Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2022 Aug 1.
Published in final edited form as: J Aging Health. 2021 Aug-Sep;33(7-8 Suppl):60S–67S. doi: 10.1177/08982643211014971

The Association of Cultural Participation and Social Engagement With Self-Reported Diagnosis of Memory Problems Among American Indian and Alaska Native Elders

Collette Adamsen 1, Spero M Manson 2, Luohua Jiang 3
PMCID: PMC9135353  NIHMSID: NIHMS1802553  PMID: 34167346

Abstract

Objective:

This study examines the association of cultural participation and social engagement with self-reported diagnosis of memory problems among older American Indians and Alaska Natives (AI/ANs).

Method:

We conducted a cross-sectional study of 14,827 AI/ANs using data from the 2014–2017 cycle of the Identifying Our Needs: A Survey of Elders (ION). Logistic regression was used to examine the association of cultural participation and social engagement with self-reported diagnosis of memory problems.

Results:

Compared to older AI/ANs who reported high cultural participation and/or high social engagement, those characterized by low cultural participation and/or low social engagement exhibited significantly higher odds of a self-reported diagnosis of memory problems (OR = 1.863, 95% CI: [1.269, 2.734], p = .001).

Discussion:

Older AI/ANs who described either or both low cultural participation and low social engagement endorsed far more self-reported diagnoses of memory problems, suggesting a strong association that warrants further study for potential causality.

Keywords: American Indian, Alaska Native, memory problems, cultural participation, social engagement

Introduction

The number of older American Indians and Alaska Natives (AI/ANs) will substantially increase over the next 50 years (Griffin-Pierce et al., 2008), from 464,000 in 2012 to 1,624,000 in 2050 (Goins et al., 2015). Their aging, and concomitant risk for Alzheimer’s disease and related dementias, pose particular challenges for this historically neglected, under-resourced population (Griffin-Pierce et al., 2008). As of 2018, it is estimated that 5.7 million people in the United States suffer from Alzheimer’s disease with an anticipated increase to 14 million by 2050 (Alzheimer’s Association, 2018; Herbert et al., 2003; Plassman et al., 2007; Schaefer et al., 2019). The potential compromises of the health status and function of older AI/AN people are obvious, as are the subsequent demands on family and the increased costs to formal, as well as informal, systems of care (DHHS, CMS, 2015). However, the less tangible consequences are not as immediately evident but may be just as injurious. These consequences relate to the strength and resiliency older AI/AN adults draw from their traditions, cultural identity, and connection to community.

We know, for example, that cultural identity plays a significant role in overcoming personal challenges and in instilling a sense of coherence and belonging among AI/AN people (Kahn et al., 2016; Wexler, 2014). Indeed, the relationships older AI/AN adults enjoy with respect to their tribal communities have been shown to strengthen individual resilience, coping abilities, and self-efficacy (Ramirez & Hammack, 2014; Grandbois & Sanders, 2009). Moreover, tribal communities are strengthened by the participation of their tribal elders. Older AI/ANs are the wisdom keepers who embody life’s lessons and knowledge of how to survive in an adverse world (Kahn et al., 2016; Brave Heart & Debruyn, 1998; Grandbois & Sanders, 2009; Masten, 1994). They represent, therefore, a treasured asset in tribal communities, underscoring the ways in which cultural participation, social support, and identity can buffer Native people from contemporary vicissitudes (Cross, 1998; Kahn et al., 2016; Kulis et al., 2016; EchoHawk, 1997; Grandbois & Sanders, 2009; LaFromboise et al., 2006; Wexler, 2014; Wexler et al., 2009).

Social engagement is often defined as preserving social connections and partaking in social activities (Bassuk et al., 1999; Krueger et al., 2009). Among older, non-Native adults, social engagement is a widely recognized correlate of health status, function, and well-being (Coulton et al., 2015; Daykin et al., 2018; Fancourt & Steptoe, 2019; Jones et al., 2012; Fancourt, Perkins, Ascenso, Atkins et al., 2016; Fancourt, Perkins, Ascenso, Carvalho et al., 2016; Fancourt & Perkins, 2018; Mössler et al., 1996). It promotes social support, coping skills, cognitive stimulation, regulation of emotions, problem-solving skills, and reduced symptoms of depression. Additionally, a lack of social engagement is associated with cognitive decline. Recent studies show that older people who are not socially engaged experience lower levels of cognitive function than their counterparts who are so engaged (Barnes et al., 2004; Bassuk et al., 1999; Crooks et al., 2008; Green et al., 2008; Holtzman et al., 2004; Krueger et al., 2009; Li et al., 2019; Yeh & Liu, 2003; Zunzunegui et al., 2003). There is every reason to anticipate similar circumstances pertain to older AI/ANs, especially in light of the tight-knit, face-to-face communities in which they live.

