Memory, Alzheimer’s and “Still Alice” – a sensitive portrayal of the impact of Alzheimer’s.

“Has it ever struck you that life is all memory, except for the one present moment that goes by you so quick you hardly catch it going? “

— Tennessee William’s play “The Milk Train Doesn’t Stop Here Anymore“

Mayi sarvam idaṁ protaṁ sūtre maṇi-gaṇā iva.

“Everything rests in Me, as beads strung on a thread”

–Bhagavad Gita: Chapter 7, Verse 7

It is a miracle that we wake up in the morning to our identity, that we get out of bed connected to a stream of memories, our autobiographical self. It is mysterious, how, somewhere in our brain, a constellation of neurons fires up and coalesces at the first touch of conscious attention to resurrect our distinct selves, unfailingly consistent with my lived past. What a thing memory is? And how little we understand or value it, until it begins to show signs of degeneration or aging. Memory is a delicate balance of the factual specific and the abstract generalization, and is always in a state of flux, ingesting, discarding, sorting, and rebuilding the intricate structure of our conscious self.

One of the haunting short stories of Jorge Luis Borges, the great Argentinian writer, is about a man called Funes, who can only hold memories of the specific, the particulars of the moment. Funes loses the essential quality of categories, which is essential to the preservation of memory, in an accident. However, nothing he sees, feels, hears, or touches is ever forgotten. Every sensory perception leaves an indelible imprint in his brain. He can recall with vivid clarity the faint veins running across every leaf, the streak of white which lies buried in grey cloud, and the beguiling smile of a baby seen years ago, but the one thing he cannot do is stitch these discrete moments into a whole or place them in context. There is no past or future to those dazzling crystalline impressions, it hangs unhinged, resplendent, and real without a chronological tether to hold them together. Funes has lost that mysterious capacity of the brain to generalization, consolidate, to gather strands of memories into an episodic event. Memory, as Borges beautifully brings out in the tale, is a delicate balance between the semantic storage of facts and the episodic contexts that give meaning to the facts. One needs both to lead a normal life.

Memory-related issues are a relatively modern phenomenon. Ironically, only with increased life expectancy over the last hundred years, memory disorders have become a more prevalent condition. After all, in the early 1900s, people didn’t live long enough to feel the effects of reduced memory function. The neurons are for the most part very resilient and judiciously scattered across the surface area of the brain (not localized as it is commonly assumed to be) except for the sensory centers in the brain. It takes a severe brain injury or the natural process of chronological aging of the body to affect its structure and function. Though modern science has uncovered so much about the human brain and its working, we are still far away from a comprehensive understanding of how memory works? We now know how the neurons align to form memories, and which parts of the brain are responsible for short-term and long-term memory making. We know the genetic code of each neuron and the proteins that constitute the bulwark of the neural network. Yet with all this plethora of detail, the act of remembering is still as elusive as ever. How the self conjures, instantly, the rich and vivid array of colors, sounds, shape, and smell, from the deepest recesses of the brain and brings forth a kaleidoscope of memories – is still a mystery. Only when the capacity to remember, to retrieve memory diminishes due to old age or disease, do we really begin to understand and appreciate this extraordinary gift of memory, and the intricate tapestry of neural connections that makes this phenomenon possible? I often hear people joke about the need for memory when one can google to get all the answers. I look at such people with pity and disbelief. Memory is not just about facts, it is your very self, the wisdom stored when facts are properly digested. Echoing the thoughts of Tennessee Williams quoted earlier in this essay, we are what we are because of our memories.

One of the most common causes of age-related memory disparagement is Alzheimer’s disease. It is the slow withering away of memories, a deterioration of the quality of neurons, often imperceptibly, across years, resulting in the tragic loss of identity, function, and dignity in the individual. When Alois Alzheimer saw his new patient Auguste Decker on 26th November 1901, the first statement he wrote in his dossier (which was recovered from a hospital in Frankfurt in 1995) about Auguste was:“ Sitting up in bed, expression distraught”. What a stunning medical observation! It echoes across decades as the definite expression and state of an Alzheimer’s patient. Auguste was admitted to the psychiatric ward because she was confused, restless, and impatient. No longer able to manage her condition at home, she was brought to the hospital. Auguste Decker was the first known patient with the diagnosis of Alzheimer’s, named after the doctor himself who identified its symptoms and causes. Auguste died of complications five years later in 1906, and by that time Dr. Alzheimer had moved on to another hospital. Honoring the doctor’s request, the hospital sends the complete medical dossier on Auguste along with her brain for his study. During an examination of her brain under the microscope, Dr. Alzheimer found what would come to be known as the tell-tale signs of Alzheimer’s disease—deposits of plaques and tangles of neurons. When Dr. Alzheimer presented his paper at a conference, he had only four case studies (three more from another doctor) after five years of research to back his thesis. His paper went unnoticed. The Psychiatrist Carl Jung was the prominent attendee in that meeting, and immediately after the presentation of Dr. Alzheimer’s paper, the discussion of the group turned towards the recent developments in psychoanalysis. After all, Freud had written his best-selling book“ The interpretations of dreams” just seven years ago, and neurologists and psychotherapists were more interested in the subconscious workings than the damage and death of a few neurons in a few stray cases.

