The relation between economic stressors and higher education students' mental health during the initial outbreak of the COVID-19 pandemic.

AIMS: The COVID-19 pandemic has had a large impact on the financial situation of higher education students, disproportionately affecting students with a low socioeconomic status (SES). This raises the question of whether economic stressors related to COVID-19 have aggravated existing socioeconomic inequalities in mental health. This study examined the relationship between economic stressors and students' depressive symptoms, and the role of students' SES and countries' socioeconomic conditions. METHODS: Data from the COVID-19 International Student Well-being Study was used for multilevel analyses, with depressive symptoms as dependent variable. Three indicators measured SES: educational level of the parents, ability to borrow money from their social network, and struggling with financial resources prior to COVID-19. RESULTS: Students with a low SES had more depressive symptoms, and those not able to borrow money and with parents without higher education were more exposed to a deterioration in their financial situation. Both economic stressors (reduction in working hours and a deterioration of their financial situation) were positively related to depressive symptoms. In addition, the positive relationship between a decrease in working hours and depressive symptoms was stronger in countries with a higher unemployment rate. CONCLUSIONS: We observed socioeconomic inequalities in students' mental health, which, in part, can be ascribed to a larger exposure to the economic stressors related to COVID-19 among students' with a low SES. The macroeconomic context also played a role, as the impact of a reduction in working hours on depressive symptoms was stronger in countries with poor economic conditions.

Educational inequalities in multimorbidity at older ages: a multi-generational population-based study.

BACKGROUND: Social inequalities in multimorbidity may occur due to familial and/or individual factors and may differ between men and women. Using population-based multi-generational data, this study aimed to (1) assess the roles of parental and individual education in the risk of multimorbidity and (2) examine the potential effect modification by sex. METHODS: Data were analysed from 62 060 adults aged 50+ who participated in the Survey of Health, Ageing and Retirement in Europe, comprising 14 European countries. Intergenerational educational trajectories (exposure) were High-High (reference), Low-High, High-Low and Low-Low, corresponding to parental-individual educational attainments. Multimorbidity (outcome) was ascertained between 2013 and 2020 as self-reported occurrence of ≥2 diagnosed chronic conditions. Inequalities were quantified as multimorbidity-free years lost (MFYL) between the ages of 50 and 90 and estimated via differences in the area under the standardized cumulative risk curves. Effect modification by sex was assessed via stratification. RESULTS: Low individual education was associated with higher multimorbidity risk regardless of parental education. Compared to the High-High trajectory, Low-High was associated with -0.2 MFYL (95% confidence intervals: -0.5 to 0.1), High-Low with 3.0 (2.4-3.5), and Low-Low with 2.6 (2.3-2.9) MFYL. This pattern was observed for both sexes, with a greater magnitude for women. This effect modification was not observed when only diseases diagnosed independently of healthcare-seeking behaviours were examined. CONCLUSIONS: Individual education was the main contributor to intergenerational inequalities in multimorbidity risk among older European adults. These findings support the importance of achieving a high education to mitigate multimorbidity risk.

Patients' experience on pain outcomes after hip arthroplasty: insights from an information tool based on registry data.

BACKGROUND: Arthroplasty registries are rarely used to inform encounters between clinician and patient. This study is part of a larger one which aimed to develop an information tool allowing both to benefit from previous patients' experience after total hip arthroplasty (THA). This study focuses on generating the information tool specifically for pain outcomes. METHODS: Data from the Geneva Arthroplasty Registry (GAR) about patients receiving a primary elective THA between 1996 and 2019 was used. Selected outcomes were identified from patient and surgeon surveys: pain walking, climbing stairs, night pain, pain interference, and pain medication. Clusters of patients with homogeneous outcomes at 1, 5, and 10 years postoperatively were generated based on selected predictors evaluated preoperatively using conditional inference trees (CITs). RESULTS: Data from 6,836 THAs were analysed and 14 CITs generated with 17 predictors found significant (p < 0.05). Baseline WOMAC pain score, SF-12 self-rated health (SRH), number of comorbidities, SF-12 mental component score, and body mass index (BMI) were the most common predictors. Outcome levels varied markedly by clusters whilst predictors changed at different time points for the same outcome. For example, 79% of patients with good to excellent SRH and less than moderate preoperative night pain reported absence of night pain at 1 year after THA; in contrast, for those with fair/poor SHR this figure was 50%. Also, clusters of patients with homogeneous levels of night pain at 1 year were generated based on SRH, Charnley, WOMAC night and pain scores, whilst those at 10 years were based on BMI alone. CONCLUSIONS: The information tool generated under this study can provide prospective patients and clinicians with valuable and understandable information about the experiences of "patients like them" regarding their pain outcomes.

