Association of early-life caregiver mental health and education with incidence of mild cognitive impairment among the Chinese population: A longitudinal observational study

Abstract

Background

Mild cognitive impairment (MCI) is a critical prodromal stage of dementia, yet the role of early-life psychosocial determinants, particularly caregiver characteristics, remains underexplored.

Objective

To investigate the associations of caregiver mental health and education with offspring MCI incidence, and to examine their joint effects.

Methods

We utilized data from the China Health and Retirement Longitudinal Study (CHARLS), involving 8140 participants aged ≥45 years. The mental health (categorized as normal or abnormal) and educational level (categorized as illiterate, basic, or middle school and above) of the primary male and female caregivers were assessed retrospectively. MCI was diagnosed based on a comprehensive cognitive battery assessing orientation, episodic memory, and executive function, with scores standardized for age and education. Cox regressions were used to analysis.

Results

Over a median follow-up of 9.0 years, 873 (10.72%) participants developed MCI. Abnormal caregiver mental health was associated with an approximately 18% higher risk of incident MCI in offspring (HR [95% confidence interval]: female caregiver: 1.17 [1.02–1.35]; male caregiver: 1.18 [1.02–1.37]). Compared to having an illiterate caregiver, having a male caregiver with a basic education was associated with a 23% lower risk of MCI (HR = 0.78 [0.67–0.91]); this association was not significant for female caregivers.

Conclusions

Caregiver mental health and educational attainment are independently associated with the risk of MCI in their offspring during mid-to-late life. Interventions supporting caregiver well-being and education may contribute to dementia prevention strategies. These findings were derived exclusively from the Chinese population; caution should be taken when generalizing to other populations.

Keywords

Alzheimer's disease caregiver education longitudinal study mental health mild cognitive impairment

Introduction

Population aging has emerged as a major global health challenge, driving a rapid rise in the prevalence of neurodegenerative diseases such as dementia.¹ Mild cognitive impairment (MCI), an intermediate stage between normal cognitive aging and dementia, represents a critical window for early intervention.^2,3 While biomedical risk factors for MCI are well-documented, growing evidence underscores the importance of psychosocial and environmental determinants across the life course.^4,5

Caregiving within family contexts constitutes a sustained form of psychosocial interaction that may significantly influence developmental and cognitive trajectories.^6,7 The caregiver's emotional well-being, stress level, and socioeconomic background can profoundly influence not only their own health but also the developmental and cognitive trajectories of those under their care.^6,8 Previous studies have linked caregiver stress and mental health to adverse neurodevelopmental outcomes in children,^8–11 yet little is known about their long-term associations with MCI in later life.

Educational attainment, a key component of socioeconomic status and cognitive reserve,¹² has also been inconsistently associated with offspring cognitive outcomes across cultural contexts.^13–16 Some studies reported that both maternal and paternal education predicted better cognitive outcomes in adulthood,^14–16 while others identified gender-specific or null associations.¹³ These inconsistencies may reflect cultural, socioeconomic, or methodological differences across populations. Moreover, many of these studies are limited by small sample sizes or short follow-up periods.

Within the caregiving context, education also plays a crucial role in shaping caregiving mental health.^17,18 Caregivers with lower educational levels are more likely to experience psychological distress and caregiving burden,¹⁹ which may compromise the quality of care and, consequently, affect the cognitive health of care recipients.¹⁸ Moreover, the combined effects of caregiver mental health and education on late-life cognitive impairment remain poorly understood, particularly in non-Western populations.

To address these gaps, this study draws on data from the China Health and Retirement Longitudinal Study (CHARLS): 1) to examine the associations of the caregiver mental health and education level with the risk of MCI and 2) to explore the joint effects of caregivers’ mental health and education level on the risk of MCI among offspring of different genders.

Methods

Study design and participants

CHARLS, launched in 2011, is a nationally representative longitudinal survey of Chinese adults aged 45 years and older.²⁰ Employing a stratified, multistage, probability-proportional-to-size sampling design, CHARLS recruited approximately 17,500 participants from roughly 10,000 households across 450 villages within 150 counties/districts. Five waves of data—2011 (Wave 1), 2013, 2015, 2018, and 2020 (Wave 5)—provide a rich resource for investigating population aging.²⁰ The dataset incorporates survey weights to ensure national representativeness (details at http://charls.pku.edu.cn). Ethical approval was granted by the Peking University Institutional Review Board (IRB00001052-11015). The present study utilizes data from Waves 1–5.

