Social connectedness and cognitive outcomes in rural middle‐ to older‐age adults.

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Learn more: PMC Disclaimer | PMC Copyright Notice Alzheimers Dement . 2026 Apr 16;22(4):e71401. doi: 10.1002/alz.71401 Search in PMC Search in PubMed View in NLM Catalog Add to search Social connectedness and cognitive outcomes in rural middle‐ to older‐age adults Juyoung Park Juyoung Park 1 College of Nursing, University of Arizona, Tucson, Arizona, USA Find articles by Juyoung Park 1 , Lilah M Besser Lilah M Besser 2 Comprehensive Center for Brain Health, University of Miami School of Medicine, Boca Raton, Florida, USA Find articles by Lilah M Besser 2, ✉ , Madeleine Tourelle Madeleine Tourelle 2 Comprehensive Center for Brain Health, University of Miami School of Medicine, Boca Raton, Florida, USA Find articles by Madeleine Tourelle 2 , Christine Williams Christine Williams 3 C.E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA Find articles by Christine Williams 3 , Diane Cook Diane Cook 4 School of Electrical Engineering and Computer Science, Washington State University, Pullman, Washington, USA Find articles by Diane Cook 4 , Diana Mitsova Diana Mitsova 5 Department of Urban and Regional Planning, Florida Atlantic University, Boca Raton, Florida, USA Find articles by Diana Mitsova 5 , Sheryl Magzamen Sheryl Magzamen 6 Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA Find articles by Sheryl Magzamen 6 , Lisa Wiese Lisa Wiese 3 C.E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA Find articles by Lisa Wiese 3 Author information Article notes Copyright and License information 1 College of Nursing, University of Arizona, Tucson, Arizona, USA 2 Comprehensive Center for Brain Health, University of Miami School of Medicine, Boca Raton, Florida, USA 3 C.E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida, USA 4 School of Electrical Engineering and Computer Science, Washington State University, Pullman, Washington, USA 5 Department of Urban and Regional Planning, Florida Atlantic University, Boca Raton, Florida, USA 6 Department of Environmental and Radiological Health Sciences, Colorado State University, Fort Collins, Colorado, USA * Correspondence , Lilah M. Besser, Comprehensive Center for Brain Health, University of Miami, 7700 West Camino Real, Suite 200, Boca Raton, FL 33433, USA. Email: [email protected] ✉ Corresponding author. Revised 2026 Mar 3; Received 2025 Dec 3; Accepted 2026 Mar 19; Collection date 2026 Apr. © 2026 The Author(s). Alzheimer's & Dementia published by Wiley Periodicals LLC on behalf of Alzheimer's Association. This is an open access article under the terms of the http://creativecommons.org/licenses/by-nc-nd/4.0/ License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made. PMC Copyright notice PMCID: PMC13084533  PMID: 41988823 Abstract Social connectedness plays a vital role in cognitive health for rural adults, a population at heightened risk for Alzheimer's disease and related dementias (ADRD). We reviewed 39 primary studies examining associations between dimensions of social connectedness and cognitive function/cognitive impairment in rural adults (≥ 40 years). Most studies (56%) focused on a single dimension of social connectedness and most (82%) were cross‐sectional. Sixty‐seven percent examined social isolation, 44% examined social support, 23% examined social engagement, and 18% examined loneliness. Social connectedness was frequently associated with cognitive outcomes (≥ 90% of studies), with isolation and loneliness appearing detrimental and engagement and support appearing protective. Most were conducted in Asia (62%), with the remainder in North America (18%), Africa (18%), and Europe (5%). This review highlights four interrelated but distinct domains of social connectedness and underscores the need for longitudinal, multidimensional, and context‐specific research to inform strategies promoting cognitive resilience in rural populations. Keywords: Alzheimer's disease, cognitive function, dementia, rural, social connectedness, social engagement, social isolation, social support Highlights Social connectedness was examined across multiple dimensions, including engagement, social support, social isolation, and loneliness. The outcomes included cognitive function and cognitive impairment or dementia diagnosis. A total of 39 papers on this topic were published between January 1, 2010, and June 30, 2025, with more than 90% of studies reporting an association. There is a need for more refined measures and further examination of interactions and modifiers, such as sex. There is also a need for evaluation of interventions, as well as longitudinal and mechanistic studies. 1. OVERVIEW OF RURAL AGING AND COGNITIVE HEALTH DISPARITIES Older adults living in rural communities face a disproportionate burden of age‐related neurological conditions, including an elevated prevalence of mild cognitive impairment (MCI) and Alzheimer's disease (AD) and related dementias (ADRD). 1 , 2 , 3 Recent evidence suggests that prevalence of MCI in rural regions has reached 27%, exceeding estimates of prevalence in the general population. 4 National and cross‐sectional data indicate that rural older adults often perform worse on cognitive assessments, particularly in verbal memory and orientation, compared to their urban counterparts. 5 These disparities are rooted in broader social determinants of health. Rural populations tend to have lower levels of educational and occupational attainment, which are key protective factors that build cognitive reserve across the life course. 6 Socioeconomic disadvantage, which often is greater in rural than in urban/suburban populations, limits access to cognitively stimulating environments and lifelong learning opportunities, compounding risks over time. 7 In addition to other upstream factors, geographic isolation impedes travel and access to cognitively enriching activities. 8 Broader shortcomings in the rural built environment, such as poor walkability and lack of community infrastructure, also contribute to isolation, loneliness, and accelerated cognitive decline. 9 In rural areas, transportation barriers and limited broadband infrastructure pose unique challenges that further constrain social engagement, telehealth participation, and access to health information, all of which are critical for preserving cognitive function. 10 , 11 , 12 Although diagnosing and treating dementia can slow symptom progression, rural areas frequently lack local cognitive screening services, specialist care, and community‐based memory clinics, leading to delayed diagnoses, limited treatment of comorbidities, and restricted access to cognitive interventions. 13 , 14 Collectively, these intersecting structural, geographic, and technological barriers create conditions in which modifiable environmental and social exposures such as social connectedness exert a strong influence on cognitive trajectories. 15 Concurrently, many rural communities are characterized by close‐knit social networks, long‐standing interpersonal relationships, and strong norms of mutual aid, which may foster a sense of belonging and social cohesion. 