{"paper_id":"2344273e-ae97-4d00-a833-9c5151d29e44","body_text":"The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations Yan Zhu, Haojie Yin, Xianli Zhong, Li Wang, Qin Zhang, Ping Jia This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4960659/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Jul, 2025 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Background Adverse childhood experiences (ACEs) are among the factors affecting cognitive function in middle-aged and older adults, but the combined effects of ACEs, social isolation and functional limitations on cognitive function have not been fully explored. Methods This study used data from 6,412 middle-aged and older adults from the 2018 China Health and Retirement Longitudinal Study (CHARLS) and the 2014 CHARLS Life Histories Survey. Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, cognitive function as the dependent variable, and social isolation and functional limitations as mediating variables. Results In this study, ACEs were positively associated with social isolation and functional limitations (r = 0.081, 0.070, P < 0.01) and negatively associated with cognitive function (r=-0.132, P < 0.01). Social isolation and functional limitations had chain mediating effects on the relationship between ACEs and cognitive function. Conclusions ACEs lead to impaired cognitive functioning in middle-aged and older adults, and social isolation and functional limitations influence this relationship. These findings suggest that promoting social integration and physical exercise targeting functional limitations may be important approaches for preventing and mitigating the effects ACEs on cognitive function. Health sciences/Diseases Health sciences/Medical research Adverse childhood experiences Social isolation Functional limitations Cognitive function Middle-aged and older adults Figures Figure 1 Figure 2 Figure 3 Introduction As the world's second largest economy, China is currently home to 1.4 billion people (19.13% of the world's population) and is rapidly becoming an ageing country. It is predicted that by 2050, the population of individuals over 65 years old in China will reach 400 million, and the population of individuals over 80 years old will reach 150 million(Zeng 2012 ). By then, China will become one of the countries with the highest proportion of elderly individuals in the world. One consequence of a changing population structure is a surge in the prevalence and incidence of age-related conditions, such as cancer, chronic noncommunicable diseases, and mental health disorders. Specifically, declines in cognitive function are of considerable concern. A national survey revealed that approximately 15.5% of individuals aged 60 and above suffer from mild cognitive impairment, 6.0% exhibit dementia, and 3.9% have Alzheimer's disease(Jia et al. 2020). Cognitive decline is a prevalent phenomenon among elderly individuals, and individuals with cognitive decline are at a heightened risk of developing dementia(Manly et al. 2008 ). Maintaining sound cognitive function is a critical determinant of quality of life and independence for middle-aged and older adults. Cognitive health enables them to maintain social connections, maintain a sense of purpose, and retain the capacity for independent activities, facilitating functional recovery from illness or injury and managing residual functional limitations(Hendrie et al. 2006). Consequently, identifying risk factors associated with cognitive decline is of paramount importance for designing targeted public health interventions, ultimately contributing to the promotion of healthy ageing in China. Previous studies have identified age, education, family history, depression, and chronic illnesses as principal risk factors for cognitive decline(Brenda L. Plassman et al. 2010; Elias et al. 2005 ). Life course theory posits that early-life experiences significantly influence later-life outcomes(Glen H. Elder 1998 ). Since the emergence of research on adverse childhood experiences (ACEs)(Vincent J. Felitti et al. 1998), a growing body of evidence has underscored their pivotal role in shaping future health(Godoy et al. 2021 ; Lin et al. 2021; Bellis et al. 2019 ). Consequently, it is suggested that the aetiology of cognitive decline may trace back to early life – this hypothesis is supported by multiple empirical studies(Schalinski et al. 2018 ; Tani, Fujiwara, and Kondo 2020). The connection between ACEs and cognitive function can be elucidated through neurodevelopmental models(Bick and Nelson 2015 ), which propose that brain regions crucial for cognition, such as the hippocampus and prefrontal cortex, exhibit distinct developmental patterns during childhood and adolescence, when these patterns are highly susceptible to environmental influences, including ACEs(Pechtel and Pizzagalli 2010 ; Teicher et al. 2016 ). Therefore, cognitive dysfunction may be linked to the development of these structures, which are potentially influenced by ACE exposure(Catts et al. 2013; Hoy et al. 2011 ; Aas et al. 2013 ). While ACEs exert extensive and lasting negative effects on individuals, not all individuals with a history of ACEs manifest adverse health outcomes in adulthood. Therefore, it is important to elucidate the underlying mechanisms and protective factors that might influence the relationship between ACEs and adverse health outcomes. Identifying and addressing these factors could prevent lifelong cognitive impairments induced by ACEs. Empirical evidence suggests that social resources, such as social support and community resilience, can mitigate the cascading effects of ACEs on physical and mental well-being(Cheong et al. 2017 ; Jaffee, Takizawa, and Arseneault 2017 ; Longhi, Brown, and Fromm Reed 2021); conversely, a lack of social connectedness or social isolation, which is a well-documented risk factor for cognitive decline(Yu et al. 2020 ), can partially mediate the negative impact of ACE-related stressors on cognitive function later in life(Lin et al. 2022). Social isolation, which is characterized by limited social interaction, low participation in social activities, and solitary living(Gale, Westbury, and Cooper 2018 ), is consistently linked to various adverse health outcomes, including functional limitations and cognitive decline(Shankar et al. 2017 ; Yu et al. 2020 ). In the elderly population, functional limitations are common, with a staggering 26.81% prevalence in China(Gao et al. 2023 ), This high prevalence is due to the relevance of functional limitations to daily activities as well as their ease of measurement. Therefore, functional limitations are significant concern. From a life course perspective, significant early-life events are considered critical determinants of functional limitations or disability(Amemiya et al. 2018 ). Specifically, ACEs are associated with various negative health outcomes, such as cancer(Brown et al. 2010), depression(Cheong et al. 2017 ), cardiovascular disease(Godoy et al. 2021 ), and chronic lung disease(Anda et al. 2008), all of which can contribute to functional limitations or disabilities. Furthermore, an increasing body of research suggests that older adults with physical and functional limitations are more susceptible to cognitive decline(Wei et al. 2022 ; Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021b). In summary, previous studies have suggested that ACEs are associated with cognitive decline and that social isolation and functional limitations may play a mediating role in this relationship. To the best of our knowledge, this is the first study to explore the chain mediating effect of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. Based on a large number of previous empirical studies, this study proposes the following hypotheses: (i) ACEs can directly predict cognitive function in adulthood; (ii) social isolation mediates the association between ACEs and cognitive function; (iii) functional limitations mediate the association between ACEs and cognitive function; and (iii) social isolation and functional limitations play a chain mediating role in the association between ACEs and cognitive function. Methods Data Source The present study draws upon data from the China Health and Retirement Longitudinal Study (CHARLS), a national baseline survey initiated in 2011. The survey was conducted in 28 provinces (autonomous regions, municipalities) across 150 counties and 450 villages in 2011, 2013, 2015, and 2018, and it reached 19,000 respondents from 12,400 households by the conclusion of the national follow-up in 2018. The comprehensive questionnaire used in the CHARLS evaluates personal demographics, family structure, economic support, health status, physical measurements, health care utilization, insurance coverage, employment, retirement, pensions, income, expenditure, assets, and community characteristics. Furthermore, in 2014, the CHARLS conducted the \"Life Course Survey of Chinese Residents.\" The current study employs data from the fourth wave of the CHARLS, which was administered in 2018 and subsequently matched with the 2014 Life Course Study data. A total of 6,412 individuals completed both surveys. The CHARLS was approved by the Biomedical Ethics Committee of Peking University (IRB00001052-11015), and all participants voluntarily participated and signed an informed consent form. This study was authorized by the CHARLS database. Measures Cognitive function Cognitive function assessment was conducted using methods adapted from the U.S. Health and Retirement Study (HRS)(Crimmins et al. 2011 ), encompassing four dimensions: orientation, calculation, memory, and drawing. Orientation is assessed by the respondent's judgement of the date (year, month, day), season and day of the week, with one point awarded for each correct response, totalling 5 points. The respondents were instructed to perform five consecutive subtractions of 7 from 100, with one point awarded for each successful attempt, resulting in a maximum of 5 points for the calculation dimension. Memory is measured through immediate word recall and delayed word recall (number of words remembered after a 5-minute delay), with a score of 1 assigned to each correct repetition and a total score of 0–20. Finally, the evaluator shows the respondent a picture of two overlapping five-pointed stars and asks the respondent to draw them to test their drawing ability, awarding one point for a correct representation. The total cognitive function score ranged from 0 to 31, with higher scores indicating better cognitive function. Social isolation A social isolation index was derived based on four items. One point was assigned if participants were not married (including never married, widowed, divorced, or separated); had less than weekly contact with children (by phone, text message, mail or email, or in person); or had not participated in any social activities over the last month (e.g., interacted with friends, played Ma-jong or cards, used the internet, took part in a community-related organization, or did voluntary or charity work). Scores of social isolation ranged from 0 to 4, with higher scores indicating greater isolation(Shankar et al. 2017 ). Functional limitations The activities of daily living (ADL) and instrumental activities of daily living (IADL) scales were used to evaluate functional limitations(Chai et al. 2024 ). The ADL scale assessed dressing, eating, bathing, getting into or out of bed, going to the toilet, and controlling urination and defecation. The IADL assessed difficulties with doing household chores, preparing hot meals, shopping, managing money and taking