“He Put the Dementia Rumors to Rest”…. Or Did He?

Did Biden’s performance for the March 7th, 2024 State of the Union speech prove he does not have dementia?

The question that’s been on people’s minds for at least the last year now is - does Joe Biden have dementia?

Can he get through a live speech in front of a crowded room of people, at least half of which likely feel pretty hostile about his presence, and do it without hallucinating dead people as alive, speaking incomprehensible babble, or worse, wandering off & looking confused?

Yeah, I don’t blame you if you didn’t watch the SOTU speech. Myself, I got on an X-space and made it through the first 15 minutes of the speech, if I remember correctly.

From what I saw, and what I heard about afterwards, Biden yelled a lot, (he was “forceful” said CNN), read off of his teleprompter without too much apparent difficulty, and even clearly ad-libbed in fairly convincing fashion.

When he brought up a the Democrat-backed bill related to border security (and got booed by Republicans) Biden responded directly, saying, "oh you don't think so" and "oh you don't like that bill huh" in an off-the-cuff and kind of sneering fashion. Which turned me off, and caused me to turn it off. It just was ugly sounding.

I binged on this instead of finishing the SOTU

So, I fired up a binge session of Lost (I’m currently working my way through the final season… yeah, it took me awhile), which was much more enjoyable.

The next 24 hours or so, I started seeing posts on X like this, the first from the painfully RINO uniparty drone, Illinois congress critter Adam Kitzinger:

Similarly, from the always-nausea-inducing regime stenographer John Harwood:

So, Are they Right? Does Biden’s SOTU Speech Disprove the Dementia Rumors?

I spend way too much time on Twitter / X. I’m also an anon - some guy who claims to be a “geriatrics doctor” who works in long term care. Despite my status as an anonymous social media influencer and commentator, for some reason I get treated as a credible expert on geriatrics questions, which includes being asked, often repeatedly - “what do you think, GeroDoc? Does Joe Biden have dementia?”

Dementia Warning Signs - The Democratization of Dementia Identification

If you want a good window into my thinking, feel free to browse the linked article above.

Basically - in my experience as a clinician working with older folks in nursing homes, I’ve seen any number of instances where I’ve interacted with an older person who may present as intact, smooth-talking, sharp, and completely fool me. I’ll be convinced this person doesn’t have dementia, and wonder if there’s another explanation as to why the nurse or family member has reported whatever X, Y and Z behavior of them (e.g., storing clothes in ovens, or accusing family members of stealing, acting bizarre at a dinner party, or confusing the names of their children).

It’s only after they’ve gotten a brief cognitive exam, or perhaps some more in-depth neuropsychological screening, does it become obvious that the person’s cognitive capacities are seriously failing - and it’s in fact that these smooth-talking older people don’t look demented because they are premorbidly intelligent, socially smooth, and can cover up their deficits extremely well.

This is why when we diagnose dementia we use as objective measures as we possibly can - we use cognitive tests, we look at brain scans, labs, we comb through their charts, we ideally do semi-structured interviews with loved ones and caregivers, and - we critically depend on dementia warning signs to prompt the exam in the first place (and looking at the list above, how many warning signs has Biden exhibited in public over the last couple of years, would you say?).

But - the reverse is true too. I also can’t tell you how many times that I’ve seen people who look visibly impaired, I’m convinced dementia (like Alzheimer’s disease) is at issue, but instead delirium, drugs, or depression was actually the culprit.

But GeroDoc - if Biden has Dementia, how could he pull off the SOTU speech?

People have to remember a few things here.

First, Biden has been working in politics for nearly 45 years. Given this, delivering teleprompter-aided political speeches probably represents something we would call a highly overlearned behavior for this man - these are neural pathways that are laid down in deep grooves in Biden’s brain. Imagine a concert pianist who has been playing piano daily for the last 45 years of their life, or an avid singer, or gardener. Would you expect onset of dementia to destroy any vestiges of competency in these highly overlearned skills?
I wouldn’t!

President Biden, then a United States senator and adjunct professor, leads a discussion with students on the Delaware Law School campus (from www.widener.edu)

Second, say what you want about Biden - he’s clearly got some measure of premorbid intelligence that’s likely fairly high.

This by itself almost assures that an older person who, say, has suffered cerebrovascular insults or Alzheimer’s disease pathology or other neurodegenerative issues (say, secondary to Parkinson’s disease, etc.) will only start exhibiting obvious outward signs of deficit much later into their illness than others. Again - because they can cover their deficits so well.

FEEL THE GURN

Third and finally - I’ve been told that Biden likely was “on drugs” (performance enhancing) during his SOTU speech, and asked my opinion on this.

It is true that in very limited, circumscribed cases, geriatric physicians, typically in consultation with geropsychiatric physician colleagues, do prescribe things like Modafanil (a non-methamphetamine-derived wakefulness agent) to demented elderly patients with intractible apathy, such as this case report here.

There are even examples of elderly patients on a hospice care track being prescribed actual speed (specifically, dextroamphetamine, methylphenidate, or pemoline) in order to improve their appetite, engagement, energy, and cognition.

But I ultimately have no idea if Biden was “perked up” on any drugs before his SOTU, and honestly I don’t think it really matters. This is my view:

Biden’s relatively-intact, relatively-competent performance in front of the joint session of congress for his SOTU speech doesn’t disprove that he is suffering from a dementing illness.

Likewise, the various (and growing) number of instances where Biden presents as visibly confused, hallucinating dead people as alive, such as here and here, speaking incoherently, inexplicably wandering off during press conferences, and other concerning behaviors too numerous to mention - these examples, likewise, do not prove he *has* dementia - just that these represent a growing list of examples of, as I mentioned, “warning signs,” that would under normal circumstances have at least prompted an office visit and led a competent, independent physician to give Joe Biden at least a brief cognitive screening exam.

Why hasn’t this happened?

Well, I’ll let Joe Biden’s press secretary, Karine Jean-Pierre - the firewall between him and the press and their pesky questions - give you the answer:

That’s right. He doesn’t need one.

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