The Paradox in Positive and Negative Aspects of Emotional Functioning Among Older Adults with Early Stages of Cognitive Impairment

Abstract

Introduction: Emotional functioning in older adults is influenced by normal aging and cognitive impairment, likely heterogeneous across positive versus negative aspects of emotional functioning. Little is known about positive emotional experiences at the early stages of cognitive impairment. Methods: We assessed different aspects of emotional functioning among 448 participants aged 65+ (Normal Control (NC) = 276, Mild Cognitive Impairment (MCI) = 103, and mild dementia of the Alzheimer type (mild DAT) = 69) and tested moderators. Results: Compared to NC, older adults with MCI and mild DAT have maintained many positive aspects of emotional functioning, despite higher levels of negative affect, sadness, and loneliness. Among the oldest-old, the mild DAT group experienced higher fear and lower self-efficacy. Discussion: Older adults at early stages of cognitive impairment can experience positive aspects of emotional functioning, such as positive affect, purpose, and life satisfaction, all of which are important buildable psychological resources for coping.

Keywords

emotional functioning cognitive aging positive emotions negative emotions cognitive impairment

Introduction

Emotional functioning is influenced by both normal aging and changes in the brain due to dementia and other neurodegenerative diseases (Carbone et al., 2022; Depp et al., 2010; Fan et al., 2023). With the normal aging process, older adults generally can maintain similar, if not higher, affective well-being and emotional stability because they engage more in positivity-seeking emotional regulation strategies (Isaacowitz, 2022; Scheibe & Carstensen, 2010). However, older age is also associated with a higher risk of developing dementia, which disturbs emotional processing and may increase the prevalence of negative emotional symptoms such as depression, anxiety, agitation, and aggression (Invernizzi et al., 2022; Cerejeira et al., 2012; Ma, 2020; Van der Mussele et al., 2015). Thus, emotional functioning in older adults is a result of complex interactions of different emotion processing and regulation mechanisms influenced by the severity of cognitive impairment, likely heterogeneous across positive versus negative aspects of emotional functioning.

Growing evidence in recent years called for a specific research focus on emotional functioning during the early stages of cognitive impairment because (1) deficits in emotional processing are among the earliest signs of cognitive impairment (García-Martín et al., 2022; Halpin et al., 2017; Lanctôt et al., 2017) and (2) there is a high prevalence (>50%) of anosognosia, or lack of awareness of one’s own cognitive deficit and emotional experiences, at the more advanced stages of cognitive impairment (Jacus et al., 2023; Starkstein, 2014). Mild Cognitive Impairment (MCI) represents a stage of early cognitive impairment that may be considered the intermediate phase between normal aging and dementia of the Alzheimer type (DAT) (Knopman & Petersen, 2014): MCI is typically characterized by low performance in one or more cognitive domains that do not substantially interfere with daily functioning; in some cases, such decline in cognitive function may plateau or become reversible (Knopman & Petersen, 2014; McGirr et al., 2022). Mild DAT, in comparison, represents more severe cognitive impairment in more than one cognitive domain that interferes with independence in daily life and has a worse prognosis (Knopman & Petersen, 2014).

Characterizing emotional functioning across cognitively healthy individuals and those with MCI or mild DAT is critical because emotional symptoms are early indicators of the overall health, functional independence, and caregiving burden for older adults with cognitive impairment and their families (Ayhan et al., 2023; Ballard et al., 2009; Isik et al., 2019; Orgeta et al., 2022; Palmer et al., 2010). This knowledge can help researchers better understand: (1) in which stage of cognitive impairment do older adults start to experience worsening emotional functioning; and (2) which aspects of emotional functioning are likely to be preserved when cognitive impairment progresses from subtle in the MCI stage to more substantial in the mild DAT stage. A better understanding of these issues has important implications for supporting early care planning and interventions among older adults with cognitive impairment: early initiation of intervention programs, such as emotional regulation and cognitive training, may be appropriate and effective for providing older adults and their families strategies to cope with the worsening cognitive and emotional functioning over time (Irazoki et al., 2020; Jean et al., 2010; Larouche et al., 2015).

