Alzheimer's Playbook for Care Givers

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Amid all of the a complex research in the Alzheimer's field, research involving genetics, neuro-chemesty, imaging, and bio-markers, it is easy to lose sight of the fact that the simplest and most practical advances sometimes come from the labor of experience.

And so it is with care giving.

I wanted to draw attention to an excellent resource, based completely on direct, first-hand experience in caring for an Alzheimer's patient. I refer to Coach Broyle's Playbook for Alzheimer's Care Givers. You can download it here for free.

Inside you will find practical tips related to:
- Pacing
- Late afternoon behavior
- Refusing care
- Using the bathroom
- Dressing
- Home safety
- Wandering
- Communication
- In the car
- Eating
- Survival Tips

This resource is extremely direct and accessible and, though short, is crammed full of useful tips that were born of personal experience. To my knowledge, it is not based on any sophisticated scientific analysis but on the the pressure and necessity of finding solutions to everyday problems in caring for a loved one with Alzheimer's disease.

Please pass this along to anyone who you think might benefit from reading it.

Managing Risks for Dementia


Contributed by: Dennis Fortier, President, Medical Care Corporation
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One of my favorite types of scientific research is the "review paper" when authors collect and review the literature in a certain field and report on the depth and breadth of findings in the targeted area of study. As such, I was happy to see a recent report by the BBC that the Alzheimer's Society had chaired a panel of experts and reviewed more than 70 research papers on reducing the risk of dementia.

The report contained some elements that may be as surprising as they are important. Notably, they suggested that age 35 is probably the right time to start managing known risks in an effort to ward off dementia later in life.

I strongly suggest you click to read the BBC's synopsis of the report but the highlights are noted here:

Strong Evidence in support of:
- Get Physical Exercise
- Don't Be Obese
- Bring Down High Blood Pressure
- Reduce High Cholesterol
- Don't Smoke

Some Evidence in support of:
- Drink Modest Amounts of Alcohol
- Eat a Mediterranean Diet
- Remain or Become Socially Active

The Jury is out on:
- Brain Training
- Vitamin Supplements

The importance of this review, and other similarly scientific reviews, can not be overstated in this era of aggressive commercialization of unregulated health care solutions. There is a lot of hype in the press that has not yet been scientifically validated. Some of it might ultimately prove to be worthwhile but this review let's you know the current state of the science.

Are TV Advertisements for Aricept Misleading?

Contributed by: Dennis Fortier, President, Medical Care Corporation
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According to the FDA, they are.

Aricept is the most commonly prescribed treatment for Alzheimer's disease. It is indicated for treatment of mild to moderate dementia of the Alzheimer's type and data from FDA clinical trials suggests that it is more effective in relieving symptoms than in delaying the underlying disease.

However, recent television advertisements sponsored by Eisai (manufacturer of the drug) and Pfizer (US distributor of the drug) depict adults first meeting with a doctor, accompanied by an apparent caregiver, and then later engaged in daily activities such as gardening and caring for pets. In the opinion of the FDA, these ads suggest a level of improvement that is not supported by clinical data. The ads are currently suspended while the companies respond to the FDA's complaint.

Whatever the outcome, it is important to understand the treatment efficacy of cholinesterase inhibitors (the class of drugs to which Aricept belongs). Data from the FDA clinical trials suggest a symptomatic benefit and ongoing analysis of those data indicate a small but discernible disease delaying effect for some patients, especially those who begin treatment at an early stage of the disease. Importantly, it is now well established that a cholinesterase inhibitor combined with Namenda (a partial glutamate antagonist) yields the most benefit over the longest treatment period.

Does Pregnancy Impair Memory?


Contributed by: Dennis Fortier, President, Medical Care Corporation
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While I don't often see news stories reporting that pregnancy impairs memory, there does seem to be a generally accepted notion that pregnant women and mothers of newborn children suffer the malady. Many of you, I suspect, may be familiar with terms such as "baby-brain" and "momnesia".

