Perceived benefit

An older adult (C¹), with dementia (C²), with the belief that exercise is advantageous (C³) or a positive attitude to exercise (C⁴), will perceive

170 | P a g e the benefit (M^response1) of completing (O¹) an exercise intervention (M^resource).

An older adult (C¹), with dementia (C²), with either a carer or

themselves having previous experience of being active and participating in exercise (C⁵), and with a perception that exercise is beneficial (C⁶), will feel encouraged (M^response2) to complete (O¹) an exercise

intervention (M^resource).

The perception or feeling of benefit was an emergent concept [244, 245, 247, 250, 251, 262, 267] and could be interpreted as either a response-mechanism or context. The perception or realisation of the benefits of exercise could be a feeling or response-mechanism generated by the supporting staff and their qualities as a resource, resulting in the older adult with cognitive impairment feeling, perceiving, or recognising exercise as beneficial.

Interpretation of Suttanon et al [244] suggests the perception of benefit could be a response-mechanism that is operating when the person with cognitive impairment has “prior experience of being active, participating in exercises, and perceiving benefits of general exercise” ([244], p1180). These context features are relevant for both the participant and carer [244]. Understanding an

individual’s previous experience of exercise and their perceptions regarding it can allow tailoring of approaches [244].

However, it could also be construed from Suttanon et al [244] that a perception or realisation of the benefits of exercise may be a characteristic or feature of the person with cognitive impairment or their carer, and therefore is a context component. In reality, this is both context and response-mechanism, moving within the CMOc depending upon the individual and other context components.

171 | P a g e Reinforcement by physiological-responses

An older adult (C¹), with dementia (C²), who has the ability to

comprehend (C⁷) and who does identify physical or functional changes (C⁸) will perceive the benefit (M^response1) from completing (O¹) an exercise intervention (M^resource).

Recognition of improvements or changes in physiological-responses reinforce an individual’s perception of benefit. When improvements are made and

recognised, for example in function or physical ability, there is an improvement in participation [247]. Identification of benefit is important for both participation and the maintenance of an intervention [250, 251]. Huger et al [262] identified that persons with cognitive impairment can “suffer from multiple problems”, which could include lack of comprehension of the benefits of training. This would influence ability to identify benefits from completing exercise. Whilst this statement seems particularly negative towards participants, it could be

interpreted as a context component for certain individuals, rather than a general characteristic of all older adults with cognitive impairment.

Reinforcement by external supporter

An older adult (C¹), with dementia (C²), who has an external supporter who either understands the benefits of exercise, or who can prompt regarding the benefits of exercise, or who enables the person with dementia to compare themselves with others (C⁹), will perceive benefit (M^response1) from completing (O¹) an exercise intervention (M^resource).

Both the older adult with dementia and the carer are involved in the perception of benefit response-mechanism [250]. Synergy is required between the carer’s understanding, support, and ability to address barriers to exercise, and the

172 | P a g e participant’s comprehension [245, 250]. An emergent context was the

perception of exercise health benefits for others, which produced the support and encouragement which prompted participation. For example, an individual walking his dog demonstrates an external source as a prompt and reinforcement of the health benefits of engaging in physical activity [250]. The feeling of encouragement could also come from being able to compare themselves with others that have the same diagnosis, but only in the context where the older adult with dementia was doing well [251].

Benefit versus risk?

An older adult (C¹) with dementia (C²) who has a carer who perceives that the benefit for the person with dementia doing exercise outweighs the risk of doing exercise or the burden of extra care duties (C¹⁰) will provide support (M^response3) for the participation (O¹) in an exercise programme (M^resource1) or routine physical activity (M^resource2).

The carer’s perception and belief in the benefit of exercise must outweigh the risk, care burden, or adaption required to complete the exercise [250, 267].

Negative connotations to exercising (reminder of inability to do previously enjoyable activities or potential deterioration), adaptions, or changes to routines or daily lives that are required to support the physical activity are destructive to the perception of benefit for both the person providing the support and the person with dementia [250]. Concern regarding risks involved is a context component that is particularly relevant when the person providing support to exercise is a spouse, relative, or carer. Concern can be both facilitator and barrier to engagement in exercise, such as concern about not staying mobile and healthy versus concern about getting lost or falling [267].

173 | P a g e Types of benefit

An older adult (C¹) with dementia (C²) who has a carer who perceives benefit on mood (C¹¹), behaviour (C¹²), weight (C¹³), flexibility (C¹⁴), ageing (C¹⁵), and enjoyment of everyday life (C¹⁶) for that older adult doing exercise (C¹⁷) will provide support (M^response3) for the participation (O¹) in an exercise programme (M^resource1) or routine physical activity (M^resource2).

Benefits perceived from completing exercise were not limited to health

outcomes. Benefits reported included: mood [250, 267], behaviour, quality of everyday life [250], weight, flexibility, and ageing [267]. A contentious benefit was an attempt to re-establish previous activities or the “person” that came before the dementia diagnosis or progression of cognitive impairment [250].

Cedervall and Aberg [250] reported this perception as coming from the person providing the support. The consideration of how exercise might influence dementia or benefit falls risk was not directly reported [267].

5.3.5.2. Support

Support was a frequently reported concept and identifiable both directly [249-251] and indirectly [247] throughout extracted material. The support could be provided through supervision [252, 262], practical measures [250], supportive strategies such as making or maintaining routines [251] or through emotional support [251, 262].

There were many references to people providing the support. Examples extracted from the review material include: students [247, 249], carers [244, 245, 249, 267, 275], family members [275], physiotherapists [103, 244, 249], occupational therapists [249], trained personnel [252, 262, 265], dogs or