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Preplanned Studies: COVID-19 Stay-At-Home Orders and Older Adults’ Cognitive Health — United States, June 2018–February 2022

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  • Summary

    What is already known about this topic?

    Lack of social activities is known to negatively impact cognitive functioning and increase risk of cognitive impairment, including dementia, among older adults.

    What is added by this report?

    Coronavirus disease 2019 (COVID-19) stay-at-home orders implemented in the U.S. early during the pandemic were not found to negatively affect cognitive functioning of older adults.

    What are the implications for public health practice?

    There may have been no severe, unintended consequences of the COVID-19 stay-at-home orders in terms of their impact on cognitive functioning and risk of dementia among older adults, lending further support to use of such orders.

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  • [1] Pais R, Ruano L, Carvalho OP, Barros H. Global cognitive impairment prevalence and incidence in community dwelling older adults—a systematic review. Geriatrics 2020;5(4):84. http://dx.doi.org/10.3390/geriatrics5040084CrossRef
    [2] World Health Organization. Dementia Fact Sheets. 2021. https://www.who.int/news-room/fact-sheets/detail/dementia. [2022-9-16].https://www.who.int/news-room/fact-sheets/detail/dementia
    [3] Alzheimer’s Association. 2022 Alzheimer’s disease facts and figures. Alzheimers Dement 2022;18(4):700 − 89. http://dx.doi.org/10.1002/alz.12638.CrossRef
    [4] Sutin AR, Stephan Y, Luchetti M, Terracciano A. Loneliness and risk of dementia. J Gerontol B 2020;75(7):1414 − 22. http://dx.doi.org/10.1093/geronb/gby112CrossRef
    [5] Kotwal AA, Holt-Lunstad J, Newmark RL, Cenzer I, Smith AK, Covinsky KE, et al. Social isolation and loneliness among San Francisco Bay Area older adults during the COVID-19 shelter-in-place orders. J Am Geriatr Soc 2021;69(1):20 − 9. http://dx.doi.org/10.1111/jgs.16865CrossRef
    [6] Mather N, Jaffe LE. Woodcock-Johnson IV: reports, recommendations, and strategies. Hoboken: John Wiley & Sons. 2016. http://find.nlc.cn/search/showDocDetails?docId=-1982576029567010216&dataSource=ucs09&query=Woodcock-Johnson%20IV.http://find.nlc.cn/search/showDocDetails?docId=-1982576029567010216&dataSource=ucs09&query=Woodcock-Johnson%20IV
    [7] Sepúlveda-Loyola W, Rodríguez-Sánchez I, Pérez-Rodríguez P, Ganz F, Torralba R, Oliveira DV, et al. Impact of social isolation due to COVID-19 on health in older people: mental and physical effects and recommendations. J Nutr Health Aging 2020;24(9):938 − 47. http://dx.doi.org/10.1007/s12603-020-1469-2CrossRef
    [8] Suárez-González A, Rajagopalan J, Livingston G, Alladi S. The effect of COVID-19 isolation measures on the cognition and mental health of people living with dementia: a rapid systematic review of one year of quantitative evidence. EClinicalMedicine 2021;39:101047. http://dx.doi.org/10.1016/j.eclinm.2021.101047CrossRef
  • TABLE 1.  Cognitive test score descriptive statistics, United States, June 2018–February 2022.

