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Objectives: We examined longitudinal changes in cognitive and physical function and associations between change in function and falls in people with and without mild cognitive impairment (MCI). Design: Prospective cohort study with assessments every 2 years (for up to 6 years). Setting: Community, Sydney, Australia. Participants: Four hundred and eighty one people were classified into three groups: those with MCI at baseline and MCI or dementia at follow-up assessments (n = 92); those who fluctuated between cognitively normal and MCI throughout follow-up (cognitively fluctuating) (n = 157), and those who were cognitively normal at baseline and all reassessments (n = 232). Measurements: Cognitive and physical function measured over 2–6 years follow-up. Falls in the year following participants’ final assessment. Results: In summary, 27.4%, 38.5%, and 34.1% of participants completed 2, 4, and 6 years follow-up of cognitive and physical performance, respectively. The MCI and cognitive fluctuating groups demonstrated cognitive decline, whereas the cognitively normal group did not. The MCI group had worse physical function than the cognitively normal group at baseline but decline over time in physical performance was similar across all groups. Decline in global cognitive function and sensorimotor performance were associated with multiple falls in the cognitively normal group and decline in mobility (timed-up-and-go test) was associated with multiple falls across the whole sample. Conclusions: Cognitive declines were not associated with falls in people with MCI and fluctuating cognition. Declines in physical function were similar between groups and decline in mobility was associated with falls in the whole sample. As exercise has multiple health benefits including maintaining physical function, it should be recommended for all older people. Programs aimed at mitigating cognitive decline should be encouraged in people with MCI.

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

Objective: Mild cognitive impairment (MCI) is considered an intermediate stage between normal cognitive function and dementia. Fall risk is increased in this group, but there is limited literature exploring specific fall risk factors that may be addressed in fall prevention strategies. The aim of this study was to examine risk factors for falls in older people with MCI, focusing on cognitive, psychological and physical factors. Methods: Participants (n = 266, 45% women) were community-dwelling older people aged 70–90 years who met the criteria for MCI. Cognitive, psychological, sensorimotor and physical assessments, physical activity levels, medication use, general health and disability were ascertained at baseline. Falls were monitored prospectively for 12 months. Results: During follow-up, 106 (40%) participants reported one or more falls. Poorer visual contrast sensitivity, increased postural sway, lower levels of weekly walking activity, higher levels of depressive symptoms and psychotropic medication use were significantly associated with faller status (≥1 falls) in univariable analyses. Of these factors, poor visual contrast sensitivity, increased postural sway and psychotropic medication use were found to be significant independent predictors of falls in multivariable analysis while controlling for age and sex. No measures of cognitive function were associated with falls. Conclusions: Poor visual contrast sensitivity, impaired balance and psychotropic medication use predicted falls in community-dwelling people with MCI. These risk factors may be amenable to intervention, so these factors could be carefully considered in fall prevention programs for this population.

Objectives: The Sunbeam trial significantly reduced falls in long-term aged care (LTC) residents. The current study's primary objective was to undertake subgroup analysis of the Sunbeam trial, to determine whether the intervention was effective for reducing falls in LTC residents with mild-moderate cognitive impairment/dementia. Secondary objectives were to determine intervention effects on cognitive and physical function. Design: Subgroup analysis of a cluster randomized controlled trial (RCT). Setting and Participants: Permanent residents of LTC in Australia who participated in the Sunbeam trial with Addenbrooke's Cognitive Examination-Revised (ACE-R) scores <83 (Mini-Mental State Examination >14 = main trial inclusion criteria). Methods: Of 221 participants, 148 had an ACE-R <83 and were included in this study. Sixteen LTC residences (clusters) were randomized to receive either the Sunbeam program or usual care. The Sunbeam program involved two 1-hour sessions/week of tailored and progressive resistance and balance training for 25 weeks followed by a maintenance program (two 30-min sessions/week of nonprogressive exercise for 6 months). Assessments were conducted at baseline, 6 months, and 12 months. Falls were recorded using routinely collected data from the LTC incident management systems. Results: Rate of falls (50%) and risk of falls (31%), multiple falls (40%), and injurious falls (44%) were reduced in the intervention group. The intervention group had significantly better balance (static and dynamic) and sit-to-stand ability when compared with the control group at 6 months and significantly better dynamic balance at 12 months. There were no serious adverse events. Conclusions and Implications: The Sunbeam Program significantly reduced falls and improved physical performance in cognitively impaired LTC residents. This is a novel and important finding, as many previous studies have excluded people with cognitive impairment/dementia and inconsistent findings h

