Older Mexicans and Latinos in the United States: Where Worlds Meet 3031488083, 9783031488085

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Jacqueline L. Angel · Flavia C. Drumond Andrade · Fernando Riosmena · Silvia Mejia-Arango   Editors

Older Mexicans and Latinos in the United States Where Worlds Meet

Older Mexicans and Latinos in the United States

Jacqueline L. Angel Flavia C. Drumond Andrade Fernando Riosmena  •  Silvia Mejia-Arango Editors

Older Mexicans and Latinos in the United States Where Worlds Meet

Editors Jacqueline L. Angel LBJ School and Center on Aging and Population Sciences The University of Texas at Austin Austin, TX, USA Fernando Riosmena Department of Sociology and Demography Institute for Health Disparities Research San Antonio, TX, USA

Flavia C. Drumond Andrade School of Social Work University of Illinois at Urbana-Champaign Urbana, IL, USA Silvia Mejia-Arango Institute of Neuroscience, School of Medicine UT Rio Grande Valley Harlingen, TX, USA

ISBN 978-3-031-48808-5    ISBN 978-3-031-48809-2 (eBook) https://doi.org/10.1007/978-3-031-48809-2 This work was supported by National Institutes of Health- R13 grant (5R13AG029767-11). © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Paper in this product is recyclable.

Foreword

In the intricate tapestry of the human experience, few threads are as intertwined and deeply colored as the phenomenon of aging. As time relentlessly moves forward, it brings with it not only the inevitable transformation of our bodies but also the evolution of societies and cultures. Nowhere is this more evident than in the lives of Latino individuals, whose journey through the later stages of life reflects a rich blend of traditions, challenges, and triumphs that span the United States and Mexico. In Where Worlds Meet: Growing Older in Mexico and Aging Latinos in the United States, we embark on a deep exploration of the Latino aging experience, shining light on the shared struggles and the remarkable resilience that define these vibrant communities in both countries. Though marked by physical boundaries, the border between Mexico and the United States is far from a line of separation when it comes to familial ties, cultural heritage, and the flow of lives. As the global landscape shifts and economies fluctuate, the movement of people across this border has led to a unique phenomenon— one where older adults find themselves straddling two worlds, two identities, and two sets of challenges. The relevance of studying the Latino aging experience in both Mexico and the United States cannot be overstated, for it offers an unparalleled opportunity to examine how cultural factors, socioeconomic circumstances, and health systems shape individual and family lives. This book delves deep into the intricate interplay between the societal constructs of aging in Mexico and the United States. It paints a vivid picture of the multifaceted ways in which culture, family dynamics, and community support influence cognition and the lived experiences of Latino elders. From the picturesque towns of Mexico, where generations often coexist under one roof, to the bustling urban centers of the United States, where cultural identity becomes both a source of strength and a challenge, we are taken on a journey that transcends geographical borders and delves into the bodies and minds of those who are navigating the challenges of growing older. People of Hispanic and Latin American descent are one of the fastest-growing minoritized populations in the United States, and they are more likely to develop cognitive impairment than non-Latino Whites. Levels of acculturation have long v

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been linked to several related health outcomes, and today, work is accumulating that investigates acculturation in relation to cognition and brain aging. That is why, in 2022, the annual International Conference on Aging in the Americas focused on “Cognitive Aging in Mexico and Latino Communities in the United States: Deconstructing Resilience.” During the conference, there was a strong consensus about the need to address upstream factors, including policies that promote socioeconomic well-being and quality educational attainment (an important protective factor vs. cognitive impairment later in life), expanding long-term care services and support, and addressing the adverse health effects of exposure to discrimination to achieve health equity. There was also consensus about the need for longitudinal studies to identify critical periods of intervention to reduce initial disparities, contextual analyses to explore intersectionality and the linkages among various forms of resilience, and more exploratory studies focusing on community definitions and perspectives on resilience. Overall, the current literature points to a greater need to examine contextual factors that will allow us to discern the conditions under which stress may have detrimental effects for Latino adults. Also, there is a need to invest in economic opportunities to promote brain health equity. This includes investing in brain-health-­ related infrastructure and economic support in disadvantaged and rural communities. The private sector, including healthcare companies, should leverage its significant philanthropic giving to invest in initiatives that support brain health. These investments could yield substantial health benefits and possibly contribute to increased community resilience against cognitive impairment. One of the most compelling aspects of the Latino aging experience is the resilience that shines through despite adversities. Throughout history, the Latino community in the United States has demonstrated an unparalleled ability to withstand and overcome challenges. Whether it be economic disparities, language barriers, or the intricacies of assimilation, older Latinos have shown a remarkable capacity to adapt, preserve their heritage, and contribute to the rich diversity of American society. Contrary to the resilient Latino community phenomenon observed in many parts of the Southwest, some studies suggest that residence in urban and non-­Southwestern Hispanic communities may be a risk factor for worse health outcomes. Future research should examine environmental and financial influences that may improve resilience with reference to physical decline and social isolation. In this field, many questions remain, including resilience definition and measurement in the context of healthy cognitive aging; what factors contribute to cognitive health disparities between ethnic minority populations; how interventions can be developed to cost-­ effectively promote resilience in diverse populations; and how to increase the participation of minoritized older adults in cognitive interventions to reduce cognitive health disparities and achieve health equity. In the face of health disparities, limited access to healthcare, and often demanding labor conditions, Latino elders have displayed extraordinary strength and resourcefulness. This book illuminates the ways in which community networks, often rooted in faith and shared heritage, provide crucial support systems for these

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older adults. The experiences shared within these pages serve as a reminder that even in the face of adversity, the Latino community’s deep sense of familial connection and mutual support can be a source of healing and empowerment. This book also delves into the important role that policy and advocacy play in shaping the trajectory of Hispanic aging experiences. From discussing the need for culturally sensitive healthcare approaches to addressing systemic barriers that hinder access to resources, the book underscores the urgent necessity for collaborative efforts between government agencies, nonprofit organizations, and local communities to ensure that the Latino aging population can thrive, regardless of where they reside. In a world that often emphasizes the challenges of aging, this text brings a refreshing perspective—a celebration of the richness that comes with a life well-­ lived, a culture well-preserved, and a community well-supported. The chapters contained within these pages remind us that growing older is not merely a biological process but a cultural and social journey that deserves attention, respect, and admiration. As you embark on this literary journey through the aging experiences of Latino older adults in both Mexico and the United States, may you be inspired by their resilience, moved by their needs, and enlightened by the complex tapestry of experiences that make up the Latino aging phenomenon. This book builds a bridge that connects us across borders, reminding us of the shared humanity that unites us all. Instituto Nacional de Geriatría  Luis Miguel Gutiérrez Robledo Mexico City, Mexico August 2023

Preface: Where Worlds Meet: Growing Older in Mexico and Aging Latinos in the United States (6th Edition). Springer Nature

Population aging, which until a few years ago seemed to be a problem for the distant future, has become an immediate reality in nations that have undergone the demographic transition from high mortality and fertility to low levels of both. This is not only true in nations with higher levels of development, such as Japan and the United States, but in middle-income nations, such as Mexico, as well. By 2025, one of every four individuals in high-, middle-, and upper-income countries is expected to be 65 or older (World Health Organization, 2022). This aging of populations will create a new world that will place strains on many traditional institutions and require new ways of addressing problems related to the health and the support of older individuals. At the population level, aging is the result of lower fertility and lower mortality combining to produce more rapid increases in the median age, reflecting the growing number of older individuals relative to younger individuals. By 2035, the United States will have entered a new demographic and social reality in which older people outnumber children, the consequences of which are not well understood (U.S. Census Bureau, 2018). Nor can we definitively predict how population aging will affect racial and ethnic minorities, different geographical regions, and different social classes. As we have noted, population aging is a present and growing reality in many middle- and lower-income countries, including the vast majority of Latin America, where life expectancies in old age have continued to rise despite major recent but seemingly short-lived setbacks due to the COVID-19 pandemic. Longer lives, combined with declining fertility, will create fiscal and administrative challenges for individuals, families, and communities, as well as for governments and health-care systems at all levels. Longer periods of frailty and infirmity lead to a greater need for family assistance at a time when families are becoming smaller and more dispersed geographically, and communities are challenged in their caregiving capacities by broader economic and social pressures. The sixth edition of the series on Aging in the Americas is motivated by a growing interest in the study of aging in Mexico and the Latino-origin population of the United States and particularly the sources of resilience to the vulnerabilities

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just described. As the United States grows old, “minority” groups—perhaps most notably, Latinos—will continue to become an ever-growing segment of the labor force. The Social Security Administration forecasts that by 2025 at least one of the 2.4 or fewer workers who will support a largely non-Hispanic White older population will be a minority group member (Social Security Administration, 2022). The structural disadvantages that plague a large fraction of young Hispanic and African American workers undermine their own economic well-being, as well as their collective capacity to support older Americans of all races/ethnicities who are living longer than ever before. Mexico mirrors these demographic trends. Data from the 2020 census confirmed the rapid population aging taking place in Mexico; during the last 30  years, the share of those aged 60 and over has doubled from 6 to 12%, and life expectancy at birth has increased from 70.1 to 75.2. In a context of high health disparities, older Mexicans suffer from higher rates of hypertension, diabetes, arthritis, depression, and dementia than Latinos in the United States (Andrade, 2010; Andrade & López-­ Ortega, 2017). Such health vulnerabilities are of great concern today, especially given the recent weakening of the health-care system in Mexico, despite modest progress in poverty. These vulnerabilities are of great concern for the future, as their accumulation will likely present serious economic and social challenges to individuals, families, communities, as well as municipal, state, and national governments. This new reality is reflected in an increasing old-age dependency ratio, which means that fewer employed individuals will pay taxes to support the care of older adults (a support ratio of 15.5/100 workers in 1950 to 8.7 in 2020). In Mexico that seismic demographic shift negatively impacts the country’s social security and public health systems (Angel et al., 2017). The severity of the problem is reflected in the fact that Mexico provides little financial support for long-term care services and supports (Gutiérrez Robledo et al., 2012). As a consequence, the nation has a relatively underdeveloped system of institutional and more formalized community care. As in the United States, the family remains a major source of support for Mexican older parents (Angel et al., 2016). Extreme poverty among the older population has forced the Mexican government to introduce a federal noncontributory social pension program for those over 65 who receive no other coverage (Aguila & Angel, 2021). A novel aspect of this volume is that the theme expands upon the social determinants of healthful aging by identifying multiple domains of resilience that serve as potential protective factors that can protect health in high-risk environments. The “big picture” in Latino health literature is mixed. Population health is depicted as positive in terms of lower overall morbidity and a longevity advantage compared to the US population. Conversely the literature reflects concerns about substantially higher risk in Latino subpopulations for specific chronic disease conditions in middle adulthood and higher disability and dementia rates in later adulthood. This “cross-over” from positive to negative of health profiles that accompany the aging process requires careful examination of its pace and the nature of health decline, as well as the forces that slow the process.

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The literature on Latino health among older adults includes findings regarding protective effects of place in conserving health, functioning, and cognition that counteract otherwise adverse social and environmental circumstances. If and how these protective factors selectively weaken in later adulthood has not been carefully studied. Chapters in the volume examine the moderating role of social psychological, physical environment, and social contexts in mitigating effects of social determinants on various health outcomes. We will extend our recent work on putative effects of space, time, and place beyond primarily deterministic risk models by first focusing on the intersections between domains of resilience in aging among Latino populations comparatively in the United States and Mexico and second addressing how sources of resilience at the personal level intersect with resilience at the social network, community support, economic-occupational participation, and political levels.

Organization of the Book To address these issues, the collection Where Worlds Meet: Growing Older in Mexico and Aging Latinos in the United States includes 15 chapters that were part of the 15th installment of the International Conference on Aging in the Americas (ICAA), funded by the National Institute on Aging. The conference, held at the University of Illinois, Chicago in September 2022, highlighted how individual, family, and community resilience can impact health. Each chapter is written by noted investigators from different social scientific and public health disciplines in both nations and presents insights into new challenges arising from population aging and health in the Americas. The chapters in the book draw special attention to each country’s population size, its growth, and the resilience of individuals and communities in the face of serious disadvantages. They examine individual and structural factors that optimize health and well-being. The authors examine implications of how the characteristics of individual families, neighborhoods, and government relate to protecting the frailest citizens. Both Mexico and the United States face objectively difficult situations in anticipating the changing needs and desires of older populations with fewer children and higher levels of potential dependency. It is in this context that the various chapters explore the construct of resilience, conceived of as that constellation of factors that allows individuals and communities to thrive. These chapters go beyond a strictly clinical and biomedical perspective of resilience, broadly construed, to examine the ways in which larger social, economic, and cultural contexts affect aging and health among Mexicans and Mexican Americans. The collection provides fresh data for understanding these concepts in other cultural and social settings. In addition to reviewing the literature, the authors also present crucial areas of research that require immediate attention to serve the growing aging population and propose key research priorities and next steps in both countries.

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Section Themes As part of this conference, participants presented commissioned papers that address several important issues that comprise four sections in what follows. We begin with an introductory chapter that reviews three decades of research in the field. We summarize current work and debates and future directions in research on aging and health of the US Hispanic and Mexican Populations. Part I focuses on cognitive aging and resilience. Topics of interest include which interventions can be introduced earlier in life to increase cognitive reserve, how can cognitive research be enhanced throughout the life course and in later life, and which cultural and social resources can be mobilized to promote brain health and enhance the quality of life. Part II examines aspects of the cultural context of cognitive aging and dementia. The structural elements influencing healthful aging in Mexicans and Latinos in the United States are covered in Part III.  Contributors provide fresh data and policy insights for increasing awareness on the critical importance of improving the quality of lives of older adults in both countries. Altogether, the collection of papers brings a transdisciplinary lens to state-of-the art research addressing the most critical issues on aging and health in the Americas. Lastly, we would like to thank all the people involved in this project. First and foremost, we thank each one of the authors for their contributions. Our sincere gratitude also goes to our colleagues who engaged in the review process to provide expertise for improvement in the quality of the chapters. We also would like to thank the National Institutes of Health; the Alzheimer’s Association; and the School of Social Work and the Center on Health, Aging and Disability at the University of Illinois Urbana-Champaign for their financial sponsorship of the 2022 ICAA conference. Special thanks to Lauren Hormiga for her editorial assistance and Summer Xia Yu for her assistance on conference communications. Without their commitment, this edited collection would not have become a reality. Austin, TX, USA  Jacqueline L. Angel Urbana, IL, USA  Flavia C. Drumond Andrade San Antonio, TX, USA  Fernando Riosmena Harlingen, TX, USA  Silvia Mejia-Arango 9/3/23

 

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References Aguila, E., & Angel, J. L. (2021). Retirement and supplemental income programs for low-income older Mexican-Origin adults in the United States and Mexico. Public Policy & Aging Report, 31(3), 89–95. https://doi.org/10.1093/ppar/prab010 Andrade, F. C. D. (2010). Measuring the impact of diabetes on life expectancy and disability-free life expectancy among older adults in Mexico. The Journals of Gerontology: Series B, 65B(3), 381–389. https://doi.org/10.1093/geronb/gbp119 Andrade, F. C. D., & López-Ortega, M. (2017). Educational differences in health among middleaged and older adults in Brazil and Mexico. Journal of Aging and Health, 29(6), 923–950. https://doi.org/10.1177/0898264317705781 Angel, J.  L., Angel, R.  J., López-Ortega, M., Robledo, L.  M. G., & Wallace, R.  B. (2016). Institutional context of family eldercare in Mexico and the United States. Journal of CrossCultural Gerontology, 31(3), 327–336. https://doi.org/10.1007/s10823-­016-­9291-­3 Angel, J.  L., Vega, W., & López-Ortega, M. (2017). Aging in Mexico: Population trends and emerging issues. The Gerontologist, 57(2), 153–162. https://doi.org/10.1093/geront/gnw136 Gutiérrez Robledo, L. M., Ortega, M. L., & Lopera, V. E. A. (2012). The state of elder care in Mexico. Current Translational Geriatrics and Experimental Gerontology Reports, 1(4), 183–189.http://link.springer.com/article/10.1007/s13670-­012-­0028-­z# Social Security Administration. (2022). The 2022 annual report of board of trustees of the federal old-age and survivors insurance and federal disability insurance trust funds. https://www.ssa. gov/OACT/TR/2022/index.html. U.S.  Census Bureau. (2018). Older people projected to outnumber children for first time in U.S. history. Retrieved 5/2/2020 from https://www.census.gov/newsroom/press-­releases/2018/ cb18-­41-­population-­projections.html World Health Organization. (2022). Aging and health. Retrieved 5/223/23 from https://www.who. int/news-­room/fact-­sheets/detail/ageing-­and-­health. Geneva, Switzerland

Contents

Part I Introduction – Three Decades of Research 1

Aging and Health in the Americas: Past, Present and Future Research on the U.S. Hispanic and Mexican Populations������������������������������������������������������������������������    3 Jacqueline L. Angel, Kyriakos S. Markides, Fernando M. Torres-Gil, and William A. Vega

Part II Cognition: Conceptual and Measurement Issues 2

Acculturation in Context: A Framework for Investigating Cognitive and Brain Aging in People of Hispanic and Latin American Descent������������������������������������������������������������������   27 Melissa Lamar, Lisa L. Barnes, and David X. Marquez

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Deconstructing Resilience in Cognitive Aging in Mexico and Latino Communities in the United States: Consensus Agenda Findings and Recommendations����������������������������   49 Sunshine Rote, Ángela Gutiérrez, and Flavia Cristina Drumond Andrade

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Resilient Cognitive Aging in Latinx and Mexican American Populations������������������������������������������������������   59 George W. Rebok, Tania M. Rodriguez, and Rachel Wu

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Contextualizing the Effects of Stress on Cognitive Health in U.S. Latinx Adults��������������������������������������������   79 Elizabeth Muñoz and Jean Choi

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Part III Sociocultural Influences on Health 6

Alzheimer’s Disease Among Communities of Color: The Role of Place for Brain Health Equity��������������������������������������������   99 Stipica Mudrazija, William A. Vega, Jason Resendez, and Stephanie Monroe

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Heritage, Birthplace, Age at Migration, and Education as Life Course Mechanisms Influencing Cognitive Aging Among Latinos������������������������������������������������������������������������������  119 Catherine García, Marc A. Garcia, Mara Getz Sheftel, and De’Lisia S. Adorno

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The Mediterranean and MIND Dietary Patterns: Associations with Cognition and Psychological Distress Among Latinos ��������������������������������������������������������������������������  151 Diana Morales, Jacqueline Guzman, Yuliana Soto, and Susan Aguiñaga

Part IV Ethnicity, Migration and Healthful Aging 9

Impact of Comorbidity on Cognitive Function of Possible Vascular Origin ��������������������������������������������������������������������  169 Sara Gloria Aguilar-Navarro, Silvia Mejia-Arango, and Alberto José Mimenza-Alvarado

10 Resilient  Communities: Aging in Place��������������������������������������������������  183 Jennifer J. Salinas, Mary Miller, and Roy Valenzuela 11 Impact  of Ethnic Enclaves on Life-Space Mobility for the Oldest Mexican-Americans��������������������������������������������������������  193 Felipe Antequera, Phillip Cantu, Soham Al Snih, and Jacqueline L. Angel 12 D  ementia Trends and Health-Care Access Among Older Latinx Adults During the COVID-19 Pandemic������������������������  209 Josefina Flores Morales, Jennifer Archuleta, Esmeralda Melgoza, and Julian Ponce Part V Policy and Health/Aging Policy in Mexico and the U.S. 13 Income  Supplements and Subjective Life Expectancy for Low-Income Older Adults����������������������������������������������������������������  227 Seokmin Kim and Emma Aguila 14 Noncontributory  Pensions as Human Rights in Mexico����������������������  249 Ronald J. Angel and Verónica Montes-de-Oca

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15 Health  Insurance Coverage and Forgoing Care in Mexico: The Role of Seguro Popular��������������������������������������������������������������������  265 Jose Eduardo Cabrero Castro and Brian Downer 16 Health  Equity and Aging in the Hispanic/Latino Population of the United States��������������������������������������������������������������  283 Octavio N. Martinez Jr

Part I

Introduction – Three Decades of Research

Chapter 1

Aging and Health in the Americas: Past, Present and Future Research on the U.S. Hispanic and Mexican Populations Jacqueline L. Angel, Kyriakos S. Markides, Fernando M. Torres-Gil, and William A. Vega

Introduction Mexicans and Mexican Americans are aging in ways that reflect their different social, historical, and political contexts. This chapter summarizes what the literature reveals about the health and aging of these two populations. We focus on research that deals with population aging and the changing needs for assistance it entails. We begin with an overview of the history of the field. This discussion calls attention to the significant progress that has been made over the last four decades in the study of the health and financial well-being of older adults in the Americas. It identifies major themes, conceptual and theoretical perspectives, methodological approaches, and their public health relevance. We end with a synopsis of directions for further investigation. The review proceeds with an examination of the distinct cultural and political contexts in which Mexicans and Mexican Americans age. Subsequently, we examine the social and demographic aspects of each population using health survey data. As we describe, high levels of poverty that persist into old age leave older people of

J. L. Angel (*) LBJ School and Center on Aging and Population Sciences, The University of Texas at Austin, Austin, TX, USA e-mail: [email protected] K. S. Markides Department of Preventive Medicine and Population Health, The University of Texas Medical Branch, Galveston, TX, USA F. M. Torres-Gil Luskin School of Public Policy, University of California, Los Angeles, CA, USA W. A. Vega Florida International University, Miami, FL, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. L. Angel et al. (eds.), Older Mexicans and Latinos in the United States, https://doi.org/10.1007/978-3-031-48809-2_1

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Mexican descent on both sides of the border vulnerable to poor health and diminished quality of life. The U.S.  National Institute on Aging (NIA) has supported much of this research, prioritizing a risk assessment paradigm that examines both individual (genetic, biological, clinical) and socioeconomic factors that raise the risk of poor outcomes (National Institute on Aging, 2020). The latest stage in the production of social and behavioral scientific-based knowledge addresses key thematic areas, including the dynamics of the aging process using longitudinal data; multi-level models of the interaction between genetics and society; cross-national research on population aging and health; race and ethnic-based disparities in dementia; and the mechanisms through which resilience and resources affect the health and well-being of older adults and their caregivers.

