McCain, Reagan, and Mild Cognitive Impairment
Mild Cognitive Impairment, or MCI, is a diagnosis usually
made in retrospect, after someone has already developed Alzheimer’s
disease. In its early phases, the characteristic memory lapses of MCI can look
a lot normal brain aging. Forgetting someone’s name, where you left your
car keys, or where you set down your reading glasses last night is normal as we
get older – and these lapses get worse when we are anxious or depressed. In
screening for MCI one is asked to repeat and then remember the names of three
objects (e.g. book, apple, table) after a brief distraction – this is a standard
part of the “mini mental state examination.” Missing one object is
not diagnostic, but it is a bit worrisome especially when an object is not
recalled after a clue is given (“a piece of fruit”). Another
characteristic of MCI is variability of mental performance. We all have our
good and bad days, but wide swings in mental function without an explanation
(stress, fatigue, medications) may be a sign of MCI. Men who develop Alzheimer’s
are more likely to be crabby or aggressive than women, and some gadfly
geriatricians have even tried estrogens as treatment (dumb idea).
Now this is not breaking news. We all knew that before
people become demented, there are premonitory (or, as we say in medicine, “premorbid”
– love that word) indications. The problem is on the front end – not all who seem like they have MCI actually have it, and at least half of
those who do have MCI are not actually slipping into the early stages of
Alzheimer’s. Seasoned observers can often intuit the differences between
real MCI and just normal forgetfulness of aging with careful observations –
it’s called clinical judgment. Clinical judgment is fallible, but often
on target because it is a highly integrative cognitive function that rapidly takes
all sorts of information into account and creates a pattern. A doctor can use
it to make a brilliant diagnosis (or not), and maybe it is how Rome taxi drivers
can go 60 miles an hour on medieval cobblestone streets without killing very
many people.
Lots of my geriatrician buddies and I concluded that Reagan
had early Alzheimer’s in his first term, and it was clear in his second-term
debates with Mondale. That avuncular, grandfatherly joking was all too familiar
to us old-people-doctors. And truly, in retrospect there was no doubt that he
had developed MCI within the first few years of his first term.
Some unpleasant thoughts occurred to me during the second
Obama-McCain debate. McCain’s “that one” remark was not a
sign of disrespect – I think McCain temporarily forgot Obama’s
name! The (as my wife termed it) Elmer Fudd-grumpy behavior of McCain triggered
a worrisome diagnostic pattern recognition for this geriatrician, who is not-very-young
himself. The rather dramatic change that I have observed in the way McCain
thinks and processes information over the past four years is troubling. Does he
have MCI? The fact that he is 72 years old makes this a lot more plausible
concern. If so, by the end of the first term of a presidency, there is about a
30-50% chance that his cognitive impairment would advance, and a more than 10%
chance that he would have developed clinically-evident, nursing-home-grade Alzheimer’s
disease. After having barely survived 8 years of an idiot in the White House, I
am not sure we can afford to run the risk of having a grumpy old man with MCI
running our beleaguered country.
Jack D. McCue
Answerjack is a Fellow of the American Geriatrics Society, and a Clinical Professor of Medicine at the
University of California, San Francisco
