Brandão et al.

Multidisciplinary Respiratory Medicine (2018) 13:2

DOI 10.1186/s40248-017-0114-3

RESEARCH ARTICLE Open Access

Home exercise improves the quality of

sleep and daytime sleepiness of elderlies: a
randomized controlled trial
Glauber Sá Brandão1,2*, Glaucia Sá Brandão Freitas Gomes2, Glaudson Sá Brandão3, Antônia A. Callou Sampaio2,
Claudio F. Donner4, Luis V. F. Oliveira5 and Aquiles Assunção Camelier1,6

Abstract
Background: Aging causes physiological changes which affect the quality of sleep. Supervised physical exercise is
an important therapeutic resource to improve the sleep of the elderlies, however there is a low adherence to those
type of programs, so it is necessary to implement an exercise program which is feasible and effective. The study
aimed to test the hypothesis that a semi-supervised home exercise program, improves sleep quality and daytime
sleepiness of elderlies of the community who present poor sleep quality.
Methods: This was a randomized controlled trial study, conducted from May to September 2017, in Northeastern
Brazil, with elderlies of the community aging 60 years old or older, sedentary, with lower scores or equal to 5 at the
Pittsburgh Sleep Quality Index (PSQI) and without cognitive decline. From one hundred ninety-one potential
participants twenty-eight refused to participate, therefore, one hundred thirty-one (mean age 68 ± 7 years), and
88% female, were randomly assigned to an intervention group - IG (home exercise and sleep hygiene, n = 65) and a
control group - CG (sleep hygiene only, n = 66). Sleep assessment tools were used: PSQI, Epworth sleepiness scale
(ESS) and clinical questionnaire of Berlin. The level of physical activity has been assessed by means of International
Physical Activity Questionnaire adapted for the elderly (IPAQ) and Mini-Mental State Examination for cognitive
decline. All participants were assessed before and after the 12-week intervention period and, also, the assessors
were blind.
Results: The IG showed significant improvement in quality of sleep with a mean reduction of 4.9 ± 2.7 points in the
overall PSQI (p < 0.01) and in all its 7 components of evaluation (p < 0.05), and improvement of secondary endpoint,
daytime sleepiness, a decline of 2.8 ± 2.2 points in the ESS (p < 0.01).
Conclusion: Our results suggest that semi-supervised home exercise is effective in improving the quality of sleep
and self-referred daytime sleepiness of sedentary elderlies of the community who presented sleep disorders.
Trial registration: Ensaiosclinicos.gov.br process number: RBR-3cqzfy.
Keywords: Community elderly, Exercise, Sleep

* Correspondence: gbrandao@uneb.br
1
Bahiana School of Medicine and Public Health, Salvador, BA, Brazil
2
Department of Education (DEDC-VII), University of the State of Bahia –
UNEB, Rua Visconde do Rio Branco 162, Centro, Senhor do Bonfim, BA CEP
48970-000, Brazil
Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 2 of 9

