a recent community survey showed that quality of life ( qol ) decreases progressively with age in the general population : the elderly were shown to perceive their qol as much lower than young people . the presence of chronic inflammatory , endocrine   and degenerative diseases   is associated with reduced qol ; the association of such diseases with mood disorders may be a determining factor amplifying this reduction . physical activity and exercise have recently been shown to improve qol in elderly people with neurodegenerative diseases   and depressive disorders . exercise is associated with better qol in elderly people with major depressive disorder living in the community , and there are strong evidence that physical training improve daily living performance and qol in frail elderlies long - term care institutionalized decreases in sleep and motility are common risk factors for psychological distress in old age , related to poorer qol . a recent survey revealed a positive chronic association between exercise and time of waking after sleep onset , as well as a small positive acute association between exercise and general sleep quality rating in elderly people . thus , physical activity not only appears to affect the qol of older people with chronic diseases , but also physical factors such as sleep , which can be considered a general indicator of well - being and a prodromal symptom of physical and mood disorders in people without chronic disease or depression . moreover , long - term exercise in aging adults has been shown to provide , besides musculoskeletal and cardiovascular positive effects , also a improvement on cognitive functions , such as memory , attention and executive functions [ 14 , 15 ] . prevention programs for the elderly , for example against falls , stressed the importance of the effect of physical exercise on psychosocial variables closely related to perceived qol . it has been suggested that a high perceived qol is an important motivational factor in preventive programs against chronic vascular diseases in the elderly , and it has been shown that long - term physical activity , even in elderlies with chronic diseases and without a clear relationship with a dose - response effect , is related to positive effects on qol by postponing disability and enhancing independent living . thus , if chronic illnesses and depression can affect qol , it is also conceivable that a good perceived qol might be considered a preventive factor against these same disorders in the elderly . a senior who feels well takes better care of himself and eats better , leading to more careful routine clinical examinations . the present study aims to verify the effect on qol of an intensive fitness program in an elderly sample without depression as compared to a lighter postural - type fitness program . the study was carried out as part of the  a chentannos in salude  ( a typical sardinian saying , which could be translated as i hope you ll live a hundred years in good health  ) trial , a prospective population - based study for seniors carried out by the italian olympic committee ( coni ) in sardinia , approved by coni sardinia and conducted at the italian olympic committee in cagliari , italy , aiming to verify the physiological modifications induced by exercise in the elderly . participants were recruited by an announcement in a local newspaper , by medical doctors , and by flyers in pharmacies . approximately 350 people aged 65 or older were invited to participate and were contacted by phone to inform them about the study . more or less 180 people indicated their interest in participating in the study and were added to the list of inclusion - exclusion criteria , established by the doctors on the team . inclusion required at least one criteria between sedentary and dysmetabolism according to a medical check - list . in particular , sedentary was defined by an expenditure of energy of less than 1.5 metabolic equivalents ( mets ) , corresponding to remain sitting , reclined , or lying during most of the day ; according to the physical activity guidelines for older adults , we considered sedentary subjects that performed less than 30 minutes per day of moderate physical activity on five or fewer days per week . according to the american hearth association criteria , dysmetabolism was defined by the presence of at least one among : basal glycaemia  100 mg / dl , systolic blood pressure  130 mmhg and/or diastolic blood pressure  85 mmhg , high - density lipoprotein plasma cholesterol  40 mg / dl ( men ) or  50 mg / dl ( women ) , low - density lipoprotein plasma cholesterol  160 mg / dl ( men ) or  150mg / dl ( women ) , plasma triglycerides  150 mg / dl , waist circumference  102 cm ( men ) or  88 cm ( women ) , or a waist circumference of  94 cm ( men ) or  80 cm ( women ) in presence of 2 other criteria among the precedents . exclusion criteria were the presence of : any disease that could be a contraindication to performing a stress test ( such as unstable ischemic heart disease , uncontrolled hypertension , severe arrhythmia , valvular heart disease ) ; any osteoarticular pathology incompatible with exercise ( severe osteoporosis , acute connective tissue diseases , recent fractures , etc . ) ; neurological diseases or outcomes of debilitating neurological disorders ( stroke , dementia , neurodegenerative diseases , etc . ) ; neoplasms in place or disabling outcomes of cancer ; moderate to severe anemia ( hb<10 mg / dl ) ; obesity with bmi > 35 . moreover , subjects were included only if they did not have difficulty in reaching the gym where the trial was performed . all participants selected underwent a detailed medical examination , including anthropological measures ; electrocardiogram , blood pressure , and spirometry at rest and under stress test ; blood sampling for complete blood count ( cbc ) , glycaemia , total cholesterol , hdl and ldl cholesterol , triglycerides , azotemia , creatinine , cortisol . participants were randomly assigned in a 1:1 fashion to two different groups : vag ( vigorous activity group ) and pgg ( postural gymnastic group ) . the study was a 12-week randomized controlled trial with fitness sessions 3 times a week , 36 sessions in all , each session lasting 1 hour . participants continued their regular activity level and dietary habits and were instructed not to engage in any other physical program while participating in the study . the study started in april 2013 ( t0 ) and ended in july 2013 ( t1 ) . data were collected and included in the analysis only for subjects that completed 90% of the sessions with a maximum absence of 3 non - consecutive days . twelve weeks later , subjects were again assessed ( t2 ) , in order to measure wellbeing after the program and the potential persistence of results . according to acsm guidelines , physical activity ( pa ) was established as 60% to 84% of the heart rate reserve ( hrr ) and monitored continuously during activity with the heart - rate monitor polar t31 codedand also transmitted by a telemetry system ( hosand ) to the fitness professionals . the individual hrr for each participant was assessed according to the estimated maximal heart rate formula , where hrmax = 206.9- ( 0.67 x age ) . baseline hr was registered for all participants for three days , in the morning immediately after waking up , and the mean data was utilized . pa for the vag consisted of three phases : 1 ) warm up , up to 10-min , up to 60% of hrr 2 ) active phase , 45-min , from > 60% to 84% hrr 3 ) cool down , up to 10-min , < 60% of hrr . the active phase was designed as a mixture of aerobic and anaerobic exercises . the protocol design integrated drills of  life movements  , strength and balance . warm up phase , up to 60% of hrr , was designed with slow , dynamic movements using large muscle groups of the lower , middle and upper body , moving through full range of motion . subjects began with simple walks around the room with various arms movements , including some static and dynamic balance exercises and stretching for principal muscular groups . 60% to 84% hrr , was designed with dynamic exercises with and without the use of a platform ( step ) , continuous exercise with gradual increase of the difficulty and the intensity , departing from the walk around the step alternated to the basic step ( step up and down from the base with alternate footstep ) to reach the alternate lifts with inferior limbs flexes , extended out or flexed behind ( knee lift , side leg , leg curl ) , creating some brief and easy sequences to repeat . the last part of the active phase we have been introduced integrated multiple plane exercises for upper and lower limbs using elastic resistances ( xertube ) . cool down phase , < to 60% of hhr , it included cardio respiratory cool - down exercises followed by relaxation , postural control and spine mobility exercises in prone position ( knee - wrist ) in support on the platform , exercises of static equilibrium on 4 and 2 supports , with open and closed eyes and with activation of the cores muscles . it also included some post - stretch exercises to return muscles to a pre - exercises length for the muscular groups mostly involved during the workout . pa for the pgg was designed to maintain the heart rate  to 40% of hrr . it included static and dynamic exercise for postural control and spine mobility exercise in a prone position ( knee - wrist ) with support on the platform and static equilibrium exercises on 4 and 2 supports , with eyes open and closed and with activation of core muscles . pa was conducted by fitness professionals with degrees in sports and physical education and continuously monitored by a supervisor responsible for the hrr activity level . depressive symptoms in the two groups were measured at the three steps in the study by means of the patient health questionnaire ( phq9 ) . this self - administered questionnaire is a brief , field - tested screening for depression . the assessment is fast and easy , helping clinicians in the diagnosis and treatment of depression . a score between 10 and 15 indicates the presence of relevant depressive symptoms , while a score higher than 15 allows the diagnosis