Title: Factors Affecting Cognitive Function According to Gender of in

Community-dwelling Elderly

Type of manuscript: Original article, Survey

Author: Kim, Miwon, http://orcid.org/0000-0002-4142-1202, Sangmyung University

Park, Jeong-Mo, http://orcid.org/0000-0002-5354-2335, Kyungin Womens University

Correspondence: Kim, Mi-won, Dept. Nursing Science, Sangmyung Univ., Sangmyungdaero 31, Dongnam-gu,

Cheonan-si, Chungchungnamdo, Korea. Cell phone: 010-5036-1642, FAX: 041-550-5545, Email: kmw@smu.ac.kr,

Email address: kmw@smu.ac.kr

Conflicts of interest of all listed authors: There are no conflicts of interest to declare.
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Factors affecting cognitive function according to gender in

community-dwelling elderly individuals

Abstract
Objectives: This study aimed to identify the factors affecting the cognitive
function of elderly people in a community by gender.

Methods: 4,878 of secondary data of people aged ≥65 years in 2016 at a dementia
prevention center in Geyangu in Incheon. Data were obtained through MMSE-DS
and a questionnaire. The data were statistically analyzed using analysis of variance,
analysis of covariance, and hierarchical regression.

Results: There were significant differences in cognitive function according to sex,

and the differences were significant even when age was controlled, but gender
differences disappeared when education was controlled. Age, education, social
activities, number of diseases, and alcohol consumption affected cognitive function
through interaction with gender, but interaction with gender disappeared when
education was controlled. Regression analysis showed that depression, cohabitant,
social activities etc., had a significant impact on both men and women under
controlled education and age. In men, the effect of social activities was greater than
that of women, and only hyperlipidemia had the effect in women.

Conclusions: The differences in gender-related cognitive functions were due to

differences in gender education levels. The level of education is considered to have a
great influence on cognitive function in relation to the economic level, occupation,
and social activity.

Key words: Cognitive function, Elderly, Gender

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1. Introduction

1.1 Necessity of the study

In 2000, the population aged 65 years and older in South Korea exceeded 7% of the total
population and entered the aging society. As of 2017, the elderly population already exceeded
13.8% [1] and the elderly population is still rapidly growing. The rapid aging of the population
has social and economic cost implications, resulting in personal and social burdens. Aging is
also a direct cause of many degenerative diseases, including dementia, the most serious
neurodegenerative disease, which our society has to face due to aging [2]. According to the 3rd
Dementia Management Integration Plan, the number of patients with dementia is expected to
exceed 1 million in 2024 and 2 million in 2014 [3]. Also, 10-15% of elderly patients with mild
cognitive impairment are diagnosed with Alzheimer’s disease, 80% of whom progress to
dementia 6 years later [4]. The decline in cognitive function due to aging progresses slowly,
making it difficult to pathologically determine the exact timing of onset of dementia. However,
once it has progressed to dementia, it causes deterioration in the quality of life of patients and
their families and huge medical expenses, leading to high economic burden at the individual and
national levels. Therefore, countermeasures against this are urgently needed [2]. Since no
effective drug and treatment for cognitive impairment and dementia is currently available, early
detection of modifiable risk factors for cognitive impairment and prevention of cognitive
impairment and delaying the onset of dementia through related early intervention is an
important task of the National Dementia management project [2]. In line with this, the Dementia
Screening Project for the Early Detection of Dementia has intensively been implemented at
public health centers nationwide since 2010. As a result, the number of patients with mild
cognitive impairment undergoing treatment increased from 24,602 in 2010 to 105,598 in 2014
with an annual increase rate of 43.9% [5].

Factors affecting cognitive impairment that have been identified so far include age, educational
level, gender [6,7,8,9,10], health life factors such as drinking and smoking [7], depression [11],
social factors such as social activity and occupation, history of disease, and BMI (body mass
index) [12]. However, among these factors, age, education, and depression are consistently

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reported as risk factors for cognitive impairment, but these factors are not all consistent among
studies. When cognitive decline is regarded as a continuous process from normal cognitive
function to mild cognitive impairment and dementia, the identification and management of
influential factors such as cognitive decline-related demographic characteristics, comorbid
diseases and health habits may contribute to the delay or prevention of dementia [6]. However,
previous studies on prediction models for cognitive function have been conducted in patients
with cognitive impairment or dementia; thus, there is a limitation to generalizing the results of
those studies [6]. In order to determine factors for preventing cognitive decline, it is also
necessary to conduct studies involving the entire elderly population living in the community,
including the elderly with normal cognitive function and cognitive decline.

Cognitive decline is expected in all elderly people rather than a specific group, and those with
cognitive decline have a wide range of characteristics in addition to demographic characteristics
including gender. Therefore, it is difficult to see that cognitive decline factors identified in the
whole elderly population may have the same effects in the sub-elderly group. In order to prevent
cognitive decline more effectively, it is necessary to manage factors that are most appropriate
for each participant based on demographic, lifestyle and health status factors [6] which were
found to be significantly associated with cognitive decline. The basic distinction in establishing
intervention plans suited for target participantss is gender, and it is thus necessary to identify
factors affecting cognitive decline according to gender and to establish intervention plans based
on such a gender difference. Many previous studies investigating factors for the cognitive
decline have reported that a difference prevalence of cognitive decline in men and women was
[6,7,8,9,10,13]. Kim et al., [14] compared cognitive function using the Korean version of Mini-
Mental Status Examination optimized for screening dementia (MMSE-DS), MMSE-KC (Korea
n version of MMSE in the Korean version of CERAD Assessment Packet) and K-
MMSE(Korean-MMSE) and reported that gender among education period, age and gender was
found to have the greatest effect on cognitive function as measured by all the tools. However,
studies identifying differences in influential factors according to gender are scarce and the
results are inconsistent. Women are reported to have more cognitive decline than men [6,7]. In
this regard, it has been explained that a longer duration of education in men served as a

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protective factor for cognitive impairment [9], and it has also been explained that it was related
to the fact that older age is more common in women than men [7,9]. Furthermore, drinking in
addition to age and education also influence the gender difference in cognitive function. Women
consume far less alcohol than men; hence, the need for gender-controlled studies [13]. However,
it has not been clearly explained which factors may affect gender difference in cognitive
function.

