The health status: the ignored risk factor in dementia incidence. NEDICES cohort.

BACKGROUND: The causes of the dementia decrease in affluent countries are not well known but health amelioration could probably play a major role. Nevertheless, although many vascular and systemic disorders in adult life are well-known risk factors (RF) for dementia and Alzheimer disease (AD), health status is rarely considered as a single RF. AIM: To analyse whether the health status and the self-perceived health (SPH) could be RF for dementia and AD and to discuss its biological basis. METHODS: We analysed different objective health measures and SPH as RF for dementia and AD incidence in 4569 participants of the NEDICES cohort by means of Cox-regression models. The mean follow-up period was 3.2 (range: 0.03-6.6) years. RESULTS: Ageing, low education, history of stroke, and "poor" SPH were the main RF for dementia and AD incidence, whereas physical activity was protective. "Poor" SPH had a hazard ratio = 1.66 (95% CI 1.17-2.46; p = 0.012) after controlling for different confounders. DISCUSSION: According to data from NEDICES cohort, SPH is a better predictor of dementia and AD than other more objective health status proxies. SPH should be considered a holistic and biologically rooted indicator of health status, which can predict future development of dementia and AD in older adults. CONCLUSIONS: Our data indicate that it is worthwhile to include the SPH status as a RF in the studies of dementia and AD incidence and to explore the effect of its improvement in the evolution of this incidence.

Predementia constructs: Mild cognitive impairment or mild neurocognitive disorder? A narrative review.

BACKGROUND: Predementia is a heuristic umbrella concept to classify older adults with cognitive impairment who do not suffer dementia. Many diagnostic entities have been proposed to address this concept, but most of them have not had widespread acceptance. AIMS: To review clinical definitions, epidemiologic data (prevalence, incidence) and rate of conversion to dementia of the main predementia constructs, with special interest in the two most frequently used: mild cognitive impairment (MCI) and minor neurocognitive disorder (miNCD). METHODS: We have selected in three databases (MEDLINE, Web of Science and Google scholar) the references from inception to 31 December 2019 of relevant reviews, population and community-based surveys, and clinical series with >500 participants and >3 years follow-up as the best source of evidence. MAIN RESULTS: The history of predementia constructs shows that MCI is the most referred entity. It is widely recognized as a clinical syndrome harbinger of dementia of several etiologies, mainly MCI due to Alzheimer's disease. The operational definition of MCI has shortcomings: vagueness of its requirement of "preserved independence in functional abilities" and others. The recent miNCD construct presents analogous difficulties. Current data indicate that it is a stricter predementia condition, with lower prevalence than MCI, less sensitivity to cognitive decline and, possibly, higher conversion rate to dementia. CONCLUSIONS: MCI is a widely employed research and clinical entity. Preliminary data indicate that the clinical use of miNCD instead of MCI requires more scientific evidence. Both approaches have common limitations that need to be addressed.

Characterizing functional alterations in instrumental activities of daily living using latent class analysis: a population-based study (NEDICES).

Background and Objectives: The existence of different patterns of functional impairment in older adults has scarcely been addressed. This research investigates major patterns of functional impairment based on Pfeffer's Functional Activity Questionnaire (FAQ).Research Design and Methods: The participants come from NEDICES (Neurological Disorders in Central Spain), a prospective population-based cohort study. A total of 3837 individuals without dementia who completed the Spanish version of the FAQ was selected. Latent Class Analysis (LCA) was carried out to examine potential cluster subgroups based on FAQ responses.Results: The FAQ showed good internal consistency (Cronbach's alpha: 0.86) and moderate correlation (r = -.40) with cognitive performance on the Mini-Mental State Examination (MMSE-37). The response patterns revealed the presence of three latent classes: absence of functional alteration (Class 1), established functional alteration (Class 2), and minimal functional alteration (Class 3). Moreover, the probability of resolving Items 2 ('shopping alone for…'), 3 ('heating water…'), 4 ('preparing a balanced meal'), and 9 ('travelling out of neighbourhood…') was close to 0% for Class 2 membership, while those with the lowest probability of resolution for Class 3 were Items 2 and 9. Items 3 and 4 were the best to discriminate between different grades of functional alterations (Class 2 vs. Class 3).Discussion and Implications: Our findings indicate that the combination of overall FAQ score and item response pattern may help to classify individuals with different subtypes of functional impairment. The Spanish version of the FAQ is a useful tool for detection of functional impairment in older adults.

