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.

Longitudinal alcohol-related brain changes in older adults: The Sydney Memory and Ageing Study.

Increases in harmful drinking among older adults indicate the need for a more thorough understanding of the relationship between later-life alcohol use and brain health. The current study investigated the relationships between alcohol use and progressive grey and white matter changes in older adults using longitudinal data. A total of 530 participants (aged 70 to 90 years; 46.0% male) were included. Brain outcomes assessed over 6 years included total grey and white matter volume, as well as volume of the hippocampus, thalamus, amygdala, corpus callosum, orbitofrontal cortex and insula. White matter integrity was also investigated. Average alcohol use across the study period was the main exposure of interest. Past-year binge drinking and reduction in drinking from pre-baseline were additional exposures of interest. Within the context of low-level average drinking (averaging 11.7 g per day), higher average amount of alcohol consumed was associated with less atrophy in the left (B = 7.50, pFDR = 0.010) and right (B = 5.98, pFDR = 0.004) thalamus. Past-year binge-drinking was associated with poorer white matter integrity (B = -0.013, pFDR = 0.024). Consuming alcohol more heavily in the past was associated with greater atrophy in anterior (B = -12.73, pFDR = 0.048) and posterior (B = -17.88, pFDR = 0.004) callosal volumes over time. Across alcohol exposures and neuroimaging markers, no other relationships were statistically significant. Within the context of low-level drinking, very few relationships between alcohol use and brain macrostructure were identified. Meanwhile, heavier drinking was negatively associated with white matter integrity.

Protocol of a 12-week eHealth programme designed to reduce concerns about falling in community-living older people: Own Your Balance randomised controlled trial.

INTRODUCTION: Concerns about falling (CaF) are common in older people and have been associated with avoidance of activities of daily life. Exercise designed to prevent falls can reduce CaF, but the effects are usually short-lived. Cognitive behavioural therapy (CBT) can reduce CaF for longer but is not readily available in the community and unlikely to prevent falls. A multidomain intervention that combines CBT, motivational interviewing and exercise could be the long-term solution to treat CaF and reduce falls in older people with CaF. This paper describes the design of a randomised controlled trial to test the effectiveness of two different 12 week self-managed eHealth programmes to reduce CaF compared with an active control. METHODS: A total of 246 participants (82 per group) aged 65 and over, with substantial concerns about falls or balance will be recruited from the community. They will be randomised into: (1) myCompass-Own Your Balance (OYB) (online CBT programme) intervention or (2) myCompass-OYB plus StandingTall intervention (an eHealth balance exercise programme), both including motivational interviewing and online health education or (3) an active control group (online health education alone). The primary outcome is change in CaF over 12 months from baseline of both intervention groups compared with control. The secondary outcomes at 2, 6 and 12 months include balance confidence, physical activity, habitual daily activity, enjoyment of physical activity, social activity, exercise self-efficacy, rate of falls, falls health literacy, mood, psychological well-being, quality of life, exercise self-efficacy, programme adherence, healthcare use, user experience and attitudes towards the programme. An intention-to-treat analysis will be applied. The healthcare funder's perspective will be adopted for the economic evaluation if appropriate. ETHICS AND DISSEMINATION: Ethical approval was obtained from the South Eastern Sydney Local Health District Human Research Ethics Committee (2019/ETH12840). Results will be disseminated via peer-reviewed journals, local and international conferences, community events and media releases. TRIAL REGISTRATION NUMBER: ACTRN12621000440820.

Age-Related Risk of Serious Fall Events and Opioid Analgesic Use.

