The Effect of Education on the Onset and Rate of Terminal Decline

Differences in the time of onset and magnitude of terminal decline were examined in three cognitive domains: processing speed, episodic memory, and global function. In addition, cognitive reserve was investigated by testing whether education affected the onset or rate of decline across these domains. Eight hundred ninety-six community-dwelling Australian adults aged ≥ 70 years were assessed up to four times over 12 years, with vital status followed for 17 years. For each of the cognitive measures, a series of change point models were fitted across the 20 years before death to find the optimal point at which terminal decline was distinguished from preterminal decline. Change points were then assessed separately for high- and low-education groups. The change points were 8.5 years for processing speed (95% CI: 6.0-11.2 years), 7.1 years for global function (6.2-9.3), and 6.6 years for episodic memory (5.3-7.1). The rate of decline was two to four times greater in the terminal phase relative to the preterminal phase, depending on the domain. Increased education changed the terminal decline effect differently for each of the three tests, either by significantly hastening the onset of terminal decline and decreasing the rate of decline, or by increasing the rate of either preterminal or terminal decline. Analyses were repeated excluding participants diagnosed with dementia, with no substantive change to the outcomes. In conclusion, the rate and onset of terminal decline varied somewhat across cognitive domains. Education affected terminal decline differently across the domains, but this modification was not consistent with the predictions of cognitive reserve theory.