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Does education explain the terminal decline in the oldest-old? Evidence from two longitudinal studies of ageing

Conference contribution
Authors Dorina Cadar
Blossom C. M. Stephan
Carol Jagger
Boo Johansson
Scott M. Hofer
Andrea M. Piccinin
Graciela Muniz-Terrera
Published in The Lancet
Volume 386
Issue Supplement 2
Pages S26
ISSN 0140-6736
Publication year 2015
Published at Department of Psychology
Pages S26
Language en
Subject categories Psychology


AbstractBackground Cognitive performance substantially deteriorates close to death, as postulated by the terminal decline hypothesis. However, the association between education and terminal decline remains controversial. This study investigated the role of education in terminal decline in two European longitudinal studies of oldest-old. Methods Participants were from the Newcastle 85+, UK (n=702), and Octogenarian Twins (OCTO-Twin), Sweden (n= 845). They were assessed biannually over three and five consecutive waves, respectively. In a coordinated analysis, multilevel models were used to examine the association between education and terminal decline on mini-mental state examination (MMSE), controlling for age at baseline, dementia incidence, sex, and time to death from the study entry within each cohort. Cognitive decline was modelled as a linear function of time to death in both cohorts and as a quadratic function in the OCTO-Twin study (because of longer follow-up). Education was a continuous measure (ranging from 6 to 20 years in Newcastle 85+ and 0 to 23 years in OCTO-Twin). Findings A typical British man, aged 85 at baseline, with 10 years’ education, entered the terminal phase at around 2·5 years before death, and the mean rate of decline was −1·04 MMSE points with each year closer to the time of death (SEM 0·25, p<0·0001). By contrast, a Swedish man, aged 83 years, with an average of 7 years’ education, entered the terminal phase at around 8 years from death, after which the rate of cognitive decline steepened by −1·70 points per year closer to the time of death (SEM 0·20, p<0·0001) and accelerated by −0·11 (SEM 0·01, p<0·0001). Education was positively associated with the estimated mean MMSE scores before death only in OCTO-Twin (0·43, SEM 0·15; p=0·003) and did not attenuate the rate of terminal decline in either cohort. Interpretation Decline and acceleration of this decline were detectable in both studies before death, with steeper rates of decline observed in the Swedish cohort. However, this process was not lessened by education itself. This work contributes to a better understanding of the transition from the subtle cognitive changes associated with age to those of neurological substance, and the role of education in this decline. Funding The funding sources of this work were the Alzheimer's Society (grant number 144) and the Medical Research Council (unit programme number MC_UU_12019/1).

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