Delivery of Neuropsychological Interventions for Adult and Older Adult Clinical Populations: An Australian Expert Working Group Clinical Guidance Paper.

Delivery of neuropsychological interventions addressing the cognitive, psychological, and behavioural consequences of brain conditions is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings. However, there are numerous approaches to neuropsychological intervention, requiring different sets of skills, and with varying levels of supporting evidence across different diagnostic groups. This clinical guidance paper provides an overview of considerations and recommendations to help guide selection, delivery, and implementation of neuropsychological interventions for adults and older adults. We aimed to provide a useful source of information and guidance for clinicians, health service managers, policy-makers, educators, and researchers regarding the value and impact of such interventions. Considerations and recommendations were developed by an expert working group of neuropsychologists in Australia, based on relevant evidence and consensus opinion in consultation with members of a national clinical neuropsychology body. While the considerations and recommendations sit within the Australian context, many have international relevance. We include (i) principles important for neuropsychological intervention delivery (e.g. being based on biopsychosocial case formulation and person-centred goals); (ii) a description of clinical competencies important for effective intervention delivery; (iii) a summary of relevant evidence in three key cohorts: acquired brain injury, psychiatric disorders, and older adults, focusing on interventions with sound evidence for improving activity and participation outcomes; (iv) an overview of considerations for sustainable implementation of neuropsychological interventions as 'core business'; and finally, (v) a call to action.

Quality of life and psychological health after mild traumatic brain injury in older people: Three- and six-month follow up.

OBJECTIVES: Examine quality of life (QoL) and psychological health after mild traumatic brain injury (mTBI) in older people (65+ years) at 3- and 6-month follow-up and explore which injury factors predicted QoL. METHODS: mTBI patients were compared to trauma comparison (TC) and community comparison (CC) groups. QoL and psychological health were measured at both timepoints. After accounting for 3-month psychological health, injury severity, neuroimaging, and 3-month neuropsychological performance were assessed as predictors of 6-month QoL. RESULTS: Overall 3-month QoL was lower for mTBI (Cohen's d = 0.938) and TC (Cohen's d = 0.485) groups compared to CCs, but by 6 months only mTBI patients continued to report poorer overall QoL (Cohen's d = 0.577) and physical QoL (Cohen's d = 0.656). Despite group differences, QoL for most (~92%) was within normative limits. 3-month psychological health predicted QoL 6-months postinjury (ß = -.377, 95% CI -.614, -.140) but other proposed risk factors (GCS <15, neuroimaging, 3-month neuropsychological performance) did not uniquely predict QoL. CONCLUSIONS: Older adults following mTBI reported lower QoL up to 6-months postinjury compared to non-injured peers, indicating that mTBI patients were particularly susceptible to ongoing differences in QoL 6-months postinjury.

Mild Traumatic Brain Injury and Functional Outcome in Older Adults: Pain Interference But Not Cognition Mediates the Relationship Between Traumatic Injury and Functional Difficulties.

OBJECTIVE: To examine functional status of older people 3 months after mild traumatic brain injury (mTBI) and identify whether pain interference or cognition mediates any relationship found between injury status and functional outcomes. SETTING: Patients admitted to a Melbourne-based emergency department. PARTICIPANTS: Older adults 65 years and older: 40 with mTBI, 66 with orthopedic injury without mTBI (TC), and 47 healthy controls (CC) without injury. DESIGN: Observational cohort study. MAIN MEASURES: Functional outcome was measured using the World Health Organization Disability Assessment Schedule (WHODAS 2.0) and single- and dual-task conditions of the Timed-Up-and-Go task. Pain interference and cognitive performance at 3 months post-injury were examined as mediators of the relationship between injury status (injured vs noninjured) and functional outcome. RESULTS: Patients with mTBI and/or orthopedic injury reported greater difficulties in overall functioning, including community participation, compared with noninjured older people (CC group). Both trauma groups walked slower than the CC group on the mobility task, but all groups were similar on the dual-task condition. Pain interference mediated the relationship between injury status and overall functioning [ b = 0.284; 95% CI = 0.057, 0.536), community participation ( b = 0.259; 95% CI = 0.051, 0.485), and mobility ( b = 0.116; 95% CI = 0.019, 0.247). However, cognition did not mediate the relationship between injury status and functional outcomes. CONCLUSIONS: Three months after mild traumatic injury (with and without mTBI), patients 65 years and older had greater functional difficulties compared with noninjured peers. Pain interference, but not cognition, partially explained the impact of traumatic injury on functional outcomes. This highlights the importance of reducing pain interference for older patients after injury (including mTBI) to support better functional recovery.

