Social Determinants of Health, Resilience, and Premature Cognitive Aging in End-stage Renal Disease

Only 13% of the 780,000 adults living with end-stage renal disease (ESRD) have normal cognitive function. We found that 14.0% of ESRD patients aged 35-49 experience severe cognitive impairment and 2.9% have a co- occurring functional dependence suggestive of Alzheimer’s disease and related dementia (AD/ADRD). After dialysis initiation older (≥65) patients experience a 21-25% lifetime risk of AD/ADRD. Younger ESRD patients experience premature cognitive aging requiring the study of cognition and AD/ADRD across the lifespan. Black ESRD patients are more than twice as likely to develop cognitive impairment and 70%-78% more likely to be diagnosed with AD/ADRD; this disparity is comparable to a 10 year increase in age. While social determinants of health (SDOH) are known contributors to health disparities in community-dwelling older adults, its impact on cognitive aging among ESRD patients is understudied. Measurement of SDOH is crucial to identifying ESRD patients who are at risk of premature cognitive aging and those who are resilient. Elucidating mechanisms by which SDOH impacts cognitive aging will lead to interventions and policies that may prevent the devastation of AD/ADRD for ESRD patients. ESRD patients are the ideal population to elucidate these mechanisms: 1) 30% of patients are Black; 2) 87% experience premature cognitive aging; 3) all enroll in a national registry and 65% in Medicare for measurement of institutional SDOH. For all adult ESRD patients in the national registry/Medicare database, we will glean 23 SDOH from publicly available data and identify 3 indicators of institutional SDOH. Then, we will link these data to our ongoing, NIA-funded, multi-center, prospective cohort study (FAIR, n=5,275) of aging and ESRD to fully characterize SDOH. This is the oldest (>12 years) ESRD cohort study that includes longitudinal measures global and domain specific cognitive function. The National Kidney Foundation, Alzheimer’s Association, and a local community advisory board will guide the design and interpretation of the following aims: 1) To estimate the impact of SDOH on incident AD/ADRD; 2) To quantify the contributions of lifecourse SDOH on cognitive impairment and decline; and 3) To test whether resilience to SDOH protects against cognitive impairment and decline. By taking a lifecourse approach and engaging community, family, and patient stakeholders in all phases of our study, we will identify feasible targets for improving resilience. These potential targets for interventions and policies to counter SDOH will likely generalize to other populations with chronic diseases.