Oliver Sacks (1933-2015)

"Oliver Sacks, the world-renowned neurologist and author who chronicled maladies and ennobled the afflicted in books that were regarded as masterpieces of medical literature, died Aug. 30 at his home in Manhattan. He was 82."

-- the lead of Emily Langer's Washington Post obituary

"You are an abomination. I wish you had never been born."

-- an observation made to Olliver Sacks, quoted by Emily Langer

by Ken

The death of Oliver Sacks can't have surprised anyone, least of all Oliver Sacks himself, since he had gone as public as a person can (writing in the New York Times) with the news that he had terminal cancer. But that doesn't make it any less earth-shaking. For a lot of us, an overwhelming amount of what we've come to learn about the workings (and nonworkings) of the human brain, and even the human mind (i.e., the brain in working context) have come through his prolific and deeply felt writings.

In August 2010, for example, I wrote -- in some awe -- a post called "Oliver Sacks opens a window, personally, on the condition of 'face-blindness,'" about Sack's just-appeared New Yorker piece about prosopagnosia, whose sufferers are unable to recognize faces. In the piece he made me see how this goes to the heart of the way we perceive and make sense of the world around us -- and also startled me with the revelation that his knowledge of the condition began at first hand.

Here's a bit more of Emily Langer's WaPo obit:

An Englishman who made his life in America, Dr. Sacks devoted his career to patients with rare, seemingly hopeless conditions of the nervous system. He distinguished himself both in the clinic and on the printed page and was often called a “poet laureate” of modern medicine.

His books, many of which were bestsellers, generally took the form of clinical anecdotes. A man who mistakes his wife for a hat, an artist who can no longer see in color, a hospital full of patients gloriously, but fleetingly, “awakened” from years-long catatonia: In each case, Dr. Sacks sought to uncover some wisdom, medical or moral.

Not surprisingly, the obit is mostly admiring, but Emily does cite two general, quite harsh criticisms. The one I've quoted above is buried pretty deep in the piece; we'll come back to it. Here's the other:

Dr. Sacks discomfited some readers, who maintained that he capitalized on his patients’ suffering to form handy parables. Tom Shakespeare, a British disability rights activist, called him “the man who mistook his patients for a literary career.”

Now I haven't read the source, and I don't especially care to seek it out. It's possible that in context Tom Shakespeare isn't a total nincompoop and is conjuring a trap that the kind of writing Oliver Sacks did has to guard against. It doesn't sound like that's what he meant, but let's entertain the possibility that he's not the total nincompoop this quote would make him out to be. If you were to make up a list of writers -- neurological professionals or otherwise -- who had the largest positive impact on understanding of and care for the neurologically impaired, my guess is that Oliver Sacks would occupy the top 50 positions, at a conservative estimate.

For a fuller appreciation, we're going to turn to his longtime New Yorker and medical colleague Jerome Groopman, the magazine's great writer on medical subjects. So let's turn back to the other judgment rendered about Sacks, which as it happens came from the subject's mother. Now when a man has been called "an abomination" by his mother, who further expressed the wish that he had never been born, you would think it might have a certain, um, piquancy, a certain resonance, in his life's story.

Even if you didn't know what might have produced such a judgment, I'm guessing you wouldn't have much difficulty guessing. Here's the quote again, with a bit more context:

Oliver Wolf Sacks, one of four sons in an observant Jewish family with many scientists, was born in London on July 9, 1933.

Both his parents, he said, were “medical storytellers.” He went on house calls with his father, a Yiddish-speaking family doctor, and studied anatomy with his mother, a surgeon who sought to instill in her son a love of anatomy by performing dissections with him.

She also instilled in him what he described as a sense of shame about his sexuality.

“You are an abomination,” she told him, Dr. Sacks recalled, when she learned of her son’s homosexual leanings. “I wish you had never been born.”

Dr. Sacks reflected on the exchange years later in “On the Move,” a memoir that would be his last volume published in his lifetime.