Importance: Opioid analgesics may be associated with increased risk of falls, particularly among older adults. Objective: To quantify the age-related risk of serious fall events among adults prescribed opioids by opioid exposure, time from initiation, and daily dose. Design, Setting, and Participants: This population-based cohort study conducted in New South Wales, Australia, used data linking national pharmaceutical claims to national and state datasets, including information on sociodemographic characteristics, clinical characteristics, medicines use, health services utilization, and mortality (POPPY II study). It included adults (18 years or older) who initiated prescription opioid treatment, which was defined as no prior dispensing during the preceding 365 days, between January 1, 2005, and December 31, 2018. Data were analyzed from February to June 2023. Exposure: Time-dependent periods of opioid exposure were evaluated from dispensing records. Main Outcome and Measures: Serious fall events identified from emergency department, hospitalization, and mortality records. Negative binomial models were used to assess associations between time-dependent opioid exposure (overall, by time from initiation, and by dose), age, and risk of fall events. Models were adjusted for known fall risk factors, including other fall risk-increasing drugs, frailty risk, and prior serious fall events. Results: The cohort comprised 3 212 369 individuals who initiated prescription opioid treatment (1 702 332 women [53%]; median [IQR] age at initiation, 49 [32-65] years). Overall, 506 573 serious fall events were identified, including 5210 fatal falls. During exposure to opioids, the risk of serious fall events was elevated among all age groups; compared with the group aged 18 to 44 years, this risk was highest among those 85 years or older (adjusted incident rate ratio, 6.35; 95% CI, 6.20-6.51). Across all age groups, the first 28 days following opioid initiation was a time of increased serious fall risk; this risk increased with age. Among individuals aged 18 to 84 years, associations were identified between higher daily opioid doses and serious fall events. Conclusions and Relevance: The results of this cohort study suggest that prescription opioids were associated with increased risk of serious fall events among adults of all ages, with individuals 85 years or older at greatest risk. These risks should be considered when prescribing opioids, particularly for individuals with preexisting risk factors or when opioids are prescribed at higher doses. Targeted falls prevention efforts may be most effective within the first month following opioid initiation.

Subcutaneous ketamine infusion in palliative patients for major depressive disorder (SKIPMDD)-Phase II single-arm open-label feasibility study.

BACKGROUND: Ketamine at subanaesthetic dosages (≤0.5mg/kg) exhibits rapid onset (over hours to days) antidepressant effects against major depressive disorder in people who are otherwise well. However, its safety, tolerability and efficacy are not known for major depressive disorder in people with advanced life-limiting illnesses. OBJECTIVE: To determine the feasibility, safety, tolerability, acceptability and any antidepressant signal/activity to justify and inform a fully powered study of subcutaneous ketamine infusions for major depressive disorder in the palliative setting. METHODS: This was a single arm, open-label, phase II feasibility study (Australian New Zealand Clinical Trial Registry Number-ACTRN12618001586202). We recruited adults (≥ 18-years-old) with advanced life-limiting illnesses referred to four palliative care services in Sydney, Australia, diagnosed with major depressive disorder from any care setting. Participants received weekly subcutaneous ketamine infusion (0.1-0.4mg/kg) over two hours using individual dose-titration design. Outcomes assessed were feasibility, safety, tolerability and antidepressant activity. RESULTS: Out of ninety-nine referrals, ten participants received ketamine and were analysed for responses. Accrual rate was 0.54 participants/month across sites with 50% of treated participants achieving ≥ 50% reduction in baseline Montgomery-Åsberg Depression Rating Scale, meeting feasibility criteria set a priori. There were no clinically relevant harms encountered. CONCLUSIONS: A future definitive trial exploring the effectiveness of subcutaneous infusion of ketamine for major depressive disorder in the palliative care setting may be feasible by addressing identified study barriers. Individual dose-titration of subcutaneous ketamine infusions over two hours from 0.1mg/kg can be well-tolerated and appears to produce transient antidepressant signals over hours to days.

Exploring community mental health service use following hospital-treated intentional self-harm among older Australians: a survival analysis.

OBJECTIVES: This study aimed to examine the impact of community mental health (CMH) care following index hospital-treated intentional self-harm (ISH) on all-cause mortality. A secondary aim was to describe patterns of CMH care surrounding index hospital-treated ISH. DESIGN: A longitudinal whole-of-population record linkage study was conducted (2014-2019), with index ISH hospitalization (Emergency Department and/or hospital admissions) linked to all available hospital, deaths/cause of death, and CMH data. SETTING: Australia's most populous state, New South Wales (NSW) comprised approximately 7.7 million people during the study period. CMH services are provided statewide, to assess and treat non-admitted patients, including post-discharge review. PARTICIPANTS: Individuals with an index hospital presentation in NSW of ISH during the study period, aged 45 years or older. INTERVENTION: CMH care within 14 days from index, versus not. MEASUREMENTS: Cox-proportionate hazards regression analysis evaluated all-cause mortality risk, adjusted for relevant covariates. RESULTS: Totally, 24,544 persons aged 45 years or older experienced a nonfatal hospital-treated ISH diagnosis between 2014 and 2019. CMH care was received by 56% within 14 days from index. Survival analysis demonstrated this was associated with 34% lower risk of death, adjusted for age, sex, marital status, index diagnosis, and 14-day hospital readmission (HR 0.66, 95% CI 0.58, 0.74, p < 0.001). Older males and chronic injury conveyed significantly greater risk of death overall. CONCLUSIONS: CMH care within 14 days of index presentation for self-harm may reduce the risk of all-cause mortality. Greater effort is needed to engage older males presenting for self-harm in ongoing community mental health care.

