Lifetime discrimination burden, racial discrimination, and subclinical cerebrovascular disease among African Americans

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.

Pathways to Racial/Ethnic Inequalities in Dementia

Individuals from minoritized racial/ethnic groups face a disproportionate burden of Alzheimer's disease and related dementias. This health inequality reflects structural racism, which creates and sustains racial differences in social determinants of health, including education access and quality, economic stability, social and community context, neighborhood and built environment, and health care access and quality. Thus, understanding pathways that lead to dementia inequalities requires addressing individual- and system-level factors. This article summarizes evidence linking each social determinant of health to racial/ethnic inequalities in dementia, emphasizing upstream factors and mechanisms as potential levels of intervention. The importance of resilience in marginalized groups as well as critical research considerations for dementia inequalities are also discussed. Future directions highlight the need to understand the common and unique mechanisms driving inequalities across minoritized groups, where research is lacking.

Genome-wide transcriptome differences associated with perceived discrimination in an urban, community-dwelling middle-aged cohort

Discrimination is a social adversity that is linked to several age-related outcomes. However, the molecular drivers of these observations are poorly understood. Social adverse factors are associated with proinflammatory and interferon gene expression, but little is known about whether additional genes are associated with discrimination among both African American and White adults. In this study, we examined how perceived discrimination in African American and White adults was associated with genome-wide transcriptome differences using RNA sequencing. Perceived discrimination was measured based on responses to self-reported lifetime discrimination and racial discrimination. Differential gene expression and pathway analysis were conducted in a cohort (N = 59) stratified by race, sex, and overall discrimination level. We found 28 significantly differentially expressed genes associated with race among those reporting high discrimination. Several of the upregulated genes for African American versus White adults reporting discrimination were related to immune function IGLV2-11, S100B, IGKV3-20, and IGKV4-1; the most significantly downregulated genes were associated with immune modulation and cancer, LUCAT1, THBS1, and ARPIN. The most enriched gene ontology biological process between African American and White men reporting high discrimination was the regulation of cytokine biosynthetic processes. The immune response biological process was significantly lower for African American women compared to White women reporting high discrimination. Discrimination was associated with the expression of small nucleolar RNAs, long noncoding RNAs, and microRNAs associated with energy homeostasis, cancer, and actin. Understanding the pathways through which adverse social factors like discrimination are associated with gene expression is crucial in advancing knowledge of age-related health disparities.

Associations between discriminatory experiences and dementia in the Health and Retirement Study

Dramatic racial and ethnic disparities in dementia necessitate research into potential risk factors and points of intervention. Using data from a large sample (n = 13,733) of older US residents participating in the Health and Retirement Study between 2006 and 2016, we investigated relationships between everyday and major discrimination and development of dementia. Data on self-reported everyday and major discrimination were collected via questionnaires. Algorithmic classification of probable dementia status was determined via a battery of cognitive tests. We used logistic regression models, and analyses were stratified by race and ethnicity and sex. We found that overall, more frequent experiences of everyday discrimination were associated with higher odds of developing dementia (odds ratio (OR) = 1.18; 95% confidence interval (CI): 1.10, 1.27; p < 0.001). Estimates stratified by race similarly suggested the positive association between everyday discrimination and odds of dementia onset was highest in non-Hispanic Black participants (OR: 1.30; 95% CI: 1.13, 1.51; p < 0.001). Our results reveal a link between frequency of everyday experiences of discrimination and dementia onset and highlight the role of psychosocial exposures in health and disease. This study underlines the impact that psychosocial stressors can have on cognitive health. Interventions addressing psychosocial risk factors experienced disproportionately by historically marginalized groups may be crucial in the goal to mitigate dementia disparities and achieve dementia equity.

Nursing's Role in Psychosocial Health Management After a Stroke Event: A Scientific Statement From the American Heart Association

INTRODUCTION

Stroke can have profound psychosocial health implications. These constructs are often overlooked and undertreated yet can be as devastating as the physical, functional, and cognitive consequences after stroke.

