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. 2023 Feb 4;38(6):983–989. doi: 10.1093/arclin/acad014

Sense of Purpose in Life and Beliefs and Knowledge of Alzheimer’s Disease

Angelina R Sutin 1,✉, Yannick Stephan 2, Martina Luchetti 3, Damaris Aschwanden 4, Amanda A Sesker 5, Xianghe Zhu 6, Antonio Terracciano 7
PMCID: PMC10456211  PMID: 36744681

Abstract

Objective

A sense of purpose in life is associated with healthier cognitive outcomes, including lower risk of Alzheimer’s Disease (ad). The present research examines whether purpose is also associated with beliefs and knowledge of ad.

Method

A random subsample (N = 1,187) of community-dwelling participants from the Health and Retirement Study completed a module on self-reported beliefs and knowledge of ad.

Results

Purpose in life was associated with lower perceived threat of ad and greater belief that modifiable factors (e.g., physical activity) decrease risk. Associations were not moderated by experience with ad or depressive symptoms. Purpose was unrelated to beliefs that genetics or stress increase risk or knowledge of ad.

Conclusions

Individuals with a sense of purpose are less concerned about risk of developing ad and believe modifiable factors reduce risk. These beliefs may support engagement in behaviors that reduce risk and be one psychological pathway through which purpose protects against ad.

Keywords: Alzheimer’s disease, Dementia, Alzheimer’s belief, Alzheimer’s threat, Purpose in life

Alzheimer’s disease (ad) and related dementias are common among older adults (Alzheimer’s Association, 2022) and a feared outcome of aging (Metlife Foundation, 2011). There are lay beliefs about what can be done to help maintain cognitive health with age (Vaportzis & Gow, 2018). Among the top factors that the public believes will help maintain cognitive health is to have a purpose in life (Vaportzis & Gow, 2018). That is, there is a lay perception that living a purposeful life protects against cognitive decline with age. Empirical evidence supports these beliefs: individuals who report a greater sense of purpose have less cognitive decline in older adulthood (Kim, Shin, Scicolone, & Parmelee, 2019) and are less likely to develop dementia (Sutin, Aschwanden, Luchetti, Stephan, & Terracciano, 2021).

Less is known, however, about how purpose felt by individuals is associated with attitudes, beliefs, and knowledge about ad. There is a growing literature, for example, on dementia-related threat, generally defined as an “emotional response to the perceived threat of developing dementia” (p. 277) (Kessler, Bowen, Baer, Froelich, & Wahl, 2012). The construct of dementia-related threat has emerged from more general models of disease worry as applied specifically to worry about dementia (Kessler et al. 2012; Werner, AboJabel, & Maxfield, 2021) and has been associated with cognitive health, including worse executive function among cognitively healthy older adults (Caughie et al., 2021). In addition to perceived threat of ad, there are other beliefs and knowledge about ad that individuals may hold that are distinct from feelings of threat. Beliefs about risk factors for the development of ad, for example, may shape behaviors that individuals engage in (Vaportzis & Gow, 2018). Individuals who believe that modifiable behaviors (e.g., physical activity) can decrease risk may be more likely to engage in such behaviors, whereas individuals who believe that nonmodifiable risk factors (e.g., genetics) increase risk may be less motivated to engage in behaviors that may decrease risk. Finally, knowledge about ad is an additional domain that is relevant for both help-seeking behavior when it is needed (i.e., individuals with more knowledge are more likely to seek help) and how to care for close others with dementia (Parker, Barlow, Hoe, & Aitken, 2020).

The present research builds on previous research in the Health and Retirement Study (HRS) that has examined the sociodemographic (Roberts, McLaughlin, & Connell, 2014) and mental health (Ostergren, Heeringa, Leon, Connell, & Roberts, 2017) predictors of beliefs and knowledge of ad to examine the association between a sense of purpose in life and three aspects of beliefs and knowledge of ad: ad threat, beliefs about risk and protective factors, and knowledge of ad. The literature on purpose in life suggests that it tends to be protective against psychological distress (e.g., depressive symptoms; Musich, Wang, Kraemer, Hawkins, & Wicker, 2018) and perceptions of cognitive decline (i.e., subjective beliefs that one’s cognition has gotten worse over time; Sutin, Luchetti, Stephan, & Terracciano, 2021a). Greater distress and worse perceived cognition are also associated with greater dementia threat (Werner, AboJabel, & Maxfield, 2021). As such, we expect that greater purpose will be associated with less ad threat. We do not make specific hypotheses for either beliefs about risk factors or ad knowledge. We further address whether these associations are moderated by personal experience with knowing someone with ad because such exposure has been found to modify associations between individual characteristics and ad threat (Suhr & Kinkela, 2007). Finally, we test whether the associations are moderated by age, objective cognitive function, and depressive symptoms.

