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Funding: NIA AG 12975 1997-2008 NIDDK DK 60753, AG10129, AG10220; USDA 00-35200-9073

Migration, nativity and cultural orientation as predictors of decline in cognitive status, incidence of dementia/CIND and all cause mortality in The Sacramento Area Latino Study on Aging.

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Funding: NIA AG 12975 1997-2008 NIDDK DK 60753, AG10129, AG10220; USDA 00-35200-9073

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  1. Migration, nativity and cultural orientation as predictors of decline in cognitive status, incidence of dementia/CIND and all cause mortality in The Sacramento Area Latino Study on Aging Mary N. Haan, MPH, DrPH, Vivian Colon Lopez, MPH, Hector M Gonzalez, PhDKala Mehta, DSc Ladson Hinton, MDUniversity of Michigan, School of Public Health, EpidemiologyUniversity of California San Francisco, School of Medicine, Geriatrics University of California, Davis, School of Medicine, Psychiatry Funding: NIA AG 12975 1997-2008 NIDDK DK 60753,AG10129, AG10220; USDA 00-35200-9073

  2. History of the Mexico-US Border and migration Fluctuations in • Immigration policy and practice • Economic and political motivations for migration • Economic demand for cheap labor in agriculture Crossing “Borders” is not synonymous with cultural change: Often borders change leaving people in place

  3. Why would migration influence health in old age? Early life exposures • Social, cultural and socioeconomic • Physical: environmental, nutritional, infectious Transitions: • Cultural changes = ‘Acculturation’ • Socioeconomic advances (or not) Differences in exposures to risk factors • Environmental • Behavioral • Social Changes in exposures • Timing of exposure: early life vs later life • Age-related effects of exposure at early vs later life

  4. Cultural orientation ‘Acculturation’ - Adoption of behaviors/beliefs of culture in new country/location Immigration ≠ change in cultural orientation • US born • Socioeconomic status (SES), diversity of community (mono-ethnic vs. poly ethnic) • Foreign born • SES, timing of education, community, discrimination Defining cultural orientation • Typical: language, contact with own ethnic group vs. others, celebration of traditions • Cultural flexibility: ability to cross cultural boundaries • Not synonymous with nativity

  5. Socioeconomic status: a major predictor of health and death in all populations SES and immigration • Attainment of higher SES • Age at migration (post-migration education) • Education before and after migration • Success in overcoming discrimination to improve status • Languages spoken/learned Education vs. financial status • Which is more influential for health?

  6. Sacramento Area Latino Study on Aging: Cohort Study Study Population • 1,789 Latinos aged 60+, primarily Mexican ancestry (85%) • 49% US born and 51% Mexico or another Latin American country • 58.3% female • Mean age at baseline: 71 (60-101) • 51% Spanish speaking Study period • Baseline: 1998-99 • Annual follow-up through 2008 • Semi annual phone interviews In home clinical evaluations and interview • Cognitive testing, clinical assessments • Socio-demographic factors • Medical history

  7. Analysis questions Is there a difference by nativity for • All cause mortality? • Cognitive decline? • Incidence of dementia combined with cognitive impairment without dementia (CIND)? Is cultural orientation associated with these outcomes? Are the associations between nativity or cultural orientation influenced by SES?

  8. Mortality or dementia/CIND incidence Non parametric survival analysis (life tables) Proportional hazards models Lost to follow-up treated as alive or as non demented Effect modification Adjustment for confounding Change in cognition Mixed linear models Testing for model fit with AIC 3MSE errors Log(101-3mse) Effect modification Adjustment for confounding Approach to analysis of 4-year follow-up

  9. Key Outcome Measures (four years) Mortality : Ascertainment via multiple reports, NDI, vital statistics (n=317 deaths: 52% in US born) Dementia/CIND 3-stage evaluation process including screening, clinical evaluation and case adjudication using standard criteria (N=111; 36% in Mexican/Latin born) Cognitive change: Modified Minimental State Exam (3MSE)

  10. Key exposure measures Nativity: Country of birth (US, Mexico, Other Latin American) Cultural orientation: Cuellar scale: language, contact, friendships Sum of items: (0-54), Alpha = 0.88 Health at baseline: Stroke Type 2 diabetes Health insurance and source of medical care

