The Behavioral Variant Frontotemporal Dementia Phenocopy Syndrome: A Review.

OBJECTIVES: The relatively recent identification of a subgroup of patients with apparent behavioral variant frontotemporal dementia (bvFTD) that fails to progress with time has led to a reevaluation of our understanding of bvFTD, and a growing body of research that attempts to characterize the mimic or "phenocopy" syndrome. In this article, we review the literature relating to the phenocopy syndrome, focusing in particular on distinguishing characteristics and potential etiologies. METHODS: Published articles were identified via a systematic search of PubMed and Embase. Observational and interventional studies, case reports, and case series were sought for inclusion. RESULTS: While bvFTD and the phenocopy syndrome are clinically indistinguishable at initial presentation, the presence or absence of characteristic changes on neuroimaging predicts 2 very different illness trajectories. The etiology for the phenocopy presentation remains uncertain. It is likely that the syndrome represents a heterogenous assortment of clinical frontal syndromes encompassing atypical neurodegenerative, psychiatric, psychological, and as yet unknown neuropsychiatric causes. CONCLUSIONS: Although the prognosis of the phenocopy syndrome is generally held to be more favorable than that of bvFTD, patients and families are subject to major disruption in their relationships and social and occupational functioning. Early recognition is crucial to facilitate timely interventions aimed at maintaining relationships, roles, and quality of life of those affected.

Social factors may mediate the relationship between subjective age-related hearing loss and episodic memory.

Objectives: To investigate whether the relationship between subjective age-related hearing loss (SARHL) and episodic memory functioning is mediated by measures of social functioning.Methods: Using data from 8,163 adults over 50 that participated in the Irish Longitudinal Study of Ageing (three waves, each two years apart), we used a multiple mediation model within a Structural Equation Modelling framework to explore potential social mediators of the relationship between SARHL and episodic memory functioning, controlling for demographic and health covariates.Results: Neither the direct effect of self-reported hearing difficulties on memory functioning (ß = -.03), nor the total effect (ß = .01), were significant. A small inconsistent indirect effect of self-reported hearing difficulties on episodic memory via weekly social activity engagement (ß = -.002) was found.Conclusions: Self-reported hearing difficulties may exert an indirect effect on episodic memory via weekly social activity engagement. The findings may have implications for identification of individuals at risk of memory decline in later life.

Bones of Contention: A Comprehensive Literature Review of Non-SSRI Antidepressant Use and Bone Health.

Osteoporotic fractures are associated with major morbidity and mortality, particularly among older age groups. In recent decades, selective serotonin reuptake inhibitors (SSRI) antidepressants have been linked to reduced bone mineral density and increased risk of fragility fracture. However, up to one-third of antidepressant prescriptions are for classes other than SSRIs. Older patients, who are particularly vulnerable to osteoporosis and its clinical and psychosocial consequences, may be prescribed non-SSRI antidepressants preferentially because of increasing awareness of the risks SSRIs pose to bone health. However, to date, the skeletal effects of non-SSRI antidepressants have not been comprehensively reviewed. In this article, we collate and review the available data and discuss the findings. Based on the current literature, we tentatively suggest that tricyclic antidepressants may increase the risk of fracture via mechanisms other than a direct effect on bone mineral density. The risk is apparently confined to current users only and is greatest in the earliest stage of treatment, diminishing thereafter. There is, as yet, insufficient data to conclusively determine the effects of other antidepressant classes on bone. Judicious prescribing of antidepressants among higher risk groups necessitates a thorough review of the individual's risk factors for osteoporosis as well as attention to their falls risk. Further longitudinal, rigorously controlled studies are needed to answer some of the remaining questions on the effects of non-SSRI antidepressants on bone and the mechanisms by which they are exerted.

Depressive symptoms predict increased social and emotional loneliness in older adults.

