The purpose of this article was to examine the interracial (black versus white) and intraracial (U.S.-born blacks versus African Caribbeans) differences in neuropsychiatric symptoms (depression, psychoses, and agitation) among dementia patients residing in nursing homes. The study was conducted in three nursing homes in Brooklyn, two ofwhich were predominantly black and one was predominantly white. The final sample consisted of 218 black and 68 white patients with dementia.

Blacks were significantly younger, less educated, less likely to be female, less likely to have had a skilled occupation, and more likely to be separated/divorced or single compared with whites. Blacks also had equal or lower scores on all health measures, but were more likely to have been admitted to the nursing home from an acute care hospital. Finally, blacks were more likely to have lived alone prior to institutionalization than whites, indicating lower levels of social support. Using logistic regression to predict black versus white race, the authors constructed a multivariate model that was able to correctly classify 84% of the cases. The following variables were statistically significant predictors of black race in this model: younger age, less education, semi/unskilled occupation, widowhood, admission form acute care hospital, and lower mini-mental status exam scores and the absence of clinical depression.

There were no demographic or predisposing factors differences between African Americans and African Caribbeans except African Americans were significantly more likely to be widowed. A multivariate model based on these variables was not able to accurately differentiate African American and African Caribbean patients.

The authors found that among black patients, 85% of probable depressives and 67% of probable major depressives were not identified as depressed by the professional staff. Among white patients, the professional staff did not identify 92% of probable depressive and 83% of probable major depressives. Since this pattern could reflect clinician patterns in recording depression on medical charts rather than clinician patterns in recognizing illness, it is noteworthy that only 1 of 6 black patients who was rated as having probable depression by research staff, and 0 of 6 white patients received an antidepressant. However, it is also informative to note that only 3 of 9 blacks who were identified as being depressed by the nursing home staff and 1 of 3 whites received an antidepressant. Relatively larger proportions of patients with high research screens for psychoses or aggressivity received antipsychotics, but the proportion for both blacks and whites did not reach even 40%.

The authors aimed to examine interracial (black versus white) and intraracial (US born blacks versus African Caribbeans) differences in neuropsychiatric symptoms (depression, psychoses, and agitation) among dementia patients residing in nursing homes using a model (described by George, 1989). However, the model and the interpretation of the model were insufficiently described in this article, and it is therefore difficult to interpret the findings. Some of the data provided were provocative nonetheless.

First, although there were a number of demographic differences between blacks and whites, there appeared to be few differences in depression, psychosis and agitation. The authors suggest that "one possibility is that although black families may be more prone to tolerate symptoms and avoid institutionalization, when blacks live alone with few social supports and with difficulties in ADL, institutionalization is more likely to occur, particularly following an acute hospitalization. Consequently, institutionalization may occur at lower levels of neuropsychiatric symptomatology than are found among other black dementia patients in the community who have strong social supports." This will require direct testing, as the present data do not support or refute this rather complex argument.

The authors also suggest that "increased standardization of admission criteria and treatment in nursing homes may also account for homogeneity in types of patients and their treatment." They concluded that "because African Americans with dementia who are living alone, when hospitalized, are at risk for institutionalization, intervention should be aimed at augmenting their support systems so that they will be more likely to remain in the community."

Second, the treatment patterns were quite disturbing. The authors note that the use of medications was much lower in the predominantly white nursing home than in either of the predominantly black nursing homes. The low use of medications, according to the authors, "may reflect increased vigilance exhibited by staff in the nursing homes concerning federal regulation that proscribe the use of unnecessary drugs." They also suggested that this might reflect "failure to recognize serious depression of may patients, and may have prolonged symptomatology of psychoses and aggressivity and creased an unnecessary burden for staff treating these patients [and for the patients]."

The authors attribute the lack of differences between African Americans and African Caribbeans to "the increased standardization of nursing home admission criteria along with their SES and racial similarities."