Hostname: page-component-cd9895bd7-dzt6s Total loading time: 0 Render date: 2024-12-27T13:27:11.039Z Has data issue: false hasContentIssue false

Environmental influences on healthy and active ageing: a systematic review

Published online by Cambridge University Press:  06 November 2012

MICHAEL ANNEAR*
Affiliation:
Department of Medicine, University of Otago, Christchurch, New Zealand.
SALLY KEELING
Affiliation:
Department of Medicine, University of Otago, Christchurch, New Zealand.
TIM WILKINSON
Affiliation:
Department of Medicine, University of Otago, Christchurch, New Zealand.
GRANT CUSHMAN
Affiliation:
Faculty of Environment, Society and Design, Lincoln University, Lincoln, New Zealand.
BOB GIDLOW
Affiliation:
Faculty of Environment, Society and Design, Lincoln University, Lincoln, New Zealand.
HEATHER HOPKINS
Affiliation:
Faculty of Environment, Society and Design, Lincoln University, Lincoln, New Zealand.
*
Address for correspondence: Michael Annear, Department of Medicine, University of Otago, PO Box 4345, Christchurch, New Zealand. E-mail: [email protected]

Abstract

This paper explores the evidence for environmental influences on older adult health and activity participation, identifies current knowledge gaps and limitations within this literature, and offers recommendations for future research via a systematic appraisal of 83 quantitative and qualitative studies. A Cochrane-type review procedure was followed, which incorporated structured database searches, inclusion and exclusion criteria, quality appraisal of included studies, and peer review. The review findings identify support for both personal and environmental influences on health and activity participation in later life. Reported personal influences include ethnicity and cultural norms, energy and motivation, sex, age, education, genetic heritage, self-efficacy, and personal financial circumstances. Reported environmental influences on activity participation include climate, level of pollution, street lighting, traffic conditions, accessibility and appropriateness of services and facilities, socio-economic conditions, aesthetics, pedestrian infrastructure, community life, exposure to antisocial behaviour, social network participation, environmental degradation, level of urbanism, exposure to natural settings, familiarity with local environment and others. Recommendations for future research include the need for innovative research methods; involvement of older adults as research collaborators; investigation of wider aspects of the active ageing concept; in-depth assessment of the environmental characteristics of areas; investigation of the pathways leading from environment to health and activity participation; and more theoretically informed research or increased contribution of research to theory development.

Type
Articles
Copyright
Copyright © Cambridge University Press 2012 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Anaby, D., Miller, W. C., Eng, J. J., Jarus, T., Noreau, L. and Group, P. R. 2009. Can personal and environmental factors explain participation of older adults? Disability & Rehabilitation, 31, 15, 1275–82.Google Scholar
Aneshensel, C. S., Wight, R. G., Miller-Martinez, D., Botticello, A. L., Karlamangla, A. S. and Seeman, T. E. 2007. Urban neighborhoods and depressive symptoms among older adults. Journals of Gerontology: Psychological Sciences and Social Sciences, 62B, 1, S52–59.CrossRefGoogle Scholar
Annear, M. J., Cushman, G. and Gidlow, B. 2009. Leisure time physical activity differences among older adults from diverse socioeconomic neighborhoods. Health and Place, 15, 2, 482–90.CrossRefGoogle ScholarPubMed
Avlund, K., Lund, R., Holstein, B. and Due, P. 2004. Social relations as determinant of onset of disability in aging. Archives of Gerontology and Geriatrics, 38, 1, 8599.CrossRefGoogle ScholarPubMed
Balfour, J. and Kaplan, G. 2002. Neighbourhood environment and loss of physical function in older adults: evidence from the Alameda County study. American Journal of Epidemiology, 155, 6, 507–15.Google Scholar
