On November 6, 1994, former President Ronald Reagan penned a handwritten letter to inform the American public that he had just been diagnosed with Alzheimer’s disease.

"I have recently been told that I am one of the millions of Americans who will be afflicted with Alzheimer's disease. Upon learning this news, Nancy and I had to decide whether as private citizens we would keep this as a private matter or whether we would make this news known in a public way. In opening our hearts, we hope this might promote greater awareness of this condition. Perhaps it will encourage a clearer understanding of the individuals and families who are affected by it."

Though Alzheimer's disease has been characterized in scientific literature since the early 1900s, in 1994 the lay American public had yet to see it be manifested or formally diagnosed in a figure as prominent and powerful as a president. As stated in Reagan’s letter, awareness of the disease was low, and very few Americans had any personal experience dealing with those who were afflicted by it. He subsequently received a tremendous outpouring of sympathy and support in the wake of the announcement, then quietly retreated into the privacy of convalescence until he died in 2004.

But it wasn't long before Americans became increasingly curious about whether Reagan exhibited signs and symptoms of dementia prior to his retirement, and what impact his cognitive impairment may have had on his presidency. In 2011, his two sons Ron and Michael Reagan engaged in heated literary disagreements about when they first spotted their father’s memory lapses, and if those momentary lapses ever occurred while he was our nation's chief executive.

Even before Ronald Reagan became the oldest elected president, his mental state was a political issue. His adversaries often suggested his penchant for contradictory statements, forgetting names and seeming absent-mindedness could be linked to dementia.

Moreover, in 2015, researchers conducted extensive longitudinal analysis of Reagan's speeches and behavior to better clarify the trajectory of his cognitive decline over time. As clinical advancement and public awareness of Alzheimer's have grown, likewise has our speculation into the role the disease may have played in many of the perilous Reagan-era policies that remain so entrenched in American politics today. That the public persists in this line of inquiry three decades past his presidential tenure is a profound illustration of just how much the mental status of the “POTUS” matters.

As we arrive at the six-month mark of Donald Trump’s imperiled attempt to be president, discussion of his mental health and neuropsychological fitness to serve has become relatively commonplace. Unlike in 1994, Americans are now necessarily more attuned to the cardinal signs and symptoms of cognitive impairment because its prevalence has rapidly increased with the aging of the Baby Boomer generation.

At 71 years old (and with a family history of Alzheimer's in a first-degree relative), Donald Trump surpasses Ronald Reagan as the oldest person to ever be sworn in as president, and once again we are faced with the prospect of governance by insidious, age-related brain degeneration, and the perils of being governed by Instability-in-Chief. Not only has Reagan's hope for more awareness of Alzheimer's disease come to fruition, but the ways in which his family and administrative circle navigated his illness are now extremely instructive for understanding the very peculiar presidency of Donald Trump.

To this point, most political observers have come to regard the blatant nepotism within Trump's administration as relatively routine and expected of a megalomaniac who aspires to be a despotic mob boss. His children’s presence within the highest levels of government (despite lack of adequate qualifications to serve) has regrettably come to be normalized as a new factor of life, and yet another quirky perk of hiring an outsider to make America great again, rather than the colossal conflict of interest and wanton display of incompetence it has proven to be since his inauguration. 

But what if he actually keeps his family so close because his instability now requires constant care, assistance, and supervision? What if he can't fire them for their many improprieties and incompetencies because he literally can't function without them? In other words, how much of his adult children’s egregiously inexplicable and unethical involvement in their father’s beleaguered administration is rooted in their as-of-yet undisclosed caregiver status?

To date, Ivanka Trump has “ceremonially” sat in as president for her father on numerous occasions, while her husband and eldest brother have reportedly done most of the grunt work of colluding with Russia to steal the 2016 election. Collectively they serve as POTUS by proxy, and by all outward appearances Trump wouldn't be where he is today without their unyielding loyalty and assistance. While the ongoing treason investigations will center on whether his family members took these nefarious actions with Trump's knowledge and blessing in order to keep his hands clean, it is simultaneously possible that they also did so because he simply isn't cognitively, emotionally, or physically capable of committing his own crimes without help anymore.

Upon Nancy Reagan’s death in 2016, a common theme emerged from the many glowing obituaries written in her honor. Amidst the typical fawning over her fashion sense and charming hospitality was a now generally accepted reverence for the role she played as not just first lady, but as POTUS by proxy. Over time she has gradually received credit for influencing his selection (and firing) of chiefs of staff, orchestrating the removal of his national security advisor due to disagreements about his handling of the Soviet Union, and crafting his response to Iran-Contra.

Perhaps good old-fashioned Republican hypocrisy explains why her significant influence on her husband’s presidency has been received so much more approvingly than that of Hillary Clinton and Michelle Obama, but how much of that approval also rests with tacit acknowledgement and understanding that as his primary caregiver her executive assistance became essential to his presidency with the acceleration of his cognitive decline?

As we continue to discover just how enmeshed and complicit Trump’s family is in his misdeeds, it would also be wise to remember that their pervasive presence as POTUS by proxy is a harbinger of not only his illegality, but also his worsening instability and incapability of competent service to our country.

“I was the one who was always calling people.” - Nancy Reagan