Falls prevention interventions in older adults with cognitive impairment: a systematic review of reviews

Aim: This critical review explores the review material on falls prevention interventions in older adults with a cognitive impairment such as dementia. Method: A critical, systematic, review of review method was used. Five large electronic databases, MEDLINE, EMBASE, AMED, CINAHL, and the Cochrane electronic library, were searched. The search terms ‘falls’, ‘rehabilitation’, ‘falls prevention’, ‘interventions’, ‘cognitive impairment’, ‘dementia’, and ‘Alzheimer’s disease’, were used. All available reviews were marked against predetermined inclusion and exclusion criteria. Results: There were seven reviews which met the inclusion criteria. Only one of the included reviews had a homogenous population of adults with a cognitive impairment. Exercise was the most commonly reported intervention, included in 91 studies and all seven reviews. Multifactorial and multicomponent falls prevention programmes were also frequently reported. Reports of efficacy were inconsistent for all interventions. Conclusion: Evidence for falls prevention interventions for adults with cognitive impairment is varied and inconclusive. When compared to literature for falls interventions in healthy older adults, both primary and synthesis studies in older adults with cognitive impairment are lacking in quality, number and homogeneity of sample population and interventions. Promising results are emerging but clinical recommendations cannot be made at this time

Systematic scoping review of frameworks used to develop rehabilitation interventions for older adults

Objectives: Rehabilitation interventions for older adults are complex as they involve a number of interacting components, have multiple outcomes of interest and are influenced by a number of contextual factors. The importance of rigorous intervention development prior to formal evaluation has been acknowledged and a number of frameworks have been developed. This review explored which frameworks have been used to guide the development of rehabilitation interventions for older adults.Design: Systematic scoping review.Setting: Studies were not limited for inclusion based on setting.Participants: Studies were included that featured older adults (>65 years of age).Interventions: Studies were included that reported the development of a rehabilitation intervention.Primary and secondary outcome measures: Data was extracted on study population, setting, type of intervention developed and frameworks used. The primary outcome of interest was the type of intervention development framework.Results: Thirty-five studies were included. There was a range of underlying medical conditions including mild cognitive impairment and dementia (n=5), cardiac (n=4), stroke (n=3), falls (n=3), hip fracture (n=2), diabetes (n=2), breast cancer (n=1), Parkinson’s disease (n=1), depression (n=1), chronic health problems (n=1), osteoarthritis (n=1), leg ulcer (n=1), neck pain (n=1) and foot problems (n=1). The intervention types being developed included multicomponent, support-based, cognitive, physical activities, nursing-led, falls prevention and occupational therapy-led. Twelve studies (34%) did not report using a framework. Five frameworks were reported with the Medical Research Council (MRC) Framework for Developing and Evaluating Complex Interventions being the most frequently cited(77%, n=17).Conclusion: At present the MRC Framework is the most popular for developing rehabilitation interventions for older adults. Many studies do not report using a framework. Further, specific guidance to assist this complex field of rehabilitation research is required

Pre- and post-operative voice therapy (PaPOV): Development of an intervention for patients with benign vocal fold lesions

Background: Pre- and post-operative voice therapy may improve voice and quality-of-life outcomes for patients undergoing phonosurgery to remove benign vocal fold lesions (BVFLs). However, what constitutes voice therapy in this population is poorly described, resulting in a poor evidence base, lack of clinical guidelines and unwarranted variation in management. In order to develop the evidence base, a robust, iterative process of intervention development work should precede feasibility testing and effectiveness studies. Methods & procedures: Guidance for developing complex interventions, drawing on evidence, theory and modelling, was used to inform the development of a pre- and post-operative voice therapy intervention entitled 'PaPOV'. Data from four sources of evidence were synthesized using a published triangulation protocol. Data from a systematic review, national survey of current practice, expert interview study, and patient and public involvement conversations were used to populate a triangulation matrix, outlining components of a PaPOV. Data were coded to reflect areas of agreement, dissonance and silence with each component of the intervention. Based on this evidence, an assessment of convergence for each intervention component could be made. Outcomes & results: In total, 61 components of the PaPOV intervention were explored. Of these, 27 were categorized as having stability of consensus according to a priori criteria. A total of 34 failed to meet the criteria. This was more frequently due to silence (27) rather than dissonance (seven) in the data. By evidencing areas of agreement and stability of consensus across data sources, the validity of individual findings has been enhanced. Furthermore, the study has exposed specific areas of the intervention that lack consensus and require exploration through further intervention development studies. Conclusions & implications: This systematic triangulation process has contributed to the development of a PaPOV intervention for patients with BVFLs. Exploration of specific components relating to the intervention will allow outstanding questions to be answered in preparation for feasibility testing

