Social class, dementia and the fourth age

Report on the Joint Workshop on the Relations between Health Inequalities, Ageing and Multimorbidity, Iceland, May 3-4, 2023

This paper is a summary of key presentations from a workshop in Iceland on May 3-4, 2023 arranged by Aarhus University and with participation of the below-mentioned scientists. Below you will find the key messages from the presentations made by: Professor Jan Vandenbroucke, Department of Clinical Epidemiology, Aarhus University, Emeritus Professor, Leiden University; Honorary Professor, London School of Hygiene & Tropical Medicine, UKProfessor, Chair Henrik Toft Sørensen, Department of Clinical Epidemiology, Aarhus University and Aarhus University Hospital, DenmarkProfessor David H. Rehkopf, Director, the Stanford Center for Population Health Sciences, Stanford University, CA., USProfessor Jaimie Gradus, Department of Epidemiology, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Johan Mackenbach, Emeritus Professor, Department of Public Health, Erasmus University Rotterdam, HollandProfessor, Chair M Maria Glymour, Department of Epidemiology, Boston University School of Public Health, Boston University, Boston, Massachusetts, USProfessor, Dean Sandro Galea, School of Public Health, Boston University, Boston, Massachusetts, USProfessor Victor W. Henderson, Departments of Epidemiology & Population Health and of Neurology & Neurological Sciences, Stanford University, Stanford, CA, US; Department of Clinical Epidemiology, Aarhus University, Aarhus, DK.

Social class and the risk of dementia: A systematic review and meta-analysis of the prospective longitudinal studies

BACKGROUND

The association between belonging to a disadvantaged socio-economic status or social class and health outcomes has been consistently documented during recent decades. However, a meta-analysis quantifying the association between belonging to a lower social class and the risk of dementia has yet to be performed. In the present work, we sought to summarise the results of prospective, longitudinal studies on this topic.

METHODS

We conducted a systematic review and meta-analysis of prospective, longitudinal studies measuring the association between indicators of social class and the risk of all-cause/Alzheimer's dementia. The search was conducted in four databases (Medline, Embase, Web of Science and PsychInfo). Inclusion criteria for this systematic review and meta-analysis were: (a) longitudinal prospective study, (b) aged ⩾60 years at baseline, (c) issued from the general population, (d) no dementia at baseline and (e) mention of social class as exposure. Exclusion criteria were: (a) study of rare dementia types (e.g. frontotemporal dementia), (b) abstract-only papers and (c) articles without full text available. The Newcastle-Ottawa scale was used to assess the risk of bias in individual studies. We calculated the overall pooled relative risk of dementia for different social class indicators, both crude and adjusted for sex, age and the year of the cohort start.

RESULTS

Out of 4548 screened abstracts, 15 were included in the final analysis (76,561 participants, mean follow-up 6.7 years (2.4-25 years), mean age at baseline 75.1 years (70.6-82.1 years), mean percentage of women 58%). Social class was operationalised as levels of education, occupational class, income level, neighbourhood disadvantage and wealth. Education (relative risk (RR)=2.48; confidence interval (CI) 1.71-3.59) and occupational class (RR=2.09; CI 1.18-3.69) but not income (RR=1.28; CI 0.81-2.04) were significantly associated with the risk of dementia in the adjusted model. Some of the limitations of this study are the inclusion of studies predominantly conducted in high-income countries and the exclusion of social mobility in our analysis.

CONCLUSIONS

We conclude that there is a significant association between belonging to a social class and the risk of dementia, with education and occupation being the most relevant indicators of social class regarding this risk. Studying the relationship between belonging to a disadvantaged social class and dementia risk might be a fruitful path to diminishing the incidence of dementia over time. However, a narrow operationalisation of social class that only includes education, occupation and income may reduce the potential for such studies to inform social policies.

BRAINCODE for Cognitive Impairment Diagnosis in Older Adults: Designing a Case-Control Pilot Study

An early, extensive, accurate, and cost-effective clinical diagnosis of neurocognitive disorders will have advantages for older people and their families, but also for the health and care systems sustainability and performance. BRAINCODE is a technology that assesses cognitive impairment in older people, differentiating normal from pathologic brain condition, based in an EEG biomarkers evaluation. This paper will address BRAINCODE's pilot design, which intends to validate its efficacy, to provide guidelines for future studies and to allow its integration on the SHAPES platform. It is expected that BRAINCODE confirms a regular clinical diagnosis and neuropsychologic tests to discriminate 'normal' from pathologic cognitive decline and differentiates mild cognitive impairment from dementia in older adults with/without subjective cognitive complains.

