What aspects of the pandemic had the greatest impact on adolescent mental health: duration of lockdown or subjective experience?

BACKGROUND: The COVID-19 pandemic negatively impacted global mental health, with adolescents experiencing disproportionate effects. Limited research has explored the impact of different pandemic restrictions on adolescent mental health, and only a few studies have examined the longer-term impacts of the pandemic on adolescent mental health. These investigations are crucial for informing public health policies, particularly the integration of mental health care in future public health emergencies. METHODS: This study aimed to investigate the impact of lockdown duration and the impact of adolescents' subjective experiences of the pandemic on their wellbeing, internalising symptoms, and externalising symptoms. Australian adolescents (N = 1,001, mean age = 14.2 years) completed a baseline survey in 2021, shortly after pandemic lockdowns were lifted (Time 1), and a follow-up survey approximately 12 months later (Time 2). Predictors of interest were the total duration of COVID-19 lockdowns across 2020-2021, and adolescents' subjective experiences of the pandemic on their social connections, learning, technology use and family relationships. A range of covariates were included in analyses to examine subgroup differences. RESULTS: Linear mixed-effects models indicated that total duration of the lockdown was not associated with any of the outcomes at Time 1 or Time 2 (all ps > 0.017). Negative subjective experience of the pandemic on learning was associated with greater externalising symptoms at both Time 1 (t = 5.17, df = 980, p <.001) and Time 2 (t = 2.72, df = 708, p =.007). Negative subjective experience of the pandemic on social connection was associated with greater internalising symptoms at Time 2 only (t = 3.20, df = 709, p =.001). Negative subjective experience of the pandemic on family relationships or technology use was not associated with any of the outcomes at Time 1 or Time 2 (all ps > 0.017). CONCLUSIONS: Adolescents' negative subjective experience of the pandemic on learning and social connections was associated with greater internalising and externalising symptoms after the lockdown had been lifted. Duration of lockdowns was not associated with any of the primary outcomes. During future public health emergencies, mental health interventions should be tailored to assist adolescents to adapt to new learning environments, and to build and maintain social connections.

The relationship between cognitive and affective control and adolescent mental health.

Background: Cognitive control problems have been implicated in the etiology and maintenance of mental health problems, including depression, in adults. Studies in adolescents have been more equivocal, with some showing changes in cognitive control in adolescents with mental health problems, whereas others fail to show an association. This study examines whether adolescent mental health is associated with affective control, the application of cognitive control in affective contexts, which shows more protracted development than cognitive control. Methods: The present study investigated the association of cognitive and affective control with depressive symptomatology and self-reported diagnostic history of mental health problems in adolescents. The study included 1929 participants (M age = 13.89) from the Future Proofing Study (N = 6,388, 11-16 years), who completed affective (incl., affective stimuli) and/or cognitive (incl., neutral stimuli) versions of a working memory (backward digit-span) and/or shifting (card-sorting) task at least once within 3 weeks of assessing mental health. Results: Poorer working memory was associated with greater depressive symptomatology in adolescents (ß = -0.06, p = .004), similarly across cognitive and affective control conditions (ß = -0.02, p = .269). Adolescents with self-reported diagnostic history of mental health problems had significantly poorer shifting ability in affective compared to cognitive control conditions (b = 0.05, p = .010), whereas for adolescents with no self-reported diagnoses, shifting ability did not differ between conditions (b = -0.00, p = .649). Conclusions: The present analyses suggest that working memory difficulties, in particular, may be associated with the experience of current depressed mood in adolescents. Problems with affective shifting may be implicated in a range of mental health problems in adolescents. Given the ubiquitous need for efficient cognitive functioning in daily life, enhancing cognitive and affective control in adolescents may be a promising means of improving functioning across a range of domains, including affective functioning, and by extension, adolescent mental health.

Psychometric properties of the Distress Questionnaire-5 (DQ5) for measuring psychological distress in adolescents.

