Racial and Ethnic Disparities in Serious Psychological Distress Among Those With Alzheimer's Disease and Related Dementias

Healthcare Expenditures Among Older Immigrants in the United States With Alzheimer's Disease and Related Dementias: Population-Based Study Between 2007 and 2020

OBJECTIVES

Using nationally representative data sets, this study examined differences in healthcare expenditures between U.S.-born and foreign-born individuals aged 65 and above by the presence of Alzheimer's disease and related dementias (ADRD) and cognitive limitations (CL). This study further examined whether healthcare expenditures among foreign-born individuals vary by their duration of residence in the United States.

METHODS

The study used the 2007-2020 Medical Expenditure Panel Survey and employed generalized linear regression models to estimate differences in healthcare expenditures between U.S.-born and foreign-born older adults with ADRD, CL, and without ADRD or CL. Survey weights were applied to all estimates.

RESULTS

Our study identified significant differences in healthcare expenditures among older adults by the presence of ADRD/CL and immigrant status. Having ADRD/CL had a more pronounced impact on high healthcare expenditures among foreign-born older adults than U.S.-born adults with ADRD/CL, thereby diminishing the difference in healthcare expenditures by U.S. nativity status for the older adults with ADRD or CL. In the analysis further distinguishing immigrants by their duration of residence, lower healthcare expenditures were primarily observed among foreign-born individuals with ADRD or CL who had lived in the United States for less than 10 years.

DISCUSSION

Our results suggest potential shifts in costs resulting from delayed access to, and diagnosis or treatment of ADRD at a younger age, leading to increased healthcare needs and expenses among U.S. foreign-born older adults.

Ethno-racial differences in depressive symptom endorsement: Evaluation of brief forms of the Geriatric Depression Scale in older adults

BACKGROUND

Depression among older adults is a pressing public health concern, necessitating accurate assessment tools. The Geriatric Depression Scale (GDS) offers a brief and efficient means of screening depressive symptoms, yet its performance across ethno-racial groups remains understudied. This study aimed to compare the ability of various brief forms of the GDS to detect depressive symptoms and to assess potential ethno-racial differences in symptom endorsement among White, Black/African-American, and American Indian/Alaska Native older adults.

METHODS

Data were obtained from the Wisconsin Alzheimer's Disease Research Center (ADRC) clinical cohort, comprising 555 cognitively healthy individuals at risk for dementia. We used participants' baseline data for this cross-sectional analysis. Depressive symptoms were assessed using multiple brief forms of the GDS, derived from a systematic review and meta-analysis. We examined internal consistency and correlations with global Clinical Dementia Rating (CDR) scores. We conducted Kruskal-Wallis tests and post hoc pairwise comparisons to assess ethno-racial group differences in symptom endorsement.

RESULTS

Descriptive statistics revealed a predominance of female and White participants, with notable representation from Black and American Indian/Alaska Native groups. All GDS versions demonstrated moderate to high internal consistency. Significant positive correlations were observed between GDS scores and global CDR scores. Ethno-racial group differences in depressive symptom endorsement were evident, with Black participants consistently reporting higher levels of symptoms across most GDS versions. However, American Indian/Alaska Native participants endorsed significantly fewer symptoms than Black participants in one GDS version.

CONCLUSION

The study highlights the importance of considering ethno-racial differences in depressive symptomatology when assessing older adults. While the GDS demonstrates overall reliability, variations in symptom endorsement across different ethno-racial groups underscore the need for culturally sensitive assessment tools and interventions. Future research should further explore these group differences and develop tailored approaches to depression screening and treatment in diverse older adult populations.

