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Lancet Healthy Longev. Author manuscript; available in PMC 2022 December 14.
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Published in final edited form as:

Lancet Healthy Longev. 2022 November ; 3(11): e740–e753. doi:10.1016/S2666-7568(22)00199-4.

Associations between social connections and cognition: a

global collaborative individual participant data meta-analysis
Suraj Samtani, PhD,
Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

Gowsaly Mahalingam, MDataSc,

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Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

Ben Chun Pan Lam, PhD,

Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

Darren M Lipnicki, PhD,

Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

Maria Fernanda Lima-Cost, PhD,

Center for Studies in Public Health and Aging, René Rachou Research Center, Oswaldo Cruz
Foundation, Belo Horizonte, Brazil
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Sergio Luís Blay, PhD,

This is an Open Access article under the CC BY-NC-ND 4.0 license. http://creativecommons.org/licenses/by-nc-nd/4.0/
Correspondence to: Dr Suraj Samtani, Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health,
UNSW Sydney, Sydney, NSW 2052, Australia [email protected].
*Members are listed in the appendix
Contributors
SSa was responsible for conceptualisation, data curation, formal analysis, investigation, methodology, project administration,
validation, and writing the original draft. GM was responsible for data curation, investigation, formal analysis, methodology, project
administration, validation, visualisation, and writing the original draft. BCPL was responsible for methodology and writing the
original draft. DML was responsible for conceptualisation, data curation, and methodology. HB, PSS, and Y-HJ were responsible for
conceptualisation, funding acquisition, investigation, methodology, and supervision. MFL-C, EC-C, XS, MGu, P-MP, IS, NS, K-WK,
SR-H, SSh, MGa, MC, and TPN were responsible for conceptualisation, data curation, and investigation. SLB, AG, JN, TRS, SR, AP,
EJ, TFH, and KN were responsible for data curation and investigation. RM, DS, and MV-D were responsible for conceptualisation,
funding acquisition, and investigation. All authors were responsible for reviewing and editing the manuscript. SSa and GM accessed
Author Manuscript

and verified the data. SSa and GM had full access to all the data in the study and had final responsibility for the decision to submit for
publication.
Declaration of interests
HB declares consulting fees from Biogen; advisory board fees from Nutricia, Roche, Skin2Neuron, and Cranbrook Care; and grant
funding through the EU Joint Programme–Neurodegenerative Disease Research (JPND) from the National Health and Medical
Research Council Australia. DML declares funding to their institution by the US National Institute on Aging–National Institutes of
Health (NIA–NIH) award (number RF1AG05753 1RF1AG057531–01). RM declares funding from the JPND. HW declares a research
grant from the JPND for the SHARED project (grant number HESOCARE-329–109). PSS declares payments for advisory board
meetings for Biogen Australia and Roche Australia, and funding to the university for another cohort study (OATS), unrelated to the
submitted work. SSa declares payments for lectures from New York University Sydney and University of Sydney; grant funding from
the Dementia Australia Research Foundation, unrelated to the submitted work; and grant funding from the JPND and National Health
and Medical Research Council Australia. NS declares that they are the chair of the data safety monitoring board for a study funded
by the NIH at Albert Einstein College of Medicine. DS declares funding under the aegis of the JPND (National Center for Research
and Development in Poland, project number JPND/06/2020). JM declares funding as part of the SHARED consortium, a JPND that is
supported by the Alzheimer’s Society (reference 469) in the UK. All other authors declare no competing interests.
 Samtani et al. Page 2

Department of Psychiatry, Federal University of São Paulo, São Paulo, Brazil

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Erico Castro-Costa, PhD,

Center for Studies in Public Health and Aging, René Rachou Research Center, Oswaldo Cruz
Foundation, Belo Horizonte, Brazil

Xiao Shifu, MD,

Department of Geriatric Psychiatry, Shanghai Mental Health Center, Shanghai Jiaotong
University School of Medicine, Shanghai, China

Maëlenn Guerchet, PhD,

Inserm U1094, IRD UMR270, University of Limoges, CHU Limoges, Epidemiology of Chronic
Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth,
Limoges, France

Pierre-Marie Preux, PhD,

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Inserm U1094, IRD UMR270, University of Limoges, CHU Limoges, Epidemiology of Chronic
Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth,
Limoges, France

Antoine Gbessemehlan, PhD,

Inserm U1094, IRD UMR270, University of Limoges, CHU Limoges, Epidemiology of Chronic
Diseases in Tropical Zone, Institute of Epidemiology and Tropical Neurology, OmegaHealth,
Limoges, France

Ingmar Skoog, PhD,

Department of Psychiatry and Neurochemistry, Neuropsychiatric Epidemiology Unit, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health, University of
Gothenburg, Mölndal, Sweden; Psychiatry, Cognition and Old Age Psychiatry Clinic, Sahlgrenska
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University Hospital, Gothenburg, Sweden

Jenna Najar, PhD,

Department of Psychiatry and Neurochemistry, Neuropsychiatric Epidemiology Unit, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health, University of
Gothenburg, Mölndal, Sweden; Psychiatry, Cognition and Old Age Psychiatry Clinic, Sahlgrenska
University Hospital, Gothenburg, Sweden

Therese Rydberg Sterner, PhD,

Department of Psychiatry and Neurochemistry, Neuropsychiatric Epidemiology Unit, Institute of
Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health, University of
Gothenburg, Mölndal, Sweden

Nikolaos Scarmeas, PhD,

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1st Department of Neurology, Aiginition University Hospital of Athens, National and Kapodistrian
University of Athens, Athens, Greece; Taub Institute for Research in Alzheimer’s Disease and the
Aging Brain, The Gertrude H Sergievsky Center, Department of Neurology, Columbia University,
New York, NY, USA

Ki-Woong Kim, PhD,

Department of Neuropsychiatry, Seoul National University Bundang Hospital, Seongnam, South
Korea; Department of Psychiatry, Seoul National University College of Medicine and Department

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 Samtani et al. Page 3

of Brain and Cognitive Science, College of Natural Sciences, Seoul National University, Seoul,
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South Korea

Steffi Riedel-Heller, PhD,

Institute of Social Medicine, Occupational Health and Public Health, Faculty of Medicine,
University of Leipzig, Leipzig, Germany

Susanne Röhr, PhD,

Institute of Social Medicine, Occupational Health and Public Health, Faculty of Medicine,
University of Leipzig, Leipzig, Germany; Global Brain Health Institute, Trinity College Dublin,
Dublin, Ireland

