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.

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.

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.

Dementia risk reduction in practice: the knowledge, opinions and perspectives of Australian healthcare providers.

This study examined Australian primary healthcare providers' knowledge about dementia risk factors and risk reduction and their perspectives on barriers and enablers to risk reduction in practice. Primary healthcare providers were recruited through Primary Health Networks across Australia (n=51). Participants completed an online survey that consisted of fixed-responses and free-text components to assess their knowledge, attitudes and current practices relating to dementia risk factors and risk reduction techniques. The results showed that Australian primary healthcare providers have good knowledge about the modifiable risk factors for dementia; however, face several barriers to working with patients to reduce dementia risk. Commonly reported barriers included low patient motivation and healthcare system level limitations. The most commonly reported recommendations to helping primary healthcare providers to work with patients to reduce dementia risk included increasing resources and improving dementia awareness and messaging. While the results need to be interpreted in the context of the limitations of this study, we conclude that collaborative efforts between researchers, clinicians, policy makers and the media are needed to support the uptake of risk reduction activities in primary care settings.

Mild cognitive impairment in Aboriginal Australians.

INTRODUCTION: Aboriginal Australians have among the highest rates of dementia worldwide, yet no study has investigated the subtypes, risk factors, or longer term outcomes of mild cognitive impairment (MCI) in this population. METHODS: A total of 336 community-dwelling Aboriginal Australians aged ≥60 years participated in a longitudinal study, completing a structured interview at baseline. MCI (amnestic subtype, aMCI; non-amnestic subtype, naMCI) and dementia were diagnosed via cognitive screening, medical assessment, and clinical consensus. Associations between life-course factors and baseline MCI subtypes were examined using logistic regression. Conversion to dementia was assessed at 6-year follow-up. RESULTS: Prevalent aMCI (n = 24) was associated with older age (odds ratio [OR] = 1.68, 95% confidence interval [CI]: 1.12 to 2.53), head injury (OR = 3.19, 95% CI: 1.35 to 7.56), symptoms of depression (OR = 1.52, 95% CI: 1.04 to 2.24), and lower blood pressure (OR = 0.53, 95% CI: 0.33 to 0.86). Prevalent naMCI (n = 29) was associated with low education (OR = 4.46, 95% CI: 1.53 to 13.05), unskilled work history (OR = 5.62, 95% CI: 2.07 to 13.90), higher body mass index (OR = 1.99, 95% CI: 1.30 to 3.04), and moderate to severe hearing loss (OR = 2.82, 95% CI: 1.06 to 7.55). A small proportion of MCI cases reverted to intact at follow-up (15%), but most remained stable (44%), developed dementia and/or died (41%). DISCUSSION: Sociodemographic and clinical factors both contributed to baseline MCI and were distinct for MCI subtypes, with similar patterns of conversion to dementia for amnestic and non-amnestic MCI.

Factors Associated with the High Prevalence of Dementia in Older Aboriginal Australians.

Dementia prevalence in Aboriginal and Torres Strait Islander Australians is three to five times higher than the general Australian population. A better understanding of the underlying biomedical and social risk factors is needed to guide dementia prevention in Aboriginal Australians. The current study is the first to examine potential risk factors for dementia in the majority urban and regional population, with a representative sample of 336 Aboriginal Australians aged 60 years and older. Participants included 45 people with a dementia diagnosis (n = 27 probable/possible Alzheimer's disease); and 286 people without dementia. Univariate logistic regression analyses (controlling for age) identified childhood trauma, mid-life factors (history of unskilled work, past high-risk alcohol use), and medical factors (history of stroke, head injury with loss of consciousness, epilepsy) as risk factors for dementia. Multivariable analysis revealed age, childhood trauma, unskilled work, stroke, and head injury as independent predictors of all-cause dementia. A range of comorbid factors related to dementia was also identified (i.e., functional impairment, incontinence, recent hospital admission, low body mass index, living in residential care, depression, current high-risk alcohol use, social isolation, low physical activity levels). These findings extend previous outcomes in a remote Aboriginal population by highlighting that life-course social determinants of health, in addition to neurological disorders, likely play an important role in elevating dementia risk. Certain psychosocial and medical exposures are highly prevalent in Aboriginal Australians, similar to other indigenous populations, and should be considered when designing targeted and culturally appropriate prevention initiatives to reduce the burden of dementia.