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Physical activity participation can improve the physical health and social and emotional wellbeing of Aboriginal and Torres Strait Islander peoples. The evaluation of physical activity programmes can elicit a clearer understanding of where these impacts occur and to what extent. We describe applying a collaborative approach to the selection of a set of measures that can be used to examine health and wellbeing impacts of Indigenous community running groups.Physical activity, health and wellbeing measurement tools previously used with Aboriginal and Torres Strait Islander peoples were collated. Participants in the collaborative process were nine female running group members aged 30+ years from a regional New South Wales (NSW) town. The Indigenous research method, Yarning, explored views of participating in the group on health and wellbeing and how these could be measured using those collated measurement tools.Runners described participating for holistic physical, mental and social reasons and stated the importance of the group participating together and providing social support to each other. There was broad support for the identified physical activity, lifestyle, physical health, and social and emotional wellbeing measures, with social networks and sports injuries identified as additionally relevant.Co-selecting measures to evaluate a physical activity programme for Aboriginal and Torres Strait Islander participants can better inform the development of relevant future healthy lifestyle programme evaluation, revealing factors that may be missed as relevant by researchers. SO WHAT?: This process presents an example of determining evaluation measures with Aboriginal and Torres Strait Islander participants that could be applied more broadly to evaluation design.

As populations age globally, cooperation across multi-sector stakeholders is increasingly important to service older persons, particularly those with high and complex health and social needs. One such population is older people entering society after a period of incarceration in prison. The ‘ageing epidemic’ in prisons worldwide has caught the attention of researchers, governments and community organisations, who identify challenges in servicing this group as they re-enter the community. Challenges lie across multiple sectors, with inadequate support leading to dire consequences for public health, social welfare and recidivism. This is the first study to bring together multi-sector stakeholders from Australia to form recommendations for improving health and social outcomes for older people re-entering community after imprisonment. A modified nominal group technique was used to produce recommendations from N=15 key stakeholders across prison health, corrections, research, advocacy, aged care, community services, via online workshops. The importance and priority of these recommendations was validated by a broader sample of N=44 stakeholders, using an online survey. Thirty-six recommendations for improving outcomes for this population were strongly supported. These recommendations entail two important findings about this population: (1) They are a high-needs, unique, and underserved group at risk of significant health and social inequity in the community, (2) Multi-sector stakeholder cooperation will be crucial to service this growing group.

BackgroundDigital inequity refers to the inequality and exclusion experienced by those who lack the same opportunities or circumstances to support the development of digital skills as the rest of modern society. One rapidly growing and highly vulnerable group to digital inequity is older people attempting to reintegrate into society after release from prison, where technology access is limited. Inadequate support for digital skills in this population entails widespread consequences for public health, human rights, social welfare and recidivism. This qualitative study is the first to: examine digital inequity experienced by older people who have been incarcerated, understand the effects of this on reintegration to society, and begin informing appropriate solutions.MethodSemi-structured interviews were conducted with N=15 older people (mean age= 57) who had been released from an Australian prison in the last two years, regarding their experiences of digital literacy since leaving prison. Reflexive thematic analysis was conducted under a critical realist lens.ResultsThe analysis resulted in six themes that illustrated the extent of digital inequity experienced by this population, and key challenges for improving digital literacy: ‘surviving in a digital world’, ‘stranger in a foreign world’, ‘questioning the digital divide’, ‘overcoming your “old” self’, ‘don’t like what you don’t know’, and ‘seeking versus finding help’.ConclusionsThe digital inequity that older people experience during and after incarceration creates additional challenges for a growing group who are already medically and socially marginalised. Prioritisation of this group for digital literacy initiatives both during incarceration and in the community will have benefits for their health, social and financial reintegration. Their unique life experiences should be considered in designing and delivering these programs.

Purpose When properly designed and implemented, prison-to-community transition programs targeting older prisoners could potentially save resources, reduce reoffending rates and contribute to improved public protection and safety. However, older prisoners transitioning to community are often neglected and overlooked, and thus, interventions targeted to address their needs are limited. The purpose of this study was to identify barriers and enablers to health and social services for older prisoners transitioning to community. Design/methodology/approach A qualitative study was conducted using focus group discussions with corrections officers, community corrections officers and parole officers (n = 32) in four correctional centres, two community corrections offices (CCOs) and one parole unit in New South Wales (NSW) in 2019. The authors used thematic analysis to analyse the findings. Findings The study identified three main themes relating to barriers and enablers: organisational, social and economic and individual and family and seven sub-themes: planning the transition, communication, assisting prisoners, transition programs, officers’ knowledge and scope of work, social and economic issues and offenders’ conditions Research limitations/implications The processes required to ensure effective prison-to-community transition of older prisoners are not well-developed suggesting the need for more systemic and organised mechanisms. Implications of the barriers and enablers for policy, research and practice are discussed. Originality/value This study identified a composite of barriers and enablers to health and social services for older prisoners in NSW prisons and CCOs.

