Cognitive test score and 25-Year mortality risk; Does race matter?
Objectives: Despite our knowledge on the effect of cognitive test score on subsequent risk of mortality, few studies have compared Blacks and Whites for this association. The current study was conducted on Black-White differences in the magnitude of the association between baseline cognitive test score and all-cause mortality in a nationally representative sample of adults in the United States over 25 years.
Methods: We used data of the Americans’ Changing Lives Study (ACL), 1986 – 2011, a national prospective cohort in U.S. The study followed 3,361 adults (2,205 White and 1,156 Blacks), age 25 and older, for up to 25 years. The independent variable was cognitive test score measured at baseline (1986) using the 4-item version of the Short Portable Mental Status Questionnaire, treated in two different ways (as a dichotomous and as a continuous variable). The dependent variable was time to death (due to all causes) during the follow up period. Covariates included baseline age, gender, education, income, number of chronic diseases, self-rated health, and depressive symptoms. Race (Black versus White) was the focal effect modifier. We used a series of Cox proportional hazards models in the total sample, and by race, in the absence and presence of health variables.
Results: Overall, cognitive test score predicted mortality risk. A significant interaction was found between race and baseline cognitive test score suggesting that baseline cognitive test score has a weaker protective effect against all-cause mortality for Blacks in comparison to Whites. In race-stratified models, cognitive test score at baseline predicted risk of all-cause mortality for Whites but not Blacks, in the absence and presence of baseline socio-economic and health variables. The results were similar regardless of how we treated baseline cognitive test score.
Conclusions: In the United States, baseline cognitive test score has a weaker protective effect against all-cause mortality over a long period of time for Blacks than Whites. The finding is in line with the Minorities Diminished Returns theory and is probably due to structural and interpersonal racism.
- Salthouse TA. What do adult age differences in the Digit Symbol Substitution Test reflect? J Gerontol. 1992;47(3):121–8.
- Royall DR, Lauterbach EC, Kaufer D, Malloy P, Coburn KL, Black KJ; Committee on Research of the American Neuropsychiatric Association. The cognitive correlates of functional status: a review from the Committee on Research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci. 2007 Summer;19(3):249-65.
- Lavery LL, Dodge HH, Snitz B, Ganguli M. Cognitive decline and mortality in a community-based cohort: the Monongahela Valley Independent Elders Survey. J Am Geriatr Soc. 2009;57: 94–100.
- Iwasa H, Gondo Y, Yoshida Y, Kwon J, Inagaki H, Kawaai C, et al. Cognitive performance as a predictor of functional decline among the non-disabled elderly dwelling in a Japanese community: A 4-year population-based prospective cohort study. Arch Gerontol Geriatr. 2008;47:139–49.
- Johnson JK, Lui LY, Yaffe K. Executive function, more than global cognition, predicts functional decline and mortality in elderly women. J Gerontol A Biol Sci Med Sci. 2007;62: 1134–41.
- Nguyen HT, Black SA, Ray LA, Espino DV, Markides KS. Cognitive impairment and mortality in older mexican americans. J Am Geriatr Soc. 2003;51(2):178-83.
- Rosano C, Newman AB, Katz R, Hirsch CH, Kuller LH. Association between lower digit symbol substitution test score and slower gait and greater risk of mortality and of developing incident disability in well-functioning older adults. J Am Geriatr Soc. 2008;56:1618–25.
- Swan GE, Carmelli D, LaRue A. Performance on the digit symbol substitution test and 5-year mortality in the Western Collaborative Group Study. Am J Epidemiol. 1995;141:32–40.
- Dewey ME, Saz P. Dementia, cognitive impairment and mortality in persons aged 65 and over living in the community: a systematic review of the literature. Int J Geriatr Psychiatry. 2001;16:751–61.
- Cano C, Samper-Ternent R, Al Snih S, Markides K, Ottenbacher KJ. Frailty and cognitive impairment as predictors of mortality in older Mexican Americans. J Nutr Health Aging. 2012;16(2):142-7.
- Moody-Ayers SY, Mehta KM, Lindquist K, Sands L, Covinsky KE. Black-white disparities in functional decline in older persons: the role of cognitive function. J Gerontol A Biol Sci Med Sci. 2005 ; 60(7):933-9.
- Assari S, Moghani Lankarani M; Burgard S, Black White Difference in Long Term Predictive Power of Self-Rated Health on All-Cause Mortality in United States. Annals Epidemiology. 2015.
- Assari S, Burgard S, Black-White differences in the effect of baseline depressive symptoms on deaths due to renal diseases: 25 year follow up of a nationally representative community sample. J Renal Injury Prev. 2015.
