From the Department of Neurology (A.L.C.S.); Department of Biostatistics, Epidemiology, and Informatics, (A.L.C.S.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Radiation Medicine and Applied Sciences (A.R.), University of California, San Diego; Memory Impairment and Neurodegenerative Dementia (MIND) Center (J.A.H., T.H.M., M.G.), University of Mississippi Medical Center, Jackson; Department of Psychiatry and Behavioral Sciences (V.K.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Biostatistics and Bioinformatics (L.W.), Duke University, Durham, NC; Department of Population Health (J.R.P., J.C.), New York University Grossman School of Medicine, New York; Department of Epidemiology (A.G.), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD; National Institute on Aging Intramural Program (K.W.), Baltimore, MD; Department of Epidemiology (A.K.-N.), University of North Carolina at Chapel Hill; and National Institute of Neurologic Disorders and Stroke Intramural Research Program (R.F.G.), Bethesda, MD.
Neurology. 2024 Dec 10;103(11):e210030. doi: 10.1212/WNL.0000000000210030. Epub 2024 Nov 15.
Race and ethnicity are proxy measures of sociocultural factors that influence cognitive test performance. Our objective was to compare different regression-based cognitive normative models adjusting for demographics and different combinations of easily accessible/commonly used social determinants of health (SDoH) factors, which may help describe cognitive performance variability historically captured by ethnoracial differences.
We performed cross-sectional analyses on data from Black and White participants without mild cognitive impairment/dementia in the Atherosclerosis Risk in Communities Study who attended visit 5 in 2011-2013. Participants underwent a battery of 11 cognitive tests (3 domains: memory, executive function, language). We fit 6 separate normative models for each cognitive test, all including age and education, with different combinations of race, the Wide Range of Achievement Test (education quality proxy), and area deprivation index (neighborhood deprivation) associated with current residence. We compared model fits and calculated concordances/discordances between models using z-scores derived from each normative model and a z-score <-1.5 threshold for impairment.
Participants (n = 2,392) had a mean age of 74.4 years, 60.4% were female, and 17.1% were of self-reported Black race. The "Full" model with race alongside demographic and SDoH measures consistently outperformed other nested submodels (likelihood ratios ≥ 100) for all domains/tests except Delayed Word Recall. Models with education quality alone ("WRAT") generally outperformed models with neighborhood deprivation ("ADI") or race ("Race") alone for memory and language tests while "Race" models performed better for executive function tests. Adding neighborhood deprivation to education quality ("WRAT + ADI") did not improve models vs using "WRAT" alone. Across all domains/tests, the concordance compared with the "Full" model was lower for "Education" and "ADI" models than for other nested models. Although numbers were small, there was greater discordance among Black (range = 8.2%-23.2%) compared with White (range = 2.2%-3.4%) participants, particularly for Boston Naming Test and executive function tests.
Education quality outperformed neighborhood disadvantage as an additional/alternative SDoH measure in normative models and may be useful to collect in cognitive aging studies. While performance varied across cognitive domains and tests, routinely reported SDoH variables (education level, education quality, late-life neighborhood deprivation) did not fully account for observed ethnoracial variability; future work should evaluate SDoH across the lifespan in more ethnoracially diverse populations.
种族和民族是影响认知测试表现的社会文化因素的替代指标。我们的目的是比较不同的基于回归的认知规范模型，这些模型调整了人口统计学因素和不同的易于获得/常用的健康社会决定因素（SDoH）因素的组合，这些因素可能有助于描述历史上由种族差异所捕捉到的认知表现的变异性。
我们对参加 2011-2013 年社区动脉粥样硬化风险研究（Atherosclerosis Risk in Communities Study）第五次访视的无轻度认知障碍/痴呆的黑人和白人参与者的数据进行了横断面分析。参与者接受了 11 项认知测试（3 个领域：记忆、执行功能、语言）的测试。我们为每个认知测试拟合了 6 个单独的规范模型，所有模型都包含年龄和教育，以及与当前居住地相关的种族、广泛成就测试（教育质量代理）和区域剥夺指数（邻里剥夺）的不同组合。我们比较了模型拟合度，并使用每个规范模型得出的 z 分数和<-1.5 的损伤阈值，计算了模型之间的一致性/不一致性。
参与者（n=2392）的平均年龄为 74.4 岁，60.4%为女性，17.1%为自我报告的黑人种族。对于所有领域/测试，除了延迟单词回忆外，种族与人口统计学和 SDoH 测量相结合的“完整”模型（似然比≥100）始终优于其他嵌套子模型。仅使用教育质量的模型（“WRAT”）通常优于仅使用邻里剥夺的模型（“ADI”）或种族（“Race”）的模型，而对于记忆和语言测试，使用“Race”模型的效果更好。而对于执行功能测试，添加邻里剥夺到教育质量（“WRAT+ADI”）并没有比单独使用“WRAT”的模型更好。在所有领域/测试中，与“完整”模型相比，“教育”和“ADI”模型的一致性较低。尽管数量较少，但黑人参与者（范围为 8.2%-23.2%）之间的差异比白人参与者（范围为 2.2%-3.4%）更大，特别是在波士顿命名测试和执行功能测试中。
教育质量优于邻里劣势，成为认知老化研究中额外/替代的 SDoH 指标，可能有助于收集。虽然认知领域和测试的表现存在差异，但常规报告的 SDoH 变量（教育水平、教育质量、晚年邻里剥夺）并未完全解释观察到的种族差异；未来的工作应该在更多种族多样化的人群中评估整个生命周期的 SDoH。
