LARRC Scholar Pilot Projects
Award Year 2016-2017
Vineeta Chand, Ph.D.
Dr. Vineeta Chand is a Lecturer in Sociolinguistics and a researcher within the Centre for Research in Language Development throughout the Lifespan at the University of Essex, UK. Her research broadly explores the relationship between socio-cultural and cognitive factors on language development and change at the individual and community level in two areas: linguistic and communicative changes associated with dementia, and diachronic language development and changes in multilingual repertoires in northern India. Dr. Chand received her PhD in Linguistics from UC Davis, and completed her postdoctoral training in the Department of Neurology, UC Davis.
Project: Latino cognitive health, bilingual proficiency and language efficiency
This project seeks to test the relationship between bilingual proficiency, communicative efficiency and the age of onset of Alzheimer's among Latinos in northern California. Research on the protective (reserve) role of bilingualism for delaying Alzheimer’s disease (AD) age of onset and decline trajectory has offered conflicting findings, problematized in part by inconsistencies and lack of rigor in how bilingual proficiency is measured. In addition, a quantitative language efficiency measure, idea density (ID, a measure of how content-full language is), shows promise as a measure of cognitive reserve in White American populations, but is unexplored in ethnic minority populations, and in non-English data. Dovetailing with these, aging and cognitive health research recognizes the pressing need to develop a better understanding of factors unique to or offering distinct associations to cognitive health in American minority populations. Latinos with a range of Spanish and English fluencies are the largest US ethnic minority group, projected to grow from 16.3% of the population in 2010 to 28.6% in 2060 (US Census 2010), while the aging Latino population is one of the fastest growing older adult populations. This LARRC research project will 1) measure and model the protective role of bilingual proficiency and idea density in both Spanish and English for Latinos in the UCD ADC longitudinal cohort, and 2) test bilingual proficiency and language efficiency measures in each language as potential unique markers of cognitive reserve which predict decline trajectories.
Sunshine Rote, Ph.D.
Sunshine Rote is an Assistant Professor at the Raymond A. Kent School of Social Work at the University of Louisville. Dr. Rote’s research focuses on the social patterning of health and health-related behaviors with a special emphasis on the Mexican-origin population. Her recent research utilizes both quantitative and qualitative data to describe the sources of stress and resiliency within Latino caregiver stress processes. Dr. Rote received her PhD in Sociology from Florida State University and completed her postdoctoral training at the University of Texas Medical Branch in the Sealy Center on Aging.
Project: Cognitive Functioning and Support Need in the Mexican-Origin Population.
In the next few decades, the number of Mexican American elders with Alzheimer’s Disease and Related Disorders (ADRD) will increase dramatically. Given the fact that this population underutilizes formal care services, the degree of elder-care responsibilities in the Mexican American family is likely to increase in the coming decade. However, little is known about the nature and extent of need for assistance with day-to-day activities and emotional support due to ADRD-related decline. The proposed study employs a longitudinal study of 3,050 older Mexican-origin individuals, the Hispanic Established Populations for the Epidemiologic Studies of the Elderly (H-EPESE, 1993/94-2010/11). Using Growth Mixture Modeling and seven waves of survey data spanning 18 years, the current proposal seeks to (1) examine the role of cognitive functioning for long-term patterns in instrumental and emotional support need and (2) estimate the role of migration-related factors (nativity status, age at migration, and acculturation) in shaping the relationship between cognitive impairment and support need. A key methodological innovation of this project is moving from static, cross-sectional analyses and standard growth models to growth mixture modeling (GMM), which allows for examinations of greater diversity in the life experiences of older Mexican Americans over time. Results from this study will lead to a better understanding of at which point in the dementia stage biomedical, public health, and social service interventions are most needed. Results will also inform a larger project on identifying both care recipient and caregiver factors in predicting dementia-related unmet support need over time.
