Racial and ethnic differences in trends in dementia prevalence and risk factors in the United States

Introducing social determinants of health to the Alzheimer's Disease Research Center network: Development and implementation in the Uniform Data Set

The Alzheimer's Disease Research Centers (ADRCs) consortium represents a critical locus of research on Alzheimer's disease and related disorders (ADRD) prevention, diagnosis, and intervention. Through the National Alzheimer's Coordinating Center's (NACC) standardized protocol, the Uniform Data Set (UDS), ADRCs have collected rich, harmonizable clinical and cognitive data. However, the collection of social data has been sparse and Center specific, constraining ADRD science that addresses research priorities on social determinants of health (SDOH) and health equity. Capitalizing on the transition to a revised UDS version 4, an interdisciplinary committee representing 10 ADRCs reviewed the literature and instrumentation, ultimately creating a brief module covering multiple domains and levels of exposure required for mechanistic studies of SDOH and brain health. This article offers rationale, empirical support, and guidance for using the selected constructs: transportation security, financial security, social connectedness, health care experiences, and discrimination, as well as recommendations for next steps that each ADRC can take to maximize local and field-level progress. HIGHLIGHTS: Social determinants of health (SDOH) play a role in Alzheimer's disease and related dementias (ADRD) risk, diagnosis, care, and research participation. A new module adds SDOH to a revised Uniform Data Set (UDS) for the Alzheimer's Disease Research Center (ADRC) consortium. UDS SDOH include transportation, socioeconomic status, social relationships, health care, and discrimination. We provide evidence for causal SDOH associations with ADRD and guidelines for use. We include recommendations for next steps and expanding the impact of the SDOH module.

Mortality patterns in patients with type 2 diabetes mellitus and late-onset Alzheimer's disease in the United States: a retrospective analysis from 1999 to 2020

BACKGROUND

Late-onset AD refers to the occurrence of AD after the age of 65. It is the primary cause of late-onset dementia. Studies indicate that persons diagnosed with diabetes are more susceptible to late-onset AD. Diabetes manifests as insulin resistance, which can have significant effects on cognitive function and contribute to the development of AD.

METHODS

The CDC WONDER database was used to determine the crude death rates (CR) and age-adjusted mortality rates (AAMRs) per 100,000 individuals, 65 years and above. Joinpoint Regression Program was used to examine the changes in AAMR in the form of annual percent change (APC) and average annual percent change (AAPC).

RESULTS

From 1999 to 2020, late-onset AD and diabetes were associated with 185,059 deaths in the older US population, demonstrating an increasing trend (AAPC = 2.87). Females (20.38) had higher AAMR than males (19.62). Non-Hispanic (NH) African Americans experienced the highest AAMR (28.01), while non-Hispanic Asians experienced the lowest (16.09). AAMRs varied by region (West: 23.53, Midwest: 21.51, South: 21.0, Northeast: 13.50). States with the highest AAMR percent change were Nebraska and Louisiana; those with the lowest were Montana and New Hampshire. Most deaths occurred at hospice/nursing facilities (57.96%). Non-metropolitan areas showed a higher mortality burden (25.05) than metropolitan areas (19.02).

CONCLUSIONS

There was an increasing mortality trend for late-onset AD among the population with diabetes in the US, with high mortality in females, NH African Americans, and the Western region.

Effects of Medicare predictors in health disparities in the risk of Alzheimer's disease

INTRODUCTION

Disparities in Alzheimer's disease (AD) and related dementias (ADRD) persist across race/ethnicity, sex, and US geographic regions, but limited quantitative information exists to explain how specific predictors contribute to these disparities. Many traditional methods lack precision in addressing both exposure (higher prevalence of a predictor) and vulnerability (higher risk associated with a predictor) effects. This study introduces an approach that leverages population attributable fraction (PAF) to analyze and explain AD/ADRD disparities using Medicare data.

METHODS

We applied our method to Medicare claims data from a nationally representative sample of the US adults aged 70, 75, 80, and 85. The analysis focused on six types of disparities: Black-White, Hispanic-White, Native American-White, Asian-White, female-male, and stroke-belt versus non-stroke-belt states. Predictors included Medicare/Medicaid dual eligibility as an indicator of low income and 10 AD/ADRD-related diseases. The method quantified the exposure and vulnerability effects of each predictor on the observed disparities.

RESULTS

Low income and vulnerability to arterial hypertension were the primary contributors to AD/ADRD disparities, with cerebrovascular diseases and depression as notable secondary predictors. The exposure effect dominated for income-related disparities, while hypertension's effect was largely driven by increased vulnerability. Racial disparities (Black-White, Hispanic-White) were most affected by income and hypertension, while female-male and stroke-belt disparities were less influenced by the examined predictors.

DISCUSSION

Our findings indicate that different intervention strategies are needed to address AD/ADRD disparities. Income-related disparities require targeting exposure (e.g., socioeconomic improvements), while hypertension-related disparities suggest a focus on managing vulnerability (e.g., better control of hypertension). The developed approach offers a robust framework for explaining disparities and designing targeted interventions. Further application to other datasets and exploration of additional predictors could enhance understanding and lead to more effective prevention strategies for AD/ADRD disparities.

Highlights

Our new approach addresses disparities leveraging the concept of population attributable fraction for Cox models.Exposure and vulnerability mechanisms of health disparity generation are evaluated.Vulnerability to hypertension is a consistent dominant factor in Alzheimer's disease (AD) risk disparities.Predictors explain AD disparities better in Black and Hispanic populations.Disparities in AD are driven by exposure to socioeconomic status suggesting targeted interventions.

Prevalence of dementia diagnoses in a safety net health system

INTRODUCTION

Older adults from minoritized and socioeconomically disadvantaged backgrounds commonly receive health care in safety net health settings and may be at high risk of dementia. We assessed the prevalence of diagnosed dementia in a large safety net health system.

METHODS

International Classification of Disease 10th Revision codes were used to classify presence of dementia for 147,689 older adults with at least one ambulatory encounter in 2019 using electronic health record data. Prevalence was calculated for the sample overall and by age cohort, sex, and race/ethnicity.

RESULTS

Diagnosed dementia prevalence was 0.3% for adults 50 to 64 and 3.0% for adults aged ≥ 65. Adults with diagnosed dementia were older, less likely to speak English, and had more medical comorbidities and higher health-care use than those without.

DISCUSSION

This study's estimates of dementia prevalence were considerably lower than other samples, which may be due to incomplete coding or to underdiagnosis of dementia in a safety net setting.

HIGHLIGHTS

Six percent to 10% of older adults do not have Medicare and often receive health care in safety net health systems; however, little information exists about dementia care in this practice setting. The Los Angeles County Department of Health Services is the nation's second largest municipal health system and provides ambulatory care to > 30,000 older adults annually, of whom > 85% are from minoritized populations and 60% of whom do not have Medicare. We used International Classification of Disease 10th Revision codes and demographic and clinical information derived from the electronic health record to estimate age-adjusted prevalence of dementia in this safety net health setting. Prevalence of diagnosed dementia was significantly less than expected based on national samples, likely reflecting significant underdiagnosis and/or undercoding of dementia in this practice setting.

Disparities by sex, race/ethnicity, and education in trends in the disability burden in the United States, 1996-2018

Research remains inconclusive on whether increased longevity is resulting in disability compression. Using the Health and Retirement Study and multistate models, this study is the first to examine trends (between 1996-2006 and 2008-18) across multiple key aspects of disability burden: namely, lifetime risk and age at onset of disability; recovery and mortality of the disabled; and disability-free life expectancy (DFLE) at age 50 in the United States' older population. Furthermore, we differentiate these trends by key socio-demographic factors: sex, race/ethnicity, and educational attainment. The analysis shows that over four-fifths of the total life expectancy increase at age 50 was in DFLE. This was accompanied by a one-year postponement in disability onset and insignificant recovery from disability. However, lifetime risk of disability remained unchanged between periods. Disability trends improved more for women than men. Latinx and the lowest-educated adults experienced no improvement in disability onset. The lowest-educated Whites exhibited substantial health deterioration.

Considerations in the clinical use of amyloid PET and CSF biomarkers for Alzheimer's disease

Amyloid-β (Aβ) positron emission tomography (PET) imaging and cerebrospinal fluid (CSF) biomarkers are now established tools in the diagnostic workup of patients with Alzheimer's disease (AD), and their use is anticipated to increase with the introduction of new disease-modifying therapies. Although these biomarkers are comparable alternatives in research settings to determine Aβ status, biomarker testing in clinical practice requires careful consideration of the strengths and limitations of each modality, as well as the specific clinical context, to identify which test is best suited for each patient. This article provides a comprehensive review of the pathologic processes reflected by Aβ-PET and CSF biomarkers, their performance, and their current and future applications and contexts of use. The primary aim is to assist clinicians in making better-informed decisions about the suitability of each biomarker in different clinical situations, thereby reducing the risk of misdiagnosis or incorrect interpretation of biomarker results. HIGHLIGHTS: Recent advances have positioned Aβ PET and CSF biomarkers as pivotal in AD diagnosis. It is crucial to understand the differences in the clinical use of these biomarkers. A team of experts reviewed the state of Aβ PET and CSF markers in clinical settings. Differential features in the clinical application of these biomarkers were reviewed. We discussed the role of Aβ PET and CSF in the context of novel plasma biomarkers.

