Ageism and Elections: Louise Aronson and Ken Covinsky

Eric 00:00

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And, Alex, who do we have with us today?

Alex 00:06

Today we’re delighted to welcome back Louise Aronson, geriatrician professor of medicine at UCSF in the division of Geriatrics, author of Elderhood. We’ve had her on multiple times. Louise, thank you so much for joining us today.

Louise 00:17

It’s a pleasure as always.

Alex 00:19

And we have Ken Covinsky, frequent host, frequent guest on this podcast, who is also in geriatrics at UCSF in the division of Geriatrics. Ken, welcome back to GeriPal.

Ken 00:28

Great to be here, Alex.

Eric 00:30

So this is a hot topic. We’re going to push this one out early. This is going to be about ageism and elections. We’ve got a lot to talk about here. But before we do, who has the song request for Alex?

Alex 00:43

I do.

Alex 00:48

Well, the issue was this was like kind of an emergency podcast. We’ve had multiple people over the last week come up to us and say, can you please do a podcast about ageism and elections? We want some clear eyed thinking about this. And yesterday quickly asked Louise Aronson and Ken Covinsky to join us. So given that time was short, I just proposed, for what it’s worth, by Buffalo Springfield, because it’s a good kind of like rallying cry, you know, it’s time for some disruption, call to arms, sort of song from the sixties. So here’s a little bit of it.

Alex 02:00

There’S battle.

Alex 02:02

(singing) “….everybody look what’s going down.”

Eric 02:30

What is going down?

Ken 02:33

Bravo.

Alex 02:34

That was excellent.

Eric 02:37

So we’re going to do things a little different. We actually opened up to Twitter or X or whatever you want to call it, to start us off with some of these questions about what’s going down right now with ageism and elections. Right now, I would say this has been a constant issue in elections where age comes up not infrequently. I think John McCain and Obama, and anybody remembers that there was a lot of discussion about Obama being too young and McCain being too old. I think McCain was 71. Now, how old is Trump? Have it down here somewhere. Trump is 78. Biden’s 81. It came up with Feinstein. She died in the Senate at age 90. So not new, but Alex, do you want to start us off with some of the Twitter questions?

Alex 03:30

Sure. Thank you to our listeners for sending in your questions. The first question is from Anand Ayer. How do we find balance between not being ageist but expressing legitimate concern? Louise, let’s go to you with this.

Louise 03:47

I think I might have a kind of different answer to many people on that one where I would argue that not expressing concern when it’s warranted could be a version of ageism. When you ignore the bad parts of things, you’re not telling the full story, you’re not giving voice. And we’ve certainly seen this with racism and other isms. So we need to discuss the full spectrum of aging honestly, or when we discuss the good parts, we will lack credibility.

Eric 04:17

How do you think about that? Ken?

Ken 04:20

I think that was very well said, Louise. I think what ageism, when you get right down to it, is, is not really seeing the individual in front of you and the individual in the setting of what they’re trying to accomplish and what matters to them, that it’s always appropriate. When you have a question about somebody’s ability to do what matters and do what you might say is their daily functional tasks, are they in a position to be able to do it? I think one thing that’s a little bit different about some of the settings we’re describing is, as geriatricians, we focus on often the here and now that we deal with people’s circumstances now, and we think about helping them do their best now, you know, we’re in kind of an unusual situation where there’s also a prognostic component as to, you know, what do certain things we see bode for the future.

Eric 05:25

So, like, if you’re seeing somebody who’s having more difficulty doing things, doing tasks for that, they used to be able to do quite well themselves. Worried about what that means over the next two, four, six years, whatever their terms are.

Ken 05:40

That’s right. And if we’re seeing somebody in the clinic, how they might be able to do things in four years, we’re looking ahead to try to slow any progression down. But a lot of what we’re going to be focused on is where are you now and how can we help you in a. Now?

Eric 06:00

Yeah, it also sounds like from you, Ken, it also depends on the tasks you’re being asked to do. Right.

Ken 06:06

That’s exactly right. And one of the things that, and I think you alluded to this, Louise. One of the things that I fear from the current debate and discussion, there’s a lot of lack of empathy and compassion going on here. And I’d really hate to see a lot of this generalized to discussions about aging in general, because there’s a lot of cases where I, you know, people who are dealing with difficulties can really have really excellent lives and do almost everything. So, you know, that we don’t want to generalize, to like what’s going on in a very unique situation to all of aging.