Method

Participants and Procedure

Participants were from the HRS (Sonnega et al., 2014), an ongoing longitudinal study of individuals aged 50 years and older living in the United States and their spouses, regardless of age (i.e., spouses younger than 50 could participate). The HRS is funded by the National Institute on Aging and administered by the University of Michigan, including ethical oversight and written informed consent prior to each assessment. The research reported here is based on deidentified data that are available publicly from HRS (https://hrs.isr.umich.edu/about). Participants are reinterviewed every 2 years, with an additional psychosocial assessment every 4 years (in a cycle where half the participants complete it in each 2-year cycle). The 2010 assessment included an experimental module on ad that included self-report questions about beliefs and knowledge of ad. A subset of randomly selected participants from the 2010 assessment completed this module (n = 1,819). Of these participants, n = 1,187 also reported on their purpose in life in the 2006 (35.6% [n = 423]), 2008 (47.3% [n = 562]), or 2010 (17% [n = 202]) leave-behind questionnaire. Participants who did not have complete data on purpose in life to be included in the analyses (n = 632) were younger (d = 0.80, p < .01), had fewer years of education (d = 0.17, p < .01), were more likely to be African American (χ2 = 30.99, p < .01) or otherwise identified (χ2 = 53.16, p < .01), and had worse cognitive function (d = 0.22, p < .01). There was no difference in sex (χ2 = 0.019, p = .921).

Measures

Purpose in life. Sense of purpose was assessed with a seven-item version of the Purpose in Life subscale from the Ryff Scales of Psychological Well-Being (Ryff, 1989). Items (e.g., “I have a sense of direction and purpose in my life”) were rated on a scale from 1 (strongly disagree) to 6 (strongly agree) and the mean taken in the direction of greater purpose (alpha = 0.76).

Beliefs and knowledge about ad. Participants responded to items about perceived beliefs and knowledge about ad that have been validated previously in the HRS (Ostergren et al. 2017; Roberts et al. 2014). Perceived ad threat was measured with three items on the individual’s perception of threat: “You would like to know your chances of someday getting Alzheimer’s.” “You believe you will get Alzheimer’s someday.” “You worry about getting Alzheimer’s someday.” These items were rated on a scale from 1 (strongly agree) to 5 (strongly disagree). Following Ostergren and colleagues (2017), the mean was taken across these three items. Even with moderate reliability (alpha = 0.65), we aggregated these items because the associations with purpose were similar with each individual item (see below). Participants also rated two items on beliefs about factors that increase risk: stress and genetics (“Do you believe stress [genetics] is very important, somewhat important, or not at all important in increasing a person’s chances of getting Alzheimer’s?”) and four items on beliefs about modifiable factors that may help reduce risk (“keeping physically active,” “keeping mentally active,” “eating a healthy diet,” “taking vitamins or dietary supplements”). These items were rated on a scale from 1 (not at all) to 3 (very important). Following Ostergren and colleagues (2017), these four items on modifiable factors were averaged into beliefs about modifiable risk factors (alpha = 0.80). ad knowledge was measured with four true/false items from the Alzheimer’s Disease Knowledge Scale (Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009): “Once people have AD, they are no longer capable of making informed decisions about their own care.” “Prescription drugs that prevent AD are available.” “It is safe for people with Alzheimer’s to drive as long as they have a companion in the car at all times.” and “Having a parent or sibling with AD increases the chance of developing it.” ad knowledge was the sum of correct answers on these four items. Similar composite scores have been used in previous studies of ad beliefs and knowledge (Ostergren et al. 2017; Roberts & Connell, 2000). Finally, participants reported on whether they knew anyone with ad with one item for family and one item for non-family, which were coded into 1 = knows a family member with ad and 1 = knows a non-family member with ad, both compared to 0 = does not know anyone with ad.

