Election on the Brain

Trump vs. Biden: decoding the older brain

Presiding over the United States may be the world’s most powerful job, but the workload is hell. George Washington complained, Woodrow Wilson called it “preposterous” and, after President Barack Obama took office, his hair turned grey before he turned 50. In 2009, a provocative study suggested that a stint in the White House is such a pressure cooker that it can age presidents at twice the speed of other mortals. So what might the velocity be in times like these?

A global pandemic is upending the world order. The virus behind it is killing more people in the U.S. than in any other developed country. Some 30 million people are jobless, the U.S. economy is sputtering and protests for racial justice are forcing a reckoning across the country, erupting into deadly clashes between left and right, Black and white.

Whoever takes the helm in 2021 faces a task beyond daunting, a 247, ultra-demanding challenge of Herculean proportions. Of course, a Roman god is not in the running. The choice is down to two septuagenarian men – the oldest presidential candidates in U.S. history – and fears abound that neither one has the stamina nor mental fitness for the job.

Never has the aging brain been such a pressing issue on the ballot – and with good reason. Neuroimaging studies increasingly show that time is a vandal, destroying the brain in random bits and pieces. But research also finds that mental deterioration is not inevitable, that some brains do age better than others. What American voters will have to decide on Nov. 3 is which candidate has staved off cognitive decline enough to run the country.

Is it former Vice-President Joseph R. Biden Jr., the 77-year-old Democrat who underwent surgery for two cerebral aneurysms in 1988, a self-described “gaffe machine” who has mixed up which state he was in – repeatedly – and, during his Super Tuesday victory speech in March, mistook his wife for his sister?

Or is it the 74-year-old incumbent,

President Donald J. Trump, a selfdescribed “stable genius” who wondered if injecting the body with disinfectant could beat COVID-19, who peddles the conspiracy theories of others and his own, who has bragged about the size of his “nuclear button,” a nuclear weapon system he was supposed to keep secret, “acing” a dementia test and, according to the Fact Checker database of the Washington Post, has lied more than 20,000 times since taking office? Most notably is Trump’s own admission that, from the earliest days of the pandemic, he has deliberately misled the American public about the severity of the novel coronavirus when he understood it to be an airborne killer.

An army of mental health experts – including Trump’s niece – believe the president’s erratic behaviour is not so much a symptom of an aging brain as an ailing one, describing his vindictive narcissism as the hallmark of a personality disorder. Mary Trump, a clinical psychologist, writes in her new book, Too Much and Never Enough, that her uncle’s “pathologies are so complex and his behaviors so often inexplicable that coming up with an accurate and comprehensive diagnosis would require a full battery of psychological and neuro-physical tests, that he’ll never sit for.”

The U.S. military bars people with most psychiatric disorders from serving in its ranks, and an estimated 80 per cent of Fortune 100 companies require high-level job candidates to undergo psychological tests. Yet those vying to be commander-inchief of a country of more than 330 million citizens and the U.S. Armed Forces, the most powerful military on the planet, face no such assessments – a fact that brain experts both in and outside the U.S. lament.

“They should go through a lot of psychological testing if they are going to be responsible for the nuclear bomb and responsible for many important decisions and be the head of the army,” says Dr. Zaid Nasreddine, the Canadian neurologist who designed the dementia-screening test Trump says he “aced.”

Nasreddine developed the 10-minute 30-question exam in the ’90s as a time-saver to detect cognitive impairment when he was a young doctor eager to see more patients in a day. The Montreal Cognitive Assessment, or the MoCA, which includes tasks that evaluate memory, executive function and verbal fluency, is now used in 65 languages and more than 200 countries. Still, Nasreddine says, “not in my wildest dreams” did he imagine a U.S. president would wield it as proof he’s mentally fit for his job and as a challenge to Biden to beat his score.

“[Trump] is turning it into an IQ test, which is not the purpose of the test,” says Nasreddine. “It’s not to measure how skilled you are but to measure if you have any cognitive disorder.”

Usually, he explained, the test is given to suss out Alzheimer’s or dementia in older adults showing signs of mild cognitive impairment, such as forgetfulness, or to those who have suffered a stroke, concussion or other brain injury. But former White House physician Dr. Ronny Jackson said the president insisted he take such a test in 2018, when critics were voicing concerns over his mental fitness and, this summer, Trump has said repeatedly his “amazing” results prove he is “cognitively there.”

