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Original Research Article
Dement Geriatr Cogn Disord 2006;21:65–73
DOI: 10.1159/000089919
Mental, Physical and Social Components in
Leisure Activities Equally Contribute to Decrease
Dementia Risk
Anita Karp
a
Stephanie Paillard-Borg
a
Hui-Xin Wang
a
Merril Silverstein
a, b
Bengt Winblad
a
Laura Fratiglioni
a
a
Aging Research Center, Division of Geriatric Epidemiology, Department of Neurotec, Karolinska Institutet, and
the Stockholm Gerontology Research Center, Stockholm , Sweden;
b
Andrus Gerontology Center,
University of Southern California, Los Angeles, Calif. , USA
subjects with high scores in all or in two of the compo-
nents (RR of dementia = 0.53; 95% CI: 0.36–0.78). Conclu-
sions: These fi ndings suggest that a broad spectrum of
activities containing more than one of the components
seems to be more benefi cial than to be engaged in only
one type of activity.
Copyright © 2006 S. Karger AG, Basel
Introduction
After retirement, leisure activities usually constitute a
relatively larger part of the daily life and may take on the
role of providing mental stimulation, social engagement
and physical activity that was earlier offered by school or
employment. Consequently, leisure activities in old age
have been a common focus for studies regarding several
outcomes like mortality [1–3] , cognition [4–8] , morbidity
[9] and well-being [10–12] .
In recent years, prospective studies have found an as-
sociation between leisure activities and decreased risk
of Alzheimer’s disease (AD) and dementia [13] . It has
been suggested that engagement in leisure activities may
result in functionally more effi cient cognitive networks,
hereby providing a cognitive reserve that could delay the
onset of clinical manifestations of dementia [14]
. Men-
tally stimulating activities, in particular, have been as-
Key Words
Dementia risk Leisure activities, mental, physical and
social components Elderly population
Abstract
Background: There is accumulating evidence in the lit-
erature that leisure engagement has a benefi cial effect
on dementia. Most studies have grouped activities ac-
cording to whether they were predominantly mental,
physical or social. Since many activities contain more
than one component, we aimed to verify the effect of all
three major components on the dementia risk, as well as
their combined effect. Methods: A mental, social and
physical component score was estimated for each activ-
ity by the researchers and a sample of elderly persons.
The correlation between the ratings of the authors and
the means of the elderly subjects’ ratings was 0.86. The
study population consisted of 776 nondemented sub-
jects, aged 75 years and above, living in Stockholm, Swe-
den, who were still nondemented after 3 years and were
followed for 3 more years to detect incident dementia
cases. Results: Multi-adjusted relative risks (RRs) of de-
mentia for subjects with higher mental, physical and so-
cial component score sums were 0.71 (95% CI: 0.49–1.03),
0.61 (95% CI: 0.42–0.87) and 0.68 (95% CI: 0.47–0.99), re-
spectively. The most benefi cial effect was present for
Accepted after revision: September 3, 2005
Published online: November 23, 2005
Anita Karp
ARC-Äldrecentrum
Box 6401 (Olivecronas väg 4)
SE–113 82 Stockholm (Sweden)
Tel. +46 8 6906856, Fax +46 8 6906889, E-Mail anita.karp@neurotec.ki.se
© 2006 S. Karger AG, Basel
1420–8008/06/0212–0065$23.50/0
Accessible online at:
www.karger.com/dem
Karp /Paillard-Borg /Wang /Silverstein /
Winblad
/Fratiglioni
Dement Geriatr Cogn Disord 2006;21:65–73
66
sociated with signifi cantly reduced risk of incident de-
mentia [15–19] . Being engaged in social recreational ac-
tivities [18, 20] and having a rich social network [21]
have also been found to have a protective effect against
dementia. In addition, engaging in regular physical ac-
tivity has been suggested as an important component of
a preventive strategy against AD [22] and, in women,
against cognitive decline at 6–8 years of follow-up [23] .
However, other reports did not confi rm such an associa-
tion [16, 18] .
Most studies of leisure activities and dementia have
grouped activities according to whether they were pre-
dominantly mental, physical or social. Indeed, activities
may simultaneously embody one or more of these three
aspects. As an example, dancing [19] is a physical activ-
ity that contains social interaction, as well as a certain
degree of cognitive involvement, at least if the dance re-
quires learning new steps and turns. Hence, identifying
the activities according to their predominant component
may lead to an underestimation of other components. For
instance, several common leisure activities classifi ed as
social or mental in nature also contain light physical ac-
tivity which, although modest, may be of great impor-
tance for the health of elderly people.
