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Abstract

Alzheimer's disease and related dementias (ADRD) pose a massive public health challenge, affecting over 6.7 million Americans aged 65 and older—a number projected to double by 2050. Despite advances in pharmacological treatments, there remains no cure or method to reverse the disease. This paper highlights the role of psychological stress as a critical yet underappreciated risk factor for cognitive decline and reviews its complex interplay with behavioral, social, and biological mechanisms. Chronic psychological stress drives physiological and behavioral changes that are linked to accelerated cognitive deterioration, particularly in older adults. Early interventions can target stress management and behavioral prevention strategies, which include physical activity, healthy diet, and social engagement. Further, key barriers to meaningful policy change to prevent and slow ADRD include lack of public awareness, stigma around mental health and aging, and misaligned funding incentives. Policy initiatives can improve brain health literacy, increase equitable access to services, and enhance community-level and environmental factors to promote healthy aging. Prioritizing stress reduction and promoting early detection and prevention can meaningfully reduce ADRD risk and progression, improving public health broadly.

Keywords

cognitive decline dementia prevention policy psychological stress aging social determinants of health cognitive function

Social Media

Policy initiatives can help reduce the burden of Alzheimer's disease by addressing psychological stress. Early intervention through stress management, public awareness campaigns, and improving lifestyle factors can delay the onset of dementia and promote healthier brain aging.

Highlights

Chronic psychological stress is a modifiable risk factor for cognitive decline. Biological, social, and behavioral pathways interweave to increase the risk for Alzheimer's disease and related dementias (ADRD) and accelerate their progression.

Prevention strategies aimed at promoting cognitive brain health are critically important and include stress management, physical activity, healthy diet, and social engagement.

Barriers that hinder effective policy implementation include lack of public awareness, stigma around mental health and aging, and misaligned funding incentives.

Public health recommendations include improving brain health literacy, expanding equitable access to services related to mental health and aging, and creating community-level initiatives, such as enhancing neighborhood environments.

Intervening early (e.g., midlife), with more attention to stress management and prevention strategies, could promote healthy aging and reduce the societal burden of ADRD.

Alzheimer's disease (AD) is currently the 7th leading cause of death in the U.S., contributing not only to premature death but also to significant suffering among individuals with AD and their loved ones (Alzheimer's Association, 2024). Currently, more than 6.7 million people aged 65 and older are inflicted with AD and related dementias (ADRD). This number is expected to double by 2060, with projected annual costs for health care and long-term care approximating a trillion dollars annually (Alzheimer's Association, 2024). Although recent advances in pharmacological treatments offer some hope in slowing the progression of ADRD (e.g., Huang et al., 2023), no treatment has proved capable of halting or reversing the disease. Further, of the leading causes of death, AD is the only disease that has undergone a substantial rise in annual death rates in recent years, increasing 140.9% from 2000 to 2021 (Alzheimer's Association, 2024). An increasing body of research highlights the importance of psychosocial and behavioral factors in preventing or delaying the onset of age-related cognitive decline. A recent report from the Lancet Commission identified 12 modifiable risk factors that appear to be particularly strong targets for dementia prevention and estimated that 40% of worldwide dementia cases could be prevented or delayed through targeted intervention (Livingston et al., 2020).

Intervening early, before ADRD symptoms are evident, offers the greatest potential to slow or prevent cognitive decline. In this context, prevention strategies aimed at promoting cognitive brain health throughout life are particularly needed. A key but underappreciated factor in these efforts is psychological stress and how individuals respond to it. This paper will explore the known effects of psychological stress on cognitive health, examining the social, emotional, behavioral, and biological mechanisms that link stress to cognitive decline. We then outline key barriers to meaningful policy change to promote healthy aging. Lastly, we offer policy implications related to stress that could significantly mitigate cognitive deterioration and, in doing so, improve public health on a broad scale.

