Restricted accessResearch articleFirst published online 2025-8
Racial and socioeconomic influences on the interplay between Alzheimer's disease-related dementia and cardio-cerebrovascular disease in an aging population
Cardio and cerebrovascular disease (CVD) and Alzheimer's Disease-Related Dementia (ADRD) significantly impact older adult populations, with interlinked pathways influencing risk and progression. In Hawaii, where over 20% of the population is 65 or older and ethnic diversity is among the highest in the U.S., the relationship between ADRD and CVD requires closer examination, especially concerning racial and socioeconomic factors.
Objective
This study aims to assess the effects of race, ethnicity, and socioeconomic status on the bidirectional risk pathways between ADRD and CVD among older populations in Hawaii.
Methods
Utilizing a multistate modeling framework, we analyzed nine years of longitudinal Medicare data to track transitions between ADRD, CVD, and mortality outcomes. We investigated associations among racial and ethnic groups, including Native Hawaiian and other Pacific Islander (NHPI), Asian Americans (AA) and white populations, accounting for socioeconomic status to identify disparities in risk progression and outcomes.
Results
The analysis revealed notable racial and socioeconomic disparities in the transitions between ADRD, heart disease (HD), Stroke, and mortality among Hawaii's older population. Overall, lower socioeconomic status indicates increased risks for transitioning to more severe clinical states and mortality. However, such effects were found to be varied among races: AA, NHPI, and whites. Our findings suggest that socioeconomic status modifies the ADRD, HD, Stroke progression dynamics across different ethnicities.
Conclusions
This study highlights the significant role of race/ethnicity and socioeconomic status in the complex progression of ADRD and CVD.
ManlyJJJonesRNLangaKM, et al.Estimating the prevalence of dementia and mild cognitive impairment in the US: the 2016 health and retirement study harmonized cognitive assessment protocol project. JAMA Neurol2022; 79: 1242–1249.
3.
The Alzheimer’s Association. 2024 Alzheimer's disease facts and figures. Alzheimers Dement2024; 20: 3708–3821.
Joynt MaddoxKEElkindMSVAparicioHJ, et al.; American Heart Association. Forecasting the burden of cardiovascular disease and stroke in the United States through 2050-prevalence of risk factors and disease: a presidential advisory from the American Heart Association. Circulation2024; 150: e65–e88.
6.
SaeedALopezOCohenA, et al.Cardiovascular disease and Alzheimer's disease: the heart-brain axis. J Am Heart Assoc2023; 12: e030780.
7.
TublinJMAdelsteinJMDel MonteF, et al.Getting to the heart of Alzheimer disease. Circ Res2019; 124: 142–149.
8.
SiriwardhanaCCarrazanaELiowK, et al.Racial/ethnic disparities in the Alzheimer's disease link with cardio and cerebrovascular diseases, based on Hawaii medicare data. J Alzheimers Dis Rep2023; 7: 1103–1120.
9.
StamatelopoulosKPolCJAyersC, et al.Amyloid-beta (1-40) peptide and subclinical cardiovascular disease. J Am Coll Cardiol2018; 72: 1060–1061.
10.
Cortes-CanteliMIadecolaC. Alzheimer's disease and vascular aging: JACC focus seminar. J Am Coll Cardiol2020; 75: 942–951.
11.
MuellerKThielFBeutnerF, et al.Brain damage with heart failure: cardiac biomarker alterations and gray matter decline. Circ Res2020; 126: 750–764.
12.
LiTBaoXLiL, et al.Heart failure and cognitive impairment: a narrative review of neuroimaging mechanism from the perspective of brain MRI. Front Neurosci2023; 17: 1148400.
13.
VogelsRLvan der FlierWMvan HartenB, et al.Brain magnetic resonance imaging abnormalities in patients with heart failure. Eur J Heart Fail2007; 9: 1003–1009.
14.
DeckersKSchievinkSHJRodriquezMMF, et al.Coronary heart disease and risk for cognitive impairment or dementia: systematic review and meta-analysis. PLoS One2017; 12: e0184244.
JoundiRAFangJYuAY, et al.Abstract 67: Risk and time-course of post-stroke dementia: A population-wide cohort study, 2002–2022. Stroke2024; 55: A67.
17.
ChinKS. Pathophysiology of dementia. Aust J Gen Pract2023; 52: 516–521.
18.
AttemsJJellingerKA. The overlap between vascular disease and Alzheimer’s disease - lessons from pathology. BMC Med2014; 12: 206.
19.
