The program has shown that one key tactic for encouraging beneficial aging is physical activity. Virtual reality (VR) therapy offers significant improvements in motor function and overall general health in patients with various conditions. Virtual reality technology is a potential approach to rehabilitation, but there is yet no clear evidence about how it affects older individuals’ frailty11.
According to our findings, older persons who live in communities may benefit from a 4-week home-based exergame program in terms of improved physical function and decreased fear of falling. Thus, the development and dissemination of exergames for use at home may broaden the variety of options and activities accessible to senior citizens25. Thus, the purpose of this study was to evaluate how a virtual reality-based home-based physical rehabilitation program affected the functional results of older adults who were frail.
Our findings demonstrated that the VR regimen was viable, with no negative effects, maximal adherence (no dropouts), and acceptable usability for weak older persons. These findings align with the existing body of literature11,26, It implies that exposure to virtual reality is a good way to encourage physical activity in older persons while maintaining safety and tolerability27. To the best of our knowledge, VR has never been used as an exercise facilitation tool in an older adult population, even though multiple research projects have used exercise programs in this age range.
There is some indication of our full sample in the epidemiology statistics, and it was found that males were more prevalent in the intervention and control groups. The greater prevalence of males in both the intervention and control groups in the home-based physical rehabilitation study via virtual reality (VR) for frail older adults can be explained by a few potential factors, such as sex differences in frailty prevalence, as numerous studies have shown that frailty is generally more prevalent among older women than older men. This is likely due to various biological, social, and lifestyle factors, which could be qualified to the specific characteristics of the study setting or recruitment strategies28. Like29, who has the research on the relationships between knee extension strength and hand grip strength and physical frailty-related variables, found that men were more common in both groups; however, this finding was dissimilar from that of30, in which females were more prevalent.
The age of the older adults in the control group ranged from 60 to less than 65 years, while the age of the older adults in the intervention group ranged from 70 years and older. In line with the current results, a randomized controlled trial was conducted by31,32,33 to assess the effectiveness of a multisystem physical exercise intervention for fall prevention and improving quality of life in older individuals at risk of frailty. The results showed that the intervention group’s older adult population was older than the control groups. However, inconsistent with the findings of RCT performed by34 The majority of older persons were 66.4 years old in the control group and 66.9 years old in the intervention group when the effects of a home-based, exergaming intervention were evaluated. In line with the results of the present study, a study performed by35,36,37 revealed no differences in demographic or clinical variables at baseline between participants in both groups.
The medical history of frail older adults in both groups was recorded. Most older adults in the intervention and control groups reported ‘yes’ regarding suffering from any disease. Among them, diabetes mellites was among the most prevalent types of chronic diseases. Nonetheless, a quasi-randomized comparative analysis of two exergame therapies was carried out by30, who discovered that musculoskeletal issues were among the most common forms of chronic illnesses in older persons after researching the impact of home-based exercise games on cognition and balance.
The association between frailty and drug use has been described repeatedly in the literature, including in a recent review38,39. Given that many medications may worsen physical health, it makes sense that there would be a link between such medications and the main components of frailty. Our results concerning the types of medications used indicated that most frail older adults in both groups consumed hypoglycemic agents.
According to our findings, most older adults did not smoke. Likewise, in characterizing the research population’s baseline attributes and based on frailty at baseline40, When frailty and medication-related issues were examined among community-dwelling older persons in Europe, it was shown that most frail older adults did not smoke.
Our results showed that there was no statistically significant difference in the medical history of frail older adults between the two groups at baseline. This may be because the intervention and control groups at baseline suggest a few important points, such as an effective randomization process during the study design and homogeneity of the study population in terms of their health status and medical backgrounds, as well as appropriate inclusion/exclusion criteria to ensure that the participants in both groups had similar medical histories and were suitable for the rehabilitation intervention. Similarly, a study by41 found no statistically significant variations in the viability and efficacy of a customized home-based motor training program for older persons living in the community.
The reduction in these frailty criteria in the intervention group during the follow-up period can be explained by the potential benefits of the home-based VR physical rehabilitation program, which enhanced bodily performance, as the VR-based rehabilitation program likely helped improve the participants’ muscle strength, endurance, and mobility, leading to reduced slowness in movement and better grip strength. Thus, targeted exercise and increased physical activity may have helped alleviate the feelings of exhaustion and fatigue experienced by frail older adults42.
