The cognitive fitness of President of the United States Donald Trump and the ethics of his cognitive evaluation have been the topic of intense discussion among both the general public and medical professionals in recent months.1 Most modern presidents of the United States have undergone routine yearly medical assessments during their tenure in office. On January 16, 2018, the physician to the president, Rear Admiral Ronny Jackson, MD, held a press briefing on President Trump’s first such assessment, which included the Montreal Cognitive Assessment (MoCA), an extensively validated screening tool for mild cognitive impairment in older individuals.2 Jackson’s announcement was notable because President Trump is thought to be the first President of the United States to undergo formal cognitive evaluation while in office.
In the days immediately after this announcement, a large spike occurred in web searches for the term Montreal Cognitive Assessment. Details of the test were widely reported in mainstream media, with several large news networks explicitly inviting members of the general public to undertake the test themselves.3,4 Because several studies have pointed to the presence of a learning effect in those who undergo repetitive longitudinal testing,5,6 we sought to characterize the reporting on the MoCA after Jackson’s announcement and to ascertain which test details were disseminated to the public.
We systematically searched for online news articles using the keywords “Montreal Cognitive Assessment” in Google News, with date limits from January 15, 2018, to January 21, 2018; all identified articles discussing the MoCA in association with President Trump were extracted. Using Google Trends, we also obtained worldwide search trends for the same term between January 10, 2018, and January 20, 2018, with the term Mini-Mental State Examination (another test of cognitive function) used as a comparator.
We identified 405 unique news articles, of which 190 discussed the MoCA in association with President Trump. Of these articles, 102 (53.7%) included part or all of the MoCA, with 84 (44.2%) presenting the questionnaire in its entirety, either via hyperlink (67 [35.3%]) or embedded directly into the body of the article (33 [17.4%]). A total of 17 articles (8.9%) presented the answer key, and 33 (17.4%) directly invited the reader to self-administer the test. All identifiable versions of the MoCA contained within articles were version 1; alternate versions were only referenced indirectly via hyperlink to the MoCA website (http://mocatest.org). Google Trends results showed that search interest in the MoCA increased substantially after Jackson’s announcement, while search interest in the Mini-Mental State Examination remained low (Figure).
The announcement of President Trump’s cognitive evaluation prompted considerable public interest in the MoCA. More than half of all recovered news articles presented contents of the test, and 1 in 6 directly invited readers to undertake it.
The result of this sudden and rapid dissemination of the MoCA’s contents is not immediately apparent; however, given ongoing interest in age-associated cognitive function, public awareness of specific cognitive tests, such as the MoCA, may continue to increase. It is possible that the MoCA’s applicability may be compromised in individuals exposed to its contents via such mainstream media reporting. This presents a problem for clinicians, because the presence of a learning effect could result in decreased sensitivity, eroding the MoCA’s chief usefulness in identifying patients with mild cognitive impairment. Future research is warranted to validate test performance in populations with direct exposure to the questionnaire’s content or grading scheme.
In the meantime, clinicians assessing patients with the MoCA should be aware of this potential exposure to the test and should therefore consider routinely inquiring whether a patient has previously been exposed to the MoCA. As most news articles published version 1, using alternative versions 2 or 3 of the MoCA in formal clinical settings among preexposed patients may serve as a mitigation strategy.
Corresponding Author: Hourmazd Haghbayan, MD, Department of Medicine, University of Toronto, 200 Elizabeth St, Ste RFE 3-805, Toronto, ON M5G 2C4, Canada (hourmazd.haghbayan@mail.utoronto.ca).
Published Online: July 16, 2018. doi:10.1001/jamaneurol.2018.1777
Author Contributions: Dr Haghbayan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Haghbayan, Coomes, Cheema.
Acquisition, analysis, or interpretation of data: Haghbayan, Coomes, Shojania.
Drafting of the manuscript: Haghbayan, Coomes.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Haghbayan, Coomes.
Administrative, technical, or material support: Haghbayan, Coomes, Cheema.
Supervision: Shojania.
Conflict of Interest Disclosures: None reported.
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