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Commentary
Emerging evidence contradicts the hypothesis
that bilingualism delays dementia onset.
A Commentary on “Age of dementia diagnosis
in community dwelling bilingual and monolingual
Hispanic Americans” by Lawton et al., 2015
Esme Fuller-Thomson
Sandra Rotman Endowed Chair, Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, ON,
Canada
The hypothesis that bilingualism delays the onset of dementia
has been heartily embraced by the media in the UK, US and
elsewhere (e.g., BBC News, 2013; CBS News; CBC News; Times
of India). One business that sells programs to teach second
language acquisition claims “there is ample scientific evi-
dence that speaking another language significantly delays
dementia.” (Rosetta Stone, 2013) Yet, is this true? Lawton,
Gasquoine and Weimer's (2015) article throw into consider-
able doubt the validity of this claim.
The original research suggesting that bilingualism post-
pones dementia onset was conducted by Bialystok and her
colleagues who compared monolingual and bilingual referrals
to a memory clinic in Toronto, Canada (Bialystok, Craik, &
Freedman, 2007). Using patient, family member or caregiver
recall of time of first symptoms, the authors concluded that
bilingual patients' first symptoms of dementia were, on
average, 4 years later than monolinguals. The authors sug-
gested that the complex cognitive demands associated with
bilingualism contribute to cognitive reserve, which, in turn,
delays the onset of dementia symptoms (Craik, Bialystok, &
Freedman, 2010).
Several other retrospective studies from memory clinics
have found similar findings, including a later study in Toronto
(Craik et al., 2010), and a recent study in India (Alladi et al.,
2013). However, contradictory findings have also been noted
in research using similar study designs. For example,
Chertkow et al.’s (2010) study found that bilingualism status
E-mail address: esme.fuller.thomson@utoronto.ca.
http://dx.doi.org/10.1016/j.cortex.2015.01.024
0010-9452/© 2015 Elsevier Ltd. All rights reserved.
was not associated with age of onset of Alzheimer disease
among non-immigrant English Canadians. Gollan, Salmon,
Montoya, and Galasko (2011) also found no association be-
tween bilingualism and age of dementia onset for bilinguals
who had at least a high school level of education, although the
relationship was found for those who had not graduated from
high school. Clare et al. (2014) study in Wales found that the
age at diagnosis of Alzheimer's disease for monolingual An-
glophones was three years younger than for WelsheEnglish
bilinguals (76.2 years versus 79.3 years), although this failed to
reach statistical significance (p ¼ .089). Monolinguals were
significantly less cognitively impaired at time of diagnosis
than bilinguals (p ¼ .048), which could explain the trend
observed in monolinguals' younger age at diagnosis.
The design of these studies, however, makes them partic-
ularly vulnerable to methodological problems. These include
the possibility of selection bias due to the use of patients at a
memory clinic, potential recall bias in caregivers' reporting of
date of patients' first dementia symptoms and the confound-
ing effect of immigration status (Fuller-Thomson & Ku, 2014;
Lawton et al., 2015, Sanders, Hall, Katz, & Lipton, 2012).
While a true randomized controlled trial would be an ideal
design to examine the effect of bilingualism on age of de-
mentia onset, this would never be feasible. The next best
method to investigate a causal link between bilingualism and
the age of dementia onset is a large prospective cohort study of
community-dwelling bilingual and monolingual individuals
 c o r t e x 6 6 ( 2 0 1 5 ) 1 7 0 e1 7 2
who are free of dementia at baseline. Such a study should also
use a baseline assessment of bilingualism status, frequent
waves of data collection, a long follow-up period and the
determination of dementia diagnosis by a team of experts,
including neurologists. To date, four studies have fulfilled
these rigorous criteria (Crane et al., 2009; Lawton et al., 2015;
Sanders et al., 2012; Zahodne, Schofield, Farrell, Stern, &
Manly, 2014) and all four have failed to provide any support
for the hypothesis that bilingualism delays the onset of
dementia.
