Strength together: examining risk and protective factors associated with dementia and cognitive impairment in Aboriginal and Torres Strait Islander peoples through harmonisation of landmark studies.

BACKGROUND: Rates of dementia for Aboriginal and Torres Strait Islander peoples are three to five times greater compared to non-Indigenous Australians, with earlier age of onset. However, the risk and protective factors that drive these higher rates vary across existing cohort studies, with minimal findings on the role of vascular risk factors beyond stroke. Harmonisation of data across studies may offer greater insights through enhanced diversity and strengthened statistical capabilities. This study aims to combine three landmark cohort studies of Aboriginal and Torres Strait Islander participants to better understand the determinants of cognitive health and dementia. METHODS/DESIGN: Three cohort studies - the Kimberley Healthy Adults Project (KHAP, N = 363), Koori Growing Old Well Study (KGOWS, N = 336) and Torres Strait Dementia Prevalence Study (TSDPS, N = 274) - share a similar research methodology with demographic, medical history, psychosocial factors, cognitive tests and consensus clinical diagnoses of cognitive impairment and dementia. Associations between risk and protective factors of interest and the presence of dementia and/or cognitive impairment diagnoses will be evaluated by univariable and multivariable logistic regression in a harmonised cross-sectional cohort of 898 participants. Factors associated with incident dementia and/or cognitive impairment will be assessed in a subset of KHAP (n = 189) and KGOWS participants (n = 165) who were available in longitudinal follow-up, after exclusion of those with baseline dementia or cognitive impairment. Analyses in relation to outcome measure of death or dementia will be conducted to account for the competing risk of death. Logistic regression will be used to evaluate the association between the individual components of the 16-component Kimberley Indigenous Cognitive Assessment (KICA) tool and the presence of dementia and cognitive impairment determined by independent consensus diagnoses. Multivariable binary logistic regression will be used to adjust for the effect of confounding variables. Results will be reported as odds ratios (OR) with 95% confidence intervals (95% CI). DISCUSSION: Greater understanding of risk and protective factors of dementia and cognitive impairment relevant to Aboriginal and Torres Strait Islander peoples may improve approaches across the life course to delay cognitive decline and reduce dementia risk.

Medications and cognitive risk in Aboriginal primary care: a cross-sectional study.

BACKGROUND: Aboriginal and Torres Strait Islander people are ageing with high rates of comorbidity, yet little is known about suboptimal prescribing in this population. AIM: The prevalence of potentially suboptimal prescribing and associated risk factors were investigated among older patients attending primary care through Aboriginal Community Controlled Health Services (ACCHSs). METHODS: Medical records of 420 systematically selected patients aged ≥50 years attending urban, rural and remote health services were audited. Polypharmacy (≥ 5 prescribed medications), potentially inappropriate medications (PIMs) as per Beers Criteria and anticholinergic burden (ACB) were estimated and associated risk factors were explored with logistic regression. RESULTS: The prevalence of polypharmacy, PIMs and ACB score ≥3 was 43%, 18% and 12% respectively. In multivariable logistic regression analyses, polypharmacy was less likely in rural (odds ratio (OR) = 0.43, 95% confidence interval (CI) = 0.24-0.77) compared to urban patients, and more likely in those with heart disease (OR = 2.62, 95% CI = 1.62-4.25), atrial fibrillation (OR = 4.25, 95% CI = 1.08-16.81), hypertension (OR = 2.14, 95% CI = 1.34-3.44), diabetes (OR = 2.72, 95% CI = 1.69-4.39) or depression (OR = 1.91, 95% CI = 1.19-3.06). PIMs were more frequent in females (OR = 1.88, 95% CI = 1.03-3.42) and less frequent in rural (OR = 0.41, 95% CI = 0.19-0.85) and remote (OR = 0.58, 95% CI = 0.29-1.18) patients. Factors associated with PIMs were kidney disease (OR = 2.60, 95% CI = 1.37-4.92), urinary incontinence (OR = 3.00, 95% CI = 1.02-8.83), depression (OR = 2.67, 95% CI = 1.50-4.77), heavy alcohol use (OR = 2.83, 95% CI = 1.39-5.75) and subjective cognitive concerns (OR = 2.69, 95% CI = 1.31-5.52). High ACB was less common in rural (OR = 0.10, 95% CI = 0.03-0.34) and remote (OR = 0.51, 95% CI = 0.25-1.04) patients and more common in those with kidney disease (OR = 3.07, 95% CI = 1.50-6.30) or depression (OR = 3.32, 95% CI = 1.70-6.47). CONCLUSION: Associations between potentially suboptimal prescribing and depression or cognitive concerns highlight the importance of considering medication review and deprescribing for these patients.

