Who is the president?

During the course of cognitive decline patients will tend to maintain their interpersonal functioning until the very end; it's famously said of dementia that the social graces are the last to go. In fact, it's surprising how often a patient will be able to converse fluently and pleasantly, but when asked directly is entirely unable to say what the month or even the year is.

Of course, to provide appropriate treatment it's important to accurately assess the extent of cognitive deficits. A question traditionally asked by psychiatrists and neurologists as a quick bedside test of the patient's awareness of current events is "who is the president?" If you can't answer that, it's a pretty good sign that you're not well engaged, for one reason or another.

However, this question has become more and more difficult to use over the past few years. Asking it would often provoke strong but non-medical opinions. This was particularly true during rotations at Veteran Administration hospitals; vets would frequently become quite agitated at the topic. I remember that early in my training, say in 2004, this was a routine question during neuro and psych histories, whereas now I hear it used infrequently and rarely ask it myself.

However, from time to time doctors fall into the old habit. The question slips out, and there's a moment when the rounding team holds its collective breath: are we going to have to take several minutes out of a rushed rounding schedule to head off a patient's (or clinician's) political polemic? But that seems to have changed this month. Evidently the election made quite an impression on a wide range of people. Several times I've seen patients who were minimally conversant, but when the recent election is mentioned will become more alert and are able to recall names and details.

Maybe I'll start asking my patients a question that seems to be both diagnostic and therapeutic: "who is the president-elect?"