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Article

Population Surveillance of Dementia Mortality

Department of Medicine, College of Medicine, Howard University, 2041 Georgia Ave., Washington, DC 20060, USA
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2011, 8(4), 1244-1257; https://doi.org/10.3390/ijerph8041244
Submission received: 7 March 2011 / Revised: 12 April 2011 / Accepted: 12 April 2011 / Published: 20 April 2011

Abstract

:
Geographic and temporal variation in occurrence of dementia within the US has received little attention despite its importance for generation of new etiologic hypotheses and health services research. We examine methodological problems in the use of vital statistics data for assessing variation over time, among states and within states in the US. We analyzed the US multiple cause of death files for 2005–2006 and 1999–2000 US deaths with Alzheimer’s Disease (International Classification of Disease 10th revision code G30) and other dementias (codes F01, F02, R54) coded as underlying or contributing cause of death based on the death certificate. Age-adjusted death rates were computed by year, state or county for persons aged 65 years and over. In 2005–2006 combined, 555,904 total deaths occurred with any dementia type (212,386 for Alzheimer’s disease) coded as underlying or contributing cause. Among the states, age-adjusted rates per 100,000 per year varied by two fold ranging from 458 in New York to 921 in Oregon. Similar geographic patterns were seen for Alzheimer’s disease. However, between 1999–2000 and 2005–2006 the US death rate for all dementia increased only from 559 to 695 (24%) while that for Alzheimer’s disease doubled from 135 to 266. Use of specific (G30, F01) versus non-specific diagnoses (F02, R54) varied among states and over time, explaining most of the temporal increase in rate of Alzheimer’s disease. Further research is needed to assess artifacts of diagnosis, certification or coding, utilization of health services, versus biological variation as possible causes of temporal and geographic variation to enhance utility of mortality data for dementia monitoring and research.

1. Introduction

Already a major burden in affluent countries, few doubt that population aging trends will continue to increase the burden of dementia worldwide [1,2]. By 2002, Alzheimer’s disease had become the sixth leading cause of death for persons 65 years and over in the US [3]. Many publications have detailed the geographic variation in stroke mortality in the US [46]. However, geographic variation in occurrence of dementia within the US has received little attention despite its potential importance for generation of new etiologic hypotheses and health services research. A few authors have reported international variation in dementia prevalence rates [710]. The hypotheses are that the rate of death with Alzheimer’s Disease or other dementia varies among states, within states and over time in the US.

2. Experimental Section

Data were analyzed from the US multiple cause of death files for 2005–2006 and 1999–2000 [11]. Data from each death certificate were coded to yield a single underlying cause of death and up to twenty multiple causes as well as demographic data. These mortality data were examined for all deaths occurring in the fifty states and the District of Columbia. Deaths of foreign residents and of residents who died abroad were not included. Deaths with Alzheimer’s Disease (International Classification of Disease 10th revision [ICD-10] codes G30.0, Alzheimer's disease with early onset; G30.1, Alzheimer’s disease with late onset; G30.8, Other Alzheimer's disease; G30.9, Alzheimer’s disease, unspecified) coded as underlying or a contributing cause of death were enumerated [12]. Also enumerated were vascular dementia (F01.0, Vascular dementia of acute onset; F01.1 Multi-infarct dementia; F01.2, Subcortical vascular dementia; F01.3, Mixed cortical and subcortical vascular dementia; F01.8, Other vascular dementia; F01.9, Vascular dementia, unspecified); Unspecified dementia (F03); and senility (R54). Death counts shown are totals for each two-year period (1999–2000, 2005–2006). Coding was completed by computer software and does not vary among states. Using the 2000 US standard population, age-adjusted death rates per 100,000 per year (average annual rate for each two-year period) were computed by state or county for persons aged 65 years and over; population estimates and standard methods are documented elsewhere [11]. Maps of death rates were created to show approximate quartiles of state or county rates using mapping software created by the Centers for Disease Control and Prevention [11]. Rates were considered unreliable when based on fewer than 20 deaths (hatched areas on maps). White areas labeled “other” represent counties with fewer than 6 deaths or population less than 100,000. “Background” refers to any areas excluded by the user.

