- Email: [email protected]
Mild cognitive impairment
Correspondence
ABC is therefore evidence based3–5 and is not driven by PEPFAR but by African countries,2 which is critical for sustainability. We know how to prevent HIV transmission—it is urgent that we mobilise resources to do so in a locally appropriate manner. Condom programmes receive support from numerous partners, making PEPFAR support for a balanced ABC portfolio all the more necessary. Shifting resources to “C” at the expense of “AB”, as called for in your Editorial, could compromise expansion of programmes to empower young people to say no to sex and to empower individuals to restrict their number of sexual partners. Difficult decisions about funding must continue to be made in partnership with host governments. Many more lives will be saved if we can remain focused on urgently addressing unmet HIV prevention needs, recognising that ABC is currently the most effective way to do that. We declare that we have no conflict of interest. The views and opinions expressed in this letter do not necessarily reflect those of the governments of Namibia or the USA.
Richard Kamwi, *Thomas Kenyon, Gary Newton [email protected] Minister of Health and Social Services, Windhoek, Namibia (RK); Director, Global AIDS Program, Centers for Disease Control and Prevention, Windhoek, Namibia (TK); and Director, United States Agency for International Development, Windhoek, Namibia (GN) 1 2
3
4
5
The Lancet. HIV prevention policy needs and urgent cure. Lancet 2006; 367: 1213. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913–15. Kirungi WL, Musinguzi J, Madraa E, et al. Trends in antenatal HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sex Transm Infect 2006; 82 (suppl 1): i36–41. Cheluget B, Baltazar G, Orege P, Ibrahim M, Marum LH, Stover J. Evidence for population level declines in adult HIV prevalence in Kenya. Sex Transm Infect 2006; 82 (suppl 1): i21–26. Mahomva A, Greby S, Dube S, et al. HIV prevalence and trends from data in Zimbabwe, 1997-2004. Sex Transm Infect 2006; 82 (suppl 1): i42–47.
www.thelancet.com Vol 367 June 17, 2006
Mild cognitive impairment As participants in a workshop and authors of an associated Seminar on mild cognitive impairment (MCI; April 15, p 1262),1 we are aware of the complexities of organising and summarising quasiconsensus conferences. Despite the attempt to examine where MCI stands as a clinical entity, no agreement emerged from our workshop as to its clinical use. Is it a syndrome, a risk state, or should it become a new diagnosis? The concerns we raised during the workshop session about the social and ethical aspects deserve more emphasis than appeared in the Seminar. MCI meets none of Kendell’s six criteria for validating a clinical syndrome with certainty.2 Is the labelling of the historically obvious—ie, that with age we all experience variable cognitive changes—a key research discovery, or does it represent inappropriate medicalisation of ageing? Ron Petersen and one of us (PW) surveyed the 53 workshop participants by email after the meeting and asked whether the term MCI should be used in clinical practice. Of the 37 who responded, only 21 of these selected experts on MCI answered “yes.” The lack of consensus; arbitrary nature of the label; heterogeneity in proposed criteria, presentation, and outcomes; and unclear, but potentially damaging, effect on older people with complaints about their memory suggest that we should not use the term clinically. In fact, in this 100th anniversary year of Alzheimer’s disease, the term MCI asks us to question more deeply the relations between ageing and degenerative brain diseases as well as the role of medicine—particularly expensive technologically driven molecular genetic approaches—in creating
false hope about ageing-associated cognitive disorders. We declare that we have no conflict of interest.
*Peter Whitehouse, Henry Brodaty [email protected] Department of Neurology, Case Western Reserve University, Cleveland, OH 44120, USA (PW); and University of New South Wales, Sydney, Australia (HB) 1
2
Gauthier S, Reisberg B, Zaudig M, et al, on behalf of the participants of the International Psychogeriatric Association Expert Conference on mild cognitive impairment. Mild cognitive impairment. Lancet 2006; 367: 1262–70. Kendell RE. Clinical validity. Psychol Med 1989; 19: 45–55.
I am aware of Peter Whitehouse and Henry Brodaty’s concerns about the appropriateness of using mild cognitive impairment (MCI) as a clinical entity, but I disagree with their assertion that MCI does not meet Kendell’s criteria, and argue that MCI meets them more adequately than most of the disorders currently included in the fourth revision of the Diagnostic and Statistical Manual. The “medicalisation of ageing” construct proposed by Whitehouse and Brodaty was deleted from an earlier version of the Seminar1 because the other authors did not agree with its implications. The survey to which Whitehouse and Brodaty refer was done casually and not in any rigorous fashion, and, consequently, referring to it in this type of communication is inappropriate. A similar survey involving a larger cohort of practitioners (n=200) at the International Psychogeriatric Association meeting in Stockholm in September, 2005, indicated that about 150 (75%) of attendees use MCI as a clinical diagnosis. I am a consultant to Elan Pharmaceuticals.
Ronald C Petersen [email protected] Mayo Clinic College of Medicine, Rochester, MN 55905, USA 1
Gauthier S, Reisberg B, Zaudig M, et al, on behalf of the participants of the International Psychogeriatric Association Expert Conference on mild cognitive impairment. Mild cognitive impairment. Lancet 2006; 367: 1262–70.
