National Guide

Chapter 8 | The health of older people

Brain health, cognition and dementia







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      2. Brain health, cognition and dementia

The health of older people | Brain health, cognition and dementia 

Dr Sylvia Nicholls   

Key messages

  • Aboriginal and Torres Strait Islander people experience higher rates of cognitive impairment and dementia than non-Indigenous Australians, with onset at an earlier age.1–3
  • A proactive approach should be taken to strengthen protective factors and reduce vulnerabilities to the development of cognitive impairment.4
  • Cognitive impairment and dementia are not an expected or inevitable part of ageing.4,5
  • A whole-of-life approach should be undertaken to support early neurodevelopment and educational attainment, and to prevent brain injuries/insults throughout the lifetime.6
Type of preventive activity - Screening
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 50 years and over Assess risk factors and ask about memory and thinking; for example, ‘Do you have any worries about your memory or thinking?’ Opportunistically Strong Aboriginal and Torres Strait Islander-specific national guidelines4,7 Higher prevalence and lower age of onset of cognitive impairment and dementia in Aboriginal and Torres Strait Islander population
People suspected of or experiencing cognitive changes Conduct cognitive assessment with a validated tool, such as the cognitive assessment domain of the Kimberley Indigenous Cognitive Assessment (KICA-Cog), General Practitioner Assessment of Cognition (GPCOG) and Standardised Mini-Mental State Examination (SMMSE)

History taking

Physical examination

Computed tomography (CT) scan brain and baseline bloodsA

Magnetic resonance imaging (MRI) brain could be performed if availableB		 Annually Strong National guidelines4,7 As per clinical guidelines
Type of preventive activity - Behavioural
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people (for primary prevention) and people with cognitive impairment (for secondary prevention) Promote protective factors: healthy diet, physical activity, healthy weight, sleep and social/cultural and mental engagement

Promote smoking cessation and safe alcohol consumption

Reduce cardiovascular risk factors: obesity, hypertension, cholesterol, heart disease, diabetes

Monitor mood and be alert for depression

Ask about, assess and treat hearing impairment		 Opportunistically Strong National and international guidelines4–7 Promoting protective factors and reducing risk factors optimises brain health and can prevent or delay the progress of dementia
Type of preventive activity - Medication
Who/target population What When Strength of recommendation Key source(s) and reference(s) Rationale/key considerations informing recommendation
All people aged 50 years and over Review medication regularly including ceasing/minimising anticholinergic medications Opportunistically Good practice point Best practice guide4 Many medications, including those with anticholinergic activity, can contribute to cognitive impairment


ACT scan brain, full blood count, urea and electrolytes, liver function tests, thyroid function tests and vitamin B12/folate8 is recommended. Conduct syphilis and HIV serology if risk factors are present.
BMRI brain is not associated with a Medicare rebate in primary care to investigate cognitive impairment.
 
  • People with multiple medications, complex dosage regimes and/or cognitive impairment may benefit from a dose administration aid.
  • Aboriginal and Torres Strait Islander people are eligible for services through My Aged Care from age 50 years.

Clinical guidelines

Assessment tools

Other resources

Background

Dementia is a growing health concern in Australia and throughout the world, with increased age being the most significant risk factor.1,6 Delaying and preventing the onset of dementia are valuable focus areas for primary healthcare services. The Best-practice guide to cognitive impairment and dementia care for Aboriginal and Torres Strait Islander people attending primary care services outlines recommended principles of care.4
 
In 2022, an estimated 401,300 people in Australia were living with dementia.1 This corresponds to 84 people per 1000 Australians aged 65 years and over. With the ageing population, this number is expected to more than double by 2058.1 Aboriginal and Torres Strait Islander people experience disproportionately higher levels of dementia (three- to five-fold higher) than non-Indigenous Australians, with a younger age at diagnosis.1–3,9 It is projected the number of Aboriginal and Torres Strait Islander people experiencing dementia will increase 4.5- to 5.5-fold, from an estimated 30,000 in 2016 to 167,000 in 2051.10