A study this week in the British Journal of Psychiatry contradicts the hearsay. In the study, 806 women between the ages of 20 and 24 were recruited and followed for up to eight years. Memory and cognition were assessed at various points and results were compared between those who were mothers, those who were pregnant, and those who were nulliparous. Importantly, no significant cognitive change was noted as a function of motherhood nor pregnancy.

While it is plausible that pregnant women have concerns and distractions that could prevent them from storing information that they might otherwise retain, and mothers of young children might have interrupted sleep patterns that could affect their alertness or processing speed, there does not appear to be a deeper, underlying association between pregnancy and perceived memory loss.

10 Ways to Keep Your Brain Sharp

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Headlines of this nature are ubiquitous in the press and are often followed by thinly veiled advertisements for a nutriceutical, a natural herb of some sort, or a new game designed to challenge your brain.

Nonetheless, there are some well validated choices one can make that increase the likelihood of maintaining good brain health. I try to emphasize those choices in this blog as a means of separating the science from the hype. I noticed a nice summary yesterday posted at NaturalNews.com and wanted to pass it along to you readers.

The suggestions include physical exercise, proper diet, intellectual and social stimulation, and quitting smoking. You can read about all ten suggestions here with a succinct description of each.

Support for the Amyloid Hypothesis

Contributed by: Dennis Fortier, President, Medical Care Corporation
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A prevalent theory explaining the cause of Alzheimer's disease is that amyloid deposits accumulate in the brain and disrupt cell function.

While this hypothesis has driven the majority of drug development efforts over the past three years, the theory has some apparent weaknesses that must be explained. Specifically, researchers have not been able to explain why some adults with extensive amyloid deposits do not have Alzheimer's disease.

A study out of UCSF and published in Behavioral Neurology lends some support to the amyloid hypothesis. The authors reviewed over 100 published studies that involved PET scans and the PIB compound and found that there is a strong correlation between amyloid load in the brain and cognitive decline due to Alzheimer's disease. Importantly, they have documented support for the notion that there is a time lag between amyloid build-up and cognitive decline.
"Amyloid deposits appear to reach a plateau early in the disease course, when patients experience very mild symptoms or no symptoms at all," says Rabinovici, a recipient of new investigator awards from the Alzheimer's Association and the National Institute on Aging. "By the time patients have developed the symptoms of Alzheimer's disease, clinical decline and brain changes are occurring independently of further amyloid accumulation. This suggests that we have been starting treatment too late, and that amyloid-based therapies are most likely to work very early in the disease process."
Gaining a deeper understanding of the progressive pathology of Alzheimer's disease will be critical in developing effective treatment. In the meantime, the body of evidence supporting earlier intervention continues to grow.

Neuro-Imaging and Alzheimer's: The Basics

Contributed by: Dennis Fortier, President, Medical Care Corporation
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Rarely a day goes by when I do not see several news items about the role of neuro-imaging in detecting, treating, or monitoring the progression of Alzheimer's disease. Here are a few comments to bear in mind as you consume the daily press.

Magnetic Resonance Imaging (MRI) yields an image of brain structure and will reveal tumors, strokes, and (importantly for Alzheimer's disease) atrophy (or shrinkage) in particular parts of the brain that can be helpful in reaching an accurate diagnosis.

Positron Emission Tomography (PET) yields an image of brain metabolism and reveals where brain cells are engaged the healthy activities of their daily function. In some instances, this can reveal an earlier stage of a problem than MRI would reveal because cells may have stopped functioning but remained intact structurally.

Many news stories report on "tracers" or agents such as PIB that, once injected into the blood, make their way to the brain and bind with the beta amyloid, rendering it clearly visible in the scan. This is important because many scientists believe beta amyloid accumulation may be the cause of Alzheimer's disease.

While the PET/PIB studies are generally promising, public optimism should be tempered by the fact that the PIB compound has some significant practical shortcomings. It decays rapidly and must be injected very quickly after being manufactured. For that reason alone, the prospect of wide-spread use in a clinical setting is a distant one.

How Doctors View Dementia Compared to Other Common Health Problems


Contributed by: Dennis Fortier, President, Medical Care Corporation
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As we note often in this space, there is a significant gap between the state of our scientific knowledge about Alzheimer's (and other causes of dementia) and the actual standards of care that most patients receive when they visit their physician.

