Association of work-family experience with mid- and late-life memory decline in US women

Impact of work type and APOE-e4 status on cognitive functioning in older women

Prior research indicates that APOE-e4 allele(s) and working without compensation may be independently associated with risk for cognitive decline. This study investigated whether the interaction of type of work (paid versus unpaid) and presence of APOE-e4 allele(s) was associated with cognitive dysfunction in women in mid- and late-life. Participants included 340 females (mean age = 74.7 years) from the Alzheimer's Disease Neuroimaging Initiative (ADNI) dataset. A two-way ANOVA to assess the simple main effects of type of work and APOE-e4 allele status on cognition as well as their interaction was performed. A two-way ANCOVA including age, education, and marital status as covariates was also conducted. The presence of one or two APOE-e4 allele(s) and unpaid work was associated with greater cognitive dysfunction. A significant interaction effect revealed engagement in paid work, regardless of the presence of APOE-e4 allele(s), was associated with better cognitive functioning. Consistent with prior literature, women who engage in unpaid forms of labor for the majority of their life may be at higher risk for cognitive decline, regardless of presence of APOE-e4 allele(s). Further research is needed to identify the factors related to unpaid labor that may increase risk for cognitive dysfunction.

Alzheimer's disease as a women's health challenge: a call for action on integrative precision medicine approaches

Alzheimer's Disease (AD) is marked by pronounced sex differences in pathophysiology and progression. However, the field has yet to fully recognize AD as a women's health issue, delaying the development of targeted preventative strategies and treatments. This perspective explores the elements impacting AD in women, identifying sex specificity in risk factors, highlighting new diagnostic approaches with electronic health records, and reviewing key molecular studies to underscore the need for integrative precision medicine approaches. Established AD risk factors such as advancing age, the apolipoprotein E4 allele, and poorer cardiovascular health affect women differently. We also shed light on sociocultural risk factors, focusing on the gender disparities that may play a role in AD development. From a biological perspective, sex differences in AD are apparent in biomarkers and transcriptomics, further emphasizing the need for targeted diagnostics and treatments. The convergence of novel multiomics data and cutting-edge computational tools provides a unique opportunity to study the molecular underpinnings behind sex dimorphism in AD. Thus, precision medicine emerges as a promising framework for understanding AD pathogenesis through the integration of genetics, sex, environment, and lifestyle. By characterizing AD as a women's health challenge, we can catalyze a transformative shift in AD research and care, marked by improved diagnostic accuracy, targeted interventions, and ultimately, enhanced clinical outcomes.

Promoting diverse perspectives: Addressing health disparities related to Alzheimer's and all dementias

Dementia research lacks appropriate representation of diverse groups who often face substantial adversity and greater risk of dementia. Current research participants are primarily well-resourced, non-Hispanic White, cisgender adults who live close to academic medical centers where much of the research is based. Consequently, the field faces a knowledge gap about Alzheimer's-related risk factors in those other groups. The Alzheimer's Association hosted a virtual conference on June 14-16, 2021, supported in part by the National Institute on Aging (R13 AG072859-01), focused on health disparities. The conference was held entirely online and consisted of 2 days of core programming and a day of focused meetings centered on American Indian and Alaska Natives and on LGBTQIA+ populations. Over 1300 registrants attended discussions focused on the structural and systemic inequities experienced across diverse groups, as well as ways to investigate and address these inequities.

Care sequences leading to the diagnosis of Alzheimer's disease and related dementias: An analysis of electronic health records

BACKGROUND

We examined the sequences of clinical care leading to diagnoses of Alzheimer's disease and related dementias (ADRD) using electronic health records from a large academic medical center.

METHODS

We included patients aged 65+ with their first ADRD diagnoses from January 1, 2014 to December 31, 2019. Using state sequence analysis, care sequences were defined by the ordering of healthcare utilizations occurred in the 2 years before ADRD diagnosis.

RESULTS

Of 3621 patients (median age 80), nearly half followed a care sequence of having one primary care visit close to their ADRD diagnosis. Additional care sequences included periodic (n = 322, 8.9%) and multiple (n = 416, 11.5%) outpatient visits to primary care and having one (n = 395, 10.9%), multiple (n = 469, 13.0%), or highly frequent (n = 357, 10.7%) outpatient visits to other specialties. Patients' sociodemographic traits contributed to the variability in care sequences.

