A dreaded diag­no­sis, that dimmed and doom­ing dilemma. Feared, some­times fought, too often for­got­ten. It is the grayest, ghastli­est ele­phant in the room: dementia.

What is demen­tia? I, like many oth­ers who ded­i­cate their pro­fes­sional efforts to its study and treat­ment, have no good answer. I believe we are lost in our lex­i­con, try­ing to define a brain state so vex­ing and elu­sive it dri­ves us out of our minds.

I hope we can do bet­ter, and I am not alone. In a sen­si­tive and forward-looking edi­to­r­ial enti­tled Demen­tia: A Word to be For­got­ten, Drs. Tra­cht­en­berg and Tro­janowski of the Uni­ver­sity of Penn­syl­va­nia argue that alter­nate terms are more appro­pri­ate for research, clin­i­cal, and every­day set­tings. From sci­en­tific and bio­log­i­cal per­spec­tives, demen­tia is unspe­cific and sub­jec­tive. Within the walls of the physician’s office, deliv­er­ing the diag­no­sis of demen­tia can erect unin­tended walls around patients and fam­i­lies; vul­ner­a­ble indi­vid­u­als, assum­ing that the “cruel con­no­ta­tions in the lay lan­guage” actu­ally apply to them, are unnec­es­sar­ily iso­lated. The authors recount a patient and care­giver expe­ri­ence upon first hear­ing the term applied:

An imme­di­ate epiphany occurred, and sud­denly the poten­tial dan­ger and threat­en­ing sen­tence of the word became man­i­fest. It was fright­en­ing that some­body might say it to her while she was still able to fully grasp and sense its toxic effect and that it would has­ten and seal her fate in the man­ner of a self-fulfilling proph­esy. (Archives of Neu­rol­ogy 2008;65(5):594)

Words to Live by

Idiot, midget, lunatic, and many other pejo­ra­tive terms have thank­fully been excised from clin­i­cal and polite dis­cus­sion. The result­ing advan­tage goes beyond con­for­mity to stan­dards of socially-acceptable dis­course. It enables the pro­duc­tive con­sid­er­a­tion of lim­i­ta­tions which should not be dis­missed or ignored. In the case of cog­ni­tive and behav­ioral dis­or­ders of aging, many resist con­fronting their con­cerns, pre­fer­ring self-conscious group chuck­les sur­round­ing “senior moments.” What’s more, prac­tic­ing physi­cians have few incen­tives or resources to probe for late-life neu­ropsy­chi­atric con­di­tions. While nihilism pre­vailed for some time, atti­tu­di­nal change has taken hold. Proac­tive peo­ple are arriv­ing at spe­cialty eval­u­a­tion cen­ters with mild cog­ni­tive symp­toms, well before one would ever con­sider drop­ping the D-bomb. Con­se­quently, we need to employ alter­na­tive con­cepts to sig­nify the pres­ence of poten­tially seri­ous brain dysfunction.

Wit­ness Brain Fitness

Sharp­Brains read­ers young and old already know that Brain Fit­ness is an achiev­able goal. Increas­ing pub­lic aware­ness and diverse tools and venues for pur­su­ing suc­cess­ful brain aging now exist. Use­ful start­ing points for dis­cus­sion are emerg­ing, many reflect­ing the con­cept of pos­i­tive cog­ni­tion. But what do you call that ghastly gray elephant?

Brain Fail­ure describes the loss of Brain Fit­ness, and fit­tingly refers to the state of men­tal degen­er­a­tion and depen­dence expe­ri­enced by mil­lions. Of the many more aging indi­vid­u­als who are threat­ened to endure such a fate, the rea­son­able approach is to con­front the pos­si­bil­ity of Brain Fail­ure by pur­su­ing Brain Fit­ness. Nihilists and slack­ers are of course wel­come to slip down the bliss­ful slope toward Brain Dis­as­ter. Those who per­ceive signs of Brain Fail­ure should seek help in iden­ti­fy­ing the bio­log­i­cal and envi­ron­men­tal deter­mi­nants of their symp­toms. Cog­ni­tive and behav­ioral dis­or­ders are com­mon in aging, and are now rou­tinely detected and treated at ear­lier stages than ever before. When med­ical and neu­rode­gen­er­a­tive diag­noses are com­mu­ni­cated, there is no ben­e­fit in evok­ing stigma or sound­ing the death knoll. Regard­less, if I had to choose an obso­lete and hurt­ful label, I’d rather be senile than demented. Every­one famil­iar with Brain Fail­ure under­stands it can be unremit­ting and cruel; we must also rec­og­nize that is reme­di­a­ble. Brain Fit­ness is still the goal, even in the throes of Brain Failure.

– Dr. Joshua Stein­er­man wrote this arti­cle for Sharp­Brains. Dr. Stein­er­man is Assis­tant Pro­fes­sor of Neu­rol­ogy at New York’s Albert Ein­stein Col­lege of Med­i­cine, where he directs the Neu­rode­gen­er­a­tive Dis­ease Clin­i­cal Tri­als Program.  He is the found­ing sci­en­tist of ProG­evity Neuroscience.

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