Modifiable and Non-Modifiable Risk Factors for Dementia Among Non-Hispanic White and Black Populations Aged 50-64 in the United States, 2006-2016

BACKGROUND AND OBJECTIVES

Non-Hispanic Black populations (NHB) have a significantly higher prevalence of dementia than non-Hispanic Whites in the U.S., and the underlying risk factors may play a role in this racial disparity. We aimed to calculate risk scores for dementia among non-Hispanic White (NHW) and non-Hispanic Black populations aged 50-64 years over a period of 10 years, and to estimate potential differences of scores between NHW and NHB.

RESEARCH DESIGN AND METHODS

The Health and Retirement Study from 2006 to 2016 was used to calculate the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) risk score, a validated score for predicting dementia risk. Weighted average CAIDE score, as well as CAIDE score for modifiable factors hypertension, obese, hypercholesterolemia, physical inactivity), and non-modifiable factors (age, sex, education) were calculated for adults aged 50-64 years with normal cognition for 2006-2008, 2010-2012, 2014-2016. The associations of race with CAIDE score and elevated CAIDE score were examined.

RESULTS

A total of 10,871 participants were included in the analysis. The CAIDE score showed declining trends for NHB from 2006 to 2016, while NHB consistently had a higher total CAIDE score and CAIDE score for modifiable factors from 2006 to 2016, but not for non-modifiable factors.

DISCUSSION AND IMPLICATIONS

NHB had a higher level of dementia risk factors than NHW among adults aged 50-64 years in the U.S. from 2006 to 2016, and the difference is attributable to modifiable risk factors, which holds promise for risk reduction of dementia.

Racial and ethnic differences in white matter hypointensities: The role of vascular risk factors

INTRODUCTION

White matter hypointensities (WMHs) are markers of cerebrovascular pathology associated with cognitive decline. Reports of racial and ethnic differences in WMHs have been inconsistent across studies. This study examined whether race and ethnicity influence WMH burden and whether vascular risk factors explain these differences.

METHODS

Data from the National Alzheimer's Coordinating Center included 7132 Whites, 892 Blacks, 283 Asians, and 661 Hispanics. Baseline and longitudinal WMHs were examined using linear regression and mixed-effects models across racial and ethnic groups, controlling for demographics and vascular risk factors.

RESULTS

Adjusting for vascular risk factors reduced WMH burden differences and eliminated differences in temporal regions in Black versus White older adults. For Hispanics, differences became significant after adjusting for vascular risk factors.

DISCUSSION

Although some racial and ethnic WMH disparities are influenced by vascular risk factors, others persist, highlighting the need for multidimensional approaches when targeting WMHs in diverse populations.

HIGHLIGHTS

Current research is inconsistent as to whether there are racial differences in white matter hypointensities (WMHs). Blacks exhibit higher WMH burden than Whites, mediated by vascular factors. In Hispanics, WMH differences emerged only after adjusting for vascular risk factors.

Advancing Alzheimer's Disease and Related Dementias Research: The Johns Hopkins Alzheimer's Disease Resource Center for Minority Aging Research

ObjectiveThis article introduces a special issue on advancing Alzheimer's disease (AD) and AD-related dementias (ADRD) research drawing from research conducted by the Johns Hopkins Alzheimer's Disease Resource Center for Minority Aging Research (JHAD-RCMAR).MethodWe describe the JHAD-RCMAR, highlighting work of early career investigators in the JHAD-RCMAR, summarize key accomplishments, and propose recommendations for next steps in ameliorating disparities in cognitive decline and AD/ADRD risk.ResultsArticles in this special issue report on innovative research focused on basic, clinical, psychosocial, or health services aspects of minority aging, AD/ADRD, and health disparities. In addition, we include a paper on how mixed methods can be used to enhance health equity in research on AD/ADRD and cognitive impairment.DiscussionThe Supplement helps fill a critical knowledge gap regarding drivers of disparities in cognitive decline or risk in AD/ADRD, thereby informing future work as it relates to AD/ADRD and health equity.

Racial/Ethnic Differences in Neuropsychological Test Performance in Frontotemporal Degeneration

Racial disparities in neuropsychological test performance are well documented in Alzheimer's Disease (AD) but have received little attention in frontotemporal degeneration (FTD). Identification of potential disparities in neuropsychological performance is critical to identify ways to improve inclusivity in clinical research and care of representative FTD populations. We evaluated disparities in neuropsychological performance among individuals with clinically diagnosed FTD (behavioral variant FTD [bvFTD] or primary progressive aphasia [PPA]) using data from the National Alzheimer's Coordinating Center (NACC) collected between September 2005 and November 2023. Only 10% of NACC FTD cases are from racially/ethnically minoritized groups. Black (n=56), Hispanic (n=77) and White (n=1301) individuals were evaluated in the cognitive domains of episodic memory, working memory, processing speed, cognitive flexibility, attention, category fluency and lexical retrieval, in addition to global cognition across Uniform Data Set versions 1 to 3. Linear regressions examined the association between racial/ethnic group and cognitive scores covarying for disease stage, age, sex, and education. After adjusting for age, sex, and education using NACC established normative correction, binary logistic regression examined group differences in the proportion of participants classified as impaired (<=-1.5 normative z-score) for each cognitive test. Minoritized individuals, on average, had lower scores and/or greater likelihood of impairment (odds ratio; OR) on measures of global cognition (Black: β = -3.63; OR = 2.74; Hispanic: β = -2.50), lexical retrieval (Black: β = -4.31; OR = 3.28; Hispanic: β = -2.90; OR = 3.81), processing speed (Black: β = 26.80; OR = 4.07; Hispanic: β = 21.31; OR = 2.37), cognitive flexibility (Black: β = 46.65; OR = 3.35), attention (Hispanic: β = -0.39), working memory (Black: β = -0.79; Hispanic: β = -0.42), episodic memory (Hispanic: β = -1.67), and category fluency (Hispanic: β = -1.28). We did not identify any neuropsychological tests where White individuals performed worse than minoritized individuals. These findings indicate racial/ethnic differences in neuropsychological test performance on measures of global cognition, executive function, and lexical retrieval. Critically, these tests are used in diagnosis and monitoring of FTD. Future efforts must focus on increasing research participation in underrepresented populations with FTD to support the diverse needs of individuals, and an understanding of social determinants of health in FTD to evaluate potential sources of the observed differences across racial and ethnic groups.

Ethnic and racial influences on blood biomarkers for Alzheimer's disease: A systematic review

BACKGROUND

Little is known about confounding factors influencing Alzheimer's disease (AD) blood biomarker concentrations.

OBJECTIVE

The objective of this systematic review was to explore the available evidence for the influences of ethnicity and race on AD blood biomarker concentrations.

METHODS

We conducted a comprehensive systematic search in PubMed and Web of Science databases spanning from inception until 15 June 2023. We included studies that utilized plasma or serum biomarkers (amyloid-β [Aβ], total tau [t-tau], phosphorylated tau [p-tau], neurofilament light [NfL], and glial fibrillary acidic protein [GFAP]), compared individuals with AD to healthy controls, and included a minimum of two ethnic or racial groups for comparison. A total of 10 studies were included in the qualitative synthesis. All studies were conducted in the US.

RESULTS

Seven studies reported differences in blood biomarker concentrations between ethnic or racial groups. However, after adjusting for medical conditions and social determinants of health, the differences became non-significant in two of the studies. The included studies differed in their included covariates and their statistical approaches, which complicated the interpretation of the observed differences.

CONCLUSIONS

The available evidence suggests that ethnicity and race may influence blood biomarker concentrations. However, it remains unclear to what extent these differences are mediated by differences in social determinants of health and medical conditions. Future studies are needed to explore ethnic and racial differences in blood biomarkers, including studies in diverse samples outside the US.

Social patterning of cognitive impairment in Colombia: evidence from the SABE 2015 study

INTRODUCTION

Dementia, an increasingly critical public health concern in low and middle-income countries, is associated with lower socioeconomic status, early cognitive impairment, and elevated dementia-related mortality risk. This study seeks to estimate the prevalence of cognitive impairment, investigate its links with social indicators, and visualize social gradients across different regions in Colombia.

METHODS

Secondary data analysis from the SABE 2015 survey, multinomial regression analyses, and equiplot graphs.

RESULTS

A sample of 23,694 individuals 60 years or older from Colombia. Higher risks were observed among individuals with dark skin color (OR 1.27; 95%CI: 1.10 - 1.47), lower educational levels (OR 3.01; 95%CI:2.04 - 4.42) and reading illiteracy (OR 2.14; 95%CI: 1.87 - 2.46). Inequity patterns were identified by region of residence and income.

DISCUSSION

This study underscores the need for targeted interventions aimed at reducing health inequities. The results highlight the higher prevalence rates of cognitive impairment among socially disadvantaged individuals.

A Dual Group-Based 11-Year Trajectory Analysis of Cognitive Impairment and Transport Restriction for Community-Dwelling Older Adults

OBJECTIVES

To examine the trajectories of cognitive impairment and transport restriction over time and the interrelation between these trajectories among older adults.

METHODS

Group-based trajectory modeling was used on the longitudinal National Health and Aging Trends Study (NHATS) over 11 years from 2011 to 2021, among 5753 participants, stratified by age in 2011 to three groups of 65-74 years, 75-84 years, and 85 years and above.