15 , 16 , 17 These features can facilitate informal social support, frequent intergenerational contact, and meaningful social roles, potentially buffering against cognitive decline. 15 , 17 Such community‐level strengths highlight the importance of examining both the risks and protective aspects of rural social environments when evaluating social connectedness and cognitive outcomes. 15 , 16 , 17 1.1. Social connectedness as a determinant of cognitive health Social connectedness, which includes social engagement, social support, social isolation, and loneliness, is a multifaceted construct that encompasses the quality and quantity of social relationships and interactions. 18 It integrates objective components, such as the structure of social networks, and subjective components, including perceived quality of and satisfaction with relationships. Social connectedness is increasingly recognized as a modifiable determinant of cognitive health, encompassing both protective elements (e.g., engagement and support) and risk factors (e.g., isolation and loneliness). 19 , 20 , 21 Positive social relationships, often facilitated through social engagement and support, can promote cognitive reserve by stimulating mental processes, reducing stress, and encouraging health‐promoting behaviors. 21 In contrast, social isolation and loneliness have been linked to cognitive decline and dementia through mechanisms such as chronic stress, inflammation, and reduced neuroplasticity. 22 , 23 This paper is intended to bridge the current multidimensional gap in research between social connectedness, cognitive function/impairment, and ADRD diagnosis in rural residents. 1.2. Purpose of this paper The exposome, first conceptualized as the totality of environmental exposures from conception onward, has been expanded to encompass physical, chemical, social, lifestyle, and biological exposures accumulated over the life course that influence health. 24 , 25 This framework provides a comprehensive lens for understanding how lifelong exposures shape cognitive health. Within this perspective, social connectedness represents an important yet understudied domain of the social exposome in relation to rural older adult health. Specifically, multidimensional aspects of social connectedness, including engagement, support, isolation, and loneliness, warrant closer attention. 18 , 26 Despite growing recognition of social connectedness as a modifiable factor for cognitive health, little is known about how these relationships manifest in rural populations. Although social connectedness is frequently studied in aging research, rural populations remain underrepresented, with most studies based on urban or general populations. 27 Rural residents may face distinct contextual and environmental challenges, including limited instrumental support and reduced opportunities for engagement, that make them uniquely vulnerable. This paper has three research objectives: (1) synthesize current evidence on the relationship between social connectedness and cognitive function and cognitive impairment/ADRD diagnosis in rural middle‐ to older‐age adults; (2) identify critical knowledge gaps in the literature regarding how social engagement, social support, social isolation, and loneliness influence cognitive aging in rural contexts, in conceptualization, and measurement across diverse settings; and (3) propose future directions for research, intervention, and practice that are culturally and contextually responsive to the needs of rural communities. Various conceptualizations of social connectedness in relation to health including cognition/dementia are available from worldwide experts (e.g., Droes et al., 28 Samtani et al., 29 and Holt‐Lunstad 30 ). For example, the sentinel work by Holt‐Lundstad et al. revealed the importance of social connections as a public health priority. 30 , 31 The current review was guided by a conceptual framework (Figure 1 ) that centers on four domains of social connectedness hypothesized to impact cognitive health. In addition to social engagement and social support, our framework highlights social isolation and loneliness, two key domains previously linked to dementia outcomes in the “Dementia prevention, intervention, and care: 2024 report of the Lancet standing commission.” 32 FIGURE 1. Open in a new tab Conceptual framework of social connectedness and its core components. Although the burden of AD/ADRD is most pronounced in older adults, in our review, we included rural adults aged ≥ 40 to reflect midlife as a critical period when social and environmental exposures accumulate, and early cognitive changes may begin to emerge. This broader age range captures evidence on prevention and risk modification, as emphasized in dementia risk research highlighting the role of midlife social and lifestyle factors in shaping later‐life cognitive outcomes. 32 , 33 2. METHODS The authors followed a structured approach to identify and synthesize current evidence. A comprehensive search of three electronic databases (PubMed, Embase, Web of Science) was conducted to pull eligible peer‐reviewed articles published between January 1, 2010, and June 30, 2025, using a combination of key search terms related to social connectedness (social engagement, social isolation, social alienation, alienation, social marginalization, loneliness, lonely, withdrawn, remote, social support, social connectedness, remoteness, disconnected, separated, separation, secluded, seclusion, segregated, segregation) and cognitive/ADRD outcomes (cognition, cognitive, memory, brain aging, brain ageing, Alzheimer, Alzheimer's, neurodegenerative, dementia, cognitive impairment) filtered for rural populations (countryside, non‐urban, rural). Only primary studies were included to ensure that the discussion reflects direct associations between dimensions of social connectedness and cognitive outcomes. Articles were “eligible” for inclusion if they examined associations between one or more facets of social connectedness with cognitive function, impairment, or ADRD diagnosis, included data on adults ≥ 40 years, and highlighted assessments in rural populations and communities. Studies were excluded if they lacked direct measures of cognitive function/ADRD diagnoses, did not focus on social connectedness in rural populations, or were not a primary resource. Titles and abstracts were screened by a first author (M.T.), and articles deemed uncertain were further evaluated through a full‐text review using the stated inclusion criteria. A second author (J.P.) examined a subset of both included and excluded articles to verify accuracy of the screening process. Titles/abstracts and full texts that required further evaluation were independently reviewed by two reviewers. Discrepancies were discussed and resolved through consensus to ensure consistent application of inclusion and exclusion criteria. After the full‐text review by four additional authors (L.B., C.W., D.M., L.W.), 39 studies met inclusion criteria for data extraction (Figure 2 ). The findings were organized into four conceptual categories of social connectedness, guided by operational definitions from the literature. Each subsection describes the construct, its relevance to cognition, rural‐specific findings, and key gaps or limitations in the evidence base. FIGURE 2. Open in a new tab Final sample of papers included in review. CF, cognitive function; SC, social connectedness. 