Pre- and post-operative voice therapy (PaPOV): Development of an intervention for patients with benign vocal fold lesions

Background: Pre- and post-operative voice therapy may improve voice and quality-of-life outcomes for patients undergoing phonosurgery to remove benign vocal fold lesions (BVFLs). However, what constitutes voice therapy in this population is poorly described, resulting in a poor evidence base, lack of clinical guidelines and unwarranted variation in management. In order to develop the evidence base, a robust, iterative process of intervention development work should precede feasibility testing and effectiveness studies. Methods & Procedures: Guidance for developing complex interventions, drawing on evidence, theory and modelling, was used to inform the development of a pre- and post-operative voice therapy intervention entitled ‘PaPOV’. Data from four sources of evidence were synthesized using a published triangulation protocol. Data from a systematic review, national survey of current practice, expert interview study, and patient and public involvement conversations were used to populate a triangulation matrix, outlining components of a PaPOV. Data were coded to reflect areas of agreement, dissonance and silence with each component of the intervention. Based on this evidence, an assessment of convergence for each intervention component could be made. Outcomes & Results: In total, 61 components of the PaPOV intervention were explored. Of these, 27 were categorized as having stability of consensus according to a priori criteria. A total of 34 failed to meet the criteria. This was more frequently due to silence (27) rather than dissonance (seven) in the data. By evidencing areas of agreement and stability of consensus across data sources, the validity of individual findings has been enhanced. Furthermore, the study has exposed specific areas of the intervention that lack consensus and require exploration through further intervention development studies. Conclusions & Implications: This systematic triangulation process has contributed to the development of a PaPOV intervention for patients with BVFLs. Exploration of specific components relating to the intervention will allow outstanding questions to be answered in preparation for feasibility testing. WHAT THIS PAPER ADDS: What is already known on the subject BVFLs cause dysphonia by preventing vocal fold closure, impacting on vibratory characteristics and increasing compensatory muscle tension. Management for these patients is variable with them being offered phonosurgery, voice therapy, pharmacological management or a combined approach. Pre- and post-operative voice therapy may improve both voice and quality-of-life outcomes. This patient group has unique complexities when considering voice therapy, including surgical preparation, wound healing and epithelial mobilization. What this paper adds to existing knowledge This study uses a robust triangulation process to synthesize current evidence and patient experiences in order to inform the development of a PaPOV. It outlines some of the key components and considerations when delivering pre- and post-operative voice therapy to adults with BVFLs. Furthermore, it serves as a methodological example for intervention development in complex interventions, highlighting key guidance and recommended processes for developing and evaluating complex interventions. What are the potential or actual clinical implications of this work? The 61 components discussed as potential ‘ingredients’ for a PaPOV enable clinicians to reflect on key considerations when planning and delivering voice therapy to adults with BVFLs. This study highlights the pitfalls both clinically and in research of failing to describe interventions adequately and the benefits of using accurate, specific and agreed terminology in clinical practice, such as that outlined in the Rehabilitation Treatment Specification System (TRSS)

“We Just Don’t Know Where They Are”: The Geographical Distribution of Exercise Classes for Older People, Including Those Living with Dementia in the East Midlands

Older people living with dementia are advised to exercise to remain independent. Although several exercise classes for older people take place across the UK, there is limited information about the geographical distribution of these classes. This study identified the location and explored the population characteristics of the classes in a UK region, to aid improved access to exercise. Using a geographical information system, data were collected on population characteristics, including size and age, socio‐economic status, and rurality of the exercise classes in one area of the UK (East Midlands, population 5 million). The relationship between data sets was explored and a visual representation of these patterns was provided. A systematic internet search identified 520 exercise classes, evenly spread across the region and areas of socio‐economic deprivation: 471 (90%) were in urban areas; 428 (80%) were in areas where less than 20% of the population was over 65 years of age; and 13 (2%) stated that they were suitable for people with dementia. People living with dementia are less likely than older people without dementia to have access to exercise classes

The Impact of a Dementia-Friendly Exercise Class on People Living with Dementia: A Mixed-Methods Study

Exercise has multiple benefits for people living with dementia. A programme of group exercise classes for people with dementia and their family carers has been established in a University sports centre. This study aims to explore the impact of this programme on participants with dementia and their carers. A mixed-methods design including a prospective, repeated measures cohort study followed by focus groups was employed. Physiological and cognitive outcome measures were repeated at baseline and three months in a cohort of people with dementia attending a group exercise class. Focus groups on the participants’ experiences and their perceptions of the impact of the exercise class on their lives were then conducted. The results were analysed and mapped on a model, to illustrate the components that most likely promote participation. Sixteen participants (n = 8 with dementia, and n = 8 carers) were recruited, and completed both baseline and follow up assessments. Positive mean differences were found in physical activity (4.44), loneliness (1.75), mood (1.33) and cognition (1.13). Ten participants were included in the focus groups, which found that accessibility of the exercise venue, opportunities for socialisation and staff who were experienced working with people living with dementia were key to participants reporting benefits. The four key themes from the focus group data were synthesised to produce a model outlining the components that might generate a positive impact of the exercise classes and promote participation. Exercise classes for people with dementia can be delivered with success in novel environments such as University sports centres. There is some indication of improvement over a short period of time. The model derived from this study will inform strategies to promote attendance at dementia-friendly exercise classes

