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RESEARCH AND PRACTICE

Effects of Social Integration on Preserving Memory Function


in a Nationally Representative US Elderly Population
| Karen A. Ertel, ScD, M. Maria Glymour, ScD, and Lisa F. Berkman, PhD

Memory loss is a prominent feature of aging


Objectives. We tested whether social integration protects against memory loss
and is associated with substantial declines in and other cognitive disorders in late life in a nationally representative US sam-
quality of life and increased risk of dementia,1,2 ple of elderly adults, whether effects were stronger among disadvantaged indi-
institutionalization,3 and mortality.4 Few effec- viduals, and whether earlier cognitive losses explained the association (reverse
tive strategies for prevention or treatment have causation).
been identified.5 Several studies have sug- Methods. Using data from the Health and Retirement Study (N = 16 638), we
gested that features of the social environment examined whether social integration predicted memory change over 6 years.
are important predictors of cognitive outcomes Memory was measured by immediate and delayed recall of a 10-word list. Social
among the elderly (those aged 50 and older; integration was assessed by marital status, volunteer activity, and frequency of
contact with children, parents, and neighbors. We examined growth-curve models
for a review, see Fratiglioni et al.6 ). For exam-
for the whole sample and within subgroups.
ple, Fratiglioni et al. reported that limited social
Results. The mean memory score declined from 11.0 in 1998 to 10.0 in 2004.
networks were associated with increased risk
Higher baseline social integration predicted slower memory decline in fully ad-
of incident dementia,7 Barnes et al. found that justed models (P < .01). Memory among the least integrated declined at twice the
high social networks and high social engage- rate as among the most integrated. This association was largest for respondents
ment reduced the rate of cognitive decline,8 with fewer than 12 years of education. There was no evidence of reverse causation.
Bassuk et al. reported that individuals with Conclusions. Our study provides evidence that social integration delays mem-
many social ties were at lower risk of incident ory loss among elderly Americans. Future research should focus on identifying the
cognitive decline than were individuals with specific aspects of social integration most important for preserving memory. (Am
few social ties,9 and results from Zunzunegui J Public Health. 2008;98:12151220. doi:10.2105/AJPH.2007.113654)
et al. indicated that elderly men and women
with few social ties, poor social integration, and
social disengagement were at greater risk of regarding HRS sampling and interview and 11 571 (56.9%) provided memory scores
cognitive decline.10 These strong studies clearly methods have been published elsewhere.11,12 at all 4 assessments. We excluded respon-
indicate the importance of social relations in Briefly, enrollment was based on a multistage dents for whom data on covariates were
shaping cognitive decline. area probability sample of households, with missing (n = 542) or who scored below the
We examined the association between social supplemental sampling from a Medicare list 10th percentile of memory scores at baseline
integration and memory loss in a large, repre- for those born in 1914 or earlier. Communi- (n = 1553), for a final sample of 16 638. We
sentative sample of US residents born before ties with high fractions of Black or Hispanic excluded respondents with the lowest mem-
1948. We explored 3 related issues: whether residents were oversampled. Enrollment oc- ory scores to avoid bias caused by floor ef-
the associations found in previous studies curred in 3 waves (1992, 1993, and 1998), fects on the memory score. Respondents ex-
would be generalizable to a nationally repre- depending on birth year and spouses birth cluded because of low memory scores were
sentative sample of elderly in the United States, year. Most interviews were conducted by tele- significantly (P < .01) different from the rest
whether the effects would be stronger among phone. Our analyses were restricted to nonin- of the study sample for all covariates; for all
individuals in socially and economically disad- stitutionalized individuals interviewed in health measures, the excluded had statistically
vantaged conditions, and whether the results 1998, the first year with adequate social inte- significant worse baseline scores.
could be attributable to reverse causation. Al- gration measurements. Respondents were fol-
though it has limited clinical data, the Health lowed for up to 6 years (4 assessments), Assessment of Memory
and Retirement Study (HRS) provided an ex- through the 2004 interview. All data were The interviewers read a list of 10 common
cellent opportunity to address these 3 issues. based on self-report or direct assessment. nouns to the respondents. Immediately after-
For our study, we used information on so- ward, the respondents were asked to recall as
METHODS cial integration, sociodemographic characteris- many words as possible. After a 5-minute
tics, and health conditions gathered in 1998 delay during which other (unrelated) ques-
Study Population and memory scores assessed in 1998, 2000, tions were asked, the interviewers asked the
The HRS is a longitudinal, biennial inter- 2002, and 2004. Of 20 325 eligible respon- respondents to recall the words again. Details
view survey of a nationally representative co- dents, 18 733 (92.2%) provided at least 1 regarding the development, implementation,
hort of US adults 50 years and older. Details memory score during the follow-up period and validation of the recall test are available