In their recent study using a sample of 1,789 participants
from the Sacramento Area Latino Study on Aging who were
followed for up to 10 years, Lawton et al. (2015) not only
included the design features discussed above, but they also
examined another potential confounding factor by investi-
gating whether immigrant status affected the relationship.
The authors found that the link between bilingualism and age
of onset remained non-significant even when immigrant sta-
tus was addressed. Moreover, the direction of the observed
association suggests that the lack of support for the hypoth-
esis is not due to low power, despite the fact that there were
only 54 monolinguals and 27 bilinguals who developed de-
mentia during the course of the study: In the study, mono-
lingual participants were older at the time of diagnosis with
dementia than bilingual participants (81.1 vs 79.3 years),
although the age difference did not reach statistical signifi-
cance (p ¼ .26). This finding is particularly surprising for two
reasons: 1) it is in the opposite direction of that predicted by
the theory that bilingualism delays dementia onset, and; 2)
monolingual respondents also had many fewer years of edu-
cation, on average, than bilinguals (4.99 years vs 7.70 years).
Lower levels of education are consistently associated with a
substantially higher risk of incident Alzheimer's disease
(Beydoun et al., 2014). Therefore, one would anticipate that the
monolinguals in this sample, due to their lower average level
of education, should have an earlier age of onset of dementia
than the bilinguals, even if bilingualism itself offered no pro-
tective advantage. It would be interesting to know if the un-
expectedly disadvantageous association between bilingualism
and age of onset of dementia reaches statistical significance
when adjustments are made for education level.
Consistent with the findings of Lawton et al. (2015), two of
the three other prospective studies of bilingualism and inci-
dent dementia also report results in the opposite direction to
that expected if bilingualism delayed the onset of dementia.
Using data from the Einstein Aging Study, Sanders et al. (2012)
assessed incident dementia in a sample of 1,779 fluent
English-speaking community-dwellers from the Bronx, NY
who were aged 70 and over at baseline. The follow-up period
was up to 16 years. The majority of the non-native English
speakers had acquired English during their childhood. In the
most highly-educated groups (those with at least 16 years of
education), non-native English speakers had four times the
likelihood of developing dementia during the study compared
with native English speakers (HR ¼ 3.97; 95% CI ¼ 1.62e9.75).
No significant association was found between bilingualism
and incident dementia in those with fewer years of education.
In a study of 2,299 Japanese-American men born and raised in
Hawaii who were the children of Japanese immigrants, Crane
et al. (2009) found that the likelihood of incident all-cause
171
dementia in a seven year follow-up period was lower for uni-
lingual Anglophones than for bilingual respondents (i.e., Jap-
anese and English speakers), although the difference just
failed to reach statistical significance (HR for unilinguals
compared with bilinguals ¼ .68; 95% CI ¼ .46e1.02).
In the remaining prospective study, Zahodne et al. (2014)
studied 1,067 Hispanic immigrants living in Manhattan who
were followed for up to 23 years. Self-assessed bilingualism
was associated with lower odds of subsequent dementia onset
in bivariate analysis. However, once education, gender and
age at enrollment were adjusted for, the association was no
longer significant.
Lawton et al. (2015) study is the second publication in 2014
and the most recent of four methodologically rigorous pro-
spective studies published in the past five years investigating
the link between bilingualism and the age of dementia onset.
