President Joe Biden was declared fit for duty by his physician after his annual physical on Feb. 28, the same month a special counsel report raised concerns about his memory. However, the 81-year-old did not undergo a cognitive exam because both his primary care doctor and neurologist said it wasn't necessary, according to White House press secretary Karine Jean-Pierre.
Neurologists told NBC News the memory issues the president has displayed recently — namely forgetting dates and mixing up names — do not indicate Biden has dementia and instead could just be a normal part of aging.
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Still, Biden's age and fitness for the presidency are top of mind for many voters heading into the 2024 election. A Feb. 6 national NBC poll found three-quarters of respondents, including half of Democrats, have concerns about his mental and physical health.
Less than half of respondents felt the same way about Republican frontrunner former President Donald Trump, who's also had memory issues, recently mixing up fellow presidential candidate and former Gov. Nikki Haley and former Speaker of the House Nancy Pelosi. Trump has also confused Biden and former President Barack Obama at least seven times, Forbes reported.
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At the press conference after Biden's physical, Jean-Pierre said he “passes a cognitive test every day" because he constantly “moves from one topic to another topic, understanding the granular level of these topics.” And within hours of the release of the special counsel report, Biden staunchly defended his cognition, telling reporters, "My memory's fine," though later in his speech he mixed up the names of two heads of state for the third time that week.
So, what are the signs that a person, especially an older adult, is in need of a cognitive exam or screening for dementia? Here's what experts say. (These experts have not treated Biden or Trump and stress that only their medical teams can provide an assessment of their cognition.)
What is dementia?
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Dementia is a decline in cognitive function that, by definition, interferes with people’s daily activities, according to the National Institutes of Health (NIH). This includes memory, reasoning and overall thinking, and some people experience personality changes.
Approximately one-third of people 85 and older have some form of dementia, according to the NIH.
“Dementia becomes more common with advanced age, but not all adults will develop dementia with age,” Dr. Audrey Chun, professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai in New York City, tells TODAY.com.
The NIH emphasized that dementia is "not a normal part of aging," as many people live to their 90s and beyond without any signs of it.
What causes dementia?
Dementia is caused by changes in the brain that affect the cells' ability to communicate with each other. Different parts of the brain have different functions, from memory to movement to reasoning, so symptoms depend on which part of the brain is damaged.
The risk of dementia rises as you age and if you have a family history, per Mayo Clinic. However, leading a healthy lifestyle may reduce the risk of developing dementia — such as eating a balanced diet, exercising regularly, not drinking alcohol, sleeping well, and maintaining healthy weight, blood pressure and cholesterol levels.
Types of dementia include:
- Alzheimer’s disease (the most common)
- Frontotemporal dementia (what Bruce Willis has)
- Lewy body dementia
- Vascular dementia (caused by strokes)
- Huntington’s disease (inherited disorder causing uncontrollable dance-like movements)
- HIV-associated dementia
- Creutzfeldt-Jacob disease (rare brain disorder)
- Parkinson’s disease dementia
What are the signs someone should be tested for dementia?
“It is crucial for folks to appreciate that, with aging, it is common to occasionally forget names or misplace items,” Dr. Michael S. Okun, director of Norman Fixel Institute for Neurological Diseases at University of Florida Health and medical advisor to the Parkinson’s Foundation, tells TODAY.com.
Another normal memory change with age is not being able to remember memories from many years ago.
But forgetting recent events is more of a warning sign because dementia tends to affect the part of the brain that houses short-term memory first, Dr. Paul Newhouse, clinical core leader for the Vanderbilt Alzheimer’s Disease Research Center, said.
For example, not remembering a recent shopping trip would be worrisome. “What I’m more concerned about is: Can you remember what happened yesterday, or an hour ago?” Newhouse said.
Another sign a person's memory loss is more than normal aging is when they don't realize they're forgetting things, said Dr. Thomas Wisniewski, director of NYU Langone Health’s Alzheimer’s Disease Research Center and its Center for Cognitive Neurology.
And if a patient has noticed cognitive deficits or if the people around them have, that should also merit an evaluation, Chun explains.
Other indications to see a doctor for a possible dementia diagnosis include:
- Impairment that affects major activities during daily life (such as filing taxes, managing personal finances or driving)
- Consistently having difficulty completing familiar tasks
- Struggling with visual images or spatial representations
- Social withdrawal
- Getting lost in a familiar neighborhood
- Hallucinating
- Losing balance
Does age matter when testing for dementia?
“Though age is always a consideration ... we must appreciate that various forms of dementia can occur across all age groups,” Okun says. He advocates for changing the perception that dementia is “simply an old person’s disease.”
For example, compared to other types of dementia, one rare form dementia, known as frontotemporal dementia, often develops at a younger age. Former talk show host Wendy Williams, 59, was recently diagnosed with it.
The U.S. Preventive Services Taskforce, which provides evidence-based recommendations for preventative health, does not have definitive guidance on whether older adults should be screened for cognitive impairment, citing insufficient evidence.
Medicare, however, does suggest the annual wellness visits of its beneficiaries should include cognitive evaluation, says Chun.
Why is it important to test for dementia?
“Typically, we screen for conditions when we can either cure or mitigate the condition if detected early,” Chun notes. “Although there is no cure for dementia, there are important conversations and preparations that need to take place in the early stages of disease.”
Experts say early testing for dementia helps to:
- Confirm the diagnosis
- Assess the severity
- Determine the underlying cause, including reversible conditions, such as vitamin-B12 deficiency or thyroid disease
- Help the family and doctor understand the prognosis and plan for the future
- Provide treatment options specific to the diagnosis
- Allow doctors and patients take advantage of the treatments available, if there are any
“When it comes to considering a diagnosis of dementia, it is important that we both test and follow folks closely over time as there may be lifestyle modifications or medications which may be recommended,” Okun emphasizes.
What’s the most effective way to test for dementia?
“There is no single clinical test for dementia since dementia is a large category of neurologic disorders that affect cognition," Chun explains.
The first step is to see a doctor who can go through a person's medical and family history and perform a complete neurological exam to determine possible causes.
Testing often begins with a cognitive screen, Chun adds.
One highly regarded and validated screening test is the Montreal Cognitive Assessment, known as MoCA, which takes about 10 minutes to complete. Another one is the mini-mental state examination, which takes five to 10 minutes.
Okun says it's especially helpful to track suspected dementia cases by giving these tests multiple times over an extended period to see if scores decline, which may be a sign of worsening cognition.
If a doctor is concerned about cognitive impairment, next they perform blood tests and special imaging to examine the brain, Chun says.
“An abnormal MoCA should prompt the clinician to consider the next step, which may possibly be MRI,” Okun adds.
Blood tests can look for reversible conditions that can lead to cognitive impairment, such as B12 deficiency, electrolyte imbalances, infections, thyroid abnormalities and sometimes syphilis testing in the right clinical setting.
“Depending on the suspected cause, a clinician may pursue (additional) blood tests, such as (for Alzheimer’s dementia), or an advanced neuroimaging study called a PET scan,” Okun explains.
If you or a loved one are experiencing signs of cognitive decline, your first step should be to see your primary care provider.
This article first appeared on TODAY.com. More from TODAY:
