Abstract
Social determinants of health are the conditions in which people are born, work, live, and age and the wider set of forces and systems that shape the conditions of daily life. They affect every area of life, particularly health and health care. There is increasing focus on modifiable factors that affect cognition and risk of Alzheimer disease and related dementias (ADRDs). This article examines the impact of various social determinants of health, which are potentially reversible, on the incidence, prevalence, and risk of ADRDs and cognition. Various social determinants of health affect cognition and risk of ADRDs. Lower socioeconomic status (SES) and less education are associated with a higher incidence of ADRDs, whereas higher SES and education level appear to be protective, leading to a deceleration of time to diagnosis. In terms of employment, manual labor is associated with a higher risk of ADRDs. Higher body mass index in midlife and a decreasing body mass index in old age are associated with a higher risk of ADRDs. Furthermore, lower food security in early and late life is associated with a higher risk of ADRD diagnosis. Neighborhoods that are economically disadvantaged with fewer physical resources are associated with a higher risk of ADRDs. Higher levels of social engagement have a protective effect on diagnosis of ADRDs. Higher levels of stress are associated with a higher likelihood of developing ADRDs. Early-life adversity is associated with an increased risk of ADRDs, and further work in this area will be illuminating. Racial discrimination also leads to higher risk of ADRDs through the direct effect of discrimination and indirectly through lower SES, educational level, employment, and residential segregation. With an aim of reducing of ADRDs, future work in enhancing education, improving socioeconomic conditions, work, and neighborhood environments, and eliminating racial discrimination could potentially have a drastic impact.
Key words
Introduction
Alzheimer disease and related dementias (ADRDs) refer to the cumulative of most common forms of neurodegenerative illnesses that present with dementia and cognitive impairment. Illnesses included under this umbrella term include Alzheimer disease, frontotemporal lobar degeneration, dementia with Lewy bodies, vascular dementia, and multifactorial dementias.
1
The prevalence of ADRDs is estimated to be 5 million adults older than 65 years in the United States, and these numbers are set to increase to an estimated 13 million in 2060.NINDS. Focus on alzheimer's disease and related dementias. 2020; Available from: https://www.ninds.nih.gov/Current-Research/Focus-Disorders/Alzheimers-Related-Dementias.
2
With these rapidly increasing numbers, there has been a significant focus on the modifiable factors that may cause or affect the prevalence of ADRDs.Social determinants of health (SDHs) are defined by the World Health Organization as “conditions in which people are born, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”
3
These determinants are the nonmedical factors that affect and influence health outcomes. These factors include forces and systems such as political structures, socioeconomic constructs, and cultural norms. The Healthy Population initiative by the US Department of Health and Human Services conceptualized SDHs to have 5 main categories: economic stability, education, social and community context, health and health care, and neighborhood and built environment.WHO. Social determinants of health. 2011; Available from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.
4
The aim of formulating the concept of SDHs was to create a standardized framework of assessing the various social dimensions that affect the health outcomes for all the different populations.U.S. Department of health and human services, o.o.d.p.a.h.p. Healthy people 2030. 2020; Available from: https://health.gov/healthypeople/objectives-and-data/social-determinants-health.
There is a considerable body of literature on the effect of SDHs. SDHs have been conceptualized as being upstream or downstream in nature. Downstream SDHs are factors that are temporally close to health effects and include health care, health-related attitudes, beliefs, and behaviors.
5
Upstream SDHs are the fundamental factors that set causal pathways in motion, leading to downstream health effects. These factors include educational level, early-life stress, intergenerational transfer of advantage and health, employment situation, as well as neighborhood conditions.5
The categorization based on immediate and distant causality leads to a broader understanding of SDHs and their effect on health. This understanding then can lead to interventions at various levels to address the upstream and downstream SDHs.SDHs and ADRDs
In this general overview, we summarize the evidence on the effect of individual SDHs on the incidence, prevalence, and risk of ADRD. For this review, studies that addressed cognitive function and rate of cognitive decline in response to various SDHs were also included. The SDH categories included here are economic stability, educational level, social and community context, health and health care, and neighborhood and built environment. A deeper understanding of SDHs in relation to cognition and ADRD risk is vital because these are potentially modifiable factors at systemic, community, and individual levels.