Origin of the Investigation of Population Aging and Health Grebler’s seminal work The Mexican-American People: The Nation’s Second Largest Minority (1970) motivated interest in the empirical study of Hispanics, drawing attention to the population’s size, growth, and serious disadvantages (Grebler et  al., 1970). Many scholars who examined the disadvantages in health indicators affecting Hispanics aligned with the earlier work of Moynihan, who had argued that poverty is a product of the learned present orientation of those who grew up in poverty (Moynihan, 1965). Individuals who never witness a payoff to effective long-term planning never inculcate the middle-class ability to delay gratification and do not learn to plan for their own futures. Based on this perspective, scholars hypothesized that social environments in which disadvantaged individuals grow up may not create a strong work ethic or the capacity necessary to resist the desire for immediate gratification. Individuals who have been socialized in this way are unlikely to respond to educational opportunities or interventions directed at changing their behavior or reducing their health risks. This theory and its variations that posit a “culture of poverty” are still a matter of much contention. Anthropologist Oscar Lewis (Lewis, 1975) offered an alternative in his study of urban slums, proposing a structural model of economic and political factors as the underlying cause of poverty. Based on his research of certain cities that were immigration gateways, urban enclaves (colonias) in the U.S. were viewed as a place of community and support for Mexican Americans growing old. This research provided a contrast with the earlier U.S. characterization of an irreversible urban crisis. In a seminal volume by Hayes-Bautista et al. (1990), The Burden of Support presented a new aspirational focus of the developing potential of the Mexican American population in the U.S., based on an in-depth demographic analysis of social stratification and growth trends (Hayes-Bautista et al., 1990). This work and the research that followed suggested that a more complex analysis was needed to anticipate and interpret the challenges and needs of the rapidly expanding Latino population, and improve understanding of positive social development potential and conservation of population health.

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Since then, informal residential population settlements increased as the result of the lack of affordable housing; these present challenges to many municipalities in Mexico and the U.S., and especially along the Mexico-Texas border (Ward, 2015). The mega metropolis produces homelessness and overcrowding, resulting in congestion, pollution, crime, and disease for those U.S. and Mexican groups with the fewest resources (Montes de Oca et al., 2008). What is also clear is that urbanization has affected both rural and urban families in later life. For example, internal migration from the countryside to the city has led to older adults being left behind. Explanations of poverty that emphasize the limited opportunities available to individuals based on their racial and ethnic characteristics suggest that institutional racism perpetuates high rates of poverty among minority Americans (Williams & Collins, 1995). Poverty in turn damages health through unsafe and unhealthful social environments, low educational levels, and inadequate medical care, as well as feelings of helplessness and hopelessness (Angel & Angel, 2015). Research in this tradition demonstrates that the fundamental nature of the labor market that places frican-Americans and Hispanics at a disadvantage in terms of health insurance also undermines health and well-being (Angel & Angel, 2009). Historically, Hispanics have disproportionately situated in low-wage service jobs and informal employment, which undermines their ability to accumulate wealth (Telles & Ortiz, 2008). The epidemiologic research of Vega et  al. (1998) reported much higher rates of lifetime psychiatric disorders among Mexican Americans born in the U.S. compared to Mexicans residing in Mexico City based on field diagnostic interviews, suggesting that social stress and adaptation to lower income status in the U.S. is associated with increasing health risks (Vega et al., 1998). Discriminatory practices in the real estate market have confined many members of racial minority groups to unsafe neighborhoods, with few local employment opportunities, few community resources, and inferior schools (Ortiz & Telles, 2012; Wilson, 1996). Such confinement and the cycle of poverty it creates engenders chronically high levels of physical and social stress that increase the risk of poor health and diminished vitality (Langner & Michael, 1963). To varying degrees, low-income neighborhoods lack the social capital and material resources that can help individuals and families improve their chances for a better life. At the community level, existing research has identified the concept of resilience as a useful way to characterize the positive qualities of neighborhood health and cohesion. This world focuses on neighborhood activism and—more as protective of physical and mental health—outcomes in contexts and linkages of neighborhood assets, intact families, adequate child supervision, and more, including local government and private non-profit organizations (Vega et al., 2011). Resilience, as a social protective factor, reflects both the economic and political circumstances of the community and its social capital, which is defined as the product of positive interactions and opportunities offered by well-functioning social institutions and supportive social networks (e.g., public, private for-profit and nonprofit sectors, and family). The concept of resilience promises to inform both theory and research at the intersection of aging, community, and urban processes, to provide useful models for conceptualizing the contribution to health of potential protective factors related to social capital (Aldrich & Meyer, 2014; Bourdieu, 1986).

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Throughout the life course, people experience adversity and, if successful, they persevere and thrive. Poverty, relative deprivation, and stress experienced early in life compound the exposure of low-income individuals, families, and communities to a variety of stressors throughout adulthood and increase their risk of demoralization and depression in late life (Ferraro, 2011). These stressors also reflect serious vulnerabilities related to gender. Older disadvantaged women experience more social disruption in their lives than more affluent women, and they frequently experience a cascade of unfavorable life events that are often difficult to overcome (Aranda et al., 2001).

 he 1980s and the Establishment T of Hispanic Ethnogerontology In the mid-1980s, researchers with federal funding shed further light on individual and structural risk factors affecting older adult health. Markides’ study of older Mexican Americans and Anglos in San Antonio, Texas (Markides & Martin, 1983), as well as his study of three generations of Mexican-American families, also in San Antonio (Markides et al., 1986), introduced concepts and measures that changed how gerontologists think about cultural norms of aging as they pertain to extended (multigenerational) households, kin relationships, and social support. This research eventually led to the discovery of the “Hispanic Epidemiological Paradox” with which Markides is mostly closely identified (Markides & Coreil, 1986). The study identified that, despite sharply lower than average socioeconomic status, impaired access to health care, and high prevalence of activity limitations and chronic disease, the Mexican-American population had higher life expectancy than non-­ Hispanic whites or blacks. Subsequent studies found that the effect is greater among immigrants than U.S.-born Mexican Americans (Boen & Hummer, 2019; Riosmena et al., 2017). Later studies have also found that the “paradox” affects measures of older adult health and well-being apart from life expectancy (Hayward et al., 2014; Markides & Eschbach, 2005; Palloni & Arias, 2004). Data from the Hispanic Health and Nutrition Examination Survey (HHANES) addressed many questions regarding the health and mortality of Hispanics, primarily Mexican Americans in the Southwestern U.S. HHANES data were gathered in 1982–84 and covered Mexican Americans in the Southwest, Cuban Americans in Dade County, Florida, and Puerto-Ricans in the greater New York City area. It was paired with the sister survey of non-Hispanic whites, Blacks and Asians, the National Health and Nutrition Examination Survey (NHANES) (Centers for Disease Control, 1982). Studies using the HHANES examined the impact of race, Hispanic ethnicity, and immigration on Hispanics’ mental health. For example, Angel and colleagues examined the correspondence of a physician’s evaluation of an individual’s health with that of the individual, and how the degree of correspondence differed between Mexican Americans, blacks, and non-Hispanic whites (Angel et al.,

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2000). The earlier NHANES (1976–80) survey provided information on evaluated and self-reported health status for blacks and non-Hispanics whites (Solis et al., 1990). Such analyses provided new information on the impact of culture and minority group status on self-perceived health for individuals with specific health conditions, as well as for individuals with different levels of global evaluations of self-rated health. Research drawing on the HHANES study illustrated how sources of identity and the sense of affiliation based on racial/ethnic group membership influence the frequency of use of mental health and access to medical services by individuals with emotional problems (Angel & Thoits, 1987). This finding clarified the imperative to understand the impact of language, culture, as well as economic and demographic factors, on the somatic expression of depressive affect and on the inappropriate use of medical services in older adults (Krause & Baker, 1992). During this period, Hazuda conducted a series of studies focusing on the process, measurement, and health consequences of acculturation and assimilation in the Mexican American population (Hazuda et al., 1986). For example, The San Antonio Longitudinal Study of Aging, a community-based study comparing disability trajectories of older Mexican Americans and European Americans, led to the development of a detailed disablement process model. Research continues to draw on the model, particularly that section designed to identify optimal targets of intervention to prevent, slow, or reverse progression toward disability triggered by chronic diseases such as diabetes and arthritis. Building on Cuellar’s Acculturation Scale used in the Hispanic Established Populations for Epidemiologic Studies of the Elderly (HEPESE) (Cuellar et  al., 1980), Hazuda and colleagues created scales for measuring multiple dimensions of acculturation and structural assimilation, that is, functional integration into the majority white, English-speaking U.S. society (Hazuda, Stern, & Haffner, 1988b). The Hazuda Acculturation and Assimilation scales made it possible to explore the differential effect of these sociocultural processes on various health outcomes (Hazuda, Stern, & Haffner, 1988b). Data from The San Antonio Heart Study illustrated the effects of socioeconomic status, acculturation, and assimilation on obesity and diabetes in Mexican Americans (Hazuda, Haffner, et al., 1988a). Other work explored the interaction between sociocultural status and the burden of cognitive impairment in older Mexican Americans (Simpao et al., 2005). In addition to acculturation and assimilation scales, research on the Hispanic population and predictors of Hispanic mortality benefitted from the development of valid and reliable measures of subgroups using indicators of parental surnames, birth place of both parents, self-declared ethnic identity, and ethnic background of grandparents across different age, gender, and socioeconomic characteristics of neighborhoods (Hazuda et  al., 1986). In this vein, investigators used the Hazuda Ethnic Algorithm in several major epidemiologic studies to identify participants as Mexican American or European American (or non-Hispanic white), including the San Antonio Heart Study, the HEPESE, and the San Luis Valley Diabetes Study. It has also become a major tool in genetic studies involving Hispanic populations.

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Although Congress passed a law in 1976 that mandated federal agencies collect and analyze data distinguishing Americans of Spanish origin or descent from other groups, these racial/ethnic classifications were not designed for scientific or anthropological activities. In 1977, the Federal Office of Management and Budget (OMB) developed standards across agencies for this type of data collection that would be compatible, nonduplicated, and exchangeable. The 1980 Census included a question about whether the respondent was of Spanish or Hispanic origin or descent, and for those who answered “yes” whether they were Mexican, Mexican American, Chicana/o, Cuban, or Puerto Rican. Hispanics can be of any race (U.S. Census Bureau, 2021). This question followed the question about the respondent’s race.

 he 1990s and the Beginning of the Longitudinal Study T of Mexican-American Elderly Health (the Hispanic EPESE) Informed by empirical observations from the HHANES and regional studies, the NIA recognized the mutability of the Hispanic population. It also recognized the need for data addressing the health and functional status of older Hispanics, as HHANES was limited to persons under 75 and its sample of those over 65 was small. The problem of under sampling older adult populations was widespread, but was accentuated for Hispanic-Latinos in national population data sets assessing both physical and mental health status. In 1990, NIA launched a new research portfolio for funding, including a longitudinal health and disability study to address these issues, the HEPESE (National Institute on Aging, 2023). The primary objective was to understand subgroups of the Hispanic population 65 and over and to compare them with other racial and minority ethnic groups modeled after four different EPESE communities of non-­Hispanic whites and blacks conducted in the mid-80  s (East Boston, Massachusetts; New Haven, Connecticut; five counties in the Piedmont region of North Carolina; and two rural counties in Iowa). As part of this initiative, the NIA funded the HEPESE, a longitudinal cohort study of a large sample of older Mexican Americans who resided in five southwestern states: Texas, California, New Mexico, Arizona, and Colorado (Markides et  al., 1997). The HEPESE has been the primary source of information on aging in the Mexican American population since its inception in 1993–1994 with a cohort of 3050 people age 65 and over (Cantu & Markides, 2019). A new cohort of individuals 75 and older was added in 2004–05 (n = 932). Extensive in-home interviews were conducted in person at two- to three-year intervals, yielding ten waves with the original cohort and four waves with the replenished cohort. The last waves collected data on the caregiver’s health. The tenth wave of data was collected in 2020–2021 in an abbreviated form because of the COVID-19 pandemic. The sample size of the HEPESE provides the statistical power necessary to obtain stable estimates of the extent to which certain risk factors for mortality and

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morbidity operate differently in Mexican Americans than in non-Hispanic white Americans, African-Americans, Asian Americans, and Native Americans. At each wave, these data encompass performance measures of physical mobility (POMA), height and weight, and blood pressure; self-reported chronic conditions, functional capacity, and mental status; along with demographics, nativity, immigration history, sources of retirement income, health coverage, access to medical care, and mortality. Trained bilingual interviewers performed anthropometric assessments and performance-­based assessments of physical functioning. The HEPESE has produced over 400 scholarly publications on the health, functioning, and health care needs of community-dwelling older adults, including 27 PhD dissertations.

A New Focus Beginning this century, the NIA’s Hispanic aging and health research agenda has prioritized studies that investigate the interaction of genes and the environment to estimate the impact of the nature and magnitude of risk on the human life span. This included a series of studies examining the Hispanic Epidemiological Paradox and testing competing social, environmental, and biobehavioral science explanations of lower mortality. A critical theoretical point of contention was the relative contribution to human life expectancy of agency (the capacity to act on one’s own behalf) versus structure (socioeconomic factors that limit the ability of humans to act as agents). In 2012, the NIA added genetic data to the Health and Retirement Study (HRS), a 30-year nationwide survey of the health, economic, and social status of older Americans and the baby boomer cohort (Health and Retirement Study, n.d.). Articles using HRS data have aimed at disentangling genetic explanations (biomarkers) from social and behavioral factors, along with their effect on disease risk and healthful aging in non-Hispanic white and black populations. Less is known regarding the Hispanic population by nation of origin. A comprehensive list of references exists at the University of Michigan (Health and Retirement Study, 2023). Although health problems must be addressed from multiple levels of analysis and types of interventions, using genetic profiles in Hispanic aging research raises an important question of how an understanding of human biology informs our understanding of the social aspects of aging in new and novel ways, especially in relation to race, ethnicity, and social class (Angel, 2011). Few studies had addressed the question of how knowledge of group membership can be combined with biological and social factors to help understand the unique health risks of older Hispanics, given that much of the literature on health outcomes of any group cannot examine individual differences in disease susceptibility. Diabetes, for example, is polygenic and involves multiple genes, is affected by environmental factors, and clearly affects health profoundly (Gonzalez et al., 1999). Like all human populations, the Mexican-origin population reflects generations of

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genetic mixing, in this case of European and Native American populations. As a result, the ethnic label, like all others, reflects historical and political factors more than exclusively genetic factors. The promising contribution of genetics is in its potential to allow researchers on aging to more accurately identify individuals at highest risk of specific diseases and their complications. However, genetics would enable that with patients of any other ethnicity as well. Identifying biological markers might also make more targeted and effective interventions possible (Hernandez & Blazer, 2006). Physicians, for instance, can look for markers of Type II diabetes such as high glucose levels and high glycosylated hemoglobin (A1C) in patients who identify as Mexican or Mexican Americans. Hernandez and Blazer (2006) acknowledge that there is a dearth of new methods of analysis that could measure the complex genetic and environmental architecture of multifactorial diseases, including cardiovascular disease, diabetes, cancer, arthritis, and neuropsychiatric disorders. Additionally, these authors contend that, while the number of genetic variations thought to be involved in diabetes and other-related cardiovascular conditions are common in older adults, a single genetic/environmental model of disease for an entire population may not be possible (Hernandez & Blazer, 2006). Importantly, the 2020 Lancet Commission Report on Alzheimer’s Disease was also supportive of multifactorial origins of dementia. Meta analyses revealed that, in addition to well-­ known predictors (education, hypertension, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, and low social contact) associated with late adulthood, a combination of other genetic and environmental factors—excessive alcohol consumption, traumatic brain injury, and air pollution—accounted for risk of dementia (Livingston et al., 2020). Of all U.S. racial/ ethnic groups, Hispanics have the highest rate of metabolic syndrome, a group of conditions that elevates the risk of diabetes and heart disease. The problem of metabolic syndrome is pertinent to those in midlife, as it represents a target for modifying the pathway to lower neurocognition and unhealthy neurocognitive aging (González et al., 2018).

The Conference Series on Aging in the Americas In 2000, my colleagues and I recognized the need to coordinate our efforts and communicate our findings in order to foster research and mentor young scholars. The result was the Conference Series on Aging in the Americas (CAA), designed to encourage state-of-the-art research on Mexicans and U.S. Hispanics, with a particular focus on Mexican Americans, and to understand the very complicated experience of the Hispanic population diaspora and its effects on health (Angel, 2014). Examining the social, emotional, environmental, behavioral, and biological characteristics of the Hispanic population was seen by the conference investigators as necessary to identify root causes and develop interventions to reduce and eliminate disparate health burdens and lifespan status.

