Characterising Australian memory clinics: current practice and service needs informing national service guidelines

Background: Memory clinics (MCs) play a key role in accurate and timely diagnoses and treatment of dementia and mild cognitive impairment. However, within Australia, there are little data available on current practices in MCs, which hinder international comparisons for best practice, harmonisation efforts and national coordination. Here, we aimed to characterise current service profiles of Australian MCs. Methods: The ‘Australian Dementia Network Survey of Expert Opinion on Best Practice and the Current Clinical Landscape’ was conducted between August-September 2020 as part of a larger-scale Delphi process deployed to develop national MC guidelines. In this study, we report on the subset of questions pertaining to current practice including wait-times and post-diagnostic care. Results: Responses were received from 100 health professionals representing 60 separate clinics (45 public, 11 private, and 4 university/research clinics). The majority of participants were from clinics in metropolitan areas (79%) and in general were from high socioeconomic areas. While wait-times varied, only 28.3% of clinics were able to offer an appointment within 1-2 weeks for urgent referrals, with significantly more private clinics (58.3%) compared to public clinics (19.5%) being able to do so. Wait-times were less than 8 weeks for 34.5% of non-urgent referrals. Only 20.0 and 30.9% of clinics provided cognitive interventions or post-diagnostic support respectively, with 7.3% offering home-based reablement programs, and only 12.7% offering access to group-based education. Metropolitan clinics utilised neuropsychological assessments for a broader range of cases and were more likely to offer clinical trials and access to research opportunities. Conclusions: In comparison to similar countries with comprehensive government-funded public healthcare systems (i.e., United Kingdom, Ireland and Canada), wait-times for Australian MCs are long, and post-diagnostic support or evidence-based strategies targeting cognition are not common practice. The timely and important results of this study highlight a need for Australian MCs to adopt a more holistic service of multidisciplinary assessment and post-diagnostic support, as well as the need for the number of Australian MCs to be increased to match the rising number of dementia cases

Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: Study protocol for a phase II cluster randomised controlled trial

© 2019 Author(s) (or their employer(s)). Introduction Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. Methods and analysis The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. Ethics and dissemination Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies

Reaction Time and Postural Sway Modify the Effect of Executive Function on Risk of Falls in Older People with Mild to Moderate Cognitive Impairment

Objectives To explore the relationship between cognitive performance and falls in older people with mild to moderate cognitive impairment (CI) by investigating the mediational effects of medical, medication, neuropsychological, and physiological factors. Design Secondary analysis, prospective cohort study. Setting Community and low-level care. Participants 177 older people (aged 82 ± 7 years) with mild to moderate CI (MMSE 11–23; ACE-R < 83). Measurements Global cognition and six neuropsychological domains (memory, language, visuospatial, processing speed, executive function [EF], and affect) were assessed. Participants also underwent sensorimotor and balance assessments. Falls were recorded prospectively for 12 months. Results The EF domain was most strongly associated with multiple falls (relative risk [RR]: 1.50, 95% CI: 1.18–1.91). Global cognition was not associated with falls (RR: 1.09, 95% CI: 0.92–1.30). Additional analyses showed that participants with poorer EF (median cutpoint) were more likely to be taking centrally acting medications and were less physically active. They also had significantly worse vision, reaction time, knee extension strength, balance (postural sway, controlled leaning balance), and higher physiological fall risk scores. Participants with poorer EF were 1.5 times (RR: 1.50, 95% CI: 1.03–2.18) more likely to have multiple falls. Mediational analyses demonstrated that reaction time and postural sway reduced the relative risk of EF on multiple falls by 31% (RR: 1.19, 95% CI: 0.81–1.74). Conclusions Within this sample of older people with mild to moderate CI, poorer EF increased the risk of multiple falls. This relationship was mediated by reaction time and postural sway,suggesting cognitively impaired older people with poorer EF may benefit from fall prevention programs targeting these mediating factors

Inaccurate judgement of reach is associated with slow reaction time, poor balance, impaired executive function and predicts prospective falls in older people with cognitive impairment

Background: Awareness of physical ability may impact fall risk during everyday tasks. Therefore, we investigated perceived reach (PR; estimation of furthest reach distance), maximal reach (MR) and reach judgement error (RJE), and their relationships with neuropsychological and physical performance, and falls in older people with cognitive impairment (CI). Methods: Prospective cohort study of 110 (mean age = 82 ± 7 years; female = 52%) older people with mild-moderate CI (MMSE 11–23; Addenbrooke's Cognitive Examination-Revised (ACE-R) < 83). PR, MR and detailed neuropsychological and physical assessments were assessed at baseline. Participants were divided into tertiles based on their absolute RJE. Falls were recorded prospectively over 12 months with the assistance of carers. Results: The populations mean MR was 79 ± 10 cm and PR was 75 ± 13 cm, indicating participants tended to underestimate their reach ability. The large RJE tertile performed significantly poorer in measures of global cognition (ACE-R; OR 0.54 95%CI 0.31–0.95) and executive function (Trail Making Test B; OR 1.84 95%CI 1.00–3.36) and had increased concern about falling (Falls Efficacy Scale-International; OR 2.01 95% CI 1.06–3.79) compared to the minimal RJE tertile. The moderate and large RJE tertile groups had significantly slower hand reaction time and larger postural sway on foam compared to the minimal RJE tertile. Each 1% increase in RJE increased the risk of falls by 2% (RR 1.02 95%CI 1.01–1.03). This relationship withstood adjustment for other fall risk factors (sway on foam, Trail Making Test B and ACE-R). Conclusions: Inaccurate reach judgement predicts future falls and is associated with poorer global cognitive performance and executive function, increased concern about falling, slower reaction time and poorer balance. Our results offer insight into the disparity between actual and perceived physical capabilities in people with CI, and how this impacts their risk of falling

