Arch Neuropsychiatry 2023;60:356−362

RESEARCH ARTICLE https://doi.org/10.29399/npa.28217

The Relationship of Depression Level and Physical Activity with

Postural Control in Geriatric Individuals
Tuba Yerlikaya1 , Melis Bağkur1 , Serkan Taş2 , Adile Öniz1,3 , Murat Özgören3,4,5
1
Faculty of Health Sciences, Physiotherapy and Rehabilitation Department, Near East University, Nicosia, Cyprus
2
Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Toros University, Mersin, Turkey
3
Institute of Graduate Studies, Department of Neuroscience, Near East University, Nicosia, Cyprus
4
Faculty of Medicine, Department of Biophysics, Near East University, Nicosia, Cyprus
5
Near East Research Innovation and Technology Area, Nicosia, Cyprus

ABSTRACT

Introduction: The aim of this study was to investigate the relationships
between functional performance, physical activity level, and depression
level with postural control in older adults.
Methods: Data were collected from 48 community-dwelling subjects
aged ≥65 years. As measurement parameters, Sway mobile balance
application for postural control, Sit – Stand Test for lower extremity
muscle strength, SenseWear armband for physical activity level, Mini-
Mental Test for mental status and Beck Depression Inventory (BDI) for
depression level were used.
Results: Sway score was positively correlated with total energy
expenditure (TEE) (r=0.28, p=0.04) and number of steps (r=0.30, p=0.03)
and negatively correlated with BDI (r=-0.33, p=0.03). The BDI score was
negatively correlated with all physical activity parameters. While lower
extremity strength, which indicates functional performance, showed
moderate-good correlation with physical activity parameters, it showed
moderate negative correlation with BDI (r=-0.63, p<0.001). Body mass
index value positively correlated with TEE (r=0.34, p=0.01)
Conclusions: The results of this study showed a significant correlation
between postural control, physical activity, and depression level. A
sufficient level of physical activity is important for the maintenance
and improvement of depression level and postural control system. The
relationship between physical activity, depression level and postural
control should not be ignored in healthy aging.
Keywords: Healthy aging, depression, physical activity, postural control,
fall risk

Cite this article as: Yerlikaya T, Bağkur M, Taş S, Öniz A, Özgören M. The Relationship of Depression Level and Physical Activity with Postural Control in Geriatric
Individuals. Arch Neuropsychiatry 2023;60:356−362.

INTRODUCTION
The elderly population is proportionally gaining a larger portion in the
global population. The elderly population is also known to be frailer,
and their health is more sensitive. A significant percentage of elderly
individuals, who make up the fastest growing segment of the population,
experience psychological distress such as depression. About 1% of older
adults have major depression and 8–15% show depressive symptoms (1).
The health of an individual is not only physical but more of an interplay
of mind, body, and social contexts (2). It is commonly observed that the
mental and emotional status are hand in hand with physical well-being.
On top of the current trends, the pandemic has been reported to cause
increased emotional stress among geriatric population (2,3). These
conditions require a closer look into the relationship of physical conditions
and depressive level for addressing an ideal psychophysical endurance.
Many previous studies have reported that physical activity can prevent
geriatric depression. Cross-sectional analyzes have consistently shown
that active individuals report fewer depressive symptoms than those who
are less active (4–6). As a common failure pattern in elderly derives from
the lack of physical fitness (i. e., loss of balance causing falls etc.). Age-
related changes in the neuromuscular system, such as musculoskeletal
Highlights
• Depression level is associated with physical activity (PA)
and postural control.
• PA and depression levels are important for the
prevention of falls in the elderly.
• Psychophysical endurance should be considered as a
major factor in healthy aging.
changes and those in the integration of sensory information, may cause
postural control problems in geriatric individuals (7). These changes in
the neuromuscular system due to aging are reportedly associated with
a loss of postural control and an increased risk of falling in older people
(8). Long-term curfews during the coronavirus disease 2019 (COVID-19)
pandemic as part of quarantine measures have limited the level of
physical activity (PA) and increased psychological problems (9). In turn,
such measures exacerbated negative effects of the aging process.