RESULTS

For transport restrictions, these trajectory groups were: (1) a majority with no restrictions, (2) low and increasing or stable, and (3) moderate or high and decreasing. The overall pattern was largely consistent across the three age groups, with the older group showing a higher predicted likelihood of transport restrictions compared to the younger group. For each of the three age groups, there were two cognitive impairment trajectories including (1) low and (2) increasing cognitive impairment. The proportions of increasing cognitive impairment were 12.3% among the 65-74 years old, 27.3% among the 75-84 years old, and 40.4% among the 85 years and above old. Compared with those with no transport restriction, the other two trajectories with either low or moderate transport restrictions were more likely to belong to increasing cognitive impairment. The odds ratio was 3.06 (95% CI 2.0-4.68) for low & increasing transport restrictions versus 1.57 (95% CI 0.96-2.56) for moderate & decreasing transport restrictions among 65-74 years old. The odds ratio was 2.38 (95% CI 1.68-3.38) for low & increasing transport restrictions versus 1.88 (95% CI 1.39-2.55) for moderate & decreasing transport restrictions among 75-84 years old.

CONCLUSIONS

Cognitive impairment was more likely to co-occur with those with low and increasing transport restrictions than with those with moderate and decreasing transport restrictions. Addressing transport restriction among older adults holds the potential to ameliorate cognitive outcomes.

The Interaction Between Indigenous Identity and Rural Residency in Dementia Prevalence Among Ecuadorian Older Adults

BACKGROUND AND OBJECTIVES

While recognizing the acknowledged difference in dementia prevalence between Indigenous and non-Indigenous populations, most previous studies were conducted in the Global North. This study aims to examine the relationship between Indigenous ethnic identity and dementia status with a special focus on urban-rural differences among older adults in Ecuador.

RESEARCH DESIGN AND METHODS

Data came from Ecuador's Survey of Health, Welfare, and Aging, derived from a probability sample of households in Ecuador. The final sample comprised 4,984 adults aged 60 or older. Dementia status was assessed through 3 indicators: low scores on a cognitive assessment, the number of difficulties in instrumental activities of daily living, and self-reported dementia diagnosis. Logistic regression and multivariate decomposition analyses were utilized.

RESULTS

Indigenous participants, even after adjusting for sociodemographic and health-related factors, exhibited a higher likelihood of having dementia compared to their non-Indigenous counterparts. Among Indigenous participants, those residing in rural areas had a higher likelihood of having dementia status, while there was no significant urban-rural difference observed among non-Indigenous participants. Rural residency and covariates explain 91.0% of the observed difference in dementia prevalence between Indigenous and non-Indigenous older adults.

DISCUSSION AND IMPLICATIONS

Indigenous older adults who are living in rural areas are at particularly high risk of having dementia largely because they have presently recognized modifiable risk factors. These findings underscore the urgent need to prioritize provisions of appropriate and equitable service related to dementia for Indigenous people living in rural areas outside high-income countries.

The role of Southern context in shaping life course exposures linked to dementia incidence for Black and White older adults in the United States

While racial inequities in dementia risk are well-documented in the United States, research has paid less attention to role of US Southern context in shaping dementia risk through life course exposures. In this study, we examine how Southern birth and Southern residence in adulthood are linked to dementia incidence for Black and White older adults in the United States. Using the Health and Retirement Study (N = 15,613), we estimate a series of hazard models to evaluate how life course risk factors such as childhood health and social disadvantage, education, adult socioeconomic status, health behaviors, and cardiometabolic conditions impact the association between Southern life course residency and dementia risk. We find different patterns in how Southern life course context shapes dementia risk among Black and White adults, with dementia risk among Blacks especially sensitive to combinations of Southern life course context. These findings demonstrate the importance of considering potential heterogenous life course pathways to cognitive aging and health that may be shaped by larger socio-historical experiences.

Neuroimaging and biofluid biomarkers across race and ethnicity in older adults across the spectrum of cognition

Neuroimaging and biofluid biomarkers provide a proxy of pathological changes for Alzheimer's disease (AD) and are useful in improving diagnosis and assessing disease progression. However, it is not clear how race/ethnicity and different prevalence of AD risks impact biomarker levels. In this narrative review, we survey studies focusing on comparing biomarker differences between non-Hispanic White American(s) (NHW), African American(s) (AA), Hispanic/Latino American(s) (HLA), and Asian American(s) with normal cognition, mild cognitive impairment, and dementia. We found no strong evidence of racial and ethnic differences in imaging biomarkers after controlling for cognitive status and cardiovascular risks. For biofluid biomarkers, in AA, higher levels of plasma Aβ42/Aβ40, and lower levels of CSF total tau and p-tau 181, were observed after controlling for APOE status and comorbidities compared to NHW. Examining the impact of AD risks and comorbidities on biomarkers and their contributions to racial/ethnic differences in cognitive impairment are critical to interpreting biomarkers, understanding their generalizability, and eliminating racial/ethnic health disparities.

Perceptions about dementia clinical trials among underrepresented populations: a nationally representative survey of U.S. dementia caregivers

BACKGROUND

The research community has historically failed to enroll diverse groups of participants in dementia clinical trials. A unique aspect of dementia care research is the requirement of a study partner, who can attest to the care recipient's clinical and functional capacity. The aim of this study is to assess racial and ethnic differences and the importance of various trial considerations among dementia caregivers, in their decision to participate in clinical research as study partners.

METHOD

We embedded a vignette about a hypothetical dementia clinical trial in a nationally representative survey of U.S. dementia caregivers, oversampling non-Hispanic Black and Hispanic caregivers. Dementia caregivers were asked about their willingness to participate in the trial with their care recipient and rated the importance of nine considerations in hypothetical decisions to participate. Caregiver demographic characteristics were analyzed as predictors of trial participation in a base demographic model. In a second reasons model caregiver demographic characteristics and the rated importance of the nine considerations were separately analyzed as predictors; both models used survey-weighted logistic regression.

RESULT

The sample consisted of 610 dementia caregivers, including 156 non-Hispanic Black and 122 Hispanic caregiver participants. In the base demographic model, hypothetical trial participation was negatively associated with older caregiver age (OR (odds ratio) = 0.72, p = < 0.001). In the reasons model, the rated importance of a social responsibility to help others by participating in research was significantly associated with participation (OR = 1.56, p = 0.049), while the importance of the possibility of the care recipient experiencing serious side effects was negatively associated with participation (OR = 0.51, p = 0.003). In both models there was no significant difference in hypothetical participation between non-Hispanic Black and non-Hispanic White caregivers, or between Hispanic and non-Hispanic White caregivers.

CONCLUSION

Hispanic and non-Hispanic Black dementia caregivers were not less likely than non-Hispanic White dementia caregivers to participate in a hypothetical dementia clinical trial. Our study suggests that failures to recruit diverse populations in dementia clinical research are not attributable to less willingness among members of underrepresented groups but may instead reflect structural barriers and historic exclusion from trial participation.

The ADNI4 Digital Study: A novel approach to recruitment, screening, and assessment of participants for AD clinical research

INTRODUCTION

We evaluated preliminary feasibility of a digital, culturally-informed approach to recruit and screen participants for the Alzheimer's Disease Neuroimaging Initiative (ADNI4).

METHODS

Participants were recruited using digital advertising and completed digital surveys (e.g., demographics, medical exclusion criteria, 12-item Everyday Cognition Scale [ECog-12]), Novoic Storyteller speech-based cognitive test). Completion rates and assessment performance were compared between underrepresented populations (URPs: individuals from ethnoculturally minoritized or low education backgrounds) and non-URPs.

RESULTS

Of 3099 participants who provided contact information, 654 enrolled in the cohort, and 595 completed at least one assessment. Two hundred forty-seven participants were from URPs. Of those enrolled, 465 met ADNI4 inclusion criteria and 237 evidenced possible cognitive impairment from ECog-12 or Storyteller performance. URPs had lower ECog and Storyteller completion rates. Scores varied by ethnocultural group and educational level.

DISCUSSION

Preliminary results demonstrate digital recruitment and screening assessment of an older diverse cohort, including those with possible cognitive impairment, are feasible. Improving engagement and achieving educational diversity are key challenges.

HIGHLIGHTS

A total of 654 participants enrolled in a digital cohort to facilitate ADNI4 recruitment. Culturally-informed digital ads aided enrollment of underrepresented populations. From those enrolled, 42% were from underrepresented ethnocultural and educational groups. Digital screening tools indicate > 50% of participants likely cognitively impaired. Completion rates and assessment performance vary by ethnocultural group and education.

Data sharing as the foundation of discovery: ADNI and breakthroughs in Alzheimer's disease

The COVID pandemic has shown that when the research community comes together, we can conquer the most complex biomedical challenges. Collaboration and teamwork among federal agencies, private organizations, and researchers have been crucial in the development of vaccines and therapeutics against COVID. Possibly the first example of such cross-functional collaboration is the Alzheimer's Disease Neuroimaging Initiative (ADNI), the largest and longest continually monitored Alzheimer's study. ADNI was designed and operated as a public-private partnership, managed by the Foundation for the National Institutes of Health. This article shows how recent successes in the Alzheimer's field are directly a result of ADNI's open and transparent sharing of knowledge, expertise, and resources, which have allowed researchers to advance their understanding of Alzheimer's and tackle challenges in a relatively short period of time. ADNI's approach to open-source innovation also served as a model for addressing other complex diseases and led to numerous collaborative research initiatives. HIGHLIGHTS: The Alzheimer's Disease Neuroimaging Initiative (ADNI) was designed, structured, and operated as a public-private partnership, managed by the Foundation for the National Institutes of Health. The recent successes in the Alzheimer's field are directly a result of ADNI's efforts. Open and transparent sharing of knowledge, expertise, and resources allowed researchers to advance their understanding of Alzheimer's and tackle challenges in a relatively short period of time.

