Analysis of the implementation of the TEIA Program

Inter-subject evaluation (1^st evaluation)

With regard to the inter-subject evaluation in the 1^st evaluation, it is important to point out some data.

Regarding the distribution of the gender variable, either in the total sample or in the two groups that constitute it, the distribution was equal and with a representation of 50% for each of the genders, unlike most studies where there was a greater representation of the female gender^34,35, as well as, in the Portuguese population, between the age group 80-84 years-old, the average age in our study, where about 62% of the population is female³.

As for marital status, they are married and widowed with greater expression, followed by separate/divorced and single marital status in both study groups, analogous to the study by Possamai Menezes et al.³⁶. The distribution of educational qualifications showed that 50% or more of the participants in both groups had educational qualifications higher than the 1^st cycle, coinciding with another study³³.

Regarding the other variables, in the inter-subject analyzes in the 1st assessment, confirmed with the respective statistical tests, it was found that the groups did not have statistically significant differences, except for the BMI value and the physical performance dimension of the life questionnaire associated with health SF-36. This allowed us to conclude that the groups before the implementation of the TEIA program were very equivalent, thus contributing to guarantee the internal validity of the study. Given that the more similar the program and control groups are in recruitment and the more these similarities are confirmed by the tests of the 1st assessment, the more effective this control will be²¹.

Intra-subject evaluation (program group)

There were several findings that met with the implementation of the program, namely: the reduction in blood pressure, the decrease in heart rate, the decrease in weight and consequently the BMI and repositioning in the BMI categories. As well as the change in the perception of quality of life associated with urinary incontinence; the decrease in fear of falling; better balance performance; improvement in cognitive aptitude and variation in the perception of health-related quality of life.

The systolic and diastolic value, in the program group, suffered a statistically significant decrease. Based on the norm on arterial hypertension defined by the General Directorate of Health, 2013, the systolic values ​​changed from a high normal classification to a normal classification. The diastolic values, on the other hand, maintain an optimal classification³⁷. The value of heart rate at rest from the 1^st to the 2^nd evaluation decreased, this finding is in agreement with the relationship that exists between the effect of physical activity and the decrease in HR at rest³⁸.

Now approaching the assessment of weight and BMI, it was found that in the intra-subject assessment of the program group there was weight loss, on average of 1kg and consequently the BMI also decreased, leading to a repositioning of the BMI category. Although this average value maintains this sub-sample in the pre-obese category, it is noteworthy that there was a variation in the number of people who went from the obese grade I category to pre-obese. Once again, the relationship between physical activity and the reduction in weight and BMI was proven³⁹.

The perception of quality of life associated with urinary incontinence was assessed through the International Consultation on Incontinence Questionnaire - Short Form; it was found that there was a decrease in the mean score of the questionnaire. Contributing to this score reduction was the tendency of score decrease in all the questions in the questionnaire that contribute to the final score. This variation in results can be attributed to the analysis that was carried out to question 6, in the first assessment, which in this way allowed us to understand which types of urinary incontinence were more frequent, in the sub-sample, and thus adapt to more effective strategies to reduce the frequency, the quantity and impact of urinary incontinence, proving the relationship between pelvic floor muscle training and behavioral therapy as predictors of improved quality of life associated with urinary incontinence^40,41.

Analyzing now the Falls Efficacy Scale I score, it was found that there were differences between the 1^st and 2^nd assessment in the program group, with the average score increasing. Through these values, it was found that the fear of falling decreased, since the participants are more confident in performing the 10 tasks that the scale includes, thus enhancing the association between balance training and fear of falling^35,42.

The scores of the Tinetti test, Berg Balance Scale and Timed Up and Go test also changed from the 1^st to the 2^nd assessment. In the Tinetti Test and in the Berg Balance Scale, the average score increased and the mode of the scores was also in favor of the trend towards an increase in the score. The average time of the Timed Up and Go test decreased from the 1^st to the 2^nd assessment. Through these results, we can attest that program group participants improved mobility and consequently improved gait, balance, static and dynamic performance, which may be a predictor of decreased risk of falling in the elderly^31,33,43.

When analyzing the performance of the participants in relation to the execution of instrumental activities of daily living, it was found that there were no statistically significant differences between the 1^st and 2n^d assessments, and the average score of the Lawton-Brody Index remained. However, in the analysis of the score variation for each item in the Index, it was found that there were statistical differences in the responses to the items "Taking care of the house", "Preparing food", "Going shopping" and "Use of transportation", or that is, the answers that confer greater independence had an increase from the 1^st to the 2^nd assessment. The above leads us to infer that the participants felt more confident in performing domestic tasks, such as taking care of the house and preparing food, as well as going abroad.

The relationship between fear of falling, quality of life and performing instrumental activities of daily living was established in the studies by Jahana and Diogo, 2007 and Fhon et al., 2012. Effectively, the TEIA Program contributed to reducing the fear of falling, but despite the fact that the average score did not change, it was evident that in certain instrumental activities of daily living there was an improvement in the confidence to perform them, namely, in the instrumental activities mentioned above. Similar results have been obtained in other studies^44,45.

