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Effect of Self-Care Management Program on the Quality of Life and Self-Efficacy

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DOI: 10.5829/idosi.wjns.2014.56.72

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World Journal of Nursing Sciences 3S: 56-72, 2014
ISSN 2222-1352
© IDOSI Publications, 2014
DOI: 10.5829/idosi.wjns.2014.56.72

Effect of Self-Care Management Program on the Quality of Life and

Self-Efficacy of Geriatric Patients with Parkinson's Disease
1
Marwa Ibrahim Mahfouz, 1Hanaa Abou El-soued Hussein and 2Magda Mahmoud Mohammad

1
Gerontological Nursing, Alexandria University, Alexandria, Egypt
2
Gerontological Nursing, Damanhur University, Damanhur, Egypt

Abstract: Parkinson's disease is one of the long-term multifocal neurological conditions which have undesirable
consequences on geriatric patients' independence and quality of life (QOL). So, those compromised patients
need to be learn about personalized self-care interventions adopted to their needs in order to achieve finest
control over their health condition, feel confident in one’s ability to manage such progressive and degenerative
symptoms and develop an acceptable level of progress in all life domains and overall wellbeing. The study
aimed to determine the effect of self- care management program on the quality of life and self-efficacy of geriatric
patients with Parkinson's disease. The study was carried out in neuropsychiatric outpatient clinic of El-Hadara
Orthopedic and Traumatology University Hospital in Alexandria, Egypt. The study sample consisted of 22
geriatric patients with idiopathic Parkinsonism. Five tools were used in this study; Parkinson's disease Geriatric
Patients' Demographic and Health Information Structured Interview Schedule, Mini-mental State Examination,
the Modified Hoehn and Yahr Staging Scale, the Self-Efficacy for Managing Chronic Disease Scale and the
39-items Parkinson's Disease Questionnaire. Results showed that less than two thirds (63.3%) of the studied
patients with Parkinson's disease reported poor quality of life of total domains. The factors most closely
associated with poor QOL were mobility, body discomforts and impaired daily activities. The improvements of
these features therefore become an important target in the self-care management of the disease developed in
this study, in addition to the other domains affected passively with PD. After application of the educational
program, an observed measured improvement in both PD geriatric patients' quality of life and their self-efficacy
was evident immediately post program which returned back gradually during the follow-up weeks later,
although still significant. Further, PD suffers’ QOL was greatly linked and correlated significantly with their
self-efficacy. It could be concluded that application of self-care strategies is effective in increasing the quality
of life of seniors who suffer from Parkinson's disease and help in improvement of their self-efficacy. The authors
recommended that self-care interventions should be incorporated into the routine nursing practice for geriatric
patients with Parkinson's disease and involving their family care-givers to affect positively their quality of life
and consequently their self-efficacy.

Key words: Personalized-Care Strategies Parkinson’s Disease Superiority Of Life Confidence In One’s
Own Abilities Diseased Seniors

INTRODUCTION most common neurodegenerative diseases that only

The unknown etiology and unpredictable course of
Parkinson's disease progression make it one of the more
mysterious and complex of all neurological disorders [1].
Parkinson's disease (PD) is a progressively debilitating
disorder predominantly causes motor and non-motor
dysfunctions and possesses the second ranking of the
outnumbered by Alzheimer’s dementia in older adults [2].
It is thought that the neurochemical imbalances seen in
PD disrupts the neural circuitry of the basal ganglia
resulting in reduction in the size and speed of sequential
movements and manipulative tasks, in addition to
irregularity in automated cognitive events, mood,
behavior and all other disease features [3].

