IntroductionOlder people experiencing homelessness (PEH) are a rapidly growing population at risk of accelerated aging and the early onset of geriatric conditions. One construct that shows promise in predicting age-related decline is frailty. Better understanding the rates and causes of frailty in PEH may improve understanding of its antecedents, thereby facilitating more targeted health and aged care service interventions. The aim of this study was to conduct a rapid review on the prevalence and determinants of frailty in adult PEH.MethodsWe conducted a rapid review of primary research papers studying PEH and frailty or frailty-related concepts.ResultsFourteen studies were included, which indicate that frailty presents earlier and at higher rates in PEH than community-dwelling cohorts. A notable difficulty for many aging PEH was early-onset cognitive impairment which was associated with a range of negative functional outcomes. Another recurrent theme was the negative impact that drug and alcohol use and dependence can have on the health of PEH. Further, psychosocial and structural determinants such as loneliness, living in an impoverished neighborhood and being female had statistically significant associations with frailty and functional decline in PEH.Discussion and implicationsPEH in their 40s and 50s can be frail and experience geriatric conditions, including cognitive impairment. Factors that have important relationships to frailty and functional decline in PEH include cognitive deficits, drug and alcohol dependence and loneliness, as well as upstream determinants such as gender and ethnicity. More targeted data and research on these factors, including cohort studies to better investigate their potentially causal effects, is important for researchers and practitioners assessing and treating frailty in PEH, particularly those interested in early intervention and prevention.Prospero registration IDCRD42022292549.

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.

BACKGROUND Serious games have the potential to transform the field of cognitive assessment. The application of a serious game-based assessment is particularly exciting in the context of prison where interventions are urgently needed to address the rapid increase of currently incarcerated older people globally, and the heightened risks of dementia and cognitive decline present in this population. Game-based assessment are assumed to be fun, engaging and suitable alternatives to traditional cognitive testing, but these assumptions remain mostly untested in older people. This is especially true for older people in prison, whose preferences and needs are seldom heard and may deviate from those previously captured in research on cognition and serious games. OBJECTIVE The purpose of this study was to understand the design preferences of older people in prison for a cognitive game-based assessment. METHODS This study used reflexive thematic analysis, underpinned by critical realism, and applied the technique of abduction. Four focus groups with a total of twenty people (n=20) were conducted with older people (aged 50+, 45+ for Aboriginal people) across three distinct prison environments in Australia. RESULTS Self-Determination Theory (SDT) was used as a theoretical foundation to interpret the results. Three themes were generated. (#1) Goldilocks: getting gameplay difficulty ‘just right’ through optimal challenge. The first theme emphasises the participants’ collective desire for an individualised optimal level of difficulty in serious gameplay. (#2) 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 these can be condescending. (#3) 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 maximise in-game autonomy. CONCLUSIONS The collection of these themes provides novel insights into key game design preferences for marginalised older people. CLINICALTRIAL N/A

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.

Introduction and Aims. People with alcohol use disorder (AUD) exhibit high rates of comorbidity with cognitive deficits, particularly for executive function (EF). Cognitive impairment has previously been found to be related to poorer outcomes in substance use treatment. However, traditional interventions to improve cognitive function within this group have encountered both high attrition and low retention rates. This paper reports on the feasibility of providing a cognitive remediation intervention at an outpatient alcohol treatment service in Sydney, Australia. Design, Methods and Results. Due to lower-than-expected recruitment rates, the paper details a case series of five clients recruited to a 9-week group intervention using Goal Management Training (GMT; a structured program which targets EF). 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, with only one participant remaining until the end of the program. Discussion and Conclusions. It is thus concluded that this program in its current form is not suitable for this cohort in this outpatient setting. Suggestions are made for tailoring GMT and other approaches to increase engagement and retention in future interventions.