Gee, Wouldn't It Be Bad if the President Had Alzheimer's Disease?

So why can't we talk about it?

The mental state of the President of the United States is important not just to the nation, but to the entire world. Ever since the Hur report came out allegedly about classified documents in Biden’s possesion, Biden’s mental state has been a hot podcast topic, but there is no measured and scientific discussion of this most serious topic. Alzheimer’s disease (AD) is a difficult disease to diagnose especially by people like me who have no clinical credentials and have never met Joe Biden. But I do know a lot about AD. Not only is it in my family, I’ve done a lot of research on the topic. So rather than say what Joe Biden may or may not have, I think it may be both interesting and alarming to consider what could happen if any person serving a term in the White House had AD.

Named after Dr. Alois Alzheimer, a German psychiatrist and neurologist, AD is a brain disease which cause brain cells to die, brain connections to shut down, and brain mass to shrink. The variable symptoms of AD occur depending on what parts of the brain get turned off. Once part of the brain dies, it never regenerates. It never gets better. The brain pathways or circuits cannot be re-routed.

Short-term memory loss occurs in the early stages of AD, but as the disease advances, major personality changes can occur as well. Speech can be affected (slurring of words) and people may make nonsensical statements or use the wrong words. There is impaired executive function, that is, the ability to make reasonable decisions and logical choices. Motor skills and walking can be impaired, and there is a typical stiff gait observed in AD patients. A person with AD loses their sense of direction and can be unable to judge volumes (such as how much coffee to pour into a cup). Eventually, people with AD cannot care for themselves or function; some people die of AD when their brain is so diminished it can no longer regulate even basic functions like breathing or heartbeat.

AD is a progressive disorder and there is no cure. There are a few treatments but none can actually stop AD, much less reverse it. Being progressive means that the person with AD will never be better in the future than they are at this very moment. There is no “better tomorrow” like you might have with a cold. A person with AD may plateau for a while, but they do not get better. Thus, a President with AD that is impairing his ability to fulfill the duties of his office today will be equally if not more impaired by AD tomorrow.

Agitation is a common symptoms as AD advances. This may result in a bizarre actions, such as verbal changes (screaming, yelling, making weird noises, emotional outbursts) as well as negativity and the use of inappropriate language. This can sometimes result in inappropriate physical acts, such as inappropriate touching, scratching, spitting, biting, hitting, throwing objects, or slamming doors. Sometimes the changes are more whimsical. My very no-nonsense grandfather got AD and used to sing childhood nursery rhymes. A President with AD might give a speech and then lapse into a creepy whisper-voice or he may say nonsensical things. He may struggle to find the right word and never actually find it. He may start to shout for no reason.

Sleep architecture (that’s the medical word) gets disrupted and people with AD may become extreme insomniacs or sleep much too much. Symptoms tend to grow worse at the end of the day; “sundowning” refers to extremely pronounced evening and night-time symptoms. A President with AD would have to schedule mostly daytime events to be at his best. A President with AD might fall asleep at important meetings.

In general, AD is a disease of old age. Early-onset AD occurs when AD is diagnosed in a person under the age of 65. There are extraordinarily rare cases of younger people getting AD such as the 19-year-old man in China who has had AD symptoms for the past two years. While there is a genetic mutation associated with AD, not all people with the mutation get AD and the majority of people with AD are not genetically predisposed to it. In short, we don’t know why some people get AD and others do not, just that anyone—and particularly people past the age of 80—can develop AD.

Dementia is the umbrella term; AD is a specific type of dementia but an exceedingly common one. About 60% to 80% of people with dementia have AD. Some people have more than one type of dementia at the same time and some people with pre-existing mental illness get AD. In such cases, the symptoms can be worse and may be more unusual.

One of the first symptoms of AD is relatively mild: short-term memory loss. Short-term memory loss can be impaired in otherwise healthy people when they are under a lot of stress, get sick, or are sleep deprived. Memory blips also occur with the natural course of aging. However, with AD these recent memories fade rapidly. This would make it hard for a President to follow negotiations or peace talks with foreign leaders; he would be unable to remember what was just said or who said it. It would be challenging for him to read a report, briefing, or book and recollect what was read.

