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Perceived Discrimination and Cognition in Older African Americans

Published online by Cambridge University Press:  18 May 2012

L.L. Barnes ,
T.T. Lewis ,
C.T. Begeny ,
L. Yu ,
D.A. Bennett  and
R.S. Wilson
L.L. Barnes*
Affiliation:
Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago Illinois Department of Neurological Sciences, Rush University Medical Center, Chicago Illinois Department of Behavioral Sciences, Rush University Medical Center, Chicago Illinois
T.T. Lewis
Affiliation:
Department of Epidemiology & Public Health, Yale University School of Medicine, New Haven, Connecticut
C.T. Begeny
Affiliation:
Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago Illinois
L. Yu
Affiliation:
Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago Illinois Department of Neurological Sciences, Rush University Medical Center, Chicago Illinois
D.A. Bennett
Affiliation:
Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago Illinois Department of Neurological Sciences, Rush University Medical Center, Chicago Illinois
R.S. Wilson
Affiliation:
Rush Alzheimer's Disease Center, Rush University Medical Center, Chicago Illinois Department of Neurological Sciences, Rush University Medical Center, Chicago Illinois Department of Behavioral Sciences, Rush University Medical Center, Chicago Illinois
*
Correspondence and reprint requests to: Lisa L Barnes, Rush Alzheimer's Disease Center, Rush University Medical Center, Armour Academic Center, 600 S. Paulina, Suite 1038, Chicago, IL 60612. E-mail: [email protected]
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Abstract

Existing evidence suggests that psychosocial stress is associated with cognitive impairment in older adults. Perceived discrimination is a persistent stressor in African Americans that has been associated with several adverse mental and physical health outcomes. To our knowledge, the association of discrimination with cognition in older African Americans has not been examined. In a cohort of 407 older African Americans without dementia (mean age = 72.9; SD = 6.4), we found that a higher level of perceived discrimination was related to poorer cognitive test performance, particularly episodic memory (estimate = −0.03; SE = .013; p < .05) and perceptual speed tests (estimate = −0.04; SE = .015; p < .05). The associations were unchanged after adjusting for demographics and vascular risk factors, but were attenuated after adjustment for depressive symptoms (Episodic memory estimate = −0.02; SE = 0.01; Perceptual speed estimate = −0.03; SE = 0.02; both p's = .06). The association between discrimination and several cognitive domains was modified by level of neuroticism. The results suggest that perceived discrimination may be associated with poorer cognitive function, but does not appear to be independent of depressive symptoms. (JINS, 2012, 18, 1–10)

Keywords

African AmericanCognitive functionEpidemiologyPsychological stressDepressive symptomsCohort study
Type
Research Articles
Information
Journal of the International Neuropsychological Society , Volume 18 , Issue 5 , September 2012 , pp. 856 - 865
Copyright
Copyright © The International Neuropsychological Society 2012

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References

Albert, M., Smith, L.A., Scherr, P.A., Taylor, J.O., Evans, D.A., Funkenstein, H.H. (1991). Use of brief cognitive tests to identify individuals in the community with clinically diagnosed Alzheimer's disease. International Journal of Neuroscience, 57, 167–178.Google ScholarPubMed
Arvanitakis, Z., Bennett, D.A., Wilson, R.S., Barnes, L.L. (2010). Diabetes and cognitive systems in older black and white persons. Alzheimer Disease & Associated Disorders, 24, 37–42.CrossRefGoogle ScholarPubMed
