Strength together: examining risk and protective factors associated with dementia and cognitive impairment in Aboriginal and Torres Strait Islander peoples through harmonisation of landmark studies.

BACKGROUND: Rates of dementia for Aboriginal and Torres Strait Islander peoples are three to five times greater compared to non-Indigenous Australians, with earlier age of onset. However, the risk and protective factors that drive these higher rates vary across existing cohort studies, with minimal findings on the role of vascular risk factors beyond stroke. Harmonisation of data across studies may offer greater insights through enhanced diversity and strengthened statistical capabilities. This study aims to combine three landmark cohort studies of Aboriginal and Torres Strait Islander participants to better understand the determinants of cognitive health and dementia. METHODS/DESIGN: Three cohort studies - the Kimberley Healthy Adults Project (KHAP, N = 363), Koori Growing Old Well Study (KGOWS, N = 336) and Torres Strait Dementia Prevalence Study (TSDPS, N = 274) - share a similar research methodology with demographic, medical history, psychosocial factors, cognitive tests and consensus clinical diagnoses of cognitive impairment and dementia. Associations between risk and protective factors of interest and the presence of dementia and/or cognitive impairment diagnoses will be evaluated by univariable and multivariable logistic regression in a harmonised cross-sectional cohort of 898 participants. Factors associated with incident dementia and/or cognitive impairment will be assessed in a subset of KHAP (n = 189) and KGOWS participants (n = 165) who were available in longitudinal follow-up, after exclusion of those with baseline dementia or cognitive impairment. Analyses in relation to outcome measure of death or dementia will be conducted to account for the competing risk of death. Logistic regression will be used to evaluate the association between the individual components of the 16-component Kimberley Indigenous Cognitive Assessment (KICA) tool and the presence of dementia and cognitive impairment determined by independent consensus diagnoses. Multivariable binary logistic regression will be used to adjust for the effect of confounding variables. Results will be reported as odds ratios (OR) with 95% confidence intervals (95% CI). DISCUSSION: Greater understanding of risk and protective factors of dementia and cognitive impairment relevant to Aboriginal and Torres Strait Islander peoples may improve approaches across the life course to delay cognitive decline and reduce dementia risk.

Prevalence of functional limitations in older remote-living Aboriginal Australians.

INTRODUCTION: To better tailor prevention and care strategies, there is a need to identify modifiable factors associated with functional impairment in older Aboriginal people, and related service needs. OBJECTIVE: To investigate the prevalence and associated factors for functional impairment in older Aboriginal people, and related service needs. DESIGN: Cross-sectional survey of 289 Aboriginal people aged ≥45 years living in the remote Kimberley region of Western Australia. Factors associated with functional impairment were explored with logistic regression. FINDINGS: 41.2% (95% CI 35.6%-47.0%) of participants required assistance with at least one I/ADL, and 26.0% (95% CI 21.2%-31.3%) required assistance with two or more I/ADLs. A core activity limitation (required assistance with showering, dressing or cooking) was reported by 15.9% (95% CI 12.1%-20.6%). In multivariable logistic regression analyses, older age, diabetes, difficulty walking, head injury, higher depression score and worse cognition were associated with needing help with two or more I/ADLs, while older age, history of stroke, higher depression score and worse cognition were associated with the presence of a core activity limitation. The proportion of participants receiving support with I/ADLs ranged from 71.2% to 97.6%. Support was generally provided by family and friends rather than service providers. DISCUSSION: The key modifiable factors associated with functional impairment in older Aboriginal people living in remote regions are diabetes, depression and cognitive impairment. Services required are transport and socio-cultural activities, and ensuring support for family providing the majority of care. CONCLUSIONS: This study highlights the need for holistic prevention strategies and care for older Aboriginal people with functional limitations and their families.

Risk, protective, and biomarkers of dementia in Indigenous peoples: A systematic review.

INTRODUCTION: Dementia is an emergent health priority for Indigenous peoples worldwide, yet little is known about disease drivers and protective factors. METHODS: Database searches were conducted in March 2022 to identify original publications on risk, protective, genetic, neuroradiological, and biological factors related to dementia and cognitive impairment involving Indigenous peoples. RESULTS: Modifiable risk factors featured across multiple studies include childhood adversity, hearing loss, low education attainment, unskilled work history, stroke, head injury, epilepsy, diabetes, hypertension, hyperlipidemia, depression, low BMI, poor mobility, and continence issues. Non-modifiable risk factors included increasing age, sex, and genetic polymorphisms. Education, ex-smoking, physical and social activity, and engagement with cultural or religious practices were highlighted as potential protective factors. There is a paucity of research on dementia biomarkers involving Indigenous peoples. DISCUSSION: Greater understanding of modifiable factors and biomarkers of dementia can assist in strength-based models to promote healthy ageing and cognition for Indigenous peoples.