The relationships among various SDHs and their effect on health outcomes are complex and highly interlinked.
5
Educational attainment, for example, affects health outcomes through multiple pathways. It can lead to varying levels of health-related behaviors; affect employment, working conditions, income, social standing, and social support; and cause stress. All these various pathways affect health outcomes. Hence, the ultimate effect on health outcomes of each factor is nuanced and complex. A full discussion of the causality and relationships is beyond this overview. However, the overall principles of interlinkage of SDHs also apply to the study of the effect of all individual SDHs on ADRD diagnosis.Economic Stability
Socioeconomic Status
Socioeconomic status (SES) is an SDH with a significant effect on ADRDs, with lower levels of wealth and SES being associated with a higher incidence of ADRD. Cadar et al
6
determined that the incidence of dementia was 1.68 times higher for those in the lowest quintile of wealth compared with those in the highest quintile.6
In addition, lower SES is associated with an accelerated cognitive decline. Ajnakina et al7
found that intermediate and low levels of wealth were associated with an accelerated time to dementia diagnosis by 12 and 18 months, respectively. In a cross-sectional study in the United States, a clear relationship was observed between annual household income and subjective cognitive decline. Those with a higher annual income had considerably lower odds of subjective cognitive decline than those with an income >$10,000.8
Analysis of one longitudinal cohort study estimated the effect of SES during childhood and early and later adulthood. The study found that stable, high SES is associated with a better memory function at baseline and slower decline compared with low SES at all 3 points in life.9
Hence, lower SES (as measured by household income) is associated with a higher incidence of ADRD, whereas higher SES appears to be protective and leads to a deceleration of time to diagnosis.Employment
Employment as an SDH seems to modify ADRD risk through the type of work. The literature suggests an association between less intellectually intensive employment and higher risk and incidence of ADRD. A systematic review in 2016 by Gracia Rebled et al
10
reported on longitudinal studies and concluded that individuals with manual occupations have a higher risk of developing cognitive impairment than others who had occupations with more intellectual workload. One longitudinal cohort study11
from the United Kingdom found that increasing complexity of employment in midlife was modestly, but independently, associated with better cognitive functioning in later life. A retrospective case-control study12
from Japan found that the odds of dementia were higher for those with a history of so-called blue-collar jobs than for white-collar jobs. Multiple studies have replicated this association with primary lifetime occupation, suggesting that occupations that require manual labor may be associated with worse cognitive performance, whereas more complex occupations with higher intellectual demands are associated with a lower risk of dementia.13
A twin case-control study found that having a job with higher requirements of reasoning, mathematics, and language was associated with lower dementia risk.14
Food Insecurity
Food insecurity, defined generally as limited access to food because of a lack of resources,
15
affects cognitive function across the lifespan. In a systematic review, Na et al15
found that early-life food insecurity doubled the odds of dementia. A longitudinal study16
found baseline food insecurity to be associated with a 2-year decline in cognitive functioning, with worse food security leading to accelerated decline in cognitive function.Education
Educational level affects ADRDs in various studies and settings. The most consistent findings are an association between low educational level and higher risk of ADRDs and lower baseline cognitive scores. A systematic review by Sharp et al
17
found that, of the 88 studies included, 51 studies (58%) reported a significant effect of lower educational level on risk of dementia. The greatest risk of dementia was found in those with the lowest levels of education.17
Many studies have also found a protective effect of higher educational levels. The Chicago Health and Aging Project (CHAP), a longitudinal, population-based study, found that more years of formal education were associated with a higher baseline global cognitive score as well as a lower risk of Alzheimer disease (AD).18
Studies also suggest that education may be protective against cognitive decline. The Analysis of the Health and Retirement Study found that higher educational level decreases the probability of cognitive impairment, with highly educated individuals living up to 1.6 to 1.9 years less with cognitive impairment compared with less well-educated peers.19
The literature indicates a clear association between lower educational level, quantified in number of years, with higher risk of ADRDs, whereas more education is associated with higher baseline cognitive functions and a deceleration to the time of ADRD diagnosis.Health and Health Care
Body Mass Index
The relationship between weight and ADRDs is complex, with evidence of associations with low or high body mass index (BMI) in different stages of life. Midlife obesity, defined as a BMI of >30 kg/m2, has been found in several large meta-analyses to be associated with increased risk of developing dementia.
