A Pilot Study for the Healthy Actions and Lifestyles to Avoid Dementia or Hispanos y el ALTo a la Demencia Program (HALT-AD)
Phase: NA
Conditions: Dementia, Alzheimer's Disease, Dementia Prevention
Sponsor: Alzheimer's Disease Cooperative Study (ADCS)

 
 
 
 
 
 
 
 
 
 
 
HALT-AD Protocol and Analysis Plan 
 
HALT-AD Pv1.4 10Mar2023 
 
"Healthy Actions and Lifestyles to Avoid Dementia or Hispanos y el ALTo a la Demencia 
Program" (HALT-AD) 
 
NCT05350410 
 
10 March 2023 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HOWARD FELDMAN, MDCM, FRCP(C) 
PROFESSOR, DEPARTMENT OF NEUROSCIENCES 
DIRECTOR, ALZHEIMER’S DISEASE COOPERATIVE STUDY (ADCS) 
DEAN, ALZHEIMER’S DISEASE AND NEURODEGENERATIVE RESEARCH 
9500 Gilman Drive La Jolla, California 92037-0949 TEL: (858) 246-1347 FAX: (858) 246-1414 

 
 
 
Protocol Title: 
A Pilot Study for the Healthy Actions and Lifestyles to Avoid Dementia 
or Hispanos y el ALTo a la Demencia program (HALT-AD) 
Protocol Acronym: 
HALT-AD 
Sponsor: 
UC San Diego Health 
Protocol Version: 
1.4 10MAR 2023 
Co-Principal Investigators: 
Howard Feldman, MDCM, FRCP(C) 
Director, Alzheimer’s Disease Cooperative Study 
Professor, Department of Neurosciences 
Dean, Alzheimer’s Disease and Neurodegenerative Research 
University of California, San Diego 
9500 Gilman Drive, MC 0949 
La Jolla, CA 92037-0949 
Sarah Banks, PhD, ABPP-CN 
Associate Professor 
Departments of Neurology and Psychiatry 
University of California, San Diego 
9500 Gilman Drive, MC 0949 
La Jolla, CA 92037-0949 
 
 
 
 
 
 
Confidentiality Statement 
The information in this document contains information that is privileged or confidential and may 
not be disclosed unless such disclosure is required by applicable laws and regulations. In any 
event, persons to whom the information is disclosed must be informed that the information is 
privileged or confidential and may not be further disclosed by them. These restrictions on 
disclosure will apply equally to all future information supplied to you, which is indicated as 
privileged or confidential. 

 
HALT-AD Study Protocol 
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SIGNATORE PAGE 
 
(SIGNATURES ON FILE AT ADCS) 
 
 
 
 
 
Howard Feldman, MDCM, FRCP(C) 
Director, Alzheimer's Disease Cooperative Study 
Professor, Departme nt of Neu roscie nces 
Dean, Alzhe i mer ' s and Neurodegenerative Research 
Univers i ty of Cali fornia , San Diego 
 
 
 
 
 
 
 
Sarah Banks, PhD, ABPP-CN 
Associate Professor 
Departme nts of Neurolo gy and Psychiatry 
University of California, San Diego 
ft M Z-.2, 20 i 3 
D ate (MMDDDYYY) 
 
 
 
 
 
 
04/03/2023 
 
 
Date (MMDDDYYY) 

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HALT-AD Study Protocol 
 
 
 
Protocol Synopsis 
 
Title 
A Pilot Study for the Healthy Actions and Lifestyles to Avoid Dementia or 
Hispanos y el ALTo a la Demencia program (HALT-AD) 
Background 
& Rationale 
Alzheimer’ disease and dementia are common, and feared. Recent scientific 
advances have underscored the significant population attributable risk of 
modifiable risk factors including those whose modification particularly when 
combined could delay or prevent dementia. However, there is an important 
gap in having this opportunity translated by individuals to make lifestyle 
changes and address their personal risk factors to preserve their brain health 
and preventing dementia. The preventive message does not fit the medical 
model well and the opportunity is not reaching the public or engaging it 
through public health programs that can intervene to bridge the gap. Healthy 
Actions and Lifestyles to Avoid Dementia or Hispanos y el ALTo a la 
Demencia program (HALT- AD) is a novel bilingual educational program 
that will focus on reducing risk factors with the ultimate goal of preventing 
dementia. It will be centered around a web-based interactive virtual online 
platform that will be developed to be dynamic, engaging, and interactive. 
HALT-AD will be complemented by remote facilitated support discussion 
groups which will focus on the content of the educational material and the 
invocation of change through participant engagement and compliance. 
Prior to launching the full HALT-AD program, it is essential that we conduct 
a preliminary pilot study to evaluate the program’s first prototype including: 
the usability of- and engagement with- the online platform, users’ 
acceptability of the learning content and facilitated support discussion 
groups. As well, effectiveness of the program in changing knowledge, self- 
efficacy, and dementia-related lifestyle risk measures will be assessed. 
This initial four-months pilot study will focus on at least three educational 
courses (such as: introduction to dementia and risk factors, sleep, diet, and 
social connectivity). The information generated from this study will help 
inform the development of the second program’s prototype, expected to 
benefit from the initial pilot to become more user-friendly, effective and 
accessible to our target audience. 
Study Design 
This pilot study will be a longitudinal study of an inception cohort exposed 
to the HALT AD online educational program for a four month study. It will 
utilize pre- and post- intervention collection of quantitative and qualitative 
data to evaluate the program’s first prototype. 
Target 
Population 
• Cognitively normal midlife and older-adult participants will be 
eligible to participate in this pilot study with the following inclusion 
criteria; Ages 50-85 

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• 
Montreal Cognitive Assessment-Telephone/Blind version (T-MoCA) 
Score >18/22 
• Sufficient proficiency in English or Spanish to undergo clinical 
assessment and participate in an online educational program. 
• Technical ability to participate in an online educational program (i.e. 
computer/tablet and internet access; ability to send and receive 
emails) 
• Sufficient vision and hearing to participate in online educational 
program (judgement of site investigator) 
Number of 
Participants 
A total of 20 participants will be enrolled at UCSD 
• 10 participants will complete the English version of HALT-AD 
• 10 participants will complete the Spanish version of HALT-AD 
We are aiming to recruit 50% women and to enroll a diverse participant 
sample across varied age ranges within both language groups. 
Study 
Duration 
Estimated duration of the entire pilot evaluation period is approximately 4 
months (including participant enrollment, pilot study, focus groups and 
completion of data collection) 
• Individual HALT-AD participation: 3 Months participation in online 
HALT-AD program 
Study Goal 
and Aims 
Overall Goal: To conduct a preliminary pilot study to evaluate the first 
prototype of HALT-AD. 
Aims: 
1. To evaluate engagement with- the online platform 
2. To evaluate preliminary evidence on the effectiveness of the program 
in changing 
a) knowledge, 
b) self-efficacy, and 
c) dementia-related lifestyle risk factors. 
3. To determine users’ acceptability of the program content 
4. To determine users’ acceptability and satisfaction with the facilitated 
support discussion groups 
5. To evaluate the usability of the online platform 
Outcome 
Measures 
Primary Outcome Measures: 
1. Users’ engagement with- the HALT-AD online platform as measured 
by: 
• The total amount of time (in minutes) spent per user on all 
courses combined 

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• The percentage of participants who completed all courses 
Secondary Outcome Measures: 
1. Preliminary evidence on the effectiveness of the program in changing 
knowledge, self-efficacy, and dementia-related lifestyle risk factors 
will be evaluated by: 
• Change from baseline in knowledge on the HALT-AD 
knowledge assessment survey at 4 months 
• Change from baseline in self-efficacy on the New General 
Self-Efficacy Scale at 4 months 
• Change from baseline in lifestyle risk on the HALT-AD 
Lifestyle Risk Assessment Survey at 4 months 
Exploratory Outcome Measures: 
1. Users’ acceptability of the HALT-AD program content will be 
determined by: 
• HALT-AD Course Acceptability Survey 
• Focus group discussion 
2. Users’ acceptability and satisfaction with the facilitated support 
discussion groups will be determined by: 
• Facilitated support discussion group Acceptability Survey 
• Focus group discussion 
3. The usability of the online platform will be evaluated by: 
• HALT-AD User Experience Survey 
• Net Promotor Score Survey 
Statistical 
Plan 
Descriptive statistics will be used for quantative data. Change scores will be 
computed where applicable. Change = (4 months score - baseline score). 
Continuous data will be presented with mean, standard deviations, median, 
minimum and maximum and 95% confidence intervals. Categorical data will 
be presented as proportions and percentages. Changes in continuous outcome 
measures between baseline and post-intervention will be analyzed by 
repeated measures t-test. 
Qualitative data generated from focus groups, logs, and open-ended survey 
questions will be thematically analyzed using inductive qualitative coding. 
Sample Size and Power 
Given that this pilot study is being conducted to contribute to the 
development of the HALT-AD program, we did not power to detect an 

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intervention effect size over time. The sample size for the pilot was estimated 
based on prior experience in the development of similar programs. 

