Levels of frailty and frailty progression in older urban- and regional-living First Nations Australians.

OBJECTIVES: To explore the prevalence of frailty, association between frailty and mortality, and transitions between frailty states in urban- and regional-living First Nations Australians. STUDY DESIGN: Secondary analysis of longitudinal data from the Koori Growing Old Well Study. First Nations Australians aged 60 years or more from five non-remote communities were recruited in 2010-2012 and followed up six years later (2016-2018). Data collected at both visits were used to derive a 38-item Frailty Index (FI). The FI (range 0-1.0) was classified as robust (<0.1), pre-frail (0.1- < 0.2), mildly (0.2- < 0.3), moderately (0.3- < 0.4) or severely frail (≥0.4). MAIN OUTCOME MEASURES: Association between frailty and mortality, examined using logistic regression and transitions in frailty (the percentage of participants who changed frailty category) during follow-up. RESULTS: At baseline, 313 of 336 participants (93 %) had sufficient data to calculate a FI. Median FI score was 0.26 (interquartile range 0.21-0.39); 4.79 % were robust, 20.1 % pre-frail, 31.6 % mildly frail, 23.0 % moderately frail and 20.5 % severely frail. Higher baseline frailty was associated with mortality among severely frail participants (adjusted odds ratio 7.11, 95 % confidence interval 2.51-20.09) but not moderately or mildly frail participants. Of the 153 participants with a FI at both baseline and follow-up, their median FI score increased from 0.26 to 0.28. CONCLUSIONS: Levels of frailty in this First Nations cohort are substantially higher than in similar-aged non-Indigenous populations. Screening for frailty before the age of 70 years may be warranted in First Nations Australians. Further research is urgently needed to determine the factors that are driving such high levels of frailty and propose solutions to prevent or manage frailty in this population.

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.

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.

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.

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.

Potentially modifiable dementia risk factors in all Australians and within population groups: an analysis using cross-sectional survey data.

BACKGROUND: Dementia is the second leading cause of disease burden in Australia. We aimed to calculate the population attributable fractions (PAFs) of dementia attributable to 11 of 12 previously identified potentially modifiable health and social risk factors (less education, hearing loss, hypertension, obesity, smoking, depression, social isolation, physical inactivity, diabetes, alcohol excess, air pollution, and traumatic brain injury), for Australians overall and three population groups (First Nations, and those of European and Asian ancestry). METHODS: We calculated the prevalence of dementia risk factors (excluding traumatic brain injury) and PAFs, adjusted for communality, from the cross-sectional National Aboriginal and Torres Strait Islander Health Survey (2018-19), National Aboriginal and Torres Strait Islander Social Survey (2014-15), National Health Survey (2017-18), and General Social Survey (2014) conducted by the Australian Bureau of Statistics. We conducted sensitivity analyses using proxy estimates for traumatic brain injury (12th known risk factor) for which national data were not available. FINDINGS: A large proportion (38·2%, 95% CI 37·2-39·2) of dementia in Australia was theoretically attributable to the 11 risk factors; 44·9% (43·1-46·7) for First Nations Australians, 36·4% (34·8-38·1) for European ancestry, and 33·6% (30·1-37·2) for Asian ancestry. Including traumatic brain injury increased the PAF to 40·6% (39·6-41·6) for all Australians. Physical inactivity (8·3%, 7·5-9·2), hearing loss (7·0%, 6·4-7·6), and obesity (6·6%, 6·0-7·3) accounted for approximately half of the total PAF estimates across Australia, and for all three population groups. INTERPRETATION: Our PAF estimates indicate a substantial proportion of dementia in Australia is potentially preventable, which is broadly consistent with global trends and results from other countries. The highest potential for dementia prevention was among First Nations Australians, reflecting the enduring effect of upstream social, political, environmental, and economic disadvantage, leading to greater life-course exposure to dementia risk factors. Although there were common dementia risk factors across different population groups, prevention strategies should be informed by community consultation and be culturally and linguistically appropriate. FUNDING: Australian National Health and Medical Research Council and University College London Hospitals' National Institute for Health Research (NIHR) Biomedical Research Centre, and North Thames NIHR Applied Research Collaboration.

Frameworks for cultural adaptation of psychosocial interventions: A systematic review with narrative synthesis.