For these reasons, the present study considers activi-
ties as having a multidimensional profi le, each manifest-
ing various combinations of mental, social and physical
involvement. Using data from subjects in the Kungshol-
men Project, we hypothesize that all three components
are relevant protective factors against dementia, and that
a combined benefi cial effect may be present. Because re-
duced participation in leisure activities may very well be
a consequence and not a cause of cognitive decline in the
preclinical phase of dementia [16, 18, 19] , the present
study lags predictors relative to dementia diagnosis by an
average of 6 years through excluding subjects diagnosed
as demented at fi rst follow-up. Furthermore, we excluded
subjects with low baseline cognition, and adjusted for
cognitive function at baseline.
Materials and Methods
Study Population
Subjects were derived from the Kungsholmen Project, a longi-
tudinal population-based study of aging and dementia. All resi-
dents of the Kungsholmen district of Stockholm, Sweden, aged 75
years or older in October 1987 (n = 2,368), were asked to participate
in the initial examination. Subjects who agreed and signed an in-
formed consent were interviewed by nurses, examined by physi-
cians, and tested by psychologists during the baseline (1987–1989),
fi rst follow-up (1991–1993) and second follow-up (1994–1996) ex-
aminations.
Of the 1,810 eligible participants who underwent the baseline
examination, 1,473 were diagnosed as nondemented. The detailed
procedures are available elsewhere [24, 25] . Since institutionaliza-
tion or impaired cognition may limit subjects’ activity [4] , 98 sub-
jects whose Mini-Mental State Examination (MMSE) scores [26]
were less or equal to 23 or who were living in an institution were
also excluded from the present study; thus, 1,375 persons remained
for analysis. By the fi rst follow-up examination, 269 subjects had
died, 172 refused participation and 934 participated, of whom 158
were diagnosed as demented. Thus, the population for the present
study was composed of those 776 subjects participating and still
nondemented at the fi rst follow-up examination. Out of these, 732
subjects were followed for another 3 years (second follow-up) to
detect incident dementia cases (44 subjects refused to participate
to the second follow-up).
Diagnosis of Dementia
Incident dementia cases examined in this study were those
subjects who developed dementia during the second follow-up
period. At each follow-up examination, all cohort subjects were
clinically examined following a standardized protocol, which in-
cluded personal and family history collected by nurses, clinical
examination conducted by physicians and psychological tests ad-
ministered by trained personnel. If a participant was not able to
answer, an informant, usually the subject’s next of kin, was inter-
viewed. The study design has been described in detail elsewhere
[24, 25] . Time of dementia onset was assumed to be the midpoint
between the fi rst and second follow-up examinations or the time
of death.
Dementia diagnoses were made according to the Diagnostic and
Statistical Manual of Mental Disorders, Third Edition-Revised cri-
teria [26] following the same three-step procedure used at baseline
examination [24] . First, a preliminary diagnosis was made by the
examining physician. Second, all cases were independently re-
viewed by a specialized clinician and a second diagnosis was made.
If the diagnoses were in agreement, they were accepted as the fi nal
decision. In case of disagreement, a third opinion was obtained and
the concordant diagnosis was accepted. When only one item of the
diagnostic criteria was not fulfi lled, the subject was classifi ed as af-
fected by ‘questionable dementia’, which is in contrast with ‘clini-
cally defi nite dementia’. Both groups were included in the analyses.
For those participants (n = 172) who had died between the fi rst and
second follow-up examinations, a preliminary diagnosis was made
by a physician through consulting medical records and death cer-
tifi cates, and then reviewed by a senior clinician. When only dis-
charge diagnoses from hospitals or death certifi cates were available,
the reported diagnosis was accepted.
Assessment of Activity
Information on leisure activities was obtained from the subjects
by means of a personal interview carried out by trained nurses at
baseline (1987–1989) with open questions. Subjects were asked:
whether they regularly engaged in any particular activities, the type
of activities and the frequency of participation. The leisure activi-
ties were grouped into 29 main types of activities. A mental, social
and physical component score was assigned to each of the 29 ac-
tivities. Two authors of this study (A.K. and S.P.-B.) independent-
ly assigned scores to each activity based on their own evaluations
Mental, Physical and Social Components
in Leisure Activities and Dementia Risk
Dement Geriatr Cogn Disord 2006;21:65–73
67
and then discussed with a third author (L.F.) in order to reach con-
sensus. The grading of the three components was coded as: 0 = none,
1 = low, 2 = moderate, 3 = high ( table 1 ).