Barnes, D.E., Alexopoulos, G.S., Lopez, O.L., Williamson, J.D., Yaffe, K. (2006). Depressive symptoms, vascular disease, and mild cognitive impairment: Findings from the Cardiovascular Health Study. Archives of General Psychiatry, 63, 273–279.CrossRefGoogle ScholarPubMed
Barnes, L.L., Mendes de Leon, C.F., Lewis, T.T., Bienias, J.L., Wilson, R.S., Evans, D.A. (2008). Perceived discrimination and mortality in a population-based study of older adults. American Journal of Public Health, 98, 1241–1247.CrossRefGoogle Scholar
Barnes, L.L., Mendes de Leon, C.F., Wilson, R.S., Bienias, J.L., Bennett, D.A., Evans, D.A. (2004). Racial differences in perceived discrimination in a community population of older blacks and whites. Journal of Aging and Health, 16, 315–337.CrossRefGoogle Scholar
Beckner, V.E., Tucker, D.M., Delville, Y., Mohr, D.C. (2006). Stress facilitates consolidation of verbal memory for a film but does not affect retrieval. Behavioral Neuroscience, 120, 518–527.CrossRefGoogle Scholar
Bennett, D.A., Schneider, J.A., Buchman, A.S., Mendes de Leon, C., Bienias, J.L., Wilson, R.S. (2005). The Rush Memory and Aging Project: Study design and baseline characteristics of the study cohort. Neuroepidemiology, 25, 163–175.CrossRefGoogle ScholarPubMed
Benton, A.L., Sivan, A.B., Hamsher, K.d., Varney, N.R., Spreen, O. (1994). Contributions to neuropsychological assessment. (2nd ed.) New York: Oxford University Press.Google Scholar
Boardman, J.D. (2004). Stress and physical health: The role of neighborhoods as mediating and moderating mechanisms. Social Science & Medicine, 58, 2473–2483.CrossRefGoogle ScholarPubMed
Borrell, L.N., Roux, A.V., Jacobs, D.R. Jr., Shea, S., Jackson, S.A., Shrager, S., Blumenthal, R.S. (2010). Perceived racial/ethnic discrimination, smoking and alcohol consumption in the Multi-Ethnic Study of Atherosclerosis (MESA). Preventive Medicine, 51, 307–312.CrossRefGoogle ScholarPubMed
Boyle, L.L., Lyness, J.M., Duberstein, P.R., Karuza, J., King, D.A., Messing, S., Tu, X. (2010). Trait neuroticism, depression, and cognitive function in older primary care patients. American Journal of Geriatric Psychiatry, 18, 305–312.CrossRefGoogle ScholarPubMed
Brickman, A.M., Cabo, R., Manly, J.J. (2006). Ethical issues in cross-cultural neuropsychology. Applied Neuropsychology, 13, 91–100.CrossRefGoogle ScholarPubMed
Brondolo, E., Gallo, L.C., Myers, H.F. (2009). Race, racism and health: Disparities, mechanisms, and interventions. Journal of Behavioral Medicine, 32, 1–8.CrossRefGoogle ScholarPubMed
Brondolo, E., Libby, D.J., Denton, E.G., Thompson, S., Beatty, D.L., Schwartz, J., Sweeney, M., Gerin, W. (2008). Racism and ambulatory blood pressure in a community sample. Psychosomatic Medicine, 70, 49–56.CrossRefGoogle Scholar
Brown, C., Matthews, K.A., Bromberger, J.T., Chang, Y. (2006). The relation between perceived unfair treatment and blood pressure in a racially/ethnically diverse sample of women. American Journal of Epidemiology, 164, 257–262.Google Scholar
Caswell, L.W., Vitaliano, P.P., Croyle, K.L., Scanlan, J.M., Zhang, J., Daruwala, A. (2003). Negative associations of chronic stress and cognitive performance in older adult spouse caregivers. Experimental Aging Research, 29, 303–318.CrossRefGoogle ScholarPubMed
Cooper, J.A., Sagar, H.J. (1993). Incidental and intentional recall in Parkinson's disease: An account based on diminished attentional resources. Journal of Clinical and Experimental Neuropsychology, 15, 713–731.Google ScholarPubMed
Costa, P.T., McCrae, R.R. (1992). Revised NEO Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI) professional manual. Odessa, FL: Psychological Assessment Resources.Google Scholar
