Department of Global Health, Boston University School of Public Health, Boston, Massachusetts.
Population Studies Center, University of Pennsylvania, Philadelphia.
JAMA Neurol. 2020 Dec 1;77(12):1543-1550. doi: 10.1001/jamaneurol.2020.2831.
Vital statistics are the primary source of data used to understand the mortality burden of dementia in the US, despite evidence that dementia is underreported on death certificates. Alternative estimates, drawing on population-based samples, are needed.
To estimate the percentage of deaths attributable to dementia in the US.
DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort study of the Health and Retirement Study of noninstitutionalized US individuals with baseline exposure assessment in 2000 and follow-up through 2009 was conducted. Data were analyzed from November 2018 to May 2020. The sample was drawn from 7489 adults aged 70 to 99 years interviewed directly or by proxy. Ninety participants with missing covariates or sample weights and 57 participants lost to follow-up were excluded. The final analytic sample included 7342 adults.
Dementia and cognitive impairment without dementia (CIND) were identified at baseline using Health and Retirement Study self- or proxy-reported cognitive measures and the validated Langa-Weir score cutoff.
Hazard ratios relating dementia and CIND status to all-cause mortality were estimated using Cox proportional hazards regression models, accounting for covariates, and were used to calculate population-attributable fractions. Results were compared with information on cause of death from death certificates.
Of the 7342 total sample, 4348 participants (60.3%) were women. At baseline, 4533 individuals (64.0%) were between ages 70 and 79 years, 2393 individuals (31.0%) were between 80 and 89 years, and 416 individuals (5.0%) were between 90 and 99 years; percentages were weighted. The percentage of deaths attributable to dementia was 13.6% (95% CI, 12.2%-15.0%) between 2000 and 2009. The mortality burden of dementia was significantly higher among non-Hispanic Black participants (24.7%; 95% CI, 17.3-31.4) than non-Hispanic White participants (12.2%; 95% CI, 10.7-13.6) and among adults with less than a high school education (16.2%; 95% CI, 13.2%-19.0%) compared with those with a college education (9.8%; 95% CI, 7.0%-12.5%). Underlying cause of death recorded on death certificates (5.0%; 95% CI, 4.3%-5.8%) underestimated the contribution of dementia to US mortality by a factor of 2.7. Incorporating deaths attributable to CIND revealed an even greater underestimation.
The findings of this study suggest that the mortality burden associated with dementia is underestimated using vital statistics, especially when considering CIND in addition to dementia.
尽管有证据表明在死亡证明上痴呆症的报告不足，但生命统计数据仍是了解美国痴呆症死亡率负担的主要数据来源。需要使用基于人群样本的替代估计方法。
估计美国痴呆症死亡人数的百分比。
设计、地点和参与者：对参加美国健康与退休研究的非机构化成年人进行了一项前瞻性队列研究，基线暴露评估于 2000 年进行，随访至 2009 年。数据分析于 2018 年 11 月至 2020 年 5 月进行。该样本来自 7489 名年龄在 70 至 99 岁之间的成年人，直接或通过代理人进行访谈。排除了 90 名缺失协变量或样本权重的参与者和 57 名失访的参与者。最终分析样本包括 7342 名成年人。
在基线时，使用健康与退休研究的自我或代理报告的认知测量和经过验证的 Langa-Weir 评分切点，通过认知测量和经过验证的 Langa-Weir 评分切点来识别痴呆症和认知障碍但无痴呆症（CIND）。
使用 Cox 比例风险回归模型估计与全因死亡率相关的痴呆症和 CIND 状况的风险比，考虑了协变量，并用于计算人群归因分数。结果与死亡证明上的死因信息进行了比较。
在总共 7342 名样本中，4348 名参与者（60.3%）为女性。在基线时，4533 名参与者（64.0%）年龄在 70 至 79 岁之间，2393 名参与者（31.0%）年龄在 80 至 89 岁之间，416 名参与者（5.0%）年龄在 90 至 99 岁之间；百分比是加权的。2000 年至 2009 年间，归因于痴呆症的死亡人数百分比为 13.6%（95%CI，12.2%-15.0%）。与非西班牙裔白人参与者（12.2%，95%CI，10.7%-13.6%）相比，非西班牙裔黑人参与者（24.7%，95%CI，17.3%-31.4%）和受教育程度低于高中的成年人（16.2%，95%CI，13.2%-19.0%）的痴呆症死亡率负担显著更高，而与受教育程度较高的成年人（9.8%，95%CI，7.0%-12.5%）相比。死亡证明上记录的根本死因（5.0%，95%CI，4.3%-5.8%）低估了痴呆症对美国死亡率的影响，其倍数为 2.7。将归因于 CIND 的死亡人数包括在内，会发现对痴呆症对美国死亡率的影响的低估程度更大。
这项研究的结果表明，使用生命统计数据低估了与痴呆症相关的死亡率负担，尤其是在考虑到除痴呆症之外的 CIND 时。
