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Alzheimer Dis Assoc Disord. Author manuscript; available in PMC 2012 October 1.
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Alzheimer Dis Assoc Disord. 2011 October ; 25(4): 289–304. doi:10.1097/WAD.0b013e318211c83c.
The Relationship between Education and Dementia An Updated

Systematic Review
Emily Schoenhofen Sharp, M.A. and
University of Southern California, Department of Psychology, 3620 McClintock Ave, Los Angeles,
CA, 90089, Phone: 310-662-3494, Fax: 213-746-5994
Margaret Gatz, Ph.D.
University of Southern California, Department of Psychology, 3620 McClintock Ave, Los Angeles,
CA, 90089, Phone: 213-740-2212, Fax: 213-746-5994
Emily Schoenhofen Sharp: [email protected]; Margaret Gatz: [email protected]
Abstract
Objective—The purpose of this study was to review the relationship between education and
dementia.
Methods—A systematic literature review was conducted of all published studies examining the
relationship between education and dementia listed in the PubMed and PsycINFO databases from
January 1985 to July 2010. The inclusion criteria were a measure of education and a dementia
diagnosis by a standardized diagnostic procedure. Alzheimer’s disease and Total Dementia were
the outcomes.
Results—A total of 88 study populations from 71 articles met inclusion criteria. Overall, 51
(58%) reported significant effects of lower education on risk for dementia whereas 37 (42%)
reported no significant relationship. A relationship between education and risk for dementia was
more consistent in developed compared to developing regions. Age, gender, race/ethnicity, and
geographical region moderated the relationship.
Conclusions—Lower education was associated with a greater risk for dementia in many but not
all studies. The level of education associated with risk for dementia varied by study population
and more years of education did not uniformly attenuate the risk for dementia. It appeared that a
more consistent relationship with dementia occurred when years of education reflected cognitive
capacity, suggesting that the effect of education on risk for dementia may be best evaluated within
the context of a lifespan developmental model.
Keywords
Alzheimer’s disease; dementia; education; risk factors
The purpose of the paper is to provide an updated systematic review of the literature on the
relationship between education and dementia over the past 25 years. Mortimer1 was one of
the first people to propose a relationship between years of formal education and risk for
dementia. He suggested that psychosocial factors such as education may be protective
against diagnosable dementia by raising the level of “intellectual reserve”. The first large-
scale study to investigate this relationship was a dementia prevalence survey in Shanghai,
China.2 The authors found that having no formal education was strongly associated with a
Correspondence concerning this article should be addressed to Emily Schoenhofen Sharp, University of Southern California,
Department of Psychology, 3620 McClintock Avenue, Los Angeles, CA 90089-1061. [email protected].
Sharp and Gatz Page 2
higher prevalence of dementia. Since this early work, many researchers have studied the
relationship between level of education and risk for dementia.
Several reviews of the relationship between education and dementia have been previously
published. Katzman3 and Mortimer4 both concluded that low education was likely a risk
factor for dementia. In contrast, in a review of international studies, Gilleard5 argued that
methodological and ascertainment biases were driving the relationship between low
education and an increased risk for dementia. There have been two selective recent reviews.
Caamaño-Isorna and colleagues6 conducted a meta-analysis of 19 studies and concluded that
low education met epidemiologic criteria as a risk factor for dementia. In a meta-analysis of
15 incidence studies, Valenzuela and colleagues reported that high education was protective
against risk for dementia.7
Broad observations from the literature and previous reviews have suggested that the
relationship between education and dementia is strongest and most consistent for individuals
with no or very low education, in Alzheimer’s disease cases, and in dementia prevalence
studies. Criticisms have focused on ascertainment and diagnostic bias, confounding
elements such as age and gender, and that education may be a surrogate for other
unmeasured variables. Researchers have proposed a number of mechanisms to explain the
relationship between education and risk for dementia including: brain reserve, cognitive
reserve, “use it or lose it”, the brain-battering hypothesis, ascertainment/diagnostic bias, and
education as a proxy for a third variable(s). However, it remains unclear as to what

