An Internet-Based Intervention Augmented With a Diet and Physical Activity Consultation to Decrease the Risk of Dementia in At-Risk Adults in a Primary Care Setting: Pragmatic Randomized Controlled Trial.

BACKGROUND: There is a need to develop interventions to reduce the risk of dementia in the community by addressing lifestyle factors and chronic diseases over the adult life course. OBJECTIVE: This study aims to evaluate a multidomain dementia risk reduction intervention, Body Brain Life in General Practice (BBL-GP), targeting at-risk adults in primary care. METHODS: A pragmatic, parallel, three-arm randomized trial involving 125 adults aged 18 years or older (86/125, 68.8% female) with a BMI of ≥25 kg/m2 or a chronic health condition recruited from general practices was conducted. The arms included (1) BBL-GP, a web-based intervention augmented with an in-person diet and physical activity consultation; (2) a single clinician-led group, Lifestyle Modification Program (LMP); and (3) a web-based control. The primary outcome was the Australian National University Alzheimer Disease Risk Index Short Form (ANU-ADRI-SF). RESULTS: Baseline assessments were conducted on 128 participants. A total of 125 participants were randomized to 3 groups (BBL-GP=42, LMP=41, and control=42). At immediate, week 18, week 36, and week 62 follow-ups, the completion rates were 43% (18/42), 57% (24/42), 48% (20/42), and 48% (20/42), respectively, for the BBL-GP group; 71% (29/41), 68% (28/41), 68% (28/41), and 51% (21/41), respectively, for the LMP group; and 62% (26/42), 69% (29/42), 60% (25/42), and 60% (25/42), respectively, for the control group. The primary outcome of the ANU-ADRI-SF score was lower for the BBL-GP group than the control group at all follow-ups. These comparisons were all significant at the 5% level for estimates adjusted for baseline differences (immediate: difference in means -3.86, 95% CI -6.81 to -0.90, P=.01; week 18: difference in means -4.05, 95% CI -6.81 to -1.28, P<.001; week 36: difference in means -4.99, 95% CI -8.04 to -1.94, P<.001; and week 62: difference in means -4.62, 95% CI -7.62 to -1.62, P<.001). CONCLUSIONS: A web-based multidomain dementia risk reduction program augmented with allied health consultations administered within the general practice context can reduce dementia risk exposure for at least 15 months. This study was limited by a small sample size, and replication on a larger sample with longer follow-up will strengthen the results. TRIAL REGISTRATION: Australian clinical trials registration number (ACTRN): 12616000868482; https://anzctr.org.au/ACTRN12616000868482.aspx.

A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern.

ABSTRACTBackground:Behavioral and psychological symptoms of dementia (BPSD) are a common problem in long-term care facilities (LTC). Clinical guidelines dictate that first-line treatments for BPSD are psychosocial and behavioral interventions; if these are unsuccessful, psychotropic medications may be trialed at low doses and their effects can be monitored. METHODS: There have previously been no studies with nationally representative samples to investigate psychotropic administration in LTCs in Australia. This study determines the prevalence of psychotropic administration in a representative stratified random sample of 446 residents living with dementia from 53 Australian LTCs. Questionnaire and medical chart data in this study is drawn from a larger cross-sectional, mixed methods study on quality of life in Australian LTCs. RESULTS: It was found that 257 (58%) residents were prescribed psychotropic medications including: antipsychotics (n = 160, 36%), benzodiazepines (n = 136, 31%), antidepressants (n = 117, 26%), and anti-dementia medications (n = 9, 2%). BPSD were found to be very common in the sample, with 82% (n = 364) of participants experiencing at least one BPSD. The most prevalent BPSD were depression (n = 286, 70%) and agitation (n = 299, 67%). CONCLUSIONS: Although detailed background information was not collected on individual cases, the prevalence found is indicative of systematic industry-wide, over-prescription of psychotropic medications as a first-line treatment for BPSD. This study highlights a clear need for further research and interventions in this area.

