INFORMATION FOR HEALTH CARE PROFESSIONALS
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PREVALENCE/RISK FACTORS
Chen
CP.Transcultural
expression of subcortical vascular disease.J
Neurol Sci 2004 Nov 15; Vol. 226 (1-2), pp. 45-7.OBJECTIVE:
To describe variations in the epidemiology of stroke and dementia, the
recognition of dementia as an entity across cultures, the cultural
specificity of screening tools and assessment instruments, and cultural
influences on the management of stroke and dementia. RESULTS: Several
studies have pointed out differences in the subtypes and outcomes from
stroke across different world regions. Notably, non-Western populations
may have a higher rate of hemorrhage, whilst in ischemic stroke
subcortical vascular disease is predominant. A low prevalence of
dementia has been demonstrated in many studies of non-Western
populations. Factors proposed to account for this include protective
family attitudes, a lower frequency of ApoE4 and the high mortality of
non-Western dementia subjects, which may mask a high age-specific
incidence rate. Other medical factors such as training, diagnostic
skills, the availability of investigations and healthcare provision may
also play a role, as would patient specific cultural attitudes towards
ageing and mental health, together with differences in language, social
customs and literacy. It has been suggested that there is a major
difference between Western and Asian nations in the ratio of vascular
dementia to Alzheimer disease. However, few epidemiological field
studies have utilized neuroimaging and the reported rates for particular
diagnoses should be interpreted cautiously. A recent population study in
Japan, which utilized screening by neuropsychologists and CT scanning,
showed that vascular dementia accounted for nearly half the cases of
dementia. Subcortical vascular disease accounts for the majority of
patients with vascular dementia (VaD).
Weiner M, Rosenberg et. al. Comparison of Alzheimer’s Disease in Native Americans and Whites International Psychogeriatrics 2003 Dec;15(4): This study compared medical history and findings on initial clinical examination in Native Americans diagnosed with possible or probable Alzheimer’s disease (AD) at Native American satellite clinics of the University of Texas (UT) Southwestern Medical Center’s Alzheimer’s Disease Center with those of Whites diagnosed with probable AD at the UT Southwestern Medical Center’s Alzheimer’s Disease Clinic. Results: In relation to Whites, Native Americans had slightly but significantly greater age at onset of symptoms (71.7 vs. 69.6 years, t = -2.08, p = .04) and equivalent cognitive scores at evaluation (Mini-Mental State Exam score = 17.4 vs. 18.5, t = 0.98, p = .33), despite significantly lower educational level (11.4 vs. 13.4 years, t = 5.63, p < .001). Native Americans were more frequently depressed on examination (22.8% vs. 9.5%, χ2 = 12, p = .001) and reported diabetes, hypertension, and heart disease significantly more often than did Whites (p < .01 for all), but their survival time after AD diagnosis was similar to that of Whites despite these comorbidities. Conclusions: With the exception of a greater prevalence of depression and cardiovascular risk factors in Native Americans than in Whites, Native Americans had a course of illness similar to that of Whites.
Husaini
BA, Sherkat DE, Moonis M, Levine R, Holzer C, Cain VA.
Racial
differences in the diagnosis of dementia and in its effects on the use
and costs of health care services.
Psychiatr Serv.
2003 Jan;54(1):92-6 This study
examined differences in the prevalence of dementia among a random sample
of Medicare beneficiaries (N=33,680)
by race and gender as well as racial differences in
the effects of dementia on the use and costs of health care services. .
RESULTS: Diagnoses of dementia were significantly more prevalent among
African-American beneficiaries than among white beneficiaries (5 percent
compared with 3.9 percent). Persons with dementia had higher rates of
health service use, particularly for inpatient care, and
African-American persons with dementia had the highest levels of service
use. Health care costs were also significantly higher for African
Americans with a diagnosis of dementia. Among patients of either race,
costs were substantially higher among those with comorbid psychiatric
conditions. CONCLUSIONS: Racial differences in the prevalence of
dementia are clearly evident. Race also plays a role in the effects of
dementia on the use and costs of health services, with higher rates of
expensive inpatient care among African Americans.
Zetterberg H, Wahlund LO, Blennow K. Cerebrospinal fluid markers for prediction of Alzheimer's disease. Neurosci Lett. 2003 Nov 27; 352(1): 67-9. A major diagnostic challenge when people seek advice for cognitive dysfunction is to differentiate between mild cognitive impairment (MCI) and incipient Alzheimer's disease (AD). We show that a combination of three cerebrospinal fluid biochemical markers, total-tau, phospho-tau and beta-amyloid(1-42), can detect incipient AD among patients fulfilling the criteria for MCI with a sensitivity of 68% (95% CI 45-86%) and a specificity of 97% (95% CI 83-100%). The usefulness of these markers is further emphasized by the finding of a positive predictive value of 94% and a negative predictive value of 81%.
Hendrie HC, Osuntokun BO, Hall KS,
Ogunniyi AO, Hui SL, Unverzagt FW, Gureje O, Rodenberg CA, Baiyewu O,
Musick BS. Prevalence of Alzheimer's disease and dementia in two
communities: Nigerian Africans and African Americans. Am J Psychiatry.