Corresponding Author: Marwa Ibrahim Mahfouz, Gerontological Nursing, Alexandria University, Alexandria, Egypt.
E-mail: marwa871975@gmail.com.
56
 World J. Nursing Sci., 3S: 56-72, 2014
The diagnosis of PD is done clinically as the disease
hasn’t any biomarkers. Out of all clinical data, response to
levodopa is the most discriminatory in the differential
diagnosis of PD from other types of Parkinsonism. While
scientists agree that there is a dopamine deficiency in
persons with PD, the mainly cause of the dopamine loss
still remains unidentified A mutation in LRRK2 gene is the
most frequent cause of the disease known to date [4].
The worldwide incidence of PD is thought to vary
between 1.5 and 22 patients/100 thousands
population/year and millions more remaining undiagnosed
with a widely ranged prevalence in door to door surveys
[5]. PD prevalence is 1.3% in men versus 1.6% in women
[6]. Unfortunately, Egypt ranks the third in the world
among the countries of the highest prevalence rate of the
disease with a rate of 1.103 per 100 thousands population,
specifically in the rural areas, south of Cairo along the
River Nile, probably because of poverty [7].
Quality of life (QOL) of geriatric patients with PD
comprises the total effect that this condition has on a
person's bio-psycho-social wellbeing and his or her actual
and desired life. For people living with chronic diseases
such as PD, QOL may change daily and even frequently
within the course of a day, as they struggle to adapt to
and manage the challenges which the disease thrusts
upon them [8].
Often the PD older adult patient experiences a
constellation of biological, psychological or emotional,
cognitive and social symptomatology. The physical
symptoms of PD typically affecting QOL are tremor,
rigidity, bradykinesia and troubles with manual dexterity.
Some of the aspects that affected intensely in QOL for
those patients and their families include: impaired
mobility, balance and nutrition; sleep disturbances,
fatigue, altered libido, blurred vision and other autonomic
nervous system-related aspects. These features can make
it difficult for PD patients to perform routine activities of
daily living (ADLs), such as dressing, bathing and
grooming; getting out of bed or arising from a seated
position; and walking or climbing stairs [9].
While physical symptoms are critical to the clinical
diagnosis, PD is not solely a motor control and movement
disorder. Dementia, depression and anxiety are common
psychological syndromes reported [10]. Not only do older
adult patients with PD struggle with the physical and
psychological impairments of the disease, the dissociation
of emotional expressivity (expressive dysprosodia) and
facial expression has a profound effect on their social
57
relationships and activities. Although the inner feelings
are intact, the incongruence may lead to social
embarrassment among these patients [11].
Hypophonia and other voice changes occur in
80-90% of these patients; and 45-50% has articulation
changes. Patients are cognizant of their distractibility and
difficulty with word-finding and thought processing while
engaging in conversation [12]. As a consequence of their
speech and communication difficulties, PD older adult
patients reported that they experienced loss of self-
esteem, loss of dignity, humiliation and altered
socialization processes ranging from apprehension,
disengagement, to complete withdrawal. Written
communication is further affected due to tremors resulting
in the typical micrographic handwriting seen in PD [13].
Although drug therapy is the major treatment
modality for the disease, it may have its own reverse
consequences and side effects that can also impact the
QOL for the patients causing symptoms such as
dyskinesia, hedonistic dopamine dysregulation syndrome,
freezing, orthostatic hypotension, hallucinations,
psychoses and visual disturbances. “Off” states
potentially occur when PD medications wear off and are
no longer available to control the symptoms until more
medication is given and reaches an adequate blood level
to control patients' manifestations. Non-adherence to
prescribed drug and other treatment regimens could result
in negative consequences to patients' quality of life, such
as increased frequency of “on-off’ states, falls, injuries
and others [14].
Fortunately, there are several other beneficial
underutilized treatment modalities available to aid in the
management and control of PD symptoms that include
exercises, environmental design, rehabilitation and social
support systems, all of which may be effective in
improving QOL for those patients [15].
In this respect, PD older adult patients, like patients
with other chronic diseases, have to learn how to live with
and self-manage their symptoms and disease-related
issues on a daily basis. Central to the ability of self-
managing their disease is having the confidence that they
have the knowledge, skills and ability, i.e., self-efficacy, to
carry out the required behaviors and tasks to achieve the
desired goals. Self-care is vital necessary for Parkinson
diseased older adults and involved the ability of
individuals, families and communities to promote health,
prevent disease and cope with illness and disability with
or without the support of a healthcare provider [16].
 World J. Nursing Sci., 3S: 56-72, 2014
Because in our Egyptian community, the concept of
self-care management for PD is out the light of health care
interest, patients suffer from more confusing everyday
struggles, for which lacking essential knowledge and
practice to effectively deal with.
Significance of the Study: Self-care management through
PD patient education should be directed toward avoiding
or limiting functional disability, achieving a slower
progress in this chronic disease that considered incurable
and maintaining independent living for as long as
possible. Extant research is limited regarding the role of
patient education for disease self-management in
Parkinson's disease and ultimately, the influence of such
factors on patient's QOL and self-efficacy for managing
the disease. Successful self-care will not occur unless the
views, opinions, beliefs and attitudes of patients
themselves are considered as key components of
therapeutic encounters.
To what extent the geriatric patients with PD could
improve their well-being and resume their familiar lifestyle,
becomes a critical issue. Improvement in quality of life and
the ability to retain activities of daily living should
therefore be the goals of outcome criteria for the
gerontological nurses in clinical trial designs focused on
the elderly with PD. So, there is a growing need to identify
the effectiveness of patient education in enhancing PD
geriatric patients' self-reported QOL and self-efficacy
through self-management program.
Aim of the Study: To determine the effect of self-care
management program on the quality of life and self-
efficacy of geriatric patients with Parkinson's disease.
Research Hypotheses:
Geriatric patients with Parkinson's disease who
receive the proposed self-care strategies exhibit
higher quality of life post the intervention than
before.
Geriatric patients with Parkinson's disease who
receive the proposed self-care strategies exhibit
improved self-efficacy post the intervention than
before.
MATERIALS AND METHODS
Research Design: The study used a pretest-posttest and
follow-up research design.
58
Research Setting: This study was conducted in
neuropsychiatric outpatient clinic of El-Hadara
Orthopedic and Traumatology University Hospital. It is
affiliated to Alexandria University and it was selected as
one of the biggest university hospitals that provided best
services for neurological and psychiatric diseases in
Alexandria, Egypt.
Additionally, it includes sections for orthopedic
surgery and emergency operations, outpatient clinics and
CT scan. The hospital power reached 449-bed. The
neuropsychiatric outpatient clinic is specialized in
manifestation of neuropsychiatric disorders which specify
five days per week for providing medical services from
Saturdays along Wednesdays. However, only Sundays
are determined for treating and following PD patients
whose number amounted to 31 patients (28 geriatric
patients with different degrees of idiopathic PD 60 years
and over “only those with idiopathic PD which related to
unknown etiology with certain degrees were selected
according to inclusion criteria” and 3 patients with other
forms of Parkinsonism under 60 years old declined later)
Subjects: A convenient sample of 22 geriatric patients
(out of 28) of both sexes diagnosed with idiopathic
parkinsonism (PD) attending the previous clinic for follow
up of their therapeutic regimen with the following criteria,
were eligible to participate and enrolled in the current
study:
Older adults 60 years and above (as Parkinsonism
can affect people of different age due to known
causes which differ from Parkinson's disease of
unknown etiology).
Had disease duration between 1-5 years. Because of
their limited experience with the disease
manifestations, geriatric people diagnosed with PD
for less than one year were excluded from this study
and those over 5 years will be also not included
because of the progressive nature of the disease (get
more worse) takes place over a period of 5 years,
usually accompanied severe disabilities that obstruct
patient abilities to follow self-care program
instructions and being dependent on others to fulfill
needs (according to specialist’s recommendation of
duration) .
Had no other chronic disabling illnesses or
neurological disorders (i.e. CV Stroke), Participants
with an illness in addition to PD, that impacted
activities of daily living might have difficulty
separating those experiences unique to PD.
 World J. Nursing Sci., 3S: 56-72, 2014
Compliance with a stable dose of medications for at
least a month.
Were able to ambulate independently, or with an
assistive device.
Score of 26 or greater in Mini-Mental State Exam
(MMSE) (normal = 26 in PD) or with mild cognitive
impairment (18- 25)
Were at a modified Hoehn and Yahr stages (an
assessment of disease severity) of 2, 2.5 and 3. Since,
it was likely that those at a modified Hoehn and Yahr
stage of 0 or 1 (unilateral disease) have not
experienced significant life-style changes, so only
those at stage 2 , 2.5 and 3 (starting from bilateral
disease without impairment of balance to mild to
moderate bilateral disease; some postural instability;
and physically independent) were included in this
study
Tools: In order to fulfill the objective of the study, five
tools were used
Tool I: PD Geriatric Patients’ Demographic and Health
Information Structured Interview Schedule: Developed
by the researchers and completed by all participants
verbally prior to the initial interview. Data were collected
on age, gender, educational level, marital status,
occupational background, socioeconomic status, & onset
of PD diagnosis, other diagnoses and current
medications, use of assistive devices, participation in
medical insurance system and patient’s rate of health.
Tool II: Mini-Mental State Examination (MMSE): The
MMSE is an effective screening tool that used to
systematically and thoroughly assess mental status of
community dwelled older adults. It is a 30-question
measure that developed by Folstein et al . [17], translated
into Arabic language by Elokl [18] and approved to be
valid and reliable (r= 0.93).
It tested ten areas of cognitive function: memory,
orientation to time and place, attention, calculation,
naming, repetition, registration, language, praxis and
copying of a design. The MMSE has two sections.
The first section has a maximum score of 21 and focuses
on attention, memory and orientation and requires vocal
