Trump, dementia, and the 25th amendment

The “cognitive examination” to which Trump refers is the Montreal Cognitive Assessment, or MoCA. Here’s a sample test.

What follows is based on my interviews of several experts on various types of dementia, including their relation to personality disorders.

That Trump has been given this test at least three times per his own description should be extraordinarily alarming, assuming you believe that the possibility that Trump is in the early stages of some form of dementia is a bad thing. It should be setting off alarm bells because patients are given this test only if health professionals have a serious concern that dementia is present. Certainly administering the test multiple times is a massive red flag.

The test is extremely elementary — any adult of normal intelligence who isn’t drunk or concussed or the like should be able to answer all the questions easily — and the fact that Trump both believes this is some sort of intelligence test, and that it’s a tremendous accomplishment to “ace” it, as he claims to have done (who knows what actually happened?) could itself be a sign of his malignant narcissism, or more likely of the interaction between that lifelong condition and his more recent cognitive deterioration. Trump, it’s true, has always been extremely stupid even without reference to geriatric pathologies, so all these factors are very difficult to disentangle.

Some general observations about dementia, which is a subject that obviously terrifies Trump, as his Truth Social post above illustrates:

(1) Dementia is often multi-factorial. That someone has Alzheimer’s, for example, certainly doesn’t mean they don’t have or will not develop vascular dementia, or frontotemporal dementia, or Lewy Body dementia.

(2) Various biomarkers allow various kinds of dementia to be diagnosed in ways that go beyond clinical observation. In this regard the case of frontotemporal dementia (FTD) is particularly interesting, as it has a very strong genetic component, and genetic testing can reveal both whether someone with dementia symptoms should be tested for its presence in particular, and whether people who are asymptomatic are likely to develop the condition eventually. (One researcher suggested that it would be very public-spirited of, say, Mary Trump to get genetic testing for this purpose, since she is collaterally part of Donald Trump’s genetic line).

(3) Alzheimer’s can be diagnosed in part by testing for the presence of amyloid plaques on the brain. If these are found, a couple of new drugs can be administered intravenously to slow the progression of the disease. This makes the recurrent presence of bruising on Trump’s hand, and his increasingly obvious attempts to hide it, at least rather suggestive. (It’s been suggested to me that Trump might get a hand IV for such infusions because they take a long time, a hand IV would preserve mobility better than the inside of the elbow, plus it would preserve the elbow for blood draws).

(4) The development of dementia tends to be an extremely drawn out process. The preclinical stage of the disease, in which the underlying pathologies are already present but are not yet producing observable symptoms, can last ten or 15 years or more. The subclinical stage — in which symptoms are present but are sufficiently subtle to be ignored, especially if you are, say, president of the United States — can also last years. Early stage dementia may well feature many days or at least stretches of several hours during which the patient displays no symptoms. This of course can often make the border between the subclinical and clinical phases obscure, again especially if there are strong social or political motivations for such obscurity to exist. The difficulty here is the so-called cliff effect, where dementia operates like bankruptcy in The Sun Also Rises: “gradually, then suddenly.”

(5) Given all this, the mechanisms of the 25th amendment, which is the constitutional escape hatch that is designed to remove a cognitively unfit president, are extremely clumsy and inadequate. Note that by its own terms the amendment allows Congress to create an independent body that would certify the president’s unfitness. Yet Congress has neglected to ever create such a body, so we’re stuck with a process in which a majority of the cabinet — all of whose members can be fired by the president at any time for any or no reason — has to perform this task at the behest of the Vice President, and all this must then be ratified by two-thirds majorities in each house of Congress. So as emergency mechanisms go, it’s a bad one, given the underlying political situation, which of course is the whole problem in the first place.

(6) Adding to all this dysfunction is the long history of presidential administrations that weren’t nearly as corrupt or mendacious as the present one being, to put it gently, disingenuous about the actual health of the occupant of the Oval Office. When one considers that history, the idea that this White House will ever voluntarily disclose what’s going on with Trump’s evident cognitive deterioration is nothing but a sick joke.

(7) Another big factor here is the massive social and political dysfunction produced by the so-called “Goldwater rule,” which in its current form attempts to prohibit mental health professionals from even opining on the cognitive condition of public figures. This is absurd and incredibly counter-productive, especially in a circumstance like this one, in which the astounding fact that the president of the United States is, according to the president himself, being tested for dementia repeatedly is somehow being treated by our political, legal, and media institutions with a truly astonishing level of denial and/or insouciance.