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Associations of Schizophrenia Symptoms and Neurocognition With Physical Activity in Older Adults With
Schizophrenia
Heather Leutwyler, Erin M. Hubbard, Dilip V. Jeste, Bruce Miller and Sophia Vinogradov
Biol Res Nurs 2014 16: 23 originally published online 19 September 2013
DOI: 10.1177/1099800413500845

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Special Section Article

Biological Research for Nursing


2014, Vol 16(1) 23-30
Associations of Schizophrenia Symptoms The Author(s) 2013
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and Neurocognition With Physical Activity DOI: 10.1177/1099800413500845
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in Older Adults With Schizophrenia

Heather Leutwyler, RN, PhD, FNP-BC, CNS1, Erin M. Hubbard, MA1,


Dilip V. Jeste, MD2, Bruce Miller, MD3, and Sophia Vinogradov, MD4,5

Abstract
Background: Low levels of physical activity contribute to the generally poor physical health of older adults with schizophrenia.
The associations linking schizophrenia symptoms, neurocognition, and physical activity are not known. Research is needed to
identify the reasons for this populations lack of adequate physical activity before appropriate interventions can be designed
and tested. Design and Methods: In this cross-sectional study, 30 adults aged 55 years with schizophrenia were assessed
on symptoms (Positive and Negative Syndrome Scale), neurocognition (MATRICS Consensus Cognitive Battery), and physical
activity (Sensewear ProArmband). Pearsons bivariate correlations (two-tailed) and univariate linear regression models were used
to test the following hypotheses: (1) more severe schizophrenia symptoms are associated with lower levels of physical activity and
(2) more severe neurocognitive deficits are associated with lower levels of physical activity. Results: Higher scores on a speed-of-
processing test were associated with more average daily steps (p .002) and more average daily minutes of moderate physical
activity (p .009). Higher scores on a verbal working memory task were associated with more average daily minutes of moderate
physical activity (p .05). More severe depressive symptoms were associated with more average daily minutes of sedentary
activity (p .03). Conclusion: Physical activity interventions for this population are imperative. In order for a physical
activity intervention to be successful, it must include components to enhance cognition and diminish psychiatric symptoms.

Keywords
schizophrenia, physical activity, symptomatology, neurocognition

Schizophrenia is a severe chronic psychotic disorder (National activity may hinder a persons ability to care for his or her
Institute of Mental Health [NIMH], 2007). Older adults with health needs. The multitude of chronic medical conditions
schizophrenia are an expanding segment of the population, and people with schizophrenia experience, such as chronic obstruc-
data indicate that their physical health status is exceedingly tive pulmonary disease, can jeopardize their ability to achieve
poor (Chafetz, White, Collins-Bride, Nickens, & Cooper, optimal levels of physical activity.
2006; Kilbourne et al., 2005; Parks, Svendsen, Singer, Foti, Investigators have tested various physical activity programs
& Mauer, 2006). Low levels of physical activity contribute to in people with schizophrenia that have included activities such
this poor health status. Viertio et al. (2009) found, for example, as walking and weight training (Gorczynski & Faulkner, 2010).
that decrements in physical activity contribute to poor health The impacts of these programs on physical activity levels were
outcomes, increased use of health services, and decreased qual-
ity of life in older adults with schizophrenia. In order to
1
improve the physical activity levels of older adults with schizo- Department of Physiological Nursing, University of California, San Francisco,
phrenia, tailored interventions are needed. Before interventions CA, USA
2
can be successfully designed and tested, however, researchers Sam and Rose Stein Institute for Research on Aging, Department of Psychiatry
and Neurosciences, University of California, San Diego, CA, USA
must identify the reasons for this populations inadequate 3
Memory & Aging Center, University of California, San Francisco, USA
levels of physical activity. 4
Department of Psychiatry, University of California, San Francisco, CA, USA
5
The U.S. Department of Health and Human Services (2008) San Francisco VA Medical Center, San Francisco, CA, USA
defines physical activity as any bodily movement that enhances
health. Optimization of physical activity may help delay dis- Corresponding Author:
Heather Leutwyler, RN, PhD, FNP-BC, CNS, Department of Physiological
ability and maintain independence (Tirodkar, Song, Chang, Nursing, University of California, 2 Koret Way, N631A, Box 0610, San
Dunlop, & Chang, 2008). Physical activity also enhances mood Francisco, CA 94143, USA.
and cognition (Deslandes et al., 2009). Limitations in physical Email: heather.leutwyler@nursing.ucsf.edu

