Transitions across cognitive states and death among older adults in relation to education: A multistate survival model using data from six longitudinal studies

Annie Robitaille, Ardo van den Hout, Robson J.M. Machado, David A. Bennett, Iva Čukić, Ian J. Deary, Scott Hofer, Emiel O. Hoogendijk, Martijn Huisman, Boo Johansson, Andriy V. Koval, Maaike van der Noordt, Andrea M. Piccinin, Judith J.M. Rijnhart, Archana Singh-Manoux, Johan Skoog, Ingmar Skoog, John Starr, Lisa Vermunt, Sean CloustonGraciela Muniz Terrera

Research output: Contribution to journalArticle

7 Scopus citations


Introduction: This study examines the role of educational attainment, an indicator of cognitive reserve, on transitions in later life between cognitive states (normal Mini-Mental State Examination (MMSE), mild MMSE impairment, and severe MMSE impairment) and death. Methods: Analysis of six international longitudinal studies was performed using a coordinated approach. Multistate survival models were used to estimate the transition patterns via different cognitive states. Life expectancies were estimated. Results: Across most studies, a higher level of education was associated with a lower risk of transitioning from normal MMSE to mild MMSE impairment but was not associated with other transitions. Those with higher levels of education and socioeconomic status had longer nonimpaired life expectancies. Discussion: This study highlights the importance of education in later life and that early life experiences can delay later compromised cognitive health. This study also demonstrates the feasibility and benefit in conducting coordinated analysis across multiple studies to validate findings.

Original languageEnglish (US)
JournalAlzheimer's and Dementia
Publication statusAccepted/In press - Jan 1 2018



  • Cognition
  • Dementia
  • Education
  • Life expectancy
  • Multistate modeling
  • Socioeconomic status

ASJC Scopus subject areas

  • Epidemiology
  • Health Policy
  • Developmental Neuroscience
  • Clinical Neurology
  • Geriatrics and Gerontology
  • Cellular and Molecular Neuroscience
  • Psychiatry and Mental health

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