Parkinsonism and Related Disorders 14 (2008) 397e406

www.elsevier.com/locate/parkreldis

Parkinson’s disease and functional decline in older Mexican Americans

Myra G. Schneider*, Michelle Shardell
Department of Epidemiology & Preventive Medicine, University of Maryland School of Medicine,
660 West Redwood Street, Suite 200, Baltimore MD 21201-1596, USA
Received 18 December 2006; received in revised form 31 October 2007; accepted 11 November 2007

Abstract

The purpose of this study was to establish prevalence and five-year incidence, and explore functional decline among older Mexican
Americans with Parkinson’s disease (PD). Using data from the Hispanic EPESE, baseline characteristics were compared across PD response
profiles. Weighted generalized estimating equations (GEE) modeled the association between PD and outcomes. Prevalence was 1.30%;
incidence at wave 4 was 1.18%. Those with prevalent PD had worse function than those without PD at each wave. Progressive functional decline
across time was observed among those with PD. Older Mexican Americans with PD often live in the community, and those who provide care for
them may be overburdened.
Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Parkinson’s disease; Disability; Mexican Americans; Elderly

1. Introduction dwelling older Hispanics. We used data from the Hispanic

Parkinson’s disease (PD) is a chronic progressive neuro-
logical disorder that results in significant disability with pro-
gressive loss of independence and increasing financial burden
[1e3]. PD occurs in all countries and affects ethnic groups
worldwide [4,5]. Although the introduction of levodopa and
other pharmacologic therapies over the last two decades
has delayed morbidity and mortality, the high rates of associ-
ated motor decline and disability make PD a major public
health problem [6].
Although Hispanics comprise a rapidly growing segment of
the US population, little is known about their health, including
the transition from health to disability [7,8]. Hispanics have
more functional limitations and higher levels of disability
than other racial/ethnic groups [9e13]. The few studies that
have explored PD estimates have reported higher rates among
Hispanics [14e16]. To date, however, there has been no
research on the consequences of PD among community-
* Corresponding author. Tel.: þ1 410 706 3733; fax: þ1 410 706 4433.
E-mail address: mschneid1@verizon.net (M.G. Schneider).
Established Populations of the Epidemiologic Study of the
Elderly (H-EPESE), a representative sample from five south-
western states, to investigate the incidence and prevalence of
self-reported PD and to explore functional decline among
older Mexican Americans.
2. Methods
2.1. Data collection
Data are from the Hispanic Established Populations of the Epidemiologic
Study of the Elderly (H-EPESE), designed to assess the mental and physical
health, and functional status of older community-dwelling Mexican American
adults. Funded by the National Institute on Aging, H-EPESE is a community-
based study of 3050 Mexican American subjects age 65 and older from five
southwestern states: Texas, California, Colorado, Arizona, and New Mexico
[12]. The study was modeled after the design of the Established Populations
for the Epidemiologic Studies of the Elderly (EPESE), 1981e1993 (East Bos-
ton, MA, rural Iowa, New Haven, Connecticut, North Carolina) [17]. A multi-
stage area probability sampling design was employed. When weighted for the
actual number in the five-state area, the sample represents approximately
500,000 Mexican Americans age 65 and older. Community-dwelling, non-
institutionalized Mexican American subjects age 65 and older were eligible
for participation in the study. Institutionalized subjects were excluded. In-
home face-to-face interviews and assessments were conducted in Spanish or

