Iris Murdoch--A Case Study of an Individual’s Tragic Battle with Alzheimer’s Disease

Elegy for Iris
By John Bayley (Picador USA, 1999)
275 pages

Iris and her Friends-A Memoir of Memory and Desire
By John Bayley (Norton, 2000)
275 pages

Reviewed by: Dr. Michael J. Taylor

The staggeringly high incidence of Alzheimer's disease (AD)--an estimated 5-10% amongst the over 65 age group--is well known to clinicians working within all fields of adult medicine. The incidence of Alzheimer's and other forms of dementia, in those over 85, is estimated to be as high as 47%. With shifting demographics creating a rapidly expanding cohort of patients over 65 years of age, the absolute numbers of those suffering from AD will make the collective tragedy of this devastating disease more apparent. In dealing with the myriad medical, behavioural and psychosocial problems stemming from the increase in the number of Alzheimer's patients, it may become increasingly difficult for clinicians, particularly those working in long-term care facilities, to recognize the devastating impact that dementia can have on both patients and their loved ones. It may also become more difficult to stay aware of the fact that the patient's individuality is lost within the common symptoms of advanced dementia. In two recent books about his wife, Iris Murdoch, also an Alzheimer's disease patient, the writer and literary critic John Bayley elegantly describes the full impact of this devastating disease; he manages to remind the reader that love and devotion can be unfailingly strong even in the face of adversity. The book also serves as a powerful reminder of the individual tragedy of AD.

Born in Dublin in 1919, Iris Murdoch began her career as a fellow and tutor in Philosophy at Oxford. She went on to obtain international acclaim as a writer of philosophy, and of plays and works of fiction that included The Sea, The Sea, which won the prestigious Booker Prize for literature in 1978. The first sign of Iris' Alzheimer's disease appeared in 1994 while she was at a literary conference at the University of the Negev in Israel. This episode is painfully recalled in John Bayley's first novel dealing with his wife's disease, Elegy for Iris. Published in 1999, the New York Times' best-selling Elegy for Iris met with a great deal of both critical and popular success, and justifiably so. The book is a moving and honest portrayal of Bayley's daily struggle in caring for his wife, accompanied by touching accounts of the couple's courtship, marriage, and early life together. Throughout the book, Bayley effectively juxtaposes episodes from his present with episodes from the past. Perhaps most memorable is the account of Bayley swimming with his wife in their earlier days in a small nook that was part of a river near their home. The reader is presented with a tranquil scene of two young lovers finding refreshment in a quietly flowing river surrounded by lush vegetation on a hot summer day. Abruptly, this scene shifts to a more current one that is almost pitiable but ultimately rather moving. This time we find Bayley trying to undress his wife, who is now in an advanced stage of her disease, and coaxing her into the river so that they may continue the ritual swim that had, in the past, been so important to them.

Elegy for Iris is so full of frank and honest observations about Iris Murdoch's disease that it will sound familiar to anyone having had contact with Alzheimer's patients. Surprisingly, the tone throughout much of the book is rather positive, although there is an underlying melancholy. This melancholy is apparent as Bayley discusses his life with Iris prior to the onset of her disease, meditates on the complexities of their relationship, and describes the dutiful, at times seemingly heroic, way in which he cares for his ailing wife. It is a tone that changes rather noticeably in Bayley's follow-up to Elegy for Iris titled Iris and her Friends. Those expecting more of the same as in Elegy for Iris will be greatly surprised by this much darker book, that continues where Elegy for Iris left off, with an account of Bayley's struggle to care for his wife as her disease progresses. Though Bayley's technique of changing rapidly between past and present remains easily recognizable, in Iris and her Friends, Bayley has lost the gentle and almost passive tone he previously used when describing the experience of caring for his wife. In place of this tone, the voice of Iris and her Friends expresses Bayley's frustration and despair in dealing with the daily struggles of being a caregiver. It is a voice that is at times shocking. For instance, when Bayley loses his patience with his now silent wife while having difficulty dressing her, he finds himself suppressing a desire to actually strike her, staring at her with an ironic smile and saying "do you know how much I hate you?"