Screening for psychological distress may assist in identifying at-risk adolescents. While several measures of adolescent psychological distress have been used, most have limited or suboptimal psychometric properties. This study aimed to assess the psychometric properties of the Distress Questionnaire-5 (DQ5), a brief measure of psychological distress, in a large community-based sample of adolescents. Data for the study (n = 3117) were drawn from the baseline and 6-week follow-up assessments of the Future Proofing Study, which collected data from three cohorts of Year 8 students (M = 13.9 years; 48% female) between August 2019 and May 2022. Participants completed the DQ5 at each measurement occasion, as well as measures of depression, generalised and social anxiety, and suicidal ideation. The DQ5 had good fit to a unidimensional construct, with standardised factor loadings ranging between 0.69 and 0.90. The scale had strong criterion (AUC ranged from 0.84 to 0.93) and predictive (AUC ranged from 0.81 to 0.87) validity when compared against indicators for depression, generalised anxiety, social anxiety and suicidal ideation. The DQ5 cut-point of ≥14 had 80% sensitivity and 90% specificity for identifying adolescents meeting symptom thresholds for any of the assessed mental health conditions. Changes in DQ5 scores over 6 weeks had moderate associations with changes in other symptom scales, suggesting sensitivity to change. In conclusion, the DQ5 demonstrates strong psychometric properties and is a reliable measure of psychological distress in adolescents. Given its brevity and ease of interpretation, the DQ5 could be readily used in schools to screen for psychological distress in students.

Implementing a Digital Depression Prevention Program in Australian Secondary Schools: Cross-Sectional Qualitative Study.

BACKGROUND: Depression is common during adolescence and is associated with adverse educational, employment, and health outcomes in later life. Digital programs are increasingly being implemented in schools to improve and protect adolescent mental health. Although digital depression prevention programs can be effective, there is limited knowledge about how contextual factors influence real-world delivery at scale in schools. OBJECTIVE: The purpose of this study was to examine the contextual factors that influence the implementation of the Future Proofing Program (FPP) from the perspectives of school staff. The FPP is a 2-arm hybrid type 1 effectiveness-implementation trial evaluating whether depression can be prevented at scale in schools, using an evidence-based smartphone app delivered universally to year 8 students (13-14 years of age). METHODS: Qualitative interviews were conducted with 23 staff from 20 schools in New South Wales, Australia, who assisted with the implementation of the FPP. The interviews were guided by our theory-driven logic model. Reflexive thematic analysis, using both deductive and inductive coding, was used to analyze responses. RESULTS: Staff perceived the FPP as a novel ("innovative approach") and appropriate way to address an unmet need within schools ("right place at the right time"). Active leadership and counselor involvement were critical for planning and engaging; teamwork, communication, and staff capacity were critical for execution ("ways of working within schools"). Low student engagement and staffing availability were identified as barriers for future adoption and implementation by schools ("reflecting on past experiences"). CONCLUSIONS: Four superordinate themes pertaining to the program, implementation processes, and implementation barriers were identified from qualitative responses by school staff. On the basis of our findings, we proposed a select set of recommendations for future implementation of digital prevention programs delivered at scale in schools. These recommendations were designed to facilitate an organizational change and help staff to implement digital mental health programs within their schools. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1136/bmjopen-2020-042133.

Associations Between Smartphone Keystroke Metadata and Mental Health Symptoms in Adolescents: Findings From the Future Proofing Study.

BACKGROUND: Mental disorders are prevalent during adolescence. Among the digital phenotypes currently being developed to monitor mental health symptoms, typing behavior is one promising candidate. However, few studies have directly assessed associations between typing behavior and mental health symptom severity, and whether these relationships differs between genders. OBJECTIVE: In a cross-sectional analysis of a large cohort, we tested whether various features of typing behavior derived from keystroke metadata were associated with mental health symptoms and whether these relationships differed between genders. METHODS: A total of 934 adolescents from the Future Proofing study undertook 2 typing tasks on their smartphones through the Future Proofing app. Common keystroke timing and frequency features were extracted across tasks. Mental health symptoms were assessed using the Patient Health Questionnaire-Adolescent version, the Children's Anxiety Scale-Short Form, the Distress Questionnaire 5, and the Insomnia Severity Index. Bivariate correlations were used to test whether keystroke features were associated with mental health symptoms. The false discovery rates of P values were adjusted to q values. Machine learning models were trained and tested using independent samples (ie, 80% train 20% test) to identify whether keystroke features could be combined to predict mental health symptoms. RESULTS: Keystroke timing features showed a weak negative association with mental health symptoms across participants. When split by gender, females showed weak negative relationships between keystroke timing features and mental health symptoms, and weak positive relationships between keystroke frequency features and mental health symptoms. The opposite relationships were found for males (except for dwell). Machine learning models using keystroke features alone did not predict mental health symptoms. CONCLUSIONS: Increased mental health symptoms are weakly associated with faster typing, with important gender differences. Keystroke metadata should be collected longitudinally and combined with other digital phenotypes to enhance their clinical relevance. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry, ACTRN12619000855123; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377664&isReview=true.

