The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations

doi:10.21203/rs.3.rs-4960659/v1

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The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations

https://doi.org/10.21203/rs.3.rs-4960659/v1

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Background

Adverse childhood experiences (ACEs) are among the factors affecting cognitive function in middle-aged and older adults, but the combined effects of ACEs, social isolation and functional limitations on cognitive function have not been fully explored.

Methods

This study used data from 6,412 middle-aged and older adults from the 2018 China Health and Retirement Longitudinal Study (CHARLS) and the 2014 CHARLS Life Histories Survey. Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, cognitive function as the dependent variable, and social isolation and functional limitations as mediating variables.

Results

In this study, ACEs were positively associated with social isolation and functional limitations (r = 0.081, 0.070, P < 0.01) and negatively associated with cognitive function (r=-0.132, P < 0.01). Social isolation and functional limitations had chain mediating effects on the relationship between ACEs and cognitive function.

Conclusions

ACEs lead to impaired cognitive functioning in middle-aged and older adults, and social isolation and functional limitations influence this relationship. These findings suggest that promoting social integration and physical exercise targeting functional limitations may be important approaches for preventing and mitigating the effects ACEs on cognitive function.

Health sciences/Diseases

Health sciences/Medical research

Adverse childhood experiences

Social isolation

Functional limitations

Cognitive function

Middle-aged and older adults

As the world's second largest economy, China is currently home to 1.4 billion people (19.13% of the world's population) and is rapidly becoming an ageing country. It is predicted that by 2050, the population of individuals over 65 years old in China will reach 400 million, and the population of individuals over 80 years old will reach 150 million(Zeng 2012). By then, China will become one of the countries with the highest proportion of elderly individuals in the world. One consequence of a changing population structure is a surge in the prevalence and incidence of age-related conditions, such as cancer, chronic noncommunicable diseases, and mental health disorders. Specifically, declines in cognitive function are of considerable concern. A national survey revealed that approximately 15.5% of individuals aged 60 and above suffer from mild cognitive impairment, 6.0% exhibit dementia, and 3.9% have Alzheimer's disease(Jia et al. 2020). Cognitive decline is a prevalent phenomenon among elderly individuals, and individuals with cognitive decline are at a heightened risk of developing dementia(Manly et al. 2008). Maintaining sound cognitive function is a critical determinant of quality of life and independence for middle-aged and older adults. Cognitive health enables them to maintain social connections, maintain a sense of purpose, and retain the capacity for independent activities, facilitating functional recovery from illness or injury and managing residual functional limitations(Hendrie et al. 2006). Consequently, identifying risk factors associated with cognitive decline is of paramount importance for designing targeted public health interventions, ultimately contributing to the promotion of healthy ageing in China.

Previous studies have identified age, education, family history, depression, and chronic illnesses as principal risk factors for cognitive decline(Brenda L. Plassman et al. 2010; Elias et al. 2005). Life course theory posits that early-life experiences significantly influence later-life outcomes(Glen H. Elder 1998). Since the emergence of research on adverse childhood experiences (ACEs)(Vincent J. Felitti et al. 1998), a growing body of evidence has underscored their pivotal role in shaping future health(Godoy et al. 2021; Lin et al. 2021; Bellis et al. 2019). Consequently, it is suggested that the aetiology of cognitive decline may trace back to early life – this hypothesis is supported by multiple empirical studies(Schalinski et al. 2018; Tani, Fujiwara, and Kondo 2020). The connection between ACEs and cognitive function can be elucidated through neurodevelopmental models(Bick and Nelson 2015), which propose that brain regions crucial for cognition, such as the hippocampus and prefrontal cortex, exhibit distinct developmental patterns during childhood and adolescence, when these patterns are highly susceptible to environmental influences, including ACEs(Pechtel and Pizzagalli 2010; Teicher et al. 2016). Therefore, cognitive dysfunction may be linked to the development of these structures, which are potentially influenced by ACE exposure(Catts et al. 2013; Hoy et al. 2011; Aas et al. 2013).