Correspondence Address: Tuba Yerlikaya, Faculty of Healthy Science, Near East University, Nicosia, Cyprus • E-mail: tuba.yerlikaya@neu.edu.tr
Received: 11.05.2022, Accepted: 21.10.2022, Available Online Date: 21.08.2023
©Copyright 2022 by Turkish Association of Neuropsychiatry - Available online at www.noropskiyatriarsivi.com

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Body sway is defined as slight postural movements that an individual makes
to maintain balance. The increased amount of body sway that occurs with
aging is considered a suitable indicator of one’s ability to maintain balance.
Decreased postural sway indicates better body balance, while increased
postural sway indicates impaired balance that may lead to a fall (10). In
geriatric individuals, increased postural sway has been shown to increase
the risk of falls and injury (11). Falls among the older population cause
tissue injury, fracture, fear of falling, and loss of function and are even cited
as one of the main causes of death (12). Falls increase the need for medical
care and treatment as well as the length and cost of care (13).
Factors affecting postural control in geriatric individuals have long been
the subject of various studies. Postural sway is significantly reduced in
individuals who perform PA and are engaged in various sports (14).
However, few studies have specifically addressed how different levels
of daily PA affect postural control (10,15,16). There is insufficient
information regarding the connection between postural control and
indirect depression level effects on balance and falling. While some
studies have shown how an individual’s depression level affects general
balance (standing, standing up and sitting activities), almost no studies
have addressed how this affects postural sway (17).
Determining factors that affect postural control in geriatric individuals
without dementia may help improve therapeutic approaches which aim
to prevent falls in this population. It can be proposed that the depressive
mindset would limit the physical activity levels which in turn would
cause postural control to deteriorate. Therefore, the aim of this study
is to investigate the relationship between postural control and physical
performance (i. e. different amounts of PA) –depression levels in a sample
of geriatric individuals.
METHOD
Individuals
This descriptive correlational study was conducted between July and
November 2020 with 48 older adults (33 females) aged ≥65 years (mean
age: 72.56±7.2 years). The participants were selected from subjects who
responded to an announcement in randomly selected rural villages in
the province of Nicosia, North Cyprus. The participants meeting the
inclusion criteria were evaluated in order of application. The demographic
information form and the Mini-Mental State Examination (MMSE) of
participants included in study were filled in line with their statements
and in presence of a physiotherapist. Those included in the study were
volunteer participants who were able to communicate while following
instructions and who could walk with or without walking aids. Subjects
with any of the following criteria were excluded from the study: 1)
neurological disease, 2) recurrent dizziness, 3) severe vision or hearing loss,
and 4) any musculoskeletal problem affecting the ability to maintain an
upright posture or sit and rise from a chair. Four subjects who completed
the relevant evaluation tests but did not wear the required armband
for the requested period were excluded from the study. All participants
were evaluated by the same physiotherapist on an individual session as
appointed to each participant. The evaluation period lasted approximately
60 minutes, with rest intervals given between tests. For the measurement
of daily PA, an armband was applied to the subject’s arm. All participants
provided written informed consent prior to the study. The research study
received ethical approval (YDU/Date: 30.07.2020; Project number: 1137).
Evaluation Tools
Body Mass Index
For the anthropometric measurements, the participants’ height was
measured using a non-elastic measuring tape (brand name SECA)
attached to a wall. Tanita MC-180MA III device was used for the
participants’ weight analysis. Body Mass Index (BMI) was calculated by
Yerlikaya et al. Psychophysical Endurance Dynamics in Elderly
dividing the body weight (in kilograms) by the square of the height (in
meters).
Beck Depression Inventory
The Beck Depression Inventory (BDI) measures the physical, emotional,
and cognitive symptoms seen in individuals with depression. It is a self-
assessment scale that includes 21 symptom categories, with a maximum
score of 63. A higher total score indicates a more severe level of
depression. According to BDI scores, depressive level were classified into
four categories, as follows: 0–10: normal; 11–16: depressive mood; 17–20:
mild depressive symptoms; 21–26: moderate depressive symptoms; >26:
severe depressive symptoms (18). Accordingly, in our study, individuals
were divided into two groups; those who were normal BDI (1–9) and
those with depressive BDI (10–37).
Mini-Mental State Examination
The MMSE, used to measure mental state, consists of five parts:
orientation, recording memory, attention-calculating, recall, and
language. The maximum total MMSE score is 30, with ≥24 indicating
normal and ≤23 indicating dementia. This test was used as an exclusion
criterion and thus the whole group was comprised of individuals with
MMSE over 23 points (Normal) (19).
Sit-to Stand Test
The sit - to stand test (STS) was used to evaluate exercise tolerance
and skeletal muscle power in the lower extremities of the subjects.
After explanation of the instructions and precautions to be taken by a
researcher, each individual was seated in the middle of a chair with no
armrests and a seat height of 48 cm. Each participant was positioned
upright with a straight back, arms crossed in front, and feet flat on the
floor. The participant was then asked to repeat as many rounds of sitting
to standing as possible within 30 seconds, and the number completed
was recorded. The procedure was repeated after a 5-minute break. The
maximum value obtained between the two trials was accepted as the
participant’s score (20). The test was terminated after 30 seconds or when
the participant could not perform the action or wanted to end the test.
Sway Mobile Balance Application
The Sway mobile balance application (Sway) (SWAY Medical, Tulsa, OK,