of major depressive disorders . the sf-12 is a self - evaluation in the previous month of : physical activity , limitations due to physical problems on roles or activities , pain , emotional and general health status , vitality , social activities and mental health . comparison of phq9 scores between groups was carried out by means of anova 1-way statistics . the scores for the sf-12 in the two groups were compared with the normative score for a large national sample standardized by age and sex , drawn from a national survey in italy   by anova 1-way statistics . to test differences between the two groups ( vag and pgg ) on the sf-12 and phq9 over time , we conducted a multivariate analysis of variance ( manova ) , with  group  as the between - subjects factor . each subject in the study was identified with a code number not amenable to their name by researchers . the study was approved by the board of the  comitato olimpico nazionale italiano  ( coni ) of the sardinia region . the study was carried out as part of the  a chentannos in salude  ( a typical sardinian saying , which could be translated as i hope you ll live a hundred years in good health  ) trial , a prospective population - based study for seniors carried out by the italian olympic committee ( coni ) in sardinia , approved by coni sardinia and conducted at the italian olympic committee in cagliari , italy , aiming to verify the physiological modifications induced by exercise in the elderly . participants were recruited by an announcement in a local newspaper , by medical doctors , and by flyers in pharmacies . approximately 350 people aged 65 or older were invited to participate and were contacted by phone to inform them about the study . more or less 180 people indicated their interest in participating in the study and were added to the list of inclusion - exclusion criteria , established by the doctors on the team . inclusion required at least one criteria between sedentary and dysmetabolism according to a medical check - list . in particular , sedentary was defined by an expenditure of energy of less than 1.5 metabolic equivalents ( mets ) , corresponding to remain sitting , reclined , or lying during most of the day ; according to the physical activity guidelines for older adults , we considered sedentary subjects that performed less than 30 minutes per day of moderate physical activity on five or fewer days per week . according to the american hearth association criteria , dysmetabolism was defined by the presence of at least one among : basal glycaemia  100 mg / dl , systolic blood pressure  130 mmhg and/or diastolic blood pressure  85 mmhg , high - density lipoprotein plasma cholesterol  40 mg / dl ( men ) or  50 mg / dl ( women ) , low - density lipoprotein plasma cholesterol  160 mg / dl ( men ) or  150mg / dl ( women ) , plasma triglycerides  150 mg / dl , waist circumference  102 cm ( men ) or  88 cm ( women ) , or a waist circumference of  94 cm ( men ) or  80 cm ( women ) in presence of 2 other criteria among the precedents . exclusion criteria were the presence of : any disease that could be a contraindication to performing a stress test ( such as unstable ischemic heart disease , uncontrolled hypertension , severe arrhythmia , valvular heart disease ) ; any osteoarticular pathology incompatible with exercise ( severe osteoporosis , acute connective tissue diseases , recent fractures , etc . ) ; neurological diseases or outcomes of debilitating neurological disorders ( stroke , dementia , neurodegenerative diseases , etc . ) ; neoplasms in place or disabling outcomes of cancer ; moderate to severe anemia ( hb<10 mg / dl ) ; obesity with bmi > 35 . moreover , subjects were included only if they did not have difficulty in reaching the gym where the trial was performed . all participants selected underwent a detailed medical examination , including anthropological measures ; electrocardiogram , blood pressure , and spirometry at rest and under stress test ; blood sampling for complete blood count ( cbc ) , glycaemia , total cholesterol , hdl and ldl cholesterol , triglycerides , azotemia , creatinine , cortisol . participants were randomly assigned in a 1:1 fashion to two different groups : vag ( vigorous activity group ) and pgg ( postural gymnastic group ) . the study was a 12-week randomized controlled trial with fitness sessions 3 times a week , 36 sessions in all , each session lasting 1 hour . participants continued their regular activity level and dietary habits and were instructed not to engage in any other physical program while participating in the study . the study started in april 2013 ( t0 ) and ended in july 2013 ( t1 ) . data were collected and included in the analysis only for subjects that completed 90% of the sessions with a maximum absence of 3 non - consecutive days . twelve weeks later , subjects were again assessed ( t2 ) , in order to measure wellbeing after the program and the potential persistence of results . according to acsm guidelines , physical activity ( pa ) was established as 60% to 84% of the heart rate reserve ( hrr ) and monitored