Yet as Nasreddine and other experts note, the exam is not designed to pick up all mental health and psychiatric issues or the decline in reasoning that can become more common later in life.

As it is, the voters’ best chance to assess the cognitive state of the candidates may come with the three presidential debates scheduled for the final weeks of the campaign.

“How the candidates handle themselves in the spontaneity of debates tells you a lot about how they are functioning cognitively,” says Dr. Mark Fisher, a neurologist and professor of political science at the University of California at Irvine. They offer viewers an opportunity “to look for focused, coherent answers as indicators of good cognitive function.”

A SOBERING VIEW

When the Founding Fathers signed the American Constitution in 1787, their only agerelated concern was that some candidates would be too young for public service, so they set minimum requirements: 25 to be a representative; 30 to be a senator; and 35 for president. It never occurred to them to set a maximum, since life expectancy at the time was 38.

But the expected lifespan of a human has risen 40 years since then and, with it, the belief and confidence that advanced age should be no barrier to any realm of human endeavour, whether it’s running a marathon or running for office. Unfortunately, the bravado generally outstrips the realities of brain biology.

Using ever more sensitive neuroimaging techniques, scientists peering inside the aging brain usually

find the view is sobering. The threepound marvel that houses the human mind, with its capacity to store the equivalent of every movie ever made in a cubic millimetre of tissue, shrinks significantly between the ages of 40 and 80, losing neurons and the crucial links between them. What researchers see is an organ damaged by the chronic conditions that tend to develop as people age, such as high blood pressure, high cholesterol, Type 2 diabetes and obesity.

“All these conditions affect how well our brains are fed nutrients and vascularized,” says Teresa LiuAmbrose, the Canada Research Chair in physical activity, aging and cognitive neuroscience at the University of British Columbia. “We start seeing deficits in the small vessels that feed deep into the brain, so you don’t have a stroke – as when a major vein or artery is compromised – but you have localized death of the brain tissue … [which] affects how your brain activates and functions.”

As specific brain areas atrophy, microbleeds starve the brain’s crucial white matter, the fatty sheaths that coat nerve fibres to speed connections between brain cells. LiuAmbrose likens white matter to “the highways and roadways of a city” that enable one area of the brain to speak quickly to another, and losing it, she says, “is like blowing up a roadway.”

These micro-insults to the brain can start accumulating when people are still in their 40s, she says, forcing the older brain to function differently. For example, “when young people do a task, the activation patterns are typically very constrained to a certain area that’s known to play a part in the performance of that task. With older adults, we tend to see a diffuse activation pattern where it seems like the brain is trying to recruit additional areas to allow the performance.”

Sometimes the recruitment effort pays off, and researchers find an older adult can perform just as well as a younger one, if not better, on certain cognitive tasks.

But when it doesn’t, it can lead to memory slips and cognitive deficits, particularly in executive function – setting goals, planning, organizing, controlling impulses and making sound decisions. Executive function is the highly evolved capacity that stems from the prefrontal cortex directly behind the forehead and, to work well, it relies on strong connections to other brain regions – links that vascular damage can disrupt.

Still, experts agree cognitive deterioration is not everyone’s destiny. Like faces, brains are similar, but no two are identical, and how they function over time also depends on education, experience, exercise and mental activity. Liu-Ambrose points out while some brains decline when people are in their 50s and 60s, others stay sharp into their 80s. “That’s why there is so much focus now on your vascular health because what’s good for your heart is good for your brain.”

“THE HEALTHIEST INDIVIDUAL EVER”

Medical exams, like psychological assessments, are not legally required of presidential candidates. But traditionally most offer doctors’ reports vouching for their general fitness to do the job. In the case of both Biden and Trump, there’s evidence their vascular health is imperfect.

The summary from Biden’s doctor, released last December, says the former senator from Delaware has an irregular heartbeat, takes an anticoagulant to reduce his chances of developing blood clots and a statin drug to control his blood lipid levels. But it also notes CT scans show no recurrence of the cerebral aneurysms he had surgically repaired in 1988.

Psychology professor Angela Gutchess, who specializes in aging brain research at Brandeis University in Waltham, Mass., suspects Biden’s aneurysms were the result of “an underlying structural deficit rather than reflecting cardiovascular health … the fact that [they developed] so long ago, and they’re not linked with age-related conditions, make them seem like less of a concern.”