De Jong, G.M., van Sonderen, E., Emmelkamp, P.M. (1999). A comprehensive model of stress. the roles of experienced stress and neuroticism in explaining the stress-distress relationship. Psychotherapy and Psychosomatics, 68, 290–298.CrossRefGoogle ScholarPubMed
Dotson, V.M., Kitner-Triolo, M.H., Evans, M.K., Zonderman, A.B. (2009). Effects of race and socioeconomic status on the relative influence of education and literacy on cognitive functioning. Journal of the International Neuropsychological Society, 15, 580–589.CrossRefGoogle ScholarPubMed
Ekstrom, R.B., French, J.W., Harman, H.H., Kermen, D. (1976). Manual for kit of factor-referenced cognitive tests. Princeton, NJ: Educational Testing Service.Google Scholar
Essed, P. (1991). Knowledge and resistance: Black women talk about racism in the Netherlands and the USA. Feminism & Psychology, 1, 201–219.CrossRefGoogle Scholar
Ewart, C.K., Suchday, S. (2002). Discovering how urban poverty and violence affect health: Development and validation of a Neighborhood Stress Index. Health Psychology, 21, 254–262.CrossRefGoogle ScholarPubMed
Folstein, M.F., Folstein, S.E., McHugh, P.R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.CrossRefGoogle ScholarPubMed
Gale, C.R., Martyn, C.N., Cooper, C. (1996). Cognitive impairment and mortality in a cohort of elderly people. British Medical Journal, 312, 608–611.CrossRefGoogle Scholar
Glymour, M.M., Manly, J.J. (2008). Lifecourse social conditions and racial and ethnic patterns of cognitive aging. Neuropsychology Review, 18, 223–254.CrossRefGoogle ScholarPubMed
Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A., Evans, D.A. (2003). Alzheimer disease in the US population: Prevalence estimates using the 2000 census. Archives of Neurology, 60, 1119–1122.CrossRefGoogle ScholarPubMed
James, B.D., Boyle, P.A., Buchman, A.S., Barnes, L.L., Bennett, D.A. (2011). Life space and risk of Alzheimer disease, mild cognitive impairment, and cognitive decline in old age. American Journal of Geriatric Psychiatry, 19, 961–969.CrossRefGoogle ScholarPubMed
Johnson, A.S., Flicker, L.J., Lichtenberg, P.A. (2006). Reading ability mediates the relationship between education and executive function tasks. Journal of the International Neuropsychological Society, 12, 64–71.CrossRefGoogle ScholarPubMed
Kaplan, E.F., Goodglass, H., Weintraub, S. (1983). The Boston Naming Test. Philadelphia: Lea & Febiger.Google Scholar
Karp, A., Kareholt, I., Qiu, C., Bellander, T., Winblad, B., Fratiglioni, L. (2004). Relation of education and occupation-based socioeconomic status to incident Alzheimer's disease. American Journal of Epidemiology, 159, 175–183.CrossRefGoogle ScholarPubMed
Kessler, R.C., Mickelson, K.D., Williams, D.R. (1999). The prevalence, distribution, and mental health correlates of perceived discrimination in the United States. Journal of Health and Social Behavior, 40, 208–230.CrossRefGoogle ScholarPubMed
Klarman, M.J. (2004). From Jim Crow to civil rights: The Supreme Court and the struggle for racial equality. New York: Oxford University Press.CrossRefGoogle Scholar
Knepp, M.M., Friedman, B.H. (2008). Cardiovascular activity during laboratory tasks in women with high and low worry. Biological Psychology, 79, 287–293.CrossRefGoogle ScholarPubMed
Kohout, F., Berkman, L., Evans, D., Cornoni-Huntley, J. (1993). Two shorter forms of the CES-D (Center for Epidemiological Studies Depression) depression symptoms index. Journal of Aging and Health, 5, 179–193.Google ScholarPubMed
Kuzma, E., Sattler, C., Toro, P., Schonknecht, P., Schroder, J. (2011). Premorbid personality traits and their course in mild cognitive impairment: Results from a prospective population-based study in Germany. Dementia and Geriatric Cognitive Disorders, 32, 171–177.CrossRefGoogle ScholarPubMed