The "friends" of the title is not a reference to Iris' companions but is used by Bayley as a somewhat elusive metaphor to describe the silence and passivity that "visit" his wife as her disease progresses. It is these "visitations" that allow Bayley to explore his own memories as his wife's memory continues to decline. It is in these recollections, full of engaging anecdotes, that the reader may find respite from the, often upsetting, accounts of Bayley's situation. It soon becomes apparent that living within his own memories is Bayley's method of coping with the tragedy surrounding him. What the reader of both books cannot fail to notice is that while in Elegy for Iris Bayley's reminiscences were concerned with his life with Iris, in Iris and her Friends, Iris is completely absent from any account of his early life. It is as though Bayley is suggesting that he himself must forget his wife in order to escape from the pain of his current situation. However as the book draws to a close, Bayley's love and dependence on his wife are clearly reaffirmed through a touching description of his fear and anxiety of losing Iris as her condition deteriorates to the point where she must be transferred to a nursing home. What follows is a heart-breaking but beautifully rendered account of Iris' final days.

Despite their short length, neither Elegy for Iris nor Iris and her Friends make for light reading. In both books, Bayley brilliantly uses his skills as a writer to lead the reader on an emotional journey, throughout which the most intimate and personal details of his life before and after his marriage to Iris, and during the long course of her illness, are divulged in a fluid and literary style. Of course it is impossible for Iris Murdoch not to lose some measure of dignity, given that both books focus so heavily on her in an advanced stage of dementia. This is particularly true of the latter of the two novels. It is in the first novel that Bayley's balanced juxtaposition of the past with the present serves to remind the reader that his ailing wife was a dynamic, vibrant and intellectual woman before the onset of her disease.

Though intended for a general audience, caregivers of patients with Alzheimer's disease may find solace in Bayley's honest portrayal of his own experiences. In the end, Bayley has provided an unforgettable account of the full impact of Alzheimer's disease, and a reminder to anyone encountering patients with this disease that behind what Bayley refers to as the "mask" of Alzheimer's disease are unique individuals who lived, loved and were loved in return. Certainly, no one reading Bayley's two courageous accounts of his own experiences, can fail to notice that the tragedy of Alzheimer's disease affects both patients and their loved ones. Indeed, both books may offer a great deal to clinicians who, in encountering this disease on a daily basis, may forget that Alzheimer's is a tragedy which is unique to every individual afflicted with it.

The Queen Mother Passes the Century Mark

Her Majesty Queen Elizabeth the Queen Mother, born the Honourable Elizabeth Angela Marguerite Bowes-Lyon on the 4th of August 1900, has joined the group of healthy centenarians. The Queen Mother, widow of King George VI, has for generations been one of the most popular members of Britain's Royal Family. Adding to her popularity was her decision, at age 95, to undergo surgery for a second hip replacement. The Queen Mother had already had one hip replaced in a routine operation in 1995. Britain marked the 100th birthday of the Queen Mother with a pageant mixing military bands and carnival floats. With the aid of two walking sticks the Queen Mother mounted stairs to a special stage and, despite her age and the heat, insisted on standing through the royal salute of 7, 000 troops.

Oxford Textbook of Geriatric Medicine 2nd Edition

Oxford Textbook of Medicine 2nd Edition

Editors :J. Grimley Evans, T. Franklin Williams, R. Lynn Beattie, J-P. Michel, G.K. Wilcock
Oxford University Press, Toronto, 2000

Reviewed by: Shabbir M.H. Alibhai, MD, FRCP(C)

Geriatric textbooks come in several varieties. Some focus on specific content areas and are both comprehensive and detailed. Others cover pertinent areas of geriatrics in a portable overview fashion. A third group--which includes the Oxford Textbook of Medicine--is comprised of stand-alone reference texts that combine the best of both broad-based coverage and comprehensiveness, bringing together the art and science of medicine in one heavy tome. This is an onerous task in which the Oxford Textbook of Medicine succeeds well in some areas but not so well in others.

As the focus of my review of this large volume (over 1,200 pages), I chose, in addition to doing a general overview of the 27 sections of this guide, to examine several subject areas. These areas are representative of well-known evidence-based areas of geriatrics (anticoagulation in atrial fibrillation), of emerging fields that show some level I evidence but that lack in consensus (cognitive enhancing therapy in dementia) and finally, of topics that elicit much opinion, but which are based on little data (pharmacological treatment of delirium).