While ACEs exert extensive and lasting negative effects on individuals, not all individuals with a history of ACEs manifest adverse health outcomes in adulthood. Therefore, it is important to elucidate the underlying mechanisms and protective factors that might influence the relationship between ACEs and adverse health outcomes. Identifying and addressing these factors could prevent lifelong cognitive impairments induced by ACEs. Empirical evidence suggests that social resources, such as social support and community resilience, can mitigate the cascading effects of ACEs on physical and mental well-being(Cheong et al. 2017; Jaffee, Takizawa, and Arseneault 2017; Longhi, Brown, and Fromm Reed 2021); conversely, a lack of social connectedness or social isolation, which is a well-documented risk factor for cognitive decline(Yu et al. 2020), can partially mediate the negative impact of ACE-related stressors on cognitive function later in life(Lin et al. 2022). Social isolation, which is characterized by limited social interaction, low participation in social activities, and solitary living(Gale, Westbury, and Cooper 2018), is consistently linked to various adverse health outcomes, including functional limitations and cognitive decline(Shankar et al. 2017; Yu et al. 2020). In the elderly population, functional limitations are common, with a staggering 26.81% prevalence in China(Gao et al. 2023), This high prevalence is due to the relevance of functional limitations to daily activities as well as their ease of measurement. Therefore, functional limitations are significant concern. From a life course perspective, significant early-life events are considered critical determinants of functional limitations or disability(Amemiya et al. 2018). Specifically, ACEs are associated with various negative health outcomes, such as cancer(Brown et al. 2010), depression(Cheong et al. 2017), cardiovascular disease(Godoy et al. 2021), and chronic lung disease(Anda et al. 2008), all of which can contribute to functional limitations or disabilities. Furthermore, an increasing body of research suggests that older adults with physical and functional limitations are more susceptible to cognitive decline(Wei et al. 2022; Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021b).

In summary, previous studies have suggested that ACEs are associated with cognitive decline and that social isolation and functional limitations may play a mediating role in this relationship. To the best of our knowledge, this is the first study to explore the chain mediating effect of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. Based on a large number of previous empirical studies, this study proposes the following hypotheses: (i) ACEs can directly predict cognitive function in adulthood; (ii) social isolation mediates the association between ACEs and cognitive function; (iii) functional limitations mediate the association between ACEs and cognitive function; and (iii) social isolation and functional limitations play a chain mediating role in the association between ACEs and cognitive function.

Data Source

The present study draws upon data from the China Health and Retirement Longitudinal Study (CHARLS), a national baseline survey initiated in 2011. The survey was conducted in 28 provinces (autonomous regions, municipalities) across 150 counties and 450 villages in 2011, 2013, 2015, and 2018, and it reached 19,000 respondents from 12,400 households by the conclusion of the national follow-up in 2018. The comprehensive questionnaire used in the CHARLS evaluates personal demographics, family structure, economic support, health status, physical measurements, health care utilization, insurance coverage, employment, retirement, pensions, income, expenditure, assets, and community characteristics. Furthermore, in 2014, the CHARLS conducted the "Life Course Survey of Chinese Residents." The current study employs data from the fourth wave of the CHARLS, which was administered in 2018 and subsequently matched with the 2014 Life Course Study data. A total of 6,412 individuals completed both surveys. The CHARLS was approved by the Biomedical Ethics Committee of Peking University (IRB00001052-11015), and all participants voluntarily participated and signed an informed consent form. This study was authorized by the CHARLS database.

Measures

Cognitive function

Cognitive function assessment was conducted using methods adapted from the U.S. Health and Retirement Study (HRS)(Crimmins et al. 2011), encompassing four dimensions: orientation, calculation, memory, and drawing. Orientation is assessed by the respondent's judgement of the date (year, month, day), season and day of the week, with one point awarded for each correct response, totalling 5 points. The respondents were instructed to perform five consecutive subtractions of 7 from 100, with one point awarded for each successful attempt, resulting in a maximum of 5 points for the calculation dimension. Memory is measured through immediate word recall and delayed word recall (number of words remembered after a 5-minute delay), with a score of 1 assigned to each correct repetition and a total score of 0–20. Finally, the evaluator shows the respondent a picture of two overlapping five-pointed stars and asks the respondent to draw them to test their drawing ability, awarding one point for a correct representation. The total cognitive function score ranged from 0 to 31, with higher scores indicating better cognitive function.

