Reducing the risk of mental illness and dementia with age

Good mental health plays a crucial role in our lives, but the older we get, the less likely we are to receive adequate interventions.

This is despite evidence showing that treatments tailored to middle-aged to older adults can be very successful, especially when a holistic approach is taken that considers the person’s mental, physical and cognitive health.

Commonwealth and Victorian government policies emphasize the need for integrated mental and physical health care. This is particularly important as we age, given that we already know that conditions such as depression increase the risk of dementia.

A recent report by the Australian Institute of Health and Welfare (AIHW) was a timely reminder of the importance of dementia risk reduction strategies. The report shows that dementia is – for the first time – the leading cause of disease burden in Australians aged 65 and over.

In 2019, our multidisciplinary research team received funding to develop national guidelines to provide Australians over 50 who have concerns about their cognitive abilities with information about the type of physical activity (PA) needed not only to maintain of form and prevention of falls, but also for maintaining mental and brain health.

Our team works closely with health services, including the Older People’s Mental Health Program at NorthWestern Mental Health and the Royal Melbourne Hospital (RMH), focusing on non-pharmacological ways to improve mental health and reduce the risk of dementia.

Together with our clinical colleagues, we identified that Older People Multidisciplinary Assessment and Treatment Teams (APATTs) in the Victorian public health system – tasked with providing comprehensive mental health support to older members of the community – would benefit from new evidence in guidelines for better include PA interventions in their models of care.

We developed a project centered around a collaboration between researchers from the University of Melbourne, the University of New South Wales and the University of Western Australia, as well as clinicians in mental health, community rehabilitation, physiotherapy and general practitioners (GPs).

It aimed to investigate the feasibility, utility and effectiveness of incorporating PA guidelines into the APATT service. This project received funding from the Medical Research Future Fund (MRFF) and we were ready to start the study when COVID-19 hit.

The project had to be postponed. But although we could not conduct the research in the public mental health system, we were able to engage directly with members of the Australian community.

Between May and August 2020, seniors aged 65 to 74 had the greatest increase in anxiety and worry, while seniors aged 75 and over were most vulnerable to experiencing significant psychological distress.

With MRFF approval, we adapted our protocol to create the Exercise for Cognitive Health (EXCEL) study, a flexible, person-focused PA intervention.

The aim was to help middle-aged and older adults with symptoms of depression, anxiety or stress and concerns about their cognition to make small but significant changes in their PA to meet the advice offered by the guidelines, and to improve their mental, physical and cognitive health.

EXCEL had three phases.

Phase 1 centered around co-designing an evidence-based model by talking to individuals from this cohort about their own challenges, strengths and barriers. This stage was critical to ensure that the unique factors associated with middle-aged and older adults with mental and cognitive problems were addressed by our intervention.

In Phase 2, our research team created the content for our intervention, which included exercise videos, workbooks, and online diaries, and then conducted the 12-week PA intervention.

Central to the design of EXCEL was that, in addition to providing participants with personalized PA prescriptions and equipment such as dumbbells and exercise bands, we also provided regular online coaching sessions with trained researchers who explored and addressed barriers and facilitators to the exercises that could adapt to any necessary changes during the 12 weeks.

Our team of psychiatrists, psychologists, physiologists, social workers and occupational therapists had to juggle a combination of scientific rigor and flexible problem-solving while adapting to lockdown scenarios.

This includes co-ordinating the delivery of exercise equipment across Australia, recording large numbers of exercise videos on mobile phones or calling participants directly when video calls do not connect.

More than 50 people participated in the study, with evidence showing strong adherence to the prescribed exercise program, along with improvements in measures of mental health.

In phase 3, we asked what our participants thought about the intervention through a series of semi-structured interviews.

One theme that emerged was that coaching helped turn participants’ intentions into action by providing accountability, building confidence, and strategies for overcoming barriers to program engagement in a way that reached them on a personal level.

One EXCEL participant shared how the coach helped them move.

“I remember being told (by my coach) that anything is better than nothing, so I thought, ‘Okay, okay, I’ll just go and walk around the block.’ At least I can say I went for a walk, and of course I would walk further than just around the block.

By the end of the 12-week program, this person’s health had improved.

“I wouldn’t get high so early. I actually had to push myself to get puffy, whereas before I was walking down the street…my heart rate would go up, but now it doesn’t.”

Exercise is a practical and well-studied intervention that helps improve cognitive, mental, and physical health outcomes in middle-aged and older adults.

The EXCEL study demonstrated that behavior change support shifts intention to action—helping middle-aged to older adults with mental health symptoms and cognitive problems to adopt PA guidelines.

Although our EXCEL project was not what was planned due to the pandemic, it was rewarding to experience the enthusiasm and determination of older community members who were actively managing their mental and cognitive health needs.

It is important to emphasize the importance of personalized and tailored interventions.

The success of EXCEL sets the stage for improving comprehensive care protocols for older Australians with mental health symptoms and cognitive problems.

It also shows us that information and communication technologies can help this age group overcome distance and isolation.

The EXCEL team consists of Professor Nikola Lautenschlager, Docent Catherine Ellis, Dr Eleanor Curran, Dr Kay Cox, Professor Victoria Palmer, Dr Terence Chong, Jennifer Southam, Alyssa Westphal, Dr Tom Rego, Rebecca Moorhead, Rhoda Lai, Prof Karin Anstey, Dr- Dr. Brett Coulson and Dr. Francine Moss.

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