Busting The Myth of Alzheimer's

Peter Whitehouse and Daniel George wrote a book called The Myth of Alzheimer's.  In it, they claim that "there is no such thing as Alzheimer's Disease."  "Alzheimer's Disease represents our culture's attempt to make sense of the natural process of brain aging that we cannot fully control."  So, in an attempt to control it, "we've created an antagonist" and named it Alzheimer's Disease.

They claim that because we don't know the "singular cause" of Alzheimer's, because we can't cure it, and because we can't differentiate Alzheimer's from normal brain aging, we should stop diagnosing people with this "label."  Labeling someone with Alzheimer's only causes them harm from the stigma attached to it.  We should stop treating people with Alzheimer's medications, and we should certainly stop looking for a cure.  Dementia is just normal aging, and you can't cure aging.

Wow.  Where do I begin?

Let's start with cancer.  We don't know yet what causes cancer or how to cure it.  We treat it with crude, non-specific poisons that risk the very life of the person who takes them.  There used to be a HUGE stigma attached to having cancer.  Remember when everyone called it "the big C?"  Cancer is not caused by one singular process.  It is caused by a complex interaction between genetic and environmental influences.  Should we not call cancer a disease?  Of course not.  Do we not tell someone they have cancer because of the stigma that might be placed on them?  Of course not.  Do my chances of developing cancer increase as I age?  Yes, they do.  Is cancer a normal part of normal aging?  No, it is not.

Likewise, we can think about heart disease.  Do most people develop accumulations of plaque in their arteries as they get older?  Yes, they do.  If untreated, will most people develop cardiovascular disease if they live long enough?  Yes, they will.  So is having cardiovascular disease a normal part of normal aging?  No.  Over the course of 50-100 years, we, as human beings who eat fatty foods and don't exercise enough, develop plaques that clog our blood vessels.  This leads to decreased blood flow to the heart which leads to oxygen deprivation of the heart muscle which causes a heart attack.  Do we just accept this as normal aging and do nothing about it?  No, we do not.  We diet and exercise.  We go to the doctor and get tested to see how much plaque we might have blocking our arteries.  And we take medications, like statins, to decrease the buildup of these plaques, decreasing our chances of getting a heart attack.

Proclaiming that Alzheimer's is not a disease and that dementia is due to normal aging is simply wrong and irresponsible.

Genetic mutations in the genes for presenilin-1, presenilin-2, and amyloid precursor protein CAUSE Alzheimer's Disease 100% of the time. Malfunctions caused by mutations in these proteins result in a buildup of amyloid beta 42, causing clogs in neural synapses, causing dementia.  This process causes disease.  A malfunctioning presenilin-1, presenilin-2, or amyloid precursor protein is not a normal part of normal aging.

Normal aging is forgetting someone's name.  Alzheimer's is forgetting your spouse's name.

Yes, diagnosis is tricky today.  We are still developing the tools sensitive enough to measure what needs to be measured to detect Alzheimer's Disease.  An MRI is not sensitive enough.  A blood test won't reveal it.  Plaques (are you looking at diffuse or neuritic?) and tangles are not accurate correlates.  Pencil and paper tests are only so telling.  Again, think about cancer. Diagnosing cancer can include tests and scans that have false positives and false negatives.  It can involve invasive surgeries to rule it in or out, to determine if the mass is benign or malignant.  The diagnostic process may be imperfect, but we use every piece of information we have available today.  Just because diagnosing Alzheimer's today is difficult, it doesn't mean that there isn't a disease there to diagnose!

And we should diagnose Alzheimer's if it's there.  Why?  Because we can treat it with Aricept and Namenda.  Because we can exercise, eat a Mediterranean diet, meditate, and stay mentally active.  Convincing people that Alzheimer's is not a disease and should not be diagnosed will needlessly keep people who are suffering with dementia away from doctors, away from Aricept and Namenda, away from planning responsibly for their future. In denial. Not to mention frustrated and scared.

Maybe, in the future, we will be able to treat this disease without saying the words "You have Alzheimer's Disease."  My grandfather died in 1978 of heart failure at the age of 69.  My father had high cholesterol in his fifties and went on a statin. He walks several miles a day. He is now 67, and his cholesterol levels are low. He has never had a chest pain. He was never told that he had heart disease. He was at risk. I hope he outlives my grandfather by a couple of decades.