Clinicians' views on cognitive assessment with Aboriginal Australians.

BACKGROUND: A shortage of standardised cognitive assessment tools for use with Aboriginal Australians is evident. Clinicians also miss the range of guidelines necessary to inform test selection and interpretation for all Aboriginal clients. This mixed methods study examines clinicians' confidence, views and current practices when conducting cognitive assessments with Aboriginal Australian clients. METHODS: Clinicians were asked about factors that influence their likelihood of using standardised testing in Aboriginal vs non-Indigenous Australian people. Twenty-one health professionals with experience conducting cognitive assessments with Aboriginal and non-Aboriginal Australians participated. Clinicians were presented with a series of different scenarios per the client's level of education and language of origin via an online survey. Clinicians rated their likelihood and confidence using standardised cognitive assessment for each scenario. Open-ended questions captured clinicians' views and information about their current clinical practices. RESULTS: Clients' age, education and language of origin influence the likelihood of clinicians' use of standardised cognitive assessment measures with Aboriginal people. Overall, clinicians reported feeling only slightly more confident working with non-Indigenous clients than Aboriginal clients. Qualitative data indicate a lack of consistency regarding test selection. CONCLUSION: Clinicians expressed concerns about the validity of available cognitive assessment tools for use with Aboriginal Australians and the absence of evidence to assist decision-making. Cited barriers included language, educational attainment and cultural factors.

Looking out across the front yard: aboriginal peoples' views of frailty in the community - A qualitative study.

OBJECTIVE: Frailty is one of the most significant challenges to healthy ageing. Aboriginal Australians experience some of the highest levels of frailty worldwide, and despite this, no studies have explored frailty from an Aboriginal perspective. This is important because Aboriginal understandings and priorities in frailty may differ from Western/mainstream frailty frameworks. Furthermore, this lack of research severely hampers healthcare planning and service delivery. As a starting point, this study aims to understand the experiences, attitudes, and perceptions that Aboriginal older adults hold regarding frailty. DESIGN: A qualitative study that utilized the Indigenous research method of Yarning for data collection as a culturally appropriate process for engaging Aboriginal peoples. Yarning circles and one-on-one yarns with 22 Aboriginal adults aged 45+ years living in one Australian capital city took place online and over the phone to explore the views that Aboriginal adults hold around frailty. Data were analysed thematically by Aboriginal researchers. RESULTS: Seven key thematic areas were identified: (1) Keep in with culture; (2) Physical markers of frailty; (3) Frailty throughout the life course; (4) Social, cultural, and psychological understandings of frailty; (5) We want information about frailty; (6) Appropriate and positive wording; (7) Frailty assessment. CONCLUSIONS: There was interest and engagement in the concept of frailty by Aboriginal older adults and approaches to frailty that extend beyond the physical to address cognitive, psychosocial, cultural and spiritual domains are likely to be more acceptable to this population. Culture and community connectivity are essential elements in preventing and alleviating frailty and have wider positive implications for Aboriginal health and wellbeing. Existing tools in practice to assess frailty are not aligned with Aboriginal cultural norms. Culturally appropriate frailty assessment methods co-designed with the community which incorporate holistic and multidimensional approaches are urgently needed.

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.

A Self-Guided Online Cognitive Behavioural Therapy to Reduce Fear of Falling in Older People: a Randomised Controlled Trial.

