Biden gets call to take cognitive test: here's how it works

President Biden is facing calls to undergo cognitive testing and make the results public after his disastrous debate last month, and amid a series of reports about his apparent decline in recent months.

Concerns only grew when public documents revealed that a neurologist specializing in Parkinson's disease had visited the White House. The administration has since said that the doctor in question has been a neurological advisor to the White House Medical Department for more than a decade.

Rep. Adam Schiff (D-Calif.) has called for cognitive testing for both Biden and former President Trump. Former Republican presidential candidate Nikki Haley has also suggested that such tests should be mandated for politicians over a certain age.

Trump, who is approaching 80, has often bragged about his own performance on cognitive tests. However, author Ramin Setoodeh recently claimed that Trump has struggled with his memory in several post-presidential interviews, often forgetting previous conversations and confusing the chronology of certain events.

To clarify what cognitive tests are, The Hill spoke with Carla Perissinotto, a professor in the department of geriatrics at the University of California, San Francisco.

Types of testing

There are several tests that can be performed to check cognitive health and function.

A simple screening test that is often used to detect signs of dementia is the Mini-Cog. In this test, participants are asked to listen to and repeat three words that are read to them and to draw a clock.

If the results of this screening are abnormal, it is a sign that the patient should undergo more advanced testing, such as the Mini-Mental Status Examination or the recently developed Montreal Cognitive Assessment (MoCA).

Trump has previously boasted of passing the MoCA test with a perfect score. Kevin O'Connor, physician to the president, wrote in February that Biden underwent a “very detailed neurological exam” during his annual physical that yielded “reassuring” results. He did not say whether cognitive tests were involved.

Both tests assess mental disorder by asking the patient questions and evaluating different cognitive areas, such as language, memory and attention.

“When you think about cognitive health, there are different domains of cognitive functioning,” Perissinotto said. “And what I mean by that is most people just think about memory, but it's not just about memory. It's also your visual-spatial function, your executive function, your abstraction and your memory and your orientation.”

Sanjay Gupta, CNN's chief medical correspondent and neurosurgeon, recently wrote that “the MoCA does not provide the level of cognitive testing that the medical experts I spoke to would like to see Biden implement.”

Who can perform testing?

Media attention intensified this week after reports emerged that Kevin Cannard, a neurologist and Parkinson's expert, has made repeated visits to the White House recently.

The administration has not specified what Cannard's recent visits were about, but has repeatedly said the president is not being treated for Parkinson's disease or any other neurological condition.

Perissinotto noted that no specialists are needed to perform such cognitive tests.

“GPs can perform screening tests, and given the number of elderly people, this is certainly something that all GPs should be doing,” Perissinotto said.

However, she noted that training for these types of tests is not always a given.

“I think it's sad that historically in medical education we haven't been trained very well in this area and so there are definitely shortcomings when it comes to getting people to do these tests,” Perissinotto said.

Who should get tested?

According to Perissinotto, a major misconception about cognitive tests is that they should only be performed when patients suspect something is wrong.

“I would say, no, that's not true. It's actually important to do them even in healthy people, to get a sense of baseline,” she said.

“Because people are very good at hiding their cognitive impairment. So people who are very social, who, you know, have a lot of education — they can mask things. And so I’ve had patients where I wouldn’t suspect it, and it’s missed because they have a great social talent. And then you ask them to draw a clock and it’s completely off, for example.”

Cognitive testing is recommended during annual Medicare wellness visits, and Perissinotto says it's most helpful to establish a baseline early on, between ages 65 and 70, to detect signs of cognitive decline.

“What I find difficult in my practice is when I have someone who is in their late 70s or 80s and I do one of these tests, and they are limited and I don't even know when it started.”

Changes in memory are not the only indicator of cognitive decline, the geriatrician stressed.

Certain forms of dementia can manifest themselves primarily through behavioral changes. And some changes are just natural as we grow older.

She explained that as we get older, “we process things more slowly. We may find it harder to remember things, meaning you try to think of the word and it's harder to get it out of your head, but it's still there. Those are normal signs of aging.”

Perissinotto also emphasized that there is a difference between mild cognitive impairment and dementia. He defined dementia as cognitive changes that do not affect daily life.

“Dementia occurs when it actually affects your ability to perform your activities of daily living and your instrumental activities of daily living,” such as grocery shopping, paying bills, or answering the phone.

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