Neuropsychological Assessments for Clinicians

[00:00:00] They go, how do you know? There's nothing in my ear. You haven't even looked. And I was like, valid. Damn, you right? Yeah. I haven't looked valid. Has anyone looked? I'm like, I'm like you right as hell. So I was like, I'll eat my words. I'm gonna go get an O. Go right now. Now how to be patient. Welcome back to How To Be Patient podcast, where we talk about Margaret's grievances, my grievances, and sometimes the grievances of other people, all their, and sometimes mental status exam to control our emotions.

Yeah. So this is gonna be a fun we're doing and welcome to 2026. Oh yeah. I'm like, okay. So when this is airing, it's gonna be probably the first week of the new year. So we're in the future. We're manifesting for us two months from now. Okay. Future press. And what do you want your New Year's resolution to be?

One of the things I like that I've, you guys, you're actually getting us on the fly today because we had a schedule mishap. Uh, I'm telling them they can know in our last episode we were arguing about something on [00:01:00] Patriots. So they can they can hear the reality. Yeah. Well, welcome to, to the inside guys.

This is behind the curtain. Um, there was a thing that went around that was viral last year that was like, what if your New Year's resolution was something fun? And I was like, oh, that would be, that would be nuts. What if it was just fun and not just another discipline Olympics? I think mine's just gonna be something that I'll absolutely fulfill.

Like I wanna look at my phone more, you know, I could achieve that. No problem. Just I'm already do, I'm starting on my New Year's resolution right now, actually. I know. Just gluing it. Well, you should get the Google glasses or whatever. Then you could achieve it 24 7. Sleep in them. You eating them? Your podcasts in them.

The meta glasses, dude. Oh, are they meta? Yeah, that's my resolution. It's what is the meta You destroy Every meta glass that I come across just gonna punch people wearing. I don't know. I, he's a civil servant. I just, I feel less and less the need to record things about my daily life. Bad thing for your influencer career, [00:02:00] really.

It's, um, I think I'm more comfortable like recording things when they're staged. Mm-hmm. And I'm spending more time on a stage, I don't know if I've shared this yet on the podcast, but I'm taking improv classes. Hey, so it's all, it's all the purpose is just to get better at podcasting and be a therapist, I think.

Is it? No, it's, it's because I'm trying to find, like rekindle my comedy self and it's a good way to be silly and accept, I feel like you missed that part of yourself stupid. That was like really alive when you were doing the skits and like, it's not that you wanna do the skits anymore, but that part of you that was like in creative flow was so precious to you and you were so good at it.

And that's your one compliment for 2026. Yeah. So maybe that's my New Year's resolution is to just like get in my creative flow. Be funnier and to make it a smart goal. It's gonna be to get to improv 3 0 1, the advanced improv class Whatcha are in right now. 1 0 1. 1 0 1. Intro to Improv. Improv. Which honestly it's a good segue into [00:03:00] the topic of today, which is gonna be the neuro cognitive What you gonna ask me what mine is?

Oh yeah. Right. There's, there's a woman we need to ask her about her New Year's resolution. Yeah. Season three men taking note, always asking, struggling with the reciprocity. Yeah. It's, it's really, it hasn't gotten to me yet. It's gonna get a, a man on the podcast every time. What is your new resolution? I think, um, I have been having some exciting conversations with a book agent and possibly a publisher, um, for like a, a journal basically like a, not a scientific journal, but like something based on like the bad art every day style of like essay and then journal prompts.

So I can't control if that happens, but I think there's part of me that is scared of it and is like, I'll do that someday in the future, but it's like I write journals anyway online. So I think trying my best to like show up well for any happenings with that. And then just feel proud of how I handle the [00:04:00] opportunity and not feel like I wasted the opportunity to write a book, to like go to the meetings and like be like, here's the idea and the outline and like dah, dah, dah, to attend the book meeting.

Literally just to not be like, actually gimme 10 more years and then mm-hmm. I can think about, yeah, I mean at some point the, the moment will be right now when you have to write the book, so might as well prepare for it. Yeah. Yeah. And it's not gonna be like, the thing that's like proposed is not like, I'm gonna write a 300 like page textbook on a literature view on something.

Like, it would not be that kind of mental load. So. This one I think I can be not scared of, but, so that's my 2026 resolution is be not scared of books. Okay. We're gonna conquer our fears of books and we're gonna be silly in front of strangers, not a, not a bad set of New Year's res. I love it. So if you're, if you're listening to this while in the gym for your nearest resolution, that, that's a pretty fair one.

[00:05:00] Exercise is always good. Just remember, whatever you want in life is on the other side of being consistent. So just try to see it through whatever you're doing in the influencer side of you comes out. Every once in a while, God's coming out. It's like, uh, it's like the venom side of me. The form music bench 2 25 again.

No, I'm a, I'm a marathon runner now. It's what I do. I've changed. Wait, you ran one, right? Yeah, but, but by the time hopefully I'll run a trail, uh, 30 miles mile is the trail. When is that? It's November 22nd. Wait, that's so soon. It's like two weeks. Yeah. Oh, are you scared? Are you ready for it? Are you scared?

Um, your coffee machine broke, but dude, I, I've been running a lot on the road and I'm like, wait, the race is on the trail. So I bought the trail shoes. I follow this guy, Andy Glaze, and he told me what kind of shoes to get. So what a name. Hopefully Andy knows what he's talking about. I mean, the guy ran the Moab two [00:06:00] 40, so I think he's got it.

Have you ever finished a race in your running career that you've been like, I feel great about that, and that was awesome? Mm, yeah. Probably twice. Twice? Okay. Well, we'll see what 2026 is to bring maybe an ultra thought. Yeah. Maybe more races we feel good about. Okay. So we've done my year's resolution, we've done your year's resolution, the cognitive checking, and now we have the, the main event of today's episode, which is the neurocognitive assessment and how we can actually use them clinically to be somewhat helpful.

So I think a lot these assessments get a lot of flack because some people will see them as like purely pedantics and like, yes, you're doing all these psychometrics, who cares? Um, but I 50% agree with that. I care and I care. So, but I'm really good at it. Mm-hmm. We're gonna be talking about the, like in general, like five main, like neurocognitive domains.

There's a [00:07:00] lot of different ways that you can split the neurocognitive domains. We're kind of like categorize them, um, around executive function language, um, complex attention, memory and recall, and, and visual spatial, um, management. So, and when you say neurocognitive exam, who does the neuro, who does these?

Uh, you can do it. And you can too with the power of a mocha or a mini mental SaaS exam. But there are more advanced batteries of it that you can do, um, or neuropsychologists usually do. So people with PhDs in neuropsychology. Okay, so we will take a quick break and when we come back, let's get it started with, Hmm.

Let's do complex attention. This is probably something every, everybody needs a little bit about. Biggest party, the on air. Okay. We'll be back with complex attention.