To begin with, this reference is written by numerous distinguished contributors from various fields of clinical geriatrics and gerontology, basic science, ethics, and research. The editors and authors are an internationally diverse group that brings together ideas in modern geriatrics from several continents. The text and tables are nicely formatted and easy to read, although the almost absolute lack of colour, and limited illustrations, make it visually challenging at times. There are very few annoying typographical errors. Chapters are organized logically, although in the organ-based medicine sections it would have been nice to have, consistently, an introductory chapter on the physiology of aging of each organ system. The index is also easy to use although a bit sparse at times (e.g. B12 is only listed under cobalamin and vitamin B12, not B12).

In its capacity as a comprehensive overview of geriatrics, this textbook does well in offering the reader some nice chapters about the demographics of aging, and about aging in developing countries. There is welcome coverage of a number of other miscellaneous topics like the concepts of frailty and "failure to thrive", and the roles of geriatric day hospitals and stroke units. Unfortunately, some topics (e.g., fecal incontinence) which are not well covered in traditional texts and review articles, are covered sparsely in this book as well. From my own perspective, the very thin chapter on cancer and aging is embarrassing. The section on ethics mentions nothing about religiosity and the impact of traditional beliefs on many patients' and caregivers' ethical positions with respect to their medical treatment.

In terms of evidence-based medicine, the offerings vary in quality. The editors have tried very hard to cover the subject matter succinctly, but numerous times throughout the book the material ends up being too terse. The anticoagulation literature in chronic atrial fibrillation, for example, is summarized well in text and tabular form, but a short paragraph on paroxysmal atrial fibrillation management gives questionable recommendations with no references to any literature. Several pivotal cardiovascular and diabetic clinical trials are not mentioned at all, and the controversies regarding the estimation of creatinine clearance in the elderly are largely ignored. Despite the completion of over twenty large randomized trials testing cognitive enhancing therapy in dementia, only a few paragraphs struggle to summarize this challenging body of information. Conversely, in delirium management, the writer justly discusses the limited amount of evidence which exists to guide treatment and goes on to offer what amount to some clinical management pearls given the paucity of controlled trials.

Two final points deserve mention: First, there are many sections where practical flow-charts or algorithms could have been added which would have aided clinical decision-making and clarified the subject matter. Second, there is a nice little collection of paper instruments and scales in the useful information chapter, although it would have been nice to get a standardized guide to scoring the Folstein MMSE along with the actual instrument.

At the end of the day, there is enough information from a tremendous variety of sources and experts in this volume to make it a welcome addition to the library of a physician with a strong interest in geriatrics. However, it needs to be spruced up to compete with more sophisticated electronic/ online offerings and to appeal to physicians looking for better and clearer science. A good book, but temper your expectations.

On Not Doctoring the Family--Too Weird and Dangerous

A. Mark Clarfield, MD

Although I am a doctor, I have fought a long and more or less successful battle against becoming my own family's doctor. I know that I am not alone in struggling with this dilemma. It is not that we physicians don't love our old relatives, and certainly, it is not that we don't want to help out. The reason we wish to stay out of family health matters is, simply put, fear. As medical practitioners we are afraid that since family members are so near and dear to us, our judgment might be impaired if we acted as their physician.

Of course in an emergency, most MDs would do whatever became necessary. Dr. Howard Bergman, Chief of Geriatrics at Montreal's Jewish General Hospital declared, "A Heimlich manoeuvre or cardiac massage would be accomplished almost as a reflex, should--G-d forbid--anyone close to me need such an intervention."

Personally, I have, on occasion, gently steered family members away from certain operations and diagnostic procedures when my advice was sought. I have even viewed and passed judgment on my own father's cardiac angiogram before he underwent coronary artery bypass surgery several years ago. Like most physicians, I have looked into my children's ears, and have, albeit reluctantly, prescribed antibiotics for my offspring.

Dr. Ilan Benjamin, a Montreal family physician, agrees but offers, "Whenever I can, I duck the issue and get my family off to a real doctor, someone who may well like them enough, but does not love them too dearly.