medications. The items were scored on a four-point scale: 1 = no difficulty, 2 = difficulty but can still complete, 3 = difficulty and need help, and 4 = cannot do it. The total functional limitation score ranged from 11 to 44, with higher scores indicating severe functional limitation. Adverse Childhood Experiences The life history module of the CHARLS in 2014 collected data on ACEs that occurred before the age of 18 years. We collected 13 ACEs in this study. According to previous research(Yin et al. 2024 ), these ACEs were divided into 3 different categories: conventional ACEs (physical abuse, emotional neglect, domestic violence, family crime, family mental illness, family substance abuse, and parental divorce or separation), expanded ACEs (unsafe living conditions, peer bullying, bad friendship experiences), and new ACEs (parental death, sibling death, and parental disability). We calculated the cumulative ACE score and the cumulative score for each dimension. Covariate Information The covariates in this study included age, sex (0 = female, 1 = male), ethnicity (0 = other, 1 = Han), and education level (0 = illiterate, 1 = primary school and below, 2 = junior high, and 3 = high school and above). Statistical analysis First, IBM SPSS version 25.0 was used for descriptive statistics and correlation analysis of the data. Continuous variables are expressed as the means and standard deviations, and categorical variables are expressed as frequencies and percentages. Next, before analysing the indirect effects, a completely direct model was used to analyse the impact of ACEs on cognitive function in middle-aged and older adults. Then, Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, social isolation and functional limitations as the mediating variables, and cognitive function as the dependent variable. The maximum likelihood method and bootstrap method were used to test the mediating model, and the 95% CI for bias correction was calculated; P < 0.05 was considered to indicate statistical significance. Results Participant Characteristics The statistical characteristics of the study sample are presented in Table 1 . Among the 6412 participants, 2933 (45.7%) were men and 3479 (54.3%) were women; the mean age was 66 (SD = 9.7) years, and the vast majority had a low level of education. Furthermore, the average cognitive function score was 11.38 (SD = 7.17), the average social isolation score was 1.79 (SD = 0.96), and the average functional limitation score was 13.35 (SD = 4.54). The average ACE score was 1.93 (SD = 1.53), 84.1% reported experiencing one or more ACEs, and the incidence of cumulative ACEs and each dimension is shown in Fig. 1 . Table 1 Descriptive Characteristics of participants Variables Levels Observed N (%) Mean (SD) Minimum Maximum ACEs (0–13) scores 2.02 (1.55) 0 8 Conventional ACEs (0–7) scores 0.86 (0.92) 0 5 Physical abuse yes 1,825 (28.46) Emotional neglect yes 1,678 (26.17) Domestic violence yes 560 (8.73) Family crime yes 32 (0.5) Mental illness in the family yes 921 (14.36) Household Substance Abuse yes 456 (7.11) Parents divorced or separated yes 50 (0.78) Expanded ACEs (0–3) scores 0.59 (0.73) 0 3 Unsafe living conditions yes 603 (9.4) Peer bullying yes 1,084 (16.91) Bad friendship experiences yes 2,110 (32.91) New ACEs (0–3) scores 0.57 (0.70) 0 3 Parental death before age 17 yes 1,157 (18.04) Death of a sibling before age 17 yes 1,051 (16.39) Parental disability yes 1,425 (22.22) Cognitive function (0–31) scores 11.38 (7.17) 0 30 Social isolation (0–4) scores 1.79 (0.96) 0 4 Functional limitation (11–44) scores 13.35 (4.54) 11 44 Demographic characteristics Age (45–108) 66 (9.71) 45 108 Sex Male 2,933 (45.7) Female 3,479 (54.3) Ethnicity Han 5902 (92.0) Other 510 (8.0) Education Illiterate 1,670 (26.0) Primary school and below 2,934 (45.8) Junior high school 1,165 (18.2) Senior high school and above 643 (10.0) Notes. Sample N = 6,412. ACEs, Adverse Childhood Experiences. Correlation Analysis Correlation analysis was conducted on the social isolation score, functional limitation score, ACEs, and cognitive function score, and the results showed that the correlations between these key study variables were significant. ACEs were positively correlated with social isolation (r = 0.081, P < 0.01) and functional limitations (r = 0.070, P < 0.01), whereas cognitive function was negatively correlated with ACEs (r=-0.132, P < 0.01), social isolation (r=-0.317, P < 0.01), and functional limitations (r=-0.293, P < 0.01). These findings suggested that higher ACE scores are correlated with greater levels of social isolation and severe functional limitations. The detailed results are shown in Table 2 . Table 2 Correlation coefficients between key study variables (N = 6412) variables Cognitive function ACEs Social isolation Functional limitation Cognitive function 1 ACEs -0.132** 1 Social isolation -0.317** 0.081** 1 Functional limitation -0.293** 0.070** 0.176** 1 **Correlation is significant at the 0.01 level (2-tailed). ACEs = Adversity Childhood Experiences. Direct association between ACEs and cognitive function Before proceeding with the mediation analysis, we used a total direct model to determine the effects of ACEs on the cognitive function of middle-aged and older people. As shown in Table 3 , in the model, we include age, sex, education, and ethnicity as control variables. The model exhibited an excellent fit: χ 2 /df = 0, CFI = 1, TLI = 1, RMSEA = 0.000, SRMR = 0.000. Therefore, the results demonstrated a statistically significant direct effect of ACEs on cognitive function (β = 0.060, 0.001). Table 3 Direct model regression weight DV IV Std. Est. S.E. Est./S.E. P-Value R² Cognitive function ACEs -0.037 0.009 -3.920 *** 0.423 Age -0.274 0.010 -27.198 *** Sex 0.025 0.010 2.455 0.014 Education 0.504 0.010 49.494 *** Ethnicity 0.013 0.010 1.273 0.203 ***P < 0. 001 Multiple Indirect Effects Model After controlling for age, sex, education, and ethnicity, the indirect relationships between ACEs and cognitive function are illustrated in Table 4 and Fig. 2 . The multiple mediation model demonstrated a strong fit: χ 2 /df = 0, CFI = 1, TLI = 1, RMSEA = 0.000, SRMR = 0.000. Table 5 provides a comprehensive analysis of the total effect, direct effect, and mediating pathways, along with their 95% confidence intervals. Specifically, the impact of ACEs on cognitive function through social isolation is -0.099, which constitutes 16.3% of the overall effect. The contribution of functional limitations was − 0.022, accounting for 10.3% of the total effect. The combined influence of social isolation and functional limitations on cognition amounts to -0.015, or 2.5% of the total effect. The direct effect of ACEs on cognitive function was − 0.433, representing 71.0% of the total effect. All the confidence intervals of the mediation paths exclude zero, thus indicating that social isolation and functional limitations significantly mediated the effect of ACEs on cognitive function. However, the difference in mediation effects between these two factors was not statistically significant (β=-0.037, P = 0.086). Table 4 Model regression weight of the impact of ACEs on cognitive function scores DV IV Std. Est. S.E. Est./S.E. P-Value R² Cognitive function ACEs -0.094 0.011 -8.186 *** 0.167 Social isolation -0.267 0.011 -24.067 *** Functional limitation -0.240 0.010 -23.505 *** Functional limitation ACEs 0.057 0.012 4.558 *** 0.034 Social isolation 0.171 0.013 13.523 *** Social isolation ACEs 0.081 0.013 6.423 *** 0.006 ***P < 0. 001. Table 5 Total, direct, and indirect effects of ACEs on cognitive function, social isolation and functional limitation as mediators Point Estimate Product of Coefficients 95%CI bias corrected S.E. Est./S.E. P-Value Lower Upper INDIRECT EFFECTS SI -0.099 0.016 -6.215 *** -0.133 -0.070 FL -0.063 0.014 -4.541 *** -0.091 -0.036 SI→FL -0.015 0.003 -5.658 *** -0.021 -0.010 Total indirect -0.177 0.023 -7.868 *** -0.222 -0.134 DIRECT AND TOTAL EFFECTS Direct -0.433 0.053 -8.156 *** -0.541 -0.331 Total -0.610 0.058 -10.540 *** -0.728 -0.500 CONTRASTS SI VS FL -0.037 0.021 -1.715 0.086 -0.080 0.004 SI VS SI→FL -0.084 0.014 -6.060 *** -0.114 -0.059 FL VS SI→FL -0.047 0.014 -3.336 0.001 -0.075 -0.020 ***P < 0. 001. SI = Social isolation, FL = Functional limitation. Additionally, we constructed three models to analyse the pathway relationships between three dimensions of ACEs and cognitive function, as shown in Table 6 and Fig. 3 . Conventional ACEs, expanded ACEs, and new ACEs all had significant direct effects on cognitive function, with the expanded ACEs showing the strongest direct effect (β = -1.237, p < 0.001). Among the three dimensions, the total association between expanded ACEs and cognitive function was the strongest (β = -1.69, p < 0.001). Social isolation and functional limitations mediated the relationship in expanded ACEs more than in conventional ACEs, accounting for 26% of the total effect, but this association was not significant for new ACEs (β = -0.007, p = 0.226). Table 6 Direct and Indirect Effects of each dimension of ACEs on cognitive function in Later Life Effect β SE P-Value 95%CI Total effect CACEs- Cognitive function -0.436 0.098 *** -0.629 to -0.248 EACEs- Cognitive function -1.690 0.124 *** -1.945 to -1.425 NACEs- Cognitive function -0.420 0.125 ** -0.670 to -0.177 Direct effect CACEs- Cognitive function -0.312 0.089 *** -0.485 to -0.134 EACEs- Cognitive function -1.237 0.012 *** -1.478 to -1.020 NACEs- Cognitive function -0.255 0.114 * -0.484 to -0.038 Indirect effect CACEs-SI- Cognitive function -0.080 0.027 ** -0.135 to -0.029 CACEs-FL- Cognitive function -0.032 0.024 0.170 -0.079 to 0.013 CACEs-SI-FL- Cognitive function -0.013 0.004 ** -0.022 to -0.005 EACEs-SI- Cognitive function -0.281 0.033 *** -0.348 to -0.218 EACEs-FL- Cognitive function -0.128 0.030 *** -0.188 to -0.071 EACEs-SI-FL- Cognitive function -0.044 0.006 *** -0.058 to -0.033 NACEs-SI- Cognitive function -0.043 0.035 0.224 -0.114 to 0.025 NACEs-FL- Cognitive function -0.115 0.031 *** -0.178 to -0.057 NACEs-SI-FL- Cognitive function -0.007 0.006 0.226 -0.018 to 0.004 Notes. SI = Social isolation, FL = Functional limitation. ACEs, Adverse Childhood Experiences. CACEs, Conventional adverse childhood experiences. EACEs, Expanded adverse childhood experiences. NACEs, New adverse childhood experiences. ***P < .001, **P < .01, *P < .05 Discussion This study is the first to examine the chain mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function among middle-aged and older adults in China. Initially, the results of this study demonstrated a significant direct effect of cumulative ACE scores on cognitive function in middle-aged and older adults (confirming Hypothesis 1), consistent with findings by Schalinski, Tani, and others. This association may occur due to changes in brain structure and poor neurodevelopmental function in various brain regions, such as the limbic, hippocampal, and prefrontal areas, leading to inefficient memory and executive functions(Dannlowski et al. 2012 ; Hawkins et al. 2021 ). As summarized by Danese et al., individuals with a history of ACEs exhibit widespread and significant deficits across various cognitive domains, including processing speed, executive function, perceptual reasoning, memory, and language comprehension(Danese et al. 2017). Furthermore, the direct effects of various dimensions of the ACE on cognitive function are significant, suggesting that any type of ACE can adversely affect cognitive function in adulthood. In the structural equation model we constructed, all paths were significant, thus providing support for Hypotheses 2, 3, and 4. This indicates that the impact of ACEs on cognitive function in adulthood can be explained through mediating variables, as predicted. Social isolation partially explains the relationship between ACEs and cognitive function, which may be interpreted through the stress-buffering hypothesis. Specifically, positive social interactions can reduce the psychological distress caused by ACEs, protect hippocampal neurons, and diminish neurotoxicity(Cohen and Wills 1985), all of which are crucial for maintaining cognitive function with age(McEwen and Sapolsky 1995). Additionally, lower levels of social isolation reflect more interpersonal interactions within one's social network. Therefore, adults may benefit from social interactions and adopting healthier lifestyle habits, such as quitting smoking and drinking, which may also help to protect cognition. Thus, fostering social integration through larger social networks and increased social participation might be particularly important for individuals affected by ACEs. Furthermore, our study revealed that ACEs are positively correlated with an increase in functional limitations and a decrease in cognitive function, consistent with recent research findings. Amemiya et al.