SchneiderJAWilsonRSCochranEJ, et al.Relation of cerebral infarctions to dementia and cognitive function in older persons. Neurology2003; 60: 1082–1088.
GreenbergSMBacskaiBJHernandez-GuillamonM, et al.Cerebral amyloid angiopathy and Alzheimer disease - one peptide, two pathways. Nat Rev Neurol2020; 16: 30–42.
22.
JäkelLDe KortAMKlijnCJM, et al.Prevalence of cerebral amyloid angiopathy: a systematic review and meta-analysis. Alzheimers Dement2022; 18: 10–28.
23.
GreenbergSMVernooijMWCordonnierC, et al.Cerebral microbleeds: a guide to detection and interpretation. Lancet Neurol2009; 8: 165–174.
Martinez-RamirezSGreenbergSMViswanathanA. Cerebral microbleeds: overview and implications in cognitive impairment. Alzheimers Res Ther2014; 6: 33.
26.
TronconeLLucianiMCogginsM, et al.Aβ amyloid pathology affects the hearts of patients with Alzheimer's disease: mind the heart. J Am Coll Cardiol2016; 68: 2395–2407.
27.
HallLGCzeczorJKConnorT, et al.Amyloid beta 42 alters cardiac metabolism and impairs cardiac function in male mice with obesity. Nat Commun2024; 15: 258.
28.
KimWKimEJ. Heart failure as a risk factor for stroke. J Stroke2018; 20: 33–45.
29.
AdelborgKSzépligetiSSundbøllJ, et al.Risk of stroke in patients with heart failure: a population-based 30-year cohort study. Stroke2017; 48: 1161–1168.
30.
SposatoLAHilzMJAspbergS, et al.Post-stroke cardiovascular complications and neurogenic cardiac injury: JACC state-of-the-art review. J Am Coll Cardiol2020; 76: 2768–2785.
31.
BattagliniDRobbaCLopes da SilvaA, et al.Brain–heart interaction after acute ischemic stroke. Crit Care2020; 24: 163.
32.
SposatoLALamMAllenB, et al.First-ever ischemic stroke and incident major adverse cardiovascular events in 93 627 older women and men. Stroke2020; 51: 387–394.
MokuauNDeLeonPHKaholokulaJK, et al.Challenges and promise of health equity for Native Hawaiians. In: BogardKMcBride MurryVAlexanderC (eds) Perspectives on Health Equity and Social Determinants of Health. Washington, DC: National Academies Press (US), 2017, pp.169–183.
41.
MadanAArchambeauOGMilsomVA, et al.More than black and white: differences in predictors of obesity among native hawaiian/pacific islanders and European Americans. Obesity (Silver Spring)2012; 20: 1325–1328.
42.
NaʻaiDRaphaelKL. CKD In native Hawaiians and pacific islanders: trouble in paradise. Clin J Am Soc Nephrol2019; 14: 1661–1663.
43.
UchimaOWuYYBrowneC, et al.Disparities in diabetes prevalence among native Hawaiians/other pacific islanders and Asians in Hawai‘i. Prev Chronic Dis2019; 16: 180–187.
WangAYHuHYOuYN, et al.Socioeconomic status and risks of cognitive impairment and dementia: a systematic review and meta-analysis of 39 prospective studies. J Prev Alzheimers Dis2023; 10: 83–94.
46.
SchultzWMKelliHMLiskoJC, et al.Socioeconomic status and cardiovascular outcomes: challenges and interventions. Circulation2018; 137: 2166–2178.
47.
AvanADigalehHDi NapoliM, et al.Socioeconomic status and stroke incidence, prevalence, mortality, and worldwide burden: an ecological analysis from the global burden of disease study 2017. BMC Med2019; 17: 191.
48.
KreatsoulasCAnandSS. The impact of social determinants on cardiovascular disease. Can J Cardiol2010; 26: 8C–13C.
49.
Powell-WileyTMBaumerYBaahFO, et al.Social determinants of cardiovascular disease. Circ Res2022; 130: 782–799.
50.
PetersenJDWehbergSPacknessA, et al.Association of socioeconomic status with dementia diagnosis among older adults in Denmark. JAMA Netw Open2021; 4: e2110432.
51.
WilliamsJSWalkerRJEgedeLE. Achieving equity in an evolving healthcare system: opportunities and challenges. Am J Med Sci2016; 351: 33–43.
52.
FiscellaKWilliamsDR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med2004; 79: 1139–1147.
53.
WilliamsDRMohammedSALeavellJ, et al.Race, socioeconomic status, and health: complexities, ongoing challenges, and research opportunities. Ann N Y Acad Sci2010; 1186: 69–101.
