Yulin Chu, N.P.

Racial Disparity in AD
Per U.S. Department of Health and Human Services (HHS) (2013) reports, some populations are unequally burdened by Alzheimer’s disease (AD), including racial and ethnic minorities. According to Alzheimer’s Association (AA) reports, the likelihood of developing AD and other dementias is overall at two times more likely for African Americans and about 1.5 times more likely for Hispanics than whites (U.S. Medicine, 2010).

In the past decade, many studies in the U. S. reported the similar results.  Hispanics had an earlier age of onset (Alzheimer symptoms may strike Latinos almost seven years before white Americans) and greater severity of Alzheimer’s symptoms at their initial evaluation.African Americans had a slightly older age at disease onset but higher levels of cognitive impairment and dementia than whites at their initial evaluation. African-Americans aged 55 to 64 years were more than three times as likely to have AD as their European American counterparts. The disparity grows as age increases (AA, 2004; U.S. Medicine, 2010).  However, these ethnic and racial differences in AD prevalence are not consistent from community to community and may result from environmental factors, such as less education or income, poorer diets, or reduced access to health care.

Health, Socioeconomic, and Education Factors
We’ve long known that African Americans and Hispanics have a higher risk of AD than white Americans. But we’ve never had a clear explanation—until now. At the AA International Conference in Boston, socioeconomic factors are blamed for that disparity (Sathian, 2013). Socioeconomic factors play a role in the mental deterioration associated with aging. Findings from the Health Recovery Services show that having a low level of education, having a low income and having lived in a rural area as a child are all more common in people with cognitive impairment than in people with normal cognition, regardless of race or ethnicity. According to the report, African Americans and Hispanics make up a disproportionately large number of the socioeconomically disadvantaged people in the US, with both groups showing a lower income level and lower education level than their white counterparts (US Medicine, 2010).

According to the report, there are no known genetic factors that explain the greater prevalence of AD and other dementia in African Americans and Hispanics. However, conditions such as high blood pressure, heart disease, stroke and diabetes are known risk factors for AD and are more common in both groups than in whites (Sathian, 2013; US Medicine, 2010).  Findings from the 2006 Health and Retirement Study show that high blood pressure was more common in people aged 55 and older with cognitive impairment than in those with normal cognition in each of the three broad racial and ethnic groups. The same relationship exists between cognitive status and heart disease, diabetes and stroke (US Medicine, 2010). The report goes on to note that high BP and diabetes are treatable conditions that, if addressed early in life, could reduce the prevalence of AD later in life.

The studies found that African-American participants with lower levels of education had poorer cognitive function and physical function (leg strength, balance, and walking speed) compared with similarly educated whites. More years of education were associated with better physical and cognitive health in both groups, and the positive effect of 12 years of education was similar for both groups (NIH, 2013). Among whites with cognitive impairment, 47% had less than 12 years of education compared with only 11% of those with normal cognition (US Medicine, 2010).  Interestingly, additional years of education beyond high school had a significantly greater positive impact on physical and cognitive health in old age for African-Americans than for whites. Those with the highest levels of educational attainment enjoyed similar levels of cognitive health and physical function in old age. The study suggests that achieving greater levels of higher education in minorities might be helpful in reducing health disparities in old age (NIH, 2012).

Gender Disparities in AD
Almost two-thirds of Americans with AD are women. Scientists believe that the gender difference in Alzheimer’s prevalence results primarily from differences in lifespan. Because AD is an age-related disease and women typically live longer than men, women may simply be more likely to survive long enough to develop the disorder (NIH, 2012). However, past research suggests that women on average suffer from more severe symptoms of AD than men. In addition, a study of a large Minnesota population found that men age 70 to 84 developed MCI, a possible precursor to AD, at substantially higher rates than women of the same ages (Roberts et al., 2012). The leaders of that study speculate that the AD process begins earlier in men than it does in women, but women decline more rapidly once the disease process starts.

Gender differences in other health factors may also contribute to the increased risk and/or severity of AD in women. Alzheimer’s disease impacts women disproportionately with regard to care giving. Women do most of the care giving for family members with the disorder (more than 70 percent of the unpaid caregivers for people with AD and other forms of dementia are women), and they suffer a greater burden of related stress and depression (Carter et al., 2012).  At the same time, women who themselves suffer from Alzheimer’s receive less care and social support than do men with the disorder. The data also suggest that husbands who are caregivers show greater physiological risk than do their peers who are not caregivers, with higher rates of obesity, triglycerides, blood pressure reactivity to acute stressors, and poorer immune function. In contrast, such differences are not as great between wives who are caregivers and wives who are not (NIH, 2012).

