Archives of Clinical Neuropsychology 36 (2021) 1266–1273

Psychosocial Protective Factors in Cognitive Aging: A Targeted Review

Laura B. Zahodne*,†
Department of Psychology, University of Michigan, Ann Arbor, MI 48109, USA
*Corresponding author at: Department of Psychology, University of Michigan, 530 Church St., Ann Arbor, MI 48109 USA.
Tel.: 734-764-4098; fax: 734-764-3520.
E-mail address: lzahodne@umich.edu (Laura B. Zahonde)
Accepted 16 June 2021

Abstract
Objective: The lack of disease-modifying pharmacological agents for dementia highlights the critical importance of prevention,
but known modifiable factors (e.g., education, physical health and health behaviors, depression, and social isolation) do not
fully represent potential intervention targets. Positive psychosocial factors predict cognitive aging outcomes above and beyond
known risk factors and may also correspond to upstream determinants that open up new avenues for prevention and intervention,
as well as for reducing racial/ethnic inequalities in dementia. In this brief report, I summarize contemporary evidence for three
positive psychosocial factors that appear to be particularly relevant to cognitive aging: perceived control, religious involvement,
and social relations.
Methods: Targeted review and synthesis of published studies.
Results: Each of the multidimensional constructs appears to contain “active ingredients” that could help to optimize cognitive
aging through disparate mechanisms. Although historically marginalized racial/ethnic groups face disproportionate barriers to
accessing certain psychosocial protective factors (e.g., perceived control), these same groups also exhibit naturally occurring
sources of psychosocial resilience (e.g., religious involvement) that allow them to achieve better late-life cognitive health than
would be otherwise expected. With regard to social relations, converging evidence from disparate studies shows that fostering
late-life friendships in particular may have high potential for building cognitive reserve and promoting healthy cognitive aging.
Conclusions: Positive psychosocial factors represent culturally relevant resources that, through careful research, could
ultimately be harnessed to promote better cognitive aging for a growing and increasingly diverse population of older adults.

Keywords: Dementia; Elderly/Geriatrics/Aging; Alzheimer’s disease

Introduction

Dementia is a growing global public health concern (Prince et al., 2013). The lack of disease-modifying pharmacological
agents highlights the critical importance of prevention, and a recent review concluded that one third of dementia cases may be
preventable (Livingston et al., 2017). Modifiable factors identified as having the strongest evidence base include: education,
physical health and health behaviors (i.e., hearing loss, hypertension, obesity, smoking, physical inactivity, and diabetes),
depression, and social isolation (Livingston et al., 2017). However, many of these factors are notoriously difficult intervention
targets, particularly for older individuals. In addition to having independent links to dementia risk, positive psychosocial factors
are also deeply interconnected with these modifiable factors and, in many cases, correspond to upstream determinants. For
example, social relations during childhood affect educational attainment and later life health (Sharifian, Kraal, Zaheed, Sol, &
Zahodne, 2019; Sharifian & Zahodne, 2020; Zahodne, Ajrouch, Sharifian, & Antonucci, 2019). Therefore, positive psychosocial
factors may act as levers that can help individuals avoid risk factors and accumulate protective factors as they age.

© The Author(s) 2021. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
https://doi.org/10.1093/arclin/acab051
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Additional rationale for a focus on positive psychosocial factors relates to the observation that some of the identified protective
factors in dementia (e.g., education) appear to affect cognitive level but not rates of cognitive decline (Piccinin et al., 2013;
Zahodne et al., 2011). In contrast, psychological (e.g., depression), and social (e.g., social interaction) factors appear to have
robust effects on both levels and changes in brain and/or cognitive aging (Pruitt et al., 2020; Zahodne, Ajrouch, Sharifian, &
Antonucci, 2019; Zahodne, Gongvatana, Cohen, Ott, & Tremont, 2013; Zahodne, Stern, & Manly, 2014), as well as functional
ability (Zahodne, Devanand, & Stern, 2013). Thus, targeting an individual’s psychosocial context may have broad implications
for aging.
Finally, positive psychosocial factors are highly relevant to the major public health and health justice concern of dementia
inequalities. Specifically, racially patterned structural disadvantages lead to differential access to psychosocial protective factors,
and psychosocial risk and protective factors help to explain dementia inequalities that persist despite controlling for the “usual
suspects” in disparities research (e.g., socioeconomic status and cardiometabolic health). In addition, some positive psychosocial
factors (e.g., religious involvement) reflect naturally occurring protective resources for certain groups that have been historically
disadvantaged (Kraal, Sharifian, Zaheed, Sol, & Zahodne, 2019). Therefore, interventions targeting these factors may be highly
culturally relevant. In this targeted review, I summarize recent evidence that positive psychosocial factors, which have received
relatively less attention in the literature on dementia prevention to date, have high potential to optimize cognitive aging.

