Amid concerns about Biden’s mental acuity, experts reveal how cognitive tests work and what they reveal
On the heels of President Joe Biden's lackluster debate, Fox News Digital spoke with leading neurologists to determine how cognitive tests work, as well as what they can and can’t identify.
After President Biden’s lackluster debate performance sparked renewed concerns about his mental acuity, both sides of the political spectrum have been clamoring for him to take a cognitive test.
Biden has not seen a neurologist, but did undergo his annual physical exam in February, Dr. Kevin O’Connor, physician for the president, said in a July 8 statement from the White House.
The doctor reiterated that Biden's physical exam did not reveal concerns about a neurological disorder.
In a recent interview with George Stephanopoulos, Biden remained noncommittal about formal cognitive testing, noting, "I have a cognitive test every single day" — meaning by performing his duties as president of the United States.
Many Americans, however, have wanted greater transparency.
"I am writing today to request that you urge President Biden, in the strongest possible terms, to take a cognitive and neurological exam and to share the results with the American people," Sen. Lindsey Graham (R-S.C.) wrote to Dr. O’Connor on July 12.
The United States Preventative Services Task Force (USPSTF) states on its website that there is insufficient evidence to recommend screening tests for cognitive impairment in older adults.
The free Medicare annual wellness visit, however, does cover detection of cognitive impairment, according to the Centers for Medicare & Medicaid Services website.
Fox News Digital spoke with leading neurologists to determine how cognitive tests work, as well as what they can and can’t identify.
None of the doctors who offered comments have assessed or treated President Biden.
"Cognitive tests are designed to measure a range of mental functions and abilities, targeting specific areas such as memory, attention and concentration, language and processing speed," Dr. Fred Cohen, assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai in New York, told Fox News Digital.
These tests are divided into three types: screening tests, mental status examinations and neuropsychological testing.
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"The Montreal Cognitive Assessment (MoCA), the Mini-Mental State Examination (MMSE) and neuropsychological testing are all important tools doctors and neuropsychologists can employ to assess a person’s behavior and thinking ability," Dr. Michael S. Okun, medical adviser for the Parkinson’s Foundation and director of the Fixel Institute for Neurological Diseases at University of Florida Health, told Fox News Digital.
The first step is often a screening test, but that does not diagnose any specific disease – it can only suggest the possibility of cognitive impairment, experts say.
Further testing is needed to identify the underlying cause.
Dementia describes a group of conditions in which people have an impaired ability to remember, think or make decisions, which disrupts their daily activities, according to the U.S. Centers for Disease Control and Prevention (CDC)’s website.
There are many types of dementia, but Alzheimer’s disease is the most common.
"There is rock-solid data that 5% to 8% of folks over the age of 60 will later develop dementia," Okun said.
This data was partly why Congress passed a law prohibiting commercial pilots from flying after the age of 65, he noted.
Dementia risk increases with age. By the time people are in their 80s or 90s, the chances are between 10% and 30%, according to Okun.
The MMSE (Mini-Mental State Examination) is a 30-point questionnaire that assesses various cognitive functions, including memory and orientation.
It can be used to monitor changes over time, Cohen said.
The 11-question test, introduced in 1975, is a quick dementia screen that typically takes about five to 10 minutes to administer, according to experts.
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Some of the questions ask the person to perform specific tasks, like providing the current date and year, subtracting 7 from 100 repeatedly, recalling three unrelated objects after three minutes, and following a three-step command, such as "take a paper in your right hand, fold it in half and put it on the floor," Cohen said.
Like the MMSE, the MoCA (Montreal Cognitive Assessment) is scored out of 30 points, but takes slightly longer to administer, Cohen said.
It includes tasks such as drawing a clock, naming animals, recalling lists of words or numbers, and making "abstractions" — such as stating "fruit" when given an apple and orange.
"Former President Trump has mentioned that he took a cognitive test that included identifying animals, indicating that he was likely given the MoCA," Cohen said.
People receive points for correct answers on both tests — lower scores indicate greater concern for cognitive deficiency.
"The MoCA takes about 10 minutes to administer, and it is a little better than the MMSE, especially if your goal is to screen for mild cognitive impairment," Okun added.
These tests can only reveal what is going on at that moment in time; they cannot determine how someone is functioning in their everyday life, according to experts.
The screening tools may identify potential cognitive issues, but more comprehensive testing is required if a deficiency is suspected, Cohen cautioned.
"The MoCA and MMSE are considered by experts to be broad and shallow tests, and therefore should only be applied for screening and triage," Okun added.
People can achieve a perfect or near-perfect score on a MoCA or MMSE but still have significant cognitive impairment, he noted.
The tests also don’t consider the mood of the individual – so if someone is depressed, that person may score lower, according to previous research.
Language barriers, physical handicaps or lower levels of education can also affect the results, experts say.
This type of testing, which takes several hours, is a true comprehensive assessment that can be applied for diagnosis of cognitive disorders, according to Okun.
A neuropsychologist tailors the test to the individual’s presenting symptoms.
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"Neuropsychologists spend a great deal of time gathering a detailed history that goes well beyond what a general doctor, neurologist or psychiatrist may have time to collect during their usually brief consultation(s)," he added.
The specialist may ask if the person has difficulty searching for words in conversation or uttering the wrong words or sounds within a word.
Specialists may also ask if someone forgets notable events or repeats the same comment, misplaces items, bumps into things or gets lost in thought.
"Folks should be aware that the MoCA and the MMSE are not a replacement for neuropsychological testing, even if a person achieves perfect or near-perfect scores," Okun advised.
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He recommends considering this testing when family and friends notice any changes, no matter how small, in their loved one’s behavior or job performance.
Added Okun, "The comprehensive testing will form the basis for a treatment plan and provide a critical baseline performance, which can be used to track disease progression."