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24 Biological Research for Nursing 16(1)

mixed. In general, the studies provide support for the physiolo- Performance tests in participants aged 55 and older included
gical and psychological benefits of physical activity in people walking ability on a timed 6.1-m course, ability to rise from
with schizophrenia; however, adherence to the programs was a chair, walking 2 m flat, walking 2 m on toes, climbing up and
consistently low. To date, only one published study has down two steps, squatting, and handgrip strength. Of the 6,927
described a physical activity program that was focused on older persons evaluated, 185 participants were identified as having
adults with schizophrenia (Leutwyler, Hubbard, Vinogradov, had a diagnosis of a psychotic disorder some time in their lives
& Dowling, 2012), and only one study has explored the barriers as follows: schizophrenia (n 61, mean age 53.4 years), other
to physical activity in this population (Leutwyler, Jeste, Hub- nonaffective psychosis (n 79, mean age 57.9 years), and
bard, & Vinogradov, 2013). These studies suggest that, though affective psychosis (n 45, mean age 53.9 years). Interviews,
older adults with schizophrenia are interested in becoming case notes, and standard symptom scales were used to calculate
more physically active, the symptoms of schizophrenia are summary scores for positive, disorganized, and negative
often a considerable barrier to physical activity. symptoms in this subgroup. In the group with nonaffective psy-
Schizophrenia symptoms can be categorized as positive, chosis, mobility difficulties were associated with greater sever-
negative, depressive/anxious, disorganized, excitatory, and ity of symptoms.
other (Poole, Tobias, & Vinogradov, 2000). Positive symptoms In addition to psychiatric symptoms, people with schizo-
include hallucinations and delusions. Negative symptoms phrenia have impaired neurocognition (Keefe et al., 2006).
include apathy, emotional withdrawal, and motor retardation. Neurocognition links cognitive constructs, in theory, to partic-
Depressive/anxious symptoms include depression and anxiety. ular brain regions, systems, and processes. Neurocognitive
Disorganized symptoms include conceptual disorganization. impairment is a central aspect of schizophrenia and is distinct
Excitatory symptoms include tension and euphoric mood. from the symptomatology of the disease (Matza et al., 2006).
Other symptoms include preoccupation, stereotyped thinking, Fundamental dimensions of cognitive impairment in schizo-
and disorientation. These symptoms can significantly impact phrenia include working memory, attention/vigilance, verbal
the physical health of people with schizophrenia. For example, learning and memory, visual learning and memory, reasoning
investigators found a positive association between number of and problem solving, speed of processing, and social cognition
medical problems and severity of schizophrenia symptoms (Matza et al., 2006; Nuechterlein, 2004). Cognitive impairment
(Dixon, Postrado, Delahanty, Fischer, & Lehman, 1999; Fried- in people with schizophrenia is a strong predictor of impaired
man et al., 2002). Some patients with schizophrenia believe psychosocial functioning, affecting, for example, work and
that engaging in effective self-care is not possible when psy- social behavior (Matza et al., 2006; McGurk, Mueser, DeRosa,
chotic symptoms become overwhelming (El-Mallakh, 2006). & Wolfe, 2009). Neurocognition may also impact physical
Inagaki et al. (2006) found that schizophrenia symptoms may health.
play a role in the delay of diagnosis and treatment of cancer. Two studies have evaluated the relationship between neuro-
For example, in patients with severe negative symptoms, by the cognition and physical function, but none have specifically
time the cancer was diagnosed, the disease had advanced and explored physical activity and neurocognition in schizophrenia
was no longer amenable to first-line treatment; it was often not (Chwastiak et al., 2006; Friedman et al., 2002). In one study,
possible to provide early notification to patients who refused or investigators evaluated 124 institutionalized geriatric patients
interrupted treatment; and they had more difficulty understand- with schizophrenia to identify characteristics that best pre-
ing and cooperating with the treatment. In addition, symptoma- dicted changes in self-care functions associated with aging
tology may limit insight into illness, which can lead to missed (Friedman et al., 2002). Functional status, negative symptoms,
opportunities for participating in activities to prevent and cognitive functioning, and health status worsened over the
screen for diseases (Copeland, Zeber, Rosenheck, & Miller, course of the 4-year study. Path analysis demonstrated that con-
2006; Jeste, Gladsjo, Lindamer, & Lacro, 1996). Less than current changes in cognitive functioning had the largest effect
adequate medical treatment has been associated with many fac- on changes in functional status, with greater degrees of cogni-
tors in patients with schizophrenia, such as stigma and commu- tive decline associated with increased loss in functional status.
nication barriers (Leutwyler & Wallhagen, 2010). In the case of In Chwastiak and colleagues study (2006), researchers evalu-
less than adequate medical treatment for comorbid medical ated the interrelationship between neurocognitive function and
conditions in these patients, investigators also found an associ- physical function using baseline data from the Clinical Anti-
ation with higher depression scores and number of positive psychotic Trials of Intervention Effectiveness (CATIE) trial,
symptoms (Vahia et al., 2008). a national multisite trial of antipsychotic pharmacotherapy that
Only one study has explored the relationship between collected data from more than 1,400 patients (ages 1865
psychiatric symptoms and aspects of physical activity (physical years, mean age 40.6 years). Neurocognitive function was mea-
function) in older adults with schizophrenia (Viertio et al., sured using a neurocognitive assessment battery that included
2009). In that study, a nationally representative sample of 11 measures of verbal fluency, working memory, verbal learn-
6,927 persons in Finland self-reported mobility limitations and ing and memory, social cognition, motor function, attention,
underwent performance tests. Self-reported mobility was and executive function. Results showed that more severe
assessed with questions about activities that involve mobility neurocognitive impairment was associated with poorer physi-
such as moving around the house, running, and bicycling. cal function.

