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Published in final edited form as: Arch Gerontol Geriatr. 2021 May 9;95:104432. doi: 10.1016/j.archger.2021.104432

Impact of Early Life Socioeconomic Status on Decision Making in Older Adults Without Dementia

Gali H Weissberger a, S Duke Han b,f,g,h, Lei Yu c,e, Lisa L Barnes c,d,e, Melissa Lamar c,d, David A Bennett c,e, Patricia A Boyle c,d
PMCID: PMC8175072  NIHMSID: NIHMS1707564  PMID: 34034033

Abstract

Objectives:

A growing body of evidence points to the negative impact of early life socioeconomic status (SES) on health and cognitive outcomes in later life. However, the effect of early life SES on decision making in old age is not well understood. This study investigated the association of early life SES with decision making in a large community-based cohort of older adults without dementia from the Rush Memory and Aging Project.

Materials and Methods:

Cross-sectional data from the Rush Alzheimer’s Disease Center Memory and Aging Project was analyzed. Participants were 1044 community-dwelling older adults without dementia (M age = 81.15, SD = 7.49; 75.8% female; 5.4% non-White). Measures of financial and healthcare decision making and early life SES were collected, along with demographics, global cognition, and financial and health literacy.

Results:

Early life SES was positively associated with decision making (estimate = 0.218, p = 0.027), after adjustments for demographic covariates and global cognition, such that a one-unit increase in early life SES was equivalent to the effect of being four years younger in age as it pertains to decision making. A subsequent model demonstrated that the relationship was strongest in those with low literacy, and weakest for those with high literacy (estimate = −0.013, p = 0.029).

Conclusions:

Findings from this study suggest that early life SES is associated with late life decision making and that improving literacy, a modifiable target for intervention, may buffer the negative impact of low early life SES on decision making in older adulthood.

Keywords: aging, early life conditions, socioeconomic status, decision making, literacy, financial and health behaviors

Introduction

There is a growing body of literature citing the negative impact of low early life socioeconomic status (SES) on health outcomes in later life. Specifically, lower early life SES has been associated with worse physical outcomes including greater risk of stroke, greater risk of cardiovascular disease, smaller adult brain hippocampal size, and increased mortality rates (1–5). Lower childhood SES has also been associated with negative mental health consequences such as depression and psychological distress (6–9), and negative cognitive consequences such as lower literacy skills, worse intellectual functioning, and poorer performances on neuropsychological tests later in adulthood (7, 10–12).

Despite our growing knowledge of the negative impact of poor early life SES on health outcomes in older adulthood, little is known about the impact of early life SES on decision making in older adulthood. As individuals reach older adulthood, they are faced with increasingly complex health and financial decisions, such as allocation of retirement funds, medical and treatment decisions associated with declining health, and advanced planning for end-of-life. Along with these important decisions, deficits in decision making have been reported in older adults (13–18). Furthermore, we previously showed that poor decision making in older adulthood is associated with increased risk of poorer health outcomes, including risk of Alzheimer’s disease and mortality (19, 20). Thus, understanding factors that contribute to decision making in old age is of utmost importance for improving the health and well-being of this age group.

Decision making functions emerge in a gradual fashion from late infancy through adolescence (21, 22). For several reasons, children from disadvantaged SES backgrounds may fall behind in terms of developing decision making skills. Income inequality and disproportionate poverty observed in disadvantaged communities during childhood can hinder the development of critical skills necessary for advancing both educationally and occupationally. Additionally, children from impoverished backgrounds often face poorer access to learning materials, poorer access to library resources, and stigma associated with low SES status that further limits opportunities for upward social mobility (7, 10–12, 23, 24). These disadvantages can have negative downstream effects on academic achievement, intellectual functioning, and other important skills including decision making that are carried forward into adulthood. For example, children from low-SES familial backgrounds have been shown to enter high school with reading literacy skills that are on average five years behind peers from high SES backgrounds (11). Of particular relevance to decision making, literacy and more specifically financial and health literacy, described as the ability to access, understand, and use information to promote positive health and financial outcomes (25, 26), has been shown by our group (27) and others (28, 29) to be positively associated with decision making in old age. Thus, financial and health literacy skills, which begin to develop during childhood and evolve throughout adulthood, may form the foundation of information and tools needed to make informed decisions in older adulthood. It follows that promoting financial and health literacy over the lifespan may help individuals from lower SES backgrounds overcome the lack of access to resources and enrichment opportunities that often accompany lower SES (7) and may otherwise lead to poor decision making. This notion is supported by literacy intervention studies that show improvements in decision making following interventions implemented during adulthood (28, 30).