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The core objective of CAA installments (ICAAs) is to define the construct of healthful aging and to identify its correlates, in addition to conducting epidemiologic studies of illness, morbidity, and mortality in the Mexican-origin population (Angel & Angel, 2006). This effort involves (1) identification of social determinants of health among Mexican Americans in the U.S. and Mexicans in Mexico; (2) assessment of the consequences of these health outcomes for longterm care policies and practice; and (3) development of a set of goals for advancing healthful aging, preventive health care practices, and long-term care. To accomplish this goal, CAA scholars do not focus on general aspects of healthful aging. Instead, each presenter provides in-depth coverage of specific topical areas—causes and consequences of the Hispanic paradox, health disparities, mental health, cognitive aging, and long-term care service use—linking these areas to integrated topics being considered and discussed throughout the conference series. The initial CAA meeting, entitled: Critical Social Policy Issues: Aging in Mexico and the U.S., held at the University of Texas at Austin in 2001, began a discussion of the influences of family and demographic factors on the health of older individuals of Mexican origin using the Mexican Health and Aging Study (MHAS), HRS, and the HEPESE. One of the worldwide HRS sister studies, the MHAS research received NIA funding in 2001 for a prospective panel study of individuals 51 years and older in Mexico, and has since conducted follow-up interviews over the last 20 years: 2012, 2015, 2018, 2021 (Mexican Health and Aging Study, 2022). The MHAS allows for cross-national comparisons of aging processes, migration history, and its impact on multiple health outcomes and economic well-being, using similar data to that from the U.S. population (Angel et al., 2021; Angel et al., 2009; Mejia-­ Arango et al., 2020; Wong et al., 2015). The second conference in 2005, and subsequent ICAA installments, included an expanded number of papers to address conceptual, empirical, and methodological issues related to population health and aging for Mexicans in both countries (Angel & Whitfield, 2007). Topics spanned demography, migration, place-based disparities, economics of sustainable aging, social networks, and support in different health domains. Extending previous research on Hispanic aging and health, the series encompasses topics in two different social, historical, and political contexts: Mexicans in Mexico and Mexican Americans residing in the U.S. At each ICAA, papers investigate the structural similarities and differences in the association among indicators of social vulnerability, to assess the extent to which various health outcomes reflect individual-level factors and structural or contextual factors related to economics and the health care system. As a result of increasing life expectancies, both populations inevitably experience the chronic conditions of age, including serious cognitive decline and dementia. In the future, this new longevity will place serious strains on the ability of governments and families to cope (World Health Organization, 2022). Table 1.1 provides a list of topics covered in each ICAA installment, 14 of which received NIA funding.

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Table 1.1  CAA History of Iterationsa Year 2001 2005 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023

Location U.T. Austin U.T. Austin U.T. Austin U.T. Austin U.T. Austin- Bridging U. of Southern California U.T. Austin U. of Colorado, Boulder Mexico City- Bridging U.T. San Antonio, TX U. of Southern California U. of Arizona, Tucson Mexico City- Bridging ICAA-Texas RCMAR UTMB- Galveston, Virtual U. of Illinois, Chicago University of South California 2024 UT Austin

Focus Intergenerational Support Health and Aging Biobehavioral Dimensions Disability and Long-term Care Two Nations Growing Old (AARP) Cross-National Comparative Studies Demography & Policy Adaptation and Latino Integration Formal and Informal Support Contextualizing Border Health Space, Time, and Place Foundations and Frontiers Mental Health and Cognitive Aging Grant Writing Workshop Resilience and Aging in the Americas Health Resilience and Diversity Health and Aging of Mexican Populations on Both Sides of the Border Challenges of Dementia and Healthful Aging in the Americas

Convened during National Hispanic Heritage Month and Mexico’s Independence Day.

a

The ICAA’s Consensus Building Sessions (CBS), in which a transdisciplinary cadre of senior and early career investigators and emerging scholars come together following the closing keynote, provide an opportunity to examine and reflect on major concepts and methods covered at the meeting. Moderators of each table structure the group conversations to establish a consensus on areas of agreement and disagreement on current and emerging issues for binational research. The approach provides a set of guidelines, including three questions, for fostering effective engagement and discussion pertaining to the meeting objectives. The following three questions, for example, were used at the 2022 ICAA CBS, Resilience and Aging in the Americas: 1. What does resilience mean and encompass conceptually? (i.e., frameworks and domains); 2. What are the social protective mechanisms of resilience? (i.e., variables and measurements); and 3. What are unique contexts of caregivers and what is their role in resilience? A longer life span and poorer health in Mexicans in Mexico and Mexican Americans in the U.S. draws attention to the fact that longevity is necessary but not sufficient for successful aging. Increasingly, factors related to the quality of life are of theoretical and practical interest. Others agree. According to the Pan American Health Organization, healthy aging refers to optimizing opportunities to maintain and improve physical and mental health, independence, and quality of life (Pan American Health Organization, 2023).

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Since the inception of ICAA meetings we have conceptualized “healthful aging” as certainly the absence of serious disease and disability, but also the capacity to engage socially with family and others and to remain psychologically balanced. We have focused on the public health interventions that make this possible. Although there are many definitions of successful aging (Lamb, 2017), we argue that healthy aging in the broadest sense includes processes that lead to optimal physical functioning, mental well-being, and social engagement. This ideal state of physical well-­ being, emotional fulfillment and social engagement is similar to Maslow’s concept of self-actualization, in which the achievement of one’s full human potential depends on more than material factors. According to Maslow, wealth is not the ultimate goal in life, nor does it bring satisfaction independent of what one does with it (Maslow, 1987). Yet, money and wealth are hardly irrelevant to satisfaction. In Maslow’s theory, self-actualization requires the satisfaction of what he termed “deficiency needs,” a concept that refers to the differentiation between higher- and lower-order needs that are part of a hierarchy of life challenges. Over the past two decades, Maslow’s metaphor of “hierarchy of needs” offers a useful perspective for understanding the correlates and modifiable risk factors associated with quality of life and longevity in two vulnerable populations in different settings. Health and aging research has encompassed qualitative, quantitative, and multimethod studies of cross-sectional and longitudinal data that contain demographics and sociocultural factors, including migration and immigration processes relevant to both Mexicans and Mexican Americans. ICAA Scholars’ transdisciplinary approach has provided multiple insights spanning sociology, psychology, behavioral economics, gerontology, geriatrics, public policy, nutrition, social work, and demography. We have contributed significantly to a series of important questions, but much more work needs to be done. What follows next is a highlight of three critical issues that remain unexplored.

 ealthful Aging: Risk and Resilience: Do Protective Factors H Selectively Weaken in Later Life? The health literature overall produces a mixed picture of Hispanic health. The group has lower overall morbidity (except in old age) and a longevity advantage compared to the U.S. population (National Center for Health Statistics, 2015). However, Hispanic subpopulations have high risk for specific chronic disease conditions in mid adulthood, and higher disability and dementia rates in later adulthood than the overall U.S. population (Angel et  al., 2015; Boen & Hummer, 2019; Hill et  al., 2012). This “crossover” from positive to negative health profiles that accompanies the aging process requires examination of this “weathering effect” (González et al., 2009). The literature on Hispanic health among older adults includes studies showing that place has protective effects in conserving health, functioning, and cognition

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that counteract otherwise adverse social and environmental circumstances. Resilience as a concept connotes a dynamic social ecology of protective processes in which culture and context shape positive health outcomes despite adverse circumstances. Resilience can be broadly measured according to various personal and social factors that affect responses and adaptations to adversity. Factors such as social network, previous experience with adversity, self-efficacy, financial status, adequate facilities for recreation, and support in the physical environment for personal growth interact to influence health resilience outcomes. Such a collective effort requires resources and adaptability at all levels of government and the market. Mexico has greater limitations than the U.S. in supportive services. Given the fact that institutional capacities are a key to healthful aging, research must focus on the interaction between individual resilience and community and governmental resources in different political contexts and economic sectors (Angel et al., 2016). It is essential to investigate how these characteristics and causal pathways of resilience affect the burden of disease for aging Hispanics and the ability of their social networks to support them. The key issue is identification of factors and processes that are consequential for sustaining health into later adulthood and the well-­ being of aging Hispanics who experience persistent economic inequality as the result of structural disadvantage. An examination of patterns associated with place and the webwork of social, emotional, and instrumental resources, including social and behavioral adaptations that are unique to environmental conditions, will produce essential knowledge for revitalizing vulnerable communities with policies and programs that optimize health. Sources of identity formation are very relevant to personal development, social incorporation into communities, and successful role transitions between early and mid-adulthood. These sources include maintenance of beliefs and practices supporting healthy lifestyles, formation of oppositional identities, and educational attainment, all important putative determinants in healthy aging shaped by different responses to community environments and the selective availability of protective resources. Previous research on social and behavioral pathways to health resilience has been limited by research portraying older Mexican Americans through a single lens of disadvantage, without accounting for the local economy, culture, and environment. Social determinants of healthful aging operate in multiple domains of resilience, defined as protective factors that operate selectively in high-risk environments to conserve health. Some evidence affirms that urban areas with a high degree of civic engagement and social resilience have lower rates of disease, increased longevity and economic well-being, as well as other health benefits. The empirical meaning of and access to social resilience remains poorly understood. Surprisingly, cities with high inequality indices are characterized by better health for immigrants, perhaps because the total resource base and occupational opportunities are also greater (Hamilton & Kawachi, 2013). The health protective effects of place are unlikely to be universal among Hispanics due to differential socialization, immigration,

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and educational experiences by generation. The result is heterogeneity of Hispanic lifestyles, and unique personal circumstances that affect life course histories of older Hispanics as they age. Future research must examine the moderating role of social psychological, physical environment, and social contexts in mitigating the effect of social determinants on various health outcomes. Research must go beyond deterministic risk models by focusing on the intersections between domains of health resilience in aging among Hispanic populations in the U.S., Mexico, and elsewhere. Naturally occurring assets in communities, including family support systems and formal organizations, may have protective health effects. For example, cities are becoming more age segregated due to gentrification, yet community participation to counter the weakening effects on community cohesiveness is often activated as a response. Recent studies show that the most successful cities will have high social resilience, meaning that they develop and identify new ways to engage and support residents of all age groups. At the 2021 ICAA, which focused on the concept of resilience, participants examined methodologies for data collection at the individual and macro level. The discussions identified several areas for future research, as summarized below (see chapter 3 for 2022 ICAA findings). First, scholars should employ other sources of information, including administrative records, to complement self-reports of social stressors, to identify mechanisms that may mediate the protective aspects of resilience, and health outcomes— physical, mental, emotional and comorbidities. Second, they should apply a transdisciplinary perspective of the concept of resilience, in order to explore the multidimensional adaptation process and the operationalization of these various dimensions. They should also explore the application of the Collaboratory Framework for terms used in research of reserve and resilience (Vaqué-Alcázar et  al., 2022). Third, they should develop adequate measures of dimensions of adaptation to adversity, trauma, stigma, racism, discrimination, and stressors of life course-related challenges, such as novel markers of resilience at young ages. Some of these measures may be complemented by biomarkers (e.g., telomeres, cortisol, and allostatic load). Fourth, they should develop a clear definition of individual and collective agency. The agency process, in which individuals act on their own behalf or when social groups act together, shapes health resilience outcomes. Fifth, in addition to agency, they should employ measures of internal locus of control, self-efficacy, and self-esteem. Sixth, they should examine the utility of measures of cognitive flexibility and reserve, to understand trajectories of resilience at older ages (Livingston et al., 2020). To accomplish this, they will need to explore the use of mixed-methods longitudinal designs (Hiebel et  al., 2021). Seventh, they should include the contribution of measures of the type, extent, and quality of social engagement, connections, and social adaptations in light of the multilevel dimensions of resilience in social and behavioral health investigations. They should incorporate ecological designs to measure all these complex levels and relationships. Eighth, they should understand that data limitations may continue to exist, as many of the variables we can collect are proxies of what we want to measure. Researchers must consider culture, norms, values, and religion, as well as

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pride and aspirations in diverse groups of Hispanics and Mexicans, including indigenous people (Angel & Avala, 2022). Ninth, they should incorporate a gender proxy within an intersectional perspective with a shared understanding of the feminization of aging, in order to develop conceptual models of the determinants of resilience and healthful aging. They will need to consider issues related to race, ethnicity, gender, nativity, migration, and documented status, as well as the gender-based life-­ long structural disadvantages associated with job mobility, wealth accumulation, and health care access (Rote & Angel, 2021). Tenth, they should examine the operationalization characteristic of social policy interventions that affect the work and living conditions of Mexican and Mexican American men and women during natural disasters, war, and global pandemics.

Has Morbidity Been Compressed? A core objective of public health and preventive medicine is to extend the period of life during which individuals are functioning at a high level, thereby improving healthy, active life expectancy. Although this is an admiral goal, the question of whether we can achieve it—and if so, how—remains. In the ideal case, individuals experience a brief period of incapacity and decline near the end of life. Such an outcome requires that, in addition to delaying death, medical science and public health aim to postpone the onset of disability (high compression of morbidity). Angel posits that two alternatives to a long life with a short period of disability present themselves (Angel, 2011). One is early-onset disability accompanied by a relatively short period of incapacity before an early death. The other is perhaps worst of all from a resource demand perspective: early-onset disability accompanied by a long period of incapacity before death. This latter scenario leads to a basic dilemma that we might term a “public health or prevention paradox.” It is the consequence of an ability to increase life expectancy through medical interventions and behavioral risk reduction, but a lower level of success at preventing or significantly postponing the onset of disabling disease. This scenario happens in a system that prevents mortality from diseases that tend to produce relatively early death, such as behaviorally related cancers and cardiovascular disease, but does not prevent conditions that create decline leading to disability, but not early death. It is a likely outcome if the degenerative and incapacitating diseases of old age prove less amenable to prevention than fatal diseases. Fundamental causes associated with aging may mean that, if one lives long enough, one’s risk of illness and disability is very high (Link & Phelan, 2002). In this case, we may be extending life through interventions only to increase the period of compromised functioning. If prevention is not possible, medical management and assistance may be the only option. The result is that individuals consume a large fraction, if not most, of the medical care they consume in their lives during the last few years of life (Cohen & Yu, 2012).

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Thus, while an increased period of morbidity associated with rising life expectancy, low socioeconomic status, and low access to quality care—particularly among foreign-born Hispanics—is worthy of serious attention, the question is how to improve healthful aging for everyone, which also means that longer lives will certainly mean greatly increased costs to society associated with increased dependency. In the absence of significant rationing, a long but unhealthy life implies a potentially long period of dependency and medical care use and potentially crushing financial and care-giving burdens for both families and the state.

Dementia Support: What Are the Institutional Responses? Despite high rates of chronic conditions, Hispanics on average live as long as or longer than non-Hispanic white Americans (Markides & Eschbach, 2005). Their increasing life spans mean they inevitably experience the chronic conditions of age, including serious cognitive decline and dementia. Hispanic caregivers have historically cared for relatives for protracted periods without utilizing community resources (Rote et al., 2019). Hispanic caregivers are at higher risk for the stress associated with intensive caregiving, particularly when caring for persons living with dementia, due to higher rates of neuropsychiatric dementia-related symptoms, delays in diagnosis, and limited access to formal, paid care (Hinton et al., 2006). This new epidemiological reality for aging Hispanic populations will inevitably place serious strains on the capacity for coping of both the state and the family (World Health Organization, 2022). Older Mexican-origin U.S. citizens and residents are highly dependent on Medicare and Medicaid for basic health care, and increasingly for long-term care, either in institutions or in the community, much as older Mexicans depend on state-sponsored care. The needs of aging populations in both countries pose serious challenges to municipal, state, and federal governmental agencies, as well as to private citizens (Angel, 2014). As of yet, the extent to which fiscal austerity and changes to programs such as Medicare and Medicaid affect Mexican-origin families as well as their aging parents is poorly understood. Closing the knowledge gap requires closer attention. In particular, little is known about the socioeconomic consequences of Hispanic dementia in either the U.S. or Mexico. Exact estimates are unavailable regarding the total cost: health sector costs (direct costs), the value of decreased or lost productivity by the individual or caregiver(s) (indirect costs), the cost of pain and suffering (intangible costs), and hidden costs (such as downsizing to a smaller home) (U.S. Department of Health and Human Services, 2023). People in Mexico and the U.S. differ greatly in their reliance on state-sponsored programs, the family, and the local community in the care of older adults. In the U.S., the federal government provides Social Security retirement income and Medicare benefits to most citizens 65 and older. Social Security is an important source of retirement income for all Americans, but particularly so for Hispanics, who have less wealth and are less likely than Anglos to have a private retirement

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plan. Social Security represents over 90 percent of the total income of 52.6 percent of older Hispanics (Social Security Administration, 2022). Both countries struggle to provide low income older adults with all the services and supports they need. Mexico presents a difficult situation, given the absence of a specialized long-term care system. As a result, Mexico has traditionally left the family to provide the primary source of economic and instrumental support for older adults. Today, however, the government is assuming a larger role in assuring the economic security of the elderly. In Mexico, employment-based pension coverage is low. In 2021, only 26.1 percent of adults 60 years and older had a pension (FIAP International, 2021). Some local and state governments offer non-contributory social pensions, and in 2012 the federal government introduced Setenta y mas (seventy and older) (Angel & Montes de Oca, 2020). Setenta y mas originally covered poor elders in small rural areas in 2007, but the Peña administration expanded it in 2013, making it universal for individuals over 65 with no other pension (Salinas-­ Rodríguez et  al., 2014). Bi-monthly payments, however, are low (Aguila & Angel, 2021). While historically the family has been the primary source of caregiving in both Mexico and the U.S., reductions in family size and ever-increasing life spans mean that this may not continue to be a viable solution. Because of the lack of caregiver support programs in both countries, caregivers, who are mostly women, have to reduce hours of work or leave their jobs altogether in order to care for aging parents, generating labor instability and reductions in pension contributions, among other problems (Kelley et al., 2015). These trends will, in turn, reduce the proportion of older adults who are able to turn to their children for basic care needs. Migration within and between both countries also complicates care arrangements, as adult children often move far from their place of birth and their parents’ homes. These demographic and social changes mean that the future support and caregiving needs of Hispanics and others in both countries may not be easily addressed through community-­based solutions. Both countries can benefit from promoting informal care programs as long as the programs are evaluated and regulated appropriately, and their consequences, trade-­ offs, and long-term adverse effects are understood (Angel et  al., 2021). Specific policies and programs to address gender, race/Hispanic ethnicity, and rural/urban disparities in the availability of health care in general and to promote informal care are needed. Many technology-driven programs will require considerable investment; international collaboration would be useful, but incentives for adoption are precarious. Much research is also needed to determine the social factors that determine the quality of care that older adults receive through community-based long-­ term care programs. In Mexico, the state must assume a stronger stewardship role, in order to guide institutional innovations and to provide human and economic resources for long-term care, with special efforts made to support caregivers (Montes de Oca et al., 2008). An important goal for both nations should be creating new care strategies such as respite support, including the expansion of government-funded day-care centers for older adults. This is fundamental not only for improving the health and well-being of older adults, but also for supporting family members and other informal care

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givers who often must relinquish their main economic activity, or their personal development in general. Intergenerational Day Centers, a new model in adult and child day care, offer benefits for both children and older adults while optimizing shared space in public places (Norouzi & Angel, 2023). Mexico and the U.S. face a similar set of issues in caring for dependent individuals. One promising solution is to target long-term care at the federal level. For both nations, it is critical to engage in advocacy to facilitate national and federal legislation aimed at promoting the use of public health organizations to empower communities and families to deliver care that is appropriate to local needs and cultural preferences. Differing familial, community, and federal contexts will necessitate divergent solutions. As the populations of both countries age, traditional non-governmental organizations (NGOs) and faith-based organizations (FBOs) are redefining their missions to include serving the vulnerable elderly. Although research has addressed the efforts of major NGOs in facilitating eldercare in many parts of the world, the role of more local NGOs and FBOs in caring for the old and infirm in Mexico and the U.S. is less well understood. Yet the potential of such non-governmental sources of care is significant and should be investigated. While federal and state governments control major economic resources, local organizations possess social capital and are in daily contact with members of their community. They are potentially in a position to significantly supplement the efforts of governmental agencies to deal with the needs of frail older members of the community. In the U.S., the federal government allows faith-based institutions to receive funding for community improvement projects. Given their social importance, the potential role of NGOs and FBOs in improving the lives of older impoverished citizens and their families deserves serious attention. Moving to the Next Stage in Research on Aging in the Americas. Over the last three decades, ICAA has made significant contributions to the field of healthful aging in the Americas and has fostered the careers of scholars interested in minority aging. These efforts have resulted in a number of research advances, and led to a greater understanding of individual and structural factors that influence the health and life chances of vulnerable Americans across the life course. Yet, much still remains to be done. The outlines of that future agenda are illuminated by issues raised in this chapter. The major areas we identify are understanding the changing nature of caregiving, the causes and consequences of dementias and chronic conditions, demographic and social correlates of changes in filial supports, increased bi-­ national collaboration, and the development of appropriate data sources. The next stage of Hispanic Aging will require a more complex set of research, scholarship, data analytical skills and a deeper understanding of policy implications. With the U.S. and Mexico rapidly aging, the social, economic, and political implications of rapid demographic change must be addressed effectively to avoid fiscal disaster and human suffering. The U.S. is becoming majority-minority, with Latinos representing a significant share of this diverse nation. Mexico will continue to experience a decline in cohort replacement rates. The next stage is challenging, yet exciting and full of opportunities to prepare both nations for their new demographic and social realities of aging.