Eric 06:50

Yeah, Louise, I can imagine, too. So, you know, having watched, you know, President Biden, Biden’s performance both during the last debate and rewatched previous debates, that there seems to be a difference. You hear people, a lot of talking heads on tv. Some of them say, you know, come up with a specific diagnosis, whether it be dementia, Lewy body disease, anything else? Other people say, oh, no, this is just normal cognitive aging. And I can imagine on both sides of those spectrum, both of those, in a way, is potentially like an ageist attitude for an older adult, let alone the side topic of should we be diagnosing somebody? And I think that’s one of our Twitter comments by watching a performance live.

Alex 07:40

Yeah, I’ll just read that Twitter comment to give voice to person who wrote it. Cecilia Poon says, what are some best practices to highlight professional ethics? To not diagnose or speculate about a diagnosis of someone not under our care and definitely not diagnosed in public, while balancing the professional responsibility to dispel myths and misinformation. As someone who’s been on tv interviewed quite a bit, Louise, let’s go to you with that.

Louise 08:10

Well, I think obviously, you don’t want to break the law and you don’t want to violate professional ethics. There is a tension. If you are concerned that your silence can be a form of complicity and bad behavior, too, we have a certain amount of expertise. So you have to kind of walk a fine line in saying, I am unable to make a diagnosis without seeing a patient. I am unable to make certain pronouncements. Here are the things that concern me as a clinician, and there’s an array of things that could lead to this. But I think clinical concerns are legitimate to bring up.

If you’re talking about someone who’s in a position to do harm to others and then hearkening back to Ken’s point of empathy, I think we’re seeing a lot of just, like, get rid of old people instead of, you know, there are ways you can function and live a fulfilling life and also spending your last days, I mean, I think of Feinstein being wheeled in, looking horrific. I mean, that is a heck of a thing to do to your life and your loved ones. So I think there’s all kinds of room for greater empathy for what the human might do with individual might do with their remaining life. And also our responsibility as experts to raise some warnings when we see things that could have damaging impact, whether it’s an older person driving or an older person serving in an office, with impact on many people.

Eric 09:54

So it’s interesting because there is such thing called the Goldwater rule. American Psychiatric Association, APA, came out with it because I’ll read it on the fact magazine in 1964 during that race that said that 1189 psychiatrists say Goldwater is psychologically unfit to be president. And since that rule, which was an embarrassment for the APA, they came out with a Goldwater rule saying that you shouldn’t be diagnosing people if you’re not actually seeing them. Interestingly enough, Ama also has a similar rule. AMA code of ethics refrain from making clinical diagnoses about individuals, public officials, celebrities, persons in the news. They have not, if they have not had the opportunity to personally examine. So can I ask a question?

Louise 10:45

What years were those? Because we also live in a different context, and I think in politics, we’re getting into all sorts of trouble with rules that were set down hundreds of years ago, and there may be some set down ten years ago where we have access to a whole lot more information than clinicians used to.

Eric 11:01

Yeah, but we, I mean, it’s an active AmA and APA rule. So Ama, you can get a code of ethics, it will say, to do that. So I don’t know when the AMA rule came out. I do know the APA rule was in the sixties. With that said, we don’t have a lot of information. You have snippets of information. Like, there were times, like during the debate with Biden, I thought, man, it’s impressive. Like, he’s able to recall all these facts. And there’s times where I cringed during the bait.

But we know is that even if you do like neuropsychic, it takes a full assessment to actually diagnose somebody with a disease. You see a lot of people talking about Parkinson’s disease. We all know this as clinicians. You see somebody walking down the street, you’re like, oh, that’s like a parkinsonian gate right there. I have not diagnosed that person with Parkinson’s disease.

Louise 11:53

And Eric we’re talking about raising concerns, not making diagnoses. Sorry, Ken.