For this analysis, exclusions were made for the following reasons: 8467 participants due to missing data on caregiver mental health, caregiver education, baseline cognitive function, or age; 1101 participants with either brain disease related to cognitive impairment or mild cognitive impairment at baseline. This yielded a final analytical sample of 8140 participants (Figure 1).

Assessment of caregiver's mental health and education

Caregiver's mental health at participants’ childhood was assessed retrospectively using three items from the CHARLS life-history module: how often they felt nervous or anxious, became upset or afraid, and whether they experienced sadness or depression lasting two weeks or more; the details has been provided in the Supplemental Material. These items were derived from validated constructs in epidemiological studies of psychological distress. The three items were summed into a total score (0–7). A median split was applied to enhance interpretability: 0–1 indicates normal mental health, and 2–7 indicates abnormal mental health. This cutoff was chosen based on the observed threshold effect in the relationship between the raw score and MCI risk, as well as the need to maintain statistical stability given the sparse distribution of participants at higher score levels. Accounting for the evolution of China's schooling system, the caregiver's education was classified into three levels: illiterate, basic (incomplete primary, home school, or elementary), and middle school or above.

Assessment of MCI

At baseline, participants received a face-to-face assessment from four cognitive function dimensions: concentration, episodic memory, and executive function. Time orientation was assessed by asking participants to state the current year, month, day, weekday and season; one point was awarded for each correct answer, giving a total between 0 and 5. Episodic memory was measured with the CERAD word-list task. Interviewers read aloud ten unrelated words in three successive trials and recorded the number of words correctly recalled after the third presentation as the immediate recall score, which could range from 0 to 10. About 30 min later, participants were asked to recall the same words again, and the number correctly recalled was recorded as the delayed recall score, also ranging from 0 to 10. The final episodic memory score was the average of the immediate and delayed recall scores, yielding a value between 0 and 10. Executive function was rated from two brief tasks. Numerical testing required participants to subtract 7 from 100 and continue subtracting 7 from the resulting number up to five times, earning one point for each correct answer (0–5). The pentagon drawing test involved participants being asked to copy a drawing of two intersecting pentagons; a fully correct reproduction earned one point. Global cognitive function was the sum of the concentration (time orientation), episodic memory (immediate word recall, delayed word recall), and executive function (numerical ability and pentagon drawing test) scores, ranging from 0 to 21 points.

The global cognitive function was further standardized for age (10-yeas age band) and education. Participants whose cognitive function fell more than 1.5 standard deviations below the norm were classified as having MCI.²¹ Cognitive function was assessed at waves 1–5, and MCI was evaluated at each wave.

Assessment of covariates

Data collection was conducted by trained interviewers through comprehensive household assessments and standardized questionnaires.²⁰ At Wave 1 (baseline), participants reported age, sex, and educational attainment. The raw ten-level education variable (from illiterate to post-graduate) was categorized into three categories: no formal education (illiterate, unfinished primary, or traditional/home schooling), middle school or below, and high school or above. Depressive symptoms were evaluated with the 10-item Center for Epidemiologic Studies Depression Scale (CES-D-10; range 0–30), with a score ≥10 denoting depression.²² Early-life circumstances were ascertained from the Wave 4 life-history module, which elicited information on the mental health and education of participants’ primary female and male caregivers and socioeconomic status. Caregivers were restricted to biological, adoptive, or step-parents; any other guardian category or absence of a caregiver was excluded owing to missing data. Family financial situation was assessed by asking participants to rate their household's economic standing before age 17 relative to the average local family at the time: better, about the same, worse, or much worse.

Statistical analyses

Baseline characteristics of the participants were stratified according to MCI status. Categorical variables were reported as frequencies and percentages and were compared with chi-square tests. Continuous variables were expressed as means ± standard deviations and were evaluated using independent-samples t-tests.

Cox proportional hazards models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the risk of MCI in relation to caregivers’ metal health and education. Follow-up time was calculated from the Wave 1 enrollment date; the origin of the time-scale was the day of entry. The primary endpoint was the date of the first MCI diagnosis. Participants who remained free of MCI were censored at the earliest occurrence of death, loss to follow-up, or the end of follow-up. To test the additive interaction between caregivers’ mental health and education on the risk of MCI on offsprings, we created a combined exposure variable: mental health (normal versus abnormal) and education (illiterate versus educated). Additive interaction was quantified with the relative excess risk due to interaction (RERI), the attributable proportion (AP), and the synergy index (S), all computed from the Cox model coefficients and their covariance matrix using the delta method. In sensitivity analysis, we repeated the analyses further adjusting for caregiver's role (biological, adoptive, or step-parents). p-values <0.05 were considered statistically significant. All statistical analyses were performed using Stata SE 16.0 for Windows (Stata Corp, College Station, TX).

