Toxic Psychosocial Stress, Resiliency Resources and Time to Dementia Diagnosis in a Nationally Representative Sample of Older Americans in the Health and Retirement Study from 2006–2016
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
Inclusion and Exclusion Criteria
2.2. Measures
2.2.1. Primary Determinants: Psychosocial Factors
2.2.2. Other Measures
2.2.3. Outcome: Assessment of Dementia
2.3. Statistical Analyses
3. Results
3.1. Race Is Associated with Incident Dementia, and Disparities Persist According to Level of Mastery
3.2. Toxic Stress Is Associated with Incident Dementia; Relationship Varies by Level of Mastery
3.3. Toxic Stress Is Associated with Incident Dementia: Relationship Varies by Level of Education
3.4. Other Factors Associated with Incident Dementia
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Characteristic | All (N = 6516) | White/Caucasian (N = 5440) | Black/African American (N = 844) | Other (N = 232) | |
---|---|---|---|---|---|
Dimensions of Toxic Stress | N (%) | N (%) | N (%) | N (%) | p-Value |
Cumulative stress a | |||||
Median (IQR) | 2.0 (1.0, 3.0) | 2.0 (1.0, 3.0) | 1.0 (1.0, 3.0) | 1.0 (1.0, 3.0) | |
0 events | 1358 (22.0) | 1143 (21.9) | 167 (22.2) | 48 (23.1) | 0.9104 |
1+ events | 4817 (78.0) | 4073 (78.1) | 584 (77.8) | 160 (76.9) | |
Life course stress | |||||
Median (IQR) | 1.0 (0.0, 2.0) | 1.0 (1.0, 2.0) | 1.0 (0.0, 2.0) | 1.0 (0.0, 2.0) | |
0 events | 1547 (25.0) | 1299 (24.8) | 193 (25.6) | 55 (26.4) | 0.7962 |
1+ events | 4642 (75.0) | 3929 (75.2) | 560 (74.4) | 153 (73.6) | |
Recent Stress | |||||
Median (IQR) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | |
0 events | 5084 (81.8) | 4320 (82.3) | 598 (78.8) | 166 (78.7) | 0.0292 |
1+ events | 1132 (18.2) | 926 (17.7) | 161 (21.2) | 45 (21.3) | |
Everyday Discrimination | |||||
Median (IQR) | 1.0 (0.0, 1.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | |
0 events | 5722 (90.7) | 4888 (92.2) | 649 (82.0) | 185 (85.3) | <0.0001 |
1+ events | 590 (9.3) | 416 (7.8) | 142 (18.0) | 32 (14.7) | |
Lifetime Discrimination | |||||
Median (IQR) | 0.0 (0.0, 1.0) | 0.0 (0.0, 1.0) | 0.0 (0.0, 1.0) | 0.0 (0.0, 1.0) | |
0 events | 4397 (70.8) | 3802 (72.6) | 445 (58.8) | 150 (71.1) | <0.0001 |
1+ events | 1810 (29.2) | 1437 (27.4) | 312 (41.2) | 61 (28.9) | |
Chronic work-Discrimination b | |||||
Median (IQR) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | 0.0 (0.0, 0.0) | |
0 events | 2852 (91.5) | 2390 (92.3) | 356 (87.7) | 106 (85.5) | 0.0004 |
1+ events | 266 (8.5) | 198 (7.7) | 50 (12.3) | 18 (14.5) | |
Chronic stress | |||||
Median (IQR) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (2.0, 4.0) | |
Low | 4122 (70.6) | 3519 (71.5) | 473 (66.6) | 130 (64.4) | 0.0039 |
High | 1712 (29.4) | 1403 (28.5) | 237 (33.4) | 72 (35.6) | |
Perceived constraints | |||||
