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Donald Trump has been acting a little weird lately, even for him. During a speech he gave in Davos, Switzerland, last week, he kept mixing up Iceland and Greenland. Mistaking one country for another is far from abnormal for him, but it is a touch odd, considering his current obsession with Greenland. An obsession which, as he very publicly wrote to the Norwegian prime minister, is related to the fact that he wasn’t awarded the Nobel Peace Prize—a bizarre conflation, given that Greenland is a Danish territory, not a Norwegian one. During a recent meeting with oil executives, he spontaneously stood up, walked over to the window to gaze at his ballroom construction project, then returned to his seat. When someone fainted in the Oval Office in November, he barely reacted. He’s been dozing off in meetings, which led Dick Cheney’s doctor to call for a medical evaluation. (Then again, it’s hardly the first time he’s slept in public.) He recently underwent advanced imaging of either an MRI or CT scan, neither of which is standard preventive care. And his speech continues to descend into gobbledygook.

Some of the recent episodes have reinvigorated the conversation of whether it’s just Trump being his unfiltered, unbothered Trump self or if it’s possible that, at 79 years old, he’s showing signs of cognitive decline or even dementia. Joe Biden faced similar speculations during his run for a second term (which, it later came out, were well founded: Biden had been declining due to his age more than was let on). It’s impossible to diagnose a person without a personal examination and full medical history. But I called up some experts to learn more about what behaviors tell them that a patient could be losing their mental faculties, and whether Trump might—perhaps—be displaying them.

In general, people follow three different trajectories of aging, explains Carolyn Aldwin, an aging researcher at Oregon State University. There’s normal aging, in which a little cognitive decline happens: The right word is often on the tip of your tongue, or you sometimes forget why you walked into a room. It becomes more concerning when these memory and attentional problems interfere with day-to-day functioning, like if you can’t remember how to get home, or you leave the stove on. That’s the second trajectory: mild cognitive impairment. Lots of factors can cause this impairment, and depending on the underlying factor, it won’t always be progressive or permanent. (For instance, urinary tract infections, certain medications, and vitamin B12 deficiency are all common treatable causes of cognitive impairment in aging adults.) If the cause of the mild cognitive impairment is neurodegenerative disease, though, that tends to be the start of progressive decline, says Stephen Gomperts, a neurologist who specializes in dementia at Massachusetts General Hospital.

Which leads us to the third trajectory, dementia, a broad umbrella term that encapsulates several diseases with different symptoms depending on which part of the brain is affected. The unifying criterion for dementia is that the person has lost independence, Gomperts explains. That benchmark can become complicated when a person receives social support from someone, like a spouse (or a presidential support team), but “the key is a change from baseline,” he says. “If a person always had everyone doing everything for them, then I don’t think you’d ever be able to tell.” That’s yet another reason why it’s hard to assess whether a public figure, whose support is behind the scenes, has dementia.

That leaves armchair doctors—and myself, a health journalist observing from her laptop—to evaluate the signs and symptoms. Dementia tends to be thought of mostly as a memory-loss disease, but there are many other aspects, including disorientation, difficulty balancing, poor coordination, trouble multitasking, confusion, wandering, apathy, irritability, impulsivity, poor judgment, and social inappropriateness. Some of these sound like Trump, don’t they? But fitting the symptoms isn’t so telling on its own, experts say. Here, too, it’s critical to consider an individual’s change from baseline. What indicates cognitive impairment in one person might be normal for another who has always been that way.

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I’ll emphasize again that it’s impossible to diagnose an individual from afar—but because Trump has been in the limelight for so long, there is some public record of his baseline and how it may have changed over the years. For instance, Trump was a very eloquent speaker back in the 1990s, with the ability to speak in whole paragraphs and make coherent arguments. Today, though, “he has really severe language problems,” Aldwin says. “He can’t complete sentences. He wanders off topic. He gets very confused.” A particular concern for Aldwin is that he frequently makes something called phonemic paraphasic errors, when a person substitutes a sound or syllable that resembles the intended word. For instance, during his Davos speech, Trump said of Venezuela: “We appreciate all of the cooperation we’ve been giving,” instead of (presumably) “given”—which then seems to lead him to change course into this odd addendum: “We’ve been giving great cooperation.” Could his trouble pronouncing acetaminophen be a phonemic paraphasic error? Maybe, the experts I spoke to said. But it could also be that he didn’t care to learn the word.

Apathy is another aspect of dementia. Indeed, many of Trump’s social behaviors—rudeness, hostility—can be present in dementia. But it’s difficult and subjective to try to parse what could indicate decline and what is just Trump’s personality (or personality disorder, as some have speculated that he has malignant narcissistic disorder). On one hand, certain things seem worse than usual: Though the president is a long-standing name-caller, calling a reporter “piggy” to her face was bad even for him. But it could also just be that, with few people standing up to him, he feels empowered to act however he wants, suggests Gill Livingston, a psychiatrist at University College London who led the Lancet’s commission on dementia in 2020. (And he has used the “pig” insult in reference to a woman before.)

Did he wander off during the oil executive meeting because he’s having attentional issues or because he was just bored? Did he stand awkwardly near the fainting scene in the Oval Office because he wasn’t fully processing what was happening or because he just didn’t really care? The mix-up between Greenland and Iceland might be out of the ordinary for a typical detail-oriented head of state, but that’s never been Trump. “You have to keep in mind that Donald Trump is an unusual person and always has been an unusual person,” says Livingston.

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Also, she points out, people have long speculated that the president might have dementia. (In 2017 STAT did a deep dive into his language struggles and explored whether cognitive decline could be behind them—most of the experts thought it likely that “something was going on,” whether that be dementia, normal aging, stress, or something else.) Different forms of cognitive impairment can indeed progress at different timelines. But if he had the beginnings of neurodegenerative-caused dementia back then, Livingston thinks, it would be impossible to hide by now. She says he would now be finding it difficult to write even an incoherent letter about the Nobel Peace Prize to a prime minister, for instance, or even to remember what the Nobel Peace Prize is.

That doesn’t rule out possible cognitive impairment or other types of disease. “He clearly has difficulties,” says Aldwin. “How severe those are can really only be established by testing.” And that, unfortunately, is unlikely to happen anytime soon.