Diversity in Cognitive Aging Quiz 3

NIH Health Disparities Framework Levels of Influence

individual, interpersonal, community, societal

NIH Health Disparities Framework Domains of Influence

biological, behavioral, physical/built environment, sociocultural environment, healthcare system

NIH Health Disparities Framework Health Outcomes

individual health, family/organizational health, community health, population health

other frameworks

gender & sexual minority health disparity framework, social & cultural influence of Native Hawaiian health, historical & sociocultural influences for American Indian and Alaska Native nations

socio-ecological theory

suggests that context plays an important role in the development of health problems

individual health is nested in relationship, community, and societal relationships

1. health is influenced by multiple levels (individual, interpersonal, community, society)

2. the same environment may have different effects on an individual’s health depending on a variety of factors

3. individuals and groups operate in multiple environments (e.g. workplace, neighborhood, larger geographic communities) that “spill over” and influence each other

4. there are personal and environmental intervention points that exert vital influences on health and well-being

life course theory

the study of physical or social exposures during gestation, childhood, adolescence, young adulthood, and later adult life, on health outcomes

the accumulation of different types of exposures (such as environmental, socioeconomic, and behavioral) may cause long term damage

critical period

a limited time window in which an exposure can have adverse effects on health outcomes

damage is permanent and irreversible

sensitive period

a time period when an exposure has a stronger effect on disease risk than it would at other times; outside the sensitive time period the effect of any exposure will be weaker

damage may be reversible

health equity requires

multi-level and multi-domain interventions

physical environment

encompasses places, infrastructure, neighborhoods, and communities

top 10 environmental causes of death

1. stroke

2. ischemic heart disease

3. unintentional injuries

4. cancer

5. chronic respiratory diseases

6. diarrheal disease (viral or bacterial pathogens)

7. respiratory infections

8. neonatal conditions

9. malaria

10. intentional injuries

environmental factors

air pollution, inadequate water & sanitation, chemicals, radiation, community noise, occupational risks, agricultural practices, built environments, climate change, housing, rural vs. urban, walkability, food access, green space, transportation

when you think about environment, always ask yourself:

what types of toxins/contaminant/pollutants are you exposed to in your environments?

what type of resources are available in your environments?

theoretical models of toxin exposure

• immediate effects - brief exposure to a toxin causes a damage/disease quite promptly

• sensitive/critical period - exposure during an especially sensitive window of time is extremely influential, and after the temporal window closes, the exposure is no longer relevant

• cumulative biological - each exposure period induces permanent physiologic harm and increases risk for disease

geographic information systems (GIS)

a tool that facilitates understanding the relationship between geographic data and health

area deprivation index (ADI)

a measure that ranks neighborhoods based on socioeconomic disadvantage, assessing factors like income, education, and employment to evaluate health disparities

census tract

geographical representation of an area

community-level sampling

allows for the level or spread of a contamination to be measured at the community or neighborhood level

does not account for person-specific differences in mobility, behavior, or time spent in microenvironments which may contribute the most to their total exposure

personal-level sampling

personal monitoring is thought to be the gold standard in external exposure assessment; usually entails GPS, phone, or wearable sensor-based technology

consequences of segregation

• the activation of deleterious biopsychosocial pathways due to chronic stress (individual level)

• repeated exposure to adverse conditions within certain neighborhoods (community level)

• laws that lead to inequitable access to quality healthcare services (societal level)

effects of redlining

• lower levels of public/private investment

• decreased property values

• decreased education and healthcare access

• higher density housing/poorer quality public housing

• fewer parks/green spaces

• less reliable city services

• more factories/industrialized areas = pollution

environment & dementia risk study

• study objective - to evaluate the association between long-term exposure to ambient air pollution and dementia incidence in older adults

• pollution metrics of interest - PM2.5, NO2, ozone (O3)

• covariates - neighborhood SES, behavioral risk factors, health-care capacity variables

• results - PM2.5 associated with greatest risk for developing dementia, followed by NO2; Black people, people on Medicaid, and people 75 and older are at greatest risk for dementia from each toxin

green space & dementia risk study

• study objective - to investigate associations between road proximity and exposures to air pollution, and effects greenness, on non-Alzheimer’s dementia, Parkinson’s and Alzheimer’s disease, and multiple sclerosis within a population-based cohort

• results - NO2 increased risk while greenness decreased risk

air pollution effect on the brain

1. once inhaled, pollutants can enter the brain directly via the olfactory pathway

2. they may also enter indirectly through the circulatory system after they penetrate lung tissue

3. both of these cause inflammation within local tissue

4. this systemic inflammation can cause neuroinflammation and cerebrovascular damage

5. pollutants can also activate the hypothalamic-pituitary-adrenal (HPA) axis; activation of the stress response increases cortisol levels in the blood

