A lengthy Justice Department report on President Biden’s handling of classified documents contained some surprising assessments of his well-being and mental health.
Biden, 81, was an “old man with a bad memory” and “diminished faculties” who “did not remember when he was vice president,” said special counsel Robert K. Hur.
In conversations recorded in 2017, Biden was “often painfully slow” and “struggled to remember events and sometimes struggled to read and convey his own notebook entries.” Biden was so deteriorated that a jury was unlikely to convict him, Hur said.
Republicans were quick to attack, some call the president unfit for office and demanding his dismissal.
But while the report disparaged Biden’s mental health, medical experts said Friday that its judgments were not based on science and that its methods were nothing like those doctors use to assess possible cognitive decline.
In its simplest form, the problem is one that doctors and family members have been grappling with for decades: How do you know when an episode of confusion or a memory lapse is part of a serious impairment?
The answer: “Not so,” said David Loewenstein, director of the center for cognitive neuroscience and aging at the University of Miami Miller School of Medicine.
Diagnosis requires a battery of sophisticated, objective tests that explore several areas: different types of memory, language, executive function, problem solving, and spatial and attention skills.
The tests, he said, determine whether a medical condition exists and, if so, its nature and extent. Verbal stumbles are not proof, Dr. Loewenstein and other experts said.
“Forgetting an event doesn’t necessarily mean there’s a problem,” said Dr. John Morris, a professor of neurology at Washington University in St. Louis.
Hur, the special prosecutor, based his conclusions on a five-hour interview conducted over two days (the two days after Hamas’ surprise attack on Israel) and a review of interviews with a ghostwriter recorded in 2017.
But scientifically identifying a memory problem requires doctors to evaluate the change in a person’s cognitive function over time and determine that its magnitude is sufficient to reduce the patient’s ability to perform usual activities, said Dr. Morris.
The best way to determine whether such a change has occurred is to compare the results of a current memory test with the results of a test taken five or 10 years ago, he added. Alternatively, doctors can interview someone who knows the patient well (usually a close family member) to get an idea of whether there has been a decline.
Recall is just one aspect of cognition, said Dr. Mary Ganguli, a professor of psychiatry, neurology and epidemiology at the University of Pittsburgh.
To make an accurate diagnosis, a geriatric psychiatrist might ask how long the patient has had problems with the ability to plan and organize, or express themselves. If the person is forgetful, what does he forget and when?
“We want to know what particular losses were observed, not just ‘memory’,” Dr. Ganguli said. “Was it something specific when the person was tired or sick, or does it happen constantly and increase in frequency?”
It’s important to rule out other possible causes that may affect cognitive function, such as a stroke or head injury, or even the use of certain common medications, Dr. Ganguli added.
For example, a common culprit of memory lapses is diphenhydramine (sold as Benadryl and other brand names). People who take it chronically to fall asleep often become forgetful as a result. (Patients often tell her they take Tylenol at night, she said, but Tylenol PM actually contains diphenhydramine.)
Dementia has a distinctive pattern of memory loss, which should not be confused with routine forgetfulness, Dr. Ganguli added. A person with dementia typically forgets recent events, such as what they had for breakfast, but remembers things from the distant past, such as a wedding day.
A detailed examination can take an hour, Dr. Ganguli said, and may also involve interviews with family members. A family doctor might perform a more abbreviated assessment, including quick memory tests like the Mini Mental State Examination or the Montreal Cognitive Assessment, known as MoCA.
In those tests, patients are asked the date and time and location of the doctor’s office. They may be asked to draw a clock that shows a specific time. They are told several words and, shortly after, asked to repeat them.
To assess cognitive status, Dr. Loewenstein typically administers a series of much longer, more probing objective tests. It is a basic tenet of the field to never diagnose a patient you have not seen in a medical setting, he said.
Dr. Loewenstein said he was outraged by experts “who had the audacity to make diagnoses by saying, ‘Oh, this person went to the refrigerator and forgot why,’ or ‘Oh, they substituted someone’s name for another name when they have other names.’ “. things in their minds.’”