24-hour sleep-wake regularity and cognitive aging among 74,733 middle-aged and older adults from the US and Europe: The LifeSPAN Consortium

Abstract Importance: Irregular sleep-wake patterns have been associated with poor health and cognitive outcomes, yet evidence linking 24-hour sleep-wake regularity to cognitive decline or dementia remains inconsistent. Particularly, regularity can be measured as regularity of rest-wake, sleep-wake or overall 24-hour activity, but it is unclear which aspects are most relevant for cognitive aging. Objective: To assess associations of rest-wake, sleep-wake, and 24-hour activity regularity with cognitive decline and dementia risk. Design: Observational prospective study comprised of six US and European cohorts: MrOS (sleep study between 2003-2005, mean follow-up: 7.1 years), Rotterdam Study (2004-2007, 11.6 years), MESA (2010-2013, 8.2 years), MAP (2005-2018, 7.2 years), Whitehall II (2012-2013, 6.9 years), and UKB (2013-2015, 7.9 years). Setting: Cohort-specific estimates were pooled using random-effects meta-analysis. Analyses were done between June 2025 and March 2026. Participants 74,733 dementia-free adults with multi-day actigraphy were included across cohorts: MrOS (age: 67-96 years, female:0%), MESA (54-95y, female:54.6%), Rotterdam Study (46-98y, female:55.0%), MAP (56-100y, female:77.1%), Whitehall II (59-83y, female:25.9%), and UKB (55-78y, female:55.5%). Exposure: Day-to-day rest-wake regularity (Rest Regularity Index, RRI), day-to-day sleep-wake regularity (Sleep Regularity Index, SRI), and 24-hour activity regularity (Interdaily Stability, IS) were derived from multi-day actigraphy. Main Outcome: Outcomes were risk of dementia and changes in global cognition. Results: Across six cohorts, 1,906 dementia cases occurred among 74,733 participants. After adjusting for demographics, health behaviors, depressive symptoms and cardiovascular comorbidities, each 1-SD higher regularity score was associated with an 9-14% lower dementia risk (pooled hazard ratios: RRI 0.86 95%CI: [0.79-0.95]; SRI 0.87[0.79-0.97]; IS: 0.91[0.88-0.95]). Associations were approximately linear. Age-stratified analyses showed directionally stronger associations among adults aged < 65, although meta-regression did not support an interaction(p > 0.55). Greater regularity was associated with modestly slower decline in global cognition (pooled {beta} per 1-SD higher score of RRI per year: 0.003, 95%CI [0.001-0.006]). Conclusions & Relevance: Greater regularity of rest-wake, sleep-wake, and 24-hour activity rhythms was associated with lower dementia risk and modestly slower global cognitive decline. These findings suggest that 24-hour sleep-wake regularity is a relevant behavioral marker of cognitive aging and may inform future efforts to identify or intervene on early risk.