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Leutwyler et al. 25

evaluate the meaning of these symptoms, and respond to these


meanings in a biopsychosocial manner. The outcome in the
Symptom Experience present study was physical activity. Our goal was to increase
our understanding of the relationships between the symptom
experience and outcome in order to be able to design physical
activity interventions tailored specifically for the older adults
with schizophrenia.

Design
We used a cross-sectional design to examine our hypotheses.
All participants gave written informed consent, and the Com-
Outcomes and Components of mittee on Human Research at the UCSF and the Department
Symptom Status Symptom Management of Veterans Affairs Medical Center approved the protocol.
Strategies
We maintained anonymity and confidentiality according to the
committees guidelines.
Figure 1. Relationships among the primary dimensions of the theory
of symptom management. Adapted, with permission from John Wiley, Participants and Settings
from Dodd et al., 2001.
We recruited participants from three sites: a transitional
residential and day treatment center for older adults with
The studies by Chwastiak et al. (2006), Friedman et al.
severe mental illness; a locked residential facility for adults
(2002), and Viertio et al. (2009) suggest that more severe
diagnosed with serious mental illnesses; and an intensive
symptomatology and impaired neurocognition negatively
case-management program. We used multiple sites in order
impact physical function. The findings of these studies are lim-
to obtain a sample with a range of psychiatric symptoms and
ited, however, by the lack of objective assessment of physical
levels of physical activity. Institutional review board-
activity and of a comprehensive neurocognitive assessment. In
approved information about the study was posted at these
addition, no studies to date have evaluated the relationships
sites, and staff were also informed about the study. We also
between psychiatric symptoms and neurocognition and physi-
accepted participant referrals from the community and other
cal activity specifically in older adults with schizophrenia. The
participants. Participants were remunerated US$60 after
purpose of the present study was to explore these relationships
completion of the first assessment, US$30 after they wore a
in older adults with schizophrenia, testing the following
physical activity monitor for 1 week, and a bonus payment
hypotheses: (1) more severe schizophrenia symptoms are asso-
of US$20 if they completed all of the study procedures.
ciated with lower levels of physical activity and (2) more
Participants were English-speaking adults, aged 55 years or
severe neurocognitive deficits are associated with lower levels
older, with a Diagnostic and Statistical Manual of Mental Dis-
of physical activity.
orders (Fourth Edition; DSM-IV) diagnosis of schizophrenia or
schizoaffective disorder who passed a capacity-to-consent test
Method based on comprehension of the consent form.
Theoretical Framework
The theoretical framework for this study was the University of
Procedures
California, San Francisco (UCSF) theory of symptom manage- Data collection began in May 2010 and concluded in July 2012.
ment (TSM; Dodd et al., 2001). The TSM embraces the Assessments took place at a private meeting room at the facility
perspective that effective management of a symptom or group the person attended or at the UCSF-SFVAMC Center for
of symptoms demands consideration of the symptom experi- Neurobiology and Psychiatry or the Tenderloin Clinical
ence, symptom management strategy, and outcomes. The Research Center. The assessment included completion of a
outcomes dimension specifies that outcomes emerge from the demographic questionnaire, confirmation of diagnosis using
symptom management strategies as well as from the symptom the Structured Clinical Interview for DSM Disorders, neuro-
experience. Symptom management is viewed as a dynamic cognitive assessments, assessment of schizophrenia symptoms,
process that is modifiable by both individual outcomes and the and instruction on the wearing of a SenseWear Pro armband
influences of the nursing domains of person, health/illness, and (SWA; BodyMedia Inc, Pittsburgh, PA) for 1 week. Additional
environment. Figure 1 depicts the conceptualized relationships clinical data obtained by research staff included blood pressure,
among the dimensions of the theoretical framework. waist circumference, weight, height, and patient report of
For the present study, our assessment of the symptom expe- smoking status and educational level. It took two to five meet-
rience included evaluations of schizophrenia symptomatology ings to complete the assessment, depending on the individual
and neurocognition. Individuals perceive these symptoms, participants.