Understanding the impact of slowing disease progression for individuals with biomarker-confirmed early symptomatic Alzheimer's disease

Recent advances in development of amyloid-targeting therapies support the potential to slow the rate of progression of Alzheimer's disease. We conducted a narrative review of published evidence identified through a targeted search of the MEDLINE and EMBASE databases (2020-2023), recent presentations at disease-specific conferences, and data updates from cohort studies in Alzheimer's disease to describe the trajectory of the progression of Alzheimer's disease. Our findings enable the interpretation of clinical trial results and the value associated with slowing disease progression across outcomes of relevance to patients, care partners, clinicians, researchers and policymakers. Even at the earliest stages, Alzheimer's disease imposes a substantial burden on individuals, care partners, and healthcare systems. The magnitude of the burden increases with the rate of disease progression and symptom severity, as worsening cognitive decline and physical impairment result in loss of functional independence. Data from cohort studies also indicate that slowing disease progression is associated with decreased likelihood of needing extensive clinical care over at least 5 years, decreased care partner burden, and substantial individual and societal cost savings. Slowed disease progression is of significant benefit to individuals with Alzheimer's disease, their loved ones, and the healthcare system. As clinicians and policymakers devise strategies to improve access to treatment earlier in the disease spectrum, they should carefully weigh the benefits of slowing progression early in the disease (e.g. preservation of cognitive and functional abilities, as well as relative independence) to individuals, their loved ones, and broader society.

A Preliminary Analysis of Stress Burden and Cognitive Function and Clinically Adjudicated Cognitive Outcomes in Black American Adults

BACKGROUND

The combination of exposure to multiple stressors and psychological distress may contribute to the disproportionate burden of dementia risk among Black Americans. This study estimates the effect of an index of stress and psychological distress (ie, "stress burden") on cognitive function and clinically adjudicated cognitive outcomes among older Black American adults, and examines sleep as a mediator.

METHODS

The sample included 204 Black adults (79% female; mean age = 64 years) from Pittsburgh, PA, USA. Stress burden comprised 3 self-reported stress and distress measures assessed in 2016: discrimination, psychological distress, and posttraumatic stress. Potential mediators included actigraphy-assessed sleep duration and efficiency from 2018. Cognitive battery and clinical adjudication in 2019 assessed cognitive function and clinically adjudicated outcomes. Causal mediation analysis estimated the direct effect between stress burden and cognitive outcomes, and indirect effects through sleep, after adjusting for sociodemographics and hypertension.

RESULTS

Higher stress burden had a significant direct effect on lower executive functioning and visuospatial performance. However, there were no significant indirect effects (ie, mediation) by sleep disturbances on any domain of cognitive function assessed. Also, there were no significant direct or indirect effects on clinically adjudicated outcomes.

CONCLUSIONS

Multiple stressors often co-occur and may contribute to racial disparities in cognitive health. Findings suggest that higher stress burden had negative effects on functioning in executive and visuospatial domains in this community-based sample of older Black American adults. However, there was no evidence of mediation by sleep. Findings highlight the importance of continued work to identify modifiable pathways between stress burden and cognitive health disparities.

The determinants of mental health inequalities between Chinese migrants and non-migrants during the Shanghai 2022 lockdown: a Blinder-Oaxaca decomposition

BACKGROUND

The mental health inequality between migrants and non-migrants was exacerbated by the COVID-19 pandemic. Identifying key determinants of this inequality is essential in promoting health equity.

METHODS

This cross-sectional study recruited Shanghai residents by purposive sampling during the city-wide lockdown (from April 29 to June 1, 2022) using an online questionnaire. Migration statuses (non-migrants, permanent migrants, and temporary migrants) were identified by migration experience and by household registration in Shanghai. Mental health symptoms (depression, anxiety, loneliness, and problematic anger) were assessed by self-report scales. The nonlinear Blinder-Oaxaca decomposition was used to quantify mental health inequality (i.e., differences in predicted probabilities between migration groups) and the contribution of expected correlates (i.e., change in predicted probability associated with variation in the correlate divided by the group difference).

RESULTS

The study included 2738 participants (771 [28.2%] non-migrants; 389 [14.2%] permanent migrants; 1578 [57.6%] temporary migrants). We found inequalities in depression (7.1%) and problematic anger (7.8%) between permanent migrants and non-migrants, and inequalities in anxiety (7.3%) and loneliness (11.3%) between temporary migrants and non-migrants. When comparing permanent migrants and non-migrants, age and social capital explained 12.7% and 17.1% of the inequality in depression, and 13.3% and 21.4% of the inequality in problematic anger. Between temporary migrants and non-migrants, age and social capital also significantly contributed to anxiety inequality (23.0% and 18.2%) and loneliness inequality (26.5% and 16.3%), while monthly household income (20.4%) and loss of monthly household income (34.0%) contributed the most to anxiety inequality.

