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Motivation as a mechanism underpinning exercise-based falls prevention programmes for older adults with cognitive impairment: a realist review
  1. Vicky Booth1,
  2. Rowan Harwood2,
  3. Jennie E Hancox3,
  4. Victoria Hood-Moore1,
  5. Tahir Masud4,
  6. Phillipa Logan1
  1. 1 Division of Rehabilitation Ageing and Wellbeing, School of Medicine, University of Nottingham, Nottingham, UK
  2. 2 School of Health Sciences, University of Nottingham, Nottingham, UK
  3. 3 School of Medicine, University of Nottingham, Nottingham, UK
  4. 4 Health Care of the Older Person, Nottingham University Hospitals NHS Trust, Nottingham, UK
  1. Correspondence to Dr Vicky Booth; Vicky.Booth{at}


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 ‘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 ‘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.

  • dementia
  • rehabilitation medicine
  • sports medicine

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  • Contributors VB completed the search, data extraction, analysis and synthesis of the review as part of her PhD (PhD in Rehabilitation and Ageing, School of Medicine, University of Nottingham). RH, VH-M, TM and PL supervised the development of the review and critically reviewed all text and theory development as part of the stakeholder group. JEH critically reviewed the findings against established motivational theories and assisted in content development. All authors contributed to the content of the review, read and approved the final manuscript.

  • Funding This paper presents independent research funded by the Alzheimer’s Society, UK, with the Healthcare Management Trust through a Clinical Training Fellowship (grant number 206), and the UK National Institute for Health Research under its Programme Development Grants (RP-DG-0611-10013) and Programme Grants (RP-PG-0614-20007) for Applied Research funding scheme.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

  • Patient consent for publication Not required.