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Demographics and the Epidemiological Risk Factors for Dementia in Hispanic/Latino Populations

  • Leticia E. FernándezEmail author
  • Norman J. Johnson
Chapter
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Abstract

The aging of the Hispanic/Latino population, their projected gains in life expectancy, and their high prevalence of chronic health conditions raise concerns about the well-being of their elder in the coming decades. This chapter examines demographic and epidemiologic risk factors for dementia in Hispanics/Latinos as well as provides estimates of the prevalence of dementia and associated mortality risks in a sample of elderly Hispanics/Latinos. Aging trends come from the 2014 National Population Projections by the Census Bureau. Their prevalence and mortality rates are estimated using data from the National Longitudinal Mortality Study (NLMS). The NLMS sample in this study consists of Hispanics/Latinos of any race and non-Hispanic White individuals in selected Current Population Study (CPS) surveys who were enrolled in Medicare and who reached age 65 between 1991 and 2011. The findings confirm that male and female Hispanics/Latinos have a higher prevalence of dementia than non-Hispanic White individuals in the same age groups for ages 60–64 and 65–69 and for females ages 70–74. At older ages, Hispanics/Latinos have similar or lower rates of dementia than non-Hispanic/Latino White individuals. We find differences in the prevalence of dementia by Hispanic country of origin and by educational attainment, but not by nativity (U.S.-born vs. foreign-born). In terms of mortality, Hispanics/Latinos afflicted with dementia are less likely to die at each age group compared to non-Hispanic White individuals with dementia. These patterns could be idiosyncratic to our Medicare-CPS linked sample, warranting further research.

Keywords

Dementia Epidemiology Hispanics with Dementia Latinos Mortality Rates Risk Factors 

Introduction

Previous studies report that the prevalence of dementia among elder Hispanics is about one and a half times higher than for non-Hispanic Whites and that these differences seem to remain throughout the oldest (85+) age groups (Demirovic et al., 2003; Gurland et al., 1999; Manly & Mayeux, 2004; Semper-Ternent et al., 2012). Tabulations using 2014 Medicare data estimate that 6.9% of non-Hispanic Whites ages 65 and older have a dementia diagnosis compared to 11.5% of Hispanics in the same age group (Alzheimer’s Association, 2016a). Researchers suggest that about one-third of Hispanics that survive dementia-free to age 65 could develop dementia in their later years (Haan et al., 2003; Mayeda, Glymour, Quesenberry, & Whitmer, 2016). The risk of dementia among Hispanics increases severalfold if comorbidities such as Type 2 diabetes mellitus and other cardiovascular diseases are present (Haan et al., 2003). Differences in the risk of dementia have been observed among Hispanic subgroups. Caribbean Hispanics tend to have higher risk than Mexican Americans (Haan et al., 2003; Tang et al., 2001). However, there are additional factors such as lifestyle, prevalence of cardiovascular disease, genetics, and socioeconomic status that are associated with differences in risk of developing dementia (Lines & Wiener, 2014).

This chapter provides an overview of the arguments supporting increased concern for risk of dementia in the Hispanic population, including shifts toward an older age distribution in the coming decades. Using data from the National Longitudinal Mortality Study (NLMS), we link data from the Current Population Survey (CPS) to Medicare claims and to mortality outcomes from the National Death Index to estimate the prevalence of dementia among Hispanics ages 65 and older who are enrolled in Medicare, and we provide estimates of their mortality risks.

Literature Review

Dementia describes a group of neurodegenerative diseases that cause progressive cognitive decline, destroying a person’s memory, ability to reason, and independence to perform daily activities (Alzheimer’s Association, 2016a). This cognitive decline is the result of damaged or destroyed neurons (brain nerve cells) in the areas involved in cognitive and other functions (Alzheimer’s Association, 2016a, 2016b). In most cases, symptoms of dementia become apparent as individuals reach their mid-60s or later, and its progression can be devastating for individuals, caregivers, and the healthcare system (Alzheimer’s Association, 2016b; Chatterjee et al., 2016; Ninomiya, 2014; Plassman et al., 2007; van den Berg & Splaine, 2012). In the advanced stage, dementia causes severe functional limitations and may become an underlying or a contributing factor in a person’s death (Alzheimer’s Association, 2016a). As an underlying cause, dementia may lead to difficulty eating or swallowing, thus giving rise to complications that may result in death (Wilkins, Parsons, Gentleman, & Forbes, 1999). Alternatively, dementia may indirectly increase risks of mortality by reducing a person’s physical resistance to illnesses (Aguero-Torres, Fratiglioni, Guo, Viitanen, & Winblad, 1999; Newcomer, Covinsky, Clay, & Yaffe, 2003; Wilkins et al., 1999).

Several subtypes of dementia exist. The most prevalent type of dementia is Alzheimer’s disease accounting for 60 to 80% of cases (this percentage increases with age), followed by vascular dementia at about 17% to 20% (Alzheimer’s Association, 2016b; Barnes & Yaffe, 2011; Plassman et al., 2007). Other forms of dementia account for the remainder and include mixed dementia (dementia of the Alzheimer’s type and vascular dementia), Parkinson’s disease, dementia with Lewy bodies, physical brain injury, Huntington’s disease, Creutzfeldt–Jakob disease, frontal temporal dementia/Pick’s disease, and normal pressure hydrocephalus (Alzheimer’s Association, 2016b; Chatterjee et al., 2016; Chen, Lin, & Chen, 2009; Plassman et al., 2007). In this chapter, we refer to dementia in general, including all subtypes, except when specifically noted otherwise.

