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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Continuum (Minneap Minn). 2022 Jun 1;28(3):872–884. doi: 10.1212/CON.0000000000001088

Health Disparities in Dementia

Joyce (Joy) E Balls-Berry, Ganesh M Babulal
PMCID: PMC9924306  NIHMSID: NIHMS1867322  PMID: 35678407

Abstract

PURPOSE OF REVIEW:

Causes of health disparities in Alzheimer disease and related dementias (ADRD) in the United States are multifactorial. This article contextualizes health disparities as they relate to the neurodegenerative processes of ADRD.

RECENT FINDINGS:

Older adults’ life expectancy has increased such that a 65-year-old is expected to live 19 or more years and an 85-year-old can expect to live, on average, 6 to 7 years longer. Individuals of certain ethnoracial groups (Black, Hispanic/Latino, American Indian/Alaska Native, and Native Hawaiian/Pacific Islander) may be at a higher risk of incident ADRD compared to non-Hispanic/Latino White people. These differences in a higher risk of ADRD across ethnoracial groups persist despite no statistically significant differences in the rate of cognitive decline over time. The intersectionality of social determinants of health, experiences with discrimination and oppression, and access to care are related to the issue of justice and the risk for and expression of ADRD. The theoretical frameworks of various health disparities provide organized approaches to tracking the progression of health disparities for diverse patients.

SUMMARY:

ADRD health disparities are complex. Neurologists and their care teams must consider the main reasons for clinical ADRD evaluations of members of ethnoracial groups and the factors that may impact patient adherence and compliance with diagnostic and management recommendations.

INTRODUCTION

Physicians and other health care providers are becoming more familiar with health disparities, health equity and inequity, and social determinants of health.1 Often, these terms are used in conjunction with examining differences in ethnoracial (ie, the intersectionality of race and ethnicity) health that biological or genetic variations may not explain. These terms are linked directly to social values, institutional documents often codified in laws and policies, ethics, and opportunities. A key feature of each of these terms is the word health. What does health look like or even feel like? Is health simply the absence of disease? Does it relate only to our physical and mental state? As defined by the World Health Organization, health is a state of complete wellbeing and not just the absence of disease.2

Health is crucial in every stage of our lives and functions on a dynamic continuum that is continuously influenced by the interaction of genetics, behavior, sociocultural factors, and the environment. Chronic diseases of aging, such as cancer, hypertension, hyperlipidemia, and Alzheimer disease and related dementias (ADRD), disproportionately impact more adults in ethnoracial diverse groups. These differences are not necessarily associated with biology but are correlated with social forces such as access and utilization of health care, delays and/or lapses in care, misdiagnosis, insurance status, and education.3 All patients deserve fair and equitable treatment. However, major differences exist among ethnoracial groups in access to quality health care. Bioethicists argue that this is a principle of justice that is integrally connected to health care research.4 Health disparities in ADRD in the United States are multifactorial.3,5 The cultural beliefs of patients and their families, lack of trust in the health care system, unequal allocation of and access to resources, and differences in the ability to make informed health care decisions all influence risk for and expression of ADRD.6 The perceptions of patients and families about what represents normal aging or cognitive decline may delay care for persons affected by neurodegenerative diseases. However, beyond the perceptions of patients and families, structural vulnerability, implicit and explicit bias, functional and health literacy, and cultural norms play a role in clinical diagnosis. They may lead to clinical uncertainty and delays in referrals for patients by well-meaning care teams. For example, racial bias results in disparate management for patients needing lifesaving treatment for cardiac diseases.7 Black people who live in the United States have higher rates of emergency department visits, more inpatient hospitalizations, higher length of hospitalizations, and higher health care costs than non-Hispanic/Latino White people.6 The goal of this article is to highlight the salient and latent roles of health disparities within ADRD.