Social isolation

A social isolation index was derived based on four items. One point was assigned if participants were not married (including never married, widowed, divorced, or separated); had less than weekly contact with children (by phone, text message, mail or email, or in person); or had not participated in any social activities over the last month (e.g., interacted with friends, played Ma-jong or cards, used the internet, took part in a community-related organization, or did voluntary or charity work). Scores of social isolation ranged from 0 to 4, with higher scores indicating greater isolation(Shankar et al. 2017).

Functional limitations

The activities of daily living (ADL) and instrumental activities of daily living (IADL) scales were used to evaluate functional limitations(Chai et al. 2024). The ADL scale assessed dressing, eating, bathing, getting into or out of bed, going to the toilet, and controlling urination and defecation. The IADL assessed difficulties with doing household chores, preparing hot meals, shopping, managing money and taking medications. The items were scored on a four-point scale: 1 = no difficulty, 2 = difficulty but can still complete, 3 = difficulty and need help, and 4 = cannot do it. The total functional limitation score ranged from 11 to 44, with higher scores indicating severe functional limitation.

Adverse Childhood Experiences

The life history module of the CHARLS in 2014 collected data on ACEs that occurred before the age of 18 years. We collected 13 ACEs in this study. According to previous research(Yin et al. 2024), these ACEs were divided into 3 different categories: conventional ACEs (physical abuse, emotional neglect, domestic violence, family crime, family mental illness, family substance abuse, and parental divorce or separation), expanded ACEs (unsafe living conditions, peer bullying, bad friendship experiences), and new ACEs (parental death, sibling death, and parental disability). We calculated the cumulative ACE score and the cumulative score for each dimension.

Covariate Information

The covariates in this study included age, sex (0 = female, 1 = male), ethnicity (0 = other, 1 = Han), and education level (0 = illiterate, 1 = primary school and below, 2 = junior high, and 3 = high school and above).

Statistical analysis

First, IBM SPSS version 25.0 was used for descriptive statistics and correlation analysis of the data. Continuous variables are expressed as the means and standard deviations, and categorical variables are expressed as frequencies and percentages. Next, before analysing the indirect effects, a completely direct model was used to analyse the impact of ACEs on cognitive function in middle-aged and older adults. Then, Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, social isolation and functional limitations as the mediating variables, and cognitive function as the dependent variable. The maximum likelihood method and bootstrap method were used to test the mediating model, and the 95% CI for bias correction was calculated; P < 0.05 was considered to indicate statistical significance.

Participant Characteristics

The statistical characteristics of the study sample are presented in Table 1. Among the 6412 participants, 2933 (45.7%) were men and 3479 (54.3%) were women; the mean age was 66 (SD = 9.7) years, and the vast majority had a low level of education. Furthermore, the average cognitive function score was 11.38 (SD = 7.17), the average social isolation score was 1.79 (SD = 0.96), and the average functional limitation score was 13.35 (SD = 4.54). The average ACE score was 1.93 (SD = 1.53), 84.1% reported experiencing one or more ACEs, and the incidence of cumulative ACEs and each dimension is shown in Fig. 1.

Table 1

Descriptive Characteristics of participants
Variables	Levels	Observed N (%)	Mean (SD)	Minimum	Maximum
ACEs (0–13)	scores		2.02 (1.55)	0	8
Conventional ACEs (0–7)	scores		0.86 (0.92)	0	5
Physical abuse	yes	1,825 (28.46)
Emotional neglect	yes	1,678 (26.17)
Domestic violence	yes	560 (8.73)
Family crime	yes	32 (0.5)
Mental illness in the family	yes	921 (14.36)
Household Substance Abuse	yes	456 (7.11)
Parents divorced or separated	yes	50 (0.78)
Expanded ACEs (0–3)	scores		0.59 (0.73)	0	3
Unsafe living conditions	yes	603 (9.4)
Peer bullying	yes	1,084 (16.91)
Bad friendship experiences	yes	2,110 (32.91)
New ACEs (0–3)	scores		0.57 (0.70)	0	3
Parental death before age 17	yes	1,157 (18.04)
Death of a sibling before age 17	yes	1,051 (16.39)
Parental disability	yes	1,425 (22.22)
Cognitive function (0–31)	scores		11.38 (7.17)	0	30
Social isolation (0–4)	scores		1.79 (0.96)	0	4
Functional limitation (11–44)	scores		13.35 (4.54)	11	44
Demographic characteristics
Age (45–108)			66 (9.71)	45	108
Sex
Male		2,933 (45.7)
Female		3,479 (54.3)
Ethnicity
Han		5902 (92.0)
Other		510 (8.0)
Education
Illiterate		1,670 (26.0)
Primary school and below		2,934 (45.8)
Junior high school		1,165 (18.2)
Senior high school and above		643 (10.0)
Notes. Sample N = 6,412. ACEs, Adverse Childhood Experiences.

