Diversity and disparity in dementia: the impact of ethnoracial differences in Alzheimer disease

Implementing early detection of cognitive impairment in primary care to improve care for older adults

Primary care is the ideal setting for early detection of mild cognitive impairment (MCI) and Alzheimer's disease and related dementias (ADRD), as it serves as the primary point of care for most older adults. With the growing aging population, reliance on specialists for detection and diagnosis is unsustainable, highlighting the need for primary care-led assessment. Recent research findings on successful brain health prevention strategies, AD diagnostic tools, and anti-amyloid treatments empower primary care to play a central role in early detection and intervention. Primary care-focused resources are being developed, including tools for cognitive assessments and materials designed to educate patients about brain health and initiate discussions on lifestyle modifications, thereby making early detection more feasible and efficient. Identifying risk factors early enables providers to implement interventions that can slow cognitive decline and improve outcomes for patients and caregivers. If left undetected and unmanaged, MCI and ADRD can lead to worse outcomes, including increased falls, hospitalizations, financial vulnerability, and caregiver stress. Early detection enables the identification of reversible causes of cognitive impairment, supports the management of comorbidities worsened by cognitive decline, mitigates safety risks, and can preserve quality of life. Importantly, primary care is essential for addressing ADRD-related health disparities that disproportionately affect racial minorities, rural populations, and those of lower socioeconomic status. With a focus on the United States healthcare system, this perspective addresses how implementing early detection practices into primary care can improve outcomes for patients and caregivers, reduce societal burdens, and promote health equity in ADRD care.

Depression Symptoms Moderate Associations between Daily Functioning and Neuropsychological Performance in Mexican American Adults

OBJECTIVE

The influence of depression on the relationship between cognition and daily living in aging Mexican American adults requires further investigation, given projected trends in general growth as well as prevalence of depression and Alzheimer's disease and related dementias (ADRD) in this population.

METHOD

In the present study, we examined the extent to which depression (assessed using the Geriatric Depression Scale - 15 item version) moderated the association between reported daily functioning (assessed using the Functional Activities Questionnaire [FAQ]) and objective neuropsychological performance in aging Mexican American adults in the National Alzheimer's Coordinating Center cohort.

RESULTS

Worse reported daily functioning (higher FAQ scores) was associated with worse memory and language performance among participants without elevated depression symptoms (ps < .05), but no associations were observed among those with elevated symptoms (ps > .05). Moreover, depression did not moderate associations of reported daily functioning with performance in attention and working memory or executive functioning and processing speed (ps > .05).

CONCLUSIONS

Aging Mexican American adults with elevated depression symptoms may have subjective informant reports of daily functioning that are discrepant from their objective performance on formal tests of memory and language. Within the context of neuropsychological evaluations for ADRD, failure to adequately assess mood to inform the nature of cognitive and/or functional changes could result in misdiagnosis and lead to delayed, premature, and/or improper intervention with this population.

Financial Toxicity in Dementia Caregiving: Sociodemographic Predictors in a U.S. Nationally Representative Survey

BACKGROUND AND OBJECTIVES

"Financial toxicity" describes the negative effects of medical expenses on financial security and health-related quality of life. Beyond dementia, financial toxicity is used to address the financial and health consequences of illness. Here, we utilize the COmprehensive Score for financial Toxicity (COST) to examine the experience of financial toxicity in dementia caregiving.

RESEARCH DESIGN AND METHODS

We conducted a nationally representative survey of 317 dementia caregivers. Financial toxicity was defined as COST<26 and categorized as mild (COST ≥14 and <26), moderate (COST >0 and <14), or severe (COST = 0). Nested multivariable regression examined potential predictors of financial toxicity. Mediation analyses were performed to assess whether the influence of basic caregiver demographic predictors was mediated by care recipient clinical characteristics, caregiver socioeconomic demographics, or relational characteristics.

RESULTS

52.7% of dementia caregivers in the United States experience financial toxicity. Of those, 73.1% endure mild, 25.7% moderate, and 1.2% severe toxicity. 69.5% of Black, 54.1% of Hispanic, and 42.3% of White caregivers report financial toxicity, with prevalence significantly higher in Black caregivers compared to White caregivers (p = .017). Older caregiver age was associated with less financial toxicity (p = .024). Caregiver employment status mediated this effect, with retirement associated with less financial toxicity (p < .001) and unemployment associated with greater financial toxicity (p < .001).

DISCUSSION AND IMPLICATIONS

Most dementia caregivers in the United States experience financial toxicity, with Black caregivers bearing the highest risk. Older caregiver age protects against financial toxicity, reflecting the relationship between age and employment status.

How much can biomarkers explain sociodemographic inequalities in cognitive dysfunction and cognitive impairment? Results from a machine learning model in the Health and Retirement Study

BackgroundBiomarkers may be pathways by which social adversity affects cognitive aging and Alzheimer's disease and related dementias (ADRD) risk.ObjectiveHow much variance in cognitive dysfunction and cognitive impairment onset do blood-based and physiological biomarkers provide above and beyond easily attainable sociodemographic variables, and how much can biomarkers explain differences in cognitive functioning and ADRD by sociodemographic variables?MethodsWe utilize machine learning to generate measures of predicted cognitive dysfunction and cognitive impairment incidence based on 91 biomarkers, identify the relative importance of each biomarker, and examine how much these biomarkers mediate sociodemographic differences.ResultsMarkers related to cellular aging, neurodegeneration, diet and nutrition, immune functioning, and lung function were identified as important. Biomarkers mediated 47.2-77.3% of the variance associated with age, 22.7-35.2% of racial/ethnic differences in cognitive dysfunction, and 12.5-17.6% of educational differences.ConclusionsBiomarkers provide the potential to understand pathways linking sociodemographic characteristics to cognitive functioning and health. Future research should consider additional biomarkers and evaluate the specific systems that put people at risk for cognitive impairment.

On the complexity of biomarker-driven diagnoses of Alzheimer's disease

Updated criteria pertaining to the diagnosis of Alzheimer's disease (AD) have sparked debate over the reliance on biomarkers-particularly amyloid-β and phosphorylated tau. While biomarkers promise earlier detection and standardized criteria, the potential extension and interpretation of their use in asymptomatic individuals remains controversial. Many individuals with abnormal biomarker profiles never experience cognitive decline, raising concerns about overdiagnosis, unintended negative psychosocial consequences and the blurring line between risk and definitive diagnosis. We, and others, argue that biomarker positivity should be reframed not as a definitive diagnosis but rather as an indicator of elevated risk, particularly in the absence of cognitive symptoms. Doing so better aligns with current evidence, preserves clarity in diagnosis, and avoids unintended psychosocial consequences. Crucially, the role of cognitive reserve-influenced by education, other life experiences and structural inequities-must be considered, particularly among racially and ethnically diverse populations historically underrepresented in AD research. Biomarker thresholds (as well as neuropsychological tools) derived from predominantly non-Hispanic white cohorts may not generalize across groups, risking misclassification and inequity. As the field moves towards precision medicine and AI-driven risk models, inclusive data and culturally valid frameworks are essential. Ultimately, embracing a risk-based, multifactorial approach respects the complexity of AD and promotes equitable care. This perspective calls for interdisciplinary collaboration to refine diagnostic strategies that are scientifically grounded, socially conscious and responsive to the lived realities of diverse populations. Only then can we responsibly integrate biomarkers into practice without sacrificing nuance.

Harmonized cognitive performance in an older adult cohort of Vietnamese American immigrants: The VIP study

INTRODUCTION

Vietnamese Americans represent an understudied population with unique risk factors relevant to cognitive aging. The current study sought to model global cognition in the Vietnamese Insights into Cognitive Aging Program (VIP) study and harmonize ability estimates with the National Alzheimer's Coordinating Center (NACC) Uniform Data Set.

METHODS

Cognitive data from VIP (N = 548) and NACC (N = 15,923) were analyzed using item response theory. Seven common items were assessed for differential item functioning (DIF); items without salient DIF were used to harmonize the cognitive composite score across the two cohorts.

RESULTS

Although five of the seven common items showed evidence of DIF, the magnitude of this DIF was negligible, affecting the factor score estimates of only 12 (2.19%) VIP participants by more than one standard error.

DISCUSSION

Global cognitive functioning can be estimated in Vietnamese American immigrants with minimal bias and psychometrically matched to one of the largest studies of cognitive aging and dementia worldwide.

