A prospective association between social isolation and cognitive performance among older adults in Europe: the role of loneliness and poor oral health.

OBJECTIVES: The relationship between social isolation, loneliness, and tooth loss and cognition in older people is poorly understood. We examine how social isolation and cognitive performance are associated prospectively among older adults, as well as how tooth loss and loneliness are related to this association. METHODS: Using data from 26,168 participants aged ≥50 from the Survey of Health, Ageing and Retirement in Europe (SHARE), we explored the association between social isolation, loneliness, tooth loss and cognition. We used bootstrapping with resampling strategies for testing a moderated mediating model. RESULTS: Higher social isolation was associated with poorer cognitive performance (B = -0.20, 95% CI = -0.03, -0.01; R2 =0.60), an association mediated by the respondent's number of missing teeth (B = -0.001, 95% CI = -0.002, -0.001). Higher levels of social isolation were associated with a greater number of missing teeth, and a higher number of missing teeth was linked with poorer cognition. We also found that loneliness moderated the relationship between social isolation and both the number of missing teeth (B = -0.11, p = 0.047) and cognitive performance. CONCLUSION: In later life, social isolation and loneliness are associated with shoddy oral health and poor cognitive status. Clinicians and policymakers should be aware of both the association between social isolation and feelings of loneliness on dentition and oral health and their relationship to the cognitive status of older adults.

Awareness and knowledge of dementia and its communication disorders amongst Brazilian speech and language therapists.

BACKGROUND: Speech and language therapists (SLTs) play an important role in assessing and rehabilitating communication disorders in people with dementia, but there is evidence to suggest that they do not receive appropriate training to provide management and support during their training. AIM: To investigate the level of awareness and knowledge that practising SLTs from Brazil have about dementia and their role in the care of dementia through an online survey. METHODS & PROCEDURES: An online survey tool was developed to collect information from practising Brazilian SLTs regarding their knowledge about dementia, awareness about their role in the care of people with dementia, and opinions on how SLTs may be better prepared to work in the dementia field. The survey was disseminated via social media, websites, and e-mail lists of researchers and stakeholders. OUTCOMES & RESULTS: A total of 227 SLTs completed the survey. Participants showed good knowledge of dementia in general, while their answers were less accurate on primary progressive aphasia. Regarding the awareness by SLTs of their role in the care of people with dementia, most agreed or strongly agreed that SLTs could help people in the diagnosis, treatment and prevention of dementia (> 80%). However, fewer participants agreed or strongly agreed that they felt confident in contributing to the treatment and diagnosis process of dementia (about 50%). To improve the training of SLTs in Brazil, most participants believed that it would be necessary to improve the teaching of dementia at the undergraduate speech and language therapy curriculum level and to develop recommendations or guidelines about speech and language therapy practice in dementia. CONCLUSIONS & IMPLICATIONS: The results of this survey point to a need for improvement in the knowledge and confidence of Brazilian SLTs about dementia. To reach this goal, targeted training courses and applied practice opportunities should be embedded within university curricula and training programmes. WHAT THIS PAPER ADDS: What is already known on the subject Many studies confirm the importance of speech and language therapy in the non-pharmacological treatment of people with dementia. However, other evidence suggests to a possible lack of training for Brazilian SLTs, especially in the curriculum of undergraduate courses. What this paper adds to existing knowledge This study reveals that Brazilian SLTs have substantial knowledge of dementia and recognize the significance of their role in treating people with dementia. However, a minority expressed confidence in their ability to assess and treat people with dementia. What are the potential or actual clinical implications of this work? The findings of this research demonstrate that Brazilian SLTs have good knowledge of dementia and endorse their professional role in dementia care; however, they lack confidence in their own skills and expertise in diagnostic assessment and treatment of dementia. Interventions aimed at boosting the SLT's confidence level could lead to improved patients outcomes and overall quality of care within clinical settings.

Allostatic-interoceptive anticipation of social rejection.