Positive Psychosocial Factors and Cognitive Aging

The field of positive psychology investigates how positive subjective experiences, positive individual traits, and positive
institutions can improve quality of life and prevent pathology (Seligman & Csikszentmihalyi, 2000). Positive psychosocial
factors can include a diverse set of constructs at the individual, interpersonal, and community levels (Bronfenbrenner & Ceci,
1994). For example, the NIH Toolbox Emotion module measures eudaimonic (e.g., life satisfaction and purpose in life) and
hedonic (e.g., positive affect) well-being, self-efficacy, friendship, and social support as positive psychosocial factors that may
be relevant to health (Salsman et al., 2013). Importantly, factor analytic work indicates that positive psychosocial factors do
not just reflect the absence of negative psychosocial factors such as depression (Zahodne, Nowinski, Gershon, & Manly, 2014).
Although positive psychosocial factors are correlated with negative psychosocial factors, they also represent a distinct dimension
such that an individual can score at the high or low end of both negative and positive dimensions (Diener, 2000; Watson &
Tellegen, 1985).
The Broaden & Build theory describes how positive psychosocial factors can influence health above and beyond negative
psychosocial factors (Fredrickson, 2001, 2013; Fredrickson & Branigan, 2005). Specifically, positive emotional states allow
thoughts and behaviors to be guided not by automatic responses, which predominate during negative emotional states and periods
of stress, but rather by more novel, creative, and flexible responses. Acting in these novel ways builds important cognitive,
psychological, and social resources that can ultimately benefit health, including cognitive health in late life. Other mechanisms
that may link positive psychosocial factors to better cognitive aging include reducing the physiological impact of stressors
(Frankenhaeuser, 1983; Fredrickson & Levenson, 1998; Fredrickson, Mancuso, Branigan, & Tugade, 2000; Marmot, Bosma,
Hemingway, Brunner, & Standsfeld, 1997); facilitating better sleep (Phelan, Love, Ryff, Brown, & Hedrich, 2010); improving
immune function (Friedman, Hayney, Love, Singer, & Ryff, 2007); increasing motivation, confidence and/or interest in healthy
behaviors such as physical exercise and cognitively stimulating activities (Bandura, 1989; Barnes, Mendes de Leon, Wilson,
Bienias, & Evans, 2004; Lachman, Neupert, & Agrigoroaei, 2011); and developing a broader set of neural networks that can
be brought online in the event that primary networks become compromised by age-related disease (Bennett, Schneider, Tang,
Arnold, & Wilson, 2006; Sharifian, Sol, Zahodne, & Antonucci, 2022).
In the current paper, I focus on three positive psychosocial factors that appear to be particularly relevant to cognitive aging:
perceived control, religious involvement, and social relations. These factors span the individual, interpersonal, and community
levels and therefore represent multiple points of intervention to optimize cognitive aging and reduce cognitive disparities.

