Aging Heads of State: The Politics of Dementia and Geriatric Cognitive Disorders

Current news nurture the impression that large and important states are governed by elderly people, and occasional reports indicate that there is a number of lesser known countries ruled by rather seasoned leaders. It may therefore be worthwhile to find out whether the age of international political leaders is really on the rise, and what the significant examples of age-associated complications are. There is a rich literature with autobiographies, biographies and learned volumes about ailing heads of state [for classic examples, see 1-4]. PubMed and other sources of scientific literature contain numerous contributions about diseases of monarchs, elected and influential politicians over the centuries. Internet sources like Wikipedia and others frequently update lists of political figures and after several years of studying this subject, one can confirm that such regular updates are useful, as the political landscape must necessarily undergo permanent changes.

This paper aims to take a snapshot of the current age records in politics, examine the development of the mean ages of politicians from 1990 to 2020 and present several of the earlier and contemporary examples of heads of state who were cognitively challenged.

Sources freely available on the Internet were used to identify the ages and times in power for ruling heads of state including monarchy. Every number was confirmed by at least 2 references considered reliable. The following groups of countries with related geographical, historical, cultural and political backgrounds were summarized for the calculations of mean ages of their leading political figures in the years 1990, 2000, 2010 and April 2020: Community of Independent States (CIS, plus Georgia): Armenia, Azerbaijan, Belorus, Georgia, Kazakhstan, Kyrgyzstan, Moldava, Tajikistan, Ukraine and Uzbekistan; Western Europe (EU members before or in 1990): Belgium, Denmark, France, Germany, Greece, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain and the UK; Gulf States: Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates; Middle America: Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama; North Africa: Algeria, Egypt, Libya, Morocco, Tunisia; Panther States: Indonesia, Malaysia, Philippines, Thailand, Vietnam; South America: Argentine, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, Venezuela; sub-Saharan Africa: 40 countries in 1990, 42 in 2000 and 2010, 41 in 2020 (due to unclear situation in Sudan); Tiger States: Hong Kong, Singapore, South Korea, Taiwan. Groups of 1 or 2 singular countries will not be considered.

The world’s oldest head of state with 94 years is most certainly also one of the most popular, Queen Elizabeth II. She is followed by Sabah al-Ahmad al-Jabar al Sabah, the Emir of Kuwait, aged 90, and Raul Castro with 88, first secretary of the Cuban Communist Party.

A remarkable number of elderly statesmen can be found in the Middle East: the president of Lebanon, Michel Aoun with 85; the president of Palestine, Mahmoud Abbas with 84; Prince Khalifa bin Salman al Khalifa (84), prime minister of Bahrain; and Salman bin Abdulaziz al-Saud (84), King and prime minister of Saudi Arabia. Beji Caid Essebsi from Tunisia, with 95 years the oldest president internationally, died in 2019, and Mahathir Mohamad from Malaysia, who had again become president of Malaysia with 92, resigned with 94 years early in 2020.

Robert Mugabe from Zimbabwe was forced to step down at the age of 93 and died 2 years later in 2019. Omar al-Bashir had to retire with 74 years in 2019 after he had been the president of Sudan for only 20 years. Hastings Kamuzu Banda had been the prime minister of Malawi from 1966 until he retired in 1994 at the age of 96. Paul Biya from Cameroon, aged 87, is currently the oldest serving African president and with 44 years in power also the international record holder, distancing Nguema Mbasogo (77/40 years) from Equatorial Guinea, Denis Nguesso from the Republic of Congo (76/36 years) and Yoweri -Museveni from Uganda (75/34 years). Three other heads of State from sub-Saharan Africa managed to stay in power for >25 years: Isaias Afwerki (74) from Eritrea, Idriss Deby (67) from Chad and Paul Kagame from Rwanda (62). Only 5 leaders from other continents managed to hold on to power for the same period of time: Ali Khamenei (80/38 years) of Iran, Hun Sen (67/35 years) in Cambodia, Nursultan Nazarbayew (79/28 years) in Kazakhstan, Emamoli Rahmon (67/27 years) from Tajikistan (67/27 years) and Alexander Lukashenko (65/25 years) in Belarus.

Several points attract attention: the Middle East appears a cradle for elderly heads of state; sub-Saharan Africa seems a breeding ground for extended periods in power. It is not immediately evident whether such regional specificities increase the number of elderly leaders in different parts of the world.

