Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Advisory Council January 2021 Meeting Presentation: Racial and Ethnic Disparities

Monday, January 25, 2021

Printer Friendly Version in PDF Format (17 PDF pages)


Research Update on Racial and Ethnic Disparities in Dementia

Jennifer J. Manly

Columbia University Medical Center, Taub Institute for Research on Alzheimer's Disease and the Aging Brain

  • Supported by
    • NIA R01AG16206, R01AG028786, RF1AG056164 (PI: Manly)
    • NIA RF1AG054070 (PIs: Manly/Brickman)
    • NIA RF1AG058067 (PIs: Brickman/Manly)
    • NINDS U01NS041588 (PIs: Howard/Manly)
    • NIA RF1AG054023 (PI: Mayeux)

Figure 2. Dementia Incidence Rates per 1000 Person-Years by Age and Race-Ethnicity, 2000-2013

Line Chart.
Evidence of Racial/Ethnic Disparities, Kaiser Permanente Northern California, Mayeda et al., 2016

Trends in Relative Incidence and Prevalence of Dementia Across Non-Hispanic Black and White Individuals in the United States, 2000-2016

Line Charts: P value for trend = 0.71 and P value for trend = 0.65.
Power et al., 2020

Cerebrovascular disease

Brain scan screen shot.
Brickman et al., Arch Neurol, 2008

WMH and language

Scatter Charts: Language of Non-Hispanic White and African American.
Zahodne et al, CAR 2015

Hippocampal volume

Brain scan screen shot.

Hippocampal vol. and incident dementia

Line Charts: Comparison of Hiipocampal value below, and at or above sample, mean for Non-Hispanic White and Non-Hispanic Black.

Intergenerational differences in white matter hyperintensity volume

Line Chart comparing Parents Generation and Offspring Generation for Whites, Blacks and Hispanics.

Morris et al. 2019 conclude that there are race-dependent biological mechanisms that contribute to expression of AD

Scatter Charts: Compares NHW and AA for Standardized uptake value ratios and Cerebrospinal fluid t-tau.
Karin L. Meeker, PhD, Julie K. Wisch, PhD, Darrell Hudson, PhD, Dean Coble, PhD, Chengjie Xiong, PhD, Ganesh M. Babulal, PhD, OTD, Brian A. Gordon, PhD, Suzanne E. Schindler, MD, PhD, Carlos Cruchaga, PhD, Shaney Flores, BS, Aylin Dincer, BA, Tammie L. Benzinger, MD, PhD, John C. Morris, MD, and Beau M. Ances, MD, PhD. Socioeconomic Status Mediates Racial Differences Seen Using the AT(N) Framework.

In NACC, Whites with MCI had higher likelihood of progression to dementia than Blacks with MCI… why?

Graphic showing project comparisons.
Gleason et al., Alzheimer's and Dementia, 2019

Receiver operating curves for classification of clinical diagnosis of AD with plasma biomarkers

Line Charts: Comparing NfL, P-tau217, P-tau181, Tau, and AB42/AB40. The four charts give information for Total Sample, Non-Hispanic White, Non-Hispanic Black, and Hispanic.
Brickman et al., under review

Alzheimer's Disease and All-cause Dementia Mortality by Race and Place of Birth

United States Maps showing 5 ranges of information: 0.64-0.72, 0.73-0.91, 0.92-1.10, 1.11-1.30, and 1.31-1.37. Maps are broken into: Blacks, Alzheimer's; Whites, Alzheimer's; Blacks, All-Cause Dementia; and Whites, All-Cause Dementia.
Glymour et al., Alzheimer Dis Assoc Disord 2011
Odds ratios for Alzheimer's or all-cause dementia-related mortality in 2000, by race and state of birth, compared to the national average, based on empirical Bayes (shrinkage) random effect estimates from logistic models, US born blacks and whites ages 65-89.

