Effect of Cognitive Reserve on Risk of Cognitive Impairment and Recovery After Stroke: The KOSCO Study

Minyoung Shin, Min Kyun Sohn, Jongmin Lee, Deog Young Kim, Sam-Gyu Lee, Yong-Il Shin, Gyung-Jae Oh, Yang-Soo Lee, Min Cheol Joo, Eun Young Han, Junhee Han, Jeonghoon Ahn, Won Hyuk Chang, Min A Shin, Ji Yoo Choi, Sung Hyun Kang, Youngtaek Kim, Yun-Hee Kim, Minyoung Shin, Min Kyun Sohn, Jongmin Lee, Deog Young Kim, Sam-Gyu Lee, Yong-Il Shin, Gyung-Jae Oh, Yang-Soo Lee, Min Cheol Joo, Eun Young Han, Junhee Han, Jeonghoon Ahn, Won Hyuk Chang, Min A Shin, Ji Yoo Choi, Sung Hyun Kang, Youngtaek Kim, Yun-Hee Kim

Abstract

Background and Purpose- The theory of cognitive reserve (CR) was introduced to account for individual differences in the clinical manifestation of neuropathology. This study investigated whether CR has a modulating effect on cognitive impairment and recovery after stroke. Methods- This study is an interim analysis of the Korean Stroke Cohort for Functioning and Rehabilitation. A total of 7459 patients with first-ever stroke were included for analysis. Education, occupation, and composite CR scores derived from those 2 variables were used as CR proxies. Scores from the Korean version of the Mini-Mental State Examination analyzed for 30 months after stroke onset were analyzed. Results- Lower CR increased the risk of cognitive impairment after stroke. The odds ratio was 1.89 (95% CI, 1.64-2.19) in patients with secondary education and 2.42 (95% CI, 2.03-2.90) in patients with primary education compared with patients with higher education. The odds ratio was 1.48 (95% CI, 1.23-1.98) in patients with a skilled manual occupation and 2.01 (95% CI, 1.42-2.83) in patients with a nonskilled manual occupation compared with patients with a managerial or professional occupation. In the multilevel model analysis, the Korean version of the Mini-Mental State Examination total score increased during the first 3 months (1.93 points per month) and then plateaued (0.02 point per month). The slopes were moderated by the level of education, occupation, and composite CR score: the higher the level of education, occupation, or CR score, the faster the recovery. In the older adult group, the Korean version of the Mini-Mental State Examination scores showed a long-term decline that was moderated by education level. Conclusions- Education and occupation can buffer an individual against cognitive impairment caused by stroke and promote rapid cognitive recovery early after stroke. In addition, higher education minimizes long-term cognitive decline after stroke, especially in older patients. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03402451.

Keywords: cognitive dysfunction; cognitive reserve; education; longitudinal studies; occupation; risk factors; stroke.

Figures

Figure 1.
Figure 1.
Flow chart of participants. K-MMSE indicates Korean version of the Mini-Mental State Examination; and KOSCO, Korean Stroke Cohort for Functioning and Rehabilitation.
Figure 2.
Figure 2.
Cognitive changes after stroke onset for the 4 education groups and 4 occupation groups. A-1, Exponential model for the educational groups. A-2, Piecewise regression model for the educational groups. B-1, Exponential model for the occupational groups. B-2, Piecewise regression model for the occupational groups. K-MMSE indicates Korean version of the Mini-Mental State Examination.
Figure 3.
Figure 3.
Cognitive changes after stroke onset for the 4 educational groups by age group. A, Piecewise regression model for the younger group (age <65 y). B, Piecewise regression model for the older group (age ≥65 y). K-MMSE indicates Korean version of the Mini-Mental State Examination.

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