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April 6, 1994, Vol 271, No. 13 >
ARTICLE | April 6, 1994

Influence of Education and Occupation on the Incidence of Alzheimer's Disease FREE

Yaakov Stern, PhD; Barry Gurland, MD; Thomas K. Tatemichi, MD; Ming Xin Tang, PhD; David Wilder, PhD; Richard Mayeux, MD
[+] Author Affiliations

Reprint requests to Sergievsky Center, 630 W 168th St, New York, NY 10032 (Dr Stern).


JAMA. 1994;271(13):1004-1010. doi:10.1001/jama.1994.03510370056032
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References

Objective.  —Several cross-sectional studies have found an association between Alzheimer's disease (AD) and limited educational experience. It has been difficult to establish whether educational experience is a risk factor for AD because educational attainment can influence performance on diagnostic tests. This study was designed to determine whether limited educational level and occupational attainment are risk factors for incident dementia.

Design.  —Cohort incidence study.

Setting.  —General community.

Participants.  —A total of 593 nondemented individuals aged 60 years or older who were listed in a registry of individuals at risk for dementia in North Manhattan, NY, were identified and followed up.

Interventions.  —We reexamined subjects 1 to 4 years later with the identical standardized neurological and neuropsychological measures.

Main Outcome Measure.  —Incident dementia.

Results.  —We used Cox proportional hazards models, adjusting for age and gender, to estimate the relative risk (RR) of incident dementia associated with low educational and occupational attainment. Of the 593 subjects, 106 became demented; all but five of these met research criteria for AD. The risk of dementia was increased in subjects with either low education (RR, 2.02; 95% confidence interval [CI], 1.33 to 3.06) or low lifetime occupational attainment (RR, 2.25; 95% CI, 1.32 to 3.84). Risk was greatest for subjects with both low education and low life-time occupational attainment (RR, 2.87; 95% CI, 1.32 to 3.84).

Conclusions.  —The data suggest that increased educational and occupational attainment may reduce the risk of incident AD, either by decreasing ease of clinical detection of AD or by imparting a reserve that delays the onset of clinical manifestations.(JAMA. 1994;271:1004-1010)

