Disparities in the treatment of dementia among medicare beneficiaries
Copyright 2008 by The Gerontological Society of America
Racial and Ethnic Disparities in the Treatment of
Ilene H. Zuckerman, Priscilla T. Ryder, Linda Simoni-Wastila, Thomas Shaffer,
Masayo Sato, Lirong Zhao, and Bruce Stuart
Lamy Center on Drug Therapy and Aging, Department of Pharmaceutical Health Services Research,
University of Maryland School of Pharmacy, Baltimore.
Objectives. Numerous studies have documented disparities in health care utilization between non-Hispanic White and
minority elders. We investigated differences in anti-dementia medication use between non-Hispanic White and minoritycommunity-dwelling Medicare beneficiaries with dementia.
Methods. Using multivariate analysis with generalized estimating equations, we estimated prevalence ratios (PRs) for
anti-dementia medication use by race/ethnicity for 1,120 beneficiaries with dementia from years 2001 through 2003 ofthe Medicare Current Beneficiary Survey.
Results. After adjusting for demographics, socioeconomics, health care access and utilization, comorbidities, and
service year, we found that anti-dementia medication use was approximately 30% higher among non-HispanicWhites compared to other racial/ethnic groups (PR ¼ 0.73, 95% confidence interval [CI] ¼ 0.59, 0.91). As for individualracial/ethnic groups, prevalence disparities remained significant for non-Hispanic Blacks (PR ¼ 0.75, 95% CI ¼ 0.57,0.99) and non-Hispanic others (PR ¼ 0.50, 95% CI ¼ 0.26, 0.96) but were attenuated for Hispanics (PR ¼ 0.84, 95%CI ¼ 0.59, 1.20).
Discussion. Results provide evidence that racial/ethnic disparities in utilization of drugs used to treat dementia exist
and are not accounted for by differences in demographic, economic, health status, or health utilization factors. Findingsprovide a foundation for further research that should use larger numbers of minority patients and consider dementia typeand severity, access to specialty dementia care, and cultural factors.
Key Words: Dementia—Health disparities—Anti-dementia medication—Medicare beneficiaries.
I N general, disease burden falls disproportionately on are more likely to be undiagnosed or misdiagnosed relative to
minority populations. Even at older ages, minorities tend
non-Hispanic Whites (Clark et al., 2005; Leo, Narayan, Sherry,
to have poorer health status, whether measured by disease
Michalek, & Pollock, 1997); however, with population-based
incidence, prevalence, or severity (National Center for Health
sampling and careful diagnostic techniques employing neuro-
Statistics, 2007). Eliminating health disparities is one of two
psychological and laboratory testing following National In-
overarching goals of Healthy People 2010 (U.S. Department of
stitute of Neurological and Communicative Disorders and
Health and Human Services, 2000), the disease prevention and
Stroke–Alzheimer’s Disease and Related Disorders Association
health promotion agenda of the U.S. Department of Health and
(NINCDS-ADRDA) criteria, the prevalence of dementia may
Human Services. The Institute of Medicine’s 2002 ground-
be relatively higher in minority populations. One community-
breaking report Unequal Treatment: Confronting Racial and
based survey, with diagnoses confirmed using clinical testing
Ethnic Disparities in Health Care (Smedley, Stith, & Nelson,
and NINCDS-ADRDA criteria, found the prevalence of
2003) and the National Healthcare Disparities Report (Agency
Alzheimer’s disease among African American men to be 2.5
for Healthcare Research and Quality, 2006) documented
times greater than the prevalence among non-Hispanic White
disparities in health care access. Disparities extend to inequal-
men (Demirovic et al., 2003). Both non-Hispanic Blacks and
ities in access to medications. Older minorities are less
Latinos transition to long-term care at more advanced stages of
likely than majority elders to utilize prescription drugs or to
dementia (Stevens et al., 2004; Yaffe et al., 2002).
increase their numbers of prescriptions over time (Briesacher,
Minorities also may be less likely to be prescribed anti-
dementia medications. One study found that, considered
Dementia is a chronic and serious disease, with an estimated
together, minority patients (non-Hispanic Blacks, Asians, and
worldwide societal cost of $315.4 billion in 2005 (Wimo,
Latinos) in Alzheimer’s disease research centers in California
Winblad, & Jonsson, 2007). According to findings from the
had 40% lower odds of acetylcholinesterase inhibitor use
2002 Medicare Current Beneficiary Survey (MCBS), approx-
compared to Whites (Mehta, Yin, Resendez, & Yaffe, 2005).
