#TrumpIsNotWell vs. Sleepy Joe: On the weaponization of dementia in politics, and its bleak future.

When Ronald Reagan, who died of Alzheimer’s disease in 2004, ran for president at age 69 and a second time at 73, senility was part of the public debate. The Democratic Party used it in their campaign. After a presidential debate, a senior Democrat told the press: “Reagan showed his age”.

When dementia is mentioned today, the discourse is much more aggressive. The basic mental capacity of both candidates is under scrutiny. On one hand there is the 74-year-old US president, who has been accused of neurological decline long before cameras caught his difficulties descending a ramp or lifting a glass of water, and long before he failed to name the town in which he stood. On the other there is his 77-year-old challenger, who has been accused of neurological decline because of weak debate performances, his gaffes, and what some perceive as an aura of mental slowness. Both candidates have been attacked from the left and the right: The Republican-leaning Lincoln Project helped propagate #TrumpIsNotWell. The journalist Jeremy Scahill from the Intercept, associated with the left, claimed in his podcast: “Voters are going to see Joe Biden in what I think can only be called mental decline and they are going to wonder if he should be in charge of the nuclear arsenal. And the fact that Trump is also in clear mental decline, that’s not exactly reassuring.” Importantly, the president himself is leading the attack. “Biden does not even know he’s alive”, he said in an interview and in a campaign event.

A lot is disturbing about these debates. Two aspects in particular: 1. That these are often not genuine concerns by people who care, but indeed accusations, attacks. At times it seems that some in one camp almost wish dementia upon the opposite candidate. 2. That the debates come with a public (and at times grotesquely unqualified) discussion of dementia symptoms and diagnosis.

Regardless of how convenient and convincing arguments for someone’s dementia may seem when they concern the person we don’t want, we need to spend more time criticizing the political weaponization of dementia, especially since recent developments in dementia and mental health research will likely make the debate worse. The victims will be not only politicians, but also the dementia community.

Dementia screening

Two tools are commonly used in diagnosis and tracking of dementia: the Mini Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA). I prefer the MoCA, but they are both very similar. They are brief, cover a range of cognitive aspects (e.g. visuospatial processing, working memory, executive function), and testers need only relatively little training. They also share the same flaws: Brief tests do not provide a satisfactory cognitive profile, and both fail to detect early, subtle change caused by dementia. In that context, Trump’s boasting about recalling five words after a few minutes has been rightfully ridiculed. You cannot “ace” a dementia test, and if neurologists commend you for naming them in the right order, they are only trying to make you feel comfortable. It’s nothing “incredible” because we see it often, and there are not extra points for listing words in the right order. Also, to get all the fact-checking out of the way, you are being asked beforehand to keep the words in memory, so if you are being tested, the recall doesn’t come as a surprise.

The fact that he was asked to take the MoCA has raised eyebrows, although in my view it does not hurt to test someone his age, and with his power. At the same time, while I wouldn’t be so proud about performing well in a dementia test, and while naming a camel is easy for almost everyone, we should keep in mind that most people in Trump’s age, even with his education, are not expected to get all answers right.

So, knowing that the test is flawed, and not knowing the test conditions nor Trump’s score, this debate taught us nothing new about the president’s “fitness for office”. Worse yet, the wide dissemination of the MoCA by the press and in social media, sometimes with the invitation to “take the test that Trump took” (please don’t) hurts the clinical effort to identify dementia reliably. It is a blessing that the MoCA is widely accessible, but the intention was never to make it public to the degree it is now. Some newspapers have refrained from publishing the entire test in order to protect its validity, but both the MoCA and the MMSE are easy to google. Even knowing that they are available may make the work of neurologists more difficult, and we need to recognize that dementia detection is a matter for healthcare professionals.

I also worry about the association of negative character traits with dementia. Dementia eventually brings behaviour change, but vindictiveness, racism or autocratic tedencies will never be explained by it. Dementia doesn’t turn people into bullies, and it does not need dementia to be one.

Biden’s convention speech

Can Biden deliver a speech? By the final evening of the Democratic National Convention, attacks on Biden’s mental fitness had reached such a bizarre peak that the ability to read from a teleprompter became the object of speculation. It is true that someone with more advanced dementia will not be able to deliver a convention speech. However, the many people who have attended events by the Alzheimer’s Society and similar organizations have seen people with a dementia diagnosis give good speeches, either read or off-the-cuff. A decent speech doesn’t show that you are cognitively healthy.

At the same time, a bad speech does not prove that someone has dementia. Biden, for example, has struggled with stuttering since his childhood, and still uses phrasing techniques to improve his fluency. One should therefore not be surprised if he struggles occasionally. So again, the debate has brought no new understanding, and at the same time contributed to the misportrayal of dementia. It’s a waste of time and attention.

Advances in dementia screening and their dangers to public debate

We must control our impulses now, or else the situation will become worse as methods for detecting dementia (or other cognitive health issues) evolve. Dementia is the 5th leading cause of death in the world, and therefore, dementia detection has become a very urgent challenge.

Several approaches are based on big behavioural data. My own work involves models which may help detect change in language use which can be a sign of dementia. Other approaches use gait (e.g. walking speed, step size, symmetry). These are data that are easy to acquire, and, in the case of politicians, very public. A study of Ronald Reagan’s language at press conferences during his presidency concluded that signs of Alzheimer’s disease increased during that period. A different study investigated the books of Iris Murdoch, who also died of Alzheimer’s, and found that her last lacked the lexical diversity of her early work. These methods will become more accurate, and, thanks to open science, widely available. As we now see speculation online about whether Trump is having “mini-strokes” based on some 10-second clip, lay people will use software to make claims about dementia based on corpora of public data from contemporary public figures. The use of “real” methods, whether correctly or not, appropriately or not, will strengthen these claims with scientific veneer that will be enough for many to accept them as fact. If we don’t correct the discourse now, the future will be more troubling.