20
,21
However, the relationship between ADRD risk and BMI changes in late life. In a longitudinal cohort of older clergy (>70 years of age), a decrease of one unit in BMI was associated with a 35% increase in the risk of AD compared with persons with no change in BMI.22
Other studies also reported similar findings with additional reports of faster rate of cognitive decline in those with decreasing BMI.23
,24
Stress
Stress is an important SDH and is postulated to affect health via its affects on the hypothalamus-pituitary-adrenal axis as well as via inflammation.
5
Knowledge about the impact of stress, particularly through the impact of glucocorticoids on the hippocampus and frontal lobes,25
has led to interest in interventions aimed at addressing the overall long-term physical effects of stress on the body.26
The effect of stress on ADRD diagnosis has been studied, with higher stress levels correlated with poor baseline cognition and higher ADRD risk. In a 6-year longitudinal cohort study, higher levels of perceived stress were related to a lower baseline cognitive score as well as a faster rate of cognitive decline.27
A longitudinal cohort study in the African American population found that higher perceived stress is associated with a faster rate of cognitive decline.28
Neighborhood and Built Environment
ADRDs are also affected by a neighborhood's environmental quality and local resources, which are often studied by measuring the socioeconomic status of the neighborhood demographics. A systematic review by Wu et al
29
found that most studies had associations between local deprivation and poor cognitive function, cognitive decline, and higher risk of cognitive impairment. Local deprivation was measured by community SES and deprivation indexes. In a retrospective cohort study based in Hong Kong,30
neighborhood economic disadvantage was associated with cognitive decline. The association between economically disadvantaged neighborhood and cognitive decline was also seen in a systematic review by Besser et al.31
Clarke et al32
investigated the effect of neighborhood environment, stratified by the presence of community centers, vicinity to public transport, and neighborhood walkability, as well as quality of public spaces. The presence of neighborhood resources was associated with a slower rate of cognitive decline.32
A longitudinal study33
over four years in China found that older adults living in neighborhoods with better social and physical resources had better cognitive function and slower rate of cognitive decline.The environmental attributes of neighborhoods, such as air quality, may also affect ADRD. In a retrospective cohort study
34
in the United Kingdom, higher levels of residential exposure to air pollutants, such as nitrogen dioxide and particulate matter, were associated with a higher risk of dementia. In a systematic review,35
13 studies from various parts of the world confirmed findings of a higher risk of dementia in settings of higher air pollution.Social and Community Context
Social Engagement
Low levels of social engagement (social exclusion or isolation) have also been viewed as an important SDH that affects cognition. One narrative review
36
found an overall association between social isolation and poor cognitive function in a range of studies. There are extensive data on social engagement that point to a protective effect of higher levels of middle- and late-life social engagement, reducing the risk of ADRD diagnosis in later life.37
In a longitudinal, population-based, cohort study,38
increased levels of social engagement, as measured by social activity and support, were associated with improved cognitive functions at baseline. A retrospective analysis also found that higher numbers of social networks and levels of social engagement were associated with better baseline cognitive function. Furthermore, longitudinally, high numbers of social networks and higher social engagement reduced the rate of subsequent cognitive decline by 39% and 91%, respectively.39
These findings were also supported by subsequent meta-analyses.40
,41
Early-Life Adversity
Early-life adversity is another SDH that may have relevance for ADRD. Analysis from CHAP found that early-childhood adversity was associated with poorer baseline cognitive performance in African American participants. This difference was not mediated by years of education.
