Aging & Mental Health

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Loneliness and the risk of dementia among older

Chinese adults: gender differences

Zi Zhou, Ping Wang & Ya Fang

To cite this article: Zi Zhou, Ping Wang & Ya Fang (2017): Loneliness and the risk of
dementia among older Chinese adults: gender differences, Aging & Mental Health, DOI:
10.1080/13607863.2016.1277976

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AGING & MENTAL HEALTH, 2017
http://dx.doi.org/10.1080/13607863.2016.1277976

Loneliness and the risk of dementia among older Chinese adults: gender
differences
Zi Zhoua,b, Ping Wanga,b and Ya Fanga,b
a
State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Xiamen University, Xiamen, Fujian, China; bKey Laboratory of Health
Technology Assessment of Fujian Province University, School of Public Health, Xiamen University, Xiamen, Fujian, China

ABSTRACT ARTICLE HISTORY

Objective: The objective of this study was to examine whether loneliness was associated with the risk Received 1 October 2016
of developing dementia in Chinese older adults and whether the association was moderated by Accepted 19 December 2016
gender. KEYWORDS
Method: A 3-year cohort study was conducted using data from the 2008/2009 and 2011/2012 waves Loneliness; dementia; older
of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Multiple logistic regression was used adults; gender differences;
to analyze the relationship between loneliness and dementia. The interaction between loneliness and China
gender was also evaluated.
Results: At 3-year follow-up, 393 of the 7867 participants had dementia. Loneliness was associated
with dementia (odds ratio (OR) D 1.31, 95% confidence interval (CI) D 1.11–1.56) after adjustment for
sociodemographic characteristics, lifestyle, and baseline health status. A significant interaction
between loneliness and gender was also found (OR D 0.81, 95% CI D 0.65–0.99).
Conclusion: Loneliness increased the risk of developing dementia among people aged 65 years and
older in China. Moreover, the effect of loneliness on dementia risk varied by gender. Specifically, men
who felt lonely were more likely to suffer from dementia than women.

Introduction isolation, loneliness receives limited attention in dementia

prevention studies.
Dementia is defined as a clinical syndrome characterized by
Loneliness is defined as an unsatisfied feeling associated
progressive deteriorations in multiple cognitive domains that
with discrepancies between an individual’s actual and desired
are severe enough to interfere with daily functioning (Qiu, De
social relationships (Steptoe et al., 2013; Victor, Scambler,
Ronchi, & Fratiglioni, 2007). Prevalence and incidence studies
Bowling, & Bond, 2005). Loneliness is relatively prevalent
indicate that the number of people with dementia will con-
among older adults with weakening social networks (Routa-
tinue to increase (Prince et al., 2015). An estimated 8.18 million
salo, Savikko, Tilvis, Strandberg, & Pitkala, 2006; Yang & Victor,
people over the age of 60 years had dementia in mainland
2008). According to previous researchers (Holwerda et al.,
China in 2012 (Wu et al., 2013). This number is predicted to
2014;Wilson et al., 2007), older adults who feel lonely but not
reach 20.30 million in 2030 and 48.68 million in 2050 (Wu et al.,
socially isolated have a higher risk of developing dementia
2013). Given its significant economic burden, dementia has
and cognitive impairment, compared with those who do not
become a major challenge both in elderly care systems and in
feel lonely. However, Tilvis et al., 2004 reported inconsistent
public health (World Health Organization, 2015). The high bur-
findings about the association between loneliness and cogni-
den of dementia care underscores the urgent need to conduct
tive decline. Beyond these few studies with divergent results
research on the prevention of dementia among older adults.
regarding the association between loneliness and dementia,
Dementia is a serious disease that has a variety of effective
research exploring the extent to which gender moderates this
treatments existing (medication, memory training) but incur-
relationship is scant. A recent study shows that the intensity
able at this point in time. Researchers have reported that liv-
of loneliness varies between men and women and that loneli-
ing alone (Holwerda et al., 2014), being unmarried (van Beek,
ness is more strongly associated with adverse mental health
Frijters, Wagner, Groenewegen, & Ribbe, 2011), and lacking
conditions in men than in women (Zebhauser et al., 2014).
social support (Zhang, Edwards, Yates, Li, & Guo, 2014) can
Moreover, the incidence of dementia varies by gender (Qiu
lead to social isolation (Holwerda et al., 2014). Such isolation
et al., 2007; Wu et al., 2013; Zhou et al., 2006). Thus, it is rea-
might accelerate the onset of dementia. Social isolation is a
sonable to speculate that the association between loneliness
straightforward and objective measure that quantitatively
and the onset of dementia varies by gender.
reflects the decreasing size of an individual’s social network
Nevertheless, research on the relationship between loneli-
and social contacts (Pitkala, Routasalo, Kautiainen, & Tilvis,
ness and dementia among Chinese older adults is limited. A
2009; Steptoe, Shankar, Demakakos, & Wardle, 2013). Such
study indicates that the older adults in Eastern societies have
isolation among individuals with dementia has prompted
a stronger sense of loneliness compared to older adults in the
increasing concern among scholars (Karp, Parker, Wang, Win-
Western societies, due to the different cultures and social poli-
blad, & Fratiglioni, 2005; Wallin, Kivipelto, & Gustafson, 2013).
cies (de Jong Gierveld & Tesch-Ro €mer, 2012).Thus, this issue is
However, referring to an individual’s subjective feeling of