Anticipating social stress evokes strong reactions in the organism, including interoceptive modulations. However, evidence for this claim comes from behavioral studies, often with inconsistent results, and relates almost solely to the reactive and recovery phase of social stress exposure. Here, we adopted an allostatic-interoceptive predictive coding framework to study interoceptive and exteroceptive anticipatory brain responses using a social rejection task. We analyzed the heart-evoked potential (HEP) and task-related oscillatory activity of 58 adolescents via scalp EEG, and 385 human intracranial recordings of three patients with intractable epilepsy. We found that anticipatory interoceptive signals increased in the face of unexpected social outcomes, reflected in larger negative HEP modulations. Such signals emerged from key brain allostatic-interoceptive network hubs, as shown by intracranial recordings. Exteroceptive signals were characterized by early activity between 1-15 Hz across conditions, and modulated by the probabilistic anticipation of reward-related outcomes, observed over distributed brain regions. Our findings suggest that the anticipation of a social outcome is characterized by allostatic-interoceptive modulations that prepare the organism for possible rejection. These results inform our understanding of interoceptive processing and constrain neurobiological models of social stress.

Life-Course Brain Health as a Determinant of Late-Life Mental Health: American Association for Geriatric Psychiatry Expert Panel Recommendations.

This position statement of the Expert Panel on Brain Health of the American Association for Geriatric Psychiatry (AAGP) emphasizes the critical role of life course brain health in shaping mental well-being during the later stages of life. Evidence posits that maintaining optimal brain health earlier in life is crucial for preventing and managing brain aging-related disorders such as dementia/cognitive decline, depression, stroke, and anxiety. We advocate for a holistic approach that integrates medical, psychological, and social frameworks with culturally tailored interventions across the lifespan to promote brain health and overall mental well-being in aging adults across all communities. Furthermore, our statement underscores the significance of prevention, early detection, and intervention in identifying cognitive decline, mood changes, and related mental illness. Action should also be taken to understand and address the needs of communities that traditionally have unequal access to preventive health information and services. By implementing culturally relevant and tailored evidence-based practices and advancing research in geriatric psychiatry, behavioral neurology, and geroscience, we can enhance the quality of life for older adults facing the unique challenges of aging. This position statement emphasizes the intrinsic link between brain health and mental health in aging, urging healthcare professionals, policymakers, and a broader society to prioritize comprehensive strategies that safeguard and promote brain health from birth through later years across all communities. The AAGP Expert Panel has the goal of launching further activities in the coming months and years.

Freedom and loneliness: dementia caregiver experiences of the nursing home transition.

BACKGROUND: the transition to nursing home care has previously been linked to negative outcomes for spousal caregivers of persons with dementia (PwD). However, little is known about the experience or trajectory of loneliness in spousal caregivers during this time. OBJECTIVES: to explore experiences of loneliness in caregivers during the nursing home admission of their spouse or partner with dementia. METHODS: semi-structured interviews were conducted with 11 individuals living in Ireland between Oct 2020 and June 2021, who were married to/partnered with a PwD who had, in the past 7 years, moved to full-time nursing home care. Data were collected and analysed using a deductive qualitative analytic strategy in the grounded theory tradition. RESULTS: data were interpreted in the context of Weiss' typology of social and emotional loneliness and indicated that social loneliness increased for many at the point of diagnosis, decreasing somewhat after the transition, while emotional loneliness increased across the transition. Data were used to refine an existing synthesised model of loneliness, providing an updated model of the causes and contexts of loneliness. CONCLUSIONS: the transition to nursing home care differentially affects loneliness subtypes. Results have implications for other transitions, which should be assessed in terms of various subtypes of loneliness. Our refined theoretical synthesis model of loneliness also warrants further evaluation.

Care burden, loneliness, and social isolation in caregivers of people with physical and brain health conditions in English-speaking regions: Before and during the COVID-19 pandemic.

BACKGROUND: Public health restrictions due to the COVID-19 (SARS CoV-2) pandemic have disproportionately affected informal caregivers of people living with long term health conditions. We aimed to explore levels of care burden, loneliness, and social isolation among caregivers of people with enduring physical and brain health conditions in English-speaking regions worldwide, by investigating outcomes before and during the COVID-19 pandemic. METHODS: A cross-sectional anonymous online survey data from 2287 English-speaking caregivers of people with long term health conditions from four English-speaking regions (UK, Ireland, USA, New Zealand) included measures of care burden, loneliness, and social isolation, reported before and during the COVID-19 pandemic. Analyses were descriptive, followed by an ordinal regression model for predictors of burden. RESULTS: Compared to pre-pandemic levels, all caregivers experienced a significant increase in burden, loneliness, and isolation. Caregivers of people with both brain health and physical conditions were the most burdened and had the highest levels of loneliness and isolation compared to caregivers of people with either a brain health or physical condition only. The increase in care burden among caregivers of people with brain health challenges was associated with caregiver's gender, moderate and severe emotional loneliness, magnitude and frequency of isolation during the pandemic, and care circumstances (cohabitation with the care recipient, restrictions on the ability to provide care). CONCLUSIONS: Health and social care interventions should target caregivers' care circumstances and psychological outcomes, particularly in women, accounting for the significant additional burden of care, loneliness, and isolation resulting from pandemic-related restrictions.

