Statement of Principles

concerning

ALZHEIMER DISEASE
(Balance of Probabilities)

(No. 34 of 2019)

The Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(3) of the Veterans' Entitlements Act 1986.

Dated 1 March 2019

Contents

1 Name

2 Commencement

3 Authority

4 Repeal

5 Application

6 Definitions

7 Kind of injury, disease or death to which this Statement of Principles relates

8 Basis for determining the factors

9 Factors that must exist

10 Relationship to service

11 Factors referring to an injury or disease covered by another Statement of Principles

Schedule 1 - Dictionary

1 Definitions

1               Name

This is the Statement of Principles concerning Alzheimer disease (Balance of Probabilities) (No. 34 of 2019).

2               Commencement

              This instrument commences on 25 March 2019.

3               Authority

This instrument is made under subsection 196B(3) of the Veterans' Entitlements Act 1986.

4               Repeal

The Statement of Principles concerning Alzheimer-type dementia No. 23 of 2010 (Federal Register of Legislation No. F2014C00072) made under subsections 196B(3) and (8) of the VEA is repealed.

5               Application

This instrument applies to a claim to which section 120B of the VEA or section 339 of the Military Rehabilitation and Compensation Act 2004 applies.

6               Definitions

The terms defined in the Schedule 1 - Dictionary have the meaning given when used in this instrument.

7               Kind of injury, disease or death to which this Statement of Principles relates

(1)          This Statement of Principles is about Alzheimer disease and death from Alzheimer disease.

Meaning of Alzheimer disease

(2)          For the purposes of this Statement of Principles, Alzheimer disease means a central nervous system neurodegenerative disorder meeting the following clinical diagnostic criteria (derived from DSM-5):

1. Evidence of major neurocognitive disorder or mild neurocognitive disorder.
2. There is insidious onset and gradual progression of impairment in one or more cognitive domains.  There is steady progressive, gradual decline in cognition, without extended plateaus.
3. There is either:

(i)            evidence of a causative Alzheimer disease genetic mutation from family history or genetic testing; or

(ii)         clear evidence of decline in memory and learning, except where there are atypical presentations of Alzheimer disease.

D.           The cognitive deficits in Criteria A, B and C are not primarily due to any of the following:

(i)            delirium;

(ii)         another mental disorder (for example, major depressive disorder, schizophrenia); or

(iii)       cerebrovascular disease, another neurodegenerative disease (for example, neurocognitive disorder with Lewy bodies, Parkinson's disease, Huntington's chorea), brain tumour, subdural haematoma, the effects of a substance, or systemic disorder (for example, hypothyroidism, vitamin B12 or folic acid deficiency, niacin deficiency, hypercalcaemia, neurosyphilis, human immunodeficiency virus infection).

Note: atypical presentations of Alzheimer disease, DSM-5, major neurocognitive disorder and mild neurocognitive disorder are defined in the Schedule 1 – Dictionary.

(3)          While Alzheimer disease attracts ICD‑10‑AM code G30.0, G30.1, G30.8 or G30.9, in applying this Statement of Principles the meaning of Alzheimer disease is that given in subsection (2).

(4)          For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.

Death from Alzheimer disease

(5)          For the purposes of this Statement of Principles, Alzheimer disease, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's Alzheimer disease.

Note: terminal event is defined in the Schedule 1 – Dictionary.

8               Basis for determining the factors

On the sound medical‑scientific evidence available, the Repatriation Medical Authority is of the view that it is more probable than not that Alzheimer disease and death from Alzheimer disease can be related to relevant service rendered by veterans or members of the Forces under the VEA, or members under the MRCA.

Note: MRCA, relevant service and VEA are defined in the Schedule 1 – Dictionary.

9               Factors that must exist

At least one of the following factors must exist before it can be said that, on the balance of probabilities, Alzheimer disease or death from Alzheimer disease is connected with the circumstances of a person's relevant service:

(1)          smoking at least 20 pack-years of cigarettes, or the equivalent thereof in other tobacco products, before the clinical onset of Alzheimer disease, and where smoking has ceased, the clinical onset of Alzheimer disease has occurred within five years of cessation;

Note: pack-years of cigarettes, or the equivalent thereof in other tobacco products is defined in the Schedule 1 - Dictionary.               

(2)          undergoing a course of therapeutic radiation for cancer, where the brain was in the field of radiation, at least ten years before the clinical onset of Alzheimer disease;

(3)          being obese for at least ten years before the clinical onset of Alzheimer disease;

Note: being obese is defined in the Schedule 1 - Dictionary.             