(Amemiya et al. 2018 ) found that childhood adversity is associated with functional limitations, with elderly individuals who reported two or more ACEs having greater functional impairment than those without ACEs. These findings suggest a significant dose‒response relationship. Moreover, physical and functional limitations are significantly correlated with a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a; Wei et al. 2022 ). A possible explanation for these results is that ACEs may increase the risk of low socioeconomic status, which is associated with poor health behaviours and disease states and is potentially linked to greater functional limitations. However, functional restrictions, including the ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL), may be fundamental in the neurodegenerative processes leading to cognitive decline(Rajan et al. 2012 ). Additionally, elderly individuals with functional limitations may lose opportunities to engage in physical exercise and cognitive activities, further leading to a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a). Importantly, the results of this study also revealed the chained mediating role of social isolation and functional limitations between ACEs and cognitive function. This finding provides new evidence for the literature, demonstrating that ACEs may have a negative impact on subsequent cognitive function by affecting functional limitations through social isolation. These insights are crucial for mitigating the adverse effects of early-life stress and promoting health in adulthood. Limitations To the best of our knowledge, this study is the first to investigate the sequential mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. However, it is essential to acknowledge several limitations. First, the cross-sectional design precludes the examination of temporal precedence between the mediators and causal effects. Second, retrospective data collection raises the possibility of recall bias, as current cognitive status might influence the recollection of ACEs. Finally, given the multifaceted nature of cognitive function, future research should consider a broader array of potential influencing factors. Conclusion This study employed data from CHARLS 2014 and 2018 to explore the dual impact of ACEs on cognitive function, both directly and indirectly, through social isolation and functional limitations. To mitigate these effects, strategies focusing on enhancing social engagement and preventing functional decline are crucial. Encouraging middle-aged and elderly individuals to actively engage in cognitive activities and regular physical exercise is recommended to postpone cognitive decline and foster healthy ageing. Declarations Fundings This work was supported by the Health Commission of Sichuan Province (grant numbers 2023YFS0070). The funders played no role in the study design, data collection and analysis, publication decision, or manuscript preparation. 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Godoy, Lucas C., Claudia Frankfurter, Matthew Cooper, Christine Lay, Robert Maunder, and Michael E. Farkouh. 2021. 'Association of Adverse Childhood Experiences With Cardiovascular Disease Later in Life', JAMA Cardiology , 6. Hawkins, Misty A. W., Harley M. Layman, Kyle T. Ganson, Jennifer Tabler, Lucia Ciciolla, Cindy E. Tsotsoros, and Jason M. Nagata. 2021. 'Adverse childhood events and cognitive function among young adults: Prospective results from the national longitudinal study of adolescent to adult health', Child Abuse & Neglect , 115. Hendrie, Hugh C., Marilyn S. Albert, Meryl A. Butters, Sujuan Gao, David S. Knopman, Lenore J. Launer, Kristine Yaffe, Bruce N. Cuthbert, Emmeline Edwards, and Molly V. Wagster. 2006. 'The NIH Cognitive and Emotional Health Project', Alzheimer's & Dementia , 2: 12-32. Hoy, K., S. Barrett, C. Shannon, C. Campbell, D. Watson, T. Rushe, M. Shevlin, F. Bai, S. Cooper, and C. Mulholland. 2011. 'Childhood Trauma and Hippocampal and Amygdalar Volumes in First-Episode Psychosis', Schizophrenia Bulletin , 38: 1162-69. Jaffee, S. R., R. Takizawa, and L. Arseneault. 2017. 'Buffering effects of safe, supportive, and nurturing relationships among women with childhood histories of maltreatment', Psychological Medicine , 47: 2628-39. Jia, Longfei, Yifeng Du, Lan Chu, Zhanjun Zhang, Fangyu Li, Diyang Lyu, Yan Li, Yan Li, Min Zhu, Haishan Jiao, Yang Song, Yuqing Shi, Heng Zhang, Min Gong, Cuibai Wei, Yi Tang, Boyan Fang, Dongmei Guo, Fen Wang, Aihong Zhou, Changbiao Chu, Xiumei Zuo, Yueyi Yu, Quan Yuan, Wei Wang, Fang Li, Shengliang Shi, Heyun Yang, Chunkui Zhou, Zhengluan Liao, Yan Lv, Yang Li, Minchen Kan, Huiying Zhao, Shan Wang, Shanshan Yang, Hao Li, Zhongling Liu, Qi Wang, Wei Qin, Jianping Jia, Meina Quan, Yan Wang, Wenwen Li, Shuman Cao, Lingzhi Xu, Yue Han, Junhua Liang, Yuchen Qiao, Qi Qin, and Qiongqiong Qiu. 2020. 'Prevalence, risk factors, and management of dementia and mild cognitive impairment in adults aged 60 years or older in China: a cross-sectional study', The Lancet Public Health , 5: e661-e71. Lin, Li, Bing Cao, Weiqing Chen, Jinghua Li, Yuying Zhang, and Vivian Yawei Guo. 2022. 'Association of Adverse Childhood Experiences and Social Isolation With Later-Life Cognitive Function Among Adults in China', JAMA Network Open , 5. Lin, Li, Harry Haoxiang Wang, Ciyong Lu, Weiqing Chen, and Vivian Yawei Guo. 2021. 'Adverse Childhood Experiences and Subsequent Chronic Diseases Among Middle-aged or Older Adults in China and Associations With Demographic and Socioeconomic Characteristics', JAMA Network Open , 4. Longhi, Dario, Marsha Brown, and Suzette Fromm Reed. 2021. 'Community-wide resilience mitigates adverse childhood experiences on adult and youth health, school/work, and problem behaviors', American Psychologist , 76: 216-29. Manly, Jennifer J., Ming‐X Tang, Nicole Schupf, Yaakov Stern, Jean‐Paul G. Vonsattel, and Richard Mayeux. 2008. 'Frequency and course of mild cognitive impairment in a multiethnic community', Annals of Neurology , 63: 494-506. McEwen, Bruce S, and Robert M Sapolsky. 1995. 'Stress and cognitive function', Current Opinion in Neurobiology , 5: 205-16. Pechtel, Pia, and Diego A. Pizzagalli. 2010. 'Effects of early life stress on cognitive and affective function: an integrated review of human literature', Psychopharmacology , 214: 55-70. Rajan, K. B., L. E. Hebert, P. A. Scherr, C. F. Mendes de Leon, and D. A. Evans. 2012. 'Disability in Basic and Instrumental Activities of Daily Living is Associated with Faster Rate of Decline in Cognitive Function of Older Adults', The Journals of Gerontology Series A: Biological Sciences and Medical Sciences , 68: 624-30. Schalinski, Inga, Martin H. Teicher, Almut M. Carolus, and Brigitte Rockstroh. 2018. 'Defining the impact of childhood adversities on cognitive deficits in psychosis: An exploratory analysis', Schizophrenia Research , 192: 351-56. Shankar, Aparna, Anne McMunn, Panayotes Demakakos, Mark Hamer, and Andrew Steptoe. 2017. 'Social isolation and loneliness: Prospective associations with functional status in older adults', Health Psychology , 36: 179-87. Tani, Yukako, Takeo Fujiwara, and Katsunori Kondo. 2020. 'Association Between Adverse Childhood Experiences and Dementia in Older Japanese Adults', JAMA Network Open , 3. Teicher, Martin H., Jacqueline A. Samson, Carl M. Anderson, and Kyoko Ohashi. 2016. 'The effects of childhood maltreatment on brain structure, function and connectivity', Nature Reviews Neuroscience , 17: 652-66. Vincent J. Felitti, Robert F. Anda, Robert F. Anda, Robert F. Anda, Alison M. Spitz, Valerie Edwards, Mary P. Koss, and James S. Marks. 1998. 'Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults', American Journal of Preventive Medicine , 14: 245-58. Wei, Xiao, Heng Liu, Li Yang, Zihan Gao, Jinke Kuang, Kexin Zhou, and Mengfan Xu. 2022. 'Joint developmental trajectories and temporal precedence of physical function decline and cognitive deterioration: A longitudinal population-based study', Frontiers in Psychology , 13. Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun. 2021a. 'The Bidirectional Association Between Physical and Cognitive Function Among Chinese Older Adults: A Mediation Analysis', The International Journal of Aging and Human Development , 92: 240-63. ———. 2021b. 'The Bidirectional Association Between Physical and Cognitive Function Among Chinese Older Adults: A Mediation Analysis', Int J Aging Hum Dev , 92: 240-63. Yin, Haojie, Yan Zhu, Limei Tan, Xianli Zhong, and Qing Yang. 2024. 'The impact of adverse childhood experiences on depression in middle and late life: A national longitudinal study', Journal of Affective Disorders , 351: 331-40. Yu, Bin, Andrew Steptoe, Yongjie Chen, and Xiaohua Jia. 2020. 'Social isolation, rather than loneliness, is associated with cognitive decline in older adults: the China Health and Retirement Longitudinal Study', Psychological Medicine , 51: 2414-21. Zeng, Yi. 2012. 'Toward deeper research and better policy for healthy aging – using the unique data of Chinese longitudinal healthy longevity survey', China Economic Journa , 5: 131–49. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 31 Jul, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 21 May, 2025 Reviews received at journal 10 May, 2025 Reviewers agreed at journal 30 Apr, 2025 Reviews received at journal 15 Apr, 2025 Reviewers agreed at journal 31 Mar, 2025 Reviewers agreed at journal 31 Mar, 2025 Reviewers invited by journal 24 Mar, 2025 Editor assigned by journal 08 Dec, 2024 Editor invited by journal 30 Aug, 2024 Submission checks completed at journal 30 Aug, 2024 First submitted to journal 22 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4960659\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":359363807,\"identity\":\"7302f183-565e-4bb1-b2f8-42f630c41d0a\",\"order_by\":0,\"name\":\"Yan Zhu\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Neijiang First People's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yan\",\"middleName\":\"\",\"lastName\":\"Zhu\",\"suffix\":\"\"},{\"id\":359363808,\"identity\":\"3cef2eb9-800d-4d4e-a274-40947bfa7f57\",\"order_by\":1,\"name\":\"Haojie Yin\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Neijiang First People's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Haojie\",\"middleName\":\"\",\"lastName\":\"Yin\",\"suffix\":\"\"},{\"id\":359363809,\"identity\":\"67416499-8eed-4787-aead-0f728ecfd5bc\",\"order_by\":2,\"name\":\"Xianli Zhong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Neijiang First People's Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xianli\",\"middleName\":\"\",\"lastName\":\"Zhong\",\"suffix\":\"\"},{\"id\":359363810,\"identity\":\"ef12c018-c6f4-48cb-88f9-0d2481011a80\",\"order_by\":3,\"name\":\"Li Wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sichuan Academy of Medical Sciences, Sichuan Provincial People’s Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Li\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"},{\"id\":359363811,\"identity\":\"d3752257-9f77-476b-9e54-cde67196c364\",\"order_by\":4,\"name\":\"Qin Zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Sichuan Academy of Medical Sciences, Sichuan Provincial People’s Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Qin\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":359363812,\"identity\":\"188c64cf-0c7f-44b2-b6cb-6a9b1154ae79\",\"order_by\":5,\"name\":\"Ping Jia\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuUlEQVRIiWNgGAWjYLACCQMGOTb25gOkaTHm4zmWQJpFifMkchSIU8rf3nvwgUWBXXobQw4Dw4+KbUS46cy5ZAMJg+TcNoazBxh7ztwmwpobOWYSEgbMuW2MfQnMjG1EaJG/kWP+Q8KgPp2NmceAOC0GQFuAIXY4gY2NWC2GZ84YAx123LCNhy3hIFF+kTveY/hZ4k+1vPz8xwcf/KggxvtAwCwBZRwgTj0QMH4gWukoGAWjYBSMSAAAx5k2DjsC66EAAAAASUVORK5CYII=\",\"orcid\":\"\",\"institution\":\"Sichuan Academy of Medical Sciences, Sichuan Provincial People’s Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Ping\",\"middleName\":\"\",\"lastName\":\"Jia\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-08-23 00:59:25\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4960659/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4960659/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1038/s41598-025-12822-w\",\"type\":\"published\",\"date\":\"2025-07-31T16:21:00+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":65586736,\"identity\":\"8abece91-9350-4169-a5f1-f7f520918e61\",\"added_by\":\"auto\",\"created_at\":\"2024-09-30 09:22:26\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":41057,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePrevalence of ACEs in the sample (total ACEs scores and dimensions).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4960659/v1/e6fb5deb4830b684023f48e4.png\"},{\"id\":65587859,\"identity\":\"a26a227d-a1de-4826-b0ca-61583d9a7300\",\"added_by\":\"auto\",\"created_at\":\"2024-09-30 09:30:26\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":69035,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMultiple mediation model between adverse childhood experiences and cognitive function scores with social isolation and functional limitationas mediators. Path values are the path coefficients. ***P\\u0026lt;0. 001.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4960659/v1/e8f426dd4edf4b00c52f6878.png\"},{\"id\":65586737,\"identity\":\"d45bf674-23e6-497c-aa9c-1ad96a5b690a\",\"added_by\":\"auto\",\"created_at\":\"2024-09-30 09:22:26\",\"extension\":\"png\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":122740,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMultiple mediation model between three dimensions of adverse childhood experiences and cognitive function scores with social isolation and functional limitation as mediators. Path values are the path coefficients. ***P\\u0026lt;0. 001.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4960659/v1/606faf7fd8646de012620761.png\"},{\"id\":88268162,\"identity\":\"eac16971-7d37-44d5-92bd-4b31c493f1a1\",\"added_by\":\"auto\",\"created_at\":\"2025-08-04 16:49:43\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1247742,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4960659/v1/4ee004a6-52e7-4819-a8a0-b44b2a540acd.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eAs the world's second largest economy, China is currently home to 1.4\\u0026nbsp;billion people (19.13% of the world's population) and is rapidly becoming an ageing country. It is predicted that by 2050, the population of individuals over 65 years old in China will reach 400\\u0026nbsp;million, and the population of individuals over 80 years old will reach 150\\u0026nbsp;million(Zeng \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e2012\\u003c/span\\u003e). By then, China will become one of the countries with the highest proportion of elderly individuals in the world. One consequence of a changing population structure is a surge in the prevalence and incidence of age-related conditions, such as cancer, chronic noncommunicable diseases, and mental health disorders. Specifically, declines in cognitive function are of considerable concern. A national survey revealed that approximately 15.5% of individuals aged 60 and above suffer from mild cognitive impairment, 6.0% exhibit dementia, and 3.9% have Alzheimer's disease(Jia et al. 2020). Cognitive decline is a prevalent phenomenon among elderly individuals, and individuals with cognitive decline are at a heightened risk of developing dementia(Manly et al. \\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e2008\\u003c/span\\u003e). Maintaining sound cognitive function is a critical determinant of quality of life and independence for middle-aged and older adults. Cognitive health enables them to maintain social connections, maintain a sense of purpose, and retain the capacity for independent activities, facilitating functional recovery from illness or injury and managing residual functional limitations(Hendrie et al. 2006). Consequently, identifying risk factors associated with cognitive decline is of paramount importance for designing targeted public health interventions, ultimately contributing to the promotion of healthy ageing in China.\\u003c/p\\u003e \\u003cp\\u003ePrevious studies have identified age, education, family history, depression, and chronic illnesses as principal risk factors for cognitive decline(Brenda L. Plassman et al. 2010; Elias et al. \\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e2005\\u003c/span\\u003e). Life course theory posits that early-life experiences significantly influence later-life outcomes(Glen H. Elder \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e1998\\u003c/span\\u003e). Since the emergence of research on adverse childhood experiences (ACEs)(Vincent J. Felitti et al. 1998), a growing body of evidence has underscored their pivotal role in shaping future health(Godoy et al. \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e; Lin et al. 2021; Bellis et al. \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e2019\\u003c/span\\u003e). Consequently, it is suggested that the aetiology of cognitive decline may trace back to early life \\u0026ndash; this hypothesis is supported by multiple empirical studies(Schalinski et al. \\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e; Tani, Fujiwara, and Kondo 2020). The connection between ACEs and cognitive function can be elucidated through neurodevelopmental models(Bick and Nelson \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e2015\\u003c/span\\u003e), which propose that brain regions crucial for cognition, such as the hippocampus and prefrontal cortex, exhibit distinct developmental patterns during childhood and adolescence, when these patterns are highly susceptible to environmental influences, including ACEs(Pechtel and Pizzagalli \\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e2010\\u003c/span\\u003e; Teicher et al. \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e2016\\u003c/span\\u003e). Therefore, cognitive dysfunction may be linked to the development of these structures, which are potentially influenced by ACE exposure(Catts et al. 2013; Hoy et al. \\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e2011\\u003c/span\\u003e; Aas et al. \\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e2013\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eWhile ACEs exert extensive and lasting negative effects on individuals, not all individuals with a history of ACEs manifest adverse health outcomes in adulthood. Therefore, it is important to elucidate the underlying mechanisms and protective factors that might influence the relationship between ACEs and adverse health outcomes. Identifying and addressing these factors could prevent lifelong cognitive impairments induced by ACEs. Empirical evidence suggests that social resources, such as social support and community resilience, can mitigate the cascading effects of ACEs on physical and mental well-being(Cheong et al. \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e; Jaffee, Takizawa, and Arseneault \\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e; Longhi, Brown, and Fromm Reed 2021); conversely, a lack of social connectedness or social isolation, which is a well-documented risk factor for cognitive decline(Yu et al. \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e), can partially mediate the negative impact of ACE-related stressors on cognitive function later in life(Lin et al. 2022). Social isolation, which is characterized by limited social interaction, low participation in social activities, and solitary living(Gale, Westbury, and Cooper \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e), is consistently linked to various adverse health outcomes, including functional limitations and cognitive decline(Shankar et al. \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e; Yu et al. \\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e2020\\u003c/span\\u003e). In the elderly population, functional limitations are common, with a staggering 26.81% prevalence in China(Gao et al. \\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e2023\\u003c/span\\u003e), This high prevalence is due to the relevance of functional limitations to daily activities as well as their ease of measurement. Therefore, functional limitations are significant concern. From a life course perspective, significant early-life events are considered critical determinants of functional limitations or disability(Amemiya et al. \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e). Specifically, ACEs are associated with various negative health outcomes, such as cancer(Brown et al. 2010), depression(Cheong et al. \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e), cardiovascular disease(Godoy et al. \\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e), and chronic lung disease(Anda et al. 2008), all of which can contribute to functional limitations or disabilities. Furthermore, an increasing body of research suggests that older adults with physical and functional limitations are more susceptible to cognitive decline(Wei et al. \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e; Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021b).\\u003c/p\\u003e \\u003cp\\u003eIn summary, previous studies have suggested that ACEs are associated with cognitive decline and that social isolation and functional limitations may play a mediating role in this relationship. To the best of our knowledge, this is the first study to explore the chain mediating effect of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. Based on a large number of previous empirical studies, this study proposes the following hypotheses: (i) ACEs can directly predict cognitive function in adulthood; (ii) social isolation mediates the association between ACEs and cognitive function; (iii) functional limitations mediate the association between ACEs and cognitive function; and (iii) social isolation and functional limitations play a chain mediating role in the association between ACEs and cognitive function.