Saul
Day of Reckoning
The road wound endlessly through the flower-covered grounds of Roxboro Hospital. I thought Monique had tricked me. She told me we were going to see Dr. Tremblay, who is considered the guru for Alzheimer’s in Canada, and maybe the world. She said Dr. Horowitz is not an expert, and so only someone like Dr. Tremblay would really know. I was worried, not so much about maybe having Alzheimer’s, but that she was going to have me committed. You see, Roxboro is a mental hospital. She assured me that Dr. Tremblay’s office was not part of the hospital; rather, he just rented office space there. I figured maybe this was a conspiracy being perpetrated by Monique to get me out of the way so she could marry that guy who sings those romantic songs on television.
I had been to Roxboro only once, many years ago, and that was to visit one of my former associates from Legrand et Fils, the paper company I managed. His name was Jean-Paul something or other. A nice guy, but nuts! I figured that out my first day on the job, when he started chanting like he was a French-Canadian rabbi or something. Grand-Luc Legrand, the owner, so called not because of a stout girth, but, rather, as a tribute to his incredible height, didn’t figure it out for a few years, or maybe he didn’t want to know. But when Jean-Paul set fire to a huge pile of paper in front of him and the floor supervisor, practically blowing up the building, even he had to acknowledge it. Jean-Paul was committed the next day.
Roxboro is typical of the mental hospitals you see in the movies—gray, dank, and scary—not somewhere I would like to spend any meaningful time, that’s for sure. I would make quite a scene if they tried to get me committed there. That you can count on.
But it turned out Monique was telling me the truth. The office was in a small house by the back entrance of the hospital, probably a caretaker’s house years ago. I knew she was right when I spotted the brass plaque with Dr. Tremblay’s name on it on the front door. We waited in the empty anteroom until he bounded up the stairs, introduced himself, and led the way down to a large room in the basement.
Dr. Tremblay pointed to a chair in front of his desk, and I sat down beside Monique. He began asking her questions—like if I misplaced things. Well, of course I misplace things; everyone does. And that’s all she had to tell him. But no, she pulled out a wad of paper and told him a whole bunch of things—most of which I am sure were lies.
He asked Monique if I sometimes got lost. She told him how I had left the house to get a newspaper and was gone for hours. And how Westmount security called her to come and get me down at the station near City Hall, or whatever they call it now. I jumped in and reminded her that they were the banana police. The doctor didn’t know what banana police are, so I figured maybe he had a problem.
Monique explained that they are Westmount security officers who drive these yellow jeeps and aren’t really police, but give parking tickets and call the real police if there is a serious problem. He nodded like he really knew that, but I doubt it.
Then she told him about the incident with my trousers. I don’t know what happened, but I watched myself jump up from my seat and grab her by the shoulders. He was on our side of his big desk before you could say “yikes”—that’s what I used to say when I was a kid: “yikes.”
Next thing I knew, I was back in my seat, and the doctor was between Monique and me, leaning against the desk and continuing his interrogation. He asked Monique if I had lost interest in the things I used to love to do. She said I used to love the outdoors, tennis, and golf, but now all I do is stay in the den and watch television. Now that may be true, but at my age, what does she want me to do, take up bungee jumping?
The doctor smiled at me as he returned to his desk. I guess that was to reassure me or something. Then he started asking me all kinds of foolish questions. Like what floor we were on. I told him we were in the basement, but you would think he would have known that. Then he asked me who the president of the United States was. That one, I didn’t know, but I told him there are probably some Americans who wouldn’t get that one, either. He smiled. Then he asked me what the day and date were. I knew it was Monday because Monique hadn’t gone to her volunteer thing yesterday, but the date? “No,” I mumbled, “I don’t know the date.”
“What’s my name?” he asked. I explained that I didn’t want to be rude, but I meet so many people. He nodded and smiled again.
The doctor then asked me to count backward from one hundred by sevens.
“Ninety-three,” I said quickly. Ninety-three minus seven? I thought for a minute about that one as I closed my eyes. “Eighty-six,” I ventured. He nodded his head. Now I was on a roll. Eighty-six minus seven? I closed my eyes again, but it just wouldn’t come. I figured I might as well guess. “Seventy-something … seventy-five?” I finally mumbled. He said something about my doing fine and that I could stop. I protested that I could get the next one right, but my mind went blank.
Then he held up some pictures of things and asked me what they were. The first two were easy, a flower and a house. I missed the next one, which he told me was a volcano, and I missed the one after that. Actually, I knew it, but I just couldn’t find the word. He said it was a funnel. After a few more pictures, some of which I identified, he gave me a piece of paper with some lines on it. It kind of looked like a house. He asked me to draw it. I did the best I could, but I knew it wasn’t very good. I told him I’d never been very artistic.