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26 Biological Research for Nursing 16(1)

Measures instrument included average daily steps taken and average


daily minutes of physical activity categorized as sedentary
A trained member of the research staff administered all of the
(02.9 metabolic equivalents [METS]), moderate (35.9
assessments. The research staff completed a formal practicum
METS), vigorous (68.9 METS), and very vigorous (9
and lab training with the UCSF-SFVAMC Center for Neuro-
METS). Participants were fitted with the SWA and informed
biology and Psychiatry. Research staff passed an observed
about the activities the device would monitor during baseline
practicum before administering the instruments to participants.
data collection. Participants were reminded to take the SWA
off only when showering or performing other activities during
Symptomatology. Psychiatric symptoms were measured with the which the device might get wet. Additionally, they were given
Extended Positive and Negative Syndrome Scale (PANSS; an information sheet that described proper placement and con-
Kay, Fiszbein, & Opler, 1987; Poole et al., 2000). The extended tact information for study staff if they had questions at any
PANSS is a 35-item instrument, with each item consisting of time. The devices were returned at the next scheduled meeting.
a 7-point (17) rating scale. The instrument comprises six If the participant was unable to attend, arrangements were
subscales measuring positive, negative, excited, depressed anx- made for a convenient time and location for retrieval.
ious, disorganized, and other symptoms. Lindenmayer, Harvey,
Kahn, and Kirkpatrick (2007) reported that the PANSS demon-
strated good-to-excellent reliability in assessing symptoms and Data Analysis
changes in symptoms during the course of treatment in clinical Physical activity data were analyzed descriptively for the entire
trials with participants diagnosed with schizophrenia. The scale sample then compared across two groups for each of the two
takes approximately 60 min to administer. Items are summed to hypotheses: low versus high symptomatology and low versus
determine scores on the six subscales and the total score (the high neurocognition. We used the median scores on the total
sum of all six subscales). Higher scores on the PANSS reflect PANSS and the global cognition score of the MCCB to deter-
more severe symptomatology. mine the cut points for low versus high groups. Then, Pearsons
bivariate correlations (two-sided) were conducted on the entire
Neurocognition. The Matrics Consensus Cognitive Battery sample. Variables that were significant at p < .10 in bivariate
(MCCB) was used to assess neurocognition on each of the fol- analysis were included in univariate linear regressions models.
lowing seven domains identified as separable, fundamental We estimated that, with a sample size of 30, at a significance
dimensions of cognitive impairment in schizophrenia which level of .05, the null hypothesis that the Pearsons correlation
have a likely sensitivity to intervention (Nuechterlein, 2004): coefficient would equal 0 would have 80% power to detect a
speed of processing (SOP), attention/vigilance, working mem- population effect size of .531.
ory, verbal learning, visual learning, reasoning and problem
solving, and social cognition. Speed-of-processing tests include
Trail Making Test: Part A, Brief Assessment of Cognition in
Schizophrenia (BACS) Symbol Coding, and Category Fluency Results
(animal naming). Attention/vigilance tests include Continuous A total of 30 participants were included in the analyses. Our
Performance TestIdentical Pairs (CPT-IP). Working memory sample was part of a larger study (N 47) that evaluated the
tests include the Wechsler Memory Scale (WMS) Spatial Span impact of neurocognition and schizophrenia symptoms on
and Letter-Number Span. Verbal learning includes the Hopkins mobility. The 30 participants for the present study were those
Verbal Learning TestRevised. Visual Learning includes the who had consented to the SWA-wearing period in addition to
Brief Visuospatial Memory TestRevised. Reasoning and the mobility assessments. All 30 completed the study. Sociode-
problem solving includes Neuropsychology Assessment Battery mographic and clinical characteristics are presented in Table 1.
(NAB) Mazes. Social cognition consists of the Mayer-Salovey- The majority of participants were male, the average age was 60
Caruso Emotional Intelligence Test: Managing Emotions. years, and the average years of self-reported education were 14.
T-scores were calculated for each cognitive domain, selected More than half of the participants were current smokers. The
individual tests, and an overall global composite score. Lower mean body mass index (BMI) for the sample was 30.3 kg/m2
T-scores on the MCCB tests reflect poorer neurocognition. and mean waist circumference was 113 cm.
The average total PANSS score was 75 (standard deviation
Physical Activity. Steps and energy expenditure were measured [SD] 27), indicating the sample was moderately ill (Leucht
with the SWA. Patients wore the device over the left triceps et al., 2005). The mean MCCB global overall composite
muscle at all times, including while sleeping and except during T-score was 18.1 (SD 14. 24, range 14 to 42). Table 2
bathing or water activities, for 5 days. This device samples data presents a summary of the performance on the MCCB domains
from a heat flux sensor, a galvanic skin response sensor, a skin (reported as T-scores) and the PANSS subscales. We calculated
temperature sensor, a near body temperature sensor, and a global and attention/vigilance scores for only 29 of the 30 par-
biaxial accelerometer. Previous research determined that the ticipants because 1 participant refused to complete the CPT-IP.
SWA accurately estimates energy expenditure in older adults All participants wore the armband for a minimum of 5 days.
(Mackey et al., 2011). Outcome variables measured with this Table 1 lists the average daily steps taken and average number