CONCLUSIONS

Several distinct patterns of care leading to ADRD diagnoses were identified. Integrated care models are needed to promote early identification of ADRD.

HIGHLIGHTS

Dementia patients followed distinct care pathways prior to their dementia diagnoses. Key sociodemographic traits contributed to the variation in the sequences of care. Racial differences in the sequencing of care were also found, but only in women.

Mid-life employment trajectories and subsequent memory function and rate of decline in rural South Africa, 2000-22

AIM

To investigate mid-life employment trajectories in relation to later-life memory function and rate of decline in rural South Africa.

METHODS

Data from the Agincourt Health and Socio-Demographic Surveillance System were linked to the 'Health and Ageing in Africa: A Longitudinal Study of an INDEPTH Community in South Africa' (HAALSI) in rural Agincourt, South Africa (N = 3133). Employment was assessed every 4 years over 2000-12 as being employed (0, 1, 2 and ≥3 time points), being employed in a higher-skill occupation (0, 1, 2 and ≥3 time points) and dynamic employment trajectories identified using sequence analysis. Latent memory z-scores were assessed over 2014-22. Mixed-effects linear regression models were fitted to examine the associations of interest.

RESULTS

Sustained mid-life employment from 2000-12 (β = 0.052, 95% CI: -0.028 to 0.132, 1 vs 0 time points; β = 0.163, 95% CI: 0.077 to 0.250, 2 vs 0 time points; β = 0.212, 95% CI: 0.128 to 0.296, ≥3 vs 0 time points) and greater time spent in a higher-skill occupation (β = 0.077, 95% CI: -0.020 to 0.175, 1 vs 0 time points; β = 0.241, 95% CI: 0.070 to 0.412, 2 vs 0 time points; β = 0.361, 95% CI: 0.201 to 0.520, ≥3 vs 0 time points) were associated with higher memory scores in 2014/15, but not subsequent rate of memory decline. Moving from a lower-skill to higher-skill occupation was associated with higher memory function, but a faster rate of decline over 2014-22.

CONCLUSIONS

Sustained mid-life employment, particularly in higher-skill occupations, may contribute to later-life memory function in this post-Apartheid South African setting.

Number of children and cognitive function among Chinese menopausal women: The mediating role of depressive symptoms and social participation

OBJECTIVES

This study examined the association between number of children and cognitive function and its possible hormone and psychosocial pathways in Chinese menopausal women.

METHODS

We analyzed data from the China Health and Retirement Longitudinal Study (CHALRS), including 4803 menopausal women. Ordinary least squares (OLS) regression modeling and structural equation modeling (SEM) were applied to explore the association between number of children and cognitive function and the potential mechanisms.

RESULTS

Overall, the median number of biological children was three among participants. The cognitive function score decreased significantly with increasing numbers of children [β = -0.547, 95 % confidence interval (CI): -0.677, -0.416]. There was a significant interaction between number of children and residence (P = 0.003). Compared with older women with three or less children, women with more than three children had worse cognitive function (β = -0.798, 95 % CI: -1.081, -0.514). Mediation analysis verified that depressive symptoms and social participation partially mediate the associations between the number of children and cognitive function.

LIMITATIONS

First, because of the cross-sectional design, our study was unable to make causal inferences. Second, information about endogenous estrogen exposure was not collected in CHARLS. Third, recall bias may exist due to the use of self-reported data.

CONCLUSION

Our results indicated that a higher number of children is associated with an increased risk for cognitive impairment. We suggest paying special attention to mental and social health among women with multiple children (>3).

Racial Differences in Employment and Poverty Histories and Health in Older Age

INTRODUCTION

Black Americans encounter more barriers in the job market and earn less than White Americans. However, the extent to which racial disparities in employment and poverty histories impact health is not fully understood. This study characterized employment‒poverty histories for Black and White middle-aged adults and examined their association with health.

METHODS

Respondents born in 1948-1953 and enrolled in the 2004 Health and Retirement Study (N_Black=555, N_White=2,209) were included. Sequence analysis grouped respondents with similar employment‒poverty trajectories from 2004 to 2016, and confounder-adjusted regression analyses estimated the associations between these trajectories and health in 2018. Analyses were conducted in 2021-2022.

