Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 38 Page 39 Page 40 Page 41 Page 42 Page 43 Page 44 Page 45 Page 46 Page 47 Page 48 Page 49 Page 50 Page 51 Page 52 Page 53 Page 54 Page 55 Page 56 Page 57 Page 58 Page 59 Page 60 Page 61 Page 62 Page 63 Page 64 Page 65 Page 66 Page 67 Page 68 Page 69 Page 70 Page 71 Page 72 Page 73 Page 74 Page 75 Page 76 Page 77 Page 78 Page 79 Page 80 Page 81 Page 82 Page 83 Page 84 Page 85 Page 86 Page 87 Page 88 Page 89 Page 90 Page 91 Page 92 Page 93 Page 94 Page 95 Page 96 Page 97 Page 98 Page 99 Page 100 Page 101 Page 102 Page 103 Page 104 Page 105 Page 106 Page 107 Page 108AGING IN THE 21S T CENTURY 44 Other health events put patients at risk for cognitive decline, including hip fracture (Bentler et al. 2009) and a new diagnosis of chronic ob- structive pulmonary disease (Hung et al. 2009). Having diabetes is associated with dementia, but over eight years of follow-up, a new diagnosis of diabetes does not predict the onset of dementia (Q. Wu et al. 2015). Cross-national comparisons also provide useful insight on factors associated with cognitive functioning. Langa et al. (2009) compare non-His- panic whites over age 64 on the same measures of memory and orientation available in both the HRS and ELSA. Compared to their counterparts in England, US adults score significantly better on a cognitive scale. Older adults in the US have more risks for heart disease and other diseases that may lead to poorer cognitive function. But US adults tend to be wealthier, better educated, and have less depression, which accounts for some of the US cognitive advantage. US adults are also more likely to be taking medications for hyper- tension, which may help cognitive function. Interestingly, although depression is a risk factor for cognitive decline, Saczynski et al. (2015) follow HRS participants for six years and show that the use of antidepressants does not make any difference in cognitive changes. Behavioral Factors Recent research examines the potential impact of exercise and other modifiable risks on cognitive decline. With longitudinal data from HRS linked to dementia diagnosis in ADAMS, Bowen (2012) examines whether a history of vigorous physical activity three or more times per week affects the risk of subsequent dementia. Age, female sex, presence of the APOE e4 allele, a history of stroke, and poorer cognitive functioning at baseline are all associated with an increased risk of dementia. Mild drinking (one to three drinks per week) as well as being overweight or obese confer significant protection against dementia. In addition, vigorous physical activity for at least 12 months over the study period reduces dementia risk by 21%. Maintaining optimal body weight may be especially important to reduce risk of cog- nitive decline. Xiang and An (2015a) show that being underweight, having a body mass index less than 18.5, is a robust risk factor for onset of cognitive impairment in later life. Loneliness is emerging as a signifi- cant health risk. One study follows HRS participants aged 65 and older from 1998 to 2010 and finds that loneliness and depressive symptoms both lead to cognitive decline over that period. Looking at the reciprocal direction of effect, they show that low cognitive function pre- dicts increasing loneliness (Donovan et al. 2016). Comorbid Conditions Some studies examine the association of medical conditions and dementia with the goal of provid- ing information to increase clinician awareness in treating older patients with multiple chronic conditions and risks. For example, Gure et al. (2012) find that approximately 40% of HRS par- ticipants over age 66 with heart failure have some degree of cognitive impairment. In this group, the prevalence of cognitive impairment consistent with dementia is 15%. Multiple studies identify other neuropsychi- atric symptoms as comorbid with dementia. For example, depressive symptoms are associated with lower immediate and delayed word recall in the HRS (Gonzales et al. 2008). The prevalence of depression in the ADAMS sample is 8.5% for those with normal cognitive status increasing to 13.4% for those with CIND, and to 20.0% for those with dementia (Steffens et al. 2009). Similarly, Okura et al. (2010) show that other neuropsychiatric symptoms, such as anxiety, ag- itation, elation and delusions are prev- alent among those with cognitive impairment. The percentage of those with three or more symptoms increases sharply going from mild to moderate dementia (from 15.2% to 44.3%) but then decreases slightly with severe dementia (38.2%). Some research suggests that neuropsychiatric symptoms may actually precede dementia (Beaudreau et al. 2012).