Objectives: Understanding the relationship between white matter hyperintensities (WMHs) and cognitive and physical decline in people with dementia will assist in determining potential treatment strategies. Currently there is conflicting evidence describing the association between WMHs and cognitive decline and, WMHs association with declines in objective measures of physical function have not been examined. We examined the relationship between baseline WMH volume and physical/cognitive decline over one-year in older people with dementia. Methods: Twenty-six community-dwelling older people with dementia (mean age = 81 ± 8 years; 35% female) were assessed at baseline and follow-up (one-year) using the Addenbrooke’s Cognitive Examination-Revised (including verbal fluency), Trail Making Test A, the Physiological Profile Assessment (PPA), timed-up-and-go (TUG) and gait speed. WMH volumes were quantified using a fully automated segmentation toolbox, UBO Detector. Results: In analyses adjusted for baseline performance, higher baseline WMH volume was associated with decline in executive function (verbal fluency), sensorimotor function (PPA) and mobility (TUG). Executive function (semantic/category fluency) was the only domain association that withstood adjustment for age, and additionally hippocampal volume. Conclusions: In unadjusted analyses, WMH volume was associated with one-year declines in cognitive and physical function in older people with dementia. The association with executive function decline withstood adjustment for age. More research is needed to confirm these findings and explore whether vascular risk reduction strategies can reduce WMH volume and associated cognitive and physical impairments in this group.

Introduction: Dementia and depression often coexist. Understanding how concomitant comorbidities affect function can improve assessment and management strategies. We examined the relationship between cognitive, psychological, and physical function and depressive symptoms in people with cognitive impairment. Methods: Cross-sectional study using baseline data from the iFOCIS randomized controlled trial involving 309 participants with mild-moderate cognitive impairment. The association between cognitive (Addenbrooke’s Cognitive Examination-III [ACE-III], Frontal Assessment Battery), psychological (Goldberg Anxiety Scale; Iconographical Falls Efficacy Scale), and physical (Physiological Profile Assessment; Short Physical Performance Battery [SPPB]) function, and quality of life (QoL), physical activity levels and activities of daily living, and depressive symptoms (15-item Geriatric Depression Scale [GDS]) were assessed (adjusted for age, sex, education, and ACE-III as appropriate). Results: Participants with depressive symptoms (GDS ≥4) had significantly more falls in the previous year and a higher number of comorbidities than people without depressive symptoms (GDS <4). Each point increase in the GDS was associated with better memory, higher levels of anxiety and concern about falling, poorer balance, slower gait speed, and reduced QoL. The relationship between the GDS and poor balance and QoL withstood additional adjustment for comorbidity tertiles. The relationship between GDS and concern about falls withstood additional adjustment for previous falls (12 months) and SPPB scores. Conclusions: Depressive symptomatology is associated with poorer physical and psychological function and reduced QoL in people with cognitive impairment. These factors should be considered when assessing and intervening in this group. Future research could examine these relationships longitudinally to establish causality and examine intervention efficacy in this group.