The Music Engagement Program for people with Alzheimer's disease and dementia: Pilot feasibility trial outcomes.

Alzheimer's disease and dementia are common, highly disabling conditions frequently requiring residential care. This exploratory proof-of-concept study aimed to determine if the specialised Music Engagement Program (MEP) was sustainable, acceptable, and effective in improving quality of life, emotional wellbeing, and depression symptoms in this population. Sixteen residents, six staff members, and three family and community members took part in the evaluation of the MEP for people living with dementia in a residential aged-care nursing home in Canberra, Australia. Multiple methods were used. Quantitative evaluation assessed residents' depression symptoms (Cornell scale) at pre- and post-intervention, and emotional wellbeing pre- and post-session. Qualitative interviews with staff, and family and community members addressed the MEP's acceptability and potential sustainability. Results showed residents' mean depression scores were reduced from pre- to post-intervention (p = .039; dz = 0.72). Interviews established multiple benefits for residents including improved mood, calmness, and reduced aggression. However, staff did not believe it was feasible to continue the MEP sessions beyond the trial period without an external facilitator, citing potential difficulties in adhering to internal activities due to time constraints. This pilot study provides encouraging preliminary evidence for the MEP's acceptability and potential effectiveness for improving depression and wellbeing in this group.

Lifestyle Risk Factors and Cognitive Outcomes from the Multidomain Dementia Risk Reduction Randomized Controlled Trial, Body Brain Life for Cognitive Decline (BBL-CD).

BACKGROUND/OBJECTIVES: To evaluate the efficacy of a multidomain intervention to reduce lifestyle risk factors for Alzheimer's disease (AD) and improve cognition in individuals with subjective cognitive decline (SCD) or mild cognitive impairment (MCI). DESIGN: The study was an 8-week two-arm single-blind proof-of-concept randomized controlled trial. SETTING: Community-dwelling individuals living in Canberra, Australia, and surrounding areas. PARTICIPANTS: Participants were 119 individuals (intervention n = 57; control n = 62) experiencing SCD or MCI. INTERVENTION: The control condition involved four educational modules covering dementia and lifestyle risk factors, Mediterranean diet, physical activity, and cognitive engagement. Participants were instructed to implement this information into their own lifestyle. The intervention condition included the same educational modules and additional active components to assist with the implementation of this information into participants' lifestyles: dietitian sessions, an exercise physiologist session, and online brain training. MEASUREMENTS: Lifestyle risk factors for AD were assessed using the Australian National University-Alzheimer's Disease Risk Index (ANU-ADRI), and cognition was assessed using Alzheimer's Disease Assessment Scale-Cognitive subscale, Pfeffer Functional Activities Questionnaire, Symbol Digit Modalities Test (SDMT), Trail Making Test-B, and Category Fluency. RESULTS: The primary analysis showed that the intervention group had a significantly lower ANU-ADRI score (χ2 = 10.84; df = 3; P = .013) and a significantly higher cognition score (χ2 = 7.28; df = 2; P = .026) than the control group. A secondary analysis demonstrated that the changes in lifestyle were driven by increases in protective lifestyle factors (χ2 = 12.02; df = 3; P = .007), rather than a reduction in risk factors (χ2 = 2.93; df = 3; P = .403), and cognitive changes were only apparent for the SDMT (χ2 = 6.46; df = 2; P = .040). Results were robust to intention-to-treat analysis controlling for missing data. CONCLUSION: Results support the hypothesis that improvements in lifestyle risk factors for dementia can lead to improvements in cognition over a short time frame with a population experiencing cognitive decline. Outcomes from this trial support the conduct of a larger and longer trial with this participant group.

"Would you like to join me for a walk?" The feasibility of a supervised walking programme for people with dementia who wander.

