Prevalence of Physical Inactivity and Associated Factors Among Older Caregivers of Older Adults

Abstract

Objective: The aim of this study is to analyze the prevalence of physical inactivity (PI) and associated factors in older caregivers of older adults. Method: A cross-sectional study was conducted including 312 older caregivers. Sociodemographic, clinical, and care-related characteristics were considered the independent variables for the determination of associated factors with PI in the logistic regression model. Results: The prevalence of PI was 75.3% (95% confidence interval [CI] = [70.1%, 80.0%]). The following factors were associated with PI: being female (odds ratio [OR] = 2.8, 95% CI = [1.3, 5.9]), being older than 75 years of age (OR = 7.1, 95% CI = [2.2, 22.9]), not having a marital life (OR = 4.2, 95% CI = [1.1, 15.8]), being prefrail (OR = 6.2, 95% CI = [1.7, 21.9]), and being frail (OR = 14.8, 95% CI = [3.8, 57.7]). Discussion: The prevalence of PI was high and associated with the female sex, an advanced age, and not being married. Specific public policies considering these results should be created for older caregivers.

Keywords

exercise family health primary prevention health promotion motor activity

Introduction

A caregiver is a person who provides care to a dependent individual. Such care involves practical help, emotional support, and financial support. Culturally, care in Brazil occurs in the family environment (Camarano, 2010). Brazilian caregivers are mostly women (wife or daughter of the care recipient) in a stable relationship (married or with a long-time partner), between 50 and 60 years of age, and with a low level of education (Brigola et al., 2017; Gratão et al., 2010; Inouye, Pedrazzani, Pavarini, & Toyoda, 2009). Care tasks exceed 10 hr a day, and reports of stress, burden, and poor health are frequent. About half of caregivers do not receive assistance and did not have previous training for caring for their loved ones (Gratão et al., 2010; Santos-Orlandi et al., 2017; Vieira, Fialho, de Freitas, & Jorge, 2011).

The burden of providing care often exerts a negative impact on biopsychosocial aspects of the caregiver (Loureiro, Fernandes, da Nóbrega, & Rodrigues, 2014; Tomomitsu, Perracini, & Neri, 2014). Caregivers of older adults have higher levels of fatigue, body pain, and other physiologic problems than noncaregivers (Corazza et al., 2014; Neri et al., 2011; Pinquart & Sorensen, 2003). Accompanied by the aging of the population, more people require care, and an increasing number of older adults find themselves in the role of informal caregiver (Neri et al., 2012). When the caregiver is also an older adult, the psychological and physical impacts can be even greater, exerting a negative on the performance of activities of daily living (Chen, Chen, & Chu, 2015; Corazza et al., 2014; Jull, 2010; Neri et al., 2011). Caregivers of spouses report more depressive symptoms, lower psychological well-being, more financial strain, and greater physical burden than caregivers who are sons, daughters, or children-in-law of a dependent individual (Pinquart & Sorensen, 2011).

Caregivers may have intrinsic and extrinsic characteristics related to a less active lifestyle (Amaral, Guerra, Nascimento, & Maciel, 2013; Farran et al., 2008; Fredman et al., 2008; Marquez, Bustamante, Kozey-Keadle, Kraemer, & Carrion, 2012; Santos & Cunha, 2013; Von Kanel et al., 2011). Long periods of daily care, the responsibility of providing care, a lack of formal training, and the absence of assistance in the care process can affect one’s access to self-care strategies (Jowsey, McRae, Gillespie, Banfield, & Yen, 2013; Jull, 2010). Caring for an older adult with severe dependence, as dementia or heart disease conditions, has also been described as a stronger barrier to a healthier lifestyle (Aggarwal, Liao, Christian, & Mosca, 2009; Mochari-Greenberger & Mosca, 2012; Von Kanel et al., 2011), that includes the practice of regular physical activity.

Physical inactivity is considered one of the most important risk factors associated with morbidity and mortality throughout the world (Lee et al., 2012). Older adults are identified as the most vulnerable age group to being physically inactive, with a prevalence rate of physical inactivity generally higher than 70% (Casado-Pérez et al., 2015; Hallal et al., 2012; Malta et al., 2015; Silva et al., 2014). Although physical activity could help minimize the harmful effects of the caregiver’s burden as well as the biopsychosocial changes involved in the aging process (Christofoletti et al., 2011; Hirano et al., 2011; Lambert et al., 2016), individuals decrease their level of physical activity immediately after taking on the burden of caring for a family member (Beesley, Price, & Webb, 2011). Studies indicate that approximately 85% of caregivers do not practice any physical activity (Aggarwal et al., 2009; Farran et al., 2008; Marquez et al., 2012; Von Kanel et al., 2011).

Negative beliefs regarding the aging process, a lack of information on the importance of physical activity, an unfavorable environment, the absence of public policies addressing this issue, and a lack of information with regard to time management may be regarded as hindrances for older adults to engage in regular physical activity (Moschny, Platen, Klaassen-Mielke, Trampisch, & Hinrichs, 2011; Nicholson et al., 2013; Rha, Park, Song, Lee, & Lee, 2015).

Some researchers have conducted interventions involving both the caregiver and care recipient or have made use of frequent telephone contacts in an effort to encourage caregivers to participate in physical activities (Cuthbert et al., 2016; Dal, Bello-Haas, O’Connell, Morgan, & Crossley, 2014; Rodriguez-Sanchez et al., 2014). In one investigation, caregivers reported a preference for short exercises performed several times a day (Marquez et al., 2012). Studies have also demonstrated the need to expand research on physical activity to caregivers (Lambert et al., 2016; Loi et al., 2014).

Studies with older caregivers have analyzed burden, diseases, depression, and social support as outcomes related to care tasks (Chen et al., 2015; Corazza et al., 2014; Marquez et al., 2012; Neri et al., 2012; Rodrigues, Watanabe, & Derntl, 2006). However, there is a lack of information on the prevalence of physical activity and associated factors among older caregivers, especially in Brazil. Because access to health promotion is weak in middle income countries, studies that provide such information can contribute to strengthening public policies and health professionals who work with caregivers.