Alzheimer’s is typically an old-age ailment—a sixty-plus disease, generally. As the body ages, the brain atrophies. But in some cases, the origins of Alzheimer’s disease can begin early. The slow degeneration of the neurons takes place over years until it begins to manifest as memory and attention deficiencies. A sudden lapse in memory, unexpected disorientation in one’s bearings, a momentary forgetfulness that doesn’t feel right, a feeling of inner restlessness—these are the preliminary symptoms of what could potentially be Alzheimer’s. And as the disease progresses, the patients lose their capacity to anchor themselves in the world. They become disjointed, cut off from the self, amnesic, and loss of several capacities. As the disease takes root, it often strips people of their dignity and makes them dependent on others. The body continues to be strong, but the enervating mind that enlivens the body gradually becomes unmoored, untethered, and amnesic. Forgetfulness becomes a distinctive trait, not merely of facts (which is common with all of us), but of events in chronological time. It is impossible for others to experience or understand this state, this condition of progressive unknowing and regression, that Alzheimer’s can induce in a patient. In Shakespeare’s play “As you like it”, Jacques called the last stage of man: “second childishness and mere oblivion; Sans teeth, sans eyes, sans taste, sans everything”. But the question is: Does Alzheimer’s strip a man away of his core self, “Sans everything”? It doesn’t. Despite the loss of every capacity and faculty dear to the individual as the disease ravages the brain, they continue to retain their essential essence. Anyone who has cared for an Alzheimer’s patient will attest to it. There are moments of lucidity, or clarity, when a piece of music, a picture, a casual conversation, a meeting, or just an infinitesimal break from the grip of amnesia can bring back the original fullness of the self, the self before the disease set in. Alzheimer’s patients often look lost, distraught, and listless, with no initiative of their own; but deep down, the center remains intact. Those close to them, care for them and can witness glimpses of that self, every once in a while. In Dr. Oliver Sack’s wonderful book “Musicophilia”, he describes a person with Alzheimer’s, a musician, who can sing along once the cue is given to him. Even though the disease had taken away everything else from him, the psyche still retained his musical self intact. It could burst into a song without skipping a beat and a word, but once the music stops, he would relapse into the listless world of the disease.

In recent times, “ Still Alice”, a book by Lisa Genova, adapted for the screen in 2014, captures the predicament of the early onset of Alzheimer’s with commendable sensitivity. Julianne Moore played an academy award-winning role as Dr. Alice Howland, fifty years old, a distinguished linguist and cognitive psychologist at Columbia University, diagnosed with Alzheimer’s at the peak of her career. Her first experience of something wrong happens during a routine presentation to her class, when she suddenly slips midway during her lecture, groping for a word, unable to articulate her thought. She immediately senses that this is not an instance of casual forgetfulness, which is quite common, but a void in perception, a crack in the continuity of something vital within. The rest of the movie is about the slow degeneration of vital capacities, progressive escalation of the disease, and the impact it has on the family, her social life, career, and most importantly, on herself – the loss of dignity and independence, which was so crucial and emblematic of Alice’s existence before the illness. That an esteemed processor of linguistics, author of a seminal book on the subject, can lose her capacity to speak, and find it difficult to remember words, is tragic. The movie also focuses on the emotional toll Alzheimers can impose on the family. Watching their loved one gradually shrink into a cocoon, losing touch with the world around, is painful. There has to be a readjustment to the priorities of everyone around. Caring for someone with Alzheimer’s is a full-time job, and requires deep love and empathy. The caretaker should believe that the person who once was is still is, and only such a conviction, such a strong bond of love can make a difference in the patient’s life. In one of the most heartbreaking climaxes of modern times, Alice’s daughter, Lydia, a theater artist, reads out a long poem she has written, to her mother who has now completely receded into the grip of the disease. Alice listens to her daughter’s voice without any visible reaction. After Lydia finishes the recitation, she inches close to her mother, and gently asks her “ Mom, did you listen to the poem. what was this poem about?. Alice slowly turns around, and after a deep pause, and with much difficulty says “Love. It is about love”. Alice still is, despite the ravages of the disease.