3. RESULTS Table 1 provides an overview of the 39 studies, including the first author, year of publication, sample size, geographic region, study type (longitudinal vs. cross‐sectional), and categorized cognitive outcomes. The majority of included studies were conducted outside the United States, specifically in rural settings in Asia (62% in Asia, 18% in North America, 18% in Africa, and 5% in Europe). Of the 39 studies, 7 used longitudinal designs 34 , 35 , 36 , 37 , 38 , 39 , 40 with follow‐up periods ranging from 1 year 35 to 8 years, 34 while the remaining studies were cross‐sectional. Cognitive outcomes were classified as (1) cognitive function based on standardized cognitive tests (CF), (2) cognitive impairment identified through cognitive testing without clinical evaluation (CIT), (3) clinically diagnosed cognitive impairment (CID), or (4) self‐reported cognitive impairment (CIR). Table 2 classifies the studies by dimensions of social connectedness and summarizes the corresponding measures. Table 3 presents the number of studies finding associations for each social connectedness domain and cognitive outcome. Table S1 provides supporting information, detailing each study's social and cognitive measures, sample characteristics, key associations, and rural relevance. TABLE 1. Summary of study characteristics (39 studies). First author (year) Type a Sample size Outcome Location Geographic region Asia North America Africa Europe Bian (2024) CS 13,027 CIT China X Bincy (2022) CS 1000 CIT India X Byrne (2022) CS 5358 CF U.S. X Chen (2024) L 75,214 CIT China X Fjell (2018) CS 166 CIT Norway X Gao (2024) CS 2229 CF, CIT China X Gela (2022) CS 393 CIT Ethiopia X Gui (2024) CS 791 CF China X Hager (2016) L 72 CF Canada X Han (2022) CS 913 CIR China X Handajani (2023) CS 4236 CIT Indonesia X Harling (2020) CS 5059 CF, CIT South Africa X Hsu (2025) CS 4400 CF Taiwan X Hu (2022) CS 17,589 CID China X Jadenur (2022) CS 125 CIT India X Jennings (2021) CS 3668 CF South Africa X Jennings (2022) CS 3959 CF South Africa X Kitro (2024) CS 984 CIT Thailand X Kyaw (2023) CS 541 CF South Africa X Liu (2025) CS 7189 CF China X Mahadevan (2025) CS 13,098 CF Indonesia X Musyimi (2024) CS 3546 CIT Kenya X Oremus (2019) CS 21,241 CF Canada X Pan (2022) L 7990 CF China, U.S. X X Peng (2023) L 5135 CF China X Pengpid (2024) CS 3418 CIT South Africa X Quick (2022) CS 21,241 CF Canada X Rai (2024) CS 2525 CF India X Ren (2022) L 2781 CID China X Shukla (2025) CS 200 CF India X Verity (2018) CS 375 CID Canada X Verma (2020) CS 297 CIT India X Wang (2023) L 6795 CF China X Wong (2019) CS 333 CID Canada X Xu (2021) CS 483 CF China X Yang (2018) CS 10,923 CIT China X Yates (2017) CS 2813 CIT Wales X Zhong (2016) L 2995 CF China X Zhou (2025) CS 17,962 CF China X Total n % b : 24 (62%) 7(18%) 7 (18%) 2(5%) Open in a new tab Notes : CS = cross‐sectional, L = longitudinal, that is, examined change in outcome over time (change in cognitive function over time or development of cognitive impairment/dementia diagnosis over time); CF = cognitive function determined from cognitive tests, CIT = cognitive impairment determined from cognitive testing (no clinical evaluation), CID = clinical diagnosis of cognitive impairment, CIR = cognitive impairment from self‐report. a Follow‐up time for longitudinal studies: Chen: 8 years, Hager: 1 year, Pan: 2 years, Peng: 6 years; Ren: 4 years, Wang: 7 years, Zhong: 6 years. b Columns are not mutually exclusive; one study can include multiple geographic regions. TABLE 2. Categorization of 39 studies by social connectedness dimensions. First Author (Year) Social engagement Social support Social isolation Loneliness Social connectedness measure(s) Bian (2024) ✔ Social engagement: degree of active social interaction Bincy (2022) ✔ ✔ Social support and social isolation: social network score (Lubben Social Network Scale (LSNS‐18) Byrne (2022) ✔ ✔ ✔ Social isolation: social technology use (with children, family, friends); and latent construct based on measures of loneliness (UCLA loneliness scale), social support (perceived support), and social isolation (contact with social network). Chen (2024) ✔ Social isolation: living alone Fjell (2018) ✔ ✔ Social support: OSLO‐3; Social isolation: Marital status Gao (2024) ✔ Social isolation: empty nest status (living alone or only living with their spouses vs. living with others), marital status Gela (2022) ✔ Social support: Oslo Social Support Scale Gui (2024) ✔ Social support: perceived social support (self‐reported by source, e.g., friend, relative, children, spouse, sibling, and neighbor) Hager (2016) ✔ Social isolation: marital status (married, single, widow/widower, divorced) Han (2022) ✔ ✔ Social engagement: social participation latent variables (work‐centered, entertainment‐centered, family‐centered); Social isolation: Marital status Handajani (2023) ✔ ✔ Social engagement: participation in community meetings, volunteering, and neighborhood and religious activities; Social isolation: Marital status Harling (2020) ✔ ✔ Social support: social network characteristics (number of contacts, kinship status of contacts, residential distance to contacts, network size, support types); Social isolation: marital status (married, never married, separated/divorced, widowed), living status (with others vs. alone), frequency of communication with social network Hsu (2025) ✔ Social engagement (measured degree of social participation and whether it included socializing or helping participation, or mostly working/low social participation). Hu (2022) ✔ Social isolation: marital status, self‐reported social contact Jadenur (2022) ✔ Social isolation: widow/widower status (vs. married) Jennings (2021) ✔ ✔ ✔ Social engagement: grandparents’ caregiving for grandchildren and providing care to person in household; social support: perceived social support; social isolation: marital status (vs. widowed), number of people in household, frequency of social interaction Jennings (2022) ✔ Social isolation: marital status Kitro (2024) ✔ ✔ Social isolation: marital status and living alone; loneliness: self‐reported loneliness Kyaw (2023) ✔ Loneliness: Center for Epidemiologic Studies‐Depression Scale Liu (2025) ✔ Social isolation: social interactions determined from Simplified Lubben Social Network Scale (LSNS‐6)) Mahadevan (2025) ✔ ✔ ✔ Social engagement: number of community activities; social support: family/emotional support; social isolation: marital status Musyimi (2024) ✔ Loneliness: UCLA Loneliness Scale Oremus (2019) ✔ Social support: Social support availability from medical outcomes study‐social support survey Pan (2022) ✔ Social engagement: Grandparent caregiving of grandchildren Peng (2023) ✔ ✔ Social support: intergenerational financial transfers and perceived availability of future support; social isolation: living alone and weekly contact with children Pengpid (2024) ✔ Loneliness: UCLA Loneliness Scale Quick (2022) ✔ Social support: social support availability Rai (2024) ✔ ✔ Social support