Drawing upon cross-sectional data acquired from 14,827 older AI/AN adults during the 2014–2017 cycle of Identifying Our Needs: A Survey of Elders (ION), this article examines the associations of cultural participation and social engagement with cognitive status among older AI/ANs, specifically with their self-reported diagnosis of memory problems.

Methods

Data Source

In 1999, the National Resource Center on Native American Aging launched the Identifying Our Needs: A Survey of Elders (ION) to assess the needs of this special population. Over the ensuing decades, every 3 years, older American Indians, Alaska Natives, and Native Hawaiians completed a health and social needs questionnaire, which was either self- or interviewer-administered. Eligibility requirements included (1) 55 years of age or older; (2) membership in a federally recognized tribe, and (3) qualifying for Older Americans Act (OAA) Title VI services. Title VI provides grants to improve nutrition, provide supportive services, and promote caregiving for tribal elders.

OAA Tribal Title VI program directors and staff administered the surveys to local elders. We sought systematic randomized samples of program participants. However, this ultimately proved impractical and beyond the Title VI staff’s ability to carry out, resulting in a large convenience sample recruited from a known universe, but subject to uncertain selection biases. Study details have been published previously (Adamsen et al., 2018; Schroeder et al., 2018).

Study Population

The present analyses drew upon survey data from the 2014–2017 cycle. After excluding Native Hawaiian respondents, the dataset yielded 14,827 older AI/AN members of federally recognized tribes. Participants resided in 28 states and represented 11 of 12 Indian Health Service regions.

Study Approvals

The original study, Health and Social Needs Assessment of Native American Elders, was approved in 2007 and has been granted continued approval each year by the University of North Dakota Institutional Review Board (approval number IRB-200712–139). In addition, a tribal resolution was obtained from each participating tribe granting permission to administer the survey to the elders in their communities. Consent was sought and obtained verbally by survey administrators. Administration for Community Living grantors reviewed and approved this article before publication.

Cultural Participation, Social Engagement, and Self-Reported Diagnosis of Memory Problems

Cultural participation was determined by the answer to the question: “Do you participate in cultural practices that include traditional food, music, and customs?” Response options included all of the time, most of the time, a good bit of the time, some of the time, a little of the time, and none of the time. In like fashion, social engagement was operationalized in terms of the answer to: “How often do you get out and socialize (attend church/religious meetings, clubs/organizations you belong to, or attend cultural activities/traditional ceremonies)?” The respondent was asked to indicate the number of times per month s/he socialized as her/his response. Cultural participation and social engagement were then combined to create a categorical variable yielding four categories: low cultural participation + low social engagement, low cultural participation + high social engagement, high cultural participation + low social engagement, and high cultural participation + high social engagement. With respect to cultural participation, responses of all of the time, most of the time, a good bit of the time, and some of the time were categorized as “high” cultural participation, while responses of a little of the time and none of the time were coded as “low” cultural participation. During exploratory data analysis, we found 8 or less times per month versus 9 or more times per month was a change point with respect to the association between social engagement and self-reported diagnosis of memory problems. Therefore, social engagement was also treated as a binary variable. Responses of 9 or more times per month were recoded as “high” social engagement and 8 or less times per month as “low” social engagement. Self-reported diagnosis of memory problems was determined by asking the participant, “Have you been diagnosed with Alzheimer’s disease, dementia, or other problems with memory or thinking?” The response options provided were yes and no.

Covariates

Selected covariates included age (continuous), gender (male/female), annual personal income (<$15,000, $15,000 to < $25,000, $25,000 to < $50,000, ≥ $50,000), education (<high school diploma, high school diploma, and beyond high school), employment status (employed and unemployed), marital status (married or living with partner, single/never married, divorced, separated, or widowed), and residence (resided on reservation and off reservation). These covariates represented key demographics thought to have an effect on health-related outcomes of older AI/ANs. In addition, self-reported clinical diagnosis of depression (yes and no) and feeling downhearted and blue (all of the time/good bit of the time, some of the time, a little of the time, and none of the time) were included as covariates because they are thought to have an effect on self-reported diagnosis of memory problems of older AI/ANs.

