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    Did President Reagan have mild cognitive impairment while in office?

    Living longer with Alzheimer's Disease


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    Dr. Sherman
    At age 69, Ronald Reagan was the oldest man ever to be elected President. At his death at age 93, he had lived longer than any other U.S. President, despite his suffering from probable Alzheimer's Disease (AD) during the last 10 years of his life (1994-2004).

    Although much has been written about President Reagan's apathy and inattentiveness during his second term, there is no medical documentation of his having had AD while occupying the Oval Office. Neither of the physicians who cared for him during his second term reported any signs or symptoms of AD while he was in office,1 claiming that they only saw initial signs in 1992, approximately 2 years before his handwritten, heart-wrenching letter to the American people announcing that he would be "one of the Americans who will be afflicted with Alzheimer's Disease."

    Looking back four years, however, to his last year in the White House (1988), is it possible that President Reagan was suffering, not from AD, but rather from mild cognitive impairment (MCI)? MCI is a transition state between healthy aging and very mild AD, progressing to AD at a rate of 10% to 15% per year. Fifty percent of patients with MCI convert to AD in 3 to 5 years.

    Edmund Morris, who had unprecedented access to President Reagan as his official biographer, suggests the possibility of MCI when he writes: "...in all the years I observed Ronald Reagan until 1992—when he suddenly became weird—I never saw any signs of cognitive dementia. There were...days late in his Presidency when he drifted off, as old men do. On May 29, 1988, for example, he emerged from an extended one-on-one with Gorbachev unable to recall a word that had been said."2

    A diagnosis of MCI can be made if the patient meets all of the following criteria:

    1. a memory complaint, corroborated by an informant;

    2. abnormal memory function documented by impaired delayed recall of one paragraph from a subtest of the Wechsler Memory Scale-Revised (figure, p. 15);

    3. normal general cognitive function;

    4. no or minimal impairment in activities of daily living; and

    5. not sufficiently impaired to meet the standard criteria for AD.3


    Figure. z score for MCI patients relative to controls
    In 1989, one year after leaving office, President Reagan was thrown from a horse in Mexico and developed a subdural hematoma, which was surgically removed. At that time, he underwent psychological testing, which showed no evidence of AD. Whether there were abnormalities on these tests that could now be classified as consistent with MCI is not known.

    Although there may be much speculation about if and when he developed MCI, there is little doubt that President Reagan lived a long time with AD. According to life expectancy tables, the average life span of an average 83-year-old male is 5.7 years. In a prospective, observational study of 521 persons with newly-recognized AD, the median survival from diagnosis at age 83 was approximately 3.5 years—a 40% reduction in lifespan.4 Only 25% of these 83-year-olds with AD lived longer than 6 years, suggesting that the former President developed AD on a foundation of physical and/or mental health and/or was the beneficiary of life-prolonging care. In this same study, patients age 85 and older with gait disturbance, wandering, and comorbid conditions, including diabetes mellitus and congestive heart failure, had the poorest survival. Other studies have shown that decreased survival correlates with the presence of behavioral disturbances, falling, and extrapyramidal signs.

    12

    12


    Dr. Sherman
    At age 69, Ronald Reagan was the oldest man ever to be elected President. At his death at age 93, he had lived longer than any other U.S. President, despite his suffering from probable Alzheimer's Disease (AD) during the last 10 years of his life (1994-2004).

    Although much has been written about President Reagan's apathy and inattentiveness during his second term, there is no medical documentation of his having had AD while occupying the Oval Office. Neither of the physicians who cared for him during his second term reported any signs or symptoms of AD while he was in office,1 claiming that they only saw initial signs in 1992, approximately 2 years before his handwritten, heart-wrenching letter to the American people announcing that he would be "one of the Americans who will be afflicted with Alzheimer's Disease."

    Looking back four years, however, to his last year in the White House (1988), is it possible that President Reagan was suffering, not from AD, but rather from mild cognitive impairment (MCI)? MCI is a transition state between healthy aging and very mild AD, progressing to AD at a rate of 10% to 15% per year. Fifty percent of patients with MCI convert to AD in 3 to 5 years.

    Edmund Morris, who had unprecedented access to President Reagan as his official biographer, suggests the possibility of MCI when he writes: "...in all the years I observed Ronald Reagan until 1992—when he suddenly became weird—I never saw any signs of cognitive dementia. There were...days late in his Presidency when he drifted off, as old men do. On May 29, 1988, for example, he emerged from an extended one-on-one with Gorbachev unable to recall a word that had been said."2

    A diagnosis of MCI can be made if the patient meets all of the following criteria:

    1. a memory complaint, corroborated by an informant;

    2. abnormal memory function documented by impaired delayed recall of one paragraph from a subtest of the Wechsler Memory Scale-Revised (figure, p. 15);

    3. normal general cognitive function;

    4. no or minimal impairment in activities of daily living; and

    5. not sufficiently impaired to meet the standard criteria for AD.3


    Figure. z score for MCI patients relative to controls
    In 1989, one year after leaving office, President Reagan was thrown from a horse in Mexico and developed a subdural hematoma, which was surgically removed. At that time, he underwent psychological testing, which showed no evidence of AD. Whether there were abnormalities on these tests that could now be classified as consistent with MCI is not known.

    Although there may be much speculation about if and when he developed MCI, there is little doubt that President Reagan lived a long time with AD. According to life expectancy tables, the average life span of an average 83-year-old male is 5.7 years. In a prospective, observational study of 521 persons with newly-recognized AD, the median survival from diagnosis at age 83 was approximately 3.5 years—a 40% reduction in lifespan.4 Only 25% of these 83-year-olds with AD lived longer than 6 years, suggesting that the former President developed AD on a foundation of physical and/or mental health and/or was the beneficiary of life-prolonging care. In this same study, patients age 85 and older with gait disturbance, wandering, and comorbid conditions, including diabetes mellitus and congestive heart failure, had the poorest survival. Other studies have shown that decreased survival correlates with the presence of behavioral disturbances, falling, and extrapyramidal signs.

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    Fredrick T. Sherman, MD, MSc, Medical Editor
    Dr. Sherman is Medical Director for Senior Services, Mount Sinai NYU Health; Medical Director for Senior Health Partners; and Clinical ...