8 and 17

Recommendation 2: evidence statements 1, 2, 3 and 17

Recommendation 3: evidence statements 4 and 18

Recommendation 4: IDE

Evidence statements

Evidence statement 1 (Mixed exercise)

Two meta-analyses (Arent et al. 2000, MA+; Netz et al. 2005, MA+), together comprising 68 controlled trials from many developed countries, since augmented by four other rigorous trials in the Netherlands (2), Norway and the USA, together provide strong evidence that mixed exercise programmes generally have small-to-moderate effects on mental wellbeing. As the reported exercise programmes cover a range of types, settings and countries, firm conclusions about the duration of programmes and the frequency of sessions are difficult. It is clear, however, that exercise of moderate intensity (not well defined in the meta-analyses) has beneficial effects on physical symptoms and psychological wellbeing.

The programmes evaluated were generally community-based, well organised and run by trained instructors. The findings apply to similar populations (relatively healthy and independent, and motivated to take exercise) in similar community settings in the UK. The sole qualitative study (Hardcastle and Taylor 2001, Q+) highlights the importance of appropriate facilities and good supervision.

Evidence statement 2 (Strength and resistance exercises)

Meta-analysis of four US trials that included a total of 1733 independent frail older people aged 65+ living in the community. Four of the SF-36 scales were used to evaluate similar resistance exercise interventions. A significant small-to-moderate improvement in emotional health was reported (Schechtman and Ory 2001, MA+). The findings are likely to be broadly applicable to frail older people in a range of settings in the UK.

Of six smaller controlled studies evaluating the benefit of resistance exercise for older people in general, five reported significant positive effects, mostly on the Profile of Mood States (POMS) measure (a self-reported measure of general mood over the past week). As all six were of poor quality, this finding should not be considered robust.

Evidence statement 3 (Aerobic exercise)

A medium-sized RCT in the US showed that both interventions – supervised aerobic brisk walking and 'toning and stretching' – generated similar trajectories of Memorial University of Newfoundland Scale of Happiness (MUNSH) and Satisfaction with Life Scale (SWLS) scores over 12 months in sedentary adults aged 60 to 75. These trajectories showed significant growth in happiness and satisfaction over the six-month exercise period, followed by a significant decrease at 12 months (McAuley et al. 2000, RCT+). The findings are likely to be broadly applicable to similar populations in the UK.

Evidence statement 4 (Walking interventions)

A walking programme delivered to older people in 28 heterogeneous neighbourhoods in Portland, Oregon by trained leaders three times a week over six months improved SF-12 mental health and SWLS scores relative to control neighbourhoods (Fisher and Li 2004, Cluster RCT+). This cluster randomised trial recruited 279 people to the intervention group (of whom 156 completed the intervention) and compared them with 303 controls who received education only. Though recruitment and retention of participants is important for such programmes, the results are likely to be broadly applicable to similar populations in the UK.

Evidence statement 8 (Group-based health promotion)

There is evidence from one well-designed longitudinal trial (Clark et al. 1997, RCT++; Clark et al. 2001, RCT++) that weekly educational sessions led by occupational therapists promoted and maintained positive changes in the SF-36 mental health score in participants recruited from two federally-subsidised apartment complexes for older adults in the US. Though the findings are likely to be broadly applicable to a similar population in the UK, the findings may not generalise to those in other circumstances (for example, owner–occupiers and nursing home residents). A small pilot study adapted the intervention for the UK context (Mountain et al. 2006, Q+). The findings indicate that the intervention 'Lifestyle Matters' is acceptable to older people with diverse health status living in private housing, and a range of positive benefits were reported.

Well elderly intervention model (Clarke et al. 1997)

The 'Well elderly' study (RCT, USA) evaluated the efficacy of preventative occupational therapy to reduce health-related decline among urban, multi-ethnic independent-living older adults.

The central theme of the programme was health through occupation, broadly defined as regularly performed activities such as grooming, exercising and shopping. The programme was delivered in weekly (6–10 people, 2 hours) and monthly (one to one, 1 hour) sessions over a 9-month period.

The key intent of the treatment was to help participants better appreciate the importance of meaningful activity in their lives, as well as to impart specific knowledge (didactic teaching) about how to select or perform activities (direct experience) so as to achieve a healthy and satisfying lifestyle across a broad range of activities. One-to-one sessions involved asking people to analyse the role of each activity in affecting health and wellbeing in his or her personal life.

Sessions were delivered by occupational therapists trained in working with elderly populations. Modular programmatic units centred on topics listed in recommendation 1. Full details of the occupational therapy protocol are available from the authors:

Clark F, Azen SP, Zemke R, Jackson J, Carlson M, Mandel D et al. (1997) Occupational therapy for independent-living older adults: a randomized controlled trial. JAMA 278 (16): 1321–26.

Lifestyle matters intervention model (Mountain et al. 2006)

The 'Lifestyle matters' study (Q+, UK) was an adapted version of the 'Well elderly' intervention piloted in the UK to determine its feasibility in a UK setting.

The programme ran for 8 months, although the authors are confident that participants would be able to derive benefit from a shorter programme. A mix of qualified occupational therapy staff working with others is considered the best arrangement.