3. Results and Discussion

Results. Among 555,904 with any dementia diagnosis in 2005–2006, 212,386 deaths occurred with Alzheimer’s disease coded as underlying (142,518) or contributing cause (69,868). Among the states, age-adjusted rates per 100,000 for all dementia varied by two fold ranging from 458 in New York to 921 in Oregon (Table 1). Rates varied by over three fold for Alzheimer’s disease ranging from 133 in New York to 419 in Washington (Supplementary Table 1). Figure 1 shows that high rates (>816 per 100,000) for dementia were seen in the Pacific Northwest, some mountain states, Northern New England, East-south central states and the Carolinas. Rates >300 per 100,000 for Alzheimer’s disease were seen in the Pacific Northwest, Northern New England, East-south central states and the Dakotas (Supplementary Figure 1). Low rates were seen in Southern New England and the Mid-Atlantic, Hawaii, Nevada and Florida for both categories.
Figure 2 shows death rates for dementia by county. Panel A shows high rates in most Oregon counties, western counties of Washington, and some counties in Mountain states. Alzheimer’s rates were also high in the San Francisco Bay area and much of southern California (Supplementary Figure 2). Panels B and C show high rates in Ohio and northern New England but low rates in most New York counties including New York City and Long Island. Alzheimer’s rates were also low in these areas, but high in the eastern counties of the Dakotas, western Iowa, and Ohio. Panel D shows high rates in many counties in the Appalachian region, Carolinas but low rates in south and central Florida. Alzheimer’s disease showed similar patterns except higher in the Gulf States (Supplementary Figure2). In the US in 2005–2006, death rates per 100,000 for all dementias were higher outside large metropolitan areas (693–759) than in central cities (650) or fringe metropolitan areas (673).
Between 1999–2000 and 2005–2006, the US death rate per 100,000 for dementia increased from 559 to 695 (24%) but doubled from 135 (92,927 deaths) to 266 for Alzheimer’s disease. Figure 3 shows that geographic patterns were similar to those in 2005–2006 for all dementias. Between 1999–2000 and 2005–2006 for Alzheimer’s disease, Arkansas, Louisiana, Mississippi and Arizona rose markedly in ranking (Supplementary Figure 3); for example, the rate in Louisiana rose from 152 to 320 per 100,000, a larger relative increase but similar absolute increase compared to that in Washington (248 to 419).
To assess the extent to which geographic patterns and trends in Alzheimer’s disease rates might be attributed to variation in diagnostic practices, the numbers of deaths with different diagnostic codes were compared in the US and in states with highest and lowest Alzheimer’s Disease rates (Table 2). Interstate differences were marked with respect to the proportion of deaths assigned to the specific diagnoses of Alzheimer’s disease or vascular dementia versus non-specific diagnoses (dementia unspecified, senility); the former were used in 59% of cases in Washington but only 32% of cases in New York. The age-adjusted rate per 100,000 of death for all dementias was 559 in the US, 724 in Washington and 368 New York in 1999–2000 and 695, 840 and 458, respectively, in 2005–2006. Therefore, the difference between Washington and New York in rates of dementia is not merely due to use of difference diagnoses or ICD-10 codes. However, the increase in deaths with any dementia diagnosis in the US or these states between 1999–2000 and 2005–2006 was much less for dementia than that seen for Alzheimer’s Disease, which was mostly due to increasing use of that specific diagnosis over time.
Discussion. This analysis of data from the US multiple cause files is the first to our knowledge to establish inter- and intra-state patterns of geographic variation in death with or Alzheimer’s disease and other dementias. Strengths of this study include its provision of previously lacking data, its use of recent data, its complete coverage of the US population eliminating sampling errors. High rates of death with dementia were seen in the Pacific Northwest, Northern New England, and Southern Appalachia. Low rates were seen in Southern New England and the Mid-Atlantic, Hawaii and Florida. Between 1999–2000 and 2005–2006 use and coding of the diagnosis of Alzheimer’s disease increased so that the US death rate doubled for Alzheimer’s disease but increased only 24% for all dementia.