Twelve West European prime ministers today have a mean age of 51 years, much younger than presidents and monarchs with an average of 67 years (Fig. 1). Six heads of state in the Gulf now show a higher mean age of 70 than in 1990 with 62 years. There is no remarkable difference to the current mean age of leading politicians (prime ministers and chief executives) in the Tiger and Panther States. Heads of state in Middle and South America and also in the Community of Independent States (including Georgia) are on average almost 10 years younger compared to those of the Gulf, Tiger and Panther States (Fig. 1). North Africa today shows the typical age difference between younger prime ministers and older presidents (including the King of Morocco). The data on 40 and more sub-Saharan countries demonstrate a steady age increase of the acting heads of state between 1990 and 2020. This includes the outstanding examples mentioned above (see “Ages and Places”).

In summary, Western Europe currently has the youngest prime ministers compared with the other parts of the world shown in Figure 1; presidents and monarchs are usually older in countries with elected prime ministers; heads of state in the Gulf, Tiger, Panther and sub-Saharan States now are more than a decade older than in Western Europe.

One could begin with King Saul or his healer and successor David, who both allegedly suffered from remarkable mental problems in old age [5, 6]. Ailments of the elderly – but not specifically of elderly heads of state – had been a topic in classical volumes (e.g., Cicero, Cato maior). On very close scrutiny one would find the rare but highly suspicious example of senility in historical figures well before 1900, but the characteristic cognitive issues were not usually age related. The court diseases (morbi aulici, maladies de cour) [7] of the Middle Ages usually included the consequences of affluence from gluttony to high-risk behaviors. Obesity as a visible side effect of luxury and a sedentary lifestyle has burdened politicians until today, and this probably began before William the Conqueror (Table 1). The legendary fisher king of Arthurian fame suffered a terrible lesion of his groin, a typical wound experienced during tournaments. Such after-effects of period-specific contact sports, including the sequelae of severe cerebral concussions and bleeds, handicapped many heroic noblemen. Henry VIII was one of the very last examples (Table 1).

Rex inutilis, the useless king, has been a pivotal political and legal dilemma in Europe since the early Middle Ages particularly because the welfare of a country was bound to the well-being of the God-sent king [8]. Intermarriage became a problem with nobility detached more and more from ordinary people. King George III of Britain (1738–1820) and his cousin Christian VII of Denmark (1749–1808) both developed incapacitating diseases which crippled urgent reforms during the Age of Enlightenment [6, 9]. Schizotypal King Ludwig II of Bavaria (1845–1886) could no longer understand the signs of time and tragically drowned together with Bernhard von Gudden, professor of neuropsychiatry [10]. Ludwig’s younger brother and successor Otto (1848–1916) early on developed severe paranoid schizophrenia with a relentless course. Ironically, the physicians who were ordered to watch over him while in custody made essential contributions to neuroscience (Gudden, Kraepelin, Nissl and others) [6]. Naturally, other factors neither associated with genes nor with peculiar high-risk behavior may have contributed to the mental troubles in noble patients. Ludwig II and also Taisho-tenno of Japan (1879–1926), for example, contracted meningitis and endured recurrent symptoms for the rest of their lives.

Numerous examples of monarchs with primary (e.g., genetic) or secondary (e.g., metabolic and traumatic) cognitive impairment (rex inutilis or morbi aulici) can be found over many centuries. The descriptions and early interpretations of their cases do not usually allow for a reliable diagnosis. This changes around the turn to the 20th century.

Contemporary neuropsychiatric concepts and diagnoses are still rooted in thoughts, methods and insights gathered a hundred years ago. Therefore, descriptions from the last century are easier to translate into modern diagnoses. The medical histories of US American presidents are documented particularly well, and a number of them are listed in Table 2.