AIM

This scientific statement aims to evaluate 5 important aspects of psychosocial health (depression, stress, anxiety, fatigue, and quality of life) after a stroke to provide a framework for related nursing care across the poststroke continuum.

METHODS

A narrative review of the literature published from 2018 to 2023 was conducted with databases such as PubMed/MEDLINE, ClinicalTrials.gov, PsychInfo/EBSCOHost, PsychArticles, CINHAL, and the Cochrane Library.

RESULTS

Findings reveal a gap in evidence-based nursing interventions for addressing poststroke psychosocial needs. Critical strategies for shaping therapeutic nursing care include enhanced screening with validated tools; educating stroke survivors, families, and staff on symptom recognition, prevention, and treatment; and ensuring appropriate pharmacological management and access to psychological and psychosocial interventions, including referrals to social services and other essential support systems. Care should be comprehensive and interdisciplinary. Nurse-led research can benefit from more inclusive inclusion, including individuals with recurrent strokes and preexisting psychosocial conditions, focusing on the impact of structural racism and care disparities and expanding evidence-based nursing interventions.

CONCLUSIONS

Although there is limited high-level evidence on the nursing care for patients with suboptimal psychosocial health after stroke, nurses have a crucial role in addressing these needs. Enhanced screening, assessment, supportive services, and education are vital to ensure that patients receive the necessary treatment and care.

Discrimination and Cardiovascular Health in Black Americans: Exploring Inflammation as a Mechanism and Perceived Control as a Protective Factor

OBJECTIVE

Inflammation may be an integral physiological mechanism through which discrimination impacts cardiovascular health and contributes to racial health disparities. Limited research has examined psychosocial factors that protect against the negative effects of discrimination on inflammation. Perceived control is a promising possible protective factor, given that it has been shown to moderate the relationship between other psychosocial stressors and physiological outcomes. This study thus tested whether systemic inflammation mediated the link between discrimination and cardiovascular health and whether perceived control moderated this relationship.

METHODS

Data for this project included 347 non-Hispanic/Latinx Black adults (mean [standard deviation] age = 51.64 [11.24] years; 33% female) taken from the Midlife in the United States study. Perceived control and daily discrimination were assessed via self-report, and inflammation was measured via circulating levels of C-reactive protein (CRP), interleukin-6 (IL-6), fibrinogen, and tumor necrosis factor α. Cardiovascular health was measured by morbidity of cardiovascular conditions: heart disease, hypertension, and/or stroke.

RESULTS

CRP (indirect effect: b = 0.004, 95% confidence interval [CI] = 0.001-0.007) and fibrinogen (indirect effect: b = 0.002, 95% CI = 0.0003-0.005) mediated the link between discrimination and cardiovascular conditions. Perceived control moderated the relationship between discrimination and CRP ( F (1, 293) = 4.58, Δ R2 = 0.013, b = -0.02, SE = 0.01, p = .033). CRP mediated the link between discrimination and cardiovascular conditions only for those who reported low levels of perceived control (Index = -0.003, 95% CI = -0.007 to -0.0001).

CONCLUSION

Findings provide empirical evidence of inflammation as a mechanism linking discrimination to cardiovascular conditions among Black Americans. Additionally, perceived control may be protective. Findings could suggest beliefs about control as a potential intervention target to help reduce the negative effects of discrimination on cardiovascular health among Black Americans.