Objectives: Explorations of relationships between loneliness and depression have focused on loneliness as a uni-dimensional construct. We hypothesised that reciprocal relationships may exist between depressive symptomatology and social and emotional subtypes of loneliness.Methods: Using data from 373 adults aged over 50, who participated in an observational cohort study, we employed a cross-lagged approach within a Structural Equation Modelling framework, to investigate reciprocal links between depressive symptomatology, and social and emotional loneliness, across two waves of data collection, two years apart (controlling for age, sex, education, comorbidities, social network index, and perceived stress).Results: Both depressive symptomatology and loneliness decreased slightly between waves. Auto-regressive effects were strong for all three variables of interest. Cross-lagged pathways were evident, such that depressive symptomatology at baseline predicted both emotional (ß = 0.26, p < 0.05) and social (ß = 0.17, p < 0.05) loneliness at follow-up. Neither emotional (ß = 0.07, p > 0.05) nor social (ß = 0.05, p > 0.05) loneliness at baseline predicted depressive symptomatology at follow-up.Conclusions: Results challenge existing understanding of the associations between loneliness and depression. Further investigation of emotional and social loneliness in individuals with depressive disorders is warranted. Findings are discussed in relation to mechanisms that may explain the relationships observed, and possible implications.

Mediating the relationship between loneliness and cognitive function: the role of depressive and anxiety symptoms.

Objective: To evaluate the relationship between loneliness and cognitive functioning, and whether depressive and anxiety symptoms have intermediate roles therein.Methods: Information about 7,433 participants of the Irish Longitudinal Study on Ageing (a prospective, representative cohort study), aged over 50, was collected at three time-points two years apart, and analysed using Structural Equation Modelling to assess whether depressive and anxiety symptoms mediate the relationship between loneliness and cognitive functioning. Cognitive functioning was measured as a latent factor, with four indicators: measures of immediate and delayed word recall, verbal fluency, and a global measure (the MMSE). Loneliness was measured using the UCLA Loneliness scale, depressive symptoms using the CES-D-ML scale, and anxiety symptoms using the HADS-A scale.Results: Loneliness at time-point 1 predicted cognitive functioning at time-point 3, ß = -0.103, p < 0.001, and depressive (ß = 0.426, p < 0.001) and anxiety (ß = 0.410, p < 0.001) symptoms at time-point 2. Depressive (ß = -0.020, p = 0.001) but not anxiety (ß = -0.000, p = 0.658) symptoms mediated the relationship between loneliness and cognitive functioning, total effect: ß = -0.123, p < 0.001.Conclusion: The relationship between loneliness and cognitive functioning is in part explained by its relationship with depressive symptoms. Statistically, the mediation model helps us understand possible mechanisms through which loneliness impacts cognitive functioning. Results have implications for cognitive functioning interventions for older adults, and imply that loneliness is also a worthwhile target for intervention.

Is the Quick Mild Cognitive Impairment Screen (QMCI) more accurate at detecting mild cognitive impairment than existing short cognitive screening tests? A systematic review of the current literature.

OBJECTIVES: Differentiating normal cognition, mild cognitive impairment (MCI), and dementia is important, as these conditions differ in terms of their prognosis and treatment. Existing short cognitive screening tests vary widely in their accuracy, sensitivity, and specificity at detecting MCI and dementia. The Quick Mild Cognitive Impairment Screen (QMCI) was developed in 2012 as a fast and accurate "MCI specific" screening test. The aim of the current study was to conduct a literature review to compare the accuracy, sensitivity, and specificity of the QMCI at differentiating normal cognition, MCI, and dementia to existing short cognitive screening tests at their optimal cut-off scores. METHODS: A search of the electronic journal databases EBSCO, Psych info, and Science Direct was undertaken using the keywords "Quick Mild Cognitive Impairment Screen," "QMCI," "accuracy," "sensitivity," and "specificity." Results of individual studies were examined, and 2 × 2 tables were drawn up to obtain the overall accuracy, sensitivity, and specificity of each test across the studies included. RESULTS: Results from individual studies show that the QMCI has higher accuracy at detecting MCI and dementia than these cognitive screens. Pooled analysis shows that it also has greater sensitivity and specificity at optimal cut-off points for each test. CONCLUSIONS: Based in the current review, the QMCI represents a more accurate, sensitive, and specific screening test for MCI and dementia than the SMMSE or the MoCA. This has important implications in screening for cognitive impairment.

Cognitive functioning among cognitively intact dementia caregivers compared to matched self-selected and population controls.