  11. Key exposures: Coding for socioeconomic status

  12. Part 1: Culture, immigration, health and socio-demographic factors

  13. Higher in Mexican/Latin- Age: 71 vs. 70 Spanish speaking: 89% vs. 31% Fair or Poor Self rated health: 57% vs. 41% No medical insurance: 16% vs. 2.5% Residence in Latino neighborhood: 42% vs. 28% Main occupation in agriculture Higher in US- Mean years of education: 9.6 years vs. 5.0 years Own your home: 78% vs. 56% Mean cultural scale: 31 vs. 14 Prevalence (%) of type diabetes: 33% vs. 25% Prevalence (%) of stroke 12% vs. 7% Socio-demographic and health differences* by nativity at baseline * Significant differences only

  14. Mean years of education by total household income by country of birth

  15. Cultural orientation by SES and nativityfrom an ANOVA including SES, nativity, gender, and age * * * * * Significant (p<.0001) by nativity

  16. Conclusions: Part 1 • US born have higher education at every income level than Mexican/Latin born • Mexican/Latin born are disproportionately in the lowest education and income group • Cultural score increases with income and education • Cultural score is lower for Mexican/Latin born at every level of SES vs. US born

  17. Part 2: All cause mortality

  18. All cause 4-year mortality by nativity and gender

  19. Predictors of all-cause mortality by gender in SALSAfrom proportional hazards models with simultaneous adjustment(only significant at p<0.01 shown) * Reference for SES: low income, low education

  20. Nativity and all cause mortality by gender and agefrom proportional hazards models* stratified on gender *Adjusted for age, gender, nativity, SES, diabetes, stroke, age*nativity

  21. Part 2: Conclusions: mortality • There are no overall differences in mortality by nativity among men • Women born in Mexico/Latin America have lower mortality risk than women born in US • This advantage disappears with age so that older Mexican born women have higher mortality risk than older US born women • Age, SES and health are major predictors of mortality independent of nativity and do not influence the association

  22. Part 3: Cognitive decline

  23. Change in Errors on the Modified Minimental State Exam (3MSE) over 4 years by nativity and for a 1 SD difference in cultural orientation from an adjusted* mixed linear model *Age, gender, SES, diabetes, stroke: p value for time*nativity = 0.03

  24. SES as a predictor of change on the 3MSE from an adjusted*mixed linear model *Adjusted for age, gender, nativity, stroke, diabetes, time*SES, P interaction=0.005

  25. Part 3: Conclusions: Cognitive Decline • Errors on the 3MSE increased among those born in Mexico/Latin American increased more rapidly than among those born in the US • A 1 SD difference (12 points) on the cultural scale was associated with an average increase in errors on the 3MSE of 2 points • Those with low education and income had more errors on the 3MSE that persisted over 4 years • Those with higher education, regardless of income or nativity, had fewer errors

  26. Part 4: Dementia/CIND incidence

  27. Risk of dementia/CIND and cultural orientation by tertilesfrom adjusted proportional hazards models* Adjusted for age, gender, SES, diabetes, stroke

  28. Risk of dementia/CIND associated with 1 SD difference in cultural score by nativity from stratified proportional hazards models* (0.52-0.78) (0.94-1.01) Age,gender,cultural score,SES, diabetes, stroke

  29. Predictors of dementia/CIND incidence in SALSAfrom a proportional hazards model with simultaneous adjustment*

  30. Risk of dementia/CIND associated with combined income and education in study participants from proportional hazards models *Adjusted for age, gender, stroke, diabetes

  31. Part 4: Conclusions: dementia/CIND • Anglo cultural orientation is associated with a lower risk of dementia/CIND, even after adjustment for SES • Anglo cultural orientation is associated with a lower risk of dementia/CIND among Mexican born but not among US born • Older age, lower SES, presence of diabetes, stroke are associated with higher risk of dementia/CIND • Nativity is not associated with incidence of dementia/CIND • Higher education is associated with lower risk of dementia/CIND regardless of income

  32. Final Conclusions • Nativity is not associated with mortality overall • Aging may modify the risk of death among women so that the Mexican/Latin advantage disappears with increasing age • Among Mexican/Latin born, dementia risk is lower for those with more Anglo orientation • Lower socioeconomic status increases risk of outcomes regardless of nativity

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