The determinants of physical inactivity for older caregivers can be the basis for establishing strategies to induce this population to adopt a healthy lifestyle based on their needs and their daily routines. Moreover, understanding factors associated with physical inactivity in older caregivers may offer clues regarding how to develop public policies that grant this population equal access to viable self-care strategies.

The aim of the present study was to analyze the prevalence of physical inactivity and associations with socioeconomic and health characteristics, and aspects related to providing care among older caregivers. We hypothesize the following:

Hypothesis 1: The prevalence of physical inactivity among older caregivers is high and the socioeconomic and health characteristics and aspects related to providing care are factors associated with physical inactivity.

Method

A cross-sectional study was conducted in urban and rural areas covered by the Family Health Strategy (FHS) in the city of Sao Carlos, which is located in the central western portion of the state of Sao Paulo, Brazil. The municipality has 18 Family Health Units (FHUs), two of which are located in rural districts. The population consisted of individuals aged 60 years or older registered with a primary care service and who provided informal care to a dependent older adult living in the same home.

Primary care services were contacted for the addresses of homes with two or more older adults (total = 594 residences); N = 69 were not found at home, n = 26 caregivers and/or care recipients had died, n = 28 had moved to another address, n = 84 declined to participate in the study, and n = 36 did not meet the eligibility criteria. Details of the sample are described elsewhere (Luchesi et al., 2016). Among the 351 older caregivers interviewed, n = 39 who did not have complete information on all independent variables analyzed in the present study were excluded from the sample. A comparative analysis revealed no significant differences between the older caregivers who were included in the study (n = 312) and those who were excluded (n = 39). Figure 1 displays the flowchart of the participant selection process.

Figure 1.

Detailed participant selection process; São Carlos, Brazil, 2014.

Data were collected between April and November 2014 through interviews performed by trained researchers at the participants’ homes. The data collection instrument addressed the following aspects of the older caregivers:

International Physical Activity Questionnaire (IPAQ): The IPAQ is divided into four components: job-related activity, transportation-related activity (traveling in vehicles, bicycling, walking), housework, and leisure activity. The questions address physical activity in the previous 7 days and measure the number of days and amount of time spent practicing moderate and vigorous activities. For the present study, the transportation-related and leisure activity domains were used. Individuals who performed 150 min per week of moderate physical activity or ≥75 min per week of vigorous physical activity in these two domains together were classified as active and those who did not perform this amount of physical activity per week were classified as physically inactive (Garber et al., 2011).

Katz Index: This index is used to measure one’s performance on six basic activities of daily living: eating, sphincter control, transferring, hygiene, dressing, and bathing (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963). The participants were classified as either independent or dependent (on one or more of the six functions; current study Cronbach’s α = .893).

Lawton and Brody Scale: This scale is used to evaluate the degree of dependence with regard to instrumental activities of daily living: using the phone, traveling, shopping, preparing meals, performing chores, taking medications, and handling money. For each activity, a score of 1 corresponds to complete dependence, a score of 2 corresponds to partial dependence, and a score of 3 corresponds to independence. The final score ranges from 7 to 21 points: 7 points = complete dependence, 8 to 20 points = partial dependence, and 21 points = independence. The participants were categorized as either independent or partially dependent (because they were caregivers, none was completely dependent; Santos & Virtuoso Junior, 2008; current study Cronbach’s α = .700).

Sociodemographic data: sex (female or male), age (60-74 years, 75 years or more), schooling (illiterate, up to 4 years of school, 5 or more years of school), marital status (with or without a partner), monthly family income (not informed, less than the Brazilian monthly minimum wage [equal to R$724 at time of data collection], ≥ monthly minimum wage), and place of residence (rural or urban area).

Aspects related to providing care: number of years spent caring for another older adult (0-4, 5 or more) and number of hours spent per day caring for another older adult (1-5, 6-10, >10).

Zarit Burden Interview (ZBI): The ZBI is a caregiver self-report measure with 22 items. Each item has five response options scored from 0 to 4 points: never, rarely, sometimes, frequently, and always. The total ranges from 0 to 88 points with higher scores denoting a greater degree of perceived burden (Scazufca, 2002; current study Cronbach’s α = .851).

Geriatric Depression Scale (GDS): The GDS has 15 items in a “yes/no” format used to indicate the presence of depressive symptoms. Scores higher than 5 points indicate the risk of depression (Yesavage et al., 1983; current study Cronbach’s α = .732).

Perceived Stress Scale (PSS): The PSS is used to evaluate the level of perceived stress by older adults. Each of the 14 items has response options that are scored from 0 to 4. The final score ranges from 0 to 56, with higher scores denoting a greater degree of perceived stress (Cohen, Kamarck, & Mermelstein, 1983; current study Cronbach’s α = .815).

Addenbrooke’s Cognitive Examination–Revised (ACE-R): The ACE-R addresses five cognitive domains (attention and orientation, memory, verbal fluency, language, and visual/spatial ability) and includes the Mini-Mental State Examination, Clock Drawing Test, and two verbal fluency tests. The total ranges from 0 to 100 points, with higher scores denoting a better cognitive status (Carvalho & Caramelli, 2007). For statistical purposes, the participants were divided into groups with scores above and below the median. The median scores were adjusted for level of schooling: 39 for illiterate individuals, 62 for those with 1 to 4 years of study, 78 for those with 5 to 8 years of study, and 83 for those with 9 or more years of study.

