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Risk Reduction of Cognitive Decline and Dementia: WHO Guidelines. Geneva: World Health Organization; 2019.

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Risk Reduction of Cognitive Decline and Dementia: WHO Guidelines.

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Evidence profile: social activity for reducing the risk of cognitive decline and/or dementia

Scoping question:

For adults with normal cognition or mild cognitive impairment, is preserving and promoting a high level of social activity more effective than usual care or no intervention in reducing the risk of cognitive decline and/or dementia?

Background

Cognitive function is strongly correlated with functional status, quality of life and independence in older adults(1, 2). While some declines in cognitive function is considered to be normal with ageing, the degree and severity of this trajectory has been shown to be modifiable. Importantly, certain lifestyle factors have been shown to be neuroprotective against cognitive decline and dementia. One such protective factor is social engagement(2).

Social engagement is an important predictor of wellbeing throughout life(3). Social disengagement conversely, has been shown to place older individuals at increased risk of transitioning into cognitive impairment and dementia(4). A systematic review and meta-analysis of longitudinal cohort studies showed that lower social participation (RR = 1.41; 95% CI 1.13 to 1.75), less frequent social contact (RR = 1.57; 95% CI 1.32 to 1.85) and loneliness (RR = 1.57; CI 1.32 to 1.85) was associated with higher rates of incident dementia(5).

Individuals often face barriers to the preservation of social activity, relationships and networks in later life. Age-related factors that contribute to diminished social engagement include but are not limited to retirement, driving cessation, reduced mobility, living alone, death of partners and loved ones, as well as health conditions that affect motor-cognitive status.

Better understanding of the relationship between social engagement and cognitive function is therefore critical to the maintenance of health and wellbeing of the ageing population. This review seeks to examine whether the promotion and preservation of social activity in late life is effective in reducing the risk of cognitive decline and dementia in older adults.

Part 1. Evidence review

Scoping questions in PICO format (population intervention, comparisons, outcome)

For adults with normal cognition or mild cognitive impairment, is preserving and promoting high level of social activity more effective than usual care or no intervention in reducing the risk of cognitive decline and/or dementia?

Populations

  • Adults with normal cognition or mild cognitive impairment

Interventions

  • Preservation and promotion of social activity1 including community and family engagement

Comparison

  • Care as usual or no intervention

Outcomes

Search Strategy

Searches using the following strategies (or similar) were conducted as follows

  • (“social interaction” or “social Networks” or “social processes” or “social behaviour” or “social behavior” or “community networks” or “social media” or family) and (dementia or cognit* or “mild cognitive impairment” or MCI or “cognitive dysfunction” or neuropsycholog* or Alzheime*) and (systemati* or meta-analys*)2

Searches were conducted in:

  • Medline
  • Cochrane
  • PsycInfo
  • Embase
  • Global index medicus/Global Health Library
    • WHO regional data base
    • WHOLIS
  • Database of impact evaluations
  • AJOL
  • KoreaMed
  • IndMED
  • HrCak
  • ArabPsycNet
  • HERDIN NeON
  • EurasiaHealth

List of systematic reviews identified by the search process

Included in GRADE3 tables

  • Kelly, M. E., Duff, H., Kelly, S., McHugh Power, J. E., Brennan, S., Lawlor, B. A., & Loughrey, D. G. (2017). The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A systematic review. Systematic Reviews, 6 (1), 259

PICO table

Intervention/ComparisonOutcomesSystematic reviews used for GRADEExplanation
1Preservation and promotion of social activity including community and family engagement versus care as usual or no interventionCognitive function (or cognitive test results using validated instruments)
  • Global cognition measured by composite measures (ADAS-Cog, MMSE, MDRS)
Kelly, M. E., Duff, H., Kelly, S., McHugh Power, J. E., Brennan, S., Lawlor, B. A., & Loughrey, D. G. (2017). The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A systematic review. Systematic Reviews, 6 (1), 259.Systematic review is relevant. Includes samples of adults with normal cognition who were administered social activity interventions. Cognitive outcomes were included. RCTs were included. AMSTAR 24 rating is Low.
Incident MCINo reviews identified.No reviews identified.
Incident DementiaNo reviews identified.No reviews identified.
Quality of lifeNo reviews identified.No reviews identified.
Functional level (ADL, IADL)No reviews identified.No reviews identified.
Adverse eventsNo reviews identified.No reviews identified.
Drop-out ratesNo reviews identified.No reviews identified.

