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Notes -
Obviously, most are highly interested in the president’s mental status right now so I figured I’d outline some related medical content.
Caveat- I’m not a geriatrician because fuck that (sorry if you are), so if anyone wants to throw out more specific domain knowledge feel free.
As is usual for medicine, terms are both highly specific and something that specialties don’t necessarily agree on, I’ll skip most of this to avoid blathering about the difference between a mild vs. major neurocognitive disorder vs. dementia as much as possible, but is it worth noting that the word dementia in a colloquial sense can end up being used to refer to normal or above normal age related cognitive decline and changes (which is likely what is happening to the president), or it can be used to refer to one of several highly specific disease process that may result in things like fast or slow progression, or extremely worrying symptoms like hallucinations.
A lot of people have commented “well my grandpa had looked like that” type comments and that’s not necessarily bad data but specific diagnosis of this stuff is surprisingly complicated and unsatisfying since a lot of it requires looking at the overall “clinical” picture and going “yeah probably” (including waiting years to see if progressive decline is happening) with confirmation being only available post-mortem if at all. One of the reasons for this is that the wheels falling off your brain results in some weird shit, some people get behavioral changes years before they get memory problems which leads to them getting diagnosed with something completely different, or something that is not even a “dementia” at all. It’s a huge pain in the ass.
As an aside, I think we may good evidence that the Biden administration is aware of and lying about his neurologic health, which I think many suspect but something that we can point to as evidence is helpful.
Readers may be aware that for a number of years Biden has been publishing his health assessments due to questions about his medical health and fitness. I have used these as a teaching tool because they are exceptionally well written notes and learners can get quite a bit from them. They can be found via google, however: https://www.whitehouse.gov/wp-content/uploads/2024/02/Health-Summary-2.28.pdf. Caveat – I don’t have specific knowledge on presidential notes, it may be standard of care to neglect to mention the specific stuff I’m going to talk about. But I question that.
If you read his note, you’ll observe he had a very extensive neurologic exam (as every president probably does and everyone probably should but doesn’t), but he actually has notable neurologic findings. These are ultimately unexciting and not related to the problem at hand, but it means his neurologic exam was performed and reported. Problem: a neuro exam includes assessment of cognition, sensorium, etc. It’s not all reflex hammers and muscle tone (for shits and giggles here’s a citation PMID: 32491521). Sidebar: this note does seem to rule out most pathology with notable physical component like Parkinson’s or cerebellar problems. Since specific deficits are present and commented on, I actually believe that.
However, I do believe his mental status exam is not being reported on, or was declined. Every patient who sees a doctor is having their mental status assessed. Most of this is invisible and often it’s not commented on in documentation. For a primary care provider role, you don’t need to comment on thought process and affect, but you will eyeball the person and if something looks off chase it.
Your doctor is paying attention to what you are saying and how you are saying, but mostly this is on autopilot. Standard of care is to assess orientation “who are you” “where are you right now” “what’s the date and time.” You might not get these questions every time because if you are having a complicated conversation with the doctor, they’ll assume you are oriented (rightly so) and then spare you the stupid questions. Asking them is however the standard of care, and you bet Biden is getting asked those questions and other basic mental status exam questions, which typically include things like some basic math and read back of three objects at five minutes.
Example MSE: https://meded.ucsd.edu/clinicalmed/mental.html
Now with someone in Biden’s age range, gaffes, stress levels, and observed behavior I’d want to do a more exhaustive test. Again, my feeling of what represents standard of care is that he needs a higher level of screening tool, which I do not see reported. Likely declined or deliberately skipped by his physician.
So, what are these? Two standard ones you can look are the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). You can google these yourself and these are what inspired me to write this. For the most part there isn’t fancy brain imaging or lab tests, we ask you to name a lion on a sheet of paper and you can’t and you get a “dementia” diagnosis.
The fact that nobody gave him an MMSE, reported that he got full points (which he should if he’s the fucking president) and has pointed to that as positive evidence….that’s concerning.
These instruments can be performed by anyone, I want to see Trump chase Biden around with a MoCA sheet, shouting “do you have a moment to talk about your mental status???” The tougher part is ruling out medical causes of illness, which they did as normal.
TLDR: Typically, if you come in for a neuro-cognitive assessment you’ll get labs and imaging, but the doctor will know the level of impairment from history taking (including with family) and from the physical exam. The history taking requires some art, but the exam portion comes on a sheet of paper and can be performed by basically anybody in under 20 minutes. It’s not asking the president to sit in an MRI for a couple hours. This has concerning implications.
what does that mean? is there a picture of a lion and you can call it simba? i feel like i'm going to fail the dementia test.
One of the tests asks you to identify three distinctive animals from a drawn picture - a lion, camel, and rhino.
People do get this wrong, sometimes people that you wouldn't guess because they stay sharp in some areas but not others.
I think they were picked because the silhouettes are known to nearly everybody in the western world (charismatic megafauna!).
Top 10 all time prog rock band name, for sure.
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