Background CONSORT stands for Consolidated Standards of

The natural process of human aging causes important Reporting Trials [17].
organic changes, resulting in mental and physical alter-
ations which involve quality of life of the elderlies [1, 2]. Participants
Among the main health problems observed in elderly The study involved elderly aged 60 years or older, living
population, with the incidence increasing proportionally in the city of Senhor do Bonfim - BA in the Brazil
with age, sleep disorders are among the most prevalent, Northeastern region, in the period from May to Septem-
and more than 50% of the elderlies complain about their ber 2017. The recruitment occurred throughout the
sleep quality [3–6]. community, initially through local newspapers, radio, re-
For this specific population, the pharmacologic thera- ligious centers, encounter groups of elderlies, senior
peutic approach still is the most commonly used to treat residence, association neighborhoods and in the senior
sleep disorders [7]. However, the frequent use of sleeping project developed by the municipal government. Inclu-
pills alter sleep architecture and they are associated to sion criteria were: absence of regular exercise in the last
several adverse effects such as sedation, excessive drow- three months before the beginning of the study and
siness daytime, increased risk of falling and higher func- score more than or equal to 5 in the Sleep Quality Index
tional dependency [7, 8], which usually are frequently Pittsburgh (PSQI-BR) [18]. We excluded the subjects
observed in elderlies [9]. Therefore, alternative strategies presenting cognitive decline according to the Mini-
are needed to improve the quality of sleep in this popu- Mental State Examination [19] or performing treatment
lation. The physical exercise of mild to moderate inten- for sleep disorders (including the use of sleep medica-
sity, presents positive results in the sleep quality of tions) or presenting any clinical condition that would
elderlies and it is recommended as one of the key fea- contraindicate the performance of physical activity, iden-
tures of preventive and therapeutic non-pharmacologic tified through a medical and physiotherapic evaluation.
intervention [10, 11]. However, despite scientific evi- The study was approved by the Ethics Committee on
dence demonstrating the benefits of physical exercise in Research Involving Human Subjects of Bahia School of
health and quality of life, yet there is little adhesion to Medicine and Public Health and all participants agreed
this strategy by the elderlies [12]. to participate and signed the free and informed consent.
The difficulty in the transfer to the location of the This trial is registered in ensaiosclinicos.gov.br (identi-
exercises, schedule conflict with household tasks, fier: RBR-3cqzfy).
conditioning difference between participants and the lim- After meeting the eligibility criteria, the subjects were
ited supply of free programs associated to the low eco- identified in consecutive order of entry into the study and
nomic power of this population, are possible explanations were then randomly allocated according to a sequence of
for the low adhesion [13, 14]. These difficulties presented random numbers generated by the Research Randomizer
by the majority of the elderlies in supervised exercises, (https://www.randomizer.org/). This randomization was
associated with the benefits of their practice, encourage of the closed type, with concealment of the allocation,
the development of other feasible programs which allow generating two groups, being one the control group (CG)
greater adherence. In a recent systematic review, the au- and the other the intervention group (IG).
thors concluded that home-based exercise programs show All the elderlies involved in the present study partici-
better adherence when compared to group programs [15]. pated in a 40-min presentation with explanations about
However, according to our knowledge, a single reference the experimental procedure and they received educa-
was located on the practice of semi-supervised home tional leaflets containing guidelines on life habits related
exercise and quality of sleep of elderlies [16]. to feeding, hydration and sleep hygiene. The IG partici-
In view of the foregoing and considering this know- pants were informed that they should follow lifestyle
ledge gap, the present study aimed to test the hypothesis guidelines and conduct a home physical exercise
that an alternative program of activities, through program. For that, they participated in a theoretical-
physical exercise performed at home, semi-supervised, practical training aimed at the adequate accomplishment
easy to perform and low cost, improves the perception of the proposed exercises and received a primer devel-
of sleep quality, and excessive daytime sleepiness of oped by the researchers, with illustrated and written
sedentary elderly people in the community who present guidelines on the accomplishment of the exercises, as
sleep disorders. well as a journal to record the weekly frequency of its
accomplishment. The researchers, after making sure that
Methods the subjects could perform all the exercises adequately,
Study design guided the family members to help and stimulate the
It is an analytical, experimental, randomized, con- practice and encouraged the elderlies to call in situations
trolled, single blind study conducted according to the of problems or doubts. The participants of the CG were
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 3 of 9

