Special Aspects of Dementia for African-Americans

Early studies reported increased prevalence of dementia in elderly African-Americans but more recent research (mainly in urban areas) indicates that if age and educational attainment are controlled, the rates are comparable to other groups.

• Dementia in Black patients is more likely to be attributed to vascular than other causes.
• Common scales such as ADL and MMSE are reliable in African-American patients but MMSE may need adjusted for education level.

 

As early symptoms may not be recognized and families provide significant coping strategies, patients may not come to medical attention until late in the process or some crisis intervenes.

Being alert for cognitive and memory problems (plus family stress) during visits for medical problems, can lead to earlier recognition of dementia and possible intervention. The high prevalence of medical problems also suggests that screening for “preventable causes” such as polypharmacy, thyroid disease, depression, and metabolic causes is particularly important in African American elders. The diagnosis has to be handled with tact and hope.

• Cognitive and memory symptoms are likely to be attributed to normal aging.
• Patient may not recognize symptoms or attribute them to other medical conditions or medications.
• Patient and family may not believe perceive that medical attention is appropriate or worthwhile for dementia symptoms.
• Family members may be very protective of elderly relatives and strive to maintain dignity, normality, and respect. Family may be reluctant to share concerns about the elderly patient with inappropriate outsiders.
• The term “dementia” is regarded as offensive by some African-Americans.

 

Helping the patient and family manage dementia requires developing a trusting relationship with mutual goals based on the patient’s welfare.

Physicians must remain respectful of the elderly patient, even in advanced dementia, and be careful about terminology. Particular sensitivity is required in discussing advance directives and end of life care. Throughout the dementing illness, the elderly Black patient continues to require management and risk reduction for multiple medical conditions.

• Families are typically principal caretakers and may be reluctant to involve outsiders
• Family support system may include extended family, fictive kin, and church community
• Health, social service and other formal agencies may be viewed with suspicion
• Religion and spiritual meaning may be very important for patient and caretakers
• Care plan has to allow for respect and role of elders in family
• Plan has to accommodate medical comorbidities
• Options may be limited by poverty and other socioeconomic factors
• Clinical trials of medications and treatments may not have involved adequate numbers of African-Americans to detect unique issues
• Traditionally, nursing home care is not an attractive/acceptable option
• Families may be very sensitive to being given substandard care or abandoned by physicians