BACKGROUND: Traditional face-to-face cognitive behavioural therapy (CBT) has been successful at reducing fear of falling (FOF) in older people but can be labour-intensive and costly. Online CBT has been suggested as a cost-effective alternative but has not yet been tested in the context of FOF. This study evaluates the effectiveness of a readily available, self-guided and generalised online CBT program (myCompass) on reducing FOF in older people. METHODS: Fifty community-dwelling older people with FOF received a paper-based health education program, and half were randomly assigned to receive three selected modules from myCompass for 6 weeks. The primary outcome was feared consequences of falling at 6 weeks. Secondary outcomes were concern about falling, balance confidence, activity avoidance, physical activity, exercise self-efficacy, health literacy and mental health at 6/26/52 weeks and falls incidence at 12 months. RESULTS: All intervention participants completed at least 2-out-of-3 myCompass modules. There was a significant main effect of time on feared consequences of falling (Cohen's f = 0.55). The group by time interactions for concern about falling (f = 0.28), stress (f = 0.26) and social support for health (health literacy) (f = 0.26) was also significant, favouring the control group. The overall attrition rate at 12 months was 24% (n = 12). CONCLUSION: The high program compliance and low attrition rate suggest that online CBT is feasible among older people. However, the myCompass program had no effect at reducing FOF in older people. A more targeted CBT program with a well-integrated psychoeducation module on FOF might be the solution to boost the therapeutic effects of a generalised CBT program at reducing FOF for older people.

Theoretical framework of concerns about falling in older people: the role of health literacy.

Adherence and participation can be improved in health programs for older people with concerns about falling. While health literacy empowers older people to have greater control over their health, little is known about the extent to which health literacy influences health behaviours associated with concerns about falling in older people. This study aimed to synthesise current findings on health literacy, concerns about falling and falls to propose a multicomponent theoretical model on health literacy and concerns about falling. The model was developed based on a review of the literature, existing frameworks and models on health literacy and concerns about falling. Existing evidence on the relationship between health literacy and concerns about falling in older people is limited. Evidence from other research areas, however, shows that health literacy is closely related to many of the determinants of concerns about falling. More research is needed to clarify the impact of health literacy on intervention adherence and decision-making processes of older people with concerns about falling. Our model offers a novel perspective on the role of health literacy in health behaviours associated with concerns about falling, suggesting new research directions and providing insights for clinicians to consider health literacy when managing older patients with concerns about falling.

Global rural health disparities in Alzheimer's disease and related dementias: State of the science.

INTRODUCTION: Individuals living in rural communities are at heightened risk for Alzheimer's disease and related dementias (ADRD), which parallels other persistent place-based health disparities. Identifying multiple potentially modifiable risk factors specific to rural areas that contribute to ADRD is an essential first step in understanding the complex interplay between various barriers and facilitators. METHODS: An interdisciplinary, international group of ADRD researchers convened to address the overarching question of: "What can be done to begin minimizing the rural health disparities that contribute uniquely to ADRD?" In this state of the science appraisal, we explore what is known about the biological, behavioral, sociocultural, and environmental influences on ADRD disparities in rural settings. RESULTS: A range of individual, interpersonal, and community factors were identified, including strengths of rural residents in facilitating healthy aging lifestyle interventions. DISCUSSION: A location dynamics model and ADRD-focused future directions are offered for guiding rural practitioners, researchers, and policymakers in mitigating rural disparities. HIGHLIGHTS: Rural residents face heightened Alzheimer's disease and related dementia (ADRD) risks and burdens due to health disparities. Defining the unique rural barriers and facilitators to cognitive health yields insight. The strengths and resilience of rural residents can mitigate ADRD-related challenges. A novel "location dynamics" model guides assessment of rural-specific ADRD issues.

Community co-selection of measures to evaluate the health and wellbeing impact of Aboriginal and Torres Strait Islander community running groups.

ISSUE ADDRESSED: Physical activity participation can improve the physical health and social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. The evaluation of physical activity programmes can elicit a clearer understanding of where these impacts occur and to what extent. We describe applying a collaborative approach to the selection of a set of measures that can be used to examine health and wellbeing impacts of Indigenous community running groups. METHODS: Physical activity, health and wellbeing measurement tools previously used with Aboriginal and Torres Strait Islander peoples were collated. Participants in the collaborative process were nine female running group members aged 30+ years from a regional New South Wales (NSW) town. The Indigenous research method, Yarning, explored views of participating in the group on health and wellbeing and how these could be measured using those collated measurement tools. RESULTS: Runners described participating for holistic physical, mental and social reasons and stated the importance of the group participating together and providing social support to each other. There was broad support for the identified physical activity, lifestyle, physical health, and social and emotional wellbeing measures, with social networks and sports injuries identified as additionally relevant. CONCLUSIONS: Co-selecting measures to evaluate a physical activity programme for Aboriginal and Torres Strait Islander participants can better inform the development of relevant future healthy lifestyle programme evaluation, revealing factors that may be missed as relevant by researchers. SO WHAT?: This process presents an example of determining evaluation measures with Aboriginal and Torres Strait Islander participants that could be applied more broadly to evaluation design.

