Frail, Stressed, Stiff, and Blinking: An Aging Expert on Biden’s Shocking Debate

Joe Biden’s disastrous debate performance against Donald Trump has prompted widespread concerns about Biden’s age, his mental and physical fitness to be president, and whether he has got what it takes to lead the Democratic Party and defeat Trump in November. A torrent of post-debate reporting has additionally revealed that for some time, numerous people who have closely observed or had private interactions with the president have themselves witnessed evidence of accelerating age-related decline. Biden and his aides, however, continue to deny these accounts, and they insist he’s plenty fit to serve and win his reelection campaign.

What no one can deny is what tens of millions of people saw for themselves during the debate. By now we know a lot about what pundits, editorial boards, unnamed Democratic lawmakers, panicked donors, Biden’s family, and thousands of poll respondents thought about the debate, but how worrying was Biden’s performance to someone who studies aging? Do any of the Biden team’s subsequent explanations for the debacle line up with the science? Does our 81-year-old president need to be tested for a movement disorder? To find out I spoke with Steven N. Austad, author and distinguished professor of biology at the University of Alabama at Birmingham, where he holds the Protective Life Endowed Chair in Healthy Aging Research.

In a few interviews last year, including one with my colleague, you convincingly explained why voters shouldn’t worry about Biden’s health or capabilities just because of his age, and said that you didn’t think age would be major factor in the 2024 race unless something dramatic emerged. You also said that “the pressure and the grueling pace of presidential campaigns” would “tell us quite a bit” about the candidates’ health. Biden’s recent debate meltdown seems to have been a textbook example of both scenarios.

You viewed the debate twice, once with the sound on and once with the sound off. What were you watching for, as an expert on aging, and what did it tell you?
Well, the first thing I did was I watched very carefully how they walked in to the lecterns, and Biden actually walked in faster than Donald Trump did. But once he got to the lectern, he was very stiff, his voice was very husky, he didn’t have much in the way of facial expressions. And to me, it looked like somebody who we would say is frail. Frail being a scientific term. And relative to what I saw for the State of the Union address, which wasn’t all that long ago, there’s been a fairly dramatic change.

Now, I have to say that this is only one instance, but I’ve said all along that in most presidential campaigns, you learn virtually nothing about the candidates from pretty much everything, but that this one would be different because we’d be able to see the candidates under some stress. And one of the things that we lose with aging is our ability to recover from stress. And it looked to me like Biden was very stressed. He was blinking a lot when he was talking, and it was shocking to me, the difference between that appearance and his appearance during the State of the Union.

I almost thought that maybe he was over-prepared, that he’d been practicing so much that he was trying to mention and remember every single statistic that everyone had told him he had to bring out. And there was nothing spontaneous. It was like somebody had turned on a switch and he was going through all these thoughts and they were pretty disconnected. We’re used to Donald Trump having disconnected thoughts but Biden doesn’t usually do that the same way. He may stumble over a word, but in the debate he stumbled over a lot of words.

One of the many explanations Biden and his team have put forth for his poor debate performance was that he overprepared. They’ve also said he had a cold, and that he hadn’t been able get enough sleep or recover from his recent Europe trip, which ended more than a week beforehand. Have any of those explanations made sense to you?
No, they haven’t, especially because he knew coming into the debate that his age was an issue. So if you were ever going to exaggerate the energy and vitality that you have, that would be the time to do it. And there was just no evidence of energy. This concept of frailty, which is a medical term, one of the things is low energy. Even his talking voice, sometimes it was not that easy to hear. And then he was staring down at his notes all the time. I mean, it was a shocking performance to me.

Now, I have to say, there was nothing in the performance that made me think that he’s not capable of doing what he needs to be doing at this time. But I’m thinking if this is something that really is that different between the State of the Union and now, thinking a year or two into the future, it’s very disconcerting.

Dr. Sanjay Gupta has written an op-ed in which he says, citing conversations he’s had with other brain specialists who watched the debate, that “the president should be encouraged to undergo detailed cognitive and movement disorder testing, and those results should be made available to the public.” Do you agree with that?
I do, but I think in all fairness that the other candidate ought to agree to do the same. In fact, what my suggestion throughout all of this has been is that we ought to have an independent panel of physicians that do the presidential physical examination every year, and we get full reports on it, because the president’s or the candidate’s personal physicians are not likely to be open and honest if there are disturbing things to report.