Lee, S., Kawachi, I., Grodstein, F. (2004). Does caregiving stress affect cognitive function in older women? The Journal of Nervous and Mental Disease, 192, 51–57.CrossRefGoogle ScholarPubMed
Lewis, T.T., Aiello, A.E., Leurgans, S., Kelly, J., Barnes, L.L. (2010). Self-reported experiences of everyday discrimination are associated with elevated C-reactive protein levels in older African-American adults. Brain, Behavior, and Immunity, 24, 438–443.CrossRefGoogle ScholarPubMed
Lewis, T.T., Barnes, L.L., Bienias, J.L., Lackland, D.T., Evans, D.A., Mendes de Leon, C.F. (2009). Perceived discrimination and blood pressure in older African American and white adults. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 64, 1002–1008.CrossRefGoogle ScholarPubMed
Lewis, T.T., Everson-Rose, S.A., Powell, L.H., Matthews, K.A., Brown, C., Karavolos, K., Wesley, D. (2006). Chronic exposure to everyday discrimination and coronary artery calcification in African-American women: The SWAN Heart Study. Psychosomatic Medicine, 68, 362–368.CrossRefGoogle ScholarPubMed
Lewis, T.T., Kravitz, H.M., Janssen, I., Powell, L.H. (2011). Self-reported experiences of discrimination and visceral fat in middle-aged African-American and Caucasian women. American Journal of Epidemiology, 173, 1223–1231.CrossRefGoogle ScholarPubMed
Liston, C., McEwen, B.S., Casey, B.J. (2009). Psychosocial stress reversibly disrupts prefrontal processing and attentional control. Proceedings of the National Academy of Sciences of the United States of America, 106, 912–917.CrossRefGoogle ScholarPubMed
Luo, Y., Waite, L.J. (2005). The impact of childhood and adult SES on physical, mental, and cognitive well-being in later life. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60, S93–S101.CrossRefGoogle ScholarPubMed
Lupien, S.J., Maheu, F., Tu, M., Fiocco, A., Schramek, T.E. (2007). The effects of stress and stress hormones on human cognition: Implications for the field of brain and cognition. Brain and Cognition, 65, 209–237.CrossRefGoogle ScholarPubMed
Manly, J.J. (2006). Deconstructing race and ethnicity: Implications for measurement of health outcomes. Medical Care, 44, S10–S16.CrossRefGoogle ScholarPubMed
Manly, J.J., Byrd, D.A., Touradji, P., Stern, Y. (2004). Acculturation, reading level, and neuropsychological test performance among African American elders. Applied Neuropsychology, 11, 37–46.CrossRefGoogle ScholarPubMed
Manly, J.J., Jacobs, D.M., Touradji, P., Small, S.A., Stern, Y. (2002). Reading level attenuates differences in neuropsychological test performance between African American and White elders. Journal of the International Neuropsychological Society, 8, 341–348.CrossRefGoogle ScholarPubMed
Manly, J.J., Smith, C., Crystal, H.A., Richardson, J., Golub, E.T., Greenblatt, R., Young, M. (2011). Relationship of ethnicity, age, education, and reading level to speed and executive function among HIV+ and HIV− women: The Women's Interagency HIV Study (WIHS) neurocognitive substudy. Journal of Clinical and Experimental Neuropsychology, 33, 853–863.CrossRefGoogle ScholarPubMed
Manly, J.J., Touradji, P., Tang, M.X., Stern, Y. (2003). Literacy and memory decline among ethnically diverse elders. Journal of Clinical and Experimental Neuropsychology, 25, 680–690.CrossRefGoogle ScholarPubMed
Margarinos, A.M., Verdugo, J.M., McEwen, B.S. (1997). Chronic stress alters synaptic terminal structure in hippocampus. Proceedings of the National Academy of Sciences of the United States of America, 94, 14002–14008.CrossRefGoogle Scholar
Mays, V.M., Cochran, S.D., Barnes, N.W. (2007). Race, race-based discrimination, and health outcomes among African Americans. Annual Review of Psychology, 58, 201–225.CrossRefGoogle ScholarPubMed