Ecological Momentary Intervention to Replace Sedentary Time With Physical Activity to Improve Executive Function in Midlife and Older Latino Adults: Pilot Randomized Controlled Trial

BACKGROUND

Exercise interventions often improve moderate to vigorous physical activity, but simultaneously increase sedentary time due to a compensatory resting response. A higher level of sedentary time is associated with a lower level of executive function, while increased moderate to vigorous physical activity is associated with improved global cognition and working memory among Latino adults. Latino adults are the fastest-growing minority group in the United States and are at high risk for cognitive decline, spend more time sedentary compared to non-Hispanic populations, and engage in low levels of physical activity. Interventions that are culturally appropriate for Latino adults to replace sedentary time with physical activity are critically needed.

OBJECTIVE

This study aims to develop and test the feasibility and acceptability of an ecological momentary intervention (EMI; delivered in real time) that is individually designed to replace sedentary time with physical activity in Latino adults.

METHODS

This pilot study randomized 39 (n=26, 67% female; mean age 61, SD 5.8 years) community-dwelling, Spanish-speaking Latino adults (1:1 allocation) to either a 6-week EMI program designed to replace sitting time with physical activity (20/39, 51%) or physical activity guidelines education (19/39, 49%). The program was conducted on the web and in Spanish. The intervention was individualized based on individual interview responses. The intervention included the use of a Fitbit activity monitor, weekly didactic phone meetings, interactive tools (SMS text messages), and coach-delivered feedback. Feasibility and acceptability were assessed via study satisfaction (Likert scales), motivation (ecological momentary assessment), retention, and compliance. Sedentary time and physical activity were assessed via 7-day actigraphy. Cognitive performance was assessed via the trail making test part A and B (part B=executive function) and via the National Institutes of Health Toolbox remote cognitive assessment. Statistical analysis included a linear model on change score from baseline, adjusting for age, sex, and education, emphasizing effect size.

RESULTS

Participant satisfaction with EMI was high (9.4/10), with a high degree of motivation to replace sitting time with physical activity (9.8/10). The intervention compliance rate was 79% with low difficulty using the Fitbit (1.7/10). Weekly step count increased in the intervention group by 5543 steps (group difference: d=0.54; P=.05) and sedentary time decreased by a mean 348 (SD 485) minutes (group difference: d=0.47; P=.24) compared to controls, with moderately strong effect sizes. The trail making test part B improved in the intervention group (mean -35.26, SD 60.35 seconds), compared to the control group (mean 7.19, SD 46 seconds; group difference: d=0.74; P=.01). No group differences were observed in other cognitive measures.

CONCLUSIONS

An individualized EMI designed for midlife and older Latino adults has the potential to replace sitting time with physical activity and improve executive functioning. The intervention was feasible and well received with a high degree of satisfaction.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04507464; https://tinyurl.com/44c4thk5.

COVID-19 outcomes among patients with dementia and age-matched controls who were hospitalized in 21 US health-care systems

INTRODUCTION

COVID-19 had devastating impacts worldwide. However, most research examining the impact of dementia on COVID-19 outcomes has been conducted in Europe and Asia and has not examined dementia subtypes.

METHODS

A retrospective analysis of electronic health record data from 21 US health-care systems examined relationships of all-cause dementia, Alzheimer's disease (AD), and vascular dementia with in-hospital mortality, intensive care unit (ICU) admission, and hospital stay duration.

RESULTS

All-cause dementia, but not AD or vascular dementia independently, was associated with increased mortality risk, the inclusion of discharge to hospice as a mortality equivalent increased risk for mortality for all-cause dementia, and AD and vascular dementia. Patients with all-cause dementia and AD were less likely to be admitted to the ICU than patients without. Patients with any form of dementia had longer hospital stays than patients without.

DISCUSSION

Dementia was associated with increased mortality or hospice discharge, decreased ICU admissions, and longer hospital stays.

HIGHLIGHTS

Only all-cause dementia was associated with increased mortality risk. This risk was lower than what has been published in previous research. Combining mortality and hospice discharge increased risk for all dementia subtypes. All-cause and Alzheimer's disease (AD) dementia were associated with decreased intensive care unit admissions. All-cause, vascular, and AD dementia were associated with longer hospital stays.

Heterogeneous treatment effects of sodium-glucose cotransporter 2 inhibitors on risk of dementia in people with type 2 diabetes: A population-based cohort study

INTRODUCTION

Sodium-glucose cotransporter 2 (SGLT2) inhibitors exhibit potential benefits in reducing dementia risk, yet the optimal beneficiary subgroups remain uncertain.

METHODS

Individuals with type 2 diabetes (T2D) initiating either SGLT2 inhibitor or sulfonylurea were identified from OneFlorida+ Clinical Research Network (2016-2022). A doubly robust learning was deployed to estimate risk difference (RD) and 95% confidence interval (CI) of all-cause dementia.

RESULTS

Among 35,458 individuals with T2D, 1.8% in the SGLT2 inhibitor group and 4.7% in the sulfonylurea group developed all-cause dementia over a 3.2-year follow-up, yielding a lower risk for SGLT2 inhibitors (RD, -2.5%; 95% CI, -3.0% to -2.1%). Hispanic ethnicity and chronic kidney disease were identified as the two important variables to define four subgroups in which RD ranged from -4.3% (-5.5 to -3.2) to -0.9% (-1.9 to 0.2).

DISCUSSION

Compared to sulfonylureas, SGLT2 inhibitors were associated with a reduced risk of all-cause dementia, but the association varied among different subgroups.

HIGHLIGHTS

New users of sodium-glucose cotransporter 2 (SGLT2) inhibitors were significantly associated with a lower risk of all-cause dementia as compared to those of sulfonylureas. The association varied among different subgroups defined by Hispanic ethnicity and chronic kidney disease. A significantly lower risk of Alzheimer's disease and vascular dementia was observed among new users of SGLT2 inhibitors compared to those of sulfonylureas.

Factors Associated With Psychological Wellbeing in Home Care Older Adults With Alzheimer's Disease: A Longitudinal Analysis

The long-term symptoms associated with Alzheimer's disease pose significant challenges to the psychological wellbeing of patients. This longitudinal study aims to analyze the effects of socioeconomic factors and physical health factors on the psychological wellbeing of older patients diagnosed with Alzheimer's disease (AD) receiving home care, as well as the moderating role of aging and care support in influencing their psychological wellbeing. Data from the Health and Retirement Study (N = 628 older Alzheimer's patients) were analyzed using pooled ordinary least squares fixed-effects models. Findings suggest that Alzheimer's patients' psychological wellbeing was significantly affected by factors including cohabitation, gender, assistance frequency, age, education, and daily activity challenges, with assistance and increasing age mitigating some daily difficulties. The findings underline the multifactorial nature of psychological wellbeing among older Alzheimer's patients in home care and the critical role of social and physical health determinants in shaping these outcomes.

Racial and ethnic differences in the risk of dementia diagnosis under hypothetical blood pressure-lowering interventions: The Multi-Ethnic Study of Atherosclerosis

INTRODUCTION

Substantial racial and ethnic disparities in hypertension and dementia exist in the United States. We evaluated the effect of maintaining systolic blood pressure (SBP) below clinical thresholds on dementia incidence.

METHODS

We included 6806 Multi-Ethnic Study of Atherosclerosis participants (44 to 84 years old). We implemented the parametric g-formula to simulate the hypothetical interventions to reduce SBP below 120 and 140 mmHg over time, accounting for time-varying confounding. We estimated risk ratios (RRs) and risk differences for dementia incidence at 19 years.

RESULTS

The RRs (95% confidence intervals [CIs]) comparing an intervention reducing SBP below 120 mmHg to no intervention were 0.93 (0.87 to 0.99) for total sample, 0.95 (0.88 to 1.02) for White, 0.90 (0.79 to 1.02) for Black, 0.90 (0.78 to 1.05) for Latino, and 1.16 (0.83 to 1.55) for Chinese American participants. Results for lowering SBP below 140 mmHg and with death as competing event were attenuated.

DISCUSSION

The reduction of SBP below 120 mmHg over time has modest effects on reducing dementia incidence. More work is needed to understand the heterogeneity across racial and ethnic groups.

HIGHLIGHTS

There is a potential beneficial effect in lowering SBP to reduce the risk of dementia, which may vary by race and ethnicity. The percentage of participants who would need intervention on blood pressure to meet clinical thresholds is greater for Black and Latino communities. Results are sensitive to the way that death is specified in the research question and analysis.

Learning ratio performance on a brief visual learning and memory test moderates cognitive training gains in Double Decision task in healthy older adults

Cognitive training using a visual speed-of-processing task, called the Useful Field of View (UFOV) task, reduced dementia risk and reduced decline in activities of daily living at a 10-year follow-up in older adults. However, there was variability in the achievement of cognitive gains after cognitive training across studies, suggesting moderating factors. Learning trials of visual and verbal learning tasks recruit similar cognitive abilities and have overlapping neural correlates with speed-of-processing/working memory tasks and therefore could serve as potential moderators of cognitive training gains. This study explored the association between the Hopkins Verbal Learning Test-Revised (HVLT-R) and Brief Visuospatial Memory Test-Revised (BVMT-R) learning with a commercial UFOV task called Double Decision. Through a secondary analysis of a clinical trial, we assessed the moderation of HVLT-R and BVMT-R learning on Double Decision improvement after a 3-month speed-of-processing/attention and working memory cognitive training intervention in a sample of 75 cognitively healthy older adults. Multiple linear regressions showed that better baseline Double Decision performance was significantly associated with better BVMT-R learning (β =  - .303). This association was not significant for HVLT-R learning (β =  - .142). Moderation analysis showed that those with poorer BVMT-R learning improved the most on the Double Decision task after cognitive training. This suggests that healthy older adults who perform below expectations on cognitive tasks related to the training task may show the greatest training gains. Future cognitive training research studying visual speed-of-processing interventions should account for differing levels of visuospatial learning at baseline, as this could impact the magnitude of training outcomes and efficacy of the intervention.