Although the health significance of positive aspects of emotional functioning in later life has been widely documented (Meier et al., 2021; Ong et al., 2011; Pressman et al., 2019), most studies of older adults with MCI or mild DAT primarily emphasized negative aspects of emotional functioning, such as depression and loneliness (Holwerda et al., 2014; Ma, 2020; Van der Mussele et al., 2015). While a growing number of studies in recent years have examined positive emotional experiences among individuals with DAT, including constructs related to psychological well-being and self-efficacy, these studies usually focused on a single aspect of positive experience. This makes it challenging to synthesize information or make meaningful comparisons across studies due to the large variations in study methods (Bell et al., 2022; Dos Santos et al., 2018). Although quality of life as a construct relevant to successful aging has been examined among individuals living with more advanced stages of dementia, this construct alone may not fully reflect all aspects of emotional well-being that are important and meaningful to individuals with cognitive impairment (Martyr et al., 2018). For instance, positive affect, meaning and purpose, life satisfaction, and self-efficacy are aspects of emotional functioning integral to developing resilience in the context of chronic stress, including the stress of living with cognitive impairment (Arenaza-Urquijo & Vemuri, 2020; Harris, 2008). A more systematic approach to examining these positive emotional experiences among older adults with MCI or mild DAT is essential for identifying psychological resources to cope with challenges faced by older adults with cognitive impairment (Martyr et al., 2018).

It is important to note that certain subgroups of older adults may be more vulnerable to compromised emotional functioning based on their sociodemographic characteristics. For instance, the oldest-old (those aged 80 and above) with MCI or mild DAT may differ from their younger counterparts in their emotional functioning as evidence suggests that age-related protective effect in emotional processing and regulation generally start to deteriorate after reaching the age of 80 (Charles & Carstensen, 2010; Goveas et al., 2016; Scheibe & Carstensen, 2010). Hence, age group (<80 and 80+) likely moderates the relationship between cognitive status and emotional functioning. Besides age, gender may also be an important effect moderator specific to aggression as prior literature documented that gender differences in physical aggression are salient among individuals across different developmental stages (Kim et al., 2022; Zuidema et al., 2009). A better understanding of these moderators would contribute to better identification of subgroups of older adults at a higher risk of suffering from worsened emotional functioning with the onset of cognitive impairment. However, many practical challenges, e.g., the difficulty of recruiting the oldest-old without cognitive impairment, prevented a great number of prior studies from testing these moderators due to the limitations in sample representativeness.

To fill these gaps, this current study aimed to investigate differences in emotional functioning among cognitively normal (NC) older adults, older adults with MCI, and older adults with mild DAT. Unique also to our study is the addition of a sample of cognitively intact adults aged over 80. Our main hypothesis is that older adults at early stages of cognitive impairment experience higher negative emotions, though not necessarily compromised psychological well-being compared to cognitively healthy older adults. We additionally hypothesize that the differences in negative aspects of emotional functioning may appear as early as the MCI stage and that age group (age<80, 80+) moderates the relationship between cognitive status and emotional experiences. To ensure breadth of assessment, we evaluated many dimensions of emotional functioning using the NIH Toolbox Emotion Battery (NIHTB-EB), a comprehensive set of computerized measures of emotional functioning validated for use in a representative sample of the US general population (Salsman et al., 2013).

Methods

Participants

Data were drawn from English-speaking participants who took part in the Advancing Reliable Measurement in Alzheimer’s Disease and Cognitive Aging (ARMADA) study (S. Weintraub et al., 2021). The ARMADA study is an ongoing, multi-center, longitudinal study of older adults aged 65 and above and collects multidimensional aspects of health, including cognitive function and well-being data among older adults with and without cognitive impairment with biomarkers and other neurological and clinical data (Weintraub et al., 2021). Participants were recruited from the existing cohorts of nine participating institutions (Alzheimer’s Disease Center or other affiliated longitudinal studies of aging and dementia). Participants were eligible to be included in the ARMADA cohort if they (1) were participants of a source study at one of the nine recruiting institutions; and (2) had a research diagnosis of mild DAT (Clinical Dementia Rating Scale [CDR] Global Score = 1) or MCI (amnestic single or multidomain: Global CDR = .5) (Karpouzian-Rogers et al., 2023; Weintraub et al., 2022). The research diagnosis of cognitive impairment was multi-tiered, consisting of the assignment to a clinical profile based on information obtained from participants, study partner, neuropsychological testing and examination, and additional neuroimaging or laboratory data (Weintraub et al., 2022). Similarly, cognitively normal individuals were recruited and enrolled if they were 65 or older, with no significant complaints of cognitive impairment, and with normal cognition judged by clinical interview and mental status examination. Participants were excluded from the study if they had disorders with similar symptoms as dementia, a history of any major chronic psychiatric disorder, central nervous system disease, substance abuse, serious medical illness, chronic use of neuroleptic or hypnotic medications, or if they were unable to provide consent. Approval was obtained from the institutional review board at the coordinating site (STU00205290) and each of the nine recruitment sites. Informed consent was obtained from participants before the start of the study. Detailed descriptions of the study design, recruitment procedures and analysis plans can be found in a prior publication (S. Weintraub et al., 2021).

