Is poor health literacy a risk factor for dementia in older adults? Systematic literature review of prospective cohort studies


      • A bidirectional relationship exists between health literacy and cognitive function.
      • This systematic review explored the relationship between health literacy and incident dementia in prospective cohort studies.
      • Adjusted models showed that low health literacy leads to a higher dementia risk in older adults.
      • Further research is required to establish the role of health literacy as a key risk factor for dementia.


      Increasing evidence suggests a bidirectional relationship exists between levels of health literacy (HL) and cognitive impairment in later life. However, it is unclear whether low levels of HL can lead to a higher risk of dementia. This systematic review explored prospective cohort studies to find out whether HL is a risk factor for incident dementia in older adults. A search was conducted in Medline, PsycINFO, Embase, PubMed and Scopus and 5450 documents were initially retrieved. The grey literature and references of the selected papers were also consulted. Papers were selected and assessed by three researchers independently. Findings were reported in line with the PRISMA guidelines and quality appraisal was conducted using the STROBE checklist. Four studies were included for quality appraisal, data extraction and synthesis, all of which were conducted in the United States between 2014 and 2018. Adjusted analyses showed that in all studies people with low levels of HL had a significantly higher risk of incident dementia over time than people with adequate levels of HL. Low HL or total literacy (financial plus HL) was also a risk factor for mild cognitive impairment in two studies, irrespective of an Alzheimer’s disease genotype. There was a statistically significant positive association between total literacy scores and the post-mortem amount of plaques and tangles suggestive of Alzheimer’s disease. Our findings suggest that low levels of HL might lead to higher future dementia risk. However, as only a few longitudinal studies have been conducted in this area, further research is needed to establish the role of HL as a key risk factor for dementia. Researchers should use standardized HL-specific measurement tools so that future studies in this area are robust and comparable. Primary health care professionals might wish consider individual’s HL when planning and implementing dementia risk reduction in order to improve its long-term effectiveness.


      AD (Alzheimer’s disease), HL (health literacy), MCI (mild cognitive impairment)


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        • Alzheimer’s Disease International
        World Alzheimer Report 2018: the State of the Art of Dementia Research.
        New Frontiers, 2018 (London)
        • Kingston A.
        • Comas-Herrera A.
        • Jagger C.
        Forecasting the care needs of the older population in England over the next 20 years: estimates from the Population Ageing and Care Simulation (PACSim) modelling study.
        Lancet Public Health. 2018; 3: e447-e455
        • Frankish H.
        • Horton R.
        Prevention and management of dementia: a priority for public health.
        Lancet. 2017; 390: 2614-2615
        • World Health Organization
        Global Action Plan on the Public Health Response to Dementia.
        2017: 2017-2025
        • Livingston G.
        • Sommerlad A.
        • Orgeta V.
        • Costafreda S.G.
        • Huntley J.
        • Ames D.
        • Ballard C.
        • Banerjee S.
        • Burns A.
        • Cohen-Mansfield J.
        • Cooper C.
        • Fox N.
        • Gitlin L.N.
        • Howard R.
        • Kales H.C.
        • Larson E.B.
        • Ritchie K.
        • Rockwood K.
        • Sampson E.L.
        • Samus Q.
        • Schneider L.S.
        • Selbæk G.
        • Teri L.
        • Mukadam N.
        Dementia prevention, intervention, and care.
        Lancet. 2017; 390: 2673-2734
        • Sørensen K.
        • Van den Broucke S.
        • Fullam J.
        • Doyle G.
        • Pelikan J.
        • Slonska Z.
        • Brand H.
        E. Consortium Health Literacy Project, Health literacy and public health: a systematic review and integration of definitions and models.
        BMC Public Health. 2012; 12: 80
        • Sudore R.L.
        • Mehta K.M.
        • Simonsick E.M.
        • Harris T.B.
        • Newman A.B.
        • Satterfield S.
        • Rosano C.
        • Rooks R.N.
        • Rubin S.M.
        • Ayonayon H.N.
        • Yaffe K.
        Limited literacy in older people and disparities in health and healthcare access.
        J. Am. Geriatr. Soc. 2006; 54: 770-776
        • Magnani J.W.
        • Mujahid M.S.
        • Aronow H.D.
        • Cene C.W.
        • Dickson V.V.
        • Havranek E.
        • Morgenstern L.B.
        • Paasche-Orlow M.K.
        • Pollak A.
        • Willey J.Z.
        Health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the american heart association.
