This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting,pagination and proofreading process which may lead to differences between this version and the Version of Record.
Please cite this article as an ‘Accepted Article’, doi:10.2188/jea.JE20190337
Received December 20, 2019; accepted July 27, 2020; released online September 19, 2020

Original Article

Cultural engagement and incidence of cognitive impairment: A
six-year longitudinal follow-up of the Japan Gerontological

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Evaluation Study (JAGES)

Akiho Sugitaa, Ling Lingb, Taishi Tsujic,d, Katsunori Kondod,e,

a

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r

Ichiro Kawachif

Faculty of Medicine, Chiba University, Chiba, Japanb

Graduate School of Medical and Pharmaceutical Sciences,

Faculty of Health and Sport Sciences, University of Tsukuba,

Tokyo, Japan

Center for Preventive Medical Sciences, Chiba University,

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d

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c

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Chiba University, Chiba, Japan

Chiba, Japan

Center for Gerontology and Social Science, National CenterAcefor Geriatrics and Gerontology, Aichi, Japanf

Department of Social and Behavioral Sciences, Harvard T.H.

Chan School of Public Health, Boston, Massachusetts, UnitedStates1
Copyright © 2020 Akiho Sugita et al. This is an open access article distributed under the terms of Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Corresponding author:
Katsunori Kondo, Center for Preventive Medical Sciences,1-8-1 Inohana, Chuo Ward, Chiba City, Chiba 260-8670 JapansioE-mail: kkondo@chiba-u.jp

Ver

ORCID: 0000-0003-0076-816X

Short title (Running Title): Cultural engagement and incidence

Tables: 3
Figures: 2

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Supplementary tables: 3

edof cognitive impairmentnChiba University2

Abstract
Background: Active engagement in intellectually enriching activities reportedly lowers the risk ofncognitive decline; however, few studies have examined this association, including engagement inassociated with lower risk of cognitive impairment.

siotraditional cultural activities. This study aimed to elucidate the types of cultural engagementVer

Methods: We examined the association between cultural engagement and cognitive impairment
using Cox proportional hazards models in a cohort of 44,985 participants (20,772 males and 24,213
females) aged 65 years or older of the Japan Gerontological Evaluation Study from 2010 to 2016.

ed

Intellectual activities (e.g., reading books, magazines, and/or newspapers), creative activities (e.g.,
crafts and painting), and traditional cultural activities (e.g., poetry composition [haiku], calligraphy,pt

and tea ceremony/flower arrangement) were included among cultural engagement activities.
Results: Over a follow-up period of six years, incident cognitive disability was observed in 4,198

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respondents (9.3%). After adjusting for potential confounders such as depression and social support,

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intellectual activities were protectively associated with the risk of cognitive impairment (hazard
ratio, HR for those who read and stated that reading was their hobby: 0.75 [95% confidence interval,
CI 0.66–0.85] and those who read but did not consider reading a hobby: 0.72 [95% CI, 0.65–0.80]).
Engagement in creative activities was also significantly correlated with lower risk of cognitive
impairment (crafts: 0.71 [95% CI, 0.62–0.81] and painting: 0.80 [95% CI, 0.66–0.96]). The
association between traditional cultural activities and the risk of cognitive impairment was notstatistically significant.

3Conclusions: Engagement in intellectual and creative activities may be associated with reduced riskof dementia.

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Keywords: prevention, dementia, cultural activity, reading, hobby

IntroductionVer

Societies experiencing rapid population aging are grappling with the parallel rise in cases ofdementia. There has been a rapid growth in the number of people with dementia not only in highincome countries but also low and middle-income countries.1

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In Japan, the situation is even more pressing. The estimated number of people aged 65 orolder stood at 35.89 million as of October 2019, accounting for 28.4% of the nation’s total

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population,2 with both figures hitting record highs. The share of the older population was the highest
among 263 countries and regions in the world.3 According to a government report, in 2012, one inceseven older adults aged 65 and above had dementia, with this figure estimated to reach one in nineAcpeople in 2025.4

Current pharmacological treatment of dementia (e.g., cholinesterase inhibitors and N-methyl

D-aspartate receptor antagonists) is only able to address the relief of symptoms or prevent the
progression of dementia; the damage to brain cells is permanent. Therefore, the only viable
population approach to dementia is to focus on prevention. Specifically, modifiable factors such as
cognitive training, exercise, and strong social support may be associated with increased brain andcognitive reserve.1

4

In observational studies, engagement in mentally challenging activities has been suggested to
be protectively associated with dementia risk.5-12 The effects of leisure activities (e.g., reading, radionand TV, gardening, puzzles, social visits, going to the theater, cinema, and museums)5-11 andsiocomputer use11, 12 have been evaluated.

However, such studies have not been without limitations. For example, these studies did notVercontrol for major confounders for cultural engagement, such as depression,6-8 or visual or hearing
impairment,6-9,11 as well as receiving/giving social support.5-12 Additionally, some of the “intellectual
activities” and/or “cultural activities” examined in previous studies included physical activities (e.g.,edgoing to the theater, cinema, and museums),5, 6 playing games, or simple tasks.7 Since existingstudies have shown associations between such activities and dementia or cognitive impairment,9, 10, 13

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we focused on the concept of cultural engagement in this study.
As for participation in uniquely Japanese forms of cultural engagement, including poetrycecomposition (haiku), calligraphy, tea ceremony/flower arrangement, the influences on the risk ofAcdementia remain unclear. Japan has achieved the world’s longest healthy life expectancy and life
expectancy for both sexes in 2013.14 Engagement in traditional cultural activities is possibly one of
the reasons why Japanese older people can maintain their health. In a cohort of 27 patients withneurocognitive disorders, an intervention based on a flower arrangement program improved
dysfunctions in visuospatial memory and recognition in patients.15 However, no study has examined
the long-term association between engagement in Japanese cultural activities and the risk ofcognitive deterioration among Japanese older adults living almost independent lives at baseline.