Ken 11:58

No. Well, you said the key, I think you said the key word, Louise, is that one of the things, I think, that’s often missed in this discussion, and in part, some of the rush to diagnosis, is, in fact, ageist in itself, because it belies the enormous complexity and diversity and heterogeneity we could see in various events. So, for example, there are lots of people with gates that, quote, look parkinsonian, but they have arthritis and they’re just stiff, and maybe they have a little bit of neuropathy, and they’re generally well functioning. And what you see doesn’t bode a negative prognosis.

And sometimes that parkinsonian gait is Parkinson’s. The point, though, that sometimes, clinically, what you see is something that is a concern, that demands evaluation, and that rushing to a diagnosis belies and disrespects the complexity and the needs of the person in front of you. So that I just sort of seen so much guessing diagnosis, so much ridicule over Twitter. So people have ridiculed, for example, the notion that a cold medicine can cause significant, serious dysfunctioning in an otherwise older person. And all of us, as geriatricians have seen healthy people on Benadryl who’ve gotten incredibly dysfunctional from that. At the same time, you wouldn’t necessarily rush to say that’s the answer.

The point is, I see something concerning here, and the outcome of the evaluation can lead to a whole range of different conclusions, ranging from a one time event. We don’t have to be concerned of something that’s a harbinger of something else. And often, I don’t quite know what’s going on, but I’m going to have to follow you for longer to understand what this all means.

Louise 14:05

And because it’s geriatrics, some combination thereof.

Eric 14:13

There’s this interesting point between ageism and ableism, because a lot of people, we’re hearing a lot about Parkinson’s disease. Parkinson’s, like, I’m not concerned about a president having Parkinson’s disease, agree? That doesn’t mean that somebody has cognitive impairment. And I think you hear a lot of these terms being thrown out by these pundits, these armchair doctors, sometimes real doctors.

Louise 14:39

Real doctors, yes.

Eric 14:41

What are your thoughts on that, Louise?

Louise 14:44

I think we have to be cautious. I guess I feel it’s our social responsibility to raise concern. And as Ken said, to say, there’s an evaluation, and is this acute, or is it longer term? But to actually make a diagnosis without the patient in front of you. I think we need to be really cautious, partly because there are guidelines and partly because everybody’s made mistakes. And that’s why we have a comprehensive evaluation of patients.

Eric 15:11

And I feel like it’s different between, you know, making a diagnosis and, I mean, the reason we have debates, the reason we have all these things, the reason we have these histories about knowing, knowing people, seeing how they are, is that you kind of want to know how people perform doing a specific task, like a debate. We have these debates because we think that there is a component of them that’s really important when selecting individuals, not only hearing kind of what the platform is for their party, but also seeing how they, like, mentally spar with their opponent. You could argue, is that the right thing? But you kind of want to do kind of like, if you were an airplane pilot, you kind of want to know, like, can this person still fly a plane? I think this is coming comes down to a non second question. Is that right, Alex?

Alex 16:03

Yeah, we can go there to a non second question. Do we have different litmus tests for office versus driving? Max Age, you know, as doctors, clinicians, max age to practice medicine, operate a crane. Eric gave this example, or maybe it was Ken. Yesterday we were talking about doing this podcast. Well, what if your surgeon came to you and spoke in a way that made you concerned about his cognitive abilities? Now, how would you feel about the surgeon doing that operation?

Eric 16:34

Yeah, that was me. Like, if you were going to go to a cabbage tomorrow, surgeon comes up and not incredibly coherent, a little bit tangential, how much confidence would you have going into that surgery? Or would you have second thought, would.

Louise 16:46

Not have the surgery? I don’t know about you guys, but I don’t know. My God, you’re not like talking about a hangnail. So it depends a little bit, too. What are the stakes, right. And how concerned are you? And is this a job where variability is okay and safe or where it’s not? You know, there’s so many different things here. And I think as a society, you know, we’ve added decades to life, many of which where people function really well and actually function better in some regards that we are not yet taking full advantage of. But we haven’t quite figured out how. How to help people transition off when that becomes appropriate.

And one of the things we talk about so often in geriatrics is about function, not age. So this age cut off thing, I feel like, has its origins in, you know, child related things. When are you old enough to drive or drink or go to war? Although the whole thing that you can go to war three years before you can have a beer is a little weird to me. So that’s not perfect either. But I think we really need to figure out how to have conversations about function and how to think about what the requirements are for each individual profession, perhaps.