USA), an FDA-approved application that uses a three-axis accelerometer,
was used for the evaluation of balance. Sway has been reported as a valid
and reliable method to assess balance (21). The Sway balance test consists
of five standing positions: 1) feet together, 2) tandem stance [left foot
forward], 3) tandem stance [right foot forward], 4) single leg stance [right],
and 5) single leg stance [left] (Figure 1). The subjects were blindfolded
and instructed to remain in each position for 10 seconds on a stable
surface. In each position, the individual was asked to hold the measuring
device perpendicular to the midpoint of the sternum and to maintain
this position. During the test, the therapist stood next to the subject to
avert the risk of falling. Three measurements were taken at 5-minute
intervals, and the average of the three measurements was recorded. The
balance scores were interpreted by the deflection acceleration on the
accelerometers being determined by calculations not disclosed by SWAY
Medical. This parameter has been unchanged for all measurements
therefore all results for future studies should refer to the current version
of the device and its software (22). After positions were completed, a final
balance score ranging from 0–100 was produced and recorded, with a
higher score indicating better balance.
SenseWear Armband
Physical activity level was measured using SenseWear armband monitors
(armband model: MF-SW; BodyMedia®, 2009; Pittsburgh, PA, USA). This
monitor is a non-invasive, wireless, multi-sensor monitor attached
to the left triceps midpoint using an adjustable strap. The monitor
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Yerlikaya et al. Psychophysical Endurance Dynamics in Elderly
Figure 1. A series of photos of a 72-year-old male subject holding the phone (while using the Sway balance app) perpendicular to the sternum. The subject was asked to stand for
10 seconds in each of the following positions: feet together (far left photo), tandem positions (right foot forward and left foot forward; second and third photos, respectively), and on
one leg (right leg and left leg; fourth and fifth photos, respectively) on a hard floor with eyes closed.
relies on several heat sensors (heat flux, galvanic skin response, skin
temperature, body temperature, and movement determined by a tri-
axial accelerometer) in addition to a tri-axial accelerometer to measure
PA intensity and time, number of steps, total energy expenditure (TEE),
active energy expenditure (AEE), average metabolic equivalents (average
METs) and other motion-related parameters. Each participant was asked
to wear the monitor for 24 hours on a routine day (23).
Statistical Analysis
The sample size was calculated using SPSS Sample Power 3.0 software (IBM
Corporation, Armonk, NY, USA). The calculations were based on an alpha
level of 0.51 with an expected correlation coefficient value of 0.50 between
depression and balance performance and a desired power level of 80% (24).
The estimated sample size was calculated to be at least 29 participants (25).
Data obtained in the study were analyzed statistically using SPSS version
22 software (IBM, USA). Conformity of the data to normal distribution was
assessed using visual methods (histograms, probability plots) and analytical
methods (Kolmogorov-Smirnov test, Shapiro-Wilk test). The Mann-
Whitney U test was used to compare the parameters between males and
females. Relationships between the assessed parameters were investigated
using Spearman’s correlation analysis. The correlation analysis results were
classified as poor (0.00–0.20), fair (0.21–0.40), moderate (0.41–0.60), good
(0.61–0.80), or very good (0.81–1.00). Data is given as means ± standard
deviations and correlation coefficients (r). A value of p<0.05 was accepted
as statistically significant.
RESULTS
A total of 52 subjects were enrolled in the study. After the exclusion of
four subjects who removed the SenseWear armband device before the
desired time, 48 participants were ultimately included. The mean age of
the 48 subjects was 72.56±7.20 years, and the mean body mass index was
28.77±5.10 kg/m2. The study sample was identified as a representative
older adult group.
The mean BDI and MMSE scores of the subjects were 10.06±8.07 and
26±2.1, respectively (Table 1).
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The mean Sway and STS scores of subjects were 76.9±13.95 and 8.9±2.09,
respectively. The average PA parameters of subjects were TEE score
8974±1835, AEE score 304.6±340.1, average METs score 1.22±0.18, PA
duration score 19.95±18.3, and number of steps 6018±4170. When the
parameters were compared by gender, only difference was observed in
TEE score (p=0.04) (Table 1).
The correlation analyses revealed that Sway score was positively
correlated with TEE (r=0.28, p=0.04) and number of steps (r=0.30, p=0.03).
Sway score was negatively correlated with BDI (r=-0.33, p=0.03) (Figure
2). No relationship was found between postural control and functional
performance (r=0.22, p=0.13).
Here, overall activity was determined to be positively correlated with
balance, and negative mood was determined to limit performance.
Postural control improved and PA level increased with lower levels of
depression. Furthermore, as depression level increased, postural control
was negatively affected.
Sit - to stand test scores showed a moderate-to-good correlation with
TEE (r=0.36, p=0.01), average METs (r=0.39, p=0.00), AEE (r=0.42, p<0.001),
number of steps (r=0.43, p<0.001), and BDI scores (r=-0.63, p<0.001).
Mini-Mental State Examination scores were positively correlated with
STS scores (r=0.30, p=0.02), average METs (r=0.28, p=0.04), and number of
steps (r=0.29, p=0.04). Beck Depression Inventory scores were negatively
correlated with all PA parameters (Figure 2). Body mass index value
positively correlated with TEE (r=0.343, p=0.01). No correlation was
found between BMI and other parameters (p>0.05) (Table 2).
Age, sway, number of steps, PA duration, STS, AEE values differed between
nondepressive individuals [BDI (1–9), n=30)] and individuals with
depressive symptoms [BDI (10–37), (n=18)], in favor of nondepressive
individuals. The physical dimensions in Figure 2 show the correlations
between BDI and the overall sub parameters. The group with higher BDI
scores depicts a worsened overall physical status varying from the daily
number of steps to Sway balance score.
Arch Neuropsychiatry 2023;60:356−362 Yerlikaya et al. Psychophysical Endurance Dynamics in Elderly