Stress and Brain Health Connections

Pathways Involving Psychological Stress

Psychological stress—defined here as subjective feelings of strain in response to negative events—is a well-established risk factor for both mental and physical health issues, including cognitive decline (Almeida, 2024; Glaser & Kiecolt-Glaser, 2005; McEwen, 2004). The relationship between stress and cognitive health is complex and involves behavioral, social, emotional, and physiological processes. Stress not only directly influences cognitive function (as reviewed further below) but also exacerbates psychosocial and behavioral risk factors for AD, such as social isolation (Campagne, 2019), disrupted sleep (Lücke et al., 2022; Sin et al., 2017), poor diet (Yau & Potenza, 2013), and physical inactivity (Stults-Kolehmainen & Sinha, 2014)—all of which are associated with accelerated cognitive decline (Barthold et al., 2024; Dickinson et al., 2011; Randolph & Randolph, 2022). Physiologically, there are well-characterized pathways by which the body's responses to stress can affect cognitive health. Chronically elevated cortisol, the body's primary stress hormone, can impair memory and disrupt hippocampal function—a brain area critical for learning and memory (Kirschbaum et al., 1996; Lupien et al., 1997; Magri et al., 2006). Stress also elevates proinflammatory markers, such as cytokines, which are associated with cognitive decline (Vodovotz et al., 2024; Wright & Engeland, 2023). Moreover, negative emotions and repetitive negative thinking, such as worry and rumination, can prolong the physiological effects of stress (Smyth et al., 2013) and have been linked to the buildup of amyloid and tau proteins (key biomarkers of AD) as well as accelerated cognitive decline (Marchant et al., 2020).

Chronic psychological stress (i.e., stress that occurs over extended periods) is strongly linked to cognitive decline and increased risk of mild cognitive impairment (MCI) and dementia. Among older adults, higher levels of perceived stress are consistently associated with worse cognitive performance and the development of cognitive impairment, findings that are robust to demographic and socioeconomic differences (Kulshreshtha et al., 2023). Moreover, adults aged 65 and older who report higher stress experience more rapid cognitive deterioration across multiple cognitive domains (Aggarwal et al., 2014; Munoz et al., 2015; Turner et al., 2017). Elevated stress has also been shown to predict the onset of amnestic MCI, a precursor to AD, further highlighting the importance of psychological stress as a critical risk factor in cognitive aging (Katz et al., 2016).

Stress has not been linked with cognitive decline solely among older adults. Stress exposure earlier in life can have long-lasting effects, with consequences that persist for decades (D'Amico et al., 2023; Sindi et al., 2017). For example, individuals reporting high levels of job strain in midlife tend to experience reduced cognitive functioning in older age (Andel et al., 2012). Such findings underscore the value of early intervention on stress, such as through stress management in midlife, for reducing long-term risk of cognitive decline.

Stress-related psychological, social, and behavioral targets for prevention

As noted, stress is intertwined with multiple behavioral and social factors that are increasingly recognized to be risk factors for accelerated cognitive decline. Importantly, these factors—often grouped under “lifestyle medicine” (Short & Mollborn, 2015)—pose risks that go beyond genetic susceptibility (Lourida et al., 2019). Several key behavioral factors have been identified as particularly powerful risk factors relevant to prevention. One of the strongest risk factors for cognitive decline is physical inactivity. Being highly sedentary is associated with an increased risk of cognitive decline, and physical activity interventions have consistently demonstrated cognitive benefits in multiple clinical trials (Zhao et al., 2022).

Dietary interventions also appear to be strong targets for reducing cognitive decline. The “MIND” diet, specifically developed to prevent ADRD, has shown promising results in multiple trials: It appears to slow symptom progression and to reduce risk for developing AD (Bhuiyan et al., 2023). The MIND diet emphasizes regular consumption of fresh fruits and vegetables, whole grains, and protein sources such as fish, poultry, and plant-based foods, while limiting red meat, processed foods, and sugary items. Ongoing research is investigating the role of polyunsaturated fatty acids (PUFAs) and other potential mechanisms related to the MIND diet (Bhuiyan et al., 2023). For example, regular consumption of fatty fish, which is rich in PUFAs and antioxidants, has been associated with decreased rates of cognitive decline and ADRD (Godos et al., 2024).

Adequate sleep is another important prevention target. Poor or insufficient sleep has been shown to precede ADRD and is associated with faster cognitive decline (Lloret et al., 2020; Zhang et al., 2022). Although causal connections between sleep patterns and the emergence of AD are not yet fully established, the mechanisms through which healthy sleep patterns protect cognitive function are becoming better understood and non-pharmacological sleep-based therapeutic approaches show promising effects on markers of neurodegeneration (e.g., tau protein) and on memory (Cordone et al., 2021).

