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Chapter 1: INTRODUCTION


The purpose of this chapter is to

present background information regarding the research area of
this study and to outline the rationale for selecting this research area. The chapter introduces the
research topics covered and outlines the purpose of this study before summarizing the conten
t of
each chapter.


1.1.

Introduction to Research Topic

Falls are a major cause of injury in older adults in the UK and injuries from falls impose
substantial financial burdens on the health services in the UK (
Scuffham et al., 2003
). Falls affect
many differen
t factors of physical and mental well
-
being in older adults and this is reflected in
the variety of research areas concerning falls. Studies have been conducted to investigate
physiological factors linked to falls risk, such
as, lower limb muscle strength,

impaired vision,
reaction time, balance, peripheral sensation (Lord et al., 1994) and gait pattern (Maki, 1997).
Other areas of research have looked into the effects of falling, including the influence of falls on
psychological parameters such as fear of
falling (
Maki et al., 1991
; Maki, 1997), falls efficacy
(
Yardley et al., 2005
) and quality of life (
Cumming et al., 2000
).

There are many known intrinsic and extrinsic risk factors for falling, including age, gender,
falls history, environmental hazards, f
ootwear and clothing
(WHO Europe, 2007)
and it is difficult
to control for all these factors without deviating from common ethical principles. In any case,
without controlling these risk factors it is difficult to establish cause and effect relationships
b
etween the risk factors and falling
-

an issue discussed in the literature review. However, the
identification of associated risk factors may be useful in the development of efficient and cost
effective methodologies for screening and reducing falls risk i
n older adults. As the ageing
population of the UK grows the development of cost effective preventative strategies to
minimise the number of patients admitted to hospital for falls
-
related injuries is vital (Scuffham
et al., 2003).


1.2.

A Background to Falling

1.2.1.

Population and life expectancies for older adults worldwide

Recent estimations indicate that in developed countries there are more older adults aged
over 60 years than children aged under 14 years and it is projected that by 2050 there will be a
ratio of

two older adults for one every child (United Nations [UN], 2004)
.
The 2004 revision of
the UN report of World Population Prospects estimated there to be 688 million older adults
2


aged over 65 years worldwide in 2005 based on the national census data collec
ted in 2000 (UN,
2004) and that by the year 2050 this number would grow to be almost 2 billion. The same report
also projected that in more developed regions of the world there would be an increase in life
expectancy at birth from 76 years in 2005 to 82 ye
ars by 2050, with the percentage of the
population aged 60 years or over increasing from 20 per cent to 32 per cent by 2050.


1.2.2.

Population and life expectancies for older adults in the UK and Wales

In Wales it is estimated that 10% of the population is co
mprised of adults aged between 65
and 74 years, and a further 9% of the population are over the age of 75 (Welsh Assembly
Government [WAG], 2010). With life expectancy for older adults increasing across the UK and in
Wales, the percentage of adults over th
e age of 60 years is also increasing. In Wales between
1931 and 2010 it is estimated that the number of adults aged between 65
-
74 years has
increased by 5%, while the number of adults aged over 75 years has increased by 7% (WAG,
2010). The most notable gro
wth between the genders has been in the female population, which
has seen an increase from only 2% in 1931 to 10% of females over the age of 75 years in 2010
(WAG, 2010). The life expectancy of those born in Wales is 77.2 years for males and 81.6 years
for

females (Office for National Statistics [ONS], 2011). Compared with this national average, life
expectancies at birth for those belonging to the same demographic group living in Ceredigion,
Mid
-
Wales are longer


80.4 years and 84.1 years for males and f
emales, respectively (ONS,
2011). Life expectancies identified less than ten years earlier in the same county were shorter
for men at 78.4 years and for women at 81.9 years which supports a predicted increase in life
expectancy within the county (ONS, 2007
).


1.2.3.

Falls incidence and injury

As risk of falling increases with age (Lord, 1990), so does risk of injury from accidental falls
(Scuffham et al., 2003). Combined with an ageing population this could be interpreted to
indicate that incidence of age
-
related

illnesses and injuries from falls will continue to increase
(WHO, 2007), particularly if preventative measures are not taken in the immediate future.

Patients aged over 75 years are three times more likely to attend Accident and Emergency
services (A&E)
as a result of an unintentional fall than any other age group, and are eleven times
more likely to be hospitalised after an unintentional fall than those in the 60
-
64 year age group
(Scuffham et al., 2003). Between 2007 and 2009, death rates from accidenta
l falls in England and
Wales in adults aged 65
-
74 years were 8.7 per 100,000 (National Centre for Health Outcomes
Development [NCHOD], 2011). Moreover, rate of mortality in recurrent fallers has been
3


estimated to be around twice that of the general populat
ion (Gribbin et al., 2009).

Over 90% of hip fractures are associated with falls (Youm et al., 1999), and hip fracture
accounts for approximately two thirds of the cost of inpatient fracture care in the UK (Kanis,
1993). Hip, spine, upper arm and pelvic fr
actures have been found to be more common in older
adults


in particular in older women (Johansen et al., 1997) which is in agreement with findings
that indicate that older women are also more likely to experience a fall than their male
counterparts (Prud
ham and Evans, 1981).

Injuries caused by falls are a major cause of disability in people aged above 75 in the UK, and
therefore represent a major health concern for this growing age group (Scuffham et al., 2003).
When compared to the rest of the UK, the po
pulation of Wales has a lower disability
-
free life
expectancy than that of England; from the age of 65 years onwards men and women in Wales
are predicted to live with a disability for at least half of their remaining life (Breakwell and
Bajekal, 2006). In
the case of hip fracture, increasing numbers of adults are living to an age
where they are at an increased risk of fracture (Marks, 2010). One of the factors contributing to
the growing ageing population of survivors from hip fracture is improved acute car
e, which will
result in increased health costs incurred by long
-
term health services provision for those who
encounter disability as a result of their fall (Marks, 2010). The increasing need for these services
in older adults has been attributed to an age
-
related tendency to experience illness as well as
increased time taken to recover from injury (Marks, 2010).

In 1997, overall fracture incidence in the UK was estimated to be 21.1/1000/year
(23.5/1000/year in males and 18.8/1000/year in females; Johansen e
t al., 1997). These estimates
were calculated using fracture incidence of patients admitted to the A & E Department at Cardiff
Royal Infirmary in the 12 months following April 1 1994. When applied to population estimates
of 51.6 million in England and Wale
s from the national census in 1994, overall fracture incidence
is estimated to have been 1.1 million that year (Johansen et al., 1997).


1.2.4.

Cost of falling

Costs incurred by fall
-
related injury present a great economic burden on health services. In
1999 the total cost to the UK government of unintentional falls in older adults was estimated to
be £981 million


59.2% of which was incurred by the NHS (Scuffham

et al., 2003). In the same
year 78% of hospital admissions for fall related incidents were for patients aged over 75 years


fall
-
related injuries in this age group alone incurred 66% of total costs (Scuffham et al., 2003).
Long
-
term care for falls accoun
ted for 48.5% of total age group costs in adults over the age of 75
years for falls (Scuffham et al., 2003). Ten years on, present costs incurred by the NHS due to
4


falls are £1.7 billion per year (Age UK, 2010)


a marked increase of around £700 million si
nce
1999. Therefore the cost of meeting the increasing requirements for provision of adequate
preventative measures and treatments for falls for the ageing UK population is growing
(Scuffham et al., 2003). Avoidance of long
-
term care costs may be possible
if effective and cost
efficient falls prevention measures are implemented before patients develop multiple risk
factors for falling.


1.3.

Study Outline

Multi
-
Factorial Falls Risk Assessments (MFFRA) and Interventions (MFFRI) are methods used
to identify and re
duce falls risk in older adults (Tinetti et al., 1994). MFFRA may include a general
health examination, review of falls history and medications, home hazard and vision
assessments, as well as anthropometric measures and measures of strength and balance (Ti
netti
et al., 1994). Corresponding MFFRI would aim to address risk factors identified in the MMFRA,
for example, they may involve changes to prescribed medication, home visits to assess hazards
in the patient’s home and alterations to optical prescriptions

as well as offering patients the
opportunity to participate in exercise targeting strength and balance (Tinetti et al., 1994;
Davison et al., 2005).

One type of intervention targeted at reducing falls risk factors that has been examined is
exercise to im
prove strength and balance (Lord et al., 1994; Shumway
-
Cook et al., 1997; Yoo et
al., 2010). Physiological benefits of participation in exercise programmes in older adults have
been demonstrated, including improved balance, walking ability and strength (Sh
umway
-
Cook et
al., 1997). Research studies have also demonstrated that exercise interventions can result in
patients reporting improvements in psychological falls risk factors, for example, fear of falling
(Yoo et al., 2010).

