Learn about the roles that one’s sex (determined by genes and chromosomes), and gender (social role and preferred orientation) play in the risk for developing Alzheimer’s disease (AD) in men. We examine how they may impact the course of the disease.
Hector’s wife and daughter first noticed his memory problems when he was in his mid- 70’s.* His long-term memory was just fine, and he could tell detailed stories from his youth…repeatedly. But he needed reminders to remember what happened yesterday. Without his GPS he was having more difficulty finding his way around, and his GPS was getting more difficult to use. He was making less of an effort to pursue his hobbies. He felt more anxious around others, and so he wasn’t looking forward to seeing his friends. He still managed all his customary daily activities, remembered to shower, and drove as well as usual. He balanced his checkbook and he paid his bills on time, but any errands or tasks he forgot to write down in his notebook weren’t likely to get done. His high cholesterol, history of concussions during an active high school football career, and his long-term smoking habit all increased his risk for developing dementia. His wife urged him to get evaluated. His primary care clinician did cognitive screening, blood tests, and an MRI. Nothing remarkable was seen on the blood tests or MRI, but his delayed recall of a word list was abnormally low. Hector was showing signs of mild neurocognitive impairment.
*Vignettes in this article are fictionalized to protect the confidentiality of the individuals whose stories inspired them.
Hector’s story and his examination results suggest that he is in the early stage of a mild cognitive decline, possibly the one in which memory is most affected. For many people, this condition is an early step on the path to AD. As a man, Hector’s sex (determined by his genes, and specifically by his possession of a Y chromosome) and his gender (his social role and preferred orientation) play important roles in his risk for developing AD and the course which his disease will take. Clinicians and researchers have been learning more about this issue lately, and here are some of the things they’ve found:
- As a man, Hector’s risk of developing AD is less than a woman’s. The average 65-year-old man, for example, has a 6.3 percent risk of developing AD during the remainder of his life while the risk for a 65-year-old woman is 12 percent, nearly twice as great. There is still uncertainty about whether this is because women live longer. Sex-related effects help to lower men’s risk. One way that sex affects risk is through the male hormone, testosterone. Some testosterone is transformed into estrogen, and estrogen seems to protect healthy brain cells. Men in later life do not experience the massive decrease in estrogen levels that women do after menopause, and that may reduce men’s risk for AD. Sex also affects the danger of various risk factors. One of these, the E4 version of the apolipoprotein gene, referred to as ApoE4, is a less potent risk factor for men than for women.
- Hector’s gender, his culturally determined role behavior, also plays a key role in his risk of developing AD. In some ways, gender has worked on Hector’s behalf. As a man in his 70s, he was raised during an era when men typically reached a higher level of education. Men of his era also tended to be more physically active than women. Higher educational level and physical activity have protective benefits against AD.
On the other hand, his generation of men smoked and drank alcohol more heavily than women, and these are risk factors for developing AD. The demographics of these risk factors are changing as women’s educational achievements match men’s. Unfortunately, women now smoke and drink more, too.
- Hector is married, which has a protective benefit for men and also means that his wife and daughter are likely to become his caregivers if his mild neurocognitive disorder progresses to AD. Hector’s family will want to know that men with AD experience a slower cognitive decline during the course of AD. On the other hand, men do not survive for as long a period as women after diagnosis, perhaps because they are typically diagnosed later in the course of the disease.
- As a man with AD, Hector may become challenging to care for at home. Men with AD are more likely than women to develop combative or aggressive behavior. In one study, hospitalized men with dementia and behavioral symptoms were less likely to be discharged back home than women with dementia and behavioral symptoms. The women’s symptoms were less likely to include aggression.
Some of the ways in which sex and gender affect risk and disease course are modifiable through healthy lifestyle changes such as smoking cessation and physical activity. And Hector’s family will be better prepared to support him through the course of his illness by understanding how his sex and gender may alter the path of his journey, and theirs, through his illness.
Hector did indeed develop AD during the year after his evaluation. His wife and daughter cared for him until aggressive behavior made it necessary for him to live in a more restrictive setting, an Assisted Living Facility’s Memory Disorders Unit. With behavioral and medication treatment there, he was able to live a relatively enjoyable life for several more years, until his smoking-related bronchitis left him vulnerable to an infection that grew into pneumonia, which eventually caused his death.