Testing the fitness of aging brains: Most voters support cognitive exams for older politicians

Amid concerns about the mental fitness of US presidential candidates – Joe Biden is 81 and Donald Trump is 77 – some have called for mandatory cognitive testing for older politicians. A recent one poll showed that 75% of voters support such measures, with support highest among the oldest group of Americans surveyed.

The Gazette asked clinical neuropsychologist Julie Brody Magid, Psy.D., clinical director of the McLean Memory Disorders Assessment Clinic and instructor of psychology at Harvard Medical School, what functions cognitive tests measure, warning signs of mental decline, and how we maintain the brain can keep health. The interview has been edited for length and clarity.

What Do Cognitive Tests Assess?

In general, cognitive tests assess a range of functions, including memory, attention and concentration, language, spatial skills, orientation and executive functioning. There are cognitive screening measures that provide a quick overview of various cognitive functions.

Currently, the most commonly used cognitive screening test is the Montreal Cognitive Assessment, MoCA. In the past, the Folstein Mini Mental State Exam was widely used by physicians. These are abbreviated cognitive screening measures that take five or ten minutes to administer and score.

What does the MoCA test entail?

The MoCA test includes tasks that assess attention, orientation, naming objects, learning a short list of words, and verbal reasoning tasks such as analogies. It has a total score of 30 points. It is a standardized test, administered the same way every time.

You earn a raw score based on your performance, which determines whether your skills are within the normal expected range for your age and background. For example, given a person’s education and performance, is a person’s performance where we would expect it to be? Or does the screening test indicate a decline?

Who can perform well on the MoCA test?

There are very talented, smart people who can perform relatively well on a cognitive screening test like the MoCA, even if they have undergone some changes in their everyday skills. When you think of lawyers, doctors or professors, it is clear that they have strong intellectual capacity, and what we call cognitive reserve, which is your cognitive savings account for being intelligent, educated and enriched.

Some people can “cruise” on their reserve even when they have subtle problems because their basic skills were so strong. Sometimes we identify a patient who functions very well and still performs relatively well on a MoCA test, but may have subjective cognitive complaints.

Some people come into my memory clinic and say, “Something’s wrong, I can’t remember clearly, I feel like I’m getting worse.” They may notice it themselves or the family may notice changes. Those screening tests themselves have some use, but they don’t tell the whole story.

The clinical information provided by the patient or family during the interview about the course of change compared to who that person was at their highest level of functioning is very important. We need both sets of information to make distinctions about what a cognitive screening score means and when further elaboration is needed.

What are the red flags that can warn of cognitive changes?

A red flag is that people show signs of forgetting quickly, for example when they are having a conversation and something is discussed or planned, then minutes or hours later they forget it, and after being told it again, they still forget it. Rapid forgetting with repetitive questions is usually not an age-appropriate memory change.

That kind of memory change indicates Alzheimer’s disease, a disorder in the storage or retention of memory. Sometimes short-term memory loss can be accompanied by subtle language changes, with people unable to find words, especially when naming objects. Often they start using general words such as ‘the thing’, ‘the whatchamacallit’, or they might describe the object but they can’t name it. These are some signals we are looking forward to.

In vascular dementia, a risk factor for developing Alzheimer’s disease, we see more problems with executive functioning, such as problems with organization and keeping paperwork in order; people lose track of bills because they leave them somewhere or don’t address them.

We see people with vascular risk factors who have difficulty with reasoning and problem solving. For example, due to poor judgment, they get into a minor car accident and then don’t know how to deal with it. Some people have reduced initiation and motivation; they stop doing things they’ve always been passionate about and can’t explain why. Slowed processing speed is often reported in daily functioning; everything takes much longer to work through and complete.

Is cognitive decline part of normal aging?

There are age-related changes that occur throughout our lives. As we age, there are some brain changes that occur as part of the normal aging process; White matter changes result from arteries becoming narrowed or blocked by atherosclerotic plaque. This can start around age 60.

When that happens, there is some processing slowdown, difficulty accessing information, retrieving that memory clearly, and finding words efficiently; some people consider these experiences as “senior moments.”

We also have some cell loss and atrophy in the brain that occurs with normal aging. In neuroimaging we see an age-related volume loss in the cortex or gray matter, which plays an important role in many functions, including memory/learning and language. All these changes are part of normal aging.

When is the right time to take a cognitive test?

What we generally suggest is that if a patient has so-called subjective cognitive complaints because he notices change, a cognitive screening should be performed. However, one of the difficult aspects of dementia, especially certain forms such as Alzheimer’s disease, is that the disease can affect the consciousness center of the brain, and people do not notice the changes in themselves, but the family, partner or doctor notices the changes.

If there is any indication from subjective cognitive complaints or objective observation that that person is showing signs of early decline, that is the time to at least perform a neurocognitive screening test. That’s often the start of the workup process, which can also include neuroimaging and blood tests, because other medical problems besides dementia can cause people to have cognitive problems.

Cognitive changes can result from hypothyroidism, anemia, vitamin deficiency, sleep apnea, low blood pressure, unstable blood sugar levels and a range of medical problems that can be reversible and allow the person to stabilize.

Correction of vision and hearing problems can also improve cognition. Mental health problems such as depression and anxiety can also affect cognition, but with proper targeted treatment, cognition can return to baseline. We need to think holistically about all the factors that can contribute to someone developing cognitive problems, to see which ones are treatable and possibly reversible.

What are the most important steps to maintain our cognitive health?

There is good research to support the Mediterranean diet for promoting successful aging and brain health. Exercise is very important because you exercise the heart muscle and maintain cardiovascular health.

There are studies showing that exercise infuses the brain with blood, which can lead to neural growth and protection of important areas such as the hippocampus. Exercise can delay the onset of cognitive symptoms or help prevent dementia.

Research among people with cognitive disorders has shown that those who exercise perform better on average on cognitive tests and often perform better in their functioning than those who do not exercise. Sleep is also very important for maintaining cognitive health; at least seven to eight hours of sleep per night is needed to remove debris from the brain.

It is critical to manage medical comorbidities such as hypertension, high cholesterol, diabetes, smoking, sleep apnea, sedentary lifestyle, hearing/vision disorders, and depression.

We also recommend limiting alcohol and marijuana use. We often see older adults consuming excessive amounts of alcohol, which puts them at risk of cognitive decline and falls. There is literature supporting that meditation and stress reduction promote brain health and cognitive functioning.

Other factors that promote brain health include engaging in activities that stimulate your brain, such as doing crossword puzzles, learning a language, playing an instrument, discussing current events and playing interactive games. Maintaining social connections and support is critical for mood stability and cognitive functioning.

Finally, it is very important to overcome the stigma associated with potentially losing your cognitive skills and reach out for an assessment when you see the first warning signs.

If you allow these problems to persist for too long, there will be fewer effective intervention options. We have a number of good tools and resources available to support people’s functioning and manage symptoms, and there are many more interventions in the pipeline right now.

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