People with alcohol use disorder (AUD) exhibit high rates of comorbidity with cognitive deficits, particularly for executive function (EF). Cognitive impairment has been related to poorer outcomes in substance use treatment. Goal management training (GMT), a structured, therapist-led manualised intervention targeting EF, has demonstrated positive preliminary results in substance use disorder (SUD) treatment programs.. However, these studies have had strict exclusion criteria (e.g. excluding clients with mental health disorders), and the feasibility of running such a program in a broader SUD outpatient setting is unclear. The primary aim of this study was to determine the outcomes and feasibility of a cognitive remediation intervention at an outpatient alcohol treatment service in Sydney, Australia. Clients were referred to the study based on risk of cognitive deficits (as indicated by objective cognitive impairment on a screening tool or relevant collateral clinical information). Eligibility criteria included diagnosis of a current alcohol use disorder and abstinence for 2 or more weeks. The intervention consisted of 9 weekly GMT sessions. Out of 34 clients referred, 11 were eligible to participate, and of these, five were allocated to the intervention group and two to a waitlist control group. Due to poor recruitment, statistical analyses between groups were not possible; instead, this study presents a case series of the five clients recruited to the 9-week group intervention using GMT. Clients engaged in the intervention presented with a range of deficits in their cognitive functioning at baseline. Despite positive comments from participants regarding the intervention, there was a high level of attrition; while four clients (80%) completed at least four sessions, only one participant remained until the end of the nine-session program. In its current form, this program is not suitable for this cohort in the outpatient setting. Suggestions are made for tailoring GMT and other approaches to increase engagement and retention in future interventions.

BACKGROUND Serious games have the potential to transform the field of cognitive assessment. The use of serious game–based cognitive assessments in prison environments is particularly exciting. This is because interventions are urgently needed to address the rapid increase in the number of currently incarcerated older adults globally and because of the heightened risks of dementia and cognitive decline present in this population. Game-based assessments are assumed to be fun, engaging, and suitable alternatives to traditional cognitive testing, but these assumptions remain mostly untested in older adults. This is especially true for older adults in prison, whose preferences and needs are seldom heard and may deviate from those previously captured in studies on cognition and serious games. OBJECTIVE This study aimed to understand the design preferences of older adults in prison for a game-based cognitive assessment. METHODS This study used reflexive thematic analysis, underpinned by critical realism, and applied the technique of abduction. Overall, 4 focus groups with a total of 20 participants were conducted with older adults (aged ≥50 years; aged ≥45 years for Aboriginal and Torres Strait Islander people) across 3 distinct prison environments in Australia. RESULTS Self-determination theory was used as a theoretical foundation to interpret the results. Overall, 3 themes were generated: Goldilocks—getting gameplay difficulty just right through optimal challenge (the first theme emphasizes the participants’ collective desire for an individualized optimal level of difficulty in serious gameplay), Avoiding Childish Graphics—gimmicky gameplay can be condescending (the second theme raises the importance of avoiding immature and childlike gameplay features, as some older end users in prison felt that these can be condescending), and A Balanced Diet—meaningful choice and variety keeps game-based assessments fun (the third theme highlights the strong user preference for meaningful choice and variety in any serious game–based cognitive assessment to maximize in-game autonomy). CONCLUSIONS The collection of these themes provides novel insights into key game design preferences of marginalized older adults.

Purpose The Australian prisoner population has experienced a dramatic increase in the number of older inmates over the past decade, consistent with the greying of the prisoner population that is being observed worldwide. Reviews suggest the need for further evidence and practice outside of the USA. This paper aims to review and discuss the cost and social implications of the rising health-care needs of this population in Australia. Design/methodology/approach A review of international research and policies is presented, as well as the results of basic economic modelling relating to the expected rise in health-care costs of the ageing prisoner population in Australia. Findings Taking into consideration the continued rise in incarceration rates, the calculations show that the health costs of prisoners could increase by anywhere between 17% and 90% depending on whether the increase of older prisoners continues as it has in the past decade. These trends are likely to continue over the next decade and will result in higher health costs of prisons under a number of different imprisonment scenarios. Policy responses in Australia have been slow so far, with most initiatives being undertaken in the USA with promising results. Practical implications The authors suggest that in the absence of a coordinated policy response, covering a range of interventions, costs will continue to increase, particularly as this population continues to age more rapidly than the general population due to an accumulation of risk factors. Well-conceived interventions would be a worthwhile investment from both financial and social perspectives. Originality/value To the best of the authors’ knowledge, this is the first commentary to acknowledge this rising public health issue and to both review and model its implications for the future.