Dementia has a complex aetiology, with individual, societal and environmental factors contributing to risk. Non-modifiable risk factors for dementia include age, gender, family history and genetic polymorphisms.5 In a study based in Aboriginal communities in the Kimberley region of Western Australia, factors associated with dementia included older age, male, fewer years of formal education, head injury, smoking, stroke and epilepsy.11 At follow-up five years later, risk factors for the development of cognitive impairment included age, head injury, stroke, analgesic medication (excluding aspirin), low body mass index and higher systolic blood pressure.2 In the Koori Growing Old Well Study (KGOWS and KGOWS-II), factors identified for mild cognitive impairment and dementia included older age, childhood stress and trauma, limited work opportunities, multifactorial acquired brain injury, fewer years of formal education, vision and hearing loss, low physical activity, polypharmacy, male and the presence of the apolipoprotein gene E type 4 allele (APOE-epsilon 4).9,12,13 

The 2020 update of the Lancet Commission on Dementia Prevention, Intervention and Care determined 12 risk factors that are potentially modifiable and contribute to the development of an estimated 40% of dementia worldwide:6

  1. hypertension
  2. hearing impairment
  3. smoking
  4. obesity
  5. depression
  6. physical inactivity
  7. diabetes
  8. low social engagement
  9. alcohol consumption
  10. traumatic brain injury
  11. fewer years of formal education
  12. air pollution

 
The 2024 update of the Lancet Commission added two more dementia risk factors: untreated vision loss and high low-density lipoprotein cholesterol.
 
In a recent analysis of Australian Bureau of Statistics data, 38.2% of cases of dementia in the Australian population were theoretically attributed to 11 risk factors (national prevalence data for traumatic brain injury were not available).14 Using prevalence data from the National Aboriginal and Torres Strait Islander Social Surveys, 44.9% of cases of dementia in Aboriginal and Torres Strait Islander people were determined to be attributable to these 11 risk factors14 (see Table 1).

 

Table 1. Potentially modifiable dementia risk factors in Aboriginal and Torres Strait Islander peopleA
Risk factor Definition Attributable fraction to modifiable dementia risk (%)
Obesity BMI ≥30 kg/m2, based on height and weight measured at the time of survey response, or self-reported height and weight if no physical measurements were available 7.6
Physical inactivity Did not meet the Australian Department of Health 2014 physical activity and sedentary behaviour guidelines, based on self-report 7.9
Smoking Smoking any number of cigarettes daily 3.4
Fewer years of formal education Eight years or less of formal school education completed 3.8
Diabetes Reported having diabetes as a long-term condition, which was defined as current and had lasted, or was expected to last, for six months or more 5.1
High blood pressure Having ever been told by a doctor or nurse that they had high blood pressure as a long-term condition 4.6
Depression Reported having depression or feelings of depression as a long-term condition 3.1
Hearing impairment (age ≥55 years) Reported deafness, partial deafness or hearing loss, as a long-term condition 6.9
Excessive alcohol consumption Drinking more than 21 units (168 g or 213 mL) of alcohol weekly 0.7
Social isolation Frequency of contact with family or friends outside the household less than once per month 0.8
Air pollution Living in an urban area according to the Australian Statistical Geography Standard digital boundaries 1.1
AAdapted from See et al14 based on the Lancet Commission on Dementia Prevention, Intervention, and Care,6 using self-reported survey data from the Australian Bureau of Statistics, National Aboriginal and Torres Strait Islander Health Survey (2018–19), the National Aboriginal and Torres Strait Islander Social Survey (2014–15), the National Health Survey (2017–18) and the General Social Survey (2014).
BMI, body mass index.
 

