President Trump recently took a physical to assess his overall health.
Although these physicals are routine for sitting presidents, this one
has gotten unusual attention because it included an additional component:
a mental status exam.
According to media reports, Trump had a memory screening exam added to
his usual physical by White House medical staff. They apparently wanted
to rule out early signs of dementia or memory loss. Trump apparently did
just fine on the exam, scoring a 100-percent.
We have seen memory screening exams many times before in our practice.
That’s because we represent people with brain injuries or other
cognitive problems. Exams like the one taken by Trump are sometimes used,
and more importantly
misused, to test people with brain injuries.
The test taken by Trump is called the Montreal Cognitive Assessment. It
is designed as a preliminary screening tool for mild cognitive problems.
It is often given to elderly patients suspected of having early Alzheimers
or other types of dementia.
The MCO is a very basic test. The 30-point test only requires test-takers
to do simple things, like identify drawings of a lion and a rhinoceros.
Test-takers also have to copy a simple line sketch of a cube; match the
letter A to the number 1, the letter B to the number 2, etc. They are
asked to recall a list of five words and repeat short lists of numbers
forward and backward.
The great majority of people who don’t have cognitive problems or
dementia do well on the test. Most brain injured clients do well on the
test too, because it’s so basic that it doesn’t detect the
type of more subtle problems brain injuries create. Mild to moderate brain
injuries typically cause problems with things like high-level reasoning
or decisionmaking, and not rudimentary things like identifying drawings
Nevertheless, defense examiners will sometimes pronounce that our client
with a traumatic brain injury are “fine” or “normal”
because they pass tests like the MCO. This is wrong, because preliminary
screening tests for dementia were never designed to detect most forms
of traumatic brain injury. To ferret out brain injury, more comprehensive
neuropsychological tests, such as those “for executive function,”
are much more appropriate. Defense examiners often decline to give those
tests, or just ignore the results when they come back unfavorable.
The Trump exam actually illustrates all this pretty well. While the MCO
gives us some assurance that our President isn’t suffering from
age-related cognitive decline, it doesn’t tell us about his (pardon
the pun) executive function. That is, critical skills for a President
like high-level decisionmaking, making judgment calls under stress, and
impulse control are not even part of the test. It just doesn’t tell
either Trump’s supporters or his opponents much about things that matter.
The MCO doesn’t tell us much about the executive function of a client
who suffers a traumatic brain injury either. The client may be able to
identify a picture of a lion, but that doesn’t mean he or she is
in the clear on tasks which require critical thinking and judgment.