Also, in the analysis of the 15-question Geriatric Depression Scale, it was found that there were no statistical changes in the intra-subject analysis. It was found that in the program group, the mean score of the participants remained in the cohort points suggestive of “no depressive symptoms”. Allied to this data was the fact that there was an increase in the percentage of the number of participants, who moved to this classification.

The fear of falling and the frequency of falls can make the elderly person more anxious and more depressed, therefore it leads to social isolation, decreased physical activity, spending more time sitting or lying down, impairing mobility and independence in self-care. We have already verified with the implementation of the TEIA Program, the participants reduced their fear of falling and this factor can be reflected in depressive symptoms^44-46.

The decay of cognitive function can lead to an increase in the number of falls in the elderly population, and for this reason, cognitive stimulation was included in the structure of the TEIA Program. The average score of the 6-item Cognitive Decline Test scale, from the 1^st to the 2^nd assessment in the program group, decreased, suggesting better cognitive performance, which means that the implementation of a cognitive stimulation program for the elderly population contributes to a better performance in cognitive functions³².

Guszman et al., 2015 established the relationship between fear of falling and cognition, that is, when the first increases, the second is declining, with an intrinsic relationship between cognition and the level of physical activity, which can lead to limited mobility, meaning, mobility is affected by cognition if it limits physical activity⁴⁷. The TEIA Program was shown to improve confidence, mobility, gait performance and balance, leading to a reduction in fear of falling. It also improved the performance of cognition, soon the cognitive functions, namely those related to the fear of falling, prospered. The relationship between the training of cognition and the fear of falling was evidenced.

It was our intention to understand how the TEIA Program interfered with the quality of life associated with the health of the participants. Through the scores of the SF-36 Health Associated Life Questionnaire, in its various dimensions, it was found that in the intra-subject evaluation of the program group, there were statistically significant differences, both in the physical component (physical function, physical performance, pain and general health) or in the mental component (vitality, social function, emotional performance and mental health). The aforementioned, proves that the TEIA Program had a positive implications for the quality of life of the participants^31,48.

Regarding the intra-subject evaluations of the program group, it was validated that the TEIA Program introduced statistically significant changes in the quality of life associated with urinary incontinence, fear of falling, balance performance, whether static or dynamic, mobility, gait, in some instrumental activities of daily living, in depressive symptoms, cognitive function and health-related quality of life. In all these variables, there was an improvement in their performance, which translates into better physical and mental performance, as well as benefits in the perception of quality of life. Training allowed for secondary gains, such as the decrease in tension values, heart rate, weight and BMI.

Inter-subject evaluation 2^nd assessment

With regard to the inter-subject assessment, after the implementation of the TEIA Program, it was found that in the perception of quality of life when it is associated with urinary incontinence, there were statistically significant differences, findings in agreement with the study by Berlezi et al., 2013⁴⁹ showing again the relation between pelvic floor muscle training and behavioral therapy, and the perception of quality of life associated with urinary incontinence.

Regarding the assessment of fear of falling, it was found that although there was a decrease in fear of falling after the implementation of the TEIA Program in the program group, there were no statistically significant differences between the program group and the control group, a very similar result to that found in other studies^31,42, this fact may be related to the sample size.

When examining the scores of the Tinetti test, Berg Balance Scale and the running time of the Timed Up and Go test, it was found that there were statistically significant differences. We can conclude that the TEIA Program, in its balance training component, managed to improve static and dynamic balance, mobility, gait, stability in walking, which indirectly produced a decrease in the risk of falling in agreement with the findings of other studies^13,33,42, contributing to the evidence of the relation between balance training and decreased risk of falls in the elderly people.

In the assessment of dependence on instrumental activities of daily living and depression, it was validated that there were no differences between groups. In a study on cognitive stimulation by Apóstolo et al., 2011 findings were the same, although they showed gains in the intra-subject evaluation in the program group, as happened after the implementation of the TEIA Program¹¹, attributing this data to the sample size.

In the cognition variable, despite the statistically significant differences, in the intra-subject evaluation in the program group, it was found that there were no statistically significant gains between the groups. We can infer that this analysis may be related to the fact that the sample is small to support this difference. No studies were found that used only the 6-item Cognitive Decline Test scale, in order to relate the results.

The statistically significant differences observed in the intra-subject assessment, regarding the perception of quality of life associated with health, were not confirmed in the inter-subject assessment for the physical component. It’s different evidence to what was found in the study by Kyrdalen et al., 2013, in which there were differences between groups in the physical component, but not in the mental component³¹.

In short, the 2^nd evaluation showed intergroup differences in the perception of quality of life associated with urinary incontinence, in balance performance, in gait, in the perception of quality of life associated with health in the mental component. There were no statistically significant changes in the cognition variable, which may be related to the fact that the study sample was small.