This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless, they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is an understanding of how to develop an intervention for people with mild cognitive impairment and dementia to promote their independence, stability, and physical activity.Introduction:Older adults with dementia are at a high risk of falls. Standard interventions have not been shown to be effective in this patient population potentially due to poor consideration of dementia-specific risk factors. An intervention is required that addresses the particular needs of older people with dementia in a community setting.Methods:We followed guidelines for the development of an intervention, which recommend a structured approach considering theory, evidence and practical issues. The process used 15 information sources. Data from literature reviews, clinician workshops, expert opinion meetings, patient-relative interviews, focus groups with people with dementia and clinicians, a cross-sectional survey of risk factors, a pre-post intervention study and case studies were included. Data were synthesized using triangulation to produce an intervention suitable for feasibility testing. Practical consideration of how an intervention could be delivered and implemented were considered from the outset.Results:Elements of the intervention included individually tailored, dementia-appropriate, balance, strength and dual-task exercises, functional training, and activities aimed at improving environmental access, delivered using a motivational approach to support adherence and long-term continuation of activity. We focussed on promoting safe activity rather than risk or prevention of falls.Conclusion:We used a systematic process to develop a dementia-specific intervention to promote activity and independence while reducing falls risk in older adults with mild dementia.

ObjectivesThis 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.DesignA realist review of the literature.Data sourcesEMBASE, MEDLINE, CINAHL, the Cochrane Library, PsycINFO and PEDRO.Eligibility criteriaPublications reporting exercise-based interventions for people with cognitive impairment, including dementia, living in the community.Data extraction and synthesisA ‘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.ResultsAn 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.ConclusionMotivation 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 numberCRD42015030169.

ObjectivesRehabilitation 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.DesignSystematic scoping review.SettingStudies were not limited for inclusion based on setting.ParticipantsStudies were included that featured older adults (>65 years of age).InterventionsStudies were included that reported the development of a rehabilitation intervention.Primary and secondary outcome measuresData were extracted on study population, setting, type of intervention developed and frameworks used. The primary outcome of interest was the type of intervention development framework.ResultsThirty-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).ConclusionAt 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.

Introduction: Proprioceptive assessments of the wrist inform clinical decision making. In wrist rehabilitation, joint position sense has emerged as one way of assessing conscious proprioception with varying methods and minimal psychometric analysis reported. The purpose of this study was to standardise the wrist joint position sense test method for clinical use and to determine its test-retest reliability in a healthy population. Methods: Four wrist positions (20 and 45 flexion, 20 and 45 extension) were measured twice in a random order, by a single rater, using a universal goniometer on the same day. The absolute error in degrees between each position and reposition was calculated. For relative reliability analysis, the intraclass correlation coefficient (3,1) was calculated. For absolute reliability the standard error of the measurement was calculated and Bland-Altman plots visually inspected. Results: Fifty-five healthy volunteers (mean age 31.1 SDAE10.25 years) were assessed. The mean absolute error, summarised for all positions for test and retest, was 3.98. The intraclass correlation coefficients were poor to fair (0.07-0.47), and standard error of the measurement was 2 (rounded) for all positions. The limits of agreement were fairly narrow, and the Bland-Altman plots showed random distribution of errors for each position, therefore the measurement error was clinically acceptable. Conclusions: The active wrist joint position sense test using goniometry demonstrated poor to fair test-retest reliability and acceptable measurement error in healthy volunteers. The wrist joint position sense angle of 20 flexion was the most reliable.

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