Then he gave me another piece of paper with a circle and the number twelve at the top. He told me to fill in the other numbers of the clock and make the hands show ten to eleven. It didn’t look like a clock then, or after I’d scribbled on it.
After that, he had me walk across the room in some funny way. I did what he said and I did it well, because I saw him put a check mark in a box on his sheet. Then he pulled some tubes out of a drawer and asked me to sniff them and tell him what they smelled like. Some of them didn’t smell at all, I told him. He put an x, not a check mark, this time.
The doctor turned to me and asked me my birth date. By now I was tired, but I really wanted to show him I knew it. “February,” I said. “February the tenth.”
Monique nodded like I was right. Well, of course I was right. Everyone knows their birthday.
“What year?” he asked.
My face flushed. After a moment, I shook my head and told him I wasn’t quite sure.
Then the doctor wanted to know if I remembered what we first talked about when we arrived at his office.
“What do you mean?” I said.
He asked me to describe our earlier conversation. I told him I remembered some of it. “Good,” he replied. “Tell me.”
It seemed like he had rattled off so many things so quickly. They all blurred into something in my brain that I couldn’t make out. I was having trouble even getting the words out—and to be frank, I wasn’t sure which words I wanted to come out. He stood there in front of me, leaning back against his desk, patiently waiting for my response. I glanced over at Monique. Her mascara was running.
Monique
Confirmation
I guess I already knew it. But when a man in a white coat with more diplomas on his wall than there are flowers on my bedroom wallpaper confirmed Dr. Horowitz’s diagnosis that Saul has Alzheimer’s, it felt like they might as well have been closing the lid of his coffin.
Saul kept glancing over at me for help when he didn’t know the answers to Dr. Tremblay’s questions. I looked over at his stooped shoulders and tired face. This was not the man I married. Not the man whose booming voice frightened those around him. Not the man who was so tough on the children. All of that is gone. Now he seems more like my child than my husband. But I don’t need another child. I need a husband.
I could tell he was embarrassed. I wanted to help him with the answers, if only to preserve his dignity. That is one of the few things he has left, but Alzheimer’s will rob him of that soon enough.
After the examination, Dr. Tremblay asked Saul to wait in the anteroom so he could talk to me. Saul didn’t budge. My first thought was that he was just being stubborn, not one of his best traits. Then I realized that he didn’t understand the doctor’s request. The same way he didn’t understand when the doctor had pulled a piece of paper out of his drawer and held it up. The words Close your eyes were printed on it in block letters. Saul looked at the paper as if it were blank. Finally, the doctor asked him if he knew what it meant. Saul said yes, but he continued to stare straight ahead. The doctor glanced over at me with a reassuring look and put the paper back in its place.
Dr. Tremblay stood up and asked Saul to go outside with him. Saul looked over at me. I nodded. Then the doctor followed him out to the waiting room, returning alone a few moments later.
He cleared his throat—not once, but twice—and then stated Saul had Alzheimer’s and that it was still in what he called the early to moderate stage. He said there might be good days, when Saul was more or less lucid, others when he would appear to be lucid but drift off, and just plain bad days.
“The bottom line,” he explained, “is that it may sometimes be hard for you to understand where Saul is in this quickly changing landscape.” Those were his exact words.
He said it wouldn’t be too long until it got worse. I asked him what that meant. He cleared his throat again and told me that Saul had anomia. He said that meant when Saul couldn’t find the word he wanted, he would describe characteristics of the word––like calling a toothbrush a tooth cleaner, or a key a door opener.
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.
I ordered a computer scan of the brain, as well as some blood tests for Mr. Reimer as a complement to a clinical evaluation. The results of the latter will give me a fairly accurate depiction of where he fits on the one-to-seven Reisberg Scale. Number three represents minimal cognitive dysfunction. By the time patients get to number seven, they are usually in a care facility, unable to function at all, even to lift their heads or open their eyes for any meaningful period of time.
Assuming the tests confirm my preliminary diagnosis, I will start him on medication, which will not slow down the disease but will help alleviate the symptoms for at least a few months, or maybe even a year or two, giving him a better quality of life during that time.
I will also schedule an appointment with Mr. Reimer’s wife, the primary caregiver, not only to search out more information on the progress of her husband’s disease, but also to evaluate her own health and coping skills. She told me she has a history of heart problems, high blood pressure, and elevated cholesterol. Taking care of her husband will put a lot of stress on Mrs. Reimer, so we have to be especially careful.
I spend more than half my time doing research into possible cures, but I know deep down that any significant discovery that would eradicate this horrific disease is years away. That is too many years to stave off the death sentence that I pronounced on Mr. Reimer today.