The present study used data from more than 1000 older persons enrolled in an ongoing cohort study of aging to investigate whether early life SES, based on parental education level and number of children in the household, is associated with financial and healthcare decision making in old age. Given an expansive body of literature citing the effects of low early life SES on poorer access to resources throughout childhood and into adulthood (7, 10–12, 23, 24), we hypothesized that lower early life SES would be associated with poorer financial and healthcare decision making in older adulthood and that this association would persist after adjusting for cognition. We additionally hypothesized that financial and health literacy would modify the impact of early life SES on decision making, given findings that suggest that financial and health literacy are associated with better decision making in older adulthood (28, 29), and that literacy can be improved throughout the lifespan (30).

Materials and Methods

Participants

Participants included 1044 older adults without dementia enrolled in the Rush Memory and Aging Project (MAP), a cohort study of aging and dementia that began in 1997 (31). Participants are recruited into MAP from community organizations, subsidized housing, and local residential facilities (e.g., retirement homes, senior housing facilities) in the Chicago metropolitan area. Dementia is diagnosed in accordance with NINCDS/ADRDA criteria (32) by a clinician with expertise in aging and dementia, as previously described (33).

A study of decision making was introduced into MAP in 2010. At the time of these analyses, 1369 subjects were eligible to complete the decision making sub-study. Of these, 77 refused, 63 died and 45 withdrew prior to agreeing to participate, and 25 had incomplete data. Of the 1159 participants that completed the decision making sub-study, 64 were deemed to have dementia and were excluded from the analyses, leaving a total of 1095 subjects without dementia. An additional 51 participants were missing a variable of interest, leaving a sample of 1044 with complete data for these analyses.

Study procedures were conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of Rush University Medical Center. Written informed consent was obtained from all participants prior to study participation. All participants also signed a repository consent allowing their data to be repurposed. More information on access to the data can be found at www.radc.rush.edu.

Assessment of Cognition

All participants underwent a comprehensive neuropsychological assessment that includes 21 measures, from which a cognitive composite score is derived. Measures included word list memory (total number of words recalled immediately after the three learning trials), word list recall (total words recalled after a delay), and word list recognition from the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD) battery, immediate and delayed recall conditions of Logical Memory Story A and the East Boston Story, verbal fluency (animals, fruits/vegetables), the Boston Naming Test, the National Adult Reading Test, forward and backward conditions of the Wechsler Memory Scale-revised Digit Span subtest, Digit Ordering, the Symbol Digit Modalities test, Number Comparison, the Judgment of Line Orientation test, Standard Progressive Matrices, and Stroop color naming and word reading conditions. Two of the 21 measures, The Complex Ideational Material test and the Mini Mental Status Examination (MMSE), were used for descriptive and clinical diagnostic purposes only and were not included in the composite score. Raw scores on the nineteen measures used to derive a composite score of cognition (34) were converted to z scores using the baseline mean and standard deviation of all subjects enrolled in MAP. Each participant’s standardized z scores were then averaged to yield a composite global cognition score, as has been published previously (17, 31, 34). A clinical neuropsychologist with expertise in aging and Alzheimer’s disease reviews data from this battery of cognitive tests and participant background information to determine presence of cognitive impairment (35).