Therefore, the present study aimed to investigate factors affecting cognitive function in the
community-dwelling elderly, to identify factors affecting cognitive decline according to gender.

2. Subjects and Methods

2.1 Study design and participants

This is a cross-sectional study designed to investigate factors affecting cognitive function in the
elderly using data obtained from elderly individuals aged 65 years or older who underwent early
dementia screening at a dementia prevention center located in Geyangu in Incheon, South Korea
in 2016. The participants underwent dementia screening by examiners who visited homes,
community centers and senior citizen centers.

2.2 Instruments

1) Cognitive function-related variables

Age, gender, educational level, economic status, social life (past occupation, number of social
activities, religion), history of disease (diabetes, hypertension, stroke, hyperlipidemia, number
of comorbid diseases), and health habits (drinking, smoking, exercise) were examined.

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2) Cognitive screening tool

Cognitive function state was examined using the MMSE-DS [14]. Levels of cognitive
impairment were classified according to a standard table that classified scores lower than the
[mean - 1.5 standard deviation] as cognitive impairment based on normative values for the
elderly. The reliability of this tool, as reported by Kim et al., [14] was Cronbach’s α=. 826, and
its reliability in the present study was Cronbach’s α=.839.

3) Depression scale

The degree of depression was assessed using the Short Form Geriatric Depression Scale-
Korean version of the 15-item Short Form Geriatric Depression Scale (S-GDS) originally
developed by Sheikh & Yesavage [15]. The Korean version was translated and standardized by
Ki [16]. The scores range from 0 to 15 points on a 2-point scale (1 point for ‘yes’ and 0 point
for ‘no’), and a higher score indicates a higher degree of depression. The degree of depression is
classified as normal state for a score of less than 4 points, mild depression for a score of 5-8
points and severe depression for a score of more than 9 points. Its reliability in a study by Ki [16]
was Cronbach’s α=.884.

2.4 Data collection

For secondary data analysis, the present study obtained the consent from the head of the
institution for the scope and contents of the data and was approved by the official Institutional
Review Board designated by the Ministry of Health and Welfare Affairs (IRB No. PO1-201703-
21-019). Data were collected through dementia screening as part of an early dementia screening,
publicity and education project at a dementia prevention center from December 2015 to the end
of December 2016. Dementia screening was performed by 4 nurses who completed a
specialized dementia education and were systemically educated about the screening method.

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After all the participants were briefed about the purpose and contents of the screening and the
present study and provided their consent for the use of the screening results, the screening and
data collection were performed in a quiet place on a 1:1 basis.

2.5 Data analysis

The data were obtained from 4,878 participants with complete entries among those who
received dementia screening, and were analyzed using SPSS version 18.0 (IBM Corp, Armonk,
NY, USA). Differences in gender distribution of all the variables were analyzed using real
numbers, percentages and chi-square test. Cognitive function by gender for each variable was
analyzed using t-test and analysis of variance (ANOVA), the interaction of each variable with
gender was analyzed using two way ANOVA, and the interactions of each variable with gender
when age and education was controlled were analyzed using analysis of covariance. The factors
affecting cognitive impairment were analyzed using hierarchical regression. The significance
level for the statistical test was set to .05.

3. Results

3.1 Distribution of cognitive function-related variables according to gender

We identified differences in the distribution of age, depression, education period, economic

status, cohabitation type, social life, history of disease, and lifestyle habits among the
participants according to gender (Table 1).

First, 77.2% of the participants were female, and the proportion of elderly individuals aged 85
years or older was higher among the women (10.5% for men, 14.40% for women, p<.001). The
proportion of those with education period of 7 years or longer was higher in men (60.9% in men,
23.35% in women, p<.001). There was no significant difference in depression, presence of
diabetes and presence of stroke between the men and women, whereas there were significant

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difference in past job, social activities, religion, cohabitation type, economic status, presence of
hypertension and hyperlipidemia, number of comorbid diseases, drinking, smoking, and
exercise status according to gender. In addition, a higher proportion of men had past jobs (83.87%
vs. 29.94% of men and women, respectively). A higher proportion of women had two social
activities compared to men (19.77% vs. 12.16%, respectively), as well as a religion (70.0% and
53.84%, respectively). Regarding cohabitation type, 18.83% of men and 34.63% of women
lived alone. A higher proportion of men were medical aid beneficiaries compared to women
(7.12% and 5.15%, respectively). Hypertension and hyperlipidemia were more common in
women (48.2% vs. 61.35%, and 9.19% vs. 18.37%, respectively). A higher proportion of
women had more than three comorbidities compared to men (18.5% vs. 12.52%, respectively).
The proportion of elderly individuals who engaged in regular exercise was higher among men
than women (62.34% vs. 51.01%, respectively). Again, a remarkably smaller proportion of men
were non-smokers and non-drinkers compared to women (29.64% vs. 97.29% and 21.53% vs.
89.68%, respectively).

3.2 Gender comparison of cognitive function score according to each variable

The cognitive function scores by gender were 25.53±43.72 points in men and 23.76±4.47 in the
women, showing a significant difference (F=54.31, p<.001).