Median (IQR) | 2.0 (1.0, 3.0) | 2.0 (1.0, 3.0) | 2.0 (1.0, 3.0) | 2.0 (1.0, 4.0) | |
Low | 4214 (66.9) | 3561 (67.3) | 534 (67.5) | 119 (55.6) | 0.0016 |
High | 2081 (33.1) | 1729 (32.7) | 257 (32.5) | 95 (44.4) | |
Measures of resilience | |||||
Personal mastery | |||||
Median (IQR) | 5.0 (4.0, 6.0) | 5.0 (4.0, 6.0) | 5.0 (4.0, 6.0) | 5.0 (4.0, 6.0) | |
Low | 2189 (34.7) | 1850 (34.9) | 273 (34.5) | 66 (30.7) | 0.4374 |
High | 4113 (65.3) | 3446 (65.1) | 518 (65.5) | 149 (69.3) | |
Control over health | |||||
Median (IQR) | 8.0 (6.0, 9.0) | 8.0 (6.0 9.0) | 8.0 (6.0, 9.0) | 8.0 (7.0, 9.0) | |
Low | 2795 (44.8) | 2381 (45.4) | 336 (43.1) | 78 (36.8) | 0.0281 |
High | 3444 (55.2) | 2866 (54.6) | 444 (56.9) | 134 (63.2) | |
Control over finances | |||||
Median (IQR) | 8.0 (6.0, 10.0) | 8.0 (6.0, 10.0) | 8.0 (6.0, 10.0) | 9.0 (7.0, 10.0) | |
Low | 2207 (35.2) | 1878 (35.6) | 263 (33.4) | 66 (31.0) | 0.2085 |
High | 4064 (64.8) | 3393 (64.4) | 524 (66.6) | 147 (69.0) | |
Control over social life | |||||
Median (IQR) | 8.0 (7.0, 10.0) | 8.0 (7.0, 10.0) | 9.0 (7.0, 10.0) | 9.0 (7.0, 10.0) | |
Low | 1899 (30.4) | 1630 (31.0) | 207 (26.9) | 62 (29.2) | 0.0637 |
High | 4342 (69.6) | 3629 (69.0) | 563 (73.1) | 150 (70.8) | |
Positive Social Support (PSS) | |||||
PSS: spouses/partners | |||||
Median (IQR) | 4.0 (3.0, 4.0) | 4.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | |
Low | 1882 (42.1) | 1569 (40.6) | 230 (51.8) | 83 (51.2) | <0.0001 |
High | 2587 (57.9) | 2294 (59.4) | 214 (48.2) | 79 (48.8) | |
PSS: children | |||||
Median (IQR) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 4.0 (3.0, 4.0) | 3.5 (3.0, 4.0) | |
Low | 2979 (50.6) | 2559 (51.7) | 320 (43.1) | 100 (50.3) | <0.0001 |
High | 2910 (49.4) | 2388 (48.3) | 423 (56.9) | 99 (49.7) | |
PSS: Other family members | |||||
Median (IQR) | 3.0 (2.0, 4.0) | 3.0 (2.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (2.0, 4.0) | |
Low | 4268 (70.0) | 3666 (71.8) | 454 (58.3) | 148 (70.5) | <0.0001 |
High | 1827 (30.0) | 1441 (28.2) | 324 (41.7) | 62 (29.5) | |
PSS: Friends | |||||
Median (IQR) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (3.0, 4.0) | 3.0 (2.0, 4.0) | |
Low | 4172 (68.8) | 3539 (69.3) | 484 (64.6) | 149 (71.6) | 0.0391 |
High | 1889 (31.2) | 1565 (30.7) | 265 (35.4) | 59 (28.4) | |
PSS: all relationship groups | |||||
Median (IQR) | 8.0 (7.0, 10.0) | 8.0 (7.0, 10.0) | 8.0 (7.0, 9.0) | 8.0 (7.0, 9.0) | |
Low | 3502 (55.3) | 2897 (54.4) | 474 (59.6) | 131 (60.4) | 0.0076 |
High | 2835 (44.7) | 2427 (45.6) | 322 (40.4) | 86 (39.6) | |
Negative Social Support (NSS) | |||||
NSS: spouses/partners | |||||
Median (IQR) | 2.0 (2.0, 2.0) | 2.0 (2.0, 2.0) | 2.0 (2.0, 3.0) | 2.0 (1.0, 3.0) | |
Low | 3377 (75.7) | 2948 (76.4) | 319 (72.3) | 110 (68.7) | 0.0196 |
High | 1084 (24.3) | 912 (23.6) | 122 (27.7) | 50 (31.3) | |
