Depression, childhood trauma, and physical activity in older Indigenous Australians.

OBJECTIVES: Indigenous Australians experience higher levels of psychological distress compared to the general population. Physical activity is a culturally acceptable approach, associated with reduction of depressive symptoms. The protective properties of physical activity for depressive symptoms are yet to be evaluated in older Indigenous Australians. DESIGN: A two-phase study design comprised of a qualitative thematic analysis following a quantitative regression and moderation analysis. PARTICIPANTS: Firstly, a total of 336 Indigenous Australians aged 60 years and over from five NSW areas participated in assessments on mental health, physical activity participation, and childhood trauma. Secondly, a focus group of seven Indigenous Australians was conducted to evaluate barriers and facilitators to physical activity. MEASUREMENTS: Regression and moderation analyses examined links between depression, childhood trauma, and physical activity. Thematic analysis was conducted exploring facilitators and barriers to physical activity following the focus group. RESULTS: Childhood trauma severity and intensity of physical activity predicted depressive symptoms. Physical activity did not affect the strength of the relationship between childhood trauma and depression. Family support and low impact activities facilitated commitment to physical activity. In contrast, poor mental health, trauma, and illness acted as barriers. CONCLUSION: Physical activity is an appropriate approach for reducing depressive symptoms and integral in maintaining health and quality of life. While situational factors, health problems and trauma impact physical activity, accessing low-impact group activities with social support was identified to help navigate these barriers.

Use of tricyclic antidepressants and other anticholinergic medicines by older Aboriginal Australians: association with negative health outcomes.

BACKGROUND: Aboriginal and Torres Strait Islander Australians have a relatively high prevalence of multimorbidity requiring treatment with medications. This study examines medication use and anticholinergic burden (ACB) among a cohort of older Aboriginal and Torres Strait Island people. METHOD: This cross-sectional study involving five Aboriginal communities (two in metropolitan Sydney and three on the mid-north coast of New South Wales) used a structured interview process to assess cognition, depression, and activities of daily living for a cohort of older adults (aged 60 years and over). Participants also reported on their health status, medical history, and prescription medications during the interview. ACB was calculated, and its association with adverse health outcomes including cognitive impairment, falls, hospitalization, and depressive symptoms were examined. RESULTS: Most participants (95%) were taking at least one regular medication with polypharmacy (≥5 medications) observed in 43% of participants; 12.2% had a significant ACB (≥3) with antidepressants being a major contributor. Anticholinergic medication use was associated with cognitive impairment, recent hospitalization (past 12 months), and depressive symptoms. After controlling for age, sex, and comorbidity, only the presence of depressive symptoms remained significantly associated with the use of anticholinergic medication (odds ratio 2.86; 95% confidence interval 1.48-5.51). CONCLUSIONS: Clinically significant ACB was common in older Aboriginal Australians and was largely attributable to inappropriate use of tricyclic antidepressants. Greater awareness of medication-related risk factors among both health care professionals and Aboriginal communities can play an important role in improving health and quality of life outcomes.

Reflections on working and walking gently together in collaboration and partnership in Aboriginal ageing research.

PROBLEM: An important aspect of the work that takes place in and across our Aboriginal Health and Ageing research group is about building partnerships between Aboriginal and Torres Strait Islander peoples and non-Indigenous people. Partnerships are created between colleagues and co-researchers as well as with community Elders, Aboriginal community-controlled organisations, community groups and associations and individuals. SETTING: To fully realise this has required an introspective look at the way we function as a team of Aboriginal researchers and non-Indigenous researchers working together. It has challenged us to explore and determine our shared visions and shared outcomes and to develop strong, enduring and authentic partnerships by putting culture at the centre of everything we do. KEY MEASURES FOR IMPROVEMENT: This wisdom-led approach has fostered the development of a shared narrative about research WITH Aboriginal and Torres Strait Islander communities and a shared language of research collaboration. STRATEGIES AND EFFECTS OF CHANGE: This paper aims to provide an opportunity to reflect on the key elements of co-design which have underpinned our work together across cultures both within team and within community. LESSONS LEARNT: This paper will provide lived examples of the co-design and co-creation process utilised by our team in working with community. It will further share a model which underpins these experiences. It provides a framework to refer to and reflect upon, which commits to working with shared respect, shared meaning, shared knowledge and an enriched experience of collaboratively working and walking and learning together.

