The presidential battle for the White House typically includes criticizing your opponent’s policy ideas and even exposing any closeted skeletons – but this year, the debate has gotten more personal with questions about age and mental health being raised.
Depending on who wins the election in November, a record will be broken: 77-year-old Joe Biden could be the oldest candidate to win a first-term presidency or 74-year-old Donald Trump, already the oldest president, could become the oldest second-term president.
But physicians with expertise on the aging brain urge voters not to be overly focused on age alone.
“It’s very important to focus on experience, on who the person is and policy issues rather than age,” said Dr. Gary Small, professor of psychiatry and biobehavioral sciences and the Parlow-Solomon professor on aging at University of California, Los Angeles’ David Geffen School of Medicine.
“A lot of people assume that an older brain is not as good a brain, but that is not necessarily true. We know that as people age, they actually become wiser. They have more experience to solve problems. They have less anxiety. When we’re younger, we tend to be more concerned about peer pressure. We’re about managing for the future. When you get older, you solve a lot of problems in your life, and there’s a sense of having been there and done that,” Small said. “You develop mental resilience, which is an important asset of an older person.”
‘Sleepy’ or ‘missing something’
Age should not be thought of as a single discriminating factor, according to Dr. Richard Isaacson, trustee of the McKnight Brain Research Foundation.
“I don’t really think of age as a discriminating factor in terms of when to choose someone that’s going to be in a leadership position, even if it’s in the most powerful position in the land,” Isaacson said. “What I would say is you have to pick the best person for the job.”
Earlier this year, Trump and his allies started to zero-in on Biden’s mental fitness as an attack strategy.
The campaign hurled personal insults and baseless insinuations, calling him “Sleepy Joe” and highlighting moments when he stumbled over words on the campaign trail – a strategy seeming to be an intensified version of Trump’s playbook from 2016, when his allies and he, without evidence, cast doubt on Hillary Clinton’s health.
The attacks from Trump and his allies weaponize Biden’s tendency to stumble over words, use the wrong word or interrupt himself in the middle of long answers by saying, “anyway,” and changing course. To supporters of a former vice president who in December 2018 called himself a “gaffe machine,” those long-time verbal tics have always been part of Biden’s public persona. They are made even more forgivable to his supporters by Biden’s openness about overcoming a stutter.
In an interview over the weekend with “Fox News Sunday” host Chris Wallace, Trump said Biden is “mentally shot,” “can’t put two sentences together” and “he’s not competent to be President.”
Biden’s aides have said that by questioning Biden’s mental capacity, the President is steering the campaign toward questions of character and fitness.
“This is asinine to tee up – because it’s 10,000 times worse for him,” a Biden adviser said in April about Trump. Biden’s advisers and Democratic allies have pointed out that Trump is guilty of many of the same verbal tics he is attacking Biden over, and frequently lies and embraces conspiracy theories.
As an example of how easily Trump could be parodied, Biden’s aides pointed to a video from “The Daily Show” in which Fox News hosts and commentators’ comments about Biden’s mental acuity were interspersed with videos of Trump’s own verbal flubs.
Biden spokesman Andrew Bates tweeted “The Daily Show” video, which has been viewed millions of times on Twitter, on March 25, in response to Trump spokesman Matt Wolking tweeting: “When is the last time Joe Biden was lucid?”
“Prompting voters to evaluate candidates’ mental states is a catastrophic proposition for Donald Trump, so we’re never going to discourage him from going there,” Bates said.
In May, in an interview with CNN’s Dana Bash in Delaware – Biden’s first in-person interview since being knocked off the campaign trail by the coronavirus pandemic – the presumptive Democratic presidential nominee also responded to Trump and his reelection campaign’s frequent suggestions that Biden is senile or has lost a step.
Asked how he would answer those attacks, Biden told Bash: “Watch me.”
“Look, I mean, talk about a guy who’s missing a step,” he said of Trump. “He’s missing something. I don’t want to get down into giving him nicknames but this is a fellow who looks like he’s having trouble controlling his own emotions.”
Throughout Trump’s presidency, experts have called for his mental health to be evaluated. In 2018, White House physician Dr. Ronny Jackson received an urgent letter from dozens of doctors and health professionals urging him to perform basic mental health tests on the President.
While reviews of the past five presidents’ physical exams show only a brief mention of mental health and none of the records include a readout of the mental health tests, that letter from physicians pointed out that mental evaluations are routine during physicals, particularly for patients who are 66 or older. Trump is 74. Medicare guidelines suggest patients in this age range should be evaluated for cognitive and neural health function.
The White House has dismissed questions about Trump’s mental fitness, calling them “disgraceful and laughable.” They said that mental health testing was not something Trump would undergo. It will be up to Trump what information he shares with the public.
‘Our brains age just like the rest of our bodies’
Overall research suggests that the average person’s cumulative skills, memory and knowledge – known as “crystalized abilities” – tend to improve until we reach 60 years old and then plateau until around age 80.
“Our brains age just like the rest of our bodies,” Small said.