    VariableNumbers testPicture vocabulary testVerbal analogies testSerial seven subtraction test
    Number of states, N51515151
     With stay-at-home order40404040
     Without stay-at-home order11111111
    Number of observations (%)8,090 (100.0)7,974 (100.0)7,861 (100.0)7,684 (100.0)
     With stay-at-home order (%)6,985 (86.3)6,884 (86.3)6,783 (86.3)6,653 (86.6)
     Without stay-at-home order (%)1,105 (13.7)1,090 (13.7)1,078 (13.7)1,031 (13.4)
    Cognitive score, Mean (SD)51.17 (9.10)54.26 (8.48)51.33 (8.89)4.494 (1.078)
     With stay-at-home order51.24 (9.13)54.28 (8.55)51.35 (8.93)4.494 (1.081)
     Without stay-at-home order50.72 (8.88)54.13 (7.99)51.21 (8.63)4.493 (1.063)
    Note: The 51 States includes the 50 states and the District of Columbia. Numbers, picture vocabulary, and verbal analogies scores reported in the Understanding America Study were converted to standardized scores, where 50 is the mean and 10 is the standard deviation. A score of 50 means that the person’s cognitive ability is equal to that of the average person in the general population, a score of 60 means that the person’s ability is one standard deviation above average, and a score of 40 means that the person’s ability is one standard deviation below average. The serial seven subtraction test scores range from 0 to 5.
    Abbreviation: SD=standard deviations.
    Download: CSV

    TABLE 2.  Summary statistics of individual characteristics, United States, June 2018–February 2022.

    VariableTotalStates with
    stay-at-home order
    States without
    stay-at-home order
    P-value
    No. of observations (N)8,0906,9851,105
    Age (Mean, SD)63.1 (9.0)63.2 (9.0)62.6 (8.5)0.036
    Gender0.19
     Female (%)4,389 (54.3)3,762 (53.9)627 (56.7)
     Male (%)3,700 (45.7)3,222 (46.1)478 (43.3)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Immigrant status<0.001
     Non-immigrant (%)4,425 (54.7)3,688 (52.8)737 (66.7)
     First generation immigrant (%)738 (9.1)690 (9.9)48 (4.3)
     Second or third generation immigrant (%)2,757 (34.1)2,462 (35.2)295 (26.7)
     Missing (%)170 (2.1)145 (2.1)25 (2.3)
    Marital status<0.001
     Never married (%)782 (9.7)720 (10.3)62 (5.6)
     Married (%)4,823 (59.6)4,130 (59.1)693 (62.7)
     Separated/divorced/widowed (%)2,484 (30.7)2,134 (30.6)350 (31.7)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Level of education<0.001
     High school graduate or under (%)1,810 (22.4)1,516 (21.7)294 (26.6)
     Some college-no degree (%)1,965 (24.3)1,662 (23.8)303 (27.4)
     Bachelor's degree (%)2,935 (36.3)2,578 (36.9)357 (32.3)
     Master's degree and over (%)1,380 (17.1)1,229 (17.6)151 (13.7)
    Hispanic ethnicity0.59
     No (%)7,423 (91.8)6,401 (91.6)1,022 (92.5)
     Yes (%)666 (8.2)583 (8.3)83 (7.5)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Race0.080
     White only (%)6,628 (81.9)5,696 (81.5)932 (84.3)
     Black only (%)635 (7.8)568 (8.1)67 (6.1)
     Others (%)798 (9.9)695 (9.9)103 (9.3)
     Missing (%)29 (0.4)26 (0.4)3 (0.3)
    Employment status0.20
     Currently working (%)3,293 (40.7)2,825 (40.4)468 (42.4)
     Retired (%)2,798 (34.6)2,443 (35.0)355 (32.1)
     Others (%)1,992 (24.6)1,710 (24.5)282 (25.5)
     Missing (%)7 (0.1)7 (0.1)0 (0.0)
    Household income0.001
     Less than 30,000 USD2,004 (24.8)1,699 (24.3)305 (27.6)
     30,000 to 59,999 USD2,169 (26.8)1,857 (26.6)312 (28.2)
     60,000 to 99,999 USD1,980 (24.5)1,708 (24.5)272 (24.6)
     100,000 USD or more1,912 (23.6)1,696 (24.3)216 (19.5)
     Missing (%)25 (0.3)25 (0.4)0 (0.0)
    Presence of other household members0.071
     No (%)1,832 (22.6)1,609 (23.0)223 (20.2)
     Yes (%)6,253 (77.3)5,371 (76.9)882 (79.8)
     Missing (%)5 (0.1)5 (0.1)0 (0.0)
    Note: Values shown are numbers of individuals with percentages of individuals for each category in parentheses, unless otherwise indicated for continuous variables where means are shown with SD in parentheses.
    Abbreviation: SD=standard deviations; USD=US dollar.
    Download: CSV

    TABLE 3.  DID estimates of stay-at-home order on cognitive health and loneliness, United States, June 2018–February 2022.