NSS: children | |||||
Median (IQR) | 2.0 (1.0, 2.0) | 2.0 (1.0, 2.0) | 2.0 (1.0, 2.0) | 2.0 (1.0, 2.0) | |
Low | 2503 (42.3) | 2162 (43.5) | 260 (34.8) | 81 (40.1) | <0.0001 |
High | 3416 (57.7) | 2808 (56.5) | 487 (65.2) | 121 (59.9) | |
NSS: other family members | |||||
Median (IQR) | 1.0 (1.0, 2.0) | 1.0 (1.0, 2.0) | 1.0 (1.0, 2.0) | 2.0 (1.0, 2.0) | |
Low | 3459 (56.8) | 3015 (59.1) | 346 (44.5) | 98 (46.9) | <0.0001 |
High | 2631 (43.2) | 2088 (40.9) | 432 (55.5) | 111 (53.1) | |
NSS: friends | |||||
Median (IQR) | 1.0 (1.0, 2.0) | 1.0 (1.0, 2.0) | 1.0 (1.0, 2.0) | 1.0 (1.0, 2.0) | |
Low | 3900 (64.4) | 3369 (66.1) | 409 (54.5) | 122 (58.6) | <0.0001 |
High | 2158 (35.6) | 1731 (33.9) | 341 (45.5) | 86 (41.4) | |
NSS: all relationship groups | |||||
Median (IQR) | 5.0 (4.0, 7.0) | 5.0 (4.0, 6.0) | 5.0 (4.0, 7.0) | 5.0 (4.0, 7.0) | |
Low | 3612 (57.0) | 3065 (57.6) | 436 (54.8) | 111 (51.1) | 0.0711 |
High | 2727 (43.0) | 2261 (42.4) | 360 (45.2) | 106 (48.9) | |
Onset of Dementia | 0.0959 | ||||
No | 6178 (94.8) | 5172 (95.1) | 788 (93.4) | 218 (94.0) | |
Yes | 338 (5.2) | 268 (4.9) | 56 (6.6) | 14 (6.0) |
Characteristic | n/N | Unadjusted HR (95% CI) | p-Value | Adjusted HR c (95% CI) | p-Value |
---|---|---|---|---|---|
Race | |||||
Black (AA) vs. Caucasian | 56/844 | 1.86 (1.39, 2.48) | <0.0001 | 1.70 (1.20, 2.40) | 0.0033 |
Other vs. Caucasian | 14/232 | 1.79 (0.96, 3.37) | 0.0674 | 1.41 (0.61, 3.24) | 0.4155 |
Toxic stress (TS) measures | |||||
Cumulative stress d | |||||
Continuous measure | 298/6106 | 1.17 (1.09, 1.30) | 0.0003 | 1.14 (1.04, 1.24) | 0.0071 |
Baseline cumulative stress | |||||
0 events | 55/1358 | 1.00 | 1.00 | ||
1+ events | 243/4817 | 1.43 (1.04, 1.98) | 0.029 | 1.37 (0.97, 1.94) | 0.0739 |
Change in stress (increase vs. no change) | 52/1292 | 1.18 (0.85, 1.63) | 0.3192 | 1.25 (0.88, 1.78) | 0.2137 |
Life course stress | |||||
Continuous measure | 299/6120 | 1.18 (1.07, 1.29) | 0.0011 | 1.13 (1.03, 1.24) | 0.0133 |
Baseline life course stress | |||||
0 events | 58/1547 | 1.00 | 1.00 | ||
1+ events | 241/4401 | 1.47 (1.10, 1.96) | 0.0097 | 1.42 (1.05, 1.92) | 0.0244 |
Change in stress (increase vs. no change) | 51/1143 | 1. 30 (0.92, 1.84) | 0.1324 | 1.40 (0.97, 2.02) | 0.0744 |
Recent stress | |||||
Continuous measure | 301/6147 | 1.28 (1.01, 1.64) | 0.0427 | 1.25 (0.97, 1.62) | 0.0891 |
Baseline recent stress | |||||
0 events | 254/5084 | 1.00 | 1.00 | ||
1+ events | 47/1132 | 1.49 (1.03, 2.16) | 0.0389 | 1.39 (0.95, 2.03) | 0.0854 |
Change in stress (increase vs. no change) | 19/613 | 1.01 (0.60, 1.70) | 0.9718 | 1.01 (0.56, 1.80) | 0.9842 |
Everyday discrimination | |||||
Continuous measure | 310/6241 | 1.66 (1.45, 1.89) | <0.0001 | 1.60 (1.37, 1.87) | <0.0001 |
Baseline everyday discrimination | |||||
