I have for a long time and in sometimes heated arguments with my daughter argued that Joe Biden had been an outstanding president, the best and only real candidate to run this year. And like all democrats, Thursday night’s debate gave rise to shock, deep sadness, terror and panic.
The question which everyone is asking themselves, if not each other, silently if not openly, is not whether the President had a “bad night”, or whether he is slower than he used to be or stumbles on his words. We are forced to ask, but most cases unwilling to utter the question, “Is there something medically wrong with Joe Biden’s cognitive abilities? Are his faculties actually deteriorating?”
This is not a question which the audience, or the commentators, or the pundits or even the family can accurately answer. It requires a professional medical and neurological assessment.
True, he came roaring back the next day, and – if you just listen to the words, or read them, was able to make a multitude of intelligent cogent points in the debate itself. But the cliché about dementia or even an aging memory is that we can remember with total clarity events or arguments from earlier in our lives but have trouble processing a new question, or a question asked, as was perhaps the case with the moderators, in a slightly different form than we expected. It appeared that Joe Biden could not logically process new questions to give cogent answers. Was this a sign of actual dementia?
We cannot answer that question with a journalistic or political voice vote. It will require an actual neurologic evaluation to either to put the question to rest, in which case we move on, or to confirm our fears, in which case we need to consider the consequences.
As most people reading this blog already know, I am an emergency room doctor. I am not a neurologist. We are, however, almost daily asked to consider whether and how a patient, usually but not always an older patient, has a change in mental status. In cognitive ability.
I am not referring to the obvious – stroke, coma, seizure. I mean the subtle change, what I call “this is not my father” syndrome. The family, for some reason it is usually the daughters, brings their 80 year -old father in because “he is not right”. “He is not himself”. “You don’t know my father -he is sharp as a tack –this is not my father!”
I have found that these vague but definite reports of a palpable change in the mental facility or personality of the person might end up resolving into three categories:
- The unmasking of a gradual but comfortably ignored onset of dementia. We hear at first that he is ‘sharp as a tack,’ but with questioning, well, this actually started sometime last year, and he wasn’t himself at Thanksgiving, and then at Cousin Margaret’s wedding, etc. etc. It has been some time coming, but the family just didn’t really want to see it until he wandered off and something had to be done today.
- An acute medical issue such as stroke, infection, chemical imbalance or drug interaction which looks like cognitive decline but resolves as soon as the medical issue is addressed. He had been fine until he fell three weeks ago, and is getting slowly worse. CT shows blood pressing on his brain. We take out the blood and he is back to arguing quantum physics with his best friend the physicist.
- A rare but serious rapidly progressive medical dementia – Parkinson’s, Lewy body dementia, slow virus infection like Jakob-Creutzfelt, and other rare occurences. I saw a case of Jakob-Creutzfelt disease during my medical residency, when a captain of industry had a very slow onset of what looked like a personality change – sharper, meaner, less tolerant. Then his logic started to fail, then speech, then movement and he was dead in months. Rare, very very rare, but devastating.
And it takes a specific, focused medical and neurologic evaluation, often using extensive technology to separate these. But the bottom line is – these are medical questions and they are not going to be solved by the press, the pundits, the party hierarchy, or even the family – without expert medical help.
Here would be my suggestion to the President’s team. (Don’t you wish there were some way to get suggestions to the president’s team, other than just talking to ourselves in a bubble?)
- Announce that, while he still feels young, sharp and vital, there have been enough messages from media, from friends, from events, and now from this debate performance, which he has watched, that he cannot ignore the possibility that there might, might be something worsening in his thought processes.
- Acknowledge that it is his duty not only to himself and his family but to the American people to answer the question, once it has now been raised.
- Recognize that we democrats have always supported public science, and vowed to follow the science.
- Set up publicly, explicitly and transparently a specific medical evaluation session. Check into Walter Reed hospital for a week. Invite the top neurologic physicians in the country to join a team of the doctors there. One of the heads of NIH neurology, Dr Walter Koroshetz, was a medical student where I was a resident, and he is one of the nation’s, and perhaps history’s smartest doctors. Ask the chairs of neurology of Harvard, Yale, Hopkins, Penn, to join and conduct a week – long assessment. CTs, MRIs, cognitive tests, EEGs, intra-cranial dopplers – the works.
- Set up a press conference with the doctors at the end of the session.
One of three outcomes is possible:
- Reversible temporary illness. His serum sodium was low, they corrected it, now he can debate ten Donald Trumps.
- He is absolutely fine. It was a bad night. He stumbled over a couple of words, got a little nervous and it took a while to get back, but his points, his ability to synthesize and understand arguments is completely intact. Then we go on doubly resolved that Joe Biden is the man for the job.
- He has either a slowly progressive or a more rapidly progressive medical dementia. In that case, he steps aside, adding to his legacy his perspective, ability to reflect on himself, and to put the country first. He retires with sadness, but as a great hero.
How the party would handle that can be widely debated. Anyone who reads this blog knows I have ideas about that, but since today’s purpose is to offer a medical opinion, I will leave it at that.
I have loved Joe Biden, and think he is a great president. Had he encountered less active opposition he could have left one of our nation’s greatest legacies. I know his heart is in the right place. I hope he will take the opportunity to have a clear impartial medical evaluation to inform his decisions.
If he is A-Ok, then we must stand with him.
If not, then he must make the appropriate decisions.
A week at Walter Reed would tell us which is the correct way.