Background and Objectives The police are often the first to attend domestic violence events in New South Wales (NSW), Australia, recording related details as structured information (e.g., date of the event, type of incident, premises type) and text narratives which contain important information (e.g., mental health status, abuse types) for victims and perpetrators. This study examined the characteristics of victims and persons of interest (POIs) suspected and/or charged with perpetrating a domestic violence-related crime in residential care facilities. Research Design and Methods The study employed a text mining method that extracted key information from 700 police-recorded domestic violence events in NSW residential care facilities. Results Victims were mostly female (65.4%) and older adults (median age 80.3). POIs were predominantly male (67.0%) and were younger than the victims (median age 57.0). While low rates of mental illnesses were recorded (29.1% in victims; 17.4% in POIs), “dementia” was the most common condition among POIs (55.7%) and victims (73.0%). “Physical abuse” was the most common abuse type (80.2%) with “bruising” the most common injury (36.8%). The most common relationship between perpetrator and victim was “carer” (76.6%). Discussion and Implications These findings highlight the opportunity provided by police text-based data to offer insights into elder abuse within residential care facilities.

Objective: Post-diagnosis service delivery for young-onset dementia (with onset prior to 65 years) recently moved to the disability system in an attempt to address systemic barriers to best practice in aged care. The objective of this study was to examine experiences and satisfaction with disability services so far among people with young-onset dementia and their care partners and identify strategies for service and system improvement. Methods: The 151 participating Australians living with young-onset dementia or providing informal care to a person with young-onset dementia were recruited via social media, advocacy bodies and specialist medical clinics. A cross-sectional online survey asked participants to provide a timeline of their interactions with the disability system so far and rate their satisfaction with the disability system, aged care and disability services. Results: Participants reported a mean age at symptom onset of 55 years. In all, 53% were diagnosed with Alzheimer’s disease and 25% were diagnosed with frontotemporal dementia. Sixty percent had received an approved plan from the National Disability Insurance Scheme, although 3% were rejected. More than 27% waited longer than 6 months to receive their plan, and half waited at least a month post-approval to access services. Less than 30% agreed that the National Disability Insurance Scheme understands dementia, and fewer than half felt that the process of accessing National Disability Insurance Scheme funding is easy and fast enough. Nonetheless, respondents remained overwhelmingly in favour of young-onset dementia services remaining in the disability system rather than in aged care. Conclusions: While people with young-onset dementia and their care partners strongly agree with their inclusion in the National Disability Insurance Scheme, a relatively low level of experience with dementia in the disability workforce and a lack of integration with the healthcare and aged care systems continue to create important barriers for accessing the services they need.

Background and Objectives Elder abuse is a complex problem, and barriers to reporting and help-seeking include shame and fear of loss of relationships with key family members. Elder mediation has been identified as one promising method of alternative dispute resolution. This study aimed to investigate the accessibility of elder mediation services among diverse groups of older adults, from the perspective of practitioners in a large Australian jurisdiction. Research Design and Methods The study employed a sequential mixed-methods approach, comprising a thematic analysis of semistructured interviews (N = 17) and an online survey of practitioners (N = 49) involved in referral to, or provision of, elder mediation services. Accessibility was conceptualized using existing theoretical frameworks, spanning practical (logistics-related), and normative (justice- and culture-related) dimensions. Results Factors limiting accessibility of elder mediation services included lack of community and practitioner awareness of elder abuse and elder mediation, discomfort with the mediation process, financial costs, lack of services in regional and remote areas, and complex service systems for older people. Within the mediation process, difficulties in assessing and accommodating cognitive and other impairments, managing power imbalances, and determining the appropriateness of the dispute for mediation were influential. Discussion and Implications This study showed that mediation can be a promising and effective approach to resolving disputes involving older people. The emergent perceptive dimension (community and practitioner awareness) emphasizes the importance of awareness-raising efforts surrounding both elder abuse and the potential of mediation as a viable pathway, the training of elder-mediators as well as resourcing elder mediation services, especially in rural and remote locations.

Objectives This study aims to explore the journey to dementia diagnosis and reaction to the diagnosis from the perspective of people with young-onset dementia living in the community from diverse areas in Australia (metropolitan, regional, rural) and their family caregivers. Methods Semi-structured interviews were conducted with community-dwelling people with early to moderate young-onset Alzheimer’s disease ( n = 8) or frontotemporal dementia ( n = 5) and one person with both Alzheimer’s disease and frontotemporal dementia, and family caregivers of community-dwelling people with young-onset Alzheimer’s disease and/or frontotemporal dementia ( n = 28). This study employed interpretive description. Thematic analysis was conducted for emergent themes, comparisons and interplay between themes. Findings The journey to the diagnosis is characterised as involving an extensive period of the gradual worsening of symptoms, drawn out investigations, and difficulties facing the prospect of a diagnosis of young-onset dementia. Participants with young-onset dementia struggled to manage their symptoms and the process of seeking a diagnosis was often slow due to difficulties during the course of their medical investigations and feeling reluctance to face the possibility of having dementia. Once participants finally received the diagnosis of young-onset dementia, participants with young-onset dementia and their family caregivers experienced feelings of devastation and shock, in some cases denial and avoidance, and even, confirmation and relief at having received a diagnosis. In some instances, participants experienced more than one of these reactions. There was a profound realisation by participants that a diagnosis of young-onset dementia had serious implications on their life and future. Conclusion The journey to diagnosis was found to be a drawn-out process and receiving the diagnosis was a shock for both people with young-onset dementia and their family caregivers. The findings highlight the significance of the role healthcare professionals play in both the diagnostic and post-diagnostic journey, particularly in terms of supporting patients with young-onset dementia and their family caregivers.

