Before the presidential debate between former President Donald Trump and President Joe Biden amped up the discussion about mental fitness, voters were already asking how old is too old to be president of the United States and whether there should be age limits or at least testing for candidates.

After what USA Today called a “stumbling debate performance by Biden,” the conversation has heated up, with a twist. Now there are calls for the president to take a cognitive test, which he has so far declined to do.

Biden, at 81, the oldest U.S. president ever, sloughed off the suggestion he commit to cognitive testing in an interview on Friday. “I have a cognitive test every day,” he told ABC’s George Stephanopoulos, referring to the challenges of his job as the country’s leader. Trump, who is three years younger, did take a standard test of cognition, the Montreal Cognitive Assessment, when he was president, earning the standard 30 out of 30 score.

It’s not an intelligence test, but rather it screens for specific signs of cognitive decline in different parts of the brain, measuring ability like memorizing a five-word list, identifying pictures of animals, drawing the face of an analog clock and performing seemingly simple subtraction.

The test’s creator, Canadian neurologist Dr. Ziad Nasreddine, told MarketWatch it is supposed to be easy for someone who doesn’t have impaired cognition. If someone struggles, it suggests a need for more thorough testing.

“It’s a very, very low bar for somebody who carries the nuclear launch codes in their pocket to pass and certainly nothing to brag about,” Jonathan Reiner, a cardiologist and professor of medicine and surgery at the George Washington School of Medicine & Health Sciences, told The Washington Post in January.

The test is not for flubs, which both candidates have made fairly often, such as Trump saying Nikki Haley was in charge of security during the Jan. 6 attack on the Capitol when he meant former Democratic House Speaker Nancy Pelosi, as the Post noted.

Biden’s lifelong stutter is not a cognitive issue or something that’s part of the test, either.

But during the debate, Biden fumbled and sometimes appeared to lose his train of thought. Since then, he has resisted increasing calls to take and then publish the results of a cognitive assessment. And Trump’s published results are nearly six years old, though he said he’s been tested more recently.

Meanwhile, the two are already the oldest presidents in the nation’s history and whoever wins this election will hold that record.

Who needs cognitive testing?

As people age, some decline in cognition isn’t unusual, Dr. Christine Cliatt Brown, a behavioral neurologist and an assistant professor of neurology in the Cognitive Neurology Division at the University of Utah, told Deseret News. Memory and processing speed decline in old age.

Vocabulary gets better with age.

But all of it varies a lot from person to person, she said, adding that while age is a risk factor for cognitive decline, it’s not the only factor. She added that people at much younger ages can also have cognitive decline, including dementia.

Testing is a good idea when a person has noticed a change in their own memory or if family members believe they see changes that they think are more than one would expect with normal aging, said Cliatt Brown.

She was not asked to weigh in on the presidential candidates’ cognition, but was instead asked about cognitive testing in general.

The Alzheimer’s Association recommends that anyone showing signs of mental decline be assessed, but it also notes that a cognitive assessment should be part of the annual wellness visit for all Medicare beneficiaries. What’s called the Mini-Cog is a three-minute test of memory recall and a “scored clock-drawing test” can also show if the person needs further testing.

The first stop is often the primary care doctor, Cliatt Brown said, where a short screening like the MoCA or a similar screening test could be used. Most who do well on that screening don’t have to go further in testing — “unless the person or family is convinced there’s a big change” and no medical reason can be identified. She also told Deseret News that those simple screening tests might not be as sensitive to cognitive decline for people who are highly educated, such as physicians or lawyers, among others.

The next step would be neuropsychological testing, which is much more extensive. Such testing takes three to four hours. It looks at memory, executive function and language, among other things, and compares a person’s performance to what might be expected given their age and education attainment.

Several experts have told the Deseret News numerous times that an early sign of cognitive impairment is difficulty drawing an analog clock face, which requires proper spacing and putting numbers in order and determining what the hands of the clock look like and their position. Drawing an accurate analog clock face is very difficult for someone whose executive function is diminishing.

