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Social patterning of cognitive impairment in Colombia: evidence from the SABE 2015 study

BMC Geriatrics volume 24, Article number: 1002 (2024) Cite this article

Abstract

Introduction

Dementia, an increasingly critical public health concern in low and middle-income countries, is associated with lower socioeconomic status, early cognitive impairment, and elevated dementia-related mortality risk. This study seeks to estimate the prevalence of cognitive impairment, investigate its links with social indicators, and visualize social gradients across different regions in Colombia.

Methods

Secondary data analysis from the SABE 2015 survey, multinomial regression analyses, and equiplot graphs.

Results

A sample of 23,694 individuals 60 years or older from Colombia. Higher risks were observed among individuals with dark skin color (OR 1.27; 95%CI: 1.10 – 1.47), lower educational levels (OR 3.01; 95%CI:2.04 – 4.42) and reading illiteracy (OR 2.14; 95%CI: 1.87 – 2.46). Inequity patterns were identified by region of residence and income.

Discussion

This study underscores the need for targeted interventions aimed at reducing health inequities. The results highlight the higher prevalence rates of cognitive impairment among socially disadvantaged individuals.

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Background

Worldwide, dementia cases are on the rise, currently affecting 50 million people, with over half of those affected living in low and middle-income countries. This number is expected to grow significantly, particularly in the Americas, where estimates suggest that 63% of the population will be affected by 2030, and this figure will rise to 68% by 2050 [1, 2].

Health outcomes, including the risk of dementia, often follow a social gradient, with individuals of lower socioeconomic status (SES) experiencing worse health than those who are more advantaged [3, 4]. People with low SES are more vulnerable to poor mental health, early cognitive impairment, and higher dementia-related mortality [5, 6]. Social factors such as income, education, and employment significantly influence the rates and severity of cognitive impairment and dementia symptoms [7]. Furthermore, the unequal distribution of known dementia risk factors such as access to education, a healthy diet, and treatment for non-communicable diseases exists across countries [8]. Studies, primarily from high-income countries, have shown that lower educational levels, manual occupations, and low income are linked to higher dementia risks [9,10,11,12,13,14]. Additionally, higher dementia incidence has been observed among women and ethnic-racial minorities in the United States, including African Americans, Latinos-Hispanics, and American/Alaska Native Indigenous populations [15,16,17,18,19].

Dementia has no cure yet, but it has modifiable risk factors that make it somehow preventable. Public health strategies aimed at addressing these factors could reduce or delay 40% of cases globally, lowering associated costs and burdens [20,21,22]. In Latin America, modifying risk factors could prevent 56% of dementia cases due to its distinct population profile [23].

In Colombia, health inequities have been described among women and indigenous people [24], regarding the incidence of high blood pressure [25], a risk factor for dementia, and mental health disorders [26]. Studies show that cardiovascular and metabolic risk, strongly linked with dementia risk, have an inverse relation to education in women and a positive relation to physical capital in men [27]. Dementia has been found to be more prevalent among low SES groups in Colombia [28,29,30,31,32]. Nevertheless, the social pattern of cognitive impairment in the older population based on multiple social factors remains unknown.

Using the information from the SABE 2015 study in Colombia [33], this study has three aims. First, to estimate the overall prevalence of cognitive impairment without dementia and dementia in Colombia and across social groups. Second, to establish the association between indicators of social position and both outcomes. Finally, to identify graphically if there is a social gradient for the prevalence of both outcomes across social categories within Colombian regions. The significance of this study lies in its ability to offer quantitative data that can advocate for the importance of interventions aimed at preventing cognitive impairment and reducing health disparities within high-risk and disadvantaged populations.

Based on the evidence mentioned above, we proposed a conceptual model that shows the relationship between indicators of social position and cognitive impairment (Fig. 1). This conceptual model offers a comprehensive view of the factors influencing the social gradient of cognitive impairment in Colombia. It places education as a crucial socioeconomic status indicator but acknowledges the roles of other indicators like occupation, income, and physical capital. Additionally, it considers leisure activities as indirect indicators of SES. Beyond SES, the model highlights the impact of other social determinants, including ethnicity/race and place of residence in Colombia regions. These factors may interact with non-modifiable risk factors such as age and sex, contributing to the complex landscape of cognitive health disparities in the Colombian population.