Researchers used the Lancet framework to determine the level of preventable dementia for each risk factor for people living in the Torres Strait and Northern Peninsula area of north Queensland and identified even higher rates of potentially modifiable risk.15 Using health check data, 52.1% of dementia was determined to be preventable, with 9.4% attributed to hypertension 9% to diabetes, 8% to obesity and 5.3% to smoking, as the most significant factors identified (using population attributable fraction analysis).15
 
This high prevalence of risk factors reflects the known impact of social determinants on dementia risk for people throughout the world. For Aboriginal and Torres Strait Islander people, the ongoing effects of colonisation and disruption of traditional ways of life have contributed to chronic diseases, reduced education/work opportunities and socioeconomic disadvantage.4
 
Dementia is a clinical syndrome characterised by progressive impairment of brain function, which may include changes in language, memory, attention, perception, social cognition and other cognitive skills, caused by a range of disease processes. Dementia can be a primary condition or secondary to another medical condition.5 The International classification of diseases 11th revision describes dementia as:

… the presence of marked impairment in two or more cognitive domains relative to that expected given the individual’s age and general premorbid level of cognitive functioning, which represents a decline from the individual’s previous level of functioning.16

Furthermore, the cognitive changes are not attributable to normal ageing and significantly affect activities of daily living.16 Mild neurocognitive disorder ‘is characterised by mild impairment in one or more cognitive domains’, with the cognitive impairment ‘not severe enough to significantly interfere with an individual’s ability to perform activities related to personal, family, social, education and/or occupational functioning’.16
 
The most common aetiology, accounting for 50–75% of people with dementia, is Alzheimer’s Disease (AD), characterised by accumulation of amyloid-β plaques and neurofibrillary tangles.7,17 Cholinergic transmission is compromised in AD, leading to the role of cholinesterase inhibitors in symptomatic treatment.17 Numerous studies have shown that mixed pathologies account for the vast majority of people with AD, including deposition of α-synuclein and TAR DNA-binding protein-43 (TDP-43), as well as cerebrovascular lesions.17 Dementia due to AD often has memory impairment as the presenting symptom, with additional cognitive domains affected as the disease progresses. Mental and behavioural symptoms such as low mood, apathy, psychosis and aggression, as well as gait disturbance and seizures, may also be present.16
 
Pure vascular dementia accounts for 10% of cases and is caused by cerebrovascular conditions (ischaemic or haemorrhagic).7 Vascular dementia can have a rapid onset and may be related to identified vascular events.16 The cognitive domains affected in vascular dementia depend on the infarct territory, but may include impairments in information processing, complex attention and executive functioning tasks.16
Dementia due to Lewy body disease is attributed to the presence of α-synuclein in Lewy bodies with a variable distribution in the brain stem, limbic area, forebrain and neocortex.16 There is also neuronal depletion in the substantia nigra. Lewy body dementia causes prominent executive dysfunction, visual hallucinations, fluctuating cognition, REM sleep disturbances and parkinsonian motor signs.17
 
Frontotemporal dementia is associated with neurodegenerative disorders that affect the frontal and temporal lobes. Frontotemporal dementia may be characterised by a range of behavioural symptoms, language difficulties, personality change and impaired executive function depending on the underlying pathophysiology.16

Healthy brain from the start of life

It is never too early or too late in the life course for dementia prevention.6

Healthy development in utero that continues into childhood provides the foundation for optimal neurological development. Factors that contribute to healthy neurodevelopment in pregnancy include adequate nutrition (eg folate or iodine) and the avoidance of certain infectious diseases and toxins. Ear health and hearing, as well as cognitive stimulation in childhood and education contribute to the development of cognitive reserve, which helps protect the brain against dementia.6 

A meta-analysis of early life risk factors identified food deficiency, childhood head trauma, poor learning experience in childhood and shorter leg length (considered a proxy for nutritional status in childhood) as being associated with increased risk of dementia and cognitive impairment.18 Childhood adversity, as measured with higher scores on the Childhood Trauma Questionnaire, was associated with all-cause and Alzheimer’s dementia.19 This study, which included participants from the KGOWS, adjusted results for age, depression and anxiety/post-traumatic stress disorder and found a 66% increased risk of a dementia diagnosis associated with childhood stress and trauma.9,19 

Globally, studies have suggested that hearing impairment is associated with lower cognition, with every 10-dB reduction in hearing in adulthood significantly increasing the risk of dementia.5,6 Moderate to severe hearing loss was identified as a risk factor in the KGOWS (borderline significance, with P=0.05).12 The pathways to dementia are likely multifactorial, including the neurological impact of auditory deprivation, reduced capacity for social engagement and fewer educational/employment opportunities over the lifetime due to hearing loss. 

