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Cited by 354Dementia and Cognitive Impairment ResearchAlzheimer's disease research and treatmentsCognitive Abilities and Testing

Education and rates of cognitive decline in incident Alzheimer's disease

Open access
Scarmeas, N·2005·Journal of Neurology, Neurosurgery & Psychiatry
DOI 10.1136/jnnp.2005.072306PMC PMC2077720
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Abstract

BACKGROUND: Some (but not all) epidemiological studies have noted faster rates of progression in high education patients with Alzheimer's disease (AD), which has been attributed to harbouring/tolerating a higher pathological burden at the time of clinical dementia for subjects with higher education. We wanted to assess the relationship between education and rates of decline in AD. METHODS: During the course of a community based multiethnic prospective cohort study of individuals aged > or = 65 years living in New York, 312 patients were diagnosed with incident AD and were followed overall for 5.6 (up to 13.3) years. The subjects received an average of 3.7 (up to 9) neuropsychological assessments consisting of 12 individual tests. With the aid of a normative sample, a standardised composite cognitive score as well as individual cognitive domain scores were calculated. Generalised estimating equation models were used to examine the association between education and rates of cognitive decline. RESULTS: Composite cognitive performance declined by 9% of a standard deviation per year. Rates of decline before and after AD incidence were similar. For each additional year of education there was 0.3% standard deviation lower composite cognitive performance for each year of follow up. The association between higher education and faster decline was noted primarily in the executive speed (0.6%) and memory (0.5%) cognitive domains and was present over and above age, gender, ethnicity, differential baseline cognitive performance, depression, and vascular comorbidity. CONCLUSIONS: We conclude that higher education AD patients experience faster cognitive decline.

AI snapshot

Written from the paper’s full text.

TL;DR

In a multiethnic community cohort of 312 incident Alzheimer's disease patients, higher educational attainment was associated with slightly faster cognitive decline after accounting for baseline cognition and other covariates. The effect was most apparent in executive speed and memory, while pre- and post-diagnosis decline rates were similar.

Key findings

  • Composite cognition declined by about 9% of a standard deviation per year (b = −0.09, p < 0.001); pre-incidence and post-incidence slopes were nearly identical (−0.09 vs −0.08 SD/year; interaction p = 0.57).
  • Each additional year of education was linked to an extra 0.003 z-score-unit decline per follow-up year on the composite (p = 0.012), described in the abstract as 0.3% of an SD per year. Domain interactions were significant for executive speed (b = −0.006, p = 0.002), memory (b = −0.005, p = 0.002), and abstract reasoning (b = −0.003, p = 0.047), but not visual-spatial or language.
  • At baseline, future AD patients scored 0.37 SD below matched controls about 3.8 years before diagnosis, and 0.89 SD below at the incidence visit.
  • The education–decline association persisted after adjustment for age, gender, ethnicity, baseline cognition, literacy, vascular risk factors, and depression; no evidence indicated that ethnicity or literacy modified the relationship.

Methods

  • Prospective community-based multiethnic cohort in northern Manhattan; 312 incident AD patients (mean age 81.6 years, mean education 7.1 years, 54% Hispanic, 33% black, 12% white) drawn mostly from WHICAP cohorts, followed on average 5.6 years (maximum 13.3) with 3.7 assessments (maximum 9) and 1159 total cognitive evaluations.
  • Diagnosis used standardized clinical examination, a neuropsychological battery in English or Spanish, consensus conference, DSM-III-R and NINCDS-ADRDA criteria; composite and domain z-scores were derived from 548 cognitively healthy age-, gender-, and education-matched controls.
  • Generalized estimating equation models tested education, time, and an education×time interaction, adjusted for age, gender, ethnicity, and baseline cognitive score; supplementary models examined pre/post incidence, nonlinear time, ethnicity, literacy, vascular comorbidity, and depression.