However, psychological factors

such as exercise motivation and influences on motivation, for
example psychological need satisfaction, have yet to be studied in participants of falls
prevention exercise interventions despite being applied to other sport and exercise research
settings (B
artholomew et al., 2011; Hagger et al., 2006). In fact, supervised post
-
treatment
exercise intervention prescribed to breast cancer survivors has been shown to encourage

an
adaptive exercise motivational profile (Milne et al., 2008)


the effects of which
could include
increased long term adherence to exercise
. Results such as these could suggest that similar
results for change in motivation may be found in other patient groups participating in exercise
-
based interventions, including falls prevention progra
mmes.

There is an also absence of research literature examining changes in psychological well
-
being
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indicators throughout the course of participation in falls prevention interventions. Psychological
well
-
being indicators, such as quality of life, are often

included in screening processes to identify
persons eligible for participation in studies, for example quality of life
-

however, these are not
often repeated after completion of the intervention (Lord et al., 2005). Therefore opportunities
to evaluate th
e effectiveness of falls prevention interventions in enhancing psychological well
-
being have been missed.

The purpose of this study is to examine changes in a range of psychological parameters in
participants of an exercise intervention targeting older adu
lts with strength and balance deficits
and a history of falling. Some of these measures have been examined in the context of other falls
prevention interventions for older adults, including falls efficacy and fear of falling, while others
such as psycholog
ical need satisfaction, motivation and changes in self
-
reported quality of life
are unexplored in the context of falls interventions. Implications for findings could include
identification of modifiable psychological risk factors and benefits that could be

used for
discrimination and evaluation of individuals.


1.4.

An Overview of the Thesis

Chapter 2 presents a review of literature focusing on topics relevant to this study, including
critical discussion of findings from other studies that have contributed towa
rds the hypotheses
forwarded in this study. Descriptions of the study design and methodology used to collect data
in the study are presented in Chapter 3, alongside the rationale for their use. Chapter 4 presents
the results, which include changes in parti
cipants’ psychological outcome measures over the
duration of the exercise intervention programme. These results are then discussed in Chapter 5
with reference to the literature discussed in Chapter 2. The final chapter, Chapter 6, draws fial
conclusions re
garding the implications of the findings for understanding factors related to falls
risk in older adults, as well as the limitations of the study and future research questions that
require consideration.


1.5.

Chapter Summary

This chapter has introduced the
research area, outlined the focus for this study and provided
an overview of the contents of the thesis. The next chapter presents a review of literature
relevant to the topics of this study.



6


Chapter 2: LITERATURE REVIEW


The purpose of this chapter is to review literature concerning the research into falls and the
relationships demonstrated between psychological factors and risk of falling in older adults. The
beginning of the chapter concentrates on the definition and epi
demiology of falling in the UK and
Wales, including incidence and health costs incurred by falling. The chapter then considers
interventions used to prevent falls. This is followed by a discussion of psychological theories and
outcome measures that have be
en used in previous falls research studies.


2.1.

Definition of Falling

A faller is defined as someone who has fallen one or more times during the last six to twelve
months; a person who has fallen more than twice during this defined time period is considered a
recurrent faller (Masud and Morris, 2001). There are many variatio
ns in definitions of the term
falling used in research studies, including many subdivisions of the category of falls.

Many definitions commonly describe the event of falling as “unintentional” (Buchner et al.,
1993), “inadvertent” (Kellogg Group, 1987; Ca
rter et al., 2002; Tideiksaar, 2002), “unexpected” (Lach
et al., 1991) or “involuntarily” (Means et al., 1996)


with the odd exception of “intentional”
(Tideiksaar, 2002). The Cochrane Review (Gillespie et al., 2009) identified that the most commonly
used

definition for falling in studies was that of Buchner and colleagues (1993, p. 300):
“Unintentionally coming to rest on ground, floor, or other lower level; excludes coming to rest
against furniture, wall, or other structure.” The term “unintentional” ref
ers to the absence of a
conscious or intentional action on the part of the faller that would result in them coming to rest on
the ground. There is often the addition of other specific inclusion and exclusion criteria to meet the
requirements of the study b
eing conducted, for example, without loss of consciousness (Kellogg
Group, 1987) or “
inadvertently coming to rest on the ground or other lower level with or without
loss of consciousness

and other than as a consequence of sudden onset of
paralysis
,
epilept
ic
seizure
, excess alcohol intake, or overwhelming external force
” (Close et al., 1999 p. 93). Different
definitions may specifically include (Tideiksaar, 2002) or exclude coming to rest on an item of
furniture (Buchner et al., 1993).

Falls can also be cla
ssified in different ways, for example: intentional or unintentional, (Scuffham
et al., 2003) and injurious or non
-
injurious (Koski et al., 1996). There are also differences in
interpretation of the meaning of the term ‘falling’ between groups, for example
: health
professionals, researchers and high risk falls groups such as older adults (Zecevic et al., 2006).
Evidence has been found that when defining a fall older adults are more likely to focus on why, when
7


and how a fall happened as well as its conseque
nces, for example, motor control (slip, trip or
stumble), loss of balance, environmental landing and injury, as opposed to describing the
biomechanical events of the fall itself


which is more commonly identified in research
-
based
definitions of falling (
Zecevic et al., 2006). Falls are also more likely to be reported as “unspecified
falls” in older patients (Scuffham et al., 2003). It could be speculated that this is partly due to
differences in interpretation of the term falling between older adults, hea
lth professionals and
researchers.

The overall effect of the use of such a range of definitions can be the variation in the outcomes
for different studies (Masud and Morris, 2001), as well as outcomes for treatments and
interventions within health service
s (Zecevic et al., 2006). In 2005 the Prevention of Falls Network
Europe (ProFaNE) made recommendations for the development of a common outcome data set for
use in falls research which included definitions of terminology and research domains. Therefore the

definition used in this study is that recommended by ProFaNE, defining a fall as
“an unexpected
event in which the participants come to rest on the ground, floor, or lower level” (Lamb et al., 2005,
p. 1619).


2.2.

Risk Factors: Assessment and Intervention

2.2.1.


Ri
sk Factors for Falls

Risk of falling has been shown to increase with age (Lord, 1990; Prudham and Evans,
1981). Many risk factors for falling in older adults have been identified in the research
literature. A prospective community
-
based research study by K
oski and colleagues (1996
found that injurious falls in older adults over the age of 70 are associated with older age,
absence of Achilles and quadriceps reflexes, muscular weakness, gait impairment, reduced
mid
-
arm circumference, impaired orthostatic reac
tion, reduced step length, use of four or
more medications, the use of long
-
acting benzodiazepines, calcium blockers, anti
-
inflammatory drugs and antidiabetic drugs. In a systematic review of studies (Oliver et al.,
2004) looking at both individual clinica
l risk factors and clinical assessment tools for falls risk
in older adults, gait instability, agitated confusion, urinary incontinence, a history of falling
and prescription of sedative or hypnotics drugs were all repeatedly identified as significant
risk

factors for falling in studies conducted across a range of research settings, populations
and risk factors. A report by WHO Europe (2007) presents a list of fourteen intrinsic and
three extrinsic risk factors associated with falling in older adults (See T
able 2.1.).

Intrinsic Risk Factors

Extrinsic Risk Factors

History of falling

Impaired mobility and gait

Environmental hazards

8











Table 2.1:
Intrinsic and extrinsic risk factors selected from the research literature by
WHO Europe (2007)


Differences in risk factors that may discriminate between fallers and recurrent fallers have
been suggested, for example visual contrast sensitivity, quadriceps strength, lower limb
proprioception, reaction time, and sway on a compliant
(foam rubber) surface with the eyes
open (Lord et al., 2003). Findings from preliminary research studies like these have been
implemented in the development of clinical falls screening tools, such as the Physiological Profile
Assessment (PPA; Lord et al.,

2003). Notably, however, all risk factors measured in this specific
screening tool are physiological and none are psychological


highlighting the need for increased
focus on such factors. Fear of falling is an example of a psychological risk factor for f
alls (Tinetti
et al., 1990), and has been shown to be greater in individuals with a history of falling (Arfken et
al., 1994). Fear of falling is discussed in a later section of this literature review.