Idiopathic pneumoperitoneum in a single case: an unusual entity.

Idiopathic pneumoperitoneum (IP) cases are rare and presents with varying symptoms, which makes propositions of standard treatments, clinically impracticable. There are limited IP therapies in the literature, necessitating a need, to continually highlight unique cases for the purpose of clinical education and training. This case describes an IP and management of a 34-year-old male who recently underwent a laparoscopic cholecystectomy. Patient presented to the emergency room with recurrent gastrointestinal (GI) symptoms. Despite two negative exploratory laparotomies without confirmatory evidence of GI perforations, the GI symptoms persisted, making it an unusual case. The surgeons elected to a multispecialty approach, detailing patient-specific symptoms, and corresponding treatments of the case. Based on the successful outcome of this patient, detailed knowledge of medical history, repeated physical assessments and patient-specific and comprehensive approach was shown to reduce unnecessary exploratory laparotomy, improved clinical outcomes and decrease in complications.

Risk factors for dementia and self-harm: A linkage study.

INTRODUCTION: People living with dementia experience poor mental health and high rates of self-harm. We investigated risk factors for self-harm in people aged > 40 years living with dementia and risk factors for dementia after self-harm. METHODS: Using linked hospital data from New South Wales, Australia, we defined a dementia cohort (n = 154,811) and a self-harm cohort (n = 28,972). Using survival analyses, we investigated predictors of self-harm for the dementia cohort, and predictors of dementia for the self-harm cohort. RESULTS: We found self-harm or dementia diagnoses occurred most often within 24 months of a dementia diagnosis or initial self-harm presentation, respectively. Men living with dementia, and people with complex psychiatric profiles, had the greatest risk of self-harm. Men who had self-harmed had the greatest risk of dementia diagnoses. DISCUSSION: Men and people with complex psychiatric profiles and dementia may particularly benefit from post-diagnosis mental and behavioral support to reduce risk of self-harm.

Management of Enteroatmospheric Fistula (EAF) Using a Fistula-Vacuum Assisted Closure (VAC) in a Complicated Abdominal Trauma Case.

Enteroatmospheric fistula (EAF) is a relatively rare complication of patients undergoing open abdomen (OA) for damage control surgery. Mortality rates are high due to the increased risk of peritonitis, intraabdominal abscess, sepsis, and new perforations. There are a wide range of EAF management therapies in the literature, however, there are limited options on cases involving fistula-vaccum assisted closure (VAC) therapy. This case describes the treatment course of a 57-year-old, male admitted for blunt abdominal trauma secondary to a motor vehicle accident. Upon admission the patient underwent damage control surgery. The surgeons elected to have the patient's abdomen open, applying a mesh to promote healing. After several weeks of hospitalization an EAF was discovered in the abdominal wound subsequently managed by utilizing a fistula-VAC technique. Based on the successful outcome of this patient, fistula-VAC was shown as an effective way to promote wound healing while reducing the chances of complications.

Attempted suicide in older people in New South Wales, Australia, 1870-1908.

This study examines attempted suicide in older people between 1870 and 1908 in (NSW), Australia. Statistical Registers of NSW indicate persons aged 60+ had disproportionately high rates of apprehension (10.9%) and conviction (13.0%) for attempted suicide. Newspaper reports of 110 suicide attempts in older people indicate that alcohol misuse, poor health, depression, being tired of living, financial problems, relationship difficulties, loss events and insanity were the main issues. Most were treated compassionately with medical care and support, albeit sometimes in a gaol setting. Medical casebooks of persons aged 60+ years with suicide attempts (n = 49) or suicidal ideation (n = 43) admitted to hospitals for the insane indicated that over 75% were psychotic and 50% had melancholia.

Help-Seeking and Barriers to Service Use amongst Men with Past-Year Suicidal Ideation and not in Contact with Mental Health Services.