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TABLE OF CONTENTS 
LIST OF ABBREVIATIONS: 
9 
1.0 INTRODUCTION 
10 
1.1 
BACKGROUND 
10 
1.2 
RATIONALE 
10 
2.0 STUDY DESIGN 
11 
3.0 STUDY GOAL AND AIMS 
11 
3.1 
OVERALL GOAL 
11 
3.2 
AIMS 
11 
4.0 OUTCOME MEASURES 
12 
5.0 ETHICS AND REGULATORY CONSIDERATIONS 
12 
5.1 
ELECTRONIC INFORMED CONSENT 
12 
5.2 
POTENTIAL RISKS AND BENEFITS ASSOCIATED WITH THIS STUDY 
13 
5.2.1 
Potential Risks 
13 
5.2.2 
Potential Benefits 
13 
6.0 PARTICIPANT SELECTION 
13 
6.1 
INCLUSION CRITERIA 
13 
6.2 
EXCLUSION CRITERIA 
14 
7.0 STUDY PROCEDURES 
14 
7.1 
STUDY VISITS 
14 
7.1.1 
Remote Study Visits 
14 
7.1.2 
Pre-Screening Telephone Questionnaire (within a month prior to baseline) 
15 
7.1.3 
Telephone Screening (within a month prior to baseline) 
15 
7.1.4 
Baseline/ HALT-AD Program Launch (+/- 30 days) 
15 
7.1.5 Month 4/ End of HALT-AD Program 
16 
7.1.6 
Post-Pilot Focus Groups 
16 
7.2 
HALT-AD PROGRAM DESCRIPTION 
17 
7.2.1 
Overview 
17 
7.2.2 
Program Registration 
18 
7.2.3 
Program Elements 
18 
7.3 
MONTHLY FACILITATED DISCUSSION GROUP 
19 
7.4 
HALT-AD ACTIVITY DATA 
19 
7.5 
COMPENSATION 
20 
8.0 STUDY PROCEDURE DESCRIPTIONS 
20 
8.1 
SOCIODEMOGRAPHICS 
20 
8.2 
MEDICAL/SURGICAL/FAMILY HISTORY 
20 
8.3 
HEIGHT/WEIGHT/BMI 
20 
8.4 
HEARING AND VISION ASSESSMENT 
20 
9.0 STUDY-SPECIFIC INSTRUMENTS 
20 
9.1 
COGNITIVE MEASURES 
20 
9.1.1 
Montreal Cognitive Assessment-Telephone/Blind Version (T-MoCA) 
20 

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9.2 
QUESTIONNAIRES 
21 
9.2.1 
Knowledge Assessment Survey 
21 
9.2.2 
The New General Self-Efficacy Scale 
21 
9.2.3 
Lifestyle Risk Assessment 
21 
9.2.4 
HALT-AD User Experience Survey 
21 
9.2.5 
Net Promoter Score (NPS) Survey 
21 
9.2.6 
HALT-AD Course Acceptability Survey 
21 
9.2.7 
HALT-AD Facilitated discussion group Acceptability Survey 
21 
10.0  EARLY DISCONTINUATION PROCEDURES 
22 
11.0 ADVERSE EVENTS 
22 
11.1 
EVALUATION AND REPORTING OF ADVERSE EVENTS 
22 
11.2 
ASSESSMENT OF ADVERSE EVENTS 
23 
12.0 STATISTICAL CONSIDERATIONS 
24 
12.1 
ANALYSIS PLAN 
24 
12.2 
SAMPLE SIZE AND POWER 
24 
13.0 RECORDING AND COLLECTION OF DATA 
24 
13.1 
CASE REPORT FORM 
24 
13.1.1 HALT-AD Website Server 
27 
13.1.3 REDCap Surveys 
28 
13.1.4 Focus Groups Recordings and Transcription 
28 
13.2 
STUDY FILES AND PARTICIPANT SOURCE DOCUMENTS 
28 
13.3 
RATER TRAINING 
28 
13.4 
INCIDENTAL FINDINGS 
28 
14.0  PUBLICATIONS POLICY AND SHARING OF DATA 
28 
15.0 REFERENCES 
30 
16.0 APPENDICES 
31 
APPENDIX 1: SCHEDULE OF EVENTS 
31 
16.1 
APPENDIX 2: SURVEY INSTRUMENTS 
32 
16.1.1 Knowledge Assessment Survey 
32 
16.1.2 New General Self-Efficacy Scale 
33 
16.1.1   HALT-AD User Experience Survey 
33 
16.1.1 Net Promoter Score (NPS) Survey 
34 
16.1.2 HALT-AD Course Acceptability Survey 
34 
16.1.3 HALT-AD Facilitated discussion group Acceptability Survey 
36 
16.1.4 HALT-AD Lifestyle Risk Assessment 
36 
16.2 
APPENDIX 3: SCREENING QUESTIONS 
37 
16.2.1 PRE-SCREENING TELEPHONE INTERVIEW 
37 
16.2.2 HEARING AND VISION 
40 
16.3 
APPENDIX 4: BASELINE ASSESSMENTS 
43 
16.3.1 SOCIODEMOGRAPHIC INFORMATION 
43 
16.3.2 MEDICAL HISTORY 
46 
16.3.3 CURRENT MEDICATIONS 
51 

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 LIST OF ABBREVIATIONS: 
 
AD 
Alzheimer’s Disease 
ADRD 
AD and related dementias 
AE 
Adverse event 
BMI 
Body Mass Index 
CMS 
Centers for Medicare and Medicaid Services 
CRF 
Case Report Form 
HALT-AD 
Healthy Actions and Lifestyles to Avoid Dementia 
ICF 
Informed Consent Form 
NGSE 
New General Self-Efficacy 
NPS 
Net Promoter Score Survey 
T-MoCA 
Montreal Cognitive Assessment-Telephone/Blind Version 
UEQ 
User Experience Questionnaire 
ICMJE 
International Committee of Medication Journal Editors 

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1.0 
INTRODUCTION 
 
1.1 
Background 
Alzheimer’s disease (AD) is the single most feared disease associated with aging [1, 2], having a 
devastating social and economic impact on patients, families, and the community [3]. With its 
aging demographic, the growth of affected Americans is exponential with one person diagnosed 
every 67 seconds in the United States. The annual cost of AD to the US economy is over $260 
million [4]. Over 84,000 individuals have AD in San Diego county alone [5], and 690,000 across 
California. There is a 35% increase projected within approximately the next decade [3]. 
Coinciding with these general trends for America’s aging population, there are currently just 
over 4 million Hispanic Americans ages 65 and over in this group, which is projected to grow to 
almost 20 million by 2060 [6], with 3.6 million having AD [7]. Currently, close to half (45%) of 
all older Hispanic Americans are living in two states, California and Texas. Given that this 
population is disproportionately affected by social determinants leading to poor health outcomes 
placing them at increased risk of AD [8], the development of culturally informed preventive 
interventions that target modifiable risk factors to reduce dementia risk in Hispanics is 
paramount. 
Progress in finding effective pharmaceutical treatments to modify or definitively treat AD and 
related dementias (ADRD) has been extremely disappointing [9]. Recent research underscores a 
population attributable risk of 28.2% associated with a range of modifiable risk factors across the 
lifespan [10], and encouraging results from studies combining multiple risk factors as a focus of 
their intervention [11]. In turn, efforts to successfully modify lifestyle and other health factors 
(e.g., vascular health, physical activity, diet, sleep etc.) addressing personalized risk could have 
an enormous long-term benefit in delaying or preventing dementia. While the medical sector and 
Centers for Medicare and Medicaid Services (CMS) are constantly innovating individual service 
delivery [12], insufficient attention has been given to systematically translating biomedical 
research on lifestyle changes to reduce dementia risk through information at the population level 
that can promote effective behavioral change. Indeed, this approach is our best current 
opportunity for dementia risk reduction. 
1.2 
Rationale 
Healthy Actions and Lifestyles to Avoid Dementia or Hispanos y el ALTo a la Demencia 
program (HALT- AD) is a novel bilingual educational program that will focus on reducing risk 
factors with the ultimate goal of preventing dementia. It will be centered around a web-based 
interactive virtual online platform that will be developed to be dynamic, engaging, and 
interactive. Through interactive courses, the educational content of HALT-AD will provide 
guidance on modifiable lifestyle risk factors and the identification of treatable medical conditions 
including cerebrovascular health, sleep, sensory loss, social isolation, mood, diet, and physical 
activity. 
Participants in HALT-AD will be provided with personalized risk profiles, will be encouraged to 
learn about their risk factors and how they can effectively modify them, and will be provided 
with feedback on their progress. They will participate in facilitated support discussion groups, 

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which will focus on the content of the educational material and the invocation of change through 
participant engagement and compliance. 
Prior to launching the full HALT-AD program, it is essential that we conduct a preliminary pilot 
study to evaluate the program’s first prototype. At the end of the 3-month pilot program, 
evaluations will include: the usability of- and engagement with- the online platform and users’ 
acceptability of the learning content and facilitated support discussion groups. As well as, 
evaluating preliminary evidence on the effectiveness of the program in changing knowledge, 
self-efficacy, and dementia-related lifestyle risk factors. The program will also be evaluated on 
metrics such as being user friendly, engaging, supportive and communicative, with the potential 
for scalability to state- and national-levels. 
This initial four-months pilot study will focus on at least three educational courses (introduction 
to dementia and lifestyle risk factors, sleep and diet). It may also include a fourth educational 
course on social connectivity and lonliness. Completion of this initial pilot study will allow for a 
round of improvements informed by data from the program, on usability, as well as feedback 
from participants and citizen advisors. This will allow for an iterative process to build the 
program to its full content, with feedback to optimize the user experience and ensure the 
accessibility of the content. The information generated from this study will help inform the 
development of the second program’s prototype, expected to benefit from the initial pilot to 
become more user-friendly, effective and accessible to our target audience. 
 
2.0 
STUDY DESIGN 
 
This pilot study will be a longitudinal study of an inception cohort exposed to the HALT AD 
online educational program for a four-month study. It will utilize pre- and post- intervention 
collection of quantitative and qualitative data to evaluate the program’s first prototype. 
 
