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PREVALENCE/RISK FACTORS

Chen CP.Transcultural expression of subcortical vascular disease.J Neurol Sci  2004 Nov 15; Vol. 226 (1-2), pp. 45-7.OBJECTIVE: To describe variations in the epidemiology of stroke and dementia, the recognition of dementia as an entity across cultures, the cultural specificity of screening tools and assessment instruments, and cultural influences on the management of stroke and dementia. RESULTS: Several studies have pointed out differences in the subtypes and outcomes from stroke across different world regions. Notably, non-Western populations may have a higher rate of hemorrhage, whilst in ischemic stroke subcortical vascular disease is predominant. A low prevalence of dementia has been demonstrated in many studies of non-Western populations. Factors proposed to account for this include protective family attitudes, a lower frequency of ApoE4 and the high mortality of non-Western dementia subjects, which may mask a high age-specific incidence rate. Other medical factors such as training, diagnostic skills, the availability of investigations and healthcare provision may also play a role, as would patient specific cultural attitudes towards ageing and mental health, together with differences in language, social customs and literacy. It has been suggested that there is a major difference between Western and Asian nations in the ratio of vascular dementia to Alzheimer disease. However, few epidemiological field studies have utilized neuroimaging and the reported rates for particular diagnoses should be interpreted cautiously. A recent population study in Japan, which utilized screening by neuropsychologists and CT scanning, showed that vascular dementia accounted for nearly half the cases of dementia. Subcortical vascular disease accounts for the majority of patients with vascular dementia (VaD).

 

Weiner M, Rosenberg et. al.  Comparison of Alzheimer’s Disease in Native Americans and Whites International Psychogeriatrics 2003 Dec;15(4): This study compared medical history and findings on initial clinical examination in Native Americans diagnosed with possible or probable Alzheimer’s disease (AD) at Native American satellite clinics of the University of Texas (UT) Southwestern Medical Center’s Alzheimer’s Disease Center with those of Whites diagnosed with probable AD at the UT Southwestern Medical Center’s Alzheimer’s Disease Clinic. Results: In relation to Whites, Native Americans had slightly but significantly greater age at onset of symptoms (71.7 vs. 69.6 years, t = -2.08, p = .04) and equivalent cognitive scores at evaluation (Mini-Mental State Exam score = 17.4 vs. 18.5, t = 0.98, p = .33), despite significantly lower educational level (11.4 vs. 13.4 years, t = 5.63, p < .001). Native Americans were more frequently depressed on examination (22.8% vs. 9.5%, χ2 = 12, p = .001) and reported diabetes, hypertension, and heart disease significantly more often than did Whites (p < .01 for all), but their survival time after AD diagnosis was similar to that of Whites despite these comorbidities. Conclusions: With the exception of a greater prevalence of depression and cardiovascular risk factors in Native Americans than in Whites, Native Americans had a course of illness similar to that of Whites.

Husaini BA, Sherkat DE, Moonis M, Levine R, Holzer C, Cain VA.
Racial differences in the diagnosis of dementia and in its effects on the use and costs of health care services.
Psychiatr Serv. 2003 Jan;54(1):92-6 This study examined differences in the prevalence of dementia among a random sample of Medicare beneficiaries (N=33,680) by race and gender as well as racial differences in the effects of dementia on the use and costs of health care services. . RESULTS: Diagnoses of dementia were significantly more prevalent among African-American beneficiaries than among white beneficiaries (5 percent compared with 3.9 percent). Persons with dementia had higher rates of health service use, particularly for inpatient care, and African-American persons with dementia had the highest levels of service use. Health care costs were also significantly higher for African Americans with a diagnosis of dementia. Among patients of either race, costs were substantially higher among those with comorbid psychiatric conditions. CONCLUSIONS: Racial differences in the prevalence of dementia are clearly evident. Race also plays a role in the effects of dementia on the use and costs of health services, with higher rates of expensive inpatient care among African Americans.

Zetterberg H, Wahlund LO, Blennow K. Cerebrospinal fluid markers for prediction of Alzheimer’s disease. Neurosci Lett. 2003 Nov 27; 352(1): 67-9. A major diagnostic challenge when people seek advice for cognitive dysfunction is to differentiate between mild cognitive impairment (MCI) and incipient Alzheimer’s disease (AD). We show that a combination of three cerebrospinal fluid biochemical markers, total-tau, phospho-tau and beta-amyloid(1-42), can detect incipient AD among patients fulfilling the criteria for MCI with a sensitivity of 68% (95% CI 45-86%) and a specificity of 97% (95% CI 83-100%). The usefulness of these markers is further emphasized by the finding of a positive predictive value of 94% and a negative predictive value of 81%.