So in [00:08:00] 2026, my goal is to open a very small private practice as a post-grad psychiatrist. And one of the tools that has helping me do it is Simple practice. Preston, have you heard of Simple Practice? Yeah, I have heard of Simple Practice. Actually. I use it as a patient, well I guess my therapist technically uses Simple Practice and is it in fact simple?

It's very simple. It's, it's convenient. Um. I would recommend. Yeah, well, from, from the therapist side, simple Practice is an all-in-one EHR that is HIPAA compliant, high trust certified, and it is built specifically for therapists. So it brings scheduling, billing, insurance, and client communication into one place so that you are not juggling multiple systems just to run your practice.

Or if you're Preston's therapist to see him I, I mean I'm enough to handle as is. She doesn't need to worry about other complicated things. And if you're just starting out or growing your practice, there's also credentialing service that takes the headache out of insurance enrollment, which honestly can be a huge lift and something that I was a little scared of.

So if you're ready to start the business side of your practice, now is the perfect [00:09:00] time to try Simple Practice. Do it with us. Well, I guess me in the future, and Margaret now. So start with a seven day free trial, then get 50% off your first three months. Just go to simple practice.com to claim the offer.

That's simple practice.com.

When you think about like. Assessing attention. Defining attention. How, what words come to mind? Um, what is attention? Why is attention, why does everyone want attention? Attention, yeah. Um, including us. Mm-hmm. I think I think of attention, I guess I'm just gonna say things that come to mind. So I feel like I think about working memory.

So the ability to hold bits of information while like, kind of manipulating them in the mind. I think about in like the A DHD sense, the ability to control and maintain where the sort of beam of attention goes versus like the dysregulation of that. So like the ability to listen to someone answer the question of what their [00:10:00] New year's, uh, 20, 26 resolution is if you mm-hmm.

I feel like that was shade, right? Is chat, was that shade Chat. Chat was that shade, but good example. Please continue. That's like kind of. I, I think also it's like a complex overlapping of different functions, or I guess maybe not overlapping, but like if someone is experiencing chronic fatigue or if they're experiencing the like kind of alarm signal in their body of acute pain that might impact like arousal and alertness and ability to direct attention in other places.

But I wouldn't necessarily call that attention, but just things that impact again, the control of the attentional beam. Yeah, like there are many processes that come together from various aspects of the bio psychosocial model that affect the final like mechanism or operation of attention. So I, I like the analogy you're using of the [00:11:00] beam.

I kind of, I think about like a laser pointer. Almost, and maybe sometimes the laser pointer is like bright and it can po focus on exactly what you want to, and sometimes it gets dim and kind of flickers. So when, when I think or try to define attention, I think about it as the, the ability to direct, sustain and shift focused with volition, which is pretty much exactly what you said.

And that's kind of how I would like divide them into like the three like subcategories of attention. So there's sustained attention, which is like, how long can you, like, stay working on the thing that you're working on? And there's selective attention. So that's your ability to block out distractors while focusing on the thing that you're trying to focus on.

And then alternating intention. So your ability to kind of set switch between tasks or within a task. And that, um, has a lot more to do with like your working memory. While you're like operating or, or multitasking. I know, you know, people talk about how your brain can't truly multitask, which is true. But while you're focusing on [00:12:00] one task, your working memory is still keeping track of the other tasks in the background and that, and you use complex attention to kind of work on those two things.

What, what were kind of like, what questions? Either on the moca or in like with if you're bedside and you're assessing memory like briefly, right? Like not this complex. Like what kind of questions or tasks elicit this Great question. Am I getting in your way? No, this is like exactly where we'd be going next with this.

Just three seasons in. It's all done. Yeah. Yeah. So, um, when I'm trying to see if someone is like, capable of sustaining their attention, because one of the, like most common things we're looking for in the hospital is delirium and delirium affects a lot of the medial structures, which, um, actually have a lot of impact.

Impact in how we direct and control our attention. So the default mode network sits right along the perus and the posterior cingulate cortex, which are like right there in the middle. And then it starts to get dysregulated as you become delirious. So anyways, you're like, okay, is this person [00:13:00] delirious or do they just, you know, they like to throw hands every, every evening at five.

Well, my hand throwing time and I got a question for you, and that question is, can you say the months of the year backwards is usually a great one to start out with and like, but for the sake of rapport, um, or just to kind of see if someone's. You know, uh, able to converse with you. I usually have 'em say it forwards.

Mm-hmm. Or I'll say the, the days of the week forwards. So it's not as much an a function of attention to just say something that you're familiar with. If you've done a thousand times, it's almost like a song, like you could sing A, B, C, D, F, G, like without really have to think too hard about it. But saying your ABC's backwards, you have to stop yourself and you're not using like your motor memory, so to speak.

So they can do January, February, March, April, and then they go through the whole year forward, no problem. But then to go backwards, you have to hold it in your head, like you have to picture December, November, [00:14:00] October, September. And usually what will happen is if someone has impaired attention, they might get to about in September and then August, and then they'll start going back down.

So it's December, November, October, September, August. September, October, November, December, kinda like that. How do you think about that? And like you're saying, like when we assess for delirium, how do you think about that test? Like let, let's say that's the result you got is that they can kind of go forward rote, but like when they start to go backwards, they get to September and kind of fall off.

Um, what kind of finding would make you think more of the waxing and waning, I guess, arousal and alertness that are part of attention versus like, this is part of a dementia or other kind of attentional disorder? So, I mean, the, the waxing and waning arousal and delirium, uh, we're not gonna be able to assess at like that single moment in time.

Right? Because as they're waxing and waning, we're like seeing them at one [00:15:00] moment. Yeah. So I think. Regarding the arousal part, it's like, are you even awake enough to talk? Mm-hmm. You know? 'cause if someone's just like, they're like falling asleep while you're trying to talk to them, you're not gonna get a good attention assessment out of them if they're just like so sleepy.

Because the other thing about being in the hospital is that people get tired. Yeah. Being, being tired and wanting to go back to sleep and not wanting to like engage is not a sign of delirium in and of itself. I guess my question is, how does the test help in the assessment? Like, if it's like, I get, we can't, we don't, we need to get multiple points to see if they're like, kind of going up and down.

But like if you, if they do that, what does that say when you're at the bedside assessing for delirium? Or is it just like one data point and then you're gonna check eight hours later and they're very different in that data point? Well, even, even when these patients are up, yeah. They'll, they'll still do poorly on the attention testing.

Oh. Even if they're, okay. So then the attention. Stays the same in delirium? Yeah. Like their, [00:16:00] their arousals, waxing and waning. Got it. Yes. But they're not getting back to a hundred percent and they're still gonna be struggling with the attention testing. Huh. So that's, that's where like, this is helpful because you come in, it's 10 in the morning, they are up, they are engaging with you, and you're talking, you're like, things are going like pretty normal, like, you know, all, all these answers at least sound superficially coherent.