Physiological risk factors have been shown to vary acco
rding to various intrinsic and extrinsic
parameters. As an example of this, differences in risk factors exist between intrinsic parameters
such as gender, for example, in men and women over the age of 70 years (Campbell et al., 1989;
Prudham and Evans, 198
1). In men, increased body sway, decreased physical activity levels, gait
impairment, and a history of stroke and arthritis in the knees have been associated with an
increased risk of falls (Campbell et al., 1989). In contrast, systolic blood pressure lowe
r than 110
mmHg while standing, total number of drugs, including psychotropic drugs and drugs liable to
cause postural hypotension, as well as evidence of muscle weakness are all factors that have
been associated with increased falls risk in women (Campbel
l et al., 1989; Koski et al., 1996).

It is possible for intrinsic risk factors to influence extrinsic risk factors. For example, intrinsic
risk factors such as frailty and poor hand grip strength have been associated with an increased
likelihood of being
housebound


an extrinsic or environmental risk factor and as such those
who are more frail and weak are at greater risk of falling indoors (Bath and Morgan, 1999). In
contrast, more active individuals who spend greater amounts of time outdoors, for exampl
e
Age

Gender

Living alone

Ethnicity

Medicines

Medical conditions


Sedentary behaviour

Psychosocial status

Nutritional deficiencies

Impaired cognition

Visual impairments

Foot problems


Footwear and clothing

Inappropriate walking aids or
assistive devices




9


spending time walking for relaxation purposes, are more likely to experience a fall outdoors.
However, again this tendency for outdoor falls is also suggested to be a function of
compromised physical health status (Bath and Morgan, 1999).

Extrinsic risk
factors such as footwear and environmental hazards (See Table 2.1) are
relatively simple to alter which makes them easy to control for in research studies and suitable
for inclusion in interventions to reduce risk and therefore they may be more likely to b
e
considered modifiable risk factors. However, intrinsic risk factors vary in their capacity for
modification. For example, intrinsic risk factors such as age, falls history, gender and ethnicity
are all un
-
modifiable risk factors for falls, however, other

intrinsic risk factors, such as
medications, sedentary behaviour and visual problems are more easily modifiable. In particular
physical activity may be increased by increasing self
-
determined motivation and greater
psychological need satisfaction through
application of psychological theories, such as Self
-
determination Theory (Ryan and Deci, 2000a) to provide environments which support these
changes, which is discussed later in this chapter.

The large number of studies looking at different risk factors and

using different interventions
means that it is difficult to evaluate their effectiveness in reducing falls risk (Gillepsie et al.,
2009). This is also underpinned by unidentifiable risk factors that cannot be accounted for in
research studies, as well as
risk factors that cannot be controlled by the researcher, such as
illnesses that have not yet been diagnosed. For example, participants of a study may have
undiagnosed early onset diseases such as Parkinson’s or Alzheimer’s diseases that are unlikely to
be

reported in the screening process, but may influence measures of physiological or
psychological variables and thus influence the overall findings. Other lifestyle factors, such as
diet and access to transport and health services due to location can also b
e difficult to control
for in research studies. Due to these limitations it has not been possible to create a finite list of
all risk factors for falls, but to compile a relatively comprehensive group of risk factors


some of
which can be modified and con
trolled. The varying influence and interaction between risk
factors for different people and in different environments mean that falls risk assessments and
interventions must be individualised to meet in order to be most effective; however, some
standardis
ation in research studies is also needed to ensure findings are comparable.


2.2.2.


Multi
-
Factorial Falls Risk Assessment

Multi
-
Factorial Falls Risk Assessments (MFFRA) are used to identify people at greater risk of
falling through the identification of the num
ber and magnitude of risk factors affecting them.
Modifiable risk factors can then be addressed as part of a single or multi
-
factorial intervention.
10


Modifiable risk factors that have been measured as part of multi
-
factorial assessment in
research studies i
nclude both extrinsic and intrinsic risk factors, such as postural hypotension
(Tinetti et al., 1994), deficits of strength, balance and gait (Lord et al., 2003; Tinetti et al., 1994;
Shumway
-
Cook et al., 1997), impaired vision (Lord et al., 2003; Shumway
-
Cook et al., 1997) and
psychological parameters, such as falls efficacy or fear of falling (Tinetti et al., 1994; Shumway
-
Cook et al., 1997), depression and level of independence in Activities of Daily Living (ADLs;
Tinetti et al., 1994). A risk assessment

may also include an assessment of home hazards (Tinetti
et al., 1994), as well as a medications review (Tinetti et al., 1994).


2.2.3.


Research
-
based evidence: Falls prevention interventions

Falls prevention interventions are used to modify risk factors identified in high risk
individuals during a falls risk assessment


with the purpose of reducing overall falls risk. In a
Cochrane review of 111 randomised controlled trials (RCT) comparing th
e effectiveness of
different interventions for falls (Gillespie et al., 2009) it was concluded that Multi
-
Factorial Falls
Risk Interventions (MFFRI) can help to reduce falls rates in community
-
dwelling older adults. It
was concluded that due to the complex
ity of MFFRI the precise factors that determine their
resulting effectiveness still need to be identified; the intervention methods used and the risk
factors which they target are varied, and so is their effectiveness for reducing falls risk and
incidence
in older adults (See Table 2.2).

Table 2.2.:

Falls interventions reviewed in the Cochrane review by Gillespie et al. (2009)

11


Other than in individuals with a

vitamin D
deficiency, the use of v
itamin D supplements
was
not found to reduce falls and with the

exception of those with the highest baseline risk of falling,
such as those with visual impairment, home safety improvement also showed no beneficial
effect (Gillespie et al., 2009). Medication review was found to be effective in reducing falls risk,
part
icularly where reductions in medications to improve sleep, anxiety and depression were
identified (Gillespie et al., 2009). First eye cataract surgery and insertion of a pacemaker where
carotid sinus hypersensitivity was indicated were also found to be eff
ective in reducing falls
incidence (Gillespie et al., 2009). Of all intervention methods reviewed, supervised group
exercise, including Tai Chi, as well as individually prescribed exercise programmes at home, are
suggested to be the most effective methods
of reducing falls risk and incidence in older adults,
particularly if these programmes focus on improving two or more of the following: strength,
balance, flexibility,

or endurance (Gillespie et al., 2009) as these interventions target the
reduction of kno
wn risk factors for falling, such as impaired mobility and sedentary behaviour
(See Table 2.1). The argument for use of exercise for the purpose of falls risk reduction is
supported by the conclusion of another systematic review of RCTs


which reports tha
t
interventions including weight bearing, balance and strengthening exercise can be used to
reduce falls and fall
-
related fractures in individuals with low bone density (de Kam et al., 2009).
The results from this review showed that
exercise
-
based
i
nterven
tions for targeting balance and
strength were effective in the majority of the studies for improving balance and strengthening
lower extremity muscles and back extensors respectively. Therefore a similar conclusion to that
of the Cochrane review (Gillespie

et al., 2009) was made supporting the use of exercise to
reduce falls, fall
-
related fractures, and falls risk factors in this review. These include
recommendations for exercise interventions for patients with osteoporosis to use weight
-
bearing activities,

balance exercise, and strengthening exercises to reduce falls risk.


2.2.4.

National Institute for Health and Clinical Excellence guidelines

In 2004 the National Institute for Clinical Excellence (NICE) released clinical practice
guidelines for the assessment an
d prevention of falls in older people in the UK called NICE
Clinical guideline 21 (NICE 21, 2004). The key priorities for implementation of these
guidelines include case/risk identification of falls in older adults, along with multi
-
factorial
falls risk as
sessment and interventions which health professionals must offer to patients
identified as being at risk of falling.



12


2.2.4.1.

Recommendations for Assessment of Falls Risk

NICE 21 (2004) recommends that those patients identified at risk of falling by healthcare
p
rofessionals should be assessed using an individualised multi
-
factorial falls risk
assessment. Components that may be included in the assessment are listed in the
guideline (see Figure 2.1 below).



An individualised multi
-
factorial assessment or intervention, as described in Figure
2.1, refers to assessment and intervention of patients’ individual risk factors. For
example, a patient requiring a MFFRA who has previously been diagnosed and
prescribed
appropriate medication for osteoporosis would not be assessed for
osteoporosis. However, they may benefit from a medications review as part of their
assessment to identify if any of their other prescribed medications are “culprit” drugs,
and therefore a po
ssible contributory risk factor to their recurrent falls.



Older people who present for medical attention because of a fall, or report recurrent falls in the past
year, or demonstrate abnormalities of gait and/or balance should be offered a multi
-
factor
ial falls risk
assessment. This assessment should be performed by healthcare professionals with appropriate skills
and experience, normally in the setting of a specialist falls service. This assessment should be part of
an individualised, multi
-
factorial i
ntervention.