education is and how it can be discussed as a uniform concept across diverse populations.
How can a relatively small number of years of formal education occurring early in life affect
risk for dementia in old age? This review advances the literature by providing a broad
systematic review of both dementia prevalence and incidence studies. We were particularly
interested in examining the pattern of results across studies that evaluated multiple levels of
education and potential moderators of the relationship including geographical region and
gender.
METHODS
We selected a systematic review over a meta-analysis for the current paper. Meta-analyses
require a standard of uniformity across studies in terms of design and statistical methods.
Across the reviewed studies, level of education was categorized quite differently and the
relationship with dementia was analyzed in a variety of ways. In a meta-analysis, it is also
standard practice to include one result from one publication from a given study population.
These requirements may have limited the number of study results available to review and
obscured patterns within the literature. Finally, a primary goal of this review was to be as
inclusive as possible, with the particular aim to include studies from both developed and
developing regions of the world.
The systematic review of the literature was conducted using PubMed and PsycINFO
databases of all published articles from January 1985 to July 2010. Search terms included
combinations and variations of education, years of education, educational attainment, risk
factors, Alzheimer’s disease, dementia, prevalence, and incidence. This search strategy was
supplemented by reviewing the reference sections of all identified studies and previous
reviews. All articles were published in English. We included studies that evaluated the
relationship between years of education and Alzheimer’s disease as well as studies that
combined all types of dementias into a Total Dementia outcome. We did not include studies
of other dementia subtypes (e.g. vascular dementia) nor did we evaluate cognitive decline.
Both dementia prevalence and incidence studies were included and were identified in the
traditional manner. Prevalence studies collected education and dementia diagnostic data at
baseline. Incidence studies collected education and diagnostic data during a first wave of
study. Initially disease-free individuals were then followed up at a later time point with a
dementia diagnostic evaluation to identify incident dementia cases within that population.
The criteria for this review were less strict than a meta-analysis. We did not restrict the type
of study (e.g. by excluding prevalence studies or case-control studies) or set a minimum
sample size. The two selection criteria were a measure of actual years of education and that
dementia cases were diagnosed using a standardized assessment procedure such as the
Diagnostic and Statistical Manual of Mental Disorders,8–10 International Classification of
Diseases,11,12 Cambridge Mental Disorders of the Elderly Examination,13 the National
Institute of Neurological and Communicative Disorders and Stroke-Alzheimer’s Disease and
Related Disorders Association.14 Two studies15,16 used the Clinical Dementia Rating
(CDR)17 scale score to differentiate the dementia sample; here we selected the results based
on analysis of dementia cases with CDR=1 (mild dementia) or greater.
The literature search returned over 250 articles. This number was reduced to 93 articles after
the abstracts were reviewed. After the selection criteria were applied, 71 articles remained.
Two outcomes were defined: Alzheimer’s disease (AD) and Total Dementia (all dementia
subtypes combined). Some studies reported a result for AD or Total Dementia and some
studies reported results for both outcomes. Educational attainment was categorized
differently across the studies.
There was great heterogeneity across the 71 articles. Specifically, studies could have
analyzed the relationship between education and dementia using years of education, 2-
categories of education (e.g. illiterate vs. literate) or 3 or more categories of education as the
independent variable. Any study that included three or more levels of education, analyzed
populations independently, or examined both AD and Total Dementia as outcomes could
have reported both significant and nonsignificant results in the same study. We were
concerned that one significant result might be interpreted as evidence for an overall
education-dementia relationship while any nonsignificant effects (in the same study) might
be overlooked. Thus, to compare results across studies and to more exactly identify any
patterns across results, we implemented a count system that identified study results as
significant or nonsignificant based on reported confidence intervals or p-values.
We selected the statistical model that adjusted for age and sex when available. All
adjustment variables are listed in the tables. An estimated odds ratio (OR), relative risk
(RR), or hazard ratio (HR), and the respective 95% confidence intervals and p-values (when
given) were extracted from the univariate or multivariate model described in each paper.
ORs were reported in prevalence studies whereas an ORs, RRs or HRs may have been
reported in incidence studies. In the few cases where an odds ratio was not provided and
enough data were presented in the original paper, we calculated an unadjusted odds ratio. It
is important to note that ORs may overestimate the effect size compared to RRs or HRs.
Results were considered to be significant if the reported confidence intervals did not include
zero or the p-value was less than .05.
A total of 34 studies reported results based on the relationship between high education and
risk for dementia. For comparison purposes, we took the reciprocal of the risk estimate and
confidence intervals so that the direction of results would be the same across studies. A total
of 31 studies reported results for three or more levels of education. To facilitate
comparisons, in the tables we present the results from the lowest educational category
compared to the highest (reference) category. A total of 10 studies examined education as a
continuous variable, and the risk estimate corresponds to change in risk per year of
education. Study data are presented separately for prevalence and incidence studies (Tables
1 and 2). Within each table, study results are grouped in chronological order within
geographical regions.
RESULTS
Of the 71 articles that met inclusion criteria, 3 prevalence studies reported results from
multiple study sites,23,33,45 two studies analyzed gender separately,55,58 and three studies
analyzed multiple racial/ethnic groups separately.34,77,78 Thus, while there are 71 articles,
the results reported in this paper are based on 88 total study populations. Nearly the same
number of prevalence and incidence studies met our selection criteria. Study results for the
relationship between low education and prevalent dementia are reported in Table 1 (N=46).
Study results for the relationship between low education and incident dementia are reported
in Table 2 (N=42).
Overall, 51 studies (58%) reported a significant effect of lower education on risk for
dementia whereas 37 studies (42%) reported no significant relationship between lower
education and a dementia outcome. Of the 88 total studies, 27 examined the relationship
between education and AD, 37 studies examined the relationship between education and
Total Dementia, and 24 studies analyzed the relationship for both outcomes.
To compare across prevalence and incidence studies, we selected one result from the each of
the 88 study populations. If a study examined both dementia outcomes, we selected the
Total Dementia outcome. Of the 46 prevalence studies, 28 studies (61%) reported a
significant effect of low education on risk for dementia. Of the 42 incidence studies, 23
studies (55%) reported a significant effect of low education on dementia risk (See Figure 1).
In the following sections, we report results within each study type (prevalence or incidence)
and study outcome (AD and/or Total Dementia). Later, we specifically discuss studies with
three or more levels of education, studies by geographical region, and studies evaluating
age, gender and race/ethnicity.
Education and Dementia Prevalence Studies

A total of 46 studies examined the relationship between low education and dementia
prevalence (See Table 1). Effect sizes reported by prevalence studies are presented in Figure
2. A total of 22 studies did not adjust for any covariates (such as age or sex) in the statistical
models.
Alzheimer’s disease—Of the 14 studies that analyzed the relationship between low
education and AD, 10 studies found a significant effect such that low education was
associated with a significant increased risk for AD.26,30,31,33,34,37,41–43,48 In contrast, 4
studies reported no association between education and risk for AD.18,33–35 Total Dementia.
Of the 22 studies that analyzed the effect of education on Total Dementia prevalence, 13
studies reported a significant effect such that lower education was associated with an
increased risk for Total Dementia.2,23,28,36,38,44–47,49 In contrast, 9 studies found no
significant relationship.19,20,45 Both outcomes. Of the remaining 10 prevalence studies that
examined both AD and Total Dementia as outcomes, 3 studies reported a significant effect
of lower education on risk for both dementia outcomes,21,24,29 3 studies reported no
significant association for either outcome,15,27,40 and 2 studies found only AD to be
significant;25,39 whereas, 2 other studies found only Total Dementia to be significant.22,32
Education and Dementia Incidence Studies

A total of 42 studies examined the relationship between low education and incident
dementia (see Table 2). Effect sizes reported by incidence studies are presented in Figure 3.
A total of 8 studies did not adjust for any covariates in the statistical models.
Alzheimer’s disease—Of the 13 studies that analyzed the relationship between low
education and risk for AD, 7 studies reported significant effects such that lower education
was associated with an increased risk for AD.54,55,57,66,69,72,83 In contrast, 6 other studies
reported no significant relationship.58,65,70,71,74,81 Total Dementia.. Of the 15 studies that
examined whether low education was associated with an increased risk for Total Dementia,
8 studies reported significant effects for low education on risk for Total
Dementia.60,64,67,75–78 In contrast, 7 studies reported no significant association.50–53,77,80,85
Both Outcomes. Of the remaining 14 incidence studies that examined both dementia
outcomes, 7 studies found a significant relationship for both outcomes,56,59,61–63,79,84 a total
of 5 reported no significant relationship for either outcome,16,25,58,68,82 and 2 reported only
one of the outcomes to be significant (one AD and one Total Dementia).58,73
Multiple Categories of Education

