Introduction Falls in aged residential care (ARC) pose a major health problem with up to 70% of residents falling each year. Whilst there is strong evidence for effective falls prevention exercise programmes for community dwelling older adults the same cannot be said for older adults living in ARC. The populations are dissimilar and the different fall risk factors for older adults living in ARC are important to consider when designing fall prevention interventions for older adults living in ARC. High proportions of ARC residents have cognitive dysfunction and physical impairments, resulting in a population at high risk of falls. Despite the high incidence of falls in this population, fall prevention exercise programmes have not included components that target cognition. This thesis addresses both fall prevention exercise programmes and the potential for such programmes to be delivered in the context of ARC.

A programme of cognitive exercise (Cognitive Stimulation Therapy) has been found to improve cognition in older adults and is delivered to ARC residents in New Zealand (NZ). This programme is manualised and structured by activities such as discussions around news topics, singing and word games. As this was an established programme in ARC it had the potential to be explored as a possible vehicle to deliver physical fall prevention exercises in addition to its focus on cognitive exercise. On this basis, the first objective of this thesis was to develop and evaluate a fall prevention exercise programme that could be combined with Cognitive Stimulation Therapy that addressed the fall risk factors of cognitive dysfunction and decreased balance and lower limb weakness for older adults living in ARC.

The ARC environment can be viewed as a complex adaptive system. Characterised by uncertainty, emergence and unpredictability, the system responds to anything new by flexing, adjusting and adapting to a new way of working. When viewed this way, a fall prevention intervention programme is an event in the system and impacts on the interactions of the person-place-time network which changes relationships, displaces current activities and redistributes resources. On this basis, the second objective of this thesis was to understand the complexities around the delivery of a fall prevention exercise programme in the complex context of ARC.

Methods A programme that combined Cognitive Stimulation Therapy and physical fall prevention exercises (CogEx) was developed along with training manuals to support programme delivery. Physical exercises were incorporated into the CST. Existing CST facilitators were trained to deliver the physical exercise as part of CogEx. A feasibility randomised controlled trial was used to evaluate the CogEx in two ARC facilities. The plan was to undertake a fully powered randomised controlled trial to test the effectiveness of CogEx in decreasing fall in people living with dementia in ARC. However, the learnings from the CogEx study led us to pivot and explore some of the complexities that impacted the successful implementation of CogEx. To explore these complexities a qualitative sub-study was undertaken on a falls prevention exercise trial that was underway in ARC. This study was a type 1 hybrid effectiveness-implementation design exploring factors influencing the maintenance of a fall prevention programme in ARC as usual practice. For the qualitative component, Interviews and focus groups were held with stakeholders at different levels of ARC organisation (senior management, onsite management, exercise group facilitators) who were involved with the program.

Results The feasibility study demonstrated that physical exercises could be combined with the CST session to form CogEx; however, the fidelity of the combined programme was poor. Due to the feasibility issues identified a decision was made to stop further work on the CogEx intervention and move to understanding the complexities around delivery of falls prevention in ARC.

The qualitative study identified that the factors influencing the embedding of a falls prevention exercise programme into ARC could be categorised as: the influence of business models and philosophies; requirements for evidence; and valuing the contribution of physiotherapy in falls prevention.

Conclusion A fall prevention exercise programme was developed that incorporated physical and cognitive exercise for ARC residents (CogEx). However, the fidelity of the programme was poor. The factors that impacted the fidelity of fall prevention exercise programmes and the decision to embed them into routine practice reflected the complex context of ARC.

Any future research into implementing falls prevention in ARC should use co-design with all ARC stakeholders. As they know the contextual minutiae that external researchers do not. This may result in interventions that are sustained beyond the availability of research funding and translate to become part of routine practice.