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Education and rates of cognitive decline in incident Alzheimer's disease
Open accessAbstract
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.
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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.
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Abstract
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Education and rates of cognitive decline · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Additionally, there was no evidence that the relationship between education and cognitive decline varied by ethnicity: time6education6ethnicity: b = 0.03; p = 0.23.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Education and rates of cognitive decline · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Education and rates of cognitive decline · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There was no evidence of differential rates of decline for different literacy levels: b = 0.01; p = 0.43.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“None of the vascular variables was significant in this model.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There was no evidence of different rates of decline among ethnicities: time6ethnicity: b = 20.009;p = 0.65.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“For each additional year of education there was 0.3% standard deviation lower composite cognitive performance for each year of follow up.”
- Also stated in: § Education and rates of cognitive decline · plain
“In models adjusted for baseline cognitive performance, each additional year of education was associated with an additional decline of 0.003 z score units of the composite cognitive score per year of follow up (table 3; fig 1).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Abstract
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passes- Also stated in: § Education and rates of cognitive decline · plain
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Additionally, there was no evidence that the relationship between education and cognitive decline varied by literacy: b = 20.001;p = 0.60.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesA result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Composite cognitive performance declined by 9% of a standard deviation per year.”
- Also stated in: § Decline of cognition over time · hedged
“For the composite score, b was 20.09 (p,0.001),indicating a 9% decline in the score per year of follow up.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Abstract
Strength:plain· not yet calibratedn = 312Tests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passes- Also stated in: § Decline of cognition over time · hedged
- Probably not a substantial claim. 15
- It may state two separate claims as one. 19
- The quote only partly states this claim. 1
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“Men performed slightly better than women: mean baseline composite score was -0.35 for men and -0.50 for women (p = 0.03).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education, baseline cognitive performance, and demographic characteristics
Strength:plain· not yet calibratedCausal:correlational· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The results were similar in supplementary analyses that used language domain as the outcome in the form of a recoded four level categorical variable.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Distribution of cognitive scores
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education, baseline cognitive performance, and demographic characteristics
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There was no association between education and gender (mean years of education 7.2 for males and 7.1 for females; p = 0.86).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education, baseline cognitive performance, and demographic characteristics
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“However, we included baseline scores as covariates in the analyses and the results were unchanged.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
Load-bearingStrength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education, baseline cognitive performance, and demographic characteristics
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Pre-incidence visits only
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education, baseline cognitive performance, and demographic characteristics
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it. It may state two separate claims as one.
A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“The composite z score, and all cognitive domain scores with the exception of the language domain, were normally distributed.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Distribution of cognitive scores
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“There was no significant association between education and LDL, history of heart disease, stroke, or current smoking.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Education and rates of cognitive decline
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A result the paper reports from its own data — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Pre-incidence visits only
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one. The quote only partly states this claim.
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In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
What the sources say
- Not checked yetcites [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.
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In the paper
“Clinical diagnosis was based on uniform application of widely accepted criteria via a consensus diagnostic conference procedure.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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In the paper
“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”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
What the sources say
- Not checked yetcites 8 9 60 61
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In the paper
“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).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Outcomes
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In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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- The authors state this as an assumption: The progression of AD pathology does not differ as a function of education.
In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
What the sources say
- Not checked yetcites 1 2 43
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“We used a comprehensive battery of cognitive assessment, permitting evaluation of a full range of cognitive domains.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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In the paper
“The data were examined to ensure that the variables included in the models met the model assumptions (that is, normality).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Statistical analyses
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In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Sample and procedure
What the sources say
- Not checked yetcites [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.
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What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
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In the paper
“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”
§ Education and rates of cognitive decline in incident Alzheimer's disease > Sample and procedure
What the sources say
- Not checked yetcites [33] 33. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Washington, DC: American Psychiatric Association, 1987.
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes✗ Load-bearing: fails✓ Based: passesProbably not a substantial claim. The paper’s conclusions may not depend on it.
What the paper did — it cites no source for this, so there is none to check. The quote shows it is in the paper.