Background: : Understanding the relationship between white matter hyperintensities (WMHs) and gait may assist in understanding the central control of gait and determining treatment modalities. These relationships are yet to be realized in older people with dementia. Objective: : To examine the association between WMH volume and gait under single-task and dual task (DT) conditions in people with dementia. Methods: : Twenty-eight community-dwelling older people with dementia (median age=83 years; [IQR=77–86]; 36% female) had timed gait speed assessed at usual pace. Gait (speed, stride length, cadence) was assessed using the GAITRite® mat under three conditions (n = 18/28): a) single-task, b) functional DT: carrying a glass of water and c) cognitive DT: counting backwards from 30. WMH volumes were quantified using a fully automated segmentation toolbox. Results: : Total, temporal and parietal WMH volumes were negatively correlated with timed and functional DT gait speed, and with stride length under single-task, functional DT and cognitive DT conditions. Frontal WMH volumes were negatively correlated with timed gait speed and stride length under single-task and functional DT conditions. Participants with higher total WMH burden had significantly slower timed and functional DT gait speed and reduced stride length under single-task, functional DT and cognitive DT conditions compared to participants with lower WMH burden. Conclusions: : WMH volume was associated with slower gait speed and reduced stride length, but not cadence, under single-task and DT conditions in people with dementia. Further research is needed to confirm these findings and determine whether vascular risk management can improve gait in older people with dementia.

Introduction One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. Methods and analysis This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. Ethics and dissemination Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. Trial r

Objective: To determine whether impairments across cognitive and affective domains provide additional information to sensorimotor deficits for fall prediction among various populations. Design: We pooled data from 5 studies for this observational analysis of prospective falls. Setting: Community or low-level care facility. Participants: Older people (N=1090; 74.0±9.4y; 579 female); 500 neurologically intact (NI) older people and 3 groups with neurologic disorders (cognitive impairment, n=174; multiple sclerosis (MS), n=111; Parkinson disease, n=305). Interventions: None. Main Outcome Measures: Sensorimotor function was assessed with the Physiological Profile Assessment, cognitive function with tests of executive function, affect with questionnaires of depression, and concern about falling with falls efficacy questionnaires. These variables were associated with fall incidence rates, obtained prospectively over 6-12 months. Results: Poorer sensorimotor function was associated with falls (incidence rate ratio [95% CI], 1.46 [1.28-1.66]). Impaired executive function was the strongest predictor of falls overall (2.91 [2.27-3.73]), followed by depressive symptoms (2.07 [1.56-2.75]) and concern about falling (2.02 [1.61-2.55]). Associations were similar among groups, except for a weaker relationship with executive impairment in NI persons and a stronger relationship with concern about falling in persons with MS. Multivariable analyses showed that executive impairment, poorer sensorimotor performance, depressive symptoms, and concern about falling were independently associated with falls. Conclusions: Deficits in cognition (executive function) and affect (depressive symptoms) and concern about falling are as important as sensorimotor function for fall prediction. These domains should be included in fall risk assessments for older people and clinical groups.

Background: The evidence to support effective fall prevention strategies in older people with cognitive impairment (CI) is limited. The aim of this randomized controlled trial (RCT) was to determine the efficacy of a fall prevention intervention in older people with CI. Method: RCT involving309 community-dwelling older people with CI. The intervention group (n = 153) received an individually prescribed home hazard reduction and home-based exercise program during the 12-month study period. The control group (n = 156) received usual care. The primary outcome was rate of falls. Secondary outcomes included faller/multiple faller status, physical function, and quality of life. Results: Participants' average age was 82 years (95% CI 82-83) and 49% were female. There was no significant difference in the rate of falls (incidence rate ratio [IRR] 1.05; 95% confidence interval [95% CI] 0.73-1.51). A sensitivity analysis, controlling for baseline differences and capping the number of falls at 12 (4 participants), revealed a nonsignificant reduction in fall rate in the intervention group (IRR 0.78; 95% CI 0.57-1.07). Analyses of secondary outcomes indicated the intervention significantly reduced the number of multiple fallers by 26% (RR 0.74; 95% CI 0.54-0.99) when adjusting for baseline differences. There was a differential impact on falls in relation to physical function (interaction term p-value =. 023) with a significant reduction in fall rate in intervention group participants with better baseline physical function (IRR 0.60; 95% CI 0.37-0.98). There were no significant between-group differences for other secondary outcomes. Conclusions: This intervention did not significantly reduce the fall rate in community-dwelling older people with CI. The intervention did reduce the fall rate in participants with better baseline physical function. Clinical Trials Registration Number: Australian and New Zealand Trials Registry ACTRN12614000603617.