Maybe, in the future, the treatment of Alzheimer's will look more like this, more preventative. Family history, an amyloid-specific scan, and some neuropsychological testing show you're at risk for developing Alzheimer's, so you go on medication and stave off symptoms to maintain quality of life for as long as possible.

Growing old without Alzheimer's.

But we have to bust Whitehouse and George's myth and acknowledge first that Alzheimer's is a disease.

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Alzheimer's: A New Earth

A lot of people I know are reading A New Earth by Eckhart Tolle and discovering a new consciousness. Oddly enough, a number of people I know with Alzheimer’s have already discovered this new consciousness but not through A New Earth. They discovered it through Alzheimer’s.

Huh?

Let me try to explain.

Following a diagnosis of Alzheimer’s, you are no longer an engineer, a teacher, an accountant. You are no longer a tennis player, a chess player, a piano player. You are no longer good at math. You are no longer good in the kitchen.

You ask yourself, “Who am I now?”
You ask yourself, “Has my real self died?”

You are no longer the YOU you used to be. You are having trouble even remembering the YOU you used to be. Your FORMER Self is gone. Alzheimer’s has greedily taken hold of your former Self, is clenching it with both hands, and won’t give it back. The loss of this former Self is experienced like a death. You grieve the death of your former Self.

But once the grief has passed, you may be able to see what is left, no longer obscured by the former Self. What remains is the REAL self.

Huh?

Here’s an excerpt from my next book, LIVING ALZHEIMER’S which speaks to this discovery and includes a quote from Eckhart Tolle’s A New Earth:

I'm nothing short of awed by Jay's transformation. Here's a man who has been diagnosed with a disease synonymous with death, but the man before me, in this present moment, is not a dying man. He is not angry, depressed, resentful, blaming, jealous, fearful, or in denial. How is this possible? How can he not be angry about the loss of his successful career, his identity, as an architect? How can he not be resentful about the fatigue and the loss of cognitive capabilities that interfere with his days? How can he not be consumed with fear about his future? Why doesn't he feel lost?

Some time after our conversation, I read every one of the books Jay recommended. I will forever be grateful to him for introducing me to this knowledge that has changed the way I look at the world and inhabit my own life. Thinking of Jay's transformation, I'm struck still while reading Eckhart Tolle's A New Earth. And I get it.

"Whatever they had identified with, whatever gave them their sense of self, is taken away. Then suddenly and inexplicably, the anguish or intense fear initially felt gave way to a sacred sense of Presence, a deep peace, serenity, and complete freedom from fear....When forms that you had identified with, that gave you your sense of self, collapse or are taken away, it can lead to a collapse of the ego, since ego is identification with form. When there is nothing to identify with anymore, who are you? When forms around you die or death approaches, your sense of Beingness, of I Am, is freed from its entanglement with form: Spirit is released from its imprisonment in matter...You realize your true identity as consciousness itself, rather than what consciousness had identified with. That's the peace of God. The ultimate truth of who you are is not I am this or I am that, but I Am."

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Happy Valentine's

John and Mary have been married for fifty-three years. Mary has Alzheimer’s Disease and lives in an Alzheimer’s Care Facility. John visits her every day. Every day, Mary does not know who he is.

Today is Valentine’s Day. He thinks about how much he loves his wife, about all she has meant to him, about all they’ve shared together over fifty-three years. When he visits her today, he brings her a rose and a box of her favorite chocolates.

As he offers his gifts to her, he says, “Happy Valentine’s Day, sweetie.”

She accepts the lovely rose and her favorite chocolates with polite pleasure.

He then says, “I love you, Mary.” And he tries to give her the gentlest kiss.

She swats at him and screams.

“Mary, I’m your husband. I’m John, your husband.”

Mary looks repulsed and scared and would get up out of her chair and run out of the room if she could.

“Get out!” she yells and covers her face with her hands.

“I love you, Mary. I’m your husband, John. Look at me, I love you.”

He tries to take one of her hands away from her face and hold it in his. She used to love holding his hand.

Mary squeezes her eyes shut and screams, “Help me! Somebody help me!”