Black-White differences in perceived lifetime discrimination by education and income in the MIDUS Study in the U.S

There is growing evidence on the negative effects of perceived discrimination on health outcomes and their interactions with indicators of socioeconomic status. However, less has been studied on whether income and education lead individuals of a different race to encounter different discriminatory experiences in their lifetime. Using data from the national survey of the Midlife Development in the United States-MIDUS 1 (1995-1996) and MIDUS Refresher (2011-2014)-on eight measures of perceived lifetime discrimination, this study compares discriminatory experiences of Black and White persons in two time periods. We applied generalized structural equation models and generalized linear models to test multiplicative effects of income and education by race on lifetime discrimination. In both periods, we find substantive disparities between White and Black people in all types of lifetime discrimination, with Black people reporting much higher levels of discrimination. Such disparities exacerbated in the top cohorts of society, yet these associations have changed in time, with White individuals reporting increasing levels of discrimination. Results show that, for Black people in the mid-1990s, perceived discrimination increased as education and income increased. This finding persisted for education by the early 2010s; income effects changed as now both, low- and high-income Black people, reported the highest levels of discrimination. These findings highlight a policy conundrum, given that increasing income and education represent a desirable course of action to improve overall discrimination and health outcomes. Yet, we show that they may unintendingly exacerbate racial disparities in discrimination. We also show that the U.S. is moving toward a stagnation period in health outcomes improvement, with racial disparities in discrimination shrinking at the expense of a deterioration of whites' lifetime discriminatory experiences. Our results highlight the need for a multi-systems policy approach to prevent all forms of discrimination including those due to historical, institutional, legal, and sociopolitical structures.

Longitudinal associations between racial discrimination and hippocampal and white matter hyperintensity volumes among older Black adults

RATIONALE

Non-Hispanic Black older adults are at higher risk of Alzheimer's disease and related dementias (ADRD) than non-Hispanic Whites, which reflects racial disparities in both brain and cognitive health. Discrimination may contribute to these disparities, but much of the research on discrimination and ADRD outcomes is cross-sectional and/or does not disaggregate experiences of discrimination by attribution. Focusing specifically on racial discrimination and considering longitudinal brain outcomes may advance our understanding of the role of discrimination in explaining disproportionate rates of ADRD among non-Hispanic Black older adults.

METHODS

In total, 221 non-Hispanic Black participants in the Washington Heights-Inwood Columbia Aging Project completed multiple measures of discrimination at one time point and structural magnetic resonance imaging (MRI) scans at two time points. Everyday discrimination and lifetime discrimination were operationalized first as aggregate experiences of discrimination (regardless of identity attributions) and then as racial discrimination per se. MRI outcomes included hippocampal and white matter hyperintensity (WMH) volumes. Latent difference score models estimated associations between the discrimination measures and each MRI outcome over four years.

RESULTS

Aggregate discrimination (regardless of attributions) was not associated with either outcome. Lifetime racial discrimination was associated with lower initial hippocampal volume. Everyday racial discrimination was associated with faster accumulation of WMH over time.

CONCLUSIONS

Racial discrimination may be detrimental for brain aging among non-Hispanic Black older adults, which may contribute to their disproportionate dementia burden. Disaggregating discrimination by attribution may clarify research on racial inequalities in brain and cognitive aging, as racial discrimination appears to be particularly toxic.

Eradicating Racism: An Endocrine Society Policy Perspective

The Endocrine Society recognizes racism as a root cause of the health disparities that affect racial/ethnic minority communities in the United States and throughout the world. In this policy perspective, we review the sources and impact of racism on endocrine health disparities and propose interventions aimed at promoting an equitable, diverse, and just healthcare system. Racism in the healthcare system perpetuates health disparities through unequal access and quality of health services, inadequate representation of health professionals from racial/ethnic minority groups, and the propagation of the erroneous belief that socially constructed racial/ethnic groups constitute genetically and biologically distinct populations. Unequal care, particularly for common endocrine diseases such as diabetes, obesity, osteoporosis, and thyroid disease, results in high morbidity and mortality for individuals from racial/ethnic minority groups, leading to a high socioeconomic burden on minority communities and all members of our society. As health professionals, researchers, educators, and leaders, we have a responsibility to take action to eradicate racism from the healthcare system. Achieving this goal would result in high-quality health care services that are accessible to all, diverse workforces that are representative of the communities we serve, inclusive and equitable workplaces and educational settings that foster collaborative teamwork, and research systems that ensure that scientific advancements benefit all members of our society. The Endocrine Society will continue to prioritize and invest resources in a multifaceted approach to eradicate racism, focused on educating and engaging current and future health professionals, teachers, researchers, policy makers, and leaders.