3.0 
STUDY GOAL AND AIMS 
 
3.1 
Overall Goal 
To conduct a preliminary pilot study to evaluate the first prototype of HALT-AD. 
3.2 
Aims 
1. To evaluate engagement with- the online platform 
 
2. To evaluate preliminary evidence on the effectiveness of the program in changing 
knowledge, self-efficacy, and dementia-related lifestyle risk factors 
3. To determine users’ acceptability of the program content 
4. To determine users’ acceptability and satisfaction with the facilitated support discussion 
groups 

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5. To evaluate the usability of the online platform 
 
4.0 
OUTCOME MEASURES 
 
4.1 
Primary Outcomes 
4.1.1 Users’ engagement with- the HALT-AD online platform as measured by: 
• the total amount of time (in minutes) spent per user on all courses combined 
• the percentage of participants who completed all courses 
4.2 
Secondary Outcomes 
4.2.1 Preliminary evidence on the effectiveness of the program in changing knowledge, self- 
efficacy, and dementia-related lifestyle risk factors will be evaluated by: 
• Change from baseline in knowledge on the HALT-AD knowledge assessment 
survey at 4 months 
• Change from baseline in self-efficacy on the New General Self-Efficacy Scale 
(NGSE) at 4 months 
• Change from baseline in lifestyle risk on the HALT-AD Lifestyle Risk 
Assessment Survey at 4 months 
4.3 
Exploratory Outcomes 
4.3.1 Users’ acceptability of the HALT-AD program content will be determined by: 
• HALT-AD Course Acceptability Survey 
• Focus group discussion 
4.3.2 Users’ acceptability and satisfaction with the facilitated support discussion groups will 
be determined by: 
• Facilitated Discussion Group Acceptability Survey 
• Focus group discussion 
4.3.3 The usability of the online platform will be evaluated by: 
• HALT-AD User Experience Survey 
• Net Promotor Score Survey 
 
5.0 
ETHICS AND REGULATORY CONSIDERATIONS 
5.1 
Electronic Informed Consent 
For the purposes of this study, the consent process will be completed remotely. A telephone 
call with the participant and a study coordinator will be scheduled in order to facilitate the 
informed consent discussion and to address any questions from the participant. 

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The electronic Informed Consent Form (ICF) will be maintained in REDCap. Participants will 
review the consent information and electronically sign the ICF directly within REDCap. The 
REDCap e-Consent Framework provides standardized tools to obtain consent and store consent 
documentation with a certification screen and a storage function which automatically generates 
a ‘hard-copy’ PDF of the signed form. Participants will be able to download and keep a copy of 
the ICF for their records. The completed PDFs will be securely stored in REDCap’s File 
Repository and will only be accessible to the program manager, study coordinators and Co- 
Principle Investigators (co-PIs). These files will be kept separate from other study data 
maintained in REDCap, which will be de-identified and coded by Participant ID only (see 
Figure 2 (page 23) for a description of how study will be entered and stored in REDCap) 
It will be made clear to each potential participant that informed consent may be withdrawn at 
any time without needing to give a reason and that such withdrawal will not compromise the 
relationship between the participant and the Investigator nor the participant’s future treatment. 
The ICF will be provided in a language fully comprehensible to the prospective participants 
and ample opportunity must be given to inquire about the details of the study. 
5.2 
Potential Risks and Benefits Associated with this Study 
5.2.1 
Potential Risks 
Risks associated with study participation are minimal and may include fatigue and/or frustration 
associated with cognitive screening at baseline and participating in an online educational 
program. Questionnaires on mood and lifestyle risk may increase negative affect. In order to 
mitigate these risks, participants will be reminded they can skip questions or take breaks. If a 
participant mentions negative emotions, the study coordinator will alert Dr.Sarah Banks, co-PI 
and clinical psychologist, who will attempt to contact the participant within 48 hours to suggest 
mental health resources. 
There may be limits in protecting confidentiality during facilitated group discussions and focus 
groups. Participants will be reminded to keep group discussions confidential but this cannot be 
guaranteed. 
 
5.2.2 Potential Benefits 
Participants in this study may experience benefits from participating in a web-based educational 
program including increased knowledge and engagement regarding ways to promote their brain 
health, and possible positive reduction in their risk profiles, though such improvement cannot 
be predicted with any certainty. This study is expected to benefit the general community in 
the future by promoting public interest, literacy, and engagement in lifestyle interventions for 
brain health and dementia prevention through dissemination of HALT-AD to the broader public. 
 
6.0 
PARTICIPANT SELECTION 
 
A total of 20 participants will be enrolled at UCSD with 50% (n=10) completing the English 
version of HALT-AD and 50% (n=10) completing the Spanish version. We are aiming to recruit 

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50% women and to enroll a diverse participant sample across varied age ranges within both 
language groups. 
6.1 
Inclusion Criteria 
Participants must meet all of the following inclusion criteria to be eligible for enrollment: 
1. Signed informed consent must be obtained and documented (from the participant). 
2. Sufficient proficiency in English or Spanish to undergo clinical assessment and 
participate in an online educational program. 
3. Ages 50-85 
4. Montreal Cognitive Assessment-Telephone/Blind Version (T-MoCA) score >18/22 
5. Technical ability to participate in an online educational program (i.e. ability to operate a 
computer/tablet and gain internet access; ability to send and receive emails) 
6. Sufficient vision and hearing to participate in online educational program (judgement of 
site investigator) 
7. Ability to sit comfortably for a period of at least 30 minutes 
6.2 
Exclusion Criteria 
1. Participants who, in the opinion of the co-PIs, are not able to complete trial procedures or 
adhere to the schedule of study assessments will be excluded from study participation. 
2. Individuals where English or Spanish is not sufficiently proficient for clinical assessment, 
and participation in a web-based educational program. 
3. Participants who do not have sufficient vision and hearing to participate in an online 
educational program 
4. Individuals who do not have the technical ability to participate in an online educational 
program. Technical ability is defined as ability to operate a computer/tablet and gain 
internet access; ability to send and receive emails) 
5. Total Score on the T-MoCA <18 
6. Individuals who have an advanced degree (e.g. Master’s, MD, PhD) in an area related to 
brain health will not be eligible to participate. 
 
7.0 
STUDY PROCEDURES 
 
7.1 
Study Visits 
The schedule of study visits and procedures to be performed at each visit are outlined below 
and summarized in the Schedule of Events table (Appendix 1). A detailed description of 
study procedures is located in Section 8.0. and a detailed description of study instruments is 
located in Section 9.0 
 
7.1.1 Remote Study Visits 

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Pre-screening and screening visits will be conducted remotely over telephone. Participants will 
need access to a computer or mobile device in order to participate in HALT-AD and complete 
baseline and follow-up surveys on REDCap. 
 
7.1.2 Pre-Screening Telephone Questionnaire (within a month prior to baseline) 
Interested participants will be invited to complete a brief pre-screening questionnaire over 
telephone with a study team member to ascertain potential elegibility for the study. Participants 
will be asked to provide verbal assent prior to completing the questionnaire. Questions will 
include age, education, language fluency and access to technology needed to participate in the 
study. Total time to complete the pre-screening questionnaire is approximately 5-10 minutes. 
 
7.1.3 
Telephone Screening (within a month prior to baseline) 
Following the pre-screening procedures described above, potentially eligible participants will be 
invited to complete the electronic informed consent process (see section 5.1). Once participants 
have electronically signed the ICF, the following procedures will be conducted remotely via 
telephone during the screening period (Estimated Time to Complete: up to 1 hour). Screening 
procedures may be completed over multiple days as long as all procedures are completed within 
30 days prior to baseline. Procedures and instruments will be adapted for remote administration 
(see section 8.0 Study Procedure Descriptions and section 9.0 Study-Specific Instruments). 
The following procedures will be conducted during the screening period (Estimated Time: 1.0- 
1.5 hours): 
• Review of inclusion/exclusion criteria 
• T-MoCA 
• Hearing and Vision assessment 
• Evaluation and confirmation of eligibility 
Following completion of the screening assessments above, the co-PIs will be responsible for 
confirming participant eligibility to be enrolled in the study. 
 
7.1.4 Baseline/ HALT-AD Program Launch (+/- 30 days) 
Participants who are confirmed to be eligible to participate and enrolled in the study, will then 
complete the following baseline assessments. These may be completed on the same day as the 
screening visit, as long as they are conducted following the screening assessments and 
confirmation of eligibility (total estimated time approximately 30 min): 
• Documentation of demographics, medical history (including past medical procedures and 
family history), medications 
• Self-Report Height, Weight 
• Body Mass Index (BMI) calculation (based on self-report current height and weight) 
• Knowledge Assessment Survey 

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Following completion of the above baseline assessments, participants will be enrolled in the 
HALT-AD online program and will be provided with instructions for logging into and beginning 
their participation in the program (see section 7.2 for a complete description of HALT-AD). 
Participants will also complete the following baseline assessments directly within the online 
HALT-AD program (total estimated time approximately 30 min-1.0 hour): 
• New General Self-Efficacy Scale (NGSE) 
• Lifestyle Risk Assessment 
• Goal setting 
Throughout the participants’ participation in the 3-Month HALT-AD program, a study coordinator 
will maintain contact with the participant by telephone or email to check-in with participants, 
provide reminders about upcoming HALT-AD program elements and be available to answer any 
questions that may arise. E-mails will be sent from a secure UCSD health e-mail account. 
 