After an aide comes in and settles Mary down, John leaves, heartbroken that he can’t spend meaningful time with his beloved wife on Valentine’s Day.

John can still have meaningful time with Mary. But he has to give up his old relationship with her in order to have a new one. The parts of Mary’s brain where John lived, the parts that housed Mary’s memories of the last fifty-three years, are either not working or are missing. Think about that. She has no memory of being diagnosed with Alzheimer’s, no memory of John, of being his wife, of being sixty, fifty, forty, or thirty years old. This information simply does not exist in her brain. Like it is for all of us, her truth, her reality, is based on the information she does have in her brain.

To Mary, she is only twenty-five years old. She knows no information beyond that. That is her truth. Imagine being twenty-five years old, and an eighty-year-old man you don’t recognize insists that he’s your husband, that he loves you and wants to kiss you. You’d fight him off, too!

John has to give up on being right and the truth according to his bigger brain and work with the truth as Mary lives it. He should not insist that he is her husband. To her, he is an old man, someone’s grandfather, and she is a young woman. He has to find a new relationship---

She has a beautiful smile. It reminds him of his granddaughter’s who lives far away. Would she mind if he visits with her for a while?

Where is she from? Well how about that! They’re from the same home town and can spend time reminiscing about life there.

He has a box of chocolates. Her favorite. Would she like one?

And go from there.

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

The Beginning

I've started writing my next book, a nonfiction collection of conversations with people in the early stages of Alzheimer's Disease. Here's an excerpt from the Introduction--- Please feel free to comment. I'd love to hear what you think!

Alzheimer’s disease.

Now close your eyes. What do you think of? Who do you see? I see an eighty-five-year old woman with short, white hair, wrinkled skin, and polyester pants. I see her forgetting when she ate breakfast and when she was born. Forgetting where the bathroom is and where she lives. Forgetting the name of the United States President and the names of her children. I see her forgetting her own name. Forgetting me. I see my grandmother.

You might have imagined your own grandmother. Or your elderly parent. Maybe you don’t know anyone with Alzheimer’s. Maybe you imagined Gena Rowlands in The Notebook or Julie Christie in Away From Her.

Most of us know what Alzheimer’s disease looks like. Or do we?

Like most people who come to know Alzheimer’s in a loved one, I’ve read and learned a lot about this disease, from the molecular and clinical to the self-help and how-to-care-for. But for the most part, what we know about Alzheimer’s is gleaned from experience with elderly people diagnosed well into the progression of this disease. Because we as a culture expect eighty-year-olds to be normally forgetful, because retired grandparents are no longer accountable to corporate bosses, because they don’t have to produce a certain number and quality of widgets each day, because they might be widowed and living alone with no one to regularly witness the full extent of what is happening, because it is far easier to deny what is happening well after we suspect it or even trip over it, we don’t usually see Alzheimer’s in its beginning.

And unfortunately, once this disease marches past the beginning, we can no longer really know what that beginning was like. Beyond the beginning, clogged synapses, faulty neurotransmission, inflammation, and cell death take the upper hand. Beyond the beginning, those parts of the brain that mediate memory and language and that inform awareness and identity become increasingly inaccessible. People with Alzheimer’s who’ve deteriorated past the beginning stages can no longer remember the recent time period of their personal history that was ‘the beginning’. They can’t describe what it feels like to have Alzheimer’s Disease because those communications skills aren’t working. And more confounding, they may no longer be capable of understanding that they even have Alzheimer’s disease.

We know what Alzheimer’s disease is like from the point of view of the tireless, loving caregiver. We know what it is like from the point of view of the Hollywood director. But, what is having Alzheimer’s disease like from the point of view of the person with Alzheimer’s? What does the face and voice of early-onset Alzheimer’s look and sound like?

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Finding Your Kaleidoscopes

You’re at a party in the middle of telling a story about your favorite childhood toy, but you can’t for the life of you come up with its name.

“Oh, what’s it called?” you ask yourself as you rummage around in your brain.

This classic tip-of-the-tongue phenomenon is something most people experience occasionally. For some usually frustrating period of time, a word that is stored in long-term memory refuses to be grabbed and recalled. Most people know they know it and have access to some aspect of the target word while in this state, like its meaning, the first letter, or the number of syllables.