But that’s an excellent idea. In fact, my thought is if he wants to come back from this, I mean… There’s another debate, he’s having this [ABC News] interview. If this was a one-time-only thing because of travel or any of that, which I don’t believe, then he ought to be a lot different in a casual conversation. But it just seemed to me that he was trying to spit out all these things that he had memorized, and he was having a really difficult time doing it. Whereas Trump was spontaneous — it was one non sequitur after another, but he had some bluster and hand gestures and all the things that showed more energy than Biden did.

It also seemed like maybe this was the first debate that Trump had really prepared for, like he was a little bit more disciplined, though maybe that’s just because they were shutting his mic off all the time, or because Biden was such a mess.
Yeah, I have a feeling it had to do with the fact that he knew he was not going to be able to run around the stage and do the kind of stuff he’s done before. Listening to Trump — he’s been doing this for a long time now, these rants where he interrupts himself halfway through a sentence. He starts off with something, and then says something else. People are used to that and they expect it of him. But for Biden, it was really worrisome. From just a medical perspective, looking at him today versus a few months ago is very concerning. A movement disorder examination would not be a bad idea, if he wanted to reassure people. That’s one thing he could do, if you could have it in a believable context, if it wasn’t by personally chosen physicians.

What kind of movement disorder should they be looking for?
Parkinsonian disorder. Because he had that frozen-mask face. I’m certain that’s what the neurologists [Gupta spoke with] were thinking of when they suggested that he should be evaluated for cognitive and movement disorders.

When you spoke with my colleague a year ago, you emphasized that Biden has always had speech issues — between his stutter and his gaffes and such. But it seems like what we saw at the debate, and what people have been reporting about private interactions with him, is something very different.
Yes. This didn’t seem like that. Before when he’d do this, he’d sometimes make a joke out of it. He just looked incredibly stressed to me. He was really worried that he was going to do something dreadful — which he did, actually — but the amount of blinking that he did when he was thinking, that’s a sign of stress and anxiety.

If this was a temporary failing because of whatever, he’s going to have some chances to show that. But it didn’t look to me like something that was going to turn around, just because he knew this is the time he had to look vigorous, he had to look together. I’m sure he knew that it was the most critical thing going into this debate — to look like a vigorous 81-year-old, not like a frail and feeble 81-year-old.

Right after the debate, Biden appeared at a small rally and looked and sounded like a different person, and then again at a campaign event the next day where he was far more animated and coherent. It was a stunning contrast, and prompted many to wonder where that Joe Biden was during the debate. One of the possible explanations was that when he’s using a teleprompter, he doesn’t seem to have the same problems.
I read about [those post-debate appearances,] but I haven’t seen them. If that’s true, then that puts a different light on it. Also, if that’s true, we’ll see it in his conversation with Stephanopoulos. But I’m dubious about these sorts of things. Certainly it would be useful for him to have a teleprompter, but if he can’t have a casual conversation and sound in command, that’s going to be really worrisome.

And now, obviously, everything he says and does, how he appears and sounds, is going to be under a microscope.
Every time he does one of his verbal blunders, now it’s going to be magnified. Again, he’s had those issues for years, but this seems like something different. Repeatedly mistaking billion and trillion, that kind of thing, that’s a little bit different. When’s the next debate?

September, if they hold it at all.
Oh, it’s a long time.

And if Biden is still a candidate at that point.
If I were him, I would want to have a full cognitive and movement disorder evaluation, even if I didn’t release it to the public, just so I’d have better information about what I’m going through. Because unless [the debate] was a real aberration, it’s very worrisome.

The Biden camp has been trying to set up opportunities — including interviews, campaign events, and Biden’s big ABC News interview — for him to demonstrate that the debate was an outlier. What will you be looking for in those public appearances?
I’m looking for him to not look scripted. As long as he’s reading off a teleprompter, I don’t think we can tell much. I would certainly watch his facial expressions, which seemed pretty frozen to me. I’d watch his gestures, he seemed very, very stiff. Those are the main things. His gait is always going to be shuffling. Like I said, he came onto the debate stage faster than Trump did. But from that point on, he just looked down all the time. I guess he was either thinking or reading notes. It was very distressing to see.