This problem, which is not limited to the dementia field, may be particularly noteworthy in the dementia field because an intense research effort is moving the field quickly forward and busy physicians cannot stay current with the rapid pace of scientific discovery.

A recent study published in the Journal of the American Geriatrics Society has clearly documented one factor that contributes to this gap. It is physician attitudes about their own ability to help patients and their perceptions about the availability of outside support resources.

In the study, primary care physicians were surveyed on their attitudes toward three common problems that they face in clinical practice; heart disease , diabetes, and dementia. The following trends were clearly noted:

More PCPs strongly agreed that:
  • older patients with dementia are difficult to manage (23.8%) than for heart disease (5.0%) or diabetes mellitus (6.3%);
  • PCPs can improve quality of life for heart disease (58.9%) and diabetes mellitus (61.6%) than for dementia (30.9%);
  • older patients should be routinely screened for heart disease
    (63.8%) and diabetes mellitus (67.7%) than dementia(55.5%);
  • their organizations have expertise/referral resources to manage diabetes mellitus (49.4%) and heart disease (51.8%) than dementia (21.1%)
In my opinion, the 2nd and 4th points may have a strongest detrimental effect on care.

The second point suggests that physicians are unaware of how much they can improve a patient's health through timely intervention, a careful diagnosis, and proper treatment of the dementing disorder at hand.

The 4th point probably prevents PCP's from offering appropriately constructive care plans to the families of demented patients. If they do not feel there are adequate systems and support resources for demented patients in their communities, they may choose to temper expectations and resign the family to an unnecessarily dire prognosis.

Education for the public will play a major role in the fight against Alzheimer's and other forms of dementia but clearly, a strong dose of physician education will also be required.

The purpose of this blog is to spread useful information as broadly as possible. If you found this article worthwhile, please share it with your online networks using the share button below.

Perspective on Diagnosing Alzheimer's Early

Contributed by: Dennis Fortier, President, Medical Care Corporation
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One theme that recurs in this blog is the benefit of early diagnosis and intervention against Alzheimer's disease. Since we currently diagnose the disease, on average, in the mild to moderate dementia stages, most patients miss out on several years of treatment (and possible disease delaying effects) during the earlier stages of illness.

This topic was discussed recently on the Alzheimer's Blog at the Mayo Clinic site and I thought there were some good points made by the author of the posting, by a follow-up entry, and by some of the readers who left comments. I encourage you to check it out.

The Brain Today Twit Stream

Contributed by: Dennis Fortier, President, Medical Care Corporation
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To write about the daily news in this space, we track hundreds of online sources to uncover the news that is most important and most relevant to our audience.

While we don't blog about every news item, we often highlight stories of interest on Twitter. If you would like to stay abreast of those stories in addition to the ones we discuss in this blog, please follow our Twit Stream by clicking on the link below:

Follow Brain Today on Twitter: click here

The Unseen Side Effects of a Healthy Heart


Contributed by: Dennis Fortier, President, Medical Care Corporation
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Do you know the chances of surviving a heart attack? According to WebMD, they’re actually pretty good at about 85%.

That doesn’t mean that anyone wants to test the statistics personally nor does “survival” guarantee a high quality of life thereafter. But it may be true that as public awareness grows about heart attack victims who fully recover and live well, the prospect of heart failure becomes less of a deterrent from an unhealthy life style.

In fact, WebMD also notes that survival has become more likely despite the fact that heart attack victims are in generally worse cardio-vascular health (more high blood pressure and diabetes) than in the past. This suggests that the better survival rate is due to better medical techniques, not to a general trend toward improved vascular health.

Healthy Hearts Maintain Healthy Brains
Importantly, there are other, less obvious but perhaps more compelling reasons to care for your heart. Mainly, good vascular health is extremely important to maintaining a healthy brain. While most of us accept the fact that our tennis serve will likely slow as we age, few are so willing to accept the prospect of diminishing cognitive capacity. The good news is that cognitive decline is far from inevitable and we probably don’t need to accept it.

