Identifying and Addressing Social Determinants of Health to Reduce the National Burden of and Inequities in Dementia

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PROJECT SUMMARY/ABSTRACT Alzheimer’s disease and related dementias (ADRD) are an escalating national crisis that shapes overall levels of population health including average life expectancy. Critically, in order to effectively address this crisis, it is imperative that we identify its root causes, which may include social determinants of health (SDoH) such as education spending and social mobility, and that we modify these root causes through corresponding policies. While a handful of SDoH have been shown to predict cognitive decline and ADRD, important questions remain about which SDoH are root social drivers i.e., have the greatest impacts. Despite increasing calls for comparative assessments to unpack and address the root causes—the social determinants—of ADRD, we lack knowledge on the relative ADRD burden and economic impacts associated with modifying SDoH, including policies such as the social security benefits tax. Furthermore, we have yet to establish which subpopulations are most affected by SDoH. Given this information, there are critical needs to accurately estimate SDoH impacts, including by subpopulation; and to translate these estimates into priority-setting tools including impacts on ADRD burden and costs. Left unaddressed, these critical needs will hinder the development of policies to more effectively reduce ADRD burden and inequities. Our overall objective is to use large multilevel, longitudinal datasets and quasi-experimental approaches to construct the first comparative assessment evidence base on the social drivers of ADRD burden and inequities. We will accomplish our overall objective by pursuing the following specific aims using data in adults age 50+ from: the nationally-representative Mortality Disparities in American Communities Study, linked to national mortality databases; the nationally-representative Health and Retirement Study, linked to Medicare claims data; and the NIH’s All of Us Program, a multiethnic study linked to electronic health records (EHR) data on diagnoses/treatments of health conditions: Aim 1) To assess the impacts of area-level SDoH including state policies as protective factors against ADRD mortality, that may vary across health disparity populations; Aim 2) To evaluate the impacts of area-level SDoH on memory decline in middle-aged adults and incidence of cognitive impairment and dementia in older adults; Aim 3) To explore the mechanisms through which area-level SDoH may protect against ADRD incidence and cognitive impairment/decline, including physical/mental health disorders and biomarkers; and Aim 4) To ascertain which area-level SDoH, if modified, are expected to yield the greatest reductions in levels of and inequities in ADRD burden and costs. Regarding impact, we will identify the most promising SDoH on which to intervene to yield improvements in ADRD burden and inequities. We will further establish the pathways to differential vulnerabilities by subpopulation. By translating estimates into population health metrics, we anticipate our project will have high translational impact through guiding policymakers' evidence-based decisions about policies to more effectively reduce the burden of and inequities in ADRD among Americans.