7.1.5 Month 4/ End of HALT-AD Program 
Following completion of the 3-Month HALT-AD program, participants will complete the 
following assessments remotely via the REDcap survey tool (total estimated time approximately 
1.0 hour): 
• HALT-AD User Experience Survey 
• Net Promoter Score Survey 
• HALT-AD Course Acceptability Survey 
• Facilitated Discussion Group Acceptability Survey 
• Knowledge Assessment Survey 
Participants will also complete the following end of study assessments directly within the online 
HALT-AD program (total estimated time approximately 30 min-1.0 hour): 
• New General Self-Efficacy Scale (NGSE) 
• Lifestyle Risk Assessment 
• Review of Goals 
 
7.1.6 Post-Pilot Focus Groups 
Following completion of the 3-month HALT-AD program, participants may be invited to 
participate in an end of study remote focus group(s) to further evaluate user-experience and 
satisfaction with HALT-AD. This will allow the study team to address in more detail the 
components that have been surveyed in the questionnaires on usability and acceptability: (e.g. 
level of difficulty and interest in the content, strengths and weaknesses, confidence in the 
content, applicability and impact in everyday life, clarifications, quality of design, animation and 
visual effects, effort needed, motivation for behavioral change). Participant feedback and 
responses will be used to make any necessary changes to the web-based HALT-AD program 
prior to launch of the full program. Total time to participate in the focus group is approximately 
2 hours (1 hour to discuss web-based platform and 1 hour to discuss facilitated discussion 
groups). 

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Focus groups will be conducted remotely over video-call in smaller groups of approximately 5- 
10 other participants. Participants will need access to a computer, tablet or mobile device capable 
of making video-calls. The focus group discussions will be audio-recorded for transcription. All 
identifiable information will be removed from the transcripts and replaced by unique coded 
Participant ID number. Recordings will be destroyed once the focus group discussion has been 
transcribed. 
 
7.2 
HALT-AD PROGRAM DESCRIPTION 
7.2.1 Overview 
HALT-AD is a novel bilingual program that will focus on preventing dementia. The program 
will include an easily accessed interactive, online web-based program that will direct participants 
to engage in different evidence-based content, to learn and become motivated to change their 
personalized profile of modifiable risk factors. It will include up to date information and 
evidence for lifestyle risk factor modification that can be addressed to promote brain health and 
reduce dementia risk. HALT-AD will include learning courses that will be aligned with those 
modifiable risk factors with significant population attributable risk of dementia. 
HALT-AD is a bilingual bicultural program with options to participate in English or Spanish. 
The program is developed as a collaborative effort by UCSD investigators with recognized 
expertise in the program’s content areas, along with significant input from older-adult Citizen 
Advisors and Promotores (community health workers), ensuring cultural relevance and assisting 
in feedback within its iterative development. 
For this initial pilot study, HALT-AD will focus on up to four initial learning courses: 
• Introductory Course 
• Diet 
• Sleep or Physical Activity 
• Social Connectivity and Loneliness 
Once the full program is developed, additional learning courses will include, vascular factors 
(hypertension, diabetes, obesity and cerebrovascular health), physical activity (exercise), mood 
(depression and stress), mindfulness, sensory (vision and hearing) and cognitive training. Topic 
matters will also include advice on how to navigate the healthcare system as well as courses 
myths and popular misconceptions regarding brain health, and how risk profiles may differ in 
men and women. 

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Figure 1. HALT-AD Program Description 
7.2.2 Program Registration 
Participants will receive instructions on how to register and participate in the program at the 
baseline study visit. As outlined in Figure 1 at enrollment, participants will join a welcome page 
that will explain the program, followed by registration and creation of a personal password. Their 
registration will include demographic and lifestyle questions. 
 
7.2.3 Program Elements 
Participants will be provided access to HALT-AD where they will participate for approximately 
1-2 hours a month for 3 months, from home, with their own devices and at their own time. 
Information within the courses will contain scientific evidence, explanation of principles and 
mechanisms that underlie positive effects, specific recommendations (e.g. a healthy recipe to 
make at home), suggestions to improve behavior in everyday life and typical barriers and tips to 
circumvent them. Participants will also be able to revisit course material as often as they would 
like. Additional program elements will also include interactive activities, quizzes and a resource 
library. 
 
7.2.3.1 Personalized Profiles 
Participants will be asked to complete a brief online lifestyle risk assessment at the beginning 
and end of their participation in the program. Questions will be related to the content in the 
program courses (e.g. sleep, diet, and mindfulness/compassion). A personalized profile will be 
developed for each participant based on their responses to the lifestyle risk assessment. A visual 

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aide (e.g. sliding scale) will be used on the program dashboard to show the participant their risk 
level in each lifestyle domain. 
 
7.2.3.2 Goal Setting 
Participants will also be asked to set goals based on their risk profile and to re-visit and update 
their goals at the end of the 3 month program. 
 
7.3 
Facilitated discussion group 
Participants will also participate in moderated remote discussion groups that will focus on 
learning and promotion of behavioral change. Discussion groups will occur approximately every 
3 weeks and will be moderated by a social worker (ASW or LCSW) called HALT Helper 
Sessions will be filled on a rolling basis, with a variety of meeting times available to 
accommodate other commitments such as caregiving. Before each discussion group, the HALT 
Helper will review what the group is (and is not) and it will be made clear to participants that this 
is not group therapy but rather a facilitated discussion to focus on content that is being addressed 
in HALT-AD and to promote healthy lifestyle changes. Participants will also be reminded of the 
importance to maintain confidentiality during the group sessions and the limits to 
privacy/confidentiality due to the group setting at the beginning of each session. 
 
7.4 
HALT-AD Activity Data 
The following data will be automatically collected through the HALT-AD program in order to 
evaluate user activity and engagement with the program: 
 
Program Level Reporting 
Course Started % 
How many users started the course 
Course Complete % 
How many users completed the course 
Course Passed % 
How many users passed the course 
Minutes per learner 
Average time spent per learner on a 
module 
Average Score 
Average Score per learner in a course 
Participant Level Reporting 
Course Started % 
How many courses were started by the 
learner 
Course Complete % 
How many courses were completed by 
the learner 
Course Passed % 
How many courses were passed by the 
learner 
Minutes per Course 
Average time spent per course 
No identifiable information will be included in the study data set. All study data from HALT-AD 
will be de-identified and linked to the unique Participant ID prior to being included in the study 
database. 

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7.5 
Compensation 
Participants will be compensated $100 in the form of a gift card for their time and effort. 
Compensation will be provided at the end of the study or upon early withdrawal. Early 
withdrawal after completion of Baseline will not impact the amount of compensation provided. 
 8.0 STUDY PROCEDURE DESCRIPTIONS 
 
8.1 
Sociodemographics 
Sociodemographic data (sex, age, handedness, languages, marital/partner status, living 
circumstances, education, employment history) will be captured. 
 
8.2 
Medical/Surgical/Family History 
Relevant medical and surgical history will be captured as well as relevant medical history of 
first-degree relatives. A list of current medications will also be documented. 
 
8.3 
Height/Weight/BMI 
Participants will be asked to self-report current height and weight during the baseline visit. 
Responses will be used to calculate BMI using the NIH BMI Metric Calculator 
(https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmi-m.htm). 
 
 
8.4 
Hearing and Vision Assessment 
Vision and hearing ability will be assessed by questions on perceived visual and auditory ability 
and an inventory of aids used. Participants must have relatively sufficient vision (with corrective 
lenses or other aids) so that they can identify symbols, stimuli and text presented on a computer 
screen in front of them. Participants must also have sufficient hearing (corrected with hearing 
aids or other voice amplification devices) to be able to follow spoken instructions and 
information that is presented only verbally. 
 
9.0 
STUDY-SPECIFIC INSTRUMENTS 
 
9.1 
Cognitive Measures 
9.1.1 Montreal Cognitive Assessment-Telephone/Blind Version (T-MoCA) 
The T-MoCA is a 5-10-minute test that has been validated for remote administration by 
telephone and provides a global assessment of cognition, covering domains of memory, 
language, attention and executive functioning [13]. The T-MoCA has been modified from the 
original MoCA to remove items requiring paper and pencil administration and visual stimuli. 
The total possible score is 22 with a cutoff score of greater or equal to 18 to indicate normal 
cognitive functioning. 

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9.2 
Questionnaires 
9.2.1 Knowledge Assessment Survey 
Brief questionnaire that will be developed as the HALT-AD program content is finalized to 
assess general knowledge of dementia including risk factors, brain health and prevention. 
Participants’ knowledge will be assessed pre and post participation in HALT-AD. 
 
9.2.2 The New General Self-Efficacy Scale 
Self-Efficacy is a concept that refers to one’s global confidence in their ability to cope with 
demanding or novel situations. The New General Self-Efficacy scale is an 8-item 5-point likert 
scale (strongly disagree (1) to strongly agree (5)) which measure one’s perceived competence in 
dealing with a range of stressful or challenging situations [14]. The scale will be completed 
online within HALT-AD. 
 
9.2.3 Lifestyle Risk Assessment 
Questionnaire to be developed by course leads to assess dementia risk based on HALT-AD Pilot 
Courses (e.g. Sleep, Diet, Physical Activity, Mindfulness/Compassion). Risk scores for each 
domain will be calculated. 
 
9.2.4 HALT-AD User Experience Survey 
Questionnaire adapated for HALT-AD based on questions from the User Experience 
Questionnaire (UEQ) available at https://ueqtryitout.ueq-research.org/. Participants will be asked 
to decide as spontaneously as possible which conflicting terms (e.g. annoying vs. enjoyable) 
better describes the HALT-AD program. 
 
9.2.5 Net Promoter Score (NPS) Survey 
The Net Promoter Score (NPS) Survey is a metric used in customer experience programs to 
measure the loyalty of customers to a product (What is Net Promoter Score? (Updated 2020) | 
Qualtrics AU). NPS scores are measured with a single question survey “How likely is it that you 
would recommend [Organisation X/Product Y/Service Z] to a friend or colleague?” and reported 
with a number from -100 to +100, a higher score is desirable. 
 
9.2.6 HALT-AD Course Acceptability Survey 
Questionnaire developed by the HALT-AD team to evaluate overall acceptability and 
satisfaction with the course content for the HALT-AD program. There are a total of 15 items 
including both multiple choice and open-ended questions (see Appendix 2). 
 