    ParameterCognitive Test Score
    Numbers testPV testVA testSSS test
    DID estimate−0.184 (0.436)
    [−1.060, 0.691]
    0.221 (0.250)
    [−0.281, 0.722]
    0.757 (0.582)
    [−0.412, 1.926]
    −0.041 (0.041)
    [−0.124, 0.041]
    R20.2660.2950.2340.078
    N8,0907,9747,8617,684
    States51515151
    Note: Difference-in-differences models were estimated with least squares and include controls listed in Table 2, state-fixed effects and quarter-fixed effects. Each observation is an individual-quarter. State-clustered standard errors are in parentheses and 95% confidence intervals are in brackets. None of the coefficients reached statistical significance.
    Abbreviation: PV=picture vocabulary; VA=verbal analogies; SSS=serial seven subtraction; DID=difference-in-differences.
    Download: CSV

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COVID-19 Stay-At-Home Orders and Older Adults’ Cognitive Health — United States, June 2018–February 2022

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Summary

What is already known about this topic?

Lack of social activities is known to negatively impact cognitive functioning and increase risk of cognitive impairment, including dementia, among older adults.

What is added by this report?

Coronavirus disease 2019 (COVID-19) stay-at-home orders implemented in the U.S. early during the pandemic were not found to negatively affect cognitive functioning of older adults.

What are the implications for public health practice?

There may have been no severe, unintended consequences of the COVID-19 stay-at-home orders in terms of their impact on cognitive functioning and risk of dementia among older adults, lending further support to use of such orders.

  • 1. Department of Population Health Sciences, Weill Cornell Medical College, Cornell University, New York, NY, U.S.
  • 2. The Comparative Health Outcomes, Policy and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, U.S.
  • Corresponding author:

    Jing Li, jli0321@uw.edu

    Online Date: November 11 2022
    Issue Date: November 11 2022
    doi: 10.46234/ccdcw2022.203
  • The global prevalence of cognitive impairment is estimated to be 19% (1), with more than 55 million people living with dementia worldwide (2) and 6.5 million in the U.S. (3). While lack of social activities is known to negatively impact cognitive functioning and increase risk of cognitive impairment including dementia among older adults (4), little is known on the effect of coronavirus disease 2019 (COVID-19) related stay-at-home orders on older adults’ cognitive health. This study examined the impact of the COVID-19 stay-at-home orders implemented in certain states of the U.S. and the cognitive health of older adults. Stay-at-home orders requested residents to stay at home as much as possible, and many public shops and venues to close down temporarily (5). This research used data from the U.S. Understanding America Study (UAS), a longitudinal internet survey representative of individuals aged 50 and above in the U.S., and the COVID-19 State Policies (CUSP) database. A difference-in-differences (DID) approach was used to compare trajectories of four cognitive scores before and after state-specific stay-at-home orders were implemented between states with and without COVID-19 stay-at-home orders. This study found no significant relationship between state-specific stay-at-home policies and cognitive health of U.S. older adults.

