Health Disparities In Dementia4

Current Reality and Estimated Predications for Future

By: Shannon Marling, CTRS/ VCU Graduate Student of Gerontology Tracey Gendron, MSG Instructor/ Clinical Coordinator

VCU Department of Gerontology

S1

Minorities are the fastest growing segment of the older adult population 65 & older Between 1990-2030 population projected increases 600%

11

555%

500% 400%

328%

300%

300% 200% 100%

160% 93%

0% White

Non-White

Hispanics

African-American Asian and Pacific (non-Hispanic) Islanders

Slide 2 S1

United States Represents indiviudals from 17 spanish speaking countries Asian Americans represent at least 20 different countries and 60 distinct ethnicities SMarling, 10/23/2009

S1

Percentages of Minorities within the US Population by Selected Age Groups: 2010-2050 70 60

54

50 40

45

49

54 45

58

62 55

49

46

40

50 42

40

35

35

35 29

30

20

20

24

10 0

All Ages

Under 18 yrs 2010

Source: Population Division: US Census Bureau Released: August 14, 2008

2020

2030

18-64 yrs 2040

2050

65+

Slide 3 S1

based on population projections, immigration projections and estimates vary with in resources ranges go upwards to 50 or more of population SAHPAdmin, 10/26/2009

Projections of the Population by Race and Hispanic Origin for the United States: 2008-50 (Resident population as of July 1. Numbers in thousands) Race and Hispanic Origin1 Total Population One race White Black AIAN Asian NHPI Two or more races

2008 2010 2015 2020 2025 2030 2035 2040 2045 2050 304,228 310,233 325,540 341,387 357,452 373,504 389,531 405,655 422,059 439,010 299,076 304,734 319,105 333,913 348,831 363,621 378,263 392,875 407,640 422,828 242,803 246,630 256,306 266,275 276,281 286,109 295,729 305,247 314,852 324,800 39,031 39,909 42,137 44,389 46,594 48,728 50,810 52,868 54,911 56,944 3,076 3,188 3,472 3,759 4,039 4,313 4,590 4,875 5,167 5,462 13,599 14,415 16,527 18,756 21,109 23,586 26,169 28,836 31,577 34,399 564 592 662 734 808 885 965 1,048 1,134 1,222 5,151 5,499 6,435 7,474 8,620 9,883 11,268 12,781 14,418 16,183

Non-Hispanic White alone

199,804 200,853 203,208 205,255 206,662 207,217 206,958 206,065 204,772 203,347

Hispanic Race alone or in combination:2 White Black AIAN Asian NHPI

46,697

49,726

57,711

66,365

75,772

85,931

96,774 108,223 120,231 132,792

247,261 251,400 261,922 272,835 283,890 294,881 305,782 316,707 327,840 339,441 41,098 42,163 44,906 47,748 50,626 53,519 56,453 59,454 62,534 65,703 4,855 5,025 5,463 5,907 6,342 6,770 7,204 7,654 8,119 8,592 15,519 16,472 18,952 21,586 24,385 27,352 30,472 33,722 37,090 40,586 1,118 1,176 1,325 1,480 1,643 1,814 1,993 2,181 2,376 2,577

1

Hispanics may be of any race. 'In combination' means in combination with one or more other races. The sum of the five race groups adds to more than the total population because individuals may report more than one race. Abbreviations: Black = Black or African American; AIAN = American Indian and Alaska Native; NHPI = Native Hawaiian and Other Pacific Islander 2

Note: The original race data from Census 2000 are modified to eliminate the “some other race” category. This modification is used for all Census Bureau projections products and is explained in the document entitled “Modified Race Data Summary File Technical Documentation and ASCII Layout” that can be found on the Census Bureau website at http://www.census.gov/popest/archives/files/MRSF-01-US1.html Source: Population Division, U.S. Census Bureau; Release Date: August 14, 2008

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Estimates of Dementia in United States  The Aging, Demographic, and Memory Study

(ADAMS) study estimated the total number of individuals in the United States with dementia to be 3.8 million17  According to the Alzheimer’s Association 2009 Facts and Figures Report  5.3 Million persons of all ages are affected with Alzheimer’s

disease (AD)  1 in 8 individuals 65 and older have AD  Every 70 seconds a person is diagnosed with the disease, this is forecasted to become every 33 seconds

 Between 2000- 2025 State and Regional

percentages of increase in the number of individuals with AD will be in the double digits21