There were significant differences in cognitive function scores in the whole group, male
participants and female participants according to age, education, depression, past occupation,
economic status, cohabitation type, drinking and exercise. There was no significant difference in
cognitive function score according to the presence or absence of diabetes in the whole group,
male and female participants.

However, the cognitive function scores differed between the whole group, male and female
participants according to number of social activities, religion, hypertension, brain disease,
number of comorbid diseases and smoking. There was no significant difference in cognitive
function scores according to number of social activities in the whole group with a significant

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difference in the men (F=5.78, p<.001) and no difference in the women. There was a significant
difference in cognitive function score according to religion in the whole group (F=10.58,
p=.001), but the difference was not significant in men and was significant in women (F=8.58,
p=.001). There were significant differences in cognitive function scores according to presence
or absence of hypertension in the whole group (F=5.07, p=.024), but the difference was not
significant in each gender group. There was a significant difference in cognitive function scores
according to hyperlipidemia in the whole group (F=41.59, p<.001), but there was no difference
in the men, whereas there was a difference in the women (F=58.98, p<.001). Those with
hyperlipidemia had higher cognitive function scores. There was no significant difference in
cognitive function scores according to the presence or absence of stroke in the whole group, but
there was a significant difference in the men (F=5.23, p<.022) and there was no difference in the
women. There was no difference in cognitive function scores according to smoking status in
each gender group.

Looking at cognitive function scores by each variable section, men with a high cognitive
function score of more than 26 points included those aged 69 years old or younger (26.61±3.16),
those in their 70’s (26.35±3.20), those with education period of 7-12 years (26.40±2.97), those
with hyperlipidemia (26.07±3.73), those with 1-2 diseases (26.70±3.61) and those who did
exercise (26.05±3.13). Women with high cognitive function score of more than 26 points
included those aged 69 years old or younger (26.32±3.31), those with education period of 7-12
years (26.52±2.84) and those with education period of more than 13 years (27.12±2.82). On the
other hand, men with a low cognitive function score of less than 23 points included those with
education period of less than 3 years (22.73±415), while women with a low cognitive function
score of less than 23 points included those aged 80 years or older (22.7±4.65), those with
education period of 0-3 years (21.58±4.5), those with severe depression (21.45±5.72), those
living with non-spouse (22.44±4.97), those with medical aid (21.96±5.72), current drinkers
(22.33±3.72), those who stopped smoking (22.98±5.35) and those who did not exercise
(22.97±4.80).

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3.3 Gender interaction with cognitive function-related factors

Two-way ANOVA was performed to determine the interaction of each variable affecting
cognitive function with gender using gender and each variable as independent variables. As a
result, the variables that interacted with gender in affecting cognitive function scores included
age (F=1.86, p=.001), education period (F=3.56, p=.014), social activities (F=1.94, p=.008),
cohabitation type (F=64.15, p=.016), number of comorbid diseases (F=2.74, p=.042) and
drinking (F=4.62, p=.010). Hypertension, stroke and smoking did not show gender interactions
and the main effects were not significant, showing that hypertension, stroke and smoking did
not affect cognitive function. Past job, religion, economic status, hyperlipidemia and exercise
showed significant main effects without interactions with gender.

Age and education period have been found to have a great effect on cognitive function and
have gender difference in cognitive function in previous studies. In assess for possible interac
tive variables after controlling for gender and other variables, two-way ANOVA between
gender and each variable was performed by using age and education period as covariate
s. When gender interactions with each variable and main effects when only age was controlled
were identified, the results showed that only the number of comorbid diseases and drinking had
significant interactions with gender (F=3.57, p=.013, F=4.08, p=.017), and all interactions with
gender disappeared when only education was controlled.

3.4 Factors affecting cognitive function according to gender

The aptness of the regression equation was found to be acceptable for men with a tolerance
of .730-.970, variance inflation factor (VIF) of 1.031 –1.369 and Durbin-Watson statistic of
1.898 and for women with a tolerance of .732-.973, VIF of 1.028-1.366 and Durbin-Watson
statistic of 1.835.

To identify factors affecting cognitive function when controlling for education and age,
education and age were first input and then the remaining variables were input to perform

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hierarchical regression analysis by gender (Table 4).

For the male participants, the effect of education (β=.30) and age (β=-.17) on cognitive
function scores was R2=.139. The effects of depression (β=-.16, p<.001), living with non-spouse
(β=-.11, p<.001), social activities (β=.10, p<.001), economic status (β=-.09, p=.002), exercise
(β=.08, p=.005), presence or absence of stroke (β=.06, p=.027) and presence or absence of
religion (β=.06, p=.043) on cognitive function score were low but significant. The effect of
these variables on cognitive function score was R2=.088, and the total explanatory power was
R2=.222

For the female participants, the effect of education period (β=.36, p<.001) and age (β=-.24,
p<.001) on cognitive function score was R2=.253. Depression (β=-.16, p<.001), living with non-
spouse (β=-.08, p<.001), hyperlipidemia (β=.05, p=.001), economic status (β=-.06, p<.001),
social activities (β=.04, p=.002), exercise (β=.04, p=.011), and the presence or absence of
religion (β=-.03, p=.018) had significant effects on cognitive function score, the effect of these
variables on cognitive function score was R2=.057, and the total explanatory power was R2=.310.