    This study conducted an observational retrospective cohort study. The study population included U.S. adults aged 50 and older who participated in UAS and answered survey questions relevant to cognitive health between June 2018 and February 2022. UAS is a nationally representative longitudinal internet panel survey of more than 9,000 adults older than 18 years. Our outcome variables were four cognitive scores from numbers, picture vocabulary, verbal analogies, and serial seven subtraction tests. The tests were designed to measure the respondent’s quantitative reasoning and lexical knowledge according to the Woodcock-Johnson Tests of Cognitive Abilities (6). Survey questionnaires containing these tests were fielded in two waves, one in June 2018, and the other in July 2020. The respondents could take a test in each wave any time after it became available; only those who participated in the first wave were eligible to participate in the second wave. We included in our analyses all individuals who participated in at least one wave to improve precision of estimates, although only those who participated in both waves contributed to DID coefficients. The independent variable was implementation of stay-at-home orders from the CUSP database. Implementation was treated as a binary variable that equals 1 if the state issued a stay-at-home order (treatment group) and 0 if the state did not issue any order or issued but did not specifically restrict movement of the general public during the study period (control group). Our control variables included gender, age, immigration status, marital status, education, ethnicity, race, presence of other household members, employment status, and household income. These variables were also obtained from UAS.

    This research examined summary statistics of key variables, and t-tests for continuous variables and Chi-squared tests for categorical variables were used to compare means between treatment and control groups. Our DID model specification was as follows:

    $$ {y}_{i,s,q}={\beta }_{0}+{\beta }_{1}\left({d}_{s}{\times p}_{q}\right)+{X}_{i,q}\gamma +{\delta }_{q}+{\alpha }_{s}+{\varepsilon }_{i,q,s} $$ (1)

    where the dependent variable $y $ is a cognitive test score for individual $ i $, state $ s $, and quarter $ q $. $ {d}_{s} $ is an indicator for whether state $ s $ implemented strict stay-at-home orders. $\; {p}_{q} $ is an indicator for whether quarter $ q $ is after the second quarter of 2020, since most states implemented stay-at-home orders between March and April 2020. $ {X}_{i,q} $ contains individual-level sociodemographic control variables in quarter $ q $. $ {\delta }_{q} $ and $ {\alpha }_{s} $ are quarter and state-fixed effects. ${\varepsilon}_{i,q,s}$ is the error term and is clustered at the state level. We conducted secondary analyses on subsamples stratified by age (65 or over vs. under 65), gender and whether the individual lived alone. All analyses were performed using Stata BE 17.0 (StataCorp, College Station, TX, U.S.A.).

    Table 1 shows the numbers of state and person-wave observations for each of the four cognitive tests and the average test scores in states with stay-at-home orders (treatment group) and without stay-at-home orders (control group). Forty states out of 51 issued a stay-at-home order between March and April 2020. During the study period, the total number of observations per panel was about 8,000, of which over 80% were from the treatment group, with an average of approximately 170 observations per treatment state compared to approximately 100 per control state. The average cognitive test score was slightly higher in states with stay-at-home orders than in states without stay-at-home orders in all panels. Relative to the control states, treatment states had higher proportions of immigrants and unmarried people and higher average education levels and household incomes (Table 2). To assess selective attrition between Wave 1 and Wave 2, we compared summary statistics by the number of waves the respondent participated in (Supplementary Table S1). Although we did not find large differences between those who participated in only one wave of cognitive assessment versus two, the former had somewhat higher socioeconomic status than the latter in terms of education and income. Table 3 shows the differential change in cognitive scores in states with stay-at-home orders relative to states without stay-at-home orders. None of the associations was statistically significant. In terms of coefficient magnitudes, stay-at-home orders were associated with lower numbers test and serial seven subtraction test scores compared to states without stay-at-home orders, by 0.184 points and 0.041 points, respectively. In contrast, stay-at-home orders were associated with increased picture vocabulary test and verbal analogies test scores by 0.221 and 0.757 points, respectively. Subgroup analyses yielded consistent results (not shown).

