Double Jeopardy for Older Adults of Color: An Urgent Call to Address Frailty Disparities in the United States
Karen Bandeen Roche, PhD
Frank Hurley and Catharine Dorrier Chair of Biostatistics
Johns Hopkins Bloomberg School of Public Health
Co-Director, Johns Hopkins Older Americans Independence Center
Sarah Szanton, PhD, MSN, RN
FAAN, ANP
Professor
Endowed Professor for Health Equity and Social Justice
Director, Center for Innovative Care in Aging
Roland Thorpe, Jr., PhD
Co-Director DrPH Concentration in Health, Equity, and Social Justice
Professor
Racial inequality that has been embedded in US structures and institutions has been exposed by twin catastrophes of 2020. In the height of the early novel coronavirus pandemic, Black, Latinx, and Native Americans were roughly 5 times as likely to be hospitalized for COVID-19 than their white peers, and Black Americans were twice as likely to die as whites (CDC COVID-19 Hospitalization by Race/Ethnicity, accessed 11/18/20). The killing of George Floyd, Ahmaud Arbery, Breonna Taylor, and others highlight the fact that people of color in the US continue to disproportionately experience police and vigilante violence along with other forms of inequality, including substandard housing, under-resourced schools, and restricted access to living-wage employment.
As one observes that highly publicized disparities in health and safety disproportionately affect young and middle-aged individuals, it can be tempting to predict that inequities lessen or even out in old age. Some have argued this (Meich, 2009). Motivated by studies we have performed as well as others’, we fear that such an approach—whether arising from complacency or misunderstanding—will leave older people of color in America with considerably diminished quality of life and heightened risk of other adverse outcomes. Frailty is a case in point. In a study to evaluate national racial/ethnic prevalence disparities, we found that the odds of frailty among non-Hispanic Black and Hispanic older adults were inflated approximately 1.5 times compared to non-Hispanic White older adults, after adjusting for age, sex, income, BMI, and comorbidity (Usher et al., 2020). Relative to a non-Hispanic white sociodemographic group with 15% prevalence—likely a quite typical group, given an estimated overall national prevalence of 15.3% (Bandeen-Roche et al., 2015)–this translates into prevalence of roughly 21% for non-Hispanic Blacks and Hispanics. We further found that, for Black older adults, relative Black versus white disparities were comparable across income quartiles (and the estimated percentage inflation in frailty odds actually was greatest in the highest income quartile). This means that intersectionality looms large; added risks appear to aggregate when under-represented race/ethnicity and economic disadvantage are taken together.
Disparities in frailty experience may provide a particularly telling case because of implications for other risks as well as for mechanisms leading to the disparity in older age. The studies described above employed physical frailty phenotype (PFP) ascertainment of frailty. Under the PFP paradigm, frailty is hypothesized as a clinically recognizable syndrome arising from critical dysregulation in physiological systems governing energy production and use as well as stress response, resulting in vulnerability to adverse outcomes following stressors (Fried et al., 2001; Bandeen-Roche et al., 2020). With heightened frailty prevalence, older Americans of color or minority ethnicity may disproportionately frequently experience amplified physiological vulnerability together potentially with impaired access to resources by which to compensate, leading to a vulnerability “double-hit” putting them at particularly amplified risk for adverse outcomes. Considering frailty as an outcome of unraveling stress response regulation, moreover, may provide insight into mechanisms leading to such a large race disparity in frailty in late life; stress response stands to be impaired with chronically elevated stress over the life course, and this is exactly what one might hypothesize to follow from the persistent experience of socioeconomic inequities, social injustice, and structural racism. It is the inextricably intertwined historical context and life experiences that many older Black Americans have endured that position their bodies for poor outcomes, such as frailty.
It follows that the need for research to discover the etiology of late life frailty, and then to intervene on or buffer it, is particularly urgent for reducing racial/ethnic disparities in the health and well-being of older Americans. Meanwhile, efforts to buffer the implications of frailty for older Americans need not wait. Interventions with proven effectiveness for reducing stressors in the home environment already exist; CAPABLE, an evidence-based program which provides tailored occupational therapy, nursing, and handy worker services to enhance function of older adults aging at home and prevent costly institutional care, is a strong example of these. Programs and policies to reduce disparities in opportunity to maintain good health also could have high impact. These are needed to address health facilitators that are unavailable to many older adults of color, including ready transportation by which to access health care, high-quality nutrition, and neighborhood environments in which to safely engage in physical activity—all essential to staving off frailty and reducing its impact. If feasibility mandates, these interventions could be targeted—for example, using methods to assess pre-frailty pioneered by our Older Americans Independence Center as well as other groups. Screening to identify pre-frail and frail older Americans of color could not be more timely in the face of the COVID-19 pandemic. We suspect that the etiology underlying frailty intersects considerably with the etiology of susceptibility to the novel coronavirus, and conversely infection may contribute to future frailty. Finally, whether to bolster robustness and resilience in the short term or for protection against future health threats, addressing frailty among older Americans of color is a matter of the highest import for researchers, clinicians, and policymakers alike.