TWO DIFFERENT CANDIDATES, TWO DIFFERENT BRAINS

By Vince Greenwood, Ph.D., founder of DutyToInform

With the election looming, the anxiety in the electorate over the stakes is palpable. In our hyper-partisan atmosphere, that anxiety is frequently channeled into the demonization of the candidate of the opposing tribe. In this election cycle, that demonization has often taken the form of castigating the President as “senile” or “demented.” Fox and other right-wing media outlets have put out (creative) video mashups of his verbal disfluencies. Perceptions that Biden is too old to serve are reinforced by deceptively edited videos that portray him as confused and wandering.
Of course, concerns about Biden’s cognitive health have skyrocketed after seeing his struggles at the debate.
Recently, we have seen the same concern raised about Trump. Mashups of his verbal slip-ups have emerged. More substantively, experts from the fields of clinical neurology and psychology have weighed in on the peculiar quality of Trump’s linguistic and cognitive struggles, noting that his observed difficulties seem to indicate a disease process of neurological decline rather than normal aging.
The country is correct to have serious concerns about the possibility of such cognitive decline. If either Biden or Trump were displaying signs that signaled the beginning stage of a degenerative brain disease, it would have profound implications for their fitness for office. Such a condition would seriously compromise their ability to handle the responsibilities of the office as well as their ability to ward off further deterioration of their neurological condition. It is a fateful diagnosis.
A seriousness of concern over this possibility must be met by a serious assessment not marked by cherry-picking bad moments from the candidates or equating signs of normal aging with cognitive decline. Is it possible to make a more scientific and objective assessment of Biden and Trump’s brain health? Or are we restricted to the arena of dueling video mashups?