Several politicians listed in Table 2 developed cognitive impairment late while still in office (Antonio Salazar; Urho Kekkonen; Harold Wilson; John Paul II; Ronald Reagan) or soon thereafter (Margret Thatcher; Helmut Kohl; Pierre Trudeau; Jacques Chirac; George Herbert W. Bush) so that their political legacy remained largely untarnished [11, 12]. The US presidents in Table 2 are not the only ones with medical and particularly mental problems, but they have been selected for this lineup because of their prominent cognitive deficits. The first example, William H. Taft, is atypical, because his underperformance was reversible [13]. He disappointed those who had expected a much more dynamic presidential leadership. Taft regained enthusiasm when he lost weight after his presidency and became an impressive chief justice in and after 1921. Boris Yeltsin is a later and less impressive example of recovery after his time in office with better control of his risk factors alcohol, obesity and sleep apnea. Taft’s successor, Woodrow Wilson, was not a healthy man when he was elected president [11, 14]. He had suffered from first symptoms of a vascular disease in 1896 before he was appointed president of Princeton University in 1902, became governor of New Jersey in 1911, lost his first wife in 1914 and married his second wife Edith on the advice of his physician Admiral Cary T. Grayson. The USA entered World War I in 1917. He appeared confused during the peace negotiations in Paris in April 1919 and suffered a severe stroke in October 1919, which left him severely disabled and incommunicado for several months while his wife and his physician ran government affairs. Woodrow Wilson’s medical history bears striking resemblance to Lenin’s fate on the other side of the Atlantic (Table 3).

Lenin’s last utterances and scribblings were desperate attempts to prevent Stalin from succeeding as a general secretary (“Stalin is too rude and this defect … becomes intolerable in a general secretary”). Lenin died young, at the same age as his father, who had also developed cerebrovascular disease [15, 16]. At around the same time the admired gentleman politician and new French president Paul Deschanel began to show extravagant behavioral changes but retained enough insight to step down (frontotemporal dementia appears the most likely diagnosis) [17].

The senile and exhausted Reichspräsident Paul von Hindenburg, worn out by the endless political push and pull of the late Weimar republic, gave in to his ultra-conservative coterie and handed the political power over to former corporal Adolf Hitler in 1933, whom he had loathed so much a little earlier [11]. Years later another war hero, 84-year-old French marshal Petain, head of the Vichy regime, became convinced that a collaboration with Nazi Germany, even against French resistance fighters, was honorable and advantageous [17, 18]. Ominous erratic behavior had been observed in the 1930s, but a clear diagnosis of dementia was only made in 1947.

The serious hypertension of Franklin D. Roosevelt had been left untreated for too long, and the cognitive consequences could no longer be overlooked at the Yalta peace conference in 1945 (Fig. 2). Roosevelt succumbed to a major stroke a few weeks after the conference [19, 20]. Churchill produced symptoms and signs of cerebrovascular disease in the 1950s [21, 22]. Stalin became a victim of his own paranoia when he suffered a fatal stroke in 1953, and none of the medical specialists he had prosecuted was available [21, 23].

Somatic frailty and cognitive rigidity afflicted the history of communism ever more. Breshnew endured symptoms of atherosclerosis during the last years of his life in office. Andropow and Tschernenko only lasted for 1 or 2 years as multimorbid general secretaries [11]. They were followed by Michail Gorbachev, whose mere pace of reforms stressed out the senile GDR troika of Erich Honecker (1912–1994), Willi Stoph (1914–1999) and Erich Mielke (1907–2000), 2 of them stricken by disease. At the turn from 1989 to 1990 Wojciech W. Jaruszelski of Poland was 67 (but seemed much older), Ramiz Alia of Albania 75, Bruno F. Straub from Hungary 76, Gustav Husak of Czechoslovakia 77, and Todor Zhivkov from Bulgaria 79. It is almost touching to see how a feeble and pitiful 71-year old Nicolae Ceausescu of Romania tried to placate and soothe the crowd at his last public speech in Bucharest on December 22, 1989, 3 days before he and his unpopular wife Elena (73) were executed. Mao Tse Tung developed amyotrophic lateral sclerosis, and Deng Xiaoping suffered from Parkinson’s disease. Fidel Castro was left as one of the last men standing, be it on shaky feet and increasingly demented (Table 2).

At around the same time in Tunisia president Habib Bourguiba’s dementia became evident, and he fell victim to a medical coup d’état, led by his own prime minister Ben Ali (Table 2). Later Ben Ali’s failing mental powers were compensated by his wife Laila Trabelsi. The Arab Spring started in Tunisia, swept the Ali clan to Jeddah in Saudi Arabia, led to the downfall of Hosni Mubarak in Cairo and the killing of Muammar al Gaddafi in Tripolis. Both had long fallen behind their own progressive images. The Royal family of Saudi Arabia however remained impervious. It was founded by Abd al-Aziz ibn Saud (1876–1953), who had 45 sons. His son Saud and first successor was removed from power in 1964, followed by his third son Faisal, murdered in 1975. The fifth son, King Chalid, died from heart disease in 1982, followed by his son Fahd until 2005, by Abdullah until 2015 and then his 32nd son Salman until today, all of whom suffered from strokes. Salman is severely handicapped by a hemiparesis and dysarthria and tragically relies on Crown Prince Mohammad bin Salman al Saud. Abd al-Aziz Bouteflika (Table 2), former president of the UN general assembly, president of Algeria from 1999 and repeatedly re-elected, suffered a minor stroke in 2013, 2 strokes in 2014 with paresis, dysarthria and cognitive impairment, and could finally be convinced not to stand for a fifth term in 2019.

