Ageing Research Reviews 67 (2021) 101269

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Ageing Research Reviews

journal homepage: www.elsevier.com/locate/arr

Review

Is personality associated with dementia risk? A meta-analytic investigation

Damaris Aschwanden a, *, Jason E. Strickhouser a, Martina Luchetti a, Yannick Stephan b,
Angelina R. Sutin a, Antonio Terracciano a
a
Florida State University, Tallahassee, USA
b
Euromov, University of Montpellier, France

A R T I C L E I N F O A B S T R A C T

Keywords: This study provides a quantitative synthesis of the prospective associations between personality traits (neurot­
Personality traits icism, extraversion, openness, agreeableness, conscientiousness) and the risk of incident Alzheimer’s disease and
Dementia related dementias. We conducted five separate meta-analyses with 8–12 samples (N = 30,036 to 33,054) that
Alzheimer’s disease
were identified through a systematic literature search following the MOOSE guidelines. Higher neuroticism (HR
Meta-Analysis
Neuroticism
= 1.24, 95% CI [1.17, 1.31]) and lower conscientiousness (HR = 0.77, 95% CI [0.73, 0.81]) were associated with
Conscientiousness increased dementia risk, even after accounting for covariates such as depressive symptoms. Lower extraversion
(HR = 0.92, 95% CI [0.86, 0.97]), openness (HR = 0.91, 95% CI [0.86, 0.96]), and agreeableness (HR = 0.90,
95% CI [0.83, 0.98]) were also associated with increased risk, but these associations were less robust and not
significant in fully adjusted models. No evidence of publication bias was found. The strength of associations was
unrelated to publication year (i.e., no evidence of winner’s curse). Meta-regressions indicated consistent effects
for neuroticism, openness, and conscientiousness across methods to assess dementia, dementia type, follow-up
length, sample age, minority, country, and personality measures. The association of extraversion and agree­
ableness varied by country. Our findings indicate robust associations of neuroticism and conscientiousness with
dementia risk.

1. Introduction
Dementia is a leading cause of disability among older adults world­
wide (Alzheimer’s Association, 2017; Baumgart et al., 2015; Livingston
et al., 2017). The most common type of dementia is Alzheimer’s disease,
a progressive neurodegenerative disease that often begins with patho­
logical changes in the brain and then progresses to mild cognitive
impairment and dementia. Dementia is associated with considerable
physical, psychological, social, and economic burden on the individual,
their caregivers and families, and society at large (Alzheimer’s Associ­
ation, 2017; World Health Organization, 2019). As such, the World
Health Organization (WHO) recognizes dementia as a public health
priority (World Health Organization, 2019). The etiology of dementia is
complex and a broad range of risk factors across multiple domains
contribute to risk of developing the disease. These factors range from
genetic (e.g., ε4 variant of the apolipoprotein E; Deckers et al., 2015)
and sociodemographic (e.g., education; Baumgart et al., 2015) to envi­
ronmental (e.g., exposure to pollution; Peters et al., 2019) factors.
Within this continuum, a growing literature suggests that personality
traits are risk factors for Alzheimer’s disease and related dementias
(Chapman et al., 2019; Kaup et al., 2019; Terracciano et al., 2014;
Wilson et al., 2007). Personality refers to relatively enduring differences
in behaviors, thoughts, and feelings (Allemand et al., 2008; Costa and
McCrae, 1992; Löckenhoff et al., 2008). The Five-Factor Model (FFM)
organizes personality into five basic traits (Costa and McCrae, 1992):
neuroticism (the tendency to experience negative emotions and diffi­
culties with impulse control), extraversion (the tendency to be sociable,
energetic, and assertive), openness (the tendency to be creative and to
prefer variety), agreeableness (the tendency to be trusting, cooperative,
and altruistic), and conscientiousness (the tendency to be organized,
responsible, and disciplined). These individual differences are relatively
stable across most of the adult lifespan and predict important life out­
comes such as health (Strickhouser et al., 2017). Of the FFM personality
traits, neuroticism and conscientiousness emerge as the most important
predictors for cognitive health. Specifically, higher neuroticism and
lower conscientiousness have been associated with an increased risk of
developing Alzheimer’s disease (Duchek et al., 2019; Terracciano et al.,
2014) and dementia more generally (Kaup et al., 2019; Singh-Manoux

* Corresponding author at: Department of Geriatrics, College of Medicine, Florida State University, 1115 West Call Street, Tallahassee, FL, 32306, USA.
E-mail address: damaris.aschwanden@med.fsu.edu (D. Aschwanden).

