Biden faces calls to take cognitive test: Here’s how that works

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

Concerns were only fanned further when public records brought to attention that a neurologist who specializes in Parkinson’s disease had visited the White House. The administration has since said that the physician in question has been the neurology consultant for the White House Medical Unit for more than a decade. 

Rep. Adam Schiff (D-Calif.) has called for both Biden and former President Trump to undergo cognitive tests, and former GOP presidential candidate Nikki Haley has suggested such tests should be required of politicians over a certain age.  

Trump, who is nearing 80, has often boasted about his own performance on cognitive tests. However, author Ramin Setoodeh recently claimed that Trump struggled with his memory in multiple postpresidential interviews, often forgetting prior conversations and mixing up the chronology of certain events. 

To provide clarity on what cognitive testing is, The Hill spoke with Carla Perissinotto, professor in the division of geriatrics at the University of California, San Francisco. 

Types of tests 

There are a variety of 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. This test involves asking participants to listen and repeat three words listed to them and drawing a clock. 

If the results of this screening are abnormal, that would be a sign for a patient to undergo more advanced tests such as the mini mental status examination or the more 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 an “extremely detailed neurologic exam” during his annual physical that yielded “reassuring” results. He did not mention if any cognitive tests were involved. 

Both tests assess mental impairment by asking questions of patients, evaluating different areas of cognition like language, recall and attention. 

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

Sanjay Gupta, CNN’s chief medical correspondent and a neurosurgeon, recently wrote that “the MoCA isn’t the same level of cognitive testing the medical experts I spoke to would like to see Biden do.”

Who can perform tests 

Media scrutiny ramped up this week after reports emerged that Kevin Cannard, a neurologist and Parkinson’s expert, repeatedly visited the White House recently. 

The administration still has not specified what Cannard’s recent visits were about, though it has repeatedly said the president is not being treated for Parkinson’s or any neurological disorder.

Perissinotto noted that specialists are not needed to conduct such cognitive tests. 

“Primary care doctors are able to do screening tests. And certainly, given the number of older adults, this is something that should be done by all primary care physicians,” said Perissinotto. 

She noted, however, that training for these sorts of tests isn’t always ubiquitous. 

“I think what’s sad is, historically in medical training, we don’t get trained very well on this and so there’s certainly some deficits in terms of 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 can hide their cognitive impairment very well. So, people that are very social that, you know, have high education — they’re able to mask things. And so I’ve had patients where I would not suspect it, and it’s been missed because they have great social graces. And then you ask them to draw a clock and it’s completely off, for example.” 

Cognitive tests are recommended during Medicare annual wellness visits and, according to Perissinotto, having a baseline early on between the ages of 65 and 70 is extremely helpful in tracking signs of cognitive decline. 

“What’s hard for me, in my practice, is when I have someone who comes in maybe in their late 70s or 80s and I do one of these tests. And they’re impaired and I don’t kind of know when it started.” 

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

Certain types of dementia can present primarily through behavioral changes. And some changes are simply natural with aging. 

She explained that as we get older “we process things slower. We may have a harder time recalling things, which means that you’re trying to think of the word and it’s harder to come up out of your brain, but it’s still there. Those are normal signs of aging.” 

Perissinotto also emphasized there is a difference between mild cognitive impairment and dementia, defining the former as cognitive changes that don’t affect one’s daily life.

“Dementia is when it’s actually affecting your ability to do your activities of daily living and your instrumental activities of daily living,” like getting groceries, paying bills or answering the phone.