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eData Source\\u003c/h2\\u003e \\u003cp\\u003eThe present study draws upon data from the China Health and Retirement Longitudinal Study (CHARLS), a national baseline survey initiated in 2011. The survey was conducted in 28 provinces (autonomous regions, municipalities) across 150 counties and 450 villages in 2011, 2013, 2015, and 2018, and it reached 19,000 respondents from 12,400 households by the conclusion of the national follow-up in 2018. The comprehensive questionnaire used in the CHARLS evaluates personal demographics, family structure, economic support, health status, physical measurements, health care utilization, insurance coverage, employment, retirement, pensions, income, expenditure, assets, and community characteristics. Furthermore, in 2014, the CHARLS conducted the \\\"Life Course Survey of Chinese Residents.\\\" The current study employs data from the fourth wave of the CHARLS, which was administered in 2018 and subsequently matched with the 2014 Life Course Study data. A total of 6,412 individuals completed both surveys. The CHARLS was approved by the Biomedical Ethics Committee of Peking University (IRB00001052-11015), and all participants voluntarily participated and signed an informed consent form. This study was authorized by the CHARLS database.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec4\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eMeasures\\u003c/h2\\u003e \\u003cdiv id=\\\"Sec5\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eCognitive function\\u003c/h2\\u003e \\u003cp\\u003eCognitive function assessment was conducted using methods adapted from the U.S. Health and Retirement Study (HRS)(Crimmins et al. \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e2011\\u003c/span\\u003e), encompassing four dimensions: orientation, calculation, memory, and drawing. Orientation is assessed by the respondent's judgement of the date (year, month, day), season and day of the week, with one point awarded for each correct response, totalling 5 points. The respondents were instructed to perform five consecutive subtractions of 7 from 100, with one point awarded for each successful attempt, resulting in a maximum of 5 points for the calculation dimension. Memory is measured through immediate word recall and delayed word recall (number of words remembered after a 5-minute delay), with a score of 1 assigned to each correct repetition and a total score of 0\\u0026ndash;20. Finally, the evaluator shows the respondent a picture of two overlapping five-pointed stars and asks the respondent to draw them to test their drawing ability, awarding one point for a correct representation. The total cognitive function score ranged from 0 to 31, with higher scores indicating better cognitive function.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec6\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eSocial isolation\\u003c/h2\\u003e \\u003cp\\u003eA social isolation index was derived based on four items. One point was assigned if participants were not married (including never married, widowed, divorced, or separated); had less than weekly contact with children (by phone, text message, mail or email, or in person); or had not participated in any social activities over the last month (e.g., interacted with friends, played Ma-jong or cards, used the internet, took part in a community-related organization, or did voluntary or charity work). Scores of social isolation ranged from 0 to 4, with higher scores indicating greater isolation(Shankar et al. \\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e2017\\u003c/span\\u003e).\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eFunctional limitations\\u003c/h2\\u003e \\u003cp\\u003eThe activities of daily living (ADL) and instrumental activities of daily living (IADL) scales were used to evaluate functional limitations(Chai et al. \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e). The ADL scale assessed dressing, eating, bathing, getting into or out of bed, going to the toilet, and controlling urination and defecation. The IADL assessed difficulties with doing household chores, preparing hot meals, shopping, managing money and taking medications. The items were scored on a four-point scale: 1\\u0026thinsp;=\\u0026thinsp;no difficulty, 2\\u0026thinsp;=\\u0026thinsp;difficulty but can still complete, 3\\u0026thinsp;=\\u0026thinsp;difficulty and need help, and 4\\u0026thinsp;=\\u0026thinsp;cannot do it. The total functional limitation score ranged from 11 to 44, with higher scores indicating severe functional limitation.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eAdverse Childhood Experiences\\u003c/h2\\u003e \\u003cp\\u003eThe life history module of the CHARLS in 2014 collected data on ACEs that occurred before the age of 18 years. We collected 13 ACEs in this study. According to previous research(Yin et al. \\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e2024\\u003c/span\\u003e), these ACEs were divided into 3 different categories: conventional ACEs (physical abuse, emotional neglect, domestic violence, family crime, family mental illness, family substance abuse, and parental divorce or separation), expanded ACEs (unsafe living conditions, peer bullying, bad friendship experiences), and new ACEs (parental death, sibling death, and parental disability). We calculated the cumulative ACE score and the cumulative score for each dimension.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec9\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCovariate Information\\u003c/h2\\u003e \\u003cp\\u003eThe covariates in this study included age, sex (0\\u0026thinsp;=\\u0026thinsp;female, 1\\u0026thinsp;=\\u0026thinsp;male), ethnicity (0\\u0026thinsp;=\\u0026thinsp;other, 1\\u0026thinsp;=\\u0026thinsp;Han), and education level (0\\u0026thinsp;=\\u0026thinsp;illiterate, 1\\u0026thinsp;=\\u0026thinsp;primary school and below, 2\\u0026thinsp;=\\u0026thinsp;junior high, and 3\\u0026thinsp;=\\u0026thinsp;high school and above).\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eFirst, IBM SPSS version 25.0 was used for descriptive statistics and correlation analysis of the data. Continuous variables are expressed as the means and standard deviations, and categorical variables are expressed as frequencies and percentages. Next, before analysing the indirect effects, a completely direct model was used to analyse the impact of ACEs on cognitive function in middle-aged and older adults. Then, Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, social isolation and functional limitations as the mediating variables, and cognitive function as the dependent variable. The maximum likelihood method and bootstrap method were used to test the mediating model, and the 95% CI for bias correction was calculated; P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 was considered to indicate statistical significance.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eParticipant Characteristics\\u003c/h2\\u003e \\u003cp\\u003eThe statistical characteristics of the study sample are presented in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. Among the 6412 participants, 2933 (45.7%) were men and 3479 (54.3%) were women; the mean age was 66 (SD\\u0026thinsp;=\\u0026thinsp;9.7) years, and the vast majority had a low level of education. Furthermore, the average cognitive function score was 11.38 (SD\\u0026thinsp;=\\u0026thinsp;7.17), the average social isolation score was 1.79 (SD\\u0026thinsp;=\\u0026thinsp;0.96), and the average functional limitation score was 13.35 (SD\\u0026thinsp;=\\u0026thinsp;4.54). The average ACE score was 1.93 (SD\\u0026thinsp;=\\u0026thinsp;1.53), 84.1% reported experiencing one or more ACEs, and the incidence of cumulative ACEs and each dimension is shown in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDescriptive Characteristics of participants\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariables\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eLevels\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eObserved\\u003c/p\\u003e \\u003cp\\u003eN (%)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eMean\\u003c/p\\u003e \\u003cp\\u003e(SD)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eMinimum\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eMaximum\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eACEs (0\\u0026ndash;13)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e2.02\\u003c/p\\u003e \\u003cp\\u003e(1.55)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eConventional ACEs (0\\u0026ndash;7)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.86\\u003c/p\\u003e \\u003cp\\u003e(0.92)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePhysical abuse\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,825 (28.46)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEmotional neglect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,678 (26.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDomestic violence\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e560 (8.73)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFamily crime\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e32 (0.5)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMental illness in the family\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e921 (14.36)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHousehold Substance Abuse\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e456 (7.11)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParents divorced or separated\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e50 (0.78)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eExpanded ACEs (0\\u0026ndash;3)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.59\\u003c/p\\u003e \\u003cp\\u003e(0.73)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eUnsafe living conditions\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e603 (9.4)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePeer bullying\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,084 (16.91)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBad friendship experiences\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2,110 (32.91)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eNew ACEs (0\\u0026ndash;3)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.57\\u003c/p\\u003e \\u003cp\\u003e(0.70)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e3\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParental death before age 17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,157 (18.04)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDeath of a sibling before age 17\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,051 (16.39)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eParental disability\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eyes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,425 (22.22)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eCognitive function (0\\u0026ndash;31)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e11.38\\u003c/p\\u003e \\u003cp\\u003e(7.17)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e30\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eSocial isolation (0\\u0026ndash;4)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e1.79\\u003c/p\\u003e \\u003cp\\u003e(0.96)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eFunctional limitation (11\\u0026ndash;44)\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003escores\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e13.35\\u003c/p\\u003e \\u003cp\\u003e(4.54)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e44\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003eDemographic characteristics\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge (45\\u0026ndash;108)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e66\\u003c/p\\u003e \\u003cp\\u003e(9.71)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e45\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e108\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eMale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2,933 (45.7)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e3,479 (54.3)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEthnicity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHan\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5902 (92.