OBJECTIVE: Men are less likely than women to engage with formal mental health services for suicidality. We describe the sources of support, barriers to service use, and coping strategies of men with past-year suicidal ideation who are not receiving formal mental health services. METHOD: Australian men experiencing past-year suicidal ideation who also did not receive formal mental health services within the past year (n = 176) completed a survey that assessed help-seeking behaviors, coping strategies and styles, use of general services, barriers to service use, and individual-level characteristics. Analyses included descriptive statistics and bivariate analyses. RESULTS: The most common type of support was self-help resources, and self-reliance was the most common barrier to formal mental health service use. Most participants had seen a GP for non-mental-health-related reasons in the past year. Men who did not seek any help for their suicidality experienced lower instrumental barriers and perceived need for support, and lower levels of certain coping styles. Limitations included a cross-sectional design and small sample size. CONCLUSION: The current study provides insight into the help-seeking experiences of men with past-year suicidality and not receiving formal mental health services. The findings suggest it may be helpful to improve the linkage between online and informal sources of support and evidence-based interventions.HIGHLIGHTSOnline self-help, friends, and partners were the most commonly used sources of help.A subset of men (42%) with lower perceived need for help did not seek any support.Despite no past-year formal mental health service use, 80% of the men had seen a GP.

Biodegradable temporising matrix: use of negative pressure wound therapy shows a significantly higher success rate.

OBJECTIVE: The purpose of this case series was to evaluate the efficacy of a synthetic biodegradable temporising matrix (BTM; PolyNovo Biomaterials Pty Ltd, Australia) and compare the outcome of BTM patients with and without negative pressure wound therapy (NPWT). METHOD: A retrospective chart review was conducted on patients admitted with deep full-thickness burns, traumatic or complex wound injuries treated with BTM. Electronic medical records and images were evaluated by a team of clinical professionals. Endpoints included: the measure of successful BTM integration; and comparison between patients treated with and without NPWT. Additional measures were BTM total surface area, BTM sites, timeliness of BTM application and any complications. RESULTS: A total of 28 patients were evaluated and 23 (82.1%) demonstrated overall successful BTM integration. Patients treated with BTM in conjunction with NPWT (n=16) demonstrated a significantly higher (p=0.046) integration rate compared to patients treated without NPWT (n=12) (93.8% versus 58.3%, respectively). Patients treated with BTM with NPWT continued to successfully integrate and sustain favourable outcomes despite the presence of severe infection or the development of haematomas. CONCLUSION: A significantly higher integration rate was demonstrated when BTM was used in conjunction with NPWT. The results of this study further support the efficacy of successful integration of BTM as a replacement for tissue loss in the treatment of deep, full-thickness burns, traumatic and complex wound injuries, and particularly favourable outcomes with the use of NPWT. To the best of our knowledge, this is the first reported case series comparing the clinical outcomes of BTM with and without the use of NPWT.

Death by suicide among aged care recipients in Australia 2008-2017.

OBJECTIVE: To characterize the features of aged care users who died by suicide and examine the use of mental health services and psychopharmacotherapy in the year before death. DESIGN: Population-based, retrospective exploratory study. SETTING AND PARTICIPANTS: Individuals who died while accessing or waiting for permanent residential aged care (PRAC) or home care packages in Australia between 2008 and 2017. MEASUREMENTS: Linked datasets describing aged care use, date and cause of death, health care use, medication use, and state-based hospital data collections. RESULTS: Of 532,507 people who died, 354 (0.07%) died by suicide, including 81 receiving a home care package (0.17% of all home care package deaths), 129 in PRAC (0.03% of all deaths in PRAC), and 144 approved for but awaiting care (0.23% of all deaths while awaiting care). Factors associated with death by suicide compared to death by another cause were male sex, having a mental health condition, not having dementia, less frailty, and a hospitalization for self-injury in the year before death. Among those who were awaiting care, being born outside Australia, living alone, and not having a carer were associated with death by suicide. Those who died by suicide more often accessed Government-subsidized mental health services in the year before their death than those who died by another cause. CONCLUSIONS: Older men, those with diagnosed mental health conditions, those living alone and without an informal carer, and those hospitalized for self-injury are key targets for suicide prevention efforts.

Telephone cognitive screening with older Aboriginal Australians: A preliminary study.