July 2008, Vol 98, No. 7 | American Journal of Public Health Ertel et al. | Peer Reviewed | Research and Practice | 1215
RESEARCH AND PRACTICE

elsewhere.12 The sum of words correctly re- Currently married respondents received 1 depressive symptoms (measured with a modi-
membered in the immediate and delayed re- point for marital status; all others (currently fied 7-item Center for Epidemiological Studies
call tasks made up the memory score used in separated, divorced, widowed, or never mar- Depression Scale). Presence of vascular dis-
our analysis. There are several alternative ried) received 0 points. Respondents were ease was defined by the self-reported presence
methods of calculating a memory score from asked if they spent any time volunteering for of at least 1 of the following conditions: dia-
the recall test administered in the HRS, in- religious, educational, health-related, or other betes, hypertension, and stroke.
cluding using the immediate recall score charitable organizations. Respondents who Age, gender, race (White, Black, other),
alone, using the delayed recall score alone, or volunteered at least 1 hour in the past year years of completed schooling (range = 017)
creating a savings score (delayed recall score received 1 point in this domain; respondents household income, and household wealth
divided by immediate recall score). We exam- who did not volunteer any hours received 0 were assessed at baseline. Household income
ined the use of each of these alternative points. Respondents were considered to have and wealth were adjusted for household size
methods, and the results were consistent with contact with parents if they had weekly or and natural log transformed to bring in the
the results obtained by using the sum of im- more frequent contact (by phone, mail, or in right tail of the distribution. Coding from the
mediate and delayed recall. The sum score, person) with any parent (including mother, fa- Research and Development Corporation HRS
however, showed the best construct validity, ther, mother-in-law, or father-in-law). Respon- data set15 was used for income, wealth, and
and results from the sum score were conser- dents with no living parents were coded as physical health variables.
vative; thus, we present the results from the missing this domain. Contact with children
sum score only. was dichotomized on the basis of whether the Statistical Analysis
Although impaired memory score is not a participant or the participants spouse had We used linear growth-curve models to
clinical diagnosis, a substantial body of re- contact (by phone, in person, or by mail) with test the hypothesis that individuals with higher
search shows its importance as a health out- offspring (including children-in-law and baseline social integration would experience a
come and a potential early warning sign of stepchildren) once a week or more frequently. slower rate of decline in memory scores during
more severe cognitive impairment.13,14 In the Unfortunately, for married participants, both the follow-up period. Growth-curve models al-
HRS sample, memory score predicted subse- spouses contact with children was assessed lowed us to examine the trajectory of memory
quent risk of self-reported memory-related with a single combined question. Respon- scores by level of baseline social integration,
disease, institutionalization, and mortality dents without living children were coded as average rate of memory change over time, and
(results available from the authors). The HRS missing this domain. Contact with neighbors differences in rate of change by level of social
interviews included additional cognitive mea- was based on whether the respondents re- integration (i.e., the interaction of social inte-
sures, notably the Telephone Interview for ported getting together with neighbors just gration with time). We used linear modeling to
Cognitive Status (TICS). We focused only on to chat or for social visits weekly or more aid in the interpretability of results.
the memory measure because the TICS was frequently. Covariates were added to the model in 3
not assessed for all age-eligible respondents; In initial analyses, for simplicity of display, stages, with only those significant at the
additionally, the TICS was unlikely to be sen- we compared respondents with the highest < .05 level remaining in the model. The first
sitive to early cognitive losses because of the quartile of integration with all others. In sub- stage included core sociodemographic covari-
restricted range (013) of scores, which re- sequent analyses, we modeled social integra- ates. The second stage added adjustment for
sulted in a large fraction of respondents at tion as a continuous variable. baseline health characteristics (previous re-
each wave obtaining the highest score. search has indicated that social integration af-
Assessment of Covariates fects physical health, so we assessed the asso-
Assessment of Social Integration The following information about health was ciation of social integration and memory
We assessed baseline social integration measured at baseline: prevalent health condi- change with and without simultaneous adjust-
across 5 domains of social activity: marital tions (self-reported presence of high blood ment for physical health). The third stage
status, volunteer activities, and contact with pressure, diabetes, cancer, lung disease, heart added interaction terms between time and
parents, children, and neighbors. We set spe- disease, stroke, psychiatric problems, and each covariate that predicted baseline mem-
cific criteria for integration in each domain arthritis), mobility, large muscle index (diffi- ory score. Interaction terms were retained in
and assigned 1 point for each domain in culty sitting for 2 hours, getting up from a the final model only if they were significant.
which respondents were integrated. If respon- chair, stooping or kneeling or crouching, and Stratified models were examined for sub-
dents were missing data for a domain, their pushing or pulling a large object), limitations groups defined by gender, age (younger than
integration score for that domain was set to on basic activities of daily living (bathing, eat- 65 years or 65 years or older), race (Black or
missing. The sum of nonmissing values for all ing, dressing, walking across a room, and get- White), years of education (less than 12 vs 12
domains was the individuals social integra- ting in and out of bed), fine motor skills, in- or more), and presence of at least 1 of 3 vascu-
tion score (range = 05). If respondents were strumental activities of daily living (using a lar disorders (diabetes, hypertension, and
missing all domains, their social integration telephone, taking medication, handling stroke) that are risk factors for memory-related
score was set to missing. money, shopping, and preparing meals), and diseases.16,17 All covariates selected for the