Measures

Emotional functioning was assessed using the NIH Toolbox Emotion Battery (NIHTB-EB), which measures four primary domains (Salsman et al., 2013): Negative Affect, Social Relationships, Psychological Well-Being, and Stress and Self-Efficacy. The Negative Affect domain reflects overall negative emotions, including measures of Anger-Affect, Anger-Hostility, Anger-Physical Aggression, Fear-Affect, Fear-Somatic Arousal, and Sadness. The Social Relationships domain is comprised of measures assessing Loneliness, Friendship, Perceived Rejection, Perceived Hostility, Emotional Support, and Instrumental Support, all of which reflect an individual’s perception of social relationship and social support. The Psychological Well-Being domain represents the overall feeling of contentedness with respect to self and life, including measures of Positive Affect, Life Satisfaction, and Meaning and Purpose. Finally, the Stress and Self-Efficacy domain consists of measures of Perceived Stress and Self-Efficacy, reflecting an individual’s psychological distress and adaptive capacity.

The NIHTB-EB is self-administered and takes approximately 20–30 minutes to complete (Salsman et al., 2013). Survey data were collected at in-person visits, and a trained test administrator was available to the participant throughout the session to answer questions. All measures were administered as part of the standard emotion battery in the NIH Toolbox App. Seven scales (i.e., Anger-Affect, Fear-Affect, Sadness, Positive Affect, Life Satisfaction, Meaning and Purpose, and Self-Efficacy) were administered as computerized adaptive tests (CATs). CATs adjust difficulty to a participant’s ability and improve test efficacy by reducing the number of items needed to achieve a certain level of reliability (Gershon et al., 2013). In the NIHTB-EB, those tests end once an individual reaches the reliability (Cronbach α) of .90, which typically requires four to six items (Pilkonis et al., 2013; Salsman et al., 2014). The rest were administered as fixed length forms, including Anger Hostility (5 items), Anger-Physical Aggression (5 items), Fear-Somatic (6 items), Loneliness (5 items), Friendship (8 items), Perceived Rejection (8 items), Perceived Hostility (8 items), Emotional Support (8 items), Instrumental Support (8 items), and Perceived Stress (10 items). See Supplemental Table S1 for details.

NIHTB-EB has demonstrated good reliability (Cronbach αs ranging from .90 to .98 across scales) and acceptable convergent validity (correlation coefficients ranging from .60 to .92 across scales) among adult participants in prior literature (Kupst et al., 2015; Pilkonis et al., 2013; Salsman et al., 2013, 2014). Its validity and appropriateness for use have been documented among individuals with cognitive impairment, including individuals with Mild Cognitive Impairment, dementia, Parkinson’s, multiple sclerosis, and traumatic brain injury, spinal cord injury, and stroke (Carlozzi et al., 2017; Chaparro et al., 2016; Fox et al., 2022; Lopez et al., 2023; Yu et al., 2022). Moreover, test administrators were trained to make sure that participants accurately understood and were able to respond to NIHTB-EB instruments during the in-person interviews.

For each item, participants indicate the extent to which a given statement was true or the frequency of a given event. For example, participants rated the extent to which the statement “I can solve most problems if I try hard enough” (Self-Efficacy) was true, or the frequency of feeling “unable to control the important things in your life?” (Perceived Stress). As our analysis adjusts for age and other demographic covariates, we used the demographically unadjusted standard T-scores automatically generated by the NIH Toolbox App. Unadjusted standard T-scores (normative mean of 50 and a standard deviation of 10, where higher scores indicate a higher degree of the construct being assessed) reflect one’s overall level of functioning (not in the context of age, gender, education level, or other demographic factors). For instance, a T-score of 60 in Sadness suggests a higher-than-average level of Sadness, whereas a T-score of 40 in Positive Affect suggests a lower-than-average level of Positive Affect.

We also evaluated summary scores for Negative Affect, Psychological Well-being, and Social Relationships. Briefly, the summary scores are weighted average scores of individual scales within a latent factor based on the psychometrically validated factor structure of the NIHTB-EB, which are then normalized to a T-score distribution (Babakhanyan et al., 2018). The Negative Affect summary score is derived from the scores on individual measures of Anger-Affect, Anger-Hostility, Fear-Affect, Sadness, and Perceived Stress; the Social Relationships summary score is based on individual scales of Loneliness, Friendship, Perceived Rejection, Emotional Support, and Instrumental Support; the Psychological Well-Being summary score is based on individual scales of Positive Affect, Life Satisfaction, and Meaning and Purpose (Babakhanyan et al., 2018). See Supplemental Table S1 for additional summary score details.

