Nordic Psychology

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Active lifestyle as a reflection of cognitive reserve:

The Modified Cognitive Reserve Scale

Kristiina Relander, Kaisa Mäki, Lauri Soinne, Juan García-García & Marja
Hietanen

To cite this article: Kristiina Relander, Kaisa Mäki, Lauri Soinne, Juan García-García & Marja
Hietanen (2021): Active lifestyle as a reflection of cognitive reserve: The Modified Cognitive
Reserve Scale, Nordic Psychology, DOI: 10.1080/19012276.2021.1902846

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Nordic Psychology, 2021
https://doi.org/10.1080/19012276.2021.1902846 RESEARCH ARTICLE

Active lifestyle as a reflection of cognitive

reserve: The Modified Cognitive Reserve Scale
KRISTIINA RELANDER1, KAISA MÄKI1, LAURI SOINNE2, JUAN GARCÍA-GARCÍA3 & MARJA HIETANEN1
Correspondence address: Kristiina Relander, Clinical Neurosciences, Neuropsychology, University of Helsinki and
Helsinki University Hospital, Helsinki, Finland. Email: kristiina.relander@helsinki.fi

Abstract
Cognitive reserve (CR) refers to individual differences in cognitive processing that can
protect from and compensate for functional decline related to ageing or brain pathology.
The CR theory postulates that attaining an active and cognitively stimulating lifestyle can
accumulate CR. The Cognitive Reserve Scale (CRS) is a questionnaire that measures lifelong
attainment in leisure activities. This cross-sectional study aimed to examine the usefulness,
validity and reliability of a modified Finnish translation of the CRS, the Modified Cognitive
Reserve Scale (mCRS). The mCRS consists of 20 questions concerning studying and
information seeking, hobbies and social relationships during three age phases: young
adulthood (18–35 years), adulthood (36–64 years) and late adulthood (
65 years). A group of
69 neurologically healthy adults aged 26–78 filled the mCRS and completed a
neuropsychological test battery. We examined the internal consistency of the mCRS and
associations between the mCRS, demographical variables and cognitive performance. The
mCRS was normally distributed and showed satisfactory internal consistency (Cronbach’s
alpha 0.81). It was significantly associated with occupation (ԑ2 ¼ 0.14) and education (rho ¼
0.51) but not with age or gender. There were significant associations between the mCRS
and verbal reasoning (rho ¼ .306), visual reasoning (r ¼ .319), learning (r ¼ .293) and
inhibition (rho ¼ -.368). Our study suggests that the mCRS is a reliable and valid method to
assess lifelong leisure activity. The mCRS is related to other factors that enhance CR,
occupation and education, and associated with cognitive performance of healthy adults. It
provides an easily administrable means to assess lifelong attainment in stimulating
leisure activities.

Keywords: cognitive reserve, leisure time, questionnaires, neuropsychological assessment

Introduction
Cognitive reserve (CR) refers to efficiency of cognitive task processing that provides protec-
tion against functional manifestations of brain diseases, injury or ageing. The concept of CR
aims to explain why ageing or brain pathology can be associated with a varying degree of
clinical symptoms (Stern, 2002). Higher CR has been associated with less cognitive decline
1
Clinical Neurosciences, Neuropsychology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
2
Clinical Neurosciences, Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
3
Health Research Center, Psychology Department, University of Almer
ıa, Spain.

© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-
NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use,
distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered,
transformed, or built upon in any way.
2 Kristiina Relander et al.

