Intended for healthcare professionals

Observations

The president’s cognitive health: winning with the MoCA

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k424 (Published 02 February 2018) Cite this as: BMJ 2018;360:k424
  1. Krishna Chinthapalli, neurology registrar
  1. Royal Surrey County Hospital, Guildford, UK
  1. vkcpersonal{at}gmail.com

After several calls from high profile psychiatrists with concerns about Trump’s mental health, what does the MoCA tell us about his cognitive health?

Donald Trump recently made the headlines for taking the Montreal cognitive assessment (MoCA) screening test (www.mocatest.org), as part of his annual medical examination.1 It originally wasn’t included in the US president’s assessment, but his physician, Ronny Jackson, says: “The reason we did the cognitive assessment is plain and simple—because the president asked me to do it. He said ‘Is there a test or some type of screen that we can do to assess my cognitive ability?’”2

“I looked at a variety. We picked one that was a little bit more involved. It was longer. It was the more difficult one of all of them. It took significantly longer to complete.”2

It comes after several high profile psychiatrists expressed concerns about Trump’s mental health.

And how did Trump fare? “More #winning. 30 out of 30,” his son tweeted afterwards. This merely means that Trump is unlikely to have mild cognitive impairment or early Alzheimer’s disease. It does not test judgment, personality, or other aspects of the mind.

The MoCA was devised by Ziad Nasreddine, a Canadian neurologist who has been interviewed by global news outlets in the past week. “As a neurologist and researcher, I’m just very happy with the recognition of the MoCA—though the website went down, with 600 000 requests per minute. I have been proud of the rapid uptake of the test globally, and this is the cherry on top,” he told The BMJ.

In 1996, Nasreddine was working at a memory clinic in Montreal. “We had no neuropsychologists, and I found that full testing took up to two hours for each patient so I was only seeing two or three patients a day. All the existing screening tools were for established dementia and not comprehensive in the different cognitive domains. So I decided upon a 10 to 15 minute ‘scan’ of the brain. If we imagine that the mini-mental state examination (MMSE) is an x ray and full neuropsychometric testing is a magnetic resonance imaging scan, the MoCA would be like a computed tomography scan that clinicians could use for rapid screening for mild cognitive impairment. I tried to maximise efficiency with easily scored and validated items that could all fit on one page. Items that were not as useful in early dementia were omitted. For example, writing a sentence tests language and praxis, both affected late in Alzheimer’s disease, so we did not use this.”

In 2005, Nasreddine and colleagues published a validation study with a small number of patients showing that the MoCA had up to 90% sensitivity for mild cognitive impairment compared with 18% for the MMSE.3 This sparked interest around the world. At the outset, it was designed in English and French for use in Montreal. “We granted permission for translations when asked by dementia researchers in other countries,” Nasreddine says. “Now it is available for 65 different languages.”

He has developed further versions of the MoCA, including for blind or illiterate people, as well as online training. An electronic version can assess the time taken to answer as a measure of processing speed. The newest edition of the written test includes a second score to assess delayed recall, and using this score may assist prediction of how long it takes for people with mild cognitive impairment (MCI) to develop Alzheimer’s disease.4

Perhaps most importantly, Nasreddine says that the MoCA may be distributed and used without permission by health professionals, hospitals, clinics, and universities. He has no plans to change this. This is in stark contrast to the MMSE, now only available for $1.62 (£1.14; €1.3) per form, with heavy restrictions including not showing the test to patients.5

Nasreddine’s latest project is to develop another rapid electronic test, to assess driving ability. “We are asked about driving by nearly every patient and caregiver with mild cognitive impairment or early dementia and it is difficult to answer based on current tests” he told The BMJ.

Given that current and former US presidents are not allowed to drive on public roads, it is unlikely that Trump will be asking to take this new test.

Footnotes

  • Provenance and peer review: Not commissioned; not externally peer reviewed.

  • Competing interests: I have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

References

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