For comparison purposes, we chose to present the lowest level of education compared to the
highest level (the reference group). However, 31 studies reported results by dividing
education into three or more categories and identified each level as significant or not
significant. Thus, these studies could have reported a significant result for one category of
education, but, a nonsignificant result for another category. Of these 31 studies, 4 reported
significant results across all levels compared to the reference level and 6 studies reported no
significant result for any level compared to the reference level. The remaining 21 studies
reported both significant and nonsignificant results, with the lowest level of education
always representing significant risk and at least one middle level not associated with risk for
dementia compared to the reference level. Generally, when education is divided into more
than two categories, there is likely to be reduced statistical power for finding a significant
effect of a category of education closer to the reference group. Yet overall, whether low
education was related to risk for dementia was unrelated to how education was defined
across studies. For example, the definition of low education ranged from illiterate to less
than 15 years, while the highest education level (reference category) ranged from literate to
17+ years.
Geographical Region
Studies examining the relationship between education and dementia were carried out in both
developed and developing regions. Across all identified studies, 31 studies were conducted
in Europe, 27 in North America, 18 in Asia (including one study in Guam), 9 in Latin

America, 2 in the Middle-East, and 1 in Africa. Again for the following, if a study examined
both dementia outcomes, we selected the Total Dementia outcome in our count. Across the
31 European studies, 19 studies reported significant associations between education and a
dementia outcome;21–24,26,28,29,54–64 whereas, 12 studies reported no significant
association.18–20,25,27,50–53,55,58 Of the 27 North American studies, 17 studies reported
significant effects of education on dementia risk;30–34,36,37,66,67,69,72,75–79 whereas, 10
studies reported no significant associations.16,34,35,65,68,70,71,73,74,77 Of the 18 studies
conducted in Asia, 8 studies reported significant associations between education and a
dementia outcome; 2,38,41–44,83,84 whereas, 10 studies reported no significant
associations.15,39,40,45,80–82 Of the 9 Latin American studies, 5 reported significant
associations between education and a Total Dementia; 45–47 whereas, 4 studies reported no
significant associations.45, 85 No studies in Latin America reported on risk for AD. Two
studies included in this review were conducted in Israel and reported an effect of low
education on risk for AD48 and Total Dementia.49 One study conducted in Nigeria, Africa,
did not find a significant association between no education and risk for AD.33 Figure 4
illustrates the results across prevalence and incidence studies within each geographical
region.
To further evaluate the distribution by region, we divided the studies into two categories:
developed and developing regions. A total of 64 studies were from primarily developed
regions (North America, Europe, Japan, and Israel) and 24 studies were from primarily
developing regions (Asia, Latin America, and Africa). We note that while we present the
10/66 Dementia Research Study Group reportas 10 different studies (three of which were
significant), that paper reported a significant pooled meta-analyzed estimate (OR=0.83;
CI=0.75–0.90), such that more years of education was associated with a decreased risk for
Total Dementia.44 Of the 64 studies from developed regions, 41 studies (64%) reported
significant associations between education and a dementia outcome, whereas 23 studies
(36%) reported no significant findings between level of education and dementia risk. Across
the 24 studies from developing regions, 10 studies (42%) reported a significant association
between education and a dementia outcome. In contrast, 14 studies (58%) studies reported
no significant findings between level of education and dementia risk (See Figure 5). Overall,
studies from developing regions were more likely to be dementia prevalence studies and less
likely to single out AD as the dementia outcome.
Age, Gender, and Race/Ethnicity

Of the 88 study populations, 30 studies did not adjust for age or any other covariates in the
statistical analysis. A total of 2 studies specifically evaluated the impact of gender. In each
study, men and women were analyzed separately and the results indicated a significantly
increased risk for dementia in women with the lowest level of education, but no significant
effect of low education on risk for dementia in men.55,58 Furthermore, Ott and colleagues58
describe a reanalysis of the cross-sectional data from the previously published dementia
prevalence survey21 and confirmed a notably larger effect of low education on risk for
dementia in women (OR=4.07) compared to men (OR=1.80). The results for race/ethnicity
were varied. Two studies found no significant association between low education and risk
for dementia within a minority group,34,77 whereas one study reported a greater risk for the
minority group.78 Two other studies analyzed the same population of African Americans
and found a significant effect of low education on risk for AD and Total Dementia.32,33
DISCUSSION
Collapsing across all study types and dementia outcomes, we found that 58% of studies
reported significant effects of education on risk for dementia; whereas, 42% of studies
reported no significant effects. Previous reviews have suggested that the effect of education
was stronger in studies evaluating individuals with no or low education, in studies
evaluating risk for AD, and in dementia prevalence studies. This review did not find more
significant effects for studies where the lowest category was no or extremely low levels of
education as compared to studies where the lowest category included more years of
education. How researchers categorized education seemed to reflect cultural context, with
developing countries having lower cutoffs. This review found that whether low education
was associated with dementia did not depend on what cutoffs defined low education. This
finding suggests that the relationship between education and dementia is perhaps more
nuanced than previously suggested. Mainly, it does not appear to be the case that adding
years of education adds uniform protection against risk for dementia.
Whether the relationship between education and AD is stronger than for other dementia
subtypes remains unclear. In this review, AD cases often made up a large percentage of the
Total Dementia outcome and we were unable to include other separate dementia outcomes
such as vascular dementia. However, when examining studies that evaluated both outcomes,
it was equally as common for the AD outcome to be significant as the Total Dementia
outcome (when the other was not). This suggests that the relationship between education and
dementia may not be unique to AD.
The results of this review suggest that prevalence studies reported a significant effect of low
education on dementia risk more often than incidence studies. However, a much greater
number of prevalence studies did not adjust analyses for age or sex making it difficult to
compare across study type. Similarly, we found no clear evidence that the dementia
prevalence studies reported larger risk estimates compared to dementia incidence studies.
Differences across study populations

