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Analysis

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice

BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4218 (Published 01 November 2017) Cite this as: BMJ 2017;359:j4218

Re: Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice

The question of patient centred diagnosis in Old Age Psychiatry can demand consideration not only of which investigations to conduct but also of what to conclude once the results have been received. Increased awareness of and treatment options for dementia over the last 15 years have resulted in patients being referred to Memory Services at an ever earlier stage of cognitive decline and, whilst this supports the admirable aim of timely diagnosis, it also feeds the dilemma over the degree of cognitive and functional impairment necessary for a diagnosis of dementia. Patients with significant functional decline are diagnosed with dementia and offered treatment, whilst those experiencing minimal impact on independent functioning are judged to have mild cognitive impairment and offered annual review.

But what about those borderline cases with a little functional impairment: how much is enough and to what extent might this be confounded by additional physical health concerns and frailty? If we suspect that a patient might have prodromal Alzheimer's Disease, then at what point should we use the 'D' word? This is an inexact science and patient wishes have a crucial role to play in the breaking of bad news and subsequent management decisions. Some have their eyes wide open to the possibility of a degenerative disease and demand treatment at the earliest opportunity. Others are anxious or in denial and would prefer to soldier on for as long as possible without the psychological burden of knowing that they have a terminal illness. Doctors can and should guide, but we must also listen to our patients' wishes and be prepared for diagnostic decisions to be staged through a period of further observation, collaboration and discussion. Watchful waiting can aid both the diagnosis and the therapeutic relationship.

Competing interests: No competing interests

09 November 2017
Mike Devine
Consultant in Old Age Psychiatry
NELFT NHS Foundation Trust
Barking & Dagenham OAMHT & Memory Service, Broad Street Centre, Morland Road, Dagenham, Essex RM10 9HU