G. Adriana Perez, PhD, ANP-BC, FAAN
Adriana Perez is an Assistant Professor of Nursing and Senior Fellow, at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, School of Nursing. Her research promoting healthy aging in older Latinas has been funded by the National Hartford Center of Gerontological Nursing Excellence (NHCGNE), NIH/NINR individual NRSA, National Coalition of Ethnic Minority Nurses, and St. Luke’s Health Initiative. As a result of her work and because of the high relevance to environmental health policy, she was selected as a Congressional/Health and Aging Policy Fellow (2011-2013)supported by the Atlantic Philanthropies and Centers for Disease Control & Prevention. Dr. Perez is a board-certified Adult Nurse Practitioner, a Fellow of the American Academy of Nursing and serves as chair of the Academy’s Expert Panel on Aging. She received her PhD from Arizona State University, College of Nursing & Health Innovation where she also completed a Claire M. Fagin Postdoctoral Fellowship, funded by the NHCGNE.
Project: Physical Activity & Cognitive Health Among Older Latinas
Latinos experience a higher risk of developing chronic cognitive diseases, including Alzheimer’s and other dementias compared to non-Latino whites. Much of the cognitive disease burden has been associated with cardiovascular disease risk factors that include high cholesterol, high blood pressure, diabetes and physical inactivity. Of the major modifiable risk factors, physical inactivity has been found to affect the largest segment of the population, particularly those with lower socio-economic status, older adults, women and Latinos. This public health concern is particularly critical among older Latinas. Almost 50% of older Latinas report that they do not engage in any leisure time physical activity, compared with 29.2% of non-Latino white women. The proposed project is consistent with the National Institute on Aging goals in the “Aging Well in the 21st Century: Strategic Directions for Research on Aging,” which includes improving the health, well-being, and independence of adults as they age. The objective of this research is to address important gaps in the literature by expanding our understanding of cognitive health promotion among older Latinas through regular physical activity. Including the perspective of the population gives older, minority women an important voice in designing feasible, acceptable and culturally relevant interventions that promote physical activity and cognitive health. This study includes a secondary analysis of both qualitative focus group data and results from a community based Wellness Motivation Intervention (WMI) among older Latinas.
Award Year 2015-2016
A. Susana Ramírez , Ph.D.
A. Susana Ramírez is Assistant Professor of Public Health Communication at the University of California in Merced.
Dr. Ramírez’ research employs mixed methods to understand the multiple levels of communication influence on health behaviors and to reduce cancer-related health disparities among Latino populations. Her research fundamentally seeks to answer the question: What does it mean to communicate in a culturally appropriate manner in the context of an acculturatively diverse and dynamic population?
Her published research has examined the development of and effectiveness of culturally tailored messages for Latina populations, knowledge and beliefs about cancer risk factors, and health information seeking behaviors. Currently funded research examines the feasibility of using mobile phones for tailored behavior change communications among Latinos, social marketing strategies to increase food access, mapping the health information environment, and multilevel communication strategies to create a culture of health in a diverse community.
Dr. Ramírez completed a Cancer Prevention Fellowship (postdoctoral) in the National Cancer Institute’s Division of Cancer Control and Population Sciences, Health Communication and Informatics Research Branch. Dr. Ramírez earned a PhD in Communication from the Annenberg School for Communication at the University of Pennsylvania, a Master of Public Health from Harvard University, and a Bachelor of Arts in Communication from Santa Clara University.
Project: Innovative application of communication theory to increase Latino research participation
This project addresses the challenge of communicating in a culturally appropriate manner with caregivers of aging Latinos. Specifically, we will collect data to create a culturally tailored peer navigator intervention to enhance decision-making among caregivers of Latino patients with dementia who experience neuropsychiatric symptoms (NPS). Recommended treatment for NPS is non-pharmacological, but many patients take antipsychotic medications for these symptoms, despite the increased risk of death through cardiac arrhythmias, cardiovascular disease, pneumonia, and all-cause mortality and the FDA’s black box warning. Antipsychotic medication use for NPS is especially high among Latino dementia patients, who are more likely than other groups to live in the community with family members providing most care. A reduction in pharmacological treatment for NPS is recommended, yet factors that influence family caregivers’ treatment decision-making are not well understood. This is particularly true for Latino populations, for whom there exist specific cultural factors that may affect the dementia caregiving context. A significant barrier to understanding caregiving needs for Latino populations is their chronic underrepresentation in clinical research that might help to elucidate those needs. Thus, the project is based on the premise that challenges in recruiting Latinos to participate in clinical research are similar to those posed in effective health communication, and that we can leverage theories and methods of communication science to increase participation of Latinos in clinical research. The proposed study has two distinct but related components. We will begin by developing and evaluating a research participation process to engage caregivers of Latino dementia patients in clinical research, using communication theory to identify stakeholders and recruit research participants. To address the substantive gaps in the literature regarding cultural factors and caregiving support needs, we will conduct focus groups with caregivers of Latinos with dementia that will directly inform the development of an intervention to support their decision-making about dementia treatment.