“We are all creatures of our upbringings, our cultures, our times,” he wrote. “My mother did not mean to be cruel, to wish me dead. She was suddenly overwhelmed, I now realize, and she probably regretted her words or perhaps partitioned them off in a closeted part of her mind. But her words haunted me for much of my life and played a major part in inhibiting and injecting with guilt what should have been a free and joyous expression of sexuality.”

Now, as promised, here's the beautiful piece Jerome Groopman put up this afternoon on the New Yorker website:

Oliver Sacks, a dear colleague of mine at The New Yorker and in the world of medicine, was an inspiration to me and to countless physicians. A great deal will be said in the coming days about Oliver’s unique literary output -- masterful books including “An Anthropologist on Mars,” “Awakenings,” and “The Man Who Mistook His Wife for a Hat.” But we should remember that he also embodied in his medical practice a kind of ideal approach -- creative, sensitive, and large-hearted -- to his many patients. He was an extraordinary and exemplary doctor.

Neurology is often depicted as a discipline of great detachment. Sacks, who was eighty-two when he died, trained in the field before the advent of the CT scan and the MRI. He learned to observe his patients in extreme detail, calling on his professional training and uncanny perception to make meticulous analyses of motor strength, reflexes, sensation, and mental status; in doing so, he arrived at a diagnosis that might locate a lesion within the anatomy of the brain or spinal cord. And yet, because medical technology had only gone so far in those days, once this intellectual exercise was completed, there was often very little that could be done to ameliorate most neurological maladies.

Sacks showed that it was possible to overcome this limited perspective. He questioned absolutist categories of normal and abnormal, healthy and debilitated. He did not ignore or romanticize the suffering of the individual. He sought to locate not just the affliction but a core of creative possibility and a reservoir of potential that was untapped in the patient. There was case history, for instance, of a color-blind painter who lost all perception of color discovered he could capture the nuances of forms and shapes in hues of black and grey with great mastery.

As both a physician and as a writer, Oliver’s two great themes were identity and adaptation. Illness, he made plain, need not rob us of our essential selves -- and this was something he exemplified in his final months, as a he continued to write remarkable essays even as cancer began to sap his strength and overwhelm him. Sacks understood our frequent ability to adapt, and emphasized that the capacity for someone to adapt to a particular condition -- amnesia, blindness, deafness, migraines, phantom-limb syndrome, Asperger’s syndrome, and countless other conditions -- cannot be known from the outset. These concepts grew from his study of zoology and evolution at Oxford. He similarly saw in medicine a great diversity among individual patients, and the inherent uncertainty of the outcome of a particular disorder. These unknowns gave hope to patients guided by the right doctor -- a hope he captured in his description, in “Awakenings,” of catatonic-seeming encephalitis patients at Beth Abraham Hospital, in the Bronx, who had been written off as “locked in” and then revived, at least provisionally, by drugs like L-Dopa.

Sacks was a contrarian who refused to compromise this approach to the sick and the suffering. He resisted the powerful current of modern practice that seeks the generic. He rejected a monolithic mindset, and retrieved the individual from the obscuring blanket of statistics. This put him outside of the academy, exiled to chronic-care institutions. Through his writing, Sacks ultimately received recognition for advancing a unique form of clinical scholarship that was largely abandoned: the study of the single person within the context of his own life. Ever the acute observer, his case histories confirmed that under a single diagnostic term was a spectrum of human biology. No two patients are ever the same, he emphasized. When examining patients on the autistic spectrum, for example, he highlighted, and informed the public about, individuals with the capacity to draw precisely from memory, the capacity to make calculations nearly at the speed of a computer, or the ability to listen to a piece of music and reproduce it on the piano.

Sacks made house calls, not only in California and New York where he practiced, but globally, visiting Dr. “Bennet,” a surgeon with Tourette’s syndrome in rural Canada or the autistic artist Stephen Wiltshire on a tour of Europe. In these visits, he practiced what might be called the medicine of friendship, showing genuine interest and respect to people who are often shunned. This was the therapeutic intervention when neurology lacked effective pills or procedures.