- Assari S. Hostility, Anger, and Cardiovascular Mortality among Blacks and Whites. Res Cardiovasc Med. 2015.
- House, James S., James M. Lepkowski, Anne M. Kinney, Richard P. Mero, Ronald C. Kessler, and A. Regula Herzog. The Social Stratification of Aging and Health. J Health Soc Behav. 1994; 35(3):213–34.
- House JS, Kessler RC, Herzog AR. Age, Socioeconomic Status, and Health. Milbank Quarterly 1990; 68(3):383–411.
- Assari S. Zivin K. Burgard S. Long-Term Reciprocal Associations Between Depressive Symptoms and Number of Chronic Medical Conditions: Longitudinal Support for Black? White Health Paradox. J Racial Ethnic Health Disparities 2015. 2 (4). 589-597.
- McDowell I. Measuring health: A guide to rating scales and questionnaires. New York, NY: Oxford University Press. 2006.
- Pfeiffer E . A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients. Journal of the American Geriatrics Society 1975, 23, 433–441.
- Xu M, Thomas, P. A., Umberson D. Marital Quality and Cognitive Limitations in Late Life. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, gbv014.2015.
- Gallo JJ. Handbook of geriatric assessment. Jones & Bartlett Learning. 2006.
- Chang YW, Chen WL, Lin FG, Fang WH, Yen MY, Hsieh CC, Kao TW. Frailty and its impact on health-related quality of life: a cross-sectional study on elder community-dwelling preventive health service users. PLoS One. 2012;7(5):e38079.
- DeSalvo KB, Bloser N, Reynolds K, He J, Muntner P. Mortality prediction with a single general self-rated health question. A meta-analysis. J Gen Intern Med. 2006;21(3):267-75.
- Kondo N, Sembajwe G, Kawachi I, van Dam RM, Subramanian SV, Yamagata Z. Income inequality, mortality, and self rated health: meta-analysis of multilevel studies. BMJ. 2009 10;339:b4471.
- Idler EL, Benyamini Y. Self-rated health and mortality: A review of twenty-seven community studies. J Health Soc Behav. 1997;38:21–37.
- Lundberg O. Manderbacka K. Assessing Reliability of a Measure of Self-Rated Health. Scandinavian Journal of Social Medicine 1996; 24(3):218–24.
- Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1:385–401.
- Amtmann D, Kim J, Chung H, Bamer AM, Askew RL, Wu S, et al. Comparing CESD-10, PHQ-9, and PROMIS depression instruments in individuals with multiple sclerosis. Rehabil Psychol. 2014; 59(2):220–9.
- Zhang W, O'Brien N, Forrest JI, Salters KA, Patterson TL, Montaner JS, et al. Validating a shortened depression scale (10 item CES-D) among HIV-positive people in British Columbia, Canada. PLoS One. 2012;7(7), e40793.
- Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10(2):77–84.
- Ferraro KF, Kelley-Moore JA. Self-rated health and mortality among black and white adults: examining the dynamic evaluation thesis. J Gerontol B Psychol Sci Soc Sci. 2001 Jul;56(4):S195-205.
- Dowd JB, Zajacova A. Does the predictive power of self-rated health for subsequent mortality risk vary by socioeconomic status in the US? Int J Epidemiol. 2007;36(6):1214-21.
- Regidor E, Guallar-Castillón P, Gutiérrez-Fisac JL, Banegas JR, Rodríguez-Artalejo F. Socioeconomic variation in the magnitude of the association between self-rated health and mortality. Ann Epidemiol. 2010;20(5):395-400.
- Williams DR, Sternthal M. Understanding racial-ethnic disparities in health: sociological contributions. J Health Soc Behav. 2010;51 Suppl:S15-27.
- Carle AC, Weech-Maldonado R, Ngo-Metzger Q, Hays RD. Evaluating measurement equivalence across race and ethnicity on the CAHPS Cultural Competence Survey. Med Care. 2012;50(9 Suppl 2):S32-6.
- Sachs-Ericsson N, Blazer DG. Racial differences in cognitive decline in a sample of community-dwelling older adults: the mediating role of education and literacy. Am J Geriatr Psychiatry. 2005; 13(11):968-75.
- Fei M, Qu YC, Wang T, Yin J, Bai JX, Ding QH. Prevalence and distribution of cognitive impairment no dementia (CIND) among the aged population and the analysis of socio-demographic characteristics: the community-based cross-sectional study. Alzheimer Dis Assoc Disord. 2009 ;23(2):130-8.