Correlation Analysis

Correlation analysis was conducted on the social isolation score, functional limitation score, ACEs, and cognitive function score, and the results showed that the correlations between these key study variables were significant. ACEs were positively correlated with social isolation (r = 0.081, P < 0.01) and functional limitations (r = 0.070, P < 0.01), whereas cognitive function was negatively correlated with ACEs (r=-0.132, P < 0.01), social isolation (r=-0.317, P < 0.01), and functional limitations (r=-0.293, P < 0.01). These findings suggested that higher ACE scores are correlated with greater levels of social isolation and severe functional limitations. The detailed results are shown in Table 2.

Table 2

Correlation coefficients between key study variables (N = 6412)
variables	Cognitive function	ACEs	Social isolation	Functional limitation
Cognitive function	1
ACEs	-0.132**	1
Social isolation	-0.317**	0.081**	1
Functional limitation	-0.293**	0.070**	0.176**	1

**Correlation is significant at the 0.01 level (2-tailed). ACEs = Adversity Childhood Experiences.

Direct association between ACEs and cognitive function

Before proceeding with the mediation analysis, we used a total direct model to determine the effects of ACEs on the cognitive function of middle-aged and older people. As shown in Table 3, in the model, we include age, sex, education, and ethnicity as control variables. The model exhibited an excellent fit: χ²/df = 0, CFI = 1, TLI = 1, RMSEA = 0.000, SRMR = 0.000. Therefore, the results demonstrated a statistically significant direct effect of ACEs on cognitive function (β = 0.060, 0.001).

Table 3

Direct model regression weight
DV	IV	Std. Est.	S.E.	Est./S.E.	P-Value	R²
Cognitive function	ACEs	-0.037	0.009	-3.920	***	0.423
	Age	-0.274	0.010	-27.198	***
	Sex	0.025	0.010	2.455	0.014
	Education	0.504	0.010	49.494	***
	Ethnicity	0.013	0.010	1.273	0.203

***P < 0. 001

Multiple Indirect Effects Model

After controlling for age, sex, education, and ethnicity, the indirect relationships between ACEs and cognitive function are illustrated in Table 4 and Fig. 2. The multiple mediation model demonstrated a strong fit: χ²/df = 0, CFI = 1, TLI = 1, RMSEA = 0.000, SRMR = 0.000. Table 5 provides a comprehensive analysis of the total effect, direct effect, and mediating pathways, along with their 95% confidence intervals. Specifically, the impact of ACEs on cognitive function through social isolation is -0.099, which constitutes 16.3% of the overall effect. The contribution of functional limitations was − 0.022, accounting for 10.3% of the total effect. The combined influence of social isolation and functional limitations on cognition amounts to -0.015, or 2.5% of the total effect. The direct effect of ACEs on cognitive function was − 0.433, representing 71.0% of the total effect. All the confidence intervals of the mediation paths exclude zero, thus indicating that social isolation and functional limitations significantly mediated the effect of ACEs on cognitive function. However, the difference in mediation effects between these two factors was not statistically significant (β=-0.037, P = 0.086).

Table 4

Model regression weight of the impact of ACEs on cognitive function scores
DV	IV	Std. Est.	S.E.	Est./S.E.	P-Value	R²
Cognitive function	ACEs	-0.094	0.011	-8.186	***	0.167
	Social isolation	-0.267	0.011	-24.067	***
	Functional limitation	-0.240	0.010	-23.505	***
Functional limitation	ACEs	0.057	0.012	4.558	***	0.034
	Social isolation	0.171	0.013	13.523	***
Social isolation	ACEs	0.081	0.013	6.423	***	0.006