This did not mean Sacks was a Luddite. He was an avid reader of scientific journals, fascinated by scientific advancements in imaging the nervous system at work. He engaged in dialogue with Nobel laureates and lab scientists about the nature of consciousness, providing what they lacked -- the insights of a naturalist, a field worker.

Sacks also embodied an attribute that can be lost after people become famous: a boundless generosity of spirit. He encouraged young doctors and scientists to record their experiences and communicate them in prose, celebrating their endeavors rather than seeing them as a form of competition or threat. I believe his intense curiosity and boundless energy moved him to want to learn from the succeeding generation, as great teachers do.

Over the past years, Oliver revealed a part of his life that was once considered a debility and disorder -- his sexual orientation. The demeaning of this part of his person, he believed, was the cause for his descent into amphetamine abuse. Drugs may well have killed him decades ago, before his contributions to medicine and writing. It was clinical work, caring for others with competence and compassion, that proved therapeutic for the doctor, giving him the strength to break the powerful grip of drug use. After decades of celibacy, Oliver shared the last eight years of his life with the writer Billy Hayes.

In May, after I had reviewed “On the Move: A Life,” his autobiography, he sent me a letter about what he wanted to accomplish in the time left to him. “In whatever time remains,” he aimed to “pull together another book of case histories–some large … some small, even miniature.” Every dimension of the patient was meaningful in his thinking.

#

"Lewy Body Dementia" sounds like more fun than it is -- that word "dementia" is probably a good tip-off

Lewy Bodies may sound like things you'd enjoy playing with, but apparently not so much.

by Ken

Didn't I say way back, well, awhile ago, that one thing I really, really didn't want was to find myself on the dementia beat? Well, here am I bearing cheery news about yet another form we can add to the smorgasbord of dementia delights we can hold ourselves ready for -- unless, as Michael Kinsley might put it, a big, big truck comes along to carry us off first.

"Lewy Body Dementia"?

We all know all about Alzheimer's, right? And maybe a little about Parkinson's -- especially if we've read Michael Kinsley (see link above)? And probably it's occurred to many of us that there are other forms of dementia, maybe many other forms of dementia, lying in wait for us out there.

Typically, to make life even more charming, we can expect these other forms as well to be "difficult to diagnose," as the report below puts it, though the difficulty is mitigated somewhat by the limited options for treatment anyway. Just recently, faced with the possibility of, finally, an actual test for Alzheimer's, we pondered the question of whether you'd want to know that you have it.

Very likely you too are on the mailing list for Johns Hopkins Health Alerts, a bustling enterprise whose white papers and other publications actually do draw on the substantial medical resources of the Johns Hopkins community. (Please note that the link is there purely for informational, not for promotional, purposes. It just would have seemed wrong to bring them up without offering a link.) Usually the e-mails tease you with questions to which you might like to know some of the answers, for which you need to buy the publication on offer. (Yes, I've bought a couple, and have to admit that one I found quite useful. They always come with a money-back guarantee, so you can't get really hosed. One would like to think that Johns Hopkins wouldn't be eager to risk its reputation for the sake of some extra bucks. Again, I offer this strictly for informational and not promotional purposes.)

Sometimes, however, we get a freebie, as in this case. Maybe there just isn't an eager market for Lewy's Bodies info -- yet.

Understanding the Signs
of Lewy Body Dementia

Most people associate dementia with Alzheimer's disease. But 1.3 million Americans have another form of dementia called Lewy body dementia or dementia with Lewy bodies. This progressive neurological disorder is named for the Lewy bodies -- tiny deposits of a protein called alpha-synuclein -- found in certain areas of the brain. Over time, these proteins accumulate and cause the death of brain cells. This results in impairments in certain cognitive functions, such as memory, language processing, emotions and behavior, as well as control of movement.

Some experts identify two types of Lewy body dementia: dementia with Lewy bodies, in which cognitive symptoms appear within a year of neurological problems such as slowness of movement and impaired balance, and Parkinson's disease dementia, in which cognitive symptoms appear more than a year after the onset of movement problems.