Regulating Stem Cell Products

The US Food and Drug Administration's (FDA) Biological Response Modifiers Advisory Committee convened in July to begin the process of formalizing regulations for the development of stem cell products. Dr. Jay Siegel, director of the FDA's Office of Therapeutic Research and Review, said that they are trying to get information on what would constitute appropriate controls and testing to set the grounds for human research.

Significant Implications for Canadian Social Programs and the Canadian Health Care System

One of the most comprehensive demographic analyses of life expectancy in the major industrial countries suggests that average life expectancy has been miscalculated. The study examined mortality over five decades and found that "median forecasts of life expectancy are substantially larger than in existing official forecasts".

The paper, which appeared in the June 15th edition of Nature, suggests that Canadians can expect to live four years longer than previously estimated. Canada's previously estimated average life expectancy was 81.67 for the year 2050, the new estimate suggests that Canadians will live to be 85.26.

Sponsored by the US National Institute of Aging, the study is certain to have a wide impact in pension planning and healthcare policy circles. This miscalculation of life expectancy could throw off official calculations of various pension and health care costs by as much as 20%. It is suggested that long-term planners may have to go back to the blackboard and revise their models.

The study suggests that each additional year of life expectancy will add approximately 5% to the cost of programs for the elderly, i.e. those over 65. This cost is ascertained using the so-called 'dependency ratio', which is a measure of the population over 65 relative to the population between the ages of 20-65. This measure allows social planners to determine the relative numbers of working people required to support the retirement age population.

For Canadian Physicians the study suggests that their practices will become much 'grayer' than predicted and that geriatric management and clinical issues will predominate.

Source

1. Shripad T, Nan L, Carol B. A universal pattern of mortality decline in the G7 countries. Nature 405, 789-792 (2000).

The Life and Times of a 110 Year-Old Man

An Exclusive Interview with Ben Holcomb's Daughter, Leona Ford, in Carnegie, Oklahoma

Ben Holcomb was listed in the Guinness Book of Records as the oldest living person for the year 2000. He was born on July 3rd, 1889 in Robinson, Brown Country, Kansas, to Chestnut Wade Holcomb (1844-1902) and Nancy Sarah Jane Sharp (1848&endash;1920). He was the youngest of eight children and was named for the 23rd President, Benjamin Harrison. His father marched with William Tecumseh Sherman across Georgia in 1864 during the American Civil War. Benjamin Holcomb's family homesteaded in what is now Dewey County, when the Araphaho and Cheyenne lands were opened to settlement.

Q: Are there any other long-lived members in the family?

A: His oldest brother died at 78 of encephalitis. That year there was an outbreak of this disease. His next oldest brother died at 96 years of age. His other brothers and sisters all lived to be over seventy but none of them had a spectacularly long life span.

Q: How is your father's health right now?

A: Daddy is not sick in any fashion right now. He has never had any major diseases; no heart attacks or strokes, although he has been blind in one eye since he was 31.

Q: Can he walk around?

A: He is now in a wheel chair and this is because a nurse insisted that he use a wheel chair when he was 107. He came to the nursing home when he was 105.

Q: What did he do for a living?

A: He farmed all his life, although he also worked as a cook during the Second World War.

Q: Did he smoke or drink? What about his diet?

A: He never smoked or drank at all. My older sister, told me that she thought he drank one or two beers on occasion, but nothing more than this. His family always had milk; they were farmers. When there were a lot of us at home we often had corn-meal mash. We would fry this cornmeal mash and have it for breakfast. He ate a lot of greens and he liked to add vinegar to his greens. He didn't eat much in the way of eggs and he had a special liking for catfish.

Q: How was his mood? His spirit and personality?

A: He has always been in a good humor, full of life. He always had a grin on his face. I have never heard him blame anybody for anything. He has accepted every turn and difficulty he has encountered. He was a farmer and to farm around here means to know hardship. Some years can be very hard. I have a great big photograph of him, the sort of photograph they take at fairs, in the 30s of him leaning over a broken down plow, and there is a caption under the photograph that says that "I am going to keep farming until I lose my last dime". He overcame terrible hardships with his farming. He was conservative when times were good so he still had enough money to live another few years without depending on anybody.

Q: How is his memory?

A: It has gotten slow in the last few years.

Q: Has he taken any medications?

