First: Cognitive Interview

My greatest fear in the whole aging process is not what I will look like, or even that whole incontinence thing, it is, to put it simply: losing my mind. No, I do not mean the "going crazy" kind of losing my mind, I mean, forget who I am, or who my family members are, and lose my mind in a technical sense. I will never forget that scene in The Notebook where Allie's moment of clarity is broken and she starts screaming for help while she is dancing with her husband, Duke. She is completely lost and you can't help but break for Duke and cry with him when he begins to cry. Because of this fear, I have done a pretty stellar job at avoiding all contact with the D word. Well, that was the case, until as a part of our clinical training we had to do student interviews at a nursing home with patients.

In a group of 3, we interviewed two females, one-by-one. This interview, however, was not the history taking we had practiced for months with the typical "history of present illness" and "past medical history". Instead, this interview, given to us on a sheet to read off of in front of the patient, included tasks and was much more than simply having a patient talk about his/her medical condition. The first item on the list was to have the patient answer some pretty relevant directed questions like "how long had they been in the nursing home?", "why were they there?", "what did they do during the day?", "did they need any help in their daily functioning (like dressing and eating)?" and "did they have any relatives that come to visit and if so, who?". The most important question to ask, however, was "how many years of schooling did they have", as the answer to this question is considered critical in determining a patient's level of dementia (This makes sense as a demented rocket scientist might find these questions insanely easy, even in his/her demented state). Both women that we interviewed did a pretty good job with these questions, though it was obvious that our second patient had much more difficulty forming words and speaking. In addition, our second patient kept referring to a car accident that happened in the past, but as she spoke, she kept changing the timing of the event in her head. At first, it came right before she went to the nursing home, and after, it came early in her life so she did not go to a lot of school, and even still, it came later on to prevent her from doing a job. It was clear that this was a key event in her life, it was just unclear when it occurred. 

Following this brief question and answer session, the next student asked the patient some of the questions we had learned to ask before, like "what day of the week was it" "what year", and "what state were we in". The answers to these questions were no trouble for either patient. Then, the student had the patients remember a list of objects (and asked them to repeat them about 5 minutes later), only this time, they had to remember a list of 5, not 3, words. This made three (and my inability to ever remember that damned third word) seem like child's play. Both women insisited that they had bad memories and would remember none of the words, but they actually both did really well considering what they had prepared me for. The first patient remembered 4 out of 5 words and the second remembered 3 out of 5, only really failing because she combined the words pen and tie to make the word pie (A logical jump if you ask me). The last question asked by this student was a math problem. The student read out loud: "You have 100$ and you go to a store and buy a dozen apples for $3 and a tricycle for $20. How much did you spend? How much money do you have left". First of all, I need a pen and paper to do math as evidenced by my abilities to do pulse rate calculations on the spot (or lack thereof) and to me (and even my classmates too), the subtraction for how much left, was not that easy. Secondly, using number words like a dozen apples and tricycle, I feel confuses the point of the exercise and just adds excess irrelevant numbers to the problem. Sure, I did not design the question so I am no expert, but to me, it is no wonder both women missed it. The most interesting part of this exercise was that while the second patient said the wrong number for how much she spent, she explained to my friend (when prompted) that the apples cost 7 dollars and the tricycle cost 20, so she spent 27 dollars. Even if she was not using the right numbers for the math, she sure did a great job convincing herself that she was right.

The next student had the task of doing the part of the interview that we had never done before. First, the patient was asked to name as many animals as she could in one minute. This task, upon discussion afterword, brought some laughter amongst our classmates at the animals people came up with, or chose to be stuck on and repeat over and over again (like an armadillo, for instance). During this task, it was not uncommon for the patient to try to distract you with conversation as an attempt to try and distract you from realizing that they had actually stopped naming animals. One of my patients did just that and went on and on about the animals she chose being the animals she had growing up and the animals she liked, etc, all the while in the end, she only named about 5 animals when the norm is 15. During this task, my classmate felt bad for the patient and tried to coax her into remembering some names with comments like "what about animals that are on a farm"?. Though he later got reprimanded by our clinical tutor for "helping them", they were such sweet old ladies and it was really hard to just sit there and watch them forget. It was even harder when they know that they were wrong, or that they were messing up, and then they worry that something is wrong with them. If I wasn't playing by the book, I would have done exactly what he did.

Next, another student gave the patient a list of numbers and the patient had to repeat them backwards, like if it was 5-7, she would have to say 7-5. The second patient was the only one who had trouble with this task, and this trouble only came in the longest list, or the one of 4 numbers. Then, the patients were asked to draw and label a clock and then were told to draw the clock at 1:45 (though most often patients are told to draw 10 minutes after 11). This was one of the most interesting tasks to watch as the first woman drew the clock normally, but she had difficulty with what 45 meant, and the second woman drew all the numbers on one side of the clock (in reverse order), repeating the number 5 and almost repeating the number 3. In addition, she did not even attempt to draw 1:45. (well, OK she started to draw the hand on the 1, and perhaps because it was so far off from where a normal clock would have a 1, she got even more confused, and stopped). While we had seen some of this stuff in our neuro class (images of clocks from hemi neglect, for example), to see it in person was....fascinating, to say the least:

The women were then asked to pick out the triangle from a group of images of a circle, a triangle, and a square. Interestingly, both women missed this. This miss was most surprising for the first woman, as she had been performing virtually normal all along and this seemed like a very odd thing for her to...just now...miss. They did both know which of the objects of all the objects was the biggest, however.

Finally, for their last task, the women were read a story and then asked questions about the story later. The story was as follows:

Jill was a very successful stockbroker. She made a lot of money on the stock market. Then she met Jack, a devastatingly handsome man. She married him and had three children. They live in Chicago. She then quick her job and stayed at home to bring up the children. When they were teenagers, she went back to her job. She and Jack lived happily ever after. 

My first reaction: Jack and Jill...really? Did one go up a hill and the other come tumbling after?

My second: Devastatingly handsome...prove it.

But, it did not matter what the story content was or my reaction to it. Instead, it mattered if the patients remembered the female's name, what her job was, when she went back to her job, and what state she lived in. The last question, in my opinion, was a tricky one, as the story told about Chicago and NOT Illinois (hint: Chicago is not a state ;)). With the story, Patient 1 comprehended well and got all of the questions right, but Patient 2, missed all but 1 question. After this part of the interview was over, we tallied up their scores. A range of scores meant the patient was normal, another meant the patient had mild cognitive impairment, and the last meant the patient was demented. The ranges vary with education, as mentioned before. It was clear from our scoring that our second patient was demented, while our first, had MCI and might just be on her way (or have old age related memory issues). What is sad is this entire interview and diagnosis set is not used to necessarily help treat the patient. Instead, its main purpose is really to just understand how much help a person needs, especially with things like taking medication and common tasks like brushing their teeth. Although I wish there was a better outlook for these patients, I guess its better to have the right help when you need it

At the end of the day, you might be wondering if I left less worried about dementia. Well, the answer is No. I did not. But luckily, thanks to my day at the nursing home I now know what they are going to ask me when the time is right....and perhaps... I will get to studying.