The Wisdom Paradox Page 7

  This may have sounded like a snap judgment, gratuitous even, but I was better equipped for making it than most people. A neuropsychologist with (then) almost twenty years of clinical experience and a reputation for diagnostic acumen, I make a living by studying, diagnosing, and treating various brain diseases affecting the mind. I was also doing research, publishing scientific papers, and writing books about the brain and the mind, and the numerous ways in which they may go wrong. The incoherence that so struck me in Reagan’s responses would have raised my diagnostic antennae coming from anyone, and Ronald Reagan was not exempt.

  My hunch about Reagan was strengthened some time later, during the last day of his presidency, as I was watching George Bush’s inauguration on TV. Reagan walked past the honor guard, approached the imposing leather chair prepared for him, slumped into the chair, and was immediately asleep, his head dropping on his chest instantaneously. “Brain stem gone,” I said to myself, alluding to the part of the brain that is in charge of maintaining the arousal necessary for sound mental activities. At this point I was convinced that a significant portion of Reagan’s second term had taken place in the shadow of his slippage toward early dementia.

  My conclusion that Ronald Reagan was suffering from Alzheimer’s disease or a similar dementing condition was sealed soon after he left office and well before the first official intimation to that effect. As I was watching Reagan’s interviews about the Iran-Contra affair, I was impressed, almost shocked, by the sincerity of his denial of any memories of the events, by the befuddled and incredulous expression on his face when the events and names of people were being thrown at him by the interviewers. Contrary to the opinion of many commentators, I was convinced that Reagan was not dissembling, that he was not attempting to hide anything. With the confidence of an experienced clinician, I felt that he truly did not remember. Ronald Reagan was suffering from early dementia.

  Of course, my diagnosis via television was subsequently confirmed when the “official” diagnosis was made in 1994 at Mayo Clinic, and Reagan’s hereditary risk factors revealed (both his mother and older brother had suffered from dementia). The former president’s own courageous admission of his illness earned him my respect and that of many other people. Were my earlier observations of Ronald Reagan indicative of outright dementia, or did they still belong in the gray area of “neuroerosion” or “mild cognitive impairment,” the early prodrome of things to come? Ultimately, this is a matter of semantics more than of substance, since we are talking about a gradual downslide devoid of discrete boundaries and not about an abrupt transition, a decline that came to an end in 2004, ten years after the “official” diagnosis of dementia and considerably longer after it had actually begun to set in.

  Heroes and Villains

  My clinical television study of Ronald Reagan brings us to a much broader issue. His case is certainly not unique. The paradox of human society is that the age of ascendancy to the summit of power in our political, cultural, and business institutions is also the age of onset of numerous forms of neurological decline. A large number of world political leaders are men and women in their sixties and seventies. And while we accept as a given the inevitability that by this age assorted physical infirmities accumulate, society is by and large oblivious to the fact that by this age dementia also develops in a significant number of people.

  The illusion that the demigod figures who make it to the summit of human society are spared the indignity of brain rot is precisely that: an illusion. Dementia operates on the basis of age and genetic vulnerability, just like any physical malady. Dementia is an age-related physical malady affecting the brain, just as coronary insufficiency is an age-related physical malady affecting the heart. The mind is not exempt from the fundamental laws of biological decay.

  One might expect that the individuals who make it to the very top are brighter than the population as a whole, and this is probably mostly true. But history is replete with instances of individuals endowed with great intellectual powers succumbing to dementia toward the end of their lives for reasons of genetics, or for some yet-to-be understood environmental reasons. Contrary to our wishful thinking, an exalted social status does not offer protection in these matters, nor, as it turns out, does a great intellectual power.

  It is intuitively plausible, and certainly teleologically “desirable,” that great minds should be protected from decay. Indeed, the last decade has witnessed a paradigm shift in neuroscience, as the evidence began to accumulate that vigorous mental life reshapes the brain itself and helps protect it from biological rot. (Much more about this later in the book.) But other factors, like heredity, are less malleable, at least today.

  The history of science and philosophy is similarly replete with poignant observations of decaying great minds. Isaac Newton, Immanuel Kant, and Michael Faraday all suffered dramatic memory loss with age. Among the more recent examples, Claude Shannon, the father of information theory, was diagnosed with Alzheimer’s disease toward the end of his life.

  But mental decline in a scientist is not likely to result in a societal disaster. It may have a retarding effect, delaying a great discovery or invention by years, decades, or even generations, but hardly a precipitously catastrophic one. Besides, most great scientists have their definitive insights relatively early in their careers. By the time dementia is likely to strike, they will have already made their seminal contribution to society long ago, and their decline, sad as it may be on a personal level, is no longer of broad historical relevance.

  Not so with a political leader, a powerful statesman at the helm of a major military or state machine, when the age of supreme power often overlaps with the age of early cognitive decline, under whose shadow fateful decisions are made. Mental infirmity may take many forms, from what I call mild “neuroerosion” to frank dementia, but the brain machinery of the sublime and the ridiculous is fundamentally the same. A world leader whose decisions affect the lives (and deaths) of thousands of people fundamentally employs the same brain machinery as the owner of a family-run neighborhood bodega making a decision about what brand of canned tuna to stock next week. This means that the consequences of an early “mild” dementia, which may be imperceptibly benign in a neighborhood grocer, will be perilously magnified in a world leader through the sheer impact of his mental faux pas.

