Discordance Between Subjective and Objective Cognitive Function in Older Korean Americans

Abstract

Objectives: To examine predictors of membership in discordant groups identified by subjective and objective measures of cognitive function. Methods: Participants in the Study of Older Korean Americans (N = 2046) were classified according to their subjective cognitive ratings (excellent/very good/good vs. fair/poor) and Mini-Mental State Examination scores (normal cognition vs. cognitive impairment), yielding two discordant groups: (1) positive ratings but cognitive impairment and (2) negative ratings but normal cognition. Logistic regression models examined how the discordant group membership was associated with personal resources. Results: Among those with positive cognitive ratings, the odds of belonging to the discordant group were associated with low personal resources (advanced age and lower levels of education, acculturation, and knowledge about Alzheimer’s disease). However, an opposite pattern was observed among those with negative ratings. Discussion: The pattern of discordance suggests ways to promote early detection of cognitive impairment and close the gap in cognitive health care.

Keywords

cognitive aging cognitive function subjective cognitive rating minority older adults health appraisals acculturation

Introduction

Population aging accompanied by the increasing prevalence of dementia has prompted attention to cognitive aging (Blazer et al., 2015). Emerging evidence suggests that older individuals with racial and ethnic minority backgrounds have a heightened cognitive health risk (Díaz-Venegas et al., 2016; Mayeda et al., 2016; Zhang et al., 2016) but delay help-seeking for cognitive health needs (Cooper et al., 2010; Kenning et al., 2017; Mukadam et al., 2013). Cognitive disadvantages and service underutilization are particularly pronounced among those who are foreign-born (Franco & Choi, 2020; Moon et al., 2019; Weden et al., 2017). Given the dearth of information on the cognitive status of older Asian Americans—a fast-growing segment of the US population and a leading group among foreign-born immigrants (Batalova & Alperin, 2018)—the present study focuses on older Korean Americans and examines the mechanisms underlying their cognitive health.

With an estimated population of 1.8 million, Koreans represent the fifth largest Asian American subgroup (Pew Research Center, 2017). Because most Koreans have arrived in the United States since the 1965 passage of the Immigration and Naturalization Act, the current population of older Korean Americans consists predominantly of foreign-born first-generation immigrants (Pew Research Center, 2017). Due to linguistic and cultural barriers, many of these individuals manifest physical and mental health problems and experience challenges in health service use (Kim et al., 2015; Park et al., 2015). Although information on their cognitive health is scarce, existing studies demonstrate that older Korean Americans have high levels of concerns about and stigma associated with cognitive impairment (Jang et al., 2018, 2020; Lee et al., 2010).

A sizable body of the literature suggests that there is great variation in how older individuals perceive and evaluate their own health and function (McMullen & Luborsky, 2006; Solar & Irwin, 2010). With respect to cognition, a meta-analysis of 53 studies reports that the association between subjective cognitive rating and objectively measured cognitive function is only low to moderate (Crumley et al., 2014). It is worthy of note that racial and ethnic minorities demonstrate a weaker association between subjective and objective measures of cognitive function than non-Hispanic whites (e.g., Blazer et al., 1997; Jackson et al., 2017; Zlatar et al., 2018). Such discordance could lead to racial and ethnic disparities in dementia diagnosis and treatment (Cooper et al., 2010; Kenning et al., 2017; Mukadam et al., 2013). Given the role of self-evaluations in detecting cognitive impairment and initiating care-seeking behaviors (Centers for Disease Control and Prevention [CDC], 2019; Hurt et al., 2012; Jungwirth et al., 2004; Snitz et al., 2015), it is important to explore how subjective cognitive ratings correspond to objective cognitive performance and what predict their potential discordance.

Some individuals may rate their own cognitive ability positively despite the impaired status of cognition, while others may have negative self-evaluations, complain about memory loss, and have worries about developing Alzheimer’s disease even when they show no objective signs of cognitive impairment. Both situations of discordance have practical implications. For the former, the inability to recognize cognitive deficits or denial of impairment could inhibit the proper and timely use of medical care, and for the latter, unnecessary worry could provoke excessive anxiety and fear. Our focus on the discordance is in line with targeted dementia prevention efforts that prioritize the characterization of individuals at risk and the promotion of early detection and diagnosis (CDC, 2019; Jessen et al., 2014; Snitz et al., 2015).

