Bridging the gap through awareness
The term “health disparity” originated in the 1990s, yet differences in health outcomes among racial groups have existed for many centuries and continue to cause one of the biggest challenges in our healthcare system. According to the Centers for Disease Control and Prevention, health disparities are defined as preventable differences in the burden of disease, injury, violence or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic and other population groups and communities.
Minority racial and ethnic groups in the United States are more likely to suffer from major chronic conditions such as hypertension, diabetes, cancer and dementia. These differences can be seen in disease incidence and prevalence, morbidity and mortality rates, and when and how care is accessed.
In the United States, Alzheimer’s disease and related dementias (ADRD) have profound health disparities disproportionally affecting racial minority groups (Kawas, et al, 2021). The most prevalent type of dementia is Alzheimer’s disease. It affects about 5.3 million people in the country and will increase to approximately 16 million by 2050 (Rodriguez, et al, 2018).
Studies have shown the prevalence of ADRD is greater in Black and Latino patients. According to the Alzheimer’s Association (March 2020), Black patients are two times more likely and Latino patients are about 1.5 times more likely than white Americans to have Alzheimer’s and other dementias. The differences in incidence rates can be due to multiple factors such as genetics, social determinants of health and relationship with the healthcare system. Through awareness, we are able to begin closing gaps in these disparities.
Testing
To obtain an accurate diagnosis for ADRD, providers obtain patients’ medical history, laboratory results and imaging studies. In addition, a combination of cognitive, neurological and psychiatric assessments and screening tools are used for evaluation of ADRD. An important aspect of obtaining an early and accurate diagnosis of ADRD is providing reliable screening tools.
Studies have shown clinical screening tools for ADRD are less reliable for minority racial and ethnic groups (Gianatassio et al, 2019). This lack of reliability is often attributed to educational levels and cultural differences, which can affect the ability to accurately diagnose cognitive impairment and decline (Babulal et al, 2019). Furthermore, current screening tools used for minority and racial ethnic groups can lead to underdiagnosis or misdiagnosis. In a study conducted by Giantassio et al (2019), non-Latino Black patients had approximately double the risk of underdiagnosis than non-Latino white patients.
Timing
Benefits of early detection of ADRD include earlier education, treatment and support services for both patients and their family members. Research has shown that Black and Latino patients were less likely to receive a timely diagnosis of mild cognitive impairment versus dementia compared with white Americans, despite higher incidences of ADRD.
Differences in time of diagnosis in minority racial and ethnic communities can be due to clinician bias, performance of screening tools, cultural differences in what is considered normal aging or delays in seeking care from a provider for memory impairments (Kawas, et al, 2021). Early diagnosis is crucial to slowing progression and providing greater quality of life.
Treatment
Once an accurate diagnosis is obtained, treatment can include anti-dementia medication.
The Food and Drug Administration has approved several agents to slow or stabilize the progression of ADRD. These medications include cholinesterase inhibitors memantine and aducanumab.
Studies have shown minority racial and ethnic groups are less likely to be prescribed anti-dementia medications. In a study conducted by Zuckerman et al (2008), the use of anti-dementia medications was 30% higher among non-Latino white patients compared to other minority racial and ethnic groups.
Closing the Gap
Our understanding of ADRD continues to evolve, but there are still significant gaps in our understanding of how the disease impacts racial and ethnic minorities. ADRD studies are early in production, especially for minority racial and ethnic groups. The lack of representation, recruitment and retention of minority groups in studies continues to be a major barrier (Bubulal, 2018).
To increase participation, it’s not only important to develop culturally appropriate screening and diagnostic tools, but also to increase diversity among researchers and providers, include and train culturally diverse researchers, and assist in the development of appropriate and diverse screening and diagnostic tools.
Educating both providers and family members is another integral step in closing the gap. Patients and their family members may not have a clear understanding of ADRD or may have cultural differences in what is defined as cognitive decline. Clear communication among diverse populations is key to development of an effective treatment plan.
ADRD is a global health crisis, and as the incidence of ADRD continues to rise, closing the gaps in these disparities is key to the development of continued research and anti-dementia management.
References
Alzheimer’s Association (2020, March). Race, Ethnicity and Alzheimer’s. Retrieved from https://aaic.alz.org/downloads2020/2020_Race_and_Ethnicity_Fact_Sheet.pdf.
Babulal, G. M., Quiroz, Y. T., Albensi, B. C., Arenaza‐Urquijo, E., Astell, A. J., Babiloni, C., Bahar‐Fuchs, A., Bell, J., Bowman, G. L., Brickman, A. M., Chételat, G., Ciro, C., Cohen, A. D., Dilworth‐Anderson, P., Dodge, H. H., Dreux, S., Edland, S., Esbensen, A., Evered, L., … O’Bryant, S. E. (2018). Perspectives on ethnic and racial disparities in alzheimer’s disease and related dementias: Update and areas of immediate need. Alzheimer’s & Dementia, 15(2), 292–312. https://doi.org/10.1016/j.jalz.2018.09.009
Centers for Disease Control and Prevention. (2017, January 31). Health disparities. Centers for Disease Control and Prevention. https://www.cdc.gov/aging/disparities/index.htm
Farina, M. P., Hayward, M. D., Kim, J. K., & Crimmins, E. M. (2019). Racial and educational disparities in dementia and dementia-free life expectancy. The Journals of Gerontology: Series B, 75(7). https://doi.org/10.1093/geronb/gbz046
Gianattasio, K. Z., Prather, C., Glymour, M. M., Ciarleglio, A., & Power, M. C. (2019). Racial disparities and temporal trends in dementia misdiagnosis risk in the United States. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 5(1), 891–898. https://doi.org/10.1016/j.trci.2019.11.008
Kawas, C. H., Corrada, M. M., & Whitmer, R. A. (2021). Diversity and disparities in dementia diagnosis and care. JAMA Neurology, 78(6), 650. https://doi.org/10.1001/jamaneurol.2021.0285
Rodriguez, F. S., Aranda, M. P., Lloyd, D. A., & Vega, W. A. (2018). Racial and ethnic disparities in dementia risk among individuals with low education. The American Journal of Geriatric Psychiatry, 26(9), 966–976. https://doi.org/10.1016/j.jagp.2018.05.011
Zuckerman, I. H., Ryder, P. T., Simoni-Wastila, L., Shaffer, T., Sato, M., Zhao, L., & Stuart, B. (2008). Racial and ethnic disparities in the treatment of dementia among Medicare beneficiaries. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 63(5). https://doi.org/10.1093/geronb/63.5.s328
Cynthia Giannetti, NP
Cynthia Giannetti is a certified Adult Medicine Nurse Practitioner at Wellstar Health System. She has a master’s degree in nursing from Felician College and a bachelor’s degree in psychology from Lehman College. She is a certified diabetes educator (CDE) with more than 11 years of nursing experience in various healthcare settings.