Multi
-
factorial assessment may include the following:

-

identification of falls history

-

assessment of gait, balance and mobility, and muscle weakness

-

assessment of osteoporosis risk

-

assessment of the older person’s perceived functio
nal ability and fear relating to falling

-

assessment of visual impairment

-

assessment of cognitive impairment and neurological examination

-

assessment of urinary incontinence

-

assessment of home hazards

Figure 2.1:

Recommendations for multi
-
factorial assessment in NICE Clinical Guideline 21 (2004; adapted from
p. 8
-
9).




13


2.2.4.2.

Recommendations for Preventative Interventions

The NICE guideline (2004) states that all older adults with a history of falling must be
considered

for a multi
-
factorial intervention (see

Figure 2.2 below).


All older people with recurrent falls or assessed as being at increased risk of falling should be

considered for an individualised multi
-
factorial intervention.

In successful multi
-
factorial in
tervention programmes the following specific components are common
(against a background of the general diagnosis and management of causes and recognised risk
factors):

-

strength and balance training

-

home hazard assessment and intervention

-

vision a
ssessment and referral

-

medication review with modification/withdrawal.


Following treatment for an injurious fall, older people should be offered a multidisciplinary
assessment to identify and address future risk, and individualised intervention aimed
at promoting
independence and improving physical and psychological function.



Figure 2.2.:
Recommendations for multi
-
factorial interventions in NICE Clinical Guideline 21
(2004; adapted from p. 7)

While the recommendation is made for strength and balance
training to be included
in multi
-
factorial interventions in NICE 21 guideline (2004) no specific recommendations
are made concerning how the interventions should be delivered and which exercises
should be included. More specific evidence
-
based recommendati
ons (Skelton and Dinan,
1999) for components and delivery have been made for targeted exercise interventions
for reducing falls risk in the Guidelines for exercise programming for the frail elderly
(2005; See Appendix 2.1). For example, for large muscle gr
oups resistance exercise
should include 8
-
10 repetitions building from 2 to 3 sets starting at 50% of each
individual’s one maximal repetition (1
-
RM) increasing to 80% over a period of 12 weeks.
Other recommendations concern the physical and social environ
ment in which the
services are provided, including the abilities of the course instructor to communicate
and provide a socially supportive atmosphere in which participants are able to develop a
sense of ownership, and importantly pay attention to participa
nts’ perceptions and
psychosocial need (See Appendix 2.1.), which include providing an enjoyable and social
atmosphere that contributes towards a nurturing environment for enhancing motivation
14


(Deci and Ryan, 2000a). The omission of these or similar eviden
ce
-
based
recommendations in the NICE 21 guideline (2004) could be criticised as these are they
are critical in the development of standards for exercise based falls prevention
interventions.


2.2.4.3.

Recommendations for Research

In the 2004 NICE 21 guideline,
recommendations were also made for future areas of
research concerning the development of effective and appropriate falls risk assessment
and intervention


these include the need to:



identify the components of multi
-
factorial interventions that are most i
mportant with
respect for reducing falls risk and cost
-
effective in different settings and patient groups



measure the impact of these interventions on reducing falls incidence and injury



investigate whether individuals can be stratified by falls risk to i
dentify who will most
benefit from multi
-
factorial assessment and intervention.


2.2.4.4.

Review of Guidelines 2011

The 2011 review of NICE 21 guideline (NICE, 2011) was conducted by a Guideline
Development Group and a panel of stakeholders, which included members

of the
National Patient Safety Agency, Vifor Pharma UK, Department of Health (England), Older
People and Dementia Branch, National Care Forum, British Psychological Society,
UKCPA, RCP, NHS direct, Royal National Institute of Blind People, British Diete
tic
Association, Royal College of Nursing and The College of Optometrists. The review
concluded that no changes to the current NICE guideline on falls in older adults are
required as there had not been enough conclusive findings from the research literatur
e
to alter the direction of the current guideline. However, recommendations were made
for more RCTs of exercise based interventions, which adds further to the rationale for
conducting this study. Other recommendations that also support the need for this
re
search study were for standardised assessment of fear of falling and multi
-
factorial
assessment; the measurement of psychological factors, including fear of falling, for
evaluation of the efficacy of exercise
-
based interventions are explored in this study
.




15


2.3.

Fear of Falling and Falls Efficacy

2.3.1.

Definition

Bandura (1989, p. 1175) defines self
-
efficacy as a person’s “beliefs about their capabilities
to exercise control over events that affect their lives. Self
-
efficacy beliefs function as an
important
set of proximal determinants of human motivation, affect, and

action.” Self
-
efficacy
is also defined as a person’s perceived ability to complete a task or activity successfully (Tinetti
and Powell, 1993). Sc
ales of self
-
efficacy measure efficacy beliefs concerning factors that
influence the quality of functioning in the selected activity domain. Fall
-
related efficacy, also
refer
red to as falls efficacy, is one’s perceived ability to avoid falling.

The Falls Efficacy Scale (FES; Tinetti et al., 1990) was developed as a measure of fear of
falling (FOF), which has been defined as a "low perceived self
-
efficacy at avoiding falls duri
ng
essential, nonhazardous activities of daily living" (Tinetti et al., 1990, p. P239). After one or
more falls or near misses a person at risk of falling may feel that the next fall may have more
serious consequences to either their mental or physiologica
l health. It is this realisation that
may cause them to be more alert to potential hazards, resulting in increased caution when
performing ADLs. Additional caution demonstrated when performing ADLs as a result of a fear
of falling at this level is a reason
able response to the danger of falling. However, a greater fear
of falling may affect the physical and social mobility of the person, as they may avoid specific
activities or situations to avoid falling. Fear of falling can be situational, for example, if
a person
was performing a specific ADL at the time of a previous fall, they may associate this ADL with
falling, and therefore develop symptoms of anxiety when they perform this ADL, for example,
elevated heart rate, a shortness of breath, or feeling faint
. In an attempt to reduce these
symptoms these lasting concerns can lead to avoidance of performing specific behaviours and
activity restriction despite the individual still being physically capable of performing them
(Tinetti and Powell, 1993). In cases o
f non
-
situational fear of falling, rather than avoiding only
the ADLs with which they associate falling persons will avoid other ADLs, even if they believe
that they are capable of performing it. Fear of falling, whether situational or non
-
situational
can
result in a reduction of mobility and activity levels, for example if falls risks are perceived
to be greater outside the house a person with a fear of falling may restrict their activities
outside the house. As such, this reduced level of activity may res
ult in a reduction in physical
health and mobility, for example atrophy of the muscles, and psychological well
-
being from a
reduction in social interaction. In turn, the reduction in physiological and psychosocial function
caused indirectly by the fear of
falling can further increase the risk of falling, and therefore is
an important factor to address in older adults at a high risk of falling.

16


However, there is evidence that fear of falling is not always accompanied by avoidance
behaviours. For example, in
a study of 1,064 population
-
based community
-
dwelling older
adults by Murphy et al. (2002) only 44% of participants who had reported having a fear of
falling also reported restricted activity levels. The findings from this study also found that
activity res
triction was associated with health status, slow timed physical performance,
disability in Activities of Daily Living (ADLs) and poor psychosocial function, and longitudinal
research may be useful in finding any causal relationships between activity restri
ction and
these factors. An example of research that has examined FOF and falls efficacy as individual
concepts is a RCT of a Tai Chi intervention by Li and colleagues (2005). This study examined the
extent to which falls efficacy regulates FOF by comparin
g measures of FOF using the Survey of
Activities and Fear of Falling in the Elderly (SAFFE; Lachman et al., 1998) and falls efficacy using
the ABC scale (Powell and Myers, 1995)


an extension of the FES (Tinetti et al., 1990) in a
cohort of older adults r
ecruited from a health system database. The results showed that falls
efficacy increased as a result of the Tai Chi intervention, and that these improvements were
indicated to be an underlying mechanism for the co
-
existent reduction in fear of falling. Res
ults
from both of these studies could be used to argue that although FOF and falls efficacy may co
-
exist and influence each other, they still require individual measurement as evidence of one
does not necessitate the other.

The FES was developed by Tinetti

and colleagues (1990) to expand the FOF concept from
being dichotomous to continuous. In other words, rather than either being either fearful or not
fearful of falling, the extent to which a person is fearful of falling is represented by their degree
of f
alls efficacy on a continuous scale. However, despite this proposed representation of FOF as
a continuous concept, FOF is still only associated with low falls efficacy. It could be that a
relative degree of FOF should be associated with degrees of falls, a
s suggested in Figure 2.3.








