Electronic letters to:

Practice:
Howard H. Feldman, MD, Claudia Jacova, PhD, Alain Robillard, MD, Angeles Garcia, MD PhD, Tiffany Chow, MD, Michael Borrie, MB ChB, Hyman M. Schipper, MD PhD, Mervin Blair, BSc, Andrew Kertesz, MD, and Howard Chertkow, MD
Diagnosis and treatment of dementia: 2. Diagnosis
CMAJ 2008; 178: 825-836 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read eLetter] No need for a neuropsychological eval?
Sharon L. Smith   (28 March 2008)
[Read eLetter] Dementia diagnosis, before trying to know the cause?
Mohammad M Rahman   (28 March 2008)

No need for a neuropsychological eval? 28 March 2008
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Sharon L. Smith

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Re: No need for a neuropsychological eval?

mainelyneuropsych{at}wildblue.net Sharon L. Smith

The article, "Diagnosis and Treatment of Dementia (2. Diagnosis) states, regarding one patient: "There is no indication for functional neuroimaging or neuropsychological testing given the strength of the clinical diagnosis."

While diagnosis of dementia is indeed a useful aspect of neuropsychological assessment, staging of dementia is also important. Information about the rate and severity of the client's cognitive decline will be vital in the management of her illness.
Dementia diagnosis, before trying to know the cause? 28 March 2008
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Mohammad M Rahman
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Re: Dementia diagnosis, before trying to know the cause?

md.mrahman{at}sympatico.ca Mohammad M Rahman

I commend the efforts of Howard H. Feldman and colleagues to simplify dementia diagnosis for Family physicians. However, I strongly object to the authors’ suggestion of establishing dementia before finding its cause in a patient. To reach a diagnosis before exploration of causes is not the scientific way.

I refer the readers to “Diagnostic Criteria Influence Dementia Prevalence,” by Johannes Wancata in Am J Geriatr Psychiatry 15:1034-1045, December 2007 and “The Effect of Different Diagnostic Criteria on the Prevalence of Dementia,” by Timo Erkinjuntti and colleagues in The New England Journal of Medicine 337:1667-1674, December 1997.

Dementia diagnosis criteria are different in different parts of the world. Patients with cognitive impairments may have dementia diagnosis under North American criteria (e.g. DSM-III-R, DSM-IV-TR) but not under WHO (e.g. ICD-9, ICD-10), Cambridge (e.g. CAMDEX) or ‘historical’ criteria, and vice versa.

I would argue that “dementia” is actually an arbitrary compilation of some cognitive symptoms and not a real diagnosis. When the cause is unknown, treatment cannot be attempted.

The real diagnosis for dementia symptoms should base on the cause of the dementia symptoms. The real diagnosis, therefore, are what we currently know as the cause based dementia sub-types.

In my opinion, the job for the physician is not to initially try to match patients’ symptoms with one or more established dementia diagnosis criteria, but to take a systematic history focused on the cause and lesion site. When history-suggested physical examination maneuvers, cognitive tests and investigations are complete, diagnosis of the symptoms of ‘dementia’ will be complete. Problem location and cause establishes diagnosis, not the other way around.

Conflict of Interest:

None declared