and social isolation: Cohen's Social Network Index (network diversity, network size, network embeddedness) Ren (2022) ✔ Social support: Social Support Rating Scale Shukla (2025) ✔ Social engagement: participation in social activities of community groups Verity (2018) ✔ Social isolation: marital status Verma (2020) ✔ ✔ Social isolation: Living alone and marital status; loneliness: UCLA Loneliness Scale Wang (2023) ✔ ✔ Social support: perceived future support by relatives/friends; social isolation: marital status, residing with children, living alone, and frequency of meeting and communication with children Wong (2019) ✔ Social isolation: lives alone, marital status Xu (2021) ✔ Social support: Latent construct based on perceived family support (multidimensional scale of perceived social support), sense of community, Brief Sense of Community Scale, and satisfaction of connectedness with others (friends, family) Yang (2018) ✔ ✔ Social support: family support and support when in need; social isolation: social participation, marital status, visits from children Yates (2017) ✔ ✔ Social support and social isolation: Lubben Social Network Scale (LSNS‐6) Zhong (2016) ✔ ✔ Loneliness: self‐reported loneliness; social isolation: marital status, co‐residence with family members Zhou (2025) ✔ ✔ Social engagement: grandparent caregiving for grandchildren and social activities (volunteering, community activities, etc.); social isolation: marital status Total (%) a : 9 (23%) 17 (44%) 26 (67%) 7 (18%) Open in a new tab a Columns are not mutually exclusive (one paper can address more than one dimension of social connectedness). TABLE 3. Summary of findings from 39 studies. Papers examining cognitive function (CF) Papers examining cognitive impairment (CI) Social connectedness category At least one association found Total unique papers At least one association found Total unique papers Social engagement 6 studies: [ 36 , 41 , 42 , 45 , 46 , 47 ] 6 studies: [ 36 , 41 , 42 , 45 , 46 , 47 ] 3 studies: [ 43 , 44 , 48 ] 3 studies: [ 43 , 44 , 48 ] Social support 10 studies: [ 14 , 37 , 39 , 41 , 52 , 53 , 54 , 55 , 59 , 61 ] 11 studies: [ 14 , 37 , 39 , 41 , 45 , 52 , 53 , 54 , 55 , 59 , 61 ] 6 studies: [ 38 , 56 , 57 , 58 , 61 , 62 ] 7 studies: [ 38 , 56 , 57 , 58 , 60 , 61 , 62 ] Social isolation 10 studies: [ 37 , 39 , 40 , 42 , 45 , 52 , 59 , 73 , 75 , 80 ] 13 studies: [ 35 , 37 , 39 , 40 , 41 , 42 , 45 , 52 , 59 , 61 , 73 , 75 , 80 ] 11 studies: [ 34 , 48 , 56 , 58 , 61 , 62 , 73 , 74 , 76 , 78 , 79 ] 15 studies: [ 1 , 34 , 44 , 48 , 56 , 58 , 60 , 61 , 62 , 73 , 74 , 76 , 77 , 78 , 79 ] Loneliness 3 studies: [ 40 , 52 , 94 ] 3 studies: [ 40 , 52 , 94 ] 3 studies: [ 1 , 77 , 93 ] 4 studies: [ 1 , 77 , 93 , 95 ] Total 20 (95% of total on CF) 21 18 (90% of total on CI) 20 Open in a new tab Note : CF = outcomes include cognitive test scores at baseline/cross‐sectionally and/or change in cognitive test scores over time; CI = outcomes include clinical diagnosis of cognitive impairment (e.g., mild cognitive impairment, dementia) or cognitive impairment (yes/no) based on cognitive test cut points. 3.1. Social engagement: behavioral participation 3.1.1. Definition/construct The most behavioral and specific of the dimensions, social engagement refers to active participation in meaningful social activities and roles that connect individuals to others, such as volunteering, caregiving, or attending religious services or community events that provide cognitive stimulation and emotional fulfillment (Figure 1 ). 16 , 21 It encompasses both the frequency and quality of social interactions and represents a key behavioral component within the broader construct of social connectedness. As highlighted in a systematic review, 21 research has typically prioritized frequency of social activity, such as attending community events, paid work, or caregiving, while fewer studies have assessed the quality or diversity of engagement. 41 Mechanistically, social engagement may reduce dementia risk through increased social support, reduced stress, and sustained cognitive activity. 16 , 21 It may offer mental stimulation, a sense of purpose, and emotional connection, thereby supporting both cognitive reserve and psychological well‐being. 36 In addition to direct cognitive benefits, social engagement has been shown to improve mental health, which may serve as a mediator between engagement and cognition. Social engagement is considered an important behavioral component of social connectedness, offering cognitive stimulation and emotional enrichment through interactions with others and participation in society. 3.1.2. Associations with cognition from reviewed rural literature Among the studies included in our rural‐centered literature review, nine examined social engagement. One study included a mixed United States–China sample, 30 while the remaining studies included rural regions of China, 36 , 42 , 43 , 44 South Africa, 45 India, 46 Taiwan, 47 and Indonesia. 41 , 48 Most studies focused on the frequency of participation in activities, such as attending community events, paid work, or caregiving, 43 , 44 , 45 while fewer studies examined the quality or diversity of engagement. 41 Structured and purposeful roles, such as grandchild caregiving or paid work, provided cognitive stimulation, social identity, and a sense of meaning. 36 , 45 Across these studies, social engagement was consistently associated with better cognitive outcomes. Middle‐ to older‐age adults who engaged in meaningful social or community roles, such as caregiving, volunteering, religious involvement, and participation in community groups, demonstrated better cognitive outcomes. 36 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 In addition, stronger social ties were associated with lower rates of depression and better memory performance. 42 3.2. Social support: emotional/instrumental help 3.2.1. Definition/construct Social support refers to the perceived or actual availability of emotional support (e.g., empathy, trust), instrumental support (e.g., help with tasks), and informational support (e.g., guidance or advice) from others (Figure 1 ). 49 It includes both structural aspects, such as the size and composition of one's social network, and functional aspects, such as emotional warmth, practical aid with daily activities, and the sense of belonging. Social support fosters cognitive health through positive relationships, which have been shown to enhance coping capacity, reduce stress reactivity, and promote psychological well‐being, all key pathways known to mitigate worsening cognitive impairment and decrease risk of ADRD onset. 16 , 50 The broader scientific literature suggests that adequate social support is a protective factor for cognitive health, assisting people to manage stress, build resilience, and reduce depressive symptoms, each linked to a lower risk of cognitive decline. Supportive relationships buffer the negative effects of stress and depression on cognition, while also promoting well‐being and resilience that may slow age‐related decline. 