The structural and social determinants of Alzheimer's disease related dementias

doi:10.1002/alz.13027

Review

. 2023 Jul;19(7):3171-3185.

doi: 10.1002/alz.13027. Epub 2023 Apr 19.

The structural and social determinants of Alzheimer's disease related dementias

Paris B Adkins-Jackson¹, Kristen M George², Lilah M Besser³, Jinshil Hyun⁴, Melissa Lamar⁵, Tanisha G Hill-Jarrett⁶, Omonigho M Bubu⁷, Jason D Flatt⁸, Patricia C Heyn⁹, Ethan C Cicero¹⁰, A Zarina Kraal¹¹, Preeti Pushpalata Zanwar^{12

13}, Rachel Peterson¹⁴, Boeun Kim¹⁵, Robert W Turner 2nd¹⁶, Jaya Viswanathan¹⁷, Erin R Kulick¹⁸, Megan Zuelsdorff¹⁹, Shana D Stites²⁰, Miguel Arce Rentería²¹, Elena Tsoy²², Dominika Seblova²³, Ted K S Ng^{24

25}, Jennifer J Manly¹¹, Ganesh Babulal^{26

27

28

29}

Affiliations

¹ Departments of Epidemiology & Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA.
² Department of Public Health Sciences, University of California, Davis School of Medicine, Davis, California, USA.
³ Comprehensive Center for Brain Health, University of Miami Miller School of Medicine, Miami, Florida, USA.
⁴ The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, New York, USA.
⁵ Rush Alzheimer's Disease Center and the Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA.
⁶ Department of Neurology, Memory and Aging Center, University of California, San Francisco, California, USA.
⁷ Departments of Psychiatry, Population Health & Neurology, New York University Grossman School of Medicine, New York, New York, USA.
⁸ Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas, Nevada, USA.
⁹ Center for Optimal Aging, Marymount University, Arlington, Virginia, USA.
¹⁰ Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.
¹¹ Department of Neurology, Columbia University, New York, New York, USA.
¹² Applied Health Economics & Outcomes Research & Health Policy, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹³ NIA Funded Network on Life Course and Health Dynamics and Disparities, University of Southern California, Los Angeles, California, USA.
¹⁴ School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA.
¹⁵ School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.
¹⁶ Clinical Research & Leadership, Neurology, The George Washington University, Washington, D.C., USA.
¹⁷ Bethesda, Maryland, USA.
¹⁸ MPH Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania, USA.
¹⁹ School of Nursing, Alzheimer's Disease Research Center, and School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
²⁰ MA Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²¹ Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York, USA.
²² Department of Neurology, Memory and Aging Center, University of California San Francisco, Global Brain Health Institute, University of California San Francisco and Trinity College Dublin, San Francisco, California, USA.
²³ Second Faculty of Medicine, Charles University, Prague, Czech Republic.
²⁴ Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA.
²⁵ Center for Innovation in Healthy and Resilient Aging, Arizona State University, Phoenix, Arizona, USA.
²⁶ Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA.
²⁷ Institute of Public Health, Washington University in St. Louis, St. Louis, Missouri, USA.
²⁸ Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., USA.
²⁹ Department of Psychology, Faculty of Humanities, University of Johannesburg, South Africa.

PMID: 37074203
PMCID: PMC10599200
DOI: 10.1002/alz.13027

Review

The structural and social determinants of Alzheimer's disease related dementias

Paris B Adkins-Jackson et al. Alzheimers Dement. 2023 Jul.

. 2023 Jul;19(7):3171-3185.

doi: 10.1002/alz.13027. Epub 2023 Apr 19.

Authors

Affiliations

¹ Departments of Epidemiology & Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA.
² Department of Public Health Sciences, University of California, Davis School of Medicine, Davis, California, USA.
³ Comprehensive Center for Brain Health, University of Miami Miller School of Medicine, Miami, Florida, USA.
⁴ The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, New York, USA.
⁵ Rush Alzheimer's Disease Center and the Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA.
⁶ Department of Neurology, Memory and Aging Center, University of California, San Francisco, California, USA.
⁷ Departments of Psychiatry, Population Health & Neurology, New York University Grossman School of Medicine, New York, New York, USA.
⁸ Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas, Nevada, USA.
⁹ Center for Optimal Aging, Marymount University, Arlington, Virginia, USA.
¹⁰ Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.
¹¹ Department of Neurology, Columbia University, New York, New York, USA.
¹² Applied Health Economics & Outcomes Research & Health Policy, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
¹³ NIA Funded Network on Life Course and Health Dynamics and Disparities, University of Southern California, Los Angeles, California, USA.
¹⁴ School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA.
¹⁵ School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.
¹⁶ Clinical Research & Leadership, Neurology, The George Washington University, Washington, D.C., USA.
¹⁷ Bethesda, Maryland, USA.
¹⁸ MPH Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania, USA.
¹⁹ School of Nursing, Alzheimer's Disease Research Center, and School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
²⁰ MA Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
²¹ Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York, USA.
²² Department of Neurology, Memory and Aging Center, University of California San Francisco, Global Brain Health Institute, University of California San Francisco and Trinity College Dublin, San Francisco, California, USA.
²³ Second Faculty of Medicine, Charles University, Prague, Czech Republic.
²⁴ Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA.
²⁵ Center for Innovation in Healthy and Resilient Aging, Arizona State University, Phoenix, Arizona, USA.
²⁶ Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA.
²⁷ Institute of Public Health, Washington University in St. Louis, St. Louis, Missouri, USA.
²⁸ Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., USA.
²⁹ Department of Psychology, Faculty of Humanities, University of Johannesburg, South Africa.