Frailty: This aspect was assessed based on the frailty phenotype proposed by Fried et al. (2001), which has five components. (a) Unintentional weight loss was determined based on the answer to the question, “Have you lost any weight in the last 12 months without dieting?” Affirmative answers of weight loss greater than 4.5 kg or 5% of habitual body weight were considered positive for this component. (b) Fatigue was evaluated with two questions from the Center for Epidemiological Studies–Depression—(i) “How often in the last week did you feel that everything demanded great effort?” and (ii) “How often in the last week did you feel you could not carry on with your activities?” Answers of “always” or “most of the time” for either question were considered positive for this component. (c) Weakness was indicated by the mean of three consecutive measures of grip strength on dominant side in kilogram-force using a Jamar hydraulic dynamometer (model SH5001; SAEHAN®, Lafayette, IL, USA). Strength categorized in the lowest quintile after controlling for sex and body mass index was considered positive for this component. (d) Slowness was indicated by the mean of three consecutive measures of the time (in seconds) required to walk 4.6 m in a straight line on flat terrain at a normal pace with or without the use of a cane or walker. Two meters were added to the beginning and end of the track to allow for acceleration and deceleration (total length of track = 8.6 m). Mean speed categorized in the lowest quintile after controlling for sex and height was considered positive for this component. (e) Low physical activity level was indicated by an affirmative answer to the question, “Do you believe you practice less physical activities when compared with 12 months ago?” Having three or more of the five phenotype components characterized the individual as frail, having one or two components characterized the individual as prefrail, and having no components characterized the individual as nonfrail or robust (Fried et al., 2001).

Statistical Analysis

The data were entered (double entry) on EpiData® version 3.1, validated and exported to the Statistical Package for Social Science (SPSS), version 17.0. The prevalence of physical inactivity was estimated with a 95% confidence interval (95% CI). Descriptive analyses involved the calculation of frequencies as well as mean, standard deviation, and median values. Crude and adjusted logistic regression models were created to analyze factors associated with physical inactivity. For such, a hierarchical approach was used. Variables with a p value ≤ .20 in the crude analysis were selected for the adjusted models. Data were entered into two levels: (a) sociodemographic variables and (b) remaining variables. Associations with a p value ≤ .05 in the adjusted models were considered significant.

This study received approval from the municipal secretary of health and the human research ethics committee of Federal University of São Carlos (process number 416.467/2013) and was conducted in compliance with Resolutions 466/12 and 251/97 of the Brazilian National Board of Health. All participants received clarifications regarding the objectives and signed a statement of informed consent.

Results

Among the 312 participants, 76.9% were female, 77.9% were between 60 and 74 years old, mean age was 69.5 ± 7.1 years, 60.6% had 1 to 4 years of schooling, 90.7% had a partner, 53.8% had a household income lower than the monthly minimum wage, and 77.2% lived in urban areas. Regarding health conditions, 35.6% of the participants had a score lower than the median on the ACE-R, indicating cognitive impairment. Moreover, 56.4% were classified as prefrail, 86.5% were independent with regard to basic activities of daily living, and 57.7% partially dependent with regard to instrumental activities of daily living. The majority did not exhibit depressive symptoms (78.2%) and the mean PSS score was 18.4 ± 9.8. With regard to the characteristics of the care provided, the majority reported that they had fulfilled the role of caregiver for 5 or more years (51.3%), with predominance of 1 to 5 hr of care a day (64.1%). The mean burden score (ZBI) was 17.8 ± 13.9 (Table 1).

Table 1.

Sociodemographic, Health, and Care-Related Characteristics of Older Caregivers (n = 312); São Carlos, Brazil, 2014.

Variables	Categories	Total
Variables	Categories	n	%
Sociodemographic characteristics
Sex	Male	72	23.1
Sex	Female	240	76.9
Age (years)	60-74	243	77.9
Age (years)	75+	69	22.1
		69.5 (7.1)^a
Schooling	Illiterate	64	20.5
	1-4 years	189	60.6
	5 years or more	59	18.9
Marital situation	With partner	283	90.7
Marital situation	Without partner	29	9.3
Kinship with older care recipient	Partner	259	84.9
	Father/mother	26	7.4
	Brother/sister	13	3.7
	Father-in-law/mother-in-law	7	2.0
	Other	7	2.0
Household income (R$)	Not informed	18	5.8
	<BMMW	168	53.8
	≥BMMW	126	40.4
Place of residence	Urban area	241	77.2
Place of residence	Rural area	71	22.8
Clinical and health characteristics
Depressive symptoms	Absent	244	78.2
Depressive symptoms	Present	68	21.8
Perceived stress		18.4 (9.8)^a
Cognitive performance^b	Above median	201	64.4
Cognitive performance^b	Below median	111	35.6
Frailty level	Frail	65	20.8
	Prefrail	176	56.4
	Nonfrail	71	22.8
BADL	Dependent on one to six activities	42	13.5
BADL	Independent	270	86.5
IADL	Partially dependence	180	57.7
IADL	Independence	132	42.3
Burden		17.8 (13.9)^a
Care characteristics
Care duration (years)	0-4 years	152	48.7
Care duration (years)	5 years or more	160	51.3
Care hours/day	1-5	200	64.1
	6-10	60	19.2
	>10	52	16.7

Note. BMMW = Brazilian monthly minimum wage; BADL = basic activities of daily living; IADL = instrumental activities of daily living.

Mean (SD).

Median scores: 39 for illiterate individuals, 62 for those with 1 to 4 years of schooling, 78 for those with 5 to 8 years of schooling, and 83 for those 9 or more years of schooling.

The prevalence of physical inactivity was 89.4% (95% CI = [85.5%, 92.6%]) in relation to leisure, 87.2% (95% CI = [82.9%, 90.7%]) in relation to transportation, and 75.3% (95% CI = [70.1%, 80.0%]) in relation to both domains. Women are more physically inactive than men (p = .026).