No rule that says he must

Adding to the clamor, The New York Times reported this week that a Parkinson’s disease expert visited the White House “eight times in eight months from summer to this spring,” based on visitor logs to the White House. The logs, however, don’t show who was visited or indicate whether the doctor met with the president.

The White House released a letter Monday from Dr. Kevin O’Connor, the president’s physician, regarding those visits by Dr. Kevin Cannard, the Parkinson’s specialist. He wrote Cannard had been the neurology consultant to the White House Medical Unit since 2012, noting he is the “longest serving neurologist at Walter Reed National Military Medical Center and in the Military Healthcare System,” among other credentials.

“Prior to the pandemic, and following its end, he has held regular Neurology Clinics at the White House Medical Clinic in support of the thousands of active-duty members assigned in support of White House operations. Many military personnel experience neurological issues related ot their service, and Dr. Cannard regularly visits the WHMU as part of this General Neurology practice,” per the letter.

Cannard also conducted each of Biden’s neurological exams that were part of his annual physical, O’Connor wrote, quoting findings of the most recent physical, released February 28: “An extremely detailed neurologic exam was again reassuring in that there were no findings which would be consistent with any cerebellar or other central neurological disorder, such as stroke, multiple sclerosis, Parkinson’s or ascending lateral sclerosis, nor are there any signs of cervical myelopathy. This exam did again support a finding of peripheral neuropathy in both feet. No motor weakness was detected. He exhibits no tremor, either at rest or with activity. He demonstrates excellent fine motor dexterity. But a subtle difference in heat/cold sensation could be elicited as it was last year. This heat/cold sensation deficit was detected a couple of inches higher on his ankle/calf this year, which is not unexpected. There may; in fact, be day to day subjective variation of these findings, as during last year’s exam, this area of sensation deficit was actually found to be smaller than the year before.”

The Post reported that medical teams at the White House perform many functions, but notes there is no remedy should a president have cognitive issues. “The White House medical unit performs frequent drills to prepare for any contingency when the president could be incapacitated, from being wounded in a shooting to suffering a heart attack — or even caught in the vicinity of a nuclear explosion. But former staffers said there has been relatively little effort to prepare for what to do if they think an 81-year-old president is suffering from mental decline. While some high-risk professions, like commercial aviation, have a formalized process where pilots can be grounded until further testing if a physician suspects cognitive impairment, there’s no similar trigger for a president.”

In a column for CNN, neurologist Dr. Sanjay Gupta noted that even presidents are entitled to keep their medical records private, whether they should or not. But Gupta has also joined the chorus asking the president to submit to testing and release the results.

The questions are not unique to Biden, he writes.

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“Trump does at times display some of these same signs as Biden, including nonsensical rants as well as confusing names and current events. He said he’d undergone the Montreal Cognitive Assessment, known as MoCA, in the past. According to his medical team, he received a perfect score when he took the test in 2018. Trump said he took a second cognitive test for his last physical exam at the end of 2023 and ‘aced it.’ In a note at the end of last year, Dr. Bruce Aronwald wrote that Trump’s cognitive exams ‘were exceptional.’ Trump has not released his actual medical records, and memos about his health that were previously released have at times used hyperbolic language, unusual for medical documentation,” per Gupta.

Testing limitations

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As The Wall Street Journal reported, one cognitive test would not be able to provide the last word on a president’s mental fitness to serve. The tests are a screening tool. “Doctors would have to conduct further evaluation, including commissioning more tests like a PET scan” should the test result be concerning.

And a cognitive assessment might not even be the right test, per the Journal article. “Dr. Lon Schneider, a professor of psychiatry, neurology and gerontology at the University of Southern California’s Keck School of Medicine, said a more apt assessment for both Biden and Trump would be a decisional-capacity evaluation. Schneider said these assessments, conducted through interviews, are similar to evaluations done in court cases to determine competency.”

Schneider added, “This is not a matter of pass/fail, of ‘Come in and take your screening test for presidential competency or not, and if you score above 28 you’re competent and if you score below 28 you’re incompetent.’ It’s much more complicated for all of us.”

The number of folks calling for that first step, however, is growing.

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