RESULTS

More than 23% of Black respondents experienced both employment and poverty fluctuations, including bouts of extreme poverty (<50% of the federal poverty threshold), whereas no trajectory for White respondents included extreme poverty. Adversities in employment‒poverty were associated with worse health. For example, among Black respondents, those who experienced both employment and poverty fluctuations had worse cognition than those employed and not poor (β= -0.55 standardized units, 95% CI= -0.81, -0.30). Similarly, among White respondents, those who experienced employment fluctuations had worse cognition than those employed (β= -0.35, 95% CI= -0.46, -0.24). Notably, the employed and not poor trajectory was associated with worse survival among Black respondents than among White respondents.

CONCLUSIONS

Employment fluctuations were associated with worse health, especially cognitive function, where the association was stronger among Black Americans who experienced both employment fluctuations and poverty. Findings highlight the importance of enhancing employment stability and of antipoverty programs, especially for Black Americans.

2023 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease, including prevalence and incidence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report examines the patient journey from awareness of cognitive changes to potential treatment with drugs that change the underlying biology of Alzheimer's. An estimated 6.7 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, and Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States. In 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death, Alzheimer's was the seventh-leading cause of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated by the COVID-19 pandemic in 2020 and 2021. More than 11 million family members and other unpaid caregivers provided an estimated 18 billion hours of care to people with Alzheimer's or other dementias in 2022. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $339.5 billion in 2022. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the paid health care workforce are involved in diagnosing, treating and caring for people with dementia. In recent years, however, a shortage of such workers has developed in the United States. This shortage - brought about, in part, by COVID-19 - has occurred at a time when more members of the dementia care workforce are needed. Therefore, programs will be needed to attract workers and better train health care teams. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2023 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $345 billion. The Special Report examines whether there will be sufficient numbers of physician specialists to provide Alzheimer's care and treatment now that two drugs are available that change the underlying biology of Alzheimer's disease.

Association Between Supplemental Nutrition Assistance Program Use and Memory Decline: Findings From the Health and Retirement Study

BACKGROUND AND OBJECTIVES

Studies on the effect of the Supplemental Nutrition Assistance Program (SNAP) on the cognitive health of older adults are scarce. We sought to examine the associations between SNAP use and memory decline among SNAP-eligible US older adults.

METHODS

Participants aged 50+ years and SNAP-eligible in 1996 from the Health and Retirement Study were included. Participants' SNAP eligibility was constructed using federal criteria. Participants also self-reported whether they used SNAP. Memory function was assessed biennially from 1996 through 2016 using a composite score. To account for preexisting differences in characteristics between SNAP users and nonusers, we modeled the probability of SNAP use using demographic and health covariates. Using linear mixed-effects models, we then modeled trajectories of memory function for SNAP users and nonusers using inverse probability (IP) weighting and propensity score (PS) matching techniques. In all models, we accounted for study attrition.

RESULTS

Of the 3,555 SNAP-eligible participants, a total of 15.7% were SNAP users. At baseline, SNAP users had lower socioeconomic status and a greater number of chronic conditions than nonusers and were more likely to be lost to follow-up. Our multivariable IP-weighted models suggested that SNAP users had worse memory scores at baseline but slower rates of memory decline compared with nonusers (the annual decline rate is -0.038 standardized units [95% CI = -0.044 to -0.032] for users and -0.046 [95% CI = -0.049 to -0.043] for nonusers). Results were slightly stronger from the PS-matched sample (N = 1,014) (the annual decline rate was -0.046 units [95% CI = -0.050 to -0.042] for users and -0.060 units [95% CI = -0.064 to -0.056] for nonusers). Put in other words, our findings suggested that SNAP users had approximately 2 fewer years of cognitive aging over a 10-year period compared with nonusers.

DISCUSSION

After accounting for preexisting differences between eligible SNAP users and nonusers as well as differential attrition, we find SNAP use to be associated with slower memory function decline.

Sex-Specific Protective Effects of Cognitive Reserve on Age-Related Cognitive Decline: A 5-Year Prospective Cohort Study

BACKGROUND AND OBJECTIVES

Females have a higher age-adjusted incidence of Alzheimer disease than males but the reasons for this remain unclear. One proposed contributing factor is that, historically, females had less access to education and, therefore, may accumulate less cognitive reserve. However, educational attainment is confounded by IQ, which in itself is a component of cognitive reserve and does not differ between sexes. Steeper age-related cognitive declines are associated with increased risk of dementia. We, therefore, evaluated the moderating effects of 2 proxies for cognitive reserve, education and IQ, on the steepness of age-related declining cognitive trajectories in unimpaired older males and females.