To validate the scoring, 13 cognitively intact, elderly raters (7
men, 6 women), aged 75 years or more, but not participants in the
Kungsholmen study, were asked to individually fi ll in a small ques-
tionnaire containing a list of all 29 activities together with scoring
instructions. The overall correlation between the consensus ratings
of the authors and the means of the elderly subjects’ ratings was
0.86. Reliability analyses were performed. For all three components
taken together, Cronbach’s
was high; 0.90 indicating high inter-
rater consistency. Cronbach’s
values for each of the components
were: 0.89 for the mental component, 0.95 for the physical compo-
nent and 0.82 for the social component. Since the disagreements
between researchers and elderly raters mainly concerned the social
component of activities, four fi nal ratings (handicraft, travels, sing-
ing and collections) were changed to better fi t the elderly raters’
opinion. Table 1 shows the fi nal decision regarding the component
scores for the 29 activities and the frequency of each activity.
The three components were highly correlated. The Pearson cor-
relation coeffi cients were 0.76 between the mental and social com-
ponent score sums, 0.77 between the physical and social and 0.58
between the physical and mental component score sums.
Covariates
We used all covariates with available baseline information from
our database that may have acted as possible confounders: age, sex,
education, cognitive functioning, comorbidity, depressive symp-
toms and physical function at baseline examination. Information
about age and sex was derived from the National Population Reg-
ister. Information about highest level of formal education was col-
lected through personal interview. Cognitive function was mea-
sured by using MMSE [27] since there is a global impairment of
cognitive functioning in the preclinical phase of AD [28] . Depres-
sive symptoms were assessed by two self-reported symptoms: being
in a low mood and/or often feeling lonely. Both of these symptoms
are included in the Center for Epidemiological Studies Depression
Scale [29] . Physical function was defi ned as disability in at least
Table 1. List of activities, scorings (0 = none; 1 = low; 2 = moderate; 3 = high) and frequency of participation
Type of activity Scores Subjects
mental physical social n %
Reading literature 3 0 0 152 20.8
Handicraft: needlework, weaving, knitting 2 1 1 146 19.9
Doing crossword puzzles 3 0 0 94 12.8
Political or cultural interests 3 1 3 75 10.2
Playing cards or chess 3 0 3 71 9.7
Visiting the summerhouse 2 2 2 70 9.6
Attending courses 3 1 2 59 8.1
Watching TV 2 0 0 55 7.5
Going to theatres or concerts 3 1 2 55 7.5
Doing sport 1 3 2 49 6.7
Going to exhibitions or museums 3 1 1 47 6.4
Meeting friends, participating in groups 2 1 3 47 6.4
Walking 1 3 1 37 5.1
Listening to radio 2 0 0 33 4.5
Travelling 3 2 2 29 4.0
Gardening and fl owers 2 2 1 29 4.0
Painting, drawing, photo 3 0 0 26 3.6
Engaging in family or charity 2 2 3 23 3.1
Doing outdoor activities 2 3 2 23 3.1
Collecting stamps or other items 3 0 0 18 2.5
Cooking food 2 1 1 17 2.3
Writing 3 0 1 16 2.2
Housekeeping 1 2 0 15 2.0
Attending church activities 2 1 3 15 2.0
Playing music 2 1 2 14 1.9
Doing solitaire 2 0 0 9 1.2
Following the stock market 3 0 0 8 1.1
Playing bingo 2 1 3 7 1.0
Singing 2 1 2 7 1.0
No activity at all 0 0 0 153 20.9
Karp /Paillard-Borg /Wang /Silverstein /
Winblad
/Fratiglioni
Dement Geriatr Cogn Disord 2006;21:65–73
68
one of the basic activities of daily living: bathing, dressing, toilet-
ing, continence, feeding or transfer [30] .
Data of previous diseases were obtained by reviewing hospital
discharge diagnoses through the Stockholm Computerized Inpa-
tient Register System. These diagnoses were made according to
the International Classifi cation of Disease, 8th edition [31] : coro-
nary heart disease (ICD-8: 410–414), cerebrovascular disease
(ICD-8: 430–438), diabetes mellitus (ICD-8: 250), malignancy
(ICD-8: 140–208 and 230–239) and hip fracture (ICD-8: 820).
