Skip to main content Accessibility help

Degree of cognitive impairment and mortality: a 17-year follow-up in a community study

  • J. Santabárbara (a1) (a2), R. Lopez-Anton (a2) (a3), G. Marcos (a1) (a2) (a4) (a5), C. De-la-Cámara (a2) (a6) (a7) (a8), E. Lobo (a1) (a2), P. Saz (a2) (a6), P. Gracia-García (a2) (a7) (a8), T. Ventura (a2) (a4) (a6) (a8), A. Campayo (a2) (a6) (a7) (a8), L. Rodríguez-Mañas (a9), B. Olaya (a2) (a10), J. M. Haro (a2) (a10), L. Salvador-Carulla (a11), N. Sartorius (a12) and A. Lobo (a2) (a4) (a6)...



To test the hypothesis that cognitive impairment in older adults is associated with all-cause mortality risk and the risk increases when the degree of cognitive impairment augments; and then, if this association is confirmed, to report the population-attributable fraction (PAF) of mortality due to cognitive impairment.


A representative random community sample of individuals aged over 55 was interviewed, and 4557 subjects remaining alive at the end of the first year of follow-up were included in the analysis. Instruments used in the assessment included the Mini-Mental Status Examination (MMSE), the History and Aetiology Schedule (HAS) and the Geriatric Mental State (GMS)-AGECAT. For the standardised degree of cognitive impairment Perneczky et al's MMSE criteria were applied. Mortality information was obtained from the official population registry. Multivariate Cox proportional hazard models were used to test the association between MMSE degrees of cognitive impairment and mortality risk. We also estimated the PAF of mortality due to specific MMSE stages.


Cognitive impairment was associated with mortality risk, the risk increasing in parallel with the degree of cognitive impairment (Hazard ratio, HR: 1.18 in the ‘mild’ degree of impairment; HR: 1.29 in the ‘moderate’ degree; and HR: 2.08 in the ‘severe’ degree). The PAF of mortality due to severe cognitive impairment was 3.49%.


A gradient of increased mortality-risk associated with severity of cognitive impairment was observed. The results support the claim that routine assessment of cognitive function in older adults should be considered in clinical practice.


Corresponding author

* Address for correspondence: Dr A. Lobo, Departamento de Psiquiatría, Universidad de Zaragoza, Calle Domingo Miral, s/n, 50009 Zaragoza, Spain. (Email:


Hide All
Alvarez Solar, M, de Alaiz Rojo, AT, Brun Gurpegui, E, Cabañeros Vicente, JJ, Calzón Frechoso, M, Cosío Rodríguez, I, García López, P, García-Cañedo Fernández, R, Pardo González, I, Suárez-González, A (1992). Functional capacity of patients over 65 according to the Katz index. Reliability of the method. Atencion Primaria/Sociedad Española de Medicina de Familia y Comunitaria 10, 812816.
Armitage, P (1955). Tests for linear trends in proportions and frequencies. Biometrics 11, 375386.
Bassuk, SS, Wypij, D, Berkman, LF (2000). Cognitive impairment and mortality in the community-dwelling elderly. American Journal of Epidemiology 151, 676688.
Bruce, ML, Hoff, RA, Jacobs, SC, Leaf, PJ (1995). The effects of cognitive impairment on 9-year mortality in a community sample. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences 50, 289296.
Campayo, A, Alvarez-Silva, I, Saz, P, Barcones, M, Gutiérrez-Galve, L, Lobo, A (2009). A new autopsy interview for the assessment of factors potentially related to death in depressed medical patients. Behavioral Medicine 35, 4556.
Carrière, I, Ryan, J, Norton, J, Scali, J, Stewart, R, Ritchie, K, Ancelin, ML (2013). Anxiety and mortality risk in community-dwelling elderly people. British Journal of Psychiatry 203, 303309.
Copeland, JR, Beekman, AT, Braam, AW, Dewey, ME, Delespaul, P, Fuhrer, R, Hooijer, C, Lawlor, BA, Kivela, SL, Lobo, A, Magnusson, H, Mann, AH, Meller, I, Prince, MJ, Reischies, F, Roelands, M, Skoog, I, Turrina, C, deVries, MW, Wilson, KC (2004). Depression among older people in Europe: the EURODEP studies. World Psychiatry: Official Journal of the World Psychiatric Association (WPA) 3, 4549.
Daly, LE (1998). Confidence limits made easy: Interval estimation using a substitution method. American Journal of Epidemiology 147, 783790.
Dartigues, JF, Amieva, H (2014). Letter to the editor: cognitive frailty: rational and definition from an (I.a.N.a./i.a.g.g.) international consensus group. Journal of Nutrition, Health, and Aging 18, 95.
Denollet, J, Maas, K, Knottnerus, A, Keyzer, JJ, Pop, VJ (2009). Anxiety predicted premature all-cause and cardiovascular death in a 10-year follow-up of middle-aged women. Journal of Clinical Epidemiology 62, 452456.
Dewey, ME, Copeland, JR (2001). Diagnosis of dementia from the History and Aetiology Schedule. International Journal of Geriatric Psychiatry 16, 912917.
Dewey, ME, Saz, P (2001). Dementia, cognitive impairment and mortality in persons aged 65 and over living in the community: a systematic review of the literature. International Journal of Geriatric Psychiatry 16, 751761.
Dewey, ME, Copeland, JRM, Lobo, A, Saz, P, Día, JL (1992). Computerized diagnosis from a standardised history schedule: a preliminary communication about the organic section of the HAS-AGECAT system. International Journal of Geriatric Psychiatry 7, 443446.
Di Carlo, A, Baldereschi, M, Amaducci, L, Maggi, S, Grigoletto, F, Scarlato, G, Inzitari, D (2000). Cognitive impairment without dementia in older people: prevalence, vascular risk factors, impact on disability. The Italian Longitudinal Study on Aging. Journal of the American Geriatrics Society 48, 775782.
Edge, SB, Compton, CC (2010). The American Joint Committee on Cancer: the 7th edition of the AJCC cancer staging manual and the future of TNM. Annals of Surgical Oncology 17, 14711474.
Folstein, MF, Folstein, SE, McHugh, PR (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189198.
Gracia-García, P, de-la-Cámara, C, Santabárbara, J, Lopez-Anton, R, Quintanilla, MA, Ventura, T, Marcos, G, Campayo, A, Saz, P, Lyketsos, C, Lobo, A (2013). Depression and incident Alzheimer disease: the impact of disease severity. American Journal of Geriatric Psychiatry [Epub ahead of print]
Grueter, BE, Schulz, UG (2012). Age-related cerebral white matter disease (leukoaraiosis): a review. Postgraduate Medical Journal 88, 7987.
Helvik, AS, Engedal, K, Selbæk, G (2013). Three-year mortality in previously hospitalized older patients from rural areas–the importance of co-morbidity and self-reported poor health. BMC Geriatrics 13, 17.
Hughes, CP, Berg, L, Danziger, WL, Coben, LA, Martin, RL (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry 140, 566572.