0 events | 242/5722 | 1.00 | 1.00 | ||
1+ events | 68/590 | 2.84 (2.03, 3.96) | <0.0001 | 2.74 (1.89, 3.98) | <0.0001 |
Change in stress (increase vs. no change) | 10/148 | 2.23 (1.11, 4.49) | 0.0257 | 2.65 (1.32, 5.29) | 0.0069 |
Lifetime discrimination | |||||
Continuous measure | 300/6138 | 1.23 (1.04, 1.44) | 0.0134 | 1.20 (1.00, 1.44) | 0.0556 |
Baseline lifetime discrimination | |||||
0 events | 209/4397 | 1.00 | 1.00 | ||
1+ events | 91/1810 | 1.40 (1.07, 1.83) | 0.0161 | 1.33 (0.98, 1.81) | 0.0695 |
Change in stress (increase vs. no change) | 17/475 | 1.49 (0.87, 2.55) | 0.1425 | 1.56 (0.86, 2.85) | 0.1399 |
Chronic work discrimination | |||||
Continuous measure | 95/3060 | 1.13 (0.76, 1.68) | 0.5388 | 0.81 (0.41, 1.60) | 0.542 |
Baseline work discrimination | |||||
0 events | 84/2852 | 1.00 | 1.00 | ||
1+ events | 11/266 | 1.42 (0.73, 2.78) | 0.2969 | 0.92 (0.34, 2.52) | 0.8704 |
Perceived constraints | |||||
Continuous measure | 310/6224 | 1.24 (1.13, 1.36) | <0.0001 | 1.22 (1.10, 1.35) | 0.0002 |
Baseline perceived constraints | |||||
Low constraints | 151/4214 | 1.00 | 1.00 | ||
High constraints | 159/2081 | 1.61 (1.21, 2.13) | 0.0016 | 1.61 (1.19, 2.18) | 0.0024 |
Change in stress (increase vs. no change) | 47/1084 | 1.45 (0.98, 2.14) | 0.0633 | 1.71 (1.13, 2.58) | 0.0115 |
Ongoing chronic stressors | |||||
Continuous measure | 227/5765 | 1.35 (1.16, 1.58) | 0.0002 | 1.31 (1.11, 1.56) | 0.0021 |
Baseline chronic stress | |||||
Low chronic stress | 140/4122 | 1.00 | 1.00 | ||
High chronic stress | 87/1712 | 2.04 (1.50, 2.79) | <0.0001 | 1.99 (1.37, 2.88) | 0.0005 |
Change in stress (increase vs. no change) | 32/859 | 1.34 (0.86, 2.10) | 0.1911 | 1.60 (1.02, 2.52) | 0.0428 |
Resilience-promoting factors (RPF) | |||||
Personal mastery | |||||
Continuous measure | 310/6231 | 0.87 (0.78, 0.97) | 0.0117 | 0.86 (0.77, 0.97) | 0.0119 |
Baseline personal mastery | |||||
Low mastery | 152/2189 | 1.00 | 1.00 | ||
High mastery | 158/4113 | 0.80 (0.63, 1.02) | 0.0723 | 0.78 (0.59, 1.02) | 0.0659 |
Change in measure (decrease vs. no change) | 45/1064 | 1.12 (0.79, 1.56) | 0.533 | 1.13 (0.81, 1.57) | 0.3464 |
Positive social support (PSS) domains | |||||
PSS from spouses/partners | |||||
Continuous measure | 211/4403 | 0.92 (0.71, 1.19) | 0.5164 | 0.98 (0.76, 1.28) | 0.9069 |
Baseline PSS (spouse/partner) | |||||
Low PSS | 94/1882 | 1.00 | 1.00 | ||
High PSS | 117/2587 | 0.94 (0.67, 1.31) | 0.7023 | 1.05 (0.73, 1.50) | 0.791 |
Change in measure (decrease vs. no change) | 15/394 | 1.08 (0.60, 1.93) | 0.7954 | 1.11 (0.60, 2.05) | 0.7408 |
PSS from children | |||||
Continuous measure | 291/5820 | 0.77 (0.62, 0.94) | 0.0134 | 0.78 (0.63, 0.97) | 0.0276 |
Baseline PSS (Children) | |||||
Low PSS | 138/2979 | 1.00 | 1.00 | ||
High PSS | 153/2910 | 0.76 (0.60, 0.95) | 0.0182 | 0.76 (0.61, 0.96) | 0.0193 |