INTRODUCTION: Psychosocial dementia interventions may be less effective when used with populations for whom they were not initially intended. Cultural adaptation of interventions aims to increase effectiveness of interventions by enhancing cultural relevance. Use of theoretical frameworks may promote more systematic cultural adaptation. The aim of this review was to provide a comprehensive synthesis of published cultural adaptation frameworks for psychosocial interventions to understand important elements of cultural adaptation and guide framework selection. METHOD: Five scientific databases, grey literature and reference lists were searched to January 2023 to identify cultural adaptation frameworks for psychosocial interventions. Papers were included that presented cultural adaptation frameworks for psychosocial interventions. Data were mapped to the framework for reporting adaptations and modifications to evidence-based interventions, then analysed using thematic synthesis. RESULTS: Twelve cultural adaptation frameworks met inclusion criteria. They were mostly developed in the United States and for adaptation of psychological interventions. The main elements of cultural adaptation for psychosocial interventions were modifying intervention content, changing context (where, by whom an intervention is delivered) and consideration of fidelity to the original intervention. Most frameworks suggested that key intervention components must be retained to ensure fidelity, however guidance was not provided on how to identify or retain these key components. Engagement (ways to reach and involve recipients) and cultural competence of therapists were found to be important elements for cultural adaptation. CONCLUSIONS: Comprehensive frameworks are available to guide cultural adaptation of psychosocial dementia interventions. More work is required to articulate how to ensure fidelity during adaptation, including how to identify and retain key intervention components.

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.

Accelerated aging in people experiencing homelessness: A rapid review of frailty prevalence and determinants.

Introduction: Older people experiencing homelessness (PEH) are a rapidly growing population at risk of accelerated aging and the early onset of geriatric conditions. One construct that shows promise in predicting age-related decline is frailty. Better understanding the rates and causes of frailty in PEH may improve understanding of its antecedents, thereby facilitating more targeted health and aged care service interventions. The aim of this study was to conduct a rapid review on the prevalence and determinants of frailty in adult PEH. Methods: We conducted a rapid review of primary research papers studying PEH and frailty or frailty-related concepts. Results: Fourteen studies were included, which indicate that frailty presents earlier and at higher rates in PEH than community-dwelling cohorts. A notable difficulty for many aging PEH was early-onset cognitive impairment which was associated with a range of negative functional outcomes. Another recurrent theme was the negative impact that drug and alcohol use and dependence can have on the health of PEH. Further, psychosocial and structural determinants such as loneliness, living in an impoverished neighborhood and being female had statistically significant associations with frailty and functional decline in PEH. Discussion and implications: PEH in their 40s and 50s can be frail and experience geriatric conditions, including cognitive impairment. Factors that have important relationships to frailty and functional decline in PEH include cognitive deficits, drug and alcohol dependence and loneliness, as well as upstream determinants such as gender and ethnicity. More targeted data and research on these factors, including cohort studies to better investigate their potentially causal effects, is important for researchers and practitioners assessing and treating frailty in PEH, particularly those interested in early intervention and prevention. Prospero registration ID: CRD42022292549.

Design Preferences for a Serious Game-Based Cognitive Assessment of Older Adults in Prison: Thematic Analysis.

BACKGROUND: Serious games have the potential to transform the field of cognitive assessment. The use of serious game-based cognitive assessments in prison environments is particularly exciting. This is because interventions are urgently needed to address the rapid increase in the number of currently incarcerated older adults globally and because of the heightened risks of dementia and cognitive decline present in this population. Game-based assessments are assumed to be fun, engaging, and suitable alternatives to traditional cognitive testing, but these assumptions remain mostly untested in older adults. This is especially true for older adults in prison, whose preferences and needs are seldom heard and may deviate from those previously captured in studies on cognition and serious games. OBJECTIVE: This study aimed to understand the design preferences of older adults in prison for a game-based cognitive assessment. METHODS: This study used reflexive thematic analysis, underpinned by critical realism, and applied the technique of abduction. Overall, 4 focus groups with a total of 20 participants were conducted with older adults (aged ≥50 years; aged ≥45 years for Aboriginal and Torres Strait Islander people) across 3 distinct prison environments in Australia. RESULTS: Self-determination theory was used as a theoretical foundation to interpret the results. Overall, 3 themes were generated: Goldilocks-getting gameplay difficulty just right through optimal challenge (the first theme emphasizes the participants' collective desire for an individualized optimal level of difficulty in serious gameplay), Avoiding Childish Graphics-gimmicky gameplay can be condescending (the second theme raises the importance of avoiding immature and childlike gameplay features, as some older end users in prison felt that these can be condescending), and A Balanced Diet-meaningful choice and variety keeps game-based assessments fun (the third theme highlights the strong user preference for meaningful choice and variety in any serious game-based cognitive assessment to maximize in-game autonomy). CONCLUSIONS: The collection of these themes provides novel insights into key game design preferences of marginalized older adults.

