Wolfgang Meins, German neuropsychologist, psychiatrist, neurologist, and geriatrician, has reviewed Joe Biden's public appearances and describes typical signs of a specific type of dementia. This raises the politically sensitive question: Is Biden still fit for office?

„Is Biden senile or a victim of a campaign?“ This question was posed by ZDFheute two weeks ago, and they answered it roughly like this: Okay, he's no longer the youngest, and he might have had one or two minor lapses, which, of course, the malicious Republicans exploited through cleverly edited video sequences. They should be silent considering what their idol Trump has already done. Moreover, the White House doctor apparently gave the green light for another term for Biden. So, nothing to see here! To be fair to ZDF, such assessments have been the prevailing in the public opinion so far.

But those who believed that the so-called German mainstream media would finally address the health issues of the US President, which became glaringly apparent even to laymen during the CNN event on June 27, were disappointed. Instead, they now act as if they were terribly surprised: No one could have known that the President was already this senile. Even at this moment, they couldn't abandon their anti-Trump reflexes, stating that Trump mostly lied during the CNN duel – a kind of desperate relativization.

However, this is not about Trump today, but rather about the frequent media dithering on how to describe Biden's recent performance on CNN. Even WELT avoided any close reference to medical terminology and wondered whether the US President, „due to his advanced age of 81, might no longer be able to meet the demands of the world's most powerful office.“ A few days later, the term „senility“ was applied to the President. The term „senile“ seems to be more popular among the journalistic Trump-haters and Biden fans since it appears to sufficiently describe the increasingly evident mental and physical issues of the US President.

An Obsolete Term

However, the term „senile“ is a very unsuitable concept for the question at hand, which has rightfully almost entirely disappeared from medical terminology over the last 50 years. In the past, medical science lacked the fundamental knowledge to reliably distinguish the normal aging process from the effects of concomitant, often age-associated diseases, particularly Alzheimer's disease. In more recently published medical textbooks of various fields, the term „senile“ is usually no longer found. In my somewhat old psychiatry lexicon (2007), the following definition is offered: „More colloquial term for the negative sides of old age.“ One could indeed put it that way.

However, our protagonist does not merely display the wide spectrum of negative effects physiologically associated with aging: that this or that joint might hurt after gardening, sleep may no longer be as refreshing, the walking distance during hiking was somehow significantly longer in the past, and mental activities don't function as quickly as before. These and much more symptoms accompany aging, more for some than others. It becomes truly unpleasant, however, when certain diseases join these „normal“ side effects of aging. The probability of this is quite high, as several diseases are significantly more common in older age.

The topic of interest here is not about aging or being old per se, but about the frequent accompaniment of this lifespan by burdensome or severely disabling diseases, which may even have the potential to end the ability to live independently. This applies whether or not the affected person has an appropriate awareness of their illness, i.e. a mostly realistic idea of what is still possible to him and what is not (any longer). President Biden seems to lack such a consciousness of his disease state – and quite significantly for that matter. The mere fact that he believes that he can handle another term speaks for itself.

Different Symptomatology from Alzheimer's Disease

The media trivialization of his condition as merely senile is also inappropriate because Biden symptoms are characteristic of a specific type of dementia, which is immediately obvious for an expert who observes him briefly on TV. This disease belongs to the group of vascular dementias, which make up about 20 percent of all dementia cases. This group includes stroke patients where the blockage of a major brain artery has damaged cognitively relevant brain areas.

Another significant subtype of vascular dementias is Binswanger's disease, also know as subcortical arteriosclerotic encephalopathy (SAE) –  which is most likely the disease Biden is suffering from – a slowly progressing atherosclerosis of smaller brain arteries which evolves over years, often facilitated by high blood pressure. Consequently, this leads to chronic blood flow disturbances in certain subcortical structures containing fibers and nerve tracts that connect various brain areas or extend towards the spinal cord. These damaged brain structures can be detected through MRI scans.