1353-8020/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.parkreldis.2007.11.015
398 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406
in English by trained interviewers, lasting approximately 90 min, including
15 min for medical assessments (blood pressure, weight, height, vision testing,
and performance-based tests of physical function). Data have been collected in
four waves between 1993 and 2001. Of the 3050 subjects at baseline, follow-up
data were collected on 2439 subjects in 1995e1996, on 1980 subjects in
1998e1999, and on 1685 in 2000e2001. The response proportion at baseline
(1993e1994) was 86%. A more detailed description of the rationale, methods
and sample characteristics can be found elsewhere [12]. Other diseases inves-
tigated using these data have included arthritis, diabetes, stroke, hypertension,
heart attack, and cancer [18e24].
2.2. Measures
2.2.1. Parkinson’s disease
An estimate of lifetime prevalence was established by asking respondents
whether they had ever been told by a physician that they had Parkinson’s dis-
ease at the second and fourth waves of data collection. Questions about Parkin-
son’s disease were not asked during waves 1 and 3.
2.2.2. Functional limitations and disability
Functional capacity was measured by performance-based assessments of
physical function (POMAs) [25e27]. This objective measure consisted of
three tasks (standing balance, walking, and chair stands). Each test was
scored from 0 to 4. Those who could not complete a test received a score
of 0. A summary performance score was created by summing the scores for
all three tests (range 1e11). Disability was measured by self-reported de-
pendencies of activities of daily living (ADLs) and instrumental activities
of daily living (IADLs) [28e30]. A summary measure of ADLs (e.g. eating,
bathing, dressing) was computed by adding the number of items the partic-
ipant could not perform independently (range 0e7). A summary measure of
IADLs (e.g. using the telephone, shopping) was also computed by adding
the number of items the participant could not perform (range 1e10). Higher
numbers of ADL and IADL dependencies (tasks with which the individual
requires assistance) indicate greater disability, and lower POMA scores indi-
cate worse physical function. Both performance-based and self-report mea-
sures were included to determine robustness of results to method of
measurement, and because self-reports may be influenced by non-physical
factors related to culture and language [31].
2.2.3. Socio-demographic characteristics
Age (in years), sex, education (highest grade achieved), marital status
(married: yes/no), living arrangements, acculturation (language of interview:
English/Spanish), and migrancy status (US born, years in US among those
not US born) were used in this study.
2.2.4. Cognitive status
The Mini-Mental State Examination (MMSE) was administered as part of
the baseline interview and in subsequent follow-up interviews. The MMSE,
a 30-item measurement instrument used to assess cognitive function, was
treated as a continuous measure (range 0e30) [32]. The version administered
in this survey by bilingual interviewers was adopted from the Diagnostic In-
terview Scale (DIS) and has been used in prior community surveys [33] and
did not include clock-drawing tests or copying figures. The Spanish MMSE
has been used successfully in community surveys of Mexican Americans
[34]. Lower scores suggest worse cognitive impairment [35e37]. Cognitive
impairment is often associated with PD [38].
2.2.5. Depressive symptoms
Depression occurs in approximately 40% of PD patients [39]. A translation
developed for the Hispanic HANES (National Health and Nutrition Examination
Survey) was used for the 20-item Center for Epidemiologic Studies Depression
scale (CES-D) [40]. Items were summed (0e60) for use as a continuous measure.
2.2.6. Health status
Number of chronic conditions has been associated with functional impair-
ment [41e43]. Number of medical conditions was included as a summary
measure of chronic disease status (heart attack, stroke, cancer, hypertension,
arthritis, hip fracture, or diabetes), as were self-rated health assessments,
shown to be strongly related to objective measures of health and to mortality
[44,45].
2.2.7. Body mass index (BMI)
Body mass index was calculated by dividing respondents’ weight (mea-
sured in kilograms) by the square of height (measured in meters). Body
mass index <22 has been associated with functional limitations.
2.2.8. Smoking status
Smoking (current/former/never) has been associated with PD [46,47].
2.2.9. Health care utilization
Respondents were asked about physician visits and hospital stays during
the 12 months prior to the interview.
2.3. Statistical analysis
Information on PD status was collected at the second and fourth waves;
thus PD status was a semi time dependent predictor. Those with ‘‘prevalent
PD’’ reported having been told by a doctor or other health care professional
at the second wave that they had PD. Those with ‘‘incident PD’’ responded
negatively at the second wave and affirmatively at the fourth wave to questions
regarding PD diagnosis. Those classified as ‘‘never PD’’ responded negatively
at the fourth wave and never developed PD. Those who responded negatively
at the second wave, but were missing at the fourth wave were classified as
‘‘non-prevalent.’’ Any other response pattern was classified as ‘‘incomplete
PD status.’’
Baseline characteristics were compared across PD response profile using
ANOVA for continuous variables and chi-square or Fisher’s exact tests for bi-
nary and categorical variables. The same methods were used to compare base-
line characteristics between those who were missing versus those who were
observed at the second wave, and to compare baseline characteristics and sec-
ond wave outcomes (ADLs, IADLs, and POMAs) between those who were
missing versus those who were observed at the fourth wave, among those still
in the study at the second wave. The former comparisons assessed the degree
to which the sample included in the analysis was representative of the baseline
cohort; the latter comparisons assessed the degree to which the cohort at the
final visit (wave 4) was representative of the cohort at the second wave (the
earliest outcome data included in analyses, because PD status is only assessed
during waves 2 and 4).
Prevalent PD diagnosis at wave 2 and incident PD diagnosis at wave 4
were calculated using survey-weighted percentages. Weighted generalized es-
timating equations (GEE) that account for intra-person correlation and differ-
ential probabilities of inclusion into the H-EPESE cohort were used to model
the association between PD and the outcomes ADLs, IADLs, and POMAs at
waves 2e4. An exchangeable correlation structured was assumed for each
GEE, and robust standard errors were estimated. For each outcome, two
models were fit. In model 1, assessments at waves 2 and 3 were made by com-
