{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,29]],"date-time":"2026-07-29T17:38:54Z","timestamp":1785346734671,"version":"3.55.0"},"reference-count":54,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2023,2,15]],"date-time":"2023-02-15T00:00:00Z","timestamp":1676419200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Cognitive impairment is an age-relevant intermediate stage where cognition declines to a state between the normal aging process and dementia. Earlier studies reported that depression, inappropriate nighttime sleep duration (NSD), and limited leisure activity engagement are cognitive impairment risk factors among older adults. Thus, we postulated that interventions on depression, sleep duration, and leisure activity engagement can reduce cognitive impairment risk. However, no earlier research ever explored this.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>The data of 4,819 respondents aged 60 years and above, without cognitive impairment at baseline and with no prior history of memory-related diseases, including Alzheimer's disease, Parkinson's disease, and encephalatrophy, were obtained from the China Health and Retirement Longitudinal Study (CHARLS) between 2011 and 2018. The parametric g-formula, an analytic tool for estimating standardized outcome distributions using covariate (exposure and confounders)-specific estimates of the outcome distribution, was used to estimate 7-year cumulative cognitive impairment risks among older Chinese adults, under independent hypothetical interventions on depression, NSD, and leisure activity engagement, which was subdivided into social activity (SA) and intellectual activity (IA) for the different intervention combinations.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>The observed cognitive impairment risk was 37.52%. Independent intervention on IA was the most effective factor in reducing incident cognitive impairment, with a risk ratio (RR) of 0.75 (95% confidence interval [CI]: 0.67\u20130.82), followed by depression (RR: 0.89, 95% CI: 0.85\u20130.93) and NSD (RR: 0.88, 95% CI: 0.80\u20130.95). The joint intervention combining depression, NSD, and IA interventions could reduce the risk by 17.11%, with an RR of 0.56 (95% CI: 0.48\u20130.65). In subgroup analyses, independent interventions on depression and IA had analogously significant effects on men and women. However, interventions on depression and IA had stronger effects on literate than illiterate individuals.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>Hypothetical interventions on depression, NSD, and IA reduced cognitive impairment risks among older Chinese adults, both independently and jointly. The findings of the present study suggest that the intervention measures on depression, inappropriate NSD, limited intellectual activities, and their combination may prove to be effective strategies for preventing cognitive impairment among older adults.<\/jats:p><\/jats:sec>","DOI":"10.3389\/fpubh.2023.1088833","type":"journal-article","created":{"date-parts":[[2023,2,15]],"date-time":"2023-02-15T11:37:56Z","timestamp":1676461076000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":12,"title":["Incidence of cognitive impairment after hypothetical interventions on depression, nighttime sleep duration, and leisure activity engagement among older Chinese adults: An application of the parametric g-formula"],"prefix":"10.3389","volume":"11","author":[{"given":"Nan","family":"Zhang","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fenghui","family":"Chen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Cui","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ping","family":"Yan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2023,2,15]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"24","DOI":"10.1186\/s12889-020-10069-w","article-title":"Estimation of losses of quality-adjusted life expectancy attributed to the combination of cognitive impairment and multimorbidity among Chinese adults aged 45 years and older","volume":"21","author":"Xiong","year":"2021","journal-title":"BMC Public Health."