42
A cross-sectional study from Australia used the Childhood Trauma Questionnaire (CTQ) to assess for early-life adversity in the Aboriginal Australian population. The authors found that higher CTQ scores were associated with a higher risk of AD in later life. This association remained even when depression and anxiety as well as posttraumatic stress disorder were controlled for in their analysis.43
Racial Discrimination
Discrimination has been conceptualized as a significant SDH.
3
Discrimination is defined as the differential treatment of a group or individual, which is unfair or unjustified, on the basis of differences (race, ethnicity, sex, sexuality) that lead to disadvantages or harm to the group or individual.WHO. Social determinants of health. 2011; Available from: https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1.
44
,Services, U.S.D.o.H.a.H. Healthy people 2020-discrimination. 2020 [cited 2021; Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination.
45
In addition to differential treatment, discrimination also includes a disparate effect, wherein rules or procedures lead to some groups or individuals being favored over others.46
It is well known that minority ethnic populations, including African American and Hispanic populations, have a higher incidence and prevalence of dementia compared with their white counterparts.2
,47
,48
Minority ethnic populations have also been shown to present with greater levels of cognitive impairment and have a faster decline in cognition.49
,50
Given the considerable racial disparities, we focus on the effect of racial discrimination on ADRDs. The effect of racial discrimination can be viewed at 2 different levels: macro (structural racism or discrimination) and individual. Residential segregation and inequitable distribution of health care and education are all examples of structural discrimination.44
,Services, U.S.D.o.H.a.H. Healthy people 2020-discrimination. 2020 [cited 2021; Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination.
51
Individuals also face discrimination, which has been studied by the effect of perceived racial discrimination.Perception of discrimination itself seems to affect cognitive function, which may affect the risk of dementia. Data on the effect of perceived discrimination on ADRD risk are limited, and most available data address cognitive function. A first of its kind cross-sectional study by Barnes et al
52
found that perceived discrimination was associated with poor global cognitive function. A retrospective analysis of the Health and Retirement Study cohort found that non-Hispanic Black people had the highest perceived discrimination, followed by Hispanic people. Non-Hispanic Black people had worse memory at initial presentation, via impact of depressive symptoms and loss of external locus of control on memory. They also had a faster rate of cognitive decline, which appeared to be due to perceived discrimmination.53
Another prospective cohort study54
of African American women found that the experiences of both individual and institutional racism were associated with worse subjective cognitive function. Racial discrimination is generally associated with poor mental and physical health, which themselves appear to increase the risk of dementia.55
Structural racial discrimination acts through various SDHs, such as educational level, SES, employment, and neighborhood status, and can affect cognition and risk of ADRDs. Educational attainment has racial differences: only 22% of Latino adults (≥25 years of age) had an associate's degree or higher compared with non-Hispanic white adults (46%) and black adults (31%) according to the US Census Bureau.
56
Generally, Black study participants have fewer years of formal education compared with their White counterparts.Santiago DA, C.-G.E., Taylos M. The condition of latinos in education: 2015 factbook. 2015 [cited 2020; Available from: https://www.nccpsafety.org/assets/files/library/The_Condition_of_Latinos_in_Education.pdf.
18
,57
In a longitudinal study, African Americans with high educational levels had almost twice higher risk of dementia than White people with high educational levels. In addition, the risk of highly educated Black individuals was the same as that of White individuals with low educational levels.58
The decreased protective effect of higher educational level in the African American population may be attributable to poorer quality of education, as found in a longitudinal cohort study57
in which accounting for early-life educational quality moderated the racial disparity in cognitive function.Racial differences in SES also affect ADRD diagnosis. The distribution of annual household median incomes by race is variable: non-Latino White people earn $62,950, Black people earn $36,898, and Hispanic people earn $45,148.