Traumatic brain injury, such as skull fracture, oedema, brain injury or bleed, was associated with dementia and Alzheimer’s disease particularly, with highest risk 6–12 months after injury.6

Head injury was identified as a risk factor in Australian studies particularly for all-cause dementia rather than Alzheimer’s disease.2,12

For more on preventing and managing risk factors for cognitive impairment and dementia, refer to Chapter 2: Healthy living and health risks and Chapter 5: Preconception and pregnancy care.

Promote community awareness

Older Aboriginal people have conveyed the need for greater understanding about dementia within communities, as well as awareness of services for dementia care.9 Increased community awareness helps reduce stigma, which can be a barrier to seeking assessment and treatment. Under-recognition of dementia symptoms may contribute to delayed or non-diagnosis. In a Western Australian project exploring awareness of dementia by community members and staff, reduced community awareness was thought to contribute to feelings of shame.20 This was also identified in a study of staff within Aboriginal Community Controlled Health Organisations, where ‘issues of denial, stigma, and fear of losing independence’ were barriers ‘in the process of providing dementia diagnosis and care in Aboriginal communities’.21 Community and family members seek to support individuals to remain on Country; however, access to culturally safe aged care services is required. Resources and training (for staff and families) should be culturally appropriate and considerate of different literacy levels within communities.21 Projects such as Caring for Spirit22 and Let’s CHAT Dementia23 focus on community education, and the resources are available for wider use in primary care.

Enhance protective factors

Building and maintaining cognitive reserve is associated with lower dementia risk.24 Individuals with higher cognitive reserve appear to tolerate neuropathological changes with fewer dementia symptoms. Cognitive reserve can be built and protected through frequent physical activity, reducing depression, avoiding excessive alcohol consumption, treating hearing impairment, attaining high levels of education6 and employment that requires skills training.12

Maintaining an active mind and socialisation in older age, including later retirement, appears to be neuroprotective. Computerised cognitive training has showed domain-specific benefit, but not improved cognition overall.6 World Health Organization (WHO) guidelines state that cognitive training may be offered to healthy older adults, but the evidence ranges from very low to low in quality5 and is not specific to Aboriginal and Torres strait Islander people. The use of hearing aids appeared to mitigate the increased risk of dementia with hearing impairment.6 Studies have shown good social engagement and moderate to vigorous physical activity were associated with reduced dementia risk.6 The recommendation for physical activity is strong for healthy adults and conditional for adults with mild cognitive impairment.5 WHO guidelines state there is insufficient evidence that social engagement is effective as an intervention; however, the overall positive impact on wellbeing is acknowledged.5

The Mediterranean diet (moderate evidence) or a healthy balanced diet (low to high evidence for different dietary components) are both recommended by the WHO to reduce the risk of cognitive decline and/or dementia.5 Vitamins B and E, polyunsaturated fatty acids and multicomplex supplementation are not recommended (moderate evidence).5 Adherence to the Mediterranean–DASH Intervention for Neurodegenerative Delay (MIND) diet, which encompasses the Mediterranean dietary pattern, has been reported to be associated with less cognitive decline and lower rates of Alzheimer’s disease,25 and is identified as ‘promising’ by the WHO.5 It is further enhanced with neuroprotective foods, including a high intake of green leafy vegetables, legumes, whole grains and berries. Moderate to high amounts of fish are recommended. Red meats, processed meats, pastries and sweets, fast fried foods are all minimised.25 Clinical guidelines for mild cognitive impairment and dementia6,7 recommend a Mediterranean (-like) diet for brain health.8

Traditional Aboriginal and Torres Strait Islander diets, characterised by day-to-day and seasonal variation, included a ‘wide range of plant items (such as tubers, fruits, seeds and legumes), honey, eggs, small mammals, reptiles, fish, shellfish, crustaceans and insects’.26 Larger game, for example ‘kangaroo, wallaby, emu, turtle, crocodile and dugong’, were generally hunted by men.26 This nutritionally dense diet, despite not being interrogated for neuroprotection, is consistent with the principles for healthy eating as recommended by the Australian dietary guidelines.27 However, access to traditional bush foods can be difficult, particularly for people living in metropolitan and non-remote areas (refer to Chapter 2: Healthy living and health risks, Healthy eating).