Overall, there was more consistent support for an education-dementia relationship in
developed compared to developing regions of the world. This finding may seem a bit
paradoxical because developing regions have more older adults who are uneducated or
poorly educated, yet a lower prevalence of dementia.5,86 This pattern may be explainable if
we consider that individuals in developing countries generally have a shorter life expectancy
and may die before either developing or evidencing symptoms of dementia. Thus, education
may be unrelated to dementia due to the simultaneous lack of education and lack of
dementia cases.40,43
In developing regions, even more than in developed regions, low education may be
especially reflective of lifelong disadvantages such as poorer maternal health, poor nutrition,
or exposure to infection.43,80 In addition, access to education may more often be based on
social class than on intellectual promise or on principles of equal access regardless of ability
to pay for an education 2,16,25,33,63 Further, the proportion of individuals who are illiterate or
of very low education is often notably greater in rural than in urban samples, yet this more
poorly educated sample is not necessarily at greater risk for dementia 20,30 In Mexico, for
example, low education was associated with an increased risk for dementia in urban
participants but not in rural participants.45
In terms of differences related to the age of the study population, many studies reported that
the oldest participants had significantly fewer years of education and were also significantly
more likely to be diagnosed with dementia – suggesting a cohort effect.44 Despite model
adjustments for age, the strong tendency for older cohorts concurrently to have fewer years
of education and higher rates of dementia may potentially inflate the association between
education and dementia.
In terms of gender differences, although most studies adjusted for sex in the statistical
models, Letenneur and colleagues56 pointed out that most studies do not consider the
potential for moderation of the education-dementia association based on age or sex. This is
important because women live longer, or have greater survival, and thus have more time to
develop and express a dementing disease.16,87 When modeling sex separately, the
Rotterdam Study58 and two separate studies using EURODEM data 55,88 found a significant
effect of education on risk for dementia only in women. Women in this cohort had both
fewer and qualitatively different educational opportunities compared to men (despite
presumably equivalent intellectual capacity). For example, Zhang and colleagues42 noted
that prior to 1950, only women belonging to the highest social class were given access to
education in China. In developed regions as well, women born at the end of the nineteenth
and beginning of the twentieth century may have experienced educational disadvantages
reflecting lifelong socioeconomic disparities.20,42,43,55,83
In terms of race/ethnicity differences, the available studies suggest that for ethnic minority
groups low education may not correspond to lesser cognitive capacity. Harwood and
colleagues34 found that low education was a risk factor for AD in White participants but not
in Hispanic participants (mainly Cuban immigrants), despite the fact that the Hispanic
participants had an equivalent number of years of education and often worked in jobs below
their educational level. Two studies evaluated African American participants compared to
White participants. After adjusting for age, Fitzpatrick et al.77 reported an increased risk for
dementia in White participants with low education (less than high school), but not African
American participants with the same level of education. In contrast, Shadlen and
colleagues78 found a considerably higher dementia risk for African American participants
with low education (less than 10 years) compared to a reference group of white participants
with the same level of education. However, the higher dementia risk for African American
participants was notably lessened in an analysis that controlled for baseline cognitive ability
– suggesting that years of education may not have been a reliable indicator of cognitive
capacity. In keeping with the observation that differences in level and quality of educational
opportunities available to minorities in the older cohorts may change the meaning of
education, some researchers have suggested that literacy or reading level may be a better
indicator of what education is thought to represent than years of education in minority
groups.89 In an entirely African American sample in Indianapolis, Indiana, Hall and

colleagues90 found that the combination of low education and rural residence until age 19
greatly increased risk for AD. However, when rural residence was included as a covariate,
low education alone was not a significant risk factor.
Overall, across developing and developed countries, women and men, racial and ethnic
minorities and individuals from the dominant majority group, education appears to have a
more consistent relationship with dementia in populations where educational attainment is
reflective of intellectual ability rather than privilege.
Methodological factors
The concerns illustrated above lead us into a discussion about methodological limitations in
assessing the relationship between education and dementia. The potential for ascertainment
and diagnostic biases was a major methodological concern raised in almost every article
reviewed here as well as in previous reviews. This bias refers to the potential for individuals
with low educational attainment to inherently perform more poorly on cognitive testing used
to assess for dementia compared to individuals with more education, despite no differences
in functional impairment.76,91 Cognitive tests have been suggested to be especially biased
when evaluating illiterate or uneducated individuals.5,15,80
Studies have adopted different approaches to reduce the potential for such bias, including
creating different screening cutoffs based on education,2,85 clinically evaluating a proportion
of participants who initially screen negative for dementia,30,42 and developing more
sensitive measures of dementia for populations in developing countries.92 In this review,
two studies utilized autopsy-verified dementia outcomes. Munoz 35 reported no relationship
between education and risk for dementia. In contrast, a mega-study of autopsy-confirmed
dementia cases in Europe found that education was predictive of dementia diagnoses but
was not predictive of differences in brain pathology.64 Overall, given the various measures
taken to correct for such bias, as well as research specifically evaluating the effectiveness of
these methodologies,54,76 we are reasonably confident that the results are not solely due to
biased or invalid dementia diagnosis.
What is Education?
In this review, we concluded that years of education can mean different things when
evaluated within the context of culture and cohort. The quantity of education that was
important to lessening dementia risk varied quite dramatically by population and region and
seems to be tied to the unique demands of a given society. For example, the dementia risk
associated with illiteracy in a developing region83 may be similar to the dementia risk
associated with completing up to 10 years in a developed region.34 We still do not know
why the difference of just a few years of early education can have an association with late
life risk for dementia.
A number of studies have evaluated potential mediators of the relationship between

education and dementia and found that the association disappeared after accounting for
factors such as familial risk and leg length.93 In contrast, other studies found a persistent
association even after accounting for health, lifestyle, or familiality.28, 29,61 Studies that
evaluated brain pathology at autopsy found disease pathology to be unrelated to years of
education.35,64 In the papers reviewed here, the cognitive reserve theory94 was the most
cited mechanism to explain the relationship between education and dementia. Based on the
results of this review, where we have highlighted the broad definition of low education
across study populations as well as the important mediators of this relationship, we suggest
that it is important to think of education as a proxy or surrogate indicator.
To illustrate this point, we present a developmental framework (See Figure 6) that expands
on a model identifying relationship between childhood mental ability and survival.95 In our
model, educational attainment is influenced by pre-education factors that contribute to
cognitive development such as genetics, parental socioeconomic status (SES) and
socioemotional influences. Brain development is an unmeasured baseline factor that
influences access to early education and the ability to profit from education. Adult SES is a
post-education factor, strongly related to educational attainment (particularly in developed
regions). Adult SES, in turn, is associated with environments, such as occupation or
exposure to toxins, and to behaviors such as diet, exercise, and lifestyle. In this model, level
of education does not affect risk for dementia directly, but it affects (and is affected by) a
multitude of factors across the lifespan.
In support of the cognitive reserve theory, it seems that low education has a stronger
association with dementia when education is reflective of cognitive capacity rather than
privilege and when low education is associated with other risk factors across the lifespan.
However, the amount of education that is subsequently associated with a statistical risk for
dementia is contingent on an individual’s environment and can vary greatly across
populations, cohorts, gender and race/ethnicity. Finally, educational attainment is not a static
event. It seems that for some individuals, years of education may correspond to a greater
interest in learning or a tendency to seek out cognitively stimulating activities across the
lifespan. For other individuals, years of formal education tells us little about their subsequent
cognitive endeavors.
STRENGTHS AND LIMITATIONS