A systematic review and narrative synthesis of the experiences with caring for older people living with dementia in Sub-Saharan Africa.

BACKGROUND: In low- and middle-income countries, including sub-Saharan Africa little is known about the experiences with caring for people living with dementia. The purpose of this systematic review and narrative synthesis was to examine the experiences with caring for older people living with dementia at home. RESULTS: In total, 366 abstracts were identified and following screening, 19 studies were included in the synthesis. Six themes were identified: conceptualising dementia, caregiving arrangements, the impact of caregiving, caregiver identity and role, managing caregiving, unmet caregiver needs. CONCLUSION: There is a dearth of research in relation to caregiving for older people living with dementia in sub-Saharan Africa. There is need for better information campaigns and support programs directed at family and professional caregivers in this context.

The Latin American Brain Health Institute, a regional initiative to reduce the scale and impact of dementia.

Latin American and Caribbean countries face complex challenges to improve brain health and reduce the impact of dementia. Regional hubs devoted to research, capacity building, implementation science, and education are critically needed. The Latin American Brain Health Institute represent an important step to address many of these needs.

Dementia in Africa: Current evidence, knowledge gaps, and future directions.

In tandem with the ever-increasing aging population in low and middle-income countries, the burden of dementia is rising on the African continent. Dementia prevalence varies from 2.3% to 20.0% and incidence rates are 13.3 per 1000 person-years with increasing mortality in parts of rapidly transforming Africa. Differences in nutrition, cardiovascular factors, comorbidities, infections, mortality, and detection likely contribute to lower incidence. Alzheimer's disease, vascular dementia, and human immunodeficiency virus/acquired immunodeficiency syndrome-associated neurocognitive disorders are the most common dementia subtypes. Comprehensive longitudinal studies with robust methodology and regional coverage would provide more reliable information. The apolipoprotein E (APOE) ε4 allele is most studied but has shown differential effects within African ancestry compared to Caucasian. More candidate gene and genome-wide association studies are needed to relate to dementia phenotypes. Validated culture-sensitive cognitive tools not influenced by education and language differences are critically needed for implementation across multidisciplinary groupings such as the proposed African Dementia Consortium.

Fear of Dementia and the Obligation to Provide Aggregate Research Results to Study Participants.

A general obligation to make aggregate research results available to participants has been widely supported in the bioethics literature. However, dementia research presents several challenges to this perspective, particularly because of the fear associated with developing dementia. The authors argue that considerations of respect for persons, beneficence, and justice fail to justify an obligation to make aggregate research results available to participants in dementia research. Nevertheless, there are positive reasons in favor of making aggregate research results available; when the decision is made to do so, it is critical that a clear strategy for communicating results is developed, including what support will be provided to participants receiving aggregate research results.

The Behavioral Variant Frontotemporal Dementia Phenocopy Syndrome: A Review.

OBJECTIVES: The relatively recent identification of a subgroup of patients with apparent behavioral variant frontotemporal dementia (bvFTD) that fails to progress with time has led to a reevaluation of our understanding of bvFTD, and a growing body of research that attempts to characterize the mimic or "phenocopy" syndrome. In this article, we review the literature relating to the phenocopy syndrome, focusing in particular on distinguishing characteristics and potential etiologies. METHODS: Published articles were identified via a systematic search of PubMed and Embase. Observational and interventional studies, case reports, and case series were sought for inclusion. RESULTS: While bvFTD and the phenocopy syndrome are clinically indistinguishable at initial presentation, the presence or absence of characteristic changes on neuroimaging predicts 2 very different illness trajectories. The etiology for the phenocopy presentation remains uncertain. It is likely that the syndrome represents a heterogenous assortment of clinical frontal syndromes encompassing atypical neurodegenerative, psychiatric, psychological, and as yet unknown neuropsychiatric causes. CONCLUSIONS: Although the prognosis of the phenocopy syndrome is generally held to be more favorable than that of bvFTD, patients and families are subject to major disruption in their relationships and social and occupational functioning. Early recognition is crucial to facilitate timely interventions aimed at maintaining relationships, roles, and quality of life of those affected.