Data Analysis

Descriptive statistics were used to examine the differences in sample characteristics across those characterized as NC, MCI, and mild DAT. One-way analysis of variance (ANOVA) tests were used to examine the differences in unadjusted means of emotional functioning measures by clinical status (three levels: NC, MCI, and mild DAT). General linear models were used to estimate the adjusted mean for each emotional health measure, controlling for age group (two levels: <80 and 80+), gender, marital status (Married vs. Divorced/Never Married/Separated/Other), and education (<College, College graduate and Postgraduate). For models with significant covariates, we additionally tested whether there was an interaction between the significant covariate and clinical status. If a significant interaction effect between a covariate and clinical status on an emotional health score was found, the adjusted means were estimated for each level of the covariate. Partial effect size estimates (partial eta squared; $η^{2}$ ) were computed to measure the effect size of the clinical status in models. Post-hoc Tukey pairwise comparisons were performed to further examine the differences in adjusted means in each pair of the three clinical groups.

An a priori power analysis was conducted using G*Power3 (Faul et al., 2007) to test the difference across the three independent group means using one-way ANOVA, a small to medium effect size ( $η^{2}$ = .05), and an alpha of .05. Result showed that at least 62 participants per group were needed to achieve a power of .80 and our sample sizes have exceeded this requirement across all three groups.

Results

Sample Characteristics

A total of 448 English-speaking participants (n_NC = 276, n_MCI = 103, n_{mild DAT} = 69) from the baseline data of the ARMADA study were included in the analyses. The mean age of the entire sample was 78.01 years (SD = 8.25 years), with 42.79% of participants aged 80 and older. Approximately half of the sample (53.22%) was female, 40.58% was married, and 76.05% had a college degree or higher. Compared to the MCI and the mild DAT group, a greater proportion of older adults in the NC group were aged 80 or older (NC = 48.81%, MCI = 34.62%, mild DAT = 30.99%,

χ^{2} (2)

= 11.11, p < .01), females (NC = 60.51%, MCI = 41.35%, mild DAT = 42.25%,

χ^{2} (2)

= 15.21, p < .001), and with college degree or higher (NC = 80.80%, MCI = 69.23%, mild DAT = 67.61%,

χ^{2} (4)

= 14.00, p < .01). There were no statistically significant differences in the distribution of race and ethnicity across the three groups (all ps > .05). See Table 1 for more details.

Table 1.

Sample Characteristics.

	NCN = 276	MCIN = 103	Mild DATN = 69	$χ^{2}$	df	p-value
Age category N (%)
<80	141 (51.09)	68 (65.38)	49 (69.01)
≥80	135 (48.91)	36 (34.62)	22 (30.99)	11.11	2	<.01
Gender N (%)
Male	109 (39.49)	61 (58.65)	41 (57.75)
Female	167 (60.51)	43 (41.35)	30 (42.25)	15.21	2	<.001
Race N (%)
White	235 (85.14)	88 (84.62)	63 (88.73)
African American	35 (12.68)	15 (14.42)	4 (5.63)
Other	6 (2.17)	1 (.96)	4 (5.63)	7.10	4	.13
Ethnicity N (%)
Hispanic	6 (2.17)	4 (3.85)	3 (4.23)
Non-Hispanic	270 (97.83)	100 (96.15)	68 (95.77)	1.29	2	.52
Education N (%)
< College	53 (19.20)	32 (30.77)	23 (32.39)
College graduate	80 (28.99)	29 (27.88)	26 (36.62)
Postgraduate	143 (51.81)	43 (41.35)	22 (30.99)	14.00	4	<.01
Marital status N (%)
Married	205 (74.28)	44 (42.31)	19 (26.76)
Not married	71 (25.72)	60 (57.69)	52 (73.24)	69.30	2	<.001

Note. NC = Cognitively normal. MCI = Mild Cognitive Impairment. Mild DAT = Dementia of the Alzheimer type. Not Married = Divorced/Never Married/Separated/Other.

Unadjusted Differences in Emotional Functioning By Clinical Status

As shown in Table 2, participants reported different levels of overall Negative Affect (F (2,2) = 7.78, p < .001,

η^{2}

= .050) and Psychological Well-Being (F (2,2) = 3.82, p = .023,

η^{2}

= .025). There were no statistically significant differences in the summary scores of Social Relationships across the three groups (F (2,2) = .05, p = .95,

η^{2}

< .001). The effect sizes of group differences in Negative Affect and Psychological Well-Being were considered small to medium (Cohen, 1992).

Table 2.

Unadjusted Means in Different Aspects of Emotion Functioning.