In the paper
“Fifth, years of schooling cannot completely capture all aspects of educational experience (that is, different quality of education in different educational systems, etc).”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
Strength:plain· not yet calibratedTests✓ Asserted: passes✗ Checkable: fails✗ Load-bearing: fails✗ Based: failsProbably not a substantial claim. It may be too vague to check against evidence. The paper’s conclusions may not depend on it. The paper may give no reason why it holds.
A conclusion the paper draws from its own results — it cites no other source for it, so there is none to check. The quote shows it is in the paper.
In the paper
“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.”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesIt may state two separate claims as one.
In the paper
“Many prospective studies have suggested that higher education is associated with reduced risk of incident AD. 11 20 45-51”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
What the sources say
- Not checked yetcites 11 20 45-51
Tests✓ Asserted: passes✓ Checkable: passes✓ Load-bearing: passes✓ Based: passesProbably not a substantial claim.
In the paper
“The used standard diagnostic criteria have a sensitivity of ,81% with a specificity of ,70%.59”
§ Education and rates of cognitive decline in incident Alzheimer's disease > DISCUSSION
What the sources say
- Not checked yetcites [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.
Strength:plain· not yet calibratedTests✓ Asserted: passes✓ Checkable: passes? Load-bearing: unclear✓ Based: passesIt may state two separate claims as one.
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”
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 source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
In the citing paper
“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]
Experimental — accuracy not yet measuredThe cited source says what the claim attributes to it.
In the citing paper
“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
MinorThe 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.
“the postincidence follow up was relatively limited (1.8 years)”
“| After incidence (n = 131) | | | | Years from incidence to | 3.9 (2.39) | 0.9-11.1 | | last evaluation | | |”
Visit counts do not match the reported total
MinorThe numbers of patients with two through nine evaluations imply 1,154 assessments, not the reported 1,159.
“Overall, the 312 included AD subjects had 1159 separate cognitive assessments.”
“More specifically, 110 (35%) had two evaluations, 47 (15%) had three, 60 (19%) had four, 40 (13%) had five, 37 (12%) had six, 14 (5%) had seven, three (1%) had eight, and one (0.3%) had nine.”
Citations
Cites
Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975) · Journal of Psychiatric Research · doi:10.1016/0022-3956(75)90026-6 · Cited by 88,282
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Hirono, N., Mori, E., Ikejiri, Y., Imamura, T., Shimomura, T., Hashimoto, M., Yamashita, H., & Ikeda, M. (1997) · PubMed · Cited by 21,012
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3 of the 68 references couldn’t be matched to a known paper.
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Items 301–354 of 354
Leighty, R. E. (2009) · Digital Commons - University of South Florida (University of South Florida) · Cited by 1
López-Fernández, V. (2011) · Buleria (Universidad de León) · doi:10.18002/10612/1744 · Cited by 1
Bosch, B. (2010) · LA Referencia (Red Federada de Repositorios Institucionales de Publicaciones Científicas) · Cited by 1
Sex Differences in the Associations between Education, Neuropathology, and CognitionPreprint
Raeesi, S., Zeighami, Y., Morrison, C., & Dadar, M. (2026) · medRxiv · doi:10.64898/2026.09.03.26362216 · Cited by 1
The course of mild cognitive impairment and the role of comorbidity
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Relationship of emotion and cognition to wandering behaviors of people with dementia
Lee, K. H. (2011) · Deep Blue (University of Michigan)
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“Results like those presented here are in line with some epidemiological and clinical data [64,65] which support the theory of education as being protective to the development of AD.”
ResultLaske, C. (2007) · Zeitschrift für Gerontopsychologie & -psychiatrie · doi:10.1024/1011-6877.20.1.59
ALZHEIMERʼS COGNITIVE DECLINE IS FASTER IN PEOPLE WITH HIGH EDUCATION
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Galkina, E. I., & Grinstein, G. (2014) · International Conference on Information Visualisation (IV) · doi:10.1109/iv.2014.67
“One explanation being that individuals with a higher education retain apparent cognitive performance longer than those with less education - a phenomenon referred to as “cognitive reserve” – yet ultimately declined precipitously, displaying the same degree of impairment as the more gradual decliners [5].”