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RESEARCH AND PRACTICE

final population-wide model were included in


stratified models.
To examine the possibility that memory loss
before baseline confounded the association
between social integration and subsequent
memory decline, we performed additional
analyses on 2 subsamples. For 1 subsample,
we excluded respondents who were most
likely to have already experienced memory
loss: respondents in the lowest 25th percen-
tile of baseline memory score. For the second
subsample, we focused on respondents who
participated in memory assessments in 1993
(n = 3762), 5 years before our social integra-
tion assessment. In this subsample, we tested
whether 1993 memory scores predicted
1998 social integration.
To account for the complex sampling design
Note. Models adjusted for age at baseline; age squared; sex; wealth; income; race; education; Center for Epidemiological
of the HRS, we used 1998 sample weights Studies Depression Scale; health conditions; mobility; large muscle index; activities of daily living; instrumental activities of
and clustering variables. We present 95% con- daily living; time indicator variables for 2000,2002, and 2004; and interaction terms between each time variable and level of
fidence intervals (CIs) for hypothesis tests. All social integration.
analyses were conducted with SAS 9.0 (SAS FIGURE 1Flexible growth-curve models showing predicted change in memory scores
Institute Inc, Cary, NC ). The PROC MIXED across 6 years of follow-up, by level of social integration at baseline: Health and
procedure was used for growth-curve models. Retirement Study, United States, 19982004