The individual and combined impacts of pre-existing diabetes and dementia on ischemic stroke outcomes: a registry-based cohort study

BACKGROUND

Individually, diabetes mellitus and dementia are associated with poorer outcomes after stroke. However, the combined impact of these pre-existing factors on acute ischemic stroke (AIS) outcomes has not been examined.

METHODS

All consecutive patients with AIS admitted to Norfolk and Norwich University Hospitals between 2003 and 2016 (catchment population ~ 900,000) were divided into four groups: those with neither diabetes nor dementia (reference), with diabetes without dementia, with dementia without diabetes, and with both co-morbidities. In-hospital mortality, length of hospital stay (LoS), and disability outcomes were analysed using logistic regressions. Post-discharge mortality and recurrence were assessed using Cox regressions. Additionally, interaction terms were added to the models for the short-term outcomes and long-term mortality to test for synergistic effects of diabetes and dementia. Models were adjusted for age, sex, Oxfordshire Community Stroke Project classification, comorbidities, hematological and biochemical measures, and antithrombotic medications.

RESULTS

The cohort was 10,812 patients with 52% females and a median age of 80. The median follow-up was 3.8 years for stroke recurrence and 5.5 years for mortality. No significant differences between the four groups existed for in-hospital mortality and post-stroke disability. Patients with dementia had significantly longer LoS (OR 2.25 [95% CI: 1.34-3.77] and 1.31 [1.02-1.68] with and without diabetes, respectively). Patients with both comorbidities had the highest risk of stroke recurrence (HR 2.06 [1.12-3.77]), followed by those with only dementia (1.59 [1.15-2.20]) and only diabetes (1.25 [1.06-1.49]). Similarly, the patient group with both diabetes and dementia had the highest long-term mortality risk (1.76 [1.33-2.37]). The hazard ratios for patients with only dementia and only diabetes were 1.71 [1.46-2.01] and 1.19 [1.08-1.32], respectively. No significant interactions were seen between diabetes and dementia with regards to their effects on the outcomes.

CONCLUSION

Individual and cumulative impacts of the two conditions on long-term mortality and stroke recurrence were notable. However, no synergistic impact of the two comorbidities were seen on the stroke outcomes tested in our study. Therefore, tailoring the management of stroke patients based on additional requirements associated with each pre-existing condition will be more impactful towards improving outcomes.

Charting Alzheimer's Disease and Dementia: Epidemiological Insights, Risk Factors and Prevention Pathways

Alzheimer's disease (AD), the most common cause of dementia, is a complex and multifactorial condition without cure at present. The latest treatments, based on anti-amyloid monoclonal antibodies, have only a modest effect in reducing the progression of cognitive decline in AD, whereas the possibility of preventing AD has become a crucial area of research. In fact, recent studies have observed a decrease in dementia incidence in developed regions such as the US and Europe. However, these trends have not been mirrored in non-Western countries (Japan or China), and the contributing factors of this reduction remain unclear. The Lancet Commission has delineated a constrained classification of 12 risk factors across different life stages. Nevertheless, the scientific literature has pointed to over 200 factors-including sociodemographic, medical, psychological, and sociocultural conditions-related to the development of dementia/AD. This narrative review aims to synthesize the risk/protective factors of dementia/AD. Essentially, we found that risk/protective factors vary between individuals and populations, complicating the creation of a unified prevention strategy. Moreover, dementia/AD explanatory mechanisms involve a diverse array of genetic and environmental factors that interact from the early stages of life. In the future, studies across different population-based cohorts are essential to validate risk/protective factors of dementia. This evidence would help develop public health policies to decrease the incidence of dementia.

Social determinants of health but not global genetic ancestry predict dementia prevalence in Latin America

INTRODUCTION

Leveraging the nonmonolithic structure of Latin America, which represents a large variability in social determinants of health (SDoH) and high levels of genetic admixture, we aim to evaluate the relative contributions of SDoH and genetic ancestry in predicting dementia prevalence in Latin American populations.

METHODS

Community-dwelling participants aged 65 and older (N = 3808) from Cuba, Dominican Republic, Mexico, and Peru completed the 10/66 protocol assessments. Dementia was diagnosed using the cross-culturally validated 10/66 algorithm. Multivariate linear regression models adjusted for SDoH were used in the main analysis. This study used cross-sectional data from the 1066 population-based study.

RESULTS

Individuals with higher proportions of Native American (>70%) and African American (>70%) ancestry were more likely to exhibit factors contributing to worse SDoH, such as lower educational levels (p < 0.001), lower socioeconomic status (p < 0.001), and higher frequency of vascular risk factors (p < 0.001). After adjusting for measures of SDoH, there was no association between ancestry proportion and dementia probability, and ancestry proportions no longer significantly accounted for the variance in cognitive performance (African predominant p = 0.31 [-0.19, 0.59] and Native predominant p = 0.74 [-0.24, 0.33]).

DISCUSSION

The findings suggest that social and environmental factors play a more crucial role than genetic ancestry in predicting dementia prevalence in Latin American populations. This underscores the need for public health strategies and policies that address these social determinants to effectively reduce dementia risk in these communities.

HIGHLIGHTS

Countries in Latin America express a large variability in social determinants of health and levels of admixture. After adjustment for downstream societal factors linked to SDoH, genetic ancestry shows no link to dementia. Population ancestry profiles alone do not influence cognitive performance. SDoH are key drivers of racial disparities in dementia and cognitive performance.

Performance of the Modified Caregiver Strain Index in a Sample of Black and White Persons Living With Dementia and Their Caregivers

BACKGROUND AND OBJECTIVES

This study examined the performance of the Modified Caregiver Strain Index (MCSI) in a sample of Black and White caregivers of persons living with dementia.

RESEARCH DESIGN AND METHODS

Data on 153 dyads enrolled in the Care Ecosystem dementia care management program were analyzed, including sociodemographic variables, dementia severity, and caregiver burden and wellbeing. Factor structure, item-response patterns, and concurrent validity were assessed across racial groups.

RESULTS

Differences between Black and White caregivers included gender, dyad relation, and socioeconomic disadvantage. Factor structure and item loadings varied by racial cohort, with parameters supporting a 3-factor model. For Black caregivers, finances and work, emotional and physical strain, and family and personal adjustment items loaded together on individual factors. For White caregivers physical and emotional strain items loaded on separate factors, although personal and family adjustment items loaded with work and financial strain items. Item-level analysis revealed differences between groups, with Black caregivers endorsing physical strain to a greater degree (p = .003). Total MCSI scores were positively correlated with concurrent measures like the PHQ-9 (White: r = 0.67, Black: r = 0.54) and the GAD-2 (White: r = 0.47, Black: r = 0.4), and negatively correlated with self-efficacy ratings (White: r = -0.54, Black: r = -0.55), with a p < .001 for all validity analysis.

DISCUSSION AND IMPLICATIONS

The MCSI displayed acceptable statistical performance for Black and White caregivers of persons living with dementia and displayed a factor structure sensitive to cultural variations of the construct. Researchers results highlight the inherent complexity and the relevance of selecting inclusive measures to appropriately serve diverse populations.

Social Environment, Lifestyle, and Genetic Predisposition With Dementia Risk: A Long-Term Longitudinal Study Among Older Adults

BACKGROUND

The role of social environment, that is, the aggregate effect of social determinants of health (SDOHs), in determining dementia is unclear.

METHODS

We developed a novel polysocial risk score for dementia based on 19 SDOH among 5 199 participants in the Health and Retirement Study, United States, to measure the social environmental risk. We used a survival analysis approach to assess the association between social environment and dementia risk in 2006-2020. We further studied the interaction between social environment and lifestyles, and explored racial disparities.

RESULTS

The study participants (mean age = 73.4 years, SD = 8.3; 58.0% female; 11.6% African American) were followed up for an average of 6.2 years, and 1 089 participants developed dementia. Every 1-point increase in the polysocial risk score (ranging from 0 to 10) was associated with a 21.6% higher risk (adjusted hazard ratio [aHR] = 1.21, 95% confidence intervals [95% CI] = 1.15-1.26) of developing dementia, other things being equal. Among participants with high social environmental risk, regular exercise and moderate drinking were associated with a 43%-60% lower risk of developing dementia (p < .001). In addition, African Americans were 1.3 times (aHR = 2.28, 95% CI = 1.96-2.66) more likely to develop dementia than European Americans, other things being equal.

CONCLUSION

An adverse social environment is linked to higher dementia risk, but healthy lifestyles can partially offset the increased social environmental risk. The polysocial risk score can complement the existing risk tools to identify high-risk older populations, and guide the design of targeted social environmental interventions, particularly focusing on improving the companionship of the older people, to prevent dementia.

Perceptions about dementia clinical trials among underrepresented populations: A nationally representative survey of U.S. dementia caregivers

Background

The research community has historically failed to enroll diverse groups of participants in dementia clinical trials. A unique aspect of dementia care research is the requirement of a study partner, who can attest to the care recipient's clinical and functional capacity. The aim of this study is to assess racial and ethnic differences and the importance of various trial considerations among dementia caregivers, in their decision to participate in clinical research as study partners.