In the United States (U.S.), the prevalence of dementia among individuals over 70 years old is approximately 14.0%. A breakdown of this estimate shows that 5.0% of individuals aged 71 to 79 suffer dementia, that its prevalence increases to 24.2% among individuals aged 80 to 89, and to 37.4% among individuals aged 90 and older (Plassman et al., 2007). The prevalence of Alzheimer’s disease, the most common form of dementia, is about 3% among individuals 65 to 74, but it increases to 18% for those 75 to 84, and to 33% among individuals 85 or older (Hebert, Weuve, Scherr, & Evans, 2013). In 2016, it was estimated that 5.2 million individuals ages 65 and older had Alzheimer’s disease in the United States, about 11% of the elder population. The number is expected to reach 7.1 million by 2025 and 13.8 million by 2050 (Alzheimer’s Association, 2016a; Hebert et al., 2013).

Growth and Aging of the Hispanic/Latino Population

In 2015, there were 56.6 million individuals of Hispanic origin, representing 17.6% of the U.S. population. Hispanics are a young, fast-growing, and diverse population. They are projected to reach 105 million in 2050 and 119 million in 2060, accounting for 26.5% and 28.6% of the nation’s population, respectively (Colby & Ortman, 2015; U.S. Census Bureau, 2014a). Past and continuous immigration and gains in life expectancy suggest that in the coming decades Hispanics will be increasingly represented in older age groups in the U.S. population (Alzheimer’s Association, 2013; Colby & Ortman, 2015; Haan et al., 2003). Table 1.1 shows the U.S. Census Bureau’s 2014 National Population Projections of total and Hispanic populations for the next few decades. Although Hispanics have a younger age distribution than the country’s population as a whole, the percentage for people age 65 and older is projected to more than double between 2015 and 2050, reaching 16% (U.S. Census Bureau, 2014a). This projection reflects expected gains in life expectancy for all groups in the coming decades (Ortman, Velkoff, & Hogan, 2014).
Table 1.1

Estimated and projected age distribution of total and Hispanic U.S. population 2015, 2030, and 2050

Projected population by age group and Hispanic origin

2015a

2020

2030

2040

2050

Total U.S. population (in 1000s)

321,419

334,503

359,402

380,219

398,328

Percent 0 to 17 years

22.9

22.2

21.2

20.6

20.1

Percent 18 to 64 years

62.2

61.0

58.2

57.8

57.9

Percent 65 years and older

14.9

16.9

20.6

21.7

22.1

Total

100.0

100.0

100.0

100.0

100.0

U.S. Hispanic origin populationb (in 1000s)

56,593

63,551

77,463

91,626

105,550

Percent 0 to 17 years

32.1

30.0

26.8

25.4

24.2

Percent 18 to 64 years

61.3

62.2

62.3

61.0

59.9

Percent 65 years and older

6.7

7.9

10.9

13.6

15.9

Total

100.0

100.0

100.0

100.0

100.0

Life expectancy at birth

     

Hispanic female

84.2

84.3

84.5

85.3

86.4

Hispanic male

79.6

80.0

80.6

81.7

83.2

Life expectancy at age 65

     

Hispanic female

22.4

22.4

22.5

22.9

23.7

Hispanic male

20.0

20.0

20.0

20.0

21.2

Population age 65 and older (in 1000s)

47,761

56,441

74,107

82,344

87,996

Percent non-Hispanic

92.2

91.1

88.6

84.9

80.9

Percent native Hispanic

3.50

3.8

4.6

5.7

7.6

Percent foreign-born Hispanic

4.30

5.0

6.8

9.4

11.4

Total

100.0

100.0

100.0

100.0

100.0

Population age 85 and older (in 1000s)

6287

6727

9132

14,634

18,972

Percent non-Hispanic

93.5

92.1

90.9

90.0

86.9

Percent native Hispanic

3.1

3.7

3.8

4.2

5.2

Percent foreign-born Hispanic

3.4

4.2

5.2

5.8

7.9

Total

100.0

100.0

100.0

100.0

100.0

Source: U.S. Census Bureau, 2014a (National Projections)

aThe population age distribution for 2015 comes from the Annual Estimates of the Resident Population by Sex, Age, Race, and Hispanic Origin for the United States and States: April 1, 2010 to July 1, 2015 (U.S. Census Bureau, 2016). All other figures are from the 2014 National Projections developed by the U.S. Census Bureau Population Division (U.S. Census Bureau, 2014a, 2014b)

bNative and foreign-born Hispanics combined

As shown in Table 1.1, the life expectancy at birth for Hispanic males is projected to increase from 79.6 years in 2015 to 83.2 years by 2050 and for females, from 84.2 to 86.4 for the same period. For Hispanics who attain the age of 65, gains in life expectancy are more modest but still positive. Hispanic male life expectancy at 65 is projected to increase from 20.0 years in 2015 to 21.2 years by 2050 and for females, from 22.4 to 23.7 (U.S. Census Bureau, 2014b). Table 1.1 also shows that the nation’s population 65 and older is projected to increase by nearly 18 million people between 2020 and 2030, as the last generation of the baby boomer cohort (born between 1946 and 1964) reaches age 65 (U.S. Census Bureau, 2014a). In the following decades, Hispanics will become an increasing share of the fast-growing 65 and older population, reaching 20% in 2050; that is, one out of five elderly will be of Hispanic/Latino descent (U.S. Census Bureau, 2014a).