HIGHLIGHTS

This is the first known study to model cognition in older Vietnamese Americans. Global cognition was harmonized with minimal bias across two diverse cohorts. Differential item functioning was found in five of seven items, but the impact was not salient. Results create new opportunities to study health disparities in an underrepresented group.

Screening for Cognitive Decline by Lay Navigators: A Scoping Review

Innovative ways of screening for cognitive decline are urgently needed to increase detection and access to early treatment, particularly for those at highest risk for morbidity and mortality. The aim of this scoping review was to identify how cognitive screening is conducted within primary care and other clinical settings, specifically focusing on the use of lay navigators. Using Arksey and O'Malley's framework for scoping reviews, inclusive of collaborators' feedback, we included English-language research articles published after 2010 and identified ten articles. We found that lay navigators could effectively screen for common memory problems, provide support to patients and caregivers' needs, and deliver standardized education. Incorporating cognitive screening by lay navigators can facilitate earlier access to effective treatment, especially by those burdened by existing disparities. Future research and widespread adoption of these innovative methods may improve earlier screening and thus early detection and treatment in primary care settings.

Editorial introduction to the special issue on biomarker-based diagnosis of Alzheimer's disease: A synthesis of the commentaries

We introduce a special issue of the Journal of Neuropsychology dedicated to a recent paradigm shift in Alzheimer's disease diagnosis. Joint workgroups from the (US) National Institute on Aging and the Alzheimer's Association (NIA-AA) recently issued policy guidelines reclassifying Alzheimer's disease as a biological entity. These guidelines shift the onus of diagnosis in favour of protein biomarkers, relegating cognitive symptoms (e.g. subjective memory and language disorders) as supportive rather than core features. We invited experts in the study of Alzheimer's disease and Related Disorders (ADRDs) to express their views on this paradigmatic shift in dementia management. In this editorial, we synthesize some of the main points advanced in the commentaries. Contributors identified the promise of blood-based biomarker testing for improving equitable detection of dementia in large swathes of the world population. This enthusiasm was tempered by concerns about the biomarker-only diagnostic approach, including the potential for significant harm (e.g. stigma, depression, suicide) caused by labelling asymptomatic older adults who might otherwise never behaviourally express the underlying disease pathology.

Addressing Disparities in Alzheimer's Disease-Related Healthcare Through Understanding Factors Contributing to Perceived Vulnerability Among Latinos in Northern Manhattan: A Qualitative Report

INTRODUCTION

US Latinos face an increased prevalence of Alzheimer's disease (AD). Identifying factors contributing to Latinos' perceived vulnerability to AD can help clinicians and researchers target disparities in AD healthcare and education for a minority population that is disproportionately impacted by AD. By better understanding perceived vulnerability, which can influence health and help-seeking behaviors, healthcare providers can more effectively aid Latino communities.

METHODS

We conducted semi-structured interviews in English or Spanish with 216 Latino participants (average age 53 years) living in northern Manhattan to assess perceived vulnerability of AD. Interviews were 70-95 min and were transcribed, coded, and thematically analyzed across the "perceived vulnerability" code.

RESULTS

Factors influencing perceived vulnerability to AD among Latinos were organized into three key categories: predisposing factors, psychosocial factors, and self-perceptions. Family history and perceptions of aging were common reasons that participants believed they were likely or unlikely to develop AD.

DISCUSSION

With a culture-specific analysis of factors influencing perceived vulnerability to AD among Latinos, clinicians can allay unnecessary concerns and researchers can disseminate more accurate information and health recommendations across Latino populations.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT04471779. Date Registered: July 15, 2020.

Whole Genome Variable Number Tandem Repeat Analysis in Alzheimer Disease

Background and Objectives

Investigation into different allelic variants may yield new associative genes to predict late-onset Alzheimer disease (LOAD). Variable number tandem repeats (VNTRs) are important polymorphic components of the genome; however, they have been previously overlooked because of their complex genotyping. New software can now determine differing lengths of VNTRs; however, this has not been tested in a large case-control population.

Methods

We used VNTRseek to genotype over 200,000 tandem repeats in 9,501 cases and controls from the Alzheimer's Disease Sequencing Project. We first identified limiting factors of this analysis and then examined the association of VNTRs with AD diagnosis in a subset of non-Hispanic White participants.

Results

We found that VNTRs were highly associated with areas of the genome with a high number of previously identified variants. From our case-control analysis, we identified 9 VNTRs with a repeat allele length associated with LOAD including VNTRs on DSC3, NR2E3, CCNY, PKP4, GRAP, and MAP6.

Discussion

We were able to show the feasibility of this new type of analysis in large-scale whole-genome sequencing data and identify promising VNTRs that are associated with LOAD.

Predicting explainable dementia types with LLM-aided feature engineering

MOTIVATION

The integration of Machine Learning and Artificial Intelligence (AI) into healthcare has immense potential due to the rapidly growing volume of clinical data. However, existing AI models, particularly Large Language Models (LLMs) like GPT-4, face significant challenges in terms of explainability and reliability, particularly in high-stakes domains like healthcare.

RESULTS

This paper proposes a novel LLM-aided feature engineering approach that enhances interpretability by extracting clinically relevant features from the Oxford Textbook of Medicine. By converting clinical notes into concept vector representations and employing a linear classifier, our method achieved an accuracy of 0.72, outperforming a traditional n-gram Logistic Regression baseline (0.64) and the GPT-4 baseline (0.48), while focusing on high-level clinical features. We also explore using Text Embeddings to reduce the overall time and cost of our approach by 97%.

AVAILABILITY AND IMPLEMENTATION

All code relevant to this paper is available at: https://github.com/AdityaKashyap423/Dementia_LLM_Feature_Engineering/tree/main.

Comparison of the neuropsychological-actuarial and clinical-consensus approaches to diagnosis of mild cognitive impairment in an ethnically diverse sample

Objective: Some studies show using neuropsychological-actuarial mild cognitive impairment (MCI) criteria may produce lower reversion rates (i.e. reverting from a cognitive diagnosis to no diagnosis) and higher associations with Alzheimer's disease biomarkers compared to conventional methods, but this has not been evaluated in a Hispanic sample. This study evaluated neuropsychological-actuarial MCI criteria performance in the Texas Alzheimer's Research and Care Consortium (TARCC) cohort compared to clinical-consensus diagnosis. Method: Data from 2,110 TARCC participants (47% Hispanic) were utilized. McNemar tests evaluated the performance of neuropsychological-actuarial versus clinical-consensus criteria in those who remained stable or converted to dementia over 3 annual visits, stratified by ethnicity (Hispanic vs. non-Hispanic). Chi-square analysis was used to compare frequencies of APOE ε4 allele positivity by diagnostic method. Results: Significantly more Hispanic participants were diagnosed with MCI using neuropsychological-actuarial criteria than were non-Hispanics, χ2(1) = 195.3, p < .001, ϕ = 0.32. Hispanic participants meeting neuropsychological-actuarial MCI criteria at baseline were more likely to revert at follow-up, χ2(1) = 10.04, p < .01, ϕ = 0.10. No differences in reversion rate were found between Hispanic and non-Hispanic individuals with clinical-consensus MCI diagnoses, χ2(1) = 0.38, p = .60. There was no association between APOE ε4 allele positivity and neuropsychological-actuarial diagnosis, while there was an association for clinical-consensus diagnoses χ2(1) = 15.1, p < .001, ϕ = 0.09. Conclusions: In TARCC, the clinical-consensus MCI diagnostic method produced fewer cases of reversion compared to the neuropsychological-actuarial method, particularly in Hispanic participants. This is consistent with recent research investigating the use of the neuropsychological-actuarial method in African American/Black individuals. Caution is warranted when using neuropsychological-actuarial criteria among individuals with diverse backgrounds.

Development and evaluation of a healthcare decision-making intervention for African American parent-adult daughter dementia dyads: a mixed-methods study protocol

INTRODUCTION

There is a higher proportion of African American care partners due to African American older adults having more than twice the prevalence of Alzheimer's disease and related dementias (ADRD) compared with non-Hispanic white older adults in the USA. African American adult daughters are the largest group of care partners of African American persons living with ADRD. Within this role, they are faced with navigating multiple health-related decisions to optimise the quality of life of their parent with ADRD, which can negatively influence their own quality of life. This study is guided by three conceptual frameworks: National Institute on Aging's Health Disparities Research Framework, Black Family Socio-Ecological Context Model and Superwoman Schema. The purpose of this study was to develop a structured culturally responsive prototype intervention that will improve the healthcare decision-making self-efficacy and quality of life of African American parent-adult daughter dementia dyads. The prototype intervention will be piloted in a single-group clinical trial to evaluate feasibility, acceptability and preliminary efficacy.

