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Access Type

WSU Access

Date of Award

January 2022

Degree Type


Degree Name




First Advisor

Lisa J. Rapport


The theory of cognitive reserve is often invoked to explain why some people with multiple sclerosis (MS) exhibit better cognitive performance than expected for their level of disease progression. The most common estimate of cognitive reserve is years of education; however, few studies have examined how cognitively enriching activities outside of formal education contribute to cognitive reserve. Furthermore, education quality often provides a better estimate of cognitive reserve than education quantity, particularly among Black Americans, among whom access to high-quality education has been systematically restricted and who tend to exhibit particularly severe MS health outcomes. The present study examined three proxies of reserve—years of education, education quality, and cognitive enrichment—and the extent to which the relationship between these proxies of reserve and cognitive performance differs based on race.

The sample included 82 adults with MS (50% White, 50% Black) who underwent a neurological examination and a brief neuropsychological evaluation. Participants completed an objective assessment of education quality and reported their engagement in cognitively enriching activities across various life periods.

The results indicated that education quality and cognitive enrichment were more strongly associated with cognitive performance than years of education. Examining the relative contributions of education quality and cognitive enrichment towards reserve yielded a threshold effect. Cognitive enrichment was not associated with cognitive performance among participants with high education quality. In contrast, among participants with low education quality, cognitive enrichment was strongly associated with cognitive performance, suggesting that high engagement in cognitively enriching activities provided a similar level of protection as high education quality. Furthermore, among the Black participants, cognitive enrichment and educational quality moderated the relationship between disease progression and cognitive performance. However, among the White participants, cognitive enrichment did not provide additional protection beyond the buffering effect of education quality.

The findings demonstrate that cognitive reserve can be built through multiple routes, including formal education and informal cognitive enrichment. Healthcare for MS should incorporate cognitively enriching activities as a treatment recommendation, particularly for Black Americans and other MS populations with disproportionately limited access to high-quality education and who are therefore most vulnerable to cognitive decline.

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