Statistical Analysis

Sample characteristics were summarized by frequencies and percentages of categorical variables. Chi-square tests were performed to compare the characteristics of older AI/ANs who self-reported diagnosis of memory problems to those who did not report such problems.

Logistic regressions (separate logistic regression models adjusted by age and gender only) were employed to assess the association of self-reported diagnosis of memory problems with cultural participation and social engagement and each of the covariates without controlling for differences in other covariates (except age and gender). Multivariate logistic regressions—adjusted by age, gender, self-reported clinical diagnosis of depression, feeling downhearted and blue, annual personal income, education, employment status, marital status, and residence—were used to examine the association of self-reported diagnosis of memory problems with cultural participation and social engagement while adjusting for the differences in all the covariates considered. All analyses were conducted using IBM SPSS Statistics software (version 25).

Results

Table 1 displays the sample characteristics for respondents by self-reported diagnosis of memory problems. A small percentage (4.2%) of older AI/ANs self-reported a diagnosis of memory problems. Older AI/ANs characterized by low cultural participation and low social engagement endorsed substantially higher rates of memory problems than those reporting high cultural participation and high social engagement (6.6% vs. 2.9%, p < .001). Furthermore, those who reported a diagnosis of depression, feeling downhearted and blue all of the time to a good bit of the time, an income less than $15,000, an education less than a high school diploma, being unemployed, 75 years or older, and male reported higher percentages of self-reported memory problems compared to their counterparts.

Table 1.

Sample Characteristics by Self-Reported Diagnosis of Memory Problems among Older AI/ANs

Characteristic Total Yes N = 690 No N = 13,789 p Value
Cultural Participation and Social Engagement <.001**
Low cultural participation and low social engagement 44.7% (2508) 6.6% (166) 93.4% (2342)
Low cultural participation and high social engagement 55.3% (3097) 4.2% (130) 95.8% (2967)
High cultural participation and low social engagement 24.5% (1745) 5.2% (91) 94.8% (1654)
High cultural participation and high social engagement 75.5% (5389) 2.9% (154) 97.1% (5235)
Depression <.001**
Depression 13.2% (1899) 9.6% (182) 90.4% (1717)
No Depression 86.8% (12500) 3.4% (428) 96.6% (12072)
Downhearted and Blue <.001**
All of the time/good bit of the time 8.4% (1193) 8.2% (98) 91.8% (1095)
Some of the time 17.3% (2455) 5.3% (131) 94.7% (2324)
A little of the time 33.1% (4696) 4.6% (217) 95.4% (4479)
None of the time 41.3% (5864) 2.6% (154) 97.4% (5710)
Annual personal income <.001**
<$15k 47.4% (6058) 5.1% (309) 94.9% (5749)
$15 to <$25k 23.3% (2980) 3.6% (106) 96.4% (2874)
$25k to <$50k 20.7% (2643) 2.6% (68) 97.4% (2575)
≥$50k 8.6% (1099) 2.2% (24) 97.8% (1075)
Education <.001**
<High School Diploma 23.9% (3377) 5.9% (199) 94.1% (3178)
High School Diploma 35.6% (5033) 4.2% (209) 95.8% (4824)
Beyond High School 40.5% (5730) 3.2% (186) 96.8% (5544)
Employment Status <.001**
Employed 31.5% (4400) 0.9% (40) 99.1% (4360)
Unemployed 68.5% (9572) 5.8% (554) 94.2% (9018)
Marital Status <.001**
Married or living with partner 39.5% (5562) 3.4% (191) 96.6% (5371)
Single/never married 14.7% (2065) 3.6% (75) 96.4% (1990)
Divorced or separated 21.6% (3037) 3.4% (103) 96.6% (2934)
Widowed 24.3% (3427) 6.4% (220) 93.6% (3207)
Residence <.001**
On Reservation 66.6% (9414) 3.9% (369) 96.1% (9045)
Off of Reservation 33.4% (4711) 4.8% (224) 95.2% (4487)
Age (year)
55–64 years old 37.8% (5439) 2.4% (131) 97.6% (5308) <.001**
65–74 years old 38% (5469) 3.1% (170) 96.9% (5299)
75+ years old 24.2% (3491) 8.9% (309) 91.1% (3182)
Gender
Male 39.1% (5568) 4.7% (260) 95.3% (5308) .041*
Female 60.9% (8659) 4% (343) 96% (8316)
Open in a new tab

