AGING DOCTORS, AGING PRESIDENTS: SHOULD COGNITIVE TESTING BE MANDATORY?

Author: Richard Novak

The Anesthesia Consultant

At the academic medical center where I work, when a physician reaches the age of 74½ years he or she must pass cognitive testing to retain their medical staff privileges. The testing includes a peer-conducted clinical skills assessment by three medical staff members, a comprehensive physical exam, and cognitive screening under supervision of the neuropsychiatry department, to address the applicant’s capacity to perform the clinical privileges requested.

Should the President of the United States who is 82 years old, or his Republican opponent who is 78 years old, be required to do the same?

Following President Biden’s poor performance in the June 27th, 2024 debate versus Donald Trump, there have been calls for Biden to step down. His extended pause, followed by the out-of-context and unclear statement that “at least we beat Medicare,” provided a vivid image of him faltering. Media sources are calling for President Biden to undergo cognitive testing. Is he mentally impaired? Is he in cognitive decline? No one knows whether any objective tests of his mental acuity have been performed. Because of the Health Insurance Portability and Accountability Act of 1996 (HIPPA), the President’s medical tests are private.

Cognitive decline is defined as “the gradual loss of thinking abilities such as learning, remembering, paying attention, and reasoning.” In mild cognitive impairment, a patient has decreased ability to reason, remember, use language, make judgments, and perceive the world around them accurately. In further progression to dementia, a patient will have trouble with activities of daily living, including driving, paying bills, taking care of their living space, their body and their health.

How does one make an accurate diagnosis of cognitive decline or dementia? As always in medicine, the process begins with taking a history. The patient may explain their difficulties, but more commonly those around the patient will report the individual is having mental difficulties. A physical examination of the patient will show few specific clues to a diagnosis of cognitive decline, but cognitive tests are seen as reliable. A screening test may be as brief as the Mini-Cog. The Mini-Cog is a three-minute screening test for cognitive impairment. The test consists of three steps: Step 1 is Three Word Registration, Step 2 is Clock Drawing, and Step 3 is Three Word Recall Scoring.

MINI-COG STEP 1 (Three Word Registration): To administer the test, you look directly at a patient and say, “Please listen carefully. I am going to say three words that I want you to repeat back to me now and try to remember. The three words are (select one of the lists of three words from the versions below). Please say them for me now.”

Version 1: Banana Sunrise Chair

Version 2: Leader Season Table

Version 3: Village Kitchen Baby

Version 4: River Nation Finger

Version 5: Captain Garden Picture

Version 6: Daughter Heaven Mountain

If the patient is unable to repeat the words after three attempts, you move on to Step 2.

MINI-COG STEP 2 (Clock Drawing): You say: “Next, I want you to draw a clock for me. First, put in all the numbers where they go.” When that is completed, say: “Now, set the hands to 10 past 11.” You utilize a preprinted circle on a blank page for this exercise.

You move to Step 3 if the clock is not complete within three minutes.

MINI-COG STEP 3 (Three Word Recall Scoring): You ask the person to recall the three words you stated in Step 1.

SCORING: Word Recall = 0-3 points, 1 point for each word spontaneously recalled without cueing. Clock Draw= 0 or 2 points, with a normal clock = 2 points. A normal clock will have all numbers placed in the correct sequence and approximately correct position (12, 3, 6 and 9 are in anchor positions) with no missing or duplicate numbers. The clock hands are pointing to the 11 and 2 (11:10) positions. Hand length is not scored. Inability or refusal to draw a clock = 0 points. TOTAL SCORE = Word Recall score + Clock Draw score.  Some studies consider a score of 3 or less diagnostic of cognitive impairment, other studies require a score of 2 or less.

Another screening test for cognitive decline is the AD8 Dementia Screening Interview. Eight questions are asked. The answers to each question are “YES, a change,” “NO, no change,” or “N/A, don’t know.”  “YES, a change” indicates that there has been a change in the last several years (most likely caused by cognitive thinking and memory problems).