relative to brain pathology in, e.g. Alzheimer’s disease (Stern, 2012), cerebral small vessel
disease (Jokinen et al., 2016) and multiple sclerosis (Sandroff et al., 2016). Recently, diverse
terminology and concepts underlying CR and its neural background have been under
debate (Cabeza et al., 2018; Nilsson & Lo €vd
en, 2018; Stern et al., 2018). Both genetic factors
and enriching experiences can enhance the individual’s capacity to perform particularly
demanding tasks, and, most importantly, to cope with cognitive changes related to age or
pathology (Cabeza et al., 2018; Stern, 2017; Stern et al., 2018).
Various enriching experiences, such as education, occupational demands and leisure activ-
ities associate with better cognitive performance relative to age or level of pathology
(Chapko et al., 2018; Opdebeeck et al., 2016). Although widely used as proxies for CR, the
aforementioned enriching experiences should, however, not be regarded as direct measures
of CR. Instead, they represent factors that may increase CR (Jones et al., 2011; Nilsson &
Lo€vd
en, 2018; Stern et al., 2018). Concerning lifelong accumulation of CR, leisure activity is
of particular interest. Primary cognitive abilities and early life socioeconomic factors, such as
given historical and societal situation and available family support, may have a great influ-
ence on educational possibilities and occupational choices. Moreover, long-lasting educa-
tional and occupational choices are largely made in early adulthood. While genetic,
socioeconomic, educational and occupational variables may also influence free time activ-
ities, changes towards more stimulating leisure life can also be made in advanced age in
order to buffer against cognitive deterioration and to gain more active years towards later
life. Hence, promoting awareness on cognitively stimulating free time choices may have
beneficial effects on CR throughout life.
Several assessment methods have been developed to assess engagement in cognitively
stimulating leisure activities, such as studying, hobbies and social activity. The majority of
these instruments are cross-sectional questionnaires (Lara et al., 2017; Lojo-Seoane et al.,
2014; Scarmeas et al., 2001; Wilson et al., 2002). However, engagement in leisure activities
may vary across different stages of life, for instance because of the variability of the associ-
ated social and occupational demands. Moreover, individuals prone to dementing illness
may gradually withdraw from cognitively stimulating and social activities already before
overt clinical symptoms appear and become diagnostic, which may bias cross-sectional
assessment of leisure activity and its connections with cognitive status in late adulthood.
Thus, cross-sectional measures on leisure activity may not capture the full picture of lifelong
cognitive stimulation and its association with cognitive functioning.
Some assessment methods have also been introduced to examine leisure activity across
different phases of life. The Cognitive Reserve Index questionnaire (CRIq) is a half-structured
interview that measures total years spent in education, occupational attainment and leisure
activities (Nucci et al., 2012). Due to the rather demanding assessment method, the CRIq
cannot be completed without an interviewer. The Lifetime of experiences questionnaire
(LEQ) assesses educational, occupational and leisure activity with different age-related ques-
tions during three age phases, and is only administrable for people over 65 years of age
(Valenzuela & Sachdev, 2007). The Cognitive Reserve Scale (CRS) (Leo
n et al., 2014) over-
comes the aforementioned disadvantages. The questionnaire covers a broad range of leis-
ure activities during three different age phases: early adulthood, adulthood and late
adulthood. The participants can fill the CRS independently, and it can be applied at any
age. The CRS was originally developed and validated in Spanish (Leon et al., 2011, 2014;
 Active lifestyle as a reflection of cognitive reserve 3

Leon-Estrada et al., 2017; Rold
an-Tapia et al., 2017) and has later been applied in Italy
(Altieri et al., 2018) and Chile (Cancino et al., 2018). In the present study, some items of the
original scale were excluded and modified in order to increase construct validity of the
questionnaire.
Leisure activity is important to be assessed and promoted in order to accumulate CR
through the life span. However, available methods to measure lifelong enriching free time
activity are scarce. This study aimed to examine the usefulness, validity and reliability of a
modified Finnish translation of the CRS, the Modified Cognitive Reserve Scale (mCRS) in
healthy Finnish people. We examined the associations between the mCRS, other reserve-
inducing variables and cognitive functioning.

