Are We Talking About the Same Thing? Black/African Americans' Response to the BRFSS Cognitive Decline and Caregiver Modules.

The Behavioral Risk Factor Surveillance System (BRFSS) is a randomized national U.S. telephone survey administered by state health departments. This study aimed to identify how Black/African Americans understand BRFSS caregiver and cognitive decline surveys and terminology to inform health messaging that centers the Black/African American experience. In focus groups, BRFSS surveys were administered to Black/African Americans (n = 30) aged ≥ 45 in Oregon. Participants were asked how they interpreted BRFSS terms 'memory loss' and 'confusion,' how these terms related to Alzheimer's and dementia, and about caregiving and cognitive decline experiences. The culturally responsive Africana Worldview guided interpretation, which centers the Black/African American experience and individuals within interdependent relationships and community identity when explaining behaviors of people from the African diaspora. BRFSS survey responses differed from focus group responses to the same questions. Two participants reported providing care in the past two years on the survey; in discussions, 21 participants reported providing care in the past two years. Interpretations of BRFSS terminology varied greatly. Differences between age-related cognitive changes, dementia and Alzheimer's disease were unclear. Cognitive decline was largely understood in terms of identity loss and relationship changes with the affected individual, and how that individual's relationship changed within community. Caution is advised when using BRFSS data to frame messaging because key cognitive health terms are not universally understood. Messaging that apply the Africana Worldview centralizes relationships and community rather than impact on individual's day-to-day activities, may be more effective for Black/African Americans and for other groups with different cultural and life experiences.

The African American Dementia and Aging Project (AADAPt): An Oregon-based Longitudinal Study.

Objectives: The vast majority of studies on aging, cognition, and dementia focus on non-Hispanic white subjects. This paper adds to the extant literature by providing insight into the African American aging experience. Here we describe the study design and baseline characteristics of the African American Dementia and Aging Project (AADAPt) study, which is exploring aging and cognition in African American older adults in Oregon. Methods: African American older adults (n=177) participated in AADAPt, a longitudinal study that collected data on cognitive, physical, and social functioning in annual visits since 2000. Results: AADAPt participants had risk factors for developing dementia in future, such as hypertension and hyperlipidemia, but also reported protective factors such as high social engagement. Conclusions: The AADAPt project offers new insights into aging in older African Americans that includes data on cognition, social engagement, and physical health, which are crucial for understanding the experience of under-represented groups and making future studies more inclusive. These findings reflect a window of time for a geographically-focused cohort, and the lessons learned from this study likely have broader implications for shaping the health of these older African American adults. Keywords: African American, Dementia, Observational Study.

Walking and Social Reminiscence in Gentrifying Neighborhoods: Feasibility and Impact on Cognitive, Physical, and Mental Health Among Older Black Adults in the SHARP Study.

BACKGROUND AND OBJECTIVES: Two exploratory 6-month pilots of triadic walking with culturally celebratory social reminiscence in gentrifying neighborhoods tested feasibility and health impact among normal and mildly cognitively impaired (MCI) older Black adults. RESEARCH DESIGN AND METHODS: Fourteen triads walked 1-mile 3x/week, using a navigational application with image-based reminiscence prompts. Focus groups evaluated perceived health impact and experience. Primary outcome measures were program evaluations (feasibility), pre-post self-report health, Montreal Cognitive Assessment, blood pressure, and weight. Analysis used mean rank scores for program evaluations, pre-post paired t-tests for health outcomes, and thematic coding for 30 focus groups. RESULTS: Feasibility: Retention was 74% and 86% for pilots, and 92%, respectively, were "extremely likely" to recommend to friends/family. Mean rank scores indicated appropriate pace and dose, effective conversational prompts, and program readiness with minor changes. Health impact: Self-rated health, mood, activity levels, and energy improved, days feeling downhearted decreased, and days feeling calm/peaceful were maintained or improved. Among Cohort 2, cognitive assessment scores were maintained or improved for 67%; for MCI, 76% had mean improvement of 2.4 (p=.045). Blood pressure and weight decreased for 78% and 44% respectively. Focus groups: Perceived impact of triadic walking included increased physical and social activity outside the program, increased awareness of cognitive decline risk and personal agency, and deep-seated sense of community connection. DISCUSSION AND IMPLICATIONS: Triadic walking provides structure, accountability, connection, and purpose, motivating sustained engagement. Walking programs that center socialization, particularly within culturally meaningful contexts, may be more effective among older Black adults.

