I’m a practicing psychiatrist who spends about 50% of my clinical time doing inpatient geriatric psychiatry(which is mostly dementia with behavioral disturbances), so these are a few points I’ve been frustrating by:
1) Whenever a family member brings us a patient who is having some trouble with their memory or executive functioning, depending on their age and the circumstances we may initially ask ourselves “is this an organic or reversible cause”? That means doing things like ruling out prominent vitamin deficiencies(vitamin B1, B12, or folate), ruling out infectious processes, ruling our metabolic/electrolyte derangement, ruling out substance abuse/intoxication or withdrawl is the culprit, ruling out brain tumors, and a few other things. Some of these are very easy to rule out without any testing; some require labs or imaging. But again it depends on the context and situation. If I see a 94 yo woman whose family states over the last 5 years she’s slowly become more and more forgetful and her executive functioning has gradually declined and she’s clearly not in a state of delirium, I’m not going to do a big organic workup generally because it seems pretty obvious what’s going on. However in a 57 yo woman where the symptoms came on less gradually, sure….that merits a much more intensive organic workup.
The media is not making the above distinctions and really explaining the concept of “ruling out organic pathology” well. This part is generally done by a physician- typically a neurologist, sometimes an internist. If patients happen to see me first instead of their pcp or a neurologist I’ll start this workup as well when appropriate.
2) Once organic/reversible causes have been ruled out, it’s typically not a physician who does ‘the testing’. We keep hearing the media throw out terms like ‘cognitive testing’. What they are likely referring to is ‘neuropsych testing’. And this is generally done by a psychologist who specializes in this(sometimes a neuropsychologist). Generally a psychiatrist like myself or a neurologist would refer a patient to a psychologist for this neuropsych testing.
Also the term ‘neurological testing’ has been thrown around some by the media.(but they never use the term neuropsych testing which i feel is more appropriate here) ‘neurological testing’ could refer to parts of the organic workup I describe above I guess; or it could refer to aspects of the neuropsych testing done by a psychologist. But it’s ‘neuropsych testing’, done by a psychologist and not a physician, is what Biden really needs to be referred to after the organic workup is done.
The media is botching all these terms. And even Dr Gupta(and I agree with 95% of his remarks today as they pretty much echo what I’ve been saying all along) didn’t do a very good job of explaining these things.
3) Finally, Biden and the biden team are intentionally blurring the issues. 90% of the concern being expressed does not deal with him being easily fatigued, or being weaker, or not being able to run as fast(he actually referenced this today). Or even his gait(although a parkisonian gait may be telling related to the cognitive issues). Instead most of the concern deals with his global cognitive functioning(memory, processing information, forming thoughts, etc). By continuing to reference these other things, they are attempting to sidestep the main concern.
And biden and the media are focusing on when he last saw his doctor(presumably his internist?) in genera. While his pcp or an internist could do the organic cause workup like I described above(again this is done to rule out reversible/organic causes of cognitive problems, and if negative you move on to neuropsych testing), in general pcps/internists don’t spend a lot of time on annual physicals or maintenance appts focusing on the neuropsychiatric aspect of things. They may ask a few basic screening questions involving orientation(or maybe even asking a patient to do serial 7’s or spell a word backwards or whatever), this is generally not the focus of these appts.
Here biden and the media both are really sidestepping the primary issue. I think the media is partly doing it because they don’t understand the order of the workup, don’t understand the terminology, and don’t understand the process.
tldr version: It’s fine for biden to see a physician to initially rule out organic causes(although based on the chronicity and Biden’s age and clinical appearance that seems like more of a formality), but really what he needs to address all these concerns is neuropsych testing. Which is generally done by not a physician but a psychologist/neuropsychologist.
I hope this was helpful, from a workup or terminology perspective, to anyone who has followed the story and reporting. Note that I’m also not taking a strong opinion on whether Biden is ‘fit to serve here’, but like Dr Gupta I do believe he should undergo neuropsych testing so some of these concerns can be answered.