The impact of COVID-19 and bushfires on the mental health of Australian adolescents: a cross-sectional study.

BACKGROUND: When COVID-19 spread to Australia in January 2020, many communities were already in a state of emergency from the Black Summer bushfires. Studies of adolescent mental health have typically focused on the effects of COVID-19 in isolation. Few studies have examined the impact of COVID-19 and other co-occurring disasters, such as the Black Summer bushfires in Australia, on adolescent mental health. METHODS: We conducted a cross-sectional survey to examine the impact of COVID-19 and the Black Summer bushfires on the mental health of Australian adolescents. Participants (N = 5866; mean age 13.61 years) answered self-report questionnaires about COVID-19 diagnosis/quarantine (being diagnosed with and/or quarantined because of COVID-19) and personal exposure to bushfire harm (being physically injured, evacuated from home and/or having possessions destroyed). Validated standardised scales were used to assess depression, psychological distress, anxiety, insomnia, and suicidal ideation. Trauma related to COVID-19 and the bushfires was also assessed. The survey was completed in two large school-based cohorts between October 2020 and November 2021. RESULTS: Exposure to COVID-19 diagnosis/quarantine was associated with increased probability of elevated trauma. Exposure to personal harm by the bushfires was associated with increased probability of elevated insomnia, suicidal ideation, and trauma. There were no interactive effects between disasters on adolescent mental health. Effects between personal risk factors and disasters were generally additive or sub-additive. CONCLUSIONS: Adolescent mental health responses to community-level disasters are multi-faceted. Complex psychosocial factors associated with mental ill health may be relevant irrespective of disaster. Future research is needed to investigate synergistic effects of disasters on young mental health.

The Future Proofing Study: Design, methods and baseline characteristics of a prospective cohort study of the mental health of Australian adolescents.

OBJECTIVES: The Future Proofing Study (FPS) was established to examine factors associated with the onset and course of mental health conditions during adolescence. This paper describes the design, methods, and baseline characteristics of the FPS cohort. METHODS: The FPS is an Australian school-based prospective cohort study with an embedded cluster-randomized controlled trial examining the effects of digital prevention programs on mental health. Data sources include self-report questionnaires, cognitive functioning, linkage to health and education records, and smartphone sensor data. Participants are assessed annually for 5 years. RESULTS: The baseline cohort (N = 6388, M = 13.9 years) is broadly representative of the Australian adolescent population. The clinical profile of participants is comparable to other population estimates. Overall, 15.1% of the cohort met the clinical threshold for depression, 18.6% for anxiety, 31.6% for psychological distress, and 4.9% for suicidal ideation. These rates were significantly higher in adolescents who identified as female, gender diverse, sexuality diverse, or Aboriginal and/or Torres Strait Islander (all ps < 0.05). CONCLUSIONS: This paper provides current and comprehensive data about the status of adolescent mental health in Australia. The FPS cohort is expected to provide significant insights into the risk, protective, and mediating factors associated with development of mental health conditions during adolescence.

The impact of COVID-19 on the lives and mental health of Australian adolescents.

There has been significant disruption to the lives and mental health of adolescents during the COVID-19 pandemic. The purpose of this study was to assess the psychological and lifestyle impact of the pandemic on Australian adolescents, using an online survey, administered during the outbreak. Self-report surveys were administered online to a sample of 760 Australian adolescents aged 12-18 years assessing impact on a range of domains including behaviour, education, relationships, lifestyle factors (exercise, technology use, and sleep), and mental health outcomes (psychological distress, loneliness, health anxiety and well-being). Results showed that three quarters of the sample experienced a worsening in mental health, since the pandemic began, with negative impacts reported on learning, friendships and family relationships. There were also high higher levels of sleep disturbance, psychological distress and health anxiety, relative to normative samples. Effects on mental health were worse among those who reported a previous diagnosis of depression and/or anxiety relative to those without no such history. Adolescents are already vulnerable to the onset of mental illness at this developmental stage, and the current research underscores the need to find rapid and accessible ways to support adolescent mental health during times of crisis.