Figure 1.

Flowchart of the study population.

Results

Characteristics of the study population

Table 1 summarizes the baseline characteristics by MCI status.

Table 1.

Characteristics of the study population by mild cognitive impairment (N = 8140).

Characteristics	MCI-free (n = 7267)	MCI (n = 873)	p
Age, years	57.26 ± 8.76	60.29 ± 9.71	<0.001
Female	3771 (51.91)	465 (53.39)	0.411
Education			<0.001
No formal education	1722 (23.70)	228 (26.15)
Middle school and below	2810 (38.68)	407 (46.67)
High school and above	2733 (37.62)	237 (27.18)
Depression symptom	2234 (31.80)	376 (45.36)	<0.001
Family's financial situation			0.008
Better	723 (9.95)	68 (7.81)
Same	3949 (54.36)	466 (53.50)
Worse	1155 (15.90)	127 (14.58)
Much worse	1438 (19.79)	210 (24.11)
Female caregiver's education
Illiterate	6354 (87.44)	813 (93.13)	<0.001
Basic	778 (10.71)	55 (6.30)
Middle school and above	135 (1.86)	5 (0.57)
Male caregiver's education			<0.001
Illiterate	4064 (55.92)	570 (65.29)
Basic	2578 (35.48)	249 (28.52)
Middle school and above	625 (8.60)	54 (6.19)
Female caregiver's mental health	1.77 ± 1.40	1.88 ± 1.44	0.039
Normal	4626 (63.66)	502 (57.50)	<0.001
Abnormal	2641 (36.34)	371 (42.50)
Male caregiver's mental health	1.67 ± 1.31	1.76 ± 1.36	0.055
Normal	4992 (68.69)	558 (63.92)	0.004
Abnormal	2275 (31.31)	315 (36.08)

Values are mean ± standard deviation or n (%).

Missing data: 5 for gender; 4 for education; 4 for family's financial situation.

Compared to participants who remained MCI-free, those who developed MCI were older, had lower educational attainment, reported more depressive symptoms, and were more likely to describe their family's financial situation as “much worse. Additionally, both female and male caregivers of incident-MCI participants were more often illiterate, and female caregivers more frequently exhibited abnormal mental health.

Association between caregiver's mental health/education and MCI

During the follow-up (median [interquartile range]: 9.00 [8.92–9.00] years), 873 (10.72%) participants developed MCI. In fully-adjusted Cox models (Table 2), abnormal mental health in caregivers, whether female or male, was modestly associated with an approximately 18% higher incidence of offspring MCI (female caregiver: HR 1.17, 95% CI 1.02–1.35; male caregiver: HR 1.18, 95% CI 1.02–1.37).

Table 2.

Hazard ratios (HRs) and 95% confidence intervals (CIs) for the association between caregiver's mental health/ education and subsequent mild cognitive impairment (MCI).

	No. of participants	No. of cases	Incidence rate (%)	HR (95% CI)^a	p
Female
Mental Health
Normal	5128	502	9.79	1.00 (Ref)	-
Abnormal	3012	371	12.32	1.17 (1.02, 1.35)	0.030
Education
Illiterate	7167	813	11.34	1.00 (Ref)	-
Basic	833	55	6.60	0.77 (0.58, 1.02)	0.071
Middle school and above	140	5	3.57	0.44 (0.18, 1.05)	0.065
Male
Mental Health
Normal	5550	558	10.05	1.00 (Ref)	-
Abnormal	2590	315	12.16	1.18 (1.02, 1.37)	0.021
Education
Illiterate	4634	570	12.30	1.00 (Ref)	-
Basic	2827	249	8.81	0.78 (0.67, 0.91)	0.002
Middle school and above	679	54	7.95	0.76 (0.57, 1.03)	0.075

^aModels were adjusted by age, sex, education, depression symptoms at baseline, and family's financial situation at childhood.