And they've like, kind of explained away the conflicting situations of the night before. And then you bring on the, the attention questions and you're like, oh, there's still a lot of like difficulty with this. Another one that's really good is, uh, to spell world backwards. So if you're listening right now, I want you to just try to, try to do that and think about how hard it is so you, you really have to hold the word world, like picture it in your head and then go D-L-R-O-W.

You can walk it backwards. Like I, I, I have to picture it every time I do it. That's a really challenging task to [00:17:00] sustain attention for. So that's usually one run to trouble with, I I, most of the time I avoid that. Um, unless people are like of a higher, like, like college educated or higher level. Mm-hmm.

Because I think sometimes just like not a helpful test for people who aren't like, particularly literate and like there's no point in like, like making this an IQ test. Like it's really to see like, can you stay focused on something. Um, and then when you're doing the mocha, the portions of the exam, um, will be the serial sevens so that the math part where you have to start at a hundred and subtract seven backwards.

'cause you have to keep holding something in your mind. All you staying focused on it hate, they hate that one in the emergency department. I'm like another one. I didn't hate it in the clinic too. I, I don't think anyone likes doing math ever. So, um, that's, it's, it's. I would say most helpful in, um, assessing for delirium.

Um, there are some, uh, patients with frontotemporal dementia that it might come through. Mm-hmm. Um, that they're [00:18:00] like having trouble, like sustaining their attention. And then in most forms of def of dementia, as it gets progressive enough, they're gonna start to have deficits in all domains. So you'll see the attention portion start to wane off as well.

And for listeners, it's probably not sensitive enough to pick up, it's not used as an A DH ADHD test. Yeah. Just for people not in the field. Like it's, it's a little too blunt of a tool for most A DHD cases. No, I think it's, it's good to include, like, this is a blood pressure cuff. It's not, it's not like a intravenous monitor.

Yeah. You know, like te like getting your map at any given time. Um, and then it's, it's tough because like people can, can compensate in other ways mm-hmm. And not say social racism intact. Yeah. Yeah. Um, okay. So dealer's choice. Uh, I guess that was most of what I had for attention right now. We won't get into like the neuroanatomy or anything like that.

Just what you can do with the test and, and where you're going with it. So what, what do you want to talk about next? Um, [00:19:00] visual-spatial. Okay. Visual spatial. So this, this section of the mocha is the cube drawing portion. Mm. Yes. So how good are you at art? And I, and I guess I will talk a little bit about the brain regions here.

So this is, a lot of this is in your parietal lobe, so kind of the back, right back left a lot. And it affects your cerebellum too. So really how good are you at relating to stuff in space and then integrating coordinated movements and, and planning motor movement. Mm-hmm. So, um, visual spatial, um, testing is, um, one of the signs that like.

I, someone has like posterior prial, posterior cortical atrophy. There's no like type of dementia or like TBI that's gonna be like so specific for, for this, but it can be a sign of like function later on, I guess is how I put it. So some, some of the interesting tests that you can do with this outside of like having someone copy a cube is there's a [00:20:00] graph seizure.

So you can hold their hand out, hold their palm out, and then trace like an eight in their palm. So you have to think about, like, you have to incorporate a lot of somatotopic sensory calibration to say like, okay, like the direction of someone's finger in my palm going back and forth, where does that sit in space and how do I like interpret that?

So, so that's a good way to test it. The other thing you can look for is, um, they can imitate your hand signs. So like, Margaret, can you do this? Having a stroke or by the like common like trauma, the tron common piece. I can that, yeah. Yeah. So, so if you weren't able to do this, this would be idio motor apraxia.

Nice. And so it takes your, your mirror neurons have to look at my body shape and be like, huh, where is he sitting in space? And then use your body to recreate that. So I was, I got like dinged in clinic because I would be like doing stuff that was like, too complicated. Like, I'd be like, I'd be like, [00:21:00] you were like, why can, can you do the Dougie right now with me?

They're like, no, right now. I'm like, I'm like, hit the gritty, or I swear to God I'm diagnosing you with dementia. Um, no fans and flex, but I actually do. I, so, so this one's pretty good. And then I, I like interlace my fingers like this. Mm-hmm. Um, and then I'll take like two fingers and I link them like that.

Imagine, right. And you, and then you do this. Yeah. And then I go, how did I do that? Stop. Oh wow. One of like, what is drawing the clock on the mocha? Not, I guess I'm thinking of like hemi neglect, and if that counts as visual spatial, like when someone draws a clock, I mean, yeah, it is like drawing the clock is, it includes like visual spatial function includes attention function.

Like people are like, oh, this is a good point. The clock drawing is executive function, and yes it is, but in order to accomplish the things that you need to do executive function, you [00:22:00] have to incorporate all of these other like subdomains and processes in the brain. I feel like this is an important point and like for listeners who are less familiar with this kind of idea of the brain, instead of thinking of the brain, I know we've talked about this, but instead of thinking about the brain as these like disparate parts that each like little section has its job, you should think about it, of like a ball of tangled necklaces all together.

That's a more accurate depiction. Am I wrong? No, it's good. Uh, that it's hard and it's hard. And similarly, it's frustrating to try to tease 'em apart from one another, um, in terms of the circuitry. Mm-hmm. So just saying that like a test, like drawing the clock, which is when you, on the mo you ask 'em to draw a circle and draw a clock and then with the hands point at the time.

Um, and so there's, so ma there's actually quite a few functions there that can go wrong if other related used functions are down. Mm-hmm. Yeah, absolutely. Um, I will say that when someone's, um, visualist [00:23:00] spatially impaired, um, selectively or more than like other domains, or when someone becomes so progressive, they start to show, show visual spatial impairment.

Um, it's important to think about things like driving privileges. Mm-hmm. Because your ability to operate a motor vehicle predict where you're gonna be in space and interact with other moving objects going at. Lethal speeds if you make mistakes is, is severely impaired if you like, can't employ this like part of your mind.

So, and what are you thinking diagnostically, like when you say, when people get this impaired in this region, what kind of, what's your differential that comes up when that region's impaired? If it's in an older patient, like the most likely, um, neurodegenerative disease would be Alzheimer's that's gonna have like parietal impairment and then eventually, and, and so I think that's actually most of the time where the conversation is where someone has Alzheimer's disease, but it starts out with just mild cognitive impairment.[00:24:00] 

They're normally a high functioning and you're just kind of watching them along as they slowly progress. Mm-hmm. And you as the doctor, have to decide each step of the way, at what point do I take these privileges away? At what point do I assess their dysfunction to be at the level where like this is no longer safe.

So I would say that. Using things like this cube drawing or like visual spatial assessment, it may not necessarily be the definitive diagnostic tool. It can be helpful as a prognostic tool. Got it. Okay. That makes sense. And we just did our dementia episode, so just did Yeah. Tune into that episode for more.

Yeah. Um, okay. I think that was kind what I had for visual spatial. And are you using any of tools? Are you bringing out that bag that, that was one of your best tiktoks of all time? And I will tell you that straight up, the like neuro, when they show up to a console bag of stuff, are any of the tools still coming with you?