},{"key":"B2","doi-asserted-by":"publisher","first-page":"706","DOI":"10.14336\/ad.2017.0928","article-title":"The prevalence of mild cognitive impairment in China: a systematic review","volume":"9","author":"Xue","year":"2018","journal-title":"Aging Dis."},{"key":"B3","doi-asserted-by":"publisher","first-page":"179","DOI":"10.3233\/jad-200383","article-title":"Effect of a multimodal lifestyle intervention on sleep and cognitive function in older adults with probable mild cognitive impairment and poor sleep: a randomized clinical trial","volume":"76","author":"Falck","year":"2020","journal-title":"J Alzheimers Dis."},{"key":"B4","doi-asserted-by":"publisher","first-page":"84","DOI":"10.3390\/geriatrics5040084","article-title":"Global cognitive impairment prevalence and incidence in community dwelling older adults-a systematic review","volume":"5","author":"Pais","year":"2020","journal-title":"Geriatrics (Basel)."},{"key":"B5","doi-asserted-by":"publisher","first-page":"2847","DOI":"10.3390\/ijerph16162847","article-title":"Changes in cognitive function and risk factors for cognitive impairment of the elderly in China: 2005\u20132014","volume":"16","author":"Zhang","year":"2019","journal-title":"Int J Environ Res Public Health."},{"key":"B6","unstructured":"2022"},{"key":"B7","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1159\/000257086","article-title":"prevalence of cognitive impairment: effects of level of education, age, sex and associated factors","volume":"28","author":"Mill\u00e1n-Calenti","year":"2009","journal-title":"Dement Geriatr Cogn Disord."},{"key":"B8","doi-asserted-by":"publisher","first-page":"73","DOI":"10.1177\/0164027506294245","article-title":"Education and cognitive decline in older Americans: results from the ahead sample","volume":"29","author":"Alley","year":"2007","journal-title":"Res Aging."},{"key":"B9","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1016\/j.socscimed.2018.08.024","article-title":"Gender matters: productive social engagement and the subsequent cognitive changes among older adults","volume":"229","author":"Lee","year":"2019","journal-title":"Soc Sci Med."},{"key":"B10","doi-asserted-by":"publisher","first-page":"1454","DOI":"10.1177\/07334648211064796","article-title":"Adverse childhood experiences and mild cognitive impairment in later life: exploring rural\/urban and gender differences using CHARLS","volume":"41","author":"Zhang","year":"2022","journal-title":"J Appl Gerontol."},{"key":"B11","doi-asserted-by":"publisher","first-page":"286","DOI":"10.1177\/0253717620981556","article-title":"Geriatric depression and cognitive impairment\u2014an update","volume":"43","author":"Mukku","year":"2021","journal-title":"Indian J Psychol Med."},{"key":"B12","doi-asserted-by":"publisher","first-page":"2138","DOI":"10.3760\/cma.j.cn112338-20201106-01313","article-title":"Association between sleep duration and cognitive impairment in Chinese people aged 65 years and older","volume":"42","author":"Wei","year":"2021","journal-title":"Zhonghua Liu Xing Bing Xue Za Zhi."},{"key":"B13","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1093\/geront\/gnab046","article-title":"Longitudinal relationship of leisure activity engagement with cognitive performance among non-demented, community-dwelling older adults","volume":"62","author":"Armstrong","year":"2022","journal-title":"Gerontologist."},{"key":"B14","doi-asserted-by":"publisher","first-page":"184","DOI":"10.1016\/j.jad.2015.09.022","article-title":"Computerized cognitive training and functional recovery in major depressive disorder: a meta-analysis","volume":"189","author":"Motter","year":"2016","journal-title":"J Affect Disord."},{"key":"B15","doi-asserted-by":"publisher","first-page":"1383","DOI":"10.4088\/JCP.tk16043ah5c","article-title":"Cognitive impairment in patients with depression: awareness, assessment, and management","volume":"78","author":"Culpepper","year":"2017","journal-title":"J Clin Psychiatry."},{"key":"B16","first-page":"146","article-title":"Six-month follow-up of cognitive impairment and depressive symptoms in late-onset depression","volume":"25","author":"Wong","year":"2015","journal-title":"East Asian Arch Psychiatry."