https://doi.org/10.1016/j.arr.2021.101269
Received 16 June 2020; Received in revised form 8 September 2020; Accepted 2 February 2021
Available online 6 February 2021
1568-1637/© 2021 Elsevier B.V. All rights reserved.
D. Aschwanden et al.
et al., 2020). In a previous meta-analytic project, we found that not only
higher neuroticism and lower conscientiousness, but also lower open­
ness and agreeableness were associated with increased risk of Alz­
heimer’s disease (Terracciano et al., 2014). A few recent studies further
suggest that lower extraversion, openness, and agreeableness are related
to increased risk of incident dementia (Aschwanden et al., 2020;
Chapman et al., 2019; Duberstein et al., 2011; Singh-Manoux et al.,
2020; Terracciano et al., 2017b), but the findings for these traits are
mixed. It is also unclear whether there are factors that moderate these
associations.
Since our meta-analytic project in 2014 (Terracciano et al., 2014),
the published findings on personality and dementia have expanded
considerably. However, there has been no systematic attempt to assess
publication bias or to examine potential moderators of the meta-analytic
associations. The goal of this study is thus twofold: First, we aim to
provide an up-to-date estimation of the association between the FFM
personality traits and risk of incident all-cause dementia (hereafter,
“dementia” is used when referring to our outcome variable). The present
study of five meta-analyses with at least N = 30,036 individuals is six
times larger than the total samples examined previously (N = 5054;
Terracciano et al., 2014), which should provide more robust estimates of
effect sizes. Furthermore, our previous work focused on published
studies using a clinical diagnosis of Alzheimer’s disease. We expand on
this by including studies that (a) examined all causes of dementia (i.e.,
not just Alzheimer’s disease) and (b) applied cognitive cut-off scores to
classify dementia. Second, we aim to fill a major gap in the literature by
addressing potential publication bias and testing several potential
moderators. It is crucial to assess publication bias because it can lead to
overestimated effects and may suggest the existence of non-existing ef­
fects in meta-analysis (van Aert et al., 2019). It is also important to
examine factors that potentially moderate the meta-analytic associa­
tions since this provides insights in the robustness and generalizability of
the findings. Therefore, the current study tested whether the
meta-analytic associations vary by classification of dementia (clinical
diagnosis vs. cognitive cut-off score) and other important aspects, such
as follow-up time, year of publication, dementia type, country, average
age of the sample, proportion of minority, and personality measure.
Based on previous literature, we hypothesized that higher neuroti­
cism and lower conscientiousness would be associated with an increased
risk of incident dementia. We further expected lower openness and
agreeableness to be associated with increased dementia risk because we
found such associations when estimates were pooled across studies in
the previous meta-analytic project (Terracciano et al., 2014). We ex­
pected, however, stronger associations for neuroticism and conscien­
tiousness than for openness and agreeableness.
2. Methods
2.1. Meta-analyses
The meta-analyses were prepared in accordance with the MOOSE
recommendations for meta-analyses of observational studies (Stroup
et al., 2000). The MOOSE checklist can be found in the supplemental
material S2. The research question was formed using the PICO frame­
work (Schardt et al., 2007) with P (participants) = cognitively unimpaired
older adults at baseline; I (Intervention) = no intervention / exposure,
observational (cohort study); C (Comparison) = level of personality traits
(individual differences), and O (Outcome) = risk of incident Alzheimer’s
disease and all-cause dementia.
2.1.1. Eligibility criteria
Studies on the relation between personality and risk of dementia
were included if the following criteria were met: (1) Study design: Studies
were longitudinal. (2) Publication status: Studies were published in an
English language, peer-reviewed journal. (3) Measure of dementia:
Studies reported how dementia was assessed. Dementia classification
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Ageing Research Reviews 67 (2021) 101269
was through (a) clinical diagnosis, (b) neuropathological evaluation, or
(c) by a cut-off for cognitive performance. (4) Measure of personality:
Studies reported how personality was measured and assessed at least
one of the following traits: neuroticism, extraversion, openness, agree­
ableness, and/or conscientiousness.
2.1.2. Search strategy
A systematic literature search of five electronic databases covering
all years up to June 2020 was conducted. The databases searched were
MEDLINE provided by PubMed, Science Direct, Web of Science as well
as psycINFO and psycARTICLES provided by APA PsycNet. The search
terms used were personality OR personality traits OR neuroticism OR
conscientiousness OR extraversion OR openness OR openness to experience
OR agreeableness OR five factor OR big five AND dementia OR Alzheimer’s*.
Further, the reference lists of previous work were screened for additional
studies. A first researcher (DA) screened the titles and keywords of each
article for eligibility. Those meeting initial screening criteria were then
screened at the abstract level. If a study appeared to meet eligibility
criteria, full-text articles were obtained. The full text-articles of the
remaining studies were then independently assessed for inclusion by a
second researcher (AT). Discrepancies were discussed and resolved.
2.1.3. Statistical analysis
To reduce variability across studies, we generally chose the risk es­
timates from the main model, with age, gender, education, and race/
ethnicity as covariates. In addition, we conducted supplementary ana­
lyses with studies that accounted for depressive symptoms. Effects re­
ported as linear regression coefficients (Duchek et al., 2019) were
exponentiated to get the odds ratio.1 Effects reported as odds ratios
(Wilson et al., 2005) and risk ratios (Wilson et al., 2006) were directly
considered as hazard ratios (HRs). The HRs and confidence intervals
were inverted in one study that presented one unit decrease (vs. in­
crease) in personality traits in relation to dementia risk (Wang et al.,
2009). The log-transformed HR and standard error were scaled in five
studies (Johansson et al., 2014; Wang et al., 2009; Wilson et al., 2005,
2006, 2007) to correspond to the effect associated with a difference of
one standard deviation (1 SD) on the trait. Calculation of the pooled
mean effect size was conducted using random-effect model
meta-analyses. Between-study heterogeneity was quantified using tau2,
Hedges Q, and I2 statistics (Higgins et al., 2003). I2 ranges between 0%
and 100%, whereof values exceeding 50% were considered to represent
large heterogeneity (Bellou et al., 2017).
Given the lack of consensus around measures of publication bias, we
incorporated three strategies for its assessment. First, the distribution of
obtained effect sizes was examined in a funnel plot and the Egger’s test
for funnel plot asymmetry (Egger et al., 1997) was used to evaluate
whether the distribution was significantly asymmetrical. Second, we
applied a trim and fill procedure to obtain a bias-corrected estimate of
the overall effect (Duval and Tweedie, 2000). Third, the precision-effect
test and precision-effect estimate with standard errors (PET-PEESE;
Stanley and Doucouliagos, 2014) was used to estimate the effect size
that would be expected in a hypothetical study with a standard error of
zero. PET adjusts for small-study effects (i.e., the tendency of studies
with smaller samples to produce larger effect sizes) and assesses if there
is a true effect beyond publication bias. If PET is significant (i.e., indi­
cation of true effect), the additional PEESE provides a better estimate as
it corrects for a non-linear association between the reported effect size
1
Note that, for neuroticism and conscientiousness, Duckek and colleagues
(2019) report both regression coefficients and odds ratios in their article, but
for the remaining traits, only regression coefficients are provided (in supple­
mental material). To be consistent in the calculation across all traits, we
exponentiated the regression coefficients for all of them rather than taking the
odds ratios for neuroticism and conscientiousness and exponentiating the co­
efficients for the remaining traits.
D. Aschwanden et al.
and standard errors (Stanley and Doucouliagos, 2014). We also con­
ducted p-curve analyses (Simonsohn et al., 2015, 2014) to explore the
consistency and distribution of statistically significant results and to
distinguish whether significant findings were likely or unlikely to be the
result of selective reporting.
We followed up the meta-analyses with a series of meta-regressions
to help identify potential sources of heterogeneity when estimating
the pooled hazard ratios. First, we tested whether results differed be­
tween studies that used a clinical diagnosis to assess dementia compared
to studies that relied on cognitive performance, as the latter may include
more misdiagnosis. Second, we tested whether the associations were
moderated by the length of follow-up since the time interval could be
informative on the potential for reverse causation. Third, we tested
whether year of publication moderated the strength of the associations
because effect sizes tend to become smaller in later studies (Combs,
2010). Next, we tested whether the findings generalize to other de­