9.2.7 HALT-AD Facilitated discussion group Acceptability Survey 
Questionnaire to be developed in collaboration with the group facilitator. Questions will assess 
overall satisfaction and utility of the the monthly facilitated discussion groups. 

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 10.0 
EARLY DISCONTINUATION PROCEDURES 
 
Participants are free to withdraw from study participation at any time, for any reason, and 
without prejudice. 
Study Discontinuation for an individual participant may occur in the following circumstances: 
1. Withdrawal of informed consent by the participant. 
2. Adverse event or other significant medical condition which, in the opinion of the 
Investigator, render it necessary to remove the individual from study participation. 
3. Any other occurrence that, in the Investigator’s opinion, makes continued participation 
contrary to the participant’s best interests. 
If co-PIs discover sufficient reasonable cause for the premature termination of the study, the 
terminating party will provide written notification to the participant documenting the reason for 
study termination. 
 
 11.0 
ADVERSE EVENTS 
 
 
An adverse event (AE) is any untoward medical occurrence in a participant that occurs from the 
time of the baseline visit and up to 30 days after study participation has ended. For the purposes 
of reporting on the this study, an AE is defined as any unfavourable or unintended sign, 
symptom, or disease associated with study participation that is both non-serious and either 
temporally or causally related to study procedures. Pre-existing conditions, which increase in 
frequency or severity or worsen in nature during, or as a consequence of, a study procedure, 
may also be considered an AE if it meets the definition of being both non-serious and related 
to a study procedure. Adverse events that occur prior to the baseline visit will be documented as 
medical history. 
An AE does not include: 
• Medical or surgical procedures (e.g., surgery, endoscopy, tooth extraction, transfusion). 
The condition that leads to the procedure is the AE. 
• Situations   where   an   untoward   medical   occurrence  has   not 
occurred (e.g., 
hospitalization for elective surgery, social and/or convenience admissions). 
• Worsening of symptoms associated with an associated co-morbid condition and not 
related to a study procedure. 
11.1 
Evaluation and Reporting of Adverse Events 
All AEs (i.e., a new event or an exacerbation of a pre-existing condition) that occur from the 
baseline visit to the end of the pilot study and are related to the study procedures will be 
recorded as an AE in the study database. Adverse events that occur prior to the baseline visit 
will be documented as medical history. The Investigator will follow all AEs until the AE 

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resolves, or until the Investigator determines the event is chronic or clinically stable. If an 
AE remains unresolved at the conclusion of the study, the Investigator will make a clinical 
assessment to determine whether continued follow-up of the AE is warranted. 
11.2 
Assessment of Adverse Events 
All AEs will be promptly documented on the Adverse Event CRF and assessed by the 
Investigator. Details of the event will include the dates of onset and resolution, severity, 
relationship to study procedures, seriousness, whether the event caused the participant to 
withdraw from the study, and outcome. 
Severity: Severity will be graded and recorded according to the table below. 
 
 
Severity 
Definition 
Mild 
Awareness of event but easily tolerated 
Moderate 
Discomfort enough to cause interference with usual activity 
Severe 
Inability to carry out usual activity, incapacitating, requires 
medical intervention 
 
Relationship: The relationship of the AE to study procedures will be determined by the 
Investigator, and assessed using the following definitions: 
 
 
 
Relatedness 
Description 
Not Related 
There is no evidence of a causal relationship and a causal 
relationship cannot be reasonably attributed to the study 
procedures. The event is clearly due to extraneous causes. 
Unlikely Related 
A poor temporal relationship exists between the event onset and 
study procedures. The event could easily be explained by the 
participant’s clinical state, intercurrent illness, or concomitant 
therapies. 
Possibly Related 
A relationship cannot be ruled out with certainty and the event 
may be related. There is some evidence to suggest a causal 
relationship but the influence of other factors may have 
contributed to the event, such as the participant’s clinical 
condition or concomitant treatment. 
Probably Related 
The event is likely related to study participation. There is 
evidence to suggest a causal relationship, such as reasonable 
temporal sequence from procedure. The influence of other 
factors is unlikely. 
Definitely Related 
The event is clearly related to study participation. There is clear 
evidence to suggest a causal relationship. The influence of other 
factors can be ruled out. 

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These criteria, in addition to good clinical judgment, should be used as a guide for 
determining the causal assessment. 
 
 12.0 
STATISTICAL CONSIDERATIONS 
 
12.1 
Analysis Plan 
Descriptive statistics will be provided for each timepoint on HALT-AD measures and change 
scores will be computed where applicable. Change = (4 months score - baseline score). 
Continuous data will be presented with mean, standard deviations, median, minimum and 
maximum and 95% confidence intervals. Categorical data will be presented as proportions and 
percentages. We will examine the proportion of participants reaching a defined threshold on 
usability measures. Changes in continuous outcome measures between baseline and post- 
intervention will be analyzed by repeated measures t-test. 
Furthermore, the continuous measures collected directly from the program will be analyzed to 
evaluate program use during the 3-month period. User engagement as measured by the average 
total amount of time (in minutes) spent on all courses combined and the percentage of 
participants who completed all courses, overall and by age, gender and educational level will be 
tracked. 
The post-pilot interviews/focus groups will collect more detailed feedback on the experience 
with the program and these will be guided by the results obtained on the usability and 
functionality questionnaires. Qualitative analyses (content analysis) will be used for responses to 
open-ended questions (e.g. suggestions for improvements of the web platform) obtained during 
focus groups. Answers to open-ended questions will be first transcribed verbatim in Word, then 
the text will be imported into MAXQDA. Thematic analysis will be conducted in MAXQDA to 
identify common themes arising from the focus group discussions. Themes will be defined and 
described in a Table format. Saturation will be reached and analysis will be considered complete 
when no new themes are identified. 
12.2 
Sample Size and Power 
Given that this pilot study is being conducted to contribute to the development of the HALT-AD 
program, we did not power to detect an intervention effect size over time. The sample size for 
the pilot was estimated based on prior experience in the development of similar programs. 
 
 13.0 
RECORDING AND COLLECTION OF DATA 
 
13.1 
Case Report Form 
The co-PIs and study team will be trained on elecontric case report form (eCRF) completion. The 
investigator is responsible for all entries in the eCRF for completeness, accuracy and clarity. The 
investigator or designee should complete the eCRF as soon as possible after the information is 

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collected. The investigator is responsible to endorse all the information recorded in the eCRF and 
will provide formal approval of the final submitted data. 
All electronic data captured on the eCRF will be de-identified and coded by unique Participant 
ID. Electronic files will either be stored within REDCap or in study files on the password 
protected UCSD Health File server (see Figure 2 and Figure 3 below for descriptions of the data 
flow in REDCap and UCSD Health File Server) . All study files will only be accessible to study 
co-PIs and team members. 
The program manager for this study will be responsible for storing all participant identifying 
information (name, contact, e-mail address) and to maintain the master file that links the 
participant to their unique Participant ID on a secure password-protected UCSD Health File 
server. This master file will be kept separate from all other de-identified study data generated in 
this study. 

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Figure 2. REDCap Data Flow 
Baseline 
Assessments 
• Study Coordinator conducts 
following assessments over 
telephone with participant: 
➢ Sociodemographics 
➢ Vision and Hearing 
➢ Medical History 
➢ T-MoCA 
• Study Coordinator enters 
participant responses 
directly into e-CRF coded in 
REDCap 
• E-mail link sent to complete 
survey directly in REDCap: 
➢ Knowledge Assessment 
• Data is identified by unique 
Participant ID only 
• Data is securely stored and 
saved in REDCap 
End-of-Study 
Assessments 
 E-mail link sent to 
participants to complete 
the following surveys 
directly in REDCap: 
➢ HALT-AD User 
Experience Survey 
➢ Net Promoter Score 
Survey 
➢ HALT-AD Course 
Acceptability Survey 
➢ Facilitated 
Discussion Group 
Acceptability Survey 
➢ Knowledge 
Assessment 
 Data is identified by 
unique Participant ID 
only 
 Data is securely stored 
and saved in 
REDCap 

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Figure 3. UCSD Health File Server Data Flow 
 
 
 
 
 
13.1.1 HALT-AD Website Server 
The HALT-AD website will be hosted on the UCSD Amazon Cloud server. Participants will be 
asked to provide their e-mail address and name to register for HALT-AD. This information will 
be encrypted and kept on the server in a separate location from the program data. Raw program 
data will linked to unique Participant ID and provided in excel format to be stored with other 
study data on asecure password-protected UCSD Health File Server (see Figure 2 for a 
description of the data flow for the HALT-AD program) 
HALT-AD Study 
Assessments 
• Assessments 
conducted directly in 
HALT-AD program 
will be provided in 
.csv file format to be 
saved to study files 
on UCSD Health File 
Server 
• Assessments 
include: 
➢ New General Self- 
Efficacy Scale 
➢ Lifestyle Risk 
Assessment 
• .csv data will be de- 
identified and linked 
to unique Participant 
ID only 

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13.1.3 REDCap Surveys 
Data and questionnaires that are not collected directly within the online HALT-AD website, will 
be securely collected and stored in REDCap. All study data from REDCap will be de-identified 
and coded by unique Participant ID only (see Figure 1 for a description of the study data that will 
be stored within REDCap). 
13.1.4 Focus Groups Recordings and Transcription 
Audio-Recordings from the focus group(s) will be transcribed. All identifiable information will 
be removed from the transcriptions and names will be replaced by unique Participant IDs. 
Audio-recordings will be permanently deleted once transcription is complete. The de-identified 
transcriptions will be stored with other study data on a secure password-protected UCSD Health 
file server (see Figure 2 UCSD Health File Server Data Flow). 
13.2 
Study Files and Participant Source Documents 
Participant confidentiality is strictly held in trust by the study investigators and research staff. 
Authorized representatives may inspect all documents and records required to be  maintained 
by the Investigator. The study site will permit access to such records. Any data, forms, reports, 
and other records that leave the site will be identified only by a participant identification 
number to maintain confidentiality. 
The co-PIs must maintain adequate and accurate records to enable the conduct of  the study   
to be fully documented and the study data to be subsequently verified. These documents 
include Investigators’ Study Files, original participant source documents generated at the 
study site, or completed source document worksheets. The term “original” means the first 
recording of the data. 
The co-PIs will ensure theinvestigator files are maintained, including essential documents such 
as the study protocol and its amendments, informed consents, staff curriculum vitae, 
correspondence, and other appropriate documents. 
13.3 
Rater Training 
Study staff will be trained on the assessments and study specific cognitive, functional and 
behavioral measures that are described in Sections 8.0 and 9.0. study database. 
13.4 
Incidental Findings 
In the event that an incidental finding is identified as being medically significant, the program 
manager will link the participant code to the participant identity and the finding will be passed on 
to the co-PIs within 24 hours. The co-PIs will be responsible for determining the significance of 
the finding, arranging appropriate follow-up and informing the primary care physician (if 
provided). 
 