The eight questions in the AD8 Dementia Screening Interview are:

1. Problems with judgment (e.g., problems making decisions, bad financial decisions, problems with thinking).
2. Less interest in hobbies/activities
3. Repeats the same things over and over (questions, stories, or statements)
4. Trouble learning how to use a tool, appliance, or gadget (e.g., VCR, computer, microwave, remote control)
5. Forgets the correct month or year
6. Trouble handling complicated financial affairs (e.g., balancing a checkbook, income taxes, paying bills)
7. Trouble remembering appointments
8. Daily problems with thinking and/or memory

The final score is a sum of the number items marked “YES, a change”. The Total AD8 score ranges from 0 to 8. A score of 0 – 1 equates to normal cognition. A score of 2 or greater means that cognitive impairment is likely present. A score in the impaired range indicates the need for further assessment. A normal score suggests that cognitive impairment is unlikely, but can’t rule out a very early disease process

A screening test by itself doesn’t diagnose dementia, but a test like the AD8 can detect early cognitive changes.  More sophisticated tests are available to neurologists and psychiatric professionals to assess cognitive decline.

 

The graph above, published on a Northwestern University website, describes the existence of SuperAging.

At Northwestern, SuperAging is a research term for individuals who are 80 years of age and older and yet have the cognitive ability equivalent to people in their 50s or 60s. Researchers are studying SuperAgers to understand how they are aging with minimal mental deficiency. A factor that sets SuperAgers apart is a high number of specialized brain cells known as Von Economo neurons. Von Economo neurons are believed to be important for social interaction and are found in highly social species with such as elephants, dolphins and whales. Humans with dementia often have decreased numbers of these neurons. SuperAgers have four to five times the number of Von Economo neurons when compared with normal aging adults.

Cognitive Decline in Aging Doctors

As more physicians work into their 70s or 80s, there will likely be a rise in doctors practicing with cognitive impairment, potentially placing the health of their patients at risk. Data on the number of cognitively impaired physicians is sparse. A study of computerized testing of 356 American physicians aged 65 years and older found 9% with cognitive impairment (reference: Cognitive Impairment in Aging Physicians) A recent report of cognitive testing of MDs aged 70 years and older during recredentialing in one hospital system discovered 13% had significant cognitive deficits likely to impair their ability to practice medicine independently.

Should there be mandatory retirement for late career doctors? Pilots for most airlines in the United States must retire after age 65. Judges in most states in America must retire by age 70–75. A mandatory retirement age for MDs could be interpreted as discrimination against elder physicians, and unfortunately remove many competent doctors from practice at a time when we already have a physician shortage in America.

Cognitive Decline in Aging Presidents or Presidential Candidates

In an ideal world, an aging President would be a SuperAger. The individual who controls the world’s largest nuclear arsenal needs to have excellent judgment and high mental competence. If the President’s physicians perform cognitive testing and the President scores very high, this would be a reassuring fact. Although the President’s private medical records are protected under HIPAA law, if the White House chose to divulge excellent cognitive scores, it would be solid news for the voters in our country. If the President’s physicians perform cognitive testing and the scores show cognitive decline, this raises an ethical dilemma. By keeping the tests private and covered up, an impaired President is allowed to continue his or her commanding role, and the United States is in peril of bad decision making and tactical mistakes. For the tests to be made public, the White House must not be handcuffed by health privacy laws and admit that there is a problem for the well-being of the nation. If the President is impaired, someone else should be running the country.

If President Biden had cognitive testing and the tests were normal, then more likely than not he has no mental shortcomings which would limit his ability to lead our country. Letting the voters know the results is reassuring. If President Biden had cognitive testing and the tests were abnormal, then more likely than not he has mental shortcomings which limit his ability to lead our country. It seems imperative to let the voters know the results.

Uncertainty about a doctor’s cognitive ability is a problem with a concrete solution. Test the doctor, and if he or she is significantly impaired, remove them from the workforce.