17 Social support also promotes emotional regulation and coping skills, encourages health‐promoting behaviors, and improves access to medical care, 51 which together may shape cognitive trajectories. These mechanisms highlight the multifaceted role of social support in sustaining cognitive function, as well as reducing ADRD risk, in later life. 3.2.2. Associations with cognition from reviewed rural literature In our literature review, we identified 17 studies that examined social support in relation to cognitive outcomes. Research across diverse rural settings spanned multiple countries, including one in the United States, 52 two in Canada, 53 , 54 six in China, 14 , 37 , 38 , 39 , 55 , 56 one in Ethiopia, 57 two in India, 58 , 59 one in Indonesia, 41 one in Norway, 60 two in South Africa, 45 , 61 and one in the United Kingdom, 62 consistently linked various measures of social support to cognitive health in middle‐ to older‐age adults. These studies including rural participants showed that strong emotional, instrumental, informational, and perceived support is associated with lower odds of cognitive impairment, slower cognitive decline, and better cognitive functioning. 14 , 37 , 38 , 39 , 41 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 61 , 62 Also, anticipated future support also appeared to be protective against cognitive decline, as shown in studies including rural residents in China. 37 , 56 Perceived support from children, friends, and neighbors in rural China was positively associated with cognition, particularly when support came from multiple sources. 55 In Indonesia, trust through social cohesion (interpreted as a form of collective support) was found to be a significant determinant of episodic memory among rural residents. 41 Other studies 60 , 62 highlighted inconsistencies in the support–cognition relationship, indicating a need for more nuanced measurement approaches that capture both structural and subjective dimensions of social support. While family members remain central in providing care and assistance, support from non‐relatives, such as neighbors and community members, can offer distinct benefits in rural contexts where collective interdependence is often essential. 55 Research by Gela et al., 57 using the Oslo Social Support Scale in a rural cohort, found that individuals with poor social support were 2.5 times more likely to develop cognitive impairment compared to those with strong support. This highlights the protective role of social support in sustaining cognitive function. Consistent findings across other studies of rural participants in this review reinforce that both familial and community‐based support networks may buffer against the adverse effects of stressors in rural settings. Overall, social support emerges as a significant protective factor for cognitive health, although its effects vary depending on type, context, and population, underscoring the importance of tailored strategies for supporting cognitive resilience in rural older adults. 3.3. Social isolation: objective lack of contact 3.3.1. Definition/construct Social isolation is the objective condition of having few social relationships or infrequent contact across life domains (Figure 1 ). 63 , 64 Social isolation reflects reduced social interactions, participation, and network size, often measured by living alone, low communication frequency, and minimal community involvement. 63 , 65 Isolation can arise from individual factors such as health decline, bereavement, retirement, mobility limitations, or sensory impairments, as well as contextual factors such as geographic distance, low population density, and limited transportation or services, barriers especially evident in rural areas. 66 , 67 Over time, these challenges can accumulate, increasing the risk of socially disconnected living environments for middle‐ to older‐age adults. 68 Social isolation is thus a multidimensional construct reflecting both the extent and circumstances of limited social participation, with important implications for health and well‐being in aging rural populations. Findings from the broader literature suggest that lack of social contact limits opportunities for emotional, informational, and practical support, contributing to cognitive decline, depression, and higher mortality risk. 65 , 66 Social isolation is recognized as a significant risk factor for cognitive decline, operating through behavioral, psychosocial, and biological pathways. The National Academies of Sciences, Engineering, and Medicine 8 reported that its health risks are comparable to high blood pressure, smoking, or obesity and are strongly linked to an elevated risk of dementia. Isolation limits opportunities for cognitively stimulating activities and reduces emotional, informational, and instrumental support, thereby eroding cognitive reserve. 69 , 70 Neurobiological mechanisms may involve heightened stress responses, increased inflammation, and reduced neurogenesis. 71 Although limited, several emerging studies from the broader body of longitudinal research reinforce the association between social isolation and cognitive decline. For example, Evans 72 found that older adults with high levels of isolation experienced significantly greater declines in verbal fluency and memory over 4 years, even after adjusting for demographic and health factors. 3.3.2. Associations with cognition from reviewed rural literature In this review, a total of 26 studies included rural samples and examined the associations between social isolation and cognition outcomes. The studies spanned multiple countries, with ten conducted in China, 34 , 37 , 39 , 40 , 42 , 44 , 56 , 73 , 74 , 75 four in India, 58 , 59 , 76 , 77 three in Canada, 35 , 78 , 79 one in the United States, 52 one in Norway, 60 two in Indonesia, 41 , 48 three in South Africa, 45 , 61 , 80 one in Thailand, 1 and one in Wales. 62 Social isolation was typically characterized as reduced social contact, living alone, and being unmarried/widowed, and these factors were associated with poorer cognitive outcomes. 34 , 37 , 39 , 40 , 42 , 45 , 48 , 52 , 56 , 58 , 59 , 61 , 62 , 73 , 74 , 75 , 76 , 78 , 79 , 80 In these studies, sex‐specific effects were apparent; in rural India and China, widowed or unpartnered women exhibited accelerated cognitive decline compared to their socially connected peers. 4 , 45 In both high‐ and low‐income countries, socially isolated rural residents often had poorer cognitive performance and higher rates of cognitive impairment. For example, isolation was linked to poorer cognitive scores in the United States. 52 In India, China, and Canada, those living alone or with small, homogeneous networks, often used as indicators of social isolation, were more often cognitively impaired. 58 , 74 , 78 , 79 Evidence from China highlights multiple mechanisms linking social isolation to cognitive decline. Liu et al. 75 found that social isolation predicted later depression, which in turn led to greater subjective cognitive decline, illustrating how isolation can trigger a cascade of psychological and cognitive risks. Other studies found that socially isolated older adults, particularly those with small, homogeneous networks, had higher rates of cognitive impairment. 