Belonging, endurance, and resistance: Black placemaking theory in primary care.

Black-Americans continue to experience pervasive health disparities. Factors contributing to increased disease risk include a general mistrust of biomedical institutions among Black Americans. The purpose of this focus group study was to identify, among Black patients who regularly seek care from a primary provider, salient themes regarding barriers to 1) receiving quality primary care; and 2) adhering to medical recommendations. We examined transcripts of eight focus groups held remotely with 29 Black patients (aged 30-60 years) who had established primary care providers. Using grounded theory and an inductive thematic analysis of the transcripts, we identified three themes (belonging, endurance, and resistance) consistent with Black placemaking theory. Our findings suggest that reducing health disparities for Black Americans will require clinical initiatives that emphasize: 1) attention to social influences on health behavior and to features of medical institutions that mark them as White spaces (belonging); 2) recognition of, as well as sensitivity to, community awareness of the systemic and interpersonal barriers to health and safety that many Black adults endure; and 3) reframing avoidant (resistant) behaviors as protective strategies among Black patients. Examining primary care in this way-through the lens of Black placemaking theory-reveals how culturally meaningful approaches to harnessing the specialized knowledge and resilience that clearly exists among many Black communities can improve health care delivery.

Internet-Based Conversational Engagement Randomized Controlled Clinical Trial (I-CONECT) Among Socially Isolated Adults 75+ Years Old With Normal Cognition or Mild Cognitive Impairment: Topline Results.

BACKGROUND AND OBJECTIVES: Social isolation is a risk factor for cognitive decline and dementia. We conducted a randomized controlled clinical trial (RCT) of enhanced social interactions, hypothesizing that conversational interactions can stimulate brain functions among socially isolated older adults without dementia. We report topline results of this multisite RCT (Internet-based conversational engagement clinical trial [I-CONECT]; NCT02871921). RESEARCH DESIGN AND METHODS: The experimental group received cognitively stimulating semistructured conversations with trained interviewers via internet/webcam 4 times per week for 6 months (induction) and twice per week for an additional 6 months (maintenance). The experimental and control groups both received weekly 10 minutes telephone check-ins. Protocol modifications were required due to the coronavirus disease 2019 pandemic. RESULTS: A total of 186 participants were randomized. After the induction period, the experimental group had higher global cognitive test scores (Montreal Cognitive Assessment [primary outcome]; 1.75 points [p = .03]) compared with the control group. After induction, experimental group participants with normal cognition had higher language-based executive function (semantic fluency test [secondary outcome]; 2.56 points [p = .03]). At the end of the maintenance period, the experimental group of mild cognitive impairment subjects had higher encoding function (Craft Story immediate recall test [secondary outcome]; 2.19 points [p = .04]). Measure of emotional well-being improved in both control and experimental groups. Resting-state functional magnetic resonance imaging showed that the experimental group had increased connectivity within the dorsal attention network relative to the control group (p = .02), but the sample size was limited. DISCUSSION AND IMPLICATIONS: Providing frequent stimulating conversational interactions via the internet could be an effective home-based dementia risk-reduction strategy against social isolation and cognitive decline. CLINICAL TRIALS REGISTRATION NUMBER: NCT02871921.

Including Socially Isolated Black, Older Old Adults (Aged 80 and Above) with and without Mild Cognitive Impairment in a Clinical Trial: Recruitment Strategies and Perspectives.

Objective: This study describes strategies for the recruitment of socially isolated older old Black individuals to participate in the "Internet-based conversational engagement clinical trial (I-CONECT)" (Clinical Trial.gov: NCT02871921) and lessons learned in this critical population segment. Methods: Best practice strategies to recruit the target population included mass mailings, advertisements, and direct community outreach, including the collaboration with a community group created to reach Black individuals interested in research participation. We also made protocol changes to measure recruitment criteria for older old Black adults more accurately and to increase their participation. Results: Descriptive data related to the challenges and successes in recruiting Black participants compared to the White participants is presented. The primary site contacted 17,523 primarily White potential participants and enrolled/randomized 145 White and 2 Asian/mixed race participants (0.8%). The Midwest site contacted 12,141 Black potential participants and enrolled/randomized 39 (0.3%) participants. Discussion: While best practices were employed, several factors complicated recruitment, including the need to adjust recruitment criteria, navigate regional regulations, and respect diverse community preferences. Conclusion: Older old African Americans are reachable and willing to participate in research when considering their beliefs and practices, influenced by their community and experience.