It turns out there is a legitimate path to arriving at an informed, scientifically-based opinion about the possibility of neurodegenerative disease. Traveling down that path involves a thorough search for relevant data and then subjecting that data to the specific diagnostic guidelines laid out in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the authoritative guide of the mental health profession. At the end of that journey we find that one of the candidates is very likely in a stage of cognitive decline, while one is displaying signs of normal aging.
But, we have to acknowledge and address two significant obstacles in the journey. First, Biden and Trump control what medical exams they will undertake and what information will be released to the public. They have chosen not to undergo a comprehensive neuropsychological exam. Second, without their cooperation, it is difficult to diagnose for neurodegenerative illness at a distance. The frustration over the lack of collaboration that limits the health information available to the public is detailed in a recent New York Times article, What Are We Told About the Health of Biden and Trump? They Decide. The problems in diagnosing cognitive decline at a distance are enumerated in a recent Washington Post article, What Science Tells Us About Biden, Trump and Evaluating an Aging Brain. These authors — unbiased investigative journalists and several quoted medical and psychological experts- conclude that we can only offer an informed opinion on Biden and Trump’s brain health if we have their collaboration in a thorough assessment. Anyone who claims otherwise, they warn, is way over their skis and likely has partisan motives.
However, even given these obstacles, we don’t have to throw our hands up with regard to evaluating possible cognitive decline in Biden or Trump. To make a good-faith effort to determine if one has meaningful cognitive decline suggestive of brain illness, you must start with the definitions and diagnostic criteria enumerated in DSM-5. DSM-5 is considered the diagnostic bible of the mental health profession for good reason. For example, the definitions and diagnostic guidelines for neurological dysfunction result from a five-year effort by the Neurocognitive Disorders Work Group. The Work Group consisted of the world’s leading experts in clinical neurology and psychiatric research and relied on the latest advances in scientific knowledge. Their recommendations, in turn, were reviewed by several overarching DSM-5 panels of experts.
DSM-5 has brought cohesion to the diagnostic task by disentangling the many causes of cognitive decline (e.g., Alzheimer’s, Parkinson’s. traumatic brain injury) from the outcomes of brain health problems. The diagnosis of neurodegenerative illness is based on these outcomes and captured in two basic syndromes: Mild Neurocognitive Disorder and Major Neurocognitive Disorder. The diagnostician’s primary responsibility is determining if the patient meets the diagnostic criteria for either syndrome. If so, then you try to determine the disorder’s underlying cause.
The diagnostic criteria for diagnosing a Neurocognitive Disorder (NCD) are clear and straightforward. There are just three basic guidelines:
(1)Diagnosis of NCD is all about cognitive decline from a previous, healthier baseline.
(2) The essential data to judge decline is based on performance in six cognitive domains: complex attention, executive functioning, learning and memory, language, perceptual-motor abilities, and social cognition. The diagnostician’s task is to measure the possible decline in these six and only these six domains.
(3) Depending on whether you find a “modest” or “substantial” decline, even if just in one domain, a diagnosis of Mild or Major Neurocognitive Disorder (NCD) must be considered.
While the guidelines for diagnosing NCD are simple, the process for securing sufficient, relevant information (data points) to assess cognitive decline is anything but given the candidate’s lack of cooperation to undergo a comprehensive exam. However, rather than give up the chase immediately, we can turn to three sources of information: medical records Biden and Trump have released to the public; informant reports such as biographies, autobiographies, insider accounts, and investigative profiles; and videotape that allows for direct behavioral observation.
I scoured these sources. The detailed findings of that effort are here.
Below is a summary of the findings on possible cognitive decline for Biden and Trump.
Results from released medical records
For President Biden
He underwent his annual physical exam in February, which generated a six-page report to the public that included lab findings and summaries from specialists in cardiology, orthopedics, and, most critically, neurology. As noted in the report: An extremely detailed neurologic exam was again reassuring in that there were no findings which would be consistent with any cerebellar or other central neurological disorder…
There was nothing in the report to support the finding of cognitive decline that would lead to a diagnosis of Neurocognitive Disorder. Nor does Biden suffer from any illness at the present that would put him at risk for Neurocognitive Disorder. However, it should also be emphasized that the annual physical exam fails to generate sufficient relevant information to rule out the possibility of such a diagnosis.
For ex-President Trump
There is very little detail in Trump’s health reports. The most recent report (November 2023) is a three-paragraph statement where his physician described his health as “excellent.” Earlier health reports have been described as “fawning and vague.”
In 2018, Trump reported that he had taken the Montreal Cognitive Assessment Test (MoCA), a one-page, 30-point test that can be administered in 10 minutes. The MoCA is considered an initial screening device that can detect signs of full-scale dementia. Trump reported a perfect score of 30, claiming doctors told him that “rarely can anybody do what you just did” and that the test contains “very hard” questions. In fact, the average score on the test is 27 (and even that average is taken from a sample of people suspected of cognitive impairment). A score of 30 is considered normal, not exceptional.
The lack of any specifics in his medical reports, coupled with their blatant politicization, prevents any serious appraisal of whether Trump does or does not display brain illness.
Results from informant data
This source of information is particularly helpful in assessing the domains of executive functioning, attention, and social cognition. These domains consist of a broad swath of behavior, much of it occurring off-camera. To get a decent appraisal, one must assess these behaviors over many situations and over months if not years. Thus, information from close observers (colleagues, employees, family, friends, journalists who have had open access) or biographers with multiple insider sources gives us the best opportunity to assess these domains.
For President Biden:
Biden receives high marks in all three domains. While some drop-off in attention capabilities is a feature of normal aging, there do not appear to be any concerns from insider accounts about his focus. He is detail-oriented and spends many nights after dinner reading scores of pages of briefing material to prepare for the next day’s agenda. He is known for his ability to synthesize a good deal of information and reportedly runs meetings in an organized and efficient manner. His reputation for reaching across the aisle and collaborating successfully with others also reflects well on his executive functioning.
Biden’s emotional intelligence (social cognition) is often lauded. He is known for his empathy. He appears to have close relationships and connects well with people, even if they may have different political orientations.
For ex-President Trump:
From many insider accounts, biographies, and even his autobiographical efforts, we have copious evidence that Trump’s functioning in these areas is markedly below average. He has a notoriously short attention span, disdains the planning, focus on details, and self-control that comprise executive functioning, and has a lifelong history of disagreeableness and lack of empathy that are at the heart of competent social cognition.
However, while there is ample evidence of Trump’s struggles in the arenas of attention, executive functioning, and social cognition, these difficulties do not appear to be the result of a neurodegenerative disease process. Remember, diagnosing a Neurocognitive Disorder requires the demonstration of decline in one or more of the six cognitive domains. A comprehensive review of the biographies of Trump reveals persistent deficiencies in these areas dating back to childhood.
Results from videotape
Reams of videotape for Biden and Trump enable us to make many behavior observations to evaluate for possible cognitive decline. This source of information is particularly relevant for the domains of memory, perceptual-motor skills (how one can navigate through the world physically), and language.
For President Biden
In the memory and perceptual-motor domains, Biden does display some difficulties. He sometimes mixes up names. His gait is cautious and he stumbles occasionally. However, these behaviors are associated with normal aging not brain illness.
For ex-President Trump
Trump occasionally mixes up people — Nikki Haley for Nancy Pelosi is one example — rather than just names, which can be a sign of cognitive decline. Trump’s bent, forward-listing posture, jerking right arm and leg, and arm weakness are more worrisome physical signs than a cautious gait and occasional stumble.
We have now summarized findings from two data sources on five of the six cognitive domains that need to be assessed for possible decline that carries with it a serious concern of early dementia. Biden, whatever struggles he might have with aging, does not display signs of cognitive decline. Trump does display red flags in some areas. However, neither candidate has sufficient data to warrant a definitive diagnosis. Here is where further testing would be invaluable to the national conversation about their fitness.
This brings us to the sixth and final domain…
Evaluation of Findings in the Language Domain
Fortunately, this domain does not require collaboration with the candidates. That’s because you can execute a detailed, clinically meaningful appraisal directly from speech samples, which are readily available on YouTube. Furthermore, you can zero in on the decline in the language domain by comparing speech samples from the past to the present.
This study (full results here) is what I undertook in a manner designed to inject a measure of objectivity and scientific rigor into the assessment. I created a checklist of seven specific verbal expressive behaviors linked to neurodegenerative brain illness. At the same time, I developed a list of seven specific verbal expressive behaviors associated with normal aging, such as speech volume and rate. I then applied the checklists to randomly selected speech samples of Biden and Trump from middle age and the recent past.
The differences between the two candidates in the language domain were compelling and prognosticative. President Biden did not display any meaningful decline in any of the verbal markers linked to brain illness, while ex-President Trump displayed shifts in all seven verbal markers.
Thus, Trump shows clinically significant signs of cognitive decline in the language domain beyond normal aging, while Biden does not.
The authors of the chapter on Neurocognitive Disorders deemed that you only have to show a decline in one of the six critical cognitive domains to be strongly considered for a diagnosis. The implications of these findings in the language domain are profound. First, it is quite likely that suboptimal functioning in the other five domains has begun to set in, even if not immediately apparent. Second, the great majority of individuals with early dementia progress to full-scale dementia, where the capacity for independent living is severely threatened.
It certainly appears we have… Two different candidates, two different brains.

Further Reading
Does Trump Or Biden Display Neurocognitive Disorder? Where We Stand Now

The Impact of Donald Trump’s Diagnosed Personality Disorder on Key Cognitive Domains