Department of Psychiatry and Behavioural Science, Royal Free and University College Medical School, London
Haringey Healthcare NHS Trust, London
Camden and Islington NHS Community Trust, London
Department of Psychiatry and Behavioural Science, Royal Free and University College Medical School, London
Camden and Islington NHS Community Trust, London
Department of Psychiatry and Behavioural Science, Royal Free and University College Medical School, London
Correspondence: G. Livingston, Department of Psychiatry and Behavioural Sciences, Royal Free and University College Medical School, Wolfson Building, 48 Riding House Street, London WIN 8AA, UK. Tel: 020 7530 2309 ; Fax:020 7530 2304; e-mail: g.livingston{at}ucl.ac.uk
Declaration of interest This study was part funded by the Ethnic Health Unit, Department of Health.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To compare the prevalence of dementia and depression in older migrants with those born in the UK.
Method A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough.
Results Compared with those born in the UK, the prevalence of dementia was raised in AfricanCaribbeans (17.3%, relative risk=1.72, Cl=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36, Cl=0.17-0.87). All those of AfricanCaribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P<0.0000). The overall prevalence of depression was 18.3% (95% Cl=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, Cl=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population.
Conclusions The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The interview
We used the shortened version of the Comprehensive Assessment and Referral
Evaluation (Short-CARE; Gurland et
al, 1984) to elicit psychiatric symptoms and diagnoses. This
is a valid and reliable questionnaire for older people in the community. It
has diagnostic scales for depression and dementia and a scale for activity
limitation (designed to identify those who need help with day-to-day living).
The description of dementia has been validated against an outcome of
deteriorating cognition or death (Kay
et al, 1985). Validation has been completed
cross-nationally but not in specific ethnic groups.
We used the Client Sociodemographic and Service Receipt Inventory (CSSRI) amended for use in older people (Knapp, 1995). Items included gender, age, marital status, accommodation, self-designated ethnicity, country of birth, mother tongue, number of years of education, level of schooling and provision of services in the past 3 months. To classify ethnicity, the interviewers showed the list of ethnic classification in the 1991 census and asked which best described the participant.
In addition, we asked "Do you have any health problems?" as a screening question for subjective health problems. If the answer was "yes", a further question was asked: "Can you tell me what they are?". The answers were noted and a nurse or doctor categorised for analysis (e.g. cardiovascular, diabetic, psychiatric). The interviewer asked whether respondents had drunk alcohol in the past 6 months. If so, a second stage-screening questionnaire was completed (Luttrell et al, 1997). Present and past smoking habits were recorded.
Analysis
In order to increase statistical power we grouped country of birth (COB)
into six categories: UK, Ireland, Greece/Turkey/Cyprus (Cyprus), other
European country, Africa/Caribbean and others. We calculated prevalence,
relative risk (RR) and 95% confidence intervals (CI) of morbidity. We used
2 analysis to test for significant associations in categorical
data and the MannWhitney test for associations between ordinal and
categorical variables. We carried out a post hoc analysis of known
risk factors for depression or dementia to test for difference. Logistic
regression analysis was used to identify significant independent predictors of
depression and dementia. For both analyses we entered: living in residential
accommodation; age; years of education (divided at median); gender; English as
first tongue; owner-occupation; and having drunk alcohol in the past 6 months.
For dementia we entered: African/Caribbean and Irish COB; diabetes; current
smoker; cardiovascular drugs; and self-reported cardiovascular ill health. For
depression we entered: Cyprus COB; living alone; subjective health problems;
and needing help in the activities of daily living (ADL).
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Ethnicity and country of origin
Ethnicity and COB are given in Table
1. Respondents were born in 50 countries. Ninety-three (94.9%)
people born in Africa/Caribbean were Black. Five people declined to designate
an ethnicity. We found only a minor difference between respondents' COB and
ethnic group. In order to avoid repetition, the following analyses present
only COB data.
|
Compared with the UK-born group, all of the migrant groups were significantly younger, particularly AfricanCaribbeans (Table 2). We found no difference in housing tenure (owner-occupied dwellings) between the UK-born, Irish and AfricanCaribbeans. All non-UK-born groups were significantly less likely to speak English as a first language. Those born in Ireland, Europe and particularly Cyprus had significantly fewer years of education. However, the Cypriot, European and other groups were significantly more likely to be home-owners. The Cypriot and Europe-born groups also were much less likely than the UK-born group to be living alone. Diabetes was recorded for 10.3% of the whole population. Significantly higher rates were found in the Cypriot group (24.3%) and in the AfricanCaribbeans (33.7%) (Table 3). We found little difference between groups in recorded use of cardiovascular medication, current smoking and drinking alcohol (Table 3). The Cypriot group was less likely to report alcohol consumption in the previous 6 months (Table 3). Of those interviewed, 46.5% had given up smoking. The Cypriots (28.2%, P=0.001) and AfricanCaribbeans (24.5%, P=0.00001) were less likely to have given up smoking than the UK-born (48.5%).