Clinical and Blood Biomarker Trajectories after Concussion: New Insights from a Longitudinal Pilot Study of Professional Flat-Track Jockeys.

There is a recognized need for objective tools for detecting and tracking clinical and neuropathological recovery after sports-related concussion (SRC). Although computerized neurocognitive testing has been shown to be sensitive to cognitive deficits after SRC, and some blood biomarkers have shown promise as indicators of axonal and glial damage, the potential utility of these measures in isolation and combination for assisting SRC diagnosis and tracking recovery is not well understood. To provide new insights, we conducted a prospective study of 64 male and female professional flat-track jockeys (49 non-SRC, 15 SRC), with each jockey undergoing symptom evaluation, cognitive testing using the CogSport battery, and serum biomarker quantification of glial fibrillary acidic protein (GFAP), tau, and neurofilament light (NfL) using a Simoa HD-X Analyzer. Measures were performed at baseline (i.e., pre-injury), and 2 and 7 days and 1 and 12 months after SRC. Symptoms were most pronounced at 2 days and had largely resolved by either 7 days or 1 month. CogSport testing at 2 days revealed cognitive impairments relative to both non-concussed peers and their own pre-injury baselines, with SRC classification utility found at 2 days, and to a slightly lesser extent, at 7 days. Relatively prolonged changes in serum NfL were observed, with elevated levels and classification utility persisting beyond the resolution of SRC symptoms and cognitive deficits. Finally, SRC classification performance throughout the 1st month after SRC was optimized through the combination of cognitive testing and serum biomarkers. Considered together, these findings provide further evidence for a role of computerized cognitive testing and fluid biomarkers of neuropathology as objective measures to assist in the identification of SRC and the monitoring of clinical and neuropathological recovery.

Observed Strategies on Naturalistic Associative Memory Tasks in Healthy Older Adults and Amnestic Mild Cognitive Impairment.

BACKGROUND: Understanding the strategies people with amnestic mild cognitive impairment (aMCI) spontaneously use can inform targeted memory training. METHOD: Strategy use was observed for 99 people with aMCI and 100 healthy older adults (HOA) on two memory tasks. RESULTS: No differences were found between aMCI and HOA in the amount or types of strategies used, but strategy use varied with task. Association was more effective for one task, whereas on the other task, use of written notes or multiple strategies were detrimental to performance and related to poorer performance than active (spaced) retrieval, for aMCI. CONCLUSION: Our findings suggest the importance of identifying ineffective habits, in addition to instruction in more beneficial approaches.

Cognitive performance in older people after mild traumatic brain injury: Trauma effects and other risk factors.

OBJECTIVE: Cognitive symptoms are common in the initial weeks after mTBI, but recovery is generally expected within three months. However, there is limited information about recovery specifically in older age cohorts. Therefore, this study investigated cognitive outcome three months after mTBI in older adults (≥ 65 years) compared to trauma and community age-matched controls and explored risk factors for outcome after traumatic injury. METHODS: Older mTBI patients (n = 40) and older adults with mild traumatic injury but without head injury (n = 66) were compared to a noninjured community control group (n = 47). Cognitive assessment included neuropsychological and computerized tests. Group differences were compared on individual tasks and overall cognitive performances using composite scores. Regression analyses identified predictors of outcome for trauma patients and moderator analyses explored possible interactions of mTBI severity with age and cognition. RESULTS: As well as lower performances in processing speed and memory, both trauma groups had significantly lower performance on composite neuropsychological (d = .557 and .670) and computerized tasks (d = .783 and .824) compared to noninjured controls. Age, education, and history of depression were direct predictors of cognitive performance after mild traumatic injury (with or without head injury). Further moderation analysis demonstrated that mTBI severity (Glasgow Coma Scale < 15) moderated the impact of older age on computerized assessment (ß = -.138). CONCLUSIONS: Three months after mild trauma (regardless of head injury), older people demonstrate lower cognition compared to noninjured peers. However, severity of mTBI (Glasgow Coma Scale < 15) can interact with older age to predict poorer cognitive outcomes.

Subjective Cognitive Decline: Level of Risk for Future Dementia and Mild Cognitive Impairment, a Meta-Analysis of Longitudinal Studies.