 14.0 
PUBLICATIONS POLICY AND SHARING OF DATA 
 
The results of this study will be disclosed or published only in combined form based upon the 
statistical analysis performed by the study Investigators. No identifiable personal information 
will be included in any publication or presentation. Authorship of publications resulting from this 

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study should accurately reflect the academic contribution of individuals to the design and 
implementation of the trial, analysis of the data and preparation of the manuscript. All funding 
partners will be acknowledged. All publications that arise from the use of study data will give 
acknowledgement, attribution, or co-authorship as appropriate in accordance with the 
International Committee of Medication Journal Editors (ICMJE) standards. 

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 15.0 
REFERENCES 
 
 
1. 
Metlife Foundation. What America Thinks - Metlife Foundation Alzheimer’s Survey. 
Available 
at: 
https://www.metlife.com/content/dam/microsites/about/corporate- 
profile/alzheimers-2011.pdf. 2011. 
2. 
Ostergren, J.E., et al., The Influence of Psychosocial and Cognitive Factors on Perceived 
Threat of Alzheimer's Disease. Am J Alzheimers Dis Other Demen, 2017. 32(5): p. 289- 
299. 
3. 
Association, A.s., Alzheimer’s Disease Facts and Figures 2020. 2020, Alzheimer’s 
Dement. 
4. 
Hurd, M.D., et al., Monetary costs of dementia in the United States. N Engl J Med, 2013. 
368(14): p. 1326-34. 
5. 
Agency, C.o.S.D.H.a.H.S., The Alzheimer's Project Clinical Rountable. Alzheimer’s 
disease and related dementias in San Diego county. . 2018. 
6. 
Living, A.f.C., Profile of Older Americans. 2019. 
7. 
Network, U.E.R.R.I.o.A.L.s., Latinos and Alzheimer’s Disease: New Numbers Behind the 
Crisis. 2016. 
8. 
Velasco-Mondragon, E., et al., Hispanic health in the USA: a scoping review of the 
literature. Public Health Rev, 2016. 37: p. 31. 
9. 
Cummings, J., et al., Alzheimer's disease drug development pipeline: 2018. Alzheimers 
Dement (N Y), 2018. 4: p. 195-214. 
10. 
Livingston, G., et al., Dementia prevention, intervention, and care. Lancet, 2017. 
390(10113): p. 2673-2734. 
11. 
Kivipelto, M., et al., The Finnish Geriatric Intervention Study to Prevent Cognitive 
Impairment and Disability (FINGER): study design and progress. Alzheimers Dement, 
2013. 9(6): p. 657-65. 
12. 
Cummings, J., C. Reiber, and P. Kumar, The price of progress: Funding and financing 
Alzheimer's disease drug development. Alzheimers Dement (N Y), 2018. 4: p. 330-343. 
13. 
Pendlebury, S.T., et al., Telephone assessment of cognition after transient ischemic attack 
and stroke: modified telephone interview of cognitive status and telephone Montreal 
Cognitive Assessment versus face-to-face Montreal Cognitive Assessment and 
neuropsychological battery. Stroke, 2013. 44(1): p. 227-229. 
14. 
Chen, G., S.M. Gully, and D. Eden, Validation of a new general self-efficacy scale. 
Organizational research methods, 2001. 4(1): p. 62-83. 

 
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 16.0 
APPENDICES 
 
APPENDIX 1: Schedule of Events 
 
UCSD HALT-AD PILOT STUDY SCHEDULE OF EVENTS 
PROCEDURES 
SCREE 
NING 
BASELINE 
MONTH 1 
MONTH 2 
MONTH 3 
MONTH 4 
Remote Study Procedures (on Zoom or REDCap) 
ELECTRONIC INFORMED CONSENT (E- 
CONSENT) 
X 
INCLUSION/EXCLUSION CRITERIA EVALUATED 
X 
SOCIODEMOGRAPHICS 
X 
MEDICAL/SURGICAL/FAMILY HISTORY 
X 
WEIGHT, HEIGHT (participant estimates) and BMI 
X 
HEARING AND VISION ASSESSMENT 
X 
MONTREAL COGNITIVE ASSESSMENT (MoCA) 
X 
HALT-AD USER EXPERIENCE SURVEY 
X 
NET PROMOTER SCORE SURVEY 
X 
HALT-AD COURSE ACCEPTABILITY SURVEY 
X 
KNOWLEDGE ASSESSMENT SURVEY 
X 
X 
FACILITATED DISCUSSION GROUP 
ACCEPTABILITY SURVEY 
X 
FOCUS GROUPS 
X 
HALT-AD Online Assessments 
NEW GENERAL SELF-EFFICACY SCALE (NGSE) 
X 
X 
LIFESTYLE RISK ASSESSMENT (Diet, Sleep, 
Mindfulness) 
X 
X 
GOAL SETTING AND REVIEW 
X 
X 
FACILITATED DISCUSSION GROUPS1 
X* 
X* 
X* 
1 *Facilitated Discussion Groups will occur approximately every three weeks in between Months 1-3. They will occur prior to the start of each new content module. 

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16.1 APPENDIX 2: Survey Instruments 
16.1.1 Knowledge Assessment Survey 
Below are some statements about brain health and dementia prevention. Please read each 
statement carefully and choose whether you think the statement is True or False. 
1. If I am healthy, my brain should not age at all over time. 
2. As I age, I will most certainly have dementia. 
3. People from Hispanic or African American backgrounds have a higher risk of developing 
Alzheimer’s Disease. 
 
4. Being physically inactive and being obese are two examples of factors that can increase 
our chances of developing Alzheimer’s Disease. 
5. Hanna may avoid dementia by making healthier lifestyle changes such as getting better 
sleep, eating a healthier diet, and being more physically active. 
6. There are many reasons why older adults may feel lonely. Reasons include losing family 
members, facing difficulties in moving around, and well as feeling empty and sad. 
7. Everyone experiences loneliness the same way. It is not personal, and it does not differ 
across people. 
8. People that are lonely have an increase in abnormal proteins in their brain. The 
accumulation of abnormal proteins in the brain occurs during the development of 
Alzheimer’s Disease. 
9. If you are feeling lonely, there is nothing you can do to overcome your loneliness. 
10. Sometimes, when we are very lonely, making personal initiatives such as joining a 
volunteering social group does not always work. That’s totally OK. 
11. An average adult should be getting 7-9 hours of sleep a day. Getting 4-6 hours of sleep 
a night on a weekly basis does not significantly affect brain function, since it is only a few 
hours less than the recommended amount. 
12. When we haven’t sleep for 24 hours, our cognitive abilities decrease to a point that is 
like when someone is legally drunk. 
13. Lack of sleep can affect our health in a variety of ways, including increasing our risk of 
developing a stroke, weakening our immune defenses, and contributing weight gain. 
14. Developing new habits and routines like going outdoors, practicing mindfulness, 
cultivating social relationships, creating a daily routine, reducing caffeine intake at night, 
and seeking help when needed are all lifestyle changes that can improve sleep. 
15. Because sleep issues are so personal, there are no treatments. 

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16. A combination of exercises, including aerobic, non-aerobic, endurance, and more, are all 
extremely helpful in keeping our mind resilient and can potentially protect our brains from 
changes that happen with aging. 
17. Physical activity and exercise are only helpful for those younger than 65. 
18. Pain, dizziness, shortness of breath, tightness in the chest while exercising are healthy 
symptoms that are a result of being physically active. 
19. Measuring our heart rate and comparing it to our target heart rate is the only way we can 
check to see if we are exercising at a moderate-intensity level. 
20. Setting SMART goals and using a common habit as a habit trigger for physical exercise 
are two easy ways to help us maintain a physically active lifestyle in the long-term. 
 
 
16.1.2 New General Self-Efficacy Scale 
1. I will be able to achieve most of the goals that I have set for myself. 
2. When facing difficult tasks, I am certain that I will accomplish them. 
3. In general, I think that I can obtain outcomes that are important to me. 
4. I believe I can succeed at most any endeavor to which I set my mind. 
5. I will be able to successfully overcome many challenges. 
6. I am confident that I can perform effectively on many different tasks. 
7. Compared to other people, I can do most tasks very well. 
8. Even when things are tough, I can perform quite well. 
 