5In this study, we hypothesized that there is an association between cultural engagement(including uniquely Japanese forms of cultural activities) and cognitive impairment. We focused onnthree specific aspects: intellectual activities (e.g., reading books, magazines, and/or newspapers),siocreative activities (e.g., crafts and painting), and traditional cultural activities (e.g., poetry

composition [haiku], calligraphy, and tea ceremony/flower arrangement). We sought to investigateVerwhether forms of cultural engagement are associated with lower risk of cognitive impairment, asthese associations have not been fully identified yet.

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Material and Methods
Study sample

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The Japan Gerontological Evaluation Study (JAGES) is a nationwide cohort study established in2010 to examine prospectively the predictors of healthy aging.16 A total of 95,827 community-cedwelling people aged 65 or older in 13 municipalities within Japan were mailed our baselineAcquestionnaire from August 2010 to January 2012. Of the 62,426 individuals who responded to theinvitation (response rate 65.1%), 5,739 respondents were removed owing to missing/invalid
information about gender and/or age. After excluding an additional 1,444 respondents who did notagree to the use of their data and those with invalid ID numbers, 55,243 participants remained
available for analyses.
The questionnaire survey inquired about respondents’ personal characteristics, health status,and health habits. As shown in Fig.1, of the 55,243 eligible participants from the baseline survey, we
excluded 2,544 who were not independent in their activities of daily living (ADL). We also removed6

6,641 respondents who failed to answer the section of the survey asking about their engagement incultural activities.

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In order to address the possibility of reverse causality (i.e., low engagement in culturalsioactivities being a marker for pre-existing cognitive decline), we performed analyses excluding afurther 1,073 respondents whose follow-up periods were ≤ 1 year.

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Finally, our longitudinal sample was n = 44,985 (male: n = 20,772, female: n = 24,213).
Table 1 summarizes the characteristics of the final analytic sample. Males made up 46.2% of thesample; the mean age was 73.6 years (standard deviation 5.81). For females, the mean age was 73.9

edyears (standard deviation 5.97).

During 242,934 person-years of follow-up (mean 1,971 and maximum 2,328 days), cognitivept

impairment developed in 4,198 cases (9.3%) (Table A.1.). The overall incidence rate was 17.28 per
1,000 person-years. For males, during 110,947 person-years of follow up (mean 1,950 days),cecognitive impairment developed in 1,821 cases (1.6%). The overall incidence rate was 16.4 per 1,000

Acperson-years. For females, during 131,988 person-years of follow up (mean 1,990 days), cognitive
impairment developed in 2,377 cases (1.8%). The overall incidence rate was 18.0 per 1,000 personyears.

Outcome variable
Our primary outcome was cognitive impairment. Participants in our study were linked to Japan’sLong-Term Care Insurance (LTCI) registry, which includes a standardized in-home assessment ofcognitive disability.17 Registration in the national LTCI scheme is mandatory, and each applicant
7requesting long-term care is assessed for eligibility to receive services (e.g., home help) by a team oftrained investigators dispatched from the certification committee in each municipality. During thenhome visit, each individual is assessed with regard to their ADL and instrumental ADL, cognitivesiofunctioning (e.g., short-term memory, orientation, and communication) as well as mental andbehavioral disorders (e.g., delusions of persecution and confabulation) using a standardized protocol.

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Following the assessment, the applicants are classified into one of 8 levels (0: Independent to 7:
Needs constant treatment in a specialized medical facility) according to the severity of their
cognitive disability status. The resulting index of cognitive disability is strongly correlated with theed

Mini-Mental State Examination (Spearman’s rank correlation r = −0.73, p < 0.001)18 and level 1 ofthe cognitive decline scale has been demonstrated to correspond with a 0.5 point rating on theptClinical Dementia Rating scale (specificity and sensitivity 0.88, respectively).19 The initialmonths.

cecertification is valid for six months, after which periodic re-assessments are conducted every 12

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In the present study, we defined our outcome as being certified as level 2 or higher (a state inwhich a subject at least manifests some symptoms, behaviors, or communication difficulties thatmight hinder daily activities).20, 21

Explanatory variable
First, participants were asked “Do you have any hobbies, or are you taking any lessons?” If theyanswered “yes,” they were asked to choose all activities they were engaged in from among the 25
choices mentioned on the questionnaire. Among all the activities included in the questionnaire, we
8defined cultural engagement as activities that did not involve physical activities (such as golf, groundgolf, gate ball, walking/jogging, etc.), nor playing games such as mahjong or interacting with the PC.

nThus, among intellectual-cultural or cognitive leisure activities described in previous studies, 5-12, 22sioreading books, magazines, and/or newspapers; crafts; and painting were selected as representing
forms of cultural engagement. Traditional Japanese cultural activities including poetry compositionVer(haiku), calligraphy, and tea ceremony/flower arrangement also met our criteria.

As for reading, we divided respondents into three groups based on the results of the survey on
their hobbies and their answers to two questions: “Do you read newspapers?” and “Do you readedbooks or magazines?” The three groups were as follows: 1) those who read books, magazines, and/or
newspapers and stated that reading was a hobby, 2) those who read books, magazines, and/or

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newspapers but stated that reading was not a hobby, and 3) those who did not read (control group).