As noted above, the 2020 Lancet Commission on Dementia Prevention, Intervention and Care identified 12 risk factors that contribute to the development of an estimated 40% of dementia worldwide (with data mainly from high-income countries).6 The treatment of cardiovascular disease and metabolic syndrome is consistently recommended for the detection, assessment and management of mild cognitive impairment.6,8 

In Australia, the risk factor with the highest population attributable fraction was physical inactivity, and this was consistent across people of European, Asian and Aboriginal and Torres Strait Islander ethnicity.14 Physical inactivity, particularly in mid- to late life, is universally linked with a greater risk of cognitive decline.6 Obesity (body mass index >30 kg/m2), but not overweight (body mass index 25–30 kg/m2), is consistently associated with dementia risk globally, and weight loss improves attention and memory.6 In Australia, obesity has the second highest population attributable fraction for Aboriginal and Torres Strait Islander people.14 The WHO recommend interventions to reduce mid-life overweight and obesity with low to moderate evidence supporting a reduction in dementia risk.5 

Mid-life (defined in the Lancet Commission as from age 40 years) hypertension, characterised by systolic blood pressure >140 mmHg, is an independent risk factor for dementia. Reducing blood pressure in people with hypertension reduces cardiovascular events and deaths.28 Although optimal blood pressure treatment targets have been reported as less than 120/80mmHg,29 international dementia guidelines recommend aiming for systolic blood pressure <130mmHg.6 Type 2 diabetes is associated with increased risk of any type of dementia, however, whether specific medications change the risk is not clear and intensive glycaemic control has not been shown to independently decrease this risk.6 The management of combined cardiovascular risk factors, including hypertension, diabetes and dyslipidaemia, is recommended to reduce the risk of dementia.5 Furthermore, increased air pollution (exposure to nitrogen dioxide, fine ambient particulate and carbon monoxide) and poor sleep quality have all been identified as modifiable risk factors for dementia.6 

Hazardous alcohol intake is a particular risk for the development of younger-onset dementia.30 The KGOWS identified that high-risk alcohol consumption was associated with increased dementia risk.12 A reduction or cessation of hazardous and harmful drinking is consistently recommended.5,6 Smoking is also associated with an increased risk of dementia, which can be partly ameliorated by smoking cessation. Cessation of tobacco smoking is recommended by the WHO for cognition and other health benefits.5 

Depression can be both a risk factor and part of the clinical course of dementia.6 Depression and anxiety may be experienced in response to diagnosis and early symptoms. There is a lack of evidence that differentiates between severity and treated or untreated depression.6 In the KGOWS, current symptoms of depression and a history of adverse childhood experiences, but not a previous history of depression, were associated with dementia (P=0.02).12 Potentially, this increased risk may also be extended to other mental health conditions, including schizophrenia and bipolar affective disorder.31 The Good Spirit, Good Life quality of life tool has been developed and validated for use with and for older Aboriginal people.32 In the validation study, depression and anxiety were associated with lower quality of life scores.32 Social and cultural determinants of health are explored in the Good Spirit, Good Life tool, including asking ‘Do you get to have a yarn and spend time with family or friends?’ and ‘Do you feel connected to cultural ways?’.32 

A medication review should be conducted, particularly to identify psychoactive or anticholinergic medication.4,33 Medications with anticholinergic effects should be avoided in older adults due to their known association with cognitive impairment and falls risk.34 An older person may have a high anticholinergic burden due to multiple medications of low anticholinergic activity. In a Cochrane review of adults with normal cognition at baseline, anticholinergic burden was investigated as a prognostic factor for the development of cognitive impairment (inclusive of dementia, mild cognitive impairment and cognitive decline).34 The results were heterogeneous but included several studies reporting increased risk of cognitive decline in people with an anticholinergic ‘burden’ compared with those on no or minimal anticholinergic medications.34 Using data from the KGOWS, researchers found that 47% of participants were taking anticholinergic medication, with the most common being amitriptyline, paroxetine and doxepin.33 In that study, anticholinergic medication was associated with symptoms of depression, but not falls, cognitive impairment or hospitalisation.33 Hypnotic medications have been associated with dementia risk.6