6. prolonged activation of inflammatory cytokines and cortisol alter the brain

exposure to greener, natural environments can reduce pollutant levels and increase exposure to health-promoting chemicals

heat & hospitalizations study

• study objective - to evaluate the effects of heatwaves on hospitalizations and deaths; to examine whether individual-level (age, sex) and community-level (community vegetation) factors altered the consequences of heatwaves on hospitalizations

• results - most hospitalizations on first day and 4-5 days after heatwave started; older patients more likely to be hospitalized; women AD patients more likely to be hospitalized; roughly 13% of hospitalized patients lived in suburbs with high community vegetation; roughly 50% of hospitalized patients in suburbs with low community vegetation died

cultural identity formation

• vertical transmission - transfer of cultural elements from parents

  • more common in small, traditional societies

• oblique transmission - transfer of cultural elements from non-parental adults (other members of parent’s generation)

• horizontal transmission - transfer of cultural elements from peers

  • more common in modern, economically developed societies

cultural transmission within the same culture

• enculturation - through passive and social learning, the developing individual gradually acquires the values, language, and core elements of the immediate culture

• socialization - through formal instruction or the deliberate shaping of the child’s behaviors and beliefs; ensures members of the cultural group learn those attributes deemed by broader society to be an essential way of life

acculturation

the bidirectional process of change and accommodation that occurs when two or more cultural groups come into direct contact; the exchange of cultural elements between members of different cultures

4 outcomes of acculturation

• assimilation - accepts receiving culture, rejects one’s own

• integration - bicultural adoption of receiving culture and relative retention of heritage culture

• marginalization - rejects both cultures

• separation - rejects receiving culture, accepts one’s own

acculturation and health outcomes

acculturation strategies are linked to mortality and chronic disease burden

marginalization is generally linked to higher levels of stress and chronic diseases

incredibility variability in health outcomes among Latinos of Mexican, Puerto Rican, Cuban, and other cultural heritage groups

factors that explain the variability: socioeconomic status, education level, language fluency, immigration status, and the number of generations that have lived in the US

effects of culture on decision to seek care

• perceived susceptibility and severity of dementia - there are cross-cultural differences in time to initial dementia evaluation and level of impairment; in general, minority groups are generally more impaired and in the later stages of the disease process at initial evaluation

• perceived benefits of seeking care - minority groups have less access to care; less awareness or knowledge of medication options; higher levels of familial responsibility an caregiving

• perceived threats of seeking care - discrimination; stigma; cultural competency of providers

culturally biased test items

Boston Naming Test is a picture naming task that is commonly used in dementia assessments but may disadvantage individuals from diverse cultural backgrounds who are unfamiliar with the items

Americans value speed over accuracy, and the interpretation of crossing out 2s and 7s is based on speed over accuracy

American culture emphasizes attunement to a focal object and is less sensitive to context; Americans made fewer errors on the absolute task but made more errors in the relative task

cultural factors in cognitive assessments

• education (level, quality literacy)

• culture (and acculturation)

• language (spoken and English proficiency)

• economic (issues)

• communication (style)

• testing situation (comfort and motivation)

• intelligence (concept of)

• context of immigration

biological impact of stress

hyperactivation of amygdala, increased attention and memory, anxious mood state, increase heart rate and blood pressure, immune system suppression, increased glucose levels and adiposity deposits

HPA axis

hypothalamic-pituitary-adrenal axis is responsible for regulating bodily functions that include increasing glucose levels for energy, suppressing immune response, and promoting fight or flight response

temporal course of stress response

rapid increase in physiological response followed by a recovery; the degree of the physiological response is directly proportional to the perceived threat

the body should return to pre-stress levels of functioning/homeostasis after the threat has passed

allostasis - an adaptive change in physiological functioning to respond to a threat

• short-term allostasis can help to overcome acute challenges and ensure survival by forcing systems to function outside their normal ranges (temporary adaptive change)

• long-term allostasis is maladaptive because prolonged changes in physiological functioning are taxing on the body

• repeated exposure to the same stressor can lead to a failure to habituate or adapt

allostatic load

takes into consideration the long-term cost of repeated stress and wear-and-tear on the body and brain

is a measure of the strain on the body produced by ups and downs of physiological systems under challenge

chronic stress permanently alters the body’s physiological response

higher allostatic load (more abnormal biomarkers) is associated with an increased risk for death and can be observed across the lifespan, including in children

the negative effects of stress can potentially be translated into disease outcomes and health disparities later in life

is associated with more widespread reductions in brain volume in older adults relative to other health conditions

structural violence

a way of understanding the inequities and explains how the organization of society has put individuals and populations in harm’s way