METHODS

The Tasmanian Healthy Brain Project, a long-term cohort study, recruited healthy Australians aged 50-80 years without cognitive impairment. Baseline cognitive reserve was measured using educational history and IQ, measured by the Wechsler Test of Adult Reading, Full Scale Predicted IQ (WTAR-FSIQ). Cognitive trajectories for language, executive function, and episodic and working memory over 5 years were extracted from neuropsychological assessments. The adjusted effects of education, estimated IQ, and APOE allelic variant on cognitive trajectories were compared between males and females.

RESULTS

Five hundred sixty-two individuals (mean [SD] age 60 [6.7] years; 68% male; 33% APOE ε4+) were followed up over 5 years with 1,924 assessments and 24,946 cognitive test scores (annualized attrition rate 6.6% per year). Estimated IQ correlated with years of education (p < 0.001). Estimated IQ interacted with sex to moderate age-related cognitive trajectories (p = 0.03; adjusted for education); lower IQ males experienced steeper declining trajectories than higher IQ males, but lower IQ females had similar steepness of declining trajectories to higher IQ females. Education was not associated with rate of cognitive decline (p = 0.67; adjusted for WTAR-FSIQ). There were no significant differences in age-related cognitive trajectories between APOE genotypes in either sex.

DISCUSSION

IQ, a measure of cognitive reserve, predicted the steepness of declining cognitive trajectories in males only. Education did not explain as much variation in cognitive trajectories as IQ. Our findings do not support the hypothesis that historical sex disparities in access to education contribute to the higher female incidence of Alzheimer disease.

Consideration of sex and gender in Alzheimer's disease and related disorders from a global perspective

Sex or gender differences in the risk of Alzheimer's disease and related dementias (ADRD) differ by world region, suggesting that there are potentially modifiable risk factors for intervention. However, few epidemiological or clinical ADRD studies examine sex differences; even fewer evaluate gender in the context of ADRD risk. The goals of this perspective are to: (1) provide definitions of gender, biologic sex, and sexual orientation. and the limitations of examining these as binary variables; (2) provide an overview of what is known with regard to sex and gender differences in the risk, prevention, and diagnosis of ADRD; and (3) discuss these sex and gender differences from a global, worldwide perspective. Identifying drivers of sex and gender differences in ADRD throughout the world is a first step in developing interventions unique to each geographical and sociocultural area to reduce these inequities and to ultimately reduce global ADRD risk. HIGHLIGHTS: The burden of dementia is unevenly distributed geographically and by sex and gender. Scientific advances in genetics and biomarkers challenge beliefs that sex is binary. Discrimination against women and sex and gender minority (SGM) populations contributes to cognitive decline. Sociocultural factors lead to gender inequities in Alzheimer's disease and related dementias (ADRD) worldwide.

Work-family trajectories and health: A systematic review

BACKGROUND

Work and family lives interact in complex ways across individuals' life courses. In the past decade, many studies constructed work-family trajectories, some also examined the relation with health. The aims of this systematic review were to summarise the evidence from studies constructing work-family trajectories, and to synthesise the evidence on the association between work-family trajectories and health.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, SocINDEX and Web of Science databases. Key search terms related to work, family and trajectories. Studies that built combined work-family trajectories or examined the relationship between work and family trajectories were included. Risk of bias was assessed independently by two authors. The identified work-family trajectories were summarised and presented for men and women, age cohorts and contexts. The evidence on the association with health as antecedent or consequence was synthesised.

RESULTS

Forty-eight studies, based on 29 unique data sources, were included. Thirty-two studies (67%) were published in 2015 or later, and sequence analysis was the primary analytic technique used to construct the trajectories (n = 43, 90%). Trajectories of women were found to be more diverse and complex in comparison with men. Work-family trajectories differed by age cohorts and contexts. Twenty-three studies (48%) examined the association between work-family trajectories and health and most of these studies found significant associations. The results indicate that work-family trajectories characterised by an early transition to parenthood, single parenthood, and weak ties to employment are associated with worse health outcomes.