4. Discussion

The proportion of elderly participants aged 85 years or older was higher among women, and
the proportion of those with education period of less than 3 years was higher among women,
which were similar to the distribution of age and education period in the studies by Kim et al.
[14] and Park et al. [25] of community-dwelling elderly people. Furthermore, the results of the
present study found that the proportion of those who engaged in regular exercise was higher
among men, which has been reported as a cognitive function protective factor in previous
studies [19,20], and smoking and drinking, which have been reported as cognitive function risk
factors were more frequent in the men. From these results, it can be predicted that the difference
in gender distribution of cognitive function protective factors or risk factors, or the relationship
between those factors and gender might affect the gender differences in cognitive function.

The difference in cognitive function according to cognitive function-related variables (Table 2)

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was not the same between the entire group and the groups according to gender. In other words,
cognitive function scores in the whole group did not differ according to social activity, diabetes,
stroke and number of comorbid diseases, which can be interpreted as variables that may not
affect cognitive function. However, in the male group, there was a significant difference in
cognitive function according to the number of social activities, stroke and the number of
comorbid diseases, whereas there was no significant difference in cognitive function according
to religion, hypertension and smoking that showed significant differences in cognitive function
in the entire group. The analysis results of only female participants also showed that there was
no difference in cognitive function according to smoking in the female participants, in which a
difference was found in the analysis results of the whole group, and also showed that there was
a significant difference in cognitive function according to the number of comorbid diseases in
the female participants, in which no difference was found in the whole group.

Looking at cognitive function scores according to cognitive variables, possible risk factors for
both sexes included short education period, high depression, ‘no past job,' ‘living with non-
spouse family members,' ‘economic status-national health insurance subscribers’ ‘non-drinkers’
and ‘no exercise’. Depression has been considered as a predictor of cognitive function in many
previous studies [19,21,22]; it is therefore an important factor for maintaining cognitive
function, and it is thought that continuous attention should be paid to depression to prevent
decline in cognitive function. Living with family in terms of cohabitation type is accepted as a
cognitive protective factor. Fratiglioni et al. [24] and Park et al. [25] reported that elderly
individuals living alone had a relatively low cognitive function compared to those living with
family, and explained that such results were due to the fact that elderly people living alone had a
lack of emotional and cognitive stimulation and sense due to isolated life with little family and
social ties. However, the present study found that elderly individuals living with their spouse in
the whole group, male and female participants had the highest cognitive function scores,
followed by elderly people living alone and elderly people living with non-spouse family, which
were different from the results of previous studies showing that living alone had a negative
effect on cognitive function. Recently, Kim [7] reported that living alone had an insignificant
effect on cognitive function. This suggests that the cohabitation type of Korean elderly people is

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also changing to be couple-oriented, and living with children other than spouse is considered not
to be protective of cognitive function compared to living alone. Continuous observational
studies regarding cohabitation-related factors in Korean elderly people are needed.

Regarding drinking among lifestyle factors, ‘never-drinkers’ and ‘those who stopped drinking’
among the male participants had a lower cognitive function than the current drinkers, whereas
the ‘current drinkers’ in the female group were found to have the lowest cognitive function
score (22.33±5.25 points), suggesting that the effects of drinking on cognitive function may
differ according to gender. The studies by Park & Song [8], Shin et al. [19], and Kim & Shim
[27] have reported that drinking was associated with cognitive function; however, Anstey et al.
[28] reported through a systematic literature review that drinking was not associated with
dementia. The results of the present study also showed that the effects of drinking on cognitive
function were not clear. In this regard, it is necessary to investigate the degree and duration of
drinking and to examine their relationship with other confounding variables.

Males and female participants who exercised were found to have high cognitive function in
the present study, which was consistent with the results of previous studies investigating the
effects of physical activity on cognitive impairment [22,25]. Therefore, the present study
confirmed that exercise was protective of cognitive function.

Meanwhile, the results of the present study showed differences in cognitive function between
the whole group and each gender group according to the number of social activities, religion,
hypertension, diabetes, hyperlipidemia, stroke, number of comorbid diseases, and smoking. It
was difficult to compare the results of the present study with those of other studies since there
was a paucity of studies reporting on gender differences in cognitive function. Vascular risk
factors such as hypertension and diabetes are estimated to be risk factors for the progression of
cognitive decline and transition from mild cognitive impairment to dementia [26]. The results of
the present study showed that in the entire group, there was no difference in cognitive function
according to diabetes and according to hypertension and stroke, which were inconsistent with
the results of previous studies [8,25]. Further studies are needed to investigate the degree of
hypertension and duration of disease. The present study showed that only among female

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participants, there were differences in cognitive function according to hyperlipidemia and there
were a higher cognitive function in the female participants with hyperlipidemia than those
without hyperlipidemia, suggesting that hyperlipidemia may have a positive effect on cognitive
function in women. In a study by Park et al. [25], hyperlipidemia was reported as a protective
factor for mild cognitive impairment because it showed a negative relative risk and odds ratio,
which were similar to the results of a study by Vidoni et al., [29] reporting that a low cholesterol
or a low body mass index acts as a risk factor for cognitive impairment.

There was no significant difference in cognitive function according to stroke in the entire
group and among female participants. However, there was a significant difference in cognitive
function according to stroke only in male participants (F=5.23, p=.022), showing that stroke was
a risk factor for cognitive function among male participants, and this finding was similar to the
results of a study by Park et al. [25] revealing that stroke had a greater relative risk in men than
women.

The cognitive function according to smoking status was not different in each gender group,
and the lowest cognitive function score was observed in never-smokers in the entire group
(23.9±4.41 points). The results of the present study showed that smoking did not negatively
affect cognitive function. These findings are similar to the results of studies by Shin et al. [19,22]
reporting that there was no difference in cognitive function between elderly people with mild
cognitive impairment and normal elderly people according to smoking status. However, Park et
al. [25] and Kim [7] have reported that smoking was a risk factor for cognitive function. More
detailed studies on the effects of smoking on cognitive function are thus needed.

