@article{2987432,
    title = "Education and the moderating roles of age, sex, ethnicity and apolipoprotein epsilon 4 on the risk of cognitive impairment",
    author = "Makkar, S.R. and Lipnicki, D.M. and Crawford, J.D. and Kochan, N.A. and Castro-Costa, E. and Lima-Costa, M.F. and Diniz, B.S. and Brayne, C. and Stephan, B. and Matthews, F. and Llibre-Rodriguez, J.J. and Llibre-Guerra, J.J. and Valhuerdi-Cepero, A.J. and Lipton, R.B. and Katz, M.J. and Zammit, A. and Ritchie, K. and Carles, S. and Carriere, I. and Scarmeas, N. and Yannakoulia, M. and Kosmidis, M. and Lam, L. and Fung, A. and Chan, W.C. and Guaita, A. and Vaccaro, R. and Davin, A. and Kim, K.W. and Han, J.W. and Suh, S.W. and Riedel-Heller, S.G. and Roehr, S. and Pabst, A. and Ganguli, M. and Hughes, T.F. and Jacobsen, E.P. and Anstey, K.J. and Cherbuin, N. and Haan, M.N. and Aiello, A.E. and Dang, K. and Kumagai, S. and Narazaki, K. and Chen, S. and Ng, T.P. and Gao, Q. and Nyunt, M.S.Z. and Meguro, K. and Yamaguchi, S. and Ishii, H. and Lobo, A. and Lobo Escolar, E. and De la Cámara, C. and Brodaty, H. and Trollor, J.N. and Leung, Y. and Lo, J.W. and Sachdev, P. and for Cohort Studies of Memory in an International Consortium (COSMIC)",
    journal = "Archives of Gerontology and Geriatrics",
    year = "2020",
    volume = "91",
    publisher = "Elsevier Ireland Ltd",
    issn = "0167-4943",
    doi = "10.1016/j.archger.2020.104112",
    keywords = "apolipoprotein E4;  apolipoprotein E4, academic achievement;  adult;  age;  aged;  aging;  Article;  Asian;  Black person;  Caucasian;  cognitive defect;  cohort analysis;  controlled study;  disease association;  economics;  ethnicity;  female;  follow up;  gender;  genetic difference;  geography;  heterozygote;  high school;  human;  major clinical study;  male;  middle aged;  middle school;  Mini Mental State Examination;  neurobiology;  politics;  prediction;  primary school;  priority journal;  risk reduction;  sex difference;  social aspect;  survival analysis;  cognitive defect;  educational status;  ethnic group;  genetics;  longitudinal study;  risk factor;  very elderly, Aged;  Aged, 80 and over;  Apolipoprotein E4;  Cognitive Dysfunction;  Educational Status;  Ethnic Groups;  Female;  Humans;  Longitudinal Studies;  Male;  Risk Factors",
    abstract = "Background: We examined how the relationship between education and latelife cognitive impairment (defined as a Mini Mental State Examination score below 24) is influenced by age, sex, ethnicity, and Apolipoprotein E epsilon 4 (APOE*4). Methods: Participants were 30,785 dementia-free individuals aged 55–103 years, from 18 longitudinal cohort studies, with an average follow-up ranging between 2 and 10 years. Pooled hazard ratios were obtained from multilevel parametric survival analyses predicting cognitive impairment (CI) from education and its interactions with baseline age, sex, APOE*4 and ethnicity. In separate models, education was treated as continuous (years) and categorical, with participants assigned to one of four education completion levels: Incomplete Elementary; Elementary; Middle; and High School. Results: Compared to Elementary, Middle (HR = 0.645, P = 0.004) and High School (HR = 0.472, P < 0.001) education were related to reduced CI risk. The decreased risk of CI associated with Middle education weakened with older baseline age (HR = 1.029, P = 0.056) and was stronger in women than men (HR = 1.309, P = 0.001). The association between High School and lowered CI risk, however, was not moderated by sex or baseline age, but was stronger in Asians than Whites (HR = 1.047, P = 0.044), and significant among Asian (HR = 0.34, P < 0.001) and Black (HR = 0.382, P = 0.016), but not White, APOE*4 carriers. Conclusion: High School completion may reduce risk of CI associated with advancing age and APOE*4. The observed ethnoregional differences in this effect are potentially due to variations in social, economic, and political outcomes associated with educational attainment, in combination with neurobiological and genetic differences, and warrant further study. © 2020 Elsevier B.V."
}