This is the brain on health disparities: Their role in dementia

Emily Willingham

About Emily Willingham

Emily Willingham (@ejwillingham) is AHCJ's core topic leader on the social determinants of health. She is a science journalist whose work has appeared in the Washington Post, San Francisco Chronicle, Wall Street Journal, Scientific American, and Forbes, among others, and co-author of "The Informed Parent: A Science-Based Guide to Your Child's First Four Years."

Photo: NIH Image Gallery via Flickr

In a recent commentary in JAMA Neurology, Elisa de Paula França Resende, M.D., of the University of California, San Francisco, and colleagues write about how social determinants of health affect demographic patterns of dementia in the United States. Noting that with an aging population, the prevalence of dementia will increase substantially, Resende and her co-authors write that of the social determinants affecting dementia risk, health and socioeconomics act more strongly than do race or cultural identifiers. I will add here that being female also is involved in dementia risk, as women are at greater risk for it than men.

Some factors that feed into dementia are ones that people can change — if they have the wherewithal to do so. For example, a “quality education” is a factor in dementia that Resende and colleagues cite, but of course accessing a quality education depends on a host of other social factors. Low educational attainment, for example, is linked to an 8-year earlier onset of dementia. Other equally complex “modifiable” factors include a healthy diet and hypertension treatment, which are, again, highly dependent on social determinants of access and quality.

Resende and her co-authors say that where incomes are lower, dementia is more common and its onset is a decade earlier compared to high-income populations. The throughline factors involved include less access to formal education and leisure time, higher stress, and poor nutrition and living conditions. That association of low educational attainment and dementia may find its advancing footholds in other conditions, such as diabetes. Brains that don’t gain access to quality education and enjoyable mental challenge in early life are at a greater risk for later markers of compromise and even have smaller volume in some areas. Finally, living in poverty and having limited education access bridges the obesity-dementia link.

Even factors that some in wealthier conditions take for granted, such as access to protective helmets can make or break dementia risk. A history of head trauma is linked to increased risk, write Resende and colleagues, but where money is short, protective headgear isn’t easily acquired.

Although these authors say that race and ethnicity are less powerful factors than socioeconomic status in dementia risk, they elaborate on that by noting the association between socioeconomic status and race or ethnicity. In the United States, black people have higher rates of dementia and faster cognitive decline compared with people from other ethnic or ancestral backgrounds. Resende and colleagues say that when findings are corrected for socioeconomic status, race no longer remains influential. In other words, there is nothing intrinsic about being black that leads to dementia. It’s about money and access.

After making these observations, these authors go on to offer some steps to address the inequities that leave some people more vulnerable to dementia than others. They call for more research into prevention and for policies to address socioeconomic and health inequalities. In the meantime, journalists have plenty of narrative threads to pursue.

Some areas that might be worth pursuing:

  • Biomarkers research: Resende and her colleagues note that often the emphasis is on the costs of biomarker research, which they say is overstated, and that underlining costs “fortifies inequity and propagates stigma.” Stories aren’t just about what researchers are trying to find, but where the funding is going and where it isn’t, and why.
  • Researchers of dementia: The commentary also describes one initiative, the Global Brain Health Institute, in which the authors participate. The initiative’s goal is in part to include researchers from diverse backgrounds. Stories are to be had that look at the intersection of what a researcher brings to the bench for dementia research and how that can inform their work.
  • Investigations and data visualizations of dementia prevalences relative to per capita socioeconomic factors, demographics, geographic proximity to centers of research, and other determinants.
  • The protective headgear aspect, which is underreported in this context and can tie into how access to tools and equipment that some may tend to take for granted will be available.

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