Perceived Control

Perceived control refers to the extent to which one feels like they are in control of important life outcomes (Lefcourt, 2014).
Greater perceived control is prospectively linked to better cognitive aging (Seeman, McAvay, Albert, Merrill, & Rodin, 1996).
Indeed, epidemiological studies of national samples comprising largely non-Hispanic Whites (Zahodne, Nowinski, et al., 2014a)
and more racially/ethnically diverse regional samples (Zahodne, Watson, Seehra, & Martinez, 2018) confirm that stronger control
beliefs are associated with better late-life cognition above and beyond other positive and negative psychosocial factors. Further,
stronger control beliefs are uniquely associated with preserved episodic memory in the context of smaller hippocampal volumes,
suggesting that having stronger control beliefs may help build cognitive reserve (Zahodne, Schupf, & Brickman, 2018). Stronger
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control beliefs may also attenuate the negative cognitive impact of low educational attainment (Zahodne, Nowinski, Gershon,
& Manly, 2015b), indicating that they may represent a potential intervention target to offset early-life disadvantage. Together,
these studies point to a role for control beliefs in cognitive aging, both directly as well as through interactions with other known
risk and protective factors.
Control beliefs also appear to play a role in racial inequalities in cognitive aging. For example, perceived constraints (i.e.,
external control) partially mediate Black-White disparities in cognition in the National Survey of Midlife in the United States
(MIDUS; Zahodne, Manly, Smith, Seeman, & Lachman, 2017), as well as Black-White and Hispanic-White disparities in the
Washington Heights-Inwood Columbia Aging Project (WHICAP; Zahodne et al., 2021). Further, perceived constraints partially
mediate Black-White disparities in the efficacy of two cognitive interventions implemented in the advanced cognitive training
for independent and vital elderly (ACTIVE) multisite clinical trial (Zahodne et al., 2015a).
Perceived control may influence cognitive aging through behavioral, motivational, and/or affective pathways (Lachman,
2006). Importantly, perceived control is modifiable in that it reflects a learned view that can change over time and in response
to experience (Eizenman, Nesselroade, Featherman, & Rowe, 1997). Both internal (e.g., personal mastery and self-efficacy;
Seeman et al., 1996; Zahodne, Nowinski, et al., 2014; Zahodne, Watson, et al., 2018) and external (e.g., perceived constraints;
Zahodne et al., 2015a, 2017, 2021) control beliefs have been linked to cognitive aging outcomes. Given that internal control is
more likely to be shaped by an individual’s micro-environment (e.g., family and peers) and external control is more likely to
be shaped by an individual’s macro-environment (e.g., larger social structures; Hughes & Demo, 1989), these results support
multiple potential levels of intervention. However, the observation that external control is most relevant to cognitive disparities
clearly points to the need to prioritize societal-level interventions.

Religious Involvement

Although much work on racial/ethnic inequalities in cognitive aging has emphasized risk factors like socioeconomic
disadvantage, associations between race/ethnicity and cognitive aging reflect the sum of both risk and resilience pathways
(Fig. 1). Historically marginalized groups can display not only higher levels of certain risk factors, but also higher levels of certain
protective factors that offset the negative effects of social disadvantage and lead to better cognitive outcomes than expected based
on the presence of various risk factors. Therefore, the overall measured associations between race and cognitive aging outcomes
may actually underestimate the negative impacts of racially patterned social disadvantage. Considering both risk and resilience
pathways can not only improve the accuracy of risk estimates but also point to additional, culturally relevant intervention targets.
Religious involvement is one culturally relevant resilience factor with a rich history in the literature on minority health,
particularly African American health (Taylor, Chatters, & Levin, 2003). Religious involvement is a multidimensional construct
that includes not only strength of religious belief, but also various behaviors and relationships. A recent study parsed this
multidimensional construct into three components (i.e., strength of religious belief, frequency of attending formal religious
services outside the home, and frequency of praying privately) and showed that both non-Hispanic Black and Hispanic
participants in the Health and Retirement Study (HRS) reported higher levels of each component of religious involvement
than non-Hispanic Whites, consistent with previous research (Kraal et al., 2019). In turn, two of these components (i.e.,
attending services and praying privately) were positively associated with episodic memory. Importantly, even though these
two racial/ethnic groups exhibited “lower” overall memory performance than non-Hispanic Whites, these disparities were offset
by the two independent resilience pathways involving religious involvement.

Fig. 1. Mediation framework showing that group differences in cognition reflect the sum of both risk and resilience pathways. The “total effect” of belonging
to a particular social group on cognition is the sum of all “indirect effects” through both risk and resilience factors, as well as any residual “direct effects” that
cannot be explained with available variables.
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This evidence suggests that religious involvement may represent a naturally occurring resource within certain social groups
and that its protective effects extend to cognitive aging. Of note, it is not religious belief per sé that appears to be protective, but
rather its associated active, stimulating, and/or social behaviors. This pattern of findings highlighting “behavior” fits well with
the larger cognitive aging literature demonstrating the many cognitive benefits of active lifestyles (Sajeev et al., 2016). Future
research should focus on building community partnerships (e.g., community-based participatory research) to identify and better
understand additional, naturally occurring resources that could lead to culturally relevant interventions and recommendations
for optimizing cognitive aging and eliminating racial/ethnic inequalities.