Background: Understanding how the age of dementia symptom onset affects the longitudinal course of dementia can assist with prognosis and care planning. Objective: To synthesize evidence regarding the relationship of age of symptom onset with the longitudinal course of sporadic Alzheimer’s disease (AD), vascular dementia (VaD), and frontotemporal dementia (FTD). Methods: We searched Medline, CINAHL, Embase, PsycINFO, PubMed, and Scopus for longitudinal studies that examined the impact of sporadic AD, VaD, or FTD symptom onset age on measures of cognition, function, or behavioral symptoms. Studies that examined age at diagnosis only were excluded. Quantitative meta-analysis was conducted where studies reported sufficient data for pooling. Results: Thirty studies met all inclusion criteria (people with AD (n = 26), FTD (n = 4)) though no studies examined VaD. Earlier onset of AD was associated with more rapid annual cognitive decline (estimate = –0.07; 95% CI –0.14 to 0.00; p = 0.045). Most studies that stratified their sample reported that younger AD onset (usually

ObjectivesTo examine the sociodemographic and diagnostic factors associated with a discharge from hospital to residential aged care (RAC) for younger people (aged 15–64 years) with neuropsychiatric disorders.DesignAn exploratory case–control study using a historic cohort of people with neuropsychiatric disorders. Cases were people transferred to RAC on hospital discharge during the study period. Controls were people not transferred to RAC on discharge during the study period.SettingPublic and private hospital admissions in New South Wales (NSW), Australia.ParticipantsPeople aged 15–64 years with a neuropsychiatric disorder hospitalised in NSW between July 2002 and June 2015 (n=5 16 469).Outcome measuresThe main outcome was transferred to RAC on discharge from hospital. We calculated ORs for sociodemographic and diagnostic factors to determine factors that may impact discharge to RAC.ResultsDuring the period of data capture, 4406 people were discharged from hospitals to RAC. Discharge to RAC was most strongly associated with diagnoses of progressive neurological and cognitive disorders. Acute precipitants of RAC transfer included a broad range of conditions and injuries (eg, Wernicke’s encephalopathy, stroke, falls) in the context of issues such as older age, not being partnered (married or de facto), living in areas of lower socioeconomic status, functional issues and the need for palliative care.ConclusionsThere are multiple intersecting and interacting pathways culminating in discharge from hospital to RAC among younger people with neuropsychiatric disorders. Improved capacity for interdisciplinary home care and alternative housing and support options for people with high support needs are required.

Introduction Both genetic and nongenetic factors contribute to the risk profile of young onset dementia (YOD), but risk factors often co-occur. This matched case-control study examined whether nongenetic risk factors cluster together, to inform targeted prevention efforts. Methods Ninety-six participants with non-autosomal-dominant degenerative and/or vascular YOD and 175 controls were recruited to 2 Australian epidemiological studies. Risk exposure was retrospectively self-reported and/or informant-reported. Results Each additional exposure increased the risk for YOD, though only where vascular dementia was included in the analysis. Cluster analysis identified 4 risk groups, one of which reported a high probability of exposure to all risks and a significantly higher risk for YOD. Discussion Results suggest that combinations of nongenetic risk factors confer more risk for young onset vascular dementia, and possibly primary degenerative YOD, than a single factor on its own. Compared with their same-age peers, some people with YOD experience a lifetime of risk exposure starting from early in life.

Although young onset dementia (YOD) causes high levels of burden and distress, factors that contribute to its onset are not well understood. Identifying relevant modifiable risk and protective factors for YOD can inform efforts to prevent or delay onset of symptoms to later in life.Studies of modifiable factors for YOD have increased in frequency in recent years. Poor educational attainment and low socioeconomic status, a history of heavy alcohol use, and poor cardiovascular health may be key targets for YOD prevention or delay. Traumatic brain injury has attracted significant attention but evidence of its importance is limited except in cases occurring secondarily to the injury.A growing body of evidence suggests that modifiable risk factors have a role in modulating the age of dementia onset. Clinicians should be aware that many people with YOD will present with complex histories of multifactorial (including modifiable and nonmodifiable) risk exposure. Exploring trajectories of risk and gene-environment interactions is an important future research direction and will inform targeted prevention efforts.