1995 Oct;152(10):1485-92 OBJECTIVE: This article reports on a
prevalence study of dementia and Alzheimer's disease among residents
aged 65 years and older in two communities: Yorubas (N = 2,494) living
in Ibadan, Nigeria, and African Americans (N = 2,212 in the community
and N = 106 in nursing homes) living in Indianapolis, Indiana. RESULTS:
The age-adjusted prevalence rates of dementia (2.29%) and Alzheimer's
disease (1.41%) in the Ibadan sample were significantly lower than those
in the Indianapolis sample, both in the community-dwelling subjects
alone (4.82% and 3.69%, respectively) and in the combined nursing home
and community samples (8.24% and 6.24%, respectively). The prevalence
rates of dementia and Alzheimer's disease increased consistently with
advancing age in both study groups. CONCLUSIONS: This study reports significant differences in rates of dementia
and Alzheimer's disease in two different communities with similar ethnic
origins.
Haan MN, Mungas DM, Gonzalez HM, et
al. Prevalence of dementia in
older latinos: the influence of type 2 diabetes mellitus, stroke and
genetic factors. : J Am Geriatr Soc. 2003 Feb;51(2):169-77.OBJECTIVES:
To estimate dementia prevalence in older Mexican Americans (N=1789),
determine the distribution of dementia by etiology, and evaluate the
contribution of type 2 diabetes mellitus, stroke, and apolipoprotein E (ApoE)
genotype to dementia.
RESULTS: Overall dementia prevalence was 4.8%. Prevalence in those aged
85 and older was 31%. Education and Anglo cultural orientation was
negatively associated with dementia risk. Risk of dementia was nearly
eight times higher in those with both type 2 diabetes mellitus and
stroke. Forty-three percent of dementia was attributable to type 2
diabetes mellitus, stroke, or a combination of the two. ApoE allele
frequency was E2 5.9%, E3 90.1%, and E4 4%. Those with any E4 and 4-4
combinations had a higher risk for dementia than those with the E3-3
combination. CONCLUSIONS:
Dementia prevalence in this ethnic group is similar to that reported in
Canadian and European studies but lower than in Caribbean-Hispanics
residing in the United States. The etiological fraction of dementia
attributable to type 2 diabetes mellitus and stroke is substantial and
points toward the need for intervention research and treatment with the
goal of reducing neurological sequelae in groups with high prevalence of
type 2 diabetes mellitus.
Huang ZB, Neufeld RR, Likourezos A et
al. Sociodemographic
and health characteristics of older Chinese on admission to a nursing
home: a cross-racial/ethnic study.
OBJECTIVES: To investigate sociodemographic characteristics (SDCs) and
health status of older Chinese newly admitted to a nursing home (NH) in
New York City r near Chinatown. PARTICIPANTS: Two hundred fifty-eight
(125 Chinese, 57 white, 53 Hispanic, and 23 black) of 292 residents
consecutively admitted from November 1992 to May 1997. RESULTS: The
majority of these Chinese were first-generation immigrants
and spoke primarily Cantonese or Mandarin Chinese. Compared with whites,
they were more likely to be married, less likely to have lived alone,
more likely to be using Medicaid, less likely to make medical decision
alone, and more likely to depend on family members for decision-making.
Nearly three-quarters of Chinese had cognitive impairment. There was an
underdiagnosis of dementia in the Chinese subjects on admission. Severe
dependence in activity of daily living was identified in more than
one-third of Chinese. Fewer Chinese were using psychotropic medications
on admission than the whites. Similar to other groups, many of the
Chinese subjects were incontinent of bowel and bladder and had chewing
or swallowing problems, hypertension, anemia, and stroke. CONCLUSION:
TThese findings suggest that Chinese residents are as frail as other
racial/ethnic residents on admission. NHs caring for older Chinese need
to be sensitive to the presence of dementia, and require a staff that
can speak Cantonese and Mandarin Chinese and is comfortable negotiating
with families who are more likely to be the designated decision makers.
Fitten
LJ, Ortiz F, Ponton M. Frequency of Alzheimer's disease and
other dementias in a community outreach sample of Hispanics. J
Am Geriatr Soc 2001 Oct;49(10):1301-8
In nonrandom community outreach sample utilizing established criteria
for the diagnosis of dementia type, the authors reported that forty percent of subjects
had had undiagnosed cognitive symptoms for 3 or more years. Of those
demented, 38.5% had AD and 38.5% met criteria for Vascular Dementia(
VascD). The best predictors of VascD were hypertension and cerebrovascular
disease, whereas apolipoprotein E4 allele best predicted AD. Twenty
percent of the sample was clinically depressed but not demented. CONCLUSIONS:
This sample of Hispanic patients compared to white patients had lower
rates of AD and higher rates of VascD than expected. The percentage
of clinically depressed older individuals was also high. These findings
could have implications for differential cultural and genetic risk factors
for dementia among diverse ethnic/racial groups.