|
|
Dementia and country of birth
The prevalence of dementia and relative risk of each migrant group compared
with the UK-born is given in Table
4. We found no association between migration per se and
dementia (10% UK v. 9.6% migrants). However, in comparison with
UK-born subjects we found statistically significant differences in two migrant
groups: the prevalence of dementia was higher in the African-Caribbeans and
lower in the Irish (Table
4).
|
In logistic regression analysis the significant independent predictors of dementia were: living in residential accommodation (OR=3.2, CI=2.44-4.30, P<0.0001); age (OR=1.1, CI=1.06-1.14, P<0.0001); African-Caribbean (OR=3.6, CI=1.43-9.16, P<0.007); and years of education (OR=0.6, CI=0.32-0.98, P<0.04). COB Ireland was no longer a predictor when other factors were corrected.
Depression
A total of 18.3% of the population had a diagnosis of depression. Women
(22.5%) were more likely than men (12.2%) to have depression (OR=2.08, 95%
CI=1.46-2.99, P=0.00002). A higher proportion of widowed (23%) and
separated/divorced (21.6%) respondents had depression than those who were
single (13%) or married/cohabiting (14.6%) (single and married v. the
rest: 14% v. 23%, OR=1.8, CI=1.3-2.5, P<0.001).
There was no significant difference overall according to COB or between the rates of depression in those born in the UK compared with others. The Cypriots alone of the migrant groups had a significantly raised rate of depression (28.2% v. 18.0%). No one from Cyprus spoke English as a first language. Those born in Cyprus were significantly more likely to have self-reported physical health difficulties (94.4% v. 86.2%) but were no more likely to have limitations in ADL.
Using a forward stepwise logistic regression the significant independent predictors of depression were: needing help with ADL (OR=3.0, CI=2.11-4.26, P<0.0000); being female (OR=2.0, CI=1.41-3.0, P=0.002); subjective ill-health (OR=2.3, CI=1.5-4.52, P=0.02).
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Limitations
The definition of race and ethnicity as variables in epidemiological
research is contentious (Bhopal,
1997). To avoid the problems of misclassification we have tried to
make this process as transparent as possible. Community-based studies such as
ours, carried out in an inner-city area, will invariably include a complex
constellation of migrant and minority ethnic groups. Statistical power in
relatively small samples often is achieved by combining groups, with some loss
of precision. In this study we attempted to balance this by collecting both
self-assessed ethnicity and COB and then assigning migrants to the most
appropriate category. For example, a small number of Irish-born people gave
their self-assigned ethnicity as British but were grouped as Irish migrants.
The COB categories that we have chosen reflect as tightly as possible
geographical region, cultural similarity and generally perceived group
identity. In the analysis, we found only minor differences between the choice
of ethnicity or COB as the explanatory variable. We chose not to examine only
the simple dichotomy of migrant status because this might mask important
putative differences between migrant groups. Most of our interviewees spoke
good English. We attempted to interview those who did not (n=28) by
using their families as interpreters. We were unable to interview 15 people
because they did not speak enough English.
Despite African-Caribbean migrants being significantly younger with relatively few residents in residential accommodation, we found that they had a significantly raised prevalence of dementia compared with UK-born and other minority groups. This excess remained when we excluded the small number of people from Africa and the Caribbean who were Asian or White.
Cross-cultural assessment of dementia in older people has particular pitfalls related to language and literacy skills, particularly the use of culturally biased screening instruments that rely on language recognition and familiarity with test situations in people with cognitive impairment (Lindesay, 1998). In this study, the findings do not appear to arise either through language or literacy difficulties. When known risk factors for various types of dementia are considered, being born in Africa/Caribbean and migrating remains a significant independent predictor of dementia.