METHODS AND ANALYSIS

This study will be conducted in two phases using an explanatory sequential mixed-methods design, wherein qualitative data collection follows quantitative data collection to explain the findings. In the first phase, the quantitative data collection will examine the behavioural, sociocultural and environmental lifecourse influences on healthcare decision-making self-efficacy and the quality of life of 70 African American parent-adult daughter dementia dyads (ie, persons living with ADRD and their adult daughter care partners). The qualitative data collection will consist of a nested sample of 15 dementia dyads and focus on the decision-making processes that affect current and future healthcare use for the parents living with ADRD. Further, this study will explore how these processes influence the quality of life of both members. In phase 2, integrated findings from phase 1 will provide the basis for the development of the prototype intervention using design thinking and intervention mapping with key informants and community advisory board oversight. Once the prototype intervention is developed, a clinical trial will be conducted. This trial will enrol a new sample of 20 African American parent-adult daughter dementia dyads using a pretest-post-test design.

ETHICS AND DISSEMINATION

The first phase of the study has been approved by the Emory University Institutional Review Board and is registered on ClinicalTrials.gov (NCT05139290). This study will contribute to the development of a structured culturally responsive prototype intervention for African American parent-adult daughter dementia dyads. The findings will determine whether a larger randomised controlled trial is warranted. Results of the research will be disseminated in both academic and community settings.

TRIAL REGISTRATION NUMBER

NCT05139290.

Race and Incident Dementia Among Older Black and Older White Men

The objective of this study was to determine if racial differences exist between older Non-Hispanic Black (NHB) and White (NHW) men in incident dementia over 11 years (2011-2022) in the National Health and Aging Trends Study (NHATS). The analytic sample included 2395 community-dwelling NHB and NHW men free of dementia at baseline who self-identified as Non-Hispanic Black (NHB) and White (NHW). Dementia was assessed at each visit using a validated algorithm developed by NHATS. After adjusting for demographics, place, and health-related characteristics in the Cox proportional hazard models, older NHB men had an increased risk of dementia (hazard ratio: 1.63, 95% confidence interval: [1.22-2.17]) compared to older NHW men. There may be unique factors such as stressors, patterns of genes, or perhaps nutrition that older NHB men possess and experience throughout their lives that contribute to the increased incident dementia.

PLAN-Dementia literacy education and navigation for Korean elders with probable dementia and their caregivers: Rationale, methods, and design of a community-based, randomized, controlled, multi-site clinical trial

BACKGROUND

Linkage to medical services is key to early detection, diagnosis, and care for dementia. Yet, racial and ethnic minoritized older adults and their caregivers are particularly vulnerable to inequity in dementia care due to limited dementia literacy. Mobilizing community resources such as community health workers (CHWs) can benefit older patients and their caregivers who are challenged by linguistic barriers and low health literacy.

METHODS

Preparing for healthy aging through dementia Literacy education And Navigation (PLAN), is a CHW-led intervention program designed to promote linkage to medical services for dementia and caregiver outcomes in a multi-site clinical trial in the Greater Washington and New York metropolitan areas. This protocol describes the rationale, design, and methods of the PLAN trial.

CONCLUSION

We recruited 288 dyads of eligible Korean American older adults with undiagnosed dementia and their caregivers, totaling 576 participants. Data collection is ongoing. Findings from this trial will contribute to knowledge around identifying community-dwelling older adults with probable dementia with limited health resources as well as navigating appropriate medical evaluation and support.

CLINICALTRIALS

gov identifier: NCT03909347.

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.

Framing dementia care in families with a migration background: An analysis of practitioners' and family caregivers' views and experiences

Little is known regarding the ways in which practitioners' views and approaches impact support for persons with a migration background (PwM) caring for individuals with dementia. This paper responds to this knowledge gap by identifying how practitioners frame dementia care in families with a migration background, and how these frames can be understood in light of the experiences of PwM caring for a family member with dementia. A total of 41 participants were included. Namely, 10 practitioners (i.e., health and social care workers) and 31 PwM caring for a family member with dementia. All participants were part of a qualitative research project on dementia care in Dutch families with a migration background. Practitioners' expressed frames were identified through Hochschild's interpretive framework of "framing and feeling rules." Thereafter, practitioners' identified frames were related to the care-experiences of PwM caring for a family member with dementia. Findings indicate that practitioners operate within an approach that does not sufficiently take into account the uniqueness of each family caregiver. This leads to frictions within the practitioner-client relationship. We thus highligh the need for discussions about the tenability of practitioners' views and approaches in an increasingly globalized and diverse society.

Dementia health matters: Influence of literacy, fears, and endorsements on dementia risk mitigation and screening among community-dwelling older adults

BACKGROUND

Up to one-third of dementia cases may be preventable, with evidence suggesting that modifying lifestyle and health behaviors can significantly lower the risk of developing dementia. However, motivating older adults to adopt and sustain these changes poses a considerable challenge, particularly when facing the specter of dementia.

AIM

To explore the interaction effect between dementia fear and dementia literacy on the perceived ability of community-dwelling older adults to reduce dementia risk and engage in dementia screening.

METHOD

A cross-sectional study involving 1,067 community-dwelling older adults was conducted from August 2022 to December 2023. Participants completed surveys assessing their dementia literacy, personal dementia fear, motivation to change lifestyle and health behaviors, and willingness to engage in investigational screening for memory in primary care.

FINDINGS

Personal dementia fear exhibited significant positive correlations with motivation to change lifestyle and health behavior (r = 0.621, p < 0.001) and investigational screening for memory in primary care (r = 0.559, p < 0.001), indicating that higher levels of fear are associated with increased motivation. Second, dementia literacy demonstrated positive correlations with motivation to change lifestyle and health behavior (r = 0.349, p < 0.001) and investigational screening (r = 0.269, p < 0.001), suggesting that more excellent knowledge enhances perceived ability. Lastly, both dementia literacy and personal dementia fear were positively correlated with motivation to change health behaviors, with respective effects of β = 0.266 and β = 0.595, highlighting their interactive role in shaping perceptions of risk reduction and screening.

IMPLICATION

The significant contributions of dementia literacy, personal dementia fear, and their interaction highlight the importance of these factors in accepting investigational screening for memory in primary care.

The Effects of APOE Alleles, Cognitive Activities, and Social Activities on Cognitive Decline in African Americans

OBJECTIVES

Older African Americans are among the fastest-growing populations, yet are underrepresented in studies examining risk factors related to decline. The present study examines whether biological factors (apolipoprotein [APOE] alleles) interact with behavioral factors including cognitive activities (e.g., reading, playing games) and social activities (e.g., participating in social groups) to predict cognitive decline in African Americans.

METHODS

In total, 734 African American adults from the Minority Aging Research Study, aged 65 and older (with no known dementia at the time of enrollment), underwent annual cognitive testing for up to 10 years. At baseline, APOE status was determined and participants reported their frequency of participation in social and cognitive activities. Structural equation modeling was used to examine the effects of APOE, cognitive activities, and social activities on cognitive decline, and their interaction effects over a 10-year period.

RESULTS

The number of APOE alleles had an effect on cognitive decline, such that a greater number of APOE4 alleles was associated with greater cognitive decline, whereas a greater number of APOE2 alleles was associated with less cognitive decline. Cognitive and social activities did not interact with APOE count to predict cognitive decline; however, APOE4 and social activities had additive, independent effects on cognitive decline.

DISCUSSION

Results replicate prior findings linking APOE4 to cognitive decline and highlight the importance of APOE2 and social activities in delaying cognitive decline in African Americans.

