MCI or CRS, why the name of a decline of memory matters.

April 2013- References to Wellness Exam etc at end.

MCI is the latest medical diagnosis that had previously been called early stage Alzheimers, which was at one time called Senile Dementia.  The Initials stand for Mild Cognitive Impairment--I'll leave the interpretation of CRS for later.  There is a little known clause in the massive Affordable Care Act- or ACA, informally known as Obamacare  that will increase this diagnosis among the elderly- with unexamined adverse effects.

This change in our acceptance of medicaliazation of old age so far has gone unnoticed, as it is packaged in the form of more vibrant longer life, and better yet, that it will come at no cost at all, rather paid for by future efficiencies.  This is illustrated in memory decline, to some degree a universal that is as ubiquitous as diminution of  balance, height and strength.  It is something that societies have dealt with from the beginning of civilization, which always includes acceptance of of all aspects of aging-- ending with death.

This paper by the Alzheimers Association describes this requirement and their recommendations for the testing.  It included this paragraph that leads to the problem I explore:

These comments are supported by a number of studies showing that cognitive impairment is unrecognized in 27%–81% of affected patients in primary care.  

Now think about this for a second.  The ACA does not say that physicians may include assessment for cognitive impairment, but that they must if you choose to have the Annual Wellness Visit.   The political-cultural aspect of this is illustrated by the contrast with another part of this session.  The cognitive assessment is required, while discussion of end of life planing, because of the objections from the right, is optional.

Note in the paragraph above that the range of those who do not recognize such impairment is as high as 81%.  What this shows is there will be a large number of elderly people who are going about their lives, maybe even laughing about their memory decline, who will be told that this condition is nothing to joke about, rather a disease that must be monitored by physicians. (So severe according to a recent N.Y. Times article that there is a one in eight change of it becoming full Alzheimers within a single year)  One way of we oldsters dealing with this is making a parody out of this "medical condition"  describing it by the alternative name in my title, CRS which we laughingly say means, "Can't Remember Shit!"

When I first discovered this aspect of the Annual Wellness Visit I wrote this essay, that was both a personal reaction and a broader description of the fiscal consequences of this mandate and other aspects of the ACA.  It is important to clarify that my objection is not to gathering data about memory decline, which is a severe problem for the individual and for society, but rather that the procedure mandating this during the Medicare Annual Wellness Visit ignores principles of informed consent and damages the doctor patient relationship, most important to people worried over memory loss.

In the essay linked above I describe my experience with an Alzheimers research project at UCSD, where one of my criticisms is that they do not collect and analyze all of the data  from everyone who goes through their screening procedure. The key difference, one that is far from trivial, is that everyone, including myself, who availed himself of their mental tests made a personal decision to do so with full knowledge that they could get feedback that would be disturbing.  Let me be clear, those who volunteer for research on dementia have my admiration, along with those medical scientists who work in this area.

There is another important point that may have been obfuscated in my previous essay, which is there certainly are neurological diseases that cause severe memory loss.  While there is presently no cure, or even treatment to forestall the severe stages of the most common of these diseases, it is certainly feasible that such could be discovered.   I highlight normal decline of memory of aging, (the tail of the bell curve of this process being similar to the disease)  because there is a dearth of those who make this point, --who defend existing coping mechanisms that preserve well being of those elderly who choose it.  For those in the early stages of one of the degenerative irreversible neurological conditions, this could be only a temporary amelioration of the emotional effects of the disease, but this coping mechanism of trivialization or denial should be an option left open to the individual, rather than negated by government policy.

Let me be clear, there are doctors who form relationships with their patients where this cognitive assessment is just a part of what one physician described as the "art and science of medical care."  Advisor, confident, conduit to treatment to preserve life and health---this is the ideal relationship that does not need this law to perpetuate.  And the rare abrupt anomalous decline of cognition should certainly be referred for immediate follow up, as this overshadows the potential harm of this mandate for the vast majority of those with degenerative or normal decline of memory.