We attempted to be as inclusive as possible in this review covering the last 25 years of the
literature. We included both prevalence and incidence studies and did not exclude case-
control studies or studies with small sample sizes. However, it is possible that relevant
studies were excluded because of how dementia was diagnosed or how the data were
reported. As with any review, negative publication bias is an important consideration. It may
be that some studies did not find an association between education and dementia and these
nonsignificant findings were not reported in a published paper. Any exclusion of
nonsignificant findings would warrant an even more cautious discussion of the association
between education and dementia. Methodological challenges to this current review included
the multiple and potentially conflicting results due to how education was defined and
analyzed, multiple dementia outcomes, and varied study populations. Because it was
difficult to summarize across such diverse studies, we employed a count system to examine
study results. We acknowledge that this approach does not give a statistical account of the
association between education and dementia. However, it seemed important to clearly
present the pattern of study results across and within this diverse group of study populations.
CONCLUSION
Overall, the results of this review suggest that the education-dementia relationship may be
more complex than previously suggested in the aging literature. The results suggest that
lower education is associated with an increased risk for dementia for some but not all
studies. Further, the level of education that was most associated with dementia risk varied
considerably by study region as well as by age, gender, and race/ethnicity. We did not find
clear evidence that prevalence studies reported stronger or more consistent significant
effects of education on risk for dementia compared to incidence studies. The existence of an
education-dementia relationship seems strongly tied to the unique demands of an
individual’s environment. We suggest that education is best described as a proxy for a
trajectory of life events, beginning prior to and extending beyond the years of formal
education, that either increase or decrease an individual’s risk for dementia.
Acknowledgments
The authors gratefully thank Bob Knight, John J. McArdle, Nancy L. Pedersen, and Merril Silverstein for their
insightful comments.
This research was supported in part by a grant from the National Institute on Aging: Multidisciplinary Research
Training in Gerontology (5T32AG00037, Principal Investigator: Eileen Crimmins, PhD).
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FIGURE 1.
Pattern of Study Results by Study Type (Prevalence or Incidence). Note. Each study is
counted once. If a study analyzed both outcomes, the result for Total Dementia is shown.
FIGURE 2.
Reported Effect Size (OR) and 95% Confidence Interval from Analysis of Lower Education
and Risk for Dementia Prevalence. Note. OR indicates Odds Ratio. All studies are presented
without differentiation. Studies vary in how education was defined, sample size, and model
covariates.
FIGURE 3.
Reported Effect Size (OR/RR/HR) and 95% Confidence Interval from Analysis of Lower
Education and Risk for Dementia Incidence. Note. OR indicates Odds Ratio, RR, Relative
Risk, and HR, Hazard Ratio. All studies are presented without differentiation. Studies vary
in how education was defined, sample size, and model covariates.
FIGURE 4.
Pattern of Study Results by Prevalence and Incidence within Geographical Regions. Note. P
= Prevalence; I= Incidence. Each study is counted once. If a study analyzed both dementia
outcomes, the result for Total Dementia is shown.
FIGURE 5.
Pattern of Study Results for Developed and Developing Regions. Note. Each study is
counted once. If a study analyzed both dementia outcomes, the result for Total Dementia is
shown.
FIGURE 6.
Lifespan Developmental Model for a Relationship between Education and Dementia. (Note.
Adapted from Deary IJ, Whiteman MC, Starr JM, et al. The impact of childhood intelligence
on later life: following up the Scottish mental surveys of 1932 and 1947. J Pers Soc Psychol.
2004;86:130–147 Copyright 2004 by the American Psychological Association)
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
TABLE 1
Study Results for Low Education and Dementia Prevalence (N=46)
Number & Type Odds Ratios (95% CI)

of Dementia
First Author (Year) Country, Study Name Sample Size Age Cases Adjustment variables Education Variable AD p Total Dementia p
Sharp and Gatz
EUROPE (N=12)
Amaducci18 (1986) Italy 116:97 C/C >40 116 AD Unadjusted Illiterate Literate 4.00 (not given)^ 0.37
O’Connor19 (1991) United Kingdom 1768 ≥ 75 163 TD Unadjusted <15 years 1.31 (0.90–1.90)^
≥ 15 years 1
Bonaiuto20 (1995) Italy 48:96 C/C ≥ 60 48 TD Age, sex Illiterate Literate* 1.40 (0.60–3.10)^ 0.44
1
Ott21 (1995) Netherlands, Rotterdam Study 7528 ≥ 55 339 AD Age, sex Primary Education >Secondary 4.00 (2.50–6.20) 3.20 (2.20–4.60)
474 TD Education* 1 1
Prencipe22 (1996) Italy, Aquila Study 1147 ≥ 65 50 AD Age, sex < 3 years 1.80 (1.00–3.40)^ 2.00 (1.20–3.30)
78 TD ≥ 3 years 1 1
Azzimondi23 (1998) Rural Sicily: Troina, Italy 365 >74 80 TD Unadjusted ≤ 2 years 7.4 (3.3–18.3)
>2 years 1
Azzimondi23 (1998) Urban Sicily: S. Agata Militello, 408 >74 116 TD Unadjusted ≤ 2 years 3.2 (1.9–5.2)
Italy > 2 years 1
De Ronchi24 (1998) Italy 495 ≥ 61 29 AD Age, sex No Education Any Education* 4.7 (2.30–9.40) 5.0 (2.10–12.1)
56 TD 1 1
Gatz25 (2001) Sweden 77:154 AD C/C ≥ 65 77 AD Age, sex ≤ 6 years 2.26 (1.02–5.02) 1.47 (0.82–2.62)^
131:262 TD C/C 131 TD > 6 years 1 1
Harmanci26 (2003) Turkey, TAPS 57:127 C/C ≥ 70 57 AD Unadjusted No schooling Higher Education Ŧ* 8.38 (1.78–39.56)
1
Tognoni27 (2005) Italy 1600 ≥ 65 68 AD Age, sex Years of Education 0.88 (0.77–1.00)^ 0.91 (0.82–1.01)^
100 TD
Gatz28 (2007) Sweden, HARMONY 394:7786 ≥ 65 394 TD Age, sex ≥ 6 years 1.89 (1.35–2.65)
C/C >6 years 1
NORTH AMERICA (N=9)
Ngandu29 (2007) Finland, CAIDE 1,388 ≥ 65 48 AD Age, sex, follow-up, 0–5 years 6.67 (2.44–16.67) 5.00 (2.13–12.50)
61 TD community residence ≥ 9 yearsŦ* 1 1
Canadian Study of Health and Canada, CSHA 258:535 C/C ≥ 65 258 AD Age, sex, community 0–6 years 4.00 (2.49–6.43)
Aging30 (1994) residence ≥ 10 years* 1
Mortel31 (1995) USA 150:188 C/C ≥ 60 150 AD Unadjusted <High School 2.43 (1.38–4.31)
≥ High School* 1
Page 22