Figure 2.3.
: Diagrammatic representation of a continuous scale of fear of falling parallel to a continuous
scale of falls efficacy, i.e.: a high
measure of falls efficacy is associated with a lower degree of fear of
falling





High


High


Low


Low


Falls efficacy scale

FOF scale

17


Lack of disparity between FOF and falls efficacy may have significant effects on how
research findings are interpreted and implemented in the design of falls interventions,
including use of fear of falling and falls efficacy as a predictor of falls risk. Concerns regarding
the broad recommendations for screening and assessment of FOF were expressed in a review
of NICE guideline 21 (2011) by a stakeholder from the Royal Colleg
e of Physicians (RCP), which
included a recommendation for a revision of the original guideline to include more
standardisation of assessment. If one term was used throughout the literature, outcome
measures and their meaning would be more comparable betwe
en research studies. As
discussed below research concerning the influence of fall history on fear of falling and falls
efficacy in older adults has had varying outcomes.


2.3.2.

Prevalence

Fear of falling and avoidance behaviours due to fear of falling are highly

prevalent in
community
-
dwelling older adults (Zijlstra et al., 2007a). Research studies of population
-
based
samples suggest that between 25% and 54% of community dwelling older adults are estimated
to have a fear of falling (Murphy et al., 2002; Zijlstra
et al., 2007a), while over 47% are reported
to have restricted or curtailed activity (Zijlstra et al., 2007a). Between 44% and 66% of older
adults report both a fear of falling and activity restriction (Murphy et al., 2002; Zijlstra et al.,
2007a). While
measuring tools for FOF and falls efficacy have been examined for test re
-
test
reliability in UK
-
based samples (Kempen et al., 2008; Yardley et al., 2005), there is a lack of
literature reporting prevalence of these modifiable, yet highly influential risk
factors in the UK
older adult population.


2.3.3.

Implications

Older adults with a history of falling are more likely to develop a FOF than those with no
history of falling (Howland et al., 1998;

Murphy et al., 2002; Arfken et al., 1994)


FOF is also
more prevalent in female than male older adults
(Howland et al., 1998)
. FOF
is a risk factor for
falling (Cumming et al., 2000) and therefore it is important to assess and manage FOF alongside
other risk factors to reduce risk of falling. Falls efficacy has been found to be independently
correlated with physical and social functio
ning, undertaking ADLs and independent ADLs (iADLs)
and activity curtailment (Tinetti et al., 1994; Howland et al, 1998; Cumming et al., 2000). It is
therefore understandable that reductions in fall
-
related efficacy and increased fear of falling
have been
associated with deterioration or reduced quality of life in older adults (Arfken et al.,
1994; Cumming et al., 2000; Lachman et al., 1998), frailty (Arfken et al., 1994), as well as
18


impaired function, loss of independence (Cumming et al, 2000)

and increase
d susceptibility to
depression (Arfken et al., 1994; Murphy et al., 2002)
. Without intervention recurrent falls can
result in cyclical increments in FOF and risk of falling, contributing towards repeated reduction of
quality of life, and decreased physical

and social functioning (See Figure 2.4). For example a
history of falling and FOF are risk factors for falls that increase with recurrent falling (Arfken et
al., 1994). However intervention to reduce FOF reduces risk of falling (de Kam, et al., 2009)
whic
h in turn reduces FOF (See Figure 2.4).

Further evaluation of the prevalence of FOF and falls efficacy in the UK older adult
population will enable more informed and effective management of falls. Considering the
prevalence and influence of FOF on such a r
ange of parameters the need for interventions
specifically targeting reduction of FOF in older adults has been highlighted in several studies
(Tennstedt et al., 1998; Cumming et al., 2000).









Figure 2.4.:
Visual representation of cyclic relationship between falls incidence and FOF, both with and
without
intervention to reduce FOF


2.3.4.

Intervention

FOF has been significantly associated with a history of falling and health status (Howland et
al., 1993) and many of the predisposing factors for FOF relate to falls risk (Murphy et al., 2002).
It has therefore been suggested that preventive measures to re
duce fear of falling may also
reduce falls risk (Murphy et al., 2002). As such, the NICE guideline (2004, p. 11) states that “Falls
prevention programmes should also address potential barriers such as low self
-
efficacy and fear
1
st

Fall

With
Intervention

Without
intervent
ion

Recurrent Falls

Increased
FOF

Increased
falls risk

Reduced
falls
incidence


Reduced
falls risk

Reduced
FOF

19


of falling”. Other health be
nefits to older adults resulting from increased falls efficacy through
intervention include improved quality of life, increased ability to perform ADLs and greater
social functioning (Tennstedt et al., 1998; Cumming et al., 2000).

A systematic review of randomized controlled trials by Zijlstra (2007b) identified several
studies of interventions that had found significant reductions in FOF. The review identified a
number of studies showing that home
-
based exercise, as well as fall
-
re
lated multi
-
factorial
programmes and community
-
based tai chi delivered to groups effectively reduce FOF in
community
-
dwelling older adults. Interestingly the article also found that only three of the
effective interventions had been targeted specifically t
owards reducing FOF


evidence contrary
to other evidence
-
based recommendations of targeted intervention (Tennstedt et al., 1998).

In other findings, Tennstedt and colleagues (1998) reported no reduction in falls risk despite
effectively reducing FOF in a

sample of community
-
dwelling older adults through a targeted
intervention. This lack of reduction in falls risk was attributed to increased activity in response to
the reduced FOF


the overall benefits were identified more as the effects of increased act
ivity
and confidence on quality of life and independence. Findings such as these support the
argument that FOF is independent of falls risk (Maki et al., 1991).

As discussed above, falls efficacy is regulated by many factors, including previous
experience
s, such as falls history. By influencing their sense of control, competence and ability in
activities they might perceive to be high risk, falling may determine a person’s belief in their own
ability to avoid falling and thus their motivation to participat
e in these activities. Motivational
theories, such as self
-
determination theory and its sub
-
theories (Deci and Ryan, 1985), propose
different types of motivation and identify different motivational climates that may enhance or
hinder these types of motivat
ion, as discussed in more detail below.


2.4.

Self
-
determination Theory

2.4.1.

Overview

Self Determination Theory (SDT) is a motivational theory developed by Deci and Ryan
(1985) comprised of several sub
-
theories, including Cognitive Evaluation Theory (CET; Ryan
a
nd Deci, 2000). In application, SDT enables the investigation of self
-
motivation, based on
inherent growth tendencies and innate psychological need (Ryan and Deci, 2000a). SDT
proposes a continuum of different types of motivation which are arranged from le
ft to right
by degree of self
-
regulation (See Figure 2.5; Hagger and Chatzisarantis, 2007).



20


2.4.2.

Types of motivation.

2.4.2.1.

Intrinsic motivation

Positioned on the far right end of the continuum (See Figure 2.5.), intrinsic
motivation has the highest level of autonomy and most intrinsically regulated form of
behaviour of all the motivational types on the continuum. To be intrinsically motivated is
t
o undertake a particular activity for inherent satisfaction, for example, to exercise for
sheer pleasure, without seeking an external reward (Ryan and Deci, 2000a).




Figure 2.5:

Schematic representation of self
-
determination theory illustrating the fea
tures of
three of the component sub
-
theories: Basic psychological need theory, cognitive evaluation theory,
and organismic integration theory (Hagger and Chatzisarantis, 2007, p. 8).


2.4.2.2.

Extrinsic motivation

Located between intrinsic motivation and amotivati
on on the continuum (See Figure
2.5), there are four different classifications of extrinsic motivation each varying in their
level of autonomy (Hagger and Chatzisarantis, 2007).



21


2.4.2.2.1.

External Regulation

External regulation is the least autonomous, and
therefore the most highly
controlled classification of all extrinsically motivated behaviours (Hagger and
Chatzisarantis, 2007). It is characterised by motivation to meet externally defined
demands, for the purpose of attaining external reward (Ryan and De
ci, 2000a;
Hagger and Chatzisarantis, 2007). According to SDT, once external rewards or
demands are absent, the extrinsic motivation to carry out the activity or behaviour
no longer prevails (Ryan and Deci, 2000a; Hagger and Chatzisarantis, 2007). For
exam
ple: an externally motivated patient referred by their GP to participate in
exercise classes to reduce their risk of falling might only continue with the classes as
long as they are specifically required to by their GP or the exercise instructor.