Mechanisms. Major geographic variation in mortality with dementia could be explained by variations in disease prevalence, a function of incidence and duration. This could result from more sophisticated or accessible care resulting in longer survival with the disease, higher incidence, or both in areas with higher versus lower rates. Cardiovascular risk factors such as hypertension have been hypothesized to be risk factors for Alzheimer’s disease and other dementias [12]. However, geographic patterns of stroke mortality were different from those for dementia, with relatively low rates in the Pacific Northwest and northern New England and high rates in the Atlantic Coastal Plain [4]. However, east, and south-central states were high for both. Further, an analysis of trends in stroke mortality predicted that Oregon and Washington, Pacific states, would rise greatly in relative ranking consistent with dementia patterns in 2005–2006 [13]. Like dementia, coronary heart disease mortality was reported to be high in the Ohio River Valley and Carolinas, but, unlike dementia, low in the Pacific Northwest and high in New York [5]. If healthy elderly persons moved from northern New England and Ohio to south and central Florida this could produce higher death rates in the former than in the latter [14,15].
Limitations of this study mean that statistical artifact due to patterns of diagnostic practice and completion of death certificates cannot be excluded as a contributor to geographic and temporal variation in mortality with all dementia [15]. Diagnostic inaccuracy may result in under-ascertainment of specific conditions at death despite introduction of codes for them with ICD-10 [16,17]. Multiple cause data were used to reduce tendency of underlying cause data to underestimate to role of chronic conditions such as dementia on mortality due to immediate causes such as pneumonia and cardiovascular disease. Yet, diagnostic practice may be driven by the availability of specialist care and diagnostic modalities such as magnetic resonance imaging and computerized tomography as well as patients’ access to all these. Lack of personnel and facilities or poor access may tend to increase the use of non-specific diagnoses such as unspecified dementia and senility as well as failure to diagnose dementia before death. Fewer than 10% of deaths from natural causes were autopsied [18]. For deaths occurring outside an institution, the death certificate might be completed by a coroner without physician input. The increasing use of specific diagnoses nationwide seen in this study likely reflects the spread of awareness among physicians and the public and increasing utilization of diagnostic technology among the elderly [2]. Location of dementia research programs might increase awareness in some areas. However, of 30 Alzheimer’s Disease Centers funded by the National Institutes of Health at major medical centers, only 4 were located in the 10 states with the highest Alzheimer’s disease death rates while 7 were located in the 10 states with the lowest rates [19]. California with 6 centers ranked 17th. The current study could not address failure by certifiers to mention chronic dementia at all. When death rates are computed, inaccuracies of population counts and estimates can also limit the utility of data. However, every attempt is made by the U.S. Bureau of Census to understand and compensate for known problems. For example, to accommodate geographic shifts of the Alabama, Louisiana, Mississippi, and Texas populations resulting from Hurricanes Katrina and Rita in 2005, the U.S. Census Bureau developed adjustments in the methodology for state and county population estimates [11]. Aging of the population may not totally be accounted for by age-adjustment, e.g., in trend analysis, since the top bracket was 85 years and over. If elderly persons move from their customary state of residence after dementia diagnosis, their residence at death may not reflect long-term environmental exposure and hence hinder hypothesis generation [20]. Further research addressing these methodological issues would enhance the feasibility of ecological studies of Alzheimer’s disease with respect to known or suspected risk-modifying factors (e.g., hypertension) has been done in the past for cancer [2123].