Alexander Pabst, PhD,

Institute of Social Medicine, Occupational Health and Public Health, Faculty of Medicine,
University of Leipzig, Leipzig, Germany
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Suzana Shahar, PhD,

Centre for Healthy Aging and Wellness, Faculty of Health Sciences, Universiti Kebangsaan
Malaysia, Kuala Lumpur, Malaysia

Katya Numbers, PhD,

Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

Mary Ganguli, MD,

Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA;
Department of Epidemiology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA;
Department of Neurology, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Erin Jacobsen, MS,

Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA

Tiffany F Hughes, PhD,

School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA; Department of Sociology,
Anthropology, and Gerontology, Youngstown State University, Youngstown, OH, USA

Michael Crowe, PhD,

Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA

Tze Pin Ng, PhD,

Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of
Singapore, Singapore

Jane Maddock, PhD,

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MRC Unit for Lifelong Health and Ageing, University College London, London, UK

Anna Marseglia, PhD,

Division of Clinical Geriatrics, Centre for Alzheimer Research, Department of Neurobiology, Care
Sciences, and Society, Karolinska Institutet, Stockholm, Sweden

René Mélis, PhD,

Department of Geriatrics, Radboud University Medical Centre, Nijmegen, Netherlands

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 Samtani et al. Page 4

Dorota Szcześniak, PhD,

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Department of Psychiatry, Wroclaw Medical University, Wroclaw, Poland

Henrik Wiegelmann,
Department of Health Care Research, Institute of Public Health and Nursing Research, University
of Bremen, Bremen, Germany

Myrra Vernooij-Dassen, PhD,

Faculty of Medical Sciences, Radboud University, Nijmegen, Netherlands

Yun-Hee Jeon, PhD,

Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, University of
Sydney, Sydney, NSW, Australia

Perminder S Sachdev, PhD,

Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Author Manuscript

Sydney, Sydney, NSW, Australia

Henry Brodaty, DSc

Centre for Healthy Brain Ageing, Discipline of Psychiatry, Faculty of Medicine and Health, UNSW
Sydney, Sydney, NSW, Australia

SHARED consortium for the Cohort Studies of Memory in an International Consortium

(COSMIC)*

Summary
Background.—Poor social connections (eg, small networks, infrequent interactions, and
loneliness) are modifiable risk factors for cognitive decline. Existing meta-analyses are limited
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by reporting aggregate responses, a focus on global cognition, and combining social measures into
single constructs. We aimed to investigate the association between social connection markers and
the rate of annual change in cognition (ie, global and domain-specific), as well as sex differences,
using an individual participant data meta-analysis.

Methods—We harmonised data from 13 longitudinal cohort studies of ageing in North America,
South America, Europe, Africa, Asia, and Australia. Studies were eligible for inclusion if they had
baseline data for social connection markers and at least two waves of cognitive scores. Follow-up
periods ranged from 0 years to 15 years across cohorts. We included participants with cognitive
data for at least two waves and social connection data for at least one wave. We then identified
and excluded people with dementia at baseline. Primary outcomes were annual rates of change in
global cognition and cognitive domain scores over time until final follow-up within each cohort
study analysed by use of an individual participant data meta-analysis. Linear mixed models within
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cohorts used baseline social connection markers as predictors of the primary outcomes. Effects
were pooled in two stages using random-effects meta-analyses. We assessed the primary outcomes
in the main (partially adjusted) and fully adjusted models. Partially adjusted models controlled for
age, sex, and education; fully adjusted models additionally controlled for diabetes, hypertension,
smoking, cardiovascular risk, and depression.

Findings—Of the 40 006 participants in the 13 cohort studies, we excluded 1392 people with
dementia at baseline. 38 614 individual participants were included in our analyses. For the main

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models, being in a relationship or married predicted slower global cognitive decline (b=0·010,
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95% CI 0·000–0·019) than did being single or never married; living with others predicted
slower global cognitive (b=0·007, 0·002–0·012), memory (b=0·017, 0·006–0·028), and language
(b=0·008, 0·000–0·015) decline than did living alone; and weekly interactions with family and
friends (b=0·016, 0·006–0·026) and weekly community group engagement (b=0·030, 0·007–0·052)
predicted slower memory decline than did no interactions and no engagement. Never feeling
lonely predicted slower global cognitive (b=0·047, 95% CI 0·018–0·075) and executive function
(b=0·047, 0·017–0·077) decline than did often feeling lonely. Degree of social support, having a
confidante, and relationship satisfaction did not predict cognitive decline across global cognition
or cognitive domains. Heterogeneity was low (I2=0·00–15·11%) for all but two of the significant
findings (association between slower memory decline and living with others [I2=58·33%] and
community group engagement, I2=37·54–72·19%), suggesting robust results across studies.

Interpretation—Good social connections (ie, living with others, weekly community group
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engagement, interacting weekly with family and friends, and never feeling lonely) are associated
with slower cognitive decline.

Funding—EU Joint Programme–Neurodegenerative Disease Research grant, funded by the

National Health and Medical Research Council Australia, and the US National Institute on Aging
of the US National Institutes of Health.

Introduction
The 2020 Lancet Commission on dementia prevention estimated that tackling social
isolation could prevent 4% of dementia cases worldwide.1 Social isolation is one aspect
under the umbrella term social health.2 Social connections, a key concept for social
health, have components pertaining to structure (eg, social networks and living situation),
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function (eg, social support), and quality (eg, loneliness and relationship quality).3 Socially
stimulating environments promote neuroprotective mechanisms,4 and social connections
are theorised to contribute to cognitive reserve,5 whereby the brain actively copes with
neuropathology by using alternative pre-existing or compensatory cognitive processes.6
Bridging (ie, loose social ties providing cognitive stimulation) and bonding (ie, close
social ties buffering stress and influencing function of the neuroendocrine system and the
hypothalamic–pituitary–adrenal axis) pathways have been proposed to lead from social
connections to cognitive health.4

Meta-analyses show associations between poor social connections and increased risk of
cognitive decline. A meta-analysis of 43 studies reported that poorer social connection
indicators pertaining to both structure and function predicted greater cognitive decline.7
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However, this meta-analysis combined various social connection markers and so could not
reach definitive conclusions about specific markers. Another meta-analysis of 39 studies
reported that social activity and social support were associated with decline in global
cognition and specific cognitive domains.8 Frequent social activity was associated with
improved memory, executive function, visuospatial ability, and processing speed, whereas
frequent social support was associated only with improved memory.8 Existing meta-analyses
are limited by the use of aggregated data from studies that adjust differently for potential
confounders (eg, one study did not adjust for confounders9 and another study adjusted for