AIMS AND OBJECTIVES: Five of the eight focus areas of Bowen's Feasibility Framework were utilised to assess the feasibility of implementing the Safe Walking Program (SWP) with people with severe dementia who wander in long-term care (LTC). BACKGROUND: Dementia-related wandering in LTC is associated with adverse outcomes related to intensity (malnutrition, exhaustion and pain, injury) and type of walking (sleep deprivation, resident violence and elopement, death). There is little evidence guiding best practice for managing wandering in LTC. DESIGN: The SWP involved a three-week trial of taking residents (n = 7) for a 30-min supervised walk, 30 min before individual peak walking activity periods (PWAP), outside the care facility. Quantitative (real-time observation and 24/7 Actigraph™ data: not reported here) and qualitative data were collected pre-, during and postintervention. METHODS: Feasibility to implement the SWP protocol was evaluated using a protocol fidelity checklist completed at the end of each scheduled intervention. Acceptability and sustainability of the programme were evaluated through staff interviews. RESULTS: Eighty per cent of scheduled walks commenced and were completed, with 91% of walks lasting the full 30 min. Care staff reported benefits for participants and care staff. The perceived sustainability of the SWP in the LTC setting was impacted by the strict timing of the walk to coincide with participant's individual PWAP. The use of care staff to lead some scheduled walks was seen as interfering with care routines. CONCLUSIONS: To enhance the acceptability/sustainability of the SWP in LTC, further testing of the importance of dose and timing is required. Consideration needs to be given to suggested modifications to the protocol. IMPLICATIONS FOR PRACTICE: The SWP is an acceptable and enjoyable activity for people with severe dementia who wander. Utilising walking tracks around the neighbourhood was perceived as being an important element of the programme.

Evaluation of the Music Engagement Program for people with Alzheimer's disease and dementia: Study protocol for a pilot trial.

BACKGROUND: Alzheimer's disease and dementia are prevalent conditions globally. People with Alzheimer's disease and dementia commonly experience mental health problems, negative emotional states, and behavioural disturbance. Music therapy has previously been used in this population to improve symptoms of mental health problems; however, there is a paucity of evidence-based programs that also explore positive outcomes such as overall quality of life, social outcomes, as well as the acceptability and sustainability of these programs. AIMS: This project aims to evaluate the effectiveness of the specialised Music Engagement Program (MEP) in improving quality of life, wellbeing, and depression symptoms, in aged-care residents with Alzheimer's disease and dementia. The project also aims to explore how the MEP could be applied and maintained on a broader level throughout the aged-care community. METHODS: The intervention will take place over 8 weeks in an aged-care facility for people living with dementia in Canberra, Australia. Weekly 45-60-min group singing sessions will be led by a music facilitator. RESULTS: The results of the study will be submitted for publication in relevant academic journals and mental health conferences, disseminated to participants on request, to the residential care facility, and via the lead researcher's website. CONCLUSIONS: This study can provide an indication of the feasibility of the MEP in enhancing the mental health and wellbeing of individuals with Alzheimer's disease and dementia. Further investigation will be required to establish the MEP's ability to be maintained on an ongoing basis with minimal costs and administrative support. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry (ANZCTR): ACTRN12618001690246.

Body, Brain, Life for Cognitive Decline (BBL-CD): protocol for a multidomain dementia risk reduction randomized controlled trial for subjective cognitive decline and mild cognitive impairment.

