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Table 1. 
Cohort Characteristics
Cohort Characteristics
Table 2. 
Age at Onset
Age at Onset
Table 3. 
Potential Confounders
Potential Confounders
1.
US Census Bureau QT-P6, Race Alone or in Combination and Hispanic or Latino: 2000 Data Set.  Washington, DC: US Census Bureau; 2003. Census 2000 Summary File 1 (SF 1) 100-Percent Data
2.
US Census Bureau National Population Projections II: Detailed Files: Total Population by Age, Sex, Race, Hispanic Origin, and Nativity.  Washington, DC: US Census Bureau; 2003
3.
US Census Bureau The Older Population in the United States: March 2002 Detailed Tables.  Washington, DC: US Census Bureau; 2002
4.
Gurland  BJWilder  DELantigua  R  et al.  Rates of dementia in three ethnoracial groups. Int J Geriatr Psychiatry 1999;14481- 493
PubMedArticle
5.
Tang  MXCross  PAndrews  H  et al.  Incidence of AD in African-Americans, Caribbean Hispanics, and Caucasians in northern Manhattan. Neurology 2001;5649- 56
PubMedArticle
6.
Tang  MXStern  YMarder  K  et al.  The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. JAMA 1998;279751- 755
PubMedArticle
7.
Perkins  PAnnegers  JFDoody  RSCooke  NAday  LVernon  SW Incidence and prevalence of dementia in a multiethnic cohort of municipal retirees. Neurology 1997;4944- 50
PubMedArticle
8.
Cohen  CIMagai  C Racial differences in neuropsychiatric symptoms among dementia outpatients. Am J Geriatr Psychiatry 1999;757- 63
PubMedArticle
9.
Harwood  DGBarker  WWOwnby  RL Depressive symptoms in Alzheimer's disease: a cross-ethnic comparison of Cuban-American and white non-Hispanic patients.  In: Vellas  B, Fitten  J, Frisoni  G, eds. Research and Practice in Alzheimer's Disease. Paris, France: Serdi; 1998:163-172
10.
Falcon  LMTucker  KL Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts. J Gerontol B Psychol Sci Soc Sci 2000;55S108- S116Article
11.
Green  RCCupples  LAKurz  A  et al.  Depression as a risk factor for Alzheimer disease: the MIRAGE Study. Arch Neurol 2003;60753- 759
PubMedArticle
12.
Farrer  LACupples  LAHaines  JL  et al.  Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease: a meta-analysis: APOE and Alzheimer Disease Meta Analysis Consortium. JAMA 1997;2781349- 1356
PubMedArticle
13.
Maestre  GOttman  RStern  Y  et al.  Apolipoprotein E and Alzheimer's disease: ethnic variation in genotypic risks. Ann Neurol 1995;37254- 259
PubMedArticle
14.
Mayeux  RStern  YOttman  R  et al.  The apolipoprotein epsilon 4 allele in patients with Alzheimer's disease. Ann Neurol 1993;34752- 754
PubMedArticle
15.
Duara  RBarker  WWLopez-Alberola  R  et al.  Alzheimer's disease: interaction of apolipoprotein E genotype, family history of dementia, gender, education, ethnicity, and age of onset. Neurology 1996;461575- 1579
PubMedArticle
16.
Sevush  SPeruyera  GCrawford  FMullan  M Apolipoprotein-E epsilon 4 allele frequency and conferred risk for Cuban Americans with Alzheimer's disease. Am J Geriatr Psychiatry 2000;8254- 256
PubMed
17.
Harwood  DGBarker  WWLoewenstein  DA  et al.  A cross-ethnic analysis of risk factors for AD in white Hispanics and white non-Hispanics. Neurology 1999;52551- 556
PubMedArticle
18.
Romas  SNSantana  VWilliamson  J  et al.  Familial Alzheimer disease among Caribbean Hispanics: a reexamination of its association with APOE. Arch Neurol 2002;5987- 91
PubMedArticle
19.
Minagar  ASevush  SBertran  A Cerebral ventricles are smaller in Hispanic than non-Hispanic patients with Alzheimer's disease. Neurology 2000;55446- 448