},{"key":"B17","doi-asserted-by":"publisher","first-page":"502","DOI":"10.1016\/j.eurpsy.2004.09.003","article-title":"Six-month course of mild cognitive impairment and affective symptoms in late-life depression","volume":"19","author":"Adler","year":"2004","journal-title":"Eur Psychiatry."},{"key":"B18","doi-asserted-by":"publisher","first-page":"309","DOI":"10.18632\/aging.102616","article-title":"Changes in sleep duration and 3-year risk of mild cognitive impairment in Chinese older adults","volume":"12","author":"Zhu","year":"2020","journal-title":"Aging."},{"key":"B19","doi-asserted-by":"publisher","first-page":"20623","DOI":"10.18632\/aging.103948","article-title":"Improvement in sleep duration was associated with higher cognitive function: a new association","volume":"12","author":"Hua","year":"2020","journal-title":"Aging."},{"key":"B20","doi-asserted-by":"publisher","first-page":"565","DOI":"10.1093\/sleep\/34.5.565","article-title":"Change in sleep duration and cognitive function: findings from the Whitehall II study","volume":"34","author":"Ferrie","year":"2011","journal-title":"Sleep."},{"key":"B21","doi-asserted-by":"publisher","first-page":"498","DOI":"10.1097\/nmd.0000000000001159","article-title":"Sleep duration change and cognitive function: a national cohort study of Chinese people older than 45 years","volume":"208","author":"Lian","year":"2020","journal-title":"J Nerv Ment Dis."},{"key":"B22","doi-asserted-by":"publisher","first-page":"125","DOI":"10.1016\/j.jad.2020.12.007","article-title":"Prospective associations between change in sleep duration and cognitive impairment: findings from the Singapore Chinese health study","volume":"281","author":"Wu","year":"2021","journal-title":"J Affect Disord."},{"key":"B23","doi-asserted-by":"publisher","first-page":"225","DOI":"10.1080\/01924788.2019.1651188","article-title":"The relationship between subjective cognitive impairment and activity participation: a systematic review","volume":"44","author":"Wion","year":"2020","journal-title":"Act Adapt Aging."},{"key":"B24","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1186\/s13195-020-00691-6","article-title":"Associations between social and intellectual activities with cognitive trajectories in Chinese middle-aged and older adults: a nationally representative cohort study","volume":"12","author":"Li","year":"2020","journal-title":"Alzheimers Res Ther."},{"key":"B25","doi-asserted-by":"publisher","first-page":"697","DOI":"10.1001\/jamapsychiatry.2018.0657","article-title":"Association of daily intellectual activities with lower risk of incident dementia among older Chinese adults","volume":"75","author":"Lee","year":"2018","journal-title":"JAMA Psychiatry."},{"key":"B26","doi-asserted-by":"publisher","first-page":"2149","DOI":"10.2147\/ndt.s160036","article-title":"The relationship of individual social activity and cognitive function of community Chinese elderly: a cross-sectional study","volume":"14","author":"Su","year":"2018","journal-title":"Neuropsychiatr Dis Treat."},{"key":"B27","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1007\/s10654-020-00694-5","article-title":"Hypothetical blood-pressure-lowering interventions and risk of stroke and dementia","volume":"36","author":"Rojas-Saunero","year":"2021","journal-title":"Eur J Epidemiol."},{"key":"B28","doi-asserted-by":"publisher","first-page":"473","DOI":"10.1007\/s10654-017-0293-4","article-title":"Target trial emulation: teaching epidemiology and beyond","volume":"32","author":"Labrecque","year":"2017","journal-title":"Eur J Epidemiol."},{"key":"B29","doi-asserted-by":"publisher","first-page":"1393","DOI":"10.1016\/0270-0255(86)90088-6","article-title":"New approach to causal inference in mortality studies with sustained exposure periods\u2014application to control of the healthy worker survivor effect","volume":"7","author":"Robins","year":"1986","journal-title":"Mathemat Modell."},{"key":"B30","doi-asserted-by":"publisher","first-page":"889","DOI":"10.1097\/ede.0000000000000160","article-title":"The parametric G-formula for time-to-event data: intuition and a worked example","volume":"25","author":"Keil","year":"2014","journal-title":"Epidemiology."