Alzheimer’s Disease

Tout casse. Tout passe.
(Everything breaks. Everything passes away.)
— French Proverb

Art helps us to live our lives.
— American Poet Wallace Stevens

All organic phenomena proceed through the following evolution: conception, incubation, birth, development, maturation, reproduction, senescence, and death. As doctors, it is part of our charge to help make the transitions from one phase to another as smooth as possible. Diseases, whether caused by microbe, trauma, nutritional deficiency, hormone imbalance, or degeneration, are the bumps, potholes, and sometimes the bottomless pits on that road between here and eternity.

While our scientific wizardry has grown immeasurably in its power to conquer diseases, nature — sly nature — always finds new ones to take their place. Simple infectious diseases have largely been overcome. Complex, multiple-drug-resistant infections have filled the void. Acute diseases are increasingly controlled. Chronic disease and resultant disability are expanding with our aging population.

As we are mortal, it will always be our eventual fate to bow before time’s gaze. As our science and technology expand, it seems that our success is ironically reflected partly in the number of people who live to suffer from the slow, relentless, and cruel breakdown in function that characterizes the chronic diseases. While no degenerative disease wins hands down as “the cruelest,” certainly Alzheimer’s Disease (AD) would make the short list.

AD is certainly amenable to study. The pathologist’s microscope reveals intracellular neurofibrillary tangles, extracellular amyloid plaque, and loss synapses. The non-specific CT, MR, PET, and EEG results are mostly helpful for excluding other CNS diseases. Clinically, it is characterized by gradual loss of global higher cognitive function, behavior disturbances, loss of various competencies, and mild response to acetyl cholinesterase inhibitors and NMDA receptor antagonists. These facts help us understand the technical side of AD but don’t give us much insight into what it feels like actually to have the disease.

To leave the bedside or laboratory and enter into the inner experience of the AD patient requires an imaginative leap. There are no accurate first-hand accounts that allow us to see from his eyes and hear from his ears. Delirium, dementia’s crazy cousin, can be visited with an overdose of various drugs (or alcohol) as well as with certain forms of cerebritis. These temporary states sometime later can be told as not-necessarily-inaccurate tales of dread, woe, or adventure. In contrast, the cognitive decline of true dementia is (as Hamlet said of death itself) a country from whose land no traveler has returned.

David Wagoner, a Northwest poet, aims at this interior landscape of first-person-singular Alzheimer’s in his poem “Into the Nameless Places.” In response to the question, “Your name is?” he has the spokesman of the poem answer:

Not on the tip of my tongue, but slipping away
And only half-returning when I call it
To mind, to mind me like a child
As it used to when I recited it
More clearly and easily than any other answer.
It waits shyly, a little way off, uncertain
Whether it must come back to touch my lips
Or whether I'll follow it slowly in good time
Into the nameless places it longs for.

The sadness a grown “child” feels for a parent suffering from Alzheimer’s combines the odd mixture of nostalgia, gratitude, and conflict over the realization that the physical vessel of the parent is becoming increasingly emptied of the “chronicle” that made their relationship alive. This is captured by Bob Hicok in a poem for his mother, called, simply, “Alzheimer’s.” Note how the poem shifts between the cognitive perspective of the patient (“chairs move by themselves,” etc.) and the emotional perspective of the son-narrator:

Chairs move by themselves, and books.
Grandchildren visit, stand
new and nameless, their faces’ puzzles
missing pieces. She’s like a fish

in deep ocean, its body made of light.
She floats through rooms, through
my eyes, an old woman bereft
of chronicle, the parable of her life.

And though she’s almost a child
there’s still blood between us:
I passed through her to arrive.
So I protect her from knives,

stairs, from the street that calls
as rivers do, a summons to walk away,
to follow. And dress her,
demonstrate how buttons work,

when she sometimes looks up
and says my name, the sound arriving
like the trill of a bird so rare
it’s rumored no longer to exist.

Finally, to visit the poignancy and strangeness of what it must be like to have the shrouded sense of something being wrong, we turn to Kelly Cherry’s poem, “Alzheimer,” written for her father, once a professional musician. In the middle stages of the disease, patients are vaguely aware of their disabilities, and aware, too, that they are not able to do anything about it. The poem also reminds us that familiar surroundings and people allow an Alzheimer’s patient to remain “functional” within a scaffolding of love and concern.

He stands at the door, a crazy old man
Back from the hospital, his mind rattling
like the suitcase, swinging from his hand,
That contains shaving cream, a piggy bank,
A book he sometimes pretends to read,
His clothes. On the brick wall beside him
Roses and columbine slug it out for space, claw the mortar.
The sun is shining, as it does late in the afternoon
in England, after rain.
Sun hardens the house, reifies it,
Strikes the iron grillwork like a smithy
and sparks fly off, burning in the bushes —
the rosebushes —
While the white wood trim defines solidity in space.
This is his house. He remembers it as his,
Remembers the walkway he built between the front room
and the garage, the rhododendron he planted in back,
the car he used to drive. He remembers himself,
A younger man, in a tweed hat, a man who loved
Music. There is no time for that now. No time for music,
The peculiar screeching of strings, the luxurious
Fiddling with emotion.
Other things have become more urgent.
Other matters are now of greater import, have more
Consequence, must be attended to. The first
Thing he must do, now that he is home, is decide who
This woman is, this old, white-haired woman
Standing here in the doorway,
Welcoming him in.

Alzheimer’s is a dramatic example of what happens when an essential organ fails. With new research we may yet win the battle with Alzheimer’s. That’s the good news. The “bad” news is that, as happened with the last century’s rheumatic fever, syphilis, or uncontrollable hypertension, some new disease will take its place. This is the human condition, and we have no choice but to call it our own. Remember, as the wag says, “Life is an invariably fatal, sexually-transmitted condition.” But on the way toward our inevitable fatality we are, as doctors, provided with an unequaled opportunity to appreciate, to be of service, to learn, and to love. Stevens says that art helps us to live our lives. These particular poems can offer us an inspirational hand as physicians and friends to Alzheimer’s patients and their families.