Change in measure (decrease vs. no change) | 34/804 | 1.13 (0.74, 1.71) | 0.565 | 1.26 (0.84, 1.88) | 0.2559 |
PSS from other family members | |||||
Continuous measure | 295/6024 | 1.03 (0.90, 1.19) | 0.6656 | 1.00 (0.86, 1.17) | 0.9528 |
Baseline PSS (family) | |||||
Low PSS | 201/4268 | 1.00 | 1.00 | ||
High PSS | 94/1827 | 0.89 (0.66, 1.18) | 0.398 | 0.82 (0.60, 1.13) | 0.2219 |
Change in measure (decrease vs. no change) | 38/947 | 1.13 (0.73, 1.78) | 0.5732 | 1.24 (0.76, 2.02) | 0.3851 |
PSS from friends | |||||
Continuous measure | 292/5994 | 0.99 (0.82, 1.20) | 0.9427 | 1.04 (0.85, 1.27) | 0.6909 |
Baseline PSS (friends) | |||||
Low PSS | 206/4172 | 1.00 | 1.00 | ||
High PSS | 86/1889 | 0.99 (0.73, 1.33) | 0.989 | 1.04 (0.75, 1.45) | 0.8085 |
Change in measure (decrease vs. no change) | 28/824 | 0.95 (0.56, 1.63) | 0.8593 | 0.99 (0.56, 1.73) | 0.9611 |
PSS from all relationship groups | |||||
Continuous measure | 314/6265 | 1.05 (0.99, 1.11) | 0.1288 | 1.03 (0.97, 1.09) | 0.3369 |
Baseline PSS (all groups) | |||||
Low PSS | 172/3502 | 1.00 | 1.00 | ||
High PSS | 142/2835 | 1.21 (0.93, 1.55) | 0.1456 | 1.04 (0.78, 1.39) | 0.7726 |
Change in measure (decrease vs. no change) | 57/1311 | 1.40 (0.95, 2.06) | 0.0902 | 1.40 (0.92, 2.13) | 0.1106 |
Negative social support (NSS) domains | |||||
NSS from spouses/partners | |||||
Continuous measure | 209/4395 | 1.13 (0.91, 1.40) | 0.2722 | 1.07 (0.84, 1.36) | 0.5814 |
Baseline NSS (spouse/partner) | |||||
Low NSS | 156/3377 | 1.00 | 1.00 | ||
High NSS | 53/1084 | 1.17 (0.83, 1.65) | 0.3627 | 1.12 (0.72, 1.74) | 0.6077 |
Change in measure (increase vs. no change) | 23/528 | 1.72 (0.95, 3.12) | 0.0731 | 1.83 (0.91, 3.68) | 0.087 |
NSS from children | |||||
Continuous measure | 293/5850 | 1.41 (1.16, 1.72) | 0.001 | 1.35 (1.08, 1.69) | 0.0102 |
Baseline NSS (children) | |||||
Low NSS | 102/2503 | 1.00 | 1.00 | ||
High NSS | 191/3416 | 1.77 (1.27, 2.46) | 0.0011 | 1.68 (1.16, 2.45) | 0.0069 |
Change in measure (increase vs. no change) | 25/772 | 1.06 (0.65, 1.73) | 0.8272 | 1.12 (0.66, 1.90) | 0.6626 |
NSS from other family members | |||||
Continuous measure | 293/6019 | 1.52 (1.24, 1.86) | 0.0001 | 1.43 (1.14, 1.80) | 0.0028 |
Baseline NSS (family) | |||||
Low NSS | 156/3459 | 1.00 | 1.00 | ||
High NSS | 137/2361 | 1.82 (1.37, 2.42) | <0.0001 | 1.77 (1.29, 2.44) | 0.0007 |
Change in measure (increase vs. no change) | 42/876 | 1.40 (0.93, 2.10) | 0.1038 | 1.50 (0.99, 2.26) | 0.0563 |
NSS from friends | |||||
Continuous measure | 292/5991 | 1.43 (1.12, 1.82) | 0.0051 | 1.33 (1.03, 1.70) | 0.0268 |
Baseline NSS (friends) | |||||
Low NSS | 171/3900 | 1.00 | 1.00 | ||
High NSS | 121/2158 | 1.54 (1.13, 2.10) | 0.0074 | 1.58 (1.14, 2.21) | 0.0073 |
Change in measure (increase vs. no change) | 34/693 | 1.70 (1.00, 2.89) | 0.0495 | 1.85 (1.12, 3.05) | 0.0171 |