Slide 5 S2

Some regions will experience as much as a 30-50% increase of individuals with AD Asian Americans are missing from this slide , important to notice that minorities are effected at a greater rate, appears to espeically be true in the 85 and older adult range SMarling, 10/27/2009

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Types of dementia among Whites, Blacks, Hispanics and Asians from Nine Alzheimer’s Disease Diagnostic and Treatment Centers20

Slide 6 S4

Study from 4 california memory clinics and reflective of national trends on disease prevelance and ethnicities, higher rate of vascular dementia in African Americans and hispancis SAHPAdmin, 10/26/2009

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Prevalence of Dementia for Hispanics  One study suggested that barriers to health care access may

significantly delay diagnosis and treatment in the Hispanic population Hispanics living in the US diagnosed with AD3 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0

2009

2050

Slide 7 S5

Last bullet- important to mention because delay of diagnosis and treatment can skew the prevelance data numbers, we also know that it was not until about 1993 that educational material was developed or targeted to the hispanic population so there is a delay in education for this community Dr. Pyles and Dr maximfield will go further into detail on this topic, we also kno SAHPAdmin, 10/26/2009

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Prevalence of Dementia for African American  AD often referred to as the “Silent Epidemic” among African

Americans due to a disproportionally high rate of diagnosis of the disease  African American older adults are reported to have a higher rate

of AD and vascular dementia in a diagnostic screening and assessment17  African Americans have a greater filial risk for developing AD  Misdiagnosis and under-diagnosis is likely to occur in

Non-Hispanic blacks with dementia

Slide 8 S4

- sepaking on bullet # 2 as compared to white non-hispanci cumulative risk for the development of AD appears to be higher in AA, 60% higher risk of type 2 diabiteis, found to have higer rates of hypertension - #4 mis-diagnosi and under diagnoisi is going to skew the data meaning we may not be getting a clear picture of the actual numbers SMarling, 10/27/2009

S7

Prevalence of Dementia for Asian American Population  There is a gap in the literature and research in regard to

Asian American population affected with dementia  Asian American elders show a greater prevalence of

dementia than the general population  Controlling for lifetime prevalence of mental illness, Asian

Americans are less likely to use mental health services than white Americans

Slide 9 S7

the gap in literature is starting to close regarding Asian Americans, even articles as recent as 2008 indicated there still remains a gap in reseach and literature Medicare did not have a catorgory for Asians until the 1990, prior to that it was White, Black and Other Asian Americans are often discoruaged from participating in research SAHPAdmin, 10/26/2009

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Why is misdiagnosis and under-diagnosis more likely to occur among minority groups?  Variables related to culture, race and education that underlie ethnic group differences on cognitive test performance  One study found that older adults who have limited health literacy were significantly less likely to have a primary physician or source of care16  Acculturation – the level at which people participate in the values, language and practices of their own ethnic community verses those of the dominant community  One study found that a disconnect existed between the language being used by medical professionals and African Americans accessing services6  Poor assessment tools with cultural and ethnic bias's may result in false–positive screening, especially for African Americans  Asian Americans and African Americans have shown through studies to hold the cultural view that dementia is “normal” part of the process of aging12

Slide 10 S5

Language has a huge influence on diagnosis and has been reported by several groups to be an issue in diagnosis and access to services- with regard to assesment procedures and tool, language has been experienced by some ethnic groups as culturally inappropriote and at times even racsist MMSE cut off of 23 has lead to an over diagnosis of dementia among AA - last bullet- aa who viewed dementia as normal part of the aging process were found in two memeory clincis to access services 5-7 years the firs signs of dementia - early intervention leads to increase in care, decrease in cost, decrease in care giver burden SMarling, 10/27/2009

S8

Racial and Ethnic Disparities in Accessing Care  Stigmatization of severe and chronic mental illness have been

identified as a factors that heavily influences health disparities in Asian Americans

 Among individuals age 65 and older:  Asians have the highest rate of un-insurance 6%, compared to  Hispanics 5%  Blacks 1%, and  White .02 %1

 Older adults with a 6th grade reading level are twice as likely to have at

least three indicators of poor health care access16

 Hispanics have the lowest education levels of any group in the United

States

Slide 11 S8

- number 3- one resource indicated that 47% of the population is considered functionally illiterate SAHPAdmin, 10/26/2009

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Racial and Ethnic Disparities in Accessing Care  The 2006 National Health Care Disparities Report (NHDR)

found that a lower quality of care was received by Asians as compared to whites for a one third of the measures that were tracked in the report2  African Americans have been underrepresented in clinical

trials for potential treatments for AD  Some studies have suggested that genetic risk factors for AD

are different among ethnicities and that environmental factors may differently affect and interact with genetic factors

Slide 12 S3

bullet number 2- minorities in general have been found to be less likely to be presribed anit-dementia medications- is this because there is less eperical data available? meaning these factors interact differently in the causes of AD, with out enough reseach reasons for this remain unclear SMarling, 10/27/2009

Reference List:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21.

