Curr Neurol Neurosci Rep (2012) 12:511–519 early as possible. However, the diagnostic profiles of different dementia subtypes are not 100 % distinct, and the correlation between clinical and pathological diag- noses is not perfect, even when based on the most advanced tools [18]. Furthermore, diagnostic profiles exhibit a great deal of heterogeneity, even among patients who share the same pathology, and some are frankly atypical [29]. Because of these challenges, ac- curate diagnosis requires an experienced clinician, sup- ported by an array of complex tools [7 , 30] Obstacles to Diagnosis of Dementia in Poor Populations Many factors contribute to limited diagnosis of dementia in resource-poor areas (Table 1). Three major obstacles are (1) low health literacy, (2) limited access to health care, and (3) the stigma associated with dementia. The extent of health illiteracy, including ignorance of the connection between behavioral, cognitive, or physical signs and the disease [31], is difficult to estimate but very important, as is lack of awareness that appropriate care/treatment is available [32]. Surprisingly, such ignorance often exists in educated individuals and even in healthcare professionals [33]. Lack of knowledge in healthcare workers particularly affects their ability to recognize early signs of dementia. Many people in developing countries believe that the characteristic signs of dementia are part of normal aging or a nonpathological deviation [34]. Improving health literacy is the goal of health promotion and education programs, which are often given low priority in resource-poor settings. On the other hand, the impact of a lack of specific or scientific knowl- edge should not be overestimated. Cultures in developing Table 1 Likely causes of limited dementia diagnoses in resource-poor areas - Initial symptoms are subtle and fluctuating - Inability to recognize cognitive, behavioral, or functional impairment as a consequence of dementing illness - Accommodation, denial, and rationalization of symptoms as due to aging and adverse circumstances - High tolerance for health problems in elderly individuals - Person with early symptoms does not feel the need to seek treatment - Relatives do not believe symptoms are treatable - Demoralization regarding medical assistance, due to ignorance of available treatments - Do not know where to go for diagnosis - Family is afraid of psychiatric stigma (demented is often equated to being crazy) - Physician underemphasizes the importance of symptoms - Perception that physicians will miss the diagnosis and will make the family waste time and money in apparently unnecessary tests - Costs of diagnosis in terms of effort, time, economic costs 513 countries often have knowledge about signs, based on com- mon sense and traditional practices, that informs choices about care/treatment [35]. Limited access to health care is a universal problem in diagnosing dementia in LMICs. Geriatric care is generally minimal, and there is virtually no concept of continuing care for aging adults [36–38]. In addition to inadequate numbers of personnel and facilities, the costs involved in accessing services and long waits for appointments are common bar- riers. If an elderly person has to travel a long distance to receive a diagnosis and treatment, he or she must weigh the likelihood of improvement against the difficulties and costs of travel [39]. Travel where public transportation is not adequate for people with physical disabilities can be a limitation. Additionally, the patient and his or her care- takers might fear that there is no effective treatment, that treatment will require expensive drugs, or that the patient might have to stay at an asylum or hospice. Any or all of these factors might prevent a potential patient or caregiver from seeking medical attention, particularly in the case of a chronic condition that has established slowly, such as dementia. The social stigma associated with mental health problems is a barrier to diagnosing dementia [40–42]. When dementia is medicalized and acquires the label of a disease, the social value of the individual and his or her family often suffers [11, 35]. Even when it is not labeled as a disease, signs of dementia are a fairly common condition in many resource- poor regions, and most people have a negative expectation of recovery [11]. Behavioral changes associated with de- mentia sometimes elicit abuse, neglect, or loss of family members’ respect [40]. Even healthcare workers are some- times guilty of a negative attitude toward dementia patients [41–43]. In addition to health illiteracy, poor access to healthcare, and social stigma, diagnosing dementia in poor populations remains problematic for a number of reasons. Although the clinical features and complications of dementia have been relatively well defined [44], expression of behavioral and cognitive signs and symptoms might be modulated by so- cioeconomic conditions [41], possibly accounting for some of the phenotypic heterogeneity of various subtypes. Long- term studies are needed of the effects of lifestyles in devel- oping countries on each of the dementia subtypes [45]. Although some genetic and environmental modifiers have been identified [46–48], it is still not possible to predict the likely course of the illness, even when dominant mutations are present [45]. The effects of concomitant comorbidities, such as hypertension and diabetes, are not clearly under- stood, particularly when untreated or uncontrolled for most of the life of the patient [49]. Practical approaches to overcoming some obstacles to diagnosis of dementia have been addressed in the context