Difficult to diagnose. No specific brain scans or lab tests can pinpoint the presence of Lewy body dementia, although a type of scan, DAT, or dopamine transporter SPECT scan, can support the diagnosis. Diagnosis of Lewy body dementia is based on identifying the symptoms -- which can vary widely in severity from person to person -- and then ruling out other possible causes such as certain drugs.

The progressive decline of mental function is the primary symptom of Lewy body dementia, but what sets it apart from Alzheimer's disease is the presence of subtle symptoms referred to as parkinsonism because they're not fully suggestive of Parkinson's disease and because hallucinations are common at the beginning of Lewy body dementia. Some symptoms common to early Lewy body dementia and other forms of dementia include:

• Memory loss, difficulty with reasoning, problem solving, visual and spatial judgment and multitasking
• Behavior and mood changes, including depression, anxiety and delusions
• Confusion
• Sleep problems

Certain symptoms are more pronounced in Lewy body dementia than in other forms of dementia:

• Movement difficulties, such as muscle rigidity, a shuffling gait, tremors and loss of coordination, are similar to Parkinson's symptoms but appear more spontaneously.
• Unlike with Alzheimer's, acute episodes of drowsiness and worsened cognition are common, accompanied by worsening attention, focus and alertness. The fluctuation in mental alertness occurs intermittently and can vary from day to day and even hour to hour.
• Vivid hallucinations appear in the early stages of the disease, whereas they tend to occur in later stages of Alzheimer's.
• Sleep problems, particularly REM (rapid eye movement) sleep behavior disorder -- in which the patient acts out dreams, may move in ways that appear violent and may fall out of bed -- may start years before memory symptoms and cause excessive daytime sleepiness.
• Falls, delusions, brief episodes of unconsciousness and fainting are common.
• The part of the nervous system that regulates automatic actions may be affected, resulting in fluctuations in blood pressure, heart rate and body temperature; sexual dysfunction; constipation; or dry eyes or mouth.

Now don't you feel better?

#

Do you want to know if you have Alzheimer's?

Say, how 'bout those Rangers?

by Ken

There are questions that don't have easy answers, and maybe not even a good answer. In the May AARP Bulletin, Peter Janet raises one heck of a nasty question:

Do you want to know if you have Alzheimer's?

He writes:

When researchers recently announced a promising new blood test for Alzheimer's disease -- one that could be as simple to perform as a standard cholesterol test -- reactions were mixed. While some experts heralded the news, others worried that, until effective treatments are available, learning that you're likely to develop Alzheimer's could cause more harm than good.

CERTAINLY THE VICTIM PATIENT -- SHOULD KNOW

If it were most any other sort of disease, I think most of us would say, of course the patient should know. So why should Alzheimer's be any different? There can be real advantages.

• "Experts say that developing a test for Alzheimer's allows for the possibility of more effective treatment. 'The main problem with treating Alzheimer's disease today is that the medicines are probably given too late to do much good," says Howard Federoff, M.D., professor of neurology at Georgetown University Medical Center, who was part of the team that developed the test. "Our research reports a biomarker that will allow us to select patients who have very early disease, and we can determine if medicines are more effective when given earlier.

"There's already good evidence that simple lifestyle changes can help slow the likelihood of developing dementia, says Jason Karlawish, M.D., professor of medicine at the University of Pennsylvania, who was not involved in developing the test. "A heart-healthy diet, physical activity, and social and cognitive stimulation can help preserve cognitive function," he says. People who learn that they are at high risk of developing Alzheimer's may be more motivated to make healthy changes.

• "Early detection would allow people to make informed decisions about their care before the symptoms of Alzheimer's get in the way -- one reason both the Alzheimer's Association and the Alzheimer's Foundation of America support early diagnosis."

ON THE OTHER HAND: "THERE ARE WORRIES"

The fact is, Alzheimer's isn't like most any other sort of disease.

• " 'A positive result on a test like this could be devastating,' says Craig Klugman, a bioethicist who chairs the Department of Health Sciences at DePaul University. 'It could change people's outlook on life, making them anxious, depressed and withdrawn. Suddenly you find yourself living with this sense of doom that can affect every dimension of your life.' "

• "People who test positive might also suffer the added burden of feeling stigmatized or ashamed, experts warn."

