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Systematic review of the effect of education on survival in Alzheimer's disease

  • Matt Paradise (a1), Claudia Cooper (a1) and Gill Livingston (a1)

Background: According to the cognitive reserve model, higher levels of education compensate for the neuropathology of Alzheimer's disease (AD), delaying its clinical manifestations. This model suggests that for any level of cognitive impairment, people with more education have worse neuropathology than those with less education and will therefore have shorter survival post-diagnosis. This is the first systematic review of the relationship between more education and decreased survival in people with AD.

Methods: We reviewed the literature systematically, searching electronic databases and reference lists of included studies. We used Centre for Evidence Based Medicine criteria for inclusion and rating of the validity of cohort studies that reported the relationship of education to survival in people with AD.

Results: 22 studies met inclusion criteria. We found Grade A evidence (highest evidence level) that more education was not associated with decreased survival post-diagnosis in AD. Only one of 11 studies rated 1b (highest level of quality) supported our hypothesis that more education predicted reduced survival after adjusting for age, gender and dementia severity; it comprised African-Caribbean participants, who had on average more severe cognitive impairment than other studies' participants.

Conclusions: Education delays the onset of the dementia syndrome in AD, but does not lead to earlier death after diagnosis.

Corresponding author
Correspondence should be addressed to: Matt Paradise, Department of Mental Health Sciences, University College London, Holborn Union Building, Archway Campus, Highgate Hill, London, N19 5LW, U.K. Phone: +44 (0) 207 2885931 Email:
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Agüero-Torres H., Fratiglioni L., Guo Z., Viitanen M. and Winblad B. (1998). Prognostic factors in very old demented adults: a seven-year follow-up from a population-based survey in Stockholm. Journal of the American Geriatrics Society, 46, 444452.
Bennett D. A. et al. (2003). Education modifies the relation of AD pathology to level of cognitive function in older persons. Neurology, 60, 19091915.
Bowen J. D. et al. (1996). Predictors of mortality in patients diagnosed with probable Alzheimer's disease. Neurology, 47, 433439.
Brehaut J. C., Raina P. and Lindsay J. (2004). Does cognitive status modify the relationship between education and mortality? Evidence from the Canadian Study of Health and Aging. International Psychogeriatrics, 16, 7591.
Bruandet A. et al. (2008). Cognitive decline and survival in Alzheimer's disease according to education level. Dementia and Geriatric Cognitive Disorders, 25, 7480.
Burns A., Lewis G., Jacoby R. and Levy R. (1991). Factors affecting survival in Alzheimer's disease. Psychological Medicine, 21, 363370.
Claus J. J. et al. (1998). Predicting survival in patients with early Alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 9, 284293.
Del Ser T., Hachinski V., Merskey H. and Munoz D. G. (1999). An autopsy-verified study of the effect of education on degenerative dementia. Brain, 2309–2319.
Dijkstra A., Sipsma D. H. and Dassen T. W. N. (1998). Care dependency and survival among female patients with Alzheimer's disease: a two-year follow-up. Croatian Medical Journal, 39, 365370.
Fratiglioni L. et al. (1991). Prevalence of Alzheimer's disease and other dementias in an elderly urban population: relationship with age, sex, and education. Neurology, 41, 18861892.
Freels S., Nyenhuis D. L. and Gorelick P. B. (2002). Predictors of survival in African American patients with AD, VaD, or stroke without dementia. Neurology, 59, 11461153.
Fritsch T. et al. (2001). Effects of educational attainment on the clinical expression of Alzheimer's disease: results from a research registry. American Journal of Alzheimer's Disease and Other Dementias, 16, 369376.
Froehlich T. E., Bogardus S. T. Jr. and Inouye S. K. (2001). Dementia and race: are there differences between African Americans and Caucasians? Journal of the American Geriatrics Society, 49, 477484.
Ganguli M., Dodge H. H., Shen C., Pandav R. S. and DeKosky S. T. (2005). Alzheimer disease and mortality: a 15-year epidemiological study. Archives of Neurology, 62, 779784.
Geerlings M. I., Deeg D. J., Schmand B., Lindeboom J. and Jonker C. (1997). Increased risk of mortality in Alzheimer's disease patients with higher education? A replication study. Neurology, 49, 798802.
Geerlings M. I. et al. (1999). Cognitive reserve and mortality in dementia: the role of cognition, functional ability and depression. Psychological Medicine, 29, 12191226.
