Dementia is a disorder that arouses major public health interest and concern. It has been projected that there will be a global increase in the number of people affected from about 46.8million in 2018 to 131million by 2050; global cost of care for 2015 was put at US$818 billion (Prince et al., Reference Prince2015). Consequently, such development will lead to tremendous social and financial cost on family and society. Currently, there is no cure for dementia and that has led to increased research activities on prevention strategies, which often has to start with a number of midlife activities. These include regular exercise, diet, treatment of cardiovascular risk factors, and social and educational stimulation through life.
Cognitive decline is a major aspect of dementia; indeed, it usually predates its onset. In both prevention and treatment of dementia reducing the rate of cognitive decline is a major investment in delaying onset or limiting severity. There are two major ways of treating dementia and these are broadly referred to as pharmaceutical and non-pharmaceutical. Pharmacological treatment broadly refers to use of cholinesterase inhibitors and mematine; of course, there is the hope for introduction of anti- amyloid drugs in the near future. Non-pharmacological treatment methods refer to psychoeducation, cognitive training, exercise, and leisure activities among others, some of which have cultural coloration. The term non-pharmacological intervention has been criticized as not being specific enough by Zeisel et al. (Reference Zeisel2016) who went on to suggest ecopsychosocial intervention.
In this paper, The relation of close friends to cognitive performance in old age: the mediating role of leisure activities (Ihle et al., Reference Ihle2018b) report that having close friends enhances cognitive reserve through leisure activities and may help preserve cognitive function in older adults. Previously, the group had reported on cognitive reserve, social capital, and cognitive performance in old age (Ihle et al., Reference Ihle2018a). Markers of cognitive reserve here are education, cognitive level of job, and leisure activities, while markers of social capital are numbers of significant family members and number of close friends. In another report, The association of educational attainment, cognitive level of job, and leisure activities during the course of adulthood with cognitive performance in old age: the role of openness to experience. Ihle et al. (Reference Ihle2016) reported that higher education level, higher cognitive job experience, higher number of leisure activities, and higher score on openness were significantly associated with better cognitive performance. Openness in this context is a measure of personality dimension from the Big Five Inventory (Rammstedt and John, Reference Rammstedt and John2007). Engaging in leisure activities was greater in individuals with high openness to experience and individuals with higher openness experience also showed better cognitive performance (Ihle et al., Reference Ihle2016). It would appear that certain other variables could influence selection of leisure activities and even influence education and job selection. In the current paper, individuals show greater engagement in leisure activities if they have large number of close friends. This finding remains robust after adjusting for potentially confounding variables like education, marital status, retirement status, gender, and subjective health status. This is a cross-sectional study which has its limitations; however, the result of one longitudinal study differs somehow. Hakansson et al. (Reference Hakansson2009) in a prospective population study with mean follow-up time of 21 years observed that people in marriage or living with a partner in midlife (mean age 50 years) were less likely to have cognitive impairment at ages between 65 and 79 years when compared with those divorced, widowed, separated, or never married. It is intriguing that in their study, marriage protects against cognitive decline. In the present study, it does not appear that robust. It could be argued that the closest friend an individual has in a marriage that is free of rancor is his or her spouse. The authors admit some limitations in the present study which include possible selection bias, in that, participants in the study were expected to complete a test of vocabulary ability as well as trail making tests. Participants who fail to complete these tests were not included in analysis; thus, it is possible that those who already have some impairment of cognitive abilities might have been excluded; however, the study aimed to recruit cognitively normal individuals only.
Despite the limitations, the public health implications of the study are enormous, for both treatment (non-pharmacological) and prevention strategies in dementia. It could be presumed that having close friends and engaging in leisure activities should at least be preventive of cognitive decline in older adults who are currently not married. In a review by Larson (Reference Larson2010), there was emphasis on compression of cognitive morbidity as a strategy for delaying the onset of Alzheimer's disease by extension limiting Disability Life Years in persons with dementia, as it is conceivable that some may die of causes other than dementia as age advances before dementia sets in. In an earlier review (Fratiglioni et al., Reference Fratiglioni2004), it was pointed out that higher levels of cognitive functioning could be due to leisure activities that are stimulating and that leisure activities correlated negatively with cognitive decline. Leisure activities may include attending cultural events, music, singing, reading books, or magazines and solving cross word puzzles. Lautenschlager et al. (Reference Lautenschlager2008) in a randomized control trial, reported that physical exercise protected persons with mild cognitive impairment from further cognitive decline when compared with usual treatment group; the difference remained for 18 months after the trial was over. More importantly, the effect size due to exercise was significantly larger than that of cholinesterase inhibitors.
In conclusion, it would appear that the role of close friends and leisure activities in relation to cognitive performance can only be part of a whole and not the whole in the process of enhancing cognitive performance or delaying cognitive decline. Zeisel et al. (Reference Zeisel2016) commented that because of the poor definition of non-pharmacological treatment method (which they likened to a state of non-hate rather than love), not much attention has been paid to this treatment or prevention arm of dementia when compared with drug development, as a matter of fact non-pharmacological treatment methods receive relatively poorer funding. Efforts in this area as shown by the findings in this paper will most likely bring the desired change.
