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Key points
- Alzheimer’s disease (AD) is not only a universal neuropsychological condition, but is also sensitive to culture.
- The prevalence of AD is affected by the culture of the individual.
- Education, acculturation, and stigma associated with AD diagnosis affect its prevalence.
Written by Urvi Mange, junior research assistant at the Department of Psychology, Monk Prayogshala.
Dementia is a blanket term used to define a syndrome whose underlying cause is a disease in the brain, either chronic or gradual in nature. It involves the impairment of multiple higher cortical and executive functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment.
Although the state of consciousness is unaffected, deterioration in emotional control, social behavior, or motivation is noticed. Alzheimer’s disease has been primarily viewed as a neuro-psychological condition; hence, it has been assumed that it is universal across all affected populations, irrespective of their cultures.
Anthropologist Politt was one of the early researchers to point out the lack of research relating to the socio-cultural implications of AD. He encouraged researchers to question the impact of experiences (positive and negative) leading to old age and their relationship with dementia later in life.
His claims were supported by research showing that people who were either neglected or provided with minimum care were more prone to AD. A further indication of culture as an important determinant comes from a study evaluating its influence on cognitive factors using a standardized psychological tool. Here, neglecting the use of culture-friendly language and examples in the assessment of AD can lead to measurement errors.
Similarly, the most widely used tool to test for cognitive impairment, i.e., the Mini-Mental Status examination (MMSE), has been under scrutiny. A comparative study testing white and African American patients with AD showed that the MMSE cut-off was biased toward identifying AD in white as opposed to African American patients. A solution to this measurement error would be to not rely exclusively on these biased screening tools but to come up with neuropsychological batteries involving tasks such as tracing, ensuring the tests are culture-fair.
Another solution would be to ensure harmonization, i.e., to ensure that the tool employed for diagnosis matches the population characteristics in terms of language and culture.
Another determinant that mediates the relationship between culture and Alzheimer’s disease is health beliefs relating to AD. For instance, research shows that African Americans view AD as a small threat as opposed to white samples. They often believe that memory loss, cognitive impairments, and executive difficulties are a result of normal aging, God’s will, or fate. This belief further affects how much help individuals choose to seek.
Additionally, another area where culture seems to play a minor role is in the prevalence patterns of dementia amongst different cultures. Studies show that AD is more prominently diagnosed in Western countries as opposed to vascular type dementia, which is diagnosed more frequently in Asian countries, with the exception of Korea, which seems to follow the pattern of Western countries.
Another study on understanding the relationship between race, AD prevalence, and risk perception indicated that African Americans are unaware of the fact that they are more likely to develop AD as opposed to whites. Additionally, as a result of the impaired risk perception in African Americans, their ability to seek help is also affected.
Researchers have thus suggested accounting for these cultural biases and developing a model that is culture-fair with regard to assessment as well as intervention.
A 1996 study conducted on English and non-English-speaking Australian participants showed that AD was managed differently among these two groups. The results show that non-English speaking patients were under-referred and, when referred, were mostly suggested to be placed in care homes, indicating that their diagnosis was done at a later stage of the disease.
In order to provide an equal right to healthcare, it is imperative to recruit non-white research cohorts and identify risk factors that contribute to AD in these groups. It is essential to keep in mind Luria’s view that cognitive abilities are culture-bound, and measuring, gauging, and treating them out of that context is not very helpful.
Furthermore, being highly educated is thought to set back the onset of AD by magnifying one’s cognitive reserve. The cognitive reserve model refers to the capacity of the brain functionality to remain resilient to the presenting AD neuropathology. In short, one can conclude that the brain's cognitive reserve aids in dealing with AD symptomatology, and hence a stronger reserve helps preserve brain functions better in presence of AD as opposed to a weak reserve. A strong cognitive reserve is achieved by higher education, and thus any society’s education system plays an essential role in managing AD symptoms.
Last, acculturation has been found to be a contributing factor to AD, but the association is weaker. On the other hand, subjective experiences of discrimination, social isolation, and insufficient social contacts and network seem to significantly affect cognitive abilities impaired in AD.
Geographical variation has also been noted with regard to the prevalence of dementia. For instance, research including Asian cultures shows that the prevalence of dementia is lower among Indians and Malays as opposed to native Chinese in Singapore.
As evident from the growing research into the cultural basis of AD, a lot is still unknown and misunderstood. In order to have a holistic plan to manage AD in individuals, it is of utmost importance that we build on the cultural understanding of AD and cater to people of different cultures with cultural sensitivity.
