When the 46th President of the United States took the debate stage a week ago, it became apparent, even from his first answer, that this would not be the performance he hoped for.
For me as a brain specialist, it was concerning to watch President Joe Biden, and it quickly became clear that I was not alone in my reaction. Over the past week, I received more than a dozen calls, texts and emails from medical colleagues who, like me, specialize in the brain. It wasn’t that what we noticed was necessarily new but that it was particularly pronounced, and right from the start of the debate.
From a neurological standpoint, we were concerned with his confused rambling; sudden loss of concentration in the middle of a sentence; halting speech and absence of facial animation, resulting at times in a flat, open-mouthed expression. To be clear, these are only observations, not in any way diagnostic of something deeper, and none of these doctors wished to suggest that was the case.
The consensus from the doctors reaching out to me, however, was that the president should be encouraged to undergo detailed cognitive and movement disorder testing, and those results should be made available to the public.
Over the past five years, I have reported extensively on the advances in the world of treating and reducing risk of dementia, including Alzheimer’s disease, Lewy body dementia and vascular dementia. For the documentary “The Last Alzheimer’s Patient,” I even went through extensive cognitive testing to demonstrate what it entailed and determine whether I had problems with executive functioning, judgment or memory lapses, as well as blood tests to determine things like the level of abnormal proteins that may be present in my brain and my B12 levels. My sense of smell and my genetic risk factors were checked. This type of testing is not necessary for most people as a matter of routine, but every one of the brain doctors I spoke to recommended that level of examination for Biden.
Biden’s health history
The last official report in February was a health summary which concluded that the president was “fit for duty.” The White House said a team of 20 doctors, including a neurologist, participated in completing his physical. An “extremely detailed” neurologic exam found nothing consistent with neurological disorders, the summary said. It also found no evidence of Parkinson’s disease that might explain his stiff gait and decreased expression in his face. Although Parkinson’s disease is the most common cause of parkinsonism – a set of movement symptoms such as stiffness and tremor – there are other causes as well, and it was not clear in the medical report that those had been investigated. They did find evidence of neuropathy and arthritis in his feet, which can cause numbness, weakness and pain. There was no mention of any sort of cognitive testing.
Biden was examined by his physician after the debate to check on a cold, the White House said, but it was a “brief check” and not a physical. When White House press secretary Karine Jean-Pierre was asked this week whether Biden should receive and release the results of any kind of cognitive test, she replied that his medical team has said it’s “not necessary.”
It’s true that the trajectory of aging varies from person to person. Biden is 81, and former President Donald Trump is 78. Both have already lived longer than the average American male lifespan of 74.8 years. This isn’t necessarily surprising, as both men have access to high-quality health care, and they don’t drink or smoke. Biden’s medical team has previously disclosed that he had two separate brain operations for aneurysms, including one that ruptured on the left side of his brain, in 1988, and there is some evidence that this type of hemorrhage may increase the risk of delayed cognitive problems later in life. Trump’s father died of Alzheimer’s disease at 93. Neither man has any other known risk factors for cognitive decline.
Trump does at times display some of these same signs as Biden, including nonsensical rants as well as confusing names and current events. He said he’d undergone the Montreal Cognitive Assessment, known as MoCA, in the past. According to his medical team, he received a perfect score when he took the test in 2018. Trump said he took a second cognitive test for his last physical exam at the end of 2023 and “aced it.” In a note at the end of last year, Dr. Bruce Aronwald wrote that Trump’s cognitive exams “were exceptional.” Trump has not released his actual medical records, and memos about his health that were previously released have at times used hyperbolic language, unusual for medical documentation.
The MoCA isn’t the same level of cognitive testing the medical experts I spoke to would like to see Biden do, but it could serve as an initial screening tool for cognitive decline. For Trump, this might be considered either a screening test or a baseline to understand how his cognition might be changing. It’s not clear that Biden has ever had such a baseline examination for comparison.
An ‘episode’ or a ‘condition’?
To be clear, there are aspects of aging that can be beneficial to the job of the presidency. Older people may “have something called crystalized intelligence, which is the accumulated wisdom associated with the passage of time,” according to Jay Olshansky, professor at the School of Public Health at the University of Illinois-Chicago. This is our knowledge that comes from learning and experiences.
On the other hand, there are definitely aspects of cognition that decline as we age — especially fluid abilities like processing speed, attention span and memory. This is normal and expected and doesn’t necessarily stand in the way of someone’s ability to do their job. But for a minority of us, that decline is steeper and can lead to dementia. Think of this as the difference between forgetting where you put your keys and not understanding what your keys are for.
Still, determining a diagnosis of dementia is not as straightforward as many believe, and there are many other things that could account for the clinical observations I described above. A poor night’s sleep or low blood sugar can have an impact. A viral illness or the medications used to treat those symptoms can result in temporary brain fog.
Biden and his aides have said it was a “bad night.” The White House press team said Biden had a cold but did not take any medications to treat symptoms. After the debate, Jean-Pierre added that he had jet lag following overseas travel earlier in the month and worked late doing his presidential duties as well as preparing for the debate. According to three sources briefed on these comments, Biden told Democratic governors during a meeting at the White House on Wednesday that he will stop scheduling events after 8 p.m. so he can get more sleep. The debate started at 9 p.m. Eastern.
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“It’s a legitimate question” whether Biden’s debate performance was an “episode” or a “condition,” former House Speaker Nancy Pelosi said during an MSNBC interview Tuesday.
That is precisely why detailed testing is important. It can help determine whether there is a simpler explanation for the symptoms displayed or if there is something more concerning. As a doctor, I would want to understand the possibility of underlying dementia because, over the past several years, we have learned that there are medical treatments and lifestyle changes that can delay and, in some cases, even reverse the symptoms of the disease. These are hopeful days when it comes to dementia, and early diagnosis and treatment is better than it has ever been.
Seeking answers
With an election looming in November, we don’t have answers about Biden.
The White House has rejected requests from the press to release more medical records and question Biden’s physician, Dr. Kevin O’Connor. Biden’s press secretary said O’Connor watched the debate and had no concerns afterward.
Elected officials, like anyone else, are entitled to some level of privacy, and under federal health-care laws, there is no ability for someone to obtain personal medical information on an individual unless authorized, even the president. There is also no requirement for the president or candidates to disclose that information. Most do not. In fact, in the 23 years I have been reporting on these topics, only Sen. John McCain — one of the oldest presidential candidates in US history — shared all of his records with me and the American public.
We often hear that observing a candidate on the campaign trail is the best assessment of the individual’s physical and cognitive health. Back in 2020, Biden said he was “constantly tested” by the work of running for president. “All you’ve got to do is watch me,” he said then.
The country is watching now, and that assessment gives cause for concern — and a need for transparent testing.