- Shih RA, Ghosh-Dastidar B, Margolis KL, Slaughter ME, Jewell A, Bird CE, Eibner C, Denburg NL, Ockene J, Messina CR, Espeland MA. Neighborhood socioeconomic status and cognitive function in women. Am J Public Health. 2011 Sep;101(9):1721-8.
- Farfel JM, Nitrini R, Suemoto CK, Grinberg LT, Ferretti RE, Leite RE, Tampellini E, Lima L, Farias DS, Neves RC, Rodriguez RD, Menezes PR, Fregni F, Bennett DA, Pasqualucci CA, Jacob Filho W; Brazilian Aging Brain Study Group. Very low levels of education and cognitive reserve: a linicopathologic study. Neurology. 2013 Aug 13;81(7):650-7.
- Bassuk SS, Wypij D, Berkman LF. Cognitive impairment and mortality in the community-dwelling elderly. Am J Epidemiol 2000;151:676–688.
- Bruce ML, Hoff RA, Jacobs SC et al. The effects of cognitive impairment on 9-year mortality in a community sample. J Gerontol B Psychol Sci Soc Sci 1995;50B:P289–P296.
- Jorm AF, Henderson AS, Kay DK et al. Mortality in relation to dementia, depression, and social integration in an elderly community sample. Int J Geriatr Psychiatry 1991;6:5–11.
- Shapiro E, Tate RB. The impact of a mental status score and a dementia diagnosis on mortality and institutionalization. J Aging Health 1991;3:28–46.
- Kelman HR, Thomas C, Kennedy GJ et al. Cognitive impairment and mortality in older community residents. Am J Public Health 1994;84:1255–1260.
- Johansson B, Zarit SH. Early cognitive markers of the incidence of dementia and mortality: A longitudinal population-based study of the oldest old. Int J Geriatr Psychiatry 1997;12:53–59.
- Jagger C, Clarke M. Mortality risks in the elderly: five-year follow-up of a total population. Int J Epidemiol. 1988;17(1):111-4.
- Johansson B, Zarit SH. Early cognitive markers of the incidence of dementia and mortality: a longitudinal population-based study of the oldest old. Int J Geriatr Psychiatry. 1997;12(1):53-59.
- Palmer K, Wang H-X, Backman L, Winblad B, Fratiglioni L. Differential evolution of cognitive impairment in nondemented older persons: results from the Kungsholmen Project. Am J Psychiatry. 2002;159(3):436-442.
- Ingles JL, Fisk JD,Merry HR, Rockwood K. Five-year outcomes for dementia defined solely by neuropsychological test performance. Neuroepidemiology. 2003; 22(3):172-178.
- Guehne U, Luck T, Busse A, Angermeyer M, Riedel-Heller SG. Mortality in individuals with mild cognitive impairment: results of the Leipzig Longitudinal Study of the Aged (LEILA75_). Neuroepidemiology. 2007; 29(3-4): 226-234.
- Edwards JD,Wadley VG, Vance DE, Wood K, Roenker DL, Ball KK. The impact of speed of processing training on cognitive and everyday performance. Aging Ment Health. 2005;9:262–71.
- Wadley VG, Benz RL, Ball KK, Roenker DL, Edwards JD, Vance DE. Development and evaluation of home-based speed of- processing training for older adults. Arch Phys Med Rehabil. 2006;87:757–63.
- Wilson RS, Aggarwal NT, Barnes LL, Bienias JL, Mendes de Leon CF, Evans DA. Biracial population study of mortality in mild cognitive impairment and Alzheimer disease. Arch Neurol. 2009 ;66(6):767-72.
- Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc. 1992; 40:922–35.
- Iwasa H, Kai I, Yoshida Y, Suzuki T, Kim H, Yoshida H. Information processing speed and 8-year mortality among community-dwelling elderly Japanese. J Epidemiol. 2014;24(1):52-9.
- Rapp MA, Reischies FM. Attention and executive control predict Alzheimer disease in late life: results from the Berlin Aging Study (BASE). Am J Geriatr Psychiatry. 2005;13:134–41.
- Evans DA, Smith LA, Scherr PA, Albert MS, Funkenstein HH, Hebert LE. Risk of death from Alzheimer’s disease in a community population of older persons. Am J Epidemiol. 1991;134(4):403-412.
- Katzman R, Hill LR, Yu ES, et al. The malignancy of dementia: predictors of mortality in clinically diagnosed dementia in a population survey of Shanghai, China. Arch Neurol. 1994;51(12):1220-1225.
- Agüero-Torres H, Fratiglioni L, Guo Z, Viitanen M, Winbald B. Mortality from dementia in advanced age: a 5-year follow-up study of incident dementia cases. J Clin Epidemiol. 1999;52(8):737-743.
