Title: The APPLE Tree programme: Active Prevention in People at risk of dementia through Lifestyle, bEhaviour change and Technology to build REsiliEnce
Funder: Economic and Social Research Council

Abstract: Our team includes six leading universities, a World Wide Fingers (WWF) consortium member, Public Health England and a broad coalition of third sector and service delivery organisations. We want to find out how emerging knowledge about dementia prevention can help the whole older population, especially people from vulnerable groups. We plan to build an effective and cost-effective intervention to prevent dementia that reaches marginalised groups, so our programme reduces, rather than compounds, existing inequities in care. Core objectives are to: 1. Design and test a dementia prevention programme based on the evidence and strategy described in the Dementia roadmap and 2017 Lancet Commission on dementia (streams 3/5). a. Co-produce a multimodal intervention to enable targeted behaviour changes in people at higher dementia risk, especially those from marginalised groups who are most at risk. b. Test whether it is feasible to deliver in practice. c. Define a 'state of the art' APPLE-Tree battery of measures to evaluate the biological, environmental and social mechanisms of action of dementia prevention; and use it in the planned randomised controlled trial. d. Test hypotheses that our intervention will reduce cognitive decline over two years and is cost-effective, relative to an information-only control. e. If it does, apply for funding to test whether it prevents dementia over 5 years. 2. Produce an effective, national implementation approach, with Public Health England and other stakeholders, so that if our intervention works, vulnerable groups, not only healthy, early adopters, will use it (stream 4). a. Convene an implementation group with change leaders and frontline staff b. Use the Knowledge-to-Action Model to produce an implementation guide 3. Build theoretical understanding of how civil society does or does not respond to the challenge of dementia prevention, using ethnographic and qualitative methods (stream 1). a. Develop the theoretical account of "limited but limitless ageing" (how active ageing can coexist with physical, mental or cognitive limitations) for people at risk of dementia. b. Explore how social inequalities influence active dementia prevention and how civil society supports involvement of marginalised groups in dementia prevention. c. Explore the impact of social inequities on individual and societal motivations for active dementia prevention. d. Contribute to current dementia prevention debates and inform health and social care policy. 4. Develop a deep understanding of how the NHS currently engages in dementia prevention, to assist interpretation of findings and implementation (stream 2). a. Find out using big data, what preventative care older primary care populations who are at high and low risk of dementia currently receive. b. Investigate in qualitative interviews, facilitators and barriers to receiving primary care that may prevent dementia; and whether there are social inequities in the likelihood of this, or in having memory concerns recorded or specialist referral. 5. Prepare for a future digital version of our intervention, by developing and acceptability testing an app to support it (stream 3 and 5). a. Develop an app to support people to make and sustain the targeted behavioural changes. b. Test acceptability and usage, including in marginalised groups c. Explore how barriers to digital participation in dementia prevention are structured and overcome. 6. Embed knowledge exchange to ensure findings learn from, and deliver for, all intended beneficiaries. a. Work with academic and non-academic partners to create and deliver an impactful knowledge exchange events programme, and to disseminate and implement findings. 7. Increase dementia research capacity, with strong, practical support for doctoral, post-doctoral and early career researchers.

Lay abstract: We plan to make and test a prevention programme to lower older people's chances of getting dementia. The half of older people (aged 60+) who have problems with "cognition" (memory, orientation and other thinking) have more chance of getting dementia, so we will design an approach that works for them. We will design our programme with people who will use, run and pay for it, and will think especially about how it will work for people from more deprived and minority ethnic groups, who are more likely to get dementia. Our programme will help older people make changes that can prevent dementia. These are: 1. Being more socially and mentally active 2. Eating more healthily 3. Being more physically active 4. Looking after their mental and physical health 5. Stopping smoking 6. Reducing alcohol. We will learn from therapies that have worked, but are too time consuming and expensive to run outside of research studies. What we will find out Stream 1: What do people with memory problems, including those from minority ethnic or more deprived backgrounds, do now to try to avoid dementia? Stream 2: Do people with a higher chance of getting dementia get the right help from their GPs (such as blood pressure checks) to prevent it? What makes this more and less likely? Stream 3: What should our face to face, personalised programme be like? Which "app" design will work best in helping prevent dementia? Do people with memory problems, including people from vulnerable groups, use it? Stream 4: How do people who will use, run and pay for our programme if it works, think it should be designed and used? Stream 5: Do people who take part in our programme have less cognitive problems over two years than people who only receive an information leaflet? If so, how did it work, and is it good value for money? How we will do it We will review past research and interview around 80 older people, their families and professionals, to find out how the NHS and society help older people live healthier lives to prevent dementia. We will look at how people think about memory problems and preventing dementia. We will use a database with 14 million UK primary care records, to see who is getting health care that can prevent dementia. We will work with Age-UK, the Alzheimer's society, Care organisations, local authorities and Public Health England. We will randomly allocate 704 people with memory problems without dementia, so they have an equal chance of receiving the new programme or an information leaflet. We plan that the programme will be 10 group sessions over 6 months. We will offer individual sessions for people who cannot come to groups. Two facilitators will lead the groups. They will be trained and supervised by an experienced psychologist to keep to a manual so the programme is delivered in the same way each time. Groups will take place in a range of places to be accessible to all. We will ask people taking part to complete questionnaires, including a memory test and give a voluntary blood sample, before the programme starts and 6 and 24 months later. We will interview around 50 people taking part (including those who drop out) or running the groups to hear what went well and what could be better. As more care and therapies move online, we risk leaving vulnerable people behind. We will ask engineers to design an easy to use app to support people to make the lifestyle changes that prevent dementia. We will support them to build it, then try it out with study participants, including people from vulnerable groups (we can lend them computers if they don't have their own and are willing). We can look at how this helps to get the new programme to people who need it most in future work. Our programme could make a huge difference to individuals, the NHS and society, by reducing the number of people who get dementia.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: NEUROLOGICAL