INTRODUCTION: One in three people aged 65 years and over fall each year. The health, economic and personal impact of falls will grow substantially in the coming years due to population ageing. Developing and implementing cost-effective strategies to prevent falls and mobility problems among older people is therefore an urgent public health challenge. StandingTall is a low-cost, unsupervised, home-based balance exercise programme delivered through a computer or tablet. StandingTall has a simple user-interface that incorporates physical and behavioural elements designed to promote compliance. A large randomised controlled trial in 503 community-dwelling older people has shown that StandingTall is safe, has high adherence rates and is effective in improving balance and reducing falls. The current project targets a major need for older people and will address the final steps needed to scale this innovative technology for widespread use by older people across Australia and internationally. METHODS AND ANALYSIS: This project will endeavour to recruit 300 participants across three sites in Australia and 100 participants in the UK. The aim of the study is to evaluate the implementation of StandingTall into the community and health service settings in Australia and the UK. The nested process evaluation will use both quantitative and qualitative methods to explore uptake and acceptability of the StandingTall programme and associated resources. The primary outcome is participant adherence to the StandingTall programme over 6 months. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the South East Sydney Local Health District Human Research Ethics Committee (HREC reference 18/288) in Australia and the North West- Greater Manchester South Research Ethics Committee (IRAS ID: 268954) in the UK. Dissemination will be via publications, conferences, newsletter articles, social media, talks to clinicians and consumers and meetings with health departments/managers. TRIA

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

White Matter Hyperintensities (WMHs) are associated with impaired gait, balance and cognition and increased fall risk in cognitively healthy older people. However, few studies have examined such relationships in older people with dementia. Understanding the role of WMHs in falls may assist in developing effective fall prevention strategies. We investigated the relationship between baseline WMHs, cognitive and sensorimotor function and prospective falls in older people with dementia. Twenty-eight community-dwelling older people with mild-moderate dementia (MMSE 11–23; ACE-R < 83) underwent magnetic resonance imaging and assessment of sensorimotor and cognitive (global and processing speed) function at baseline. WMHs, were quantified using a fully automated segmentation toolbox, UBO Detector (https://cheba.unsw.edu.au/group/neuroimaging-pipeline). Falls were ascertained prospectively for 12-months using monthly calendars with the assistance of carers. The median age of the participants was 83 years (IQR 77–86); 36% were female; 21 (75%) fell during follow-up. Using Generalized Linear Models, larger volumes of total WMHs were found to be significantly associated with poorer global cognitive and sensorimotor function. Using modified Poisson regression, total, periventricular and deep WMHs were each associated with future falls while controlling for age, sex, intracranial volume and vascular risk. Each standard deviation increase in total and periventricular WMH volume resulted in a 33% (RR 1.33 95%CI 1.07–1.66) and 30% (RR 1.30 95%CI 1.06–1.60) increased risk of falling, respectively. When the deep WMH volume z-scores were dichotomized at the median, individuals with greater deep WMH volumes had an 81% (RR 1.81 95% CI 1.02–3.21) increased risk of falling. WMHs were associated with poorer sensorimotor and cognitive function in people with dementia and total, periventricular and deep WMHs were associated with falls. Further research is needed to confirm these preliminary