mentia types (Alzheimer’s disease vs. all-cause dementia) and samples
from other countries (USA vs. other) given our previous meta-analytic
Fig. 1. Flow diagram for identifying eligible studies. In the present meta-analytic investigation, 12 articles (results from 13 samples) were included.
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Ageing Research Reviews 67 (2021) 101269
work focused on Alzheimer’s disease and consisted of US samples only
(Terracciano et al., 2014). To further test the generalizability of our
findings, the following moderators were examined: age of the sample,
proportion of minority, and personality measure. The latter was grouped
by the two most common measures across the samples (i.e., NEO
Five-Factor Inventory (NEO-FFI) vs. not NEO-FFI and Midlife Develop­
ment Inventory (MIDI) Personality Scale vs. not MIDI). Except for year of
publication, all moderators were dichotomized to facilitate
meta-regressions.
The meta-analyses and meta-regressions were conducted using the
“metafor” package (Viechtbauer, 2010) in R software. The HR were
log-transformed, and their standard errors were computed from the re­
ported confidence intervals to conduct the analyses using “metafor”.
Z-scores were calculated by dividing the log-transformed HR by its
standard error (Dear et al., 2019) to enable the p-curve analyses. P-curve
analyses were conducted using the online app (version 4.06) provided at
http://www.p-curve.com/app4/.
D. Aschwanden et al.
3. Results
3.1. Literature search
Fig. 1 summarizes the screening procedure. A breakdown of the
database searches is provided in the supplemental material S1. The
literature search revealed 1740 total hits (abstracts). Two articles
(Wilson et al., 2006, 2005) were identified by screening the reference
list of our previous meta-analytic work (Terracciano et al., 2014) and a
recent article was identified as it comes from our research group
(Aschwanden et al., 2020). After title, keyword, and abstract screening,
the full texts of 23 articles were obtained. Thereof, the results from 13
cohorts were included in the present study and the number of included
samples varied across traits: neuroticism k = 12; extraversion k = 10;
openness k = 9; agreeableness k = 8; conscientiousness k = 9. Table 1
provides a summary of the characteristics of included samples.
3.2. Personality and dementia risk
The HR from each study and the pooled association are presented in
Table 2. By pooling the results from 12 studies, we found that for every
SD increase in neuroticism, the risk of dementia increased by 24% (HR =
1.24, 95% CI [1.17, 1.31], p < .001). Fig. 2 contains the forest plot
summarizing the individual study estimates for neuroticism. Of the 12
studies, 9 studies reported a significant association. Heterogeneity was
non-significant according to the Q-value and less than moderate refer­
ring to the I2-value (Q = 13.67, df = 11, p = .252; I2 = 13.29%).
For extraversion, the meta-analysis of 10 studies showed that higher
extraversion was associated with decreased dementia risk (HR = 0.92,
95% CI [0.86, 0.97], p = .004). Of these 10 studies, 2 studies reported a
significant effect (Fig. S1). Heterogeneity was non-significant according
to the Q-value and less than moderate referring to the I2-value (Q =
11.05, df = 9, p = .272; I2 = 19.64%).
We found a significant association for openness, such that open
people were at lower risk of dementia (HR = 0.91, 95% CI [0.86, 0.96], p
< .001). Of note, the association was significant in only 1 of the 9 studies
included in the meta-analysis (GEM, Duberstein et al., 2011; Fig. S2).
The Q and I2 values suggested homogeneity across studies (Q = 3.53, df
= 8, p = .897; I2 = 0%).
For agreeableness, the meta-analysis of 8 studies showed that
agreeable individuals were at lower risk of dementia (HR = 0.90, 95% CI
[0.83, 0.98], p = .014). Two of the 8 included studies reported signifi­
cant results (Fig. S3). Heterogeneity was non-significant referring to the
Q-value and less than moderate according to the I2-value (Q = 5.82, df =
6, p = .444; I2 = 46.16%).
Higher scores on conscientiousness were associated with reduced
risk of incident dementia (HR = 0.77, 95% CI [0.73, 0.81], p < .001). Of
the 9 included studies, 8 studies found a significant association (Fig. S4),
and there was no evidence of heterogeneity (Q = 5.46, df = 8, p = .708;
I2 = 0%).
3.2.1. Accounting for depressive symptoms
We conducted supplementary analyses with those studies that
accounted for depressive symptoms in addition to demographic factors,
and some of these studies also controlled for vascular and genetic risk
factors. Table S1 lists the covariates that were included in each study.
The number of included studies varied between traits: k = 6 for
neuroticism; k = 4 for extraversion; k = 3 for openness; k = 2 for
agreeableness; and k = 4 for conscientiousness. In all studies, depressive
symptoms were measured using a version of the Center for Epidemio­
logic Studies-Depression Scale, except in KPS and PPSW. In KPS,
depressive symptoms were assessed by self-reported problems such as
persistently feeling lonely or in a low mood. In PPSW, depression was
assessed using DSM-III criteria for major depressive disorders. The
supplementary analyses showed that higher neuroticism (HR = 1.13,
95% CI [1.04, 1.22]) and lower conscientiousness (HR = 0.80, 95% CI
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Ageing Research Reviews 67 (2021) 101269
[0.74, 0.86]) were still associated with increased dementia risk, but the
effects of the remaining traits were non-significant (see Table S1).
3.3. Publication bias
The Egger’s test, the trim and fill method, and the PET-PEESE found
no evidence of publication bias for all personality traits (Table 3). Fig. 3
shows the p-curve for neuroticism by displaying the 9 studies (out of 12)
that were statistically significant. The application excludes non-
significant results. The p-curve analysis provides information about
the evidential value: If the half p-curve test is right-skewed with p < .05,
or both the half and full test are right-skewed with p < .1, then p-curve
analysis indicates the presence of evidential value (Simonsohn et al.,
2015). For neuroticism, both conditions were met (p < .0001 and p
=0.0002, respectively; see supplemental material S3), suggesting
evidential value and providing reassurance that the significant findings
were unlikely to be the result of selective reporting. This was also the
case for conscientiousness (supplemental material S3). For the remain­
ing traits, no p-curve was calculated since there were only few signifi­
cant individual study results (Carter et al., 2019).
3.4. Meta-regressions
Across the eight moderators tested, two statistically significant ef­
fects were found (Table 4). Country moderated the association of de­
mentia risk with extraversion (HR = 0.88, 95% CI [0.90, 0.98], p = .019)
and agreeableness (HR = 1.15, 95% CI [1.03, 1.29], p = .015). The as­
sociation between higher extraversion and lower dementia risk was
statistically non-significant in American samples (HR = 0.98, 95% CI
[0.91, 1.05], p = .542), while it was significant in studies from other
countries (HR = 0.87, 95% CI [0.81, 0.93], p < .001). The opposite
pattern was found for agreeableness: Higher scores on this trait were
protective against dementia in US studies (HR = 0.85, 95% CI [0.80,
0.92], p < .001), but not in samples from other countries (HR = 0.93,
95% CI [0.75, 1.16], p = .535).
For all personality traits, the results were similar across dementia
classification, follow-up length, dementia type, age of sample, minority,
and personality measure. It is particularly worth noting that the asso­
ciations did not vary by classification of dementia. Follow-up analyses
showed that the effect sizes were comparable, although slightly stronger
for studies that relied on a clinical diagnosis. For example, for neuroti­
cism, the effects were HR = 1.26 (95% CI [1.16, 1.36], p < .001) in
studies using a clinical diagnosis and HR = 1.21 (95% CI [1.12, 1.30], p
< .001) in those using a cognitive cut-off to classify dementia. For
conscientiousness, the hazard ratios were HR = 0.75 (95% CI [0.69,
0.80], p < .001) in studies using a clinical diagnosis and HR = 0.80 (95%
CI [0.74, 0.85], p < .001) in those applying a cognitive cut-off.
4. Discussion
The meta-analytic results showed that higher neuroticism and lower
conscientiousness were associated with increased dementia risk. Lower
levels of extraversion, openness, and agreeableness were also related to
increased dementia risk, although to a weaker extent. The effects of
neuroticism and conscientiousness, but not for the other traits, remained
significant in models that further accounted for depressive symptoms.
There was no evidence for publication bias. The association of neurot­
icism, openness, and conscientiousness did not vary by the tested
moderators. Of note, the results were similar in studies that examined
Alzheimer’s disease compared to all-type dementia, and the results were
only slightly stronger in studies that used a clinical diagnosis compared
to ascertainment based on cognitive cut-off scores and medical records.
The findings for publication bias and meta-regressions will be discussed
in more detail below, followed by a discussion of possible explanations
for the personality-dementia associations and potential implications for
future research.
 D. Aschwanden et al.
Table 1
Characteristics of the Studies Included in the Meta-Analyses.
Study (Authors & Country N tot N Age M (SD) Female% Education M Minority Follow- Personality Personality Type of Dementia Covariates (main model)
Year) dem (SD) (%) up (M traits measure dementia classification
years)

