Alzheimer's Disease and its Related Dementias among Asian Americans, Native Hawaiians, and Pacific Islanders: A Scoping Review

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%.

Dementia-Related Disparities in Adult Day Centers: Results of a Bivariate Analysis

PURPOSE

Adult day services (ADS) are a valuable resource for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD) and serve a large population of late-life immigrants, often with limited English proficiency (LEP). This secondary data analysis examined potential disparities in diagnosis, dementia severity, medical complexity, and dementia-related behavioral problems in persons with AD/ADRD with LEP within the ADS setting.

METHOD

The current study used data from TurboTAR, the electronic health record for ADS in California. Bivariate analyses were conducted to examine differences in clinical management for those with and without LEP.

RESULTS

Of 3,053 participants included in the study, 42.3% had LEP. Participants with LEP had higher rates of emergency department use and medication mismanagement. However, due to non-standard data collection, there was a significant amount of missing data on language preference (38.1%) and race/ethnicity (46.5%). Although these findings suggest LEP may play a role in the clinical management of persons with AD/ADRD in ADS, missing data caused by lack of standardized collection compromise the results.

CONCLUSION

It is essential to improve data collection practices in ADS on language, race, and ethnicity to help identify health disparities and promote equitable care for marginalized older adults. [Journal of Gerontological Nursing, 50(4), 42-47.].

Trends in Cardiovascular Mortality Among Patients With Alzheimer's Disease in the United States from 1999 to 2020

This study aimed to compare the trends in cardiovascular diseases (CVDs)-related mortality in patients with Alzheimer's disease (AD) and in the general population aged ≥65 years. Data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research Multiple Cause of Death dataset were used to determine national trends in age-adjusted CVD mortality rates (AAMR) and average annual percent change (AAPC) values in patients with AD and the overall population aged ≥65 years from 1999 to 2020. Data for AAMR and AAPCs were also stratified by age, gender, ethnicity/race, geographical region, urbanization status, and subgroups of CVD. Trends in the overall AAMR stratified by gender, age, ethnicity/race, geographical region, urbanization status, and CVD subgroups were statistically different between patients with AD and the overall population (overall AAPC for CVD mortality rate in patients with AD = -3.5% [confidence interval -4.1% to -2.9%] vs -2.6% [confidence interval -2.3% to -2.9%] in overall population, p = 0.01). Differences in the decrease in the mortality rates between patients with AD and the overall population were found to be statistically different across all stratifications except for the change in the mortality rates for hypertensive diseases (p = 0.05), females (p = 0.2), and Asian or Pacific Islanders (p = 0.09). In conclusion, CVD-related mortality in patients with AD decreased over the last 2 decades, and decreases were more prominent than seen in the general population aged ≥65 years. These results may help focus public health efforts to optimize CVD health in patients with AD.

What Matters to Chinese and Korean American Dementia Caregivers: Navigating Cultural Influences in Dementia Care from Caregivers' Perspectives

Background

Chinese and Korean Americans are among the fastest-growing minority groups in the US but face disparities in income and limited English proficiency, leading to health inequities in Alzheimer's disease and related dementias (ADRD) care.

Objective

This study aims to understand cultural influences in ADRD care from the perspectives of Chinese and Korean American caregivers to inform culturally sensitive support for caregivers in Asian immigrant populations.

Methods

We conducted a study that was part of a broader project aimed at informing the cultural adaptation of the NYU Caregiver Intervention-Enhanced Support (NYUCI-ES) program specifically for Chinese and Korean American caregivers managing multiple chronic conditions. In our interviews with 14 Chinese American and 11 Korean American caregivers, we focused on how their roles as primary caregivers were influenced by cultural and family expectations, the impact of caregiving on their personal and emotional well-being, and the specific barriers they face in accessing healthcare for themselves and their relatives with dementia.

Results

Cultural beliefs and values significantly influenced the perceptions and utilization of support systems among Chinese and Korean American caregivers. Family stigma and adherence to cultural norms impacted their caregiving experiences. The study also highlighted the added burden during the pandemic and the potential benefits of telehealth and information technology in ADRD care.

Conclusions

Developing culturally tailored, person-centered programs is crucial to meeting the unique needs of Chinese and Korean American caregivers. This research contributes to understanding and supporting this vulnerable population, promoting healthcare equity for ADRD patients and caregivers.

Designing dementia care activation program for Filipino American caregivers

OBJECTIVE

This research study aims to identify the fundamental components of community adaptation for a culturally tailored care partner activation program for Filipino American family caregivers of patients with Alzheimer's Disease and related dementia (ADRD).

DESIGN

The study utilized focus group interviews with community nurse leaders, stakeholders, and family caregivers of patients with ADRD.

