Reducing the risk of mental illness and dementia as we age

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

This is despite evidence showing treatments tailored for middle to older age adults can be highly successful, particularly when taking a holistic approach that considers a person’s mental, physical and cognitive health.

Commonwealth and Victorian government policies highlight the need for integrated mental and physical healthcare. This is particularly important as we age, given we now know that conditions like depression increase the risk of dementia.

A recent report from the Australian Institute of Health and Welfare (AIHW) was a timely reminder of the importance of dementia risk reduction strategies. The report shows dementia – for the first time – is 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 give Australians in the 50-plus age group, who have concerns about their cognition, information about the kind of physical activity (PA) needed not only to stay fit and prevent falls, but to also support mental and brain health.

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

Together with our clinical colleagues, we identified that the multidisciplinary aged persons assessment and treatment teams (APATTs) in the Victorian public health system – tasked with providing holistic mental health support for older community members – would benefit from the new evidence in the guidelines to better incorporate PA interventions into their models of care.

We designed a project centred around collaborations between researchers at the University of Melbourne, the University of New South Wales and the University of Western Australia, as well as mental health clinicians, community rehabilitation, physiotherapy and general practitioners (GPs).

It aimed to examine the feasibility, usefulness 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 begin the research when COVID-19 hit.

The project had to be postponed. But while we couldn’t conduct the research in the public mental health system, we could engage with members of the Australian community directly.

Between May and August 2020, older people aged between 65 and 74 years had the largest increase in anxiety and worry, while older people aged 75 and over were the most vulnerable to experiencing significant psychological distress.

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

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

EXCEL had three phases.

Phase 1 centred around co-designing an evidence-based model by speaking to individuals within this cohort about their own challenges, strengths and barriers. This stage was critical to ensure that the unique factors relevant to middle and older adults with mental and cognitive concerns were addressed by our intervention.

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

Central to the EXCEL design was that in addition to providing participants with personalised PA prescriptions and equipment like dumbells and exercise bands, we also provided regular online coaching sessions with trained researchers that explored and addressed barriers and enablers to exercise that could adapt to any changes needed over the 12 weeks.

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

This included coordinating the delivery of exercise equipment across Australia, recording a large number of exercise videos on mobile phones or directly calling participants when video calls wouldn’t connect.

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

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

One theme that emerged was that coaching helped turn a participant’s intention into action by providing accountability, confidence building and strategies to overcome barriers to engaging with the program, in a way that reached them at a personal level.

One EXCEL participant shared how the coach helped them get moving.

“I remember being told (by my coach) that anything is better than nothing, so I’d think, ‘Okay, well I’ll just go and walk around the block. At least I can say I’ve gone 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 as puffed as early. I actually had to push myself to get puffed, whereas before walking down the street … my heart rate would be increasing, whereas now it doesn’t.”

Exercise is a practical and well-researched intervention to help improve cognitive, mental and physical health outcomes for middle and older age adults.

The EXCEL study demonstrates behaviour change support shifts intention to action – helping middle to older aged adults with mental health symptoms and cognitive concerns to adopt the PA guidelines.

While our EXCEL project wasn’t what was planned due to the pandemic, it was rewarding to experience the enthusiasm and grit of older community members who were actively addressing their mental and cognitive health needs.

Importantly, it highlighted the importance of personalised and tailored interventions.

The success of EXCEL sets a foundation for improving protocols of holistic care for older Australians with mental health symptoms and cognitive concerns.

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

The EXCEL team is made up of Professor Nicola Lautenschlager, Associate Professor Kathryn Ellis, Dr Eleanor Curran, Dr Kay Cox, Professor Victoria Palmer, Dr Terence Chong, Jennifer Southam, Alissa Westphal, Dr Tom Rego, Rebecca Moorhead, Rhoda Lai, Professor Kaarin Anstey, Dr Brett Coulson and Dr Francine Moss.

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