NSS from all relationship groups | |||||
Continuous measure | 314/6267 | 1.18 (1.11, 1.26) | <0.0001 | 1.14 (1.06, 1.23) | 0.0004 |
Baseline NSS (all groups) | |||||
Low NSS | 172/3612 | 1.00 | 1.00 | ||
High NSS | 142/2727 | 1.73 (1.34, 2.24) | <0.0001 | 1.68 (1.22, 2.33) | 0.0022 |
Change in measure (increase vs. no change) | 75/1695 | 1.29 (0.93, 1.80) | 0.1269 | 1.48 (1.03, 2.11) | 0.0321 |
Control of social life | |||||
Continuous measure | 306/6172 | 0.86 (0.83, 0.88) | <0.0001 | 0.86 (0.83, 0.89) | <0.0001 |
Baseline control of social life | |||||
Low control | 162/1899 | 1.00 | 1.00 | ||
High control | 144/4342 | 0.43 (0.35, 0.54) | <0.0001 | 0.43 (0.34, 0.54) | <0.0001 |
Change in measure (decrease vs. no change) | 44/1308 | 0.97 (0.68, 1.40) | 0.8718 | 1.29 (0.86, 1.95) | 0.2156 |
Control of health | |||||
Continuous measure | 306/6169 | 0.90 (0.85, 0.95) | 0.0001 | 0.90 (0.85, 0.96) | 0.0014 |
Baseline control of health | |||||
Low control | 172/2795 | 1.00 | 1.00 | ||
High control | 134/3444 | 0.69 (0.52, 0.90) | 0.0074 | 0.71 (0.52, 0.96) | 0.0286 |
Change in measure (decrease vs. no change) | 46/1364 | 0.91 (0.63, 1.30) | 0.5881 | 0.99 (0.67, 1.45) | 0.9555 |
Control of finances | |||||
Continuous measure | 2309/6201 | 0.89 (0.85, 0.93) | <0.0001 | 0.90 (0.86, 0.94) | <0.0001 |
Baseline control of finances | |||||
Low control | 143/2207 | 1.00 | 1.00 | ||
High control | 166/4064 | 0.53 (0.41, 0.69) | <0.0001 | 0.55 (0.42, 0.73) | <0.0001 |
Change in measure (increase vs. no change) | 59/1724 | 0.87 (0.65, 1.17) | 0.348 | 1.06 (0.77, 1.47) | 0.7022 |
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Nkwata, A.K.; Zhang, M.; Song, X.; Giordani, B.; Ezeamama, A.E. Toxic Psychosocial Stress, Resiliency Resources and Time to Dementia Diagnosis in a Nationally Representative Sample of Older Americans in the Health and Retirement Study from 2006–2016. Int. J. Environ. Res. Public Health 2022, 19, 2419. https://doi.org/10.3390/ijerph19042419
Nkwata AK, Zhang M, Song X, Giordani B, Ezeamama AE. Toxic Psychosocial Stress, Resiliency Resources and Time to Dementia Diagnosis in a Nationally Representative Sample of Older Americans in the Health and Retirement Study from 2006–2016. International Journal of Environmental Research and Public Health. 2022; 19(4):2419. https://doi.org/10.3390/ijerph19042419
Chicago/Turabian StyleNkwata, Allan K., Ming Zhang, Xiao Song, Bruno Giordani, and Amara E. Ezeamama. 2022. "Toxic Psychosocial Stress, Resiliency Resources and Time to Dementia Diagnosis in a Nationally Representative Sample of Older Americans in the Health and Retirement Study from 2006–2016" International Journal of Environmental Research and Public Health 19, no. 4: 2419. https://doi.org/10.3390/ijerph19042419