 Hendrie HC, Osuntokun BO, Hall KS, Ogunniyi AO, Hui SL, Unverzagt FW, Gureje O, Rodenberg CA, Baiyewu O, Musick BS. Prevalence of Alzheimer’s disease and dementia in two communities: Nigerian Africans and African Americans. Am J Psychiatry. 1995 Oct;152(10):1485-92 OBJECTIVE: This article reports on a prevalence study of dementia and Alzheimer’s disease among residents aged 65 years and older in two communities: Yorubas (N = 2,494) living in Ibadan, Nigeria, and African Americans (N = 2,212 in the community and N = 106 in nursing homes) living in Indianapolis, Indiana. RESULTS: The age-adjusted prevalence rates of dementia (2.29%) and Alzheimer’s disease (1.41%) in the Ibadan sample were significantly lower than those in the Indianapolis sample, both in the community-dwelling subjects alone (4.82% and 3.69%, respectively) and in the combined nursing home and community samples (8.24% and 6.24%, respectively). The prevalence rates of dementia and Alzheimer’s disease increased consistently with advancing age in both study groups. CONCLUSIONS: This study  reports significant differences in rates of dementia and Alzheimer’s disease in two different communities with similar ethnic origins.

Haan MN, Mungas DM, Gonzalez HM, et al.  Prevalence of dementia in older latinos: the influence of type 2 diabetes mellitus, stroke and genetic factors. : J Am Geriatr Soc. 2003 Feb;51(2):169-77.OBJECTIVES: To estimate dementia prevalence in older Mexican Americans (N=1789), determine the distribution of dementia by etiology, and evaluate the contribution of type 2 diabetes mellitus, stroke, and apolipoprotein E (ApoE) genotype to dementia.  RESULTS: Overall dementia prevalence was 4.8%. Prevalence in those aged 85 and older was 31%. Education and Anglo cultural orientation was negatively associated with dementia risk. Risk of dementia was nearly eight times higher in those with both type 2 diabetes mellitus and stroke. Forty-three percent of dementia was attributable to type 2 diabetes mellitus, stroke, or a combination of the two. ApoE allele frequency was E2 5.9%, E3 90.1%, and E4 4%. Those with any E4 and 4-4 combinations had a higher risk for dementia than those with the E3-3 combination. CONCLUSIONS: Dementia prevalence in this ethnic group is similar to that reported in Canadian and European studies but lower than in Caribbean-Hispanics residing in the United States. The etiological fraction of dementia attributable to type 2 diabetes mellitus and stroke is substantial and points toward the need for intervention research and treatment with the goal of reducing neurological sequelae in groups with high prevalence of type 2 diabetes mellitus.

Huang ZB, Neufeld RR, Likourezos A et al.  Sociodemographic and health characteristics of older Chinese on admission to a nursing home: a cross-racial/ethnic study. OBJECTIVES: To investigate sociodemographic characteristics (SDCs) and health status of older Chinese newly admitted to a nursing home (NH) in New York City r near Chinatown. PARTICIPANTS: Two hundred fifty-eight (125 Chinese, 57 white, 53 Hispanic, and 23 black) of 292 residents consecutively admitted from November 1992 to May 1997. RESULTS: The majority of these Chinese were first-generation immigrants and spoke primarily Cantonese or Mandarin Chinese. Compared with whites, they were more likely to be married, less likely to have lived alone, more likely to be using Medicaid, less likely to make medical decision alone, and more likely to depend on family members for decision-making. Nearly three-quarters of Chinese had cognitive impairment. There was an underdiagnosis of dementia in the Chinese subjects on admission. Severe dependence in activity of daily living was identified in more than one-third of Chinese. Fewer Chinese were using psychotropic medications on admission than the whites. Similar to other groups, many of the Chinese subjects were incontinent of bowel and bladder and had chewing or swallowing problems, hypertension, anemia, and stroke. CONCLUSION: TThese findings suggest that Chinese residents are as frail as other racial/ethnic residents on admission. NHs caring for older Chinese need to be sensitive to the presence of dementia, and require a staff that can speak Cantonese and Mandarin Chinese and is comfortable negotiating with families who are more likely to be the designated decision makers.

Fitten LJ, Ortiz F, Ponton M.  Frequency of Alzheimer’s disease and other dementias in a community outreach sample of Hispanics. J Am Geriatr Soc 2001 Oct;49(10):1301-8
In nonrandom community outreach sample utilizing established criteria for the diagnosis of dementia type, the authors reported that forty percent of subjects had had undiagnosed cognitive symptoms for 3 or more years. Of those demented, 38.5% had AD and 38.5% met criteria for Vascular Dementia( VascD). The best predictors of VascD were hypertension and cerebrovascular disease, whereas apolipoprotein E4 allele best predicted AD.  Twenty percent of the sample was clinically depressed but not demented. CONCLUSIONS: This sample of Hispanic patients compared to white patients had lower rates of AD and higher rates of VascD than expected. The percentage of clinically depressed older individuals was also high. These findings could have implications for differential cultural and genetic risk factors for dementia among diverse ethnic/racial groups.

