In recent interviews, President Donald Trump has been boasting about a cognitive test that he took recently and “aced.” It’s not the first time — he made similar remarks in January 2018. But he once again has not said what test he took or what his score was, making it difficult to know what to make of his claims.
He has, however, provided a few clues.
In an interview with Chris Wallace on “Fox News Sunday,” in which Wallace said one question was to identify an elephant, Trump did not contradict him. One popular test, the Montreal Cognitive Assessment, or MOCA, has a drawing of three animals that patients are asked to identify. It is a 10-minute screening exam meant to highlight possible problems with thinking and memory.
But it is by no means definitive or even diagnostic, experts pointed out. And as the president tries to draw a contrast between his mental faculties and those of former Vice President Joe Biden, a fellow septuagenarian he expects to face off against in November’s election, some experts criticize his politicization of such cognitive screening tests.
“The way our president is having a conversation about mental health is not helpful,” said Dr. Jason Karlawish, a dementia researcher at the University of Pennsylvania’s Perelman School of Medicine
“You would think he would understand clearly what the test result was and why the test was done,” Karlawish said, “and not turn it into a competition about mental health.”
Here are some answers to questions about cognitive exams, what they measure and how specialists decide whether a patient really is impaired.
Q: What is the MOCA?
A: This screening test was designed about 20 years ago as a possible replacement for another test, the Mini-Mental State Examination, which had been widely used since the 1970s to look for outright dementia. The MOCA is used in all 31 of the National Institute on Aging’s Alzheimer Disease Centers.
While there are many such screening tests, the MOCA is gaining acceptance because it is a bit harder than the Mini-Mental and can pick up problems that occur in the earliest stage of dementia, mild cognitive impairment — a sort of everyday forgetfulness.
About 1 in 5 people over age 65 have MCI, and roughly one-third will develop Alzheimer’s disease within five years.
Q: What does the test ask?
A: MOCA has approximately 30 questions meant to briefly assess memory, attention and concentration, control and self-regulation, and other mental skills.
To test memory, for example, the examiner reads five words at a rate of one per second and asks the subject to repeat them immediately and then again after some time has passed.
To assess attention and concentration, subjects are read a list of five digits and asked to repeat them in the order they were provided and then in reverse order. The subjects also are asked to count backward from 100 in increments of 7.
Other exercises include drawing a clock with the hands pointing to 11:10 and identifying a lion, rhino or camel. A perfect score is 30. A score from 26 to 30 is considered normal.
Q: Do medical societies recommend cognitive screenings?
A: No. Such exams are not like mammograms for breast cancer and colonoscopies for colon cancer. With those tests, doctors can get a diagnosis and begin treatment.
But they are only part of an assessment of the mental functioning of an older adult. It can be more valuable to ask family members or others who know the patient well whether the person has been inefficient at tasks they once did well, like negotiating a new route when driving or following a recipe.
Screening tests like the MOCA cannot rule out declines in reasoning or memory, or difficulties with planning or judgment. The test is just too blunt an instrument, and for many high-functioning people, too easy.
For that reason, dementia specialists say they would not make a diagnosis based on a screening exam like the MOCA.
Nonetheless, Medicare recipients are often given cognitive screenings, Karlawish said. That is because Congress instituted a requirement that Medicare cover a brief cognitive screening test as part of the annual wellness exam.
Q: Shouldn’t a perfect score be reassuring?
A: Maybe. But the test is not that difficult, and the problem with a single test is that the doctor doesn’t know what the subject’s starting point was. Usually it’s the trend over time that suggests a problem.
And even then, the tests can be too blunt an instrument to detect declines in many highly educated people for whom, say, counting backward from 100 by 7’s is not a challenge until dementia is well-established.
Q: So how do doctors detect cognitive problems?
A: It’s not easy. What physicians look for is a slow decline. They start by simply talking to the patient: Has she noticed memory problems, or issues with judgment or reasoning?
It’s also important for the physician to talk to someone who knows the patient well because people who are slipping cognitively do not always recognize it. “Lack of awareness or insight can be part of the package” of dementia, said Dr. Ronald Petersen, director of the Alzheimer’s Disease Research Center at the Mayo Clinic in Rochester, Minnesota. (He emphasized that he was speaking in general terms, not specifically about Trump’s case.)
If the doctor is concerned, and if a family member also says the subject is forgetful or repeating himself, and if this behavior is becoming a pattern — all those factors will influence the decision to “pursue this to the next level,” Petersen said.
Some patients simply prefer not to know if they are developing dementia. But those who do are given a neuropsychological test much more difficult and intense than the MOCA. And doctors will repeat it over time.
In such a test, for example, the examiner reads a short story and asks the subject to repeat it. Thirty minutes later, the subject is asked to repeat the story again.
The subject is also asked to draw geometric shapes and to remember them a half-hour later. The examiner may ask the subject to recall a list of 15 words as many as five times and then recall them 30 minutes later.
Q: What about Alzheimer’s?
A: The results of neuropsychological tests can tell doctors how a subject is performing relative to others of the same age, sex and education level. If the doctor thinks something is amiss, a clinical exam might follow to figure out what might be causing the problem.
Most cases of dementia result from Alzheimer’s disease. An MRI scan can help with diagnosis. It can detect a stroke and other conditions. It also can determine if the hippocampus, the memory center of the brain, is shrinking, as happens in Alzheimer’s.
A PET scan that uses glucose measures the activity of brain cells. Cells starting to falter and die, especially in certain areas of the brain, may be a sign of Alzheimer’s disease.
Neither scan is itself diagnostic, Petersen said. Instead, the results add to the weight of evidence suggestive of Alzheimer’s disease.
Another test, which costs $5,000 to $7,000 and generally is not covered by insurance, is a scan to look for amyloid protein in the brain. Occasionally people have these accumulations but not dementia.
But because amyloid is a part of the Alzheimer’s pathology, a lack of it means the subject does not have Alzheimer’s disease.