When attending on a modestly-sized, community-based, high-volume psychiatric crisis unit, it isn’t always possible to immediately access the full-spectrum of diagnostic resources that are available at the big tertiary centers. For example, if a patient is admitted to a large university inpatient ward and shows signs of forgetfulness, a battery of neuropsychological testing can be readily ordered as a first step to see if, in fact, the patient is suffering from measurable cognitive decline, and if so, to determine the best course of action. The academic centers, because of their focus on education and training, are quick to do ‘the million dollar work-up,’ and many patients who probably don’t need it are nevertheless blessed with the attention of numerous mental health sub-specialists.
But if you are in a small town, short-staffed, and have no neuropsychologist on your treatment team, you may have to rely on simple screening tools that can be administered at bedside; only if there persists evidence of cognitive impairment on such screenings would you then make the (sometimes outside) referrals to further delineate what is ongoing.
The Mini Mental Status Exam (MMSE) is a relatively quick 30-point questionnaire that examines cognitive facets such as short term memory, word recall, object identification, and simple task performance. But if you’re backed-up with six admissions, the ten minutes to perform a MMSE on each subject means an hour of extra work in your already chaotic day.
You’re blessed if you have a medical student or resident to do an MMSE for you, but if you don’t, you need the simplest basic memory/ concentration screening possible.
Just ask the patient where they are. Ask the day, date, month, year, and season. Ask the most recent holiday. And ask who is the U.S. President. No, this isn’t the most sensitive tool, but a person with delirium or dementia will usually stumble, and throw up the requisite red flag indicating the need for referral for more detailed examination.
In this current election cycle, though, I’ve added for fun one add’n question of my own design: name any one person who is running for President (recall at one point, there were more than 16 declared candidates between the two parties). For all but the truly addled, it’s nigh impossible to live in America of 2016 and not be aware, even in passing, that primaries and caucuses are brewing.
In asking this specific question of hundreds of patients with every imaginable mental disorder over the past six months, I’ve observed a very interesting phenom.
Young. Old. All races. Every level of education. Both genders. Psychotic. Neurotic. Organic. On Rx or off. I hear it every day.
Now, there are variations. Sometimes it’s just his surname. Other times, unmistakable descriptors such as “the crazy guy with all the money, the fake tan, and the hair,” or “that dude who thinks the Mexicans are going to pay for a wall.” But there’s no doubt whom they mean.
Even the ones whom I suspected had early dementia answered as the rest.
A couple of times, I thought I had uncovered a heretofore unheard reply, only to have my hopes dashed at the very end with a compound answer:
“Rubio… and then there’s that guy Trump.”
“Christie… and that rich bastard with the Atlantic City casino.”
“Bernie… and that slick New York billionaire with the big mouth.”
“Cruz… boy I wish he’d put the Donald in his place.”
Only once – ONCE – in the past months did someone say “Hillary.” And then stop. I must have appeared expectant (“and…?”) as the patient looked at me quizzically, breaking my train of thought and resulting in the fumbling of papers.
My point in all of this? Probably nothing. And come November 2016 it’ll be back to the simple vanilla questions. But in the meantime, I can’t help but appreciate the late great P.T. Barnum’s old saw that “there’s NO such thing as bad publicity.”
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[Copyright 2013 @ The Alienist’s Compendium]