imately 3.4 million Medicare beneficiaries are diagnosed with
Thus, there may be racial/ethnic disparities in dementia
Alzheimer’s disease and related disorders, more than half of
incidence, prevalence, access to health care services, and
whom (approximately 2 million) live in the community
(Gruber-Baldini, Stuart, Zuckerman, Simoni-Wastila, & Miller,
The U.S. Food and Drug Administration has approved two
2007; Stuart et al., 2007). Non-Hispanic Blacks with dementia
classes of drugs to treat symptoms of cognitive deficit in
RACIAL DISPARITIES IN DEMENTIA MEDICATION
Alzheimer’s disease and related disorders: cholinesterase
proxy report (‘‘sample person ever told had Alzheimer’s
inhibitors (donepezil, rivastigmine, galatamine, and tacrine)
disease or dementia’’). We determined dementia status from
and an N-methyl-D-aspartate receptor antagonist (memantine).
claims alone for 49.9% of respondents, from self-reports only
Using a national data set of community-dwelling Medicare
for 23.7%, and from both sources for 26.4%. We chose
beneficiaries, we investigated the use of these prescription anti-
covariates from a literature review and from preliminary
dementia medications to compare prevalence by non-Hispanic
analysis. Covariates included age (less than 65 years, 65–74,
75–84 and 85 years and older), gender, U.S. census region,residence in a metropolitan statistical area, income, education,marital status, source of dementia diagnosis (claims data, self-/
proxy report, or both), source of survey information (self-reportor proxy respondent for at least half of the interviews),
prescription drug insurance coverage, use of other medication
The study sample consisted of 1,606 person-years of
classes, and year of observation. We estimated comorbid
observation of 1,120 community-dwelling Medicare beneficia-
disease burden by using a count of comorbid disease classes.
ries with a reported diagnosis of dementia from the MCBS foryears 2001 through 2003. The MCBS is a continuous sampleof U.S. Medicare recipients conducted by the Centers for
Medicare & Medicaid Services. Although the use of sampling
We compared use or nonuse of anti-dementia medications by
weights for single years of the MCBS would allow it to be
using chi-square tests and t tests. Multivariate analysis with
nationally representative of Medicare beneficiaries, we could
generalized estimating equations (GEE) estimated the condi-
not use weights in our analysis because individuals may have
tional effect of race/ethnicity on anti-dementia drug use,
crossed years. Furthermore, because the MCBS oversamples
controlling for the covariates listed above. This analysis yielded
certain groups (e.g., those younger than 65 years of age), our
prevalence ratios (PRs) rather than prevalence odds ratios. With
unweighted sample was not necessarily representative of
26% of the sample using medication, odds ratios would not
Medicare beneficiaries as a whole. The MCBS uses a rotating
have been an accurate estimation of actual prevalence. Odds
panel design; beneficiaries or their proxies are interviewed in
ratios are always further from the null value of 1.0 with the
their homes three times per year for a maximum of 4 years by
disparity increasing with higher prevalence (Rothman &
using computer-assisted personal interviewing technology.
Greenland, 1998). GEE is especially useful for investigations
Respondents are asked a battery of questions relating to
with binary outcomes and correlated data. With efficient
demographic characteristics, health status, pharmaceutical and
parameter estimation and accurate standard errors, GEE is
other health care utilization and expenditures, and health
better at correcting for clustering and other types of correlation
insurance coverage. The MCBS links survey information to
(Hanley, Negassa, Edwardes, & Forrester, 2003). Standard
Medicare Parts A and B claims that contain diagnostic
errors are recalibrated to account for similarity of measures, or
indicators as well as payment information. We excluded 42
correlation, by the same individual across differing lengths of
observations from the analysis because of a missing value; all
observation (Fitzmaurice, Laird, & Ware, 2004). Logistic
observations analyzed had complete information.
regression analysis is less suited to this analysis. Logisticregression does not consider nonindependence due to correla-tion; it also yields prevalence odds ratios rather than PRs and
thus would have overestimated the association of race/ethnicity
The dependent variable was the annual prevalence of use of
and medication use. We assumed a binomial distribution and
any anti-dementia medication, namely donepezil (AriceptÒ),
used a log link function to report PRs. We calculated PRs and
rivastigmine (ExelonÒ), galantamine (RazadyneÒ/ReminylÒ), or
their associated 95% confidence intervals (CIs) by using PROC
memantine (NamendaÒ), by non-Hispanic Whites and minori-
GENMOD in SAS 9.1.3 (Deddens, Petersen, & Lei, 2003).