Racial disparities by US region of primary school education in HRS

Line charts showing comparisons of West, South, Midwest and Northeast. Charts include: Years of schooling, Cognitive status, Predicted racial difference for years of schooling, and Vocabulary.
Liu, Glymour, Zahodne, Weiss, and Manly, JINS (2015)

Place of birth and dementia risk among Kaiser Northern CA participants

Figure. Cumulative Incidence Dementia Adjusted for Death Rates by Birth Place
Line chart comparing Born in an HSMS and Born outside an HSMS.
High stroke mortality states: top quintiles of stroke mortality rates (i.e., states with >83 stroke deaths per 100 000 people older than 35 years) Alabama, Alaska, Arkansas, Louisiana, Mississippi, Oklahoma,Tennessee, SouthCarolina, and West Virginia.
All participants had been in Northern California for 23+ years (since 1973)
Gilsanz et al., JAMA Neurol 2017

Global cognition, early-life residence, and schooling at age 12

Line chart comparing Legally Desegregated and Segregated Schools in the Northeast/Midwest and South.
Lamar et al., 2020

Counties with the highest % of Blacks and Latinos living with dementia also have fewer neighborhood resources

Bar Chart comparing Highest Prevalence and Lowest Prevalence for several categories. Percentage of families living in poverty: Black Counties 15%, 9%; Latino Counties 17%, 12%. Median household income: Black Counties $45,580, $64,348; Latino Counties $46,459, $62,656. Individuals under the age of 65 without health insurance: Black Counties 14%, 7%; Latino Counties 18%, 11%. Percentage of individuals with access to exercise opportunities: Black Counties 55%, 83%; Latino Counties 52%, 77%. Percentage of adults that have a bachelor's degree: Black Counties 16%, 32%; Latino Counties 19%, 27%.
Mudrazija, Vega, Resendez, and Monroe (2020)

UK Policy Change Increased Executive Functioning in Late Life

Figure 9. Effect of 1947 Reform on Executive Functioning (Conditional on Leaving Before 16)
Scatter charts comparing Males and Females for 1923-1938..
From Banks and Mazzona, 2012

Natural Experiments: IV Estimates for Education
HRS through 2002, n=10,964

Estimated effect of 1 year ed'n on cognitive test scores
Model covariates Memory Cognition
βIV 95% CI^ βIV 95% CI^
1. Unadjusted 0.33 (0.27, 0.39) 0.19 (0.12, 0.26)
2. Birthyear, and sex 0.30 (0.14, 0.46) 0.34 (0.05, 0.63)
3. Model 2 + birth state 0.18 (0.02, 0.33) 0.03 (-0.22, 0.27)
4. Model 3 + state condns 0.34 (0.11, 0.57) -0.06 (-0.37, 0.26)
5. OLS estimates 0.09 (0.08, 0.10) 0.15 (0.14, 0.16)
Glymour, JECH, 2008

Less memory decline in older adults born later

Line chart comparing Memory Performance for those Born 1921-1935 and Born 1905-1920.
Vonk et al., 2019

REGARDS Participants are more geographically diverse than other US cohorts of older adults

United States map showing White and African American participants.
N = 30,239

Length of School Year

Line chart comparing the average days in school year for Blacks (AL, AR, MO, SC), Whites (AL, AR, SC), and All (MO, NY, CA).

Student Teacher Ratio

Line chart comparing NC and SC Whites and Blacks, and NY All over 1917 and 1943.