Ken 18:06

Well, also, Eric and Luz, I want to give an addendum to the 80 year old surgeon because, yes, if an 80 year old surgeon came to me and they seemed confused and tangential, I would be very worried. And my ideal surgeon would be an 80 year old surgeon who still has good motor function and good cognitive function, because that 80 year old surgeon is going to bring their 50 years of wealth and wisdom to that. Well, I should say wealth of wisdom.

Eric 18:39

I love that operate because my example.

Louise 18:41

That’s wealth as well. They ain’t no geriatrician.

Eric 18:49

The surgeon coming to you, you actually don’t need the age. In that example, if you took out the age, you should have similar.

Louise 18:57

Yeah, he’s 42 and drunk. He’s not operating on me. You know, like, I don’t care.

Eric 19:00

Yeah, and if he says no, it’s just a bunch of Benadryl I took. I still don’t like, no, I don’t want you taking Benadryl tomorrow. Like, you still have to be able to be able to. Well, if you take Benadryl, show up.

Louise 19:13

Work and are incoherent, there are a whole lot of problems going on.

Eric 19:17

Yeah, yeah.

Ken 19:18

And one thing to kind of keep in mind about cognition as people, age is like, you know, who knows exactly what the normal changes of aging? But one thing that probably does happen with aging is slowing of cognitive speed. So, like, when I was in my twenties and I do quantitative stuff for a living, I could, like, multiply numbers in my head super fast. If you gave me, like, a twelve digit number to remember, I could spit it back. I can’t do that anymore, you know, should I acknowledge that, Alex? Maybe you don’t want to work with me anymore. And though, at the same time, I think with age, there’s a certain wisdom that happens with that slower thinking and that that slower thinking does not impact functional ability, and that maybe with that slower thinking, you understand nuance and substance more. And it’s not a bad thing.

Eric 20:22

And there are some studies that support that, too. With experience comes wisdom. With age comes wisdom. Also potentially better able to handle conflict. So there’s a lot of things that age gives you with time, but we’re.

Louise 20:38

Also doing that thing where we reduce age to a single something so Ken and I are in the early phases of older age contemporaries. We’re just arriving. And are things different. Oh, my God. Right. But I agree with Ken. There are things I’m much worse at, and there are things I’m much better at, and I hope it’s coming out even for the sake of patients and friends. You know, you can ask them, but it’s different as you move through the decades of old age. I think the relative balance tips at some point, and it is a version of ageism not to include that we don’t want to become like those people who are like, you can live forever and feel great forever. You know, you just have to exercise 4 hours a day and get 10 hours of sleep and eat. Because that isn’t true.

Eric 21:25

Because that’s attention. Right. In aging research, Ken, like, there’s this thought, like, yeah, you were talking about this yesterday. What are your thoughts on that? The balance, this tension that we see in geriatrics aging research?

Ken 21:39

Well, yes. I mean, so there’s actually been this long debate about this term successful aging, where people have argued that the goal of gerontology is to prevent all the physical and cognitive stuff that we see happen with adults advancing age. And I actually think that’s really a lot of that’s been to the detriment of the field, that what we really want to do is, of course, people want to live without disability for as long as possible, but we have a responsibility to value and treasure people wherever they are and help them live the best quality of lives in whatever state they’re in. And there are many, many people who have various levels of disability, both physical and cognitive, that have very good lives. So this notion that everybody has to live free of disease is really critical. I think the other part, though, I think we were talking about, Eric, is that you can have problems in one sphere and compensate for it in another sphere. And you were alluding to this with a like, well, yeah, actually, just because you have Parkinson’s disease does not imply that you necessarily have cognitive problems. There are a lot of people who have the physical disabilities of aging, but are cognitively fully able. So the mere fact that you see somebody walking more stiffly or walking more slowly or, God forbid, like that horrendous magazine cover of persons in walkers is like, God, like, oh, you’re in a walker. You can’t be in public office. Like, that’s absolutely absurd.

Louise 23:31

With ageism.

Eric 23:33

Another good example, like we saw four years ago, there was a candidate who I believe won, who showed a lot of executive function issues, disinhibition issues. And there’s a lot of talk about dementia in that case. Turns out, no, he just kind of disinhibited his entire life. Like, this is not a progressive neurological disorder. This is just personality.

