Pounding the Pavement: Is the Path to Brain Health Steeper for People Experiencing Greater Socioeconomic Deprivation?

Dementia is a global public health priority. Physical activity has myriad health benefits, including for reducing dementia risk. To increase physical activity, detailed understanding of influencing factors is needed. Socioeconomic deprivation affects many aspects of health and wellbeing. Qualitative research with older people experiencing socioeconomic deprivation is needed to explore barriers and enablers to engaging in physical activity, with the view to co-designing interventions for implementation trials. A whole of society approach is pivotal to improving effectiveness of physical activity interventions for older adults with cognitive impairment, and target support for people experiencing socioeconomic deprivation, to improve their health outcomes.

Too late for early intervention? The Healthy Ageing Service's mental health response.

OBJECTIVES: This paper describes the rationale for and development of an innovative mental health service for people aged over 65 years living in Northern and Eastern Melbourne, Victoria, Australia. CONCLUSION: The Healthy Ageing Service (HAS) was established in July 2020 to provide care for people aged over 65 years experiencing mild-to-moderate mental health concerns. It embraces a prevention and early intervention model of care. It provides primary consultation and brief intervention, secondary consultation, and capacity building to the primary healthcare sector. This innovative service is a Commonwealth-funded partnership between two tertiary mental health service providers that incorporates the recommendations from two major Royal Commissions. It demonstrates a service that acts as a bridge between primary and specialist mental health care, thereby extending mental health services to target the 'missing middle' and is potentially a model for mental health service provision throughout Victoria and Australia.

The Associations Between Neuropsychiatric Symptoms and Cognition in People with Dementia: A Systematic Review and Meta-Analysis.

Most people with dementia experience neuropsychiatric symptoms (NPS), including anxiety, depression or disinhibition. There is growing interest in the relationship between NPS and cognitive impairment, but data is still limited. This study aimed to investigate the specific associations between NPS and cognition in people with dementia. MEDLINE, EMBASE and PsycINFO were searched for published, peer-reviewed studies of associations between at least one NPS and one cognitive ability in people with dementia. The quality of the studies was assessed with the NIH National Heart, Lung and Blood Institute's quality assessment tools. A meta-analysis was conducted using Robumeta package for R. Ninety studies were included. We found significant associations between NPS, global cognition and cognitive domains, e.g. apathy was associated with global cognitive and memory impairment; dysphoria was associated with worse attention; delusions with executive dysfunction. Increased NPS in people with dementia are associated with worse cognitive performance. There were few studies looking at associations between some neuropsychiatric clusters and cognitive abilities, and there was little research on causal relationships. Our review was limited by the inclusion of studies that reported associations in specific formats, and most included people with a diagnosis of Alzheimer's disease (AD). However, given the large number of studies, this is unlikely to have biased results. More research is needed that includes diverse people with different dementia syndromes. Registration: PROSPERO 2020 CRD42020165565.

Physical Activity for Cognitive Health: A Model for Intervention Design for People Experiencing Cognitive Concerns and Symptoms of Depression or Anxiety.

BACKGROUND: People experiencing cognitive concerns and symptoms of depression or anxiety are at risk for Alzheimer's disease and dementia. We know physical activity can benefit cognition but understanding how to best support engagement is an ongoing challenge. Evidence-based conceptual models of factors underpinning physical activity engagement in target populations can inform intervention tailoring to address this challenge. OBJECTIVE: This study (part of a pragmatic physical activity implementation trial) aimed to develop a specified model of physical activity engagement in people experiencing depressive or anxiety symptoms and cognitive concerns, to enable optimized dementia risk reduction intervention tailoring. METHODS: We employed a qualitative design, triangulating data from three sources: semi-structured individual interviews with people experiencing cognitive concerns and mild to moderate depressive or anxiety symptoms; review of published evidence; and the Capability, Opportunity and Motivation system of behavior, an existing behavioral science model. Findings were integrated to develop a contextualized model of mechanisms of action for optimizing engagement. RESULTS: Twenty-one participants were interviewed, and 24 relevant papers included. Convergent and complementary themes extended understanding of intervention needs. Findings highlighted emotional regulation, capacities to enact intentions despite barriers, and confidence in existing skills as areas of population-specific need that have not previously been emphasized. The final model provides specificity, directionality, and linked approaches for intervention tailoring. CONCLUSION: This study demonstrated that people experiencing cognitive concerns and symptoms of depression or anxiety require different interventions to improve physical activity engagement. This novel model can enable more precise intervention tailoring, and, ultimately, benefits for a key at-risk population.