Overheating (exhaustion), weight loss (shrinkage), slowness of movement, lack of physical activity, and inadequate grip strength are the five frailty criteria among frail older persons. These criteria were high prior to the program and decreased throughout the follow-up. Regarding the five frailty criteria, some of them increased in the control group both immediately following the program and throughout follow-up, while other criteria remained unchanged.
Similarly, a study43 when older persons in rural southern Korea were given visual-guided exercise programs to measure their physical frailty, the effect of high-speed power training was shown to have a substantial negative impact on their frailty state and scores. This difference was observed between the experimental and control groups.
Similarly, a multicenter randomized controlled trial12 assessed the impact of a collaborative exercise program under supervision on the functional performance of institutionalized older persons who were fragile. The results of a 2-way analysis of covariance showed a substantial improvement in between-group analysis following the intervention. However, unlike the outcomes of a multicenter cross-sectional study performed by44, who investigated the connection between older persons’ self-reported physical frailty and sensor-based sports participation assessments and found no discernible differences.
Frailty indices of elderlies in both groups on the three occasions (before, immediately after, and during follow-up). Finally, during the follow-up, the participants in the intervention exhibited considerably decreased frailty indices compared to the control group. The partial eta squared values suggested a considerable impact size of the intervention (ηp2 = 0.491).
Consistent with the current results, a study was performed by45, who found that there was a significantly greater decrease in the frailty index in the intervention group than in the control group. In addition, the results of a randomized controlled trial performed on prefrail and frail older adults46 showed that both intervention groups improved frailty status, with an impact magnitude that was higher than the control groups. Furthermore, there was a significant variation between the two groups in three of the five physical traits associated with the frailty phenotype: lack of activity, impoverished walking speed, and weakness. Exergaming exercise also considerably restored tiredness.
According to our findings, virtually reality-based physical exercise has been promoted as a possible means of enhancing the health of senior citizens in both clinical and nonclinical groups. When used in conjunction with traditional exercises, this type of intervention can help older persons who might not be motivated to perform traditional exercises recover more effectively. Furthermore, getting older adults to engage in physical exercise can be difficult; as a result, creative and unique strategies are needed to grab their interest and encourage adherence28.
Our findings showed that prior to the program, there were no statistically significant changes between the intervention and control groups in terms of physical performance dimensions. This may be justified by the increase in physical fitness, which suggested that the home-based VR physical rehabilitation program was effective at improving the overall physical and functional status of the frail older adults in the intervention group47. Similarly, a meta-analysis study performed by9 revealed that substantial evidence demonstrated that interactive VR training interventions increased lower limb muscle strength, walking speed, and balance. In addition48, reported that VR training interventions increased balance.
These findings were also obtained in a study performed by49, Researchers investigated the impact of guided remote rehabilitation on the functional performance of older persons living in the community. Their findings raised the possibility that tele-rehabilitation might be a viable substitute for in-person rehabilitation in terms of enhancing functional performance in older adults living in the community.
In addition, meta-analysis was performed by50 and demonstrated that engaging in virtual reality exercise significantly improved physical health and total physical aspect scores. However, there were significant advancements in the balance berg scale cut but not in the timed-up-and-go or 8-foot-up-and-go scores. Additionally51,52, studied the impact of exercise gaming on older persons in good health and found a statistically significant impact on equilibrium.
On the other hand, in contrast to the above53, there was no improvement in balance or gait among older persons who participated in in-home multicomponent exergame training, according to research on the impacts on brain volume and physical function. This might be the case since treatment adherence is one of the most crucial elements in attaining positive outcomes in terms of balance and fall prevention. Given that this population may occasionally become dependent, that they typically struggle with technology, and that treatment sessions are conducted at home, an extended course of treatment may cause participants to lose interest, which will decrease adherence to the program27.
Nonetheless, our findings were inconsistent with those of a study performed by54, the chair-stand test showed no discernible positive impact, according to that research. These discrepancies in the research results point to the variability of the data that have been published, indicating that exergames may be a good way to encourage older persons to be more physically active. With regard to fear of fall in the intervention and control groups before the program, no statistically significant variation was observed between the groups. The partial eta square in the intervention group (ηp2 = 0.495) indicated that the effect size was large. Similarly, meta-analysis worked by9 revealed that substantial evidence demonstrated that interactive VR training interventions reduced fall risk.