Limitations

  • Stated: clinical diagnosis without biomarkers may misclassify dementia type; the standard criteria had sensitivity around 81% and specificity around 70%.
  • Stated: reliance on pre-incidence data and limited post-incidence follow-up (1.8 years) may miss later disease stages; only linear and quadratic time terms were tested; education may be a proxy for unmeasured factors; years of schooling may not capture education quality.
  • Evident: post-incidence analyses included only 131 of 312 patients, limiting power; the language domain had a ceiling effect and was skewed; the observational design cannot establish causality.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/jnnp.2005.072306

Cites

65 of 65 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 9 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Higher education was associated with faster decline in the memory domain.

    “The association between higher education and faster decline was noted primarily in the executive speed (0.6%) and memory (0.5%) cognitive domains and was present over and above age, gender, ethnicity, differential”
    • Also stated in: § Education and rates of cognitive decline · plain
      “there was an association between education and z score decline for executive speed, memory, and abstract reasoning domains”
    Quote in the paperSubstantial claim
  • Findingown data

    Ethnicity did not modify the education-decline relationship in the models.

    “Additionally, there was no evidence that the relationship between education and cognitive decline varied by ethnicity: time6education6ethnicity: b = 0.03; p = 0.23.”
    Quote in the paperNot a substantial claim
  • Findingown data

    There was no association between education and the rate of visual-spatial decline.

    “There was no association between education and rates of abstract reasoning (b = 20.002;p = 0.191), visual-spatial (b,20.001;p = 0.987), or language (b = 0.002; p = 0.168) decline.”
    • Also stated in: § Education and rates of cognitive decline · plain
      “there was no association between education and rates of visual-spatial and language decline (table 3; fig 1).”
    Quote in the paperSubstantial claim
  • Findingown data

    There was no association between education and the rate of language decline.

    “There was no association between education and rates of abstract reasoning (b = 20.002;p = 0.191), visual-spatial (b,20.001;p = 0.987), or language (b = 0.002; p = 0.168) decline.”
    • Also stated in: § Education and rates of cognitive decline · plain
      “there was no association between education and rates of visual-spatial and language decline (table 3; fig 1).”
    Quote in the paperSubstantial claim
  • Findingown data

    There was no evidence of differential rates of cognitive decline by literacy level.

    “There was no evidence of differential rates of decline for different literacy levels: b = 0.01; p = 0.43.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 15
  • May combine two claims. 19
  • The quote only partly states this claim. 1

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Men had slightly better baseline composite cognitive performance than women.

    “Men performed slightly better than women: mean baseline composite score was -0.35 for men and -0.50 for women (p = 0.03).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Results were similar when the language domain was analyzed as a recoded four-level categorical variable.

    “The results were similar in supplementary analyses that used language domain as the outcome in the form of a recoded four level categorical variable.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Age and baseline composite cognitive score were not associated.

    “There was no association between age and education (r = 0.09, p = 0.14) or between age and baseline composite score (r = 0.10, p = 0.08).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Education and gender were not associated.

    “There was no association between education and gender (mean years of education 7.2 for males and 7.1 for females; p = 0.86).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Including baseline scores as covariates in the analyses did not change the results, addressing the alternative explanation that higher education patients perform better at diagnosis and have more room for decline.

    “However, we included baseline scores as covariates in the analyses and the results were unchanged.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Hispanic subjects had lower baseline cognitive performance than black subjects but similar performance to white subjects.

    “In post-hoc Scheffe's tests, Hispanic subjects (mean baseline composite z score -0.57) had significantly lower baseline cognitive performance as compared to black subjects (mean baseline composite z score 20.32) but had similar baseline cognitive performance as compared to white subjects (mean baseline composite z score -0.38).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the same pre-incidence model, there were no differential rates of decline by education for abstract reasoning (b = -0.002; p = 0.33), visual-spatial (b = -0.001; p = 0.81), and language (b = -0.001; p = 0.78).

    “There were no differential rates of decline for abstract reasoning (b = 20.002;p = 0.33), visual-spatial (b = 20.001;p = 0.81), and language (b = 20.001;p = 0.78).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Age and education were not associated.

    “There was no association between age and education (r = 0.09, p = 0.14) or between age and baseline composite score (r = 0.10, p = 0.08).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The composite z score and all cognitive domain scores except language were normally distributed.