Guralnik J. M., Land K. C., Blazer D., Fillenbaum G. G. and Branch L. G. (1993) Educational status and active life expectancy among older blacks and whites. New England Journal of Medicine, 329, 110116
Helmer C., Joly P., Letenneur L., Commenges D. and Dartigues J. F. (2001). Mortality with dementia: results from a French prospective community-based cohort. American Journal of Epidemiology, 154, 642648.
Heyman A., Peterson B., Fillenbaum G. and Pieper C. (1996). The consortium to establish a registry for Alzheimer's disease (CERAD). Part XIV: Demographic and clinical predictors of survival in patients with Alzheimer's disease. Neurology, 46, 656660.
Hier D. B., Warach J. D., Gorelick P. B. and Thomas J. (1989). Predictors of survival in clinically diagnosed Alzheimer's disease and multi-infarct dementia. Archives of Neurology, 46, 12131216.
Hui J. S., Wilson R. S., Bennett D. A., Bienias J. L., Gilley D. W. and Evans D. A. (2003). Rate of cognitive decline and mortality in Alzheimer's disease. Neurology, 61, 13561361.
Hussain S. K., Altieri A., Sundquist J. and Hemminki K. (2008). Influence of education level on breast cancer risk and survival in Sweden between 1990 and 2004. International Journal of Cancer, 122, 165169.
Jagger C., Clarke M. and Stone A. (1995). Predictors of survival with Alzheimer's disease: a community-based study. Psychological Medicine, 25, 171175.
Katzman R. (1993). Education and the prevalence of dementia and Alzheimer's disease. Neurology, 43, 1320.
Larson E. B. et al. (2004). Survival after initial diagnosis of Alzheimer disease. Annals of Internal Medicine, 140, 501509.
Livingston G., Leavey G., Kitchen G., Manela M., Sembhi S. and Katona C. (2001). Mental health of migrant elders: the Islington study. British Journal of Psychiatry, 179, 361366.
Lopez O. L., Brenner R. P., Becker J. T., Ulrich R. F., Boller F. and DeKosky S. T. (1997). EEG spectral abnormalities and psychosis as predictors of cognitive and functional decline in probable Alzheimer's disease. Neurology, 48, 15211525.
Moritz D. J., Fox P. J., Luscombe F. A. and Kraemer H. C. (1997). Neurological and psychiatric predictors of mortality in patients with Alzheimer disease in California. Archives of Neurology, 54, 878885.
O'Carroll R., Whittick J. and Baikie E. (1991). Parietal signs and sinister prognosis in dementia: a four-year follow-up study. British Journal of Psychiatry, 358–361.
Pavlik V. N., Doody R. S., Massman P. J. and Chan W. (2006). Influence of premorbid IQ and education on progression of Alzheimer's disease. Dementia and Geriatric Cognitive Disorders, 22, 367377.
Qiu C., Backman L., Winblad B., Agüero-Torres H. and Fratiglioni L. (2001). The influence of education on clinically diagnosed dementia incidence and mortality data from the Kungsholmen Project. Archives of Neurology, 58, 20342039.
Regan C., Katona C., Walker Z., Hooper J., Donovan J. and Livingston G. (2006). Relationship of vascular risk to the progression of Alzheimer disease. Neurology, 67, 13571362.
Roe C. M., Xiong C., Miller J. P. and Morris J. C. (2007). Education and Alzheimer disease without dementia: support for the cognitive reserve hypothesis. Neurology, 68, 223228.
Satz B. (1993). Brain reserve capacity on symptom onset after brain injury: a formulation and review of evidence for threshold theory. Neuropsychology, 7, 273295.
Schoenberg B. S., Kokmen E. and Okazaki H. (1987). Alzheimer's disease and other dementing illnesses in a defined United States population: incidence rates and clinical features. Annals of Neurology, 22, 724729.
Steenland K., Henley J and Thun M. (2002). All-cause and cause-specific death rates by educational status for two million people in two American Cancer Society cohorts, 1959–1996. American Journal of Epidemiology, 156, 1121.
Stern Y., Alexander G. E., Prohovnik I. and Mayeux R. (1992). Inverse relationship between education and parietotemporal perfusion deficit in Alzheimer's disease. Annals of Neurology, 32, 371375.
Stern Y., Tang M. X., Denaro J. and Mayeux R. (1995). Increased risk of mortality in Alzheimer's disease patients with more advanced educational and occupational attainment. Annals of Neurology, 37, 590595.
Tang X. et al. (2001). Incidence of AD in African-Americans, Caribbean Hispanics, and Caucasians in northern Manhattan. Neurology, 56, 4956.
van Dijk P. T., Dippel D. W. and Habbema J. D. (1991). Survival of patients with dementia. Journal of the American Geriatrics Society, 39, 603610.
Walsh J. S., Welch H. G. and Larson E. B. (1990). Survival of outpatients with Alzheimer-type dementia. Annals of Internal Medicine, 113, 429434.
Wilson R. S. et al. (2006). Cognitive decline and survival in Alzheimer's disease. International Journal of Geriatric Psychiatry, 21, 356362.
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International Psychogeriatrics
  • ISSN: 1041-6102
  • EISSN: 1741-203X
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