- Helmer C, Joly P, Letenneur L, Commenges D, Dartigues J-F. Mortality with dementia: results from a French prospective community-based cohort. Am J Epidemiol. 2001;154(7):642-648.
- Tschanz JT, Corcoran C, Skoog I, et al; Cache County Study Group. Dementia: the leading predictor of death in a defined elderly population: the Cache County Study. Neurology. 2004;62(7):1156-1162.
- Fitzpatrick AL, Kuller LH, Lopez OL, Kawas CH, Jagust W. Survival following dementia onset: Alzheimer’s disease and vascular dementia. J Neurol Sci. 2005; 229-230:43-49.
- Ganguli M, Dodge HH, Shen C, Pandav RS, DeKosky ST. Alzheimer’s disease and mortality: a 15-year epidemiological study. Arch Neurol. 2005;62(5):779-784.
- Kim G, DeCoster J, Chiriboga DA, Jang Y, Allen RS, Parmelee P. Associations between self-rated mental health and psychiatric disorders among older adults: do racial/ethnic differences exist? Am J Geriatr Psychiatry. 2011;19(5):416-22.
- Jang Y, Park NS, Kang SY, Chiriboga DA. Racial/Ethnic Differences in the Association Between Symptoms of Depression and Self-rated Mental Health Among Older Adults. Community Ment Health J. 2014;50(3):325-30.
- Korhonen PE, Kautiainen H, Mäntyselkä P. Screening for cardiovascular risk factors and self-rated health in a community setting: a cross-sectional study in Finland. Br J Gen Pract. 2014;64(627):e611-5.
- Keyes, Corey LM. The Black–White paradox in health: Flourishing in the face of social inequality and discrimination. Jf personality 2009; 77(6): 1677-1706.
- Barnes DM, Keyes KM, Bates LM. Racial differences in depression in the United States: how do subgroup analyses inform a paradox. Soc Psychiatry Psychiatr Epidemiol 2013; 48(12): 1941-1949.
- Shipley BA, Der G, Taylor MD, Deary IJ. Cognition and all-cause mortality across the entire adult age range: health and lifestyle survey. Psychosom Med. 2006;68(1):17-24.
- Shipley BA, Der G, Taylor MD, Deary IJ. Cognition and mortality from the major causes of death: the Health and Lifestyle Survey. J Psychosom Res. 2008;65(2):143-52.
- Shipley BA, Der G, Taylor MD, Deary IJ. Association between mortality and cognitive change over 7 years in a large representative sample of UK residents. Psychosom Med. 2007;69(7):640-50.
- Richards M1, Shipley B, Fuhrer R, Wadsworth ME. Cognitive ability in childhood and cognitive decline in mid-life: longitudinal birth cohort study. BMJ. 2004 6;328(7439):552.
- Blankson AN, McArdle JJ. A Brief Report on the Factor Structure of the Cognitive Measures in the HRS/AHEAD Studies. J Aging Res. 2014; 2014:798514.
- Slater CH, Lorimor RJ, Lairson DR. The independent contributions of socioeconomic status and health practices to health status. Prev Med. 1985;14(3):372-8.
- Feinstein JS. The relationship between socioeconomic status and health: a review of the literature. Milbank Q. 1993;71(2):279-322.
- Rebok GW, Ball K, Guey LT, Jones RN, Kim HY, King JW, Marsiske M, Morris JN, Tennstedt SL, Unverzagt FW, Willis SL; ACTIVE Study Group. Ten-year effects of the advanced cognitive training for independent and vital elderly cognitive training trial on cognition and everyday functioning in older adults. J Am Geriatr Soc. 2014 Jan;62(1):16-24. doi: 10.1111/jgs.12607.
- Ball K, Berch DB, Helmers KF, Jobe JB, Leveck MD, Marsiske M, Morris JN, Rebok GW, Smith DM, Tennstedt SL, Unverzagt FW, Willis SL; Advanced Cognitive Training for Independent and Vital Elderly Study Group. Effects of cognitive training interventions with older adults: a randomized controlled trial. JAMA. 2002 Nov 13;288(18):2271-81.
- Willis SL, Tennstedt SL, Marsiske M, Ball K, Elias J, Koepke KM, Morris JN, Rebok GW, Unverzagt FW, Stoddard AM, Wright E; ACTIVE Study Group. Long-term effects of cognitive training on everyday functional outcomes in older adults. JAMA. 2006 Dec 20;296(23):2805-14.
- Hampstead BM, Gillis MM, Stringer AY. Cognitive rehabilitation of memory for mild cognitive impairment: a methodological review and model for future research. J Int Neuropsychol Soc. 2014 Feb;20(2):135-51. doi: 10.1017/S1355617713001306.