My position should not be confused with an earlier medical paternalism, where doctors withheld the truth about the severity of a patient's prognosis.  What I describe could be just as inexcusable, the physician imposing his/her diagnosis without the patient knowing that a condition is being evaluated. This simplistic one sentence mandate for an evolving, unreliable cognitive assessment with potential devastating emotional consequences must not be allowed to stand.

If the decision of public policy is to do otherwise, it should be only after open discussion, rather than remain unknown to the patient as is the current case of this mandated evaluation in the Medicare Annual Wellness Visit.
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References:

This MCI assessment is discussed in this article in The Journal of Family Practice,  Assessing for cognitive impairment is now mandated as part of the Medicare Annual Wellness Visit.   Finding this requirement in the actual text of the law is difficult but it can be located beginning on pp 1154 of the text.  that states,  "The Affordable Care Act stipulates that clinicians must assess individuals aged 65 and older for cognitive impairment as part of their annual wellness visit ."
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This was expanded for the article, Normal Aging or Disease-the Demarcation Fades in Sept. Oct. 2013 issue of The Humanist 
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This link is to required elements of the visit from the Medicare Service Bureau booklet:

Pg. 7. (pdf pagination adds 2)

Detection of any cognitive impairment that the beneficiary may have (includes the
assessment of a beneficiary’s cognitive function by direct observation, with due consideration of information obtained by way of patient reports or concerns raised by family members, friends, caretakers, or others);

In addition to the physician, this evaluation may be performed by:
Pg 3

A physician assistant, nurse practitioner, or clinical nurse specialist; or a medical professional (including a health educator, a registered dietitian or nutrition professional, or other licensed practitioner) or a team of such medical professionals, working under the direct supervision of a physician.

Pg 8
Medical records must document that a health professional provided, or provided and referred, all required elements of the AWV. You should use appropriate screening tools normally used in a routine physician’s practice.
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This short video produced by Medicare, explains the Annual Wellness Visit, with no mention of the cognitive evaluation that is done.
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A long personal story that relates tangentially to this essay
My Alzheimer's Screening, personal narrative and technical discussion
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This post mortem  study illustrates how MCI is in the center of continuum of normals and Alzheimers disease.  This is evidence that the three categories are billing codes rather than discrete medical conditions.

Persons with mild cognitive impairment were intermediate in terms of Braak stage and CERAD and NIA-Reagan neuropathologic criteria for AD compared to the other two groups. In multiple regression analyses, persons with mild cognitive impairment had intermediate levels of AD pathology from those without cognitive impairment and those with dementia 
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Mild cognitive impairment: historical development and summary of research

Is an extensive survey that ends with this:

Although clearly valuable as a research tool, it may be debated whether physicians in clinical practice should consider a diagnosis of MCI for individual patients. Because MCI is a heterogeneous entity comprising a variety of neuropathological and psychiatric disorders, and because dementia is not an inevitable outcome, the term may carry too little prognostic and diagnostic weight to legitimize its widespread use on a case-by-case basis. Furthermore, the lack of universally agreed upon criteria and the public's unfamiliarity with the concept could result in increasing uncertainty, anxiety, and misunderstanding

It goes on to suggest that the clinician rather give the relative prognosis based on the subsets of the MCI condition.  From reading this long survey with over a 150 references, the probability that a general practitioner, much less a para- professional,  has mastered the current state of this research is minimal.
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Report on frequency, mandated tests, and payment of annual wellness exam.
Elements of AWV:

Patient's medical history
Family history
List of patient's current physicians and other health care professionals
Height
Weight
Body mass index (or waist circumference)
Blood pressure
Other appropriate measurements based on medical history
Cognitive impairment screening
Depression screening
Functional ability and level of safety screening
Five- to 10-year schedule for preventive tests, immunizations and screenings
Lists of risk factors, including mental health or other previously identified mood disorders
Health education and referrals for preventive counseling services
Health education and referrals for promoting wellness (e.g. weight loss, physical activity, smoking cessation, fall prevention and nutrition)

Donny Trump, Come Home All is Forgiven

August 19, 2016

Last week, as part of the Donald Trump pivot, his  new Campaign Manager, Kellyanne Conway, was interviewed by Chris Mathews introducing the “New kind and gentle” candidate, previously made famous by leading a mob of acolytes that he boasted, without rebuttal,  would support him if he killed an innocent stranger on a busy street.
 