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only demographic variables and baseline cognition10). Furthermore, existing evidence about
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social connection markers and cognitive decline is mainly from North America and Europe,
and these meta-analyses have not included loneliness, which is associated with increased
cognitive decline in some cohort studies.11

Sex differences are important to investigate because women have faster cognitive decline
than do men in global cognition and executive function.12 One study reported that increased
memory decline was associated with baseline social isolation (ie, a combination of living
situation, frequency of social contact, and membership of community or religious groups at
baseline) for men and accumulated social isolation (ie, social isolation across multiple waves
of the study) for women.13 Interaction with community groups has been associated with
slower cognitive decline for men than for women.14 Scientific literature on sex differences
in the associations between social connection function or quality and cognitive decline,
however, is sparse. For instance, social support was reportedly protective against memory
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decline for only men in one study,15 whereas high baseline loneliness was associated with
cognitive decline for only women in another cohort study.16

We aimed to investigate the association between various social connection markers and
cognition (ie, global and domain-specific), as well as sex differences, using an individual
participant data meta-analysis, which has fewer limitations than does a traditional meta-
analysis. First, we hypothesised that improved social connections (eg, in terms of social
structure, function, and quality) are associated with a decreased rate of global cognitive
decline. Second, we hypothesised that markers of improved social connection structure are
associated with slow decline across all cognitive domains, whereas markers of improved
social connection function and connection quality are associated specifically with slow
memory decline.8 Finally, we hypothesised that sex differences exist in the association
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between social connection markers and cognitive function. Specifically, improved baseline
social connection structures (eg, being in a relationship and high interaction frequency)
are associated with a slow rate of cognitive decline only for men, given previous
research.13,17,18

Methods
Contributing studies and participants
We collected and harmonised data from 13 longitudinal cohort studies of ageing
from around the world: Bambuí Cohort Study of Ageing (Bambuí, Brazil);19 China
Longitudinal Aging Study (CLAS, China);20 English Longitudinal Study of Ageing
(ELSA, England, UK);21 Epidemiology of Dementia in Central Africa (EPIDEMCA,
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Central African Republic and Republic of the Congo);22 Gothenburg H70 Birth Cohort
Studies (the H70 study, Sweden);23 Hellenic Longitudinal Investigation of Aging and
Diet (HELIAD, Greece);24 Korean Longitudinal Study on Cognitive Aging and Dementia
(KLOSCAD, South Korea);25 Leipzig Longitudinal Study of the Aged (LEILA75+,
Germany);26 Neuroprotective Model for Healthy Longevity among Malaysian Older Adults
Towards Using Ageing (LRGS TUA, Malaysia);27 Sydney Memory and Ageing Study
(MAS, Australia);28 Monongahela-Youghiogheny Healthy Aging Team (MYHAT, USA);29
Puerto Rican Elderly Health Conditions Study (PREHCO, Puerto Rico);30 and Singapore

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Longitudinal Study of Ageing (SLAS, Singapore).31 We identified studies for inclusion

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from the Cohort Studies of Memory in an International Consortium (COSMIC) for the
Social Health and Reserve in the Dementia Patient Journey (SHARED) consortium. ELSA
was identified through a literature search of the longitudinal studies with multiple social
connection variables and was not part of COSMIC. Studies were eligible if they had
baseline data for social connection markers and at least two waves of cognitive scores
(sample characteristics of cohorts are provided in the appendix p 4). We did not apply
any date restrictions. Within each study, we included participants who had social data for
at least one wave and cognitive data for at least two waves. We excluded participants
with dementia at baseline. We conducted an individual participant data meta-analysis to
examine the associations between baseline social connections (ie, relationship status, living
situation, frequency of interactions with family and friends, engagement in community
groups, social support, having a confidante, relationship satisfaction, and loneliness) and
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change in cognition over time (ie, global cognition, memory, language, and executive
function). We used the STROBE reporting checklist to describe our study (appendix pp
1–2).

The project was approved by the University of New South Wales Sydney Human Research
Ethics Committee (HC200268). The contributing cohorts had previous ethics approval
(appendix p 3). Written informed consent was exclusively or predominantly obtained from
participants in all studies, including consent to share da other scientific research (appendix p
3). For EPIDEMCA, consent was obtained from family when the participant was unable to
express their consent. For both EPIDEMCA and LRGS TUA, verbal consent and thumbprint
mark was obtained from people who were illiterate. Further participant consent for this
study was not deemed necessary as only fully de-identified data were shared with the
analysis team.
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Procedures
We completed a COSMIC studies data request to collect data from twelve cohorts, and
applied for access to ELSA data separately. We requested data for participants with social
data for at least one wave and cognitive data for at least two waves. We collected data for
cognitive scores and diagnoses, physical health and lifestyle risk factors for cognitive decline
or dementia, and any social variables. The data were shared and stored in a secure OneDrive
folder with multifactor authentication. The data were queried and confirmed by SSa and GM
via descriptive statistics and visual analyses and cross-checked with original studies where
discrepancies, errors, or outliers were noticed.

Global cognition, memory, language, and executive function measures, including descriptive
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statistics and proportion of missing data, are shown in the appendix (pp 5–6). Total scores
for cognitive screening tests (ie, the Mini-Mental State Examination in most cohorts) were
used to assess global cognition, rather than creating a composite of domain scores. The
standardisation process for global cognition and cognitive domain scores is described in the
appendix (p 8).

Covariates that were included in the models were harmonised in line with previous research
by COSMIC.32 The measures and harmonisation protocols used for the covariates are

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described in the appendix (pp 9–13). We controlled for age, sex, and education in the main
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(partially adjusted) models using data from all 13 cohorts. In fully adjusted models, we also
controlled for previous history of diabetes, hypertension, smoking, cardiovascular disease
risk (ie, previous history of angina, myocardial infarction, and any other heart disease),
and depression. Fully adjusted models included ten cohorts with data available for the
aforementioned covariates (ie, Bambuí,19 CLAS,20 ELSA,21 the H70 study,23 HELIAD,24
KLOSCAD,25 LEILA75+,26 LRGS TUA,27 MAS,28 and MYHAT29).

