Does Dementia Discriminate?

By: Dr. Bryan Hansen 

With more than one in 10 people 65 or older having dementia, it is likely that every person will experience its impact personally, among family, or among friends. More than 47 million people worldwide are living with dementia and that number is expected to triple by 2050, making dementia the most pressing international health issue of this century. In addition, dementia’s global monetary costs are staggering–we spend over $820 billion annually caring for persons with dementia and about two-thirds of that cost is associated with family care and social supports.

Dementia 101 in 101 Seconds 

Dementia’s prevalence, diagnosis, prevention, treatment, and outcomes are all associated with health disparities for different groups of people, for example:

• 2 million men but 3.4 million women have dementia
• Dementia in Blacks and Hispanics may be diagnosed 1-2 years later than in non-Hispanic Whites
• People living in disadvantaged neighborhoods have a biomarker of Alzheimer’s disease at an earlier age
• Non-Hispanic whites are 30% more likely to be prescribed dementia-delaying medicines

Unfortunately, though the research contributing to our knowledge about health disparities is growing, we have a long way to go. Minority groups and women are underrepresented in clinical research and have been for a long time. Even when they are involved, scientists have not been consistent in reporting or investigating differences by race, ethnicity, or gender. This is important because we know less about the factors that have the greatest potential to prevent or treat dementia among women and minorities compared to what we know about preventing or treating dementia among non-Hispanic white men. However, we do know that the science shows that there are ways to reduce the risk of developing dementia even if a person lives to an advanced age.

So, who is most likely to have dementia? The biggest risk factor is a person’s age. However, even among people of the same age, there are disparities.

Gender Disparity

Women are more likely than men to develop dementia, with women making up almost two-thirds of people with Alzheimer’s disease in the United States.

Racial and Ethnic Disparity

Numerous studies have found that Hispanics are one and a half times as likely, and blacks are about twice as likely and to develop dementia than non-Hispanic whites, even though non-Hispanic whites are the largest group living with dementia in the United States. There is also a smaller but very important body of literature suggesting that American Indians/Alaskan Natives have close to the same risk of developing dementia as blacks do. On the other hand, Asian-Americans have the lowest risk of developing dementia of all these race or ethnic groups.

What are the disparities in diagnosis, treatment, and outcomes?

There are disparities in all three areas. First, blacks and Hispanics are more likely to be diagnosed with dementia later in the disease process and have greater cognitive impairment at diagnosis than are non-Hispanic whites. Second, non-Hispanic whites and Hispanics are more likely than blacks to be prescribed medications that are intended to delay dementia progression. Third, non-Hispanic white persons with dementia are more likely to be And finally, despite earlier diagnosis and greater rates of medication prescription, non-Hispanic whites have a higher mortality rate from dementia than blacks or Hispanics.

So, what does all this tell us? And what can we do about it?

There is good news regarding prevention and the potential to address some of these disparities. A recent review found that approximately 35% of dementia risk is modifiable, or risk that can be changed with intervention. The study found that there were nine such risk factors:

• Low levels of education
• Social isolation
• Depression in later life
• Hypertension and obesity in midlife
• Physical inactivity
• Smoking
• Diabetes
• Hearing loss

Of these, low education levels and hearing loss contributed to almost half of the modifiable risk for dementia, suggesting that increasing education levels and preventing hearing loss are critically important areas to focus on if we are to substantially reduce the lifetime risk of developing dementia. In addition, there is encouraging ongoing research modifying one genetic factor, the apolipoprotein E (ApoE) ε4 allele, that contributes an additional 7% to the risk of developing Alzheimer’s disease.

Social determinants of health are at the center of any discussion regarding health inequities—they contribute to the disparities we see in dementia prevalence, diagnosis, treatment, and outcomes. When we address social factors, such as increasing access to quality education and supportive social connections among people, along with health and lifestyle factors, such as cardiovascular wellness and hearing loss prevention, we can reduce the risk of dementia across the globe. In addition, increasing the participation of minority groups in health research and reporting their data is increasingly urgent. We can reduce the toll dementia is taking globally; but we must act, and the clear path for action is to decrease social and health inequities locally, nationally, and internationally!

This blog is a part of the “Dialogues in Health Equity” series by the Health Equity Faculty Interest Group. They are committed to decreasing health disparities experienced by local and global communities by promoting social justice and health equity through nursing practice, research, education, and service.

Bryan R. Hansen, PhD, MSN, RN, APRN-CNS, ACNS-BC is an Assistant Professor at Johns Hopkins School of Nursing (JHSON) and Principal Faculty of the Center for Innovative Care in Aging. He has practiced as a psychiatric nurse, a psychiatric nursing clinical instructor, and adult forensic nurse examiner and currently practices as an adult health clinical nurse specialist.