1. Do Māori and Pacific peoples present with dementia at a younger age?
Saturday, 27th October 2018
Do Māori and Pacific peoples present with dementia at a younger age?
Dr Susan Yates
Clinical Psychologist / Neuropsychologist / Research Fellow
Ethnicity may affect presentation to clinical services in people with dementia; however, no studies have examined this in Māori or Pacific peoples in New Zealand (NZ). Our objective was to examine the routinely collected clinical data from a memory assessment service in South Auckland to examine the presentation of dementia in major NZ ethnic groups.

2. Estimated Dementia in NZ
2016 estimates:
62,287 people in NZ have dementia, with 170,212 by 2050
Total economic cost associated: $1.7 billion
Total burden of disease cost associated: $5.0 billion
Overseas research indicates 50 – 80% of cases are undiagnosed/undocumented
Based on 2016 estimates, over 62,000 people in NZ have dementia and by 2050 over 170,000 people will have dementia. Despite this, research suggests between 50-80% of cases are not diagnosed or documented, despite the huge financial cost that this has on the health system as well as families.

3. Estimated Dementia in NZ
But these are estimates – what about actual data?

4. Real NZ Data
NZ DHB data
CDHB Princess Margaret Hospital: Strong link between PWD and cargiver QoL; costs increase with dementia severity; increased carer distress with less support
Data collection is poor or not routinely collected on dementia in most health settings
Other existing research
‘Dementia in Old age and the need for services’ (1983)
LiLACS NZ Study: No difference between older Maori and non-Maori for dementia prevalence. ? Accuracy as only a screening and not a Maori-specific tool.
Margaret Dudley: A Maori approach to the assessment and management of dementia (ongoing research)
The answer is there is little actual data available. What we do know, is that based on a PhD research study of 53 people with dementia and their carers in Canterbury, there is a strong link between the QoL of people with dementia and their carers, that increased costs were associated with increased dementia severity; and increased carer distress was associated with less support.
Otherwise data in DHB settings collection is poor or not routinely collected on dementia in most health settings
In the early 80, 598 people over the age of 65 were approached (all people over 80, 1/6 between 75-79, and 1/20 in years) in both community and residential homes. Based on administration of the MSQ (questionnaire scored out of 10) and third party questions,
7.7% of participants were considered to have a diagnosis of moderate or severe dementia. No data provided on ethnic differences.
The LiLACS NZ Study more recently also looked at dementia as one of their subfindings. The outcomes of this indicated that there is no difference in dementia prevalence between older Maori and non-Maori, but they questioned the accuracy of the assessment as it was not a Maori-specific tool.

5. CM Health Memory Team
Retrospective observational study using routinely collected clinical data from people referred to the Counties Manukau Health Memory Team
Referral criteria: primary concern of observable cognitive decline, irrespective of age. Community dwelling.
Demographic data (age, sex and ethnicity) and dementia sub-type and severity were analysed.

6. CM Health Memory Team 1106 people referred in 4 years (2013-2016)
Mean age = 74.6 years. 42% = male
40% NZ European, 26% Pacific peoples, 16% Māori, 5% Asian, 12% other/unknown (equivalent to CMDHB population)
785/1106 were assessed (remainder diverted or declined)
74 required an interpreter (mostly Pacific, n=65)
60% dementia (77% new), 13% MCI, 17% deferred due to medical or psychiatric illness, 10% no diagnosis.
Our sample: 360 patients with a new diagnosis of dementia

7. Univariate results NZ European Pacific Māori Other Total (n=360)
NZ European
Pacific
Māori
Other
Total (n=360)
Sample size
142 (39%)
126 (35%)
42 (12%)
49 (14%)
360 (100%)
Mean age (SD)
79.2 (7.4)
74.3 (7.6)
70.2 (7.6)
78.0 (8.5)
76.2 (8.3)
Gender
(n, % male)
65 (46%)
44 (35%)
17 (40%)
25 (51%)
151 (42%)
Dementia severity
Mild
dementia
81 (57%)
56 (44%)
25 (58%)
187 (52%)
Moderate to severe dementia
61 (43%)
70 (56%)
18 (42%)
24 (49%)
173 (48%)
Dementia subtype
Alzheimer’s disease
67 (47%)
51 (40%)
21 (49%)
23 (47%)
162 (45%)
Vascular dementia
23 (16%)
18 (14%)
10 (23%)
4 (8%)
55 (15%)
Mixed dementia
32 (23%)
38 (30%)
4 (9%)
8 (16%)
82 (23%)
Other dementias
20 (14%)
19 (16%)
8 (18%)
14 (29%)
61 (17%)