REFERENCES

1 +
Zhang MY, Katzman R, Jin H, et al.  The prevalence of dementia and Alzheimer's disease (AD) in Shanghai, China: impact of age, gender and education. Ann Neurol . 1990;:27:428-437.
2 +
Dartigues JF, Gagnon M, Miche P, et al.  Le programme de recherche paquid sur l'epidémiologie de la démence méthodes et résultats initiaux. Rev Neurol (Paris) . 1991;;147:225-230.
3 +
Bonaiuto S, Rocca WA, Lippi A, et al.  Impact of education and occupation on prevalence of Alzheimer's disease (AD) and multi-infarct dementia (MID) in Appignano, Macerata Province, Italy. Neurology . 1990;;40( (suppl 1) ):346. Abstract.
4 +
Fratiglioni L, Grut M, Forsell Y, et al.  Prevalence of Alzheimer's disease and other dementias in an elderly urban population: relationship with age, sex and education. Neurology . 1991;;41:1886-1892.
5 +
Sulkava R, Wikström J, Aromaa, et al.  Prevalence of severe dementia in Finland. Neurology . 1985;;35:1025-1029.
6 +
Korczyn AD, Kahana E, Galper Y.  Epidemiology of dementia in Ashkelon, Israel. Neuroepidemiology . 1991;;10:100. Abstract.
7 +
Friedland R.  Epidemiology, education, and the ecology of Alzheimer's disease. Neurology . 1993;; 43:262-249.
8 +
Katzman R.  Education and the prevalence of dementia and Alzheimer's disease. Neurology . 1993;; 43:13-20.
9 +
Mortimer JA.  Do psychosocial risk factors contribute to Alzheimer's disease?  In: Henderson AS, Henderson JH, eds. Etiology of Dementia of Alzheimer's Type . New York, NY: John Wiley & Sons Inc; 1988;:39-52.
10 +
Gurland BJ.  The borderlands of dementia: the influence of sociocultural characteristics on rates of dementia occurring in the senium. Aging . 1981;;15: 61-84.
11 +
Satz P.  Brain reserve capacity on symptom onset after brain injury: a formulation and review of evidence for threshold theory. Neuropsychology . 1993;;7:273-295.
12 +
Stern Y, Alexander GE, Prohovnik I, Mayeux R.  Inverse relationship between education and parietotemporal perfusion deficit in Alzheimer's disease. Ann Neurol . 1992;;32:371-375.
13 +
Stern Y, Stricks L, Alexander G, Prohovnik I, Mayeux R.  Relationship between occupational demands and parietotemporal perfusion in Alzheimer's disease. Ann Neurol . 1992;;32:270. Abstract.
14 +
Kittner SJ, White LR, Farmer ME, et al.  Methodological issues in screening for dementia: the problem of education adjustment. J Chronic Dis . 1986;; 39:163-170.
15 +
Beard CM, Kokmen E, Offord K, Kurland LT.  Lack of association between Alzheimer's disease and education, occupation, marital status, or living arrangement. Neurology . 1992;;42:2063-2068.
16 +
Stern Y, Andrews H, Pittman J, et al.  Diagnosis of dementia in a heterogeneous population: development of a neuropsychological paradigm-based diagnosis of dementia and quantified correction for the effects of education. Arch Neurol . 1992;; 49:453-460.
17 +
Buschke H, Fuld PA.  Evaluating storage, retention, and retrieval in disordered memory and learning. Neurology . 1974;;24:1019-1025.
18 +
Benton AL. The Visual Retention Test . New York, NY: The Psychological Corp; 1955;.
19 +
Wechsler D. Wechsler Adult Intelligence Scale—Revised . New York, NY: The Psychological Corp; 1981;.
20 +
Mattis S.  Mental status examination for organic mental syndrome in the elderly patient.  In: Bellak L, Karasu TB, eds. Geriatric Psychiatry . New York, NY: Grune & Stratton; 1976;.
21 +
Kaplan E, Goodglass H. Weintraub S. Boston Naming Test . Philadelphia, Pa: Lea & Febiger; 1983;.
22 +
Benton AL, Hamsher KD. Multilingual Aphasia Examination . Iowa City: University of Iowa; 1976;. Manual, revised in 1978.
23 +
Goodglass H, Kaplan D. The Assessment of Aphasia and Related Disorders . 2nd ed. Philadelphia, Pa: Lea & Febiger; 1983;.
24 +
The Rosen Drawing Test . Bronx, NY: Veterans Administration Medical Center; 1981;.
25 +
Katzman R, Brown T, Fuld P.  Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry . 1983;; 140:734-738.
26 +
Blessed G, Tomlinson BE, Roth M.  The association between quantitative measures of dementia and of senile changes in the cerebral grey matter of elderly subjects. Br J Psychol . 1968;;225:797-811.
27 +
Schwab JF, England AC.  Projection technique for evaluating surgery in Parkinson's disease.  In: Gillinghan FS, Donaldson MN, eds. Third Symposium on Parkinson's Disease . Edinburgh, Scotland: E & S Livingstone; 1969;:152-157.
28 +
Spitzer RL, Williams JBW. Structured Clinical Interview for DSM III-R—Hamilton Version . New York: New York State Psychiatric Institute; 1986;.
29 +
Hamilton M.  A rating scale for depression. J Neurol Neurosurg Psychiatry . 1960;;23:56-62.
30 +
Williams JBW.  A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry . 1988;;45:742-747.
31 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
32 +
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 the Department of Health and Human Services Task force on Alzheimer's disease. Neurology . 1984;;34:939-944.
33 +
Hughes CP, Berg L, Danziger WL, et al.  A new clinical scale for the staging of dementia. Br J Psychiatry . 1982;;146:566-572.
34 +
Lawless JF. Statistical Model and Methods for Lifetime Data . New York, NY: John Wiley & Sons Inc; 1982;.
35 +
Kaplan EL, Meier P.  Nonparametric estimation from incomplete observations. J Am Stat Assoc . 1958;;53:457-481.
36 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co; 1986;:311-326.
37 +
Aronson MK, Ooi WL, Morgenstern H, et al.  Women, myocardial infarction, and dementia in the very old. Neurology . 1990;;40:1102-1106.
38 +
Zimetbaum P, Frishman W, Aronson M.  Lipids, vascular disease and dementia with advancing age: epidemiologic considerations. Arch Intern Med . 1991;;151:240-244.
39 +
Risberg J, Gustafson L.  Regional cerebral blood flow in psychiatric disorders.  In: Knezevic S, Maximilian V, Mubrin Z, Prohovnik I, Wade J, eds. Handbook of Regional Cerebral Blood Flow . Hillsdale, NJ: Erlbaum; 1988;:219-240.
40 +
Friedland RP, Brun A, Bundinger TF.  Pathological and positron emission tomographic correlations in Alzheimer's disease. Lancet . 1985;;1:228.