ties. Respondents self-reported medication use. In addition to
Because the usual tests of model fit are not valid for GEE
querying respondents about specific medications used, inter-
models, we assessed goodness of fit by using an experimental
viewers reviewed medication containers as part of the thrice-
technique based on aggregates of residuals with an associated
yearly in-home interview during Years 2, 3, and 4. Respondents
p value of .9060, indicating a satisfactory model (SAS Institute,
were asked to keep all medication containers, insurance slips, and
receipts for medications, and the interviewers reviewed thesematerials at each interview. If a medication named in a previousround of interviewing was not listed, the respondent was queried
about its use during the period. Thus, prescription fills were
The ethnic/racial distribution of the sample was 76.3% non-
recorded, but actual medication use was not observed. We
Hispanic White, 11.7% non-Hispanic Black, 8.1% Hispanic,
determined race/ethnicity, our variable of interest, from the self-
and 3.8% non-Hispanic other (see Table 1). The mean age
report from the in-home computer-assisted personal interview-
of the sample was 80 years (SD ¼ 11), and nearly 60%
ing interview. We determined dementia diagnosis status from
were female. Approximately 26% of the sample received at
the presence of International Classification of Diseases–9
least one anti-dementia medication, most commonly donepezil
codes 331.0, 331.1, 331.2, 331.7, 290.xx (excluding 290.8 and
and less frequently rivastigmine, galantamine, or memantine.
290.9), 294.xx (excluding 294.9), or 794.xx on one or more
The sample differed significantly by race for anti-dementia
inpatient hospital, skilled nursing facility, home health, hospital
medication use, age, income, education, marital status, region,
outpatient, or physician supplier/carrier claim or from self-/
urban residence, and proxy response. Whites most often used
Table 1. Characteristics of the Sample by Racial/Ethnic Group (N ¼ 1,120)
White (n ¼ 855; 76.3%) Black (n ¼ 131; 11.7%) (n ¼ 91; 8.1%) Other (n ¼ 43; 3.8%) (N ¼ 1,120)
Use of any anti-dementia drug (p ¼ .0022)
Proxy respondent for half or more interviews (p ¼ .0011)
Notes: FPL ¼ federal poverty level; MSA ¼ metropolitan statistical area; SNF ¼ skilled nursing facility. aCardiovascular, antidepressant, or antipsychotic medication. p ! .05 except where shown.
anti-dementia medication (28.7%, p ¼ .0022), were in the
urban metropolitan areas (91.2%, p , .0018), lived in the South
highest income group (27.7%, p , .0001), had education
(68.1%, p , .0001), and had a proxy respondent for at least half
beyond high school (35.1%, p , .0001), and were currently
of the interviews (57.1%, p ¼ .0011).
married (45.6%, p , .0001); Hispanics most often were
In addition to the race/ethnicity comparisons shown in
younger than 65 years of age (19.8%, p , .0001), lived in
Table 1, we also performed bivariate comparisons between
RACIAL DISPARITIES IN DEMENTIA MEDICATION
Table 2. Multivariate Analysis of Prevalence Ratios for
Table 3. Multivariate Analysis of Prevalence Ratios for
Anti-Dementia Medications for Non-Hispanic
Anti-Dementia Medications for Non-Hispanic
White Versus Minority Medicare Beneficiaries
Note: Non-Hispanic Whites is the reference group. PR ¼ prevalence ratio;
anti-dementia medication users and nonusers (data not shown).
Compared to those not receiving anti-dementia medication,
anti-dementia medication users were older (M ¼ 81.3 years vs
79.7, t ¼ À2.89, p ¼ .0040), were more often currently married
(53.6% vs 38.5%, v2 ¼ 40.2, p , .0001), used more
cardiovascular (80.1% vs 74.1%, v2 ¼ 4.2, p ¼ .0401) and
antidepressant medications (38.1% vs 29.1%, v2 ¼ 8.2, p ¼
.0041), more frequently had prescription drug insurance (79.4%
vs 71.1%, v2 ¼ 7.6, p ¼ .0058), and were more likely to have
their dementia status ascertained both from claims data and
from self-report (52.2% vs 17.4%, v2 ¼ 134.7, p , .0001).