Social Relations

Because social development is cumulative, the comprehensive study of social relations involves a life course approach. Social
relations experienced during earlier phases of development can influence social resources available later on, and social relations
at any point in the life course can therefore have consequences for cognitive aging (Sroufe, Coffino, & Carlson, 2010). Indeed,
social experiences during a relatively early phase of development (i.e., childhood) have been linked to later-life physical and
cognitive health (Zhang, Xu, Li, Liu, & Choi, 2020). For example, in the reasons for geographic and racial differences in
stroke (REGARDS) study, retrospective reports of important social resources (e.g., love, affection, trust, and encouragement)
during childhood were positively associated with episodic memory performance decades later, above and beyond childhood
socioeconomic status and household composition (Zahodne, Sharifian, Manly, et al., 2019). This cognitive advantage was
maintained over at least 10 years and was mediated by higher educational attainment and better mid-life health. Similarly, data
from the Wisconsin longitudinal study (WLS) indicate that positive mother–child interactions retrospectively reported around
age 53 predicted better episodic memory performance 10 years later, as well as slower memory decline over the subsequent
7 years (Sharifian & Zahodne, 2020). These protective cognitive effects of positive mother–child interactions operated, in large
part, through higher educational attainment, as well as through better social development in midlife.
Although intervening during childhood is likely to have broad and enduring effects, fostering later-life social relations may
also represent an opportunity to optimize cognitive aging. For example, greater social support in late life is associated with better
executive functioning and processing speed above and beyond a whole host of other positive and negative psychosocial factors,
as well as physical health, in the national norming study for the NIH Toolbox (Zahodne, Nowinski, et al., 2014). However,
much of the research on late-life social relations and cognition includes coarse indicators of social relations, which limits the
translation of findings into actionable interventions. Social relations is a multidimensional construct that can include social
network structure (e.g., size and composition), function (e.g., emotional, informational, and material support), and quality (i.e.,
perceived satisfaction with social relationships; Holt-Lunstad, 2018).
In order to translate research findings to interventions, more specific and comprehensive measurement is needed so that the
“active ingredients” of social relations that are most likely to benefit cognitive health can be identified and operationalized. More
detailed conceptualization and operationalization of social relations is also needed to clarify potential mechanisms underlying
the protective effects of social network characteristics on cognitive aging. For example, it may be that social network structure
(i.e., size and contact frequency), yields cognitive benefits via mental stimulation. In contrast, the quality of social relations may
yield cognitive benefits by preventing and/or buffering against the neurotoxic effects of stress (Fig. 2). Finally, also important
for the development of interventions is a recognition that these different dimensions of social relations are influenced by both
individual and situational characteristics (Kahn & Antonucci, 1980). It is therefore necessary to consider contextual factors if
the long term goal is to develop social network interventions that are not only efficacious, but also targeted and effective.
A recent paper used data from the HRS to deconstruct social relations into dimensions most relevant for cognitive aging
(Zahodne, Ajrouch, Sharifian, & Antonucci, 2019). Results indicated that both social network structure and quality are uniquely
associated with memory level, but only structure is additionally predictive of subsequent rates of memory decline. Specifically,
having a spouse or partner predicted less future decline, which could reflect greater availability of material resources (e.g.,
wealth) and social support, as well as social monitoring of health behaviors (Carr & Springer, 2010). Follow-up work taking a
life course approach and considering individual differences has additionally revealed that age at first marriage and time spent
unmarried following one’s first marriage are particularly consequential for cognitive aging among previously married women
(Zaheed et al., in press).
However, the single strongest predictor of better memory aging in the HRS study was not marital status, but rather more
frequent interactions with non-family members (i.e., friends) (Zahodne, Ajrouch, Sharifian, & Antonucci, 2019). Having
a large, friend-focused social network was also associated with better cognitive functioning in the more racially balanced
WHICAP sample, particularly among non-Hispanic Black older adults (Sharifian, Manly, Schupf, Brickman, & Zahodne, 2019).
Importantly, follow-up work on social network composition has clarified that having more family members in a network is not
“bad” so long as it does not limit interactions with friends (Sharifian, Kraal, Zaheed, Sol, & Zahodne, 2020). Specifically, more
1270 L.B. Zahodne / Archives of Clinical Neuropsychology 36 (2021); 1266–1273

Fig. 2. Schematic of how different social network characteristics may operate through different mechanisms to influence cognitive aging outcomes.