The prevalence rates of physical inactivity were higher among women (78.3%), individuals older than 75 years (94.2%), illiterate individuals (79.7%), those with no partner (89.7%), those with a household income between 0 and 2 times the monthly minimum wage (81.1%), and those who lived in urban areas (76.3%). Regarding health conditions, the prevalence rates of physical inactivity were higher among subjects with an ACE-R score below the median (81.1%), those classified as frail (95.4%), those who were partially dependent with regard to instrumental activities of daily living (79.4%), and those who were independent with regard to basic activities of daily living (85.7%). Caregivers who spent 6 to 10 hr per day providing care for older adults and were caring for up to 4 years had the highest prevalence rates of physical inactivity (76.3% and 80.0%, respectively). The following factors were associated with physical inactivity among older caregivers in the adjusted analysis: being female (odds ratio [OR] = 2.8, 95% CI = [1.3, 5.9]), belonging to the age group older than 75 years (OR = 7.1, 95% CI = [2.2, 22.9]), not having a partner (OR = 4.2, 95% CI = [1.1, 15.8]), being categorized as prefrail (OR = 6.2, 95% CI = [1.7, 21.9]), and being categorized as frail (OR = 14.8, 95% CI = [3.8, 57.7]; Table 2).

Table 2.

Prevalence of Physical Inactivity and Associated Factors (n = 312); São Carlos, Brazil, 2014.

Variables	Categories	%	Unadjusted		p	Adjusted		p
Variables	Categories	%	OR	(95% CI)	p	OR	(95% CI)	p
Sociodemographic characteristics
Sex	Male	65.3	1.0			1.0
Sex	Female	78.3	1.9	[1.1, 3.4]	.026	2.8	[1.3, 5.9]	.005
Age group (years)	60-74	70.0	1.0			1.0
Age group (years)	≥75	94.2	7.0	[2.4, 19.9]	.000	7.1	[2.2, 22.9]	.001
Schooling	5 years or more	61.0	1.0			1.0
	1-4 years	78.3	1.1	[0.5, 2.2]	.816	0.6	[0.2, 1.3]	.913
	Illiterate	79.7	2.5	[1.1, 5.6]	.025	1.1	[0.3, 2.8]	.545
Marital status	With partner	73.9	1.0			1.0
Marital status	Without partner	89.7	3.0	[0.9, 10.4]	.031	4.2	[1.1, 15.8]	.029
Household income (R$)	≥ 3 × BMMW	71.6	1.0			1.0
	< 2 × BMMW	81.1	1.3	[0.4, 4.4]	.955	1.0	[0.3, 4.0]	.847
	Not informed	77.8	0.8	[0.2, 2.7]	1.455	0.8	[0.2, 3.5]	.943
Place of residence	Urban area	76.3	1.0		.438	—	—	—
Place of residence	Rural area	71.8	0.8	[0.4, 1.4]		—	—	—
Health and clinical characteristics
Depressive symptoms	Absent	73.4	1.0		.131	1.0
Depressive symptoms	Present	82.4	1.7	[0.8, 3.4]		1.3	[0.5, 3.1]	.633
Perceived stress		18.4 (±9.8)^a	0.9	[0.9, 0.9]	.043	1.0	[0.9, 1.0]	.557
Cognitive performance	Above median	72.1	1.0			1.0
Cognitive performance	Below median	81.1	1.6	[0.9, 2.9]	.081	1.0	[0.5, 1.9]	.989
Frailty levels	Nonfrail	53.5	1.0			1.0
	Prefrail	76.7	6.3	[1.9, 21.0]	.003	6.2	[1.7, 21.9]	.005
	Frail	95.4	17.9	[5.1, 62.6]	.000	14.8	[3.8, 57.7]	.000
IADL	Independent	69.7	1.0		.050	1.0
IADL	Partially dependent	79.4	1.7	[1.0, 2.8]		1.5	[0.8, 2.7]	.241
BADL	Independent	85.7	1.0		.100	1.0
BADL	Dependent on one to six activities	73.7	2.1	[0.9, 5.3]		1.3	[0.5, 3.6]	.567
Burden		17.8 (13.9)^a	1.0	[0.9, 1.0]	.572	—	—	—
Care characteristics
Care duration (years)	0-4	76.3	1.0		.691	—	—	—
Care duration (years)	5 or more	74.4	1.1	[0.6, 1.8]		—	—	—
Hours of care/day	1-5 hr	75.0	1.0			—	—	—
	6-10 hr	80.0	0.7	[0.4, 1.5]	.426	—	—	—
	>10	71.2	1.2	[0.6, 2.4]	.573	—	—	—

Note. — denotes variables did not remain in adjusted model (unadjusted analysis p < .2). OR = odds ratio; CI = confidence interval; BMMW = Brazilian monthly minimum wage; IADL = instrumental activities of daily living; BADL = basic activities of daily living.

Mean (SD).

Discussion

In the present study, most of the older caregivers were female, between 60 and 74 years of age, with low levels of schooling and household income. This profile is in agreement with descriptions in previous studies (Pinquart & Sorensen, 2011; Tomomitsu et al., 2014).

The prevalence of physical inactivity was higher than that reported in a Brazilian survey of older adults residing in major Brazilian cities (Malta et al., 2015). Previous studies report that less than 20% of family caregivers engage in physical activities for at least 20 min 3 times a week (Farran et al., 2008; Von Kanel et al., 2011). This likely occurs due to the demands of caring, which requires energy, financial resources, work, patience, and time, leading many caregivers to neglect their own self-care (Loureiro et al., 2014).

Being female, being older than 75 years, not having a partner, and being prefrail or frail were associated with higher prevalence rates of physical inactivity. Previous studies analyzing different age groups report that the prevalence of a low level of physical activity increases with age and the same sociodemographic characteristics are strongly associated with performing less physical activity (Casado-Pérez et al., 2015; Hallal et al., 2012; Malta et al., 2015). However, the samples in the studies cited were not older caregivers. Thus, this is the first study in Brazil on factors associated with physical inactivity in this specific population.

Despite changes with regard to social roles in society in recent years, women spend much of their time involved in domestic chores and providing care (Farran et al., 2008; Von Kanel et al., 2011). Older women perform an average of 3.77 more hours of care per week compared with older men (Del Bono, Sala, & Hancock, 2009). Moreover, older women are more often incapable of performing basic and instrumental activities of daily living (Alexandre et al., 2012, 2014), which may affect the ability to engage in regular physical activity (Casado-Pérez et al., 2015; Hallal et al., 2012; Malta et al., 2015).