paring those with prevalent PD to those without prevalent PD (i.e., those with
incident PD at wave 4, those who were PD-negative over the course of follow-
up, and those with non-prevalent PD). The assessment at wave 4 compared
those with incident PD and those with prevalent PD (as separate groups) to
those who never had PD. Baseline characteristics were included in model 2.
Only the baseline values of the adjustment variables were used, because values
at later times may be partially due to PD status, and hence may be in the causal
pathway between PD, function, and disability. Thus, model 2 estimated time-
specific associations, controlling for baseline age, sex, education, marital sta-
tus, cognition, depressive symptoms, self-rated health, language of interview,
smoking status, body mass index, number of co-morbidities, living arrange-
ments, migrancy status, time in the US (for those not born in the US), and
life satisfaction. Health care utilization (hospitalization and number of doctor
visits in the past year) was explored descriptively. The date of PD diagnosis
was not collected; therefore health care utilization was not included in model
2 because it may be a consequence of PD status or a reflection of PD severity.
Time-specific mean differences and 95% confidence intervals were calculated
 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406
for each model. Global chi-square likelihood ratio tests were used to assess the
association between PD status and each outcome over time. Wald tests were
performed to assess time-specific associations between PD and each outcome.
3. Results
Among 3050 participants enrolled in the H-EPESE, 2438
were interviewed at the second wave. Thirty-four of those
interviewed reported having been diagnosed with PD, preva-
lence 1.30% (95% CI: 0.86%, 1.97%). Estimated prevalence
was higher among women (1.60%, 95% CI: 0.94%, 2.70%)
compared to men (0.90%, 95% CI: 0.49%, 1.65%), but not
significantly so ( p-value ¼ 0.16). Among 1686 participants
interviewed at the fourth wave, 21 were classified as having
incident PD, estimated five-year incidence was 1.18% (95%
CI: 0.74%, 1.88%). Estimated five-year incidence was similar
for women (1.19%, 95% CI: 0.64%, 2.20%) compared to men
(1.17%, 95% CI: 0.57%, 2.38%), p-value ¼ 0.97. Table 1
shows age- and sex-specific prevalence and five-year inci-
dence. Prevalence and five-year incidence were higher among
those who were at least 70 years old compared to those who
were 65e70 years old (prevalence: 2.02% versus 0.42%, inci-
dence: 1.70% versus 0.68%). In addition, among those 65e70
years old, prevalence and five-year incidence were higher for
men compared to women (prevalence: 0.49% for men versus
0.34% for women, p-value ¼ 0.65; incidence: 1.28% for men
versus 0.26% for women, p-value ¼ 0.10), whereas, among
those aged at least 70 years old, prevalence and incidence
were higher for women compared to men (prevalence:
2.47% for women versus 1.39% for men, p-value ¼ 0.21;
incidence: 2.09% for women versus 1.04% for men, p-value ¼
0.21). Only 13 of the 34 with prevalent PD remained in the
study (18 died, three were lost to follow-up). In addition,
two participants with missing PD status at the second wave
reported PD diagnosis at wave 4. Fig. 1 shows the flow of par-
ticipants throughout the study.
Baseline characteristics across PD response profile are pre-
sented in Table 2. The overall baseline mean (SD) age in the
H-EPESE cohort was 73.1 (6.8) years. Fifty-eight percent of
Table 1
Age and sex-specific prevalence and five-year incidence
Age Males (N ¼ 1047) Female (N ¼ 1471)
# (%) 95% CI # (%)
Prevalence
65e70 3(0.49) (0.14%, 1.69%) 4(0.34)
70þ 9(1.39) (0.69%, 2.79%) 18(2.47)
Males (N ¼ 654) Female (N ¼ 1031)
Incidence
65e70 6(1.28) (0.54%, 3.01%) 1(0.26)
70þ 3(1.04) (0.30%, 3.52%) 11(2.09)
*Age-specific tests comparing men and women.
Prevalence: Overall prevalence 1.30% (95% CI: 0.86%, 1.97%). Prevalence among women (1.60%, 95% CI: 0.94%, 2.70%). Prevalence among men (0.90%, 95%
CI: 0.49%, 1.65%). P-value for sex: 0.16.
Incidence (for five years from wave 2 to wave 4): Overall incidence 1.18% (95% CI: 0.74%, 1.88%). Incidence among women (1.19%, 95% CI: 0.64%, 2.20%).
Incidence among men (1.17%, 95% CI: 0.57%, 2.38%). P-value for sex: 0.97.
399
the H-EPESE cohort was female. Those with prevalent PD
and non-prevalent PD were the oldest, while those never diag-
nosed with PD were the youngest. All baseline factors except
smoking status and language of interview varied significantly
across PD response profiles. Those with follow-up data had
better cognition and were less depressed at baseline than those
lost to follow-up ( p-value < 0.01; data not shown). Among
those still in the study at wave 2, those interviewed at wave
4 had better function at wave 2, were younger and more likely
to be female, had fewer co-morbidities, higher body mass in-
dex, better cognition, fewer depressive symptoms, and better
self-rated health than those who were missing at wave 4
(data not shown). In addition, those who completed all four
waves of the study were found at wave 1 to be younger, had
fewer ADL and IADL difficulties, higher POMA scores,
higher body mass indexes, higher cognitive functioning, fewer
depressive symptoms, better self-rated health and life satisfac-
tion, and less time in the US compared to those who did not
complete all four waves of the study (not shown).
More participants with prevalent PD were interviewed in
English (although not significantly so), and had been in the
US longer. Among the 3050 participants who began the study,
by wave 4, 940 (31%) died, 131 (4%) refused to participate,
and 297 (10%) were lost to follow-up. Within the year prior
to visit two, 486 (20% non-PD, 29% PD) of those interviewed
had been hospitalized at least once. Also, 86% without PD and
93% with PD visited a doctor at least once. Those with PD vis-
ited the doctor a median (inter-quartile range [IQR]) 9 (3e12)
times, while those without PD visited the doctor a median
(IQR) of 4 (2e12) times. During the year prior to wave 3,
464 (23% non-PD, 35% PD) of those interviewed had been
hospitalized and 89% of those without PD and 100% of those
with PD visited a doctor at least once; 43 of them (41 non-PD,
1 PD, 1 incomplete PD status) required some assisted living.
Those with PD visited the doctor a median (IQR) of 10.5
(3.5e19.5) times on average (SD), while those without PD vis-
ited the doctor a median (IQR) 4 (2e10) times. Lastly, 389
(23% non-PD, 30% incident PD, 62% prevalent PD) of those
interviewed at wave 4 had been hospitalized during the
Overall (N ¼ 2518) P-value*
95% CI # (%) 95% CI
(0.11%, 1.03%) 7(0.42) (0.17%, 1.04%) 0.65
(1.38%, 4.38%) 27(2.02) (1.27%, 3.19%) 0.21
Overall (N ¼ 1685)
(0.04%, 1.51%) 7(0.68) (0.31%, 1.51%) 0.10
(1.09%, 3.97%) 14(1.70) (0.95%, 3.01%) 0.32
400 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406