2.4.2.2.2.

Introjec
ted Regulation

Introjected regulation of motivation involves a higher level of control than
external regulation, through reward or punishment for performance via internal
contingencies. Those who demonstrate introjected behaviour typically seek external
ap
proval and aim to avoid external disapproval (Hagger and Chatzisarantis, 2007).
The locus of causality for introjected regulation is still perceived to be external and is
not considered to be part of the self, despite the behaviour being internally driven
(Ryan and Deci, 2000a). As an example: a patient whose motivation is regulated
through introjection may only continue to attend an exercise class to avoid feelings
of guilt and attain the approval of friends or family.


2.4.2.2.3.

Identified Regulation

Identified re
gulation of behaviour is relatively autonomous in comparison to
external and introjected behaviours (Hagger and Chatzisarantis, 2007). Regulation
through identification means that extrinsic behaviours are self
-
endorsed and
therefore result from the persona
l value associated with the external goal or reward
(Ryan and Deci, 2000a). An example of a person whose motivation is regulated
through identification would be someone who continues to attend classes because
they identify with the values and purpose of ex
ercise participation.




22


2.4.2.2.4.

Integrated Regulation

Integrated behaviours are the most autonomously regulated of all
extrinsically motivated behaviours (Ryan and Deci, 2000a). These behaviours are
further assimilated with a person’s own life goals and personal
values compared
with behaviours regulated through identification (Hagger and Chatzisarantis, 2007).
However, despite being all the more volitional, the behaviours are still separable
from intrinsically regulated cues by the fact that they are not carried o
ut for their
inherent enjoyment (Ryan and Deci, 2000a). For example: a patient whose
regulation of behaviour is integrated is more likely to assimilate the values of the
exercise classes with their own and these become anchored in their own personality
and

lifestyle.


2.4.2.3.

Amotivation

Positioned on the far left end of the continuum (See Figure 2.5.) at the low end of
the scale of autonomy, amotivation is a total absence of motivation or intention to carry
out a given action or behaviour and thus there is also
no regulation of the behaviour
(Ryan and Deci, 2000a). An example of this is a patient who has been referred to an
exercise programme by their GP or an exercise instructor but has no intention to
participate and therefore does not attend the classes.


2.5.

Cogn
itive Evaluation Theory

2.5.1.


Overview

Cognitive Evaluation Theory (CET) is a sub
-
theory of SDT designed to explain the
different forms of motivation (Ryan and Deci, 2000a). CET states that there are three needs
that must be satisfied to facilitate autonomous m
otivation; these needs are for autonomy,
relatedness and competence (Hagger and Chatzisarantis, 2007; See Figure 2.5).


2.5.2.


Definitions

2.5.2.1.

Autonomy

Autonomy concerns the self
-
endorsement of one’s actions (Hagger and
Chatzisarantis, 2007)


it is the inherent n
eed to be in control of one’s own behaviour
and actions, as opposed to being controlled by another person or external factor.



23


2.5.2.2.

Relatedness

Relatedness is the innate need to interact with others


this need is most satisfied in
contexts that provide a pers
on with a sense of belonging and connectedness (Hagger
and Chatzisarantis, 2007). Without this sense of relatedness a person is likely to
experience a feeling of alienation and insecurity and therefore they may be less likely to
enjoy or exhibit an interes
t in a given activity.


2.5.2.3.

Competence

Competence is the inherent need to feel capable of one’s own ability to perform a
particular activity


a similar concept to self
-
efficacy (Ryan and Deci, 2000a). CET theory
argues that social
-
contextual events that
develop feelings of competence during activity,
for example positive feedback and rewards, can enhance intrinsic motivation for that
activity.


2.6.

Linking Self Determination Theory with Cognitive Evaluation Theory

Self Determination Theory (SDT; Deci and Ryan
, 1985) enables the identification of different
types of behavioural regulation. These types of regulation are influenced by factors that are
considered in sub
-
theories of SDT, including the satisfaction of psychological needs for
autonomy, competence and
relatedness (Ryan and Deci, 2000a). SDT states that the degree of
self
-
regulation in a given behaviour (i.e.: whether someone is intrinsically or extrinsically
motivated or entirely amotivated) is partly dependent upon the satisfaction of these three
psych
ological needs (See Figure 2.5; Hagger and Chatzisarantis, 2007). When exposed to
environments that support satisfaction of these psychological needs more self determined forms
of behavioural regulation (i.e.: intrinsic motivation and internalized forms of

extrinsic
motivation) are facilitated. Conversely, when one or more psychological needs are neglected,
these self determined forms of regulation are thwarted, and instead extrinsic motivation and
amotivation thrive.


2.7.

Application of theory to exercise for
older adults

2.7.1.

Self
-
determination Theory

Evidence has been published to suggest that there are numerous positive effects
resulting from participation in targeted exercise interventions on falls risk factors in older
adults (Gillespie et al., 2009). Understa
nding the influence of motivation over exercise
behaviour is important in development of effective exercise interventions. It allows
24


investigation of how interventions can be adapted to accommodate for the needs of this
population, and increase motivation
and reduce barriers to exercise. SDT is an example of
motivational theory used in exercise domains
(Ryan and Deci, 2000a)
. For example, SDT has
been applied as a theoretical framework for studies investigating overweight and obese
populations (Edmunds et a
l., 2007) and adolescents (Gillison et al., 2006) to examine
predictive relationships between need satisfaction, autonomy support, exercise motivational
or behavioural regulation and well
-
being (Edmunds et al., 2007; Gillison et al., 2006).
However, while
there has been some, research focusing on the use of SDT to predict and
evaluate exercise behaviours in aging populations is lacking.

Edmunds and colleagues (2006) conducted a study examining how

psychological need
satisfaction and motivational regulation
relate to and predict exercise behaviour in a sample
of 369 participants aged from 16 to 64 years recruited from fitness, community and retail
settings. The results showed that
age was an independent predictor of total exercise
behaviour, along with introj
ected regulation. It was concluded that SDT can be used to
predict exercise behaviours above those accounted for by demographic characteristics, i.e.:
age and gender (Edmunds et al., 2006). However, the participants used in the research study
are not entir
ely representative of the general population; the recruitment environments
were limited and thus may have influenced the social demographic groups represented
within the group.

Other studies have looked at how physical activity is associated with motivatio
nal
regulation in groups with age
-
related diseases, such as rheumatoid arthritis and participants
of a cardiac rehabilitation intervention (Hurkmans et al, 2010; Russell and Bray 2010). A
recent study by Hurkman and colleagues (2010) used a postal survey t
o administer self
-
report questionnaires to 271 patients of outpatient clinics for rheumatoid arthritis (
mean ±
SD age 62 ± 14). The

survey measured current physical activity level, regulation style and
autonomy supportiveness (the amount they feel supporte
d) using the
Short Questionnaire
to Assess Health
-
Enhancing Physical Activity, Treatment Self
-
Regulation Questionnaire and a
modified version of the Health Care Climate Questionnaire, respectively. The results from
the survey showed that being of a younger

age, female, educated to a higher level, having a
shorter disease duration and lower disease activity, and being more autonomously regulated
were all univariately associated with higher reported levels of physical activity. These
findings are in agreement

with those of Edmunds and colleagues (2006), who also found
younger age and more intrinsic regulation predicted higher levels of physical activity.
However, these findings may also be influenced by the manner in which participants were
25


recruited


those i
ndividuals that responded may represent a proportion of the population
who are generally more autonomously regulated to begin with; amotivated individuals may
be under represented as they are less likely to be motivated to respond to the survey.
Another st
udy of patients of a similar age (mean ± SD age 62.83 +/
-

10.78) enrolled in an
outpatient cardiac rehabilitation programme (Russell and Bray, 2010) which measured the
same psychological measures also found that more self
-
determined motivation was
associat
ed with greater levels of physical activity. However, the study was cross
-
sectional
which means that it did not allow for the examination of change in the same group of
participants over time; differences that are measured at the various points of progres
s in the
programme could be influenced by differences in the representational groups rather than a
result of the intervention. In addition, the cross
-
sectional design allows correlation of
variables to be identified, but it is not possible to establish any

causal relationships.

One important limitation of greater volumes of research literature concerning changes
in motivational styles in exercise groups with age
-
related diseases is that it does not
necessarily accurately represent the general older adult p
opulation who may not live with
these specific diseases or conditions. For example, persons with conditions that are more
commonly associated with reduced quality of life, high mortality or morbidity rates, such as
heart disease are also more likely to be
motivated to participate in physical activity. In
comparison, relatively healthy individuals with no indication of such illnesses may not be as
motivated to participate in exercise as they do not perceive there to be substantial benefits
to warrant such be
haviours. Therefore, there is a need for more research in to the
associations between motivation and exercise behaviour from a SDT perspective in healthy
adult populations.