informed that they should only continue with their minutes with moderate and/or vigorous intensity during
activities of daily living and follow the guidelines related a normal/usual week. This variable was dichotomized,
to their habits of life. and those who performed less than 150 min per week of
Previously, before the beginning of the study, there moderate and/or vigorous physical activity were consid-
were systematic trainings of assistants, five students of ered non-active and active those who performed more
the physiotherapy course, exclusively for the evaluation, than 150 min per week.
and ten other assistants, also students of the physiother-
apy course, for home monitoring of the elderlies, five Intervention
visited the subjects of the IG and the other five visited The home exercise program was based on American
the elderlies of the CG. The distribution of the number College of Sports Medicine recommendations for
of subjects to be evaluated and the number of domiciles exercise and physical activity with the elderly [24]. The
to be visited was done in an equivalent way among the exercise program was composed by a combination of
research assistants. aerobic exercises, muscle strengthening, balance, coord-
ination and flexibility, prioritizing exercises involving
Evaluation protocol and procedures large muscle groups. The protocol lasted 12 consecutive
Assessments weeks, with minimum frequency of three weekly ses-
The evaluations were performed before and after the sions, predicted time of 40 min and performing 2–3 sets
intervention period, by a doctor, a physiotherapist and with 5–15 repetitions for each exercise, a target effort
the assistants, in which, the elderly received standard rate of 13–15 (“a bit difficult” to “difficult”) in the range
verbal instructions regarding the procedures and they of perceived exertion Borg 6–20 points [25], being the
were evaluated individually in an appropriate room. The exercise performed in the convenience turn chosen for
researchers in charge of the data analysis were blinded the elderly. The exercises were performed individually at
to groups of subjects, avoiding possible biases. home by each participant, having no supervision during
A general physical and clinical evaluation was per- implementation; however, receiving guidance through
formed, with collection of socioeconomic, demographic, home visits every 15 days. The subjects were instructed
anthropometric, and self-referenced morbidities data. to increase exercise intensity, using as parameter the
The quality of sleep, excessive daytime sleepiness, the Borg range and proportional form for their
risk of obstructive sleep apnea syndrome and the level of implementation capacity, assessed by research assistants
physical activity were also evaluated. in each visit.
The primary endpoint of the present study was the The exercises were conducted by using the subject’s
quality of self-reported sleep, verified through the own weight body and with the help of some low-cost
Pittsburgh Sleep Quality Index (PSQI). The PSQI was equipment (e.g., recyclable plastic bottles to demarcate
developed in 1989 by Buysse DJ [20] and validated for the signaling route rods and weights of 1 and 2 kg for
the Brazilian population [18]. This instrument allows an implementing the resistance exercises). The protocol
assessment of the quality of sleep, categorizing the sub- was performed as follow:
jects in good or bad sleepers.
The secondary endpoint was presence of excessive  Warm up exercises - Free-active exercises involving
daytime sleepiness recorded using the Epworth Sleepiness upper and lower limbs and movements of rotation
Scale (ESS), validated in Brazil [21]. of the shoulders associated with breathing exercises;
In order to assess the potential risk of the presence of  Aerobic exercises - Displacement of a stick with
obstructive sleep apnea (OSA) we used the Berlin both hands, starting from the knees up over the
clinical questionnaire [22]. This instrument considers a head and returning to the knees. Ambulation
high risk for OSA, when two or more categories present exercises with alternating bending of the thighs
positive score and when it shows none or only one cat- and approaching the knees to the hands on the
egory with a positive score the risk for OSA is low. opposite side;
In the evaluation of the anthropometric variables,  Endurance Exercises - Upper limbs departing from
Body Mass Index (BMI) was calculated from the weight the position with the extended elbow and the hand
in kilograms divided by the height in squared meter. resting on the opposite thigh, moving the whole
The level of physical activity was assessed using the limb diagonally upward and then returning the
International Physical Activity Questionnaire (IPAQ) hand to the thigh. For the lower limbs, squatting
adapted for the elderly [23]. It is an instrument that exercises, starting from the sitting position on a
allows estimating the weekly energy expenditure of phys- chair and with arms crossed in front of the body,
ical activities related to labor, transportation, domestic lifting to the orthostatic position and then returning
tasks and leisure, performed for at least 10 continuous to the sitting position;
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 4 of 9