Table 2 summarizes the multivariate associations of self-reported diagnosis of memory problems with cultural participation and social engagement, diagnosis of depression, feeling downhearted and blue, education, employment, income, marital status, age, and gender. In the models, adjusted by age and gender only, the odds of self-reported diagnosis of memory problems were significantly associated with cultural participation and social engagement, diagnosis of depression, feelings of downhearted and blue, education, employment, income, and marital status. Older AI/ANs were more likely to endorse self-reported diagnosis of memory problems if they identified low cultural participation or low social engagement, diagnosis of depression, feelings of downhearted and blue all of the time to a good bit of the time, an education less than high school, and a personal annual income of less than $15,000 compared to those who did not report memory problems. Conversely, older AI/ANs were less likely to note self-reported diagnosis of memory problems if employed, married or living with a partner, and female. Residence was not significantly associated with memory problems.

Table 2.

Association of Self-Reported Diagnosis of Memory Problems with Cultural Participation and Social Engagement among Older AI/ANs

Characteristics Univariate Odds Ratioa N = 14,827 95% CI p Value Multivariate Adjusted Odds Ratiob N = 14,827 95% CI p Value
Cultural Participation and Social Engagement <.001 .005
Low cultural part./low social engagement 2.149 1.557 2.965 <.001 1.863 1.269 2.734 .001
Low cultural part./high social engagement 1.523 1.130 2.052 .006 1.592 1.122 2.258 .009
High cultural part./low social engagement 1.584 1.237 2.028 <.001 1.546 1.158 2.065 .003
High cultural part/high social engagement (ref)
Depression
Depression 3.563 2.951 4.303 <.001 2.774 2.135 3.605 <.001
Downhearted and Blue <.001 <.001
All of the time/good bit of the time 3.802 2.902 4.981 <.001 2.402 1.654 3.486 <.001
Some of the time 2.236 1.753 2.851 <.001 1.800 1.293 2.506 <.001
A little of the time 1.925 1.555 2.384 <.001 1.762 1.319 2.354 <.001
None of the time
Education .046 .846
Less than grade 12 1.309 1.057 1.621 .013 1.081 .811 1.440 .596
High school diploma only 1.119 .912 1.373 .281 1.014 .769 1.337 .921
Education beyond high school (ref)
Employment
Employed .219 .157 .306 <.001 .301 .194 .466 <.001
Income <.001 .181
<$15k 1.984 1.296 3.035 .002 1.030 .595 1.785 .915
$15k to <$25k 1.315 .836 2.068 .237 .746 .422 1.319 .314
$25k to <$50k 1.059 .658 1.703 .814 .947 .532 1.689 .855
≤ $50k (ref)
Marital Status .088 .125
Married or living with a partner .771 .617 .963 .022 .773 .578 1.034 .083
Single/never married .992 .742 1.327 .959 .816 .556 1.197 .299
Divorced or separated .857 .663 1.107 .237 .678 .482 .954 .026
Widowed (ref)
Residency
Reside on Reservation .890 .748 1.058 .187 .964 .762 1.221 .763
Age
Age (years) 1.074 1.064 1.083 <.001 1.064 1.051 1.078 <.001
Gender
Female .783 .662 .925 .004 .678 .536 .857 .001
Open in a new tab
a

Adjusted by age and gender.

b

Adjusted all the other variables in the table

The multivariate analyses, after controlling for all demographic variables, revealed that cultural participation and social engagement were significantly associated with self-reported diagnosis of memory problems. Older AI/ANs who exhibited low cultural participation and low social engagement (OR = 1.863, 95% CI: [1.269, 2.734], p < .001), low cultural participation and high social engagement (OR = 1.592, 95% CI: [1.122, 2.258], p = .009), and high cultural participation and low social engagement (OR = 1.546, 95% CI: [1.158, 2.065], p = .003) were significantly more likely to self-report diagnoses of memory problems compared to those who reported high cultural participation and high social engagement. Furthermore, after adjusting for other demographic characteristics, older AI/ANs who were employed (OR = .301, 95% CI: [.194, .466], p <.001), divorced or separated (OR = .678, 95% CI: [.482, .954], p = .026), and female (OR = .678, 95% CI: [.536, .857], p = .001) were significantly less likely than their reference group to acknowledge self-reported diagnoses of memory problems. Education, income, and residency were not significantly associated with the dependent variable in the multivariate model.

Discussion

Our study found significant associations between cultural participation and social engagement with self-reported diagnosis of memory problems among older AI/ANs. Participants reporting low cultural participation and low social engagement endorsed higher rates of memory problems.

