Thursday, October 14, 2004

A puzzle in a Senate race

Mary Jacoby at Salon reports on perplexing behavior of a Kentucky senator who's running for re-election. The 72-year old senator has long been considered a shoo-in. But apparently, since February of this year, there are concerns:

"Oct. 12, 2004 - It's no secret in Kentucky that Sen. Jim Bunning, a Republican who was expected to coast to reelection on Nov. 2, has been acting strange. Over the past few months, Bunning has angrily pushed away reporters, exchanged testy words with a questioner at a Rotary Club and stuck to brief, heavily scripted remarks at campaign events, delivered in a halting monotone. The former major league baseball star now travels the Bluegrass State with a special police escort, at taxpayer expense. His explanation? Al-Qaida may be out to get him.

"More substantively, the incumbent would agree to only one debate with his Democratic challenger, state Sen. Daniel Mongiardo. And the rules Bunning negotiated were bizarrely rigid: The encounter could not be live; the taping has to occur in the afternoon, not the evening; no audience could be present in the studio; and, under threat of legal action, Mongiardo could not use any sound clips or video of Bunning's debate performance in campaign advertisements.

"This apparent fear of the spontaneous has spurred rumors in Kentucky that Bunning, a member of the Baseball Hall of Fame, is suffering from some sort of dementia, perhaps Alzheimer's..." Ms. Jacoby goes on to describe further examples of troubling behavior.

I often see families who are trying to understand and cope with an older relative's behavior. I like challenges like this. Is there a significant change in the mental state of the patient? If so, why? The first step is always a detailed history, with a timeline. What was the previous level of memory, cognition, and functioning? Exactly how has it changed over time? (And how reliable are the informants?) It's like detective work. Then, a careful exploration of medical problems that can affect cognition in older adults. (I can't tell you how many older people become disoriented and delirious because of an infection, or some other medical condition.)

Then, a review of medications, including over-the-counter meds. So many are known to interact, and so many are known to affect cognition. Are they taking meds as prescribed? (Common scenario: an infection causes disorientation; then, the confused person gets their meds mixed up, or entirely forgets to take them. The confusion then worsens, sometimes dramatically.) And how much alcohol is on board? Has alcohol use stopped suddenly, causing withdrawal symptoms? We also check for mood disorders and other psychiatric conditions. Depression, anxiety, bipolar disorder - all can affect thinking and behavior.

And while exploring all this, I'm also considering the dreaded question: could it be dementia? Many families bring their elderly relatives to my office with that question. I have to be so patient, and so careful, when probing for this diagnosis. How frightening and painful for some, to hear a doctor ask, "Can you tell me the date?" - knowing the potential consequences of a wrong answer. It can be excruciating.

I can't speculate about anyone's condition, based on news reports and editorials. I hope that anyone who's showing signs of a troubling "mental status change" is talking to their doctor. These conditions tend to not improve with time. With the aging of the boomers, these issues will arise more frequently, and not just in political campaigns. But can voters demand that a senator (or any public official) reveal medical records, or undergo an evaluation and demonstrate competency? I'll be interested to see how events unfold in Kentucky.

Afterthought: "these conditions tend to not improve with time" alone. If it's delirium, and you find and treat the cause, things can get better. If it's dementia, there are things that can slow the decline. But "wait and see," without any intervention, tends to lead to more deterioration.
Sometimes people wait until there's a crisis. Then our phones really start to ring.
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