Maintaining social connections and reducing loneliness are also increasingly recognized as critical for maintaining cognitive health and independence in aging (Guarnera et al., 2023; Harrington et al., 2023; Henry et al., 2023; Majoka & Schimming, 2021). An important aspect of the power of social relationships is their strong link with mental health, including depression and anxiety. In conjunction with a lack of social connection, depression and anxiety (which are themselves strongly linked to cognitive health) can hinder efforts to seek care or maintain healthy behaviors (Van Orden & Heffner, 2022).

This key set of behavioral and social factors—exercise, diet, sleep, and social engagement—are deeply intertwined with psychological stress and its emotional and physiological effects. Stress can undermine efforts to maintain healthy behaviors; ironically, these same behaviors buffer the negative effects of stress. For example, insufficient sleep amplifies negative emotional responses to stress, whereas physical activity can reduce stress-related negative mood (Sin et al., 2020). Additionally, whereas stressful days generally lead to higher negative mood, those who stay physically active appear to experience less intense increases in negative mood linked to a stressor compared to those who are less active—a buffering effect that is particularly noticeable when physical activity occurs closer in time to a stressor (Puterman et al., 2017). Social integration and loneliness also modulate emotional and physiological stress responses, influencing healthy aging trajectories (Graham-Engeland, 2024; Harrington et al., 2023; Van Bogart et al., 2021).

Stress and related behaviors are often shaped by social determinants of health—the conditions in which people live and work and which are influenced by factors such as economic stability, education, access to healthcare, and the quality of the environment (Majoka & Schimming, 2021). Individuals with lower income, less education, or living in disadvantaged neighborhoods face greater stress and have fewer resources to cope with aging-related challenges (Wiese et al., 2023). For example, cognitive decline occurs faster among those experiencing more negative life events, especially if they have fewer years of education (Tschanz et al., 2013). Historically marginalized groups, such as Black, Hispanic, and LGBTQIA + populations, face unique stressors from discrimination and systemic oppression, contributing to the disparities in cognitive health and ADRD that have been observed in such groups (Cuevas & Williams, 2018; Harrington et al., 2024; Majoka & Schimming, 2021; Wardecker et al., 2021).

Changing and cumulative stress burden in daily life

The burden of stress across multiple life stages appears to be increasing, highlighting the need for a deeper understanding of its impact on cognitive health. Historically, older adults have reported fewer daily stressors and healthier emotional responses compared to younger adults, largely attributed to age-related differences in experiences and emotional regulation (Almeida et al., 2023). However, recent trends suggest that this age-related advantage may be diminishing. Middle-aged and older adults are now reporting more frequent stressors compared to previous generations. For instance, middle-aged adults in the 2010s experienced a 19% increase in stressor frequency compared to those in the 1990s, with stressors related to finances and future plans increasing by 61% and 52%, respectively (Almeida et al., 2020). A key driver of this trend may be that traditional coping strategies, which historically helped build resilience, are proving less effective against modern stressors, such as economic uncertainty, working later in life, and technological change. Financial pressures, including the need to stay in the workforce longer due to economic necessity, contribute to cumulative stress exposure. Increases in such pressures may have weakened the emotional resilience that older adults once exhibited.

The effects of stress accumulate, both biologically (via wear and tear on physiological systems) and behaviorally (through ingrained emotional and social patterns), accelerating diseases related to aging over time (Epel et al., 2018). Midlife thus appears to be a particularly critical time window for stress intervention. As noted above, this stage of life often involves the convergence of significant work-related stress, financial concerns, and caregiving responsibilities, all of which can intensify vulnerability to cognitive decline (D'Amico et al., 2023; Sindi et al., 2017). Addressing stress during this time is crucial, as it sets the stage for health in later life, including how long individuals will live independently and in good health. This said, even older adults, particularly those without symptoms of ADRD, can benefit from targeted intervention. For example, increasing physical activity levels in older adults has been shown to improve cognitive health, and the greatest improvements occurred in previously sedentary individuals (Sink et al., 2015). Hence, early intervention is important, but intervention efforts can be beneficial at all ages.

As research on stress mechanisms and interventions continues to grow, policymakers, clinicians, and individuals must prioritize prevention. Broad estimates suggest that delaying the onset of Alzheimer's symptoms by even a few years could extend life by 2.7 years and save approximately $500,000 per person in the U.S. among individuals who would eventually develop the disease (Zissimopoulos et al., 2014). Understanding the links between stress and cognitive aging is key to shaping policies that promote long-term cognitive health.