	NCMean (SD)	MCIMean (SD)	Mild DATMean (SD)	p-value	$η^{2}$
Summary Scores
Negative Affect	43.92 (8.44)	48.34 (9.10)	47.66 (10.28)	<.001	.050
Social Relationships	50.13 (8.52)	49.79 (9.03)	50.22 (8.76)	.951	<.001
Psychological Well-being	52.19 (8.99)	49.21 (8.11)	49.63 (8.70)	.023	.025
Negative Affect
Anger-Affect	45.90 (8.56)	46.96 (9.58)	48.45 (10.67)	.101	.010
Anger-Hostility	41.94 (7.46)	44.58 (8.59)	43.04 (8.44)	.015	.019
Anger-Physical Aggression	44.07 (4.67)	45.17 (6.67)	47.01 (8.73)	.001	.031
Fear-Affect	48.08 (8.87)	50.49 (9.72)	50.96 (10.21)	.016	.019
Fear-Somatic Arousal	47.47 (7.72)	47.37 (9.29)	47.57 (10.48)	.988	<.001
Sadness	46.18 (9.94)	48.70 (9.30)	49.99 (10.50)	<.001	.023
Social Relationships
Loneliness	49.45 (9.21)	49.61 (9.35)	51.68 (10.12)	.205	.007
Friendship	50.33 (9.21)	50.46 (8.28)	49.19 (8.18)	.593	.002
Perceived Rejection	47.41 (8.38)	48.51 (9.19)	48.26 (9.82)	.495	.003
Perceived Hostility	40.01 (7.88)	49.25 (8.25)	48.55 (8.61)	.403	.004
Emotion Support	46.78 (8.68)	46.84 (8.21)	46.92 (7.70)	.992	<.001
Instrumental Support	50.04 (10.21)	51.40 (9.26)	53.20 (7.55)	.039	.014
Psychological Well-being
Positive Affect	48.91 (7.67)	48.12 (7.88)	47.63 (7.55)	.384	.004
Life Satisfaction	56.40 (9.21)	53.76 (9.30)	54.23 (10.34)	.026	.016
Meaning and Purpose	50.35 (9.36)	49.04 (8.95)	48.45 (8.48)	.197	.007
Stress and Self-efficacy
Perceived Stress	44.91 (8.36)	46.28 (9.59)	47.33 (10.44)	.093	.011
Self-Efficacy	51.77 (8.65)	50.92 (8.59)	48.41 (9.45)	.018	.018

Note. NC = Cognitively normal. MCI = Mild Cognitive Impairment. Mild DAT = Mild Dementia of the Alzheimer type. Mean and SD were calculated based on unadjusted-scores.

*p < .05, **p < .01, ***p < .001.

Within the Negative Affect domain, the main effect of clinical status was statistically significant on measures of Anger-Hostility (F (2, 445) = 4.27, p = .015, $η^{2}$ = .019), Anger-Physical Aggression (F (2, 445) = 7.04, p = .001, $η^{2}$ = .031), Fear-Affect (F (2,445) = 4.21, p = .016, $η^{2}$ = .019), and Sadness (F (2,445) = 5.33, p < .001, $η^{2}$ = .023). Within the Social Relationships domain, Instrumental Support was the only measure that showed a statistically significant difference across the three groups (F (2,446) = 3.26, p = .039, $η^{2}$ = .014). In the Psychological Well-Being domain, there was a significant group difference in Life Satisfaction (F (2,446) = 3.69, p = .03, $η^{2}$ = .02). A significant main effect of clinical status was also found in Self-Efficacy scores (F (2,446) = 4.07, p = .018, $η^{2}$ = .018). All of these effect sizes were considered small (Cohen, 1992).

Adjusted Differences in Emotional Functioning by Clinical Status

The main effect of clinical status on the adjusted means of different aspects of emotional functioning across the NC, MCI, and mild DAT groups are presented in Table 3

Table 3.

Adjusted Means in Different Aspects of Emotional Functioning — Main Effects.

	NCAdjusted Mean (SE)	MCIAdjusted Mean (SE)	Mild DATAdjusted Mean (SE)	p-value	Partial $η^{2}$
Summary scores
Negative Affect	44.00 (.73)	48.18 (1.06)	47.65 (1.22)	.003	.039
Social Relationships	50.50 (.70)	49.59 (1.02)	49.44 (1.17)	.675	.003
Psychological Well-Being	52.09 (.71)	49.40 (1.03)	49.07 (1.18)	.073	.018
Negative Affect
Anger-Affect	46.08 (.58)	46.66 (.92)	48.13 (1.15)	.310	.005
Anger-Hostility	42.09 (.50)	44.34 (.90)	42.83 (.99)	.064	.012
Fear-Somatic Arousal	47.53 (.54)	47.24 (.87)	47.53 (1.09)	.958	<.001
Sadness	45.93 (.62)	49.00 (.99)	50.53 (1.25)	.002	.028
Social Relationships
Loneliness	48.94 (.58)	50.16 (.93)	52.89 (1.17)	.015	.019
Friendship	50.28 (.55)	50.65 (.88)	49.08 (1.11)	.507	.003
Perceived Rejection	47.49 (.56)	48.34 (.89)	48.21 (1.12)	.698	.002
Perceived Hostility	48.58 (.50)	48.46 (.80)	47.47 (1.01)	.627	.002
Emotional Support	47.01 (.53)	46.62 (.85)	46.33 (1.05)	.840	<.001
Instrumental Support	50.82 (.59)	50.46 (.93)	51.55 (1.16)	.751	.001
Psychological Well-Being
Positive Affect	48.69 (.48)	48.46 (.77)	47.97 (.96)	.813	<.001
Life Satisfaction	56.35 (.59)	53.92 (.94)	54.22 (1.16)	.070	.012
Meaning and Purpose	50.25 (.58)	49.23 (.92)	48.58 (1.14)	.402	.004
Stress and Self-Efficacy
Perceived Stress	44.83 (.57)	46.36 (.91)	47.51 (1.14)	.099	.011