• "The stress of learning that you are likely to develop Alzheimer's could even worsen the symptoms of forgetfulness and confusion. 'What was a simple momentary lapse of memory before now becomes a terrifying symptom of this dread disease,' says Klugman.

"Indeed, a recent study looked at the effect of telling people that they carry a genotype that puts them at high risk of developing Alzheimer's. Those who learn that they tested positive judge their memories more critically and perform worse on memory tests than those who are not told."

• "Like almost all tests, the new blood test isn't perfect. The 90 percent accuracy rate means that some people would be told they will likely develop Alzheimer's over the next several years when, in fact, they won't. 'That would mean someone's life was turned upside down for nothing,' says Klugman."

SO, SHOULD PEOPLE WHO HAVE ALZHEIMER'S KNOW?

Good question. Say, how 'bout those Rangers making the Stanley Cup finals?

#

"I wanted to hear her talk with confidence . . . not in the self-pitying voice [of her] old age -- an abandoned mother" (Andrew Lam)

On HuffPost, where Andrew Lam also posts, this photo (unidentified on both New America Media and Nation of Change postings, is captioned: "Lunch at my uncle's home in Saigon in 1972. I'm in my mother's arms."

by Ken

Believe me, I'm not angling for the DWT dementia beat, but it beats writing about such self-created mental dysfunctionals as Rafael "Ted from Alberta" Cruz (and his worse-than-McCarthy list of Obama "crimes" -- see Dana Milbank's masterful "Ted Cruz, the reckless accuser"); or that "noisome arrogant little man" George Will, ridiculing the First Lady's public voicing of concern for the kidnapped Nigerians ("Is there anyone on the planet who is a bigger ass in a wig than George Will?"); or Gov. Kris "NJ Fats" KrispyKreme, whose lies are now so all-consuming and laid on so thick that you wonder if he's begun to believe some of his fables; or 15-minutes-of-fame sociopath Cliven Bundy, whose "Thugs Suddenly Deny They Pointed Weapons at Federal Agents (LMFAO)."

No, these people have all, in their own ways, chosen to deform and/or disable their brains into tangled contraptions incapable of taking in and honestly processing information. It's almost a relief to turn to people who can't help themselves. For people who've had a close encounter with dementia (which, as I noted in writing a couple of weeks ago about Michael Kinsley's remarkable April 28 New Yorker "personal history" piece, "Have You Lost Your Mind?: More bad news for boomers," is more and more of us) or who think about being engulfed by what Kinsley called "the tsunami of dementia that is about to swamp us" (which is also more and more of us), the subject exerts a mighty, sometimes irresistible pull.

Now Andrew Lam, the Vietnamese-born essayist and short-story writer who deals frequently with Asian-American issues, which often involves writing about food, has given us a powerful piece called "Talking About the Past, and Cooking, With Mother, originally published on New America Media, where Andrew is an editor as well as frequent contributor, and reprinted on Nation of Change, where I encountered it. (There's also a Vietnamese version posted.)

Possibly you can resist continuing to read a piece that begins:

"Why don't you call me anymore?" she asks on the phone, her voice plaintive, barely above a whisper. "No one remembers me, no one cares if I die."

"Mother, I called 3 days ago."

"Liar! That never happened."

It happened. She just no longer can recall.

It's possible, as I say, that you can resist reading more. And if you can, more power to you. I couldn't.

Andrew goes on to explain:

Five years ago, my mother, who is now 81, was diagnosed with Alzheimer’s, and her short-term memories are now almost non-existent. Unless something very dramatic—death, divorce, accidents, a marriage—happens to those very dear to her she retains nothing of the immediate past. She has, too, become paranoid and housebound. The once vivacious, outgoing and beautiful woman has become frail and depressed. Though my two older siblings and I visit my parents in Fremont practically every week, as we all live in the Bay Area, my mother nevertheless feels isolated and confused due to her increasing dementia.

But when it comes to the distant past, and especially when it involves cooking, it is another story altogether.