BackgroundCapacités de réserve, vieillissement cérébral et maladie d'Alzheimer
Foubert-Samier, P. A. (2013) · theses.fr (ABES)
Laks, J., Coutinho, E. S. F., Junger, W. L., Silveira, H., Mouta, R., Baptista, E. M. R., Contino, A. L. B., Barca, M. L., Selbæk, G., Engedal, K., et al. (2010) · DOAJ (DOAJ: Directory of Open Access Journals)
Devanand, D., Lee, J. J., Luchsinger, J. A., Manly, J. J., Marder, K. S., Mayeux, R. P., Scarmeas, N., Schupf, N., Stern, Y., & Mailman, J. P. (2012)
Self-citationAlzheimer's Home and Community-Based Waiver Program: An Evaluation
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IMMUNOTHERAPY IN COMBINATION WITH BEHAVIORAL ENRICHMENT IN A CANINE MODEL OF AGING
Davis, P. R. (2014) · UKnowledge (University of Kentucky)
Tarpin-Bernard, F., Croisile, B., Bélier, S., Allain, G., & Noir, M. (2007) · HAL
Semantic Representations in Monolingual and Bilingual Connectionist Networks
Rendell, N., & Davelaar, E. J. (2015) · Journal of Cognitive Science · doi:10.17791/jcs.2015.16.3.322
Abner, E. L. (2013) · UKnowledge (University of Kentucky)
Hackett, L. P. (2015) · ODU Digital Commons (Old Dominion University) · doi:10.25777/sxze-8j56
Bilingualism delays clinical manifestation of Alzheimer's
Woumans, E., Santens, P., Sieben, A., Versijpt, J. J., Stevens, M., & Duyck, W. (2015)
Longitudinal Effects of Cognitive Reserve and Vascular Risks in Aging and Dementia
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DOCTORAT DE L'UNIVERSITE BORDEAUX 2
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Fernandes, S. M. S. R., & Rodríguez, J. L. S. (2010) · Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT)
Memory decline and Aβ amyloid as markers of neurodegeneration in preclinical Alzheimer's disease
Lim, Y. Y. (2013) · Minerva Access (University of Melbourne)
Estudio de la memoria de trabajo en sujetos adultos portugueses
Morais, R. M. E. S. (2015) · Gredos (University of Salamanca) · doi:10.14201/gredos.129777
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“It has been shown that those with higher education have a later onset of clinical AD but quicker rates of cognitive decline after AD onset [41,42].”
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A linguagem ao longo da vida : que implicações de que gramática em que momento?
Pinto, M. D. G. L. C. (2010) · Portuguese National Funding Agency for Science, Research and Technology (RCAAP Project by FCT)
Joo, Y. Y., Cha, J., Jeremy Freese, A., & Hayes, M. (2021) · Research Square · doi:10.21203/rs.3.rs-139515/v2
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Joo, Y. Y., Cha, J., Jeremy Freese, A., & Hayes, M. G. (2021) · Research Square · doi:10.21203/rs.3.rs-707867/v1
Disease-specific neurorehabilitation systems
Selzer, M. E., Clarke, S., Cohen, L. G., Kwakkel, G., & Miller, R. H. (2014) · Cambridge University Press eBooks · doi:10.1017/cbo9780511995590.044
The Effect of Diabetes and Hypertension on Cognition: Mechanisms that Impair & Protect
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Kim, T., Bae, J., Hong, S., Jeon, H. J., & Moon, Y. (2024) · Korean Journal of Physiology and Pharmacology · doi:10.4196/kjpp.24.239
“Sex (p = 0.024) and education period (p = 0.003) showed significant associations with MMSE scores, consistent with existing knowledge [16,17].”