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Covariates and mediators

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Following previous reports, we included basic demographic information, including age (65–69, 70–
74, 75–79, 80–84, or ≥ 85 years),19 educational level (< 6 years, 6–9 years, 10–12 years, or ≥ 13
years),1 household equivalized income (low: < 2,000,000 yen, middle: 2,000,000–3,999,999 yen, or
high: ≥ 4,000,000 yen),23 marital status (married, widowed/divorced, or unmarried), and employment
status (employed, not working [never been employed or retired]).24 We also included otherpotentially modifiable risk factors for dementia that could influence participation in culturalactivities, i.e. variables that could confound the association between our exposure and outcome:hearing loss, hypertension, obesity, smoking, diabetes, physical inactivity, and depression.1 We
9evaluated physical activity in terms of hours of walking per day and frequency of going out.
Depressive symptoms were measured by the Geriatric Depression Scale-15 (GDS-15), with mildndepression defined as a score of ≥ 5 points and severe depression as ≥ 10 points.25 We includedsioalcohol consumption as an additional covariate,26 as well as visual impairment because it can affectreading habits.

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We also assessed variables that could potentially mediate the association between cultural
engagement and cognitive impairment. Social support is a potential mediator, i.e. engagement incultural activities increases social interaction with other people, thereby raising the probability ofedreceiving/giving social support to others.

Following previous JAGES cohort studies, social support was assessed in terms of fourptvariables: receiving or providing emotional support, and receiving or providing instrumental
support.20, 25, 27 We assessed emotional support by asking “Do you have someone who listens to yourceconcerns and complaints?” and “Do you listen to someone’s concerns and complaints?” WeAc

measured instrumental support by asking “Do you have someone who looks after you when you aresick and confined to the bed for a few days?” and “Do you look after someone when he/she is sickand confined to the bed for a few days?” We also included frequency of contact with friends (never,once or twice a month, about once a week, two to three times a week, or almost daily).

Statistical analysis
We calculated descriptive statistics for all variables and confirmed gender differences through thechi-square test. A Cox proportional hazards model was employed to determine the association
10

between cultural engagement variables and incident cognitive impairment. The interaction term
between gender and cultural engagement was not statistically significant. Therefore, we performednthe analyses without gender stratification. The cultural engagement variables were added separately.

sioIn Model 1, we statistically adjusted for age, education, equivalent income, marital status,

employment status, hearing loss, hypertension, obesity, smoking, diabetes, hours of walking per day,Verfrequency of going out, depression, visual impairment, and alcohol consumption. In Model 2, weadded social support and network as potential mediators of the association between cultural
engagement and cognitive impairment.

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In the analyses, we excluded respondents who developed cognitive impairment within one
year of the baseline questionnaire to exclude reverse causality.

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The significance level was set at p < 0.05. Statistical analyses were performed using IBM®

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SPSS® Statistics V25 (Armonk, NY: IBM Corp).

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Ethical considerations

The JAGES protocol was reviewed and approved by the Ethics Committee on Research of Human
Subjects at Nihon Fukushi University (approval No. 1005) and the Ethics Committee at the
Chiba University Faculty of Medicine (approval No. 2493).

Results
Gender differences in cultural engagement

11

The chi-square test revealed the existence of gender differences in each category (Tables 1 and 2).
Male and female respondents reported different activity profiles (Table 2). Males reported slightlynhigher engagement in intellectual activities (e.g., reading books, magazines, and/or newspapers)siocompared to females, regardless of whether reading was a hobby. However, females showed higher
involvement in other forms of cultural engagement, including creative activities (e.g., crafts andVerpainting) and traditional cultural activities (e.g., poetry composition [haiku], calligraphy, and tea
ceremony/flower arrangement).

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Cultural engagement in relation to cognitive impairment

The results from Models 1 and 2 of the Cox proportional hazards analyses are depicted in Table 3,pt

including HRs and 95% CIs for the outcomes and covariates. Model 2 includes the 15 variables from
Model 1 and an additional 5 variables related to social support and network.

ceIntellectual activities (e.g., reading books, magazines, and/or newspapers) were significantlyAc

related to reduced risk of cognitive impairment after adjustment for all covariates. In Model 2, forthose who read and stated that reading was their hobby, the HR was 0.75 (95% CI, 0.66–0.85). Those
who read but did not consider reading a hobby showed a similar trend in the risk of cognitive
impairment (0.72 [95% CI, 0.65–0.80]). Figure 2 depicts the Kaplan-Meier curves for the cumulativerisk of developing cognitive impairment according to whether participants read books, magazines,
and/or newspapers, and whether or not reading was a hobby.
Involvement in creative activities such as crafts (0.71 [95% CI, 0.62–0.81]) and painting(0.80 [95% CI, 0.66–0.96]) was also related to a significant decline in the risk of cognitive12

impairment. Writing short poems (0.93 [95% CI, 0.78–1.12]), calligraphy (0.91 [95% CI, 0.77–
1.08]), and tea ceremonies/flower arrangement (0.96 [95% CI, 0.78–1.18]) were associated withnreduced HRs of cognitive impairment in Model 1; however, none reached statistical significance.

sioEngagement in Japanese traditional cultural activities was not significantly associated with the riskof cognitive impairment.

Ver

The development of cognitive impairment according to the number of cultural engagement
forms at baseline (Table A.2.) and the risk of cognitive impairment according to the number ofedcultural engagement forms at baseline (Table A.3.) are shown in the supplemental materials.