Sex differences in the incidence and prevalence of young-onset Alzheimer's disease: A meta-analysis.

OBJECTIVES: The lifetime incidence of Alzheimer's disease is higher in women than in men, but it remains unclear if similar sex differences exist in young-onset Alzheimer's disease (YOAD). This systematic review test the hypothesis that women have a higher prevalence and incidence of YOAD than men. METHODS: We searched Pubmed and Embase (inception to 11 June 2020) for original publications of population-based observational studies with data on the prevalence and/or incidence of YOAD, defined as a medical diagnosis of Alzheimer's disease before the age of 65 years. Data on cross-sectional and/or prospective numbers, percentages, incidences, and incidence rates (in person-years) were derived from included studies. Quality assessment was done using the Nottingham Ottawa Scale. Meta-analyses were done to test the hypothesis that women have a higher prevalence and incidence of YOAD than men. RESULTS: After screening of 3252 titles, 12 articles were included. The pooled prevalence was 0.4% (confidence interval [CI] = 0.1-2.1) in women and 0.2% (CI = 0-1.2) in men (six studies, relative risk [RR] = 1.54, CI = 0.69-3.44, I2  = 38%). The pooled incidence was 0.02% (CI = 0.01-0.08) in women and 0.01% (CI = 0-0.05) in men (five studies, RR = 1.50, CI = 0.91-2.48, I2  = 0%). The incidence rates per 100,000 person-years ranged from 0 to 132 in women and from 0 to 42 in men. CONCLUSIONS: Given the low prevalence and wide CIs, no firm conclusions can be drawn. Large-scale studies are required to verify that women are more likely than men to develop YOAD.

Long-term antipsychotic use and cognitive decline in community-dwelling older adults with mild-moderate Alzheimer disease: Data from NILVAD.

INTRODUCTION: Previous evidence has suggested that antipsychotic use may be associated with accelerated cognitive decline in those living with dementia. However, the cognitive effects of long-term antipsychotic use in community-dwelling older adults with mild-moderate Alzheimer disease (AD) has not been explored to date. METHODS: We assessed the impact of long-term antipsychotic use on the rate of cognitive decline (Alzheimer's Disease Assessment Scale-Cognitive Subsection) and dementia progression (Clinical Dementia Rating-Sum of Boxes [CDR-Sb]/Disability Assessment for Dementia [DAD]) over 18 months in older adults with mild-moderate AD. RESULTS: Of 509 participants with mild-moderate AD, one-tenth (54/509; 10.6%) were prescribed an antipsychotic for the 18-month study duration. Antipsychotic use was significantly associated with accelerated cognitive decline at both 12 (ß: 3.53, 0.91-6.17, p = 0.008) and 18 months (ß: 3.81, 0.49-7.14, p = 0.024) in addition to greater dementia progression at both 12 (ß: 1.85, -0.97-2.73, p < 0.001 for CDR-Sb/ß: -3.33, -5.56-1.10, p = 0.003 for DAD) and 18 months (ß: 1.41, 0.16-2.67, p = 0.027 for CDR-Sb/ß: -3.86, -6.64 to -1.08, p = 0.006 for DAD). APOE ε4 carriers experienced significantly greater cognitive decline with long-term antipsychotic use. CONCLUSIONS: Long-term antipsychotic use was associated with greater cognitive decline and dementia progression in community-dwelling older adults with mild-moderate AD. Our findings are consistent with previous evidence encouraging cautious and careful consideration of risks versus benefits of antipsychotic usage in those with AD.

Defining brain health: A concept analysis.

OBJECTIVES: Brain health is an important focus for coming decades due to population ageing. Although the term 'brain health' is increasingly used in lay and professional settings, a clear definition of the term is lacking. We conducted an analysis of the concept of brain health to inform policy, practice, and research. METHODS: We applied a hybrid concept analysis method involving three stages: (1) a review of the extant literature for definitions of brain health; (2) field work, involving an international survey of 'brain health' researchers and practitioners; and (3) a final analysis, integrating the findings into a working definition and model. RESULTS: Our review of the literature identified 13 articles defining brain health, six of which proposed their own definition. Our survey revealed that the term 'brain health' was used in diverse ways based on different theoretical frameworks. From the review and survey, we extracted attributes, antecedents, and consequences of brain health. These were synthesized into a definition of brain health as a life-long, multidimensional, dynamic state consisting of cognitive, emotional and motor domains underpinned by physiological processes and can be objectively measured and subjectively experienced. It is influenced by eco-biopsychosocial determinants. CONCLUSION: This working definition of brain health is a foundation for developing policy, practice, research and advocacy. The definition needs to be operationalised through further development of empirical referents, including cross-cultural understanding, adaptation and validation.