Relative to nonusers, anti-dementia medication users were less
likely to use the services of hospitals (27.9% vs 40.4%, v2 ¼
14.6, p ¼ .0001), hospices (2.1% vs 6.9%, v2 ¼ 9.4, p ¼ .0022),
or skilled nursing facilities (7.2% vs 15.0%, v2 ¼ 11.5, p ¼
.0007). They were also less likely to live in poverty (13.1% vs
27.0%, v2 ¼ 24.7, p , .0001). There were no other significant
differences between medication users and nonusers.
We compared the prevalence of anti-dementia medication by
racial/ethnic group (see Table 2). In the unadjusted model, the
PR comparing all minorities to non-Hispanic Whites was 0.61
(95% CI ¼ 0.48, 0.77). The adjusted model included de-
mographics (gender, age, marital status, and geographic
location), socioeconomic status (income and education), source
of diagnosis (claims data, self-report, or both), self- or proxy
reporting, comorbidity count, health care utilization variables
(prescription insurance status, hospital, skilled nursing facility
and hospice stay, use of other drug classes), and year. The PR
final model, urban or suburban residence (PR ¼ 1.30, 95% CI ¼
1.09, 1.57) and use of other drug classes (PR ¼ 1.50, 95% CI ¼
1.16, 1.95) were associated with higher prevalence of use.
Being never married, divorced, or separated (PR ¼ 0.33, 95%
CI ¼ 0.17, 0.61); having a single source for dementia diagnosis
(PR ¼ 0.37, 95% CI ¼ 0.31, 0.44, for claims data only; PR ¼
Notes: PR ¼ prevalence ratio; CI ¼ confidence interval; FPL ¼ federal
0.35, 95% CI ¼ 0.28, 0.44, for self-report only); being a proxy
respondent rather than a self-report (PR ¼ 0.82, 95% CI ¼ 0.71,
a85 years or older is the reference group.
0.95); lacking supplemental prescription insurance coverage
(PR ¼ 0.76, 95% CI ¼ 0.63, 0.92); and using hospice services
cGreater than 300% FPL is the reference group. d
(PR ¼ 0.49, 95% CI ¼ 0.27, 0.89) predicted lower prevalence
Postsecondary education is the reference group.
of anti-dementia drug use. We repeated the analyses with
Currently married is the reference group.
individual minority racial/ethnic groups entered simultaneously
Diagnosis from both claims data and self-report is the reference group.
g11 or more comorbid conditions is the reference group.
in both models (see Table 3). Prevalence disparities remained
hCardiovascular, antidepressant, or antipsychotic medications.
significant for non-Hispanic Blacks (PR ¼ 0.75, 95% CI ¼ 0.57,
0.99) and non-Hispanic others (PR ¼ 0.50, 95% CI ¼ 0.26,0.96) but were attenuated for Hispanics (PR ¼ 0.84, 95% CI ¼0.59, 1.20).
of the Alzheimer’s type, anti-dementia medications were
Relative to non-Hispanic Whites, community-dwelling
indicated for use in only mild to moderate disease during our
minority Medicare beneficiaries with dementia had an ap-
study years (U.S. Food and Drug Administration, 2003);
proximately 30% lower prevalence of anti-dementia medication
therefore, medication might have been considered inappropriate
use in the years 2001 through 2003. The finding of lower
for community-dwelling minority elders with more advanced
prevalence among minority Medicare beneficiaries was ex-
tremely robust, persisting even after we adjusted for demo-
Non-Hispanic Blacks make proportionately more mental
graphic, economic, health status, health care access, and
health visits to primary care providers rather than to special-
utilization factors. Our findings are similar in magnitude to
ists and thus receive fewer prescriptions for psychotropics
the 40% lower prevalence for non-Whites found by Mehta and
(Snowden, 2001). Poorer access to specialty dementia care may
colleagues (2005) in their investigation of acetylcholinesterase
explain some of the disparity with regard to dementia medi-
inhibitor use in California Alzheimer’s disease centers in the
cations. In addition, non-Hispanic Blacks have higher relative
years 1999 through 2003. Our study reinforces their findings by
rates of vascular dementia, and medications considered in this
using a national community-dwelling sample rather than one
investigation were approved for use in Alzheimer’s disease
from a specialty clinical setting. When we examined racial/
rather than for vascular and other types of dementia during the
ethnic groups individually, PRs remained statistically signifi-
study years. Thus, non-Hispanic Blacks in particular may havereceived proportionately fewer prescriptions for anti-dementia
cant for non-Hispanic Blacks and non-Hispanic others but lost
medications, because the use of these medications was not
significance for Hispanics, possibly because of the small
indicated for dementia types other than Alzheimer’s disease.