continuously during activity with the heart - rate monitor polar t31 codedand also transmitted by a telemetry system ( hosand ) to the fitness professionals . the individual hrr for each participant was assessed according to the estimated maximal heart rate formula , where hrmax = 206.9- ( 0.67 x age ) . baseline hr was registered for all participants for three days , in the morning immediately after waking up , and the mean data was utilized . pa for the vag consisted of three phases : 1 ) warm up , up to 10-min , up to 60% of hrr 2 ) active phase , 45-min , from > 60% to 84% hrr 3 ) cool down , up to 10-min , < 60% of hrr . the protocol design integrated drills of  life movements  , strength and balance . warm up phase , up to 60% of hrr , was designed with slow , dynamic movements using large muscle groups of the lower , middle and upper body , moving through full range of motion . subjects began with simple walks around the room with various arms movements , including some static and dynamic balance exercises and stretching for principal muscular groups . active phase , from > 60% to 84% hrr , was designed with dynamic exercises with and without the use of a platform ( step ) , continuous exercise with gradual increase of the difficulty and the intensity , departing from the walk around the step alternated to the basic step ( step up and down from the base with alternate footstep ) to reach the alternate lifts with inferior limbs flexes , extended out or flexed behind ( knee lift , side leg , leg curl ) , creating some brief and easy sequences to repeat . the last part of the active phase we have been introduced integrated multiple plane exercises for upper and lower limbs using elastic resistances ( xertube ) . cool down phase , < to 60% of hhr , it included cardio respiratory cool - down exercises followed by relaxation , postural control and spine mobility exercises in prone position ( knee - wrist ) in support on the platform , exercises of static equilibrium on 4 and 2 supports , with open and closed eyes and with activation of the cores muscles . it also included some post - stretch exercises to return muscles to a pre - exercises length for the muscular groups mostly involved during the workout . pa for the pgg was designed to maintain the heart rate  to 40% of hrr . it included static and dynamic exercise for postural control and spine mobility exercise in a prone position ( knee - wrist ) with support on the platform and static equilibrium exercises on 4 and 2 supports , with eyes open and closed and with activation of core muscles . pa was conducted by fitness professionals with degrees in sports and physical education and continuously monitored by a supervisor responsible for the hrr activity level . depressive symptoms in the two groups were measured at the three steps in the study by means of the patient health questionnaire ( phq9 ) . this self - administered questionnaire is a brief , field - tested screening for depression . the assessment is fast and easy , helping clinicians in the diagnosis and treatment of depression . a score between 10 and 15 indicates the presence of relevant depressive symptoms , while a score higher than 15 allows the diagnosis of major depressive disorders . the sf-12 is a self - evaluation in the previous month of : physical activity , limitations due to physical problems on roles or activities , pain , emotional and general health status , vitality , social activities and mental health . comparison of phq9 scores between groups was carried out by means of anova 1-way statistics . the scores for the sf-12 in the two groups were compared with the normative score for a large national sample standardized by age and sex , drawn from a national survey in italy   by anova 1-way statistics . to test differences between the two groups ( vag and pgg ) on the sf-12 and phq9 over time , we conducted a multivariate analysis of variance ( manova ) , with  group  as the between - subjects factor . each subject in the study was identified with a code number not amenable to their name by researchers . the study was approved by the board of the  comitato olimpico nazionale italiano  ( coni ) of the sardinia region . 21 subjects were assigned to treatment with the vag ( 12 males , 9 females ) , mean age 69.243.94 ; 21 subjects were assigned to treatment with the pgg ( 14 males and 7 females ) , mean age 70.05.374 ) . in the vag , 3 subjects reported at least one previous depressive episode , one of them being treated with antidepressant drugs . two other subjects were receiving benzodiazepines . in the pgg , one person reported at least one previous depressive episode . 