The upside: coping and psychological resilience in Australian adolescents during the COVID-19 pandemic.

BACKGROUND: Since the COVID-19 outbreak, few studies have investigated the positive psychological consequences on young people. This study examined resilience, positive experiences, and coping strategies reported by Australian adolescents during COVID-19. METHODS: Self-report surveys were administered online to a sample of 760 Australian adolescents aged 12-18 years. Quantitative and qualitative methods were used to assess resilience, positive experiences, and coping strategies. Exploratory regression analyses were conducted to explore the relationship between resilience and demographics and mental illness history, as well as between resilience and positive experiences. RESULTS: Overall, adolescents were somewhat resilient (M = 20.93, SD = 8.29). They reported positive experiences during COVID-19, including increased empathy, compassion, gratitude, and connection with others, and reported using a range of active coping strategies. Having a mental illness history and identification as female or non-binary gender were associated with lower resilience (Bs > 2.82, ps < 0.001). Further, resilience was associated with decreased psychological distress (OR = 0.89, p < 0.001) and with increased positive experiences (ORs > 1.03, ps < 0.001). CONCLUSIONS: Our results indicate that Australian adolescents commonly reported positive experiences and used active coping strategies during COVID-19. Some young people demonstrated higher levels of resilience and were able to make the most out of an unpredictable situation that severely disrupted their daily routine. However, further prospective research using longitudinal methods is necessary to examine causal relationships between variables. An implication of our findings is that resilience-building programs for adolescents may be effective in increasing adaptability after adversity (e.g., climate change, bushfires, pandemics).

Protocol for the process evaluation of a complex intervention delivered in schools to prevent adolescent depression: the Future Proofing Study.

INTRODUCTION: Process evaluations provide insight into how interventions are delivered across varying contexts and why interventions work in some contexts and not in others. This manuscript outlines the protocol for a process evaluation embedded in a cluster randomised trial of a digital depression prevention intervention delivered to secondary school students (the Future Proofing Study). The purpose is to describe the methods that will be used to capture process evaluation data within this trial. METHODS AND ANALYSIS: Using a hybrid type 1 design, a mixed-methods approach will be used with data collected in the intervention arm of the Future Proofing Study. Data collection methods will include semistructured interviews with school staff and study facilitators, automatically collected intervention usage data and participant questionnaires (completed by school staff, school counsellors, study facilitators and students). Information will be collected about: (1) how the intervention was implemented in schools, including fidelity; (2) school contextual factors and their association with intervention reach, uptake and acceptability; (3) how school staff, study facilitators and students responded to delivering or completing the intervention. How these factors relate to trial effectiveness outcomes will also be assessed. Overall synthesis of the data will provide school cluster-level and individual-level process outcomes. ETHICS AND DISSEMINATION: Ethics approval was obtained from the University of New South Wales (NSW) Human Research Ethics Committee (HC180836; 21st January 2019) and the NSW Government State Education Research Applications Process (SERAP 2019201; 19th August 2019). Results will be submitted for publication in peer-reviewed journals and discussed at conferences. Our process evaluation will contextualise the trial findings with respect to how the intervention may have worked in some schools but not in others. This evaluation will inform the development of a model for rolling out digital interventions for the prevention of mental illness in schools. TRIAL REGISTRATION NUMBER: ANZCTRN12619000855123; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377664&isReview=true.

A trial protocol for the effectiveness of digital interventions for preventing depression in adolescents: The Future Proofing Study.

