Is old ever too old? Cognitively impaired politicians, judges and physicians

A 60-plus-year-old judge allows her law clerk to don judicial robes while presiding over cases for nearly a year before her dismissal with Alzheimer’s disease. An elderly surgeon continues to operate but forgets the location of his office.

As neurologists specializing in cognition, we know that nearly a third of adults 65 years and older suffer from mild cognitive impairment or dementia, climbing to over half by our mid-80s, most often from Alzheimer’s disease. Despite these sobering statistics, many of us view aging as optional, deferred with technology. We expect to work into our 80s, replacing our joints and our heart valves when necessary. Unfortunately, our brains can defy our wishes, often shrinking or shriveling despite our best efforts.   

In this month’s issue of Neurology: Clinical Practice, an American Academy of Neurology publication, we discuss the growing number of physicians 65 and older still practicing medicine, approximately 95,000 strong, and the need to determine fair and reliable ways to identify those whose level of cognitive impairment poses harm to their patients. This challenge is not unique to medicine, one of many professions in which reduced decision-making capacity can negatively affect public wellbeing. 

Commercial pilots undergo rigorous medical evaluations up to twice annually, with mandatory retirement at 65. Interstate truck drivers must have bi-annual physical examinations recorded on standardized forms. Not so for physicians, presidents, senators, lawyers and federal judges whose decisions can profoundly impact our safety.  

The average age of U.S. senators (62), representatives (58) and federal judges (69) continues to grow ever higher, but none of these individuals is required to have regular evaluations of their general or cognitive health. Our recent crop of leading presidential candidates, who ranged in age from 70 to 78, offered only brief summaries from their physicians vouchsafing good health, with limited actual data allowing the public, or as we argue, a neutral third party, to judge for themselves. This, despite the fact that over two-thirds of Americans, regardless of party affiliation, believe presidential candidates should undergo cognitive examinations.

Supreme Court Justice Sandra Day O’Connor, now suffering from Alzheimer’s disease, was a proponent of a mandatory retirement age for judges. However, we propose individualized determinations rather than a one-retirement-age-fits-all approach. Cognitive aging varies as considerably as we do as individuals. Some 70-year-old surgeons may perform a heart transplant as well as their 45-year-old colleagues, their judgment enhanced by wisdom and experience. We would be deprived of their outstanding service if age-based retirement were mandated.  

Claims that the public can readily discern the status of a candidate’s brain or general health are untrue. Even impaired politicians can retain their long-standing capacity to project a certain image of themselves, relying on scripted answers and have staff who can cover for them. Presidents Woodrow Wilson, Franklin Delano Roosevelt and Ronald Reagan come to mind. The American public needs the protection of agencies, such as the Food and Drug Administration (FDA) and the Federal Trade Commission’s Bureau of Consumer Protection, precisely because it is not feasible for ordinary citizens to evaluate hidden threats. Similar oversight is essential for elected officials and licensed professionals whose compromised health can affect our safety.  

Despite pushback against such assessments, judicious cognitive screening at age 65 and older for women and men in positions affecting public safety is urgently needed. Unfortunately, brief, 30-question screening tests such as the Mini-Mental State Examination or the Montreal Cognitive Assessment miss significant brain impairment in many, especially highly educated persons, just as an EKG is not sufficient to detect heart disease in others. What adequate testing looks like can be decided on by a neutral third party such as state-based physician health programs, or by within-agency protocols, as with the Federal Aviation Authority (FAA). Neutral oversight should also be mandated for federal and supreme court justices who currently have lifetime tenure, and for our elected officials, including our representatives, our senators and our presidents.  

Concerns about the individual injustice of ageism must be weighed against the public harm from age-based brain disease. Is old ever too old? Yes, if, after a fair evaluation, such a person demonstrates cognitive deficits significant enough to pose serious danger to the public. We must address this issue. Our lives depend on it. 

Dr. Gayatri Devi is Clinical professor of neurology at Downstate Medical Center, New York City, author of “Spectrum of Hope: An Optimistic and New Approach to Alzheimer’s Disease and Other Dementias.”

Dr. Kirk R. Daffner is the Wimberly professor of neurology at Harvard Medical School and the Muss Clinical director of the Alzheimer Center at Brigham and Women’s Hospital, Boston.