11 subjects were receiving pharmacological treatment , in 7 cases multiple drug treatment . in the pgg , 15 subjects were taking medication , in11 cases multiple drugs . in the vag , concomitant organic diseases were : hypertension ( 8 subjects ) , hypercholesterolemia ( 3 subjects ) and osteoporosis ( 2 subjects ) ; in the pgg , 8 subjects were suffering from hypertension , 5 from diabetes mellitus ( type 1 in one case ) , 4 from hypercholesterolemia , 4 from non - severe heart disease ( heart failure , atrial fibrillation , aorto - coronary bypass ) , 3 from thyroid diseases ( post - surgical hypothyroidism , hashimoto 's thyroiditis ) and 2 from musculoskeletal diseases ( arthritis , osteoporosis ) . two subjects in the vag group and one in the pgg group dropped out of the study . table 1 shows the score on the phq9 at t0 , t1 , and t1 . both the vag and pgg showed low phq9 scores at t0 , ( anova 1 way : vag : f=0.004 ; p=0.996 ; df 1 , 57,59 ; pgg : f= ; 0.078 ; p=0.925 ; df 1 , 54,56 ) , and scores did not change considering the two factors of time and group ( see table 1 . manova phq9 : time f=0.865 ; p=0.431 ; df 2 , 32 ; group f=0.284 ; p=0.598 ; df 1 , 33 ; time*group f=1.689 ; p=0.201 ; df 2 , 32 ) . table 2 shows sf-12 scores at t1 and t2 for the vag , pgg and a normative sample . at the end of the study ( t1 ) , the level of qol measured by means of sf-12 scores was better in both the vag and the pgg groups than in the normative standardized sample . sf-12 scores for the two groups decreased slightly 12 weeks after the end of the trial ( t2 ) , with no significant differences considering the two factors of time and group ( see table 3 . manova sf-12 : time f=1.386 ; p=0.247 ; df 1 , 35 ; group f=0.246 ; p=0.623 ; df 1 , 35 ; time*group f=0.026 ; p=0.872 ; df 1 , 35 ) . however , the difference between the vag and the normative sample remained statistically significant ( anova 1 way : f=5.52 ; p=0.019 ; df 1 , 703 , 704 ) , while the level of qol in the pgg group did not differ from the normative sample ( anova 1 way : f=3.10 ; p=0.079 ; df 1 , 703 , 704 ) . the results of the study indicate that a sample of elderly people undergoing either a demanding exercise program or a light postural gymnastic program for 12 weeks had a subjective level of appreciation in their qol , at the end of the trial , higher than the average for individuals of the same age and sex living in the community . the scores for perceived qol tended to decrease 12 weeks after the end of the trial , although the difference between the scores at the end of the trial and the 12-weeks - later scores did not significantly differ between groups and time . nevertheless , while the sample of subjects in the pgg group did not differ as compared with the general population , the sample in the vag group maintained a higher level of qol than the normative score for a community sample . previous evidence from the literature stated the effectiveness of exercise in improving mental wellbeing in older people , particularly with a group - based physical activity supervised by trained leaders , with a minimum of two weekly exercise sessions of 45 minutes each . the concept of mental well - being as positive psychological functioning encompassing happiness , life satisfaction and self - esteem [ 27 , 28 ] is quite different from that represented by quality of life , a notion including a more general concept regarding all relevant aspects of life . our findings suggest that exercise might be associated with a wide range of components of wellbeing , such as subjective satisfaction in life . notably , the training group in the present study performed vigorous mixed aerobic / anaerobic physical activity , while most of the trials carried out on healthy elderly people consisted of mild to moderate mixed or aerobic exercise . nevertheless , the drop - out rate in the vag group was low ( 9.5% ) , confirming demanding pa to also be appropriate for elderly people , who are able to adapt and respond to both endurance and strength training . the role of physical activity as a clinical management strategy for depression in the elderly has been widely debated . a recent review of the literature concluded that evidence from high - quality studies was generally positive , but that the effect on depression was minimal . it was argued that participation in physical recreational activities might lead to better qol outcomes , and this effect has been shown as well in patients suffering from treatment - resistant depression [ 32 , 33 ] . qol has become an important outcome criterion for psychiatric intervention , particularly in chronic disorders . patients suffering from either current depressive disorder or milder depressive symptoms have been showed to have worse physical , social , and role functioning , and to feel more physical pain than patients without chronic depressive conditions . moreover , a high qol has been shown to be related to positive outcomes in preventive intervention in healthy elderly people , like healthy nutrition and physical activity behavior , recognized as reducing the risk of premature lethality from myocardial infarction , arterial hypertension , colon cancer , type 2 diabetes , osteoporosis and obesity . recently , it has been highlighted the role of exercise in enhancing metabolic , structural and functional dimensions of the aging brain , determining neuroprotection and preserving cognitive performance . the neurotrophic effect of exercise , which is well known in animals , has been shown in humans and hypothesized