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References Aguila, E., & Angel, J. L. (2021). Retirement and supplemental income programs for low-income older Mexican-origin adults in the United States and Mexico. Public Policy & Aging Report, 31(3), 89–95. https://doi.org/10.1093/ppar/prab010 Aldrich, D.  P., & Meyer, M.  A. (2014). Social capital and community resilience. American Behavioral Scientist, 59(2), 254–269. https://doi.org/10.1177/0002764214550299 Angel, R.  J. (2011). Agency versus structure: Genetics, group membership, and a new twist on an old debate. Social Science & Medicine, 73(5), 632–635. https://doi.org/10.1016/j. socscimed.2011.06.039 Angel, J. L. (2014). Epilogue. In W. A. Vega, K. S. Markides, J. L. Angel, & F. Torres-Gil (Eds.), Challenges of Latino aging in the Americas (Vol. 3rd, pp. 424–432). Springer Nature. Angel, J. L., & Angel, R. J. (2006). Minority group status and healthful aging: Social structure still matters. American Journal of Public Health, 96, 1152–1159. Angel, R. J., & Angel, J. L. (2009). Hispanic families at risk: The new economy, work, and the welfare state. Springer Sciences. Angel, R. J., & Angel, J. L. (2015). Latinos in an aging world: Social, psychological, and economic perspectives. Routledge. Angel, R. J., & Montes-de-Oca Zavala, V. (2022). When strangers become family the role of civil society in addressing the needs of aging populations. Routledge. Angel, R. J., & Montes de Oca, V. (2020). Social rights of the elderly as part of the new human rights agenda. Noncontributory Pensions and Civil Society in Mexico, 40(1), 127–149. https:// doi.org/10.1891/0198-­8794.40.127 Angel, R., & Thoits, P. (1987). The impact of culture on the cognitive structure of illness. Culture, Medicine and Psychiatry, 11(4), 465–494. https://doi.org/10.1007/BF00048494 Angel, J. L., & Whitfield, K. E. (2007). The health of aging Hispanics: The Mexican-origin population. Springer Science. Angel, R., Ostir, G. V., Frisco, M. L., & Markides, K. S. (2000). Comparison of a self-reported and a performance-based assessment of mobility in the Hispanic established population for epidemiological studies of the elderly. Research on Aging, 22(6), 715–737. https://doi. org/10.1177/0164027500226006 Angel, R. J., Angel, J. L., & Hill, T. (2009). Subjective control and health among Mexican-origin elders in Mexico and the United States: Structural considerations in comparative research. Journal of Gerontology: Social Sciences, 64B, 390–401. Angel, R.  J., Angel, J.  L., & Hill, T.  D. (2015). Longer lives, sicker lives? Increased longevity and extended disability among Mexican-origin elders. The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 70(4), 639–649. https://doi.org/10.1093/ geronb/gbu158 Angel, J.  L., Angel, R.  J., López-Ortega, M., Robledo, L.  M. G., & Wallace, R.  B. (2016). Institutional context of family eldercare in Mexico and the United States. Journal of Cross-­ Cultural Gerontology, 31(3), 327–336. https://doi.org/10.1007/s10823-­016-­9291-­3 Angel, J. L., Vega, W. A., Gutiérrez Robledo, L. M., López-Ortega, M., Andrade, F. C. D., Grasso, S. M., & Rote, S. M. (2021). Optimizing dementia Care for Mexicans and for Mexican-origin U.S. Residents. The Gerontologist, 62(4), 483–492. https://doi.org/10.1093/geront/gnab075 Aranda, M.  P., Castaneda, I., Lee, P.  J., & Sobel, E. (2001). Stress, social support, and coping as predictors of depressive symptoms: Gender differences among Mexican Americans. Social Work Research, 25(1), 37–48. Retrieved from ://WOS:000169058800005. Boen, C. E., & Hummer, R. A. (2019). Longer—But harder—Lives?: The Hispanic health paradox and the social determinants of racial, ethnic, and immigrant–Native health disparities from midlife through late life. Journal of Health and Social Behavior, 60(4), 434–452. https://doi. org/10.1177/0022146519884538 Bourdieu, P. (1986). The forms of capital. In J. Richardson (Ed.), Handbook of theory and research for the sociology of education (pp. 241–258). Greenwood.

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Part II

Cognition: Conceptual and Measurement Issues

Chapter 2

Acculturation in Context: A Framework for Investigating Cognitive and Brain Aging in People of Hispanic and Latin American Descent Melissa Lamar, Lisa L. Barnes, and David X. Marquez

People of Hispanic and Latin American descent are one of the fastest growing minoritized populations in the United States, and they are approximately 1.5 times as likely to develop Alzheimer’s dementia as older non-Latino Whites (Fitten et al., 2001; Perkins et  al., 1997). While levels of acculturation, that is, the process by which people of Hispanic and Latin American descent (hereafter described as Hispanics/Latinos) adapt to the U.S. and potentially adopt its values and practices, have long been linked to a number of health outcomes, work is accumulating that investigates acculturation in relation to cognition and brain aging. Furthermore, evolving theories of acculturation (Abraido-Lanza et  al., 2006; Abraido-Lanza et  al., 2016; Lara et  al., 2005; Lopez-Class et  al., 2011; Schwartz et  al., 2010; This work was supported by a grant from the National Institute on Aging (R01 AG062711). M. Lamar (*) Rush Alzheimer’s Disease Center, Chicago, IL, USA Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA The Institute for Minority Health Research, Department of Medicine, University of Illinois Chicago, Chicago, IL, USA e-mail: [email protected] L. L. Barnes Rush Alzheimer’s Disease Center, Chicago, IL, USA Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, IL, USA Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA D. X. Marquez Rush Alzheimer’s Disease Center, Chicago, IL, USA Department of Kinesiology and Nutrition, University of Illinois Chicago, Chicago, IL, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. L. Angel et al. (eds.), Older Mexicans and Latinos in the United States, https://doi.org/10.1007/978-3-031-48809-2_2

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Viruell-Fuentes, 2007) suggest it is not a static, linear process but a dynamic exchange between Hispanics/Latinos and other members of the “host” society that emerges from and is reinforced by broader socioenvironmental determinants vital to a process that is the focus of this chapter—“acculturation in context.” Thus, in addition to acculturation-related factors (e.g., language preference and/or years in the U.S.), socioenvironmental determinants at both the individual (e.g., perceived discrimination, family, and/or cultural stressors) and neighborhood (e.g., ethnic enclaves, safety, and crime rates) level need to be integrated into Alzheimer’s disease and related dementia (ADRD) research with older Hispanics/Latinos. This chapter will discuss the evolution of culturally compatible research in Hispanics/ Latinos in the U.S. and aims to encourage a larger, more inclusive perspective that incorporates people of Hispanic and Latin American descent regardless of geographic location.

Acculturation in Context: Framework Rationale By 2030, the Hispanic/Latino population in the U.S. that is 65 years and older will increase by ~225% compared to a 65% increase in non-Latino Whites (Greenberg, 2009). Also, by this time, rates for ADRD will disproportionately increase for older Hispanics/Latinos—as much as 832% (Greenberg, 2009). In the Americas, over half of the region’s 200 million older adults live in Latin America and the Caribbean where age-specific prevalence rates of ADRD outstrip that of the U.S.  Taken together, there will be 16 million people with dementia in Latin American and Caribbean countries by 2050 and 11 million in the U.S. (ADI/Bupa, 2013). Thus, approximately 22% of the total global prevalence of ADRD will exist in the Americas. In addition to being at the forefront of the ADRD epidemic, Hispanics/Latinos also have higher rates of cardiovascular disease (CVD) risk factors including uncontrolled hypertension and type 2 diabetes (Pirzada et al., 2023). Across meta-analytic studies and large-scale, population-based investigations of older adults in the U.S. regardless of race or ethnicity, individual CVD risk factors, including but not limited to type 2 diabetes (Bangen et al., 2015; Guan et al., 2022; Lamar et al., 2015; Reitz et al., 2017; Verdelho et al., 2010), hypertension (Allan et al., 2015; Brickman et al., 2010; Guan et al., 2022; Lamar et al., 2022; Marcus et al., 2011), smoking (Brickman et al., 2008), and elevated body mass index (Jagust et al., 2005; Windham et al., 2017), have been associated with reductions in brain structures (i.e., frontal, parietal, and temporal lobe volumes; white matter regions; select subcortical structures). Furthermore, the population attributable risk of a single CVD risk factor like hypertension, diabetes, smoking, or obesity as related to dementia is 15% in the U.S. (Lee et  al., 2022). When comorbid, these CVD risk factors are collectively associated with structural brain alterations in many of the same regions associated with ADRD (Cox et al., 2019; see Lamar et al., 2020 for review); they also associate with reductions in cognitive performance (e.g., Lamar et  al., 2019), longitudinal

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cognitive decline (e.g., Downer et al., 2016; Gardener et al., 2016), as well as risk for (e.g., Guan et al., 2022) and development of dementia (e.g., Samieri et al., 2018). Collectively, these CVD risk factors, along with other associated risk factors, contribute to a combined population attributable ADRD risk of 41% regardless of race or ethnicity (Lee et al., 2022) and 34% for Hispanics/Latinos (Nianogo et al., 2022). In contrast, in Latin America and the Caribbean, the percentage of dementia cases attributable to CVD risk factors and other associated risk factors increases to 56% (Mukadam et al., 2019)—higher than that of U.S. estimates, as well as those noted worldwide (i.e., 35%; Mukadam et al., 2019). While great strides have been made to document how CVD risk factors and other modifiable factors negatively impact cognition and brain aging in Hispanics/Latinos (Collins et  al., 2009; Downer et  al., 2016; Insel et  al., 2005; Jagust et  al., 2005; Lamar et al., 2019; Lamar, Drabick, et al., 2021b; Mayeda et al., 2013; Pasha et al., 2015; Ramirez et al., 2007; Stickel et al., 2019; Tarraf et al., 2020; Zeki Al Hazzouri et al., 2013), these risk factors do not completely account for the noted disparity seen in ADRD for this growing group of individuals (see Alzheimer’s Association, 2021 for review). In fact, even other well-documented genetic risk factors for cognitive decline and Alzheimer’s dementia among non-Latino White adults do not manifest the same level of risk in Hispanics/Latinos regardless of geographic location (Johnson et al., 2014; O’Bryant et al., 2013). For example, the influence of apolipoprotein E (APOE) genotypes on mild cognitive impairment (MCI) and ADRD have not consistently shown the same pattern of risk (e4) or protection (e2; Xiao et al., 2023) among Hispanics/Latinos. Furthermore, APOE has not related to cognitive decline (Chan et al., 2023) or amyloid load (Duara et al., 2019) in the same manner as seen in non-Latino White older adults. This may be due in part to the heterogeneity of heritage backgrounds (Granot-Hershkovitz et al., 2021) and the cultural characteristics they represent, as well as the additional contributions of and heterogeneity in other social determinants of health (SDOH; Parra et  al., 2021) in this diverse population. Thus, investigating unique and culturally compatible contributors of risk as well as resilience to ADRD in Hispanics/Latinos is a logical next step and one that may prove critical for global health initiatives (Matthews et al., 2019; Parra et al., 2021). One unique and culturally compatible factor shown to be an important contributor to health in older Hispanics/Latinos, particularly in the U.S., is acculturation. Historically defined as the process of adapting to a new environment and potentially adopting its values and practices, acculturation has been associated with several health outcomes, including cardiovascular health in U.S.-based Hispanics/Latinos, in both positive and negative ways. Some, mainly cross-sectional studies report that Hispanic/Latino adults with lower levels of acculturation to the U.S.—quantified by non-U.S.-based nativity, later age at immigration, shorter length of residence in the U.S., or Spanish language preferences—have lower levels of cardiovascular risk when considering the presence/absence of hypertension, diabetes, hypercholesterolemia, obesity, and smoking (Daviglus et  al., 2016; Kershaw et  al., 2016; Ortega et  al., 2020); however, other studies report associations in the opposite direction (Kandula et  al., 2008; Lopez et  al., 2014), and still others report no relationship

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(Chang et al., 2015; Padilla et al., 2011). In a multiethnic cohort (22% Hispanic/ Latino), however, higher levels of acculturation to the U.S. (i.e., U.S. nativity, longer length of residence in the U.S., and speaking English in the home) were associated with lower odds of having average to ideal cardiovascular health (Osibogun et al., 2021). Overall, some aspects of acculturation appear to be more, or less, detrimental to cardiovascular health in Hispanics/Latinos (Pirzada et al., 2023), and it is these same cardiovascular health indices that are linked to cognition and brain health (Collins et al., 2009; Downer et al., 2016; Insel et al., 2005; Jagust et al., 2005; Lamar et al., 2019; Lamar et al., 2021b; Mayeda et al., 2013; Pasha et al., 2015; Ramirez et al., 2007; Stickel et al., 2019; Tarraf et al., 2020; Zeki Al Hazzouri et al., 2013). Thus, acculturation may contribute to health disparities in cognition, brain aging, and ADRD in Hispanics/Latinos; aspects of acculturation may also allow for resilience against these disparities, potentially changing the narrative to one of increasing health equity for Hispanic/Latino communities. Increasingly, studies are focused on the role of acculturation on cognitive and brain aging within Hispanics/Latinos; however, results are mixed. Some studies report that Hispanics/Latinos with lower levels of acculturation as measured by such indices as non-U.S.-based nativity and cultural orientation, as well as Spanish-­ language preferences, were more likely to show cognitive impairment (Mejia et al., 2006; Ramirez et al., 2007) and higher dementia risk (Martinez-Miller et al., 2020; Moon et al., 2019) than those with higher levels of U.S.-based acculturation, while other studies have not found these associations (Farias et  al., 2011; Flores et  al., 2017). A few studies showed the opposite results: for example, lower levels of U.S.based cultural orientation and higher levels of cognition (Vasquez et  al., 2019). Some of these discrepancies may be explained by subtle nuances inherent in many of these acculturation-related measures that have hitherto gone unexplored. For example, when years in the U.S. and age at migration are considered, results highlight the fact that the duration and timing of each of these factors is important to consider for cognitive performance (Alam et al., 2022) and dementia risk (Vasquez et al., 2022). Furthermore, sex differences (Casanova & Aguila, 2020) and cognitive status (Mendoza et al., 2022) have been shown to moderate the associations between acculturation-related factors and cognition, particularly when socioeconomic status is taken into consideration (Casanova & Aguila, 2020). To our knowledge, only study included brain imaging to understand what may link acculturation to cognition (Rodriguez et  al., 2022); however, with 45 Hispanic/Latino participants all diagnosed with MCI, it is difficult to generalize the results. Thus, acculturation may be an important determinant of cognitive and brain aging, although more nuanced work is needed if we are to understand discrepant results to date, and studies should incorporate neuroimaging where possible (Babulal et al., 2019; Parra et al., 2021; Quiroz et al., 2022) if we are to fill the aforementioned gaps in the literature. The work in this space may be aided by the evolving theories of acculturation and more recent health disparities research frameworks. As previously stated, theories of acculturation have evolved over time to reflect a more nuanced approach that incorporates the lived experience associated with this culturally relevant concept (Abraido-Lanza et  al., 2006; Abraido-Lanza et  al., 2016; Lara et  al., 2005;

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Lopez-Class et al., 2011; Schwartz et al., 2010; Viruell-Fuentes, 2007). Furthermore, priorities for research across the Americas have simultaneously evolved to incorporate many of the same levels of analyses when considering health disparities in aging and ADRD (Hill et al., 2015; Parra et al., 2018; Parra et al., 2021).

Acculturation in Context: Framework Defined Acculturation is no longer seen as a static, linear process (Fig. 2.1a), but rather as a dynamic exchange (Fig.  2.1b) between new and host members of society that emerges from and is reinforced by broader socioenvironmental determinants (Abraido-Lanza et al., 2006; Abraido-Lanza et al., 2016; Lara et al., 2005; Lopez-­ Class et al., 2011; Schwartz et al., 2010; Viruell-Fuentes, 2007) vital to a process being called acculturation in context (Abraido-Lanza et al., 2016). As illustrated by Fig.  2.1b, acculturation in context is measured not only by acculturation factors reported in the literature but should also capture the context of the lived experience both at an individual as well as a neighborhood level. Many such socioenvironmental determinants of health have been studied in isolation (Estrella et al., 2021; Farfel et al., 2021; Marquine et al., 2022; Munoz et al., 2021) or with select socioeconomic and psychosocial factors (Wang et al., 2022; Zahodne et al., 2021) and predominantly in other minoritized populations (Barnes et al., 2004; Cintron et al., 2023; Dark et al., 2023; Lewis et al., 2009; Nkwata et al., 2021; Zahodne et al., 2017). By applying them to the acculturation construct, acculturation takes on a more comprehensive and dynamic approach. Thus, acculturation-related factors including nativity, Spanish/English language, and social preferences are considered in concert with other relevant lived experience factors including individual- and

Fig. 2.1  Initial (a) and more recent (b) theoretical frameworks to guide acculturation research

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neighborhood-­ level factors. For example, individual-level factors may include everyday or lifetime encounters with discrimination, social isolation, social networks, and other culturally relevant stressors as well as resilience factors including key aspects of cultural identity in Latino communities, like the importance of family and family relations. Likewise, neighborhood-level factors that are contingent upon the environment, but may also exert their effect on the individual directly or indirectly (Besser et  al., 2017), may include, but are not limited to, levels of crime, access to healthy/unhealthy food vendors and recreation options, as well as ethnic enclaves that promote cultural identity and economic activity. This more comprehensive acculturation in context framework may help to explain previously conflicting results in the acculturation and cognition literature employing more static and restricted definitions (Xu et al., 2017). While there should be key components of acculturation in context that investigators have determined over time are valid in older adults (Medina et al., 2023) and critical for inclusion in all studies, the framework is flexible. Such flexibility will ensure that the concept of acculturation in context (i.e., the dynamic exchange between members of society that emerges from and is reinforced by broader socioenvironmental determinants) may be applied not only to individuals living through a change from their location of origin to another location but also to any group experiencing health disparities in brain aging when compared to another majority group. This fluidity may provide more holistic approaches to improve health equity in brain aging, not only for older Hispanics/Latinos but other understudied populations as well, and provide evidence of how lived experience may positively and negatively impact cognitive and brain aging. Guidance and scientific justification for inclusion of individual-level socioenvironmental factors in the acculturation in context framework as it relates to cognition and brain aging for Hispanics/Latinos, who have been understudied when it comes to these factors, may be found in empirical studies of other minoritized populations. For example, risk factors including higher levels of perceived discrimination (Barnes et  al., 2012a; Nkwata et  al., 2021) and smaller social networks (Barnes et al., 2004) have independently been associated with lower levels of cognitive functioning and ADRD risk in African Americans. These relationships may be due, in part, to the relationship of these same variables to CVD risk factors (Lewis et al., 2009), inflammation (Byrd & Allen, 2023), and depression (Zahodne et al., 2019) as well as other socioeconomic factors (Majoka & Schimming, 2021). Similar relationships between discrimination, social cohesion, and cognition (Estrella et  al., 2021; Farfel et al., 2021) as well as more culturally compatible risk factors including acculturation-related stress and cognition are beginning to be reported for Hispanics/Latinos (Estrella et al., 2021; Lamar et al., 2021a; Marquine et al., 2022; Munoz et al., 2021), supporting their incorporation into an acculturation in context framework. Furthermore, relationships of these variables with CVD risk factors (Hernandez et al., 2017), inflammation (Caceres et al., 2021), and other psychosocial factors (Estrella et al., 2021) are increasingly evident for Hispanics/Latinos as well. In contrast, many resilience factors that are protective against cognitive decline in non-Latino White older adults (e.g., purpose in life; Boyle et al., 2010; Wingo