So how does one take good care of their heart and reap the brain related benefits? What exactly should one do? The answer is to focus on managing those risks that are known to be associated with poor heart health.

These risks include monitoring and controlling blood pressure, cholesterol, and body mass. Making the heart work extra hard to pump blood through the body is a strain that, when considered cumulatively across many years, can greatly increase the likelihood of emergent problems. The primary behaviors one should adopt are well known and should not come as a surprise; they are sensible diet and regular physical exercise.

In terms of diet, there are many helpful resources available including a very good one at the Mayo Clinic. In general, one should be sure to get the necessary proteins, vitamins, and minerals while avoiding high calorie foods containing unhealthy amounts of saturated and trans fats.

Regarding physical exercise, it needn’t be overly rigorous as much as it should be regular. Walking may be the most under-rated form of exercise but its benefits to the heart and brain are well documented. Starting each day with a 30-40 minute walk at a pace slightly faster than leisurely is easy on muscles and joints but beneficially demanding on the heart and lungs.

The Unseen Side Effects
The unseen but well established side effects of taking care of one’s heart include a healthier brain and better cognition. Evidence has been pouring in for the last year that these benefits may be much greater than many of us initially understood. In the last few months alone, our knowledge of the link between vascular health and cognitive health has increased significantly.

For example, a study at UCLA showed a strong link between obesity and brain shrinkage, a study published in the journal Neurology showed that high blood pressure is associated with memory loss, and Kaiser Permanente published that even borderline high-cholesterol increases the risk for dementia.

There is no doubt that keeping an oxygen-rich supply of blood flowing freely to the brain is key to maintaining good intellectual health and to aging with cognitive vitality. You can accomplish this through all of the well-established approaches to vascular health that we’ve all been hearing about for decades. The good news is that everything you can do to keep your heart healthy will also benefit your brain.

The purpose of this blog is to spread useful information as broadly as possible. If you found this article worthwhile, please share it with your online networks using the share button below.

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How to Read the News: Part 5 of 5


Contributed by: Dennis Fortier, President, Medical Care Corporation
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The purpose of the Brain Today blog is to distill the daily news about brain health and help the public understand the essential meaning of each article. Through time however, I have found myself clarifying the same themes over and over again. Five of these themes are explored in this five-part series “How to Read the News About Alzheimer’s and Dementia”.

How to Read the News About Alzheimer’s and Dementia - Part 5 “No Cure” is not Nearly as Bad as it Sounds

For some reason, journalists feel compelled to point out the fact that Alzheimer’s has no cure. The mere mention of this basic truth tends to cast a pall over the topic and suggests a direness that is not necessary. Diabetes has no cure; hypertension has no cure; multiple sclerosis has no cure; yet all of those diseases are reported in the press with optimism about treatment that never seems to follow Alzheimer’s disease.

I concede that available treatment for Alzheimer’s disease generally yields only modest effects and sometimes none at all. However, some patients respond quite well to treatment and physicians have no way of distinguishing responders from non-responders ahead of time. For this reason, it makes sense to get all AD patients on treatment as early as possible to optimize treatment efficacy for all.

Also, the realm of treatment goes beyond the pharmaceutical arena. Solid research shows that physical activity, a good diet, social engagement, an educated caregiver, intellectual stimulation, and perhaps certain supplements are components of a robust treatment plan that can slow progression of symptoms in many patients. Reading that a single component of treatment, say a certain drug, has an unimpressive impact on disease progression is not enough to conclude that treatment is worthless.

Finally, a major barrier to effective treatment is that we generally fail to diagnose AD in a timely manner. Most patients are diagnosed after several years of symptoms when significant brain damage has already occurred and treatment is unlikely to help. Certainly we cannot cure the disease at that late stage but an earlier intervention might delay it long enough to prevent the patient from becoming demented. New drugs in the FDA approval pipeline might halt it all together.

The bottom line is that stating, “AD has no cure”, obscures the fact that it can be treated with some degree of success, for many people, especially when diagnosed in an early stage. Many diseases have no known cure but we manage them in the medical system with a sense of purpose and optimism. We need to approach AD in a similar manner.