Our selection of predictors of the discordant group membership was guided by the literature on health appraisals, which postulates that self-rated health is a complex construct influenced not only by one’s physical health status but also by sociocultural and psychological dimensions (McMullen & Luborsky, 2006; Solar & Irwin, 2010). For example, unrealistic health assessments (i.e., health pessimism/optimism) are exacerbated among those with limited personal resources (e.g., low education) and comorbid mental health conditions (e.g., symptoms of depression and anxiety) (Borawski et al., 1996; Ruthig et al., 2011). Of variables specific to immigrants, length of stay in the United States and the level of acculturation are important personal resources that enable individuals to realistically and accurately assess their health status (Lommel & Chen, 2016; Salant & Lauderdale, 2003). Another potential resource specific to cognitive health is knowledge about Alzheimer’s disease. Studies suggest that awareness and understanding of Alzheimer’s disease play an important role in shaping individuals’ perceptions of cognitive health and care-seeking behaviors (Jang et al., 2018; Lee et al., 2010).

Based on the aforementioned review, we hypothesized that the odds of belonging to a group whose cognitive performance is discordant with subjective evaluations of cognitive function would be increased among individuals challenged by lack of personal resources (e.g., lower education, fewer years in the United States, and lower levels of acculturation and perceived knowledge about Alzheimer’s disease) and by physical and mental health problems (e.g., more numbers of chronic medical conditions, greater levels of functional disability, and severer symptoms of depression).

Methods

Participants

The data for this study were obtained as part of the Study of Older Korean Americans (SOKA), a multistate survey of Korean immigrants aged 60 years and older. In an effort to increase the generalizability of findings, sites for the SOKA were selected from states with differing Korean population densities: California, New York, Texas, Hawaii, and Florida. In each state, a primary metropolitan statistical area with a representative proportion of Korean Americans was selected: Los Angeles, New York, Austin, Honolulu, and Tampa. Due to the difficulties in identifying a representative sample of the older Korean American population, the SOKA employed culturally and linguistically sensitive sampling strategies rather than basing on standardized probability sampling.

More specifically, community-based volunteer samples of convenience were recruited by a team of investigators who shared the language and culture of the target population. At each of the five SOKA sites, the project began with the compiling of a database of Korean-oriented resources, services, and amenities in the area; this database not only facilitated the research team’s efforts for community engagement but also guided the selection of specific data collection locations. In the development of these databases and in their use at each site, community advisors’ input was actively solicited. At each of the five sites, surveys took place at multiple locations and events (e.g., churches, temples, grocery stores, small group meetings, and cultural events) from April 2017 to February 2018. The SOKA questionnaire was in Korean, developed through a back-translation and reconciliation method. The questionnaire was designed to be self-administered, but trained interviewers were onsite for anyone who needed assistance. Upon completion of the SOKA questionnaire, each participant was also assessed for cognitive function using the Mini-Mental State Examination (MMSE; Folstein et al., 1975) by trained research personnel. All participants were paid US $20 each for participation. The project was approved by a university’s Institutional Review Board. All participants were informed of the study’s goals and signed an informed consent form. A total of 2176 individuals participated in the survey. After removal of those who had data missing on the MMSE or subjective cognitive ratings (n = 126) or whose cognitive status suggested severe impairment (MMSE score <10; n = 4), the final sample for the present study consisted of 2046 participants.

Measures

Subjective cognitive ratings

Self-evaluation of cognitive status was assessed with a single question: “How would you rate your overall cognitive health?” The original response coded on a 5-point scale was dichotomized either as positive ratings (0 = excellent/very good/good) or negative ratings (1 = fair/poor). The wording of the question and coding scheme is in line with the extensive literature on self-rated health (DeSalvo et al., 2006). The single-item rating has been used as a subjective indicator of overall cognitive function in previous studies (e.g., Cutler, 2015; Jang et al., 2020; O’Shea et al., 2016).