 
16.1.1 HALT-AD User Experience Survey 
Decide as spontaneously as possible which of the following conflicting terms better describes the 
HALT-AD web platform (website). There is no "right" or "wrong" answer. Only your personal 
opinion counts! 
 
annoying 
O O O O O O O 
enjoyable 
not understandable 
O O O O O O O 
understandable 
creative 
O O O O O O O 
dull 
easy to learn 
O O O O O O O 
difficult to learn 
valuable 
O O O O O O O 
inferior 
boring 
O O O O O O O 
exciting 
not interesting 
O O O O O O O 
interesting 

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unpredicatble 
O O O O O O O 
predicatble 
fast 
O O O O O O O 
slow 
inventive 
O O O O O O O 
conventional 
obstructive 
O O O O O O O 
supportive 
good 
O O O O O O O 
bad 
complicated 
O O O O O O O 
easy 
unlikable 
O O O O O O O 
pleasing 
usual 
O O O O O O O 
leading edge 
unpleasant 
O O O O O O O 
pleasant 
secure 
O O O O O O O 
not secure 
motivating 
O O O O O O O 
demotivating 
meets expectations 
O O O O O O O 
does not meet expectations 
inefficient 
O O O O O O O 
efficient 
clear 
O O O O O O O 
confusing 
impractical 
O O O O O O O 
practical 
organized 
O O O O O O O 
cluttered 
attractive 
O O O O O O O 
unattractive 
friendly 
O O O O O O O 
unfriendly 
conservative 
O O O O O O O 
innovative 
 
 
16.1.1 Net Promoter Score (NPS) Survey 
“How likely is it that you would recommend HALT-AD to a friend or colleague?” 
 
16.1.2 HALT-AD Course Acceptability Survey 
 
1) Overall, was it easy to understand the information presented in the courses? 
  Not at all easy 
  Slightly easy 
  Moderately easy 
  Very easy (skip to question 3) 
  Extremely easy (skip to question 3) 
2) What changes can we make for information to become more understandable? 
 
 
3) Rate the overall amount of information presented in the courses: 
  Too little 
  About right 
  Too much 
4) Generally, was the information presented in the courses boring? 

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  Not at all boring (skip to question 6) 
  Slightly boring 
  Moderately boring 
  Very boring 
  Extremely boring 
5) What changes can we make for information to become less boring? 
 
 
6) Generally, was the information presented to you in the courses helpful? 
  Not at all helpful 
  Slightly helpful 
  Moderately helpful 
  Very helpful 
  Extremely helpful 
7) Generally, did you find the activities in the courses to be interesting? 
  Not at all interesting 
  Slightly interesting 
  Moderately interesting 
  Very interesting (skip to question 9) 
  Extremely interesting (skip to question 9) 
8) How can we change the activities to make them more interesting? 
 
9) Generally, did you find the activities in the courses to be helpful? 
  Not at all helpful (skip to question 11) 
  Slightly helpful (skip to question 11) 
  Moderately helpful (skip to question 11) 
  Very helpful 
  Extremely helpful 
10) In what ways were the activities helpful? (skip to question 12) 
 
 
11) How can we change the activities to make them more helpful? 
 
 
12) Generally, were the quiz questions clear? 

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  Not at all clear 
  Slightly clear 
  Moderately clear 
  Very clear 
  Extremely clear 
13) Overall, was the information in the courses new to you? 
 
  Not at all new 
  Slightly new 
  Moderately new 
  Very new 
  Extremely new 
14) Overall, did you find the information in the courses to be uplifting? 
  not at all uplifting 
  Slightly uplifting 
  Moderately uplifting 
  Very uplifting 
  extremely uplifting 
15) How likely are you to recommend these courses to a family member, friend or colleague? 
  extremely unlikely 
  Unlikely 
  Likely 
  Extremely likely 
 
16.1.3 HALT-AD Facilitated discussion group Acceptability Survey 
Questionnaire to be developed in collaboration with the group facilitator. Questions will assess 
overall satisfaction and utility of the the monthly facilitated discussion groups. 
 
16.1.4 HALT-AD Lifestyle Risk Assessment 
Questionnaire developed by course leads to assess dementia risk based on HALT-AD Pilot 
Courses (e.g. Sleep, Diet, Physical Activity, Mindfulness/Compassion). Risk scores for each 
domain will be calculated. 

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16.2 
APPENDIX 3: Screening Questions 
 
16.2.1 PRE-SCREENING TELEPHONE INTERVIEW 
Thank you for your interest in the Healthy Actions and Lifestyles to Avoid Dementia or Hispanos 
y el ALTo a la Demencia program (HALT- AD) study. My name is [name], and I am [role/title] at 
the [site name]. Are you able to understand me well in English, or should I give you the 
following information in Spanish? 
Is this a good time to talk? (If Yes, proceed with verbal consent language below. If No, confirm 
with participant when would be a good time to call back) 
 
The HALT-AD study is designed to determine if a new online educational program and 
discussion groups, available in English and in Spanish, can help midlife and older adults learn 
how to prevent dementia through lifestyle changes. Before we offer the HALT-AD program to a 
large group, we are conducting an initial pilot study to help us assess the usability of the 
program. Your participation in this pilot study would help us learn how well the program is 
working and to make changes before the larger study begins. 
 
In order to see if you are eligible to participate in this study, I would like to ask you some 
questions about your background. This is completely voluntary and you can stop at any time. If 
you give me your verbal permission, I will write down your responses and enter them into the 
study data base. This will allow us to see what recruitment methods work well and to potentially 
make changes in the future. No information that can identify you will be included in the study 
database. Your contact information will be securely stored at the study site and will be kept 
separate from your responses to this questionnaire. If you are not eligible for this study, we will 
delete your contact information unless you give us permission to keep it to re-contact you if 
eligibility for this study changes or to see if you are interested in participating in a future study 
(see section B below for optional permission to re-contact ineligible participants). 
Now, would you like to see if you are eligible to participate? q Yes q No 
Do you give me your permission to continue with the questions and permission to also write the 
responses down?q Yes q No 
[YES, continue below Section A; NO, continue below Section B] 
Section A: 
1. First, can you please tell me how you heard about this study (select all that apply)? 
☐ Flyer 
☐ Social Media 
☐ Word of mouth (please specify): 
☐ Family member 
☐ Friend 
☐ Neighbor 
☐ Other (please specify):   
 
☐ Other (please specify):   
 

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2. What is your age?   
 
3. Have you been diagnosed with dementia or Alzheimer's disease? q Yes q No 
4. Do you have access to a computer or tablet that connects to the internet? q Yes q No 
5. Do you understand the basic functions of the computer or tablet and can you navigate to 
different web pages on the internet? q Yes q No 
6. Do you have the ability to send and receive emails? q Yes q No 
7. Do you have an advanced educational degree in an area related to brain health? q Yes q 
No 
8. What is your primary language?   
 
9. Participants are able to complete the online educational program in either English or Spanish. 
In which language would you prefer to participate?   
 
10. a) On a scale from 0 to 10, please select your level of proficiency in speaking [language 
participant indicates on Question 7]: 
• 
None (0) 
• 
Very low (1) 
• 
Low (2) 
• 
Fair (3) 
• 
Slightly less than adequate (4) 
• 
Adequate (5) 
• 
Slightly more than adequate (6) 
• 
Good (7) 
• 
Very good (8) 
• 
Excellent (9) 
• 
Perfect (10) 
 
b) On a scale from 0 to 10, please select your level of proficiency in understanding spoken 
language in [language participant indicates on Question 7]: 
• 
None (0) 
• 
Very low (1) 
• 
Low (2) 
• 
Fair (3) 
• 
Slightly less than adequate (4) 
• 
Adequate (5) 
• 
Slightly more than adequate (6) 
• 
Good (7) 
• 
Very good (8) 
• 
Excellent (9) 
• 
Perfect (10) 
*≥ 7 out of 10 is considered proficient 
If potential participant does not pass this pre-screen or target recruitment per language, gender, 
or age group is currently full, proceed to B below. 

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If potential participant does pass this pre-screen, proceed with providing information on next 
steps: inviting potential participant to receive electronic informed consent form for their review 
and scheduling a telephone call to discuss the ICF and answer any questions they may have. 
 
Section B: 
If potential participant does not meet eligibility criteria [say] 
Unfortunately, you are not eligible for this specific study. 
Would you be willing to be contacted in the future if eligibility for this pilot study changes or to 
participate in a future study? q Yes q No 
If participant cannot be enrolled because recruitment in target group (language, gender, age 
range) is full [say] 
Unfortunately, recruitment in this pilot study based on your eligibility [specify reason i.e. 
language group, gender, age range] is currently full. 
Would you be willing to be contacted to participate in a future study? q Yes q No 
Thank you so much for your time today. We appreciate you. 

