Archives of Gerontology and Geriatrics 60 (2015) 196–200

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Archives of Gerontology and Geriatrics

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

Cognitive function and associated factors among older people

in Taiwan: Age and sex differences
Cheng-Lun Li a, Hui-Chuan Hsu a,b,*
a
Department of Health Care Administration, Research Center on Health Policy and Management, Asia University, No. 500, Lioufeng Road, Wufeng,
Taichung 41354, Taiwan
b
Department of Medical Research, China Medical University Hospital, China Medical University

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

Article history: Purpose: The aim of this study was to examine cognitive function and the risk and the protective factors
Received 31 October 2013 by age and sex among Taiwanese older people.
Received in revised form 6 October 2014 Methods: The data were from a nation-representative panel of older people in Taiwan. The participants
Accepted 7 October 2014
completing both the 2003 and 2007 waves were included for analysis in this study (n = 3228).
Available online 17 October 2014
Descriptive analysis and generalized linear model were applied, and the samples were stratified by age
groups and by sex.
Keywords:
Results: The factors related to higher cognitive function at the intercept included being younger, male,
Cognitive function
higher education, and doing unpaid work. At the time slope, the age effect and physical function
Longitudinal study
Older adults difficulties would reduce the cognitive function across time, while education and providing
Age difference informational support would increase the cognitive function across time. There were age- and sex-
Gender difference differences in the factors related to cognitive function, particularly on the working status and social
participation.
Conclusion: Different health promotion strategies to target these populations should be accordingly
developed.
ß 2014 Elsevier Ireland Ltd. All rights reserved.

1. Introduction cognitive function (Fernandez Martinez et al., 2008; Matthews

Cognitive impairment has significant negative impacts for older
people. Dementia or severe cognitive impairment not only affects
the quality of life for older people but also causes a heavy burden
for their families and increases medical costs for society. Only
when the cognitive impairment is mild is it possible to prevent
worsening of the progression (Weimer & Sager, 2009). Previous
studies have explored the risk factors for cognitive function
impairment and the incidence of dementia (Burton, Campbell,
Jordan, Strauss, & Mallen, 2013; Loef & Walach, 2013; Teixeira
et al., 2012; Wang et al., 2010; Yen et al., 2010), and some studies
have tried to explored the changes in the cognitive function of
older people (Eisele et al., 2012; Matthews, Marioni, & Brayne,
2012; Piccinin et al., 2012; Yen et al., 2010). Furthermore, age and
sex have been demonstrated to be significant risk factors for
* Corresponding author at: Department of Health Care Administration,
Asia University, No. 500, Lioufeng Road, Wufeng, Taichung 41354, Taiwan.
Tel.: +886 4 23323456x1827; fax: +886 4 23332970.
E-mail address: gingerhsu@seed.net.tw (H.-C. Hsu).
et al., 2012; Piccinin et al., 2012; Proust-Lima et al., 2008; Yen et al.,
2010). The patterns and factors related to the cognitive function
over time in different age and sex groups have not been compared
thoroughly in the existing literature.
Previous studies have found factors related to cognitive
impairment among older people. The incidence of cognitive
impairment is related to being older, being female, and having a
lower education level (Kawas, Gray, Brookmeyer, Fozard, &
Zonderman, 2000; Miech et al., 2002; Sabia et al., 2009; Shadlen
et al., 2006; Yen et al., 2010). Certain chronic diseases are
associated with cognitive impairment, including diabetes, chronic
kidney disease, vascular diseases, and stroke (Duron & Hanon,
2008; Etgen, Chonchol, Forstl, & Sander, 2012; Gorelick, 2005;
Kilander, Nyman, Boberg, Hansson, & Lithell, 1998; Mok et al.,
2004; Muller, Grobbee, Aleman, Bots, & Van Der Schouw, 2007;
Okereke et al., 2008; Tzourio, 2007). Cognitive impairment is
associated with frailty (Auyeung, Lee, Kwok, & Woo, 2011; Boyle,
Buchman, Wilson, Leurgans, & Bennett, 2010; Curcio, Henao, &
Gomez, 2014; Faria Cde, Lourenco, Ribeiro, & Lopes, 2013; Han, Lee,
& Kim, 2014; Kilgour, Todd, & Starr, 2014; Shimada et al., 2013;
Samper-Ternent, Al Snih, Raji, Markides, & Ottenbacher, 2008). In

