Cognitive Decline and the Presidential Race

Dementia: What We Don't Know

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As the presidential race heats up, accusations about who is most demented, President Biden or Donald Trump, grab the headlines. Commentators speculate whose brain leaks the most neurons and who should reside in a locked facility rather than live in the White House.

How Speculation on Trump's and Biden's Mental Acuity Affects Us

Ignored in this political debate are those of us at that "certain age" who wonder when family, friends, or anyone under 50 will jump to the same unwarranted diagnosis of dementia when we aren’t sure whether Taylor Swift is a singer or an endangered bird species.

I was recently asked by a major news outlet to speculate whether President Biden was showing signs of dementia because he could not remember dates. Similar questions have been raised on other news programs. Unfortunately, speculation about Biden's and Trump's cognitive health is rarely based on knowledge of dementia. What is dementia, and can we say whether either, neither, or both suffer from it?

The National Institute of Health defines dementia as “the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person's daily life and activities.” This is a nice scientific definition but less than helpful when determining whether it's time to lock Uncle Ralph up because he can’t remember his address or find his car in the Costco parking lot.

Early dementia is difficult to separate from behaviors considered "quirky." Does asking the same question three times or forgetting the names of grandchildren signal the presence of dementia, or is it a normal consequence of an aging brain, behaviors thought to be examples of "senior moments?"

As the dementia journey progresses, distinctions between what would be considered a senior moment and dementia become clearer, as they did when a friend walked the length of San Francisco looking for his house after we played a game of handball.

How can you tell if a friend, a relative, you, or a politician has begun the journey? Here are three guidelines that may help.

1. Dementia Is Not the Same as a Poor Memory

The physicist Michio Kaku maintained that the brain is more complicated than the universe. Within the brain’s spiderweb of 100 trillion connections, a multitude of factors can affect our ability to retrieve memories, ranging from the amount of sleep you got last night to the impact an event had on you 30 years ago. The inability to retrieve a specific memory, like the day of the week, is not an absolute sign of dementia.

2. There Are Various Types of Memory Problems with Different Effects on Dementia

There are five types of memory:

1. sensory
2. short-term
3. long-term
4. sequential
5. executive function, also known as working memory.

Problems in each result from different types of brain glitches. Take long-term memory, for example. At 78, I have no recollection of my 60th birthday party, a grand affair orchestrated by my family. Unfortunately, for months prior to and shortly after the party, I was suffering from a severe sleep disorder.

Since sleep is necessary for short-term memories to become long-term memories, it can explain why I don’t remember the embarrassing stories friends told at my party, but I can still recall 1964 memories (prior to my sleep disorder) of a mounted policeman’s horse in Montgomery, Alabama, as it pushed me against a wall.

Long-term memory problems, such as those similar to those of my birthday party, differ from other types of memory problems. For example, the role of executive function memory is to pull together various types of memories and organize them so that we can understand something or perform a task.

A friend, who had early-onset Alzheimer’s disease, related a frightening example of what happens when a problem occurs in working memory. When he was crossing the street and approached the curb, he couldn’t remember how to climb onto it. He stood paralyzed as cars tried to avoid him.

The seemingly simple movement actually relied on memories of what to do when approaching an obstacle and the leg movements required for initiating the task—a pattern his brain either lost or could not retrieve. Clearly, having a long-term memory problem would not be as indicative of dementia as would an executive function memory loss.

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3. A Bizarre Memory Problem Does Not Necessarily Point to Dementia

Think of your brain as a computer during its worst day. Files mysteriously disappear, strange messages appear demanding money, and keyboard strokes start taking seconds to register instead of instantly. You get the picture.

You call the service representative, and, after being sent through a lengthy answer tree, 15 minutes later, you reach a computer-generated voice that says, “Turn off your computer, then restart it,” and then she’s gone, leaving you to face the problem alone. You turn off and on the computer, and, miraculously, life is good again. Your computer has recovered. It remembered! You don’t know why the problems started, nor do you know why they disappeared—other than a miracle hidden inside a switch.

The company’s answer to your computer’s memory problem was based on a range of possibilities. The same is true when members of the medical community are asked to make a judgment on whether a specific behavior early in the disease’s progression signals dementia. To render an opinion, they should rely on at least three factors:

1. Frequency. How often was the behavior exhibited?

2. Severity. Was the memory error understandable (saying 1934 instead of 1935 for his birth date) or strange (saying Chevrolet instead of 1935)

3. Circumstances. Can overwhelming circumstances, like caring for a dying relative, explain not remembering what you had for breakfast?

Despite what you believe scientists and neurologists know about the brain, they guess more often than we would like to think. Guesses can be based on intuition or tests that range from remembering six objects to a five-hour comprehensive battery. Regardless of the thoroughness, results during the early stages of dementia should be qualified by the behaviors' frequency, severity, and circumstances.

The Takeaway

Don’t be too quick to call someone demented or accept the diagnosis from others. While a diagnosis of dementia is more reliable later in the journey, it lacks the certainty of physics—or even basic arithmetic—during its initial stages.

And while you may want to believe that the outlandish remarks of friends, relatives, or politicians can be attributed to dementia, don’t rule out it being a senior moment or just plain stupidity.