Katz, S, Ford, AB, Moskowitz, RW, Jackson, BA, Jaffe, MW (1963). Studies of illness in the aged. The index of ADL: a standardized measure of biological and psychosocial function. Journal of the American Medical Association 185, 914919.
Kelaiditi, E, Cesari, M, Canevelli, M, van Kan, GA, Ousset, PJ, Gillette-Guyonnet, S, Ritz, P, Duveau, F, Soto, ME, Provencher, V, Nourhashemi, F, Salvà, A, Robert, P, Andrieu, S, Rolland, Y, Touchon, J, Fitten, JL, Vellas, B (2013). Cognitive frailty: rational and definition from an (I.A.N.A./I.A.G.G.) international consensus group. Journal of Nutrition, Health, and Aging 17, 726734.
Kelman, HR, Thomas, C, Kennedy, GJ, Cheng, J (1994). Cognitive impairment and mortality in older community residents. American Journal of Public Health 84, 12551260.
Kunst, AE, Mackenbach, JP (1994). The size of mortality differences associated with educational level in nine industrialized countries. American Journal of Public Health 84, 932937.
Launer, LJ, Brayne, C, Dartigues, JF, Hofman, A (1992). European studies on the incidence of dementing diseases: a report of the EURODEM Research Group. Neuroepidemiology 11, 122.
Lawton, MP, Brody, EM (1969). Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist 9, 179186.
Lobo, A, Folstein, MF, Escolar, V (1988). Higher mortality and diagnostic validity of “delirium” syndromes in oncological patients. In Psicosomática y Cáncer (ed. Lobo, A and Tres, A). Ministerio de Sanidad y Consumo: Madrid.
Lobo, A, Saz, P, Marcos, G, Día, JL, De-la-Cámara, C (1995). The prevalence of dementia and depression in the elderly community in a southern European population. The Zaragoza study. Archives of General Psychiatry 52, 497506.
Lobo, A, Saz, P, Marcos, G, Día, JL, de la Cámara, C, Ventura, T, Morales Asín, F, Fernando Pascual, L, Montañés, JA, Aznar, S (1999). [Revalidation and standardization of the cognition mini-exam (first Spanish version of the Mini-Mental Status Examination) in the general geriatric population]. Medicina Clínica 112, 767774.
Lobo, A, Saz, P, Marcos, G, Día, JL, De la Cámara, C, Ventura, T, Montañés, JA, Lobo-Escolar, A, Aznar, S, ZARADEMP Workgroup (2005). The ZARADEMP-Project on the incidence, prevalence and risk factors of dementia (and depression) in the elderly community: II. Methods and first results. European Journal of Psychiatry 19, 4054.
Margiotta, A, Bianchetti, A, Ranieri, P, Trabucchi, M (2006). Clinical characteristics and risk factors of delirium in demented and not demented elderly medical inpatients. Journal of Nutrition, Health and Aging 10, 535539.
Modrego, PJ, Ferrández, J (2004). Depression in patients with mild cognitive impairment increases the risk of developing dementia of Alzheimer type: a prospective cohort study. Archives of Neurology 61, 12901293.
Moe, JO, Steingrímsdóttir, ÓA, Strand, BH, Grøholt, EK, Næss, Ø (2012). Trends in educational inequalities in old age mortality in Norway 1961–2009: a prospective register based population study. BioMed Central Public Health 12, 911.
Morris, MC (2012) Nutritional determinants of cognitive aging and dementia. Proceedings of the Nutrition Society 71, 113.
Nguyen, HT, Black, SA, Ray, LA, Espino, DV, Markides, KS (2003). Cognitive impairment and mortality in older Mexican Americans. Journal of the American Geriatrics Society 51, 178183.
Northridge, ME (1995). Annotation: public health methods-attributable risk as a link between causality and public health action. American Journal of Public Health 85, 12021204.
Park, MH, Kwon, DY, Jung, JM, Han, C, Jo, I, Jo, SA (2013). Mini-Mental Status Examination as predictors of mortality in the elderly. Acta Psychiatrica Scandinavica 127, 298304.
Patel, CJ, Rehkopf, DH, Leppert, JT, Bortz, WM, Cullen, MR, Chertow, GM, Ioannidis, JP (2013). Systematic evaluation of environmental and behavioral factors associated with all-cause mortality in the United States National Health and Nutrition Examination Survey. International Journal of Epidemiology 42, 17951810.
Perneczky, R, Wagenpfeil, S, Komossa, K, Grimmer, T, Diehl, J, Kurz, A (2006). Mapping scores onto stages: mini-mental state examination and clinical dementia rating. American Journal of Geriatric Psychiatry 14, 139144.