Covariates. Covariates were sociodemographic factors and cognitive function concurrent with the Alzheimer’s module. Sociodemographic factors were age in years, sex (0 = male, 1 = female), race (two dummy-coded variables that compared 1 = Black and 1 = Otherwise identified to 0 = white), and education in years. Cognitive function was measured with the modified Telephone Interview for Cognitive Status (TICSm) (Crimmins, Kim, Langa, & Weir, 2011) that was the sum of three cognitive tasks: memory recall (possible range 0–20), serial 7 s (possible range 0–5), and backward counting (possible range 0–2; total TICSm range = 0–27). Covariates were selected due to their association with purpose in life (Mei et al., 2020), risk of AD (Alzheimer’s Association, 2022), and/or beliefs and knowledge of ad (Roberts et al. 2014) that may contribute to how purpose is associated with beliefs and knowledge of ad. To test moderation by psychological distress, depressive symptoms were measured with an eight-item (yes/no) version of the Center for Epidemiological Studies Depression scale; items were summed (range 0–8).

Statistical Approach

Linear regression was used to examine the association between purpose in life and ad threat, perceived risk factors, and ad knowledge. Each outcome was regressed on purpose in life and the covariates. No correction was made for multiple comparisons. We report the p-value to three decimal places to allow readers to make their own judgements. We further tested whether the association between purpose and ad threat, beliefs, and knowledge was moderated by knowing someone with ad, age, cognitive function, or depressive symptoms by adding the interaction term to the model (separately for each factor). Knowing someone with ad was coded into two dummy variables that compared knowing family with ad (=1) or knowing non-family with ad (=1), both compared to not knowing someone with ad (=0). Of note, it was not possible to ascertain whether the participant knew both family and non-family with ad from the questions participants were asked about knowing someone with ad.

Results

Descriptive statistics are in Table 1 and correlations among all study variables are in Supplementary material online, Table S1. Table 2 shows the results of the regression analysis. Purpose was related negatively to ad threat (β = −0.11, p < .001): Participants higher in purpose were less likely to want to know their chances of someday getting Alzheimer’s (β = −0.06, p = .048), less likely to believe that they were going to develop ad (β = −0.09, p = .002), and were less worried about it (β = −0.09, p = .002) than participants who scored lower in purpose. Interestingly, purpose was unrelated to beliefs about factors that may increase risk of ad (stress, genetics) but was associated positively with the aggregate beliefs that modifiable factors help to reduce risk (the association with the individual items were β = 0.14 for physical activity [p < .001], β = 0.08 for mental activity [p = .006], β = 0.10 for diet [p = .001], and β = 0.07 for vitamins [p = .021]). The standardized beta coefficient for the association between purpose and modifiable factors (β = 0.12; Table 2) was at least twice as strong or nearly twice as strong in magnitude as the standardized beta coefficient for either the demographic factors (e.g., β = 0.03 for gender; Table 2) or cognitive function (β = 0.02; Table 2). Purpose was unrelated to ad knowledge (both the composite score (see Table 2) and each individual item [results not shown, p-values ranged from .419 to .826]). Purpose was also unrelated to personal experience with ad (knowing either a family member with ad: odds ratio = 1.10, 95% confidence interval = 0.95–1.26, p = .210 or a non-family member with ad: odd ratio = 0.98, 95% CI = 0.79–1.21, p = .853, both compared to not knowing anyone with ad), and none of the associations was moderated by personal experience with a family or non-family member with ad (all interactions ns). The pattern of associations was identical when participants who scored within the dementia range on the TICSm were excluded from the analysis (n = 26). The negative association between purpose and ad threat was slightly stronger among relatively younger than relatively older participants (βpurpose x age = 0.07, p = .012). There were no interactions between purpose and age, cognitive function, or depressive symptoms on any of the ad belief or knowledge measures (all interactions ns).

Table 1.