http://dx.doi.org/10.1016/j.archger.2014.10.007
0167-4943/ß 2014 Elsevier Ireland Ltd. All rights reserved.
 C.-L. Li, H.-C. Hsu / Archives of Gerontology and Geriatrics 60 (2015) 196–200
addition, social support and social engagement have been found to
influence cognitive function and dementia in old age (Zunzunegui,
Alvarado, Del Ser, & Otero, 2003), and social support may be a
stronger protective predictor for women than for men (Baumeister
& Sommer, 1997; Fratiglioni, Paillard-Borg, & Winblad, 2004).
In this study, we aimed to explore the cognitive function and
the factors related across time by age and sex in older Taiwanese
people. This study is expected to provide information about the
factors related to the cognitive function in older adults in different
groups and to enable the development of prevention/intervention
strategies.
2. Methods
2.1. Data and samples
The data were from the ‘‘Taiwan Longitudinal Study of Aging
(TLSA)’’. The samples of the TLSA were drawn from the elderly
population with multi-stage proportional probability sampling,
initiated with a sample of 4049 older people aged 60 years or more
in 1989. The samples were face-to-face interviewed from 1989 to
2007, every 3 or 4 years. Supplemental samples aged 50–66 years
were added to the cohort in 1996 and in 2003. In this study, the
data from 2003 to 2007 were used. Only those participants who
completed both the 2003 and 2007 waves were included in the
analysis. Overall, the sample size was 3226 individuals.
2.2. Measures
2.2.1. Dependent variable
Cognitive function was measured by the Short Portable Mental
Status Questionnaire (SPMSQ) (Pfeiffer, 1975) in both 2003 and
2007. There were only eight items available in both waves, and the
8-item scale has been applied and validated (Purser, Fillenbaum,
Pieper, & Wallace, 2005; Yen et al., 2010). Thus, the 8 items as used
as the measures of cognitive function. The questions included the
following: what is your home address; what is today’s date; what
day is today; how old are you; what is your mother’s surname; who
is the current president and the last president; and subtract 3 from
20 for a total of four consecutive times. Each item was scored as
0 or 1. If the item was answered as ‘‘unknown’’, the item was scored
as 0. The scores ranged from 0 to 8. The scores in 2003 and
2007 were used as repeated measures of the outcome variable.
2.2.2. Independent variables
The independent variables included the fixed variables and the
repeatedly measured variables. The fixed independent variables
included age, sex, educational years, and frailty. Other independent
variables (marital status, chronic diseases, physical function
difficulties, social support, and social participation) were repeated
measures in both waves.
2.2.2.1. Fixed variables. The demographic variables included sex,
age and educational years. The definition of physical frailty
referred to the study of Fried et al. (2001). Because some of the
variables were unavailable in the data, proxy variables were used.
(1) Weight loss: The unintentional loss of more than 10 pounds
between 2003 and 2007. (2) Poor grip strength: To perform
grasping objects with the fingers with any difficulty. (3) Exhaus-
tion: Two items from the CES-D scale were used (Kohout, Berkman,
Evans, & Cornoni-Huntley, 1993), asking ‘‘I felt that everything I did
was an effort’’ and ‘‘I could not get going’’ in the last week, giving a
score of 0–3. Persons answering ‘2’ or ‘3’ to either question were
categorized as frail. (4) Walking 200–300 m with any difficulty. (5)
Low physical activity: Defined as not performing regular exercise.
The respondents who exercised two times per week or less were