“I know it begins with the letter K.”

Eventually, either through concentrated effort, bumping into the right associations, or when no longer consciously focusing on hunting it down, the word magically surfaces.

“Kaleidoscope!”

The average twenty-five-year-old experiences one to two tip-of-the-tongues a week. And the frequency of this normal phenomenon does increase with age. But for someone with Alzheimer’s, missing words interfere far more often and typically don’t offer helpful clues. These missing words aren’t so much on the tip of the tongue, ready to spit themselves out. They’re hiding somewhere deep in the brain. For someone with Alzheimer’s, this difficulty with recalling the names of everyday names and objects is called “anomia.”

Here’s where the concept of ‘exercising your brain’ or cognitive retraining can be extremely helpful. If you’re experiencing anomia and having trouble getting to the word KALEIDOSCOPE because amyloid beta goo is blocking the main roads to it, then having other, goo-free roads that lead to KALEIDOSCOPE can help you.

If you only have two neurons that have learned to connect to the word KALEIDOSCOPE and those two connections become jammed, then the word is inaccessible. Forgotten. But if you have ten neurons that have made connections to the word KALEIDOSCOPE, then those two gooey pathways can be detoured. The main roads that had always been the quickest routes are blocked, so it may take a longer time to retrieve the word, but you can still get there.

So the more connective neural roads you build to a piece of information, the more likely it is that you’ll still be able to get to that piece of information as some of your roads become impassable.

“Childhood toy” is blocked.
“Tube containing mirrors and pieces of colored glass or paper” is blocked.
Beatles song, Lucy in the Sky with Diamonds, Girl with the eyes:

“Kaleidoscope!”

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Treatment Without Numbers

I know a widely-respected neurologist at a prestigious, teaching hospital who once said,

“Treating dementia is like rearranging the chairs on the deck of the Titanic.”

And he’s not alone in the medical community with this philosophy. I’ve heard many stories of doctors, both neurologists and general practice physicians, who are reluctant to prescribe treatment for Alzheimer’s Disease. They believe that the current drugs available don’t make a difference. They believe the current drugs are not cost effective.

Aricept and Namenda do not cure Alzheimer’s.
They do not stop the progression of the disease.
The cognitive capabilities of everyone who has Alzheimer’s Disease will get worse despite taking these medications.
No one gets out of Alzheimer’s alive.

But what about quality of life? What about the value of making each day a little less foggy, less frustrating, less isolated, less stressful for as long as possible? What about living as fully as possible with whatever time you have?

Do doctors not bother to prescribe calcium channel blockers or statins to elderly patients with heart disease because they’re likely going to die soon anyway? Are patients with cancer denied surgery, chemotherapy, or radiation if it’s known that these treatments will only buy time before the cancer ultimately kills them?

In the diagnosis and treatment of any patient, doctors have been trained to measure and quantify. Cholesterol levels are measured. There is a number. Blood pressure is taken. There’s another number. Patients are given medication, and doctors look to these numbers to evaluate whether the treatment is working. The number changed. The treatment worked.

There is no dementia protein that can be measured in the blood. There is often nothing visible in a brain scan. There is no number physicians can point to that can measure discrete changes in cognition. A doctor can’t put a patient with Alzheimer’s on Aricept or Namenda and then in six months say, “Things look great. We see a 25% decline in the accumulation of amyloid beta in your brain.” Or, “Wonderful. Your glutamatergic neurotransmission is up significantly.”

But just because there’s no numerical index of biological improvement that can currently be measured, it doesn’t mean the improvement isn’t there.

We’re all on the Titanic. We’re all going to die. For those of you with Alzheimer’s disease who are taking an Acetylcholinesterase Inhibitor (Aricept, Exelon, Reminyl) and/or Namenda, do you feel like you’re just pointlessly rearranging the deck chairs?

Tell us what you notice about your capabilities and mental health while on these medications. What value do these drugs have for you? Caregivers, tell us what you notice.

What do we know without knowing any numbers?

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

The Valley of the Baby Dolls

I recently read ‘DANCING WITH ROSE: Finding Life in the Land of Alzheimer’s’ by Lauren Kessler. In it, she reveals the inner life of an Alzheimer’s care facility. I liked so much about this book but want to share one part in particular for now.