RESULTS
TABLE 1Sample Characteristics Among Participants, by Social Integration Quartile:
There was substantial heterogeneity in the Health and Retirement Study, United States, 1998
extent of social integration in our study sample.
Nearly one half of the sample reported contacts Participants With Participants With
All Participants High Social Integration Low Social Integration
in 3 or more domains, whereas more than
(N = 16 638) (Highest Quartile) (Lowest 3 Quartiles)
20% of the sample reported contacts in 0 or 1
Mean (SE) or % No. Mean (SE) or % No. Mean (SE) or % No.
domain. The baseline (1998) characteristics of
the respondents and their memory scores at Age, y 64.5 (0.08) 16 638 59.3 (0.11) 3496 65.9 (0.09) 13 142
each assessment by level of baseline social inte- Women 57.6 16 638 50.2 3496 59.7 13 142
gration are shown in Table 1. Respondents with Education, y 12.6 (0.02) 16 638 13.4 (0.04) 3496 12.3 (0.03) 13 142
high social integration were significantly White 88.4 16 638 91.4 3496 87.5 13 142
(P<.01) different from respondents with low CES-D score 1.5 (0.01) 16 638 1.1 (0.03) 3496 1.6 (0.02) 13 142
social integration for every covariate examined: Health conditions 1.5 (0.01) 16 638 1.2 (0.02) 3496 1.6 (0.01) 13 142
they were younger, were more likely to be Memory score at each wave
male and White, were more highly educated, 1998 11.0 (0.03) 16 638 11.9 (0.05) 3496 10.7 (0.03) 13 142
were healthier, and had better memory scores 2000 10.4 (0.03) 14 614 11.3 (0.06) 3226 10.1 (0.03) 11 388
at each assessment. Respondents in this sample 2002 10.2 (0.03) 13 341 11.2 (0.06) 3053 9.9 (0.04) 10 288
were aged 51 to 99 years at baseline. 2004 10.0 (0.03) 12 335 10.9 (0.06) 2914 9.7 (0.04) 9421
We first examined how memory scores
Note. CES-D = Center for Epidemiological Studies Depression Scale. Means, standard errors, and percentage values were
changed over the 6-year follow-up period by weighted to account for the complex sampling design of the Health and Retirement Study. All differences between
comparing people with high versus low social participants with high and low social integration were statistically significant (P < .01).
integration and adjusting for baseline sociode-
mographic and health variables (Figure 1).
Respondents with high social integration and dents with low social integration, respondents characterization of change over time, the
low social integration had similar memory with high social integration in 1998 had decline in memory scores was nearly linear.
scores at baseline (1998) but diverged over slower rates of memory decline over time. To aid in interpretation, we treated time as a
successive assessments. Compared with respon- When we allowed a flexible (i.e., nonlinear) linear variable in subsequent models.

July 2008, Vol 98, No. 7 | American Journal of Public Health Ertel et al. | Peer Reviewed | Research and Practice | 1217
RESEARCH AND PRACTICE