Since this dementia affects different brain structures than Alzheimer's disease, the symptoms are also mostly different. While Alzheimer's disease develops exclusively cognitive symptoms, aside from possible behavioral disorders, SAE also affects motor systems. This typically leads to the symptoms observed in Biden: slurred speech with a progressively quieter voice and a relatively mild and fluctuating Parkinsonian gait disorder. This results in a shuffling and constrained gait pattern, which he frequently tries to consciously counteract in public with varying success, often appearing rather odd.

A Highly Complex Disorder

In Alzheimer's dementia, cognitive impairments primarily involve memory and learning abilities. Biden also shows weaknesses in this area, often directly or indirectly visible in numerous video sequences – for example, through the excessive use of teleprompters and briefings with very simple notes, which do not always suffice. However, the leading and very characteristic cognitive impairment in Biden, typical for SAE, is an executive dysfunction.

This is a highly complex disorder that can only be broadly characterized here. It involves so-called metacognitive processes, which coordinate multiple sub-processes flexibly to achieve a certain intention. This dysfunction in Biden can be observed in his recent CNN appearance when he loses his thread of thought and can't find it again, or similarly, when a line of thought fades away, or when, as recently at the G7 summit in Italy, he suddenly and seemingly inexplicably shifts his focus to something entirely irrelevant in that situation.

Similar to Alzheimer's disease, SAE typically progresses slowly and steadily. However, unlike Alzheimer's, SAE can also lead to sudden deteriorations due to an increased risk of (minor) brain infarctions caused by damaged blood vessels. To assess the progression of SAE in Biden, it's helpful to remember where he is cognitively coming from. He was once one of the most successful Democratic politicians, winning his Senate seat five times in a row and – hard to believe – was considered the best speaker among the Democrats for a time.

Colleague O’Connor

At the end of February this year, the White House physician Kevin O’Connor certified that the President was sufficiently fit for another term: „President Biden is a healthy, active, robust 81-year-old man who remains fit to successfully execute the duties of the Presidency.” The neuropsychological dementia assessment demanded by Republicans, such as the MoCA test, was deemed unnecessary by O’Connor. Given Biden's obvious cognitive problems, this seems like medical malpractice.

This test, which Trump passed without issues, measures not only memory performance but also (among other things) the mentioned executive functions with two subtests: under time pressure, the patient must alternately connect letters and numbers, e.g., 1 - A - 2 - B - 3 - C, and then complete the seemingly simple clock test by drawing a clock with all 12 numbers in a given circle and setting the hands to 10 past 11. This seems simple but presents unsolvable problems for patients with executive dysfunctions. Given this context, it's hard to imagine Biden passing this test without errors.

Neither the Democrats nor O’Connor seemed concerned by Special Counsel Robert Hur's congressional appearance this February regarding Biden's document affair. According to reports, Biden struggled to remember events and read his own notes. „He didn’t remember when he was Vice President, forgot on the first day of the conversation when his term ended, and on the second day, when it began.” And what was Biden’s response? „I’m an old man, and I know what the hell I’m doing. I’m President, and I’ve gotten this country back on its feet.” This response reminds the author of typical situations from his dementia clinic when the wife had just described her once socially important husband's recent lapses.

Open Questions

In conclusion, several questions remain: How will the Democrats persuade their clearly unfit and unaware President to withdraw from his re-election bid? No idea, let’s wait and see.

Or: Should Biden, hypothetically, decide to retire in Florida and buy a large estate, the question of his legal capacity might arise during the complex purchase negotiations. How would a psychiatrist's assessment turn out then?

These considerations raise further questions: Can US regulations issued by Biden in recent weeks or months, or those he may issue in the future, be challenged due to alleged incapacity? And what about international treaties and agreements? I fear O’Connor's decision to forgo a test might backfire significantly.

About the Author: Prof. Dr. med. Dipl.-Psych. Wolfgang Meins is a neuropsychologist, psychiatrist, neurologist, geriatrician, and adjunct professor of psychiatry. In recent years, he has primarily worked as a court expert in civil law. He is based in Hamburg, Germany.

For the German Version see here.