54.
SiriwardhanaCCarrazanaELiowK, et al.Cardio and cerebrovascular diseases risk among Alzheimer's disease patients and racial/ethnic disparities, based on Hawaii medicare data. J Alzheimers Dis Rep2024; 8: 1529–1540.
National Academies of Sciences, Engineering, and Medicine. Accounting for Social Risk Factors in Medicare Payment: Identifying Social Risk Factors. Washington, DC: National Academies Press, 2016.
CookRJLawlessJF. Multistate Models for the Analysis of Life History Data. 1st ed. New York: Chapman and Hall/CRC, 2017.
61.
AndersenPKKeidingN. Multi-state models for event history analysis. Stat Methods Med Res2002; 11: 91–115.
62.
AalenOOJohansenS. An empirical transition matrix for non-homogeneous Markov chains based on censored observations. Scand J Stat1978; 5: 141–150.
63.
DattaSSattenGA. Validity of the aalen–johansen estimators of stage occupation probabilities and Nelson–Aalen estimators of integrated transition hazards for non-Markov models. Stat Prob Lett2001; 55: 403–411.
64.
DattaSSattenGA. Estimation of integrated transition hazards and stage occupation probabilities for non-Markov systems under dependent censoring. Biometrics2002; 58: 792–802.
65.
AndersenPKKleinJP. Regression analysis for multistate models based on a pseudo-value approach, with applications to bone marrow transplantation studies. Scand J Stat2007; 34: 3–16.
66.
KleinJPvan HouwelingenHCIbrahimJG, et al.Handbook of Survival Analysis (1st ed). New York: Chapman and Hall/CRC, 2013.
67.
National Research Council (US) Panel on Race, Ethnicity, and Health in Later Life; AndersonNBBulataoRACohenB, editors. Critical Perspectives on Racial and Ethnic Differences in Health in Late Life. Washington (DC): National Academies Press (US); 2004. 9, Race/Ethnicity, Socioeconomic Status, and Health, https://www.ncbi.nlm.nih.gov/books/NBK25526/ (2004, accessed 25 October 2024).
68.
SangaramoorthyMShariff-MarcoSConroySM, et al.Joint associations of race, ethnicity, and socioeconomic status with mortality in the multiethnic cohort study. JAMA Netw Open2022; 5: e226370.
69.
CannonJAMcMurrayJJQuinnTJ. ‘Hearts and minds’: association, causation and implication of cognitive impairment in heart failure. Alzheimers Res Ther2015; 7: 22.
70.
AndersonCMMcAllasterSAYoneokaGM, et al.Hawai'i rural health program: shaping the next generation of rural doctors. Hawaii J Health Soc Welf2022; 81: 20–23.
MorisakoAKTauali'iMAmbroseAJH, et al.Beyond the ability to pay: the health status of native Hawaiians and other pacific islanders in relationship to health insurance. Hawaii J Med Public Health2017; 76: 36–41.
FelixHNarcisseMRRowlandB, et al.Level of recommended heart attack knowledge among native Hawaiian and pacific islander adults in the United States. Hawaii J Med Public Health2019; 78: 61–65.
75.
SmithMVanNRobertsA, et al.Disparities in Alzheimer disease and mild cognitive impairment among native Hawaiians and pacific islanders. Cogn Behav Neurol2021; 34: 200–206.
76.
KanayaAMHsingAWPanapasaSV, et al.Knowledge gaps, challenges, and opportunities in health and prevention research for Asian Americans, native Hawaiians, and pacific islanders: a report from the 2021 national institutes of health workshop. Ann Intern Med2022; 175: 574–589.
77.
LeongRYangFLeeJJ, et al.Underrepresentation of Asian Americans, native Hawaiians, and other Pacific islanders (AA & NHPI) in cancer clinical trials that led to FDA approvals in 2010–2022. J Clin Oncol2024; 42: 11026–11026.
78.
TaparraK. Pacific islanders searching for inclusion in medicine. JAMA Health Forum2021; 2: e210153.
ShahuAOkunrintemiVTibuakuuM, et al.Income disparity and utilization of cardiovascular preventive care services among U.S. adults. Am J Prev Cardiol2021; 8: 100286.
81.
RosengrenASmythARangarajanS, et al.Socioeconomic status and risk of cardiovascular disease in 20 low-income, middle-income, and high-income countries: the prospective urban rural epidemiologic (PURE) study. Lancet Glob Health2019; 7: e748–e760.
82.