Staying in touch with the community: understanding self-reported health and research priorities in older Aboriginal Australians.

OBJECTIVES: Aboriginal Australians experience higher rates of non-communicable chronic disease, injury, dementia, and mortality than non-Aboriginal Australians. Self-reported health is a holistic measure and may fit well with Aboriginal views of health and well-being. This study aimed to identify predictors of self-reported health in older Aboriginal Australians and determine acceptable research methodologies for future aging research. DESIGN: Longitudinal, population-based study. SETTING: Five communities across New South Wales, Australia (two urban and three regional sites). PARTICIPANTS: Aboriginal and Torres Strait Islander people (n = 227; 60-88 years, M = 66.06, SD = 5.85; 145 female). MEASUREMENTS: Participants completed baseline (demographic, medical, cognitive, mental health, and social factors) and follow-up assessments (self-reported health quantified with 5-point scale; sharing thoughts on areas important for future research). Predictors of self-reported health were examined using logistic regression analyses. RESULTS: Self-reported health was associated with sex, activities of daily living, social activity participation, resilience, alcohol use, kidney problems, arthritis, falls, and recent hospitalization. Arthritis, kidney problems, and resilience remained significant in multiple logistic regression models. CONCLUSIONS: Perceived resilience and the absence of certain chronic age-related conditions predict older Aboriginal peoples' self-reported health. Understanding these factors could inform interventions to improve well-being. Findings on acceptable research methodologies suggest that many older Aboriginal people would embrace a range of methodologies within long-standing research partnerships, which is an important consideration for Indigenous population research internationally.

Childhood Stress and Adversity is Associated with Late-Life Dementia in Aboriginal Australians.

OBJECTIVES: High rates of dementia have been observed in Aboriginal Australians. This study aimed to describe childhood stress in older Aboriginal Australians and to examine associations with late-life health and dementia. DESIGN: A cross-sectional study with a representative sample of community-dwelling older Aboriginal Australians. SETTING: Urban and regional communities in New South Wales, Australia. PARTICIPANTS: 336 Aboriginal and/or Torres Strait Islander Australians aged 60-92 years, of whom 296 were included in the current analyses. MEASUREMENTS: Participants completed a life course survey of health, well-being, cognition, and social history including the Childhood Trauma Questionnaire (CTQ), with consensus diagnosis of dementia and Alzheimer disease. RESULTS: CTQ scores ranged from 25-117 (median: 29) and were associated with several adverse childhood indicators including separation from family, poor childhood health, frequent relocation, and growing up in a major city. Controlling for age, higher CTQ scores were associated with depression, anxiety, suicide attempt, dementia diagnosis, and, specifically, Alzheimer disease. The association between CTQ scores and dementia remained significant after controlling for depression and anxiety variables (OR: 1.61, 95% CI: 1.05-2.45). In contrast, there were no significant associations between CTQ scores and smoking, alcohol abuse, diabetes, or cardiovascular risk factors. CONCLUSIONS: Childhood stress appears to have a significant impact on emotional health and dementia for older Aboriginal Australians. The ongoing effects of childhood stress need to be recognized as people grow older, particularly in terms of dementia prevention and care, as well as in populations with greater exposure to childhood adversity, such as Aboriginal Australians.

Comparison of Three Cognitive Screening Tools in Older Urban and Regional Aboriginal Australians.

BACKGROUND: Validated cognitive screening tools for use in urban and regional Aboriginal populations in Australia are lacking. METHODS: In a cross-sectional community-based study, 235 participants were assessed on the Mini-Mental State Examination (MMSE), the Rowland Universal Dementia Assessment Scale (RUDAS) and an urban modification of the Kimberley Indigenous Cognitive Assessment (mKICA). Performance on these cognitive screening tools was compared to dementia diagnosis by clinical consensus. RESULTS: All tests were culturally acceptable with good psychometric properties. Receiver operating characteristic curve analyses revealed that the MMSE and mKICA were the most accurate. CONCLUSION: The MMSE is an effective cognitive screening tool in urban Aboriginal populations. The mKICA is a good alternative when illiteracy, language or cultural considerations deem it appropriate. The RUDAS also has adequate validity in this population.