Barnett, K., Buys, L., Lovie-Kitchin, J., Boulton-Lewis, G., Smith, D. and Heffernan, M. 2007. Older women's fears of violence: the need for interventions that enable active ageing. Journal of Women and Aging, 19, 3, 179–93.Google Scholar
Beckett, M., Goldman, N., Weinstein, M., Lin, I. F. and Chuang, Y. L. 2002. Social environment, life challenge, and health among the elderly in Taiwan. Social Science and Medicine, 55, 2, 191209.CrossRefGoogle ScholarPubMed
Berke, E. M., Gottlieb, L. M., Moudon, A. V. and Larson, E. B. 2007 a. Protective association between neighborhood walkability and depression in older men. Journal of the American Geriatrics Society, 55, 4, 526–33.Google Scholar
Berke, E. M., Koepsell, T. D., Moudon, A. V., Hoskins, R. E. and Larson, E. B. 2007 b. Association of the built environment with physical activity and obesity in older persons. American Journal of Public Health, 97, 3, 485–92.Google Scholar
Bird, S., Radermachers, H., Feldmans, S., Sims, J., Kurowski, W., Brownings, C. and Thomas, S. 2009. Factors influencing the physical activity levels of older people from culturally-diverse communities: an Australian experience. Ageing & Society, 29, 8, 1275–94.CrossRefGoogle Scholar
Booth, M., Owen, N., Bauman, A., Clavisi, O. and Leslie, E. 2000. Social-cognitive and perceived environment influences associated with physical activity in older Australians. Preventive Medicine, 31, 1, 1522.Google Scholar
Bowling, A., Barber, J., Morris, R. and Ebrahim, S. 2006. Do perceptions of neighbourhood environment influence health? Baseline findings from a British survey of ageing. Journal of Epidemiology and Community Health, 60, 6, 476–83.Google Scholar
Bowling, A. and Grundy, E. 1998. The association between social networks and mortality in later life. Reviews in Clinical Gerontology, 8, 4, 353–61.Google Scholar
Breeze, E., Jones, D., Wilkinson, P., Bulpitt, C., Latif, A. and Fletcher, A. 2005. Area deprivation, social class and quality of life among people aged 75 years and over in Britain. International Journal of Epidemiology, 34, 2, 276–83.CrossRefGoogle ScholarPubMed
Brown, S. C., Mason, C. A., Lombard, J. L., Martinez, F., Plater-Zyberk, E., Spokane, A. R., Newman, F. and Pantin, H. 2009. The relationship of built environment to perceived social support and psychological distress in Hispanic elders: the role of ‘eyes on the street’. Journals of Gerontology, 64B, 2, 243–46.Google Scholar
Cagney, K. A., Browning, C. R. and Wen, M. 2005. Racial disparities in self-rated health at older ages: what difference does the neighborhood make? Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60, 4, 181–90.Google Scholar
Catalani, C. and Minkler, M. 2010. Photovoice: a review of the literature in health and public health. Health Education & Behavior, 37, 3, 424–51.Google Scholar
Chodzko-Zajko, W., Proctor, D., Singh, M., Minson, C., Nigg, C., Salem, G. and Skinner, J. 2009. Exercise and physical activity for older adults: position stand. Medicine and Science in Sports and Exercise, 41, 7, 1510–30.Google Scholar
Connell, B. R. and Wolf, S. L. 1997. Environmental and behavioral circumstances associated with falls at home among healthy elderly individuals. Archives of Physical Medicine and Rehabilitation, 78, 2, 179–86.CrossRefGoogle Scholar
Davis, K., Drey, N. and Gould, D. 2009. What are scoping studies? A review of the nursing literature. International Journal of Nursing Studies, 46, 10, 1386–400.CrossRefGoogle ScholarPubMed
Davis, M. A., Moritz, D. J., Neuhaus, J. M., Barclay, J. D. and Gee, L. 1997. Living arrangements, changes in living arrangements, and survival among community dwelling older adults. American Journal of Public Health, 87, 3, 371–7.CrossRefGoogle ScholarPubMed
Day, R. 2008. Local environments and older people's health: dimensions from a comparative qualitative study in Scotland. Health and Place, 14, 2, 299312.Google Scholar
Dean, A., Kolody, B., Wood, P. and Matt, G. E. 1992. The influence of living alone on depression in elderly persons. Journal of Aging and Health, 4, 1, 318.CrossRefGoogle Scholar