Comorbidity was defi ned as subjects who had any of these fi ve
diseases.
Statistical Analyses
To evaluate the differences in baseline characteristics between
participants and drop-outs, logistic regression was used. Cox pro-
portional hazards regressions were performed to estimate the rela-
tive risk (RR) of incident AD and dementia associated with mental,
physical and social components in the different leisure activities.
The mental, physical and social components were analysed in
the following ways:
(1) We fi rst intended to tap the intensity of involvement in each
component by using a threshold to signify moderate/high involve-
ment: for each person and each component (mental, physical and
social), the number of moderately/highly (2–3) scored activities
were summed up separately and then divided into three categories.
The analyses were performed for each component, contrasting sub-
jects with one, and subjects with two or more moderately/highly
scored activities with subjects without any moderately/highly
scored activity.
(2) In order to measure the accumulation of each component
across the range of activities, the rated scores were added to a sum
of scores for each person and each component. This sum score was
analysed using (a) the continuous variable, (b) four groups with a
similar number of cases and (c) two groups dichotomized according
to the median value.
(3) To capture the combined effect of the three components in
reducing the dementia risk, combinations of the mental, physical
and social components were created using the sum score for each
component after dichotomization according to the median value.
All of the associations studied were fi rst assessed using simple
models including age and sex, and then adjustments for all covari-
ates described above were carried out. Age and MMSE score were
entered into the models as continuous variables. Education was
entered as a categorical variable ( 1 12 years, 8–12 years and
! 8 years of schooling). Sex (female vs. male), comorbidity (the
presence of coronary heart disease, cerebrovascular disease, dia-
betes
mellitus, malignancy or hip fracture vs. the presence of none
of them), depressive symptoms (yes vs. no) and physical function-
ing (dependent vs. independent) were entered as dichotomous
variables.
Results
The baseline study population consisted of 776 sub-
jects, but 44 persons refused second follow-up examina-
tion. While non-participants had less comorbidity than
participants, there were no differences with respect to age,
sex, education, cognitive functioning, depressive symp-
toms and physical functioning.
A total of 123 subjects developed clinical dementia
during the second follow-up. Table 2 shows the baseline
characteristics of the study population and incident de-
mentia cases.
The multi-adjusted RRs of dementia associated with
participation in 1–2 activities, and participation in
3–7 activities, versus no participation were 0.77 (95%
CI: 0.51–1.15) and 0.56 (95% CI: 0.31–0.99), respec-
tively
.
Table 2. Baseline characteristics of the study population (n = 732)
and of the incident dementia cases detected at second follow-up
(1994–1996)
Characteristic Participants
(n = 732)
n
Incident dementia
cases (n = 123)
n%
Age groups
75–79 364 36 9.9
80–84 232 55 23.7
85+ 136 32 23.5
Sex
Female 543 93 17.1
Male 189 30 15.9
Education
1
^7 years 386 70 18.1
6
8 years 343 53 15.5
MMSE score
24–26 178 38 21.3
27–30 554 85 15.3
Comorbidity
1
Yes 179 46 25.7
No 550 77 14.0
Depressive symptom
1
Yes 201 53 26.4
No 528 70 13.3
Physical dependence
2
Yes 132 30 22.7
No 592 93 15.7
Number of activities
0 153 37 24.2
1–2 400 67 16.8
3–7 179 19 10.6
1
For 3 subjects, information was missing.
2
For 8 subjects, information was missing.
Mental, Physical and Social Components
in Leisure Activities and Dementia Risk
Dement Geriatr Cogn Disord 2006;21:65–73
69
To examine if moderate/high-scored activities were
most benefi cial, the number of moderately/highly scored
activities were added up and then divided into three cat-
egories. In comparison to subjects with none or low (0–1)
involvement in the mental component, persons who had
one moderately/highly (2–3) rated activity had a multi-
adjusted RR of 0.90 (95% CI: 0.57–1.41), and persons
with two or more moderately/highly rated activities had
an RR of 0.67 (95% CI: 0.42–1.05). Regarding the phys-
ical component, the multi-adjusted RR of dementia was
0.87 (95% CI: 0.55–1.39) for subjects engaged in one
moderately/highly rated activity and 0.44 (95% CI: 0.14–
1.39) for being engaged in two or more moderately/high-
ly rated activities. For the social component, the multi-
adjusted RR associated with engagement in one moder-
ately/highly rated activity was 0.75 (95% CI: 0.48–1.18)
and the RR associated with two or more moderately/high-
ly rated activities was 0.94 (95% CI: 0.55–1.61).
