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


Paris B. Adkins-Jackson, Departments of Epidemiology & Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York, USA.
Kristen M. George, Department of Public Health Sciences, University of California, Davis School of Medicine, Davis, California, USA.
Lilah M. Besser, Comprehensive Center for Brain Health, University of Miami Miller School of Medicine, Miami, Florida, USA.
Jinshil Hyun, The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Bronx, New York, New York, USA.
Melissa Lamar, Rush Alzheimer's Disease Center and the Department of Psychiatry and Behavioral Sciences, Rush University Medical Center, Chicago, Illinois, USA.
Tanisha G. Hill-Jarrett, Department of Neurology, Memory and Aging Center, University of California, San Francisco, California, USA.
Omonigho M. Bubu, Departments of Psychiatry, Population Health & Neurology, New York University Grossman School of Medicine, New York, New York, USA.
Jason D. Flatt, Department of Social and Behavioral Health, School of Public Health, University of Nevada, Las Vegas, Nevada, USA.
Patricia C. Heyn, Center for Optimal Aging, Marymount University, Arlington, Virginia, USA.
Ethan C. Cicero, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.
A Zarina Kraal, Department of Neurology, Columbia University, New York, New York, USA.
Preeti Pushpalata Zanwar, Applied Health Economics & Outcomes Research & Health Policy, Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
Rachel Peterson, School of Public and Community Health Sciences, University of Montana, Missoula, Montana, USA.
Boeun Kim, School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA.
Robert W. Turner, Clinical Research & Leadership, Neurology, The George Washington University, Washington, D.C., USA.
Jaya Viswanathan, Bethesda, Maryland, USA.
Erin R. Kulick, MPH Department of Epidemiology and Biostatistics, Temple University, Philadelphia, Pennsylvania, USA.
Megan Zuelsdorff, School of Nursing, Alzheimer's Disease Research Center, and School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin, USA.
Shana D. Stites, MA Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
Miguel Arce Rentería, Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University Medical Center, New York, New York, USA.
Elena Tsoy, 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.
Dominika Seblova, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
Ted K. Ng, Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA.
Jennifer J. Manly, Department of Neurology, Columbia University, New York, New York, USA.
Ganesh Babulal, Department of Neurology, Washington University School of Medicine, St. Louis, Missouri, USA.

Document Type

Journal Article

Publication Date



Alzheimer's & dementia : the journal of the Alzheimer's Association








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


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.


Clinical Research and Leadership