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The effect of education on the incidence of dementia and Alzheimer's disease in the Framingham Study

From the Department of Mathematics (Drs. Cobb and D'Agostino), Boston University; the Department of Neurology (Drs. Wolf, Au, and White), Boston University School of Medicine; the Section of Preventive Medicine and Epidemiology (Dr. Wolf), Evans Memorial Department of Clinical Research, University Hospital; and the Department of Neurology (Dr. White), Boston VA Medical Center, Boston, MA.
Supported in part by grant 5-RO1-AG08122-04 (National Institute on Aging) and contract NIH-N01-HC-38038 (National Heart, Lung, and Blood Institute).
Received August 24, 1994. Accepted in final form February 8, 1995.
Address correspondence and reprint requests to Dr. Philip A. Wolf, Department of Neurology, Boston University Medical School, 80 East Concord Street, B-608, Boston, MA 02118.

Objective: To evaluate whether low educational attainment is a risk factor for the incidence of dementia and Alzheimer's disease (AD) in the Framingham Study and to determine whether age at onset of dementia is earlier in persons with low educational levels. Design: A community-based cohort was studied longitudinally for the development of dementia. Diagnosis was made according to strict criteria by two neurologists and a neuropsychologist. Subtype of dementia and year at onset were determined. Incidence rates were compared in three education groups: less than grade school, less than high school, and more than equals high school. Participants: A total of 3,330 men and women aged 55 to 88 years. Results: During 17 years of follow-up, 258 incident cases of dementia, including 149 AD cases, were identified. Unadjusted incidence rates were significantly elevated (p less than 0.05) for dementia and non-AD dementia among the least educated. The age-adjusted relative risk for subjects with a grade school education or less compared with those who earned a high school diploma was 1.31 (95% confidence interval [CI], 0.90 to 1.90) for dementia generally, 1.04 (95% CI, 0.62 to 1.74) for AD, and 1.75 (95% CI, 1.03 to 2.98) for non-AD dementia. Age at onset of dementia did not vary by educational attainment. Conclusions: After age adjustment, low educational attainment was not a significant risk factor for the incidence of dementia generally or of AD. Low educational attainment was associated with increased risk of non-AD dementia, perhaps because of deleterious smoking habits and other risk factors for stroke in the least-educated individuals. Adequately adjusting for age and examining subtypes of dementia are important in assessing the influence of education on dementia incidence.

NEUROLOGY 1995;45: 1707-1712