Mariaelena Gonzalez, Ph.D.
Dr. Mariaelena Gonzalez is an Assistant Professor in Public Health at the University of California Merced. Her research focuses on health disparities, including oral health disparities, and the ways in which social and environmental factors affect health risk behaviors, such as tobacco use. Dr. Gonzalez’s research also focuses on the ways in which health behaviors differ between first, second, and third generation Latinos. Dr. Gonzalez received her PhD in Sociology from Stanford University, and completed her postdoctoral training at the University of California, San Francisco at the Center for Tobacco Control, Research, and Education.
Project: Understanding Oral Health Disparities in the Merced County
This project seeks to identify oral-health related factors that may contribute to the risk of cognitive impairment among Latinos in rural, low-income counties, through the use of a community-based survey. A growing body of literature has documented the relationship between tooth loss, periodontal disease, and cognitive impairment. Latinos have the highest periodontitis prevalence of all US racial-ethnic groups, placing them at high risk for oral health related diseases, and cognitive impairment. This study will assess oral health status among adult Latinos and non-Latinos in Merced County using self-reported measures. This project will analyze differences in oral health practices between Latinos and non-Latinos, test if there are oral health related disparities between Latinos and non-Latinos, and will seek to identify possible interventions to promote greater levels of oral self care and oral hygiene among Latino residents of Merced County.
Oanh Meyer, Ph.D.
Oanh Meyer, Ph.D. is currently an Adjunct Assistant Professor at the UC Davis Alzheimer’s Disease Center in the Department of Neurology. She received her doctoral training in social psychology from the University of California, Davis. Dr. Meyer studies cognitive and mental health disparities in racial/ethnic minorities and older adults from a broad, population level and also at the individual level. Some of her current research interests include dementia caregiving and mental health, social contextual determinants of cognitive decline associated with dementia, and geographic disparities in mental health for older adults.
Project: Acculturation Influences on Caregiving Intervention Outcomes in REACH II
Although the older population will increase among all racial and ethnic groups, the Latino older population is expected to grow the fastest, adding to the number of Latinos diagnosed with Alzheimer’s disease or related dementia. Caregiving for someone with dementia is associated with a variety of poor outcomes, and this burden may be even greater for Latino caregivers, thus exacerbating existing health disparities for this group. Although interventions have been developed to reduce caregiver distress for Latinos, an understanding of how within-group heterogeneity affects caregiving intervention outcomes is lacking. The proposed research is a secondary data analysis of the Resources for Enhancing Alzheimer's Caregiver Health (REACH) II trial. This multisite randomized controlled trial included a diverse sample of caregivers and their care recipients with dementia who were randomly assigned to either a multicomponent intervention or to a control condition. The present study includes the 212 Latino caregivers with data on physical and mental health outcomes as well as caregiver burden and bother. The primary goal is to characterize the role of acculturation on caregiver outcomes and to determine whether it moderates the effect of the REACH II intervention on caregiving outcomes. Although this application focuses primarily on dementia caregiving in Latino populations, study findings will have a much broader public health impact. Results may have important implications for culturally-tailored interventions for other immigrant populations (e.g., Asian American) that are also characterized by diversity in acculturation level.
Award Year 2014-2015
Laura Castro-Schilo, Ph.D.
Laura Castro-Schilo received her doctoral training in quantitative psychology at the University of California, Davis under the mentoring of Dr. Keith Widaman and Dr. Kevin Grimm. Prior to graduate school, Dr. Castro-Schilo graduated Summa Cum Laude with a BA in Psychology from California State University, Fullerton. She joined the L. L. Thurstone Psychometric Laboratory at the University of North Carolina at Chapel Hill as an Assistant Professor in the fall 2013. Her program of research is focused on the development and application of statistical models for analyzing short-term and long-term processes with an emphasis on psychometric issues. Dr. Castro-Schilo applies her methodological expertise to the study of life-span development of Mexican-origin individuals. She is interested in the identification of psychological, behavioral, and cultural factors that affect well-being in this population.