DEFINITIONS

Health disparities and health care disparities are gaining more attention as the population grows and ages, as an unequal distribution of disease prevalence and incidence is being observed. These constructs are related but not identical. Health disparities, a term coined in the 1990s, refers to instances in which a more significant impact, prevalence, incidence, or burden of a condition or health outcome (eg, disease, disability, and morbidity) is seen within one group than in another. Conversely, the term health care disparities indicates differences between groups in the availability, quality, access, and capacity of health care institutions to meet the needs of patients. Thus, health care disparities often contribute to widening health disparities. The impact of the COVID-19 pandemic in the United States is a prime example of this relationship. Black, American Indian/Alaska Native, and Hispanic/Latino adults are at a greater risk of infection (ie, more cases), more likely to be hospitalized and for extended periods, and more likely to die of COVID-19 compared to non-Hispanic/Latino White adults.8 For American Indian/Alaska Native, Black, and Hispanic/Latino adults, the increased risk of COVID-19 infection and its complications relates to enduring systemic structures that restrict access to the complex health care system needed to create, sustain, and protect life beyond normal biological processes.

In a similar vein, health equity is defined as the absence of conditions (ie, that are unfair, unjust, avoidable) that place a differential burden on certain groups or populations. Health equity serves as a guiding principle to reduce and eliminate disparities so that anyone can reach their full health potential. Integrated and emphasized within the concept of health equity is a focus on social determinants of health that reflect the daily conditions that afford or deny people the opportunities to live, learn, work, and play across the lifespan.9 Social determinants of health innervate every facet of our lives and often manifest as mediators that confer a greater vulnerability or likelihood of a group for developing a disease and thus contribute to health disparities in which underserved groups (eg, ethnoracial, rural, minoritized sex/gender) face higher mortality and morbidity, shorter life expectancy, and poorer health/functional outcomes.10 Health disparities, health care disparities, and health equity overlap and operate systematically and in concert with sociocultural, environmental, economic, geopolitical, and historical forces. Health disparities disproportionately impact minoritized communities and those who may be marginalized based on race, ethnicity, religion, sex, gender, immigration/refugee status, homelessness, and disability. Race and ethnicity are critically examined in studies as disparities exist across the ADRD context in the United States. Other minoritized and marginalized groups are likely to experience inequities in ADRD; however, published studies in the United States are minimal. These underrepresented groups deserve to be rigorously studied, and emerging frameworks contextualize this need along with the appropriate measurement. This article explores and summarizes the scholarship on health disparities in ADRD for race and ethnicity.11

RACIAL AND ETHNIC IDENTITY: TWO SIDES OF A COIN

Both race and ethnicity are social constructs (currency) in which the idea has shared meaning among members of society. Race as a construct entered the Western European language in the 15th century but was not used as a word in the English language until the 16th century. The term race has been traditionally rooted in biological classification based on physical characteristics (eg, skin color, hair color and/or texture, eye shape or color, physical build). Race conveys social positions and the grounds for identification as belonging to a particular group. The term race has three different uses. The first is as a classification, such as in official use in the laws or census. The second is a signifier (evolved because of context), which can change meaning over time. One example is a transition from the use of Caucasian to White. The term Caucasian originated in the 18th century when a German scientist and a philosopher believed that the inhabitants of the Caucasus mountain region were the purest and represented the pinnacle of civilization. Over many decades, the term was adopted into a taxonomy but has fallen out of use given pseudoscientific origins, historical bias, and inaccurate representation. The third is as a synonym, which denotes groups of people in a society. Ethnicity is situationally determined and more subjective and has overlapping subcategories. Ethnicity can be used to indicate nationality, religion, and/or language. A single country can have multiple ethnicities within its topographical boundaries, religious or spiritual beliefs can have distinct branches, and languages can vary geographically. A person can have multiple ethnicities, and, when coupled with race, an individual’s identity can be multidimensional at any age but can also change over time as they age. Both constructs (race, ethnicity) are used as heuristic labels in our social interactions with others and often guide our daily behavior. It is crucial not to assume an individual’s race and/or ethnicity but to understand how they self-identify since race and ethnicity are constructed categories not rooted in biology.