Racial Residential Segregation in Young Adulthood and Brain Integrity in Middle Age: Can We Learn From Small Samples?

Racial residential segregation is associated with multiple adverse health outcomes in Black individuals. Yet, the influence of structural racism and racial residential segregation on brain aging is less understood. In this study, we investigated the association between cumulative exposure to racial residential segregation over 25 years (1985-2010) in young adulthood, as measured by the Getis-Ord Gi* statistic, and year 25 measures of brain volume (cerebral, gray matter, white matter, and hippocampal volumes) in midlife. We studied 290 Black participants with available brain imaging data who were enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a prospective cohort study. CARDIA investigators originally recruited 2,637 Black participants aged 18-30 years from 4 field centers across the United States. We conducted analyses using marginal structural models, incorporating inverse probability of treatment weighting and inverse probability of censoring weighting. We found that compared with low/medium segregation, greater cumulative exposure to a high level of racial residential segregation throughout young adulthood was associated with smaller brain volumes in general (e.g., for cerebral volume, β = -0.08, 95% confidence interval: -0.15, -0.02) and with a more pronounced reduction in hippocampal volume, though results were not statistically significant. Our findings suggest that exposure to segregated neighborhoods may be associated with worse brain aging.

Racism and Older Black Americans' Health: a Systematic Review

We reviewed research that examines racism as an independent variable and one or more health outcomes as dependent variables in Black American adults aged 50 years and older in the USA. Of the 43 studies we reviewed, most measured perceived interpersonal racism, perceived institutional racism, or residential segregation. The only two measures of structural racism were birth and residence in a "Jim Crow state." Fourteen studies found associations between racism and mental health outcomes, five with cardiovascular outcomes, seven with cognition, two with physical function, two with telomere length, and five with general health/other health outcomes. Ten studies found no significant associations in older Black adults. All but six of the studies were cross-sectional. Research to understand the extent of structural and multilevel racism as a social determinant of health and the impact on older adults specifically is needed. Improved measurement tools could help address this gap in science.

Vascular depression in Black Americans: A systematic review of the construct and its cognitive, functional, and psychosocial correlates

Objective: Vascular burden is associated with cognitive deficits and a form of late-life depression, vascular depression (VaDep), which is marked by decreased white matter integrity, executive dysfunction, poor treatment response, and functional disability. Older Black Americans represent a vulnerable population at risk of developing VaDep, but the literature in this group is limited. Thus, the goal of this systematic review is to summarize the existing literature that informs our understanding of VaDep in older Black Americans, including cognitive, functional, and psychosocial outcomes. Method: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, studies were identified that examined the relationship between vascular disease or vascular risk factors and that either had a sample of at least 75% Black participants or conducted race-specific analyses. Thirty studies met all inclusion criterion based on review of both authors. Results: Overall, studies support the construct of VaDep in older Black Americans. There is preliminary support for VaDep-related cognitive and functional deficits, and mixed findings regarding racial disparities in prevalence of VaDep. Conclusion: This review underscores the need for further neuroimaging and neuropsychological research in Black older adults with comorbid depression and vascular disease. Findings also highlight the importance of screening for depressive symptoms in Black individuals with multiple vascular risk factors.

Racial Discrimination and White Matter Microstructure in Trauma-Exposed Black Women

BACKGROUND

Experiences of racial discrimination are linked to a range of negative brain health outcomes, but little is known about how these experiences impact neural architecture, including white matter microstructure, which may partially mediate these outcomes. Our goal was to examine associations between racially discriminatory experiences and white matter structural integrity in a sample of Black American women.