Table 1. The demographics of the participants and descriptive data of outcome measures (n=48)
n (%) or Mean ± Standard Difference
Parameters Min-Max Deviation Between Gender (p)
Female - 33 (68.8%)
Gender
Male - 15 (31.3%)
Age (years) 66–90 72.56 (± 7.2)
Height (m) 1.45–1.77 1.60 (± 0.08)
Demographic features
Weight (kg) 45–105 73.3 (± 13.8)
BMI (kg/m2) 18.18–39.44 28.77 (± 5.10) 0.29
Postural control and Sway score 37.68–94.72 76.9 (± 13.95) 0.90
Performance STS 3–14 8.9 (± 2.09) 0.06
TEE 5780–14208 8974 (± 1835) 0.04
Average METs 0.90–1.80 1.22 (± 0.18) 0.95
Physical activity AEE 0–4118 304.6 (± 340.1) 0.14
PA duration (METs) 0–180 19.95 (± 18.3) 0.25
Number of steps 462–17152 6018 (± 4170) 0.88
BDI score 1–37 10.06 (± 8.07) 0.08
Psychological measure
MMSE score 24–30 26 (± 2.1) 0.17
AEE: active energy expenditure; BDI: Beck Depression Inventory; BMI: Body Mass Index; METs: Average Metabolic Equivalents; MMSE: Mini-Mental State Examination;
PA: physical activity; STS: sit-to stand test; TEE: total energy expenditure.