Note. NC = Cognitively normal. MCI = Mild Cognitive Impairment. All models were adjusted for age, gender, education, marital status. The adjusted means of Fear-Affect, Anger-Physical Aggression, and Self-Efficacy are reported in Table 4 because they showed significant moderating effects.

*p < .05, **p < .01, ***p < .001.

. After adjusting for age group, gender, education, and marital status, a significant main effect of clinical status was shown in the Negative Affect Summary Score across the groups of NC, MCI, and mild DAT (F (2, 289) = 5.89, p = .003, partial

η^{2}

= .039). Significant main effects of clinical status were also found in the adjusted means of Sadness (F (2, 439) = 6.26, p = .002, partial

η^{2}

= .028) and Loneliness (F (2, 440) = 4.25, p = .015, partial

η^{2}

= .019) (Figure 1(a)).

As shown in Table 4, a significant interaction term of gender and clinical status was found in Anger-Physical Aggression (F (2, 437) = 3.68, p = .01), indicating that gender moderated the relationship between clinical status and Anger-Physical Aggression. As shown in Figure 1(b), the difference in the adjusted means of Anger-Physical Aggression across three groups was significant among males (F (2, 201) = 4.51, p = .012, partial

η^{2}

= .043), but not among females (F (2, 232) = .40, p = .671, partial

η^{2}

= .003). Similarly, in the models of Fear-Affect and Self-Efficacy, significant interaction terms between age group (two levels: <80, 80+) and clinical status was found (all ps < .05). Only among the oldest-old aged 80 and above, the three clinical groups significantly differed in the adjusted means of Fear-Affect (F (2, 184) = 4.76, p = .010, partial

η^{2}

= .049) and Self-Efficacy (F (2, 185) = 4.16, p = .017, partial

η^{2}

= .043).

Table 4.

Adjusted Means in Different Aspects of Emotional Functioning—Moderating Effects.

	NCAdjusted mean (SE)	MCIAdjusted mean (SE)	Mild DATAdjusted mean (SE)	p-value	Partial $η^{2}$
Fear-Affect moderated by age group
Age <80	49.07 (.83)	52.39 (1.18)	50.26 (1.40)	.088	.019
Age 80+	46.83 (.80)	46.87 (1.52)	53.69 (2.08)	.010	.049
Self-Efficacy moderated by age group
Age <80	52.21 (.75)	49.52 (1.05)	49.39 (1.26)	.071	.021
Age 80+	51.25 (.81)	53.70 (1.55)	46.38 (2.11)	.017	.043
Anger-Physical Aggression by gender
Female	44.13 (.40)	43.53 (.79)	44.55 (1.00)	.671	.003
Male	44.39 (.67)	45.90 (.87)	48.33 (1.08)	.012	.043

Note. NC = Cognitively normal. MCI = Mild Cognitive Impairment. DAT = Dementia of the Alzheimer type. All models were adjusted for age, gender, education, marital status. *p < .05, **p < .01, ***p < .001.

Pairwise Comparison of Adjusted Differences in Emotional Functioning

Results of the post-hoc Tukey pairwise comparisons are shown in Table 5. Compared to the NC group, the mild DAT and MCI groups had significantly higher levels of Negative Affect (mean difference: MCI vs. NC = 4.18, p < .01; mild DAT vs. NC = 3.65, p < .01) and Sadness (mean difference: MCI vs. NC = 3.08, p < .05; mild DAT vs. NC = 4.60, p < .01). Mild DAT group also had higher levels of Loneliness compared to the NC group (mean difference: mild DAT vs. NC = 3.95, p < .01).

Table 5.

Pairwise Comparisons Across NC, MCI, and mild DAT groups.