“We know that our brains actually shrink over time. The connections between different regions of the brain are not as tight as when we’re younger, and there are buildups of abnormal protein deposits, what we call amyloid plaques and tau tangles, that accumulate in areas of the brain that control thinking and memory,” Small said. “This is a very gradual process for the average person. These problems do not affect their everyday functioning. But when it reaches a certain threshold, then it becomes problematic.”
In other words, there is a difference between stumbling over a few words while on the campaign and truly experiencing debilitating declines in cognitive function, Small said.
“Age, in fact, is the greatest single risk factor for developing cognitive decline. But people need to realize that this is a lifelong process. In fact, by age 45 for the average person, their memory is not as good as it was 20 years ago, but these common age-related memory slips, like forgetting where you place your keys or glasses, or having a word-finding problem, that tends to be relatively stable over time and doesn’t interfere with our everyday function,” Small said.
“When a person’s cognitive decline makes them dependent on others for their daily needs, that’s the definition of dementia – and that’s when there’s a concern and doctors will prescribe medication, but any time someone is concerned about their memory, it’s a good idea to find out if this is a problematic situation or just a normal part of aging,” Small added. “Just because someone is older does not mean they have a cognitive impairment that interferes with their everyday life.”
In order to make a clinical diagnosis around a person’s cognitive fitness, “is to have a clinical relationship, is to do a very comprehensive medical workup to order specific imaging, brain imaging when needed and then order specific cognitive assessments – a more elaborate battery of cognitive tests in order to really have any degree of accuracy,” Isaacson, trustee of the McKnight Brain Research Foundation, said.
Small called it “dangerous” to refer to stumbling over words on the campaign trail as signs of mental decline.
“I think it’s very dangerous to over interpret mental slips, when you see it in an older person, and I think when we do that, it strikes me that it’s a form of age discrimination – what we call ageism,” Small said. “We know that there are many factors that affect our mental acuity, people under stress, even giving speeches will increase mental slips of people who are distracted.”
What we know about each candidate’s health
As the race to the November presidential election goes on, incidences of word slips or fatigue are likely to continue, Small added.
“You’re constantly on the road, it’s hard to get enough sleep. We know lack of sleep will affect your mental acuity. We know that stress will affect mental acuity. It’s difficult to maintain a healthy lifestyle, to exercise regularly,” Small said. “There’s a lot of adversity on the campaign trail, and that tests a person’s emotional stability.”
So what do we know about each candidate’s health? For now, there is more public information available around their physical than mental health.
Based on the medical records that have been released – President Trump is on a statin to manage his cholesterol and is considered clinically obese.
In 2018, Trump passed a Montreal Cognitive Assessment exam, which doctors use to detect “mild cognitive dysfunction.” We also know that in 2018 he underwent a coronary calcium CT scan and scored 133, indicating that plaque is present and that he has a common form of heart disease.
This past December, Biden released a summary of his medical history. The paperwork noted that he also takes a statin to lower his cholesterol and triglyceride levels, as well as Eliquis to prevent blood clots.
Biden has an irregular heart rhythm known as non-valvular atrial fibrillation, or AFib, and is of normal weight, according to the summary. In 1988, Biden suffered a brain bleed due to a ruptured cerebral aneurysm and underwent two separate brain operations. His doctor noted that he hasn’t had recurrence of aneurysms since.
‘I am a young, vibrant man’
Biden and Trump both have addressed questions about age and politics – but with different sentiments.
In April of last year, when Trump was asked how old is too old to be president, he responded, “I just feel like a young man. I’m so young. I am a young, vibrant man. I look at Joe, I don’t know about him. I don’t know.”
Biden responded to Trump’s comments during an appearance on ABC’s “The View,” saying with a chuckle, “If he looks young and vibrant compared to me, I should probably go home.”
Biden previously said in 2018 that he thought a candidate’s age is a “legitimate” issue in elections – including if he were to run for president in 2020.
“I think age is a totally legitimate thing to raise,” Biden said during a question and answer session at the Economic Club of Southwestern Michigan’s Speaker Series in October 2018. “I think it’s totally appropriate for people to look at me and say if I were to run for office again, ‘Well God darn you’re old.’ Well chronologically I am old.”
“Every voter is entitled to know exactly what kind of shape you’re in. You owe it to them. It’s a legitimate question and so I think age is relevant,” he added.
Biden’s comments came in response to a question about whether term limits or a mandatory retirement age should be implemented for members of Congress or the Supreme Court.
Then last year, Biden echoed similar viewpoints and said it’s “totally appropriate” for people to consider his age when evaluating him as a presidential candidate.
“Just like when I was 29, was I old enough? And now, am I fit enough? I’ll completely disclose everything about my health. I’m in good shape,” Biden said in a September 2019 interview with a New Hampshire newspaper, The Laconia Daily Sun.
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There is no requirement for a presidential candidate to release any of their medical history – so we may never have a complete picture of “what kind of shape” either candidate may be in when it comes to overall physical and cognitive health.
As the campaign continues, candidates face their own ultimate test to determine how well they connect with voters. In turn, voters are left to decide whether or not age really matters – and who ultimately should lead the nation.
CNN’s Dr. Sanjay Gupta, Nadia Kounang, Eric Bradner, Ryan Nobles, Dan Merica, Jen Christensen, Arlette Saenz and Veronica Stracqualursi contributed to this report.