Whether the gender difference in cognitive function as found in the present study was simply
due to gender difference or gender difference in cognitive function-related factors or due to the
results of interaction between those factors and gender is discussed as follows. When gender
difference in cognitive function was identified using age and education as covariates, which are
considered to have great effects on gender difference in cognitive function, the results showed
that there was a gender difference in cognitive function when age was controlled, but not when
education period was controlled. This means that cognitive function scores did not differ

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according to gender when the education period was the same, and differences in cognitive
function were found to be due to education period rather than age in the present study. This
finding was consistent with the results of a study by Kim [7] indicating that education was the
most influential variable on cognitive function. Lin et al., [9] described that cognitive
impairment and dementia were more likely to affect women than men, but this could be seen as
a difference in age distribution. However, the results of the present study can be interpreted
based on the explanation that cognitive impairment might progress faster as education period is
shorter and the resulting cognitive simulation is lacking [30]. This is in line with the results of a
study by Petersen et al. [17] stating that men might be relatively slower to progress from mild
cognitive impairment to dementia because they have a relatively longer education period than
women.

In addition, there were gender interactions with age, education period, social activities,
cohabitation type, drinking and the number of diseases among cognitive function-related
variables in affecting cognitive function. However, when age was controlled, social activities
and cohabitation type showed no gender interaction, and only significant main effects were
observed, suggesting that the difference in gender and age might affect cognitive function in
relation to social activities and cohabitation type. Meanwhile, drinking and the number of
diseases showed significant interactions with gender even when age was controlled. However,
when education was controlled, these variables did not show interactions with gender and the
main effects of each variable were significant. The significant interactions of these variables
with gender are interpreted to be due to gender differences in education period.

Finally, when controlling education and age which were found to significantly affect cognitive
function, the effects of the remaining variables on cognitive function were determined (Table 4).
As a result, it was found that depression in addition to education and age had a great effect on
cognitive function in both male and female participants. Considering depression as an adjustable
variable compared to education and age, it is necessary to identify factors for preventing
depression in elderly people and to provide them with interventions. The variables affecting
cognitive function after depression included living with non-spouse, number of social activities,
economic status, exercise status and religion, which were common in both male and female

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participants and the order was similar. However, social activity was in the 5 th order (β=.10) for
the male participants, and was in the 7th order (β=.045) for the female participants, indicating
that social activity seems to have more effects in the male participants. The variable that
differed between male and female participants was found to be hyperlipidemia and was found to
be a significant variable only in the female participants. As shown in <Table 3>, the interaction
of hyperlipidemia with gender was observed when age was controlled. Therefore, further studies
are needed to determine whether hyperlipidemia itself has a protective function for cognitive
function, or whether it is related to education period and economic status in addition to age.

In conclusion, the results of the present study showed that cognitive function differed
according to gender, and that this was due to differences in education period. The variables
except for depression and stroke among the variables affecting cognitive function showed
differences in cognitive function according to gender. Among the variables affecting cognitive
function used in the present study, age, education period, social activities, cohabitation type,
number of comorbid diseases and drinking were the variables that showed interactions with
gender. However, all the variables had no gender interaction when education was controlled,
and the interactions of these variables with gender seemed to be due to differences in education
period. In addition, the results of a regression analysis showed that education period and
depression were important variables that most greatly affected cognitive function, followed by
cohabitation type, economic status, exercise, social activities, religion, and stroke, which were
the same in both male and female participants. However, hyperlipidemia was added as a factor
affecting cognitive function in the female participants, and it is thus necessary to consider
gender for these factors.

The present study is significant in that it identified factors affecting cognitive function in
community-dwelling elderly people with normal cognitive function to cognitive decline and
identified that the differences in cognitive function scores according to gender were due to the
gender differences in age and education period.

In addition, the present study showed different results according to drinking, smoking,

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hypertension, stroke and the number of comorbid diseases which have been reported as risk
factors in previous studies. In this regard, future studies are needed to specifically investigate
drinking, the amount and duration of smoking, disease severity and disease name. In addition,
considering that living with non-spouse family was found to be a higher risk factor for cognitive
function than living alone, it is necessary to identify changes in factors according to the
changing society.

In the present study, the education period was found to have a greater effect on cognitive
function than age, which was predicted that education period might have greater effect on
cognitive function through its interactions with economic status, occupation and social activities.
Therefore, further studies are needed to investigate factors affecting cognitive function, the
interactions with education and the combined effects.

In addition, in this study, cognitive function was more greatly affected by age and education
period than by gender difference. It is thus thought that it is effective to provide elderly
individuals with interventional programs for improving cognitive function by segmenting them
by education period and age.

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Table 1. Distribution of cognitive-related variables by gender

Total Male Female

2
Variables Categories X p
N (%) n (%) n (%)

Gender 4878 (100.0) 1110 (22.8) 3768 (77.2)

Below 74 1868 (38.3) 475 (42.8) 1393 (37.0)

Age 75-84 2351 (48.2) 519 (46.8) 1832 (48.6) 723.30 p<.001

Above 85 659 (13.5) 116 (10.5) 543 (14.40)

0-3 years 1803 (37.00) 113 (10.20) 1690 (44.90)

4-6 years 1519 (31.10) 321 (28.90) 1198 (31.80)

Education level 13.58 p<.001
7-12 years 1365 (28.00) 552 (49.70) 813 (21.60)

Above 13 years 188 (3.90) 124 (11.20) 64 (1.70)

Normal 3664 (75.10) 830 (74.80) 2834 (75.20)