Researching this gap in the literature is important as the information gained will assist
in meeting recommendations for exercise targeting older adults. For example, the
Guidelines for exercise programming for the frail elderly (2005; See Appendix 2.1.)

i
nclude
educating participants of the benefits of exercise, implementing goal setting at appropriate
levels, and providing participants with pleasant exercise experiences. All of these
recommendations may be useful to motivate and increase adherence through

increased
positive association and experience (Resnick and Spellbring, 2000). These recommendations
are also made in NICE public health guidance 6 (2007) which are discussed in the Section
2.2.3.

Such i
ntegration of personal values and increased enjoyment

in exercise behaviour is
typical of, and therefore should result in, more autonomous regulation
(Ryan and Deci,
2000a). Autonomous motivation results in fully volitional behaviours whereas controlled
26


motivation is likely to arise from external pressure a
nd demand and lead to behaviours that
are rewarded externally (Deci and Ryan, 2008). The use of goal setting, integration of values
and education also contribute in part towards satisfying individual need for competence,
relatedness and autonomy, respectiv
ely


all of which comprise the basis of Cognitive
Evaluation Theory (Ryan and Deci, 2000a).


2.7.2.

Cognitive Evaluation Theory

Individuals with more satisfied needs for autonomy, competence and

relatedness are more likely to experience intrinsic regulation of
motivation, while less
satisfaction of psychological needs results in an increased likelihood of experiencing more
extrinsically regulated types of motivation (Ryan and Deci, 2000a). Therefore, research that
is able to identify specific influential factor
s for need satisfaction in older adults can
contribute towards the development of exercise interventions effective in satisfying these
needs and therefore resulting in more intrinsically regulated motivation.

Being a sub
-
theory of SDT, theoretical applicat
ion of CET has been limited. However, due
to the overlapping nature of these two constructs, studies that have examined differences in
need satisfaction associated with exercise or physical activity have also investigated
motivational regulation. For examp
le, as discussed in Section 2.5.3., a

study by Edmunds and
colleagues (2006
)
looked at how

motivational regulation and need satisfaction can be used
to predict exercise behaviours. In addition to those findings indicating introjected motivation
as a predic
tor for physical activity, the study also showed that satisfaction of need for
competence directly predict


and indirectly predict via identified regulation


the amounts
of strenuous exercise undertaken by participants of the study. In addition, in parti
cipants
who engaged in organised fitness classes, autonomy support (the perception degree of
autonomy support provided by their fitness instructor) and intrinsic motivation was partially
mediated by satisfaction of need for competence


findings which agre
e with relationships
suggested by SDT (Edmunds et al., 2007).

Self
-
efficacy is a theory of motivation similar in concept to the psychological need for
competence (Ryan and Deci, 2000a) and has been applied to exercise behaviour in older
adults. Findings ha
ve indicated that in active older adults increased adherence to exercise is
associated with stronger self
-
efficacy expectations (Resnick and Spellbring, 2000, which
provides further evidence in agreement with CET (Ryan and Deci, 2000a; Ryan et al, 1997)


suggesting positive relationships between need satisfaction for competence and increased
adherence. When applied to these findings, evidence of a positive relationship between
27


adherence and autonomous regulation (Wilson et al., 2003) could be interpreted t
o mean
that greater satisfaction of need for competence are associated with more autonomous
regulation in older adults. However, one limitation of the findings from the study by Resnick
and Spellbring (2000) is that the sample is representative of an alrea
dy active population,
and therefore the findings are not necessarily directly applicable to sedentary or low
physical activity populations about to commence with participation in exercise programmes.
While the research evidence concerning the relationship
between adherence and
autonomous regulation by Wilson and colleagues (2003) was based on data from a middle
-
aged sample (mean ± SD age 41.75 +/
-

10.75) and therefore may also not be directly
applicable to other adults. These limitations in the research lit
erature highlight that there is
a need for evaluation of pre
-

and post
-
intervention need satisfaction in groups of healthy,
community
-
dwelling older adults.

Resnick and Spellbring (2000) suggested that that adherence is likely to be affected by
beliefs ab
out exercise, benefits of exercise, past experiences with exercise, goals, personality
and unpleasant sensations associated with exercise


factors that are known to influence
motivation (Ryan and Deci, 2000a). Recommendations are made in NICE public healt
h
guidance 6 (2007; see Figure 3.1. in Chapter 3) that reflect on the importance of considering
such influential factors as those identified in Resnick and Spellbring’s (2000) findings.
Behavioural intervention to increase physical activity levels in older

adults has been shown
to be highly effective (Conn et al., 2011). A multiple degree of freedom analysis conducted
as part of a recent meta
-
analytic review of 358 reports examining the effectiveness of
behavioural (e.g., goal setting, contracting, self
-
mon
itoring, cues and rewards) and cognitive
(e.g., health education, decision making and providing information) interventional
approaches used to increase physical activity in older adults indicated that interventions
targeting behaviour only, are more effect
ive than any other intervention (Conn et al., 2011).


2.7.3.

Linking need satisfaction and behavioural regulation in exercise settings for older
adults

According to SDT and CET greater satisfaction of psychological needs predicts intrinsic
types of motivation


w
hich in turn can predict exercise behaviours (Edmunds et al., 2006).
Individuals who are more intrinsically motivated have been shown to be more likely to
adhere to exercise programmes than extrinsically motivated persons (Wilson et al., 2003).
Therefore,
if applied to an older adult population, greater psychological need satisfaction
will be evident in intrinsically motivated individuals who are thus more likely to maintain
28


long
-
term adherence to exercise and physical activity. They are also more likely to

experience the benefits of exercise which, in an exercise
-
based falls prevention intervention
setting, includes better functional ability (Resnick and Spellbring, 2000) and reduced FOF (Li
et al., 2005; Zijlstra et al., 2007a). These benefits contribute t
owards overall improvement in
quality of life, both mentally and physically.


2.8.

Quality of Life

2.8.1.


Definition


H
ealth
-
related quality of life (HRQoL) has been defined as “a global indicator of health
resulting from the individual’s perception of the impact
that diseases exert on different
spheres of life (physical, mental and social)” (Balboa
-
Castillo et al., 2011, p. 47) and is
commonly measured in clinical and medical settings. Other psychological definitions exist,
for example, Pavot and Deiner (1993) dev
eloped the Satisfaction with Life Scale, which
concerns measurement of well
-
being that is evaluated based on the individual person’s
weighted criteria of what is important to them in their own life. However, due to its more
frequent use in medical screenin
g and assessment, and particularly as this research thesis
concerns interventions prescribed based on such processes conducted by medical
professionals, the definition of quality of life used herein is refers to health
-
related quality of
life (HRQoL).


2.8.2.


In
fluential factors

In community
-
dwelling older adults, reduced physical activity levels and increased
sedentary behaviour are associated with accelerated decline in health
-
related quality of life
(HRQoL; Brown et al., 2003; Balboa
-
Castillo et al., 2011). Th
ere have been few studies
conducted to specifically evaluate the effects of targeted falls prevention exercise
interventions on HRQoL in the older adult population. One RCT comparing the effects of a
specialised six week balance training intervention with
a control condition of a four week
physiotherapy based intervention demonstrated equal improvements in measures of HRQoL
in both treatment groups up to twenty four weeks post
-
intervention (Steadman et al., 2003).
These results indicate that more time effic
ient interventions can be implemented in place of
longer physiotherapy
-
based interventions to result in the same changes in HRQoL outcomes.
High and low fear of falling has been shown to be able to discriminate individuals with better
and poorer HRQoL in c
ommunity
-
dwelling older adults over the age of 70 years (Li et al.,
2003) which adds HRQoL to one of the many factors that have been shown to be influenced
29


by fear of falling. The influential effect of falls history on fear of falling (Howland et al, 1998;

Murphy et al., 2002; Arfken et al., 1994)
could therefore be interpreted to indicate that falls
history has an indirect effect on HRQoL. There is evidence of direct associations between
falls history and factors that are also associated with HRQoL such as

activity restriction and
functional ability (Tinetti et al., 1994; Howland et al, 1998; Cumming et al, 2000); however
there is an absence of research literature to indicate direct links between falls history and
HRQoL. However, a RCT investigating the inf
luence of hip fracture on quality of life in a
cohort of 194 women aged over 75 years and living in the community, all of whom had
experienced one or more fall or one fall that resulted in hospitalisation, highlighted the
profound impact of hip fracture on

the quality of life of adults (Salkeld et al., 2000)


an
injury which is most likely to be caused by a fall. The findings from this study showed that
death was preferable to living in a state of health that meant loss of their home,
independence, and mos
t importantly normal quality of life in older women who have
exceeded the average life expectancy (Salkeld et al., 2000). It was concluded that falls and
fractures pose a substantial threat to quality of life in this demographic (Salkeld et al., 2000).


