Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans.

OBJECTIVE: This article reports on a prevalence study of dementia and Alzheimer's disease among two groups of subjects with the same ethnic background but widely differing environments. METHOD: The study was conducted among residents aged 65 years and older in two communities: Yorubas (N = 2,494) living in Ibadan, Nigeria, and African Americans (N = 2,212 in the community and N = 106 in nursing homes) living in Indianapolis, Indiana. The study design consisted of a screening stage followed by a clinical assessment stage for selected subjects on the basis of their performance on the screening tests. RESULTS: The age-adjusted prevalence rates of dementia (2.29%) and Alzheimer's disease (1.41%) in the Ibadan sample were significantly lower than those in the Indianapolis sample, both in the community-dwelling subjects alone (4.82% and 3.69%, respectively) and in the combined nursing home and community samples (8.24% and 6.24%, respectively). The prevalence rates of dementia and Alzheimer's disease increased consistently with advancing age in both study groups. CONCLUSIONS: To the authors' knowledge, this is the first study, using the same research method at the two sites, to report significant differences in rates of dementia and Alzheimer's disease in two different communities with similar ethnic origins.

Relationship of age, education, and occupation with dementia among a community-based sample of African Americans.

OBJECTIVE: To explore the relationship between age, education, and occupation with dementia among African Americans. DESIGN: Community-based survey to identify subjects with and without evidence of cognitive impairment and subsequent diagnostic evaluation of a stratified sample of these subjects using formal diagnostic criteria for dementia. SETTING: Urban neighborhoods in Indianapolis, Ind. SUBJECTS: A random sample of 2212 African Americans aged 65 years and older residing in 29 contiguous census tracts. MEASUREMENTS: Subjects's scores on the Community Screening Instrument for Dementia (CSI-D), formal diagnostic clinical assessments for dementia, years of education, rural residence, primary occupation, self-reported disease, and alcohol and smoking history. Caseness was defined by four separate criteria: (1) cognitive impairment as defined by the subject's performance on the CSI-D cognitive scale; (2) cognitive impairment as defined by the total CSI-D score that included a relative's assessment of the subject's functional abilities; (3) dementia as defined by explicit diagnostic criteria; and (4) possible or probable Alzheimer's disease as defined by explicit diagnostic criteria. RESULTS: The mean age was 74 years (age range, 65 to 100 years), 65% of subjects were women, the mean education was 9.6 years (age range, 0 to 16 years), 98% of the subjects were literate, and 32% reported living in a rural area until age 19 years. Service, domestic, and production occupations accounted for 55.2% of the subjects' primary occupations with a mean of 25.8 years (range, 1 to 75 years) in the primary occupation. Years of education, rural residence to age 60 years, and primary occupation were highly correlated. Caseness defined by any of the four criteria was associated with functional impairment, but the frequency of impairment increased with increasing diagnostic specificity. Age, education, and rural residence to age 60 years were significantly independently associated with caseness for cognitive impairment, dementia, and Alzheimer's type dementia. White-collar occupation was independently associated only with caseness for cognitive impairment. History of stroke was associated with caseness for cognitive impairment and dementia but not Alzheimer's disease, while history of smoking was negatively correlated with Alzheimer's disease. CONCLUSIONS: Education was independently associated with cognitive impairment and dementia among a representative community-based sample of African Americans and the association remains significant across a variety of sensitivity analyses designed to control for measurement and confounding biases. The potential protective role of education against the development of dementia among African Americans deserves further evaluation.

Longitudinal study of depression and health services use among elderly primary care patients.

OBJECTIVE: To describe the prevalence and 9-month incidence of depressive symptoms among a cohort of elderly primary care patients and to determine whether different patterns of depression are associated with different patterns of health services use. DESIGN: Prospective study of depressive symptoms as measured by the Center for Epidemiologic Studies Depression (CES-D) scale and identification of patients' outpatient health services use through an electronic medical record system. SETTING: An academic primary care group practice at an urban ambulatory care clinic. PATIENTS/PARTICIPANTS: 1711 patients aged 60 and older who completed the CES-D at baseline and 9 months later; 935 of these patients also completed the CES-D at 6 months. MEASUREMENT AND MAIN RESULTS: The prevalence of significant symptoms of depression (CES-D > or = 16) was 17.1% at baseline and 18.8% at 9 months; 26.8% of patients exceeded the threshold on the CES-D either at baseline or 9 months, and the 9-month incidence was 11.7%. Among the patients re-interviewed at both 6 and 9 months, the 6-month incidence was 12%, and the incidence between the 6- and 9-month assessments was 10%. Of the 292 patients with depression at baseline, 140 (47.6%) remained depressed at the 9-month follow-up. Baseline and 6-month CES-D score, in addition to perceived health at 6 months, explained 45% of the variance in the 9-month CES-D score. Patients above the threshold on the CES-D at any time were more likely to rate their health as fair or poor (69.8% vs 43.7%) and more likely to have an emergency room visit (40.4% vs 29.4%). These patients also had 38% more outpatient visits (7.7 vs 5.6) and 61% higher total outpatient charges ($1209 vs $751) than patients who never exceeded the CES-D threshold over the 9-month window (all P values < 0.01). CONCLUSIONS: Depressive symptoms were frequent and often persistent in this patient population. We identified patterns of oscillating severity of symptoms within individuals but relatively stable incidence and prevalence rates over a 9-month period. Patients who exceeded the threshold on the CES-D at any time during the study had significantly greater health services use and poorer perceived health.

Risk factors for incident Alzheimer's disease in African Americans and Yoruba.