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.

The Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people-a longitudinal validation study.

BACKGROUND: This study aimed to develop cut-points for the 30-item and 10-item Iconographical Falls Efficacy Scale (IconFES) in community-dwelling older people and evaluate the psychometric properties, including construct and predictive validity with respect to falls and reduced physical activity over 1 year. METHODS: Eight hundred and one participants completed the IconFES and underwent physical, psychological and cognitive measures at baseline. Physical activity was recorded at baseline and 12 months using an activity monitor, and 1-year fall incidence was collected using monthly falls calendars. RESULTS: Using receiver-operating characteristic curves and the Youden's index for history of falls, physiological fall risk and depressive symptoms, cut-points were defined to differentiate between low and high concern about falling (30-item: <53; 10-item: <19). For the 30-item IconFES, we additionally defined cut-points for low (≤40), moderate (41-58) and high (≥59) concern about falling. Groups based on these cut-points differed significantly: low coordinated stability, executive function and amount of daily walking, and high level of disability (30-item version) and female gender (low/high 30-item version). Although there were some inconsistencies across IconFES classifications, high concern about falling predicted having had multiple falls or multiple/injurious falls, low amount of daily walking and low movement intensity at 12 months. CONCLUSIONS: The developed IconFES cut-points were sensitive to variables associated with concern about falling and predicted fall incidence and physical activity restriction after 12 months. Applying these cut-points appears useful to identify older people with high concern about falling, who are at higher risk of falls and activity curtailment.

Association between health literacy and physical activity in older people: a systematic review and meta-analysis.

Physical inactivity is common in older people and contributes to morbidity and mortality. Health literacy might play a role in motivating people to become or stay physically active. However, little is known about the influence of health literacy on physical activity in older people. This review aims to determine the association between health literacy and physical activity in older people. A systematic search was conducted in CINAHL, MEDLINE, PsychINFO and CENTRAL. Inclusion criteria: (i) community-dwelling people with an average age of ≥55 and (ii) reported on the association between health literacy and physical activity. Exclusion criteria: (i) population with a health condition and (ii) case study or qualitative study. Data were extracted independently by two reviewers. Risk of bias was assessed using the Downs and Black checklist. A meta-analysis was conducted using random-effects models with inverse variance. Thirteen articles were included in the review and five articles were selected for the meta-analysis. Older people with inadequate health literacy were 38% less likely than older people with adequate health literacy to report engaging in physical activity on ≥5 days per week [odds ratio = 0.62, 95% confidence interval (CI) 0.55-0.77]. Only two articles used activity monitors; the mean number of steps taken per day was not significantly different between older people with adequate and inadequate health literacy (standardized mean difference = -0.15, 95% CI -0.30 to 0.01). Physical activity could potentially be fostered by increasing health literacy and empowering older people to make beneficial health decisions.

Clustering and Additive Effects of Nongenetic Risk Factors in Non-Autosomal-Dominant Degenerative and Vascular Young Onset Dementia.

INTRODUCTION: Both genetic and nongenetic factors contribute to the risk profile of young onset dementia (YOD), but risk factors often co-occur. This matched case-control study examined whether nongenetic risk factors cluster together, to inform targeted prevention efforts. METHODS: Ninety-six participants with non-autosomal-dominant degenerative and/or vascular YOD and 175 controls were recruited to 2 Australian epidemiological studies. Risk exposure was retrospectively self-reported and/or informant-reported. RESULTS: Each additional exposure increased the risk for YOD, though only where vascular dementia was included in the analysis. Cluster analysis identified 4 risk groups, one of which reported a high probability of exposure to all risks and a significantly higher risk for YOD. DISCUSSION: Results suggest that combinations of nongenetic risk factors confer more risk for young onset vascular dementia, and possibly primary degenerative YOD, than a single factor on its own. Compared with their same-age peers, some people with YOD experience a lifetime of risk exposure starting from early in life.