Project: Cognitive Health Benefits of Positive Emotions for Elder Mexican Americans
This project seeks to identify factors that deflect cognitive impairments and decline by focusing on positive psychological processes that improve mental and physical health and can be used to implement intervention programs for Mexican-origin elders. Specifically, we focus on positive emotions, the pathways by which they influence cognitive health, and their value in protecting cognitive health at old age. Positive emotions have been linked to a wealth of positive mental and physical health outcomes. Similarly, mental and physical health has been shown to predict cognitive health. This project brings together these two lines of research to investigate the role of positive emotions in the cognitive health of aging Mexican Americans. The proposed model posits positive emotions as factors influencing mental health, physical health, quality of social relationships, creativity, and mindfulness. These constructs act as mediators linking positive emotions to cognitive health. Moreover, positive emotions are also hypothesized to have direct effects on cognitive health. This study requires secondary analysis of longitudinal data from the Sacramento Area Latino Study on Aging (SALSA) and the University of California, Davis Alzheimer’s Disease Center (UCD ADC) Longitudinal Cohort study. We will use structural equation modeling and mixed modeling approaches to achieve the goals of the project. Analyses will be conducted with both datasets to allow for conceptual replication of the findings.
Luis G Carvajal Carmona, Ph.D.
Dr. Luis Carvajal-Carmona graduated with a Magda Cum Laude from the National University in Colombia, his native country, and obtained his PhD from University College London. For his PhD dissertation, he used genetic markers to show the asymmetrical patterns of founding admixture that gave origin to the Hispanic groups from Latin America. His PhD work is currently one of the most cited examples of directional mating in humans. He carried out postdoctoral Fellowships at the London Research Institute and the University of Oxford in the UK. His postdoctoral work led to the publication of several high impact papers, including the discovery of the first common locus associated with colorectal cancer risk in the general populations. During his career, Dr. Carvajal-Carmona has developed expertise on population and cancer genetics. He has published over 50 peer-reviewed publications in several highly impact journals such as Nature Genetics, Gastroenterology, PLoS Genetics and PNAS. His research efforts have been recognized with number of awards including the European Association for Cancer 40th Anniversary Research Award, the Division of Medical Sciences Research Award from the University of Oxford and, more recently, a prestigious V Foundation Scholarship. Dr. Carvajal-Carmona is currently an Assistant Professor at the University of California Davis where he leads a human and cancer genetics laboratory in the Genome Center. He leads several international research collaborative networks, including the CHIBCHA and COLUMBUS studies, two of the largest cancer genetics studies in Hispanic populations. His current research focuses on cancer genetics and epidemiology, cancer health disparities and global cancer health.
Project: Identification of Genetic Variants Influencing Cognitive Function using
a Genome-Wide Association Study
In In this project I will use a genome-wide association study (GWAS) to identify genetic variants that influence variation in cognitive phenotypes and endophenotypes in the Latino SALSA cohort. We will genotype, with genome-wide single nucleotide polymorphism (SNPs) arrays, ~400 subjects from our community based diversity SALSA cohort for whom DNA samples are available. Using this genetic data we will investigate associations between SNPs and cognitive function variables such as normal cognition, mild cognitive impairment or dementia and MRI measurements such as total intracranial volume, brain volume and gray matter volume. We will also test hypothesis related to the role of genetic admixture on these phenotypic traits.
Reymundo Lozano, M.D.
Dr. Lozano is a Pediatric Geneticist, who has dedicated his research to better understanding the molecular basis of genetic disorders associated with intellectual disabilities and autism spectrum disorders (ASD). He is an International Medical Graduate from Mexico and completed his subspecialty studies at UCLA. He specializes in the treatment of neurodevelopmental genetic syndromes including fragile X syndrome (FXS), Angelman syndrome, 15q duplication syndrome, 22q11 microdeletion syndrome, and Noonan syndrome and other RASopathies. His work focuses on different clinical trials for ASD and FXS. Dr. Lozano is dedicated to finding better treatments and eventually the cure for neurodevelopmental disorders. He is also studying the phenotypic variability of fragile X premutation carries and the additive effects of other “genetic hits” and environmental exposures. He pursues the genetic diagnosis of ASD, using cutting edge technology, including microarrays, mitochondrial function and whole exome sequencing. Dr. Lozano is an advocate for minority participation in clinical trials and his goal is to provide the necessary information to enhance enrollment and retention of minority participants. He is involved in identifying the linguistic and systemic barriers to early diagnosis and intervention commonly found in Hispanic children with ID and ASD. He is also interested in increasing diversity among medical students and faculty members at UC Davis.
