Updated on Tuesday, Jan. 16: President Trump asked the White House physician, Dr. Ronny Jackson, to perform a screening test for cognitive function during his medical exam last week — even though it is not a part of a standard physical for a 71-year old, Jackson told reporters at a White House news conference on Tuesday.

Jackson gave Trump the Montreal Cognitive Assessment, and Trump scored a 30 out of 30. “The reason I did it, plain and simple, is the president asked me to do it,” Jackson said, adding that there is “no indication he has any cognitive issues” and “no reason to think the president has any issues whatsoever with his thought processes.”

Jackson added, “I spend every day in the president’s presence. I see him two or three times a day. I’ve had absolutely no concern about his cognitive ability or cognitive function.”

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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.

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“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.

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  • Why is a physician in the presence of the President every day or even 2-3 times per day as he stated above. Is this usual?

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    • Pat Skerrett
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  • Like Trump said, “I can always speak for myself and the Russians – zero.” Am I clear in my communication; does that make sense to you? No, it doesn’t, does it. This is not a political issue. This is about the competency of an elected official.

    Yesterday. With members of Congress in a rare meeting with press and cameras present. It was intentionally staged as a response to the issue of mental health questions. It was planned and the president was prepared; not a ‘gotcha’ moment, not taken surprise.

    “Chain migration is bringing in many, many people with one, and often it doesn’t work out very well. Those many people are not doing us right.”

    • Those many people.

    “People — for instance, the man on the Westside Highway that killed the people and so badly wounded. You know, it’s incredible when they talk about wounded, they don’t say that arms are off, and legs are off, one person lost two legs. You know, nobody talks about it. They said eight died, but they don’t talk about the twelve people that have no legs, no arms, and all of the things. So I’m talking about everybody.”
    “I really believe that when you talk about — the subject that we’re all mentioning right now, I think they had — how many people came in? Twenty-two to twenty-four people came in through him.”

    He started with the phrase ‘chain migration’ and couldn’t remember it 45 seconds later. When he said “the subject we’re all mentioning right now,” he paused and looked down the table. Word choice was “mentioning” as opposed to ‘discussing’ or ‘talking about’.
    He followed with a confabulation — there is no basis of fact for the notion that the Uzbek jihadist brought 22-24 others. The Uzbek man entered the US through the Diversity Visa Lottery Program, which was also part of the discussion. I believe some part of the disjointed syntax and the appearance of going off-track is practiced compensation.

    Exchange about Mexico’s southern border with Guatemala:
    “We stopped them. You know why? Mexico told me, the President told me, everybody tells me — not as many people are coming through their southern border because they don’t think they can get through our southern border and therefore they don’t come. That’s what happened with Mexico. We did Mexico a tremendous favor.”
    “…the ICE officers and the Border Patrol agents — I had them just recently on — they say, if you don’t have the wall — you know, in certain areas, obviously, that aren’t protected by nature…”

    • He had them recently on what?

    “But, you know, you speak to the agents, and I spoke to all of them. I spoke — I lived with them. They endorsed me for President, which they’ve never done before — the Border Patrol agents and ICE. They both endorsed Trump. And they never did that before. And I have a great relationship with them.”

    • Trump lived with Border Patrol agents?

    http://www.whitehouse.gov/briefings-statements/remarks-president-trump-meeting-bipartisan-members-congress-immigration/

    • “The reason I did it, plain and simple, is the president asked me to do it,” Jackson said… Did he request this particular test by name? I do wonder if this guy with an MD after his name was born yesterday.

      I can envision that Trump would have someone find this test online and then go through it with him in advance. While the man is not the brightest bulb in the room but he is very smart when it comes to self-preservation –
      plotting, planning, lying and cover-ups. Evidence as presented by GC and others is pretty indicative of a some deficit although his short term memory in these settings could well be affected by stress.

      Before we jump to a dementia diagnosis in looking at short term memory problems we screen for 1) high levels of stress, 2) depression and 3) physiological impairments such as occluded cerebral arteries.

      Obvious defects in judgement may not indicate cognitive impairment, they are more likely a sign of his mental disorders which are obvious to all trained to observe such things. Both documented word choices and behaviors are diagnostic tools we can use to see the man’s inner turmoil.
      He’d just be a sad, rich fool were it not that he sits in the White House.

    • ” .. He’d just be a sad, rich fool were it not that he sits in the White House.”

      HRC would be under indictment for FOIA violations, if her goofy husband hadn’t been an accidental president.

  • Since there is verification of past President Ronald Reagan, who had Alzheimer’s disease probably while serving, were there any protocols that were followed during his term of office

  • Why stop at DJT? What about testing big FOIA violators (HRC)? Those with driving problems (Teddy)? How about 88-year-old Congressmen?

  • It’s perplexing to realize that higher cognitive brain functions aren’t evaluated routinely during the annual medical assessments of U.S. Presidents. Liver? Yeah we test for that. Blood cell counts? Yeah, we test for them. But Presidents don’t get their jobs done without a brain that is in good order. Time to update the expectations!

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