Methods and Early Recruitment of a Community-Based Study of Cognitive Impairment Among Mexican Americans and Non-Hispanic Whites: The BASIC-Cognitive Study

A Community-Based Study of Cognitive Impairment Caregiving Outcomes Pre- and During the COVID-19 Pandemic

The impact of the COVID-19 pandemic on informal caregiving was examined in a Mexican American (MA) and Non-Hispanic White (NHW) population-based cohort. 395 participants age > 65 years were recruited via door-to-door and phone recruitment as part of the Brain Attack Surveillance in Corpus Christi-Cognitive (BASIC-C) project. Both recipients and caregivers answered questions regarding the recipient's health and the COVID-19 pandemic. 15% of caregivers saw their caregiving recipient less than before the pandemic and 18% saw their recipient more than before. 55% of caregivers reported a slight to severe impact of the pandemic on their caregiving, and 45% reported no impact. For most caregivers, their caregiving role did not change markedly during the pandemic. MA and NHW caregivers had similar survey responses.

Exploring Pathways to Caregiver Health: The Roles of Caregiver Burden, Familism, and Ethnicity

OBJECTIVES

This study examines the associations of ethnicity, caregiver burden, familism, and physical and mental health among Mexican Americans (MAs) and non-Hispanic Whites (NHWs).

METHODS

We recruited adults 65+ years with possible cognitive impairment (using the Montreal Cognitive Assessment score<26), and their caregivers living in Nueces County, Texas. We used weighted path analysis to test effects of ethnicity, familism, and caregiver burden on caregiver's mental and physical health.

RESULTS

516 caregivers and care-receivers participated. MA caregivers were younger, more likely female, and less educated compared to NHWs. Increased caregiver burden was associated with worse mental (B = -0.53; p < .001) and physical health (B = -0.15; p = .002). Familism was associated with lower burden (B = -0.14; p = .001). MA caregivers had stronger familism scores (B = 0.49; p < .001).

DISCUSSION

Increased burden is associated with worse caregiver mental and physical health. MA caregivers had stronger familism resulting in better health. Findings can contribute to early identification, intervention, and coordination of services to help reduce caregiver burden.

A Community-Based Study of Dementia in Mexican American and Non-Hispanic White Individuals

BACKGROUND

Little information is available on the prevalence of cognitive impairment in Mexican American persons.

OBJECTIVE

To determine the prevalence of mild cognitive impairment (MCI) and dementia in those 65 years and older among Mexican American and non-Hispanic white individuals in a community.

METHODS

This was a population-based cohort study in Nueces County, Texas, USA. Participants were recruited using a random housing sample. The Harmonized Cognitive Assessment (HCAP) participant and informant protocol was performed after Montreal Cognitive Assessment (MoCA) screening. An algorithm was used to sort participants into diagnostic categories: no cognitive impairment, MCI, or dementia. Logistic regression determined the association of ethnicity with MCI and dementia controlling for age, gender, and education.

RESULTS

1,901 participants completed the MoCA and 547 the HCAP. Mexican Americans were younger and had less educational attainment than non-Hispanic whites. Overall, dementia prevalence was 11.6% (95% CI 9.2-14.0) and MCI prevalence was 21.2% (95% CI 17.5-24.8). After adjusting for age, gender, and education level, there was no significant ethnic difference in the odds of dementia or MCI. Those with ≤11 compared with ≥16 years of education had much higher dementia [OR = 4.9 (95% CI 2.2-11.1)] and MCI risk [OR = 3.5 (95% CI 1.6-7.5)].

CONCLUSIONS

Dementia and MCI prevalence were high in both Mexican American and non-Hispanic white populations. Mexican American persons had double the odds of mild cognitive impairment and this was attenuated when age and educational attainment were considered. Educational attainment was a potent predictor of cognitive impairment.

Differential Impact of Stroke on Cognitive Impairment in Mexican Americans and Non-Hispanic White Americans

BACKGROUND

The association between stroke and dementia is well established. Less is known about this association in underrepresented ethnic groups. In a large ethnically diverse cohort, we examined whether history of stroke was associated with cognitive impairment, and whether this relationship differed by ethnicity (Mexican American [MA] versus non-Hispanic White).

METHODS

This was a population-based cohort study conducted in Nueces County, TX, a biethnic community with a large and primarily nonimmigrant MA population. Residents aged ≥65 were recruited door-to-door or by telephone between May 2018 and December 2021. The primary exposure was history of stroke, obtained by self-report. Demographic, medical, and educational histories were also obtained. The primary outcome was the Montreal Cognitive Assessment (MoCA), a scale that evaluates multiple domains of cognitive performance. Scores were divided into 3 ordinal categories, roughly corresponding to normal cognition (MoCA 26-30), mild cognitive impairment (MoCA 20-25), or probable dementia (MoCA 0-19).