Historical investments in quality of schooling and cognition in later life
School quality provides less protection to Black peole from impairment

Table 8. Odds Ratios for prediction of prevalent cognitive impairment (N=19,795)
Variable Model 1 Model 2 Model 3 Model 4
PPYEd 0.61 (0.58, 0.63)      
   PPYED in BM   0.86 (0.78, 0.95) 0.79 (0.67, 0.92) 0.80 (0.69, 0.94)
   PPYED in BW   0.80 (0.73, 0.88) 0.73 (0.63, 0.84) 0.75 (0.64, 0.86)
   PPYED in WM   0.73 (0.65, 0.83) 0.61 (0.49, 0.75) 0.63 (0.51, 0.78)
   PPYED in WW   0.70 (0.60, 0.81) 0.59 (0.47, 0.74) 0.61 (0.49, 0.77)
Model 3 = Model 2 + State Fixed Effects
Model 4 = Model 3 + Parents Education
Manly, Murchland, Glymour, et al., under review

Project Talent, 1960

  • Nationally representative longitudinal study
  • In 1960 377,015 9th-12th graders from 1,255 schools were assessed
  • Schools were randomly sampled from cells based on region and type of school across the US
  • Large number of siblings, including twins, within sampled schools
  • Substantial minority representation within the sample
  • All students in grades 9-12 were selected to participate in two full days of data collection
  • Study collected extensive personality, knowledge, and cognitive ability data, and completion of an extensive demographic questionnaire
  • Follow-up surveys were administered at 1, 5, and 11 years after each grade cohort graduated high school

Project Talent school quality factor

Line chart comparing the School Quality Factor Centered for NH Black, NH White, Other, and Hispanic.

School quality association with SCC (AD8)

Line chart showing the Model 1 School Quality.

School quality and SCC by race/ethnicity

Line chart showing the Model 1 comparing NH White, NH Black, Hispanic, and Other.

School Quality and Cognition

Association* of change in school quality (SD) to level of cognitive abilities (SD)
Variable Beta (95% CI)
CERAD learning 0.06 (0.01; 0.10)
CERAD delayed savings 0.02 (-0.03; 0.07)
Animal fluency 0.04 (-0.002; 0.09)
Letter F fluency 0.05 (0.005; 0.09)
*Linear regression adjusting for 1960 cognitive aptitude, sex/gender, age, and a composite measure of parental socioeconomic status, and census region

Years of school contributes to cognitive reserve in Whites, but not Black or Hispanic older adults

Line Charts comparing Current Level and Average Rate of Decline of education, for White, Black, and Hispanic.
Avila et al., 2020

NIA Disparities Research Framework

FUNDAMENTAL FACTORS: Ethnicity, Gender, Age, Race, Disability Status, Identity
Environmental Sociocultural Behavioral Biological
Geographical and Polical Factors
Structural Bias
Residential Segregation
Cultural Factors
Collectictive Responses
Coping Factors
Active Coping
Problem Solving
Stress Management
Cognitive Reframing
Emotional Regulation
Physiological Indicators
Sympathetic Nervous System
HPA Axis
Socioeconomic Factors
Limited English
Social Factors
Institutional Racism
Family Stress
Financial Stress
Occupational Stress
Residential Stress
Social Mobility
Social Network
Psychosocial Risk/Resilience
Social Support
Genetic Stability
Telomere Attrition
Epigenetic Alteration
Loss of Proteostasis
Health Care
Psychological Factors
Self Concepts
Health Behaviors
Physical Activity
Cellular Function and Communication
Deregulated Nutrient Sensing
Mitochondrial Dysfunction
Cellular Senescence
Cellular Stress Response
Stem Cell Exhaustion
Intercellular Communication
Lifecourse Perspective
Hill et al., 2015

Eliminating brain health disparities

  • Changing healthy behaviors and lifestyle choices will not eliminate disparities in dementia (fundamental social causes)
  • There is evidence that lifecourse social factors, most patterned by structural racism, influence dementia risk and resilience
    • Include population feasible biomarkers to determine relative contribution
  • Economic and social policies are brain health policies
    • Policies to repair the intergenerational impact of racism and discrimination on wealth
    • Invest in schools and teachers to increase educational quality
    • Provide funds to decrease neighborhood inequalities
  • The most informative research on mechanisms of dementia disparities is not from convenience samples, but from population representative random samples