Alex 23:58

Well, there was a lot of talk about personality disorders, I’ve heard.

Eric 24:03

Yeah. So similar thing. This goes on and on and on with, with candidates. Again, you look back to the McCain Obama presidential race, and now 70, one’s looking young, 71 when he was.

Louise 24:18

Things are changing.

Eric 24:19

Yeah. And again, there was a lot of push. And interestingly, Louise, because I was doing a little research on that, when you asked a bunch of retirees, was McCain too old to be president, like, I think nearly half said yes. When you asked people less than age 35, like, only 20% thought he was too old to be president. So, like, it almost flipped your idea of ageism because it looked like older adults were more ageist around this than the younger adults. I want to get your thoughts on that.

Louise 24:52

Well, you could argue either way, were they more ageist. We know that internalized ageism is huge, and ageism against other people, you know, is rampant even among older people. But you could also argue that having grown into old age themselves, they thought of what was required of a president and how much more tired one is with passing decades, even with perfect health behavior and trying hard to sleep and doing everything right. And they thought, boy, that’s asking a lot of a person about my age. Like, you know, even I, and I have spoken to people recently about this note. They will say, look, I’m pretty healthy and high functioning. I don’t know that I could do that job. That’s a hard job. Now, admittedly, you know, when you’re president, you have legions of people helping and doing a lot of the work. But, you know, I do think there’s complexity there that sometimes is glossed over.

Alex 25:46

We’ve talked a little bit about Parkinson’s gait, and it does kind of bring in this component of physical frailty and fitness for office. Ariela Orkhabi from Boston asks, I worry about vulnerability and frailty, especially with the demanding duties of public office. And several people invoke FDR, who was in a wheelchair, because I think it was polio. Does that sound right? Yeah. And then as he was running for his second term in office, was diagnosed with heart failure and given a prognosis of his short term prognosis, decided to run anyway, was elected, and then, I think, died a year later or within a year of office.

Ken 26:28

I think that was his fourth term, Alex.

Alex 26:30

Oh, that’s his fourth term, yeah.

Louise 26:31

It was unprecedented, but felt necessary at the time.

Alex 26:35

Yeah. So what about this? What about. We’ve talked a bit about cognitive fitness. How about physical fitness, frailty, and the demands of the office? Ken?

Ken 26:46

Yes, that’s a hard question. And having not been in the White House, I can’t quite say what the physical demands are. I think there’s varying components of frailty and physical stamina. So that, for example, the type of, quote, I won’t even call it frailty, the type of disability that FDR had early in his life, which was paraplegia, seemingly had no bearing on his ability to serve as president. That, you know, I think, ironically, I think a lot of the physical components of doing hard work and hard labor when you’re older is the stuff that we actually don’t see. It’s the fatigue, so that I don’t think it’s often the walking or the going upstairs that really inhibits the demands of an intellectually demanding position. It’s really actually the fatigue and sometimes just the ability to get through the day. When people get older, they just get tired for reasons that often are hard to understand. They have good days, they have bad days. So that, I think a lot of it is actually stuff that you really can’t assess, like thirdhand through a television, kind of have to know somebody and talk to them and interview them.

Louise 28:12

And I think that’s an important distinction here. One of the people I follow on Instagram was talking about having reversed her position on this, first thinking you should step aside, and then speaking to some people in the ableism sphere, you know, or anti ableism sphere, I suppose, more accurately, like pro ableism anyway, you know, had kind of changed her mind. But I think there’s an important difference between a condition that we can mitigate, but we expect to progress versus a fixed condition. I mean, this is kind of what you were saying. I also wanted to shout out, I was just looking for it. But Rachel Bedard, a geriatrician, had a column on this in the Sunday Times this week. So that would have been the 7th, I think. Or maybe it came out on the fifth online, talking about some of the aspects of frailty. Although I might push a little harder to say that the risks of frailty with. For hospitalization, for death, for all sorts of adverse events, I think are a reason for concern.