According to the outcomes as of right now of the present study, a study performed by55 showed that the prevalence of frailty increases with age; Frailty was more common among older adults (70 years of age and above). The following groups were more likely to be frail: women, widows, the illiterate, those who did not work after retirement, those with insufficient monthly income, and those living with someone other than close relatives. On the other hand, a study performed by56 indicated that a number of variables, including the degree of education attained in elementary school, had no correlation with the presence of either prefrailty or frailty; as a result, education was included in the final multivariable model as a potential confounder.
In our investigation, there was a strong correlation found between several health variables and prefrail or frail people. Identifying the health indicators that predict frailty and using that information to guide appropriate early intervention points is recommended. Our research results offer proof of the connection between frailty and the medical record of older adults who are feeble.
This may be because a variety of health determinants are linked to frailty and prefrailty status, as certain medical history factors, such as previous hospitalization, smoking, and lack of regular checkups, are predictive of frailty in older adults, and identifying these predictive health factors can inform early intervention strategies to address and potentially prevent frailty in older populations. These findings highlight the importance of considering an individual’s medical history when assessing and managing frailty57.
Similarly, a study performed by55 revealed that older persons with several diseases, those taking five prescriptions, and those who did not take their medications as prescribed were considerably more likely to be frail. Additionally, there was a strong correlation between frailty and prior hospitalization, smoking, and routine checks.
Further study56 conducted a study on ‘frailty and determinants of health among older adults in the United States’ and revealed that many factors were strongly associated with frailty, such as ≥ 2 hospitalizations in the previous year, > 2 comorbidities, and polypharmacy, while factors associated with lower odds of having prefrailty or frailty were being married or living with a partner and not owning a home and age > 80 years, but the effect was small.
The statistically significant relationship between the medical history and physical performance of frail older adults underscores the importance of considering the impact of comorbidities and chronic health conditions when designing and implementing interventions to address frailty and encourage healthy aging and targeted management of chronic diseases and comorbidities may help improve the physical function and performance of frail older adults, potentially delaying or reversing the progression of frailty57.
The correlation involving the individual characteristics of frail older adults and their fear of falling was assessed. There was a statistically significant association between the individual characteristics of frail older adults and fear of falling, as sex and marital status; education level; monthly salary (before, immediately and during follow-up); residence (immediately and during follow-up); age (before and immediately); and current work (previously). Similarly, a study by58 revealed that sex (being a woman) was a predictor of falls in community-dwelling older adults. Dissimilar to conclusions by59, participants who suffered from fear of falling were more prone to be older and less educated than were those who had no fear of falling.
The findings from this study indicate a direct link between a previous medical history and a fear of falling. There was a statistically significant relationship between the medical history of older adults and their fear of falling during the previous year.
A study performed by59 revealed that participants who had a fear of falling were more prone to having a number of chronic diseases; Individuals who feared falling experienced higher levels of pain and sadness, were more likely to be admitted to the hospital, engaged in less strenuous activities, and fell more frequently. Additionally, a study by58 revealed a relationship between medical history of older adults and fear of falling regarding polypharmacy and a lower SPPB score.
Our results show the correlation matrix between the study variables among frail older adults in the intervention group on the three occasions. A statistically significant weak negative correlation was found between frailty and physical performance, as increasing frailty score was associated with decreasing physical performance score and vice versa. Similarly, in a study performed by [60], The scientists looked at the connection between older individuals’ frailty syndrome and physical performance and discovered a negative correlation between the two.
According to our findings, there was a statistically significant moderate positive association between the fear of falling and frailty (before, just after, and throughout follow-up). Increasing the frailty score was linked to increasing the fear of falling, and vice versa. This might be the case since activity limitation raises the likelihood of falling and vice versa, and both frailty and fear of falling can cause them. Similarly, a study performed by [61] on the factors associated with fear of falling among frail older adults revealed that greater fear of fall is also present in people who are most frail, with several studies describing the relationship between frailty and fear of falling and falls [62]; [63].
Slowness and tiredness were the frailty criteria that in our sample most significantly raised fear of falling ratings. [64] noted a connection as well. Further research should be done on these results as well, as they may indicate that criteria for identifying and preventing frailty need to be adjusted if different frailty criteria have different effects on fear of falling or other outcomes.
This is the first study, to the best of our knowledge, that assessed the impact of a virtual reality-based home-based physical rehabilitation program on the functional outcomes of frail older adults in order to investigate potential mechanisms of intervention effects. Exergaming will be incorporated into the program to support the established advantages of exercise in this susceptible group. We expect to see a drop in the frailty index as well as an increase in standing balance, gait speed, chair standing, and fear of falling.
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