Long-term memories, such as where you went to school, your birthday, or childhood memories are preserved longer, but will eventually fade as well. In the early stages of memory loss, people with AD become adept at hiding their memory blips (it’s called “masking”) but eventually memory loss becomes so severe it interferes with everyday activities. For instance, a President with memory loss might not recognize members of the press he’s known for a long time or forget key statistics or talking points when addressing the press. He might not recognize his own Cabinet members or know which Cabinet member is doing what. He may have a Secretary of Transportation who takes a two-month paternity leave and not realize he’s not in the office. A President with AD might have a Secretary of Defense who goes AWOL to have some medical procedure and never realizes he was gone.

AD also causes problems in finding the right words. A person with AD can stumble trying to find even common words, leading to long pauses which, in turn, cause them to forget what they were talking about. Sometimes a person with AD may use a completely wrong word, such as saying “ice cream” when they meant to say “nuclear disarmament” or “climate change” when they meant to say “bribe.” Math skills deteriorate and even those who once could add or multiply numbers in their head can no longer do even simple arithmetic.

AD also impairs judgment and makes it difficult for the person with AD to understand where the other person is coming from. A President with AD might think that his more than 170 suspicious activity reports (SARs) from banks are damaging but that he can hide them from the public. A President with AD might think no one realizes he is in cahoots with foreign governments.

Senses become impaired; AD is associated with a loss of the sense of smell. This can lead people with AD to prefer to eat bland foods or foods they remember fondly from their childhood, like ice cream. Rarely is a person with AD going to want to chow down on sushi or drink black coffee. A President with AD would love ice cream and consider it quite dignified to discuss nuclear annihilation while licking and slurping on a giant chocolate mint cone. (I prefer that people with the power to annihilate me not slurp on kid food in public.)

Decision-making becomes a challenge for people with Alzheimer’s disease, even for relatively easy things such as what clothes to put on in the morning or what to eat for lunch. Of course, a President with AD would have people to help get him properly dressed in the morning.

People with AD can struggle to concentrate when watching TV or reading. They mix up dates and times. They sometimes act inappropriately but they don’t mean to, such as laughing at the wrong thing or getting angry for no reason. But perhaps the best clue that a condition is Alzheimer’s rather than the normal forgetfulness that is part of natural aging is that these problems get worse and worse with time. A President with AD will make more flubs in next week’s State of the Union address than he did in last year’s speech.

The most worrisome effect of AD with respect to world leaders is impaired judgment. For ordinary people, impaired judgement may mean going out on a rainy day without an umbrella, but for a person with global responsibilities, this may mean dropping top-secret intelligence over a hot mike or deciding to evacuate Afghanistan abruptly without making proper plans to get everyone out safely. There are still Americans in Afghanistan, if they haven’t been killed, and there are still American hostages in the Middle East, if they haven’t been killed, but a President with AD would likely forget about them or not understand that having Americans held hostages abroad is a bad thing. A President with AD would not think it worth the bother to visit the site of a train car derailment in East Palestine, Ohio, and even after the fact as criticism mounted, a President with AD would not remember what happened there.

After a while, a person with AD does not know how to handle simple tasks, such as how to answer the phone. Ordinary objects may look strange and a person with AD may struggle to figure out how to open a can or make coffee, tasks they routinely did before. For a President, this may mean struggles with understanding how to use a teleprompter.

Motor skills deteriorate. This can mean that a President might stumble on the stairs to Presidential aircraft. People with AD lose their balance easily and might get distracted by seeing people and fall off a bicycle.

Inhibitions can drop as AD advances. This means that a person with AD might take off his clothes in public (not uncommon, by the way) or make lewd inappropriate remarks to a child or grab a person in a sexual way. A President with AD may be tempted to nuzzle, bite, kiss, or sniff small children or women around him.