He is right, as leaders of street gangs or organized crime gain power by ruthlessness that is never met with objections, but rather increased fealty to the leader, be it of a gangster mob or a national dictator.   Trump won the Republican nomination with this persona, but realized last week that he not could win the national election where his “gang members” do not constitute a majority.  

Since his gang has nowhere else to go,  this consummate performer is taking on a different role, a new persona, one that could grab just enough of those in the middle for him to gain the presidency.  His new part is the contrite little boy, who ran away from home and was very very bad, but really loves his mommy and daddy and even his little brother who stutters that he made fun of. He’s a full blooded spoof of Bart Simpson, as he tried to hold in his tears of embarrassment for being so bad, and convey it with a wan smile.

It only took a few words delivered from a teleprompter (as the lines had to spoken exactly as written)  at a campaign event Thursday night in Charlotte, N.C.:  His message was:  “I meant well, but you know me I sometimes lose control, but now I won’t be like that any more if you just take me back in,” 

"Sometimes, in the heat of debate and speaking on a multitude of issues, you don't choose the right words or you say the wrong thing, I have done that, and I regret it, particularly where it may have caused personal pain. Too much is at stake for us to be consumed with these issues."

Those with pets understand this; that even when the pooch got away and bit a kid, or mauled another dog, we still love the little rascal.  Or our son who got into a fight, and he really shouldn’t have started it and then lie,  saying it was the other guy, but now he really feels bad, so I will give him a big hug.

This is human nature, and the  new Trump machine knows this.  He has picked the time to reach out to those people who believe in redemption, oppose capital punishment, and want those who committed felonies to be rehabilitated and have every chance to be accepted by society….  those who ascribe to an ethos of redemption, even for those who have done great harm to many people.
Now back to another front on this full thrust of transformation of Donald J. Trump. It started during a Town Hall moderated by Chris Mathews who lives with the contradiction of belonging to a religion that considers abortion a mortal sin, while personally being in favor of it.  During this event last May Chris asked the question (full transcript) , “what about the mother, should she be punished?”   Trump, as he has never really thought through any of the defining issues of the political divide tried to cover this lack of exploring the issue with this dialogue:

MATTHEWS: Do you believe in punishment for abortion, yes or no as a principle?

TRUMP: The answer is that there has to be some form of punishment. 

MATTHEWS: For the woman. 

TRUMP: Yeah, there has to be some form.

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This was an example of Trump thinking on his feet, and his not incorporating the absurdities of distortion of logic that is part of what political discourse. has become.  Shortly after this he tried to “walk it back" (a strange locution as if one’s statement could be unsaid.)  Trump’s initial statement was rational, meaning that abortion by definition means the act of a woman destroying her own fetus.  Abortion may or may not require the participation of another person, who may be a licensed physician or someone with a coat hanger and an Oxycontin pill to ease the pain. 

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Trump didn’t know the Republican party line, which was articulated by his new campaign manager to Mathews this week,  which is a statement about “political speech” which sacrifices logic and facts to the prime motivation of influencing voters.  Specifically, it demonstrates what the conservative “pro-life” position means for the definition of “woman” 

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If abortion is murder, which is what the pro-life position states, then it would follow that the essential person to commit this homicide is the one who controls the victim, otherwise known as the fetus or unborn human being.  The  person could be a brute who takes a crowbar to the mothers belly and as such, the woman is one of the two victims of a crime. 

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 This is the logic that underlies the situation in the U.K.  In England and Wales, where abortion is legal, (Pro-choice) a women is not penalized.  Where it is illegal, (Pro-Life) in Northern Ireland, a women faces severe punishment.  This is where the right and left differ dramatically, and why Trump was initially confused, and was  expressing his genuine conclusions of one who embraced the “pro-life” position, but for instrumental purposes only.  As such he did not understand the ideological and incongruous fiction, which is that medical doctors who follow a mothers autonomous decision to destroy her fetus are the instigators of murder similar to the man with a crowbar who assaults a mother. 