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.

Aboriginal community-controlled art centres: Keeping Elders strong and connected. Articulating an ontologically situated, intergenerational model of care.

OBJECTIVE: To articulate how Aboriginal community-controlled art centres support the role of Elders and older people within an ontologically situated, intergenerational model of care. METHODS: In this paper, we draw on stories (data) generated through interviews involving 75 people associated with three Aboriginal community-controlled art centres and field notes taken during a Participatory Action Research (PAR) study. The study was undertaken in collaboration with three community-controlled art centres and two aged care providers over almost 4 years, in diverse Indigenous sovereignties, all located in geographically remote Australian locations. RESULTS: Engaging with decolonising and Indigenous theoretical frameworks, our analysis identified three interwoven meta-themes. These include connection to law and culture; purpose; and healing. Each theme had important subthemes, and all were central to upholding the well-being of older people and their families, as well as the art centre workforce, Country, and their broader communities. CONCLUSIONS: Our analysis articulates an ontologically situated model of care within Aboriginal community-controlled art centres. The model sees that older people receive care from art centres and provide care to each other, to younger generations, to art centre staff, to Country, and to their broader communities. In this model, those in receipt of care, many of whom are older people, art centre directors, and important artists, govern how care is conceptualised and delivered.

Art centres supporting our Elders - 'old people, that's where our strength comes from' - results from a national survey of Australian Aboriginal and Torres Strait Islander community controlled art centres.

INTRODUCTION: There are approximately 90 Aboriginal and Torres Strait Islander community controlled art centres across Australia, the majority in geographically remote locations. This survey explored how these centres are supporting older people, including people living with dementia, if and how they are collaborating with aged care services and what challenges and opportunities they identify in these arrangements. METHODS: An online survey was developed by a team of Aboriginal and non-Aboriginal researchers, art centre staff and art centre consultants. The survey was distributed in 2018 to art centres across Australia via their four art centre peak bodies: Desart; the Association of Northern, Kimberley and Arnhem Aboriginal Artists; the Indigenous Art Centre Alliance - Far North Queensland and Torres Strait Islands; and the Aboriginal Art Centre Hub - Western Australia. The survey was also conducted face-to-face with participants at art centre annual events; and on field trips to North Western and Central Australia, conducted as part of an overarching study. RESULTS: There were 53 completed surveys, with the highest proportion of responses (43%) from art centre managers. The survey generated 330 qualitative responses to the 13 questions that provided this option. The results showed that art centres play a wide ranging and vital role in supporting the health and wellbeing of older artists, many of whom are considered Elders within their communities, and that this reaches far beyond the production of art. The results showed that art centres are a safe place providing older people with the purpose and means to generate income, to enact governance, and to share cultural knowledge through intergenerational connection. Additionally, the results indicate that art centres provide a significant amount of direct care for older people, and that relationships are fundamental to delivering this social, emotional, spiritual and physical care. Furthermore, they showed a great deal of collaboration between art centres and aged care services, although little of this is formally documented or resourced. CONCLUSION: The survey results demonstrate that art centres play a significant and previously unexplored role in supporting the wellbeing of older people and people living with dementia in remote Aboriginal and Torres Strait Islander communities across Australia. Respondents shared diverse examples of providing physical, social, emotional, spiritual and cultural care, assistance with navigating health and aged care systems, as well as examples of collaborations with aged care and health providers. The results demonstrate opportunities to recognise and resource this vital work. These findings are particularly important in the context of Australia's recent Royal Commission into Aged Care Quality and Safety, which found that systemic change is urgently required. Additionally, Indigenous scholars have called for a swell of system reform to address inequities in health and aged care systems. They advocate for a fundamental shift from biomedical and siloed models of care to integrated models that centralise culture, intergenerational connection and the cultural determinants of health. The results show that art centres could bring their expertise to this conversation.

Strong Carers, Strong Communities: a cluster randomised controlled trial to improve wellbeing of family carers of older people in remote Aboriginal communities.