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Leutwyler et al. 27

Table 1. Demographic Characteristics and Physical Activity by Symptom Severity and Neurocognitive Function.
Symptom Severity Cognitive Function

Total Sample Low High Test Statistic Low High Test Statistic
Variable (N 30) (n 15) (n 15) (p Value) (n 15) (n 15) (p Value)

Age, years 60 (4.0) 59 (3.7) 62 (4.0) t 2.0 (.07) 60 (4.1) 60 (4.1) t 0.4 (.7)
Education, years 14 (4.0) 12.3 (3.1) 15.2 (4.2) t 2.1 (.04) 13.7 (3.3) 12.9 (2.5) t 0.7 (.5)
BMI, kg/m2 30.3 (6.1) 29.8 (7.1) 30.7 (5.0) t 0.4 (.7) 28.3 (5.4) 31.8 (6.3) t 1.6 (.1)
Waist circumference, cm 112.9 (15.0) 113.4 (16.7) 112.4 (13.8) t 0.2 (.9) 109.7 (12.1) 115.3 (17.7) t 1.0 (.3)
No. daily steps taken 4776 (3472.0) 4936.2 (3810.1) 4616.5 (3225.3) t 0.2 (.8) 4265.7 (3430.7) 5587.8 (3486.7) t 1.0 (.3)
Daily activity, min
Sedentary (02.9 METS) 1288 (147.0) 1251.1 (166.6) 1325.3 (118.8) t 1.4 (.2) 1252.3 (177.8) 1316.6 (101.7) t 1.2 (.2)
Moderate (35.9 METS) 68 (65.0) 69.2 (59.5) 67.0 (71.6) t 0.1 (.9) 56.3 (30.5) 85.4 (86.7) t 1.2 (.2)
Vigorous (68.9 METS) 1 (3.0) 1.4 (4.1) .27 (.7) t 1.1 (.3) 0.3 (0.5) 1.5 (4.2) t 1.1(.3)
Very vigorous ( 9 METS) 0 0 0 N/A 0 0 N/A
Taking antipsychotic medication 90% 93% 87% w2 0.4 (.5) 87% 93% w2 0.3 (.6)
Male 60% 67% 53% w2 0.6 (.5) 60% 64% w2 0.1 (.8)
Smoker w2 0.8 (.7) w2 2.3 (.3)
Current 53% 47% 60% 53% 7%
Past 27% 33% 20% 20% 36%
Never 20% 20% 20% 27% 57%

Note. Data presented are either mean (SD) or percent. BMI body mass index; METS metabolic equivalents; SD standard deviation.

Table 2. Mean (SD) Scores on the Extended Positive and Negative The high-symptomatology group did have worse average
Syndrome Scale (PANNS) and T-Scores on the Matrics Consensus daily physical activity outcomes than the low-symptomatology
Cognitive Battery (MCCB) Subscales for Older Adults With Schizo- group, but the differences were not significant. Similarly,
phrenia (N 30). we found no significant differences between the low- (global
Scales and Subscales/Domains Score cognition T-score < 19) versus high-neurocognition groups on
physical activity outcomes or demographic characteristics
PANSS (psychiatric symptoms) (Table 1). The low-neurocognition group did have worse aver-
PANSS total 75 (27.0) age daily physical activity scores than the high-neurocognition
PANSS positive 16 (8.8)
PANSS negative 13.5 (5.9)
group on all measures except for sedentary activity but the
PANSS depressed/anxious 9.5 (3.7) differences were not significant.
PANSS disorganized 8.3 (3.8) Pearsons two-sided bivariate correlation analysis revealed
PANSS excited 7.4 (2.8) positive associations between score on the speed of processing
PANSS other 20.2 (8.4) test (category fluency) and the average daily number of steps
MCCB (neurocognition) (p .002) and average daily minutes of moderate-intensity
Speed of processing 22.4 (15.5) physical activity (p .009), scores on depressed/anxious
Attention/vigilancea 25.8 (14.0)
Working memory 26.1 (13.3)
symptoms and average daily minutes of sedentary activity
Verbal learning 33.4 (10.1) (p .03), and scores on the verbal working memory task
Visual learning 34.4 (12.3) (letter-number span) and average daily minutes of moderate-
Reasoning and problem solving 38.9 (5.3) intensity physical activity (p .05). Table 3 shows all variables
Social cognition 32.5 (9.0) that had significant correlations at p < .10 and were subse-
Category fluency 40.2 (11.5) quently included in the univariate linear regression analyses.
Letter number span 28.6 (13.4) Results of the univariate linear regression analyses are shown
Global/overalla 18.1 (14.2)
in Table 4. Correlations between the category fluency t-score
Note. SD standard deviation. and the average number of daily steps and average daily minutes
a
n 29. of moderate-intensity physical activity, depressed/anxious
symptom severity and average daily minutes in sedentary phys-
ical activity, and letter-number span t-score and average daily
of minutes spent engaged in physical activity of each level of minutes in moderate-intensity physical activity remained signif-
intensity. icant in these analyses.
The cut point on the PANSS for the low- versus high-
symptomology groups was a score of 70. We found no sig-
nificant differences between these two groups on any of the
Discussion
physical activity outcomes or demographic characteristics Our findings in the present study provide support for our
except for years of education, with the high-symptomatology hypotheses that greater severity of schizophrenia symptoms
group having significantly more years of education (Table 1). and neurocognitive deficits are associated with lower levels of

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28 Biological Research for Nursing 16(1)

Table 3. Bivariate Correlations Between Measures of Physical Activity and Measures of Symptom Severity and Neurocognitive Function.