participation from the patient. The second section has a
maximum score of 9 and focuses on the patient’s ability to
both name and follow written and verbal instructions. The
maximum score is 30. For PD, a score of 26 or higher is an
indicative of cognitive intact functions, while that ranged
from 18-25 indicates mild cognitive dysfunction.
59
Tool III: The Modified Hoehn and Yahr Staging Scale:
The original widely- used H & Y scale developed by
Hoehn and Yahr [19] to describe the clinical progression
or the severity level of PD symptoms by observing the
patient in both standing and sitting position.
The scale was criticized as lacking sensitivity to
measure the gradual deterioration of the PD patient’s
condition. Thus, a modified version was proposed and the
scale was further divided into eight stages, ranging from
0 to 5 (“Stage 0 = No signs of disease” to “Stage 5 =
Wheelchair bound or bedridden unless aided”), with half-
point gradations between stages 1 and 2 (1.5) and stages
2 and 3 (2.5). Then it had been added to the Unified
Parkinson’s Disease Rating Scale (UPDRS).
Tool IV: The Self-Efficacy for Managing Chronic
Disease 6-Item Scale: A short scale was developed by
Lorig et al. [20] to measure the self-efficacy outcome in
Chronic Disease Self-Management Program. The scale
covers several domains that are common across many
chronic diseases, symptom control, role function,
emotional functioning and communicating with
physicians.
The score for each item is the number circled. If two
consecutive numbers were circled, the lower number
(less self-efficacy) is coded. If the numbers are not
consecutive or more than two items were missing, score
of the item was omitted. The score for the scale is the
mean of the six items and higher number indicates higher
self-efficacy.
Tool V: The 39- item Parkinson’s disease Questionnaire
(The PDQ-39): The PDQ is a set of 39 self-administered,
PD- specific multi-dimensional quality of life questions
with eight discrete domains. It was developed by
Peto et al. [21] and designed to measure key QOL areas
that had been adversely affected by PD during the
preceding month.
The eight dimensions are: (a) mobility (10 items,
negotiated mobility problems such as difficulty doing the
leisure activities or walking 100 yards) (b) activities of
daily living (6 items, represented a variety of ADL
limitations such as cutting food or dressing self) (c)
emotional well-being (6 items, declared enormous
emotional disturbances such as being depressed or
worried about the future), (d) stigma (4 items, pointed out
the social difficulties affected the lives of PD patients
such as avoid eating or drinking in public), (e) social
support (3 items, discussed the level of support PD
patients perceived from daily social interactions and
 World J. Nursing Sci., 3S: 56-72, 2014
relations such as problems concerning lack of support
from family or close friends) , (f) cognitions (4 items,
involved problems in the cognitive areas such as memory
and concentrations), (g) communication (3 items,
addressed the communication inappropriateness such as
speech difficulties impaired communication with others)
and (h) bodily discomfort (3 items, described different
bodily undesirable feelings such as pains, cramps and
aches).
Respondents are requested to affirm one of 5-point
ordinal response scoring system: 0 = never had this
problem, 1 = occasionally, 2 = sometimes, 3 = often, 4 =
always have this problem (Likert scale) according to the
frequency of patients’ experience difficulties across the
eight subscales’ items which reflect the impact of the
disease on patients’ health status , functioning and
wellbeing. Each dimension total score range from 0 (never
have difficulty) to 100 (always have difficulty). Lower
scores reflect better QOL. Dimension score equals sum of
scores of each item in the dimension divided by the
maximum possible score of all the items in the dimension,
multiplied by 100.
Total Score equals sum of scores for questions 1-39
divided by four, multiplied by 39 and then multiplied by
100.
Study Method:
An official letter was forwarded to the hospital’s
administrator to obtain the permission to attend the
clinic. Then after, the study purpose was explained to
both the hospital’s administrator, the head of the
clinic and nursing staff as well and a written
permission was obtained in order to gain their
support and cooperation during the application of
the study interventions.
For proper conduction of this study, three phases
were implemented; assessment or preparation phase,
program conduction phase and evaluation (follow
up) phase.
Phase One: “Assessment or Preparation Phase”:
Development of Tools:
Tool I was developed by the researchers based on
recent relevant literature to assess demographic and
health information of the Parkinsonian patients. The
Arabic version of tool II was used in this study.
Tools from III to V were translated into Arabic
language by the researchers and were validated by
60
juries of (5) experts in the field. Their suggestions
and recommendations were taken into consideration.
Cronbach’s coefficient alpha test was used to
ascertain the reliability of tools. Test indicated that
tool III, IV and V were 85.4% reliable, 76.8% reliable
and 91.3% reliable respectively. PD quality of life
domains ranged from 0.572 to 0.849 in reliability test).
Pilot study was carried out on 4 older adults with PD
not included in the study, selected from geriatric
medicine unit at Alexandria Main University Hospital
during their follow up appointments in order to
ascertain the relevance, clarity and applicability of
the tools, test wording of the questions and estimate
the time required for the interview. Based on the
obtained results, the necessary modifications were
done.
Development of the Self-Care Management Program:
Self-care skills and strategies were developed by the
researchers after reviewing the most recent related
literature. Self-management skills for PD comprised
areas related to a variety of professional domains,
including importance of self- management program
and basic information about PD, skills for managing
one’s medications; diet and physical exercise,
functional activities and home /environmental
modifications; managing non motor behavior,
memory problems, eating and swallowing difficulties,
eye and sleep disorders, pain and motor fluctuations,
skin and foot care, bladder and bowel function, fall
prevention, dealing with anxiety and depression,
speech intelligibility, social communication; and
identification and access of appropriate social
support systems.
Primary Assessment Outcome and Fieldwork:
Each interview took approximately 30- 45 minutes,
depending on the participant's comfort level and will
take place in the waiting area of the clinic using tools
from I to V. The preferred method used of
interviewing is one-on-one in the presence or
absence of family members or caregivers. A caregiver
may be defined as any person with the exception of
medical care providers (i.e., significant other, family
and sitter) providing care to the person with PD.
Collection of initial data covered a period of two
months and half, from the beginning of June 2011 till
the mid of August 2011.
 World J. Nursing Sci., 3S: 56-72, 2014
Phase Two: “Program Conduction Phase”:
Before the conduction of the educational and skills-
related sessions and after the first joint clinic visit;
researchers informed participants of any potential
benefits that they may experience by being in the
study which included (a) increased knowledge of and
self-confidence (self-efficacy) regarding management
of PD care and other health issues, (b) increased
problem-solving skills to deal with health-related
issues, (c) opportunities for increased social
interaction, (d) and increased QOL.
The program conducted on group bases of 4 groups
in total (2 groups with 6 elders each and two 5- elder
groups), 20-35 minutes session/week on Sundays
(the only day determined for PD patients for
receiving care and follow up, taken into consideration
that patient went to the clinic once per month),
preceding by quarter an hour summary of important
previous learnt knowledge/skills and answering
related questions.
Teaching methods included lectures, group
discussion, role-playing, brainstorming,
demonstration and re- demonstration, models,
pictures, real life demonstration, problem solving and
mastery experience (i.e. trying out the skills
introduced on the self- care program).
The total number of sessions was 56 sessions, 14
sessions per each group (one discussed topic every
meeting with a break period of 30 minutes providing
snacks and exercises practice from the second week
along with all sessions). This phase covered a period
from the mid of August 2011 till the mid of October
2012.
Handouts to improve learning and action plan
calendar were prepared and given to each participant
to identify obstacles hinder the achievement of
needed goals.
Phase Three: “Evaluation/Follow up Phase”:
Post the implementation of the self-management
program, reassessment of the quality of life domains
and self-efficacy of the participants were done by the
researchers two times; once directly after the
conduction of self-care strategies and at the sixth
week of the program implementation. The second
assessment outcomes was determined during 3
months evaluation from the mid of October 2012 to
the mid of January 2013.
61
The total period of data collection, including the
three phases covered a period of 17 months and a
half, from the beginning of June 2011 till the mid of
January 2013. Then, the difference between pre-
intervention and post-intervention scores was
determined through using the proper statistical
analysis.
Ethical Consideration: Ethical consideration was applied
through participants' informed written consent to
participate in the study. The participants’ rights were
protected by explaining the purpose and significance of
the study. Participants were reassured that their
responses will be kept anonymous and no remarks will be
made to identify the patients' identity. The patient was
informed that participation in the study is voluntary and
can withdraw at any time and that withdrawal will not
affect the level of services and care provided.
Statistical Analysis: The collected data were coded and
analyzed using PC with SPSS version 20 and tabulated
frequency and percentage were calculated. Descriptive
statistics as frequency, distribution, mean and standard
deviation were used to describe different characteristics.
The Chi-square test and Monte Carlo test were used
for testing relationship between categorical variables.
Univariate analyses, including: t-test was used to test the
significance of results of quantitative variables and to
compare the means between two unrelated groups on the
same continuous, dependent variable.
The one-way analysis of variance (ANOVA) is used
to determine whether there are any statistically significant
differences between the means of two or more
independent groups (F Test). The level of significance
selected for this study was p value equal to or less than
0.05.
RESULTS
Table (1) illustrates that the age of the study subjects
ranged from 60 to 77 years with a mean of 63.8±4.7 years.
Those in the age group of 60 years to less than 65 years
constituted more than one half of all studied PD older
adults (59.1%). More than three quarters (77.3%) of them
were males, while being married (91.0%) and illiterate
(54.6%) characterized the social and educational
background of the study sample.
Table (2) shows that 50.0% of the study subjects had
health problems other than Parkinson's disease. Around
three quarters (72.3%) of them had disorders related to
 World J. Nursing Sci., 3S: 56-72, 2014