An older age was associated with physical inactivity, which is in agreement with data described in national and international studies (Hallal et al., 2012; Malta et al., 2015). In addition to the fact that these older adults provided some type of care to other older adults, the physical, functional, and cognitive impairments that can occur with the aging process indicate greater difficulty in performing physical activity. Moreover, a high percentage of caregivers scored below the median on the cognitive test, which represents a risk for cognitive deficit and, probably, a lower quality of care in the future. This finding could be explained by the influence of a low education on the performance of the test (Cesar, Yassuda, Porto, Brucki, & Nitrini, 2017).

Approximately 90% of the older caregivers reported that they had a partner. The fact of not having a partner was associated with physical inactivity. Indeed, previous studies demonstrate that having a marital life and having family support are essential to the practice of physical activities (Duin et al., 2015; Escobar-Viera, Jones, Schumacher, & Hall, 2014).

Frailty was strongly associated with physical inactivity, as widely described in the literature (Clegg, Young, Iliffe, Rikkert, & Rockwood, 2013; Morley et al., 2013). The central physiologic mechanism for the frailty model is the dysregulation of the energy exchange. A reduction in food intake causes the loss of muscle mass, which lowers one’s physical performance and leads to lower energy expenditure. In turn, the lower energy consumption requires less food intake, which demonstrates the downward spiral of the energy exchange cycle. This spiral has many inputs, such as nutrition, physical inactivity, paralysis, hospitalization, acute disease, complications of chronic diseases, and falls (Fried et al., 2001; Morley et al., 2013).

Prefrailty and frailty lead to an increase in physical and functional limitations, which can restrict the safe, adequate practice of exercise (Alexandre et al., 2014). Therefore, the present findings are in agreement with data in the literature regarding the age-related incapacity cycle, demonstrating that inactivity generates incapacity, which, in turn, leads to further inactivity (Nóbrega et al., 1999). Older adults in developing countries are more vulnerable and frail compared with those in developed countries (Gray et al., 2016). Moreover, there is a lack of public policies supporting informal caregivers as well as places to leave older adults to offer caregivers a chance to care for themselves in Brazil, unlike what occurs in developed countries. This fact can impede older caregivers from practicing more physical activity. The factors associated with physical inactivity in the present study were not related to care characteristics, but rather to the same characteristics found among older adults in general. If Brazilian policy makers offer physical activity programs for older adults, they should consider that some are caregivers and have similar barriers as all older adults. However, it is important to consider that the factors associated with physical inactivity among caregivers in the present study may come from the specific requirements of providing care. Thus, frailty prevention and control strategies should be offered to older caregivers.

Some limitations of the present study should be mentioned. The cross-sectional design does not allow establishing temporal relations between the variables studied. Second, the analysis was restricted to physical inactivity only in the transportation-related and leisure-related domains, because studies stress the importance of reaching the ideal amount of physical activity, regardless of the domain (Garber et al., 2011). However, an individual analysis of other domains of physical activity could be relevant. The study also does not address information on formal caregivers, because most of the participants were partners of the care recipients. Moreover, all instruments were self-report resulting in nominal and categorical data. Future studies should identify variables that were not analyzed herein, such as social support, pain, and the time in which the caregiver had not performed physical activity in previous years.

In conclusion, contrary to our expectations, the results showed that the factors associated with physical inactivity were not specifically related to the task of caring, but rather gender, marital status, and the caregiver’s own aging factors, as an advanced age and conditions of frailty. As older caregivers are highly vulnerable to physical inactivity, decision makers can use these findings to establish public policies and interventions targeting this group.

Health professionals working in primary care should include the evaluation of caregivers in their routine and plan activities focused on this population. During such activities, the use of extrinsic and intrinsic motivational strategies is strongly recommended to encourage behavioral changes. Moreover, age, gender, degree of frailty, and marital status should be considered in the planning of such interventions. Physical activity and frailty prevention interventions should be offered to individuals or groups in person or by other means, such as telephone messages and smartphone applications. Individual guidance for activities that can be done at home, lectures, and educational actions in the waiting room of primary care centers are great examples of strategies to promote active living. Moreover, interventions should involve both the caregiver and care recipient in the same place and time, social and emotional support groups, and the establishment of a family care network so that other people can stay with a dependent elder individual while the caregiver exercises.

Footnotes

Acknowledgements

The authors would like to thank the nursing graduation students for their collaboration in data collection, the Municipal Office of São Carlos, the Research Support Foundation of São Paulo State (Fundação de Amparo à Pesquisa do São Paulo—FAPESP), and the National Council for Scientific and Technological Development (Conselho Nacional de Desenvolvimento Científico e Tecnológico—CNPq) for funding the research. We thank all the participants of this study.

Author Contributions

G.A.O.G. and B.M.L. participated in the study’s question elaboration, data analysis and interpretation, article writing, and final revision. F.S.O., A.C.M.G., K.G.S., and K.I. collaborated with the writing of the article. S.C.I.P. and T.S.A. collaborated with the elaboration of the study’s question, data analysis and interpretation, article writing, and final revision. A.G.B. collaborated with the writing of the article and final revision.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Bruna Moretti Luchesi

Allan Gustavo Brígola

References

Aggarwal

Liao

Christian

Mosca

(2009). Influence of caregiving on lifestyle and psychosocial risk factors among family members of patients hospitalized with cardiovascular disease. Journal of General Internal Medicine, 24, 93-98. doi:10.1007/s11606-008-0852-1

Alexandre

T. S.

Corona

L. P.

Nunes

D. P.

Santos

J. L. F.

Duarte

Y. A. O.

Lebrão

M. L.

(2012). Gender differences in incidence and determinants of disability in activities of daily living among elderly individuals: SABE study. Archives of Gerontology and Geriatrics, 55, 431-437. doi:10.1016/j.archger.2012.04.001

Alexandre

T. S.

Corona

L. P.

Nunes

D. P.

Santos

J. L. F.

Duarte

Y. A. O.

Lebrão

M. L.

(2014). Disability in instrumental activities of daily living among older adults: Gender differences. Revista de Saúde Pública, 48, 379-389. doi:10.1590/S0034-8910.2014048004754