Cognitive function

The MMSE (Folstein et al., 1975) was used as an index of global cognitive function. The MMSE includes items on time and place orientation, memory recall, attentional and computational capabilities, language ability, three-stage commands, pentagon drawing, judgment, and comprehension. Responses for each item were scored as 0 (incorrect) or 1 (correct), and total scores could range from 0 to 30. A score of 24 or below has been used as an indication of cognitive impairment (Folstein et al., 1975). The psychometric properties of the Korean version of the MMSE have been validated (e.g., Han et al., 2010); internal consistency in the present sample was satisfactory (α = .73). In the present analysis, a dichotomized score (MMSE score >24 = normal cognition and MMSE score ≤24 = cognitive impairment) was used.

Personal resource variables

Along with educational attainment (0 = ≤high school graduation and 1 = >high school graduation), two immigration-related resource variables were considered. Length of stay in the United States was coded in years, and the level of acculturation was assessed with a 12-item inventory of acculturation (Jang et al., 2007). This scale addresses English proficiency, media consumption, food consumption, social relationship, sense of belonging, and familiarity with culture and customs. Each response was coded from 0 to 3, and total scores could range from 0 to 36, with a higher score indicating greater acculturation to mainstream American culture. Internal consistency in the present sample was high (α = .91).

Perceived knowledge about Alzheimer’s disease was included as a resource variable specific to the context of cognition. It was measured by asking participants to rate how much they knew about the disease on a 4-point scale: nothing at all (1), not very much (2), somewhat (3), and very much (4).

Physical and mental health status

Chronic medical conditions and functional disabilities were used as indicators of physical health. The total count of positives on a checklist of 10 chronic diseases and conditions common in older populations (e.g., diabetes, cancer, arthritis, heart disease, and high blood pressure) was used, with a range of 0–10. Functional disabilities were assessed with a composite measure (Fillenbaum, 1988) that included activities of daily living and instrumental activities of daily living. The checklist consisted of 16 activities (e.g., walking, bathing, dressing, and managing medication), with participants indicating how well they could perform each activity. Responses were coded as 0 (without help), 1 (with some help), or 2 (unable to do). Total scores could range from 0 (no functional disability) to 32 (severe functional disability). Internal consistency of the scale in the present sample was high (α = .89).

As an indicator of mental health status, depressive symptoms were measured by the Patient Health Questionnaire 2 (PHQ 2), a short form of the PHQ 9 (Kroenke et al., 2001). It measures the frequency of experiencing two symptoms of depression over the past two weeks: (1) having little interest or pleasure in doing things and (2) feeling down, depressed, or hopeless. Each item was rated on a 4-point scale ranging from 0 (not at all) to 3 (nearly every day). Total scores could range from 0 to 6, with higher scores indicating greater levels of depressive symptoms. Internal consistency of the scale in the present sample was high (α = .80).

Background variables

Covariates included age (in years), gender (0 = female and 1 = male), and marital status (0 = not married and 1 = married).

Analytical Strategy

After reviewing the sample’s descriptive characteristics and bivariate correlations among study variables, we compared those with positive cognitive ratings (excellent/very good/good) and those with negative cognitive ratings (fair/poor) using t or chi-square tests. Subsequent group classification was based on MMSE scores. Participants with positive cognitive ratings were divided into those with normal cognition (MMSE >24; i.e., concordant group) and those with cognitive impairment (MMSE ≤24; i.e., discordant group). Similarly, participants with negative cognitive ratings were divided into those with cognitive impairment (i.e., concordant group) and those with normal cognition (i.e., discordant group). Subgroup comparisons were also performed using t or chi-square tests. In order to identify significant predictors for the discordant membership, two separate logistic regression models were examined. The predictor variables included background variables (age, gender, and marital status), personal resources (education, years in the United States, acculturation, and perceived knowledge about Alzheimer’s disease), and physical and mental health status (chronic medical conditions, functional disabilities, and depressive symptoms). All analyses were performed using IBM SPSS Statistics 27 (IBM Corp, Armonk, NY).