Rush Biracial ( USA 1064 170 73.8 (9.6) 61.9 12.9 (6.3) 50.2 NA (max N NEO FFIc AD clinical age, sex, race, education,
Wilson et al., = 6) possession of an APOE-ε4
2005) allele, follow-up time
Rush MAP (Wilson USA 648 55 80.6 (6.9) 73.5 14.6 (2.9) 6.3 3 N NEO FFI AD clinical age, sex, education
et al., 2006)
a
Rush ROS (Wilson USA 904 176 73.5− 80.0 68.0− 71.0 17.8(3.4)- NA NA (max N, E, O, A, C NEO FFI AD neuropathologic age, sex, education
et al., 2007) (6.5)a 18.2(3.3)a = 12)
KPS (Wang et al., Sweden 506 144 83.0(3.2)- 69.6− 76.4a categorical NA NA (max N, E Eysenck dementia clinical age, sex, education, ApoE-
2009) 83.9(3.7)a = 6) ε4 status, cognitive
functioning, vascular
diseases, depressive
symptoms
GEM (Duberstein USA 767 116 78.6 (3.1) 41.9 categorical 8.2 6 N, E, O, A, C NEO FFI AD, vascular clinical age, gender, education,
et al., 2011) dementia race
BLSA (Terracciano USA 1671 90 56.5 (16.0) 49.4 16.7 (2.5) 29.3 12 N, E, O, A, C NEO PI-R AD clinical age, sex, ethnicity,
et al., 2014) education
PPSW (Johansson Sweden 800 153 38− 54 100 categorical NA NA (max N, E Eysenck all-type clinical age
et al., 2014) = 38) dementia, AD,
vascular
dementia
5

