الفهرس 
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Abstract
The normal aging process is characterized by functional changes in multiple domains including neurological, cognition, sensory, and musculoskeletal, which highly impacted on the independency of older adults and their quality of life. Thus, the older adults are more vulnerable for frailty and decreased independence in performing activities of daily living. Frailty pertains to a state of vulnerability, which causes various systems of the body to exhibit reduced physiological functions and increases the risk for adverse outcomes. Thus, a critical intervention must be presented to postpone or revers the frailty state and decrease incidence of hospitalization, disability and mortality among community dwelling pre-frail older adults. Exercise interventions as multicomponent exercise program which include strength, resistance (aerobic), balance and flexibility training are considered a key factor to improve functional capacity of older adults. Moreover, this program helps to maintain older adults’ independence in performing activities of daily living, prevent, delay, reverse, or reduce the severity of frailty, or reduce the risk of adverse outcomes in irreversibly frail older adults.
The aim of this study was to:
Determine the effect of nursing intervention on the physical performance self-efficacy among community dwelling older adults in the pre-frail stage.
Study hypothesis:
Pre-frail community dwelling older adults who receive the proposed nursing intervention achieve higher scores of physical performance self-efficacy after the application of the intervention than before it.
Materials and method:
A. Materials:
Study design:
The study followed a Quasi-experimental research design (one group pretest posttest).
Setting:
This study was conducted in El-Waffa club for older adults at Alexandria.
Subjects:
The study included forty (40) pre-frail community dwelling older adults selected from the above-mentioned setting. The inclusion criteria were as follow; aged 60 years and above, able to communicate, read and write, ambulate with or without mobility aids, be in the pre-frailty state (score of 7-9 in the short physical performance battery (SPPB), and a score of 1-3 in frailty index for elders), and not having; myocardial insufficiency, uncontrolled hypertension, and upper or lower extremity fracture in the past 3 months.
Tools of the study:
Six tools were used in this study to collect the necessary data as follows:
Tool (I): Frailty Index for Elders (FIFE):
This tool was developed by Tocchi et al., 2014, it includes cognition, mood and social resources with physiological components in defining frailty, and includes a 10-items assessment instrument with scores ranging from (0-10). A score of (0) indicates no frailty; a score of (1-3) indicates pre-frailty or frailty risk; and a score of (4 or greater) indicates frailty.
Tool (ΙI): Short physical performance battery (SPPB):
This tool was developed by Guralnik et al., 1994, it is a group of measures that combines the results of the gait speed, chair stand and balance tests. The scores range from 0 (worst performance) to 12 (best performance).
Tool (ΙII): Socio-demographic and Clinical Data of Community Dwelling Elders Structured Interview Schedule:
This tool was developed by the researcher based on relevant literature to collect the following information from the study subjects and: -
A. The socio-demographic characteristics: will include items such as age, sex, marital status, educational level, and income.
B. Clinical data: will include items such as medical history, diagnosis, and pharmacological treatment.
Tool (IV): Barthel Index:
This tool was developed by Barthel et al., 1965. It is used to assess elder’s activities of daily living. The scale consists of 10 items. The total score of the scale is 20. Score from 0 to 7 indicates dependent, score from 8 to 12 indicates partially dependent and score from 13 to 20 indicates independent.
Tool (V): Instrumental activities of daily living (IADL):
This tool was developed by Lawton & brody 1969, it is used to assess more complex activities necessary for functioning in community settings, this tool contains 8 items that are rated with a summary score from 0 (low functioning) to 8 (high functioning).
Tool (VI): Exercise Self-efficacy Scale:
This tool was developed by the researcher based on relevant literature to assess the older adult’s own beliefs in his/her capabilities to successfully execute exercises. The total score was categorized as follow; a score of (15-24) indicating low self-efficacy, whereas the score of (25-34) indicating the moderate self-efficacy, and the score of (35-45) indicating high self-efficacy.
Method:
The study was carried out on three phases.
1. Preparation phase:
After the necessary approval has been taken and translation of the tools (I, II, IV, V) to Arabic language, and after developing the socio-demographic and clinical data tool, and the exercise self-efficacy, they were presented to a jury specialized in the field of nursing. A pilot study was carried out on five pre-frail older adults who attended at the club to assess the applicability, clarity and feasibility of the study tools. Then the tools (I, II, IV, V, VI) were tested for reliability using Cronbach’s alpha test. Then the proposed nursing intervention was prepared by the researcher according to the Vivifrail project. After the selection of the study subjects using tools (I, II), the study older adults were informed about the aim of the study and the time table of the sessions that were conducted at the study setting.