Figure 2. Radar plot of physical dimensions across two levels

of depression level. The physical and postural dimensions
are physical activity (PA) duration, active energy expenditure
(AEE), number of steps, total energy expenditure (TEE), Sway
and average METs. The change in postural and physical
dynamic values according to Beck depression inventory (BDI)
(1–9) level is shown in blue, and according to BDI (10–37)
level, these values are shown in red.

DISCUSSION that is not independent of mobility and depression is postural control.

This study investigated the effects of functional performance, PA level, and
depression level on postural control in a population of geriatric individuals.
When older individuals do not have a requirement that forces movement
in their work life or daily routines, movement becomes almost only related
to motivation. For this reason, the relationship between the limitation of
movement motivation and the level of depression should be expected as
an inevitable pattern. In addition, it is observed that the level of depression
increases in situations where movement restriction is obligatory (such
as COVID lockdown, convalescence from illness, etc.) (4). Another factor
In order for postural control to be sufficient and effective, it is expected
that the person’s motivation and physical movement capacity should
also be well established. We can characterize this triad as psychophysical
endurance. This endurance will perhaps have a positive effect on many
basic parameters, especially reducing the risk of falling in healthy aging.
Physical activity for individuals over 60 years of age is more beneficial
for postural stability than PA performed only at a younger age (e.g., 30
s–40 s) (26). Therefore, higher levels of PA should be encouraged for older
individuals. Studies of healthy adults and postmenopausal women aged
>60 years have shown that postural stability is associated with PA (10,16).

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Table 2. The correlation analyses result of the assessed parameters (n=48)

Average PA Number of
STS TEE METs AEE duration steps MMSE BDI BMI
SWAY 0.22 0.28* 0.22 0.26 0.26 0.30* 0.21 -0.33* 0.06

STS 0.36* 0.39* 0.42* 0.38* 0.43* 0.30* -0.63** 0.04

TEE 0.56** 0.61** 0.55** 0.45* 0.22 -0.45* 0.34

Average METs 0.61** 0.62** 0.61** 0.28* -0.38* -0.20

AEE 0.99** 0.76** 0.24 -0.58** -0.04

PA Duration 0.79** 0.24 -0.55** -0.07

Number of Steps 0.29* -0.57** 0.02

MMSE 0.22 0.14

BDI -0.11

*p<0.05, **p<0.001. AEE: active energy expenditure; BDI: Beck Depression Inventory; BMI: Body Mass Index; METs: Average Metabolic Equivalents; MMSE: Mini-Mental State
Examination; PA: physical activity; STS: sit-to stand test; TEE: total energy expenditure.

