Abstract
In the movie Still Alice, Alice, a successful woman, after being diagnosed with early onset Alzheimer's Disease (AD) loses almost all she had. Alice’s case doesn’t typically fall under the traditional age bracket for the onset of Alzheimer’s because she is only 50. However, the symptoms she displays clearly fall under the earlier DSM-IV criteria of diagnosis. Under the new DSM-5 criteria, she would still be a fit case for Alzheimer’s because she has been experiencing a gradual decline in her autonomy. She loses control over her speech, mobility and motor functions until she becomes completely dependent on her caregivers. Although, there is no cure for Alzheimer’s, there are drugs and non-drugs based approaches to the treatment that can combat or resist the progress of the disease. In addition, there are alternative treatment models for Alzheimer’s based on diet and herbs that are not strictly verified scientifically and hence not approved by the FDA. The psychiatrists and caregivers handling Alzheimer’s patients are often faced with intense ethical dilemma especially when they are required to restrict the autonomy of patients for their safety and have to speak white lies.
“Still Alice” is a movie based on the novel with the same name. The novel is authored by neuroscientist Lisa Genova. The central character Alice Howland is a Columbia professor, who is around 50 years in age. She is an accomplished professional and scholar. She has three children.
Character’s Demographics: Alice is otherwise healthy in every other way up until when she is struck with Alzheimer’s too early in her life. Traditionally, this disease strikes people who are at least in their mid-60s. Alice, after being diagnosed with early onset Alzheimer's Disease (AD) loses almost all she had. There’s no reason why she should be struck with AD at an age of 50. Her doctor points out that the condition cannot be easily diagnosed in people who are intelligent. Intelligent people are good at devising ways to appear normal.
A Description of the Presenting Problem(s): In the beginning, Alice misses just a word in the middle of her lectures. However, gradually her condition worsens. While doing her daily jog, she loses track of her way out. Her condition involves short term memory loss. She has to undergo a number of tests. Forgetfulness or forgetting things is quite normal even among healthy people. Therefore, initially her problem does not arouse concern among her care takers. However, her condition gradually attracts increasing concern that could not be taken casually.
Alice is faced with the severity of the condition she cannot wish away when she comes to know about the hereditary nature of the disease. She must face the eventual situation when she would not be able to recognize her children. Moreover, just as she has inherited the condition from her family, she must pass on the same to her children. This is truly a tragic situation but the directors have done well not to dwell on the emotional aspects of the tragedy. Instead, the film makers have attempted to put audience in the shoes of Alice. They, too, like Alice experience a vicarious sense of disorientation. The sense of incomprehension, she encounters is also shared by the audience to an extent.
Background Information: After diagnosis, an aggrieved Alice tries to come to terms with the fact that her past life as she had known and lived is over. She is a linguistics professor at Columbia University and informs her department chair about her condition. Before being struck down by AD, she was successfully enjoying the highpoint of her career. She was successful professionally as well as in the family enjoying her family life with husband and children. She has perfect relationship with Tom, Anna and Lydia, her grown up children, and John, her husband. The only problem, if that could be called a problem in her life is with Lydia, who has chosen to reject college education in favor of struggling to be an actress.
Ironically, for a linguistics professor the first sign of her condition is evidenced with her inability to remember the word “Lexicon”. The night before, at her birthday dinner, she is lost in thoughts about her dead sister which increasingly overpowers her in course of time.
The film also raises the question inherent in the title, “Still Alice”. Is Alice, still Alice? Alzheimer is a deadly disease that devastates an individual’s personality. The victim of AD gradually loses the sense of self and finds it nearly impossible to navigate through the day to day activities. The question then is, whether Alice is still Alice? Is there a basic core in her personality that can give a semblance of her former self? Is she utterly eroded? Perhaps Glatzer and Westmoreland have chosen to leave it an open question.
There is a scene in the movie when Alice is at an advanced stage of dementia. She loved New York, but now in a career move, her husband is required to relocate to Minnesota from New York. John is tempted to relocate assuming Alice is no longer the old Alice and he can take her anywhere to get her the best medical care. The question whether old Alice is still the same Alice leads to family crisis.
The film makers have also raised the issue of the role of technology. Technology provides an easy way to manage or conceal dementia symptoms. Alice’s addiction to her smartphone, especially her dependence on personal organizer functions, could possibly both be a symptom and a strategy to mask her condition (Glatzer, R., & Westmoreland, 2014).
In conclusion, it is not difficult to observe the biological, social, and psychological symptoms evidenced by the character including behavioral disturbances, misidentification, functional disability, distress and impaired interactions with environment and others.
Psychological Assessment
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association, 2013) has been revised recently. The terms major or mild NCD refer to diagnostic differentiation of the first order. Major NCDs include diagnoses such as dementia (from the previous edition of DSM-IV-Tr, APA, 2000). The disorders in this case constitute substantial level of cognitive decline (with two or more SDs) from previous functioning and interfere with the person’s independence. The DSM-5 expands the category of major NCDs, so as to include diagnoses to encompass other etiologies and age groups, such as traumatic brain injury. Mild NCD (Neurocognitive Disorder) is a newly introduced term. It recognizes a level of cognitive decline that goes beyond declines associated with normal aging changes but well below the level of a major NCD. Mild NCD is nearly the same thing that was earlier known as Mild Cognitive Impairment. In most studies conversion rates between MCI and some form of dementia (Alzheimer’s) has been reported as ranging between 20 and 40 percent (Knight and Pachana, 2015:83). The focus is on decline, not deficit. According to the new DSM criteria, memory loss is secondary to declines in speech or the use of language. Individuals with major neurocognitive disorder, according to DSM-5 exhibit deficits that interfere with their independence. It is evident that Alice is no longer independent as she encounters problems in performing simple tasks.