to be related to the increase of neurotrophic factors , such as the brain - derived neurotrophic factor ( bdnf ) , mainly in the hippocampus , involved in memory and mood disorders . this effect of exercise on old people s brain could be an important mediator for the improvement on qol , and it could protect against a cognitive decline and the loss of autonomy . conversely , it might be also argued that a high qol in elderly people could be a strong motivation to follow a healthy lifestyle , acting as preventive intervention per se . nevertheless , some methodological problems affected the assessment of qol . there is a possible measurement overlap between qol and psychopathology , especially depression , which may invalidate research results . recently , the longitudinal investigation of depression outcomes ( lido ) trial   pointed out that measures of physical and mental health functioning , and qol showed significant longitudinal associations with measures of depressive symptoms . moreover , during a current major depressive disorder , mental health - related measurements tended to get worse , while those for physical health changed the least , with measurement of change in qol in depression being intermediate . in our study , the result regarding qol can not have been influenced by a depressive condition , as it was absent in both samples before , during and after the trial . this independence of results might suggest that the improvement in qol due to physical exercise may be one of the protective factors against depression in old age . elderlies suffering from chronic conditions tend to do less physical activity , thus determining a decrease in motility and functional limitations that could affect overall wellbeing . the issue of loneliness is particularly important for older people , and social contacts might positively influence qol . moreover , qol improved in both the vag and pgg groups after exercise , proving that qol is a construct modifiable with health promotion behavior . this research was not specifically designed to prove our hypothesis ; the sample is small and the association between high qol and physical activity at the end of the trial might be due to a subject - selection bias , in particular as regards their wellbeing before exercise . . however , the tendency of scores for the normative sample to decrease to the average of scores for the national sf-12 twelve weeks after the end of the trial is a convincing argument regarding the exercise as determinant of the improve in qol . a 12-week high - intensity program of aerobic / anaerobic physical activity in a sample of subjects aged 65 and over was shown to be associated with higher qol than a lighter program of a postural type , as compared to the qol for a normative sample . after 12 weeks of de - training , the group that trained at high intensity maintained a higher level of self - rated qol as compared to both the low - intensity exercising group and the normative sample . quality of life tends to decrease with age , particularly in presence of chronic diseases and depression . physical activity improves several features related to quality of life , such as sleep and motility . we show that a high - intensity program of aerobic / anaerobic exercise results associated with a higher quality of life in a sample of elderlies , and this finding is maintained after 12 weeks of de - training . a high quality of life associated with physical activity might be a protective factor against chronic conditions in old age .
introduction : quality of life ( qol ) tends to decrease with age . 
 exercise has been shown to be effective in improving 
 some psychosocial features related to qol . 
 we carried out a randomized controlled trial to verify the long - term 
 efficacy of an intensive fitness program versus a lighter program on the qol of an elderly sample , compared to qol of a 
 large normative sample.methods:participants aged 65 years were randomly assigned in a 1:1 fashion either to a vigorous 
 physical activity program group ( vag ) or to a postural gymnastic group ( pgg ) . 
 depressive symptoms were screened 
 by phq-9 . 
 qol assessment was done by sf-12 . 
 multivariate analysis of variance ( manova ) was conducted to test 
 differences between the two groups over time . 
 comparison with the normative sample was carried out by means of 
 anova 1-way.results:both vag and pgg showed low phq9 scores at the beginning and at the end of the trial , 
 indicating the absence of depressive symptoms . at the end of the study 
 , both groups had a higher level of qol , measured 
 by means of sf-12 , than the normative standardized sample . 
 while sf-12 scores for both groups decreased slightly 12 
 weeks after the end of the trial , only the vag group maintained significantly - higher scores than those of the normative 
 sample.conclusions:a vigorous physical activity program group might be associated with better maintenance of results 
 over time as compared to a postural gymnastic program . 
 these results require future confirmation by further studies on 
 large samples .