In 2015, the National Institute on Aging (NIA) developed a theoretical framework to guide research into aging-related and health research. This framework poses an organized structure to track health disparities, encourages the examination of the multifactorial and causal pathways of health disparities related to aging, and expands efforts to develop culturally appropriate and targeted interventions for aging.12 The NIA framework takes into account a social-ecological model for health disparities research that is translatable to clinically addressing health disparities. The social-ecological model has four levels: individual, relationship, community, and societal.13 The individual level relates to genetics, biological factors, health behaviors, and personal health history. The second level, relationship, examines social networks and familial influences on health as well as cultural factors of wellness. Community is the third level and is related to the built environment of where we live, work, and receive an education. The fourth level, society, relates to the sociopolitical factors that influence health. The fundamental factors in the NIA health disparities framework are ethnoracial, gender identity, age, disability/ability status, and identity. These components are measured by environmental factors (geographic and political influences, socioeconomic variants, and health care); sociocultural factors (cultural, social, and psychological factors); behavioral factors (coping, psychosocial behaviors in connection to risk and resilience, and health behaviors); and biological factors (physiologic indicators, genetic stability, and cellular and communication function). These components impact the life course perspective and healthy aging. The World Health Organization (WHO) also developed recommendations for measuring health disparities or inequality.14 These recommendations propose a five-step monitoring process: (1) determine the scope (health topic, health indicators, and relevant dimensions); (2) obtain relevant data; (3) analyze data; (4) report the findings, and (5) implement changes. The translation of these models to health care emphasizes considering the multifactorial influences on patient action (ie, the ability to comply, adherence, and access to health care recommendations). Interventions conducted in a clinical setting begin with the patient to ensure that they have access to the resources they need for wellness.

A GROWING AND AGING POPULATION

Life expectancy for older adults has increased such that a 65-year-old can expect to live another 19 or more years, and an 85-year-old can expect to live another 6 to 7 years.15 Moreover, in the next 4 decades, this growing population of older adults will be more racially and ethnically diverse.16 By 2060 (compared to 2016), the Black older adult (≥65 years) population is expected to increase to 12% (from 3%); the Hispanic/Latino older adult population will increase to 22% (from 8%), and the Asian older adult population will increase to 9% (from 4%), whereas the non-Hispanic/Latino White older adult population will decrease to 55% (from 78%).15 In 2017, approximately 19% of Black older adults and 17% of Hispanic/Latino older adults lived in poverty compared to 7% of non-Hispanic/Latino White older adults.17 Similarly, Black, Hispanic/Latino, and American Indian/Alaska Native people are less likely to have a high school education. In addition, they lack access to health care, including primary care, emergency care, and preventive maintenance, compared to non-Hispanic/Latino White people. These disparities accumulate as an increase in risk exposure, greater disease severity, and low access to health care intersect to reduce life expectancy across ethnoracial groups.

CONCERNS OF AGING AND BRAIN HEALTH

As different communities age, concerns related to physical health and functional ability grow. These concerns often arise in response to a variety of chronic health conditions and their associated risk factors. Understanding aging and brain health often starts with exploring the epidemiologic data related to cognitive health, and in this instance, ADRD.

Epidemiology of Alzheimer Disease and Related Dementias

Along with a growing global population, the prevalence of ADRD worldwide is projected to increase to 152 million by midcentury.18 In the United States, Alzheimer disease (AD) alone accounts for 60% to 80% of all dementia cases. More than 6.2 million adults age 65 and older currently live with AD.19 Black, American Indian/Alaska Native, and Hispanic/Latino adults may have a significantly higher risk for ADRD when compared to non-Hispanic/Latino White adults.20,21 Research with longitudinal cohorts suggests that Black people are at twice the risk of incident AD compared to non-Hispanic/Latino White people despite no significant difference in cognitive decline over time between groups.22 Epidemiologic findings also support the highest risk of dementia among Black people (26.6 per 1000 person-years) and American Indian/Alaska Native people (22.2 per 1000 person-years) and intermediate risk for Hispanic/ Latino people (19.6 per 1000 person-years) compared to non-Hispanic/Latino White people (19.3 per 1000 person-years).20

