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Targets for dementia diagnoses will lead to overdiagnosis

BMJ 2014; 348 doi: (Published 01 April 2014) Cite this as: BMJ 2014;348:g2224

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Re: Targets for dementia diagnoses will lead to overdiagnosis

As Dr Brunet writes, the diagnosis belongs to the patient. And that is the problem in dementia when the patient can have little insight and often does not complain of the symptoms. This drive for GPs to increase diagnosis rates is admirable but there are many unknowns and potential dangers.

Most patients referred to my general or cognitive neurology clinic with ? dementia don't have it but a mixture of worried well, depression, anxiety, side effects of medication, previous brain injury, and sleep apnoea, all very treatable and easily missed if an established diagnosis of dementia is in place. In the last year despite writing about (Pract Neurol doi:10.1136/practneurol-2013-000796 How to do it ‘Undiagnosing’ neurological disease: how to do it, and when not to. Jan A Coebergh, Damian R Wren, Colin J Mumford) I have not been successful in removing the label of dementia in patients previously diagnosed by others who clearly did not have it (but some of the above). Patients are not happy at all not to have dementia since the label allows much support. This is uncharted territory but will probably become common with this drive for early non-specialist diagnosis (specialists get it wrong also!).

Diagnosis in those with language barriers, chronic mental illness, epilepsy, hearing and visual loss, previous substance abuse, illiteracy or a combination of these also can make it a very difficult diagnosis and the risk exists that the dementia (mis-/over)diagnosis leads to shortcuts in assessing patients' need for other investigations. These are predominantly elderly people and the focus on one diagnosis excludes a way of thinking about co-morbidity that is essential to good individualised care (? chemotherapy for your cancer; no, you have dementia).

The focus on memory symptoms of course also narrows the focus on Alzheimer's and misses the symptoms of Progressive Supranuclear Palsy, Frontotemporal Dementia and Lewy Body Dementia for example, which together constitute a large part of all dementias. The failure of all amnestic MCI to convert to Alzheimer and the behavioural phenocopy variant of Frontotemporal dementia is well documented so good follow up is needed in many difficult cases.

Empowering patients' family and friends to express concerns, standing up for the vulnerable who can't stand for themselves and assessing diagnostic difficulties and effect of co-morbidity can improve care; solely increasing diagnostic target rates is unlikely to.

Competing interests: I have been struggling to undiagnose people with a dementia diagnosis but no dementia

29 April 2014
Jan A Coebergh
Consultan Neurologist
Ashford St Peter's Hospitals
guildford road