59
One longitudinal study60
found significant racial differences in rates of dementia development. However, once socioeconomic differences were accounted for, the differences became insignificant. Another prospective cohort study61
found that a higher level of SES across the lifespan was associated with lower risk of dementia, with the effect being more pronounced for African American populations than for non-Hispanic White populations. This positive impact was also shown in another cohort study from Baltimore.62
Racial discrimination in employment has also been studied. Data indicate that African American males spend more time in search of employment, gain less work experience, and have less stable employment compared with their white counterparts.63
Furthermore, African American men and women are paid less than their White counterparts.64
Closely related to SES and employment is the concept of intergenerational drag, which refers to the passing of social assets and liabilities to descendants. Hence, the effects of educational attainment and wealth of one generation can affect the SES of the next generation, leading to the perpetuation of existing disparities.65
Racial residential segregation, defined as “the occupancy of different neighborhood environments by race,”
51
is an important manifestation of systemic discrimination that affects overall health. Previous discussion indicates that neighborhood status can affect the risk and diagnosis of ADRDs. Residential segregation was instituted in the early 20th century by policies such as discriminatory zoning, mortgage discrimination, red-lining, and restrictive covenants.51
,66
Although recently decreasing in some areas, the levels of residential segregation among minority populations, particularly for African American populations in the United States, remain high.67
Residential segregation frequently leads to underresourced neighborhoods, substandard educational opportunities, and decreased socioeconomic mobility.51
,68
The deleterious effect of residential segregation has been quantified in many studies using the Area Deprivation Index to measure the neighborhood's socioeconomic disadvantage.- Williams D.R.
- Mohammed S.A.
Racism and Health I: Pathways and Scientific Evidence.
The American behavioral scientist. 2013; 57https://doi.org/10.1177/0002764213487340
67
For example, a cross-sectional imaging study, using a mediation analysis, found that the Area Deprivation Index accounted for almost all the higher risk of AD found in African American participants.69
Discussion
The aim of this overview was to outline the effect of various SDHs on cognition and ADRDs, with a goal of ultimately highlighting areas for future work, innovation, and intervention. We found that various categories of SDHs affect cognitive function and risk of ADRDs. With the evidence of the significant effect of SDHs, policies and programs should be initiated and tailored to address the various disparities that lead to a higher risk of ADRDs. Focusing on education and providing good quality education early in life could potentially lead to a decrease in the risk of ADRDs in later life. Ensuring food security programs while addressing the obesity epidemic would have important downstream effects on ADRDs. Similarly, addressing neighborhood conditions and providing social and intellectual engagement programs from middle life onwards may prove to be protective against ADRDs. Socioeconomic inequality, possibly the most important factor tying together all the various SDHs, must take center stage. On a policy level, a more equitable distribution of wealth and resources would have a considerable direct and downstream effect on ADRDs. Structural racial discrimination needs to be addressed by legal mandates that expand early-life education, neighborhood resources, and access to employment opportunities in underprivileged areas with significant minority ethnic populations. More minority ethnic individuals need to be involved in future research as well.
This overview attempts to present an up-to-date review of some SDHs and their effect on cognition and ADRDs. Although the commentary may be limited by choice of search terms for literature review and author bias, these issues may be addressed by future systematic reviews on the topic. There is also an overall dearth of data that involve some SDHs and ADRDs, such as early-life adversity. Furthermore, most of the studies included data on individual SDHs without extensive investigation into other, potentially confounding SDHs. The list of SDHs is exhaustive, and only some of the major and most pertinent factors have been highlighted in this review. Although there is evidence linked to individual SDHs, no SDH can be fully studied in isolation. The interactions between the various SDHs are dynamic and complex, requiring further research.
Acknowledgments
Primary literature review was performed by Dr Muniza Majoka with significant contributions to writing review by Dr Corbett Schimming.
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Article info
Publication history
Published online: June 05, 2021
Accepted:
May 14,
2021
Identification
Copyright
© 2021 Elsevier Inc.