Depression Mild depression 638 (13.10) 138 (12.40) 500 (13.30) 1.66 .436

Severe depression 576 (11.80) 142 (12.80) 434 (11.50)

Never 2819 (57.79) 179 (16.13) 2640 (70.06)

Past job 1022.60 p<.001
Yes 2059 (42.21) 931 (83.87) 1128 (29.94)

0 1026 (21.03) 335 (30.18) 691 (18.34)

No. of social
1 2972 (60.93) 640 (57.66) 2332 (61.89) 92.69 p<.001
activities

More than 2 880 (18.05) 135 (12.16) 745 (19.77)

No 1665 (33.03) 533 (46.16) 2636 (30.00)

Religion 127.98 p<.001
Yes 3213 (66.97) 577 (53.84) 574 (70.0)

Alone 1514 (31.04) 209 (18.83) 1305 (34.63)

Cohabitant Spouse 1917 (39.30) 781 (70.36) 1136 (30.15) 593.98 p<.001

Non-spouse 1447 (29.66) 120 (10.81) 1327 (35.22)

Economic National health

4604 (94.40) 1031 (92.88) 3573 (94.85) 6.28 0.012
status1 insurance

20
21

Medical Aid 273 (05.60) 79 (07.12) 194 (05.15)

No 2030 (41.64) 575 (51.80) 1455 (38.65)

Hypertension 61.06 p<.001
Yes 2845 (58.36) 535 (48.20) 2310 (61.35)

No 3664 (75.11) 839 (75.59) 2825 (74.97)

DM2 0.17 1.000
Yes 1214 (24.89) 271 (24.41) 943 (25.03)

No 4084 (83.72) 1008 (90.81) 3076 (81.63)

Hyperlipidemia 52.98 p<.001
Yes 794 (16.28) 102 (9.19) 692 (18.37)

No 4641 (95.14) 1052 (94.77) 3589 (95.25)

CVA3 0.42 0.518
Yes 237 (04.86) 58 (05.23) 179 (4.75)

0 833 (17.08) 255 (22.97) 578 (15.34)

No. of disease 1-2 3209 (65.78) 716 (64.50) 2493 (66.17) 51.78 p<.001

3 or more 836 (17.14) 139 (12.52) 697 (18.50)

Never drunk 3618 (74.17) 239 (21.53) 3379 (89.68)

Alcohol Currently not

552 (11.32) 420 (37.84) 132 (3.50) 2105.34 p<.001
consumption drinking

Current drink 708 (14.51) 451 (40.63) 257 (6.82)

Never smoking 3995 (81.90) 329 (29.64) 3666 (97.29)

Current ceased
Smoking 705 (14.45) 641 (57.75) 64 (1.70) 2659.31 p<.001
smoking

Current smoking 178 (03.65) 140 (12.61) 38 (1.01)

No 2264 (46.41) 418 (37.66) 1846 (48.99)

Exercise 44.28 p<.001
Yes 2614 (53.59) 692 (62.34) 1922 (51.01)

1
Economic status = Health insurance type

2
Diabetes Mellitus

3
Cerebrovascular Accident

21
22

Table 2. Gender Comparison of Cognitive Function Score Differences by Variables

Total Male Female

Variables Categories
M (±SD) t or F(p) M (±SD) t or F(p) M (±SD) t or F(p)

Male 25.53 (±3.72) 54.31

Gender
Female 23.76 (±4.47) (p<.001)

Below 74 25.17 (±3.41) 26.32 (±3.20) 25.56 (±2.46)

303.29 25.161 202.99
Age 75-84 26.64 (±4.32) 25.04 (±3.84) 23.25 (±4.37)
(p<.001) (p<.001) (p<.001)
Above 85 23.16 (±4.60) 24.25 (±4.34) 20.86 (±5.06)

0-3 years 21.66 (±4.49) 22.73 (±4.15) 21.58 (±4.5)

4-6 years 24.71 (±3.94) 24.53 (±4.28) 24.76 (±3.84)

458.35 49.99 342.63
Education
period 7-12 years 26.47 (±2.89) 26.40 (±2.97) 26.52 (±2.84)
(p<.001) (p<.001) (p<.001)

Above 13
26.92 (±2.66) 25.53 (±3.72) 27.13 (±2.82)
years

Normal 24.62 (±4.00) 26.00 (±3.18) 24.21 (±4.12)

95.83 29.00 73.89
Depression Mild 23.23 (±4.68) 24.43 (±4.43) 22.89 (±4.69)
(p<.001) (p<.001) (p<.001)
Severe 22.00 (±5.67) 23.69 (±5.16) 21.45 (±5.72)

Never 23.40 (±4.64) 208.76 24.53 (±4.69) 15.71 23.33 (±4.63) 83.18
Past job
Yes 25.20 (±3.73) (p<.001) 25.73 (±3.47) (p<.001) 24.76 (±3.88) (p<.001)

0 23.90 (±4.95) 24.84 (±4.23) 23.44 (±5.20)

No. of 2.70 5.78 2.85
social 1 24.26 (±4.24) 25.86 (±3.33) 23.82 (±4.36)
activities (.067) (p<.001) (.300)
Above 2 24.13 (±4.07) 25.71 (±3.92) 23.84 (±4.04)

No 24.29 (±4.43) 10.58 25.53 (±4.09) 0.033 24.02 (±4.13) 8.56

Religion
Yes 23.61 (±4.44) (p<.001) 25.54 (±3.68) (.856) 23.13 (±4.69) (p=.001)

Alone 23.99 (±4.14) 25.35 (±3.54) 23.78 (±4.19)