Method

We embedded a vignette about a hypothetical dementia clinical trial in a nationally representative survey of U.S. dementia caregivers, oversampling non-Hispanic Black and Hispanic caregivers. Dementia caregivers were asked about their willingness to participate in the trial with their care recipient and rated the importance of nine considerations in hypothetical decisions to participate. Caregiver demographic characteristics were analyzed as predictors of trial participation in a base demographic model. In a second reasons model caregiver demographic characteristics and the rated importance of the nine considerations were separately analyzed as predictors; both models used survey-weighted logistic regression.

Result

The sample consisted of 610 dementia caregivers, including 156 non-Hispanic Black and 122 Hispanic caregiver participants. In the base demographic model, hypothetical trial participation was negatively associated with older caregiver age (OR (odds ratio) = 0.72, p = < 0.001). In the reasons model, the rated importance of a social responsibility to help others by participating in research was significantly associated with participation (OR = 1.56, p = 0.049), while the importance of the possibility of the care recipient experiencing serious side effects was negatively associated with participation (OR = 0.51, p = 0.003). In both models there was no significant difference in hypothetical participation between non-Hispanic Black and non-Hispanic White caregivers, or between Hispanic and non-Hispanic White caregivers.

Conclusion

Hispanic and non-Hispanic Black dementia caregivers were not less likely than non-Hispanic White dementia caregivers to participate in a hypothetical dementia clinical trial. Our study suggests that failures to recruit diverse populations in dementia clinical research are not attributable to less willingness among members of underrepresented groups but may instead reflect structural barriers and historic exclusion from trial participation.

Differentiating Prodromal Dementia with Lewy Bodies from Prodromal Alzheimer's Disease: A Pragmatic Review for Clinicians

This pragmatic review synthesises the current understanding of prodromal dementia with Lewy bodies (pDLB) and prodromal Alzheimer's disease (pAD), including clinical presentations, neuropsychological profiles, neuropsychiatric symptoms, biomarkers, and indications for disease management. The core clinical features of dementia with Lewy bodies (DLB)-parkinsonism, complex visual hallucinations, cognitive fluctuations, and REM sleep behaviour disorder are common prodromal symptoms. Supportive clinical features of pDLB include severe neuroleptic sensitivity, as well as autonomic and neuropsychiatric symptoms. The neuropsychological profile in mild cognitive impairment attributable to Lewy body pathology (MCI-LB) tends to include impairment in visuospatial skills and executive functioning, distinguishing it from MCI due to AD, which typically presents with impairment in memory. pDLB may present with cognitive impairment, psychiatric symptoms, and/or recurrent episodes of delirium, indicating that it is not necessarily synonymous with MCI-LB. Imaging, fluid and other biomarkers may play a crucial role in differentiating pDLB from pAD. The current MCI-LB criteria recognise low dopamine transporter uptake using positron emission tomography or single photon emission computed tomography (SPECT), loss of REM atonia on polysomnography, and sympathetic cardiac denervation using meta-iodobenzylguanidine SPECT as indicative biomarkers with slowing of dominant frequency on EEG among others as supportive biomarkers. This review also highlights the emergence of fluid and skin-based biomarkers. There is little research evidence for the treatment of pDLB, but pharmacological and non-pharmacological treatments for DLB may be discussed with patients. Non-pharmacological interventions such as diet, exercise, and cognitive stimulation may provide benefit, while evaluation and management of contributing factors like medications and sleep disturbances are vital. There is a need to expand research across diverse patient populations to address existing disparities in clinical trial participation. In conclusion, an early and accurate diagnosis of pDLB or pAD presents an opportunity for tailored interventions, improved healthcare outcomes, and enhanced quality of life for patients and care partners.

How Do Modifiable Risk Factors Affect Alzheimer's Disease Pathology or Mitigate Its Effect on Clinical Symptom Expression?

Epidemiological studies show that modifiable risk factors account for approximately 40% of the population variability in risk of developing dementia, including sporadic Alzheimer's disease (AD). Recent findings suggest that these factors may also modify disease trajectories of people with autosomal-dominant AD. With positron emission tomography imaging, it is now possible to study the disease many years before its clinical onset. Such studies can provide key knowledge regarding pathways for either the prevention of pathology or the postponement of its clinical expression. The former "resistance pathway" suggests that modifiable risk factors could affect amyloid and tau burden decades before the appearance of cognitive impairment. Alternatively, the resilience pathway suggests that modifiable risk factors may mitigate the symptomatic expression of AD pathology on cognition. These pathways are not mutually exclusive and may appear at different disease stages. Here, in a narrative review, we present neuroimaging evidence that supports both pathways in sporadic AD and autosomal-dominant AD. We then propose mechanisms for their protective effect. Among possible mechanisms, we examine neural and vascular mechanisms for the resistance pathway. We also describe brain maintenance and functional compensation as bases for the resilience pathway. Improved mechanistic understanding of both pathways may suggest new interventions.

Food resources and kitchen skills plus aerobic training (FoRKS+) for black adults with hypertension: A pilot trial protocol

BACKGROUND

Midlife hypertension is associated with cognitive decline and Alzheimer's disease and related dementia (ADRD), suggesting that blood pressure control may be a therapeutic target for dementia prevention. Given excess hypertension in non-Hispanic Black (NHB) adults, blood pressure control may also reduce ADRD disparities. We describe a pilot randomized controlled trial (RCT) to evaluate the feasibility and preliminary efficacy of a multicomponent lifestyle-based intervention versus enhanced usual care on cognition among middle-aged NHB adults.

METHODS AND STUDY DESIGN

The Food Resources and Kitchen Skills plus Aerobic Training (FoRKS+) study is a 2-arm, single-blinded trial that compares those receiving the FoRKS+ program (target N = 64) versus those receiving enhanced usual care (target N = 64) in local federally-qualified health centers. Key eligibility criteria include self-identified NHB adults between ages 35-75 with a mean systolic blood pressure ≥ 130 mm/Hg obtained from 24-h ambulatory blood pressure monitoring. The FoRKS+ program includes 5 weeks of hypertension self-management courses, 11 weeks of nutrition courses, and 12 weeks of aerobic training in dietitian and health coach-led virtual groups. We will collect data on primary cognitive outcomes, feasibility, hypothesized intervention mediators and moderators, and demographic and health covariates at baseline, near intervention weeks 16-, and 28 (primary outcome assessment), and week 52 follow-up. We will use mixed-effects modeling to examine intervention effects on cognition.

DISCUSSION

This pilot RCT will examine the feasibility and preliminary effects of a multicomponent lifestyle intervention on cognitive function in NHB adults, which may have implications for reducing health disparities in ADRD.

Estimating trans-ancestry genetic correlation with unbalanced data resources

The aim of this paper is to propose a novel method for estimating trans-ancestry genetic correlations in genome-wide association studies (GWAS) using genetically-predicted observations. These correlations describe how genetic architecture of complex traits varies among populations. Our new estimator corrects for biases arising from prediction errors in high-dimensional weak GWAS signals, while addressing the ethnic diversity inherent in GWAS data, such as linkage disequilibrium (LD) differences. A distinguishing feature of our approach is its flexibility regarding sample sizes: it necessitates a large GWAS sample only from one population, while the secondary population may have a much smaller cohort, even in the hundreds. This design directly addresses the existing imbalance in GWAS data resources, where datasets for European populations typically outnumber those of non-European ancestries. Through extensive simulations and real data analysis from the UK Biobank study encompassing 26 complex traits, we validate the reliability of our method. Our results illuminate the broader implications of transferring genetic findings across diverse populations.

Normative data for the Digit Symbol Substitution for diverse Hispanic/Latino adults: Results from the Study of Latinos-Investigation of Neurocognitive Aging (SOL-INCA)

INTRODUCTION

Executive functioning and processing speed are crucial elements of neuropsychological assessment. To meet the needs of the Hispanic/Latino population, we aimed to provide normative data for the Digit Symbol Substitution (DSS) test.

METHODS

The target population for the Study of Latinos-Investigation of Neurocognitive Aging included six heritage backgrounds (n = 6177). Average age was 63.4 ± 8.3 years, 54.5% were female, and mean education was 11.0 ± 4.7 years. Participants were administered the DSS as part of a larger battery. Heritage-adjusted DSS scores, and percentile cut-points were created using survey-adjusted regression and quantile regression models.

RESULTS

Age, education, sex, heritage, and language preference were associated with DSS scores.

DISCUSSION

Significant correlates of DSS performance should be considered when evaluating cognitive performance. Representative DSS norms for Hispanics/Latinos will advance assessment and accuracy of neurocognitive disorder diagnosis in clinical practice. To facilitate interpretation, we provide norms to reduce test biases and developed an online dashboard.

Highlights

Normative data for the Digit Symbol Substitution (DSS) for diverse Hispanic/Latino adults: Results from the Study of Latinos-Investigation of Neurocognitive Aging (SOL-INCA) This study is the first to develop norms for the DSS test across four regions of the United States.Factors such as age, education, sex, and Hispanic/Latino heritage and language preference are associated with differences in executive functioning and information processing speed.We created norms and an online dashboard (https://solincalab.shinyapps.io/dsst_shiny/) providing an easily accessible tool to evaluate processing speed and executive functioning in Hispanic/Latino adults.

Ethnoracial Identity and Cognitive Impairment: A Community Study

BACKGROUND

Identifying potentially modifiable risk factors associated with MCI in different ethnoracial groups could reduce MCI burden and health inequity in the population.

