Despite advances in brain health, rates of Alzheimer’s Disease and Related Dementias (ADRD) continue to rise. ADRD is multi-faceted, with many causes. As with all public health issues, a health equity framework is essential to understanding the root causes. Building a complete understanding of ADRD and healthy aging allows us to develop informed policies, practices, and services that have the greatest impact on people’s lives. A recent Healthy Interactions Podcast touched on critical points about health disparities in ADRD that are worth exploring further. ADRD can be devastating, both for people who have it, as well as their loved ones and entire communities. Nearly 7 million Americans are currently living with Alzheimer’s Disease, and that number is expected to double by 2060. Over 11 million people provide unpaid care to people living with ADRD, underscoring the need for more support for loved ones and caregivers.
Weathering and the Aging Process
Around 16% of people aged 65 and older have mild cognitive impairment (MCI), and around one-third of them will develop dementia within 5 years. Often, there is a focus on diet, exercise, and lifestyle changes, also called “modifiable risk factors,” as ways to improve cognition and brain function. While these behaviors are important, there’s more to the story. All of these modifiable risk factors are connected to the social and political drivers of health. People who experience chronic stress, trauma, and poverty are more likely to develop MCI and later ADRD. Racism and other forms of structural and institutional systems of oppression play a major role in ADRD health inequities.
When we dig deeper, we find that trauma – from chronic stress, inflammation, air pollution, illness, especially from Covid-19 infections, poverty, and brain injury – plays a considerable role in the onset of ADRD. Trauma has significant impacts on the body and mind. Expanding our definition of modifiable risk factors to include community, structural, and institutional changes is important for improving the health and quality of life for everyone. Dementia risk factors such as hypertension, lack of physical activity, and chronically poor sleep are intertwined with marginalized identity and weathering. Researcher Dr. Arline T. Geronimous coined the concept of weathering to explain the premature biological aging of brain cells due to stress, trauma, and oppression. Chronic stress wears down the body and mind, causing accelerated biological aging and can increase the risk of ADRD.
Socioeconomic Status and Brain Health
Our experiences throughout our lifetime shape our health journey. Financial stability, for example, greatly improves health outcomes. On the other hand, financial stress and anxiety, can contribute to cognitive decline. Financial health is tied to financial wealth, and passed down through the generations. Memory decline is higher for people who experienced lower socioeconomic status (SES) in childhood. In fact, adults who experienced lower family SES as children are more likely to experience lower SES as adults. This is true even when compared to people with higher SES at greater genetic risk for dementia. Similarly, persistently low wages across one’s lifetime have also been linked to an increased risk of developing dementia. These effects are magnified for marginalized groups due to discrimination and economic exploitation.
Further, people experiencing homelessness are disproportionately more likely to also experience ADRD. Housing is a key driver of health. Our homes are the bedrock of life stability. And the undue stress from losing one’s home can quite literally age the brain. Financial status impacts nearly every area of life, from housing, education, and nutrition, to physical activity and air pollution exposure. Experiencing housing instability can lead to lower cognitive function. Foreclosure has been linked to faster memory decline and an increase in dementia in older adults. Like higher SES, higher educational attainment and literacy are strong protective factors against ADRD. Access to quality higher education has also been shown to protect against memory decline in aging. Additionally, lack of livable income impacts the quality of accessible food. On the positive side, quality nutrition can aid in reducing cognitive decline.
The Link Between Air Quality and Dementia
Low-income and racialized communities are more likely to live in areas with poorer air quality. Exposure to air pollution called particulate matter 2.5, especially from agriculture and wildfires, has been linked to higher cases of dementia. People who live in racially segregated communities are often more exposed to dangerous airborne toxic metals, as they are located close to highways, construction, and utility and energy companies. Decades of systemic discrimination and environmental racism disproportionately expose communities of color to dangerous pollutants. Inhalation of concentrated 2.5 PM over time increases inflammation in the brain, leading to cognitive decline. Inhalation of these chemicals increases the inflammatory response in the brain, increasing the risk of ADRD.
What Can We Do to Collectively Support Brain Health?
The social drivers of brain health call on us to improve conditions and policies. One robust initiative that addresses brain health holistically is the Healthy Brain Initiative Road Map for American Indian and Alaska Native Peoples. This culturally-tailored and community-led resource is guided by the social and Indigenous determinants of health impacting AI/AN peoples. This strengths-based framework highlights intergenerational holistic health, Indigenous ways of knowing, cultural connectedness, and cultural sense of belonging and identity. The importance of being in community and strengthening connections to the earth are other focus areas in this resource.
Below are some additional ways that public health and healthcare professionals can reduce the community risk of ADRD and improve the social and environmental conditions that contribute to ADRD:
- Improve access to quality, affordable, and culturally responsive healthcare.
- Ensure that brain health is addressed in clinics in under-resourced areas.
- Integrate Community Health Workers into healthy aging programs and services.
- Promote intergenerational, culturally-specific programs and activities to prevent cognitive decline. These programs also promote social connectedness, feelings of belonging and purpose, and a sense of community.
- Support brain health initiatives that center the arts as healing, such as NeuroArts.
- Invest in public education and increase opportunities for college education, which protects against cognitive decline and dementia.
- When developing public health policies, focus on improving neighborhood resources. These include access to affordable housing, nourishing food, safety, health care, and clean outdoor spaces.
- Create social policies that enhance the financial well-being of low-wage workers, including increasing the minimum wage.
- Advocate for environmental cleanups and policy changes or regulations to limit or ban carbon emissions and other toxic pollutants in neighborhoods.
Together, we can prevent or slow the onset of ADRD for more people, and better support those living with ADRD and their loved ones and caregivers.