Early on in her job at the care facility, Kessler tells us about a group of ‘doll mothers.’

“One lady is sitting in the rocking chair, rocking her doll back and forth, back and forth, her eyes half-closed, her lips upturned in a half-smile. She has that dreamy look mothers have when they rock their babies. At one of the dining room tables sit Billie and two other doll mothers, all holding their swaddled babies to their chests.”

She goes on to describe both the residents and the workers fussing over the dolls, everyone playing along as if the dolls were real babies.

My grandmother who had Alzheimer's did this. She used to sit on her couch and hug them and coo at them. I think there were two dolls. I vaguely remember a stuffed bear named Henry as well, but it was the dolls she loved and mothered. I remember hearing her tell them how beautiful they were.

The first time I saw my grandmother doing this, it scared me. This was my grandmother who’d raised nine real babies now taking great care to swaddle a plastic doll. I looked to my Aunt Mary, my grandmother’s primary caregiver, for some explanation or reassurance that this behavior was somehow ‘normal’. She just looked back at me and said, “Shoot me when.”

My grandmother’s relationship with these doll babies went on for a long time. I never got used to it. What was going on inside her head? Did she honestly believe they were real babies? Was she just pretending? Did she think they were her babies or was she babysitting? By mothering and comforting these dolls, was she somehow feeling mothered and comforted herself?

I never asked her. I felt too embarrassed, too unnerved. I don’t know why they made her happy, but I know they did. Has anyone else seen this happen? Does it only happen with women with Alzheimer’s? What do you think is going on?

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Emotions Unchecked

Not too long ago, I studied acting for a year and a half. As with any approach to acting, the ultimate goal was to ‘live truthfully under imaginary circumstances.’ You don’t pretend to be enraged, grief-stricken, or in love, you actually feel these things in response to what happens. And when an actor is able to achieve this, the effect on the audience is powerful (I always think of Shirley MacLaine screaming in a heartsick rage on the beach with Jack Nicholson in Terms of Endearment. She moves me instantly to tears every time).

As grown adults, my classmates and I found this goal to be an extraordinarily difficult one to grasp. To respond readily with honest emotion, you must be able to turn off your ‘internal editor’ or your self-consciousness, your ‘monkey mind’. This is the part of your brain, that internal voice, that says to you, “Don’t say that! What will people think?” Or, “Don’t do that! You’ll be so embarrassed.” Or, “If you do that, the other actors and the audience will think you’re stupid, a jerk, or crazy.”

We’ve been socialized not to express our raw, primal emotions. We learn not to scream when we’re angry or cry when we’re sad. When we were two years old and felt overwhelmed or perceived some horrible injustice, we might’ve readily thrown ourselves onto the ground, screaming and writhing in pure anguish. But our (humiliated) parents told us not to do this, maybe punished us or refused attention, extinguishing the behavior, and gave us other tools to use other than expressing the emotion, like ‘using our words.’

Biologically, neurons from the cortex—the brain’s higher thinking centers—form powerful inhibitory connections on the neurons in the brain’s emotion centers. So raw emotion becomes strongly inhibited. Our primary job as actors is to release this inhibition and let the natural emotion happen. I remember watching a toddler throwing a fit in a store one day while I was in the middle of my training and thinking, “If only I could do that!”

Some of you caring for someone with Alzheimer’s and even some of you with Alzheimer’s may’ve noticed this disinhibition of the brain’s primary emotion centers--

Grandpa was always a quiet, reasonable man, and now he’s prone to explosions of loud, scary anger.

Grandma had always been a polite and proper lady, and now she’s being sexually provocative with the men in line at the grocery store.

What’s going on?

Alzheimer’s Disease doesn’t just disrupt memory. It also interferes with those inhibitory connections descending from the cortex to the brain’s emotion centers. Without those inhibitory signals, the emotion centers are free and clear to fire away—Rage! Grief! Lust!

So when someone with Alzheimer’s is reacting with uncharacteristic and unapologetic emotion, he or she isn’t becoming someone else or trying to be difficult. The part of the brain that learned emotional restraint is under attack. They don’t have the neurons they need to dampen or bury it. And, because this disease has likely attacked other parts of the brain involved in language, they may not have the communication skills to ‘use their words.’