Lack of social support, gender and colorectal cancer screening participation across Europe: How do screening programmes mitigate the effect of social support for men and women?

This study investigates how a lack of social support differentially affects men and women's colorectal cancer (CRC) screening participation, considering different screening strategies implemented across European countries. Although health sociology has stressed gender differences in social support and its effects on health behaviours, this was overlooked by cancer screening research. Using a data set of 65,961 women and 55,602 men in 31 European countries, we analysed the effect of social support variables on CRC screening uptake. We found that living alone and lower perceived social support were associated with lower screening uptake for both men and women. These effects were, however, stronger among men. Population-based screening programmes mitigated these effects, particularly for women, but not for men living alone. In countries with opportunistic screening programmes, social support variables remained associated with screening uptake. We conclude that cancer screening interventions should pay attention to social support and its gender-differentiated effects.

Seroprevalence trends of anti-SARS-CoV-2 antibodies and associated risk factors: a population-based study.

PURPOSE: We aimed to assess the seroprevalence trends of SARS-CoV-2 antibodies in several Swiss cantons between May 2020 and September 2021 and investigate risk factors for seropositivity and their changes over time. METHODS: We conducted repeated population-based serological studies in different Swiss regions using a common methodology. We defined three study periods: May-October 2020 (period 1, prior to vaccination), November 2020-mid-May 2021 (period 2, first months of the vaccination campaign), and mid-May-September 2021 (period 3, a large share of the population vaccinated). We measured anti-spike IgG. Participants provided information on sociodemographic and socioeconomic characteristics, health status, and adherence to preventive measures. We estimated seroprevalence with a Bayesian logistic regression model and the association between risk factors and seropositivity with Poisson models. RESULTS: We included 13,291 participants aged 20 and older from 11 Swiss cantons. Seroprevalence was 3.7% (95% CI 2.1-4.9) in period 1, 16.2% (95% CI 14.4-17.5) in period 2, and 72.0% (95% CI 70.3-73.8) in period 3, with regional variations. In period 1, younger age (20-64) was the only factor associated with higher seropositivity. In period 3, being aged ≥ 65 years, with a high income, retired, overweight or obese or with other comorbidities, was associated with higher seropositivity. These associations disappeared after adjusting for vaccination status. Seropositivity was lower in participants with lower adherence to preventive measures, due to a lower vaccination uptake. CONCLUSIONS: Seroprevalence sharply increased over time, also thanks to vaccination, with some regional variations. After the vaccination campaign, no differences between subgroups were observed.

Changes in socioeconomic resources and mental health after the second COVID-19 wave (2020-2021): a longitudinal study in Switzerland.