Materials and methods

Participants
We recruited 70 independent, neurologically healthy, native Finnish speaking participants to
this cross-sectional study as part of control population of two clinical studies. The studies
were approved by the ethical committee of the Helsinki University Hospital, Finland
(approval numbers 86/13/03/01/2014 and 105/13/03/01/2014) and performed in accordance
with the ethical standards of the Declaration of Helsinki. The participants were recruited
between 1 June 2016 and 28 February 2019 in the Neurocenter of Helsinki University
Hospital, Finland, and gave written informed consent for participation in the study. One par-
ticipant was excluded from the study due to extreme CRS values resulting from obvious
misunderstanding of instructions. The final study population consisted of 69 participants (26
women) aged 26–78 (median age 62 years). The participants were stratified into three age
groups (young adulthood, ages 18–35, 9 participants; adulthood, ages 36–64, 30 partici-
pants; late adulthood,
65 years, 30 participants).

The Modified Cognitive Reserve scale

The Modified Cognitive Reserve Scale (mCRS) consists of 20 questions concerning studying
and information seeking (4 items), hobbies (13 items) and social relationships (3 items).
Examples of items in each category are shown in Table 1. Compared with the original
Cognitive Reserve Scale (Leo
n et al., 2014), we decided to exclude four items on activities
of daily living (controlling one’s own life such as choosing clothes, controlling financial mat-
ters at home, doing housework and using basic information technology, such as the televi-
sion) because they reflect basic independence in daily life instead of cognitively stimulating
leisure activities like the other items. In addition, we modified some items in order to cap-
ture a richer picture of leisure activities. Namely, we added more examples of activities and
replaced “active shopping” with “active spectator sports, animal or nature hobby (e.g. going
to sports events, hunting, mushrooming, bird-watching or taking care of a pet).”
The items were responded on a Likert scale 0–4 (0 ¼ never, 1 ¼ once or several times per
year, 2 ¼ once or several times per month, 3 ¼ 1–2 times per week, 4 ¼ almost every day).
The participants were asked to fill the mCRS according to how much they remember attain-
ing to each activity during young adulthood (18–35 years) and, if applicable, adulthood
(36–64 years) and late adulthood (
65 years). Thus, the participants filled the mCRS 1–3
4 Kristiina Relander et al.

Table 1. Examples of translated items of the Modified Cognitive Reserve Scale.

Category Example of item
Studying and information seeking Studying during free time (e.g. language or
computer courses)

Using information technology (e.g. information seeking

from the internet, email, social media)

Hobbies Reading during free time (e.g. magazines,

newspapers, books)

Playing an instrument

Spectator sports, animals or nature (e.g. going to sports

events, hunting, mushrooming, bird-watching, taking
care of a pet)

Social relationships Meeting friends, relatives or neighbours (e.g. parties,

family dinners, meetings at a caf
e)

Spending time with people of different age (e.g. baby

sitting or visiting elderly people)

times depending on their age. Each item was averaged across the 1–3 age groups. The total
mCRS score comprised of the sum of the averaged item scores, maximum score, thus, being
80. Missing values (in total four single values, each in different participants) were imputed
with individual age-specific median scores.

Educational and occupational attainment

Educational attainment was measured as completed educational level and converted into
education years according to standard completion times in the Finnish education system
based on UNESCO’s International Standard Classification of Education 2011 (UNESCO
Institute for Statistics, 2012). Occupational attainment was scored into four classes based on
the International Standard Classification of Occupations (ISCO-08) occupational skill levels:
1 ¼ simple physical or manual routine tasks, 2 ¼ tasks that require good literacy and numer-
acy, interpersonal communication skills or manual dexterity, 3 ¼ complex tasks requiring an
extensive body of factual, technical and procedural knowledge in a specialized field,
4 ¼ tasks that require complex problem solving and decision making based on extensive
theoretical knowledge in a specialized field (International Labour Organization, 2012).
Because only one participant fell in occupational class 1, classes 1 and 2 were combined
in analyses.