Yeah. Oh yeah. I have the fanny pack. [00:25:00] What are the, what are your must haves? Oh, let, lemme lemme grab it. We'll, we'll do a hall, someone do an edit. Please don't, it'll be terrible for, okay. Hey Sr. What's in my bag? What is, what is, so I got this bag at Austin City Limits and I put a couple little plants on it.

This is, this is my little neuro bag. I have, I have other non, okay, so start out hot. We have the four

very shiny, oh wait. Ooh, you hear that? That now we're in ASMR territory. Okay. You ear funny bone with it? Yeah. Well, yeah. No, I was, I whacked my elbow with it, so I just go like, boop. It's like gets it nice and crisp, you know? Or you hit your knee too. That's how Preston puts himself to sleep. Guys, just so you know it, it's honestly so comforting.

Okay. So [00:26:00] tuning fork, I don't actually use that often.

Continue. If, if someone's having like, um, apraxia, gait disturbances, they're getting dizzy. Like I'm, and I'm thinking about proprioception. Mm-hmm. I might like zero in on it, but it's not like part of my standard battery. I mean, honestly like hearing loss intern year, I was so excited that like every psych patient I would be like, time for our neuro exam.

And then they, I like get the bag and they're like, not the bag. And I'm like, yes. The bag. They're like, I, I thought that was just the neurologist that did that. And I was like, I, I deep damn wanna be a neurologist. That's why I always get the bag. Um, anyways, uh, so if I'm thinking about proprioception, then you can do vibratory sensation.

Um, it is helpful though, and that if you're trying to assess the degree of a patient's neuropathy, which I did a lot of [00:27:00] internal medicine, so you can walk, hit the tuning fork and then walk it up their shin bone. Mm-hmm. And most of the time patients will tell you right when you hit the spot where it's like, yep, I can feel it.

No, I can't feel it. So that, that actually is helpful. I think that's like, like do we expect psychiatrists necessarily do that? No, but like in the, in the real world healthcare system, if you have a patient that's like, I don't know when they can see their PCP again, I'm like, I'm causing worsening metabolic stuff for them.

And they're older. Like, I don't know. I think it's reasonable to be like, I can, they're in my office right now. Let me test this out. So, yeah, no, I, um, VA inpatient, I've used the NU Fork to justify starting patients on Pregabalin mm-hmm. To my attending to be like, Hey, I, they will, I don't think they'll see their pcp.

Yeah. Like, this is, this will help the peripheral neuropathy and Okay. Yeah. Like, you did the exam. I'm like, and I've got the tuning fork to prove it. They're not gonna, they're like, okay, you, you can have a little pregabalin. It's a treat. You're gonna have your pregabalin pressing. I'm like, good. You just [00:28:00] put it into your holster.

Don't make me bring this out again. Okay. Uh. We know her. We love her. A classic. Yeah. Nothing else to say here. Reflex hammer. Um, this isn't even a neuro thing, it's just a pack of gum. What is that? Otoscope. Oh, stays in the bag. Stays stay thing stays on me. So the, this is a, this is an interesting one. So the reason why I got an otoscope was, um, I had, I had a patient one time, they had this delusion that there was something in their ear.

Mm. And the, like, the CT scan was negative, you know, like mm-hmm. ENT had cleared them in the, in the ed. And then like, they're coming outta the psych floor. And everyone was like, you know, like, there's nothing in your ear. And then, and then I was like, yeah. So like, you keep talking about the thing in your ear and they go, how do you know there's nothing in my ear?

You haven't even looked. And I was like, valid. Damn. You [00:29:00] right. I haven't looked valid. Has anyone looked? I'm like, I'm like, you ride as hell. So I was like, I'll eat my words. I'm gonna go get an oti. Go right now. Lemme lemme back the hell up. You're right. And I was gagged. Was there something that's here? So not, not that patient, but I did have another patient who, um, you're just looking in all sorts of, they, they kept complaining of having the psychiatrist always makes me look in my ear.

They kept complaining of having like, uh, hearing loss on one side and people kept attributing to their delusions. And of course, me, me, with my tuning fork, I, I smack and I stick it on his forehead. So I deal Weber test and it goes right to the ear. Like he was having hearing loss in, I was like, this man's got some, uh, some bone conduction.

Oh, I just know you felt like Dr. House in that moment. I know you felt, you felt better than everyone and I don't blame you. Yeah. Turns out [00:30:00] to, um, get rid of the voices. He had been shoving wax paper into his ear and had like blocked it completely. Yeah, yeah. So yeah. So we were like, well, there's some bone connection.

Look inside. We're like, there's just a lot, dude. Good. Something in there. Um, took him to ENT, got it all removed. Like they walked him up to the clinic and then walked him back down. And then they, they came back and he, he had a whole list of like proper ear care. So like, while we're still dealing with the delusions and everything, I was like, what are we gonna do about your ears?

And he's like, he's like, no Q-tips only mineral oil. I'm gonna wash it in the shower. And I was like, hot dog. This guy, this guy's got some good ear hygiene. So, um, that's, that's all I have for the otoscope. And then I used to have a feather because I thought it was funny 'cause it was like light touch. And then there's the, um, pen light, all classics.

And then there's like also festival stuff in here. So sunscreen and sunscreen [00:31:00] and uh, ear plugs. Yeah. You know, they're like the second pet point. I'm just Turing, I'm just picturing like, yeah. So I go to see the psychiatrist and he does the weirdest thing. So he makes me like, take my socks off and he puts this vibrating hammer on my feet and then he always looks in my ears and then he asks if he can sunscreen my back.

It's very, it's very odd. All the things he has in his it. And then, and then he puts in earplugs. When I'm, when I start talking, I'm talking. Doesn't make any sense. Okay. Where were we? Well, well thank you for that brief intermission to go over Preston's narrow bag, um, that I take on call. Uh, we were moving on to the next neurocognitive domain, which, which is, I'm gonna go with language because we like language and we like to yap.

So let's talk about how we assess language. And we've already kind of gone over like the aphasia episode. Yes. SLPs, we are working on it. Our SLP listener base. We're working on it. Yeah. We'll, not belabor the aphasia too much, but when you are assessing [00:32:00] language, um, there are a couple like things to divide it into.

So, so you can test for fluency. Um, and I usually do that in like two subcate. I, I say I like, I came up with this myself. The, it, it's usually tested for in two subcategories. So there's like the semantic fluency and then there's phonemic fluency. So semantics meaning like the details of the schemas that something lives in.

So a, a semantic fluency test. Margaret, are you ready? Yes. How many vegetables can you name in one minute, go. Uh, green beans, broccoli, asparagus, bell peppers. Drew am be crushing you right now. He would be kale, rat, onions, garlic. Turnips parse, parsley leaks. Do herbs count as vegetables? Yeah. Fine. I mean, they're plants.