Training the next generation of aging and cognitive health researchers.

Dementia is a growing public health concern, and African Americans and Latinos are disproportionately affected compared to White Americans. Improving cognitive health outcomes and reducing disparities requires a diverse, interdisciplinary workforce. The US Centers for Disease Control and Prevention's Healthy Brain Research Network (HBRN) Scholars Program trained racially/ethnically and gender-diverse scholars through mentored, collaborative research. Entry, exit, and alumni surveys and a Scholar Spotlight Series queried motivation, goals, acquired skills, accomplishments, program impact, and scholar perspectives. Scholars (n = 41) were majority female (n = 31, 75.6%), graduate students (n = 23, 56.1%), and racially/ethnically diverse (n = 20, 48.7%). Scholars primarily represented Medicine (n = 19, 46.3%) and Public Health (n = 12, 29.3%). Exiting scholars (n = 25) secured faculty/professional positions (n = 9, 36.0%), awards/funding (n = 12, 48.0%), and publications (n = 8, 32.0%). Alumni (n = 10) secured cognitive health-related positions/fellowships (n = 7, 70.0%). The HBRN Scholars Program is an adaptable model for other thematic networks to prepare scholars in collaborative skills critical for effective research and practice.

Traversing the Aging Research and Health Equity Divide: Toward Intersectional Frameworks of Research Justice and Participation.

Meaningful reductions in racial and ethnic inequities in chronic diseases of aging remain unlikely without major advancements in the inclusion of minoritized populations in aging research. While sparse, studies investigating research participation disparities have predominantly focused on individual-level factors and behavioral change, overlooking the influence of study design, structural factors, and social determinants of health on participation. This is also reflected in conventional practices that consistently fail to address established participation barriers, such as study requirements that impose financial, transportation, linguistic, and/or logistical barriers that disproportionately burden participants belonging to minoritized populations. These shortcomings not only risk exacerbating distrust toward research and researchers, but also introduce significant selection biases, diminishing our ability to detect differential mechanisms of risk, resilience, and response to interventions across subpopulations. This forum article examines the intersecting factors that drive both health inequities in aging and disparate participation in aging research among minoritized populations. Using an intersectional, social justice, and emancipatory lens, we characterize the role of social determinants, historical contexts, and contemporaneous structures in shaping research accessibility and inclusion. We also introduce frameworks to accelerate transformative theoretical approaches to fostering equitable inclusion of minoritized populations in aging research.

Optimization of Primary Care Among Black Americans Using Patient Portals: Qualitative Study.

BACKGROUND: Reduced patient portal use has previously been reported among Black Americans when compared with that of the general population. This statistic is concerning because portals have been shown to improve the control of chronic conditions that are more prevalent and severe in Black Americans. At their very simplest, portals allow patients to access their electronic health records and often provide tools for patients to interact with their own health information, treatment team members, and insurance companies. However, research suggests that Black American patients have greater concerns over a lack of support, loss of privacy, and reduced personalization of care compared with other Americans, which results in a disparity of portal use. OBJECTIVE: This qualitative investigation of primary care experiences of Black Americans from across the United States who participated in remote focus groups in April and May 2020 aims to explore the use and perceived value of patient portals to better understand any barriers to optimized treatment in the primary care setting. METHODS: We performed an inductive thematic analysis of 8 remote focus group interviews with 29 Black American patients aged 30-60 years to qualitatively assess the experiences of Black American patients with regular access to portals. RESULTS: Thematic analysis uncovered the following interrelated themes regarding patient portals in primary care: the optimization of care, patient empowerment, patient-provider communication, and patient burden. CONCLUSIONS: In contrast to what has been described regarding the reluctance of Black Americans to engage with patient portals, our focus groups revealed the general acceptance of patient portals, which were described overwhelmingly as tools with the potential for providing exceptional, personalized care that may even work to mitigate the unfair burden of disease for Black Americans in primary care settings. Thus, opportunities for better health care will clearly arise with increased communication, experience, and adoption of remote health care practices among Black Americans.