Policy implications and barriers to progress

Key Barriers and Implications

Lack of public awareness regarding stress. Given the clear links between psychological stress and cognitive decline, there are several key barriers to addressing stress-related cognitive health risks through policy interventions. One of the most significant barriers is the lack of public awareness regarding the long-term cognitive effects of chronic stress. Many individuals are unaware that stress is a modifiable risk factor that can exacerbate cognitive decline, especially in later life. Public health campaigns that are designed to raise awareness and promote stress management interventions are crucial. Such initiatives could help delay or reduce the risk of mild cognitive impairment (MCI), particularly if targeted at midlife when stress-related damage is known to accumulate and influence long-term brain health.

Stigma related to mental health and aging. Compounding lack of public awareness is the stigma that surrounds both mental health and aging. Such stigma contributes to stress and discourages many individuals from seeking support for memory-related issues and interventions that could benefit cognitive health. ADRD itself is stigmatized due to negative perceptions and misunderstandings linked with mental health conditions, terminal illnesses, and aging (Rosin et al., 2020). Among those with concerns about cognitive decline, the vast majority indicate that they have not discussed their concerns with a health care provider, often citing embarrassment or fear of what will happen if others are aware that they are experiencing cognitive problems (Hill et al., 2023). Such concerns affect health care decisions related to aging. For example, hearing aids can significantly reduce dementia risk for individuals with hearing loss (Lin et al., 2023), but they remain underutilized, in part due to concerns about age-related stigma and the perception that wearing a hearing aid signifies decline. Normalizing the use of hearing aids and integrating mental health screenings into routine primary care and workplace wellness programs would reduce stigma and encourage individuals to engage with preventive services earlier. Similarly, making it the norm for clinicians to involve family or close friends in discussions and care decisions could not only help with earlier detection but also would help reduce stress and barriers to planning. Such policy efforts may play a particularly significant role in slowing cognitive decline given that psychological stress and untreated conditions like hearing loss contribute to dementia risk through social isolation, depression, and other factors that can interact with and exacerbate cognitive issues.

Misalignment of funding incentives. The burden for prevention of ADRD should not solely fall on individuals and their families. Societal-level support is greatly needed but requires high-level resources. In this context, the misalignment of private funding incentives presents a significant barrier to long-term cognitive health interventions. In the U.S., health insurers and wellness programs often prioritize short-term cost savings due to the transient nature of insurance coverage, offering little incentive to invest in preventive strategies that may only show cognitive health benefits decades later. Policymakers could address this by providing tax incentives or subsidies for private companies and insurers that invest in long-term wellness and stress-reduction programs. Aligning financial incentives with long-term health outcomes would encourage broader adoption of preventive measures that could significantly reduce the societal burden of AD and other neurodegenerative diseases in the coming decades.

Inequitable access to services. The reach of stress management programs is limited by inequitable access to mental health services, particularly for marginalized and low-income populations, who often experience higher levels of chronic stress due to socioeconomic factors, discrimination, and structural barriers. Expanding public funding for such services, particularly in underserved areas, and promoting telemedicine options would help bridge this gap. Addressing social determinants of health, including financial stress and limited access to quality healthcare, would play a role in reducing cognitive health disparities across racial, ethnic, and socioeconomic groups.

Lack of brain health literacy. A key barrier to addressing cognitive health is the lack of brain health literacy—i.e., the public's limited understanding of cognitive health and the importance of prevention. ADRD is misunderstood by many people. For instance, many individuals take a fatalistic view of ADRD, believing there is little they can do to prevent these conditions, particularly if they have a family history of dementia. This mindset can discourage both early detection of risk as well as engagement in healthy behaviors that can prevent or delay symptoms. Brain health literacy involves more than just understanding the signs and symptoms of cognitive decline; it also encompasses knowledge about the modifiable lifestyle factors that influence brain health, such as stress management, diet, exercise, and sleep. Interventions aimed at improving brain health literacy—especially during midlife—can play a critical role in preventing dementia (Livingston et al., 2020). Educational efforts should emphasize that adopting brain-healthy behaviors, such as managing stress and addressing sensory deficits (like hearing loss), can significantly delay or reduce the likelihood of developing dementia. Incorporating insights from the Brain Health Literacy model (Light et al., 2024), which blends health literacy frameworks with empowerment theory, can enhance the effectiveness of such interventions. This model highlights that brain health literacy is not only about access to knowledge but also involves fostering self-efficacy and personal agency in managing one's cognitive health. Empowering individuals with the knowledge and tools to take actionable steps to preserve cognitive function can help shift attitudes from fatalism to proactive engagement in brain health maintenance.