Preferences and Perspectives of Australian General Practitioners Towards a New "Four-in-One" Risk Assessment Tool for Preventative Health: The LEAD! GP Project.

BACKGROUND: Dementia risk reduction is a public health priority and general practitioners (GPs) play a pivotal role in preventative healthcare. Therefore, risk assessment tools should be designed with GPs' preferences and perspectives in mind. OBJECTIVE: The LEAD! GP project aimed to investigate Australian GPs' preferences and perspectives relating to design, use and implementation of a new risk assessment tool that simultaneously calculates risk for four outcomes- dementia, diabetes mellitus, myocardial infarct, and stroke. METHODS: A mixed methods study using semi-structured interviews of a diverse group of 30 Australian GPs was conducted. Interview transcripts were analyzed thematically. Demographics and questions that elicited categorical answers were analyzed descriptively. RESULTS: Overall, GPs felt that preventative healthcare was important with some finding it rewarding, and others finding it difficult. GPs currently use many risk assessment tools. GPs' perception of the usefulness and negatives/barriers of tools related to clinical practice applicability, patient engagement, and practical aspects. The largest barrier was lack of time. GPs responded positively to the concept of a four-in-one tool and preferred it to be relatively short, supported by practice nurses and some patient involvement, linked to education resources, available in different formats, and integrated into practice software. CONCLUSION: GPs recognize the importance of preventative healthcare and the potential benefit of a new tool that simultaneously predicts risk for those four outcomes. Findings provide important guidance to inform the final development and piloting of this tool with potential to improve efficiency and practical integration of preventative healthcare for dementia risk reduction.

An evaluation of the aged mental health and primary care partnership program.

OBJECTIVE: To evaluate the Mental Health and Primary Care Partnership (MaP) pilot program which operated in a metropolitan Melbourne setting in 2020. METHOD: Data collection included: surveys, interviews, file audits, and an evaluation of routinely collected data, with MaP consumers, their carers, GPs, Practice Managers and Nurses located in Boroondara, and MaP and Aged Person's Mental Health Service staff. RESULTS: Thirty-five consumers aged between 66 and 101 years old (of whom 63% were female) received support from the MaP program throughout its 12-month operation. Statistically significant improvements in outcome measures assessing for psychological distress and symptoms of mental illness were observed. Strengths of the program included the single referral pathway and the provision of services for those not meeting criteria to access tertiary mental health support. Consumers and clinicians made recommendations for service improvement including provision of a longer duration of care to consumers and greater integration of community and primary care. CONCLUSIONS: It is hoped that the learnings from the MaP pilot program can be used to guide future program development.

Quality of life and loneliness post-bereavement: Results from a nationwide survey of bereaved older adults.

Older people experience bereavements more often than any other age group. National survey data collected across Australia from 633 bereaved adults aged 65+ years showed that 21% met the criteria for prolonged grief. Their quality of life was significantly lower and loneliness significantly higher compared to older people in the general population. Risk factors for the low quality of life and high loneliness post-bereavement included being female, experiencing the death of a partner, and being the full-time carer of the deceased. Time since bereavement, expectedness, and cause of death were not significantly associated with quality of life and loneliness.

Factors Influencing Long-Term Physical Activity Maintenance: A Qualitative Evaluation of a Physical Activity Program for Inactive Older Adults at Risk of Cognitive Decline: The INDIGO Follow-Up Study.

BACKGROUND: Physical inactivity is a modifiable risk factor for dementia, but there remains a research translation gap in effective physical activity (PA) implementation, particularly in the longer-term. The INDIGO trial investigated the effectiveness of a six-month PA intervention for inactive older adults at risk of cognitive decline with subjective cognitive decline or mild cognitive impairment. OBJECTIVE: This follow-up study aimed to collect feedback from INDIGO participants about their experience of involvement in the trial, including barriers and enablers to longer-term maintenance of PA. METHODS: A qualitative study using semi-structured individual interviews was conducted and transcripts analyzed thematically. All INDIGO trial completers were invited, with 29 participating (follow-up period 27-66 months post-baseline). RESULTS: At long-term follow-up, participants described INDIGO trial participation as beneficial. The theme of "Motivation" (subthemes: structure and accountability, knowledge and expected benefits, preferences and motivation, tools) followed by "Situation" (subthemes: environment and time, social aspects, aging and physical health) appeared to be critical to PA "Action". Most participants had a positive view of goal-setting and peer mentoring/support, but there was some polarization of opinion. Key factors to longer-term "Maintenance" of PA were self-efficacy and perceived benefits, habit formation, and for some participants, enjoyment. CONCLUSION: PA interventions for older adults at risk of cognitive decline should include behavior change techniques tailored to the individual. Effective techniques should focus on "Motivation" (particularly structure and accountability) and "Situation" factors relevant to individuals with the aim of developing self-efficacy, habit formation, and enjoyment to increase the likelihood of longer-term PA maintenance.

