With President Trump expected to undergo a physical examination tomorrow, much discussion has centered around whether the exam should include some sort of psychiatric examination or cognitive assessment.
Concerns were raised about the 71-year-old president’s mental fitness after he reportedly forgot names of old friends and repeated stories several times. Trump responded by tweeting that he was mentally stable and a “very stable genius.” And when reporters aboard Air Force One asked White House spokesman Hogan Gidley on Monday whether the visit would include a psychiatric examination, his answer was “No.”
“He’s sharp as a tack. He is a workhorse, and he demands his staff to be the same way,” Gidley said, according to The Hill.
Part of Medicare Wellness Exam
A cognitive assessment is part of what is covered under Medicare’s annual wellness exam, and is described as “detect[ing] any cognitive impairment the beneficiary may have,” according to the Centers for Medicare and Medicaid Services’ Medicare Learning Network website. Such examinations often include an assessment of “the beneficiary’s cognitive function by direct observation, with due consideration of information obtained via beneficiary reports and concerns raised by family members, friends, caretakers, or others,” the site noted.
A cognitive exam is also mentioned in the Geriatrics Review Syllabus, a text that helps physicians prepare for the geriatrics board exam. “Older adults with cognitive impairment, even in the absence of dementia, are at increased risk of accidents, delirium, medical nonadherence, and disability,” the text notes. “Therefore, an important feature of every assessment of an older adult, especially those ≥75 years old, is a brief cognitive screen.”
Opinions are varied on whether those assessments should be automatic. “[The reasons for a cognitive exam should] come from two places: either the patient notices something changing, or the caregiver or patient support network notices it,” said Fred Pelzman, MD, a MedPage Today columnist and associate medical director of Cornell Internal Medicine Associates in New York City. “It shouldn’t just be ‘You’re old and you need tests done’ — that could lead to overdiagnosis and overmedication.” Examples of issues of concern include patients seeming less “sharp,” their stories becoming more repetitive, their lack of ability to pay their bills or perform simple mathematical tasks, or their neglect of personal hygiene.
The U.S. Preventive Services Task Force stated that the evidence was “inconclusive” on whether cognitive screening was beneficial, noted Anne Newman, MD, MPH, chair of epidemiology at the University of Pittsburgh Graduate School of Public Health. However, the task force is currently updating its recommendation on the issue.
“Under age 80, the rates of dementia are pretty low but after age 80 the rates go up, making it more likely that screening is worthwhile,” she said in an email. “It is reasonable to test anyone with concerns about change in cognitive ability, especially after age 80. Understanding areas of deficit can help with accommodations such as medication reminders or help with paying bills and keeping appointments.”
As for which tests to use, “there are numerous screening tests that tap the main cognitive abilities such as the mini-mental status exam, the Montreal Cognitive Assessment (MoCA) and informant questionnaires,” Newman said. “These tests focus on short-term memory and language.” However, these screening tests are not very sensitive in people with a high degree of education, she added.
Effects of Chronic Illnesses, Polypharmacy
Gary Kennedy, MD, director of geriatric psychiatry at Montefiore Medical Center in New York City, noted that patients with multiple chronic conditions and those taking lots of medications may be at greater risk of developing cognitive problems, and so should be routinely screened starting at around age 65. “If the person screens positive, there some dementing disorders that are actually reversible, such as impaired cognition due to the thyroid not working properly. Or there may be some brain tumor or brain abnormality … [those types of cases] constitute less than 1% [of dementia patients] but if you’re in that 1%, you’d want that fixed.”
As for the polypharmacy, “it’s rare we can detect a [cognitive] condition that we can reverse,” Kennedy said. “But it’s not rare to find a person taking too many medications, so let’s see if we can reduce them and make that person think a little more clearly.”
For the rest of the population — especially those who are healthy and well-educated, and therefore less likely to benefit from earlier screening — regular screening should begin at age 75, he said, adding that “by age 85, one in four people are going to develop some form of dementia, so we’d like to screen them to help them plan for the future,” even if they can’t be cured.
There are several good screening instruments that are not widely used, Kennedy said. These include a picture-based memory impairment screen, developed for non-literate populations, that tests memory using a series of four pictures displayed on a computer. “It’s simple, and it gets around education and literacy. And it’s 5 minutes at the most.”
As the president’s physical draws closer, the controversy over what will be included in his examination continues to simmer. The American Psychiatric Association (APA) weighed in Tuesday with a press release reiterating its support for the “Goldwater Rule”, which directs APA members to hold their medical opinions of individuals they haven’t personally examined “in a professional setting” in check.
“We at the APA call for an end to psychiatrists providing professional opinions in the media about public figures whom they have not examined, whether it be on cable news appearances, books, or in social media,” the APA wrote in a press release issued Tuesday. “Doing otherwise undermines the credibility and integrity of the profession and the physician-patient relationship.”
Bandy Lee, MD, a member of the law and psychiatry division at the Yale School of Medicine, in New Haven, Conn., disagreed with the APA’s position. “My problem is that the APA expanded the Goldwater Rule in an unprecedented way through a dramatically different interpretation of it 2 months into this presidency,” said Lee, who spoke only for herself. “In March 2017, they turned it into a gag rule and silenced the profession. The current interpretation is at odds with what’s written and with principles of medical ethics, as well as with the universal declaration that physicians are obligated to humanitarian goals.”
“When there is reason to doubt someone’s capacity, we can order a capacity evaluation, which would be able to determine whether they have the capacity to do whatever people are questioning,” she said. “With all the questions that have arisen, the American people have a right to know even if just to reassure them.”