Aging is the main risk factor for dementia. With an ever-increasing elderly population having a longer life expectancy, there will be more individuals likely to live well into their 80s and 90s when the risk of Alzheimer’s disease and other dementias are highest (Hebert et al., 2013). In addition, the increasing representation of Hispanics in the elderly population may bring further increases in the number of people with dementia if elderly Hispanics are more likely than non-Hispanic to develop dementia (Alzheimer’s Association, 2016a). Furthermore, because of past migration trends, among Hispanics 65 and older, the foreign-born are projected to outpace the share of the native-born. In 2050, six out of every ten elderly Hispanics will be foreign-born, with implications for language preference and need for culturally appropriate healthcare services.

Epidemiology of Dementia in the Hispanic/Latino Population

Recent studies report that Hispanics tend to experience higher rates of cognitive decline and dementia than non-Hispanic Whites, while also having more comorbidities (Alvarez, Rengifo, Emrani, & Gallagher-Thompson, 2014; Clark et al., 2005; Haan et al., 2003; Manly & Mayeux, 2004; Novak & Riggs, 2004; Tang et al., 2001). In addition to age, the risks of dementia are higher for individuals with low levels of education, cardiovascular diseases, and genetic predisposition (Alzheimer’s Association, 2016a, 2016b). Cultural practices and lifestyle may also influence risks, as well as the progression of the disease (Chen et al., 2009). We discuss each of these as they pertain to the Hispanic population.

Age

After age 65, the risk of dementia doubles for each 5 years of age (Novak & Riggs, 2004). As summarized in the previous section, in the coming decades, Hispanics will increasingly be overrepresented in the age groups most at risk for dementia. In particular, in 2015, 6.5% of the individuals 85 and older were Hispanic, but this share is expected to double to 13.1% by 2050.

Low Education/Socioeconomic Status

Having more years of formal education and regularly engaging in mentally stimulating leisurely activities are both associated with lower risk of dementia (Barnes & Yaffe, 2011; Chen et al., 2009). In part, the association between education and dementia may be mediated by socioeconomic status. Low socioeconomic status has been associated with a broad range of adverse health outcomes (Galea, Tracy, Hoggatt, DiMaggio, & Karpati, 2011; Haan et al., 2003; Marmot, 2005).

Hispanics tend to have lower formal education levels than any other group in the United States. In 2015, about one-third of Hispanics ages 25 and older had less than a high school education, and only 16% had a college degree or higher education (Ryan & Bauman, 2016). As a group, foreign-born Hispanics/Latinos have much lower levels of education than their native counterparts; the educational attainment of native Hispanics/Latinos has improved in recent decades. In 2015, about 20% of native Hispanics had a college degree or higher, twice the percentage from 1994 (Administration for Community Living, 2016; Ryan & Bauman, 2016). For the older generations of Hispanics, low levels of education may translate into higher risk of developing dementia. Some studies do confirm that elder Hispanics with low socioeconomic status are more likely to have symptoms of cognitive impairment than Hispanics with higher socioeconomic status (Alzheimer’s Association, 2016a; Schneiderman et al., 2014).

Cardiovascular Risk Factors

Cardiovascular diseases, such as Type 2 diabetes mellitus, hypertension in midlife, high cholesterol, obesity in midlife, and a history of stroke have been associated with increased risk of dementia in the older ages, and these risks are heightened in the presence of comorbidities (Barnes & Yaffe, 2011; Chatterjee et al., 2016; Ninomiya, 2014). Hispanics present a high prevalence of cardiovascular disease. For instance, a study documenting self-reported health among Hispanics ages 18–74 found that half of the men and nearly 40% of the women reported high cholesterol, and obesity was reported by over one-third of the men and over 40% of the women (Daviglus et al., 2012). In addition, for both men and women, one in four reported hypertension and 17% reported diabetes (Daviglus et al., 2012; Schnaider Beeri et al., 2004). Among Hispanics ages 45–64, one-quarter had three or more of these risk factors. This percentage increased to 40% for ages 65–74. Hispanics with low education and low income, native Hispanics, and immigrant Hispanics who have lived in the United States for over 10 years were the most likely to report multiple risk factors (Daviglus et al., 2012; Schneiderman et al., 2014). It should be noted that some of the differences in the prevalence of morbidities might be due to undiagnosed conditions in recent immigrants (Barcellos, Goldman, & Smith, 2012).