PMID: 37074203
PMCID: PMC10599200
DOI: 10.1002/alz.13027

Abstract

Introduction: The projected growth of Alzheimer's disease (AD) and AD-related dementia (ADRD) cases by midcentury has expanded the research field and impelled new lines of inquiry into structural and social determinants of health (S/SDOH) as fundamental drivers of disparities in AD/ADRD.

Methods: In this review, we employ Bronfenbrenner's ecological systems theory as a framework to posit how S/SDOH impact AD/ADRD risk and outcomes.

Results: Bronfenbrenner defined the "macrosystem" as the realm of power (structural) systems that drive S/SDOH and that are the root cause of health disparities. These root causes have been discussed little to date in relation to AD/ADRD, and thus, macrosystem influences, such as racism, classism, sexism, and homophobia, are the emphasis in this paper.

Discussion: Under Bronfenbrenner's macrosystem framework, we highlight key quantitative and qualitative studies linking S/SDOH with AD/ADRD, identify scientific gaps in the literature, and propose guidance for future research.

Highlights: Ecological systems theory links structural/social determinants to AD/ADRD. Structural/social determinants accrue and interact over the life course to impact AD/ADRD. Macrosystem is made up of societal norms, beliefs, values, and practices (e.g., laws). Most macro-level determinants have been understudied in the AD/ADRD literature.

Keywords: ADRD; Alzheimer's disease; Ecological Systems Theory; classism; dementia; genderism; macrosystem; racism; sexism; social determinants of health; structural determinants.

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Conflict of interest statement

Conflicts

The authors have no conflicts to report.

Figures

**Figure 1.**
The relationships among systems within Bronfenbrenner’s Ecological System Theory.

See this image and copyright information in PMC

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References

1. Rajan KB, Weuve J, Barnes LL, McAninch EA, Wilson RS, Evans DA. Population estimate of people with clinical Alzheimer’s disease and mild cognitive impairment in the United States (2020–2060). Alzheimers Dement. 2021 Dec;17(12):1966–1975. doi: 10.1002/alz.12362. - DOI - PMC - PubMed
1. Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2022; 367–429.
1. Gómez CA, Kleinman DV, Pronk N, et al. Addressing Health Equity and Social Determinants of Health Through Healthy People 2030. J Public Health Manag Pract. 2021;27(Suppl 6):S249–S257. doi:10.1097/PHH.0000000000001297 - DOI - PMC - PubMed
1. Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. J Womens Health (Larchmt). 2021;30(2):230–235. doi:10.1089/jwh.2020.8882 - DOI - PMC - PubMed
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[1] Rajan KB, Weuve J, Barnes LL, McAninch EA, Wilson RS, Evans DA. Population estimate of people with clinical Alzheimer’s disease and mild cognitive impairment in the United States (2020–2060). Alzheimers Dement. 2021 Dec;17(12):1966–1975. doi: 10.1002/alz.12362. - DOI - PMC - PubMed

[2] Rajan KB, Weuve J, Barnes LL, McAninch EA, Wilson RS, Evans DA. Population estimate of people with clinical Alzheimer’s disease and mild cognitive impairment in the United States (2020–2060). Alzheimers Dement. 2021 Dec;17(12):1966–1975. doi: 10.1002/alz.12362. - DOI - PMC - PubMed

[3] Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2022; 367–429.

[4] Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2022; 367–429.

[5] Gómez CA, Kleinman DV, Pronk N, et al. Addressing Health Equity and Social Determinants of Health Through Healthy People 2030. J Public Health Manag Pract. 2021;27(Suppl 6):S249–S257. doi:10.1097/PHH.0000000000001297 - DOI - PMC - PubMed

[6] Gómez CA, Kleinman DV, Pronk N, et al. Addressing Health Equity and Social Determinants of Health Through Healthy People 2030. J Public Health Manag Pract. 2021;27(Suppl 6):S249–S257. doi:10.1097/PHH.0000000000001297 - DOI - PMC - PubMed

[7] Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. J Womens Health (Larchmt). 2021;30(2):230–235. doi:10.1089/jwh.2020.8882 - DOI - PMC - PubMed

[8] Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. J Womens Health (Larchmt). 2021;30(2):230–235. doi:10.1089/jwh.2020.8882 - DOI - PMC - PubMed

[9] Committee on Educating Health Professionals to Address the Social Determinants of Health; Board on Global Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine. A Framework for Educating Health Professionals to Address the Social Determinants of Health. Washington (DC): National Academies Press (US); 2016. Oct 14. 3, Frameworks for Addressing the Social Determinants of Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK395979/. Accessed January 29, 2023. - PubMed

[10] Committee on Educating Health Professionals to Address the Social Determinants of Health; Board on Global Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine. A Framework for Educating Health Professionals to Address the Social Determinants of Health. Washington (DC): National Academies Press (US); 2016. Oct 14. 3, Frameworks for Addressing the Social Determinants of Health. Available from: https://www.ncbi.nlm.nih.gov/books/NBK395979/. Accessed January 29, 2023. - PubMed

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The structural and social determinants of Alzheimer's disease related dementias

Affiliations

The structural and social determinants of Alzheimer's disease related dementias

Authors

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Abstract

Conflict of interest statement

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