Andrew recalls being on the phone with her and changing the subject, asking her, "How do you make banh tom co ngu?" ("a Vietnamese fried shrimp cake made with yam").

"Well," she responds with no hesitation, "you need both rice powder and starch. You need to make sure it's of equal part and the shrimp you keep the head, that's the best part. You need to have good, light oil." She rattles off the recipe with increasing confidence. "Be careful, if you use too much starch, it doesn't get crunchy."

I already know how to make banh tom co ngu. In fact, I learned dozens of dishes from her by simply watching or listening and occasionally assisting her in the kitchen over the years. I asked because I simply wanted to hear her talk with confidence, to have her in her element, and not in her self-pitying voice when that dominates her outlook in old age -- a mother abandoned.

Andrew fills us in on the life his mother has led, going back to her earlier married years as the wife of a high-ranking South Vietnamese general. Although she began cooking without formal training, she cooked so much, and for so many distinguished gatherings, and with so much later opportunity to avail herself of the finest professional instruction, that cooking is apparently burned into her.

"It is a sad thing therefore," he writes, "to see her so frail and forgetful and depressed, and no longer capable of cooking. She can barely make rice and heat soup."

And then he remembers a day.

"I don't know what happened," she said one day when I came to visit and wanted to cook for my parents. "Someone stole all my knives."

I kept searching and finally found three knives hidden under the sofa cushions. It was depressing: her fear of robbers and thieves is overwhelming her, to the point where she feels the need to defend herself with the knives she once used to create such fabulous, sumptuous meals.

Still, for the appetizer, I make the classic Vietnamese spring roll. I mix pork with fish sauce, black pepper, crabmeat, green onion, and vermicelli. I bring out rice papers and warm water. “Let me help,” she says. She gets up from the sofa where she often lays, listless, watching Korean soap operas.

Though she could never cook an entire meal again, she is her old self as she works. The bony fingers are guided by muscle memory. And as she rolls her spring rolls -- a scoop of mixed ground pork with crabmeat, a wet rice paper -- she begins to remember. “Back when we were in Hue, I remember making dinner for 25 guests,” she says. “Mrs. Ngoc, she would send her daughters. My gosh, that woman had six of them. And they all worked so hard.” Mother starts laughing.

She remembers the women crowding her kitchen. How they gossiped as they worked. One young woman had a great voice and often sang. They shared recipes. She remembers a gentle world long gone.

I encourage her. I give her more rice papers. And we roll cha gio together. We make more than we could possibly eat. But it doesn’t matter. We roll back the clock. We talk about food, cooking.

We talk about the past.

HuffPost caption: "My mother on Mother's Day last year."

#

"Have you lost your mind?": Contemplating "the tsunami of dementia that is about to swamp us," Michael Kinsley takes us on a tour

Illustration by Nishant Choksi

"After some reflection, I concluded that as long as I still felt infallible Parkinson's would not stop me from continuing to pursue my dream of becoming Pope."

-- Michael Kinsley, on his two-decades-past diagnosis of Parkinson's

by Ken

I guess there are people who think about the way their mind works (or doesn't) and people who don't so much. Still, I had to pause when I read this statement in Michael Kinsley's "personal history" piece in the April 28 New Yorker, "Have You Lost Your Mind?: More bad news for boomers" (unfortunately likely to be off the newsstands now, and unfortunately only an abstract is available free online): "The tsunami of dementia that is about to swamp us, as the baby boomers age, has got plenty of attention, but the reality has not sunk in." Is this so?

Before going further, let me say that this is the most stimulating and absorbing piece I've read in a long while. I guess it's also one of the more unsettling, because of the erudite and also charming yet also unrelenting way it ventures into this -- for me, at least -- disturbing matter of the diminution of brain function. It's a follow-up to a "reflections" piece Kinsley wrote for The New Yorker six years ago, "Mine Is Longer Than Yours: The last boomer game" (April 2008). In that piece he was 15 years out from a diagnosis of Parkinson's. As he wrote then, "Even fifteen years after I got the diagnosis, my symptoms are on the mild side, though no longer undetectable." He added that his symptoms "got even milder" following a procedure he'd had a couple of years ago called deep brain stimulation, or DBS --

an operation . . . to implant wires in my brain and two pacemaker-type batteries in my chest, [to] send pulses to a particular point in the brain that . . . well, I don’t really know much about how it works. But the result is that I take fewer pills than before and have much less "off" time, when the pills don’t work.