Whitest City in America: A Smaller Black Community's Experience of Gentrification, Displacement, and Aging in Place.

BACKGROUND AND OBJECTIVES: The influx of people with higher socioeconomic status into large Black communities is well documented; less is known regarding smaller, aging Black communities. Older Black adults in Portland, Oregon, among America's fastest gentrifying cities with the smallest metropolitan Black population, discussed barriers to healthy aging. Perspectives centered on the experience of gentrification, displacement, and its impact on social microsystems, place security, and aging in place. RESEARCH DESIGN AND METHODS: One-time focus groups engaged 41 Black adults aged at least 45. A demographic survey included residence area/duration. Discussions were thematically coded. Ecological Systems Theory guided interpretation. RESULTS: The majority of participants resided within gentrifying historically Black neighborhoods (89.2%), were aged at least 65 (54.6%), and lived in their neighborhood for at least 21 years (24.3%). Emergent discussion themes were rise and fall of Black ownership, displacement, race-related stress, and financial burden. Gentrification contributed to the dismantling of Black property ownership curated over generations, increased financial burden, and threatened place security. Physical displacement strained social networks, diminishing intergenerational neighborhood ties that supported aging in place. Cultural and physical displacement weakened the sense of social cohesion and belonging and induced race-related stressful interactions with new residents within original and relocation neighborhoods. DISCUSSION AND IMPLICATIONS: Gentrification in the Pacific Northwest echoes national trends, uprooting critical close-proximity social networks and deteriorating motivation to engage in neighborhood-based social activity. Smaller, aging Black communities may be particularly vulnerable to these effects, which critically affect aging in place. Data inform researchers and policymakers to better understand how gentrification affects smaller, aging Black communities.

Including older rural adults in research: Practical guidance for addressing the NIH Inclusion Across the Lifespan policy.

INTRODUCTION: The NIH Inclusion Across the Lifespan policy has implications for increasing older adult (OA) participation in research. This study aimed to understand influential factors and facilitators to rural OA research participation. METHODS: Thirty-seven rural adults aged ≥66 years participated in focus groups in community centers in four Oregon "non-metro" counties. Transcribed discussions were coded using open-axial coding by an interdisciplinary analytical team. RESULTS: Ages were 66-96 (mean 82.2) years. Majority were women (64%) and white (86%). Primary, interrelated discussion themes were Motivation and Facilitators, Perceptions of Research, and Barriers to Research Participation. Participants were motivated to engage in research because they believed research had implications for improved longevity and quality of life and potentially benefited future generations. Motivational factors influencing participation included self-benefit and improving others' lives, opportunities to socialize and learn about current research, research transparency (funding, time commitment, and requirements), and financial compensation. Perceptions influencing trustworthiness in research included funding source (industry/non-industry) and familiarity with the research institution. Barriers to research participation included transportation and concern about privacy and confidentiality. Suggestions for making research participation easier included researchers coming to rural communities and meeting participants in places where OAs gather and providing transportation and hotel accommodations. CONCLUSION: Lessons learned offer practical guidance for research teams as they address the new NIH Inclusion Across the Lifespan policy. Including OAs in research in ways that motivate and facilitate participation will be critical for a robust representation across the lifespan and in tailoring treatments to the specific needs of this population.

Perspective on the "African American participation in Alzheimer disease research: Effective strategies" workshop, 2018.

The Washington University School of Medicine Knight Alzheimer Disease Research Center's "African American Participation in Alzheimer Disease Research: Effective Strategies" Workshop convened to address a major limitation of the ongoing scientific progress regarding Alzheimer's disease and related dementias (ADRD): participants in most ADRD research programs overwhelmingly have been limited to non-Hispanic white persons, thus precluding knowledge as to how ADRD may be represented in non-white individuals. Factors that may contribute to successful recruitment and retention of African Americans into ADRD research were discussed and organized into actionable next steps as described within this report.

Results of a mindfulness intervention feasibility study among elder African American women: A qualitative analysis.

