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The letters by Dr Bowden, Kokmen et al, and Dr Jarvik present important comments related to the East Boston study. Many of the points were alluded to in the original editorial, but several may benefit from restatement.Both Kokmen et al and Dr Bowden refer to the potential problem of the standards investigators use to determine cognitive dysfunction. Dysfunction may be related to low educational achievement or it may be related to so-called age-related decline. The most common cause of dementia—Alzheimer's disease—is characterized as acquired and progressive cognitive dysfunction. A cross-sectional survey—like the East Boston survey—cannot necessarily determine whether the dysfunction was acquired or is progressive because the assessment is made at a single point in time. Further, the investigators also did not have the opportunity to assess the functional consequences of cognitive impairment related to cognitive dysfunction. Nonetheless, the East Boston and other studies all demonstrate a
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