It is widely assumed that individuals who develop mild cognitive impairment (MCI) will not recover.1 Yet nearly half of older persons with MCI regain normal cognition.2 The reason for this improvement is not well understood. This study is the first, to our knowledge, to consider whether a culture-based factor—positive age beliefs—contributes to MCI recovery.
In previous experimental studies with older persons, positive age beliefs reduced stress caused by cognitive challenges, increased self-confidence about cognition, and improved cognitive performance.3,4 We therefore hypothesized that older persons with positive age beliefs would be more likely to recover from MCI and would do so sooner compared with individuals with negative age beliefs.
The Yale University Human Investigation Committee approved this cohort study. All participants provided verbal informed consent. We followed the STROBE reporting guideline.
Participants were from the Health and Retirement Study, a national longitudinal survey. Inclusion criteria were age 65 years or older, baseline MCI as defined by Langa et al,5 at least 1 follow-up cognition assessment (measured with the Telephone Interview for Cognitive Status [TICS]) and a positive age-belief measure (assessed with the Attitude toward Aging subscale of the Philadelphia Geriatric Morale Scale [eg, disagreement with the item, “The older I get, the more useless I feel”]). Participants were dichotomized at the age-belief median into groups based on positive (<15) and negative (≥15) age beliefs. Covariates associated with MCI and/or age beliefs1-3 comprised baseline age, sex, self-reported race, education, marital status, smoking history, apolipoprotein E status, depression, cardiovascular and/or diabetes diagnosis, social isolation, sleep issues, and physical inactivity.
Cognitive recovery—the primary outcome—was defined as the first transition from MCI to normal cognition, using validated TICS cut points.5 Four nonoverlapping word lists were used to avoid practice effects. Seven data collection waves were performed (every 2 years, 2008-2020; <2% of person-survey waves were missing) (eAppendix in Supplement 1 provides additional details about data completeness and inclusion of all participants).
Analyses were conducted with 2-sided tests and SAS, version 9.4 (SAS Institute Inc). Data analyses were completed on February 15, 2023.
Our cohort study consisted of 1716 participants (953 women [55.5%] and 763 men [44.5%]), with a mean (SD) age of 77.8 (7.5) years (Table). Confirming our hypothesis, participants with MCI at baseline were significantly more likely to experience cognitive recovery if they had positive age beliefs at baseline (χ2 = 12.8; P < .001). A sensitivity analysis found that significant results did not change after adjustment for the number of participant TICS responses. The positive age-belief group had a 30.2% greater likelihood of recovery than the negative age-belief group; this recovery advantage persisted regardless of baseline MCI severity.
Also, as hypothesized, a proportional hazards model found that participants with positive age beliefs had a faster transition from MCI to normal cognition (hazard ratio, 1.26 [95% CI, 1.08-1.46]; P = .003). The positive age-belief group reached a 2-year recovery advantage over the negative age-belief group (Figure).
Among participants with normal cognition or MCI at baseline, those with positive age beliefs had lower MCI prevalence (609 [16.3%] vs 1107 [24.0%]; χ2 = 76.4; P < .001) compared with those with negative age beliefs. Additionally, among participants with normal cognition at baseline and adjusting for all covariates, those with positive age beliefs were significantly less likely to develop MCI over the following 12 years compared with those with negative age beliefs (χ2 = 26.5; P < .001).
The findings of this cohort study suggest the importance of considering the role of culture, expressed here through age beliefs, in MCI development and reversal. A limitation is that we did not examine the mechanism of positive age beliefs in cognitive recovery. However, previous studies have reported that cognition is predicted by stress levels and health behaviors, both of which can be improved by positive age beliefs.3,4,6 Considering that positive age beliefs can be strengthened,6 our findings suggest that age-belief interventions at individual and societal levels could increase the number of people who experience cognitive recovery.
Accepted for Publication: February 16, 2023.
Published: April 12, 2023. doi:10.1001/jamanetworkopen.2023.7707
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Levy BR et al. JAMA Network Open.
Corresponding Author: Becca R. Levy, PhD, Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College St, PO Box 208034, New Haven, CT 06520-8034 (becca.levy@yale.edu).
Author Contributions: Drs Levy and Slade had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Levy.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Slade.
Obtained funding: Levy.
Administrative, technical, or material support: Levy.
Supervision: Levy.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by grants U01AG032284 and R01AG067533 from the National Institute on Aging (Dr Levy). The authors thank the investigators and participants in the Health and Retirement Study, which is supported by grant U01AG009740 from the National Institute on Aging.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Data Sharing Statement: See Supplement 2.
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