Are We Talking About the Same Thing? Black/African Americans' Response to the BRFSS Cognitive Decline and Caregiver Modules

The Behavioral Risk Factor Surveillance System (BRFSS) is a randomized national U.S. telephone survey administered by state health departments. This study aimed to identify how Black/African Americans understand BRFSS caregiver and cognitive decline surveys and terminology to inform health messaging that centers the Black/African American experience. In focus groups, BRFSS surveys were administered to Black/African Americans (n = 30) aged ≥ 45 in Oregon. Participants were asked how they interpreted BRFSS terms 'memory loss' and 'confusion,' how these terms related to Alzheimer's and dementia, and about caregiving and cognitive decline experiences. The culturally responsive Africana Worldview guided interpretation, which centers the Black/African American experience and individuals within interdependent relationships and community identity when explaining behaviors of people from the African diaspora. BRFSS survey responses differed from focus group responses to the same questions. Two participants reported providing care in the past two years on the survey; in discussions, 21 participants reported providing care in the past two years. Interpretations of BRFSS terminology varied greatly. Differences between age-related cognitive changes, dementia and Alzheimer's disease were unclear. Cognitive decline was largely understood in terms of identity loss and relationship changes with the affected individual, and how that individual's relationship changed within community. Caution is advised when using BRFSS data to frame messaging because key cognitive health terms are not universally understood. Messaging that apply the Africana Worldview centralizes relationships and community rather than impact on individual's day-to-day activities, may be more effective for Black/African Americans and for other groups with different cultural and life experiences.

Impact of white matter hyperintensity volume on cognition among US Mexican American adults

OBJECTIVE

Higher white matter hyperintensity (WMH) volume is a marker of cardiovascular disease (CVD) risk. CVD risk factors increase risk for Alzheimer's disease and related dementias (ADRD). Mexican Americans (MA) and individuals of other Hispanic/Latino heritages have higher risk for CVD and ADRD. However, knowledge of associations between WMH volume and cognition in these groups remains limited.

METHOD

We conducted a cross-sectional study of associations between WMH volume and neuropsychological performance (attention/executive functioning, memory) in MA (n = 851) and non-Hispanic White (NHW; n = 747) adults in the Health and Aging Brain Study: Health Disparities.

RESULTS

The MA group (mean age = 63.72 ± 7.90 years; 66.3% female) had higher rates of consensus diagnoses of hypertension and diabetes, whereas the NHW group (mean age = 69.18 ± 8.65 years; 55.2% female) had higher rates of diagnosed CVD (ps < .01). WMH volumes were higher among individuals with CVD risk factors/conditions (ps < .01). There were differential associations between WMH and neuropsychological performance across ethnoracial groups (ps < .001), wherein associations were steeper in the NHW group than in the MA group. Lower educational level was associated with higher WMH volume in the NHW group (p < .001), but no association was seen in the MA group (p > .05).

CONCLUSIONS

Negative effects of pathological changes in the form of WMH on cognition may be less robust or consistent for MA adults than NHW adults. Furthermore, the impact of WMH on cognition in NHW adults may be mitigated by cognitive reserve related to educational attainment.

Large-scale deep proteomic analysis in Alzheimer's disease brain regions across race and ethnicity

INTRODUCTION

Alzheimer's disease (AD) is the most prevalent neurodegenerative disease, yet our comprehension predominantly relies on studies within non-Hispanic White (NHW) populations. Here we provide an extensive survey of the proteomic landscape of AD across diverse racial/ethnic groups.

METHODS

Two cortical regions, from multiple centers, were harmonized by uniform neuropathological diagnosis. Among 998 unique donors, 273 donors self-identified as African American, 229 as Latino American, and 434 as NHW.

RESULTS

While amyloid precursor protein and the microtubule-associated protein tau demonstrated higher abundance in AD brains, no significant race-related differences were observed. Further proteome-wide and focused analyses (specific amyloid beta [Aβ] species and the tau domains) supported the absence of racial differences in these AD pathologies within the brain proteome.

DISCUSSION

Our findings indicate that the racial differences in AD risk and clinical presentation are not underpinned by dramatically divergent patterns in the brain proteome, suggesting that other determinants account for these clinical disparities.

HIGHLIGHTS

We present a large-scale proteome (∼10,000 proteins) of DLPFC (998) and STG (244) across AD cases. About 50% of samples were from racially and ethnically diverse brain donors. Key AD proteins (amyloid and tau) correlated with CERAD and Braak stages. No significant race-related differences in amyloid and tau protein levels were observed in AD brains. AD-associated protein changes showed a strong correlation between the brain proteomes of African American and White individuals. This dataset advances understanding of ethnoracial-specific AD pathways and potential therapies.

Latin dance and cognitive impairment: Importance of una Mezcla of culture and science

Latinos are one of the fastest growing minority groups of the older adult population. More culturally relevant forms of physical activity, such as dance are needed to engage the older Latino population. Dance is considered a type of physical activity and is fun, challenging, and socially engaging. Our research, among others, has shown that dance is an effective form of physical activity and has been shown to improve memory and overall health. Our research demonstrates the significance of culturally relevant physical activity interventions; and the importance of involving the perceptions and input of community members from the intended population.

Trend in Respite Use by Race Among Caregivers for People Living With Dementia

BACKGROUND

Respite care provides short-term relief for caregivers. Despite efforts to promote respite use among Black caregivers, little is known if disparities in respite use between Black and White dementia caregivers have decreased over time. We examined a trend nationally to see if more recent efforts may have helped reduce disparities in respite use.

METHODS

We used a repeated cross-sectional design, with the data from 2015, 2017, and 2021 of the National Health and Aging Trends Study and National Study of Caregiving. Our study sample included 764 (in 2015), 839 (in 2017), and 521 (in 2021) non-Hispanic White and Black caregivers who provided care to older adults living with dementia, representing weighted 5 157 569 (2015), 5 877 997 (2017), and 4 712 144 (2021) dementia caregivers nationally. We conducted logistic regression models to assess the differences in respite use between White and Black caregivers over time.

RESULTS

In 2015, Black dementia caregivers had a respite care use rate 11.6 percentage points (95% CI: -16.9 to -6.4) lower than that of White dementia caregivers. However, both in 2017 and 2021, the difference in the use of respite was not statistically significant, leading to a reduced or no gap in respite use between White and Black dementia caregivers. However, respite use remained low in both groups.

CONCLUSIONS

Although the gap in respite use between Black and White dementia caregivers had been gradually narrowed over time, more efforts are needed to encourage more respite use among both groups through targeted efforts to address factors that hinder respite use.

Reflections on Dementia-Related Stigma and Direct Support Seeking by Family Caregivers as Mediating Associations Between Caregiver Stress, Burden, and Well-Being

The demanding nature of caring for relatives with Alzheimer's disease and related dementias (ADRD) can lead to family caregiver burden and poor health. The stigmatization of people with ADRD can also impact caregivers' stress, while their support-seeking strategies may mitigate negative impacts of burden on their health. To examine hypothesized relationships, the present study considered whether different dimensions of ADRD family stigma influenced the association between a care recipient's behavioral symptoms and their family caregiver's perceived burden and if direct support seeking explained a connection between caregiver burden and well-being. Family caregivers (n = 375) completed a Qualtrics survey. Path analysis revealed ADRD behavioral symptoms predicted both caregiver and layperson forms of stigma. Layperson stigma also intervened between behavioral symptoms and caregiver burden. Direct support seeking mediated the association between caregiver burden and well-being. Findings underscore the utility of including stigma within ADRD caregiver stress models and studying caregiver health from network and communication perspectives.

A Prospective Observational Cohort Study of Language Preference and Preoperative Cognitive Screening in Older Adults: Do Language Disparities Exist in Cognitive Screening and Does the Association Between Test Results and Postoperative Delirium Differ Based on Language Preference?

BACKGROUND

A greater percentage of surgical procedures are being performed each year on patients 65 years of age or older. Concurrently, a growing proportion of patients in English-speaking countries such as the United States, United Kingdom, Australia, and Canada have a language other than English (LOE) preference. We aimed to measure whether patients with LOE underwent cognitive screening at the same rates as their English-speaking counterparts when routine screening was instituted. We also aimed to measure the association between preoperative Mini-Cog and postoperative delirium (POD) in both English-speaking and LOE patients.

METHODS

We conducted a single-center, observational cohort study in patients 65 years old or older, scheduled for surgery and evaluated in the preoperative clinic. Cognitive screening of older adults was recommended as an institutional program for all patients 65 and older presenting to the preoperative clinic. We measured program adherence for cognitive screening. We also assessed the association of preoperative impairment on Mini-Cog and POD in both English-speaking and LOE patients, and whether the association differed for the 2 groups. A Mini-Cog score ≤2 was considered impaired. Postoperatively, patients were assessed for POD using the Confusion Assessment Method (CAM) and by systematic chart review.