Subjective Cognitive Decline (SCD) in older adults has been identified as a risk factor for dementia, although the literature is inconsistent, and it is unclear which factors moderate progression from SCD to dementia. Through separate meta-analyses, we aimed to determine if SCD increased the risk of developing dementia or mild cognitive impairment (MCI). Furthermore, we examined several possible moderators. Longitudinal studies of participants with SCD at baseline, with data regarding incident dementia or MCI, were extracted from MEDLINE and PsycINFO. Articles were excluded if SCD occurred solely in the context of dementia, MCI, or as part of a specific disease. Pooled estimates were calculated using a random-effects model, with moderator analyses examining whether risk varied according to SCD definition, demographics, genetics, recruitment source, and follow-up duration. Risk of study bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 tool. 46 studies with more than 74,000 unique participants were included. SCD was associated with increased risk of developing dementia (HR = 1.90, 95% CI 1.52-2.36; OR = 2.48, 95% CI 1.97-3.14) and MCI (HR = 1.73, 95% CI 1.18-2.52; OR = 1.83, 95% CI 1.56-2.16). None of the potential moderating factors examined influenced the HR or OR of developing dementia. In contrast, including worry in the definition of SCD, younger age, and recruitment source impacted the OR of developing MCI, with clinic samples demonstrating highest risk. SCD thus represents an at-risk phase, ideal for early intervention, with further research required to identify effective interventions for risk reduction, and cognitive-behavioural interventions for cognitive management. PROSPERO, protocol number: CRD42016037993.

Systematic Review and Meta-analysis of Outcome after Mild Traumatic Brain Injury in Older People.

OBJECTIVE: Older age is often identified as a risk factor for poor outcome from traumatic brain injury (TBI). However, this relates predominantly to mortality following moderate-severe TBI. It remains unclear whether increasing age exerts risk on the expected recovery from mild TBI (mTBI). In this systematic review of mTBI in older age (60+ years), a focus was to identify outcome through several domains - cognition, psychological health, and life participation. METHODS: Fourteen studies were identified for review, using PRISMA guidelines. Narrative synthesis is provided for all outcomes, from acute to long-term time points, and a meta-analysis was conducted for data investigating life participation. RESULTS: By 3-month follow-up, preliminary findings indicate that older adults continue to experience selective cognitive difficulties, but given the data it is possible these difficulties are due to generalised trauma or preexisting cognitive impairment. In contrast, there is stronger evidence across time points that older adults do not experience elevated levels of psychological distress following injury and endorse fewer psychological symptoms than younger adults. Meta-analysis, based on the Glasgow Outcome Scale at 6 months+ post-injury, indicates that a large proportion (67%; 95% CI 0.569, 0.761) of older adults can achieve good functional recovery, similar to younger adults. Nevertheless, individual studies using alternative life participation measures suggest more mixed rates of recovery. CONCLUSIONS: Although our initial review suggests some optimism in recovery from mTBI in older age, there is an urgent need for more investigations in this under-researched but growing demographic. This is critical for ensuring adequate health service provision, if needed.

Assessing prospective memory in older age: the relationship between self-report and performance on clinic-based and naturalistic tasks.

This investigation assessed the relationship between subjective self-reports and objective measures of prospective memory with forty-eight healthy, community-dwelling older-adults (> 65 years). The Prospective and Retrospective Memory Questionnaire provided the self-report data, the Cambridge Prospective Memory Test was used as a clinic-based test, and the Telephone Task (telephoning the examiner at irregular, pre-scheduled times across one week) was used as a naturalistic measure. The self-reported difficulties were negatively associated with performance on the naturalistic task, r (41) = -0.341, p = <0.05, but not the clinic-based task. Performance tasks (clinic-based and naturalistic) were moderately associated, r (41) = 0.312, p = <0.05. Tests of retrospective memory (delayed recall) and executive function (attention set-shifting) did not individually predict performance on any of the prospective memory measures. Incorporating naturalistic probes of prospective memory performance into a clinical assessment may allow insight into the experience of prospective memory challenges in older-age clients.

Social support moderates the effect of stress on the cortisol awakening response in dementia family caregivers.