In addition, as mentioned earlier, there seem to be differences in the prevalence of risk factors by country of origin or ancestry. For example, Mexican, Puerto Rican, or Dominican Hispanics tend to have a higher prevalence of Type 2 diabetes mellitus than Cuban and South Americans. In contrast, the prevalence of hypertension is reported to be higher for Dominicans, Cubans, and Puerto Ricans and lower for South Americans and Mexicans (Daviglus et al., 2012; Schnaider Beeri et al., 2004). The prevalence of Type 2 diabetes mellitus in Hispanics/Latinos, estimated at 13 to 17%, raises major concerns about future increases in the prevalence of cognitive impairment and dementia (Centers for Disease Control and Prevention, 2014; Daviglus et al., 2012; Haan et al., 2003; Noble, Manly, Schupf, Tang, & Luchsinger, 2012).

Genetic Factors

Having one or more parents or siblings with Alzheimer’s disease increases an individual’s risk of developing the disease. This may be due to a combination of shared heredity, lifestyle, or environmental factors (Green et al., 2002; Lautenschlager et al., 1996). In addition, there is a well-documented association between higher risk of dementia, specifically Alzheimer’s disease, and the presence of an identified gene on chromosome 19, the apolipoprotein E-ε4 (APOE-ε4) allele. There are three forms of the APOE gene (ε2, ε3, and ε4) from each parent. Having one copy of the APOE-ε4 gene triples the risk of developing Alzheimer’s disease, and having two copies multiplies the risk by 8–12 times compared to those without the ε4 form (Alzheimer’s Association, 2016a; Holtzman, Herz, & Bu, 2012; Loy, Schofield, Turner, & Kwok, 2014). However, this does not mean that every carrier of this gene will develop dementia. Estimates vary, but studies report that about half the individuals with Alzheimer’s do not have the APOE-ε4 allele (National Institute on Aging, 2015; Pastor & Goate, 2004). Hispanic genetic ancestry is a mixture of Amerindian (American Indian), African, and European genomes, and the percentage contribution of each tends to vary by country of origin. Generally, for example, Mexicans and Central Americans have a higher Amerindian genetic ancestry, while Caribbean groups tend to have a higher African ancestry (Campos, Edland, & Peavy, 2013). For Hispanics of Amerindian ancestry, the frequency of APOE-ε4 allele is relatively low, and the association between Alzheimer’s and the APOE-ε4 allele seems to be weaker or attenuated (Campos et al., 2013; Farrer et al., 1997; Gamboa et al., 2000). Moreover, some researchers suggest that regardless of APOE genotype, Hispanics tend to have higher risks of Alzheimer’s than non-Hispanic White individuals of the same age. This may be due to their higher prevalence of Type 2 diabetes mellitus, particularly in Mexican and Puerto Rican groups (Farrer et al., 1997; Haan et al., 2003; Plassman et al., 2007; Tang et al., 1998).

Health-Impacting Factors Associated with Lifestyle and Culture

Close to 40% of adult Hispanics are obese (Body Mass Index of 30 or higher), a risk factor for diabetes, hypertension, and other conditions associated with dementia (Daviglus et al., 2012; Flegal, Carroll, Ogden, & Curtin, 2010). Smoking has also been associated with increased risks of cognitive decline and dementia. Puerto Ricans and Cubans show higher rates of smoking than other Hispanic groups (Baumgart et al., 2015; Daviglus et al., 2012).

Some studies suggest that prescription drugs to manage cardiovascular conditions such as diabetes, high cholesterol, or hypertension may be protective of cognitive functions through their anti-inflammatory mechanisms, so that early detection and treatment of these chronic conditions may have positive impact on preventing dementia in later years (Baumgart et al., 2015; Chen et al., 2009; Ninomiya, 2014). However, Hispanics are less likely than non-Hispanics to seek regular checkups. This can result in Hispanics going undiagnosed, experiencing late diagnoses or mismanagement of chronic conditions and cognitive decline symptoms (Alzheimer’s Association, 2007; Center on Aging Society, 2003; Cooper, Tandy, Balamurali, & Livingston, 2010; Espino et al., 2001; Novak & Riggs, 2004). Early diagnosis of dementia could help individuals obtain the most benefits from available treatments to improve cognitive function and delay institutionalization, including opportunities to participate in promising clinical trials (Prince, Bryce, & Ferri, 2011). Some of the barriers to healthcare utilization among elderly Hispanics include lack of health insurance, poverty, low levels of formal education and poor health literacy, limited English proficiency, and underreporting of cognitive impairment due to the perception that memory loss is a normal part of aging (Lines & Wiener, 2014; Novak & Riggs, 2004).

Prevalence of Dementia and Mortality Risks in the Hispanic/Latino Medicare Population

Using data from the NLMS, we estimate the prevalence of dementia and risks of mortality for each 5-year age group starting with age 60. The sample consists of N = 19,832 Hispanics and N = 304,173 non-Hispanic White individuals. These individuals were enrolled in Medicare, reached age 65 between 1991 and 2011, and were matched to their individual-level responses in the CPS. We linked the sample to their Medicare claims to identify those afflicted with dementia and determined mortality outcomes by using the National Death Index (NDI).

