Post-diagnosis young onset dementia (YOD) care is often fragmented, with services delivered across aged care, health care, and social care sectors. The aim of this project was to test the feasibility and effectiveness of a learning collaborative implementation strategy for improving the cross-sector integration of care for people with YOD.

We conducted a longitudinal mixed-methods process evaluation, and recruited one representative from three Australian aged care organisations, three disability care organisations, and three organisations contracted to deliver care navigation services. One representative from each organisation joined a learning collaborative within their local area and completed a six-module online education package incorporating written resources, webinars, collaboration, and expert mentoring. Participants identified gaps in services in their region and barriers to care integration, and developed a shared plan to implement change. Normalisation Process Theory was applied to understand acceptability, penetration, and sustainability of the implementation strategy, as well as barriers and enabling factors.

Dementia knowledge measured by the Dementia Knowledge and Awareness Scale was high among the professionals at the start of the implementation period (Mean = 39.67, standard deviation = 9.84) and did not change by the end (Mean=39.67, standard deviation = 8.23). Quantitative data demonstrated that clinicians dedicated on average half of the recommended time commitment to the project. However, qualitative data identified that the learning collaborative strategy enhanced commitment to implementing integrated care and promoted action toward integrating previously disparate care services. Participant commitment to the project was influenced by their sense of obligation to their team, and teams that established clear expectations and communication strategies early were able to collaborate and use the implementation plan more effectively (demonstrating collective action). Teams were less likely to engage in the collective action or reflexive monitoring required to improve care integration if they did not feel engaged with their learning collaborative.

Learning collaboratives hold promise as a strategy to improve cross-sector service collaboration for people with YOD and their families but must maximise group cohesion and shared commitment to change.

This study aimed to examine the impact of community mental health (CMH) care following index hospital-treated intentional self-harm (ISH) on all-cause mortality. A secondary aim was to describe patterns of CMH care surrounding index hospital-treated ISH.

A longitudinal whole-of-population record linkage study was conducted (2014–2019), with index ISH hospitalization (Emergency Department and/or hospital admissions) linked to all available hospital, deaths/cause of death, and CMH data.

Australia’s most populous state, New South Wales (NSW) comprised approximately 7.7 million people during the study period. CMH services are provided statewide, to assess and treat non-admitted patients, including post-discharge review.

Individuals with an index hospital presentation in NSW of ISH during the study period, aged 45 years or older.

CMH care within 14 days from index, versus not.

Cox-proportionate hazards regression analysis evaluated all-cause mortality risk, adjusted for relevant covariates.

Totally, 24,544 persons aged 45 years or older experienced a nonfatal hospital-treated ISH diagnosis between 2014 and 2019. CMH care was received by 56% within 14 days from index. Survival analysis demonstrated this was associated with 34% lower risk of death, adjusted for age, sex, marital status, index diagnosis, and 14-day hospital readmission (HR 0.66, 95% CI 0.58, 0.74, p < 0.001). Older males and chronic injury conveyed significantly greater risk of death overall.

CMH care within 14 days of index presentation for self-harm may reduce the risk of all-cause mortality. Greater effort is needed to engage older males presenting for self-harm in ongoing community mental health care.

To characterize the features of aged care users who died by suicide and examine the use of mental health services and psychopharmacotherapy in the year before death.

Population-based, retrospective exploratory study

Individuals who died while accessing or waiting for permanent residential aged care (PRAC) or home care packages in Australia between 2008 and 2017.

Linked datasets describing aged care use, date and cause of death, health care use, medication use, and state-based hospital data collections.

Of 532,507 people who died, 354 (0.07%) died by suicide, including 81 receiving a home care package (0.17% of all home care package deaths), 129 in PRAC (0.03% of all deaths in PRAC), and 144 approved for but awaiting care (0.23% of all deaths while awaiting care). Factors associated with death by suicide compared to death by another cause were male sex, having a mental health condition, not having dementia, less frailty, and a hospitalization for self-injury in the year before death. Among those who were awaiting care, being born outside Australia, living alone, and not having a carer were associated with death by suicide. Those who died by suicide more often accessed Government-subsidized mental health services in the year before their death than those who died by another cause.

Older men, those with diagnosed mental health conditions, those living alone and without an informal carer, and those hospitalized for self-injury are key targets for suicide prevention efforts.

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.

A two-phase study design comprised of a qualitative thematic analysis following a quantitative regression and moderation analysis.

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.

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.

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.

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.

