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THE LANCET
NeurologyVol 3 June 2004 http://neurology.thelancet.com
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We identified 15 observational longitudinal studies,which were all done in Europe and in North America,
31–44
except one from China (tables 1–3).
45
With the exception of two investigations that included a large sample of volunteers,
32,38
all are population-based studies from wellknown cohort surveys focused on ageing. The initial cohortof the MacArthur Studies of Successful Aging comprisedhigh-functioning older adults, which could limit thegeneralisability of the findings.
33,41
The definition of different activities and social networkvaries largely not only in the measurements used but also inthe conceptual level of investigation. Some studies usedsimple quantitative assessment, such as number of socialties, number of activities, and time devoted to activities.Other studies took into account underlying dimensions andpossible mechanisms by examining emotional or structuralsupport, social integration, and social engagement; newinformation processing activities, cognitive activity score,experiential activities, and developmental activities; orspecific aerobic exercises. With the available information, itis not possible to identify the effect of a specific mental orphysical activity; therefore, generalisations are made aboutbroad categories. Large variation is also present in theassessment of cognitive performance, ranging from very short global cognitive tests
31
to large neuropsychologicalbatteries testing multiple cognitive domains.
32,33
Most of thestudies examined the association between the lifestyleassessed at baseline and cognitive performance at follow-up;only six studies related the lifestyle to cognitive decline. Lessvariation is present in the length of follow-up (6–7 years inmost studies). Only one study had a follow-up of less than3years,
41
and one study examined results derived from threefollow-ups expanding the observational period to 12 years.In only two studies did researchers assess midlife activity inrelation to cognitive ability after 65 years of age.
38,40
All studies controlled for demographics includingeducation, but only a few included other indicators of socioeconomic status, which could have a confounding role.Whether education sufficiently controls for the socioeconomicstatus is unclear, especially in these elderly cohorts where socialmobility was common.
46
All studies controlled for baselinecognitive performance and for health status, mostly measuredwith functional scales or self-assessment or reported diseases.Few studies explicitly controlled for depression,
31,33,37,44
and only two for personality.
32,38
As commonly happens in epidemiological research, noneof the reported studies were totally free of methodologicalproblems. Although each study has some limitations, theresearchers consistently tried to verify the possible effect of such limitations on their results. In summary, the findingsfrom these studies can be regarded as internally valid.
Randomised controlled trials
There are no randomised controlled trials that test thehypothesis that a rich social network decreases age-relatedcognitive decline.
Cognitive training
Numerous cognitive training interventions have been doneunder laboratory or small-scale clinical conditions. In general,
Review
Lifestyle and dementia
Table 2. Observational longitudinal studies of the association between non-physical leisure activities and cognition
Study, RefnAge at Non-physical activitiesFollow-upCognitive Control ReportedCountrybaseline (years)assessmentfactorsassociations(years)
Gold et al,38 316 64·7 Engaged lifestyle (SES, locus 40Intelligence (verbal, SRH, pers, Engaged lifestyle withCanada
*
men(mean atof control and intellectual nonverbal, mechanical paternal SESmaintenance of verbalfollow-up)activities)tasks)intelligenceHultsch 3225055–86Social activities; new-6Decline in cognitive CD, IADL, Intellectually challenginget al, information-processing function (memory, SH, med, activities with lower probabilityCanadaactivities; physical activitycomprehension, and speed)persof cognitive decline, but alsohigher cognition with higheractivityBosma 3483049–81Physical exercise, mental, and 3Specific tests for memory, CogAll three activities with loweret al,social activities (hours per and verbal fluency; global probability of cognitiveNetherlandsweek)cognitive test (MMSE)decline, but also highercognition with higher activity Aartsen 35207655–85Everyday activity, including 6Specific tests for memory, PFNo association of any activityet al,social, experiential, and fluid intelligence, and speed;with cognition, but information-Netherlandsdevelopmental activitiesglobal cognitive test (MMSE)processing speed withdevelopmental activityMenec,36 129267–95Social, mental, and productive6Combined physical and ADL, IADL, Greater overall activity, andCanadaactivities; number of leisure mental function indexcog, SH, social and productiveactivitiesmorb, LSactivities with better functionRichards 39191936Spare-time activity (activities 7Verbal memorySES, IQ, SH, Spare-time activity andet al,with high social and mental depphysical exercise with betterUKcomponent); physical exercise memory performance in midlife
All associations were controlled for age, gender, and education. SES=socioeconomic status. Additional control was performed for SRH=self reported health; pers=personality;CD=chronic diseases; IADL=instrumental activity daily living; SH=subjective health; med=drug use; cog=cognitive function; PF=physical function; morb=morbidity, LS=lifesatisfaction; dep=depression.
*
Confirmed by Arbuckle et al (reference 40) with a follow-up of 45 years.
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