Experts explain the workings of cognitive tests and what they reveal about Biden's mental acuity amid concerns.

Renewed concerns about President Biden's mental acuity have led both sides of the political spectrum to call for him to take a cognitive test.

Dr. Kevin O'Connor, the president's physician, stated on July 8 that Biden had not seen a neurologist but had undergone his annual physical exam in February.

The doctor confirmed that Biden's physical examination did not indicate any neurological issues.

In an interview with George Stephanopoulos, Biden stated that he does not require formal cognitive testing, as he performs his duties as president of the United States every day.

Many Americans, however, have wanted greater transparency.

On July 12, Sen. Lindsey Graham (R-S.C.) wrote to Dr. O'Connor requesting that he strongly urge President Biden to undergo a cognitive and neurological exam and disclose the results to the public.

According to the USPSTF's website, there isn't enough evidence to suggest screening tests for cognitive impairment in older adults.

According to the Centers for Medicare & Medicaid Services website, the free Medicare annual wellness visit includes cognitive impairment detection.

What exactly is a cognitive test?

Leading neurologists were interviewed by Planet Chronicle Digital to understand how cognitive tests function and what they can and cannot detect.

None of the doctors who offered comments have assessed or treated President Biden.

According to Dr. Fred Cohen, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai in New York, cognitive tests are used to evaluate various mental functions and skills, with a focus on specific domains such as memory, attention, language, and processing speed.

The tests are categorized into three groups: screening tests, mental status evaluations, and neuropsychological assessments.

Doctors and neuropsychologists can use the Montreal Cognitive Assessment (MoCA), Mini-Mental State Examination (MMSE), and neuropsychological testing to evaluate a person's behavior and cognitive abilities, according to 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, who shared this information with Planet Chronicle Digital.

A screening test is typically the initial step, but it does not confirm any particular disease; rather, it only indicates the potential for cognitive impairment, according to experts.

Further testing is needed to identify the underlying cause.

What is dementia?

The CDC's website explains that dementia refers to a set of conditions that affect memory, thinking, and decision-making abilities, causing disruptions in daily activities.

The most prevalent form of dementia is Alzheimer's disease, although there are several types of dementia.

Okun stated that there is strong evidence indicating that between 5% and 8% of seniors over the age of 60 will eventually develop dementia.

He pointed out that this data played a role in Congress passing a law prohibiting commercial pilots from flying after the age of 65.

The likelihood of developing dementia rises as individuals age, with the probability ranging from 10% to 30% in those over 80 or 90 years old, according to Okun.

What is the MMSE?

The Mini-Mental State Examination (MMSE) is a 30-point questionnaire that evaluates cognitive functions such as memory and orientation.

It can be used to monitor changes over time, Cohen said.

Since 1975, an 11-question test has been used as a quick dementia screen, typically taking between 5 to 10 minutes to administer, according to experts.

Cohen instructed the person to perform specific tasks, such as 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."

What is the MoCA?

The MoCA (Montreal Cognitive Assessment) is scored out of 30 points and takes slightly longer to administer, according to Cohen.

The tasks include drawing a clock, naming animals, recalling lists of words or numbers, and making "abstractions" such as stating "fruit" when given an apple and orange.

Most cognitive tests don’t consider the mood of the individual – so if someone is depressed, that person may score lower, experts warn.

Cohen stated that Trump mentioned taking a cognitive test with animal identification, suggesting he may have been given the MoCA, according to the former president.

Both tests award points for accurate responses, with lower scores suggesting a higher level of cognitive impairment.

Okun stated that the MoCA test takes approximately 10 minutes to administer and is slightly better than the MMSE, particularly when the aim is to identify mild cognitive impairment.

According to experts, these tests can only provide information about a person's current state, not their overall functioning in daily life.

If a cognitive deficiency is suspected, more comprehensive testing is necessary, Cohen advised.

Experts consider the MoCA and MMSE to be broad and shallow tests, and therefore recommend their use only for screening and triage purposes, according to Okun.

Despite obtaining a high score on a MoCA or MMSE, individuals may still experience significant cognitive impairment, according to the researcher.

Previous research suggests that individuals who are depressed may score lower on tests, regardless of the mood they are in.

Experts suggest that language barriers, physical handicaps, or lower levels of education can impact the outcomes.

What is neuropsychological testing?

According to Okun, this type of testing, which takes several hours, is a comprehensive assessment that can diagnose cognitive disorders.

A neuropsychologist tailors the test to the individual’s presenting symptoms.

Neuropsychologists spend more time gathering a detailed history than general doctors, neurologists, or psychiatrists during their brief consultations.

The specialist may inquire about any challenges the individual may face when searching for words during conversations or when pronouncing incorrect words or sounds within a word.

Do specialists inquire if someone forgets significant events, repeats the same remark, misplaces objects, collides with things, or becomes preoccupied?

It is advised by Okun that people should understand that the MoCA and MMSE are not a substitute for neuropsychological testing, even if someone scores perfectly or nearly perfectly.

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It is advised to take this testing into account when any alterations, no matter how minute, in the behavior or work efficiency of a loved one are observed by family and friends.

The testing will provide a critical baseline performance and track disease progression.