BACKGROUND: During the 2020/2021 winter, the labour market was under the impact of the COVID-19 pandemic. Changes in socioeconomic resources during this period could have influenced individual mental health. This association may have been mitigated or exacerbated by subjective risk perceptions, such as perceived risk of getting infected with SARS-CoV-2 or perception of the national economic situation. Therefore, we aimed to determine if changes in financial resources and employment situation during and after the second COVID-19 wave were prospectively associated with depression, anxiety and stress, and whether perceptions of the national economic situation and of the risk of getting infected modified this association. METHODS: One thousand seven hundred fifty nine participants from a nation-wide population-based eCohort in Switzerland were followed between November 2020 and September 2021. Financial resources and employment status were assessed twice (Nov2020-Mar2021, May-Jul 2021). Mental health was assessed after the second measurement of financial resources and employment status, using the Depression, Anxiety and Stress Scale (DASS-21). We modelled DASS-21 scores with linear regression, adjusting for demographics, health status, social relationships and changes in workload, and tested interactions with subjective risk perceptions. RESULTS: We observed scores above thresholds for normal levels for 16% (95%CI = 15-18) of participants for depression, 8% (95%CI = 7-10) for anxiety, and 10% (95%CI = 9-12) for stress. Compared to continuously comfortable or sufficient financial resources, continuously precarious or insufficient resources were associated with worse scores for all outcomes. Increased financial resources were associated with higher anxiety. In the working-age group, shifting from full to part-time employment was associated with higher stress and anxiety. Perceiving the Swiss economic situation as worrisome was associated with higher anxiety in participants who lost financial resources or had continuously precarious or insufficient resources. CONCLUSION: This study confirms the association of economic stressors and mental health during the COVID-19 pandemic and highlights the exacerbating role of subjective risk perception on this association.

Cervical cancer (over-)screening in Europe: Balancing organised and opportunistic programmes.

AIMS: Cervical cancer (CC) over-screening has been understudied in Europe, yet is relevant for approaching inequalities in screening uptake. Focusing on countries' screening strategies (opportunistic systems versus organised programmes), we assess in which contexts CC over-screening is more prevalent, and which women are more likely to have engaged in cervical cancer screening (CCS) within the past year. METHODS: A two-level (multilevel) design among screening women (N = 80,761) nested in 31 European countries was used to analyse data from the second wave (2013-2015) of the European Health Interview Survey. We focused on over-screening, defined as screening more frequently than the three-yearly screening interval prescribed in the European guidelines - that is, having screened within the past year. RESULTS: Higher levels of over-screening were observed in opportunistic systems compared to systems with organised programmes. In opportunistic systems, women with a higher socioeconomic position had a higher likelihood of being screened within the past year than their socioeconomic counterparts. Moreover, these differences diminished under organised programmes. CONCLUSIONS: Contexts with organised CCS programmes are more efficiently reducing over-screening, and enforcing the European guidelines. We suggest that the physician-patient relationship is an essential pathway for explaining socioeconomic differences in CC (over-)screening and for future interventions.

Is living in a household with children associated with SARS-CoV-2 seropositivity in adults? Results from the Swiss national seroprevalence study Corona Immunitas.

BACKGROUND: We aimed to determine whether living in a household with children is associated with SARS-CoV-2 seropositivity in adults and investigated interacting factors that may influence this association. METHODS: SARS-CoV-2 serology testing was performed in randomly selected individuals from the general population between end of October 2020 and February 2021 in 11 cantons in Switzerland. Data on sociodemographic and household characteristics, employment status, and health-related history was collected using questionnaires. Multivariable logistic regression was used to examine the association of living with children <18 years of age (number, age group) and SARS-CoV-2 seropositivity. Further, we assessed the influence of reported non-household contacts, employment status, and gender. RESULTS: Of 2393 working age participants (18-64 years), 413 (17.2%) were seropositive. Our results suggest that living with children and SARS-CoV-2 seropositivity are likely to be associated (unadjusted odds ratio (OR) 1.22, 95% confidence interval [0.98-1.52], adjusted OR 1.25 [0.99-1.58]). A pattern of a positive association was also found for subgroups of children aged 0-11 years (OR 1.21 [0.90-1.60]) and 12-17 years (OR 1.14 [0.78-1.64]). Odds of seropositivity were higher with more children (OR 1.14 per additional child [1.02-1.27]). Men had higher risk of SARS-CoV-2 infection when living with children than women (interaction: OR 1.74 [1.10-2.76]). CONCLUSIONS: In adults from the general population living with children seems associated with SARS-CoV-2 seropositivity. However, child-related infection risk is not the same for every subgroup and depends on factors like gender. Further factors determining child-related infection risk need to be identified and causal links investigated. TRIAL REGISTRATION: https://www.isrctn.com/ISRCTN18181860 .

Early-Life Socioeconomic Circumstances and Physical Activity in Older Age: Women Pay the Price.

