Questions about cognitive functioning are now standard in annual wellness exams for seniors paid for by Medicare, and they should be on the agenda during 71-year-old Donald Trump's first physical as president Friday, Jason Karlawish, a physician who codirects the Penn Memory Center, believes.
Between reports about the president's erratic behavior and trouble concentrating, his simplistic vocabulary and meandering communication style, it's reasonable to wonder about his health, Karlawish recently argued in an essay in Forbes.
"The topic of our president's cognitive functioning and its impact on his day-to-day life and his ability to do his job kept on recurring," said Karlawish, who is an expert on late-life cognitive disorders, like Alzheimer's disease and frontotemporal dementia.
Neither he nor Arthur Caplan, a New York University bioethicist who has called for a more transparent presidential assessment, expects any big news from the physical.
A White House spokesman did not respond this week to questions about whether the president's cognitive health would be measured on Friday. But traditional physicals have not devoted much time to brain health. "Physicals tend to be really physical," Caplan said. "They tend to be almost biochemistry exams."
Plus, the commander in chief will control what is made public about his health, and the doctors doing the evaluation work are military employees, Caplan said.
Both Caplan and Karlawish see Trump's physical as an opportunity for the country to discuss whether an independent, nonpartisan group should perform presidential medical exams that encompass a standard set of measures important to performing the job. Former President Jimmy Carter endorsed the idea in 1994, Karlawish said, but it has never gotten off the ground. Touchy subjects such as who should receive information about serious health problems — likely Congress, not the public — put consensus out of reach, Karlawish said.
"This is a topic the nation needs to start to engage," he said.
Local Democratic Congressman Brendan Boyle raised a similar issue Tuesday by introducing a bill that would assess presidential nominees for "physical and mental fitness" with a standardized medical exam. Results would be made public. In a nod to Trump's recent tweet calling himself a "stable genius," Boyle called it the Standardizing Testing and Accountability Before Large Elections Giving Electors Necessary Information for Unobstructed Selection Act (STABLE GENIUS Act).
Cognitive functioning becomes more of an issue with advancing age. According to the Alzheimer's Association, 3 percent of people aged 65 to 74 have Alzheimer's compared, with 17 percent of those 75 to 84. Trump is the oldest person to begin a first term in office. But several politicians considered his possible rivals in 2020 are older — Bernie Sanders is 76 and Joe Biden is 75. Even Oprah Winfrey, whose Golden Globes speech fueled talk that she might be a presidential contender, would be 67 in 2020.
Brain changes and mild symptoms begin years before people are diagnosed with dementia.
As more people work during what once were considered the retirement years, the issue of how to assess competency in older workers will become more pressing. Many health systems now have programs, for example, that test whether older doctors are having physical or cognitive problems that impair their ability to do their jobs.
There is no standard for when brain changes render people unable to do a job. Exactly when former President Ronald Reagan began showing signs of Alzheimer's has long been a point of controversy.
Former President Barack Obama's last physical did indeed include a lot of the usual numbers, like blood pressure and heart rate. The biggest problem his office reported was occasional acid reflux. There was a neurological exam, but it covered the sorts of things you can measure by asking a patient to track a light with his eyes, not tests that measure how well his brain is working.
Karlawish said the Affordable Care Act authorized Medicare to cover an "annual wellness visit" that includes the "detection of any cognitive impairment."
The patient and family, if present, would be asked if the patient has experienced any changes in thinking ability or memory. Karlawish said changes in the ability to manage money, medications, and driving are often early signs of cognitive trouble.
If there are concerns about impairment, a doctor typically would then give an exam that measures memory, language skills, and executive function, which refers to the ability to plan and make decisions.
People who functioned at a very high level when young can perform well on tests even when they're starting to have problems. The really important thing, Karlawish said, is whether they change over time.
Jack Ende, a Penn internist in charge of the health system's executive health program, said he believes physicians are asking their older patients about brain functioning. Executive physicals, used by some companies to make sure their leaders' health problems are caught early, take several hours, far longer than standard checkups, he said.
For patients over 65, Ende routinely asks about depression, anxiety, and stress as well as whether they're having problems with memory.
Andrew Newberg, an internal and nuclear medicine doctor who is director of research at Jefferson Health's Marcus Institute of Integrative Health, conducts daylong evaluations — most are for executives — in the Executive Great Life and Advanced Brain Health programs. Both are daylong endeavors that cost from $2,500 to $6,500. Most of the participants in the brain program are 55 and up and worried about changes or a family history. Some opt for advanced brain imaging that shows whether there are signs of amyloid, a protein associated with Alzheimer's disease, or other structural abnormalities in their brains.