HRS (Terracciano USA 10,457 433 67.17 (9.23) 60 13.19 (2.66) 17 6.29 N, E, O, A, C MIDIc dementia cognitive cutoff age, sex, race, ethnicity,
et al., 2017b) education
HABC (Kaup et al., USA 875 125 75.1− 75.3 50 ordinal 47 6.9 O, C NEO FFI dementia clinical / no covariates
2019) (2.8)a cognitive cutoff
WashU (Duchek USA 436 47 65.9 (9.2) 57 15.8 (2.6) NA 6.95 N, C NEO-FFI AD clinical age
et al., 2019)
c
Whitehall II ( United 6136 118 69.59(5.78)- 30 ordinal 10 4.37 N, E, O, A, C MIDI dementia electronical age, sex, ethnicity, marital
Singh-Manoux Kingdom 75.38(4.97) health data status, education
et al., 2020)
ELSA (Aschwanden England 6887 252 65.65 (8.31) 56.2 3.26 (2.21)b 2.5 5.68 N, E, O, A, C MIDIc dementia cognitive cutoff / age, gender, ethnicity,
et al., 2020) self-report education
HILDA ( Australia 2778 52 60.90 (8.08) 54.7 1.55 (1.79)b 1 10.96 N, E, O, A, C Mini-Markers dementia cognitive cutoff / age, gender, ethnicity,
Aschwanden Saucier self-report education
et al., 2020)

Note. Rush Biracial = Rush Memory and Aging Biracial (White, African-Americans); Rush MAP = Rush Memory and Aging Project; Rush ROS = Rush Religious Order Study; KPS = Kungsholmen Project Stockholm; GEM =
Ginkgo Evaluation of Memory Study; BLSA = Baltimore Longitudinal Study of Aging; PPSW = Prospective Population Study of Women; HRS = Health Retirement Study; HABC = Health, Aging and Body Composition