I don't know. Okay. Mm-hmm. Herbs count as vegetable, then oregano counts. Mint counts. Okay, that, that's good for [00:33:00] now. Lemon balm listeners, as you can see, Margaret is, is relying on her like vegetable schema now. Things that are like edible and plants and not fruits and then she's able to kind of like navigating through that.

Um, now we're gonna switch it up and I want you to say all the words you can think of that. Start with the letter C. Okay. Now to go. Yeah. Now go that cart coup cougar, calligraphy, Calvary, Calgary. Countess count. Did I already say cow? Cow? Mm-hmm. Uh, cool. Okay. And that's good. So you see how like a lot of those things, they weren't really that related to Calgary Cow, Countess calligraphy.

Don't you hate saying my vocabulary the same when Yeah. Well, no, you do a good job. Like you're, you're actually doing a great job of like exemplifying, um, like activating your different lexicons [00:34:00] because you, I imagine with the B words, he just goes like, bifocal, bicentennial, biannual, bi. Yeah, yeah. Bial wrong.

And I'm like, well, like not wrong. I mean, I'll, I'll call that a workaround. Um, so you want people to be pulling from different kind of like, why does that, why is that a workaround or is that not test? Does that not test it as all? Well, I mean, you're, you're, so, you're hoping to test someone's like phonemic lexicon when you ask them that.

And phonemic means it, it means like the um, like the actual syllable, like the sound of the word itself and like what. When you have, when you're thinking about like what your brain can make words from and what sounds, you have your like list of letters and it's like, okay, I've organized them by like, sounds like, uh, [00:35:00] ooh.

And like in your like little dictionary in your head, the s sounds have like lists of words. So that's what I'm asking you. What are all the s sound, s sound words, but then also in your head you've categorized things by like things that are tasty, things that are dangerous to me, things that are verbs.

Things that are nouns. And I'm asking you to like tap into one of those categories. Oh, got it. Okay. So we're trying to see how well you can access your like different little wells of information. Got it. Okay. Can we make you go? Yeah, sure. Okay. Preston, you have 30 seconds as many words that you can think of that start with the letter M.

Um. Manage meticulous, mundane, minute modicum. Um, massage massacre, meet many, um, manipulate, um, municipality, um, Monarch, um, monopoly. Okay. You're good. Oh, [00:36:00] that was kind of fun. I like that. Isn't that fun? Yeah, it's okay. You don't get to ever make fun of me for using big words though, based on what the ones you just listed.

I just spend too much time on the New York Times games, um, which is actually a perfect way to apply these, like different, um, brain flexing things. So the, um, crosswords in general do a great job of like forcing you to access your like different semantic lexicons. Uh, and like also like the New York Times connections, you, you always have to think about like how many ways something that can be interpreted.

So for example, like. Um, count can be like literally like a person or it can be a verb. Mm-hmm. Right? Yeah. Or like, or it'd be like, you know, the customer is always right, but it's spelled like WRIT or something, and then it, it, the answer on a crossword would be like the check or like a tip or something. Um, so it's like the trick with a lot of crosswords is you have to like, look at the hint and say like, okay, how many different, like, [00:37:00] schemas in my brain does this word fit into?

So it's, it's like a fun way to practice those things. Um, this is, this is helpful because different types of dementias will like fall into these different types of aphasia patterns. So we'll see patients that will like, do pretty well with semantic fluency, they'll do okay with like naming. So like, they can identify, they have, they don't have like visual agnosia, but then they, um.

Struggle a lot with, or I guess it'd be the other way around. Like they're okay at like producing speech, but they struggle a lot with like categorizing stuff. So then you can have like the semantic or logopenic subtypes of like frontal temporal dementia. That's where this can be like helpful for differentiating.

I also think that like with language, something that comes up in like the mental status exam, right, is like how do the words fit together, which is in this category, but I think is harder. I'm sure in the schizophrenia like literature there are more, and you may know like more complex tests. Mm-hmm. That can look at the like relationship between words and the [00:38:00] incorporation of like delusion reality testing, which is like what we're talking about with language often in psychiatry of okay.

Whether that's like someone's just like can't, continues around and around and is kind of circular and they're how they speak and they don't get to the point whether they're tangential or what, whether it gets to the point of like true psychosis where. There's like word salad and it's totally or tangential and kind of mm-hmm.

Not connected to each other. Um, I know we're talking like neuropsych, but I feel like there's this false, we've talked about this, I know you think this too. Like there's this false divide of we're in like neuropsych clinic and we're gonna do this. Whereas I think it, like in ideal world, psychiatrists and neurologists would be able to like combine the brain functions that are both in this region, right?

It's like the attention thing would be like, we have our, we understand our test, test attention in the like dementia realm, in the delirium realm, and then in the like executive dysfunction realm, which could be a DHD, but also other things like, [00:39:00] wouldn't that be a really smart psychiatrist? Mm-hmm. Yeah. I mean, you, you're like describing my goals in life.

You're going into, going into neuropsych, so, hey, you hear that chat or think of something cool.

Okay. Yeah. And, and even like in, within the mental status exam, you're, you're always doing neurocognitive testing. So when we say that someone's tangential and that it's hard for 'em to stay on topic, you're still discussing things like their sustained attention, they're selective attention, their working memory, because those are all things that you have to accomplish while you're in a conversation.

Right, right. And again, it's like this, the network where it's like, are they struggling to do it? This, like, which part of the stream is interrupted that is making this error come out? Like if it's like they're hallucinating another person and voice in the room that they're listening to, very different than someone with like an aphasia from a stroke.

Yeah, [00:40:00] absolutely. Um, the other part of language, um, that I always want to include is social language. So being able to identify and respond to social cues appropriately. So the lateral occipital, um, cortex, um, and the thalamus, the amygdala kind of work together for facial recognition. So there's like, there's like the fusiform face area or something, um, which is like a very specific part of your brain that is designed just for like identifying human faces is it's like that ingrained in who we are, that like we're gonna try to recognize like who a human is and what a human is.

So that works together with our emotional, emotional processing centers. A lot of that is done in like the orbital frontal cortex, and then we kind of make decisions or also feel emotions based off of our interpretations of other people's emotional expressions. So, which is it? It basically was like the mirror neurons.

Mm-hmm. So to speak that you were taught about, um, in like [00:41:00] psychology 1 0 1. This is like helpful too though because, um, when you're trying to look at, um, how people respond to or think about other people's emotions can kinda give you like an idea of like what type of disorder they may fall into. So, so one example is like, um, antisocial personality disorder or like, I know this isn't a d sm, but like psychopathy, um, as a, and define psychopathy for people.

So, so it'd be like someone who is a psychopath, I think is someone who's like, incapable of like, feeling any kind of affective empathy for another person. Like, like biologically they don't. Have any like, amount of affective empathy and affective empathy. Meaning like feeling with someone, like you see someone who is sad and you genuinely feel sad too, right?