Table 1: Description of the studied subjects according to their socio-demographic information

The studied subjects (no. = 22)
------------------------------------------------------------
Socio-demographic information Number %
Age (in years)
60 years- 13 59.1
65 years- 6 27.3
70 years 3 13.6
Min-Max 60 -77
Mean ± SD 4.7± 63.8
Sex
Male 17 77.3
Female 5 22.7
Marital status
Married 20 91.0
Divorced 1 4.5
Single 1 4.5
Educational level
Illiterate 12 54.6
Primary education 5 22.7
Preparatory education 2 9.1
Secondary education 2 9.1
University education 1 4.5

Fig. 1: Distribution of the study subjects according to self-evaluation for their health condition

cardiovascular system such as hypertension, ischemic
heart diseases and heart failure. Diabetes mellitus and a
history of previous fall were reported with an equal
percent (36.4%). While, 18.2% suffered from
psychological problems. The same table revealed also
that more than two thirds (68.2%) reported sensory
problems in the form of visual problems (66.7%), pain
(40.0%) and smell problems (13.3%). In addition to the
dopaminergic agents, more than one half (54.5%) of the
elderly with PD consumed prescribed medications for
different disorders. Cardiovascular drugs are the most
common consumed drugs 58.3%, followed by
hypoglycemic agents 33.3%. Analgesics and laxatives
were the most common drugs consumed without
prescription (90.0% and 80.0% respectively) among
45.5% of the subjects who consumed over the
counter (OTC) medications. 54.5% of PD elderly
patients used assistive devices; including eye glasses
(83.3%) followed by canes for mobility (50.0%) and
hearing aids (8.3%). Further, the vast majority (90.9%) of
the study subjects had no health insurance or enough
income for follow up their current diagnosis (Parkinson's
disease).
Figure (1) reflects that more than one half (59.0%) of
the study subjects evaluated their health condition as
moderate in wellness.

62
 World J. Nursing Sci., 3S: 56-72, 2014

Table 2: Description of the studied subjects according to their clinical data

The study subjects (no. =22)
--------------------------------------------------------------
Health status Number %
A. Health problems other than Parkinson's disease
Yes 11 50.0
Disorders related to: #
Cardiovascular system 8 72.3
Endocrinal system 4 36.4
Previous fall 4 36.4
Psychological problems 2 18.2
Gastrointestinal system 1 9.1
Respiratory system 1 9.1
No 11 50.0
B. Sensory-perceptual problems:
Yes 15 68.0
Type of sensory- perceptual problems: #
Visual problems 10 66.7
Sensation problems (pain) 6 40.0
Smell problems 2 13.3
No 7 31.8
C. Current prescribed medication consumed
Yes 12 54.5
Types of medication: #
Cardiovascular medication 7 58.3
Diabetes medication 4 33.3
Eye drops 2 16.7
Anxiolytics 2 16.7
Gastrointestinal medication 1 8.3
Respiratory medication 1 8.3
Sleep enhancer 1 8.3
Antiepileptic 1 8.3
No 10 45.5
D. Over the counter medication consumed
Yes 10 45.5
Types of medication: #
Analgesics 9 90.0
Laxatives 8 80.0
Antacids 2 20.0
No 12 54.5
E. Assistive devices used
Yes 12 54.5
Types of assistive devices: #
Eye glasses 10 83.3
Cane 6 50.0
Hearing aids 1 8.3
No 10 45.5
F. Have health insurance
No 20 90.9
Yes 2 1.9
G. Enough income for follow up
No 20 90.9
Yes 2 9. 1
#=more than one response was given