Narrative descriptions of the studies that went into the analysis

GRADE table 1: social activity versus usual care or no intervention

Kelly et al(6) conducted a systematic review to evaluate the impact of social factors, including social activity, networks and support, on cognitive function in community dwelling older adults with no known cognitive impairment. Their review was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines(8) and was of low quality as rated on the AMSTAR-2 checklist(9). They included randomised controlled trials (RCTs), twin studies and observational evidence in their search. Review findings were reported narratively. Three RCTs(10–12) which assessed the association between cognitive function and social activity were deemed eligible. Overall cognition was measured by varied composite measures of global cognition, including the ADAS-cog, MMSE, and MDRS. One of the three RCTs found social activity intervention to be significantly associated with improvements in cognitive function, p = 0.023(12). The authors noted the primary studies did not report p-values for several comparisons, and this may be a reason for the absence of numerical data in the review results.

GRADE table 1Preservation and promotion of social activity including community and family engagement versus usual care or no intervention for reducing the risk of cognitive decline and/or dementia

Author(s): Nicole Ee, Ruth Peters

Date: May 2018

Question: Preserving and promoting high level of social activity compared to usual care or no intervention for reducing the risk of cognitive decline and/or dementia

Setting: Community

Bibliography: Kelly, M. E., Duff, H., Kelly, S., McHugh Power, J. E., Brennan, S., Lawlor, B. A., & Loughrey, D. G. (2017). The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A systematic review. Systematic Reviews, 6 (1), 259 [PMC free article: PMC5735742] [PubMed: 29258596].

Certainty assessment№ of patientsEffectCertaintyImportance
№ of studiesStudy designRisk of biasInconsistencyIndirectnessImprecisionOther considerationspreserving and promoting high level of social activityusual care or no intervention

Relative

(95% CI)

Absolute

(95% CI)

Cognitive function (follow up: range 14 weeks to 12 months; assessed with: Global cognition: MMSE, ADAS-Cog, MDRS etc. (higher scores indicate better cognition))
3randomised trialsserious anot serious bserious cvery serious dpublication bias strongly suspected e183393-see commentf

⨁◯◯◯

VERY LOW

CRITICAL
Incident MCI - not measured
-------No data available.-CRITICAL
Incident Dementia - not measured
-------No data available.-CRITICAL
Quality of life - not measured
-------No data available.-IMPORTANT
Functional level (ADL, IADL) - not measured
-------No data available.-IMPORTANT
Adverse events - not measured
-------No data available.-IMPORTANT
Drop-out rates - not measured
-------No data available.-IMPORTANT

CI: Confidence interval

Explanations

a

Risk of bias: Downgraded once as primary study limitations were unclear and review lacks formal assessment of risk of bias. Results not reported for all cognitive function comparisons in primary studies; possibility of confounding factors that may influence results.

b

Inconsistency: No meta-analysis conducted. No data on CIs or I2 or effect sizes across primary studies but general finding were of no effect or small positive effects on certain domains of cognition.

c

Indirectness: Downgraded once as the review only provided details on measures of global cognition in one study population.

d

Imprecision: Downgraded twice as no numerical data provided on CIs or test scores. Only p-value for ADAS-cog provided, p = 0.0203, none for other measures of global cognition. Sample sizes were small (n=120–235).

e

Publication bias: Downgraded once as only published records in English were included; no formal assessment of publication bias was carried out.

f

Results were reported narratively

Additional evidence not mentioned in GRADE tables

Though the RCT evidence was sparse and of very low grade, the review by Kelly et al(6) also identified several observational studies which reported on the effects of social activity, networks on cognitive function. Cognitive function was primarily measured with the MMSE and results were reported narratively.

Social activity versus usual care or no intervention

In addition to RCT evidence, Kelly et al(6) identified 22 observational studies of social activity. They reported that social activity was significantly associated with higher baseline scores on five measures of global cognition in four studies. At follow-up, 12 of 14 studies found global cognition measures were positively associated with social activity.

Social networks versus usual care or no intervention

Kelly et al(6) identified nine observations studies which investigated the relationships between social network and cognition. They reported social network size and frequency of contact was associated with baseline measures of global cognition in two of five studies and six of nine studies at follow-up. Two studies found no association between global cognition and social network, and one found no association with social network size.