So people with that condition may go on to develop antisocial personality disorder because they don't have any, like, [00:42:00] why would you feel guilt or remorse if you don't have any like, negative emotions that happen when like, someone else is being tortured. So they, there are some like cases where they'll, um, use MRI to look at patients like that and they, they have underdeveloped or thinning, um, of the orbital frontal cortex.

It makes me wonder, and you know, I know our listeners are smart, so if someone might be able to decide a study to me on this, but it makes me wonder about like, what is activated, like in terms of human socializing. What is activated when people only know each other at like, like your loose relationships with people you work with, if you only see them on Zoom.

Is that part of like why Zoom feels fatiguing is like part of the like. Lack of total, or, and this could be not true, right? Like this is hypothesis. Uh, but like what, what that is, and I'm sorry this is tangential, but I do think it's interesting regarding this like, concept of, and, and I, since I work with kids, like how people develop during COVID.

Like can you [00:43:00] assess that with some tests in our battery? This is outside the scope of what we're talking about, but dude, I don't know. That'd be interesting if, I mean, we're talking about using EEG to measure brain activity for, uh, you know, things like your brain on and off chat. GBTI wonder if you, you look at the social recognition parts of your brain with an e, EG, or like in person versus on Zoom.

Mm-hmm. I imagine it's, it's just harder and that you don't activate as much like emotional reactivity and affective of empathy when you're not in person. I, I just, I, that's my hypothesis. Ultimately, I think also like we're talking about empathy, but like there's a component of empathy or feeling with that has to do.

Quite a lot with just the feeling of liking, like liking someone, liking being with them, and if that's blunted, although there's probably things that are enhanced for people who are like, have sensory needs or other things that they can control more of it. So anyway, this is a tangent, but I think it's interesting and [00:44:00] because of COVID, we all transitioned a lot of things onto that, that we kind of don't know what that's doing to our brains.

Um, in the long run. Yeah. How can I be in this Zoom session with 30 other people and feel so alone and, and look around and be alone? Crowded? Yeah. Whoa. Yet, yet, I'm just, yet I'm outta social. I'm outta pre-interview social. How can this be? It makes no sense. Those are torture. The word social is in the name.

It's right there on the title of the zoom that ends in three minutes. So, and then with, with other, um, conditions like autism spectrum disorders, so affective empathy can actually be much more intense. So when you see someone who has an emotion, you may feel that emotion much more intensely. And what's tough about autism specifically is that the other, the mentalizing where someone else is coming from that cognitive empathy to be able to like, articulate and describe what that other person's feeling, [00:45:00] why they're feeling it, and where they might be coming from, that's also impaired.

So it's like you feel this really strong emotion and you don't know where it's coming from. It can be very challenging for people with autism. A lot of it has to do, from what I've found to be like the relationship between the amygdala and the ventral media prefrontal cortex. So the amygdala helps a lot with like recognizing, uh, strong emotions in other people and in ourself.

And then it, it almost like, rather than getting filtered through the ventral media, prefrontal cortex just goes straight to your frontal lobe for you to act on it. So that, that may be somewhere around the hypothesis of like why there's like such strong emotional reactivity in, in people who have both a DHD and autism.

Because A DH ADHD also has, um, dysfunction of the ventral media prefrontal cortex, and there's a lot of like emotional reactivity in a DH adhd. I, and also, I know I, I think we talked about this in the dementias episode, but there can be kind of a difference in, I feel like clinically, at least like how the progression of [00:46:00] different dementias and at what point the social like ability to present socially well, or to kind of stay, seem well for like a 15 minute interaction in the emergency department can differ pretty widely depending on mm-hmm.

The area most impacted by the dementia process and also the course, right? Mm-hmm. And also the learning from you also where the person is starting. So the cognitive reserve can be a, a big part of this. So, um, I, I gave a talk on, on this today and one of the examples, patient, can we get an horn there? Can we get an air horn there?

I mean, I say like, I give a talk, like he was badass, but I mean, I just, I went and talked to the neuro residents about like, neuropsych assessment and I was, honestly, I was kind of nervous, but I was like, uh, you know, I'm like your colleague. Like, we'll just chat about it. We're brothers, you know? I know what I know.

You guys know and you know, and it'll be fun. We're, we're here to have fun, right? We're here to have fun and if you had fun, you won. That's what it said. Uh, on the sign above my [00:47:00] gym in elementary school. I thought you were gonna say I on podium. So, yeah, like if you have a high cognitive reserve, other people may not notice for a while as you decline.

So, um, yeah, the patient example I used had a PhD and by the time the patient came at their family's behest, the, they had been so far gone that their MO is in the teens. Yeah. Yeah. And it's like, wow, like, you know, I feel like we just noticed this in the last six months. It's like, no, this has probably been going on for years, but they, they've been able to compensate or explain away a lot of this stuff.

I also feel like it's that difficult thing like we were talking with, with attention and delirium, but from a larger scale that like if someone's been like, well, they don't see a psychiatrist or a neurologist, they only see their PCP and with the amount of turnover, understandably in healthcare, it's easy to see how meeting someone for the first time and having them say like try to describe the changes they're experiencing when they haven't gotten to that LO of moca yet could be kind of passed off as like normal [00:48:00] changes are kind of still so much higher above functioning depending on the population you're seeing that it kind of feels like, oh, that's not anything.

I don't think that necessarily we operate that way. I think people are more cognizant of this now, but you can see how it can be hard to pinpoint these changes. Like we talk about them. As though they present linearly to clinic and they often don't, and you like have met someone once and it's, they get a moca that's like higher or some, you know, whatever.

But mm-hmm. Yeah. And, and I think like for, I hate to say this, but I think like for you or I, if, if we were to like start getting like a neurodegenerative disease, we'd probably be like, our mocos would be like 30, 30, 30, 30. And then like 19. Like we would just be holding on. We'd be holding on, you know? And then, and then it would just, it it's be because like we'd need to have like a more challenging test to elicit it first, and then it, and then by the time it hits it, it we're like on, we're in free fall, I'm coming down.

And that, that's like, that's what you see with, [00:49:00] honestly with like pilots, lawyers, doctors, engineers, um, that are like experiencing like Alzheimer's disease. Is that they'll, it'll just be like. It seems like subjective issues or they're telling you their problems and you know, it's, other people are like, I'm, they've always been pretty smart, and like maybe they're not as efficient as before and, and then their milk has come up normal and then it starts to go.

So that, so that's actually why like neuropsychology testing is really important because they do everything off of percentile. So they look at people at your similar age with your similar level of education and then determine what percentile you're in. Yeah. Which is not accountable for by these bedside psychometric tests.

Right, right. Well I think like my dad, like after he had his like first resection for glio, and I can break this. My dad knows I have this podcast so I can break this part of his HBI, I think like he, my sister and I have always called him. My sister coined this, we called him like our dumble door, we called him Dumble dad.

We were like, he's just so smart, whatever. [00:50:00] And he still is, he still beats me, uh, us at like cards every time I go home. Uh, and. But the cognitive tests and like the neuropsych tests were kind of like, you're still functioning really great. And he is like, I feel so different. Like, I feel so different because like I just had brain surgery.

