Voters are rightly concerned about giving the nod to a candidate whose intellect will likely fail over the next four years. We fear that wandering fingers could mistake the atomic bomb launcher for a toilet flush button. While the twenty fifth amendment to the constitution does describe a pathway for removal of a mentally disabled president, the political process described is difficult to implement. A preemptive solution might be more appropriate.
Neurologists frequently note that early forms of degeneration often go unrecognized until a crisis proves that an individual cannot cope. In practice, the twenty fifth amendment may not allow for early detection and expeditious removal until the damage is already done. The electorate is in the best position to take preemptive action. They could block someone who is likely to wain cognitively over the four years of a presidency.
While the voters will need to assess competency in advance of an election, observing stump speeches, TV spots and well-rehearsed debate responses is not enough to detect early dementia, especially for the untrained eye. How is a voter to know if the candidate is likely to deteriorate cognitively over the next four years?
The first test for the discerning voter is to observe speech behavior. The most common form of dementia, due to Alzheimer’s disease, often presents with short term memory failure and loss of proper word production. The individual may fail to conjure up the correct word relying on general terms such as “the other guy” or “my opponent” to disguise an inability to precisely recall a name. Often there is an attempt to talk around a lost word such as saying “you know, the thing.”
Remarkably, journalists rarely, if ever, ask the speaker to clarify the suggested word in fear of embarrassment. The individual may also forget which state or place they were in at the time.
Figure 1 Figure 2
- Figure 1 (left) is a normal MRI scan of the brain.
- Figure 2(right) is MRI scan of patient with early dementia demonstrating atrophy
Another common form of dementia may be characterized by mercurial shifts in anger, irritability and lack of proper restraint in the use of curse words or other socially inappropriate comments. The later presentation becomes more relevant if the disinhibition is worse than what had been characteristically displayed over a lifetime. Some degenerative processes are easier to detect with the untrained eye, such as slowed movements and tremors.
Technically the divide between minimal cognitive impairment and dementia is crossed when an individual is no longer able to independently perform activities of everyday living. Crossing this divide is well beyond the level of function required of a president. Forgetfulness and deficient problem solving may not be as easy to detect when listening to rehearsed stump speeches in a campaign. This is an instance where formal neuropsychological testing becomes paramount.
Admittedly, we may not have comparison testing available from years ago in order to detect a progressive process, however, the expectations with someone who has been very successful in life is that their test performance should be at a zenith. If a presidential candidate tested, for example, in the tenth percentile for memory, there would be a basis for concern.
While there is no formal requirement for a candidate to submit to neuropsychological testing, a confident candidate could easily publish such results to remove any doubt about their mental capacity among the electorate. There should be proper controls for cheating including using a third party examiner, checking for stand ins, monitoring for the use of crib sheets and avoiding any loss of custody of the completed test items.
When testing mental fitness required of a President, not just any cognitive test can be used. The test battery must be complex and sufficiently difficult to memorize such as the RBANS. Simple alternative tests such as the Mini Mental Status Exam or Montreal Cognitive Assessment can be easily practiced for and would be no better than observing a rehearsed speech. Confirmatory testing may include a spinal tap and components of an MRI scan such as arterial spin labeling or quantified measures of atrophy (See Figures 1-4 on left and below).
Figure 3 Figure 4
- Figure 3 (left) is Arterial Spin labeling (ASL) MRI scan of normal individual showing signal throughout cortex of the brain
- Figure 4 (right) is Arterial Spin MRI scan of patient with early dementia showing drop out of signal in posterior aspects of brain
PET scans may also be helpful. In our clinical experience and in the literature, each of these tests has the ability to predict progression of cognitive disturbance, at least to a certain degree.
One may argue that this whole debate is unfair to the elderly, and that it is a manifestation of unfair bias. There is, however, substantial precedents for age related requirements for performance testing as part of our everyday experience. Consider the fact that in California, anyone over age seventy has to submit to and pass a written driver’s test before there can be a license renewal granted. Does it not make sense that the “driver” of our country should at least submit to a written performance test as well?
Regardless of age, it is important that we hold baseline requirements for those in positions of power. While qualities of a suitable leader tend to be subjective, we now have the ability to at least ensure that they are mentally stable. An objective report detailing candidate brain power is not only valuable voter information, it is necessary to ensure the world and the people in it are in steady hands that will push the right buttons.