The February 2002 issue of the Journal contained a number of useful reviews of the major disorders that lead to dementia. In his paper on vascular dementia, Stewart (Reference Stewart2002) suggested that we need to be ‘identifying cognitive decline at a much earlier stage than dementia’. It occurred to me some time ago that the term ‘dementia’ has outlived its usefulness. It derives from a time when mental health workers were few and only gross changes in mental state were noted and dealt with. It still carries with it the therapeutic nihilism of those times and even the anticholinesterase inhibitors do little to dispel this, as they work for only a minority and for a short period of time. The term suggests a black-and-white distinction (‘demented’ or ‘not demented’). In fact there are infinite variety of shades of grey. I have had a number of experiences of patients being referred as ‘demented’ largely for ‘disposal’ and have found that when we have taken them off toxic medication, treated their chronic chest infections, improved their diabetes and hypertension care, reduced the severity of their heart failure, got rid of their anaemia and managed their depression, anxiety or psychosis etc. we have been able to discharge them home or to relatively inexpensive long-term care. I see the person as cognitively impaired, and work to reduce the severity of that impairment — not simply by prescribing anti-dementia drugs. The widespread use of standardised ratings, such as the Mini-Mental State Examination (Reference Folstein, Folstein and McHughFolstein et al, 1975) and more advanced variations such as Cambridge Examination for Mental Disorder of the Elderly (CAMDEX; now revised, Reference Roth, Huppert and MountjoyRothet al, 1999) have greatly improved doctors' ability to screen cognitive function, and while National Institute for Clinical Excellence guidelines encourage us to think of a specific score that delineates those with dementia from those without dementia, we are all aware that this is driven by accountancy rather than by medicine. At a practical level it is possible to get through the working week without using the term dementia and more accurately convey the person's mental state by speaking of cognitive impairment and elaborating on which areas are intact and which are dysfunctional.

Having written the above I feel some reluctance to post it as I think it is likely to raise more hackles than nods of agreement. It is as if I have suggested putting down a much loved but ancient family dog just because it is no longer able to deter burglars and chase cats. I hope that in my lifetime we will have developed drugs that will prevent the onset of disorders that lead to dementia. When an effective cocktail of cleaving agents, anti-oxidants, free-radical scavengers and neurochemical enhancers is available we will all be having our cognitive functioning tested by primary care on an annual basis much as we do now with our blood pressure. The ageing pooch will then die quietly in its bed.