Racial and Ethnic Differences in Subjective Cognitive Decline

United States, 2015-2020

Karen G. Wooten, MA; Lisa C. McGuire, PhD; Benjamin S. Olivari, MPH; Eva M. J. Jackson, MPH; Janet B. Croft, PhD


Morbidity and Mortality Weekly Report. 2023;72(10):249-255. 

In This Article

Abstract and Introduction


Subjective cognitive decline (SCD), the self-reported experience of worsening or more frequent memory loss or confusion, might be a symptom of early-stage dementia or future serious cognitive decline such as Alzheimer disease* or a related dementia (ADRD).[1] Established modifiable risk factors for ADRD include high blood pressure, inadequate physical activity, obesity, diabetes, depression, current cigarette smoking, and hearing loss.[2] An estimated 6.5 million persons aged ≥65 years in the United States live with Alzheimer disease, the most common dementia.[1] This number is projected to double by 2060, with the largest increase among non-Hispanic Black or African American (Black), and Hispanic or Latino (Hispanic) adults.[1,3] Using data from the Behavioral Risk Factor Surveillance System (BRFSS), CDC assessed racial and ethnic, select demographic, and geographical differences in SCD prevalence, and prevalence of health care professional conversations among those reporting SCD. The age-adjusted prevalence of SCD during 2015–2020 was 9.6% among adults aged ≥45 years (5.0% of Asian or Pacific Islander [A/PI] adults, 9.3% of non-Hispanic White [White] adults, 10.1% of Black adults, 11.4% of Hispanic adults, and 16.7% of non-Hispanic American Indian or Alaska Native [AI/AN] adults). College education was associated with a lower prevalence of SCD among all racial and ethnic groups. Only 47.3% of adults with SCD reported that they had discussed confusion or memory loss with a health care professional. Discussing changes in cognition with a physician can allow for the identification of potentially treatable conditions, early detection of dementia, promotion of dementia risk reduction behaviors, and establishing a treatment or care plan to help adults remain healthy and independent for as long as possible.

BRFSS is a random-digit–dialed annual landline and cellular telephone cross-sectional survey of noninstitutionalized U.S. adults aged ≥18 years. The BRFSS six-question cognitive decline optional module[4] was administered to adults aged ≥45 years by all 50 states, Puerto Rico, and the District of Columbia at least once from 2015 to 2020; for states that implemented the module in multiple years, the most recent year of data was used.§ To maximize sample sizes for each racial and ethnic group, data were aggregated for survey years 2015–2020. Overall telephone response rates** across survey years ranged from 45.9% (2017) to 49.4% (2019).

Respondents were classified as experiencing SCD if they responded "yes" when asked if they had experienced worsening or more frequent confusion or memory loss in the past 12 months; those who responded "yes" were asked if they had discussed SCD symptoms with a health care professional. Analyses were conducted using SAS-callable SUDAAN (version 11.0.3; RTI International) to account for complex sample survey design and weighting. Unadjusted and age-adjusted prevalence of SCD by race and ethnicity were estimated among 215,406 study participants aged ≥45 years overall, and for groups defined by jurisdiction, sex, age, education, marital status, health insurance status, and access to a personal doctor. Estimates that did not meet reliability standards (relative SE <30%) were suppressed. T-tests with p-values <0.05 were used to denote significant differences between racial and ethnic groups and differences between groups by selected characteristics. This study was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.††

Nearly 10% of adults aged ≥45 years (9.6%) reported experiencing SCD in the past 12 months (Table 1). SCD prevalence increased among successive age groups and was lower among adults with health insurance (9.5%) than among those without health insurance (11.6%) and decreased with increasing formal educational attainment. The highest overall percentages of SCD occurred among adults who did not have a high school diploma (16.4%), those who had been married, but were not currently married (13.6%), and those aged ≥75 years (13.3%). Age-adjusted SCD was higher among AI/AN (16.7%) and Hispanic adults (11.4%) than among White adults (9.3%) and was lower among A/PI adults (5.0%); prevalence among Black adults (10.1%) was similar to that among White adults (9.3%). This pattern of racial and ethnic differences was observed across most demographic subcategories examined. Unadjusted overall prevalence of SCD was highest in Alabama (14.3%), Oklahoma (14.1%), Florida (13.6%), Louisiana (13.6%), West Virginia (13.6%), Tennessee (12.9%), and New Mexico (12.8%), and lowest in Illinois 6.1% (Table 2). Because of small sample sizes, estimates for A/PI and AI/AN adults were unstable in most states.

Among 21,299 respondents with SCD, 47.3% reported talking with a health care professional about confusion or memory loss; women (50.7%) were more likely than men (43.3%) to do so (Table 3). Overall and within racial and ethnic groups, adults with SCD symptoms who were less likely to talk to a health care professional about their symptoms were aged ≥75 years, had less education, did not have health insurance, did not have a personal doctor, and had not visited a doctor in the past year.

*Although the term "Alzheimer's disease" is frequently used, this report uses "Alzheimer disease" in accordance with the American Medical Association Manual of Style, 11th Edition, and MMWR style.
§Most recent data collection year for each jurisdiction: 2020 (Alaska, Arizona, Arkansas, California, Delaware, District of Columbia, Hawaii, Idaho, Illinois, Kentucky, Maine, Michigan, Nevada, New Hampshire, New York, North Carolina, Ohio, Oregon, Utah, Vermont, Washington, Wyoming, and Puerto Rico); 2019 (Alabama, Connecticut, Florida, Georgia, Indiana, Iowa, Kansas, Louisiana, Maryland, Minnesota, Mississippi, Missouri, Nebraska, New Mexico, North Dakota, Oklahoma, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, and Wisconsin); 2018 (New Jersey); 2016 (Massachusetts and Montana); and 2015 (Colorado).
Racial and ethnic categories were classified as American Indian or Alaska Native, non-Hispanic; Asian or Pacific Islander, non-Hispanic; Black or African American, non-Hispanic; White, non-Hispanic; Hispanic or Latino (any race). In addition to these categories, non-Hispanic persons who self-identified as another race or multiracial were classified as other and included in the total.
††45 C.F.R. part 46.102(I)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.