Amaral

F. L.

Guerra

R. O.

Nascimento

A. F. F.

Maciel

Á. C. C

. (2013). Social support and the frailty syndrome among elderly residents in the community. Ciência & Saúde Coletiva, 18, 1835-1846. doi:10.1590/S1413-81232013001400034

Beesley

V. L.

Price

M. A.

Webb

P. M.

(2011). Loss of lifestyle: Health behaviour and weight changes after becoming a caregiver of a family member diagnosed with ovarian cancer. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer, 19, 1949-1956. doi:10.1007/s00520-010-1035-2

Brigola

A. G.

Luchesi

B. M.

Rossetti

E. S.

Mioshi

Inouye

Pavarini

S. C. I.

Pavarini

S. C. I.

(2017). Health profile of family caregivers of the elderly and its association with variables of care: A rural study. Revista Brasileira de Geriatria e Gerontologia, 20, 409-420. doi:10.1590/1981-22562017020.160202

Camarano

A. A.

(2010). Caregiving in long-term to elderly—A new risk to be assumed? Rio de Janeiro. Retrieved from http://www.ipea.gov.br/agencia/images/stories/PDFs/livros/livro_cuidados.pdf

Carvalho

V. A.

Caramelli

(2007). Brazilian adaptation of the Addenbrooke’s Cognitive Examination–Revised (ACE-R). Dementia & Neuropsychologia, 2, 212-216.

Casado-Pérez

Hernández-Barrera

Jiménez-García

Fernández-de-las-Peñas

Carrasco-Garrido

López-de-Andrés

Palacios-Ceña

(2015). Time trends in leisure time physical activity and physical fitness in the elderly: Five-year follow-up of the Spanish National Health Survey (2006-2011). Maturitas, 80, 391-398. doi:10.1016/j.maturitas.2014.12.014

10.

Cesar

K. G.

Yassuda

M. S.

Porto

F. H. G.

Brucki

S. M. D.

Nitrini

(2017). Addenbrooke’s Cognitive Examination–revised: Normative and accuracy data for seniors with heterogeneous educational level in Brazil. International Psychogeriatrics, 29, 1345-1353. doi:10.1017/S1041610217000734

11.

Chen

M.-C.

Chen

K.-M.

Chu

T.-P.

(2015). Caregiver burden, health status, and learned resourcefulness of older caregivers. Western Journal of Nursing Research, 37, 767-780. doi:10.1177/0193945914525280

12.

Christofoletti

Oliani

M. M.

Bucken-Gobbi

L. T.

Gobbi

Beinotti

Stella

(2011). Physical activity attenuates neuropsychiatric disturbances and caregiver burden in patients with dementia. Clinics (Sao Paulo, Brazil), 66, 613-618. doi:10.1590/S1807-59322011000400015

13.

Clegg

Young

Iliffe

Rikkert

M. O.

Rockwood

(2013). Frailty in elderly people. The Lancet (London, England), 381, 752-762. doi:10.1016/S0140-6736(12)62167-9

14.

Cohen

Kamarck

Mermelstein

(1983). A global measure of perceived stress. Journal of Health and Social Behavior, 24, 385-396.

15.

Corazza

D. I.

Pedroso

R. V.

Andreatto

C. A. A.

Scarpari

Garuffi

Costa

J. L. R.

Santos-Galduroz

R. F.

(2014). Psychoneuroimmunological predictors for burden in older caregivers of patients with Alzheimer’s disease. Revista Espanola de Geriatria y Gerontologia, 49, 173-178. doi:10.1016/j.regg.2014.03.007

16.

Cuthbert

C. A.

King-Shier

Tapp

D. M.

Ruether

Jackson

Culos-Reed

S. N.

(2016). Renewing caregiver health and wellbeing through exercise (RECHARGE): A randomized controlled trial. Contemporary Clinical Trials, 50, 273-283. doi:10.1016/j.cct.2016.08.007

17.

Dal Bello-Haas

V. P. M.

O’Connell

M. E.

Morgan

D. G.

Crossley

. (2014). Lessons learned: Feasibility and acceptability of a telehealth-delivered exercise intervention for rural-dwelling individuals with dementia and their caregivers. Rural and Remote Health, 14, 2715.

18.

Del Bono

Sala

Hancock

. (2009). Older carers in the UK: Are there really gender differences? New analysis of the individual sample of anonymised records from the 2001 UK Census. Health and Social Care in the Community, 17, 267-273. doi:10.1111/j.1365-2524.2008.00826.x

19.

Duin

D. K.

Golbeck

A. L.

Keippel

A. E.

Ciemins

Hanson

Neary

Fink

(2015). Using gender-based analyses to understand physical inactivity among women in Yellowstone County, Montana. Evaluation and Program Planning, 51, 45-52. doi:10.1016/j.evalprogplan.2014.12.006

20.

Escobar-Viera

C. G.

Jones

P. D.

Schumacher

J. R.

Hall

A. G.

(2014). Association between living alone and physical inactivity among people with and without disability, Florida Behavioral Risk Factor Surveillance System, 2009. Preventing Chronic Disease, 11, E173. doi:10.5888/pcd11.140182

21.

Farran

C. J.

Staffileno

B. A.

Gilley

D. W.

McCann

J. J.

Castro

C. M.

King

A. C.

(2008). A lifestyle physical activity intervention for caregivers of persons with Alzheimer’s disease. American Journal of Alzheimer’s Disease & Other Dementias, 23, 132-142. doi:10.1177/1533317507312556

22.

Fredman

Cauley

J. A.

Satterfield

Simonsick

Spencer

S. M.

Ayonayon

H. N.

Harris

T. B.

(2008). Caregiving, mortality, and mobility decline: The Health, Aging, and Body Composition (Health ABC) Study. Archives of Internal Medicine, 168, 2154-2162. doi:10.1001/archinte.168.19.2154

23.