METHODS

Among 2845 adults aged 65+ years, we investigated potential risk exposures including education, physical and mental health, lifestyle, and sensory function, and their cross-sectional associations with MCI. We compared proportions of exposures between Black and White participants and explored relationships among race, MCI, and exposures. Logistic regression modeled MCI as a function of each exposure in the overall sample adjusting for age, sex, educational level, and race, and investigating race*exposure interactions.

RESULTS

Compared with White participants, Black participants had greater odds of MCI (OR 1.53; 95% CI, 1.13 to 2.06) and were more likely to report depressive symptoms, diabetes, and stroke, to have high blood pressure and BMI, and to be APOE - 4 carriers. Exposures associated with higher odds of MCI were diabetes, stroke, lifetime smoking, sleep disturbances, social isolation, loneliness, depression and anxiety symptoms, and vision and hearing loss. There were no significant interactions between race and any exposure.

CONCLUSIONS

Black participants had 53% higher odds of MCI adjusting for age, sex, and education. The same exposures were associated with MCI in Black and White participants.

Cognitive impairment and partnership status in the United States, 1998-2016, by sex, race/ethnicity, and education

Cognitively impaired adults without a partner are highly disadvantaged, as partners constitute an important source of caregiving and emotional support. With the application of innovative multistate models to the Health and Retirement Study, this paper is the first to estimate joint expectancies of cognitive and partnership status at age 50 by sex, race/ethnicity, and education in the United States. We find that women live a decade longer unpartnered than men. Women are also disadvantaged as they experience three more years as both cognitively impaired and unpartnered than men. Black women live over twice as long as cognitively impaired and unpartnered compared with White women. Lower-educated men and women live around three and five years longer, respectively, as cognitively impaired and unpartnered than more highly educated men and women. This study addresses a novel facet of partnership and cognitive status dynamics and examines their variations by key socio-demographic factors.

Cost of care for Alzheimer's disease and related dementias in the United States: 2016 to 2060

Medical and long-term care for Alzheimer's disease and related dementias (ADRDs) can impose a large economic burden on individuals and societies. We estimated the per capita cost of ADRDs care in the in the United States in 2016 and projected future aggregate care costs during 2020-2060. Based on a previously published methodology, we used U.S. Health and Retirement Survey (2010-2016) longitudinal data to estimate formal and informal care costs. In 2016, the estimated per patient cost of formal care was $28,078 (95% confidence interval [CI]: $25,893-$30,433), and informal care cost valued in terms of replacement cost and forgone wages was $36,667 ($34,025-$39,473) and $15,792 ($12,980-$18,713), respectively. Aggregate formal care cost and formal plus informal care cost using replacement cost and forgone wage methods were $196 billion (95% uncertainty range [UR]: $179-$213 billion), $450 billion ($424-$478 billion), and $305 billion ($278-$333 billion), respectively, in 2020. These were projected to increase to $1.4 trillion ($837 billion-$2.2 trillion), $3.3 trillion ($1.9-$5.1 trillion), and $2.2 trillion ($1.3-$3.5 trillion), respectively, in 2060.

Loss of Autonomy: Likely Dementia and Living Arrangement Transitions Among Mexicans and Mexican Americans

BACKGROUND AND OBJECTIVES

To examine the role of probable dementia on changes in living arrangements and mortality among very old Mexicans and Mexican Americans in 2 different nations.

RESEARCH DESIGN AND METHODS

We employ the Hispanic Established Population for the Epidemiologic Study of the Elderly and the Mexican Health and Aging Study, 2 comparable longitudinal data sets, to identify predictors of changes in living arrangements using multinomial logistic regression, controlling for cognitive status, demographic characteristics, and resources.

RESULTS

In Mexico, women with dementia who lived alone at baseline were more likely to become part of an extended family household than men with similar levels of cognitive impairment. A similar pattern emerges for the oldest Mexican-American women. Spousal loss increases the likelihood of living alone for women in the United States regardless of dementia. Although dementia elevates the risk of mortality for men living alone in the United States, in both countries, women in their 90s who lived alone with dementia had a lower risk of mortality relative to men.

DISCUSSION AND IMPLICATIONS

Longer life spans increase the risk of living alone with dementia in both countries, especially for women. Older individuals in both countries face financial hardships. Mexicans have limited formal options in dementia care. Mexican Americans with dementia continue to live alone despite low income although, unlike the Mexicans, they have access to Medicaid long-term care. For Mexico and the United States, the growing number of older individuals with dementia represents a growing public health concern.

Association Between Sleep Quantity and Quality in Early Adulthood With Cognitive Function in Midlife

BACKGROUND AND OBJECTIVE

Growing evidence supports an association between sleep quality and risk of dementia. However, little is known about whether objectively measured sleep duration and quality influence cognition in midlife, a period of importance for understanding the direction of the association between sleep and dementia. We examined the association between sleep duration and quality, measured when participants were in their mid-30s to late 40s, and midlife cognition assessed 11 years later among Black and White adults.

METHODS

As part of the Coronary Artery Risk Development in Young Adults cohort study, sleep duration and quality were assessed objectively using wrist actigraphy and subjectively by Pittsburgh Sleep Quality Index (PSQI) at 2003-2005. During 2015-2016, we evaluated midlife cognition using the Digit Symbol Substitution Test (DSST), Stroop test, Rey Auditory Verbal Learning Test, Montreal Cognitive Assessment (MoCA), and Letter Fluency and Category Fluency tests. We used multivariable logistic regression to examine the association between sleep parameters and poor cognitive performance, which was defined as a score that was >1 SD below the mean score.

RESULTS

The 526 participants (58% women and 44% Black) had a mean age of 40.1 ± 3.6 years at baseline, a mean sleep duration of 6.1 ± 1.1 hours, and mean sleep fragmentation index (calculated as the sum of the percentage of time spent moving and the percentage of immobile periods ≤1 minute) of 19.2 ± 8.1%, and 239 (45.6%) participants reported poor sleep as defined by a PSQI global score of >5. After adjustment for demographics, education, smoking, body mass index, depression, physical activity, hypertension, and diabetes, those in the highest vs lowest tertile of sleep fragmentation index had over twice the odds of having poor cognitive performance (>1 SD below the mean) on the DSST (odds ratio [OR] = 2.97; 95% CI 1.34-6.56), fluency (OR = 2.42; 95% CI 1.17-5.02), and MoCA test (OR = 2.29; 95% CI 1.06-4.94). The association between sleep fragmentation and cognitive performance did not differ by race or sex. Objective sleep duration or subjective sleep quality was not associated with cognition in midlife.

DISCUSSION

Actigraphy-measured high sleep fragmentation rather than sleep duration was associated with worse cognition among middle-aged Black and White men and women. Sleep quality is important for cognitive health even as early as midlife.

Forecasting the 20-Year Incidence of Dementia by Socioeconomic Status, Race/Ethnicity, and Region Based on Mid-Life Risk Factors in a U.S. Nationally Representative Sample

Background

Alzheimer's disease and related dementias (ADRD) incidence varies based on demographics, but mid-life risk factor contribution to this variability requires more research.

Objective

The purpose of this study is to forecast the 20-year incidence of dementia in the U.S. overall and stratified by race/ethnicity, socioeconomic status (SES), and U.S. geographic region given prior mid-life risk factor prevalence and to examine the extent to which risk factor differences 20 years ago may explain current SES, race/ethnicity, or regional disparities in dementia incidence.

Methods

We applied the Cardiovascular Risk Factors, Aging, and Incidence of Dementia (CAIDE) prediction model to the 2006 wave of the Health and Retirement Study (HRS) in participants aged 45 to 64 to estimate the 20-year risk of incident ADRD.

Results

The 20-year risk of dementia among middle-aged Americans was 3.3% (95% CI: 3.2%, 3.4%). Dementia incidence was forecast to be 1.51 (95% CI: 1.32, 1.71) and 1.27 (95% CI: 1.14, 1.44) times that in Hispanic and Non-Hispanic Black individuals respectively compared statistically to Non-Hispanic White individuals given mid-life risk factors. There was a progressive increase in dementia risk from the lowest versus highest SES quintile. For geographic region, dementia incidence was forecast to be 1.17 (95% CI: 1.06, 1.30) and 1.27 (95% CI: 1.14, 1.43) times that in Midwestern and Southern individuals respectively compared statistically to Western individuals.

Conclusions

Some disparities in dementia incidence could be explained by differences in mid-life risk factors and may point toward policy interventions designed to lessen the ADRD disease burden through early prevention.

The importance of education for understanding variability of dementia onset in the United States

BACKGROUND

Greater levels of education are associated with lower risk of dementia, but less is known about how education is also associated with the compression of dementia incidence.

OBJECTIVE

We extend the literature on morbidity compression by evaluating whether increased levels of education are associated with greater dementia compression. We evaluate these patterns across race and gender groups.

METHODS

We use the Health and Retirement Study (2000-2016), a nationally representative longitudinal study of older adults in the United States. To evaluate the onset and compression of dementia across education groups, we examine the age-specific distribution of dementia events, identifying the modal age of onset and the standard deviation above the mode (a measure of compression).

RESULTS

While the modal age of onset is around 85 years among adults with a college degree, the modal age for adults with less than a high school education occurs before age 65 - at least a 20-year difference. The standard deviation of dementia onset is about three times greater for adults with less than a high school education compared to adults with a college degree. Patterns were consistent across race and gender groups.

CONCLUSION

This research highlights the variability of dementia experiences in the older population by documenting differences in longevity without dementia and compression of dementia onset among more educated adults and less educated adults.

