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Diagnosing Dementia: Signs, Symptoms and Meaning Université de Montréal Diagnosing Dementia: Signs, Symptoms and Meaning Pa= Janice Elizabeth Graham Département d'anthropologie Faculté des arts et des sciences Thèse présentée à la Faculté des études supérieures en vue de l'obtention du grade de Philosophia Doctor 0h.D.) en anthropologie Janice E.Graharn, 1996 National Library Bibliothèque nationale I*I of Canada du Canada Acquisitions and Acquisitions et Bibtiographic Services services bibliographiques 395 Wellington Street 395, rue Wellington Ottawa ON K1A ON4 Ottawa ON KIA ON4 Canada Canada Vour fik Vorre réference Our file Notre refdrence The author has granted a non- L'auteur a accordé une licence non exclusive licence dowing the exdusive permettant à la National Library of Canada to Bibliothèque nationde du Canada de reproduce, loan, distribute or sell reproduire, prêter, distribuer ou copies of this thesis in microform, vendre des copies de cette thèse sous paper or electronic formats. la fome de microfiche/nlm, de reproduction sur papier ou sur format électroniq2e. The author retains ownership of the L'auteur conserve la propriété du copyright in this thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts f?om it Ni la thèse ni des extraits substantiels may be printed or othenvise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. Université de Montréal Faculte des Btudes superieures Cette thèse ultitulee: Diagnosing Dementia: Signs, Symptoms and Meaning presentée par: Janice E. Graham a et6 évaiuee par un jury composé des personnes suivantes: Kevin Tuite : president-rapporteur Gilles Bibeau : directeur de recherche Denis Gauvreau : codirecteur de recherche Daniel Pérusse : membre du jury Sam Migliore : examinateur externe These acceptée le 19 décembre 1996 Université de Montréal Bibliothèque Medical diagnosis is an interpretation which the physician constructs by piecing together information provided by the patient as a series of symptoms @y a patient narrative or interview) and signs @y physical examination and tests). The configuration of probabilities of these individual and intertertextual items fom a clinid text which directs physicians along one or another diagnostic path. These symptorns and signs, along with other ded information, are increasingly king wiiected and inscribed in clinid and epiderniological databases in order to address important medical and research questions as weU as to inform and direct health care policy and planning. Databases are ge~erallyused as explanatory repositones rather than interpretive texts. Yet, the coded facrs contained in the database, at one and the same time, mult the hermeneutical position and compel an attempt at interpretation and understanding. The database holds unique information - as a text of the cultures which produce it, it is subordinate to those cultures. It contains facts which cannot always be separated from values and ideas. The intenelated elements are dynarnically engaged and subject to multiple interpretations, including those of which the authors themselves may be unaware. By looking at the configurations of sets of these elements, we might be able to explore classifications and differences which the observers who initially collectai the data and crea*d the database may not have recognized. Incorporated into the body of the database are the indetenninacies, incoherences and incomrnensurabilities which make up the actual practice of the people and institutions who construct the data. This dissertation explores the concepts and constnicts of clinicians engaged in the practice of ciifferenMy diagnosing dementia. 1 migrate between the es tablished clinical diagnostic criteria (written text), the actual practice of diagnosis rnanifested by physicians who incorporate a semiological catalogue of symptoms and signs (database text), and the manner in which specialties within the expert culture of medicine differentially operationalize standardized criteria (belief text). I critically analyze the data, collected over a two year period, of 2914 clinicai assessments of elderly people as part of the Canadian Study of Health and Aging (CSHA), against information derived from the established criteria and from consultation over a five year pend with an international group of expert dementia diagnosticians. 