Over the past month or so, the media on both sides of the aisle have been filled with reports of concern about President Biden’s cognitive decline while in office.
This supports the observations of millions of Americans who watched the presidential debate last year. Several tell-all books have also been published pointing out episodes of decreased mental acuity—especially during the last two years of his administration.
Several political leaders have been quoted as to the president’s declining mental condition the last two years of his term. Many have volunteered episodes of forgetting names of key administration officials. Reports have also stated that the president may have forgotten several executive orders dealing with the environment that he had signed weeks earlier.
The key event that may explain some of his cognitive issues may have been a life- threatening event that occurred in the 1980’s, when, then-Senator Biden, had emergent brain surgery on a leaking brain aneurysm in February, 1988 repaired by Dr. Eugene George and Dr. Neal Kassell. The leaking brain aneurysm led to a subarachnoid hemorrhage, or bleeding in the space between the brain and a thin membrane that covers and protects it.
In May of 1988, President Biden returned to the operating room to have a second smaller aneurysm managed by the same surgical team. Both were “open procedures” where a clip was placed to manage the aneurysm.
However, in the modern era of neurosurgery, brain aneurysms are preferentially managed (when possible) with less invasive procedures commonly referred to as endovascular procedures where coils are placed to prevent blood flow into an aneurysm by threading a thin catheter through an artery in the wrist or groin without the need to open the skull and dissect and potentially compromise brain tissue.
There are currently no long-term studies on cognitive dysfunction related to traditional “open procedures” compared to minimally invasive approaches known such as endovascular procedures.
Known complications related to leaking aneurysms (weakened or “ballooning of blood vessels) also include spasm of small blood vessels in the brain. Such spasm of small blood vessels in the brain can also result in cognitive issues related to repairing and stabilizing such blood vessel abnormalities, whether by traditional opening of the skull (craniotomy) or even novel endovascular neurosurgical approaches. However, the risk of complications is generally known to be higher after a traditional or “open-type” procedure which involves opening the skull in an invasive manner.
What’s clear is that the President of the United States is also the most observed individual on the planet and that changes in mental sharpness can be observed and reported by thousands of outlets in comparison to a similar patient who might be enjoying retirement.
Cognitive dysfunction is a common complication of a brain bleed (such as a subarachnoid hemorrhage), which occurs when an aneurysm leaks or ruptures. This affects most people to some degree. Cognitive dysfunction can take a number of forms, such as problems with retrieval of memories prior to—but also after the bleeding occurrence. Equally concerning are issues remembering new information or facts.
Brain damage associated with leaking or ruptured aneurysms may, in some cases, increase your risk of developing dementia. Research has also implicated surgery and the type of anesthesia utilized. Many studies have reported an association between multiple general anesthetics and dementia; this association remains controversial. Contemporary reports from the late 1980’s do report some changes in then-Senator Biden.
Alzheimer’s disease is the most common dementia, followed by vascular dementia. Vascular and Alzheimer’s dementia lead to impairment in number of executive functions including word-finding difficulties, deficits in reading comprehension, confusion and impaired focus and attention. The end result are alterations in brain protein structures, the result of the abnormal processing and organization of normal proteins in the brain. Vascular dementia is primarily caused by cerebrovascular disease due to atherosclerosis leading to irregular or abnormal blood flow to critical brain structures.
There is also a large amount of research supporting the risks of developing dementia and Alzheimer’s disease from traumatic brain injuries (TBIs) from playing football, soccer, lacrosse, wrestling, boxing and other contact sports.
According to the Alzheimer’s Association, research has provided a link between moderate to severe TBIs and a greater risk of developing some form of dementia years later.
The symptoms of vascular dementia depend on the location and amount of brain tissue involved. They may appear suddenly after the acute event or slowly manifest over time.
Symptoms of Dementia:
Increased trouble doing normal daily activities because of problems with focus, communication or inability to follow directions.
Memory problems: short-or long-term memory can be affected.
Confusion which can get worse at night (so called sundowning syndrome)
Personality changes.
Mood changes such as depression or irritability.
Stride changes when walking too fast of shuffling steps.
Problems with movement, balance or both.
Diagnosing dementia or Alzheimer’s in any patient begins with evaluation by a skilled neurologist, along with specific blood biomarkers, specialized MRI scans, along with cognitive testing known as the The Montreal Cognitive Assessment (MoCA).
Alzheimer’s Disease is characterized by the presence of beta-amyloid, an abnormal substance which form sticky plaques on the brain which may result in death of brain cells. Testing for the presence of beta-amyloid plaques in the brain via specific blood biomarkers and MRI scans is critical in determining the extent of functional impairment.
Individuals reviewing the last few years of President Biden’s term might reflect on some of the events detailed in personal accounts made public in Jake Tapper’s new book, Original Sin, that may serve as insight to stratify risk of cognitive impairment in older persons with previous neurologic events, even if they occurred many decades in the past.
Dr. Peter J. Papadakos, Professor of Anesthesiology and Director of Critical Care at University of Rochester Medical Center, contributed to this article.
