Racial and Ethnic Diversity in Alzheimer's Disease:
Rising to the Challenge

Racial and ethnic diversity among older adults is rapidly increasing. The U.S. Census Bureau tells us that in 2000, ethnic minority older adults, including American Indian/Alaska Natives, Asians/Pacific Islanders, African-Americans, and Latinos/Hispanics comprised 16% of those age 65 and older. But by the year 2050, this number will more than double to 36% of the population.

One fundamental challenge for those concerned with early-stage Alzheimer’s disease (AD) is that although these census projections are striking, they tell us very little about the backgrounds and experiences of older adults. There is tremendous heterogeneity within these groups, including nationality, place of birth, immigration status, language use and bilingualism, cultural experience and educational experience.

Another major challenge for early identification of AD is that the tools we use are not as accurate when diagnosing dementia among ethnic minorities as compared to whites. This may not be surprising, given the fact that the most commonly used tests of memory and other cognitive functions were originally developed among non-Hispanic white, well-educated, English-speaking people. Several researchers are now working in clinics and on large epidemiological studies to improve the accuracy of the tests used to identify those in the earliest stages of AD. This is important because as new treatments to prevent or slow the progression of AD are developed, we want these interventions to be effective for people of all backgrounds.

Because there are social and cultural differences in the meaning of dementia and beliefs about cognitive decline among older adults, we must strive for cultural competency in our outreach and services for people with early AD. Cultural values may include beliefs that dementia-related changes are normal aging rather than an abnormal process, so that cognitive decline may not elicit concern until symptoms are well beyond the mild stages. Some cultures may be more likely to view cognitive decline as disgraceful and something that should be kept within the family, and the resulting stress experienced by caregivers can be multiplied by a real or perceived lack of support from family members or the community. Dementia may be difficult for a family to accept when the older person is the historian, mediator, and provider of emotional and financial support, for many generations of family members living in the same home. The possible contribution of limited economic, educational and health care resources throughout the life span should always be considered, but may be especially salient among ethnic minorities and immigrants. Primary care physicians who serve ethnic minorities may not have knowledge or awareness of early-stage Alzheimer’s, or may not have the time and resources to follow up on memory complaints.

The statistics tell us that it has become critical to integrate consideration of racial and ethnic diversity in our conversation about early identification of AD and early-stage services for people with Alzheimer’s and their families. Increased attention to the heterogeneity within older ethnic minorities will move us ahead as we try to improve diagnosis of early AD and advocate for high-quality services for people with early Alzheimer’s and their families.

— Dr. Jennifer Manly

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