Summary of recommendations and levels of evidence Chapter 2: Screening and assessment for unhealthy alcohol use Screening Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C). Quantity–frequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B). The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A). Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B). Assessment Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C). Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP). Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C). Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patient’s needs (Level D). Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C). Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up Brief interventions Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A). Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A). Psychosocial interventions Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A). Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A). Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D). Alcohol withdrawal management Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B). Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP). Pharmacotherapies for alcohol dependence Acamprosate is recommended to help maintain abstinence from alcohol (Level A). Naltrexone is recommended for prevention of relapse to heavy drinking (Level A). Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A). Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B). Peer support programs Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A). Relapse prevention, aftercare and long-term follow-up Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP). A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP). Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations Gender-specific issues Screen women and men for domestic abuse (Level C). Consider child protection assessments for caregivers with alcohol use disorder (GPP). Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B). Pregnant and breastfeeding women Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B). Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP). Young people Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B). Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B). Aboriginal and Torres Strait Islander peoples Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP). Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B). Culturally and linguistically diverse groups Use an appropriate method, such as the “teach-back” technique, to assess the need for language and health literacy support (Level C). Engage with culture-specific agencies as this can improve treatment access and success (Level C). Sexually diverse and gender diverse populations Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C). Seek to incorporate LGBTQ-specific treatment and agencies (Level C). Older people All new patients aged over 50 years should be screened for harmful alcohol use (Level D). Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D). Consider shorter acting benzodiazepines for withdrawal management (Level D). Cognitive impairment Cognitive impairment may impair engagement with treatment (Level A). Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A). Summary of key recommendations and levels of evidence Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities Polydrug use and dependence Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP). Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP). Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C). Co-occurring mental disorders More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP). The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A). People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C). Physical comorbidities Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A). In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A). Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A).

Purpose The purpose of this commentary is to draw upon available literature and practices related to COVID-19 and management of older incarcerated adults in Australia to highlight key matters for better risk management and care of this population during this and future infectious disease pan/epidemics. Design/methodology/approach The present commentary draws on current policies, practices and literature regarding the health, needs and management of older incarcerated adults in Australia to discuss risk, care and early release for this population during the COVID-19 pandemic. Findings Incarcerated persons experience poorer health and accelerated age-related decline compared to those in the general community. The present situation offers the opportunity to fill knowledge and practice gaps, including policies for staff training, identification of dementia and cognitive decline, assessment of mobility issues, addressing barriers to health-seeking, possibilities of medical or compassionate release, risk assessment and release protocols and post-release needs. Practical implications While Australian prisons have acknowledged the vulnerability of older persons, more focused adaptation of COVID-19-related policies to consider adults as young as 45 years are needed. Appropriate ethical identification and management of cases in this population is needed, as is discussion on issues of decarceration and medical release. Re-conceptualisation of incarcerated adults as “citizens in need of care”, rather than as “offenders to be secured”, will be beneficial. Robust, local evidence is needed to assist decision-making. Originality/value This is a comprehensive, focused review of relevant evidence, policies and practices for a growing subpopulation of prisoners worldwide with complex needs and particular vulnerability to the COVID-19.

Background and Objectives The rapid increase in the number of older offenders in many countries presents unique challenges to both correctional and health care systems. In the absence of strong empirical evidence on effective interventions, identifying best practices can help optimize the care and management of this segment of the prisoner population. Research Design and Methods We conducted a scoping review of care models, prison programs, and different interventions designed to improve the care and management of older offenders. We searched 5 bibliographic databases and other data sources including OpenGrey, agency documents, and government reports published until December 2020. This review employed commonly used steps for conducting a scoping review and applied additional tools to enhance the methodology. Results After title and abstract screening and full-text review, a total of 34 studies were included in the analysis. Four themes emerged from the review: (a) institutional logics, (b) adaptations, (c) multidisciplinary teams, and (d) person-centered care and management. Discussion and Implications Best practices identified in this review can help optimize the care and management of older offenders in mainstream prisons. Further action research is recommended to adapt and scale up the interventions.

Background Several brain reserve, vascular risk, and other modifiable factors have been associated with late-onset dementia, but their association with young onset dementia (YOD) has not been adequately explored. Objective To examine the association of cognitive reserve enhancing factors, cardiovascular risk factors (including smoking), depression, alcohol use, and traumatic brain injury (TBI) with non-autosomal dominant degenerative and/or vascular YOD. Methods Data for this matched case-control study were taken from two larger studies conducted in NSW, Australia. One comprised all people with YOD within a geographical region, while the other exclusively included Aboriginal and Torres Strait Islander participants. Dementia diagnosis was confirmed by clinical consensus, and risk exposure was retrospectively self- and/or informant-reported. Results Participants were 96 people with YOD (58.4% with probable Alzheimer's disease) and 175 age-group, sex, and sample matched control participants. Poor educational attainment, low participation in cognitive leisure activity, stroke, transient ischemic attack, and self-reported very heavy alcohol use were related to the risk of primary degenerative and/or vascular YOD. The effect of hypertension and depression varied depending on when they occurred relative to dementia onset. Current smoking was significantly associated with risk in univariate analyses but did not retain significance in multivariate modelling. There was no association with hypercholesterolemia, diabetes, or TBI of any kind. Some compensation for low educational attainment was possible via a complex occupation later in life. Conclusion Non-genetic factors have a role in YOD, though the relative importance of each factor may be different to late onset dementia. The timing and severity of exposure, as well as the potential for compensation with later protective exposures, are important considerations for potential prevention strategies.