My grandmother, who’d always leaned toward flirtatious, became at times embarrassingly outright with her sexuality when she had Alzheimer’s. She would’ve made a great actress. If only she could’ve remembered her lines.

Lisa Genova, Ph.D., author of STILL ALICE, www.StillAlice.com

Where Are the Spoons?

It takes me three tries to find the silverware drawer. I hand my seven-year-old daughter a spoon. She finishes her cereal, brushes her teeth, and we’re ready to go.

I can’t remember where I put my shoes. When searching for them, I spot my daughter’s library books that I forgot to return. Again.

After I locate my shoes, I’m finally ready to leave the house but then realize that I don’t have my sunglasses. I walk in and out of every room, hunting, desperate, mad at myself. Unsuccessful, I resign myself to spending the rest of the bright, summer day squinting when my daughter announces, “Mom, they’re on your head.”

I don’t have Alzheimer’s. I’m thirty-six years old, pregnant, and just moved into a new house in a new town. I’m tired from the move and the pregnancy and keeping up with the ceaseless needs of my life and family. And everything here is still unfamiliar.

In the old house, the silverware was kept in the drawer next to the refrigerator. Here, it is to the right of the sink. In the old house, we kicked off our shoes by the front door. Now, the front hallway is littered with towers of boxes, so our shoes end up somewhere else. My routine has been disrupted, and the mental map of where I live is under construction.

It’s no wonder I’m forgetting things. What a relief it is to know that this is normal and temporary, that once we’re moved in, once we get used to life here, once I have the baby (okay, when the baby turns four), then I’ll grab a spoon every time I reach for one and without even consciously thinking about it.

I can’t imagine what it must be like to have Alzheimer’s Disease---to experience these types of maddening lapses in cognition AND to know they will only keep happening and get worse. It must be more than frustrating and exhausting. It must be terrifying.

I think about how quick I was to give up on finding my sunglasses and do without them, and I wonder how readily people with dementia decide not to bother, to give up looking for the keys, that word, that thing.

Imagine if I’d moved AND had Alzheimer’s. This is precisely what happens in many families. Living alone becomes too dangerous for a grandmother, father, or aunt with Alzheimer’s, or the work of commuting and running two households becomes too much for caregivers living elsewhere. How difficult it must be for someone already coping with an unreliable mind to move to a new home! I’m not saying it’s wrong to have your grandmother, father, or aunt move in with you or to a care facility. I’m just saying---it must be incredibly hard to find the spoons.

Lisa Genova, author of STILL ALICE, www.StillAlice.com

Enrich Your Life

A friend of mine once posed this question to a group of people with early-onset dementia:

“What do you do to enrich your life?”

What a brilliant question! We should all poke heads up from our jobs, responsibilities, and schedules, take a look around and ask ourselves this question. It’s a brilliant question for any human being but is especially challenging and critical for those with Alzheimer’s, when what has always been life-enriching is leaving.

Following the thread of the story in a novel or movie may become too difficult, lack of coordination or memory for sequential steps may render previously beloved hobbies like woodworking, gardening, playing chess, or knitting impossibly frustrating, an intolerance for too much noise may prevent dining at a favorite restaurant, and travel may become too confusing and tiring to make it worth packing for that tropical vacation.

If the ground you’re standing on has cracked, shifted, or eroded too much to enjoy those things that have always enriched your life prior to Alzheimer’s, it’s time to assess the landscape you’re standing on now. This is also true for caregivers, whose days can become consumed with running the household alone and nights with exhaustion and isolation.

For both those with dementia and those caring for them, what you lose can be staggering and more than mildly depressing. Finding new hobbies and passions, new ways to relax and connect with friends and loved ones requires courage, determination, and creativity. I invite you to share the adaptations and strategies you’ve found with others who have begun to look. However you are affected by dementia,

What do you do to enrich your life?

Lisa Genova, author of STILL ALICE, www.StillAlice.com

Hope in Your MRI

Over the past couple of years in my conversations with people with dementia, I’ve come across a lot of confusion over MRI’s and the diagnosis of Alzheimer’s. Many were surprised to learn that their brain MRI’s were perfectly normal AND they had Alzheimer's Disease. One woman was told by her physician that because her MRI was normal, she couldn’t possibly have dementia.