CONCLUSIONS

Significant inequalities in depression and problematic anger among permanent migrants and inequalities in anxiety and loneliness among temporary migrants were observed. Strengthening social capital and economic security can aid in public health emergency preparedness and promote mental health equity among migrant populations.

Alzheimer's Disease and Related Dementias Diagnosis in the United States Among US-Born and Foreign-Born White, Black, Hispanic, and Asian Older Adults

Timely clinical diagnosis of Alzheimer's disease and related dementias (ADRD) is important for resource allocation, mitigating safety concerns, and improving quality of life. While studies have examined ADRD diagnosis disparities by race/ethnicity, few include its intersection with nativity. Our aims were to (1) estimate the odds of diagnosed ADRD among US- and foreign-born racial/ethnic groups compared to US-born White older adults and (2) make comparisons by nativity within each racial/ethnic group. We linked 2000-2017 National Health Interview Survey (NHIS) and 2001-2018 Medical Expenditure Panel Survey (MEPS) data (65 + years; n = 38,033). Race/ethnicity and nativity were measured using NHIS data. Diagnosed ADRD was determined using ICD-9 (290/294/331/797) or ICD-10 (F01/F03/G30/G31) billing codes created from self-reports during MEPS household interviews. Bivariate and multivariable analyses were adjusted for covariates based on Anderson's behavioral model of health services use. US-born Black (OR = 1.74; 95% CI = 1.48-2.05), Hispanic (OR = 1.62; 95% CI = 1.14-2.29), and foreign-born Hispanic (OR = 1.63; 95% CI = 1.24-2.15) older adults, but not foreign-born Black or Asian older adults, had higher odds of diagnosed ADRD compared to US-born White older adults after adjusting for age and sex. After additional adjustment for education, health insurance, usual source of care, and chronic conditions, only US-born Black older adults continued to show higher odds (OR = 1.54; 95% CI = 1.27-1.87) of diagnosed ADRD compared to US-born White older adults. There were no differences in ADRD diagnosis by nativity within each racial/ethnic group. Findings highlight the need for including nativity in studies comparing racial/ethnic groups to Whites to fully capture the ADRD burden among US-born Black older adults.

An outcome-wide analysis of the effects of diagnostic labeling of Alzheimer's disease and related dementias on social relationships

INTRODUCTION

This study examines how receiving a dementia diagnosis influences social relationships by race and ethnicity.

METHODS

Using data from the Health and Retirement Study (10 waves; 7,159 observations) of adults 70 years and older predicted to have dementia using Gianattasio-Power scores (91% accuracy), this study assessed changes in social support, engagement, and networks after a dementia diagnosis. We utilized quasi-experimental methods to estimate treatment effects and subgroup analyses by race/ethnicity.

RESULTS

A diagnostic label significantly increased the likelihood of gaining social support but reduced social engagement and one measure of social networks. With some exceptions, the results were similar by race and ethnicity.

DISCUSSION

Results suggest that among older adults with assumed dementia, being diagnosed by a doctor may influence social relationships in both support-seeking and socially withdrawn ways. This suggests that discussing services and supports at the time of diagnosis is important for healthcare professionals.

Suspected Undiagnosed ADRD Among Middle Eastern and North African Americans

ADRD underdiagnosis among minority populations is well-established and known to be more prevalent among women. Yet, it remains unclear if these patterns exist among adults of Middle Eastern and North African (MENA) descent. We estimated ADRD underdiagnosis among adults of MENA descent and other US- and foreign-born non-Hispanic Whites and compared sex-stratified results. We linked 2000-2017 National Health Interview Survey and 2001-2018 Medical Expenditure Panel Survey data (ages > = 65 years, n = 23,981). Undiagnosed ADRD was suspected if participants reported cognitive limitations without corresponding ADRD diagnosis. Undiagnosed ADRD was highest among adults of MENA descent (15.8%) compared to non-Hispanic Whites (US-born = 8.1%; foreign-born = 11.8%). Women of MENA descent had 2.52 times greater odds (95% CI = 1.31-4.84) of undiagnosed ADRD compared to US-born White women after adjusting for risk factors. This study contributes the first national estimates of undiagnosed ADRD among adults of MENA descent. Continued research is needed to facilitate policy changes that more comprehensively address health disparities and related resource allocation.

