CGPR: How does the diagnosis of Alzheimer’s disease (AD) vary among underprivileged populations?

Dr. Pérez Palmer: It’s well established that certain underprivileged populations have a disproportionately high prevalence of AD, like Black and Hispanic populations. Black people have twice the chance of having AD, and Hispanics are one and a half times more likely to be diagnosed with AD compared to White people (Lim AC et al, Commun Med (Lond) 2023;3(1):101). Prevalence also varies by subgroup. For example, Hispanic or Latino folks in the Caribbean have a higher rate of AD compared to other Hispanic groups (Vega IE et al, J Alzheimers Dis 2017;58(4):979–992). 

CGPR: Clinicians may wonder whether this is a factor of race and ethnicity. Are these biological constructs or social constructs? 

Dr. Pérez Palmer: Race and ethnicity are social ­constructs—the first mention of classifying people as Black and Hispanic comes from the census. When it was first established, it didn’t have any biological underpinnings. There’s a study that says that APOE4 genes have a higher chance of causing AD in White people compared to other races or ethnic groups (Powell DS et al, Front Neurol 2021;12:735036). But that does not explain the large difference in rates of AD diagnosis between racial and ethnic groups, which is due to the social determinants of health. 

CGPR: How so?

Dr. Pérez Palmer: It has a lot to do with structural racism. A person’s color and language determine where they can live, the quality of their schools or communities, and their exposure to toxins, pollutants, or violence. This extends to health care. When studies control for these socioeconomic factors, the difference in rates of AD diagnosis between racial and ethnic groups decreases significantly; in some studies, it disappears completely (Weiss J et al, Alzheimers Dement 2023;19(1):4299–4310). That’s very telling. 

CGPR: Among socioeconomic factors, which ones stand out?

Dr. Pérez Palmer: Education has a large effect. When researchers controlled for education, disparities were reduced by half (Liu C et al, Soc Sci Med 2022;312:115347). There’s also diet, smoking habits, physical activity, and language. Language is so important. We did a retrospective study at the biggest health provider in New Haven that looked at timeliness of diagnosis of dementia or mild cognitive impairment (MCI) in people who identified as Spanish speakers versus English speakers. We found that Spanish speakers were disproportionately diagnosed with dementia rather than MCI (Silva-Rudberg JA et al, Am J Geriatr Psychiatry 2024;S1064-7481(24)00041-1). This causes problems when it comes to accessing treatment—for example, patients need to be in the MCI range or have mild dementia to receive lecanemab. 

CGPR: Psychiatrists generally recommend controlling vascular risk factors in all patients, but societal factors play a large role. What advice do you have for clinicians to control vascular factors, beyond education and monitoring?

Dr. Pérez Palmer: High blood pressure may contribute to a higher prevalence of dementia in Black and Hispanic communities (Nagar SD et al, Sci Rep 2022;12(1):19797). However, we usually fail to tailor our education and behavioral interventions to the specific cultural context of the individual. General recommendations for preventing or controlling high blood pressure have been around for decades, but they are mostly based on research conducted with predominantly White groups, making them more applicable to that specific population. Using these recommendations for communities with different cultural and social backgrounds can prove ineffective. Explore the meaning of illness and wellness for your patient. When thinking about prevention or treatment of cardiovascular disease, questions like, “What do you think caused the problem?” can go a long way in building trust. You can also ask questions like, “What worries you the most about what’s happening now?” or, “What treatment do you think you should receive?” Look at the patient’s social context, including their social supports and previous experiences in the health system. Assess what resources they have available for change. Exercise is so important for cardiovascular disease. But before telling a patient to go to a gym, think about whether they can afford to do so.

CGPR: What alternatives might we suggest to patients with fewer resources that are more culturally or socioeconomically sensitive?

Dr. Pérez Palmer: If cost is an issue, optimize free activities like brisk walking or swimming in the community pool. In one study, community-based strategies tailored for Hispanic cohorts like planned walking groups, a culturally tailored aerobic dance program, and dance as an exercise all resulted in improved physical activity (Ickes MJ and Sharma M, J Environ Public Health 2012;2012:156435).

CGPR: How can clinicians build trust among underrepresented communities?

Dr. Pérez Palmer: A recent study looked at a large outreach program in the Los Angeles area to understand how trust is built in communities (Lansing AE et al, BMC Public Health 2023;23(1):1252). They found two important components: 1) building relationships and engagement and 2) embodying core values of trustworthiness. Looking specifically at what is most effective in building trust, they found that embodying benevolence is crucial—making yourself available and being an agent of helping, versus establishing yourself as master in the area. For example, you can explain that psychiatry is not an exact science: Just like a ship’s heading may need to be altered if the first route proves unsuccessful, our treatments (eg, medications, psychotherapy) will also evolve and change if they are ineffective, and the key to reaching the destination is to always communicate with each other. The study’s researchers also found that you can harness trust if you trust other people first. Additionally, creating a safe space where patients can have conversations goes a long way in building trust. 

CGPR: Can you say more about creating a safe space?

Dr. Pérez Palmer: This is where having “cultural competimility” (ie, cultural competence and humility) goes a long way. There are many things you can incorporate into your practice to tailor the experience to an individual’s particular background and comfort level. It starts with being curious and respectful. I find it useful to bring up comfort with every patient from the outset. I use a statement like, “It is myresponsibility to make sure that you are comfortable and safe to express yourself. Is there anything I can change about this space that would help achieve this? What about the way our staff and I interact with you? As we get to know each other, please feel comfortable in letting me know when I say or do something that you don’t like. You are a unique individual, and one of the ways for me to get to know you is to ask questions. I will do my best to gauge if a question or comment I make produces an unwanted response in you, but that will only take us half of the way. The other half is you letting me know.”