•

Quite a while back now, I ran into a friend I hadn't seen much in quite a while (I had to resist the temptation to call him "a former friend") at a concert, and he asked if I'd heard about a mutual professional colleague, somewhat older than us. I also hadn't had any contact with the colleague in quite a while, but back in another lifetime for me, I was -- in a small corner of his life -- his editor, and the immaculate lucidity of his raw copy lingers powerfully in memory.

It wasn't just that the colleague was broadly and deeply erudite, which he was, but that his mind was so consummately organized. If you had a question about something he had written, it was easy to ask, because he would understand effortlessly, and quite likely it was something he had already thought about. For the same reason it was easy to discuss a matter as humble as adding or striking a comma.

I don't remember whether I knew before my friend told me what the news was, but I certainly should have. The colleague was of the right age. As you've quite likely guessed, the news was that he had Alzheimer's. Overlapppingly my friend and I said almost the same thing. One of us said, as I recall, "Of all people," and the other said, "Of all minds."

This is, of course, a distinction that Alzheimer's doesn't make.

It was hardly a new subject for me. In the early '90s my stepfather was released from his horrible slide into Alzheimer's, and not that long afterward, my mother, after all those years of exhausting, enervating caregiving, began to express apprehension tinged with terror every time she couldn't remember something. I pooh-poohed her apprehensions, pointing out that she still remembered all sorts of stuff that I didn't. I'm sure I never relieved her apprehensions, and there was no reason why I should have. In time, even I had to recognize that she was slipping, and in more time, she had sunk into just the fog she had been so afraid of. The last time I saw her, when I went down to Florida for her 90th-birthday celebration in the small assisted-living facility where she was beautifully cared for by a saintly woman, I never knew whether she recognized me.

For a while I thought I was special with my Alzheimer's story. Gradually it came to seem that everyone I know had his or her own. Which is why I paused at that statement of Michael Kinsley's that the reality of that "tsunami of dementia that is about to swamp us" hasn't really sunk in. He continues:

We stave it off with jokes: Ronald Reagan goes in for his annual physical and the doctor says, Mr. President, I have bad news and worse news. Reagan says, Lay it on me, Doc. The doctor says, The bad news is that you have cancer. Reagan: And the worse news? Doctor: You have Alzheimer's. Reagan: Well, at least I don't have cancer.

Even Kinsley acknowledges that at least some of the reality, if maybe not the "tsunami," has set in.

There is a special horror about the prospect of spending your last years shuffling down the perennially unfamiliar corridors of some institution in a demented fog, your diaper hanging loose, being treated like a child by your children, watching TV all day but unable to follow even the most simpleminded propaganda on Fox News or the most facile plot twist of "Downton Abbey."

Dementia seems like an especially humiliating last stop on the road of life. There's no way to do it in style or with dignity. And you can't be sure that you're going to avoid it until the moment something else, like cancer or a big, big truck, comes along to carry you off first.

Baby boomers -- the seventy-nine million Americans born between 1946 and 1964 -- will be the second dementia generation, but the first to know that it's coming. Our grandparents generally died too young or too poor to worry about what used to be called "senility." They didn't provide much in the way of foreboding for their children, who are our parents. For us, however -- the boomers, now in our fifties and sixties -- ways of dealing with infirm and often mentally impaired parents is one of the top five subjects of conversation.