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This is what Campaign Manager, Kellyanne Conway articulated yesterday when she said that a mother who hires an abortionist is a "victim” and does not deserve any punishment.  Of course in any situation other than abortion, a person who hires another to kill someone is, as Trump initially said, committed a crime. 

The orthodox “pro-life" position would have been perfectly appropriate a century ago when women could not vote, had limited right to contract and could only be employed in positions that were closely supervised by their natural superiors, men.  It was then part of our culture that women, like children would not be responsible if they did wrong in collaboration with those of higher status. 

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Once buzz words have become ubiquitous and fraught with emotion,  the principles underlying them are never brought to light, and so the right to destroy one’s fetus becomes transformed into “Pro choice” and the antithesis of being “Pro-life.”  Donald Trump, when he said women should be punished, had not internalized the twist in assumptions of this position to make it politically acceptable, which is why he had been opposed to it most of his life.  Now, his natural desire to “be a winner" has transcended whatever humanity he may have possessed,  so it’s woman as infant that he must now endorse.  

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Donald Trump has ripped off his gangster-thug mask, to attempt to come home to the warmth of acceptance of those who will forgive the “prodigal son.”  It’s the role of a lifetime is to be deeply sorry for having offended anyone, of being a bully for so long.  We don't know how the script will play out.  The next scene could be he would reveal that when he was a child he never had the benefit of loving parents who would have  helped him be a more decent guy.  

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I have to admit that Donald Trump is one hell of a performer, whether that’s a qualification for President is another question.

Presidential Election 2016 - Beyond Partisanism

First an Introduction to the Doomsday Clock where the scope is the destruction of the planet Earth, not the solar system or galaxy or any of the individual units such as continents or countries.  The concept, defining risk and then using the closeness to midnight as the analogue to such a catastrophe works for other complex systems, as small as a species being made extinct and as large as the universe itself.  

The clock was introduced in 1947 by a group of atomic scientists  when the danger of a thermonuclear exchange would have ended civilization as we know it, and since 2007 has reflected global climate change as a separate but additive risk.  Of course, the accuracy of the clock is beyond objective evaluation, as it’s main value is heuristic,  using this known image of a minute hand approaching midnight to convey a world at risk. 

Let’s see if this works for a country, specifically our own, which has had the major influence on our world over the last century — and also is where most readers of this happen to live. The “end of the world” has its national analogue in what is called “a failed state” usually meaning a lack of effective central government with the unleashing of bestial internecine hobbesian conditions of war of all against all.  

Even after generations of children being indoctrinated by reciting a pledge to “…..a nation indivisible”  this country is held together by the most fragile of bonds,  with greater centrifugal forces than most others.   We were founded by those whose greatest aversion was to a strong central authority, so much so that they provided in their charter a prohibition against the federal government disarming the people.  This charter also protected what was to be the seed of it’s own dissolution, the enshrinement and protection of the institution of Chattel Slavery, treating other humans as property, as mules rather than fellow human beings.  Rather than a nation indivisible, our constitution until the end of the Civil War was a loose agreement by sovereign states who like England this year could have left the Union at will.

The presidential election of 2016 while taking place in a milieu of a high stakes reality show with the country focused on each daily episode of the star performer follows a pattern, first an outrageous statement, then the analysis, then often his reinterpretation of the meaning of what he said.  After at most a hiatus of a few days, this is repeated, along with televised analysis of probabilities and strategies for winning the requisite number of electoral votes for the star performer to become President. 

While the country is focused on this election drama, the national doomsday clock is getting closer to midnight by forces that are ignored since they are reduced to components, demographics of one party or the other, to be analyzed endlessly as if this were a sporting event.  Unlike the Civil War where the one demographic was the elite of the Southern States and the central issue was slavery, at this time there are multiple groups that are on the verge of armed conflict.  What makes this moment in time unique is the individual who has gained the nomination of one of the two major parties of the country, and as such has provided a nucleus for the various forces of discontent to unite.  What is also unique is this individual and his coalition have various degrees of animosity to not only the federal government, but the laws and norms that have allowed it to exist and evolve since the end of the Civil War.  