InfluentialMichallat-Bragg, G., Bennett, M., Flewitt, B. I., Kazmi, S., Smith, S. J., Wells, C. E., Hollins, A., Ash, C., Thwaites, S., Neil, W., et al. (2025) · Frontiers in Aging Neuroscience · doi:10.3389/fnagi.2025.1547834
Bertogg, A., & Stokes, J. E. (2025) · Research on Aging · doi:10.1177/01640275251383810
“…have steeper slopes of decline in later life, in part because they have greater cognitive reserve (Aartsen et al., 2019), or higher tolerance of pathologies until reaching the threshold to dementia (Scarmeas, 2005), before becoming unable to complete survey data collection and cognitive testing.”
Dauphinot, V., Laurent, M., Prodel, M., Civet, A., Vainchtock, A., Moutet, C., Krolak‐Salmon, P., & Garnier‐Crussard, A. (2024) · Figshare · doi:10.6084/m9.figshare.26384591
Cieri, F., Zhuang, X., Cordes, D., Kaplan, N., Cummings, J. L., & Caldwell, J. (2022) · Figshare · doi:10.6084/m9.figshare.19219497
Messaoudi, S. A., Alsaleh, A. B., AlSalem, L. A., Rameshbabu, S., Kumar, S., Assidi, M., Ouanes, K., Chayeb, V. A., Zitouni, H., & Almawi, W. Y. (2026) · Journal of Alzheimer s Disease · doi:10.1177/13872877261427358
“33,34 CDK5 has been extensively studied in experimental models of neurodegeneration.”
Morse, R. M., Vaqué‐Alcázar, L., Cabello‐Toscano, M. R., Solé‐Padullés, C., Mulet‐Pons, L., Trias, J. P. M., Andersson, M., Dídac Vidal-piñeiro, A., Pascual‐Leone, Á., Walhovd, K. B., et al. (2026) · GeroScience · doi:10.1007/s11357-026-02157-3
Ubuka, T., Yuyama, K., Genjima, A., Nagakura, M., Kato, K., Hayashi, S., Makino, N., Yamane, T., Hirose, T., & Yamane, Y. (2026) · Frontiers in Aging Neuroscience · doi:10.3389/fnagi.2026.1769431
La place des biomarqueurs dans les essais de prévention de la maladie d'Alzheimer
Delrieu, J. (2021) · theses.fr (ABES) · doi:10.70675/2b5f4719z01f9z4376z9dabzd5a185dc4d79
Decline in dementia patients during the COVID-19 pandemic: A cohort study in Taiwan
Tsai, M.-J., Lin, Y., Lin, Y., Chen, C.-Y., & Fuh, J. (2026) · Journal of the Chinese Medical Association · doi:10.1097/jcma.0000000000001421
“Some studies suggest that higher education accelerates decline due to greater cognitive reserve masking earlier disease, 34–36 whereas others argue that education influences baseline performance rather than the rate of deterioration.”
Sex and Life Stage Differences in the Association Between Cognitive Engagement and Cognitive ChangePreprint
Goulding, S., Raeesi, S., Anderson, J. A. E., Oliver, M. D., Barnes, L. L., Estrella, M. L., Dadar, M., & Morrison, C. (2026) · medRxiv · doi:10.64898/2026.09.11.26362841
Cognitive reserve, emotion perception and theory of mind in non‐demented Parkinson's disease
MacPherson, S. E., Terruzzi, S., Pennacchio, M., & Papagno, C. (2026) · Journal of Neuropsychology · doi:10.1111/jnp.70082
Lifestyle factors and Alzheimer-type dementia : the link between exercise and cognitive change
Farina, N. (2014) · UPT. Syiah Kuala University Library (Syiah Kuala University)
Metadata
- 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)
- 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
- bronze
- doi.org
- 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
- Life Sciences › Neuroscience › Cellular and Molecular Neuroscience › 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
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
A language model drew the claims from the paper on 2026-09-29, under version 3 of the claim definition (model deepseek-v4.1-flash, prompt extract-v3).
A second model labelled each claim on 2026-09-29 (model jev-1.13-20260917, definition revision gold-guideline-v0.2).
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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