RESULTS

The research revealed that education and knowledge about the disease, community-based services and facilities, support groups and resources, spiritual and cultural values, and access to transportation are all critical components for community adaptation.

CONCLUSION

The findings suggest that a culturally tailored care partner activation program that incorporates these components can enhance the quality of life for Filipino American caregivers and their loved ones with ADRD. The nursing implications of the study underscore the importance of nurses being culturally competent and sensitive to the unique challenges faced by Filipino American caregivers. Nurses can provide valuable support to caregivers by educating them, connecting them with community resources, and advocating for culturally responsive care practices.

Using community-based geographical information system (GIS) to recruit older Asian Americans in an Alzheimer's disease study

OBJECTIVE

This study aims to show the usefulness of incorporating a community-based geographical information system (GIS) in recruiting research participants for the Asian Cohort for Alzheimer's Disease (ACAD) study for using the subgroup of Korean American (KA) older adults. The ACAD study is the first large study in the USA and Canada focusing on the recruitment of Chinese, Korean and Vietnamese older adults to address the issues of under-representation of Asian Americans in clinical research.

METHODS

To promote clinical research participation of racial/ethnic minority older adults with and without dementia, we used GIS by collaborating with community members to delineate boundaries for geographical clusters and enclaves of church and senior networks, and KA serving ethnic clinics. In addition, we used socioeconomic data identified as recruitment factors unique to KA older adults which was analysed for developing recruitment strategies.

RESULTS

GIS maps show a visualisation of the heterogeneity of the sociodemographic characteristics and the resources of faith-based organisations and KA serving local clinics. We addressed these factors that disproportionately affect participation in clinical research and successfully recruited the intended participants (N=60) in the proposed period.

DISCUSSION

Using GIS maps to locate KA provided innovative inroads to successful research outreach efforts for a pilot study that may be expanded to other underserved populations across the USA in the future. We will use this tool subsequently on a large-scale clinical genetic epidemiology study.

POLICY IMPLICATION

This approach responds to the call from the National Institute on Aging to develop strategies to improve the health status of older adults in diverse populations. Our study will offer a practical guidance to health researchers and policymakers in identifying understudied and hard-to-reach specific Asian American populations for clinical studies or initiatives. This would further contribute in reducing the health and research disparity gaps among older minority populations.

Non-Partner Sexual Violence Among Asian American, Native Hawaiian, and Pacific Islander Adults: A Scoping Review

The Asian American, Native Hawaiian, and Pacific Islander (AANHPI) population is rapidly growing in the United States. Despite sexual violence being a persistent and significant public health issue, research on this topic among AANHPIs is lacking. The study objective is to conduct a systematic scoping review on the published literature on non-partner sexual violence among AANHPIs to identify gaps and priorities to inform actionable research. The systematic review was conducted following the PRISMA Protocol for Systematic Reviews. Database searches were conducted of MEDLINE, Embase, PsycINFO, and Cochrane Central of Clinical Trials, along with and AgeLine and CINAHL for peer-reviewed articles describing non-partner sexual violence among AANHPIs. The search was limited to articles in English published after 1990. Each citation was reviewed by two trained independent reviewers, with a third researcher resolving any conflicts. Of the 998 articles screened and subsequently 496 full-text articles assessed for eligibility, 38 articles were included in the final analysis. The majority of studies did not report disaggregated data for AANHPI subgroups, with most focusing on East Asian subgroups and little evidence on NHPI communities. Most studies were cross-sectional, quantitative, and employed non-probability sampling. There was a lack of studies on effectiveness of interventions and validity of sexual violence-related measures. Our review provides a first step in mapping the extant literature on non-partner sexual violence among this underserved and under-researched population and will serve as a guide for future research, policy, and intervention.

Alzheimer's disease (AD) knowledge in Korean Americans: identifying knowledge gaps and misconceptions and examining predictors of AD knowledge

OBJECTIVES

This study examined Alzheimer's disease (AD) knowledge and its predictors among Korean Americans (KAs).

DESIGN

Convenience sampling was used to recruit KAs in the Greater Washington metropolitan area. A total of 268 KAs participated in the study and completed a cross-sectional survey in 2014. Using the Alzheimer's Disease Knowledge Scale (ADKS), overall and domain knowledge was assessed. Multiple regression analyses were conducted for overall and domain knowledge with predictors including exposure to AD, social engagement, sources and frequency of health-related information, stigmatic beliefs (pity, antipathy, and social distance), English proficiency, and education.