According to some of the reporting since the debate, Biden now has good days and bad days, and the ratio may be shifting. One of the biggest concerns is that he is experiencing some kind of rapid decline. What are the warning signs of that?
Well, I mean we saw a lot of the warning signs of that. And again, it’s a question of whether these are one-time-only events. Which I doubt, but it’s possible, I suppose. This is the kind of thing that happens with aging or even with specific neurological diseases. There are good days and bad days, but the bad days become more and more common and the good days become less and less common. I’d say we probably have the next week to figure out whether there’s any possibility that he can go ahead and finish out the campaign.

It’s an unprecedented moment in presidential politics, to say the least.
I think at the congressional or senatorial level, we’ve seen this before. But at the presidential level, no. I mean, I can’t imagine Biden sitting with other world leaders in a conference and behaving like he behaved on debate night. That would be very disturbing to them, I’m sure.

According to multiple reports, foreign officials have already noticed his apparent diminished capacity in person and have expressed their concerns.
Those are credible reports. I’m a little bit suspicious of the motives of all of this reporting, but there’s been such an avalanche of it from all angles that it’s made me think there’s probably something to it. It hasn’t just been Fox News, it’s been the Washington Post.

You’ve said before that you thought that the White House was doing a pretty good job of being transparent about Biden’s health, as far as releasing his medical reports and what information they include. Biden’s last medical report, which came out in February, said he was “fit for duty.” Are you more skeptical about their transparency now?
No. They’ve released really solid figures, but what that suggests to me is that there’s been a dramatic change between February and now. And that happens. That’s one of the things about aging, that things can change much more rapidly and dramatically than they would in a younger person. And so I would like to see something from them about his status now. And certainly, if this kind of performance is repeated in any other venue when he’s not reading off a teleprompter, then I’d say he really needs to be evaluated again. And I’m just wondering if he’s now got some issue, and they’re just not releasing it. I mean, it’s easy to release good news, that’s no problem.

How much do you think ageism has played a role in the post-debate fallout?
It’s always in the background, but I think at this point there’s been justification for all these questions that have come up. I think ageism was a large part of all the conversation before, but it’s all been pushed into the background now by actual evidence. I’ve always said there are 81-year-olds that run marathons. There are 81-year-olds that write historical tomes. And there are 81-year-olds that can’t get out of their wheelchair. Biden used to seem vigorous for his age; now he doesn’t, and at a time when he knew he needed to appear younger than his age. ​​We’ll see. I mean, if you get him away from the teleprompter and he seems in command of the issues and he seems to have some energy and some humor and some gestures — this is the movement disorder thing, is you want him not to be so stiff.

How do you think it affects the public’s perception of aging, that this has, for now, become the number-one issue in arguably the most important presidential campaign in memory?
Unfortunately, I think the focus is going to be entirely on the negative aspects of aging. And the things that have worked to Biden’s advantage in the past — experience, making wise decisions under difficult conditions — those things are going to be forgotten now, I’m afraid. It’s all going to be, “Well, what do you expect of an 81-year-old?”

Soon after the debate, as the calls for Democrats to replace Biden began to multiply, Franklin Foer wrote a piece for the Atlantic arguing that it was time for somebody to take away Biden’s keys, citing the dynamic families face when an elderly relative is no longer able to drive safely.
I did it with my mother.

Yeah, it’s not something I’m looking forward to having to do with my parents, who are also in their 80s and don’t run the country. But that’s what it inevitably comes down to, right? It’s family members who need to lead these efforts, even when it’s the president.
I would hope that his wife is paying a lot of attention to this, because she’s got to see him in times when nobody else does. And I just hope that she’s not just blindly loyal to him, regardless. It sounds like he’s not inclined to drop out, but maybe if his wife, his close friends, his longtime advisors say, “Look Joe, this is not going to end well. And if you want to preserve your reputation, people remember all the good stuff you did — maybe it’s time.” We’ll see.

Biden’s aides and allies keep complaining that the attention on his age and fitness for reelection is unfair. But it’s also unfair to continue to expect someone to do things at an advanced age that they might not be capable of doing anymore. Putting the politics aside — if Biden really can’t do this, imagine how bad he’s going to feel if the rest of his campaign is a rolling disaster and then he loses. We don’t just take away someone’s keys to protect others.
Exactly. I would hope that people who have his best interests at heart, and who see him in private moments, would be honest with him.

I originally spoke with Professor Austad shortly before Biden’s big ABC News interview aired on Friday. He emailed afterward to let me know that, “Despite what the post-interview commentators said, I did find Biden’s interview somewhat reassuring. Still, it’s a sample size of two. The coming weeks should be revealing.”