Assessment of Decision Making

Financial and healthcare decision making are assessed using a 12-item decision making assessment measure (16, 36), which was specifically designed to measure decision making in older adults. The assessment was modified from a similar scale (16, 36). Participants are presented with information about health maintenance organization (HMO) plans (healthcare module) and financial information about mutual funds (financial module) and asked six questions of varying difficulty level (simple to complex) per module that assess comprehension and integration of the information in the modules. For example, in a complex item, participants are presented with seven mutual funds and asked to select the most appropriate fund given pre-specified preferences (e.g., Pamela wants a management fee of less than X%, a gross annual rate of return of X%, and a minimum investment of X). Total score ranges from 0–12 and represents the number of items answered correctly. Previous research has shown appropriate psychometric properties including high inter-rater reliability and short-term temporal stability (16, 36). Our group previously reported that performance on this measure was associated with cognition (19), personality (i.e., risk aversion preferences,(37) financial and healthcare literacy (27), and risk of mortality (20), in older adults without dementia.

Assessment of Early Life Socioeconomic Status (SES)

Early life socioeconomic status (38) is a composite index based on three indicators of household SES level: paternal education (number of years), maternal education (number of years), and number of children in the family. Number of children in the family is multiplied by negative one, and all indicators are then z-scored using the mean and standard deviation of the entire Rush Memory and Aging Project cohort. The composite measure of early life SES is the average of the three z-scores. This measure has been shown to be associated with cognitive functioning in late life in a previous study by our group (38). Other studies utilizing similar metrics of early life SES (e.g., parental occupation, income level, education, family size) also report negative cognitive and physical health outcomes associated with early life SES (5, 12).

To further characterize early childhood SES in our sample, we examined the bivariate association between early life SES and financial need during childhood (39). The measure is comprised of two questions about financial need covering the period of time from birth to 18 years of age: “When you were growing up, how often was there not enough to eat?” and “When you were growing up, how often did you have to wear dirty clothes?” Participants were asked to respond on a 5-point likert scale from “Never” (0) to “Always” (4). Responses to the two items are summed such that scores range from 0–8.

Assessment of Literacy

The financial and health literacy assessment queries knowledge of health and financial information, concepts, and numeracy, as described in previous work (27, 40). The 32-item measure contains nine questions devoted to health literacy, including questions that ask about Medicare, following doctors’ prescription instructions, and perceived drug risk among other health topics. The remaining 23 questions are devoted to financial literacy, many of which were adapted from the Health and Retirement Survey (29, 41). Questions include simple monetary calculations (numeracy) and knowledge of financial concepts such as stocks, bonds, “FDIC”, and interest rates (see (27) appendix for full assessment). In accordance with previous studies (40, 42, 43), percent total correct is calculated for healthcare literacy and financial literacy separately, and the two percentages are averaged to determine a total literacy score for each participant. Chronbach’s alpha was 0.77 for the total literacy score, indicating adequate internal reliability of the measure (27).

Demographic covariates

Age is calculated based on birthdate. Sex, race, and education (in years) were selfreported. For these analyses, race was converted to a binary variable of White and non-White given low numbers of non-White older adults in the sample. Income level was acquired at the time of participants’ baseline assessment. A single question asks participants to select one of ten levels of total family income ($0–$4,999; $5,000 – $9,999; $10,000 – $14,999; $15,000 – $19,999; $20,000 – $24,999; $25,000 – $29,999; $30,000 – $34,999; $35,000 – $49,999; $50,000 – $74,999; $75,000 and over). Income score ranges from 1–10, with 10 indicating the highest income bracket.

Statistical Analyses

Descriptive statistics and bivariate associations of variables of interest and covariates were first examined. Independent sample t-tests explored group differences in early life SES for sex and race. To explore the relationship between early life SES and decision making in older adulthood, we conducted a series of linear regression models. A first set of models regressed decision making on early life SES. We then explored whether literacy modifies the relationship between early life SES and decision making by including additional terms for literacy and the interaction of literacy and early life SES. All models included terms to control for potentially confounding effects of age, education, sex, race, and global cognition, unless otherwise noted. Finally, a sensitivity analysis covarying for the additional effect of income was conducted with a subsample of participants (n = 958).