To combat these challenges, public health initiatives should prioritize culturally tailored and community-based education programs that raise awareness about the modifiable nature of many dementia risk factors. Such programs should target diverse populations, particularly underserved groups who may face additional barriers to accessing information and care. These initiatives can encourage early detection and help shift the focus from inevitable decline to prevention, potentially reducing the societal burden of dementia over time.

Additional considerations for community-level factors

In addition to individual-level intervention (e.g., stress management, education), addressing community-level factors is crucial in mitigating the risk of ADRD. Neighborhood environments play a significant role in cognitive health, with multiple community factors contributing to stress and cognitive decline. For example, exposure to poor air quality, limited access to healthcare, excessive noise, and few opportunities for social connection are all associated with increased ADRD risk (Wiese et al., 2023). A promising approach for community-level intervention involves enhancing the “cognability” of neighborhoods—designing environments that actively support cognitive health. Cognability (Light et al., 2024) refers to the degree to which physical and social environments are structured to facilitate cognitive engagement and reduce stress. Communities can improve cognability by increasing access to green spaces, ensuring safe and walkable neighborhoods, and creating opportunities for social connection and lifelong learning. Such interventions have the potential to reduce chronic stress and promote healthier cognitive aging by offering residents more opportunities to engage in mentally stimulating and socially enriching activities.

Caregiving stress

Although it is beyond the scope of this paper to review the robust body of work on caregiving, the issue of caregiving stress is an important concern for cognitive brain health. At some point, the disease progression of ADRD often involves caregiving by a spouse or other family members. These individuals (who are typically unpaid and approximately two-thirds women) provide 83% of such care, with a value of $346.6 billion in unpaid time worked (Alzheimer's Association, 2024). The majority (59%) report high or very high emotional stress; further, the incidence of depression in dementia caregivers is 30% to 40% higher than that observed in other forms of caregiving (Alzheimer's Association, 2024). Stress related to caregiving may have long-reaching effects, increasing the risk of future dementia among care providers and potentially even their family members (Norton et al., 2010). Thus, strategies to decrease caregiving-related stress may help prevent ADRD risk.

Concluding remarks

Stress matters for brain health because it is a powerful, modifiable risk factor for cognitive decline and AD. A growing body of research demonstrates that psychological stress accelerates cognitive deterioration through behavioral, social, and physiological mechanisms. Although pharmacological treatments continue to advance, focusing on stress reduction as a preventive strategy offers an invaluable opportunity to alter the trajectory of cognitive decline. Multiple modifiable factors have been identified that can slow, delay, or prevent dementia (Livingston et al., 2020), including behavioral patterns related to diet, physical activity, and sleep; given that these can have cumulative effects and interact in complex ways with stress and social context, interventions targeting stress that are tailored to individuals/families, which include community-level elements, and which are multi-faceted (focusing on multiple behavioral parameters) will likely be of highest value.

From a policy perspective, addressing psychological stress is a viable strategy for reducing the population-level risk of neurodegeneration. Such an approach is likely to both promote public health and substantially reduce costs associated with ADRD (Zissimopoulos et al., 2014). Policies that improve brain health literacy, reduce stigma around aging and mental health, and increase access to stress-management resources can have a profound impact. By prioritizing stress reduction and integrating it into broader health initiatives, we can significantly decrease the risk of cognitive impairment and improve the overall quality of life among aging populations.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the National Institute on Aging (grant number AG003949-38, AG081719).

ORCID iD

Jennifer E. Graham-Engeland

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Psychological Stress and Cognitive Brain Health: Policies to Reduce Dementia Risk

Abstract

Keywords

Social Media

Highlights

Stress and Brain Health Connections

Pathways Involving Psychological Stress

Stress-related psychological, social, and behavioral targets for prevention

Changing and cumulative stress burden in daily life

Policy implications and barriers to progress

Key Barriers and Implications

Additional considerations for community-level factors

Caregiving stress

Concluding remarks

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References