Mild Cognitive Impairment, dementia, and a happy patient.

This week I contributed to a patient’s happiness.

It is hard to quantify the effect a doctor’s actions on their patient.

For example, ‘I am afraid the results aren’t good,’ is not something to buoy the spirit and neither is, ‘Let’s see what the surgeon has to say.’

Doctors can be prophets of doom.

Occasionally it is, ‘The biopsy was clear,’ which is of course positive, although, in the world of the geriatrician, for that is me, our swing-o-meter tends to tip in one direction.

This week I had a different experience.

It began with a local scheme to improve the care of people living with dementia.

In different localities (mostly towns or parts of cities across England) the commissioners, that is, the people responsible for divvying-up the money sent to them from Central Government, develop schemes to incentivise GPs, mostly with an eye on the issues of particular concern in that area (the health problems of Brixton might be different to those of Brighton or Bermondsey, for example).

Where I live, we have a ‘dementia and mild cognitive impairment’ scheme, called a ‘LES’ which stands for Locally Enhanced Service.

And, this is my problem, and the basis for this blog.

I have written lots on the topic of dementia over the years. It is one of the areas of medicine that I think I know about, as to whether I am an expert is for others to determine, let’s call me a specialist. For the most, I think I know what I am talking about when I talk about dementia.

Mild Cognitive Impairment, usually shortened to ‘MCI’ is something else.

I’ve never liked MCI.

MCI is a diagnostic criterion (similar in my mind to ‘borderline personality disorder,’ as in something that only a particular kind of doctor could think-up as a label for another human being) that is as vague in its definition as it is to be the individual receiving the appelation.

Dementia is easy.

Dementia is a disease affecting the brain which is progressive – it worsens over time, and it eventually affects all elements of a person’s self. Their personality, memory, mood, interests, and so on. There are various patterns, as in, Alzheimer’s disease and Posterior Cortical Atrophy, although essentially, everyone who had dementia is different to everyone else; it is, you could say, the quintessence of an individualised disease.

Mild Cognitive Impairment is less so.

What is it?

To explain, let’s talk about what happens to everyone as they age.

As you get older, certainly after your 20’s or 30’s, everything starts to fall away, for some (like me) it’s your hair, for others, the first niggles of arthritis, chronic diseases sneak-in like COPD and type 2 diabetes. Your concentration, focus or short-term recall is blunted, you are no longer as quick on the uptake. Tiny wrinkles form. Hair grows in unexpected places.

All this an uphill struggle towards, well, death, that we hope will come somewhere in our 80’s.

Alongside all this disintegration (despite your growth in possibly knowledge and skill) is a slowing of cognition. Your mental processes are less agile. You forget more, you are less able to jump from thought or action one to two to three.

(Accepting that this falling-off for some happens in their 50’s or 60’s or later – for exceptions to the rule, please see Benjamin Zephaniah or Uri Geller).

The outcome with respect to memory is a slowing, a limiting, a shortening. We call this healthy ageing. Perhaps the effects of too many cigarettes, whisky shorts, or head injuries.

This is not a disease, it is the human condition, part of the quid pro quo for keeping going.

For some, the ageing process is accelerated, not as bad as in Progeria, more like when you have a reading speed on Audible that is 1.2 times the normal. You finish the book ahead of others.

‘He looks 70,’ might be said of a person in their 50’s who has had a rough ride.

And so too with memory or cognition, that is, all the processes inherent in your sense of self.

This condition, where an individual’s memory is worse than expected for their age but not a) progressive and does not b) interfere with the person’s quality of life or ability to live autonomously is, Mild Cognitive Impairment.

MCI is also not progressive beyond the super-added effects of ageing that we all encounter.

The science says that ten per cent of people diagnosed with MCI will progress to develop dementia, just as a certain proportion of people in their 40’s and 50’s who have aching joints will progress to develop crippling arthritis.

Ageing and disease processes combined.

Now, back to the LES.

The LES stipulates that doctors working in primary care (GPs and others) will review each of their patients who have a diagnosis of dementia once a year.

This, as far as I am concerned is great and I’d advise perhaps a more frequent assessment.

The complication arises when the request was attached to reviewing people with dementia and MCI.

It is called the ‘dementia and mild cognitive impairment LES’

This is a bit like putting people with bipolar disorder (major psychiatric illness) in the same grouping as people with mild depressive illness (so called, minor psychiatric illness) (You’ve got to love those (mostly American) psychiatrists and their love of placing people in diagnostic boxes).

And so, if you don’t know the difference between dementia and MCI, when someone sees a patient, it is easy to fall into the perception that the person has dementia rather than MCI.

People are often diagnosed with MCI in memory clinics, ‘Your memory is not as bad as someone who has dementia, you have MCI.’

And yet, they were referred to the memory clinic which they perceive as the dementia clinic and it is hard for them to get over this, to realise that although they are in the clinic with people who have dementia, that is not what they have.

Clinic visits are full of heightened emotions and anxiety and especially during Covid when many of these assessments were undertaken on the phone, the full meaning of the outcome does not pass to the patient.

When someone shouts ‘Tiger!’ you don’t necessarily wait to hear the ‘has gone’. We are hardwired to the bad stuff.

And so, it was with my patient.

She has MCI.

She thought she had dementia.

I met her and explained all that I have just written – perhaps in fewer words and with less cynicism.

And so, my patient, and her husband left the clinic, with a carefully jotted piece of A4 on which I illustrated what I have just said. (With my new birthday pen).

‘What can we do?’ They asked.

‘Look after your blood pressure, your diabetes and keep mentally active’

They went away happy.

Another case of de-diagnosis.