Cultural Factors to Perpetuate Disparities in AD
Regarding culturally correlated factors that perpetuate inequity in AD, Dilworth-Anderson (2012) focus on four salient disparities and social justice issues in the management of AD:
1.  Differences in perception about the causes of AD: Perceptions of dementia, particularly myths and fallacies, negatively affect early access, diagnosis, and treatment of AD. Having dementia was perceived by some Latinos as being “crazy” or having “bad blood” (Gallagher-Thompson, et al., 1997). Asian families often have stigmatizing perspectives and meanings attached to dementia (Lui, et al., 2008).
2.  Disparities in screening to validate the existence of the disease: Ethnic and cultural bias in current screening and assessment tools is well documented (AA, 2011). Stephenson et al. (2001) reported that bias in screening tests have been shown to disproportionately misclassify as many as 42 percent of black Americans without dementia as being demented versus only 6 percent of whites. These differences reflect an overestimation of AD and dementia diagnoses among blacks and a bias in the current data and literature. At the same time, there is substantial evidence of underreporting of dementia among African Americans.
3.  Disparities in timing of diagnosis of the disease: Early diagnosis of AD allows medical professionals to intervene and treat a number of symptoms as soon as individuals begin to show signs of Alzheimer’s disease. Teng (2002) reported that key factors in misdiagnosis of dementia include language barriers and interpretation and low levels of education among elders.
4.  Disparities in access to care to treat the disease. After the onset of early AD, they face barriers to obtain diagnoses and service, and they are less likely to participate research program either due to lack of knowledge or fear of unethical treatment in history (AA, 2004).

These four risk factors are interconnected in creating and perpetuating disparities among older minority Americans and impacting health outcomes. The literature is inadequate in explaining the critical question of why caregivers, especially minorities, underutilize services that are needed and may be within reach (Dilworth-Anderson, 2012).

Actions towards Eliminating Disparities
From the above information, we understand that the health disparities in AD are preventable. Most of the causes of these disparities can be eliminated. Helping to eliminate health disparities and creating a more socially justice will require that we not only speak about cultural competency, but take con¬crete steps toward this process. 1. We should know and understand the culture influence to the disparities and provide education to public regarding the barriers among the elderly minorities. 2. There is a need to highlight the health disparities and issues of social injustice among our most vulnerable populations such as the elderly (Dilworth-Anderson, 2012). As DNP or Ph.D. students, we should make public aware of the health disparities in AD and to draw public attention in exposure and explanation about this critical issue.  3. We should emphasize the risk factors in perpetuating disparities among older minorities and impacting health outcomes.
 
References
Alzheimer’s Association (5/2010). Changing the trajectory of AD. alz.org. Retrieved from http://www.alz.org/alzheimers-disease-trajectory.asp
Alzheimer’s Association (5/18/2004). Hispanics/Latinos and Alzheimer’s disease. olz.org. Retrieved from http://www.alz.org/national/documents/report-hispanic.pdf
Alzheimer’s Association (2011). Alzheimer’s disease facts and figures.  Alzheimer’s & Dementia, 7 (2).
Carter, C. L., Resnick, E., Mallampalli, M., Kalbarczyk, A. (2012). Sex and gender differences in Alzheimer’s disease: recommendations for future research. Journal of Women’s Health, 21(10), 1018-1023.
Dilworth-Anderson, P. (2012). Social Justice, health disparities, and culture in the care of the elderly.  Journal of Law, Medicine & Ethics, Spring, 2012.
Gallagher-Thompson, D., Leary, M. C. Ossinalde, C., Romero, J. J., Wald, M. J., & Fernandez-Gamarra, E.  (1997). Hispanic Caregivers of Older Adults with Dementia: Cultural Issues in Outreach and Intervention.  Group 21(2), 211-232.
Lui, D., Hinton, L., Tran, C., Hinton, D., Baker, J. C. (2008). Reexamin¬ing the Relationships Among Dementia, Stigma, and Aging in Immigrant Chinese and Vietnamese Family Caregivers.  Journal of Cross Cultural Gerontology 23(3), 283-289.
Roberts, R. O., Geda, Y. E., Knopman, D. S., Cha, R. H., Pankratz, V. S., Boeve, B. F., Tangalos, E. G., Ivnik, R. J., Rocca, W. A., Petersen, R. C. (2012). The incidence of MCI differs by subtype and is higher in men: the Mayo Clinic Study of Aging. Neurology, 78(5), 342-351
Sathian, S. (2013). Socioeconomic disparities account for higher Alzheimer’s risk in African-Americans. Daily Dose, 7/15/2013. Retrieved from http://www.boston.com/lifestyle/health/blogs/daily-dose/2013/07/15/socioeconomic-disparities-account-for-higher-alzheimer-risk-african-americans/EhUlbTNtlCqQhNJAtTmt0K/blog.html
Stephenson, J.  (2001). Racial barriers may hamper diagnosis, care of patients with Alzheimer disease.  American Medical Association 286 (7), 779-780.
Teng, E. (2002). Cultural and educational factors in the diagnosis of dementia.  Alzheimer Disease and Associated Disorders 16 (2), S77-S79.
U.S. Department of Health and Human Services. (2013). National Plan to Address Alzheimer’s Disease: 2013 Update [Adobe Digital Editions version]. Retrieved from http://aspe.hhs.gov/daltop/napa/NatlPlan2013.pdf
U. S. Medicine. (4/2010). Racial Disparities Among Alzheimer Patients Cause Concern.
Marathon Medical Communications, Inc.   Retrieved from http://www.usmedicine.com/articles/racial-disparities-among-alzheimer-patients-cause-concern.html#.UmmzY4fD8dU