TABLE 2Estimates of Memory Decline the basis of the final model, we predicted that among individuals with strong risk factors for
For Time (In Years), Baseline Social in 1 year, individuals with the lowest social memory-related disease, social integration
Integration, and the Interaction integration (integration = 0) would have, on may provide an important buffer against
Between Time and Social Integration: average, a 0.29-point decline in memory memory decline (interaction of time and social
Health and Retirement Study, United score per year, compared with a 0.14-point integration: B=0.04; 95% CI = 0.03, 0.05).
States, 19982004 annual decline for individuals with the highest These results suggest that low social inte-
social integration (integration = 5). Thus, gration puts people at risk of accelerated
Estimate (95% CI) P memory decline among the most integrated memory loss, but it is also possible that our
Model 1 was less than half the rate of the least inte- results were attributable to reverse causation
Time 0.32 (0.34, 0.30) <.01 grated. To assess whether these results prima- (i.e., poor memory or memory decline causing
Social integration 0.01 (0.03, 0.05) .74 rily reflected the effect of one particular com- social withdrawal).18 This could bias our re-
Time social 0.04 (0.03, 0.05) <.01 ponent of integration, we repeated these sults only if prior memory losses predicted
integration analyses excluding each item of the social in- both low social integration and accelerated
Model 2 tegration measure one by one. With each ver- future memory loss. To test this possibility, we
Time 0.33 (0.35, 0.31) <.01 sion of the social integration score, individuals repeated our analyses by excluding respon-
Social integration 0.02 (0.06, 0.02) .35 with higher social integration had slower rates dents below the 25th percentile of memory
Time social 0.04 (0.03, 0.05) <.01 of memory decline and the significance of so- score in 1998, who may have already experi-
integration cial integration remained largely unchanged. enced some memory loss. The results in this
Model 3 We then examined growth-curve models in restricted sample were similar to the results
Time 0.29 (0.32, 0.26) <.01 subgroups to explore whether the association in the whole sample (interaction of time and
Social integration 0.00 (0.04, 0.04) .84 between social integration and memory dif- social integration: B=0.03; 95% CI = 0.02,
Time social 0.03 (0.02, 0.04) <.01 fered by gender, age, race, education, or pres- 0.03). This suggests that declines in cognitive
integration ence of a vascular disorder (Table 3). In analy- function before baseline were unlikely to ex-
ses stratified by gender, education, and vascular plain the observed longitudinal association
Note. CI = confidence interval. Model 1 was adjusted disorder, the results were similar to those for between 1998 social integration and memory
for sociodemographic factors (age at baseline, age
squared, gender, wealth, income, race, and education). the full study sample: social integration was decline over 6 years of follow-up.
Model 2 was adjusted for sociodemographic factors protective against memory decline. The results As a further test of reverse causation, we
and baseline health conditions (depressive symptoms, of models stratified by age and race were examined the association between memory
health conditions, mobility, large muscle index, basic
activities of daily living [bathing, eating, dressing, slightly different. Similar to the full study sam- score in 1993 and social integration in 1998
walking across a room, and getting in and out of bed], ple, in the subgroup of respondents 65 years (because of the staggered enrollment in the
and instrumental activities of daily living [using a and older and in the subgroup of White re- HRS, it was possible to conduct this test in
telephone, taking medication, handling money,
shopping, and preparing meals]). Model 3 was spondents, social integration was protective only a subsample of oldest respondents).
adjusted for sociodemographic factors, baseline health against memory decline. Among those younger After adjustment for sociodemographic char-
conditions, and the following interaction terms: than 65 years, however, social integration was acteristics and measures of health in 1993,
education time and health conditions time.
associated with memory score at baseline but memory score in 1993 explained less than
not with memory decline over time. Among 1% of the variability in social integration in
The growth-curve models of the relation Blacks, the interaction of time and social inte- 1998 (B=0.01; 95% CI = 0.00, 0.02).
between baseline social integration and mem- gration was not significant, although the wide
ory change over 6 years are shown in Table 2. confidence intervals suggested that this may DISCUSSION
In model 1, memory score declined an have been because of reduced statistical power
average of 0.32 (95% CI = 0.34, 0.30) in this relatively small subgroup. We found that high levels of social integra-
points per year. Respondents with higher Education-stratified models suggested that tion predicted a slower rate of memory de-
baseline social integration had slower rates of social integration may be particularly impor- cline in a nationally representative sample of
decline in memory: the average rate of de- tant for individuals with fewer than 12 years US residents 50 years and older who were
cline was 0.04 (95% CI = 0.03, 0.05) points of education (interaction of time and social followed prospectively for 6 years. The associ-
faster for each decrease in number of do- integration: unstandardized parameter esti- ation between higher social integration and re-
mains of social integration. The results were mate [B]=0.05; 95% CI= 0.03, 0.07). Re- duced memory decline was consistent in most
largely unchanged after adjustment for health spondents with low education showed a par- subgroups and was largest among respondents
status (model 2). In the final model (model 3), ticularly precipitous decline as time progressed with fewer than 12 years of education and
which was additionally adjusted for significant (B= 0.36; 95% CI = 0.41, 0.31), averag- with vascular conditions. Being in the highest
predictors of change in memory over time, ing a decrease in memory score of 1 point level of social integration ameliorated more
memory score declined an average of 0.29 every 3 years. Finally, results stratified by the than half of the age-related decline in mem-
(95% CI = 0.32, 0.26) points per year. On presence of a vascular disorder showed that ory. There is evidence that recency and speed

1218 | Research and Practice | Peer Reviewed | Ertel et al. American Journal of Public Health | July 2008, Vol 98, No. 7
RESEARCH AND PRACTICE