It is well established that ADRD is underreported on death certificates.23,24 A 2014 study using a national representative longitudinal cohort of communitydwelling adults aged 70 and older (n = 7342) found that dementia and cognitive impairment without dementia were both systematically underreported.25 More important, the underestimation is more significant for Black and Hispanic/Latino people than for non-Hispanic/Latino White people and for those with lower education (eg, having less than a high school education compared to having a college degree).26 Findings from neuropathologic data suggest that a higher risk for ADRD exists among Black people. Using data from the National Alzheimer’s Coordinating Center (NACC), Black people (n = 110) were more likely to have AD, Lewy body, and vascular pathologies than their non-Hispanic/Latino White counterparts (n = 2500).27 These results remained statistically significant after controlling for age at death, years of education, and cognitive functioning. Along with having greater incidence of vascular conditions (eg, infarcts, hemorrhages), Black people had higher Braak stage and Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) neuropsychological battery scores for neuritic and diffuse plaques and higher NIA-Reagan and CERAD diagnostic criteria for AD.27,28 Similarly, mixed pathologies and cerebrovascular diseases are more prevalent in Black and Hispanic/Latino decedents compared to non-Hispanic/Latino White decedents.29

BIOMARKERS

The biological study and contributions of amyloid and tau proteins, among others, in AD progression have facilitated the development of molecular biomarkers. Imaging modalities (positron emission tomography [PET], MRI), CSF studies, and emerging plasma analytes can measure the pathophysiologic burden across adult populations. Examination of ethnoracial differences in biomarkers may provide additional data about the progress of the disease. A 2020 systematic review and meta-analysis examined potential differences in biofluid biomarkers between Black and non-Hispanic/Latino White participants.30 Only five studies were included in the review, and the findings from the meta-analysis suggest significantly lower levels of CSF total tau and phosphorylated tau at position 181 (p-tau181) in Black participants (n = 334) than in non-Hispanic/Latino White participants (n = 1146). This finding remained consistent in samples from both cognitively normal and symptomatic participants.30 In screening for a clinical trial using amyloid PET imaging, Black participants (n = 144) had lower cerebral amyloid than non-Hispanic/Latino White participants (n = 3689).31 One cross-sectional study found a differential effect of APOE ε4 across race, in which Blacks with APOE ε4 had a lower concentration of CSF total tau and p-tau181 than non-Hispanic/Latino White people.32 In contrast, a longitudinal study did not find any difference in the effect of APOE ε4 on the cognitive decline between Blacks and non-Hispanic/Latino Whites over 18 years.33 Emerging biomarkers such as triggering receptor expressed on myeloid cells 2 (TREM2) provide a further overview of the pathologic cascade. TREM2 is an essential mediator of the innate immune response to cerebral amyloid.34 Initial findings show differences between Black and non-Hispanic/Latino White participants in CSF-soluble TREM2, suggesting a differential risk for genetic variants that may influence AD risk.35

A 2020 study examined different risk profiles and compared Black and non-Hispanic/Latino White cognitively normal older adults (age 65 or older) using data from the NACC.36 The primary outcome was progression to a Clinical Dementia Rating of 0.5 with primary etiologic diagnosis of AD, adjusting for covariates, including self-reported race, APOE ε4, sex, baseline age, education, body mass index, and all potential combinations of two-way and three-way interactions. The results found multiple factors interacted (age, APOE ε4, sex, and body mass index) to differentially influence the risk of AD between Black and non-Hispanic/Latino White people.36 The study concluded that examining ethnoracial differences in AD risk tends to be oversimplified in models that may not examine the complex interactions between major risk factors. For example, when APOE genotype and body mass index are taken into account, Black people may have a lower risk for AD than non-Hispanic/Latino White people. Biological and genetic factors may confer an elevated risk for ADRD across ethnoracial groups. However, it is well established that social determinants of health account for more than 50% of the variance in health outcomes.37 When examining Medicare beneficiary data, researchers found that Black, Hispanic/Latino, and Asian people were less likely to receive a timely dementia diagnosis than non-Hispanic/Latino White people.38 Additionally, older age and residing in a neighborhood with greater disadvantages were also independently associated with a delayed diagnosis and less comprehensive evaluation.

