How to test if President Trump’s memory is declining

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Carlos
Barria/Reuters

  • The White House told reporters President Trump will not
    receive psychiatric testing during his physical exam Friday —
    but cognitive assessments haven’t been confirmed or
    denied.
  • Cognition can be tested by measuring vocabulary: the
    number of unique words compared as a percentage of total ones
    used to describe something. 
  • Memory is tested by asking a patient to remember of
    list of numbers and then repeat them in reverse
    order. 
  • If there are signs of cognitive decline, examiners will
    compare President Trump’s levels to that of other
    college-educated men his age in order to determine if it’s a
    result of pathology or normal aging. 

When President Trump has his physical exam on Friday, there is
little chance he will repeat the same story within a span of 10
minutes or fail to recognize old friends, as the explosive new
book “Fire and Fury” by Michael Wolff asserts he has done in the
past.

But the mental deterioration that causes such memory lapses would
be detectable on standard cognitive tests.

The White House told reporters on Monday that psychiatric tests
would not be conducted as part of the president’s physical, but
did not explicitly rule out cognitive assessments.

The physical, which will take place at Walter Reed National
Military Medical Center, comes amid an increasingly public debate
about whether Trump is suffering cognitive decline precipitous
enough to impair his capacity to carry out the work of the
presidency.

Unlike tests for emotional instability, personality disorder, or
other psychiatric disorders that some armchair diagnosticians
have speculated Trump may have, assessments of cognitive status
are relatively objective and quantitative.

“There are sophisticated tests to probe different areas of mental
functioning, including memory, attention, and judgment,” said
psychologist David Reiss, who contributed to the 2017 book “The
Dangerous Case of Donald Trump.”

“There has been a lot about Trump turning the wrong way or
forgetting something, or saying something mangled,” Reiss said.
But “it’s not consistent; there are other times when he doesn’t
do that. From a clinical point of view, yeah, they’re notable,
but they get much more play than is warranted: Anybody who’s
being taped all day will sometimes turn the wrong way. A lot of
these things are basically meaningless unless they’re
consistent.”

Cognitive tests are not part of a standard physical, and there is
no record of previous presidents (who routinely released the
results of their physicals) having them. The White House has not
said whether Trump will. However, his weekend
tweets
 in response to Wolff’s claims —
bragging that he is a “very stable
genius”
— reignited calls for him to do so.

The window of language

One way neuropsychologists evaluate cognitive function is through
language, which can be a tip-off to early-stage dementia. Indeed,
the apparent decline in Trump’s spontaneous speech — that is, the
unscripted answers he gives in interviews and press conferences —
was one of the first behaviors that spurred debate about whether
he was suffering cognitive decline or mild cognitive impairment.
(MCI is the stage before Alzheimer’s, which Trump’s father had
for six years before his death at age 93 in 1999.)

“There are changes in spoken language before people start
noticing other symptoms,” said neuropsychologist Duke Han of the
University of Southern California, lead author of
a study last
month concluding that a deterioration in language often indicates
the presence in the brain of the amyloid protein that’s
considered the marker for Alzheimer’s.

“Memory problems get manifested as language symptoms,” Han said.
‘The tip-of-the-tongue’ phenomenon can be an early sign of it. So
can losing the name of something uncommon, like ‘abacus’ or
‘trellis.’ That makes sense because one of the first areas of the
brain to be affected in dementia are the temporal lobes, which
house semantic [word meaning] knowledge.”

Clinicians can measure language ability by having a patient
describe a picture, for instance, said Dr. Seyed Sajjadi of the
University of Southern California, a neurologist who specializes
in dementias. “But you can also just let him talk.”

In that case, the physician could measure vocabulary level and
the number of unique words as a percentage of total words. The
latter should be high; a low percentage indicates repetition and
possibly difficulty accessing the correct word from semantic
storage. A physician can also listen for sentence length, another
marker of complex thought, memory, and forethought.