        Circulation. 2018; 138: e48-e74
        • Zheng M.
        • Jin H.
        • Shi N.
        • Duan C.
        • Wang D.
        • Yu X.
        • Li X.
        The relationship between health literacy and quality of life: a systematic review and meta-analysis.
        Health Qual. Life Outcomes. 2018; 16: 201
        • Sudore R.L.
        • Yaffe K.
        • Satterfield S.
        • Harris T.B.
        • Mehta K.M.
        • Simonsick E.M.
        • Newman A.B.
        • Rosano C.
        • Rooks R.
        • Rubin S.M.
        • Ayonayon H.N.
        • Schillinger D.
        Limited literacy and mortality in the elderly: the health, aging, and body composition study.
        J. Gen. Intern. Med. 2006; 21: 806-812
        • James B.D.
        • Boyle P.A.
        • Bennett J.S.
        • Bennett D.A.
        The impact of health and financial literacy on decision making in community-based older adults.
        Gerontology. 2012; 58: 531-539
        • Rovner B.W.
        • Casten R.J.
        • Leiby B.E.
        Determinants of activity levels in African Americans with mild cognitive impairment.
        Alzheimer Dis. Assoc. Disord. 2016; 30: 41-46
        • Lee Y.
        • Chi I.
        Do cognitive leisure activities really matter in the relationship between education and cognition? Evidence from the aging, demographics, and memory study (ADAMS).
        Aging Ment. Health. 2016; 20: 252-261
        • Then F.S.
        • Luck T.
        • Luppa M.
        • Konig H.-H.
        • Angermeyer M.C.
        • Riedel-Heller S.G.
        Differential effects of enriched environment at work on cognitive decline in old age.
        Neurology. 2015; 84: 2169-2176
        • Pertl M.-T.
        • Benke T.
        • Zamarian L.
        • Martini C.
        • Bodner T.
        • Karner E.
        • Delazer M.
        Do patients with mild cognitive impairment understand numerical health information?.
        J. Alzheimer Dis. 2014; 40: 531-540
        • Han S.D.
        • Boyle P.A.
        • James B.D.
        • Yu L.
        • Bennett D.A.
        Poorer financial and health literacy among community-dwelling older adults with mild cognitive impairment.
        J. Aging Health. 2015; 27: 1105-1117
        • Han J.H.
        • Bryce S.N.
        • Ely E.W.
        • Kripalani S.
        • Morandi A.
        • Shintani A.
        • Jackson J.C.
        • Storrow A.B.
        • Dittus R.S.
        • Schnelle J.
        The effect of cognitive impairment on the accuracy of the presenting complaint and discharge instruction comprehension in older emergency department patients.
        Ann. Emerg. Med. 2011; 57 (e2): 662-671
        • Lee J.-Y.
        • Park S.
        • Kim K.W.
        • Kwon J.E.
        • Park J.H.
        • Kim M.D.
        • Kim B.-J.
        • Kim J.L.
        • Moon S.W.
        • Bae J.N.
        • Ryu S.-H.
        • Yoon J.C.
        • Lee N.-J.
        • Lee D.Y.
        • Lee D.W.
        • Lee S.B.
        • Lee J.J.
        • Lee C.-U.
        • Jhoo J.H.
        • Cho M.J.
        Differences in knowledge of dementia among older adults with normal cognition, mild cognitive impairment, and dementia: a representative nationwide sample of Korean elders.
        Arch. Gerontol. Geriatr. 2016; 66: 82-88
        • Kobayashi L.C.
        • Wardle J.
        • Wolf M.S.
        • von Wagner C.
        Cognitive function and health literacy decline in a cohort of aging English adults.
        J. Gen. Intern. Med. 2015; 30: 958-964
        • Boyle P.A.
        • Yu L.
        • Wilson R.S.
        • Segawa E.
        • Buchman A.S.
        • Bennett D.A.
        Cognitive decline impairs financial and health literacy among community-based older persons without dementia.
        Psychol. Aging. 2013; 28: 614-624
        • Gupta V.K.
        • Winter M.
        • Cabral H.
        • Henault L.
        • Waite K.
        • Hanchate A.
        • Bickmore T.W.
        • Wolf M.S.
        • Paasche-Orlow M.K.
        Disparities in age-associated cognitive decline between African-American and Caucasian populations: the roles of health literacy and education.
        J. Am. Geriatr. Soc. 2016; 64: 1716-1723
        • Geboers B.
        • Uiters E.