McKhann, G., Drachman, D., Folstein, M., Katzman, R., Price, D., Stadlan, E.M. (1984). Clinical diagnosis of Alzheimer's disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology, 34, 939–944.CrossRefGoogle ScholarPubMed
Merz, C.J., Wolf, O.T., Hennig, J. (2010). Stress impairs retrieval of socially relevant information. Behavioral Neuroscience, 124, 288–293.CrossRefGoogle ScholarPubMed
Morris, J.C., Heyman, A., Mohs, R.C., Hughes, J.P., van Belle, G., Fillenbaum, G., Clark, C. (1989). The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part I. Clinical and neuropsychological assessment of Alzheimer's disease. Neurology, 39, 1159–1165.Google Scholar
Neupert, S.D., Mroczek, D.K., Spiro, A. (2008). Neuroticism moderates the daily relation between stressors and memory failures. Psychology and Aging, 23, 287–296.CrossRefGoogle ScholarPubMed
Ong, A.D., Fuller-Rowell, T., Burrow, A.L. (2009). Racial discrimination and the stress process. Journal of Personality and Social Psychology, 96, 1259–1271.CrossRefGoogle ScholarPubMed
Operario, D., Fiske, S.T. (2001). Ethnic identity moderates perceptions of prejudice: Judgments of personal versus group discrimination and subtle versus blatant bias. Personality and Social Psychology Bulletin, 27, 550–561.CrossRefGoogle Scholar
Orpana, H.M., Lemyre, L., Kelly, S. (2007). Do stressors explain the association between income and declines in self-rated health? A longitudinal analysis of the National Population Health Survey. International Journal of Behavioral Medicine, 14, 40–47.CrossRefGoogle Scholar
Paradies, Y. (2006). A systematic review of empirical research on self-reported racism and health. International Journal of Epidemiology, 35, 888–901.CrossRefGoogle ScholarPubMed
Park, H.L., O'Connell, J.E., Thomson, R.G. (2003). A systematic review of cognitive decline in the general elderly population. International Journal of Geriatric Psychiatry, 18, 1121–1134.CrossRefGoogle ScholarPubMed
Pearlin, L.I. (1989). The sociological study of stress. Journal of Health and Social Behavior, 30, 241–256.CrossRefGoogle ScholarPubMed
Pinel, E.C. (2002). Stigma consciousness: The psychological legacy of social stereotypes. Journal of Personality and Social Psychology, 76, 114–128.Google Scholar
Potvin, O., Forget, H., Grenier, S., Preville, M., Hudon, C. (2011). Anxiety, depression, and 1-year incident cognitive impairment in community-dwelling older adults. Journal of American Geriatrics Society, 59, 1421–1428.CrossRefGoogle ScholarPubMed
Radloff, L. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measure, 1, 385–401.CrossRefGoogle Scholar
Raven, J.C., Court, J.H., Raven, J. (1992). Manual for Raven's progressive matrices and vocabulary. (1992 ed.) Oxford: Oxford Psychologists Press.Google Scholar
Salvatore, J., Shelton, J.N. (2007). Cognitive costs of exposure to racial prejudice. Psychological Science, 18, 810–815.CrossRefGoogle ScholarPubMed
Satariano, W.A. (1997). The disabilities of aging--looking to the physical environment. American Journal of Public Health, 87, 331–332.CrossRefGoogle Scholar
Schulz, A.J., Gravlee, C.C., Williams, D.R., Israel, B.A., Mentz, G., Rowe, Z. (2006). Discrimination, symptoms of depression, and self-rated health among African American women in Detroit: Results from a longitudinal analysis. American Journal of Public Health, 96, 1265–1270.CrossRefGoogle ScholarPubMed
Sheffield, K.M., Peek, M.K. (2011). Changes in the prevalence of cognitive impairment among older Americans, 1993–2004: Overall trends and differences by race/ethnicity. American Journal of Epidemiology, 174, 274–283.CrossRefGoogle ScholarPubMed