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16.2.2 HEARING AND VISION 
 
Hearing 
1. How would you describe your hearing (with a hearing aid if you use one)? 
£Excellent 
£Very good 
£Good 
£Fair 
£Poor 
2. Do you have sufficient hearing (corrected with hearing aids or other voice amplification 
devices) to be able to follow spoken instructions and information that is presented only 
verbally? 
£Yes 
£No 
£Don’t know 
3. Do you find it difficult to follow a conversation if there is background noise, such as TV, 
radio or children playing, even if using a hearing aid or assistive device as usual? 
£Yes 
£No 
£Don’t know 
4. Do you use a hearing aid or specialized equipment, or services for persons who are deaf or 
hard of hearing, for example, a volume control telephone or TV decoder? 
£Yes 
£No 
£Don’t know 
5. If YES, Which of the following equipment do you use to hear better? (check all that apply) 
£Hearing aid 
£Computer to communicate (e.g., email or chat services) 
£Volume control telephone 
£TTY or TTD 
£Message relay service 
£Other phone-related devices (e.g., flashers) 
£Closed caption TV or decoder 
£Amplifiers (e.g., FM, acoustic, infrared) 
£Visual or vibrating alarm 
£Cochlear implant 

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£Another aid (please  specify):   
 
 
 
 
 
 
Vision 
6. If your hearing loss began before middle age, is it likely to have been 
 Present from early childhood 
 Due to noise exposure at work 
 Due to a disease or medical condition? 
1. How would you characterize your eyesight (using glasses or corrective lens if you use 
them)?  Excellent 
 Very Good 
 Good, Fair 
 Poor 
 Non-existent (non-existent = blind) 
2. Do you have relatively sufficient vision (with corrective lenses or other aides) so that 
you can identify symbols, stimuli and text presented on a computer screen in front of 
you? 
 Yes 
 No 
 Don’t know 
3. Do you wear glasses? 
 Yes 
 
 No 
 Near (Reading) 
 Distance 
 Don’t know 
4. Besides glasses or contact lenses, do you use any aids or specialized equipment for 
persons who are blind or visually impaired, for example, magnifiers or Braille reading 
materials?  Yes 
 No 
 Don’t know 
5. If YES, Which of the following aids do you use? (Please choose all that apply) 
 Magnifiers 
 Braille reading materials 
 Larger print reading materials 
 Talking books 
 Recording equipment or portable note-takers 
 Closed circuit devices (e.g., CCTVs) 

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 A computer with Braille, large print, or speech access 
 A white cane 
 A guide dog 
Another aid (please specify):   
 

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16.3 
APPENDIX 4: Baseline Assessments 
 
16.3.1 SOCIODEMOGRAPHIC INFORMATION 
 
BIRTH; SEX; GENDER IDENTITY 
 
1. What is your date of birth?  
/   
 
MM 
YYYY 
2. People living in the United States come from many different cultural and racial 
backgrounds. Which racial category do you identify with? (Choose all that 
apply): 
☐ American Indian or Alaskan 
☐ Native Asian 
☐ Native Hawaiian or other Pacific Islander 
☐ Black or African American 
☐ White 
☐ Latin American 
☐ More than one race 
☐ Unknown or prefer not to answer 
3. Which ethnic category do you identify with? 
☐ Hispanic or Latino 
☐ Not Hispanic or Latino 
☐ Unknown or prefer not to answer 
4. What sex was originally listed on your birth certificate? 
☐ Female 
☐ Male 
5. Do you think of yourself as: 
☐ Female 
☐ Male 
☐ Transgender woman/trans woman/male-to-female (MTF) 
☐ Transgender man/trans man/female-to-male (FTM) 
☐ Genderqueer/gender nonconforming neither exclusively male nor female 
☐ Additional gender category (or other; please specify):   
 
☐ Decline to answer 
 
HANDEDNESS 
 
1. What is your hand preference? (Hand used predominantly, not necessarily 

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hand you write with exclusively) 
☐ Left 
☐ Right 
☐ Ambidextrous 
MARITAL / PARTNER STATUS 
 
1. What is your current marital/partner status? (Choose the one that describes you now) 
☐ Single 
☐ Married 
☐ Domestic partnership 
☐ Separated 
☐ Divorced 
☐ Widowed 
CURRENT LIVING CIRCUMSTANCES 
 
1. Please describe your living environment: 
☐ House or apartment/condominium that you own 
☐ Apartment/condominium or house that you rent 
☐ Retirement home (autonomous living) 
☐ Residence for semi-autonomous individuals 
☐ Nursing home or long-term care (assisted living) 
☐ Other, please specify:   
 
 
2. Please describe your living environment: 
☐ Urban 
☐ Suburban 
☐ Rural 
3. With whom do you live? (Please check all that apply) 
☐ I live alone 
☐ Spouse/significant other 
☐ Children/grandchildren 
☐ Other members of the family 
☐ Friend(s) 
☐ Other (specify):    
 
 
EDUCATION 
 
2. What is the highest grade or level of school you completed or the highest 
degree obtained? (Choose one) 

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☐ Never attended school 
☐ Some primary/grade school; specify number of years completed:   
 
☐ Completed primary/grade school 
☐ Some high school; specify number of years completed:   
 
☐ Completed high school. Graduated? YES £ NO £ 
☐ GED 
☐ Apprenticeship; specify number of years completed:   
 
☐ Technical school or community college; specify number of years completed: 
  
 Graduated? YES £ NO £ 
☐ Some university; specify number of years completed:   
 
☐ Undergraduate degree at university; please specify degree/specialty (e.g. B.A., 
B.Sc., B.Eng., LL.B., B.Ed., etc.):   
 
☐ Some graduate (post-undergraduate) school; specify number of years 
completed:   
 
☐ Graduate degree at university; please specify degree/specialty (e.g., M.A., 
M.Sc., Ph.D., LL.M., other graduate degree):   
 
EMPLOYMENT HISTORY 
 
1. What is your current employment status? (Choose one) 
☐ Paid employment 
☐ Retired 
☐ Voluntary/unpaid work 
☐ Unemployed 

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16.3.2 MEDICAL HISTORY 
 
Past Medical History 
1. History of type II diabetes? 
  
 Yes 
  
 No 
  
 Unknown 
2. Currently being treated for type II diabetes? 
  
 Yes 
  
 No 
  
 Unknown 
3. Currently being treated for high blood pressure? 
  
 Yes 
  
 No 
  
 Unknown 
4. Past head trauma? 
  
 Yes 
  
 No 
  
 Unknown 
4a. If Yes, what was the date of the most recent head trauma? 
 
MM/DD/YYYY 
5. Is there a history of strokes? 
  
 Yes 
  
 No 
  
 Unknown 
5a. If there is a history of strokes, when did the last stroke occur? 
 
MM/DD/YYYY 
6.Have you experienced any episodes of fainting or blackouts? 
  
 Yes 
  
 No 
6a. If Yes, when was the lasttime you fainted or had a blackout? 

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7 History of any type of seizure? 
  
 Yes 
  
 No 
  
 Unknown/Uncertain 
7a. If Yes, when was the last known seizure? 
 
MM/DD/YYYY 
8. History of epilepsy (recurrent seizures)? 
  
 Yes 
  
 No 
  
 Unknown 
8a. If Yes, when was the last epileptic event? 
 
MM/DD/YYYY 
9. History of malignant cancers? 
  
 Yes 
  
 No 
  
 Unknown 
9a. If Yes, in remission? 
  
 Yes 
  
 No 
  
 Unknown 
9b. If Yes, what was the date of remission? 
 
MM/DD/YYYY 
10. Current diagnosis of a mental health or behavioral disorder? 
  
 Yes 
  
 No 
  
 Unknown 
10a. If Yes, please specify:   
 
10b. If Yes, are medications currently being taken to treat this disorder? 
  
 Yes 
  
 No 

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 Unknown 
11. Drug or alcohol dependency or a history of drug or alcohol abuse? 
  
 Yes 
  
 No 
  
 Unknown 
12. Currently have a diagnosis of obstructive sleep apnea? 
  
 Yes 
  
 No 
  
 Unknown 
12a. If yes, who made the diagnosis: 
  
 Primary care physician 
  
 Neurologist 
  
 Psychiatrist 
  
 Sleep Center 
  
Other 
12b. If Yes, please indicate one of the following in regards to participant treatment? 
  
 Yes, treatment prescribed and compliant 
  
 Yes, treatment prescribed and not fully compliant 
  
 No 
  
 Unknown 
 
13. Please indicate all the surgical procedures that you have undergone, as well as your age and 
whether a general anesthetic was administered. 
Type of surgery 
Age 
General anesthetic? 
Yes 
No 
Unknown 
£ 
Cataract surgery 
  
  
  
Heart surgery: 
  
  
  
£ 
Coronary bypass surgery 
  
  
  
£ 
Pacemaker surgery 
  
  
  
£ 
Coronary stent insertion 
  
  
  
£ 
Angioplasty 
  
  
  
£ 
Bariatric surgery 
  
  
  
£ 
Gastrectomy 
  
  
  
£ 
Bowel surgery (e.g. for adhesions, cancer, resection) 
  
  
  

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☐ Urology surgery (e.g. bladder, kidney) 
  
  
  
☐ Hip replacement 
  
  
  
☐ Knee replacement 
  
  
  
☐ Other(s): 
  
  
  
 
 
Family History 
14. Please indicate which of your blood relatives have/had a history of any of the following 
conditions. 
Condition 
Family 
history 
Relative(s) affected 
Age of Onset 
(if known) 
Number of 
relatives affected 
Yes 
No 
1st ° 
2nd ° 
A. Neurological disorders 
Memory problems without a 
diagnosis of dementia 
££ 
Alzheimer's dementia 
££ 
Frontotemporal dementia 
££ 
Other dementia (specify): 
££ 
Parkinson's disease 
££ 
Epilepsy or seizures 
££ 
Stroke 
££ 
Multiple sclerosis 
££ 
Amyotrophic lateral sclerosis 
(ALS) 
££ 
B. Mental health disorders 
Depression 
££ 
Bipolar disorder 
££ 
Other mood disorder 
££ 
Anxiety disorder 
££ 
Schizophrenia 
££ 
Suicide or suicide attempt 
££ 
C. Other disorders 
Diabetes mellitus 
££ 
Cancer 
££ 
Heart disease 
££ 
Hypertension 
££ 

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Other: 
££ 

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16.3.3 CURRENT MEDICATIONS 
 
Instructions: The participant should have on hand all their current medications and supplements (herbal, 
vitamins) or a list of current medications from the pharmacy (plus an accounting of supplements if not 
prescribed by a physician). With this information, fill out the table below. Be sure to include injected 
medications/supplements. 
 
Medication Name 
Indication 
Start Date 
(YYYY) 
(Interviewer Note: If more space is needed than provided on this page, print more 
pages and paginate accordingly.) Total number of current medications (incl. 
supplements and vitamins) 

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