African-Caribbeans
The excess of hypertension in the African-Caribbean population in the West
is well-documented (Cooper & Rotimi,
1997), as is an increased mortality in this group from
cerebrovascular disease (Wild &
McKeigue, 1997). We did not complete a diagnostic assessment in
this part of the study and therefore cannot subtype the dementias. It seems
reasonable to speculate, however, in this relatively young population with an
excess of diabetes and high risk of cerebrovascular disease, that many of the
dementias may be vascular contributions. Despite the known excess of
hypertension in this population, there was not a significant increase, in our
population, of Black older people who reported that they had cardiovascular
illness or who were taking antihyptertensive medication. This suggests that,
despite the excess of morbidity and mortality in this group, hypertension in
Black people is insufficiently detected or treated. Energetic screening and
treatment of this high-risk population for hypertension and associated risks
of diabetes, obesity and smoking has the potential to prevent some of these
vascular dementias. This is important because of individual disability and
suffering, the lack of ability to reverse vascular dementias, the effect on
carers (Livingston et al,
1996) and the economic consequences of dementia
(Livingston et al,
1997). More research is required not only to clarify the subtypes
of dementia in this population but also to find out more about appropriate and
effective ways of implementing preventative strategies.
A much lower proportion of people born in Africa/Caribbean than their counterparts had given up smoking, suggesting that the communication of public health messages is unsatisfactory. Black patients perceive racial discrimination in health care (Hutchinson & Gilvarry, 1998). Thus the number of consultations in general practice by Black elders is higher than their White counterparts (Blakemore, 1982; Barker, 1994), yet referral to secondary health care and social services of ethnic elders is less than the indigenous population (Manthorpe & Hettiaratchy, 1993; Barker, 1994; Shah & Dighe-Deo, 1997).
We were unable to show that minority ethnic (or migrant) status in itself constitutes a risk factor for depression. Depression, however, may present with different patterns of symptoms in different cultures. The language of distress used by African Americans differs from that on which structured diagnoses are made and may lead to an underestimate of levels of distress and anxiety (Heurtin-Roberts et al, 1997). When screening for depression in older people, lower cutpoints have been found to be appropriate for older Black people living in the UK (Abas et al, 1998). This may account for the apparent low prevalence of depression, in our study, in those born in Africa or the Caribbean.
Greek Cypriots
The Cypriot (predominantly Greek Cypriot) group appears to be the only
migrant group at higher risk for depression, despite the absence of known risk
factors for depression, such as living alone, loss of partner and being
female. The associates of vulnerability in this group appear to be fewer years
of education, subjective and objective ill health and lack of English as a
first language. They may experience greater isolation and be less able to
access appropriate treatment. More work is required to understand the factors
related to depression in this group.
Clinical implications
Ethnicity and migrant status are not in themselves predictors of dementia
or depression in older people. Despite being significantly younger, people of
Africa/Caribbean COB were much more likely to have dementia and neither
education nor language appeared to account for this. It is likely that this is
due to vascular risk factors. With energetic treatment there is the potential
for primary or secondary prevention of such dementia.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Acheson, D. (1998) Independent Inquiry into Inequalities in Health Report. London: HMSO.
Barker, J. (1994) Research Perspectives on Ageing: Black and Asian Old People in Britain. London: Age Concern Research Unit.
Bhatagner, K. & Frank, J. (1997) Psychiatric disorders in elderly from the Indian subcontinent living in Bradford. International Journal of Geriatric Psychiatry, 12, 907 -912.[CrossRef][Medline]
Bhopal, R. (1997) Is research into ethnicity
and health racist, unsound, or important science? BMJ,
314, 1751.
Blakemore, K. (1982) Health and illness among the elderly of minority ethnic groups living in Birmingham: some new findings. Health Trends, 14, 69 -72.[Medline]
Blazer, D. G., Landerman, L. R., Hays, J. C., et al (1998) Symptoms of depression among community dwelling elderly African-American and white older adults. Psychological Medicine, 28, 1311 -1320.[CrossRef][Medline]
Cochrane, R. & Bal, S. S. (1989) Mental hospital admission rates of immigrants to England: a comparison of 1971 and 1981. Social Psychiatry and Psychiatric Epidemiology, 24, 2-11.[Medline]
Cooper, R. & Rotimi, C. (1997) Hypertension in blacks. American Journal of Hypertension, 10, 804 -812.[CrossRef][Medline]
Ebrahim, S., Patel, N., Coats, M., et al (1991) Prevalence and severe morbidity among Gujarati Asian elders: a controlled comparison. Family Practice, 1, 57-61.