197
coded as having low physical activity. The respondents who met
three or more of the five criteria above were considered to be frail;
those who met one or two criteria were considered pre-frail; and
those with none of the criteria were considered non-frail.
2.2.2.2. Repeatedly measured variables. Marital status was defined
as having a spouse or not. Chronic diseases were selected from
those related to higher cognitive impairment risks, including
hypertension, diabetes mellitus, heart disease, and stroke. The
cumulative number of the four chronic diseases was used for
analysis.
Physical function difficulty was assessed by the activities of
daily living (ADLs), including following items: eating, clothing,
transferring (getting up from a chair or from bed), using the toilet,
taking a bath, and walking indoors. Each item was scored 0–3,
ranging from no difficulty at all to unable to perform the activity.
The physical function difficulty scores ranged from 0 to 18.
The respondent’s social support was assessed by measuring
their received emotional support, received instrumental support,
and provided information support. Emotional support was
measured as the degree of received care from their family
members, relatives, or friends. Each item was scored from 1 to
5, and the total scores ranged from 0 to 20. Higher scores indicated
that more support was received. Received instrumental support
items were determined by asking ‘‘when you need someone to
help, is there anyone who can help you or not’’ and were coded yes
or no. Providing informational support was assessed by the
questions ‘‘do you feel the help of your family is useful or not’’ and
‘‘do your family consult your opinion when they make decisions’’.
Each item was scored from 1 to 3, and the total scores ranged from
2 to 6.
Social participation included working status and participating
in volunteer or social groups. Working status was coded as doing
paid work, unpaid work, and no work. Social group participation
was coded as yes/no, which was defined as participating in any
group of the following: volunteering in social services, religious
group, union or occupational organization, social service or
volunteer work, political group, community action or service
group, clan association, and elderly club.
2.3. Analysis
Descriptive analysis and the generalized linear model of a time-
linear function with normal distribution were applied for the
analysis. The entire sample was first analyzed, and then the
samples were stratified by age groups (aged less than 65 or more)
and by sex and analyzed accordingly. The analysis was conducted
using SPSS version 19.0 for Windows (IBM Inc., New York,
Armonk).
3. Results
The descriptive data of the samples in the two waves are
described in Table 1. The average of the cognitive function score
reduced a little from 2003 (mean = 7.76, SD = 0.59) to 2007
(mean = 7.53, SD = 0.96). In fact, about 22.43% of the respondents
declined, 68.46% of them remained constant, and 9.11% improved.
The results of the generalized linear model are shown in
Table 2. The dependent variable was defined as the cognitive
function scores in 2 waves. Model 1 indicates the results of the
entire sample. The time slope was negative but not significant,
indicating that the cognitive function did not reduce significantly
across time. The factors related to higher cognitive function at the
intercept included being younger (b = 0.009, p < 0.001), male
(b = 0.128, p < 0.001), higher education (b = 0.025, p < 0.001), and
doing unpaid work (b = 0.091, p < 0.001). At the time slope, the age
198 C.-L. Li, H.-C. Hsu / Archives of Gerontology and Geriatrics 60 (2015) 196–200