Despite the considerable prevalence of cognitive impairment in substance-using populations, there has been little investigation of the utility of cognitive screening measures within this context. In the present study the accuracy of three cognitive screening measures in this population was examined-the Mini-Mental State Examination (MMSE), the Addenbrooke's Cognitive Examination-Revised (ACE-R), and the Montreal Cognitive Assessment (MoCA).A sample of 30 treatment-seeking substance users and 20 healthy individuals living in the community were administered the screening measures and a neuropsychological battery (NPB). Agreement of classification of cognitive impairment by the screening measures and NPB was examined.Results indicated that the ACE-R and MoCA had good discriminative ability in detection of cognitive impairment, with areas under the receiver-operating characteristic (ROC) curve of .85 (95% confidence interval, CI [.75. .94] and .84 (95% CI [.71, .93]) respectively. The MMSE had fair discriminative ability (.78, 95% CI [.65, .93]). The optimal cut-score for the ACE-R was 93 (impairment = score of 92 or less), at which it correctly classified 89% of individuals as cognitively impaired or intact, while the optimal cut-score for the MoCA was26 or27 depending on preference for either specificity or sensitivity. The optimal cut-score for the MMSE was29; however, this had low sensitivity despite good specificity.These findings suggest that the MoCA and ACE-R are both valid and time-efficient screening tools to detect cognitive impairment in the context of substance use.

Objective: Prospective memory (PM) is crucial to the maintenance of functional independence in late adulthood and is consistently impaired in mild cognitive impairment (MCI). There remains a need for brief but valid measures of this construct that can be used as part of a comprehensive clinical assessment of cognition. Since the distinctiveness of PM cues is argued to determine the degree of strategic, controlled demands of PM paradigms, two variants of a brief measure were developed, one of which presented low-salience and the other high-salience PM cues. Method: A large cohort of older adults with normal cognition or MCI was assessed with one of the two variants of our brief, novel measure of PM. Participants were asked to remember to execute PM tasks where the target cue was either high or low in salience, while concurrently engaged in an ongoing task of olfactory assessment. Results: The task was able to discriminate between groups of participants with MCI or no cognitive impairment, albeit with a small effect size. The high-salience cue improved performance on the PM task; however, there was no interaction of cue salience with group. Conclusions: These results suggest that the temporal reliability and construct validity of very brief measures of the type used in this study need further exploration to determine their potential to provide meaningful insights into PM function. This measure may have utility as a brief screening tool, with identified deficits being followed up with a more comprehensive PM assessment.

Introduction:The prisoner population is ageing, and consideration is needed for how to best support those with age-related health conditions in the system. Existing work practices and organizational structures often fail to meet the needs of prisoners with dementia, and prison staff experience high levels of burden because of the increased needs of these prisoners. Little is known about the best method of responding to the needs of this growing subpopulation of prisoners.Method:A scoping review was conducted to answer the question: what are the perceived best care options for prisoners with dementia? To be included, publications had to be publicly available, reported on research findings, or viewed opinions and commentaries on care practices relevant to older prisoners with dementia. Searches were conducted in 11 databases to identify relevant publications. Data from the included publications were extracted and summarized into themes.Results:Eight themes were identified that could support better care practices for prisoners with dementia: (1) early and ongoing screening for older prisoners; (2) specialized services; (3) specialized units; (4) programs or activities; (5) adaptations to current contexts; (6) early release or parole for older prisoners with dementia deemed at low risk of reoffending; and (7) training younger prisoners (8) as well as staff to assist older prisoners with dementia. Besides practical strategies improving care practice, costs, prison-specific resources, and staff skills were highlighted as care barriers across all themes. A lack of empirical evidence supported these findings.Conclusion:One of the implications of the international ageing prison population is the higher number of people living with dementia being incarcerated. Suggestions for best care approaches for prisoners with dementia now need to move from opinion to empirical approaches to guide practice.

Excessive alcohol use is associated with a wide range of physical, psychological and social consequences, and is responsible for a significant proportion of the burden of disease globally. An area which has received increasing interest is alcohol-related brain damage, not just because of the cost to the individual and society through resource utilization, but also because of the potential for prevention and reversibility. This paper aims to review the current literature on this subject and seeks to explore issues around diagnosis and treatment of alcohol-related brain damage.

Young onset dementia (YOD), where symptoms of dementia have an onset before the age of 65, has become more prominent due to the population increase from the Baby Boomer generation. This clinical perspective examines key issues in the assessment, diagnosis and management of YOD. Challenges in the assessment and diagnosis of YOD are partly due to the diverse range of types of YOD, where degenerative dementias are less common and secondary dementias more common than in late onset dementia. Early symptoms are broad and include depression, behavioural change, neurological disorders, systemic disorders and mild cognitive impairment (MCI). Perceived diagnostic delay may result in frustration and distress in people with YOD and their families. Chronic depression and MCI are associated with longer time to diagnosis, and in these situations, clinicians need to establish appropriate review processes and communicate clearly. A diagnosis of YOD may have marked consequences for a younger person, including early retirement, financial impacts and the psychological challenge of coming to grips with cognitive decline. Partners, children and other supporters often have unmet needs, feel burdened by care and are at high risk of physical and emotional consequences. Concerns about the heritability of dementia may add to family distress. Recent community service developments in Australia for YOD are outlined and the challenges of residential care described.