Green RC, Cupples LA, Go R et al. Risk of dementia among white and African American relatives of patients with Alzheimer disease. JAMA 2002 Jan 16;287(3):329-36. Evidence exists that the incidence of Alzheimer disease (AD), as well as risk attributable to specific genetic factors such as apolipoprotein E (APOE) genotype, may vary considerably among ethnic groups. Family studies of probands with AD offer an opportunity to evaluate lifetime risk of dementia among relatives of these probands. OBJECTIVE: To compare lifetime dementia risk estimates among relatives of white and African American probands with probable or definite AD. CONCLUSION: First-degree relatives of African Americans with AD have a higher cumulative risk of dementia than do those of whites with AD. However, in this study, the additional risk of dementia conferred by being a first-degree relative, by being female, or by the probability of having an APOE epsilon4 allele appeared similar in African American and white families. These data provide estimates of dementia risk that can be used to offer counseling to family members of patients with AD.
Gurland BJ, Wilder DE, Lantigua R et al. Rates of dementia in three ethnoracial groups. Int J Geriatr Psychiatry. 1999 Jun;14(6):481-93. Rates of dementia may vary among ethnoracial groups. Randomly selected elderly persons from each of three ethnoracial groups (Latinos, African-Americans, non-Latino Whites) residing in northern Manhattan in New York City were screened for dementia. RESULTS: Age-specific prevalence of dementia was found to be higher in Latinos and African-Americans than in non-Latino Whites; incidence rates were consistent with this finding. Ethnoracial groups did not vary in the proportion of dementias diagnosed as Alzheimer's disease. However, level of education was strongly associated with rates of dementia and, when age and education were simultaneously controlled, the ethnoracial differences in rates were not consistently found. CONCLUSIONS:. The higher rates found in Latino and African-American groups, relative to non-Latino Whites, are associated with clear and substantial functional dependencies and hence have important implications for qualities of life and service needs.
Tang MX, Stern Y, Marder K et al. The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. JAMA. 1998 Mar 11;279(10):751-5. OBJECTIVE: To investigate in this prospective study, from 1991-1996, the association between the APOE-epsilon4 allele and AD in elderly African Americans, Hispanics, and whites. PARTICIPANTS: A total of 1079 Medicare recipients without AD or a related disorder at baseline a community in New York City. RESULTS: Compared with individuals with the APOE-epsilon3/epsilon3 genotype, the relative risk (RR) of AD associated with 1 or more copies of the APOE-epsilon4 allele was significantly increased among whites (RR, 2.5; 95% confidence interval [CI], 1.1-6.4), but not among African Americans (RR, 1.0; 95% CI, 0.6-1.6) or Hispanics (RR, 1.1; 95% CI, 0.7-1.6). In the absence of the APOE-epsilon4 allele, the cumulative risks of AD to age 90 years, adjusted for education and sex, were 4 times higher for African Americans (RR, 4.4; 95% CI, 2.3-8.6) and 2 times higher for Hispanics (RR, 2.3; 95% CI, 1.2-4.3) than for whites. In the presence of an APOE-epsilon4 allele, the cumulative risk of AD to age 90 years was similar for individuals in all 3 ethnic groups. CONCLUSION: The presence of an APOE-epsilon4 allele is a determinant of AD risk in whites, but African Americans and Hispanics have an increased frequency of AD regardless of their APOE genotype. These results suggest that other genes or risk factors may contribute to the increased risk of AD in African Americans and Hispanics.
Green RC, Cupples LA, Go R Risk of dementia among white and African American relatives of patients with Alzheimer disease. JAMA 2002 Jan 16;287(3):329-36 OBJECTIVE: To compare lifetime dementia risk estimates among relatives of white and African American probands with probable or definite AD.DESIGN AND SETTING: Risk analysis using data collected by questionnaire and supplemental records between May 1991 and March 2001 at 17 medical centers contributing to the Multi-Institutional Research in Alzheimer's Genetic Epidemiology Study. PARTICIPANTS: A total of 17 639 first-degree biological relatives and 2474 spouses of 2339 white AD probands, and 2281 first-degree biological relatives and 257 spouses of 255 African American AD probands. CONCLUSION: First-degree relatives of African Americans with AD have a higher cumulative risk of dementia than do those of whites with AD. However, in this study, the additional risk of dementia conferred by being a first-degree relative, by being female, or by the probability of having an APOE epsilon4 allele appeared similar in African American and white families. These data provide estimates of dementia risk that can be used to offer counseling to family members of patients with AD.
NEUROBIOLOGY
PEI-JUNG LU*,
GERBURG WULF*, XIAO ZHEN ZHOU* et al.The
prolyl isomerase Pin1 restores the function of Alzheimer-associated
phosphorylated tau protein.