CONCLUSIONS

Work-family trajectories differed greatly between men and women, but differences seemed to decrease in the youngest cohorts. Given the current changes in labour markets and family formation processes, it is important to investigate the work and family lives of younger cohorts. Work-family trajectories were associated with health at different life stages. Future research should examine longitudinal associations of work-family trajectories with health and focus on elucidating why and under which circumstances some trajectories are associated with better or worse health compared with other trajectories.

2022 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on family caregivers, the dementia workforce and society. The Special Report discusses consumers' and primary care physicians' perspectives on awareness, diagnosis and treatment of mild cognitive impairment (MCI), including MCI due to Alzheimer's disease. An estimated 6.5 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available. Alzheimer's disease was officially listed as the sixth-leading cause of death in the United States in 2019 and the seventh-leading cause of death in 2020 and 2021, when COVID-19 entered the ranks of the top ten causes of death. Alzheimer's remains the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. More than 11 million family members and other unpaid caregivers provided an estimated 16 billion hours of care to people with Alzheimer's or other dementias in 2021. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $271.6 billion in 2021. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Members of the dementia care workforce have also been affected by COVID-19. As essential care workers, some have opted to change jobs to protect their own health and the health of their families. However, this occurs at a time when more members of the dementia care workforce are needed. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are almost three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 22 times as great. Total payments in 2022 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $321 billion. A recent survey commissioned by the Alzheimer's Association revealed several barriers to consumers' understanding of MCI. The survey showed low awareness of MCI among Americans, a reluctance among Americans to see their doctor after noticing MCI symptoms, and persistent challenges for primary care physicians in diagnosing MCI. Survey results indicate the need to improve MCI awareness and diagnosis, especially in underserved communities, and to encourage greater participation in MCI-related clinical trials.

2021 Alzheimer's disease facts and figures

This article describes the public health impact of Alzheimer's disease (AD), including incidence and prevalence, mortality and morbidity, use and costs of care, and the overall impact on caregivers and society. The Special Report discusses the challenges of providing equitable health care for people with dementia in the United States. An estimated 6.2 million Americans age 65 and older are living with Alzheimer's dementia today. This number could grow to 13.8 million by 2060 barring the development of medical breakthroughs to prevent, slow or cure AD. Official death certificates recorded 121,499 deaths from AD in 2019, the latest year for which data are available, making Alzheimer's the sixth-leading cause of death in the United States and the fifth-leading cause of death among Americans age 65 and older. Between 2000 and 2019, deaths from stroke, heart disease and HIV decreased, whereas reported deaths from AD increased more than 145%. This trajectory of deaths from AD was likely exacerbated in 2020 by the COVID-19 pandemic. More than 11 million family members and other unpaid caregivers provided an estimated 15.3 billion hours of care to people with Alzheimer's or other dementias in 2020. These figures reflect a decline in the number of caregivers compared with a decade earlier, as well as an increase in the amount of care provided by each remaining caregiver. Unpaid dementia caregiving was valued at $256.7 billion in 2020. Its costs, however, extend to family caregivers' increased risk for emotional distress and negative mental and physical health outcomes - costs that have been aggravated by COVID-19. Average per-person Medicare payments for services to beneficiaries age 65 and older with AD or other dementias are more than three times as great as payments for beneficiaries without these conditions, and Medicaid payments are more than 23 times as great. Total payments in 2021 for health care, long-term care and hospice services for people age 65 and older with dementia are estimated to be $355 billion. Despite years of efforts to make health care more equitable in the United States, racial and ethnic disparities remain - both in terms of health disparities, which involve differences in the burden of illness, and health care disparities, which involve differences in the ability to use health care services. Blacks, Hispanics, Asian Americans and Native Americans continue to have a higher burden of illness and lower access to health care compared with Whites. Such disparities, which have become more apparent during COVID-19, extend to dementia care. Surveys commissioned by the Alzheimer's Association recently shed new light on the role of discrimination in dementia care, the varying levels of trust between racial and ethnic groups in medical research, and the differences between groups in their levels of concern about and awareness of Alzheimer's disease. These findings emphasize the need to increase racial and ethnic diversity in both the dementia care workforce and in Alzheimer's clinical trials.