TABLE 3Estimates of Memory Decline in Stratified Models For Time (In Years), Baseline Social of cognitive decline are more potent predic-
Integration, and the Interaction Between Time and Social Integration: Health and Retirement tors of mortality than is stable but low cogni-
Study, United States, 19982004 tive function,1921 thus making changes in the
rate of decline particularly salient.
Unstandardized Parameter
No. Estimate (95% CI) P The major limitations of this study included
the nonrandomized study design and limita-
Gender tions in the measures of social integration and
Men 6 774
health. Our measure of social integration did
Time 0.28 (0.32, 0.24) <.01
not include all possible types of social connec-
Social integration 0.01 (0.07, 0.05) .69
Time social integration 0.03 (0.02, 0.04) <.01
tions. By using the sum of integration in mul-
Women 9 864 tiple domains, we believe we obtained an
Time 0.29 (0.33, 0.25) <.01 overall indicator of the level of integration.
Social integration 0.00 (0.05, 0.05) .96 This measure, however, did not contain infor-
Time social integration 0.03 (0.02, 0.04) <.01 mation about the quality of these contacts;
Age the HRS did not assess quality of relation-
Younger than 65 y 8 320 ships during this time frame. At least 1 study
Time 0.16 (0.20, 0.12) <.01 has indicated that emotional support, rather
Social integration 0.07 (0.01, 0.13) .02
than contacts, is important for cognitive out-
Time social integration 0.00 (0.01, 0.01) .89
comes.22 Data on health conditions were self-
65 y or older 8 318
Time 0.38 (0.42, 0.34) <.01 reported, and therefore it is possible that un-
Social integration 0.04 (0.10, 0.02) .22 measured health experiences may have
Time social integration 0.04 (0.03, 0.05) <.01 affected levels of memory and integration.
Race We addressed this possibility by excluding re-
White 13 967 spondents at baseline who had poor memory
Time 0.29 (0.32, 0.26) <.01 scores, but further studies with more-intensive
Social integration 0.01 (0.05, 0.03) .77 data collection on health status will have to
Time social integration 0.03 (0.02, 0.04) <.01 explore this possibility. Additionally, although
Black 2 133
we controlled for activities of daily living and
Time 0.24 (0.32, 0.16) <.01
instrumental activities of daily living in our
Social integration 0.03 (0.08, 0.14) .55
Time social integration 0.02 (0.01, 0.05) .12 analyses, the HRS did not have physical or
Education cognitive activity data that would have allowed
12 y or more 12 347 us to further control for activities that may be
Time 0.26 (0.29, 0.23) <.01 related to cognitive function and decline.
Social integration 0.01 (0.04, 0.06) .73 Our findings are consistent with prior
Time social integration 0.03 (0.02, 0.04) .02 studies based in Chicago, Illinois,8 New
Fewer than 12 y 4 291 Haven, Connecticut,9 Honolulu, Hawaii,23
Time 0.36 (0.41, 0.31) <.01 urban Sweden,7 and suburban Spain,10 all of
Social integration 0.05 (0.13, 0.03) .23
which reported that social engagement or
Time social integration 0.05 (0.03, 0.07) <.01
social network structure predicted reduced
Vascular disordera
No 8 039 rate of cognitive decline or lower risk of inci-
Time 0.27(0.31, 0.23) <.01 dent dementia.
Social integration 0.00 (0.06, 0.06) .98 Our study overcame some of the important
Time social integration 0.02 (0.01, 0.03) <.01 challenges in previous research on social inte-
Yes 8 599 gration and cognitive decline. The HRS is the
Time 0.31 (0.35, 0.27) <.01 largest longitudinal, nationally representative
Social integration 0.02 (0.04, 0.08) .52 study of the US elderly population; the large
Time social integration 0.04 (0.03, 0.05) <.01 sample allowed informative assessment of ef-
Note. CI = confidence interval. Models were adjusted for age at baseline, age squared, gender, wealth, income, race, education, fects of social integration across population
depressive symptoms, health conditions, mobility, large muscle index, basic activities of daily living [bathing, eating, dressing, subgroups. Additionally, because the HRS
walking across a room, and getting in and out of bed], instrumental activities of daily living [using a telephone, taking conducted memory assessments before 1998,
medication, handling money, shopping, and preparing meals], and interactions between time and education and health
conditions. Models within gender, age, and education were not controlled for clustering within households. we were able to provide evidence that reverse
a
This was defined as the presence of at least 1 of the following: diabetes, hypertension, or stroke. causation was an unlikely explanation for our
results.