Nature 1999; 399: 784 - 788
One of the neuropathological
hallmarks of Alzheimer's disease is the neurofibrillary tangle, which
contains paired helical filaments (PHFs) composed of the
microtubule-associated protein tau. Tau is hyperphosphorylated in PHFs,
and phosphorylation of tau abolishes its ability to bind microtubules
and promote microtubule assembly,. Restoring the function of
phosphorylated tau might prevent or reverse PHF formation in Alzheimer's
disease. Phosphorylation on a serine or threonine that precedes proline
(pS/T–P) alters the rate of prolyl isomerization and creates a binding
site for the WW domain of the prolyl isomerase Pin1 (refs 8,9,10,11,
12,13,14). Pin1 specifically isomerizes pS/T–P bonds and regulates the
function of mitotic phosphoproteins,. Here we show that Pin1 binds to
only one pT–P motif in tau and co-purifies with PHFs, resulting in
depletion of soluble Pin1 in the brains of Alzheimer's disease patients.
Pin1 can restore the ability of phosphorylated tau to bind microtubules
and promote microtubule assembly in vitro. As depletion of Pin1
induces mitotic arrest and apoptotic cell death, sequestration of Pin1
into PHFs may contribute to neuronal death. These findings provide a new
insight into the pathogenesis of Alzheimer's disease.
SYMPTOM PATTERNS
Hinton L, Haan M, Geller S, Mungas
D. Neuropsychiatric symptoms in Latino
elders with dementia or cognitive impairment without dementia and
factors that modify their association with caregiver depression.
Gerontologist. 2003 Oct;43(5):669-77. The purpose of this study
was to determine neuropsychiatric symptom frequency and intensity in
demented and cognitively impaired but not demented Latino elderly
persons, evaluate whether overall neuropsychiatric symptom intensity is
associated with higher levels of caregiver depression, and identify
factors that modify the relationship between neuropsychiatric symptoms
and caregiver depression. RESULTS: For most neuropsychiatric
symptoms, prevalence and intensity were significantly higher in the
demented group compared with the CIND group. The overall
neuropsychiatric symptom intensity score was significantly associated
with caregiver depression. The strength and direction of the association
of neuropsychiatric symptoms with caregiver depression was found to vary
by three factors: whether the caregiver was the care recipient's spouse,
whether the care recipient had dementia or CIND, and the care
recipient's age. IMPLICATIONS: Neuropsychiatric symptoms may play a
significant role in caregiver depression among Latino families. However,
the impact of neuropsychiatric disturbances on Latino caregivers may
differ depending on characteristics of both the caregiver and care
recipient.
Bassiony MM, Warren A, Rosenblatt A
et. al. Isolated hallucinosis
in Alzheimer's disease is associated with African-American race. Int
J Geriatr Psychiatry 2002 Mar;17(3):205-10. OBJECTIVES: The
aim of this investigation was to study the relationship between isolated
hallucinosis and race in Alzheimer's disease. CONCLUSIONS:
African-American patients with Alzheimer's disease are more likely to
have isolated hallucinations than Caucasian patients even after
statistical adjustment for multiple confounding variables, which might
distort this association. This finding has implications for our
understanding of the etio-pathogenesis of hallucinations in Alzheimer's
disease and for meeting health service needs of African-American
patients.
ASSESSMENT
Raymond L. Ownby, Dylan G.
Harwood et al.
Factor Structure of the Cornell Scale for Depression in
Dementia for Anglo and Hispanic Patients With Dementia
. Am.
J. Geriatr. Psychiatry 2001 9: 217-224 The authors assessed the
equivalence of the factor structure of the Cornell Scale for
Depression in Dementia (CSDD) in samples of Anglo and
Hispanic patients with Alzheimer's disease (AD). Analyses
showed overall similarity in the CSDD factor structure for
the two groups but also revealed differences in factor
content for several items. The authors discuss the relevance
of these differences for those using the CSDD with Hispanic
AD patients.
COMORBID ILLNESS
Teresi JA, Abrams R, Holmes D et al. Influence of Cognitive
Impairment, Illness, Gender, and African-American Status on Psychiatric
Ratings and Staff Recognition of Depression Am. J. Geriatr.
Psychiatry 2002 10: 506-514 The authors examined the multivariate
relationships between depression recognition by staff members
and characteristics of nursing home residents. African
Americans were generally seen by psychiatrists as having less
depressive symptomatology than residents from other
ethnic groups. The data
suggest that nurse aides, perhaps because they see residents
more often or because they are less influenced by demographic
characteristics, may be the most valid source of information
about residents' depression. In contrast, after partialing
out the degree of depression severity, nurses tended to
overrecognize depression among African-American residents.
Social workers underrecognized depression among residents
with cognitive impairment and/or Parkinson disease and among
women, and overrecognized depression among African Americans.
CAREGIVING
Hallen WE,
Gitlin LN et al. Well-being, appraisal, and coping in African-American
and Caucasian dementia caregivers: findings from the REACH study.The
current study utilized participants from four sites of the REACH
(Resources for Enhancing Alzheimer's Caregiver Health) multi-site study
to compare well-being, appraisal, and religious coping by race.