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.

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.

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.

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.

The role of demographic change in explaining the growth of Australia's older migrant population living with dementia, 2016-2051.

OBJECTIVE: To examine the demographic drivers contributing to the future growth in the population of older migrants in Australia living with dementia. METHODS: Using birthplace-specific cohort-component projection models, we projected the number of older migrants living with dementia. ABS data on births, deaths, migration and birthplace were used, alongside Australian Institute of Health and Welfare (AIHW) estimates of dementia prevalence with birthplace dementia weights calculated from administrative data. RESULTS: The number of older migrants living with dementia is projected to increase from about 134,423 in 2016 to 378,724 by 2051. Increases in populations with dementia varied considerably, from a slight decrease for those born in Southern & Eastern Europe to over 600% increases amongst the South-East Asia, Southern & Central Asia, and Sub-Saharan Africa-born populations. CONCLUSIONS: Cohort flow is the primary driver increasing the number of older migrants living with dementia. This growth is largely inevitable because the cohorts are already living in Australia as part of the migrant population, but currently at ages below 60 years. IMPLICATIONS FOR PUBLIC HEALTH: High relative growth and shifting birthplace composition in the number of migrants living with dementia poses implications for culturally appropriate care, health care access and workforce needs to support migrant families, carers and their communities.

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.

Demographic drivers of the growth of the number of Aboriginal and Torres Strait Islander people living with dementia, 2016-2051.

OBJECTIVE: To examine the demographic drivers that contribute to the future growth in the population of Aboriginal and Torres Strait Islander peoples living with dementia in Australia. METHODS: Design: Multistate, Indigenous status, cohort component, population projection model. SETTING: National-level, Aboriginal and Torres Strait Islander population. DATA: Data prepared by the Australian Bureau of Statistics on births, deaths, migration and identification change. Australian Institute of Health and Welfare estimates of dementia prevalence alongside estimates from several studies. MAJOR OUTCOME MEASURES: Number of older people living with dementia alongside a decomposition of demographic drivers of growth. RESULTS: By 2051, the relative growth in the number of Aboriginal and Torres Strait Islander peoples aged 50+ with dementia ranges from 4½ to 5½ times (under three prevalence scenarios) its 2016 estimate. Cohort flow (the gradual movement of younger cohorts into the 50+ age group, and the depletion of older cohorts from death, over time) is a key driver of the growth in the number of older people living with dementia. CONCLUSIONS: High growth in the number of people living with dementia poses implications for culturally appropriate care, health-care access and support for Aboriginal and Torres Strait Islander families, carers and their communities.

Development and initial validation of the falls health literacy scale.

OBJECTIVES: (i) To develop the Falls Health Literacy Scale (FHLS), a health literacy tool specific to falls, (ii) to evaluate the FHLS's construct validity towards differentiating individuals with different fall-related health literacy, and (iii) to determine its reliability, construct validity and structure in an older population. METHODS: The initial FHLS, developed based on Sørensen et al.'s health literacy model, was first administered to 144 participants aged ≥18 years for feedback and scale improvement and preliminary analysis to determine the FHLS's construct validity in identifying individuals with different fall-related health literacy. After scale refinement, the FHLS was validated in 227 community-living people aged ≥65 years. RESULTS: Adult participants with more fall prevention knowledge scored higher on the initial FHLS than those with less fall prevention knowledge (p≤0.001). The final FHLS includes a 25-item subjective and a 14-item objective scale. Older people with ≥1 fall in the past year reported lower FHLS-subjective scores than those who had no falls (Cohen's [d]=0.29, confidence interval [CI]:0.03-0.56, p=0.03). Older people with lower levels of education had lower FHLS-objective scores than their more educated counterparts (d=0.51, CI:0.38-1.43, p≤0.001). Factor analysis of the FHLS-subjective generated six subscales, with CFA showing adequate model fit (RMSEA=0.077, CFI=0.883 and χ2/df =2.35). FHLS-subjective (25-item) showed good reliability, with Cronbach's alpha=0.93, mean inter-item correlation=0.34 (range -0.03-0.81) and intra-class coefficient =0.86 (95% CI:0.69-0.93). CONCLUSION: The novel, context-specific FHLS displayed good construct validity and reliability. The FHLS holds promise as a screening tool to differentiate individuals with different degrees of fall-related health literacy, which may help guide fall prevention interventions.

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

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

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.