Medical Examiner

There Is a Very Useful Test We Could Use to Track Politicians’ Cognitive Decline

Everyone gets slower as they age. The unusualness of this decline can be tracked with data.

President Donald Trump reacts to a question from a reporter during discussion with business owners and their families in the Oval Office on Tuesday.

Kevin Lamarque/Reuters

On Thursday, when President Donald Trump announced his controversial decision to move the U.S. Israeli embassy from Tel Aviv to Jerusalem, an unusual aspect of his announcement became a focus of the coverage: At the end, when Trump said “God bless the United States,” it came out more like “United Shhtates.” While White House representatives said the president’s throat was dry, it spurred plenty of speculation.

One particularly nuanced response came from Ford Vox, an expert in brain injury medicine at the Shepherd Center in Atlanta. In a piece for Stat, he convincingly argued there might be something physically wrong with the president—and that he needs to be tested. In the piece, which is titled “I’m a brain specialist. I think Trump should be tested for a degenerative brain disease,” Vox writes:

In turning my attention to the president, I see worrisome symptoms that fall into three main categories: problems with language and executive function; problems with social cognition and behavior; and problems with memory, attention, and concentration. None of these are symptoms of being a bad or mean person. Nor do they require spelunking into the depths of his psyche to understand. Instead, they raise concern for a neurocognitive disease process in the same sense that wheezing raises the alarm for asthma.

By the end of the story, Vox concludes that, as least according to his analysis, the president is most likely exhibiting signs of dementia. He should, Vox argues, be submitted to a battery of tests to determine if this is the case. This is not the first—or likely the last—time that Trump has been accused of various mental impairments. Like other articles, there’s nothing about this Vox’s piece that seems more likely to compel the president, his family, or Congress to take any action. But unlike the many pieces that have litigated Trump’s mental health from afar, the solution to how to test for this sort of disorder is actually significantly more straightforward.

In June, Slate’s own Jeremy Samuel Faust wrote about something called the Mini-Mental State Exam. The test, when administered by a professional, is a quick way of assessing the cognitive capacity of an individual who is unsure if they had a “senior moment” or if they found themselves in the midst of a more serious decline. The administer watches for how well a person follows instructions, pays attention, and remembers new details. It is also calibrated to the individual—the first test does not yield a diagnosis. But it does provide a baseline (unique to each person, depending on external factors like education), and once a baseline is established, it can provide extremely useful data as the months and years go by. Indeed, this is often how doctors manage to assess patients who are reluctant or unable to recognize their own decline. Faust wrote the piece following John McCain’s own on-camera lapse, and in it he noted the particular service it might provide in the case of politicians:

In most lines of work, a person’s cognitive decline is “checked” in some manner, most likely by his supervisor. Sometimes it takes a nudge from a co-worker. At age 80, my grandfather was not-so-gently urged to retire by his physician colleagues. But people who can’t be fired—elected officials, especially those with lifetime appointments—have no such checks in place. Hypothetically, yes, elections are supposed to address this, but a politician’s staff and family often “cover” for the individual—either intentionally or unintentionally. You see the same thing with family members and close associates of anyone suffering mental decline—admitting that such decline is more than just normal aging is an extremely emotional task, so it’s entirely understandable why these lapses might occur.

It’s also why I think it would be good policy to ask seniors (geriatric medicine specialists focus on patients starting approximately at the age 65 or 70) in positions of public service to submit to serial MMSE testing.

Trump is 71 years old. At his age, some 5 percent of Americans show signs of dementia. That’s a pretty small number, and even if a leader, especially the president, began to show marked mental decline, what to do about that would be a long and ethically complicated conversation.

What is obvious, though, is that when the stakes are this high, we can’t turn our backs on these kinds of questions. And a good place to start is in gathering as much data as we can.