BACKGROUND: Depression frequently first emerges during adolescence, and one in five young people will experience an episode of depression by the age of 18 years. Despite advances in treatment, there has been limited progress in addressing the burden at a population level. Accordingly, there has been growing interest in prevention approaches as an additional pathway to address depression. Depression can be prevented using evidence-based psychological programmes. However, barriers to implementing and accessing these programmes remain, typically reflecting a requirement for delivery by clinical experts and high associated delivery costs. Digital technologies, specifically smartphones, are now considered a key strategy to overcome the barriers inhibiting access to mental health programmes. The Future Proofing Study is a large-scale school-based trial investigating whether cognitive behaviour therapies (CBT) delivered by smartphone application can prevent depression. METHODS: A randomised controlled trial targeting up to 10,000 Year 8 Australian secondary school students will be conducted. In Stage I, schools will be randomised at the cluster level either to receive the CBT intervention app (SPARX) or to a non-active control group comparator. The primary outcome will be symptoms of depression, and secondary outcomes include psychological distress, anxiety and insomnia. At the 12-month follow-up, participants in the intervention arm with elevated depressive symptoms will participate in an individual-level randomised controlled trial (Stage II) and be randomised to receive a second CBT app which targets sleep difficulties (Sleep Ninja) or a control condition. Assessments will occur post intervention (both trial stages) and at 6, 12, 24, 36, 48 and 60 months post baseline. Primary analyses will use an intention-to-treat approach and compare changes in symptoms from baseline to follow-up relative to the control group using mixed-effect models. DISCUSSION: This is the first trial testing the effectiveness of smartphone apps delivered to school students to prevent depression at scale. Results from this trial will provide much-needed insight into the feasibility of this approach. They stand to inform policy and commission decisions concerning if and how such programmes should be deployed in school-based settings in Australia and beyond. TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry, ACTRN12619000855123. Registered on 31 May 2019. Clinical Trial Notification Scheme (CTN), CT-2019-CTN-02110-1-v1. Registered on 30 June 2019.

Validation and Normative Data for the Modified Telephone Interview for Cognitive Status: The Sydney Memory and Ageing Study.

OBJECTIVES: Telephone-based cognitive screens, such as the Telephone Interview for Cognitive Status (TICS), can potentially reduce the barriers and costs of assessing older adults. However, validation of clinically relevant psychometric properties is lacking in a large and comprehensively assessed sample of older adults. Furthermore, published normative data may lack sensitivity as they have not used regression-based demographic corrections or accounted for cases with subsequent dementia. We address these gaps using the modified TICS (TICS-M; a modified, 13-item, 39-point version) and provide an online norms calculator for clinicians and researchers. DESIGN: Prospective longitudinal study. SETTING: Sydney, Australia. PARTICIPANTS: A total of 617 community-living older adults, aged from 71 to 91 years. MEASUREMENTS: The measures used included the TICS-M, the Mini-Mental State Examination (MMSE), Addenbrooke's Cognitive Examination-Revised (ACE-R), and a comprehensive neuropsychological test battery. Descriptive statistics, correlations, area under the curve, and regression analyses were used to determine the validity and normative properties of the TICS-M. RESULTS: TICS-M total scores (mean = 24.20; SD = 3.76) correlated well with the MMSE (0.70) and ACE-R (0.80) and moderately with neuropsychological tests tested noncontemporaneously. A cutoff score of 21 or lower reliably distinguished between those with and without incident dementia after 1 year (sensitivity = 77%; specificity = 88%) but was less reliable at distinguishing mild cognitive impairment from normal cognition. TICS-M scores decreased with age and increased with higher education levels. The robust normative sample, which excluded incident dementia cases, scored higher on the TICS-M and with less variability than the whole sample. An online calculator is provided to compute regression-based norms and reliable change statistics. CONCLUSIONS: In a large sample of community-dwelling older adults, the TICS-M performed well in terms of construct validity against typical screening tools and neuropsychological measures and diagnostic validity for incident dementia. The comprehensive, regression-based, and robust normative data provided will help improve the sensitivity, accessibility, and cost-effectiveness of cognitive testing with older adults. J Am Geriatr Soc 67:2108-2115, 2019.

Plasma apolipoproteins and physical and cognitive health in very old individuals.

Apolipoproteins play a crucial role in lipid metabolism with implications in cardiovascular disease, obesity, diabetes, Alzheimer's disease, and longevity. We quantified 7 apolipoproteins in plasma in 1067 individuals aged 56-105 using immunoassays and explored relationships with APOE polymorphism ε2/3/4, vascular health, frailty, and cognition. ApoA1, ApoA2, ApoB, ApoC3, ApoE, ApoH, and ApoJ decreased from mid-life, although ApoE and ApoJ had U-shaped trends. Centenarians had the highest ApoE levels and the lowest frequency of APOE ε4 allele relative to younger groups. Apolipoprotein levels trended lower in APOE ε4 homozygotes and heterozygotes compared with noncarriers, with ApoE and ApoJ being significantly lower. Levels of all apolipoproteins except ApoH were higher in females. Sex- and age-related differences were apparent in the association of apolipoproteins with cognitive performance, as only women had significant negative associations of ApoB, ApoE, ApoH, and ApoJ in mid-life, whereas associations at older age were nonsignificant or positive. Our findings suggest levels of some apolipoproteins, especially ApoE, are associated with lifespan and cognitive function in exceptionally long-lived individuals.