1 explore the process of standardizing the cntetia in order to establish reliability and validity, fundamental to large population health studies, and 1 challenge the non-anthropological tradition of reading a database Iike a telephone book, a series of if-then statements givbg rise to binary algorithms. Instead, employing an "encyclopedian approach to reading a text, 1 propose and develop heuristically a methodology which incorporates an intertextual, conditional approach to reading the database. By applying an analogy of the epidemiological database as a cultural text, the relationships and coordinations between the datum prove to delineate patterns and redundancies which characterize the subategories of dementia, and the specific diagnostic approaches of the physicians engaged in diagnosis, filtered as they are through the pnsms of their specialty. There are many different routes to diagnosis - many different configurations of signs and symptoms which represent bundles of criteria, appear to work. The clinician's semiological catalogue determines the diagnosis. Local specialty cultures within medicine - ps ychiatry , neurolog y, geriatrics, intemal medicine and family prac tice - each have their own doctor's bag of favourite tests which assist them in their interpretation of the symptorns and signs to formulate a meaningful diagnosis. As components of this catalogue are adjusted with time and place and situation, with adjus tments to criteria, the context bound subjectivity of diagnostic categories is made evident. This, in turn, pavas the way for a plethora of novel possibilities in the ever shifting tectonic diagnostics revolving around dementia, criteria, and data. En 199 1, j'ai et6 té& par l'équipe chargée de l'Étude sur la Santé et le Vieillissement au Canada @WC), une -tude épid&niologique effectuée sur une population représentative de Canadiens 5gés de 65 ans et plus. objectif p~cipalde 1'6îude était de déterminer la wuence de la démence, y compris la maladie d'Alzheimer. J'avais à évaluer la fiabilite et la validité de I'etude ainsi qu'à trouver une signification dans la multitude de données chiques obtenues de 18 centres d'études, de Terre-Neuvejusqu'en Colombie-Britannique. J'ai entrepris de comprendre la signification des données, du diagnostic et de la démence. Environ 8 % de tous les Canadiens âgés de 65 ans et plus (un total de 252,600 personnes) soufient d'une forme de demence. Parmi eux, il y en a 161,000 qui souflrent de la maladie d'Alzheimer. Mal@ le fait que l'identification du syndrome soit conceptueliement differente de l'identification de la cause, on réfke g6néralement à ces deux actions comme étant le diagnostic. Récemment, on a révisé le diagnostic basé sur le syndrome (ja définition de la démence). Les d6fïnitions etiologiques (l'identification des maladies qui causent la démence, telle la maladie d'Alzheimer) ont subi des raffinements et des changements. La reconnaissance de causes de la démence qui n'étaient pas reconnues auparavant a coïncidé avec des changements considérables dans la manière dont on définit les causes établies . A defaut d'indicateurs biologiques disponibles, l'identification de la cause de la démence dépend des symptômes et des signes cliniques. Le diagnostic médical que le médecin formule progressivement constitue une interpr6tation des informations relevées par le patient comme une série de symptômes (par entrevue du client) et de signes (par examen physique et tests médicaux). La configuration de probabiiith de ces individus et les Etsintertextue1s produisent un texte clinique qui amène les médecins à suivre telle ou telle direction diagnostique. On recueille et enregistre ces symptômes et signes, ainsi que toute autre information pertinente dans des bases de données chiques et épidt5miologiques afin de poser d'importantes questions médicales et de recherche pour informer et permettre l'élaboration de la planification des politiques des soins de santé. D'habitude, on utilise la base de dom& comme réceptacle d'explications plutdt que comme textes interpr6tatifs. Néanmoins, les fiits codifiés contenus dans la base de données, remettent en qdon le point de vue herméneutique et obligent à un effort d'interprétation et de compréhension. Il y a dans la base de données des renseignements uniques - en tant que textes des cultures qui la constituent, la base de données est subordom6e à ces cultures. Les bases de données contiennent des faits qu'on ne peut pas toujours s-er des valeurs et des idées. Comme produit culturel, les données sont produites au lieu d'&te tout simplement recueillies. Les faits particuliers, les 616rnents d'uifonnations recueillis au cours d'un examen médical, par exemple, sont des constructions ciblées qui représentent un dialogue entre les symptômes ressentis par le patient et les résultats découverts par le médecin au cours de l'examen. Le processus, parce que les observations auxquelles le médecin attribue une signification sont un produit de sa formation, fait partie d'un imaginaire social. Les symptômes, signes et comportements relevés par le client sont recueillis et classés par le médecin selon un système logique qui incorpore
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