Understanding cognitive impairment in the U.S. through the lenses of intersectionality and (un)conditional cumulative (dis)advantage

Grounded in theories of intersectionality and cumulative (dis)advantage, we develop
complementary formalizations of (dis)advantage to study disparities in cognitive impairment:
Conditional Cumulative (Dis)Advantage that reflects inequalities in outcomes and Unconditional
Cumulative (Dis)Advantage that additionally accounts for inequalities in opportunities. We study
the properties of these formalizations and show that cumulative disadvantage does not imply
cumulative advantage. Using these formalizations and incidence-based multistate models, we
analyze the Health and Retirement Study to assess how racial/ethnic, nativity, gender, early-life
adversity, and educational (dis)advantages accumulate into three important metrics for
characterizing later-life cognitive impairment—lifetime risk, mean age at first impairment, and
cognitive health expectancies. We find that the benefits and penalties of one (dis)advantage depend
on positionality on the other axes of inequality. Black women and Latinas experience Conditional
Cumulative Disadvantage in cognitive impairment: they are penalized more from having lower
education than Whites. White men experience Conditional Cumulative Advantage: they benefit
more from higher education than Blacks or Latinx. However, when accounting for racial/ethnic
inequities in educational opportunities, results ubiquitously show Unconditional Cumulative
Disadvantage. Our formalization provides a mathematical grounding for cumulative
(dis)advantage, and the empirical results comprehensively document the multi-dimensional,
intersecting axes of stratification that perpetuate inequities in cognitive impairment.