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Health Inequities Among Patient Populations With AD


A discussion on the disparity in access to quality health care between various patient populations.

Neil Minkoff, MD: We know that it has been expounded upon recently: the inequities in the health care system and some of the things that Mr Dan Gasby has alluded to or spoken about. How are you seeing that in your practices and in the work you are overseeing around early diagnosis or prevention?

Richard Isaacson, MD: Most people do not realize that African Americans and Latino Americans are at an increased risk compared with Caucasian Americans. Some people do not realize that, whether it is because of additional genetic factors or vascular risk factors, we do not understand all the reasons. Aside from being at greater risk, there are some important differences that most physicians do not realize. As an example, when Hispanic Americans get diagnosed, they get diagnosed several years later than non-Hispanic Americans. Not only do they get diagnosed later, but their cognitive test scores are further along, meaning more progressed, when they get diagnosed. These inequities are critical, and we have to figure out ways to address this.

I practiced at the University of Miami for a while, and I had a large Hispanic population in my practice. I learned that there are some misconceptions. As we get older, it is normal for people to develop cognitive impairments, and senility is a normal thing to happen. What we need to do is understand what the educational opportunities are and how to intervene. We need people who look like people. We need people to step up and educate about how this happened to them and say, “I look like you.” We need to change the way we think about this disease and take this disease seriously. See a doctor. Do not have this stigma. This is something we can do about it.

The other thing is from a genetics perspective. There are a lot of complicated things from sex differences to other considerations. For example, women are at a higher risk of Alzheimer disease than men. When I was in medical school, I learned that women were at higher risk because they live longer than men, and that made sense to me, but we now know that that is not the case. Dan and I have worked closely with Maria Shriver, and she has an organization that has pumped a lot of research into this to start asking more of these questions. We are now doing research at our program [at Weill Cornell Medicine] that is showing that the perimenopause transition may be a critical window of opportunity where we may have to do something about it. There are also certain stressors that are unique to women. Widowhood, for example, fast-forwards the likelihood of developing dementia. For example, with body fat that accumulates around the midsection, which is called belly fat or visceral fat, women have 39% higher risk of dementia when they have excess visceral fat over a specific amount.

When we get into all these different permutations, another important permutation is genetic. The APOE4 variant is the most common genetic risk for Alzheimer disease. Women are at a higher risk of Alzheimer disease than men with that gene. This is a confusing part, but African Americans with the APOE4 variant are at a lower risk compared with non–African Americans. There is a lot of complexity here, and I cannot summarize it all here. Just know that there is a problem. We now know that there is a problem, and what we need to do over the next several years is address the problem in a targeted way.

Transcript edited for clarity.

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