Here are the links to each other part of this series:
Part 1 of 5: Be Aware of the Author's Definition of AD
Part 2 of 5: Don't be Mislead by Data on Treatment Efficacy
Part 3 of 5: Common Assertions about Diagnostic Accuracy Hide Truth
Part 4 of 5: The Term "Dementia" Cannot be Interpreted Loosely

How to Read the News: Part 4 of 5


Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

The purpose of the Brain Today blog is to distill the daily news about brain health and help the public understand the essential meaning of each article. Through time however, I have found myself clarifying the same themes over and over again. Five of these themes are explored in this five-part series “How to Read the News About Alzheimer’s and Dementia”.

How to Read the News About Alzheimer’s and Dementia - Part 4 The Term “Dementia” cannot be Interpreted Loosely

The term dementia is commonly used quite carelessly in the general press and is all too often interchanged inappropriately with the term “Alzheimer’s disease”. However, it has a very specific definition that is well understood by the scientists and physicians who are often quoted in articles for public consumption.

The problem arises when journalists and editors are not sensitive to the definition and proceed to use the term recklessly. I wrote in more detail about this here, but according to the Diagnostic and Statistical Manual for Mental Disorders, American Psychiatric Association, dementia is a clinical state characterized by loss of function in multiple cognitive domains. Diagnostic features include: memory impairment and at least one of the following: aphasia, apraxia, agnosia, disturbances in executive functioning. In addition, the cognitive impairments must be severe enough to cause impairment in social and occupational functioning.

The point I most want to emphasize is in the last line (“must be severe enough to…”) of the definition above. Dementia is a state of fairly severe impairment. Special tests are not really required to detect dementia, as any physician should be able to recognize it after a short interaction with the patient. Subtle memory loss or difficulties with language are not dementia.

In terms of interpreting the news, you might be surprised how often you will read about a method for diagnosing dementia or a drug for treating dementia. This is a sign of an uninformed source because dementia is merely a description of the severity of the cognitive problem. A reliable source would write about a method for diagnosing some medical condition (that might cause dementia) or a drug for treating a medical condition (that might cause dementia).

Being aware of this common mistake will help you gauge the reliability of any source you happen to be reading.

Here are the links to each other part of this series:
Part 1 of 5: Be Aware of the Author's Definition of AD
Part 2 of 5: Don't be Mislead by Data on Treatment Efficacy
Part 3 of 5: Common Assertions about Diagnostic Accuracy Hide Truth
Part 5 of 5: "No Cure" Not as Bad as it Sounds

How to Read the News: Part 3 of 5


Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

The purpose of the Brain Today blog is to distill the daily news about brain health and help the public understand the essential meaning of each article. Through time however, I have found myself clarifying the same themes over and over again. Five of these themes are explored in this five-part series “How to Read the News About Alzheimer’s and Dementia”.

How to Read the News About Alzheimer’s and Dementia - Part 3 
Common Assertions About Diagnostic Accuracy Hide the Truth

This message will be succinct because the problem is quite simple. The problem is the insistence of most journalists to include, in all Alzheimer’s disease (AD) related articles, the fact that definitive diagnosis of the disease requires a brain biopsy. This essentially means that we cannot know for sure that one has AD until after death when an autopsy can be performed. The false (and dangerous) implication is that, without a diagnosis, we cannot treat.

The danger arises because this fact seems to suggest that, prior to autopsy, we have no idea whether or not a person has AD. That is simply not true. In fact, both specialists and primary care physicians alike can achieve a clinically acceptable level of diagnostic accuracy by following published guidelines for working up a cognitive complaint. The literature in this area shows that physicians can generally achieve better than 90% accuracy in diagnosing AD.

The next time you read that AD cannot be definitively diagnosed prior to death, be sure to remember that, like other well-known diseases, it can be effectively (if not definitively) diagnosed at a much earlier stage of severity. More importantly, don’t allow yourself to make the false conclusion that, without an autopsy, we cannot achieve adequate certainty to intervene with treatment.