With regard to caregiver education (Table 2), compared with caregivers who had never attended school, both female and male caregivers with basic education showed HRs around 0.77 (female: 0.77, 0.58–1.02; male: 0.78, 0.67–0.91); the association was significant only among male caregivers. Similarly, caregivers with middle-school education or above also demonstrated a risk reduction, but the 95% CIs were wide and crossed the null (female: HR 0.44, 0.18–1.05; male: HR 0.76, 0.57–1.03). These patterns suggest that higher caregiver education may be modestly protective, but the evidence remains tentative.

Additive interaction between caregiver mental health and education

Compared with caregivers who were both illiterate and had abnormal mental health, offspring's incidence rates of MCI were lowest when caregivers had normal mental health and some education (female 5.3%, male 8.2%). In fully-adjusted Cox models (Figure 2), this combination was associated with the lowest risk of MCI relative to the same reference (female HR = 0.61, 95% CI 0.42–0.87; male HR = 0.70, 95% CI 0.57–0.86). Estimates for the other joint exposures fell between these extremes, yet none of the additive-interaction indices (RERI, AP, or S) approached statistical significance in either sex, indicating no evidence of departure from additivity.

Figure 2.

Hazard ratios (HRs) and 95% confidence intervals (CIs) of subsequent mild cognitive impairment (MCI) in relation to joint effect of caregiver's mental health and education. Models were adjusted by age, sex, education, depression symptoms at baseline, and family's financial situation at childhood. Measures of additive interaction for MCI (mental health [abnormal versus normal]; education [illiterate versus educated]): relative excess risk due to interaction (RERI) = 0.008, 95% CI: −0.373–0.389, p = 0.967 for female; RERI = 0.045, 95% CI: −0.199–0.296, p = 0.642 for male; attributable proportion due to interaction (AP) = 0.013, 95% CI: −0.611–0.637, p = 0.967 for female; AP = 0.065, 95% CI: −0.287–0.417, p = 0.641 for male; synergy index (S) = 0.980, 95% CI: 0.375–2.560, p = 0.968 for female; S = 0.869, 95% CI: 0.430–1.755, p = 0.348 for male.

Sensitivity analysis

After further adjustment for caregiver's role, the results remained essentially unchanged (Supplemental Table 2).

Discussion

In this longitudinal study, caregiver psychosocial characteristics were modestly associated with offspring MCI risk. Abnormal caregiver mental health was linked to higher MCI incidence, while caregiver education, particularly among males, showed a protective effect. The combination of normal mental health and some education was associated with the lowest risk, though no statistical interaction was detected.

This study revealed a significant association between caregivers’ psychological health and the risk of MCI in their offspring. Offspring of caregivers with psychological abnormalities were found to exhibit a markedly higher incidence of MCI. This finding underscores that caregivers, who already endure long-term physical and emotional strain, may also influence their children's cognitive development through the family's emotional climate, interaction patterns, and parenting styles. While prior research has established links between parental psychological distress and cognitive, linguistic, socio-emotional, and motor delays in infants and toddlers (6–30 months), as well as associations between caregiver trauma and child neurodevelopmental trajectories, these studies have primarily assessed cognitive and neurological functions during infancy or childhood.^8–11 The association between parental mental health and the onset of MCI after the age of 50 remains largely unexplored. Supporting the potential for caregiver psychological states to impact cognitive function within a family system, a study by Lou et al.²³ demonstrated that worsening depressive symptoms in caregivers were significantly associated with an increased risk of MCI and cognitive decline in elderly care recipients. Although that study focused on care recipients rather than offspring, its implications suggest a potential mechanism through which a caregiver's psychological state could affect the cognitive health of other family members.

With regard to educational attainment, we found that among male caregivers, those with at least basic education had offspring with significantly lower MCI risk than did illiterate caregivers. In contrast, no analogous trend was observed among female caregivers. This result is in line with the findings of some studies.^24–26 Education is widely considered to enhance individuals’ cognitive reserve, thereby delaying cognitive decline.^27,28 Indeed, prior studies have documented positive correlations between parental education and offspring late-life cognitive functioning, often attributed to improvements in the cognitively stimulating home environment and healthier behavioral patterns.^29–31 In Chinese samples, paternal literacy has been found to correlate with offspring cognitive outcomes;^24–26 in European contexts, maternal education appears more salient.^13,32 These findings imply that parental educational attainment may shape offspring cognitive health via effects on the family cognitive environment, but that the specific effects are likely moderated by cultural and gender factors. Our findings extend this line of inquiry by showing that caregiver education level is associated with offspring cognitive outcomes.