2.8.3.

As
sessment and Implications

As a function of health
-
related outcome measures, particularly in clinical or medical
settings where time and cost efficiency are paramount, HRQoL is often assessed through
self
-
report questionnaires. Measurement of HRQoL in can b
e used for two purposes within
research studies: for discrimination of individuals according to HRQoL, for example:
identification of participants suitable for inclusion in a study (Lord et al, 2005), and for
evaluation of changes in HRQoL over a given tim
eframe, for example: before, during and
after completion of an intervention (Steadman et al, 2003).

The Prevention of Falls Network Earth (ProFaNE; Lamb et al., 2005) recommend the
Short Form 12
(SF
-
12; Ware et al., 1996)

and European Quality of Life Instr
ument (EuroQoL
EQ
-
5D; EuroQol Group, 1990). Preference of the SF
-
12 over the EuroQoL in data collection in
previous studies has been based on the SF
-
12 providing a broader assessment of mental and
physical health than the EuroQoL EQ
-
5D. The SF
-
12 is
compri
sed of 12 items, each belonging
to one of
eight scales, the responses to their corresponding items


producing two summary
scores for physical and mental health (See Appendix 2.2.). The SF 12 also has a response
format that may be better suited for adminis
tration in older adult populations (Lamb et al.,
2005). However, a factor that may be considered in terms of cost to service providers is that
no license fee is required to use the EuroQoL EQ
-
5D, unlike the SF
-
12.

30


In clinical and health settings it is com
monplace to record factors influential to quality
of life such as previous hip fracture and falls in a patient’s case history. Fear of Falling (FOF)
is also an influential factor for HRQoL (Li et al., 2003) and may be measured using the FES
-
I
(Yardley et a
l., 2005) (See Section 2.4.) as part of MFFRA. However, quality of life itself is not
as frequently recorded in a patient history despite growing evidence of its significance in
patient recovery. For example, assessments of quality of life have been used i
n previous
studies to supplement clinical assessment of chronic health conditions, including cancer
(Goodwin et al., 2003) and arterial diseases (Permanyer
-
Miralda et al., 1991). Other
influential factors such as activity restriction and functional ability

are measurable through
specific items belonging to the scales under the Physical and Mental Health Summary
Measures of the SF
-
12 (
Ware et al, 1996; See Appendix 2.2.). As an example, activity
restriction and functional ability can be assessed through resp
onses to the items concerning
Physical Functioning (PF) and Role
-
Physical (RP) which are summary measures of Physical
Health (PCS), and Role
-
Emotional (RE) which is a summary score of Mental Health (MCS)
(
Ware et al, 1996) respectively.



2.8.4.

Strategy and Poli
cy for Older People in Wales

The Welsh Assembly Government’s Strategy for Older People in Wales (2003) is a
response to over 100 recommendations made in research
-
based reports regarding the
responsibilities of the government to older adults and published b
y an Advisory Group in
May 2002, entitled ‘When I’m 64..…or more’. The Strategy for Older People was developed
to address fundamental issues associated with an ageing population in Wales and to
construct relevant and valid policies and programmes to improv
e provision of health care
and quality of life in later life, while adhering to United Nations Principles for Older Persons
(1991; See Appendix 2.3.). The Principles, which cover the topics of independence,
participation, care, self fulfilment and dignity
of older adults, are reflected by the aims of the
Strategy


particularly concerning the promotion of health and well
-
being in older adults.
For example:

Principle 11:
“Older persons should have access to health care to help them to maintain or
regain the
optimum level of physical, mental and emotional well
-
being and to prevent or
delay the onset of illness.”

United Nations Principles for Older Persons (1991 p. 2)

One of the five key aims of the Strategy directly responds to this principle, including
refere
nce to the approaches to be used to address the issue:

31



“To promote and improve the health and well
-
being of older people through integrated
planning and service delivery frameworks and more responsive diagnostic and support
services”
.

The Welsh Government provided £10 million of funding to implement the Strategy
during the first 3 years, which was used in part to develop the National Service Framework
for Older People in Wales (NSF; 2006).

The role of the NSF is to set evidence
-
based n
ational standards to improve provision of
quality health and social care. Its purpose is also to improve access to these services for
older people across Wales, which include specialist services for Stroke, Falls and Fractures
and Mental Health in Older Ad
ults. The standards set by the NSF (2006) focus on:



Age Discrimination



Person Centred Care



Promoting Health and Well
-
being



Challenging Dependency



Intermediate Care



Hospital Care



Stroke



Falls and Fractures



Mental Health in Older People



Medicines and Older P
eople


The rationale for the NSF standards in the promotion of health and well
-
being in older
age are to present a vision of older age that promotes good health, vitality, independence,
and active citizenship, as well as a reduction in the impact of disabi
lity and illness on health
and well
-
being. The key interventions proposed to address this rationale, including the aim
to extend the healthy life expectancies of older adults, are:



Initiatives to address the social, economic and environmental factors that
influence
health



Availability of integrated health promotion activities of specific benefit to older
people



Within a conducive environment, providing support for individuals to take more
responsibility for their own health and well
-
being

32




Offering access to

mainstream health promotion and disease prevention
programmes

(National Service Framework for Older People in Wales, 2006)


The proposal that interventions should provide environments that support for older
adults to take responsibility for their own
health and well
-
being links to the importance of
environmental factors on exercise motivation and HRQoL. The emphasis on providing this
type of supportive environment is reflective of the environments that are conducive with
with nurturing more autonomous
regulation of exercise behaviours in SDT and CET (Ryan
and Deci, 2000a). Links can also be made between these effects of these environments on
motivational regulation and HRQoL as discussed earlier (See Sections: 2.5., 2.6., and 2.7.).

Current and predicte
d increases in fall
-
related health issues paired with a growing
population of older adults means that these recommendations need to be applied to falls
prevention strategies to reduce risk of falling in older adults, and therefore ease the
economic burden
on health services for the treatment of fall
-
related injuries. The planned
actions to implement these interventions between 2003 and 2007 included local community
and health, social care and well
-
being strategies, specific and accessible health promotion
p
rogrammes that are evidence
-
based and monitored, as well as local commissioning
strategies to ensure the accessibility of primary care services, including exercise referral
schemes along with screening and prevention programmes.

2.8.5.

Guidelines and guidance

The

NICE public health guidance 16 for mental wellbeing and older people published in
2008 with a specific focus on role of occupational therapy, physical activity walking and
training interventions in promoting mental wellbeing in older adults. The recommend
ations
for physical activity made in this guidance document include offering individualised,
community
-
based exercise and physical activity programmes including strength and
resistance exercise, particularly for frail older adults, which also support the N
ICE 21
guideline (2004) recommendation for strength and balance training for those identified at
risk of falling. Other recommendations made by the NICE public health guidance 16 (2008)
include ensuring that these exercise programmes reflect the preference
s of older people,
which links to providing exercise environments that are supportive of need satisfaction
(Ryan and Deci, 2000a). Further recommendations are also made for frequency and duration
of exercise sessions and how to enhance adherence: attendanc
e to sessions at least once or
twice a week and to complete 30 minutes of exercise on five days a week or more, which is
33


concurrent with the recommendations made in the Guidelines for exercise programming for
the frail elderly (2005; See Appendix 2.
1
) by e
ducating participants on the benefits of regular
exercise and providing examples of ADLs that contribute towards these bouts of exercise, for
example, housework, gardening or shopping. The guidance also recommends encouraging
regular feedback so that motiv
ation of the participants can be monitored. This type of
feedback is instrumental in the development of interventions that provide optimal
environments for achievement of need satisfaction and is conducive for more intrinsic forms
of motivation (Deci and R
yan, 2000a).

2.9.

Self
-
determination Theory
,
Cognitive Evaluation Theory and Well
-
being

Greater need satisfaction has been shown to predict more intrinsic types of motivation,
which can be used to predict exercise behaviours (Edmunds et al, 2006), including adh