 Balance and coordination exercises - Walk on a test was used for confirmation. Due to the normal distri-
straight line on the ground and walk from queued bution of variables, parametric statistics were used, and
obstacles with progressively smaller distances. When intra-group comparisons were performed using Student’s
possible, the exercise evolved and the walk was t-test for paired samples.
performed by placing the heel of one foot on the A subgroup analysis of extracts of age was pre-
toes of the other foot (standing foot). specified in the study protocol, as it was done with more
than two groups that had parametric distribution, we
Note: To ensure safety, these exercises were performed used one-way ANOVA. The significance level set to for
close to fixed furniture in the house, making it possible the analyses was set at p < 0.05 and statistical procedures
to lean when needed. were analyzed and processed in the Statistical Package of
Social Sciences (SPSS 21.0). IBM SPSS version 21 (IBM,
 Stretching Exercises - Starting from a sitting Armonk, NY).
position on the bed or a chair, with your knees in
extension trying to reach the tip of the feet; from Results
the sitting position in a chair and with the feet One hundred and ninety-one potential elderlies candi-
resting on the ground, perform the rotation of the dates were screened by phone. 28 elderlies refused to
trunk to one side and elevation of the upper limb, participate in the examination, therefore 163 elderlies
on the same side, above the head, stretching as high were enrolled in the study, of which 32 were excluded ac-
as possible. cording to the eligibility criteria. 131 subjects were ran-
domized elected, and thus constituted the IG with 65
During the period of 12 consecutive weeks, the sub- participants and the CG with 66 subjects. During the
jects of both groups received periodic home visits with study, there were follow up losses of 2 participants of the
the purpose of continuing with the guidelines on lifestyle CG and 4 of the IG, allowing to 125 elderlies to conclude
and encouraging the adherence to the program; however the follow up. A summary of the randomization, partici-
the IG, in addition to guidelines on habits of life, pant flow, and follow up losses during the trial are shown
received specific follow up regarding exercise practice in Fig. 1.
and assistance to possible adverse events. After three The patients involved in the present study showed a
months, the participants of both groups were re-evaluated predominance of females (88%); mean age 68 ± 7 years and
and at the end of protocol the elderlies of the IG were a mean BMI of 27.3 ± 4, indicative of pre-obesity. The
encouraged to continue with the exercises, while the CG socioeconomic profile showed a predominance of low
was made available the follow up of the home exercises income in relation to the monthly minimum wage (84.8% ≤
for the same period performed with the IG. 2 minimum wage) and low schooling (86.3% ≤ 3 years of
The adherence to the exercise was verified through the study). 87% of the elderlies presented a level of physical
weekly records filled out by the subjects themselves, activity considered active (IPAQ > 150 min per week).
with the help of family members and certified by the Most of the subjects lived with their families (88%), were
assistants during the home visits. nonsmokers (91%), non users of alcoholic beverages (88%)
and presented as main self-reported morbidities anxiety,
Statistical analysis arthrosis, hypertension and diabetes. 38.2% of the subjects
The sample size calculation based on recent studies [16] are considered to be at high risk for OSA because they
demonstrated that it would take 63 participants per present a positive score in two or more categories of the
group to obtain a statistical power of 80% in the detec- Berlin Clinical Questionnaire. The mean PSQI score was
tion of 2-point difference with 5% alpha, considering a 11.2 ± 3.2 and ESS score was 8.6 ± 2.8. The Table 1 pre-
standard deviation estimated 4 points. The principle of sents the characteristics of the two groups, at baseline,
intention-to-treat analysis was respected and for the with no statistically significant difference.
missing data the sensitivity analysis was performed The exercise average frequency over the entire 12-
through simple imputation using the mean of the vari- week period was 4 ± 0.6 days per week, with a minimum
ables. To detect if randomization produced comparable of 3 days per week performed by 3 participants and a
groups, the characteristics of both groups were com- maximum of 6 days per week performed by 1 partici-
pared before the intervention using the Student’s t-test pant. All participants of the IG had 100% adherence to
for independent samples in relation to the numerical the exercises and there was no report on any type of
variables and the Pearson chi-square test for categorical njury related to the intervention program.
variables. To test the normality of the data, the histogram, Figure 2 shows an analysis of the overall quality of sleep
mean and median, standard deviation, skewness and improvement, by comparing the global PSQI score before
kurtosis were analyzed and the Shapiro-Wilk normality and after the intervention in each group, demonstrating
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 5 of 9

Fig. 1 Flowchart of the study

that the improvement of sleep quality was statistically Discussion

significant only in the IG with a mean reduction of The results of the present study showed that seden-
4.9 ± 2.7 points (p < 0.001) compared to 0.7 ± 2.8 in tary elderlies who present sleep disorders while
the CG (p = 0.061). Subgroup analysis by ANOVA, participating in a semi-supervised home physical exer-
performed in the IG, showed that the improvement in cise program presented significant improvement in
overall sleep quality did not present a significant dif- sleep quality and reduction of self-reported excessive
ference when comparing the ages 60 to 69, 70 to79 daytime sleepiness, verified in a non-objective way
and ≥80-year-old, p = 0.15. through questionnaires, being consistent with the
Table 2 shows the sleep evaluation components hypotheses of the study and configuring a clinically
constituting the PSQI, demonstrating that only the GI relevant change.
showed statistically significant improvements in all Our results are consistent with previous studies
components. which demonstrated the efficacy of physical exercise
The evaluation of the presence of daytime sleepi- programs in sleep quality and in the reduction of
ness in the groups, through ESS before and after the daytime sleepiness in the elderlies [10, 11, 26, 27].
intervention, in each group, found that only the IG However, these studies used exercise programs with
presented a statistically significant reduction, with a professional supervision during their execution, in
mean variation of 2.8 ± 2.2 points (p < 0.001) com- addition to being performed in training and/or
pared to 0.14 ± 2.3 (p = 0.63) in the CG (Fig. 3). rehabilitation centers, which is a limiting factor for
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 6 of 9

