This week, the President of the United States will give the State of the Union Address. It will be broadcast not only here in the United States, but around the world. The individual who is giving this address is not cognitively intact. In fact, there is sufficient evidence to suggest that he may have serious impairments in executive functioning, a set of brain-based cognitive processes that enable individuals to plan, focus attention, remember instructions, and manage multiple tasks to achieve goals.
Since being elected in 2016, the President has demonstrated continuous decline in these areas. Some have made it to late night television, where jokes and memes are shared. Most have been behind doors and explained away or covered up. But it can no longer be denied: he is not capable of serving.
Unspoken Fear
Such behavior in a loved one or friend is typically noticed, but tolerated. That toleration often carries with it the unspoken fear that our loved one or friend has “dementia”. That word now carries a particular dread because there is no turning back. There is no magic pill. There is no single food or mind-game that will stop the inevitable decline in functioning.
It is bad enough that this happens within families. But it is even more problematic in our political structures. As a democracy, we have never developed the language, the legal infrastructure, or the political will to confront cognitive decline in our elected leaders. The result is a dangerous gap between reality and democratic accountability — one that we are now forced to reckon with.
Removal from Office
Removal of elected officials was incorporated into the Constitution. What was anticipated (and acknowledged) by the Framers were the moral and ethical failings of humans. There was no provision for “dementia” because back in the late 1700s, “senility” was considered an inevitable state of aging. Of course, the lifespan back then hovered around 35-40 years.
Removal of a President for reasons other than treason, bribery, or other crimes or high misdemeanors wasn’t dealt with until the 20th century. After FDR died in office after being elected four times, a two-term limit was imposed (22nd Amendment). After Kennedy was assassinated, power was given to the Cabinet to ensure continuity in the event of death, resignation or removal or (and this is important) s/he is “unable to discharge the duties of the Presidency” (25th Amendment).
What Wasn’t Anticipated by the Framers
The minimum age requirement for the Presidency remains unchanged – it’s 35. An age of maturity that would have been considered the final stage of life back in 1788. What the Framers couldn’t have anticipated is the human lifespan doubling.
The tensions between age, maturity, and cognitive functioning now sit at the very center of what our nation needs to come to terms with: we have a aging president who cannot govern, and a cabinet that refuses to acknowledge that he is unable to discharge the duties of the office.
Reagan and Biden
Presidents Reagan and Biden are the most recent office holders to illustrate this tension. Reagan, who left office at seventy-seven, showed signs of cognitive decline during his second term. His official diagnosis of Alzheimer’s disease came in 1994, five years after leaving the White House.
Biden struggled visibly in public settings during the latter portion of his presidency — halting speech, apparent confusion, and moments of evident disorientation that his staff and party worked strenuously to contextualize or minimize. No official diagnosis of cognitive impairment has been provided.
In both cases, the pattern was the same: observable symptoms, institutional denial, and a public left to interpret what it was seeing without any authoritative framework for addressing the problem. In both cases, people covered for and took steps to hide the functional impairments of the most powerful person on the planet.
Observed, but Denied
We need to ask ourselves why? Why are we so reluctant to name and address the decline in cognitive functioning? The medical and psychiatric communities have made significant advances in understanding dementia and age-related cognitive decline, but a clear, standardized, and politically actionable diagnostic threshold has yet to be established.
Cognitive decline exists on a spectrum. It progresses at different rates in different individuals. Early-stage impairment may be subtle enough that even trained clinicians disagree about its significance. The standard tools — the Montreal Cognitive Assessment (MoCA), neuropsychological testing, clinical observation — can detect deficits, but they do not generate a clear legal line that a court, a cabinet, or a Congress can point to and say: here is the moment at which a leader is no longer competent to serve.
Cognitive Decline is Frightening
This ambiguity is compounded by our collective fears in confronting the condition at all. Cognitive decline is frightening. It threatens our sense of continuity, identity, and control. In our personal lives, we delay difficult conversations with aging parents and spouses far longer than is wise. We wait until a crisis, where others can step in and figure out what to do.
In our political lives, we replicate this avoidance on a national scale. Voters who have invested their hopes and identities in a particular leader rationalize what they observe. Staffs whose careers depend on proximity to power manage appearances rather than address underlying realities. Opposing parties, aware that raising the issue risks appearing opportunistic, hesitate to press it forcefully. The media, sensitive to accusations of bias, often equivocates. And so the denial persists.
The Elephant in the Room
It can no longer be denied that our current President’s conduct warrants serious professional attention. Based on observable public behavior — patterns of speech, responses to unscripted questions, apparent difficulty tracking sequential logic, and recurring factual errors that go uncorrected — there is a reasonable clinical basis for concern about his cognitive function.
