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Black–White Disparities in Functional Decline in Older Persons: The Role of Cognitive Function

¹ San Francisco Veterans Affairs Medical Center, California.
² Department of Medicine, Division of Geriatrics, University of California, San Francisco.
³ School of Nursing and Center for Aging and Life Course, Purdue University, West Lafayette, Indiana.

Address correspondence to Sandra Moody-Ayers, MD, or Kenneth Covinsky, San Francisco VA Medical Center (181G), 4150 Clement Street, San Francisco, CA 94121. E-mail: sandra.moody{at}med.va.gov or covinsky{at}medicine.ucsf.edu

Background. Black elders have a greater frequency of functional decline than do white elders. The impact of cognitive function on explaining black–white disparities in functional decline has not been extensively explored.

Methods. To compare the extent to which different risk domains (comorbidity, smoking, socioeconomic status (SES), self-rated health, and cognitive function) explain more frequent functional decline in black elders, we studied 779 black and 4892 white community-dwelling adults aged 70 and older from the Assets and Health Dynamics Among the Oldest Old (AHEAD), a population-based cohort study begun in 1993. Our primary outcome was worse functional status at 2 years than at baseline. We used logistic regression to compare the unadjusted with the adjusted black–white odds ratios (ORs) after adjusting for each risk domain.

Results. At baseline black participants aged 70–79 had higher rates of smoking, diabetes, and hypertension; lower SES; and worse cognitive function than did white participants (p <.05 for all). The mean cognitive score was 15.7 in black and 21.8 in white participants (p <.01). Black participants had a higher frequency of 2-year functional decline than did white participants (10.9% vs 4.7%; OR = 2.61, 95% confidence interval [CI], 1.69–4.03 adjusted for age and sex). Adjustment for comorbidity and smoking did not significantly change the black–white OR, whereas self-rated health and SES accounted for about half the risk. Adjustment for cognitive function accounted for nearly all the associated decline (OR = 1.10, 95% CI, 0.67–1.79). Among participants aged 80 and over, those who were black had significantly lower risk for functional decline after adjustment for cognitive function (OR = 0.61, 95% CI, 0.38–0.96 vs OR = 1.08, 95% CI, 0.70–1.66 adjusted for age and sex only).

Conclusions. Cognitive function mediated the higher frequency of functional decline among black elders. Efforts to understand cognitive function may enhance our understanding of black–white disparities in health outcomes.