Next, the total scores of each of the three components
were examined. The mental score sums ranged from 0 to
18, the physical score sums from 0 to 12 and the social
score sums from 0 to 13. The mental component differed
from the physical and social components in that it had no
subjects with a 0 score, aside from the group of subjects
who participated in no activities at all. All of the three
components’ score sum distributions were positively
skewed.
When fi rst analysed as continuous variables, multi-ad-
justed RRs indicated that greater score sums in the men-
tal component (RR = 0.94, 95% CI: 0.87–1.00) and phys-
ical component (RR = 0.89, 95% CI: 0.77–0.99) appeared
to lower the risk of dementia. Higher score sums in the
social component were not signifi cantly associated with
lower risk of dementia when analysed continuously
(RR = 0.95, 95% CI: 0.87–1.04).
All of the components’ score sum distributions were
then categorized into approximate quartiles ( table 3 ).
Having mental component score sums above 3 was sig-
nifi cantly associated with a decreased risk of dementia,
when controlled for age, sex, education, baseline MMSE
Table 3. RRs of dementia in relation to degree of estimated mental, physical and social component score sums
in baseline leisure activities
n Dementia
cases
RR (95% CI)
1
RR (95% CI)
2
Mental component score sum
0 153 37 1.0 1.0
1–3 207 38 0.75 (0.47–1.18) 0.82 (0.52–1.31)
4–7 251 34 0.61 (0.38–0.98) 0.67 (0.42–1.08)
8 or more 121 14 0.49 (0.26–0.93) 0.56 (0.29–1.07)
Higher score (0–3 vs. 4–18) 372 48 0.67 (0.46–0.98) 0.71 (0.49–1.03)
Physical component score sum
0 285 67 1.0 1.0
1 165 22 0.55 (0.34–0.89) 0.58 (0.36–0.95)
2–3 182 24 0.61 (0.38–0.99) 0.64 (0.40–1.04)
4 or more 100 10 0.51 (0.26–0.99) 0.59 (0.30–1.16)
Higher score (0 vs. 1–12) 447 56 0.57 (0.40–0.81) 0.61 (0.42–0.87)
Social component score sum
0 261 62 1.0 1.0
1 103 13 0.49 (0.27–0.90) 0.53 (0.29–0.97)
2–3 179 23 0.48 (0.29–0.78) 0.51 (0.31–0.82)
4 or more 189 25 0.61 (0.38–0.98) 0.69 (0.43–1.13)
Higher score (0–1 vs. 2–13) 368 48 0.64 (0.44–0.93) 0.68 (0.47–0.99)
For each component (mental, physical and social) two Cox regression models were performed: one analysing
the component score sum as a 4-category indicator variable, and the second as a dichotomous variable.
1
Adjusted for age, sex, education, baseline MMSE score, comorbidity and physical functioning.
2
Adjusted for age, sex, education, baseline MMSE score, comorbidity, physical functioning and depressive
symptoms.
Karp /Paillard-Borg /Wang /Silverstein /
Winblad
/Fratiglioni
Dement Geriatr Cogn Disord 2006;21:65–73
70
score, comorbidity and physical functioning. When the
depressive symptoms (feeling alone and in a low mood)
were added to the model, the association did not reach
the 0.05 level of signifi cance. The mental component
score sum, categorized in four grades, showed a signifi -
cant trend (p = 0.043) in relation to dementia risk. Having
a physical and social component score larger than or
equal to 1 was signifi cantly related to a lower risk of de-
mentia after adjustments for all covariates. There was no
trend with regard to the four score sum categories for the
physical or the social components. The basic adjusted
(only age and sex adjustments) results were similar.
Table 3 also shows the RRs of dementia in relation to
the sum of scores of mental, physical and social compo-
nents using the approximate medians for dichotomiza-
tion. The median for the mental component score was 4,
for the physical component 1 and for the social compo-
nent 2. When analysed one by one, all three components
were protective against dementia, although the mental
score was not entirely signifi cant when adjusted for all
covariates.