Introduction and Aims The Australian Treatment Outcomes Profile (ATOP) is a brief instrument that assesses a range of substance use, health and well-being measures over the past 28 days. Previously, it has been validated in general adult Australian alcohol and other drug (AOD) treatment populations. However, the increasing number of older-aged clients attending AOD treatment warrants the instrument to be validated for this population. The aim of this study was to validate the ATOP for use in older AOD populations, by comparing it with validated ‘gold standard’ measures used in older populations. Design and Methods A convenience sample of 99 participants aged ≥50 attending specialist AOD services in Sydney, Australia were administered the ATOP by a researcher, along with alcohol use (AUDIT) and health questionnaires [Physical Health Questionnaire-15, 12-item short-form Health Survey (SF-12) and Geriatric Depression Scale]. Results The ATOP items had strong agreement with the comparison instruments. The highest correlation was between the 28 days alcohol use and the AUDIT. ATOP psychological health scores highly correlated with the SF-12 mental health subscale and the Geriatric Depression Scale, and ATOP physical health scores significantly correlated with the SF-12 physical health subscale and the Physical Health Questionnaire-15. The ATOP Quality of Life score significantly correlated with all health measures. Discussion and Conclusions The ATOP has good concurrent validity with other validated substance use and health measures in an older population. Comparison with general older populations demonstrated the poorer health of this group of older AOD clients in particular.[Lintzeris N, Monds L A, Rivas G, Leung S, Withall A, Draper B. The Australian Treatment Outcomes Profile instrument as a clinical tool for older alcohol and other drug clients: A validation study. Drug Alcohol Rev 2016;35:673-677]

OBJECTIVE The objective of this study is to identify factors determining the time to diagnosis for young-onset dementia (YOD), defined as dementia with symptom onset before age 65 years, by mapping the diagnostic pathways. METHODS Participants were recruited via healthcare professionals, community support organisations or were self-referred. Information was obtained by interviews with the person with YOD and their carer, and medical record reviews. Clinical dementia diagnoses were independently ratified by consensus review. RESULTS Participants included 88 people with YOD (mean age of onset = 55.4 years), due to Alzheimer's disease (AD) (53.4%, n = 47), frontotemporal dementia (FTD) (15.9%, n = 14) and other causes (30.7%, n = 27). Median time from symptom onset to first consultation was 2.3 years, to dementia diagnosis 3.2 years, to family awareness of dementia diagnosis 3.5 years and to final diagnosis of the type of dementia 4.7 years. Non-dementia diagnoses occurred in 48.9%, including depression (30.7%) and mild cognitive impairment (MCI) (17.0%). Participants with younger age of onset had significantly longer time to first consultation and family awareness of the dementia diagnosis. The time to dementia diagnosis was significantly longer when the participant presented with MCI or depression and when the dementia was other than AD or FTD. MCI was associated with significantly longer time to family awareness of dementia diagnosis. CONCLUSIONS Factors impacting on time to diagnosis vary with the stage of diagnosis in YOD. Longer time to dementia diagnosis occurred in people who were younger at symptom onset, when MCI or depression was present, and in dementias other than AD and FTD. Copyright © 2016 John Wiley & Sons, Ltd.

Introduction and Aims The number of older clients attending drug and alcohol (D&A) services is increasing, although there is insufficient knowledge regarding service needs for this group. The aim of this study was to document the patterns of substance use, health status, cognition, social conditions, and health service utilisation of older clients in D&A treatment. Design and Methods A cross-sectional observational study of 99 clients aged ≥50 years (M = 55, SD = 4.5; 77% male) attending specialist D&A services (N = 30 alcohol treatment, N = 69 opioid treatment) in Sydney, Australia. Participants completed a confidential research interview. Findings were compared to aggregated data from younger opioid substitution treatment (OST) clients attending the same services (N = 214). Results Alcohol (46%), benzodiazepines (40%) and cannabis (38%) were the most commonly reported substances used in the past 4 weeks; 23% reported no recent substance use, and 17% reported using three or more drugs. Participants reported high levels of physical and mental health problems, social isolation, low levels of employment, and a third reported difficulties with daily living activities. Forty percent had been injured in a fall in the past 12 months. The mean Addenbrooke's Cognitive Examination-R score was 82.4 ± 9.6, with 40% performing at a level consistent with severe cognitive impairment. A significantly higher proportion of older participants used alcohol and benzodiazepines than younger clients, and older participants had significantly poorer psychological health, physical health and quality of life. Discussion and Conclusions DA●●:●●–●●]

