Dementia Tests, Reconsidered

Thinking about: Your Health

As you get older, you will be asked to take medical tests. First comes a colonoscopy, maybe at age 45, and when you turn 65, your doctor might start giving you a cognitive assessment, informally referred to as a dementia test. President Trump took one in 2018 and got a perfect 30 out of 30 points. He took it again in 2025, with the same perfect score. In his terminology, he aced it. This week he went in for more medical tests but a cognitive exam apparently wasn’t included.

I will be honest: Trump is aging well. At 79, he is still playing golf. He is also making trips to distant places involving considerable jet lag, but remains functional on arriving. And while not traveling, he can cope with what looks like a demanding schedule. Although I am six years younger, I’m not sure I could keep up with him.

With aging comes memory loss. In my case, it is a curiously selective process. Although I am able to remember the detailed structure of a seventy-thousand-word manuscript, I have to rely on Google maps to go to a store that five years ago I would have driven to “on autopilot.” Part of the reason is that I don’t go out nearly as much as I used to. Instead, I stay home and write. Memory loss at an advanced age is inevitable, and given that I have limited capacity for memory, it seems wise to “spend it” on things that matter to me. At this point, writing matters much more than navigating my city.

My mother had dementia, and because she lived nearby, I was a frequent visitor. On one visit, I watched her take a cognitive exam in which she was asked to identify a crudely drawn rhinoceros. She misidentified it as a pterodactyl—which, if you have to misidentify it, is a pretty impressive misidentification, particularly on the part of someone who graduated from high school in a logging town in Montana and didn’t subsequently attend college.

Some medical tests require preparation. Before taking a blood test, for example, you might be required to fast. And before taking a colonoscopy, you will not only have to refrain from eating solid food but have to drink an inordinate amount of fluid. Patients can also come up with their own preparation routine, with the goal of “improving” their test results. When they are scheduled to take a blood test for cholesterol, for example, they might stop eating eggs.*

I did something like this when, a few months ago, I was scheduled to have a cognitive exam. I was aware that Trump had received a perfect score on his, and for reasons that I don’t fully understand, I took myself to be in competition with him. I therefore spent some time “studying for” the test. More precisely, I thought about questions that I had been asked on the tests I had taken in the past and reflected on how best to answer them:

• If they asked if I knew where I was, I would say, “Right here, of course!”

• If they asked what day of the week it was, along with the date, month, and year, I would complain that as a retired person, my days are pretty much alike, meaning that I don’t really need to know these things. And if I did—well, that’s what cell phones are for.

• If they asked me to spell “world” backward, I would respond with a “cognitive pun”: “Do you mean D-L-R-O-W or D-E-L-R-I-H-W?”

• If they asked me to draw a clock showing a time of 10 past 11, I would respond with a request for clarification: “Do you want a digital or analog clock?”

This is all very clever, I thought, but what if they were having a bad day? Did I really want to run the risk of annoying the person who was assessing my cognitive ability? I subsequently decided that it would be wise to keep my jokes to a minimum.

I also started thinking about my motivation for coming up with them. I suspect that it was a desire to provide my inquisitors with extra evidence that I wasn’t demented. I also suspect that a deep-seated fear lurked behind this desire. As someone who identifies as a Thinker, I am frightened by the prospect that my rational powers will someday fail me—that the aging process will transform me into the pure Feeler I started out as.

When test day came, I realized that I wasn’t being asked the questions I had expected. It turns out that there are two commonly-used cognitive tests, the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). Both have 30 as a perfect score, but the questions they use to determine that score are different. In recent years, I had been taking the MMSE, but this time the doctor was giving me the MoCA.

I was therefore surprised when my doctor gave me five rather than three words to memorize—and even more surprised that I was able to remember them.

I was also surprised when she asked me to count backward from 100 by 7. For me, this was no challenge, inasmuch as I do backward subtraction whenever I need to distract my restless mind in the middle of the night.** Another way I mentally distract myself is by making a mental list of the people who have been president while I have been alive. There are fourteen of them, starting with Truman. (I doubt that Trump does this, but if he did, his list would be the same as mine—and silver lining, he would appear on it twice!)

Another surprise was when I was asked to come up with words that begin with F, but not names of people or countries, with a time limit of one minute. This sounds easy, but try doing it under pressure, when your mental acuity is being tested. By the end of the minute, I had come up with only eleven words, one of which was “flatulence.” Like I say, I was desperate.

At the end of the test, the doctor informed me that I had done quite well, coming only one point short of a perfect score. “One more F-word would have done it,” she said. On hearing this, a twelfth F-word immediately came to mind, and in case you are wondering, that word wasn’t “fudge.”

These more-and-better-thinking posts usually have a specific takeaway, but I’m not sure this one does. Maybe the lesson is that even Thinkers can be too clever by half.

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*Such steps are arguably misguided. For one thing, egg consumption does not appear to have a substantial impact on blood cholesterol. Also, for the test to provide medically useful information, you should eat as close to your regular diet as you can before taking the test.

**Instead of counting back from 100 by 7s, I count back from 147 by 3s, allowing only one subtraction per breath. Sometimes I am asleep before reaching 100. If you also have a restless mind at night, maybe you want to give this a try? And maybe Trump could do this instead of spending the night cranking out texts filled with ALL CAPS?