METHODS

We recruited 116 Black American women as part of a long-standing study of trauma. Participants completed assessments of racial discrimination, trauma exposure, and posttraumatic stress disorder and underwent diffusion tensor imaging. Fractional anisotropy and mean diffusivity values were extracted from major white matter tracts throughout the brain.

RESULTS

Experiences of racial discrimination were associated with significantly lower fractional anisotropy in multiple white matter tracts, including the corpus callosum, cingulum, and superior longitudinal fasciculus (ps < .004), even after accounting for variance associated with trauma, posttraumatic stress disorder, and demographic- and scanner-related factors.

CONCLUSIONS

These findings suggest that experiences of racial discrimination are independently related to decrements in white matter microarchitecture throughout the brain. In individuals who have experienced other types of adversity, racial discrimination clearly has additive and distinctive deleterious effects on white matter structure. Our findings suggest a pathway through which racial discrimination can contribute to brain health disparities in Black Americans; the deleterious contributions of racial discrimination on the microstructure of major white matter pathways may increase vulnerability for the development of neurodegenerative disorders as well as the development of mental health problems.

At the Intersection of Race, Socioeconomics, and Chronic Illness: A Case and Frame Analysis of Two Survivor-Caregiver Dyads in the Aftermath of Stroke

Although the overall incidence of stroke in the United States has decreased in recent years, the incidence of stroke among Black Americans has not changed. This has resulted in a widening gap between White and Black stroke survivors and their families. A variety of factors contribute to this inequity including social determinants of health (e.g., adverse life events, discrimination, neighborhood deprivation, lack of access to health care). This article uses a "case and frame" approach, through the lens of ecological systems theory, to illustrate how social determinants of health express themselves in two stroke survivor-caregiver dyads living in a large Midwestern city. We draw out implications for practice and policy in social work and related disciplines that focus on recognizing the impact of social determinants of health, developing culturally-specific interventions that mitigate unique stressors but that also leverage unique strengths, and building capacity for cultural competence and cross-cultural health communication within organizations.

The accelerated aging phenotype: The role of race and social determinants of health on aging

The pursuit to discover the fundamental biology and mechanisms of aging within the context of the physical and social environment is critical to designing interventions to prevent and treat its complex phenotypes. Aging research is critically linked to understanding health disparities because these inequities shape minority aging, which may proceed on a different trajectory than the overall population. Health disparities are characteristically seen in commonly occurring age-associated diseases such as cardiovascular and cerebrovascular disease as well as diabetes mellitus and cancer. The early appearance and increased severity of age-associated disease among African American and low socioeconomic status (SES) individuals suggests that the factors contributing to the emergence of health disparities may also induce a phenotype of 'premature aging' or 'accelerated aging' or 'weathering'. In marginalized and low SES populations with high rates of early onset age-associated disease the interaction of biologic, psychosocial, socioeconomic and environmental factors may result in a phenotype of accelerated aging biologically similar to premature aging syndromes with increased susceptibility to oxidative stress, premature accumulation of oxidative DNA damage, defects in DNA repair and higher levels of biomarkers of oxidative stress and inflammation. Health disparities, therefore, may be the end product of this complex interaction in populations at high risk. This review will examine the factors that drive both health disparities and the accelerated aging phenotype that ultimately contributes to premature mortality.

Association of Disease Severity and Socioeconomic Status in Black and White Americans With Multiple Sclerosis

OBJECTIVE

To compare clinical and imaging features of multiple sclerosis (MS) severity between Black Americans (BA) and White Americans (WA) and evaluate the role of socioeconomic status.

METHODS

We compared BA and WA participants in the Multiple Sclerosis Partners Advancing Technology Health Solutions (MS PATHS) cohort with respect to MS characteristics including self-reported disability, objective neurologic function assessments, and quantitative brain MRI measurements, after covariate adjustment (including education level, employment, or insurance as socioeconomic indicators). In a subgroup, we evaluated within-race, neighborhood-level indicators of socioeconomic status (SES) using 9-digit ZIP codes.

