Timely debate

From the frontline – Bad medicine: dementia, published in the BMJ, 1 June 2012,

Reply by Dr Peter J. Gordon as a rapid-response to the BMJ, 22nd June 2012

Timely debate
Dr Spence in his Bad Medicine series spares no specialty in his wish to encourage debate. Responses are varied, often defensive, and I have been interested to see the response so far of my own specialty to his piece on dementia[1].

The early diagnosis of dementia is an area of legitimate debate. New definitions of dementia (and cognitive disorders more generally) are to be presented in the forthcoming editions of ICD11 and DSM-V. The universal problem that these classifications face is that thresholds of disorders rarely have hard and fast demarcations. In the particular case of ‘early dementia’ it is possible that in the genuine wish to pick up an irreversible condition we are inadvertently over-inclusive when making a judgment on what it means to have ‘significant’ functional impairment[2]. Many other illnesses have seen this gradual mission creep[3]. The risk is that we ensnare a fearful populace: those of our elderly who may never progress to dementia[4]. For this reason I would suggest that we need a diagnostic system that considers risk of disease and gives emphasis to the longitudinal course of the condition. Dementia is by definition a progressive condition; much subtle cognitive impairment is stable or indeed improving and therefore by definition not dementia.

More generally I am worried that we have oversimplified the concept of Alzheimer’s. At the level of policy, implementation, advocacy and medical journalism most of the talk is as though Alzheimer’s disease and its early diagnosis were quite clear-cut things, when the reality is far more complicated[5].

Such a reductionist approach and the language of fear associated with it (generally unremittingly grim) is actually worsening stigma. Dr Spence’s language falls into this trap but the questions he raises deserve wider discussion and open debate may help reduce stigma.

The informed views of older people, whether they have cognitive loss or not, have not been properly sought. Such consultation needs to happen amidst honest airing of what it is to age and the far from simple implications of early memory loss. It is important that such discussions do not rely solely upon the dominant bio-medical paradigm and that they include social and historical understandings of brain ‘disease’[6].

In addition to the ‘post-diagnostic checklists’ which are needful, pragmatic but unavoidably gloomy, we should talk about the positive attributes that stay with people. We must not allow overwhelming negativity to dictate popular and professional understanding. Here I agree with Van Rensburg et al about the power of words and ‘therapeutic nihilism’. However I disagree with the same authors that we should not be concerned about suicidal behaviour[7]. I have seen suicidal behaviour associated with cognitive loss and suggest only that we must keep our minds open to the potential risks of the enthusiasm for early diagnosis[8]. A major theme of the issue of the BMJ in which this ‘Bad Medicine’ piece appeared was Assisted Dying.

The organisation Alzheimer Scotland suggests that in our approach to the detection of dementia we make a ‘timely’ diagnosis[9].  I have argued here some of the reasons why I support this approach. I urge our profession to have an open debate on this. I suggest that we reflect on what we may learn from other specialties but insist we seek the informed views of our elderly.

My film, Primum non forgetful, tries to look at early diagnosis from a scientific, pragmatic and philosophical perspective:


 


[1] Spence, D. Bad Medicine: Dementia. BMJ 2012: 344:e3859.

[2]NICE guidelines (in Scotland SIGN guidelines

[3] Gordon, P. How we risk getting it wrong in cognitive screening too BMJ 2012; 344:e4043

[4] Frances, A. DSM5 Minor Neurocognitive Disorder. Psychol Today. 2012, 16 Feb.

[5] Alzheimer’s Disease International. World Alzheimer report 2011: The benefits of early diagnosis and intervention. 2011. http://www.alz.co.uk/research/WorldAlzheimerReport2011ExecutiveSummary.pdf.

[7] Van Rensburg, Al-Salihy, Rubinsztein. Rapid Response reply to Bad Medicine: Dementia. BMJ 2012: 344:e3859.

[8] Brian Draper, Carmelle Peisah, John Snowdon, Henry Brodat Early dementia diagnosis and the risk of suicide and euthanasia Alzheimer’s & Dementia 6 (2010) 75–82. New South Wales, Australia

[9] Alzheimer Scotland. Action on dementia

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