Exercise interventions to reduce anxiety in mid-life and late-life anxiety disorders and subthreshold anxiety disorder: a systematic review.

Background: Anxiety disorders are highly prevalent and cause significant distress, disability, and cost. Medication adverse effects and interactions increase in mid-life and late-life, highlighting the need for effective non-pharmacological interventions. Objectives: We aimed to evaluate the extent of evidence supporting exercise interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life. Design: Systematic review. Data Sources and Methods: We searched MEDLINE, PsycINFO, Embase, Emcare, Ovid Nursing, CINAHL Plus, Cochrane Library, Health Collection, Humanities & Social Sciences Collection, and https://clinicaltrials.gov databases for trials published January 1994-May 2019. Randomised controlled trials of exercise interventions involving aerobic exercise or resistance training for adults aged 40 years and above with anxiety or subthreshold anxiety disorders in residential or health settings were identified. The primary outcome was change in anxiety. We excluded trials including participants aged below 40 years, participants with diagnosis of separation anxiety, selective mutism, obsessive-compulsive disorder, acute stress disorder and post-traumatic stress disorder, and head-to-head comparisons of interventions. Trial quality was assessed using the Cochrane Risk of Bias Tool and evidence synthesised in narrative form. Results: Four trials totalling 132 participants met inclusion criteria, although some had methodological limitations. Interventions included a home-based resistance training intervention, supervised group-based aerobic intervention, Tai Chi intervention, and supervised group-based aerobic and strength intervention. Three trials included late-life participants and the fourth mid-life. Three trials demonstrated greater reductions in anxiety in the intervention group compared with control. The fourth trial showed pre-post reductions in anxiety in both groups, with between-group difference not reaching statistical significance. Conclusion: There is limited supportive evidence suggesting that exercise interventions have potential to be effective, feasible and safe non-pharmacological interventions for anxiety and subthreshold anxiety disorders in mid-life and late-life. The heterogeneity, limited number and high risk of bias of some trials meant that we were not able to conduct a meta-analysis. Tailoring of interventions may improve uptake and reduce dropout. The paucity of research in this area with only four included trials demonstrates the urgent need for future and larger trials to provide proof of concept, data about effective types and doses of exercise interventions, and guidance to community, clinical, and public health services.

Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial.

OBJECTIVES: To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs). METHODS: Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8-12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest RESULTS: We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61-100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11-1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02-0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%). CONCLUSIONS: Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.

Testing the use of translation apps to overcome everyday healthcare communication in Australian aged-care hospital wards-An exploratory study.

AIMS AND OBJECTIVES: To trial three mobile translation apps in the healthcare setting to address language barriers in everyday care between healthcare staff and older people with limited English proficiency (LEP). DESIGN: A mixed-methods exploratory study. METHODS: A two-month trial of three translation apps was conducted across four aged-care hospital wards. Observed interactions during use of translation apps were recorded, and staff surveys regarding the use of translation apps were collected at the end of the trial. Data were analysed using descriptive statistics and thematic content analysis of open-ended responses in the surveys and observations. Findings from the thematic content analysis are reported using the Standards for Reporting of Qualitative Research (SRQR) checklist. RESULTS: Translation apps were mostly used for identifying pain and assisting with activities of daily living. Qualitative findings revealed that translation apps aided staff in providing care and improved rapport; however, practical shortcomings were identified.

The Support Person's Preferences and Perspectives of Physical Activity Programs for Older Adults With Cognitive Impairment.