RESULTS

Of 1,214 BAs and 7,530 WAs with MS, BAs were younger, had lower education level, and were more likely to have Medicaid insurance or be disabled or unemployed than WAs. BAs had worse self-reported disability (1.47-fold greater odds of severe vs. mild disability, 95% CI 1.18, 1.86) and worse performances on tests of cognitive processing speed (-5.06 fewer correct, CI -5.72, -4.41), walking (0.66 seconds slower, 95% CI 0.36, 0.96) and manual dexterity (2.11 seconds slower, 95% CI 1.69, 2.54). BAs had more brain MRI lesions and lower overall and gray matter brain volumes, including reduced thalamic (-0.77 mL, 95% CI -0.91, -0.64), cortical (-30.63 mL, 95% CI -35.93, -25.33), and deep (-1.58 mL, 95% CI -1.92, -1.23) gray matter volumes. While lower SES correlated with worse neuroperformance scores in WAs, this association was less clear in BA.

CONCLUSION

We observed a greater burden of disease in BAs with MS relative to WAs with MS, despite adjustment for SES indicators. Beyond SES, future longitudinal studies should also consider roles of other societal constructs (e.g., systemic racism). Such studies will be important for identifying prognostic factors and optimal treatment strategies among BAs with MS is warranted.

Race and other sociodemographic categories are differentially linked to multiple dimensions of interpersonal-level discrimination: Implications for intersectional, health research

Objectives

To examine whether intersections of race with other key sociodemographic categories contribute to variations in multiple dimensions of race- and non-race-related, interpersonal-level discrimination and burden in urban-dwelling African Americans and Whites.

Methods

Data from 2,958 participants aged 30–64 in the population-based Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used to estimate up to four-way interactions of race, age, gender, and poverty status with reports of racial and everyday discrimination, discrimination across multiple social statuses, and related lifetime discrimination burden in multiple regression models.

Results

We observed that: 1) African Americans experienced all forms of discrimination more frequently than Whites, but this finding was qualified by interactions of race with age, gender, and/or poverty status; 2) older African Americans, particularly African American men, and African American men living in poverty reported the greatest lifetime discrimination burden; 3) older African Americans reported greater racial discrimination and greater frequency of multiple social status-based discrimination than younger African Americans; 4) African American men reported greater racial and everyday discrimination and a greater frequency of social status discrimination than African American women; and, 5) White women reported greater frequency of discrimination than White men. All p’s < .05.

Conclusions

Within African Americans, older, male individuals with lower SES experienced greater racial, lifetime, and multiple social status-based discrimination, but this pattern was not observed in Whites. Among Whites, women reported greater frequency of discrimination across multiple social statuses and other factors (i.e., gender, income, appearance, and health status) than men. Efforts to reduce discrimination-related health disparities should concurrently assess dimensions of interpersonal-level discrimination across multiple sociodemographic categories, while simultaneously considering the broader socioecological context shaping these factors.

Reparations for Black American descendants of persons enslaved in the U.S. and their potential impact on SARS-CoV-2 transmission

BACKGROUND

In the United States, Black Americans are suffering from a significantly disproportionate incidence of COVID-19. Going beyond mere epidemiological tallying, the potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored.

METHODS

We compared the COVID-19 time-varying Rt curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates βi→j for 4 cells of the simplified next-generation matrix (from which R0 is calculated for structured models) for the outbreak in Louisiana. Lastly, we considered the potential structural effects monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention βi→j and consequently R0.

RESULTS

Once their respective epidemics begin to propagate, Louisiana displays Rt values with an absolute difference of 1.3-2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring Rt below 1. Reasoning through the consequences of increased equity via matrix transmission models, we demonstrate how the benefits of a successful reparations program (reflected in the ratio βb→b/βw→w) could reduce R0 by 31-68%.

DISCUSSION

While there are compelling moral and historical arguments for racial-injustice interventions such as reparations, our study considers potential health benefits in the form of reduced SARS-CoV-2 transmission risk. A restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would also be distributed across racial groups, benefiting the population at large.