Ageing Research Reviews 67 (2021) 101269

Study; WashU = Study conducted at Washington University in St. Louis; Whitehall II = Whitehall II Study; ELSA = English Longitudinal Study of Aging; HILDA = Household, Income and Labour Dynamics in Australia; Ntot
= total sample size; Ndem = number of incident dementia cases; M = mean; SD = standard deviation; NA = not applicable (information not found); N = neuroticism; E = extraversion; O = openness; A = agreeableness; C =
conscientiousness; NEO FFI = NEO Five Factor Inventory; NEO PI–R = Revised NEO Personality Inventory; MIDI = Midlife Development Inventory; AD = Alzheimer’s disease. If type of dementia is not specified here, the
original study used dementia more generally as outcome variable. Risk estimates from the main model were used (with age, gender, education, and race/ethnicity as covariates). In two studies, the main model also
included APOE-ε4 allele status and follow-up time (Rush Biracial) or vascular diseases, depressive symptoms, and cognitive functioning (KPS). In two other studies, the main model consisted of age, gender, and education
only (Rush MAP, ROS). In two further studies, we chose the model with age only (PPSW, WashU) and without covariates (HABC), respectively, because their further models were adjusted for various behavioral and health
variables (e.g., smoking, hypertension). a is not provided for the total sample, participants were categorized into groups for use in descriptive statistics; b on a scale from 0 to 6; c only four items were used to assess
neuroticism.
D. Aschwanden et al. Ageing Research Reviews 67 (2021) 101269

Table 2
Risk of Incident Dementia Associated with Personality Traits Reported in Each Study, Meta-Analytical Effect Sizes, and Heterogeneity.
HR 95% CI [LL, UL]
Study Sample size
N E O A C

Rush Biracial 1064 1.338 [1.065, 1.682]a – – – –

Rush MAP 648 1.480 [1.143, 1.918] – – – –
Rush ROS 904 1.192 [1.008, 1.409] 1.093 [0.911, 1.312] 0.905 [0.759, 1.081] 0.899 [0.764, 1.059] 0.812 [0.693, 0.951]
KPS 506 1.078 [0.892, 1.303] 0.834 [0.693, 1.003] – – –
GEM 767 1.390 [1.160, 1.670] 0.900 [0.740, 1.080] 0.780 [0.640, 0.950] 0.860 [0.710, 1.040] 0.760 [0.630, 0.930]
BLSA 1671 1.371 [1.085, 1.733] 0.860 [0.687, 1.077] 0.889 [0.708, 1.117] 0.858 [0.680, 1.083] 0.692 [0.549, 0.873]
PPSW 800 1.095 [0.936, 1.282] 0.936 [0.790, 1.107] – – –
HRS 10,457 1.180 [1.070, 1.300] 0.980 [0.890, 1.090] 0.940 [0.860, 1.040] 0.830 [0.750, 0.910] 0.800 [0.730, 0.880]
HABC 875 – – 0.890 [0.740, 1.060] – 0.750 [0.640, 0.890]
WashU 436 1.250 [0.894, 1.740] 1.112 [0.802, 1.542] 0.995 [0.712, 1.388] 0.918 [0.658, 1.278] 0.634 [0.457, 0.881]b
Whitehall II 6136 1.320 [1.160, 1.490] 0.850 [0.750, 0.970] 0.940 [0.830, 1.070] 1.080 [0.940, 1.250] 0.720 [0.640, 0.810]
ELSA 6887 1.199 [1.054, 1.364] 0.867 [0.770, 0.976] 0.892 [0.787, 1.010] 0.964 [0.852, 1.090] 0.814 [0.723, 0.915]
HILDA 2778 1.641 [1.143, 2.355] 0.758 [0.505, 1.137] 0.895 [0.593, 1.351] 0.685 [0.491, 0.956] 0.788 [0.538, 1.155]
Meta-analytic results
k (Ntot / Ndem) 12 (33,054 / 1806) 10 (31,342 / 1581) 9 (30,911 / 1409) 8 (30,036 / 2528) 9 (30,911 / 1409)
random model 95% CI [LL, UL] 1.236 [1.151, 1.327] 0.949 [0.879, 1.024] 0.909 [0.863, 0.959] 0.901 [0.829, 0.979] 0.771 [0.734, 0.811]
z (p-value) 5.85 (<.001) − 1.35 (0.176) − 3.54 (<.001) − 2.45 (0.014) − 10.14 (<.001)
tau2 0.01 0.01 0.00 0.01 0.00
I2 (in%) 46.59 48.30 0.00 46.16 0.00
Q (p-value); df 20.24 (0.042); 11 17.05 (0.048); 9 3.53 (0.897); 8 13.14 (0.069); 7 5.46 (0.708); 8

Note. Rush Biracial = Rush Memory and Aging Biracial (White, African-Americans); Rush MAP = Rush Memory and Aging Project; Rush ROS = Rush Religious Order
Study; KPS = Kungsholmen Project Stockholm; GEM = Ginkgo Evaluation of Memory Study; BLSA = Baltimore Longitudinal Study of Aging; PPSW = Prospective
Population Study of Women; HRS = Health Retirement Study; HABC = Health, Aging and Body Composition Study; WashU = Study conducted at Washington
University in St. Louis; Whitehall II = Whitehall II Study; ELSA = English Longitudinal Study of Aging; HILDA = Household, Income and Labour Dynamics in Australia;
HR = hazard ratio; 95% CI = 95% confidence intervals, LL and UL indicate the lower and upper limits of the confidence intervals; N = neuroticism; E = extraversion; O
= openness; A = agreeableness; C = conscientiousness; k = number of studies; Ntot = total sample size; Ndem = number of total incident dementia. Between-study
heterogeneity was quantified using tau2, Q and I2 values (Higgins et al., 2003). However, these statistics tend to be underpowered in view of the small numbers of
studies and inference about heterogeneity should be made with caution. a To scale the log-transformed HR and standard error in Rush Biracial (Wilson et al., 2005), we
assumed that their reported SD = 11.3 resulted from an outlier or data entry error and used SD = 5 as done by Terracciano et al. (2014). The gist of results did not
change when using the adapted versus the originally reported SD. b The OR provided for conscientiousness in WashU (Table 4 in Duchek et al., 2019) is in the wrong
direction; the absolute value was taken before exponentiating (J. M. Duchek, personal communication, June 30, 2020). We included the corrected OR for consci­
entiousness, that is, OR = .634, 95% CI [.457, .881].