African-American (n = 295) and Caucasian (n = 425) dementia caregivers
from four cities (Birmingham, Memphis, Boston, and Philadelphia) were
compared in their demographics, care recipient characteristics, mental
and physical health, and psychosocial coping resources including
appraisal and religious coping. African-American caregivers reported
lower anxiety, better well-being, less use of psychotropic medications,
more benign appraisals of stress and perceived benefits of caregiving,
and greater religious coping and participation, than Caucasian
caregivers. Self-rated health did not differ by race, but
African-American caregivers reported more unhealthy behaviors than
Caucasian caregivers
Ayelon
L, Arean A. Int J Geriatric Psychiatry
ObjectivesThe
present study evaluated knowledge of Alzheimer's disease (AD) in four
ethnic groups of older adults. MethodsNinety-six Anglo, 37 Latino, 30
Asian, and 30 African American older adults completed a short survey
about AD. Results:Results indicated that Anglo older adults are
significantly more knowledgeable about AD than African American, Asian,
and Latino older adults. Level of education partially accounted for
differences in knowledge of AD between Latino to Anglo older adults.
After controlling for age, number of years of speaking English was
associated with knowledge of AD in Asian older adults. Conclusions:The
results suggest that certain ethnic minority groups do not have
sufficient information about AD, and this may explain the lack of AD
service use by minorities. Extensive evaluation of barriers to knowledge
of AD is needed in order to specifically target minority groups and
educate them about AD and the importance of early intervention
Zhan
L. J Gerontol Nurs] 2004 Aug; Vol. 30 (8), pp. 19-29.The purpose of
this study was to examine the experiences of Chinese American caregivers
who provide care for family members with Alzheimer's disease (AD).
Individual interviews were conducted with four family caregivers.
Results revealed ethnocultural and structural barriers that Chinese
family caregivers experienced, including stigmatization of AD in the
Chinese community, a lack of knowledge about AD, a lack of culturally
and linguistically appropriate AD services, nega tive interactions with
health-care providers, and difficulty with English. This study vides
cultural knowledge and insights nurses who care for AD clients and their
fam ilies. Overcoming barriers and working with Chinese American
families and their community are needed to improve access and dementia
services for Chinese American patients and their families.
Aranda MP, Villa VM, Trejo L, Ramirez R, Ranney M.El Portal Latino Alzheimer's Project: model program for Latino caregivers of Alzheimer's disease-affected people. Soc Work. 2003 Apr; 48(2): 259-71.The article describes the El Portal Latino Alzheimer's Project--a dementia-specific outreach and services program targeting Latino caregivers in the Los Angeles County area. The project is an example of an interorganizational community-based collaborative developed to provide an array of coordinated, ethnic-sensitive services to Latino dementia-affected adults and their family caregivers, using culturally specific outreach and services delivery strategies. Results of an evaluation of service utilization indicate a reduction in barriers to care and an increase in services utilization. Los Angeles County provides a natural urban laboratory to study the special needs and circumstances of older Latinos dealing with chronic and debilitating illnesses. Implications for social work practice are discussed.
Hinton L, Haan M, Geller S, Mungas D. Neuropsychiatric symptoms in Latino elders with dementia or cognitive impairment without dementia and factors that modify their association with caregiver depression. Gerontologist. 2003 Oct; 43(5): 669-77.PURPOSE: The purpose of this study was to determine neuropsychiatric symptom frequency and intensity in demented and cognitively impaired but not demented Latino elderly persons (N=95), evaluate whether overall neuropsychiatric symptom intensity is associated with higher levels of caregiver depression, and identify factors that modify the relationship between neuropsychiatric symptoms and caregiver depression. RESULTS: For most neuropsychiatric symptoms, prevalence and intensity were significantly higher in the demented group compared with the CIND group. The overall neuropsychiatric symptom intensity score was significantly associated with caregiver depression. The strength and direction of the association of neuropsychiatric symptoms with caregiver depression was found to vary by three factors: whether the caregiver was the care recipient's spouse, whether the care recipient had dementia or CIND, and the care recipient's age. IMPLICATIONS: Neuropsychiatric symptoms may play a significant role in caregiver depression among Latino families. However, the impact of neuropsychiatric disturbances on Latino caregivers may differ depending on characteristics of both the caregiver and care recipient.
Covinsky KE, Newcomer R, Fox P, Wood J, Sands L, Dane K, Yaffe K.
Patient and caregiver characteristics associated with
depression in caregivers of patients with dementia J Gen Intern Med.
2003 Dec; 18(12): 1006-14.OBJECTIVE: The goal of this study was to
determine the characteristics of 5627 patients and their caregivers
which were associated with depression among caregivers of patients with
dementia at 8 locations in the United States. RESULTS: 32% of caregivers
reported 6 or more symptoms of depression and were classified as
depressed. Independent patient predictors of caregiver depression
included younger age white and Hispanic ethnicity (OR, ,
lower education, greater ADL dependence and behavioral disturbance,
particularly angry or aggressive behavior Independent caregiver
predictors of depression included low income, being female spouse,
hours spent caregiving and functional dependence (. CONCLUSION:
Caregiver depression is a complex process, influenced by ethnicity as
well as diverse patient and caregiver characteristics. Efforts to
identify and treat caregiver depression will need to be
multidisciplinary and focus on multiple risk factors simultaneously.