Wave 1: N=3050

Wave 2:

Returned Dead Refused Unlocateable

N=2439 N=237 N=106 N=268

Wave 3:

Returned Dead Refused Cannot Locate Returned Dead Refused Cannot Locate Returned Dead Refused Cannot Locate
N=1899 N=376 N=76 N=88 N=39 N=11 N=40 N=16 N=43 N=33 N=6 N=186

Wave 4:

Returned Returned Returned Returned Returned Returned Returned Returned Returned

N=1539 N=34 N=27 N=29 N=6 N=4 N=35 N=3 N=6

Dead Dead Dead Dead Dead Dead Dead Dead Dead

N=232 N=9 N=8 N=4 N=2 N=2 N=4 N=0 N=16

Refused Refused Refused Refused Refused Refused Refused Refused Refused

N=61 N=27 N=7 N=4 N=24 N=1 N=2 N=1 N=1

Cannot Cannot Cannot Cannot Cannot Cannot Cannot Cannot Cannot

Locate Locate Locate Locate Locate Locate Locate Locate Locate
N=67 N=6 N=46 N=2 N=8 N=9 N=2 N=2 N=163

Fig. 1. Flow chart of participants throughout the study.

previous year, 24 (23 non-PD, 1 incident PD) of them required
some assisted living. Eighty-nine percent of those without PD
visited a doctor while 100% of those with prevalent PD or in-
cident PD visited a doctor. Participants were not asked about
the number of doctor visits in the year prior to wave 4. It is
unknown whether those diagnosed with PD received their di-
agnosis within one year of a follow-up visit; therefore it is un-
known whether differences in number of visits between those
with and without a PD diagnosis are responsible for
differential PD diagnosis or are a consequence of earlier diag-
noses. At wave 2, when those who never become diagnosed
with PD are differentiated from those who have incident PD
at wave 4, we see that the health care utilization among those
with incident PD is similar to those with prevalent PD: 95% of
those who will be diagnosed with PD between waves 2 and 4
visited a doctor during the year prior to wave 4 for a median
(IQR) of 8 (3e12) times.
At wave 2, study participants reported dependency for an
average (SD) of 0.64 (1.79) ADLs. The mean (SD) number
of dependent ADLs at waves 3 and 4 were 0.93 (2.02) and
0.96 (2.01), respectively. Those with prevalent PD had more
ADL dependency than those without PD at each wave
(Adjusted Mean Difference [95% CI]); wave 2,2.17 [0.44,
3.89]; wave 3, 1.08 [0.34, 2.50]; wave 4, 3.34 [1.18, 5.50];
see Table 3, (model 2). Those with incident PD had more
ADL dependency than those without PD at wave 4 (Adjusted
Mean Difference [95% CI]: 0.51 [0.35, 1.38]; Table 3, model
2), but not significantly so. The overall adjusted association
between PD and ADL dependency was significant (Global
P-value ¼ 0.001, Table 3, model 2), although estimates were
attenuated relative to the unadjusted association (Table 3,
model 1). At wave 2, participants reported dependency for
an average (SD) of 2.30 (3.20) IADLs. The mean (SD) number
of dependent IADLs at waves 3 and 4 were 2.61 (3.46) and
2.65 (3.46), respectively. Table 4 presents the estimated asso-
ciation between PD and IADL dependency. Those with prev-
alent PD had more IADL dependency than those without PD
at each time (Adjusted Mean Difference [95% CI]: wave 2,
3.80 [2.20, 5.40]; wave 3, 2.48 [0.63, 4.33]; wave 4, 4.25
[1.79, 6.74]; Table 4, model 2). Those with incident PD had
more IADL dependency than those without PD at wave 4
(Adjusted Mean Difference [95% CI]: 1.30 [0.04, 2.53];
Table 4, model 2). There was a minor change in the estimate
after controlling for baseline confounders (Table 4, model
1). The overall adjusted associations between PD and IADL
dependency were weaker than the unadjusted associations