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.

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.

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).

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.

People with dementia can face barriers when trying to access care after a diagnosis, particularly in young-onset dementia (YOD). Little is known about the effects of ethnicity on the use of anti-dementia medication and variations between age groups. The aim of this study was to analyze national data on variations in the uptake of anti-dementia medication between people with YOD and late-onset dementia (LOD).

Cross-sectional longitudinal cohort study.

Data from the U.S. National Alzheimer’s Coordinating Centre were obtained from September 2005 to March 2019.

First visits of people with a diagnosis of Alzheimer’s disease (AD) dementia, Lewy body dementia (LBD), and Parkinson’s disease dementia (PDD) were included.

Logistic regression was used to analyze the effects of education and ethnicity on use of cholinesterase inhibitors and memantine, accounting for YOD/LOD, gender, living situation, severity stage, and comorbidities.

In total, 15,742 people with AD dementia and LBD/PDD were included, with 11,019 PwD having completed a first follow-up visit. Significantly more people with YOD used memantine than those with LOD, while fewer used cholinesterase inhibitors. PwD from minority ethnic backgrounds used memantine and cholinesterase inhibitors less often than those from a White ethnic background. Logistic regression analysis showed that ethnicity was a significant determinant of both memantine and cholinesterase inhibitors usage, while education was only a significant determinant for memantine usage.

Findings highlight the impact of social factors on current usage of anti-dementia medication and the need for more resources to enable equitable use of anti-dementia medication.

Use of antipsychotic drugs in long-term aged care (LTC) is prevalent and commonly exceeds the recommended duration, but contributors to this problem are not well understood. The objective of this study is to provide a snapshot of the features of and contributors to prolonged use of antipsychotic medications (>12 weeks) among a sample of LTC residents.

We present retrospective and baseline data collected for the Australian Halting Antipsychotic Use in Long-Term Care (HALT) single-arm longitudinal deprescribing trial.

Twenty-four long-term care facilities in Sydney, Australia.

The HALT study included 146 older people living in 24 Sydney LTC homes who had been prescribed a regular antipsychotic medication for at least 3 months at baseline.

Detailed file audit was conducted to identify the date and indication recorded at initial prescription, consenting practices, longitudinal course of prescribing, and recommendations for review of antipsychotic medication. Behavioural and psychological symptoms of dementia (BPSD) and functional dependence at baseline were assessed via LTC staff interview. Cognition at baseline was assessed in a participant interview (where possible).

Antipsychotics were prescribed for 2.2 years on average despite recommendations by a doctor or pharmacist for review in 62% of cases. Consent for antipsychotic prescription was accessible for only one case and contraindications for use were common. Longer use of antipsychotics was independently associated with higher dose of the antipsychotic drug and greater apathy, but not with other BPSD.

Antipsychotic medications appeared to be prescribed in this sample as a maintenance treatment in the absence of active indicated symptoms and without informed consent. Standard interventions, including recommendations for review, had been insufficient to ensure evidence-based prescribing.

To follow-up a cohort of older people who self-harmed, their carer, and general practitioner (GP) and examine their reflections on the self-harm, care experiences, and outcomes.

Qualitative in-depth interviews.

Two teaching hospitals and associated community services.

Twelve-month follow-up of participants aged 80 or older who self-harmed, their nominated carers, and GPs.

A geriatric psychiatrist gathered data through patient and carer interviews using a narrative inquiry approach and from medical records. Interviews were audio recorded and transcribed. N-VIVO facilitated data organization for thematic analysis. Questionnaires sent to the patient’s GP examined their perspectives and aspects of care relating to the self-harm.

Nineteen patients (63% baseline sample), 29 carers (90.6%), and 11 GPs (36.7%) were available at follow-up. Themes emerging from patients were “denial and secrets;” “endless suffering;” “more invalidation;” “being heard;” and “miserable in care.” Themes from carer interviews were “denial and secrets;” “patient’s persistent wish to die;” “abandonment by clinicians;” “unending burden for the carer;” and “distress regarding placement.” General practitioner themes were “the problem is fixed;” “the troops have arrived;” and “I understand.”

Factors contributing to self-harm persisted at follow-up. Positive and negative responses were identified in the older person’s system, highlighting areas for potential intervention. A conceptual framework for understanding self-harm in the very old was derived that emphasized the importance of understanding individual needs, the interpersonal context of the older person, and carer burden. Interventions should improve communication, facilitate shared understanding of perspectives, and provide support at all levels.

