To investigate how differences in income and education levels may contribute to disparities in incidence of Alzheimer’s disease and related dementia (ADRD), we compared ADRD incidence in traditional Medicare claims for 11,132 Black and 7703 White participants aged 65 and over from a predominantly low-income cohort. We examined whether the relationship between ADRD incidence and race varied by income or education. Based on 2015 incident ADRD diagnoses, Black and White participants had unadjusted incidence rates of 26.5 and 23.2 cases per 1000 person-years, respectively (rate ratio 1.14, 95% CI 1.05–1.25). In multivariable Cox proportional hazard models, the relationship between race and incident ADRD diagnosis did not vary by education level (p-interaction = 0.748) but was modified by income level (p-interaction = 0.007), with higher ADRD incidence among Black participants observed only among higher income groups. These results highlight the importance of understanding how race and economic factors influence ADRD incidence and diagnosis rates.
AmjadH.RothD. L.SheehanO. C.LyketsosC. G.WolffJ. L.SamusQ. M. (2018). Underdiagnosis of dementia: An observational study of patterns in diagnosis and awareness in US older adults. Journal of General Internal Medicine, 33(7), 1131–1138. https://doi.org/10.1007/s11606-018-4377-y
2.
BarnesL. L.BennettD. A. (2014). Alzheimer’s disease in African Americans: Risk factors and challenges for the future. Health Affairs, 33(4), 580–586. https://doi.org/10.1377/hlthaff.2013.1353
3.
BeydounM. A.WeissJ.BeydounH. A.Fanelli-KuczmarskiM. T.HossainS.El-HajjZ. W.EvansM. K.ZondermanA. B. (2022). Pathways explaining racial/ethnic disparities in incident all-cause and Alzheimer’s disease dementia among older US men and women. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 8(1), Articlee12275. https://doi.org/10.1002/trc2.12275
4.
ChenC.ZissimopoulosJ. M. (2018). Racial and ethnic differences in trends in dementia prevalence and risk factors in the United States. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 4(1), 510–520. https://doi.org/10.1016/j.trci.2018.08.009
5.
ChenY.TysingerB.CrimminsE.ZissimopoulosJ. M. (2019). Analysis of dementia in the US population using medicare claims: Insights from linked survey and administrative claims data. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 5(1), 197–207. https://doi.org/10.1016/j.trci.2019.04.003
EvansD. A.HebertL. E.BeckettL. A.ScherrP. A.AlbertM. S.ChownM. J.PilgrimD. M.TaylorJ. O. (1997). Education and other measures of socioeconomic status and risk of incident alzheimer disease in a defined population of older persons. Archives of Neurology, 54(11), 1399–1405. https://doi.org/10.1001/archneur.1997.00550230066019
8.
FillenbaumG. G.HeymanA.HuberM. S.WoodburyM. A.LeissJ.SchmaderK. E.BohannonA.Trapp-MoenB. (1998). The prevalence and 3-year incidence of dementia in older Black and white community residents. Journal of Clinical Epidemiology, 51(7), 587–595. https://doi.org/10.1016/s0895-4356(98)00024-9
9.
FitzpatrickA. L.KullerL. H.IvesD. G.LopezO. L.JagustW.BreitnerJ. C. S.JonesB.LyketsosC.DulbergC. (2004). Incidence and prevalence of dementia in the cardiovascular health study. Journal of the American Geriatrics Society, 52(2), 195–204. https://doi.org/10.1111/j.1532-5415.2004.52058.x
GianattasioK. Z.PratherC.GlymourM. M.CiarleglioA.PowerM. C. (2019). Racial disparities and temporal trends in dementia misdiagnosis risk in the United States. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 5(1), 891–898. https://doi.org/10.1016/j.trci.2019.11.008
12.
GriffithsR. I.O’MalleyC. D.HerbertR. J.DaneseM. D. (2013). Misclassification of incident conditions using claims data: Impact of varying the period used to exclude pre-existing disease. BMC Medical Research Methodology, 13(1), 32. https://doi.org/10.1186/1471-2288-13-32
13.
GrodsteinF.ChangC.-H.CapuanoA. W.PowerM. C.MarquezD. X.BarnesL. L.BennettD. A.JamesB. D.BynumJ. P. W. (2022). Identification of dementia in recent Medicare claims data, compared with rigorous clinical assessments. The Journals of Gerontology: Series A, 77(6), 1272–1278. https://doi.org/10.1093/gerona/glab377
14.