Table 1 the female respondents, being younger, having higher education

Sample characteristics.
being non-frail, working on paid work or unpaid work, having less
Characteristics Mean (SD) or % physical difficulties at the intercept would be related to higher
2003 2007 cognitive function; while higher education, having less physical
functional difficulties, and providing informational support would
Age 62.73 (9.64) –
Years of education 7.13 (4.50) –
be related to increased cognitive function over time.
Sex
Men 46.40% – 4. Discussion
Women 53.60% –
Physical frailty
In this study, the cognitive function of two waves among the
Frail 3.66% –
Pre-frail 57.37% – Taiwanese older people was examined, and the differences
Non-frail 38.97% – associated with age and sex were compared. In general, being
Cognitive function score 7.76 (0.59) 7.53 (0.96) younger, males, having higher education, still working, having less
Physical function difficulties 0.07 (0.64) 0.21 (1.38) physical function difficulties, and providing more informational
Marital status
support, were related to higher cognitive function. There were age-
No spouse 21.73% 26.04%
Having a spouse 78.27% 73.96% and sex-differences in the factors related to cognitive function.
Working status Past studies have only found a relationship between physical
Paid work 38.3% 32.6% function difficulty and cognitive impairment (Dodge et al., 2005;
Unpaid work 33.9% 31.5%
Fauth et al., 2013). Our study found the associations of physical
No work 27.7% 35.9%
Social group or volunteering function difficulties with cognitive function particularly for males
participation and females, and particularly significant for the older group. The
Yes 46.5% 48.0% mechanism of cognitive function improvement may vary in different
No 53.5% 52.0% ages, or there may be confounding factors related to age and sex with
Emotional support 16.64 (2.82) 16.66 (2.66)
respect to cognitive function. Further research about the age effect
Received instrumental support 0.91 (0.28) 0.90 (0.29)
Providing informational support 5.07 (1.06) 4.94 (1.10) on the improvement of cognitive function is suggested.
Hypertension Providing more informational support was significant with
Yes 30.29% 37.79% cognitive function. Providing informational support or advice for
No 69.71% 62.21%
their family/friends may increase the stimulation of cognitive
Diabetes
Yes 11.25% 15.16%
function (Bassuk, Glass, & Berkman, 1999), and then shows a
No 88.75% 84.84% protective effect, particularly for the people with less social
Heart disease connection such as the older and female elderly. Another
Yes 15.07% 17.39% explanation is that the providing of informational support was
No 84.93% 82.61%
concurrent with the cognitive function trajectory in the models,
Stroke
Yes 2.23% 3.10% and thus, those who had better cognitive function were able to
No 97.77% 96.90% provide more informational support for their family/friends. When
Note. n = 3226.
they received good feedback from the social network, their
cognitive function would increase over time.
The effects of working status and participating in social groups
effect (b = 0.002, p < 0.01) and physical function difficulties on cognitive function found in previous studies (Hsu, 2007;
(b = 0.028, p < 0.001) would reduce the cognitive function across Winningham & Pike, 2007; Zunzunegui et al., 2003) were also
time, while education (b = 0.004, p < 0.001) and providing replicated in this study. However, the effect of working status and
informational support (b = 0.023, p < 0.001) would increase the social participation showed different effects by age and gender.
cognitive function across time. Doing paid or unpaid work was only significant for females, and
Because age and sex were significant to cognitive function, doing unpaid work was significant for the older group only.
Model 2 shows the results of the age stratification, and Model Participating in volunteering/social groups was significantly
3 shows the results of the sex stratification. Model 2A shows the beneficial only for the males but not significant for the females.
results of those younger who were aged less than 65 years old. The The younger participants may still have had a job during the
younger respondents who were male, having higher education, survey, but the older participants may have retired. Thus, doing
having a spouse, and providing more informational support at the unpaid work (such as taking care of grandchildren or doing
intercept, were more likely to have higher cognitive function housework) still make the older people living actively, and further
across time. Education and providing informational support even being beneficial for the cognitive function. The gender difference
increase a little bit cognitive function across time. Model 2B shows may be related to the gender inequality of the older cohorts in
the results of the older samples (aged 65 years old or more). For the Taiwanese society. For the older cohorts of Taiwanese elderly, the
older respondents, being younger, being male, having higher females did not have an equal chance to obtain education or were
education, doing unpaid work at the intercept were more likely to not allowed to work, other than being housewives. Thus, for those
have higher cognitive function; while having less physical function females who were doing paid work must be the ones with higher
difficulties and providing more informational support at the time socioeconomic status or having great working ability, and their
slope were more likely to increased higher cognitive function cognitive function was more likely to be higher and maintained.
across time. The relationship between physical frailty and cognitive
Model 3A and 3B are the results for the male and female function in the elderly was found in previous research (Auyeung
respondents, respectively. For the male respondents, being et al., 2011; Boyle et al., 2010; Buchman, Boyle, Wilson, Tang, &
younger, having higher education, participating in volunteering Bennett, 2007; Curcio et al., 2014; Kilgour et al., 2014), but the
or social groups at the intercept were more likely to have higher effect of frailty only showed on females only in this study. One
cognitive function. At the time slope, age and physical function explanation was that frailty was an essential health problem for
difficulties would reduce the cognitive function while providing the female elderly in Taiwan. Another possible reason was that
informational support would increase it across time. Regarding to frailty was defined as the fixed variable in this study (due to weight
 C.-L. Li, H.-C. Hsu / Archives of Gerontology and Geriatrics 60 (2015) 196–200 199