Other relevant guidelines

Dementia, disability and frailty in later life – mid-life approaches to delay or prevent onset: https://www.nice.org.uk/guidance/ng16

Part 2. From evidence to decisions

Summary of evidencePreserving and promoting high level of social activity compared to usual care or no intervention for reducing the risk of cognitive decline and/or dementia

Patient or population: Adults with normal cognition or mild cognitive impairment

Setting: Community

Intervention: Preserving and promoting high level of social activity

Comparison: Usual care or no intervention

OutcomesAnticipated absolute effects* (95% CI)Relative effect (95% CI)№ of participants (studies)Certainty of the evidence (GRADE)Comments
Risk with usual care or no interventionRisk with preserving and promoting high level of social activity

Cognitive function

assessed with: Global cognition: MMSE, ADAS-Cog, MDRS etc. (higher scores indicate better cognition)

follow up: range 14 weeks to 12 months

The mean cognitive function was 0The mean cognitive function in the intervention group was 0 (0 to 0)-

576

(3 RCTs)

⨁◯◯◯

VERY LOW a,b,c,d,e,f

Incident MCI - not measuredNo data available.--
Incident Dementia - not measuredNo data available.--
Quality of life - not measuredNo data available.--
Functional level (ADL, IADL) - not measuredNo data available.--
Adverse events - not measuredNo data available.--
Drop-out rates - not measuredNo data available.--
*

The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

CI: Confidence interval

GRADE Working Group grades of evidence

High certainty: We are very confident that the true effect lies close to that of the estimate of the effect

Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different

Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect

Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect

Explanations

a

Risk of bias: Downgraded once as primary study limitations were unclear and review lacks formal assessment of risk of bias. Results not reported for all cognitive function comparisons in primary studies; possibility of confounding factors that may influence results.

b

Inconsistency: No meta-analysis conducted. No data on CIs or I2 or effect sizes across primary studies but general finding were of no effect or small positive effects on certain domains of cognition.

c

Indirectness: Downgraded once as the review only provided details on measures of global cognition in one study population.

d

Imprecision: Downgraded twice as no numerical data provided on CIs or test scores. Only p-value for ADAS-cog provided, p = 0.0203, none for other measures of global cognition. Sample sizes were small (n=120–235).

e

Publication bias: Downgraded once as only published records in English were included; no formal assessment of publication bias was carried out.

f

Results were reported narratively

Annex. PRISMA5 flow diagram for systematic review of reviews – social activity for reducing risk of cognitive decline and/or dementia

Note

Note. Kelly et al(6) was included both narrative syntheses/GRADE and additional information.

References

1.
Cigolle CT, Langa KM, Kabeto MU, Tian Z, Blaum CS. Geriatric conditions and disability: The health and retirement study. Annals of internal medicine. 2007;147(3):156–64. [PubMed: 17679703]
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Wang H-X, Xu W, Pei J-J. Leisure activities, cognition and dementia. Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 2012;1822(3):482–91. [PubMed: 21930203]
3.
Cherry KE, Walker EJ, Brown JS, Volaufova J, LaMotte LR, Welsh DA, et al. Social Engagement and Health in Younger, Older, and Oldest-Old Adults in the Louisiana Healthy Aging Study. Journal of Applied Gerontology. 2011;32(1):51–75. [PMC free article: PMC3604902] [PubMed: 23526628]
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Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle in late life might protect against dementia. The Lancet Neurology. 2004;3(6):343–53. [PubMed: 15157849]
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Kuiper JS, Zuidersma M, Voshaar RCO, Zuidema SU, van den Heuvel ER, Stolk RP, et al. Social relationships and risk of dementia: a systematic review and meta-analysis of longitudinal cohort studies. Ageing research reviews. 2015;22:39–57. [PubMed: 25956016]
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Kelly ME, Duff H, Kelly S, Power JEM, Brennan S, Lawlor BA, et al. The impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: a systematic review. Systematic reviews. 2017;6(1):259. [PMC free article: PMC5735742] [PubMed: 29258596]
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Kane RL, Butler M, Fink HA, Brasure M, Davila H, Desai P, et al. Interventions to Prevent Age-Related Cognitive Decline, Mild Cognitive Impairment, and Clinical Alzheimer’s-Type Dementia. AHRQ Comparative Effectiveness Reviews. Rockville (MD): Agency for Healthcare Research and Quality (US); 2017. [PubMed: 28759193]
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Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. International Journal of Surgery. 2010;8(5):336–41. [PubMed: 20171303]
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Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017;358. [PMC free article: PMC5833365] [PubMed: 28935701]
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Mortimer JA, Ding D, Borenstein AR, DeCarli C, Guo Q, Wu Y, et al. Changes in brain volume and cognition in a randomized trial of exercise and social interaction in a community-based sample of non-demented Chinese elders. Journal of Alzheimer’s Disease. 2012;30(4):757–66. [PMC free article: PMC3788823] [PubMed: 22451320]
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Park DC, Lodi-Smith J, Drew L, Haber S, Hebrank A, Bischof GN, et al. The impact of sustained engagement on cognitive function in older adults: the synapse project. Psychological science. 2014;25(1):103–12. [PMC free article: PMC4154531] [PubMed: 24214244]
12.
Pitkala KH, Routasalo P, Kautiainen H, Sintonen H, Tilvis RS. Effects of Socially Stimulating Group Intervention on Lonely, Older People’s Cognition: A Randomized, Controlled Trial. The American Journal of Geriatric Psychiatry. 2011;19(7):654–63. [PubMed: 21709611]