The following documents have informed the recommendations in this guide:

  • Best-practice guide to cognitive impairment and dementia care for Aboriginal and Torres Strait Islander people attending primary care4
  • Nationally informed recommendations on approaching the detection, assessment, and management of mild cognitive impairment8 (journal article)
  • Clinical practice guidelines and principles of care for people with dementia7

Population-wide screening for dementia is not recommended in current guidelines.4,7 Case finding involves identifying people who are at increased risk, asking about memory and thinking and responding to concerns raised by the individual or family members. It is suggested that case finding commence at age 50 years for Aboriginal and Torres Strait Islander people.4

Early detection allows for the management of reversible causes of cognitive impairment and intervention to prevent or delay disease progression. Early diagnosis allows for the person with dementia to make plans for the future, including applications for enduring powers of attorney, enduring guardianship and advance care planning.7

 The initial step in early detection involves obtaining a history and collateral history:

  • obtain a history from the person themselves and from family/close friends (with the person’s consent)
  • determine any medical conditions that may be contributing to the cognitive decline and/or are potentially reversible.

A medication review is recommended.

A physical assessment should be performed in addition to an assessment of functional capacity, including the ability to follow commands and communication abilities.

If cognitive impairment is suspected, the following tests and investigations are recommended in primary care:4,7,8

  • full blood count, urea and electrolytes, liver function tests, thyroid function tests, vitamin B12/folate
  • syphilis and HIV serology if risk factors are present7
  • cognitive function screening tests (preferably one that has been validated for use with Aboriginal and Torres Strait Islander people35), such as:
    • Kimberley Indigenous Cognitive Assessment (KICA), 10-item version of the KICA (KICA screen)
    • SMMSE
    • RUDAS
  • CT scan brain and/or MRI brain, if access is possible.

The KICA tool is a culturally appropriate assessment screen, developed for use with people living in rural and remote areas.36 It has also been modified for Aboriginal and Torres Strait Islander people living in urban and regional Australia, and is validated as an assessment tool.37,38 The KICA consists of a cognitive assessment (the KICA-Cog) and functional assessment. The KICA screen is a shortened, 10-item version of the KICA-Cog.7 Interpreters may be required for the assessment. The SMMSE and RUDAS have been evaluated in Aboriginal populations in urban and regional New South Wales and have demonstrated good sensitivity and specificity.35

Other cognitive screening tools that may be used in primary care include GPCOG, the Montreal Cognitive Assessment and clock drawing test.8

Mental health assessment is recommended, including screening for depression and psychosis.7

Timely referral to a memory assessment clinic, geriatrician or psychiatrist for secondary consultation should be made if cognitive impairment is suspected or demonstrated.7 This will facilitate further investigations, multidisciplinary assessment and access to medications if clinically indicated (eg cholinesterase inhibitors and memantine). Allied health assessment could also be facilitated by GPs.