RESULTS

KAs reported a 59% accuracy in the overall AD knowledge. At the domain level, KAs were most knowledgeable about assessment and diagnosis and least knowledgeable about caregiving. Our regression analyses showed that having a college degree or higher is associated with a greater overall AD knowledge. Three domain models of life impact, risk factors, and caregiving turned out to be significant: Having a college degree or higher is a predictor of greater knowledge in all three domains. Having more pity stigmatic beliefs is related to greater knowledge in both life impact and caregiving domains while having less pity stigmatic beliefs is associated with more risk factor knowledge; having less social distance stigmatic beliefs is associated with greater life impact knowledge; and having less antipathy stigmatic beliefs is related to better caregiving knowledge.

CONCLUSION

Our findings revealed areas of misconceptions and knowledge gaps in KAs which need to be addressed in educational interventions. Different knowledge status across the domains demonstrates a multi-dimensional nature of AD knowledge. Multivariate findings confirmed the robust role of education in overall and domain AD knowledge. The effect of different AD stigmatic beliefs on certain AD knowledge domains suggests ways of how stigma change can be efficient for the purpose of increasing AD domain knowledge in KAs.

Cultural differences in caring for people with dementia: a pilot study of concern about losing face and loneliness in Chinese American and European American caregivers

OBJECTIVES

Heavy demands upon dementia caregivers can lead to a number of poor health outcomes including declines in physical, mental, and brain health. Although dementia affects people from all backgrounds, research in the US has largely focused on European American caregivers. This has made providing culturally-competent care more difficult. This study begins to address this issue by empirically examining how culturally-shaped beliefs can influence loneliness in family caregivers of people with dementia.

METHODS

We conducted a preliminary questionnaire study with Chinese American and European American family caregivers of people with dementia (N = 72).

RESULTS

Chinese American caregivers were more concerned than European American caregivers about losing face, which in turn, was associated with greater loneliness. This pattern remained when accounting for caregiver gender, age, and relationship to the person with dementia.

CONCLUSIONS

These preliminary findings highlight the role that cultural beliefs can play in adverse caregiver outcomes, and suggest that addressing concerns about losing face may be an important way for healthcare providers to help reduce loneliness among Chinese American caregivers.

CLINICAL IMPLICATIONS

Understanding how cultural beliefs influence caregiver outcomes is critical as healthcare professionals work to provide culturally-competent care and design culturally-sensitive interventions.

Quality of Life Ratings and Proxy Bias in Primary Progressive Aphasia: Two Sides to the Story?

A valid measure of quality of life is important for clinical goal setting and for evaluating interventions. In the amnestic dementias, proxy-raters (e.g. friends, families, clinicians) typically rate quality of life lower than the self-ratings given by the person with dementia - a proxy bias. This study investigated whether the same proxy bias occurs in Primary Progressive Aphasia (PPA), a language-led dementia.Quality of life was measured in 18 individuals with PPA using self-ratings, and proxy-ratings by their main communication partner, using the Quality of Life in Alzheimer's Disease Scale.There was no strong evidence for proxy bias at a group level, with no consistent pattern across dyads, where proxy- and self-ratings did not show good levels of agreement. We suggest that self-ratings and proxy-ratings of quality of life in PPA are not interchangeable. Higher-powered investigation of the patterns observed here is warranted in future studies.

Understanding Challenges and Coping Strategies Experienced by Chinese American Family Caregivers of Persons with Dementia

The purpose of this study was to explore the caregiving experience of Chinese American family caregivers of persons with dementia with a focus on challenges and coping strategies. Using a qualitative study design, we conducted semi-structured interviews with 26 Chinese American family caregivers and analyzed the data using thematic analysis. We also identified their caregiving experience specific to the COVID-19 pandemic. First, four themes were discovered: (1) filial obligations, (2) preference for utilizing home- and community-based supports, (3) relying on primary care doctors, and (4) helping behaviors. Two additional COVID-19-related themes were identified: (1) social isolation and (2) perceived discrimination. We suggested interventions at the individual, community, and societal level not only to support various challenges experienced by this ethnic group but also to promote their coping strategies.

Assessing Equitable Inclusion of Underrepresented Older Adults in Alzheimer's Disease, Related Cognitive Disorders, and Aging-Related Research: A Scoping Review

BACKGROUND AND OBJECTIVES

The rapidly aging and diversifying U.S. population is challenged by increases in prevalence of Alzheimer's disease (AD) and aging-related disorders. We conducted a scoping review to assess equitable inclusion of diverse older adult populations in aging research focused on National Institutes of Health (NIH)-sponsored research.

RESEARCH DESIGN AND METHODS

The scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-Scr) Protocol. The search was limited to NIH-funded studies focusing on aging, AD and Alzheimer's disease-related dementias (ADRD) and included adults aged 55+. The priority populations and health disparities put forth by the NIA Health Disparities Framework serve as a model for guiding inclusion criteria and for interpreting the representation of these underrepresented groups, including racial ethnic minorities, socioeconomically disadvantaged, rural populations, groups with disabilities, and LGBTQ communities.

