Rate of memory decline in AD is related to education and occupation: cognitive reserve?

Neurology. 1999 Dec 10;53(9):1942-7. doi: 10.1212/wnl.53.9.1942.


Objective: To determine whether the rate of decline in performance on a memory test is more rapid in AD patients with higher versus lower educational and occupational attainment.

Background: Epidemiologic and imaging studies have suggested that, given comparable clinical severity of dementia, AD pathology is more advanced in patients with higher educational and occupational attainment. Because educational and occupational attainment should not influence the progression of AD pathology, and because severe AD pathology will eventually produce a mortality-causing condition, people with higher attainment might experience clinical AD for a shorter time and have a more rapid clinical progression.

Methods: A total of 177 AD patients were tested yearly for up to four study visits with the Selective Reminding Test (a memory test). Analysis of prospective change in the total recall score was performed by applying generalized estimating equations to regression analyses with repeated measures.

Results: At the initial visit, scores were comparable in the high- and low-education and the high- and low-occupation groups. Overall, memory scores declined by approximately 1 point yearly (p<0.01). There was a more rapid decline in memory scores in patients with higher educational (p<0.057) and higher occupational attainment (p<0.02). The authors then stratified patients based on their initial memory scores. The more rapid decline in memory scores associated with higher educational and occupational attainment was noted only in the group with low initial scores (p<0.05 for both). The full group and stratified group analyses were also repeated controlling for other potentially relevant variables including age, gender, race, ethnicity, and the presence of extrapyramidal signs, stroke, or at least one apolipoprotein E-epsilon4 allele. The results remained unchanged.

Conclusions: Memory declined more rapidly in AD patients with higher educational and occupational attainment. This adds support to the idea that the discontinuity between the degree of AD pathology and the observed clinical severity of AD is mediated through some form of reserve.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Alzheimer Disease / diagnosis*
  • Alzheimer Disease / genetics
  • Alzheimer Disease / psychology
  • Amnesia / diagnosis*
  • Amnesia / genetics
  • Amnesia / psychology
  • Apolipoprotein E4
  • Apolipoproteins E / genetics
  • Career Mobility*
  • Cognition Disorders / diagnosis*
  • Cognition Disorders / genetics
  • Cognition Disorders / psychology
  • Disease Progression
  • Educational Status*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Mental Recall
  • Neuropsychological Tests
  • Risk Factors


  • Apolipoprotein E4
  • Apolipoproteins E