CONTACT Ya Fang fangya@xmu.edu.cn

© 2017 Informa UK Limited, trading as Taylor & Francis Group
2 Z. ZHOU ET AL.
Figure 1. Flow diagram of included and excluded participants.
critical in China, where loneliness is relatively prevalent
among older adults due to the increasing ‘empty-nest’ family
(Luo & Waite, 2014). Findings from the China National Survey
showed that the prevalence of loneliness among Chinese
elderly individuals was 15.6% in 1992 and 29.6% in 2002
(Yang & Victor, 2008). In addition, findings from a survey con-
ducted in the Anhui Province of China showed that 78.1% of
older adults in the rural area felt moderate to severe levels of
loneliness (Wang et al., 2011).
Therefore, this study was guided by two hypotheses:
(1) loneliness increases the risk of developing dementia and
(2) men who feel lonely are more likely to suffer from demen-
tia than women, after adjustment for social isolation, and
other potential confounders (sociodemographic characteris-
tics, lifestyle, and baseline health status) among older adults
aged 65 years and older.
Methods
Data and study population
Data were drawn from the Chinese Longitudinal Healthy Lon-
gevity Survey (CLHLS), a large nationally representative survey
conducted in waves over the following years: 1998, 2000,
2002, 2005, 2008/2009, and 2011/2012. The participants were
selected from 22 of 31 provinces in China in which 85% of the
total Chinese population resided. The 2008/2009 wave was
the first wave of the CLHLS to measure important risk factors,
such as intake of nuts and milk, which reportedly are associ-
ated with dementia risk (O’Brien et al., 2014; Ozawa et al.,
2014). Therefore, the latest two waves (2008/2009 and 2011/
2012) were selected to conduct a 3-year follow-up cohort
study. Duke University Health System’s Institutional Review
Board (IRB) members reviewed and approved this study.
Detailed information about the CLHLS study design can be
found elsewhere (Zeng, 2004).
In this study population, 16,954 participants were surveyed
at baseline (2008/2009). We excluded participants who
were under 65 years of age (n D 391), those who suffered
from dementia at baseline (n D 240), those who had incom-
plete information (n D 650), and those who died before 2011/
2012 from a cause other than dementia (n D 5243), and
those who were lost for 3-year follow-up (n D 2563). Data
from the resulting sample of 7867 participants were analyzed
(Figure 1).
Measurements
Dementia
The measurement of dementia was based on self- or proxy-
reported physician diagnosis in response to two questions:
(1) Are you suffering from dementia? (2)Have you been diag-
nosed with dementia by a physician? (Glymour & Avendano,
2009). Only those who answered ‘yes’ to both questions were
considered as incident dementia. We also included individuals
who suffered from dementia prior to death.
Loneliness
Loneliness was measured using one question (Holwerda et al.,
2014): ‘Do you often feel lonely?’ Response options included
‘never’, ‘seldom’, ‘sometimes’, ‘often’, and ‘always’. The item
was scored respectively on a scale ranging from 1 to 5, with
higher scores indicating greater loneliness.
Social isolation
People who lived alone, who were not married, or who lacked
social support was considered to be socially isolated (Hol-
werda et al., 2014). We dichotomized these three indicators in
this study. A social support index was administered based on
the type of social ties with four questions relating to talking
about daily life, expressing thoughts, being sick, and seeking
help (Feng, Hoenig, Gu, Yi, & Purser, 2010). When all four
responses were ‘no’, we regarded a participant as lacking
social support (coded 0). Otherwise, we considered the partic-
ipant to have social support (coded 1).
 AGING & MENTAL HEALTH 3

Covariates Table 1. Baseline characteristics of 7867 participants.