63
 World J. Nursing Sci., 3S: 56-72, 2014

Table 3: The effect of self-care management program on the quality of life of geriatric patients with Parkinson's disease
Elders' Mean Scores Elders' Mean Scores Elders' Mean Scores
Pre-program Immediate Post-program 6 weeks Post-program Test of significance
--------------------------------------------------------------------------------------------------------- (ANOVA Test)
Total percent score** Total percent score** Total percent score** ----------------------------
PDQ_39_SI sub items Mean ± SD Mean ± SD Mean ± SD P1 P2
Mobility 71.25±14.6 50.5±14.7 57.9±16.1 F:2.706 F:6.101
P:0.064 P:0.004*
Activity of daily livings (ADLs) 59.8±14.8 44.9±15.7 49.6±14.8 F:6.923 F:3.918
P:0.001* P:0.015*
Emotional wellbeing 59. 3±17.6 40.3±14.5 48.1±17.3 F:0.864 F:1.116
P:0.595 P:0.435
Stigma 58.5±15.5 40.9±13.2 45.4±14.0 F:3.001 F:4.455
P:0.040* P:0.009*
Social support 59.4±24.5 44.3±16.5 51.8±18.5 F:1.942 F:2.027
P:0.138 P:0.123
Cognition 60.5±16.2 38.3±11.2 43.4±15.1 F:6.787 F:3.565
P:0.001* P:0.021*
Communication 59.4±19.2 44.6±11.9 50.3±14.8 F:1.872 F:2.816
P:0.151 P:0.047*
Bodily discomfort 69.7±18.10 43.9±8.5 57.1±14.6 F:0.909 F:1.503
P:0.527 P:0.244
PDQ_39_SI TOTAL Score 63.3±11.2 44.4±10.4 51.2±11.8 F:11.715 F:3.584
P:0.003* P:0.062
F: ANOVA test P: p value of ANOVA test
Significant P =0.05 P ** Lower score reflects better QOL P1: Stands for adjusted Bonferroni p-value for ANOVA with repeated measures for comparison
between pre with immediate post-program
P2: Stands for adjusted Bonferroni p-value for ANOVA with repeated measures for comparison between pre with 6 weeks post-program

Table (3) illustrates that there was an observed
improvement in overall score of quality of life of geriatric
patient with Parkinson's disease immediately after the
application of self-care management program and the
difference is statistically significant (F= 11.715, P=0.003*).
After six weeks duration from the end of the program, the
quality of life was still improved (51.2±11.8) in comparison
to its level prior the application of the program (63.3±11.2)
with no statistically significant difference (F=3.584,
P= 0.062). Generally, after six weeks, all domains of quality
of life were slightly returned back in comparison to its
level immediately after the application of the program.
Immediately after the application of self-care
management program, the highest level of quality of life
was reported in cognition which significantly improved
(38.3±11.2) in comparison to its level prior the application
of the program (60.5±16.2) and the difference was
statistically significant (F= 6.787, P= 0.001*). Moreover,
after six weeks, the cognition was still better (43.4±15.1)
in comparison to its level before the application of
the program with a statistically significant difference
(F= 3.565, P= 0.021*).
On the other hand, as the physical function was the
most deteriorated aspect of QOl; the mobility was slightly
improved immediately after the application of the program
(50.5±14.7) in comparison to its level before (71.25±14.6)
which proved to be insignificant (F= 2.706, P= 0.064).
Fortunately, the mobility is still slightly improved after six
weeks (57.9 ±16.1) if compared to its level prior the
program (71.25±14.6) with a statistically significant
difference (F= 6.101, P= 0.004*). In addition, bodily
discomfort domain was improved immediately after the
program and after six weeks (43.9±8.5, 57.1±14.6
respectively) and the difference was not statistically
significant (F= 0.909, P= 0.527, F= 1.503, P=0.244
respectively). Furthermore, Activity of daily livings of
geriatric patients with Parkinson's disease was
significantly improved immediately after the program and
after six weeks (44.9±15.7, 49.6±14.8 respectively) in
comparison to its level before it (59.8±14.8) with
statistically significant difference (F= 6.923, P= 0.001*,
F= 3.918, P=0.015* respectively).
The program elevated the social support domain of
QOL immediately after its application and then next the six
weeks period (44.3±16.5, 51.8±18.5 respectively) in
comparison to its level before it (59.4±24.5) with no
statistically significant difference (F= 1.942, P= 0.138,
F= 2.027, P=0.123 respectively). Communication
domain experienced nearly the same level of
enhancement immediately after the program (44.6±11.9)

64
 World J. Nursing Sci., 3S: 56-72, 2014

Table 4: The effect of self-care management program on Self-efficacy of geriatric patients with Parkinson's disease
Mean ± SD Scores ** Test of significance (ANOVA Test)
------------------------------------------------------------------------------------------ ---------------------------------------
Item Total allowed score Pre-program Immediate Post-program 6 weeks Post-program P1 P2
Self-efficacy 60 21.2±7.2 30.6±5.7 29.1±5.7 F: 3.376 F: 2.102
P: .038* P:0.135
F: ANOVA test P: p value of ANOVA test
*Significant p=0.05 **Higher number indicates higher self-efficacy P1: Stands for adjusted Bonferroni p-value for ANOVA with repeated measures for
comparison between pre with immediate post-program
P2: Stands for adjusted Bonferroni p-value for ANOVA with repeated measures for comparison between pre with six weeks post-program