Descriptive statistics for all study variables

Variable Mean (SD) or % (n)
Age (years) 68.31 (10.67)
Age range 34–98
Sex (female) 57% (677)
Race (Black) 15.1% (179)
Race (otherwise identified) 4.5% (53)
Race (white) 80.4% (955)
Education (years) 12.90 (2.89)
Cognitive functiona 15.32 (4.20)
Depressive symptomsb 1.24 (1.84)
Purpose in lifec 4.68 (0.91)
AD threatd 2.78 (1.01)
Beliefs about AD risk factorse
Stress 1.84 (0.78)
Genetics 2.37 (0.67)
Modifiable factors 2.30 (0.53)
Physical activity 2.34 (0.68)
Mental activity 2.58 (0.61)
Healthy diet 2.35 (0.71)
Vitamins or supplements 1.95 (0.70)
AD knowledgef 2.39 (0.92)
Know someone with AD
Family member (yes) 12.9% (153)
Non-family member (yes) 51.9 (616)
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Notes: N = 1,187. SD, standard deviation; AD, Alzheimer’s disease.

aScore on the modified Telephone Interview for Cognitive Status. Scores could range from 0 to 27.

bScore on the modified Center for Epidemiological Studies Depression scale (possible range 0–8).

cResponse scale ranged from 1 (strongly disagree) to 6 (strongly agree).

dResponse scale ranged from 1 (strongly disagree) to 5 (strongly agree).

eResponse scale range from 1 (not at all) to 3 (very important).

fSum of correct responses on four items.

Table 2.

Association between purpose in life and beliefs and knowledge about AD

Predictor AD threat Increase risk Decrease risk AD knowledge
Stress Genetics Modifiable factors
β p β p β p β p β p
Age (years) -0.15 <.001 0.00 .859 -0.14 <.001 0.00 .895 -0.08 .004
Sex (female) 0.02 .580 -0.05 .092 0.07 .014 0.03 .310 0.00 .983
Race (black) -0.02 s.411 0.20 <.001 -0.05 .073 0.05 .094 -0.13 <.001
Race (otherwise) 0.02 .517 0.09 <.001 0.01 .626 0.04 .130 -0.04 .124
Education 0.04 .213 -0.21 <.001 0.11 <.001 -0.07 .033 0.15 <.001
Cognitive function -0.08 .020 -0.07 .022 0.00 .935 0.02 .502 0.18 <.001
Purpose in life -0.11 <.001 -0.02 .500 -0.04 .157 0.12 <.001 -0.02 .557
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Notes: N = 1,187. AD = Alzheimer’s disease. Results are the same when year of purpose in life assessment is included as an additional covariate.

Discussion

Previous research on perceptions of cognitive aging has found that the general public believes that having a purpose in life is one of the most important factors that protects against declines in cognition with age (Vaportzis & Gow, 2018). Empirical evidence supports this perception: a recent meta-analysis indicated that individuals with a greater sense of purpose in life are at lower risk of incident dementia, a protective association that replicated in eight samples (Sutin et al., 2023). Missing from this literature is how individuals with higher purpose in life perceive risk of ad and their beliefs and knowledge about the factors that increase or decrease risk. The present research addresses this issue by showing that greater purpose in life is associated with lower perceived threat of developing ad and with greater belief that modifiable factors can lower the risk of developing ad. Purpose was unrelated to ad knowledge or to belief that either genetics or stress increase risk.

This research makes at least two contributions to the literature. First, purpose in life is associated with a lower perceived threat of ad, including less interest in knowing the chances of someday getting Alzheimer’s, less likely to believe that they were going to develop ad, and less worry about it. This lower worry is well supported by the evidence that individuals with more purpose are at lower risk of dementia (Sutin et al., 2021). Such beliefs may also act as a self-fulfilling prophecy. In other domains, self-perceptions of better health (Daly, Sutin, & Robinson, 2017), behavior (Zahrt & Crum, 2017), and subjective age (Stephan, Sutin, Luchetti, & Terracciano, 2017) are associated with better long-term outcomes. The exact mechanisms that explain why perceptions are associated with better outcomes are not well understood. Individuals who perceived themselves as healthier and who are not anxious about developing chronic disease may feel less stress (Joshanloo, 2022), and less stress may help improve mood (de Vibe, Bjørndal, Tipton, Hammerstrøm, & Kowalski, 2012) and increase engagement in health-promoting behaviors (Sagui-Henson, Levens, & Blevins, 2018). Such perceptions may also be associated with less anxiety, which may help protect the brain over time, whereas greater anxiety increases risk for cognitive impairment (Sutin, Stephan, & Terracciano, 2018).