frequent interactions with friends prospectively predicted less subsequent memory decline, but the frequency of interactions
with family members was not uniquely associated with memory. These longitudinal analyses of observational data cannot
confirm causation, but it is notable that experimental and interventional research supports a causal link between interacting with
non-family members and better cognitive performance (Dodge et al., 2015; Ybarra, Winkelman, Yeh, Burnstein, & Kavanagh,
2011).
Multiple studies from disparate data sets and study designs converge on the unique benefits of friends for cognitive aging,
which is consistent with theoretical work on the relative roles of family relationships versus friendships, as well as close versus
weak ties (see Sharifian et al., 2022). With regard to mechanisms, the social psychology literature indicates that friendships,
compared to family relationships, are rated as being a greater source of companionship (Crohan & Antonucci, 1989; Quan-Haase,
Mo, & Wellman, 2017). Studies using experience sampling suggest that interactions with friends yield a greater sense of well-
being than interactions with family (Larson, Mannell, & Zuzanek, 1986), which could reflect the obligatory and sometimes
ambivalent nature of many family relationships (Crohan & Antonucci, 1989; Quan-Haase et al., 2017). In addition, friendships
are much more effortful to maintain than more obligatory family relationships in that they require more communication,
coordination, and activity engagement (Roberts & Dunbar, 2015). Daily diary studies reveal that individuals are more likely
to be engaged in cognitively stimulating leisure activities when with a friend than with a family member, when they are more
likely to be engaged in neutral household activities (Larson et al., 1986).
Potential mechanisms underlying the cognitive benefits of friendship were explored using data from MIDUS (Sharifian et al.,
2020). These independent data replicated the previous finding that having a friend-focused network is potentially cognitively
beneficial, but not because it protects individuals from negative effects of family. Rather, the positive association between
interacting with friends and cognitive functioning was mediated by more frequent engagement in physical and cognitively
stimulating leisure activities (Sharifian et al., 2020), which is consistent with previous literature (Ihle, Oris, Baeriswyl, & Kliegel,
2018), including daily diary studies (Larson et al., 1986).
This behavioral evidence supports the idea that the beneficial effects of social interaction, particularly with non-family
members, operates through mental stimulation. However, neural mechanisms remain to be elucidated. Results from a clinico-
pathologic study suggest that greater social interaction may buffer against the negative cognitive effects of brain pathology
(Bennett et al., 2006). Specifically, more Alzheimer’s disease-related plaques and tangles measured at autopsy were only
associated with worse cognitive functioning during life among older adults with small social networks. Among older adults
with large social networks, cognitive performance was relatively high even at the highest levels of neuropathology. These results
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are in line with the concept of cognitive reserve (as opposed to brain reserve or brain maintenance) because social network size
was not directly associated with neuropathology. Rather, having a larger social network appeared to protect against the clinical
manifestations of pathology.
This finding was recently replicated and extended using brain data collected in vivo with structural magnetic resonance
imaging, as well as more comprehensive measures of social relations (Sharifian et al., 2021). Specifically, worse brain health (i.e.,
lower cortical thickness in nine Alzheimer’s disease “signature” regions) was only associated with worse cognitive performance
among older adults with small social networks. Importantly, the critical interaction between social network characteristics
and brain health was only evident for friendships, extending the work by Bennett and colleagues (2006) by highlighting the
importance of social network structure/composition. Older adults with small friend networks showed the expected association
between worse brain health and worse cognitive performance, whereas older adults with large friend networks showed no such
link. Importantly, although friend relationships appear to be more beneficial for cognitive aging, family relationships are also
important for older adults’ health and well-being. For example, family members are likely to be a stronger source of instrumental
and emotional support (Sharifian et al., 2022). Finally, cultural differences in the structure of families, as well as the role of friends
versus family members, highlight the need for additional studies in different countries and cultural groups, as the results of the
Western studies reviewed here may not generalize to other contexts.

Conclusions

Positive psychosocial factors are robustly associated with both cognitive level and change in late life. Although historically
marginalized social groups face disproportionate barriers to accessing certain psychosocial protective factors (e.g., perceived
control over important life outcomes), these same groups also exhibit naturally occurring sources of psychosocial resilience
that allow them to achieve better late-life cognitive health than would be otherwise expected. Deconstructing multidimensional
constructs related to positive psychosocial factors is needed to elucidate mechanisms linking them to cognitive aging, as well
as to inform prevention and intervention efforts. Converging evidence from disparate studies shows that fostering friendships in
particular may have high potential for building cognitive reserve and optimizing cognitive aging. Positive psychosocial factors
may represent culturally relevant resources that, through careful research, could ultimately be harnessed to promote better
cognitive aging for a growing and increasingly diverse population of older adults.

Acknowledgments

Thank you to all of the research participants and co-authors who made much of the work cited in this paper possible. Thank
you to Neika Sharifian, Ketlyne Sol, A. Zarina Kraal, Afsara B. Zaheed, Emily P. Morris, Jordan Palms, Lindsey Meister and
Alexa Martino for comments on an earlier version of this article.

Funding

Many of the published works described in this paper were supported by the National Institute on Aging (R00AG047963,
R01AG054520, P01AG07232, R01AG037212, RF1AG054023).

Conflict of Interest

None declared.

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