    “The composite z score, and all cognitive domain scores with the exception of the language domain, were normally distributed.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Education was not significantly linked to LDL, heart disease history, stroke, or current smoking.

    “There was no significant association between education and LDL, history of heart disease, stroke, or current smoking.”
    Quote in the paperNot a substantial claim

  • May combine two claims. The quote only partly states this claim.

    Findingown data

    In a model adjusted for all covariates, among incident AD patients, higher education was associated with faster decline in memory (b = -0.004; p = 0.037) and executive speed (b = -0.008; p = 0.006) for evaluations preceding incidence.

    “There was faster decline for higher education AD patients in the memory (b = 20.004;p = 0.037) and executive speed domains (b = 20.008;p = 0.006).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The association between education and cognitive decline remained after controlling for differential cognitive performance at the initial visit and was not accounted for by literacy, vascular comorbidity, or depression.

    “The association between education and cognitive decline was still noted after controlling for differential cognitive performance at the initial visit and was not accounted for by literacy, vascular comorbidity, or depression.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Results from the Religious Order Study contested the prediction that higher education patients would have heavier brain pathological burden at clinical manifestation; the association between cognitive function and AD pathology was modified by education, with less effect of AD pathology on cognitive function for each additional year of education.

    “Results from the Religious Order Study, including clinical and neuropathological data from 130 older Catholic clergy, contested this.57 The association between cognitive function and AD pathology was modified by education: there was less effect of AD pathology on cognitive function for each additional year of education.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [57] 57. Bennett DA, Wilson RS, Schneider JA, et al. Education modifies the relation of AD pathology to level of cognitive function in older persons. Neurology 2003;60(12):1909-15.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Clinical diagnosis was based on uniform application of widely accepted criteria via a consensus diagnostic conference procedure.

    “Clinical diagnosis was based on uniform application of widely accepted criteria via a consensus diagnostic conference procedure.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Although rates of decline were examined using both linear and non-linear (quadratic) terms, other types of non-linear decline may be present.

    “Third, although we examined rates of decline using both linear and non-linear (quadratic) terms, it is possible that other types of non-linear decline may be present.8 9 60 61”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 8 9 60 61

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    There were no differences between the 548 control subjects and the 312 incident AD patients in gender, age tertiles, or education tertiles.

    “More specifically, there were no differences between the 548 subjects and the 312 incident AD patients regarding gender (x 2 = 0.19; p = 0.67), age tertiles (x 2 = 4.16 = 0.13), or education tertiles (x 2 = 1.53; p = 0.47).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The design of the present study enables testing of the hypothesis during earlier stages of disease, unlike previous reports that studied more impaired AD patients.

    “Previous reports studied more impaired AD patients (either prevalent cases or patients seeking medical attention) capturing the part of disease course corresponding to more advanced stages, while the design of the present study enables testing of the hypothesis during earlier stages of disease.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Assuming that the progression of AD pathology does not differ as a function of education, the delay in clinical onset may result from differences in rate of cognitive decline, differences in the time when cognitive decline begins, or a combination of both.

    “Assuming that the progression of AD pathology does not differ as a function of education, this delay in clinical onset may result from differences in rate of cognitive decline, differences in the time when cognitive decline begins (''inflection point''), or a combination of both.”
    Quote in the paperSubstantial claim
    • The authors state this as an assumption: The progression of AD pathology does not differ as a function of education.

  • Classified as probably not a substantial claim.

    Premisecitation

    The cognitive reserve hypothesis predicts that among AD patients with similar cognitive status, those with more CR would have or be able to tolerate more severe degrees of brain pathology.

    “The CR hypothesis predicts that among AD patients with similar cognitive status, those with more CR would have (or be able to tolerate) more severe degrees of brain pathology.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 1 2 43

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study used a comprehensive battery of cognitive assessment, permitting evaluation of a full range of cognitive domains.

    “We used a comprehensive battery of cognitive assessment, permitting evaluation of a full range of cognitive domains.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The data were examined to ensure that variables in the models met the assumption of normality.