of Dementia
Callahan32 (1996) USA 2212 African Americans ≥ 65 48 AD Unadjusted 0–5 years 3.23 (0.97–11.11)^ 0.06 3.85 (1.52–11.11)
65 TD >9 years Ŧ* 1 1
Hall33 (1998) USA 2212 African Americans ≥ 65 49 AD Age, sex 0–6 years 3.49 (1.06–11.48)
Sharp and Gatz
≤ 10 years* 1
Harwood34 (1999) USA White 393:202 C/C ≥ 65 White 392 AD Age, sex White ≤ 10 years White 3.10 (1.80–5.9)
Hispanic 188 AD >10 years 1
Hispanic 188:84 C/C Hispanic ≤ 10 years Hispanic 1.10 (0.60–1.80)^
>10 years 1
Munoz35 (2000) Canada, WODS 115:142 C/C ≥ 65 115 AD Unadjusted None UniversityŦ* 2.11 (0.49–9.01)^
1
Mortimer36 (2003) USA, Nun Study 294 ≥ 75 60 TD Age, head circumference, Years of EducationŦ 1.19 (1.09–1.30) <0.001
APOE4
Roe37 (2007) USA ADRC data 1835 (CERAD) ≥ 65 265 AD Age at death, sex, stroke, Years of educationŦ 1.09 (1.01–1.16) 0.03
depression, time to death,
neuropathology diagnosis
stage
ASIA (N=13)
Zhang2 (1990) China 5055 ≥ 55 159 TD Unadjusted No education > 6 years* 5.78 (3.62–9.24)
1
Kondo38 (1994) Japan 60:120 C/C ≥ 43 60 TD Unadjusted Elementary (6yrs) > Elementary 3.14 (not given) <0.001
1
Chandra15 (1998) India Indo-US study 5126 ≥ 55 32 AD Age Illiterate LiterateŦ* 2.50 (0.67–10.00)^ 0.10 1.11 (0.50–2.50)^
36 TD 1 1
(CDR≥1.0)
Lin39 (1998) Taiwán 2915 ≥ 65 58 AD Age, sex Years of educationŦ 1.16 (1.02–1.33) 0.05 1.04 (0.98–1.11)^
108 TD
Liu40 (1998) China, KINDS 1736 ≥ 65 35 AD Age 0 years 1.43 (0.44–4.76)^ 0.14 2.33 (0.76–7.14)^ 0.56
44 TD > 0 yearsŦ 1 1
Japan, AHS/RERF 2222 ≥ 60 74 AD Age 1.67 (1.11–2.50)
Yamada41 (1999) Years of Education Ŧ (In 3 yr
intervals)
Zhang42 (2006) China 34,807 ≥ 55 732 AD Age < 1 year 2.50 (1.25–5.00)
> 12 years Ŧ* 1
Zhou43 (2006) China 16,448 ≥ 50 301 AD Unadjusted < 1 (Illiterate) Any Education* 3.05 (2.30–4.03)
1
Galasko44 (2007) Guam 2029 ≥ 65 243 TD Age, sex Years of education Ŧ 1.15 (1.11–1.19)
Llibre Rodriguez45 (2008) China (urban) 10/66 DRSG 1160 ≥ 65 35 TD Unadjusted Linear trend across five categories of 1.04 (0.77–1.41)^
education Ŧ
Page 23

of Dementia
Llibre Rodriguez45 (2008) China (rural) 10/66 DRSG 1002 ≥ 65 24 TD Unadjusted Linear trend across five categories of 1.22 (0.72–2.08)^
education Ŧ
Llibre Rodriguez45 (2008) India (urban) 10/66 DRSG 1005 ≥ 65 90 TD Unadjusted Linear trend across five categories of 0.79 (0.41–1.52)^
Sharp and Gatz
education Ŧ
Llibre Rodriguez45 (2008) India (rural) 10/66 DRSG 999 ≥ 65 80 TD Unadjusted Linear trend across five categories of 3.85 (0.71–20.00)^
education Ŧ
LATIN AMERICA (N=8)
Herrera46 (2002) Brazil 1656 ≥ 65 118 TD Unadjusted Illiterate ≥ 8 years* 3.82 (1.51–9.66)
1
Llibre Rodriguez45 (2008) Cuba 10/66/DRSG 2944 188 TD Unadjusted Linear trend across five categories of 1.16 (1.01–1.33)
education Ŧ
Llibre Rodriguez45 (2008) Dominican Republic 10/66 DRSG 2011 ≥ 65 109 TD Unadjusted Linear trend across five categories of 1.12 (0.91–1.49)^
education Ŧ
Llibre Rodriguez45 (2008) Peru (urban) 10/66 DRSG 1381 ≥ 65 43 TD Unadjusted Linear trend across five categories of 1.37 (1.00–1.85)^
education Ŧ
Llibre Rodriguez45 (2008) Venezuela 10/66 DRSG 1904 ≥ 65 36 TD Unadjusted Linear trend across five categories of 1.47 (1.03–2.13)
education Ŧ
Llibre Rodriguez45 (2008) Mexico (urban) 10/66 DRSG 1002 ≥ 65 41 TD Unadjusted Linear trend across five categories of 2.17 (1.56–3.03)
education Ŧ
Llibre Rodriguez45 (2008) Mexico (rural) 10/66 DRSG 1000 ≥ 65 22 TD Unadjusted Linear trend across five categories of 0.68 (0.42–1.10)^
education Ŧ
Scazufca47 (2008) Brazil, SPAH 2005 ≥ 65 100 TD Age, sex Illiterate Literate 1.83 (1.18–2.86) 0.01
1
MIDDLE EAST (N=2)
Bowirrat48 (2001) Israel 821 ≥ 60 168 AD Unadjusted Illiterate ≥ 1 years 9.0 (4.4–19.00) 0.01
1
Israel 1501 ≥ 75 165 TD Age, sex, ethnic origin 3.99 (1.84–8.68) 0.000
Kahana49 (2003) Illiterate ≥ 12 years*
1
AFRICA (N=1)
Hall33 (1998) Africa, Nigeria 2494 ≥ 65 18 AD Age, sex No Education Any Education 2.15 (0.37–12.36)^
1
Note.
Ŧ
The reciprocal of original reported risk estimate is presented so that all studies are low education compared to high education.
*
Study reported results for 3 or more categories of education, but we present the lowest level compared to the highest level of education
Page 24
^
Result not significant: 95% Confidence Interval includes 1.00 or p > 0.05.
AD = Alzheimer’s disease; TD= Total Dementia; CI = Confidence Interval; C/C= case control.
Study Acronyms: Turkish Alzheimer Prevalence Study (TAPS), Cardiovascular Risk Factors, Aging, and Dementia (CAIDE), Canadian Study of Health and Aging (CSHA), Western Ontario Dementia Study (WODS), Alzheimer’s Disease Research Center (ADRC), Kinmen
Neurological Disorders Survey (KINDS), Adult Health Study (AHS)/Radiation Effects Research Foundation (RERF), 10/66 Dementia Research Study Group (DRSG), San Paulo Ageing & Health Study (SPAH).
Sharp and Gatz
Page 25
TABLE 2
Study Results for Low Education and Dementia Incidence (N=42)
OR/RR/HR (95% CI)