	MCI Versus NC(Reference)	Mild DAT Versus NC (Reference)	MCI Versus Mild DAT (Reference)
	Mean difference (SE)	Mean difference (SE)	Mean difference (SE)
Main Effects
Negative Affect	4.18 (1.33)**	3.65 (1.48)*	−.51 (1.57)
Sadness	3.08 (1.21)*	4.60 (1.45)**	1.53 (1.54)
Loneliness	1.22 (1.13)	3.95 (1.36)**	2.73 (1.44)
Moderating Effects
Fear Affect (age 80+)	.04 (1.75)	6.85 (2.30)**	6.82 (2.50)*
Self-Efficacy (age 80+)	2.45 (1.78)	−4.86 (2.32)	−7.31 (2.54)*
Anger-Physical Aggression (male)	1.52 (1.13)	3.94 (1.32)**	2.45 (1.36)

Note. NC = Cognitively normal. MCI = Mild Cognitive Impairment. DAT = Dementia of the Alzheimer type. *p < .05,**p < .01, ***p < .001.

Among the oldest-old aged 80 and above, the mild DAT group had higher levels of Fear-Affect (mean difference: mild DAT vs. NC = 6.85, p < .01) compared to the NC group. The mild DAT group also presented higher Fear-Affect (mean difference: mild DAT vs. MCI = 6.82, p < .05) and lower Self-Efficacy (mean difference: mild DAT vs. MCI = −7.31, p < .05) than the MCI group. Among male participants, higher levels of Anger-Physical Aggression were observed in the mild DAT group compared to the NC group (mean difference: mild DAT vs. NC = 3.94, p < .01).

Discussion

This study characterized multidimensional aspects of emotional functioning across cognitively normal older adults and those with MCI or mild DAT. Higher levels of sadness, loneliness, and negative affect were observed as early as the MCI stage. Despite experiencing higher levels of negative emotions, older adults at early stages of cognitive impairment were still able to maintain many positive aspects of emotional functioning even with a diagnosis of mild DAT.

Our findings add to the small but growing body of literature evaluating psychological well-being among older adults with dementia. In contrast to a few studies in which lower life satisfaction and positive affect were observed among older adults at an advanced stage of dementia (Dos Santos et al., 2018; Zank & Leipold, 2001), our results suggest that in the early stages of cognitive impairment, older adults still have the ability to experience positive affect, meaning and purpose, and life satisfaction, despite elevated levels of negative emotional experience. This inconsistency may be explained by our primary focus on the early stages of cognitive impairment: prior research suggested that dementia status is only associated with lower life satisfaction through the mediation of impaired Activities of Daily Living (ADLs); existing literature has also documented that ADLs have generally yet to be seriously impacted in the transition from cognitively healthy to MCI or mild DAT, despite compromised functioning in some aspects of the instrumental activities in daily living (A Marshall et al., 2015; Gotanda et al., 2022; Peres et al., 2006).

Notably, our findings give nuances to current intervention strategies that promote successful aging among older adults with MCI or mild DAT. Researchers generally agreed that positive emotional experiences are buildable psychological resources that can help older adults better cope with negative emotions accompanied by living with cognitive impairment. However, positive psychology approaches are commonly believed to be preventative strategies that lower the risk of developing dementia among cognitively healthy older adults rather than interventions that can still be relevant and effective even after the onset of MCI (Folkman & Moskowitz, 2000; Pressman & Cohen, 2005). For instance, purpose in life was found to be independently associated with a 19%–30% decreased risk of dementia (Bell et al., 2022; Sutin et al., 2018). Our study highlights that the onset of cognitive impairment may not necessarily hinder older adults from experiencing positive emotions. Older adults with MCI or mild DAT may still benefit from interventions that help older adults build positive psychological resources.

Previous literature shows that older adults with DAT have a higher prevalence and incidence of symptoms of depression, anxiety, and agitation, all of which are important and common clinical presentations of behavioral and psychological symptoms of dementia (van der Linde et al., 2012). While most of the prior studies targeted single aspects of negative affect, our study showed that the difference among the three clinical groups is larger in an overall negative affect, rather than at the level of individual measures. Nonetheless, there were about three to five points difference in the adjusted means of Negative Affect, Sadness, and Loneliness across groups. The magnitude of these differences was .3–.5 SD given that all scores follow a T-distribution with a mean of 50 and SD of 10. These findings can generally be interpreted as clinically meaningful because the literature suggests that .2 to .5 SD represent the minimal clinically important difference based on most distributional methods (Mouelhi et al., 2020).