We harmonised social connection markers (ie, relationship status, living situation,

engagement in community groups, interactions with family and friends, having a confidante,
relationship satisfaction, and loneliness) by consensus among multiple authors (SSa, GM,
DML, Y-HJ, MV-D, and HB) using as many potential questionnaire responses as possible.
The measures and harmonisation protocols that were used for the social connection
markers are described in the appendix (pp 14–21). Data for relationship status and living
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situation were derived mostly from demographic questions, and data for social interactions
with family and friends, having a confidante, and relationship satisfaction were derived
from single questions. Data for engagement with community groups were obtained from
single questions that represented different community groups across studies (eg, whether
participants played cards, games, bingo, or mahjong in the SLAS study31 and whether
participants attended meetings of retirement clubs or other clubs in the H70 study23).

Loneliness frequency data were available in only four studies,21,23,26,27 of which only
LRGS TUA27 used a validated loneliness scale (UCLA 3-item Loneliness Scale).33 To allow
comparison across response options for loneliness, we used similar items from ELSA21 (ie,
how often the respondent feels lonely: “hardly ever or never”, “some of the time”, “often”),
the H70 study23 (“Feeling lonely”: “never”, “seldom/sometimes”, “often”), LEILA75+26 (“I
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felt lonely”: “rarely or none of the time, less than 1 day”, “some or a little, 1–2 days”,
“occasionally or a moderate amount, 3–4 days”, “most or all the time, 5–7 days”), and
LRGS TUA27 (“How often do you feel that you lack companionship?”; “hardly ever”,
“some of the time”, “often”).

Outcomes
The primary outcomes were the annual rates of change in global cognition and cognitive
domain scores over time until final follow-up within each cohort study. The secondary
outcomes were the sex differences in the association between social connection structure
and the annual rates of change in global cognition and cognitive domain scores. We also
conducted exploratory analyses on the sex differences in the association between social
connection function or quality and cognitive decline.
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Statistical analysis
We used a two-stage individual participant data meta-analysis to pool effects across
studies,34 which enables controlling for the same covariates across studies rather than
relying on aggregate data that is adjusted for different sets of covariates. Furthermore,
variables can be defined consistently across studies, thereby reducing methodological
heterogeneity. The first stage used linear mixed modelling to estimate the association

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between social connections and cognitive outcomes within each study. We specified random
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intercept for participant and fixed effect for time in study (coded as years since baseline).
First, we examined the overall linear effect of time in study (unstandardised regression
coefficient [b]=−0·015, 95% CI −0·048 to 0·018) on cognitive function (ie, global cognition
and the cognitive domains) and the quadratic effect of time in study (b=−0·013, 95%
CI −0·032 to 0·005) on cognitive function. As the quadratic time-in-study effect was not
significant, we used a linear effect in all analyses involving social connection markers.
Model assumptions for linear mixed regression were checked and satisfied by GM. We ran
each social connection marker–cognitive outcome model separately because of differences
in the availability of social connection markers and cognitive variables across cohort studies.
In these models, a significant interaction between a social connection marker at baseline and
time in study indicates that the social connection marker was associated with annual rate of
cognitive decline.
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The second stage pooled the effects across studies by use of random-effects meta-analysis
with a restricted maximum likelihood estimator, which is a relatively unbiased and efficient
estimator of between-study variance.35 We examined heterogeneity using the I2 and τ2
statistics36 and bias using Egger’s test (appendix pp 26–27) and funnel plots (appendix pp
28–31).37 To examine sex differences in the associations between social connection markers
and change in cognition over time, we repeated the analysis with additional terms for the
interactions between sex, time in study, and social connection markers and then pooled the
interaction effects in the meta-analysis. We present b in the meta-analyses results and forest
plots. Unstandardised coefficients from the linear mixed models represent differences in
the annual rate of change in cognitive Z scores comparing the target category of the social
connection marker with the reference category. A negative b indicates that the predictor is
associated with faster decline in cognition, whereas a positive b indicates that the predictor
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is associated with slower decline in cognition. We conducted sensitivity analyses with

complete cases to determine whether the results obtained from multiple imputation for
missing data were robust.

Missing data ranged from 0·00% to 43·36% for covariates and 0·00% to 35·08% for social
connection markers. We visually inspected data to examine whether our observed variables
were related to the pattern of missingness and used auxiliary variables (ie, data from
predictors and covariates) in the multiple imputation to reduce the effect of non-random
missing data on the pattern of results.

Multiple imputation with the Markov Chain Monte Carlo method was used to impute
missing data for the demographics, covariates, and social connection markers with less than
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50% missing data, incorporating information from auxiliary variables and generating 20
imputed datasets in each study.38 Estimates computed from each imputed dataset were then
pooled by use of Rubin’s rules.39 Although multiple imputation is effective with up to 50%
missingness,39 we conducted additional sensitivity analyses to compare the major findings
when only complete cases (ie, 0% missing) were used.

We used R studio software version 4.1.2 and R packages mice for multiple imputation, lme4
for linear mixed modelling, and metafor for meta-analyses.

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Role of the funding source

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The funder of the study had no role in study design, data collection, data analysis, data
interpretation, or writing of the report.

Results
Of the 40 006 people in the 13 cohorts, we excluded 1392 people living with dementia at
baseline (ranging from no participants to 289 participants per study; appendix p 7) and 38
614 participants were included in the analyses. Sample descriptive statistics for age, sex,
education, and study timepoints are presented in appendix p 4, for covariates in appendix
p 22, and for social connection markers in appendix pp 23–25. Recruitment dates (baseline
and final follow-up year) for individual cohorts are provided in the appendix (p 4).

Follow-up periods ranged from 2 years to 15 years across cohorts, and the time in study
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for participants ranged from 0 years to 15 years, with a median of 3 years (IQR 2–
6). Participants were community dwelling in all cohorts, apart from 50 (4·8%) of 1045
participants from the LEILA75+ study, who resided in assisted living facilities (50 [0·1%] of
38 614 of the overall sample).