Background: Prospective memory refers to memory for future intentions and is a critical predictor of functional capacity in late adulthood. For many other cognitive abilities, self- and informant-rated methods of assessment are routinely used to guide clinical decision-making. However, little is known about the validity (and consequently the clinical utility) of subjective reports of prospective memory difficulties. Objective: The aim of this study was to compare clinical [mild cognitive impairment (MCI), dementia] and nonclinical older adults (healthy controls) on self- and informant-rated versions of prospective and retrospective memory function, as well as objective measures of prospective memory. Critical here was not only the assessment of between-group differences, but also whether these different methods of assessing memory function would show appropriate convergent and discriminant validity. Methods: A total of 138 participants aged between 64 and 92 years, diagnosed with dementia (n = 37), MCI (n = 48) or no impairment (n = 53), were asked to complete self- and informant-rated versions of the Prospective and Retrospective Memory Questionnaire (PRMQ). Participants also completed behavioural measures of global cognitive function [the Mini-Mental State Examination (MMSE)], as well as a behavioural measure of prospective memory (Virtual Week). Results: Self-reported impairments were equivalent across the three groups, and informant reports of impairment, while higher for those with dementia, did not distinguish MCI from controls. For the combined sample and for all three groups separately, both self- and informant reports of prospective memory showed poor convergent validity, at best correlating only weakly with Virtual Week. Self-reported prospective memory was correlated with informant report only in the dementia group, not in the control or MCI groups. Convergent and discriminant validity were poor, with self- and informant-rated prospective memory more strongly related to self- and informant-rated retrospective memory than to scores on Virtual Week. Conclusion: These data indicate that self-report and informant report may neither accurately measure prospective memory of older people, nor be sensitive to objective prospective memory difficulties in people with MCI and dementia. These data have potentially important implications for clinical practice.

Despite reporting high levels of burden, people with young onset dementia (YOD) and their caregivers underuse formal services. Whether barriers to use are similar to those for older people are unknown. The aim of this mixed-methods study was to assess both patient/caregiver-related and service-specific/contextual barriers to service use in YOD, and establish recommendations for service design.

Background:Substance use disorders in older adults are expected to increase dramatically in the coming years. Given the increased susceptibility to cognitive deficits in older substance users (defined here as aged 50+ years due to the accelerated health decline observed in this population), it is important to consider the functional correlates of cognitive impairment in these older adults. This study details the cognitive status of older individuals attending outpatient drug and alcohol (D&A) treatment services and seeks to determine of the association of cognitive impairment to self-reported daily functioning.Methods:Ninety nine clients aged 50 years or over attending outpatient D&A treatment services in Sydney, Australia participated. Cognition was assessed using the Addenbrooke's Cognitive Examination – Revised (ACE-R). Recent substance use (Australian Treatment Outcome Profile), physical and mental health (SF12, Geriatric Depression Scale), social isolation (Lubben Social Network Scale), and activities of daily living (Bayer ADL Scale) were also assessed.Results:Nearly two-thirds of participants screened positive for cognitive impairment on the ACE-R; 41% and 65% of clients met the cut-off scores for mild cognitive impairment (MCI) and more severe cognitive impairment, respectively. Self-reported seizure history was a predictor of cognitive impairment.Conclusions:The results suggest that cognitive impairment in this group is common. The assessment of cognitive status for this older group of patients should not only include the identification of cognitive impairment but also encompass mental health and social functioning. A greater understanding of the needs of this cohort will also enable better co-ordination with other health and welfare services tailored to this population.

Background:Service planning for people with younger onset dementia (YOD; an onset of symptoms before the age of 65 years) relies on prevalence estimates, with existing models based upon older people. This pilot study investigated the prevalence and causes of YOD in a defined catchment area of Eastern Sydney, Australia.Methods:The study was conducted in three stages: publicity building, case finding, and case validation. A brief structured questionnaire was sent to health professionals in the catchment area asking how many patients with YOD they had seen over the previous 12 months. Memory clinics and hospital records were also searched for YOD patients. Clinicians assigned a Statistical Linkage Key to each patient to prevent double counting, and indicated the cause of dementia. The majority of patients were validated by a review of medical case notes. Prevalence data were calculated for the following age groups: 30–64, 30–44, and 45–64 years.Results:Two hundred and four potential patients were identified, of which 141 met inclusion criteria. The primary clinical subtypes were alcohol-related dementia (18.4%), Alzheimer's disease (17.7%), vascular dementia (12.8%), and frontotemporal dementia (11.3%). Eighty-eight patients were aged 30 to 64 years on census date and were therefore included in the prevalence calculations. The overall prevalence was 68.2 per 100,000 population at risk for the 30–64-year age group (95% Confidence Interval (CI): 54.9–83.4); 11.6 per 100,000 for the 30–44-year age group (95% CI: 5.3–21.7); and 132.9 per 100,000 for the 45–64 age group (95% CI: 105.8–164.2).Conclusions:Younger onset dementia affects a significant number of people in Eastern Sydney with a diverse range of clinical types. This prevalence rate is higher than previous reports from the United Kingdom and Japan, with a different distribution of etiologies, which have important implications for service planning for this group.