    VariableNumbers testPicture vocabulary testVerbal analogies testSerial seven subtraction test
    Number of states, N51515151
     With stay-at-home order40404040
     Without stay-at-home order11111111
    Number of observations (%)8,090 (100.0)7,974 (100.0)7,861 (100.0)7,684 (100.0)
     With stay-at-home order (%)6,985 (86.3)6,884 (86.3)6,783 (86.3)6,653 (86.6)
     Without stay-at-home order (%)1,105 (13.7)1,090 (13.7)1,078 (13.7)1,031 (13.4)
    Cognitive score, Mean (SD)51.17 (9.10)54.26 (8.48)51.33 (8.89)4.494 (1.078)
     With stay-at-home order51.24 (9.13)54.28 (8.55)51.35 (8.93)4.494 (1.081)
     Without stay-at-home order50.72 (8.88)54.13 (7.99)51.21 (8.63)4.493 (1.063)
    Note: The 51 States includes the 50 states and the District of Columbia. Numbers, picture vocabulary, and verbal analogies scores reported in the Understanding America Study were converted to standardized scores, where 50 is the mean and 10 is the standard deviation. A score of 50 means that the person’s cognitive ability is equal to that of the average person in the general population, a score of 60 means that the person’s ability is one standard deviation above average, and a score of 40 means that the person’s ability is one standard deviation below average. The serial seven subtraction test scores range from 0 to 5.
    Abbreviation: SD=standard deviations.

    Table 1.  Cognitive test score descriptive statistics, United States, June 2018–February 2022.

    VariableTotalStates with
    stay-at-home order
    States without
    stay-at-home order
    P-value
    No. of observations (N)8,0906,9851,105
    Age (Mean, SD)63.1 (9.0)63.2 (9.0)62.6 (8.5)0.036
    Gender0.19
     Female (%)4,389 (54.3)3,762 (53.9)627 (56.7)
     Male (%)3,700 (45.7)3,222 (46.1)478 (43.3)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Immigrant status<0.001
     Non-immigrant (%)4,425 (54.7)3,688 (52.8)737 (66.7)
     First generation immigrant (%)738 (9.1)690 (9.9)48 (4.3)
     Second or third generation immigrant (%)2,757 (34.1)2,462 (35.2)295 (26.7)
     Missing (%)170 (2.1)145 (2.1)25 (2.3)
    Marital status<0.001
     Never married (%)782 (9.7)720 (10.3)62 (5.6)
     Married (%)4,823 (59.6)4,130 (59.1)693 (62.7)
     Separated/divorced/widowed (%)2,484 (30.7)2,134 (30.6)350 (31.7)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Level of education<0.001
     High school graduate or under (%)1,810 (22.4)1,516 (21.7)294 (26.6)
     Some college-no degree (%)1,965 (24.3)1,662 (23.8)303 (27.4)
     Bachelor's degree (%)2,935 (36.3)2,578 (36.9)357 (32.3)
     Master's degree and over (%)1,380 (17.1)1,229 (17.6)151 (13.7)
    Hispanic ethnicity0.59
     No (%)7,423 (91.8)6,401 (91.6)1,022 (92.5)
     Yes (%)666 (8.2)583 (8.3)83 (7.5)
     Missing (%)1 (0.0)1 (0.0)0 (0.0)
    Race0.080
     White only (%)6,628 (81.9)5,696 (81.5)932 (84.3)
     Black only (%)635 (7.8)568 (8.1)67 (6.1)
     Others (%)798 (9.9)695 (9.9)103 (9.3)
     Missing (%)29 (0.4)26 (0.4)3 (0.3)
    Employment status0.20
     Currently working (%)3,293 (40.7)2,825 (40.4)468 (42.4)
     Retired (%)2,798 (34.6)2,443 (35.0)355 (32.1)
     Others (%)1,992 (24.6)1,710 (24.5)282 (25.5)
     Missing (%)7 (0.1)7 (0.1)0 (0.0)
    Household income0.001
     Less than 30,000 USD2,004 (24.8)1,699 (24.3)305 (27.6)
     30,000 to 59,999 USD2,169 (26.8)1,857 (26.6)312 (28.2)
     60,000 to 99,999 USD1,980 (24.5)1,708 (24.5)272 (24.6)
     100,000 USD or more1,912 (23.6)1,696 (24.3)216 (19.5)
     Missing (%)25 (0.3)25 (0.4)0 (0.0)
    Presence of other household members0.071
     No (%)1,832 (22.6)1,609 (23.0)223 (20.2)
     Yes (%)6,253 (77.3)5,371 (76.9)882 (79.8)
     Missing (%)5 (0.1)5 (0.1)0 (0.0)
    Note: Values shown are numbers of individuals with percentages of individuals for each category in parentheses, unless otherwise indicated for continuous variables where means are shown with SD in parentheses.
    Abbreviation: SD=standard deviations; USD=US dollar.