The sample included in the main analyses (13 cohorts, n=38 614) was similar in age at
baseline (mean 70·50 years, SD 8·67; female mean age 70·63 years [SD 8·87 vs male mean
age 70·32 [8·38]) compared with the sample for the fully adjusted models (ten cohorts, n=29
718, mean 70·49 years, SD 8·65, t=−0·13, df=58 282, p=0·90; female mean age 70·72 years
[8·90] vs male mean age 70·19 years [8·30]). In the main models, married men were slightly
older (mean 69·79 [SD 7·83]) than married women (67·36 [7·59]).Furthermore, the sample
for the main analyses had a similar proportion of women (22 556 [58·4%] of 38 614 vs 17
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145 [57·7%] of 29 728; χ2=3·50, df=1, p=0·060) to and fewer years of education (mean 8·48
years [SD 4·88] vs 9·12 years [4·61]; df=58 282, p<0·0001) than did the sample for the fully
adjusted models.

Longitudinal associations between social connection markers and each of the four cognitive
outcomes for the main models are shown in Figures 1,2,3, & 4 (detailed results of
the main and fully adjusted models are shown in the appendix pp 26–27). Here, we
report the results for the main models that were replicated in the fully adjusted models.
Being married or in a relationship was associated with slower global cognitive decline
than was being single or never married. Living with others was associated with slower
global cognitive, memory, and language decline than was living alone. Yearly, monthly,
or weekly engagement in a community group was associated with slower annual memory
decline than was never engaging with community groups. Additionally, monthly or weekly
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interactions with family and friends were associated with slower memory decline than
was never interacting (appendix pp 26–27). Never feeling lonely was associated with
slower annual decline in global cognition and executive function than was often feeling
lonely. Heterogeneity estimates for the results reported here for the main models were low
(I2=0·00–15·11%), indicating that the findings were largely consistent across studies. The
exceptions were for the association between memory and living situation (I2=58·33%), for
which only the North American and South Korean cohorts showed significant results, and

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 Samtani et al. Page 11

for the association between memory and community group engagement (I2=37·54–72·19%),
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which might reflect the different activities assessed in different cohorts. These findings were
all replicated in the fully adjusted models (ie, in ten of 13 cohorts).

Several findings were inconsistent between the main and fully adjusted models. In the fully
adjusted models, monthly engagement in a community group was significantly associated
with faster global cognitive decline than was never engaging with community groups. In the
main models, yearly interactions with family and friends were associated with slower annual
decline in global cognition than was never interacting, but this association was not replicated
in the fully adjusted models (appendix pp 26–27). Sensitivity analyses using complete cases
for the main models suggested that the overall pattern of findings was consistent (appendix
pp 38–39).

In terms of sex differences, examining the pooled interaction effects of social connection
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markers with sex across cohorts (table) identified a few sex differences in the associations
between social connection markers and cognitive function. Men, but not women, who were
in a relationship or were married had faster cognitive decline in global cognition than those
not in a relationship or married. Women, but not men, who were in a relationship or were
married had slower decline in memory than those not in a relationship or married.

When examining the whole sample, there was a significant sex interaction for living with
others and being in a relationship or married, with both factors predicting slower decline
in executive function than living alone or being single or never married. Sex differences in
the association between social connection markers and annual rate of change in cognition
for individual cohorts are shown in the appendix (pp 32–37). Sensitivity analyses using
complete cases replicated the pattern of results (appendix pp 40–41).
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Discussion
In line with our hypothesis that good social connections would be associated with slower
cognitive decline over time than would poor social connections, we identified that being
married or in a relationship, living with one or more person, and never feeling lonely were
associated with slower annual decline in global cognition than were being single or never
married, living alone, and often feeling lonely. Our findings regarding relationship status are
consistent with a previous meta-analysis, which showed that being married is protective
against dementia due to slower cognitive decline.8 We also identified an association
between never feeling lonely and a slower rate of cognitive decline, similar to previous
findings.11 Overall, our findings support previous research and suggest that improved social
connection structures (eg, relationship status, living situation, and interaction frequency),
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quality (eg, loneliness), but not necessarily function (eg, social support), are associated
with decreased rates of cognitive decline. Social connections and cognitive function can
also have a bidirectional relationship, where each promotes the other, such that having
social connections promotes cognitive skills and vice versa.40 Declining cognition can also
limit social connections and vice versa. Our results support both the bridging (ie, cognitive
stimulation via doing activities with loose ties) and bonding (ie, stress buffering via close

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 Samtani et al. Page 12

relationships) pathways that have been proposed to lead from social connections to cognitive
health.4
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In terms of cognitive domains, our hypothesis that good social connection structure markers
are associated with slow decline across all cognitive domains was partly supported. Living
with others was associated with slower decline in memory and language, but not executive
function, than was living alone. We also identified that yearly, monthly, and weekly
engagement in a community group and monthly and weekly interactions with family
and friends were associated with slower memory decline than were no engagement or
interactions, although the association of yearly interactions with family and friends and
memory was not replicated in fully adjusted models. Our results are in line with another
meta-analysis that identified that social connection structure was linked specifically with
memory, although the previous meta-analysis did find associations with executive function,
which we did not.8 We also identified an association between social health structure and
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language, a relationship that was not examined in the previous meta-analysis.8 Living with
others and interacting regularly with the community and with family and friends could
provide frequent opportunities to use memory or language skills.41 Our hypothesis was
good social connection function and quality markers are associated with slower decline
in memory was not supported. However, never feeling lonely was associated with slower
executive function decline than was often feeling lonely. We identified that good social
connections structure (ie, being in a relationship and living with others) and quality (ie,
never feeling lonely) were associated with slower global cognitive decline than were being
single or never married, living alone, and feeling lonely. Importantly, associations between
specific social connection markers and specific cognitive domains might be overlooked by
focusing solely on global cognition. Feeling connected to others (vs feeling lonely) might
increase cognitive reserve by reducing stress and slowing down memory and executive
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function decline, whereas interactions with family and friends and community members
might provide cognitive stimulation and additional opportunities to practise a variety of
cognitive functions, such as memory and language, which is in line with the theorised
bridging and bonding pathways and other previous findings.4,8

As per our hypothesis, we identified a few sex differences in the associations between
social connection markers and cognition, but we did not identify support for our hypothesis
that good social health structure markers are associated with a decreased rate of cognitive
decline only for men. We identified slower rates of cognitive decline (ie, global cognition
and memory) over time for women who were in a relationship or married than for women
who were single. These findings are contrary to previous research showing that being in a
relationship or married is associated with slower cognitive decline for men only.18 Although
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older women might have few social interactions beyond their spouse due to increased
house-hold responsibilities, interactions with family and friends outside of the home can
provide opportunities for cognitive stimulation.15 Additionally, women in a relationship or
who are married might have greater financial stability and better general and cognitive
function. Across the 13 cohorts in our study, the mean age of married men in the main
models was 2·43 years greater than was the mean age of married women. This difference
in age might explain slower rates of cognitive decline for married women than for men, as
married men are older and might have cognitive decline during marriage, whereas married

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 Samtani et al. Page 13

women might have cognitive decline later in life during widowhood. Sex differences in
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the association between social connection and cognitive decline are inconclusive; some
previous studies have reported no differences,7 whereas others have reported evidence for
women benefiting from interactions with family and friends more than men do when newly
diagnosed with dementia.42 Our exploratory analyses on the sex differences between social
connection function and quality markers and cognitive decline showed no significant results.