Dementia caregiving has been associated with a range of adverse effects on the physical health of the caregiver. However, the specific mechanisms underlying the relationship between dementia caregiver stress and ill health remain unclear. The aim of this study was to investigate, using available prospective data, the relationship between perceived stress (burden) and pre-clinical indices of ill-health (cortisol awakening response and secretory immunoglobulin A) amongst dementia caregivers. The potential moderating effect of social support on the perceived stress-physiological stress/health relationship was also explored. Participants (N = 31) were caregivers of community-dwelling older adults living with dementia who were enroled in a psychoeducation support program and provided data (study questionnaire and saliva samples) at two timepoints (T1 and T2), 10 weeks apart. Hierarchical regressions were used to determine if changes in stress and social support predicted change in each of the physiological outcomes. Findings indicate that caregivers with more hours of care at T1, or with greater satisfaction with social support, were more likely to exhibit an adaptive cortisol awakening response at T2. Moreover, social support was found to buffer the effect of caregiver stress and hours of caregiving on the cortisol awakening response. Implications for future interventions targeting caregiver health are discussed.

Cognitive performance in older adults at three months following mild traumatic brain injury.

Introduction: In the context of limited research assessing outcomes following mild traumatic brain injury (mTBI) in older adults, this study evaluated cognitive outcomes through prospective memory, and expected that performance of an older mTBI group (≥65 years) would be lower compared to orthopedic and community controls. The study also explored whether cognitive resources (retrospective memory, executive function) moderated any association between presenting Glasgow Coma Scale (GCS) and prospective memory.Method: At three-months post-injury, a mTBI group (n = 39), an orthopedic control group (n = 63), and a community control group (n = 46) completed a neuropsychological assessment, including (i) prospective memory, using a standardized paper-and-pencil task (Cambridge Prospective Memory Test), an augmented reality task and a naturalistic task, and (ii) standardized measures of retrospective memory (Hopkins Verbal Learning Test) and executive function (Trail Making Test). Group performances were compared, and bootstrapped moderation analyses evaluated the role of cognitive resources in the relationship between GCS and prospective memory outcome.Results: The mTBI group, as compared to community controls, performed significantly lower on the augmented reality task (d = -0.64 to d = -0.79), and there was a small-moderate but non-significant effect (d = -0.45) on the naturalistic task. There were no differences between the mTBI group and orthopedic controls. Retrospective memory was a unique predictor of the augmented reality task (B = 1.83) and moderated the relationship between presenting GCS and the naturalistic task (B = -5.60). Executive function moderated the association between presenting GCS and augmented reality (B = -1.13) and naturalistic task (B = -1.57).Conclusions: At three-months post-mTBI, older adults are at risk of poor cognitive performance; and the relationship between GCS and prospective memory can be moderated by cognitive resources. Further follow-up is indicated to determine whether impairments resolve or persist over time.

Memory Strategy Training Can Enhance Psychoeducation Outcomes for Dementia Family Caregivers: A Randomized Controlled Trial.

This study investigated caregiver outcomes when a psychoeducation program for older people with dementia and caregivers is modified to extend practice in memory strategies. Moderation effects of increased memory strategy use were also explored. Fifty-six care dyads participated in the multicenter, randomized controlled trial comparing psychoeducation (active control) with psychoeducation and memory strategy practice (intervention). Primary outcome was memory strategy use; secondary outcome was caregiver emotional reactivity (burden, depression, and anxiety). Results showed memory strategy use significantly increased following psychoeducation for both groups. However, psychoeducation combined with memory strategy practice resulted in a significant reduction in depression for caregivers reporting at least mild baseline symptoms. Greater use of memory strategies moderated the relationship between burden and depression following intervention. Psychoeducation programs that incorporate practical memory strategy training may offer more substantial outcomes.

Pre-Test Experience and Memory Performance in Older Adults: The Impact of Test Anxiety and Self-Efficacy.

OBJECTIVE: The objective of this paper is to investigate the role of test anxiety and memory self-efficacy on memory performances in older adults. METHOD: One hundred cognitively normal, community-dwelling older adults aged 65+ participated used in this experimental study. Participants completed baseline evaluations (including pre-test anxiety) prior to being assigned to one of two experimental conditions in which they experienced either success or failure on a verbal test. They subsequently completed post-test anxiety ratings, a measure of memory self-efficacy (Memory Self-Efficacy Questionnaire), and standardized tasks of working memory and verbal episodic memory. RESULTS: Following experimental manipulation, participants in the pre-test failure condition demonstrated higher anxiety and lower memory performances. Hierarchical regression revealed that change in anxiety from pre-test to post-test predicted memory performances and mediation analyses demonstrated that these effects were explained by lower memory self-efficacy. CONCLUSIONS: For older adults, experiencing test failure prior to memory testing may result in increased test anxiety and lower memory self-efficacy leading to poorer memory performance. This has implications for diagnostic cognitive assessment for older people.