Striking differences exist between non-Hispanic/Latino White and other ethnoracial groups in sample size composition across neuropathology and biomarker studies.39 Both retrospective and prospective study designs face inherent challenges, such as the financial cost of specialized equipment; capacity; and effort to establish standardized operating procedures, participant burden, and iterative quality control. The lack of representation among ethnoracial groups and limited generalization of results is a well-established disparity in dementia research. However, the increased challenges with recruitment, enrollment, and retention of ethnoracial groups into research studies limit a critical examination in understanding how health and health care disparity increase ADRD risk and progression.3 Current longitudinal cohorts and prospective studies need to examine and revise inclusion and exclusion criteria as well as assess the presence and magnitude of selection bias toward ethnoracial groups.40 A 2020 study using NACC data found that older Black adults had a lower progression risk to cognitive impairment compared to non-Hispanic/Latino White adults.41 However, the enrollment source was examined and found to significantly differ between groups; Black people were mainly recruited from the community, whereas non-Hispanic/Latino White people were recruited from dementia clinics, leading to sampling/selection bias.

BLOOD-BASED SCREENING FOR ALZHEIMER DISEASE

Conventional imaging and CSF biomarkers provide valuable insight into the pathophysiologic process of AD. However, their combined procedural burden, equipment cost, and limited geographic access prohibit universal screening to aid in early detection. A blood test intended for use in patients experiencing problems with memory and thinking was recently released. Using a mass spectrometry platform, the test can determine whether a patient is likely to have cerebral amyloid.42 The resulting Amyloid Probability Score provides the likelihood of AD based on an algorithm that incorporates the patient’s age, ratio of amyloid-β peptides (Aβ42/Aβ40), and APOE ε4 proteoform in the blood. Race was not found to affect the Amyloid Probability Score or predictive value/accuracy of the test. Currently, the test is only available by physician prescription, and patients are responsible for paying out-of-pocket since Medicare, Medicaid, and private insurance payers do not currently cover the costs of the test. However, a financial assistance program is available for patients who qualify medically and financially based on a tiered household size and income eligibility. Wealth disparities have long persisted across ethnoracial groups in the United States. The 2019 Survey of Consumer Finances revealed a widening wealth gap; the average non-Hispanic/Latino White family has 5 times the wealth of a Hispanic/Latino family and 8 times the wealth of a Black family.43 This prepandemic trend persists across the lifespan and accounts for inheritances, family support, home ownership, and retirement accounts. Systemic inequities in health care (underinsured/uninsured), coupled with medical mistrust and substantial wealth disparities, will undoubtedly influence who will benefit the most from early screening tests, such as the blood test mentioned above, or future disease-modifying treatments. Adults who self-identify as non-Hispanic/Latino White will more likely have access to and take advantage of new screening tools, diagnostic platforms, and effective and efficacious treatments for ADRD.

