Original Study| Volume 21, ISSUE 11, P1689-1695.e1, November 2020

Download started.


Clustering of Behavioral Changes and Their Associations With Cognitive Decline in Older Adults



      To examine (1) the clustering of reduced falls-efficacy, social withdrawal, and physical activity withdrawal in Irish adults aged 50 years and older, and (2) the concurrent and prospective associations of these clustered behaviors with cognitive decline.


      Longitudinal cohort study.

      Setting and Participants

      Data were from 4571 participants (mean age 64.5 ± 8.6, 54.9% women) in The Irish Longitudinal Study on Ageing, a population-based study.


      Changes in social and physical activity and falls-efficacy from 2012/2013 to 2014/2015 were used to define the behaviors of social withdrawal, physical activity withdrawal, and reduced falls-efficacy. Patterns of behaviors were associated with concurrent (2012/2013–2014/2015) and prospective (2014/2015–2016/2017) changes in immediate recall, delayed recall, and verbal fluency using random effects mixed models.


      Eighty-six percent of participants had social withdrawal, physical activity withdrawal, or reduced falls-efficacy, and 15% had all 3 behaviors. Participants with all 3 behaviors showed the greatest declines in immediate recall (concurrent: B = −0.51, confidence interval [CI] = −0.77 to −0.25; prospective: B = −0.51, CI = −0.78 to −0.25), delayed recall (concurrent: B = −0.40, CI = −0.61 to −0.18; prospective: B = −0.47, CI = −0.69 to −0.25) and verbal fluency (concurrent: B = −1.05, CI = −1.58 to −0.52; prospective: B = −1.29, CI = −1.83 to −0.74).