Objectives: Physical activity (PA) is beneficial for older adults' cognition. There is limited research investigating perspectives of support persons (SPs) of next-of-kins (NOKs) with cognitive impairment. This exploratory study aimed to investigate perspectives of SPs of older adults with Alzheimer's Dementia (AD) or Mild Cognitive Impairment (MCI). Methods: A telephone survey of 213 SPs of NOKs from the Australian Imaging, Biomarkers and Lifestyle Flagship Study of Ageing (AIBL) was undertaken to quantitatively assess SPs' beliefs and knowledge about PA benefits, current PA level of their NOK, and PA program preferences. The contribution of age, gender, diagnosis and mental health symptoms was assessed using multiple logistic regression analyses. Results: Many SPs were aware of PA benefits for memory (64%) and believed it would help their NOK (72%). Older SP age was associated with less awareness of benefits (p = 0.016). SPs caring for male NOKs were more likely to believe that PA would be helpful than those caring for female NOKs (p = 0.049). NOK AD diagnosis (rather than MCI) (p = 0.014), older age (p = 0.005) and female gender (p = 0.043) were associated with lower PA levels. SPs were mixed regarding preference for their NOKs to participate in individual (45%) or group (54%) PA. Many SPs wanted to participate in PA with their NOK (63%). Conclusions: The results highlight that SPs have high levels of awareness of the cognitive benefits of PA, and describe their preferences regarding PA programs. The findings provide new information to inform targeted public health messaging, PA prescribers and providers, and future research directions.

Ethnic Differences in Barriers and Enablers to Physical Activity Among Older Adults.

Despite its well-known health benefits, most older adults do not commit to undertaking sufficient physical activity (PA). In this study we aimed to examine the perceived benefits of and barriers and enablers to PA from the perspectives of older Caucasian and Chinese adults living in Australia. Individual and group interviews with 17 Caucasian (mean age: 72.8 years) and 47 Chinese adults (mean age: 74.0 years) were conducted and analysed using thematic analysis. Overall, participants knew about the benefits of PA on physical health but had inconsistent views on its benefits on mental and cognitive health. Older Caucasian and Chinese adults reported similar barriers (e.g., health issues, costs, bad weather and lack of time) and enablers (e.g., improving health; environmental enablers such as adequate and walkable spaces and good natural environment; peer support; and self-motivation) to PA. In comparison, older Chinese adults reported barriers more often, and reported some unique barriers relating to language and culture issues. The findings contribute to developing targeted PA programs for older Caucasian and Chinese adults.

General population perspectives of dementia risk reduction and the implications for intervention: A systematic review and thematic synthesis of qualitative evidence.

BACKGROUND: Evidence for the potential prevention of dementia through lifestyle risk factor modification is growing and has prompted examination of implementation approaches. Understanding the general population's perspectives regarding dementia risk reduction is key to implementation. This may provide useful insights into more effective and efficient ways to help people change relevant beliefs, motivations and behaviour patterns. We conducted a systematic review and thematic synthesis of qualitative evidence to develop an integrated model of general population dementia risk reduction perspectives and the implications for intervention in research and implementation contexts. METHODS AND FINDINGS: We searched electronic databases, supplemented by lateral search techniques, to identify studies published since 1995 reporting qualitative dementia risk reduction perspectives of the non-expert general population who do not have dementia. Thematic synthesis, incorporating an expert panel discussion, was used to identify overarching themes and develop an integrated model to guide intervention to support individuals to adopt and maintain dementia risk reduction behaviour patterns. Quality of included studies and confidence in review findings were systematically appraised. We included 50 papers, reflecting the views of more than 4,500 individuals. Main themes were: 1) The need for effective education about a complex topic to prevent confusion and facilitate understanding and empowerment; 2) Personally relevant short- and long-term benefits of dementia risk reduction behaviour patterns can generate value and facilitate action; 3) Individuals benefit from trusted, reliable and sensitive support to convert understanding to personal commitment to relevant behaviour change; 4) Choice, control and relevant self-regulatory supports help individuals take-action and direct their own progress; 5) Collaborative and empowering social opportunities can facilitate and propagate dementia risk reduction behaviour change; 6) Individual behaviour patterns occur in social contexts that influence beliefs through heuristic processes and need to be understood. Findings indicate that, for intervention: 1) education is key, but both content and delivery need to be tailored; 2) complementary interventions to support self-regulation mechanisms and social processes will increase education effectiveness; 3) co-design principles should guide intervention design and delivery processes; 4) all interventions need to be supported by context-specific data. CONCLUSIONS: This systematic review and thematic synthesis provides a comprehensive, integrated model of the dementia risk reduction perspectives of the general population and intervention approaches to support behaviour change that can be applied in clinical trial and real-world implementation settings. Findings extend existing knowledge and may assist more effective intervention design and delivery.