NEIGHBORHOOD AND BUILT ENVIRONMENT

The term built environment is used to describe spaces and places created by humans for human activity and includes buildings, parks, transportation (roads), utility networks, telematics, and overall accessibility. The neighborhood is proximal to most people, and its conditions exert direct/indirect effects on an adult’s biological and behavioral maturation and can be measured to understand their impact on health. Legislative policies may not always be a clear answer in removing barriers within the environment. The Affordable Care Act implementation saw greater health care access and use for non-Hispanic/Latino White people but minimal change for Black people.44 Poor neighborhoods are sources of low employment opportunities, remote green space, poor education quality, lack of healthy food options, discrimination, structural racism, and limited health care access.45 Black, American Indian/Alaska Native, and Hispanic/Latino people disproportionately reside in neighborhoods replete with abandoned buildings, substandard housing, restricted access to municipal services and first responders, toxins (eg, lead, asbestos), and industrialized businesses.46 These communities are food deserts, offer limited resources for advancement, and see higher homicide rates and drug use, resulting in a lower life expectancy.47 The Area Deprivation Index (ADI) ranks neighborhoods by socioeconomic status and disadvantage based on 17 factors, including education, employment, and housing, from the US Census Data.48 Using Medicare data (n = 255,744), residence in a more disadvantaged neighborhood (higher ADI) was associated with a greater rate of rehospitalization.49 A 2020 study of decedent pathologic data from the NACC found that greater ADI (more disadvantage) was related to neuropathologic AD with 2.18 greater odds for people living in the highest decile of ADI.50 Location (a proxy for socioeconomic status) is a modifiable risk factor for cardiovascular and small vessel disease.51

STRESS AND HEALTH BEHAVIORS

Stress and coping resources are multidimensional, are not distributed equally, and fuel health disparities in the United States.52 Weathering is the concept that people under chronic stress experience accumulated disadvantages over the life course and experience accelerated aging.53 Black adults 18 to 64 years of age have a significantly higher allostatic load (or a larger cumulative burden of stress and life events) compared to non-Hispanic/Latino White adults, regardless of income level.54 The weathering effects of chronic stress exposure, accumulated over the life course, are posited to cascade into biological dysregulation at the cellular level.55 Examples of these include shortened telomere length, increased levels of inflammatory markers, and decline in immune system functioning.56,57 Poorer communities have greater stress exposure because of lower levels of stable employment and safe housing and higher levels of violence, while simultaneously providing coping resources that are deleterious to health, such as greater access to high-fat calorie-dense food, alcohol, and illicit drugs.58 Adoption of deleterious health behaviors comes with a significantly higher risk of ADRD.59 Because of widespread and deeply entrenched residential segregation, many ethnoracial groups continue to reside in communities that are simultaneously more stressful (eg, great concentrations of poverty) and lacking in equitable access to health-promotive resources. Emerging work on stress suggests that at least one midlife stressor, specific problems with resources, was associated with increased dementia risk.60

EXPOSURE TO DISCRIMINATION IS TOXIC

Exposure to discrimination (eg, race, sex, gender identity or expression, age, disability, religion) at the interpersonal level is highly stressful.61,62 Although studies have documented that direct experiences with racial discrimination are harmful to health (eg, increased risk of heart attack),63 a growing body of evidence indicates that racism has broader harmful health effects.64 In a sample (n = 407) of Black adults older than 64 years of age, perceived discrimination contributed to worse cognitive functioning.65 In a nationally representative sample (n = 12,053), higher weight (eg, body mass index) discrimination was associated with a 40% increased risk of dementia over a decade-long follow-up period.66 Experiences of discrimination resonate across the life course as individuals ruminate on these experiences and change their behaviors. Anticipatory stress or resistance to discrimination affects multiple health outcomes, including overweight/obesity and sleep outcomes.67 This also includes avoidance behavior or the development of a palatable public identity to prevent instances of discriminatory treatment.68

REVIEWING HISTORY AND PHYSICAL EXAMINATIONS

Determining a patient’s main reason for a health care visit is necessary to provide appropriate care, but reviewing the history and physical examination during the assessment is key to addressing the patient’s health disparities and increasing their wellness. Bourgois and colleagues69 propose the use of a structural vulnerability assessment tool for every clinical encounter. The tool has eight domains: financial security, residence, risk environments, food access, social network, legal status, education, and discrimination (TABLE 11-1).69 The domains allow for further exploration of nonclinical factors such as safety, housing, socioeconomic status, and issues of discrimination.