      Conclusions and Implications

      The clustering of social withdrawal, physical activity withdrawal, and reduced falls-efficacy is common. Presence of multiple behaviors was associated with greater cognitive declines, suggesting a cumulative association of these behaviors with cognitive decline. These findings guide (1) identification of vulnerable groups, (2) intervention design, and (3) care planning for people presenting with 1 or more of these changes in behavior.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Laddu D.
        • Parimi N.
        • Cauley J.A.
        • et al.
        The association between trajectories of physical activity and all-cause and cause-specific mortality.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 1708-1713
        • Agahi N.
        • Lennartsson C.
        • Kareholt I.
        • et al.
        Trajectories of social activities from middle age to old age and late-life disability: A 36-year follow-up.
        Age Ageing. 2013; 42: 790-793
        • Aggio D.
        • Papachristou E.
        • Papacosta O.
        • et al.
        Trajectories of self-reported physical activity and predictors during the transition to old age: A 20-year cohort study of British men.
        Int J Behav Nutr Phys Act. 2018; 15: 14
        • Kelly M.E.
        • Duff H.
        • Kelly S.
        • 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.
        Syst Rev. 2017; 6: 259
      1. Nyman S.R. Barker A. Haines T. The Palgrave Handbook of Ageing and Physical Activity Promotion. Palgrave Macmillan, Cham, London2018
        • Barrett A.
        • Savva G.
        • Timonen V.
        • Kenny R.A.
        Fifty Plus in Ireland 2011: First results from the Irish Longitudinal Study on Ageing (TILDA).
        Trinity College Dublin: Dublin,. 2011; 52
        • Livingston G.
        • Sommerlad A.
        • Orgeta V.
        • et al.
        Dementia prevention, intervention, and care.
        Lancet. 2017; 390: 2673-2734
        • Zunzunegui M.V.
        • Alvarado B.E.
        • Del Ser T.
        • et al.
        Social networks, social integration, and social engagement determine cognitive decline in community-dwelling Spanish older adults.
        J Gerontol B Psychol Sci Soc Sci. 2003; 58: S93-S100
        • Verghese J.
        • LeValley A.
        • Derby C.
        • et al.
        Leisure activities and the risk of amnestic mild cognitive impairment in the elderly.
        Neurology. 2006; 66: 821-827
        • Saczynski J.S.
        • Pfeifer L.A.
        • Masaki K.
        • et al.
        The effect of social engagement on incident dementia: The Honolulu-Asia Aging Study.
        Am J Epidemiol. 2006; 163: 433-440
        • Sun F.
        • Norman I.J.
        • While A.E.
        Physical activity in older people: A systematic review.
        BMC Public Health. 2013; 13: 449
        • Kelly M.E.
        • Loughrey D.
        • Lawlor B.A.
        • et al.
        The impact of exercise on the cognitive functioning of healthy older adults: A systematic review and meta-analysis.
        Ageing Res Rev. 2014; 16: 12-31
        • Scherder E.
        • Scherder R.
        • Verburgh L.
        • et al.
        Executive functions of sedentary elderly may benefit from walking: A systematic review and meta-analysis.
        Am J Geriatr Psychiatry. 2014; 22: 782-791
        • Scheffer A.C.
        • Schuurmans M.J.
        • van Dijk N.
        • et al.
        Fear of falling: Measurement strategy, prevalence, risk factors and consequences among older persons.
        Age Ageing. 2008; 37: 19-24
        • Auais M.
        • French S.
        • Alvarado B.
        • et al.
        Fear of falling predicts incidence of functional disability two years later: A perspective from an international cohort study.
        J Gerontol A Biol Sci Med Sci. 2018; 73: 1212-1215
        • Cumming R.G.
        • Salkeld G.
        • Thomas M.
        • et al.
        Prospective study of the impact of fear of falling on activities of daily living, SF-36 scores, and nursing home admission.
        J Gerontol A Biol Sci Med Sci. 2000; 55: M299-M305
        • Peeters G.
        • Leahy S.
        • Kennelly S.
        • et al.
        Is fear of falling associated with decline in global cognitive functioning in older adults: Findings from the Irish Longitudinal Study on Ageing.
        J Am Med Dir Assoc. 2018; 19: 248-254.e3
        • Deshpande N.
        • Metter E.J.
        • Lauretani F.
        • et al.
        Activity restriction induced by fear of falling and objective and subjective measures of physical function: A prospective cohort study.
        J Am Geriatr Soc. 2008; 56: 615-620
        • Donoghue O.A.
        • Cronin H.
        • Savva G.M.
        • et al.
        Effects of fear of falling and activity restriction on normal and dual task walking in community dwelling older adults.
        Gait Posture. 2013; 38: 120-124
        • Fontana L.
        • Kennedy B.K.
        • Longo V.D.
        • et al.
        Medical research: Treat ageing.
        Nature. 2014; 511: 405-407
        • Deary I.J.
        • Corley J.
        • Gow A.J.
        • et al.
        Age-associated cognitive decline.
        Br Med Bull. 2009; 92: 135-152
        • Morley J.E.
        • Morris J.C.
        • Berg-Weger M.
        • et al.
        Brain health: The importance of recognizing cognitive impairment: An IAGG consensus conference.
        J Am Med Dir Assoc. 2015; 16: 731-739
        • Kearney P.M.
        • Cronin H.
        • O'Regan C.
        • et al.
        Cohort profile: The Irish Longitudinal Study on Ageing.
        Int J Epidemiol. 2011; 40: 877-884
        • Whelan B.J.
        • Savva G.M.
        Design and methodology of the Irish Longitudinal Study on Ageing.