206.27 17.62 130.93
Cohabitant Spouse 25.51 (±3.55) 25.86 (±3.45) 25.27 (±3.59)
(p<.001) (p<.001) (p<.001)
Non-spouse 22.55 (±4.98) 23.74 (±5.00) 22.44 (±4.97)

Economic National health

24.25 (±4.27) 38.17 25.64 (±3.58) 12.977 23.85 (±4.37) 33.23
status1 insurance

22
23

Medical Aid 22.58 (±5.60) (p<.001) 24.09 (±5.02) (p<.001) 21.96 (±5.72) (p<.001)

No 24.33 (±4.38) 5.07 25.46 (±3.69) 0.43 23.88 (±4.54) 1.79

Hypertensio
n
Yes 24.04 (±4.36) (0.024) 25.61 (±3.76) (.512) 23.68 (±4.14) (0.181)

No 24.17 (±4.38) 0.117 25.50 (±3.79) 0.33 23.78 (±4.47) 0.29

DM2
Yes 24.13 (±4.34) (.744) 25.65 (±3.51) (0.567) 23.69 (±4.46) (0.588)

No 23.98 (±4.45) 41.59 25.48 (±3.72) 2.33 23.49 (±4.56) 58.98

Hyperlipide
mia
Yes 25.07 (±3.83) (p<.001) 26.07 (±3.73) (0.127) 24.93 (±3.83) (p<.001)

No 24.18 (±4.36) 1.46 25.59 (±3.70 5.23 23.76 (±4.45) 0.16

CVA3
Yes 23.83 (±4.63) (.227) 24.45 (±3.97) (.022) 23.63 (±4.82) (.686)

0 24.37 (±4.45) 25.25 (±3.73) 23.98 (±4.68)

0.81 12.97 33.23
No. of
1-2 24.11 (±4.36) 26.70 (±3.61) 23.62 (±4.45)
disease
(.486) (p<.001) (p<.001)
Above 3 24.18 (±4.33) 25.09 (±4.35) 24.00 (±4.30)

Alcohol Never 23.84 (±4.47) 25.15 (±4.23) 23.75 (±4.47)

consumptio Ceased 45.13 6.84 10.85

24.53 (±4.36) 26.03 (±3.30) 24.55 (±3.72)
n drinking
(p<.001) (p=.001) (p<.001)
Currently
25.49 (±3.53) 25.22 (±3.79) 22.33 (±5.25)
drinking

25.37 (±3.75) 23.77 (±4.44)

Never 23.90 (±4.41)

40.43 0.43 0.66

25.61 (±3.72) 23.56 (±5.24)
Smoking Ceased
25.42 (±3.92)
smoking (p<.001) (0.648) (0.518)

Currently
25.02 (±4.21) 25.57 (±3.68) 22.97 (±5.35)
smoking

24.68 (±4.41) 22.98 (±4.80)

No 23.29 (±4.78) 172.78 36.94 113.62
Exercise
(p<.001) 26.05 (±3.13) (p<.001) 24.51 (±3.98) (p<.001)
Yes 24.91 (±3.83)

23
24

1
Economic status = Health insurance type

2
Diabetes Mellitus

3
Cerebrovascular Accident

24
 25

1 Table 3. Gender interaction in the effect of variables on cognitive function

CV1: Age CV1: Education

Gender*Variable
Variables Variables Gender*Variable Gender*Variable
F (P)
F (P) F (P)

(CV) Age - 687.453 (p<.001) -

(CV) Education - - 683.20 (p<.001)

Age Age 10.141 (p<.001) - 6.31 (p<.001)

Gender 44.682 (p<.001) 130.181 (p<.001) 2.56 (.110)

Gender*Age) 1.856 (.001) - 1.11 (.055)

(CV) Age - 270.07(p<.001) -

(CV) Education - - 1099.203 (.000)

Education level Education 153.551 (p<.001) 104.97 (p<.001) -

Gender 403 (.525) 2.98 (.085) .092 (.761)

Gender*Education 3.562 (.014) 1.82 (.141) -

(CV) Age - 743.92 (p<.001) -

(CV) Education - - 1038.37 (p<.001)

Depression Gender 60.68 (p<.001) 53.46 (p<.001) 3.28 (.070)

Depression 10.93 (p<.001) 14.30 (p<.001) 8.03 (p<.001)

Gender*Depression 1.03 (.421) .91 (.557) 1.17 (.291)

(CV) Age - 599.32 (p<.001) -

(CV) Education - - 1017.58 (p<.001)

Past job Gender 32.58 (p<.001) 41.15 (p<.001) 5.81 (.016)

Past job 47.94 (p<.001) 17.35 (p<.001) 21.06 (p<.001)

Gender*Past job .39 (.531) 1.16 (.281) .17 (.683)

(CV) Age - 774.23 (p<.001) -

No. of
social (CV) Education - - 1097.86 (p<.001)
activities
Gender 2.96 (0.85) 6.08 (.014) 1.23 (.267)

25
26

No. of social activities 2.99 (p<.001) 8.00 (p<.001) 4.82 (p<.001)

Gender* No. of social

1.94 (.008) 1.17 (.275) 1.38 (.126)
activities

(CV) Age - 700.72 (p<.001) -

(CV) Education - 1063.98 (p<.001)

Religion Gender 40.60 (p<.001) 40.90 (p<.001) .15 (.695)

Religion 7.86 (p<.001) 9.89 (p<.001) 5.84 (p<.001)

Gender*Religion 2.11 (.076) 1.64 (160) 2.12 (.075)

(CV) Age - 453.65 (p<.001) -

(CV) Education - - 896.60 (p<.001)