Results

Univariate and Bivariate Description of the Sample

Table 1 presents descriptive characteristics of the overall sample (N = 2046). The mean age of the participants was 73.2 years (SD = 7.93), with a range of 60–100. About 67% were women, about 40% were not married, and over 60% had attained a high school degree or less (60.2%). Compared to the national statistics on older Asian Americans (55% women, 35% unmarried, and 62% high school graduation or less) (Administration for Community Living, 2019), the present sample included slightly more women and unmarried individuals but had a comparable educational attainment. Years of residence in the United States and level of acculturation averaged 31.4 (SD = 12.1) and 12.2 (SD = 7.07), respectively. The mean score for the perceived knowledge about Alzheimer’s disease was 2.83 (SD = .98). With regard to health status, mean scores for chronic medical conditions, functional disabilities, and depressive symptoms were 1.57 (SD = 1.40), 1.67 (SD = 3.43), and 1.03 (SD = 1.54), respectively. About one-third (33.2%) had negative ratings on cognitive function. The mean score on the MMSE was 26.7 (SD = 2.91), and about 19% of the sample was in the category of cognitive impairment.

Table 1.

Descriptive Characteristics of the Overall Sample and Group Comparisons by Subjective Cognitive Ratings.

	Overall sample (N = 2046)	Positive cognitive ratings (n = 1367)	Negative cognitive ratings (n = 679)	t or (χ²)
	% or M ± SD	% or M ± SD	% or M ± SD	t or (χ²)
Age, years	73.2 ± 7.93	72.4 ± 7.84	75.0 ± 7.81	−7.14***
Gender
Female	66.8	63.6	73.0	(18.1***)
Male	33.2	36.4	27.0
Marital status
Not married	39.2	34.7	48.4	(35.5***)
Married	60.8	65.3	51.6
Education
≤high school graduation	60.2	51.9	76.8	(116.1***)
>high school graduation	39.8	48.1	23.2
Years in the United States	31.4 ± 12.1	32.4 ± 12.1	29.3 ± 11.8	5.45***
Acculturation	12.2 ± 7.07	13.8 ± 6.99	8.98 ± 6.03	15.2***
Knowledge about Alzheimer’s disease	2.83 ± .98	2.97 ± .96	2.54 ± .98	9.42***
Chronic medical conditions	1.57 ± 1.40	1.35 ± 1.32	2.02 ± 1.45	−10.4***
Functional disability	1.67 ± 3.43	1.15 ± 2.97	2.76 ± 4.02	−10.1***
Depressive symptoms	1.03 ± 1.54	.67 ± 1.24	1.77 ± 1.81	−15.8***
Subjective cognitive ratings
Positive rating (excellent/very good/good)	66.8	──	──	──
Negative rating (fair/poor)	33.2	──	──	──
Cognitive function (MMSE)	26.7 ± 2.91	27.2 ± 2.54	25.7 ± 3.33	11.2***
Normal cognition (>24)	81.5	86.8	70.8	77.0***
Cognitive impairment (≤24)	18.5	13.2	29.2

Note. MMSE: Mini-Mental State Examination. ***p < .001.

We also examined bivariate correlations among study variables (not shown in tabular format). All variables were correlated with in the expected directions. The highest correlation coefficient was between years in the United States and acculturation (r = .42, p < .001), and there was no concern about collinearity. The two dichotomized variables of subjective cognitive ratings and cognitive function were moderately associated with each other (r = .19, p < .001). Both negative ratings and cognitive impairment were commonly associated with older age, female gender, unmarried status, lower education, fewer years in the United States, lower levels of acculturation and perceived knowledge about Alzheimer’s disease, and greater levels of chronic medical conditions, functional disability, and depressive symptoms.

Table 1 also presents comparisons between those with positive cognitive ratings (n = 1367) and those with negative cognitive ratings (n = 679). The two groups were significantly different in all variables considered. The group with negative cognitive ratings was older, included more women and those who were unmarried, and had lower education, fewer years of residence in the United States, lower acculturation, poorer reported knowledge about Alzheimer’s disease, more physical health constraints, and more symptoms of depression than did the group with positive cognitive ratings. A significant group difference was also found in the objective measure of cognitive function. Over 13% of those with positive ratings fell in the category of cognitive impairment, and the corresponding figure in the group with negative ratings was 29.2%.