56 , 74 Overall, our review of studies including rural participants suggests that social isolation is both a direct risk factor for cognitive decline and a marker of broader social vulnerabilities, such as financial strain and reduced quality of life. 58 Interventions such as social technology use may offer promise but more evidence is needed to identify effective, context‐specific strategies for mitigating isolation's cognitive impacts in rural aging populations. A lack of meaningful social connections has significant consequences for cognitive health. Byrne et al. 52 found that older adults experiencing high levels of isolation demonstrated worse cognitive outcomes, although the negative effects were partially mitigated when the participants used social technologies to maintain connections. These findings highlight the importance of addressing structural barriers to connectivity in rural settings, such as limited transportation options and inadequate digital infrastructure, to reduce isolation and promote cognitive resilience. 52 3.4. Loneliness (Subjective experience of social deficit or deprivation) 3.4.1. Definition/Construct Loneliness is a subjective feeling of distress or dissatisfaction stemming from a perceived gap between desired and actual social relationships (Figure 1 ). Unlike social isolation (an objective construct), loneliness is based on personal, subjective perception that reflects an inner sense of lacking emotional closeness, companionship, or belonging; it may occur even in the presence of frequent social contact. 81 Loneliness can involve feelings of emptiness, exclusion, or insufficient intimacy; it is multidimensional, spanning emotional, social, and existential domains. 8 , 82 Loneliness is increasingly recognized as a significant factor influencing health and cognitive function, especially in older adults. 8 , 81 In the general literature, loneliness has emerged as an important and independent risk factor for cognitive decline. Systematic reviews have demonstrated that higher levels of loneliness are associated with declines in memory, processing speed, and overall cognitive performance, potentially through stress‐related neurobiological pathways. 83 , 84 Existing evidence underscores that the subjective experience of loneliness, feeling socially disconnected, can have significant consequences for brain health, even when objective measures of social contact are similar. 85 Loneliness may relate to cognitive decline via intertwined psychological, behavioral, and biological pathways. For example, longitudinal studies demonstrate that loneliness predicts both lower baseline cognitive function and accelerated decline over time, even after adjusting for depression, social isolation, and other confounding factors. 72 , 86 Loneliness may undermine cognitive reserve by limiting opportunities for mentally stimulating activities and social interaction, thereby reducing resilience to age‐related neural changes. 87 Neurobiological evidence suggests that loneliness can trigger chronic stress responses, including elevated cortisol levels, heightened inflammation, and structural brain changes such as reduced hippocampal and prefrontal volumes, regions essential for memory and executive function. 88 , 89 , 90 Loneliness has also been linked to higher risks of depression and sleep disturbances, both of which are known to negatively affect cognitive performance. Large‐scale, population‐based analyses across diverse settings confirm that loneliness is associated with poorer outcomes in memory, attention, processing speed, and global cognition. 91 Also, in a 10‐year analysis of Framingham data, loneliness was associated with lower executive function, reduced cerebral volume, greater white matter hyperintensity, and increased risk of incident dementia, after adjusting for education and depression. 92 Collectively, these findings identify loneliness as a potent, independent risk factor for cognitive impairment, underscoring the need for interventions that address not only social contact but also perceived emotional connection in older adults. 3.4.2. Associations with cognition from reviewed rural literature In our review of the literature including rural participants, seven studies examined loneliness and cognitive outcomes: one from the United States, 52 one from Kenya, 93 one from India, 77 two from South Africa, 94 , 95 one from China, 40 and one from Thailand. 1 In these studies, loneliness was associated with poorer cognitive outcomes across these diverse regions. 1 , 40 , 52 , 77 , 93 , 94 In rural Kenya, Musyimi et al. 93 reported that 36% of older adults screening positive for dementia also reported loneliness, compared to 30% of those screening negative, with loneliness being associated with greater prevalence of dementia. Byrne and Ghaiumy Amaraky 52 found in US data that a social connectedness measuring including loneliness predicted lower cognitive scores, with lonely individuals being vulnerable despite partial buffering from social technology use. A study in India linked loneliness to higher odds of cognitive impairment, 77 while research from China showed that chronic loneliness, compared to transient experiences, was particularly harmful for long‐term cognitive health. 40 Together, these findings confirm loneliness as a key, modifiable risk factor for cognitive decline in rural aging populations, with chronic loneliness posing a greater risk. Notably, the association between loneliness and cognitive function/impairment was observed across regions, underscoring its global relevance in rural contexts. 3.5. Distribution of social connectedness domains in reviewed rural literature The largest proportion of studies in this rural‐focused review (Table 2 ) examined social isolation (26 studies), which was often assessed through indicators such as marital status (unmarried), living arrangements, and frequency of contact. Social support was the next most frequently studied construct (17 studies), highlighting both perceived and received forms of support (e.g., emotional, instrumental, and financial) as important protective factors for cognitive outcomes with rural populations. Loneliness was examined in only seven studies, sometimes using validated scales such as the UCLA Loneliness Scale. Social engagement was reported in nine studies, focusing on participation in family, community, and leisure activities. Of the 39 studies reviewed, 22 (56%) examined a single dimension. Seventeen studies addressed multiple dimensions simultaneously, showing how social engagement, social isolation, loneliness, and support concurrently shape cognitive health in rural contexts. Collectively, these findings underscore that the various dimensions of social connectedness, including structural, functional, and subjective, are variably represented but consistently significant in explaining cognitive trajectories among rural older adults. The consistent pattern across multiple dimensions of social connectedness being associated with cognitive outcomes may partially reflect the geographic distribution of the studies, as many were conducted in Asian contexts, including China and India, where family‐based caregiving and intergenerational support are central to older adults’ well‐being. In these settings, older adults often rely more heavily on instrumental forms of support, such as financial assistance or help with daily activities. Because these forms of support are more visible and easier to measure than other aspects of connectedness, social support has been examined more frequently than engagement or loneliness. In contrast, loneliness appears less emphasized, possibly because it is less commonly conceptualized as a distinct construct in these cultural contexts and is often assessed indirectly through measures of social support or social engagement. 