The truth is, especially if you’re in the early stages of Alzheimer’s, there will likely be no cellular loss visible on your MRI. You can be forgetting how to drive home a mile from your house and the MRI image of your brain can look completely normal. How can this be?

It used to be the standard thought that amyloid plaques and/or neurofibrillary tangles got deposited in the brain, and these deposits “gunked” up the neurons and caused them to die. And this neuronal death caused Alzheimer’s.

Here’s the new thinking.

The cognitive deficits–the symptoms of dementia–occur BEFORE the plaques form, before the neurons die. In the brain of someone with Alzheimer’s, there is too much of a soluble protein called Amyloid Beta 42. Either too much is made or not enough is cleared away. When too much is present in the synapse, these individual little peptides stick together and form small oligomers. These oligomers of Amyloid Beta 42 lodge in the synapses and interfere with synaptic transmission—the ability of neuron #1 to give it’s electrochemical information to neuron #2. Through a complex molecular cascade, these oligomers are specifically impairing neurotransmission through NMDA receptors, a very important kind of transmission necessary for something called Long Term Potentiation.

So these oligomers of Amyloid Beta 42 lodge in synapses and prevent good neurotransmission from neuron #1 to neuron #2. And behaviorally, new information isn’t learned. Or old information can’t be accessed. Synaptic plasticity suffers. Over time, because these synapses aren’t working properly and because of inflammation and other problems, those nerve axon terminals will retract. Eventually, unable to function, the neurons will die, leaving behind empty space (the atrophy seen on an MRI) and possibly heaps of Amyloid Beta 42 in amyloid plaques.

So it all starts as an attack on the synapses. The degree of dementia correlates only with synapse dysfunction, not with neuronal loss, not with number of plaques, not with atrophy on an MRI.

The cure for dementia then, the kind of treatments that will be disease-altering, will
1. Impede production of Amyloid Beta 42, or will
2. Increase clearance of already-produced Amyloid Beta 42, or will
3. Prevent Amyloid Beta 42 from sticking to itself so it can’t form oligomers, or it will
4. Rip these already-formed oligomers apart.

The beauty and the hope in all of these treatments—people suffering from symptoms of dementia can be treated BEFORE they’ve experienced any neuron death. If the synapses are fixed, neurotransmission can work again. Function can be restored!

Lisa Genova, author of STILL ALICE, www.StillAlice.com

Away From Her

Last night, I saw the movie AWAY FROM HER starring Julie Christie (Fiona) and Gordon Pinsent (Grant). Fiona, a bright and active woman, develops Alzheimer’s disease, and the story explores what happens to her relationship with her husband and what remains of the love in their 44-year marriage as her shared memories of their life together disappear. The movie is respectful to many of the realities of living with Alzheimer’s and doesn’t commit Fiona instantly to vacant oblivion. Christie delivers a powerfully authentic performance, revealing layers of awareness colored by confusion, embarrassment, panic, humor, and resilience through an ever-thickening fog of dementia. And Pinset’s portrayal of her husband’s denial and then heartbroken devotion are believable and moving as well.

I fully recommend the film, but I do think it simplified a lot. For example, although we see what Alzheimer’s does to Fiona and Grant, their story contains no children, no siblings, no friends or colleagues, no grandchildren. In my family and in others I know, the impact and loss from Alzheimer’s are felt not just by the person with dementia and his or her caregiver. It ripples through the family, through friends of family, through the community they live in. And it affects everyone differently.

What did you think of the movie?
How has Alzheimer’s affected you?

Lisa Genova, author of STILL ALICE, www.StillAlice.com

How Did I Get Here?

How did I get here? So many of my roads have led me here, it must be inevitable. Let me start at the beginning.

Inspired by the stories by Oliver Sacks and a curiosity for understanding how the brain works to affect behavior and reveal who we are, I entered the graduate program in neuroscience at Harvard in 1994. I quickly became interested in the mechanisms underlying addiction, how the same drug administered chronically could hijack our natural reinforcement systems and dissociate wanting from liking. My lab bench was just down the hall from Rudy Tanzi and others who were working to crack the genetic code for Alzheimer’s. I graduated with a PhD in the spring of 1998 with a keen interest in the Alzheimer’s research being conducted down the hall, but I wouldn’t say I’d been directly touched by Alzheimer’s disease yet. That came next.