Low Back Pain and Substance Use: Diagnostic and Administrative Coding for Opioid Use and Dependence Increased in U.S. Older Adults with Low Back Pain

OBJECTIVE

Low back pain (LBP) is a leading cause of pain and disability. Substance use complicates the management of LBP, and potential risks increase with aging. Despite implications for an aging, diverse U.S. population, substance use and LBP comorbidity remain poorly defined. The objective of this study was to characterize LBP and substance use diagnoses in older U.S. adults by age, gender, and race.

DESIGN

Cross-sectional study of a random national sample.

SUBJECTS

Older adults including 1,477,594 U.S. Medicare Part B beneficiaries.

METHODS

Bayesian analysis of 37,634,210 claims, with 10,775,869 administrative and 92,903,649 diagnostic code assignments.

RESULTS

LBP was diagnosed in 14.8±0.06% of those more than 65 years of age, more in females than in males (15.8±0.08% vs. 13.4±0.09%), and slightly less in those more than 85 years of age (13.3±0.2%). Substance use diagnosis varied by substance: nicotine, 9.6±0.02%; opioid, 2.8±0.01%; and alcohol, 1.3±0.01%. Substance use diagnosis declined with advancing age cohort. Opioid use diagnosis was markedly higher for those in whom LBP was diagnosed (10.5%) than for those not diagnosed with LBP (1.5%). Most older adults (54.9%) with an opioid diagnosis were diagnosed with LBP. Gender differences were modest. Relative rates of substance use diagnoses in LBP were modest for nicotine and alcohol.

CONCLUSIONS

Older adults with LBP have high relative rates of opioid diagnoses, irrespective of gender or age. Most older adults with opioid-related diagnoses have LBP, compared with a minority of those not opioid diagnosed. In caring for older adults with LBP or opioid-related diagnoses, health systems must anticipate complexity and support clinicians, patients, and caregivers in managing pain comorbidities. Older adults may benefit from proactive incorporation of non-opioid pain treatments. Further study is needed.

Sarcoidosis Epidemiology: Race Matters

Rather than a single disease entity, sarcoidosis may be a constellation of "sarcoidoses" with a characteristic pattern of organ involvement and clinic course, depending upon the triggering exposure and underlying epidemiologic factors such as race. This review examines the racial disparities inherent to sarcoidosis disease course and mortality and discusses factors that may be responsible for these findings. In the United States, black patients with sarcoidosis experience more severe pulmonary disease, more multiorgan involvement, and an overall worse prognosis with higher rates of hospitalization and mortality. Beyond inherent genotype, ascertainment and access to medical care, physician implicit bias, and patient perceived discrimination likely play a role. Moving forward, epidemiologic concepts can be used to formulate strategies for control, treatment, and even prevention of disease in black Americans at risk for developing life-altering or life-threatening sarcoidosis phenotypes. Identification and rectification of modifiable risk factors such as socioeconomic status, lack of insurance, and financial barriers to care as well as the incorporation of implicit bias training for physician will likely lead to improvement in discordant outcomes.

Everyday discrimination and subsequent cognitive abilities across five domains

OBJECTIVE

Previous research suggests that everyday discrimination is associated with worse concomitant performance in several cognitive domains, as well as faster subsequent declines in episodic memory. This study aimed to extend knowledge on the specificity, durability, and mechanisms of associations between everyday discrimination and cognition by using a comprehensive neuropsychological battery and a longitudinal mediation design.

METHOD

Participants included 3,304 older adults in the Health and Retirement Study Harmonized Cognitive Assessment Protocol. Discrimination was assessed using the Everyday Discrimination Scale. Depressive symptoms were assessed with the 8-item Center for Epidemiological Studies Depression Scale. Vascular diseases were quantified as the self-reported presence of hypertension, diabetes, and heart disease. Confirmatory factor analysis was used to estimate episodic memory, executive functioning, processing speed, language, and visuoconstruction across a battery of 13 neuropsychological tests. Structural equation models controlled for sociodemographics and baseline cognition ascertained 2 to 4 years prior.