    “The data were examined to ensure that the variables included in the models met the model assumptions (that is, normality).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductreasoning

    The study is one of the largest examining this hypothesis and provided sufficient power for detection and more precise calculation of effects and ability to control for potential confounders.

    “This is one of the largest studies examining this hypothesis and provided sufficient power for detection and more precise calculation of effects of interest as well as the ability to control for potential confounders.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Probable or possible AD diagnosis used NINCDS-ADRDA criteria.

    “For the diagnosis of probable or possible AD, the criteria of the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association 34 were used.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [34] 34. McKhann G, Drachman D, Folstein M, et al. Clinical diagnosis of Alzheimer's disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer's Disease. Neurology 1984;34(7):939-44.

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning

    Evaluations were performed approximately every 1.5 years for an average of 5.6 years (up to 13.3), providing multiple assessments and permitting more accurate slope calculations.

    “Evaluations were performed approximately every 1.5 years for an average of 5.6 (and up to 13.3) years, which provides multiple assessments of cognitive performance and therefore permits more accurate slope calculations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Dementia diagnosis used DSM-III-R criteria.

    “the criteria used for the diagnosis of dementia as required by the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R).33”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] 33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington, DC: American Psychiatric Association, 1987.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based).

    Study design and conductnone given

    Years of schooling cannot completely capture all aspects of educational experience.

    “Fifth, years of schooling cannot completely capture all aspects of educational experience (that is, different quality of education in different educational systems, etc).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Because AD pathology progresses independently of educational attainment or CR, when pathological burden becomes more severe and widespread, sufficient neural substrate is no longer available and a faster decline may ensue.

    “However, because AD pathology progresses independently of educational attainment (or CR), when pathological burden becomes more severe and widespread, sufficient neural substrate is no londer available and a faster decline may ensue.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Many prospective studies have suggested that higher education is associated with reduced risk of incident AD.

    “Many prospective studies have suggested that higher education is associated with reduced risk of incident AD. 11 20 45-51”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 11 20 45-51

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The used standard diagnostic criteria have a sensitivity of approximately 81% and a specificity of approximately 70%.

    “The used standard diagnostic criteria have a sensitivity of ,81% with a specificity of ,70%.59”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [59] 59. Knopman DS, DeKosky ST, Cummings JL, et al. Practice parameter: diagnosis of dementia (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001;56(9):1143-53.

      Not checked in the free run.

29 of 29

  • The paper relies on this without support.

    Pathological changes of Alzheimer's disease are present in the brain many years before clinical symptoms of dementia appear.

    “the pathological changes of AD are present in the brain many years before the onset of clinical symptoms of dementia”

  • The paper relies on this without support.

    Previous studies of education and AD progression usually used clinic-referred patients, which limits generalizability to the general population.

    “subjects studied in previous reports were usually clinic referred AD patients, which could limit generalisability to the population.”

  • The paper relies on this without support.

    Previous studies of education and AD progression used prevalent AD patients recruited at various disease stages, so they could not accurately control for disease duration.

    “previous studies were of prevalent AD patients who were recruited at various stages of their disease.Time of disease onset could only be estimated retrospectively or inferred by cognitive performance status.Therefore, previous studies could not accurately control for duration of disease.”

  • The paper relies on this without support.

    Most previous investigations used limited neuropsychological measures that do not assess many cognitive domains and can suffer from floor and ceiling effects.

    “most previous investigations have used limited neuropsychological measures that do not assess many cognitive domains and can suffer from floor and ceiling effects resulting in inadequately assessed cognitive performance.”

  • The paper relies on this without support.

    Most previous reports did not adequately control for education-related differences in baseline cognitive performance.

    “most previous reports did not adequately control for the potential effect on rates of cognitive decline of education related differences in baseline cognitive performance.”

  • The authors state this as an assumption.

    The progression of AD pathology does not differ as a function of education.

