Limited formal education is strongly associated with lower cognitive status, functional disability and frailty status in older adults

Brigola, Allan Gustavo; Alexandre, Tiago da Silva; Inouye, Keika; Yassuda, Monica Sanches; Pavarini, Sofia Cristina Iost; Mioshi, Eneida

doi:10.1590/1980-57642018dn13-020011

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Dementia & Neuropsychologia

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Original Article • Dement. neuropsychol. 13 (2) • Apr-Jun 2019 • https://doi.org/10.1590/1980-57642018dn13-020011 copy

Limited formal education is strongly associated with lower cognitive status, functional disability and frailty status in older adults

Associação entre baixa escolaridade, desempenho cognitivo reduzido, incapacidade funcional e fragilidade em idosos

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT.

Limited formal education is still common in ageing populations. Although limited formal education seems to be independently and negatively associated with cognition, functional abilities and frailty in ageing, no studies have examined whether the gradient of limited formal education has an impact on health in later life.

Objective:

to examine the relationship of limited formal education with cognitive status, functional abilities, and frailty status.

Methods:

a cross-sectional study was conducted involving 540 older adults stratified into groups: no formal education, 12-24 months of education, and 25-48 months of education. Cognitive screening (MMSE), functional abilities (Lawton Index), and frailty (CHS criteria) were measured. Regression analyses were performed.

Results:

27% had no formal education, 21% had 12-24 months of formal education, and 55% had 25-48 months of formal education. Limited formal education has a clear gradient of negative impact: No formal education was associated with scoring below MMSE cut-off scores (OR = 7.9), being totally/partially dependent for IADLs (OR = 2.5) and frail (OR = 2.0). Having 12-24 months of education was associated with scoring below MMSE cut-off scores (OR = 5.2) and with being frail (OR = 2.0). The No formal education group was 10.1 times more likely to have worse cognitive scores, worse functional abilities and frailty/pre-frailty status concomitantly (CCoFF), while older adults who had 12-24 months of education had a 4.6 times greater chance of having CCoFF.

Conclusion:

limited education had a gradient association with cognitive performance, functional disability and frailty. These findings clearly emphasize the importance of prevention through education from childhood to older age.

Key words:
cognition; instrumental activities of daily living; frailty; education; developing countries

		Total (N = 540)	No education (n = 145)^a	12-24 months of education (n = 113)^b	25-48 months of education (n = 282)^c
Age (min 60; max 98), Means (95 CI)^±1 ±1 F = 19.2; p < 0.01; a≠b, a≠c, b = c.		72.1 (71.4-72.7)	75.5 (74.0-77.0)	70.9 (69.5-72.3)	71.0 (69.9-71.6)
Sex (male), % ^#1 #1 Stat = 0.4; p = 0.812; a = b, a = c, c = b.		44.1	42.8	42.5	45.4
Setting (rural), % ^#2 #2 Stat = 20.6; p < 0.01; a≠b, a≠c, b = c.		75.0	89.0 (0.3: 0.2-0.5)	69.0 (1.0: 0.6-1.7)	70.2 (1.0)
Living with someone in marital-like relationship, %^#3 #3 Stat = 10.0; p < 0.01; a≠b, a≠c, b = c.		89.1	82.1 (2.3: 1.3-4.3)	92.0 (0.9: 0.4-2.1)	91.5 (1.0)
Occupation, %	Retired	63.9	68.3	54.0	65.6
	Retired with casual work	12.0	11.7	10.6	12.8
	In full-time work	5.6	2.8	5.3	7.1
	Doing unpaid work	18.5	17.2	30.1	14.5
Cognition: MMSE (max score 30) Means (95 CI)^±2 ±2 F = 104.1; p < 0.01; a≠b, a≠c, b≠c.		21.00 (20.6-21.4)	17.0 (16.3-17.9)	20.1 (19.3-21.0)	23.3 (22.9-23.8)
Proportion of older adults who scored below cut-off (MMSE), %		44.3	73.1	60.2	23.0
IADL: Lawton & Brody Index (max score 21) Means (95 CI) ^±3 ±3 F = 23.8; p < 0.01;a≠b, a≠c, b = c.		16.6 (16.2-16.9)	14.6 (13.9-15.3)	17.4 (16.7-18.0)	17.2 (16.8-17.7)
IADLs: totally dependent, %		4.3	6.49	2.7	3.5
IADLs: partially dependent, %		75.0	82.1	75.2	71.3
Frailty criteria (n of factors max 5) Means (95 CI)^±4 ±4 F = 11.5; p < 0.01; a≠b, a≠c, b = c.		1.7 (1.6-1.8)	2.2 (1.9-2.4)	1.7 (1.4-1.9)	1.5 (1.4-1.8)
Frail, %		27.6	40.0	29.2	20.6
Pre-frail, %		52.2	46.2	52.2	55.3
Non-frail, %		20.2	13.8	18.6	24.1

Variables	MMSE
Variables	Below cut-off (MMSE)
Age >74y	1.6 (1.1-2.5)^* * p < 0.05.
Males	0.8 (0.5-1.3)
Rural setting	0.7 (0.4-1.3)
No formal education	7.9 (4.9-12.6)^* * p < 0.05.
12-24 months of education	5.2 (3.2-8.3)^* * p < 0.05.

Variables	Lawton & Brody Index
Variables	IADL partially/totally dependent
Age >74y	2.3 (1.3-4.0)^* * p < 0.05.
Males	5.3 (3.0-9.2)^ p < 0.01.
Rural setting	0.4 (0.5-1.6)
No formal education	2.5 (1.3-4.7)^ p < 0.01.
12-24 months of education	1.2 (0.7-2.1)

Variables	Frailty groups
Variables	Frail	Pre-frail
Age >74y	7.3 (3.4-15.4)^ p < 0.01.	4.0 (2.0-7.9)^ p < 0.01.
Males	0.4 (0.2-8)^* * p < 0.05.	0.6 (0.3-1.0)
Rural setting	0.2 (0.1-0.5)^ p < 0.01.	0.4 (0.2-0.7)^ p < 0.01.
No formal education	2.0 (1.0-3.9)^* * p < 0.05.	1.0 (0.5-1.9)
12-24 months of education	2.0 (1.0-4.1)^* * p < 0.05.	1.3 (0.7-2.4)

Variables	CCoFF condition
Variables	Concomitant below cut-off (MMSE), at least one IADL dependence and pre-frailty or frailty (CCoFF)
Age >74y	3.3 (1.6-6.9)*
Males	3.7 (1.7-7.7)*
Rural setting	0.7 (0.3-1.4)
No formal education	10.1 (4.3-23.6)**
12-24 months of education	4.6 (2.2-9.8)*

Academia Brasileira de Neurologia, Departamento de Neurologia Cognitiva e Envelhecimento R. Vergueiro, 1353 sl.1404 - Ed. Top Towers Offices, Torre Norte, São Paulo, SP, Brazil, CEP 04101-000, Tel.: +55 11 5084-9463 | +55 11 5083-3876 - São Paulo - SP - Brazil
E-mail: revistadementia@abneuro.org.br | demneuropsy@uol.com.br

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[1] Eneida Mioshi. School of Health Sciences / University of East Anglia - Norwich Research Park - Norwich NR4 7TJ - United Kingdom. E-mail: e.mioshi@uea.ac.uk