Gender Inequality in Dementia

Women's Equality Day

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Women’s Equality Day, August 26th, 2020, celebrates the 100th anniversary of the 19th Amendment. A major milestone for gender parity was reached on August 18, 1920, when women won a hard-fought battle for the right to vote through the ratification of the 19th amendment to the constitution of the United States.

One hundred years after that epic event, real equality under the law and in all aspects of life including health remains elusive. One hundred years later, women still earn about 81.6 cents for each dollar earned by a man, and thus need to work about 25 percent more time than men do to make up the difference. That statistic is even worse for women of color: Black women are typically paid just 62 cents for every dollar paid to white, non-Hispanic men.

Economic and political inequalities flow over into other areas of life. In the United States, healthcare access is tied to employment and income — and the vast majority of jobs without health benefits are held not by white men but by women and especially by women of color, creating unequal health outcomes. We honor the women who have fought for equality across the centuries by taking this moment in history to examine health disparities for women in dementia, why that happens, and what we as a society can possibly do to address this issue.

As modern women, we have Lucretia Mott, Elizabeth Cady Stanton, Susan B. Anthony, Ida B. Wells-Barnett, Frances Ellen Watkins Harper, and many other brave pioneers to thank for the strides made in women’s equality in the last several hundred years. These remarkable women fought tirelessly for equality and the right to vote, and paved the way for the ratification of the 19th Amendment in 1920:

“The right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex. Congress shall have power to enforce this article by appropriate legislation.”

Powerful words delivered by then-U.S. Secretary of State Bainbridge Colby that enabled women to vote for the first time in the United States. And women have continuously turned up at the polls. Since 1964, the number of female voters has exceeded the number of male voters in every presidential election. Lest we think this battle was won so long ago, it’s important to know that the suffrage fight continued for another 64 years when Mississippi, the last state, finally ratified the Amendment in 1984.

While the constitution now guarantees the right to vote for women, it does not address other areas of inequality that persist, especially in the economic and social spheres which have profound impact on women’s health. Healthcare should be accessible to all regardless of gender, race, education, and socioeconomic status. But education, income, and wealth accumulation gaps continue for women well into the 21st century. These gaps create a health disparity for women, and they are disproportionately impacted by diseases like Alzheimer’s and other dementias.

I lost both of my grandmothers to Alzheimer’s disease, and I can think of no better way to honor their memory on Women’s Equality Day than to shine a light on the health disparities for women in dementia: how they are affected at greater rates and how that impacts their lives.

Women Are Disproportionately Affected by Dementia

More than 5 million Americans are living with Alzheimer’s or other dementia, and according to the World Health Organization (WHO), it is estimated that 50 million are living with dementia globally.

Dementia is not an equal opportunity disease. Two-thirds of those living with dementia are women. Based on the Aging, Demographics, and Memory Study, it is estimated that among people age 71 and older, 16 percent of women have Alzheimer’s or other dementias compared with 11 percent of men. Why the disparity?

Women Live Longer Than Men

With age as the biggest known risk factor for dementia, longer life expectancy is attributed as a prevailing reason why women have higher rates of dementia than men.

According to the WHO, “Women generally live longer than males — on average by six to eight years...and the extra years of life for women are not always lived in good health,” which could in part, be due to dementia. A woman in her 60s is twice as likely to develop Alzheimer’s than breast cancer over the course of her lifetime, according to the Women’s Alzheimer’s Movement.

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Living longer does not account for the gap in dementia rates for women. Other factors play key roles in the unequal health outcomes women experience around cognitive health.

Social Determinants of Health

A healthy lifestyle such as a balanced diet, regular exercise, and adequate sleep does much to sustain both physical and mental health even into old age. Many people are unaware that social and economic factors such as education and income are often better predictors of health outcomes than our genes.

Sarah Lenz Lock, senior vice president for policy and brain health at AARP and executive director of the Global Council on Brain Health believes social determinants have a huge impact on women’s brain health. “Women face more challenges due to lower educational levels, they have fewer economic resources, they provide more caregiving for their families and they experience more stress — and these factors can have an effect on the risk of cognitive decline,” said Lock.

“Social determinants are the housing we live in...whether there’s gender equity, whether we are victims of violence, whether there are opportunities to actually live one’s life fully,” said Sandro Galea, Dean and Robert A. Knox Professor at Boston University School of Public Health, in a podcast interview with Smarter Healthcare. “We tend to see health as something that happens in my body, in your body. And that approach results in a limiting. And in fact, we know now that the world around us matters much more to our health than does biology. The social factors matter much more than biology.”

Challenges Faced by Women

For the first time, in 2019 women made up the majority of the college-educated workforce: 29.5 million working women had at least a bachelor’s degree compared to 29.3 million men in the workforce. But the parity seems to end there.

There continues to be fewer women in leadership positions. For instance:

• Women make up only 27.6 percent of CEOs.
• Only 7.4 percent of the Fortune 500 companies have a woman CEO.
• Currently, out of 100 senators only 26 are women.
• In Congress, women make up 23.7 percent of representatives at the national level.