  1. Australian Institute of Health and Welfare (AIHW). Dementia in Australia. AIHW, 2024 [Accessed 5 May 2024].
  2. Lo Giudice D, Smith K, Fenner S, et al. Incidence and predictors of cognitive impairment and dementia in Aboriginal Australians: A follow-up study of 5 years. Alzheimers Dement 2016;12(3):252–61. doi: 10.1016/j.jalz.2015.01.009.
  3. Russell SG, Quigley R, Thompson F, et al. Prevalence of dementia in the Torres Strait. Australas J Ageing 2021; 40(2): e125-32. doi: 10.1111/ajag.12878.
  4. Belfrage M, Hughson J, Gouglas H, LoGiudice D. Best-practice guide to cognitive impairment and dementia care for Aboriginal and Torres Strait Islander people attending primary care. The University of Melbourne, 2022 [Accessed 5 May 2024].
  5. World Health Organization (WHO). Risk reduction of cognitive decline and dementia: WHO guidelines. WHO, 2019 [Accessed 5 May 2024].
  6. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet 2020;396(10248):413–46. doi: 10.1016/s0140-6736(20)30367-6.
  7. Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Guideline Adaptation Committee, 2016 [Accessed 5 May 2024].
  8. Woodward M, Brodaty H, McCabe M, et al. Nationally informed recommendations on approaching the detection, assessment, and management of mild cognitive impairment. J Alzheimers Dis 2022; 89(3):803–09. doi: 10.3233/jad-220288.
  9. Radford K, Allan W, Donovan T, et al. Sharing the wisdom of our Elders final report. Neuroscience Research Australia, 2019 [Accessed 5 May 2024].
  10. Temple J, Wilson T, Radford K, et al. Demographic drivers of the growth of the number of Aboriginal and Torres Strait Islander people living with dementia, 2016–2051. Australas J Ageing 2022; 41(4):e320–27. doi: 10.1111/ajag.13116.
  11. Smith K, Flicker L, Dwyer A, et al. Factors associated with dementia in Aboriginal Australians. Aust N Z J Psychiatry 2010;44(10):888–93. doi: 10.3109/00048674.2010.491816.
  12. Radford K, Lavrencic LM, Delbaere K, et al. Factors associated with the high prevalence of dementia in older Aboriginal Australians. J Alzheimers Dis 2019;70(s1):S75–85. doi: 10.3233/jad-180573.
  13. Lavrencic LM, Delbaere K, Broe GA, et al. Dementia incidence, APOE genotype, and risk factors for cognitive decline in Aboriginal Australians: A longitudinal cohort study. Neurology 2022;98(11):e1124–36. doi: 10.1212/WNL.0000000000013295.
  14. Sue See R, Thompson F, Russell S, et al. Potentially modifiable dementia risk factors in all Australians and within population groups: An analysis using cross-sectional survey data. Lancet Public Health 2023;8(9):e717–25. doi: 10.1016/S2468-2667(23)00146-9.
  15. Thompson F, Russell S, Quigley R, et al. Potentially preventable dementia in a First Nations population in the Torres Strait and Northern Peninsula area of north Queensland, Australia: A cross sectional analysis using population attributable fractions. Lancet Reg Health West Pac 2022;26:100532. doi: 10.1016/j.lanwpc.2022.100532.
  16. World Health Organization (WHO). Neurocognitive disorders. In: ICD-11 for mortality and morbidity statistics. WHO, 2022 [Accessed 5 May 2024].
  17. Chin KS. Pathophysiology of dementia. Aust J Gen Pract 2023;52(8):516–21. doi: 10.31128/AJGP-02-23-6736.
  18. Wang XJ, Xu W, Li JQ, Cao XP, Tan L, Yu JT. Early-life risk factors for dementia and cognitive impairment in later life: A systematic review and meta-analysis. J Alzheimers Dis 2019;67(1):221–29. doi: 10.3233/JAD-180856.
  19. Radford K, Delbaere K, Draper B, et al. Childhood stress and adversity is associated with late-life dementia in Aboriginal Australians. Am J Geriatr Psychiatry 2017;25(10):1097–106. doi: 10.1016/j.jagp.2017.05.008.
  20. Gubhaju L, Turner K, Chenhall R, et al. Perspectives, understandings of dementia and lived experiences from Australian Aboriginal people in Western Australia. Australas J Ageing 2022;41(3):e284–90. doi: 10.1111/ajag.13045.