Project: The aging effects differences in Latinos and Caucasians with
the premutation of FMR1 gene
Fragile X syndrome (FXS) and Fragile X-associated disorders (FADs) are related to mutations in the Fragile X Mental Retardation 1 gene. The premutation is associated with a variety of diseases and abnormal aging, including memory and cognition deficits as well as tremor and ataxia. FXTAS (fragile X-associated tremor/ataxia syndrome) is a neurodegenerative disorder that is observed in about 40% of males with the premutation. The premutation is associated with increased levels of FMR1-RNA (which leads to neurotoxicity) as well as with diminished levels of the FMRP (FMR1 encoded protein) which is responsible for cognition deficits and psychopathological disorders observed in premutation carriers. We aim to phenotype the clinical, psychological, psychiatric and molecular profiles of Latino premutation adults who we have been already identified in our GP study, and to make a comparison with Caucasian premutation adults who have been already phenotype and genotype in our GP study. We also aim to analyze the genetic admixture that could influence the phenotype differences on the Latino participants.
Award Year 2012-2014
Carolina Apesoa-Varano, Ph.D.
Ester Carolina Apesoa-Varano is an assistant professor at the Betty Irene Moore School of Nursing at UC Davis. Apesoa-Varano earned Bachelor of Arts degrees in Spanish and Latin-American Literature and Sociology at State University of New York, Oneonta, in 1997. She earned a Master of Arts in Sociology from California State University, Sacramento, in 2000 and a Doctor of Philosophy in Sociology from UC Davis in 2008. Apesoa-Varano was a Building Interdisciplinary Research Careers in Women’s Health (BIRCWH) Scholar, part of a prestigious National Institute of Health program, from 2011 to 2012. Prior to joining the School of Nursing, she was a postdoctoral scholar in the UC Davis School of Medicine Department of Psychiatry and Behavioral Sciences where her research focused on barriers to depression care in diverse, older men’s health.
Project: Social Capital and Ethnicity: A Qualitative Longitudinal Study of Caregiving Experience,
Burden, and Reward among Alzheimer’s Disease Latina Caregivers
While the literature on caregiving and caregiver intervention is vast, we lack understanding of effective interventions to support Latina caregivers who are more likely to report high levels of burden, depression, and stress compared to other ethnic groups. The overall purpose of this pilot longitudinal qualitative study is to show how social capital and ethnicity impact Latina caregivers’ experiences and the nature of their social resources over time as they care for someone with AD. The study is a purposive, non-probability sample of Latina family caregivers of a patients with AD recruited and assessed through the UC Davis Alzheimer’s Disease Center database. Structured physical and mental health data will be collected using two questionnaires and analyzed for descriptive statistics. Qualitative interviews will be converted to text and thematically analyzed.
Lorena Garcia, Ph.D.
Lorena Garcia is an assistant professor in Public Health Sciences at the UC Davis School of Medicine. Dr. Garcia’s expertise is in chronic health, aging, endocrinology and metabolism, minority health, and health disparities.
Dr. Garcia’s current research also includes examining raw milk consumption in Mexico through funding from the UC Global Health Institute Junior Faculty Fellowship. The Raw Milk/Leche Bronca Study is a global health collaboration that will study the consumption, characteristics and views/beliefs of raw milk/leche bronca (RM/LB) in rural communities of Mexico which have high outmigration to the USA.
Dr. Garcia was formerly an Interdisciplinary Women’s Health Research (IWHR) Scholar from the NIH-sponsored BIRCWH (Building Interdisciplinary Research Careers in Women's Health) program at the UC Davis School of Medicine. Her research focused on health disparities in Mexican, White and African American women, where she looked at metabolic and nutritional syndromes, particularly obesity, pre-diabetes, diabetes and health-related complications, such as heart disease, stroke, and high blood pressure.
Dr. Garcia received a Doctor of Public Health from the Department of Epidemiology at UCLA in 2002 and a Masters of Public Health in Epidemiology/Biostatistics from Boston University in 1996. She has been engaged in Latino health research since the early 1990s with a special interest in health disparities, chronic disease, aging, behavioral health, injury and violence prevention in the Latino community.