KornblithE.BahorikA.BoscardinW. J.XiaF.BarnesD. E.YaffeK. (2022). Association of race and ethnicity with incidence of dementia among older adults. JAMA, 327(15), 1488. https://doi.org/10.1001/jama.2022.3550
15.
LangaK. M.LarsonE. B.CrimminsE. M.FaulJ. D.LevineD. A.KabetoM. U.WeirD. R. (2017). A comparison of the prevalence of dementia in the United States in 2000 and 2012. JAMA Internal Medicine, 177(1), 51–58. https://doi.org/10.1001/jamainternmed.2016.6807
16.
LaVeistT. A. (2005). Disentangling race and socioeconomic status: A key to understanding health inequalities. Journal of Urban Health, 82(3), iii26–iii34. https://doi.org/10.1093/jurban/jti061
ManlyJ. J.GlymourM. M. (2021). What the aducanumab approval reveals about alzheimer disease research. JAMA Neurology, 78(11), 1305–1306. https://doi.org/10.1001/jamaneurol.2021.3404
19.
ManlyJ. J.TangM.-X.SchupfN.SternY.VonsattelJ.-P. G.MayeuxR. (2008). Frequency and course of mild cognitive impairment in a multiethnic community. Annals of Neurology, 63(4), 494–506. https://doi.org/10.1002/ana.21326
20.
MardenJ. R.Tchetgen TchetgenE. J.KawachiI.GlymourM. M. (2017). Contribution of socioeconomic status at 3 life-course periods to late-life memory function and decline: Early and late predictors of dementia risk. American Journal of Epidemiology, 186(7), 805–814. https://doi.org/10.1093/aje/kwx155
21.
MatthewsK. A.XuW.GagliotiA. H.HoltJ. B.CroftJ. B.MackD.McGuireL. C. (2019). Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015–2060) in adults aged ≥65 years. Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association, 15(1), 17–24. https://doi.org/10.1016/j.jalz.2018.06.3063
22.
MayedaE. R.GlymourM. M.QuesenberryC. P.WhitmerR. A. (2016). Inequalities in dementia incidence between six racial and ethnic groups over 14 years. Alzheimer’s & Dementia, 12(3), 216–224. https://doi.org/10.1016/j.jalz.2015.12.007
23.
MeyersD. J.MorV.RahmanM.TrivediA. N. (2021). Growth in Medicare advantage greatest among Black and hispanic enrollees. Health Affairs, 40(6), 945–950. https://doi.org/10.1377/hlthaff.2021.00118
24.
NobleJ. M.SchupfN.ManlyJ. J.AndrewsH.TangM.-X.MayeuxR. (2017). Secular trends in the incidence of dementia in a multi-ethnic community. Journal of Alzheimer’s Disease, 60(3), 1065–1075. https://doi.org/10.3233/jad-170300
25.
Nuru-JeterA. M.MichaelsE. K.ThomasM. D.ReevesA. N.ThorpeR. J.LaVeistT. A. (2018). Relative roles of race versus socioeconomic position in studies of health inequalities: A matter of interpretation. Annual Review of Public Health, 39(1), 169–188. https://doi.org/10.1146/annurev-publhealth-040617-014230
26.
OdyC.MsallL.DafnyL. S.GrabowskiD. C.CutlerD. M. (2019). Decreases in readmissions credited to medicare’s program to reduce hospital readmissions have been overstated. Health Affairs, 38(1), 36–43. https://doi.org/10.1377/hlthaff.2018.05178
27.
PerkinsP.AnnegersJ. F.DoodyR. S.CookeN.AdayL.VernonS. W. (1997). Incidence and prevalence of dementia in a multiethnic cohort of municipal retirees. Neurology, 49(1), 44. https://doi.org/10.1212/wnl.49.1.44
RodriguezF. S.ArandaM. P.LloydD. A.VegaW. A. (2018). Racial and ethnic disparities in dementia risk among individuals with low education. The American Journal of Geriatric Psychiatry, 26(9), 966–976. https://doi.org/10.1016/j.jagp.2018.05.011
30.