OBJECTIVES: Cognitive screening via telehealth is increasingly employed, particularly during the COVID-19 pandemic. Telephone adaptations of existing cognitive screening tests must be validated across diverse populations. The present study sought to evaluate an existing 26-point telephone adaptation of the Mini-Mental State Examination (tMMSE) in a sample of older Aboriginal Australians. Additionally, we aimed to evaluate a telephone adaptation of the urban version of the Kimberley Indigenous Cognitive Assessment short-form (tKICA screen). METHODS: A sub-sample (n = 20) of participants (aged 55-69 years; 11 women) who had completed an in-person cognitive assessment (MMSE and KICA screen) within the past 6 months as part of the Koori Growing Old Well Study completed telephone-based cognitive testing without an assistant. RESULTS: There was moderate correlation and reasonable agreement between MMSE versions (rs  = 0.33; p = 0.2), although the limits of agreement were unacceptably wide (-4.1 and 4.8 points difference). Poorer performance was seen on the tMMSE for Season (p = 0.02) and Phrase (p = 0.02) items, and better performance for three-word Recall (p = 0.03). KICA-screen versions were poorly correlated (rs  = 0.20; p = 0.4) with telephone scoring a mean of 2.17 points below the face-to-face score, greater bias observed at the lower end of the performance and worse scores for Season (p = 0.02) and Recall (p = 0.001) items. Age and education were not associated with telephone screening performance. Hearing impairment was associated with poorer performance on the tKICA screen (p = 0.04) but not the tMMSE (p = 0.6). CONCLUSIONS: Results indicate that telephone administration of the MMSE and/or KICA screen is not equivalent to in-person testing for older Aboriginal people, and further revision and evaluation are required.

Psychiatric service delivery for older people in hospital and residential aged care: An updated systematic review.

OBJECTIVE: To review studies reporting on the effectiveness of psychiatry service delivery for older people and people with dementia in hospital and residential aged care. METHODS: A systematic search of four databases was conducted to obtain peer-reviewed literature reporting original research published since June 2004 evaluating a psychiatry service for older people (aged 60 years and over) or people with dementia in inpatient or residential aged care settings. RESULTS: From the 38 included studies, there was consistent low-to-moderate quality evidence supporting the effectiveness of inpatient older persons' mental health wards (n = 14) on neuropsychiatric symptoms, mood, anxiety and quality of life. Inpatient consultation/liaison old age psychiatry services (n = 9) were not associated with improved depression, quality of life or mortality in high-quality randomised studies. However, low-quality evidence demonstrated improved patient satisfaction with care and reduced carer stress. The highest quality studies demonstrated no effect of psychiatric in-reach services to residential aged care (n = 9) on neuropsychiatric symptoms but a significant reduction in depressive symptoms among people with dementia. There was low-quality evidence that long-stay intermediate care wards (n = 6) were associated with reduced risk for dangerous behavioural incidents and reduced costs compared to residential aged care facilities. There was no effect of these units on neuropsychiatric symptoms or carer stress. CONCLUSIONS AND IMPLICATIONS: The scarcity of high-quality studies examining the effectiveness of old age psychiatry services leaves providers and policy-makers to rely on low-quality evidence when designing services. Future research should consider carefully which outcomes to include, given that staff skill and confidence, length of stay, recommendation uptake, patient- and family-reported experiences, and negative outcomes (i.e. injuries, property damage) are as important as clinical outcomes.

Ethnic disparities in the uptake of anti-dementia medication in young and late-onset dementia.

OBJECTIVES: People with dementia can face barriers when trying to access care after a diagnosis, particularly in young-onset dementia (YOD). Little is known about the effects of ethnicity on the use of anti-dementia medication and variations between age groups. The aim of this study was to analyze national data on variations in the uptake of anti-dementia medication between people with YOD and late-onset dementia (LOD). DESIGN: Cross-sectional longitudinal cohort study. SETTING: Data from the U.S. National Alzheimer's Coordinating Centre were obtained from September 2005 to March 2019. PARTICIPANTS: First visits of people with a diagnosis of Alzheimer's disease (AD) dementia, Lewy body dementia (LBD), and Parkinson's disease dementia (PDD) were included. MEASUREMENTS: Logistic regression was used to analyze the effects of education and ethnicity on use of cholinesterase inhibitors and memantine, accounting for YOD/LOD, gender, living situation, severity stage, and comorbidities. RESULTS: In total, 15,742 people with AD dementia and LBD/PDD were included, with 11,019 PwD having completed a first follow-up visit. Significantly more people with YOD used memantine than those with LOD, while fewer used cholinesterase inhibitors. PwD from minority ethnic backgrounds used memantine and cholinesterase inhibitors less often than those from a White ethnic background. Logistic regression analysis showed that ethnicity was a significant determinant of both memantine and cholinesterase inhibitors usage, while education was only a significant determinant for memantine usage. CONCLUSIONS: Findings highlight the impact of social factors on current usage of anti-dementia medication and the need for more resources to enable equitable use of anti-dementia medication.