Subgroup Comparisons by Subjective Cognitive Ratings and Cognitive Function

Subsequently, comparative subgroup analyses by subjective cognitive ratings were conducted (Table 2). Two separate sets of comparisons were made; the first between the group with positive ratings and normal cognition (i.e., concordant group) and the group with positive ratings but cognitive impairment (i.e., discordant group); the second between the group with negative ratings and cognitive impairment (i.e., concordant group) and the group with negative ratings but normal cognition (i.e., discordant group). Within the group with positive ratings, those in the discordant group had more disadvantaged characteristics (e.g., advanced age, female gender, unmarried status, low education/acculturation/knowledge about Alzheimer’s disease, and poor physical health status). On the other hand, among those with negative ratings, membership in the discordant group was associated with younger age, male gender, married status, higher education, greater levels of acculturation, better knowledge about Alzheimer’s disease, and better physical health status.

Table 2.

Group Comparisons by Subjective Cognitive Ratings and Cognitive Function.

	Positive cognitive ratings (n = 1367)		t (χ²)	Negative cognitive ratings (n = 679)		t (χ²)
	Normal cognition: Concordance	Cognitive impairment: Discordance		Cognitive impairment: Concordance	Normal cognition: Discordance
	(n = 1187)	(n = 180)		(n = 198)	(n = 481)
	% or M ± SD			% or M ± SD
Age	71.4 ± 7.42	78.4 ± 7.89	−11.5***	78.4 ± 6.99	73.6 ± 7.69	7.65***
Male	33.7	27.2	(7.47**)	13.6	32.4	(25.1***)
Married	68.6	43.6	(42.9***)	34.7	58.5	(31.7***)
>high school graduation	52.4	19.1	(68.7***)	7.6	29.7	(38.4***)
Years in the United States	32.4 ± 12.1	32.1 ± 12.1	.35	28.2 ± 12.1	29.8 ± 11.7	−1.57
Acculturation	14.4 ± 6.81	10.2 ± 7.11	7.38***	6.80 ± 5.34	9.89 ± 6.07	−6.13***
Knowledge about Alzheimer’s disease	3.06 ± .89	2.38 ± 1.15	9.10***	2.29 ± 1.07	2.64 ± .92	−4.27***
Chronic medical conditions	1.29 ± 1.29	1.72 ± 1.43	−4.05***	2.37 ± 1.51	1.87 ± 1.40	4.16***
Functional disability	.90 ± 2.48	2.81 ± 4.84	−8.13***	4.45 ± 4.85	2.09 ± 3.42	6.98***
Depressive symptoms	.64 ± 1.21	.82 ± 1.48	−1.71	1.94 ± 1.88	1.70 ± 1.78	1.58

** p < .01. *** p < .001.

Logistic Regression Models of the Membership in the Discordant Groups

Table 3 presents separate regression models predicting membership in the two types of discordant groups. In the model of the discordant group membership among those with positive cognitive ratings (i.e., positive ratings but cognitive impairment), the odds were substantially increased by advancing age (odds ratio [OR] = 1.11, 95% confidence interval [CI] = 1.07–1.14) and reduced by education (OR = .35, 95% CI = .22–.56), acculturation (OR = .96, 95% CI = .92–.99), and knowledge about Alzheimer’s disease (OR = .72, 95% CI = .60–.87).

Table 3.

Logistic Regression Models of the Discordant Group Membership.