A: Do you know what hydrogene is? He used that for a while. My sister was a nurse and she put him on all sort of medications. But that was my sister. The only medication he takes now is metamucil.

Q: What else do you think might account for his long life? Does anything else come to mind?

A: He liked to keep his weight under control. If he gained a couple of pounds he would cut out cream or sugar or eat less. He didn't do this to please his wife, he did it just for himself. I would also say he enjoyed life. He liked women too.

Q: Longevity is an inherited characteristic. You might have another twenty to thirty years of life ahead of you.

A: If I do I will thank the Lord.

Rewiring the Ferret Brain

Scientists from the Massachusetts Institute of Technology have managed to rewire the brains of young ferrets so that nerves from the retina are redirected to grow into the auditory thalamus. The study was designed to determine whether activity in a sensory pathway has a specific, instructive role in the development of cortical networks. Modules of neurons sharing a common property are a basic organizational feature of the mammalian sensory cortex. Previously, it had been believed that the visual cortex relied heavily on an intrinsic scaffold of neuronal connections, which are little influenced by activity. The primary visual cortex (V1) is characterized by orientation modules, which are groups of cells that share a preferred stimulus orientation and are organized into a highly ordered orientation map. Results from this study and others demonstrate that much of what characterizes the functional organization of the visual cortex can also be established within the primary auditory cortex (A1) by delivering retinal inputs to A1 through the auditory thalamus. Furthermore, behavioural studies on these 'rewired' ferrets demonstrate that the animals show behavioural responses to visual stimuli that are presented only to the neurons feeding into the rewired cortex; essentially, the animals are seeing with their auditory cortex.

Source

1. Sharma et al. 2000. Nature. 404:871-76.

A World of Xenografts without Hyperacute Rejection

Since the 17th century, when a dog bone was allegedly used to repair the skull of a Russian aristocrat, xenotransplantation technology has come a long way. Today, we have had experiences in transplanting not only bones, but also such complex organs as kidneys and hearts. However, xenotransplantation still faces some major obstacles including a serious shortage of donor organs, and hyperacute rejection of some organs after transplantation. Fortunately, a number of new approaches to solving these problems are being successfully explored. Some of them were presented at the recent BIO 2000 conference held in Boston, USA.

One of the new approaches, directed at solving the problem of hyperacute rejection, involves the transplantation of thymokidneys. A thymokidney is a kidney with vascularized autologous thymic tissue under its capsule. A recent study lead by Dr. David Sachs of the Massachusetts General Hospital in Boston, USA, demonstrated that vascularized thymic grafts were tolerated in large animals. The next step for Dr. Sachs group will be to test induction of tolerance with thymokidney across the major histocompatibility complex (MHC) II mismatch barrier.

Another strategy is being developed by PPL, a biotechnology company based in Scotland. PPL is hoping to create transgenically cloned pigs with a specific gene inactivated to avoid rejection. Pig organs are considered to be the best option for transplantation with humans because of their similarity to human organs both in size and function. While there are some concerns regarding potential retrovirus transmission, little debate has occurred regarding the ethical appropriateness of using pig organs.

Creating transgenic pigs is extremely challenging and will rely on the completion of two steps: the successful cloning of pigs, and the successful knock-out or inactivation of a gene(s) that plays a crucial role in organ rejection. Both steps require a significant amount of research as well as a little bit of luck. Fortunately, the first step has been completed: five healthy piglets have just been cloned. The gene knock-out study on cloned pigs can now begin. One of the primary 'candidates' for the knock-out is a gene responsible for the natural killer T-cell reaction, which is often the primary reason for xenotransplant organ rejection. Thus, we may soon have a xenograft option, which is well tolerated and is also available in virtually unlimited numbers.

Another interesting approach, which is currently being tested by various labs, involves construction of bio-artificial organs. This approach depends on the availability of building materials, which are primarily embryonic human stem cells and natural or artificial polymers. Because of some similarity between this procedure and cloning, there is an on-going ethical debate about whether these stem cells are in fact embryos and, thus, whether this strategy is altogether appropriate.

In conclusion, major improvements in xenograft transplantation technology are currently being made. Trials with humans using whole animal organs have not yet been undertaken. However, trials with cells and tissue, such as Genzyme's Nucrocell PD and HD (for Parkinson's and Huntington's diseases), and extra-corporeal assist devices, such as Circe Biomedical's HepatAssist liver support system, are currently underway.