Table 2
Trajectory of cognitive function among Taiwanese older people by generalized linear model, 2003–2007.

Variable Model 1 Model 2A Model 2B Model 3A Model 3B

Total samples Younger (age < 65) Older (age  65) Male Female

Intercept 7.895 (0.150)*** 7.598 (0.194)*** 8.501 (0.394)*** 8.065 (0.168)*** 7.778 (0.266)***
Age 0.009 (0.002)*** 0.002 (0.003) 0.018 (0.005)*** 0.008 (0.019)*** 0.009 (0.003)**
Gender (male) 0.128 (0.030)*** 0.082 (0.027)** 0.168 (0.062)** – –
Years of education 0.025 (0.003)*** 0.016 (0.003)*** 0.038 (0.006)*** 0.014 (0.004)*** 0.038 (0.005)***
Frail 0.111 (0.068) 0.007 (0.075) 0.175 (0.117) <0.001 (0.087) 0.215 (0.102)*
Pre-frail 0.020 (0.030) 0.008 (0.025) 0.089 (0.071) 0.011 (0.035) 0.047 (0.050)
Marital status (no spouse) 0.014 (0.034) 0.067 (0.034)* 0.050 (0.059) 0.029 (0.045) 0.021 (0.050)
Working status (paid work) 0.043 (0.038) 0.031 (0.036) 0.093 (0.084) 0.004 (0.040) 0.176 (0.077)*
Working status (unpaid work) 0.091 (0.036)* 0.029 (0.041) 0.132 (0.059)* 0.021 (0.044) 0.197 (0.064)**
Social participation (yes) 0.028 (0.026) 0.016 (0.023) 0.051 (0.050) 0.059 (0.029)* 0.011 (0.043)
Physical function difficulties 0.025 (0.020) 0.006 (0.023) 0.025 (0.032) 0.013 (0.023) 0.071 (0.035)*
Received emotional support 0.003 (0.005) 0.005 (0.005) 0.005 (0.010) 0.003 (0.006) 0.005 (0.009)
Received instrumental support 0.022 (0.048) 0.043 (0.045) 0.021 (0.088) 0.002 (0.053) 0.041 (0.084)
Providing informational supports 0.018 (0.015) 0.031 (0.015)* 0.008 (0.026) 0.011 (0.017) 0.016 (0.025)
Chronic disease numbers 0.019 (0.016) 0.014 (0.015) 0.044 (0.027) 0.007 (0.018) 0.049 (0.026)
Time 0.091 (0.053) 0.051 (0.083) 0.102 (0.129) 0.020 (0.061) 0.163 (0.093)
Time * age 0.002 (0.001)** 0.001 (0.001) 0.002 (0.002) 0.002 (0.001)** 0.001 (0.001)
Time * gender (male) 0.020 (0.011) 0.010 (0.010) 0.016 (0.021) – –
Time * years of education 0.004 (0.001)** 0.004 (0.001)*** 0.003 (0.002) 0.001 (0.001) 0.006 (0.002)**
Time * frail 0.014 (0.024) 0.025 (0.028) 0.034 (0.039) 0.035 (0.030) 0.042 (0.036)
Time * prefrail 0.007 (0.011) 0.007 (0.009) 0.036 (0.023) 0.000 (0.012) 0.012 (0.018)
Time * Martial status 0.000 (0.012) 0.001 (0.012) 0.005 (0.020) 0.005 (0.015) 0.001 (0.018)
Time * working status (paid work) 0.004 (0.013) 0.004 (0.013) 0.003 (0.028) 0.005 (0.014) 0.001 (0.027)
Time * working status (unpaid work) 0.020 (0.013) 0.009 (0.015) 0.017 (0.020) 0.016 (0.016) 0.008 (0.022)
Time * social participation (yes) 0.014 (0.009) 0.001 (0.009) 0.021 (0.017) 0.003 (0.010) 0.022 (0.015)
Time * physical function difficulties 0.028 (0.056)*** 0.005 (0.007) 0.031 (0.009)*** 0.015 (0.007)* 0.031 (0.009)**
Time * received emotional support 0.001 (0.019) 0.001 (0.002) 0.002 (0.003) <0.001 (0.002) 0.003 (0.003)
Time * received instrumental support 0.020 (0.017) 0.008 (0.016) 0.048 (0.030) 0.024 (0.018) 0.011 (0.029)
Time * providing informational support 0.023 (0.005)*** 0.011 (0.005)* 0.033 (0.009)*** 0.025 (0.006)*** 0.022 (0.008)*
Time * chronic disease numbers 0.004 (0.005) 0.007 (0.006) 0.008 (0.009) 0.004 (0.006) 0.015 (0.009)