- Hampstead BM, Sathian K, Moore AB, Nalisnick C, Stringer AY. Explicit memory training leads to improved memory for face-name pairs in patients with mild cognitive impairment: results of a pilot investigation. J Int Neuropsychol Soc. 2008 Sep;14(5):883-9. doi: 10.1017/S1355617708081009.
- Hampstead BM, Stringer AY, Stilla RF, Giddens M, Sathian K. Mnemonic strategy training partially restores hippocampal activity in patients with mild cognitive impairment. Hippocampus. 2012 Aug;22(8):1652-8. doi: 10.1002/hipo.22006.
- Hampstead BM, Sathian K, Phillips PA, Amaraneni A, Delaune WR, Stringer AY. Mnemonic strategy training improves memory for object location associations in both healthy elderly and patients with amnestic mild cognitive impairment: a randomized, single-blind study. Neuropsychology. 2012 May;26(3):385-99. doi: 10.1037/a0027545.
- Hampstead BM, Stringer AY, Stilla RF, Deshpande G, Hu X, Moore AB, Sathian K. Activation and effective connectivity changes following explicit-memory training for face-name pairs in patients with mild cognitive impairment: a pilot study. Neurorehabil Neural Repair. 2011 Mar-Apr;25(3):210-22. doi: 10.1177/1545968310382424.
- Hampstead BM, Sathian K, Bikson M, Stringer AY. Combined mnemonic strategy training and high-definition transcranial direct current stimulation for memory deficits in mild cognitive impairment. Alzheimers Dement (N Y). 2017 May 15;3(3):459-470. doi: 10.1016/j.trci.2017.04.008.
- Hampstead BM, Mosti CB, Swirsky-Sacchetti T. Cognitively-based methods of enhancing and maintaining functioning in those at risk of Alzheimer's disease. J Alzheimers Dis. 2014;42 Suppl 4:S483-93. doi: 10.3233/JAD-141476.
- Assari, S. Unequal gain of equal resources across racial groups. Int. J. Health Policy Manag. 2018, 7, 1–9.
- Assari, S. Health disparities due to blacks’ diminished return: Public Policy Solutions. Soc. Issues Policy Rev. 2018, 12, 112–145.
- Assari, S.; Lankarani, M.M. Race and Urbanity Alter the Protective Effect of Education but not Income on Mortality. Front. Public Health 2016, 4, 100.
- Assari, S.; Thomas, A.; Caldwell, C.H.; Mincy, R.B. Blacks’ Diminished Health Return of Family Structure and Socioeconomic Status; 15 Years of Follow-up of a National Urban Sample of Youth. J. Urban Health 2018, 95, 21–35.
- Assari, S. The Benefits of Higher Income in Protecting against Chronic Medical Conditions Are Smaller for African Americans than Whites. Healthcare 2018, 6, 2.
- Assari, S. Life Expectancy Gain Due to Employment Status Depends on Race, Gender, Education, and Their Intersections. J. Racial Ethn. Health Disparities2017.
- Assari S. General Self-Efficacy and Mortality in the USA; Racial Differences. J Racial Ethn Health Disparities. 2017 Aug;4(4):746-757. doi: 10.1007/s40615-016-0278-0.
- Assari S. Whites but Not Blacks Gain Life Expectancy from Social Contacts. Behav Sci (Basel). 2017 Oct 16;7(4). pii: E68. doi: 10.3390/bs7040068.
- Assari S. Race, sense of control over life, and short-term risk of mortality among older adults in the United States. Arch Med Sci. 2017 Aug;13(5):1233-1240. doi: 10.5114/aoms.2016.59740.
- Rushton, J. P., & Jensen, A. R. (2005). Thirty years of research on race differences in cognitive ability. Psychology, public policy, and law, 11(2), 235.
- Assari, S.; Caldwell, C.H. Teacher Discrimination Reduces School Performance of African American Youth: Role of Gender. Brain Sci. 2018, 8, 183.
- Assari, S. Parental Education Attainment and Educational Upward Mobility; Role of Race and Gender. Behav. Sci. 2018, 8, 107.
- Assari, S. Race, Intergenerational Social Mobility and Stressful Life Events. Behav. Sci. 2018, 8, 86.
- Assari, S. Does School Racial Composition Explain Why High Income Black Youth Perceive More Discrimination? A Gender Analysis. Brain Sci. 2018, 8, 140.
- Assari, S.; Moghani Lankarani, M. Workplace Racial Composition Explains High Perceived Discrimination of High Socioeconomic Status African American Men. Brain Sci. 2018, 8, 139.
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