Rait, G, Fletcher, A, Smeeth, L, Brayne, C, Stirling, S, Nunes, M, Breeze, E, Ng, ES, Bulpitt, CJ, Jones, D, Tulloch, AJ (2005). Prevalence of cognitive impairment: results from the MRC trial of assessment and management of older people in the community. Age and Ageing 34, 242248.
Regal-Ramos, RJ, Salinero-Fort, MA, Cruz-Jentoft, AJ (2005). Mortality predictive factors of a clinical cohort of elderly patients. Atencion Primaria/Sociedad Española de Medicina de Familia y Comunitaria 36, 480486.
Rikkert, MG, Tona, KD, Janssen, L, Burns, A, Lobo, A, Robert, P, Sartorius, N, Stoppe, G, Waldemar, G (2011). Validity, reliability, and feasibility of clinical staging scales in dementia: a systematic review. American Journal of Alzheimer's Disease and Other Dementias 26, 357365.
Rockhill, B, Newman, B, Weinberg, C (1998). Use and misuse of population attributable fractions. American Journal of Public Health 88, 1519.
Sartorius, N, Semrau, M, Burns, A, Lobo, A, Rikkert, MO, Robert, P, Stoppe, G (2013). Symposium on the development of an instrument allowing the staging of care for patients with dementia. In World Psychiatric Association Congress.
Saz, P, Dewey, ME (2001). Depression, depressive symptoms and mortality in persons aged 65 and over living in the community: a systematic review of the literature. International Journal of Geriatric Psychiatry 16, 622630.
Saz, P, Launer, LJ, Día, JL, De-La-Cámara, C, Marcos, G, Lobo, A (1999). Mortality and Mental Disorders in a Spanish elderly population. International Journal of Geriatric Psychiatry 14, 10311038.
Schoevers, RA, Geerlings, MI, Deeg, DJ, Holwerda, TJ, Jonker, C, Beekman, AT (2009). Depression and excess mortality: evidence for a dose response relation in community living elderly. International Journal of Geriatric Psychiatry 24, 169176.
Schultz-Larsen, K, Rahmanfard, N, Kreiner, S, Avlund, K, Holst, C (2008). Cognitive impairment as assessed by a short form of MMSE was predictive of mortality. Journal of Clinical Epidemiology 61, 12271233.
Scott, WK, Macera, CA, Cornman, CB, Sharpe, PA (1997). Functional health status as a predictor of mortality in men and women over 65. Journal of Clinical Epidemiology 50, 291296.
Tárraga, LL (1995). Evaluación del deterioro cognitivo y funcional de la demencia. Escalas de mayor interés en la Atención Primaria. In El Médico Ante la Demencia y su Entorno, Módulo 1 (ed. Boada, M and Tárraga, L). Bayer SA: Barcelona.
Therneau, TM, Grambsch, PM (2000). Modeling Survival Data: Extending the Cox Model (ed. Dietz, K, Gail, M, Krickeberg, K, Samet, J and Tsiatis, A). Springer-Verlag: New York.
Thiébaut, AC, Bénichou, J (2004). Choice of time-scale in Cox's model analysis of epidemiologic cohort data: a simulation study. Statistics in Medicine 23, 38033820.
Vieta, E, Reinares, M, Rosa, AR (2011). Staging bipolar disorder. Neurotoxicity Research 19, 279285.
Weinstein, G, Goldbourt, U, Tanne, D (in press). Angina pectoris severity among coronary heart disease patients is associated with subsequent cognitive impairment. Alzheimer Disease and Associated Disorders.
Wiesli, P, Schwegler, B, Schmid, B, Spinas, GA, Schmid, C (2005). Mini-Mental State Examination is superior to plasma glucose concentrations in monitoring patients with suspected hypoglycaemic disorders during the 72-hour fast. European Journal of Endocrinology/European Federation of Endocrine Societies 152, 605610.
Zhang, Y, Shi, Z, Liu, M, Liu, S, Yue, W, Liu, S, Xiang, L, Lu, H, Liu, P, Wisniewski, T, Wang, J, Ji, Y (2014). Prevalence of cognitive impairment no dementia in a rural area of Northern China. Neuroepidemiology 15, 197203.


Degree of cognitive impairment and mortality: a 17-year follow-up in a community study

  • J. Santabárbara (a1) (a2), R. Lopez-Anton (a2) (a3), G. Marcos (a1) (a2) (a4) (a5), C. De-la-Cámara (a2) (a6) (a7) (a8), E. Lobo (a1) (a2), P. Saz (a2) (a6), P. Gracia-García (a2) (a7) (a8), T. Ventura (a2) (a4) (a6) (a8), A. Campayo (a2) (a6) (a7) (a8), L. Rodríguez-Mañas (a9), B. Olaya (a2) (a10), J. M. Haro (a2) (a10), L. Salvador-Carulla (a11), N. Sartorius (a12) and A. Lobo (a2) (a4) (a6)...


Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed