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Meta-Analysis
. 2025 Mar 3;8(3):e252002.
doi: 10.1001/jamanetworkopen.2025.2002.

Education Levels and Poststroke Cognitive Trajectories

Mellanie V Springer  1   2 , Rachael T Whitney  3   4 , Wen Ye  5 , Emily M Briceño  1   3   4   6 , Alden L Gross  7 , Hugo J Aparicio  8   9 , Alexa S Beiser  8   9   10 , James F Burke  11 , Mitchell S V Elkind  12   13 , Rebecca A Ferber  3 , Bruno Giordani  14 , Rebecca F Gottesman  15 , Rodney A Hayward  2   3   4   16 , Virginia J Howard  17 , Adam S Kollipara  3   4 , Silvia Koton  7   18 , Ronald M Lazar  19 , W T Longstreth Jr  20   21 , Sarah T Pendlebury  22   23   24 , Jeremy B Sussman  2   3   4   16 , Evan L Thacker  25 , Deborah A Levine  1   2   3   4
Affiliations
Meta-Analysis

Education Levels and Poststroke Cognitive Trajectories

Mellanie V Springer et al. JAMA Netw Open. .

Abstract

Importance: Acute stroke is associated with accelerated, years-long cognitive decline. Whether education levels are associated with faster cognitive decline after stroke is unclear.

Objective: To evaluate the association of education level with poststroke cognitive decline and to determine whether age at stroke modifies the association.

Design, setting, and participants: Individual participant data meta-analysis of 4 US cohort studies (January 1971 to December 2019). Analysis began August 2022 and was completed in January 2024.

Exposures: Education level (less than high school, completed high school, some college, and college graduate).

Main outcomes and measures: Harmonized cognitive outcomes were global cognition (primary outcome), memory, and executive function. Outcomes were standardized as t scores (mean [SD], 50 [10]); a 1-point difference represents a 0.1-SD difference in cognition, with higher score representing better function. Linear mixed-effect models estimated the trajectory of cognitive decline after incident stroke.

Results: The analysis included 2019 initially dementia-free stroke survivors (1048 female [51.9%]; median [IQR] age at stroke, 74.8 [69.0-80.4] years; 339 with less than a high school education [16.7%]; 613 who completed high school [30.4%]; 484 with some college [24.0%]; 583 with a college degree or higher [28.9%]). Median (IQR) follow-up time after stroke was 4.1 (1.8-7.2) years. Compared with those with less than a high school degree, college graduates had higher initial poststroke performance in global cognition (1.09 points higher; 95% CI, 0.02 to 2.17 points higher), executive function (1.81 points higher; 95%CI, 0.38 to 3.24 points higher), and memory (0.99 points higher; 95% CI, 0.02 to 1.96 points higher). Compared with stroke survivors with less than a high school education, there was a faster decline in executive function among college graduates (-0.44 points/y faster; 95% CI, -0.69 to -0.18 points/y faster) and those with some college education(-0.30 points/y faster; 95% CI, -0.57 to -0.03 points/y faster). Education level was not associated with declines in global cognition or memory. Age did not modify the association of education with cognitive decline.

Conclusions and relevance: In this pooled cohort study, the trajectory of cognitive decline after stroke varied by education level and cognitive domain, suggesting that stroke survivors with a higher education level may have greater cognitive reserve but steeper decline in executive function than those with a lower education level.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Briceño reported receiving grants and personal fees from the National Institutes of Health (NIH) outside the submitted work. Dr Aparicio reported receiving grants from the American Academy of Neurology (Career Development Award) outside the submitted work. Dr Burke reported receiving grants from the NIH outside the submitted work. Dr Giordani reported receiving grants from the NIH outside the submitted work. Dr Howard reported receiving grants from the NIH, National Institute of Neurological Disorders and Stroke (NINDS), and National Institute on Aging (NIA) outside the submitted work. Dr Longstreth reported receiving grants from the NIH outside the submitted work. Dr Thacker reported receiving grants from the NIH and NIA outside the submitted work. Dr Levine reported receiving grants from Northwestern University and the NIH outside the submitted work. No other disclosures were reported.

Figures

Figure.
Figure.. Participant Flow Diagram
See this image and copyright information in PMC

References

    1. Pendlebury ST, Rothwell PM; Oxford Vascular Study . Incidence and prevalence of dementia associated with transient ischaemic attack and stroke: analysis of the population-based Oxford vascular study. Lancet Neurol. 2019;18(3):248-258. doi:10.1016/S1474-4422(18)30442-3 - DOI - PMC - PubMed
    1. Pendlebury ST, Rothwell PM. Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis. Lancet Neurol. 2009;8(11):1006-1018. doi:10.1016/S1474-4422(09)70236-4 - DOI - PubMed
    1. Kessels RP, Eikelboom WS, Schaapsmeerders P, et al. . Effect of formal education on vascular cognitive impairment after stroke: a meta-analysis and study in young-stroke patients. J Int Neuropsychol Soc. 2017;23(3):223-238. doi:10.1017/S1355617716001016 - DOI - PubMed
    1. Levine DA, Galecki AT, Langa KM, et al. . Trajectory of cognitive decline after incident stroke. JAMA. 2015;314(1):41-51. doi:10.1001/jama.2015.6968 - DOI - PMC - PubMed
    1. Levine DA, Wadley VG, Langa KM, et al. . Risk factors for poststroke cognitive decline: the REGARDS study (reasons for geographic and racial differences in stroke). Stroke. 2018;49(4):987-994. doi:10.1161/STROKEAHA.117.018529 - DOI - PMC - PubMed

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