Number & Type of Dementia
Sharp and Gatz
EUROPE (N=19)
Bickel50 (1994) Germany 422 ≥ 65 60 TD Age Elementary only > Elementary 1.48 (0.60–3.40)^
1
Paykel51 (1994) United Kingdom 1195 ≥ 75 49 TD Age <14 years Not given n.s.
≥ 14 years 1
Persson52 (1996) Sweden 374 ≥ 70 38 TD Unadjusted > Elementary Any vocational Not given n.s.
1
Schmand53 (1997) Amsterdam, AMSTEL 2063 ≥ 65 152 TD Age, sex, DART-IQ, occupation, ≥ 8 years 0.86 (0.57–1.31)^
management, # of diseases, family >8 years 1
history
Geerlings54 (1999) Netherlands, AMSTEL 3778 ≥ 55 77 AD Age, sex ≥ 6 years 2.09 (1.29–3.38)
> 6 years 1
Launer55 (1999) Europe, EURODEM 12,943 ≥ 65 352 AD Age, age-squared, sex, study Women 4.55 (1.64–12.57)
< 8 years 1
> 11 years
Men < 8 years 1.00 (0.48–2.04)^
> 11 years 1
Letenneur56 (1999) France, PAQUID study 2881 ≥ 65 140 AD Age, sex < Primary school 1.81 (1.30–2.53) <0.001 1.83 (1.37–2.44) <0.001
190 TD ≥ Primary school 1 1
Nielsen57 (1999) Denmark, Odense Study 2452 ≥ 65 102 AD Unadjusted < 7 years Not given 0.003
≥ 7 years
Ott58 (1999) Netherlands, Rotterdam Study 6827 ≥ 55 97 AD Age, Age-squared Women < 7 years ≥ 11 years* 2.00 (1.00–3.90)^ 2.10 (1.10–3.90)
137 TD 1 1
Men < 7 years ≥ 11 years* 0.60 (0.20–1.70)^ 0.70 (0.30–1.50)^

1 1
Gatz25 (2001) Sweden 54:108 AD C/C ≥ 65 54 AD Age, sex ≤ 6 years 2.17 (0.69–6.86)^ 1.25 (0.60–2.60)^
90:180 TD C/C 90 TD >6 years 1 1
Qiu59 (2001) Sweden, Kungsholmen Project 1296 ≥ 75 109 AD Age, sex < 8 years 2.70 (1.40–5.00) 2.10 (1.30–3.50)
147 TD ≥ 11 years* 1 1
Anttila60 (2002) Finland 1449 ≥ 65 70 TD Unadjusted Years of Education Ŧ 1.22 (1.11–1.35)
Di Carlo61 (2002) Italy, ILSA 3208 ≥ 65 67 AD 127 TD Age, sex 0–5 years 2.94 (1.04–8.33) 2.27 (1.18–4.35)
11 years Ŧ* 1 1
Page 26
OR/RR/HR (95% CI)

Karp62 (2004) Sweden, Kungsholmen Project 931 ≥ 75 76 AD Age, sex 2–7 years 2.70 (1.30–5.40) 2.40 (1.30–4.40)
101 TD >10 years* 1 1
Ravaglia63 (2005) Italy, CSBA 937 ≥ 65 72 AD Age, sex ≤ 3 years 2.66 (1.02–6.89) 0.04 2.20 (1.07–4.53) 0.03
Sharp and Gatz
115 TD ≥ 6 years* 1 1
Brayne64 (2010) Europe, EClipSE 872 >65 486 TD Unadjusted Years of Education Ŧ 1.12 (1.06–1.20)
NORTH AMERICA (N=18)