CGPR: What have you found to work best in establishing trust in the Hispanic population whom you work with?

Dr. Pérez Palmer: Be aware of mistrust due to racism. Be honest, authentic, and personal. The personal aspect is so important—I’ve found that many of my Hispanic patients prefer to talk face-to-face. You must have that personal connection. You have to meet the person and interact with them. Empathic listening is important, as is having bidirectional and mutual conversations, which is a sign of respect. I have also noticed benefit to demonstrating vulnerability. Being a doctor carries a lot of respect in our community. By showing vulnerability, showing that we make mistakes, this levels the playing field and helps build trust. 

CGPR: What helps in improving cross-cultural care of older adults with dementia?

Dr. Pérez Palmer: Especially in patients with dementia, it’s important to build a relationship with your patient’s supports based on respect, empathy, and curiosity. In the early stages of dementia, you want to understand your patient’s preferences for decision making, including family involvement. Collaboration is essential; you are making decisions together, not for them, and sometimes this means agreeing to disagree. Consider the services available to the patient and their supports, such as use of their preferred language. Cultural factors significantly influence family involvement in caregiving. For example, I’ve had several Latino/Hispanic patients with dementia whose families experience caregiver burden, especially when the patient requires 24/7 supervision. However, these families often resist increased care or support due to a strong emotional attachment to family and a clear hierarchical family structure, also known as “familismo.” It comes with the expectation for children to take care of their parents—seeking placement for a loved one can be seen as abandonment. For these patients, I’ve found that adult day programs help alleviate caregiver burden while respecting cultural values, as they allow the person with dementia to spend most of the day with trained professionals and then return home in the afternoon. 

CGPR: Can you tell us more about using a patient’s preferred language? Many patients say they are fine with English, which can be misleading.

Dr. Pérez Palmer: Yes, some Hispanic people may say so out of respect, to avoid burdening the doctor, or because of pride or embarrassment. We want to use interpreters when needed, and it’s on us to remember to use them. If you struggle to understand your patient, if you notice pauses when explaining something, or if a patient is unable to teach back, these signs can point you toward using an interpreter. This extends to both verbal and written information. You want language to be both culturally and linguistically appropriate and to meet the literacy needs of your patient. Explaining that it is you (the clinician) who needs the interpreter to effectively do your job is a good place to start. You can also work with your organization’s interpreter service to prepare and offer written information, in the appropriate language, that describes the benefits of using an interpreter. Lastly, remind the patient that it is your or your institution’s policy to use interpreters when needed.

CGPR: What tips do you have on approaching the discussion of dementia when families are in denial?

Dr. Pérez Palmer: Educate the patient, family, and supports. An interesting study looked at Hispanic patients and their caregivers with a Caribbean background. When asked about their perception of dementia and its course, researchers found that most subjects thought that dementia was a natural part of aging (Azar M et al, Alzheimer Dis Assoc Disord 2017;31(4):328–334). This was because they didn’t have access to the right information—they never learned about the difference between normal aging and dementia. You want to give patients a baseline understanding of normal aging and its course: “You may have some trouble remembering words, but you’re going to remember them eventually.” I recommend being very practical and using examples. I talk about the domains that usually remain stable as we age. In normal aging, patients should be able to remember the details of an event when given yes-or-no questions, or to continue using well-practiced skills such as riding a bike. Also, they should be able to remember the sequence of recent events, like that they went to the grocery store before watching a movie last Friday.

CGPR: What steps can clinicians take to improve diversity in the geriatric psychiatry workforce?

Dr. Pérez Palmer: Having a diverse workforce is good for patients, and it’s a learning experience for clinicians too. We should look at recruiting, and then retention. For example, we need to have structural opportunities or mentorships available. If you look at psychiatry residencies in the nation, fewer than 10% of incoming residents come from underrepresented groups (Hubbard A et al, Psychiatr Clin North Am 2022;45(2):283–295). There are numerous barriers, including financial burden and a lack of representation. 

CGPR: Tell us more about the benefits of having a diverse workforce.

Dr. Pérez Palmer: Having a similar background can help patients seek care, follow the plan, and stay involved in treatment. Sharing nuances of a cultural context is something that is very hard to learn if you have not been raised in the same social context. If a clinician understands the barriers—what being a Latino person entails, for example—they can understand the patient better. Additionally, language may be a limitation to how patients express themselves. When patients see someone who looks and speaks like they do, who understands what they’re trying to convey, it drives change. 

CGPR: What resources are there for people of underrepresented groups living with dementia and their caregivers?

Dr. Pérez Palmer: I always recommend the Alzheimer’s Association (www.alz.org). They have extensive resources, both at a local and national level. These include educational resources and support groups that patients can attend virtually. However, in these populations, resources should be available in the community because that’s what people are looking for. On the association’s website, you can find resources specifically for LGBTQIA+ communities: There’s the GLMA (www.glma.org), and you have a directory of clinicians who specialize in helping this specific population. Additionally, the FDA’s website offers educational, printable information for patients and caregivers at www.tinyurl.com/rjhnj4w6.

CGPR: How can clinicians learn more about communicating with older adults from other backgrounds or cultures?

Dr. Pérez Palmer: In the VA, there are many trainings on diversity, especially around helping older adults and people with dementia. The American Psychiatric Association has resources for educational purposes on cultural humility, divided among ethnic and racial groups. Additionally, the Administration for Community Living’s website has a curated list of educational resources for clinicians on diversity and cultural competency: www.tinyurl.com/bdh6n78j. The NIH’s National Institute on Aging covers several important dimensions of caring for a diverse older population and offers tips and resources on providing culturally sensitive care: www.tinyurl.com/yzh9wjmy.

CGPR: Thank you for your time, Dr. Pérez Palmer.