RESULTS

One thousand eight hundred one participants completed MoCA screening (55% female; 50% MA, 44% Non-Hispanic White, 6% other), of whom 12.4% reported history of stroke. Stroke prevalence was similar across ethnicities (X2 2.1; P=0.34). In a multivariable cumulative logit regression model for the ordinal cognition outcome, a stroke by ethnicity interaction was observed (P=0.01). Models stratified by ethnicity revealed that stroke was associated with cognitive impairment across ethnicities, but had greater impact on cognition in non-Hispanic Whites (cumulative odds ratio=3.81 [95% CI, 2.37-6.12]) than in MAs (cumulative odds ratio=1.58 [95% CI, 1.04-2.41]). Increased age and lower educational attainment were also associated with cognitive impairment, regardless of ethnicity.

CONCLUSIONS

History of stroke was associated with increased odds of cognitive impairment after controlling for other factors in both MA and Non-Hispanic White participants. The magnitude of the impact of stroke on cognition was less in MA than in Non-Hispanic White participants.

Neighborhood SES and Cognitive Function Among Hispanic/Latinx Residents: Why Where You Live Matters

INTRODUCTION

Few studies have examined the impacts of neighborhood SES and individual ethnicity and SES characteristics on cognitive function in aging populations. Hispanics/Latinx are more likely to have cognitive impairment and be community dwellers than non-Hispanic Whites. Neighborhood factors can have greater impacts on the relationship between Hispanics/Latinx and cognitive function. This study examines these relationships in Nueces County, Texas.

METHODS

A mixed-effects regression analysis of data from 1,140 older adults participating in the Brain Attack Surveillance in Corpus Christi - Cognitive project from 2018 to 2020 was completed. Cognitive function was measured with the Montreal Cognitive Assessment, a cognitive screening measure. Participant addresses were geocoded to obtain census tracts, which were proxies for neighborhoods. Neighborhood SES was measured by household median income, percentage of Hispanic/Latinx residents, and percentage of residents aged ≥65 years with Medicaid, all from the American Community Survey. Interactions were used to examine the impact of neighborhood SES on ethnicity and cognitive function.

RESULTS

The sample consisted of 62.5% Hispanic/Latinx and 37.5% non-Hispanic White participants. Results from the F-statistics, test of effects, indicate that being older (F4,1138=45.04; p<0.001), being a man (F1,1130=4.35; p<0.050), having low education (F3,1121=40.83; p<0.001), completing the Montreal Cognitive Assessment test in Spanish (F1,1140=15.35; p<0.001), and being Hispanic/Latinx (F1,962=20.84; p<0.001) were all associated with lower Montreal Cognitive Assessment scores. Neighborhood income was positively associated (F1,69.6=6.95; p<0.050) with Montreal Cognitive Assessment scores. Neighborhood income (β=0.32; p<0.050) and percentage with Medicaid (β=0.06; p<0.050) independently moderated the associations between ethnicity and Montreal Cognitive Assessment scores.

CONCLUSIONS

Findings suggest that neighborhood SES could further impact cognitive function independent of individual characteristics. This could be attributed to minimal resources in communities with lower SES, impacting policies and programs for older individuals, particularly those with worse cognitive function.

Recruitment of Older Adults With Dementia for Research: An Integrative Review

Recruitment of persons with dementia into research studies is essential to provide evidence for effective care and treatment. However, recruitment is known to be difficult for this population. The current integrative review was undertaken to synthesize evidence surrounding best practices for recruiting older adults with dementia into research. Fourteen studies were identified that examined recruitment strategies for persons with cognitive impairment over a 10-year time period. Most studies were retrospective and descriptive. Studies revealed three facilitators and three barriers for recruitment. Facilitators included community partnerships and trust, incentives, and use of multiple recruitment methods. Barriers included non-targeted recruitment methods, gatekeepers, and mistrust. Further studies, including randomized controlled trials, are needed to determine specific strategies that yield effective recruitment. Theoretically based recruitment strategies need to be defined and tested and the measures of recruitment efforts standardized to compare effectiveness and build a science of recruitment. [Research in Gerontological Nursing, 15(5), 255-264.].

Dementia care needs for individuals and caregivers among Mexican Americans and non-Hispanic Whites

Mexican Americans (MA) are more likely to have cognitive impairment and dementia (CID), be diagnosed at an earlier age and live with CID longer, compared to non-Hispanic Whites (NHW). While studies have examined unmet needs of individuals with CID and their caregivers, few have focused on MA populations in the U.S. This paper examines the needs of community-residing individuals with CID and their caregivers in Nueces County, Texas, a county with one of the largest MA populations in the U.S., while exploring ethnic differences in needs identified. Using concept mapping, a mixed-method approach, qualitative input on perceived needs by informal caregivers and health professionals was collected. Participants then sorted and rated perceived needs. Using this information, multidimensional scaling and cluster analyses were conducted to map the relationship between perceived needs and determine their importance and priority. Five clusters were derived for caregivers and four for the health professionals. Themes across both caregivers and health professionals highlighted the need for specialized and team-based medical care, caregiver support and training, along with socio-economic and physical needs that help with day-to-day care of individuals with CID. Among caregivers, MA rated financial resources as more important and of higher priority compared to NHW. The health professionals' perspectives were aligned with those of all caregivers. By understanding the needs of caregivers and individuals with CID, we can help families deal with this disease and let caregivers thrive. This is especially important for minority populations like MAs.