PURPOSE OF THE STUDY: Caregiving for a person with dementia is frequently used to model the impact of chronic stress on health, including cognitive functioning. However, the prevalence of typically healthier, self-selecting non-caregiving control groups could contribute to a picture of poorer caregiver performance and overstate the negative effects of stress. We investigated differences in cognitive performance between dementia caregivers and two groups of non-caregivers recruited using different sampling methods. DESIGN AND METHODS: We compared cognitive function and psychological wellbeing among 252 spousal dementia caregivers with demographically matched non-caregiving control groups drawn from (1) a population study and (2) a self-selecting sample. Comparable cognitive measures included immediate and delayed recall, processing speed reaction time and verbal fluency. RESULTS: Caregiver and non-caregiver performance was comparable on most cognitive domains. However, caregivers outperformed both control groups on processing speed (p ≤ .05) and reaction time (p ≤ .05), despite having higher levels of stress and depression (ps < .001). Furthermore, caregivers had significantly better free recall than self-selecting controls (p < .001). IMPLICATIONS: Our results, overall, do not support the idea that caregiving is associated with stress-induced cognitive deficits. Rather, the trend toward better caregiver performance is consistent with the healthy caregiver hypothesis.

Public knowledge and understanding of dementia-evidence from a national survey in Ireland.

Background: there is growing consensus around the importance of population level approaches which seek to improve public knowledge and awareness of dementia. Aim: to assess knowledge of the relationship between dementia and ageing, and of the risk and protective factors associated with it, among the general public in Ireland. Design: cross-sectional survey. Participants selected using quota sampling based on Census data. Methods: the final sample of 1,217 respondents provided estimates of dementia knowledge in the Irish population. Logistic regression was used to assess the impact of potential predictor variables on knowledge of dementia. Results: a majority (52%) reported that they knew someone living with dementia. Just 39% were confident that they could tell the difference between the early signs of dementia and normal ageing. Less than half (46%) believed that there were things they could do to reduce their risk of developing dementia, and knowledge of risk and protective factors for dementia was very poor. Although significant differences were seen according to area of residence, social class and experience of dementia, even those groups with 'better' understanding demonstrated substantial knowledge deficits regarding risk and protective factors. Conclusions: the general public in Ireland are confused about the relationship between dementia and ageing, and knowledge of risk and protective factors for dementia is very poor. While not dissimilar to those reported internationally, the findings present a challenge to those tasked with promoting behaviour change and interventions to delay or prevent the onset of dementia.

The detection, diagnosis, and impact of cognitive impairment among inpatients aged 65 years and over in an Irish general hospital - a prospective observational study.

BACKGROUND: The diagnosis of dementia remains inadequate, even within clinical settings. Data on rates and degree of impairment among inpatients are vital for service planning and the provision of appropriate patient care as Ireland's population ages. METHODS: Every patient aged 65 years and over admitted over a two-week period was invited to participate. Those who met inclusion criteria were screened for delirium then underwent cognitive screening. Demographic, functional, and outcome data were obtained from medical records, participants, and family. RESULTS: Consent to participate was obtained from 68.6% of the eligible population. Data for 143 patients were obtained. Mean age 78.1 years. 27.3% met criteria for dementia and 21% had mild cognitive impairment (MCI). Only 41% of those with dementia and 10% of those with MCI had a previously documented impairment. Between-group analysis showed differences in length of stay (p = 0.003), number of readmissions in 12 months (p = 0.036), and likelihood of returning home (p = 0.039) between the dementia and normal groups. MCI outcomes were similar to the normal group. No difference was seen for one-year mortality. Effects were less pronounced on multivariate analysis but continued to show a significant effect on length of stay even after controlling for demographics, personal and family history, and anxiety and depression screening scores. Patients with dementia remained in hospital 15.3 days longer (p = 0.047). A diagnosis is the single biggest contributing factor to length of stay in our regression model. CONCLUSIONS: Cognitive impairment is pervasive and under-recognized in the acute hospital and impacts negatively on patient outcomes.

Reliability and Validity of the International Dementia Alliance Schedule for the Assessment and Staging of Care in Ireland.

