An Absent Mind(8)

He said Saul’s test scores showed what was typical at this stage—to leave sentences unfinished, repeat phrases, use words that mean nothing, like “That’s cool” or “You’re right.” And it’s also normal at this stage to forget how to make sentences, have less interest in conversation, and not understand simple commands.

I asked him what happens in the final stage. He looked down at the floor and said something like, “Let’s take this one step at a time.” I told him I wanted to know now. He said he had another patient in the anteroom and suggested it would be better for me to see a counselor at the Alzheimer’s Society. Could it be that bad that even a doctor was uncomfortable discussing it?





Saul





Groundhog Day


There was this movie, Groundhog Day, with some comic and a gorgeous actress with dark, curly hair who is always on those TV commercials for some shampoo. God, I wish I could think of the name—no, not his—hers. She was a real piece!

As I recollect, and forgive me if I don’t get it quite right, this weather reporter would keep going through the same stuff day after day. I remember thinking at the time, Hey, that wouldn’t be so bad if I could spend every day with her. Well, it didn’t quite work out that way, did it?

I mean, I often catch myself doing the same thing over and over, and even if I don’t realize it, I’m sure I do repeat stuff, but the only one I see every day is Monique. Now, I’m not saying she’s an eyesore. In fact, in her day she was quite something. Those knockers could stand up to anyone’s back then. Today, they don’t stand up at all—gee, I should be a comic! But let’s face it: She’s no beauty, certainly not today.

So I end up in a B-movie version of Groundhog Day. One that will never end, until the end. And by then, maybe it won’t matter if that actress is there or not. I guess at least with Monique, I know she’ll be there. That actress might have blown me off for another guy and not even have come to my funeral.





Dr. Tremblay





Death Sentence


I have specialized in dementia for over thirty years and have seen thousands of probable Alzheimer’s cases. I say probable, because so far, absent a brain biopsy, we haven’t had sufficient tools to state with absolute certainty that a person has Alzheimer’s. Although there is a study that analyzes spinal fluid for amyloid beta, a protein fragment that forms plaque in the brain, and tau, a protein that leaks out of dying nerve cells in the brain. It seems that all the subjects in the study who had Alzheimer’s had the plaque, and all of those with mild cognitive impairment who had the plaque went on to develop Alzheimer’s within five years.

There are also noninvasive tests like positive emission topography, which can detect a decrease in glucose consumption; electroencephalograms, which examine a slowing of the alpha rhythm; and magnetic resonance imaging, which can identify a decrease in volume in the hippocampus, where Alzheimer’s always starts. But these tests usually only reinforce our preliminary findings on assessments like the mini mental state examination or the Buschke selective reminding test.

I performed several tests on Mr. Reimer. It was quite clear to me, even before he scored only seventeen out of thirty on the MMSE—a score of twenty-four or higher indicates some degree of normality, but in point of fact, most fully functioning people would have a near-perfect score—that he was in the early stage and perhaps close to the middle stage of Alzheimer’s. He did no better on the clock test or the trail-making test.

I don’t want to get technical with you here, but it is important that you have at least some comprehension about how Alzheimer’s affects the brain, so that you can understand what happens to people like Mr. Reimer. I will try to explain it to you in concise layman’s language, although we doctors seem to have difficulty parsing convoluted medical terms.

Alzheimer’s is characterized by the formation of cellular debris in the form of plaques and tangles. The plaques float between the neurons, while the tangles attack the neurons from inside the cell membranes. But regardless of how they go about their destruction, they achieve the same result, preventing the neurons from communicating with one another. As clumps of neurons die, specific functions such as short-term memory, spatial relationships, reasoning, and eventually things like muscle coordination, and even swallowing, are affected. The result is always death.

One of the sad things about this horrible disease is the time line. On average—and I say on average, because it’s different for everyone—it takes about six to ten years for the disease to run its course. I have seen it take a much shorter time in patients with early-onset Alzheimer’s, where the disease starts when the person is in his forties or fifties—but that’s usually a specific inherited gene and not what Mr. Reimer has—to over twenty years in rare cases.

Mr. Reimer and his wife just left my office. He already has some anomia—difficulty in finding the right word, but is capable of circumlocution—talking around the word that can’t be recalled. He seems to have only the beginnings of agnosia. What I mean by that is he can still recognize most objects and know what they’re for. For instance, he knew what to do with the pen he used to draw on one of the assignments I gave him. And he still recognizes those around him. And as for apraxia, spatial relationships, and motor skills, he had only a little trouble, which is normal in the earlier part of the disease.