Poor social connections have been proposed to affect cognitive function via multiple
pathways. Strong social ties promote cognitive health via cognitive stimulation and affect the
function of the neuroendocrine system and activation of the hypothalamic–pituitary–adrenal
axis via psychosocial processes (eg, stress buffering).4 Being in a relationship or married,
living with others, and frequent social interactions might provide opportunities for cognitive
stimulation and reduce cognitive decline via the stress buffering pathway. Although our
effect sizes represented a 1–2% reduction in the rate of cognitive decline per year, these
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results might accumulate over decades. Nevertheless, having poor social connections is
one contributing factor for cognitive decline and should be considered alongside other risk
factors when trying to reduce the risk of cognitive decline.

Our study had several strengths. Previous meta-analyses or collaborative studies have relied
on data from North America and Europe, used combined or conflated social connection
markers, used aggregated statistics from studies with diverse sets of covariates, and focused
solely on global cognition as the outcome. We harmonised data from 13 longitudinal
cohorts, including culturally diverse and low-income and middle-income countries (ie,
Brazil, China, and Central African Republic). Our sample was well powered and more
representative than were many previous studies examining social connections and cognitive
outcomes in older adults. Using an individual participant data meta-analysis, we controlled
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for the same covariates across studies. Additionally, harmonisation allowed us to examine
multiple markers of social connections as risk factors for cognitive decline. We have
strictly delineated between structural, functional, and quality markers of social connections.3
Previous studies have emphasised the need to measure and assess distinct markers of social
connections as they might have varying effects on different cognitive domains.8 We went
beyond previous studies by examining associations with memory, executive function, and
language, rather than only global cognition. We also examined previously underinvestigated
sex differences across multiple social connection markers and change in cognitive function
for global cognition and specific cognitive domains.

There were some limitations to our study. Harmonising data from multiple studies entailed a
loss of granularity and precluded analyses involving detailed categories of social connection
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markers. Our results might have been affected by the contributing cohort studies not using
validated measures of social connections. For instance, most cohort studies used single
questions for concepts such as loneliness instead of validated scales. Few studies provided
data for relationship satisfaction (ie, four studies) or loneliness frequency (ie, three studies),
emphasising the need for improved quality of data for social connection quality. Disparities
in the number of social connection markers between cohort studies meant that we could
not compute composite scores for social connection domains (ie, structure, quality, and
function) or control for other social connection markers when examining the association

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 Samtani et al. Page 14

between specific social connection markers and cognitive outcomes. It is possible that
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other social connection markers (eg, loneliness) might confound the relationship between
a specific social connection marker and a cognitive outcome (eg, being in a relationship
and global cognition). In our study, the meta-analyses models had to be run with different
groupings of studies for each social connection predictor–cognitive outcome pair. Future
research should investigate the interaction of social connection markers with each other
and cognitive outcomes by use of data from studies that included the same set of social
connection markers. Reverse causality might affect our results, as cognitive skills are
required to maintain social connections, although we excluded people living with dementia
at baseline to minimise the risk. Finally, due to the absence of data for social connection
markers at follow-up, we examined only baseline differences in social connection markers
and were unable to examine changes in social connection markers over time. Future research
could investigate if changes in social connections affect the rate of cognitive decline over
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the course of dementia. The biopsychosocial pathways leading from having good social
connection structure and function to stable cognition function (or vice versa) have not been
explored.

Although most cohort studies include measures of only social connections, social health has
been expanded to include the individual’s ability to adapt to and manage challenges that
influence their social participation and activities.43 More theory and measures of this ability
to adapt are needed to get an understanding of the dynamic nature of social health.

To summarise, harmonised individual participant data from 13 longitudinal cohort studies of

ageing were meta-analysed at the participant level to examine the association between social
connections and risk of cognitive decline. Better social connection structure (eg, relationship
status, living situation, and interaction frequency) and quality (eg, never lonely), but not
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function (eg, social support and having a confidante), were associated with slower rates
of cognitive decline. Additionally, being in a relationship or married was associated with
slower decline in memory, but only for women.

Data sharing
All aggregate participant data are presented either in the manuscript or appendix. Individual
participant data cannot be made publicly available because they are protected by a
confidentiality agreement. Data were provided by the contributing studies to COSMIC on
the understanding and proviso that the relevant study leaders be contacted for further use
of their data and additional formal data sharing agreements be made. Researchers can apply
to use COSMIC data by completing a COSMIC Research Proposal Form available from
https://cheba.unsw.edu.au/consortia/cosmic/research-proposals.
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Supplementary Material
Refer to Web version on PubMed Central for supplementary material.

Acknowledgments
The head of COSMIC is PSS, and the study coordinator is DML. The research scientific committee leads the
scientific agenda of COSMIC and provides ongoing support and governance; it is comprised of member study