Among the sociodemographic characteristics, age was a con- Variables N (%)
tinuous variable, and female, rural, and institution were coded Loneliness
as binary variables (yes/no). Education was classified as illiter- Always 143 (1.82)
Often 462 (5.87)
ate (0) or literate (1). Sometimes 1748 (22.22)
Lifestyle, exercise, current smoking, and current drinking Seldom 2377 (30.21)
were coded as dichotomies (yes/no). Nut and milk intake fre- Never 3137 (39.88)
Social isolation
quency was coded as sometimes/rarely/never (0) or always/ Living alone 1309 (16.64)
often (1). Not being married 3326 (42.28)
For baseline health status, the Mini-Mental State Examina- Lack of social support 708 (9.00)
Sociodemographic characteristics
tion (MMSE) was used to assess cognitive functioning. The Age, mean(SD) 83.09 (10.92)
highest possible total score is 30, with lower scores indicating Female 4316 (54.86)
poorer cognitive functioning. Activities of daily living (ADL) Rural 4866 (61.85)
Education 3331 (42.34)
disability was measured using an adapted version of the scale Institution 105 (1.33)
that contains items relating to six daily tasks: dressing, eating, Lifestyle
toileting, bathing, indoor activities, and continence. Exercise 2566 (32.62)
Smoking 1565 (19.89)
Responses ranged from 1 (could do the activity indepen- Drinking 1532 (19.47)
dently) to 3 (unable to do the activity independently and Nut intake 1625 (20.66)
needed help all the time) (Wallace, 2007). When participants Milk intake 2696 (34.27)
Baseline health status
indicated that they were fully independent in performing all Stroke/Cerebrovascular diseases 417 (5.30)
tasks on the scale, we coded this as 0. Otherwise, it was coded Hypertension 1423 (18.09)
as 1. Information on stroke/cerebrovascular diseases, hyper- Diabetes 208 (2.64)
Cognitive function, mean(SD) 22.71 (8.38)
tension, and diabetes was determined similar to information ADL disability 900 (11.44)
on dementia. Note. ADL D activities of daily living.