Tuskegee syphilis study

a controversial clinical study conducted in the United States between 1932 and 1972, which involved knowingly withholding treatment for syphilis (penicillin) from African American men to study the disease's progression

led to the 1979 Belmont Report and federal laws and regulations requiring institutional review boards for the protection of human subjects in research studies

Henrietta Lacks

was an African American woman whose cancer cells were taken without her knowledge or consent in 1951. Her cells, known as HeLa cells, were vital for medical research and contributed significantly to advancements in cancer and infectious diseases

medical mistrust

an absence of trust that health care providers and organizations genuinely care for patients’ interests, are honest, practice confidentiality, and have the competence to produce the best possible results

related to past legacies of mistreatment, but also stems from people’s contemporary experiences of discrimination in health care - from inequities in access to health insurance, health care facilities, and treatments to institutional practices that make it more difficult to obtain care

Belmont principles

1. respect for persons - participants should be treated as autonomous individuals, and those with less autonomy should be afforded special protection

   • informed consent - procedure by which potential participants learn about the study, including its risks and benefits, and decide whether or not they would like to participate

2. beneficence - researchers must take protections to minimize harm to their participants and ensure their well-being

   • anonymous study - no identifying information collected

   • confidential study - identifying information collected but protected and not disclosed to others

3. justice - there must be a fair balance between the kinds of people who participate in the research and the kinds of people who benefit from it

institutional review board (IRB)

committee responsible for interpreting ethical principles and ensuring that university researchers are abiding by these principles in their studies

nature vs nurture

current view is interconnected, not opposing alternatives

many behaviors are the result of biological predispositions and environmental experiences

eugenics

coined by sir Francis Galton, who believed that intelligence was genetically determined and that we could measure it scientifically

the scientific attempt to genetically improve the human species through selective parenthood

development of IQ tests

created by Alfred Binet and Theodore Simon to help identifying children in French schools who needed more help

Binet’s cardinal principles:

• the scores are practical devices and they do not define anything innate or permanent; we may not designate what they measure as “intelligence”

• the score is a rough empirical guide for identifying learning-disabled children who need special help; it is not a device for normal children

• whatever the cause of the difficulty in children identified for help, emphasis shall be placed on improvement through special training; low scores shall not be used to mark children as innately incapable

Henry Goddard was an American psychologist that dismantled Binet’s intentions and used the IQ test to sort people into intellectual categories

• he found that 80% of the population of immigrants that he studied were “feeble-minded”

Robert Yerkes used IQ testing on army recruits in WWI

abuse of IQ testing lead to US laws of compulsory sterilization policies (inspiration for the Nazis)

Flynn effect

the observed rise over time in standardized IQ test scores (approx. 3 points per decade)

using old norms means we overestimate the person’s current IQ

use of old norms make it harder to diagnose someone as impaired; current norms are a more accurate estimation of current abilities

clinical trials

3 phases before being approved

placebo-controlled - study participants are randomly chosen to receive the experimental treatment, and some receive a placebo

double-blinded - participants and study staff are unaware of who receives the drug and who gets the placebo

Aduhelm/Aducanumab

outcomes of interest - amyloid reduction and cognitive decline

futility analyses from pooled data showed the drug trial was unlikely to show positive therapeutic effects

post-hoc analyses of EMERGE (high dose) vs ENGAGE (low dose) arms found “some evidence of efficacy in that drug reduced amyloid levels”

a lot of adverse events like edema, amyloid-related imaging abnormalities (ARIA), and microhemorrhage caused a lot to withdraw from the study

only the high dose in EMERGE had any cognitive effects

was very expensive like bruh

justice

describes a state where the dismantling of structural and systemic inequities (and the laws and policies that sustain them) is not only achieved, but new structures and systems are instituted that deliberately reinforce their elimination

community-based participatory research (CBPR)

community-based - grounded in the needs, issues, concerns of the communities, and the community-based organizations that serve them

participatory - directly engages communities and community knowledge in the research process

action based and oriented - enhances the strategic action that leads to community transformation and social change

goal is to create an equal partnership that ensures we create interventions that are responsive to the community’s needs

CBPR practices

• varying degrees to which the community is involved, but they are involved

• research design is done with community and academic representatives; ongoing and cyclic process

• needs assessment, data collection, implementation, and evaluation is everyone’s responsibility

• long-term sustainability is a priority

benefits to CBPR

helps dismantle the lack of trust communities may exhibit in relation to research

enhances the 3 R’s (rigor, relevance, reach)

cons to CBPR

costly

time consuming

academy is not well integrated with community in many places

history of harm against communities may contribute to hesitancy to form partnerships or engage

a4 clinical trial

wanted at least 20% of people screened for enrollment at each recruitment site to be form minoritized racial and ethnic groups; only 8% were

they weren’t screening enough minority participants (doing a good job of recruiting from the potential pool)

sci-comm

practice of informing, educating, and raising awareness of science-related topics