Prevalence of dementia in urban and regional Aboriginal Australians.

BACKGROUND: This study aimed to determine the prevalence of dementia in collaboration with urban/regional Aboriginal communities. METHODS: A census of Aboriginal and Torres Strait Islander men and women aged 60 years and above in the target communities identified 546 potential participants, with 336 (61.5%) participating in this cross-sectional study. Participants completed a structured interview and cognitive screening tests. One hundred fifty-three participants also completed a detailed medical assessment. Assessment data were reviewed by a panel of clinicians who determined a diagnosis of dementia or mild cognitive impairment (MCI) according to standard criteria. RESULTS: Crude prevalence of dementia was 13.4%, and age-standardized prevalence was 21.0%. The most common types of dementia were Alzheimer's dementia (44%) and mixed dementia diagnoses (29%). Estimated prevalence of MCI was 17.7%. CONCLUSION: Consistent with previous findings in a remote population, urban and regional Aboriginal Australians face high rates of dementia at younger ages, most commonly Alzheimer's dementia.

The Koori Growing Old Well Study: investigating aging and dementia in urban Aboriginal Australians.

BACKGROUND: Dementia is an emerging health priority in Australian Aboriginal communities, but substantial gaps remain in our understanding of this issue, particularly for the large urban section of the population. In remote Aboriginal communities, high prevalence rates of dementia at relatively young ages have been reported. The current study is investigating aging, cognitive decline, and dementia in older urban/regional Aboriginal Australians. METHODS: We partnered with five Aboriginal communities across the eastern Australian state of New South Wales, to undertake a census of all Aboriginal men and women aged 60 years and over residing in these communities. This was followed by a survey of the health, well-being, and life history of all consenting participants. Participants were also screened using three cognitive instruments. Those scoring below designated cut-offs, and a 20% random sample of those scoring above (i.e. "normal" range), completed a contact person interview (with a nominated family member) and medical assessment (blind to initial screening results), which formed the basis of "gold standard" clinical consensus determinations of cognitive impairment and dementia. CONCLUSION: This paper details our protocol for a population-based study in collaboration with local Aboriginal community organizations. The study will provide the first available prevalence rates for dementia and cognitive impairment in a representative sample of urban Aboriginal people, across city and rural communities, where the majority of Aboriginal Australians live. It will also contribute to improved assessment of dementia and cognitive impairment and to the understanding of social determinants of successful aging, of international significance.

Dementia Incidence, APOE Genotype, and Risk Factors for Cognitive Decline in Aboriginal Australians: A Longitudinal Cohort Study.

BACKGROUND AND OBJECTIVES: Aboriginal Australians are disproportionately affected by dementia, with incidence in remote populations approximately double that of non-Indigenous populations. This study aimed to identify dementia incidence and risk factors in Aboriginal Australians residing in urban areas, which are currently unknown. METHODS: A population-based cohort of Aboriginal Australians ≥60 years of age was assessed at baseline and 6-year follow-up. Life-course risk factors (baseline) were examined for incident dementia or mild cognitive impairment (MCI) through logistic regression analyses; adjustments were made for age. APOE genotyping was available for 86 people. RESULTS: Data were included from 155 participants 60 to 86 years of age (mean 65.70 years, SD 5.65 years; 59 male). There were 16 incident dementia cases (age-standardized rate 35.97/1,000 person-years, 95% confidence interval [CI] 18.34-53.60) and 36 combined incident MCI and dementia cases. Older age (odds ratio [OR] 2.29, 95% CI 1.42-3.70), male sex (OR 4.14, 95% CI 1.60-10.77), unskilled work history (OR 5.09, 95% CI 1.95-13.26), polypharmacy (OR 3.11, 95% CI 1.17-8.28), and past smoking (OR 0.24, 95% CI 0.08-0.75) were associated with incident MCI/dementia in the final model. APOE ε4 allele frequency was 24%; heterozygous or homozygous ε4 was associated with incident MCI/dementia (bivariate OR 3.96, 95% CI 1.25-12.50). DISCUSSION: These findings provide evidence for higher dementia incidence in Aboriginal Australians from urban areas, where the majority of Aboriginal people reside. This study also sheds light on sociodemographic, health, and genetic factors associated with incident MCI/dementia at older ages in this population, which is critical for targeted prevention strategies.