As you've no doubt calculated, if you still have some of your wits about you, six years after Kinsley's 2008 piece, he is now 20 years-plus past his original Parkinson's diagnosis, and the symptoms still seem to him relatively mild. But he is concerned enough that he has undergone a new round of testing, which could be compared against earlier tests. And while the tests confirm that he still has a high level of cognitive function, under the extended time and stress conditions of the tests, the results show that his function deteriorates, in some tests quite badly. For someone who most of his life has had such a high level of intelligence function, this is clearly distressing. But perhaps more distressing to him is the realization rather forcibly impressed on him that his opinion of his function level and of the validity of some of the tests doesn't count, precisely because of his diagnosis, his "condition."

As he already wrote at the top of the new piece:

"Write about what you know," the creative-writing teachers advise, hoping to avoid twenty-five stories about robots in love on Mars. And what could you know better than the inside of your own head?

Almost anything. And almost anyone else is better positioned than you are to write about the foreign land between your ears. You are the person least qualified to be writing about changes in your own brain, since you need your brain to comprehend those changes. It's like trying to fix a hammer by using the hammer you're trying to fix.

Without getting into robots on Mars, I remember vaguely, from the nineteen-sixties, a comic-book tale about some residents of our three-dimensional world who go through a hole in space, or something like that, and find themselves living in two dimensions. "And nothing's changed," one says, triumphantly, unable to see what we can see: that he is now the approximate shape and depth of a postage stamp. Maybe this is what the descent into dementia is like: everyone around you knows or suspects you have it, but to yourself you seem the same.

Already in 2008 Kinsley wrote:

Sometimes I feel like a scout from my generation, sent out ahead to experience in my fifties what even the healthiest boomers are going to experience in their sixties, seventies, or eighties. There are far worse medical conditions than Parkinson’s and there are far worse cases of Parkinson’s than mine. But what I have, at the level I have it, is an interesting foretaste of our shared future—a beginner’s guide to old age.

Many of the symptoms of Parkinson’s disease resemble those of aging: a trembling hand, a shuffling gait, swallowing—or forgetting to swallow, or having trouble swallowing—a bewildering variety of pills. Of the half-dozen or so main Parkinson’s drugs, the most effective by far goes by the trade name Sinemet. Its principal ingredient is levodopa, a chemical that turns into dopamine in the brain. Levodopa works differently for different people, and often stops working or develops intolerable side effects. But for me right now Sinemet’s effects last about four hours. During those four hours, I go through the whole cycle of life, or, at least, the adult part. I take a pill and shortly feel as if I am twenty. My mood is sunny and optimistic, I move fluidly, I’m full of energy—I don’t know whether to go out and run a couple of miles or finish that overdue book review. This feeling lasts for a couple of hours, then it starts to wear off. Another half hour, maybe, and I’m back where I belong, in middle age. Half an hour after that, I’m feeling old, stiff, tired, and gloomy. Then I pop another pill and the cycle starts all over.

In 2014, the new New Yorker piece itself is the most vivid testimony to the continued high level of Kinsley's function. Of course as a writer he doesn't have to be overly concerned about the questions of endurance and fatigue that emerged so alarmingly in the recent round of testing. Presumably he can pause and return to a piece as often as he needs to, and can still produce at a level that we can confirm for him -- since his opinion is no longer accorded significance by the doctors -- is indistinguishable from that of the writing he has produced in the past.

But already in 2008, again, he wrote:

This terror of being written off prematurely (like being buried alive) makes it difficult to write about a medical condition that may linger and get worse slowly for decades while you try to go about your life like a normal person. People say, in all kindness, “Hey, you look terrific,” which leaves you wondering what they were expecting, or how you looked the last time you saw them. They seem taken aback that you are around at all. The first time you hear or read a casual reference to “healthy persons,” it is a shock to realize that you are permanently disqualified for that label. And then you realize—even more shockingly—that you’re the only one who’s shocked. Everyone else has adjusted, reassigned you, and moved on. Even if you feel fine, you walk around in an aura of illness.

For anyone who has already been pondering that "tsunami of dementia that is about to swamp us," and perhaps even for those who haven't been, I can't recommend the new piece highly enough. Kinsley is a terrific, even dazzling, writer, and his charm is irresistible, an invaluable attribute as he insists on dragging us through some emotional terrain that most of us would do anything in our power to resist.

#