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Division of General Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
b
Veterans Affairs Center for Practice Management and Outcomes Research, Ann Arbor, MI, USA
c
Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
d
Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, WA, USA
e
Department of Medicine, Division of Geriatric Medicine, University of Pennsylvania, Philadelphia, PA, USA
f
Department of Economics, Harvard University, and the National Bureau of Economic Research, Cambridge, MA, USA
g
Department of Psychiatry, Bioethics Program, and Center for Behavioral and Decision Sciences in Medicine, University of Michigan,
Ann Arbor, MI, USA
Abstract
Background: Recent medical, demographic, and social trends might have had an important impact
on the cognitive health of older adults. To assess the impact of these multiple trends, we compared
the prevalence and 2-year mortality of cognitive impairment (CI) consistent with dementia in the
United States in 1993 to 1995 and 2002 to 2004.
Methods: We used data from the Health and Retirement Study (HRS), a nationally representative
population-based longitudinal survey of U.S. adults. Individuals aged 70 years or older from the
1993 (N 7,406) and 2002 (N 7,104) waves of the HRS were included. CI was determined by
using a 35-point cognitive scale for self-respondents and assessments of memory and judgment for
respondents represented by a proxy. Mortality was ascertained with HRS data verified by the
National Death Index.
Results: In 1993, 12.2% of those aged 70 or older had CI compared with 8.7% in 2002 (P .001).
CI was associated with a significantly higher risk of 2-year mortality in both years. The risk of death
for those with moderate/severe CI was greater in 2002 compared with 1993 (unadjusted hazard ratio,
4.12 in 2002 vs 3.36 in 1993; P .08; age- and sex-adjusted hazard ratio, 3.11 in 2002 vs 2.53 in
1993; P .09). Education was protective against CI, but among those with CI, more education was
associated with higher 2-year mortality.
Conclusions: These findings support the hypothesis of a compression of cognitive morbidity
between 1993 and 2004, with fewer older Americans reaching a threshold of significant CI and a
more rapid decline to death among those who did. Societal investment in building and maintaining
cognitive reserve through formal education in childhood and continued cognitive stimulation during
work and leisure in adulthood might help limit the burden of dementia among the growing number
of older adults worldwide.
2008 The Alzheimers Association. All rights reserved.
Keywords:
1. Introduction
*Corresponding author. Tel.: 734-615-8341; Fax: 734-936-8944.
E-mail address: klanga@umich.edu
Dementia, a decline in memory and other cognitive functions that leads to a loss of independent function [1], is a
common geriatric syndrome that exacts considerable impact
1552-5260/08/$ see front matter 2008 The Alzheimers Association. All rights reserved.
doi:10.1016/j.jalz.2008.01.001
135
wealth is associated with lower levels of disability throughout the life course, likely through multiple causal pathways
[30,31], and might have contributed to declining levels of
dementia during the past 15 years.
To investigate the impact of these multiple trends on
dementia prevalence and mortality, we used a large nationally representative study of older Americans to identify
individuals with cognitive impairment (CI) consistent with
dementia in 1993 and 2002 and then followed each cohort
to determine 2-year mortality for those with and without
impairment.
2. Methods
2.1. Data and study population
We used data from the 1993 and 2002 waves of the
Health and Retirement Study (HRS) [32]. In selecting our
study samples from the HRS, our main analytic goal was to
identify two similar nationally representative cohorts of
older individuals (age 70 or older) in 1993 and 2002, characterize their cognitive function by using the same cognitive
tests in each year, and then follow each cohort for 2 years to
determine mortality for individuals with (1) normal cognitive function and (2) CI consistent with dementia. The CI
category was further subdivided into mild CI and moderate/
severe CI (described more fully below).
The HRS is a biennial, longitudinal, nationally representative survey of U.S. adults, but new cohorts have been
entered into the study at different times [33]. As a result,
3,419 individuals in our analysis were included in both the
1993 and 2002 cohorts, whereas 4,024 were included only
in 1993 and 4,205 only in 2002. The standard errors for all
parameter estimates and the P values for statistical tests
comparing results across the 1993 and 2002 cohorts were
adjusted for this overlap in samples [34].
The 1993 wave of the HRS was limited to individuals
who were living in the community (ie, not residing in
nursing homes). Of the 7,443 HRS respondents who were
70 or older at the time of their 1993 interview, 793 (10.7%)
had died by the 1995 interview, and 24 (0.3%) had unknown
status. The 2002 wave of the HRS included both communitydwelling and institutionalized adults. Of the 7,624 respondents who were 70 or older at the time of the 2002 interview, 473 (6.2%) were in a nursing home at the time of
interview. These respondents were excluded from the analysis to ensure comparable community-dwelling cohorts in
both years. Of the remaining 7,151 respondents, 722
(10.1%) died by the 2004 interview, and 33 (0.5%) had
unknown status. We excluded the small number of respondents with unknown vital status at the 2-year follow-up. The
overall response rate for the HRS survey was 80.4% in 1993
and 86.9% in 2002 [33].