Table 5: Correlation between self-efficacy and quality of life of the study subjects pre the application, immediately after the application of self-care management
program and six weeks post program
Self-efficacy
-----------------------------------------------------------------------------------------------------------------------------------------------------
Pre-program Immediate post-program Six weeks post-program
----------------------------------- ---------------------------------- --------------------------------
DQ_39_SI sub items X2 MC
p X2 MC
p X2 Mc
p
Mobility 172.812 0.001* 224.617 0.001* 330.234 0.001*
ADLs 135.758 0.001* 140.855 0.001* 230.162 0.001*
Emotional wellbeing 167.964 0.131 67.196 0.015* 134.302 0.011*
Stigma 144.323 0.007* 78.024 0.048* 131.681 0.085
Social support 92.893 0.198 74.517 0.165 103.597 0.042*
Cognition 125.557 0.033* 74.601 0.046* 160.832 0.013*
Communication 118.135 0.001* 54.696 0.024* 104.481 0.007*
Bodily discomfort 105.191 0.162 32.960 0.082 111.967 0.256
PDQ_39_SI TOTAL Score 251.334 0.002* 240.107 ?0.001* 390.646 0.001*
X2: Chi-square test MCp: Monte Carlo P value *Significant P 0.05

but the difference didn't reached to significant level
(F= 1.872, P=0.151). After the sixth-week duration, it still
improved if compared to its level prior the program
application (59.4±19.2) and the difference became
statistically significant (F= 2.816, P= 0.047*).
Before the application of the program, feeling
stigmatized among geriatric patients with Parkinson's
disease was (58.5±15.5) which significantly improved
immediately after the program and after six weeks
(40.9±13.2, 45.4±14.0 respectively) as well as proved to be
significant (F= 3.001, P= 0.040*, F= 4.455, P=0.009*
respectively). This is followed by emotional well-being;
which improved immediately after the program and after
the period of six weeks follow up (40.3±14.5, 48.1±17.3
respectively) if compared to its level before (59.3±17.6)
with no statistically significant difference (F= 0.864,
P= 0.595, F= 1.116, P=0.435 respectively).
Table (4) reveals that there was an observed
improvement in self-efficacy of geriatric patient with
Parkinson's disease along all levels of the program
evaluation. Immediately after the application, high level of
self-efficacy was reported (30.6±5.7) in comparison to its
level pre- the application (21.2±7.2) with a statistical
significant difference (F= 3.376, P=0.038*). Moreover, six
weeks post program, self-efficacy of the study subjects
(29.1±5.7) was still higher than its level prior the
application of the program (21.2±7.2) but the difference
didn't reach to the significance level (F=2.102, P= 0.135).
Table (5) reflects that there was an observed
significant correlation between self-efficacy of the study
subjects and their quality of life immediately after the
application of self-care management program. This was in
relation to mobility, activities of daily livings, emotional
well-being, stigma, cognition and communication; the chi
square was (224.617, 140.855, 67.196, 78.024, 74.601, 54.696
respectively) and P value was (<0.001*, <0.001*, 0.015*,
0.048*, 0.046*, 0.024 respectively).
The table also portrayed that there was a significant
correlation between self-efficacy of the study subjects
and their quality of life after six weeks from the end of the
program. This was regarding mobility, activities of daily
livings, emotional well-being, social support, cognition
and communication; the chi square was (330.234, 230.162,
134.302, 103.597, 160.832, 104.481respectively) and P value
was (0.001*, 0.001*, 0.011*, 0.042*, 0.13*, 0.007*
respectively).
On the other hand, it was observed that there was no
significant correlation founded between self-efficacy of
the study subjects and their bodily discomfort either
immediately after the application of the program or six
weeks post program; (X2 = 32.960, 0.082 respectively), (P=
111.967, 0.256 respectively).