Objectives: The aim of this study was to investigate physical decline over 1-year in a cohort of older people across the cognitive spectrum. Methods: Physical function was assessed using the Physiological Profile Assessment (PPA) in 593 participants (cognitively normal [CN]: n = 342, mild cognitive impairment [MCI]: n = 77, dementia: n = 174) at baseline and in 490 participants available for reassessment 1-year later. Neuropsychological performance and physical activity (PA) were assessed at baseline. Results: Median baseline PPA scores for CN, MCI and dementia groups were 0.41 (IQR = −0.09–1.02), 0.66 (IQR = −0.06–1.15) and 2.37 (IQR = 0.93–3.78) respectively. All baseline neuropsychological domains and PA were significantly associated with baseline PPA. There were significant interaction terms (Time × Cognitive Group, Global Cognition, Processing Speed, Executive Function and PA) in the models investigating PPA decline. In multivariate analysis the Time × Executive Function and PA interaction terms were significant, indicating that participants with poorer baseline executive function and reduced PA demonstrated greater physical decline when compared to individuals with better executive function and PA respectively. Discussion: Having MCI or dementia is associated with greater physical decline compared to CN older people. Physical inactivity and executive dysfunction were associated with physical decline in this sample, which included participants with MCI and dementia. Both factors influencing physical decline are potentially amenable to interventions e.g. exercise.

Understanding the characteristics of physical activity and daily-life gait in older people with dementia may help identify those at risk of negative health outcomes and inform targeted interventions. Questionnaires are often used to assess physical activity but may be more affected by recall bias in people with dementia and provide little information about daily-life gait characteristics. The aim of the study was to assess differences in daily-life activity levels and gait characteristics between community-dwelling older people with mild to moderate dementia (n=45; mean age 81±6 years, 42% female) and age-sex matched (1:2) cognitively-healthy controls (n=90). Participants wore a tri-axial accelerometer (DynaPort MoveMonitor, McRoberts) on their lower back for 7 days and were assessed on neuropsychological and physical performance. Compared to age-sex matched controls, participants with dementia demonstrated reduced daily-life activity (fewer steps per day, fewer and shorter walking bouts, and lower daily walk time) and walking intensity (reduced speed, stride length and cadence). Participants with dementia also had significantly increased within-walk variability (stride time) and less regular gait (higher sample entropy). Within the group of participants with dementia, higher daily-life activity levels were associated with greater self-reported physical activity and better executive function. Fallers (1+ falls past year) with dementia had significantly reduced daily-life activity and walking speed when compared to non-fallers with dementia. In conclusion, people with dementia are less active in daily-life and present with significant impairments across multiple gait domains when compared to age-sex matched controls. These findings highlight opportunities for targeted interventions and support further research to examine interventions aimed at addressing these deficits.

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

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

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

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

Climate change is a major threat to food security in Pacific Island countries, with declines in food production and increasing variability in food supplies already evident across the region. Such impacts have already led to observed consequences for human health, safety and economic prosperity. Enhancing the adaptive capacity of Pacific Island communities is one way to reduce vulnerability and is underpinned by the extent to which people can access, understand and use new knowledge to inform their decision-making processes. However, effective engagement of Pacific Island communities in climate adaption remains variable and is an ongoing and significant challenge. Here, we use a qualitative research approach to identify the impediments to engaging Pacific Island communities in the adaptations needed to safeguard food security. The main barriers include cultural differences between western science and cultural knowledge, a lack of trust among local communities and external scientists, inappropriate governance structures, and a lack of political and technical support. We identify the importance of adaptation science, local social networks, key actors (i.e., influential and trusted individuals), and relevant forms of knowledge exchange as being critical to overcoming these barriers. We also identify the importance of co-ordination with existing on-ground activities to effectively leverage, as opposed to duplicating, capacity.