“The importance of language as a cognitive domain is
underappreciated,” said Sajjadi. It can be a window “into not
only memory but also executive function, such as the ability to
plan a sentence, which you need for the generation of complex
sentences” with multiple dependent clauses.

A physician can also evaluate a patient’s cognitive function
through his quality of speech, said psychologist Ben Michaelis,
who is in private practice in New York City and has done
neuropsychological testing at the request of courts, “including
whether [a person] is thinking and talking in a linear way.” The
physician would listen for tangential remarks and non sequiturs,
he said, and generally whether the patient can stay on topic and
follow the give-and-take of a conversation.

In these types of analyses, Reiss said, “I’d listen for the
ability to give a history, not repeating himself, making sense,
and not wandering. Are the responses direct? Defensive?
Logical? Consistent? What is the general flow of information? An
answer that might be reasonable but is inconsistent with
someone’s education and background could be significant,” raising
a red flag.

Measuring memory

Another faculty that could be measured in a cognitive exam is
memory.

If Trump is indeed repeating the same three stories in the span
of 10 minutes, it could be an indication of impaired short-term
memory, Michaelis said. (On the other hand, Wolff says Trump used
to repeat stories inside of 30 minutes, raising the possibility
that repetition is a longstanding conversational gambit of his.)
“Making new memories” such as I just told
that story
 “is one of the things that goes
when people get older, and is a sign of neurological impairment,”
Michaelis said.

Memory is a key
component
 of cognitive capacity, required
for comparing options (alternatives need to be kept in mind
simultaneously), making judgments (you have to remember pros and
cons in order to weigh them), and plotting and executing strategy
(you have to remember the steps to form them into an overall
plan). It is also one of the first abilities to decline in both
normal cognitive aging and pathological aging of the sort that
precedes dementia.

Standard cognitive testing — variously called mental status
exams, cognitive testing, or neuropsychological testing — would
also show how well Trump is functioning.

Asking a patient to listen to a list of digits (6, 9, 8, 3,
8) and repeat them in that order tests working memory, while
saying them in reverse order (8, 3, 8, 9, 6) tests both memory
and mental agility (some people see the digits in their mind’s
eye and read them from right to left).

Doing a dot-to-dot that includes letters as well as numbers
(1-A-2-B-3  …), a component of the commonly used Montreal
Cognitive Assessment, demonstrates the ability to keep two
different categories in mind simultaneously.

Drawing a clock whose hands show 10 past 11 indicates the ability
to remember, form a mental image, and transfer it to paper.
Naming animals shown in line drawings tests memory and language.
Tapping the table each time an “A” is spoken in a string of
letters (A, M, L, A, Y, U, P, N, A, A, C … ) tests attention, as
does counting backwards by 7’s from 100.

Like memory, the brain’s processing speed is especially
vulnerable to aging. One standard test of this asks the patient
to look at a picture and find as many examples of, say, a circle
or an X or other simple symbol as possible in two minutes.
Another shows a list of symbols corresponding to each of five
letters (? is for A, { is for B, # is for C …), after which the
patient is given a list of letters and has to write the
corresponding symbol for as many as possible in a minute.

25th Amendment

Whether any cognitive decline is the result of pathology or just
normal aging can be determined in two ways, said USC’s Han.

One is by comparing Trump’s cognitive status to that of other men
his age and with his education. If he falls in the range for
71-year-olds with a college degree (he has a bachelor’s from the
Wharton School of the University of Pennsylvania), then even if
his language, memory, and other mental capacities have declined
over the years he is probably not suffering from early
Alzheimer’s or other dementia.

The other way is by determining how sharp any decline is. That
requires a baseline, which reportedly does not exist for Trump,
at least in terms of a formal medical record.

Although there seems to be no chance that Trump’s physical will
assess his brain, 56 congressional Democrats have
co-sponsored a
bill
 introduced last May that seeks to
require that of presidents. It would establish a commission,
including four psychiatrists and four physicians from other
specialties, to assess presidential fitness if Congress ordered
that.

Read the original article on STAT. Copyright 2018. Follow STAT on Twitter.

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