President Biden’s debate performance: episode or condition?

Former House Speaker Nancy Pelosi, D-Calif., said that it is valid for people to ask whether Joe Biden’s June 27, 2024 debate performance against Donald Trump, which was weak at best and incoherent at worst, was just “an episode” or part of a “condition.”

“I think it’s a legitimate question to say, is this an episode, or is this a condition,” Pelosi remarked less than a week after the debate.

“It was a bad episode, no indication of any serious condition,” Biden told ABC News’s George Stephanopoulos in an exclusive interview eight days after the debate. “I was exhausted. I didn’t listen to my instincts in terms of preparing, and it was a bad night.”

Biden took the bait that virtually everyone else swallowed except perhaps those in the medical field who understand and can distinguish between an “episode” and a “condition.” Critics failed to adopt a perspective that acknowledges the complexity and variability of many medical conditions, which often present with both chronic and acute components.

A “condition” typically refers to an ongoing, underlying health issue that persists over time. Examples include diabetes, hypertension, and chronic obstructive pulmonary disease (COPD). These conditions are characterized by their long-term nature and the need for continuous management.

An “episode,” on the other hand, usually refers to a specific, often temporary event or flare-up related to a condition. For instance, a hyperglycemic crisis in a person with diabetes, a hypertensive emergency in someone with hypertension, or an acute exacerbation of COPD are all episodes. These episodes represent acute, often severe manifestations of the underlying chronic condition.

Here are some examples to illustrate this interplay:

1. Asthma. Asthma is a chronic respiratory condition characterized by inflammation and narrowing of the airways. Patients with asthma live with the condition long-term, but they can experience acute episodes known as asthma attacks or exacerbations. These attacks are periods when symptoms suddenly worsen, often requiring immediate medical attention.

2. Rheumatoid Arthritis (RA). RA is a chronic autoimmune condition that affects the joints. Patients with RA have ongoing joint inflammation and damage. However, they can also experience acute flare-ups where symptoms like pain, swelling, and stiffness intensify, necessitating adjustments in treatment or more aggressive therapy.

3. Heart failure. Heart failure is a chronic condition where the heart’s ability to pump blood is compromised. Patients manage their condition with lifestyle changes and medications. However, they can experience acute episodes of decompensated heart failure, where symptoms such as shortness of breath, edema, and fatigue suddenly worsen, often requiring hospitalization.

4. Diabetes mellitus. Diabetes is a chronic metabolic condition characterized by high blood sugar levels. While patients manage their blood sugar levels daily, they can experience acute episodes such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), which are serious and require urgent medical intervention.

Mild cognitive impairment (MCI) fits well into the paradigm of chronic conditions with potential acute episodes. MCI represents a chronic neurological disorder characterized by a noticeable decline in cognitive abilities, such as memory and thinking skills but does not significantly interfere with daily life. This chronic nature means that individuals with MCI are at a heightened risk of developing more severe cognitive disorders, like Alzheimer’s disease or other forms of dementia.

However, individuals with MCI can also experience acute episodes or exacerbations, often triggered by other factors. For instance, an acute illness or infection, such as a urinary tract infection or pneumonia, can temporarily worsen cognitive function, leading to delirium or acute confusion. This state is often reversible with the treatment of the underlying illness.

Medication effects can also play a role in acute cognitive impairment. Certain medications, especially those with anticholinergic properties or sedatives, can acutely impair cognitive function in individuals with MCI. Adjusting or discontinuing these medications can sometimes reverse the cognitive decline.

Psychosocial stressors, such as the loss of a loved one or significant life changes, can temporarily exacerbate cognitive symptoms. Similarly, metabolic imbalances, like dehydration, electrolyte disturbances, or poorly controlled diabetes, can lead to acute cognitive changes. Addressing these imbalances can often improve cognitive function.

Management of MCI involves strategies to slow the progression of cognitive decline and enhance quality of life. This includes lifestyle interventions such as regular physical exercise, cognitive training, and a healthy diet, as well as medical management of cardiovascular risk factors like hypertension, diabetes, and hyperlipidemia. Regular cognitive assessments are also important for monitoring progression to more severe cognitive impairment.

When pressed by Stephanopoulos, Biden declined to commit to taking a cognitive exam, suggesting that his schedule and daily workload are evidence enough that he’s up to the task of being president. He also implicated his recent demanding travel schedule abroad and a “cold” as reasons for his debate meltdown. I’m not saying Biden has MCI, but if it were true, it could be managed just like exacerbations of other chronic illnesses.

Preventing acute episodes of confusion involves prompt treatment of infections and illnesses, regular review of medications to avoid those that may impair cognition, and providing psychosocial support to manage stressors and ensure a stable environment. Understanding and managing both the chronic aspects of MCI and its potential acute episodes are essential for providing comprehensive care to individuals with MCI. This approach aligns with recognizing the interrelated nature of chronic conditions and their acute manifestations in medicine.

Chronic conditions often serve as the backdrop for acute episodes. Viewing them as separate entities oversimplifies many medical conditions’ interconnectedness and dynamic nature. It is well understood in clinical practice that patient care often requires a nuanced approach that considers both chronic and acute aspects of a condition. Understanding this relationship is crucial for comprehensive treatment, as it highlights the need for both long-term management strategies and acute intervention plans.

Reflecting on the 2024 presidential election, we might recognize the significant error made by Biden and his team in allowing themselves to be constrained by an “either/or” stance, essentially falling into a false dichotomy forced to decide between an “episode” and a “condition.” While there are effective strategies for managing chronic conditions such as MCI, there is no way to prevent a pathological liar from persisting in their deceit.

Arthur Lazarus is a former Doximity Fellow, a member of the editorial board of the American Association for Physician Leadership, and an adjunct professor of psychiatry at the Lewis Katz School of Medicine at Temple University in Philadelphia, PA. He is the author of several books on narrative medicine, including Medicine on Fire: A Narrative Travelogue and Narrative Medicine: Harnessing the Power of Storytelling through Essays.

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