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eOther\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e510 (8.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEducation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIlliterate\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,670 (26.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePrimary school and below\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2,934 (45.8)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eJunior high school\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1,165 (18.2)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSenior high school and above\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e643 (10.0)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003eNotes. Sample N\\u0026thinsp;=\\u0026thinsp;6,412. ACEs, Adverse Childhood Experiences.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec13\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eCorrelation Analysis\\u003c/h2\\u003e \\u003cp\\u003eCorrelation analysis was conducted on the social isolation score, functional limitation score, ACEs, and cognitive function score, and the results showed that the correlations between these key study variables were significant. ACEs were positively correlated with social isolation (r\\u0026thinsp;=\\u0026thinsp;0.081, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01) and functional limitations (r\\u0026thinsp;=\\u0026thinsp;0.070, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), whereas cognitive function was negatively correlated with ACEs (r=-0.132, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), social isolation (r=-0.317, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01), and functional limitations (r=-0.293, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01). These findings suggested that higher ACE scores are correlated with greater levels of social isolation and severe functional limitations. The detailed results are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e\\u003ctable id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\n \\u003ccaption language=\\\"En\\\"\\u003e\\n \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\n \\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\n \\u003cp\\u003eCorrelation coefficients between key study variables (N\\u0026thinsp;=\\u0026thinsp;6412)\\u003c/p\\u003e\\n \\u003c/div\\u003e\\n \\u003c/caption\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003cth align=\\\"left\\\" style=\\\"width: 24.9617%;\\\"\\u003e\\n \\u003cp\\u003evariables\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" style=\\\"width: 23.4303%;\\\"\\u003e\\n \\u003cp\\u003eCognitive function\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" style=\\\"width: 9.9541%;\\\"\\u003e\\n \\u003cp\\u003eACEs\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" style=\\\"width: 19.1424%;\\\"\\u003e\\n \\u003cp\\u003eSocial isolation\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003cth align=\\\"left\\\" style=\\\"width: 22.5115%;\\\"\\u003e\\n \\u003cp\\u003eFunctional limitation\\u003c/p\\u003e\\n \\u003c/th\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 24.9617%;\\\"\\u003e\\n \\u003cp\\u003eCognitive function\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 23.4303%;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 9.9541%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 19.1424%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 22.5115%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 24.9617%;\\\"\\u003e\\n \\u003cp\\u003eACEs\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 23.4303%;\\\"\\u003e\\n \\u003cp\\u003e-0.132**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 9.9541%;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 19.1424%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 22.5115%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 24.9617%;\\\"\\u003e\\n \\u003cp\\u003eSocial isolation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 23.4303%;\\\"\\u003e\\n \\u003cp\\u003e-0.317**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 9.9541%;\\\"\\u003e\\n \\u003cp\\u003e0.081**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 19.1424%;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 22.5115%;\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 24.9617%;\\\"\\u003e\\n \\u003cp\\u003eFunctional limitation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 23.4303%;\\\"\\u003e\\n \\u003cp\\u003e-0.293**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 9.9541%;\\\"\\u003e\\n \\u003cp\\u003e0.070**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"left\\\" style=\\\"width: 19.1424%;\\\"\\u003e\\n \\u003cp\\u003e0.176**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd align=\\\"char\\\" style=\\\"width: 22.5115%;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\u003cp\\u003e**Correlation is significant at the 0.01 level (2-tailed). ACEs\\u0026thinsp;=\\u0026thinsp;Adversity Childhood Experiences.\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eDirect association between ACEs and cognitive function\\u003c/h2\\u003e \\u003cp\\u003eBefore proceeding with the mediation analysis, we used a total direct model to determine the effects of ACEs on the cognitive function of middle-aged and older people. As shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e, in the model, we include age, sex, education, and ethnicity as control variables. The model exhibited an excellent fit: χ\\u003csup\\u003e2\\u003c/sup\\u003e/df\\u0026thinsp;=\\u0026thinsp;0, CFI\\u0026thinsp;=\\u0026thinsp;1, TLI\\u0026thinsp;=\\u0026thinsp;1, RMSEA\\u0026thinsp;=\\u0026thinsp;0.000, SRMR\\u0026thinsp;=\\u0026thinsp;0.000. Therefore, the results demonstrated a statistically significant direct effect of ACEs on cognitive function (β\\u0026thinsp;=\\u0026thinsp;0.060, 0.001).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDirect model regression weight\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDV\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIV\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStd. Est.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eS.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEst./S.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eP-Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eR\\u0026sup2;\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eACEs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.037\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.009\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-3.920\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.423\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eAge\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.274\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-27.198\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSex\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.025\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e2.455\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.014\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEducation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.504\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e49.494\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eEthnicity\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.013\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e1.273\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e0.203\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec15\\\" class=\\\"Section2\\\"\\u003e \\u003cp\\u003e***P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0. 001\\u003c/p\\u003e \\u003cdiv id=\\\"Sec16\\\" class=\\\"Section3\\\"\\u003e \\u003ch2\\u003eMultiple Indirect Effects Model\\u003c/h2\\u003e \\u003cp\\u003eAfter controlling for age, sex, education, and ethnicity, the indirect relationships between ACEs and cognitive function are illustrated in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e and Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e. The multiple mediation model demonstrated a strong fit: χ\\u003csup\\u003e2\\u003c/sup\\u003e/df\\u0026thinsp;=\\u0026thinsp;0, CFI\\u0026thinsp;=\\u0026thinsp;1, TLI\\u0026thinsp;=\\u0026thinsp;1, RMSEA\\u0026thinsp;=\\u0026thinsp;0.000, SRMR\\u0026thinsp;=\\u0026thinsp;0.000. Table\\u0026nbsp;\\u003cspan refid=\\\"Tab5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e provides a comprehensive analysis of the total effect, direct effect, and mediating pathways, along with their 95% confidence intervals. Specifically, the impact of ACEs on cognitive function through social isolation is -0.099, which constitutes 16.3% of the overall effect. The contribution of functional limitations was \\u0026minus;\\u0026thinsp;0.022, accounting for 10.3% of the total effect. The combined influence of social isolation and functional limitations on cognition amounts to -0.015, or 2.5% of the total effect. The direct effect of ACEs on cognitive function was \\u0026minus;\\u0026thinsp;0.433, representing 71.0% of the total effect. All the confidence intervals of the mediation paths exclude zero, thus indicating that social isolation and functional limitations significantly mediated the effect of ACEs on cognitive function. However, the difference in mediation effects between these two factors was not statistically significant (β=-0.037, P\\u0026thinsp;=\\u0026thinsp;0.086).\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eModel regression weight of the impact of ACEs on cognitive function scores\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDV\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eIV\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eStd. Est.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eS.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eEst./S.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eP-Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eR\\u0026sup2;\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eACEs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.094\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.011\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-8.186\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.167\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSocial isolation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.267\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.011\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-24.067\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eFunctional limitation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e-0.240\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e-23.505\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFunctional limitation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eACEs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.057\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.012\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e4.558\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.034\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eSocial isolation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.171\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.013\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e13.523\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSocial isolation\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eACEs\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.081\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.013\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e6.423\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.006\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e***P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0. 