Between you and me

Reply to Essay: Good news about the ageing brain

published 17 October 2011 as:BMJ2011;343:d6288

Rapid-response posted 4th November 2011:

Between you and me:

What a welcome contribution this is by Professor Marcus Richards and Dr Stephani L Hatch.[1] This paper matches the standard of their last joint submission to the BMJ which asked: What do we mean by Alzheimer’s disease?[2] I suspect that time will prove the contribution made by Richards and Hatch for they have reached into the very epidemiology of human life in the real world in their wide ranging research.

As a practising NHS Psychiatrist for older adults I am faced daily with the reality of clinical dementia and so approach cognitive loss that may, or may not progress to such a state with concern. Richards and Hatch describe a cultural shift which adds great fear to ageing. This is what Stephen Post has called a ‘Hypercognitive culture.’[3]

This film ‘The diseased Other’ explores this potential culture:

<p><a href=”″>The diseased Other</a> from <a href=”″>omphalos</a&gt; on <a href=””>Vimeo</a&gt;.</p>

Current imperatives – clinical and research – are becoming blurred when it comes to ‘early detection’ of Alzheimer’s disease and Alzheimer’s dementia. This concern was covered in our letter published in the BMJ last month[4] “The pathology of [Alzheimer’s disease] defies precise definition at present. This is because its individual components all occur to some extent in normal ageing.” (Esiri and Nagy 2002, p.107) This quote comes from experts in one of the most influential textbooks on the subject.[5] In 2011 this still holds true. The logical conclusion is then to be wary of proxy-biomarkers for real pathology that may, or may not, correlate with cognitive loss; cognitive loss that may, or may not, lead to dementia.

This rapid-response column daily reveals parallel concerns about over-diagnosis of other conditions. The issue of false-positive diagnoses of Alzheimer’s disease is very real. Given that dementia is indisputably a ‘biological’ mental illness as opposed to a ‘functional’ mental illness, it is natural that we have leant very heavily upon an overly simplistic disease paradigm.

We must remember, and remind others, that the experience of the person must be understood in relational and affective terms rather than only in narrow cognitive ones. Neuro-scientific insights should not let us lose sight of the whole person: indeed our clinical assessments must garner that whole person and not be reduced, in a ‘pathway’ of ‘triage’ to cognitive tests alone.

In terms of dementia Tom Kitwood has talked of ‘Malignant social psychology’ and ‘Excess disability.’ Here we are exposed to the consequences of seeing the person for their cognition alone. Our concern is that these negative consequences will also apply to any label of cognitive loss.

I go for walks with someone who suffers from advanced Alzheimer’s dementia. Despite this person’s profound amnesia and significant impairment of language I find that on every walk my life is enriched.

The fundamental fear we all share is that in Alzheimer’s dementia we will lose our identity. In sharing such time with this person I have realised that it is eliminative – and plainly stupid – to believe that ‘brain failure’ means ‘person failure’. My co-walker has taught me a lot. Perhaps it’s in this former teacher’s gift: “a teacher affects eternity; he never knows where his influence ends.”[6]

[1] Richards, Marcus & Hatch, Stephani; Essay: Good news about the ageing brain BMJ 2011; 343:d6288

[2] Richards, Marcus & Hatch, Stephani; What do we mean by Azheimer’s disease? BMJ 2010; 341:c4670

[3] Sabat, Steven; The Experience of Alzheimer’s Disease – Life through a Tangled Veil. Blackwell Publishers. 2001

[4]Gordon, Peter & Gordon, Sian; Letter: Issues around early diagnosis of Alzheimer’s disease. BMJ 2011;343:d6613

[5] Hughes, J.’ Louw, S., & Sabat, R. Quoted in: Dementia: mind, meaning and the person. Oxford Medical Publications. 2006

[6] Adams, Henry B. The Education of Henry Adams. 1907, Chapter 20

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