PubMedArticle
20.
Chiodo  LKKanten  DNGerety  MBMulrow  CDCornell  JE Functional status of Mexican American nursing home residents. J Am Geriatr Soc 1994;42293- 296
PubMed
21.
Espino  DVLewis  R Dementia in older minority populations. Issues of prevalence, diagnosis, and treatment. Am J Geriatr Psychiatry 1998;6(suppl 1)S19- S25
PubMedArticle
22.
Stricks  LPittman  JJacobs  DMSano  MStern  Y Normative data for a brief neuropsychological battery administered to English- and Spanish-speaking community-dwelling elders. J Int Neuropsychol Soc 1998;4311- 318
PubMed
23.
Lacayo  CG A National Study to Assess the Service of the Hispanic Elderly.  Los Angeles, Calif: Asociacion Nacional por Personas Mayores; 1980
24.
US Census Bureau Educational Attainment in the United States: March 2002 Detailed Tables.  Washington, DC: US Census Bureau; 2003
25.
Sano  MDevanand  DPRichards  M  et al.  A standardized technique for establishing onset and duration of symptoms of Alzheimer's disease. Arch Neurol 1995;52961- 966
PubMedArticle
26.
McKhann  GDrachman  DFolstein  MKatzman  RPrice  DStadlan  EM 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 1984;34939- 944
PubMedArticle
27.
Morris  JCMohs  RCRogers  HFillenbaum  GHeyman  A Consortium to establish a registry for Alzheimer's disease (CERAD) clinical and neuropsychological assessment of Alzheimer's disease. Psychopharmacol Bull 1988;24641- 652
PubMed
28.
Cummings  JL The Neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology 1997;48(suppl 6)S10- S16
PubMedArticle
29.
Vilalta-Franch  JLozano-Gallego  MHernandez-Ferrandiz  MLlinas-Regla  JLopez-Pousa  SLopez  OL The Neuropsychiatric Inventory: psychometric properties of its adaptation into Spanish. Rev Neurol 1999;2915- 19
PubMed
30.
Clark  CMEwbank  DC Performance of the dementia severity rating scale: a caregiver questionnaire for rating severity in Alzheimer disease. Alzheimer Dis Assoc Disord 1996;1031- 39
PubMed
31.
Marin  GSabogal  FMarin  BVOtero-Sabogal  RPerez-Stable  EJ Development of a short acculturation scale for Hispanics. Hisp J Behav Sci 1987;9183- 205Article
32.
Folstein  MFFolstein  SEMcHugh  PR “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12189- 198
PubMedArticle
33.
Ardila  ARosselli  MPuente  A Neuropsychological Evaluation of the Spanish Speaker.  New York, NY: Plenum Press; 1994
34.
Sheikh  JIYesavage  JA Geriatric Depression Scale (GDS): recent evidence and development of a shorter version.  In: Brink  TL, ed. Clinical Gerontology: A Guide to Assessment and Intervention. New York, NY: Haworth Press; 1986:165-173
35.
Baker  FMEspino  DV A Spanish version of the geriatric depression scale in Mexican-American elders. Int J Geriatr Psychiatry 1997;1221- 25
PubMedArticle
36.
Jorm  AFJolley  D The incidence of dementia: a meta-analysis. Neurology 1998;51728- 733
PubMedArticle
37.
Haan  MNMungas  DMGonzalez  HMOrtiz  TAAcharya  AJagust  WJ Prevalence of dementia in older Latinos: the influence of type 2 diabetes mellitus, stroke and genetic factors. J Am Geriatr Soc 2003;51169- 177
PubMedArticle
38.
Manly  JJJacobs  DMTouradji  PSmall  SAStern  Y Reading level attenuates differences in neuropsychological test performance between African American and White elders. J Int Neuropsychol Soc 2002;8341- 348
PubMedArticle
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Manly  JJByrd  DTouradji  PSanchez  DStern  Y Literacy and cognitive change among ethnically diverse elders. Int J Psychol 2004;3947- 60Article
Original Contribution
May 2005