Childhood Bullying as a Risk Factor for Late-Life Psychological Distress and Cognitive Impairment

In the United States, non-Hispanic Black (19%) older adults are more likely to develop dementia than White older adults (10%). As genetics alone cannot account for these differences, the impact of historical social factors is considered. This study examined whether childhood and late-life psychological distress associated with dementia risk could explain part of these disparities. Using longitudinal data from 379 White and 141 Black respondents from the Panel Study of Income Dynamics, we assessed the association between childhood bullying and late-life dementia risk, testing for mediation effects from late-life psychological distress. Mediation analysis was computed via negative binomial regression modeling, stratified by race (White/Black), type of bullying experience (target, bully, and bully-target), and the age range at which the experience occurred (6-12, 13-16). The results indicated that late-life psychological distress fully mediated the association between Black respondents who were bullies and dementia risk. However, no significant association was observed among White respondents. These results suggest that interventions aimed at preventing and treating psychological distress throughout the lifespan could be crucial in mitigating the development and progression of dementia risk.

Effects of race, baseline cognition, and APOE on the association of affective dysregulation with incident dementia: A longitudinal study of dementia-free older adults

BACKGROUND

Affective symptoms are dementia risk factors. Mild behavioral impairment (MBI) is a neurobehavioral syndrome that refines incorporation of psychiatric symptomatology into dementia prognostication by stipulating symptoms must emerge de novo in later life and persist for ≥6 months. Here, we investigated the longitudinal association of MBI-affective dysregulation with incident dementia.

METHODS

National Alzheimer Coordinating Centre participants with normal cognition (NC) or mild cognitive impairment (MCI) were included. MBI-affective dysregulation was operationalized as Neuropsychiatric Inventory Questionnaire-measured depression, anxiety, and elation at two consecutive visits. Comparators had no neuropsychiatric symptoms (no NPS) in advance of dementia. Cox proportional hazard models were implemented to assess the risk of dementia, adjusted for age, sex, years of education, race, cognitive diagnosis, and APOE-ε4 status, with interaction terms as appropriate.

RESULTS

The final sample included 3698 no-NPS (age:72.8; 62.7 % female), and 1286 MBI-affective dysregulation participants (age:75; 54.5 % female). MBI-affective dysregulation had lower dementia-free survival (p < 0.0001) and greater incidence of dementia (HR = 1.76, CI:1.48-2.08, p < 0.001) versus no NPS. Interaction analyses revealed that MBI-affective dysregulation was associated with higher dementia incidence in Black participants than White (HR = 1.70, CI:1.00-2.87, p = 0.046), NC than MCI (HR = 1.73, CI:1.21-2.48, p = 0.0028), and APOE-ε4 noncarriers than carriers (HR = 1.47, CI:1.06-2.02, p = 0.0195). Of MBI-affective dysregulation converters to dementia, 85.5 % developed Alzheimer's disease, which increased to 91.4 % in those with amnestic MCI.

LIMITATIONS

MBI-affective dysregulation was not stratified by symptom to further examine dementia risk.

CONCLUSIONS

Emergent and persistent affective dysregulation in dementia-free older adults is associated with substantial risk for dementia and should be considered in clinical assessments.

Suspected undiagnosed ADRD among Middle Eastern and North African Americans

Background ADRD underdiagnosis among minority populations is well-established and known to be more prevalent among women. Yet, it remains unclear if these patterns exist among Middle Eastern and North African (MENA) adults. We estimated ADRD underdiagnosis among MENA and other US- and foreign-born non-Hispanic Whites and compared sex-stratified results. Methods We linked 2000-2017 National Health Interview Survey and 2001-2018 Medical Expenditure Panel Survey data (ages > = 65 years, n = 23,981). Undiagnosed ADRD was suspected if participants reported cognitive limitations without corresponding ADRD diagnosis. Results Undiagnosed ADRD was highest among MENA adults (15.8%) compared to non-Hispanic Whites (US-born = 8.1%; foreign-born = 11.8%). MENA women had 2.52 times greater odds (95% CI = 1.31-4.84) of undiagnosed ADRD compared to US-born White women after adjusting for risk factors. Discussion This study contributes the first national estimates of undiagnosed ADRD among MENA adults. Continued research is needed to facilitate policy changes that more comprehensively address health disparities and related resource allocation.

