Educational inequalities in mortality after age 65 vary across birth cohorts in Spain

To assess educational inequalities in mortality after age 65 and examine differences across birth cohorts (1920-1939 and 1940-1959) using relative (mortality risk) and absolute (survival beyond age 65) measures.

We analysed data from the population-based Girona Heart Registry (REGICOR) cohort (Spain; 1995-2019), including individuals aged ≥65 years or reaching age 65 during follow-up. Educational attainment was classified as primary, secondary, or higher. Relative inequalities in mortality were estimated using Cox regression models. Absolute inequalities were assessed through excess survival at age 65 (ES65), defined as the difference between observed and expected survival at age 65. Models were adjusted for sex, calendar period, birth cohort, and education-by-cohort interaction.

Among 6006 participants (52% women; median follow-up: 9 years), significant education-by-cohort interactions were observed. In the 1920-1939 cohort, secondary (Hazard Ratio 0.77; 95% confidence interval 0.65, 0.90) and higher education (0.76; 0.65, 0.91) were associated with lower mortality than primary education. Corresponding gains in ES65 were 0.78 (0.28, 1.29) and 0.97 years (0.35, 1.60), respectively. No associations were observed in the 1940-1959 cohort.

Educational inequalities in mortality after age 65 were present only in the older cohort. Relative and absolute measures provide complementary perspectives on inequalities in later life.