Diez Roux, A. V., Borrell, L. N., Haan, M., Jackson, S. A. and Schultz, R. 2004. Neighbourhood environments and mortality in an elderly cohort: results from the cardiovascular health study. Journal of Epidemiology and Community Health, 58, 11, 917–23.CrossRefGoogle Scholar
Dwyer, J. W., Barton, A. J. and Vogel, W. B. 1994. Area of residence and the risk of institutionalization. Journal of Gerontology, 49, 2, 7584.CrossRefGoogle ScholarPubMed
Eschbach, K., Ostir, G. V., Patel, K. V., Markides, K. S. and Goodwin, J. S. 2004. Neighborhood context and mortality among older Mexican Americans: is there a barrio advantage? American Journal of Public Health, 94, 10, 1807–12.Google Scholar
Fernandez-Ballesteros, R. 2001. Environmental conditions, health and satisfaction among the elderly: some empirical results. Psicothema, 13, 1, 40–9.Google Scholar
Fisher, K., Fuzhong, L., Michael, Y. and Cleveland, M. 2004. Neighborhood-level influences on physical activity among older adults: a multilevel analysis. Journal of Aging and Physical Activity, 11, 1, 4563.Google Scholar
Fries, J. F. 2003. Measuring and monitoring success in compressing morbidity. Annals of Internal Medicine, 139, 5, 455–9.Google Scholar
Gallagher, N. A., Gretebeck, K. A., Robinson, J. C., Torres, E. R., Murphy, S. L. and Martyn, K. K. 2010. Neighborhood factors relevant for walking in older, urban, African American adults. Journal of Aging and Physical Activity, 18, 1, 99115.CrossRefGoogle ScholarPubMed
Gauvin, L., Riva, M., Barnett, T., Richard, L., Craig, C. L., Spivock, M., Laforest, S., Laberge, S., Fournel, M. C., Gagnon, H. 2008. Association between neighborhood active living potential and walking. American Journal of Epidemiology, 167, 8, 944–53.Google Scholar
Gitlin, L. N., Mann, W., Tomit, M. and Marcus, S. M. 2001. Factors associated with home environmental problems among community-living older people. Disability & Rehabilitation, 23, 17, 777–87.Google ScholarPubMed
Grant, B. C. 2007. Retirement villages: more than enclaves for the aged. Activities, Adaptation and Aging, 31, 2, 3755.Google Scholar
Haak, M., Fange, A., Horstmann, V. and Iwarsson, S. 2008. Two dimensions of participation in very old age and their relations to home and neighborhood environments. American Journal of Occupational Therapy, 62, 1, 7786.Google Scholar
Harden, A. and Thomas, J. 2010. Methodological issues in combining diverse study types in systematic reviews. International Journal of Social Research Methodology, 8, 3, 257–71.Google Scholar
Harris, J. R., Pedersen, N. L., McClearn, G. E., Plomin, R. and Nesselroade, J. R. 1992. Age-differences in genetic and environmental-influences for health from the Swedish adoption twin study of aging. Journals of Gerontology, 47, 3, 213–20.CrossRefGoogle ScholarPubMed
Helbostad, J. L., Sletvold, O. and Moe-Nilssen, R. 2004. Home training with and without additional group training in physically frail old people living at home: effect on health-related quality of life and ambulation. Clinical Rehabilitation, 18, 5, 498508.Google Scholar
Higgins, J. and Green, S. 2011. Cochrane Handbook for Systematic Reviews of Intervention. Available online at www.cochrane-handbook.org [Accessed June 2010].Google Scholar
Holtzman, R., Rebok, G., Saczynski, J., Kouzis, A., Doyle, K. and Eaton, W. 2001. Social network characteristics and cognition in middle-aged and older adults. Journals of Gerontology: Psychological Sciences, 59B, 6, 278–81.Google Scholar
Hough, J. A., Cao, X. Y. and Handy, S. L. 2008. Exploring travel behavior of elderly women in rural and small urban North Dakota: an ecological modeling approach. Transportation Research Record, 2082, 125–31.Google Scholar
Humpel, N., Owen, N. and Leslie, E. 2002. Environmental factors associated with adults’ participation in physical activity: a review. American Journal of Preventative Medicine, 22, 3, 188–99.Google Scholar
Jansen, D. A. and von Sadovszky, V. 2004. Restorative activities of community-dwelling elders. Western Journal of Nursing Research, 26, 4, 381404.Google Scholar
