Prevention and management of dementia in Aboriginal and Torres Strait Islander peoples

Dementia is one of the leading causes of death in Australia, with rates expected to rise as the population continues to age.
 
While some research focusing on prevalence, causes and experience of dementia in Aboriginal and Torres Strait Islander populations currently exists, much remains unknown.
 
The Federal Government recently allocated additional funding through the National Health and Medical Research Council (NHMRC) to a handful of research projects that aim to boost the prevention of dementia, slow its onset and improve the quality of life of Aboriginal and Torres Strait Islander peoples experiencing the disease.
 
The Let’s CHAT (Community Health Approaches To) Dementia in Indigenous Communities is an NHMRC-funded five-year project involving 12 Aboriginal community-controlled health services. It aims to improve the detection and management of cognitive impairment and dementia in primary healthcare, predominantly through Aboriginal primary health services.

Some members of the current project team were previously involved in the development and validation of a culturally appropriate cognitive assessment tool, Kimberley Indigenous Cognitive Assessment (KICA), designed to counter a shortage of appropriate screening tools for Aboriginal and Torres Strait Islander peoples, particularly in remote areas.
 
‘Until recently there was little understanding about dementia in Aboriginal and Torres Strait Islander communities,’ Associate Professor Dina LoGiudice, Consultant Physician Aged Care, Melbourne Health and lead investigator of the Let’s CHAT Dementia project, told newsGP.
 
‘Once the KICA tool was developed, we undertook a prevalence survey assessing everyone over the age of 45 in six communities in the Kimberley [WA], and also a third of people in a neighbouring town.
 
‘From there it was noted there were very high rates of dementia – three to five times higher than in non-Indigenous populations.

‘Studies were also repeated in urban NSW and in the Torres Strait, with similar findings.’
 
According to Dr Mary Belfrage, a GP with a special interest in Aboriginal and Torres Strait Islander health and member of the Let’s CHAT Dementia team, longer life expectancies among Aboriginal and Torres Strait Islander populations are welcome, but bring with them higher rates of cognitive impairment and dementia. 
 
‘These prevalence rates are coupled with the fact that Aboriginal and Torres Strait Islander populations are ageing,’ she told newsGP.
 
‘There are more older Aboriginal and Torres Strait Islander people than there used to be, which is great, but that also means there will be potentially more older people presenting with cognitive impairment and dementia.’
 
Dr Belfrage emphasises that although significant risk factors for dementia are similar in Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians, the prevalence is an important distinction.
 
‘It is fair to say there is no evidence at this stage that there are risk factors unique to Aboriginal and Torres Strait Islander peoples,’ she said.
 
‘That is an important message – that these risk factors are relevant to both Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians.’
 
Dr Belfrage cites age as the biggest risk factor for cognitive impairment and dementia, as well as the presence of existing chronic conditions such as diabetes, obesity, epilepsy, hypertension and history of stroke. But other risks may not be as well known.
 
‘Head injuries are a significant risk factor, and there is also evidence that childhood trauma is associated with higher rates of dementia,’ Dr Belfrage said.
 
‘A history of previous head injury may be more commonly represented in Aboriginal and Torres Strait Islander populations.
 
‘More recently, in a systematic review commissioned by The Lancet, hearing impairment has also been identified as a risk factor for dementia.’
 
Dr Belfrage and Associate Professor LoGiudice have found that preventive actions in early life contribute significantly to reducing risk of cognitive impairment and dementia. They highlight a ‘life-course approach’ as being particularly relevant for Aboriginal and Torres Strait Islander peoples.
 
‘The importance of a life-course approach to dementia, which is a shift in understanding dementia generally, but particularly in Aboriginal and Torres Strait Islander peoples with potentially environmental and socio-political factors, will contribute [to minimising risk] from an early age,’ Associate Professor LoGiudice said.
 
‘The things that minimise the risk of dementia are early-life development, engaging in strong developmental learning and employment. Things that engage cognition and management of risk factors such as diabetes, hypertension and smoking in mid-life,’ Dr Belfrage said.
 
Management strategies for Aboriginal and Torres Strait Islander people with dementia are relatively the same as those for non-Indigenous Australians, according to Associate Professor LoGiudice, but it is about tailoring these to the needs of certain communities.
 
‘Possibly the principles are the same, but what we don’t know is the best way to reflect that within the cultural context of diversity within Aboriginal and Torres Strait Islander communities,’ she said.
 
One of the main goals of the Let’s CHAT Dementia project is to work closely with Aboriginal community-controlled health services to try and address the issue of dementia prevalence and provide supportive models of care.
 
‘It is a translational project, which is all about the most effective models of care and what it takes to support better detection [of dementia],’ Dr Belfrage said.
 
‘[This includes] identification of cognitive impairment and dementia, and prevention, which really taps in to the whole life-course approach and strong health-promoting principles.
 
‘Thinking about what supports health and wellbeing, which are the things that most protect a person or reduce the risk of getting dementia. Then the actual care pathways of people with dementia, which of course includes their families and carers.’
 
‘Rather than prevention, this project is more about integrating cultural principles, knowledge and evidence into the translation of clinical evidence-based guidelines, which will then be supported by a suite of tools and resources, including education for workers in all health services.’
 
Resources
September is Dementia Awareness Month. The RACGP has a number of resources available to assist GPs with assessment and management of dementia:

• Guidelines for preventive activities in general practice (Red Book) – has a chapter dedicated to dementia.
• Medical care of older persons in residential aged care facilities (Silver Book) – includes recommendations on assessment and management of dementia (the Silver Book is currently being updated).
• National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people – includes a section on screening recommendations for dementia.

Aboriginal and Torres Strait Islander cognitive impairment dementia lets chat