Untangling the Complex Web of Women and Alzheimer’s

Jun 24

Why Women in Midlife Face Greater Alzheimer’s Risk and What You Can Do About It

A puzzle head with pieces disintegrating, showing a brain affected by psychological disorders like Alzheimer s, autism, and dementia

Since June is Alzheimer’s and Brain Health Awareness Month, I wanted to share some fascinating (and somewhat unsettling) research I recently came across in Nature, a leading science journal. The article, “Why Women Experience Alzheimer’s Disease Differently from Men,” explored how a combination of genetic, biological, and social factors influences the way women experience the disease. It sent me down a rabbit hole of further reading, and what I discovered feels too important not to share, especially for women navigating midlife and menopause.

The Hidden Crisis Facing Women in Midlife

It's well known that the greatest risk factors for Alzheimer’s are age followed by being female. The first person diagnosed with Alzheimer’s, back in 1906, was a woman: Auguste Deter, who was 55 and living in Frankfurt, Germany. Auguste’s case foreshadowed a pattern we now recognize as a significant health crisis for women. According to Dr. Mary Claire Haver, author of the bestselling book “The New Menopause”, while women tend to outlive men, they often spend the last 20% of their lives in poorer health than their male peers, mostly due to frailty and dementia.

Researchers have known that women, who are typically diagnosed later than men, tend to decline faster, but, until fairly recently, they had neglected to consider sex and gender differences when studying Alzheimer’s. It remains to be seen whether efforts to correct this research gap will be supported or sidelined by today’s shifting political climate, but research at the University of California San Francisco has spotlighted the X chromosome and the menopause transition as major contributors to a woman’s risk. Scientists are hopeful that the treatment options being studied today will benefit anyone with the disease.

Initially, as their brains age, healthy women possess greater “cognitive resilience” than men, which basically means that women’s brains are better able to cope with the stresses and demands of aging. Men’s brains age more rapidly than women’s. Before women develop Alzheimer’s they have better memory than men, during both youth and old age. However, that is no longer the case once Alzheimer’s is diagnosed.

Women with Alzheimer’s disease decline more rapidly than men, lose their independence earlier, and experience greater levels of disability. According to Dr. Haver, women outnumber men by more than 2:1 in nursing homes. This disparity isn’t just because they live longer, it’s also because women are twice as likely as men to develop Alzheimer’s. When the two biggest risk factors are age and being female, it’s no wonder we women have the deck stacked against us.

It's also thought that how women with Alzheimer’s are treated may factor into their rapid decline. Unlike men, women are more likely to be given antipsychotics and antidepressants, which is considered a poor standard of care. This echoes the experience of Auguste Deter more than a century ago. The doctor who diagnosed her, Alois Alzheimer, documented his observations, stating that she was “completely delirious, drags around her bedding, calls her husband and daughter and seems to suffer from auditory hallucinations.” Lack of understanding of the disease during her lifetime led to her being committed to a psychiatric institution, where she died due to complications from bedsores.

Additionally, women are often diagnosed later than men, possibly due to their stronger verbal memory, which might mask the disease for longer. This underscores the need for diagnostic tools that account for sex differences and can help detect Alzheimer's earlier in women, before the disease has significantly progressed.

What the X Chromosome Has to Do With It

There is hope, though. Some scientists are beginning to look for clues in the sex chromosomes. The X chromosome, which has long been relegated to research relating only to reproduction, might provide a goldmine of information. It contains 5% of our genes, many of which are related to brain function and cognition. A recent study showing an association between a portion of the X chromosome and Alzheimer’s shows promise. In studies with mice, the extra X chromosome that women possess is the key to their longer lives and their greater cognitive resilience.

There were other differences between men and women within the actual X chromosome itself. In women, these differences were associated with slower cognitive decline from both age and Alzheimer’s, while in men, the difference indicated that men might be more at risk for developing Alzheimer’s. But that is before women experience the hormonal transitions associated with menopause. Women experience a dramatic decrease in estrogen levels during perimenopause, with one study identifying a 67% drop before a woman reaches menopause. This decline in estrogen is accompanied by a decline in the brain’s ability to metabolize glucose, causing the brain to start burning fat instead. This metabolic shift causes a shrinkage in brain volume and is linked to the brain fog many women report during menopause.

