It seemed like a sensible move to assess the capabilities of an 81-year-old man trying to win voter approval to remain in the White House until January 2029.
To reassure the American people, ABC's George Stephanopoulos said asked President BidenWould he be willing to take a cognitive test and share the results with the American people?
Biden resisted. In carrying out his duties as leader of the free world, he said, “I have a cognitive test every day.”
Though the president rejected the suggestion, medical experts said the idea of having Biden — along with his 78-year-old challenger, former President Trump — undergo some kind of cognitive testing did have merit.
“Let's give it to both of them,” said Doctor Louise Aronsona geriatrician at UC San Francisco.
Kevin Duffneuropsychologist at the Oregon Health & Science University's Alzheimer's Disease Research Center, compared the proposal to the longstanding practice of asking presidential candidates to release their tax returns.
There would be several types of tests to choose from. A simple screening exam might only involve a handful of questions and be completed in a few minutes. An in-depth evaluation might take an entire day.
When former White House physician Dr. Ronny Jackson Trump Evaluated in 2018he chose the popular Montreal Cognitive Assessmentor MoCA test. For about 15 minutes, patients are asked to recall a list of five words, draw a clock with its hands pointing to a certain time, do double-digit subtractions and name the animals in a drawing, among other tasks. Trump scored a perfect 30 out of 30 at the time.
Whether long or short, a good test measures multiple “domains of cognition,” Aronson says. There's short-term memory and long-term memory. There's the ability to communicate through both spoken and written language. There's attention, comprehension, judgment, reasoning, problem solving, decision making and more.
“If someone passes a test completely, that says something,” he said Doctor Laura Mosquedaprofessor of family medicine and geriatrics at the Keck School of Medicine of USC. “And if they mess up a test, that tells you something.”
According to experts, a score somewhere in between can be more difficult.
An abnormal result on a cognitive test does not necessarily mean that a patient has a real cognitive problem. In about 10% of cases, it can be attributed to a side effect of medication, an infection, a thyroid problem, a Vitamin deficiencya mood disorder such as anxiety or depression, or something else that is reversible.
“What we see all the time as geriatricians is reactions to medications,” Aronson said. “I can't tell you how many times we stop medications and the person goes back to normal.”
Sometimes it's even simpler.
“I've seen people who have been diagnosed with dementia who actually have a hearing problem, but they don't want to admit it,” Mosqueda said. “They can't hear the questions, so they give strange answers.”
Some cognitive changes are a normal part of the aging process. Thinking speed is a good example.
“As we get older, we do things more slowly,” Aronson said. That’s not necessarily a sign of cognitive impairment, she said, recalling a 101-year-old patient who missed only one point on a test but needed extra time to complete it.
If a patient's cognitive problems persist or if caregivers want to gain more insight into the specific features of the condition, a more in-depth investigation may be necessary.
The tasks are more challenging, Duff said. For example, instead of seeing if a patient can remember five words after five minutes, a neuropsychologist might give a patient 15 words and see how many he can remember half an hour later.
In the MoCA test, a score of 25 or lower is considered abnormal, regardless of other factors. A more sensitive test compares the results to the performances of other people of the same age, educational background, career history and other characteristics, Duff said.
Experts agreed that someone with Biden's background would likely perform well on a MoCA test, even if his cognition has declined.
“In certain patients who are particularly verbal, they won't remember the word they want, but they can work around it,” Aronson said. In such cases, a normal score on the test “would not necessarily rule out cognitive impairment.”
According to Duff, it's similar to an IndyCar driver who wants to compete in the Indianapolis 500 taking the same driving test the DMV uses for 16-year-olds.
“I am concerned that a relatively easy test still does not mean you are up to the challenge of leading one of the most powerful countries in the world,” he said.
This isn’t a problem limited to presidential candidates. It might be appropriate to ask pilots, bus drivers, surgeons and other people with high-responsibility jobs to take cognitive tests as they get older, experts say.
“I think you could say this is a job where your brain has to work pretty well,” Aronson said.
There is no consensus among experts on whether all older adults should be screened for cognitive impairment. The US Task Force on Preventive Services considered the matter in 2020 and determined that was not enough evidence to make a broad recommendation in one direction or the other.
One of the reasons for the hesitation is that the screening tests are not good enough, he said. Dr. Colleen Christmasa geriatrician at the Johns Hopkins School of Medicine.
“You're going to hit a lot of people who don't have problems, and you're going to miss a lot of people who do,” she said.
Moreover, the aging process varies greatly from person to person.
“It’s incredibly heterogeneous,” Christmas said. “You can’t say 80 equals old, while 75 equals young.”
Furthermore, no test, no matter how sensitive, can provide a complete picture of a patient's cognitive function. Doctors also need the results of blood tests, brain scans, and information from family members, among other things. For example, if an MRI showed evidence of several small strokes in parts of the brain that corresponded to the patient's cognitive deficits, that would point to a diagnosis of vascular dementia.
“It's like putting together a puzzle,” Mosqueda said.
Biden may be in a unique position, but his angry reaction to the idea of a cognitive test was fairly typical, Christmas said.
“I think people are so afraid of being diagnosed with dementia that it’s upsetting when your doctor or a family member suggests that you need cognitive testing,” she said. “It’s a very scary prospect.”