The very name of this candidate evokes such strong emotions of affiliation or contempt that the individual obfuscates the historic meaning of this election --whether or not he wins.  One key is a statement he proudly made on television,  “I Could Stand In the Middle Of Fifth Avenue And Shoot Somebody And I Wouldn't Lose Any Voters.”  Never in this country’s history has a candidate for any major office made such a boast, and more importantly, that it would it be seen as accurate by his supporters.

The perception that this is a variation of previous presidential elections, rather than something quite different is an illusion.  This election is the first stage of the formation of coalitions, more variegated than our Civil War, but with the potential of unleashing internecine divisiveness, that with an armed population could take an unprecedented violent course.  This takes us back to the value of a national Doomsday Clock, just as the world’s version may have alerted us to danger, so to,  one for our country could have the same salubrious effect.   Let’s dispel the idea that we are blessed by God and accept we are only the product of human effort and inspiration and the desire to make our country function, and in doing so advance humanity as much as possible.

As for politic, as a process of dispute resolution it certainly beats escalation, with the danger of the long horrors of revolution.  In any conflict one can choose to sharpen issues or to obfuscate them, to ignore stresses with the hope that they will quietly resolve themselves, with the help of incremental laws that will eventually become social norms or bring the underlying stress to a head.  It could be useful to look at the two candidates as representing these two extremes, which would at least provide a language for discussion.

A parliamentary system of government would allow for this,  as the various groups who want change can, and must, articulate their positions to vie for votes.  While this election is nominally between the traditional two parties, it is really two coalition governments vying to gain power.  The Republican candidate is seen as incoherent as the attempt to reach all the desperate groups requires he presents as a single voice which in a parliamentary system would be articulated by the leaders of various parties in the coalition who are opposed to each the other.  What makes this candidate rare, perhaps unique, is that he has risen to this high candidacy in a realm without the need for political skills or adherence to their norms.  I use the word “political” in the largest sense, which would include those who rise in a corporate business structure, or academia or even to military leadership, where building coalitions is a necessity.

This candidate does have the ability to create his own reality, even his own language with the destruction of the meaning of powerful concept-words such as “founder” “Satire” and concepts such as “Second Amendment Solutions.”  Yet, for his followers this only demonstrates his strength,  his transcending the “mess” of our current civilization he echoes the spiritual, as in Mark 14:58  "We heard Jesus say, 'I will destroy this man-made temple, and in three days I will build another…….”

The Temple is the biblical representation of “The Establishment,” a coherent language and body of laws and norms that surround us.  It provides benefits to those who prosper and pain to those who feel imprisoned by it.  What makes this candidate so rare is that he has no coherent plan, nor does he believe in a spiritual being that will transform the world;  his persona being formed by  his actual father, not being God but a wealthy successful builder who allowed him to feel that he was gifted far beyond his own capacities.  

It would be useful to consider this election, this candidate,  dispassionately, ignoring the individual to look at the revolutionary nature of his proposals, that I will not articulate here.  Most are beyond the authority of the position being contested, but would have the effect of legitimizing them, or if he were to go down in defeat, of further diminishing them in political discourse.  We may be guided by Thomas Jefferson, who was among other achievements a scholar of political philosophy who is well known for this statement from the Monticello website ,  “I hold it that a little rebellion now and then is a good thing, and as necessary in the political world as storms in the physical.”  

The Presidential election of 2016 is a rebellion, whether a little one that he endorses or one that turns out to be the fuse for a big one that he warns agains will be determined by the unknowable nature of history-shaping forces.  Jefferson’s guidance was of a time when the primitive level of technology limited devastation of wars and damage to our planet,  so the concept of a Doomsday clock didn’t apply.  But now it does, for the world and every country, state or ethnicity.  Among the challenges are those of artificial intelligence eliminating the relationship between human effort and reward, which raises issues that we don’t even have the language to address.  But language is all we have, and while we must refine our terms, expand it for discussion of choices that have not had to be made previously, we must defend this tool of civilization from being degraded by the attachment of a partisan tag that arouses visceral emotion that replaces meaning.  

