A letter to my patients:
I am a 74 yr old geriatric family doctor. Early in my career….
I was asked by the youngest son whose father was the powerful business founder and magnate of a large multimillion dollar multistate construction company to intervene on behalf of his family. Their father, a charming patriarch, had in the past two years become alarmingly more sarcastic, unconventional and inappropriate in his social presentation, and belligerent.
Dad had begun to hang out at a tavern near their warehouse, and had begun drinking more and distributing extensive monetary gifts to the delight of the patrons, many whom he did not know at all. Efforts to get dad to stop these donations, or to step down from the company or relinquish legal control to his grown children had been met with his stern derision and disapproval . The family itself had taken different sides so that the oldest son and his wife who were named in dads will as the executor and eventual president of the company were at odds with the other children and their families who wanted to legally intervene and obtain financial guardianship to prevent the company from ruin.
By appealing to his pride, I convinced him to participate in a neuropsychological evaluation that determined that he had symptoms of alcoholic dementia, depression and a condition known as frontotemporal dementia behavioral type or FTD bt. He was willing to have the family meet to discuss the implications of this and even volunteer to step out of the room to avoid any distraction. But the grown children could not agree on a course of action. Millions of dollars and months later, a disastrous hunting trip left him with exposure and pneumonia. He was hospitalized but his overall physical and mental condition had seriously deteriorated. Rehabilitation failed. He was placed in a nursing home. His cognitive condition had collapsed and the children were willing to place him under guardianship. The family remained fractured.
The media has begun to ask” Whats wrong with Donald Trump? Why can’t he pivot? Does he have some kind of illness?
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DT has many of the features of Frontotemporal dementia or FTD, previously known as Picks disease. This is far less common than Alzheimer’s and does not present initially with memory loss or word loss. A review in medical literature defines FTD as “an umbrella term for three clinical presentations: behavioral type FTD-bt, and two forms of primary progressive aphasia- non fluent and semantic. FTD-bt is the most common subtype and the hallmark is progressive change in personality and behavior early in the course of disease.”
Occurring as early as the sixth decade, the disease is hard to diagnosis initially as it overlaps with mental illness in appearance and can also be confused with variations in early onset Alzheimer’s.
FTD-bt is distinguished with disinhibition, increases in socially inappropriate behavior that is often disgusting, indifferent and embarrassing . There is increasing apathy and a loss of empathy. Patients can often be called cold or unfeeling. There is a hyperorality with unusual food preferences.
There are compulsive behaviors: perseveration, stereotypical responses and ritualistic patterns, some of which are present in more obsessive forms particularly with religious, oral or sexual aspects. Patients become more inflexible with changes in day to day preferences .Patients lack insight into these changes occurring or the distress experienced by others. They remain capable of making and prioritizing decisions but are more and more incapable of understanding anyone else’s perspective. Gradually the disease may progress to loss of memory and orientation like Alzheimer’s, and motor stiffness and bradykinesia like Parkinson’s.
With regard to speech there is a definite decline in verbal fluency, progressive verbal apraxia with difficulty in articulation, loss of proper use of words with impaired word finding, word usage, word understanding, slurring and failed sentence construction.
Nonfluent language deficits include difficulty with articulation of words with an effortful, halting and involuntary sound production, and single word meaning may be spared initially but complex sentence structure is impaired.
Semantic elements include single word loss of comprehension without loss of grammar or fluency, while overall sentences may remain coherent, individual words are misused, misplaced, or made up. There may be parsimony of speech as well as some loss of facial recognition but intact visuospatial skills.
Because these language deficits are difficult to diagnosis it may be harder to detect FTD than Alzheimer’s dementia early and diagnosing FTD is often one of exclusion. Many different parts of the brain impact speech expression, reception, production and comprehension. FTD affects very specific parts of the frontal cortex. Radiology imaging like PET and MRI scans can be suggestive but not diagnostic.
In many patients with progressive neurocognitive disorders their underlying personality features becomes more apparent. For a person with a narcissistic personality disorder like DT he will rely upon stereotypic speech patterns of his well-established misogyny and racism to interpret social situations with more disinhibited bombastic, paranoid, delusional, sarcastic, and insulting phrases that are reinforced by his FTD.
This decline can be so gradual that it is not apparent until full blown deterioration is occurring. Other physicians told my patient years ago that he did not have Alzheimer’s but missed the dementia components of his illness, which served to create more suffering for his family, postponing any accountability or resolution, since many of his family struggled with denial as well as the patient. When a patient lacks the capacity to comprehend the consequences of their cognitive disorder the situation can become dangerous for themselves and others.
Disagreeing with a dementia patient only triggers their outrage and further denial. They cannot comprehend new information or demonstrate insight, analysis, reflection. This intervention becomes a confrontation which is unkind and condescending.
DT has become a threat and a danger to the entire country, whether or not his enablers admit it. Like Biden he owes it to the country to step down, but his personality disorder and his disease will not allow this. He and his followers are likely to refuse a neurocognitive assessment from an independent qualified Gero-neuropsychology team.
But his disease is now escalating at a rapid rate. His behavior and speech at public venues and interviews is becoming so egregious that all but his most ardent MAGA and media supporters will recognize that he has to step down and I expect calls for his resignation as a candidate will become overwhelming before November.
Physicians have the obligation to make decisions that are based on a thoughtful effort to clarify the patient’s and family’s goals and values, preferences and choices, risks and benefits. Caretaking relies upon those in authority and power imposing and enforcing their solutions upon the patient, depriving the family of the opportunity to engage and grow with the challenges they are facing. Caregiving supports and empowers the family to affirm their willingness to face the turmoil and work together for a common goal that addresses everyone s dignity and values.
The tragedy for our country is that his authoritarian movement persists and his supporters remain unconvinced that they should be accountable. Understanding what we face is the first step. As caregivers of our constitution, and as citizens.
Focusing on mutual respect, accountability, integrity, compassion and participation - democratic principles of engagement are the best way to bring our country together.
He may be gone but only a resounding vote for Harris/Walz, and for the protection of our democratic values and institutions, will be the best response to his departure.