001.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab5\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 5\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eTotal, direct, and indirect effects of ACEs on cognitive function, social isolation and functional limitation as mediators\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"7\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\" morerows=\\\"2\\\" rowspan=\\\"3\\\"\\u003e \\u003cp\\u003ePoint\\u003c/p\\u003e \\u003cp\\u003eEstimate\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"3\\\" morerows=\\\"1\\\" nameend=\\\"c5\\\" namest=\\\"c3\\\" rowspan=\\\"2\\\"\\u003e \\u003cp\\u003eProduct of\\u003c/p\\u003e \\u003cp\\u003eCoefficients\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003e95%CI\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e \\u003cp\\u003ebias corrected\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eS.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003eEst./S.E.\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP-Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003eLower\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003eUpper\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eINDIRECT EFFECTS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.099\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.016\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-6.215\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.133\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.070\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFL\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.063\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.014\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-4.541\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.091\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.036\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSI\\u0026rarr;FL\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.015\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.003\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-5.658\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.010\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal indirect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.177\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.023\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-7.868\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.222\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.134\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eDIRECT AND TOTAL EFFECTS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDirect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.433\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.053\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-8.156\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.541\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.331\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.610\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.058\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-10.540\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.728\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.500\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colspan=\\\"7\\\" nameend=\\\"c7\\\" namest=\\\"c1\\\"\\u003e \\u003cp\\u003eCONTRASTS\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSI VS FL\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.037\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.021\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-1.715\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.086\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.080\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e0.004\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSI VS SI\\u0026rarr;FL\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.084\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.014\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-6.060\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.114\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.059\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFL VS SI\\u0026rarr;FL\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.047\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.014\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e-3.336\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.001\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.075\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e \\u003cp\\u003e-0.020\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e***P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0. 001. SI\\u0026thinsp;=\\u0026thinsp;Social isolation, FL\\u0026thinsp;=\\u0026thinsp;Functional limitation.\\u003c/p\\u003e \\u003cp\\u003eAdditionally, we constructed three models to analyse the pathway relationships between three dimensions of ACEs and cognitive function, as shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab6\\\" class=\\\"InternalRef\\\"\\u003e6\\u003c/span\\u003e and Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e. Conventional ACEs, expanded ACEs, and new ACEs all had significant direct effects on cognitive function, with the expanded ACEs showing the strongest direct effect (β = -1.237, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Among the three dimensions, the total association between expanded ACEs and cognitive function was the strongest (β = -1.69, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). Social isolation and functional limitations mediated the relationship in expanded ACEs more than in conventional ACEs, accounting for 26% of the total effect, but this association was not significant for new ACEs (β = -0.007, p\\u0026thinsp;=\\u0026thinsp;0.226).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab6\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 6\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eDirect and Indirect Effects of each dimension of ACEs on cognitive function in Later Life\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"6\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEffect\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eβ\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eSE\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003eP-Value\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e95%CI\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTotal effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.436\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.098\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.629 to -0.248\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-1.690\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.124\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-1.945 to -1.425\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.420\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.125\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.670 to -0.177\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eDirect effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.312\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.089\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.485 to -0.134\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-1.237\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.012\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-1.478 to -1.020\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNACEs- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.255\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.114\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e*\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.484 to -0.038\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIndirect effect\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCACEs-SI- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.080\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.027\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.135 to -0.029\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCACEs-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.032\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.024\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.170\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.079 to 0.013\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCACEs-SI-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.013\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.004\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e**\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.022 to -0.005\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEACEs-SI- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.281\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.033\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.348 to -0.218\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEACEs-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.128\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.030\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.188 to -0.071\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eEACEs-SI-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.044\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.006\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.058 to -0.033\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNACEs-SI- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.043\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.035\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.224\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.114 to 0.025\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNACEs-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.115\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.031\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e***\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.178 to -0.057\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNACEs-SI-FL- Cognitive function\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e-0.007\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.006\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e \\u003cp\\u003e0.226\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e \\u003cp\\u003e-0.018 to 0.004\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"6\\\"\\u003eNotes. SI\\u0026thinsp;=\\u0026thinsp;Social isolation, FL\\u0026thinsp;=\\u0026thinsp;Functional limitation. ACEs, Adverse Childhood Experiences. CACEs, Conventional adverse childhood experiences. EACEs, Expanded adverse childhood experiences. NACEs, New adverse childhood experiences.