OBJECTIVES: . Older African Americans have a significantly higher risk than older white Americans for cognitive decline and other health problems. Much of this may be due to the unique stressors, both historically and in-the-moment, that African Americans face in contrast to whites, such as gentrification and health disparities. Gender further exacerbates this effect. This study aims to understand stressors unique to older African American women, as well as coping strengths that have emerged organically over time for use in tailoring stress-reduction mindfulness classes in this community DESIGN AND SETTING: . A four-week mindfulness training class adapted from mindfulness-based stress reduction (MBSR) was implemented in a historically black, gentrifying neighborhood in Portland, Oregon with 10 older African American women aged 50-89. MAIN OUTCOME MEASURES: . Focus groups discussed stressors, coping, responses to mindfulness classes, and preferences to better reflect older African American cultural values and norms. RESULTS: . Stressors reflected participants' intersectionality as older black women, including neighborhood and workplace race-based microagressions, and gentrification-related cultural and generational incongruences. Coping strategies included self-care, remembering core-self amidst stress, and drawing strength from family and faith. Participants found mindfulness classes appropriate for addressing stress and felt that classes provided a forum for connecting on issues of race and community. CONCLUSION: . Tailoring classes to older African American women should consider integrating biblical teachings, African American instructors who understand socio-historical contexts of older black women's stressors and strengths, and time for group-reflection to support community building.

Terms and Measures of Cognitive Health Associated With Dementia and Alzheimer's Disease: A Scoping Review.

The Healthy Brain Initiative: National Public Health Road Map to Maintaining Cognitive Health (2007) called on the research community to disseminate its work on cognitive aging and cognitive health. The purpose of this scoping review was to (1) identify terminology that cognitive, social, and behavioral scientists use to describe cognitive aging and cognitive health, in association with dementia and Alzheimer's disease, among older adults; (2) demonstrate how such terms are defined; and (3) illustrate how these constructs are measured in research settings. Empirical studies published 2007-2018 were examined for terminology, definitions, disciplinary orientation, and measurement mechanisms. Analysis of the corpus and a detailed review of the terms "cognitive impairment" and "mild cognitive impairment" reveal that formal definitions are provided infrequently and measurement of constructs ranges widely. Overall, the variability in terminology, definitions, and measures reflects a need for greater specificity in research communication, such that cross-disciplinary collaboration can be facilitated.

Overcoming Barriers to Adopting and Implementing Pharmacotherapy: the Medication Research Partnership.

Pharmacotherapy includes a growing number of clinically effective medications for substance use disorder, yet there are significant barriers to its adoption and implementation in routine clinical practice. The Medication Research Partnership (MRP) was a successful effort to promote adoption of pharmacotherapy for opioid and alcohol use disorders in nine substance abuse treatment centers and a commercial health plan. This qualitative analysis of interviews (n = 39) conducted with change leaders at baseline and at the end/beginning of 6-month change cycles explains how treatment centers overcame obstacles to the adoption, implementation, and sustainability of pharmacotherapy. Results show that barriers to adopting, implementing, and sustaining pharmacotherapy can be overcome through incremental testing of organizational change strategies, accompanied by expert coaching and a learning community of like-minded professionals. The greatest challenges lie in overcoming abstinence-only philosophies, establishing a business case for pharmacotherapy, and working with payers and pharmaceutical representatives.

Things Are Changing so Fast: Integrative Technology for Preserving Cognitive Health and Community History.

Background and Objectives: Multimodal interventions are increasingly targeting multiple cognitive decline risk factors. However, technology remains mostly adjunctive, largely prioritizes age relevancy over cultural relevancy, and often targets individual health without lasting, community-wide deliverables. Meanwhile, African Americans remain overburdened by cognitive risk factors yet underrepresented in cognitive health and technology studies. The Sharing History through Active Reminiscence and Photo-imagery (SHARP) program increases physical, social, and cognitive activity within a culturally meaningful context that produces community deliverables-an oral history archive and cognitive health education. Design and Methods: The SHARP application was tested with 19 African Americans ≥55 years, aiming for an easy, integrative, and culturally meaningful experience. The application guided triads in walks 3 times weekly for 6 months in Portland, Oregon's historically Black neighborhoods; local historical images prompted recorded conversational reminiscence. Focus groups evaluated factors influencing technology acceptance-attitudes about technology, usefulness, usability, and relevance to integrating program goals. Thematic analysis guided qualitative interpretation. Results: Technology acceptance was influenced by group learning, paper-copy replicas for reluctant users, ease of navigation, usefulness for integrating and engaging in health behaviors, relevance to integrating individual benefit and the community priority of preserving history amidst gentrification, and flexibility in how the community uses deliverables. Perceived community benefits sustained acceptance despite intermittent technology failure. Discussion and Implications: We offer applicable considerations for brain health technology design, implementation, and deliverables that integrate modalities, age, and cultural relevance, and individual and community benefit for more meaningful, and thus more motivated community engagement.