Health in older age is shaped by early-life socioeconomic circumstances (SECs) and sex. However, whether and why these factors interact is unclear. We examined a cultural explanation of this interaction by distinguishing cultural and material aspects of SECs in the context of physical activity-a major determinant of health. We used data from 56,331 adults between 50 and 96 years old from the Survey of Health, Ageing and Retirement in Europe (SHARE), a 13-year, large-scale, population-based cohort. Confounder-adjusted logistic linear mixed-effects models showed an association between the cultural aspects of early-life SEC disadvantage and physical activity among women, but it was not consistently observed in men. Furthermore, these associations were compensated for only partially by adult-life socioeconomic trajectories. The material aspects of early-life SECs were not associated with adult-life physical activity. These findings highlight the need to distinguish different aspects of SECs because they may relate to health behaviors in diverse ways.

Lower social participation partly explains the association between perceived neighbourhood crime and depressive symptoms in European adults aged 50 years or older: A longitudinal mediation analysis.

Neighbourhood crime likely increases the risk of developing depression among older adults. However, little is known about the underlying behavioural and social pathways. We examined the association between perceived neighbourhood crime and depressive symptoms and whether this relationship was mediated by health behaviours (physical activity, smoking, and alcohol consumption) and social participation. Furthermore, we explored differential vulnerability across age, gender, education and household wealth. Data were drawn from six waves of longitudinal data (from 2004/2005 to 2017) of approximately 15,000 adults aged 50 years and older, derived from the multi-national Survey of Health, Ageing and Retirement in Europe. Perceived neighbourhood crime and covariates were measured at baseline, time-variant mediators and depressive symptoms across all waves. Confounder-adjusted mediator and outcome models were fitted with mixed-effects models. Total association was decomposed into direct and indirect pathways applying causal mediation analyses with Monte-Carlo simulations. Perceived crime was associated with higher risk of depressive symptoms; 4.6% of the effect was mediated via lower engagement in social activities (b = 0.005; 95% CI: 0.001-0.009). No mediation was detected through physical activity, smoking or alcohol consumption. Exploratory analyses revealed that the mediating role of social participation was more pronounced among participants with low household wealth (b = 0.012; 95% CI: 0.004-0.023; 7.3% mediated). Lower engagement in social activities partly explained the association between perceived neighbourhood crime and depressive symptoms in adults aged 50 years or older. Policies targeting disadvantaged communities to prevent crime and support social participation might be beneficial for population mental health, especially among financially vulnerable older residents.

Physical inactivity amplifies the negative association between sleep quality and depressive symptoms.

Poor sleep quality and physical inactivity are known risk factors for depressive symptoms. Yet, whether these factors differently contribute to depressive symptoms and whether they interact with one another remains unclear. Here, we examined how sleep quality and physical activity influence depressive symptoms in 79,274 adults 50 years of age or older (52.4% women) from the Survey of Health, Aging and Retirement in Europe (SHARE) study. Sleep quality (poor vs. good), physical activity (inactive vs. active), and depressive symptoms (0 to 12 score) were repeatedly collected (7 waves of data collection) between 2004 and 2017. Results showed that sleep quality and physical activity were associated with depressive symptoms. Specifically, participants with poorer sleep quality reported more depressive symptoms than participants with better sleep quality (b = 1.85, 95% CI = 1.83-1.86, p < .001). Likewise, compared to physically active participants, physically inactive participants reported more depressive symptoms (b = 0.44, 95% CI = 0.42-0.45, p < .001). Moreover, sleep quality and physical activity showed an interactive association with depressive symptoms (b = 0.17, 95% CI = 0.13-0.20, p < .001). The negative association between poor sleep quality and higher depressive symptoms was stronger in physically inactive than active participants. These findings suggest that, in adults 50 years of age or older, both poor sleep quality and physical inactivity are related to an increase in depressive symptoms. Moreover, the detrimental association between poor sleep quality and depressive symptoms is amplified in physically inactive individuals.

Advantaged socioeconomic conditions in childhood are associated with higher cognitive functioning but stronger cognitive decline in older age.