Owen JE, Goode KT, Haley WE. End of life care and reactions to death in African-American and white family caregivers of relatives with Alzheimer's disease. Omega (Westport). 2001;43(4):349-61. The present study addresses ethnic differences in the experience of AD caregivers around the time of their loved one's death, including life-sustaining treatment decisions and reactions to death. Compared with White caregivers, African-American caregivers were less likely to make a decision to withhold treatment at the time of death, less likely to have their relative die in a nursing home, and reported less acceptance of the relative's death and greater perceived loss. Results suggest that death after AD caregiving deserves further study, and that ethnic differences in end of life care and bereavement may be of particular importance.
McCormick
WC, Ohata CY, Uomoto J et.al. Similarities
and differences in attitudes toward long-term care between Japanese
Americans and Caucasian Americans. : J Am Geriatr Soc. 2002
Jun;50(6):1149-55. The purpose of this study was to compare
attitudes toward the use of long-term care between older Japanese
Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When
presented with a hypothetical situation in which they have dementia, 39%
of older Japanese Americans and 42% of older Caucasians intended to be
cared for at home, whereas 53% versus 38%, respectively, intended to use
nursing home care (P <.001). The subjects' perceptions of what
their families, friends, ministers, and communities would want them to
choose differed, with more uncertainty among Caucasians (P <.001). For
provision of home care, Japanese Americans were more likely to rely on
loved ones than Caucasians, who were more likely to rely on paid
providers.Being married lowered the odds of intending to use nursing
homes in any situation. We conclude that Caucasian Americans intend to
use paid home health care at higher rates than Japanese Americans if
they become disabled by dementia. Japanese Americans demonstrated more
certainty about the influences of others on their opinions, suggesting a
more stable cultural norm in this population, and intended to use more
nursing home care in the event of permanent debility (dementia).
Roth DL, Haley WE, Owen JE, et al. Latent growth models of the longitudinal effects of dementia caregiving: a comparison of African American and White family caregivers. Psychol Aging 2001 Sep;16(3):427-36. Self-report measures of depression, physical health symptoms, and life satisfaction were collected over a 2-year period from 197 family caregivers of dementia patients and 218 noncaregivers (controls). Latent growth models were used to compare changes across time for African American and White caregivers, with gender, age, and socioeconomic status serving as covariates. Results indicated that White caregivers sustained higher levels of elevated depression and decreasing life satisfaction over time compared with African American caregivers. Both groups of caregivers reported increases in physical symptoms over time. These results indicate worsening difficulties over time for many White caregivers. African American caregivers show more resilience on measures of depression and life satisfaction but are still vulnerable to increases in physical symptoms over time
Knight BG, Silverstein M, McCallum TJ, et al A sociocultural stress and coping model for mental health outcomes among African American caregivers in Southern California. J Gerontol B Psychol Sci Soc Sci 2000 May;55(3):P142-50. A sociocultural stress and coping model to explain emotional distress among caregivers of family members who have dementia across ethnic and cultural groups is presented and explored in a sample of 41 African American and 128 non-African American caregivers. In this sample, African American caregivers reported lower levels of burden but equal levels of depression and anxiety. African American caregivers were also younger and in poorer health, factors which tend to increase both burden and emotional distress outcomes. As suggested by the sociocultural stress and coping model, the influences of ethnic group variables on stress and coping processes are complex and multidirectional.
McCormick WC, Ohata CY, Uomoto J, et al.
Similarities and differences in attitudes toward
long-term care between Japanese Americans and Caucasian Americans. J Am
Geriatr Soc. 2002 Jun;50(6):1149-55.The purpose of this study was to
compare attitudes toward the use of long-term care between older
Japanese Americans (n = 1,244) and older Caucasian Americans (n =
1,354). When presented with a hypothetical situation in which they have
dementia, 39% of older Japanese Americans and 42% of older Caucasians
intended to be cared for at home, whereas 53% versus 38%, respectively,
intended to use nursing home care (P <.001). If the hypothetical
situation was hip fracture, 81% of older Japanese Americans and 72% of
older Caucasians intended to be cared for at home, with 13% of both
groups intending to use nursing home care (P = NS). The subjects'
perceptions of what their families, friends, ministers, and communities
would want them to choose differed, with more uncertainty among
Caucasians (P <.001). For provision of home care, Japanese Americans
were more likely to rely on loved ones than Caucasians, who were more
likely to rely on paid providers. Multivariate logistic regression
showed ethnicity to be independently related to intention to use nursing
home care in the dementia scenario, controlling for demographic
variables. Being married lowered the odds of intending to use nursing
homes in any situation. We conclude that Caucasian Americans intend to
use paid home health care at higher rates than Japanese Americans if
they become disabled by dementia. Japanese Americans demonstrated more
certainty about the influences of others on their opinions, suggesting a
more stable cultural norm in this population, and intended to use more
nursing home care in the event of permanent debility (dementia).
Morano
CL, Bravo M. A psychoeducational model for Hispanic Alzheimer's
disease caregivers. Gerontologist 2002 Feb;42(1):122-6
In this study, the authors recruited a purposive sample
of Hispanic caregivers who participated in a 5-day, 20-hr psychoeducational
program to increase the caregivers' understanding and acceptance of
AD, repertoire of coping skills, knowledge of resources, and expression
of concerns and emotions of caregiving. At the completion of the study
caregivers demonstrated a significant improvement on the Caregiver Knowledge
Survey, an increased awareness of community-based services, increased
willingness to attend support groups, and overall satisfaction with
the program.