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.

Factors associated with discharge from hospital to residential aged care for younger people with neuropsychiatric disorders: an exploratory case-control study in New South Wales, Australia.

OBJECTIVES: To examine the sociodemographic and diagnostic factors associated with a discharge from hospital to residential aged care (RAC) for younger people (aged 15-64 years) with neuropsychiatric disorders. DESIGN: An exploratory case-control study using a historic cohort of people with neuropsychiatric disorders. Cases were people transferred to RAC on hospital discharge during the study period. Controls were people not transferred to RAC on discharge during the study period. SETTING: Public and private hospital admissions in New South Wales (NSW), Australia. PARTICIPANTS: People aged 15-64 years with a neuropsychiatric disorder hospitalised in NSW between July 2002 and June 2015 (n=5 16 469). OUTCOME MEASURES: The main outcome was transferred to RAC on discharge from hospital. We calculated ORs for sociodemographic and diagnostic factors to determine factors that may impact discharge to RAC. RESULTS: During the period of data capture, 4406 people were discharged from hospitals to RAC. Discharge to RAC was most strongly associated with diagnoses of progressive neurological and cognitive disorders. Acute precipitants of RAC transfer included a broad range of conditions and injuries (eg, Wernicke's encephalopathy, stroke, falls) in the context of issues such as older age, not being partnered (married or de facto), living in areas of lower socioeconomic status, functional issues and the need for palliative care. CONCLUSIONS: There are multiple intersecting and interacting pathways culminating in discharge from hospital to RAC among younger people with neuropsychiatric disorders. Improved capacity for interdisciplinary home care and alternative housing and support options for people with high support needs are required.

Melancholia in late life in New South Wales and Victoria, Australia, 1871-1905: symptoms, behaviours and outcomes.

In the late nineteenth century, the prognosis of late-life melancholia was believed to be poor. The medical casebooks of 40 patients aged 60+years, admitted to two Hospitals for the Insane in New South Wales with melancholia between 1871 and 1905, were examined. Psychosis (87.5%), depressed mood (80%), suicidal behaviour (55%), physical ill health (55%), restlessness (50%) and fears of harm to self (50%) were identified. Main outcomes were discharge (40%) and death (37.5%). Victoria's Kew Hospital patient register for 1872-88 revealed 669 melancholia admissions with 30 aged 60+. Outcomes worsened significantly with age (chi square = 16.19, df = 4, p < 0.005), mainly due to higher mortality. Nineteenth-century late-life melancholia was a severe disorder despite many cases recovering.

A Focus Group Study of Palliative Physician and Consultation-Liaison Psychiatrist Perceptions of Dealing with Depression in the Dying.

Objective: To ascertain palliative physicians' and consultation-liaison psychiatrists' perceptions of depression care processes in patients with very poor prognoses, exploring key challenges and postulating solutions. Methods: A qualitative focus group study involving three 1-h online focus groups (2 palliative medicine and 1 psychiatry) were conducted between November-December 2020. Fellows and trainees were recruited from Australian and New Zealand Society of Palliative Medicine (n = 11) and Royal Australian and New Zealand College of Psychiatrists (n = 4). Data underwent conventional qualitative content analysis. Results: Participants perceived depression care to be complex and challenging. Perceived barriers included: inadequate palliative care psychiatry skills with variation in clinical approaches; lack of supportive health infrastructure (poor access to required interventions and suboptimal linkage between palliative care and psychiatry); lack of research support; and societal stigma. Suggested solutions included integrating care processes between palliative care and psychiatry to improve clinician training, establish supportive health systems and promote innovative research designs. Conclusions: Developing clinician training, supportive health systems and innovative research strategies centering on integrating palliative care and psychiatry care processes may be integral to optimising depression care when providing care to people with very poor prognoses.