Exploring the association between optimism and quality of life among informal caregivers of persons with dementia.

ABSTRACTObjective:We aimed to analyze the relationship between optimism and quality of life (QoL) among informal caregivers of patients with dementia (PWD). DESIGN: In this cross-sectional study, a hierarchical multiple linear regression analysis was used to determine the association between optimism and caregiver's QoL after controlling the effect of different covariates, including burden. PARTICIPANTS: A sample of 130 PWD and their informal caregivers underwent a comprehensive protocol of assessment. MEASUREMENTS: Caregivers completed the Battery of Generalized Expectancies of Control Scales, the Zarit Burden Interview, and the World Health Organization Quality of Life-Brief as measure of QoL. Optimism was estimated based on the combination of three expectancies of control, namely, self-efficacy, contingency, and success. RESULTS: QoL correlated positively with optimism and negatively with burden. Optimism predicted each dimension of QoL, even after controlling for the effect of sociodemographic, care-recipients' clinical covariates, and burden in all models. CONCLUSION: Optimism consistently predicted well-being and QoL in informal caregivers of PWD.

Family caregivers' perceptions of maltreatment of older adults with dementia: findings from the northwest of Spain.

Dementia is a neurocognitive disorder that implies a risk factor of maltreatment by family caregivers. In this study, we analyzed both informal caregiver's perceptions of maltreatment and aspects of the caregiver and caregiving behavior that may be associated with maltreatment. We conducted five focus groups (FGs) in three Spanish cities: Segovia, Soria and León. The themes that were identified were related to two levels of maltreatment: (a) relational and (b) institutional. At the relational level, we observed the justification of maltreatment of Older Adults with Dementia (OAswD) by family caregivers during the occurrence of behavioral symptoms. At the institutional level, we noted that lack of support from the government was considered a type of maltreatment. These themes suggest that policy issues related to healthcare should be considered.

Spanish version of the Mattis Dementia Rating Scale-2 for early detection of Alzheimer's disease and mild cognitive impairment.

OBJECTIVE: We aimed to analyse the clinical utility of the Mattis Dementia Rating Scale (MDRS-2) for early detection of Alzheimer's disease (AD) and amnestic mild cognitive impairment (MCI) in a sample of Spanish older adults. METHODS: A total of 125 participants (age = 75.12 ± 6.83, years of education =7.08 ± 3.57) were classified in three diagnostic groups: 45 patients with mild AD, 37 with amnestic MCI-single and multiple domain and 43 cognitively healthy controls (HCs). Reliability, criterion validity and diagnostic accuracy of the MDRS-2 (total and subscales) were analysed. The MDRS-2 scores, adjusted by socio-demographic characteristics, were calculated through hierarchical multiple regression analysis. RESULTS: The global scale had adequate reliability (α = 0.736) and good criterion validity (r = 0.760, p < .001) with the Mini-Mental State Examination. The optimal cut-off point between AD patients and HCs was 124 (sensitivity [Se] = 97% and specificity [Sp] = 95%), whereas 131 (Se = 89%, Sp = 81%) was the optimal cut-off point between MCI and HCs. An optimal cut-off point of 123 had good Se (0.97), but poor Sp (0.56) to differentiate AD and MCI groups. The Memory and Initiation/Perseveration subscales had the highest discriminative capacity between the groups. CONCLUSIONS: The MDRS-2 is a reliable and valid instrument for the assessment of cognitive impairment in Spanish older adults. In particular, optimal capacity emerged for the detection of early AD and MCI. Copyright © 2017 John Wiley & Sons, Ltd.

Resilience and social support as protective factors against abuse of patients with dementia: A study on family caregivers.