RESULTS

Discrimination was associated with more depressive symptoms and vascular diseases. Depressive symptoms mediated negative effects of discrimination on subsequent functioning across all 5 cognitive domains. Vascular diseases additionally mediated negative effects of discrimination on processing speed. After accounting for mediators, direct negative effects of discrimination remained for executive functioning and visuoconstruction.

CONCLUSIONS

This national longitudinal study in the United States provides evidence for broad and enduring effects of everyday discrimination on cognitive aging, which appear to be partially mediated by mental and physical health. Future research should examine additional mechanisms as well as moderators of these associations to better understand points of intervention. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Reparations for Black American Descendants of Persons Enslaved in the U.S. and Their Estimated Impact on SARS-CoV-2 Transmission

Background In the United States, Black Americans are suffering from significantly disproportionate incidence and mortality rates of COVID-19. The potential for racial-justice interventions, including reparations payments, to ameliorate these disparities has not been adequately explored. Methods We compared the COVID-19 time-varying R _t curves of relatively disparate polities in terms of social equity (South Korea vs. Louisiana). Next, we considered a range of reproductive ratios to back-calculate the transmission rates β _i→j for 4 cells of the simplified next-generation matrix (from which R ₀ is calculated for structured models) for the outbreak in Louisiana. Lastly, we modeled the effect that monetary payments as reparations for Black American descendants of persons enslaved in the U.S. would have had on pre-intervention β _i→j . Results Once their respective epidemics begin to propagate, Louisiana displays R _t values with an absolute difference of 1.3 to 2.5 compared to South Korea. It also takes Louisiana more than twice as long to bring R _t below 1. We estimate that increased equity in transmission consistent with the benefits of a successful reparations program (reflected in the ratio β _b→b / β _w→w ) could reduce R ₀ by 31 to 68%. Discussion While there are compelling moral and historical arguments for racial injustice interventions such as reparations, our study describes potential health benefits in the form of reduced SARS-CoV-2 transmission risk. As we demonstrate, a restitutive program targeted towards Black individuals would not only decrease COVID-19 risk for recipients of the wealth redistribution; the mitigating effects would be distributed across racial groups, benefitting the population at large.

Interactive Relations Across Dimensions of Interpersonal-Level Discrimination and Depressive Symptoms to Carotid Intimal-Medial Thickening in African Americans

OBJECTIVE

This study aimed to examine within-race interactions of multiple dimensions of self-reported discrimination with depressive symptoms in relation to carotid intimal-medial thickness (IMT), a subclinical marker of atherosclerosis prospectively implicated in stroke incidence, in middle-aged to older African American and white adults.

METHODS

Participants were a socioeconomically diverse group of 1941 African Americans (56.5%) and whites from the Healthy Aging in Neighborhoods of Diversity across the Life Span study (30-64 years old, 47% men, 45.2% with household income <125% federal poverty threshold) who underwent carotid IMT measurement. Discrimination was assessed across four dimensions (everyday, frequency across various social statuses, racial, and lifetime burden). The Center for Epidemiologic Studies Depression scale was used to assess depressive symptoms.

RESULTS

In cross-sectional hierarchical regression analyses, two interactions were observed in African Americans: more frequent discrimination across various social statuses (b < 0.001, p = .006) and a higher lifetime discrimination burden (b < 0.001, p = .02) were each related to thicker carotid IMT in those with greater depressive symptoms. No significant findings were observed within whites.

CONCLUSIONS

Among African Americans, those reporting high levels of discrimination and depressive symptoms have increased carotid atherosclerosis and may be at greater risk for clinical end points compared with those reporting one or neither of these risk factors. Findings suggest that assessment of interactive relationships among social and psychological factors may elucidate novel pathways for cardiovascular disease, including stroke, among African Americans.