Pilot feasibility study of a home-based fall prevention exercise program (StandingTall) delivered through a tablet computer (iPad) in older people with dementia

Objective: To assess the feasibility and safety of StandingTall—an individually tailored, progressive exercise program delivered through tablet computers—in community-dwelling older people with dementia. Methods: Fifteen community-dwelling older people with dementia (mean age = 83 ± 8 years; Montreal Cognitive Assessment 16 ± 5) received StandingTall for 12 weeks with caregiver assistance. Feasibility and safety were assessed using the System Usability Scale (SUS; scores = 0-100; a priori target >65), Physical Activity Enjoyment Scale (PACES-8; scores = 8-56), adherence (exercise minutes) and adverse events. Results: Mean SUS scores were 68 ± 21/69 ± 15 (participants/caregivers). The mean PACES-8 score was 44 ± 8. In week 2, week 7 and week 12, mean (bias-corrected and accelerated 95% CI) exercise minutes were 37 (25-51), 49 (30-69) and 65 (28-104), respectively. In week 12, five participants exercised >115 minutes. One participant fell while exercising, without sustained injury. Conclusions: StandingTall had acceptable usability, scored well on enjoyment and was feasible for participants. These results provide support for further evaluation of StandingTall in a randomised controlled trial with falls as the primary outcome

Slow gait speed is associated with executive function decline in older people with mild to moderate dementia: A one year longitudinal study

Objectives This study aimed to document change in neuropsychological, physical and functional performance over one year and to investigate the relationship between baseline gait speed and cognitive decline in this period in older people with dementia. Methods One hundred and seventy-seven older people with dementia (Mini-Mental State Examination 11–23; Addenbrooke's Cognitive Examination-Revised <83) residing in the community or low level care facility completed baseline neuropsychological, physical and functional assessments. Of these, 134 participants agreed to reassessment of the above measures one year later. Results Overall, many neuropsychological, physical and functional performance measures declined significantly over the one year study period. Baseline gait speed was significantly associated with decline in verbal fluency (B(109) = 2.893, p = 0.046), specifically phonemic/letter fluency (B(109) = 2.812, p = 0.004) while controlling for age, education, dementia drug use and baseline cognitive performance. There was also a trend for an association between baseline gait speed and decline in clock drawing performance (B(107) = 0.601, p = 0.071). Conclusions Older people with mild to moderate dementia demonstrate significant decline in neuropsychological, physical and functional performance over one year. Baseline gait speed is associated with decline in executive function over one year, suggesting shared pathways/pathology between gait and cognition

A home-based, carer-enhanced exercise program improves balance and falls efficacy in community-dwelling older people with dementia

Background: Older people with dementia are at increased risk of physical decline and falls. Balance and mood are significant predictors of falls in this population. The aim of this study was to determine the effect of a tailored home-based exercise program in community-dwelling older people with dementia. Methods: Forty-two participants with mild to moderate dementia were recruited from routine health services. All participants were offered a six-month home-based, carer-enhanced, progressive, and individually tailored exercise program. Physical activity, quality of life, physical, and psychological assessments were administered at the beginning and end of the trial. Results: Of 33 participants (78.6%) who completed the six-month reassessment ten (30%) reported falls and six (18%) multiple falls during the follow-up period. At reassessment, participants had better balance (sway on floor and foam), reduced concern about falls, increased planned physical activity, but worse knee extension strength and no change in depression scores. The average adherence to the prescribed exercise sessions was 45% and 22 participants (52%) were still exercising at trial completion. Those who adhered to ≥70% of prescribed sessions had significantly better balance at reassessment compared with those who adhered to <70% of sessions. Conclusions: This trial of a tailored home-based exercise intervention presents preliminary evidence that this intervention can improve balance, concern about falls, and planned physical activity in community-dwelling older people with dementia. Future research should determine whether exercise interventions are effective in reducing falls and elucidate strategies for enhancing uptake and adherence in this population

Effect of cognitive training on cognitive function in community-dwelling older people with mild-to-moderate dementia: A single-blind randomised controlled trial

Objectives: The purpose of this assessor-blinded, randomised controlled trial was to determine the effect of computerised cognitive training (CT) on executive function, processing speed and working memory in 61 people with mild-to-moderate dementia. Methods: The primary outcomes were forward Digit Span and Trail Making Tests (TMT) at the completion of the 6-month intervention. Secondary outcomes included cognitive and physical performance, rate of falls, participant and caregiver's quality of life and usability and adherence to the CT program. The study was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12617000364370). Results: Intervention group (n = 31) participants averaged 81 min of CT per week, and system usability scores were acceptable (participants: 68.8 ± 22.1; caregivers: 79.4 ± 23.5). There were no statistically significant differences in cognitive or physical performance outcomes between the intervention and control groups at 6- or 12-months (between-group differences [95% CI] for primary outcomes at 6-months: Forward Digit Span −0.3 [−0.8, 0.3]; TMT-A 2.7 s [−14.1, 19.5]; TMT-B −17.1 s [−79.3, 45.2]). At the 12-month follow-up reassessment, the intervention group reported significantly more depressive symptoms and had lower caregiver-rated participant quality of life and higher caregiver quality of life compared to control. Conclusions: This study showed no benefit of the CT program on working memory, processing speed and executive function. Future studies are required to better understand how CT can be used to improve cognitive and physical functioning in older people with mild–moderate dementia