INTRODUCTION: Unpaid carers have a crucial role in supporting older people with cognitive impairment and disability, but their own health and wellbeing are often impacted. There are limited data on how carer strain, depression and empowerment may be improved for carers. METHODS: This was a cluster randomised controlled trial to compare the effect of a carer support program developed with a community-based participatory action research (PAR) approach to the delivery of information sessions to 100 carers of people aged 45 years or more living in four remote Aboriginal communities in Western Australia. RESULTS: The mean age of carers was 38.3±14.9 years, 76% were female and 77% were children or grandchildren of the care recipient. Carer strain and empowerment measures did not change significantly between baseline and follow-up. A statistically significant decrease in depression scores was observed in the PAR group. However, decreases were observed in both the PAR and control groups, and the change in scores did not differ significantly between groups. Depression scores decreased most in those who had not attended high school. Overall, the proportion of participants meeting criteria for depression decreased from 18.8% at baseline to 8.3% at follow-up. CONCLUSION: A carer support program was of equivocal benefit, although this research demonstrates that the wellbeing of carers in remote Aboriginal communities can potentially be markedly improved by outreach strategies.

The Well-Being of Carers of Older Aboriginal People Living in the Kimberley Region of Remote Western Australia: Empowerment, Depression, and Carer Burden.

Objective: To describe demographic features and well-being of carers of Aboriginal Australians aged ≥45 years in remote Western Australia. Method: Carer burden, empowerment, and depression were assessed in 124 Aboriginal carers in four remote Aboriginal communities. Results: Carers were aged 38.8 ± 15.0 years, 73.4% were female, and 75.8% were children or grandchildren of the person cared for. The mean Zarit-6 score was 3.7 ± 3.6. Attending high school (odds ratio [OR] = 0.3; 95% confidence interval [CI] = [0.1, 0.7]) and feeling empowered (OR = 0.2; 95% CI = [0.1, 0.8]) were inversely associated with carer burden; female carers were less likely to feel empowered (OR = 0.4; 95% CI = [0.2, 0.9]); and empowerment was inversely associated with depression (OR = 0.3; 95% CI = [0.1, 0.7]). Discussion: Aboriginal carers in remote communities are relatively young and most are children or grandchildren. Carer burden was lower than anticipated. However, existing tools may not adequately measure Aboriginal perspectives. Education and empowerment are key factors which support programs must consider.

Prevalence and sites of pain in remote-living older Aboriginal Australians, and associations with depressive symptoms and disability.

BACKGROUND: Pain is a growing public health problem associated with significant health and functional implications. Limited data exist for Aboriginal Australians. AIMS: To describe the prevalence, severity and sites of pain, analgesic use and associated factors, including depression and disability, in remote-living Aboriginal Australians. METHODS: Cross-sectional study of 263 Aboriginal Australians aged ≥45 years from six remote Indigenous communities and the town of Derby in the Kimberley region of Western Australia between 2011 and 2013. Pain was assessed using a culturally adapted pain scale. Factors associated with pain were investigated with binary logistic regression. RESULTS: One hundred and seventy (64.6%) participants reported having pain and 53 (20.2%) reported persistent pain. Of those reporting pain, 61 (35.9%) rated it as moderate and 70 (41.2%) as severe. The most common sites of pain were back and knee, and 38 (22.4%) participants with pain indicated three or more sites of pain. Only 70 (41.2%) participants with pain were on some type of analgesic medication. After adjustment, poor vision (odds ratio (OR) = 2.21; 95% confidence interval (CI) 1.22-4.00), hypertension (OR = 1.89; 95% CI 1.03-3.45) and heart problems (OR = 2.05; 95% CI 1.01-4.14) were associated with pain. Higher depression scores were associated with more persistent pain, but pain was not significantly associated with clinically relevant depressive symptoms, or requiring assistance with two or more personal and/or instrumental activities of daily living. CONCLUSION: High levels of pain were reported, although the prevalence of persistent pain was comparable to the general population. Identifying risk factors, improving pain recognition and assessment and evaluating culturally tailored management approaches should be a priority.

Potentially suboptimal prescribing of medicines for older Aboriginal Australians in remote areas.