},{"key":"B31","doi-asserted-by":"publisher","first-page":"1599","DOI":"10.1093\/ije\/dyp192","article-title":"Intervening on risk factors for coronary heart disease: an application of the parametric G-formula","volume":"38","author":"Taubman","year":"2009","journal-title":"Int J Epidemiol."},{"key":"B32","doi-asserted-by":"publisher","first-page":"180","DOI":"10.1142\/9789813235533_0017","article-title":"Causal inference on electronic health records to assess blood pressure treatment targets: an application of the parametric G formula","volume":"23","author":"Johnson","year":"2018","journal-title":"Pac Symp Biocomput."},{"key":"B33","doi-asserted-by":"publisher","first-page":"557","DOI":"10.1007\/s10654-017-0344-x","article-title":"Hypothetical interventions to prevent stroke: an application of the parametric G-formula to a healthy middle-aged population","volume":"33","author":"Vangen-L\u00f8nne","year":"2018","journal-title":"Eur J Epidemiol."},{"key":"B34","doi-asserted-by":"publisher","first-page":"732136","DOI":"10.3389\/fmed.2021.732136","article-title":"Hypothetical Interventions for falls among older adults: an application of the parametric G-formula","volume":"8","author":"Ren","year":"2021","journal-title":"Front Med (Lausanne)."},{"key":"B35","doi-asserted-by":"publisher","first-page":"61","DOI":"10.1093\/ije\/dys203","article-title":"Cohort profile: the China Health and Retirement Longitudinal Study (CHARLS)","volume":"43","author":"Zhao","year":"2014","journal-title":"Int J Epidemiol."},{"key":"B36","doi-asserted-by":"publisher","first-page":"1892","DOI":"10.1002\/gps.5206","article-title":"Temporal precedence of cognitive function and functional abilities: a latent difference score model of the Chinese community-dwelling elders","volume":"34","author":"Wang","year":"2019","journal-title":"Int J Geriatr Psychiatry."},{"key":"B37","doi-asserted-by":"publisher","first-page":"61","DOI":"10.31887\/DCNS.2003.5.1\/cgilles","article-title":"Age-related mild cognitive deficit: a ready-to-use concept?","volume":"5","author":"Gilles","year":"2003","journal-title":"Dialog Clin Neurosci."},{"key":"B38","doi-asserted-by":"publisher","first-page":"534","DOI":"10.1002\/(sici)1099-1166(199907)14:7<534::aid-gps963>3.0.co;2-b","article-title":"Cognitive decline in ageing: are AAMI and AACD distinct entities?","volume":"14","author":"Richards","year":"1999","journal-title":"Int J Geriatr Psychiatry."},{"key":"B39","doi-asserted-by":"publisher","first-page":"3886","DOI":"10.3390\/ijerph18083886","article-title":"Comparison of depressive symptoms and its influencing factors among the elderly in urban and rural areas: evidence from the China health and retirement longitudinal study (CHARLS)","volume":"18","author":"Liu","year":"2021","journal-title":"Int J Environ Res Public Health."},{"key":"B40","doi-asserted-by":"publisher","first-page":"2511","DOI":"10.1177\/07334648221118904","article-title":"Gender-specific association between nighttime sleep duration and falls among community-dwelling middle-aged and older adults in China","volume":"41","author":"Zhang","year":"2022","journal-title":"J Appl Gerontol."},{"key":"B41","doi-asserted-by":"publisher","first-page":"316","DOI":"10.1249\/mss.0000000000002479","article-title":"Mortality effects of hypothetical interventions on physical activity and TV viewing","volume":"53","author":"Yang","year":"2021","journal-title":"Med Sci Sports Exerc."},{"key":"B42","doi-asserted-by":"publisher","first-page":"100008","DOI":"10.1016\/j.patter.2020.100008","article-title":"Gformula: an R package for estimating the effects of sustained treatment strategies via the parametric g-formula","volume":"1","author":"McGrath","year":"2020","journal-title":"Patterns (NY)"},{"key":"B43","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1001\/archgenpsychiatry.2009.50","article-title":"Major depressive disorder and hypothalamic-pituitary-adrenal axis activity: results from a large cohort study","volume":"66","author":"Vreeburg","year":"2009","journal-title":"Arch Gen Psychiatry."