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Zhang MY, Katzman R, Jin H, et al.  The prevalence of dementia and Alzheimer's disease (AD) in Shanghai, China: impact of age, gender and education. Ann Neurol . 1990;:27:428-437.
2 +
Dartigues JF, Gagnon M, Miche P, et al.  Le programme de recherche paquid sur l'epidémiologie de la démence méthodes et résultats initiaux. Rev Neurol (Paris) . 1991;;147:225-230.
3 +
Bonaiuto S, Rocca WA, Lippi A, et al.  Impact of education and occupation on prevalence of Alzheimer's disease (AD) and multi-infarct dementia (MID) in Appignano, Macerata Province, Italy. Neurology . 1990;;40( (suppl 1) ):346. Abstract.
4 +
Fratiglioni L, Grut M, Forsell Y, et al.  Prevalence of Alzheimer's disease and other dementias in an elderly urban population: relationship with age, sex and education. Neurology . 1991;;41:1886-1892.
5 +
Sulkava R, Wikström J, Aromaa, et al.  Prevalence of severe dementia in Finland. Neurology . 1985;;35:1025-1029.
6 +
Korczyn AD, Kahana E, Galper Y.  Epidemiology of dementia in Ashkelon, Israel. Neuroepidemiology . 1991;;10:100. Abstract.
7 +
Friedland R.  Epidemiology, education, and the ecology of Alzheimer's disease. Neurology . 1993;; 43:262-249.
8 +
Katzman R.  Education and the prevalence of dementia and Alzheimer's disease. Neurology . 1993;; 43:13-20.
9 +
Mortimer JA.  Do psychosocial risk factors contribute to Alzheimer's disease?  In: Henderson AS, Henderson JH, eds. Etiology of Dementia of Alzheimer's Type . New York, NY: John Wiley & Sons Inc; 1988;:39-52.
10 +
Gurland BJ.  The borderlands of dementia: the influence of sociocultural characteristics on rates of dementia occurring in the senium. Aging . 1981;;15: 61-84.
11 +
Satz P.  Brain reserve capacity on symptom onset after brain injury: a formulation and review of evidence for threshold theory. Neuropsychology . 1993;;7:273-295.
12 +
Stern Y, Alexander GE, Prohovnik I, Mayeux R.  Inverse relationship between education and parietotemporal perfusion deficit in Alzheimer's disease. Ann Neurol . 1992;;32:371-375.
13 +
Stern Y, Stricks L, Alexander G, Prohovnik I, Mayeux R.  Relationship between occupational demands and parietotemporal perfusion in Alzheimer's disease. Ann Neurol . 1992;;32:270. Abstract.
14 +
Kittner SJ, White LR, Farmer ME, et al.  Methodological issues in screening for dementia: the problem of education adjustment. J Chronic Dis . 1986;; 39:163-170.
15 +
Beard CM, Kokmen E, Offord K, Kurland LT.  Lack of association between Alzheimer's disease and education, occupation, marital status, or living arrangement. Neurology . 1992;;42:2063-2068.
16 +
Stern Y, Andrews H, Pittman J, et al.  Diagnosis of dementia in a heterogeneous population: development of a neuropsychological paradigm-based diagnosis of dementia and quantified correction for the effects of education. Arch Neurol . 1992;; 49:453-460.
17 +
Buschke H, Fuld PA.  Evaluating storage, retention, and retrieval in disordered memory and learning. Neurology . 1974;;24:1019-1025.
18 +
Benton AL. The Visual Retention Test . New York, NY: The Psychological Corp; 1955;.
19 +
Wechsler D. Wechsler Adult Intelligence Scale—Revised . New York, NY: The Psychological Corp; 1981;.