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 Samtani et al. Page 15

leaders. The COSMIC research scientific committee and additional principal investigators are listed at https://
cheba.unsw.edu.au/consortia/cosmic/scientific-committee. We thank the participants and their informants for their
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time and generosity in contributing to this research. We also thank the research teams for the contributing cohort
studies. This work was supported by the JPND project SHARED. In Australia, the project is funded by a National
Health and Medical Research Council grant (grant number APP1169489), which is awarded and governed by the
JPND. Funding for COSMIC comes from the NIA–NIH (award number 1RF1AG057531–01). The EPIDEMCA
study was funded by the French National Research Agency (ANR-09-MNPS-009–01), the AXA Research Fund
(grant 2012–Project Public Health Institute [Inserm]–PREUX Pierre-Marie), and the Limoges University Hospital
through its Appel à Projet des Equipes Émergentes et Labellisées scheme. The Bambuí Cohort Study of Ageing was
funded by Financiadora de Estudos e Projetos, Conselho Nacional de Desenvolvimento Científico e Tecnológicos,
and Fundação de Amparo Pesquisa do Estado de Minas Gerais. The HELIAD cohort was funded by the
Alzheimer’s Association, European Social Fund, and Greek Ministry of Health. The LEILA75+ study was funded
by the Interdisciplinary Centre for Clinical Research at the University of Leipzig (grant 01KS9504). The LRGS
TUA study was funded by Long-Term Research Grant Scheme at the Ministry of Higher Education (LRGS/BU/
2012/UKM-UKM/K/01). The MAS study was funded by the National Health and Medical Research Council (grant
numbers APP350833, APP568969, and APP1093083) in Australia. The MYHAT study was funded by a grant made
by NIA to the University of Pittsburgh (grant number R37AG023651). Funding for the CLAS study was from
the Ministry of Science and Technology, National Pillar Program 2009BAI77B03 and the National Key Clinical
Disciplines at Shanghai Mental Health Center (Office of Medical Affairs, Ministry of Health, 2011-873). Funding
for ELSA was provided by the National Institute of Aging (grants 2RO1AG7644-01A1 and 2RO1AG017644) and
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a consortium of UK Government departments coordinated by the Office for National Statistics. The H70 study was
supported by AgeCap-Center for Aging and Health, Riksbankens Jubileumsfond, FORTE, and the Swedish Brain
Power. The H70 study data collection was supported by The Swedish Research Council, Swedish Research Council
for Health, Working Life and Welfare, Epilife, Swedish Brain Power, The Alzheimer’s Association Zenith Award,
The Alzheimer’s Association Stephanie B Overstreet Scholars, The Bank of Sweden Tercentenary Foundation,
Stiftelsen Söderström-Königska Sjukhemmet, Stiftelsen för Gamla Tjänarinnor, Handlanden Hjalmar Svenssons
Forskningsfond, and Stiftelsen Professor Bror Gadelius’ Minnesfond. KLOSCAD was supported by a grant
from the Korean Health Technology R&D Project, Ministry of Health and Welfare, South Korea (grant number
HI09C1379 [A092077]). PREHCO was supported in part by the NIA (grants R21 AG045722 and P30AG022838).
The content is solely the responsibility of the authors and does not necessarily represent the official views of the
NIA or the NIH. SLAS was supported by a research grant (number 03/1/21/17/214) from the Biomedical Research
Council, Agency for Science, Technology and Research, Singapore.

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Research in context
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Evidence before this study

To identify gaps in the literature, we searched Web of Science and PsycINFO for
meta-analyses published in English between Jan 1, 2012, and May 5, 2022, with the
keywords “(dementia OR alzheimer* OR cognitive dysfunction OR cognitive decline)”
AND “(social OR connection* OR relationship* OR friend* OR family OR network
OR activit* OR interaction* OR health OR behav* OR support OR participat* OR
isolat*)”. Social isolation is a modifiable risk factor for dementia, accounting for about
4% of preventable cases worldwide. Recent meta-analyses have examined several facets
of social health. One of these studies reported that poor social health structure and
function predicted greater cognitive decline. Another study examined individual social
connection markers separately and found that low social participation, infrequent social
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contact, and loneliness were associated with increased risk of dementia. However, these
meta-analyses used aggregated (not individual-level) data from studies with different
covariates. Furthermore, most studies focused on global cognition, ignoring potential
associations between social connections and specific cognitive domains. Sex differences
in the link between social connections and domain-specific cognitive changes are also
underexplored. Finally, existing meta-analyses have primarily included data from North
America and Europe.

Added value of this study

To our knowledge, this study is the largest individual participant data meta-analysis of
the association between social connections and cognition. We showed that good social
connections slow cognitive decline not only in global cognition, as previous studies have
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shown, but also specifically for memory and language. Additionally, we showed that
being in a relationship or married was associated with slower memory decline than being
single or never married, but only for women. Results from this study are consistent
with previous research from Europe and North America, but we included studies from
South America, Africa, Asia, and Australia, including low-income and middle-income
countries.

Implications of all the available evidence

Good social health structure and quality appear to slow the annual rate of cognitive
decline. There should be greater emphasis on preserving or enhancing older adults’ social
relationships. We showed effects for specific cognitive domains, and future research
could further explore the bidirectional pathways between cognitive domains and social
connections.
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Figure 1: Associations between social connection markers and global cognition

Markers are categorised by structure, function, and quality. Data presented are for main
(partially adjusted) models.
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 Samtani et al. Page 20
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Figure 2: Associations between social connection markers and memory

Markers are categorised by structure, function, and quality. Data presented are for main
(partially adjusted) models.
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 Samtani et al. Page 21
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Figure 3: Associations between social connection markers and language

Markers are categorised by structure, function, and quality. Data presented are for main
(partially adjusted) models. The meta-analytic model for the association between loneliness
and language could not be run because data were available for only the H70 study.23
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 Samtani et al. Page 22
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Figure 4: Associations between social connection markers and executive function

Markers are categorised by structure, function, and quality. Data presented are for main
(partially adjusted) models.
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 Samtani et al. Page 23

Table:

Sex differences in the association between social health markers and annual change in cognition by domain in
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the main analysis

I2 (%) τ2 Interaction effect of Egger’s test, Simple main

social connection Z score (p value) effects for men
marker, sex, and and women (when
time in study, b is significant;
b (95% CI) 95% CI)