Freitas et al. (15) found that individuals with higher levels of PA had better
postural control at 60–75 years of age. In those studies, PA levels were
evaluated using questionnaires and activity monitors in individuals of
different age ranges. Similarly, in the current study, increases in TEE and
numbers of steps measured using the SenseWear armband were found
to be associated with better postural stability. The population of the
current study lived in a rural area with full access to personal gardens,
so the average step count in this study may have been somewhat higher
than that of a standard population of the same age.
There are conflicting results in the literature regarding the relationship
between lower extremity muscle strength and postural sway. While
Handrigan et al. (27) showed that the knee extensor force had no effect
on body sway, King et al. (28) showed that there was a negative correlation
between those two parameters. The results of a review study showed
that an increase in lower extremity strength after training did not affect
postural control (29). Similarly, the current study found no significant
relationship between lower extremity strength and postural control.
Changes in balance control in older populations are affected not only by
underlying physiological factors but also by some psychological factors
(30). While independence, quality of life, and levels of function are lower
in depressed older individuals, rates of disability and chronic medical
problems are higher (31). Individuals with moderate to severe depressive
symptoms are more afraid of falling than those without depression.
Depressive symptoms cause a continued fear of falling and restriction
of PA (32). Kvæl et al. (17) associated significantly higher levels of muscle
strength and balance with less depressive symptoms. In the current study,
a significant correlation was found between balance and depression
level. While the related study looked at the general balance status in
standing, standing up, sitting and turning activities with the berg balance
scale, in our study, the balance sway parameter was measured objectively.
Balance, considering the effect of physical activity on balance in older
adults, coincides with the idea that it might be related to low prevalence
of depressive symptoms (33–35). To the best of our knowledge, this is the
first study to investigate the effect of depression level on postural control
and therefore makes an important contribution to the literature.
In order to improve balance and prevent falls among older individuals,
the depression level of an individual should be evaluated in addition
to the functional level. Apart from balance training, it is important to
keep daily PA routines at certain levels to prevent worsening of these
individuals’ depression level and to reduce falls by maintaining functional
levels. During the COVID-19 pandemic, curfews and social isolation
measures implemented to prevent disease transmission caused an overall
decrease in PA levels and had an impact of depression levels of older
adults (9). Considering that decreased PA levels and worsened depression
level increase the risk of falls among older adults, practices such as tele-
rehabilitation, virtual reality, and video-based home exercises, which
can help older people exercise in the home environment, should be
widespread during pandemic situations (36). These practices also
eliminate the difficulty of transfer and facilitate the continuation of
exercise.
Depression was shown to be associated with both increased or decreased
food intake and increased or decreased physical activity (37). Many
studies have reported that low weight and obesity are associated with
depression (38). Some studies have found the opposite results (39). As
a result of the findings of the current study, no relationship was found
between BMI and physical activity and depression. The results of this
study are not fully reflected as there were not enough individuals with
low and high weight.
With respect to the relationship between cognitive function and
postural control, cognitive spatial processing is also necessary for
the regulation of standing posture, and cognitive processing affects
balance ability (40). In the current study, results differing from those
in the literature are thought to be due to the absence of a relationship
between cognitive function and postural control as there were no cases
with MMSE scores <23, which was a criterion for communicating with
the study participants (10). To better explain the effect of cognitive
function on postural control, it is essential to investigate posture
among individuals with different levels of cognitive function. Another
limitation of the current study was that the measurement parameters
could not be explored further in older adults with different levels of
depression. Accordingly, further research is needed to provide a more
detailed explanation of the depression level parameters, increasing the
number of individuals and including the general population outside of
the rural area.

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In conclusion, in this study it was found that depression level is in relation
with PA and postural control. This shows the importance of an adequate
level of PA and psychological well-being for maintaining and improving
the integrity of the postural control system. Therefore, it is important to
support geriatric populations with respect to home exercise –for example,
with tele-rehabilitation, which would increase muscle strength and balance
and strengthen the psychological system. The results point to the dynamics,
addressing optimal psychophysical endurance parameters where multiple
disciplines (psychology, psychiatry, neurology, physiology, physiotherapy,
geriatrics etc.) cross and joint efforts are necessary for healthy aging.
In this context, the depression level, postural control and functional
(physical) activity levels are all in a dynamic interplay. Furthermore,
elucidating this interplay can pave the way towards the concept of
psychophysical endurance which can be assessed as a baseline factor to
enable future research and clinical projects.
Acknowledgments: The authors would like to thank Sway Medical for allowing use of the
Sway Balance Mobile Application System free of charge during pandemic.
Ethics Committee Approval: The research study received Near East University Scientific
Research Ethics Committee ethical approval (YDU/(Date: 30.07.2020; Project number:
1137).
Informed Consent: All participants provided written informed consent prior to the study.
Peer-review: Externally peer-reviewed.
Author Contributions: Concept- TY, MB, ST, AÖ, MÖ; Design- TY, ST, MÖ; Supervision-
TY, MB, ST, AÖ, MÖ; Resource- TY, MB; Materials- TY; Data Collection and/or Processing-
TY, MB; Analysis and/or Interpretation- TY, ST, AÖ, MÖ; Literature Search- TY, MB, ST, AÖ,
MÖ; Writing- TY, MB, ST, AÖ, MÖ; Critical Reviews- ST, AÖ, MÖ.
Conflict of Interest: The authors declared that there is no conflict of interest.
Financial Disclosure: No funding has been received for this letter.
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