    “Assuming that the progression of AD pathology does not differ as a function of education”
6 of 6

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The observation of more rapid decline in higher attainment Alzheimer's disease patients was replicated in incident Alzheimer's disease, and patients who engaged in more leisure activities prior to dementia onset also showed more rapid cognitive decline.

    “We replicated this observation in patients with incident AD28 and also found more rapid decline in cognitive function in AD patients who engaged in more leisure activities prior to dementia onset29.”

    From Cognitive reserve in ageing and Alzheimer's disease (2012) · cites this paper as [28]

    Split into 2 atoms — 1 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 1 unverifiable. Expand the claim to see per-atom verdicts.

    Experimental — accuracy not yet measured

  • The rate of decline is more rapid in individuals with high reserve than those with low reserve, even when accounting for other factors that may contribute to disease course.

    “The rate of decline is more rapid in individuals with high reserve than those with low reserve, even when accounting for a multitude of other factors that may contribute to disease course27, 28, 46.”

    From Cognitive reserve in ageing and Alzheimer's disease (2012) · cites this paper as [28]

    Experimental — accuracy not yet measured

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Post-incidence follow-up duration has conflicting values

    Minor

    The discussion calls post-incidence follow-up 1.8 years, while Table 1 reports a mean of 3.9 years from incidence to the last evaluation among patients with post-incidence follow-up. The table separately lists 1.8 as the mean number of post-incidence evaluations.

  • Visit counts do not match the reported total

    Minor

    The numbers of patients with two through nine evaluations imply 1,154 assessments, not the reported 1,159.

2 of 2

Cites

Flagged first, then by citations

3 of the 68 references couldn’t be matched to a known paper.

Research works printed but not linked: 4

  1. [3]3. Mortimer JA, Ebbitt BJ, Jun SP. Neuropsychological and behavioral predictors of decline in Alzheimer's disease. J Clin Exp Neuropsychol 1991;13:109.
  2. [32]32. Schwab J, England A. Projection technique for evaluating surgery in Parkinson's disease. In: Gillinghan FS, Donaldson MN, eds. Third Symposium on Parkinson's Disease. Edinburgh, Scotland: E & S Livingstone, 1969:152-7.
  3. [33]33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington, DC: American Psychiatric Association, 1987.
  4. [61]61. Liu X, Tsai WY, Stern Y. A functional decline model for prevalent cohort data. Stat Med 1996;15(10):1023-32.

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Related

Authors
Scarmeas, N.
Affiliations
Columbia University Irving Medical Center (US)
Corresponding author
Scarmeas, N
ORCID
Scarmeas, N
Venue
Journal of Neurology, Neurosurgery & Psychiatry
Publisher
BMJ
Published
2005-07-26
Volume
77
Issue
3
Pages
308-316
ISSN
0022-3050 (ISSN-L)
DOI
10.1136/jnnp.2005.072306
PMC
PMC2077720
OpenAlex
W2071700556
Cited by
353
References
68
Citations by year
2026: 11 · 2025: 16 · 2024: 9 · 2023: 15 · 2022: 18 · 2021: 26 · 2020: 16 · 2019: 23 · 2018: 21 · 2017: 12 · 2016: 11 · 2015: 15 · 2014: 20 · 2013: 22 · 2012: 19
FWCI
8.42
Type
journal article
Language
en
Open access
Locations
  • Journal of Neurology Neurosurgery & Psychiatry (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • Columbia Academic Commons (Columbia University)
Funders
  • National Institute on Aging (P01AG007232, AG 07232)
  • National Center for Research Resources (RR 00645, M01RR000645)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
  • Health Sciences › Medicine › Physiology › Alzheimer's disease research and treatments
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Cognitive Abilities and Testing
Keywords
Alzheimer's disease, educational attainment, cognitive decline, disease progression, executive function, memory, older adults
MeSH terms
Aged, Aged, 80 and over, Alzheimer Disease, Cognition Disorders, Educational Status, Female, Follow-Up Studies, Humans, Male, Neuropsychological Tests, Prospective Studies, Psychometrics, Sick Role, Statistics as Topic, Cohort Studies, Disease Progression

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