Statistical analyses
Multiple logistic regression was used to examine whether
baseline loneliness was associated with dementia at 3-year
follow-up. We calculated odds ratios (ORs) with 95% confi-
dence intervals (CIs) for this relationship. Four models were
constructed in this study. We first tested the main effect of
loneliness on dementia risk after adjusting for social isolation
and sociodemographic characteristics (age, female, rural, edu-
cation, and institution) in model 1. Then, the lifestyle factors
(exercise, smoking, drinking, and nut and milk intake) were
entered into model 2. Baseline health status (stroke/cerebro-
vascular diseases, hypertension, diabetes, Cognitive function,
and ADL disability) were added to model 3 subsequently.
Finally, the interaction between loneliness and gender was
examined in model 4. Likelihood ratio tests were used to com-
pare the goodness of fit of these models.
Sensitivity analyses were performed to examine whether a
potential bias may be introduced by excluding those who
were lost to follow-up or dead. For the censored samples, we
assumed that people who had poor cognitive function (the
MMSE scores at baseline were under the 2SD below the mean
age-education-adjusted scores) when they left the study
would develop dementia in the next wave, reference to pervi-
ous research (Larson et al., 2006). The analyses were repeated
to test the robustness of the association between loneliness
and the incident dementia. Nine variables with missing data
(missing rate: minimum 0.01%, maximum 8.45%, and median
0.22%) were multiple imputed by NORM (Schafer & Olsen,
1998). All analyses were performed using Stata 13 (Stata Corp;
College Station, TX).
Results
Characteristics of the study population
Of the 7867 respondents at baseline, 131 had developed
dementia at follow-up, and 262 suffered from dementia
before death at 3-year follow-up. The characteristics of the
sample at baseline are shown in Table 1. Ranging from 65 to
111 years, the mean age of the participants was 83.09 years.
Nearly half of the participants (45.49%) were aged 85 years or
older. In addition, 54.86% of them were female. Of the partici-
pants, 60.12% felt different levels of loneliness. Only 39.88%
never felt lonely, 143 (1.82%) always felt lonely, and 462
(5.87%) often felt lonely. In addition, 1309 (16.64%) lived
alone, 3326 (42.28%) were not married, and 708 (9.00%)
lacked social support. Only 1.33% of them lived in an institu-
tion. Moreover, of the participants, 61.85% resided in rural,
42.34% were literate, and 32.62% exercised regularly. Less
than 20% of the participants reported smoking or drinking,
and 20.66% of them always/often ate nuts, whereas 34.27%
always/often drank milk. At baseline, the mean MMSE score of
the participants was 22.71 (SD, 8.38), approximately 5.30%
suffered from stroke/cerebrovascular diseases, and those who
reported hypertension, diabetes, and ADL disability were
18.09%, 2.64%, and 11.44%, respectively.
The association between loneliness and the risk of
dementia
The multiple logistic regression models that were developed
to predict dementia risk are presented in Table 2. The results
showed that the model fit was significantly improved in
model 2 compared to model 1 after adding lifestyle factors to
the model that included sociodemographic characteristics as
covariates (comparison of Models 1 and 2: Dx2 D 35.99, df D
5, p < 0.001). After adding baseline health status to model 3,
the Chi-square value was significantly higher than in model 2
(comparison of Models 2 and 3: Dx2 D 161.97, df D 5, p <
0.001). Then, the interaction effect of loneliness and gender
was added to model 4, and the result was also statistically sig-
nificant (comparison of Models 3 and 4: Dx2 D 4.05, df D 1,
p < 0.05). In the preliminary analyses, loneliness was nega-
tively related to dementia risk (OR D 1.22, 95% CI D 1.10–
1.35). This association was statistically significant even after
4 Z. ZHOU ET AL.

Table 2. Logistic regression analyses for the association between loneliness and cognitive function or ADL disability, and suffered from stroke/
incident dementia. cerebrovascular diseases were more likely to suffer from
Independent Odds ratio for dementia dementia than other participants.
variables Model 1 Model 2 Model 3 Model 4
Loneliness 1.22 1.22 1.15 1.31
Living alone 0.84 0.87 1.19 1.19 Sensitivity analyses
Not being married 1.33 1.30 1.24 1.22
Lack of social support 1.76 1.69 1.24 1.24 The results of sensitivity analyses showed that there were no
Age 1.07 1.06 1.03 1.03
Female 0.84 0.75 0.71 1.17
significant changes in the association between loneliness and
Rural 1.11 1.10 1.16 1.17 dementia risk (OR D 1.29, 95% CI D 1.11–1.50), and the inter-
Education 0.91 0.94 1.04 1.05 action of loneliness and gender (OR D 0.79, 95% CI D 0.65–
Institution 1.88 1.82 1.98 1.98
Exercise 0.61 0.75 0.76
0.95).
Smoking 0.85 0.89 0.90
Drinking 0.81 0.86 0.86
Nut intake 0.55 0.57 0.57 Discussion
Milk intake 1.41 1.19 1.19
Stroke/ 2.19 2.22 The aim of this study is to examine the relationship between
Cerebrovascular loneliness and dementia risk, and explored gender differences
diseases in the strength of this association among Chinese older adults
Hypertension 1.01 1.01
Diabetes 0.69 0.69 aged 65 years and older over a 3-year follow-up period. As

Cognitive function 0.95 0.95 with our hypothesis that feeling lonely contributed to a
ADL disability 2.36 2.37 higher risk of dementia, and the association between loneli-
LonelinessGender 0.81
Model x2 (df) 280.60 (9) 316.59 (14) 478.56 (19) 482.61 (20) ness and dementia risk varies by gender, even when sociode-
DModel x2 (df) 35.99 (5) 161.97 (5) 4.05 (1) mographic characteristics, lifestyle, and baseline health status
Note. ADL D activities of daily living; were taken into account.

