To the Editor.
—Dr Stern and colleagues1 propose that increased educational and occupational attainment may reduce the incidence of AD. However, because the authors fail to consider seriously the effects of poverty on exacerbating or complicating the course of AD, I believe that their conclusion may be premature. In their study, the low education/low occupation group had the highest rate of dementia. This group had an incidence of dementia of 24.9% during the follow-up period (roughly two thirds of this group were seen between 1 and 2.9 years after baseline). For a sample with a mean age of 75 years, this incidence rate is strikingly high.2 Because low education/low occupation is likely associated with low income, it seems warranted to hypothesize that lifestyle, physical illness, health care, and environmental factors associated with poverty may contribute to diminishing the cerebral reserve of persons with AD. Thus, those who are
Cohen CI. Education, Occupation, and Alzheimer's Disease. JAMA. 1994;272(18):1405. doi:10.1001/jama.1994.03520180029016