Yeah. I do not, I'm not the same person. But, but to your point of like, how do we capture it at the bedside, but also in neuropsych testing, and then how do we help people in different ranges and like know what we can improve, especially when the timelines, especially for like dementia or other things might be like, we're gonna do this thing that's gonna be really hard and slow work to maintain or to mildly improve.

And I don't know, I think I had a lot of respect for our neuropsychologists. Uh, I think their work is so needed and I think we get, need to get taught by them more as psychiatrists, very frankly. Mm-hmm. Yeah. And I, I feel really lucky that like, um, every Wednesday I rotate with like, um, like a combined [00:51:00] neuropsychology neurology clinic.

So. They have like shared patients where like we get to go see and like have them present their battery of neuropsych tests. And I like, they like show me the results and I get to like, learn new stuff from them every time. So honestly, yeah, shout out to neuropsychologists. You guys do cool stuff. Um, okay.

Uh, I can't remember what the next one was. Just fail working. Memory fail. I mean, oh, it was memory and recall. It's coming back to me now. Was that on purpose? Yes. Oh, okay. I I never catch Preston jokes. I'm making a joke. I never catch them. Social grace is broken. I'm always like, he can't be serious. Right.

Okay. So, um, there's the, okay, your, your ability to register something, identify it, and then recall it. That's all. That's all like, most of it's gonna be in your temporal lobes, in your hippocampus. Like, that one's like pretty, um. Pretty localized relative to like a [00:52:00] lot of other brain functions. So the, the part of the mocha is for this portion is at the beginning, or like early on, you say you have them repeat face, velvet, church, daisy red, or the other one is leg cotton school, tomato, white.

I think there's like, there's new versions of the mochas, you know, like they remix it with different animals, different words, different numbers. It's kind of sick, you know, like there's one with a giraffe now. Anyways, when you come back and you ask them, you know, five minutes later, can you recall any of these words?

There's more information that it can tell you than just, I can't remember, zero out of five. And, and you need to, to be thinking about that because there, there are different types of recall. So there's cold recall, there's assisted recall, and then there's recognition. So, which we talked about last week on the dementia episode.

Right, exactly. So I won't, I won't like belabor that at all. But essentially, um, [00:53:00] if you can't cold recall, but you can like assist, recall, or you're able to even like have it encoded at all, that's, that may be a sign of a white matter track issue. But our listeners who can't recall from that episode, what is that issue?

Yeah. Yes. To, to remind you. Yeah. So, so basically the, the point is, um, it's kinda like the file cabinet analogy. We're just trying to see like, did the file even make it into the cabinet and it's an issue retrieving it or did, or is the file cabinet on fire and there's nothing to store? So that's ultimately like what you are assessing for here.

Um, so if, if they can get it with a category clue, like, hey, one of them was a body part and they're like, oh, it was a face, then that's a sign that they can still retrieve it. Or you can say, Hey, like one of 'em started with a D and they're like, oh, daisy, then. They're able to use the, kinda those semantics and phonemic cues, um, which is, this is a repeat from, um, the dementia episode and then recognition or multiple choices.

It, there's honestly like hopefully, uh, if they have stored it all, they should be able to recognize it every time after five [00:54:00] minutes. And then that's actually a very good sign of like true registration impairment. If, you know, you're like, okay, between firehouse police station and church, which one was it?

And they're like, I have no idea. And that was from four minutes ago. That's a sign that was never really encoded. So I don't think I have too much else for like immediate like memory retrieval and recall sometimes that with that recall one, there can also be an element that you can suspect, uh, it can be an effort test sometimes.

So like. Unless someone is super impaired. And I'm not saying there can't be, you know, esoteric cases where there's like some very specific thing happening, but if someone can do everything and you've heard them talking while you're outside the room and they recall X, y, and z that you said a week, like a week ago, the, the likelihood that they truly cannot recall something from a few minutes before, um, again, not a slam dunk, but mm-hmm.

It makes you think like, how seriously do I take the [00:55:00] entire neuropsych exam we did on some of these when it's like, I'm pretty sure that you actually have more than that and that like you're kind of throwing in the towel on purpose a little bit sometimes. Yeah. No, no, no. Really though, like sometimes I'm like, okay, what were those words?

I don't remember. Do you wanna try? No, no. Not even a little bit. What I wanna try of. Actually, I've never heard anything you've said. Okay. This is supposed to be working with teenager. My, to be honest, you're paying attention when you're talking. Okay. Nobody said has ever meant anything to me. You were like, yeah, you, you were saying like, repeat these five words after me.

And I was like, who are the y Chino? Good lord. And then I, then I just started, you know, thinking about other stuff and I'm like, okay, well just, and that specific radiation was going. Yeah. It's like, actually we're gonna, we're gonna pivot here. Yeah. Um, one more. Yeah. So executive function. [00:56:00] Oh. Um, this is like classically the clock drawing test and, and really executive function, uh, is the, it's the culmination of cognitive processes that help an individual plan, organize and accomplish purposeful activities like what you need to execute.

So, um. To draw a clock, you have to plan the size of the clock. So you're, you're picking like how big you want the clock to be, and then you have to, uh, also plan how far apart you wanna space out any of the numbers. And then you have to orient the hands all while, all while thinking about like what the time of the clock is gonna be.

Mm-hmm. So that's a good way to like immediately kind of like combine all of those tasks together. Um, executive function isn't like one I really do at the bedside too often, outside of like clock drawing I guess. But I do get into it a lot in the history. So this is one where we also talked about this, um, more in the dementia episode, but like looking at people's instrumental activities of daily [00:57:00] living and activities of daily living.

Mm-hmm. I think one of the greatest tests of executive function is cooking at home because you quite literally have to plan, organize, execute, and accomplish multiple things that that can burn. So that, that's usually like if I'm trying to get an idea of someone's executive function, I love to start with cooking.

Mm-hmm. Or just, just who does it, if they like to do it. If they could do it, like, walk me through like how you bake a cake or something. But then outside of that, like how people do in their career is a good, um, I think proxy for executive function. So, and I think especially in like a lot of higher functioning people, that's gonna go well before any of the instrumental ADLs do.

Mm-hmm. So like we were talking about before, you know, someone who, someone who is a lawyer, they, they can probably keep accomplishing their instrumental ADLs for a long time, even with like progressive impairment. But it's, it's where they'll first notice it is. Like I wasn't able to keep up on top of cases like I was [00:58:00] before.

Yeah. Yeah. My, uh, no, I was just gonna give you an example of this. Like my, my dad wasn't retired right after he got sick, but like. He plays this game called Strata Football, which he's gonna laugh. He's gonna laugh. It's this football game from like the fifties and sixties that is just physical card games.

He couldn't play it anymore because he had less executive function basically, or maintained attention. And so he created this massive Excel spreadsheet that he then printed and put onto individual cards. But he, Fox as like an executive function support. Wow. Like an executive function crutch. Yeah. Yeah.