Some of the notable characteristics demonstrated by the character include forgetting the names of her children and forgets how to spell ‘October’. She also learns that the condition is hereditary. There are certain early signs and symptoms of AD including memory impairment, confusion with location and time, visual and space difficulties, withdrawal from social engagements, depression and changes in personality, difficulty solving problems or concentrating and problems completing the routine tasks. There are lab and brain imaging tests to determine or rule out the disease (Mayo Clinic, nd).
In a study by Koedam, et al. (2010), early onset AD patients were compared with late onset AD patients. It was found that the prevalence of non-memory presentations among the patients with early onset AD was five times more in comparison to the late-onset AD cases. The researchers, therefore, recommend that the clinical presentation of early-onset AD be more variable than for late-onset AD, and emphasis should not be limited to memory impairment as the core criteria. This study would be useful in studying about early onset of AD, as it informs on the direction of diagnosing the early-onset condition.
In yet another study, an attempt was made to identify the specific behavioral patterns and examine how the behaviors are associated with subsequent risk of dementia and AD. The examination of 2,499 participants with no dementia exhibited the clustering of functionally older adults into subpopulations with notable patterns of lifestyle behaviors. The subpopulations exhibited differences in the level of risk for dementia and AD and it is possible to target the behavioral changes among patients and encourage changes with the potential for delaying or preventing the onset of disease. This study would be useful in studying early onset of AD, considering it informs the basis of identifying the vulnerable subpopulation (Norton et al., 2012).
Treatment
Current, cure for Alzheimer’s does not exist. However, there are drugs as well as non-drugs approaches to address behavioral and cognitive symptoms. There are medications that will help lessen the symptoms or stop further progress of Alzheimer’s. These drugs are FDA approved to help with symptoms including confusion, memory loss and problems with thinking. These medications work best in early to moderate stages. There are other treatments for behavioral changes and sleep changes. There are also alternative treatments that are not supported by rigorous scientific research (alz.org).
Ethical issues
There are several ethically challenging issues encountered during the diagnosis and treatment of Alzheimer’s. When should a psychiatrist go for further testing? Should genetic screening be acceded to when a patient requests and whether they should discuss worst outcomes with patients? These are some of the ethical challenges encountered by psychiatrists and care givers. Ethical conflicts arise in respecting patient autonomy and protecting them. The other ethical dilemmas encountered include whether caregivers should lie to the patient. These issues are best handled by psychiatrists on a case to case basis (Howe, 2006).
Conclusion
In conclusion, it must be admitted that Alzheimer’s is a condition that affects the dignity and autonomy of an individual and there is little that can be done to combat the condition as of now. However, as the researches continue, it is hoped that it would not be long before science catches up with the disease. Some of the studies like Tschanz et al (2013) offer deeper insights into prevalence rates, incidence rates, modifiable risk factors, medications, lifestyle factors, live events and care environment, all which are likely to have a bearing on the development of early onset AD. There are some other studies that may prove useful in identifying early onset of Alzheimer’s. For instance, one study identifies systematic changes in art produced by people with AD (van Buren et al., 2013). The probe established that paintings developed by AD patients have more abstractions and symbolism applied, but their realism and depictive accuracy were lower. A conclusion reached in the study, which would be useful in identifying early onset of AD, relates to the identification that the neurological illness tends to alter the conceptual attributes more than the perceptual attributes. This article is useful as it provides a guide in identify qualitative changes in of brain damage thus applicable in identifying early onset of AD.
References
Alzheimer’s Association (nd) Treatments for Alzheimer’s disease. Retrieved June 27, 2015 from http://www.alz.org/alzheimers_disease_treatments.asp
Glatzer, R., & Westmoreland, W. (Directors). (2014). Still Alice [Motion Picture].
Howe, Edmund G (2006) Ethical Issues in Diagnosing and Treating Alzheimer’s Disease. Psychiatry (Edgmont). May; 3(5): 43–53
Knight, Bob G, & Pachana, Nancy A. (2015) Psychological Assessment and Therapy with Older Adults, Oxford University Press.
Koedam, E. L., Lauffer, V., van der Vlies, A. E., van der Flier, W. M., Scheltens, P., & Pijnenburg, Y. A. (2010). Early-versus late-onset Alzheimer’s disease: More than age alone. Journal of Alzheimer's Disease, 19(4), 1401-1408.
Mayo Clinic Staff (nd) Diagnosing Alzheimer’s: How Alzheimer’s is diagnosed. Retrieved June 27, 2015 from http://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers/art-20048075
Norton, M. C., Dew, J., Smith, H., Fauth, E., Piercy, K. W., Breitner, J. C., . . . Welsh‐Bohmer, K. (2012). Lifestyle Behavior Pattern is Associated With Different Levels of Risk for Incident Dementia and Alzheimer's Disease. Journal of the American Geriatrics Society, 60(3), 405-412.
Tschanz, J. T., Norton, M. C., Zandi, P. P., & Lyketsos, C. G. (2013). The Cache County Study on Memory in Aging: Factors affecting risk of Alzheimer's disease and its progression after onset. International Review of Psychiatry, 25(6), 673-685.
van Buren, B., Bromberger, B., Potts, D., Miller, B., & Chatterjee, A. (2013). Changes in Painting Styles of Two Artists With Alzheimer’s Disease. Psychology of Aesthetics, Creativity, and the Arts, 7(1), 89-94.