Discussion

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Of the three types of cultural engagement we examined, in a large sample of Japanese older adults,
intellectual activities (e.g., reading books, magazines, and/or newspapers) and creative activities

ce(e.g., crafts and painting) were significantly protectively associated with cognitive impairment, whileAc

involvement in traditional cultural activities was not significantly associated with the risk ofcognitive impairment.
In the present study, we showed that being engaged in reading books, magazines, and/or

newspapers was associated with a lower risk of subsequent cognitive impairment. Participation incrafts or painting was also related to a decreased risk of cognitive impairment. These findings wererobust even after adjustment for potential confounding variables such as age, educational level,
health status, depressive symptoms, physical exercise level, and social capital. This study, conducted13

using population-based data, suggests that there may be potential benefits of cultural engagement
activities at the population level.

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Our findings are consistent with previous reports showing the efficacy of reading in thesiocontext of cognitive impairment prevention. Although many researchers have grouped reading withintellectual-cultural or cognitive leisure activities, some studies have directly clarified theVerrelationship between reading and dementia. Geda et al. reported that reading books was associatedwith decreased odds of mild cognitive impairment.11 Verghese et al. reported that those who readseveral times per week had a decreased risk of dementia compared to those who read once per weekedor less frequently.28

Our results suggested that respondents who were engaged in reading had a lower risk ofpt

cognitive impairment than those who do not, whether or not reading was a hobby. Reading itself may
enhance brain stimulation. However, this cannot be conclusively stated as the JAGES did not inquireceabout the frequency or purposes of reading.

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We showed that those engaged in creative activities (e.g., crafts and painting) had asignificantly lower risk of cognitive impairment. Crafts such as knitting, quilting, and pottery arereportedly significantly associated with decreased risk of mild cognitive impairment11 or dementia.9
According to a recent survey on healthy aging in Korea29, an eight-week program combining
physical and recreational activity and art, including crafts (making cards, clay pendants, pressed
flowers, mandala mobiles, and eco-bags), had positive effects on cognitive function evaluated with
the MMSE-Korean. In our study, arts and crafts programs were particularly favored by females,

14which is consistent with previous reports,29, 30 although the Japanese word for “crafts” on ourquestionnaire covered knitting, sewing, beadwork, and quilting.

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Painting has been classified as producing art,22 or an expressive activity.31 Crafts can besiocategorized as such because they require creativity. It is reported that a 12-week combined program
including painting helped patients with mild Alzheimer’s disease preserve their global cognitiveVerfunction and improved their performance on attention tasks.31 Engagement in coloring or painting
positively affected behavioral symptoms in patients with dementia in a nursing home.30 Our results
suggest that painting and/or making hand-drawn postcards can also help prevent dementia in healthyedolder people.

It has been reported that a daily routine of 25 minutes of passive finger exercises

ptincorporating several movements led to improved overall ADL in older adults with dementia.32
Finger activities through crafts or painting might have had a positive effect in helping preventce

cognitive impairment.

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To the best of our knowledge, this is the first study focusing on the effects of Japanesetraditional cultural engagement on the risk of cognitive impairment. Disappointingly, no significant
associations were found. Japanese care facilities for older adults often incorporate cultural pursuits
for the rehabilitation and maintenance of functional and cognitive capacity.33 We expectedengagement in haiku composition, calligraphy, and tea ceremony/flower arrangement to stimulatecognitive functions, as these activities involve mental discipline and training. Although weinvestigated a large sample of Japanese older people, our analysis revealed no significant association
between engagement in Japanese traditional cultural activities and cognitive impairment. In theory,15

traditional cultural activities are enjoyed on special occasions, such as New Year’s, and may often
require a significant investment of time, money, in terms of cost of lessons, and basic instruments.

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Therefore, although a considerable number of participants reported engaging in popular Japanesetraditional cultural activities may delay cognitive deterioration.

siocultural activities, they might not practice these activities regularly. Routine or daily engagement inVe
r

Males reported slightly higher engagement in intellectual activities (e.g., reading books,
magazines, and/or newspapers) compared to females, regardless of whether reading was a hobby.
Females showed higher involvement in creative activities (e.g., crafts and painting), and traditionaledcultural activities (e.g., poetry composition [haiku], calligraphy, and tea ceremony/flower
arrangement). Therefore, even though the HRs for cognitive impairment are indistinguishablept

between male and female participants, it is suggested that males benefit more than females from
intellectual activities at a population level whereas females may benefit more than males fromce

creative activities and traditional cultural activities. Gender differences were described in a

Acprospective study of Swedish twins, which showed that greater participation in intellectual-culturalactivities (e.g., reading, listening to the radio or watching television, social visits, and culturalactivities such as going to the theater and cinema) was associated with a lower risk of Alzheimer’s
disease in females but not males.8
Recent studies have shown the association between greater participation in leisure activities
and a decreased risk of dementia.5, 9, 10 In the present study, those engaged in at least one culturalactivity showed a lower risk of cognitive impairment than those engaged in none. However, the risk16

of cognitive impairment was almost the same between those engaged in at least one cultural activity
and those engaged in two or more (Table A.3.).

nAlthough the mechanisms that mediate between cultural activities and cognitive impairmentsioremain unclear, acquired hippocampal neurogenesis can be cited to explain our results. Garthe et al.
demonstrated that mice living in a stimulus-rich, cognitively challenging environment demonstratedVer

improved water maze learning and that they benefited to the extent relevant to adult hippocampal
neurogenesis.34 This concept of acquired hippocampal neurogenesis can be supported by clinical or
epidemiological studies involving humans.13, 22 Cultural engagement could also help to preserveedcognitive function by promoting social interactions (which have been independently shown toprevent the onset of dementia). However, comparing the results of Model 1 and Model 2, the HRs

pt

were almost the same; therefore, we could not find evidence of mediation by social support orfrequency of meeting friends. Of course, reading is a solitary activity, and we did not expect to see

cemediation by social support. However, crafts and painting are often performed in the context ofAcsocial participation. Nevertheless, the HRs did not change after adjusting for social support andnetwork in Model 2. Hence we did not find evidence of mediation by social support, leaving thepossibility that cultural engagement may enhance brain stimulation directly, thereby helping topreserve cognitive function.
Despite the importance of the findings, several limitations of our study must be noted. First,
as we defined cognitive impairment based on functional impairment or behavioral/communicationdifficulties resulting from dementia symptoms, we did not classify the types of dementia such as
Alzheimer type, vascular dementia, or other treatable dementia. Second, since our questionnaire17consisted of yes/no questions about hobbies and reading habits, we considered neither timecommitment nor the frequency of cultural engagement. Finally, we examined one cohort, and

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verification in other cohorts, such as those including other racial or ethnic groups, is required.