Fig. 1
figure 1

Conceptual Model

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Methods

We conducted a secondary data analysis for a cross-sectional study using data from the Colombian Survey on Health, Wellbeing, and Aging 2015 (SABE Colombia 2015 for its acronym in Spanish). SABE Colombia 2015 was the first nationally representative study of aging in this country. The survey population was people above 60 years old. Individuals were selected for face-to-face computer-assisted personal interviews using a multi-stage cluster sampling procedure, using municipalities as the primary sampling unit. The total sample size was 23,694 individuals from 244 municipalities and all 32 departments [33]. The Universidad de Los Andes IRB approved the study reported in this paper.

The dependent variable was cognitive impairment, as measured in SABE Colombia 2015 [33]. This survey used a modified version of the Folstein Mini-Mental State Examination (MMSE), validated in Spanish for the Chilean version of the SABE survey. Out of 19 possible points, a cutoff point of 12 or less indicated cognitive impairment, while a score of 13 or above was considered normal [34]. Functional impairment was evaluated using four items of the Lawton and Brody functional scale [35]: phone use, transport use, handling medicines, and money management. Dementia was defined by the presence of cognitive impairment with functional impairment. Participants were classified as having cognitive impairment without dementia (CIWD) if they exhibited cognitive impairment but did not show functional impairment.

Indicators of social position included in this study were education, lifetime occupation, income, household assets, retirement benefit (type of pension plan) and race. Educational attainment was established based on the 11 categories reported by SABE 2015. We classified participants into three groups according to their educational qualifications: those with an educational qualification lower than completion of primary school, those who had completed primary school, and those with more than high school education. Reading literacy was reported using a yes/no self-reported question. For race, the survey employed an eleven-point skin color palette, with skin color defined by the pollster. For lifetime occupation, ten categories included in the SABE study were taken to classify participants into three groups: worker or dependent worker, chief or independent worker, and none. For income, three categories were built according to Colombia’s minimum wage (MW) in 2015: less than one MW, one to two MW, and more than two MW. A physical assets index was made taking the availability at the home of the following assets: radio, television, sound device, DVD, fan, computer, cellular phone, fridge, blender, washing machine, electric/gas oven, microwave oven, vacuum cleaner, water heater, air-conditioned, internet, cable television. Then participants were classified into tertiles: first (more deprived) had a mean of 4.2 assets, second a mean of 7.9 assets, and third (privileged) had a mean of 11.7 items. For this study, skin color was categorized into three groups: light (ranging from 1 to 3), medium (4 and 5), and dark (6 and above), following the procedures outlined in the SABE study [36].

Using an 18-item questionnaire reported by SABE 2015, we constructed a 6-item continuous variable for participation in leisure activities. Five items were considered cognitively challenging (reading, solving math problems, solving puzzles, tabletop games, attending classes or courses), and one included physical activity.

As covariates, we included sex, age in years, area of residence (urban, rural), marital status (married/with a partner, separated/widower, single), living alone (yes/no), and geographic region of residence were categorized according to the SABE study as follows: Atlantic (located in the north coast, including Caribbean insular territories), Pacific (located on the western coast), East Region, Orinoquia and Amazonia (located in the south and southeast area), Bogotá, and Central (located in the central area and Andean Region).

Statistical analysis

We conducted a descriptive data analysis using frequencies and percentages for qualitative variables and means and standard deviations for quantitative variables. For the first aim, we estimated overall dementia and CIWD proportions and proportions for both outcomes across the different social position variables. Also, we estimated the proportion of CIWD and dementia for age groups (60–69, 70–77, and 80 and more). Regarding the second aim, we estimated odds ratios (OR) using multinomial regression analyses. We regressed dependent variables (CIWD and dementia) on the independent social position variables of interest for this study (skin color, lifetime occupation, income, physical tertile, educational level, reading literacy, and leisure activities)). Finally, we examined associations between independent variables and CIWD and dementia using multinomial regression analyses with progressive models to get insights into how these factors were associated with CIWD and dementia; models were constructed according to the less to most modifiable factors and were adjusted for age, sex, skin color, occupation, income, physical capital, educational level and leisure activities. Multicollinearity was tested using the variance inflation factor (VIF). Results are presented as OR with 95% confidence intervals (CI). For aim three, based on the results of the multinomial regressions, we chose skin color, occupation, income, educational level, reading literacy, and leisure activities for inequity analyses. Equiplot graphs were used to identify health inequities according to the selected variables and country region of residence for dementia and CIWD. All analyses were performed using STATA release 16 (StataCorp LP, College Station, USA).