Who benefits from cognitive intervention in older age? The role of executive function.

Objective: In the context of the positive impact of cognitive interventions for age-related memory concerns, clinicians are seeking information about variables that predict optimum client response. In this study of older adults, the aim was to investigate baseline predictors of gain in memory performance, i.e. prospective memory, following a memory intervention.Methods: One hundred and one healthy older adults (H0A) and 73 older people with amnestic mild cognitive impairment (aMCI) were evaluated at 6-months after participating in a 6-week memory group intervention (LaTCH). The outcome measure was a clinic-based prospective memory task. Baseline predictors included demographic variables (age, gender, education), baseline prospective memory, and cognitive resources (retrospective memory, executive function).Results: Thirty percent of the HOA and 16% of the aMCI cohorts demonstrated reliable training effects on prospective memory test performance at 6-month assessment. Through hierarchical regressions in the HOA cohort, executive function (working memory, attention set shifting) rather than retrospective memory was the best predictor of change in prospective memory. Moderated regression did not demonstrate any interactions between retrospective memory and executive function. For the memory impaired cohort (aMCI), better baseline retrospective memory predicted greater gain in prospective memory but only when executive function was also high.Conclusions: Memory groups can improve performance on clinic-based prospective memory tests in older people with concerns about memory performance, suggesting the value of further translation studies to demonstrate functional real-world gains and quality of life improvement after training. These interventions may be especially effective for those older people with better executive function (working memory, attention set shifting).

Long-term effects of a memory group intervention reported by older adults.

The aim of this study was to examine older adults' experiences of change following a group memory intervention, the La Trobe and Caulfield Hospital (LaTCH) Memory Group programme. Semi-structured qualitative interviews were conducted with 30 individuals. Participants were healthy older adults and older adults with amnestic mild cognitive impairment (MCI) who had participated in the memory group five years previously. Transcripts were analysed for emergent themes in a workshop, using the Most Significant Change technique. The focus group derived four major themes relating to participants' experiences of change. Particularly noteworthy were themes describing a process of acceptance and normalising of memory difficulties in older age, as well as enhancement of coping and self-efficacy. The results highlight the importance of group support for older adults with and without objective memory impairment. Memory groups may use the group format to full advantage by (a) enhancing participants' experiences of universality to alleviate distress and promote coping, and (b) developing group norms to promote positive ageing, encompassing enhanced acceptance and self-efficacy.

Predictors of Long-Term Improvement in Subjective Everyday Memory Following a Memory Group Program for Older Adults.

Objective: The present study aimed to examine predictors of improvement in subjective everyday memory ability 5 years following participation in a group cognitive-behavioral memory intervention for community-living older adults, the La Trobe and Caulfield Hospital (LaTCH) Memory Group program. Method: Participants were 61 healthy older adults and data were analyzed using one-way repeated measures analysis of variance (ANOVA), hierarchical regression, and moderator analyses. Results: Although the group as a whole did not show significant gains in subjective memory ability following the intervention, greater gains in subjective memory ability were associated with poorer baseline associative memory, better baseline cognitive flexibility, and more subjective memory concerns prior to intervention. There was no interaction between the cognitive predictors and subjective memory concerns in predicting gains in subjective memory ability. Discussion: Differential benefits for more cognitively flexible individuals may derive from a greater capacity to engage skillfully in the expectancy modification aspects of the program.

Mediators of burden and depression in dementia family caregivers: Kinship differences.

OBJECTIVES: To investigate kinship differences in the caregiver stress process by developing multiple mediation models for two distinct caregiver subgroups (spouses and adult children of older adults living with dementia). The effect of four potential mediating variables (mastery, self-efficacy, satisfaction with social support, positive caregiving appraisals) on the relationship between perceived burden and depression was evaluated. METHOD: Family caregivers of a person living with dementia were recruited through national dementia and carer organisations. Participants completed a paper-based or electronic version of the study survey. A bias-corrected, accelerated bootstrapping method was used to test the effect of the four proposed mediating variables on the relationship between perceived burden and depression in each caregiver subgroup (spouses and adult children). RESULTS: Perceived burden was directly and significantly related to depression for both spouse caregivers and adult child caregivers. The mediation models explained approximately 50% of the variance in the burden-to-depression pathway for both caregiver subgroups. Mastery and social support (but not self-efficacy, nor positive caregiving appraisals) were found to individually significantly influence the impact of perceived burden on depression in spouse caregivers. All four proposed mediators failed to reach statistical significance as individual mediators of the burden-to-depression pathway in adult child caregivers. CONCLUSION: These findings demonstrate differences in the dementia caregiver experience according to kinship, and that certain mediating variables are more relevant for some subgroups of caregivers than others. Implications for the design of psychosocial interventions are discussed.