OBJECTIVES: To investigate the prevalence of polypharmacy, under-prescribing and potentially inappropriate medicine use among Aboriginal Australians living in remote Western Australia. DESIGN: Cross-sectional study. SETTING: Six remote communities and the town of Derby in the Kimberley, Western Australia. PARTICIPANTS: Aboriginal people aged 45 years or more with complete medication histories. MAIN OUTCOME MEASURES: Proportions of patients with medicine histories indicating polypharmacy, potential under-prescribing of indicated medicines, or potentially inappropriate prescribing (including potential prescribing cascades or drug interactions). RESULTS: Complete medicine histories were available for 273 participants. The mean number of prescribed medicines was 5.1 (SD, 3.6). At least one form of suboptimal prescribing was identified for 166 participants (61%), including polypharmacy for 145 (53%), potential under-prescribing of at least one indicated medicine for 33 (12%), and potentially inappropriate prescribing for 54 participants (20%). Potential prescribing cascades or drug interactions were identified for 12 participants (4%). CONCLUSIONS: Potentially suboptimal prescribing affected more than half the participating older Aboriginal Australians from the Kimberley. If generalisable to other remote Indigenous Australians, the prevalence of polypharmacy, potentially inappropriate prescribing, and under-prescribing of indicated medicines is problematic, and suggests that older Indigenous people in remote areas are at risk of medicine-related harm.

Assessment, incidence and factors associated with urinary incontinence in older Aboriginal Australians.

BACKGROUND: Little is known about urinary incontinence in older Aboriginal Australians. AIM: To describe urinary incontinence assessment, prevalence, incidence and associated conditions in older Aboriginal Australians. METHODS: Wave 1 consisted of 363 Aboriginal participants aged ≥45 years from Western Australia; 289 participants participated in Wave 2, with 184 included at both time points. Urinary incontinence was assessed by self-report, family report and the modified International Consultation on Incontinence Questionnaire (ICIQ). We investigated factors associated with incontinence with binary logistic regression. Sensitivity and specificity analyses of incontinence measures were undertaken using the ICIQ score ≥2 as the reference standard. RESULTS: Participant mean age was 61.2 ± 11.2 years. Prevalence of incontinence at Wave 2 (n = 289) using self-report was 24.6%; using ICIQ ≥2 was 22.5%; and family report 14.2%. Incidence after follow-up of 6.7 years was 33 (23.6%), higher than estimates of 5-20% in other populations. Cross-sectional associations with incontinence include female sex (odds ratio (OR) = 6.82; 95% confidence interval (CI) 2.98-15.57), stroke (OR = 3.55; 95% CI 1.43-8.77), head injury (OR = 3.15; 95% CI 1.54-6.45) and depressive symptoms (OR = 1.07; 95% CI 1.01-1.14). Longitudinal associations were age (OR = 1.05; 95% CI 1.01-1.09) and female sex (OR = 2.37; 95% CI 0.99-5.67). Sensitivity (81.5%) and specificity (93.5%) of self-report were high. CONCLUSION: The prevalence and incidence of urinary incontinence in Aboriginal Australians is high with risk factors of older age and female sex. The modified ICIQ and self-report appear to be appropriate incontinence screens. Further research to understand causes and treatments within this population is urgently required.

Falls risk assessment outcomes and factors associated with falls for older Indigenous Australians.

OBJECTIVE: To describe the prevalence of falls and associated risk factors in older Indigenous Australians, and compare the accuracy of validated falls risk screening and assessment tools in this population in classifying fall status. METHOD: Cross-sectional study of 289 Indigenous Australians aged ≥45 years from the Kimberley region of Western Australia who had a detailed assessment including self-reported falls in the past year (n=289), the adapted Elderly Falls Screening Tool (EFST; n=255), and the Falls Risk for Older People-Community (FROP-Com) screening tool (3 items, n=74) and FROP-Com falls assessment tool (n=74). RESULTS: 32% of participants had ≥1 fall in the preceding year, and 37.3% were classified high falls risk using the EFST (cut-off ≥2). In contrast, for the 74 participants assessed with the FROP-Com, only 14.9% were rated high risk, 35.8% moderate risk, and 49.3% low risk. The FROP-Com screen and assessment tools had the highest classification accuracy for identifying fallers in the preceding year (area under curve >0.85), with sensitivity/specificity highest for the FROP-Com assessment (cut-off ≥12), sensitivity=0.84 and specificity=0.73. CONCLUSIONS: Falls are common in older Indigenous Australians. The FROP-Com falls risk assessment tool appears useful in this population, and this research suggests changes that may improve its utility further.

Prevalence and incidence of frailty in Aboriginal Australians, and associations with mortality and disability.

