Sixty- five but Much Older

The dilemma of the clinical visit was to arrive at a possible diagnosis for the patient. He demurred to his wife's opinion often, maybe he became this way over the last year as he experienced declining intellectual function. Maybe he had always been the milder, softer one. He never noticed the shuffling gait. His wife commented on it while they vacationed in Italy and walked over the cobblestone streets.

He noticed not being able to find the car, not being able to read the directions and carry out tasks, like putting together a grandchild's swing set. Then he was diagnosed with diabetes and suffered from acute attacks of anxiety. Did the anxiety come as a reaction to the awareness he was truly ill? Was it tied to the forgetting? Or was anxiety something he'd always felt but was now unable to hide? At times his voice wavered and the area above the top lip whitened and flattened on his bottom lip revealing emotion behind his words.

The doctor explains the alternatives; Alzheimer's disease, Lewy Body disease, fronto temporal dementia, normal pressure hydrocephalus, and vascular Parkinsonism. With the left hand he holds the MRIs against his body while he jabs the plastic pictures into the light box with the right hand. He shows the wife and others the enlarged ventricles, explaining that with aging the brain begins to shrink. The sulci, the noodle-like outside of the cortex has atrophied and the darker cerebrospinal fluid outlines the depressions and mounds. The spouse asks whether the brain looks like that of someone who is sixty five. The physician shakes his head and replies it looks older, 65 is still young.

The patient has none of the stiffness or rigidity that comes with PD, his arms and wrists are supple in tone. While he is slow in his movements, it is not excessive. His speech is soft, remarkably so for a big man but it carries none of the urgency that patient's with PD convey. Like the tiny shuffling steps that occasionally plague patients, sometimes the words are fast, rapidly fired. He lacks everything rapid.

They know the outlook is bleak, even though the doctor doesn't feel he has Alzheimer's. He is given a new prescription for Namenda, a drug known to curb deterioration of memory. He is already taking Excelon. Hours of neuropsychiatric testing confirmed and objectified the loss in cognitive skills, though the wife was already well aware of what was gone. He doesn't pay the bills anymore. He looks to her to tell the complete story, and she holds back details to avoid embarrassing him.