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Dementia is a disorder that arouses major public health interest and concern. It has been projected that there will be a global increase in the number of people affected from about 46.8million in 2018 to 131million by 2050; global cost of care for 2015 was put at US$818 billion (Prince et al., Reference Prince2015). Consequently, such development will lead to tremendous social and financial cost on family and society. Currently, there is no cure for dementia and that has led to increased research activities on prevention strategies, which often has to start with a number of midlife activities. These include regular exercise, diet, treatment of cardiovascular risk factors, and social and educational stimulation through life.
Cognitive decline is a major aspect of dementia; indeed, it usually predates its onset. In both prevention and treatment of dementia reducing the rate of cognitive decline is a major investment in delaying onset or limiting severity. There are two major ways of treating dementia and these are broadly referred to as pharmaceutical and non-pharmaceutical. Pharmacological treatment broadly refers to use of cholinesterase inhibitors and mematine; of course, there is the hope for introduction of anti- amyloid drugs in the near future. Non-pharmacological treatment methods refer to psychoeducation, cognitive training, exercise, and leisure activities among others, some of which have cultural coloration. The term non-pharmacological intervention has been criticized as not being specific enough by Zeisel et al. (Reference Zeisel2016) who went on to suggest ecopsychosocial intervention.
In this paper, The relation of close friends to cognitive performance in old age: the mediating role of leisure activities (Ihle et al., Reference Ihle2018b) report that having close friends enhances cognitive reserve through leisure activities and may help preserve cognitive function in older adults. Previously, the group had reported on cognitive reserve, social capital, and cognitive performance in old age (Ihle et al., Reference Ihle2018a). Markers of cognitive reserve here are education, cognitive level of job, and leisure activities, while markers of social capital are numbers of significant family members and number of close friends. In another report, The association of educational attainment, cognitive level of job, and leisure activities during the course of adulthood with cognitive performance in old age: the role of openness to experience. Ihle et al. (Reference Ihle2016) reported that higher education level, higher cognitive job experience, higher number of leisure activities, and higher score on openness were significantly associated with better cognitive performance. Openness in this context is a measure of personality dimension from the Big Five Inventory (Rammstedt and John, Reference Rammstedt and John2007). Engaging in leisure activities was greater in individuals with high openness to experience and individuals with higher openness experience also showed better cognitive performance (Ihle et al., Reference Ihle2016). It would appear that certain other variables could influence selection of leisure activities and even influence education and job selection. In the current paper, individuals show greater engagement in leisure activities if they have large number of close friends. This finding remains robust after adjusting for potentially confounding variables like education, marital status, retirement status, gender, and subjective health status. This is a cross-sectional study which has its limitations; however, the result of one longitudinal study differs somehow. Hakansson et al. (Reference Hakansson2009) in a prospective population study with mean follow-up time of 21 years observed that people in marriage or living with a partner in midlife (mean age 50 years) were less likely to have cognitive impairment at ages between 65 and 79 years when compared with those divorced, widowed, separated, or never married. It is intriguing that in their study, marriage protects against cognitive decline. In the present study, it does not appear that robust. It could be argued that the closest friend an individual has in a marriage that is free of rancor is his or her spouse. The authors admit some limitations in the present study which include possible selection bias, in that, participants in the study were expected to complete a test of vocabulary ability as well as trail making tests. Participants who fail to complete these tests were not included in analysis; thus, it is possible that those who already have some impairment of cognitive abilities might have been excluded; however, the study aimed to recruit cognitively normal individuals only.
Despite the limitations, the public health implications of the study are enormous, for both treatment (non-pharmacological) and prevention strategies in dementia. It could be presumed that having close friends and engaging in leisure activities should at least be preventive of cognitive decline in older adults who are currently not married. In a review by Larson (Reference Larson2010), there was emphasis on compression of cognitive morbidity as a strategy for delaying the onset of Alzheimer's disease by extension limiting Disability Life Years in persons with dementia, as it is conceivable that some may die of causes other than dementia as age advances before dementia sets in. In an earlier review (Fratiglioni et al., Reference Fratiglioni2004), it was pointed out that higher levels of cognitive functioning could be due to leisure activities that are stimulating and that leisure activities correlated negatively with cognitive decline. Leisure activities may include attending cultural events, music, singing, reading books, or magazines and solving cross word puzzles. Lautenschlager et al. (Reference Lautenschlager2008) in a randomized control trial, reported that physical exercise protected persons with mild cognitive impairment from further cognitive decline when compared with usual treatment group; the difference remained for 18 months after the trial was over. More importantly, the effect size due to exercise was significantly larger than that of cholinesterase inhibitors.
In conclusion, it would appear that the role of close friends and leisure activities in relation to cognitive performance can only be part of a whole and not the whole in the process of enhancing cognitive performance or delaying cognitive decline. Zeisel et al. (Reference Zeisel2016) commented that because of the poor definition of non-pharmacological treatment method (which they likened to a state of non-hate rather than love), not much attention has been paid to this treatment or prevention arm of dementia when compared with drug development, as a matter of fact non-pharmacological treatment methods receive relatively poorer funding. Efforts in this area as shown by the findings in this paper will most likely bring the desired change.
Conflict of interest
None.