BACKGROUND: With no cure for dementia and the number of people living with the condition predicted to rapidly rise, there is an urgent need for dementia risk reduction and prevention interventions. Modifiable lifestyle risk factors have been identified as playing a major role in the development of dementia; hence, interventions addressing these risk factors represent a significant opportunity to reduce the number of people developing dementia. Relatively few interventions have been trialed in older participants with cognitive decline (secondary prevention). OBJECTIVES: This study evaluates the efficacy and feasibility of a multidomain lifestyle risk reduction intervention for people with subjective cognitive decline (SCD) and mild cognitive impairment (MCI). METHODS: This study is an 8-week, two-arm, single-blind, randomized controlled trial (RCT) of a lifestyle modification program to reduce dementia risk. The active control group receives the following four online educational modules: dementia literacy and lifestyle risk, Mediterranean diet (MeDi), cognitive engagement and physical activity. The intervention group also completes the same educational modules but receives additional practical components including sessions with a dietitian, online brain training and sessions with an exercise physiologist to assist with lifestyle modification. RESULTS: Primary outcome measures are cognition (The Alzheimer's Disease Assessment Scale-Cognitive-Plus [ADAS-Cog-Plus]) and a composite lifestyle risk factor score for Alzheimer's disease (Australian National University - Alzheimer's Disease Risk Index [ANU-ADRI]). Secondary outcome measures are motivation to change lifestyle (Motivation to Change Lifestyle and Health Behaviour for Dementia Risk Reduction [MCLHB-DRR]) and health-related quality of life (36-item Short Form Health Survey [SF-36]). Feasibility will be determined through adherence to diet (Mediterranean Diet Adherence Screener [MEDAS] and Australian Recommended Food Score [ARFS]), cognitive engagement (BrainHQ-derived statistics) and physical activity interventions (physical activity calendars). Outcomes are measured at baseline, immediately post-intervention and at 3- and 6-month follow-up by researchers blind to group allocation. DISCUSSION: If successful and feasible, secondary prevention lifestyle interventions could provide a targeted, cost-effective way to reduce the number of people with cognitive decline going on to develop Alzheimer's disease (AD) and other dementias.

Protocol for a pragmatic randomised controlled trial of Body Brain Life-General Practice and a Lifestyle Modification Programme to decrease dementia risk exposure in a primary care setting.

INTRODUCTION: It has been estimated that a 10%-25% reduction in seven key risk factors could potentially prevent 1.1-3.0 million Alzheimer's disease cases globally. In addition, as dementia is preceded by more subtle cognitive deficits which have substantial social and economic impact, effective preventative interventions would likely have more extensive benefits. The current study evaluates in primary care a multidomain risk-reduction intervention targeting adults with high risk of developing dementia. METHODS AND ANALYSIS: A randomised controlled trial (RCT) is being conducted to evaluate three intervention programmes using a pragmatic approach suitable to the clinic: (1) a 12-week online and face-to-face dementia risk-reduction intervention (Body Brain Life-General Practice (BBL-GP)); (2) a 6-week face-to-face group lifestyle modification programme (LMP); and (3) a 12-week email-only programme providing general health information. We aim to recruit 240 participants, aged 18 and over, to undergo a comprehensive cognitive and physical assessment at baseline and follow-ups (postintervention, 18, 36 and 62 weeks). The primary outcome is dementia risk measured with the modified version of the Australian National University-Alzheimer's Disease Risk Index Short Form. Secondary outcomes are cognitive function measured with Trails A and B, and the Digit Symbol Modalities Test; physical activity with moderate-vigorous physical activity and the International Physical Activity Questionnaire; depression with the Centre for Epidemiological Studies Depression; cost evaluation with the 12-item Short Form Health Survey, Framingham Coronary Heart Disease Risk Score and Australian Type 2 Diabetes Risk Assessment Tool; diet quality with the Australian Recommended Food Score; and sleep quality with the Pittsburgh Sleep Quality Index. ETHICS AND DISSEMINATION: This RCT is a novel pragmatic intervention applied in a primary care setting to reduce the dementia risk exposure in adults at high risk. If successful, BBL-GP and LMP will provide a versatile, evidence-based package that can be easily and quickly rolled out to other primary care settings and which can be scaled up at relatively low cost compared with other strategies involving intensive interventions. TRIAL REGISTRATION NUMBER: ACTRN12616000868482.

Achieving a National Sample of Nursing Homes: Balancing Probability Techniques and Practicalities.

Sampling design is critical to the quality of quantitative research, yet it does not always receive appropriate attention in nursing research. The current article details how balancing probability techniques with practical considerations produced a representative sample of Australian nursing homes (NHs). Budgetary, logistical, and statistical constraints were managed by excluding some NHs (e.g., those too difficult to access) from the sampling frame; a stratified, random sampling methodology yielded a final sample of 53 NHs from a population of 2,774. In testing the adequacy of representation of the study population, chi-square tests for goodness of fit generated nonsignificant results for distribution by distance from major city and type of organization. A significant result for state/territory was expected and easily corrected for by the application of weights. The current article provides recommendations for conducting high-quality, probability-based samples and stresses the importance of testing the representativeness of achieved samples.