OBJECTIVE: Scientific literature has identified different vulnerability factors associated to abuse in people with dementia (PWD), but little is known about the psychosocial protective variables against abuse. The main objective of this study is to investigate a set of caregiver and patient factors linked to abuse-related behavior of PWD. METHODS: A total of 326 primary and family caregivers, residents of the Castilla and León community (Spain), were evaluated. All participants filled out a standardized protocol, which assessed the sociodemographic characteristics, patient and care-related variables, as well as the perceived burden, resilience, and social support. Abuse-related behavior was evaluated using the Caregiver Abuse Screen. RESULTS: Results show that the severity of cognitive impairment and behavior disorders of PWD, a greater number of caregiving hours, a worse previous relationship with the caregiver, and perceived burden are positively related with abuse. However, resilience and social support showed a negative relationship with Caregiver Abuse Screen scores, suggesting a protective effect on abuse, even after controlling the effect of a number of covariates. Indeed, resilience was the only variable that remained significant after including the effect of burden. CONCLUSIONS: This paper states the role of burden in abuse of PWD, while resilience and social support are abuse protective factors. These variables should be considered in future guidelines for the prevention of abuse against PWD.

Long-term forgetting in temporal lobe epilepsy: Is this phenomenon a norm?

OBJECTIVES: This research investigated forgetting rates of patients with temporal lobe epilepsy (TLE) at brief and longer intervals. METHODS: The sample is formed by 5 patients with TLE and 10 healthy individuals. One of the patients received the diagnosis of transient epileptic amnesia (TEA). All patients underwent a standardized clinical protocol for diagnosis including a comprehensive neuropsychological assessment. In addition, two experimental tasks were used to assess the forgetting rates at 4 intervals (30s, 10min, 1day, and 1week): a story task to evaluate verbal cued recall and a route task to assess visuospatial cued recall. RESULTS: There were no significant differences between groups in forgetting rates. CONCLUSIONS: These findings suggest that forgetting patterns in patients with TLE may be heterogeneous, and the presence of accelerated long-term forgetting is not universal.

Influence of Educational Attainment on Cognition-Based Intervention Programs for Persons with Mild Alzheimer's Disease.

OBJECTIVES: This research retrospectively analyzed the effect of education on cognitive interventions carried out in patients with mild Alzheimer's disease (AD). METHODS: The total sample consisted of 75 patients with mild AD receiving treatment with cholinesterase inhibitors. The participants were divided into two groups: cognitive intervention (IG; n=45) and waiting list (WLG; n=30). Patients in the IG received either the Big Brain Academy (n=15) or the Integrated Psychostimulation Program (n=30) during 12 weeks. The influence of education on intervention effect was analyzed comparing mean change scores of the two study groups in the cognitive subscale of the Alzheimer's Disease Assessment Scale (ADAS-cog), stratified by educational level. The potential effect of age, sex, cognitive status, and type of intervention was examined using post hoc stratification analyses. RESULTS: Higher education was associated with faster cognitive decline in the WLG (effect size=0.51; p<.01). However, cognitive evolution was not influenced by education in the IG (effect size=0.12; p=.42). CONCLUSIONS: Our results suggest that cognitive intervention might delay accelerated cognitive decline in higher educated individuals with mild AD.

Physical Activity as Protective Factor against Dementia: A Prospective Population-Based Study (NEDICES).

The aim of this study was to analyze whether physical activity (PA) is a protective factor for the incidence of dementia after 3 years of follow-up. The Neurological Disorders in Central Spain (NEDICES) is a prospective population-based survey of older adults (age 65 years and older) that comprised 5278 census-based participants at baseline (1994-1995). A broad questionnaire was used to assess participants' sociodemographic characteristics, health status, and lifestyle. Subsequently, a modified version of Rosow-Breslau questionnaire was applied to classify individuals' baseline PA into groups (i.e., sedentary, light, moderate, and high). Cox regression models adjusted for several covariates (age, sex, education, previous stroke, alcohol consumption, hypertension, health related variables) were carried out to estimate the association between the PA groups and risk of dementia at the 3-year follow-up (1997-1998). A total of 134 incident dementia cases were identified among 3105 individuals (56.6% female; mean age=73.15 ± 6.26) after 3 years. Hazard ratios (HRs) of the light, moderate, and high PA groups (vs. sedentary group) were 0.40 (95% confidence interval {CI} [0.26, 0.62]; p<.001), 0.32 (95% CI [0.20, 0.54]; p<.001) and 0.23 (95% CI [0.13, 0.40]; p<.001), respectively. Even after controlling for covariates and the exclusion of doubtful dementia cases, HRs remained significant. However, a supplementary analysis showed that the dose-effect hypothesis did not reach statistical significance. PA is a protective factor of incident dementia in this population-based cohort.