In the 2019 Women in the Workplace report, 39 percent of women said they do all or most of the childcare and housework for their families, compared to just 11 percent of men.

Top jobs require longer hours and workweeks, and most women still work the infamous “double shift.” They are responsible for their children at home and housework, making it harder for them to have the support necessary to succeed in leadership positions. It’s much easier to focus on work and career when someone else is doing all or most of the childcare and managing the day-to-day needs at home.

How Those Challenges Impact Women’s Cognition

Multiple studies provide evidence of the powerful influence of social determinants of health and the impact on cognitive decline.

Lower education

• In the Rotterdam study, the risk of dementia in women with lower education was significantly increased but showed no significant effect on men.

Socioeconomic status

• In a recent study in JAMA Network Open, data showed that people who live in the most disadvantaged neighborhoods–a social determinant of health–have roughly twice the odds of having Alzheimer’s-related brain changes than people who live in the wealthiest neighborhoods. Neighborhoods of poorer socioeconomic status are characterized by low levels of education, high unemployment, and the use of public assistance.
• A JAMA Psychiatry study confirms the risk of dementia is higher in older adults with fewer economic resources compared to their wealthier peers. “Many factors could be involved. Differences in healthy lifestyle and medical risk factors are relevant,” said Professor Andrew Steptoe (UCL Institute of Epidemiology and Health), senior author of the study. “It may also be that better-off people have greater social and cultural opportunities that allow them to remain actively engaged with the world.”

According to the U.S. Census Bureau in 2017, the poverty rate for women 65 and older was 10.5 percent compared to 7.5 percent for men, and 13 percent for women between ages 18 and 24 as compared to 9.4 percent for men in the same age range. Given that the poverty rate is a social determinant of health, the risk of dementia for women is higher if they have fewer economic resources and come from poorer neighborhoods compared to women from wealthier backgrounds.

The Impact of Caregiving on Women

While many leadership roles are still male-dominated, low-wage industries like caregiving, on the other hand, are overrepresented by women, and nearly half are women of color.

In fact, two-thirds of dementia caregivers are women, and according to the Alzheimer’s Association, more than a third are daughters. And, they can also be mothers, sisters, granddaughters, and wives who must also deal with other responsibilities—the double shift.

That double shift is compounded by COVID-19 in what Sheryl Sandberg, founder of LeanIn.org, says has become a “double-double shift” as extra workload and stress are added to existing responsibilities with work-from-home circumstances and children staying home full-time during the pandemic.

Dementia caregivers are indispensable, yet many are unpaid. In 2019, more than 16 million family members and friends provided 18.6 billion hours of unpaid care to people with Alzheimer’s and other dementias, at an economic value of $244 billion. Additionally, two and a half times more women than men live full-time with a person with dementia, which can take a toll: 19 percent of women caring for those with Alzheimer’s had to quit their jobs to serve as caregivers. We seem to live in a society that values labor and contributions of women less than men, and this has profound implications for health inequality.

Given the stress associated with caregiving, layered in with the “double shift” (and during COVID-19 the “double-double shift”), it is not shocking that 30 to 40 percent of dementia caregivers report depression and emotional stress. In fact, 85 percent of the people who seek counseling for such stress and depression are women.

The COVID-19 pandemic has brought changes and added challenges to providing care for elderly people with dementia. Ninety-two percent of Alzheimer’s caregivers report higher stress because of the virus, an increase of 10 points since the last survey by UsAgainstAlzheimer’s in March.*

What Can You Do?

One thing everyone can do, especially women, is to take charge of their brain health. It is crucial to maintain a healthy lifestyle to prevent dementia and cognitive decline — eat healthy, lower alcohol consumption, and get adequate sleep. That importance was highlighted again at this year’s virtual Alzheimer’s Association International Conference. Information presented at the conference supported the fact that up to 40 percent of dementia cases globally (up from 35 percent last year) can be prevented if we change lifestyle factors. As a woman, you need to be an advocate for your own wellbeing. Remember to also test your cognition regularly to monitor your brain health, like you test your blood pressure to assess your heart health, and keep an eye on any escalating risk factors.

Organizations like The Women’s Alzheimer’s Movement, My Brain Movement, 4Mom, and WomenAgainstAlzheimer’s are making an impact on closing the dementia gender gap. “Women are at the epicenter of the Alzheimer’s crisis. That’s why we must be at the heart of the solution,” said Maria Shriver, Founder of The Women’s Alzheimer’s Movement.

On Women’s Equality Day, make a commitment to vote in November in honor of the 19th Amendment, and make a commitment to work toward closing the gender disparity in dementia in honor of equality by working with the aforementioned organizations. Join in on the fight against Alzheimer’s and other dementias: advocate, educate, take care of caregivers, fundraise, volunteer in events, and participate in clinical trials.

What will you do to make your voice heard?

* Resources

• If you’re a caregiver suffering from depression or need assistance, click here for helpful resources.
• Stress can increase your risk for dementia; test your cognition early and regularly to monitor any cognitive changes.