TABLE 11-1.

Structural Vulnerability Assessment Tool Domainsa

Domain Point of inquiry
Financial security Determining whether the patient has enough money for food, housing, utilities, and other expenses to live securely
Residence Assessing whether the patient has safe and stable housing in which to sleep and keep their possessions
Risk environments Establishing that the places the patient spends time are healthy and safe
Food access Assessing whether the patient has access to nutritious and healthy food
Social network Verifying that the patient has family, friends, or others to assist them when they have needs
Legal status Determining whether the patient has legal problems or concerns
Education Assessing the patient’s functional and health literacy
Discrimination Assessing whether the patient has experienced any form of discrimination, then determining whether the care team is able to provide care based on the patient’s experiences
Open in a new tab
a

Data from Bourgois P, et al, Acad Med.69

A key feature when using the structural vulnerability assessment tool in a patient encounter is considering whether concerns exist in any domain and then determining whether resources are available internally in the clinical area or externally that may increase health equity, quality of life, and wellness. Some key areas to consider are availability of social work, psychiatry, and case management. Continuing education on cross-cultural communication and cultural competency can enhance the understanding of the complexity of cultural distinctions of patients and their external care team and help clinicians prepare for visits related to application of the structural vulnerability assessment tool.

CONCLUSION

The causes and consequences of ADRD health disparities in the United States are complex. The connection to the patient’s ability to access resources, trust in the health care system, and ability and desire to comply with clinical recommendations represent only a few of those factors. Cases of ADRD are projected to increase threefold by midcentury.70 The growing aging patient population has changed in terms of diversity in ethnoracial factors, structural vulnerability exposure, and experience of health disparities.69 It is critical to understand the intersectionality of social determinants of health, the clinical encounter, and patient action. A patient’s level of structural vulnerability and the perceptions the patient brings to the clinical encounter will impact health equity and quality of life.

KEY POINTS.

  • Physicians and health care providers are increasingly becoming familiar with the terms health disparities, health equity, health inequity, and social determinants of health.

  • Despite the complexity of health disparities in Alzheimer disease and related dementias, an opportunity exists to address patient quality-of-life concerns using coordinated and patient-centered care.

  • Appreciating health disparities, health care disparities, and health equity is essential to understand why differences in disease burden and prevalence exist and endure.

  • Race and ethnicity are distinct socially constructed terms to self-identify that are not based in biology or genetics.

  • Over the life course, health is created, maintained, and dynamically influenced by biology, behavior, sociocultural values, and the environment.

  • Health disparities frameworks highlight the intersectionality of health at various systems to understand how disease risk is increased for ethnoracial groups.

  • Conventional PET and CSF biomarker research is often limited in the sample size of ethnoracial minoritized groups, which can impact the generalizability of the findings.

  • Blood-based biomarkers can screen a more significant proportion of the population; however, cost, availability, and access remain vital challenges to widespread use.

  • Health is differentially generated and sustained for ethnoracial groups and profoundly influenced by social (structural racism, institutional discrimination), economic (school quality, insurances), and geographic conditions (proximity to specialty clinics).

  • Delayed diagnoses for Alzheimer disease and related dementias are prevalent in ethnoracial groups and are compounded by health disparities that are present across the lifespan.

Footnotes

RELATIONSHIP DISCLOSURE:

Dr Balls-Berry has received personal compensation for serving on a patient advisory board for Dartmouth College. The blood-based amyloid test is licensed by C2N and was cofounded by colleagues of Dr Balls-Berry. Washington University will receive royalties from this test, but Dr Balls-Berry will not receive personal compensation from it. The blood-based amyloid test is licensed by C2N and was cofounded by colleagues of Dr Babulal. Washington University will receive royalties from this test, but Dr Babulal will not receive personal compensation from it.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE:

Drs Balls-Berry and Babulal report no disclosures.

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