The Social Sciences Institutional Review Board at the
University of Michigan approved the HRS, and the Medical
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Table 1
Characteristics of the 1993 and 2002 study cohorts
Variable
Age (y)
70 to 79
80 to 89
90
Mean SE
Race
White
Black
Other
Gender
Male
Female
Education (y)
12
12
13 to 15
16
Mean SE
Net worth (1993 $)
43,500
43,500 to 167,100
167,100
Mean SE
Potential caregiver network
Spouse present
Living child
No. of ADLs impaired
0
1 to 3
4 to 6
Mean SE
No. of IADLs impaired
0
1 to 3
4 to 5
Mean SE
Chronic conditions
Stroke
Diabetes
Heart disease
Hypertension
Lung disease
Cancer
Psychiatric problem
BMI (kg/m2)
18.5
18.5 to 24.9
25.0 to 29.9
30.0
Smoking status
Never
Former
Current
Respondent type
Self
Proxy
1993 (N 7,406)
2002 (N 7,104)
4,860 (67.0)
2,248 (29.1)
298 (3.9)
77.5 0.1
4,494 (64.6)
2,258 (31.2)
352 (4.3)
77.8 0.9
6,237 (90.2)
1,014 (8.0)
154 (1.8)
6,096 (89.4)
793 (7.7)
207 (2.9)
2,886 (40.0)
4,520 (60.0)
2,990 (40.8)
4,114 (59.2)
3,337 (42.0)
2,151 (30.6)
1,055 (14.8)
863 (12.7)
11.0 .09
2,350 (31.2)
2,370 (34.1)
1,194 (17.2)
1,190 (17.4)
11.8 .10
2,668 (32.5)
2,667 (36.8)
2,071 (30.6)
179,000 8,400
1,968 (26.8)
2,202 (30.7)
2,934 (42.5)
284,000 10,900
3,625 (50.4)
6,433 (87.1)
3,745 (50.1)
6,484 (90.4)
5,160 (70.8)
1,751 (23.0)
495 (6.2)
0.67 0.02
4,989 (70.9)
1,676 (23.3)
439 (5.8)
0.66 0.02
5,112 (70.3)
1,955 (25.5)
339 (4.2)
0.56 0.02
5,631 (80.0)
1,141 (15.9)
329 (4.2)
0.44 0.02
785 (10.5)
987 (12.4)
2,339 (32.0)
3,694 (49.1)
842 (11.9)
1,014 (14.0)
805 (10.8)
774 (10.7)
1,310 (17.8)
2,448 (34.1)
4,228 (59.6)
768 (11.0)
1,287 (18.4)
942 (13.2)
295 (4.0)
3,320 (46.6)
2,637 (35.7)
1,050 (13.7)
243 (3.4)
2,858 (41.1)
2,653 (37.7)
1,261 (17.8)
3,508 (47.8)
3,113 (42.5)
729 (9.7)
3,128 (44.6)
3,381 (47.6)
541 (7.7)
6,621 (89.7)
785 (10.3)
6,295 (89.9)
809 (10.1)
P value*
.08
.02
.004
.1
.001
.001
.001
.001
.9
.001
.7
.7
.001
.001
.7
.001
.005
.001
.1
.001
.001
.001
.001
.7
NOTE. Values in parentheses are weighted percentages derived by using the HRS respondent population weights to adjust for the complex sampling design of
the HRS survey.
Abbreviation: SE, standard error.
* P value for 2 or t test for a significant difference in proportion or mean between years.
Includes eating, transferring, toileting, dressing, bathing, and walking across a room.
Includes preparing meals, grocery shopping, making phone calls, taking medications, managing money.