	Discordant group membership in those with positive cognitive ratings: Positive ratings but cognitive impairment		Discordant group membership in those with negative cognitive ratings: Negative ratings but normal cognition
	Odds ratio	95% confidence interval	Odds ratio	95% confidence interval
Age, years	1.11***	1.07–1.14	.93***	.91–.96
Male	.19	.47–1.15	2.44***	1.41–4.23
Married	.69	.45–1.04	1.35	.88–2.08
>high school graduation	.35***	.22–.56	2.55***	1.34–4.83
Years in the United States	1.01	.98–1.02	1.01	.99–1.04
Acculturation	.96*	.92–.99	1.02	.98–1.06
Knowledge about Alzheimer’s disease	.72**	.60–.87	1.28*	1.05–1.57
Chronic medical conditions	.97	.84–1.12	.97	.83–1.13
Functional disability	1.04	.98–1.09	.91**	.86–.97
Depressive symptoms	.89	.77–1.04	1.03	.92–1.15
Summary statistic	−2 log likelihood = 747.4		−2 log likelihood = 585.1
Summary statistic	χ²/df = 211.1***/10		χ²/df = 130.8***/10

*p < .05. ** p < .01. *** p < .001.

In the model with those with negative cognitive ratings, the odds of belonging to the discordant group (i.e., negative ratings but normal cognition) were reduced by 7% with a one-year increase in age and by 9% with a unit increase in functional disability. Higher odds were also associated with male gender (OR = 2.44, 95% CI = 1.41–4.23), education (OR = 2.55, 95% CI = 1.34–4.83), and knowledge about Alzheimer’s disease (OR = 1.28, 95% CI = 1.05–1.57).

Discussion

Responding to the dearth of information on cognitive health in older Asian Americans (Jang et al., 2020; Kim et al., 2015), we examined predictors of membership in the discordant groups in subjective and objective measures of cognitive function in a community-based sample of older Korean Americans. Our focus on discordance is based on its implications for early detection of cognitive impairment and timely initiation of care-seeking behaviors (CDC, 2019; Hurt et al., 2012; Jungwirth et al., 2004; Snitz et al., 2015) and the potentials to close a gap in racial/ethnic disparities in dementia diagnosis and care (Cooper et al., 2010; Kenning et al., 2017; Mukadam et al., 2013). Two types of discordance were considered: (1) positive cognitive ratings but cognitive impairment and (2) negative cognitive ratings but normal cognition. Based on the literature on health appraisals (e.g., Borawski et al., 1996; Ruthig et al., 2011; Solar & Irwin, 2010), we hypothesized that individuals with a lack of personal resources and adverse health conditions would have increased odds of belonging to these discordant groups, and our analyses provide partial support.

About one third (33.2%) of the sample reported that their overall cognitive health was either fair or poor, and about 19% of the sample fell into the category of cognitive impairment (MMSE ≤24). These rates are somewhat higher than those in national samples of community-dwelling older adults in the United States (Cutler, 2015; O’Shea et al., 2016). Confirming the heterogeneity in cognitive health appraisals, 13% of the group with positive ratings was cognitively impaired, and about 70% of the group with negative ratings had normal cognition. In line with the literature (e.g., Blazer et al., 1997; Crumley et al., 2014; Jackson et al., 2017; Zlatar et al., 2018), the correlation between subjective and objective measures of cognition was modest in the present sample.

The hypothesis that older individuals with a lack of personal and health resources would have cognitive performance discordant with subjective ratings (i.e., inaccurate or unrealistic self-evaluations) was supported among those with positive cognitive ratings. Its subgroup of those with cognitive impairment (i.e., discordant group), compared with the concordant group, had lower levels of personal and health resources (e.g., advanced age, female gender, unmarried status, low levels of education/acculturation/knowledge about Alzheimer’s disease, and physical health problems). In the multivariate model, the odds of belonging to this type of discordant group increased with advanced age and lower levels of education, acculturation, and knowledge of Alzheimer’s disease. These results support the hypothesis that disadvantages or vulnerabilities in personal resources would predispose older individuals to lack awareness of cognitive deficits and have falsely positive perceptions of their cognitive status. Our findings suggest that older immigrants with low education and acculturation are likely to unrecognize early signs of cognitive impairment and miss opportunities for timely interventions. The empowering role of knowledge about Alzheimer’s disease, which is new to the literature, suggests that improving public awareness and literacy for Alzheimer’s disease could raise awareness of cognitive health needs.

