June 27th’s Donald J. Trump / Joseph R. Biden debate was notable for many reasons, one being they are the oldest presidential candidates in American history. At issue are concerns about cognitive decline. Specifically, people want to know if Trump at age 78 or Biden at 81 are up for a four-year long, high-stakes job that requires tremendous energy and mental engagement.
Debate viewers on both sides of the political isle raised concerns that Biden stumbled over many answers, losing his train of thought several times. The immediate panic is whether Biden’s faltering words are a harbinger of cognitive decline affecting his ability to lead effectively for another term.
Here are answers to four questions people should be asking about cognitive decline.
- What Is Cognitive Decline?
Cognitive decline is a deterioration in mental function. It can manifest as memory loss (e.g. trouble recalling events or names) or language problems (e.g. issues finding words or difficulty following a conversation). There can be breakdowns in concentration. As it worsens, people get disoriented, sometimes even lost in familiar places and confused about what date it is.
- What Causes Cognitive Decline?
Some cognitive decline is part of normal aging. Yet cognitive decline can also mean the brain is damaged, deteriorating, or both. Progressive decline can affect the ability to think and function independently. Neurodegenerative disease—including Alzheimer’s and Parkinson’s disease—can manifest as cognitive decline, as can other types of dementia.
Chronic health problems that affect the brain’s blood flow and how it uses energy can cause or worsen cognitive decline. For example, high blood pressure, high cholesterol, and diabetes and mental health issues like anxiety and depression are risk factors. Other triggers include head injuries, substance use, genetics, and vitamin deficiencies.
Poor sleep and high stress which undoubtedly come with the job of U.S. president can not only lead to cognitive decline but also worsen its symptoms.
- How Is Cognitive Decline Diagnosed?
Diagnosing cognitive decline requires comprehensive evaluation. That starts with a detailed history and physical. Examples of specific testing include the Mini-Mental State Examination, the Montreal Cognitive Assessment (MoCA), the Mini-Cog, or in-depth neuropsychological testing, which are typically administered by health care providers. Labs and imaging tests can help rule out other issues like infection and stroke.
Key to the diagnosis can be what others observe. Interviews with family members or colleagues help elucidate how someone’s cognition fluctuates particularly during stressful situations or at the end of the day. Biden noted he was ill with a cold during the debate which could been a cause of his poor performance.
Illness or lack of sleep can impact cognition even [in] young health[y] people yet especially in older adults like Trump and Biden. Importantly, a single episode of fluctuating cognition does not definitively diagnose the cause, define its progression or predict a specific rate of decline.
- How Can Cognitive Decline Be Prevented and Treated?
Cognitive decline can be both prevented and treated by eating a healthy diet—including fruits, vegetables and whole grains—and engaging in regular aerobic exercise and strength training.
Engaging in regular cognitive activity and social interaction can also help stave off decline, as can ensuring of 7-9 hours of nightly sleep. Stress management like meditation, yoga, and even therapy also potentially slow decline. An intensive lifestyle intervention involving diet, exercise, socializing, and supplements was shown to slow and even reduce the symptoms of Alzheimer’s in a recent clinical trial.
While Presidents get loads of social interaction, their schedule, travel and constant demands are stressful on anyone, particularly those with aging brains. The demands of the job may require an older president to prioritize activities that optimize rest, lower stress levels, and ensure regular movement.
Despite promising studies on lifestyle, new medications, and other therapies (e.g. rehabilitation), most cognitive decline can’t be fully cured. Prevention may only slow its onset. Treatment aims to slow decline, manage symptoms and improve quality of life.
Ultimately, the American Public doesn’t have enough information to decide whether either candidate has cognitive decline. Nor is there sufficient data to foretell how their decline, if present, might evolve over the next four years. What is certain is that voters will be closely observing Trump’s and Biden’s performance in speeches and interviews in the coming months for clues. Cognitive decline will likely remain a central issue on voter’s minds this November if both candidates remain in the race.
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Jesse Pines: A practicing physician with 20+ years experience in emergency care, research, innovation, health policy, value-based care, quality of care, entrepreneurship, and most recently, wellness and integrative medicine. I serve as Chief of Clinical Innovation for US Acute Care Solutions (USACS), the nation’s largest physician-owned emergency medicine practice. Previously served as full-time faculty at George Washington University (GW) and University of Pennsylvania. Currently a Clinical Professor at GW, and Professor at Drexel University. Wrote over 350 peer-reviewed publications and authored seven books. Recently awarded 2023 Collin C. Rorrie, Jr. award for Excellence in Health Policy from the American College of Emergency Physicians for work in developing the first-ever government-based alternative payment model for emergency physicians in the state of Maryland.