Results

Sample Characteristics

Descriptive statistics of the sample are presented in Table 1. The sample was well-educated, mostly female, and mostly of non-Latino White race. Bivariate correlations revealed that early life SES was positively associated with education (r = 0.380, p<0.0001), global cognition (r = 0.267, p<0.0001), decision making (r = 0.269, p <0.0001), and literacy (r = 0.265, p < 0.0001), and negatively associated with age (r = −0.164, p<0.0001). Lower early life SES was also associated with greater self-reported financial need during childhood (r = −0.180, p < 0.0001). Males had significantly higher early life SES than females (Males: M = 0.25, SD = 0.67; Females: M = 0.10, SD = 0.71; t = −2.93, p = 0.003) and White participants had significantly higher early life SES than non-White participants (White: M = 0.16, SD = 0.69; Non-White: M = −0.30, SD = 0.87; t = 4.78, p < 0.001).

Table 1.

Distribution of early life SES, literacy, decision making, and participant characteristics (N = 1044).

Mean SD
Age 81.14 7.47
Education (years) 15.59 3.13
Sex (% female) 75.8% -
Race (% non-White) 5.4% -
Global cognition composite 0.22 0.52
Financial need during childhood 0.78 1.32
Early life SES 0.14 0.71
Decision Making, total score 7.95 2.65
Literacy, total score, percent correct 69.17 14.03
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Note: SD = standard deviation; SES = socioeconomic status.

Relationship Between Early Life SES and Decision Making, and the Modifying Role of Literacy

To determine whether early life SES is associated with decision making, a set of linear regression models were conducted (Table 2). After adjusting for age, education, sex, and race (Table 2, Model 1), as well as global cognition (Table 2, Model 2), lower early life SES was associated with worse decision making scores (Table 2, Model 3). To quantify this association of early life SES with decision making, the effect size for one additional unit in SES was equivalent to four years younger in age, after adjusting for demographic factors and global cognition.

Table 2.

Association of early life SES with decision making.

Parameter Model 1 Model 2 Model 3 Model 4 Model 5
Estimate SE p-value Estimate SE p-value Estimate SE p-value Estimate SE p-value Estimate SE p-value
Age −0.112 0.010 <0.001 −0.057 0.009 <0.001 −0.055 0.009 <0.001 −0.042 0.009 <0.001 −0.043 0.009 <0.001
Sex 0.627 0.170 <0.001 0.848 0.151 <0.001 0.835 0.151 <0.001 0.570 0.148 <0.001 0.570 0.147 <0.001
Education 0.244 0.024 <0.001 0.144 0.022 <0.001 0.129 0.023 <0.001 0.097 0.022 <0.001 0.094 0.022 <0.001
Race −2.012 0.326 <0.001 −1.028 0.294 <0.001 −0.963 0.295 0.001 −0.547 0.287 0.057 −0.527 0.286 0.066
Global cognition 2.351 0.138 <0.001 2.307 0.140 <0.001 1.607 0.154 <0.001 1.617 0.154 <0.001
Early life SES 0.218 0.098 0.027 0.163 0.095 0.086 0.158 0.095 0.095
Literacy 0.054 0.006 <0.001 0.054 0.006 <0.001
Literacy*Early life SES −0.013 0.006 0.029
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Note: Model 1 investigated the association of early life SES with decision making, controlling for demographic covariates. Model 2 added global cognition as an additional covariate. Model 3 investigated the effect of literacy and the literacy by early life SES interaction on decision making. SES = socioeconomic status.

a

Females are coded as 0 and males as 1

b

Non-White race is coded as 1 and White non-Hispanic race as 0

Including a term for financial and health literacy total score (Table 2, Model 4) and its interaction with early life SES in the fully adjusted model (Table 2, Model 5) revealed that, for participants with average early life SES, greater financial and healthcare literacy was associated with better decision making (see Model 4 of Table 2). To contextualize the strength of the association of financial and health literacy with decision making, a 10% increase in the literacy score was associated with 12.6 years younger in age. In the fully adjusted model (see Model 5 of Table 2), for participants with average financial and health literacy, early life SES was not associated with decision making (p = 0.095). Further, the interaction between financial and health literacy and early life SES was significant (p = 0.029), suggesting that financial and health literacy modified the relationship between early life SES and decision making.

To explore the significant interaction between literacy and early life SES, we plotted the relationship between early life SES and decision making scores split by financial and health literacy scores falling in the 10th percentile, 50th percentile, and 90th percentile (Fig. 1). This revealed that the relationship between early life SES and decision making was strongest for those with low financial and health literacy, and weakest for those with high financial and health literacy.

