Adelman, S.; (2010) Prevalence and recognition of dementia in primary care: a comparison of older African-Caribbean and white British residents of Haringey. Doctoral thesis , UCL (University College London).

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Abstract

Background: As the elderly population in Britain continues to grow, so will the number of people with dementia. Notably, those affected will include an increasing proportion of people from black and minority ethnic (BME) communities, as they too are reaching old age in large numbers. Preliminary studies indicate that African-Caribbean people may be at higher risk of developing dementia than the indigenous, white older population, although the findings are inconclusive. It has also been hypothesised that an excess of dementia in this group may be related to an increased risk of hypertension and its ineffective detection or treatment. Hypertension and diabetes, also common in African-Caribbean people, are established risk factors for cerebrovascular disease and dementia. However, despite these findings, it has been observed that people from BME groups, including those of African-Caribbean descent, may be less likely to have their dementia treated with an equitable level of resources. Aims and Hypotheses: The aim of this study is to enhance our knowledge regarding dementia and its risk factors in older African-Caribbean people in Britain. It tests the primary hypothesis that the prevalence of dementia is higher in the African-Caribbean, than the white British-born older population, using General Practice lists in the London Borough of Haringey as sampling frames. The study also tests the secondary hypothesis, that dementia in African-Caribbean people is under-recognised in primary care and that the rate of referral to specialist dementia services is lower than that in the white-British population. Methods: The study comprises a comparative cross-sectional and a medical notes survey. Five General Practices were recruited in Haringey, North London. From their practice lists, 218 African-Caribbean people and 218 white-British people aged \geq 60 years were recruited and screened for cognitive impairment using culturally valid versions of the Mini Mental State Examination (MMSE). Those in either group who screened positive (scoring <26/30), were offered a standardised diagnostic interview and physical examination. Two independent assessors blind to ethnicity, used this information to diagnose dementia according to operationalised criteria and from this, the prevalence of dementia was calculated for each group. Participants diagnosed with dementia, had their primary care medical notes scrutinised for documentation of cognitive impairment or dementia. Use of brief screening tools for cognitive impairment and referrals to secondary health care or social services were also recorded. The frequency of documented cognitive impairment, dementia and referral to specialist services were compared between the two groups. Results: The prevalence of dementia was higher in the African-Caribbean (9.6%) than the white-British group (6.9%), and the difference was significant after controlling for age and socioeconomic status (OR=3.1; 95%CI=1.3 -7.3; p=0.012). African-Caribbean participants were on average two years younger, and those with dementia nearly eight years younger than their white-British counterparts. There was a significantly higher proportion of vascular dementia diagnosed in the African-Caribbean group, although the numbers were small and participants only met the criteria for a possible rather than probable diagnosis. There were higher rates of both treated and unrecognised hypertension in the African-Caribbean group. A history of hypertension was associated with cognitive impairment, but not dementia. The rate of documented dementia was 42% and referral to specialist dementia care 36% for all participants combined. The African-Caribbean group was at least as likely to have their dementia recognised and documented in primary care as the white-British group. However, they were less likely to be referred to specialist dementia services, although the numbers were small and this finding was not statistically significant. Conclusions: There is now strong evidence for an increased prevalence of dementia in older African-Caribbean people in Britain and that this may occur at significantly younger ages than in the indigenous white population. There is also some evidence for an excess of hypertension and vascular dementia in this group. These findings have implications for service provision and preventative interventions. Although General Practitioners are at least as likely to recognise and document a diagnosis of dementia in African-Caribbean than white people, they might be less inclined to refer them for specialist assessment. This warrants further investigation in the form of a qualitative study.

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