8. Multivariate results: age, ethnicity and dementia subtype
NZ European (n=142)
Pacific (n=126)
Maori (n=43)
Least squares mean age adjusted for ethnicity AD
78.3 (7.7)
n=67
73.1 (6.7)
n=51
70.2 (8.0)
n=21
75.0
95% CI: VD
79.6 (5.8)
n=23
74.0 (8.0)
n=18
72.5 (4.8)
n=10
76.7
95% CI:
Mixed
83.6 (6.1)
n=32
76.9 (6.9)
n=38
73.8 (6.0)
n=4
79.2
95% CI:
Other dementia
74.9 (6.8)
n=20
72.8 (9.9)
n=19
65.6 (11.3)
n=8
72.2
95% CI:

9. So what does it mean?
Māori & Pacific peoples presenting at younger ages
Possible reasons:
Selection bias – memory service sample but sample is representative of local population
Clinician bias – dementia severity and subtype
Confounding due to reduced life expectancy - but would expect reduced numbers also
Chance – p values for age are <0.0001
Or is it a real effect?
Similar findings in studies of indigenous populations Canada, Australia, United States, Guam and Brazil.

10. To find out we need an NZ dementia prevalence study
Possible mechanisms of action: is dementia onset brought forward?
Genetic risk factors: population differences in apoE4 genotypes?
Socioeconomic risk factors: education, deprivation
Medical risk factors: hypertension, diabetes, heart disease, stroke, diet, smoking, alcohol, TBI, hearing loss
To find out we need an NZ dementia prevalence study

11. LiDiA timeline 2018: Qualitative research in Māori, Pacific & Asian
2019: Translation & validity testing of 10/66 dementia protocol in Te Reo Maori, Samoan, Tongan, & Hindi
2019: Feasibility study for sampling methods
2020: NZ dementia prevalence study?
So what next?
Understanding the lived experience of dementia
Qualitative interviews with multiple communities & languages
10/66 Validity Study
Maori
Indian
Samoan
Tongan
Feasibility Study
Interviewing people in their communities, and working out the practicalities of this
And then hopefully a national NZ dementia prevalence study

12. LiDiA research team leads:
Sarah Cullum (PI)
Margaret Dudley (Māori)
Fiva Fa’alau (Samoan)
Tony Kautoke (Tongan)
Rita Krishnamurthi (Indian)
Gary Cheung (Chinese)
Susan Yates
Ngaire Kerse
Contact:

13. References
Campbell, A.J., McCosh, L.M., Reinken, J. & Allan, B.C. (1983). Dementia in old age and the need for services. Age and Ageing, 12,
Cullum, S., Mullin, K., Zeng, I., Yates, S., Payman, V., Fisher, M., & Cheung, G. (2018). Do community dwelling Māori and Pacific peoples present with dementia at a younger age and at a later stage compared with NZ Europeans? International Journal of Geriatric Psychiatry, 33(8),
Dementia Economic Impact Report 2016
Gallrach, F. (2010). Quality of Life of People with Dementia and their informal caregivers: A clinical and economic analysis in New Zealand. PhD Thesis, University of Canterbury.
Kerse N, Lapsley H, Moyes S, Zawaly K, Hayman K, LiLACS NZ Dementia: Supplementary Findings from LiLACS NZ for Section Five, ‘Service Use and Common Health Conditions’ in the report ‘Health, Independence and Caregiving in Advanced Age’. Auckland. School of Population Health, The University of Auckland.
Prince M., Bryce R., Ferri C. Alzheimer's Disease International (ADI); London: World Alzheimer Report 2011—The Benefits of Early Diagnosis and Intervention.