SamuelL. J.SzantonS. L.WolffJ. L.OrnsteinK. A.ParkerL. J.GitlinL. N. (2020). Socioeconomic disparities in six-year incident dementia in a nationally representative cohort of U.S. older adults: An examination of financial resources. BMC Geriatrics, 20(1), 156. https://doi.org/10.1186/s12877-020-01553-4
31.
SatizabalC. L.BeiserA. S.ChourakiV.ChêneG.DufouilC.SeshadriS. (2016). Incidence of dementia over three decades in the framingham heart study. New England Journal of Medicine, 374(6), 523–532. https://doi.org/10.1056/nejmoa1504327
32.
SavvaG. M.ArthurA. (2015). Who has undiagnosed dementia? A cross-sectional analysis of participants of the aging, demographics and memory study. Age and Ageing, 44(4), 642–647. https://doi.org/10.1093/ageing/afv020
33.
SheffieldK. M.PeekM. K. (2011). Changes in the prevalence of cognitive impairment among older Americans, 1993–2004: Overall trends and differences by race/ethnicity. American Journal of Epidemiology, 174(3), 274–283. https://doi.org/10.1093/aje/kwr074
34.
SignorelloL. B.HargreavesM. K.BlotW. J. (2010). The southern community cohort study: Investigating health disparities. Journal of Health Care for the Poor and Underserved, 21(1), 26–37. https://doi.org/10.1353/hpu.0.0245
35.
SteenlandK.GoldsteinF. C.LeveyA.WhartonW. (2016). A meta-analysis of Alzheimer’s disease incidence and prevalence comparing african-Americans and caucasians. Journal of Alzheimer’s Disease, 50(1), 71–76. https://doi.org/10.3233/jad-150778
36.
SternY.GurlandB.TatemichiT. K.TangM. X.WilderD.MayeuxR. (1994). Influence of education and occupation on the incidence of Alzheimer’s disease. JAMA, 271(13), 1004–1010. https://doi.org/10.1001/jama.1994.03510370056032.
37.
TangM.-X.CrossP.AndrewsH.JacobsD. M.SmallS.BellK.MerchantC.LantiguaR.CostaR.SternY.MayeuxR. (2001). Incidence of AD in african-Americans, caribbean hispanics, and caucasians in northern manhattan. Neurology, 56(1), 49–56. https://doi.org/10.1212/wnl.56.1.49
38.
TaylorD. H.ØstbyeT.LangaK. M.WeirD.PlassmanB. L. (2009). The accuracy of Medicare claims as an epidemiological tool: The case of dementia revisited. Journal of Alzheimer’s Disease, 17(4), 807–815. https://doi.org/10.3233/jad-2009-1099
39.
VanderWeeleT. J.RobinsonW. R. (2014). On the causal interpretation of race in regressions adjusting for confounding and mediating variables. Epidemiology, 25(4), 473–484. https://doi.org/10.1097/ede.0000000000000105
40.
WeuveJ.BarnesL. L.Mendes de LeonC. F.RajanK. B.BeckT.AggarwalN. T.HebertL. E.BennettD. A.WilsonR. S.EvansD. A. (2018). Cognitive aging in Black and white Americans: Cognition, cognitive decline, and incidence of alzheimer disease dementia. Epidemiology, 29(1), 151–159. https://doi.org/10.1097/ede.0000000000000747
41.
WilkinsC. H.SchindlerS. E.MorrisJ. C. (2020). Addressing health disparities among minority populations: Why clinical trial recruitment is not enough. JAMA Neurology, 77(9), 1063. https://doi.org/10.1001/jamaneurol.2020.1614
42.
WilliamsD. R.CollinsC. (2001). Racial residential segregation: A fundamental cause of racial disparities in health. Public Health Reports, 116(5), 404–416. https://doi.org/10.1093/phr/116.5.404
43.
WilliamsD. R.PriestN.AndersonN. B. (2016). Understanding associations among race, socioeconomic status, and health: Patterns and prospects. Health Psychology, 35(4), 407–411. https://doi.org/10.1037/hea0000242
44.
YaffeK.FalveyC.HarrisT. B.NewmanA.SatterfieldS.KosterA.AyonayonH.SimonsickE. (2013). Effect of socioeconomic disparities on incidence of dementia among biracial older adults: Prospective study. BMJ, 347, f7051. https://doi.org/10.1136/bmj.f7051.
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