Neuropsychological assessment
The neuropsychological test battery consisted of verbal reasoning (WAIS-IV Similarities), vis-
ual reasoning (WAIS-IV Block Design), learning (WMS-III Word list, sum score of trials 1–3),
processing speed (Stroop Color condition, time to complete), inhibition (Stroop Word condi-
tion subtracted by Color condition, times to complete), phonemic fluency and seman-
tic fluency.
 Active lifestyle as a reflection of cognitive reserve 5

Figure 1. Distribution of the mCRS (Modified Cognitive Reserve Scale) scores: total score and score in
young adulthood (18–35 years), adulthood (36–64 years) and late adulthood (
65 years).

Statistical analyses
Statistical analyses were performed with IBM SPSS 25 (IBM Corp., 2017). P-values below .05
were considered significant. Normality of the mCRS score and other variables was measured
with Kolmogorov-Smirnov test. Internal consistency of the mCRS was computed with
Cronbach’s alpha, item-item correlations and corrected item-total correlations. Effects of
gender and occupational attainment on the mCRS were calculated with independent sam-
ples t-test and Kruskal-Wallis test, respectively. Ԑ 2 was used as a measure of effect size for
Kruskal-Wallis test. Differences in the young adulthood mCRS score between age groups
were assessed with Kruskal-Wallis test. Differences in the mCRS score between different age
phases were assessed with repeated t-test within the 36–64 years group and with repeated
analysis of variance within the
65 years group. Greenhouse-Geisser test was used to adjust
for nonsphericity in repeated measures analysis of variance and p-values of post hoc tests
were Bonferroni corrected for multiple comparisons. Associations between the mCRS and
education, age in years and cognitive performance were assessed with Pearson’s and
Spearman’s correlations. In order to adjust for years of age, we also calculated partial
correlations.
6 Kristiina Relander et al.

Table 2. Characteristics of the study population.

Age, years 62 (19)

Age group

18–35 9 (13%)

36–64 30 (44%)

65 30 (44%)

Gender, female 26 (38%)

Education, years 14 (5)

Occupational skill level

1 1 (1%)

2 19 (28%)

3 15 (22%)

4 34 (49%)

mCRS

total score 38.6 ± 9.1

young adulthood 37.7 ± 10.2

adulthood 38.6 ± 9.5

late adulthood 37.8 ± 10.3

WAIS-IV Similarities 28 (6)

WAIS-IV Block design 42.67 ± 12.25

WMS-III Word list 22.13 ± 5.01

Stroop Color condition 36 (6.5)

Stroop Inhibition 22 (11.5)

Phonemic fluency 18.33 ± 6.46

Semantic fluency 22.55 ± 5.45

Data are presented as mean ± SD, median (interquartile range) or N (%).

Results
Distribution of the mCRS is shown in Figure 1. The total mCRS score ranged between 14
and 58 and was normally distributed (skewness ¼ -.17, kurtosis ¼ -.21, Kolmogorov–
Smirnov ¼ .09, p > .05). The mCRS showed satisfactory to good internal consistency:
Cronbach’s alpha was 0.81 (95% CI 0.74–0.87) for the total mCRS score and 0.78 (95% CI
0.70–0.85), 0.78 (95% CI 0.70–0.86) and 0.79 (95% CI 0.67–0.89) for young adulthood, adult-
hood and late adulthood, respectively. Corrected item-total correlations varied between
0.22 and 0.63. Inter-item correlations of the total score ranged between -0.20 and 0.61
(mean 0.18).
Characteristics of the study population are presented in Table 2. The mCRS was associated
with occupation (v2(2)¼9.66, p ¼ .008, ԑ 2 ¼ 0.14) and education (rho ¼ 0.51, p < .001) but
not with years of age or gender. Looking at the results within age groups, the young adult-
hood mCRS score was 45.2 in the 18–35 years group, 37.7 in the 36–64 years group and
 Active lifestyle as a reflection of cognitive reserve 7

Table 3. Correlations and age-adjusted partial correlations between the mCRS and cognitive
performance.
Test r p r (adjusted) p
WAIS-IV Similarities .306 b
.011 .339b
.005

WAIS-IV .319 .008 .262b .031

Block design

WMS-III Word list .293 .014 .175b NS

b
Stroop .081 NS .120b NS
Color conditiona

Stroop Inhibitiona -.368b .002 -.323 b

.007

Phonemic fluency .199 NS .239b

.0495

Semantic fluency .040 NS .013b

NS
a
Lower scores reflect better performance.
b
Nonparametric Spearman’s correlation.

p < .05.

p < .01.
NS: not significant.