Operationalizing the Diagnostic Criteria for Mild Cognitive Impairment: The Salience of Objective Measures in Predicting Incident Dementia.

OBJECTIVE: Mild cognitive impairment (MCI) is considered an intermediate stage between normal aging and dementia. It is diagnosed in the presence of subjective cognitive decline and objective cognitive impairment without significant functional impairment, although there are no standard operationalizations for each of these criteria. The objective of this study is to determine which operationalization of the MCI criteria is most accurate at predicting dementia. DESIGN: Six-year longitudinal study, part of the Sydney Memory and Ageing Study. SETTING: Community-based. PARTICIPANTS: 873 community-dwelling dementia-free adults between 70 and 90 years of age. Persons from a non-English speaking background were excluded. MEASUREMENTS: Seven different operationalizations for subjective cognitive decline and eight measures of objective cognitive impairment (resulting in 56 different MCI operational algorithms) were applied. The accuracy of each algorithm to predict progression to dementia over 6 years was examined for 618 individuals. RESULTS: Baseline MCI prevalence varied between 0.4% and 30.2% and dementia conversion between 15.9% and 61.9% across different algorithms. The predictive accuracy for progression to dementia was poor. The highest accuracy was achieved based on objective cognitive impairment alone. Inclusion of subjective cognitive decline or mild functional impairment did not improve dementia prediction accuracy. CONCLUSIONS: Not MCI, but objective cognitive impairment alone, is the best predictor for progression to dementia in a community sample. Nevertheless, clinical assessment procedures need to be refined to improve the identification of pre-dementia individuals.

Risk Factors for Mild Cognitive Impairment, Dementia and Mortality: The Sydney Memory and Ageing Study.

BACKGROUND: The nature and commonality of late-life risk factors for mild cognitive impairment (MCI), dementia, and mortality remain unclear. Our aim was to investigate potential risk factors, simultaneously in a single cohort including many individuals initially with normal cognition and followed for 6 years. METHODS: We classified 873 community-dwelling individuals (70-90 years old and without dementia at baseline) from the Sydney Memory and Ageing Study as cognitively normal (CN), having MCI or dementia, or deceased 6 years after baseline. Associations with baseline demographic, lifestyle, health, and medical factors were investigated, including apolipoprotein (APOE) genotype, MCI at baseline, and reversion from MCI to CN within 2 years of baseline. RESULTS: Eighty-three (9.5%) participants developed dementia and 114 (13%) died within 6 years; nearly 33% had MCI at baseline, of whom 28% reverted to CN within 2 years. A core set of baseline factors was associated with MCI and dementia at 6 years, including older age (per year: odds ratios and 95% confidence intervals = 1.08, 1.01-1.14 for MCI; 1.19, 1.09-1.31 for dementia), MCI at baseline (5.75, 3.49-9.49; 8.23, 3.93-17.22), poorer smelling ability (per extra test point: 0.89, 0.79-1.02; 0.80, 0.68-0.94), slower walking speed (per second: 1.12, 1.00-1.25; 1.21, 1.05-1.39), and being an APOE ε4 carrier (1.84, 1.07-3.14; 3.63, 1.68-7.82). All except APOE genotype were also associated with mortality (age: 1.11, 1.03-1.20; MCI: 3.87, 1.97-7.59; smelling ability: 0.83, 0.70-0.97; walking speed: 1.18, 1.03-1.34). Compared with stable CN participants, individuals reverting from MCI to CN after 2 years were at greater risk of future MCI (3.06, 1.63-5.72). Those who reverted exhibited some different associations between baseline risk factors and 6-year outcomes than individuals with stable MCI. CONCLUSION: A core group of late-life risk factors indicative of physical and mental frailty are associated with each of dementia, MCI, and mortality after 6 years. Tests for slower walking speed and poorer smelling ability may help screen for cognitive decline. Individuals with normal cognition are at greater risk of future cognitive impairment if they have a history of MCI.