Green RC, Cupples LA, Go R et al. Risk of dementia among white and African American relatives of patients with Alzheimer disease. JAMA 2002 Jan 16;287(3):329-36. Evidence exists that the incidence of Alzheimer disease (AD), as well as risk attributable to specific genetic factors such as apolipoprotein E (APOE) genotype, may vary considerably among ethnic groups. Family studies of probands with AD offer an opportunity to evaluate lifetime risk of dementia among relatives of these probands. OBJECTIVE: To compare lifetime dementia risk estimates among relatives of white and African American probands with probable or definite AD. CONCLUSION: First-degree relatives of African Americans with AD have a higher cumulative risk of dementia than do those of whites with AD. However, in this study, the additional risk of dementia conferred by being a first-degree relative, by being female, or by the probability of having an APOE epsilon4 allele appeared similar in African American and white families. These data provide estimates of dementia risk that can be used to offer counseling to family members of patients with AD.

Gurland BJ, Wilder DE, Lantigua R et al.  Rates of dementia in three ethnoracial groups. Int J Geriatr Psychiatry. 1999 Jun;14(6):481-93.  Rates of dementia may vary among ethnoracial groups. Randomly selected elderly persons from each of three ethnoracial groups (Latinos, African-Americans, non-Latino Whites) residing in northern Manhattan in New York City were screened for dementia. RESULTS: Age-specific prevalence of dementia was found to be higher in Latinos and African-Americans than in non-Latino Whites; incidence rates were consistent with this finding. Ethnoracial groups did not vary in the proportion of dementias diagnosed as Alzheimer’s disease.  However, level of education was strongly associated with rates of dementia and, when age and education were simultaneously controlled, the ethnoracial differences in rates were not consistently found. CONCLUSIONS:. The higher rates found in Latino and African-American groups, relative to non-Latino Whites, are associated with clear and substantial functional dependencies and hence have important implications for qualities of life and service needs.

Tang MX, Stern Y, Marder K et al.  The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. JAMA. 1998 Mar 11;279(10):751-5. OBJECTIVE: To investigate  in this prospective study,  from 1991-1996, the association between the APOE-epsilon4 allele and  AD in elderly African Americans, Hispanics, and whites.  PARTICIPANTS: A total of 1079 Medicare recipients without AD or a related disorder at baseline a community in New York City. RESULTS: Compared with individuals with the APOE-epsilon3/epsilon3 genotype, the relative risk (RR) of AD associated with 1 or more copies of the APOE-epsilon4 allele was significantly increased among whites (RR, 2.5; 95% confidence interval [CI], 1.1-6.4), but not among African Americans (RR, 1.0; 95% CI, 0.6-1.6) or Hispanics (RR, 1.1; 95% CI, 0.7-1.6). In the absence of the APOE-epsilon4 allele, the cumulative risks of AD to age 90 years, adjusted for education and sex, were 4 times higher for African Americans (RR, 4.4; 95% CI, 2.3-8.6) and 2 times higher for Hispanics (RR, 2.3; 95% CI, 1.2-4.3) than for whites. In the presence of an APOE-epsilon4 allele, the cumulative risk of AD to age 90 years was similar for individuals in all 3 ethnic groups. CONCLUSION: The presence of an APOE-epsilon4 allele is a determinant of AD risk in whites, but African Americans and Hispanics have an increased frequency of AD regardless of their APOE genotype. These results suggest that other genes or risk factors may contribute to the increased risk of AD in African Americans and Hispanics.

Green RC, Cupples LA, Go R Risk of dementia among white and African American relatives of patients with Alzheimer disease. JAMA 2002 Jan 16;287(3):329-36  OBJECTIVE: To compare lifetime dementia risk estimates among relatives of white and African American probands with probable or definite AD.DESIGN AND SETTING: Risk analysis using data collected by questionnaire and supplemental records between May 1991 and March 2001 at 17 medical centers contributing to the Multi-Institutional Research in Alzheimer’s Genetic Epidemiology Study. PARTICIPANTS: A total of 17 639 first-degree biological relatives and 2474 spouses of 2339 white AD probands, and 2281 first-degree biological relatives and 257 spouses of 255 African American AD probands. CONCLUSION: First-degree relatives of African Americans with AD have a higher cumulative risk of dementia than do those of whites with AD. However, in this study, the additional risk of dementia conferred by being a first-degree relative, by being female, or by the probability of having an APOE epsilon4 allele appeared similar in African American and white families. These data provide estimates of dementia risk that can be used to offer counseling to family members of patients with AD.