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et al., 2020) are proving to be similarly protective for Hispanics/Latinos (Estrella et al., 2021). In addition, other resilience factors central to Hispanic/Latino culture are also emerging as important. For example, older Hispanics/Latinos higher in the culturally compatible factor of familism (i.e., the level of identification/attachment of individuals with their family, a key aspect of cultural identity in Latino communities; Estrella et al., 2021) also demonstrate higher levels of some, but not all, cognitive functions. Taken together, increasing evidence points toward individual-level risk and resilience factors that are relevant to cognitive aging in Hispanics/Latinos and should be taken into account when considering acculturation within the context of their lived experience to provide a more complete profile of aging and ADRD in this population. The lived experience also includes neighborhood-level socioenvironmental factors, and empirical research suggests that where people live affects how they age, regardless of race or ethnicity (Besser et al., 2017; Wu et al., 2015a). For example, resilient environmental profiles are emerging that appear to benefit cognitive health. Specifically, urban environments with access to parks, lakes, or other waterways may directly and indirectly (via cardiovascular fitness) benefit cognition (Cerin et al., 2022). Additionally, living in areas of high land use mix (i.e., a high degree of integration among residential, agricultural, recreation, transportation, and commercial land use in a neighborhood) has been shown to reduce the odds of dementia (Wu et  al., 2015b); although more recent studies suggest this may vary by other important neighborhood-level factors like air pollution and socioeconomic levels (Cerin et al., 2023). In contrast, higher levels of racial segregation (Besser et al., 2023; Jang et al., 2022; Pohl et al., 2021) and—in some (Ruiz et al., 2021) but not all (Wu et al., 2015b) studies—crime are associated either directly or indirectly with alterations in cognition. Interestingly, while clustering of Hispanics/Latinos within neighborhoods (i.e., the barrio effect) is thought to be advantageous for some aspects of physical health in Mexican Americans (Aranda et al., 2011) and has been associated with higher levels of cognition for older adults regardless of race or ethnicity (Kovalchik et al., 2015), it was also associated with faster rates of cognitive decline (Kovalchik et al., 2015). Thus, specific neighborhood-level socioenvironmental factors may benefit from being considered within the acculturation in context framework. Composite indices of neighborhood health may also allow for a more integrated approach to investigations of neighborhood-level factors in relation to cognitive health (e.g., Zuelsdorff et  al., 2020), and initial investigations within ethno-racial groups suggest that different patterns may exist. For example, while neighborhood-­ level social vulnerability (comprised of social factors including socioeconomic, household, housing, and transportation characteristics) was associated with cognitive and motor functioning for older African Americans, it was only associated with motor functioning in Latinos despite Latinos’ higher levels of social vulnerability (Lamar et al., 2023c). Thus, whether considering multiple neighborhood-level factors or a single composite, results may be contingent upon other aspects of the neighborhood or the individual, suggesting that these factors may benefit from being considered within the acculturation in context framework as applied to cognitive aging.

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At the same time as proponents of the acculturation in context framework were writing about its importance for Hispanics/Latinos (Abraido-Lanza et  al., 2006; Abraido-Lanza et al., 2016; Lara et al., 2005; Lopez-Class et al., 2011; Schwartz et  al., 2010; Viruell-Fuentes, 2007), the National Institutes of Health/National Institute on Aging (NIA) in the U.S. published a framework “to organize factors examined in health disparities research related to aging” more broadly (Hill et al., 2015). This framework not only highlighted select participant characteristics that were important to consider, including race and ethnicity, it also organized factors across levels of analysis in such a way as to allow for research into causal pathways that may bind these factors into systems to inform future interventions (Hill et al., 2015). By defining environmental, sociocultural, behavioral, and biological factors that may help to determine the health of a population, the NIA Health Disparities Framework laid the foundation for investigators to consider which aspects of these factors may contribute to differences in health between populations and which may promote risk and resilience within a population. When taken together with the acculturation in context framework, these position papers contributed to the zeitgeist that a more comprehensive approach to understanding aging and ADRD, one that incorporated the individual and their socioenvironmental milieu, was not only needed but imperative to address and amend existing health disparities in brain aging in the U.S. A similar position has been advocated for Latin America (Parra et  al., 2021), which suggests that including individual- and neighborhood-level SDOH into work with Hispanics/Latinos has only just begun.

Acculturation in Context: Framework Applied Acculturation in context as a framework guiding comprehensive empirical investigations of cognitive and brain aging in Hispanics/Latinos is in its infancy; however, it nonetheless provides new opportunities for novel and comprehensive research to understand health disparities and increase health equity in brain aging and ADRD for this growing population. Understanding how acculturation in context relates to brain aging and ADRD in Hispanics/Latinos may also prove critical for the development of culturally compatible approaches to clinical care and interventions. A more holistic investigation of cognitive and brain aging in Hispanics/Latinos may accelerate the identification of potential targets for socioenvironmental modification to slow cognitive decline and delay the onset of Alzheimer’s disease in Hispanics/ Latinos. Achieving a more comprehensive understanding of potentially modifiable reasons for increased dementia risk in Hispanics/Latinos—regardless of geographic location—is an urgent public health issue. Applying the expanded theory of acculturation in context, we have embarked on a program of research with older Hispanics/Latinos to investigate how the factors of acculturation in context relate not only to each other but also to cognitive and brain aging and the role of cardiovascular disease risk factors on these relationships. To do this, we applied the acculturation in context framework to existing data from

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Table 2.1  Participant characteristics for acculturation in context publications

N Cohort Study Age (years) Sex (male:female ratio) Education (years)

Lamar et al., 2021a 199 LATC, MAP

Lamar et al., 2023a 192 LATC, MAP

69.7 (6.6) 38:161

69.7 (6.6) 37:155

Fleischman et al., 2023 92 LATC, Clinical Core, MAP 73.9 (6.5) 16:76

10.8 (4.7)

10.9 (4.7)

11.9 (4.8)

Note: Cohort study abbreviations represent the Rush Alzheimer’s Disease Center’s Latino Core (LATC) and the Rush Memory and Aging Project (MAP)

older Hispanics/Latinos participating in Rush Alzheimer’s Disease Center (RADC) cohort studies. De novo data collection has also begun to expand upon the acculturation in context framework as it relates to risk and resilience factors specific to our participants in the Chicagoland area. As may be seen in Table 2.1, Hispanics/Latinos contributing to initial publications were participants in one of three RADC cohort studies that have harmonized behavioral, cognitive, physical, anthropomorphic, neuroimaging, and blood-based assessments (Marquez et  al., 2020). On average, participants contributing to our acculturation in context studies were 70 years of age and reported 11 years of education. Participants were primarily female and predominantly Spanish speaking (~70%). Furthermore, while the majority reported their nativity outside of the U.S., these same individuals also reported having lived in the U.S. for, on average, four decades. In addition to providing these characteristics, participants provided information about aspects of acculturation in context and underwent a comprehensive assessment of cognitive functioning annually. Detailed elsewhere (Lamar et  al., 2021a; Lamar et al., 2023a; Marquez et al., 2020), acculturation in context measures spanned acculturation-related as well as individual-level, socioenvironmental, contextually related factors while neuropsychological test measures spanned episodic, semantic, and working memory as well as perceptual speed and visuospatial abilities. A subset of participants also agreed to biennial magnetic resonance imaging (MRI) (Fleischman et al., 2023). We began by investigating the relationship of 10 indices of acculturation in context to each other as well as to level and change in cognition (Lamar et al., 2021a). An unrotated Principal Component Analysis (PCA) returned three distinct factor loadings that accounted for approximately 70% of the variance. These orthogonal factor loadings represented unique aspects of the acculturation in context framework. Factor 1 represented acculturation-related aspects of nativity and languageand social-based acculturation; Factor 2 represented individual-level socioenvironmental experiences of discrimination, social isolation, and social networks; Factor 3 comprised a single metric, familism. After creating composite z-scores of these three factor loadings, we subjected them to individual mixed effects regression models as separate predictors of global cognition and five

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cognitive domain scores (separate outcomes) with additional terms for time in study, age, sex, education, and interactions of each of these participant characteristics with time. The acculturation-related composite score (derived from Factor 1 loadings) was positively associated with level, but not change, in global cognition, semantic memory, and perceptual speed. The individual-level socioenvironmental composite (derived from Factor 2 loadings reflecting higher levels of self-reported experiences of discrimination and social isolation as well as smaller social networks) was negatively associated with level of global cognition, episodic and working memory, and faster longitudinal decline in visuospatial ability. In contrast, the third composite representing the single Factor 3 loading of familism did not associate with level or change in any cognitive outcome. This initial paper (Lamar et al., 2021a) suggested that acculturation in context represents a multifaceted concept, aspects of which differentially contribute more so to level than to change in cognition in older Latinos. Given the known associations between cardiovascular risk factors and acculturation as well as cognition in older Hispanics/Latinos (Collins et al., 2009; Downer et al., 2016; Insel et al., 2005; Jagust et al., 2005; Lamar et al., 2019; Lamar et al., 2021b; Mayeda et al., 2013; Pasha et al., 2015; Ramirez et al., 2007; Stickel et al., 2019; Tarraf et al., 2020; Zeki Al Hazzouri et al., 2013), and the disproportionate burden of these risk factors in this same population (Pirzada et al., 2023), we then investigated our previously established acculturation in context framework as related to level and change in cardiovascular health and whether levels of cardiovascular health modified our previously published associations (Lamar et al., 2021a) between acculturation in context and cognition. Using the same composite scores as derived from the original PCA and roughly the same sample of older Hispanics/ Latinos (Table  2.1), we found that both the individual-level socioenvironmental composite and the familism score contributed to change in—more so than level of—cardiovascular health (Lamar et al., 2023a) as measured by the American Heart Association’s Life’s Simple 7, which reflects both biologic and lifestyle cardiovascular factors (Gorelick et al., 2017). In fact, higher levels of familism were associated with improvements in overall cardiovascular health over time, specifically, beneficial changes in smoking status, physical activity levels, and body mass index. Furthermore, higher levels of cardiovascular health in the face of lower levels of acculturation to the U.S. resulted in slower rates of decline in working memory, suggesting that maintaining higher levels of cardiovascular health may protect against working memory declines in older Latino adults reporting lower levels of U.S.-based, acculturation-related behaviors (Lamar et al., 2023a). Our cardiovascular health metric also unmasked novel associations between acculturation in context composite scores and cognition over time (for details, please see Lamar et al., 2023a). Taken together, the individual-level socioenvironmental as well as central ethos of Hispanic/Latino culture contributed to longitudinal change in cardiovascular health, and the combination of cardiovascular health and select aspects of acculturation in context further impact cognitive changes over time, potentially protecting against domain-specific declines in performance for older Hispanic/Latino adults.

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We have also begun exploring acculturation in context as related to brain health in a subsample of participants with neuroimaging data (Table 2.1). Results to date suggest that gross measures of white matter integrity (i.e., white matter hyperintensities as seen on T2-FLAIR images) are not related to any acculturation in context composite score (unpublished data). In contrast, more subtle alterations to white matter as quantified using diffusion tensor imaging are associated with the acculturation in context framework. Specifically, higher scores on the individual-level, contextually related, socioenvironmental composite indicative of higher levels of discrimination and social isolation as well as lower social network size were associated with lower fractional anisotropy in select left-hemisphere connections comprised of frontally mediated short and long white matter tracts (Fleischman et al., 2023). We are exploring other neuroimaging modalities that probe other, more subtle alterations to brain white matter, including the transverse relaxation time constant (T2) sensitive to brain tissue’s free water content that may suggest levels of myelin integrity throughout the brain as well as quantitative susceptibility mapping, which has shown promise in studies of age-related diseases (Bilgic et al., 2012). Initial results in very small pilot samples (Fig. 2.2) suggest cross-sectional positive associations of acculturation-related composite scores with magnetic susceptibility in prefrontal regions (Fig. 2.2a) and T2 prolongation in temporal and subcortical regions (Fig.  2.2b). More work is needed applying the acculturation in context framework to brain aging in larger cohort studies to confirm and extend our initial results. Taken together, our work demonstrates that it is possible to apply the acculturation in context framework to ongoing cognitive and brain aging research with Hispanics/Latinos. Our published work to date suggests that (1) acculturation in context is a multifaceted construct, (2) it differentially contributes to levels of and changes in cognition as well as cardiovascular health, and (3) these outcomes do not exist in isolation but demonstrate effect modification within the acculturation in

Fig. 2.2  Pilot data (n = 17) showing cross-sectional positive associations of acculturation-related composite score with (a) magnetic susceptibility in prefrontal regions and (b) T2 prolongation in temporal and subcortical regions. Results are uncorrected and did not withstand FWE correction

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context framework. Neuroimaging results showing differential associations between acculturation in context composite scores and regional brain health depending upon neuroimaging modality are promising; however, more work is needed.

 cculturation in Context: Framework Limitations A and Future Directions To ensure that work investigating acculturation in context proceeds with scientific rigor and that acculturation in context as a construct may be used in future research in other laboratories and countries, it is important to understand not only the limitations of our published work to date but also the framework limitations and how to address them with future study. Across our studies (Fleischman et al., 2023; Lamar, Barnes, et al., 2021a; Lamar et  al., 2023a), we did not have information on neighborhood-level socioenvironmental factors, which would have allowed for the most comprehensive approach to acculturation in context in our analytic samples. While we are in the process of incorporating this information in an expanded investigation of the framework, our published work is not a true reflection of the entire framework as outlined in this chapter. Although Hispanics/Latinos participating in RADC cohort studies are diverse (i.e., composed of self-identified Mexican, Puerto Rican, Cuban, and Central and South American individuals), we did not have adequate representation across these backgrounds to investigate heritage differences as has been done in other epidemiologic studies of cardiovascular (e.g., Daviglus et al., 2016) and cognitive (e.g., Gonzalez et al., 2015) health. Furthermore, advanced statistical approaches including structural equation modeling, path analyses, and latent class analyses may allow for more integration across the various aspects of acculturation in context not afforded with the PCA approach. More longitudinal study of acculturation and Hispanic/Latino aging is needed (Kunst, 2021), and longitudinal neuroimaging work remains elusive (Quiroz et al., 2022). Incorporating a temporal nature into the outcomes is important, as is considering longitudinal change in the acculturation in context framework. In fact, recent work suggests that some aspects of acculturation do decline over time (Lamar et al., 2023b). Lastly, while we have chosen to focus our assessment of acculturation in context to be in concert with the assessment of our outcomes of interest, the incorporation of early-life risk and resilience factors known to impact other minoritized populations’ cognitive aging trajectories (e.g., Barnes et al., 2012b) should also be considered. More broadly, the flexibility inherent in the acculturation in context framework provides the opportunity for other investigators to expand upon aspects of the framework. For example, work by us (Lamar et  al., 2023b) and others (Campos et al., 2019) suggest that familism may be a multifaceted construct reflecting distinct aspects of familial obligations, perceived family support, and family as

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referents. Adding these distinctions to the acculturation in context framework may help place familism within the larger conceptual model through a better understanding of extended family networks (Sabogal et al., 1987), communalism (Schwartz et al., 2010), and ethnic enclaves (Weden et al., 2017). Furthermore, language-based measures of acculturation are important to include in any assessment of acculturation in context and have been a mainstay of this area of research historically (Medina et al., 2023); however, given the number of individuals reporting knowledge of two or more languages (Krogstad & Gonzalez-Barrera, 2015), investigators need to determine best practices for incorporating the complex construct of bilingualism as relevant to their study population. Best practices should also be considered to strike a balance between the approach’s flexibility and the need to generalize and compare findings across study populations within and beyond the U.S.  For example, current results using the acculturation in context framework were based on convenience samples and while this is being corrected with prospective study and an expansion to national large-­ scale epidemiological studies of Hispanics/Latinos to increase generalizability, our research remains U.S.-centric. If the framework is to succeed beyond these borders, it must take on a more (ac)culturation-type of approach so that harmonization across studies based on core items is possible. Within this core framework, however, the flexibility to expand upon some aspects of the framework (e.g., familism) and to tailor other aspects of the framework to a particular geographic location of population of interest remains critical. Thus, more work is needed not only within the U.S. but throughout the Americas to determine these core items and more region-­ specific considerations, as has been suggested by others (Parra et al., 2018; Parra et al., 2021). Future work should also consider a citizen scientist approach to determining critical risk and resilience factors to include in the acculturation in context framework. As has been discussed, many of the items included in the initial studies were taken from research in other minoritized cohorts or initial studies within other U.S.based Hispanic/Latino cohort studies. Mixed methods approaches to other areas of ADRD research have suggested that while similarities exist between Hispanics/ Latinos in some conceptualizations of aging (Glover et al., 2020; Marquez et al., 2022), not surprisingly, there are differences. Understanding these differences and incorporating participants’ questions into our research will make the work more ecologically valid, allow us to give back to our participants, and increase the relevancy of risk, and more importantly, resilience factors in our work. In conclusion, in outlining the history and framework of acculturation in context and initial attempts to apply it to empirical study, we hope that this chapter has provided a scaffolding from which others may build their own research. Using the acculturation in context framework with its flexibility may initially lead to disparate conceptualizations or results; however, it is our hope that over time, core facets of this construct will emerge, and the framework will be defined by a global coalition of studies addressing health disparities and increasing health equity for Hispanics/ Latinos across the Americas.

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Chapter 3

Deconstructing Resilience in Cognitive Aging in Mexico and Latino Communities in the United States: Consensus Agenda Findings and Recommendations Sunshine Rote, Ángela Gutiérrez, and Flavia Cristina Drumond Andrade

Cognitive Aging Trends in the U.S. and Mexico The Latino population comprises the largest minoritized ethnic group in the U.S. In 2016, about 18% of the total U.S. population identified as Latino (Vespa et  al., 2020), and by 2060, Latinos will make up 27.5% of the total U.S. population (Vespa et al., 2020). Shifts in the age structure of the U.S. population are contributing to demographic changes for Latinos. For instance, in 2019, Latinos made up 9% of the older population and, by 2060, Latinos are projected to make up 21% of the older population (Administration for Community Living, 2020). Moreover, Latinos aged 85 and older will increase from 509,096  in 2019 to 3.4 million by 2060 (Administration for Community Living, 2020). Mexico is undergoing similar trends in population aging. For instance, the median age in Mexico is projected to increase from 27.9 years in 2015 to 42 years in 2050 (Angel et al., 2017). Furthermore, the proportion of adults 60 years and older will increase from 6.3% of the total population in Mexico in 2010 to 23% by 2050 (Central Intelligence Agency, 2015). These shifts in age structure will have profound public health implications for cognitive aging in both countries.