The protective and therapeutic value of culture for AI/ANs is acknowledged, especially with respect to health outcomes (Bassett et al., 2012). Cultural activities reinforce a sense of self, promote psychological coherence, affirm individual value, assert order in the world, and locate one within it (Cross, 1998; Grandbois & Sanders, 2009; Kahn et al., 2016; Lewis, 2016). Drumming, beading, dancing, storytelling, harvesting and preparing traditional foods, seasonal ceremonies, and praying, as well as more formal spiritual practices, revolve around elders in Native communities (Bassett et al., 2012; Lewis, 2011; Lewis & Allen, 2017). These elders give to as much as they receive from participation in this cultural life. It is not difficult, then, to imagine the benefits that may accrue in terms of fostering their cognitive well-being. If cultural participation indeed offers such benefits, can we mobilize the power of “culture as medicine” (Bassett et al., 2012) to forestall declines in memory loss among AI/ANs as they age?

Cultural practices are not just about the making of meaning, about human knowledge, or about beliefs. Like more mundane aspects of social life, they also present opportunities to interact with family, friends, and other community members and to be engaged. The gatherings of Native people—home visiting, caring for children, Bingo games, fiddling contests, lacrosse competitions, potlatches, giveaways, memorials, powwows, to name a few—are in service of this sociocentric view. Again, elders are typically at the center of such events, acting as the agents who bond infants, children, adolescents, and adults together. AI/AN peoples are socially oriented; their self-hood is rooted in the group, and they look to others for affirmation of personal value (Kahn et al., 2016; Wexler, 2014).

The literature documents that higher levels of cognitive function in older adults are associated with greater social engagement (Krueger et al., 2009). It also describes the reduced risk of late-age cognitive decline and dementia associated with satisfying social relationships, with taking part in productive and stimulating cognitive activities, and with possessing a large number of social contacts (Crowe et al., 2003; Fabrigoule et al., 1995; Fratiglioni et al., 2000; Holtzman et al., 2004; Saczynski et al., 2006; ; Scarmeas et al., 2001; Wang et al., 2002; Wilson et al., 2002). A recent study even underscores the contribution of social engagement to improved brain health and lower likelihood, as well as severity, of the pathology associated with Alzheimer’s disease (Johnson et al., 2018). For these reasons, then, maintaining or even enhancing the social lives of older AI/ANs may promise to ameliorate their risk of memory loss and related problems.

Limitations

The findings of this study and their implications are limited by several factors. First, given the cross-sectional nature of the available data, we cannot specify the nature of the relationships we found. High cultural participation and high social engagement may protect older AI/ANs from such memory problems; alternatively, memory problems may in turn lead to low cultural participation and to low social engagement. We were unable to determine from these data if these associations reflect an underlying causal mechanism or its likely valence. Nevertheless, the associations are intriguing, pose several interesting possibilities, and warrant further investigation.

Second, the self-report requirements of the survey prevented the inclusion of older AI/ANs who suffered moderate to severe memory loss. Those who participated were likely to be in the early stages of cognitive decline. Therefore, it is difficult to determine if the outcomes would have been similar among older AI/AN adults experiencing more severe memory problems. Third, the sample was recruited from OAA Title VI tribal programs. As a consequence, elders in these communities who did not meet the eligibility for Title VI programs were unable to participate in the survey. This may have reduced the representation of higher functioning, community-dwelling older adults who do not require access to nutritional and other resources available through these programs. Fourth, though the survey design called for random sampling of OAA Title VI program participants, we were not able to faithfully execute this plan. Hence, there may be unknown selection biases at work which could temper our conclusions. Last, the dependent variable—self-reported diagnosis of memory problems—is vulnerable to possible recall bias as well as inconsistencies in alleged assessment. Yet, despite these limitations, this study drew upon the largest dataset available specific to this special population and yielded robust findings consistent with the relevant literature, which had not previously considered older AI/AN adults.

Conclusion

This study confirmed associations between cultural participation and social engagement with self-reported diagnosis of memory problems among older AI/ANs. Nevertheless, cultural participation and social engagement may figure importantly in ameliorating risk of memory loss and related problems in this special population. If so, these observations support the growing call to incorporate such experiences into programs intended to prevent as well as to treat memory loss and its consequences among older AI/ANs. Pragmatically, we should seek to maximize opportunities for Native elders to actively participate in cultural practices and in the social life of their communities. With respect to the scientific agenda, careful attention to evaluating the ensuing efforts may afford us greater insight into the dynamics that underlie such relationships.

