Just by looking

Can you tell if someone has dementia just by looking?

I sometimes put this question to medical students. I am always fascinated by the answer.

Everyone knows that you can’t diagnose by looking (historically clinical textbooks have included signs – the hands of Acromegaly, the flush of lupus or, the drooping eyelids of Myasthenia.) – medicine has veered away from this approach given that we now live in times more accepting of diversity.

Some of us have big hands (or abnormally small ones, Mr T), high colour and droopy eyes and are in perfect health. Attaching a disease to a look can be dangerous.

But, there is something in it.

I can usually work out who has dementia or cognitive impairment when I am on the admissions unit at my hospital. People with dementia are more likely to be in bed, wearing pyjamas, and, not obeying the buzzer rules. They are more likely to have a sippy-cup, not have eaten their meal and have cot-sides-up during the day. (We are working to fix this through #endPJParalysis).

I suspect part of this is the damage inflicted on doctors in medical school where we are taught to be vigilant, to utilise our Sherlock.

The empty inhaler box… asthma, diabetic jam, waking stick, hearing aid. Part of understanding how we can help our patients is by enhanced communication, that is, using what is not being said to explain what is.

The other week I met a patient, we discussed her fall – what had led-up to her coming to hospital and so on; there was nothing out of the ordinary. It was only afterwards when reflecting on our conversation, I considered that there was something not quite right with her speech or manner. I therefore did what doctors do and assumed there must be more afoot; not a straightforward trip, slip or tumble.

I organised a CT scan. It showed cancer.

In Malcolm Gladwell’s book, ‘Blink’ he describes the value of reflection, intuition and non-linear cognition. We all operate at a highly evolved conscious level of thoughts and ideas – we also have within us a deeper, more atavistic sense which connects us to one another.

When one of my patients is anxious or sad, I cannot necessarily fit them into a set of pathologies, I can’t always articulate what I am feeling, but I have a sense that something is not right, just as is often the case, my patients (and very often their relatives) when ill can have an ineffable sense that something is wrong.

Whether we call this intuition, experience or the unconscious, I don’t know, most of us, when given enough time and space, away from multimedia distractions and work-pressures are able to connect in this way.

And, to the point.

I originally wanted to open this by talking about Billy Connolly’s recent DVD – High Horse Tour.

Billy has Parkinson’s disease and he covers some of his experiences in the set.

It didn’t take me long to see his bradykinesia. Unlike many with the disease, Billy has a form of Parkinson’s that slows-down his movements more than causing the characteristic shakes. I remember watching Billy years ago where he would stride across the stage, using his arms as legs as part of his Big Yin persona. No longer.

Sharp as a tack and as mentally dextrous as ever it was fantastic watching him (with very strong language) in action, he has lost none of his wit.

And back to the original question. What can you tell from looking?

I guess, very little.

You can skim the surface, leave with impressions or intuitions – it is only when we delve deeper, question, talk, chat, joke (smile) that the complexity of who and what we are comes across.

Don’t rely on a look to tell you the answer. Sure, reflect, weigh and integrate ideas and impressions, equally, do not base your management solely on the facts on the page, ensure you are aware that there is far more to every person than their sodium, potassium or haemoglobin level.

The next time a smart young doctor quotes an obscure study in the New England Journal of Medicine, slow down, insert a pause; ensure that they also have spent a moment connecting with something deeper.