},{"key":"B44","doi-asserted-by":"publisher","first-page":"1379","DOI":"10.3233\/jad-210588","article-title":"Depressive symptoms imputed across the life course are associated with cognitive impairment and cognitive decline","volume":"83","author":"Brenowitz","year":"2021","journal-title":"J Alzheimers Dis."},{"key":"B45","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1038\/nrneurol.2011.60","article-title":"Depression and risk of developing dementia","volume":"7","author":"Byers","year":"2011","journal-title":"Nat Rev Neurol."},{"key":"B46","doi-asserted-by":"publisher","first-page":"727763","DOI":"10.3389\/fnagi.2021.727763","article-title":"Exploring the bidirectional associations between short or long sleep duration and lower cognitive function: a 7-year cohort study in China","volume":"13","author":"Hua","year":"2021","journal-title":"Front Aging Neurosci."},{"key":"B47","doi-asserted-by":"publisher","first-page":"1121","DOI":"10.5665\/sleep.5768","article-title":"Sleep duration and subsequent cortical thinning in cognitively normal older adults","volume":"39","author":"Spira","year":"2016","journal-title":"Sleep."},{"key":"B48","doi-asserted-by":"publisher","first-page":"83","DOI":"10.1016\/j.jad.2022.09.031","article-title":"Bidirectional associations of intellectual and social activities with cognitive function among middle-aged and elderly adults in China","volume":"319","author":"Li","year":"2022","journal-title":"J Affect Disord."},{"key":"B49","doi-asserted-by":"publisher","first-page":"103","DOI":"10.1177\/0956797613499592","article-title":"The impact of sustained engagement on cognitive function in older adults: the synapse project","volume":"25","author":"Park","year":"2014","journal-title":"Psychol Sci."},{"key":"B50","doi-asserted-by":"publisher","first-page":"835","DOI":"10.1093\/ageing\/afv099","article-title":"Intellectual and physical activities, but not social activities, are associated with better global cognition: a multi-site evaluation of the cognition and lifestyle activity study for seniors in Asia (CLASSA)","volume":"44","author":"Lam","year":"2015","journal-title":"Age Ageing."},{"key":"B51","doi-asserted-by":"publisher","first-page":"3047","DOI":"10.1007\/s11136-016-1355-x","article-title":"Objective drivers of subjective well-being in geriatric inpatients: mobility function and level of education are general predictors of self-evaluated health, feeling of loneliness, and severity of depression symptoms","volume":"25","author":"Bie\u0144","year":"2016","journal-title":"Qual Life Res."},{"key":"B52","doi-asserted-by":"publisher","first-page":"515","DOI":"10.3390\/nu13020515","article-title":"Association of lower nutritional status and education level with the severity of depression symptoms in older adults-a cross sectional survey","volume":"13","author":"Chrzastek","year":"2021","journal-title":"Nutrients."},{"key":"B53","doi-asserted-by":"publisher","first-page":"22","DOI":"10.1016\/j.dadm.2017.08.004","article-title":"Further education improves cognitive reserve and triggers improvement in selective cognitive functions in older adults: the Tasmanian healthy brain project","volume":"10","author":"Thow","year":"2018","journal-title":"Alzheimers Dement (Amst)."},{"key":"B54","doi-asserted-by":"publisher","first-page":"525","DOI":"10.1037\/neu0000249","article-title":"Sending your grandparents to university increases cognitive reserve: the Tasmanian Healthy brain project","volume":"30","author":"Lenehan","year":"2016","journal-title":"Neuropsychology."}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2023.1088833\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,2,15]],"date-time":"2023-02-15T11:38:03Z","timestamp":1676461083000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2023.1088833\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,15]]},"references-count":54,"alternative-id":["10.3389\/fpubh.2023.1088833"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2023.1088833","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,15]]},"article-number":"1088833"}}