Nonetheless, the findings of this study can help inform evolving treatment options related to memory problems that tie in cultural and social engagement aspects specific to AI/AN elders. Studies related to this topic on this population are limited; therefore, the observations will contribute to filling the gap of much needed information related to memory problems among AI/AN elders. Furthermore, the study will help us better understand memory problems and related risks among this population, which will lead to an improvement in caregiving and treatment options for AI/AN elders.

Acknowledgment

The authors would like to thank Sara Mumby for her editorial contributions to this manuscript.

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 the National Institute on Aging [P30 AG015292, SM Manson; P30 AG059295, D Buchwald & SM Manson] and the National Institute on Minority Health and Health Disparities Center of Excellence [P60 MD000507; SM Manson]. The Identifying Our Needs: A Survey of Elders and the National Resource Center on Native American Aging (NRCNAA) are funded by the Administration for Community Living [90OI0008-03-00].

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.

References

  1. Adamsen C, Schroeder S, LeMire S, Carter P. (2018). Education, income, and employment and prevalence of chronic disease among American Indian/Alaska Native elders. Preventing Chronic Disease, 15, 170387. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Alzheimer’s Association. (2018). Alzheimer’s disease facts and figures. Alzheimer’s Dement, 4(3), 367–429. [Google Scholar]
  3. Barnes LL, Wilson RS, Mendes de Leon CF, Bennett DA (2006). The relation of lifetime cognitive activity and lifetime access to resources to late-life cognitive function in older African Americans. Aging Neuropsychology and Cognition, 13, 516–528. [DOI] [PubMed] [Google Scholar]
  4. Bassett D, Tsosie U, Nannauck S. (2012). “Our Culture is Medicine”: Perspectives of Native healers on posttrauma recovery among American Indian and Alaska Native patients. The Permanente Journal, 16(1), 19–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bassuk SS, Glass TA, Berkman LF (1999). Social disengagement and incident cognitive decline in community-dwelling elderly persons. Annals of Internal Medicine, 131(3), 165–173. [DOI] [PubMed] [Google Scholar]
  6. Brave Heart MYH, Debruyn LM (1998). The American Indian holocaust: Healing historical unresolved grief. American Indian and Alaska Mental Health Research, 8(2), 56–78. [PubMed] [Google Scholar]
  7. Coulton S, Clift S, Skingley A, Rodriguez J, 2015. Effectiveness and cost-effectiveness of community singing on mental health-related quality of life of older people: Randomised controlled trial. British Journal of Psychiatry, 207(3), 250–255. [DOI] [PubMed] [Google Scholar]
  8. Crooks VC, Lubben J, Petitti DB, Little D, Chiu V. (2008). Social network, cognitive function, and dementia incidence among elderly women. American Journal of Public Health, 98(7), 1221–1227. [DOI] [PMC free article] [PubMed] [Google Scholar]
  9. Cross T. (1998). Understanding family resiliency from a relational worldview. In McCubbin HI, Thompson EA, Thompson AI, Fromer JE. (Eds.), Resiliency in Native American Immigrant families (pp. 143–157). Sage. [Google Scholar]
  10. Crowe M, Andel R, Pedersen NL, Johansson B, Gatz M. (2003). Does participation in leisure activities lead to reduced risk of Alzheimer’s disease? A prospective study of Swedish twins. The Journals of Gerontology: Series B; 58(5), 249–255. [DOI] [PubMed] [Google Scholar]
  11. Daykin N, Mansfield L, Meads C, Julier G, Tomlinson A, Payne A, Duffy LG, Lane J, D’Innocenzo G, Burnett A, Kay T, Dolan P, Testoni S, Victor C. (2018). What works for wellbeing? A systematic review of wellbeing outcomes for music and singing in adults. Perspectives in Public Health, 138(1), 39–46. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Department of Health & Human Services, Centers for Medicare & Medicaid Services. (2015). LTSS research: Annotated literature review, caregiver support in Indian country. https://www.cms.gov/Outreach-and-Education/American-Indian-Alaska-Native/AIAN/LTSS-TA-Center/pdf/ltss-research-annotated-literature-review.pdf
  13. EchoHawk M. (1997). Suicide: The scourge of native American people. Suicide & Life-Threatening Behavior, 27(1), 60–67. [PubMed] [Google Scholar]