North Africa and the Middle East cannot only boast single record-holding heads of state (see “Ages and Places” above), a high mean age of politicians in high office (see “Age Developments over the Last 30 Years”), but also exceptional examples of cerebrovascular morbidity.

Heads of state have been challenged through the ages, but before 1900 the threats to cognitive performance had been different from the usual age-associated ailments increasingly prevalent since the beginning of the twentieth century. Today there are many examples of elderly politicians, some of whom had been in power for rather long periods of time, particularly in Africa. The mean age of political leaders has not increased significantly over the last 3 decades in most parts of the world. Fundamental historical developments were promoted or permitted by the failing cognitive capacity of ageing politicians who had been known to swing the scepter most energetically in previous times.

A clearcut medical diagnosis of severe hypertension, a large stroke, advanced Parkinson’s disease and also significant cognitive impairment or other obvious diseases is a burden and a relief at the same time. Nobody would really expect an afflicted person to fulfill the most demanding tasks, not even the patient him- or herself. But this depends on 2 conditions, first that sufficient insight is retained in order to step down and second that the patient is not being abused as a mere puppet by others for political or financial purposes. Mindful observers would easily identify such cases. The question remains what the legal and political chances are to replace the demented head of state with an appropriate successor.

Several historical events were mentioned which revealed cognitive impairment in key players while under pressure: the Paris and the Yalta peace conferences (Woodrow Wilson, Franklin D. Roosevelt); the rise of Nazi Germany (Paul von Hindenburg, Philippe Petain); the breakup of Marxism and communism (Brezhnev, Honecker, Ceausescu, …); the Arab Spring (Ben Ali, Hosni Mubarak, Muammar Gaddafi); and the rise of reckless princelings (North Korea, Saudi Arabia). In some cases, a clear diagnosis was reached in the aftermath of these events.

Political duties are demanding, and the wear and tear of years in office can be observed in many heads of state [24]. Their skills, personalities and attitudes can be very different, and there is clearly not the one ideal model for the good and sustainable politician. But are there warning signs which need to be taken more seriously in elderly candidates than in budding, promising, physically fit talents of a younger age, who may find it easier to adapt to their new roles, live up to their own promises and to the expectations of others? The absence of dementia or of mild cognitive impairment will not be good enough for a task which needs permanent mental and physical strength over long periods of time. Some of the following features may serve as markers of imminent cognitive failure and help to identify candidates at risk: the statistical risk which comes with very old age; a record of failures and how they were dealt with; signs of physical frailty and the kind of multimorbidity which may impact on endurance and cognitive capacity in due course; impaired fluency or limited communicative content, rambling style, ideological phrases instead of focused pragmatism [25]; unsubstantiated pride relying on previous achievements; mild behavioral impairment [26]; tiring easily, memory lapses; mild cognitive impairment; support-seeking gestures [27]; a tightly knitted and manipulative entourage pursuing their own interests.

This is not an attempt to rewrite political history as a history of senility or a general warning against candidates over the age of 65. Some of the historical cases presented may however help to identify individuals with an increased risk of failing in office. The importance of experience and wisdom which comes with a longer life has long been a subject of political philosophy and constitutional law. The Roman “senate,” derived from senex, old person, is an early practical manifestation of the belief that personalities, who have reached a higher age, must have done something right and that some of this knowledge may be useful for the community. However – and without stigmatizing old age – it does come with its own typical problems and perils, which can be fatal if complicated by organic [28] or nonorganic personality disorders [29, 30].

Published in Celebration of the 30th Anniversary of the inception of Dementia and Geriatric Cognitive Dis-orders 1990-2020”.

The author declares no conflicts of interest for this article.

No funding has been received.

Published in celebration of the 30th anniversary of the inception of Dementia and Geriatric Cognitive Disorders 1990–2020.