Global cognition
Structure
Being married or in a relationship 0·00% 0·00 0·033 (0·009 to 0·578) −0·42 (p=0·68) −0·023 (−0·045 to
−0·002) for men; 0·010
(−0·001 to 0·021) for
women
Living with others 14·96% 0·00 0·004 (−0·011 to 0·018) −0·82 (p=0·41)
Yearly engagement in community group 0·69% 0·00 0·013 (−0·015 to 0·042) −0·39 (p=0·70)
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Monthly engagement in community group 15·53% 0·00 −0·009 (−0·038 to 0·019) 0·03 (p=0·97) ··
Weekly engagement in community group 0·00% 0·00 0·010 (−0·013 to 0·034) −0·30 (p=0·77) ··
Yearly interactions with family and friends 0·00% 0·00 0·039 (−0·028 to 0·107) 0·44 (p=0·66) ··
Monthly interactions with family and 0·00% 0·00 0·006 (−0·019 to 0·031) −0·08 (p=0·94)
friends
Weekly interactions with family and 0·00% 0·00 0·004 (−0·017 to 0·026) 0·11 (p=0·91)
friends
Function
High availability of social support 0·45% 0·00 0·002 (−0·013 to 0·014) −1·66 (p=0·10)
Having a confidante 0·00% 0·00 −0·002 (−0·023 to 0·018) 0·10 (p=0·92) ··
Quality
High relationship satisfaction 0·00% 0·00 −0·036 (−0·078 to 0·006) −0·27 (p=0·80)
Never feeling lonely 0·00% 0·00 −0·057 (−0·140 to 0·027) 0·45 (p=0·66)
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Memory
Structure
Being married or in a relationship 7·14% 0·00 0·042 (0·010 to 0·074) 0·01 (p=0·99) −0·023 (−0·047 to 0·001)
for men; 0·024 (0·001 to
0·048) for women
Living with others 42·70% 0·00 0·009 (−0·012 to 0·031) 0·94 (p=0·35) ··
Yearly engagement in community group 8·33% 0·00 0·001 (−0·035 to 0·054) NR* ··

Monthly engagement in community group 0·00% 0·00 0·006 (−0·025 to 0·037) 0·10 (p=0·92) ··
Weekly engagement in community group 0·00% 0·00 0·017 (−0·017 to 0·051) 0·86 (p=0·39) ··
Yearly interactions with family and friends 57·32% 0·05 −0·076 (−0·389 to 0·235) −0·14 (p=0·89) ··
Monthly interactions with family and 0·00% 0·00 0·011 (−0·014 to 0·036) −1·42 (p=0·16) ··
friends
Weekly interactions with family and 52·73% 0·00 0·002 (−0·064 to 0·068) −1·90 (p=0·057) ··
friends
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Function
High availability of social support 33·13% 0·00 0·008 (−0·019 to 0·035) 0·20 (p=0·84) ··
Having a confidante 0·00% 0·00 −0·005 (−0·025 to 0·015) −0·14 (p=0·89) ··
Quality
High relationship satisfaction 0·00% 0·00 −0·029 (−0·087 to 0·028) −0·42 (p=0·67) ··

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 Samtani et al. Page 24

I2 (%) τ2 Interaction effect of Egger’s test, Simple main

social connection Z score (p value) effects for men
marker, sex, and and women (when
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time in study, b is significant;

b (95% CI) 95% CI)
Never feeling lonely 0·00% 0·00 −0·039 (−0·102 to 0·024) −0·38 (p=0·71) ··
Language
Structure
Being married or in a relationship 0·00% 0·00 0·010 (−0·024 to 0·043) −1·76 (p=0·079) ··
Living with others 0·13% 0·00 0·007 (−0·007 to 0·022) 0·87 (p=0·39) ··
Yearly engagement in community group 77·24%† 0·00 −0·001 (−0·094 to 0·092) NR* ··

Monthly engagement in community group 90·58%† 0·02 0·018 (−0·135 to 0·171) 2·61 (p=0·0069) ··

Weekly engagement in community group 47·96% 0·00 −0·011 (−0·077 to 0·055) −0·06 (p=0·95) ··
Yearly interactions with family and friends 39·08% 0·03 −0·072 (−0·343 to 0·198) −0·43 (p=0·67) ··
Monthly interactions with family and 0·00% 0·00 −0·006 (−0·030 to 0·018) −0·29 (p=0·80) ··
friends
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Weekly interactions with family and 0·00% 0·00 0·004 (−0·017 to 0·024) −0·60 (p=0·55) ··
friends
Function
High availability of social support 0·00% 0·00 0·002 (−0·011 to 0·016) 0·65 (p=0·52) ··
Having a confidante 0·00% 0·00 −0·001 (−0·022 to 0·019) 0·25 (p=0·81) ··
Quality
High relationship satisfaction 0·00% 0·00 −0·000 (−0·057 to 0·056) NR* ··

Never feeling lonely NR‡ NR‡ NR‡ NR* ··

Executive function
Structure
Being married or in a relationship 0·00% 0·00 0·046 (0·011 to 0·082) −0·38 (p=0·71) −0·027 (−0·054 to 0·000)
for men; 0·017 (−0·002
to 0·036) for women
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Living with others 0·00% 0·00 0·016 (0·001 to 0·031) 0·25 (p=0·80) −0·009 (−0·022 to 0·003)
for men; 0·005 (−0·002
to 0·013) for women
Yearly engagement in community group 61·34% 0·00 −0·033 (−0·110 to 0·045) NR* ··

Monthly engagement in community group 73·11%† 0·01 −0·034 (−0·138 to 0·070) −1·59 (p=0·11) ··

Weekly engagement in community group 0·00% 0·00 −0·035 (−0·079 to 0·010) −0·76 (p=0·45) ··
Yearly interactions with family and friends 57·15% 0·06 0·133 (−0·246 to 0·513) −0·11 (p=0·91) ··
Monthly interactions with family and 0·01% 0·00 0·008 (−0·022 to 0·038) −0·08 (p=0·93) ··
friends
Weekly interactions with family and 0·00% 0·00 0·023 (−0·002 to 0·049) −0·39 (p=0·70) ··
friends
Function
High availability of social support 0·00% 0·00 0·005 (−0·008 to 0·019) 0·54 (p=0·59) ··
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Having a confidante 0·00% 0·00 −0·024 (−0·081 to 0·033) 0·23 (p=0·82) ··

Quality
High relationship satisfaction 11·29% 0·00 −0·014 (−0·093 to 0·065) 1·37 (p=0·17) ··
Never feeling lonely 42·24% 0·00 0·042 (−0·078 to 0·162) 0·81 (p=0·42) ··

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 Samtani et al. Page 25

The model results reflect the annual change in cognition (b [95% CI]) for women compared with men and are controlled for age at baseline,
education, and sex. Positive interaction effect b indicates slower annual decline in cognition for women than for men; negative interaction effect b
indicates slower annual decline in cognition for men than for women. For sex-stratified analyses, simple main effects positive b indicates slower
annual decline in cognition than for the reference group for the specific social connection marker. NR=not reported.
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*
Some models had less than three cohort studies, and we could not compute Egger’s test for them.
†
p<0·05.
‡
Not enough data points to run analysis.
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Lancet Healthy Longev. Author manuscript; available in PMC 2022 December 14.