It Seems like Being a Politician May be an Independent Risk Factor for Dementia in the USA

With the recent Fetterman-Oz debate, the issues brought up by our octogenarian and potentially medically compromised political overlords are being talked about more than ever.

Before I go on - I’m not going to offer a diagnosis of any politician, since it’s unethical to diagnose anyone you haven’t examined, particularly without their permission. So – if you hear anything in this article (or in any of my Tweets) that sounds like a diagnosis of dementia in any public figure or politician, that’s not what I’m intending.

However – I do think it’s extremely fair to talk about how politicians present themselves to us, the general public, and our impressions of such.

We’ve at this point all seen videos of an elderly Joe Biden appearing to get lost and confused at public events, seemingly believing that dead people are alive, and acting strangely in public. We’ve watched former President Donald Trump, an older adult himself, give trademark rambling, tangential speeches, confuse names and places, and at times exhibit pretty bizarre behavior in public.

And then there’s the issue of US Pennsylvania Senatorial candidate, John Fetterman – who gave a debate performance yesterday that seems to be almost universally noted to be, shall we say, somewhat concerning.

Age is the #1 Risk Factor for Dementia – and US Politicians are Older than Ever

Relative to the median US age, yes – as the Washington Post points out in this article, US congressional leaders are getting younger, so there’s that – but while that on a certain level helps to put this state of affairs in context (e.g., in the sense that congressional leaders are simply representing their constituency in terms of chronological age), this obscures some very real issues that come with advanced age.

So here’s the elephant in the room. I want to talk about dementia.

Common knowledge in the geriatrics and dementia world – the single biggest risk factor for dementia is advanced age. That is to say, based on prevalence rates observed internationally, for every five years of older age from around 65 to 75, prevalence rates double, but then around 75 years of age and up, prevalence rates rise exponentially as age increases.

This, of course, has implications for a US congress whose average age is currently the highest it’s ever been (almost 64) and is only getting older. Nancy Pelosi, the current US House majority leader, is 82, by way of example. Joe Biden, the current sitting US President, will be 80 this November.

Of course, being old doesn’t mean you are cognitively impaired, and the world is replete with examples of people being successful and intellectually productive well into their later years – one example is actor and director Clint Eastwood, who at 92 is still directing major motion pictures. Thomas Szasz, the hugely prolific writer & former professor emeritus of psychiatry at Syracuse University, New York (whom I’ve written about before) was writing and publishing books and articles well into his 80s before his death at 92.

So, remember that age is a risk factor, and while it happens to be the most important one for developing a disabling form of cognitive impairment, by itself it does not mean one’s cognitive faculties are necessarily suspect.

Aside from Age, what else puts one at Risk from Dementia?

Dementia is first potentially identified by noting if established warning signs are present. The more warning signs you can reliably observe, the more at risk the person is.

The US government’s Department of Veteran’s Affairs has a pretty decent list of some of these warning signs – and they note (helpfully) that none of these are diagnostic of dementia or organic memory issues, but the more there are that are observed, the better idea you have that something pathologic may be going on that needs to be formally assessed, and addressed. These warning signs can include (not an exhaustive list):

• Word-finding difficulties (also known as “tip of the tongue” phenomena for us normies, or known by the clinical term as “anomia”)

• Forgetting how to use common objects or devices

• Problems with decisionmaking or judgment

• Disorientation to time, forgetting one’s schedule

• Money management errors or problems¹

• Driving issues, near-misses, crashes, getting lost in your car

• Changes in appetite, personality, mood

• Gait changes (e.g., appearing to shuffle more, wider steps, shorter steps, etc).

Other things that can put one at risk for dementia include metabolic issues, such as diabetes, high blood pressure, morbid obesity, high cholesterol – basically anything that puts you at risk for cardiovascular events like heart attacks, and stroke.

Lets Talk About Strokes

Does having a stroke, by itself, mean that one has dementia? Like advanced age, having had a stroke, by itself, doesn’t automatically lead to dementia – and in fact plenty of people have recovered from serious strokes with some functional deficits such as with lasting weakness on one side, also known as hemiparesis, or problems with vision, but cognitively they are free of dementia. As long as they have proper supports in place (like wheelchairs, grabbers, or other assistive devices) - they can function without issues. To address any nagging cognitive issues, they also may, in order to function normally, need to compensate w/ increased reliance on calendars, note-taking, or address books.²

In fact, I have a resident, named Bari³ like that at my nursing home right now. She’s in her late 60s, had a massive stroke a few years ago that took multiple months to recover from, her and now is wheelchair bound. Due to her functional deficits, Bari still receives nursing care but has since resumed being able to use her phone, stay in contact with her family, manage her finances and medical care, and as far as cognitive testing goes – she functions relatively normally (albeit with an assessment profile consistent with mild cognitive impairment, a condition I refer to below in one of the footnotes).

Bari doesn’t have any obvious issues with memory loss, confusion, or word-finding difficulties – in fact, although she has a pretty pronounced midwestern accent (she sounds a lot like Frances McDormand’s in the movie Fargo) her speech presents as normal as well. Big strokes can lead to big functional deficits, but if you’re lucky, higher-order cognitive functions and memory can be relatively spared.