65
 World J. Nursing Sci., 3S: 56-72, 2014
DISCUSSION
The current trends in the health care arena behoove
self-care management to take a more proactive role in
preservation of function and quality of life (QOL), health
promotion, complications prevention and rehabilitation;
areas ultimately critical in illnesses of late life onset and
extended years of disability. One such illness, Parkinson’s
disease (PD), has been associated with decreased quality
of life, reduction of functional capacity, depression and
difficulty in communication, deprived recreation and
restrictions in intimate and social life. PD touches all
aspects of a person’s life and certainly can have a
negative impact on the person’s QOL. Consequently, it is
worthwhile to investigate QOL issues related to PD and
apply a multidimensional approach to disease
management which addresses all aspects of the disease
process to promote QOL of patients involved with this
chronic disease [22].
Results of the present study revealed that the
percentage of geriatric patients with PD was more in the
age group 60 years to less than 65 years than those who
are in the other two age groups. This result doesn’t
contradict literatures that PD increased in incidence with
advanced age; but the fact that as motor impairment
intensify, patients display increasing dependence on
others for most aspects of basic self-care with increased
age category, which enforced family members came to the
clinic to receive routinely prescribed treatment instead of
patient who just came to the clinic in case of severely
disrupted new evident. In respect to sex, the present
study revealed that PD is reported by more males than
females. Literature explained this phenomenon; where
smoking, as a risk behavior for the disease, is more among
males. Men had been more directly exposed than women
to toxicant exposure in agriculture and head trauma; in
addition to the neuroprotection role of estrogen for
dopamine activity, or female gonadal factors that provide
resilience to dopamine loss [23-25].
PD exists a significant economic burden on PD
patients and their families. In the present study, most of
PD geriatric patients (90.9%) complained of the absence
of supported health insurance system for them and their
income wasn’t sufficient to follow their conditions with
private doctors or in specialized hospitals in addition to
the high expenses of medication which are the main
causes of the monthly visits of the outpatient’s clinics.
Similar supporting studies for this results indicated that
the annual health expenditures, costs for prescription
medications and utilization of health care services were
66
over two times greater in PD patients who also had 1.3
times more outpatient visits than their non -PD
counterparts [26]. PD patients had higher levels of costly
comorbidities. 50% of them as revealed in this study
reported health disorders with the greatest prevalence
of cardiovascular problems and diabetes mellitus.
This finding is congruent with result of previous study
which stated that these diseases in addition to
depression, falls and dementia were determinants of
higher medical costs among PD beneficiaries.
To the best of our knowledge, the present study is
the first in Egypt to directly focus on a relationship
between QOL and self-efficacy in PD and to develop a
comprehensive educational Arabic-version material
teaching the concept of self-care to those patients and
later determining the effect self-care interventions posed
on inducing their self-confidence and impacted on
different domains of their lives. The educational material
covered: all physical difficulties PD patients faced and its
related self-care interventions and coping strategies;
psychological and cognitive complaints and
demonstrated self-care measures; and other social and
recreational withdrawal activities; for its; appropriate
actions would be taken according to the patient individual
differences in capabilities level. The educational material
gave a solution for every smallest common bothersome
problem by simply identifying the suffering, probable
causes, specific problem-solving skills and appropriate
self-taking measures.
The hallmarked finding of the current study indicated
that there is an observed and a significant progress in
allover domains of the quality of life of Parkinson’s-
diseased older adults directly after the implementation of
the proposed self-care management strategies. A possible
explanation is that; this type of management succeeded in
providing a holistic approach of care which first reflected
on self-efficacy and later on QOL. Although it may seem
paradoxical, the current study also exhibited a significant
relation between those concepts where higher perception
of QOL was linked with greater trust in self to manage
arrays of PD symptoms.
Indeed, perceived mastery and maintaining personal
control found to override all other factors, including the
impact of physical disability, in predicting PD patients’
quality of life. In addition, the skills learnt through our
program acted synergistically to alter attitudes toward
the disease as can’t be managed. Furthermore, the
prolonged period of interaction between the study
partners, the researcher and the environment within which
self-care principles accomplished, provided successful
 World J. Nursing Sci., 3S: 56-72, 2014
experiences in managing the disease, making elders
persuaded to try new strategies within a supportive
and positive environment. Recently, the work of
Miertová et al. [1], proved such associations and added
that PD patient education through self-care program acted
as a buffer against the disease dilemma.
Quality of life is a concept applying to the patient’s
self-evaluation of the impact of his/her disease [27].
A notable finding in this study was that 63.3% of the
studied patients reported worsened QOL at the initial
evaluation. The mechanism proposed by the researchers
that the patients deal with a disease course that is neither
predictable nor limited to a decline in physical
functioning. Dealing with the unpredictability of the
disease means that persons with PD should deal with the
disease on daily basis, existing more emotional and
physical strains. A plethora of studies postulated many
reasons for diminished quality of life in patients with PD,
including reduced mobility, falls, motor complications,
affective disorders and sleep disorders [8, 28- 30].
Although of its complexity, many of these aspects go
unnoticed in routine clinical assessments, the results that
also assumed in the study of Soh et al. [31].
Chronic comorbidities eventually interfere with the
ability to conduct daily activities and PD patients thus
become increasingly dependent upon others, increase the
prone to further complications and prevalence of side
effects from polypharmacy [27]. In the present study,
cardiovascular drugs and hypoglycemic agents are the
most common consumed prescribed drugs besides
antiparkinsonian agents. Analgesics and laxatives are the
most common over the counter drugs consumed by the
subjects without prescription for the believe of relieve
both motor (rigidity) and non-motor (pain and chronic
constipation) dysfunction commonly experienced by the
patients.
This is more explained by the current study results
which reflected that mobility (71.25±14.6), body
discomforts (69.7±18.10) and impaired daily activities
(59.8±14.8) are among the most impaired domains of QOL.
This is an expected result, as PD is basically diagnosed
with the associated features of impaired mobility
originated from a neurological deficiency of regulated
dopamine. As disease progresses, motor impairments
intensify and patients display increasing dependence on
physical assistance for most aspects of basic self-care,
that is why 50.0% of currently studied PD patients used
assistive mobility devices. Secondly, those patients
didn’t follow any form of physical exercising besides the
age-related changes in mobility they are often exposed to.
67
The third explanation claimed from the study done by
Martinez-Martin [26] that the non-motor features of PD
contribute to an ongoing deterioration of independence
in activities of daily living, overall functional status and
QOL.
From this point, the role the exercise played in the
significant improvement in these previously mentioned
domains in the current research is profound with a
statistical significant difference. For sure, exercise either
flexibility or strengthening is an important ingredient of
self-care management, provided clear benefits for PD
patients as it improves the clinical efficacy of levodopa
treatment and gait rhythmicity, maintains balance and
mobility, delays functional decline and slows the
progression of the disease. The researcher in this study
implemented both types of training 3 times weekly for
three consecutive months, which become the primary
practice before application of any following session. Each
session was initiated by practicing of 20 minutes-exercise
to relief rigidity and associated muscle tensions. The
patient compliance with a form of balance-induced
exercise improves the gait abnormalities which could lead
to fall, that reflect positively on the domains of mobility
and bodily discomfort with a great associated
enhancement.
It could be acceptable that the self-reported
improvement was decline in the follow up period due to
lack of appropriate supervision and motivation which may
lead to non-compliance. A very recent study in Jordan
(2014) recommended the importance of continuous
reinforcement for PD patients to change their perception
toward exercising and improve their practices [32].
Although motor impairments are the most prominent
feature of PD and surely affect their ability to carry out
daily tasks independently, the cognitive impairments
associated with PD are also likely to have a significant
impact on independent functioning and performance on
ADLs skills [33]. A significant finding of the present
study was that although PD patients with severe
cognitive disturbance were excluded, 60.5% of patients
reported decline in cognition.
The fact is that we can’t separate one domain from
the other. In essence, because PD patients have a
perception in impairments in both ADL and motor
domains, they have multiple potential contributions to
cognitive dysfunction; suggesting a complex relationship
exists between cognitive, motor functioning and
performance on ADLs. Medication-induced cognitive and
motor changes may not always occur in parallel. That is,
administration of levodopa can result in improvement in