Eric 29:15

Yeah. Because any candidate prognostication does matter. Again, I think when we think about this, I think back to Ruth Bader Ginsburg, there was calls for her to retire. 2013. I think she was on her fourth or fifth cancer at that time. She was looking more frail, and there were calls for her retire because the Democrats lost the House lost the presidency, it would open up a Supreme Court position. She didn’t retire. That position did switch. And it makes me think about not just frailty from an outward perspective. And again, we get in this issue about ableism, but also this comes up in sports all the time, knowing when it’s time to retire and pass that on. I want to get your thoughts on that, Louise.

Alex 30:06

Can I interject some listener tweets that are sort of relevant here?

Eric 30:11

Yeah.

Alex 30:12

Colleen Christmas asks, what kind of assessment would adequately demonstrate someone’s ability for public office? And then Sandra Shee asks, are calls for cognitive testing meaningful ways to potentially reassure or veiled ageism?

Eric 30:30

Thoughts?

Louise 30:31

My thoughts are always, if there are functional requirements for an office, they should be applied to every applicant for that office.

Eric 30:42

Trump did a MoCA in 2020, I remember that he did the OmoC ever.

Louise 30:48

Well, yes, but also the words he lists as having been asked to remember, either he has forgotten them or he was given a very bad test because the words were so closely associated. It doesn’t actually test what the MoCA is meant to test. So there’s something in there that isn’t ringing true to this. Geriatrician, beers.

Eric 31:09

Yeah, I guess for me, my thought is, I don’t want our decision of who should be president based on how they did on a MoCA score. Like 30 out 30. Oh, yeah, they could be president because there’s a lot more to be president than that. Ken, what are your thoughts?

Ken 31:24

You know, this comes down to really classic geriatric assessment, because it’s, you know, you see the person in front of you, and you do an evaluation, and you kind of understand their strengths and deficits, and, you know, what that portends for their ability to do various works. And the issue of, like, you know, I hate. I think one of the problems with the word public office is not all public offices are the same. So what you demand of a senator could be very different from what you demand of a president, but it really is very situationally dependent. And I would sort of say that I agree that often cognitive assessment and what we call neurocognitive testing in select situations can be very useful and very revealing. We, of course, use it all the time in geriatrics. But cognitive assessment is usually not something that’s done alone. It should really be done as part of a full assessment of one’s physical and cognitive abilities. And it’s always, again, it’s not just, you don’t look at a cognitive assessment in isolation. You look at it in the context of somebody’s functioning and somebody’s position and what you’re asking them to do.

Louise 32:50

Right. And the MoCA is a screening test, and we know that highly educated, high functioning people often have a ceiling effect for a certain period of time, which can last years after they begin to show evidence of impairment. And I would really hope that both presidents and senators would have that seal would be of, you know, a person to have the ceiling effect. And so they would require a longer neuropsych evaluation.

Eric 33:13

With that said, I never know the date. I’m all surprised that people who do.

Louise 33:18

But it has to be a change from…

Alex 33:19

When Ken said he could remember twelve digit numbers, I said, whoa, because I can’t even remember a phone number much.

Eric 33:31

I can’t do phone numbers.

Louise 33:34

Maybe you’re too young. You never had to. Who knows?

Ken 33:38

I never. I didn’t have a. Yeah, I did not have a smartphone, Alex, till I was much older than you.

Eric 33:48

Go ahead, Alex, go.

Alex 33:49

Well, I wanted to ask, you know, one of the reasons we’re doing this podcast is because we’ve been approached by a lot of geriatricians, palliative care docs, people who care for older adults who say, I’m really uncomfortable with this discussion right now, and I feel like I know people are coming to me. I don’t know what to say, and I feel like I’m deeply concerned about somebody’s cognitive fitness for office, and I don’t want to be ageist. I know we’re coming to the end. We’ve kind of, this has been the subject of the podcast. We’ve talked about it quite a bit. But I wonder, like, if you were just talking to a junior faculty member, because that’s primarily coming up to us, and they wanted advice about this, and they said, look, I’m being asked to talk on local tv about this. What should I say? What advice would you give them?

Eric 34:39

Luis, you’ve done a lot of this. Yeah, you were just on the hill.