Differential Relationships Between the Montreal Cognitive Assessment and Informant-Rated Cognitive Decline Among Mexican Americans and Non-Hispanic Whites

OBJECTIVES

We compared the concurrent validity of the Montreal Cognitive Assessment (MoCA) with other cognitive screening instruments among Mexican Americans (MA) and non-Hispanic whites (NHW).

METHODS

In a community-based study in Nueces county, Texas (5/2/18-2/26/20), participants 65+ with MoCA ≤25 completed the Harmonized Cognitive Assessment Protocol. Regressions examined associations between MoCA and: 1) Mini Mental State Examination (MMSE); 2) abbreviated Community Screening Interview for Dementia (CSI-D); 3) Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE).

RESULTS

MA (n = 229) and NHW (n = 81) differed by education but not age or sex. MoCA and cognitive performance associations (MMSE, CSI-D-Respondent) did not differ between MA and NHW (p's > .16). MoCA and informant rating associations (IQCODE, CSI-D-Informant) were stronger in NHW than MA (NHW R² = 0.39 and 0.38, respectively; MA R² = 0.30 and 0.28, respectively).

DISCUSSION

Our findings suggest non-equivalence across cognitive screening instruments among MAs and NHWs.

Lack of Any Caregiving for Those with Dementia

Older adults with significant cognitive impairment require help with activities of daily living. The BASIC-Cognitive Project, set in Nueces County, Texas, is a community-based study examining trends in cognition among Mexican Americans and non-Hispanic Whites. Using cross-sectional data from a cohort study, we found that at least 7% of individuals aged 65 and older with a Montreal Cognitive Assessment (MoCA) score of < 20 (or < 15 for telephone MoCA), did not receive any caregiving help. This conservative estimate highlights an important community need for those with significant cognitive impairment and has implications regarding safety and care for older adults.

Mexican Americans Participate in Research More than Expected while non-Hispanic Whites Participate Less than Expected

OBJECTIVE

To identify Hispanic/Latinx and non Hispanic White participation rates in a community-based project using door-to-door recruitment.

METHODS

We conducted a two-stage area probability sample of housing units in Nueces County, Texas, using Census data including Mexican Americans (MAs) and non-Hispanic Whites (NHWs). From May 2018-February 2020, residents over 64 were asked to take a cognitive screen. We compared expected and observed ethnic-specific participation.

RESULTS

Nearly a thousand (996) participants enrolled. Accounting for sampling error, the observed count of MAs (n=609) significantly exceeded expectations ([inline-graphic 01], [95% CI: 521,542]). The observed count of NHWs (n=387) was less than expected ([inline-graphic 02], [95% CI: 455, 473]. The sub-group with the largest difference in observed vs. expected participants was MA women, n=376 observed, 306 (95% CI: 300, 312) expected.

CONCLUSIONS

Mexican Americans were significantly more likely to participate than expected, challenging the notion that ethnic minority populations are less likely to agree to research.

Bilingualism, assessment language, and the Montreal Cognitive Assessment in Mexican Americans

BACKGROUND/OBJECTIVES

Assessment of cognition in linguistically diverse aging populations is a growing need. Bilingualism may complicate cognitive measurement precision, and bilingualism may vary across Hispanic/Latinx sub-populations. We examined the association among bilingualism, assessment language, and cognitive screening performance in a primarily non-immigrant Mexican American community.

DESIGN

Prospective, community-based cohort study: The Brain Attack Surveillance in Corpus Christi (BASIC)-Cognitive study.

SETTING

Nueces County, Texas.

PARTICIPANTS

Community-dwelling Mexican Americans age 65+, recruited door-to-door using a two-stage area probability sampling procedure.

MEASUREMENTS

Montreal Cognitive Assessment (MoCA); self-reported bilingualism scale. Participants were classified as monolingual, Spanish dominant bilingual, English dominant bilingual, or balanced bilingual based upon bilingualism scale responses. Linear regressions examined relationships among bilingualism, demographics, cognitive assessment language, and MoCA scores.

RESULTS

The analytic sample included 547 Mexican American participants (60% female). Fifty-eight percent were classified as balanced bilingual, the majority (88.6%) of whom selected assessment in English. Balanced bilinguals that completed the MoCA in English performed better than balanced bilinguals that completed the MoCA in Spanish (b = -4.0, p < 0.05). Among balanced bilinguals that took the MoCA in Spanish, education outside of the United States was associated with better performance (b = 4.4, p < 0.001). Adjusting for demographics and education, we found no association between the degree of bilingualism and MoCA performance (p's > 0.10).

CONCLUSION

Bilingualism is important to consider in cognitive aging studies in linguistically diverse communities. Future research should examine whether cognitive test language selection affects cognitive measurement precision in balanced bilinguals.