35.4 in the
65 years group. The difference between age groups did not reach significance
(v2(2)¼5.96, p ¼ .051). Within the 36–64 years group, the mCRS score did not differ signifi-
cantly between young adulthood (mCRS score mean 37.7) and adulthood (mean 37.4).
Within the
65 years group, the mCRS score differed significantly between young adult-
hood (mean 35.4), adulthood (mean 40.0) and late adulthood (mean 37.8) (F(1,38)¼6.12,
p ¼ .011). Bonferroni corrected post hoc tests revealed that the difference in mCRS score
was significant between adulthood and young adulthood (p < .001) but not between
other contrasts.
Associations between the mCRS and cognitive performance are shown in Table 3. In sum,
there were significant correlations between the mCRS and verbal reasoning (rho ¼ .306,
p ¼ .011), visual reasoning (r ¼ .319, p ¼ .008), learning (r ¼ .293, p ¼ .014) and inhibition
(rho ¼ -.368, p ¼ .002). When adjusted for age, also phonemic fluency (rho ¼ .239, p ¼
.0495), but no longer learning correlated with the mCRS. Processing speed and semantic flu-
ency were not associated with the mCRS.

Discussion
The present study suggests that the Modified Cognitive Reserve Scale (mCRS), a modified
translation of Cognitive Reserve Scale (CRS) (Leo
n et al., 2014) is a reliable and valid method
to assess CR associated with leisure activity. The mCRS is related to occupation and educa-
tion, but not to age or gender. Most importantly, leisure activity assessed with the mCRS is
associated with a wide range of complex cognitive abilities. It provides a useful and easily
administrable means to assess lifelong attainment in cognitive stimulating leisure activities.
Our findings are concurrent with previous findings on CR and its assessment. The mCRS
was significantly associated with other factors that enhance CR, education (in line with

n et al., 2014) and occupation (in line with Altieri et al., 2018), but
Altieri et al., 2018; Leo
not with age or gender. Most importantly, the mCRS score was associated with performance
8 Kristiina Relander et al.