Gurland, B., Golden, R., Teresi, J. A., et al (1984) The Short-CARE. An efficient instrument for the assessment of depression and dementia. Journal of Gerontology, 39, 166 -169.[Medline]
Hendrie, H. C., Osuntokun, B. O., Hall, K. S., et al (1995) Prevalence of Alzheimer's disease and dementia in two communities: Nigerian Africans and African Americans. American Journal of Psychiatry, 152, 1485 -1491.[Abstract]
Heurtin-Roberts, S., Snowden, L. & Miller, L. (1997) Expressions of anxiety in African-Americans: ethnography and the epidemiological catchment area studies. Culture, Medicine and Psychiatry, 21, 337 -363.[CrossRef]
Heyman, A., Fillenbaum, G., Prosnitz, B., et al (1991) Estimated prevalence of dementia among elderly black and white community residents. Archives of Neurology, 48, 594 -598.[Abstract]
Hutchinson. G. & Gilvarry, C. (1998) Ethnicity and dissatisfaction with mental health services. British Journal of Psychiatry, 172, 95 -96.
Jarman, B. (1983) Identification of underprivileged areas. BMJ, 286, 1705 -1709.[Medline]
Kay, D. W., Henderson, A. S., Scott, R., et al (1985) Dementia and depression among the elderly living in the Hobart community: the effect of the diagnostic criteria on the prevalence rate. Psychological Medicine, 15, 771 -778.[Medline]
Knapp, M. (1985) The Economic Evaluation of Mental Health Care. Aldershot: Arena.
Leavey, G. (1999) Suicide and Irish migrants in Britain: identity and integration. International Review of Psychiatry, 11, 168 -172.[CrossRef]
Lindesay, J. (1998) Diagnosis of mental illness in elderly people from ethnic minorities. Advances in Psychiatric Treatment, 4, 219 -226.
Livingston, G., Manela, M. & Katona, C.
(1996) Depression and other psychiatric morbidity in the
carers of elderly people. BMJ,
312, 153
-156.
Livingston, G., Manela, M. & Katona, C. (1997) Cost of community care for elderly people. British Journal of Psychiatry. 171, 56-59.[Abstract]
Luttrell, S., Watkin, V., Livingston, G., et al (1997) Screening for excessive alcohol consumption in older people. International Journal of Geriatric Psychiatry. 12, 1151 -1154.[CrossRef][Medline]
Manthorpe, J. & Hettiaratchy, P. (1993) Ethnic minority elders in the U.K. International Review of Psychiatry, 5, 171 -178.
McCracken, C. F., Boneham, M. A., Copeland, J. R., et al (1997) Prevalence of dementia and depression among elderly people in Black and ethnic minorities. British Journal of Psychiatry, 171, 269 -273.[Abstract]
Murrell, S. A., Himmelfarb, S. & Wright, K. (1993) Prevalence of depression and its correlates in older adults. American Journal of Epidemiology, 117, 173 -185.[Abstract]
Office of Population Censuses and Surveys (1991) Census Ethnic Group and Country of Birth. London: Office of Population Censuses and Surveys.
Perkins, P., Annegers, J. F., Doody, R. S., et al (1997) Incidence and prevalence of dementia in a multiethnic cohort of municipal retirees. Neurology, 49, 44-50.[Abstract]
Rait, G., Burns, A. & Chew, C. (1996) Age,
ethnicity and mental illness: a triple whammy. BMJ,
313, 1347.
Richards, M., Brayne, C., Dening, T., et al (2000) Cognitive function in UK community-dwelling African Caribbean and white elders: a pilot study. International Journal of Geriatric Psychiatry, 15, 621 -630.[CrossRef][Medline]
Shah, A. K. & Dighe-Deo, D. (1997) Elderly Gujaratis and psychogeriatrics in a London Psychogeriatric Service. Bulletin of the International Psychogeriatric Association, 14, 12 -13.
Silveira, E. R. T. & Ebrahim, S. (1995) Mental health and the health status of elderly Bengalis and Somalis in London. Age and Ageing, 24, 474 -480.[Abstract]
Silveira, E. R. T. & Ebrahim, S. (1998) A comparison of mental health among ethnic minority elders and whites in East and North London. Age and Ageing, 27, 375 -383.[Abstract]
Wild, S. & McKeigue, P. (1997)
Cross-sectional analysis of mortality by country of birth in England and
Wales, 1970-92. BMJ,
314, 705
-710.
Received for publication December 22, 2000. Revision received May 21, 2001. Accepted for publication May 23, 2001.