RESULTS

Over a 3-year period (February 2019-January 2022), 2446 patients 65 years old or older were assessed in the preoperative clinic prior. Of those 1956 patients underwent cognitive screening. Eighty-nine percent of English-speaking patients underwent preoperative cognitive screening, compared to 58% of LOE patients. The odds of having a Mini-Cog assessment were 5.6 times higher (95% confidence interval [CI], 4.6-7.0) P < .001 for English-speaking patients compared to LOE patients. In English-speaking patients with a positive Mini-Cog screen, the odds of having postop delirium were 3.5 times higher (95% CI, 2.6-4.8) P < .001 when compared to negative Mini-Cog. In LOE patients, the odds of having postop delirium were 3.9 times higher (95% CI, 2.1-7.3) P < .001 for those with a positive Mini-Cog compared to a negative Mini-Cog. The difference between these 2 odds ratios was not significant ( P = .753).

CONCLUSIONS

We observed a disparity in the rates LOE patients were cognitively screened before surgery, despite the Mini-Cog being associated with POD in both English-speaking and LOE patients. Efforts should be made to identify barriers to cognitive screening in limited English-proficient older adults.

Knowledge, perceptions, and feelings associated with Alzheimer's disease and related dementias: a qualitative study among middle-aged latinas residing in an underserved agricultural community in California

BACKGROUND

Middle age is increasingly acknowledged as a critical window for prevention of Alzheimer's disease and related dementia (ADRD) since research has shown that AD develops in the course of 20-30 years (1) but we know very little about middle-aged individuals' perspectives on ADRD. Knowledge gaps are particularly large for Latinas living in regions typically underrepresented in ADRD research, such as rural and/or agricultural regions. This is important given that over the next 40 years Latinos are projected to have the largest increase in ADRD cases in the U.S. Therefore, this study aims to assess knowledge, perceptions, and feelings associated with ADRD among a sample of middle-age, Spanish-speaking Latina women.

METHOD

Using qualitative methods involving semi-structured interviews, we examined knowledge, perceptions, and feelings associated with ADRD among a subsample of the Center for Health Assessment of Mothers and Children of Salinas (CHAMACOS) study. Participants are Latina women residing in an underserved agricultural community entering mid-life (mean = 46.5 years old). Interviews were conducted with 20 women and data was analyzed with inductive thematic content analysis.

RESULTS

We identified themes regarding perceptions, knowledge, and feelings. First, participants perceive ADRD as involving (1) Loss of memory, (2) Getting lost; (3) Losing the person they once were. With regard to knowledge about ADRD, participants reported: (1) Some knowledge about protective and risk factors for ADRD, (2) No awareness of the links between cardiovascular risk factors and ADRD; (3) A desire to learn prevention methods alongside signs and symptoms of ADRD. Themes related to feelings about ADRD were: (1) Fear of developing ADRD and not being aware of reality or who they are; (2) Worry about losing relationships with loved ones and caretaking if diagnosed with ADRD; (3) Sadness about forgetting one's family and depending on others if diagnosed with ADRD.

CONCLUSION

The knowledge gaps and negative feelings associated with ADRD highlighted in this study underscore the need for ADRD interventions to include CVD prevention, particularly for mid-life Latino populations residing in rural regions.

Bridging the gap: Multi-omics profiling of brain tissue in Alzheimer's disease and older controls in multi-ethnic populations

INTRODUCTION

Multi-omics studies in Alzheimer's disease (AD) revealed many potential disease pathways and therapeutic targets. Despite their promise of precision medicine, these studies lacked Black Americans (BA) and Latin Americans (LA), who are disproportionately affected by AD.

METHODS

To bridge this gap, Accelerating Medicines Partnership in Alzheimer's Disease (AMP-AD) expanded brain multi-omics profiling to multi-ethnic donors.

RESULTS

We generated multi-omics data and curated and harmonized phenotypic data from BA (n = 306), LA (n = 326), or BA and LA (n = 4) brain donors plus non-Hispanic White (n = 252) and other (n = 20) ethnic groups, to establish a foundational dataset enriched for BA and LA participants. This study describes the data available to the research community, including transcriptome from three brain regions, whole genome sequence, and proteome measures.

DISCUSSION

The inclusion of traditionally underrepresented groups in multi-omics studies is essential to discovering the full spectrum of precision medicine targets that will be pertinent to all populations affected with AD.

HIGHLIGHTS

Accelerating Medicines Partnership in Alzheimer's Disease Diversity Initiative led brain tissue profiling in multi-ethnic populations. Brain multi-omics data is generated from Black American, Latin American, and non-Hispanic White donors. RNA, whole genome sequencing and tandem mass tag proteomicsis completed and shared. Multiple brain regions including caudate, temporal and dorsolateral prefrontal cortex were profiled.

Racial Disparities in Time to Huntington Disease Diagnosis in North America: An ENROLL-HD Analysis

Background and Objectives

There are well-documented racial and ethnic disparities in access to neurologic care and disease-specific outcomes. Although contemporary clinical and neurogenetic understanding of Huntington disease (HD) is thanks to a decades-long study of a Venezuelan cohort, there are a limited number of studies that have evaluated racial and ethnic disparities in HD. The goal of this study was to evaluate disparities in time from symptom onset to time of diagnosis of HD.

Methods

Using the ENROLL-HD periodic data set 5 (PDS5), we performed sequential multivariate linear regressions to evaluate sociodemographic factors associated with disparities in time to diagnosis (TTD) for gene-positive individuals (CAG repeats 36+) in the North America region. Sensitivity analyses included imputed multivariate regression analysis of individuals with a total motor score (TMS) of 10 or higher and those with 40+ CAG repeats. We also used descriptive statistics to present TTD data in other ENROLL-HD participating regions.

Results

Among 4717 gene-positive participants in the North American region, 89.5% identified as White, 3.4% as Hispanic or Latino, and 2.3% as African American/Black. The average TTD in the group was 3.78. When adjusting for clinical and sociodemographic variables, Black participants were diagnosed with HD 1 year later than White participants (p < 0.05). Additional factors associated with a later diagnosis included psychiatric symptoms as initial HD symptom, unemployment during baseline ENROLL visit, and higher educational attainment. Sensitivity analysis of gene-positive (36+ CAG) participants with a TMS of 10 or higher and of those with 40+ CAG repeats yielded similar findings.

Discussion

Across multiple statistical models, Black ENROLL-HD participants were diagnosed with HD 1 year later than White participants. Clinical factors suggesting a delay in HD diagnosis included psychiatric symptoms at disease onset and a negative family history of HD. Unemployment during baseline visit and higher educational attainment were sociodemographic factors suggestive of a later diagnosis. Additional multicenter qualitative and quantitative studies are needed to better understand reasons for delays in HD diagnosis among Black individuals, and the role of social and structural determinants of health in obtaining a timely HD diagnosis.

Prevalence of Unrecognized Cognitive Impairment in Federally Qualified Health Centers

Importance

There is a need for early and equitable detection of cognitive impairment among older adults.

Objective

To examine the prevalence of unrecognized cognitive impairment among older adults receiving primary care from federally qualified health centers (FQHCs).

Design, Setting, and Participants

This cross-sectional study was conducted at 5 FQHCs providing primary care in Indianapolis, Indiana, between 2021 and 2023. Participants were adults aged 65 years and older, without a diagnosis of mild cognitive impairment (MCI), dementia, or severe mental illness. Data analysis was performed from September 2023 to April 2024.

Main Outcomes and Measures

The primary outcome was a diagnosis of dementia or MCI, as determined by an interdisciplinary clinical team using data from structured patient and study partner interviews, medical record reviews, and a detailed cognitive assessment, including neuropsychological testing. Differences between participants determined to have normal cognition, MCI, and dementia were assessed statistically using analysis of variance for continuous variables, χ2 or Fisher exact tests for categorical variables, or Fisher exact test alone when expected cell counts were 5 or less.

Results

A total of 844 eligible individuals were consecutively approached, 294 consented to participate, and 204 completed the study (mean [SD] age, 70.0 [5.1] years; 127 women [62.3%]). One hundred eight participants (52.9%) were African American, 5 (2.5%) were Hispanic, 199 (97.5%) were not Hispanic, and 90 (44.1%) were White. The mean (SD) duration of education was 13.1 (2.6) years, and the mean (SD) Area Deprivation Index score was 78.3 (19.9), indicating a high level of neighborhood disadvantage. In total, 127 patients (62.3%) met the diagnostic criteria for MCI, 25 (12.3%) had dementia, and 52 (25.5%) had no cognitive impairment. Compared with non-Hispanic White individuals and after adjusting for age, sex, and education level, African American individuals were more than twice as likely to have MCI or dementia (odds ratio, 2.73; 95% CI, 1.38-5.53; P = .02).

