Ignorance is bliss: A fly-on-the wall glimpse of the cognitive exam
By Stephen D. Forman (LTCA)
Long Term Care Associates, Inc.
Knowing that the incidence of Alzheimer's disease doubles every five years after age 65, let's do everything we can as LTCI professionals to make sure America is insured before tragedy strikes.
Your intrepid reporter recently had the occasion to set up a doctor's appointment outside of normal business hours, on a Saturday afternoon. I pulled into the parking lot of the building and was met immediately by a flannel-clad fellow standing beside his red pickup truck. In one hand he held a cigarette, in the other the reins to two adorable chihuahuas. Before I entered the building, I stopped to pet the shivering dogs and struck up a light conversation with the guy.
It turns out he’s trying to get them to gobble their medicine out of the bowls set on the pavement. I share that I’m having the same problem with a cat of ours. I say goodbye and run up the stairs into the building, where I'm forced to wait in a common area until my appointment begins.
In one corner of the foyer sits a professional-looking woman — clipboard in hand, briefcase at her side — steadily and calmly posing questions to a woman in her 50s who looks a bit bewildered. As soon as I hear a question or two about "orientation to time and place," my hair stands up, and I recognize what I'm witnessing.
Could this be the legendary Minnesota Cognitive Acuity Screen, reported to accurately identify cognitive functioning in over 98 percent of cases? Surely no one expected to be disturbed in this little-used lobby on a Saturday afternoon. Quiet as a page-turn, I slip into a chair as far away as I can, embarrassed to be there, but fascinated just the same. For obvious reasons, insurance carriers are loathe to reveal the exact content of the tests to producers, for fear we will coach our applicants.
As I sat there in total silence, I wanted so badly to text someone or take notes. Instead, I had to commit to memory everything I heard and wait nearly 90 minutes until I could drive to my office and transcribe my mental notes — irony if there ever was.
As the test unfolded without break, the interviewer was kind and gentle, but also uncompromising and unreadable. It was agonizing enough watching this woman do poorly on the test, but the real kicker came when her husband showed up halfway through the test and sat down next to her — the chihuaha guy from the parking lot.
The nurse reminds him he can’t help her, but he’s fidgeting with his hat to keep his mouth shut. So he tells her to relax, take her time and she keeps turning to him to make half-jokes/half-excuses. Back at my office, here's what I wrote down before I forgot:
- Who is the current president? Do you know who the president was before him?
- How many seconds are there in a minute? How many weeks are in a year? (Her answer: "21") Do you know how many days are in a year? (Her answer: "300 something")
- What day comes after Monday?
- What did you do last Friday?
- Name three animals with tails (Her answer: "dog, cat, rat")
- Can you tell me what borders Washington State? (Her answer: "Oregon, Idaho... I give up.")
- Can you tell me why some people would say having friends is a good thing to have? (Her answer: "They’re not, they stab you in the back.")
- If you were lost in the forest in the daytime, what would you do? (Her answer: "I’d follow the creek or river downstream.")
- If you were lost in a crowded mall, what would you do? (Her answer: "I’d be scared.")
- I’m going to list eight words. When I’m done, I’d like you to repeat as many as you can remember: hippopotamus, frog, bicycle, brush, camel, toothpaste, lightbulb, fork. (Her answer: "hippo, frog...hippo, frog...that’s all, I give up.")
- [later] I’m going to list three words, and then in five minutes, I’m going to ask you to remember these three words and repeat them, all right? The three words are: apple, dog, baseball. [The interviewer then asked about three intervening questions, by no means was it five minutes, maybe two or three at most, and asked for the three words.] (Her answer: "apple, dog.")
- Can you tell me why it costs more to live in the city than out in the country? (Her answer: "Because of the taxes to pay for schools and police and firefighters.")
- Do you recall how many other people were in this waiting room when we began?
- Do you remember my name?
- Can you name five major cities in the United States? (Her answer: "You mean like Seattle?" “Yes.” "Seattle, San Francisco, Oklahoma City ... that’s all.")
- What’s 35 + 47? (Answer: "I’d need a calculator!")
- All right, what’s 6 x 8? (Answer: "40?")
- Can you tell me 20 divided by 5? (Her answer: "I was never very good at math.")
I also think there were some morality-based questions ("Can you tell me why we shouldn't shoplift?").
The title of this piece ("Ignorance is Bliss") does not refer to Mrs. Jane Doe, whom I witnessed. It speaks to the tragedy of cognitive impairment in general; this scourge that we hope to insure against, but only if we're fortunate enough that people reach us in time.
If not, then to be that fly on the wall — as I was — is to be a witness of a slow-motion car crash. Having attended a seminar on Alzheimer's and other dementias held by one of our carriers, I like to think that Mrs. Jane Doe was fortunate enough to ultimately be diagnosed with the 20 percent to 40 percent of other dementia syndromes with rare names but better prospects.
In the meantime, knowing that the incidence of Alzheimer's disease doubles every five years after age 65, let's do everything we can as LTCI professionals to make sure America is insured before tragedy strikes.