Fried

L. P.

Tangen

C. M.

Walston

Newman

A. B.

Hirsch

Gottdiener

McBurnie

M. A.

(2001). Frailty in older adults: Evidence for a phenotype. The Journals of Gerontology, Series A: Biological Sciences & Medical Sciences, 56, M146-M156.

24.

Garber

C. E.

Blissmer

Deschenes

M. R.

Franklin

B. A.

Lamonte

M. J.

Lee

I.-M.

. . . Swain

D. P.

(2011). American College of Sports Medicine position stand. Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43, 1334-1359. doi:10.1249/MSS.0b013e318213fefb

25.

Gratão

A. C. M.

do Vale

F. A. C.

Roriz-Cruz

Haas

V. J.

Lange

Talmelli

L. F. S.

Rodrigues

R. A. P.

(2010). The demands of family caregivers of elderly individuals with dementia. Revista da Escola de Enfermagem da USP, 44, 873-880. doi:10.1590/S0080-62342010000400003

26.

Gray

W. K.

Richardson

McGuire

Dewhurst

Elder

Weeks

. . . Dotchin

C. L.

(2016). Frailty screening in low- and middle-income countries: A systematic review. The American Geriatrics Society, 64, 806-823.

27.

Hallal

P. C.

Andersen

L. B.

Bull

F. C.

Guthold

Haskell

Ekelund

(2012). Global physical activity levels: Surveillance progress, pitfalls, and prospects. The Lancet (London, England), 380, 247-257. doi:10.1016/S0140-6736(12)60646-1

28.

Hirano

Suzuki

Kuzuya

Onishi

Ban

Umegaki

(2011). Influence of regular exercise on subjective sense of burden and physical symptoms in community-dwelling caregivers of dementia patients: A randomized controlled trial. Archives of Gerontology and Geriatrics, 53, e158-e163. doi:10.1016/j.archger.2010.08.004

29.

Inouye

Pedrazzani

E. S.

Pavarini

S. C. I.

Toyoda

C. Y.

(2009). Perceived quality of life of elderly patients with dementia and family caregivers: Evaluation and correlation. Revista Latino-Americana de Enfermagem, 17, 187-193. doi:10.1590/S0104-11692009000200008

30.

Jowsey

McRae

Gillespie

Banfield

Yen

(2013). Time to care? Health of informal older carers and time spent on health related activities: An Australian survey. BMC Public Health, 13, Article 374. doi:10.1186/1471-2458-13-374

31.

Jull

(2010). Seniors caring for seniors: Examining the literature on injuries and contributing factors affecting the health and well-being of older adult caregivers. Ottawa, Canada: Canadian Association of Occupational Therapists.

32.

Katz

Ford

A. B.

Moskowitz

R. W.

Jackson

B. A.

Jaffe

M. W.

(1963). Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function. Journal of the American Medical Association, 185, 914-919.

33.

Lambert

S. D.

Duncan

L. R.

Kapellas

Bruson

A.-M.

Myrand

Santa Mina

. . . Lambrou

(2016). A descriptive systematic review of physical activity interventions for caregivers: Effects on caregivers’ and care recipients’ psychosocial outcomes, physical activity levels, and physical health. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine, 50, 907-919. doi:10.1007/s12160-016-9819-3

34.

Lee

I.-M.

Shiroma

E. J.

Lobelo

Puska

Blair

S. N.

Katzmarzyk

P. T.

(2012). Impact of physical inactivity on the world’s major non-communicable diseases. The Lancet, 380, 219-229. doi:10.1016/S0140-6736(12)61031-9

35.

Loi

S. M.

Dow

Ames

Moore

Hill

Russell

Lautenschlager

(2014). Physical activity in caregivers: What are the psychological benefits? Archives of Gerontology and Geriatrics, 59, 204-210. doi:10.1016/j.archger.2014.04.001

36.

Loureiro

L. S. N.

Fernandes

M. G. M.

da Nóbrega

M. M. L.

Rodrigues

R. A. P.

(2014). Overburden on elderly’s family caregivers: Association with characteristics of the elderly and care demand. Revista Brasileira de Enfermagem, 67, 227-232. doi:10.5935/0034-7167.20140030

37.

Luchesi

B. M.

Alexandre

T. S.

Oliveira

N. A.

Brigola

A. G.

Kusumota

. . . Marques

(2016). Factors associated with attitudes toward the elderly in a sample of elderly caregivers. International Psychogeriatrics, 28, 2079-2089. doi:10.1017/S1041610216001538

38.

Malta

D. C.

Stopa

S. R.

Iser

B. P. M.

Bernal

R. T. I.

Claro

R. M.

Nardi

A. C. F.

. . . Monteiro

C. A.

(2015). Risk and protective factors for chronic diseases by telephone survey in capitals of Brazil, Vigitel 2014. Revista Brasileira de Epidemiologia, 18(Suppl. 2), 238-255. doi:10.1590/1980-5497201500060021

39.

Marquez

D. X.

Bustamante

E. E.

Kozey-Keadle

Kraemer

Carrion

(2012). Physical activity and psychosocial and mental health of older caregivers and non-caregivers. Geriatric Nursing (New York, N.Y.), 33, 358-365. doi:10.1016/j.gerinurse.2012.03.003

40.

Mochari-Greenberger

Mosca

(2012). Caregiver burden and nonachievement of healthy lifestyle behaviors among family caregivers of cardiovascular disease patients. American Journal of Health Promotion, 27, 84-89. doi:10.4278/ajhp.110606-QUAN-241

41.

Morley

J. E.

Vellas

van Kan

G. A.

Anker

S. D.

Bauer

J. M.

Bernabei

. . . Walston

(2013). Frailty consensus: A call to action. Journal of the American Medical Directors Association, 14, 392-397. doi:10.1016/j.jamda.2013.03.022

42.

Moschny

Platen

Klaassen-Mielke

Trampisch

Hinrichs

(2011). Barriers to physical activity in older adults in Germany: A cross-sectional study. The International Journal of Behavioral Nutrition and Physical Activity, 8, Article 121. doi:10.1186/1479-5868-8-121

43.