    Table 2.  Summary statistics of individual characteristics, United States, June 2018–February 2022.

    ParameterCognitive Test Score
    Numbers testPV testVA testSSS test
    DID estimate−0.184 (0.436)
    [−1.060, 0.691]
    0.221 (0.250)
    [−0.281, 0.722]
    0.757 (0.582)
    [−0.412, 1.926]
    −0.041 (0.041)
    [−0.124, 0.041]
    R20.2660.2950.2340.078
    N8,0907,9747,8617,684
    States51515151
    Note: Difference-in-differences models were estimated with least squares and include controls listed in Table 2, state-fixed effects and quarter-fixed effects. Each observation is an individual-quarter. State-clustered standard errors are in parentheses and 95% confidence intervals are in brackets. None of the coefficients reached statistical significance.
    Abbreviation: PV=picture vocabulary; VA=verbal analogies; SSS=serial seven subtraction; DID=difference-in-differences.

    Table 3.  DID estimates of stay-at-home order on cognitive health and loneliness, United States, June 2018–February 2022.

    • This study found no evidence that state-level COVID-19 stay-at-home orders in the U.S. led to significant changes in cognitive health of older adults. Previous studies of COVID-19 lockdown measures found adverse effects on mental health, such as depression and anxiety (7), and worsening cognitive ability among those with dementia, albeit not in the U.S. (8). To our knowledge, ours is the first study to examine the impact of state-level stay-at-home policies on cognitive health among the general, older population in the U.S. Results of our study may help rule out any drastic impact on the cognitive health of older adults subject to state-wide stay-at-home orders, at least in the U.S. context and during the short-term. It is possible that older adults had alternative means to remain socially active in the presence of stay-at-home orders, for example, by telephone or internet. It could also be that the relatively short time horizon and relaxed measures of stay-at-home orders without strict enforcement were simply not severe enough to impact cognition health of older adults. However, our findings should not be construed to mean that no COVID-19 related restrictions can negatively impact the cognitive health of older adults. Further research is needed to better understand the longer-term consequences of COVID-19 related restrictions in different contexts, and whether there are effective coping methods already adopted or to be adopted by older adults, their families, and public health policy makers to mitigate unintended consequences.

      The study had several limitations. First, we were unable to observe the exact extent to which study participants adhered to stay-at-home orders. Second, there was heterogeneity in the specific nature of stay-at-home order rules across states. For instance, some states allowed limited movement to conduct essential activities and others allowed movement for outdoor exercise. We were unable to study each scenario separately due to insufficient sample size, and our results should be interpreted as an average effect of these policies. Third, due to the relatively short study period, we were unable to examine long-term impact of the COVID-19 stay-at-home orders on cognitive health. Fourth, though UAS participants were broadly representative of the U.S. population, participation in individual surveys was voluntary. To the extent that those completing questionnaires on cognition were relatively cognitively healthy individuals, selection bias could have impacted the external validity of our findings. A related issue is that it is possible that those who participated in Wave 1 of each survey and experienced a larger decline in cognitive ability may have been less likely to participate in Wave 2, causing our DID estimates to be biased towards the null, although our supplementary analysis provides no direct evidence that this is the case. Finally, it is possible that COVID-19 illness may independently affect cognition, although our study design was robust to any impact of the COVID-19 pandemic common to the treated and control groups.

      Despite of these limitations, our study is one of the first to show that U.S. COVID-19 related stay-at-home order did not have severe negative consequences on the cognitive health of older adults in the general population. It lends further support for such measures to be viable public health options for combating the spread of communicable diseases like COVID-19.

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