(Table 4, model 1), but remained statistically significant
(Global P-value <0.0001 Table 4, model 2).
We also examined the association between PD and physical
performance measures (POMAs). The average (SD) POMA
score was 7.53 (3.58) at wave 2. The mean (SD) POMA score
at waves 3 and 4 were 6.36 (4.04) and 6.10 (3.62). Those with
prevalent PD had worse function than those without PD at
each wave (Adjusted Mean Difference [95% CI]: wave 2,
0.98 [4.00, 2.04]; wave 3, 1.78 [4.58, 1.02]; wave 4,
3.50 [5.69, 1.32]; Table 5, model 2). Those with incident
PD performed worse than those without PD at wave 4
(Adjusted Mean Difference [95% CI]: 0.49 [1.77, 0.78];
Table 2
Baseline characteristics of the study sample
Characteristic Prevalent PD Incident PD Never PD Non-prevalent PD Incomplete PD status Overall H-EPESE cohort P-value*
N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 N ¼ 3050
Age N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 73.1 (6.8) <0.0001
75.6 (6.8) 74.3 (5.9) 71.8 (5.7) 75.3 (7.3) 73.3 (7.9)
Married N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 1693 (55%) 0.017

M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406

21 (62%) 14 (67%) 946 (58%) 435 (52%) 277 (52%)
# Co-morbidities N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 1.3 (1.2) <0.0001
1.4 (1.4) 1.4 (1.2) 1.2 (1.1) 1.4 (1.2) 1.3 (1.2)
BMI N ¼ 27 N ¼ 20 N ¼ 1533 N ¼ 730 N ¼ 459 27.8 (5.3) <0.001
26.3 (5.4) 26.8 (5.2) 28.2 (5.1) 27.4 (5.3) 27.4 (5.8)
Highest grade N ¼ 34 N ¼ 21 N ¼ 1605 N ¼ 820 N ¼ 522 4.8 (3.9) 0.033
4.8 (4.1) 3.3 (3.3) 4.9 (3.9) 4.6 (3.9) 5.1 (3.9)
Sex (% female) N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 1759 (58%) <0.001
21 (62%) 12 (57%) 998 (61%) 440 (53%) 288 (54%)
Lang interview (% Spanish) N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 2374 (78%) 0.069
24 (70%) 18 (86%) 1268 (78%) 669 (80%) 395 (74%)
MMSE N ¼ 31 N ¼ 21 N ¼ 1558 N ¼ 762 N ¼ 481 24.7 (4.7) <0.0001
22.2 (7.2) 24.1 (5.4) 25.4 (4.0) 23.8 (5.2) 23.8 (5.5)
CES-D-baseline N ¼ 28 N ¼ 21 N ¼ 1556 N ¼ 746 N ¼ 472 9.9 (9.6) <0.0001
13.6 (11.4) 9.4 (9.9) 8.8 (8.9) 11.0 (10.4) 11.8 (9.8)
Smoke (current, former, never) N ¼ 34 N ¼ 21 N ¼ 1628 N ¼ 832 N ¼ 531 0.12
1 (3%) 2 (10%) 202 (12%) 121 (14%) 54 (10%) 380 (12%)
10 (29%) 7 (33%) 461 (28%) 255 (31%) 150 (28%) 883 (29%)
23 (68%) 12 (57%) 960 (59%) 451 (54%) 327 (62%) 1773 (58%)
Self-rated health N ¼ 24 N ¼ 18 N ¼ 1534 N ¼ 715 N ¼ 443 2.6 (0.9) <0.0001
3.1 (0.9) 2.7 (0.9) 2.6 (0.9) 2.8 (0.9) 2.6 (0.9)
US born (% Yes) N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 832 N ¼ 531 1704 (56%) 0.062
17 (50%) 11 (52%) 941 (58%) 431 (52%) 304 (57%)
Time in US (among non-US born) N ¼ 17 N¼9 N ¼ 661 N ¼ 365 N ¼ 209 41.6 (21.2) 0.022
44.6 (22.8) 41.0 (21.2) 40.0 (19.9) 42.2 (22.6) 45.5 (21.8)
Live alone N ¼ 34 N ¼ 21 N ¼ 1630 N ¼ 833 N ¼ 532 640 (21%) 0.097
4 (12%) 1 (5%) 331 (20%) 193 (23%) 111 (21%)
Life satisfaction N ¼ 24 N ¼ 18 N ¼ 1534 N ¼ 715 N ¼ 443 1.7 (0.8) 0.005
2.0 (1.0) 1.7 (0.8) 1.7 (0.8) 1.8 (0.8) 1.7 (0.8)
Income >¼10k N ¼ 31 N ¼ 21 N ¼ 1575 N ¼ 804 N ¼ 495 N ¼ 2926 0.86
5 (16%) 3 (14%) 225 (14%) 127 (16%) 70 (14%) 430 (15%)
Seen a doctor within 12 months# N ¼ 30 N ¼ 20 N ¼ 1514 N ¼ 799 N¼3 N ¼ 2366 0.34
28 (93%) 19 (95%) 1290 (85%) 690 (86%) 2 (67%) 2029 (86%)
Mean (SD) for continuous variables, count (%) for binary and categorical variables.
*ANOVA for continuous variables, Fisher’s exact test for categorical and binary variables.
#
Within 12 months prior to wave 2.