  14. Fabrigoule C, Letenneur L, Dartigues JF, Zarrouk M, Commenges D, Barberger-Gateau P. (1995). Social and leisure activities and risk of dementia: A prospective longitudinal study. Journal of the American Geriatrics Society, 43(5), 485–490. [DOI] [PubMed] [Google Scholar]
  15. Fancourt D, Perkins R. (2018). Effect of singing interventions on symptoms of postnatal depression: three-arm randomised controlled trial. The British Journal of Psychiatry, 212, 119. [DOI] [PubMed] [Google Scholar]
  16. Fancourt D, Perkins R, Ascenso S, Atkins L, Kilfeather S, Carvalho LA, Steptoe A, Williamon A. (2016a). Group drumming modulates cytokine activity in mental health service users: A preliminary study. Psychotherapy and Psychosomatics, 85, 53–55. [DOI] [PubMed] [Google Scholar]
  17. Fancourt D, Perkins R, Ascenso S, Carvalho LA, Steptoe A, Williamon A, (2016b). Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users. Plos One, 11, e0151136. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Fancourt D, Steptoe A. (2019). Cultural engagement and mental health: Does socio-economic status explain the association? Social Science & Medicine, 236, 112425. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Fratiglioni L, Wang H-X, Ericsson K, Maytan M, Winblad B. (2000). Influence of social network on occurrence of dementia: A community-based longitudinal study. Lancet, 355(9212), 1315–1319. [DOI] [PubMed] [Google Scholar]
  20. Goins RT, Schure MB, Crowder J, Baldridge D, Benson W, Aldrich N. (2015). Lifelong disparities among older American Indian and Alaska Natives. AARP: Public Policy Institute, Research Report 2015–08. https://www.aarp.org/content/dam/aarp/ppi/2015/Lifelong-Disparities-among-Older-American-Indians-and-Alaska-Natives.pdf. [Google Scholar]
  21. Grandbois DM, Sanders GF (2009). The resilience of Native American elders. Issues in Mental Health Nursing, 30(9), 569–580. [DOI] [PubMed] [Google Scholar]
  22. Green AF, Rebok G, Lyketsos CG (2008). Influence of social network characteristics on cognition and functional status with aging. International Journal of Geriatric Psychiatry, 23 (9), 972–978. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Griffin-Pierce T, Silverberg N, Connor D, Jim M, Peters J, Kaszniak A, Sabbagh MN (2008). Challenges to the recognition and assessment of Alzheimer’s disease in American Indians of the southwestern United States. Alzheimer’s & Dementia, 4(4), 291–299. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Herbert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA (2003). Alzheimer disease in the U.S. population: prevalence estimates using the 2000 census. Archives of Neurology, 60(8), 1119–1122. [DOI] [PubMed] [Google Scholar]
  25. Holtzman RE, Rebok GW, Saczynski JS, Kouzis AC, Wilcox Doyle K, Eaton WW (2004). Social network characteristics and cognition in middle-aged and older adults. The Journals of Gerontology: Series B, 59(6), 278–284. [DOI] [PubMed] [Google Scholar]
  26. Johnson SC, Koscik RL, Jonaitis EM, Clark LR, Mueller KD, Berman SE, Bendlin BB, Engelman CD, Okonkwo OC, Hogan KJ, Asthana S, Carlsson CM, Hermann BP, Sager MA (2018). The Wisconsin registry for Alzheimer’s prevention: A review of findings and current directions. Alzheimer’s & Dementia (Amsterdam), 10, 130–142. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Jones C, Backman C, Griffiths RD (2012). Intensive care diaries and relatives’ symptoms of posttraumatic stress disorder after critical illness: A pilot study. American Journal of Critical Care, 21(3), 172–176. [DOI] [PubMed] [Google Scholar]
  28. Kahn CB, Reinschmidt K, Teufel-Shone N, Oré CE, Henson M, Attakai A. (2016). American Indian elders’ resilience: Sources of strength for building a healthy future for youth. American Indian and Alaska Native Mental Health Research, 23(3), 117–133. [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Krueger KR, Wilson RS, Kamenetsky JM, Barnes LL, Bienias JL, Bennett DA (2009). Social engagement and cognitive function in old age. Experimental Aging Research, 35(1), 45–60. [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Kulis SS, Robbins DE, Baker TM, Denetsosie S, Deschine Parkhurst DA (2016). A latent class analysis of urban American Indian youth identities. Cultural Diversity & Ethnic Minority Psychology, 22(2), 215–228. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. LaFromboise TD, Hoyt DR, Oliver L, Whitbeck LB (2006). Family, community, and school influences on resilience among American Indian adolescents in the Upper Midwest. Journal of Community Psychology, 34(2), 193–209. [Google Scholar]