Table 1 Baseline characteristics by group observed as well as high frequency rates (mean of 4 ±
Variables Control group Intervention group p 0.6 days per week) and small loss of follow up (4.5%).
(n = 64) (n = 61) It has already been demonstrated in the literature that
Age (years) 69.9 ± 6.7 69.8 ± 7.4 0.76 physical exercise performed at home may result in import-
Gender (% women) 84.4 91.8 0.23 ant health benefits for the elderly and, because it is appre-
BMI (Kg/m2) 27.7 ± 4.7 27.6 ± 4.1 0.75 ciated by the elderly [29], there is still greater adherence
and continuity after the end of the program [15, 30].
Waist Circumference (cm) 93 ± 10 93 ± 10 0.76
However, the knowledge regarding the effects of home
Number of self-reported 1.9 ± 1.4 1.8 ± 1.5 0.63
morbidities
exercises on sleep quality of the elderly is still very
incipient. In the present study, the elderly who partici-
Per capita income 82.3 85.7 0.86
(% ≤ 2 minimum wages) pated in the home exercise program during the 12-week
period showed significant improvement over the primary
Education (% ≤ 3 years 75 75.9 0.54
of study) endpoint, self-reported quality of sleep, represented by a
Housing (% live with relatives) 67 71 0.85
reduction of 4.9 points in the overall PSQI score (Fig. 2).
The significant reduction in all components of PSQI
Pittsburgh Sleep Quality Index 11.4 ± 3 11 ± 3.4 0.55
assessment, especially in relation to sleep latency, sleep
Epworth Sleepiness Scale 8.5 ± 3 8.7 ± 3 0.14 duration and habitual sleep efficiency (Table 2), charac-
Berlin Questionnaire 37 39 0.23 terizes a relevant clinical improvement, being the results
(% high risk)
consistent with the study performed by Chen et al. [16].
Physical Activity – IPAQ 88 85 0.34 The authors used a similar methodology to demonstrate
(% actives)
the effectiveness of home physical exercise, by practicing
Data mean ± standard deviation or in (%); n = number of participants who
completed the follow up. No significant difference was detected between
the “Baduanjin” exercise technique in the self-reported
groups (p > 0.05) quality of sleep. In that study, 56 elderly people (mean
age 71.7 ± 8.1) were randomized, and the IG performed
the participation of the elderlies, as they present diffi- the “Baduajin” exercise in their households and the CG
culties in relation to the transfer [14, 28, 29]. did not perform any specific activity. The IG received a
However, in the present study, a home physical exer- videotape, an educational booklet with pictures about
cise program was applied, with only one-week supervi- the performance of the exercises, and they were
sion, easy to apply and low cost, which proved to be safe instructed to perform 30 min of exercise 3 times a week
and feasible, since no injuries related to training were for 12 weeks and received telephone follow up twice a
week. After this period, the IG showed a statistically
significant improvement when compared to the CG in
relation to the overall PSQI score and in 5 of the 7
evaluation components, similar to the results found in
the present study.
The secondary endpoint, excessive daytime sleepiness,
recognized as an important public health problem [31],
was evaluated through the ESS demonstrating that the
elderlies who practiced physical exercise presented a sig-
nificant reduction of excessive daytime sleepiness, when
compared to the CG, in which the reduction was not
significant (Fig. 3), being consistent with the results of
other studies which used supervised exercises of Yoga
[27] and Tai Chi [32], which also demonstrated a signifi-
cant reduction of excessive daytime sleepiness in the
exercise group, using of the same rating scale.
The analysis of variance performed in the age sub-
groups has showed a significant improvement in sleep
quality, however there was no significant difference,
demonstrating that the home exercise program was ef-
fective in the different age groups of the elderly involved
in the present study.
Fig. 2 Comparison of quality of sleep (PSQI), before and after the
One of the strengths of our study is that, after random
intervention, in each group. T-test for paired samples
allocation of subjects, both groups were periodically
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 7 of 9

Table 2 Delta of mean PSQI components related to pre- and post-intervention for each group and p of the difference
Variables Group Basal moment After 12 weeks of intervention Delta p*
Subjective sleep quality CG 1.9 ± 0.7 1.8 ± 0.6 0.1 0.16
IG 1.8 ± 0.7 1.1 ± 0.6 0.7 < 0.01
Sleep latency CG 2.0 ± 0.9 1.7 ± 0.8 0.2 0.08
IG 1.9 ± 1.0 1 ± 0.9 0.9 <0.01
Duration of the sleep CG 1.9 ± 0.9 1.6 ± 0.8 0.3 0.11
IG 2.1 ± 1 1.2 ± 0.8 0.8 <0.01
Usual sleep efficiency CG 2 ± 0.9 1.6 ± 1.1 0.4 0.06
IG 1.6 ± 1.0 0.7 ± 0.9 0.9 <0.01
Sleep Disorders CG 2 ± 0.6 1.9 ± 0.7 0.1 0.41
IG 1.9 ± 0.6 1.2 ± 0.5 0.6 <0.01
Use of sleeping medicines CG 0.3 ± 0.4 0.2 ± 0.4 0.0 0.32
IG 0.2 ± 0.4 0.1 ± 0.3 0.1 0.04
Dysfunction during the day CG 1.6 ± 1.2 1.7 ± 1 −0.1 0.57
IG 1.7 ± 1.1 1.1 ± 0.8 0.6 <0.01
Data mean ± standard deviation
*t-test for non-paired samples (p < 0.05)