401
402 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406

Table 3 Table 5
Mean differences in number of ADL dependencies between those with and Mean differences in POMA score between those with and without PD (lower
without PD (higher scores indicate greater ADL dependency) scores indicate worse physical function)
Model 1: mean difference Model 2 (model 1 þ covariates): Model 1: mean difference Model 2 (model 1 þ covariates):
(95% confidence interval) mean difference (95% (95% confidence interval) mean difference (95%
p-value confidence interval) p-value p-value confidence interval) p-value
Wave 2 Wave 2
No PD 0.00 (reference) 0.00 (reference) No PD 0.00 (reference) 0.00 (reference)
Prevalent PD 2.67 (1.31, 4.04) 1.73 (0.19, 3.27) Prevalent PD 2.17 (4.37, 0.13) 0.98 (4.39, 2.44)
p* < 0.0001 p* ¼ 0.027 p* ¼ 0.051 p* ¼ 0.58
Wave 3 Wave 3
No PD 0.00 (reference) 0.00 (reference) No PD 0.00 (reference) 0.00 (reference)
Prevalent PD 2.06 (0.80, 3.31) 1.08 (0.51, 2.67) Prevalent PD 3.41 (5.37, 1.46) 2.46 (5.49, 0.57)
p* ¼ 0.0001 p* ¼ 0.18 p* ¼ 0.001 p* ¼ 0.11
Wave 4 Wave 4
No PD 0.00 (reference) 0.00 (reference) No PD 0.00 (reference) 0.00 (reference)
PD PD
Prevalent PD 3.80 (2.27, 5.33) 3.24 (1.10, 5.39) Prevalent PD 4.48 (5.90, 3.07) 3.76 (5.98, 1.54)
p* < 0.0001 p* ¼ 0.003 p*<0.0001 p* ¼ 0.001
Incident PD 1.16 (0.30, 2.02) 0.54 (0.36, 1.45) Incident PD 1.12 (2.30, 0.05) 0.72 (1.92, 0.48)
p* ¼ 0.008 p* ¼ 0.23 p* ¼ 0.061 p* ¼ 0.24
Global test <0.0001 0.001 Global test <0.0001 0.014
P-value# P-value#
*p refers to time dependent tests comparing those with prevalent PD (waves *p refers to time dependent tests comparing those with prevalent PD (waves
2e4) and those with incident PD (visit 4) to those with no PD (reference 2e4) and those with incident PD (wave 4) to those with no PD (reference
group). group).
# #
Global test P-value refers to the overall comparison between those with (prev- Global test P-value refers to the overall comparison between those with (prev-
alent and incident) PD and without PD across all three waves (waves 2e4). alent and incident) PD and without PD across all three waves (waves 2e4).