Clinical utility of mild cognitive impairment subtypes and number of impaired cognitive domains at predicting progression to dementia: A 20-year retrospective study.

OBJECTIVE: To determine the utility of mild cognitive impairment (MCI) subtypes and number of impaired cognitive domains on initial assessment at predicting progression to dementia in a sample of memory clinic patients over a 20-year period. METHODS: A retrospective analysis was conducted of those presenting to a memory clinic with MCI from 1 January 1999 to 31 December 2018 inclusive. Those with MCI were broken down into one of the four subtypes using recommended cut-off scores on the Cambridge Cognitive Assessment (CAMCOG). Binomial logistic regression analysis was used to determine the utility of MCI subtypes and number of impaired cognitive domains as predictors for dementia. RESULTS: Overall 1188 individuals with MCI diagnosis were identified, with 378 (32%) progressing to dementia, with median [range] time to diagnosis of 2 years [1-8.4]. Six hundred and forty-nine (55%) were identified as amnestic MCI and 539 (45%) as non-amnestic MCI. Amnestic MCI was a significant predictor of progression compared to non-amnestic MCI (OR = 1.85, df = 1, P < .001). Number of cognitive domains impaired was also a significant predictor of progression to dementia (OR = 1.07, df = 1, P = .01) but the single-/multi-domain distinction was not (OR = 1.29, df = 1, P = .36). CONCLUSION: This study shows that approximately 32% of those diagnosed with MCI in a memory clinic progressed to dementia, with a median time to progression of 2 years. Those with amnestic MCI are almost twice as likely to progress to dementia than non-amnestic MCI and that therefore this is a useful distinction. However, the utility of the single- and multi-domain MCI distinction is called into question by our findings.

Factors influencing the cost of care and admission to long-term care for people with dementia in Ireland.

OBJECTIVE: To explore the factors associated with the cost of care and admission to long-term care (LTC) for people with dementia living at home in Ireland. METHODS: Data on formal and informal resource use for people with dementia, and their LTC admission, were obtained from a national study of spousal dementia caregivers. Functional status was measured using the Bristol Activities of Daily Living Scale, while behavioural and psychiatric symptoms were evaluated using the Neuropsychiatric Inventory. Multivariable regression analysis was used to model costs and the predictors of LTC admission. RESULTS: Physical and cognitive symptoms were significantly associated with costs. Severely impaired functional ability was associated with a €2,308 increase in mean total 30-day monthly costs. Psychosis was associated with a €335 increase in primary and community 30-day monthly care costs. These factors also make it more likely that a person with dementia is admitted to LTC. Having an older caregiver also increases the risk of admission to LTC, while living in a rural area and having a female caregiver reduce the likelihood of admission. CONCLUSIONS: Dependency matters for the cost of care. Physical and cognitive symptoms, caregiver age and gender, and geographic location are significant predictors of admission to LTC.

Social networks in mild-to-moderate Alzheimer disease: longitudinal relationships with dementia severity, cognitive function, and adverse events.

OBJECTIVES: Poor social networks are associated with a greater likelihood of cognitive decline, dementia, and other adverse health outcomes in later life. However, these relationships have been poorly explored in those with established Alzheimer Disease (AD), who may represent a particularly vulnerable group. METHODS: Analysis of data from the NILVAD study. We assessed social networks (Lubben Social Network Scale [LSNS]), cognition (Alzheimer's disease Assessment Scale [ADAS-Cog]) and dementia severity (Clinical Dementia Rating, Sum of Boxes [CDR-Sb]) in older adults with mild-moderate AD at baseline and at 18 months. RESULTS: 464 participants with mild-to-moderate AD were included (73.1 ± 8.3 years; 61.9% female). At baseline, a poor social network was significantly associated with a greater dementia severity, but not greater cognitive impairment. Rather than a poor social network predicting greater cognitive decline over 18 months, a greater baseline dementia severity predicted a decline in social network over 18 months (ß: -0.22, -0.42 - -0.02, p = 0.034). Finally, a poor social network was associated with a significantly increased likelihood of experiencing serious adverse events (IRR: 1.41, 1.06-1.89, p = 0.019). DISCUSSION: As dementia progresses, older adults with AD are more likely to experience a decline in social network. Further, having a poor social network was associated with a greater likelihood of experiencing serious adverse events. These findings add novel insight into the complex relationship between social networks, dementia progression and adverse events in AD, and underscore the importance of developing and maintaining social networks in AD.

