The Clock-Drawing Test and the Mini-Mental Status Exam
There are a lot of things a person with MCI could get wrong on these. At the worst end of the spectrum, they can’t draw a clock at all, or the person draws a clock that doesn’t look like a clock, in that it is not a circle or rectangle with numbers going around it. The most common results for those with dementia are: wrong time, no hands, missing numbers, the same number more than once, and a refusal to draw the clock. There are at least fifteen different scoring systems for the clock-drawing test. Most can be given and scored by an intelligent layperson, and most research shows that the simplest scoring system is as informative as the most complicated. If you can’t ace the clock-drawing test, you probably have some kind of cognitive dysfunction. If you can do well on it, whatever is wrong with you is probably not dementia.
In our second appointment, the neurologist gets down to it. （The neurologist says that Brian’s MRI has now been read by some brilliant colleague, but the neurologist still has a few questions.） Brian has a high IQ and a high EQ—he’s emotionally aware, the neurologist says. The people at the NeuroAging Institute are going to be delighted to have him in their studies: high IQ and early-onset Alzheimer’s is apparently as appealing as tall and blond is in America. Then we hear a long digression about why and how the NeuroAging Institute people are really Yale people but no longer part of Yale and, if they do find a cure for Alzheimer’s—I would roll my eyes but I am crying like my face is broken—Brian, as a participant in a clinical study, would be right at the head of the queue. Brian and I both get the basics: Brian probably （in a tone that says “definitely”） has a dementing disease. It’s probably Alzheimer’s. Very, very likely. I ask if it seems to be vascular, the result of a big stroke neither of us ever noticed, from which he is still recovering. She says, No, but there have been some ministrokes in the cerebellum. I plan to look up cerebellum and what it does as soon as I get home. It deals with motor activity, balance, and…driving.
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I say, So this thing at NeuroAging is for a second opinion, that maybe it’s not Alzheimer’s? I can see the neurologist is sorry to have to say, Not really, it would be for an evaluation, to provide more information. It’s clear this doesn’t mean different information or contradictory information, and I appreciate—for a minute—that it takes real discipline not to soften or deflect from the fact that Brian has Alzheimer’s.
She asks if Brian is incontinent and she asks him to walk around. I’m sure this is to confirm something about his balance, but I don’t ask what. （In the next three months, his balance will become a problem, but not yet.） She tells him to continue taking vitamin B-12 forever, although that’s unlikely to be the basic problem. But still. Maybe, the B-12 supplement will help. （“It can’t hurt,” I hear my father yelling from the Jewish Joke Playbook.）
Does it seem to be frontal-lobe, I ask （frontal-lobe dementia moves even more quickly than Alzheimer’s, is what I read）。 The neurologist says no.
The neurologist shows us the MRI, running a finger over the white splotches on the round gray shape of Brian’s brain. I hear that line of Diane Ackerman’s: …the brain, that shiny mound of being, that mouse-gray parliament of cells…that wrinkled wardrobe of selves stuffed into the skull like too many clothes into a gym bag.
Brian’s brain is in the slow process of unwrinkling, the gym bag emptying out. I see the white spaces where the brain no longer is, and so does he.
The neurologist runs a finger very gently over the amygdala on the MRI image. Probably something here, she says.
His brain is smaller than it should be at sixty-six—the amygdala, in particular—and the ventricles are bigger. The amygdala, this inch-long almond, deep in the temporal lobes, above the brain stem, catches my eye and takes me right back to high school biology. I say, Amygdala—that’s feelings and memories and learning? The neurologist nods, just once. I say that on the websites, and I mention Mayo Clinic （she nods several times approvingly）， they describe the Alzheimer’s trajectory as three to four to twenty years. The neurologist disagrees. “Eight to ten to maybe—maybe—twelve. But remember, he’s had these symptoms for at least two, I’d say three years.” Every Alzheimer’s website now states that people have Alzheimer’s for ten, sometimes twenty years before the early symptoms emerge. The neurologist makes clear that those eight to ten to twelve years for Brian would be the end of life, the end of his body’s life.
I have now watched enough Alzheimer’s diary videos （Who records this grief and posts it on YouTube? Who does this? I think, even though I am as grateful as I am horrified） that it’s very clear that the end of the body will be long after the end of the self. I see that in my notebook I wrote, on four different pages, Possibly Alzheimer’s, which is surprising because I already have no doubts at all.
By moving to the practical, the neurologist signals that we are coming to the end of the appointment. （Maybe she can’t take it anymore, which I understand. Brian doesn’t move an inch, but the affect he usually shows the world is unchanged: affable and easy. I am in a wet fury that this is all the help we will get.） She says that Brian probably should not be driving, even with the GPS, not because he’ll get lost （because of our directional impairment, we barely get where we wish to go, even with the GPS. In the good old days, we once spent an hour in a hotel parking lot, unable to find the exit） but because…Brian jumps in: I might be in an accident. You might kill someone, the neurologist says. We are both silent. I figure we will get Lyft on his phone over the weekend. （We do. He can’t figure out how to use it.）
She tells me to go through his wallet and take out most things, all but one credit card, and put in a card with my info on it. She seems to be describing a person who can no longer manage an independent life and I think this cannot be so, because I saw him just that morning, making his oatmeal, with lots of maple syrup and a handful of almonds, and a cup of black tea, spreading The New York Times out before him, with the air of a man getting down to work.
The neurologist asks Brian if he’s the kind of person who gives his info to strangers. He says no, with a laugh, and he adds that he is a very Italian person and his innate paranoia and xenophobia will work to his advantage here. He says these words—paranoia and xenophobia—and I think, See?! See, Doc?
No matter how I fight this, at every sentence, I also see that Brian’s world is about to get very small. One of his great pleasures is overdoing it with the groceries, involving several stops at little markets, cheese shops, the East Haven lady who makes her own Thai BBQ sauce and fries up a bag of plantains for him while he waits. At our old house, we had a refrigerator just for condiments. Even now, my older daughter always says, How can you be only two people and never have an empty fridge? That’s Brian, I say, buyer of burrata, soppressata, Meyer lemons, white peaches, Benton’s ham.
On the way home from the neurologist, who has reminded us to call NeuroAging and to come see her again sometime but no hurry, I offer to drive to Liuzzi’s （a great Italian deli） and he says no. I am as disappointed and stunned as if I’d offered him a blow job on a Sunday night and he’d said he’d rather watch some Scottish mystery.