Figure 1.

Figure 1.

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Graphical display of the significant literacy by early life SES interaction effect on total decision making score. For visualization purposes, the association of early life SES and decision making is displayed for 10th percentile, 50th percentile, and 90th percentile literacy scores. Dotted lines represent confidence intervals.

Sensitivity Analyses with Income as an Additional Covariate

We ran the same analyses, including self-reported income in the models as a covariate for a subsample of participants (n = 958). The overall findings do not change. In a model adjusting for age, sex, education, race, global cognition, and income, early life SES is associated with decision making (Estimate = 0.208, Std Error = 0.098, p = 0.034). In the model in which literacy and the literacy by early life SES interaction term are added, early life SES is no longer associated with decision making (p = 0.126), as was found in the models without income. Financial and health literacy (Estimate = 0.053, Std. Error = 0.006, p < 0.001) and the interaction term (Estimate = −0.015, Std. Error = 0.006, p = 0.012) are significantly associated with decision making.

Discussion

This study investigated the association between early life SES and decision making in a large community-based cohort sample of older adults without dementia. Consistent with our hypotheses, early life SES was positively associated with financial and healthcare decision making in older adults after controlling for age, sex, race, education, and global cognition. Furthermore, we found that financial and health literacy moderated the association between early life SES and decision making.

This study is the first to our knowledge to establish a relationship between early life SES and decision making in old age. Childhood is a critical period of time in which important skills are learned and developed. Decision making is one such skill that develops gradually from late infancy through adolescence (21, 22). Findings from this study suggest that diminished experiences due to low SES during childhood have negative effects on decision making even in older adulthood. One possible explanation for this finding is that older adults who come from low SES backgrounds may have had fewer opportunities to make financial and health decisions throughout their lives. This lack of exposure to decision making opportunities may contribute to lower decision making ability that persists into older adulthood, especially given evidence of restricted upward mobility in individuals from low SES backgrounds (44). The observation that low early life SES has negative effects on decision making in older adulthood has significant public health implications. Decision making is a critical ability that can have a profound impact on the well-being of older adults. Older adults face a myriad of significant health and financial changes that necessitate well-informed decisions. For example, older adults are faced with healthcare decisions such as deciding on advanced directives, nursing and assisted living transitions, and end-of-life decisions. They are also faced with significant financial decisions such as investments of retirement savings, distribution of social security, and transfers of wealth. These important decisions coincide with reported poorer decision making in older adults compared to younger or middle-aged adults (13–18), findings which are reported even in older adults without dementia (15, 17, 45, 46). Poorer decision making has been shown to lead to negative outcomes in older adults (19, 20, 47). Thus, understanding factors that can protect against these negative outcomes is imperative to the well-being of older adults.

In this study, we found that financial and health literacy moderated the effect of early life SES on decision making such that the association between early life SES and decision making attenuated as financial and health literacy increased. The difference in decision making across different literacy levels is particularly profound in individuals with low early life SES (Figure 1), and suggests that the development of high financial and health literacy throughout the lifespan can protect against the negative effects of low early life SES on decision making. Literacy is a complex and multi-dimensional construct that reflects one’s ability to understand and act on information retrieved from diverse contexts. Literacy has been established as an important correlate of decision making (27–29), likely because exposure to financial and health information allows individuals to make more informed decisions. Thus, knowledge of financial and health concepts may help individuals from low SES backgrounds overcome negative consequences associated with low SES, such as less access to education resources and decision making opportunities, that can negatively impact decision making. This implication is also supported by the finding that in individuals with higher early life SES, financial and health literacy had less of an effect on decision making, presumably because these individuals have access to relevant resources. Taken together, findings make a strong case for the development of interventions targeted towards improving financial and health literacy in individuals who grow up in low SES environments and suggest that such interventions will have a beneficial impact even in late life. For example, the development of support services that integrate social, health, and financial circumstances for the most vulnerable populations of older adults may help support complex decision making in older adulthood. In some cases, however, it may not be possible or feasible to improve an individual’s literacy through direct interventions. Research suggests that the presentation format of information strongly influences decision making (48, 49). Thus, healthcare and financial advisers and institutions may consider presenting information needed to make financial or healthcare decisions in a simple, clear, and comprehensible way. Doing so could increase the likelihood that an individual is able to make a well-informed decision despite lower levels of literacy.