July 2008, Vol 98, No. 7 | American Journal of Public Health Ertel et al. | Peer Reviewed | Research and Practice | 1219
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Social integration may help to preserve Avenue, Boston, MA 02115 (e-mail: lberkman@hsph. and Retirement Study. J Hum Resources. 1995;
memory through several mechanisms. One harvard.edu). 30(suppl):S7S56.
This article was accepted July 29, 2007. 12. Ofstedal M, McAuley GF, Herzog AR. Documenta-
possible mechanism is physical health: re-
tion of Cognitive Functioning Measures in the Health and
search strongly implicates vascular conditions Retirement Study. 2005. Available at: http://hrsonline.
Contributors
such as diabetes, unmanaged hypertension, K. A. Ertel participated in the conception of this study,
isr.umich.edu/docs/userg/dr-006.pdf. Accessed
January 30, 2008.
and stroke in the etiology of dementia.16,17 So- took primary responsibility for data management and
analysis, and was the primary author of the article. M. M. 13. Chapman D, Williams S, Strine T, Anda R, Moore M.
cial integration may reduce the onset of such Dementia and its implications for public health. Prev
Glymour participated in the conception of this study,
conditions and help to ameliorate their conse- provided expertise regarding the Health and Retirement Chronic Dis. 2006;3(2):A34.
quences through direct neurohormonal path- Study data and analytic techniques, and contributed sub- 14. Chodosh J, Reuben D, Albert M, Seeman T.
ways and behavioral modifications.24 Social stantially to the writing of the article. L. F. Berkman pro- Predicting cognitive impairment in high-functioning
vided overall conceptual support for data analysis and community-dwelling older persons: MacArthur Studies
ties may create pressure, either through ex- contributed substantially to the writing of the article. of Successful Aging. J Am Geriatr Soc. 2002;50:
plicit reminders or implicit behavioral norms, 10511060.
to take care of oneself, for example, by careful Acknowledgments 15. St Clair P, Bugliari D, Chien S, et al. RAND HRS
Data Documentation, Version E. Santa Monica, CA:
management of chronic conditions.25 Another The authors gratefully acknowledge funding from the
Labor & Population Program, RAND Center for the
possible mechanism is through cognitive as- National Institute of Aging (grant AG023399).
Study of Aging; 2005.
pects of social interactions: by presenting com- 16. de la Torre J. Vascular basis of Alzheimers patho-
plex cognitive and memory challenges, social Human Participant Protection genesis. Ann NY Acad Sci. 2002;977:196215.
The Health and Retirement Study was approved by the
interactions may enhance cognitive reserve,26 institutional review board at the University of Michigan.
17. de la Torre J. Is Alzheimers disease a neurode-
generative or a vascular disorder? Data, dogma, and
improve compensation in response to neuro- dialectics. Lancet Neurol. 2004;3:184190.
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About the Authors decline in a population of older African Americans Lancet Neurol. 2006;5:406412.
Karen A. Ertel, M. Maria Glymour, and Lisa F. Berkman and whites. Neurology. 2004;63:23222326. 27. Stern Y. What is cognitive reserve? Theory and
are with the Department of Society, Human Development, research application of the reserve concept. J Int Neu-
9. Bassuk S, Glass T, Berkman L. Social disengage-
and Health, Harvard School of Public Health, Boston, MA. ropsychol Soc. 2002;8:448460.
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M. Maria Glymour is a Robert Wood Johnson Health and
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Society Scholar in the Department of Epidemiology, Mail-
165173. heimers disease. Am J Geriatr Psychiatry. 1998;6:S3S18.
man School of Public Health, Columbia University, New
York, NY, and the Institute for Social and Economic Re- 10. Zunzunegui M, Alvarado B, Del Ser T, Otero A. 29. Blennow K, de Leon M, Zetterberg H. Alzheimers
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Requests for reprints should be sent to Lisa F. Berkman, ment determine cognitive decline in community-dwelling 30. Bianchetti A, Ranieri P, Margiotta A, Trabucchi M.
Chair, Department of Society, Human Development, and Spanish older adults. J Gerontol. 2003;58B:S93S100. Pharmacological treatment of Alzheimers disease.
Health, Harvard School of Public Health, 677 Huntington 11. Juster F, Suzman R. An overview of the Health Aging Clin Exp Res. 2006;18(2):158162.

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