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.

Let's CHAT (community health approaches to) dementia in Aboriginal and Torres Strait Islander communities: protocol for a stepped wedge cluster randomised controlled trial.

BACKGROUND: Documented rates of dementia and cognitive impairment not dementia (CIND) in older Aboriginal and Torres Strait Islander Peoples is 3-5 times higher than the rest of the population, and current evidence suggests this condition is under-diagnosed and under-managed in a clinical primary care setting. This study aims to implement and evaluate a culturally responsive best practice model of care to optimise the detection and management of people with cognitive impairment and/or dementia, and to improve the quality of life of carers and older Aboriginal and Torres Islander Peoples with cognitive impairment. METHODS/DESIGN: The prospective study will use a stepped-wedge cluster randomised controlled trial design working with 12 Aboriginal Community Controlled Health Services (ACCHSs) across four states of Australia. Utilising a co-design approach, health system adaptations will be implemented including (i) development of a best practice guide for cognitive impairment and dementia in Aboriginal and Torres Strait Islander communities (ii) education programs for health professionals supported by local champions and (iii) development of decision support systems for local medical software. In addition, the study will utilise a knowledge translation framework, the Integrated Promoting Action on Research Implementation in Health Services (iPARIHS) Framework, to promote long-term sustainable practice change. Process evaluation will also be undertaken to measure the quality, fidelity and contextual influences on the outcomes of the implementation. The primary outcome measures will be rates of documentation of dementia and CIND, and evidence of improved management of dementia and CIND among older Indigenous peoples attending Aboriginal and Torres Strait Islander primary care services through health system changes. The secondary outcomes will be improvements to the quality of life of older Indigenous peoples with dementia and CIND, as well as that of their carers and families. DISCUSSION: The Let's CHAT Dementia project will co-design, implement and evaluate a culturally responsive best practice model of care embedded within current Indigenous primary health care. The best practice model of care has the potential to optimise the timely detection (especially in the early stages) and improve the ongoing management of people with dementia or cognitive impairment. TRIAL REGISTRATION: ACTRN12618001485224. Date of registration: 04 of September 2019.

Development and initial validation of the Retrospective Indigenous Childhood Enrichment scale (RICE).

ABSTRACTBackground:Years of education is the most commonly used proxy measure of cognitive reserve. Other forms of cognitive stimulation in childhood may provide similar protection against cognitive decline, particularly in Indigenous groups, where education may have been lacking in quality or quantity. The Retrospective Indigenous Childhood Enrichment (RICE) scale was developed to measure non-school-based activities and environmental stimulation during childhood that are likely to have enhanced cognitive reserve. The aim of the study was to assess the validity and reliability of the RICE scale with a group of older Aboriginal Australians. METHODS: 294 Aboriginal Australian people (60-92 years), living in urban or regional areas of NSW, completed the RICE scale as part of a longer face-to-face interview. Additional data was collected on their formal education, childhood environment, and childhood trauma (Study 1). Test-retest, inter-method and inter-rater reliability were assessed in a convenience sample of a further 38 participants by re-administration of the RICE scale at two time points, approximately 14 days apart (M = 14.11, SD = 6.78) (Study 2). RESULTS: Factor analyses reduced the scale from 21 items to 18 and identified three factors: (1) Traditional, (2) Intellectual, and (3) Community. Higher scores on the RICE scale were related to higher years of formal education and lower scores on a childhood trauma questionnaire. The RICE scale had good internal consistency (Cronbach's α 0.79), and excellent test-retest reliability (ICC = 0.95, 95% CI 0.90-0.97) and inter-rater reliability (0.99, CI 95% 0.997-0.999). CONCLUSIONS: The RICE is, to our knowledge, the first standardized measure that assesses the level of childhood environmental stimulation in older Aboriginal Australians. This could provide an important supplementary measure, in addition to formal education, to investigate cognitive reserve and dementia risk in this population and enhance understanding of the links between childhood experiences and late-life cognitive decline.

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.