We focus on differences in dementia prevalence and mortality among Hispanics by sex, education, and place of birth (foreign-born vs. U.S.-born) as reported in the CPS. Dementia diagnoses, which included Alzheimer’s disease and related disorders or senile dementia, were identified from the Medicare inpatient and outpatient claims records based on the International Classification of Diseases, Ninth Revision (ICD-9; Centers for Medicare & Medicaid Services, 2014a) and Tenth Revision (ICD-10; Centers for Medicare & Medicaid Services, 2014b) codes, as recommended by the Centers for Medicare and Medicaid Services (CMS) Chronic Conditions Data Warehouse (CCW) algorithms. The three-digit ICD-9 codes included mild cognitive impairment, Alzheimer’s disease, dementia with Lewy bodies, and other cerebral degeneration (331), presenile and senile dementia, including vascular dementia (290), senility without mention of psychosis (797), and other and non-specified brain disorders (294). The corresponding three-digit ICD-10 codes included Alzheimer’s disease, dementia with Lewy bodies, other dementias (F02, G30), vascular dementia (F01), senile dementia (G31.1, R54), frontotemporal dementia (G31.01, G31.09), and other non-specified brain disorders (F03, F04, F05, F06.1, F06.8, G13.2 G13.8, G31.2, G94, R41.81).

A limitation for this type of study is that the diagnosis of dementia is influenced by differential rates of underdiagnosis and underreporting across Hispanic groups of varying socioeconomic characteristics (Kotagal et al., 2015; Lines & Wiener, 2014). In addition, the sample combines individuals who were diagnosed in a 20-year span, and changes over the years in the disease itself, its coding in the ICD system, and its criteria for a diagnosis might influence our findings. Table 1.2 compares the prevalence of dementia by 5-year age group among non-Hispanic White male and female Medicare beneficiaries with those of their similarly aged Hispanic counterparts and to Hispanics from specific countries of origin or ancestry. Our estimates show that Hispanics as a group have a higher prevalence of dementia in the younger-old groups, ages 60 to 64 and 65 to 69 (and for women, also ages 70 to 74), confirming other findings of early-onset dementia in Hispanics (Clark et al., 2005; Gurland et al., 1999; Manly & Mayeux, 2004). At older ages, our findings for this Medicare sample suggest that Hispanics have similar or lower rates of dementia than non-Hispanic White individuals.
Table 1.2

Prevalence of dementia among White non-Hispanics and Hispanics and by detailed Hispanic origin groups, Medicare beneficiaries aged 65 and oldera (confidence interval in parenthesis)

Males, % with dementia diagnosis in each age interval

Age

Non-hispanic white (N = 127,644)

All Hispanic (N = 8274)

Mexican (N = 4330)

Puerto Rican (N = 940)

Cuban (N = 1042)

Central/South American (N = 766)

Other hispanic (N = 1196)

60–64

4.0

(3.8, 4.2)

5.6

(4.6, 6.6)

5.2

(3.9, 6.6)

11.0

(7.1,14.9)

5.3

(2.2, 8.3)

4.4

(1.6, 7.2)

3.1

(1.1, 5.2)

65–69

13.0

(12.6, 13.4)

14.6

(13.0, 16.1)

15.0

(12.9,17.1)

15.8

(11.2, 20.4)

15.7

(10.8, 20.5)

12.4

(7.9, 17.0)

12.4

(8.6, 16.3)

70–74

24.1

(23.5, 24.6)

24.8

(22.6, 26.9)

25.0

(22.1, 27.9)

25.8

(19.6, 32.0)

25.9

(19.8, 32.0)

20.8

(14.2, 27.5)

24.5

(18.9, 30.2)

75–79

40.9

(40.2, 41.6)

39.3

(36.6, 42.0)

38.9

(35.1, 42.7)

39.7

(31.0, 48.4)

41.0

(34.3, 47.6)

37.6

(28.5, 46.7)

39.5

(32.7, 46.3)

80–84

57.3

(56.5, 58.1)

49.8

(46.4, 53.3)

52.9

(48.2, 57.7)

59.0

(48.5, 69.6)

42.9

(33.4, 52.3)

45.5

(34.3, 56.6)

40.9

(31.9, 49.9)

85+

73.9

(73.1, 74.7)

63.0

(58.9, 67.0)

62.9

(57.1, 68.7)

61.0

(48.6, 73.5)

65.4

(56.2, 74.5)

54.8

(37.3, 72.4)

64.5

(54.8, 74.2)

Total

28.3

(28.0, 28.5)

24.8

(23.8, 25.7)

24.6

(23.4, 25.9

26.3

(23.5, 29.1)

28.3

(25.6, 31.0)

20.5

(17.6, 23.4)

23.7

(21.3, 26.2)

Females, % with dementia diagnosis in each age interval

Age

Non-Hispanic white (N = 176,529)

All Hispanic (N = 11,558)

Mexican (N = 5592)

Puerto Rican (N = 1379)

Cuban (N = 1544)

Central/south American (N = 1378)

Other hispanic (N = 1665)

60–64

3.9

(3.7, 4.1)

4.8

(4.0, 5.6)

4.3

(3.2, 5.4)

5.8

(3.4, 8.3)

5.5

(2.8, 8.1)

5.7

(3.2, 8.3)

4.4

(2.3, 6.5)

65–69

13.2

(12.8, 13.5)