R. D. Williams, (2004) “Medicare and Communities of Color”, Medicare Brief no.11, Washington National Academy of Social Insurance, November. Moy, E., Greenburg, L., Borsky, A. (2008) Community Variation: Disparities In Health Care Quality Between Asian And White Medicare Beneficiaries. Health Affairs, 27(2). Alzheimer's Association (2004). Hispanics/Latinos and Alzheimer’s Disease. Bernstein, A., Remsburg, R. (2007). Estimated Prevalence of People With Cognitive Impairment; Results from Nationally Representative Community and Institutional Surveys. The Gerontologist, 47(3), 350-354. Byrd, L., Fletcher, A., Menifield, C. (2007). Disparities in Health Care: Minority Elders at Risk. ABNF Journal, 51-55. Clark, PP., Kutner, N., Goldstein, F., Peterson-Hazen, S., Garner, V., Zhang, R., Bowles, T. (2005). Impediments to Timely Diagnosis of Alzheimer’s Disease in African Americans. Journal of American Geriatrics Society, 53, 2012-2017. Coogle, C. Caregiver Education and Service Utilization in African American Families Dealing with Dementia. Perspectives, 141-152. Daker-White, G., Beattie, A., Gillard, J., Means, R. (2002). Minority ethnic groups in dementia care: a review of service needs, service provision and models for good practice. Ageing and Mental Health, 6(2), 101-108. Manly, J., Espino, D. (2004). Cultural influences on dementia recognition and management. Clinics in Geriatric Medicine, 20, 93-119. Fenley, R., Bobers, S., Powell, M., Berman, J., Altman, B. (2008). Effects of Alzheimers on Multi-Cultural Person Care Aides. Care Management Journals, 9(1), 4-10. Fitten, J., Ortiz, F., Ponton, M. (2001). Frequency of Alzheimer’s disease and Other Dementia in a Community Outreach Sample of Hispanics. Journal of American Geriatrics Society, 49,1301-1308. Graves, A., Larson, E., Edland, S., Bowen, J., McCormick, W., McCurry, S., Rice, M., Wenzlow, A., Uomoto, J. (1996). Prevalence of Dementia and its Subtypes in the Japanese American Population of King County, Washington State. American Journal of Epidemiology, 144(8), 760-771. Herbert, L., Scherr, P., Bienias, J., Bennett, D., Evans, D. (2003). Alzheimer Disease in the US Population. Achieves of Neurology, 60(8)1119-1122. Liu, D., Hinton, L., Tran, C., Hinto, D., Baker, J. (2008). Reeamining the Relationships Among Dementia, Stigma and Aging in Immigrants and Vietnamese Family Caregivers. Cross Cultural Gerontology, 23,283-299. Masel, M., Peek, K. (2009). Ethnic Differences in Cognitive Function Over Time. AEP (Article still in press). Sudore, R., Mehta, K., Simonsick, E., Harris, T., Newman, A., Satterfield, S., Rosano, C., Rooks, R., Rubin, S., Ayonayon, H., Yaffe, K. (2006). Limited Literacy in Older People and Disparities in Health and Health Care Access. Journal Of American Geriatrics Society ,54,770-776. Plassman, B., Langa, K., Fisher, G., Heeringa, S., Weir, D., Ofstedal, M., Burke, J., Hurd, M., Potter, G., Rodgers, W., Steffens, D., Willis, R., Wallace, R. (2007). Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study. Neuroepidemiology, 29, 125-132. Trinh, N-H., Ahmed, I. (2009). Handbook of mental health and acculturation in Asian American families, 167-178 Valle, R., Yamada, AM., Matiella, A.. (2006). Footnovelas. Clinical Gerontologist, 30(1) 71-88. Yeo, G., Gallager-Thomas. Ethnicity & the Dementias. 1996, Washington, Taylor & Frances. Alzheimer's Association, (2009) Alzheimer's Disease Facts & Figures Report . Mixed Sources