RESULTS

Our search identified 1,177 records, of which 436 articles were included in the analysis. Inclusion of individuals with ADRD and mild cognitive impairment, racial ethnic minorities, rural populations, socioeconomically disadvantaged, groups with disabilities, and LGBTQ communities were poorly specified in most studies. Studies used multiple recruitment methods, conducting studies in community settings (59%) and hospitals/clinics (38%) most frequently. Incentives, convenience factors, and sustained engagement via community-based and care partners were identified as key strategies for improved retention.

DISCUSSION AND IMPLICATIONS

This scoping review identified gaps in existing literature and aims for future work, including stronger research focus on, better inclusion of, and improved data collection and reporting of older adults from underrepresented groups.

Culture, Ethnicity, and Level of Education in Alzheimer's Disease

Alzheimer's disease (AD) is the most frequent cause of dementia, where the abnormal accumulation of beta-amyloid (Aβ) and tau lead to neurodegeneration as well as loss of cognitive, behavioral, and functional abilities. The present review analyzes AD from a cross-cultural neuropsychological perspective, looking at differences in culture-associated variables, neuropsychological test performance and biomarkers across ethnic and racial groups. Studies have found significant effects of culture, preferred language, country of origin, race, and ethnicity on cognitive test performance, although the definition of those grouping terms varies across studies. Together, with the substantial underrepresentation of minority groups in research, the inconsistent classification might conduce to an inaccuratte diagnosis that often results from biases in testing procedures that favor the group to which test developers belong. These biases persist even after adjusting for variables related to disadvantageous societal conditions, such as low level of education, unfavorable socioeconomic status, health care access, or psychological stressors. All too frequently, educational level is confounded with culture. Minorities often have lower educational attainment and lower quality of education, causing differences in test results that are then attributed to culture. Higher levels of education are also associated with increased cognitive reserve, a protective factor against cognitive decline in the presence of neurodegeneration. Biomarker research suggests there might be significant differences in specific biomarker profiles for each ethnicity/race in need of accurate cultural definitions to adequately predict risk and disease progression across ethnic/racial groups. Overall, this review highlights the need for diversity in all domains of AD research that lack inclusion and the collection of relevant information from these groups.

Alzheimer's Disease Screening Tools for Asian Americans: A Scoping Review

With growing numbers of aging Asian Americans, Native Hawaiians, and Pacific Islanders (AANHPIs), the availability of culturally and linguistically appropriate screening tools for Alzheimer's disease and its related dementias (ADRD) is needed. The aim of this scoping review is to summarize the tools that have been adapted for and validated among the AANHPI population. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol for systematic reviews, six databases were searched for peer-reviewed articles describing ADRD among AANHPIs. Among 1,477 articles screened for inclusion, 15 articles were included in the final analysis. Results showed a paucity of studies that psychometrically validate tools among this population. Furthermore, studies that culturally adapted and/or translated existing tools mostly targeted East Asian American populations. Our review provides a first step in mapping the extant literature on ADRD screening tools for this underresearched population and will serve as a guide for future research, policy, and intervention.

Stigmatising beliefs about Alzheimer's disease: Findings from the Asian American Quality of Life Survey

Responding to the public health significance of Alzheimer's Disease (AD) and lack of information on AD-related issues in Asian Americans, the present study examined the prevalence and predictors of three stigmatising beliefs about AD (beliefs that associate AD with a normal process of ageing, family embarrassment and social avoidance) using a sample of Asian Americans representing diverse ethnic groups (Chinese, Asian Indian, Korean, Vietnamese, Filipino and other Asians) and a broad age range (18-98). Guided by the Sociocultural Health Belief Model, multivariate regression models of stigmatising beliefs about AD examined the effect of demographic characteristics (age, gender, marital status, education and ethnicity) and immigration and culture-related variables (proportion of life in the U.S., English proficiency and acculturation). Data came from the 2015 Asian American Quality of Life survey (N = 2,609). Results indicate that the prevalence of stigmatising beliefs about AD varied across ethnicities. More than 63% of Vietnamese associated AD with a normal process of ageing, and about 10% of Chinese reported that they would feel embarrassed if their family member had AD. Logistic regression analyses demonstrated that advanced age, male gender, low education and limited English proficiency increased the odds of reporting one or more stigmatising beliefs about AD. The findings suggest varying degrees of AD-related misconceptions and stigmatisation and call attention to the need for culturally sensitive AD education in Asian communities.