Our findings for those with negative cognitive ratings were, however, contrary to our hypothesis. The subgroup with normal cognition despite the negative self-evaluations (i.e., discordant group) was more likely to exhibit personal and health profiles indicative of resource advantages (e.g., younger age, male gender, married status, higher levels of education/acculturation/knowledge about Alzheimer’s disease, and better physical health). In the multivariate model, younger age, male gender, higher levels of education and acculturation, and fewer functional disabilities were found to be associated with the increased odds of belonging to the discordant group with negative ratings but normal cognition. We also conducted sensitivity analyses by dividing the discordant group with normal cognition into two groups based on their MMSE scores (25–27 vs. 28–30) and found that the latter group had more advantageous characteristics than the former. When the regression model predicting the discordant group membership was performed on each group, the group with higher MMSE scores demonstrated the significant effect of personal resources in a more pronounced manner. The overall findings confirmed our hypothesis that those with personal resources may be attuned to overall health issues and particularly sensitized to cognitive concerns. Such a heightened sensitivity may lead them to have overly negative self-evaluations of their cognitive status despite no signs of impairment. Our finding on gender is also in line with the literature demonstrating men’s high expectation for their own cognitive capacities and susceptibility to negative emotional responses to cognitive deterioration (e.g., CDC, 2019; Perrig-Chiello et al., 2000). As negative self-evaluations of one’s cognitive function may lead to unnecessary worry or fear about dementia (Werner et al., 2020), interventions are in need to help older adults engage in activities for cognitive health promotion and positive coping with changes in aging. It is also important to monitor the cognitive trajectories of those in this discordant group because they might present valid concerns about their subtle cognitive deterioration which might not have been detected by the screening measure.

Several limitations to this study should be noted. First, despite a concerted effort to build a sample that reflected our target group’s cultural and linguistic challenges, the study sample was not representative, and our findings may not be generalized to the older Korean American population overall. Also, this was a cross-sectional study with limited causal inferences. Longitudinal assessments would address changes in cognition over time and indicate causal directionalities between subjective and objective measures of cognition. Indeed the prognostic utility of our classification into discordant groups could be confirmed only with longitudinal follow-up. Although participants with severe cognitive impairment (MMSE <10) were excluded, the findings for the group with cognitive impairment should be interpreted carefully given the restricted sample size and score range, as well as concerns about response reliability. Future studies should incorporate other types of psychosocial and cultural resources (e.g., neuroticism, optimism, sense of control, social, and community capital). It is also recommended to employ not only a comprehensive battery of neuropsychological testing of cognitive function but also a multi-item scale of subjective cognitive rating with validated psychometric properties.

Despite these limitations, the present study offers new insight into the correspondence between subjective and objective measures of cognitive function in a group of older immigrants whose cognitive health has rarely been studied. The finding that limited personal resources are associated with less awareness of cognitive impairment sheds light on the importance of public education programs for cognitive health and well-being. Our finding also suggests tailoring such programs to meet the needs of those with low education and acculturation. Given that a fairly large proportion of the sample had negative cognitive ratings despite their intact cognitive function, it might be beneficial to address concerns and fears about cognitive deterioration in psychoeducational and behavioral interventions. Such programs could target stress management and development of realistic health perceptions. However, attention also needs to be paid to older individuals’ various coping strategies (e.g., avoidance, denial, compensation, and optimization) in response to cognitive changes. For example, positive evaluations of cognition seen in some of the cognitively impaired may in fact reflect an adaptive strategy designed to enhance psychological well-being. Understanding and addressing the pattern of discordance would contribute to early detection of cognitive impairment and maximized benefit from available treatments for older immigrants, closing the gap in cognitive health care.

Footnotes

Author Contributions

Y. Jang planned the study, performed statistical analyses, and wrote the article. E. Y. Choi and Y. Franco assisted with statistical analyses and contributed to writing the article. N. S. Park, D. A. Chiriboga, and M. T. Kim helped to plan the study and contributed to writing the article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by the National Institute on Aging (R01AG047106, PI: Yuri Jang, PhD).

ORCID iDs

Yuri Jang

Eun Young Choi

Yujin Franco

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