S. Rote (*) Kent School of Social Work and Family Science, University of Louisville, Louisville, KY, USA e-mail: [email protected] Á. Gutiérrez Ohio University, Heritage College of Osteopathic Medicine, Athens, OH, USA e-mail: [email protected] F. C. Drumond Andrade School of Social Work, University of Illinois at Urbana-Champaign, Urbana, IL, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. L. Angel et al. (eds.), Older Mexicans and Latinos in the United States, https://doi.org/10.1007/978-3-031-48809-2_3

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An estimated 13% of Latinos 65  years or older in the U.S. live with Alzheimer’s disease and related dementia (AD+ADRD; Matthews et al., 2019). Relative to non-­Latino Whites, Latinos in the U.S. have a greater risk of developing dementia, live longer lives with dementia, and experience more neuropsychiatric expressions of dementia (Alzheimer’s Association, 2022; Mayeda et al., 2016; Salazar et  al., 2017; Wu et  al., 2016). In the next 40  years, projections indicate that Latinos will have the steepest increase in AD+ADRD relative to other racial and ethnic groups in the U.S. (Matthews et al., 2019). AD+ADRD is also a concern in Mexico. About 12.5% of men and 15.3% of women in Mexico live with dementia (Juárez-Cedillo et al., 2022). Addressing cognitive health disparities is a public health priority in both countries, as Mexico and the U.S. have national plans to prevent, manage, and delay AD+ADRD (MejiaArango et al., 2020). While attention has been paid to the downstream factors that increase the risk of AD+ADRD, such as the biological (e.g., higher chronic disease exposure) and behavioral (e.g., diet, physical inactivity) precursors, additional research is needed on environmental factors such as the physical and built environment, sociocultural environment, and health-care system and how these environments can be altered to create and support resilient communities to achieve cognitive health equity.

Healthy Aging and Types of Resilience Different types of resilience are central aspects of healthy aging. For instance, cognitive resilience recognizes that although multiple factors may influence individuals’ pathways to cognitive aging, some individuals are more resistant than others to cognitive decline and pathological changes associated with aging (Stern et al., 2019). Similarly, physical resilience refers to the ability to regain or augment function despite age-related loss or disease (Resnick et  al., 2011; Whitson et  al., 2016). Psychological and emotional resilience refers to resistance and recovery from stressful life events, where positive emotions and psychosocial resources may be the underlying mechanism by which resilient individuals overcome adversity (Turner, 2013; Ong et al., 2006). Healthy aging and resilience research can, at times, focus on individual-level factors (e.g., health behaviors), overlooking the critical role of the environment. However, to promote resilience and healthy aging, the varying environmental factors constraining opportunities for health are also important to consider. For instance, community and societal resilience (e.g., social support, health care, policy) refers to ecological factors promoting or constraining opportunities for healthy aging.

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2022 International Conference on Aging in the Americas In 2022, the annual International Conference on Aging in the Americas (ICAA) focused on the theme of “Cognitive Aging in Mexico and Latino Communities in the United States: Deconstructing Resilience.” The 2022 ICAA was held in Chicago, Illinois, for in-person attendees. Given the hybrid format of the conference, attendees also joined virtually. The conference focused on how cumulative and persistent structural social and economic disadvantages in the Mexican-origin population affect cognitive aging, brain health, and AD+ADRD.  The conference included a consensus-building activity that encouraged dialogue among participants on lessons learned from the conference and the next steps in resilience and cognitive aging research.

Consensus-Building Session The 2022 ICAA consensus-building session was informed by the National Institute on Aging (NIA) Health Disparities Framework (Hill et  al., 2015) and the Life Course Framework (Elder et al., 2003). These frameworks provide a rich overview of the important factors that create and sustain health disparities and the high-impact intervention points and pathways to target for achieving cognitive health equity. These frameworks encompass several determinants of health disparities, and efforts have been made to adapt them to specific contexts and populations (NIMHD, 2017). Engaging in dialogue during the consensus-building session allowed for a broad range of perspectives to be heard, allowing for a more comprehensive view of aging and cognitive resilience. The results of this process are expected to lead to a better understanding of the challenges and opportunities and to a more informed decision-­ making process on addressing these challenges and promoting healthy cognitive aging. At the start of the session, presenters and approximately 45 participants and attendees were present for the conference’s final day. Drs. Gutiérrez and Rote prepared materials for the event and set up the room and virtual space for participants to interact. There were five tables, and each had a specific theme covered during the conference (e.g., Cognitive Resilience, Physical Resilience, Psychological/ Emotional Resilience, Community Resilience, and Societal [health care, policy] Resilience). Participants were asked to join tables that reflected their interests and expertise. Each table included a moderator and a rapporteur. The moderators included Dr. Julie Bobitt, Dr. Mariana Lopez-Ortega, Dr. Lissette Piedra, Dr. Fernando Riosmena, and Dr. Hiram Beltrán-Sánchez. Rapporteurs, including Felipe Antequera, Jose Cabrero Castro, Kylie Heitzenrater, and Dr. Jennifer Salinas, were

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assigned a table, took notes on the discussion, and summarized the findings for their group. The three critical questions discussed by each group of participants were the following: 1. During this conference, we focused on cognitive resilience and aging; physical resilience; contextual factors and resilience; community resilience and aging; and resilience, interventions, and technology. What are the three most important things we learned about defining and measuring resilience? 2. Drawing on the NIA Health Disparities Framework, identify five major factors that promote or constrain resilience. 3. List the top three life course principles (e.g., critical periods, transitions, early life factors, cumulative dis/advantage, linked lives) that can inform efforts to promote resilience. After introducing these questions through a presentation and handout, Drs. Gutiérrez and Rote timed the session to allow 12 min per question. In the final 40 min, the moderators reported the discussion for each research question to all in attendance. Presenters, moderators, session organizers, conference organizers, and conference attendees were invited to complete a Qualtrics© survey to establish their final rankings of the three most critical areas for the above questions. The survey was sent to all attendees (n = 198), was opened by 57 attendees, and 47 conference attendees had partial or complete responses to the survey (response rate of 82% for attendees who opened the survey). Table 3.1 presents attendees’ ranking of high priorities in resilience research.

Results of Consensus-Building Activity Topic 1: Defining and Measuring Resilience The discussion for this first question focused on the challenges concerning the multidimensional nature of resilience and the need to improve how resilience is defined and measured. The highest priority area reported by attendees was the need to move beyond the individual-level factors and define resilience in terms of macrolevel factors, such as the existence of and extent to which policies and programs support Latino health and aging. Methodologically, there is a need for more research utilizing longitudinal approaches in order to understand both the short- and long-term impacts of different types of resilience. Similarly, there is a high need for research to better explore linkages among different types of resilience, especially societal resilience to biological resilience, and how these macrolevel factors “get under the

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Table 3.1  High priority areas for three topics discussed in consensus-building session Topic 1. Important topics learned on defining and measuring resilience

Topic 2. Top 5 factors that promote and/or constrain resilience in NIA HDF Topic 3. Top 5 life course principles to inform efforts to promote resilience

Ranking of high priority areas Moving Need a beyond the longitudinal individual level approach to and defining focus on resilience short- and based on long-term policies and measurement programs (26% (23% reported in the reported in top 3 issues) top 3 issues)

Better link to societal and biological resilience (20% reported in top 3 issues)

Better contextualization of resilience, which needs to involve the community in defining and measuring resilience (20% reported in the top 3 issues)

Socioeconomic Access to resources health care (28%) (28%)

Intersectionality Discrimination across race and experience ethnicity, (19%) gender, class, etc. (21%)

Early life Cumulative factors, such as disadvantage education (40%) (40%)

Linked lives (family and community support) (31%)

Policies that shape long-term care services and supports (29%)

For Latino communities and immigrants, resilience is not an option but a necessity. Consider root causes (20% reported in top 3 issues) Political empowerment (19%)

Critical periods of intervention to reduce initial disparities that widen with age and time (26%)

Note. NIA HDF National Institute on Aging Health Disparities Framework

skin”, creating and perpetuating health inequities over time. Conceptually, definitions of resilience should come from the voices of the community and reflect the lived experience of community members. The role of agency also came into question as one group emphasized that resilience may not be a choice but the only option and a requirement for healthy aging for many Latinos and immigrant older adults. Moving forward, there is a need to untangle resilience in terms of exposure to the event or circumstance that precedes or requires resilience from the emotional response and appraisal of the event or response.

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Topic 2: Factors That Promote and Constrain Resilience Drawing from the NIH Health Disparities Research Framework (Hill et al., 2015), the participants also identified the top factors that promote or constrain resilience from the lessons learned across conference sessions and presentations. The top two endorsed factors were from the environmental level of the framework and centered on socioeconomic factors and health-care access. Environmental factors shape the opportunities for socioeconomic well-being and mobilization. Socioeconomic disparities contribute to the observed racial and ethnic disparities in cognitive aging. Early-life conditions and education quality and attainment have cascading impacts over time that impact work-life and family formation as well as health behaviors in mid- and late life. Health-care availability and quality are critical for diagnosing AD+ADRD and supporting families in their caregiving skills and approaches. The third factor endorsed in the framework as a high-priority area centered on fundamental health factors, emphasizing the importance of intersectionality across race and ethnicity, gender, and socioeconomic position. Latinos is an overarching term for a heterogeneous group with varying resources, migration histories, and lived experiences, and resilience research moving forward should focus on this heterogeneity and the implications for cognitive aging. Similarly, the consensus-building discussion focused on the sociocultural level of analysis, which focuses on cultural norms, values, and social mobility. Resilience factors can shape encounters with social stressors. In the consensus-building session, it was noted that more research is needed to understand the short- and long-term cascading effects of the discrimination experience on the health and well-being of Latinos throughout the aging process. There is a high need to support resilience factors such as the political empowerment of Latino communities to mobilize for resources and support.

 opic 3: Life Course Principles to Inform Efforts T to Promote Resilience The third and final topic focused on the life course framework and sought to identify the top factors that can inform efforts to promote resilience. Similar to the results for topic 2, priorities focused heavily on socioeconomic factors. For example, efforts to promote resilience for Latinos should focus on early-life factors, such as education, that can lead to cascading impacts across the life course through cumulative advantage or disadvantage processes. There was also support for the focus on the importance of linked lives and supporting the environment and resources to bolster family and community support. Additionally, there is a great need for policies that shape long-term care services and support older adults aging in place and their family caregivers. Finally, many attendees agreed that there is a need to better understand

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critical periods of initial intervention to reduce initial disparities that widen over time and age.

Discussion The consensus-building session brought together conference attendees to discuss the major lessons learned and the next steps in resilience research among older Latinos in the U.S. and older adults in Mexico. Conference attendees represented many distinct disciplines, including economics, geriatrics, public health, sociology, health policy, and biostatistics. Conference attendees across these diverse disciplines brought expertise in resilience, health, and aging in the Americas. The results from this consensus-building session go beyond highlighting major lessons learned to how future research on resilience can be adapted to better address the needs and lived experiences of older Latinos and their families and caregivers. Across all three topics, it is evident that there was consensus in addressing upstream factors in achieving health equity. In particular, there was consensus surrounding the need to address macrolevel factors, including policies that promote socioeconomic well-being and quality educational attainment, expand long-term care services and supports, and address the adverse health effects of exposure to discrimination. There was also agreement about important methodological insights learned during the conference, including the need for (1) longitudinal studies to measure both the short- and long-term impacts of resilience and to identify critical periods of intervention to reduce initial disparities; (2) contextual analyses to explore intersectionality and the linkages among various forms of resilience, including societal and biological; and (3) exploratory studies that focus on community definitions, experiences, and perspectives on resilience. Finally, there was consensus surrounding the importance of family and community support and empowerment in addressing structural factors that impede cognitive health.

Conclusion The Latino population in the U.S., which is the largest ethnic minority group in this country, and Mexican populations are aging rapidly. Therefore, addressing factors that promote or hinder cognitive health among this population is a public health priority. To promote resilience and healthy aging among the aging Latino population in the U.S., Mexico, and other areas of Latin America, the various interpersonal, intrapersonal, community, and societal factors that promote or constrain healthy aging—and the intersections of these factors—must be addressed.

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The results from the 2022 ICAA consensus-building session reflect the need to take a life course and multi-level perspective that addresses how the disadvantages faced by populations in Mexico and Latinos in the U.S. influence brain health. Stakeholders involved in the consensus-building session highlighted the need to move beyond individual factors and more deeply examine contextual factors that shape these lifelong experiences. The implications are broad and will require data to investigate these associations, but that will ultimately lead to policies and programs that improve access to resources and strengthen communities.

References Administration for Community Living. (2020). 2020 profile of Hispanic Americans age 65 and older. https://acl.gov/sites/default/files/Profile%20of%20OA/HispanicProfileReport2021.pdf Alzheimer’s Association. (2022). 2022 Alzheimer’s disease facts and figures. https://alz-­journals. onlinelibrary.wiley.com/doi/epdf/10.1002/alz.12638?saml_referrer Angel, J.  L., Vega, W., & López-Ortega, M. (2017). Aging in Mexico: Population trends and emerging issues. The Gerontologist, 57(2), 153–162. Central Intelligence Agency. (2015). World factbook. Author. Elder, G. H., Johnson, M. K., & Crosnoe, R. (2003). The emergence and development of life course theory. In J. T. Mortimer & M. J. Shanahan (Eds.), Handbook of the life course (pp. 3–19). Springer. https://doi.org/10.1007/978-­0-­306-­48247-­2_1 Hill, C. V., Pérez-Stable, E. J., Anderson, N. A., & Bernard, M. A. (2015). The National Institute on aging health disparities research framework. Ethnicity & Disease, 25(3), 245. Juárez-Cedillo, T., Gonzalez-Figueroa, E., Gutierez-Gutierez, L., Aguilar-Navarro, S. G., García-­ Cruz, J. C., Escobedo de la Peña, J., & Suerna-Hernandez, A. (2022). Prevalence of dementia and main subtypes in Mexico: The study on aging and dementia in Mexico (SADEM). Journal of Alzheimer’s Disease, (Preprint), 1–11. Matthews, K.  A., Xu, W., Gaglioti, A.  H., Holt, J.  B., Croft, J.  B., Mack, D., & McGuire, L. C. (2019). Racial and ethnic estimates of Alzheimer’s disease and related dementias in the United States (2015–2060) in adults aged ≥65 years. Alzheimer’s & Dementia, 15(1), 17–24. Mayeda, E.  R., Glymour, M.  M., Quesenberry, C.  P., & Whitmer, R.  A. (2016). Inequalities in dementia incidence between six racial and ethnic groups over 14 years. Alzheimer’s & Dementia, 12, 216–224. Mejia-Arango, S., Aguila, E., López-Ortega, M., Gutiérrez-Robledo, L. M., Vega, W. A., Andrade, F. C. D., et al. (2020). Health and social correlates of dementia in oldest-old Mexican-origin populations. Alzheimer’s & Dementia: Translational Research & Clinical Interventions, 6(1), e12105. National Institute on Minority Health and Health Disparities. (2017). NIMHD Research Framework. https://nimhd.nih.gov/researchFramework Ong, A. D., Bergeman, C. S., Bisconti, T. L., & Wallace, K. A. (2006). Psychological resilience, positive emotions, and successful adaptation to stress in later life. Journal of Personality and Social Psychology, 91(4), 730. Resnick, B., Galik, E., Dorsey, S., Scheve, A., & Gutkin, S. (2011). Reliability and validity testing of the physical resilience measure. The Gerontologist, 51(5), 643–652. Salazar, R., Dwivedi, A. K., & Royall, D. R. (2017). Cross-ethnic differences in the severity of neuropsychiatric symptoms in persons with mild cognitive impairment and Alzheimer’s disease. Journal of Neuropsychiatry and Clinical Neurosciences, 29(1), 13–21. https://doi.org/10.1176/ appi.neuropsych.15120423

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Stern, Y., Barnes, C.  A., Grady, C., Jones, R.  N., & Raz, N. (2019). Brain reserve, cognitive reserve, compensation, and maintenance: Operationalization, validity, and mechanisms of cognitive resilience. Neurobiology of Aging, 83, 124–129. Turner, R. J. (2013). Understanding health disparities: The relevance of the stress process model. Society and Mental Health, 3(3), 170–186. Vespa, J., Armstrong, D. M., & Medina, L. (2020). Demographic turning points for the United States: Population projections for 2020 to 2060. U.S. Census Bureau. https://www.census.gov/ library/publications/2020/demo/p25-­1144.html Whitson, H. E., Duan-Porter, W., Schmader, K. E., Morey, M. C., Cohen, H. J., & Colón-Emeric, C.  S. (2016). Physical resilience in older adults: Systematic review and development of an emerging construct. Journals of Gerontology: Series A, 71(4), 489–495. Wu, S., Vega, W.  A., Rosendez, J., & Jin, H. (2016). Latinos and Alzheimer’s disease: New numbers behind the crisis. https://www.usagainstalzheimers.org/sites/default/files/Latinos-­ and-­AD_USC_UsA2-­Impact-­Report.pdf

Chapter 4

Resilient Cognitive Aging in Latinx and Mexican American Populations George W. Rebok, Tania M. Rodriguez, and Rachel Wu

Overview and Definition of Resilience The study of resilience has emerged as a key topic among gerontological researchers interested in promoting cognitively healthy aging and reducing the risks of Alzheimer’s disease and related dementias. Although there is no current consensus about the definition of resilience, there is widespread acceptance of the importance of the construct for health and successful aging. Resilience has been studied as a dynamic developmental process involving the ability of an organism or individual to adapt to environmental challenges or threats (physiologically, psychologically, socially), with roots in biomedicine and psychology (Cosco et al., 2016). Several common characteristics of resilience in older adults, including cognitive, physical, and social, have been identified, indicating that resilience is a multidimensional construct (MacLeod et al., 2016).

G. W. Rebok (*) Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA Johns Hopkins Alzheimer’s Disease Resource Center for Minority Aging Research, Johns Hopkins University, Baltimore, MD, USA Johns Hopkins Center on Aging and Health, Johns Hopkins University, Baltimore, MD, USA e-mail: [email protected] T. M. Rodriguez Department of Psychology, University of California, Riverside, Riverside, CA, USA R. Wu Johns Hopkins Alzheimer’s Disease Resource Center for Minority Aging Research, Johns Hopkins University, Baltimore, MD, USA Department of Psychology, University of California, Riverside, Riverside, CA, USA © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. L. Angel et al. (eds.), Older Mexicans and Latinos in the United States, https://doi.org/10.1007/978-3-031-48809-2_4

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Defining Resilience: Reserve, Resilience, Mental Agility Across different disciplines, there has been considerable debate about whether resilience is best conceptualized as a process, an individual personality trait, an outcome, or all the above (Reich et al., 2010). From our perspective, resilience is best defined in terms of adaptation to an adverse or stressful event. Although a resilient response may be nearly universal, it is likely to vary with the personal characteristics of the individual and the environmental forces that strengthen or weaken a response. People may differ in their “reserve capacity,” allowing one person to cope with an environmental stressor that overwhelms the coping mechanisms of another person. The focus of this chapter is on the cognitive aspects of resilience, factors that contribute to cognitive health disparities, and the design of interventions to sustain mental agility and resilience across the adult life course, especially in Latinx and Mexican American populations.

Resilience in Latinx and Mexican American Populations With the increased aging of the population, there has been an increased interest in developing concepts of resilience among older adults, but most of these models have been developed from the perspective of the majority, non-Hispanic White populations. Although there have been some attempts to understand Latinx resilience (Gonzalez, 2020), these efforts are in the early stages of development, and more work is needed with a focus on prevention of cognitive impairment and dementia given the health disparities in this area as discussed below. In building models of cognitive resilience for Latinx and Mexican American populations, it is important not to aggregate all Hispanics into one uniform ethnicity that masks the variation occurring across different Hispanic subgroups.

The “Hispanic Paradox” It has been observed that Hispanic individuals have better disease outcomes than non-Hispanic Whites despite having more risk factors (e.g., lower income, less health-care access, harsher job conditions) for poorer health outcomes, an intriguing phenomenon commonly referred to as the “Hispanic Paradox.” This paradox, in particular, has referred to lower mortality rates among Hispanics in the United States compared to Whites. Researchers have theorized that the strong social networks of family and friends in the Hispanic culture may confer some resilience, but the reasons for the paradox remain unclear (Franzini et al., 2001). To what extent

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these resilience factors explain better health and longevity in the Hispanic populations as they coexist with poorer cognitive health and elevated dementia risk in these populations needs further empirical study.