INTRODUCTION: The incidence rate of Alzheimer's disease (AD) was found to be 2 times lower in Yoruba than in African Americans. This study was aimed at identifying the factors associated with increased risk of incident AD in the two communities. METHODOLOGY: A two-stage design with initial screening using the CSI'D followed by neuropsychological test battery, relations' interview and physician assessment in a sub-sample.NINCDS-ADRDA criteria were met for AD. The risk factor variables assessed included demographic, lifestyle, medical and family history items. RESULTS: In the Yoruba, AD was associated with age (OR = 1.07) and female gender (OR = 2.93). In African Americans, age (OR = 1.09) and rural living (OR = 2.08) were the significant risk factors, while alcohol was protective (OR = 0.49). DISCUSSION: Age was a significant risk factor for AD at both sites. The higher risk of incident AD in the Yoruba female, and in African Americans who resided in rural areas in childhood were similar with the prevalence cases. Alcohol emerged a protective factor in African Americans. More studies are required, including biological measurements, to adequately explain the differences in rates.

A survey of interventional mammography practices.

To evaluate the current state of interventional mammography in the United States, surveys were sent to 1,000 randomly selected active members of the American College of Radiology (group 1) and the entire 1991 membership (n = 73) of the Society of Breast Imaging (group 2). Three hundred seventy-one (37%) group 1 and 49 (67%) group 2 responses were received. Some respondents did not answer all questions. Of group 1 respondents, 331 (93%) performed preoperative needle localization and 272 (73%) used a hook wire; 92 (25%), a J wire; and 55 (15%), a needle-dye technique. For group 2 respondents and these techniques, the results were 45 (94%), 32 (65%), eight (16%), and seven (14%), respectively. One hundred ninety-nine (62%) group 1 and 24 (55%) group 2 physicians administered local anesthetic during needle localization. Fifty-six (16%) group 1 and 25 (56%) group 2 physicians performed fine-needle aspiration cytology, as opposed to 11 (3%) and nine (20%) for core-needle biopsy, respectively. Cyst aspiration was performed by 245 (70%) group 1 and 40 (82%) group 2 respondents, galactography by 126 (36%) of group 1 and 30 (61%) of group 2, and pneumocystography by 57 (16%) of group 1 and 23 (48%) of group 2. For most procedures, informed consent was obtained by a minority of radiologists in both groups.

Preoperative needle localization in the breast: utility of local anesthesia.

Eighty-nine consecutive patients undergoing needle localization at two facilities were alternately assigned to "local-anesthesia" (n = 46) and "no-local-anesthesia" (n = 43) groups. Those in the local-anesthesia group received 1-2 mL lidocaine hydrochloride 1% subcutaneously at the expected site of insertion of the localizing needle. All patients were asked to rate the level of pain they experienced from the procedure as a whole by using a 10-cm horizontal visual analog pain scale. Data about patient age, menopausal and menstrual status, average daily caffeine intake, and whether the patients considered mammography to be a painful procedure were collected. Patients who did not receive local anesthesia had a lower mean pain score (2.52) than those who did (3.27, P = .18). Premenopausal patients in the second half of their menstrual cycle at the time of the procedure had a significantly higher pain score than those in the first half (3.54 vs. 1.70, P = .05). Patients who considered mammography a painful procedure reported a higher level of pain than those who did not (3.79 vs 2.38, P = .012). There was no relationship between age, caffeine intake, or menopausal status and pain experienced.

The therapeutic approaches of community based primary care practitioners to osteoarthritis of the hip in an elderly patient.

Predispositions to prescribe a pure analgesic, a cyclooxygenase inhibiting nonsteroidal antiinflammatory drug (NSAID) or a nonacetylated salicylate for a fictitious, uncomplicated case of osteoarthritis (OA) were surveyed in a sample of 152 community based primary care practitioners who had been characterized with respect to medical education and practice characteristics. Only 2 respondents (1%) prescribed a pure analgesic; 35% prescribed subantiinflammatory doses of cyclooxygenase inhibiting NSAID. The remainder (64%) recommended nonacetylated salicylates and cyclooxygenase inhibiting NSAID in doses large enough to achieve an antiinflammatory effect. Past participants in postgraduate rheumatology electives prescribed more costly regimens than those who had not participated (p = 0.05). When the case was altered to include a history of previous peptic ulcer, 44% chose cyclooxygenase inhibiting NSAID with adjunctive prophylaxis against NSAID induced gastropathy (e.g., misoprostol). When the complication was changed to renal insufficiency, recommendations for sulindac increased 3-fold over those for the uncomplicated case (34 vs 11%), and were most common among more recent medical school graduates and past participants in rheumatology electives (p less than 0.05 for both). The potential effects of educational and practice variables on the therapeutic strategies and costs of OA care in the community merit further systematic study.

Data management in a longitudinal cross-cultural study.

The Indianapolis-Ibadan Dementia Project compares the rates of dementia at two sites, one in the U.S.A. and one in Nigeria. This paper concentrates on the data management issues in this longitudinal cross-cultural study. Approximately 2500 elderly people were recruited at each site, and continue to be re-assessed every two years. All the data are collected on paper and then entered into a FoxPro relational database. Most of the data management, including data cleaning, is done in Indianapolis. The design of the data collection forms is particularly important in a cross-cultural study, with the questions and the coding of responses clear and simple. Since Nigeria and the U.S.A. have different levels of technological development, the computer hardware and software were chosen to be suitable for use at either site. Exchange visits have been needed to address data management issues and resolve unexpected problems. The data management on cross-cultural studies can be handled successfully, given careful planning.