ConclusionVer

In conclusion, the present analyses demonstrate that certain types of cultural engagement could
provide opportunities to prevent dementia in older adults. Intellectual activities such as reading were
protectively associated with cognitive impairment. It is also possible that creative activities such ased

crafts and painting are related to a reduced risk of cognitive impairment.

In future, there is a need for experimental and prospective longitudinal studies with longerpt

durations and involving detailed assessment of the frequency and contents of cultural engagement
and cognitive impairment to demonstrate the mechanisms underlying the results reported here.

ceIncreasing opportunities for community participation in these forms of cultural engagement throughAc

the establishment of clubs and circles may be effective in preventing dementia.

Acknowledgments

This study used data from the JAGES, conducted by the Nihon Fukushi University Center for WellBeing and Society. We are extremely grateful to all study participants for the use of their personal
data. We would like to express our deepest gratitude to everyone who participated and cooperated in
the survey.

18Authors’ contributions
Data Curation: AS and LL. Formal analysis: AS and LL. Writing-original draft: AS. Writing-reviewn& editing: TT, KK and IK. Supervision: TT, KK and IK. All authors read and approved the ﬁnal

sioversion of the manuscript.

Ver

Conflicts of interest

Dr. Kondo reports grants from The Ministry of Health, Labour and welfare, grants from Japan
Agency for Medical Research and Development (AMED), grants from Japan Science andedTechnology Agency (JST), grants from Japan Society for the Promotion of Science (JSPS), grants
from National Center for Geriatrics and Gerontology, during the conduct of the study; grants frompt

Ryobi Systems co., ltd., grants from RESOL SEIMEI NO MORI, grants from NEC Corporation,

Ac

Fundingceoutside the submitted work; .

This study used data from JAGES (the Japan Gerontological Evaluation Study).This study was
supported by JSPS (Japan Society for the Promotion of Science) KAKENHI Grant Number
JP15H01972, Health Labour Sciences Research Grant (H28-Choju-Ippan-002), Japan Agency for
Medical Research and Development (AMED) (JP17dk0110017, JP18dk0110027, JP18ls0110002,
JP18le0110009, JP19dk0110034, JP19dk0110037), Open Innovation Platform with Enterprises,
Research Institute and Academia (OPERA, JPMJOP1831) from the Japan Science and Technology
(JST)
19

Appendix
Table A.1. Sequential exclusion of respondents depending on the follow-up periods.

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Table A.2. Development of cognitive impairment according to numbers of cultural engagementsioforms at baseline.

Table A.3. Risk of cognitive impairment according to the numbers of cultural engagement forms atVerbaseline.

References

Livingston G, Sommerlad A, Orgeta V, et al. Dementia prevention, intervention, and care.

Lancet. 2017;390:2673-2734.

Statistics Bureau of Japan. Population estimates by age (five-year groups) and sex.

pt

2.

ed

1.

http://www.stat.go.jp/english/data/jinsui/2019np/index.html#a15k01-a Accessed 20.07.02.
The World Bank. Population ages 65 and above (% of total population).

ce

3.

Ac

https://data.worldbank.org/indicator/SP.POP.65UP.TO.ZS?most_recent_year_desc=true&view=map/ 2019 Accessed 19.09.23.
4.

Cabinet Office. The estimated number of older people suffering from dementia (in Japanese).

https://www8.cao.go.jp/kourei/whitepaper/w-2017/html/gaiyou/s1_2_3.html Accessed 20.06.30.
5.

Fancourt D, Steptoe A, Cadar D. Cultural engagement and cognitive reserve: museum

attendance and dementia incidence over a 10-year period. Br J Psychiatry. 2018;213:661-663.

20

6.

Hassing LB. Gender differences in the association between leisure activity in adulthood andcognitive function in old age: a prospective longitudinal population-based study. J Gerontol B

Lam LC, Ong PA, Dikot Y, et al. Intellectual and physical activities, but not social Activities,

si
o

7.

n

Psychol Sci Soc Sci. 2020;75:11-20.

are associated with better global cognition: A multi-site evaluation of the cognition and lifestyle

8.

Ve
r

activity study for seniors in Asia (CLASSA). Age Ageing. 2015;44:835-40.

Crowe M, Andel R, Pedersen NL, Johansson B, Gatz M. Does participation in leisureactivities lead to reduced risk of Alzheimer’s disease? A prospective study of Swedish twins. J

9.

ed

Gerontol B Psychol Sci Soc Sci. 2003;58:249-255.

Hughes TF, Chang CC, Vander Bilt J, Ganguli M. Engagement in reading and hobbies andptrisk of incident dementia: the MoVIES project. Am J Alzheimers Dis Other Demen. 2010;25:432438.

Verghese J, Lipton RB, Katz MJ, et al. Leisure activities and the risk of dementia in the

ce

10.

Ac

elderly. N Engl J Med. 2003;348:2508-2516.
11.