The lack of support for any bilingual advantage in incident
dementia in these four studies provides robust evidence
refuting the cognitive reserve hypothesis. All four data sets
had large samples, ranging from 1,067 (Zahodne et al., 2014) to
2,299 (Crane et al., 2009). The maximum follow-up period was
substantial in each study, ranging from 7 years (Crane et al.,
2009) up to 23 years (Zahodne et al., 2014). Neither studies
comprised of ethnically-similar respondents (Crane et al.,
2009, Lawton et al., 2015; Zahodne et al., 2014) nor
ethnically-diverse participants (Sanders et al., 2012) found
that bilingualism was protective in staving off dementia. No
association between bilingualism and delayed dementia was
found in samples restricted to US-born respondents (Crane
et al., 2009), nor samples restricted to immigrants (Zahodne
et al., 2014) nor mixed samples of immigrants and non-
immigrants (Lawton et al., 2015; Sanders et al., 2012). Bilin-
gualism was not found to delay dementia in studies where
bilingualism was based on self-report (Crane et al., 2009,
Lawton et al., 2015; Sanders et al., 2012) nor when it was
assessed by an objective measure of reading level (Zahodne
et al., 2014). The cognitive reserve hypothesis suggests that
the bilingual advantage should be particularly apparent for
those who are lifelong bilinguals (Bialystok et al., 2007), yet
studies of samples comprised predominantly of individuals
who were bilingual since childhood (Crane et al., 2009; Sanders
et al., 2012) did not find that bilingualism was protective, nor
did studies using samples where second language acquisition
occurred primarily in adulthood (Zahodne et al., 2014).
Although large, prospective community-based studies with
long follow-up periods, such as the four studies discussed
above, are very expensive and time consuming, they provide
the best avenue to evaluate the validity of biologically-
plausible hypotheses. These types of studies are somewhat
impervious to two types of bias influencing the dissemination
of smaller, cross-sectional studies' findings that fail to disprove
the null: the file drawer problem, where researchers select not
to write up their non-significant findings, and the publication
bias, where submitted articles that do not support popular
hypotheses are less likely to be published. Due to the costs and
time involved in these large-scale prospective studies and the
substantial statistical power provided by sample sizes of more
than 1000 participants, even non-significant findings in these
studies are likely to be written up for conference presentations
and submitted for publication. Furthermore, the strength of
172 c o r t e x 6 6 ( 2 0 1 5 ) 1 7 0 e1 7 2
the studies' design makes it unlikely these papers would be
refused publication.
In sharp contrast, De Bruin, Treccani, and Della Sala (2015)
suggest that smaller cross-sectional studies examining the
bilingual advantage are vulnerable to both the “file drawer”
bias, as well as a publication bias. It is highly possible that
non-significant findings in smaller studies are due to inade-
quate statistical power to reject the null hypothesis, even
when the null hypothesis is false. This fact decreases re-
searchers' motivation to write-up non-significant findings and
also lowers the likelihood that these papers will be accepted
for publication, if submitted. De Bruin et al. (2015), reviewed 13
years of conference abstracts (1999e2012) examining bilin-
gualism and executive control. They found that 63% of the
abstracts supporting the bilingual advantage had been pub-
lished by February 2014, but only 29% of abstracts that found
no bilingual advantage had been published. This difference
could not be explained by year of conference presentation, nor
sample size.
In sum, the four methodologically rigorous prospective
studies conducted to date provide no support for any bilin-
gualism advantage in dementia onset. The dramatic differ-
ence in the findings of these prospective studies in contrast to
the majority of the published smaller retrospective studies
using samples from memory clinics may be due to five prob-
lems related to the latter's study design: the file drawer
problem, a bias against publishing non-significant findings
from small studies with low to medium statistical power, a
selection bias due to use of patients from a memory clinic,
potential recall bias in caregivers' reporting of age of onset of
dementia and confounding by immigration status.
There are many good reasons to acquire a second lan-
guage, particularly for international travellers, those of us
who are citizens of bilingual countries and/or individuals who
wish to reconnect with their roots from different cultural
traditions. Counter to what some media outlets and language-
training companies may wish for you to think, however,
delaying the onset of dementia through bilingualism is not a
reason that is supported by the strongest available evidence.
Acknowledgements
Esme Fuller-Thomson would like to gratefully acknowledge
the support received from the Sandra Rotman Endowed Chair
at the University of Toronto, the helpful suggestions offered
by the anonymous reviewers and Sarah Brennenstuhl's
assistance with manuscript preparation.
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Received 14 January 2015
Reviewed 20 January 2015
Accepted 30 January 2015