Modifiable factors associated with increased risk of cognitive decline include emotional (anxiety, depression), cognitive (low social and mental stimulation), and health factors (smoking, alcohol use, sedentary lifestyle, obesity). Older adults with anxiety and depression may be at heightened risk due to direct and indirect impacts of emotional distress on cognitive decline.

Randomized controlled trial

Community sample attending a university clinic. Participants: 27 participants (female = 20) aged over 65 years (M = 72.56, SD = 6.74) with an anxiety and/or mood disorder. Interventions: two cognitive behavioral therapy (CBT) interventions (face-to-face or low intensity) that targeted emotional, health, and cognitive risks for cognitive decline.

Participants completed diagnostic interviews; self-report measures of anxiety, depression, quality of life, and lifestyle factors at baseline; post-treatment; and 3-month follow-up.

Both interventions resulted in significant and sustained improvements in depression, anxiety, quality of life, and physical and social activity. At post-treatment, face-to-face CBT demonstrated significantly greater improvements in emotional symptoms, alcohol use, and memory (exercise approached significance). At 3-month follow-up, gains were maintained and there were significantly greater increases in mental activity for face-to-face CBT, with social activity approaching significance. Conclusions: This study demonstrates the feasibility of CBT interventions to reduce emotional as well as lifestyle risk factors associated with cognitive decline in at-risk older participants. Large studies are needed to evaluate the long-term impact on cognitive decline. The trial was registered with the Australian and New Zealand Clinical Trials Registry (Trial Registration No. ACTRN12618000939291).

None.

Inappropriate use of antipsychotic medications to manage Behavioral and Psychological Symptoms of Dementia (BPSD) continues despite revised guidelines and evidence for the associated risks and side effects. The aim of the Halting Antipsychotic Use in Long-Term care (HALT) project is to identify residents of long-term care (LTC) facilities on antipsychotic medications, and undertake an intervention to deprescribe (or cease) these medicines and improve non-pharmacological behavior management.

LTC facilities will be recruited across Sydney, Australia. Resident inclusion criteria will be aged over 60 years, on regular antipsychotic medication, and without a primary psychotic illness or very severe BPSD, as measured using the Neuropsychiatric Inventory (NPI). Data collection will take place one month and one week prior to commencement of deprescribing; and 3, 6 and 12 months later. During the period prior to deprescribing, training will be provided for care staff on how to reduce and manage BPSD using person-centered approaches, and general practitioners of participants will be provided academic detailing. The primary outcome measure will be reduction of regular antipsychotic medication without use of substitute psychotropic medications. Secondary outcome measures will be NPI total and domain scores, Cohen-Mansfield Agitation Inventory scores and adverse events, including falls and hospitalizations.

While previous studies have described strategies to minimize inappropriate use of antipsychotic medications in people with dementia living in long-term care, sustainability and a culture of prescribing for BPSD in aged care remain challenges. The HALT project aims to evaluate the feasibility of a multi-disciplinary approach for deprescribing antipsychotics in this population.

Medicinal substances have been identified as common agents of both unintentional and intentional poisoning among older people, including those with dementia. This study aims to compare the characteristics of poisoning resulting in hospitalization in older people with and without dementia and their clinical outcomes.

A retrospective cohort study involving an examination of poisoning by intent involving individuals aged 50+ years with and without dementia using linked hospitalization and mortality records during 2003–2012. Individuals who had dementia were identified from hospital diagnoses and unintentional and intentional poisoning was identified using external cause classifications. The epidemiological profile (i.e. individual and incident characteristics) of poisoning by intent and dementia status was compared, along with clinical outcomes of hospital length of stay (LOS), 28-day readmission and 30-day mortality.

The hospitalization rate for unintentional and intentional poisoning for individuals with dementia was double and 1.5 times higher than the rates for individuals without dementia (69.5 and 31.6 per 100,000) and (56.4 and 32.5 per 1,00,000). The home was the most common location of poisoning. Unintentional poisoning was more likely to involve individuals residing in aged care facilities (OR 2.12; 95%CI 1.70–2.63) or health service facilities (OR 3.91; 95%CI 3.45–4.42). There were higher mortality rates and longer LOS for unintentional poisoning for individuals with dementia.

Clinicians need to be aware of the risks of poisoning for individuals with dementia and care is required in appropriate prescription, safe administration, and potential for self-harm with commonly used medications, such as anticholinesterase medications, antihypertensive drugs, and laxatives.