Geda YE, Topazian HM, Roberts LA, et al. Engaging in cognitive activities, aging, and mild

cognitive impairment: a population-based study. J Neuropsychiatry Clin Neurosci. 2011;23:149-154.
12.

Almeida OP, Yeap BB, Alfonso H, Hankey GJ, Flicker L, Norman PE. Older men who use

computers have lower risk of dementia. PLoS One. 2012;7:e44239.
13.

Tan ZS, Spartano NL, Beiser AS, et al. Physical activity, brain volume, and dementia risk:

the Framingham study. J Gerontol A Biol Sci Med Sci. 2017;72:789-795.

21

14.

Tokudome S, Hashimoto S, Igata A. Life expectancy and healthy life expectancy of Japan:

the fastest graying society in the world. BMC Res Notes. 2016;9:482.
Mochizuki-Kawai H, Kotani I, Mochizuki S, Yamakawa Y. Structured floral arrangement

n

15.

16.

si
o

program benefits in patients with neurocognitive disorder. Front Psychol. 2018;9:1328.

Kondo K, Rosenberg M, World Health Organization. Advancing universal health coverageVerthrough knowledge translation for healthy ageing: lessons learnt from the Japan Gerontological
Evaluation Study. https://apps.who.int/iris/handle/10665/279010. License: CC BY-NC-SA 3.0 IGO
Accessed 20.07.13.

Tamiya N, Noguchi H, Nishi A, et al. Population ageing and wellbeing: lessons from Japan's

ed

17.

long-term care insurance policy. Lancet. 2011;378:1183-1192.
Hisano S. Kaitei Hasegawa shiki Kan'i Chinou Hyouka Scale (HDS-R), Mini-Mental State

pt

18.

Examination (MMSE) to Syōgai Rōjin no Nichijyō Seikatsu Jiritsu do no Kanren ni tsuite. [Thecerelationship between Revised Hasegawa Dementia Scale (HDS-R), Mini-Mental State ExaminationAc(MMSE) and Bed-fast Scale, Dementia Scale] (in Japanese). Jpn J Geriatr Psychiatry. 2009;20:883891.
19.

Meguro K, Tanaka N, Kasai M, et al. Prevalence of dementia and dementing diseases in theold-old population in Japan: the Kurihara Project. Implications for long-term care insurance data.
Psychogeriatrics. 2012;12:226-234.
20.

Saito T, Murata C, Saito M, Takeda T, Kondo K. Influence of social relationship domains

and their combinations on incident dementia: a prospective cohort study. J Epidemiol Community
Health. 2018;72:7-12.
22

21.

Murata C, Takeda T, Suzuki K, Kondo K. Positive affect and incident dementia among theold. Journal of Epidemiological Research. 2016;2:118-124.
Sumowski JF, Rocca MA, Leavitt VM, et al. Searching for the neural basis of reserve against

n

22.

si
o

memory decline: intellectual enrichment linked to larger hippocampal volume in multiple sclerosis.
Eur J Neurol. 2016;23:39-44.

Takasugi T, Tsuji T, Nagamine Y, Miyaguni Y, Kondo K. Socio-economic status and

Ve
r

23.

dementia onset among older Japanese: A 6-year prospective cohort study from the Japan
Gerontological Evaluation Study. Int J Geriatr Psychiatry. 2019;34:1642-1650.
Sommerlad A, Sabia S, Singh-Manoux A, Lewis G, Livingston G. Association of social

ed

24.

contact with dementia and cognition: 28-year follow-up of the Whitehall II cohort study. PLoS Med.

25.

pt

2019;16:e1002862.

Haseda M, Kondo N, Ashida T, Tani Y, Takagi D, Kondo K. Community social capital, built

ceenvironment, and income-based inequality in depressive symptoms among older people in Japan: anAcecological study from the JAGES Project. J Epidemiol. 2018;28:108-116.
26.

Bellou V, Belbasis L, Tzoulaki I, Middleton LT, Inonnadis JPA, Evangelou E. Systematic

evaluation of the associations between environmental risk factors and dementia: An umbrella review
of systematic reviews and meta-analyses. Alzheimers Dement. 2017;13:406-418.
27.

Koga C, Hanazato M, Tsuji T, Suzuki N, Kondo K. Elder abuse and social capital in older

adults: The Japan Gerontological Evaluation Study. Gerontology. 2020;66:149-159.
28.

Verghese J, LeValley A, Derby C, et al. Leisure activities and the risk of amnestic mild

cognitive impairment in the elderly. Neurology. 2006;66:821-827.
23

29.

Kim D. The effects of a combined physical activity, recreation, and art and craft program on

ADL, cognition, and depression in the elderly. J Phy Ther Sci. 2017;29:744-747.
Cohen-Mansfield J, Marx MS, Dakheel-Ali M, Thein K. The use and utility of specific

n

30.

si
o

nonpharmacological interventions for behavioral symptoms in dementia: an exploratory study. Am J
Geriatr Psychiatry 2015;23:160-170.

Viola LF, Nunes PV, Yassuda MS, et al. Effects of a multidisciplinary cognitive

Ve
r

31.

rehabilitation program for patients with mild Alzheimer’s disease. Clinics (Sao Paulo).
2011;66:1395-1400.

Liu B, Chen X, Li Y, Liu H, Guo S, Yu P. Effect of passive finger exercises on grip strength

ed

32.

and the ability to perform activities of daily living for older people with dementia: a 12-week

33.

pt

randomized controlled trial. Clin Interv Aging. 2018;13:2169-2177.
Annear MJ, Otani J, Sun J. Experiences of Japanese aged care: the pursuit of optimal health

Garthe A, Roeder I, Kempermann G. Mice in an enriched environment learn more flexibly

Ac

34.

ce

and cultural engagement. Age and Ageing. 2016;45:753-756.

because of adult hippocampal neurogenesis. Hippocampus. 2016;26:261-271.