Table 5, model 2), but not significantly so. The adjusted

4. Discussion
estimates were attenuated relative to unadjusted estimates
(Table 5, model 1), but remained statistically significant
Neurodegenerative diseases are receiving greater attention
(Global P-value ¼ 0.030 Table 5, model 2).
with increased life expectancy, as their prevalence and inci-
dence increase dramatically with age [48]. Consideration of
Table 4 ethnic and cultural origin in epidemiologic studies may be-
Mean differences in number of IADL dependencies between those with and
come increasingly important as environmental factors in the
without PD (higher scores indicate greater IADL dependency)
etiology of PD continue to be investigated [49]. The objectives
Model 1: mean difference Model 2 (model 1 þ covariates):
of our study were to establish incidence and prevalence, and to
(95% confidence interval) mean difference (95%
p-value confidence interval) p-value explore functional decline in a group of Mexican American el-
derly with PD.
Wave 2
No PD 0.00 (reference) 0.00 (reference) PD prevalence among the Mexican American elderly in this
Prevalent PD 4.67 (3.34, 6.00) 3.55 (2.29, 4.83) study (1.30%) was similar to that among the general elderly
p* < 0.0001 p* < 0.0001 (1.50%). Prevalence was higher for women (1.60%) than for
Wave 3 men (0.90%). For comparison, Mayeux et al. [15] found prev-
No PD 0.00 (reference) 0.00 (reference) alence 3.17% for men and 1.34% for women using data from
Prevalent PD 3.72 (2.31, 5.12) 2.78 (0.92, 4.63) a Medicare survey. Romero et al. [16] reported 3.30% preva-
p* < 0.0001 p* ¼ 0.003 lence for men and 0.50% for women among older adults in
Wave 4 New Mexico. Incidence in our study (1.18%) was similar for
No PD 0.00 (reference) 0.00 (reference) women (1.19%) and for men (1.17%), but lower than that
PD
reported by Van den Eeden et al. [14] (1.66%) using an
Prevalent PD 5.10 (3.29, 6.92) 4.30 (1.90, 6.70)
p* < 0.0001 p* < 0.001 HMO sample for one year (1994e1995). However, ours was
Incident PD 1.46 (0.45, 2.47) 1.45 (0.09, 2.81) a five-year incidence rather than a one year incidence. One
p* ¼ 0.005 p* ¼ 0.037 reason for our higher prevalence in women compared to
Global test <0.0001 <0.0001 men among those at least 70 years old is survivorship bias, ow-
P-value#
ing to the shorter life spans in men compared to women. As
*p refers to time dependent tests comparing those with prevalent PD (waves some participants were missing at wave 4, and those who
2e4) and those with incident PD (visit 4) to those with no PD (reference
were missing had more functional limitations than those who
group).
#
Global test P-value refers to the overall comparison between those with (prev- were not missing at earlier waves, our incidence estimates
alent and incident) PD and without PD across all three waves (waves 2e4). should be regarded as conservative. Other studies have also
 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406
suggested that underestimation of PD in minority groups is
particularly common [15,50,51].
Those with PD visited the doctor more frequently than
those without PD. It is unclear whether increased visits are
a result of PD symptoms, or if potentially differential diagno-
sis of PD resulted from differential health care utilization.
Higher prevalence among women may reflect increased health
care utilization. Those with incident PD at wave 4 had similar
health care utilization at wave 2 as those with prevalent PD,
supporting the argument of under-diagnosis, and validating
concern that those who are diagnosed are likely the most
symptomatic.
Progressive functional decline across time was observed
among those with PD, assessed by both self-report and objec-
tive measures. Although estimates were attenuated when
potential confounding variables were controlled, the pattern
remained unchanged. Differences in physical performance as-
sessments showed a monotone pattern of more rapid decline
among those with prevalent PD compared to those without
PD. Those with PD also had more co-morbid conditions
than those without PD. However, self-reports of ADL and
IADL dependency showed a non-monotone pattern of differ-
ences: smaller differences in dependencies were observed at
wave 3 than at waves 2 and 4. These patterns are likely par-
tially due to missing data, as those with the worse function
and more dependencies at wave 2 are missing more often at
wave 3 than those with better function and fewer dependen-
cies, where most of those who were missing at wave 3 were
dead. However, this pattern of differences persisted among
those present at both waves 2 and 3 (data not shown). One ex-
planation is that those who remained in the study at wave 3 are
a select group; first, by being alive, and second, they may have
perceived more improvements or stability in ADLs and IADLs
compared to drop-outs who are still alive.
Although it is unknown to what extent reduced access to
care (e.g. supplemental insurance, availability of specialist
care) among the minority elderly has impacted racial/ethnic
differences in PD prevalence, the most likely explanation for
our disparate findings is reduced access to care. The problem
may be particularly acute among the more recent immigrants
[52]. Mexican Americans are particularly economically disad-
vantaged. They have lower education and incomes than other
Hispanic groups [12,53]. Mean education in our study was
between 4th and 5th grades, below that of the general popula-
tion of the same age [54]. In addition, half of our survey
respondents had household incomes below the poverty level
and nearly half were foreign born [53]. More participants
with prevalent PD preferred to be interviewed in English (al-
though not significantly so), and had been in the US longer,
suggesting under-diagnosis of the recent immigrants. Mexican
Americans are less likely than other older Hispanic elderly to
visit physicians [55]. Low Medicare coverage and reduced