        • Reijneveld S.A.
        • Jansen C.J.M.
        • Almansa J.
        • Nooyens A.C.J.
        • Verschuren W.M.M.
        • de Winter A.F.
        • Picavet H.S.J.
        Health literacy among older adults is associated with their 10-years’ cognitive functioning and decline - the Doetinchem Cohort Study.
        BMC Geriatr. 2018; 18: 77
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS Med. 2009; 6e1000097
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • Pocock S.J.
        • Gøtzsche P.C.
        • Vandenbroucke J.P.
        S.I. For the, the strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
        PLoS Med. 2007; 4: e296
        • Wilson R.S.
        • Yu L.
        • James B.D.
        • Bennett D.A.
        • Boyle P.A.
        Association of financial and health literacy with cognitive health in old age.
        Neuropsychol. Dev. Cognit. Sect. B, Aging Neuropsychol. Cognit. 2017; 24: 186-197
        • Yu L.
        • Wilson R.S.
        • Han S.D.
        • Leurgans S.
        • Bennett D.A.
        • Boyle P.A.
        Decline in literacy and incident AD dementia among community-dwelling older persons.
        J. Aging Health. 2018; 30: 1389-1405
        • Yu L.
        • Wilson R.S.
        • Schneider J.A.
        • Bennett D.A.
        • Boyle P.A.
        Financial and health literacy predict incident Alzheimer’s disease dementia and pathology.
        J. Alzheimers Dis. 2017; 56: 1485-1493
        • Kaup A.R.
        • Simonsick E.M.
        • Harris T.B.
        • Satterfield S.
        • Metti A.L.
        • Ayonayon H.N.
        • Rubin S.M.
        • Yaffe K.
        Older adults with limited literacy are at increased risk for likely dementia.
        J. Gerontol. Series A, Biol. Sci. Med. Sci. 2014; 69: 900-906
        • Davis T.C.
        • Long S.W.
        • Jackson R.H.
        • Mayeaux E.J.
        • George R.B.
        • Murphy P.W.
        • Crouch M.A.
        Rapid estimate of adult literacy in medicine: a shortened screening instrument.
        Fam. Med. 1993; 25: 391-395
        • McKhann G.M.
        • Knopman D.S.
        • Chertkow H.
        • Hyman B.T.
        • Jack Jr, C.R.
        • Kawas C.H.
        • Klunk W.E.
        • Koroshetz W.J.
        • Manly J.J.
        • Mayeux R.
        • Mohs R.C.
        • Morris J.C.
        • Rossor M.N.
        • Scheltens P.
        • Carrillo M.C.
        • Thies B.
        • Weintraub S.
        • Phelps C.H.
        The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease.
        Alzheimers Dement. 2011; 7: 263-269
        • Bennett D.A.
        • Wilson R.S.
        • Schneider J.A.
        • Evans D.A.
        • Beckett L.A.
        • Aggarwal N.T.
        • Barnes L.L.
        • Fox J.H.
        • Bach J.
        Natural history of mild cognitive impairment in older persons.
        Neurology. 2002; 59: 198-205
        • Teng E.L.
        • Chui H.C.
        The modified mini-mental state (3MS) examination.
        J. Clin. Psychiatry. 1987; 48: 314-318
        • Ehlenbach W.J.
        • Hough C.L.
        • Crane P.K.
        • Haneuse S.J.
        • Carson S.S.
        • Curtis J.R.
        • Larson E.B.
        Association between acute care and critical illness hospitalization and cognitive function in older adults.
        JAMA. 2010; 303: 763-770
        • Norton M.C.
        • Dew J.
        • Smith H.
        • Fauth E.
        • Piercy K.W.
        • Breitner J.C.S.
        • Tschanz J.
        • Wengreen H.
        • Welsh-Bohmer K.
        • Cache County I.
        Lifestyle behavior pattern is associated with different levels of risk for incident dementia and Alzheimer’s disease: the Cache County study.
        J. Am. Geriatr. Soc. 2012; 60: 405-412
        • Polidori M.C.
        • Nelles G.
        • Pientka L.
        Prevention of dementia: focus on lifestyle.
        Int. J. Alzheimers Dis. 2010; 2010393579
        • Bennett D.A.
        • Schneider J.A.
        • Buchman A.S.
        • Barnes L.L.
        • Boyle P.A.
        • Wilson R.S.
        Overview and findings from the rush memory and aging project.
        Curr. Alzheimer Res. 2012; 9: 646-663