Association of Race, Ethnicity, Education, and Neighborhood Context With Dementia Prevalence and Cognitive Impairment Severity Among Older Adults Receiving Medicaid-Funded Home and Community-Based Services

Published:December 04, 2022DOI:


      • What is the primary question addressed by this study?
        How do dementia prevalence and cognitive impairment severity vary according to race, ethnicity, educational attainment, and neighborhood context in a population of older adults receiving Medicaid-funded home- and community-based services in lieu of nursing home care?
      • What is the main finding of this study?
        Compared with non-Hispanic White individuals, Hispanic, but not non-Hispanic Black, individuals in the study cohort had greater severity of cognitive impairment. Dementia prevalence and cognitive impairment severity were both greater among those with less than high school education, and both were greater among those living in neighborhoods that were less socially vulnerable.
      • What is the meaning of the finding?
        Racial and ethnic group differences in dementia and cognitive impairment severity are less pronounced among older adults receiving Medicaid home- and community-based services than among other community-dwelling older adults, and older adults receiving these services may be more likely to move to lower social vulnerability neighborhoods where family members reside when they have dementia and more severe cognitive impairment.



      While racial, ethnic, and socioeconomic group disparities in cognitive impairment and dementia prevalence are well-documented among community-dwelling older adults, little is known about these disparity trends among older adults receiving Medicaid-funded home- and community-based services (HCBS) in lieu of nursing home admission. The authors determined how dementia prevalence and cognitive impairment severity compare by race, ethnicity, educational attainment, and neighborhood context in a Medicaid HCBS population.


      A cross-sectional study in Connecticut.


      Adults age ≥65 in the HCBS program, January-March 2019 (N = 3,520).


      The data source was Connecticut's HCBS program Universal Assessment tool. The authors employed two outcomes: Cognitive Performance Scale (CPS2), a 9-point measure ranging from cognitively intact-very severe impairment; and presence or not of either diagnosed dementia or CPS2 score ≥4 (major impairment). Neighborhood context was measured using the Social Vulnerability Index (SVI).


      Cohort characteristics: 75.7% female; mean(SD) age = 79.1(8.2); Non-Hispanic White = 47.8%; Hispanic = 33.6%; Non-Hispanic Black = 15.9%. Covariate-adjusted multivariate analyses revealed no dementia/major impairment prevalence differences among White, Black, and Hispanic individuals, but impairment severity was greater among Hispanic participants (b = 0.22; p = 0.02). People with more than HS education had less severe impairment (b = −0.12; p <0.001) and lower likelihood of dementia/major impairment (AOR = 0.61; p <0.001). Dementia/major impairment likelihood and impairment severity were greater in less socially vulnerable neighborhoods.


      Racial and ethnic group differences in cognitive impairment are less pronounced in Medicaid-funded HCBS cohorts than in other community-dwelling older adult cohorts. SVI results suggest that, among other possible explanations, older adults with dementia may move to lower social vulnerability neighborhoods where supportive family members reside.

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