At the Democratic National Convention in Chicago on Monday night, President Biden took the stage at 10:26 p.m. Central Time to a four-minute-long standing ovation. Throughout his historic 50-minute address, his voice was strong, albeit emotional at times. He was focused and able to connect the dots as he moved from topic to topic. Though he read from a teleprompter, he was able to improvise as well. It was the last hurrah for a president who has spent more than half a century in public service.
Contrast this with the presidential debate that occurred on June 27. The nation was stunned by the frail man who struggled to offer coherent answers. Within weeks, the sitting president had stepped aside as his party’s candidate for re-election. The entire political landscape dramatically changed at that point.
So, what happened? How can we reconcile these two vastly different performances in a short time frame? And what does it mean for the rest of Biden’s presidential term?
In the aftermath of the debate, many scoffed at the administration for saying that the president merely had a cold. Instead, observers suggested that he was suffering from an underlying dementia.
But as a geriatric psychiatrist, I think something different was happening. During the debate, Biden may have been suffering from delirium. These two conditions are not mutually exclusive and often coexist in the elderly, but delirium may be a more precise explanation for what the nation observed that evening.
While it would be both impossible and unethical of me to offer a definitive clinical diagnosis — many relevant clinical details would be needed to do that — I think delirium is a plausible explanation, especially considering that he functioned relatively well before the incident and recovered from that state over the next few days. It is a legitimate clinical prism through which one can view the presidential debate of June 27, one that might also offer some comfort to anyone concerned about Biden making it through the rest of his current presidential term.
People often use delirium to mean a complete disconnection from reality, but it isn’t always so dramatic. It is defined by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders as an acute (sudden) change in attention and awareness that develops over a short period of time and is associated with additional cognitive deficits such as memory, disorientation, and language and perceptual disturbances. Its sine quo non is the reduced ability to direct, focus, shift, and sustain attention. It typically lasts for a few hours, on and off, to a few days, but can go on for several weeks.
Delirium results from a sudden change in brain physiology brought on by a variety of causes. They include medications, withdrawal from substances including alcohol, infections, and diseases in other organs such as the liver. It is a clinical manifestation of physiological changes in the brain that can resolve over time. The nature and duration of the delirium reflect the underlying condition.
I am frequently called to provide a consultation on patients whose mental status and behavior change suddenly when hospitalized on a medical or surgical floor. The request for a consultation is typically because of disruptive behavior like pulling out intravenous lines, disorientation, or attempts to leave the hospital. Delirium will typically wax and wane: The behavioral changes that characterize delirium can come on suddenly, linger for a few hours and disappear. Major drops in attention and concentration are difficult to conceal in high-profile public settings — say, a debate stage — and may raise considerable alarm and concern. A few hours or days later, their behavior may return to baseline, though the delirium could reoccur. It’s clinically unpredictable, as much of it depends on the underlying cause.
When someone is in an episode of delirium, they appear very different from their baseline state. Behavior, during these episodes, is often described as “out of character.” Their sleep-wake cycle is often disturbed — a bit like jet lag. Patients may also actively hallucinate, become paranoid and become violent. After the episode resolves, they often have little recollection of or insight into what happened.
Mark Twain once wrote about growing old: “It is sad to go to pieces like this, but we all have to do it.” Age is an important risk factor for many brain disorders, including dementia and delirium. Delirium is more often seen in the elderly, and additional risk factors include frailty, compromised immune status, and underlying brain compromise secondary to a stroke, and degenerative disorders such as Parkinson’s or Alzheimer’s disease. These factors make one more vulnerable to the physiological brain changes that may then lead to delirium.
Delirium is common in hospitalized patients. Up to 80% of patients in the intensive care unit develop delirium at some point. On geriatric medicine and psychiatry inpatient units, the most common cause of a sudden change in behavior in a previously stable patient is delirium, often related to an infection, urinary tract or respiratory. We see it all the time!
Outside hospital settings, even seemingly benign conditions, like the common cold, can create a perfect storm that can tip a vulnerable individual to a delirium.
According to the Centers for Disease Control and Prevention, rhinoviruses are the most frequent cause of the common cold. While most rhinovirus infections cause mild symptoms, they can also cause severe illness, especially if you are frail, have a weakened immune system, or have another underlying medical condition. All colds are not the same, and a severe form of the infection can precipitate a delirium.
We may never really know what happened to President Biden on that debate stage. Given all of the developments since then, it may feel like ancient history, but it was less than two months ago — and, perhaps more importantly, it likely changed the course of history. It is important to draw back the curtain now and examine these events more objectively.
In December 2023, Queen Margarethe of Denmark announced that she would be stepping down from her role after serving her country for 52 years. In her farewell speech, she said “the time takes its toll, and the number of ‘ailments’ increases. One cannot undertake as much as one managed in the past.”
Biden probably fought through colds and jetlag all the time for most of his political career. But sometimes, as we age, a cold is no longer “just” a cold.
Anand Kumar, M.D., MHA, is a professor and head of the department of psychiatry at the University of Illinois in Chicago; and past president, American Association for Geriatric Psychiatry.