supplemental insurance is most pronounced among recent
immigrants [12,16,53]. Previous studies using this data have
indicated vulnerabilities resulting from a lack of private
Medigap supplemental coverage including limitations in
ADLs and increased mortality [53,56].
403
Access to care is suggested to make the most difference in
delaying or slowing down functional decline among function-
ally independent elderly persons [57]. Early initiation of dopa-
minergic agents in the treatment of PD may prevent loss of
mobility and suboptimal care of PD may accelerate disability
progression [58,59]. Physical function in those with PD is as-
sociated with economic resources as PD patients may incur
high expenses, including direct health care costs (drugs, phy-
sician services, and hospitalization) and indirect costs (loss
of wages or caretakers’ wages) [58,60e63]. The cost of pre-
miums, co-payments, uncovered hospital portions and uncov-
ered services can be substantial [53,64e68]. Insurance status
contributes most to disparities in the financial burden of
prescription drugs among Mexican Americans [53,63,65,67].
Reduced supplemental insurance may also affect receipt of
specialty care, including neurologists. Research suggests that
being white, having more education and higher income, and
having insurance to supplement basic Medicare coverage
promotes receipt of specialty care [53,56,69]. Working age
disadvantages place foreign born older Mexican Americans
at risk of inadequate coverage in old age with no supplemental
Medigap coverage or retirement income [52,56]. Furthermore,
limited English proficiency is associated with having poor
health, no health insurance, and no regular source of care
[70]. The high cost of adequate treatment for PD may there-
fore preclude universal access to older Mexican Americans
[67,68]. It is therefore a plausible hypothesis that reduced
access to care in this group may have contributed to the func-
tional decline we observed. Reduced access may also have
contributed to under-diagnosis, particularly among the more
recent older immigrants. Future PD studies addressing ineq-
uities in access to care are recommended [68].
PD in its late stages is associated with substantial health
and financial burden to families [8,71]. Community-dwelling
Mexican Americans have low rates of institutionalization.
Therefore, families are more likely to care for their relatives
with PD, particularly the foreign born, than are those in other
racial/ethnic groups [71e73]. These family members may be
overburdened as serious impairment may eventually over-
whelm supportive networks [26,72,74].
The results of this study must be viewed with the follow-
ing limitations in mind. Reliance upon self-reports of diag-
nosed illness without biological verification may result in
misclassification, and recall may be poorer for older than
for younger people. However, it is more plausible that un-
der-diagnosis rather than over diagnosis occurred owing to
the low levels of health care utilization in this population
[55]. Such potential differential diagnosis could lead to biased
estimation of associations, as only those with the most severe
symptoms are likely to be diagnosed, and could also help ex-
plain gender differences. It is also plausible that those with
undiagnosed PD have worse physical function than those
without PD, suggesting that our estimates are conservative.
Although use of self-report measures to determine disability
could be a limitation in that patterns may differ from perfor-
mance test patterns because self-reports measure perceptions
that may be influenced by external factors such as culture
404 M.G. Schneider, M. Shardell / Parkinsonism and Related Disorders 14 (2008) 397e406
and language, measuring functional status by both self-report
and objective measures is also an advantage. In our study, the
self-report results and the results of performance-based tests
corroborate each other.
Another limitation was the small number of people with
PD. However, despite these small numbers, the large sample
size and longitudinal cohort design facilitated estimating PD
prevalence and incidence in Mexican Americans. In addition,
many participants were lost to follow-up due to refusal or
death in this older population. However, the dominant reason
for loss to follow-up in this study is death; thus the estimates
at later times are generalizable to participants who are alive at
those times. Some participants were missing due to refusal at
wave 4, and those who were missing had more functional
limitations than those who were not missing at earlier waves,
suggesting that we are likely under-estimating incidence. Al-
though differential dropout could result in potential biases,
the inclusion of covariates in our models that differ between
completers and non-completers helped correct for these biases.
Missing data may also have contributed to smaller differences
in dependencies at wave 3 than at wave 2 or 4.
Despite these limitations, this study contributed to the
sparse information about Parkinson’s disease in older Mexican
Americans. Regardless of potential biases, this study showed
that Mexican Americans diagnosed with PD have worse
physical function and more ADL and IADL dependency
than Mexican Americans who are not diagnosed with PD,
even after controlling for known confounders, including
health-related measures. Our conclusions were robust to
methods of measurement of physical performance and disabil-
ity, suggesting that the relationship between PD and self-
reported disability is not solely explained by cultural and
language factors. Minorities bear substantial disease burden,
and further studies are needed to understand the contribution
of PD to functional decline and disability and to the needs
of these underserved persons in the community in this rapidly
growing segment of our older population.
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