by Jedediah Smith
Introduction
Mr. Biden presented to a neurologist at age 81. He had expressed no particular concerns, but his chief of staff had urged him to visit a doctor for evaluation of what he noticed as difficulties with verbal communication over the previous 4 years. In particular, his chief said that he seemed to have difficulties finding words during speeches, frequently using the wrong words and having trouble remembering names. When questioned, Mr. Biden admitted to some problems of this nature; he estimated the problems had been ongoing for “about 7 years.” Which is true. That’s when I arrived. I am Joe’s senile psychosis.
The neurologist elicited a detailed history of Mr. Biden’s cognitive and social functioning and found only mild changes in his activities of daily living or his social functioning. Mr. Biden still handled the ceremonial duties without noticeable problems. He performed well-learned chores without difficulty but increasingly asked his staff for instructions, particularly when faced with more daunting or less familiar tasks. He dressed, ate, and performed usual self-care tasks, such as shaving and toiletry, without prompting. He continued to work in his long-time profession as a government employee, although he may have experienced some mild difficulties at his job. For example, he complained that his writing was slower, messier, and more difficult (dysgraphia). Also, he couldn’t understand “the logic” of what some people said to him. At a recent summit meeting, he wandered about in a confused state when he was supposed to pose in a group picture. That’s because I led him around by the hand. I am Joe’s senile psychosis.
Only when questioned did Mr. Biden express any concern about memory. In retrospect, he and his wife both noted some short-term memory loss; for example during a press conference he shook hands with Senator Schumer, and then only moments later tried to shake his hand again, seeming baffled when the senator did not acknowledge the attempt. His ability to remember the content of recent conversations had also degraded. Mrs. Biden mentioned that he had become somewhat more repetitious (perseverative) and tended to dwell on past events. She noted that during a fundraiser, Mr. Biden repeated the same story about the events of Charlottesville in 2017 “nearly word for word” just minutes apart. He expressed less interest in new things or activities, and also seemed somewhat more irritable than he used to be, telling one periodical, the New York Times, thathe was ”frustrated’’ and ”angry as hell’’ about another, Newsweek. I don’t get angry myself; I just make Joe angry. I am Joe’s senile psychosis.
Medical History
Mr. Biden suffered from hyperlipidemia and was prescribed medication for it. In 1988, he had undergone surgery for an aneurysm which had burst and was leaking blood around the base of his brain. Surgery was successful though Biden experienced a second aneurysm and a significant blood clot in his lung, resulting in ongoing treatment with Apixaban. Some people who have had aneurysm surgery do experience longer-term health repercussions, but it is unknown whether this is relevant to his current mental condition. That is, it cannot be confirmed medically. But I know. I am Joe’s senile psychosis.
Social History
Mr. Biden completed college and claimed that he finished in the top half of his law school class, although records indicate he finished near the bottom, graduating 76th in a class of 85.
He had no recent history of tobacco smoking or alcohol use, avoiding it due to a family history of alcoholism.
Family History
Mr. Biden’s mother died at age 92 of a serious but undisclosed illness. His father died at age 86 of brain cancer. His oldest son also died of brain cancer at age 46.
Neurological Examination
Mr. Biden suffered from mild difficulties in concentration and attention in a neurological exam. For example, when asked to recite a web address, he could not identify a period and instead spelled it “D-O-T.” Language was also abnormal; he frequently used the wrong word in his spontaneous speech and when answering questions. These errors of expression (paraphasia) consisted of both words that sound similar to the correct word and those that are in the same category as the correct word. For example, when trying to name a pictured pretzel, he called it a “bagel.” He had significant difficulty naming pictured objects (anomia); he was often able to describe the object but unable to say the correct name. In some cases, he used sounds to describe objects, for example, describing a tennis racket as “phut” and America as “ASUFUTIMAEHAEHFUTBW.” I taught him that word. I am Joe’s senile psychosis.
He had some difficulty repeating a complicated sentence. Comprehension and simple reading and writing were unimpaired. He was somewhat disoriented in that he could not name the address where he was being examined, although he was able to state the day, date, and time. Memory testing showed significant impairments. He was unable to remember several objects shown to him a few minutes earlier. He was also unable to remember items of general knowledge, such as the names of recent presidents of the United States. His arithmetic abilities were impaired; he was unable to perform multiple subtractions or sum up several numbers. Thus, although Mr. Biden presented himself as a sympathetic, well-meaning, elderly man with a poor memory who was generally unaware of his impairments, a neurological examination revealed that he suffered from abnormalities in a variety of cognitive functions. I’m the one who robbed Joe of his mental state of willfulness. I am Joe’s senile psychosis.
The remainder of the neurological examination was normal. A slight tremor was present in the arms when outstretched, but this was judged to be either physiological tremor or a mild degree of benign essential tremor. The general physical examination was unremarkable. Most people are unremarkable. I should know. I am Joe’s senile psychosis.
Clinical Diagnosis
Mr. Biden was diagnosed with senile dementia arising from a brain disorder caused by trauma from his multiple aneurysms. In such cases, senility is generally not reversible. The examination showed that his memory was severely impaired, which is most consistent with SD. In addition, he displayed prominent language problems. No evidence from the neurological examination or from associated laboratory, electrophysiological, or brain imaging studies suggested any other brain disorder. Nope, just me. Joe’s senile psychosis.
Prognosis
The prognosis is that the patient’s cognitive abilities will continue to decline; his thinking and memory progressively worsen. For example, over the next 4 years after his presentation, his performance on word-generating tasks will drop. Conversation will become increasingly difficult for him, both in making himself understood and in understanding others. His cognitive changes will increasingly frustrate him. He will become more confused. His posture will change as well; he will become somewhat stooped and develop some stiffness in his limbs. He will start having some unexplained falls. He will begin to lose control over urination. During years three to four, he will increasingly suffer from agitation and require hospitalization for outbursts. He will no longer follow instructions or express himself verbally in a meaningful way. He will become completely disoriented to both place and time. If he develops a fever, indicative of infection, within a month, he’ll die.
And so will I. But that’s ok. That’s what I’m here for. I am Joe’s senile psychosis.
Jedediah Smith 