Confusion is everywhere

Published as a BMJ letter January 2013:

It seems that there is an awful lot of confusion about. It also seems to be the prevailing impression that it is our elderly who are most prone to confusion. The recent BMJ discussion about the screening for dementia has highlighted that it is both incorrect and potentially stigmatising to consider such confusion as the preserve of our older generation. (1)

At least six areas of confusion do seem prevalent when it comes to our understanding and collective approach to memory loss in old age:

1. General confusion: The general population is increasingly using the word “Alzheimer’s” instead of “dementia.” This is hardly surprising when you consider:

2. Professional confusion: NICE and SIGN Guidelines for Dementia both contain definitions of dementia and of Alzheimer’s disease, yet in the body of the guidelines, the terms are frequently used interchangeably. (2)

3. Confused ‘education’: Much post-graduate medical “education” is sponsored by the Pharmaceutical Industry. Much awareness raising by charities is also backed by the Pharmaceutical Industry. Many political imperatives are influenced by lobbyists for the Pharmaceutical Industry. We are certainly confused about where the line lies between these activities and “marketing”? (3)

4. Confusion between research and clinical agendas: Advances in research are too often extrapolated prematurely into a general clinical setting by well intentioned clinicians who may also be responding to the clamour of the latest press-release. (4)

5. Confused about risk: The communication of risk is fundamental to medical practice but is undoubtedly difficult. Every intervention has the potential for benefit and for harm. We are so keen to see the former that we sometimes forget to look for the latter. (5)

6. Confusion about science: Scientific evidence must be taken in context. Many universities are responding to this by making the Medical Humanities an integral part of their under-graduate medical curriculum.

The dictionary definition of confusion is: “a feeling that you do not understand something or cannot decide what to do.” We must resist the temptation to respond to confusion with over-simplification and instead find a way to acknowledge complexity.

(1) Observations: There is no evidence base for proposed dementia screening. Martin D Brunet, Margaret McCartney, Iona Heath, Jonathan Tomlinson, Peter Gordon, et al. 345:doi:10.1136/bmj.e8588 (Published 27 December 2012)

(2) NICE Guideline on Dementia. CG42. First published Nov 2006 and SIGN Guideline 86: Management of patients with dementia. 2006

(3) Margaret McCartney. The Patient Paradox. Pinter & Martin Ltd. 2012

(4) George, D.R; Qualls, S.H.; Camp, C.J. and Whitehouse, P.J. Renovating Alzheimer’s: “Constructive” Reflections on the New Clinical and Research Diagnostic Guidelines. The Gerontologist; doi:10.1093/geront/gns096

(5) Gigerenzer, G. Reckoning with risk: Learning to live with uncertainty. 2002. Penguin books.