We further combined the dichotomized score sums of
the three components into eight groups, with the purpose
of investigating if some specifi c activity combinations
were more benefi cial. The dichotomizations were based
on the median values described above. These results (not
shown) indicated that having high overall scores on all
three components was associated with signifi cantly lower
risks of dementia when all covariates were taken into ac-
count. In two combinations, subjects who scored high on
only two of the three components (mental and physical;
physical and social) were also signifi cantly protected
against dementia. Due to the small number of cases in
some of the combinations, subjects were merged into four
categories: (1) low in all three components, (2) one high,
(3) two high, or (4) three high. The results are shown in
table 4 . Having high scores in two or three of the compo-
nents was associated with a signifi cant reduction in risk
of dementia. When those having higher scores on two or
more of the components were combined (category 3 and
4 together), the RR ratio fell to almost half (RR = 0.53,
95% CI: 0.36–0.78).
The following additional analyses were performed to
verify the results: although we had excluded subjects with
MMSE scores ^ 23, scores above that level could still in-
fl uence the studied relation. We therefore performed ad-
ditional analyses for subjects whose MMSE scores were
more than 26 at baseline examination. The results were
largely identical for the mental and physical component
score sums and showed a similar tendency for the social
component score sum. Finally, since there were quite a
few subjects (n = 153) who did not report any activity at
all and might have been qualitatively different from the
other combinations, additional analyses were performed
treating these subjects as a separate category. The results
and overall pattern did not change, and the ‘no activity
group’ had similar RRs as the group who had a lower
score in all three components. We also performed extra
analyses excluding the subjects who did not report any
activities. Similar results were observed.
Table 4. RRs of dementia associated with combinations of higher or lower mental, physical and social score
sums
Subjects Cases RR (95% CI)
1
RR (95% CI)
2
Lower score in all of the mental,
physical and social components 228 57 1.0 1.0
Higher score in one of the mental,
physical or social components 92 15 0.63 (0.36–1.12) 0.69 (0.39–1.22)
Higher score in two of the mental,
physical or social components 141 16 0.37 (0.21–0.65) 0.39 (0.22–0.69)
Higher score in all of the mental,
physical and social components 271 35 0.57 (0.37–0.89) 0.63 (0.41–0.98)
1
Adjusted for age, sex, education, baseline MMSE score, comorbidity and physical functioning.
2
Adjusted for age, sex, education, baseline MMSE score, comorbidity, physical functioning and depressive
symptoms.
Mental, Physical and Social Components
in Leisure Activities and Dementia Risk
Dement Geriatr Cogn Disord 2006;21:65–73
71
Discussion
This study shows that participation in leisure activities
is associated with reduced risk of dementia and that each
of the mental, physical and social components is of im-
portance. When an intensity threshold was used, compar-
ing the number of activities that rated moderate to high
on the components versus no or low-rated activities, the
results were not statistically signifi cant. However, when
the subjects’ score sums for each component were taken
into account, the RRs of dementia were signifi cantly de-
creased, showing that even small contributions of the
mental, physical or social components mattered when ac-
cumulated across several activities. This was especially
relevant for the physical component, since only few el-
derly had two or more activities with moderate to high
intensity.
The most benefi cial effect was, however, present for
subjects with high scores in all or in two of the compo-
nents. In the latter group, nearly half of the subjects had
reported only one activity. Examples of these single ac-
tivities scoring high in more than one component were:
being engaged in political and cultural activities, visiting
the summerhouse, attending courses, going to the theatre
or concerts, being active in sport or outdoor activities,
travelling, being engaged in charity or church activities
or playing music together with others.
Although other researchers [8, 19] have acknowledged
the fact that most leisure activities consist of several over-
lapping components, nobody, to our knowledge, has tried
to separate the different components from each other.
This study used a new approach, where three of the au-
thors (a neurologist, a psychologist and a sociologist), and
13 elderly raters scored the mental, physical and social
components in each of the 29 common leisure activities
reported by the participants. In addition, participation in
the leisure activities was assessed on average 6 years be-
fore dementia diagnosis in an attempt to reduce the infl u-
ence of preclinical dementia. None of the covariates (age,
sex, education, baseline MMSE score, comorbidity and
physical function) could explain the reported associa-
tions. ‘Depressive symptoms’ was the only control vari-
able that marginally changed the RRs of dementia – de-
spite the crude estimation of depressive symptomatology
in the present study.
There are a number of different hypotheses concerning
the possible effect of each of the mental, physical and so-
cial dimensions of common leisure activities on dementia
development. Activation of the nerve cells might prolong
their optimal function throughout the life-span [32] .
