William Shakespeare, who survived to age 54, probably knew little of the cognitive deficits that sometimes accompany advanced aging. In fact, in his era, organic dementia of the elderly was not considered to be a public health problem meriting much attention.
One of his tragedies, however, provides us with a poet’s perception of the contentious interaction, in an aging monarch, between inordinate pride and encroaching senility. Shakespeare, with no known training in neuropsychiatry, wrote an immortal drama, “The Tragedy of King Lear,” performed on December 26, 1606, published in London in 1608 and revised for the First Folio in 1623.
The play is loosely based on the tale of a pre-Roman, Celtic ruler who descends into madness. It is a tale filled with sorrow, betrayal and senile dissolution with sufficient clinical hints to make the reader suspect that Lear was a victim of Alzheimer’s disease abetted by domestic duplicity.
Imagine that Lear is brought to a Providence physician’s office for diagnostic appraisal. He is distraught, without either a sense of identity or a family name – just Lear. He is patently confused, unwashed, unduly proud but disheveled – an elderly male, four score and more in years. He is, he tells you in a shrill voice, deeply suspicious of his children – and not without justification.
His sole problem, he whispers to you in confidence, is not himself but his three ungrateful daughters – Goneril, Regan and Cordelia – and their husbands who wish to deprive him of his trappings, wealth, companions and even his freedom of movement. In short, they wish to ground him in some medieval nursing home.
The family, on the other hand, tells this attentive physician that Lear tends to wander aimlessly in the rain on dark and stormy nights, consorting with fools, wolves and owls. He screams angry words at the indifferent trees, removes his clothing despite the cold and sings nursery songs, resurrected from a distant childhood.
And, like the brief illumination of lightning in an otherwise black night, Lear has momentary flashes of insight. Gloucester wishes to kiss his hand, but Lear responds: “Let me wipe it first, it smells of mortality.” And finally, when Lear dies, there are some who wish to resuscitate him; but those who truly love him say: “Vex not his ghost … let him pass.”
Lear was afflicted with a lengthy, progressive and irreversible disorder that is poignant, demeaning and graceless. It deprives its victims of memory, orientation, purpose, balanced judgment, problem-solving skills and, eventually, even the capacity to fulfill the most basic of everyday needs.
Ultimately, there is a loss of spirit and even personal identity, with the victim reduced to a wretched, near-vegetative existence; he is now vulnerable to threats both external and imaginary, mute, incontinent, incapable of recognizing even close relatives. And Lear’s terminal years of life, instead of being filled with the warmth and congenial protection from kith and kin, are burdened with bewilderment, duplicity and rage.
There is a specter that haunts all advanced nations: it is the specter of organic dementia of the aged, its principal form being Alzheimer’s disease. In Rhode Island, for example, over one percent of the population is afflicted with organic dementia.
To the economist, it is the most expensive organic disease in the United States, with nursing home bills of many billions of dollars per year. To the legislator, it is a subversive force that defeats earnest efforts to contain the costs of health care. To the physician, it is a lengthy, progressive disorder that allows its victim to survive without any vestiges of individuality. And to the sufferer, what a fearful thing is senile dementia! It is death without death’s peace, dignity and finality.
STANLEY M. ARONSON, MD, can be reached at firstname.lastname@example.org