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When the 46th President of the United States took the debate stage a week ago, it was clear from his opening answers that this was not the performance he was hoping for.
As a brain specialist, President Joe Biden’s actions were worrying to me. And it quickly became clear that I was not alone in my reaction. Over the past week, I have received more than a dozen calls, texts, and emails from fellow brain specialists. What we noticed was not necessarily new. But it was especially evident from the beginning of the debate.
From a neurological perspective, we were concerned by his disorganized and incoherent speech, sudden losses of concentration mid-sentence, trailing off of words, and blank facial expression that resulted in his mouth hanging open at times. To be clear, these were merely observations and in no way a diagnosis of a more serious illness, and none of these doctors wanted to suggest that this was the case.
However, the doctors who contacted me were of the opinion that the President should be encouraged to undergo extensive cognitive and motor disorder testing, the results of which should be made public.
Over the past five years, I have reported extensively on advances in the world of dementia treatment and risk reduction, including Alzheimer’s, Lewy Body Dementia, and Vascular Dementia. In the documentary “The Last Alzheimer’s Patient,” I demonstrate that, and I also underwent extensive cognitive testing to determine whether I had problems with executive function, judgment, or memory decline, as well as blood tests to determine things like levels of abnormal proteins that may be present in the brain and levels of Vitamin B12. My sense of smell and genetic risk factors were also checked. This kind of testing is not routinely necessary for most people. But every brain specialist I spoke to recommended that Biden undergo that level of testing.
The last official report released in February was a health summary concluding that the president was “fit for duty”. The White House said a team of 20 doctors, including a neurologist, participated in the president’s physical examination. The summary said an “extremely detailed” neurological examination found nothing consistent with a neurological disorder. They also found no evidence of Parkinson’s disease that could explain the president’s awkward gait and reduced facial expression. Parkinson’s disease is the most common cause of parkinsonism, a set of movement symptoms such as stiffness and tremors, but there are other causes and the medical report did not say whether they were investigated. They found evidence of neuropathy and arthritis in the feet, which can cause numbness, weakness and pain. There was no mention of any kind of cognitive testing.
The White House said Biden saw a doctor after the debate to be checked for a cold, but it was a “quick test” and not a physical. Asked this week whether Biden should take any cognitive tests and make the results public, White House spokeswoman Karine Jean-Pierre said his medical team had said “it’s not necessary.”
It is true that different people have different aging trajectories. Biden is 81 years old, former President Donald Trump is 78. Both have already outlived the average life expectancy of American men, which is 74.8 years. This is not necessarily surprising, given that both have access to quality medical care and don’t drink or smoke. Biden’s medical team previously revealed that he had surgery for two separate brain aneurysms, including one that ruptured on the left side of his brain in 1988, and there is evidence that this type of bleeding can increase the risk of cognitive impairment later in life. Trump’s father died at age 93 from Alzheimer’s disease. Neither man has any other known risk factors for cognitive decline.
Trump occasionally displays the same symptoms as Biden, including incomprehensible rants, confusing names and current events. Trump has reportedly taken the Montreal Cognitive Assessment (MoCA) in the past. His medical team said he scored perfect on the test in 2018. Trump will take a second cognitive test at his final physical exam at the end of 2023 and achieve “excellent results.” In a memo late last year, Dr. Bruce Aronwald wrote that Trump’s cognitive tests were “exceptional.” Trump has not released his actual medical records, and previously released health notes have occasionally used exaggerated language, unusual for medical documents.
While the MoCA is not the level of cognitive testing that the medical experts I spoke to would like Biden to undergo, it could serve as an early screening tool for cognitive decline. For Trump, it might be considered a screening test, or a baseline test to understand how his cognitive function is changing. It is not clear whether Biden has ever taken such a baseline test for comparison.
Admittedly, some aspects of aging may work in favor of the presidency: Jay Olshansky, a professor at the University of Illinois at Chicago’s School of Public Health, says that older people may “have what’s called crystallized intelligence, which is accumulated wisdom over time” – knowledge gained through learning and experience.
On the other hand, some aspects of cognitive ability do decline with age, especially fluid abilities like processing speed, attention, and memory. This is normal and expected, and doesn’t necessarily impede your ability to work. But for a minority of people, the decline is more precipitous and can lead to dementia. Think of it as the difference between forgetting where you put your keys and not knowing what they’re for.
Still, making a diagnosis of dementia is not as easy as many people think, and there are many other factors that could explain the clinical observations I made above. Lack of sleep or low blood sugar can play a role. Viral illnesses and the drugs used to treat their symptoms can cause temporary brain confusion.
Biden and his aides said the night was a “bad night.” White House press corps said Biden had a cold but was not taking any medication to treat the condition. After the debate, Jean-Pierre added that he was jet lagged from an international trip earlier this month and that he had been working late into the night preparing for the presidential duties and the debate. Biden told Democratic governors at a White House meeting on Wednesday that he would stop scheduling events after 8 p.m. to allow him more time to sleep, according to three sources briefed on the remarks. The debate began at 9 p.m. Eastern time.
“There’s a legitimate question as to whether Biden’s debate performance was a ‘phase’ or a ‘symptom,'” former House Speaker Nancy Pelosi said in an interview on MSNBC on Tuesday.
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That’s why a thorough examination is so important. It helps determine whether the symptoms you’re experiencing have a simpler explanation or if there’s something more worrisome. As a physician, I want to understand the potential for dementia because over the past few years, we’ve learned that there are treatments and lifestyle changes that can potentially slow and possibly even reverse the symptoms of the disease. We live in hopeful times when it comes to dementia, and early diagnosis and treatment are more advanced than ever before.
With the November election looming, answers about Biden remain scarce.
The White House has denied media requests to release more medical records or question Biden’s physician, Dr. Kevin O’Connor, though a Biden spokesman said O’Connor watched the debate and had no further concerns.
Elected officials, like everyone else, are guaranteed some degree of privacy, and under federal health care law, not even the president can access personal medical information unless authorized to do so. Nor are they required to disclose it to the president or candidates. Most candidates don’t. In fact, in the 23 years I’ve been reporting on these topics, only Senator John McCain, one of the oldest presidential candidates in U.S. history, has released his entire records to me and the American public.
Pool
In a screenshot from video, CNN chief medical correspondent Dr. Sanjay Gupta (left) reviews the medical records of Sen. John McCain, who was running for president in 2008.
We often hear that observing a candidate on the campaign trail is the best way to assess their physical and cognitive health. Biden said in 2020 that the job of running for president “tests me constantly.” “You just watch me,” he said at the time.
The country is currently monitoring the situation closely and this assessment is a cause for concern and indicates the need for transparent testing.
CNN’s Amanda Seely contributed to this report.