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Neurology India, Vol. 53, No. 3, July-September, 2005, pp. 294-295 Invited Comments Invited Comments McCaddon Andrew Department of General Practice, Wales College of Medicine, Wrexham Code Number: ni05101 Related article: ni05100 It has long been recognised that our ageing population will be accompanied by a ′silent epidemic′ of dementia that will impact upon all aspects of health care. In a prescient discussion of its implications, Beck et al observed that many ameliorable diseases in the elderly are associated with intellectual impairment that may be difficult to distinguish from irreversible brain disease [1]. In this issue of Neurology India, Srikanth et al address this important topic in a prospective study of 129 referrals to a hospital neurological unit for evaluation of cognitive disorder[2]. They discovered reversible dementias in 18% of the study sample; 11 patients had neuroinfections, 8 had normal pressure hydrocephalus and 5 were vitamin B12 deficient. The majority of these cases were clinically unsuspected but showed substantial improvement with treatment. Dementia prevalence in elderly individuals in Southern India is estimated to be 33.6 per 1000[3]. It is striking that nearly one fifth might have a reversible dementia. In fact, the true prevalence of reversible dementia may be even higher. Srikanth et al excluded patients with alcoholic dementia, depressive pseudodementia, intracranial tumours and subdural haematomas; these patients were referred to other departments for follow up. Furthermore serum B12 assays were only performed ′as deemed necessary′, but the haematological and neurological features of B12 deficiency are often unrelated in such patients.[4] The advent of sensitive but expensive tests such as homocysteine and holotranscobalamin assays now makes it possible to detect such subtle deficiencies.[5] However, there is a difficult but important ′cost/benefit′issue to be addressed. Should every patient presenting with dementia be extensively investigated for potentially reversible causes with an inherent increase in diagnostic costs? Hence it is helpful that Srikanth et al describe a distinct clinical profile to alert physicians to the possible presence of reversibility. They found that a subcortical pattern of dementia in younger patients with a short duration of symptoms was suggestive of an underlying reversible cause. Clearly more work is required to develop cost-effective clinical algorithms for the investigation of patients with cognitive disorders. As the authors note, this has special relevance for countries like India where reversible etiologies are likely to be coμn but diagnostic resources scarce. ′Silence is golden′- but can we afford to listen? References
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