in several cognitive functions. Associations between leisure activity and cognition were
roughly similar to those found with the original CRS (Leo
n et al., 2014), with significant rela-
tionships between leisure activity and learning, verbal reasoning/execution and visual rea-
soning, but not with processing speed or verbal fluency. Associations between the CRS,
memory and visuospatial abilities (Altieri et al., 2018), as well as memory and inhibition
(Rold
an-Tapia et al., 2017), have also been found in other subsequent studies. Indeed, it is
postulated that CR is based on allocating strategic or compensational resources (Stern,
2002). It has also been suggested that CR is related to strategic abilities that are less prone
to age-related decline, thus, enabling compensation of age-related decreases in other men-
tal abilities (Nilsson & Lo €vd
en, 2018). Thus, it is reasonable that reserve is associated with
complex cognitive functions that require high-level strategic competence, such as executive
functioning, learning and reasoning, rather than mechanical processing speed, which is par-
ticularly prone to deteriorating effects of ageing (Ebaid et al., 2017; Salthouse, 1996). In con-
clusion, the present findings on the interconnections between leisure activity, measured
with the mCRS and cognitive functioning are in accordance with current understanding
of CR.
Compared with the original CRS (Leo
n et al., 2014), we chose to make some modifications
to the scale. First, we excluded items measuring daily functioning, such as choosing one’s
own clothes or doing housework, which we considered less cognitively stimulating than the
other items. Secondly, we modified some items of the scale to capture a more comprehen-
sive picture of leisure activity. Internal consistency of the mCRS was acceptable (Cronbach’s
alpha 0.81 for the total score and 0.78 to 0.79 for different life stages) and even higher than
that of the original scale (0.77, total score) (Leo
n et al., 2014) and of a direct translation of
it (0.73 total score, 0.74 to 0.75 for different life stages) (Altieri et al., 2018). These results
indicate that the chosen modifications were justified. As expected (Kartschmit et al., 2019)
and in accord with Altieri et al. (2018), the inter-item correlations of the scale in the present
study were variable, reflecting the broad range of leisure activities included with an aim to
reach diverse cognitively stimulating leisure activities that different people prefer. Thus, we
suggest that the mCRS reflects cognitively stimulating free time activity comprehensively
and reliably.
The mCRS has several advantages compared to other proxies of CR. First, while educa-
tional and occupational decisions are subject to primary cognitive abilities as well as early
life socioeconomical factors and often made rather early in adulthood, changes towards
more stimulating leisure life can also be made in advanced age in order to buffer against
cognitive deterioration and to gain more active years towards later life. Thus, assessing leis-
ure activities may provide a richer picture of cognitively stimulating experiences that con-
tribute to CR. The mCRS covers a wide range of both educational, cultural and social
activities, including physical exercise. Second, because CR can be gained throughout life, it
is important to be assessed separately for different phases of life (Kartschmit et al., 2019).
The mCRS provides a means to assess lifelong attainment to leisure activity as opposed to
cross-sectional assessment methods, which are prone to bias because of varying leisure pos-
sibilities in different life stages. On the one hand, some age phases are often filled with
educational, occupational and/or parental demands and on the other hand, physical limita-
tions as well as changes in cognitive abilities may limit possibilities to take part in cogni-
tively stimulating activities in advanced age. Moreover, leisure possibilities may also vary
 Active lifestyle as a reflection of cognitive reserve 9

according to sociohistorical circumstances. The mCRS score of the oldest age group indeed
differed between age phases in the present study, whereas there were no such differences
in the 36–64 years group, supporting the view that leisure activity should be assessed separ-
ately in different stages of life especially within older adults. Third, despite the comprehen-
sive nature of the mCRS, the participants can fill it independently in a relatively short time
without an interviewer. Thus, in addition to clinical contexts such as neuropsychological
assessments, the mCRS is usable also in large epidemiological studies (Kartschmit
et al., 2019).
Limitations of the present study include a rather small sample with somewhat skewed dis-
tribution of occupational class and a restricted range of neuropsychological tests. In add-
ition, we did not use a formal translation process, such as forward and backward
translation. Instead of a direct translation, we intended to make a modified version of the
CRS by means of excluding less stimulating items and modifying some items in order to
capture a more comprehensive picture of leisure activity. These modifications resulted in
increased internal consistency compared to the original scale (Leo
n et al., 2014) and
increased its construct validity. Even in the presence of these methodological restrictions,
we were able to demonstrate the validity and reliability of the mCRS in estimating leisure
activity and its connections with CR in healthy Finnish adults. The usefulness of the mCRS
in clinical groups and longitudinal settings remain to be investigated.
While the effects of cognitive decline cannot be fully overcome, an active lifestyle may
build cognitive reserve against changes related to age or disease. The present study sug-
gests that the Modified Cognitive Reserve Scale is a valid, reliable and easily administrable
method to assess lifelong engagement in cognitively stimulating leisure activities.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
KR was supported by the P€aivikki and Sakari Sohlberg Foundation; the Finnish Cultural
Foundation [grant number 00180910]; the Finnish Concordia Fund; and Helsinki University
Central Hospital governmental subsidy funding for clinical research. KM was supported by
the Dorothea Olivia, Karl Walter and Jarl Walter Perkle
n Foundation; the P€aivikki and Sakari
Sohlberg Foundation; and Helsinki University Central Hospital governmental subsidy
funding for clinical research.

Data availability statement

Requests for sharing of data will be given individual consideration after additional approval
for sharing by the local Ethics committee.

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