%0 Report %D 2022 %T Understanding cognitive impairment in the U.S. through the lenses of intersectionality and (un)conditional cumulative (dis)advantage %A Jo Mhairi Hale %A Daniel C Schneider %A Neil K Mehta %A Mikko Myrskylä %K cognitive impairment %K cumulative (dis)advantage %K Dementia %K Education %K Health Disparities %K Intersectionality %X 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. %B MPIDR Working Paper %I Max Planck Institute %G eng %R 10.4054/MPIDR-WP-2022-029 %0 Journal Article %J SSM - Population Health %D 2020 %T Cognitive impairment in the U.S.: Lifetime risk, age at onset, and years impaired %A Jo Mhairi Hale %A Daniel C Schneider %A Neil K Mehta %A Mikko Myrskylä %K cognitive impairment %K Dementia %K Education %K Health Disparities %K Race/ethnicity %X Prior studies have analyzed the burden of cognitive impairment, but often use potentially biased prevalence-based methods or measure only years lived with impairment, without estimating other relevant metrics. We use the Health and Retirement Study (1998–2014; n = 29,304) and the preferred incidence-based Markov-chain models to assess three key measures of the burden of cognitive impairment: lifetime risk, mean age at onset, and number of years lived impaired. We analyze both mild and severe cognitive impairment (dementia) and gender, racial/ethnic, and educational variation in impairment. Our results paint a multi-dimensional picture of cognitive health, presenting the first comprehensive analysis of the burden of cognitive impairment for the U.S. population age 50 and older. Approximately two out of three Americans experience some level of cognitive impairment at an average age of approximately 70 years. For dementia, lifetime risk for women (men) is 37% (24%) and mean age at onset 83 (79) years. Women can expect to live 4.2 years with mild impairment and 3.2 with dementia, men 3.5 and 1.8 years. A critical finding is that for the most advantaged groups (i.e., White and/or higher educated), cognitive impairment is both delayed and compressed toward the very end of life. In contrast, despite the shorter lives of disadvantaged subgroups (Black and/or lower educated), they experience a younger age of onset, higher lifetime risk, and more years cognitively impaired. For example, men with at least an Associate degree have 21% lifetime dementia risk, compared to 35% among men with less than high school education. White women have 6 years of cognitively-impaired life expectancy, compared to 12 and 13 years among Black women and Latinas. These educational and racial/ethnic gradients highlight the very uneven burden of cognitive impairment. Further research is required to identify the mechanisms driving these disparities in cognitive impairment. %B SSM - Population Health %V 11 %P 100577 %G eng %R 10.1016/j.ssmph.2020.100577