Indeed, Biden has balked at Trump’s relentless attacks suggesting that he’s the “sleepy candidate” on the road to senility and has refused to be baited by the president’s taunts to take a cognitive test – “Why the hell would I?” he told CBS. During an interview with ABC anchor David Muir in late August, Biden said he’s not only fit to do the job but fit enough to serve two terms and that his behaviour speaks for itself: “Watch me, Mr. President, watch me … Look at us both, what we say, what we do, what we control, what we know, what kind of shape we’re in.”

Biden’s medical report includes other positive points related to his heart health – he has no history of high blood pressure, tobacco use or diabetes, no issues with his weight and works out five times a week.

Meanwhile,beyondgolfing,Trump is not a fan of exercise. In their book Trump Revealed, Washington Post reporters Mike Kranisch and Marc Fisher say the president gave up athletic pursuits after college, believing the human body is “like a battery, with a finite amount of energy, which exercise only depleted.”

For the most part, the president’s medical reports have been nearly as elusive as his tax returns. The doctor’s letter he offered the public before the 2016 election turned out to have been dictated to the physician by Trump himself and attested to his “astonishingly excellent” blood pressure and proclaimed he would be “the healthiest individual ever elected to the presidency.”

Since then, the limited health in

formation about Trump has fuelled speculation that the president has something to hide, particularly after he made an unscheduled visit to the Walter Reed Medical Center in Bethesda, Md., last November. Conjecture spiked again in June after Trump gave the commencement address at the U.S. Military Academy at West Point, where he appeared to have difficulty raising a water glass to his mouth and used both hands and then looked apprehensive and unsteady as he walked gingerly down the stage ramp.

Trump has vociferously dismissed the concerns that followed his West Point address, and the White House has insisted the mysterious Walter Reed visit was routine.

But in his new book, DonaldTrump v. The United States, New York Times reporter Michael S. Schmidt writes that during Trump’ s impromptu hospital visit last fall ,“Word went out in the West Wing for the vice-president [Mike Pence] to be on standby to take over the powers of the presidency temporarily if Trump had to undergo a procedure that would have required him to be anesthetized.”

In response to the book and the coverage it unleashed, Trump – who had lost his balance on another stage ramp at the New Hampshire rally – tweeted: “Now they are trying to say that your favorite President, me, went to Walter Reed Medical Center, having suffered a series of ministrokes. Never happened to THIS candidate – FAKE NEWS …”

Yet neither Schmidt’s book nor other media reports had mentioned anything about the president suffering from mini-strokes. Still, Trump had his physician, Dr. Sean Conley, take the extraordinary step of sending out an official statement that the president had not experienced or been evaluated for a stroke, mini-stroke or heart-related emergencies.

All that has been publicly released about Trump’s medical details came with a report in June that says the president’s annual physical indicates his overall health is good; he has no high blood pressure, history of tobacco or alcohol use and no diabetes. He reportedly takes the hair-growth drug Propecia to fight baldness, a medication to treat a common skin condition called rosacea and a statin drug to keep his high cholesterol in check. His weight is the only red flag. Trump, a lover of fast food, is obese.

But to neurologist Fisher, there’s something missing from Trump’s medical report that he’s noticed for years as a cause for concern – the circumference of the president’s neck. “Remember this is a man in his early 70s. He’s overweight, he’s clinically obese and, if you look at his physique, he has a thick neck.

“If you want to identify the kind of person who is at highest risk of obstructive sleep apnea, it would be an obese man in his 70s with a thick neck, and that matches up pretty well to President Trump. I don’t know if he’s ever had a sleep study, but that would be an area that deserves attention.”

Obstructive sleep apnea occurs when throat muscles intermittently relax and narrow the airway, causing breathing to repeatedly stop and start during sleep. The effect, says Fisher, “can certainly contribute to cognitive decline and it can certainly contribute to subtle neuropsychological disturbances, and we would expect that executive function would certainly be impacted.”

EXECUTIVE DYSFUNCTION

In 2014, after images of the aging brain’s deterioration had stacked up, Fisher penned a report warning its findings have troubling implications for the political world, since it was becoming increasingly common to see candidates for president and vice-presidents in their 60s and 70s.

Under the title “Executive Dysfunction, Brain Aging and