Average Daily Steps Average Min of Average Min of


Covariate r (p) Sedentary Activity r (p) Moderate Activity r (p)

PANSS (symptom severity)


Negative symptoms 0.3 (.07) 0.4 (.06) .2 (.4)
Depressed/anxious symptoms .088 (.64) 0.4 (.03)* .2 (.2)
MCCB (neurocognitive function)
Letter-number span (verbal working memory) 0.4 (.06) 0.1 (.7) 0.4 (.05)*
Speed of processing (fluency) 0.5 (.002)* 0.2 (.4) 0.5 (.009)*
Note. MCCB Matrics Consensus Cognitive Battery; PANNS Extended Positive and Negative Syndrome Scale; MIN minimum.
*p < .05.

Table 4. Mean Difference (Standard Error) in Response Variables (Physical Activity) Per Standard Deviation (SD) of Predictor Variables (Symp-
tom and Neurocognitive).

Predictor Variables

Speed of Processing p Negative p Verbal Working p Depressed/Anxious p


Response Variables (Category Fluency) Value Symptoms Value Memory (LNS) Value Symptoms Value

Avg. daily no. of steps 162.1 (48.0) .002* 198.8 (104.7) .07 90.7 (45.8) .06
Avg. daily minutes of 8.7 (4.4) .06 16.4 (6.9) .03*
sedentary activity
Avg. daily minutes of 2.6 (0.9) .009* 1.8 (0.8) .05*
moderate activity

Note. Table reports results of univariate linear regression analyses. LNS letter-number span; Avg, average.
*p < .05.

physical activity. In our sample of older adults with schizophre- including BMI, use of antipsychotic medications, and smoking
nia, better performance on a speed of processing task was asso- status. All of these factors could both contribute to level of
ciated with a greater number of average daily steps taken, better physical activity and impact psychiatric symptoms. For exam-
performance on speed of processing and verbal working memory ple, a patient with a higher BMI may find it more physically
tasks were associated with more time spent in moderate-intensity difficult to engage in moderate-intensity activity than a similar
physical activity, and greater severity of depressed/anxious patient with lower BMI. Higher BMI could also contribute to
symptoms was associated with more time spent in sedentary increased number and severity of depressive symptoms. In
activity. In addition, participants successful compliance with addition, specific psychiatric symptoms may have precluded
the SWA instructions demonstrates the feasibility of using this some people from participating. For example, individuals lack-
method for measuring physical activity levels in this population. ing acknowledgment of diagnosis or insight into their disease
Previous studies (Chwastiak et al., 2006; Friedman et al., 2002; may have declined to participate. Finally, because the treat-
Viertio et al., 2009) have similarly found associations between ment facilities from which we recruited the majority of partici-
physical activity levels and severity of symptoms and neurocog- pants are predominantly male, the majority of our sample was
nitive impairment in people with schizophrenia and other psycho- also male, potentially limiting the generalizability of our
tic disorders. More recently, investigators have found an findings to females.
association between speed of processing and aspects of physical
activity (e.g., gait speed) in older adults without serious mental ill-
ness (Donoghue et al., 2012; Rosano et al., 2012). Rosano et al. Conclusion
(2012) provide some rationale for this association by suggesting Ours is the first study, to our knowledge, to explore the associa-
that walking requires perception and interpretation of the terrains tions of neurocognitive deficits and schizophrenia symptoms
properties and obstacles in surrounding space. In our sample, it is with physical activity in older adults with schizophrenia. An
possible that slowed speed of processing may have impaired this understanding of these relationships is particularly important
interpretation process and limited the desire to walk. in order to design and implement effective physical activity
interventions in this population.
Based on our findings as well as those of previous studies,
Limitations an ideal physical activity program for this population would
Our study had several limitations. The small sample size made improve both speed of processing and physical activity levels.
it difficult to control for potentially confounding factors, Maillot, Perrot, and Hartley (2012) found that exergame