Furthermore, our study observed that compared to caregivers who were both illiterate and had psychological health problems, those caregivers who maintained good psychological health and possessed some level of education had offspring with the lowest risk of MCI. Although the statistical interaction between psychological health and education did not reach significance, the clear additive pattern supports a “cumulative psychosocial resource model” - where education and psychological health represent distinct but mutually reinforcing social and psychological capital that exert a protective effect on the next generation. Caregivers with higher education typically have better health literacy and coping strategies, enabling them to sustain more stable psychological states under caregiving stress, thereby providing the family a more positive emotional milieu and cognitively enriched environment. Meanwhile, good psychological health may enhance the efficacious conversion of educational resources into effective parenting interactions.³³ This dual advantage of education plus mental wellness may operate through improved family communication, emotional support and social functioning networks, ultimately buffering offspring MCI risk.

The exact mechanisms linking caregivers’ psychological status and educational attainment to the development of MCI in their offspring have not been fully elucidated. The selective-elimination hypothesis suggests that childhood environmental inputs influence neural structure and functionality by selectively pruning underused synaptic connections.³⁴ Parents with low education may be less able to provide cognitively stimulating environments,^35,36 and thus synaptic connections that are rarely activated might be pruned away over time.^37–39 This process could result in fewer synaptic connections and less-efficient neural networks. Over time, such deficits may contribute to poorer cognitive function and increased susceptibility to cognitive decline in later life.³⁷

Simultaneously, caregiver psychological distress is postulated to influence the family environment, caregiving practices, offspring stress regulation, and lifelong cognitive trajectories through the intergenerational mechanism of “linked lives.”^40,41 Conversely, positive emotional regulation and secure attachment patterns are more frequently demonstrated by caregivers with sound psychological health, which can mitigate the transmission of negative affect within the family.⁴² This reduction in familial stress exposure is associated with a decreased likelihood of prolonged psychological stress in offspring, thereby fostering healthier brain and cognitive development.^43,44

There are some limitations to this study. First, it should be noted that this study was conducted exclusively among the Chinese population, and caution is warranted when generalizing these findings to other ethnic or cultural contexts. Second, the exclusion of a substantial proportion of participants due to missing data on caregiver characteristics may introduce selection bias. Our comparison of included and excluded participants suggested that excluded individuals were older and less educated, which may have led to an underestimation of the true associations, as these factors are positively correlated with both caregiver characteristics and cognitive outcomes. Third, it should be noted, however, that the number of caregivers with middle-school education or above, particularly among females, was small, resulting in wide confidence intervals for the estimates in this subgroup. Thus, the null findings for female caregivers with higher education should be interpreted with caution, as they may reflect limited statistical power rather than a true absence of association.

Collectively, our results affirm that caregiver psychological well-being and education collectively represent a salient psychosocial context influencing cognitive aging. The consistent risk gradients observed, albeit without additive interaction, underscore influences distinct from conventional biomedical risks. Moving forward, mechanistic studies must unravel pathways such as chronic stress and limited cognitive reserve, testing whether supporting caregivers translates into cognitive benefits for older adults. Ultimately, effective prevention requires strategies that target not only the individual but also the foundational caregiving environments that shape cognitive life-course trajectories.

Supplemental Material

sj-docx-1-alr-10.1177_25424823261450904 - Supplemental material for Association of early-life caregiver mental health and education with incidence of mild cognitive impairment among the Chinese population: A longitudinal observational study

Supplemental material, sj-docx-1-alr-10.1177_25424823261450904 for Association of early-life caregiver mental health and education with incidence of mild cognitive impairment among the Chinese population: A longitudinal observational study by Yan Wang and Chaofeng Fan in Journal of Alzheimer's Disease Reports

Footnotes

Acknowledgements

We thank the China Health and Retirement Longitudinal Study team for providing data and training in using the datasets. We thank the students who participated in the survey for their cooperation. We thank all volunteers and staff involved in this research.

ORCID iD

Chaofeng Fan

Ethical considerations

Ethics approval for CHARLS was obtained from the Biomedical Ethics Review Committee of Peking University (IRB00001052-11015). The protocol was in accordance with the Declaration of Helsinki.

Consent to participate

All participants provided signed informed consent.

Consent for publication

Not applicable

Author contribution(s)

Yan Wang: Formal analysis; Methodology; Visualization; Writing – original draft.

Chaofeng Fan: Conceptualization; Data curation; Resources; Software; Supervision; Writing – review & editing.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

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

Data availability statement

The data of this study can be obtained on the official website of CHARLS ().

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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