Smith, A. (1982). Symbol Digit Modalities Test Manual-Revised. Los Angeles: Western Psychological Services.Google Scholar
Soetanto, A., Wilson, R.S., Talbot, K., Un, A., Schneider, J.A., Sobiesk, M., Arnold, S.E. (2010). Association of anxiety and depression with microtubule-associated protein 2- and synaptopodin-immunolabeled dendrite and spine densities in hippocampal CA3 of older humans. Archives of General Psychiatry, 67, 448–457.CrossRefGoogle ScholarPubMed
Stewart, M.G., Davies, H.A., Sandi, C., Kraev, I.V., Rogachevsky, V.V., Peddie, C.J., Popov, V.I. (2005). Stress suppresses and learning induces plasticity in CA3 of rat hippocampus: A three-dimensional ultrastructural study of thorny excrescences and their postsynaptic densities. Neuroscience, 131, 43–54.CrossRefGoogle ScholarPubMed
Taylor, T.R., Kamarck, T.W., Shiffman, S. (2004). Validation of the Detroit Area Study Discrimination Scale in a community sample of older African American adults: The Pittsburgh healthy heart project. International Journal of Behavioral Medicine, 11, 88–94.CrossRefGoogle Scholar
Trenerry, M.R., Crosson, B., DeBoe, J., Leber, W.R. (1989). Stroop Neuropsychological Screening Test Manual. Odessa, FL: Psychological Assessment Resources, Inc.Google Scholar
Troxel, W.M., Matthews, K.A., Bromberger, J.T., Sutton-Tyrrell, K. (2003). Chronic stress burden, discrimination, and subclinical carotid artery disease in African American and Caucasian women. Health Psychology, 22, 300–309.CrossRefGoogle ScholarPubMed
Watson, D., Pennebaker, J.W. (1989). Health complaints, stress, and distress: Exploring the central role of negative affectivity. Psychological Review, 96, 234–254.CrossRefGoogle ScholarPubMed
Wechsler, D. (1987). Wechsler Memory Scale-Revised manual. San Antonio, TX: Psychological Corporation.Google Scholar
Williams, D.R. (1997). Race and health: Basic questions, emerging directions. Annals of Epidemiology, 7, 322–333.CrossRefGoogle ScholarPubMed
Williams, D.R., Neighbors, H.W., Jackson, J.S. (2003). Racial/ethnic discrimination and health: Findings from community studies. American Journal of Public Health, 93, 200–208.Google ScholarPubMed
Williams, D.R., Williams-Morris, R. (2000). Racism and mental health: The African American experience. Ethnicity & Health, 5, 243–268.CrossRefGoogle ScholarPubMed
Williams, D.R., Yu, Y., Jackson, J.S., Anderson, N.B. (1997). Racial differences in physical and mental health: Socio-economic status, stress and discrimination. Journal of Health Psychology, 2, 335–351.CrossRefGoogle ScholarPubMed
Wilson, R.S., Barnes, L.L., Bennett, D.A. (2003). Assessment of lifetime participation in cognitively stimulating activities. Journal of Clinical & Experimental Neuropsychology, 25, 634–642.CrossRefGoogle ScholarPubMed
Wilson, R.S., Barnes, L.L., Kreuger, K.R., Hoganson, G., Bienias, J.L., Bennett, D.A. (2005). Early and late life cognitive activity and cognitive systems in old age. Journal of the International Neuropsychological Society, 11, 400–407.CrossRefGoogle ScholarPubMed
Wilson, R.S., Beckett, L.A., Barnes, L.L., Schneider, J.A., Bach, J., Evans, D.A., Bennett, D.A. (2002). Individual differences in rates of change in cognitive abilities of older persons. Psychology and Aging, 17, 179–193.CrossRefGoogle ScholarPubMed
Wilson, R.S., Begeny, C.T., Boyle, P.A., Schneider, J.A., Bennett, D.A. (2011). Vulnerability to stress, anxiety, and development of dementia in old age. American Journal of Geriatric Psychiatry, 19, 327–334.CrossRefGoogle ScholarPubMed
Wilson, R.S., Evans, D.A., Bienias, J.L., Mendes de Leon, C.F., Schneider, J.A., Bennett, D.A. (2003). Proneness to psychological distress is associated with risk of Alzheimer's disease. Neurology, 61, 1479–1485.CrossRefGoogle ScholarPubMed