attainment over time in the United States — the gains in which have been more substantial for women than men — has led to decreased risk for dementia.277 Interestingly, European studies have found that the relationship of lower education with dementia outcomes may be stronger in women than men.278-279 Other societal gender differences may also be at play, such as differences in occupational attainment between men and women, with a recent study showing that women who participated in the paid workforce earlier in life had better cognitive outcomes after age 60.280-282 It is unclear whether genetic risk operates differently in women and men in the development of, or susceptibility to, Alzheimer’s pathology.283 A number of studies have shown that the APOE-e4 genotype, the best known common genetic risk factor for Alzheimer’s dementia, may have a stronger association with Alzheimer’s dementia284-285 and neurodegeneration286 in women than in men. A recent meta-analysis found no difference between men and women in the association between APOE-e4 and Alzheimer’s dementia overall, although age played an interesting interactive role. That is, APOE-e4 was related to higher Alzheimer’s risk in women than men between ages 55 to 70, when APOE-e4 is thought to exert its largest effects.287 It is unclear whether the influence of APOE-e4 may depend on the sex hormone estrogen.288-289 Racial and Ethnic Differences in the Prevalence of Alzheimer’s and Other Dementias Older non-Hispanic Blacks and Hispanic Americans are disproportionately more likely than older Whites to have Alzheimer’s or other dementias.290-296 Data from the CHAP study indicates 19% of Black and 14% of Hispanic adults age 65 and older have Alzheimer’s dementia compared with 10% of White older adults.224 Most other prevalence studies also indicate that older Blacks are about twice as likely to have Alzheimer’s or other dementias as older Whites.261,297-298 Some other studies indicate older Hispanic adults are about one and one-half times as likely to have Alzheimer’s or other dementias as older White adults.298-300 These disparities have remained constant over time.292 However, the population of Hispanic persons comprises very diverse groups with different cultural histories and health profiles, and there is evidence that prevalence may differ from one specific Hispanic ethnic group to another (for example, Mexican Americans compared with Caribbean Americans).301-302 The higher prevalence of Alzheimer’s dementia in Black and Hispanic populations compared with the White population appears to be due to a higher risk of developing dementia in these groups compared with the White population of the same age.303 Race does not have a genetic basis, and genetic factors do not account for the large differences in prevalence and incidence among racial groups.303-304 Some evidence does support that the influence of genetic risk factors on Alzheimer’s and other dementias may differ by race.79-83,305 26 Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures. Alzheimers Dement 2022;18. Created from data from 8 Projected Number of People Age 65 and Older (Total and by Age) in the U.S. Population with Alzheimer’s Dementia, 2020 to 2060 figure 5 Instead, research suggests, the difference in risk for Alzheimer’s and other dementias is explained by disparities produced by the historic and continued marginalization of Black and Hispanic people in the United States — disparities between older Black and Hispanic populations and older White populations in life experiences, socioeconomic indicators, and ultimately health conditions.306 These health and socioeconomic disparities are rooted in the history of discrimination against Black individuals and other people of color in the United States, not only during interpersonal interactions, but also as enshrined in the rules, practices, and policies of U.S. banks, laws, medical systems and other institutions — that is, structural racism.307-308 Structural racism pervades many aspects of life that may directly or indirectly alter dementia risk. Structural racism influences environmental factors such as where people can live, the quality of schools in their communities, and exposure to harmful toxins and pollutants. It also influences access to quality health care, employment prospects, occupational safety, the ability to pass wealth to subsequent generations, treatment by the legal system and exposure to violence.309-311 Differences in the social and physical environment by race/ethnicity across the life course increase risk for chronic conditions that are associated with higher dementia risk, such as cardiovascular disease and diabetes. These health conditions, which disproportionately affect Black and Hispanic populations, may partially explain the elevated risk of dementia among Black and Hispanic populations.79,306,312-313 Many studies suggest that racial and ethnic differences in dementia risk do not persist in rigorous analyses that account for health and socioeconomic factors.153,226,303 The influence of structural racism may cascade and compound across the course of a person’s life. For example, some studies indicate that early life experiences with residential and school segregation can have