        J Am Geriatr Soc. 2013; 61: S265-S268
        • House J.S.
        • Robbins C.
        • Metzner H.L.
        The association of social relationships and activities with mortality: Prospective evidence from the Tecumseh Community Health Study.
        Am J Epidemiol. 1982; 116: 123-140
        • Craig C.L.
        • Marshall A.L.
        • Sjostrom M.
        • et al.
        International physical activity questionnaire: 12-country reliability and validity.
        Med Sci Sports Exerc. 2003; 35: 1381-1395
        • Tinetti M.E.
        • Richman D.
        • Powell L.
        Falls efficacy as a measure of fear of falling.
        J Gerontol. 1990; 45: P239-P243
        • Jorstad E.C.
        • Hauer K.
        • Becker C.
        • et al.
        Measuring the psychological outcomes of falling: A systematic review.
        J Am Geriatr Soc. 2005; 53: 501-510
        • Delbaere K.
        • Close J.C.
        • Mikolaizak A.S.
        • et al.
        The Falls Efficacy Scale International (FES-I). A comprehensive longitudinal validation study.
        Age Ageing. 2010; 39: 210-216
        • Chandler M.J.
        • Lacritz L.H.
        • Hynan L.S.
        • et al.
        A total score for the CERAD neuropsychological battery.
        Neurology. 2005; 65: 102-106
        • Welsh K.A.
        • Butters N.
        • Mohs R.C.
        • et al.
        The Consortium to Establish a Registry for Alzheimer's Disease (CERAD). Part V. A normative study of the neuropsychological battery.
        Neurology. 1994; 44: 609-619
        • Vaughan R.M.
        • Coen R.F.
        • Kenny R.A.
        • et al.
        Preservation of the semantic verbal fluency advantage in a large population based sample: Normative data from the TILDA Study.
        J Int Neuropsychol Soc. 2016; 22: 570-576
        • Radloff L.S.
        The CES-D scale: A self-report depression scale for research in the general population.
        Appl Psychol Meas. 1977; 3: 385-401
        • Katz S.
        • Ford A.B.
        • Moskowitz R.W.
        • et al.
        Studies of illness in the aged. The index of ADL: A standardized measure of biological and psychosocial function.
        JAMA. 1963; 185: 914-919
        • Lawton M.P.
        • Brody E.M.
        Assessment of older people: Self-maintaining and instrumental activities of daily living.
        Gerontologist. 1969; 9: 179-186
        • Folstein M.F.
        • Folstein S.E.
        • McHugh P.R.
        “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician.
        J Psychiatr Res. 1975; 12: 189-198
        • Schepens S.
        • Sen A.
        • Painter J.A.
        • et al.
        Relationship between fall-related efficacy and activity engagement in community-dwelling older adults: A meta-analytic review.
        Am J Occup Ther. 2012; 66: 137-148
        • Curcio C.L.
        • Gomez F.
        • Reyes-Ortiz C.A.
        Activity restriction related to fear of falling among older people in the Colombian Andes mountains: Are functional or psychosocial risk factors more important?.
        J Aging Health. 2009; 21: 460-479
        • Talley K.M.
        • Wyman J.F.
        • Gross C.R.
        • et al.
        Change in balance confidence and its associations with increasing disability in older community-dwelling women at risk for falling.
        J Aging Health. 2014; 26: 616-636
        • Dias R.C.
        • Freire M.T.
        • Santos E.G.
        • et al.
        Characteristics associated with activity restriction induced by fear of falling in community-dwelling elderly.
        Rev Bras Fisioter. 2011; 15: 406-413
        • Kaplan G.A.
        • Lazarus N.B.
        • Cohen R.D.
        • et al.
        Psychosocial factors in the natural history of physical activity.
        Am J Prev Med. 1991; 7: 12-17
        • Pohl J.S.
        • Cochrane B.B.
        • Schepp K.G.
        • et al.
        Falls and social isolation of older adults in the national health and aging trends study.
        Res Gerontol Nurs. 2018; 11: 61-70
        • Amboni M.
        • Barone P.
        • Hausdorff J.M.
        Cognitive contributions to gait and falls: Evidence and implications.
        Mov Disord. 2013; 28: 1520-1533
        • Campbell A.J.
        • Buchner D.M.
        Unstable disability and the fluctuations of frailty.
        Age Ageing. 1997; 26: 315-318
        • Fried L.P.
        • Xue Q.L.
        • Cappola A.R.
        • et al.
        Nonlinear multisystem physiological dysregulation associated with frailty in older women: Implications for etiology and treatment.
        J Gerontol A Biol Sci Med Sci. 2009; 64: 1049-1057
        • Kumar A.
        • Delbaere K.
        • Zijlstra G.A.
        • et al.
        Exercise for reducing fear of falling in older people living in the community: Cochrane systematic review and meta-analysis.
        Age Ageing. 2016; 45: 345-352
        • Liu T.W.
        • Ng G.Y.F.
        • Chung R.C.K.
        • et al.
        Cognitive behavioural therapy for fear of falling and balance among older people: A systematic review and meta-analysis.
        Age Ageing. 2018; 47: 520-527
        • Findlay R.A.
        Interventions to reduce social isolation amongst older people: Where is the evidence?.
        Ageing Soc. 2003; 23: 647-658
        • Gardiner C.
        • Geldenhuys G.
        • Gott M.
        Interventions to reduce social isolation and loneliness among older people: An integrative review.
        Health Soc Care Community. 2018; 26: 147-157
        • Pilotto A.
        • Cella A.
        • Pilotto A.
        • et al.
        Three decades of comprehensive geriatric assessment: Evidence coming from different healthcare settings and specific clinical conditions.
        J Am Med Dir Assoc. 2017; 18: 192.e1-192.e11