Earlier Onset of Alzheimer Disease Symptoms in Latino Individuals Compared With Anglo Individuals

Author Affiliations

Author Affiliations: Department of Neurology (Drs Clark and Glosser), Alzheimer’s Disease Center (Drs Clark, Fernandez, Ewbank, and Glosser and Mss Nuñez and Negrón), and the Population Studies Center (Dr Ewbank), University of Pennsylvania, Philadelphia; Department of Neurology, Sergievsky Center, and Alzheimer’s Disease Research Center (Dr Manly), Columbia University, New York, NY; Alzheimer’s Disease Center (Drs Ferris and Perez and Ms Torres), New York University, New York; Department of Neurology and Alzheimer’s Disease Research Center (Dr Chui), University of Southern California, Los Angeles; Department of Neurology and Alzheimer’s Disease Center (Drs DeCarli and Mungas), University of California, Davis; and the National Alzheimer’s Coordinating Center (Drs Higdon and van Belle), University of Washington, Seattle.

Arch Neurol. 2005;62(5):774-778. doi:10.1001/archneur.62.5.774
Abstract

Background  Latino individuals are the largest minority group and the fastest growing population group in the United States, yet there are few studies comparing the clinical features of Alzheimer disease (AD) in this population with those found in Anglo (white non-Latino) patients.

Objective  To compare the age at AD symptom onset in Latino and Anglo individuals.

Design  Cross-sectional assessment using standardized methods to collect and compare age at AD symptom onset, demographic variables, and medical variables.

Setting  Five National Institute on Aging–sponsored Alzheimer’s Disease Centers with experience evaluating Spanish-speaking individuals.

Patients  We evaluated 119 Latino and 55 Anglo patients who had a diagnosis of AD.

Main Outcome Measure  Age at symptom onset.

Results  After adjusting for center, sex, and years of education, Latino patients had a mean age at symptom onset 6.8 years earlier (95% confidence interval, 3.5-10.3 years earlier) than Anglo patients.

Conclusions  An earlier age at symptom onset suggests that US mainland Latino individuals may experience an increased burden of AD compared with Anglo individuals. The basis for the younger age at symptom onset remains obscure.

Latino individuals are the fasting growing ethnic group and the largest minority group in the United States, accounting for 12.5% of the mainland US population.1 By 2020, their proportion of the US mainland population is projected to increase to 17% (middle-series US Census Bureau data).2 Spanish is the most common non-English language spoken in the United States, and Latino individuals account for 10% of the US population older than 50 years.3 However, there are few studies on the clinical presentation of Alzheimer disease (AD) in this population. Although Latino people are a geographic and genetically diverse group linked by a common cultural and linguistic heritage, some reports suggest that they may differ from Anglo (white non-Latino) individuals with respect to several disease characteristics. These include a higher prevalence of AD in both Caribbean and Mexican American Latino people47 and an increased incidence of AD in the Latino population in New York, NY and Houston, Tex,4,5 compared with Anglo individuals. Notably, in the northern Manhattan Latino cohort, the difference in incidence rates was most marked for subjects younger than 75 years. The prevalence of punitive risk factors for dementia may also differ between ethnic groups. Studies of community-dwelling elderly people with and without dementia810 suggest that the prevalence of depression, which may represent a risk factor for dementia,11 is higher in Latino than Anglo individuals. In addition, some1214 but not all6,1518 studies suggest that the influence of the APOE ε4 allele as a risk factor for AD may be less robust in Latino compared with Anglo individuals. In addition, compared with Anglo patients who have a similar duration of symptoms, Latino patients are reported to have a lower mean Mini-Mental State Examination (MMSE) score and smaller ventricular size.19 Finally, a study of nursing home residents in Texas indicated that on average, Latino residents were younger, had more functional impairment, and had lower MMSE scores (even after adjustments for age and education) than Anglo residents.20

The evaluation of dementia in Latino patients presents a challenge to both community health care professionals and physicians at dementia specialty clinics. Although it is not surprising that language barriers can lead to diagnostic errors and misinterpretation of the symptoms of dementia,21 it is also possible that clinical criteria developed in Anglo populations to detect the earliest changes of cognitive impairment may not be as reliable or informative when used in other population groups. In addition, English-language psychometric age- and education-adjusted norms used to assess memory, language, and constructional praxis may not have the same performance characteristics when applied to Spanish-language subjects.22 This is especially important with respect to the assessment of older Latino individuals. Spanish is the principal language of 94% of Cuban Americans, 86% of Mexican Americans, 76% of Hispanic Americans, and 91% of Puerto Ricans living in the US mainland.23 The psychometric assessment is further compounded by the fact that elderly Latino people make up the highest proportion of individuals in any US population group who have not attained a high school education.24 Finally, a low caregiver education level may be associated with a failure to recognize the initial signs and symptoms of dementia.