AIC 14,014.997 5017.280 7777.704 6339.035 7271.953

BIC 14,224.615 5208.238 7963.402 6517.323 7446.080
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.
The reference group of the dependent variables was scores of cognitive function (SPMSQ scale). The reference group of the independent variables included: sex (female),
marital status (having a spouse), working status (no), participation in volunteering or social groups (no), frailty (non-frail). The number of chronic diseases (include:
hypertension, diabetes, heart disease and stroke).

loss was defined as the changes between these two waves), and the
change of frailty was not measured. Another Taiwanese study has
shown that cognitive function and frailty may concurrently
associated, and previous frailty may also predict later cognitive
function decline (Hsu, 2014).
There are some limitations to this study. First, there were
missing cases because of deaths or loss to follow-up. The missing
cases may be relatively healthier, and thus, the conclusion of this
study should be considered when transferred to other populations.
Second, only two waves of data were applied in this study. The
longer longitudinal dynamics of cognitive function related to
factors over the long-term were not examined. Third, only the
SPMSQ scale was available for the measure of cognitive function.
The measure of cognitive function may not be comprehensive
enough to measure different dimensions of cognitive function. A
better measurement tool is suggested in future research.
The cognitive function of older adults may be dynamic, and the
factors associated with its decline or improvement is different by
age and by sex. As the population ages, the number of older people
with cognitive impairment may increase rapidly in the future.
Focusing on the effectiveness of preventive interventions to
promote cognitive health for the older population is necessary.
Different risks and health promotion strategies to target popula-
tions should be age- and gender-sensitively developed. The older
people and females should be encouraged to engage with social
participation or work (whether paid or unpaid); the age-friendly
environment to active aging and life-long education should be
constructed in the policy. The dynamic relationship of cognitive
function and related factors are suggested be evaluated in future
research.
Conflict of interests
None.
Acknowledgments
This work was supported by grants from the National Science
Council, Taiwan, Republic of China (NSC 101-2410-H-468-008-
MY2). This study had obtained approval of Research Ethics
Committee of Central Regional Research Ethics Center, Taiwan,
R.O.C. (No. CRREC-101-062).
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