Evaluation of a dementia awareness program in the African-American community

1. Evaluation of a dementia awareness program in the African-American community Robert Friedland, MD, Daniel F Rexroth, Sean Hayes, David A. Bennet, Martin R. Farlow, Margaret Gatz, Mark A. Gluck, Thomas O. Obisesan, Suzanne Murray

2. Patho- and Saluto-genesis • Pathogenesis • the origination and development of a disease Princeton Univ. Worldnet • Salutogenesis(lat. salus = health, genere = to create) • a shift from the disease-metaphor to the vision of well-being Antonovsky, A. Health, Stress and Coping. San Francisco: Jossey-Bass. 1979

3. Incidence of AD in African Americans, Caribbean Hispanics, Caucasians in Northern Manhattan Tang et al. Neurology. 2001;56:49-56. “Compared to white individuals, the cumulative incidence of AD to age 90 years was increased twofold among African-Americans ….. Adjustment for differences in number of years of education, illiteracy, or a history of stroke, hypertension, heart disease, or diabetes did not change the disproportionate risks ….”

4. Courtesy of AdesolaOgunyi

5. Courtesy of AdesolaOgunyi

6. CWRU Kenya Aging Study

7. MountKenya

8. Mount Kenya FRAMING: a technique used to bring focus to the subject

9. Health of Africans • Major health problems in the aged are low blood pressure, malnutrition and infectious diseases • Alzheimer’s disease is less common in Africans than in African Americans or Caucasians

10. African-American Health • Major health problems are high blood pressure, diabetes, obesity • These are all risk factors for heart disease, stroke and Alzheimer's disease • Alzheimer’s disease is more common in African-Americans than Caucasians

11. Objectives • Evaluation of the impact of National African-American Alzheimer’s Disease Health Literacy Program: • a national community-based educational program targeting knowledge, attitudes, and behaviors related to risk factors for Alzheimer’s disease (AD) among African-American community members in six cities.

12. Protective Factors for Alzheimer’s Disease Non-modifiable • young age • apolipoprotein E-e2 and e3 alleles • absence of family history of dementia • absence of mild cognitive impairment • male gender Modifiable • high education and occupational achievement • vigorous participation in mental and physical activities • Avoidance of cardiac disease, diabetes & hypertension • dietary use of antioxidants, B vitamins and FISH • avoidance of high fat diet, obesity, smoking, head injury

13. Methods • 231 community program participants at three sites completed questionnaires prior to and immediately following the program. • Questionnaires were further distributed to 22 participants at two sites 2-10 weeks following the program. • Questionnaires included quantitative (5-point scale) and qualitative (open-ended) items. • Quantitative data were analyzed with non-parametric statistics, qualitative data with content analysis; results were triangulated to increase findings’ strength

14. Results • Knowledge of AD risk factors increased from baseline (=2.95-3.74) to post-program ( =3.63-4.20, P≤0.001). • Following the program, attribution of both types of items to AD increased (symptoms: =3.54-3.91, P≤0.001; normal aging =2.12-2.80, P≤0.001). • Intent to change behaviors increased from =3.16-3.67 to =3.53-4.06 (P≤0.001) except for adherence to medications ( =4.44-4.49, N/S). • Qualitative analysis revealed increased understanding of relevance of AD risk factors for African-American community members and importance of lifestyle changes and early healthcare intervention in mitigating the impact of AD.

15. Possible prevention of cognitive decline in later life • Few potentially beneficial factors were identified from the evidence on risk or protective factors associated with cognitive decline Plassman et al, Annals of Internal Medicine 2010

16. Plassman et al, 2010 “The current literature does not provide adequate evidence to make recommendations for interventions. Previous work has provided a few potential leads, such as cognitive training, physical exercise, and some nutritional patterns. These should now be pursued with potentially novel approaches and increasingly rigorous scientific methods to identify a real signal among the numerous factors throughout the life course that may contribute to complex, late-life cognitive disorders.”

17. Women's Health Initiative Memory Study: effect of hypertension and baseline blood pressure on cognitive decline and dementia in postmenopausal women • Follow up 4.5 years • “Hypertension and high blood pressure at baseline were not independently associated with MCI or probable dementia over time in older, cognitively intact, postmenopausal women enrolled in WHIMS after other potential confounders were taken into account.” • Johnson et al, 2008

18. “The absence of evidence is not evidence of absence” Carl Sagan

19. Dr. Alvan R. Feinstein (1925-2001) Sterling Professor of Medicine and Epidemiology, Yale University

20. Proposal: Longitudinal Study of Dementia Prevention

21. STUDY DESIGN

22. Conclusion • This evaluation demonstrates the effectiveness of culturally relevant, community-based programs in increasing awareness and knowledge of lifestyle risk factors and chronic disease

23. Conclusion • Differences in disease risk between Africans and African Americans is a model for demonstrating the power of lifestyle factors • AD, hypertension, heart disease, stroke, and diabetes are all uncommon in older Africans and very common in older African Americans. • These differences are almost certainly because of potentially modifiable lifestyle factors

24. Disclosures • Mason Rudd Chair, Neurology, University of Louisville • National Institute on Aging, NIH • Joseph and Florence Mandel Research Fund • GOJO Corp. • Pfizer, Forest, Eisai

26. Salutogenesis of AD: Why don’t we all get it if we live long enough? • Genes: Apo E 2,3 • Absence of: head injury high fat diet obesity diabetes (hyperinsulinemia) heart disease, hypertension and stroke smoking chronic inflammation toxic exposures • Presence of: high levels of education and physical and mental activity; fruits, vegetables, fish, nuts and B vit. intake anti-Ab antibodies alcohol use?

27. Ignorance fallacy Being ignorant is not a fallacy. We're all ignorant about a great many things. • For instance, absence of evidence that it rained (i.e. water is the evidence) may be considered as positive evidence that it did not rain. Again, in science, such inferences are always made to some limited (sometimes extremely high) degree of probability. • The challenge thus becomes to try to identify when a researcher has received a null result (found nothing) because the thing does not exist (evidence of absence), and when one simply lacks proper means of detection (absence of evidence).

28. Yams in Ghana

29. World Alzheimer Report, Alzheimer’s Disease International, 2010 • There are 36 million people living with dementia worldwide, increasing to 115 million by 2050 • 2/3 live in low and middle income countries • The societal cost of dementia is enormous, estimated at $600 Billion worldwide

30. Health of Africans • Major health problems in the aged are low blood pressure, malnutrition and infectious diseases • Alzheimer’s disease is less common in Africans than in African Americans or Caucasians

31. “Absence of evidence is not evidence of absence" Carl Sagan The Demon-Haunted World (Chapter 12 – “The Fine Art of Baloney Detection”)

32. High Dose B Vitamin Supplementation and Cognitive Decline inAlzheimer’s Disease: A Randomized Controlled Trial • Treatment period : 18 months • This regimen of high dose B vitamin supplements does not slow cognitive decline • in individuals with mild to moderate AD. • Aisen et al, 2008

33. African-American Health % median values * from Behavioral Risk Factor Surveillance System Survey, MMWR 08/27/04; 53:55-6.