The Alzheimer’s Disease Centers (ADC) program was established by the National Institute on Aging (Bethesda, Md) to promote clinical and basic investigations in AD. Minority-focused clinics were incorporated into the program in an effort to extend the investigation of neurodegenerative dementias to all population groups in the United States. This study represents the first attempt to compare a major clinical feature of AD (the age at symptom onset) between the Latino and Anglo subjects evaluated through the ADC program.

METHODS

The first phase of the study involved a nonstandardized retrospective comparison of the age at AD symptom onset registered in the database for all Latino and Anglo patients evaluated at the 5 participating ADCs. The second phase involved an expanded cross-sectional prospective comparison of Latino and Anglo patients with a clinical diagnosis of probable or possible AD. Using standardized assessment tools, the age at AD symptom onset25 and demographic and medical information were obtained for Latino and Anglo individuals with a clinical diagnosis of probable or possible AD who were evaluated at 3 East Coast (University of Pennsylvania, Columbia University, and New York University) and 2 West Coast (University of Southern California and University of California, Davis) ADC clinics.

Latino and Anglo patients who met standard diagnostic criteria for probable or possible AD26 and a knowledgeable informant willing to participate were eligible for inclusion. To reduce potential bias based on factors that affect the length of time patients maintained contact with the clinic, those whose first ADC evaluation occurred prior to January 1, 1998, were excluded from the study. To reduce the expected difference in formal education between the 2 cohorts, Anglo individuals with more than 12 years of schooling were excluded.

The knowledgeable informant, usually the patient’s spouse or adult child, participated in the standardized structured interview used to determine the age at AD symptom onset.25 In addition, the informant confirmed or provided demographic information for each participating patient, including birthplace, migration history, and years of formal education, and provided the information needed to complete the Blessed Dementia Scale,27 the Neuropsychiatric Inventory (short form),28,29 the Dementia Severity Rating Scale,30 and for Latino patients, the Acculturation Scale (short form).31 The severity of the patient’s cognitive impairment was determined using the MMSE,32,33 and symptoms of depression were assessed using the Geriatric Depression Scale (short form).34,35

An investigator meeting was held prior to the start of the study to ensure that the assessment protocol was administered in a standard manner. Using a Web-based interface, data collected at each site were entered into the study database developed and maintained by the National Alzheimer’s Coordinating Center at the University of Washington.

STATISTICAL ANALYSIS

Age at AD symptom onset was the primary response variable and was calculated as the patient’s age when the first symptom was noted, as determined by the knowledgeable informant’s responses during the age-at-onset structured interview. Models were fitted using multiple linear regression, including terms for race, sex, education, and center. Other factors and interactions were examined by adding them to this model one at a time.

One concern was that differences in observed mean age at onset could be due to differences in the age distributions of Latino and Anglo individuals in the catchment areas for the 5 centers. To test this hypothesis, we calculated estimated mean ages at onset for the Latino and Anglo populations by applying published AD incidence rates36 to 2000 US Census data for the metropolitan areas surrounding each of the 5 participating ADCs. These estimates rely only on the relative incidence rates at each age and would not be affected by changes in the level of incidence.

RESULTS

The retrospective database analysis revealed that the mean age at symptom onset for 366 Latino patients with a clinical diagnosis of AD was 68.8 years compared with 73.5 years for 2823 Anglo patients. The reason for the 4.7-year difference did not vary between the East Coast (predominantly Caribbean) and West Coast (predominantly Mexican) sites.

In the second phase of the study, 119 Latino and 55 Anglo patients were prospectively evaluated using standardized assessment tools. There were no differences between the Latino and Anglo cohorts in sex distribution, the proportion with a diagnosis of probable vs possible AD, or the severity of cognitive impairment as measured by MMSE score at the time of enrollment (Table 1). Despite the exclusion of Anglo individuals with more than 12 years of schooling, the mean level of education still differed by 4 years.

After adjusting for center, sex, and years of education, the mean age at onset for the first dementia symptom was 6.8 years (95% confidence interval [CI], 3.5-10.3 years) earlier in Latino compared with Anglo patients (Table 2). This difference in the mean age at onset did not vary by center (P = .27). In addition, the difference in age at onset by ethnic status was not significant when the comparisons were restricted to subjects from either the East or West Coast centers.