numbers in each minority group. Of interest is that the smallest
However, even if taken together, it seems unlikely that
group, the heterogeneous ‘‘non-Hispanic other’’ category, had
dementia type and disease severity could account for the entire
the greatest disparity in prevalence. In our sample, the 43 non-
30% differential between majority and minority use of anti-
Hispanic others included those reporting more than one race/
ethnicity (n ¼ 16), Asian or Pacific Islander (n ¼ 15), North
Our study has several limitations. Specific anti-dementia
American native (n ¼ 7), don’t know (n ¼ 3), and other (n ¼ 2).
medications and their indications changed within the study
Numbers were too small within this group to determine whether
years 2001 through 2003 and continue to do so; therefore,
prevalence was similar across these subcategories or whether
findings relating to this class of medications during those years
one or two subcategories strongly influenced the disparity.
may not hold true for the present or future. Numbers within
Although we cannot fully explain this disparity from our
each specific race/ethnicity group were relatively small; thus,
investigation, our findings suggest that between-race differ-
our ability to look at individual groups is limited. We lacked
ences are not due to demographic, economic, health status,
information on caregivers of people with dementia. Caregiver
access, or utilization variables. Disparities may be due to
factors may have influenced access to health care for people
differences in attitudes toward dementia in diverse cultures in
with dementia; for instance, caregiver psychological distress is
the United States, as well as cultural bias in cognitive
associated with a decreased likelihood of receipt of influenza
measurement (Manly & Espino, 2004). They might arise also
vaccine by the person being cared for (Thorpe et al., 2006).
from differences in psychosocial environment (e.g., neighbor-
Issues of disparities need investigation using data sources
hood effects) or discrimination experienced by members of
that contain higher numbers of minorities, thereby allowing for
minority groups, both of which have been proposed to be
detailed examination of prevalence and use patterns by specific
important determinants of the mental health of non-Hispanic
racial and ethnic populations. Further investigation needs to be
Blacks (Williams & Earl, 2007). If dementia is less often
undertaken with larger numbers of minority participants,
correctly diagnosed in minorities, as reported by Clark and
accounting for issues of dementia type and severity, medication
colleagues (2005) and Leo and associates (1997), our disparity
dose and duration of use, access to specialty dementia care, and
findings may underestimate the unmet treatment need among
consistency in treatment disparities across settings of care. As
minorities with dementia that has not been diagnosed.
well, dementia prevalence is greatest in nursing homes and
Differences in prescribing patterns for non-Hispanic Whites
other institutions, and evaluation of racial and ethnic disparities
and other groups might arise in several ways. Minority patients
should be considered in this vulnerable population, especially
have relatively poorer access to health care, beyond the
because a recent study reported significant racial disparities in
variation in hospital, skilled nursing facility, and hospice use
quality nursing home placement (Smith, Feng, Fennell, Zinn, &
and prescription drug insurance coverage accounted for by this
Mor, 2007). Additionally, the influence of cultural and
analysis (Smedley et al., 2003). Less contact with physicians
environmental factors in dementia treatment remains a fertile
would likely result in fewer prescriptions being written. In our
sample, non-Hispanic Whites had an average of 7.7 office visitsduring the observation period, whereas minorities made 6.9
visits; this difference is nearly statistically significant at the a ¼
This study was funded by a Grant 20050634 from the Commonwealth
.05 level (t ¼À1.90, p ¼ .058). Additionally, minority elders are
Fund. Dr. Zuckerman was supported by Award K01AG22011 from the
placed in long-term care at more advanced stages of dementia
National Institute on Aging. Dr. Ryder was supported by Training Grant
(Stevens et al., 2004; Yaffe et al., 2002), perhaps leading to
T32AG000262 in the epidemiology of aging from the National Institute onAging. We are grateful for the assistance of Dr. Ann L. Gruber-Baldini and
a disproportionate number of more severely demented minority
the helpful comments of three anonymous reviewers. A previous version of
elders remaining in the community. With the exception of
this work was presented at the AcademyHealth Annual Research Meeting,
memantine, approved in 2003 for moderate to severe dementia
RACIAL DISPARITIES IN DEMENTIA MEDICATION
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PATRIMONIO CULTURAL INMATERIAL 1)Introducción: La intervención de la UNESCO para salvaguardar el Patrimonio Cultural inmaterial –PCI-, a través de políticas de preservación y ayuda a revitalizado la posición de los pueblos que conservaron a través del tiempo sus conocimientos, tradiciones ancestrales y a su vez ha legado conocimientos, en beneficio de la humanidad, basados en