Looking back, my 85 year-old, widowed grandmother had been showing signs of dementia for years. But she was a smart and active woman, and she navigated around her symptoms with great skill for some time. And her nine children, their spouses, and her grandchildren were all content to look the other way or to pass off her cognitive mistakes to normal aging.

Then we got the phone call. She’d walked to the bowling alley at four in the morning, insisting it was middle of the day and wondering why no one was there. It was quite literally the wake-up call that forced my family to look directly at her and what was going on.

Her daughter, my Aunt Mary, moved into her house (along with my Uncle Barry) and began working from there. Her other daughters, my mother, and, less often, I came over to help out. With nothing we could actually do to alter the course of her disease, like spectators we all watched Alzheimer’s systematically disassemble the woman that was my grandmother. Ironically and almost immediately, she forgot who my Aunt Mary was. When we told her that she was her daughter, Mary, I was struck by how she never believed us and that this didn’t ruffle her. Before Alzheimer’s, if you’d told my grandmother that someone was her child who she believed wasn’t, she most certainly would’ve argued with you or laughed at you or both.

She was losing herself. I watched her studying her own face in the mirror, not comprehending the old woman’s face she saw. She didn’t know her last name, the time of day, to remember to go to the bathroom when she needed to, who her children were, who I was.

But although she lost her history and couldn’t understand who we were or why we were there (she told people my Aunt Mary was a homeless woman who’d wandered in to live with her), there were parts of my grandmother that never left her. As she always had, she loved lively company. We’re a loud, Italian family. She delighted in having us there, sitting around her kitchen table, eating, laughing to tears, telling stories. And she remained good-natured and good-humored, always willing to participate. Here’s one of my favorite exchanges—

Aunt Mary: Come on, Ma, we’re going to the movies.
Nana: Okay, I don’t know who you are, but I’m coming!

The reasons why her family loved her, the reasons why we are connected, disappeared for her, but they didn’t for us. We continued to love her, and she accepted it. She understood our hugs and kisses and smiles and returned them with great enthusiasm. I know she felt included and loved to the moment she died. I know this is my Aunt Mary’s proudest achievement in life.

So I have a background in Neuroscience and a grandmother who had Alzheimer’s disease. I’m on the road to here but not quite here yet. There were a couple of additional avenues I needed to travel first.

As I visited with my grandmother, the neuroscientist in me became fascinated with her progressive dissociation from her concept of self. I wondered what it must feel like, when those parts of the brain that inform awareness and identity become increasingly inaccessible, and I wished I’d thought to ask her more when she had the communication skills to describe it to me. A lover of learning and knowledge, she would’ve readily considered my questions. What is having Alzheimer’s disease like from the point of view of the person with Alzheimer’s? This question was the seed of the novel I would write.

I needed to meet people with Alzheimer’s in the early stages, people who could still describe what it’s like to have dementia. I found them at www.dasninternational.org, an online community of intelligent, articulate, and passionate people in their forties, fifties, and sixties with dementia who support each other and advocate for better care and a cure. They bravely shared their most vulnerable experiences, helping me to create a fictional story about a young woman with Alzheimer’s that is in every way possible faithful and respectful to what having Alzheimer’s is actually like. To these amazing friends of mine, I owe my deepest gratitude and admiration.

When I began the book, I thought I was writing a story as a neuroscientist in honor of my grandmother and family. And I thought that when I finished, I’d quickly move on to other endeavors. But in the course of writing the book, my eyes were opened to more than I’d expected. I see what people with Alzheimer’s and their loved ones struggle through, emotionally, physically, and financially. I see how difficult getting a proper diagnosis can be. I see how ignored and outcast people with Alzheimer’s become. I see how close we could be to a treatment that can stop this disease in its tracks. Seeing what I see, I knew I’d be sticking around.

I’m a neuroscientist, granddaughter, friend, and author. And I’m here. How did you get here?

Lisa Genova, author of STILL ALICE, www.StillAlice.com