  32. Lewis JP (2011). Successful aging through the eyes of Alaska native elders. What it means to be an Elder in Bristol Bay, AK. The Gerontologist, 51(4), 540–549. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Lewis JP (2016). American Indian/Alaska native elders: A growing demographic that is changing how we view aging. Journal of Gerontological Social Work, 59(4), 277–280. [DOI] [PubMed] [Google Scholar]
  34. Lewis JP, Allen J. (2017). Alaska native elders in recovery: Linkages between indigenous cultural generativity and sobriety to promote successful aging. Journal of Cross Cultural Gerontology, 32, 209–222. [DOI] [PubMed] [Google Scholar]
  35. Li J, Wang Z, Lian Z, Zhu Z, Liu Y. (2019). Social networks, community engagement, and cognitive impairment among community-dwelling Chinese older adults. Dementia and Geriatric Cognitive Disorders Extra, 9, 330–337. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Masten AS (1994). Resilience in individual development: Successful adaptation despite risk and adversity. In Wang MC, Gordon EW, (Eds.), Education resilience in inner-city America: (pp. 3–25). Erlbaum. [Google Scholar]
  37. Mössler K, Chen X, Heldal TO, Gold C. (1996). Music therapy for people with schizophrenia and schizophrenia-like disorders. Cochrane Database of Systematic Reviews, 11, 1–54. [DOI] [PubMed] [Google Scholar]
  38. Plassman BL, Langa K. m., Fisher GG, Heeringa SG, Wier DR, Ofstedal MB, Burke JR, Hurd MD, Potter GG, Rodgers WL, Steffens DC, Willis RJ, Wallace RB (2007). Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29(1–2), 125–132. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Ramirez LC, Hammack PL (2014). Surviving colonization and the quest for healing: Narrative and resilience among California Indian tribal leaders. Transcultural Psychiatry, 51(1), 112–133. [DOI] [PubMed] [Google Scholar]
  40. Saczynski JS, Pfeifer LA, Masaki K, Korf ESC, Laurin D, White L, Launer LJ (2006). The effect of social engagement on incident dementia: The Honolulu-Asia Aging Study. American Journal of Epidemiology, 163(5), 433–440. [DOI] [PubMed] [Google Scholar]
  41. Scarmeas N, Levy G, Tang MX, Manly J, Stern Y. (2001). Influence of leisure activity on the incidence of Alzheimer’s disease. Neurology, 57(12), 2236–2242. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Schaefer KR, Noonan C, Mosley M, Smith J, Galbreath D, Fenn D, Robinson RF, Manson SM (2019). Differences in service utilization at an urban tribal health organization before and after Alzheimer’s disease or related dementia diagnosis: a cohort study. Alzheimers Dement, 15(11), 1412–1419. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Schroeder S, Adamsen C, Ward C. (2018). Dental care utilization and service needs among American Indian/Alaska native/native Hawaiian Elders: 2008 to 2017. Journal of Aging and Health, 31(10), 1917–1940. [DOI] [PubMed] [Google Scholar]
  44. Wang H-X, Karp A, Winblad B, Fratiglioni L. (2002). Late-life engagement in social and leisure activities is associated with a decreased risk of dementia: A longitudinal study from Kungsholmen project. American Journal of Epidemiology, 155(12), 1081–1087. [DOI] [PubMed] [Google Scholar]
  45. Wexler L. (2014). Looking across three generations of Alaska Natives to explore how culture fosters indigenous resilience. Transcultural Psychiatry, 51(1), 73–92. [DOI] [PubMed] [Google Scholar]
  46. Wexler L, DiFulvio G, Burke T. (2009). Resilience in response to discrimination and hardship: Considering the intersection of personal and collective meaning-making for Indigenous and GLBT youth. Social Science & Medicine, 69, 565–570. [DOI] [PubMed] [Google Scholar]
  47. Wilson RS, Mendes de Leon CF, Barnes LL, Schneider JA, Bienias JL, Evans DA, Bennett DA (2002). Participation in cognitive stimulating activities and risk of incident Alzheimer disease. JAMA, 287(6), 742–748. [DOI] [PubMed] [Google Scholar]
  48. Yeh SCJ, Liu YY (2003). Influence of social support on cognitive function in the elderly. BMC Health Service Research, 3(1), 1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Zunzunegui MV, Alvarado BE, Del Ser T, Otero A. (2003). Social networks, social integration, and social engagement determine cognitive decline in community-dwelling Spanish older adults. The Journals of Gerontology: Series B, 58(2), S93–S100. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES