Racial and Ethnic Differences in the Health of Older Americans (1997) / Chapter Skim
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8 Differences in Rates of Dementia Between Ethno-Racial Groups
8 Differences in Rates of Dementia Between Ethno-Racial Groups
Pages 233-269
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From page 233... ...
Most noticeably, there is advancing impairment in the performance of the tasks of everyday living including managing personal business, shopping, cooking, dressing, feeding, and toileting. Extreme dependency on family and other care givers eventually supervenes, insight is lost, wandering and other disturbing behaviors emerge, frailty increases, and life is shortened.
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From page 234... ...
In most nursing homes and in many home care programs, longer term clients are predominantly people with dementias. Prevalence rates of dementia are low in the age group 65 to 74 but increase rapidly with age, roughly doubling with each decade and culminating in rates reported to be as high as 40 percent or more for those surviving beyond age 85.
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From page 235... ...
Typically this evaluation is carried out in a clinic equipped for conduct of an inquiry into presenting symptoms and signs, a history of the onset and course of the illness, a battery of psychological tests, general and neurological physical examination, and general and specific special investigations including brain imaging. Clinical judgment and/or algorithms are then applied to the accumulated information to make a diagnosis of dementia with reference to operational diagnostic criteria.
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From page 236... ...
Among community residents aged 65 years and older, African Americans have been found to have a higher prevalence of a diagnosis of dementia, especially vascular dementias, than non-Hispanic whites (Heyman et al., 1991~. Researchers have found concordant results using cognitive scores as an indicator of dementia, validated by diagnosis of a subsample (Folstein et al., l991~.
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From page 237... ...
The North Manhattan Aging Project and the Active Life Expectancy Study have jointly established a registry of people with dementia, stroke, and Parkinson's disease. The registry draws from a network of key informants (reporting component)
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From page 238... ...
In the reporting component, which began in 1989, study staff repeatedly scrutinize records of subjects reported to be living in or entering service sites that are known to have a high rate of dementia, such as nursing homes, home care programs, and certain neurological clinics; staff members also receive referrals according to specified criteria from key informants in a wide variety of health, social, and community sites. If a person is eligible by present or (in nursing homes)
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From page 239... ...
There is no overlap between these frames: only the Medicare list was used for elders at home, and only the nursing home list was used for elders in nursing homes. This sampling procedure is more accurate than the alternative of tracing elders not found at home to a location in a nursing home (although this was done as a mutual check on the completeness of the frames)
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From page 240... ...
We assembled a compendium instrument incorporating five widely used screens for cognitive impairment and dementia and tested it in the reporting component of the North Manhattan Aging Project. We obtained the best operating characteristics on this population from the Comprehensive Assessment and Referral Evaluation cognitive screen (Golden et al., 1984; Teresi et al., 1984)
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From page 241... ...
The two main subtypes of dementia have suggestive clinical and brain imaging indicators, but neuropathology must ultimately be combined with the in vivo signs in order to reach a definitive diagnosis. All subjects who screen positive and a proportion of subjects who fall below the critical threshold score on the screen, in both the reporting and the survey components of the registry, are referred blind for diagnostic evaluation by the research teams.
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From page 242... ...
The informant interview (again, in the survey component only) covers a similar range of information on the subject's current functioning and historical information on the course of the subject's symptoms; it is obtained independently and blind to the subject interview.
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From page 243... ...
The size and severity of the worst level were set to make possible useful comparisons with major depression (the most severe diagnostic category of clinical depression in the standard nomenclature) , and the combined size and severity of the two worst levels (intolerable and desperate affective suffering)
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From page 244... ...
is defined as impairment that, in the reporting component of the registry, predicted criterion diagnosis in about half the instances overall, with a probability between about 30 percent and 70 percent for the scores within this range. Since rates depend in part on how broad a concept of dementia is used, we refer to both advanced dementias and border-zone dementias when comparing ethno-racial groups.
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From page 245... ...
Service utilization and outcome differences might be best understood by issues of language, church affiliations, family constellations, neighborhood structures, and the matching ethno-racial health care arrangements. Definitions taken from the Random House Dictionary of the English ~ Language (Random House, 1966)
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From page 246... ...
Illiterate or marginally literate persons are disproportionately encountered in minority groups, but because they perform poorly on standardized screening instruments, they have been excluded from some studies or inadvisably combined with the next higher educational group. We documented income by having the subject (or an informant)
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From page 247... ...
Overrepresentation Sampling strategies led to overrepresentation of certain subgroups, those 75 years of age or older, non-Hispanic whites, and persons in nursing homes. Wherever appropriate, we have weighted the numbers in the cells formed by ethno TABLE 8-2 Sizes of Samples of Subjects Interviewed by Age and EthnoRacial Groups Hispanic African American White Nursing Community Home (N = 676)
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From page 248... ...
NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area; there was a proportionate group in nursing homes, N= 40. Diagnosis was made by research clinical evaluation or was generated from the probability of a diagnosis based on screen scores, which could be a decimal number.
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From page 249... ...
The age of onset was alleged to be earlier for Hispanic and AfricanAmerican groups than for non-Hispanic whites: the onset of impairments after age 84 was 8 percept, 20 percent, and 40 percent, respectively. If this information is accurate, it might in part account for the relatively lower rates of dementia among the non-Hispanic whites since a later onset leaves a shorter duration of time for the condition to exist.
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From page 250... ...
NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area. Only those elders who have a research clinical evaluation are included.
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From page 251... ...
NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area; there was a proportionate group in nursing homes, N= 40. Diagnosis was made by research clinical evaluation or was generated from the probability of a diagnosis based on screen scores.
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From page 252... ...
A multivariate regression analysis of education on rates of dementia, with age, income, gender, and ethno-racial membership taken into account is shown in Table 8-3. In this regression analysis, income for certain nursing home residents could not be reliably ascertained.
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From page 253... ...
Note: The sample was restricted to 27 subsamples of community residents (65 year and older) , N= 1,449, from the North Manhattan Aging Project target area.
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From page 254... ...
from the North Manhattan Aging Project target area. often the underlying disorder even when manifestations suggest diagnosis of another subtype.
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From page 255... ...
For all ethno-racial groups, the level of impairment increases regularly from people who are normal to those with border-zone nondementias to those with border-zone dementias. In Hispanic and African-American groups, people with advanced dementia continue this progression.
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From page 256... ...
NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area; there was a proportionate group in nursing homes, N= 40. Only the elderly who have a research clinical evaluation are included.
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From page 257... ...
NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area. Only the elderly who have a research clinical evaluation are included.
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From page 258... ...
Since the frame for the sampling was drawn from Medicare lists, all subjects in the North Manhattan Aging Project and the Active Life Expectancy Study samples have Medicare insurance. It is estimated that more than 95 percent of the population 65 years or older resident in the target area, and more than 90 percent of any of the ethnoracial groups, are enrolled in Medicare.
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From page 259... ...
Desperate FIGURE 8-6 Affective suffering in stages of cognitive impairment. NOTE: The sample was restricted to 27 subsamples of community-residing elders, 65 years and older, N= 1,449, from the North Manhattan Aging Project target area.
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From page 260... ...
, N = 1,449, from the North Manhattan Aging Project target area. Diagnosis was made by research clinical evaluation or was generated from the probability of diagnosis based on screen scores.
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From page 261... ...
These situations resulted in a smaller group of non-Hispanic whites with dementia than planned. In this presentation, the reporting component of the registry for Alzheimer' s disease and related disorders has been combined with the survey component in order to amass a representative sample of elders from both community settings and nursing homes.
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From page 262... ...
Ethno-Racial Variation in Prevalence Rates Non-Hispanic whites have dramatically lower rates of dementia than the other two ethno-racial groups. These relative rates remain consistent for concepts of dementia of varying breadth: for advanced dementia taken alone, when border-zone dementia is also included, and even if nondementia with cognitive impairment is taken into account.
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From page 263... ...
A1though there are ethno-racial differences in the types of memory problems that are the content of complaints, the increase of memory complaints in dementia is consistent for all ethno-racial groups. An excess frequency of intolerable and desperate levels of affective suffering was also found in the two dementia categories: this excess is much greater in the non-Hispanic whites and is least in the African Americans.
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From page 264... ...
Hispanics and African Americans with dementia are much less likely than non-Hispanic whites with dementia to be admitted to a nursing home. Preference for, and reliance on, home care of people with dementia rather than nursing home admission is stronger for Hispanics and African Americans than for nonHispanic whites.
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From page 265... ...
North Manhattan Aging Project, National Institute on Aging (principal investigator Barry Gurland, coprincipal investigator David Wilder) , Project 5 P01 AG7232-04.
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From page 266... ...
. Other staff members of the North Manhattan Aging Project were Virginia Barrett, Betty Barsa, Mabel Bolivar, Harold Browne, Jean Denaro, Priscilla Encarnacion, Mana Gonzalez, Lucia McBee, and Jeanne Teresi.
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From page 267... ...
Mayeux 1995b Relative rates of dementia by multiple case definitions, over two prevalence periods, in three cultural groups. American Journal of Geriatric Psychiatry 3:6-20.
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From page 268... ...
Blizard, and A Mann 1990 The Gospel Oak Study: Prevalence rates of dementia, depression and activity limitation among elderly residents in inner London.
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From page 269... ...
Wilder, and R.G. Bennett 1984 Construct validity of indicator-scales developed from the Comprehensive Assessment and Referral Evaluation interview schedule.
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