Louise 34:42

But I’m also trying to put my, you know, like, when you’re junior, it’s definitely a different call. Like, this is one of the advantages of getting older, frankly, is that you’re more comfortable in yourself and your opinion, and there is far less at stake. So I’m mindful of that as well. You don’t want at that stage, get yourself in trouble. But I think if you have concerns, it’s okay to be honest. And maybe one of the things you say is, look, I’m uncomfortable. I have concerns, and I’m also seeing a lot of ageism. And as a geriatrician, both things worry me.

Eric 35:18

Both things can be true.

Louise 35:20

But yeah, I think both things are going on. It’s a classic geriatric answer, really.

Eric 35:25

It’s pretty good. Yeah.

Ken 35:26

I think this complexity, the advice I would give is don’t rush to a diagnosis and don’t give the simple answer. Maybe the media person in front of you wants that. This is a complex situation, and I think some of us were talking as a group yesterday of like, it’s actually not an uncommon situation in geriatrics where the presentation is somebody’s daughter or spouse or son, says somebody. My loved one was not right yesterday, and I’m worried, and we were not. That’s actually probably a good hour or more. Evaluation could lead to lots of different outcomes. So I think we have to be truthful and honest and to sort of say, gosh, what we saw on that stage is something that can be ignored and does not lead to concerns. I don’t think it’s, I wouldn’t urge people to say that because it’s not honest. At the same time, to say, you.

Louise 36:32

Won’T be asked back.

Ken 36:34

Yes, at the same time say, I don’t know. And of course, there’s been lots of, like, speculation and statements about what else is happening, all of it, which is thirdhand. As doctors, we don’t deal with things thirdhand. We talk to patients and we talk to families, and we don’t, like, base it on what we read in the media. So that certainly that daughter who came to us and said, my father had concerns, and I saw this in my dad, that would, of course, mandate an evaluation, and the outcome of that evaluation is very uncertain. And there would be a lot of questions that would be involved.

There’s actually a skilled art of, like, saying, is this new or is this old? And the question of, is it new? We don’t ask just is it new? We really try. We use, hopefully, some of our wisdom of practice to really delve into that and ask questions really that get really into depth, like, well, what could they do one year ago? What has changed or what has not.

Eric 37:41

I also feel like there’s a distinction between what’s your professional opinion and what’s your political opinion and thinking about that for the first part is your professional opinion should never be diagnosed. Somebody who you don’t know all the information about, it’s just bad form. And I would, again, ama ethics say, don’t do it.

Louise 38:00

Don’t do it.

Eric 38:00

You can express concern from a professional opinion. I also think, like, doing the mental exercise. Okay, what if it’s the other candidate that I may not like? Like, a good example, if. If it’s 2020 or a Democrat and people were talking about Trump having dementia. Are you jumping on that bad wagon about that diagnosis? Are you saying, wait a second, let’s think this through? Yeah. There may be signs that you can argue around, like, disinhibition issues, but no, like. Like, you can’t make that diagnosis. And I truly feel like you can’t make that diagnosis based on, like, looking at a debate performance. But like Louise said, like. Right. You can express concern. Like, these are the red flags that we see as geriatricians.

Louise 38:45

Right. And you can do that on a whole host of things. You know, we’ve sort of focused on frailty and cognitive impairment. But you could think about other things that pose risk as people move into their eighties, you know, being. Having certain health habits or lacking certain other health habits. I mean, certain things increase a person’s risk, as does age alone of having adverse events, even if you’re going in very healthy. And so I think that has to be part of the consideration. And we can say, you know, at a population level, which, of course, media people don’t like at all, here is what we know, and that can enter into the equation. But I cannot diagnose this human being. I’ve never meth.

Alex 39:28

Yeah. Alex.

Eric 39:29

Lightning round.

Alex 39:30

Yeah, lightning round. I have a question from Kai Smith.

Louise 39:36

Wait a minute.

Alex 39:39

There’s a younger age limit for presidents? You know, I think it’s 35. Should there be an older age limit?

Louise 39:47

I think it’s an interesting question, and it’s something we need to be considering as a society across professions.

Eric 39:54

And why is that? Louise, real quick.

Alex 39:56

No.

Eric 39:57

Yeah. It wasn’t a no. Because.

Alex 39:58

Yeah, I kind of feel like because.

Eric 40:00

The heterogeneity in older age, I’d probably say no.