Effect of unawareness on rehabilitation outcome in a randomised controlled trial of multicomponent intervention for patients with mild Alzheimer's disease.

Unawareness of deficit has been shown to affect the outcome of targeted cognitive intervention programmes applied to patients with Alzheimer' disease (AD), but the effects on multimodal therapeutic approaches have not yet been explored. This research investigated the efficacy of the Multi-Intervention Programme (MIP) approach on improving cognitive, functional, affective, and behavioural symptoms in people with mild AD. In addition, we examined whether the presence of unawareness influences the MIP outcomes. Sixty-one mild stage AD patients were randomly assigned to either an experimental group which carried out an MIP individually (48 sessions, 16 weeks duration), combining diverse cognitive tasks, training in daily life and recreational activities, or a waiting list group which did not receive any treatment for the same time period. The efficacy of MIP (vs. waiting list) was tested using various standardised neuropsychological, functional, and behavioural outcome measures. Planned analyses were carried out to determine the effect of unawareness versus awareness on such outcomes. The results showed that patients overall benefited from the MIP in terms of both cognitive and non-cognitive symptoms. AD patients with awareness of deficits showed positive effects on all outcome measures in comparison with the waiting list group, while AD patients with unawareness showed improvements in non-cognitive symptoms only. In conclusion, the presence of unawareness reduces the cognitive and functional effects of MIP in patients with mild AD.

Neuropsychological Assessment for Early Detection and Diagnosis of Dementia: Current Knowledge and New Insights.

Dementia remains an underdiagnosed syndrome, and there is a need to improve the early detection of cognitive decline. This narrative review examines the role of neuropsychological assessment in the characterization of cognitive changes associated with dementia syndrome at different states. The first section describes the early indicators of cognitive decline and the major barriers to their identification. Further, the optimal cognitive screening conditions and the most widely accepted tests are described. The second section analyzes the main differences in cognitive performance between Alzheimer's disease and other subtypes of dementia. Finally, the current challenges of neuropsychological assessment in aging/dementia and future approaches are discussed. Essentially, we find that current research is beginning to uncover early cognitive changes that precede dementia, while continuing to improve and refine the differential diagnosis of neurodegenerative disorders that cause dementia. However, neuropsychology faces several barriers, including the cultural diversity of the populations, a limited implementation in public health systems, and the adaptation to technological advances. Nowadays, neuropsychological assessment plays a fundamental role in characterizing cognitive decline in the different stages of dementia, but more efforts are needed to develop harmonized procedures that facilitate its use in different clinical contexts and research protocols.

A novel abbreviated version of the Luria neuropsychological diagnosis battery: reliability and convergent validity in Spanish older adults.

OBJECTIVE: To estimate the test-retest and inter-rater reliability of the new Spanish abbreviated version of the Luria Neuropsychological Diagnosis (DNA-2) battery for older adults. METHOD: A total of thirty cognitively healthy volunteers were examined in this study. The participants completed a comprehensive standardized assessment, encompassing cognitive and functional performance. Intraclass correlation coefficients (ICC) were used to examine test-retest and inter-rater reliability. One month was allowed between administrations. Furthermore, correlations between Luria DNA-2 (total and domain subscores) and other classical cognitive measures were explored. RESULTS: The test-retest reliability on the overall Luria DNA-2 score was high (ICC= .834, 95% CI [.680, .917], p < .001). Furthermore, the inter-rater reliability for the total score demonstrated an excellent concordance between administrators (ICC= .990, 95% CI [.979, .995], p < .001). Positive and significant correlations were observed between Luria DNA-2 (both total and domain subscores) and the Addenbrooke's Cognitive Examination (ACE-III; ρ = .857, p < .001). CONCLUSIONS: This study supports the adequate reliability of the Luria DNA-2, as an abbreviated neuropsychological battery, for assessing cognitive performance in Spaniards aged 55 years and older. Future studies should continue to explore the psychometric properties of the Luria DNA-2, particularly those related to its diagnostic validity for early detection of cognitive impairment.