4. Conclusions

Marked geographic variation in rates of death with all dementia and Alzheimer’s disease occurred among US states and counties and over time. Further research is needed to assess variation in artifacts of certification versus variation in disease incidence or duration as possible causes of geographic and temporal variation. Data from multicenter studies of dementia in population-based samples of the US elderly population with validation of death-certificate diagnoses and estimation of incidence, survival and prevalence are needed to establish the magnitude and causes of geographic variation.

Acknowledgments

Obisesan was supported by career development award # AG00980 and research award #RO1-AG031517 from the National Institute on Aging and grant # U54 RR026076 from the National Center for Research Resources, National Institutes of Health. The funders had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

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Appendix

  • Suppl. Figure 1.:

    Age-adjusted rate of death with diagnosis of Alzheimer’s by state for persons aged 65 years and over: United States, 2005–2006.

  • Suppl. Figure 2.:

    Suppl. Figure 2.

    Age-adjusted rate of death with diagnosis of Alzheimer’s disease by county for persons aged 65 years and over: United States regions, 2005–2006. Panel A West, panel B Midwest, C Northeast, panel D South.
    ijerph-08-01244s002a.tif ijerph-08-01244s002b.tif

  • Suppl. Figure 3.:

    Age-adjusted rate of death with diagnosis of Alzheimer’s disease by state for persons aged 65 years and over: United States, 1999–2000.

  • Suppl. Table 1. Age-adjusted rates of death with underlying or contributing cause coded as Alzheimer's Disease among persons aged 65 years and over: United States, 2005–2006.
    Suppl. Table 1. Age-adjusted rates of death with underlying or contributing cause coded as Alzheimer's Disease among persons aged 65 years and over: United States, 2005–2006.
    RankStateCountPopulationCrude RateAge Adjusted Rate
    1Washington6,6691,457,624458419
    2Tennessee6,1641,529,447403405
    3North Dakota890185,746479375
    4Alabama4,3571,220,292357355
    5South Carolina3,7321,092,416342349
    6Vermont598164,600363336
    7South Dakota904222,881406328
    8Mississippi2,427718,511338327
    9Oregon3,384946,282358322
    10Kentucky3,4331,065,217322321
    11Maine1,325383,239346321
    12Louisiana3,3841,049,146323320
    13Ohio10,5133,061,308343320
    14Idaho1,115333,258335316
    15North Carolina6,6802,129,892314315
    16New Hampshire1,095323,149339312
    17California25,8867,782,755333309
    18Colorado2,914942,768309306
    19Arizona4,8891,551,114315304
    20West Virginia1,718555,956309302
    21Iowa3,218869,329370301
    22Oklahoma2,978941,528316301
    23Missouri5,0411,550,721325297
    24Indiana4,9601,560,133318296
    25Texas13,63846,088,00296293
    26Georgia5,0471,794,142281289
    27Kansas2,419713,211339285
    28Arkansas2,310775,273298281
    29Nebraska1,530467,522327277
    30Montana755259,700291264
    31Wisconsin4,3351,448,359299261
    32Wyoming334124,420268260
    33Virginia4,4491,751,270254256
    34Michigan6,8582,522,361272255
    35District of Columbia386138,952278250
    36Minnesota3,5871,246,758288246
    37Rhode Island886295,308300245
    38Alaska17790,102196244
    39Illinois8,2503,058,693270244
    40Pennsylvania10,0863,768,607268231
    41Delaware523226,190231230
    42Massachusetts4,5501,710,356266226
    43Utah1,008444,628227223
    44Maryland2,8271,291,826219214
    45Connecticut2,388939,127254213
    46New Jersey5,3032,252,623235213
    47New Mexico985477,957206203
    48Florida12,5976,014,797209184
    49Nevada833545,373153176
    50Hawaii646354,351182161
    51New York7,4055,041,320147133
    Suppl. Table 2. Distribution of deaths with underlying or contributing cause of dementia among persons aged 65 years and over: Washington and New York, 1999–2000 and 2005–2006.
    Suppl. Table 2. Distribution of deaths with underlying or contributing cause of dementia among persons aged 65 years and over: Washington and New York, 1999–2000 and 2005–2006.
    Alzheimer’s DiseaseVascular dementiaUnspec. dementiaSenilityTotal dementia
    2005–2006StateCountPercentCountPercentCountPercentCountPercentCountPercent
    Washington6,669481,471114,95636763613,859100
    New York7,405281,004416,120611,951726,480100
    US221,3863829,2515288,2375042,8797581,753100
    1999–2000Washington3,3424110614,0144975198,213100
    New York2,77218152110,722711,5331015,179100
    US92,927282,9571193,0295940,84712329,760100
    Figure 1. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementias by state for persons aged 65 years and over: United States, 2005–2006.