  21. Bryant J, Noble N, Freund M, et al. How can dementia diagnosis and care for Aboriginal and Torres Strait Islander people be improved? Perspectives of healthcare providers providing care in Aboriginal community controlled health services. BMC Health Serv Res 2021;21(1):699. doi: 10.1186/s12913-021-06647-2.
  22. Aboriginal Health and Ageing Program. Caring for Spirit. Aboriginal and Torres Strait Islander online dementia education. The research. Neura, 2019 [Accessed 31 May 2024].
  23. The University of Melbourne. Overview: Let’s CHAT Dementia in Aboriginal and Torres Strait Islander Communities. The University of Melbourne, n.d [Accessed 5 May 2024].
  24. LoGiudice D, Hughson J, Douglas H, Wenitong M, Belfrage M. Culturally safe, trauma-informed approach to cognitive impairment and dementia in older Aboriginal and Torres Strait Islander people. Aust J Gen Pract 2023;52(8):505–11. doi: 10.31128/AJGP-01-23-6672.
  25. van den Brink AC, Brouwer-Brolsma EM, Berendsen AAM, van de Rest O. The Mediterranean, Dietary Approaches to Stop Hypertension (DASH), and Mediterranean–DASH Intervention for Neurodegenerative Delay (MIND) diets are associated with less cognitive decline and a lower risk of Alzheimer's disease – a review. Adv Nutr 2019;10(6):1040–65. doi: 10.1093/advances/nmz054.
  26. Australian Indigenous HealthInfoNet. Summary of nutrition among Aboriginal and Torres Strait Islander people. Australian Indigenous HealthInfoNet, 2020 [Accessed 1 October 2022].
  27. National Health and Medical Research Council (NHMRC). Australian dietary guidelines. NHMRC, 2013 [Accessed 9 April 2024].
  28. Saiz LC, Gorricho J, Garjón J, Celaya MC, Erviti J, Leache L. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev 2022;11:CD010315. doi: 10.1002/14651858.CD010315.pub5.
  29. Drawz PE, Pajewski NM, Bates JT, et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure: Results from the SPRINT (Systolic Blood Pressure Intervention Trial) ambulatory blood pressure study. Hypertension. 2017;69(1):42–50. doi: 10.1161/hypertensionaha.116.08076.
  30. Hendriks S, Ranson JM, Peetoom K, et al. Risk factors for young-onset dementia in the UK Biobank. JAMA Neurol 2024;81(2):134–42. doi: 10.1001/jamaneurol.2023.4929.
  31. Ahearn EP, Szymanski BR, Chen P, Sajatovic M, Katz IR, McCarthy JF. Increased risk of dementia among veterans with bipolar disorder or schizophrenia receiving care in the VA health system. Psychiatr Serv 2020;71(10):998–1004.
  32. Gilchrist L, Hyde Z, Petersen C, et al. Validation of the Good Spirit, Good Life quality-of-life tool for older Aboriginal Australians. Australas J Ageing 2023;42(2):302–10. doi: 10.1111/ajag.13128.
  33. Mate K, Kerr K, Priestley A, et al. Use of tricyclic antidepressants and other anticholinergic medicines by older Aboriginal Australians: Association with negative health outcomes. Int Psychogeriatr 2022;34(1):71–78. doi: 10.1017/S104161022000174X.
  34. Taylor-Rowan M, Edwards S, Noel-Storr AH, et al. Anticholinergic burden (prognostic factor) for prediction of dementia or cognitive decline in older adults with no known cognitive syndrome. Cochrane Database Syst Rev 2021;5(5):CD013540. doi: 10.1002/14651858.CD013540.pub2.
  35. Radford K, Mack HA, Draper B, et al. Comparison of three cognitive screening tools in older urban and regional Aboriginal Australians. Dement Geriatr Cogn Disord. 2015; 40(1–2):22-32. doi: 10.1159/000377673.
  36. LoGiudice D, Smith K, Thomas J, et al. Kimberley Indigenous Cognitive Assessment tool (KICA): Development of a cognitive assessment tool for older Indigenous Australians. Int Psychogeriatr 2006;18(2):269–80. doi: 10.1017/S1041610205002681.
  37. Dyer SM, Laver K, Friel M, Whitehead C, Crotty M. The diagnostic accuracy of the Kimberley Indigenous Cognitive Assessment (KICA) tool: A systematic review. Australas Psychiatry 2017;25(3):282–87. doi: 10.1177/1039856216684735.
  38. Radford K, Mack HA, Draper B, et al. Comparison of three cognitive screening tools in older urban and regional Aboriginal Australians. Dement Geriatr Cogn Disord 2015;40:22–23. doi: 10.1159/000377673.




 

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