Conclusions and Relevance

This cross-sectional study found that unrecognized cognitive impairment is ubiquitous among older adults from underrepresented, minoritized racial and ethnic groups and those who are socially vulnerable receiving primary care from FQHCs. To overcome the disparity in early detection of cognitive impairment, timely, equitable, scalable, and sustainable detection approaches need to be developed.

Age-Specific Barriers and Facilitators to Research Participation Amongst African Americans in Observational Studies of Memory and Aging

BACKGROUND

Black/African Americans experience a high burden of Alzheimer disease and related dementias yet are critically underrepresented in corresponding research. Understanding barriers and facilitators to research participation among younger and older African Americans is necessary to inform age-specific strategies to promote equity in studies of early- and late-onset neurodegenerative diseases.

STUDY DESIGN

Survey respondents (n = 240) rated barriers and facilitators of research participation. Age-specific differences were evaluated using nonparametric Kruskal-Wallis tests across respondents aged 18-44 years (n = 76), 45-64 years (n = 83), and ≥ 65 years (n = 81). Strategies to mitigate barriers and promote facilitators were further explored via community-based focus groups. Pooled frequency of common themes discussed in focus groups were evaluated and compared across different ages including ≥ 45 years, ≥ 65 years, and mixed ages ≥ 45 years.

RESULTS

Younger respondents (aged 18-44 and 45-64 years) expressed a greater need for flexibility in when, where, and how research testing takes place versus adults ≥ 65 years. Focus groups emphasized long-lasting consequences of systemic racism and the need to build and foster trust to resolve barriers and promote research engagement amongst African Americans.

DISCUSSION

Age-specific strategies are needed to increase engagement, address recruitment disparities, and promote retention of African American participants in memory and aging studies across the lifespan.

Evaluating disparity of subjective cognitive decline between male veterans and non-veterans in the United States using propensity score matching estimation: A behavioral risk factor surveillance system survey cross-sectional study

Subjective cognitive decline (SCD) is one of the most important early onset symptoms of Alzheimer's Disease. Previous studies consistently reported that SCD is associated with quality of life, socio-economic factors, and related health comorbidities. However, the impact of veteran status on SCD has been little investigated. This study conducted a cross-sectional study to address disproportionate effects in subjective cognitive decline between veterans and non-veterans in the United States. Propensity score matching (PSM) was applied in this observational study to achieve covariate balancing and reduce selection bias, providing a more accurate estimate of the isolated effect of veteran status on SCD. Our study utilized 32,431 forty-five years or older non-institutionalized White, Black or African-American, and Hispanic or Latin-American male population from the 2019 Behavioral Risk Factor Surveillance System data. We first identified 10,685 paired PSM samples for the binary veteran status using the preselected covariates. Next, we performed a logistic regression for modeling the relationship between the veteran status and the SCD status using the PSM samples along with the covariates selected by a BIC-based stepwise selection. Our analyses revealed a statistically significant causal association between veteran status and SCD after PSM (odds ratio (OR): 1.16 and 95% confidence interval (CI): 1.06-1.27). We obtained a similar result before PSM with an OR of 1.20 and 95% CI of 1.10-1.31. When we focused on a minority group (Black or African-American males), we found a significantly increased veterans' risk of SCD, especially after propensity score matching (OR: 1.69, 95% CI: 1.16-2.45). We also found several factors such as employment status, difficulty dressing/walking/running errands, general health status, physical health status, unaffordability of medical costs, mental health status, and comorbid conditions including stroke, blindness, high cholesterol, and arthritis as statistically significantly associated with SCD (P-value < 0.05). Similar to post-traumatic stress disorder and traumatic brain injury, our study demonstrated a causal association between SCD and military-related activities in the United States, which has a disproportionate impact on the minority population. This study sets the groundwork to further research in this domain to diagnose neurological diseases early among veterans.

Services for Latino Family Dementia Caregivers: Is the Workforce Prepared?

The American healthcare system is ill-fitted to meet the needs of the growing population with Alzheimer's and Related Dementias (ADRD) and their caregivers, which disproportionately affects Latinos. This paper describes the caregiving process for Latino patients with ADRD from the perspective of caregivers and service providers to reveal service areas in need of improvement. Ten providers and 24 Latino caregivers were interviewed through the Miami-Dade County Aging Network. Interviews were analyzed using a grounded theory approach. Five themes emerged: lack of social service connectivity, case management challenges, unmet mental health needs, language barriers, and the need for alternative service models. Our analysis indicates insufficient training and the need to improve dementia competencies, support strategies, and understanding of cultural nuances among service providers. These findings can help inform the development of a required ADRD provider education curriculum that incorporates cultural competency training to improve the quality and effectiveness of care.

An 11-Fold Higher Risk of Incident Mild Cognitive Impairment With Hispanic Ethnicity and Baseline Neuropsychiatric Symptoms

OBJECTIVE

Neuropsychiatric symptoms (NPSs) have been linked to cognitive decline. This study explored ethnic differences and the effects of baseline NPSs on incident mild cognitive impairment (MCI) among 386 Hispanic and non-Hispanic participants from the Texas Harris Alzheimer's Research Study.

METHODS

Data on NPSs from the Neuropsychiatric Inventory Questionnaire were available for all participants. Cox proportional hazards regression models were used to estimate the effect of ≥1 NPS at baseline and Hispanic ethnicity on incident MCI over a 7-year follow-up period.

RESULTS

NPSs at baseline were associated with incident MCI for Hispanic participants but not non-Hispanic participants. Being Hispanic with at least one NPS at baseline had an 11-times higher risk of incident MCI.

CONCLUSIONS

The Hispanic participants converted to MCI to a greater extent than the non-Hispanic participants. Only depressive symptoms increased the risk of MCI among non-Hispanics. Being of Hispanic ethnicity and having NPSs appeared to jointly increase the risk of progressing to MCI. To better understand the Alzheimer's disease continuum, further studies should explore other cultural, genetic, and medical risk factors influencing disease progression. Our findings strongly suggest the need to incorporate NPSs as outcomes of disease progression in future clinical trials involving Hispanic participants.

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.

DNA Methylation Age Acceleration Mediates the Relationship between Systemic Inflammation and Cognitive Impairment

Background

Chronic inflammation and DNA methylation are potential mechanisms in dementia etiology. The linkage between inflammation and DNA methylation age acceleration in shaping dementia risk is understudied. We explored the association of inflammatory cytokines with cognitive impairment and whether DNA methylation age acceleration mediates this relationship.

Methods

In a subset of the 2016 wave of the Health and Retirement Study (n=3,346, age>50), we employed logistic regression to estimate the associations between each inflammatory cytokine (interleukin-6 (IL-6), C-reactive protein (CRP), and insulin-like growth factor-1 (IGF-1)), and both Langa-Weir classified cognitive impairment non-dementia and dementia, respectively. We calculated DNA methylation age acceleration residuals by regressing GrimAge on chronologic age. We tested if DNA methylation age acceleration mediated the relationship between systemic inflammation and cognitive impairment, adjusting for sociodemographic, behavioral factors, chronic conditions, and cell type proportions.

Results

The prevalence of cognitive impairment was 16%. In the fully-adjusted model, participants with a doubling of IL-6 levels had 1.12 (95% CI: 1.02-1.22) times higher odds of cognitive impairment. Similar associations were found for CRP and IGF-1. Participants with a doubling of IL-6 levels had 0.77 (95% CI: 0.64, 0.90) years of GrimAge acceleration. In mediation analyses with each cytokine as predictor separately, 17.7% (95% CI: 7.0%, 50.9%) of the effect of IL-6 on cognitive impairment was mediated through DNA methylation age acceleration. Comparable mediated estimates were found for CRP and IGF-1.

Conclusions

Systemic inflammation is associated with cognitive impairment, with suggestive evidence that this relationship is partially mediated through DNA methylation age acceleration.