Latino patients had less formal education than Anglo patients (7.3 years vs 11.3 years). The level of education had a modest effect on the age at symptom onset; the difference between Latino and Anglo patients became less evident as the years of education increased (P = .03). For example, the estimated difference was 10.0 years with 7 years of education but only 6.5 years with 11 years of education. For Anglo patients, the age at symptom onset decreased with increasing years of education (P = .004), whereas for Latino patients alone, the relationship between age at onset and years of education did not reach statistical significance. The fact that participants with the lowest education level tended to be Latino introduced confounding between education and ethnicity. Nevertheless, even when the analysis was restricted to Anglo and Latino patients with more than 7 years of education, the difference in age at symptom onset was 7.2 years (95% CI, 3.7-10.7 years).

There was a high correlation between the age at symptom onset and the age when the patient participated in this study (r = 0.87), indicating that the results of the analysis would not change if age at enrollment into the study were substituted for age at symptom onset. The mean difference between Anglo and Latino patients did not change significantly after controlling for whether or not memory impairment was reported as the first symptom, the patient’s Geriatric Depression Scale score at the time of enrollment in the study, or whether the patient was already an ADC subject at the time of evaluation (Table 3).

The 2 cohorts differed with respect to the prevalence of comorbid conditions. Latino patients were more likely to have hypertension (39% vs 18%) and diabetes (22% vs 13%) than Anglo patients. There was little difference between Latino and Anglo patients in MMSE scores or the subjective rating of the quality of the knowledgeable informant’s response to the standardized symptom onset assessment instrument. There was a modest association between the reported age at symptom onset and the knowledgeable informant’s relationship to the patient (spouse vs adult child) and the informant’s years of formal education. For both Latino and Anglo patients, there was a tendency for the reported age at onset to be slightly higher when the informant was an adult child (P = .03). There was a significant difference between the 2 cohorts in the knowledgeable informant’s level of education (12.2 years for Latino individuals vs 14.3 years for Anglo individuals; P = .001; 95% CI, 0.9-3.4). Although the age reported for the onset of symptoms significantly increased with an increase in the years of education of the informant (P = .005), this relationship did not modify the effect of ethnicity. There was no evidence of a relationship between the degree of acculturation in the Latino cohort and age at onset (data not shown). There was no difference in the age at symptom onset between the predominantly Puerto Rican East Coast Latino individuals and the predominantly Mexican Latino individuals evaluated at the 2 California ADCs.

When the patients enrolled in this study were compared with all patients with a clinical diagnosis of probable or possible AD who were evaluated at the participating ADCs during the previous 3 years, the only difference was a lower proportion of men (18% vs 34%) in the age-at-onset study, particularly among the Anglo cohort (33.8% in the ADCs vs 14.2% in this study). Both the age-at-onset study cohort and the much larger total ADC cohort were similar in terms of age calculated as of September 1, 2001 (data not shown).

On average, Latino individuals older than 50 years living in the communities from which the study cohorts were drawn are 3.4 years younger (mean age, 62.4 years) than their Anglo neighbors (mean age, 65.8 years). Estimating the difference in age at onset using published AD incidence rates36 with the assumption that the incidence rates are the same for white and Latino individuals yields a difference of about 1.8 years (26% of the 6.8-year difference between the 2 cohorts in the age at AD symptom onset found in this study).

COMMENT

Using a prospective standardized assessment protocol, mainland US Latino individuals with AD evaluated at 5 ADC dementia specialty clinics had a mean age at symptom onset that was 6.8 years earlier than Anglo individuals evaluated at the same clinics. The explanation for the earlier age at symptom onset remains uncertain. The difference between the 2 cohorts remained significant after adjustment for education and demographically related age differences in the portion of each cohort at risk for AD. This earlier mean age at symptom onset suggests that US mainland Latino individuals may experience an increased burden of AD compared with Anglo people. It is not known if there are comparable differences between these 2 groups in the rate of symptom progression or total duration of AD.