  Reagan was in his seventies at the time of my observations. At this age, Alzheimer’s type dementia, multiinfarct dementia (a disease of blood vessels of the brain resulting in a multitude of small strokes), and other forms of dementias are all distinct statistical possibilities. An early-stage dementing disease process often eludes detection by an untrained eye even in a leader who is constantly in the public eye. But it is particularly likely to remain unnoticed or ignored under the conditions of an authoritarian regime, where the leader is relatively exempt from popular scrutiny. Impairment of judgment, self-control, and other higher mental functions, first subtle and then increasingly transparent, takes place well before an individual becomes frankly disoriented, totally disabled, and no longer capable of hiding his mental infirmities even from distant observers.

  The past century witnessed the stewardship of more than a few “neuroeroding,” dementing, or indeed demented individuals at the helm of major nations. Dementia strikes the villains and heroes of our world in a morally agnostic way.

  On the villains’ side, Adolf Hitler suffered from severe symptoms of Parkinson’s disease toward the end of World War II. According to some reports, memory decline was also apparent. Contrary to the popular belief, Parkinson’s disease is not just a movement disorder. It often causes some degree of cognitive impairment and even outright dementia. Other conditions also exist whose outward symptoms resemble those of Parkinson’s disease, but in which serious mental impairment is expected to be present. Most common among them is Lewy body dementia, a degenerative brain disease of aging. At the age of fifty-six, toward the end of the war, Hitler was more likely to suffer from Parkinson’s disease
than from Lewy body dementia. Either way, based on simple epidemiological considerations, some mental deterioration was highly probable. Indeed, his close associate,Albert Speer writes about Hitler’s “apathy,” “mental torpor,” and difficulties with decision-making becoming increasingly evident during the second half of the war.

  The other great villains of the twentieth century were not spared either. During the last years of his life, Joseph Stalin, known for his extraordinary memory in earlier years, was reported to have memory lapses, even forgetting the names of close associates. There was a notable exacerbation of Stalin’s paranoia (a common symptom of dementia), and it became even more dangerous for those around him than before. His lieutenants “were convinced that Stalin was becoming senile,” according to Simon Montefiore. After the war, Stalin “wasn’t quite right in his head,” Nikita Khrushchev is quoted as saying, an impression shared by the visiting Yugoslav communist Milovan Djilas. Stalin’s command of Russian (not his native language, but one in which he had attained remarkable facility) deteriorated, and he had difficulties expressing himself. The loss of command of a second language, and reversal to the language of one’s childhood (in Stalin’s case Georgian), is a well-documented consequence of dementia in bilingual individuals. Stalin also suffered from transient episodes of disorientation and dizziness common in cerebrovascular disease. Montefiore further writes that in the spring of 1952 Stalin was examined by “his veteran doctor” Vladimir Vinogradov, who concluded that Stalin suffered “minor strokes and little cysts in the brain tissue of the frontal lobe.” The autopsy of Stalin’s brain, conducted in 1953 after his death of a stroke (or, as some historians believe, of poison) showed signs of arteriosclerosis of at least a five-year duration. Today his condition would be called “early multiinfarct dementia.”

  Stalin’s mentor Vladimir Lenin, arguably a villain in his own right, also suffered from multiinfarct disease of the brain (a complication from chronic syphilis infection, according to some historians). He had a series of debilitating strokes between 1922 and his death in 1924, and lost much of his use of language. Yet he continued to run the nascent Soviet state intermittently, between successive strokes, until 1923, while already undoubtedly cognitively impaired.

  Mao Zedong’s eccentricities toward the end of his life have been described as well. He was known to suffer from amyotrophic lateral sclerosis (ALS), a neurodegenerative disease, characterized by the death of motor neurons. This disorder, also known as Lou Gehrig’s disease, causes progressive loss of movements, including the control of one’s motor apparatus of speech. Toward the end of his life, Mao’s ability to communicate by means of language was so impaired that his speech became virtually unintelligible. But this may not have been the whole story. Contrary to previous neurological beliefs, the symptoms of ALS are not limited to motor difficulties. Recent research has shown that significant cognitive impairment, including outright dementia (affecting particularly the frontal and temporal lobes, where higher-order processes such as decision-making and language are based), is present in more than a third of ALS patients. This cognitive impairment affects mental flexibility, abstract reasoning, and memory.

  Yet despite their mental infirmities, Hitler, Stalin, and Mao all remained at the helm of their respective “evil empires,” as Alan Bullock points out, until the very end of their lives, compounding their lifelong propensities toward villainy with mental deterioration or outright early dementia.

  The brain diseases of aging did not spare the political heroes of the twentieth century either. Woodrow Wilson suffered a severe stroke while in office in 1919. He recovered, but only partly. According to his biographers, Wilson was a different man after his stroke. His mind became rigid, devoid of nuance, casting everything in black and white. These newly acquired untoward traits haunted the last two years of his presidency and undermined his ability to deal with the isolationist Congress, contributing to the ruin of his League of Nations policy.