2. Implementation phase
The physical exercise program was prepared to be carried out in 12 weeks (5 sessions per week) with a total of 60 sessions of physical exercise. Then the older adult was instructed to complete the wheel of (strengthening, balance and flexibility exercises), for 3 non-consecutive days and in the other days he/she only instructed to walk. A diary record was provided for each pre-frail older adult in order to track his/her progress (appendix 9).
The multicomponent exercises were done as follows; warming up stage, which includes 5-10 minutes of walking or marching in place and using chairs moving their feet and arms while seated. Then the strengthening, balance and flexibility exercises were performed in each session for 12 weeks.
3. Evaluation phase:
The researcher followed up the study subjects through the diary record. After the implementation of the study interventions, the researcher performed the posttest immediately at the end of 12th week using tools (I, II, IV, V, VI). In addition, the process of data collection started December 2019, until August 2020.
The main Results obtained were as follows:
• The age of the study subjects ranges from 60 to 84 years with a mean of (67.5 ± 5.013) around (50%) of study subjects were in age group between (65 to less than 70).
• Regarding the sex, (90%) of study subjects were female and (10%) were male.
• As regards the marital status, (50%) of study subject are married, and (50%), are non-married.
• As for educational level, (2.5 %) of the study subjects were able to read and write, (15%) of them have basic education, (45%) of them had secondary educational level, and (37.5%) of them were had university education level.
• Concerning subject’s occupation before retirement, (87.5%) of the study subjects were employee, (5%) of them were technical worker, (5%) of them were housewives. While (2.5%) of them were freelancers.
• Regarding the clinical data, (80%) of the study subjects having chronic disease, (65%) of them have controlled hypertension, (55%) of them are having diabetes mellitus, while (47.5%) of them having musculoskeletal diseases.
• As for the medication consumed by the subjects, (65%) of study subjects taking antihypertensive medication, (60%) of them taking anti-diabetic medications, (82.5%) of them taking vitamins, and (47.5%) of them taking medications for musculoskeletal diseases.
• Concerning the frailty state, there were significant changes in frailty index score before and after the study intervention with a mean of (2.3500 ± 0.62224) and (1.6250± 0.62788) respectively.
• As for the study subjects exercise self-efficacy, there were significant changes in the exercise self-efficacy score before and after the study intervention with a mean of (27.2000 ± 4.25592) and (39.3000 ± 2.73814) respectively.
• Concerning the performance of Instrumental activities of daily living, significant change in the total score was shown among the study subjects after the implementation as (p=0.033).
• Regarding the standing balance score, a highly statistically significant differences was shown among the study subjects after the implementation of the study interventions than before it as (p=0.006).
• Concerning the time for first gait speed, time for second gait speed, time for total gait speed, and chair stand, a highly statistically significant difference was shown among study subjects after the implementation of the study interventions than before it as (p=0.000).
• As for the exercise self-efficacy, physical performance, and frailty state, a significant effect was shown after the implementation of the study interventions than before it as effect sizes were (0.86, 0,81and 0.5 respectively),
Conclusion:
Based on the findings of the present study, it can be concluded that the physical performance self-efficacy of all the studied pre-frail community dwelling older adults improved after the implementation of the multicomponent exercise program than before it. Highly statistically significant differences were found in the studied older adults’ physical performance and their self-efficacy after the implementation of the study intervention. Moreover, the pre-frailty mean score of all the studied subjects improved after the implementation of the study intervention than before it.
The main recommendations suggested are:
1. Pre-frailty screening is to be done for all community dwelling older adults who attend the clubs and the outpatient clinics by the responsible health care providers.
2. Workshops about multicomponent exercise program are to be provided for the pre-frail older adults and their formal and informal care givers in the clubs and outpatient clinics to enhance their practice and to help the pre-frail older adults to return to the robust stage.
3. The multicomponent exercise program can be safely and effectively incorporated into the standard nursing practice in caring for community dwelling pre-frail older adults who attend clubs and outpatient clinics.
4. Multicomponent exercise program is to be included in the clinical curriculum of bachelor nursing students in the gerontological nursing department.