p < 0.05; p < 0.01; p < 0.001. These findings are consistent with those of existing studies
(Holwerda et al., 2014; Wilson et al., 2007). Wilson et al. (2007)
controlling for lifestyle in model 2 (OR D 1.22, 95% CI D 1.10– examined the relationship between loneliness and dementia
1.35) and baseline health status in model 3 (OR D 1.15, 95% risk among 823 older people in and around Chicago and
CI D 1.04–1.28). The results for the three indicators represent- found that loneliness contributed to the risk of late-life
ing social isolation were inconsistent. Living alone, being dementia but was not the leading causes. Holwerda et al.
unmarried were not significantly associated with the risk of (2014) conducted a community-based 3-year follow-up cohort
dementia in both models 2 and 3. However, the association study to examine whether feeling lonely rather than being
between lack of social support and dementia risk was statisti- alone could advance the progression of dementia late in life.
cally significant in model 2 (OR D 1.69, 95% CI D 1.27–2.26), On the contrary, a 10-year cohort study including 650 subjects
but change to no statistical significance after adding baseline older than 75 years in Helsinki revealed that feelings of loneli-
health status to model 3 (OR D 1.24, 95% CI D 0.92–1.67). ness contributed to the risk of experiencing cognitive decline,
After adding the interaction between loneliness and gen- but the association was not significant at 1- or 5-year follow-
der to model 4, both the main effect of loneliness (OR D 1.31, up, possibly because of the relatively small sample size and
95% CI D 1.11–1.56) and the interaction effect (OR D 0.81, limited statistical power (Tilvis et al., 2004).
95% CI D 0.65–0.99) were statistically significant. That is, feel- The finding that loneliness could contribute to the risk of
ing lonely was associated with a greater dementia risk for dementia may be explained in several ways. First, loneliness
men than women (Figure 2). In addition, participants who was associated with the dysregulation of the hypothalamic-
were older, those who lived in an institution, did not exercise pituitary adrenocortical (HPA) axis, which contributed to
regularly, sometimes/rarely/never ate nuts, had poorer inflammatory processes that led to health damage (Hawkley

Figure 2. The interaction between loneliness and gender.