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Leutwyler et al. 29

training improved physical function and speed of processing in Copeland, L., Zeber, J., Rosenheck, R., & Miller, A. (2006). Unfore-
a sample of older adults. The only published study exploring a seen inpatient mortality among veterans with schizophrenia. Med-
physical activity program for older adults with schizophrenia ical Care, 44, 110116.
suggests that exergames may be a feasible way to promote Deslandes, A., Moraes, H., Ferreira, C., Veiga, H., Silveira, H., Mouta,
physical activity in this population (Leutwyler et al., 2012). R, . . . Laks, J. (2009). Exercise and mental health: Many reasons
Future studies should explore the relationships between schizo- to move. Neuropsychobiology, 59, 191198.
phrenia symptoms and neurocognitive function and physical Dixon, L., Postrado, L., Delahanty, J., Fischer, P. J., & Lehman, A.
activity longitudinally in a larger sample of patients from a (1999). The association of medical comorbidity in schizophrenia
variety of mental health settings in order to better understand with poor physical and mental health. The Journal of Nervous and
the specific symptoms and cognitive domains that impact Mental Disease, 187, 496502.
physical activity. In addition, patients self-report of physical Dodd, M., Janson, S., Facione, N., Faucett, J., Froelicher, E. S.,
activity would help increase our understanding of the types Humphreys, J., . . . Taylor, D. (2001). Advancing the science of
of physical activities older adults with schizophrenia perform symptom management. Journal of Advanced Nursing, 33,
on a daily basis and to determine which symptoms and cogni- 668676.
tive domains influence these activities. Donoghue, O. A., Horgan, N. F., Savva, G. M., Cronin, H., ORegan,
Nurses caring for this population can begin to improve the C., & Kenny, R. A. (2012). Association between timed up-and-go
overall physical health of older adults with schizophrenia by and memory, executive function, and processing speed. Journal of
encouraging patients and mental health facilities to incorporate the American Geriatrics Society, 60, 16811686.
physical activity into their daily routines. The use of active El-Mallakh, P. (2006). Evolving self care in individuals with schizo-
video games in patients homes or treatment facilities may be phrenia and diabetes mellitus. Archives of Psychiatric Nursing, 20,
an ideal way to both promote physical activity and potentially 5564.
improve speed of processing. Furthermore, administrators at Friedman, J. I., Harvey, P. D., McGurk, S. R., White, L., Parrella, M., Ray-
both residential and outpatient facilities could provide opportu- kov, T., . . . Davis. (2002). Correlates of change in functional status of
nities for physical activity through establishment of routine institutionalized geriatric schizophrenic patients: Focus on medical
physical activity groups. The groups could be simple walking comorbidity. American Journal of Psychiatry, 159, 13881394.
groups facilitated by licensed or nonlicensed staff members Gorczynski, P., & Faulkner, G. (2010). Exercise therapy for schizo-
or volunteers. As our and previous findings indicate, caregivers phrenia. Cochrane Database of Systematic Reviews (Online), 5,
should also be aware that symptoms and cognitive difficulties CD004412.
may hinder a patients desire or ability to be more physically Inagaki, T., Yasukawa, R., Okazaki, S., Yasuda, H., Kawamukai, T.,
active and explore ways to address these barriers. Utani, E., . . . Horiguchi, J. (2006). Factors disturbing treatment for
cancer in patients with schizophrenia. Psychiatry and Clinical
Authors Note Neurosciences, 60, 327331.
The content is solely the responsibility of the authors and does not Jeste, D., Gladsjo, J., Lindamer, L., & Lacro, J. (1996). Medical comor-
necessarily represent the official views of the National Center for bidity in schizophrenia. Schizophrenia Bulletin, 22, 413430.
Research Resources or the National Institutes of Health. Kay, S., Fiszbein, A., & Opler, L. (1987). The positive and negative
syndrome scale (PANSS) for schizophrenia. Schizophrenia Bulle-
Declaration of Conflicting Interests tin, 13, 261276.
The author(s) declared no potential conflicts of interest with respect to Keefe, R. S., Bilder, R. M., Harvey, P. D., Davis, S. M., Palmer, B. W.,
the research, authorship, and/or publication of this article. Gold, J. M., . . . Lieberman, J. (2006). Baseline neurocognitive
deficits in the CATIE schizophrenia trial. Neuropsychopharmacol-
Funding ogy, 31, 20332046.
The author(s) disclosed receipt of the following financial support for Kilbourne, A., Cornelius, J., Han, X., Haas, G., Salloum, I., Coni-
the research, authorship, and/or publication of this article: This work gliaro, J., . . . Pincus, H. (2005). General-medical conditions in
was supported by the UCSF Academic Senate (Individual Investigator older patients with serious mental illness. American Journal of
Grant), National Center for Research Resources (KL2R024130 to Geriatric Psychiatry, 13, 250254.
H.L. & UCSF-CTSI UL1 RR024131), and the National Institute of Leucht, S., Kane, J. M., Kissling, W., Hamann, J., Etschel, E., &
Nursing Research (P30-NR011934-0). Engel, R. R. (2005). What does the PANSS mean? Schizophrenia
Research, 79, 231238.
References Leutwyler, H., Jeste, D., Hubbard, E., & Vinogradov, S. (2013).
Chafetz, L., White, M. C., Collins-Bride, G., Nickens, J., & Cooper, B. Were not just sitting on the periphery: A staff perspective of
A. (2006). Predictors of physical functioning among adults with physical activity in older adults with schizophrenia. The Gerontol-
severe mental illness. Psychiatric Services, 57, 225231. ogist, 53, 474483. doi:10.1093/geront/gns092
Chwastiak, L. A., Rosenheck, R. A., McEvoy, J. P., Keefe, R. S., Leutwyler, H., Hubbard, E., Vinogradov, S., & Dowling, G. (2012).
Swartz, M. S., & Lieberman, J. A. (2006). Interrelationships of Video games to promote physical activity in older adults with schi-
psychiatric symptom severity, medical comorbidity, and function- zophrenia. Games for Health Journal, 1, 381383. doi:10.1089/
ing in schizophrenia. Psychiatric Services, 57, 11021109. g4h. 2012.0051