1993 (N 7,393)
2002* (N 7,083)
Normal
Mild CI
Moderate/severe CI
6,354 (87.8)
440 (5.2)
599 (7.0)
6,413 (91.3)
257 (3.5)
413 (5.2)
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Table 3
ORs for presence of CI in 1993 and 2002 (N 14,476)
Model 1
Model 2
Model 3
Model 4
Model 5
Model 6
Model 7
0.68 (0.600.77)
0.65 (0.580.73)
0.76 (0.670.86)
0.80 (0.700.91)
0.77 (0.670.87)
0.74 (0.640.86)
0.72 (0.620.83)
Age (y)
70 to 79
80 to 89
90
Reference
2.38 (2.082.73)
6.82 (5.678.21)
Reference
2.21 (1.932.52)
5.56 (4.576.75)
Reference
2.11 (1.842.41)
5.00 (4.116.08)
Reference
2.30 (1.982.67)
5.86 (4.717.29)
Reference
2.27 (1.982.61)
5.63 (4.517.04)
Reference
2.34 (2.072.72)
6.01 (4.847.46)
Female gender
0.83 (0.720.95)
0.83 (0.720.96)
0.72 (0.620.82)
0.77 (0.660.89)
0.79 (0.660.94)
0.76 (0.640.90)
Reference
0.32 (0.280.38)
0.24 (0.190.29)
0.19 (0.150.24)
Reference
0.40 (0.350.47)
0.32 (0.260.40)
0.29 (0.220.37)
Reference
0.44 (0.380.51)
0.35 (0.280.43)
0.30 (0.230.39)
Reference
0.44 (0.380.51)
0.35 (0.280.44)
0.30 (0.230.39)
Reference
0.45 (0.390.52)
0.36 (0.290.45)
0.30 (0.230.39)
Reference
0.50 (0.430.57)
0.34 (0.280.41)
Reference
0.55 (0.470.63)
0.38 (0.330.46)
Reference
0.58 (0.500.66)
0.42 (0.350.51)
Reference
0.59 (0.510.68)
0.44 (0.360.53)
Race
White
Black
Other
Reference
2.38 (1.972.86)
2.35 (1.703.26)
Reference
2.52 (2.113.02)
2.60 (1.883.61)
Reference
2.61 (2.193.12)
2.60 (1.853.67)
Caregiver network
Spouse present
1.17 (1.011.36)
1.19 (1.031.38)
1.19 (1.031.37)
Living child
1.02 (0.821.28)
1.01 (0.811.25)
1.02 (0.831.26)
Cardiovascular risks
Stroke
Diabetes
Hypertension
2.86 (2.493.29)
1.08 (0.921.26)
0.84 (0.730.96)
2.86 (2.483.29)
1.07 (0.911.25)
0.82 (0.710.94)
Obesity
0.90 (0.731.11)
0.90 (0.731.11)
Heart disease
0.94 (0.811.10)
0.92 (0.791.07)
Smoking status
Never
Former
Current
Reference
0.99 (0.831.18)
1.14 (0.851.54)
Reference
0.98 (0.831.13)
1.12 (0.831.52)
Education (y)
12
12
13 to 15
16
Net worth (1993 $)
43,500
43,500 to 167,100
167,100
0.97 (0.801.17)
0.92 (0.771.12)
Psychiatric problem
1.86 (1.622.14)
NOTE. CI includes those with mild, moderate, or severe CI. 95% confidence intervals are in parentheses. Adjusted ORs derived by using a logistic regression model with pooled 1993 (N 7,393) and
2002 (N 7,083) data, with CI (mild, moderate, or severe) as the dependent variable. Values greater than 1 indicate increased odds of CI.
Variable
1993 (N 7,393)
2002 (N 7,098)
8.6 (7.69.6)
18.5 (14.822.1)
25.9 (21.530.3)
8.2 (7.58.9)
16.8 (12.421.1)
29.8 (24.934.6)
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Table 5
Unadjusted and adjusted HRs for 2-year mortality, 1993 and 2002 cohorts
1993
Unadjusted
Fully adjusted*
Unadjusted
Fully adjusted*
Reference
2.24 (1.852.72)
3.36 (2.744.13)
Reference
1.90 (1.562.30)
2.53 (2.043.14)
Reference
1.57 (1.232.00)
1.84 (1.412.40)
Reference
2.16 (1.592.94)
4.12 (3.225.26)
Reference
1.82 (1.342.47)
3.11 (2.344.12)
Reference
1.03 (0.651.65)
1.88 (1.332.65)
Education (y)
12
12
1315
16
Reference
0.86 (0.701.04)
0.85 (0.681.06)
0.84 (0.591.21)
Reference
0.82 (0.661.02)
0.64 (0.510.81)
0.88 (0.661.19)
1.44 (0.702.95)
0.63 (0.066.59)
2.25 (0.955.34)
1.85 (1.053.28)
2.69 (1.206.00)
1.14 (0.324.05)
3.65 (1.747.67)
2.87 (1.057.90)
0.40 (0.04 3.73)
1.71 (0.853.44)
2.93 (1.068.07)
2.44 (0.787.62)
P .09 for comparison of age- and sex-adjusted HRs in 2002 vs 1993 (3.11 vs 2.53).
Cognitive function
Normal
Mild CI
Moderate/severe CI
2002
from which were used for this analysis. The Health and
Retirement Study is performed at the Survey Research Center, Institute for Social Research, University of Michigan.
Additional support was provided by grants from the NIA
(R01 AG015911, R01 AG019805, and R01 AG027010) and
the Harvard University Interfaculty Program for Health Systems Improvement. Dr Langa was supported by a Career
Development Award from the National Institute on Aging
(K08 AG019180) and a Paul Beeson Physician Faculty
Scholars in Aging Research award. Dr Karlawish was supported by a Greenwall Faculty Scholar in Ethics and NIH
grants P30 AG10124, R01 AG020627, R01 MH071634. Dr
Larson was supported by NIA grant U01 AG06178.
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