15.4

(14.0, 16.8)

15.6

(13.6, 17.5)

19.9

(15.5, 24.3)

18.1

(13.5, 22.8)

13.5

(10.0, 16.9)

10.5

(7.2, 13.8)

70–74

23.3

(22.8, 23.8)

27.2

(25.3, 29.1)

27.1

(24.4, 29.8)

40.2

(34.1, 46.4)

25.7

(20.6, 30.8)

25.8

(20.4, 31.1)

20.1

(15.8, 24.5)

75–79

40.9

(40.3, 41.5)

41.2

(38.9, 43.4)

42.3

(39.0, 45.6)

50.2

(43.3, 57.2)

38.1

(32.6, 43.7)

39.7

(32.5, 46.8)

34.6

(28.8, 40.4)

80–84

58.9

(58.3, 59.5)

56.9

(54.3, 59.5)

55.7

(51.9, 59.5)

62.9

(54.6, 71.1)

60.4

(54.2, 66.7)

54.8

(46.4, 63.2)

54.1

47.1, 61.1)

85+

77.1

(76.6, 77.6)

71.7

(69.1, 74.4)

71.6

(67.6, 75.7)

71.8

(63.9, 79.7)

69.6

(63.3, 75.9)

74.8

(66.8, 82.7)

72.4

(66.1, 78.7)

Total

33.9

(33.6, 34.1)

29.4

(28.6, 30.3)

28.6

(27.5, 29.8)

33.1

(30.6, 35.6)

34.3

(31.9, 36.6)

26.6

(24.2, 28.9)

27.0

(24.9, 29.2)

Source: Authors’ computations, NLMS

aThe NLMS sample includes only Hispanics/Latinos of any race and non-Hispanic White individuals enrolled in Medicare who reached age 65 between 1991 and 2011 and who matched to their individual-level responses in the Current Population Survey (NLMS website: https://www.census.gov/nlms). 

Looking at particular countries of origin or ancestry, Puerto Rican male Medicare beneficiaries ages 60 to 64 have rates that are twice as high as those of other Hispanics/Latinos in the same age group (11.0%), which could be specific to the sample and require further research. We observe that Puerto Rican males have higher prevalence of dementia than other groups for ages 80 to 84 and Puerto Rican females have higher prevalence of dementia than other groups for ages 70–74, 75–79, and 80–84, although the differences are not always statistically significant (the confidence intervals overlap). These patterns could be idiosyncratic to the Medicare sample, warranting further research. Although the differences are not always statistically significant, Cuban and Mexican men, as well as Cuban, Mexican, and Central and South American women have a prevalence of dementia that is higher than for non-Hispanic White individuals prior to age 70, but are similar or lower for older ages. The lowest prevalence of dementia is found in the other Hispanics for both males and females.

Table 1.3 shows differentials in the prevalence of dementia among Hispanics/Latinos by educational attainment. As reported in the literature, males that are more educated have lower prevalence of dementia, at least before age 70, but the pattern is not as clear for females. Similarly, Table 1.4 shows that the prevalence of dementia among Hispanics does not follow a clear trend for place of birth. Finally, Table 1.5 shows the percentage of Hispanics/Latinos who died within each 5-year interval by sex and dementia diagnosis. There are three findings shown in this table that should be emphasized. First, on average, although not for every age group, individuals with dementia are at higher risk of death than those with no dementia. Second, as a group, Hispanics afflicted with dementia are less likely to die at each age group compared to non-Hispanic White individuals with dementia. Third, in general, educated Hispanics with dementia are less likely to die in each age interval than their less-educated counterparts. Education seems to be associated not only with lower prevalence of dementia among Hispanics but also with lower mortality among those who develop dementia.
Table 1.3

Prevalence of dementia among Hispanics by educational attainment, Medicare beneficiaries aged 65 and oldera (confidence interval in parenthesis)

Hispanic males, % with dementia diagnosis in each age interval

Age

Less than high school (N = 5077)

High school diploma/equivalent (N = 1628)

More than high school (N = 1566)

60–64

6.3

(4.9, 7.7)

5.4

(3.4, 7.5)

3.3

(1.5, 5.0)

65–69

15.6

(13.5, 17.6)

15.0

(11.6, 18.4)

11.2

(8.2, 14.3)

70–74

24.8

(22.1, 27.6)

27.7

(22.7, 32.7)

21.6

(17.0, 26.2)

75–79

38.4

(35.0, 41.7)

40.4

(34.0, 46.9)

41.6

(35.1, 48.1)

80–84

50.1

(45.9, 54.3)

49.2

(40.2, 58.1)

49.3

(40.8, 57.7)

85+

65.7

(61.0, 70.3)

52.1

(40.5, 63.7)

59.0

(48.5, 69.6)

Total

26.6

(25.4, 27.8)

22.2

(20.2, 24.3)

21.3

(19.3, 23.4)

Hispanic females, % with dementia diagnosis in each age interval

Age

Less than high school (N = 7562)

HS diploma/equivalent (N = 2427)

More than high school (N = 1568)

60–64

4.3

(3.3, 5.3)

5.8

(3.9, 7.7)

5.3

(3.2, 7.5)