This is not a partisan observation. It is a professional one. And it is precisely the kind of observation that our democratic system has no reliable mechanism to act upon. The Twenty-Fifth Amendment, which provides a process for removing an incapacitated president, has never been successfully invoked for cognitive reasons.
Its threshold — that the president is “unable to discharge the powers and duties of his office” — is sufficiently vague that, absent cooperation from the president himself or a near-unanimous cabinet, it is effectively inoperable.
What Do We Do?
What, then, are we to do? We need a national conversation about cognitive fitness and public office that is grounded in science rather than political convenience. This means establishing agreed-upon, independent standards for cognitive assessment — standards that apply to candidates before they take office and to officeholders at regular intervals thereafter.
It means creating institutional mechanisms for removal, insulated from partisan pressure, through which those assessments can be made and acted upon. And it means cultivating a civic culture mature enough to hold two ideas at once: that a leader can have served with distinction and also, in time, lose the capacity to continue serving.
Ensuring Our Safety
The Framers gave us a floor but not a ceiling. Politically, we are now faced with what families, doctors, and caregivers around the world are dealing with on a daily basis. We must see that our nation is kept safe, cared for and is treated with dignity by ensuring we have a leader who is cognitively intact and capable of governing.
History suggests that the cost of continued denial not just to the president, but to our country and nations worldwide is high — not merely to the dignity of individual leaders, but to the continued existence of the republic they are sworn to protect.
It is time to stop looking away.
3 responses to “When the Mind Falters: Cognitive Decline & the Crisis of Political Leadership”
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Mary, what a strong and accurate newsletter. Thanks for naming what we all see – and what we fear in this current situation. The damage being done to so many people through denial, cover-ups, and lies needs to be faced. I wonder where courage and integrity have gone? When will ‘enough BE enough’ and a peaceful, mature response to this administration be mounted.
It was bad enough in the previous administration. But this current state of affairs is devastating.
Thank you for writing today’s message. -
You raise and important subject. I had not seriously considered the possibility that our President’s erratic policies with multiple u-turns w/o consultation with those in expertise, was part of a egotistical narcisists who believes he is always right and everyone else, including the Supreme Court is wrong. As a physician, I must say that the early years of cognitive3 decline in an older person can be difficult to detect with friends, families and even patients in denial. The tests you mentioned objectify some of the early deficits, but a person in denial, may not agree they are losing executive control function. This situation is something I’ve thought about more over the last year since I could only remember 2 of 3 objects at last summer’s medicare wellness exam. I have a strong family history on my mother’s side of dementia and i turn 76 y/o this summer. I believe I’m still able to function as part-time physician caring for older adults in the long-term care settings, I made the decision to retire last December, which should fully happen by the end of June. I want to do this before one of my patients is harmed. The current President seems to enjoy his power and fame so much, that I suspect any recognition of cognitive decline will be crushed by those near to him. I don’t have an answer to your question, but hope that others may come up with fair and objective criteria for when a USA President is no long fit to be President.
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The unique “power” of this current “President” consists primarily of near-magical ability to act as a Pied Piper – entrancing a substantial national grouping – of similarly childhood-damaged / grotesquely under-educated/ inadequate-personality folk. However, unlike HIM, those folk did NOT inherit fortunes for use inflicting twisted “revenge” on a hell-world childhood – but projected now against others.
Those “others?” The “easy-mark” victims of systemic racism; “others” “guilty” of coming from a foreign land or “alien” religion; or, “guilty” of being “merely” female,” or “guilty” of loving their own gender. And in particular – the Most Hated are “guilty” of being more educated, privileged, free, affluent and thus more “happy”: (i.e. the hated “libtards”) – than is this hopeless / deliberately-worsened underclass. (See: decades of Republican assaults on education, healthcare, childcare, women, gays, the environment and Social Security.) All cruelties unnecessarily worsening the misery – of the so-called “the undeserving poor.”
In particular, this current, “GOP” president feasts on his non-stop opening of the above Pandora’s Box of fear, victimhood and rage. Darkly ironic it is, that it’s been his own “party” that helped fashion and repeatedly fill that Box of hopelessness, fear and hate. This creature’s ability to gleefully and serially re-open that box is matched only by its obvious delight in general purpose destroying (world peace, environment, economic stability, foreign aid) – thus reflecting the true barbarian’s misdirected childhood “retribution” at work. (A barbarian perhaps in deep unconscious terror of its own impending demise – see: stamping its name on everything across the land and perhaps even – as its “final act” – hoping to “take the rest of us with him.”)
Recently, a nationally-prominent psychiatrist summed up the clinical situation: “Dementia onset does NOT ‘improve’ a lifetime sociopath, a malignant narcissist or a grossly inadequate personality.” Voila.
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