Is cognitive reserve associated with the prevention of cognitive decline after stroke? A Systematic review and meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analyses of the effect of socio-behavioral cognitive reserve (CR) proxies on cognitive decline after stroke. METHOD: Three journal search and indexing databases (PubMed, Scopus and Web of Sciences) were crossed to examine the scientific evidence systematically. In addition, meta-analytic techniques, using mixed-effect methods, were carried out to estimate the impact (pooled effect size) of CR proxies on either dementia incidence or cognitive decline after stroke. RESULTS: Twenty-two studies were included in the systematic revision, whereas nineteen of them were eligible for the meta-analysis. The findings showed that high education is associated with a decreased rate of post-stroke dementia. Moreover, other CR proxies (e.g., occupation, bilingualism or social interaction) demonstrate a protective effect against non-dementia cognitive decline after stroke, although some inconsistencies were found in the literature. Regarding the meta-analysis, occupational attainment and education) showed a protective effect against post-stroke cognitive impairment diagnosis in comparison with a mixed category of different CR proxies. Second, a main cognitive change effect was found, pointing to greater cognitive change after stroke in those with low vs. high CR. CONCLUSIONS: Our findings emphasize that CR may prevent cognitive decline after stroke, but this effect can be modulated by different factors such the CR proxy and individual characteristics such as age or type of lesion. The methodological divergences of the studies (i.e., follow-up intervals, cognitive outcomes) need unification to diminish external sources of variability for predicting rates of cognitive decline after stroke.

Prediction of burden in family caregivers of patients with dementia: a perspective of optimism based on generalized expectancies of control.

The aim of this study was to investigate the predictors of burden for informal caregivers of patients with dementia. Based on a multidimensional approach of the optimism model proposed by Palenzuela, we assessed the moderating role of generalized expectancies of control (GEC) between caregiver stress and burden. A total of 130 patients with dementia and their main family caregivers were assessed from different rural areas of the province of Salamanca (Spain). Patients with dementia underwent a protocol to assess dementia stage, cognitive-functional impairment and behavioural symptoms. Meanwhile, the 20-item Battery of Generalized Expectancies of Control Scales of Palenzuela was completed by the family caregivers. Clinical variables of patients with dementia (progression and behavioural disorders) and GEC (success, self-efficacy, contingency, helplessness and luck) were considered as potential predictors of burden in the hierarchical regression analysis. The Zarit Burden Interview (ZBI) Scale was used as an outcome measure. The results indicated that the clinical variables could not predict burden in caregivers significantly; however, beliefs in personal abilities (self-efficacy) and internal locus of control (contingency) explained up to 32% of the variance in the ZBI scores. Family caregivers with high expectancies of self-efficacy and contingency are less vulnerable to stress. This research supports a base for interventions with informal caregivers and further study.

Cognitive reserve and brain maintenance in aging and dementia: An integrative review.

This research is an integrative review of scientific evidence differentiating between cognitive reserve (CR) and brain maintenance concepts. Thus, we have examined how CR socio-behavioral proxies (i.e. education, occupational attainment, and leisure activities) may help to cope with age-related cognitive decline and negative consequences of brain pathology. We also analyze lifestyle factors associated with brain maintenance or the relative absence of change in neural resources over time. Medline and Web of Science databases were used for the bibliographic search in the last 20 years. Observational cohort studies were selected to analyze the effect of different CR proxies on cognitive decline, including dementia incidence, whereas studies employing functional neuroimaging (fMRI) were used to display the existence of compensation mechanisms. Besides, structural MRI studies were used to test the association between lifestyle factors and neural changes. Our findings suggest that education, leisure activities, and occupational activity are protective factors against cognitive decline and dementia. Moreover, functional neuroimaging studies have verified the existence of brain networks that may underlie CR. Therefore, CR may be expressed either through a more efficient utilization (neural reserve) of brain networks or the recruitment of additional brain regions (compensation). Finally, lifestyle factors such as abstaining from smoking, lower alcohol consumption, and physical activity contributed to brain maintenance and were associated with the preservation of cognitive function. Advances in multimodal neuroimaging studies, preferably longitudinal design, will allow a better understanding of the neural mechanisms associated with the prevention of cognitive decline and preservation of neural resources in aging.

Psychosocial Factors Associated with Burnout and Self-Perceived Health in Spanish Occupational Therapists.