65–69

16.5

(14.7, 18.3)

15.7

(12.7, 18.6)

10.8

(7.8, 13.8)

70–74

26.4

(24.1, 28.7)

30.3

(26.2, 34.4)

25.9

(20.7, 31.0)

75–79

41.4

(38.7, 44.1)

41.9

(36.6, 47.2)

38.6

(32.0, 45.2)

80–84

56.8

(53.7, 60.0)

56.4

(50.3, 62.5)

58.3

(50.3, 66.4)

85+

70.7

(67.6, 73.8)

76.8

(70.6, 83.1)

70.8

(61.7, 79.9)

Total

31.0

(29.9, 32.0)

28.4

(26.6, 30.2)

23.7

(21.6, 25.8)

Source: Authors’ computations, NLMS

aThe NLMS sample includes only Hispanics/Latinos of any race enrolled in Medicare who reached age 65 between 1991 and 2011 and who matched to their individual-level responses in the Current Population Survey (NLMS website: https://www.census.gov/nlms).

Table 1.4

Prevalence of dementia among Hispanics by nativity, Medicare beneficiaries aged 65 and oldera (confidence interval in parenthesis)

Hispanic males, % with dementia diagnosis in each age interval

Age

Born in the United States (N = 3898)

Born in outlying U.S. territories (N = 624)

Foreign-born (N = 3359)

60–64

4.9

(3.5, 6.3)

8.3

(4.2, 12.5)

5.1

(3.6, 6.6)

65–69

14.0

(11.8, 16.2)

14.1

(8.6, 19.6)

15.1

(12.7, 17.5)

70–74

24.4

(21.3, 27.5)

23.2

(15.8, 30.6)

25.8

(22.4, 29.1)

75–79

38.1

(34.3, 41.9)

36.6

(26.2, 47.0)

40.1

(35.8, 44.3)

80–84

49.9

(45.0, 54.7)

50.9

(37.7, 64.1)

47.7

(42.1, 53.3)

85+

64.9

(59.1, 70.7)

44.7

(28.9, 60.5)

62.2

(55.9, 68.6)

Total

24.9

(23.5, 26.2)

22.4

(19.2, 25.7)

24.6

(23.1, 26.0)

Hispanic females, % with dementia diagnosis in each age interval

Age

Born in the US (N = 5237)

Born in outlying U.S. territories (N = 963)

Foreign-born (N = 4815)

60–64

5.0

(3.7, 6.3)

4.5

(2.0, 7.0)

4.2

(3.0, 5.4)

65–69

14.0

(12.0, 16.0)

18.3

(13.4, 23.2)

15.9

(13.8, 18.1)

70–74

25.5

(22.8, 28.2)

38.6

(31.4, 45.8)

25.6

(22.7, 28.5)

75–79

39.2

(35.9, 42.4)

42.4

(34.0, 50.9)

42.1

(38.5, 45.7)

80–84

53.5

(49.6, 57.3)

58.5

(47.9, 69.2)

60.3

(56.2, 64.4)

85+

75.1

(71.4,78.9)

65.8

(54.9, 76.6)

68.9

(64.7, 73.1)

Total

29.2

(27.9, 30.4)

28.6

(25.7, 31.4)

29.2

(28.0, 30.5)

Source: Authors’ computations, NLMS

aThe NLMS sample includes only Hispanics/Latinos of any race enrolled in Medicare who reached age 65 between 1991 and 2011 and who matched to their individual-level responses in the Current Population Survey (NLMS website: https://www.census.gov/nlms).

Table 1.5

Percent of individuals who died within each 5-year interval by sex, age group, and whether they had a dementia diagnosisa (confidence interval in parenthesis)

Males, % who died with and without dementia diagnosis in each age interval

Age

Non-hispanic white (N = 127,644)

Hispanic (N = 8274)

Hispanic, less than high school (N = 5077)

Hispanic, high school Diploma/equivalent (N = 1628)

Hispanic, more than high school (N = 1566)

 

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

60–64

57.0

52.2

42.9

33.3

45.8

37.4

42.3

31.9

30.8

23.8

65–69

46.3

56.2

38.7

37.0

44.6

43.5

31.3

31.7

25.5

24.5

70–74

56.1

62.6

44.8

41.0

47.3

48.8

41.2

35.6

40.3

22.2

75–79

63.0

64.0

49.0

47.1

50.8

54.3

45.1

37.3

46.7

28.7

80–84

68.7

67.2

57.9

55.9

59.8

60.7

61.0

52.5

47.0

39.7

85+

77.5

70.2

67.1

60.8

69.2

63.2

67.6

50.0

55.1

61.8

Total

64.9

58.5

51.2

39.9

54.4

46.3

46.4

34.5

43.1

26.1

Females, % who died with and without dementia diagnosis in each age interval

Age

Non-hispanic white (N = 176,529)

Hispanic (N = 11,558)

Hispanic, less than HS (N = 7562)

Hispanic, HS diploma/equivalent (N = 2427)

Hispanic, more than high school (N = 1568)

 

