Medical mystery: The last years of George H.W. Bush

When President George H.W. Bush died on Nov. 30, he was 94, making him the nation’s oldest former president ever. He also was a prime example of how staying active throughout life can promote longevity, remaining an athlete not just in school, but also throughout his political career.

Following his service in World War II, the lean, 6-foot-2 lefthander played first base for the Yale baseball team that would play in the nation’s first two college world series, in 1947 and 1948.

He was an avid tennis player, often participating in tournaments with professionals. As president, he would run miles with Secret Service agents. During one Camp David run, he pulled up with sudden shortness of breath and weakness caused by atrial fibrillation with a heart rate of 150 beats per minute, a complication of a newly diagnosed hyperthyroid condition.

In retirement, he stayed active in sports, and traveled the world, sometimes for humanitarian missions with Bill Clinton, who had kept Bush from a second presidential term.

Bush remained an athlete well beyond age 80. He had even gone sky diving at age 75 and went skydiving again, while strapped to a partner, to mark his 80th, 85th and 90th birthdays.

But in his last half-decade, Bush’s legs grew weak, and he had trouble maintaining his balance. He had a slow, shuffling gait, and then used a walker to move about.

Speech grew increasingly difficult, and he developed the perpetual appearance of strained smile, with abnormal grimacing. He showed no signs of a tremor, but when standing, he needed to plant his feet broadly to maintain his balance.

Eventually, his muscle rigidity and weakness progressed to the point that he needed a wheelchair. He became practiced at getting around in a motorized scooter.

What was causing Bush’s shuffling gait and constellation of muscle symptoms?

Bush was diagnosed with vascular parkinsonism. This is a rare condition, believed to be caused by multiple mini-strokes that damage the same structures deep in the brain affected in classic Parkinson’s disease.

In the vascular disease, symptoms of slow movements, difficulty with walking and balance, stiffness, and rigidity are produced by mini-strokes affecting the basal ganglia part of the brain. In classic Parkinson’s, which is a neurodegenerative disease, patients suffer a gradual loss of nerve cells in the same brain region.

Tremors and changes in thinking skills, symptoms of classic Parkinson’s, usually do not affect people with vascular parkinsonism.

Though it’s easy to attribute the symptoms of vascular parkinsonism to old age, it’s important to confirm the condition early so that symptom progression can be minimized through lifestyle changes and medication. A low salt, low-fat diet is recommended, smoking should be stopped, and hypertension and diabetes must be controlled. An aspirin a day may be prescribed. A regular exercise program is now recommended.

Vascular parkinsonism may be caused by abnormalities of the myelin sheath that coats brain cells, slowing and disrupting brain signals. Some experts have suggested a genetic cause. The dopamine-enhancing medication, levodopa, used to treat classic Parkinson’s disease, is not effective in half of vascular parkinsonism cases.

On April 22, 2018, the day after his wife Barbara’s funeral, the former president had to be hospitalized with a blood infection. A month later, he was back in the hospital for fatigue and low blood pressure. After he recovered, he asked his family to take him to Kennebunkport, Maine, for the summer.

On May 27, he was admitted to a Maine hospital with what was described as a mild case of pneumonia, forcing him to miss the annual Memorial Day parade. On June 12, he became the first former president to reach the milestone age of 94.

In the early fall of 2018, George H.W. Bush and family returned to his Houston home after a summer in Kennebunkport. At age 94, after multiple bouts of bronchitis, pneumonia and ICU hospitalization, Bush died in Houston. He will be remembered as a tireless humanitarian who did not allow political differences to influence his leadership.

Allan B. Schwartz, M.D., is a professor of medicine in the division of nephrology and hypertension at Drexel University College of Medicine.