Ken 40:03

I would say no.

Eric 40:04

Yeah.

Louise 40:04

But it’s like, why do you take. Well, maybe you don’t anymore, but we used to take out some appendixes that were okay so that you didn’t leave some, you know, whenever you set a limit. We’ve all seen on the younger end of the spectrum, right. There are kids who, you know, absolutely, at 18 or 21, are mature and responsible, and there are other ones. You’re like, we need to give this a decade before this guy should be allowed to do x, y, and z. Right? So you’re going to make rules that are problematic at each end. And maybe in old age, as with most things old age, it’s a combination of number plus function.

But the world likes black and white. And in certain professions, you may have to disqualify some perfectly able people like piles in order to keep out a plurality that may pose risk via illness, you know, incapacity, etcetera, as the odds get so big. I mean, if you do it like a scale, you think, would you let a 105 year old? I don’t think so. 100. You know, 95. There is some element there where age begins to matter, and I don’t think we know where it is because we don’t really know what normal aging is. We know what usual aging is for a lot of people. But I do think maybe we don’t have an answer. But I think these are really important questions that we need to be exploring in medicine and in society.

Eric 41:25

Ken?

Ken 41:26

Yeah, it was a very wise question. I would expect this kid to be, like, in a really prestigious school like Swarthmore, but.

Louise 41:36

Brainy kid.

Ken 41:39

You wonder, like, where that came from. Actually very mysterious. So I think the danger of older age cut offs is that they do a lot more harm than good, and they almost certainly will be imposed too young. So there was just the absolutely ridiculous suggestion that people should refrain from public office when they’re over the age of 75. And you hear stuff like that, and it’s like, well, wait a second. The average life expectancy of a 75 year old, the probability of living to 90 is probably greater than 50 50. And you actually can assess a 75 year old to sort of understand who is likely to be at live to 90 and who is not likely to lift a 90.

So that we actually do have the capacity to look at somebody as an individual and kind of see what things are likely to be like both right now and in the future. So is there an age cutoff at which maybe there’s enough of a demographic risk that something could happen? That assessment is required? Maybe, but I would really hesitate to have an absolute age requirement. And, you know, there’s some. There’s a thing called voters. You know.

Louise 43:08

They’Re unreliable, but there’s a risk for not having one. Right. And we’re sort of seeing that as person after person, where most of us, perhaps, according to the polls, would say maybe it’s time to move on and they’re not moving themselves on. So this, to me is akin to driving. Right. People don’t police themselves as well as they should. And in the absence of such self monitoring, we are going to get rules. Now, hopefully we would have them be as wise as and nuanced as what you just mentioned. But I think unless people start doing the right thing, and clearly people who run for office are different than many of us. But we also see this in everyday life among people who really have come to the end of their driving lives and are unwilling to accept.

Eric 43:57

Yeah, I think that, of course nobody looks forward to the challenge is fitness for office is so multidimensional. And I think that’s the might take home here. Is that because it’s so multidimensional you can just. Just focus on one part, but that’s just one part. There’s so many other aspects that you would want depending on the office that they’re being elected for that trying to. One factor like age is never going to give you a great ability to weed in or weed out people who are fit for office.

Louise 44:29

Right.

Eric 44:30

And I don’t want to say physically.

Louise 44:31

If the world were comfortable with ambiguity and complexity, we would have a hell of a lot more geriatricians in the world.

Eric 44:38

Yeah, Alex, any other lightning? Are we going to the song?

Alex 44:41

I think we got to go to the song. I don’t think Louise and Ken are very good at lightning round. Terrific answers.

Ken 44:50

Speaking about see some things that seem simple, Alex, are not.

Louise 44:57

We’ve never been into brevity. This is not a change from previous.

Eric 45:01

There’s something happening here Alex.

Alex 45:12

(singing)

Eric 46:13

Ken, Louise, thank you for joining us on this GeriPal podcast.

Ken 46:16

Thank you.

Louise 46:17

Great shout out to Alex’s dog, everybody. Check it out on YouTube if you like dogs.

Ken 46:24

You know, there is nothing like a contentious discussion and having a cute dog like just lay down at your house, very distracting. [laughter]

Eric 46:34

Thank you to our listeners for your continued support.