Dementia risk reduction in practice: the knowledge, opinions and perspectives of Australian healthcare providers.

This study examined Australian primary healthcare providers' knowledge about dementia risk factors and risk reduction and their perspectives on barriers and enablers to risk reduction in practice. Primary healthcare providers were recruited through Primary Health Networks across Australia (n=51). Participants completed an online survey that consisted of fixed-responses and free-text components to assess their knowledge, attitudes and current practices relating to dementia risk factors and risk reduction techniques. The results showed that Australian primary healthcare providers have good knowledge about the modifiable risk factors for dementia; however, face several barriers to working with patients to reduce dementia risk. Commonly reported barriers included low patient motivation and healthcare system level limitations. The most commonly reported recommendations to helping primary healthcare providers to work with patients to reduce dementia risk included increasing resources and improving dementia awareness and messaging. While the results need to be interpreted in the context of the limitations of this study, we conclude that collaborative efforts between researchers, clinicians, policy makers and the media are needed to support the uptake of risk reduction activities in primary care settings.

Patterns and preferences for accessing health and aged care services in older Aboriginal and Torres Strait Islander Australians.

OBJECTIVES: To determine preferences for health and aged care services in Aboriginal and Torres Strait Islander Australians and explore related factors. METHODS: Mixed-method, cross-sectional study including 336 Aboriginal and Torres Strait Islander people aged 60 years and older from regional and urban areas. RESULTS: Exclusive preference for Aboriginal Community Controlled services was most common. This preference significantly increased when preferences for, and use of, aged care and disability services were considered. The likelihood of holding an exclusive preference for Aboriginal Community Controlled services was higher in regional settings compared to urban and in those reporting lower engagement in traditional activities during childhood. CONCLUSIONS: These findings suggest that the majority of older Australian Aboriginal and Torres Strait Islander people prefer aged and disability care provided by Aboriginal services. Given the anticipated increase in service demand in this population, there is a growing need for culturally safe services, particularly in regional settings.

Older Aboriginal Australians' Health Concerns and Preferences for Healthy Ageing Programs.

While there is strong evidence of the need for healthy ageing programs for older Aboriginal Australians, few are available. It is important to understand older Aboriginal Australians' perspectives on healthy ageing in order to co-design culturally-appropriate programs, including views on technology use in this context. Semi-structured interviews were conducted with 34 Aboriginal Australians aged 50 years and older from regional and urban communities to explore participants' health concerns, preferences for healthy ageing programs, and receptiveness to technology. Qualitative data were analyzed using a grounded theory approach. This study found that older Aboriginal Australians are concerned about chronic health conditions, social and emotional well-being, and difficulties accessing health services. A range of barriers and enablers to participation in current health programs were identified. From the perspective of older Aboriginal people, a successful healthy ageing program model includes physical and cognitive activities, social interaction, and health education. The program model also provides culturally safe care and transport for access as well as family, community, cultural identity, and empowerment regarding ageing well as central tenets. Technology could also be a viable approach for program delivery. These findings can be applied in the implementation and evaluation of culturally-appropriate, healthy ageing programs with older Aboriginal people.

Mild cognitive impairment in Aboriginal Australians.

INTRODUCTION: Aboriginal Australians have among the highest rates of dementia worldwide, yet no study has investigated the subtypes, risk factors, or longer term outcomes of mild cognitive impairment (MCI) in this population. METHODS: A total of 336 community-dwelling Aboriginal Australians aged ≥60 years participated in a longitudinal study, completing a structured interview at baseline. MCI (amnestic subtype, aMCI; non-amnestic subtype, naMCI) and dementia were diagnosed via cognitive screening, medical assessment, and clinical consensus. Associations between life-course factors and baseline MCI subtypes were examined using logistic regression. Conversion to dementia was assessed at 6-year follow-up. RESULTS: Prevalent aMCI (n = 24) was associated with older age (odds ratio [OR] = 1.68, 95% confidence interval [CI]: 1.12 to 2.53), head injury (OR = 3.19, 95% CI: 1.35 to 7.56), symptoms of depression (OR = 1.52, 95% CI: 1.04 to 2.24), and lower blood pressure (OR = 0.53, 95% CI: 0.33 to 0.86). Prevalent naMCI (n = 29) was associated with low education (OR = 4.46, 95% CI: 1.53 to 13.05), unskilled work history (OR = 5.62, 95% CI: 2.07 to 13.90), higher body mass index (OR = 1.99, 95% CI: 1.30 to 3.04), and moderate to severe hearing loss (OR = 2.82, 95% CI: 1.06 to 7.55). A small proportion of MCI cases reverted to intact at follow-up (15%), but most remained stable (44%), developed dementia and/or died (41%). DISCUSSION: Sociodemographic and clinical factors both contributed to baseline MCI and were distinct for MCI subtypes, with similar patterns of conversion to dementia for amnestic and non-amnestic MCI.