However, researchers now attribute this drop in estrogen to some of the key differences in how Alzheimer’s affects women compared to men. Some scientists believe that, even though symptoms might not appear until a woman is in her 60s, 70s or beyond, Alzheimer’s is a disease of midlife rather than of old age.

How Estrogen Affects the Aging Brain

Research has also discovered that peri- and postmenopausal women exhibit more signs of the disease than similarly aged men. These women had lower glucose metabolism, smaller brain volume, and a greater buildup of amyloid-β, the protein in the brain associated with Alzheimer’s disease. And while for most women the symptoms of menopause tend to subside or disappear after several years, some women do not recover cognitively, which has scientists looking at the connection between brain fog during perimenopause and the risk of developing Alzheimer’s years later. This has been described as an aging brain hungry for estrogen, crying out for more estrogen by making additional receptors to try to absorb as much of the hormone as possible. And while the verdict is still out, this information does seem to support the claim that hormone replacement therapy (HRT) can help reduce the risk of dementia.

This creates an interesting paradox. Although men might have genetic factors that make them more vulnerable to developing Alzheimer's, women have biological risk factors that result in higher actual disease rates. For anyone without a history of cancer who is worried about Alzheimer’s, talking to your doctor about HRT might be beneficial. But what does this mean for women who are unable or choose not to take hormone replacement therapy? Are they just out of luck? Not necessarily.

There is a common saying in the preventive medicine world “genetics [or biology] loads the gun; lifestyle pulls the trigger.” It's like having a genetic predisposition to skin cancer versus actually developing it; many factors beyond genetics determine the final outcome, including consistently wearing sunblock. Whether someone is genetically predisposed to Alzheimer’s or biologically programmed, no one is destined to spend their final years in a nursing home suffering from dementia. There are things you can do to lower your risk, and it’s never too late or too early to start.

Below are four lifestyle choices that can help support brain health. From diet to stress management, being born female doesn’t mean you’re destined to lose your mind.

Four Lifestyle Habits to Support Brain Health

1. Diet

Your brain and your gut are intimately connected. What you eat not only affects your gut but also your brain and your mood. Many of the same foods that benefit your gut microbiome help to keep your brain healthy, with the primary goal of limiting inflammation in the body. Such a diet is rich in whole, unprocessed foods, and limits consumption of foods that can increase the risk of cognitive decline, such as red meat, sugar, fried foods, and saturated and trans fats.

With lowering inflammation in the brain as one of their key goals, researchers at Rush University Medical Center combined the best aspects of both the Mediterranean Diet and Dean Ornish’s heart-healthy DASH Diet to create the MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) Diet and found that the diet can lower a person’s Alzheimer’s risk by up to 53%, depending on how rigorously it is followed. This diet emphasizes plant-based foods, such as leafy greens, berries, nuts, seeds, legumes, and whole grains, with moderate amounts of poultry, fish, eggs, and more limited amounts of red meat and wine.

According to the Physicians Committee for Responsible Medicine, which advocates for a whole-food plant-based diet, populations that consume higher amounts of plant-based foods, especially leafy greens and cruciferous vegetables, had lower rates of dementia. Regardless of which diet you follow, incorporating the following foods into your diet and limiting your intake of sugar, processed foods, saturated fats, and alcohol* will go a long way in keeping your brain healthy for years to come.

* A note on alcohol: To date, the research is still contradictory on the benefits of wine for brain health. Some studies, like the ones that led to the MIND Diet, claim that a glass of wine per day is protectionary against Alzheimer’s. Other studies claim that even very modest consumption of alcohol, including wine, leads to long-term changes in the brain. For those with a healthy brain, there may be minimal impact to the brain, but researchers caution that as we age and our metabolism changes, alcohol should be avoided. Hopefully, with more time and more research, scientists will be able to figure out how much, if any, alcohol can be safely consumed. Until then, it’s a personal choice whether to abstain completely, only have a glass on a special occasion or relax with a glass of wine every night.

Five of the Best Foods for Preventing Dementia

While there are many foods that help support brain function, these five should be at the top of your list:

Colorful Fruits and Vegetables: Leafy greens, such as kale, spinach, broccoli, and collards. They are rich in vitamins A and C and carotenoids, which have been proven to support brain health and lower dementia risk.