Neri

A. L.

Yassuda

M. S.

Fortes-Burgos

A. C. G.

Mantovani

E. P.

Arbex

F. S.

de Souza Torres

S. V.

. . . Guariento

M. E.

(2012). Relationships between gender, age, family conditions, physical and mental health, and social isolation of elderly caregivers. International Psychogeriatrics, 24, 472-483. doi:10.1017/S1041610211001700

44.

Neri

A. L.

Yassuda

M. S.

Fortes-Burgos

A. C. G.

Mantovani

E. P.

Arbex

F. S.

Torres

S. V. S.

Silva

D. D.

(2011). FIBRA Campinas: fundamentals and methodology of a study on frailty in elderly community-dwellers. In Neri

A. L.

Guariento

M. E.

Frailty, health and well-being in elderly: data from FIBRA study Campinas (pp. 25-54). Campinas, Brazil: Alinea.

45.

Nicholson

Sniehotta

F. F.

van Wijck

Greig

C. A.

Johnston

McMurdo

M. E. T.

Mead

G. E.

(2013). A systematic review of perceived barriers and motivators to physical activity after stroke. International Journal of Stroke: Official Journal of the International Stroke Society, 8, 357-364. doi:10.1111/j.1747-4949.2012.00880.x

46.

Nóbrega

A. C. L.

da Freitas

E. V.

de Oliveira

M. A. B.

de Leitão

M. B.

Lazzoli

J. K.

Nahas

R. M.

. . . De Rose

E. H.

(1999). Official positioning of the Brazilian Society of Sports Medicine and the Brazilian Society of Geriatrics and Gerontology: Physical activity and health in the elderly. Revista Brasileira de Medicina do Esporte, 5, 207-211. doi:10.1590/S1517-86921999000600002

47.

Pinquart

Sorensen

(2003). Differences between caregivers and noncaregivers in psychological health and physical health: A meta-analysis. Psychology and Aging, 18, 250-267.

48.

Pinquart

Sorensen

(2011). Spouses, adult children, and children-in-law as caregivers of older adults: A meta-analytic comparison. Psychology and Aging, 26, 1-14. doi:10.1037/a0021863

49.

Rha

S. Y.

Park

Song

S. K.

Lee

C. E.

Lee

(2015). Caregiving burden and health-promoting behaviors among the family caregivers of cancer patients. European Journal of Oncology Nursing: The Official Journal of European Oncology Nursing Society, 19, 174-181. doi:10.1016/j.ejon.2014.09.003

50.

Rodrigues

S. L.

Watanabe

H. A.

Derntl

A. M.

(2006). The health of the elderly that care for elders. Revista da Escola de Enfermagem da USP, 40, 493-500. doi:10.1590/S0080-62342006000400007

51.

Rodriguez-Sanchez

Criado-Gutierrez

J. M.

Mora-Simon

Muriel-Diaz

M. P.

Gomez-Marcos

M. A.

Recio-Rodriguez

J. I.

. . . Garcia-Ortiz

(2014). Physical activity program for patients with dementia and their relative caregivers: Randomized clinical trial in Primary Health Care (AFISDEMyF study). BMC Neurology, 14, Article 63. doi:10.1186/1471-2377-14-63

52.

Santos

G. S.

Cunha

I. C. K. O

. (2013). Sociodemographic profile of family caregivers of elderly residents in an area covered by the Family Health Strategy in the city of São Paulo. Saúde Coletiva, 10(59), 47-53.

53.

Santos

R. L.

Virtuoso Junior

R. L.

(2008). Reliability of the Brazilian version of the Scale of Instrumental Activities of Daily Living. Revista Brasileira em Promoção da Saúde, 21, 290-296.

54.

Santos-Orlandi

A. A.

dos Brito

T. R. P.

de Ottaviani

A. C.

Rossetti

E. S.

Zazzetta

M. S.

Gratão

A. C. M.

Pavarini

S. C. I.

(2017). Profile of older adults caring for other older adults in contexts of high social vulnerability. Escola Anna Nery Revista de Enfermagem, 21(1), 1-8. doi:10.5935/1414-8145.20170013

55.

Scazufca

(2002). Brazilian version of the Burden Interview scale for the assessment of burden of care in carers of people with mental illnesses. Revista Brasileira de Psiquiatria, 24(1), 12-17. doi:10.1590/S1516-44462002000100006

56.

Silva

I. C.

Knuth

A. G.

Mielke

G. I.

Azevedo

M. R.

Goncalves

Hallal

P. C.

(2014). Trends in leisure-time physical activity in a southern Brazilian city: 2003-2010. Journal of Physical Activity & Health, 11, 1313-1317. doi:10.1123/jpah.2012-0460

57.

Tomomitsu

M. R. S. V.

Perracini

M. R.

Neri

A. L.

(2014). Factors associated with satisfaction with life among elderly caregivers and non-caregivers. Ciência & Saúde Coletiva, 19, 3429-3440. doi:10.1590/1413-81232014198.13952013

58.

Vieira

C. P. B.

Fialho

A. V. M.

de Freitas

C. H. A.

Jorge

M. S. B.

(2011). Practices of elderly’s informal caregiver at home. Revista Brasileira de Enfermagem, 64, 570-579. doi:10.1590/S0034-71672011000300023

59.

Von Kanel

Mausbach

B. T.

Dimsdale

J. E.

Mills

P. J.

Patterson

T. L.

Ancoli-Israel

Grant

. (2011). Regular physical activity moderates cardiometabolic risk in Alzheimer’s caregivers. Medicine & Science in Sports & Exercise, 43, 181-189. doi:10.1249/MSS.0b013e3181e6d478

60.

Yesavage

J. A.

Brink

T. L.

Rose

T. L.

Lum

Huang

Adey

Leirer

V. O.

(1983). Development and validation of a Geriatric Depression Screening Scale: A preliminary report. Journal of Psychiatric Research, 17, 37-49.