(1) Background: There are few studies of burnout syndrome (BS) in occupational therapists (OTs), and protective factors for BS have received little attention in the scientific literature. This research aimed to estimate the prevalence of BS, characterize the associated psychosocial factors, and analyze their relationship with health in a sample of Spanish OTs. (2) Methods: A total of 127 therapists completed the Maslach Burnout Inventory (MBI) and other standardized questionnaires measuring: personality traits (reduced five-factor personality inventory, NEO-FFI), coping styles (Coping Strategies Questionnaire, CAE), work-family conflict (Survey Work-Home Interaction Nijmegen, SWING), professional factors (role ambiguity/clarity and modified role conflict questionnaires), and the perception of health (Goldberg's General Health Questionnaire). Several correlational and multiple regression analyses were performed to study the psychosocial predictors of burnout and its relationship with health perceptions. (3) Results: 15.8% of the professionals presented BS, with emotional exhaustion (EE; 38.7%) being the most compromised dimension. Neuroticism, role conflict, negative work-family interaction, and open emotional expression (OE) significantly predicted a higher EE. The main predictors of cynicism (CY) were being male, role conflict, and OE. Role conflict, role ambiguity and social support-seeking were significant predictors of reduced professional efficiency (PE). (4) Conclusions: A high percentage of OTs with BS suggests the need for increased awareness of the importance of this syndrome in the health community. It would be critical to consider the protective factors (i.e., emotional management, social support) that help promote OTs' well-being and health.

The Distinctive Role of Grounded Optimism and Resilience for predicting Burnout and Work Engagement: A study in Professional Caregivers of Older Adults.

BACKGROUND: Resilience and optimism have been proposed as psychological resources which may help to cope better with work demands, preventing negative consequences of stress, whereas external locus of control (ELC) is considered an intra-psychic vulnerability factor associated with increased burnout. Noteworthy, the specific role of these overlapping constructs on the prevention of burnout and promotion of work engagement, respectively, remains unclear. OBJECTIVE: The main aim of this study was to compare the differential significance of resilience and optimism, joined with ELC, on the prediction of burnout and work engagement. METHOD: A sample of 265 professional caregivers of dependent older adults was assessed using an extensive standardized protocol. Optimism and ELC were measured using the Palenzuela's Battery of Generalised Expectancies of Control, and the Connor-Davidson Scale was used to estimate resilience. Moreover, the Maslach Burnout Inventory and the Utrecht Work Engagement Scale were used to measure burnout and work engagement, respectively. Different hierarchical regression models were conducted with burnout and work engagement as dependent factors. RESULTS: The results showed that more than half (51%) variance in resilience was accounted by grounded optimism scores. The ELC was the main explanatory factor of burnout, whereas optimism and resilience were the best predictors of work engagement. Finally, even after controlling the effect of resilience, the effect of optimism remained significant for predicting work engagement. CONCLUSIONS: These findings support distinctive role resilience and optimism, two closely related psychological constructs, for promoting work engagement and reducing burnout in professional caregivers of older adults.

Education and Literacy as Risk Factors of Dementia after Stroke and Transient Ischemic Attack: NEDICES Study.

BACKGROUND: A protective effect of education on cognitive decline after stroke has been claimed, but evidence from prospective population-based cohorts is very limited. The differential role of literacy and education on dementia after stroke remains unexplored. OBJECTIVE: This research addresses the role of education and literacy in dementia incidence after stroke and transient ischemic attack (TIA). METHODS: 131 participants with stroke or TIA were identified within the population-based NEDICES study (N = 5,278 persons). Participants were fully assessed at baseline (1994-1995) and incident dementia diagnosis was made by expert neurologists (DSM-IV criteria) after a mean follow-up of 3.4 years. Adjusted Cox regression analyses were applied to test the association between education, literacy, and dementia risk. RESULTS: Within the 131 subjects with stroke or TIA, 19 (14%) developed dementia at follow-up. The Cox's regression model (age and sex adjusted) showed that low education (HR = 3.48, 95% CI = 1.28, 9.42, p = 0.014) and literacy (HR = 3.16, 95% CI = 1.08, 9.22, p = 0.035) were significantly associated with a higher dementia risk. Low education was also associated with dementia when main confounders (i.e., cognitive/functional performance) were considered in the Cox's model. However, after including stroke recurrence, only low/null literacy (versus education) remained as significant predictor of dementia. Finally, low/null literacy showed an effect over-and-above education on dementia risk when both factors were introduced in the adjusted Cox's regression. CONCLUSION: These findings underline the importance of literacy to estimate cognitive decline after stroke in low-educated populations.