& Cacioppo, 2010). Second, loneliness may be a consequence
of preclinical dementia (Tilvis et al., 2004), through a behav-
ioral reaction to impaired cognition or an unobserved pathol-
ogy that leads to dementia (Wilson et al., 2007). And
loneliness that manifests as deteriorating social skills is part of
the personality change along with dementia (Sollberger et al.,
2009; Mahurin, DeBettignies, & Pirozzolo, 1991). In addition,
people who felt lonely may be more likely to engage in multi-
ple health-risk behaviors which, in turn, affect health out-
comes (Shankar, McMunn, Banks, & Steptoe, 2011).
Existing research has not examined gender differences in
the association between loneliness and dementia risk. In line
with the hypothesis (2), this study showed that the relation-
ship between loneliness and dementia was weaker in women
than in men. One possible explanation is that loneliness was
more strongly associated with adverse mental health condi-
tions in men, even though women were more inclined to feel
lonely than men (Holwerda et al., 2012; Zebhauser et al.,
2014). Lonely men are more likely to suffer from lower life sat-
isfaction and tend to be more depressed and less resilient
than lonely women (Zebhauser et al., 2014). Previous research
also indicated that the stress associated with loneliness could
bring about an inflammatory reaction, which may result in
higher mortality risk (Hermes, Rosenthal, Montag, & McClin-
tock, 2006; Holwerda et al., 2012). This inflammatory reaction
might occur in men only (Zebhauser et al., 2014). Another
possibility is that women have a greater capacity to buffer
loneliness than men (Zebhauser et al., 2014), perhaps because
women have more multifaceted networks that include close
friendships and neighbors, resulting in greater social support.
In contrast, men seek social contacted more in the public
spheres of organizational contexts, but they might rather
than serve those people who were met in this public situation
as confidants (Wellstead, 2011). In addition, feelings of loneli-
ness may lead to stress because of the absence of social inte-
gration (Burke & Segrin, 2014), and these are different
responses in men and women under stress. Previous study
have shown that, males in responses of stress are more char-
acterized by a pattern of ‘fight-or-flight’, but females always
react as ‘tend-and-befriend’, due to the gender differences in
hormone secretion and bio-behavioral mechanisms (Taylor
et al., 2000).
This study has several strengths. First, the data that we
used were collected from a highly representative sample of
Chinese older adults. The large sample size and high
response rate were adequate for the outcomes demon-
strated in this study. The fact that the study was launched in
a national population emphasizes the significance of our
findings for public health. Second, the interaction effect of
loneliness and gender on dementia was analyzed in this
study, and few studies have explored this effect. Conse-
quently, the different effects of loneliness on dementia risk
between men and women could be compared in a straight-
forward manner. In addition, our results further support the
development of a gender-specific policy aimed at prevent-
ing the onset of dementia.
Inevitably, this study also has limitations. First, incident
dementia is based on self- or proxy-reported, which may have
led to some bias. However, to a certain extent, the bias may
be alleviated by the second question ‘Have you been diag-
nosed with dementia by a physician?’ Previous studies have
shown a higher consistency between self-reported informa-
tion and clinical ascertainment (Glymour & Avendano, 2009;
AGING & MENTAL HEALTH 5
Macho n et al., 2013). Besides, the prevalence of self-reported
dementia in this study is parallel to that in China (Wu et al.,
2013) and countries in East Asia (Prince et al., 2015). Second,
only one item was used to measure loneliness in the CLHLS,
though several scales for measuring loneliness, such as the de
Jong-Gierveld Loneliness Scale or the UCLA Loneliness Scale,
were developed in previous studies (Dejonggierveld & Kam-
phuis, 1985; Russell, 1996). However, a single question or sim-
ple scale was found to be more suitable to investigate
loneliness in older adults (Victor, Grenade, & Boldy, 2006),
because it is difficult for older adults to understand the con-
cept of loneliness due to their diverse cultural backgrounds
and identities (Jylha, 2004; Victor et al., 2006). Third, because
of the lack of clinical classification of dementia in the CLHLS,
we were unable to account for the influence of subclasses of
dementia, such as Alzheimer’s disease (Wilson et al., 2007)
and vascular dementia. The subclasses might have impacted
the results of the study, such as the potential bias within the
strength of the association. Fourth, although we considered
as many available variables as possible which may associate
with incident dementia, residual confounding are still
unavoidable due to the absent of potential confounders, such
as depression, which is limited information in CLHLS. How-
ever, previous studies showed that the association between
feelings of loneliness and dementia may be at least partly
independent of depression (Wilson et al., 2007). Finally, due
to the relatively short follow-up period in this study, the possi-
bility of inverse causation could not be fully eliminated.
In conclusion, dementia as a serious disease that is incurable
at this point in time causes a severe economic and public
health burden. The results of our study indicated that feelings
of loneliness increased the risk of dementia even after control-
ling for social isolation and other potential confounders. More-
over, the strength of the association was stronger in men than
in women. These findings should be considered when devel-
oping intervention strategies to reduce the onset of dementia,
especially in men. Further research should clarify the pathway
between loneliness and dementia risk among older adults.
Moreover, longitudinal cohort studies with larger sample sizes
or longer duration of follow-up are needed to clarify the causal
relationship between loneliness and incident dementia, while
taking adequate confounding biases into account.
Acknowledgments
We would like to thank the Center for Healthy Aging and Develop-
ment Studies, Peking University for supporting this database. Data
used for this research was provided by the study entitled ‘Chinese
Longitudinal Healthy Longevity Survey’ (CLHLS) managed by the Cen-
ter for Healthy Aging and Development Studies, Peking University.
CLHLS is supported by funds from the U.S. National Institutes on
Aging (NIA), China Natural Science Foundation, China Social Science
Foundation, and UNFPA.
Disclosure statement
The authors declared no potential conflicts of interests with respect to the
authorship and/or publication of this article.
Funding
This work was supported by the National Natural Science Foundation of
China [Grant Numbers 81573257, 81602941]; the Natural Science Founda-
tion of Fujian Province of China [Grant Number 2016J0101]; U.S. National
Institutes on Aging (NIA); China Social Science Foundation; UNFPA.
6 Z. ZHOU ET AL.
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