The programme is delivered through a combination of group sessions, individual sessions and visits or outings, giving participants the opportunity to put their ideas into practice. Twenty-nine sessions are included in the manual based around a number of themes that reflect the current body of literature on ageing and quality of life. All the activities are intended as starting points; they should be tailored to meet the needs of the participants, as opposed to the activities dictating the group. The organisation of themes within the manual is arbitrary; there is no set pattern for delivery and it is not necessary to cover all themes.

Beginnings – a celebration of achievements

  • activity and health

  • the ageing process and activity

  • personal time, energy and activity

  • goals: realising hopes and wishes

  • pulling ideas together: how is activity related to health?

Maintaining mental wellbeing

  • sleep as an activity

  • keeping mentally active

  • memory

Maintaining physical wellbeing

  • nutrition

  • pain

  • keeping physically active

Occupation in the home and community

  • transportation

  • opportunities for new learning

  • experiencing new technologies

Safety in and around the home

  • keeping safe in the community

  • keeping safe in the home

Personal circumstances

  • dealing with finance

  • social relationships and maintaining friendships

  • dining as an activity

  • interests and pastimes

  • caring for others, caring for self

Full details available from: Mountain G, Craig C, Mozley C, Ball L (2006) Lifestyle matters: an occupational approach towards health and wellbeing in later life. Final report. Sheffield: Sheffield Hallam University.

Cost-effectiveness evidence

In general, community-based exercise programmes delivered by exercise professionals and activity counselling interventions delivered by primary care practice nurses were found to be cost effective with respect to mental wellbeing outcomes.

Two published economic evaluations based on RCTs were identified for inclusion in the review. One UK study was a community-based mixed exercise programme for the over 65s (Munro et al. 2004). The second study was a US health education programme in the Well-Elderly Study (Hay et al. 2002). Both studies were found to be cost effective.

Five studies that described three interventions were considered for the health economic analysis; counselling programmes to promote physical activity (Halbert et al. 2000; Helbostad et al. 2004; Kerse et al. 2005), a community-based walking scheme (Fisher et al. 2004), and a proactive nursing health promotion intervention (Markle-Reid et al. 2006).

The provision of advice from exercise specialists and group-based and home-based exercise programmes led by physiotherapists were not considered cost effective. The provision of activity counselling or 'green prescription' by primary care practice nurses was considered moderately cost effective over 6 months. However, the provision of health promotion information by community nurses was not considered cost effective over 6 months. Compared with the control group, a community-based walking intervention seemed to be most cost effective.

Evidence statement 17 (Cost-effectiveness review)

Two studies provided good evidence about the cost-effectiveness of interventions to improve the mental wellbeing of older people. First, Hay and coworkers (2002, RCT+) showed that a 2-hour group session of preventive advice from an occupational therapist per week is cost effective in the USA with an incremental cost per QALY of $10,700 (95% CI, $6700 to $25,400). Second, Munro et al. (2004, RCT+) showed that twice-weekly exercise classes led by qualified instructors are probably cost effective in the UK with an incremental cost per QALY of £12,100 (95% CI, £5800 to £61,400). While both studies are sound, one cannot be confident that such sparse findings will apply to similar populations (relatively healthy, living independently, and motivated to take advice and exercise) in similar community-based settings in the UK.

Evidence statement 18 (Cost-effectiveness analyses)

There are only two published economic analyses of interventions to improve the mental wellbeing of older people (evidence statement 16). To complement these sparse data economic modelling based on the integration of existing studies of effectiveness and existing sources of data about patient utilities and resource costs was needed. The most cost-effective intervention was a thrice-weekly community-based walking programme, delivered to sedentary older people who are able to walk without assistance (Fisher and Li 2004, Cluster RCT+). Modelling yielded an incremental cost per QALY of £7400 after 6 months, which is comparable with the two published economic analyses. Modelling was also used to enhance three RCTs of advice about physical activity. Such advice had an estimated incremental cost per QALY of £26,200 when modelled from Kerse and coworkers (2005, NCT+), who estimated the effects of the primary care 'green prescription' counselling programme in New Zealand. The estimated incremental cost per QALY rose to £45,600 when modelled from Markle-Reid and coworkers (2006, RCT++), who evaluated proactive health promotion by nurses in Canada in addition to usual home care for people over 75, and to £106,232 based on the modelling of the Norwegian physiotherapist-led exercise programme described by Helbostad et al. (2004, RCT+). However, Halbert and coworkers (2000, RCT+) reported decreased mental wellbeing in response to 20 minutes of individual advice on physical activity by an exercise specialist in general practice in Australia. Thus the advice was dominated by the control group to whom no advice was given.

Fieldwork findings

Fieldwork aimed to test the relevance, usefulness and the feasibility of implementing the recommendations and the findings were considered by PHIAC in developing the final recommendations. For details, see the fieldwork section in appendix B.

  • Fieldwork participants who work with older people were very positive about the recommendations and their potential to help promote older people's mental wellbeing. All participants welcomed the development of these recommendations and thought older people would benefit from their implementation.

  • Many participants hoped that these recommendations would lead to sustained funding for health promotion and physical activity programmes for older people. Participants with existing health promotion and physical activity schemes for older people were more confident they could implement the recommendations than those without such schemes (or who were not aware of any local provision).

  • Many participants also wanted to see greater coverage of increasing opportunities for social interaction and tackling poor mental wellbeing (for example, anxiety, depression and 'nerves'), which they thought was commonplace among older people, especially isolated older people.

  • Older people themselves welcomed the recommendations, but thought many would not be sufficiently motivated to take part in the activities outlined.