There is ample rationale for institutions and clinicians embracing the concept of perioperative brain health to incorporate years of formal education as a routine preoperative screening question. Although not perfect, years of formal education is a good surrogate measure of premorbid intellect and cognitive reserve, based on a hypothesis that education may be protective against later cognitive decline, including protection from neurological insult and neurodegeneration (J Consult Clin Psych 1984;52:885-7; Neuropsychology 1996;7:273-95; Neuropsychology 2015;29:649-57; Clin Neuropsychol 2021;36:1291-5; Handb Clin Neurol 2019;167:181-90). Years of formal education is a predictor of postoperative cognitive decline, delirium, and postoperative emergency department visits (Anesthesiology 2008;108:18-30; Lancet 1998;351:857-61; Ann Thorac Surg 1995;59:1326-30; Anesth Analg 2021;132:846-55; J Laparoendosc Adv Surg Tech A 2018;28:1100-4). Years of education is associated with health literacy and comprehension of perioperative patient materials (Arthrosc Sports Med Rehabil 2022;4:e1575-9). Acquiring years of education is particularly pertinent to providers serving older patients, those seeking to assess brain health with preoperative cognitive screening tools, and clinicians serving patients from disadvantaged neighborhoods, or individuals with limited education in the English language.

Relative to younger cohorts, older adults have markedly fewer years of formal education. More than 50% of individuals aged 65 or older have less than a high school degree or equivalency degree ( Data provided by the U.S. Census Bureau show that in 1957, fewer than 29% of individuals had completed four years of high school. Among White individuals now aged 55 (born in 1968), only 31% have a high school degree (;;; Data also suggest that the educational attainment gap increases with more advanced age; 11% of people aged 65 and 20% of people in their mid-80s have less than a high school education.. This discrepancy is enhanced relative to race and ethnicity (; Anesth Analg 2021;132:846-55).

Reduced years of education in older adults is particularly pertinent to those following the guidelines from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®)/American Geriatrics Society (AGS) Best Practice Guidelines (; Assoc Oper Room Nurs 2019;110:P6). These guidelines recommend preoperative cognitive evaluation for older adults with or without a known history of cognitive impairment or dementia (J Am Coll Surg 2012;215:453-66; J Am Coll Surg 2016;222:930-47). Although tests such as the Mini-Cog or Mini Mental State Exam may be used in preoperative clinics, the accuracy of these dementia screening tools is limited for individuals with very low educational levels. Education is a crucial variable impacting any neuropsychological test, and for individuals with fewer than eight years of formal schooling, the impact of education may supersede that of age (Neuropsychological Assessment. 5th ed, 2012; Neuropsychology 2015;29:649-57; Int Psychogeriatr 2002;14:259-71; Dement Neuropsycho 2009;3:81-7).

“Embracing the concept of perioperative brain health requires consideration of brain function, but also the appreciation of demographic variables presenting a risk to dementia, disease, and cognitive screening sensitivity/specificity.”

Individuals with fewer than eight years of education will perform differently on perioperative screening measurements. For example, the Mini-Cog test is less sensitive to dementia for individuals with fewer than five years of formal education (Dement Neuropsycho 2009;3:81-7). Individuals with fewer years of schooling may show impairment as a consequence of limited education – not dementia. This is most easily explained with clock drawing examples; i.e., individuals with fewer years of education will show more digit placement errors and increased omission of clock hands (J Am Geriatr So 2001;49:941-7; Eur Neurol 2008;60:73-8). These errors relate to educational stages such that individuals with fewer than five years of education may have limited exposure to number sense (i.e., following the requirement of “put in all of the numbers”) and time-telling (i.e., “set the hands to 10 after 11”) (Int J Art Des Educ 1999;18:10). Writing abilities needed for clock drawing details are also linked to key brain regions, including the superior parietal lobule (associated with carrying out actions in space, visuospatial and visuomotor processing), the inferior fusiform gyrus (associated with phonological processing, learning letterforms and words), and an area located just above Broca’s area (i.e., Exner’s area, involved in orthographic or graphemic representations and complex movement sequences) (Front Hum Neurosci 2014;8:155). Clock-drawing digit placement accuracy also correlates with functional connectivity between the basal nucleus of Meynert (necessary for acetylcholine production) and the anterior cingulate cortex – regions implicated in attention and mental planning (Front Aging Neurosci 2022;14:868500; Prog Neurobiol 1997;53:431-50). Time-telling skills are complicated by pulling from mathematics as well as language, visuospatial perception, and cognitive conceptual representation (J Learn Disabil 2012;45:351-60). These neuronal and developmental research findings substantiate the importance of education to brain health and cognitive screening.

There are few normative references for individuals with few years of education, however, which necessitates caution when choosing measures for perioperative screening programs. Given the negative impact of modest education on cognitive metrics, researchers are highlighting the necessity to include individuals with lower education in study samples (J Clin Exp Neuropsychol 2008;30:199-203). To ensure sufficient representation among underrepresented groups, normative studies need to represent individuals with lower years of education (Eur Neurol 2008;60:73-8; J Alzheimers Dis 2021;82:59-70; Front Aging Neurosci 2022;14:868500; J Clin Anesth 2020;62:109724). Improved norming representation may be particularly advantageous within the perioperative setting, where early preoperative cognitive detection is paramount to mitigating postoperative complications.

Fewer years of education can provide additional insight into social deprivation, which impacts patients’ postoperative outcomes. Area deprivation research shows that participants in disadvantaged neighborhoods tend to be less college-educated (Alzheimers Dement 2020;6:e12039). The incidence of Alzheimer’s disease and related dementias is disproportionately greater in lower education and racial/ethnic groups. Individuals in these communities can also experience high exposure to adverse living, learning, and working conditions (Alzheimers Dement 2020;6:e12039).

For all of the reasons described above, “years of education” is a health-associated variable worth reporting within patients’ medical records. Clinicians can rapidly add education to their considerations by asking, “How many years of school did you complete?” Skipped years count toward the total number of years. Repeated years do not add additional years. If the patient dropped out of high school, then record how many full years of school the patient completed. For example, a high school graduate counts as 12 years, a bachelor’s degree counts as 16 years, a master’s degree typically 18 years, and so forth. For clinicians acquiring education around the same time as a cognitive screener, we recommend providers ask for educational years before cognitive screening (Anesth Analg 2019;129:830-8).

Embracing the concept of perioperative brain health requires consideration of brain function, but also the appreciation of demographic variables presenting a risk to dementia, disease, and cognitive screening sensitivity/specificity. To date, the putative effect of education and sociodemographic variables has not been adequately determined in the perioperative setting. Asking for years of education can enhance patient-centered perioperative care. Acquiring education also has the potential to promote infrastructure for normative opportunities across perioperative sites administering standardized screening metrics as part of geriatric care guidelines.