Socioeconomic Inequality in the Use of Long-Term Care among European Older Adults: An Empirical Approach Using the SHARE Survey

The increase in the proportion of elderly people in developed societies has several consequences, such as the rise in demand for long-term care (LTC). Due to cost, inequalities may arise and punish low-income households. Our objective is to examine socioeconomic inequalities in LTC utilization in Europe. We use the last wave from the Survey of Health, Aging, and Retirement in Europe SHARE (Munich Center for the Economics of Ageing, Munich, Germany), dated 2017, to analyze the impact of socioeconomic status (SES) on LTC. For this purpose, we construct logistic models and control for socioeconomic/household characteristics, health status, and region. Then, concentration indices are calculated to assess the distribution of LTC. Moreover, we also analyze horizontal inequity by using the indirect need-standardization process. We use two measures of SES (household net total income and household net wealth) to obtain robust results. Our findings demonstrate that informal care is concentrated among low-SES households, whereas formal care is concentrated in high-SES households. The results for horizontal concentration indices show a pro-rich distribution in both formal and informal LTC. We add new empirical evidence by showing the dawning of deep social inequalities in LTC utilization. Policymakers should implement policies focused on people who need care to tackle socioeconomic inequalities in LTC.

Dementia as a source of social disadvantage and exclusion

OBJECTIVE

To explore perceptions of the impacts of dementia on people living with the condition and those close to them and examine the relationship between dementia, disadvantage and social exclusion.

METHODS

Semi-structured in-depth interviews were conducted with 111 participants: people with dementia (n = 19), carers (n = 28), health-care professionals (n = 21), social workers (n = 23) and service professionals (n = 20). NVivo 11 was used to code descriptions and identify impact areas.

RESULTS

Participants described social, psychological, carer, material, service-based and disparity impacts associated with the experience of dementia. Some of these impacts correspond to social exclusion associated with age, but some are distinctive to dementia.

DISCUSSION

It is argued that dementia generates its own forms of social disadvantage and exclusion. This is in addition to being subject to structural risk factors. The implications of the active effects of dementia as a social phenomenon should give rise to new policy and practice priorities.

Analyzing the chance of developing dementia among geriatric people: a cross-sectional pilot study in Bangladesh

AIM

Alzheimer's disease is the most common form of dementia, representing 60-80% of cases, and ageing is the primary risk factor for the development of Alzheimer's disease. The objective of this study was to examine the chance of developing dementia (i.e. mild cognitive impairment (MCI), Alzheimer's disease) among geriatric people in Bangladesh.

METHODS

This study included 390 adult citizens of Bangladesh (age range: 60-70 years). The Takeda Three Colors Combination (TTCC) test was used to detect the prevalence of MCI and mild dementia among the subjects, and then the Clinical Dementia Rating was used to determine the level of dementia.

RESULTS

The subjects who were aged 60-65 years included 154 with MCI, 76 with mild dementia, 1 with moderate dementia, 4 with severe dementia, and 29 without dementia. The subjects who were aged 66-70 years included 75 with MCI, 36 with mild dementia, 0 with moderate dementia, 2 with severe dementia, and 13 without dementia. The sensitivity of the TTCC was 75% and 58% for the mild dementia and MCI groups, respectively, and the specificity was 52%. The odds ratio of incorrect responses to the TTCC was 3.42 (95% confidence interval: 1.63-7.21) for subjects with mild dementia compared those without dementia. However, the TTCC outcomes revealed no significant differences between the MCI and non-dementia groups. The results showed no significant associations between cognitive decline/developing dementia and social status/occupation.

CONCLUSION

The outcomes of this study indicated that most of the subjects had MCI or mild dementia and were farmers aged 60-65 years.

Cultural representations of dementia

In a Perspective, Alexandra Hillman and Joanna Latimer discuss cultural representations of dementia in the media, film, and literature.