Social factors may mediate the relationship between subjective age-related hearing loss and episodic memory.

Objectives: To investigate whether the relationship between subjective age-related hearing loss (SARHL) and episodic memory functioning is mediated by measures of social functioning.Methods: Using data from 8,163 adults over 50 that participated in the Irish Longitudinal Study of Ageing (three waves, each two years apart), we used a multiple mediation model within a Structural Equation Modelling framework to explore potential social mediators of the relationship between SARHL and episodic memory functioning, controlling for demographic and health covariates.Results: Neither the direct effect of self-reported hearing difficulties on memory functioning (ß = -.03), nor the total effect (ß = .01), were significant. A small inconsistent indirect effect of self-reported hearing difficulties on episodic memory via weekly social activity engagement (ß = -.002) was found.Conclusions: Self-reported hearing difficulties may exert an indirect effect on episodic memory via weekly social activity engagement. The findings may have implications for identification of individuals at risk of memory decline in later life.

Bones of Contention: A Comprehensive Literature Review of Non-SSRI Antidepressant Use and Bone Health.

Osteoporotic fractures are associated with major morbidity and mortality, particularly among older age groups. In recent decades, selective serotonin reuptake inhibitors (SSRI) antidepressants have been linked to reduced bone mineral density and increased risk of fragility fracture. However, up to one-third of antidepressant prescriptions are for classes other than SSRIs. Older patients, who are particularly vulnerable to osteoporosis and its clinical and psychosocial consequences, may be prescribed non-SSRI antidepressants preferentially because of increasing awareness of the risks SSRIs pose to bone health. However, to date, the skeletal effects of non-SSRI antidepressants have not been comprehensively reviewed. In this article, we collate and review the available data and discuss the findings. Based on the current literature, we tentatively suggest that tricyclic antidepressants may increase the risk of fracture via mechanisms other than a direct effect on bone mineral density. The risk is apparently confined to current users only and is greatest in the earliest stage of treatment, diminishing thereafter. There is, as yet, insufficient data to conclusively determine the effects of other antidepressant classes on bone. Judicious prescribing of antidepressants among higher risk groups necessitates a thorough review of the individual's risk factors for osteoporosis as well as attention to their falls risk. Further longitudinal, rigorously controlled studies are needed to answer some of the remaining questions on the effects of non-SSRI antidepressants on bone and the mechanisms by which they are exerted.

Late life education and cognitive function in older adults.

OBJECTIVE: The potential role of education attained after the age of 50, for example, vocational training or recreational courses, in cognitive reserve has been unexplored. We examined the cross-sectional and prospective associations between late life education (LLE) and global cognitive function in older adults. METHODS: A total of 5306 participants (50+ years) in The Irish Longitudinal Study of Ageing answered questions about highest level of education completed and LLE (2010). Cognitive function was defined as the number of errors on the Montreal cognitive assessment (MoCA) assessed in 2010 and 2014. The association between LLE and MoCA-errors was examined using Poisson regression stratified by level of education. Sensitivity analyses were done to examine reverse causation and selection bias. RESULTS: In those with primary/no (n = 1312, incidence rate ratio [IRR] = 0.83, 95%CI = 0.70-0.99) and secondary education (n = 2208, IRR = 0.88, 95%CI = 0.80-0.97), but not tertiary education (n = 1786, IRR = 0.93, CI = 0.86-1.00), participating in LLE was associated with lower rate of MoCA errors. The prospective association between LLE and 4-year change in MoCA-errors was (borderline) statistically significant in those with primary/no education only (IRR = 0.86, CI = 0.74-1.00). Sensitivity analyses supported robustness of the findings. CONCLUSIONS: LLE may contribute to cognitive reserve and be a useful intervention to mitigate the increased risk of cognitive decline associated with low levels of education.