given the same orientations and stimuli in relation to life We also highlight the lack of reports of adverse events
habits such as feeding, hydration and sleep hygiene. during the exercise period.
These positive results presented in our study are also re- Previous studies have suggested that a direct contact
lated to the fact that, in addition to the program being with participants via phone, internet or personal visits in-
carried out at home and composed of dynamic and easy creases the adherence to home exercise programs [29, 30].
to be performed physical exercises, the elderlies received Follow up losses did not interfere in the results, since they
visits every fortnight and then they were encouraged and occurred at random, their characteristics are homoge-
oriented, by the research assistants and their relatives, in neous both in terms of quantity and quality of losses, since
relation to practice of the exercises, contributing to the they corresponded to less than 10% of the total sample
high rate of adherence and small loss of the participants. and presented reasons similar in both groups, besides the
characteristics of those who remained in the study are
comparable to those who did not remain.
All these results should be interpreted taking into
account some limitations of the present study. Firstly,
recruitment was performed with elderlies of the commu-
nity with self-reported sleep disorders, however the re-
sults may be more clinically reliable if the participants
are clinically diagnosed for the disorders. There is a pre-
dominance of females in the sample, which is justified
by the feminization of the elderly population [33, 34]
and the prevalence of sleep disorders in the female
elderly [35], however the randomization generated
equivalent distribution between groups. The inability to
blind participants in relation to the intervention may
have been tempered by the fact that each group (CG and
IG) was accompanied by different assistants, minimizing
the excitement bias applied by the IG assistants during
home visits. The monitoring of the frequency of the
exercises was self-reported, however to increase the
reliability of that information, in addition to monitoring
the frequency register during visits, family members were
Fig. 3 Comparison of improving excessive daytime sleepiness (ESS),
recruited to assist in collecting information. The quality of
before and after the intervention in each group. T test for paired samples
sleep was measured in a non-objective instrument, by
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 8 of 9

means of validated questionnaire, that represented as Consent for publication

perceived by the individual. All patients give their consent for publication in the consent form. However,
every attempt will be made to ensure the patients’ anonymity.
Future studies are needed to evaluate the effects of
semi-supervised home-based exercise programs with
Competing interests
long follow up periods and using objective strategies for All the authors declare that they have no competing interests.
assessing sleep quality, and to monitor and to quantify
treatment efficacy, making outcomes clinically more
reliable. Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Conclusions
Author details
The results of the present study suggest that the regular 1
Bahiana School of Medicine and Public Health, Salvador, BA, Brazil.
practice of semi-supervised physical exercises at home is 2
Department of Education (DEDC-VII), University of the State of Bahia –
effective in improving the self-reported quality of sleep UNEB, Rua Visconde do Rio Branco 162, Centro, Senhor do Bonfim, BA CEP
48970-000, Brazil. 3IMAIS – Diagnostic and Specialty Clinic, Senhor do Bonfim,
and the reduction of daytime sleepiness in sedentary BA, Brazil. 4Mondo Medico, Multidisciplinary & Rehabilitation Outpatient
elderly people with sleep disorders in various age groups Clinic, Borgomanero, NO, Italy. 5Medical School, University Center of Anapolis
of the elderly population. Therefore, it may be consid- – UniEVANGELICA, Anapolis, GO, Brazil. 6Department of Life Sciences (DCV),
University of the State of Bahia – UNEB, Salvador, BA, Brazil.
ered as a therapeutic, non-pharmacological, easy-to-
implement and safe resource for improving the quality Received: 25 October 2017 Accepted: 22 November 2017
of sleep of the elderlies.