Results

The survey sample size was 23,694 participants, with a mean age of 70.82 years (standard deviation [SD] 8.20); 57.3% were women. The most frequent occupation was worker or dependent worker (64,89%) and an income lower than one minimum wage (68,7%). Most participants had an educational qualification lower than primary school completion (62.6%). Reading literacy was reported as 78.2% (Table 1). The prevalence of CIWD was 8.9 and 10.8% for dementia. The prevalence of normal cognitive function decreased with age, from 91.1% in the 60–69 age group to 49.2% in those over 80 years old. The prevalence of cognitive impairment without dementia (CIWD) increased with age, from 6.0% in the 60–69 age group to 13.7% in those over 80. The prevalence of dementia also increases dramatically with age, from 2.94% in the 60–69 age group to 37.1% in those over 80 years old (Table 2).

Table 1 Descriptive Statistics of patients in the SABE study
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Table 2 Distribution of prevalence of cognitive classification by age group in adults over 60 years old
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Figure 2 shows the prevalence of CIWD and dementia according to social position variables. A comparison of the proportions for independent variables for each of the dependent variables (dementia and CIWD) is shown; statistically significant differences were found between the categories of each variable for all independent variables (p < 0.001).

Fig. 2
figure 2

Prevalence of cognitive impairment without dementia (CIWD) and dementia according to Social Position Variables. MW (minimum wage), PS (Primary School), HS (High School)

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Table 3 shows unadjusted OR for social position variables. Participants with less than primary school education had a positive association for CIWD (OR 10.18; 95%CI: 7.33 – 14.15) and dementia (OR 8.54; 95%CI 6.52- 11.17) than those with an educational level higher than high school. Reading illiteracy was associated with a higher likelihood of having CIWD (OR 4.70; 95%CI 4.28 – 5.17), or dementia (OR 6.43;95%CI 5.90 – 7.02). Participation in leisure activities was a protective factor against CIWD and dementia (OR 0.56; 95%CI 0.54–0.59), (OR 0.36; 95%CI 0.34–0.38), respectively. Analysis of multicollinearity did not show collinearity between the selected variables.

Table 3 No adjusted multinomial regression analysis
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Table 4 shows multinomial regression models adjusted for potential confounders. In model 1 for CIWD, participants with dark (OR 1.65, 95%CI: 1.44 – 1.90) and medium skin color (OR 1.33, 95%CI: 1.19 – 1.49) were more likely to have CIWD than participants with light skin color. In model 2, the negative association of dark and medium skin color with CIWD persists. In addition, no having occupation (OR 1.22, 95%CI: 1.01 -1.47) and an income less than one minimum wage (OR 2.64; 9%CI 1.75 – 3.95) or from one to two minimum wages (OR 1.90; 95%CI: 1.26 – 2.86) were associated with CIWD. In model 3, the effect of skin color persists, and the effect of occupation and income variables associated with CIWD disappeared. In this model, a lower educational level was found as an associated factor for CIWD for less than primary school (OR 5.77; 95%CI 3.96 – 8.42) and complete primary school (OR 2.66; 95%CI: 1.81 – 3.90) in comparison with more than high school educational level. Finally, in model 4 dark skin color effect persists (OR 1.27; 95%CI: 1.08–1.50), worker or dependent worker shows a protective effect (OR 0.87; 95%CI: 0.76 – 0.99), as well as having a deprived physical capital index in tertile one (OR 0.66; 95%CI: 0.56 – 0.79) or two (OR 0.76; 95%CI: 0.64 – 0.90) in comparison with tertile three, low educational attainment persists as an associated factor and reading illiteracy shows higher probability for developing CIWD (OR 2.14; 95%CI: 1.87 – 2.46), leisure activities were found to have a protective effect (OR 0.72; 95%CI: 0.68 – 0.76).