  Franklin Delano Roosevelt was felled by a lethal stroke, but a major stroke is often preceded by what is known today as multiinfarct disease, characterized by a gradual accumulation of ministrokes. In FDR’s days this condition was not known, nor were there any diagnostic tests available capable of revealing it (such as a CT scan or an MRI). Nonetheless, the decline of FDR’s mental powers and decision-making abilities, and his “new disinclination to apply himself to serious business” during the final phase of World War II, have been noted by credible historians. He was likely suffering from cognitive decline already well before his final stroke.

  And so was the man whom I admired more than virtually any other twentieth-century political leader, Winston Churchill. When he was elected to his first term as Britain’s prime minister, Churchill was already sixty-five, older than most of the last century’s other major political leaders at the time of their ascendancy to supreme power.

  Churchill’s occasional mental lapses during World War II have been noted by both his wartime associates, like Field Marshal Alanbrooke (leaving them occasionally worried about their leader’s mental state), and his biographers, like Roy Jenkins. These lapses nonetheless did not prevent him from dispatching his business with overall brilliance, if with only occasional flagging. Churchill suffered his first known minor stroke in 1949, between his two terms as prime minister. During his second, post-war term in 1951-1955, Churchill was, in the memorable words of Roy Jenkins (as sympathetic a biographer as any public figure can hope for), “gloriously unfit for office.”

  According to the accounts of those around him reviewed by Jenkins, Churchill’s energy level during his second prime-ministerial term went precipitously up and down, and so did his powers of concentration, speechwriting, and ascertaining complex ideas. He spent an inordinate amount of time playing the esoteric card game of bezique. He suffered a succession of several minor strokes. Then, in 1953, while still in office, Churchill was felled by a severe stroke and for a period of time remained wheelchair-bound, his speech slurred. By coarse neurological standard, he recovered well, but was no longer his old self, and those around him awaited, with a mixture of reverence and impatience, his resignation, which was not readily forthcoming, as he used every excuse to postpone it until April of 1955.

  More recent political history is also replete with examples of mental decay in political leaders while in office. Leonid Brezhnev, the leader presiding over the “stagnation period” of the former Soviet Union, was on many occasions toward the end of his rule less than totally coherent, his speech slurred and his gait unstable. Dmitri Volkogonov, a noted Russian historian and a three-star general close to the upper strata of the Soviet leadership, desribes Brezhnev’s demeanor during his last years in office as “senile and confused.” Reagan’s friend and Churchill’s illustrious Tory Party successor Margaret Thatcher announced her departure from public life due to a succession of “mild strokes,” and it sounded as if Lady Thatcher had been suffering from an early stage of this cognitively debilitating disease. Unlike the constraints imposed on the American or French presidency, there is no constitutional limit to the number of terms served by a British prime minister. Under a different set of circumstances, the Iron Lady may have continued to prevail again and again, and her tenure as the leader of Europe’s oldest democracy would have overlapped with the onset of an insidious dementing condition.

  The last decade of the twentieth century saw more such examples. Former presidents Boris Yeltsin of Russia and Abdurrahman Wahid (“Gus Dur”) of Indonesia are the two more recent cases of dementing leaders at the helm of some of the world’s largest nations. Yeltsin was a clinical alcoholic and a heart patient, probably suffering the irreversible changes in the brain common to these conditions. Any head of a major state who urinates on a foreign airport tarmac in front of a receiving line of dignitaries has to be more than merely drunk. Abdurrahman Wahid of Indonesia, one of the transitional figures following the deposing of Mohamed Suharto, suffered several major debilitating brain-damaging strokes. He
was notorious for his less-than-coherent ramblings.

  The stewardship of each of these two leaders to their respective countries was a mixture of good and bad. Both were known for their erratic, contradictory, and often incoherent behavior, an odd reflection of the transitional nature of their leadership. I strongly doubt that either Yeltsin or Wahid, or for that matter, Brezhnev would have passed a standard neuropsychological dementia evaluation commonly administered in North American geriatric clinics.

  This review of mental infirmities in world leaders adds up to a rather staggering picture, particularly in light of the recent revisions of what constitutes “normal aging” and what does not. Among past generations, cognitive loss, “losing one’s marbles,” or “being out of it” was considered an integral and normal part of aging. We no longer think so. In their groundbreaking book Successful Aging, John W. Rowe and Robert L. Kahn challenged the notion that mental decline is either normal or inevitable, and argued with great force that mental decline in aging is due to one or more identifiable diseases of the brain, many of them potentially preventable or treatable. They introduced the notion of “successful aging,” which among other things includes complete lucidity and mental sharpness well into old age. Rowe and Kahn argue that this, and not mental decline, is the norm. Those sprightly, astute, quick, and mentally nimble octo- and nonagenarians, such as Federal Reserve Chairman Alan Greenspan or celebrated historian Jacques Barzun, are now my role models. I always wonder whether I will be even remotely like them in my own old age, should it come to that at all.