Our aging candidates spark a valuable discussion on brain health

We need to prevent injury and protect our brains at every stage of life.

When is someone too old to do a job? How do we assess competency? 

These questions are now being asked with a heightened sense of urgency for two men who will be in their 80s if they are elected to a second presidential term. This is an age when people are well into their retirement — focusing on quality time with their families and communities while cementing their legacies, providing wisdom to the next generation and enjoying the fruits of their labor.

We show photos of how the presidency can age an individual — new tufts or even loss of white hair, wrinkles etched into shrunken faces and dark circles under tired eyes. The ultimate example of this accelerated aging process is no better reflected than in the death mask of President Abraham Lincoln, a 56-year-old man, who shouldered the burdens of a young country at war with itself. 

The presidency is often declared the hardest job on the planet. Yet, we have never really established what the physical and psychological requirements are to do this job successfully. Political pundits debate these issues. The public jokes about them. Physicians write articles about potential pathology evident in candidates. However, there have been no formal efforts to determine the metrics to be used.

Presidents end their oath for service with "to the best of my ability." But what is that ability? Should there be age-specific ranges? American presidents have faced a plethora of health conditions from paralysis, endocrinopathies, cardiac abnormalities, malignancies, gunshot wounds and even dementia. 

It is believed that President Ronald Reagan began showing signs of Alzheimer's disease during his second term. He shared his diagnosis with the nation in his poignant farewell letter after he left the presidency. 

Many were shocked to learn that he had this disease since he performed well, especially in scripted moments fitting of a prior acting career, and this was before the onslaught of social media to track every comment. Yet, did this decline in cognitive ability, even if mild, impact his comprehension of complex situations and decision-making? 

Recently, this issue has come to the forefront with the release of special counsel Robert Hur's report, which commented on President Biden's age and poor memory regarding dates, including the death of his son. One wonders how many people can't recall the dates of their loved one's passing but can remember every detail of their surroundings and the despair that filled their hearts at this tragic time. Not remembering dates around highly emotional events is a weak indicator of impairment. 

What was concerning about this report was the connotation that age is a medical condition and individuals with zero medical training are diagnosing others as armchair physicians, which can have a deleterious impact on lives and careers. In this case, statements and questions are often used to discriminate. 

It's not unreasonable to ask if a surgeon can operate, a pilot can fly,  a person can drive or a president can make cogent decisions at an advanced age. Their actions can impact safety. But we must ask if these capabilities are chronological age-dependent or biological age-dependent and if there is a correlation between the two. 

Additionally, we know that hand-eye coordination, muscle strength and bone mass can decline and vessels harden with age. But knowing what actually impacts human performance and how we quantify it are complex questions that require unbiased and apolitical subject matter experts to answer.

A positive outcome from this report is to have an honest discussion on brain health just as we do for other health issues impacting all of us. The brain is a critical organ that dictates how we live our lives. Everything is dependent on it, including how we determine if a person is alive or dead (brain death). 

Prevention, diagnosis and treatment of brain-related conditions are frequently associated with a sense of fear and dread that is there very little we can do. We try to make light of it and ease our anxiety by viewing a decline in brain or cognitive function as the embodiment of aging — the "senior moment" when one forgets, but with a laugh. 

Yet, we know now that our environment, genes, behavior and lifestyle can significantly influence how our brains change over time. Ironically, while the public fears dementia or neurocognitive impairment, one of the most significant risk factors for it is spreading freely throughout society — the SARS-CoV-2 virus which causes COVID-19. 

This is not a plot in horror films. We are seeing a buildup of "zombie" or senescent cells in infected brains which accelerate brain aging. These cells are damaged but refuse to “die” or be removed — building up in the brain and causing more inflammation and harm.

Studies are showing that this coronavirus, like viruses such as HIV, is neurotrophic — infecting and damaging brain and nerve cells. This may lead to premature dementia and other neurological conditions. Even mild infections across the lifespan, including in childhood, can result in cellular damage and the effect of multiple infections is cumulative. 

After the acute infection, many patients complain of brain fog, memory and attention lapses, challenges with finding words and multi-tasking and even personality changes. Some recover over time from this form of long COVID; however, the long-term impact is unknown.

In healthcare, we monitor vital signs as indicators of well-being. We obtain lab tests to assess for conditions that can lead to disease and we educate patients on how to modify behavior for better outcomes. 

One area that needs more attention is brain health. We need more sensitive, inexpensive and easy-to-administer tools to screen and diagnose brain conditions at an early stage and treatments to slow down or reverse the findings. Studies from microgravity in space have shown that the brain can rewire to a changing environment — a form of neuroplasticity. We need to explore how to maximize this capability on Earth.

Most importantly, we need to prevent injury and protect our brains at every stage of life. We are never too old to begin.

Saralyn Mark, MD is a geriatrician and endocrinologist and a former senior medical advisor to the White House, the Department of Health and Human Services and NASA. She is the American Medical Women's Association-Covid-19 Lead and a strategic advisor for Human Health and Performance for the Charles F. Bolden Group.