Supporting Caregivers in Ethnically Diverse Communities: Focus on Alzheimer’s Disease
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According to the Alzheimer’s Association, approximately 5.1 million people, or one out of eight people over the age of 65, currently have Alzheimer’s disease (AD). By the year 2030, the number of Americans with this progressive neurologic disorder will reach nearly 7.7 million, and by 2050, between 11 and 16 million.1 The risk of AD is significantly elevated in the African-American and Hispanic populations. Prevalence rates of all types of dementia, including AD, are higher in these groups as compared with non-Hispanic white individuals.2 African-American and Hispanic-American persons have approximately two times the incidence rates for AD as their non-Hispanic white counterparts, at 4.2% per person-year for African Americans, 3.8% per person-year for Hispanic Americans, and 1.9% for non-Hispanic white individuals3 (see Table for age-specific incidence rates). The Multi-Institutional Research in Alzheimer’s Genetic Epidemiology (MIRAGE) study4 found a cumulative relative risk (RR) of 1.6 (95% confidence interval [CI], 1.4-1.9) in African-American first-degree blood relatives of patients with AD, as compared with white individuals.
When first recognized, AD appears to be more advanced in African-American populations.2,5 Several explanations have been offered to account for the discrepancy in rates of early detection of AD found between the groups. In one study, a national sample of 1176 adults age 35 and older (48.6% white, 25.7% African American, and 25.8% Hispanic-American) showed that African-American and Hispanic- American respondents were significantly more likely to believe that AD is a normal part of aging.6
While no cure exists for the disease, early diagnosis and treatment is the optimal way to manage the symptoms of AD. Existing agents for the treatment of AD now cover all stages of AD and offer hope that dementia can be slowed. Treatment options include the cholinesterase inhibitors (ChEIs) rivastigmine and galantamine, both approved for treatment of mild-to-moderate AD, and donepezil, which is approved for treatment of mild, moderate, and severe AD. For patients with moderate-to-severe AD, memantine can be added to a ChEI such as donepezil. It is neither necessary nor desirable to discontinue the ChEI when memantine is initiated.
To enhance early detection, screening for dementia should become a part of the routine physical examination for all patients age 65 and older. The Mini-Cog exam can help to increase the number of possible AD cases identified in the primary care setting without making undue demands on physician time.7 It comprises a three-item recall task and a clock-drawing exercise. In validation studies, it has proven superior to the Mini-Mental State Examination (MMSE) in predicting dementia, even in a poorly educated, non-English–speaking population. Administering the Mini-Cog exam takes approximately 3 minutes—less than half the time required for the MMSE.7 If initial screening with the Mini-Cog indicates dementia, then a full dementia work-up should be initiated. For reimbursement purposes, the diagnostic code for “Memory Loss” can be used until the work-up is completed. Once the diagnosis is confirmed, the appropriate code can then be recorded.
Remembering the Caregiver: The “Hidden Patient”
Primary care clinicians who treat patients with AD actually have two patients: the person with AD and the caregiver of the person with AD. The very early symptoms of AD, such as memory lapses and repetitive questioning, can be trying, but the neuropsychiatric symptoms such as verbal or physical abuse or combative behavior that may manifest as the disease becomes more entrenched can take a huge toll on the caregiver. Caregiving is a time- and labor-intensive job. Thus, providing care for a family member with AD can be a source of enormous stress. Stress, in turn, can contribute to mental and physical morbidity.
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