Racial, ethnic minorities receive inequitable dementia care

Patients of a racial or ethnic minority group experienced a lower chance of receiving an earlier diagnosis of dementia or a comprehensive evaluation compared to white patients, according to findings published in JAMA Neurology.

Researchers observed ”substantial disparities” in the timeliness and comprehensiveness of dementia diagnosis when comparing the diagnoses of white patients to those identifying as Asian, Black or Hispanic.

“Whereas 23.3% of white beneficiaries received [mild cognitive impairment (MCI)] as their first diagnosis, incident MCI diagnosis was less common among Asian (12.3%), Hispanic (15.8%), and Black (18.2%) beneficiaries, even though Black and Hispanic beneficiaries, on average, were younger at incident diagnosis than white beneficiaries,” Elena Tsoy, PhD, a postdoctoral fellow in neuropsychology at the University of California San Francisco’s Memory and Aging Center, and colleagues wrote.

To investigate the link between race or ethnicity and timeliness of dementia

diagnosis and diagnostic evaluation, the researchers collected data from California Medicare fee-for-service beneficiaries from 2013 to 2015. They analyzed data from 10,472 Medicare users who received no diagnosis of dementia or mild cognitive impairment in 2013 to 2014 and were continuously enrolled in Medicare Parts A and B. The patients included in the study identified as Asian, Black, Hispanic or white and received a diagnosis of dementia or MCI from January through June 2015.

Of the patients included, 993 individuals identified as Asian, 407 identified as Black, 1,255 identified as Hispanic and 7,817 identified as white. Each group had a mean age above 80 years (mean, 82.9 years), with the oldest mean age in the white patient population (mean, 83.4 years).

The results indicated those who identified as Asian (OR, 0.46; 95% CI, 0.38-0.56), Black (OR, 0.73; 95% CI, 0.56-0.94) or Hispanic (OR, 0.62; 95% CI, 0.52-0.72) were less likely to receive a timely diagnosis compared with white patients. Asian patients experienced the lowest likelihood of receiving an MCI diagnosis (OR, 0.45; 95% CI, 0.37-0.55) and a lower likelihood of receiving a comprehensive diagnostic evaluation (incidence RR, 0.81; 95% CI, 0.74-0.87). These associations remained significant after adjustments for age, sex, comorbidity burden, neighborhood disadvantage and rurality, according to the study results from Tsoy and colleagues.

The study results showed that Black patients living in “highly disadvantaged neighborhoods” had a lower likelihood of receiving a diagnosis of MCI. Similarly, Hispanic individuals living in highly disadvantaged neighborhoods had a lower likelihood of receiving a diagnostic evaluation.

“Our findings highlight substantial gaps in diagnostic care among racially diverse older adults that are likely associated with underrepresentation in clinical trials and inequities in treatment,” the researchers wrote. “Major policy and practice efforts are necessary to address these gaps via targeted interventions for vulnerable populations.”

In a related editorial, Claudia H. Kawas, MD and María M. Corrada, ScM, ScD, of the University of California, Irvine, and Rachel A. Whitmer, PhD, of the University of California, Davis, discussed the public health implications of the study results from Tsoy and colleagues, when a majority of the studies conducted on dementia, treatment effects and biomarkers related to cognitive impairment involve highly educated, urban dwelling, non-Hispanic White participants.

“Difficult to capture in a Medicare database are cultural factors, including differences in perceptions about what is normal aging and issues of trust between different racial/ethnic groups and the medical establishment,” they wrote. “Additionally, the diagnosis of cognitive loss in diverse populations may be complicated by racial and ethnic biases inherent in cognitive screening tools widely used by clinicians and researchers.”

The challenges associated with the diagnosis and care of underserved individuals is one “we all must address,” according to Kawas, Corrada and Whitmer.