To only focus on the candidates, to root for ours and condemn the other, is a waste of what should be a time for reflection.  Simply demolishing the candidate we oppose is to admit defeat in what should be the ongoing effort to enrich the democratic process.  Our country and the world faces some harsh realities, and the suffering of those of our fellow human beings should not be ignored as we face new challenges.   

 

   

       

 

Trumps Ultimate Blasphemy of "Rigged Elections."

When Donald J. Trump made this comment yesterday, it was aimed at his largest demographic, those who need constant feeding of their inchoate contempt for this country. Trump is the man who persisted in asserting that President Obama was born in Kenya long after almost all considered it insane; but not all, not those who consume illusions of vast complex conspiracies because they are inherently un-falsifiable.  Certainly, Obama's mother could have inserted the birth announcement in the local Honolulu newspaper as part of the plan that he would run for president four decades later.  It is absurd, but not impossible, and those that buy into it have the satisfaction of being in on something that very few grasp.  Here are his words:     
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"I’m afraid the election is going to be rigged, to be honest," And later when asked about it said gave an example of a previous election where,   "you had precincts where there were practically nobody voting for the Republican."

He added, "I hope the Republicans get out there and watch very closely" during Election Day.
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This is the single most damaging example of Trumps propensity to find a nugget of truth and then send it out to the world.  This spontaneity in his utterances betrays his uncaring ignorance of the context or interpretation of what he is saying.  This man who has risen to be one of two people who will be elevated to the apex of national government authority, one who will swear to "preserve and protect" the nations laws -  from federal statutes to our Constitution as interpreted by the Supreme Court, chooses to cast doubt on the essence of choosing the individual to hold this awesome power.  "Rigged" is a word that for him means a conspiratorial illusion just like global warming, evolution and the birth place of the current President.

He closes with the suggestion that Republicans pay attention that there is no cheating, as if without his urging they would not think to do this.   What this reflects is his rarely or never having gone to a polling place to cast a vote. Each of the thousands of them are outposts of our secular ethos which inherently means that there will be members of both parties challenging the legitimacy of every single vote and following the elaborate laws of their state to prevent what he "is afraid will happen."

I know a bit about polling from my run for the nomination for N.Y. State Representative in 1993, when my name was on a printed sheet that could only be produced by one company where I had once worked. Each group of voting booths had a different list and they even randomized the order of names within them to negate top of the list advantage, meaning these had the worlds shortest press run, as low as a few copies due to non-overlapping districts and multiple levels of government.   It kept alive a typesetting technology from the nineteenth century called a Ludlow machine, soon to be made obsolete by large size computer graphic printers.  As a candidate I had the right to personally inspect each machine, and to inspect the mechanism, to verify that a pull of the lever went to the correct counter. For those who know the term "steampunk" this was the real thing, not much different than that of the original invention in 1881.

"Rigged" ----by whom?   Trump, as is his ingrained wont,  has not taken the effort to understand how the polls in the state of Ohio actually operate, what procedures have been implemented to ensure that each vote is counted, and that it is as accurate and uncorrupted as humanly possible.  He has not taken the time to learn of the severe penalties in Ohio, and every other state, for tampering with the results of a governmental election.  Why understand a body of laws, and the technology and procedures that accompany them, when in a second you can create out of thin air the myth that elections, the solemn rite of a democracy is something other than the effort to refine and protect the sacredness of a citizen's vote.

Suffrage, the right to vote, is something various groups have fought and died for; even though the process can never be perfect and there are stolen elections in spite of the ongoing effort to limit such criminal acts.  Trump's casual expression that he expects this to happen, without his doing a thing to understand the process in order to limit such vulnerability is what he is, which is why so many from both parties find him to be uniquely contemptible.