Cognitive Impairment in the Hispanic Population While the “Hispanic Paradox” suggests that Hispanics are living longer lives, they are also living harder lives (Boen & Hummer, 2019). This statement stems from Hispanics being more likely to face adversity and hardship across their lifespan, which also leads to an increased risk of poor health outcomes. Additionally, it is important to consider that a higher life expectancy is followed by higher rates of disease and disability in older age (Cantu et  al., 2013), which can ultimately be disadvantageous for older adult individuals who are spending their aging years in poor health. In line with an increased risk of poor health outcomes, cognitive health disparities exist between Hispanics and Whites. Studies investigating cognitive performance across older adults from different races/ethnicities have demonstrated that Hispanics underperform cognitively compared to their White counterparts (Díaz-­ Venegas et al., 2016, 2019; Schwartz et al., 2004; Sloan & Wang, 2005). Beyond cognitive differences in performance, Hispanics have an overall greater likelihood of developing mild cognitive impairment and dementia (Wright et  al., 2021). Hispanics are 1.5 times more likely to develop Alzheimer’s disease and related dementias (ADRD) than Whites (Alzheimer’s Association, 2020). Although Hispanics are at a higher risk for cognitive impairment and dementia, they are also less likely to obtain a medical diagnosis, and when they are diagnosed, it is usually at further stages of the disease (when significant impairment has already occurred; Lin et al., 2021). Furthermore, Hispanics live more years while cognitively impaired and/or with dementia than Whites, which may be partially due to their greater longevity (Garcia et  al., 2019). Altogether, Hispanics’ extended life expectancy and higher risk for cognitive impairment lead this population to face a heavier burden of living the remainder of their aging years cognitively unhealthy. The current cognitive health disparities are of great concern, given that Hispanics are one of the largest minority groups that make up the U.S. population (U.S. Census Bureau, 2022). The Hispanic population is expected to continue to grow at increasingly high rates, and over 50% of the U.S. population growth observed from 2010 to 2019 was accounted for by an increase in the Hispanic population (Noe-­Bustamante et  al., 2020). Importantly, among the older adult population, Hispanic older adults (aged 65 and over) are also the fastest-growing group, and it is projected that by 2050 they will increase to about 15.4 million (Ortman et al., 2014). It is anticipated that 1.3 million Hispanics will have ADRD by 2050 (Alzheimer’s Association, 2010). Overall, the Hispanic population is expected to undergo the highest increase in ADRD by 2060  in comparison to other races/ethnicities

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(Matthews et al., 2019). Moreover, in 2019, Alzheimer’s disease was the sixth leading cause of death among Hispanics (Statista Research Department, 2021). Despite Alzheimer’s disease being in the top 10 leading causes of death and the forecasted increase in ADRD among Hispanics, not much research has been done to find effective methods of increasing cognitive functioning to mitigate the existent cognitive impairment disparities and prevent ADRD.

 actors Contributing to the Cognitive Health Disparities F Between Hispanics and Whites Understanding the factors that drive the cognitive health disparities in the United States is key to reducing the rates of cognitive impairment among Hispanics. Although the focus here is specifically on cognition, it is important to be aware that there is an overlap between some of the factors that feed cognitive disparities and the factors that feed the general physical health disparities between Hispanics and Whites. Much research has been dedicated to identifying these contributing factors, some of which emerge from systemic racism that results in lifelong adversity and hardship. Such factors include (1) low socioeconomic status (encompassing low education levels, income, and wealth); (2) high prevalence of chronic health conditions; (3) experiencing prolonged stress in relation to financial burden and discrimination; and (4) biased cognitive testing. Socioeconomic Status Several studies have shown that there is a link between socioeconomic status (SES) and cognition in later adulthood (Greenfield & Moorman, 2019; Larnyo et al., 2022; Marden et  al., 2017; Muhammad et  al., 2022). Individuals who have lower SES have a higher likelihood of cognitive impairment in older adulthood compared to those with higher SES.  As such, cognitive impairment risk is higher among Hispanics given that they are more likely to have lower income and less wealth, and they face higher poverty rates than Whites (Bhutta et al., 2020; Gradín, 2012). In terms of educational attainment, a measure of SES, Hispanics have lower levels of education in comparison to Whites in the United States (Duffin, 2021). Educational attainment has also been linked to cognition in later life, where acquiring higher education can result in better cognitive functioning and decrease the risk of developing ADRD (Caamaño-Isorna et  al., 2006; Garcia et  al., 2018, 2020; Soldan et al., 2017). Limited financial resources also give rise to barriers to other resources that may be important for maintaining healthy cognition. For instance, having low SES could result in not being able to afford opportunities that can help increase cognitive abilities (e.g., learning programs). Another example is not being able to afford proper health care and related services (Escarce & Kapur, 2006). Hispanics are less likely

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to have health insurance than Whites (Artiga & Hill, 2022; ASPE, 2021; Chen et al., 2016; Rutledge & McLaughlin, 2008). Lack of health insurance among this population is partially due to their higher rates of working in low-wage jobs that do not offer health coverage (ASPE, 2021; Bucknor & Baker, 2016; Quinn, 2000). Furthermore, financial scarcity can also lead to financial preoccupation, which is also hypothesized to impose a cognitive load that may lead to poor cognitive functioning because it occupies cognitive resources (Mani et al., 2020; Zhao & Tomm, 2018). In sum, financial barriers related to SES are also of concern and pose a threat to the cognitive health of Hispanics. Chronic Health Conditions Chronic health conditions play a role in the high cognitive impairment risk observed among the Hispanic population. Disparities in physical health show that Hispanics have higher rates of obesity (Hales et al., 2017; Stierman et al., 2021) and type 2 diabetes (Schneiderman et al., 2014) than Whites, both of which have been associated with poor cognitive functioning. While some researchers have found that the link between obesity and dementia is attributed to other cardiometabolic diseases that stem from obesity (Stickel et al., 2021), such as diabetes, some findings show that obesity is independently linked to an increased risk of dementia (Whitmer et al., 2008). Research on the link between type 2 diabetes and cognitive functioning also suggests that there is an independent relationship between these two factors (Gregg et al., 2000; Luchsinger et al., 2001). Noble et al. (2012) found that the cognitive impairment observed among Hispanic participants in their study was more highly attributed to type 2 diabetes than for White participants. Another study also showed that experiencing more diabetes-related complications was linked with higher cognitive decline among Hispanics (Wu et  al., 2003). For these reasons, reducing disparities in chronic health is fundamental to help reduce the disparities in cognitive health between Hispanics and Whites. Prolonged Stress Experiencing high levels of stress chronically can result in the wear and tear of the body (also known as allostatic load; McEwen & Stellar, 1993) and negatively affect one’s health, including cognition (see Juster et  al., 2010 for a review). A recent minority stress framework proposed by Forrester et al. (2019) states that racial and ethnic disparities in cognitive health are partly explained by the elevated stress levels experienced by minority groups. This model uses the idea of allostatic load and the weathering hypothesis, which refers to the accelerated decline in health that occurs when exposed to social and economic stressors for prolonged periods of time (Geronimus et al., 2006), to describe the impact of stress on the cognitive health outcomes of minority older adults. This model highlights low SES and discrimination as key psychosocial factors contributing to high stress levels and, in turn,

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cognitive decline in late adulthood (Forrester et  al., 2019). As previously stated, compared to Whites, Hispanics in the United States are disproportionately more likely to have a low SES and live in poverty (Bhutta et al., 2020; Gradín, 2012). In terms of discrimination, Hispanics often encounter discriminatory experiences across an array of settings (e.g., jobs, health-care systems) and in their everyday lives (Findling et al., 2019; Pérez et al., 2008). As a result, the lifelong financial and discrimination-­related stress that Hispanics encounter also shapes the cognitive outcome differences between Hispanics and Whites. Another potential source of chronic stress among Hispanics may be acculturation (Smart & Smart, 1995). Coming into a new culture involves an array of stressful elements such as acclimating to a novel environment where the language and customs are different (Cervantes et al., 2016). Besides the acculturation process itself, immigrating and starting a new life in a new and unfamiliar country can be highly stressful, especially for those that may be separating from their family (Caplan, 2007). Immigrating and acculturating may also be particularly difficult and stressful for undocumented Hispanics who may live in constant fear of deportation and have an extra layer of barriers to accessing resources (Berk & Schur, 2001; CavazosRehg et al., 2007). In general, immigration and acculturative stress are associated with decreased physical and mental health (Caplan, 2007; Gonzalez-­Guarda et al., 2021; Smart & Smart, 1995), and it is possible that they also play a role in the cognitive health disparities that negatively affect Hispanics. Nonetheless, little research has been conducted to determine whether acculturation stress is related to cognition, and further research is needed to explore this potential link (Muñoz et al., 2021). Cognitive Testing Bias When assessing cognitive status and trying to determine whether someone may be cognitively impaired, the Mini-Mental State Examination (MMSE) is one of the most used tools (Folstein et  al., 1975; Tsoi et  al., 2015). One problem with this measure is that it might be culturally biased toward the Hispanic population (Ramírez et al., 2006). Studies have suggested that the MMSE tends to misjudge the cognitive abilities of Hispanic and Black individuals, resulting in false positives for cognitive impairment at higher rates among these two racial/ethnic groups in comparison to Whites (Bohnstedt et al., 1994; Ramírez et al., 2001). Additionally, errors in the MMSE are also influenced by the language in which it is administered and the translation of the measure (Escobar et al., 1986). For instance, discrepancies in perceived difficulty of some of the items in the MMSE between Spanish and English speakers have been identified (Jones, 2006; Ramírez et al., 2006). Hence, it is likely that bias in cognitive testing potentially shares some responsibility for the cognitive disparities reported among the Hispanic population. Therefore, it is recommended that neuropsychological screenings be combined with culturally informed qualitative data to assess cognitive status more accurately among racial and ethnic minorities (Singh et al., 2021).

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Cognitive Differences Among Hispanics Considering how cultural and nativity/immigration-related factors (e.g., being U.S.born versus foreign-born, age of migration, and level of acculturation) impact the cognitive trajectories of different Hispanic subgroups is also important. Starting with nativity, some research has indicated that foreign-born Hispanics, specifically Mexicans, generally have better cognitive health than U.S.-born Hispanics (Garcia et al., 2017, 2020). However, a foreign-born cognitive advantage does not seem to hold up well into late adulthood, as foreign-born Hispanics have been found to spend more years with cognitive impairment than U.S.-born Hispanics (Garcia et al., 2017, 2022). This difference may be due to a delay in the onset of cognitive impairment among U.S.-born Hispanics given that they have better access to higher education and health care than foreign-born Hispanics, leading them to spend fewer years living with impairment (Garcia et al., 2017). Relatedly, age of migration also seems to matter as some results indicate that an earlier age of migration among Mexican immigrants is linked to higher cognitive functioning (González et  al., 2009), potentially because those who migrate earlier in life have had more time to acculturate. Hispanic older adults with higher acculturation levels exhibit better cognitive performance than those with lower levels of acculturation (Alam et al., 2022; Martinez-Miller et al., 2020; Mendoza et al., 2022). Other findings suggest that migration in midlife is more cognitively advantageous than migrating in early and late life (Garcia et  al., 2017). Research on age of migration and associated cognitive outcomes have also revealed gender differences (Downer et  al., 2018; Garcia et  al., 2022), but more research is needed to disentangle mixed findings. Further research is also required to make clearer cognitive trajectory distinctions across Hispanics from different countries/regions of origin.

Resilience Building Interventions Many cognitive interventions have been developed to directly combat cognitive decline in both healthy and clinically aging populations (i.e., to build resilience against decline, see Hertzog et  al., 2008; see also Stine-Morrow & Manavbasi, 2022). These interventions can be categorized based on the primary method for increasing cognitive abilities, including targeting cognitive skills directly (e.g., training or skill learning), social/volunteering opportunities, physical fitness, or motivation/self-efficacy. Several interventions have included more than one of these targets, such as cognitive training and exercise. This section highlights representative interventions from each of the target categories that have the potential to build resilience in old age. Cognitive interventions target cognitive abilities directly, and there are two main types of cognitive interventions: cognitive training interventions and cognitive engagement interventions. Cognitive training interventions typically include

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practicing one or more cognitive abilities at a time, such as working memory or reasoning (e.g., Ball et al., 2002; Borella et al., 2013; Jaeggi et al., 2020; Nguyen et al., 2019). These training sessions can be completed on a computer/tablet or with pen and paper. These sessions typically consist of tasks that have been used as standardized cognitive measures (e.g., n-back tasks for working memory training), with more recent cognitive training interventions using more complex contexts that are “gamified” (e.g., Pahor et al., 2018). In contrast to cognitive training interventions, cognitive engagement interventions encourage older adults to engage in real-world activities, such as learning a new language, that exercise certain cognitive abilities, such as executive function (e.g., Berggren et  al., 2020; Leanos et  al., 2020; Mårtensson et al., 2012; Park et al., 2014). Because cognitive engagement interventions involve real-world activities, there may be a chance for more transfer to real-­ world function from these interventions, compared to cognitive training interventions (see Stine-Morrow & Manavbasi, 2022). Interventions increasing social interactions and volunteering opportunities also have aimed to increase cognitive abilities indirectly, while also increasing other important factors in old age, such as well-being, purpose, and function. One of the most prominent interventions in this category is the Experience Corps project (e.g., Fried et al., 2013). In Experience Corps, older adult volunteers provided support to elementary school students to address the needs of the public schools. The benefits of the intervention reached far beyond cognitive improvements, including physical and socioemotional benefits, such as feeling a greater sense of purpose. Physical fitness interventions, namely exercise, exploit one of the most-studied mechanisms for cognitive change (see Erickson et al., 2022). Physical and cognitive health are intrinsically tied, especially in terms of cardiovascular health. Aerobic and other moderate cardio exercises have been shown to increase cognitive abilities, such as executive function, in old age (e.g., Colcombe & Kramer, 2003), although there is heterogeneity in the benefits, as seems to be the case with many other types of interventions with older adults. Partially due to the significant improvements in cognitive functioning for exercise interventions, they also often have been combined with cognitive training interventions to investigate whether the combination can yield more and longer-lasting benefits (e.g., Gavelin et al., 2021; Ten Brinke et al., 2020; see also Khodadadegan et al., 2021 for a study with rats). Another series of interventions have been developed to target motivation and self-efficacy in older adults, which aim to improve healthful behaviors that may, in turn, lead to increased cognitive abilities. For example, Allison and Keller (2004) promoted self-efficacy in physical activities through encouragement, compliments on progress, and verbal persuasion and found that the intervention indirectly increased physical activity, even though self-efficacy of physical activity did not increase. This type of intervention also includes those that use growth mindset ideology (i.e., encouraging the belief that skills and abilities can be developed even in old age; Sheffler et al., 2022). Altogether, these varieties of interventions have the potential to build cognitive reserve in older adults. However, most of these studies have been conducted with a

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majority of the participants being older adults with relatively higher incomes (e.g., Tzuang et  al., 2018). Much work is needed to further investigate the potential benefits and barriers to implementing such interventions (see Rodriguez et al., 2022).

Barriers to Implementation and Possible Solutions Despite the benefits that a wide range of focused interventions can have on cognition, there is limited research that has applied and tested such interventions with Hispanic older adults. In general, recruitment and retention of minority populations in research have shown to be difficult, which is why participants are usually from the WEIRD (White, Educated, Industrialized, Rich, and Democratic) population in most psychology studies (Henrich et  al., 2010; Konkel, 2015; Thalmayer et  al., 2021). When it comes to cognitive interventions, only three studies have included more than 25% of minority representation (Tzuang et al., 2018). Thus, increasing the implementation of interventions to help promote positive cognitive change and build resiliency among Hispanics is necessary. However, there are barriers to this execution relating to the recruitment and participation of Hispanics that must be considered. The literature has identified psychological, knowledge/awareness, practical, and cultural barriers to engaging and retaining Hispanic participants in research studies. First, psychological barriers include mistrust and fear of participation that relate to researcher intentions and legal status (Calderón et al., 2006; George et al., 2014; Levkoff & Sanchez, 2003; Shedlin et al., 2011). Second, knowledge and awareness barriers involve lacking information about research opportunities and not being familiar with the way research works (Calderón et al., 2006; George et al., 2014). In the same vein, a lack of accurate information about cognitive decline and dementia could further alienate this population from purposefully seeking interventions that help improve cognitive health (Gallagher-Thompson et  al., 1996, 2003). Third, practical barriers, which often relate to low socioeconomic status, encompass time limitations due to job-related or caregiving responsibilities and lack of transportation (Calderón et  al., 2006; George et  al., 2014). Lastly, cultural barriers present issues that relate to language differences and a lack of cultural competency from researchers (Skaff et al., 2002). These barriers to participation must be addressed to effectively implement and run targeted interventions for Hispanics. Possible solutions to addressing these barriers can be derived from strategies previously utilized and/or suggested to successfully recruit and retain Hispanic participants. To combat several of the barriers, such as mistrust, fear, and cultural barriers, one notable technique is to collaborate and partner with community leaders and organizations as well as other trusted establishments, such as churches, that serve the Hispanic population (Baig et al., 2015; Carroll et al., 2011; Mendez-Luck et al., 2011; Sankaré et al., 2015; Vincent et al., 2013). Community organizations

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have greater access to individuals in the community, and they are more culturally competent when contacting and encouraging others to participate in research studies (Jagosh et  al., 2012). Besides taking on a community-based participatory research approach, increasing research staff that is bilingual and representative of the ethnicity and cultural background of the target population is important (Gallagher-Thompson et al., 2003; Skaff et al., 2002). Research staff that participants can comfortably communicate with and relate to can help with trust-building and facilitate research participation (Calderón et al., 2006). Relatedly, it is also crucial to ensure that all the research staff and involved parties are culturally competent and to incorporate culturally appropriate methodologies (Gallagher-Thompson et  al., 2003; Skaff et  al., 2002). In hand with cultural competency, interventions should be culturally tailored (e.g., be offered in Spanish) and account for the preferences and needs of the participants (Joo & Liu, 2021; McDougall et al., 2010). Providing feedback and sharing information on the findings of the intervention-­ related work with the same community and participants also helps with further establishing continual trust and future research involvement (Bonilla et al., 2022; Gallagher-Thompson et al., 2003; McDavitt et al., 2016). Presenting research goals and results to the community can also contribute to mitigating knowledge/awareness barriers. Furthermore, to diminish practical barriers, interventions should provide transportation and caregiving services and/or reimburse participants for any costs associated with making their participation feasible (Gallagher-Thompson et  al., 2003). Altogether, these efforts can lead to an increase in the engagement of Hispanic adults in research studies and interventions.

Unresolved Questions and Future Directions Although there is rapidly growing interest among gerontological researchers in the construct of cognitive resilience, many unresolved questions remain, including (1) how resilience should be defined and measured in the context of healthy cognitive aging; (2) what factors contribute to cognitive health disparities in Latinx and Mexican American older adults and other ethnic minority populations; (3) how interventions can be developed and implemented to cost-effectively promote resilience in diverse populations in midlife and later life; and (4) how to increase the participation of minoritized older adults in cognitive interventions to reduce cognitive health disparities and achieve health equity. Within the field of gerontology, there remains considerable conceptual heterogeneity in how resilience is defined and operationalized, and how the concept is related to other constructs such as cognitive reserve, brain reserve, mental agility, and so forth. Greater conceptual clarity on the shared and unique meaning of these constructs is urgently needed. Furthermore, several methodological procedures and measurement scales have been designed to assess the construct of resilience, but there is currently no “gold standard” method and no established outcome measure

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of resilience (Chmitorz et  al., 2018). According to recent reviews (Windle et  al., 2011; Cosco et al., 2016), most resilience scales have been developed and validated for younger populations, and there is an unmet need for validation studies in older adults, especially older adults from various racial/ethnic minority populations. In terms of promoting cognitively healthy aging and resilience, most interventions that have been aimed at reducing cognitive decline and dementia risk have been conducted with a majority, non-Hispanic White population (Tzuang et al., 2018), and these interventions do not necessarily translate into effective interventions for Latinx and Mexican American populations. Identifying interventions that can be optimized for use in these populations is an important future public health priority. Importantly, cognitive interventions that are designed to prevent or delay dementia onset in diverse aging populations need to include consideration of factors contributing to health disparities to ensure equitable benefits. Finally, there is an urgent need to improve the generalizability and study design of resilience-building interventions by finding more effective ways to include and engage members of under-­represented populations in cognitive aging research. Acknowledgments Prior Presentation  Portions of this chapter were presented at the 2022 International Conference on Aging in the Americas, Chicago, IL. Coauthorship  GWR and TMR are first coauthors on this chapter. RW is the senior author. Funders RW and GWR received funds from the Johns Hopkins Alzheimer’s Disease Resource Center for Minority Aging Research (JHAD-RCMAR) for preparation of this chapter. The JHAD-RCMAR is funded by the National Institute on Aging (P30AG059298).

