- A psychologist who tests business leaders and doctors for cognitive decline shared how he does it.
- His evaluation takes about an hour and involves a variety of tests, not just one.
- It’s quite challenging.
Many Americans believe that at 81, President Biden is too old to be president.
There are also concerns about the fitness of 78-year-old Republican candidate Donald Trump to serve as president. Voters are divided on whether he still has the cognitive skills needed for the job.
But experts on brain aging say the candidates’ chronological ages are to some extent misleading.
“There’s this common notion that memory declines as we get older, but it has less to do with age itself and more to do with all the nasty things that we’re at risk for as we age,” neuropsychologist Joel Kramer, director of the Neuropsychology Program at the Center for Memory and Aging at the University of California, San Francisco, told Business Insider.
“It’s exactly like your knees. Just because you get older doesn’t mean you’re going to have bad knees, but there are a lot of older people who have bad knees.”
There are simple assessments that a doctor can administer in a clinic in just a few minutes to get a rough idea of a patient’s condition. You may have heard of some of these in recent political reports.
- of Mini Cog test They will be asked to repeat and memorise a series of words and accurately draw a clock with a specific time written on it, testing not only basic memory skills but also visual-spatial control and other important brain functions.
- mocha: The Montreal Cognitive Assessment (which Trump took six years ago, while he was president) is similar to the Mini-Cog in that it involves tasks such as drawing a clock, repeating and recalling, and naming objects in simple pictures like a lion or a camel.
- Sage: It’s a test designed by Ohio State University that people can administer themselves at home.
But these aren’t perfect tools, and they’re not really what doctors use to determine whether someone is mentally fit enough for a high-ranking job. These tests are rudimentary, and people with dementia can pass them, especially if they’re in the early stages of the disease. We’re all good at hiding subtle memory problems, Kramer says. (“The last time you met someone whose name you couldn’t remember, did you lie about it for a while?”)
A full clinical evaluation to test for neurodegenerative diseases typically takes about an hour or more, Kramer said.
He taught me how clinicians can assess a child’s ability to learn and retrieve new information, multitask, and perform age-appropriate motor skills.
True cognitive assessment should be challenging
“I’m going to read you a list of words,” Kramer said. “Listen carefully, and when I finish, I want you to repeat as many as you can: hat, berry, wrench, sweater, lemon, pliers, belt, peach, drill.”
The exercises can be adapted for different ages and abilities (Kramer said he would give us a much longer list if we were to do this in person).
Later in the session, the clinician might ask you to recall, “What was on that list?” This is a test that you cannot cheat on, because the words are not written down anywhere and can easily change from session to session.
I found the multitasking portion of his assessment more difficult.
“I’m going to say some numbers. When you’re done, say them in reverse order: 4, 9, 2, 6, 3.”
It looks easy written out here, but remember, he’s just saying it out loud. You have to repeat the list back to front as you organize it in your head. I did a pretty terrible job of this.
“3, 6, 4…” Oops.
Multitasking has gotten a bad rap — we’ve all heard that it’s bad for our focus and in some ways biologically impossible — but the more complicated truth is that we’re actually doing some form of multitasking all the time, and some of it is a telltale sign of a healthy, well-functioning brain (for example, walking and talking at the same time).
The particular kind of multitasking being tested here is a key skill for any good leader: someone who can work well under pressure, filter out irrelevant information, and adapt quickly as new data comes along.
In another multitasking test used by brain experts, people are given a page with jumbled numbers and letters and are tasked with finding them on the paper, reading them out loud, matching “A” to “1” and “B” to “2,” and so on.
“You have to know where you are and what to do,” Kramer says. “It’s not rocket science, but when done as part of a multidisciplinary evaluation, they are more than just scans and neurological exams and can be sensitive to early changes associated with many syndromes.”
Simpler tasks that patients may be asked to do during the assessment include drawing something from memory (such as a clock) or saying the name of a common object aloud when shown pictures of the object.
Observing the patient in real time and assessing motor skills, speech and eye movements is also important in making a final diagnosis. By the time a family brings them in, the news is often not good, Kramer said.
“After the assessment, we sit down and say, ‘Here are the skills you need to be successful in the job. According to our assessment, you don’t have them, so it’s time for you to leave.'”
A complete neurological exam requires more than just memory testing
There is also:
- In-depth interviews with families
- Consider other medications the patient is taking and any pre-existing conditions that may make the brain vulnerable (some medications can increase the risk of dementia). “Oftentimes, small changes in medication can help,” says Kramer.
- Typically, the focus is on ruling out other non-neurological reasons that may be causing memory loss, such as depression or some other deficit.
Diagnoses vary but may include:
- MRI scans to check for cerebrovascular disease (which can be caused by small, silent strokes)
- Spinal tap or skin biopsy to look for proteins that cause Parkinson’s disease
- A new, expensive, FDA-approved blood test scans for key proteins that are a risk for developing Alzheimer’s.
- Complete blood work will be done to rule out other causes of memory loss, such as hypothyroidism or low vitamin B12 (which can be improved with diet, hormones, and supplements).
The White House’s latest health summary in February said Biden had recently undergone a “very thorough neurological examination” and was “again reassured that there were no findings consistent with cerebellar or other central nervous system disease.” The report also praised his fine motor skills.
Arguments against disclosing Biden’s cognitive test results
Journalists including George Stephanopoulos and Dr. Sanjay Gupta have called for President Biden to undergo new, in-depth cognitive testing and for the results to be made public. Given his dismal performance in the debates, people want to know whether the commander in chief would pass or fail a cognitive test for dementia now.
“I was told I was OK,” Biden told Stephanopoulos on Friday. “I take cognitive tests every day,” Biden added, alluding to the requirements of his job.
Trump continues to boast that he “performed well” on basic cognitive tests he took more than four years ago while in office, but he has also not agreed to comprehensively release the results.
But experts say these tests are not the best way to assess mental fitness for the job. Many things that have nothing to do with memory matter to job performance. These cognitive tests only rule out illness. What on earth would a passing result mean? And would a failing result guarantee Biden’s withdrawal?
Physicians themselves resist requiring cognitive testing of older doctors, partly because it’s ageist, but also because memory tests don’t tell us whether a doctor is good at their job.
“When you’re deciding who you want for this particular role, which is president, what are the attributes that really matter? Is it memory, is it empathy, is it problem-solving ability, is it relatable values, is it the ability to work with people?”