Considerations for Research and Development of Culturally Relevant Mindfulness Interventions in American Minority Communities.

As many health disparities in American minority communities (AMCs) are stress-related, there has been an increased interest in the development of mindfulness programs as potential stress reduction measures in these communities. However, the bulk of the extant literature on mindfulness research and mindfulness interventions is based upon experiences with the larger White community. The intent of this commentary is to share a framework that includes key cultural considerations for conducting research and developing culturally-salient mindfulness programs with AMCs. We build on our experiences and the experiences of other researchers who have explored mindfulness in African and Native American communities; in particular, we examine issues around community outreach with an emphatic gesture toward emphasizing protection of AMCs and their participants. Discussed are considerations with respect to attitudinal foundations in mindfulness-based research and program development with these communities. However, the overall message of this paper is not to provide a "to-do" list of research steps, but to rather, encourage researchers to turn inward and consider the development of skillful characteristics that will increase the likelihood of a successful research venture while also protecting the cultural traditions of the AMC of interest.

Promoting Adoption of Medication for Opioid and Alcohol Use Disorders Through System Change.

OBJECTIVE: The Medication Research Partnership (MRP), a collaboration between a national commercial health plan and nine addiction treatment centers, implemented organizational and system changes to promote use of federally approved medications for treatment of alcohol and opioid use disorders. METHOD: A difference-in-differences analysis examined change over time in the percentage of patients receiving a prescription medication for alcohol or opioid use disorders treated in MRP (n = 9) and comparison (n = 15) sites. RESULTS: MRP clinics experienced a 2.4-fold increase in patients receiving an alcohol or opioid prescription (13.2% at baseline to 31.7% at 3 years after MRP initiation); comparison clinics experienced significantly less change (17.6% to 23.5%) with an adjusted difference-in-differences of 12.5% (95% CI [5.4, 19.6], p = .001). MRP sites increased the patients with prescriptions to treat opioid use disorder from 17.0% (baseline) to 36.8% (3 years after initiation), with smaller changes observed in comparison sites (23.2% to 24.0%) and a 3-year post-initiation adjusted difference-in-differences of 19% (95% CI [8.5, 29.5], p = .000). Medications for alcohol use disorders increased in both MRP (9.0% to 26.5%) and comparison sites (11.4% to 23.1%). CONCLUSIONS: Promoting the use of medications to support recovery required complex interventions. The Advancing Recovery System Change Model, initially developed in publicly funded systems of care, was successfully adapted for commercial sector use. The model provides a framework for providers and commercial health plans to collaborate and increase patient access to medications.

Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use.

The Medication Research Partnership (a national health plan and nine addiction treatment centers contracted with the health plan) sought to facilitate the adoption of pharmacotherapy for alcohol and opioid use disorders. Qualitative analysis of interviews with treatment center change leaders, individuals working for the manufacturer and its technical assistance contractor, and health plan managers extracted details on the processes used to order, store, bill for, and administer extended-release naltrexone. Qualitative themes were categorized using domains from the Consolidated Framework for Implementation Research (intervention characteristics, outer setting, inner setting, and provider characteristics). Characteristics of XR-NTX that inhibited use included the complexity of ordering and using the medication; cost was also a barrier. Outer setting barriers reflected patient needs and external health plan policies on formulary coverage, benefit management, and reimbursement. Program structures, the lack of physician linkages, a culture resistant to the use of medication, and unease with change were inner setting elements that limited use of XR-NTX. Patient stereotypes and a lack of knowledge about XR-NTX affected practitioner willingness to treat patients and prescribe XR-NTX. The Consolidated Framework for Implementation Research provided a useful lens to understand and interpret the processes affecting access to XR-NTX.