OBJECTIVE: To independently assess the inter-rater reliability of the International Dementia Alliance (IDEAL) schedule in Ireland and to examine criterion validity for cognitive functioning and caregiver distress. METHODS: Two raters independently completed the IDEAL schedule based on an interview with persons diagnosed with dementia and their informal caregivers. The Clinical Dementia Rating (CDR) scale and the Zarit Burden Interview were used as reference standards for criterion validity. Intraclass coefficients (ICCs) and correlations (Spearman's ρ) were derived. RESULTS: ICCs for the IDEAL subdomains ranged from 0.77 to 1.00, indicating robust agreement between raters. Strong correlations between the CDR and the IDEAL cognitive functioning domain (ρ = 0.82) and overall summary score (ρ = 0.77) were observed. The Zarit Burden Interview and the IDEAL carer distress subdomain were moderately correlated (ρ = 0.56). CONCLUSION: This study confirmed that the IDEAL schedule is a valid and reliable instrument in the Irish population and further supports the international use of the IDEAL schedule.

Preservation of the Semantic Verbal Fluency Advantage in a Large Population-Based Sample: Normative Data from the TILDA Study.

OBJECTIVES: It is widely believed that phonemic fluency is more difficult than naming exemplars from a semantic category. Normative data in this regard are scarce, and there is considerable disagreement in the literature regarding the pattern in normal ageing and neurodegenerative conditions. Our objective was to provide normative data for semantic phonemic discrepancy scores from a large sample of older adults. METHODS: A total of 5780 community-dwelling older adults were included in this prospective, longitudinal study. Discrepancy scores were calculated by subtracting phonemic fluency score from semantic fluency score for each participant. Quantile regression was used to estimate normative values stratified for age. RESULTS: Subjects did better on testing of semantic fluency. The average discrepancy score was 9.18±6.89 words, (range, -20 to 37; n=5780). At the fiftieth percentile, those in their fifth decade produced 10 more "animals" than "letter F" words. Subjects scored one word less per decade, with an average of seven more "animal" words produced by those in their eighth decade. CONCLUSIONS: Our study is the first to provide normative data and confirms that, for animal versus letter F fluency, the semantic advantage persists into later life in a population-based sample of community-dwelling older adults. Given that a majority of clinical samples have confirmed a reverse of this pattern in Alzheimer's dementia (i.e., loss of semantic advantage in Alzheimer's disease, yielding a phonemic advantage), our findings support the clinical utility of brief fluency tests and encourage further research into their use in diagnosis and prediction of progression to dementia.

Executive functioning independently predicts self-rated health and improvement in self-rated health over time among community-dwelling older adults.

OBJECTIVES: Self-rated health, as distinct from objective measures of health, is a clinically informative metric among older adults. The purpose of our study was to examine the cognitive and psychosocial factors associated with self-rated health. METHODS: 624 participants over the age of 60 were assessed at baseline, and of these, 510 were contacted for a follow-up two years later. Measures of executive function and self-rated health were assessed at baseline, and self-rated health was assessed at follow-up. We employed multiple linear regression analyses to investigate the relationship between executive functioning and self-rated health, while controlling for demographic, psychosocial and biological variables. RESULTS: Controlling for other relevant variables, executive functioning independently and solely predicted self-rated health, both at a cross-sectional level, and also over time. Loneliness was also found to cross-sectionally predict self-rated health, although this relationship was not present at a longitudinal level. CONCLUSION: Older adults' self-rated health may be related to their executive functioning and to their loneliness. Self-rated health appeared to improve over time, and the extent of this improvement was also related to executive functioning at baseline. Self-rated health may be a judgement made of one's functioning, especially executive functioning, which changes with age and therefore may be particularly salient in the reflections of older adults.

Risk of Cognitive and Functional Impairment in Spouses of People With Dementia: Evidence From the Health and Retirement Study.

Caring for a spouse with dementia is a chronic stressor that may compromise caregivers' own cognitive functioning and capacity to provide adequate care. We examined whether having (i) a spouse with dementia and (ii) a spouse who requires assistance with activities of daily living predicted cognitive and functional impairments in respondents to the Health and Retirement Study (n = 7965). Respondents who had a spouse who requires care had poorer cognitive functioning, whereby this relationship was significantly stronger for male respondents. Having a spouse with dementia moderated the relationship between income and cognition and predicted caregiver functional impairment, though not when depression was controlled. Although we found no significant differences on any individual cognitive domains between 179 dementia caregivers and sociodemographically matched noncaregivers, our findings suggest that caregivers, especially men, and low-income individuals who have a spouse with dementia are more vulnerable to adverse cognitive outcomes. Targeting depression in spouses of people with dementia may help to prevent functional impairments.

Functional disability and death wishes in older Europeans: results from the EURODEP concerted action.