Evidence-to-decision table

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References Summary

1.
Prince, M. J.. World Alzheimer Report 2015: the global impact of dementia: an analysis of prevalence, incidence, cost and trends.. Alzheimer’s Disease International; 2015.
2.
Fratiglioni, L., Paillard-Borg, S., & Winblad, B.. An active and socially integrated lifestyle in late life might protect against dementia.. The Lancet Neurology,; 2004. [PubMed: 15157849]
3.
Kuiper JS, Zuidersma M, Voshaar RCO, Zuidema SU, van den Heuvel ER, Stolk RP, et al.. Social relationships and risk of dementia: a systematic review and meta-analysis of longitudinal cohort studies.. Ageing research reviews.; 2015. [PubMed: 25956016]
4.
Kelly, M. E., Duff, H., Kelly, S., McHugh Power, J. E., Brennan, S., Lawlor, B. A., Loughrey, D. G.. The impact ofsocial activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: A systematic review. Systematic Reviews; 19 Dec 2017. [PMC free article: PMC5735742] [PubMed: 29258596]
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Anderson, L. A., Day, K. L., Beard, R. L., Reed, P. S., & Wu, B.. The public’s perceptions about cognitive health and Alzheimer’s disease among the US population: a national review. The Gerontologist; 2009. [PubMed: 19525214]
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Low, L. F., & Anstey, K. J.. Dementia literacy: recognition and beliefs on dementia of the Australian public.. Alzheimer’s & dementia: the journal of the Alzheimer’s Association; 2009. [PubMed: 19118808]
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Yeo, L. J., Horan, M. A., Jones, M., & Pendleton, N.. Perceptions of risk and prevention of dementia in the healthy elderly. Dementia and Geriatric Cognitive Disorders; 2007. [PubMed: 17389796]
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Healthcare., Saga. Dementia more feared than Cancer new Saga Survey reveals.. Retrieved from https://www​.dementiastatistics​.org/statistics-about-dementia/public-perception/; 2016.
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Daly., S. & Allen., J.. Inequalities in mental health cognitive impairment and Dementia among older people. London, Institute of Health Equity.. Retrieved from http://www​.instituteofhealthequity​.org/resources-reports​/inequalities-in-mental-health-cognitive-impairment-and-dementia-among-older-people; 2016.
11.
Pitkala KH, Routasalo P, Kautiainen H, Sintonen H, Tilvis RS. Effects of Socially Stimulating Group Intervention on Lonely, Older People’s Cognition: A Randomized, Controlled Trial. The American Journal of Geriatric Psychiatry. 2011;19(7):654–63. [PubMed: 21709611]

Footnotes

1

Social activities are varied and difficult to define, however they may include meeting friends, attending events or functions, volunteering or participating in occupational duties or group recreational activities.6

2

Dates searched were 1 May 2016 - 1 May 2018. Additionally, the 2016 AHRQ review(7) was consulted for relevant records which systematically searched the literature between Jan 2009 – Sept 2016. In combination, the search period spanned >9 years. All abstracts were screened by two independent reviewers and with any discrepancies resolved by discussion. Full text articles were read by the same two independent reviewers and any discrepancy resolved by discussion.

3

GRADE: Grading of Recommendations Assessment, Development and Evaluation. More information: http:​//gradeworkiggroup.org

4

AMSTAR: A Measurement Tool to Assess Systematic Reviews. More information: https://amstar​.ca/index.php

5

Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., & Prisma Group. (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS medicine, 6(7), e1000097.

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