James' World 2

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Scientists are still learning about the causes of Alzheimer’s, but most agree that many factors contribute to an individual’s risk of getting the disease. Some risk factors, such as age and genes, are inescapable. Others can be modified with lifestyle changes, such as exercise and nutrition—in one study, participants were able to reduce their risk of getting Alzheimer’s by 60 percent. Although most risk studies focus on dementia in general, here are important findings about the known risk factors as they apply to Alzheimer’s.

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Joelle Bolt

Katie Peek and Joelle Bolt; Sources: Risk factor relative importance: G. Livingston et al., The Lancet, 396, 413 (2020); normal brain aging: “Alzheimer’s Disease and Other Dementias,” Mayo Clinic, 2020

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As someone who has spent most of his professional life studying how children develop, I’m often asked by parents (especially mums) why children (especially boys) are prone to pick up the nearest stick, pencil, soft toy or even banana and turn them into weapons?

Girls certainly do this too. But research – and parents’ experience – shows you’re more likely to find boys using various objects as swords, guns or grenades to attack one another.

While some parents worry this is too violent, these actions do not mean you are raising a burgeoning psychopath. Rather, they are significant components of healthy development.

Playful aggression

Role playing is a key part of children’s play, when they pretend to be someone or something else. They can do this on their own or with others.

When they do it with others it is called “sociodramatic play”. This type of play teaches children both verbal and social skills while they interact with others.

Play fighting is one form of sociodramatic play. It can include rough and tumble play, chasing one another around, superhero play, wrestling and mock fighting. Psychologists call this “playful aggression”.

This kind of play is not about hurting anybody. Rather, it provides opportunities for children to explore their world with a sense of empowerment and control (because they set the rules) and to build relationships as they negotiate the play.

How does it work?

Imagine children are playing a battle with pillow forts and cardboard swords. This is not just a question of whose fort topples first. The game will require them to read facial expressions, express themselves and develop an awareness of power dynamics (or what researchers call “relationships hierarchies”).

Relationship hierarchies are complex, but focus on power and who is in charge. During episodes of playful aggression, this might mean taking control, giving in to someone else’s idea, or sharing power. These hierarchies allow children to make decisions about who they want to play with, who to avoid, or how to adapt their behavior to create friendships.

So relationship hierarchies play an important role in emotional and social development. They teach children how to get along with one another, how to make and play within a rule structure, and how to recognize the difference between playful and harmful behavior.

For example, other children’s reactions during the game will teach them that yelling and jumping may be considered fun. But rough pushing or deliberately breaking rules – such as turning into a killer dragon when everyone else has agreed to be tigers – is not OK and will make your friends unhappy.

Why do we see this more in boys?

You might be wondering why such behaviors seem to be more evident in boys than girls. Research shows boys (on the whole) tend to be more physical in how they play.

Their play often focuses on themes related to power and dominance and playful aggression is the perfect way to experiment with these themes.

Theories about sex differences in social play extend across many research areas including psychology, neurobiology, evolutionary psychology and anthropology. Current theories link these differences to testosterone and differences in neurochemistry.

There is some evidence to suggest boys and girls are socialized differently in relation to being physical.

However, the degree of influence is contestable, given sex differences in behavior appear very early in life and in other mammals. Perhaps the socialization process exacerbates nature – and as such, nature and nurture may be working in tandem.

The end result is still the same, with more boys than girls engaging in playful aggression.

When girls role play, it tends to focus on what researchers call “tend and befriend” or on people and nurturing. For example, games built around families or looking after pets.

But this is not to say girls can’t be aggressive. However, research suggests if girls fight, it is usually done with words to hurt someone’s feelings and children are upset with each other. It is not done for fun.

Perhaps this is why playful aggression can be difficult for some mothers to understand and appreciate.

But there is no link between playful aggression in children and being aggressive as an adult.

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While there are plenty of things that teenagers worry about, dementia isn’t normally one of them. Yet one new major Alzheimer’s drug trial is recruiting people as young as 18 to answer what may be the most pressing question facing the field: Can the ravages of the disease be prevented by identifying those on track to get it and treating them up to 10 years before they show symptoms?

The recent arrival of drugs that slow the cognitive decline of Alzheimer’s in many people is a welcome breakthrough, but so far their efficacy has only been demonstrated in people with mild symptoms. By the time patients are diagnosed, their brains have already undergone extensive changes. But growing evidence suggests that taking the drugs well before that damage has occurred could significantly slow the disease and possibly even stop it in its tracks.

“Now we have drugs that can slow the disease by 30 percent or so in people with symptoms, but that’s not good enough,” says Reisa Sperling, a neurologist who heads the Center for Alzheimer Research and Treatment at Brigham and Women’s Hospital in Boston. “We want to get to 100 percent, and that means preventing people from getting to the symptomatic stages.”

Earlier and earlier

In medicine, treating a disease when it is causing pathological changes in the body, but hasn’t yet progressed far enough to cause clinical symptoms, is known as secondary prevention. (Primary prevention is heading off a disease before there is any pathology, and tertiary prevention is managing symptomatic disease to slow the worsening of symptoms.) Secondary prevention has been essential to medicine’s triumphs in reducing the risks of death and disability for those with early heart disease or diabetes. Doctors don’t wait for someone to have a heart attack before prescribing a cholesterol-lowering statin or for someone to suffer artery or kidney damage before putting them on metformin to control blood sugar.

In 2023, the results of trials of lecanemab (brand name Leqembi) and donanemab on Alzheimer’s patients with mild cognitive impairment suggested that medicine may now have the tools to bring secondary prevention to bear on the disease. Both drugs are monoclonal antibodies that target the hardened clumps of protein called amyloid plaque that form in the brains of Alzheimer’s patients.

Although much is still unknown about the mechanisms of Alzheimer’s, there is little question now that the buildup of plaque precedes symptoms by many years. In the lecanemab and donanemab trials, the earlier patients were along the long road to plaque buildup, the better the drugs did in removing most of the plaque and slowing cognitive decline. “It’s when you remove nearly all the plaque with one of these drugs that you see the real benefits in terms of symptoms,” says Randall Bateman, a physician and professor of neurology at Washington University School of Medicine.

Because patients with even mild symptoms already have a large buildup of plaque, testing the notion that plaque-fighting drugs can be more effective earlier in the buildup process means enlisting presymptomatic patients for trials. “Studies are moving toward people who are just at the borderline for being positive for plaque and treating them to try to keep them from accumulating more of it and from having symptoms,” says Susan Abushakra, a physician and researcher who is vice president of clinical development and medical affairs at Alzheimer’s-focused biotech company Alzheon in Framingham, Mass.

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Joey Guidone/Theispot

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