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Original Article Mediation analysis of leisure activities on the association between cognitive function and mortality: a longitudinal study of 42,942 Chinese adults 65 years and older
Xingxing Chen1,2orcid , Wenfan Wu3, Xian Zhang2,3, Tingxi Long2, Wenyu Zhu4, Rundong Hu2, Xurui Jin2,3, Lijing L. Yan1,2,5,6orcid , Yao Yao7,8orcid
Epidemiol Health 2022;44e2022112-0
DOI: https://doi.org/10.4178/epih.e2022112
Published online: November 27, 2022
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1School of Public Health, Wuhan University, Wuhan, China
2Global Health Research Center, Duke Kunshan University, Kunshan, China
3MindRank AI Ltd., Hangzhou, China
4Department of Geriatrics, Affiliated Kunshan Hospital of Jiangsu University, Kunshan, China
5Duke Global Health Institute, Duke University, Durham, NC, USA
6Institute for Global Health and Management, Peking University, Beijing, China
7China Center for Health Development Studies, Peking University, Beijing, China
8Center for Healthy Aging and Development Studies at National School of Development, Peking University, Beijing, China
Corresponding author:  Lijing L. Yan,
Email: lijing.yan@duke.edu
Yao Yao,
Email: yao.yao@bjmu.edu.cn
Received: 30 August 2022   • Accepted: 27 November 2022
Xingxing Chen and Wenfan Wu contributed equally to this study as co-first authors.

study aimed to evaluate whether leisure activities causally mediate these associations.
This longitudinal study included 42,246 participants aged over 65 years from the Chinese Longitudinal Healthy Longevity Survey. The Mini-Mental State Examination and a self-reported scale were used to measure cognitive status and leisure activities, respectively. We examined the associations of cognitive function and leisure activities with mortality using Cox proportional hazards models. Causal mediation analysis was used to assess whether leisure activities mediated the association between cognitive function and mortality.
Cognitive function and leisure activities were inversely associated with mortality. Leisure activities accounted for 28.3% (95% confidence interval [CI], 25.6 to 31.1) of the total effect of cognitive function and mortality. A higher mediated proportion (PM) was observed for physical leisure activities (PM, 20.1%; 95% CI, 18.0 to 22.3) than for social leisure activities (PM, 17.7%; 95% CI, 15.7 to 19.7). The mediating effect was higher among participants at younger ages (PM, 41.5%; 95% CI, 21.3 to 65.4), those with higher education levels (PM, 30.5%; 95% CI, 25.3 to 36.2), and residents of rural China (PM, 42.5%; 95% CI, 25.4 to 62.5).
Cognitive function was associated with inverse mortality. Leisure activities significantly mediated this association. Participation in leisure activities at the early stages of mild cognitive impairment could reduce the risk of mortality, which has a major impact on interventional strategies for healthy aging.

Epidemiol Health : Epidemiology and Health