 

NEUROBIOLOGY

PEI-JUNG LU*, GERBURG WULF*, XIAO ZHEN ZHOU* et al.The prolyl isomerase Pin1 restores the function of Alzheimer-associated phosphorylated tau protein. Nature 1999; 399: 784 – 788    One of the neuropathological hallmarks of Alzheimer’s disease is the neurofibrillary tangle, which contains paired helical filaments (PHFs) composed of the microtubule-associated protein tau. Tau is hyperphosphorylated in PHFs, and phosphorylation of tau abolishes its ability to bind microtubules and promote microtubule assembly,. Restoring the function of phosphorylated tau might prevent or reverse PHF formation in Alzheimer’s disease. Phosphorylation on a serine or threonine that precedes proline (pS/T–P) alters the rate of prolyl isomerization and creates a binding site for the WW domain of the prolyl isomerase Pin1 (refs 8,9,10,11, 12,13,14). Pin1 specifically isomerizes pS/T–P bonds and regulates the function of mitotic phosphoproteins,. Here we show that Pin1 binds to only one pT–P motif in tau and co-purifies with PHFs, resulting in depletion of soluble Pin1 in the brains of Alzheimer’s disease patients. Pin1 can restore the ability of phosphorylated tau to bind microtubules and promote microtubule assembly in vitro. As depletion of Pin1 induces mitotic arrest and apoptotic cell death, sequestration of Pin1 into PHFs may contribute to neuronal death. These findings provide a new insight into the pathogenesis of Alzheimer’s disease.

 

SYMPTOM PATTERNS

Hinton L, Haan M, Geller S, Mungas D. Neuropsychiatric symptoms in Latino elders with dementia or cognitive impairment without dementia and factors that modify their association with caregiver depression. Gerontologist. 2003 Oct;43(5):669-77.  The purpose of this study was to determine neuropsychiatric symptom frequency and intensity in demented and cognitively impaired but not demented Latino elderly persons, evaluate whether overall neuropsychiatric symptom intensity is associated with higher levels of caregiver depression, and identify factors that modify the relationship between neuropsychiatric symptoms and caregiver depression.  RESULTS: For most neuropsychiatric symptoms, prevalence and intensity were significantly higher in the demented group compared with the CIND group. The overall neuropsychiatric symptom intensity score was significantly associated with caregiver depression. The strength and direction of the association of neuropsychiatric symptoms with caregiver depression was found to vary by three factors: whether the caregiver was the care recipient’s spouse, whether the care recipient had dementia or CIND, and the care recipient’s age. IMPLICATIONS: Neuropsychiatric symptoms may play a significant role in caregiver depression among Latino families. However, the impact of neuropsychiatric disturbances on Latino caregivers may differ depending on characteristics of both the caregiver and care recipient.

Bassiony MM, Warren A, Rosenblatt A et. al. Isolated hallucinosis in Alzheimer’s disease is associated with African-American race. Int J Geriatr Psychiatry 2002 Mar;17(3):205-10.  OBJECTIVES: The aim of this investigation was to study the relationship between isolated hallucinosis and race in Alzheimer’s disease. CONCLUSIONS: African-American patients with Alzheimer’s disease are more likely to have isolated hallucinations than Caucasian patients even after statistical adjustment for multiple confounding variables, which might distort this association. This finding has implications for our understanding of the etio-pathogenesis of hallucinations in Alzheimer’s disease and for meeting health service needs of African-American patients.

 

ASSESSMENT

Raymond L. Ownby, Dylan G. Harwood et al.  Factor Structure of the Cornell Scale for Depression in Dementia for Anglo and Hispanic Patients With Dementia . Am. J. Geriatr. Psychiatry 2001 9: 217-224 The authors assessed the equivalence of the factor structure of the Cornell Scale for Depression in Dementia (CSDD) in samples of Anglo and Hispanic patients with Alzheimer’s disease (AD). Analyses showed overall similarity in the CSDD factor structure for the two groups but also revealed differences in factor content for several items. The authors discuss the relevance of these differences for those using the CSDD with Hispanic AD patients.


COMORBID ILLNESS

Teresi JA, Abrams R, Holmes D et al. Influence of Cognitive Impairment, Illness, Gender, and African-American Status on Psychiatric Ratings and Staff Recognition of Depression Am. J. Geriatr. Psychiatry 2002 10: 506-514  The authors examined the multivariate relationships between depression recognition by staff members and characteristics of nursing home residents. African Americans were generally seen by psychiatrists as having less depressive symptom at ologythan residents from other ethnic groups. The data suggest that nurse aides, perhaps because they see residents more often or because they are less influenced by demographic characteristics,may be the most valid source of information about residents’ depression. In contrast, after partitioning out the degree of depression severity, nurses tended to over recognize depression among African-American residents. Social workers under recognized depression among residents with cognitive impairment and/or Parkinson disease and among women, and over recognized depression among African Americans.

CARE-GIVING

 Hallen WE, Gitlin LN et al. Well-being, appraisal, and coping in African-American and Caucasian dementia caregivers: findings from the REACH study.The current study utilized participants from four sites of the REACH (Resources for Enhancing Alzheimer’s Caregiver Health) multi-site study to compare well-being, appraisal, and religious coping by race. African-American (n = 295) and Caucasian (n = 425) dementia caregivers from four cities (Birmingham, Memphis, Boston, and Philadelphia) were compared in their demographics, care recipient characteristics, mental and physical health, and psychosocial coping resources including appraisal and religious coping. African-American caregivers reported lower anxiety, better well-being, less use of psychotropic medications, more benign appraisals of stress and perceived benefits of care-giving, and greater religious coping and participation, than Caucasian caregivers. Self-rated health did not differ by race, but African-American caregivers reported more unhealthy behaviors than Caucasian caregivers

Ayelon L, Arean A. Int J Geriatric Psychiatry Objectives The present study evaluated knowledge of Alzheimer’s disease (AD) in four ethnic groups of older adults. Methods Ninety-six Anglo, 37 Latino, 30 Asian, and 30 African American older adults completed a short survey about AD. Results:Results indicated that Anglo older adults are significantly more knowledgeable about AD than African American, Asian, and Latino older adults. Level of education partially accounted for differences in knowledge of AD between Latino to Anglo older adults. After controlling for age, number of years of speaking English was associated with knowledge of AD in Asian older adults. Conclusions:The results suggest that certain ethnic minority groups do not have sufficient information about AD, and this may explain the lack of AD service use by minorities. Extensive evaluation of barriers to knowledge of AD is needed in order to specifically target minority groups and educate them about AD and the importance of early intervention

Zhan L. J Gerontol Nurs] 2004 Aug; Vol. 30 (8), pp. 19-29.The purpose of this study was to examine the experiences of Chinese American caregivers who provide care for family members with Alzheimer’s disease (AD). Individual interviews were conducted with four family caregivers. Results revealed ethnic cultural and structural barriers that Chinese family caregivers experienced, including stigmatization of AD in the Chinese community, a lack of knowledge about AD, a lack of culturally and linguistically appropriate AD services, negative interactions with health-care providers, and difficulty with English. This study provides cultural knowledge and insights nurses who care for AD clients and their families. Overcoming barriers and working with Chinese American families and their community are needed to improve access and dementia services for Chinese American patients and their families.

Aranda MP, Villa VM, Trejo L, Ramirez R, Ranney M.El Portal Latino Alzheimer’s Project: model program for Latino caregivers of Alzheimer’s disease-affected people. Soc Work. 2003 Apr; 48(2): 259-71.The article describes the El Portal Latino Alzheimer’s Project–a dementia-specific outreach and services program targeting Latino caregivers in the Los Angeles County area. The project is an example of an inter-organizational community-based collaborative developed to provide an array of coordinated, ethnic-sensitive services to Latino dementia-affected adults and their family caregivers, using culturally specific outreach and services delivery strategies. Results of an evaluation of service utilization indicate a reduction in barriers to care and an increase in services utilization. Los Angeles County provides a natural urban laboratory to study the special needs and circumstances of older Latinos dealing with chronic and debilitating illnesses. Implications for social work practice are discussed.

 Hinton L, Haan M, Geller S, Mungas D. Neuropsychiatric symptoms in Latino elders with dementia or cognitive impairment without dementia and factors that modify their association with caregiver depression.  Gerontologist. 2003 Oct; 43(5): 669-77.PURPOSE: The purpose of this study was to determine neuropsychiatric symptom frequency and intensity in demented and cognitively impaired but not demented Latino elderly persons (N=95), evaluate whether overall neuropsychiatric symptom intensity is associated with higher levels of caregiver depression, and identify factors that modify the relationship between neuropsychiatric symptoms and caregiver depression. RESULTS: For most neuropsychiatric symptoms, prevalence and intensity were significantly higher in the demented group compared with the CIND group. The overall neuropsychiatric symptom intensity score was significantly associated with caregiver depression. The strength and direction of the association of neuropsychiatric symptoms with caregiver depression was found to vary by three factors: whether the caregiver was the care recipient’s spouse, whether the care recipient had dementia or CIND, and the care recipient’s age. IMPLICATIONS: Neuropsychiatric symptoms may play a significant role in caregiver depression among Latino families. However, the impact of neuropsychiatric disturbances on Latino caregivers may differ depending on characteristics of both the caregiver and care recipient.

Covinsky KE, Newcomer R, Fox P, Wood J, Sands L, Dane K, Yaffe K. Patient and caregiver characteristics associated with depression in caregivers of patients with dementia J Gen Intern Med. 2003 Dec; 18(12): 1006-14.OBJECTIVE: The goal of this study was to determine the characteristics of 5627 patients and their caregivers which were associated with depression among caregivers of patients with dementia at 8 locations in the United States. RESULTS: 32% of caregivers reported 6 or more symptoms of depression and were classified as depressed. Independent patient predictors of caregiver depression included younger age  white  and Hispanic ethnicity (OR, , lower education, greater ADL dependence and behavioral disturbance, particularly angry or aggressive behavior Independent caregiver predictors of depression included low income, being female spouse,  hours spent care-giving and functional dependence (. CONCLUSION: Caregiver depression is a complex process, influenced by ethnicity as well as diverse patient and caregiver characteristics. Efforts to identify and treat caregiver depression will need to be multidisciplinary and focus on multiple risk factors simultaneously.

Owen JE, Goode KT, Haley WE. End of life care and reactions to death in African-American and white family caregivers of relatives with Alzheimer’s disease. Omega (Westport). 2001;43(4):349-61. The present study addresses ethnic differences in the experience of AD caregivers around the time of their loved one’s death, including life-sustaining treatment decisions and reactions to death. Compared with White caregivers, African-American caregivers were less likely to make a decision to withhold treatment at the time of death, less likely to have their relative die in a nursing home, and reported less acceptance of the relative’s death and greater perceived loss. Results suggest that death after AD care-giving deserves further study, and that ethnic differences in end of life care and bereavement may be of particular importance.

McCormick WC, Ohata CY, Uomoto J et.al.  Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans. : J Am Geriatr Soc. 2002 Jun;50(6):1149-55. The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001).  The subjects’ perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers.Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).

Dolores Gallagher-Thompson, PhD, ABPP,, David W. Coon, PhD, Nancy Solano, PhD et al. Change in Indices of Distress Among Latino and Anglo Female Caregivers of Elderly Relatives With Dementia: Site-Specific Results From the REACH National Collaborative Study. The Gerontologist 43:580-591 (2003).  The authors compare the impact of two distinct interventions on 213 female caregivers (122 Anglo and 91 Latino) care-givers of elderly relatives with dementia. Results: Overall,participants in the Coping With Care-giving condition reported a significant reduction in depressive symptoms, increased use of adaptive coping strategies, and a trend toward decreased use of negative coping strategies when compared with those in the Enhanced Support Group condition. Results were similar for both ethnic groups: there were no main effects for ethnicity,and no significant ethnicity by treatment interaction effects. Implications: This study provides empirical support that female caregivers benefit more from a skill-building approach to managing their distress than from support group membership alone. We find it very encouraging that the Latino care-givers responded well on key outcome variables, suggesting that Latinos will participate in clinical research and will benefit from their involvement when services are provided to meet their specific needs.  

Roth DL, Haley WE, Owen JE, et al. Latent growth models of the longitudinal effects of dementia care-giving: a comparison of African American and White family caregivers. Psychol Aging 2001 Sep;16(3):427-36. Self-report measures of depression, physical health symptoms, and life satisfaction were collected over a 2-year period from 197 family caregivers of dementia patients and 218 non-care-givers (controls). Latent growth models were used to compare changes across time for African American and White caregivers, with gender, age, and socioeconomic status serving as co-variates. Results indicated that White caregivers sustained higher levels of elevated depression and decreasing life satisfaction over time compared with African American caregivers. Both groups of caregivers reported increases in physical symptoms over time. These results indicate worsening difficulties over time for many White caregivers. African American caregivers show more resilience on measures of depression and life satisfaction but are still vulnerable to increases in physical symptoms over time

Knight BG, Silverstein M, McCallum TJ, et al A sociocultural stress and coping model for mental health outcomes among African American caregivers in Southern California. J Gerontol B Psychol Sci Soc Sci 2000 May;55(3):P142-50.  A sociocultural stress and coping model to explain emotional distress among caregivers of family members who have dementia across ethnic and cultural groups is presented and explored in a sample of 41 African American and 128 non-African American caregivers. In this sample, African American caregivers reported lower levels of burden but equal levels of depression and anxiety. African American caregivers were also younger and in poorer health, factors which tend to increase both burden and emotional distress outcomes. As suggested by the sociocultural stress and coping model, the influences of ethnic group variables on stress and coping processes are complex and multi-directional.

McCormick WC, Ohata CY, Uomoto J, et al. Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans. J Am Geriatr Soc. 2002 Jun;50(6):1149-55.The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects’ perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).

Morano CL, Bravo M. A psychoeducational model for Hispanic Alzheimer’s disease caregivers. Gerontologist 2002 Feb;42(1):122-6  In this study, the authors recruited a purposive sample of Hispanic caregivers who participated in a 5-day, 20-hr psychoeducational program to increase the caregivers’ understanding and acceptance of AD, repertoire of coping skills, knowledge of resources, and expression of concerns and emotions of care-giving. At the completion of the study caregivers demonstrated a significant improvement on the Caregiver Knowledge Survey, an increased awareness of community-based services, increased willingness to attend support groups, and overall satisfaction with the program.

Janevic MR, Connell CM. Racial, ethnic, and cultural differences in the dementia caregiving experience: recent findings. Gerontologist 2001 Jun;41(3):334-47 This paper reviewed studies that compare two or more racial, ethnic, national, or cultural groups on aspects of the dementia caregiving experience. These articles included comparisons involving the following groups of caregivers: African Americans, Chinese, Chinese Americans, Koreans, Korean Americans, Latinos, Whites, and residents of 14 European Union countries. Consistent with previous research, White caregivers were more likely to be spouses when compared to other groups. White caregivers tended to report greater depression and appraised care-giving as more stressful than African American caregivers. Findings were mixed regarding differences in coping and social support, but suggested that minority groups may not have more available support than Whites. Common methodological limitations were a lack of non-care-giving control groups and failure to test specific pathways by which the grouping variable (e.g., race) exerts its impact on outcome variables.

RESEARCH

Gallagher-Thompson D, Solano N, Coon D, Arean P. Recruitment and retention of latino dementia family caregivers in intervention research: issues to face, lessons to learn. Gerontologist. 2003 Feb; 43(1): 45-51 PURPOSE: This article reviews and critiques several issues of importance to those whose goal is to make intervention research with Latino caregivers more “user-friendly.” Issues range from current demographic trends showing the ever-increasing number of Latino caregivers to discussion of cultural values that influence their help-seeking behavior. IMPLICATIONS: Clinical researchers need to increase their sensitivity to such issues as cultural values and language preference and develop effective collaborations with the Latino community so that intervention research programs can be designed and implemented successfully with Latinos caring for cognitively impaired elderly family members at home.

Hinton L, Guo Z, Hillygus J, Levkoff S. Working with culture: a qualitative analysis of barriers to the recruitment of Chinese-American family caregivers for dementia research. J Cross Cult Gerontol. 2000; 15(2): 119-37. The purpose of this study was to identify how sociocultural factors, concepts of health, aging and dementia contribute to barriers  to recruitment based on a  qualitative analysis of interviews with of Chinese dementia caregivers . The following themes emerged in this analysis: 1) dementia-related changes were construed as a normal part of the aging process rather than a disease, making it more difficult to identify dementia-affected elders and to recruit families, 2) research participation was viewed as potentially harmful because it can lead to excessive worry 3) Alzheimer’s disease carries a social stigma among Chinese, leading families to shun formal diagnosis and research participation, and 4) practitioners viewed research as an intrusion offering no direct benefit to participants.

Connell CM, Shaw BA, Holmes SB et al. Caregivers’ attitudes toward their family members’ participation in Alzheimer disease research: implications for recruitment and retention. Alzheimer Dis Assoc Disord 2001 Jul-Sep;15(3):137-45  This study was conducted to examine caregivers’ attitudes toward their family members’ participation in AD research. Six focus group interviews were conducted with 38 white and 12 African-American caregivers of participants enrolled in clinical research projects. Among white caregivers, primary barriers to participation in research included the potential for no direct benefit, problems with the procedures and tests involved, lack of time and resources, and difficulty accepting the diagnosis. Among African-American caregivers, primary barriers included general skepticism about the research process and firmly established attitudes about medical treatment and help seeking that serve as disincentives to research participation. To maximize the perceived benefits of research participation, potential participants should have access to regular personal contact with staff, information about health status changes in the care recipient, and the short-term and long-term results of the research studies in which they are participants. In addition, researchers should be sensitive to the concerns that may serve as barriers to participation, particularly among African Americans.

 

HEALTH SERVICE UTILIZATION

Stevens A, Owen J. Predictors of time to nursing home placement in White and African American individuals with dementia.J Aging Health] 2004 Jun; Vol. 16 (3), pp. 375-97.OBJECTIVE: This study examined the influence of racial group identification on nursing home placement (NHP) for individuals with dementia before and after adjusting for the possible mediating effects of the caregiving context as defined by stress-process variables in 215 caregiver/care recipient dyads. METHOD: Demographics, problem behaviors, self-care impairment, and caregiver appraisal, social support, psychological well-being, and coping were used to prospectively predict Time to NHP. RESULTS: Race was a significant predictor of NHP with African American care recipients placed significantly slower than White care recipients. Race remained a significant predictor of Time to NHP after controlling for other variables that showed independent association with Time to NHP and stress-process variables. DISCUSSION: Findings suggest that stress-process variables are critical factors in Time to NHP; however, these variables do not explain fully the difference in Time to NHP seen in White and African American care recipients.

 

Roberts JS, Connell CM, Cisewski D, et al. Differences between African Americans and whites in their perceptions of Alzheimer disease. Alzheimer Dis Assoc Disord. 2003 Jan-Mar; 17(1): 19-26.  A questionnaire was  distributed to 452 adults (61% white, 39% African American; 78% female; mean age 47 years; 33% with family history of AD) and assessed : (1) illness beliefs, (2) factual knowledge, (3) sources of information, and (4) perceived subjective threat of AD. African Americans and whites were generally similar in their beliefs about common symptoms, prominent risk factors, and the effectiveness of treatments for AD (although whites expressed greater certainty in these beliefs than African Americans). In comparison to whites, African Americans showed less awareness of facts about AD, reported fewer sources of information, and indicated less perceived threat of the disorder. These preliminary findings suggest important distinctions between African Americans and whites in their knowledge about, and conceptualization of, AD. Health psychologic research suggests that such differences in illness perceptions could shape response to disease burden, assessment and diagnosis, and available health care options.

TREATMENTS

Iswasaka K, Kobayashi SJ Am Geriatr Soc 2004 Sep; Vol. 52 (9), pp. 1518-21. OBJECTIVES: To evaluate whether a traditional Chinese herbal medicine, ba wei di huang wan (BDW), improves cognitive and physical functioning in dementia patients. DESIGN: An 8-week randomized, double-blind, placebo-controlled trial. SETTING: Long-term-care facility in Japan. PARTICIPANTS: Thirty-three patients with mild to severe dementia (7 men and 26 women; mean age +/- standard deviation=84.4 +/- 7.8) were recruited and enrolled from May 2002 through September 2002. INTERVENTION: Participants were randomly assigned to the active drug (BDW) group (n=16) or the placebo group (n=17) and treated for 8 weeks. MEASUREMENT: Cognitive function and activities of daily living (ADLs); palsatility index. RESULTS: After the trial, cognitive function as assessed using the Mini-Mental State Examination (MMSE) significantly improved from 13.5 +/- 8.5 to 16.3 +/- 7.7 (P<.01, 95% confidence interval (CI)=-4.1 to -1.4) in the BDW group. The ADL score in the Barthel Index also significantly changed, from 61.8 +/- 34.6 to 78.9 +/- 21.1 (P<.01, 95% CI=-26.2 to -7.9). In contrast, MMSE and Barthel Index scores of the placebo group showed no significant change. Eight weeks after the end of the administration, MMSE and Barthel Index scores of the BDW group declined to the baseline level. The pulsatility index in the internal carotid artery as measured using Doppler sonography significantly decreased in the BDW group (2.5 +/- 1.7 to 1.9 +/- 0.5, P<.05) but not in the placebo group. CONCLUSION: These results argue the benefits of BDW in the treatment of dementia.

 

Freels S, Nyenhuis DL, Gorelick PB. Predictors of survival in African American patients with AD, VaD, or stroke without dementia. Neurology. 2002 Oct 22;59(8):1146-53.  This is a study of a hospital-based cohort of African American patients in the Chicago area with AD, vascular dementia (VaD), or stroke without dementia (SWD) were followed for up to 7 years.  RESULTS: Patients with AD who were older and had more years of education and lower Barthel ADL scores were at higher risk of death. Patients with VaD who were taking antihypertensive medication were at higher risk of death; those who were taking aspirin or antiplatelet/anticoagulant medication were at lower risk of death; and higher diastolic blood pressure was protective against death. Risk factors for death in the SWD group were older age, having ever been a smoker, and history of atrial fibrillation. Differences in survival across the three groups were not significant after adjusting for age and clinical dementia rating. CONCLUSIONS: Results in patients with VaD support the use of antiplatelet therapy for persons with VaD and suggest that optimal blood pressure may be higher in cognitively compromised poststroke patients than persons in the general population.

Green RC et al. At the 54th Annual Meeting of the American Academy of Neurology (AAN) in Boston, Dr. Robert C. Green et al  reported that rteatment with the group of anti-hypercholesterolemic agents called  statins yielded a decrease in Alzheimer’s Disease (AD)  risk, with an adjusted odds ratio of 0.21. Their subjects were 912 persons with probable or definite AD by research criteria and 1,669 of their non-demented relatives.  They were cautiously optimistic about their findings and stated that their results need to be replicated in large scale prospective studies.  Their study is unique because they recruited  includes a large percentage of African American patients (614 out of a total of 2581), adjusted their for  r educational background, and evaluated the effect of APOE genotype. They found that   neither African American ethnicity, nor the presence of the APOE e4 allele modifies the statin-AD risk association. This is the latest study to document a positive relationship between treatment with statins and lowered risk for AD.

David V. Espino and Richard Lewis Dementia in Older Minority Populations: Diagnosis, and Treatment Am. J. Geriatr. Psychiatry 1998 6: S19-S25.  Dementia continues to be a major disease that affects olderAmericans. It has been estimated that up to 25% of all community-dwellingelderly individuals in the United States suffer from signs or symptoms of dementia. Little, however, has been written on dementia as it relates to older minority populations. The purpose ofthis article is to discuss the prevalence of dementia in elderly minority populations, describe some of the unique issues relatedto the diagnosis and treatment of dementia in these populations,and make recommendations aimed toward improving the qualityof life for elderly minority individuals with dementia.