Other foods rich in carotenoids to incorporate into your diet include carrots, squash, sweet potatoes, bell peppers, tomatoes, papaya, and apricots.

Berries: One of the superfoods for brain health, berries are high in both antioxidants and flavonoids, phytochemicals that prevent cell damage and can inhibit brain damage from free radicals. Any type of berry will do, from blueberries to blackberries, strawberries to raspberries. As one of the categories of fruit that is lower in sugar, it is the only fruit recommended on the MIND diet.

Fish: Eating fish anywhere from once a week to three times a week is enough to help support brain function. Fatty fish, such as tuna and salmon, contains high amounts of Omega-3 fatty acids, which promote brain health and reduce the risk of cognitive decline.
Nuts, Seeds, Beans, and Legumes: A good source of antioxidants, Omega-3’s, as well as vitamins, minerals, healthy fats, and fiber. Adding a serving of walnuts, almonds, peanuts, soybeans, lentils, flax seeds or pumpkin seeds to your diet at least five times a week, as well as three servings of protein and fiber-rich beans, can not only help lower cholesterol and reduce the risk of heart disease but also promote brain health, by reducing the risk of Alzheimer’s.
Whole Grains: Unlike refined grains (think white flour, white pasta, white rice), whole grains contain the “whole” grain – the bran and the germ – along with more nutrients and more fiber than their refined versions. Three servings a day of quinoa, barley, brown rice, oats or other whole grains can go a long way in helping to reduce inflammation in the brain and decrease the risk of dementia.

2. Exercise

Physical activity not only improves brain health but can actually lower your risk of Alzheimer’s. According to Dr. Eileen West, a primary care doctor focused primarily on women, exercise is one of the most important methods of prevention. A meta-analysis of 58 research studies showed that regular exercise can reduce the risk of dementia by up to 20%.

Combining both aerobic exercise and strength-building activities can help. Whether it’s taking a brisk walk, running, playing sports, or engaging in activities of life, such as cleaning, gardening, and cooking, getting daily movement can help support brain health. The goal is to maintain this activity through midlife.

Dr. West suggests women should aim for at least 150 minutes of moderate activity, such as walking, every week. Mentally stimulating activities, such as doing puzzles, reading or learning something new, may also help protect the brain. Keeping the brain active builds a “cognitive reserve” that may delay symptoms of Alzheimer’s disease.

3. Sleep

Getting adequate sleep, anywhere from seven to eight hours per night, can reduce your risk of both dementia and death. Research has shown that poor sleep is associated with an increase in the amyloid-β protein that contributes to the progression of Alzheimer’s disease. One study conducted at Harvard Medical School found that those getting less than five hours of sleep a night had double the risk of developing dementia and double the risk of dying than those getting six to eight hours, regardless of age, health condition or body weight. Another study found that adults aged 50+ who got less than six hours of sleep per night had a 30% increased risk of dementia by the time they retired, compared to those getting seven hours per night.

4. Stress Management

Clinical studies have shown that chronic stress can accelerate aging which is a major risk factor for cognitive decline and Alzheimer’s disease. Depression and anxiety, which are closely related to stress, are also associated with a higher likelihood of developing dementia in later life. Nevertheless, managing stress could help reduce its effects on the brain and the body as a whole.

Techniques for managing stress include exercise and the more mindful physical practices of yoga and tai chi. Relaxation techniques such as mindful breathing and meditation have also been proven to reduce stress and anxiety, increase energy levels, as well as lower heart rate, blood pressure, and muscle tension. Journaling, creating art, practicing gratitude, self-compassion, and guided imagery can also lessen one’s stress levels and promote well-being.

If you're navigating menopause, midlife or memory shifts and want support building habits that protect your brain and your body, I’m here for you.

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The information in this article is intended for educational purposes only and is not a substitute for medical advice. Nothing in this article is intended to diagnose, treat, prevent, or cure any disease. Always consult with your healthcare provider before making any dietary, lifestyle, or supplement changes, and do not forego, delay or disregard medical advice based on the content shared in this article. Please consider your personal situation and individual needs and do your own research.