Abbreviations References
BMI: body mass index; ESS: Epworth Sleepiness Scale; IPAQ: International 1. Conte F, Arzilli C, Errico BM, Giganti F, Iovino D, Ficca G. Sleep measures
Questionnaire of Physical Activity; OSA: Obstructive Sleep Apnea; expressing “functional uncertainty” in elderlies’ sleep. Gerontology.
PSQI: Pittsburgh Sleep Quality Index 2014;60(5):448–57.
2. Durcan L, Wilson F, Cunnane G. The effect of exercise on sleep and fatigue
in rheumatoid arthritis: a randomized controlled study. J Rheumatol.
Acknowledgments
2014;41(10):1966–73.
The authors are especially grateful to the elderlies who accepted to
3. Vitiello MV, Foley DJ, Stratton KL. Prevalence of sleep complaints and
participate in the study, to the Department of Education - Campus VII, of the
insomnia in the vitamins and lifestyle (VITAL) cohort study of 77,000 men
State University of Bahia - UNEB for providing the necessary equipment for
and older women. Sleep. 2004;27:120.
the evaluation of the participants, the members of the QUALES research
4. Ohayon MM, Carskadon MA, Guilleminault C, Vitiello MV. Meta-analysis of
group for dedication in collecting the data and in the accompaniment of
quantitative sleep parameters from childhood to old age in healthy
the elderly throughout the intervention period.
individuals: developing normative sleep values across the human lifespan.
Sleep. 2004;27(7):1255–73.
Funding 5. Crowley K. Sleep and sleep disorders in older adults. Neuropsychol Rev.
This study was funded by the State University of Bahia, through the Support 2011;21(1):41–53.
Program for the Training of Teachers and Administrative Technicians (PAC); 6. Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep
LVFO receive grants Research Productivity, modality PQIB; Process no. complaints among elderly persons: an epidemiologic study of three
313053/2014–6 of National Council for Scientific and Technological communities. Sleep. 1995;18(6):425–32.
Development (local acronym CNPq), Brazil. This grants not influencing any of 7. Markota M, Rummans TA, Bostwick JM, Lapid MI. Benzodiazepine Use in
the stages of the study, from the conception, development, analysis and Older Adults: Dangers, Management, and Alternative Therapies. Mayo Clin
interpretation of the results. Proc. 2016;91(11):1632–9.
8. Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman H, Ospina H, et al. The
Availability of data and materials efficacy and safety of drug treatments for chronic insomnia in adults: a
All data and materials are available upon request. meta-analysis of RCTs. J Gen Intern Med. 2007;22(9):1335–50.
9. Van der Hooft CS, Schoofs MW, Ziere G, Hofman A, Pols HA, Sturkenboom
MC, et al. Inappropriate benzodiazepine use in older adults and the risk of
Authors’ contributions fracture. Br J Clin Pharmacol. 2008;66(2):276–82.
GSB1, LVFO, CFD and AAC provided the concept of the study, created the 10. Akbari Kamrani AA, Shams A, Shamsipour Dehkordi P, Mohajeri R. The effect
hypothesis, and wrote the original proposal. GSB1, AACS and GSB3 obtained of low and moderate intensity aerobic exercises on sleep quality in men
ethics approval. GSB1, AACS, GSBFG and GSB3 participated in the data older adults. Pakistan. J Med Sci. 2014;30(2):417–21.
collection and performed clinical evaluations. GSB1, LVFO, and AAC prepared 11. Du S, Dong J, Zhang H, Jin S, Xu G, Liu Z, et al. Taichi exercise for self-rated
the drafted manuscript. GSB3, LVFO, CFD and GSB1 were involved in the sleep quality in older people: a systematic review and meta-analysis.
critical revision of the manuscript. GSB1, AAC and LVFO co- lead Int J Nurs Stud. 2015;52(1):368–79.
investigators. GSB1, AAC, CFD and LVFO wrote this final version of this paper, 12. Gobbi S, Sebastião E, Papini CB, Nakamura PM, Valdanha Netto A, Gobbi LT,
with input from all co-authors. All authors read and approved the final et al. Physical inactivity and related barriers: a study in a community
manuscript. dwelling of older Brazilians. J Aging Res. 2012;6:1–8.
13. Franco MR, Howard K, Sherrington C, Ferreira PH, Rose J, Gomes JL, et al.
Ethics approval and consent to participate Eliciting older people’s preferences for exercise programs: a best-worst
The study was approved by the Research Ethics Committee of the Bahia scaling choice experiment. J Physiother. Korea Institute of Oriental.
School of Medicine and Public Health, process 39,072,514.6.0000.5544. All Medicine. 2015;61(1):34–41.
participants sign an informed consent form. The results of this study will be 14. Nelson ME, Layne JE, Bernstein MJ, Nuernberger A, Castaneda C, Kaliton
published in peer-reviewed journals as well as national and international D, et al. The effects of multidimensional home-based exercise on
conferences. The data collected will also be made available according functional performance in elderly people. J Gerontol A Biol Sci Med Sci.
demand. 2004;59(2):154–60.
Brandão et al. Multidisciplinary Respiratory Medicine (2018) 13:2 Page 9 of 9