But he like didn't, wouldn't have needed that before. But, so I feel like also that can be a sign that it's like people have been functioning at something for a long time and then all of a sudden it's starting to seem like they have to use other strategies or things they've not needed to do before.

Mm-hmm. And like to your point, these like highly effective people will be good at trying to come up with crutches, kind of, which is great. Mm-hmm. But also something we should think about clinically of like, why are the crutches now needed? [00:59:00] Yeah, exactly. And, and then the signs too, clinically, even if people are in denial or lack insight about their decline, it may be, um, you know, my boss hates me, so they let me go, or I decided it was time to retire.

There are times where it's like, I was worried I was a liability, which is why I wanted to retire, but it's, it's, it's across the entire spectrum. And so from the outside, you just have to look at the facts, like, okay, fact number one, like they're no longer working. You know, fact number two, they're, they're having trouble with solvency, you know, they're, their interpersonal relationships are suffering.

Um, and then you have to kind of take those explanations with a bit of a grain of salt or look into collateral. Well, I'm gonna also compare this to like, especially in outpatient. This is why we don't tend to make diagnoses of like dementia or other kind of neurocog things, unless it's a slam dunk and obvious in the inpatient setting or in the emergency department, which is the point that you made earlier of like, this is one snapshot.

I'm gonna draw parallels to [01:00:00] psychoanalysis or psychodynamic therapy, which is like, just because someone says one time in therapy that they're like mad at their parent doesn't mean their entire like structure or schema of being, can be diagnosable as like inter-family issues. Right. And similarly, if a person str, like has one, uh, like one snapshot clinical interaction, like point of this is that you don't have to, we often don't and can't capture everything in those one snapshots and we just need to not go to the other direction, which is like that first snapshot is definitely correct and got everything.

It's like kind of like mm-hmm. Holding this middle zone of, here's my hypothesis. Let's see. As I get to know someone over lunch, I mean, unless your experience with that has been different, but that's even with my patients who are more neurocog and adult, it's like, okay, we need to be really thoughtful the whole time, but we also shouldn't.

Jump a gun, I guess in and thinking we can get everything in one snap. No, [01:01:00] absolutely. Um, it's, it's like, um, it's like a scratch off ticket. You know? You don't, you don't know if you won the lottery just by on, on scratching the first thing you got. You gotta be patient, go through all the, you won the lottery Yeah.

To mentions the bad lottery. But no, you like, it's, you have to check yourself and not be complacent and you're just working with different levels of suspicion, but they're all kind of being pushed and pulled in different directions. And like, there are cases where you know, someone, like if, if someone does get fired and have interpersonal struggles and they're not functioning as well and they're struggling with memory, that could just be depression.

Mm-hmm. And then all those cognitive impairments start to turn around when you treat the depression. Right. So, so at the end of the day, all, all you're able to do with these like neurocognitive tests is just see where someone has deficits and that those are the facts that someone has deficits in these categories.[01:02:00] 

But as to what is causing those deficits is for you, the clinician to develop hypotheses about and then test those hypotheses and not be presumptuous or complacent in the conclusions that you come to. They, they may have wax paper in their ear. Yeah. Like, how are you gonna know if you don't look in the ear yourself?

You know, did you go to work and talk to their boss? Maybe their boss does suck for real. That is always a possibility for real. So you gotta, yeah, you gotta hold space for both. So that really wraps up executive function. Um, the, the game actually that I play. That uses my executive function outside of Apex Legends is, uh, man Lords shout out to Man Lords.

You guys are, every time we film, I learn Another thing that I would've bullied you before high school. Hey, just kidding. I didn't bully people in high school. There are hundreds of thousands of people in that sub Reddit [01:03:00] who will come to my defense. You're gonna come dos me. Yeah. They're, they're all lords.

So basically all you have to like manage this futile town and you have to like, assign people to chop wood or to grow vegetables or to collect berries, and then it changes throughout the seasons and you have to divert resources. And people, if someone's not working, they're not producing. You know what I mean?

So you could have populations of hundreds of people and you need to be tracking on what everyone is doing. On top of that, you need to make sure that people are in proximity to their work, right? So like, you don't want someone trekking across town to go, you know, collect wool or something. You want, you want putting all in the outro sheep farm doing this.

So anyways, if you, if you wanna see what your executive function is like, try out man Lourds. It's also really fun and I think they're about to fix the clothing patch. Sponsor, sponsor, people that know podcast. You can catch the next part of this on Patreon. It's patreon.com/happy Patient Pod. Thank you so much for [01:04:00] listening.

Um, this was a fun check out. Patreon, do you want the bonus segment? Yeah. Margaret is gonna surprise me with the bonus segment. I'm, it is, I'm not quite sure what it is and role playing. Oh, don't, um, oh God, no. Not like that. Um, if you like, uh, these kind of off the cuff shows, I'm sure we can produce them, um, very quickly or we will talk and, and you'll listen.

That that seems to be exchange that we got going on here. If you wanna see more of us go on Instagram and TikTok at Human Content pos, I'm always at its prera on, um. TikTok and Instagram. Margaret's at bad art every day, where she makes good art most of the time. Medium art sometimes. And you can find all the episodes in video on either Spotify or my YouTube at its pre row.

Shout out to everyone who's leaving all of the nice comments. I do. I don't know if I have any good comments. Oh, this is one. Margaret has such a calm and interesting approach to any conversation. [01:05:00] I love hearing her takes heart though. I'm still gonna miss seeing Preston. Um, usually Roche and Margaret's dynamic for the time being.

So this was a comment on the religious trauma and broader visions of spirituality and healthcare episode. Don't worry guys. We haven't, I've been trying to get Preston to do a solo episode the entire time we've had this show. She's like, she's like the love God. Just do one without me. Um, so thank you for asking it, Margaret.

I think you, I don't, people would love it. Yeah. And and, and I, and I fly baby bird. Okay. Yeah. Maybe I need to be a peacock and spread my wings. This is the longest outro ever. Thanks. Thanks again for listening. We're your hosts, Preston Roche and Margaret Duncan. Our executive producers are me, Preston, Roche, Margaret Duncan, will Flannery, Kristin Flannery, Aron Korney, Rob Goldman and Shanti Brook.

Rob, I don't know why I just paused a bit. I had a brain fart during your last name. Our editor and engineer is Jason Portizo. Honestly, you chat. I, I haven't met Jason, but I like shout out Jason. Jason's a cool dude. You, you. [01:06:00] We like Jason here. Our music is Bio Me of venv. To learn more about our program, disclaimer and ethics policies, submission verification, licensing terms, and our HIPAA release terms, go to how to be patient pod.com or reach out to us at how to be patient@human-content.com with any questions or concerns.

How to be patient as a human content production,

how to.

Thank you for watching. If you wanna see more of us or if you wanna see, this is lilac. She's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background[01:07:00] 

and.