20 +
Mattis S.  Mental status examination for organic mental syndrome in the elderly patient.  In: Bellak L, Karasu TB, eds. Geriatric Psychiatry . New York, NY: Grune & Stratton; 1976;.
21 +
Kaplan E, Goodglass H. Weintraub S. Boston Naming Test . Philadelphia, Pa: Lea & Febiger; 1983;.
22 +
Benton AL, Hamsher KD. Multilingual Aphasia Examination . Iowa City: University of Iowa; 1976;. Manual, revised in 1978.
23 +
Goodglass H, Kaplan D. The Assessment of Aphasia and Related Disorders . 2nd ed. Philadelphia, Pa: Lea & Febiger; 1983;.
24 +
The Rosen Drawing Test . Bronx, NY: Veterans Administration Medical Center; 1981;.
25 +
Katzman R, Brown T, Fuld P.  Validation of a short orientation-memory-concentration test of cognitive impairment. Am J Psychiatry . 1983;; 140:734-738.
26 +
Blessed G, Tomlinson BE, Roth M.  The association between quantitative measures of dementia and of senile changes in the cerebral grey matter of elderly subjects. Br J Psychol . 1968;;225:797-811.
27 +
Schwab JF, England AC.  Projection technique for evaluating surgery in Parkinson's disease.  In: Gillinghan FS, Donaldson MN, eds. Third Symposium on Parkinson's Disease . Edinburgh, Scotland: E & S Livingstone; 1969;:152-157.
28 +
Spitzer RL, Williams JBW. Structured Clinical Interview for DSM III-R—Hamilton Version . New York: New York State Psychiatric Institute; 1986;.
29 +
Hamilton M.  A rating scale for depression. J Neurol Neurosurg Psychiatry . 1960;;23:56-62.
30 +
Williams JBW.  A structured interview guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry . 1988;;45:742-747.
31 +
American Psychiatric Association, Committee on Nomenclature and Statistics. Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition . Washington, DC: American Psychiatric Association; 1987;.
32 +
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 the Department of Health and Human Services Task force on Alzheimer's disease. Neurology . 1984;;34:939-944.
33 +
Hughes CP, Berg L, Danziger WL, et al.  A new clinical scale for the staging of dementia. Br J Psychiatry . 1982;;146:566-572.
34 +
Lawless JF. Statistical Model and Methods for Lifetime Data . New York, NY: John Wiley & Sons Inc; 1982;.
35 +
Kaplan EL, Meier P.  Nonparametric estimation from incomplete observations. J Am Stat Assoc . 1958;;53:457-481.
36 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co; 1986;:311-326.
37 +
Aronson MK, Ooi WL, Morgenstern H, et al.  Women, myocardial infarction, and dementia in the very old. Neurology . 1990;;40:1102-1106.
38 +
Zimetbaum P, Frishman W, Aronson M.  Lipids, vascular disease and dementia with advancing age: epidemiologic considerations. Arch Intern Med . 1991;;151:240-244.
39 +
Risberg J, Gustafson L.  Regional cerebral blood flow in psychiatric disorders.  In: Knezevic S, Maximilian V, Mubrin Z, Prohovnik I, Wade J, eds. Handbook of Regional Cerebral Blood Flow . Hillsdale, NJ: Erlbaum; 1988;:219-240.
40 +
Friedland RP, Brun A, Bundinger TF.  Pathological and positron emission tomographic correlations in Alzheimer's disease. Lancet . 1985;;1:228.

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