Cognitive aging is characterized by large heterogeneity, which may be due to variations in childhood socioeconomic conditions (CSC). Although there is substantial evidence for an effect of CSC on levels of cognitive functioning at older age, results on associations with cognitive decline are mixed. We examined by means of an accelerated longitudinal design the association between CSC and cognitive trajectories from 50 to 96 years. Cognition included two functions generally found to decline with aging: delayed recall and verbal fluency. Data are from six waves of the Survey of Health, Aging, and Retirement in Europe (SHARE), conducted between 2004 and 2015 (n = 24,066 at baseline; 56% female, age 50+). We found a consistent CSC pattern in levels of cognitive functioning in later life. Older people with disadvantaged CSC had lower levels of cognitive functioning than those with more advantaged CSC. We also find that decline is almost 1.6 times faster in the most advantaged group compared with the most disadvantaged group. The faster decline for people with more advantaged CSC becomes less pronounced when we additionally control for adulthood socioeconomic conditions and current levels of physical activity, depressive symptoms, and partner status. Our findings are in line with the latency, pathway, and cumulative model and lend support to theories of cognitive reserve, stating that neuronal loss can no longer be repaired in people with more cognitive reserve once the underlying pathology is substantial and speed of decline is accelerated.

Linking widowhood and later-life depressive symptoms: Do childhood socioeconomic circumstances matter?

Objectives: Widowhood and adverse childhood socioeconomic circumstances (CSC) have both been linked to increased levels of depressive symptoms in old age. Beyond their independent impact on depressive symptoms, experiencing adverse CSC may also trigger a cascade of cumulative adversity and secondary stressors across the life course that shapes how individuals weather stressful life events later on.Method: We examine whether exposure to adverse CSC moderates the relationship between later-life widowhood and depressive symptoms using data from the Survey of Health, Ageing and Retirement in Europe (2004-2017).Results: Mixed-effects models revealed that both widowhood and adverse CSC were associated with increased levels of depressive symptoms among men and women. Associations between widowhood and depressive symptoms, however, were not moderated by CSC for both genders.Conclusion: Persisting differences in the levels of mental health in response to later-life widowhood did not further widen in the presence of disparities experienced early in the life course. This may reflect the life-altering impact of this age-normative, yet stressful life event across the social strata.

[Surveillance bias: when appearances are misleading]. / Biais de surveillance : quand les apparences sont trompeuses.

Public health surveillance is the ongoing collection and analysis of health-related data, followed by the timely dissemination of information useful for decisions. Surveillance bias occurs when differences in the frequency of a condition are due to variations in the modalities of detection rather than to changes in the actual risk of the condition. As a result, the true burden of diseases cannot be properly assessed. This is of growing concern because surveillance activity is more and more often based on data not designed primarily for surveillance, notably data from healthcare providers. Many diseases (such as COVID-19, prostate cancer, or hypertension) are prone to surveillance bias. It also hinders quality of care monitoring.

La surveillance en santé publique consiste à recueillir et à analyser en continu des données relatives à la santé, puis à les transformer en informations utiles pour la décision. On parle de biais de surveillance lorsque les différences de fréquence d'une maladie sont dues à des variations dans les modalités de détection plutôt qu'à des changements du risque réel de cette maladie dans la population. Ce biais est fréquent car l'activité de surveillance repose de plus en plus souvent sur des données qui ne sont pas collectées primairement pour la surveillance, notamment celles provenant des prestataires de soins de santé. De nombreuses maladies (comme le Covid-19, le cancer de la prostate ou l'hypertension) sont sujettes à un biais de surveillance. Ce biais nuit également à la surveillance de la qualité des soins.

[From evidence to quality improvement to provide high value and patient centered care]. / De la pratique fondée sur les preuves à l'amélioration de la qualité pour des soins de haute valeur centrés sur le patient.

Evidence-based practice and quality improvement should be at the heart of healthcare and public health. However, their implementation remains insufficient which is reflected in Switzerland in the high frequency of low-value care, in the wide regional variation in care practices, and in the absence of quality monitoring for the majority of healthcare processes. It is necessary to strengthen the monitoring of quality, particularly that perceived by patients, to help strengthening high-value and patient centered care. Because data do not speak for themselves, it is critical to organize how to use indicators for decision.

La pratique fondée sur les preuves et l'amélioration de la qualité devraient être au cœur des soins et de la santé publique. Leur implémentation reste néanmoins insuffisante et se traduit en Suisse par une fréquence élevée de soins de faible valeur, par d'importantes variations régionales dans la pratique de certains soins et par l'absence de monitoring de la qualité pour la majorité des processus de soins. Il faut renforcer le monitoring de la qualité, notamment celle perçue par les patients, pour faciliter la mise en œuvre de soins de haute valeur et centrés sur le patient. Les données ne parlant pas toutes seules, il faut organiser le processus qui va de la production des indicateurs à la décision.

Why Are Individuals With Diabetes Less Active? The Mediating Role of Physical, Emotional, and Cognitive Factors.

BACKGROUND: Despite the key role of physical activity in the management of diabetes, many individuals with diabetes do not engage in the recommended levels of physical activity. However, our knowledge of the mechanisms underlying the relationship between diabetes and physical inactivity is limited. PURPOSE: To investigate the associations between diabetes and the levels and evolution of physical activity across aging, and to determine whether physical, emotional, and cognitive factors mediate these associations. METHODS: Data from 105,622 adults aged 50-96 years from the Survey of Health, Ageing and Retirement in Europe (SHARE) were used in adjusted linear mixed models to examine whether diabetes was associated with physical activity levels and variations across aging. The potential mediators were subjective energy, muscle strength, physical and cognitive disability, sleep problems, depressive symptoms, and cognitive functions. The variables were measured up to seven times over a 13-year period. RESULTS: Individuals with diabetes demonstrated a lower level and a steeper decrease in physical activity across aging than individual without diabetes. Mediators explained ~53% and 94% of the association of diabetes with the level of physical activity and with the linear evolution of physical activity across aging, respectively. All mediators were significantly associated with physical activity. Physical and cognitive disability as well as depressive symptoms were the strongest mediators, while sleep was the lowest one. CONCLUSIONS: These findings suggest that the etiology of physical inactivity in individuals with diabetes can result from several physical, emotional, and cognitive changes associated with the emergence of this disease.

Cervical cancer screening programs and their context-dependent effect on inequalities in screening uptake: a dynamic interplay between public health policy and welfare state redistribution.

BACKGROUND: While organized and opportunistic cervical cancer screening (CCS) programs implemented across the European Union have increased participation rates, barriers to socioeconomically deprived women remain substantial, implying high levels of inequality in CCS uptake. AIM: This study assesses how the screening strategy (as a score based on the availability of organized population-based CCS programs), accessibility of the healthcare system (as an index of out-of-pocket expenditure as a proportion of total healthcare costs, public health expenditure as a percentage of total GDP, and general practitioner (GP) density per 10'000 inhabitants) and social protection (as a decommodification index), impact education- and income-based inequalities in CCS uptake. METHODS: A two-level design with 25-64-year-old women (N = 96'883), eligible for Pap smear screening, nested in 28 European countries, was used to analyze data from the European Health Interview Survey's second wave, using multilevel logistic regression modelling. RESULTS: Clear educational and income gradients in CCS uptake were found, which were smaller in countries with organized CCS programs, higher accessibility of the healthcare system and a higher level of decommodification. Furthermore, three-way interaction terms revealed that these gradients were smaller when organized CCS programs were implemented in countries with better accessibility of the healthcare system or a high level of decommodification. CONCLUSION: This study indicates that the combination of organized screening and high accessibility of the healthcare system or social protection is essential for having lower levels of inequality in CCS uptake. In such countries, the structural threshold for poorer and lower educated women to engage in CCS is lower. This may be explained by them having a better interaction with their GP, who may convince them of the screening test, lower out-of-pocket payments, and financial support to buffer against a disadvantageous position on the labor market.

Physicians' predictions of long-term survival and functional outcomes do not influence the decision to admit patients with advanced disease to intensive care: A prospective study.

BACKGROUND: Long-term survival and functional outcomes should influence admission decisions to intensive care, especially for patients with advanced disease. AIM: To determine whether physicians' predictions of long-term prognosis influenced admission decisions for patients with and without advanced disease. DESIGN: A prospective study was conducted. Physicians estimated patient survival with intensive care and with care on the ward, and the probability of 4 long-term outcomes: leaving hospital alive, survival at 6 months, recovery of functional status, and recovery of cognitive status. Patient mortality at 28 days was recorded. We built multivariate logistic regression models using admission to the intensive care unit (ICU) as the dependent variable. SETTING/PARTICIPANTS: ICU consultations for medical inpatients at a Swiss tertiary care hospital were included. RESULTS: Of 201 evaluated patients, 105 (52.2%) had an advanced disease and 140 (69.7%) were admitted to the ICU. The probability of admission was strongly associated with the expected short-term survival benefit for patients with or without advanced disease. In contrast, the predicted likelihood that the patient would leave the hospital alive, would be alive 6 months later, would recover functional status, and would recover initial cognitive capacity was not associated with the decision to admit a patient to the ICU. Even for patients with advanced disease, none of these estimated outcomes influenced the admission decision. CONCLUSIONS: ICU admissions of patients with advanced disease were determined by short-term survival benefit, and not by long-term prognosis. Advance care planning and developing decision-aid tools for triage could help limit potentially inappropriate admissions to intensive care.

The longitudinal relation between social reserve and smaller subsequent decline in executive functioning in old age is mediated via cognitive reserve.

OBJECTIVES: Social reserve such as having close friends helps promoting activity engagement in old age. Activity engagement in turn contributes to the accumulation of cognitive reserve and is a key predictor for maintaining executive functioning in aging. We investigated the mediating role of leisure activity engagement in the longitudinal relation between close friends and subsequent change in executive functioning as measured through performance changes in the Trail Making Test (TMT). DESIGN, SETTING, AND PARTICIPANTS: Longitudinal study with 897 older adults tested in two waves 6 years apart, analyzed using latent change score modeling. MEASUREMENTS: TMT parts A and B, leisure activity engagement, and close friends. RESULTS: A larger number of close friends in the first wave of data collection was related to a higher frequency of leisure activities in the first wave. A higher frequency of leisure activities in the first wave significantly predicted a smaller subsequent increase in TMT completion time from the first to the second wave (i.e. a smaller decline in executive functioning). Importantly, 41.3% of the longitudinal relation between a larger number of close friends in the first wave and a smaller subsequent increase in TMT completion time (i.e. a smaller decline in executive functioning) was mediated via a higher frequency of leisure activities in the first wave. CONCLUSIONS: Social reserve such as having close friends may help promoting activity engagement in old age. By enhancing individuals' cognitive reserve, this activity engagement may finally result in smaller subsequent decline in executive functioning in aging.

The relationship of obesity predicting decline in executive functioning is attenuated with greater leisure activities in old age.

Objectives: We investigated the longitudinal relationship between obesity and subsequent decline in executive functioning over six years as measured through performance changes in the Trail Making Test (TMT). We also examined whether this longitudinal relationship differed by key markers of cognitive reserve (education, occupation, and leisure activities), taking into account age, sex, and chronic diseases as covariates.Method: We used latent change score modeling based on longitudinal data from 897 older adults tested on TMT parts A and B in two waves six years apart. Mean age in the first wave was 74.33 years. Participants reported their weight and height (to calculate BMI), education, occupation, leisure activities, and chronic diseases.Results: There was a significant interaction of obesity in the first wave of data collection with leisure activities in the first wave on subsequent latent change. Specifically, obesity in the first wave significantly predicted a steeper subsequent decline in executive functioning over six years in individuals with a low frequency of leisure activities in the first wave. In contrast, in individuals with a high frequency of leisure activities in the first wave, this longitudinal relationship between obesity and subsequent decline in executive functioning was not significant.Conclusion: The longitudinal relationship between obesity and subsequent decline in executive functioning may be attenuated in individuals who have accumulated greater cognitive reserve through an engaged lifestyle in old age. Implications for current cognitive reserve and gerontological research are discussed.