Figure legends
Figure 1. Participants flow for analytic sample.
Figure 2. Kaplan-Meier curves for the cumulative risk of developing cognitive impairment according
to whether participants read books, magazines, and/or newspapers, and whether or not reading was ahobby.
24

Table 1. Characteristics of respondents by gender (baseline survey in 2010)
All (n = 44,985)nMale (n = 20,772)

%

n

%

Female (n = 24,213)
n

%

90.7
9.3
100.0

18,951
1,821
20,772

91.2
8.8
100.0

21,836
2,377
24,213

90.2
9.8
100.0

12,92813,902
10,1715,541
2,443
44,985

28.7
30.9
22.6
12.3
5.4
100.0

6,112
6,409
4,671
2,575
1,005
20,772

29.4
30.9
22.5
12.4
4.8
100.0

6,816
7,493
5,500
2,966
1,438
24,213

28.2
30.9
22.7
12.2
5.9
100.0

931
20,45014,932
7,717
955
44,985

2.1
45.5
33.2
17.2
2.1
100.0

284
8,847
6,634
4,676
331
20,772

1.4
42.6
31.9
22.5
1.6
100.0

647
11,603
8,298
3,041
624
24,213

2.7
47.9
34.3
12.6
2.6
100.0

18,185
14,686
4,304
7,810
44,985

40.4
32.6
9.6
17.4
100.0

8,494
7,697
2,170
2,411
20,772

40.9
37.1
10.4
11.6
100.0

9,691
6,989
2,134
5,399
24,213

40
28.9
8.8
22.3
100.0

32,17911,872934
44,985

71.5
26.4
2.1
100.0

17,911
2,493
368
20,772

86.2
12
1.8
100.0

14,2689,379
566
24,213

58.9
38.7
2.3
100.0

5,137
24,6399,713
5,496
44,985

11.4
54.8
21.6
12.2
100.0

821
12,692
5,886
1,373
20,772

4.0
61.1
28.3
6.6
100.0

4,316
11,947
3,827
4,123
24,213

17.8
49.3
15.8
17
100.0

16,322
17,89910,76444,985

36.3
39.8
23.9
100.0

7,602
7,956
5,214
20,772

36.6
38.3
25.1
100.0

8,720
9,943
5,550
24,213

36
41.1
22.9
100.0

28,684
5,537
10,76444,985

63.8
12.3
23.9
100.0

12,447
3,111
5,214
20,772

59.9
15
25.1
100.0

16,2372,426
5,550
24,213

67.1
10
22.9
100.0

32,6201,601
10,76444,985

72.5
3.6
23.9
100.0

14,928630
5,214
20,772

71.9
3
25.1
100.0

17,692971
5,550
24,213

73.1
4
22.9
100.0

31,053
3,168
10,76444,985

69.0
7.0
23.9
100.0

14,023
1,535
5,214
20,772

67.5
7.4
25.1
100.0

17,0301,633
5,550
24,213

70.3
6.7
22.9
100.0

28,136
6,085
10,76444,985

62.5
13.5
23.9
100.0

13,1082,450
5,214
20,772

63.1
11.8
25.1
100.0

15,0283,635
5,550
24,213

62.1
15
22.9
100.0

27,423
1,490
15,328744
44,985

61.0
3.3
34.1
1.7
100.0

7,579
1,258
11,741
194
20,772

36.5
6.1
56.5
0.9
100.0

19,844
232
3,587
550
24,213

82
1
14.8
2.3
100.0

25,377
12,253
4,779
2,576
44,985

56.4
27.2
10.6
5.7
100.0

5,203
11,062
4,020
487
20,772

25
53.3
19.4
2.3
100.0

20,174
1,191
759
2,089
24,213

83.3
4.9
3.1
8.6
100.0

9,176
14,927
19,705
1,177
44,985

20.4
33.2
43.8
2.6
100.0

1,161
6,767
12,679165
20,772

5.6
32.6
61
0.8
100.0

8,015
8,160
7,026
1,012
24,213

33.1
33.7
29
4.2
100.0

2,901
16,915
24,590579
44,985

6.4
37.6
54.7
1.3
100.0

1,161
6,767
12,679165
20,772

5.6
32.6
61
0.8
100.0

1,740
10,148
11,911
414
24,213

7.2
41.9
49.2
1.7
100.0

27,867
7,831
2,468
6,819
44,985

61.9
17.4
5.5
15.2
100.0

13,346
3,802
1,205
2,419
20,772

64.2
18.3
5.8
11.6
100.0

14,521
4,029
1,263
4,400
24,213

60
16.6
5.2
18.2
100.0

2,393
41,212
1,380
44,985

5.3
91.6
3.1
100.0

1,594
18,580598
20,772

7.7
89.4
2.9
100.0

799
22,632782
24,213

3.3
93.5
3.2
100.0

2,855
40,387
1,743
44,985

6.3
89.8
3.9
100.0

1,637
18,468667
20,772

7.9
88.9
3.2
100.0

1,218
21,9191,076
24,213

5
90.5
4.4
100.0

1,985
41,838
1,162
44,985

4.4
93.0
2.6
100.0

859
19,506407
20,772

4.1
93.9
2
100.0

1,126
22,332755
24,213

4.7
92.2
3.1
100.0

4,759
37,932
2,294
44,985

10.6
84.3
5.1
100.0

2,062
17,948762
20,772

9.9
86.4
3.7
100.0

2,697
19,984
1,532
24,213

11.1
82.5
6.3
100.0

10,146

22.6

6,194

29.8

3,952

16.3

8,739

19.4

4,209

20.3

4,530

18.7

About once a week
7,593
2–3 times a week
10,350Almost daily
6,371
Missing data
1,786
Total
44,985* Total may not become 100.0 % due to rounding off.