A scoping review of behaviour change theories in adults without dementia to adapt and develop the ‘PHYT in dementia’, a model promoting physical activity in people with dementia

Introduction:Research has established that exercise and physical activity can improve executive functioning, independence and quality of life in people with dementia. A dedicated theory explaining behaviour change in relation to physical activity in people with dementia does not exist. We aimed to develop a theoretical model which can be used to inform effective interventions to promote physical activity in people with dementia.Methods:There were five phases: 1. A search of the literature to identify theories which have been used to explain behaviour change in relation to physical activity in adult populations without a diagnosis of dementia; 2. Description of the theories (and sub-theories) and their main constructs; 3. Synthesis of the constructs; 4. Adaptation of the constructs to dementia; 5. Development and explanation of a model for physical activity in people with dementia (the ‘PHYT in dementia’).Results:We identified nine theories used to explain behaviour change in relation to physical activity in adult populations without a diagnosis of dementia. Through our synthesis, we identified nine umbrella constructs. We integrated three more dementia-relevant constructs and developed the ‘PHYT in dementia’. The model was explained by providing a practical example of its application.Discussion:Based on a scoping review of behaviour change theories in adults without dementia and following adaptation of the constructs from these theories to dementia, we derived a new theoretical model, the ‘PHYT in dementia’, which includes both individual-level and environment-level constructs. The model needs to be tested empirically, which our research team will do in the process evaluation of the Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment (PrAISED 2) study. Results from field-testing will inform refinement of the model

Protocol for the process evaluation of the Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment (PrAISED 2) Randomised Controlled Trial

Introduction. Promoting Activity, Independence and Stability in Early Dementia and Mild Cognitive Impairment (PrAISED 2) is a randomised controlled trial to test the effectiveness of an intervention to promote activity and independence amongst people with mild cognitive impairment and early dementia. To identify 'How the intervention works', we will undertake a process evaluation of PrAISED 2. This protocol outlines the rationale, aims, objectives and methods of the process evaluation. Methods. The process evaluation will use a mixed-methods design and comprise two studies: An implementation study, examining the process through which PrAISED 2 is delivered and a study on the mechanisms of impact and context, focussing on the mediating mechanisms that contribute to study outcomes. Integration of separate analysis of quantitative and qualitative data will provide a holistic view of 'how PrAISED 2 works. Conclusion. Results from this process evaluation will further the understanding of the factors that can impinge on the success of complex interventions. This will represent invaluable information for researchers undertaking further research around behaviour change among people with cognitive impairment and dementia

Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation

Background: Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs. Study design: Non-randomised, multicentre feasibility trial with embedded process evaluation. Method: Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings. Discussion: This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible. Trial registration: This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192

Motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment: a realist review

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. Objectives This review aimed to identify mechanisms underlying participation in falls prevention interventions, in older adults with cognitive impairment. In particular we studied the role of motivation. Design A realist review of the literature. Data sources EMBASE, MEDLINE, CINAHL, the Cochrane Library, PsycINFO and PEDRO. Eligibility criteria Publications reporting exercise-based interventions for people with cognitive impairment, including dementia, living in the community. Data extraction and synthesis A â €" rough programme theory' (a preliminary model of how an intervention works) was developed, tested against findings from the published literature and refined. Data were collected according to elements of the programme theory and not isolated to outcomes. Motivation emerged as a key element, and was prioritised for further study. Results An individual will access mechanisms to support participation when they think that exercise will be beneficial to them. Supportive mechanisms include having a â €" gate-keeper', such as a carer or therapist, who shares responsibility for the perception of exercise as beneficial. Lack of access to support decreases adherence and participation in exercise. Motivational mechanisms were particularly relevant for older adults with mild-To-moderate dementia, where the exercise intervention was multicomponent, in a preferred setting, at the correct intensity and level of progression, correctly supported and considered, and flexibly delivered. Conclusion Motivation is a key element enabling participation in exercise-based interventions for people with cognitive impairment. Many of the mechanisms identified in this review have parallels in motivational theory. Clinically relevant recommendations were derived and will be used to further develop and test a motivationally considered exercise-based falls intervention for people with mild dementia. PROSPERO registration number CRD42015030169