1979
ABC is therefore evidence based3–5 and is not driven by PEPFAR but by African countries,2 which is critical for sustainability. We know how to prevent HIV transmission—it is urgent that we mobilise resources to do so in a locally appropriate manner. Condom programmes receive support from numerous partners, making PEPFAR support for a balanced ABC portfolio all the more necessary. Shifting resources to “C” at the expense of “AB”, as called for in your Editorial, could compromise expansion of programmes to empower young people to say no to sex and to empower individuals to restrict their number of sexual partners. Difficult decisions about funding must continue to be made in partnership with host governments. Many more lives will be saved if we can remain focused on urgently addressing unmet HIV prevention needs, recognising that ABC is currently the most effective way to do that. We declare that we have no conflict of interest. The views and opinions expressed in this letter do not necessarily reflect those of the governments of Namibia or the USA.
Richard Kamwi, *Thomas Kenyon, Gary Newton [email protected] Minister of Health and Social Services, Windhoek, Namibia (RK); Director, Global AIDS Program, Centers for Disease Control and Prevention, Windhoek, Namibia (TK); and Director, United States Agency for International Development, Windhoek, Namibia (GN) 1 2
3
4
5
The Lancet. HIV prevention policy needs and urgent cure. Lancet 2006; 367: 1213. Halperin DT, Steiner MJ, Cassell MM, et al. The time has come for common ground on preventing sexual transmission of HIV. Lancet 2004; 364: 1913–15. Kirungi WL, Musinguzi J, Madraa E, et al. Trends in antenatal HIV prevalence in urban Uganda associated with uptake of preventive sexual behaviour. Sex Transm Infect 2006; 82 (suppl 1): i36–41. Cheluget B, Baltazar G, Orege P, Ibrahim M, Marum LH, Stover J. Evidence for population level declines in adult HIV prevalence in Kenya. Sex Transm Infect 2006; 82 (suppl 1): i21–26. Mahomva A, Greby S, Dube S, et al. HIV prevalence and trends from data in Zimbabwe, 1997-2004. Sex Transm Infect 2006; 82 (suppl 1): i42–47.
www.thelancet.com Vol 367 June 17, 2006
Mild cognitive impairment As participants in a workshop and authors of an associated Seminar on mild cognitive impairment (MCI; April 15, p 1262),1 we are aware of the complexities of organising and summarising quasiconsensus conferences. Despite the attempt to examine where MCI stands as a clinical entity, no agreement emerged from our workshop as to its clinical use. Is it a syndrome, a risk state, or should it become a new diagnosis? The concerns we raised during the workshop session about the social and ethical aspects deserve more emphasis than appeared in the Seminar. MCI meets none of Kendell’s six criteria for validating a clinical syndrome with certainty.2 Is the labelling of the historically obvious—ie, that with age we all experience variable cognitive changes—a key research discovery, or does it represent inappropriate medicalisation of ageing? Ron Petersen and one of us (PW) surveyed the 53 workshop participants by email after the meeting and asked whether the term MCI should be used in clinical practice. Of the 37 who responded, only 21 of these selected experts on MCI answered “yes.” The lack of consensus; arbitrary nature of the label; heterogeneity in proposed criteria, presentation, and outcomes; and unclear, but potentially damaging, effect on older people with complaints about their memory suggest that we should not use the term clinically. In fact, in this 100th anniversary year of Alzheimer’s disease, the term MCI asks us to question more deeply the relations between ageing and degenerative brain diseases as well as the role of medicine—particularly expensive technologically driven molecular genetic approaches—in creating
false hope about ageing-associated cognitive disorders. We declare that we have no conflict of interest.
*Peter Whitehouse, Henry Brodaty [email protected] Department of Neurology, Case Western Reserve University, Cleveland, OH 44120, USA (PW); and University of New South Wales, Sydney, Australia (HB) 1
2
Gauthier S, Reisberg B, Zaudig M, et al, on behalf of the participants of the International Psychogeriatric Association Expert Conference on mild cognitive impairment. Mild cognitive impairment. Lancet 2006; 367: 1262–70. Kendell RE. Clinical validity. Psychol Med 1989; 19: 45–55.
I am aware of Peter Whitehouse and Henry Brodaty’s concerns about the appropriateness of using mild cognitive impairment (MCI) as a clinical entity, but I disagree with their assertion that MCI does not meet Kendell’s criteria, and argue that MCI meets them more adequately than most of the disorders currently included in the fourth revision of the Diagnostic and Statistical Manual. The “medicalisation of ageing” construct proposed by Whitehouse and Brodaty was deleted from an earlier version of the Seminar1 because the other authors did not agree with its implications. The survey to which Whitehouse and Brodaty refer was done casually and not in any rigorous fashion, and, consequently, referring to it in this type of communication is inappropriate. A similar survey involving a larger cohort of practitioners (n=200) at the International Psychogeriatric Association meeting in Stockholm in September, 2005, indicated that about 150 (75%) of attendees use MCI as a clinical diagnosis. I am a consultant to Elan Pharmaceuticals.
Ronald C Petersen [email protected] Mayo Clinic College of Medicine, Rochester, MN 55905, USA 1
Gauthier S, Reisberg B, Zaudig M, et al, on behalf of the participants of the International Psychogeriatric Association Expert Conference on mild cognitive impairment. Mild cognitive impairment. Lancet 2006; 367: 1262–70.
1979