Janevic MR, Connell CM. Racial, ethnic, and cultural differences in the dementia caregiving experience: recent findings. Gerontologist 2001 Jun;41(3):334-47 This paper reviewed studies that compare two or more racial, ethnic, national, or cultural groups on aspects of the dementia caregiving experience. These articles included comparisons involving the following groups of caregivers: African Americans, Chinese, Chinese Americans, Koreans, Korean Americans, Latinos, Whites, and residents of 14 European Union countries. Consistent with previous research, White caregivers were more likely to be spouses when compared to other groups. White caregivers tended to report greater depression and appraised caregiving as more stressful than African American caregivers. Findings were mixed regarding differences in coping and social support, but suggested that minority groups may not have more available support than Whites. Common methodological limitations were a lack of noncaregiving control groups and failure to test specific pathways by which the grouping variable (e.g., race) exerts its impact on outcome variables.
RESEARCH
Gallagher-Thompson D, Solano N, Coon D, Arean P. Recruitment and retention of latino dementia family caregivers in intervention research: issues to face, lessons to learn. Gerontologist. 2003 Feb; 43(1): 45-51 PURPOSE: This article reviews and critiques several issues of importance to those whose goal is to make intervention research with Latino caregivers more "user-friendly." Issues range from current demographic trends showing the ever-increasing number of Latino caregivers to discussion of cultural values that influence their help-seeking behavior. IMPLICATIONS: Clinical researchers need to increase their sensitivity to such issues as cultural values and language preference and develop effective collaborations with the Latino community so that intervention research programs can be designed and implemented successfully with Latinos caring for cognitively impaired elderly family members at home.
Hinton L, Guo Z, Hillygus J, Levkoff S. Working with culture: a qualitative analysis of barriers to the recruitment of Chinese-American family caregivers for dementia research. J Cross Cult Gerontol. 2000; 15(2): 119-37. The purpose of this study was to identify how sociocultural factors, concepts of health, aging and dementia contribute to barriers to recruitment based pn a qualitative analysis of interviews with of Chinese dementia caregivers . The following themes emerged in this analysis: 1) dementia-related changes were construed as a normal part of the aging process rather than a disease, making it more difficult to identify dementia-affected elders and to recruit families, 2) research participation was viewed as potentially harmful because it can lead to excessive worry 3) Alzheimer's disease carries a social stigma among Chinese, leading families to shun formal diagnosis and research participation, and 4) practitioners viewed research as an intrusion offering no direct benefit to participants.
Connell CM, Shaw BA, Holmes SB et al. Caregivers' attitudes toward their family members' participation in Alzheimer disease research: implications for recruitment and retention. Alzheimer Dis Assoc Disord 2001 Jul-Sep;15(3):137-45 This study was conducted to examine caregivers' attitudes toward their family members' participation in AD research. Six focus group interviews were conducted with 38 white and 12 African-American caregivers of participants enrolled in clinical research projects. Among white caregivers, primary barriers to participation in research included the potential for no direct benefit, problems with the procedures and tests involved, lack of time and resources, and difficulty accepting the diagnosis. Among African-American caregivers, primary barriers included general skepticism about the research process and firmly established attitudes about medical treatment and help seeking that serve as disincentives to research participation. To maximize the perceived benefits of research participation, potential participants should have access to regular personal contact with staff, information about health status changes in the care recipient, and the short-term and long-term results of the research studies in which they are participants. In addition, researchers should be sensitive to the concerns that may serve as barriers to participation, particularly among African Americans.
HEALTH SERVICE UTILIZATION
Stevens
A, Owen J. Predictors of time to
nursing home placement in White and African American individuals with
dementia.J Aging Health] 2004
Jun; Vol. 16 (3), pp. 375-97.OBJECTIVE: This study examined the
influence of racial group identification on nursing home placement (NHP)
for individuals with dementia before and after adjusting for the
possible mediating effects of the caregiving context as defined by
stress-process variables in 215 caregiver/care recipient dyads. METHOD:
Demographics, problem behaviors, self-care impairment, and caregiver
appraisal, social support, psychological well-being, and coping were
used to prospectively predict Time to NHP. RESULTS: Race was a
significant predictor of NHP with African American care recipients
placed significantly slower than White care recipients. Race remained a
significant predictor of Time to NHP after controlling for other
variables that showed independent association with Time to NHP and
stress-process variables. DISCUSSION: Findings suggest that
stress-process variables are critical factors in Time to NHP; however,
these variables do not explain fully the difference in Time to NHP seen
in White and African American care recipients.
Roberts
JS, Connell CM, Cisewski D, et al.