The Case of John Fetterman, His Medical History, and his Debate Performance

Enter the case of John Fetterman and his health problems. Again, I’m not diagnosing him (his health problems are widely reported and noted here on Wikipedia, anyways – I don’t need to diagnose them) – he had a stroke, as has been widely reported and known in the media, in 2022, nearly 6 months ago as of this writing. He has history of atrial fibrillation (or a pathologically irregular heart rhythm – which often is a progenitor to having strokes). He has had this treated with an implanted pacemaker and defibrillator device. Up until fairly recently he weighed over 400 pounds and has been well-known not to take prescribed medications. He doesn’t exactly paint a picture of health (speaking of age, he is, I believe, 54 years old).

Interestingly, Fetterman also collapsed on stage in 2019. This was not reported as due to a stroke at that time – but given what’s known now, I can tell you if I was his doctor I would be very curious about that fall. This is because in my own experience, fall history and strokes often go together.

But again, who knows – maybe it was just “exhaustion.”

Then, there was his debate performance. You can watch the entire video here:

You can skip around and get a flavor for Mr. Fetterman’s performance, but I can assure you it’s not good.

He shows signs of really obvious word-finding difficulties / anomia, nonfluent speech, and at points in the debate he seems to ‘blank out’ and completely loses his train of thought during the debate performance, at times looking completely lost, like a deer in the headlights. It’s really that bad. This isn’t made up – you can watch it for yourself.

Moreover, I want you to compare and contrast this with this video taken just before Fetterman suffered his stroke six months ago:

In this case, his speech is fluent, at ease, at a normal and regular rate, and he seems very focused and in control of what he’s saying. He seems *all there*.

The reason why I bring up the “before and after” of Mr. Fetterman’s speech production is because of this, apparently another attempt at “fact checking” the idea that the idea Mr. Fetterman may be cognitively impaired based on how he spoke at the debate is wrong:

If I was a man, I'd be the man @lori2882

@FriedScones @whstancil And you are blinded by misinformation because what you're saying clearly isn't supported by science or the medical community. But your *fEeLs* should totally be our guiding principle! 🙄

Dr. Krakauer, of course, is not entirely wrong. Basically, *just because* someone has obvious problems with language, such as with a stutter, does not mean that they have a cognitive problem.

For sure! But what if they had a stroke? Previous history of falls? What if we’re not talking about a stutter but a presentation on stage that looks suspiciously similar to expressive aphasia (that’s the language disorder that caused Bruce Willis to retire from acting, if we all remember). What if it’s all of those things?

Take a look at this video:

This is an example of a young person affected by a mild version of Broca’s Aphasia, which tends to be characterized by nonfluent speech, word-finding difficulties and halting speech production.

Do you notice anything? Does the speech production of the aphasia victim in the video look…. Familiar?

To be fair to Fetterman, according to NYTimes, his campaign staff have reported that he has been assessed with a couple of very reliable, well-known cognitive tests (the SLUMS and the RBANS) and they report that his scores are in the normal range. Moreover, they report that his speech issues and his need for a closed captioning device are the result of not aphasia, but an “auditory processing issue.” So, there is that.

Concluding Thoughts

I’m not saying that John Fetterman has dementia, or even aphasia. I haven’t examined him, and so I can’t diagnose him - and his team has given all of the assurances they can (short of releasing any current medical records, which they have apparently not done) that he is functioning normally. So we will have to trust that (right?).

All I have is his reported medical history paired with his debate performance These things, particularly in light of the obvious change from his baseline presentation pre-stroke, seem pretty concerning. From my clinical experience, I’d be asking a lot of questions and I would be encouraging comprehensive neuropsychological assessment (beyond just an RBANS or a SLUMS) to really get to the bottom of things.

In my clinical experience, the more obvious someone’s deficits are to casual observation (e.g., such as in the case of John Fetterman’s, or arguably Joe Biden’s or Donald Trump’s, I suppose) – the more likely a serious cognitive disorder (such as dementia) is at play. Again – this is just an observation based on my almost two decades of experience working with people with dementia.

It seems absurd to not at least ask these kinds of questions about John Fetterman, or Joe Biden, or Donald Trump, or any of the other panoply of octagenarians currently serving as “our nations leaders.”

Is ignoring potential cognitive impairment in our nations leaders (perhaps for fear of being called “ableist” or “ageist”) in our nation’s interest?

Does it make our nation more safe, or less safe?

Regarding the charge of “ableism” (no doubt an accusation I might receive because I’m even asking these questions): Let’s be completely clear – it’s absurd to be conflating disability that is amenable to smart, caring, and empowering introduction of supports for the disability community (like ramps for wheelchair users, or sign language interpreters for the deaf community) with potential, serious, impairment due to serious neurological disease, like Alzheimer’s dementia, that may pose risks.

Shame on anyone who conflates the two for political power and ambition.

Here’s a final thought for you - a comment from the Common Sense article I linked to early in this post:

1. This one, by the way, is often one of the scariest things about dementia. Long before any other warning signs show up or a formal dementia diagnosis is proffered by a clinician (sometimes by up to six years!) major financial errors, falling victim to advance-fee and “lottery” scams, etc. is a harbinger of a later dementia diagnosis like Alzheimer’s Disease. The problem with this is that by the time the dementia itself is identified, the damage has already been done to the person’s finances, family, and legacy.

2. This, by the way, basically describes so-called mild cognitive impairment (MCI) syndrome, or what the American Psychiatric Association now calls in much more jargon-laden fashion, minor neurocognitive disorder (to distinguish it from dementia, which is now officially called major neurocognitive disorder – although most of us practitioners still just call it “MCI” and “dementia.”

3. Obviously not her real name. Details changed for anonymity.