Fig. 2. Forest plot for neuroticism. The plot

summarizes the individual study estimates and
the average effect of the random-effects (RE)
model. Effect sizes are displayed in hazard ratios
with corresponding 95% confidence intervals
(95% CI). Rush Biracial = Rush Memory and
Aging Biracial (White, African-Americans);
Rush MAP = Rush Memory and Aging Project;
Rush ROS = Rush Religious Order Study; KPS =
Kungsholmen Project Stockholm; GEM =
Ginkgo Evaluation of Memory study; BLSA =
Baltimore Longitudinal Study of Aging; PPSW =
Prospective Population Study of Women; HRS =
Health Retirement Study; WashU = Study con­
ducted at Washington University in St. Louis;
Whitehall II = Whitehall II Study; ELSA = En­
glish Longitudinal Study of Aging; HILDA =
Household, Income and Labour Dynamics in
Australia.

4.1. Publication bias
Publication bias is a major threat to the validity of every meta-
analysis as it can lead to overestimated effect sizes and the dissemina­
tion of false-positive results (Nuijten et al., 2015). Based on the tests
used in the present meta-analyses, we found no evidence for biases in the
personality-dementia literature and the significant results were unlikely
to be due to selective reporting for neuroticism and conscientiousness.
These findings, however, should be interpreted with caution because
these methods have reduced statistical power when <10 effect sizes are
examined (Sterne et al., 2011; van Aert et al., 2019). Nevertheless, it
could be that the personality-dementia literature is less affected by
publication bias because many studies examined more than one per­
sonality trait and therefore non-significant effects may be more likely to

6
D. Aschwanden et al. Ageing Research Reviews 67 (2021) 101269

Table 3 be published. In the present meta-analytic investigation, for example, 10

Publication Bias. studies investigated both neuroticism and extraversion and conse­
Estimate (p-value) quently reported not only the significant effects for neuroticism but also
Test the non-significant results for extraversion.
N E O A C

Trim and Fill 1.209 0.919 0.909 0.954 0.779

/ Egger’s (0.099) (0.890) (0.427) (0.749) (0.179) 4.2. Moderators
PET-PEESE 1.095 0.927 0.943 0.933 0.791
(0.099) (0.890) (0.427) (0.749) (0.231)
The meta-analyses indicated a high degree of consistency across
Note. N = neuroticism; E = extraversion; O = openness; A = agreeableness; C = studies for all personality traits. In view of the small numbers of studies,
conscientiousness. Publication bias was examined via Egger’s regression test for however, heterogeneity should be interpreted with caution. Given the
funnel plot asymmetry (Egger et al., 1997), the trim and fill method of adjusting
limited heterogeneity across studies, it was not surprising that the meta-
for publication bias (Duval and Tweedie, 2000), and the precision-effect test and
regressions only identified one factor (country) that significantly
precision-effect estimate with standard errors (PET-PEESE; Stanley and Dou­
couliagos, 2014).
moderated the meta-analytic results. While there was no statistically
significant association between higher extraversion and lower dementia
risk in American samples, a significant association was found in samples
from other countries. Specifically, the two studies that reported a sig­
nificant result came from the United Kingdom (Whitehall II) and En­
gland (ELSA). The association of agreeableness with dementia risk was
statistically significant in some US studies (i.e., HRS) but not in samples
from other countries (except Australia; HILDA). More research is needed
to clarify whether the association of extraversion and agreeableness
varies across different countries.
No further significant meta-regressions were found. These null
findings address substantive questions on the robustness of the associ­
ations. First, we found no significant differences between studies that
used a clinical diagnosis versus a cognitive cut-off to classify dementia,
although the effect sizes were slightly smaller for the population-based
panel studies that relied on cognitive performance. A clinical demen­
tia diagnosis is the gold standard that is normally done by health pro­
fessionals after an in-depth neuropsychological examination that
includes a structured medical history, neurological examination, infor­
mant reporting, and cognitive testing. This level of detail is often beyond
the capability of large population-based panel studies. In such studies, it
is more likely that dementia is classified based on cognitive performance
Fig. 3. P-curve for neuroticism. The observed p-curve includes 9 statistically only. Although the applied cognitive cut-offs are often validated against
significant (p < .05) results, of which 8 are p < .025. There were 3 additional a diagnosis based on DSM-III-R criteria, as in HRS (Crimmins et al.,
results entered but excluded from p-curve because they were p > .05. The p- 2011), they might be more prone to misdiagnosis or be less reliable
curve analysis provides information about the evidential value: If the half p- considering that variability in cognitive performance increases with
curve test is right-skewed with p < .05, or both the half and full test are right-
cognitive decline (Weir et al., 2011). In light of the aging population,
skewed with p < .1, then p-curve analysis indicates the presence of evidential
however, it is important to have ways to ascertain cognitive impairment
value (Simonsohn et al., 2015). Here, both conditions were met (p < .0001 and
that are less costly than neuropsychological examinations and more
p =0.0002, respectively; see supplemental material S3), suggesting evidential
value and providing some reassurance that the significant findings were un­ precise than population surveys (Crimmins et al., 2011; Weir et al.,
likely to be the result of selective reporting. 2011). The potential loss of power due to misclassification seems to be
compensated by the large and more diverse samples recruited by
population-based panel studies.
The length of follow-up did not affect the meta-analytic associations

Table 4
Findings from Meta-Regressions.
HR 95% CI [LL, UL]
Moderators
N E O A C

Dementia classification 0.967 [0.864, 1.083] 1.028 [0.905, 1.167] 1.035 [0.932, 1.151] 0.928 [0.784, 1.099] 1.066 [0.964, 1.179]
Follow-up length 0.977 [0.859, 1.110] 1.052 [0.919, 1.204] 0.986 [0.854, 1.139] 0.909 [0.750, 1.101] 1.003 [0.876, 1.149]
Year of publication 1.000 [0.989, 1.011] 0.993 [0.980, 1.006] 1.005 [0.992, 1.019] 1.006 [0.988, 1.025 0.997 [0.985, 1.009]
Dementia type 1.070 [0.946, 1.210] 1.127 [0.969, 1.311] 1.005 [0.873, 1.157] 0.983 [0.809, 1.195] 0.969 [0.848, 1.107]
Country 0.948 [0.842, 1.067] 0.885* [0.799, 0.980] 1.008 [0.904, 1.125] 1.153* [1.028, 1.292] 0.990 [0.892, 1.097]
Age 1.006 [0.866, 1.169] 1.041 [0.887, 1.221] 1.023 [0.832, 1.258] 1.166 [0.918, 1.481] 1.082 [0.881, 1.328]
Minority 1.105 [0.927, 1.317] 0.935 [0.728, 1.201] 0.975 [0.837, 1.135] 0.948 [0.702, 1.280] 0.938 [0.812, 1.084]
NEO-FFI 0.918 [0.816, 1.032] 0.905 [0.774, 1.058] 1.074 [0.950, 1.213] 1.029 [0.840, 1.261] 0.992 [0.885, 1.112]
MIDI 1.023 [0.910, 1.151] 1.000 [0.880, 1.137] 0.935 [0.834, 1.047] 0.902 [0.757, 1.074] 0.986 [0.886, 1.097]