Johnson, W., Deary, I., McGue, M. and Christensen, K. 2009. Genetic and environmental links between cognitive and physical functions in old age. Journals of Gerontology, 64B, 1, 6572.Google Scholar
Kaplan, G. A., Strawbridge, W. J., Camacho, T. and Cohen, R. D. 1993. Factors associated with change in physical functioning in the elderly: a six-year prospective study. Journal of Aging and Health, 5, 1, 140–53.Google Scholar
Kemperman, A. and Timmermans, H. 2009. Influences of built environment on walking and cycling by latent segments of aging population. Transportation Research Record, 2143, 19.Google Scholar
King, A. C., Castro, C., Wilcox, S., Eyler, A. A., Sallis, J. F. and Brownson, R. C. 2000. Personal and environmental factors associated with physical inactivity among different racial–ethnic groups of U.S. middle-aged and older-aged women. Health Psychology, 19, 4, 354–64.CrossRefGoogle ScholarPubMed
King, W., Belle, S., Brach, J., Simkin-Silverman, L., Soska, T. and Kriska, A. 2005. Objective measures of neighbourhood environment and physical activity in older women. American Journal of Preventive Medicine, 28, 5, 461–9.Google Scholar
Knipsheer, C., Van Groenou, M., Leene, G., Beekman, A. and Deeg, D. 2000. The effects of environmental context and personal resources on depressive symptomatology in older age: a test of the Lawton model. Ageing & Society, 20, 2, 183202.Google Scholar
Kobetz, E., Daniel, M. and Earp, J. A. 2003. Neighborhood poverty and self-reported health among low-income, rural women, 50 years and older. Health and Place, 9, 3, 263–71.Google Scholar
Kowal, J. and Fortier, M. S. 2007. Physical activity behavior change in middle-aged and older women: the role of barriers and of environmental characteristics. Journal of Behavioral Medicine, 30, 3, 233–42.Google Scholar
Krause, N. 1998. Neighborhood deterioration, religious coping, and changes in health during late life. The Gerontologist, 38, 6, 653–64.Google Scholar
Kubzansky, L., Subramanian, S., Kawachi, I., Fay, M., Soobader, M. and Berkman, L. 2005. Neighborhood contextual influences on depressive symptoms in the elderly. American Journal of Epidemiology, 162, 3, 253–60.Google Scholar
Lee, H. J. 1993. Comparison of selected health behavior variables in elderly women with osteoarthritis in different environments. Arthritis Care Research, 6, 1, 31–7.Google Scholar
Levac, D., Colquhoun, H. and O'Brien, K. K. 2010. Scoping studies: advancing the methodology. Implementation Science, 5, 6978.Google Scholar
Levasseur, M., Desrosiers, J. and Noreau, L. 2004. Relationships between environment and quality of life of older adults with physical disabilities. Physical and Occupational Therapy in Geriatrics, 22, 3, 3753.CrossRefGoogle Scholar
Levasseur, M., Desrosiers, J. and St-Cyr Tribble, D. 2008. Do quality of life, participation and environment of older adults differ according to level of activity? Health & Quality of Life Outcomes, 6, 3041.Google Scholar
Li, F., Harmer, P., Cardinal, B., Bosworth, M., Johnson-Shelton, D., Moore, J., Acock, A. and Vongjaturapat, N. 2009. Built environment and 1-year change in weight and waist circumference in middle-aged and older adults. American Journal of Epidemiology, 169, 4, 401–8.Google Scholar
Lian, W., Gan, G., Pin, C., Wee, S. and Ye, H. 1999. Correlates of leisure time physical activity in an elderly population in Singapore. American Journal of Public Health, 89, 10, 1578–80.Google Scholar
Lim, K. and Taylor, L. 2005. Factors associated with physical activity among older adults: a population-based study. Preventive Medicine, 40, 1, 3340.Google Scholar
Maier, H. and Klumb, P. 2005. Social participation and survival at older ages: is the effect driven by activity, content or context. European Journal of Ageing, 2, 1, 31–9.Google Scholar
Marcellini, F., Giuli, C., Gagliardi, C. and Papa, R. 2007. Aging in Italy: urban–rural differences. Archives of Gerontology and Geriatrics, 44, 3, 243–60.Google Scholar
McAuley, E., Blissmer, B., Katula, J. and Duncan, T. E. 2000. Exercise environment, self-efficacy, and affective responses to acute exercise in older adults. Psychology & Health, 15, 3, 341–55.Google Scholar