Culture, Ethnicity, and Level of Education in Alzheimer's Disease

Alzheimer's disease (AD) is the most frequent cause of dementia, where the abnormal accumulation of beta-amyloid (Aβ) and tau lead to neurodegeneration as well as loss of cognitive, behavioral, and functional abilities. The present review analyzes AD from a cross-cultural neuropsychological perspective, looking at differences in culture-associated variables, neuropsychological test performance and biomarkers across ethnic and racial groups. Studies have found significant effects of culture, preferred language, country of origin, race, and ethnicity on cognitive test performance, although the definition of those grouping terms varies across studies. Together, with the substantial underrepresentation of minority groups in research, the inconsistent classification might conduce to an inaccuratte diagnosis that often results from biases in testing procedures that favor the group to which test developers belong. These biases persist even after adjusting for variables related to disadvantageous societal conditions, such as low level of education, unfavorable socioeconomic status, health care access, or psychological stressors. All too frequently, educational level is confounded with culture. Minorities often have lower educational attainment and lower quality of education, causing differences in test results that are then attributed to culture. Higher levels of education are also associated with increased cognitive reserve, a protective factor against cognitive decline in the presence of neurodegeneration. Biomarker research suggests there might be significant differences in specific biomarker profiles for each ethnicity/race in need of accurate cultural definitions to adequately predict risk and disease progression across ethnic/racial groups. Overall, this review highlights the need for diversity in all domains of AD research that lack inclusion and the collection of relevant information from these groups.

Impaired Financial Decision-Making as an Early Indicator of Cognitive Decline: A Commentary

Cognitive impairment and dementia are public health concerns with significant financial implications for both individual households and public insurance systems. Though research has refined diagnostic tools for cognitive impairment and dementia diseases, little attention has focused on how cognitive decline may impact financial security. Research indicates that financial decision-making may be one of the first cognitive abilities impacted by cognitive decline, putting individuals at risk of financial fraud and exploitation. However, financial decision-making is not directly assessed in cognitive screenings. Identification of prodromal decline in financial decision-making may help individuals to preserve their financial security and reduce the likelihood of relying on public benefits. This commentary outlines the need for social workers and researchers to better understand the relationship between cognitive health, financial decision-making, and financial security in later life to formulate culturally responsive strategies that can uphold and benefit financial statuses, especially for minoritized communities.

Dysregulation of Endothelin-1: Implications for Health Disparities in Alzheimer's Disease

Alzheimer's disease (AD) and related dementias disproportionately impact racial and ethnic minorities. The racial and ethnic disparities in AD could be explained by differences in cerebral vascular disease pathology. Endothelin-1 (ET-1) is a potent vasoconstrictive peptide that regulates smooth muscle, endothelial cell, and pericyte contractions that may result in cerebral vascular constriction, leading to cerebral hypoperfusion; over time, ET-1 may result in neuronal injury contributing to the pathology of AD. Upregulation of the ET-1 system has been observed in African Americans when compared with non-Hispanic Whites. The role of the ET-1 system as a driver of ethnic disparities in AD requires further investigation. Targeting of the ET-1 system as a therapeutic intervention that could impact AD progression also needs further study. Dysregulation of ET-1 in Hispanic/Latino populations largely have been unexplored. Genetics linking ET-1 dysregulation and racial disparities in AD also needs further investigation. In this review, I examine how AD effects underserved minority populations and how dysregulation of the ET-1 system specifically predisposes ethnic minorities to AD. In addition, I examine the molecular interactions of the ET-1 system and amyloid beta, the role the ET-1 system in neurodegeneration, potential therapeutics for ET-1 dysregulation, and the impact on AD progression.