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Chapter 5

Contextualizing the Effects of Stress on Cognitive Health in U.S. Latinx Adults Elizabeth Muñoz and Jean Choi

Introduction Hispanics/Latina/o/e/xs (henceforth, Latinx) in the United States are projected to experience the largest increase in Alzheimer’s disease and related dementias by 2060 (Matthews et al., 2019), and they currently have a 1.5 times greater risk for Alzheimer’s disease and related dementias (ADRD) compared to non-Latinx White adults (Alzheimer’s Association, 2021). Therefore, efforts to identify risk and protective factors for reduced cognitive health are crucial. Chronic stress is an established risk factor for reduced cognitive health that may serve as a critical point for early prevention and intervention. Latinxs in the United States experience greater social, environmental, and economic disadvantages that promote chronic stress, thus increasing vulnerability to poor cognitive health outcomes. However, studies examining the link between chronic stress and cognitive health in Latinxs report mixed findings suggesting that additional risk and protective factors need to be examined. This chapter provides an overview of our research examining acculturation stress and discrimination as two sources of stress in Latinxs that may undermine cognitive health. We also explore cultural resilience against stress exposure and/or reactivity that may offset the negative sequelae of chronic stress in Latinx adults.

E. Muñoz (*) · J. Choi School of Human Ecology, Department of Human Development and Family Sciences, The University of Texas at Austin, Austin, TX, USA e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 J. L. Angel et al. (eds.), Older Mexicans and Latinos in the United States, https://doi.org/10.1007/978-3-031-48809-2_5

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Stress and Cognitive Health In the general population, a large body of work documents negative associations between chronic stress and cognitive health outcomes. Experiences of stress activate a cascade of affective and physiological responses that are detrimental to cognitive health over the long term if chronic or consistent (e.g., Lupien et al., 2009). Psychological and social stress have been linked with reduced cognitive functioning and a faster rate of decline in cognitive functioning. Higher levels of perceived stress, for example, are associated with lower average levels of, and faster rates of change in, cognitive functioning (Aggarwal et  al., 2014; Munoz et  al., 2015). Additionally, occupying demanding and stressful social roles, such as being in a stressful work environment (Andel et al., 2011) or caregiving for a family member suffering from a chronic illness (e.g., Lee et al., 2004), have been associated with poorer cognitive function. Physiological or biological markers of chronic stress, such as elevated cortisol and inflammation, are also associated with poorer cognitive function and faster rates of cognitive decline (Lupien et al., 1994). Moreover, composite measures of the allostatic load, which represents an index of the overall wear and tear of stress on the body, have been consistently linked with poorer cognitive health outcomes (D’Amico et al., 2020). Until recently, the studies on stress and adult cognitive health had been carried out in primarily non-Latinx samples or samples of unknown Latinx heritage. Further, although the primary interest is in understanding correlates of cognitive function and change in older individuals, it is also crucial to examine predictors earlier in the lifespan (i.e., during midlife) among marginalized groups (such as Latinxs) in the United States. It is increasingly understood that midlife represents a critical period of the lifespan to identify early risk factors for reduced cognitive health (Livingston et al., 2020) and represents a key developmental period to evaluate precursors of disparate cognitive health outcomes (e.g., Infurna et  al., 2020). This approach is consistent with recent calls for more research on the early detection of age-related cognitive impairment (Ryan et  al., 2019) and dementia (Livingston et al., 2020) and is based on the documented understanding that dementia neuropathology is initiated decades before a diagnosis (Gonneaud et al., 2017) and that declines in memory and executive functioning are detectable starting as early as age 20 and certainly by age 45 (Salthouse, 2009; Singh-Manoux et  al., 2012). Evaluating associations in midlife among racial/ethnic marginalized adults is also necessary to more accurately represent results that are not biased due to selection effects and limited generalizability (Zahodne et al., 2016). Marginalized individuals are exposed to more stressors throughout their life that wear down physiological systems that, in turn, diminish cognitive health earlier in the lifespan. The Weathering Hypothesis posits that because of lifetime exposures related to experiences with marginalization, racial and ethnic minoritized individuals may experience earlier onset of chronic health conditions and early mortality (Geronimus, 1992; Geronimus et al., 2006). In addition to examining the stress-cognition link in Latinx individuals, examining associations in midlife is also needed.

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 tress and Cognitive Health Outcomes in Latinx Adults: S The Importance of Context Chronic stress in Latinxs is linked with poor physical health outcomes, such as hypertension and diabetes (Gallo et  al., 2014b), and with poor mental health outcomes, such as higher depressive symptoms and anxiety (Flores et al., 2008; Perreira et al., 2015). Until recently, it was unclear if stress functioned similarly as a risk factor for reduced cognitive health among Latinx adults. Using data from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and its Sociocultural Ancillary Study (Gallo et al., 2014a), we sought to evaluate if stress was also a risk factor for reduced cognitive health in Latinx adults (Muñoz et al., 2021). Evaluating the contexts under which stressful circumstances occur is also needed. Early stress research shows that stressors perceived to be threatening to the social self, elicit more negative emotional reactions than tangential stressors (Dickerson et al., 2004; Gruenewald et al., 2004). Therefore, evaluating sources of stress relevant to racial/ethnic marginalized individuals aids in uncovering unique sources of stress and thus unique risk factors for poor cognitive health.

Acculturative Stress and Cognition in Latinxs Among Latinxs in the United States, acculturative stress refers to the psychosocial strain experienced as a result of the process of adapting to cultural norms that differ from one’s own (e.g., acculturation; Cervantes et al., 2016). Measures of acculturative stress provide additional insights into the contexts or conditions that elicit stress for Latinxs. Acculturative stress differs from traditional assessments of stress because it captures individuals’ strain perceived to be related to their heritage background and immigration experiences. Moreover, time spent in the U.S. is one measure of acculturation (Gil et  al., 2000), and greater acculturation has been linked with greater acculturative stress (e.g., Caplan, 2007), suggesting that greater immersion in the majority culture could promote stress in Latinx adults. Acculturative stress has been linked with poor mental and physical health outcomes (Caplan, 2007; Gallo et al., 2009) but had not been previously linked with cognitive function. Thus, we aimed to extend the previous literature on general chronic stress while additionally incorporating measures of acculturative stress as it can be a unique source of stress in Latinxs. Using data from 3134 Latinx individuals, we tested associations between chronic and acculturative stress and four cognitive functioning domains: psychomotor speed, verbal learning, verbal memory, and word fluency. The first question addressed in this chapter is the following: Are there differential effects of chronic versus acculturative stress on cognitive function in Latinx adults?

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Ethnic Discrimination and Cognitive Function in Latinxs Another cultural stressor threatening marginalized adults’ sense of self is ethnic discrimination. Ethnic discrimination and acculturative stress are related because they capture experiences of marginalization and unfair treatment. However, ethnic discrimination relates to unfair treatment due to someone’s ethnicity (e.g., “You are treated with less courtesy than other people because you are Latinx”) whereas acculturative stress refers to strain experienced in the process of adapting to a new culture (e.g., “Because I am Latino I have had difficulty finding the type of work I want”; Rodriguez et al., 2002). Ethnic discrimination is an important and ubiquitous social determinant of health (Devakumar et al., 2020). Ethnic discrimination presents at a structural and institutional level via policies, practices, and norms that result in differential access to opportunities for racial/ethnic minoritized individuals (Jones, 2002). At an interpersonal level, ethnic discrimination occurs when prejudice or differential assumptions about abilities, motives, and intent by an individual’s ethnicity are expressed (Pascoe & Smart Richman, 2009). Interpersonal discrimination is a subtle and ubiquitous psychosocial stressor (Clark et al., 1999; Dovidio, 2001) that has been linked with poor mental and physical health outcomes among racial/ethnic minoritized adults (Williams et  al., 2003), including Latinxs (Caplan, 2007; Gallo et al., 2009; Stein et al., 2019). Ethnic discrimination differs from general reports of discrimination because discriminatory experiences are attributed to the recipients’ ethnicity. The literature reports mixed findings with general discrimination and cognitive function. The few studies that have evaluated the association between discrimination and cognitive function indicate that discrimination is negatively associated with cognitive function among Black adults (Barnes et al., 2012; Johnson et al., 2020). A study using Health and Retirement Study data found a negative association between general discrimination and episodic memory among Black adults but not among Latinxs. The authors note, however, that the discrimination measure used in the study was developed from interviews with Black participants, and the items may not fully capture experiences of discrimination in Latinxs (Zahodne et  al., 2017b). Most recently, Lamar et  al. (2020) found that a composite of contextually related stressors that included discrimination was associated with lower cognitive function in older Latinx adults (average age  =  70). Moreover, it is important to consider that the Latinx population is diverse in multiple ways, including socioeconomically, demographically, culturally, and ethnically. Indeed, González et al. (2015) showed differences in cognitive function by heritage group (i.e., Central American, Cuban, Dominican, Mexican, Puerto Rican, South American). Thus, understanding the correlates of cognitive health among Latinxs from specific heritage backgrounds can elucidate relevant risk factors within those populations. We leveraged data from adults of Mexican origin living in California and focused on ethnic discrimination as a relevant social stressor shown to undermine cognitive function in racial and ethnic minoritized adults (Barnes et al., 2012; Zahodne et al., 2017a, b). Thus, the second research question addressed in this chapter is the following: Is ethnic discrimination associated with cognitive function in Latinx adults of Mexican origin?

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The Stress Process in Latinx Adults The term “stress” does not represent a singular behavior but rather a process that can ultimately lead to negative emotional and physiological responses if perceived as threatening and if chronic or persistent. The stress process framework (Cohen et al., 1995) and the transactional model of stress and coping (Lazarus & Folkman, 1984) demarcate a sequential process from the exposure to a negative event or stressor to the stress response. This sequential progression begins with a particular exposure to an event or demand (e.g., losing a job) that the individual may then appraise as posing a potential threat or as exceeding their coping capacities. This initial appraisal process is classically termed as a primary appraisal (Lazarus & Folkman, 1987). A perception of threat or overload initiates a secondary appraisal, which questions the individual’s coping potential and resources available to manage the stressors they are exposed to. If coping resources are inadequate, emotional (e.g., negative affect) and physiological (e.g., elevated heart rate) responses  are activated. If this process is continuously activated, chronic stress ensues increasing risk for poor mental, physical, and cognitive health outcomes. The stress process and coping perspectives underscore the key role that the appraisal of the event plays in the stress response. This stress process framework is generally supported in the literature. Nonetheless, most of the evidence is based on samples low in racial/ethnic diversity. Similar to research on contextual stressors, it is unclear if Latinx adults engage in similar processes when exposed to potentially stressful events.

Cultural Differences in Stress Appraisal: A Source of Resiliency Ruiz and colleagues proposed a Sociocultural Stress Buffering Hypothesis that illustrates how sociocultural factors may moderate the appraisals of stress in Latinxs (Ruiz et al., 2018). According to this theory, the social networks of the Latinx community may help modify primary appraisals (i.e., threat perceptions) of stress, and cultural values for collectivism enable communal coping, which buffers the adverse impacts of the secondary appraisal of stress (Ruiz et al., 2018). Ruiz and colleagues posited that the availability of social networks within the Latinx community alters primary appraisals of stress. On average, Latinxs have large social networks that foster a greater sense of affiliation and availability of support (Schweizer et  al., 1998; U.S. Census Bureau, 2009), which in turn buffer primary appraisals of stress. Moreover, the convivial collectivistic values of maintaining close, positive, and respectful relationships (Campos & Kim, 2017) within the Latinx community allow individuals to think communally about how to cope with the stressors at hand. Latinxs would, therefore, not think singularly “what am I going to do?” Rather, they would think collectivistically “what are we going to do?” when engaging in secondary coping (Ruiz et al., 2018).

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Brown et  al. (2020) provided indirect support for the Sociocultural Stress Buffering Hypothesis. Using data from the Health and Retirement Study (HRS), Brown et  al. (2020) evaluated racial/ethnic differences in stress exposure and appraisal. Using a measure that queried exposure to seven stress domains during the previous 12 months (e.g., ongoing health problems, financial strain, housing problems), they found that Black and Latinx adults (aged 52 years and older) reported greater exposure to chronic stressors than non-Latinx Whites, and they were specifically more likely to experience financial strain and housing-related stressors. However, an examination of the reported severity of the stressors included in this study indicated that Blacks and Latinxs reported being less upset by the stressors compared to their non-Latinx counterparts. Thus, although Blacks and Latinxs tended to report higher exposure to stress, they appraised these stressors as less severe. These findings are in line with Ruiz and colleagues’ propositions (2018) and suggest that there are culturally relevant factors among racial/ethnic minoritized adults that buffer negative interpretations of stressors. Brown and colleagues’ study categorized Latinx participants broadly into one ethnic group. However, given the immense diversity within the Latinx community, adopting a within-group approach to evaluate associations by heritage background is needed. We expanded from Brown and colleagues’ results and applied Ruiz and colleagues’ Sociocultural Stress Buffering Hypothesis to examine cultural differences in stress exposure and appraisal between Mexican-origin and non-Latinx White adults to address our third research question: Are there cultural differences in the stress process between Mexican-origin and non-Latinx White adults?

Methods and Results Next, we address the three research questions introduced above via three different studies and methodologies, and report their results.

 re There Differential Effects of Chronic Versus Acculturative A Stress on Cognitive Function in Latinx Adults? We addressed this question using data from 3134 Latinx adults who participated in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) and its Sociocultural Ancillary Study (Gallo et al., 2014a). Chronic stress was measured via an eight-item chronic burden scale where participants indicated the presence of ongoing stressors in major life domains (e.g., health, job, financial, relationship, network problems), whether the stressor has been ongoing for six months or more, and the severity of the stressor. To indicate the severity of the stressor, participants reported on a three-point scale if the event was “Not very stressful,” “Moderately

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stressful,” or “Very stressful.” A total count score was calculated for the stressors endorsed as ongoing for six months and reported as being moderately or very stressful (Bromberger & Matthews, 1996). We measured acculturative stress via the 17-item Hispanic Stress Inventory (Cervantes et al., 1990), which asked participants to indicate whether (i.e., yes, no) various situations occurred during the last three months (e.g., “Because I am Latino I have had difficulty finding the type of work I want”). After each yes/no response, participants indicated how much they had felt “worried or tense” about it on a 5-point scale from “Not at all worried/tense” (1) to “Extremely worried/tense” (5). If the participant endorsed any of the items, a total stress score was calculated by adding the scores from the 5-point, worried/tense Likert scale. The cognitive measures were administered by trained interviewers in a fixed order as follows: verbal learning and memory, word fluency, and psychomotor speed. After adjusting for study-related (i.e., data collection site) and demographic (e.g., age, sex, Latinx background, income, education, nativity) variables, chronic stress was associated with poorer performance in verbal learning. However, this association was no longer significant after accounting for physical and mental health outcomes. On the other hand, higher acculturative stress was associated with poorer performance in all cognitive functioning tasks and this link remained after adjusting for all covariates, which included mental and physical health.

I s Ethnic Discrimination Associated with Cognitive Function in Latinx Adults of Mexican Origin? To test whether ethnic discrimination was associated with cognitive function, we leveraged data from 1110 adults of Mexican origin living in northern California and participated in the California Families Project (Robins & Conger, 2017). Most participants were born in Mexico (85.87%), more than half were female (60.63%), and the average age at baseline was 38.18 (+/−6.10). Participants completed a 10-item ethnic discrimination scale across five waves that spanned 12 years. Using a scale from 0 (Almost never or never) to 3 (Almost always or always), they responded to items such as “You are treated with less courtesy than other people because you are Mexican/Mexican American.” In the 12th assessment wave, study participants also completed a cognitive battery that was composited into a total sum score. Our analyses controlled for age, education, and baseline intelligence scores so that the associations were relative to a proxy of baseline cognition. Results showed that ethnic discrimination scores were relatively low across the five waves (range of means: .35–.23; possible range: 0–3). Nonetheless, higher levels of discrimination were concurrently associated with lower cognitive function in the 12th assessment wave. We also observed an average gradual decrease in reports of ethnic discrimination across the 12 years. There was significant variability in this average negative trajectory through which we could identify two subgroups of change trajectories: Stable Low

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E. Muñoz and J. Choi 3 High Declining (8% of sample)

2.5 Ethnic Discrimination

Stable Low (92% of sample) 2 1.5 1 0.5 0 0

3

5 Year

7

11

Fig. 5.1  Two-class trajectory solution of ethnic discrimination in Mexican-origin adults

and High Declining. The Stable Low class reported low levels of discrimination throughout the study period. The High Declining class had higher levels of discrimination at baseline, which declined throughout the study period. Still, throughout the study period, they had higher levels of ethnic discrimination than the Stable Low class (see Fig. 5.1). The High Declining class had slightly lower cognitive scores than the Stable Low class, but this difference was not statistically significant after accounting for education. We also found that those who chose to take the interview in Spanish (versus English) and who were born in Mexico (versus in the United States) were more likely to be in the Stable Low than the High Declining ethnic discrimination change group.

 re There Differences in the Stress Process Between A Mexican-­Origin and Non-Latinx White Adults? To address our final research question focused on examining whether experiences of stress differ between Mexican-origin adults compared to non-Latinx Whites, we used data from the Health and Aging Brain Study: Health Disparities (HABS-HD). The HABS-HD is an ongoing, longitudinal, community-based study that seeks to understand health disparities in mild cognitive impairment and Alzheimer’s disease among Mexican Americans (O’Bryant et al., 2021). The HABS-HD study utilized a community-based participatory research approach that has been successful for reaching participants from underserved and minoritized populations (Marin et al., 1987). The HABS-HD protocol consisted of an interview, functional exam, and neuropsychological assessments that participants were able to complete in Spanish or English. This study was approved by the North Texas Regional Institutional

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Review Board. We examined interview data from 1039 Mexican-origin adults and 1044 non-Latinx White adults between 50 and 92 years old. Sixty-one percent of the total sample identified as female. Chronic stress was assessed with an eight-item scale where participants indicated the number of current ongoing stressors in major life domains (e.g., health, job, financial, relationship, alcohol or drug problems, caregiving; Bromberger & Matthews, 1996), whether the event had been a problem for six months or more, and how stressful it has been (1 = Not very stressful, to 3 = Very stressful). Similar to the chronic stress measure used in Muñoz et al. (2021), a total chronic stress measure was calculated for the events that were rated as having been a problem for six months or more and were reported as being moderately or very stressful (Bromberger & Matthews, 1996). We further disentangled this measure to create two separate submeasures. First, we created a total exposure score, in which we added up the total endorsements of events experienced by respondents. Second, we created an average severity score in which we averaged the perceived stressfulness of the events that were endorsed and reported as being a problem for six months or more. Independent samples’ t-test indicated no significant differences in the average number of stress exposures between Mexican-origin adults and non-Latinx Whites (see Table 5.1). As expected, Mexican-origin adults reported lower stress severity (M  =  1.78, SD  =  0.78) compared to non-Latinx Whites (M  =  2.05, SD  =  0.68; t(1,376) = 6.88, p