There was no difference in the age at symptom onset between the East Coast Latino patients (primarily of Caribbean origin) and the predominantly Mexican American Latino patients evaluated by the 2 California ADCs. In addition, although an analysis of the baseline data from a Sacramento, Calif, epidemiological cohort study found a higher risk for dementia in Latino individuals with type 2 diabetes and stroke,37 in our study there was no indication that the younger age at onset in Latino patients was associated with potential confounders such as depression, the increased prevalence of comorbid medical conditions, differences in years of education, or the degree to which Latino patients or informants retained aspects of their culture.

There are several cautions in applying the results of this study to the general population. Both the Latino and Anglo cohorts represented samples of convenience, meaning that they were drawn from individuals attending a dementia specialty clinic and therefore cannot be considered representative of the overall US mainland population. Although there are no published studies on the relationship between age at onset and years of education in Anglo individuals with 12 years of education or less, the association of an older age at onset with fewer years of education in our Anglo subjects suggests that they may not be representative of all low-education Anglo patients with AD in the US mainland. In addition, the quality of education may have differed between the Latino and Anglo cohorts and may have been a more relevant marker than the number of years spent in school.38,39

Not addressed in the study design was the possibility that a portion of the observed difference in age at onset could be due to US mainland demographic differences in the age distribution between the Latino and Anglo cohorts. However, if the age-specific incidence rates for Latino individuals are proportional to those for Anglo individuals, demographic difference would account for only 26% of the difference in age at onset observed between the 2 groups.

Measurement error and unappreciated bias in the symptom onset instrument may also confound the results, particularly if there is an unrecognized bias toward a particular group. In addition, socioeconomic and family stress associated with migration and integration into the Anglo-dominant mainland culture may bring out symptoms of depression and anxiety during the prodromal phase of AD, and this may not have been adequately captured. Finally, unmeasured confounders are always a problem in observational studies.

Despite these cautions, the findings in this study indicate that Latino individuals, the largest and fastest growing minority group in the mainland United States, appear to have an earlier age of AD symptom onset compared with Anglo individuals with a similar educational level. The factors responsible for this remain to be identified, but the observation has a potential impact on both the burden of dementia care carried by this population group and the dementia-related diagnostic and educational efforts directed toward the Latino population. From the individual patient and family standpoint as well as a public health perspective, it is important to identify modifiable factors that contribute to the symptomatic expression of AD in this significant minority group.

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Article Information

Correspondence: Christopher M. Clark, MD, 3615 Chestnut St, Philadelphia, PA 19104 (clarkc@mail.med.upenn.edu).

Accepted for Publication: October 18, 2004.

Author Contributions:Study concept and design: Clark, Mungas, Chui, Fernandez, Manly, Perez, Ewbank, Glosser, and van Belle. Acquisition of data: DeCarli, Mungas, Chui, Nuñez, Fernandez, Negrón, Manly, Ferris, Perez, Torres, and van Belle. Analysis and interpretation of data: Clark, DeCarli, Chui, Higdon, Nuñez, Fernandez, Manly, Perez, Ewbank, and van Belle. Drafting of the manuscript: Clark, Nuñez, Fernandez, Torres, and Glosser. Critical revision of the manuscript for important intellectual content: Clark, DeCarli, Mungas, Chui, Higdon, Nuñez, Fernandez, Negrón, Manly, Ferris, Perez, Ewbank, Glosser, and van Belle. Statistical analysis: Clark, Higdon, Ewbank, and van Belle. Obtained funding: Clark, Mungas, and Manly. Administrative, technical, and material support: Clark, DeCarli, Mungas, Chui, Fernandez, Manly, Ferris, and Torres. Study supervision: Clark, Chui, Nuñez, Fernandez, Manly, and Glosser.

Funding/Support: This study was supported by grants P30 AG10124 (University of Pennsylvania), P50 AG08702 (Columbia University), P30 AG08051 (New York University), P50 AG08051 (University of Southern California), P30 AG01542 (University of California, Davis), and U01 AG16976 (University of Washington) from the National Institute on Aging, Bethesda, Md.

Acknowledgment: We gratefully acknowledge Isis Hernandez, PhD, University of Southern California, for her contribution to the success of this study.

