The two primary contenders for the presidency of the United States — President Joe Biden and former President Donald Trump — will debate on Thursday, June 27, in front of a national television audience on CNN for the first of two presidential debates.
If the past is any indication, millions of people will tune in. A significant number of them don’t merely want to listen to the candidates debate immigration, climate change or gun control, important as those issues are to the country. They want to see how the candidates perform, in real time, on the national stage without teleprompters, talking points, and fawning audiences.
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They will be assessing the candidates’ mental and behavioral states. Are they able to think on their feet under pressure and respond to questions in focused and substantive ways? Do they have a grasp of the challenges facing the country? Can they present cogent arguments as to why they want to be president for an additional four years? And are they up to the job both intellectually and temperamentally.
Viewers will be scrutinizing the debate for speed of response, memory lapses, word finding difficulties, attention span, poor impulse control, and the ability to stay on message and connect the dots in real time as the debate moderators shift from topic to topic.
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The candidate’s unfiltered mental states will be on full display before a national audience that will draw its own conclusions at the end of the 90-minute debate.
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The mental state of both candidates has been unfavorably characterized in the press over the last several months: “Unhinged, rambling, incoherent” is how MSNBC journalist Nicolle Wallace characterized former President Trump’s speech at a recent rally in Nevada after the teleprompter broke down. Earlier, special counsel Robert Hur, who investigated President Biden for his handling of official documents, reported that the Biden’s memory was “significantly limited” and that he had “limited precision and recall.”
Aging trajectories
Increasing age is the most important risk factor for progressive cognitive decline toward dementia, especially Alzheimer’s disease. Both candidates are well into the age of risk — 81 years for Biden and 78 for Trump.
It’s important to note that age is just a number and provides an incomplete and sometimes misleading picture about brain health and overall functional ability. Individuals have very different aging trajectories and age alone, devoid of context, should never be on the ballot and the basis of loose speculation.
Given the importance of the presidency, much hinges on the candidates’ ability to function consistently at a very high level, both in regular moments and in times of crisis. The ability to process information rapidly and use reasoning skills and judgement to make sound decisions in the national interest are essential, non-negotiable, aspects of the job. So questions about their current cognitive state and future trajectories are not only legitimate but necessary.
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Cognitive decline often starts with lapses in memories of recent events and extends to other domains such as language and thinking speed. Members of an individual’s immediate family and close co-workers are often the first to notice a decline from a person’s premorbid baseline state and come forward with their observations. But that is unlikely to happen here.
There is deep unease nationally about the cognitive capacity of the two main presidential candidates. The media frenzy in our forever election cycle has resulted in gross distortions of the mental states of both candidates. Video clips — altered in some instances — together with other visual and audio clips presented out of context have led to inappropriate clinical diagnoses and pejorative terms being used to characterize the opponents.
Cognitive testing in real time
Age and brain discrimination are alive, well, and widespread in the U.S. And while this is regrettable, there are objective alternatives to the mischaracterization of the candidates’ mental decline.
Medical and neuropsychological tests can shed light on an individual’s mental state. A comprehensive medical screening for presidential candidates should include a thorough physical exam with relevant laboratory tests and simple paper and pencil cognitive tests. If such tests suggest mental decline, they should be followed by more elaborate cognitive testing that can identify precise domains that are compromised. In addition, there are specialized brain scans and blood tests that can further pinpoint the neurocognitive diagnoses with considerable accuracy.
This is the standard of clinical care in most settings around the country. Yet both Biden and Trump have dismissed questions about their cognitive abilities and refuse to take relevant medical and cognitive tests that will provide transparency.
On February 28, 2024, Biden received his annual physical exam at the Walter Reed National Military Medical Center; it did not include a cognitive exam. When asked about that, the White House press secretary responded by saying that his doctors determined that he didn’t need a cognitive exam. “He passes a cognitive test every day,” she asserted.
On June 15, 2024, while addressing an election rally in Detroit, Trump challenged Biden to take a cognitive test claiming that he “aced” his cognitive exam — a 15-minute exam that was administered in 2018 by then-White House physician Ronny Jackson (currently a Republican congressman from Texas) while calling the doctor Ronny Johnson.
The hubris is stunning. Perhaps it’s the precision and the potential embarrassment they fear the most. Whatever the reasons, the candidates’ reluctance to be tested further reinforces the suspicion that they have something to hide.
If there was concern about the health status of any other organ in the body, candidates would likely be quick to provide relevant test results, if only to quiet the rumors. Yet when it comes to the most vital organ of them all, opacity and obfuscation are preferred to transparency.
Given that both candidates are unlikely to change their posture on cognitive testing, the CNN-sponsored debate may prove to be cognitive testing in real time — and in public.
Presidential debates are typically part entertainment, part substance, part theater, and part seminar. The stakes are higher this year. The public has a right to be informed and the moderators therefore have a special responsibility in this regard. They need not obviously conduct formal cognitive exams on national television. That would be absurd. They can, however, hold both candidates to high standards by asking pointed questions, challenging false assertions, and imposing discipline into the process by using all tools at their disposal to enforce timing and ensure a civilized discussion.
This will not be easy but it is necessary, especially considering the overall circ*mstances. If the moderators do their jobs well and consistently during the debate, major cognitive and behavioral limitations will quickly become apparent to viewers.
That may be the compromise we live with this election cycle.
Age, cognition and behavior are all on the ballot in both visible and invisible ways and the nation has a right to know if the leading candidates for president are up to the job. Let’s hope the debate provides a few real answers.
Anand Kumar, M.D., is a professor of psychiatry and head of the department of psychiatry at the University of Illinois in Chicago, and past president of the American Association for Geriatric Psychiatry.
