This study evaluated the prevalence of suspected undiagnosed ADRD among foreign-born MENA adults compared to US- and foreign-born Whites from Europe and compared the odds of suspected undiagnosed ADRD before and after adjusting for covariates.
Prevalence estimates were higher among foreign-born MENA adults compared to US-born Whites. MENA adults had higher odds of having suspected undiagnosed ADRD; however, sex-stratified results were only significant among women. An overview of sex-specific differences and the implications that education and depressive symptoms have as potentially modifiable risk factors for ADRD among MENA adults are discussed below.
The magnitude of the higher odds of suspected undiagnosed ADRD among MENA older adults and MENA women was attenuated when education was taken into account. Previous studies have shown that adults with undiagnosed ADRD are more likely to have lower levels of education (2). Less education is not only a risk for ADRD, but a key factor that drives underdiagnosis. Older adults with lower levels of education are less likely to receive preventive health care (23), which limits their ability to be screened during primary care visits if signs and symptoms of cognitive impairment are recognized by the healthcare provider (24). Since this is the first study to explore undiagnosed ADRD among MENA adults, we are unable to compare our results to other studies that accounted for education as a risk factor for ADRD underdiagnosis. However, our finding that education levels were lower among MENA adults compared to the US-born Whites in our sample is consistent with previous research. Studies using national data sources have reported low levels of education among foreign-born MENA adults ranging from 18–32.8% (11, 13, 25–31). When stratified by sex, studies showed that 22.7–26.7% of foreign-born MENA women (13, 32) and 11% of foreign-born MENA men had less than high school education (13, 33). In the current study, we found that 10.5% of foreign-born MENA adults had less than a ninth-grade level of education in our bivariate analysis, which was not statistically significantly different than US- (5.9%) or foreign-born Whites (14.0%). Yet, we found a large disparity in education level when we stratified by sex. Only 3.4% of MENA men had less than a ninth-grade education compared to 6.8% of US- and 10.2% of foreign-born White men (P = .0385). Among women, 18.6% of MENA women had less than ninth-grade level of education compared to only 5.1% of US-born and 16.6% of foreign-born White women (p < .0001). Our results show a similar educational pattern as community-based studies in Michigan with large concentrations of older MENA/Arab populations, which found that the average years of formal education among MENA women was 2 years, with 68% reporting no formal education (34).
Depressive symptoms during late life (ages 65 and older) have also been identified as a potentially modifiable risk factor for ADRD (35). Yet, it remains unclear whether depressive symptoms are an independent risk factor for ADRD or a prodromal symptom. Self-reported cognitive limitations could reflect symptoms of depression rather than a dementia syndrome. Despite this limitation, we still found higher odds of suspected undiagnosed ADRD among MENA women even after controlling for depressive symptoms. Although depression has not been explicitly linked to ADRD underdiagnosis, previous studies have shown that older adults are less likely to receive mental health services (36) and may prefer to receive treatment from their primary care provider (37). With most older adults having other comorbid chronic conditions that need to be addressed during primary care visits (38), there may be limited opportunities for early detection and screening for ADRD while addressing other health concerns (39). Existing literature has identified a wide range (5.5%-60%) of prevalence estimates for depressive symptoms among MENA individuals using community-based convenience samples (40–42), electronic health record data (43, 44), and nationally representative samples (10, 45). For example, using linked NHIS and MEPS data, Kindratt and colleagues reported that 38.2% of MENA adults ages 65 and older had depressive symptoms (10). The prevalence was slightly higher than what we found in the current study (37.3%) that was limited to adults ages 65 and older without an ADRD diagnosis. In the current study, we found that older MENA women had a higher prevalence of depressive symptoms than men (40.8% and 34.0%, respectively). This finding is consistent with other community-based studies that demonstrate depressive symptoms were higher among MENA women compared to MENA men (34, 41, 45).
Strengths and Limitations
A strength was the use of two nationally representative data sources to uncover MENA health outcomes while no ethnic identifier is available on a national scale. The NHIS is the only nationally representative health survey that allows for MENA individuals to be disaggregated from other foreign-born adults. Several studies have used NHIS data to uncover health outcomes among foreign-born Middle Eastern and Arab American immigrant populations (11, 13, 25, 26, 29–33). By linking with MEPS, we accessed additional health information from a subsample of participants who completed the previous year’s NHIS. To our knowledge, this methodology has only been used once for measuring MENA health. This study replicates methods used by Kindratt and colleagues (2022) to link NHIS and MEPS data and broaden the sample to be inclusive of MENA individuals by also including White Africans (10). We added MEPS medical condition data files to evaluate ADRD underdiagnosis. Although our sample size included individuals with both ICD-9 and ICD-10 codes to determine ADRD diagnosis, a sensitivity analysis was conducted to ensure our findings were not biased by the change in classification system. Removing individuals with and an ADRD diagnosis from the sample allowed us to gain a better understanding of individuals suspected to be undiagnosed.
Despite the strengths, various limitations may have affected our results. The first limitation was survey language. Both NHIS and MEPS are only collected in English and Spanish; therefore, MENA adults who only speak Arabic may have been excluded from the sample. This limitation may have resulted in an underestimate of the disparity considering that monolingual Arabic speakers may be even less likely to access high-quality medical care and be diagnosed. However, because data are collected from one key representative from each household, responses from Arabic speakers may have been given by a bilingual family member. Another limitation is our inability to disaggregate US-born MENA individuals from other US-born Whites. We may have found an even larger disparity if we were able to make these comparisons without accounting for nativity status. The cross-sectional nature of the NHIS and MEPS are a limitation in that causal links could not be ascertained. Finally, since the sample was limited to adults who reported a medical condition that was directly linked to ICD-9 or ICD-10 billing code, individuals may not have shared this information during the interview. MEPS medical condition codes were designed to measure medical expenditures, not national prevalence estimates. Despite this limitation, using MEPS medical condition data allows us to expand research on MENA health while no ethnic identifier is available.