15. Ashworth NL, Chad KE, Harrison EL, Reeder BA, Marshall SC. Home versus
center based physical activity programs in older adults. Cochrane Database
Syst Rev. 2005;1:CD004017.
16. Chen MC, Liu HE, Huang HY, Chiou AF. The effect of a simple traditional
exercise programme (Baduanjin exercise) on sleep quality of older adults: a
randomized controlled trial. Int J Nurs Stud. 2012;49(3):265–73.
17. Schulz Kenneth F, Altman Douglas G, David M. CONSORT 2010 Statement:
updated guidelines for reporting parallel group randomised trials. BMJ.
2010;340:c332.
18. Bertolazi AN, Fagondes SC, Hoff LS, Dartora EG, Miozzo IC, de Barba ME, et
al. Validation of the Brazilian Portuguese version of the Pittsburgh sleep
quality index. Sleep Med. 2011;12(1):70–5.
19. Brucki SMD, Nitrini R, Caramelli P, Bertolucci PHF, Okamoto IH. Sugestões
para o uso do mini-exame do estado mental no Brasil. Arq Neuropsiquiatr.
2003;61(3 B):777–81.
20. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh
sleep quality index: a new instrument for psychiatric practice and research.
Psychiatry Res 1989;28(2): 193–213.
21. Bertolazi AN, Fagondes SC, Hoff LS, Pedro VD, Menna Barreto SS, Johns MW.
Portuguese-language version of the Epworth sleepiness scale: validation for
use in Brazil. J Bras Pneumol. 2009;35(9):877–83.
22. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the berlin
questionnaire to identify patients at risk for the sleep apnea syndrome. Ann
Intern Med. 1999;131:485–91.
23. Mazo GZ, Benedetti TRB. Adaptation of the international physical activity
questionarie for the elderly. Rev Bras Cineantropometria e Desempenho
Hum. 2010;12(6):480–4.
24. Chodzko-Zajko WJ, Proctor DN, Fiatarone Singh MA, Minson CT, Nigg CR,
Salem GJ, et al. American college of sports medicine position stand. Exercise
and physical activity for older adults. Med Sci Sports Exerc. 2009;41(7):1510–30.
25. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc.
1982;14(5):377–81.
26. Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise
improves self-reported sleep and quality of life in older adults with
insomnia. Sleep Med. 2010;11(9):934–40.
27. Chen KM, Chen MH, Chao HC, Hung HM, Lin HS, Li CH. Sleep quality,
depression state, and health status of older adults after silver yoga exercises:
cluster randomized trial. Int J Nurs Stud. 2009;46(2):154–63.
28. Morey MC, Snyder DC, Sloane R, Cohen HJ, Peterson B, Hartman TJ, et al.
Effects of home-based diet and exercise on functional outcomes among
older, overweight long-term cancer survivors: RENEW: a randomized
controlled trial. JAMA. 2009;301(18):1883–91.
29. Martin KA, Sinden AR. Who will stay and who will go? A review of older
adults adherence to randomized controlled trials exercise. J Aging Phys Act.
2001;9(2):91–114.
30. Lacroix A, Kressig RW, Muehlbauer T, Gschwind YJ, Pfenninger B, Bruegger
O, et al. Effects of a supervised versus an unsupervised combined balance
and strength training program on balance and muscle power in healthy
older adults: a randomized controlled trial. Gerontology. 2016;62(3):275–88.
31. Gooneratne NS, Weaver TE, Cater JR, Pack FM, Arner HM, Greenberg AS, et
al. Functional outcomes of excessive daytime sleepiness in older adults.
J Am Geriatr Soc. 2003;51(5):642–9.
32. Li F, Fisher ÃKJ, Harmer ÃP, Irbe D, Tearse RG, Weimer C, et al. Tai chi and
Self-rated quality of sleep and daytime sleepiness in older adults: a
randomized controlled. Trials. 2004;52(6):892–900.
33. Austad SN, Bartke A. Sex differences in longevity and in responses to
anti-aging interventions: a mini-review. Gerontology. 2015;62(1):40–6.
34. Luy MGK. Do women live longer or that men die earlier? Reflections on the Submit your next manuscript to BioMed Central
causes of sex differences in life expectancy. Gerontology. 2014;60:143–53.
35. Ohayon MM. Epidemiology of insomnia: what we know and what we still and we will help you at every step:
need to learn. Sleep Med Rev. 2002;6(2):97–111.
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research

Submit your manuscript at

www.biomedcentral.com/submit