3.6. Gaps in reviewed literature The key strength of this review is that it provides a synthesis of current evidence across multiple dimensions of social connectedness and clarifies how these interrelated domains influence cognitive health. However, this synthesis also revealed several shared methodological gaps across studies of social engagement, social support, social isolation, and loneliness in rural middle‐ to older‐age populations. First, most studies relied on cross‐sectional designs (32 of 39), limiting causal inference and the ability to disentangle temporal or bidirectional relationships between social connectedness and cognitive outcomes. Although seven longitudinal studies provide stronger evidence of temporal associations, 34 , 35 , 36 , 37 , 38 , 39 , 40 the overall evidence base remains constrained in clarifying whether social connectedness protects cognition, whether cognitive decline reduces social participation, or whether both processes occur simultaneously. Second, substantial heterogeneity exists in conceptual definitions and measurement approaches across domains. Social engagement has been operationalized using diverse activity‐based indicators, 36 , 41 , 43 , 44 , 45 , 46 , 47 , 48 social support has often relied on perceived self‐report measures without distinguishing type or quality, 37 , 53 , 55 social isolation has frequently been indexed by living alone or network size without assessing interaction frequency or voluntariness, 52 , 56 , 61 and loneliness has been measured inconsistently, with limited use of validated scales or culturally adapted instruments. 40 , 77 , 93 , 95 This variability reduces comparability across studies and complicates the synthesis of findings. Moreover, several studies examined only a single dimension of social connectedness without accounting for overlap or interaction among engagement, support, isolation, and loneliness, despite evidence that these constructs are conceptually and empirically related. 43 , 44 , 52 , 58 , 77 Third, rural‐specific contextual factors were insufficiently incorporated into analytic models. Structural barriers such as geographic isolation, transportation limitations, limited community infrastructure, agricultural or caregiving labor demands, and the digital divide were seldom operationalized. 35 , 45 , 52 , 56 , 58 In addition, multiple studies included mixed urban–rural samples but did not formally test whether associations differed by rurality, 40 , 58 , 77 leaving an important contextual interaction unexplored. Cross‐cultural differences in family structure, gender roles, widowhood, and multigenerational living arrangements were also insufficiently examined, despite their potential influence on both social connectedness and cognitive outcomes. Finally, intervention‐focused research remains limited across all four domains. None of the included studies evaluated strategies to enhance engagement, strengthen support, reduce isolation, or alleviate loneliness in rural settings. The predominance of cross‐sectional designs and the limited number of longitudinal studies 34 , 35 , 36 , 37 , 38 , 39 , 40 constrain understanding of cognitive trajectories and limit the identification of modifiable social targets for promoting cognitive resilience in rural populations. Collectively, these shared limitations underscore the need for clearer operational definitions, validated and culturally sensitive measures tailored to rural contexts, formal testing of rural–urban differences, and longitudinal and intervention designs that account for structural and contextual realities of rural aging. 4. DISCUSSION This review highlights the multifaceted ways in which social connectedness, including the dimensions of social engagement, social support, social isolation, and loneliness, influences cognitive health among middle‐ to older‐age adults living in rural areas. These dimensions can be understood as cumulative social and environmental exposures that interact with structural rural conditions (geographic isolation and limited transportation options) to shape brain health across the life course. 96 Studies consistently show that rural older adults with stronger social engagement and support from multiple sources, including family, friends, and neighbors, tend to maintain better cognitive health. Rather than relying on a single relationship, engagement across diverse social networks 55 of family, friends, neighbors, and community groups may provide broader opportunities for cognitive stimulation, emotional regulation, and role fulfillment, which collectively contribute to maintaining cognitive reserve. 97 , 98 Taken together, studies that include multiple dimensions provide stronger evidence that cognitive outcomes in middle‐ to older‐age adults living in rural areas are shaped not by any single facet of connectedness but by their combined effects. When engagement, support, isolation, and loneliness are examined together, it becomes clear that these constructs often co‐occur and reinforce one another. For example, low engagement may heighten isolation, 99 while lack of support can intensify loneliness and accelerate decline. 8 , 99 Conversely, supportive networks can buffer isolation, such as when empty‐nest adults benefit from emotional and financial assistance from non‐resident children. 100 Studies also show that subjective loneliness may diverge from objective conditions such as living alone, underscoring the need to distinguish among structural, functional, and perceptual aspects of connectedness. 101 By capturing these interactions, multidimensional approaches move the field beyond siloed constructs and provide a more comprehensive understanding of how social environments shape cognitive resilience and vulnerability in rural aging. Overall, these findings support conceptualizing social connectedness to encompass engagement, support, isolation, and loneliness. 