Differences between African Americans and whites in
their perceptions of Alzheimer disease. Alzheimer Dis Assoc Disord. 2003
Jan-Mar; 17(1): 19-26. A questionnaire was distributed
to 452 adults (61% white, 39% African American; 78% female; mean age 47
years; 33% with family history of AD) and assessed : (1) illness
beliefs, (2) factual knowledge, (3) sources of information, and (4)
perceived subjective threat of AD. African Americans and whites were
generally similar in their beliefs about common symptoms, prominent risk
factors, and the effectiveness of treatments for AD (although whites
expressed greater certainty in these beliefs than African Americans). In
comparison to whites, African Americans showed less awareness of facts
about AD, reported fewer sources of information, and indicated less
perceived threat of the disorder. These preliminary findings suggest
important distinctions between African Americans and whites in their
knowledge about, and conceptualization of, AD. Health psychologic
research suggests that such differences in illness perceptions could
shape response to disease burden, assessment and diagnosis, and
available health care options.
TREATMENTS
Iswasaka K, Kobayashi SJ Am Geriatr Soc 2004 Sep; Vol. 52 (9), pp.
1518-21. OBJECTIVES: To evaluate whether a traditional Chinese
herbal medicine, ba wei di huang wan (BDW), improves cognitive and
physical functioning in dementia patients. DESIGN: An 8-week randomized,
double-blind, placebo-controlled trial. SETTING: Long-term-care facility
in Japan. PARTICIPANTS: Thirty-three patients with mild to severe
dementia (7 men and 26 women; mean age +/- standard deviation=84.4 +/-
7.8) were recruited and enrolled from May 2002 through September 2002.
INTERVENTION: Participants were randomly assigned to the active drug (BDW)
group (n=16) or the placebo group (n=17) and treated for 8 weeks.
MEASUREMENT: Cognitive function and activities of daily living (ADLs);
palsatility index. RESULTS: After the trial, cognitive function as
assessed using the Mini-Mental State Examination (MMSE) significantly
improved from 13.5 +/- 8.5 to 16.3 +/- 7.7 (P<.01, 95% confidence
interval (CI)=-4.1 to -1.4) in the BDW group. The ADL score in the
Barthel Index also significantly changed, from 61.8 +/- 34.6 to 78.9 +/-
21.1 (P<.01, 95% CI=-26.2 to -7.9). In contrast, MMSE and Barthel Index
scores of the placebo group showed no significant change. Eight weeks
after the end of the administration, MMSE and Barthel Index scores of
the BDW group declined to the baseline level. The pulsatility index in
the internal carotid artery as measured using Doppler sonography
significantly decreased in the BDW group (2.5 +/- 1.7 to 1.9 +/- 0.5,
P<.05) but not in the placebo group. CONCLUSION: These results argue the
benefits of BDW in the treatment of dementia.
Freels S, Nyenhuis DL, Gorelick PB. Predictors of survival in African American patients with AD, VaD, or stroke without dementia. Neurology. 2002 Oct 22;59(8):1146-53. This is a study of a hospital-based cohort of African American patients in the Chicago area with AD, vascular dementia (VaD), or stroke without dementia (SWD) were followed for up to 7 years. RESULTS: Patients with AD who were older and had more years of education and lower Barthel ADL scores were at higher risk of death. Patients with VaD who were taking antihypertensive medication were at higher risk of death; those who were taking aspirin or antiplatelet/anticoagulant medication were at lower risk of death; and higher diastolic blood pressure was protective against death. Risk factors for death in the SWD group were older age, having ever been a smoker, and history of atrial fibrillation. Differences in survival across the three groups were not significant after adjusting for age and clinical dementia rating. CONCLUSIONS: Results in patients with VaD support the use of antiplatelet therapy for persons with VaD and suggest that optimal blood pressure may be higher in cognitively compromised poststroke patients than persons in the general population.
Green
RC et al.
At the 54th
Annual Meeting of the American Academy of Neurology (AAN) in Boston,
Dr. Robert C. Green et al reported that rteatment with the group
of anti-hypercholesterolemic agents called statins yielded a
decrease in Alzheimer's Disease (AD) risk, with an adjusted odds
ratio of 0.21. Their subjects were 912 persons with probable or definite
AD by research criteria and 1,669 of their non-demented relatives. They were cautiously optimistic about their findings
and stated that their results need to be replicated in large scale prospective
studies. Their study is unique because they recruited includes
a large percentage of African American patients (614 out of a total
of 2581), adjusted their for r educational background, and evaluated
the effect of APOE genotype. They found that neither African
American ethnicity, nor the presence of the APOE e4 allele modifies
the statin-AD risk association. This is the latest study to document
a positive relationship between treatment with statins and lowered risk
for AD.
David V. Espino and Richard Lewis Dementia in Older
Minority Populations: Diagnosis, and Treatment Am. J.
Geriatr. Psychiatry 1998 6: S19-S25. Dementia continues to be a
major disease that affects older Americans. It has been
estimated that up to 25% of all community-dwelling elderly
individuals in the United States suffer from signs or
symptoms of dementia. Little,
however, has been written on dementia
as it relates to older minority populations. The purpose of
this article is to discuss the prevalence of
dementia in elderly
minority populations, describe some of the unique issues related
to the diagnosis and treatment of
dementia in these populations, and make
recommendations aimed toward improving the quality of life
for elderly minority individuals with
dementia.