 World J. Nursing Sci., 3S: 56-72, 2014
motor functioning and decline in selective components of
cognitive processing. Thus, it would be possible to see
dissociable changes in cognition and ADL performance
depending on drug dosage and time of administration. or
with mild cognitive impairment to follow the instructions
taught in the interventional In this regard, it is notable to
mention that all current studied participants follow some
form of dopaminergic prescription, supporting the
previous phenomena meaning that the acute and
short-term changes in cognition may be drug related as
the recruited PD patients in this study selected to be
cognitively intact program.
Broeders et al. [34] and Leroi et al. [35] stated that
even mild cognitive impairment which were prevalent
among 15%-40% of PD patients, can lead to poor QOL.
Through self-care training for managing the cognitive
decline, the studied participants in the current study
showed an observed improvement due to cognitive
training or cognitive stimulation interventions. Examples
are visual prompts (calendars, clocks, notice boards and
notices), promote daily routine and organization, verbal
strategies and maintain independence through at least
hobbies.
One of the sound finding of this study is the
improvement in the area of pain and general bodily
discomfort. The most frequently occurring pain types in
PD are musculoskeletal and dystonic pain. A prospective
study by Santos-Garcia et al. [36] including 159 PD
patients assessed in a movement disorders unit, found a
high prevalence of pain (72.3%). They also determined
that this symptom behaved as an independent predictor
of poorer quality of life. Similarly, bodily discomfort is
prevalent among 69.7% of the studied participants in the
current research. For several, bodily discomforts are
frequent complaints during the course of the illness and
often under-recognized and inadequately treated by the
health care professionals.
Pain originates from dopamine depletion and the
development of Lewy pathology leading to frozen,
cog-wheel type of resistance and led pipe-like phenomena
characterized the disease process that is responsible for
restricted mobility or dyskinesia and disability performing
day to day tasks [37]. This type of discomfort sensations
were more reported in patients with motor- dominant
subtype than in those with the tremor- dominant one [38].
In the current study; although the degree of improvement
in discomfort doesn’t reach to be statistically significance,
there is a reduction of mean percent score immediately
after the interventions and in the follow- up weeks. As so,
self-care management implemented relieved different
68
types of bodily discomfort especially dystonia, muscle
cramps and headache through medication adjustment,
sensory tricks, stretching exercises, being more active and
move around strategies.
A suggested link between PD-related cognitive
decline, dependence and a host of PD psychological
comorbidities such as depression, apathy, anxiety and
hallucinations, was proved evidence. This assumption
finding substantially supported in the present study
where, in addition to impaired physical and cognitive
domains, poor emotional wellbeing was prevalent among
59.3% of the studied elders.
Cubo et al. [39] determined that psychological
factors affected quality of life of PD patients more than
physical factors did. Alternately, Prediger et al. [40]
suggested that the effects of the disease prevent patients
from using their customary coping strategies, which
increases anxiety and provokes tremors. Depression and
PD share overlapping symptoms in old age such as
reduced facial expression, problems with sleeping, fatigue
and reduced appetite [41].
These similar symptoms may contribute to the under
diagnosis of depression in patients with PD. Moreover,
mild depression is an especially common symptom in the
early stages of PD and is associated with increased
disabilities and rapid progression of motor symptoms
[42, 43]. Psychological status improved significantly in the
present study after application of supported measures, for
instance, practice of relaxation techniques, massage and
avoiding triggers of anxious episodes and stimulus for
controlling anxiety. For depression, the program provided
support group therapy or individual therapy using
cognitive behavioral techniques by teaching new skills to
help deal with negative thoughts and problems more
effectively. Techniques used include relaxation,
distraction and goal setting through a weekly session.
Social support buffered the adverse effects of
stressful life events. Thus, an effective social support
network can provide opportunities for positive feedback
and managing uncomfortable feelings [44]. Of special
relevance to the present study, impaired social support
and communication were reported by 59.4% of the current
studied patients. Impaired facial emotion identified in PD
appears to be correlated with a variety of interpersonal
difficulties such as complaints of frustration in social
relations and feelings of social disconnection.
In this respect, Soleimani et al. [45] mentioned that
PD imposed limitations on patients’ ability to
communicate with others and were cognizant of their
distractibility and difficulty with word-finding and
 World J. Nursing Sci., 3S: 56-72, 2014
thought processing while engaging in communication,
which influenced their decision to participate or not in
conversation. On this basis, PD patients’ perceptions
regarding their voices conveyed concern about the
decreased strength of voice; deterioration in its quality,
rate and clarity; and difficulty with initiating speech
movements. As a consequence of their speech and
communication difficulties, PD patients experience loss of
self-esteem, loss of dignity and altered socialization
processes ranging from apprehension, disengagement, to
complete withdrawal.
Speech and language therapy, social support group,
use identification cards and practical tips to improve
writing are ways of self-care taught to those patients with
social and communication difficulties in the current study.
By far, Hammarlund and colleges [46] described the
efficacy of such interventions on QOL of PD patients in
their study.
People with PD experience shame and embarrassment
as a consequence of PD symptoms and / or perceived
reactions from others (presented by 58.5% of the current
studied patients). Avoidance of social situations; avoid
eating, drinking and writing in public due to tremor and
feel embarrassed made them consequently withdraw from
society [11]. Feeling of stigmatization in PD derived from
many factors. First is the common belief that PD is a
disease only for older adults; second is linked to patient’s
perception to be a burden for caregivers; third arises from
the uncertain progression of the disease.
The contribution of PD to the stigma perception also
back to the undesirable self-image, loss of autonomy,
inability to perform not only usual work activities but also
simple motor actions, feelings of frustration and
neglecting linked to withdrawal and communication
changes in the form of voice and articulation changes in
addition to attention difficulties. These factors go on line
with the work of Burgener and Berger [47]. Changes
developed and perceived in the other domains of QOL
through the program in the current study, explained the
observed improvement in patient feeling of stigmatization
toward himself due to the disease progressive and
complicated process, through expelling out of myths
and stereotypes, changing attitudes and practicing of
self-help.
In sum, attention to quality of life features is critical
to the management of PD which should be a
multidisciplinary approach, includes a coordination of
pharmacological and non-pharmacological treatment.
Currently, gerontological nurses are the staunchest
proponents of integrating self-care management into
69
treatment plans for older adults. The most recent trends in
PD self-care management program involve working
simultaneously with the patients and his family and
modify the environment through which the program takes
place.
CONCLUSION
The findings confirmed the hypotheses of the current
study. The application of self-care strategies is elegantly
effective in upgrading the quality of life of geriatric
patients with Parkinson's disease and help in improvement
of their self-efficacy with an observed statistically
differences among the two studied constructs prior and
immediately after the program. This improvement regretted
over time but still better than before.
In the light of these results, the authors highlighted
the following recommendations:
The importance of evaluating quality of life and
self-efficacy as a part of the clinical comprehensive
assessment for patients with PD. The identification
of any deficits should be used as a rational basis for
guiding self-care management programs about
provide systematic multidisciplinary approach for
assessing the efficacy of combined pharmacological,
behavioral, occupational, physical and surgical
interventions for the relief of PD symptoms.
In-service training program should be planned and
offered periodically to nurses who deal with PD
geriatric patients in order to update their knowledge
and improve their skills about self-care management.
Then after, these types of interventions should be
incorporated into the routine nursing practice for
those patients and their involved careers; for the
reason of enhancing patients' quality of life and
consequently their self-efficacy.
Educational materials in the form of printed handouts
and colored brochures should be provided to the PD
geriatric patients and their caregivers in order to help
them following the principles of self-care strategies.
The allocation of additional resources to patient
management should be targeted in this disease and
lack of appropriate rehabilitation centers in Egypt
with qualified and specialized therapists specific for
those patients, should be overcome.
Focused exercises program should be planned and
conducted to geriatric patients with Parkinson's
disease, this help them in obtaining the optimal level
of mobility within their limited functional abilities.
 World J. Nursing Sci., 3S: 56-72, 2014
ACKNOWLEDGEMENT
The authors are thankful to all elders willing agreed
to participate in this study. Deepest gratitude also goes
to the manger of neuropsychiatric outpatient clinic of
El-Hadara orthopedic and traumatology University
Hospital who willing allowed to conducting the study
there.
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