The present study is not without its limitations. First, we assessed a predominantly non-Latino White and female, well-educated cohort of older adults. This is not representative of the greater population within the United States and future studies are needed to determine generalizability. Our cohort of older adults are likely to have higher early life SES and financial and health literacy levels compared to the general population. We also did not examine birth place or immigration status of participants, factors that may influence the relationship between early life SES and decision making in older adulthood. For example, the perceived importance of education and consequently the focus on educating children may differ among families with low education. Another important point is that most of the older adults in our sample were born in the early 1900s. The relationships between early childhood SES, literacy, and decision making may differ in younger generations of older adults, since development of these skills are also a byproduct of societal and cultural trends and resources available at any given time. For example, improvements in childhood living conditions, initiation of childhood labor laws, and advancements in managing infectious diseases had substantial downstream effects on school attendance (50, 51). The early 1900s were also a time of great immigration to Chicago (52). Thus, immigrants may be overrepresented in the particular birth epoch of our sample and this may be a source of confound in our metric of early life SES. Replicating the present findings in more representative samples and accounting for factors such as birth place and immigration status is important for understanding the impact of early life SES on decision making ability in old age; we are actively studying these issues in non-white groups. Another limitation is the cross-sectional nature of the study. Relatedly, we cannot know at which point in one’s lifetime acquiring high literacy will have the most optimal effect on the association between early life SES and decision making. For example, the older adults in our sample who came from low SES backgrounds during childhood but were classified in the high literacy group may have acquired literacy skills later in life; conversely, they may have acquired enhanced literacy skills during childhood despite their disadvantaged circumstances. There may be a critical period in which acquiring financial and health literacy best mitigates the negative effect of low early life SES on decision making. This distinction is important as the utility of interventions may depend on when they are implemented in the life course. Cross-sectional studies examining different age groups and longitudinal studies may help address this issue. Nevertheless, it is likely that intervening at any point is useful given the dynamic nature of literacy demands as individuals age. Finally, there are many ways to characterize SES, and our chosen metric provides an estimate but does not fully cover early life socio-economic circumstances. Examining the relationship of decision making and other correlates of early life SES such as family structure, deaths experienced during childhood, and quality of schooling, would all be interesting avenues to pursue in future research.

The present study also has a number of strengths, including a detailed assessment of financial and healthcare decision making in a well-characterized large cohort of older persons without dementia living in the community. An additional strength was the power to adjust for a number of important covariates including demographic factors and global cognitive functioning and to examine the potential modifying effect of financial and health literacy. This is the first study to establish a relationship between early life SES and decision making in older age. Findings from this study have important public health implications in that they suggest that, among individuals from low SES backgrounds in early life, improving financial and health literacy may have lasting effects on decision making into older adulthood. Given the known negative consequences of poor decision making in older adulthood, developing and implementing interventions that improve decision making is imperative.

Highlights.

  • We examined the effect of early life socioeconomic status (SES) on decision making.

  • A positive association between early life SES and decision making was found.

  • The relationship was strongest in those with low financial and health literacy.

  • Early life SES is associated with decision making in non-demented older adults.

  • Improving literacy may buffer the impact of early life SES on decision making.

Acknowledgments

The authors gratefully thank the Rush Memory and Aging Project staff and participants and declare no competing financial interests.

Sources of Funding

This work was supported by the National Institute on Aging at the National Institutes of Health grants R01AG017917 to DAB, R01AG033678 to PAB, R01AG055430 to SDH, and T32 AG000037 to GHW.

List of Abbreviations

SES

Socioeconomic Status

MAP

Rush Memory and Aging Project

NINDCS-ADRDA

National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer’s Disease and Related Disorders Association

CERAD

Consortium to Establish a Registry for Alzheimer’s Disease

MMSE

Mini-Mental Status Exam

Footnotes

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Conflicts of Interest

None.

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