Clinician's perspectives on gene therapy for Alzheimer's disease: A qualitative study

INTRODUCTION

We aimed to understand clinician views regarding gene therapy as a future treatment for Alzheimer's disease (AD) and potential barriers and facilitators to its use.

METHODS

We interviewed ten clinicians who treat patients with AD. Clinicians helped design a semi-structured interview including the following domains: establishing understanding, cost/access, quality of life, and religion/spirituality. Transcripts were analyzed by a coding team using descriptive content analysis with inductive approach.

RESULTS

Clinicians identified three main areas of concern: 1) potential clinician and patient understanding of gene therapy and Alzheimer's disease 2) consideration of inequity (i.e., care access, disease awareness along with education level, family support, trust in care systems); and 3) considerations in decision-making (i.e., religious/spiritual beliefs and method of treatment delivery as a decision-making tools).

DISCUSSION AND CONCLUSION

Findings highlight areas for knowledge-building for patients and clinicians alike. Clinicians must be aware of patient/family educational needs and gaps in their own clinical knowledge before engaging patients/families with new technology. Allowing time for questions is crucial to building rapport and trust.

The mediating role of systemic inflammation and moderating role of racialization in disparities in incident dementia

BACKGROUND

Exposure to systemic racism is linked to increased dementia burden. To assess systemic inflammation as a potential pathway linking exposure to racism and dementia disparities, we investigated the mediating role of C-reactive protein (CRP), a systemic inflammation marker, and the moderating role of the racialization process in incident dementia.

METHODS

In the US Health and Retirement Study (n = 6,908), serum CRP was measured at baseline (2006, 2008 waves). Incident dementia was classified by cognitive tests over a six-year follow-up. Self-reported racialized categories were a proxy for exposure to the racialization process. We decomposed racialized disparities in dementia incidence (non-Hispanic Black and/or Hispanic vs. non-Hispanic white) into 1) the mediated effect of CRP, 2) the moderated portion attributable to the interaction between racialized group membership and CRP, and 3) the controlled direct effect (other pathways through which racism operates).

RESULTS

The 6-year cumulative incidence of dementia is 12%. Among minoritized participants (i.e., non-Hispanic Black and/or Hispanic), high CRP levels ( ≥ 75th percentile or 4.73μg/mL) are associated with 1.26 (95%CI: 0.98, 1.62) times greater risk of incident dementia than low CRP ( < 4.73μg/mL). Decomposition analysis comparing minoritized versus non-Hispanic white participants shows that the mediating effect of CRP accounts for 3% (95% CI: 0%, 6%) of the racial disparity, while the interaction effect between minoritized group status and high CRP accounts for 14% (95% CI: 1%, 27%) of the disparity. Findings are robust to potential violations of causal mediation assumptions.

CONCLUSIONS

Minoritized group membership modifies the relationship between systemic inflammation and incident dementia.

Project ECHO Brain Health: Assessing the Impact of a Pilot Program to Promote Self-Efficacy Among Community Health Workers

This mixed-methods study sought to examine the impact of the Project ECHO Brain Health program on participating community health workers' (CHWs') self-efficacy to address dementia, promote brain health, and advocate for research among Latinx South Texas communities. Using an explanatory sequential design, quantitative data collected from pre- and post-program surveys were analyzed to inform the collection of qualitative data, followed by an interpretation of all findings to better understand the impact of the program on self-efficacy. Pre- and post-surveys were collected from 25 CHWs, 13 of whom later participated in individual interviews. There was a statistically significant increase in mean self-efficacy scores between the pre- and post-surveys among participants. Three categories reflecting the experiences of participants were identified from the qualitative data: addressing training needs; impact on CHWs and their practice; and community of learning. The findings suggest that Project ECHO Brain Health program is a timely intervention that may facilitate increased self-efficacy among CHWs as they navigate the impacts of dementia in their communities.

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.

A systematic review/meta-analysis of prevalence and incidence rates illustrates systemic underrepresentation of individuals racialized as Asian and/or Asian-American in ADRD research

We investigate Alzheimer's disease and related dementia (ADRD) prevalence, incidence rate, and risk factors in individuals racialized as Asian and/or Asian-American and assess sample representation. Prevalence, incidence rate, risk factors, and heterogeneity of samples were assessed. Random-effects meta-analysis was conducted, generating pooled estimates. Of 920 records across 14 databases, 45 studies were included. Individuals racialized as Asian and/or Asian-American were mainly from Eastern and Southern Asia, had higher education, and constituted a smaller sample relative to non-Hispanic white cohorts. The average prevalence was 10.9%, ranging from 0.4% to 46%. The average incidence rate was 20.03 (12.01-33.8) per 1000 person-years with a range of 75.19-13.59 (12.89-14.33). Risk factors included physiological, genetic, psychological, behavioral, and social factors. This review underscores the systemic underrepresentation of individuals racialized as Asian and/or Asian-American in ADRD research and the need for inclusive approaches accounting for culture, language, and immigration status. HIGHLIGHTS: There is considerable heterogeneity in the prevalence of ADRD among studies of Asian-Americans. There is limited data on group-specific risk factors for ADRD among Asian-Americans. The average prevalence of (ADRD) among Asian-Americans was found to be 7.4%, with a wide range from 0.5% to 46%.

Gut Microbiome Multi-Omics and Cognitive Function in the Hispanic Community Health Study/Study of Latinos- Investigation of Neurocognitive Aging

INTRODUCTION

We conducted a study within the Hispanic Community Health Study/Study of Latinos- Investigation of Neurocognitive Aging (HCHS/SOL-INCA) cohort to examine the association between gut microbiome and cognitive function.

METHODS

We analyzed the fecal metagenomes of 2,471 HCHS/SOL-INCA participants to, cross-sectionally, identify microbial taxonomic and functional features associated with global cognitive function. Omnibus (PERMANOVA) and feature-wise analyses (MaAsLin2) were conducted to identify microbiome-cognition associations, and specific microbial species and pathways (Kyoto Encyclopedia of Genes and Genomes (KEGG modules) associated with cognition.

RESULTS

Eubacterium species( E. siraeum and E. eligens ), were associated with better cognition. Several KEGG modules, most strongly Ornithine, Serine biosynthesis and Urea Cycle, were associated with worse cognition.

DISCUSSION

In a large Hispanic/Latino cohort, we identified several microbial taxa and KEGG pathways associated with cognition.

2024 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including prevalence and incidence, mortality and morbidity, use and costs of care and the ramifications of AD for family caregivers, the dementia workforce and society. The Special Report discusses the larger health care system for older adults with cognitive issues, focusing on the role of caregivers and non-physician health care professionals. An estimated 6.9 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060, barring the development of medical breakthroughs to prevent or cure AD. Official AD death certificates recorded 119,399 deaths from AD in 2021. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death in the United States. Official counts for more recent years are still being compiled. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2021, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 140%. More than 11 million family members and other unpaid caregivers provided an estimated 18.4 billion hours of care to people with Alzheimer's or other dementias in 2023. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $346.6 billion in 2023. Its costs, however, extend to unpaid caregivers' increased risk for emotional distress and negative mental and physical health outcomes. Members of the paid health care and broader community-based workforce are involved in diagnosing, treating and caring for people with dementia. However, the United States faces growing shortages across different segments of the dementia care workforce due to a combination of factors, including the absolute increase in the number of people living with dementia. Therefore, targeted programs and care delivery models will be needed to attract, better train and effectively deploy health care and community-based workers to provide dementia care. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2024 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $360 billion. The Special Report investigates how caregivers of older adults with cognitive issues interact with the health care system and examines the role non-physician health care professionals play in facilitating clinical care and access to community-based services and supports. It includes surveys of caregivers and health care workers, focusing on their experiences, challenges, awareness and perceptions of dementia care navigation.

Emergency Department Length of Stay for Older Adults With Dementia

STUDY OBJECTIVE

The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile).

METHODS

In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay.

RESULTS

We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4).

CONCLUSION

ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.

Data-driven classification of cognitively normal and mild cognitive impairment subtypes predicts progression in the NACC dataset

INTRODUCTION

Data-driven neuropsychological methods can identify mild cognitive impairment (MCI) subtypes with stronger associations to dementia risk factors than conventional diagnostic methods.

METHODS

Cluster analysis used neuropsychological data from participants without dementia (mean age = 71.6 years) in the National Alzheimer's Coordinating Center (NACC) Uniform Data Set (n = 26,255) and the "normal cognition" subsample (n = 16,005). Survival analyses examined MCI or dementia progression.