16.9
23.0
14.2
4.0
100.0

3,262
3,842
2,639
626
20,772

15.7
18.5
12.7
3
100.0

4,331
6,508
3,732
1,160
24,213

17.9
26.9
15.4
4.8
100.0

< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01< 0.01ed< 0.01< 0.01pt< 0.01ce< 0.01

Ac
Once or twice a monthsio< 0.01< 0.01< 0.01< 0.01< 0.01

Providing instrumental support
No
Yes
Missing data
Total
Frequency of meeting friends
Never

n

< 0.01

Receiving instrumental support
No
Yes
Missing dataTotal

p -value< 0.0140,787
4,198
44,985Ve
r

Characteristics
Level of cognitive impairment
0,1
2-7
Total
Age (years)
65–69
70–74
75–79
79–84
85+
Total
Educational attainment (years)
<6
6–9
10–12
≥ 13
Missing data
Total
Equivalized income (time-invariant
variable) (JPY)< 2 million
2–4 million≥ 4 million
Missing data
Total
Marital status
MarriedSingleMissing data
Total
Working status
Never worked
Stopped working
Currently working
Missing data
Total
Hypertension
No
Yes
Missing data
Total
DiabetesNo
Yes
Missing data
Total
ObesityNo
YesMissing data
Total
Hearing impairment
No
Yes
Missing data
Total
Visual impairment
No
Yes
Missing data
Total
Drinking habit
Never drankStopped drinking
Current drinker
Missing data
Total
Smoking habit
Never smoked
Stopped smoking
Current smoker
Missing data
Total
Walking time (minutes)
< 30
30–59
≥ 60
Missing data
Total
Frequency of going out
RarelyAbout once a week
Almost daily
Missing data
Total
Depression symptoms (GDS-15
points)≤4
5–9≥ 10Missing data
Total
Receiving emotional support
No
Yes
Missing data
Total
Providing emotional support
No
Yes
Missing data
Total

< 0.01< 0.01

Table 2. Types of cultural engagement
All (n = 44,985)
n%Cultural Engagement

Intellectual Activities
Reading books, magazines, and/or newspapers
Don't read
2,407
Read but it is not a hobby
35,413
Read as a hobby
7,165

Male (n = 20,772)
n
%

5.4
78.7
15.9

CraftsdetpPaintingeccANot a hobby
Hobby

Traditional Cultural Activities
Poetry composition (haiku )Not a hobby
Hobby
Calligraphy
Not a hobby
Hobby
Tea ceremony/flower arrangement
Not a hobby
Hobby

41,2203,765
43,1591,826

p -value< 0.01Creative Activities
Not a hobby
Hobby

Female (n = 24,213)
n
%

91.6
8.4
95.9
4.1

743
16,432
3,597

3.6
79.1
17.3

20,175
597

98.7
1.3
97.1
2.9

6.9
78.4
14.7

n
o
i
s

r
e
V

20,492280

1,664
18,981
3,568

20,7283,485< 0.0185.6
14.4< 0.01
22,984
1,229

94.9
5.1

< 0.01
43,861
1,124

97.5
2.5

20,356
416

98.0
2.0

23,505
708

97.1
2.9
< 0.01

43,312
1,673

96.3
3.7

20,267
505

97.6
2.4

23,045
1,168

95.2
4.8
< 0.01

43,788
1,197

97.3
2.7

20,697
75

99.6
0.4

23,091
1,122

95.4
4.6

Table 3. Risk of cognitive impairment according to frequency of participation in cultural engagement at baseline (excluding
respondents whose follow-up periods were ≤ 1 year, n = 44,985)

Cultural Engagement

Model 1Model 2

Hazard Ratio for Cognitive Impairment(95% CI)Intellectual Activities
Reading books, magazines, and/or
newspapers
Don't read
Read as a hobby
Read but it is not a hobby

1.00
0.72 (0.63–0.82)
0.71 (0.64–0.78)

1.00
0.75 (0.66–0.85)
0.72 (0.65–0.80)

1.00
0.69 (0.61–0.79)

1.00
0.71 (0.62–0.81)

1.00
0.78 (0.65-0.94)

1.00
0.80 (0.66–0.96)

Creative Activities
CraftsNot a hobby
Hobby

d
e
t
p

Painting
Not a hobby
Hobby

e
c
c
A

r
e
V

n
o
i
s

Traditional Cultural Activities
Poetry composition (haiku )Not a hobby
1.00
1.00
Hobby
0.93 (0.78–1.12)
0.97 (0.81–1.17)
Calligraphy
Not a hobby
1.00
1.00
Hobby
0.91 (0.77–1.08)
0.93 (0.79–1.10)
Tea ceremony/flower arrangement
Not a hobby
1.00
1.00
Hobby
0.96 (0.78–1.18)
1.00 (0.81–1.22)* Model 1 was adjusted for age, education, equivalent income, marital status, employment status,
hearing loss, hypertension, obesity, smoking, diabetes, hours of walking per day, frequency of going out, depression,visual impairment, and drinking habit; Model 2 includes the variables in Model 1, receiving or providing emotional
support, receiving or providing instrumental support, and frequency of meeting friends. CI denotes confidence interval.

e
c
c
A

d
e
t
p

r
e
V

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i
s

e
c
c
A

d
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t
p

r
e
V

n
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s