Presidential Physicals Should Include the Brain
Right now, the technology exists to detect the very early stages of Alzheimer’s disease -- as well as to flag abnormal protein deposits that can grow in peoples’ brains long before symptoms of dementia become apparent.
No tests of this sort will apparently be featured in Donald Trump’s Jan. 12 physical, according to those in the know, but some brain experts and medical ethicists argue they should be. Such early evaluations might one day become important for ordinary citizens, if drugs now in the pipeline prove effective in forestalling dementia symptoms. In the meantime, it behooves us all to have more information when the brain in question belongs to someone with access to classified information and nuclear codes.
The state of the current presidential brain has generated intense interest, from the gossip in journalist Michael Wolff’s new book to the concerns aired in the medical website STAT News -- including an opinion piece titled I’m a Brain Specialist. I Think Trump Should Be Tested for a Degenerative Brain Disease.
Experts say an evaluation would start with simple written and oral tasks: naming items in pictures, recalling strings of letters and numbers, calling up lists of words, and the like. If those tests signal trouble, doctors might move on to a brain scan to look for protein deposits called beta amyloid.
The role of beta amyloid was controversial for years, since some perfectly sharp people die and reveal brains full of this abnormal protein. Harvard neurology professor Rudoph Tanzi has led experiments in cultured human brain cells pointing to amyloid as a first step in the progression of Alzheimer’s disease. Amyloids can trigger growth of another abnormal protein deposit called neurofibrillary tangles, he said, and that situation can trigger excess inflammation, the death of brain cells, and full-blown dementia.
Right now, he said, it is possible to use brain imaging to see which healthy people have a lot of beta amyloid and are therefore at elevated risk. Already several drugs have been shown to reduce amyloid plaques -- and he’s gearing up to start clinical trials of another. No drugs have restored memory or thinking ability in advanced-stage patients, but Tanzi and others have high hopes for prevention by giving the drugs much earlier.
Tanzi noted that an open letter has been circulating among the medical community urging experts to demand Trump get a neuropsychological evaluation. He has not added his name, he said, because he worries the letter might be misinterpreted as a statement that Trump has dementia in the eyes of the experts. He doesn’t think Trump should be diagnosed through his television appearances, but he does agree with those who argue that all presidents should be given a genuine, science-based evaluation.
He says if such evaluations started taking place, the results wouldn’t be black or white. It’s typical for people to search for words or forget names more often in their 60s than in their 20s he said, just as older people develop problems with their knees or shoulders. At the same time, people gain wisdom with age and experience. A test result showing some risk of dementia and memory decline should be weighed alongside other factors.
Not all forms of dementia primarily affect memory. A disease called frontotemporal dementia (FTD) attacks the frontal lobe, which is the seat of judgment and impulse control. While FTD is less common than Alzheimer’s disease, it tends to hit people earlier in life -- usually starting in their 50s or 60s. Neurology professor Murray Grossman, who directs the center for FTD at the University of Pennsylvania, said that the disease is characterized by a different mix of abnormal protein deposits than Alzheimer’s, and these can be picked up in a test of spinal fluid. Some cases are characterized by extremely rigid or apathetic behavior. In other cases, people become uninhibited and prone to making inappropriate comments or gestures.
People with FTD often have very little insight into their own condition, said Grossman. They may think everything is fine, while those around them grow alarmed about their changing behavior. Some patients with this disease also develop progressive aphasia -- the loss of language.
Of course, other incapacitating conditions could impair a leader’s ability to function, and yet this presidential check-up may be less informative than some would hope. Family physician Ranit Mishori, of Georgetown University School of Medicine, warned not to confuse the number of tests done with the value of the information gathered. VIP or executive physicals, she said, often take more time and incorporate more tests than standard check-ups, but they don’t necessarily yield more information. That's because not all the tests are equally evidence-based.
In a conversation I had several months ago with NYU medical ethicist Arthur Caplan, he said he disapproved of speculation about Trump’s mental and cognitive health. In a recent piece for Forbes.com, written with University of Pennsylvania ethicist Jonathan Moreno, he urges Congress to impose a mandatory exam that would assess factors that affect a president’s ability to do the job. It would be a physical designed not for the president’s benefit, but for ours. This seems like as good a time to start such a policy as any.
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