Here are the links to each other part of this series:
Part 1 of 5: Be Aware of the Author's Definition of AD
Part 2 of 5: Don't be Mislead by Data on Treatment Efficacy
Part 4 of 5: The Term "Dementia" Cannot be Interpreted Loosely
Part 5 of 5: "No Cure" Not as Bad as it Sounds

How to Read the News: Part 2 of 5


Contributed by: Dennis Fortier, President, Medical Care Corporation
________________________________________________

The purpose of the Brain Today blog is to distill the daily news about brain health and help the public understand the essential meaning of each article. Through time however, I have found myself clarifying the same themes over and over again. Five of these themes are explored in this five-part series “How to Read the News About Alzheimer’s and Dementia”.

How to Read the News About Alzheimer’s and Dementia - Part 2 
Don’t Be Mislead by Published Data on Treatment Efficacy

I read the “facts” in nearly every article I see about Alzheimer’s treatment. Journalists and academics alike often note the same three bits of information that, while more or less true, can be very misleading. Here are the three things:
  1. There is no cure for Alzheimer’s disease
  2. Current treatments are approved for managing symptoms but not delaying the disease progression
  3. The benefits of current treatments last for about six months to a year
These bits of information lend themselves to a very discouraging picture and are often used to make the case for increased public funding or to sensationalize the story as a means of gaining readership. I understand both of those reasons for arranging the facts in the most negative light possible. The problem is that families who are in the early stages of noticing symptoms are key consumers of such stories and they often are persuaded that there is nothing they can do about the emerging problem. This leads to apathy and a steady decline without the benefit of medical intervention.

Here is a deeper perspective that I encourage you to remember when you encounter these famous three bits of information:

There is no cure for Alzheimer’s disease
This is true; there is no cure. Just like diabetes has no cure. Standard medical practice for diseases with no cure is to manage them as beneficially as possible by reducing risks that accelerate their progression, alleviating symptoms, and keeping the patient as informed and vigilant as possible against changes that should be evaluated by a physician. One should not interpret the term "no cure” to mean "no treatment” but the press seems to equate the two when referring to Alzheimer’s disease.

Current treatments are approved for managing symptoms but not delaying the disease progression
Again, this is true. But don’t confuse “approved indications” with “actual benefits”. The approval process is driven by commercial interests aimed at getting drugs to market as quickly as possible. Drug makers want the broadest possible claims but there is a trade off in that broader claims require longer and costlier clinical trials. The currently approved drugs are indicated to “reduce symptoms” but may also delay disease in some cases. However, because the FDA trials for approving the drugs were not designed to demonstrate disease delay, they are not approved for that indication. Ongoing research shows that there may be a small, but perhaps important, disease delaying effect of current treatments in some patients. To be clear, the disease delaying effect is likely to be small at best but, in terms of switching the tone of an article from nihilistic to optimistic, this is something to bear in mind.

The benefits of current treatments last for about 6-months to 1-year
When making the case that current treatments are all but useless, I see this factoid about duration of efficacy used over and over again. Here is what you need to remember. If the average duration in a population is six months to a year, that figure is comprised from the actual, measured duration in each individual subject. While some subjects, no doubt, saw no efficacy whatsoever; others may have seen a two to three year effect. This means that any given patient may respond quite well with a meaningful impact. Since physicians (and patients) cannot know in advance who will respond to treatment and who will not, everyone deserves the chance to find out. It is not defensible to deny treatment in general because the average effect on a population seems unimpressive. And by the way, even six months is a valuable chunk of time when you know you are approaching the end of your life.

So I encourage you to keep these perspectives in mind when you are reading the news about treatment efficacy. Usually there is an agenda to paint the bleakest picture possible but the facts support a rosier view.


Here are the links to each other part of this series:
Part 1 of 5: Be Aware of the Author's Definition of AD
Part 3 of 5: Common Assertions about Diagnostic Accuracy Hide Truth
Part 4 of 5: The Term "Dementia" Cannot be Interpreted Loosely
Part 5 of 5: "No Cure" Not as Bad as it Sounds