Merkin, S. S., Roux, D., Ana, V., Coresh, J., Fried, L. F., Jackson, S. A. and Powe, N. R. 2007. Individual and neighborhood socioeconomic status and progressive chronic kidney disease in an elderly population: the Cardiovascular Health Study. Social Science and Medicine, 65, 4, 809–21.Google Scholar
Michael, Y., Green, M. and Farquhar, S. 2006. Neighborhood design and active aging. Health and Place, 12, 4, 734–40.CrossRefGoogle ScholarPubMed
Mota, J., Lacerda, A., Santos, M. P., Ribeiro, J. C. and Carvalho, J. 2007. Perceived neighborhood environments and physical activity in an elderly sample. Perceptual and Motor Skills, 104, 2, 438–44.Google Scholar
Nagel, C. L., Carlson, N. E., Bosworth, M. and Michael, Y. L. 2008. The relation between neighborhood built environment and walking activity among older adults. American Journal of Epidemiology, 168, 4, 17.Google Scholar
NHS Centre for Reviews and Dissemination 2001. Undertaking Systematic Reviews of Research on Effectiveness: CRD's Guidance for Those Carrying Out or Commissioning Reviews. University of New York, New York.Google Scholar
Niva, B. and Skar, L. 2006. A pilot study of the activity patterns of five elderly persons after a housing adaptation. Occupational Therapy International, 13, 1, 2134.Google Scholar
Parra, D. C., Gomez, L. F., Sarmiento, O. L., Buchner, D., Brownson, R., Schimd, T., Gomez, V. and Lobelo, F. 2010. Perceived and objective neighborhood environment attributes and health related quality of life among the elderly in Bogota, Colombia. Social Science and Medicine, 70, 7, 1070–6.Google Scholar
Patel, K. V., Eschbach, K., Rudkin, L. L., Peek, M. K. and Markides, K. S. 2003. Neighborhood context and self-rated health in older Mexican Americans. Annals of Epidemiology, 13, 9, 620–8.CrossRefGoogle ScholarPubMed
Petticrew, M. and Roberts, H. 2006. Systematic Reviews in the Social Sciences: A Practical Guide. Blackwell Publishing, Oxford.Google Scholar
Raina, K. D., Rogers, J. C. and Holm, M. B. 2007. Influence of the environment on activity performance in older women with heart failure. Disability & Rehabilitation, 29, 7, 545–57.Google Scholar
Richard, L., Gauvin, L., Gosselin, C. and Laforest, S. 2008. Staying connected: neighbourhood correlates of social participation among older adults living in an urban environment in Montreal, Quebec. Health Promotion International, 24, 1, 4657.Google Scholar
Salvador, E. P., Florindo, A. A., Reis, R. S. and Costa, E. F. 2009. Perception of the environment and leisure-time physical activity in the elderly. Revista de Saúde Pública, 43, 6, 972–80.Google Scholar
Schieman, S. and Meersman, S. C. 2004. Neighborhood problems and health among older adults: received and donated social support and the sense of mastery as effect modifiers. Journals of Gerontology: Psychological Sciences and Social Sciences, 59B, 2, 8997.Google Scholar
Seeman, T. E., Berkman, L. F., Charpentier, P. A., Blazer, D. G., Albert, M. S. and Tinetti, M. E. 1995. Behavioral and psychosocial predictors of physical performance: MacArthur studies of successful aging. Journals of Gerontology, 50A, 4, 177–83.Google Scholar
Seeman, T. E., Bruce, M. L. and McAvay, G. J. 1996. Social network characteristics and onset of ADL disability: MacArthur studies of successful aging. Journals of Gerontology: Psychological Sciences and Social Sciences, 51B, 4, 191200.CrossRefGoogle Scholar
Smits, C., Van Rijsselt, R., Jonker, C. and Deeg, D. 1995. Social participation and cognitive functioning in older adults. International Journal of Geriatric Psychiatry, 10, 325–31.Google Scholar
Stevenson, A., Pearce, J., Blakely, T., Ivory, V. and Witten, K. 2009. Neighbourhoods and health: a review of the New Zealand literature. New Zealand Geographer, 65, 3, 211–21.Google Scholar
Subramanian, S. V., Kubzansky, L., Berkman, L., Fay, M. and Kawachi, I. 2006. Neighborhood effects on the self-rated health of elders: uncovering the relative importance of structural and service-related neighborhood environments. Journals of Gerontology: Psychological Sciences and Social Sciences, 61B, 3, 153–60.Google Scholar