References
1.
US Census Bureau QT-P6, Race Alone or in Combination and Hispanic or Latino: 2000 Data Set.  Washington, DC: US Census Bureau; 2003. Census 2000 Summary File 1 (SF 1) 100-Percent Data
2.
US Census Bureau National Population Projections II: Detailed Files: Total Population by Age, Sex, Race, Hispanic Origin, and Nativity.  Washington, DC: US Census Bureau; 2003
3.
US Census Bureau The Older Population in the United States: March 2002 Detailed Tables.  Washington, DC: US Census Bureau; 2002
4.
Gurland  BJWilder  DELantigua  R  et al.  Rates of dementia in three ethnoracial groups. Int J Geriatr Psychiatry 1999;14481- 493
PubMedArticle
5.
Tang  MXCross  PAndrews  H  et al.  Incidence of AD in African-Americans, Caribbean Hispanics, and Caucasians in northern Manhattan. Neurology 2001;5649- 56
PubMedArticle
6.
Tang  MXStern  YMarder  K  et al.  The APOE-epsilon4 allele and the risk of Alzheimer disease among African Americans, whites, and Hispanics. JAMA 1998;279751- 755
PubMedArticle
7.
Perkins  PAnnegers  JFDoody  RSCooke  NAday  LVernon  SW Incidence and prevalence of dementia in a multiethnic cohort of municipal retirees. Neurology 1997;4944- 50
PubMedArticle
8.
Cohen  CIMagai  C Racial differences in neuropsychiatric symptoms among dementia outpatients. Am J Geriatr Psychiatry 1999;757- 63
PubMedArticle
9.
Harwood  DGBarker  WWOwnby  RL Depressive symptoms in Alzheimer's disease: a cross-ethnic comparison of Cuban-American and white non-Hispanic patients.  In: Vellas  B, Fitten  J, Frisoni  G, eds. Research and Practice in Alzheimer's Disease. Paris, France: Serdi; 1998:163-172
10.
Falcon  LMTucker  KL Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts. J Gerontol B Psychol Sci Soc Sci 2000;55S108- S116Article
11.
Green  RCCupples  LAKurz  A  et al.  Depression as a risk factor for Alzheimer disease: the MIRAGE Study. Arch Neurol 2003;60753- 759
PubMedArticle
12.
Farrer  LACupples  LAHaines  JL  et al.  Effects of age, sex, and ethnicity on the association between apolipoprotein E genotype and Alzheimer disease: a meta-analysis: APOE and Alzheimer Disease Meta Analysis Consortium. JAMA 1997;2781349- 1356
PubMedArticle
13.
Maestre  GOttman  RStern  Y  et al.  Apolipoprotein E and Alzheimer's disease: ethnic variation in genotypic risks. Ann Neurol 1995;37254- 259
PubMedArticle
14.
Mayeux  RStern  YOttman  R  et al.  The apolipoprotein epsilon 4 allele in patients with Alzheimer's disease. Ann Neurol 1993;34752- 754
PubMedArticle
15.
Duara  RBarker  WWLopez-Alberola  R  et al.  Alzheimer's disease: interaction of apolipoprotein E genotype, family history of dementia, gender, education, ethnicity, and age of onset. Neurology 1996;461575- 1579
PubMedArticle
16.
Sevush  SPeruyera  GCrawford  FMullan  M Apolipoprotein-E epsilon 4 allele frequency and conferred risk for Cuban Americans with Alzheimer's disease. Am J Geriatr Psychiatry 2000;8254- 256
PubMed
17.
Harwood  DGBarker  WWLoewenstein  DA  et al.  A cross-ethnic analysis of risk factors for AD in white Hispanics and white non-Hispanics. Neurology 1999;52551- 556
PubMedArticle
18.
Romas  SNSantana  VWilliamson  J  et al.  Familial Alzheimer disease among Caribbean Hispanics: a reexamination of its association with APOE. Arch Neurol 2002;5987- 91
PubMedArticle
19.
Minagar  ASevush  SBertran  A Cerebral ventricles are smaller in Hispanic than non-Hispanic patients with Alzheimer's disease. Neurology 2000;55446- 448
PubMedArticle
20.
Chiodo  LKKanten  DNGerety  MBMulrow  CDCornell  JE Functional status of Mexican American nursing home residents. J Am Geriatr Soc 1994;42293- 296
PubMed
21.
Espino  DVLewis  R Dementia in older minority populations. Issues of prevalence, diagnosis, and treatment. Am J Geriatr Psychiatry 1998;6(suppl 1)S19- S25
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