RESULTS

Five clusters were identified: "Optimal" cognitively normal (oCN; 13.2%), "Typical" CN (tCN; 28.0%), Amnestic MCI (aMCI; 25.3%), Mixed MCI-Mild (mMCI-Mild; 20.4%), and Mixed MCI-Severe (mMCI-Severe; 13.0%). Progression to dementia differed across clusters (oCN < tCN < aMCI < mMCI-Mild < mMCI-Severe). Cluster analysis identified more MCI cases than consensus diagnosis. In the "normal cognition" subsample, five clusters emerged: High-All Domains (High-All; 16.7%), Low-Attention/Working Memory (Low-WM; 22.1%), Low-Memory (36.3%), Amnestic MCI (16.7%), and Non-amnestic MCI (naMCI; 8.3%), with differing progression rates (High-All < Low-WM = Low-Memory < aMCI < naMCI).

DISCUSSION

Our data-driven methods outperformed consensus diagnosis by providing more precise information about progression risk and revealing heterogeneity in cognition and progression risk within the NACC "normal cognition" group.

Large-scale Deep Proteomic Analysis in Alzheimer's Disease Brain Regions Across Race and Ethnicity

Introduction

Alzheimer's disease (AD) is the most prevalent neurodegenerative disease, yet our comprehension predominantly relies on studies within the non-Hispanic White (NHW) population. Here we aimed to provide comprehensive insights into the proteomic landscape of AD across diverse racial and ethnic groups.

Methods

Dorsolateral prefrontal cortex (DLPFC) and superior temporal gyrus (STG) brain tissues were donated from multiple centers (Mayo Clinic, Emory University, Rush University, Mt. Sinai School of Medicine) and were harmonized through neuropathological evaluation, specifically adhering to the Braak staging and CERAD criteria. Among 1105 DLPFC tissue samples (998 unique individuals), 333 were from African American donors, 223 from Latino Americans, 529 from NHW donors, and the rest were from a mixed or unknown racial background. Among 280 STG tissue samples (244 unique individuals), 86 were African American, 76 Latino American, 116 NHW and the rest were mixed or unknown ethnicity. All tissues were uniformly homogenized and analyzed by tandem mass tag mass spectrometry (TMT-MS).

Results

As a Quality control (QC) measure, proteins with more than 50% missing values were removed and iterative principal component analysis was conducted to remove outliers within brain regions. After QC, 9,180 and 9,734 proteins remained in the DLPC and STG proteome, respectively, of which approximately 9,000 proteins were shared between regions. Protein levels of microtubule-associated protein tau (MAPT) and amyloid-precursor protein (APP) demonstrated AD-related elevations in DLPFC tissues with a strong association with CERAD and Braak across racial groups. APOE4 protein levels in brain were highly concordant with APOE genotype of the individuals.

Discussion

This comprehensive region resolved large-scale proteomic dataset provides a resource for the understanding of ethnoracial-specific protein differences in AD brain.

Bridging the Gap: Multi-Omics Profiling of Brain Tissue in Alzheimer's Disease and Older Controls in Multi-Ethnic Populations

INTRODUCTION

Multi-omics studies in Alzheimer's disease (AD) revealed many potential disease pathways and therapeutic targets. Despite their promise of precision medicine, these studies lacked African Americans (AA) and Latin Americans (LA), who are disproportionately affected by AD.

METHODS

To bridge this gap, Accelerating Medicines Partnership in AD (AMP-AD) expanded brain multi-omics profiling to multi-ethnic donors.

RESULTS

We generated multi-omics data and curated and harmonized phenotypic data from AA (n=306), LA (n=326), or AA and LA (n=4) brain donors plus Non-Hispanic White (n=252) and other (n=20) ethnic groups, to establish a foundational dataset enriched for AA and LA participants. This study describes the data available to the research community, including transcriptome from three brain regions, whole genome sequence, and proteome measures.

DISCUSSION

Inclusion of traditionally underrepresented groups in multi-omics studies is essential to discover the full spectrum of precision medicine targets that will be pertinent to all populations affected with AD.

Describing providers' perspectives on the needs and challenges of family caregivers of African American people living with dementia

The primary purpose of this study was to explore the needs and challenges of African American family caregivers of People living with dementia (PLWD) from the perspective of service providers including healthcare and social service providers. The study conducted three online semi-structured focus group interviews with service providers (n = 15). Data were analyzed using Braun & Clarke's guide to thematic analysis approach. Five themes emerged from the analysis of the focus group data: (i) Inadequate information about resources; (ii) Dementia education; (iii) Burden of dementia on families; (iv) Limited financial support and funding; and (v) Suggestions for needed resources. Service providers expressed the lack of community-based dementia service and support programs in African American communities. Findings from the study indicated the need to provide culturally appropriate information on dementia caregiving. This study adds to the scope of knowledge by exploring the processes of seeking help and using services.

Community-Engaged Recommendations for Empowering People Living With Dementia to be Research Collaborators

As cases of Alzheimer's disease and related dementias (ADRD) increase worldwide, research design has placed additional emphasis on social and behavioral factors that affect ADRD symptomatology and quality of life. Despite this, few studies have incorporated people living with ADRD as research partners. We propose 5 community-engaged recommendations for incorporating people living with ADRD into future research as full collaborators. The proposed recommendations center the experiences of people living with ADRD as crucial contributions to scientific inquiry. The guidelines are based on experiences at a 2-day "Empowering Partnerships" workshop in 2019; post workshop activity continued through 2021 with ongoing collaborations, analysis, and reflective practice. The workshop and subsequent conversations engaged a network of people living with ADRD, informal carepartners, and researchers to collectively build their capacities to partner in all aspects of person-centered research. To empower people living with ADRD as research partners, we recommend that research teams (a) create a flexible schedule of communication and/or meetings to accommodate a wide range of ADRD symptoms, (b) generate team-specific communication strategies/guidelines, (c) incorporate lived experiences of people living with ADRD into research protocols, (d) involve people living with ADRD in all aspects of a project, beginning in the developmental stages, and (e) incorporate skilled facilitators to facilitate communication between stakeholder groups. This multi-vocal approach to research will diversify ADRD research and ensure that projects align with the priorities and capacities of principal stakeholders by incorporating individuals with a wide range of cognitive capabilities that more fully represent the diversity of ADRD experiences.

Characterizing cognitive profiles in diverse middle-aged and older Hispanics/Latinos: Study of Latinos-Investigation of Neurocognitive Aging (HCHS/SOL)

Introduction

We investigated cognitive profiles among diverse, middle-aged and older Hispanic/Latino adults in the Study of Latinos-Investigation of Neurocognitive Aging (SOL-INCA) cohort using a cross-sectional observational study design.

Methods

Based on weighted descriptive statistics, the average baseline age of the target population was 56.4 years, slightly more than half were women (54.6%), and 38.4% reported less than a high school education. We used latent profile analysis of demographically adjusted z scores on SOL-INCA neurocognitive tests spanning domains of verbal memory, language, processing speed, and executive function.

Results

Statistical fit assessment indices combined with clinical interpretation suggested five profiles: (1) a Higher Global group performing in the average-to-high-average range across all cognitive and instrumental activity of daily living (IADL) tests (13.8%); (2) a Higher Memory group with relatively high performance on memory tests but average performance across all other cognitive/IADL tests (24.6%); (3) a Lower Memory group with relatively low performance on memory tests but average performance across all other cognitive/IADL tests (32.8%); (4) a Lower Executive Function group with relatively low performance on executive function and processing speed tests but average-to-low-average performance across all other cognitive/IADL tests (16.6%); and (5) a Lower Global group performing low-average-to-mildly impaired across all cognitive/IADL tests (12.1%).

Discussion

Our results provide evidence of heterogeneity in the cognitive profiles of a representative, community-dwelling sample of diverse Hispanic/Latino adults. Our analyses yielded cognitive profiles that may assist efforts to better understand the early cognitive changes that may portend Alzheimer's disease and related dementias among diverse Hispanics/Latinos.

Highlights

The present study characterized cognitive profiles among diverse middle-aged and older Hispanic/Latino adults.Latent profile analysis of neurocognitive test scores was the primary analysis conducted.The target population consists of middle-aged and older Hispanic/Latino adults enrolled in the Hispanic Community Health Study/Study of Latinos and ancillary Study of Latinos - Investigation of Neurocognitive Aging.