People with AD are prone to delusions, which are wrong beliefs not supported by evidence or logical assumptions. It is common for people with AD to believe that something of theirs has been stolen and they may make startling accusations of improbable transgressions. Over time, a person with AD can become mistrustful of even those close to them and lapse into angry outbursts for no apparent reason. They can believe they are being mocked, abused, or cheated even by those who are devoting themselves to their care and well-being. A President with AD might lash out at his political opponents, calling them terrorists or a cult. A President with AD might become fixated with delusions that a certain political opponent is trying to “get” him and must be stopped at all costs. A President with AD might scream at his staff who show up to his meetings but not realize that some people have gone on the lam to avoid his mood swings.

Eventually, AD culminates into a period of depression, withdrawal, and inactivity. People with advanced AD often “go dark” for long periods of time. Ordinary people with AD might just spend a lot of time sitting in their room without any distractions or staring out of the window. A President with AD might need to take 40% of his term on “vacation” at places where there are no visitor logs. A President with AD might want to use taxpayer money to build a high privacy fence around his Delaware vacation home so nobody can see what is going on there (as he sits in a dark room and stares at the wall).

Medically, AD is characterized by gooey amyloid plaques in the brain; these are sticky tangles of fibers that wrap around brain cells and kill them off. Brain cells, which normally are quite talkative and communicate constantly with each other (even when we sleep) lose their ability to communicate or pass on information from one to another. The brain starts to shrivel up and die.

Other symptoms of AD include a stiff gait, loss of sensory perception (reduced ability to see and hear), and an inability to visualize spatial relationships (such as bumping into a table, not because it is not seen but because the person does not understand where he is in relation to the table). People with AD lose their sense of direction and can become very quickly disoriented in a new space. Bring a President with AD on stage in a room he has never been before and he won’t know how to get off stage. Even if you tell a President with AD as he enters the room what to do and where to go, his deficient short-term memory and his inability to navigate a new space will make it almost impossible for him to get off stage without being led.

Hallucinations can occur with even in mid-stage AD. A President with AD may be unaware of people around them but it is just as likely he may think that there are people around him who are not there. Such a President might hold out a hand to shake hands with a person who isn’t there. They also bungle people’s names, even if they were prompted or carry notecards with them.

People with mild to moderate AD lose an ability to handle money; they not only forget to pay bills, they do not understand money’s value and may grossly overestimate or underestimate prices. A President with AD may want to send hundreds of billions of dollars to Ukraine every other day, not realizing how much money that really is or asking for an accounting.

Paranoid symptoms occur in some people with AD. A President with AD may view the opposing political party as terrorists or an opposing candidate as a dangerous cult leader instead of part of the American political system. A President with AD would weaponize the Department of Justice to crush every potential enemy. A President with AD would see a grandmother who attended the January 6 rally as an evil arch-enemy who must be locked up for years in prison. A President with AD would bend all of the rules of due process to make sure his enemies were harassed, prosecuted, bankrupted, and destroyed. This would make sense to the AD-ravaged brain.

While people with AD may remember some people well, they may forget not just the names but the actual identities of those around them. They may mix up names, like calling the president of one country the president of another. They may think their wife is their sister. They may not recognize their sister at all. Long-term memories are often preserved, but as AD advances, those long-term memories get jumbled, so that they may tell stories of what they did 20 years ago—but get the events and locations and other people wrong. Sometimes people with AD fabricate stories out of whole cloth, like saying they did something or went somewhere they demonstrably never were. A President with AD might tell a fanciful story about Corn Pop and think it’s humorous (“Not a joke!”) or he may tell a clearly improbable story about traveling 17,000 miles with Chinese Premier Xi. A President with AD might claim to have been arrested in civil rights demonstrations or attended a Jewish schul as a child—when it is obvious those things did not happen.

Because AD involves disrupted cellular processes in the brain, the symptoms vary, but bit by bit, the brain dies. Brain cells do not regenerate. Short-term memory training does not help a person regain short-term memory. Lack of balance, lack of judgement, paranoid delusions, agitation… they do not get better.

Imagine if a President had this disease and nobody had the courage to talk about it frankly.