OBJECTIVES: Frailty represents a loss of homeostasis, markedly increasing the risk of death and disability. Frailty has been measured in several ethnic groups, but not, to our knowledge, in Aboriginal Australians. We aimed to determine the prevalence and incidence of frailty, and associations with mortality and disability, in remote-living Aboriginal people. STUDY DESIGN: Between 2004 and 2006, we recruited 363 Aboriginal people aged ≥ 45 years from 6 remote communities and one town in the Kimberley region of Western Australia (wave 1). Between 2011 and 2013, 182 surviving participants were followed-up (wave 2). We assessed frailty with an index, comprising 20 health-related items. Participants with ≥ 4 deficits (frailty index ≥ 0.2) were considered frail. Disability was assessed by family/carer report. Those unable to do ≥ 2 of 6 key or instrumental activities of daily living were considered disabled. We investigated associations between frailty, and disability and mortality, with logistic regression and Cox proportional hazards models. RESULTS: At wave 1 (W1), 188 participants (65.3%) were frail, and of robust people at W1 who participated in wave 2, 38 (51.4%) had become frail. Frailty emerged at a younger age than expected. A total of 109 people died (30.0%), of whom 80 (73.4%) were frail at W1. Frailty at W1 was not associated with becoming disabled, but was associated with mortality (HR = 1.9; 95% CI 1.2, 3.0). CONCLUSIONS: Frailty in remote-living Aboriginal Australians is highly prevalent; substantially higher than in other populations. Research to understand the underlying causes of frailty in this population, and if possible, reverse frailty, is urgently needed.

Incidence and predictors of cognitive impairment and dementia in Aboriginal Australians: A follow-up study of 5 years.

INTRODUCTION: Aboriginal Australians are reported to develop dementia earlier than the general population. The causes remain unknown. METHODS: This was a longitudinal study of 363 participants aged ≥45 years. Consensus diagnoses were established for cognitive impairment or dementia. RESULTS: At follow-up, 189 people (mean ± standard deviation age, 65.4 ± 10.3 years) participated, as 109 (30%) had died and 65 (18%) were unavailable. The incidence of cognitive impairment or dementia was 52.6 (95% confidence interval 33.9, 81.5) per 1000 person-years (380.3 total person-years) and for dementia was 21.0 (10.5, 42.1) per 1000 person-years (380.3 person-years total) over the age 60 years. Longitudinal risk factors associated with a decline from normal cognition to impairment were age and head injury. Other associations with cognitive decline were stroke, head injury, nonaspirin analgesics, lower BMI, and higher systolic BP. DISCUSSION: Dementia incidence in Aboriginal Australians is among the highest in the world, and is associated with age and head injury.

The Kimberley assessment of depression of older Indigenous Australians: prevalence of depressive disorders, risk factors and validation of the KICA-dep scale.

OBJECTIVE: This study aimed to develop a culturally acceptable and valid scale to assess depressive symptoms in older Indigenous Australians, to determine the prevalence of depressive disorders in the older Kimberley community, and to investigate the sociodemographic, lifestyle and clinical factors associated with depression in this population. METHODS: Cross-sectional survey of adults aged 45 years or over from six remote Indigenous communities in the Kimberley and 30% of those living in Derby, Western Australia. The 11 linguistic and culturally sensitive items of the Kimberley Indigenous Cognitive Assessment of Depression (KICA-dep) scale were derived from the signs and symptoms required to establish the diagnosis of a depressive episode according to the DSM-IV-TR and ICD-10 criteria, and their frequency was rated on a 4-point scale ranging from 'never' to 'all the time' (range of scores: 0 to 33). The diagnosis of depressive disorder was established after a face-to-face assessment with a consultant psychiatrist. Other measures included sociodemographic and lifestyle factors, and clinical history. RESULTS: The study included 250 participants aged 46 to 89 years (mean±SD = 60.9±10.7), of whom 143 (57.2%) were women. The internal reliability of the KICA-dep was 0.88 and the cut-point 7/8 (non-case/case) was associated with 78% sensitivity and 82% specificity for the diagnosis of a depressive disorder. The point-prevalence of a depressive disorder in this population was 7.7%; 4.0% for men and 10.4% for women. Heart problems were associated with increased odds of depression (odds ratio = 3.3, 95% confidence interval = 1.2,8.8). CONCLUSIONS: The KICA-dep has robust psychometric properties and can be used with confidence as a screening tool for depression among older Indigenous Australians. Depressive disorders are common in this population, possibly because of increased stressors and health morbidities.