Table 4 Multinomial adjusted analyses with progressive models
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For dementia, in model 1 (Table 4), participants with dark skin color were more likely to develop dementia (OR 1.27; 95%CI: 1.10 – 1.47) than participants with light skin color; for medium skin color, results did not show a statistically significant association. In model 2, dark skin color persisted as a factor associated with dementia. In the same way, not having an occupation (OR 1.26; 95%CI: 1.04- 1.52), income less than one minimum wage (OR 2.57; 95%CI: 1.63 – 4.03), or from one to 2 minimum wages (OR 1.65; 95%CI: 1.05 – 2.59) and being at tertile one of physical capital (OR 1.21; 95%CI: 1.02 – 1.44) were identified as associated factors. In model 3, the effect of dark skin color and not having occupation disappeared, the association with income less than one minimum wage (OR 1.67; 95% CI: 1.05 – 2.67) with dementia persists, and the effect of physical capital disappeared. An educational level less than primary school showed a higher likelihood of having dementia (OR 3.34; 95%CI: 2.33–4.77). In model 4, having a worker or dependent occupation shows a protective association with dementia (OR 0.85; 95%CI: 0.74–0.99) as well as physical capital tertile one and two (OR 0.72; 95%CI: 0.59 – 0.87) and (OR 0.79; 95%CI: 0.66 -0.95) respectively. In the fully adjusted model, there was no significant statistical association between educational level and dementia, nevertheless reading illiteracy was a factor associated to dementia (OR 2.22; 95%CI: 1.92 – 2.56), and leisure activities participation showed a protective effect (OR 0.50; 95%CI: 0.46 – 0.54).

The equiplots in Fig. 3 reflect the inequities by showing the proportion of cases in the most disadvantaged groups and the distance between the dots. Longer lines represent larger absolute inequities. The findings reveal that the Central region had the greatest inequity for skin color, with individuals with darker skin having higher proportions of CIWD cases. The Orinoquia/Amazonia region had more proportion of dementia for individuals with dark skin color, while the Pacific region showed inequities for medium and dark skin color. Regarding occupation, the Orinoquia/Amazonia region had the highest inequities for unemployed workers. The disadvantage was evident for unemployed workers living in Bogota, Pacific, and Orinoquia/Amazonia regions regarding dementia. For income and CIWD, the Atlantic and Pacific regions showed a linear pattern of inequity evidenced by the similar distance between dots, while for dementia, all the regions except the Atlantic showed a linear pattern.

Fig. 3
figure 3

Equiplots showing the proportion of cases of cognitive impairment without dementia (CIWD) and dementia for SES (Socioeconomic Status) factors by region. L (light), M(medium), D (dark), U (unemployed), DW (dependent worker), IW (independent worker), MW (minimum wage), HS (high school), PS (primary school), RI (reading illiteracy), RL (reading literacy)

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Regarding educational level and CIWD, inequities were present in the Atlantic, Pacific, and Orinoquia/Amazonia regions for less than primary school education. For dementia, all regions had more cases in the less-than-primary school group. Reading literacy also showed higher inequities across all regions, with Bogota, Pacific, and Orinoquia/Amazonia having the largest inequities in dementia cases.

Discussion

This study explored the link between social position indicators and cognitive impairment in Colombian adults over 60 years old. Results showed a pattern in which individuals with greater social disadvantage had a higher prevalence of cognitive impairment, except for occupation. Multinomial analysis revealed that factors such as dark skin color, low education, and reading illiteracy were associated with cognitive impairment without dementia, while dementia was associated with the inability to read. Prevalence rates of CIWD and dementia in Colombia were consistent with previous studies in Latin American and Caribbean (LAC) and other middle and low income countries [37]. A recent systematic review described a pooled prevalence of all-cause dementia as 10.66%, taking data from thirty-one studies across fifteen LAC countries [38] very similar to our reported prevalence of 10.8%. Regarding cognitive impairment without dementia, the prevalence ranged from 6.8% to 25.5% [39], also consistent with our reported prevalence of 8.9%.