Suggested Reading

1. Genetic Engineering News 2000, 20(8): 1,28,73.
2. Carlson BM. Stem cells and cloning: what's the difference and why the fuss? Anatomical Records 1999, 257:1-2.

Health, Illness, and Medicine in Canada 3rd Edition

Reviewed By:
Barry Goldlist, MD, FRCPC, FACP
Director, Division of Geriatric Medicine,
University of Toronto

Health, Illness, and Medicine in
Canada 3rd Edition
Juanne Nancarrow Clarke
Oxford University Press Canada 2000

I am unsure of the origins of this text, but it reads as though it was adapted from a course on the sociology of health, illness, and medicine. This might explain the clarity of the language and the fact that enough background about sociology and its jargon is given to make the text completely accessible for a neophyte such as myself. In her writing, Professor Clarke, a professor of sociology at Wilfred Laurier University, shows herself to be a gifted teacher.

The book is divided into three parts. The first part, "Sociological Perspectives" explains ways of thinking and studying about health, illness and medicine from the perspective of sociology. The four central sociological perspectives, structural functionalism, conflict theory, symbolic interactionism and feminist theory, are clearly explained with examples given. Structural functionalism and conflict theory are useful in studying and understanding large societal 'systems', which is to say social and political groups (including interest groups), and private and government-run institutions and corporations. Symbolic interactionism, with its stress on individuals and their interactions, is useful for understanding the more intimate interaction between a patient and her doctor (or between a patient and any other practitioner). Feminist theory can be a useful tool for analyzing both 'systemic issues' and individual interactions. This part also explains, and clearly illustrates, the tools that each sociological perspective uses. A physician might object to some of the concepts expressed. For example, epidemiology is called "the study of the causes and distribution of diseases" and AIDS research is given as an example. I would argue that "correlation" would be a better word than "cause" to help explain epidemiology. In my opinion, epidemiology suggested a virus as the cause of AIDS, and basic laboratory research proved it. The comment that silicone breast implants are associated with numerous health problems is based on a quote from a 1993 paper; unfortunately, the author seems to be ignoring the overwhelming and more recent epidemiological data that shows that there is no correlation. This might reflect a lack of editorial updating of this edition.

The second part of the book examines the sociology of health and illness and includes chapters on disease and death, environmental disease, social inequity, on visiting the doctor, and on the experience of being ill. All are excellent. The sections on health and inequality may be particularly sobering for less experienced physicians, some of who are from relatively privileged backgrounds.

The third part of this book is the section, which may be of greatest interest to doctors&emdash;the sociology of medicine. Chapters on related topics include discussions of the development of medical and scientific knowledge, the 'medicalization' of society, that is, the institutionalization of the practice and teaching of medicine (in the forms of hospitals and university departments), and the development of private and government organizations and structures to regulate and support the delivery of medical care. These are chapters on nursing and midwives, alternative medicine, and the medical industrial complex. As a physician, I am always concerned that medicine seems to be held to a higher degree of accountability than are some of its 'competitors'. I feel this has occurred in this book to some degree. Moreover, there are certain internal inconsistencies. We are informed at the beginning of the text that the major determinants of health are non-medical (although in some cases, as with clean water, medi-cal science played a crucial role in terms of identifying them as determinants of health). Then in chapter 11, we are informed that remunerating doctors on a capitation basis will provide an incentive for doctors to keep people healthy. Does the author feel the determinants of health are medical or non-medical? Chapter 13 examines the relationships between the male medical profession and the female nursing profession. This chapter would have been stronger had the approach been a comparative one; the provision of some examples or analysis of the relations between female doctors (half the current graduates) and nurses, who are still overwhelmingly women, would have been helpful. However, the biggest flaw in this section, is that the sole focus is on a sociological perspective. This area, in my opinion, requires a combined historical and sociological approach. Doctors, nurses, and health care are part of a much larger social picture, and understanding the development of modern medicine cannot be done without understanding the broader historical context.

Despite the few issues I have mentioned, I consider this to be an excellent text. It is clearly written and contains information relevant to the practice of medicine. It is worthwhile reading for all doctors, particularly those in primary care.