Factors Associated with the High Prevalence of Dementia in Older Aboriginal Australians.

Dementia prevalence in Aboriginal and Torres Strait Islander Australians is three to five times higher than the general Australian population. A better understanding of the underlying biomedical and social risk factors is needed to guide dementia prevention in Aboriginal Australians. The current study is the first to examine potential risk factors for dementia in the majority urban and regional population, with a representative sample of 336 Aboriginal Australians aged 60 years and older. Participants included 45 people with a dementia diagnosis (n = 27 probable/possible Alzheimer's disease); and 286 people without dementia. Univariate logistic regression analyses (controlling for age) identified childhood trauma, mid-life factors (history of unskilled work, past high-risk alcohol use), and medical factors (history of stroke, head injury with loss of consciousness, epilepsy) as risk factors for dementia. Multivariable analysis revealed age, childhood trauma, unskilled work, stroke, and head injury as independent predictors of all-cause dementia. A range of comorbid factors related to dementia was also identified (i.e., functional impairment, incontinence, recent hospital admission, low body mass index, living in residential care, depression, current high-risk alcohol use, social isolation, low physical activity levels). These findings extend previous outcomes in a remote Aboriginal population by highlighting that life-course social determinants of health, in addition to neurological disorders, likely play an important role in elevating dementia risk. Certain psychosocial and medical exposures are highly prevalent in Aboriginal Australians, similar to other indigenous populations, and should be considered when designing targeted and culturally appropriate prevention initiatives to reduce the burden of dementia.

Depression, Suicidal Behaviour, and Mental Disorders in Older Aboriginal Australians.

Aboriginal Australians experience higher levels of psychological distress, which may develop from the long-term sequelae of social determinants and adversities in early and mid-life. There is little evidence available on the impact of these on the mental health of older Aboriginal Australians. This study enrolled 336 Aboriginal Australian participants over 60 years from 5 major urban and regional areas in NSW, utilizing a structured interview on social determinants, and life-time history of physical and mental conditions; current psychosocial determinants and mental health. Univariate and multivariate analyses were utilized to examine the link between these determinants and current depressive scores and suicidality. There was a high rate of life-time depression (33.3%), current late-life depression (18.1%), and suicidal ideation (11.1%). Risk factors strongly associated with late-life depression included sleep disturbances, a history of suicidal behaviour, suicidal ideation in late-life and living in a regional location. This study supports certain historical and psychosocial factors predicting later depression in old age, and highlights areas to target for prevention strategies.

Risk factors for falls among older Aboriginal and Torres Strait Islander people in urban and regional communities.

OBJECTIVE: To examine associations between fall risk factors identified previously in other populations and falls among Aboriginal people aged 60 years and older, living in New South Wales, Australia. METHODS: Interviews were conducted with older Aboriginal people in five urban and regional communities. Associations between past falls and 22 fall predictor variables were examined using linear and multiple regression analyses. RESULTS: Of the 336 participants, 80 people (24%) reported at least one fall in the past year, and 34 (10%) reported two or more falls. Participants had an increased fall risk if they were female; used three or more medications; had arthritis, macular degeneration, depression, history of stroke; were unable to do their own housework; or were unable to do their own shopping. CONCLUSION: Falls were experienced by one-quarter of study participants. Fall risk factors identified for older Aboriginal people appear to be similar to those identified in the general population. Understanding of fall risk factors may assist with the development of appropriate and effective community-led fall prevention programs.