The Caring Corner®
The Caring Corner – the President Have Dementia?
According to one of his sons, Ronald Reagan’s fight against Alzheimer’s started while he was President. The fortieth president was officially diagnosed with the disease in 1994, half a decade after he left office. But his son Ron has shared that he had become increasingly concerned with his dad’s cognitive abilities as early as his first presidential term. He recalled becoming alarmed when the once eloquent man floundered with notes and fumbled his way through public debates. Some of Reagan’s behaviors during the presidency — struggling with words and sometimes falling asleep in public – fueled suggestions that he had early onset dementia. Yet a respected writer from the New York Times, after interviewing many of the physicians who had attended to Reagan, concluded that there was scant, if any, evidence that he had dementia while serving as president.
Fast forward to 2018, and once again people speculate that the president may have dementia. In January of this year President Trump passed with flying colors the Montreal Cognitive Assessment (or MoCA), an assessment frequently used to identify the possible presence of mild cognitive impairment. Trump supporters happily announced that he had obtained a “perfect score” or 30-out-of-30. Detractors, of course, questioned the simplicity of the test, such as the need to identify animals or draw a picture of a clock. “Armchair neurologists” point to narcissistic behaviors, confusion and other symptoms of cognitive decline.
Regardless of what you think about Donald Trump, combining medical assessments with political commentary is rarely a good idea. No one – not even a very public figure—should have his or her medical condition assessed from afar. Here are a few reasons why:
- It stigmatizes people who have dementia, Alzheimer’s and other cognitive conditions. One thing is to like or dislike a public figure. We do it all the time, and it’s our right as Americans, but to attribute any behavior to a condition that is so nuanced and hard to diagnose in its early stages as is dementia is simply unhelpful. Such statements bolster the notion that individuals who have dementia are ‘crazy’ or unable of making proper decisions. It also promotes the idea that people with dementia are incapable of working, or doing their job, which may be untrue. If you or a loved one have dementia, you want society to appreciate what it is and understand that you or they can still contribute. We need to accept that many people who have dementia are able to live full and complete lives.
- It’s unethical. Neither Donald Trump nor Ronald Reagan were the first major politicians to be challenged on their cognitive state. In 1964, Barry Goldwater, then a candidate for president, was the subject of an article titled ‘1,189 Psychiatrists say Goldwater is Psychologically Unfit to be President!’ The article’s conclusion was not based on any clinical assessment, but rather an informal poll of psychiatrists. None of them had met Goldwater, much less performed the type of clinical assessment needed to make such a determination. Goldwater lost the election, but he sued the magazine for defamation. His success in the suit led the American Psychiatric Association to develop the “Goldwater Rule”, which cautions medical professionals about making a diagnosis from a distance. The rule states that it is unethical for a psychiatric professional to provide an opinion unless he or she has performed an examination and has been given authorization to make such a statement.
- It normalizes the use of incorrect language. The words we use to describe dementia are important. There exists a substantial history of incorrect labeling when we talk about mental health conditions; casual diagnoses only make matters worse. We often use terms like OCD or bipolar, for example, in casual conversation, outside of any formal medical context. This leads to confusion and is unfair to those folks who do have such conditions. We should use equal care with the term ”dementia”. People with dementia should have a professional assessment in order to avail themselves of the support they need. A diluted, misguided understanding of the condition may discourage people from seeking medical help. If someone has dementia, we need to see the individual, and not rely on the term as a label that defines them.
- The diagnosis will probably be wrong. Human behaviors can be due to many causes. That’s why doctors tell us to get a thorough professional diagnosis if we are concerned about memory loss. There are lots of reasons why someone might be confused, including infection, poor sleep, changes in medication, stress and depression. Also, there are many types of dementia, and they are impossible to diagnose in a reliable way without the individual’s consent or cooperation. A well-done, professional diagnosis must take into account a person’s history, cognitive tests, physical exams, input from family members and a brain scan (if needed).
If you have a loved one with possible cognitive decline, a downside to the publicity around President Trump’s test is that it may now be a less reliable screening tool. When someone sees or takes a test, they become familiar with the questions and answers and score better the next time. This results in artificially improved scores. Experts warn that the public’s heightened awareness of the MoCA might obscure signs of early cognitive decline in screenings that otherwise would have relied on the tool. They are concerned that the existence of a “learning effect” could result in decreased efficacy and reduce the MoCA’s primary value in identifying cognitive change. Some experts believe that research is needed to ensure that the MoCA remains effective for people who have seen it before. They suggest that clinicians confirm with their patients if they are familiar with the MoCA before administering it. Another option is to use alternative versions (for example, not version one, but version two or three). They can also use different tests altogether. There is a plethora of alternatives, including the Mini-Mental State Exam (MMSE) and the Mini-Cog test.
Many of us do not like taking tests. The beauty of the MoCA and similar assessments is that they are short, non-invasive, easy to administer and have been scientifically proven as useful screens in identifying a strong possibility of cognitive change. A complete assessment should also include an evaluation of personal history, a physical exam, blood work and X-rays and brain scans.