Project: The Impact of Neighborhood Context on Older Latino’s Chronic Health Status
Older Latinos are more likely to reside in lower socioeconomic position (SEP) neighborhoods and to have negative health outcomes. Neighborhood context can positively and or negatively affect older Latino health. The prevalence of cardiovascular disease risk factors such as diabetes, obesity, and hypertension is particularly high among low SEP Latinos. While it is understood that health disparities and chronic disease exist by race and SEP, there is limited information on the specific role that neighborhood context plays on older Latino health and specifically to cardiovascular health. Therefore it is hypothesized that low neighborhood SEP will negatively impact older Latino’s chronic health, specifically their diabetes status. We plan to determine the relationship of neighborhood context on diabetes status for older Latino’s to examine the role of neighborhood context on changes in diabetes status and to assess whether these relationships differ by gender and nativity. Logistic regression methods and multilevel regression models will be used to analyze the covariates of interest.
Sarah Farias, Ph.D.
Sarah Farias is an Associate Professor in Neurology at the UC Davis. Primary research interests involve the development of new measures of everyday functioning applicable to older adults with cognitive impairment and dementia, and the study of the how cognitive and non-cognitive impairments influence everyday functioning. Other active research interests in the area of aging are related to the influence of vascular disease on cognitive decline, the role of cognitive reserve in moderating the effects of disease on cognition, and the development of new approaches for how to measure cognitive reserve in older adults. Dr. Farias obtained a bachelor’s in science degree from Arizona State University in 1993, and a PhD from the University of North Texas in 2000. She held an internship in the department of Neurology and Psychiatry at Tulane University and in 2002, and she was awarded a NIMH-funded summer research scholarship in Geriatric Psychiatry.
Project: Development of a community-based cognitive enrichment intervention to
promote cognitive health in Hispanic older adults
Convincing evidence suggests that engagement in cognitively, socially, and physically stimulating activities have positive effects on cognition. Multimodal interventions, which incorporate opportunities for learning and novelty along with increased physical and social activity, may offer the greatest benefits to brain health. One approach to providing this type of intervention is through volunteer work. We seek to understand the perceptions and barriers Latino older adults have regarding participation in intervention programs designed to maintain or improve cognitive health through volunteerism. We will conduct and analyze qualitative focus groups to (a) define Latino older adults’ views on volunteerism and activities that promote general cognitive health, (b) identify specific barriers to participating in volunteer work, and (c)identify facilitators to volunteerism. In Phase 2 we will conduct and analyze focus groups with leaders and stakeholders at community-based volunteer organizations. Data will be analyzed using qualitative methods and relying on collaborative expertise from within the UC Davis academic community.
Dawnte Early, Ph.D.
Dawnté R. Early is a postdoctoral fellow in the Department of Neurology at her alma mater. Dr.Early received her PhD in Human Development with a minor in Quantitative Psychology from the University of California, Davis. Dr.Early's major area of interest is examining how demographic and environmental factors contribute to cognitive decline in ethnically diverse older persons.
Project: Life experience modifiers of late life cognitive trajectories
Levels of brain pathology increase and cognitive function declines as we age. The trajectories of cognitive change, however, are heterogeneous and the degree of brain pathology account for only a fraction of the between-person variance in cognitive aging. While genetic factors almost certainly play an important role in moderating or mediating the effects of brain pathology on cognitive function, considerable evidence suggests that early childhood conditions and certain types of experiences over the lifespan can also play predictive or risk-elevating roles. We examine the hypothesis that experiences in childhood and middle adulthood modify cognitive function in late life by developing specific measures of life history variables associated with cognitive trajectories in late life. Using data from the UC Davis Alzheimer’s Disease Center longitudinal cohort, a sample of 400 equally represented by Latino’s, African Americans, and Caucasians, and where there is considerable heterogeneity in cognitive status, we will use the Life Experiences Activities Form (LEAF) to collect data on childhood and adult experiences. We predict (1) that childhood poverty is associated with lower late life cognitive performance and decline, (2) greater social interaction in mid-life is associated with less cognitive decline, (3) higher levels of cognitively stimulating activities in mid-life are associated with less cognitive decline, and (4) higher levels of physical activity in mid-life are associated with less cognitive decline.