PURPOSE: Physical illness has been shown to be a risk factor for suicidal behaviour in older adults. The association between functional disability and suicidal behaviour in older adults is less clear. The aim of this study was to examine the relationship between functional disability and death wishes in late life. METHODS: Data from 11 population studies on depression in persons aged 65 and above were pooled, yielding a total of 15,890 respondents. Level of functional disability was trichotomised (no, intermediate, high). A person was considered to have death wishes if the death wish/suicidal ideation item of the EURO-D scale was endorsed. Odds ratios for death wishes associated with functional disability were calculated in a multilevel logistic regression model. RESULTS: In total, 5 % of the men and 7 % of the women reported death wishes. Both intermediate (OR 1.89, 95 % CI 1.42; 2.52) and high functional disability (OR 3.22, 95 % CI 2.34; 4.42) were associated with death wishes. No sex differences could be shown. Results remained after adding depressive symptoms to the model. CONCLUSIONS: Functional disability was independently associated with death wishes in older adults. Results can help inform clinicians who care for older persons with functional impairment.

Paranoid symptoms and hallucinations among the older people in Western Europe.

OBJECTIVE: It is not clear whether the prevalence of psychosis increases with age. We studied the age-specific prevalence of psychotic symptoms in older people in Western Europe. METHODS: Older people without dementia (age 65-104 years, N = 8762) from the western part of Europe in the EURODEP concerted action took part in psychiatric examinations. RESULTS: In total, 2.4% of the men and 2.9% of the women had psychotic symptoms. Using a multilevel logistic regression model that included gender and age as a continuous variable, we found that a 5-year increase in age increased the prevalence of psychotic symptoms (odds ratio 1.2 95% confidence interval 1.06-1.3, p = 0.001). A second multilevel regression model showed that wishing to be dead, depressed mood, functional disability, not being married and cognitive impairment measured with Mini mental state examination were all associated with psychotic symptoms whereas gender was not. CONCLUSION: The prevalence of psychotic symptoms in non-demented older people increases with age, and these symptoms are associated with other psychopathology, social isolation and problems with daily living.

Oscillometric measure of blood pressure detects association between orthostatic hypotension and depression in population based study of older adults.

BACKGROUND: White matter hyperintensities may contribute to depression by disrupting neural connections among brain regions that regulate mood. Orthostatic hypotension (OH) may be a risk factor for white matter hyperintensities and accumulating evidence, although limited suggests it may play a role in the development of late-life depression. The aim of this study was to examine the relationship between an oscillometric measure of orthostatic hypotension and depression in population based sample of older adults. METHODS: We analysed data on adults aged 60 and over from the first wave of The Irish Longitudinal Study on Ageing (TILDA). Depression was assessed using the Center for Epidemiologic Studies--Depression (CES-D) scale and OH was assessed by a sit-to-stand orthostatic stress test; two seated blood pressure measurements were followed by a single standing blood pressure measurement. Participants self reported whether they felt dizzy, light-headed or unsteady on standing. RESULTS: Participants with symptomatic OH (SOH, n=20) had the highest mean CES-D score (mean 8.6, SE 1.6) when compared to participants with asymptomatic OH (AOH) (mean 5.6, SE .48) and participants with no OH (mean 5.2, SE .14) and this difference was significant for both comparisons (p<0.001). Linear regression analysis adjusted for socio-demographic and clinical characteristics showed that SOH was associated with higher CES-D scores (unstandardised B coefficient = 2.24; 95% CI .301 - 4.79; p =0.05) compared to participants without OH. AOH was not associated with higher CES-D scores (unstandardised B coefficient =.162; 95% CI -.681, 1.00; p= 0.70). CONCLUSIONS: Symptomatic orthostatic hypotension is associated with depression in older adults and needs to be considered in studies examining the relationship between vascular disease and depression in older adults.

Age-related hearing loss associated with differences in the neural correlates of feature binding in visual working memory.