BACKGROUND: Older people with cognitive impairment have an elevated fall risk, with 60% falling annually. There is a lack of evidence for fall prevention in this population, in part due to limited understanding of risk factors. This study examined fall risk in older people with cognitive impairment with an emphasis on identifying explanatory and modifiable risk factors. METHODS: One hundred and seventy-seven community-dwelling older people with mild-moderate cognitive impairment (Mini-Mental State Examination 11-23/Addenbrooke's Cognitive Examination-Revised <83) underwent neuropsychological, physical, and functional assessments. Falls were recorded prospectively for 12 months with the assistance of carers. RESULTS: Of the 174 participants available to follow-up, 111 (64%) fell at least once and 71 (41%) at least twice. Higher fall rates were associated with slower reaction time, impaired balance (sway on floor and foam, semitandem, near-tandem, tandem stance), and reduced functional mobility (co-ordinated stability, timed up-and-go, steps needed to turn 180°, sit-to-stand, gait velocity). Higher fall rates were also associated with increased medication use (central nervous system, total number) and poorer performances in cognitive (Addenbrooke's Cognitive Examination-Revised: visuospatial domain, cube drawing; Trail-Making Test) and psychological (Geriatric Depression Scale, Goldberg Anxiety Scale, Falls Efficacy Scale-International) tests. Multivariate analysis identified increased sway on foam, co-ordinated stability score, and depressive symptoms to be significantly and independently associated with falls while controlling for age, years of education, and Addenbrooke's Cognitive Examination-Revised score. CONCLUSIONS: This study identified several risk factors of falls in older people with cognitive impairment, a number of which are potentially modifiable. Future research involving targeted interventions addressing medication use, balance, mood, and fun

Background: Cognitively impaired older people fall twice as often as their cognitively intact counterparts. There is, however, limited information on factors that increase the risk of falls in this population. This study aimed to determine whether a group of cognitively impaired older people (CIG) perform worse than a matched group of cognitively intact older people (NCIG) on a profile of physical performance and mobility tests. Methods: One hundred and thirty-eight cognitively impaired and 276 age and gendermatched cognitively intact community-dwelling older adults (>60 years) took part in the study. Participants completed a detailed physical performance battery from which composite fall risk scores were derived. Falls were measured prospectively for 12 months with monthly falls diaries, telephone calls, and by regularly contacting participants’ “person responsible.” Results: The CIG performed worse than the NCIG in tests of reaction time, muscle strength (grip and quadriceps), balance (sway on floor, sway on foam, controlled leaning balance and near tandem standing ability), and mobility (sit to stand, timed up and go (TUG) and steps required to turn 180 degrees). The CIG had significantly higher composite fall risk scores than the NCIG and fell significantly more during follow-up (Multiple falls (2+): CIG 43%; NCIG 21%). Conclusions: Fall risk in the CIG was significantly increased due to multiple physical impairments. Physical profiles provide a means of quantifying the extent of impairment in older people with cognitive impairment and potential direction for targeting interventions for reducing fall risk.

Impaired gait may contribute to the increased rate of falls in cognitively impaired older people. We investigated whether gait under simple and dual task conditions could predict falls in this group. The study sample consisted of 64 community-dwelling older people with mild to moderate cognitive impairment. Participants walked at their preferred speed under three conditions: (a) simple walking, (b) walking while carrying a glass of water and (c) walking while counting backwards from 30. Spatiotemporal gait parameters were measured using the GAITRite® mat. Falls were recorded prospectively for 12 months with the assistance of carers. Twenty-two (35%) people fell 2 or more times in the 12 month follow-up period. There was a significant main effect of gait condition and a significant main effect of faller status for mean value measures (velocity, stride length, double support time and stride width) and for variability measures (swing time variability and stride length variability). Examination of individual gait parameters indicated that the multiple fallers walked more slowly, had shorter stride length, spent longer time in double support, had a wider support width and showed more variability in stride length and swing time (p

With an aging population, both dementia and fall-related injury pose an international health challenge. Individuals with dementia fall twice as often as cognitively intact people and are more likely to have injurious falls. Higher morbidity and rates of mortality and institutionalization after falls have also been reported in this group. There is limited but emerging literature that is attempting to define and explain why fall risk is increased in this population. This will allow for targeted fall prevention programs. Currently, there are no published randomized controlled trials that have prevented falls in community-dwelling cognitively impaired older people, and conflicting evidence is reported in hospital and residential care trials. Recent exercise interventions have demonstrated significant benefits, such as improved gait speed, strength and balance in people with cognitive impairment/dementia, providing encouraging evidence for further research and clinical interventions.