Nearly 50 years ago, I wrote a published letter objecting to the release of Gerald Ford’s full physical, including genitalia and rectal exam. I thought that was unseemly, and that expecting that level of disclosure would make it harder for women — and for a man with some irrelevant abnormality — to run for office. But I expected continuing disclosure of conditions that actually affected job performance or survival.
This year’s presidential campaigns have been a morass of misdirected attention and misleading communication. Kamala Harris gets off easy, since she disclosed enough medical information, and neither that report nor her behavior shows any particular health concerns. However, President Joe Biden and former President Donald Trump have both been caught up in the maelstrom, though differently. In my half-century as a geriatric physician, I’ve served thousands of older adults. From my perspective, the public conversation about the effects of aging on political leaders has been maddening.
Biden was widely criticized for a slow pace in walking and talking, and for having trouble quickly finding words, including names. While he has a life-long challenge with stuttering, causing some slow speech, his fluency this year was clearly worse. Pundits attributed this to age, and some implied that it signaled inadequate intellectual skills, likely to progress, and probably associated with a diminished life expectancy.
In my view, all of this missed the point. What we most need in a president is a collection of skills that is often called “executive functions.” These include the ability to sort through conflicting information, to recognize important facts and differentiate them from unreliable information, to judge other people’s skills and temperament and build a functioning team, to give coherent reasons for firm and thoughtful decisions, and to be able to strategize and implement a plan. News reports focused on word-finding and slowed speech and walking, which are easily mitigated by aides, teleprompters, and tolerance, while ignoring these executive skills, which are difficult to supplement and which any citizen would want in their leader.
The willingness to consign older adults to diminished capabilities on the basis of age was especially galling. Older age often brings experience, relationships, wisdom, and equanimity, characteristics that are often missing in young adults. Certain syndromes do become more common with age, but each older adult has only their own set of challenges. To this day, I am not aware of shortcomings in Biden’s executive functioning.
Trump is a much more difficult case. His current functioning builds on a lifetime of slick talking and succeeding by being overbearing. He evidences little regard for consistency or verifiable facts. He often launches into a bewildering array of, at best, loosely connected topics and thoughts. Many sentences are incomplete. His showmanship overwhelms any serious consideration of his current executive capabilities. Certainly, his past performance leaves substantial doubt as to whether he could now form and lead a high-functioning team, and he shows no willingness to take account of facts and rules. These, however, are long-standing issues.
The question of whether he has new or worsening deficits in mental function is made difficult by his pervasive dramatic performances. One would need to know, for example, whether his public persona is an act that he understands and strategizes to achieve, or whether it is genuine. In short, is there a different, private, Donald Trump who carefully considers facts, thinks in whole sentences, strategizes coherently, and builds a strong and capable executive team? Truly understanding that issue would be impossible at this point in the campaign, but the available evidence weighs against believing that he has an interior Machiavelli who is rationally scheming a convincing charade. His former associates report that much of his behavior is consistent, particularly his insistence on facts that have long been contradicted and his willingness to act on a poorly considered whim. Most likely, Trump has serious and long-standing shortcomings in executive functions: He appears unable to evaluate and act on new information, disinclined to attend to coherence and clarity, and limited in his ability to recognize and value skills beyond loyalty in his executive team.
Age does not explain these shortcomings, and they are not particularly likely to worsen with age except for being encouraged by life experience — for example, by gaining support from influential people, including voters. He may have some age-associated difficulties in processing information, but that would be difficult to distinguish using only the content of his public rants.
Disinhibition is a reasonably frequent syndrome in advanced old age. Affected people say or do things that they would usually have repressed, such as blurting out a blasphemy in a religious setting or angrily stating a long-repressed harsh opinion of a family member. One might contend that Trump has long been affected, but perhaps he is becoming more likely to say whatever is on his mind at the time, without filtering out random thoughts and inappropriate words. Nevertheless, focusing on aging is convenient for headline writers but less revealing than focusing on his long-term behavior.
Trump also has some noteworthy physical conditions. He is obese, celebrates an unhealthy diet, has a history of high cholesterol, and does not exercise much. In 2018, his coronary calcium score was 131, indicating a moderate risk for a cardiovascular event such as heart attack or stroke. That score is likely to worsen, even with medications. So, Trump probably has at least a moderate risk of disabling chronic conditions or death within the next four years, but estimating that risk with confidence requires much more information. The fact that he has not been forthcoming about his health should weigh on voters’ minds.
Strangely, the public discourse has not focused on the health of the vice-presidential candidates. With increasingly commonplace violence, we should know whether they are fit.
Presidential campaigns are extended job interviews for a very important and demanding job. Our president needs to manage the executive agencies and appoint strong, skilled, and thoughtful leaders. The president must manage foreign affairs and put forward both visionary and pragmatic policy approaches. The president must deserve the trust and respect of our people, our other leaders, and leaders in other countries. These and more rely on character traits, skills, and experience. Physical health is important for stamina and survival. Deficits in the functioning of the brain, especially if progressive, should be serious concerns. Biden got slammed in the press, mostly for the wrong reasons. Until recently, Trump very nearly got a pass, with the headlines mostly conveying tepid concerns focused on his age, rather than his long-standing deficits in skills, wisdom, and character. The public and our news reporters must learn to ask about and highlight each candidate’s character and skills, and to refuse to rely on the overused and under-explanatory focus on age.
Joanne Lynn, M.D., is a clinical professor of geriatrics and palliative care at the George Washington University. She has authored hundreds of articles and books, including the “Handbook for Mortals,” and she is now working to improve the financing of long-term care with federal catastrophic long-term care insurance.