Dark skin color was associated with an increased likelihood of cognitive impairment without dementia, even after adjusting for income and education. This relationship is similar with prior research that indicates that black individuals had lower education levels are at a higher probability of cognitive impairment compared to white individuals [40]. The complex relationship between race and cognitive impairment may be attributed to multiple social exposures mediated by race, including disadvantaged socioeconomic position, discrimination, and limited access to health resources, which can limit opportunities to develop cognitive skills considered protective factors against dementia [41,42,43,44].

In our study, we identified a protective association between manual or dependent work and the probability of dementia, which contradicts previous studies that have reported an increased risk of dementia associated with such occupations [45]. The complexity of occupation as an indicator encompasses a wide range of occupational exposures, including environmental factors, material deprivation, access to healthcare, pre-existing cognitive abilities, duration of the occupation, social networks, and job strain, all of which collectively shape cognitive reserve and expositional risks throughout one's life. This complexity may help explain the inconsistency observed [46, 47]. Further research is needed to validate the findings of our study.

The relationship between income and cognition needs to be clarified. Education seems to be related to income and dementia, according to our study and previous research [48, 49], which suggests that education may be more important than income in this context. However, material adversities can also increase dementia risk [50], and while previous research has found a positive association between low income and dementia, our study found a protective effect for low physical capital, suggesting that cognitive activities may be more critical than material resources for reducing dementia risk [51].

Numerous studies have found a link between higher levels of education and a decreased risk of dementia and Alzheimer's disease [11, 52]. This protection is likely due to the cognitive reserve built through education, starting in early life [53, 54]. In our study, we found a negative association between low educational levels and cognitive impairment without dementia (CIWD), as shown in the multinomial models. However, for dementia specifically, the association with educational level disappeared once we accounted for factors such as the ability to read, participation in leisure activities, and physical capital tercile. In contrast, some studies have not found an association between educational level and dementia [55,56,57]. This lack of association does not necessarily contradict the link between education and dementia risk in the Colombian population. It is important to note that the quality of education, not just the number of years completed, may also be a critical factor in understanding this relationship [12]. Therefore, additional studies are needed to explore this topic further.

Illiteracy has been associated with a higher risk of dementia due to its negative impact on cognitive function [58]. Not knowing how to read was linked to a higher likelihood of dementia, even after considering other social position variables. Reading provides means to acquire and structure new knowledge and skills beyond language, which can improve cognitive abilities [59,60,61]. From a public health perspective, increasing reading skills in the population could be a valuable tool to improve or maintain cognitive function in the old population [62]. This study found that participation in leisure activities had a protective effect on cognitive functioning, even after adjusting for social status variables other than education. While participation in leisure activities is not typically included in discussions of social status and health, it can be considered a form of cognitive stimulation highly relevant to health outcomes involving cognitive functioning [41, 63]. Previous research has suggested that participation in these activities may reflect wealth and access to resources that enable engagement in cognitively stimulating environments, regardless of educational level [55]. Further research is needed to explore the potential benefits of interventions that include literacy training and leisure activity participation in preventing cognitive decline.

Territorial polarization refers to the uneven distribution of economic resources and opportunities across different regions of a country, resulting in stark inequities in terms of wealth, education, health outcomes, and overall well-being [64]. In recent years, Colombia has experienced significant territorial polarization, with certain regions falling further behind the rest of the country regarding economic growth and development. Specifically, the Caribbean and Pacific coasts have been identified as some of the country's most impoverished areas, facing heightened levels of inequity [65]. This has led to a growing concern over the distribution of chronic non-communicable diseases, as studies have revealed the presence of socioeconomic inequities in the Colombian population [66]. To better understand these disparities, we analyzed cognitive impairment with and without dementia, examining the relationship between the region and socio-economic indicators. To facilitate a clear and concise presentation of our findings, we utilized equiplots to represent the disparities visually. Equiplots revealed clear patterns of greater inequities in historically marginalized regions such as the Caribbean, Pacific, and Orinoquia/Amazonia. Bogota, being the capital city, showed the lowest levels of inequity, likely due to the greater availability of resources and lower risks associated with socioeconomic factors. It is noteworthy that Bogota displays more pronounced disparities in the prevalence of dementia among those who are illiterate or unemployed compared to other regions. This may be attributed to the fact that in the context large urban areas, like Bogotá, healthcare services have a higher demand. Therefore, individuals with low education of unemployed have restricted access to health services and other critical resources for preserving brain health [67]. Further research is needed to analyze these findings.