Downloaded from brn.sagepub.com at UNC on September 26, 2014


30 Biological Research for Nursing 16(1)

Leutwyler, H., & Wallhagen, M. (2010). Understanding older adults serious mental illness. Alexandria, VA: National Association of
with schizophrenia: Building and eroding trust. Journal of Geron- State Mental Health Program Directors (NASMHPD) Medical
tological Nursing, 36, 3845. Directors Council. Retrieved from http://www.nasmhpd.org/docs/
Lindenmayer, J., Harvey, P., Kahn, A., & Kirkpatrick, B. (2007). publications/MDCdocs/Mortality%20and%20Morbidity%20Final%
Schizophrenia: Measurements of psychopathology. Psychiatric 20Rep-ort%208.18.08.pdf
Clinics of North America, 30, 339363. Poole, J. H., Tobias, F. C., & Vinogradov, S. (2000). The functional
Mackey, D. C., Manini, T. M., Schoeller, D. A., Koster, A., Glynn, N. relevance of affect recognition errors in schizophrenia. Journal
W., & Goodpaster, B. H., . . . Health, Aging, and Body Composition of the International Neuropsychological Society: JINS, 6,
Study. (2011). Validation of an armband to measure daily energy 649658.
expenditure in older adults. The Journals of Gerontology. Series Rosano, C., Studenski, S. A., Aizenstein, H. J., Boudreau, R. M.,
A, Biological Sciences and Medical Sciences, 66, 11081113. Longstreth, W. T., Jr, & Newman, A. B. (2012). Slower gait,
Maillot, P., Perrot, A., & Hartley, A. (2012). Effects of interactive slower information processing and smaller prefrontal area in older
physical-activity video-game training on physical and cognitive adults. Age and Ageing, 41, 5864.
function in older adults. Psychology and Aging, 27, 589600. Tirodkar, M. A., Song, J., Chang, R. W., Dunlop, D. D., & Chang,
Matza, L. S., Buchanan, R., Purdon, S., Brewster-Jordan, J., Zhao, Y., H. J. (2008). Racial and ethnic differences in activities of daily
& Revicki, D. A. (2006). Measuring changes in functional status living disability among the elderly: The case of Spanish speak-
among patients with schizophrenia: The link with cognitive ers. Archives of Physical Medicine Rehabilitation, 89,
impairment. Schizophrenia Bulletin, 32, 666678. 12621266.
McGurk, S. R., Mueser, K. T., DeRosa, T. J., & Wolfe, R. (2009). Work, U. S. Department of Health and Human Services. (2008). 2008 phys-
recovery, and comorbidity in schizophrenia: A randomized con- ical activity guidelines for Americans. Retrieved from http://www.
trolled trial of cognitive remediation. Schizophrenia Bulletin, 35, health.gov/PAGuidelines/Pdf/Paguide.pdf
319335. Vahia, I., Diwan, S., Bankole, A., Kehn, M., Nurhussein, M., Ramirez,
National Institute of Mental Health. (2007). Schizophrenia (DHHS P., & Cohen, C. (2008). Adequacy of medical treatment among
Publication No. 06-3517). Washington, DC: U. S. Government older persons with schizophrenia. Psychiatric Services, 59,
Printing Office. 853859.
Nuechterlein, K. H. (2004). Identification of separable cognitive fac- Viertio, S., Sainio, P., Koskinen, S., Perala, J., Saarni, S. I., Sihvonen,
tors in schizophrenia. Schizophrenia Research, 71, 2939. M., . . . Suvisaari, J. (2009). Mobility limitations in persons with
Parks, J., Svendsen, D., Singer, P. A., & Foti, M. (Eds.), & Mauer, B. psychotic disorder: Findings from a population-based survey.
(Technical Writer). (2006). Morbidity and mortality in people with Social Psychiatry and Psychiatric Epidemiology, 44, 325332.

Downloaded from brn.sagepub.com at UNC on September 26, 2014