Mentally stimulating activities may buffer or delay path-
ological development. Persistent engagement in effortful
mental activities may even promote plastic changes in the
brain that can circumvent the underlying dementia pa-
thology [33] . Physical activity may increase cerebral oxy-
genation, leading to improved neurotransmitter metabo-
lism. It also reduces the risk of diseases that may be risk
factors for dementia such as hypertension, diabetes and
cardiovascular disease [8] . Predominantly social leisure
activities may affect the immune system [34] , which in
turn could infl uence infl ammatory processes in the brain,
which may be involved in dementia.
When interpreting these fi ndings, one needs to take
into account some considerations. First, open-ended
questions were used to obtain information of engagement
in leisure activities. Although these types of questions can
be of great value because they capture a wide variety of
possible and sometimes unexpected answers [35] , there
is always the risk that those who did not report any ac-
tivities were subjects who differed systematically in some
important respect. We performed analyses excluding the
subjects who did not report any activities at all (as well as
treating them as a separate group), and the results showed
a similar tendency as compared to the whole group. Fur-
thermore, we could not determine if any changes in lei-
sure engagement had occurred prior to baseline. Findings
from cross-sectional studies indicate that leisure engage-
ment may decrease with age; however, longitudinal, ret-
rospective studies have reported continuity in overall en-
gagement [36] .
Secondly, we do not have access to any ‘objective’ mea-
surements of the three components, although our assess-
ment method had good interrater reliability. It is also
diffi cult to compare the importance of each component
isolated from the others, since they often occur simulta-
neously in the same activities. The fact that each activity
was used to rate all three components meant that the com-
ponents were not independent, and therefore it was prob-
lematic to defi nitively adjust for the infl uence of one com-
ponent on the other. Still, we believe that there is an ad-
vantage in this method reducing all the 29 activities to
three main components, instead of merely grouping the
activities in an exclusive manner, not allowing overlap.
In spite of the imprecision of the assessments and catego-
rizations, we were able to detect risk differences.
Thirdly, there is always the possibility that cognitive
disturbances in the preclinical stages of dementia might
affect the subject’s choice of and engagement in leisure
activities in general and in activities with a high degree
of mental components in particular. Although initial cog-
Karp /Paillard-Borg /Wang /Silverstein /
Winblad
/Fratiglioni
Dement Geriatr Cogn Disord 2006;21:65–73
72
nitive functioning was adjusted for, and activity data
were collected on average 6 years before dementia diag-
nosis and a minimum of 3 years before dementia onset,
there still exists an uncertainty about how early in the
preclinical phase of dementia relevant cognitive defi cits
appear. It is therefore premature to interpret these results
as causal or even as delaying the disease onset, since less-
er leisure engagement may be a consequence of early
symptoms. However, a prospective study as extended as
21 years has recently reported results similar to ours [19] .
Furthermore, Bennett et al. [37] investigated post-mor-
tem data in the Religious Order Study and found that the
relation between senile plaques and level of cognitive
function differed by level of education, suggesting that
differences in lifestyle may affect cognitive reserve by
partially mediating the relationship between brain dam-
age and the clinical manifestation of AD. Additionally,
in the MRC National Survey of Health and Develop-
ment, Richards et al. [8] had the opportunity to control
for the infl uence of IQ at 15 years of age, when studying
active leisure and cognition. This research group drew the
conclusion that it was unlikely that the fi nding of an as-
sociation between active leisure and cognition was a re-
fl ection of reverse causality.
This study confi rms earlier results stating that engage-
ment in leisure activities with mental, social and physical
content in late life is associated with decreased risk of
dementia. Furthermore, it was found that small contribu-
tions of the mental, physical or social components mat-
tered when accumulated. Because few elderly engaged in
more vigorous exercise, the benefi t of light physical com-
ponents in activities that are not primarily physical is
especially noteworthy.
The results also indicate that engaging in activities that
cover more than one of the mental, physical and social
components seems to be more benefi cial than to be en-
gaged in only one type of activity. Implications for public
health and community may very well be that making dif-
ferent types of activities more accessible to elderly per-
sons could reduce the risk of developing dementia.
Acknowledgements
We thank all members of the Kungsholmen Project study group
for their cooperation in data collection and management. This re-
search was supported by a grant from the Swedish Council for
Working Life and Social Research (No. 2003-0386) and the Amer-
ican Alzheimer foundation.
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