    Figure 1. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementias by state for persons aged 65 years and over: United States, 2005–2006.
    Ijerph 08 01244f1
    Figure 2. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementia by county for persons aged 65 years and over: United States regions, 2005–2006. Panel A West, panel B Midwest, panel c Northeast, panel D South.
    Figure 2. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementia by county for persons aged 65 years and over: United States regions, 2005–2006. Panel A West, panel B Midwest, panel c Northeast, panel D South.
    Ijerph 08 01244f2
    Figure 3. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementias by state for persons aged 65 years and over: United States, 1999–2000.
    Figure 3. Age-adjusted rate of death with diagnosis of Alzheimer’s disease or other dementias by state for persons aged 65 years and over: United States, 1999–2000.
    Ijerph 08 01244f3
    Table 1. Age-adjusted rates per 100,000 of death with underlying or contributing cause coded as dementia among persons aged 65 years and over: United States, 2005–2006.
    Table 1. Age-adjusted rates per 100,000 of death with underlying or contributing cause coded as dementia among persons aged 65 years and over: United States, 2005–2006.
    RankStateCountPopulationCrude RateAge Adjusted Rate
    1Oregon9,721946,2821,027921
    2Ohio29,4213,061,308961894
    3North Carolina18,9042,129,892888891
    4Vermont1,583164,600962886
    5South Carolina9,3761,092,416858877
    6Utah3,886444,628874856
    7Washington13,3661,457,624917840
    8Idaho2,954333,258886833
    9Alaska60090,102666832
    10Colorado7,897942,768838829
    11Alabama10,0971,220,292827822
    12Tennessee12,4631,529,447815818
    13West Virginia4,643555,956835815
    14Minnesota12,0011,246,758963812
    15Maine3,346383,239873810
    16Oklahoma8,016941,528851806
    17Georgia14,0881,794,142785805
    18Montana2,246259,700865780
    19Nebraska4,396467,522940780
    20New Hampshire2,737323,149847780
    21Wisconsin12,8481,448,359887772
    22Maryland10,1511,291,826786767
    23Kansas6,390713,211896746
    24Rhode Island2,694295,308912744
    25Missouri12,6261,550,721814742
    26Iowa7,985869,329919739
    27Mississippi5,457718,511759732
    28Texas34,1964,608,800742732
    29Kentucky7,7361,065,217726722
    30North Dakota1,709185,746920714
    31Indiana11,9411,560,133765712
    32Virginia12,2331,751,270699702
    33Delaware1,550226,190685682
    34Michigan18,2022,522,361722676
    35Louisiana7,0941,049,146676668
    36California55,8487,782,755718667
    37New Mexico3,196477,957669658
    38Illinois21,9853,058,693719647
    39Wyoming824124,420662644
    40South Dakota1,772222,881795637
    41Pennsylvania27,8253,768,607738635
    42Connecticut7,120939,127758634
    43Massachusetts12,6901,710,356742629
    44District Columbia962138,952692626
    45Hawaii2,491354,351703621
    46Arkansas5,014775,273647608
    47Nevada2,844545,373521604
    48Arizona9,6761,551,114624602
    49Florida39,7386,014,797661579
    50New Jersey13,6522,252,623606547
    51New York25,7145,041,320510458
    Table 2. Distribution of deaths with underlying or contributing cause of dementia among persons aged 65 years and over.
    Table 2. Distribution of deaths with underlying or contributing cause of dementia among persons aged 65 years and over.
    Alzheimer’s DiseaseVascular dementiaUnspec. dementiaSenilityTotal dementia
    2005–2006StateCountPercentCountPercentCountPercentCountPercentCountPercent
    Washington6,669481,471114,95636763613,859100
    New York7,405281,004416,120611,951726,480100
    US221,3863829,2515288,2375042,8797581,753100
    1999–2000Washington3,3424110614,0144975198,213100
    New York2,77218152110,722711,5331015,179100
    US92,927282,9571193,0295940,84712329,760100

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    MDPI and ACS Style

    Gillum, R.F.; Yorrick, R.; Obisesan, T.O. Population Surveillance of Dementia Mortality. Int. J. Environ. Res. Public Health 2011, 8, 1244-1257. https://doi.org/10.3390/ijerph8041244

    AMA Style

    Gillum RF, Yorrick R, Obisesan TO. Population Surveillance of Dementia Mortality. International Journal of Environmental Research and Public Health. 2011; 8(4):1244-1257. https://doi.org/10.3390/ijerph8041244

    Chicago/Turabian Style

    Gillum, Richard F., Ralston Yorrick, and Thomas O. Obisesan. 2011. "Population Surveillance of Dementia Mortality" International Journal of Environmental Research and Public Health 8, no. 4: 1244-1257. https://doi.org/10.3390/ijerph8041244

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