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

With dementia

No dementia

60–64

50.4

44.2

37.9

25.3

43.9

31.3

34.3

18.3

26.1

13.2

65–69

41.5

50.4

27.3

28.0

27.3

33.3

33.0

21.8

15.9

17.0

70–74

48.6

58.6

34.2

32.9

35.6

37.7

32.7

27.5

30.6

18.0

75–79

56.5

61.9

44.4

43.7

46.8

51.1

38.1

28.5

39.5

24.8

80–84

63.3

64.4

50.7

41.7

52.0

43.9

46.1

39.4

50.0

30.0

85+

73.7

68.3

63.4

52.6

65.8

56.8

61.0

43.9

48.5

28.6

Total

62.0

54.2

46.3

32.1

48.7

38.0

42.2

24.2

38.2

17.6

Source: Authors’ computations, NLMS

aThe NLMS sample includes only Hispanics/Latinos of any race and non-Hispanic White individuals enrolled in Medicare who reached age 65 between 1991 and 2011 and who matched to their individual-level responses in the Current Population Survey (NLMS website: https://www.census.gov/nlms).

Discussion

Our research shows that Hispanics/Latinos ages 60–64 tend to have higher prevalence of dementia than similarly aged non-Hispanic White individuals, which confirms patterns reported elsewhere of early-onset dementia. At the same time, mortality rates of Hispanics with dementia within each 5-year interval seem to be lower than for non-Hispanic White individuals. With the aging of the Hispanic population and the expected gains in life expectancy, the number of elderly Hispanics/Latinos with dementia may be higher than expected, and they may spend a greater number of years afflicted by dementia. There are no treatments to cure dementia, slow down its progression, or stop the damage to brain cells. However, drug treatments can lessen at least for a limited time the cognitive and behavioral symptoms of the disease (memory loss, confusion, problems with thinking and reasoning, etc.) (Alzheimer’s Association, 2016b; O’Brien et al., 2017). Responses to treatment as well as side effects vary by individual, and in general, the use of anti-dementia drugs must be balanced with the risk and severity of side effects (O’Brien et al., 2017). The hope is that in the future therapies will be developed that will stop the disease or at least improve the quality of life for people with dementia (Alzheimer’s Association, 2016b).

Therefore, strategies to improve the quality of life of elder Hispanics/Latinos in the coming years should emphasize multimodal lifestyle interventions to slow down cognitive decline and the onset of dementia (Barnes & Yaffe, 2011; Manuel et al., 2016). Seven modifiable risk factors have been identified that could reduce the prevalence of dementia in the United States and worldwide. According to Barnes and Yaffe (2011), if rates of physical inactivity were reduced, and the prevalence of midlife obesity, diabetes, midlife hypertension, depression, smoking, and low education were lowered by 10%, there would be 184,000 fewer Alzheimer’s cases in the United States (a 3.5% reduction). If the negative risk factors were lowered by 25%, 492,000 cases of Alzheimer’s could be averted (9.3% reduction) in the coming decades.

These suggested changes are likely to benefit from multilevel public health interventions that tailor messages to specific at-risk subpopulations in promoting weight loss and healthier diets, smoking cessation, engaging in frequent physical activity, and keeping regular healthcare visits to identify and manage cardiovascular diseases (Golden et al., 2012; Lopez & Golden, 2014; Middleton & Yaffe, 2010; van den Berg & Splaine, 2012). In addition, given the evidence of early-onset dementia among Hispanics, healthcare providers could suggest more frequent evaluations for the onset of cognitive disorders, as well as adopt culturally relevant instruments (Haan et al., 2003; Lee, 2010; Swedish Council on Technology Assessment in Health Care, 2008). In the past, Hispanics have been less likely than non-Hispanic Whites to be screened for cognitive decline (Alzheimer’s Association, 2013; Kotagal et al., 2015; Lines & Wiener, 2014). Furthermore, tests to assess cognitive decline might be confusing if they are culturally, educationally, and linguistically biased given that at least half of the elderly Hispanics are foreign-born with diverse levels of English language proficiency (Lines & Wiener, 2014).

Conclusion

The shift toward an older age distribution in the Hispanic population, together with projected longer lifespans in the coming decades, and relatively high prevalence of risk factors for dementia suggest that the coming years will bring increases in the number of elderly Hispanics suffering from dementia. Dementia is a devastating progressive disease that destroys a person’s cognitive abilities and eventually causes severe functional limitations that may contribute or lead to death. Aging is the main risk factor for dementia, but risks are higher in the presence of cardiovascular disease, such as diabetes and hypertension. Strategies are needed to both address and minimize the impact of this potential public health crisis.

Elderly Hispanics and their caregivers likely will need culturally and linguistically appropriate emotional, informational, and tangible support, as well as greater access to healthcare. Younger Hispanics may benefit from prevention, early detection, and treatment of a host of chronic conditions associated with dementia in later life. Behavioral modification is complex and challenging, but researchers have identified risk factors that could be targeted with culturally appropriate interventions. The challenge in the coming decades will be to turn research findings into successful programs and practices that improve the life of Hispanic elderly and their families, both those already suffering from cognitive decline or dementia and those at risk of developing dementia.

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© Springer Science+Business Media, LLC, part of Springer Nature 2020

Authors and Affiliations

  1. 1.U.S. Census BureauWashingtonUSA

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