The underlying neural mechanisms underpinning the association between age-related hearing loss (ARHL) and dementia remain unclear. A limitation has been the lack of functional neuroimaging studies in ARHL cohorts to help clarify this relationship. In the present study, we investigated the neural correlates of feature binding in visual working memory with ARHL (controls = 14, mild HL = 21, and moderate or greater HL = 23). Participants completed a visual change detection task assessing feature binding while their neural activity was synchronously recorded via high-density electroencephalography. There was no difference in accuracy scores for ARHL groups compared to controls. There was increased electrophysiological activity in those with ARHL, particularly in components indexing the earlier stages of visual cognitive processing. This activity was more pronounced with more severe ARHL and was associated with maintained feature binding. Source space (sLORETA) analyses indicated greater activity in networks modulated by frontoparietal and temporal regions. Our results demonstrate there may be increased involvement of neurocognitive control networks to maintain lower-order neurocognitive processing disrupted by ARHL.

Investigation of the effects of alcohol on sleep using actigraphy.

AIMS: To investigate the effect of alcohol consumption on the sleep and mood of healthy individuals in a college-based, mixed gender population. METHODS: Forty-seven individuals participated in this study, of whom 33 consumed alcohol and were included in the analysis. Sleep quality was objectively recorded using actigraphy. Subjects completed a daily sleep diary and bipolar Profile of Mood States Questionnaire, recording the subjective perception of sleep quality and waking mood respectively. RESULTS: Mean self-reported alcohol consumption among the drinkers was 84.6 ml ethanol/night. Mean total sleep time for those who consumed less than the mean reported intake was significantly reduced on alcohol. This reduction in sleep time was associated with increased wakefulness in the second half of the night, a truncated sleeping period and increased waking fatigue. This rebound wakefulness could not be demonstrated in those who consumed higher than the mean intake, though these individuals also reported increased waking fatigue. CONCLUSION: These results add weight to the clinical evidence that ethanol should not be used as a hypnotic due to its potential to affect both the quantity and quality of sleep. The finding that total sleep time is reduced on low doses of alcohol is novel and may arise from measuring sleep in an environment other than the sleep laboratory.

Subjective well-being amongst community-dwelling elders: what determines satisfaction with life? Findings from the Dublin Healthy Aging Study.

BACKGROUND: Life satisfaction is a subjective expression of well-being and successful aging. Subjective well-being is a major determinant of health outcomes in older people. The aim of this study was to determine which factors predicted well-being in older people living in the community as measured by their satisfaction with life. METHODS: The relationship between life satisfaction, as measured by the Life Satisfaction Index (LSI-A) and physical, cognitive and demographic variables was examined in 466 older people living in the community using a stepwise regression model. RESULTS: Depression, loneliness, neuroticism, extraversion, recent participation in physical activity, age and self-reported exhaustion, were the independent predictors of life satisfaction in our elderly cohort. CONCLUSION: Subjective well-being, as measured by the Life Satisfaction Scale, is predicted by depression, loneliness, personality traits, recent participation in physical activity and self-reported exhaustion. The mental and emotional status of older individuals, as well as their engagement in physical activity, are as important as physical functionality when it comes to life satisfaction as a measure of well-being and successful aging. These areas represent key targets for intervention.

Risk factors and mediating pathways of loneliness and social support in community-dwelling older adults.

OBJECTIVES: To develop biopsychosocial models of loneliness and social support thereby identifying their key risk factors in an Irish sample of community-dwelling older adults. Additionally, to investigate indirect effects of social support on loneliness through mediating risk factors. METHODS: A total of 579 participants (400 females; 179 males) were given a battery of biopsychosocial assessments with the primary measures being the De Jong Gierveld Loneliness Scale and the Lubben Social Network Scale along with a broad range of secondary measures. ANALYSIS: Bivariate correlation analyses identified items to be included in separate psychosocial, cognitive, biological and demographic multiple regression analyses. The resulting model items were then entered into further multiple regression analyses to obtain overall models. Following this, bootstrapping mediation analyses was conducted to examine indirect effects of social support on the subtypes (emotional and social) of loneliness. RESULTS: The overall model for (1) emotional loneliness included depression, neuroticism, perceived stress, living alone and accommodation type, (2) social loneliness included neuroticism, perceived stress, animal naming and number of grandchildren and (3) social support included extraversion, executive functioning (Trail Making Test B-time), history of falls, age and whether the participant drives or not. Social support influenced emotional loneliness predominantly through indirect means, while its effect on social loneliness was more direct. CONCLUSIONS: These results characterise the biopsychosocial risk factors of emotional loneliness, social loneliness and social support and identify key pathways by which social support influences emotional and social loneliness. These findings highlight issues with the potential for consideration in the development of targeted interventions.