Effectiveness of meaningful occupation interventions for people living with dementia in residential aged care: a systematic review.

BACKGROUND: The ability to participate in valued activities, whether for work, leisure or family, is an important aspect of personal identity. In dementia, progressive memory loss means that abilities developed over a lifetime begin to be lost as well, contributing to the loss of self and identity. Some studies have reported that activities or interventions tailored to be meaningful to the person with dementia (defined as any activity important to the individual) are more effective in addressing behavioral and psychological symptoms of dementia (BPSD) and improving quality of life (QoL) than those that are not so tailored. However, the effectiveness of individualizing interventions or activities for this population is not known. OBJECTIVES: In response to consumer feedback by the Consumer Dementia Research Network that this question ought to be addressed, this review was undertaken, the aim of which was to determine the effectiveness of meaningful occupation interventions for people living with dementia in residential aged care facilities (RACFs). INCLUSION CRITERIA: People living with dementia in RACFs (nursing homes).Any intervention that was individualized to be meaningful to the participant, versus any active control condition or usual care.Experimental and observational studies. TYPES OF OUTCOMES: Quality of life, BPSD (such as agitation, aggression, depression, wandering and apathy), mood, function, cognition and sleep. SEARCH STRATEGY: The search strategy aimed to identify both published and unpublished studies, with the following 12 databases extensively searched: PubMed, CINAHL, PsycINFO, ISI Web of Science, OTSeeker, Embase, Cochrane CENTRAL, clinicaltrials.gov, Mednar, OpenSIGLE, New York Academy of Medicine Library Gray Literature Report, ProQuest Dissertations and Theses. The search strategy was limited to papers published in English between 2004 and January 31, 2015. METHODOLOGICAL QUALITY: All studies were assessed independently by two reviewers for relevance, eligibility and methodological quality. DATA EXTRACTION: Data from included papers were extracted using a standard data extraction tool. DATA SYNTHESIS: Where possible, study results were pooled in statistical meta-analysis. Alternatively, results are presented in narrative and tabular form. RESULTS: A total of 5274 citations were identified; after removal of duplicates, assessment for relevance and eligibility, 61 studies underwent critical appraisal. Thirty-four studies met the quality criteria and were included in a quantitative synthesis. A wide range of interventions were evaluated including individualized recreational activities (13 studies), reminiscence therapy (RT) (seven studies), music therapy interventions (six studies), training staff to develop individual care plans using person-centered care (PCC) or similar approaches (three studies), animal-assisted therapy (two studies), multi-sensory interventions (MSIs) (two studies) and social interaction (one study), all of which measured a number of different outcomes. Overall, and in spite of most studies being small-scale and of relatively brief duration, all interventions with the exception of Snoezelen therapy (a MSI) reported some benefits for people with dementia living in RACFs. The most frequently reported benefits were reductions in agitation (the most frequently assessed outcome), passivity and depression, improved QoL and increases in pleasure and interest. However, the majority of studies generally implemented the intervention, whether it was individualized activities, music or RT or other, in conjunction with one-to-one social interaction, and the relative importance of the intervention in comparison to one-to-one social contact for effectiveness cannot be determined from this review. CONCLUSION: Providing meaningful or individualized tailored activities for people with dementia living in RACFs appears to be effective for a range of behavioral and psychological symptoms. The strongest evidence was for individualized activities/recreational interventions for a range of BPSD; preferred music for agitation, depression and anxiety; and RT for mood and cognitive functioning. Insufficient evidence precluded making recommendations regarding animal-assisted (dog) therapy and training staff to develop individual care plans using PCC or similar approaches, while there was no good quality evidence to show that Snoezelen was effective for any outcome. What remains unclear, however, is whether any of these interventions is more effective than the provision of one-to-one social interaction.