LiRLiRXieJ, et al.Associations of socioeconomic status and healthy lifestyle with incident early-onset and late-onset dementia: a prospective cohort study. Lancet Healthy Longev2023; 4: e693–e702.
83.
DuruOKHarawaNTKermahD, et al.Allostatic load burden and racial disparities in mortality. J Natl Med Assoc2012; 104: 89–95.
84.
CrielaardLNicolaouMSawyerA, et al.Understanding the impact of exposure to adverse socioeconomic conditions on chronic stress from a complexity science perspective. BMC Med2021; 19: 242.
85.
TanMMamunAKitzmanH, et al.Neighborhood disadvantage and allostatic load in African American women at risk for obesity-related diseases. Prev Chronic Dis2017; 14: E119.
86.
PampelFCKruegerPMDenneyJT. Socioeconomic disparities in health behaviors. Annu Rev Sociol2010; 36: 349–370.
87.
OsbornCYKripalaniSGogginsKM, et al.Financial strain is associated with medication nonadherence and worse self-rated health among cardiovascular patients. J Health Care Poor Underserved2017; 28: 499–513.
88.
WilderMEKuliePJensenC, et al.The impact of social determinants of health on medication adherence: a systematic review and meta-analysis. J Gen Intern Med2021; 36: 1359–1370.
89.
acias-KonstantopoulosWLCollinsKADiazR, et al.Race, healthcare, and health disparities: a critical review and recommendations for advancing health equity. West J Emerg Med2023; 24: 906–918.
90.
WilliamsDRSternthalM. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav2010; 51: S15–S27.
91.
Institute of Medicine (US) Committee on Assessing Interactions Among Social, Behavioral, and Genetic Factors in Health; HernandezLMBlazerDG, editors. Genes, Behavior, and the Social Environment: Moving Beyond the Nature/Nurture Debate. Washington (DC): National Academies Press (US); 2006. 2, The Impact of Social and Cultural Environment on Health, https://www.ncbi.nlm.nih.gov/books/NBK19924/ (2006, accessed 25 October 2024).
92.
BurgessDJFuSSvan RynM. Why do providers contribute to disparities and what can be done about it?J Gen Intern Med2004; 19: 1154–1159.
93.
JobCAdenipekunBClevesA, et al.Health professional's implicit bias of adult patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review protocol. BMJ Open2022; 12: e059837.
94.
JbailyAZhouXLiuJ, et al.Air pollution exposure disparities across US population and income groups. Nature2022; 601: 228–233.
95.
BerberianAGGonzalezDJXCushingLJ. Racial disparities in climate change-related health effects in the United States. Curr Environ Health Rep2022; 9: 451–464.
96.
McGuinnessDMcGlynnLMJohnsonPC, et al.Socio-economic status is associated with epigenetic differences in the pSoBid cohort. Int J Epidemiol2012; 41: 151–160.
97.
CunliffeVT. The epigenetic impacts of social stress: how does social adversity become biologically embedded?Epigenomics2016; 8: 1653–1669.
98.
NakagawaKKoenigMAAsaiSM, et al.Disparities among asians and native Hawaiians and pacific islanders with ischemic stroke. Neurology2013; 80: 839–843.
99.
FoxMHReichardA. Disability, health, and multiple chronic conditions among people eligible for both medicare and medicaid, 2005–2010. Prev Chronic Dis2013; 10: E157.
100.
ChenJSCorcoran RuizKMRivera PerlaKM, et al.Health disparities attributed to medicare-medicaid dual-eligible status in patients with peripheral arterial disease. J Vasc Surg2022; 75: 1386–1394.e3.
101.
DeckerSLKostovaDKenneyGM, et al.Health status, risk factors, and medical conditions among persons enrolled in medicaid vs uninsured low-income adults potentially eligible for medicaid under the affordable care act. JAMA2013; 309: 2579–2586.
102.
ChapelJMRitcheyMDZhangD, et al.Prevalence and medical costs of chronic diseases among adult medicaid beneficiaries. Am J Prev Med2017; 53: S143–S154.
UHERO Public Health Report Shaping Health in Hawaii: The Influences of Poverty, Housing and Food Insecurity – 2023, University of Hawaii Economic Research Organization, Shaping Health in Hawaii: The Influences of Poverty, Housing and Food Insecurity, https://uhero.hawaii.edu/wp-content/uploads/2023/07/ShapingHealthInHawaii.pdf (2023, accessed 10 September 2024).
105.
IharaES. Ethnicity matters: the socioeconomic gradient in health among Asian Americans. J Sociol Soc Welf2009; 36: Article 8.
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