Takano, T., Nakamura, K. and Watanabe, M. 2002. Urban residential environments and senior citizens’ longevity in mega city areas: the importance of walkable green spaces. Journal of Epidemiology and Community Health, 56, 12, 913–8.Google Scholar
The Cochrane Collaboration 2011. What is Publication Bias? Available online at http://www.cochrane-net.org/openlearning/html/mod15-2.htm [Accessed August 2010].Google Scholar
Unger, J. B., Johnson, C. A. and Marks, G. 1997. Functional decline in the elderly: evidence for direct and stress buffering protective effects of social interactions and physical activity. Annals of Behavioral Medicine, 19, 2, 152–60.Google Scholar
Vik, K., Lilja, M. and Nygard, L. 2007. The influence of the environment on participation subsequent to rehabilitation as experienced by elderly people in Norway. Scandinavian Journal of Occupational Therapy, 14, 2, 8695.Google Scholar
Vik, K., Nygard, L. and Lilja, M. 2007. Perceived environmental influence on participation among older adults after home-based rehabilitation. Physical and Occupational Therapy in Geriatrics, 25, 4, 120.Google Scholar
Walker, R. B. and Hiller, J. E. 2007. Places and health: a qualitative study to explore how older women living alone perceive the social and physical dimensions of their neighbourhoods. Social Science and Medicine, 65, 6, 1154–65.Google Scholar
Walsh, K. and O'Shea, E. 2008. Responding to rural social care needs: older people empowering themselves, others and their community. Health and Place, 14, 4, 795803.Google Scholar
Walters, K., Breeze, E., Wilkinson, P., Price, G. M., Bulpitt, C. J. and Fletcher, A. 2004. Local area deprivation and urban–rural differences in anxiety and depression among people older than 75 years in Britain. American Journal of Public Health, 94, 10, 1768–74.Google Scholar
Wight, R. G., Aneshensel, C. S., Miller-Martinez, D., Botticello, A. L., Cummings, J. R., Karlamangla, A. S. and Seeman, T. 2006. Urban neighborhood context, educational attainment, and cognitive function among older adults. American Journal of Epidemiology, 163, 12, 1071–8.Google Scholar
Wilcox, S., Castro, C., King, A. C., Housemann, R. and Brownson, R. C. 2000. Determinants of leisure time physical activity in rural compared with urban older and ethnically diverse women in the United States. Journal of Epidemiology and Community Health, 54, 9, 667.CrossRefGoogle ScholarPubMed
Wiles, J., Allen, R., Palmer, A., Hayman, K., Keeling, S. and Kerse, N. 2009. Older people and their social spaces: a study of wellbeing and attachment to place in Aotearoa New Zealand. Social Science and Medicine, 68, 4, 664–71.Google Scholar
Wilmoth, J. M. 2000. Unbalanced social exchanges and living arrangement transitions among older adults. The Gerontologist, 40, 1, 6474.Google Scholar
World Health Organisation 1986. Ottawa Charter for Health Promotion. Available online at www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf [Accessed June 2010].Google Scholar
World Health Organisation 2002. Active Ageing: A Policy Framework. World Health Organisation, Geneva.Google Scholar
Yao, L. and Robert, S. A. 2008. The contributions of race, individual socioeconomic status, and neighborhood socioeconomic context on the self-rated health trajectories and mortality of older adults. Research on Aging, 30, 2, 251–73.Google Scholar
Yen, I. H., Michael, Y. L. and Perdue, L. 2009. Neighborhood environment in studies of health of older adults. A systematic review. American Journal of Preventive Medicine, 37, 5, 455–63.Google Scholar
Zeng, Y., Gu, D. N., Purser, J., Hoenig, H. and Christakis, N. 2010. Associations of environmental factors with elderly health and mortality in China. American Journal of Public Health, 100, 2, 298305.Google Scholar
Zunzunegui, M., Alvarado, B., Del Ser, T. and Otero, A. 2003. Social networks, social integration, and social engagement determine cognitive decline in community-dwelling Spanish older adults. Journals of Gerontology, 58, 2, 93100.Google Scholar