4.1. Limitations Several limitations of the present review are acknowledged. Articles using alternative search terms may have captured additional pertinent studies. The search was restricted to studies published within the past 15 years, which may have excluded earlier relevant work. Also, the initial screening of titles, abstracts, and full‐text articles was conducted by a single reviewer; however, five additional reviewers examined the selected articles to confirm that they met the inclusion criteria, which helped to minimize the potential for selection bias or missed studies. Our search was limited to three major databases (PubMed, Embase, and Web of Science), so studies indexed elsewhere or in the gray literature may not have been captured. The majority of the studies found were conducted in Asian countries, which restricts generalizability to rural populations in other geographic and cultural contexts. The reviewed studies used heterogeneous measures for social engagement, social support, isolation, and loneliness, making direct comparisons challenging. Differences in scales, definitions, and thresholds may have contributed to inconsistencies in some reported associations. Most studies relied on cross‐sectional designs, limiting the ability to infer causal relationships. More longitudinal studies are needed to clarify temporal patterns and mechanisms linking these constructs. Studies relying on self‐reported data (e.g., social support) may have introduced recall bias and underreporting, particularly in populations with cognitive impairment. However, while self‐report may introduce recall error or reporting variability, subjective perceptions are inherently shaped by cultural norms, personal expectations, and social context, and therefore can represent meaningful dimensions of lived experience. Publication bias may exist, as studies with null or negative findings may be underrepresented. The predominance of cross‐sectional designs limits causal inference and underscores the need for additional longitudinal research to clarify temporal relationships between social connectedness and cognitive outcomes in rural populations. Finally, this was not intended to be a systematic review, and future studies should evaluate the weight of existing evidence based on risk of bias in the published literature. 4.2. Future directions: implications for research and practice Future research should advance measurement and intervention strategies. Improved tools are needed to capture the multidimensional nature of social connectedness, integrating both objective and subjective measures, while longitudinal studies can clarify causal pathways and cognitive trajectories. In addition, nuanced and validated measures of social isolation are needed to account for rural‐specific contexts and to explore sex‐based differences that may shape how isolation influences cognitive health. Developing culturally sensitive, context‐specific interventions is critical. Approaches should account for structural barriers common in rural settings, including geographic isolation, transportation barriers, and limited health‐care infrastructure, while leveraging community partnerships with local organizations, faith‐based groups, and trusted leaders to ensure accessibility, sustainability, and cultural relevance. To address the unique barriers faced by rural older adults, future research should prioritize rural‐sensitive and culturally appropriate interventions, such as community‐based programs, telehealth, and other virtual communication strategies to strengthen social connectedness and promote cognitive health equity. Additional studies are needed to investigate how neighborhood social and built environments relate to social connectedness and cognition/ADRD in rural populations. While rural areas, by definition, have lower population densities and fewer social and walking destinations and community resources compared to urban/suburban areas, neighborhood environments (e.g., places to relax, traffic, crime, and area deprivation) have been found to vary substantially by rural region. 102 Neighborhood factors may serve as upstream predictors of social connectedness levels (e.g., density/proximity to social destinations impacts social engagement), 103 which then influences the risk of cognitive decline/ADRD diagnosis. This potential causal pathway could be examined by determining whether social connectedness mediates associations between neighborhood social and built environments and cognition/ADRD. 104 In addition, or alternatively, associations between social connectedness and cognition/ADRD may vary depending on neighborhood conditions. For instance, it is possible that the detrimental effect of social isolation on cognition is amplified or only observed in rural areas with a constellation of harmful neighborhood characteristics such as fewer social/walking destinations and greater area deprivation (i.e., rural areas with little/no area deprivation and more community resources/amenities may help buffer against potential negative impacts of social isolation). Further work should investigate biological and psychosocial mechanisms, such as stress physiology, neuroinflammation, and cognitive reserve, to guide theory‐driven interventions. Comparative rural studies across diverse geographic and cultural contexts will also help to determine the generalizability of findings and inform scalable, evidence‐based strategies that promote cognitive resilience and healthy aging globally. Application of alternative frameworks may inform future work. For example, the Holt‐Lundstad structure, function, and quality framework 30 could inform the development of interventions to address the gaps identified in this paper regarding social connections. 5. CONCLUSION Social connectedness emerges as a key domain of the social exposome that shapes cognitive trajectories across the life course, particularly in rural communities. Social engagement, support, isolation, and loneliness each contribute uniquely to cognitive health, and rural‐specific factors further influence these relationships. These findings underscore the need for context‐specific research. Innovative models of social intervention, such as integrated community health programs and intergenerational engagement platforms, are increasingly being piloted to address rural barriers to social connectedness. Evidence from mixed‐methods and cohort studies indicates that interventions tailored to rural infrastructure and cultural contexts can effectively promote social engagement and delay cognitive decline. 45 , 101 , 105 Recognizing social connectedness as a modifiable domain of environmental exposure can inform scalable, equity‐focused strategies to reduce cognitive vulnerability in rural populations. CONFLICT OF INTEREST STATEMENT The authors declare no conflicts of interest related to this study. Author disclosures are available in the supporting information . Supporting information Supporting Information ALZ-22-e71401-s002.pdf (433.5KB, pdf) Supporting Information ALZ-22-e71401-s001.docx (2.5MB, docx) ACKNOWLEDGMENTS This work was supported by the National Institute on Aging (5R01AG083925). Park J, Besser LM, Tourelle M, et al. Social connectedness and cognitive outcomes in rural middle‐ to older‐age adults. Alzheimer's Dement. 2026;22:e71401. 10.1002/alz.71401 Juyoung Park and Lilah M. Besser are co‐first authors. DATA AVAILABILITY STATEMENT No new data were created or analyzed in this study. Data sharing is not applicable to this article as it is based on a review of previously published literature. REFERENCES 1. Kitro A, Panumasvivat J, Sirikul W, Wijitraphan T, Promkutkao T, Sapbamrer R. Associations between frailty and mild cognitive impairment in older adults: evidence from rural Chiang Mai Province. PLoS One. 2024;19:e0300264. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. Mollalo A, Kramer M, Cutty M, Hoseini B. 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