Bridging the gap between clinical trials and community care: Translating a memory group for older people with mild cognitive impairment into a community-based organisation.

OBJECTIVES: Older people with mild cognitive impairment (MCI) are seeking interventions for maintaining independence. This study investigates the feasibility of translating a research-evaluated memory group (LaTCH) into a community-based organisation by evaluating the experiences of clients and trained staff. METHODS: Dementia Australia staff trained as facilitators of memory groups for 274 people with MCI and families. Clients and staff were interviewed regarding experiences from group participation. RESULTS: Clients and staff reported benefits of shared experience through group participation, leading to greater use of compensatory strategies. Staff observed client improvement in memory-related self-confidence, thereby reducing anxiety and increasing re-engagement in life activities. In their own professional roles, staff reported increased self-efficacy, leading to greater role satisfaction. Several challenges in running and sustaining the program were also identified. CONCLUSIONS: Memory group interventions can be feasibly delivered in a community setting and increase service access opportunities for older people with memory problems.

Naturalistic Measurement of Sleep in Older Adults with Amnestic Mild Cognitive Impairment: Anxiety Symptoms Do Not Explain Sleep Disturbance.

BACKGROUND: Sleep disturbance is prevalent in Alzheimer's disease (AD). In amnestic mild cognitive impairment (aMCI), the preclinical stage of AD, deterioration in sleep quality has also been reported. Consensus is lacking, however, regarding what aspects of sleep are characteristically affected, whether the setting of the sleep recordings impacts these findings, and whether anxiety may account for the differences. OBJECTIVE: The current study aimed to address these knowledge gaps by obtaining comprehensive sleep measurement in aMCI within a naturalistic environment using in-home sleep recordings. METHODS: 17 healthy older adults and twelve participants with aMCI wore an actiwatch for two weeks to objectively record habitual sleeping patterns and completed two nights of in-home polysomnography. RESULTS: In aMCI, habitual sleep disturbances were evident on actigraphy including greater wake after sleep onset (p = .012, d = 0.99), fragmentation (p = .010, d = 1.03), and time in bed (p = .046, d = .76). Although not statistically significant, there was a large group effect on polysomnography with aMCI demonstrating less slow-wave-sleep than controls (p >.05, d = .0.83). Anxiety did not mediate the relationship between the group and sleep in this small study. CONCLUSIONS: The results indicate that people with aMCI have poorer quality sleep than healthy controls, as indicated by greater sleep disruption and less slow-wave sleep, even in naturalistic settings. Additionally, anxiety symptoms do not mediate the relationship. Therefore, this research supports the view that sleep disturbance is likely to be indicative of neuropathological changes in aMCI rather than being attributed to psychological factors.

Reduced professional efficacy is associated with a blunted salivary alpha-amylase awakening response.

The job demands-resources model (JD-R) has shown an ability to predict worker engagement and exhaustion, yet to our knowledge, research has not been conducted that assesses the JD-R model with physiological indicators of chronic stress and burnout. Using the JD-R model, we assessed if occupational stress and burnout were related to dysregulated cortisol and salivary alpha-amylase awakening responses (sAA-AR). Professional apprentice jockeys comprising of males (n = 14) and females (n = 18) provided morning saliva samples and completed self-report measures relating to job demands and resources, burnout, and perceived mental and physical health. Data was collected at two time points coinciding with naturally occurring 'low' and 'high' stress periods during the racing calendar. The jockeys reported good physical and mental health but had elevated levels of the burnout subtypes cynicism and exhaustion. Regression analyses suggested that those jockeys presenting with reduced professional efficacy in the high stress period produced a 'flattened' sAA-AR indicative of reduced autonomic nervous system (ANS) arousal, which has been associated with burnout. Further, decreases in professional efficacy explained the relationship between increased workplace stress and decreased ANS activity in the high stress period. Our findings suggest that assessments of psychological stress or physiology in isolation are not as useful as looking at both in combination, and extend previous findings on the sAA-AR.