Note. HR = hazard ratio; 95% CI = 95% confidence intervals, LL and UL indicate the lower and upper limits of the confidence intervals; N = neuroticism; E = ex­
traversion; O = openness; A = agreeableness; C = conscientiousness. Moderator effects were explored for dementia classification (dementia based on clinical diagnosis
vs. cognitive performance), follow-up length (mean above or below 10 years), year of publication (continuous variable), dementia type (dementia vs. Alzheimer’s
disease), country (USA vs. other), age of sample (mean age above or below 65), minority (mean percentage above or below 20%), and personality measure grouped by
the two most common measures across the samples (i.e., NEO-FFI vs. not NEO-FFI and MIDI vs. not MIDI).
*
p < 0.05.

7
D. Aschwanden et al.
(see also Terracciano et al., 2017). This finding is contrary to expecta­
tions from the reverse causality hypothesis that assumes personality is
changed by the underlying neuropathology in the prodromal phase of
the disease. If that were the case, the association between personality
and risk of dementia would be stronger among studies with a shorter
follow-up (with a shorter follow-up, the assessment of personality is
closer to the onset of dementia).
Year of publication did not moderate the meta-analytic findings. This
is particularly reassuring and contrary to the winner’s curse pattern of
later published studies tending to find increasingly smaller effects
(Combs, 2010).
We found no differences between studies that focused on Alzheimer’s
disease and those that used dementia more generally as an outcome.
Future studies, however, are still needed to investigate whether per­
sonality traits can help in differential diagnosis, especially for fronto­
temporal dementia or Lewy body dementia.
Finally, neither the average age nor the proportion of minority of the
samples influenced the results. Thus, across the adult life span and
across races/ethnicities, personality shared the same relations with de­
mentia risk. Likewise, personality-dementia associations were not
moderated by the personality measure used, which indicates that the
same pattern of associations holds across the two most common FFM
questionnaires, again supporting the robustness of the findings.
4.3. Potential mechanisms between personality traits and dementia risk
A recent review (Segerstrom, 2018) discussed four models that could
explain the observed associations between personality and risk of de­
mentia: common cause (e.g., through a common gene), spectrum (e.g.,
reflecting an early symptom), pathoplastic (e.g., conferring resilience to
neuropathology), and predisposition (e.g., through health behaviors).
The common cause model proposes that genes that affect personality
phenotype also affect dementia risk. Current evidence, however, sug­
gests that the relatively small genetic effects are unlikely to play a major
role in the association between personality and dementia (Luciano et al.,
2018; Stephan et al., 2018), thereby weakening evidence for this model.
The spectrum model suggests that personality is a prodrome or other
subclinical symptom of dementia. After the onset of dementia, it is
common to observe personality change (Siegler et al., 1994). For
example, a meta-analysis found large (>1 SD) declines in conscien­
tiousness and extraversion as well as increases in neuroticism from the
premorbid to current state in patients with cognitive impairment (Islam
et al., 2019). Whilst these findings support personality change during the
disease, personality does not appear to reflect a symptom before the
onset of cognitive impairment: Changes in personality were not signif­
icantly different between individuals who later did or did not develop
dementia in a longitudinal study that focused on the preclinical phase
(Terracciano et al., 2017a). Moreover, personality in adolescence, a life
stage presumably free from dementia related neuropathology, predicted
dementia risk almost five decades later (Chapman et al., 2019).
Although these findings indicate that the spectrum model is less likely,
the temporal evolution of personality change across the different phases
of dementia needs to be further clarified.
It seems more likely that personality has a predisposing or patho­
plastic relationship to dementia risk. The pathoplastic model suggests
that personality influences the presentation or course of dementia, such
that personality may contribute to resilience against neuropathology
and allows one to bear more neuropathology before experiencing
symptoms (Graham et al., 2020; Terracciano et al., 2013).
The predisposition model proposes that personality shapes dementia
risk through a cascade of effects on proximal behaviors and health
conditions. For instance, higher neuroticism and lower conscientious­
ness are associated with a worse health profile, physical inactivity,
obesity, smoking, depression, and lower education, which are risk fac­
tors for incident dementia (Bogg and Roberts, 2004; Chapman et al.,
2011; Hampson et al., 2007; Sutin et al., 2018, 2011, 2010; Terracciano
8
Ageing Research Reviews 67 (2021) 101269
et al., 2008). Moreover, cognitive engagement could be an underlying
mechanism between openness and dementia risk. Open individuals can
be described as intellectually engaged, curious, and imaginative, and
they tend to perform well on cognitive tasks (Curtis et al., 2015; Luchetti
et al., 2016). They also tend to engage in a variety of activity types such
as cognitive, social and physical activities (Stephan et al., 2014). The
engagement in cognitive and other activities may positively contribute
to cognitive reserve and protect against dementia (Chapman et al., 2012;
Gow et al., 2005; Sharp et al., 2010). Likewise, being agreeable and
extraverted could ease the formation and stability of social networks
that in turn might reduce risk of dementia (Bennett et al., 2006; Crooks
et al., 2008).
Finally, personality has not only been linked to behaviors and health
conditions, but also to dementia-related biomarkers. Although the
literature on personality and biomarkers of Alzheimer’s disease and
related dementias is limited, recent studies have found some converging
evidence that neuroticism is associated with measures of tau neurofi­
brillary tangles: A neuropathology study reported that individuals with
higher neuroticism were more likely to have advanced stages of tau
neurofibrillary tangles at autopsy (Terracciano et al., 2013). Similarly,
in samples of cognitively healthy older adults or adults in the early
stages of Alzheimer’s disease, higher neuroticism was associated with
higher tau measured using in vivo positron emission tomography or
cerebral spinal fluid (Duchek et al., 2019; Schultz et al., 2019). There is
also evidence that higher neuroticism and lower conscientiousness are
associated with reduction in regional brain volumes (Bjørnebekk et al.,
2013; Jackson et al., 2011). Furthermore, lower conscientiousness has
been linked to brain-tissue loss and other measures of brain integrity
(Booth et al., 2014).
More knowledge about the amount of neuropathological burden is
needed to differentiate between the pathoplastic and the predisposition
model. If personality is linked to better cognitive function despite
burden, the pathoplastic model would be favored (because personality
affects the appearance or severity of dementia). If personality is related
to reduced burden, the predisposition model would be favored (because
personality reduces dementia risk directly or through other variables).
Some evidence suggests a pathoplastic effect of neuroticism and a pre­
disposing effect of conscientiousness (Segerstrom, 2018), but further
research is needed to explain the personality-dementia associations.
4.4. Potential implications, strengths, and limitations
Based on the present findings, two main implications for future
research arise. First, the meta-analytic effect sizes for personality traits
were comparable with those of other health and behavioral factors
related to cognitive impairment and dementia, such as diabetes (RR =
1.18, 95% CI [1.02, 1.36]; Xue et al., 2019), hypertension (HR = 1.59,
95% CI [1.20, 2.11]; Sharp et al., 2011), physical activity (RR = 0.76,
95% CI [0.66, 0.86]; Blondell et al., 2014), cigarette smoking (RR =
1.30, 95% CI [1.18,1.45]; Zhong et al., 2015), low-to-moderate alcohol
drinking (RR = 0.74, 95% CI [0.61, 0.91]; Anstey et al., 2009), or
late-life BMI (RR = 0.83, 95% CI [0.74, 0.94]; Pedditizi et al., 2016). Of
note, the HABC study (Kaup et al., 2019) accounted for many of these
factors (i.e., depressive symptoms, hypertension, myocardial infarction,
diabetes, stroke; see Table S1) and still found a significant effect of
conscientiousness. In another study (Johansson et al., 2014), the hazard
ratio of neuroticism did not change in the fully adjusted model that
included hypertension, coronary heart disease, smoking, BMI, depres­
sion, age, and education (HR = 1.10, 95% CI [0.94, 1.28]) compared to
the main model that controlled for age only (HR = 1.10, 95% CI [0.91,
1.31]). Although the hazard ratio was non-significant in both models, it
went in the expected direction and the strength of association did not
change when accounting for clinical factors. This underlines the
importance of personality and indicates that personality should be
considered when identifying at-risk individuals. Using web-based
questionnaires, it is possible to inexpensively screen people in the
D. Aschwanden et al.
community and identify those with scores high on neuroticism and low
on conscientiousness (Chapman et al., 2014; Lahey, 2009). These in­
dividuals might benefit most from inclusion in preventive interventions.
The development of innovative personality-tailored interventions is now
necessary to move the field forward and test whether individuals high on
neuroticism and low on conscientiousness respond well to such in­
terventions. Likewise, recent research indicates that it might be possible
to change personality traits, such as reducing maladaptive aspects of
neuroticism through interventions (Chapman et al., 2014; Roberts et al.,
2017; Rüegger et al., 2017; Stieger et al., 2020). If such changes are
enduring, interventions that target personality could be incorporated
into dementia prevention and eventually into the clinical context.
Second, we identified country as moderator for the associations of
extraversion and agreeableness with dementia risk. These results may
inspire future studies to conduct preregistered replication efforts to
establish these associations and further investigate potential cross-
cultural differences. Related to this issue, there is a great need for
more studies, particularly in low-income and middle-income countries
where approximately two thirds of people with dementia worldwide live
in and the potential of dementia prevention is large (Anstey et al., 2019;
Mukadam et al., 2019).
Strengths of this work include the systematic approach to study
identification, the consideration of publication bias, and the exploration
of potential moderator variables. Nevertheless, all meta-analytic tech­
niques have limitations and should be used only to understand broad
trends in a particular field (Carter et al., 2019). Specifically, the
following issues should be considered when interpreting the present
findings. First, we did not attempt to identify unpublished studies and
we only included studies that were published in English. We were
further unable to include relevant studies that used other research de­
signs (e.g., case-control), but evidence from these studies tends to show
similar conclusions (Crowe et al., 2006). Most of the included studies did
not specify the type of dementia beyond Alzheimer’s disease and we thus
could only test whether findings differ between Alzheimer’s disease and
all-cause dementia. It would be interesting to validate our findings
regarding different etiologies of dementia (e.g., vascular dementia,
frontotemporal dementia). Although the number of included individuals
was relatively high for all five traits (ranging from N = 30,036 for
agreeableness to N = 33,054 for neuroticism), the number of studies was
relatively small (ranging from k = 8 for agreeableness to k = 12 for
neuroticism), which reduced statistical power to examine publication
bias and sources of heterogeneity.
4.5. Conclusion
Overall, the present work confirms consistent associations of
neuroticism and conscientiousness with risk of dementia. The associa­
tions of the remaining traits were also significant but less robust. We
found no evidence of publication bias, suggesting no systematic over- or
under-estimation of the estimated effects. Moreover, there was limited
evidence of heterogeneity and the associations were consistent across
studies that used different methods to assess dementia, follow-up length,
publication year, dementia type, age of the sample, proportion of mi­
nority, and personality measure. Studies are now needed to determine
whether and how neuroticism and conscientiousness could be incorpo­
rated into interventions for dementia prevention.
Funding
This work was supported by the National Institute on Aging of the
National Institutes of Health (Grant Numbers R21AG057917 and
R01AG053297). The content is solely the responsibility of the authors
and does not necessarily represent the official views of the National
Institutes of Health.
The authors declare no potential conflicts of interest concerning the
research, the authorship, and publication of this article.
9
Ageing Research Reviews 67 (2021) 101269
CRediT authorship contribution statement
Damaris Aschwanden: Conceptualization, Methodology, Formal
analysis, Investigation, Data curation, Writing - original draft, Visuali­
zation. Jason E. Strickhouser: Methodology, Formal analysis, Data
curation, Writing - review & editing, Visualization. Martina Luchetti:
Writing - review & editing. Yannick Stephan: Writing - review &
editing. Angelina R. Sutin: Conceptualization, Writing - review &
editing, Supervision. Antonio Terracciano: Conceptualization, Meth­
odology, Formal analysis, Investigation, Data curation, Writing - orig­
inal draft, Writing - review & editing, Supervision.
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.arr.2021.101269.
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