This study has limitations that should be acknowledged. The diagnosis of cognitive impairment without dementia (CIWD) and dementia was based on an abbreviated screening tool. This is not the ideal tool to diagnose CIWD and dementia and the application of accurate and precise clinical criteria may represent technical difficulties in large population studies. Therefore, the abbreviated screening tool used in the SABE study may lead to an underestimation of their prevalence due to the risk of false negatives [68] and as this is a secondary data analysis of the available data, following the clinical criteria to diagnose CIWD and dementia was not possible. Additionally, this study did not adjust for some known risk factors associated with dementia, such as hypertension, history of stroke, smoking, depression, and alcohol consumption, which could have influenced the results [69]. Nonetheless, this study adjusted for social position variables, which are increasingly recognized as determinants of health inequities and are known to affect the risk of developing various diseases, including dementia and chronic diseases [70, 71]. It's important to note that literacy was self-reported, and no instrument was used to confirm it. Consequently, the reported literacy rates were higher than the years of education reported. However, it's worth emphasizing that this self-reported literacy information is the only available data, and the significance of literacy, even without formal education completion, has been documented in the existing literature [72]. Further research on the relationship between literacy and dementia in the country should be considered as future research topic.

One strength of this study is the data collected, provided by a population-based interview that included a representative sample of the national population. This suggests that the findings may apply to decision-making at the national level [73]. Furthermore, this study is unique in that it includes multiple indicators of social position, which captures the complexity of this construct and its interrelationships, unlike many studies that rely on a single indicator of social position [49]. While this study has limitations, it provides valuable insights into the social position factors associated with cognitive impairment in Colombia. These insights can inform the development of interventions tailored to the needs of different population groups, addressing the social determinants of health to prevent the onset and progression of cognitive decline and dementia.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

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Funding

This work was supported by the Alzheimer’s Association and Alzheimer’s Society (GBHI ALZ UK-20–640663). AGB is an Atlantic Fellow for Equity in Brain Health and received fellowships from the Global Brain Health Institute.

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Authors and Affiliations

  1. Global Brain Health Institute, Trinity College Institute of Neuroscience, Trinity College Dublin, Room 0.60 Lloyd Building, Dublin, 2, Ireland

    Alejandra Guerrero Barragán

  2. Global Brain Health Institute, University of California, San Francisco (UCSF), 1651 4Th St, 3Rd Floor, San Francisco, CA, 94158, USA

    Alejandra Guerrero Barragán

  3. Universidad de los Andes, Escuela de Gobierno Alberto Lleras Camargo, Carrera 1° N° 19-27. Bloque AU, Piso 2, Bogotá, 111711, Colombia

    Alejandra Guerrero Barragán & Diego Iván Lucumí Cuesta

  4. Fundación Valle del Lili, Centro de Investigaciones Clínicas, Carrera 98 No. 18 - 49, Cali, 760032, Colombia

    Inés Elvira Gómez

  5. Facultad de Ciencias de La Salud, Departamento de Salud Pública y Medicina Comunitaria, Universidad ICESI, Calle 18 No. 122-135 Pance, Cali, 760031, Colombia

    Inés Elvira Gómez

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  1. Alejandra Guerrero Barragán
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Contributions

AG, IG, and DL were responsible for the study design and data analyses. AG was responsible for drafting the manuscript and interpreting the findings, and IG performed inequity analysis. DL and IG provided critical feedback on the draft and approved the final manuscript.

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Correspondence to Alejandra Guerrero Barragán.

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Barragán, A.G., Gómez, I.E. & Cuesta, D.I.L. Social patterning of cognitive impairment in Colombia: evidence from the SABE 2015 study. BMC Geriatr 24, 1002 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12877-024-05432-0

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BMC Geriatrics

ISSN: 1471-2318

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