(4)          having dyslipidaemia before the age of 65 years and at least ten years before the clinical onset of Alzheimer disease;

Note: dyslipidaemia is defined in the Schedule 1 - Dictionary.             

(5)          having diabetes mellitus for at least the ten years before the clinical onset of Alzheimer disease;

(6)          having hyperhomocysteinaemia at least ten years before the clinical onset of Alzheimer disease;

Note: hyperhomocysteinaemia is defined in the Schedule 1 - Dictionary.             

(7)          an inability to undertake any physical activity greater than three METs for at least five years, at least ten years before the clinical onset of Alzheimer disease;

Note: MET is defined in the Schedule 1 - Dictionary.             

(8)          inability to obtain appropriate clinical management for Alzheimer disease.

10           Relationship to service

(1)          The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.

(2)          The factor set out in subsection 9(8) applies only to material contribution to, or aggravation of, Alzheimer disease where the person's Alzheimer disease was suffered or contracted before or during (but did not arise out of) the person's relevant service.

11           Factors referring to an injury or disease covered by another Statement of Principles

In this Statement of Principles:

(1)          if a factor referred to in section 9 applies in relation to a person; and

(2)          that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(3) of the VEA;

then the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.

Schedule 1 - Dictionary  

Note:               See Section 6

1               Definitions

In this instrument:

                             Alzheimer disease—see subsection 7(2).

                               atypical presentations of Alzheimer disease means where memory and learning impairments are not predominant (nonamnestic presentations).  There are several different variants of this nonamnestic presentation including visuospatial, logopenic aphasic, visuoperceptive impairments and executive dysfunction.

                               being obese means having a Body Mass Index (BMI) of 30 or greater.

Note: BMI is also defined in the Schedule 1 - Dictionary.

                               BMI means W/H2 where:

W is the person's weight in kilograms; and

H is the person's height in metres.

                                DSM-5 means the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  Arlington, VA, American Psychiatric Association, 2013.

                               dyslipidaemia generally means evidence of a persistently abnormal lipid profile after the accurate evaluation of serum lipids following a 12 hour overnight fast, and estimated on a minimum of two occasions as:

(a)          a total cholesterol level greater than or equal to 5.5 millimoles per litre (mmol/L);

(b)          a triglyceride level greater than or equal to 2.0 mmol/L; or

(c)          a high density lipoprotein cholesterol level less than 1.0 mmol/L.

                               hyperhomocysteinaemia means a condition characterised by an excess of homocysteine in the blood.

                               major neurocognitive disorder means:

(a)          evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

(i)            concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function; and

(ii)         a substantial impairment in cognitive performance, documented by standardised neuropsychological testing or another qualified clinical assessment; and

(b)          the cognitive deficits interfere with independence in everyday activities (that is, at a minimum, requiring assistance with complex instrumental activities of daily living such as paying bills or managing medications).

                               MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour or resting metabolic rate.

                               mild neurocognitive disorder means evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on:

(a)          concern of the individual, a knowledgeable informant, or the clinician that there has been a mild decline in cognitive function; and

(b)          a modest impairment in cognitive performance, documented by standardised neuropsychological testing.

                             MRCA means the Military Rehabilitation and Compensation Act 2004.

                             pack-years of cigarettes, or the equivalent thereof in other tobacco products means a calculation of consumption where one pack-year of cigarettes equals 20 tailor-made cigarettes per day for a period of one calendar year, or 7 300 cigarettes.  One tailor-made cigarette approximates one gram of tobacco or one gram of cigar or pipe tobacco by weight.  One pack-year of tailor-made cigarettes equates to 7.3 kilograms of smoking tobacco by weight.  Tobacco products mean cigarettes, pipe tobacco or cigars, smoked alone or in any combination.

                             relevant service means:

(a)          eligible war service (other than operational service) under the VEA;

(b)          defence service (other than hazardous service and British nuclear test defence service) under the VEA; or

(c)          peacetime service under the MRCA.

Note: MRCA and VEA are also defined in the Schedule 1 - Dictionary.

                             terminal event means the proximate or ultimate cause of death and includes the following:

(a)           pneumonia;

(b)           respiratory failure;

(c)           cardiac arrest;

(d)           circulatory failure; or

(e)           cessation of brain function.

                             VEA means the Veterans' Entitlements Act 1986.