Stroke survivors with a college degree experienced faster decline in executive function after stroke despite higher initial cognitive scores than those with less education, according to a recent study.

In a pooled cohort study, researchers evaluated whether educational attainment was associated with poststroke cognitive decline across specific domains, including global cognition, executive function, and memory. The researchers, led by Mellanie V. Springer, MD, MS, of the Department of Neurology and Stroke Program at the University of Michigan in Ann Arbor, analyzed data from 2,019 dementia-free stroke survivors who were enrolled in four U.S.-based longitudinal cohort studies: the Atherosclerosis Risk in Communities study, the Framingham Offspring Study, the Reasons for Geographic and Racial Differences in Stroke study, and the Cardiovascular Health Study. Participants had at least one cognitive assessment prior to and following incident stroke, with a median follow-up period of 4.1 years (interquartile range [IQR] = 1.8–7.2 years).

Education level was categorized as less than a high school diploma, high school graduate, some college education, or a college degree or higher. Cognitive outcomes—global cognition, executive function, and memory—were harmonized across cohorts and standardized as t scores (mean = 50; standard deviation = 10), with higher scores indicating better function. The investigators used linear mixed-effects models to estimate cognitive decline over time and adjusted for prestroke cognition and multiple demographic and clinical covariates.

According to their recent study published in JAMA Network Open, at the time of stroke, participants with a college degree demonstrated significantly higher initial poststroke performance compared with those who had less than a high school education:

• global cognition (mean difference = 1.09 points; 95% confidence interval [CI] = 0.02–2.17)

• executive function (1.81 points; 95% CI = 0.38–3.24)

• memory (0.99 points; 95% CI = 0.02–1.96).

However, these participants experienced a faster rate of decline in executive function after stroke. College graduates declined 0.44 points per year more rapidly than those with less than a high school degree (95% CI = −0.69 to −0.18), and those with some college education declined 0.30 points per year faster (95% CI = −0.57 to −0.03). No significant associations were observed between education level and rates of decline in global cognition or memory. Age at stroke did not modify these associations.

Among the study's limitations were possible limited generalizability among racial or ethnic groups and difficulties with follow-up for patients with more poststroke impairment. The analysis did not include information about how severity of brain atrophy, white matter ischemic disease, or stroke compared in patients who had varying education levels.

These findings indicate that higher education is associated with better initial cognitive performance poststroke but also with steeper declines in executive function, a pattern the researchers suggested may be due to limits in cognitive reserve compensation. "In designing interventions to slow cognitive decline after stroke, researchers should consider evaluating whether the efficacy of such interventions vary by education level," they concluded.

Full disclosures can be found in the published study.