Second, a greater sense of purpose is associated with belief that there are modifiable behaviors that decrease risk of developing ad. Unlike genetics and to some extent stress (which may be modifiable in some circumstances but not in others), individuals tend to have more control over their amount of physical and mental activity and diet and vitamin use. There is the most evidence that engagement in physical (Prakash, Voss, Erickson, & Kramer, 2015) and mental (Yates, Ziser, Spector, & Orrell, 2016) activities is associated with better cognitive outcomes and may help to protect the brain with age. Diet may also be protective (Singh et al., 2014), while evidence is mostly null on vitamin supplementation (McCleery et al., 2018). Individuals higher in purpose tend to regularly engage in these behaviors. A greater sense of purpose, for example, has been associated with engaging in more physical activity (as measured by self-report; Kim, Shiba, Boehm, & Kubzansky, 2020), including when activity is measured objectively by accelerometer (i.e., when there is no shared method variance with purpose; Hooker & Masters, 2016), and perhaps propelled by the motivation to be healthy (Sutin, Luchetti, Stephan, & Terracciano, 2021b). Purpose also tends to be associated with eating a healthier diet (Hill, Edmonds, & Hampson, 2019), which may support maintaining cognitive function. As such, individuals higher in purpose both believe in the importance of modifiable behavior for preventing dementia and engage in the behaviors that protect cognition. Over time, such beliefs and behaviors may support healthier cognitive function.

There is evidence that the relation between demographic and some psychological factors and ad threat are moderated by personal experiences with ad, such that having a family member with ad amplifies the association with ad threat (Suhr & Kinkela, 2007). The present research, however, suggests that such personal experiences are irrelevant for purpose: The associations between purpose in life and ad beliefs and knowledge were similar regardless of whether participants knew someone (either family or non-family) with ad or not. This finding suggests that personal experience with someone with ad does not diminish the protective association of purpose in life. It also suggests that purpose does not necessarily diminish the positive association between ad experience and greater feelings of ad threat (Ostergren et al. 2017).

It is also of note that the associations were independent of cognitive function. Even though both purpose in life (Windsor, Curtis, & Luszcz, 2015) and beliefs and knowledge about ad (Ostergren et al. 2017) are associated with cognitive function, the associations were significant both controlling for cognitive function and when participants with cognitive impairment were excluded from the analysis. This pattern suggests aspects of purpose other than the shared association with cognition drive the relations with beliefs and knowledge of ad. In addition, the associations did not change as a function of cognition (i.e., there was no interaction), which suggests that purpose does not amplify or diminish the relation between cognitive function and beliefs and knowledge of ad.

The present research had several strengths, including a relatively large sample and measurement of a range of attitudes, beliefs, and knowledge about ad. Limitations include the single measurement of ad beliefs and knowledge, such that it was not possible to examine how perceptions change over time. The type of factors that increase risk was also limited to two factors and was not comprehensive. Future research could also test whether these perceptions are a mechanism through which purpose protects against development of ad. The sample was also drawn from an ongoing longitudinal study, and the results need to be replicated in other populations to better determine generalizability. Indeed, the sample was older, and all participants were living in the United States. Samples with other sociodemographic characteristics and samples from other countries are needed to better evaluate the generalizability of the associations. Finally, there were sociodemographic differences in who reported on their purpose in life and thus who could be included in the analyses. This positive selection into the analytic sample could underestimate the associations between purpose and beliefs and knowledge of ad. Despite these limitations, the present research suggests that a greater sense of purpose in life is associated with a more optimistic perception of ad threat and beliefs about modifiable protective factors. This perception matches empirical evidence that purpose protects against dementia, in part through engagement in modifiable behaviors.

Supplementary Material

Supplemental_Material_acad014
Click here for additional data file. (16.1KB, docx)

Acknowledgement

This study uses public data from the Health and Retirement Study, which is sponsored by the National Institute on Aging (NIA-U01AG009740) and conducted by the University of Michigan.

Contributor Information

Angelina R Sutin, Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA.

Yannick Stephan, Euromov, University of Montpellier, Montpellier, France.

Martina Luchetti, Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA.

Damaris Aschwanden, Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA.

Amanda A Sesker, Department of Behavioral Science and Social Medicine, Florida State University College of Medicine, Tallahassee, FL, USA.

Xianghe Zhu, Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA.

Antonio Terracciano, Department of Geriatrics, Florida State University College of Medicine, Tallahassee, FL, USA.

Funding

Research reported in this publication was supported by the National Institute on Aging of the National Institutes of Health under Award Number R01AG074573. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflict of Interest

None declared.

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