***P < 0. 001.

Table 5

Total, direct, and indirect effects of ACEs on cognitive function, social isolation and functional limitation as mediators
	Point Estimate	Product of Coefficients			95%CI
		Product of Coefficients			bias corrected
		S.E.	Est./S.E.	P-Value	Lower	Upper
INDIRECT EFFECTS
SI	-0.099	0.016	-6.215	***	-0.133	-0.070
FL	-0.063	0.014	-4.541	***	-0.091	-0.036
SI→FL	-0.015	0.003	-5.658	***	-0.021	-0.010
Total indirect	-0.177	0.023	-7.868	***	-0.222	-0.134
DIRECT AND TOTAL EFFECTS
Direct	-0.433	0.053	-8.156	***	-0.541	-0.331
Total	-0.610	0.058	-10.540	***	-0.728	-0.500
CONTRASTS
SI VS FL	-0.037	0.021	-1.715	0.086	-0.080	0.004
SI VS SI→FL	-0.084	0.014	-6.060	***	-0.114	-0.059
FL VS SI→FL	-0.047	0.014	-3.336	0.001	-0.075	-0.020

***P < 0. 001. SI = Social isolation, FL = Functional limitation.

Additionally, we constructed three models to analyse the pathway relationships between three dimensions of ACEs and cognitive function, as shown in Table 6 and Fig. 3. Conventional ACEs, expanded ACEs, and new ACEs all had significant direct effects on cognitive function, with the expanded ACEs showing the strongest direct effect (β = -1.237, p < 0.001). Among the three dimensions, the total association between expanded ACEs and cognitive function was the strongest (β = -1.69, p < 0.001). Social isolation and functional limitations mediated the relationship in expanded ACEs more than in conventional ACEs, accounting for 26% of the total effect, but this association was not significant for new ACEs (β = -0.007, p = 0.226).

Table 6

Direct and Indirect Effects of each dimension of ACEs on cognitive function in Later Life
Effect	β	SE	P-Value	95%CI
Total effect
CACEs- Cognitive function	-0.436	0.098	***	-0.629 to -0.248
EACEs- Cognitive function	-1.690	0.124	***	-1.945 to -1.425
NACEs- Cognitive function	-0.420	0.125	**	-0.670 to -0.177
Direct effect
CACEs- Cognitive function	-0.312	0.089	***	-0.485 to -0.134
EACEs- Cognitive function	-1.237	0.012	***	-1.478 to -1.020
NACEs- Cognitive function	-0.255	0.114	*	-0.484 to -0.038
Indirect effect
CACEs-SI- Cognitive function	-0.080	0.027	**	-0.135 to -0.029
CACEs-FL- Cognitive function	-0.032	0.024	0.170	-0.079 to 0.013
CACEs-SI-FL- Cognitive function	-0.013	0.004	**	-0.022 to -0.005
EACEs-SI- Cognitive function	-0.281	0.033	***	-0.348 to -0.218
EACEs-FL- Cognitive function	-0.128	0.030	***	-0.188 to -0.071
EACEs-SI-FL- Cognitive function	-0.044	0.006	***	-0.058 to -0.033
NACEs-SI- Cognitive function	-0.043	0.035	0.224	-0.114 to 0.025
NACEs-FL- Cognitive function	-0.115	0.031	***	-0.178 to -0.057
NACEs-SI-FL- Cognitive function	-0.007	0.006	0.226	-0.018 to 0.004
Notes. SI = Social isolation, FL = Functional limitation. ACEs, Adverse Childhood Experiences. CACEs, Conventional adverse childhood experiences. EACEs, Expanded adverse childhood experiences. NACEs, New adverse childhood experiences.

***P < .001, **P < .01, *P < .05

This study is the first to examine the chain mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function among middle-aged and older adults in China. Initially, the results of this study demonstrated a significant direct effect of cumulative ACE scores on cognitive function in middle-aged and older adults (confirming Hypothesis 1), consistent with findings by Schalinski, Tani, and others. This association may occur due to changes in brain structure and poor neurodevelopmental function in various brain regions, such as the limbic, hippocampal, and prefrontal areas, leading to inefficient memory and executive functions(Dannlowski et al. 2012; Hawkins et al. 2021). As summarized by Danese et al., individuals with a history of ACEs exhibit widespread and significant deficits across various cognitive domains, including processing speed, executive function, perceptual reasoning, memory, and language comprehension(Danese et al. 2017). Furthermore, the direct effects of various dimensions of the ACE on cognitive function are significant, suggesting that any type of ACE can adversely affect cognitive function in adulthood.