CONTRIBUTION

We incorporate conceptual insights from the life span variability and compression literature to better understand education-dementia disparities in both the postponement and uncertainty of dementia onset in the US population.

State-level desegregation in the U.S. South and mid-life cognitive function among Black and White adults

RATIONALE

Black adults experience worse cognitive function than their White peers. Although educational attainment is an important predictor of cognitive function, other aspects of education, including school desegregation, may also shape this relationship. For Black adults who grew up in the U.S. South in the 1950s-1970s, exposure to school desegregation may have altered life course pathways critical for later cognitive function.

OBJECTIVE

We determined if state variation in exposure to school desegregation in the U.S. South was associated with cognitive function at mid-life, if the association varied by race, and if the association remained after adjustment for state-level education quality and respondents' educational attainment.

METHODS

We linked historical data on state-level school desegregation to the Health and Retirement Study, a nationally representative sample of U.S. adults aged 50 and older. We restricted our sample to Black (n = 1443) and White (n = 1507) adults born between 1948 and 1963 who resided in the U.S. South during primary school. We assessed three cognition outcomes: total cognitive function, episodic memory, and mental status. We estimated race-stratified linear regression models with cluster adjustment and a final model using state fixed effects.

RESULTS

Greater exposure to desegregated primary schooling was associated with higher cognitive function and episodic memory among Black but not White adults. Among Black adults, the association between school desegregation and cognitive function and episodic memory remained after adjustment for state-level education quality and educational attainment.

CONCLUSIONS

Our findings suggest that state-level school desegregation efforts played a consequential role in shaping the cognitive function of Black adults who grew up in the U.S. South.

Environmental, Sociocultural, Behavioral, and Biological Factors Associated with Cognitive Decline, Alzheimer's Disease, and Other Types of Dementia in Black Americans

Purpose of Review

This narrative review summarizes environmental, sociocultural, behavioral, and biological factors associated with cognitive decline and dementia in Black Americans.

Recent Findings

Variations in environmental factors (education, toxins) contribute to poor cognition in Blacks. Historical context, early-life educational experiences, and environmental exposures should be considered for addressing late-life cognitive disparities. Sociocultural (stress, discrimination, social networks, social activity, loneliness) and behavioral (depression, coping, health behaviors) factors can have positive and negative implications for cognitive aging. Given these factors are not consistently shown to play a role in maintaining cognition in Blacks, further examination is needed. Cardiometabolic conditions increase the risk of cognitive issues and are more common in Blacks; thus, examination of biological mechanisms (inflammation, vascular changes, etc.) warrants further study.

Summary

Future studies should explore the impact of education and segregation and identify mechanisms linking stress and discrimination to cognitive outcomes. Further, culturally tailored programs focused on preventative behaviors are needed to enhance health outcomes and reduce disparities.

Cost effectiveness of non-drug interventions that reduce nursing home admissions for people living with dementia

INTRODUCTION

Six million Americans live with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), a major health-care cost driver. We evaluated the cost effectiveness of non-pharmacologic interventions that reduce nursing home admissions for people living with AD/ADRD.

METHODS

We used a person-level microsimulation to model the hazard ratios (HR) on nursing home admission for four evidence-based interventions compared to usual care: Maximizing Independence at Home (MIND), NYU Caregiver (NYU); Alzheimer's and Dementia Care (ADC); and Adult Day Service Plus (ADS Plus). We evaluated societal costs, quality-adjusted life years and incremental cost-effectiveness ratios.

RESULTS

All four interventions cost less and are more effective (i.e., cost savings) than usual care from a societal perspective. Results did not materially change in 1-way, 2-way, structural, and probabilistic sensitivity analyses.

CONCLUSION

Dementia-care interventions that reduce nursing home admissions save societal costs compared to usual care. Policies should incentivize providers and health systems to implement non-pharmacologic interventions.

Risk of neurodegenerative disease or dementia in adults with attention-deficit/hyperactivity disorder: a systematic review

Purpose of review

Several psychiatric disorders have been associated with an increased risk of developing a neurodegenerative disease and/or dementia. Attention-deficit/hyperactivity disorder (ADHD), a neurodevelopmental disorder, has been understudied in relation to dementia risk. We summarized existing literature investigating the risk of incident neurodegenerative disease or dementia associated with ADHD.

Recent findings

We searched five databases for cohort, case-control, and clinical trial studies investigating associations between ADHD and neurodegenerative diseases/dementia in May 2023. Study characteristics were extracted by two independent raters, and risk of bias was assessed using the Newcastle Ottawa Scale. Search terms yielded 2,137 articles, and seven studies (five cohort and two case-control studies) ultimately met inclusion criteria. Studies examined the following types of neurodegeneration: all-cause dementia, Alzheimer's disease, Parkinson's and Lewy body diseases, vascular dementia, and mild cognitive impairment. Heterogeneity in study methodology, particularly covariates used in analyses and types of ratios for risk reported, prevented a meta-analysis and data were therefore summarized as a narrative synthesis. The majority of studies (4/7) demonstrated an overall low risk of bias.

Summary

The current literature on risk of developing a neurodegenerative disease in ADHD is limited. Although the studies identified present evidence for a link between ADHD and subsequent development of dementia, the magnitude of the direct effect of ADHD on neurodegeneration is yet to be determined and better empirically designed studies are first needed. Furthermore, the mechanism of how or why ADHD is associated with an increased risk of developing a neurocognitive disorder is still unclear and should be explored in future studies.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022348976, the PROSPERO number is CRD42022348976.

The structural and social determinants of Alzheimer's disease related dementias

INTRODUCTION

The projected growth of Alzheimer's disease (AD) and AD-related dementia (ADRD) cases by midcentury has expanded the research field and impelled new lines of inquiry into structural and social determinants of health (S/SDOH) as fundamental drivers of disparities in AD/ADRD.

METHODS

In this review, we employ Bronfenbrenner's ecological systems theory as a framework to posit how S/SDOH impact AD/ADRD risk and outcomes.

RESULTS

Bronfenbrenner defined the "macrosystem" as the realm of power (structural) systems that drive S/SDOH and that are the root cause of health disparities. These root causes have been discussed little to date in relation to AD/ADRD, and thus, macrosystem influences, such as racism, classism, sexism, and homophobia, are the emphasis in this paper.

DISCUSSION

Under Bronfenbrenner's macrosystem framework, we highlight key quantitative and qualitative studies linking S/SDOH with AD/ADRD, identify scientific gaps in the literature, and propose guidance for future research.

HIGHLIGHTS

Ecological systems theory links structural/social determinants to AD/ADRD. Structural/social determinants accrue and interact over the life course to impact AD/ADRD. Macrosystem is made up of societal norms, beliefs, values, and practices (e.g., laws). Most macro-level determinants have been understudied in the AD/ADRD literature.

Barriers and solutions to Alzheimer's disease clinical trial participation for Black Americans

Introduction

Black Americans are disproportionately burdened by Alzheimer's disease (AD) relative to other racial groups in the United States and continue to be underrepresented in AD clinical trials. This review explores the primary barriers for participation in clinical trials among Black Americans and provides literature-based recommendations to improve the inclusion of Black Americans in AD clinical trials.

Methods

We searched electronic databases and gray literature for articles published in the United States through January 1, 2023, ultimately identifying 26 key articles for inclusion.

Results

Barriers to participation in clinical trials for Black Americans are rooted in social determinants of health, including access to quality education and information, access to health care, economic stability, built environment, and community context. Best practices to improve the inclusion of Black Americans in clinical trials require pharmaceutical companies to adopt a multifaceted approach, investing in innovative strategies for site selection, development of local partnerships, outreach, and education.

Discussion

While multisectoral action must occur to effectively address the disproportionate burden of AD on Black Americans, the pharmaceutical industry has an important part to play in this space due to their central role in product development and clinical trials.

Dementia literacy of racially minoritized people in a Chinese society: a qualitative study among South Asian migrants in Hong Kong

OBJECTIVES

Research on dementia literacy in Chinese societies is still emerging, and this is especially the case among racially minoritized groups. The present study explored the knowledge, causal beliefs, and help-seeking behaviors of South Asian migrants in Hong Kong about dementia. It also investigated existing community barriers related to dementia knowledge and help-seeking.

DESIGN

We conducted a qualitative study from a purposive sample of 38 older people and family caregivers from India, Pakistan, and Nepal who lived in Hong Kong. Focus groups and individual in-depth interviews were used to gather information, while thematic analysis was employed to analyze the data.

RESULTS

Five main themes were identified: normalization with stigmatization of dementia; spiritual and psychosocial attributions of dementia; familial responsibility despite potential caregiving burden; uncertainties versus openness to professional care; and barriers and opportunities in dementia literacy. Ethnic minorities recognized dementia as a disease of normal aging or a mental disorder. They also perceived spiritual and psychosocial factors as their main causes. While participants recognized the potential burden of dementia caregiving, families were their first point of help-seeking, as many of them expressed contrasting feelings of confidence or doubt toward professional services. Utilization of health education strategies, together with collaboration with community leaders, could address the barriers to dementia literacy.

CONCLUSIONS

This is the first study to explore how ethnic minorities in Asia perceive dementia and its related help-seeking behaviors in their communities. South Asian migrants in Hong Kong have a limited understanding of dementia and may experience delays in obtaining relevant community services. While culture influenced their knowledge, health education may address their misperceptions and help-seeking behaviors toward dementia. Culture- and language-specific programs could also improve dementia knowledge and health service access.