Loneliness was the only instrument in the social relationships domain that showed significant group differences, primarily driven by the differences between the mild DAT and NC groups. While it is documented that older adults living with dementia are more likely to experience social withdrawal and have a higher prevalence of loneliness (Balouch et al., 2019; Victor et al., 2020), loneliness is also known to be a predictive factor associated with 40%–60% increased risk of developing dementia in population-based studies (Holwerda et al., 2014; Sutin et al., 2020). In contrast to loneliness, no significant differences were observed in friendship, emotional support, and instrumental support across older adults with and without early stages of cognitive impairment. This indicates that although older adults with early stages of cognitive impairment in this study seems to be able to maintain their regular social contacts and support in general, they feel lonelier than cognitively healthy older adults of similar age. A possible explanation may in part due to loneliness is an in-depth emotional experience based on affective and cognitive evaluation of satisfaction with social relationship, whereas friendship and social support reflect a more objective assessment of one’s social network and the support received from the network (Van Baarsen et al., 2001). Thus, the onset of mild DAT may negatively impact the perception and interpretation of social relationships, even though minor differences were found in the actual delivery of these relationships. Nonetheless, as loneliness is both a predictor and a health outcome of dementia, it is essential that older adults negatively affected by loneliness be identified at the early stages of cognitive impairment to allow for earlier intervention to break this reciprocal feedback circle (Dodge et al., 2014). Interventions, besides facilitating the operation and performance of social relationships, should also consider incorporating ways to help older adults shape meaningful interpretations of these social contacts and relationships.

Of note, gender and age group appear to be two important moderators when examining emotional functioning among older adults with and without cognitive impairment. We observed a higher level of anger-physical aggression in the mild DAT group than the NC group, but only among male participants. This gender difference in psychological and behavioral manifestations of cognitive impairment is in accordance with existing evidence suggesting that male dementia patients are more likely than females to present aggressiveness (Kitamura et al., 2012; Resnick et al., 2021). Additionally, only among those aged 80 and above, a higher level of Fear-Affect and a lower level of Self-Efficacy was presented among mild DAT group compared to the NC or the MCI group. This suggests that those in later aging may be more vulnerable in the face of even very mild symptoms of cognitive impairment. Our study points to the need of carefully evaluating the emotional health of those aged 80 and above with even very mild cognitive impairment symptoms, and to provide additional support to alleviate anxiety and promote self-efficacy.

Study Limitations

We now outline some limitations of the present study. First, our results were based on a sample comprised mostly of adults with a college or postgraduate education, and thus, the results may not be generalizable to participants with lower educational attainment. Given that participants with low educational attainment are most vulnerable to negative cognitive and emotional outcomes of neurodegenerative diseases (Katzman, 1993; Stern et al., 1999), future research is needed to better understand the emotional functioning of this group. Second, although our sample was balanced in racial and ethnical distribution, we only focused on English-speaking older adults in the US. Since the language spoken is an indicator of culture and an important factor influencing emotional processing and attitude towards aging, future research needs to expand to populations outside of US and to non-English speaking cultures (Fung, 2013; Park et al., 1999). Third, based on current data, our study could not examine living arrangements as an important covariate associated with a wide range of emotional experiences among older adults living with cognitive impairment. Future studies of cognitive and emotional aging should further examine living arrangements as a potential protective mechanism in the face of cognitive impairment. Fourth, while the cross-sectional study design allowed us to establish baseline differences in various aspects of emotional functioning across the NC, MCI, and mild DAT groups, future investigation to assess longitudinal changes to emotional functioning across these three groups may prove beneficial. Lastly, even though the risk of anosognosia, or lack of awareness of one’s own cognitive deficit and emotional experiences, is less prevalent at the stages of MCI or mild DAT, we cannot preclude the possibility that these self-reported emotion measures may not accurately or fully represent the emotional experiences of participants due to the influence of cognitive impairment, recall bias, and social desirability.

Conclusion

In the early stages of cognitive impairment, older adults maintain similar levels of positive affect, meaning and purpose, life satisfaction, and social relationship, despite elevated levels of negative affect, sadness, and loneliness compared to the NC group. These baseline differences established in this study have important implications for intervention strategies and lay the ground for examining longitudinal trajectories of emotional health across these three groups in the future.

Supplemental Material

Supplemental Material - The Paradox in Positive and Negative Aspects of Emotional Functioning Among Older Adults with Early Stages of Cognitive Impairment

Supplemental Material for The Paradox in Positive and Negative Aspects of Emotional Functioning Among Older Adults with Early Stages of Cognitive Impairment by Manrui Zhang, Emily Ho, Cindy J. Nowinski, Rina S. Fox, Ezgi Ayturk, Tatiana Karpouzian-Rogers, Miriam Novack, Hiroko H Dodge, Sandra Weintraub, Richard Gershon in Journal of Aging and Health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by National Institute on Aging (grant number: No. 1U2CAG057441).

ORCID iD

Manrui Zhang

Data Availability Statement

Approximately 12 months after the conclusion of the ARMADA study, the data and analytic methods that support the findings will be available at the .

Supplemental Material

Supplemental material for this article is available online.

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