Cohabitant Gender 40.85 (p<.001) 44.52 (p<.001) 3.69 (p<.001)

Cohabitant 66.10 (p<.001) 23.90 (p<.001) 32.10 (p<.001)

Gender*Cohabitant 4.15 (.016) .04 (.966) .86 (.423)

(CV) Age - 677.74 (p<.001)

(CV) Education - 1108.41 (p<.001)

Economic
Gender 43.74 (p<.001) 26.52 (p<.001) .30 (.583)
status

Economic status 33.86 (p<.001) 34.19 (p<.001) 39.40 (p<.001)

Gender*Economic status 318 (.573) .52 (.470) .45 (.503)

(CV) Age - 697.340 (p<.001)

(CV) Education - 1095.398 (p<.001)

Hypertension
Gender 140.785 (p<.001) 137.485 (p<.001) .048 (.827)

Hypertension .038 (.846) 5.327 (.021) .514 (.473)

Gender*Hypertension 1.404 (.236) .890 (.346) .009 (.924)

(CV) Age - 657.986 (p<.001) -

(CV) Education - - 1079.487 (p<.001)

Hyperlipidemia Gender 42.485 (p<.001) 32.995 (p<.001) 1.029 (.311)

Hyperlipidemia 17.751 (p<.001) 6.903 (.009) 12.197 (p<.001)

Gender*Hyperlipidemia 3.083 (.079) 4.283 (.039) 3.064 (.080)

26
 27

(CV) Age - 689.253 (p<.001) -

(CV) Education - - 1098.464 (p<.001)

CVA2 Gender 15.762 (p<.001) 16.278 (p<.001) .897 (.344)

CVA 3.691 (.055) 5.868 (.015) 3.806 (.051)

Gender*CVA 2.271 (.132) 1.259 (.262) .841 (.359)

(CV) Age - 696.34 (p<.001) -

(CV) Education - - 1097.85 (p<.001)

No. of
Gender 105.45 (p<.001) 93.99 (p<.001) .78 (.377)
disease

No. of diseases .17 (.920) 2.07 (.102) .56 (.645)

Gender*No. of diseases 2.74 (.042) 3.57 (.013) 2.12 (.096)

(CV) Age - 667.61 (p<.001) -

(CV) Education - - 1093.93 (p<.001)

Alcohol
Gender 87.52 (p<.001) 95.52 (p<.001) 101 (.925)
consumption

Alcohol consumption 16.39 (p<.001) 6.52 (p<.001) 14.83 (p<.001)

Gender*Alcohol 4.62 (.010) 4.08 (.017) 3.01 (.050)

(CV) Age - 689.75 (p<.001) -

(CV) Education - - 1100.74 (p<.001)

Smoking Gender 38.97(p<.001) 29.03 (p<.001) 1.04 (.308)

Smoking .27(.763) 1.60 (.202) .67 (.513)

Gender*Smoking .89(.413) .01 (.993) 1.52 (.218)

(CV) Age - 616.97 (p<.001) -

(CV) Education - - 1003.71 (p<.001)

Exercise
Gender 119.45 (p<.001) 107.50 (p<.001) .27 (.604)

Exercise 94.69 (p<.001) 61.56 (p<.001) 46.25 (p<.001)

Gender*Exercise
Gender*Exercise .31 (.575) .11 (.740) .01 (.916)
F(P)

2 1
Co-variable

3 2
Cerebrovascular Accident

27
 28

4 Table 4. Factors influencing cognitive function according to gender

Model 1 Model 2
Gender Variables
B SE β t p B SE β t p

(Constant) 28.93 1.26 23.04 p<.001 28.39 1.40 20.28 p<.001

Education level 1.38 0.13 0.30 10.65 p<.001 1.20 0.13 0.26 9.44 p<.001

Age -.092 0.02 -0.17 -6.10 p<.001 -0.10 0.02 -0.19 -6.51 p<.001

Depression -0.17 0.03 -0.16 -5.43 p<.001

Cohabitant: Not
-1.32 0.33 -0.11 -3.99 p<.001
spouse

No. of social
0.56 0.16 0.10 3.51 p<.001
Male activities

Economic status -1.23 0.41 -0.09 -3.03 .002

Exercise 0.60 0.21 0.08 2.80 .005

2
CVA -1.05 0.48 -0.06 -2.22 .027

Religion 0.42 0.21 0.06 2.03 .043

F(p)= 89.348 (p<.001) F(p)= 18.831 (p<.001)

2 2 2 2 2 2
R =.139 Adjusted R =.137 △R =.139 R =.227 Adjusted R =.215 △R =.088

(Constant) 31.39 0.79 39.58 p<.001 31.12 .90 34.72 p<.001

Education level 1.92 0.08 0.36 23.28 p<.001 1.72 .08 .321 20.96 p<.001

Age -0.14 0.01 -0.24 -15.43 p<.001 -.14 .01 -.229 -13.38 p<.001

Depression -.21 .02 -.157 -10.93 p<.001

Cohabitant: not
-.74 .17 -.079 -4.39 p<.001
spouse

Economic status -1.30 .28 -.065 -4.65 p<.001

Female
Hyperlipidemia .63 .19 .054 3.29 .001

No. of social
.31 .10 .045 3.08 .002
activities

Exercise .33 .13 .037 2.55 .011

Religion -.33 .14 -.033 -2.37 .018

2
CVA -.63 .30 -.030 -2.09 .037

F(p)=635.992(p<.001) F(p)=99.00(p<.001)

28
 29

2 2 2 2 2 2
R =.253 Adjusted R =.252 △R =.253 R =.310 Adjusted R =.307 △R =.057

5 1
CVA: Cerebrovascular Accident

29