Beard65 (1992) USA, Rochester Epidemiology Project 241:241 C/C Not given 241 AD Unadjusted < 9 years 1.13 (0.69–1.85)^
≥ 9 years Ŧ 1
Hebert66 (1992) USA East Boston Study 513 ≥ 65 76 AD Unadjusted 0–7 years 3.79 (2.29–6.26)
≥ 8 years Ŧ 1
Stern67 (1994) USA 593 ≥ 60 106 TD Age, sex < 8 years 2.02 (1.33–3.06)
≥ 8 years 1
Cobb68 (1995) USA, Framingham Study 3330 ≥ 55 149 AD Age < Grade School 1.04 (0.62–1.74)^ 1.31 (0.90–1.90)^
258 TD ≥ High School* 1 1
Evans69 (1997) USA, Boston (EPESE) 642 ≥ 65 95 AD Age, sex, follow-up interval Years of Education Ŧ 1.20 (1.09–1.33)
Elias70 (2000) USA Framingham Study 1076 ≥ 65 109 AD Unadjusted ≤ 8th grade 0.75 (0.33–1.69)^
>High School 1
Ganguli16 (2000) USA MoVIES Project 1298 ≥ 65 94 AD Age, sex < High School Not given^ n.s. Not given^ n.s.
110 TD (CDR ≥ 1.0) ≥ High School 1 1
Kawas71 (2000) USA, BLSA 1236 ≥ 55 114 AD Age, sex 4–12 years 1.56 (0.84–2.94)^ 0.16
17–25 years Ŧ* 1
Lindsay72 (2002) Canada, CSHA 194:3894 C/C 65 194 AD Age, sex 0–8 years 1.90 (1.25–2.90)
≥ 13 years* 1
Kukull73 (2002) USA, ACT – Seattle 2356 ≥ 65 151 AD Age, sex, APOE <12 years 2.08 (1.19–3.70) 1.56 (1.00–2.50)^
215 TD >15 years Ŧ* 1 1
Wilson74 (2002) USA, Religious Orders Study 801 ≥ 65 111 AD Age, sex Years of Education Ŧ 0.99 (0.93–1.05)^
Kuller75 (2003) USA CHS-CS 3608 ≥ 65 480 TD Age < 8th grade 1.70 (1.16–2.41)
≥ 17 years* 1
Tuokko76 (2003) Canada, CSHA 838 ≥ 65 230 TD Age, sex ≤ 6 years 1.10 (1.06–1.15) <0.01
≥ 11 years 1
Fitzpatrick77 (2004) USA, CHS White 2867 ≥ 65 White 401 TD Age White < High School Not given <0.0001
≥ Some College* 1
Black 492 Black 76 TD Age Black < High School Not given^ 0.79
≥ Some College* 1
Page 27
OR/RR/HR (95% CI)

Shadlen78 (2006) USA, CHS White 2,102 Not given White 401 TD Age, sex, ascertainment method White ≤ 10 years 1.8 (1.39–2.23)
> 10 years 1
Black 207 Black 76 TD Black ≤ 10 years 4.6 (3.13–6.82)
> 10 years (white) 1
Sharp and Gatz
McDowell79 (2007) Canada, CSHA 5177 ≥ 65 532 AD 783 TD Age, sex, marital status < 6 years 2.60 (1.91–3.53) 2.60 (2.02–3.38)
≥ 13 years* 1 1
ASIA (N=5)
Li80 (1991) China 1090 ≥ 60 13 TD Age Illiterate Literate 2.47 (not given)^ 0.10
1
Yoshitake81 (1995) Japan, Hisayama Study 828 ≥ 65 42 AD Age ≤ 6 years 1.18 (0.61–2.27)^
> 6 years 1
Liu82 (1998) Taiwan 1507 ≥ 65 25 AD Age, sex Illiterate Literate Ŧ 1.39 (0.52–3.70)^ 1.59 (0.85–2.94)^
60 TD 1 1
He83 (2000) China 3024 ≥ 55 92 AD Age, sex Illiterate Any education* 3.22 (2.15–4.82)
1
Yamada84 (2008) Japan, AHS/RERF 2286 ≥ 65 80 AD Age, age2, sex, sex* age ≤ 6 years 2.50 (not given) 0.001 1.67 (not given) 0.003
206 TD ≥7 years Ŧ 1 1
LATIN AMERICA (N=1)

Nitrini85 (2004) Brazil 1538 ≥ 65 50 TD Unadjusted Illiterate (0) 2.07 (0.60–7.09)^
≥ 8 years* 1
Note.
Ŧ
Reciprocal of original study risk estimate is given so that all studies are low education compared to high education.
*
Original study reported results for 3 or more categories of education, here we report the lowest level compared to the highest level of education.
^
Result not significant: 95% Confidence Interval includes 1.00 or p > 0.05.
AD = Alzheimer’s disease; TD= Total Dementia; CI = Confidence Interval; C/C= case control; OR= Odds Ratio; RR=Relative Risk; HR=Hazard Ratio.
Study Acronyms: Amsterdam Study of the Elderly (AMSTEL), European Studies of Dementia (EURODEM), Italian Longitudinal Study of Aging (ILSA), Conselice Study of Brain Aging (CSBA), Epidemiological Clinicopathological Studies in Europe (EClipSE), Established
Populations for Epidemiologic Studies of the Elderly (EPESE), Monongahela Valley Independent Elders Survey (MoVIES), Baltimore Longitudinal Study of Aging (BLSA), Canadian Study of Health and Aging (CSHA), Adult Changes in Thought (ACT), Cardiovascular
Health Study Cognition Study (CHS-CS), Cardiovascular Heatlh Study (CHS), Adult Health Study (AHS)/Radiation Effects Research Foundation (RERF).
Page 28

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Alzheimer Dis Assoc Disord. 2011 October ; 25(4): 289–304. doi:10.1097/WAD.0b013e318211c83c.

The Relationship between Education and Dementia An Updated

education as a proxy for a third variable(s). However, it remains unclear as to what

Education and Dementia Prevalence Studies

Education and Dementia Incidence Studies

Multiple Categories of Education

in Europe, 27 in North America, 18 in Asia (including one study in Guam), 9 in Latin

Age, Gender, and Race/Ethnicity

Differences across study populations

education and dementia.

groups.89 In an entirely African American sample in Indianapolis, Indiana, Hall and

when evaluating illiterate or uneducated individuals.5,15,80

A number of studies have evaluated potential mediators of the relationship between

STRENGTHS AND LIMITATIONS

education, that either increase or decrease an individual’s risk for dementia.

43:13–20. [PubMed: 8423876]

disease: a case-control study of an Italian population. Neurology. 1986; 36:922–931. [PubMed:

94. Stern Y. Cognitive Reserve. Neuropsychologia. 2009; 47:2015–2028. [PubMed: 19467352]

147. [PubMed: 14717632]

Number & Type Odds Ratios (95% CI)

Number & Type Odds Ratios (95% CI)

Number & Type Odds Ratios (95% CI)

OR/RR/HR (95% CI)

Men < 7 years ≥ 11 years* 0.60 (0.20–1.70)^ 0.70 (0.30–1.50)^

Anttila60 (2002) Finland 1449 ≥ 65 70 TD Unadjusted Years of Education Ŧ 1.22 (1.11–1.35)

OR/RR/HR (95% CI)

NORTH AMERICA (N=18)

OR/RR/HR (95% CI)

LATIN AMERICA (N=1)

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