I think that it was 15 years ago, plus or minus, that I attended a corporate meeting for medical and health services directors. Some of United Healthcare’s luminaries were there. One of them was lecturing on assessing individuals for cognitive impairment. I suggested that a quick screen was to use the CLOX test – a test of a patient’s ability to draw a mechanical clock face showing a specific time – say 4:20 or 11:30.
He responded that clock drawing was just a test of visuospatial ability. That, of course, is only true if one asks a person to reproduce a picture of a clock showing a particular time. Being told to create a clock image without a reference image is a test of frontal lobe function – the part of the brain that is needed to plan and execute a sequence of steps needed to accomplish a task like making a sandwich, giving a coherent speech, or maybe drawing a clock.
I recall my four-year-old son creating adventure stories based on the Ninja Turtles or some other TV characters. His stories had no real beginning or progression toward an end. Children don’t develop the ability to deliver a complex, coherent story until they are in fourth grade to high school – some even later. Telling a coherent story requires the planning and execution of a mature frontal lobe, and that part of the brain isn’t fully developed until about age 25. Still, by high school, enough of the frontal lobe has matured that most students can write and tell an interesting story.
Reading from a teleprompter is more like copying a picture of a clock than it is like drawing a clock from scratch. Delivering remarks from a teleprompter requires much less frontal lobe ability than speaking extemporaneously and actually making sense.
This brings me to battery-powered boats, sharks, and evidence of cognitive impairment. Trump’s recent Las Vegas rally gives us insight into his cognitive decline. He can read a teleprompter and sound coherent only because his speechwriters have given him a coherent speech to deliver. All he needs to do is read and speak the words. But when the teleprompter fails under the triple-digit desert heat, he shows us that he cannot deliver a message. Shit, he has no message – he just yammers incoherently.
I have met and attended to many patients with various levels of dementia. In the early stages, the social graces are preserved. Patients meet you, shake your hand, say hello, engage in small talk, and seem quite normal – but more complex tasks are daunting. Later, even the social graces gradually disappear. It’s heartbreaking to watch the effacement of personality and self-efficacy that ensues in the years that follow.
Make no mistake, His Most Orange Orator is in inexorable cognitive decline.