\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec17\\\" class=\\\"Section2\\\"\\u003e \\u003cp\\u003e***P\\u0026thinsp;\\u0026lt;\\u0026thinsp;.001, **P\\u0026thinsp;\\u0026lt;\\u0026thinsp;.01, *P\\u0026thinsp;\\u0026lt;\\u0026thinsp;.05\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study is the first to examine the chain mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function among middle-aged and older adults in China. Initially, the results of this study demonstrated a significant direct effect of cumulative ACE scores on cognitive function in middle-aged and older adults (confirming Hypothesis 1), consistent with findings by Schalinski, Tani, and others. This association may occur due to changes in brain structure and poor neurodevelopmental function in various brain regions, such as the limbic, hippocampal, and prefrontal areas, leading to inefficient memory and executive functions(Dannlowski et al. \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e2012\\u003c/span\\u003e; Hawkins et al. \\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e2021\\u003c/span\\u003e). As summarized by Danese et al., individuals with a history of ACEs exhibit widespread and significant deficits across various cognitive domains, including processing speed, executive function, perceptual reasoning, memory, and language comprehension(Danese et al. 2017). Furthermore, the direct effects of various dimensions of the ACE on cognitive function are significant, suggesting that any type of ACE can adversely affect cognitive function in adulthood.\\u003c/p\\u003e \\u003cp\\u003eIn the structural equation model we constructed, all paths were significant, thus providing support for Hypotheses 2, 3, and 4. This indicates that the impact of ACEs on cognitive function in adulthood can be explained through mediating variables, as predicted. Social isolation partially explains the relationship between ACEs and cognitive function, which may be interpreted through the stress-buffering hypothesis. Specifically, positive social interactions can reduce the psychological distress caused by ACEs, protect hippocampal neurons, and diminish neurotoxicity(Cohen and Wills 1985), all of which are crucial for maintaining cognitive function with age(McEwen and Sapolsky 1995). Additionally, lower levels of social isolation reflect more interpersonal interactions within one's social network. Therefore, adults may benefit from social interactions and adopting healthier lifestyle habits, such as quitting smoking and drinking, which may also help to protect cognition. Thus, fostering social integration through larger social networks and increased social participation might be particularly important for individuals affected by ACEs.\\u003c/p\\u003e \\u003cp\\u003eFurthermore, our study revealed that ACEs are positively correlated with an increase in functional limitations and a decrease in cognitive function, consistent with recent research findings. Amemiya et al.(Amemiya et al. \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2018\\u003c/span\\u003e) found that childhood adversity is associated with functional limitations, with elderly individuals who reported two or more ACEs having greater functional impairment than those without ACEs. These findings suggest a significant dose‒response relationship. Moreover, physical and functional limitations are significantly correlated with a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a; Wei et al. \\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e2022\\u003c/span\\u003e). A possible explanation for these results is that ACEs may increase the risk of low socioeconomic status, which is associated with poor health behaviours and disease states and is potentially linked to greater functional limitations. However, functional restrictions, including the ability to perform activities of daily living (ADL) and instrumental activities of daily living (IADL), may be fundamental in the neurodegenerative processes leading to cognitive decline(Rajan et al. \\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e2012\\u003c/span\\u003e). Additionally, elderly individuals with functional limitations may lose opportunities to engage in physical exercise and cognitive activities, further leading to a decline in cognitive function(Xiaohang Zhao, Lei Jin, and Skylar Biyang Sun 2021a).\\u003c/p\\u003e \\u003cp\\u003eImportantly, the results of this study also revealed the chained mediating role of social isolation and functional limitations between ACEs and cognitive function. This finding provides new evidence for the literature, demonstrating that ACEs may have a negative impact on subsequent cognitive function by affecting functional limitations through social isolation. These insights are crucial for mitigating the adverse effects of early-life stress and promoting health in adulthood.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec19\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eTo the best of our knowledge, this study is the first to investigate the sequential mediating effects of social isolation and functional limitations on the relationship between ACEs and cognitive function in a nationally representative Chinese population. However, it is essential to acknowledge several limitations. First, the cross-sectional design precludes the examination of temporal precedence between the mediators and causal effects. Second, retrospective data collection raises the possibility of recall bias, as current cognitive status might influence the recollection of ACEs. Finally, given the multifaceted nature of cognitive function, future research should consider a broader array of potential influencing factors.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study employed data from CHARLS 2014 and 2018 to explore the dual impact of ACEs on cognitive function, both directly and indirectly, through social isolation and functional limitations. To mitigate these effects, strategies focusing on enhancing social engagement and preventing functional decline are crucial. Encouraging middle-aged and elderly individuals to actively engage in cognitive activities and regular physical exercise is recommended to postpone cognitive decline and foster healthy ageing.\\u003c/p\\u003e \"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eFundings\\u003c/h2\\u003e \\u003cp\\u003eThis work was supported by the Health Commission of Sichuan Province (grant numbers 2023YFS0070). The funders played no role in the study design, data collection and analysis, publication decision, or manuscript preparation.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eIn our article, P.J. provided guidance on the thinking and writing of the whole text. Y.Z. and HJ.Y. processed part of the data and wrote the full text. XL. Z. carried out the data processing and chart drawing of the empirical part. L.W. and Q.Z. provided us with the full text of the embellishment. All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors. All authors read and approved the final manuscript.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgment\\u003c/h2\\u003e \\u003cp\\u003eWe are grateful to all volunteers and staff who participated in China Health and Retirement Longitudinal Study for collecting and providing data.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe original data can be found at https://charls.charlsdata.com/pages/Data/2018-charls-wave4/zh-cn.html.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eAas, Monica, Unn K. Haukvik, Srdjan Djurovic, \\u0026Oslash;rjan Bergmann, Lavinia Athanasiu, Martin S. Tesli, Tone Hellvin, Nils Eiel Steen, Ingrid Agartz, Steinar Lorentzen, Kjetil Sundet, Ole A. 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Mplus 8.0 software was used to construct a structural equation model with ACEs as the independent variable, cognitive function as the dependent variable, and social isolation and functional limitations as mediating variables.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eIn this study, ACEs were positively associated with social isolation and functional limitations (r\\u0026thinsp;=\\u0026thinsp;0.081, 0.070, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01) and negatively associated with cognitive function (r=-0.132, P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.01). Social isolation and functional limitations had chain mediating effects on the relationship between ACEs and cognitive function.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eACEs lead to impaired cognitive functioning in middle-aged and older adults, and social isolation and functional limitations influence this relationship. These findings suggest that promoting social integration and physical exercise targeting functional limitations may be important approaches for preventing and mitigating the effects ACEs on cognitive function.\\u003c/p\\u003e\",\"manuscriptTitle\":\"The Impact of Adverse Childhood Experiences on Cognitive Function in Middle-Aged and Older Adults: Mediating Roles of Social Isolation and Functional Limitations\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-09-30 09:22:22\",\"doi\":\"10.21203/rs.3.rs-4960659/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2025-05-21T06:37:51+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-05-10T09:32:33+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"97875284631564285091370390650962323944\",\"date\":\"2025-04-30T11:33:59+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-04-15T14:41:00+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"80575297398839054798478502380904857625\",\"date\":\"2025-03-31T16:22:24+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"287210224432110331470899893693988230083\",\"date\":\"2025-03-31T07:39:57+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-03-24T21:21:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2024-12-08T12:05:58+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2024-08-30T10:57:02+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2024-08-30T06:00:27+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Scientific Reports\",\"date\":\"2024-08-23T00:57:04+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"scientific-reports\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"scirep\",\"sideBox\":\"Learn more about [Scientific Reports](http://www.nature.com/srep/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"Scientific Reports\",\"twitterHandle\":\"\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"Scientific Reports\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"dcc35501-47cf-4e71-8a42-eea7c39701ea\",\"owner\":[],\"postedDate\":\"September 30th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[{\"id\":38239304,\"name\":\"Health sciences/Diseases\"},{\"id\":38239305,\"name\":\"Health sciences/Medical research\"}],\"tags\":[],\"updatedAt\":\"2025-08-04T16:40:32+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-4960659\",\"link\":\"https://doi.org/10.1038/s41598-025-12822-w\",\"journal\":{\"identity\":\"scientific-reports\",\"isVorOnly\":false,\"title\":\"Scientific Reports\"},\"publishedOn\":\"2025-07-31 16:21:00\",\"publishedOnDateReadable\":\"July 31st, 2025\"},\"versionCreatedAt\":\"2024-09-30 09:22:22\",\"video\":\"\",\"vorDoi\":\"10.1038/s41598-025-12822-w\",\"vorDoiUrl\":\"https://doi.org/10.1038/s41598-025-12822-w\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4960659\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4960659\",\"identity\":\"rs-4960659\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}