In the structural equation model we constructed, all paths were significant, thus providing support for Hypotheses 2, 3, and 4. This indicates that the impact of ACEs on cognitive function in adulthood can be explained through mediating variables, as predicted. Social isolation partially explains the relationship between ACEs and cognitive function, which may be interpreted through the stress-buffering hypothesis. Specifically, positive social interactions can reduce the psychological distress caused by ACEs, protect hippocampal neurons, and diminish neurotoxicity(Cohen and Wills 1985), all of which are crucial for maintaining cognitive function with age(McEwen and Sapolsky 1995). Additionally, lower levels of social isolation reflect more interpersonal interactions within one's social network. Therefore, adults may benefit from social interactions and adopting healthier lifestyle habits, such as quitting smoking and drinking, which may also help to protect cognition. Thus, fostering social integration through larger social networks and increased social participation might be particularly important for individuals affected by ACEs.

Furthermore, our study revealed that ACEs are positively correlated with an increase in functional limitations and a decrease in cognitive function, consistent with recent research findings. Amemiya et al.(Amemiya et al. 2018) found that childhood adversity is associated with functional limitations, with elderly individuals who reported two or more ACEs having greater functional impairment than those without ACEs. These findings suggest a significant dose‒response relationship. Moreover, physical and functional limitations are significantly correlated with a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a; Wei et al. 2022). A possible explanation for these results is that ACEs may increase the risk of low socioeconomic status, which is associated with poor health behaviours and disease states and is potentially linked to greater functional limitations. However, functional restrictions, including the ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL), may be fundamental in the neurodegenerative processes leading to cognitive decline(Rajan et al. 2012). Additionally, elderly individuals with functional limitations may lose opportunities to engage in physical exercise and cognitive activities, further leading to a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a).

Importantly, the results of this study also revealed the chained mediating role of social isolation and functional limitations between ACEs and cognitive function. This finding provides new evidence for the literature, demonstrating that ACEs may have a negative impact on subsequent cognitive function by affecting functional limitations through social isolation. These insights are crucial for mitigating the adverse effects of early-life stress and promoting health in adulthood.

Limitations

To the best of our knowledge, this study is the first to investigate the sequential mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. However, it is essential to acknowledge several limitations. First, the cross-sectional design precludes the examination of temporal precedence between the mediators and causal effects. Second, retrospective data collection raises the possibility of recall bias, as current cognitive status might influence the recollection of ACEs. Finally, given the multifaceted nature of cognitive function, future research should consider a broader array of potential influencing factors.

This study employed data from CHARLS 2014 and 2018 to explore the dual impact of ACEs on cognitive function, both directly and indirectly, through social isolation and functional limitations. To mitigate these effects, strategies focusing on enhancing social engagement and preventing functional decline are crucial. Encouraging middle-aged and elderly individuals to actively engage in cognitive activities and regular physical exercise is recommended to postpone cognitive decline and foster healthy ageing.

Fundings

This work was supported by the Health Commission of Sichuan Province (grant numbers 2023YFS0070). The funders played no role in the study design, data collection and analysis, publication decision, or manuscript preparation.

Author Contribution

In our article, P.J. provided guidance on the thinking and writing of the whole text. Y.Z. and HJ.Y. processed part of the data and wrote the full text. XL. Z. carried out the data processing and chart drawing of the empirical part. L.W. and Q.Z. provided us with the full text of the embellishment. All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors read and approved the final manuscript.

Acknowledgment

We are grateful to all volunteers and staff who participated in China Health and Retirement Longitudinal Study for collecting and providing data.

Data Availability

The original data can be found at https://charls.charlsdata.com/pages/Data/2018-charls-wave4/zh-cn.html.

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The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Data Source

Measures

Cognitive function

Social isolation

Functional limitations

Adverse Childhood Experiences

Covariate Information

Statistical analysis

Results

Participant Characteristics

Correlation Analysis

Direct association between ACEs and cognitive function

Multiple Indirect Effects Model

Discussion

Limitations

Conclusion

Declarations

Fundings

Author Contribution

Acknowledgment

Data Availability

References

Additional Declarations

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