What is a cognitive test? What to know as Biden faces calls to take one

President Joe Biden has faced calls to take a cognitive test following his performance in the June 27 presidential debate, which highlighted concerns about his age and fitness.

In a July 5 interview with ABC News, George Stephanopoulos asked Biden if he would be willing to undergo a cognitive test and make the results public.

Biden demurred, saying “I have a cognitive test every single day. ... Everything I do … Not only am I campaigning, but I’m running the world.”

A week later, Michigan Gov. Gretchen Whitmer, who has campaigned for Biden, told CNN, “I don’t think it would hurt” for him to take a cognitive test.

But, what exactly is a cognitive test? What can it reveal? And when do people take it? Medical experts weigh in.

What is a cognitive test?

A cognitive test is a medical exam used to help detect cognitive decline and neurological disorders, Emily Sharp, a neuropsychologist and associate professor of neurology at the Yale School of Medicine, told McClatchy News.

“There are hundreds of cognitive tests, some of which are screening measures,” Sharp said.

One commonly used screening measure is the Montreal Cognitive Assessment, known as MoCA, Sharp said. Former President Trump took this test in 2018 and recieved a perfect score, according to NBC News.

This exam, which is available online, includes a series of simple prompts and questions.

One instructs the test taker to draw a clock at five past ten. Another asks them to identify drawings of a tiger, a horse and a duck. One asks them to name as many words that start with the letter B as they can in one minute.

The test taker is given about 10 minutes to finish, and the test is graded out of 30 points, according to the University of Toronto. Anything less than 26 is considered abnormal.

This exam, and other screening measures, are not thorough enough to diagnose illnesses, so they are often just a starting point, Sharp said.

“The gold standard for cognitive evaluation is a neuropsychological assessment,” Sharp said. “These are 3+ hour evaluations that assess cognition, behavior, and psychological functioning.”

These evaluations measure specific abilities, including attention, processing speed, working memory, motor skills and executive functioning, Sharp said.

Importantly, the tests are not graded as pass or fail.

“The overall pattern on testing identifies potential underlying neurological dysfunction and informs diagnostic considerations as well as provides recommendations for treatment and care,” Sharp said.

Who takes cognitive tests?

Many older people take basic cognitive tests — like the MoCA — as part of their routine physicals, Jacob Appel, a professor at the Icahn School of Medicine and presidential health historian, told McClatchy News.

These screening tests, which can take as little as 10 to 15 minutes, “really measure large scale decline, not subtle nuances,” Appel said.

“If there’s a suspicion of a significant neuropathology, then you might refer someone for a full battery of neurocognitive testing,” Appel said.

Anyone experiencing decreased cognitive functioning that effects their day-to-day life should think about getting a neuropsychological evaluation, Sharp said.

Presidents and cognitive tests

With the exception of Trump, no other president has publicly released the results of a cognitive test, Appel said.

Though it can be assumed that some of them, upon reaching a certain age, took cognitive tests as part of their annual physicals, Appel said.

Whether or not a cognitive test — be it a screening measure or something more comprehensive — should be required of presidents is a matter of some debate.

“Acing this test does not mean you are fit to be president,” Appel said, regarding a basic screening test, because any healthy individual, even those with slight impairments, could pass it.

Some of the more comprehensive tests are also not good gauges “because the president is a unique job that requires certain skill sets and not others,” Appel said.

For example, the ability to make logical executive decisions is highly important in a president, Appel said. But recall memory, on the other hand, might matter less.

“If it takes you a few more seconds to recall the right answer and you still get the right answer, that might matter in professional sports, but it doesn’t matter (for) running a large company or a country,” Appel said.

David Hafler, the chairman of the department of neurology at the Yale School of Medicine, told McClatchy News he would be in favor of mandatory cognitive tests.

“Anyone over the age of 70 who is going to be in high office probably should have cognitive testing made public because the one thing that’s associated with aging is cognitive decline, and there’s no getting around that,” Hafler said, noting that Yale requires physicians over 70 to take a cognitive test.

“(President Ronald) Reagan was diagnosed with Alzheimer’s disease and it maybe could have been picked up earlier,” Hafler said. “I think people ought to have that information.”

This story was originally published July 12, 2024 at 11:24 AM with the headline "What is a cognitive test? What to know as Biden faces calls to take one."