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Neurology Today:
doi: 10.1097/01.NT.0000407230.97878.80
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Bookshelf: Alzheimer Disease from the Inside Out: “As Neurofibrillary Tangles Proliferate”

McCammon, Anne MD

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Alice LaPlante, who teaches creative writing at Stanford and San Francisco State Universities, has published a best-selling book on writing and lots of short fiction. But her latest entry, Turn of Mind — a mystery and a page-turner — stands apart from the rest. In this, her first novel, the narrator is a woman in the midst of Alzheimer disease.

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Jennifer White, a respected, now retired 64-year-old Chicago hand surgeon, has a live-in caregiver. A notebook helps her remember recent events and allows friends and family to write notes. Old photographs trigger crucial, emotionally loaded memories. The reader can thus piece together the story and read between the lines. From the first paragraph we sense confusion and fear. Clearly, all is not well.

Jennifer's awareness comes and goes; she has good and bad days, and increasing trouble recognizing faces. Her medical background enables her to view her disease in a clinical, detached way: “As the neurofibrillary tangles proliferate, as the neuritic plaques harden, as synapses cease to fire and my mind rots out, I remain aware.” She hates being patronized by caregivers, yet she either does not acknowledge or cannot recall the episodes of agitation, aggression, wandering, and incontinence that leave her family at their wits' end. Her old friend and colleague, neurologist Carl Tsien, prescribes increasing doses of antipsychotic and anxiolytic medication.

Jennifer has two children — her attentive daughter Fiona, who visits often and handles finances, and her son Mark, who is troubled, angry, and demands large sums of money. Her husband, James, described as a keeper of secrets, died in a car accident.

And then there is Jennifer's longtime friend, Amanda O'Toole, found dead of head trauma at her home three doors away. Four fingers of her right hand were removed with surgical precision, apparently after death. Jennifer was the last one to see her friend alive and is an obvious suspect, but she remembers nothing, despite multiple visits from the police.

Her relationship with Amanda was close but complicated. Amanda was intelligent and politically active but also moralistic, envious, and spiteful. More than once she is described as an avenging angel, someone many people despised. As more is revealed about the relationship between the two women and their husbands, who lived almost next door for decades, it becomes clear that everyone had secrets and no one was a saint.

On one of her good days, Jennifer initiates a talk with two young people, whom she recognizes as her children, although their names escape her, informing them that she has Alzheimer disease and knows that she won't be able to live on her own much longer. In the next breath, she objects to selling her house and insists that her husband will be home for dinner any minute.

Her family can take no more and Jennifer is moved to an upscale care facility which, she observes, “is not a place where gentleness thrives. Natural selection takes care of that, both for the caring and the cared for.” We hear mention of her refusing medication and requiring restraint in bed at night. No wonder she feels incarcerated for unspecified past crimes and cunningly looks for a chance to escape.

Surprisingly eloquent and self-aware, she lives more and more in the past. Fascination with dissection led her into medicine, she remembers. “I wanted a scalpel so badly.”

Detective Megan Luton visits, gently persistent on the matter of the severed fingers. She has a special concern for Jennifer as well, having lost her life partner to early onset Alzheimer disease. “You lose the person you love. And you are left with the shell,” she says. You expect yourself to go on loving the person, “even when they are no longer there....And you long for it to be over soon.” Jennifer's mother succumbed to dementia, and she understands on some level but doesn't connect emotionally to her own situation.

Something nags at the edge of Jennifer's awareness, and worrisome small bits of information come out. The staff complains that she is disruptive, but her status as a prominent physician allows her to stay. Then, in a moment of chaos at the facility, she escapes.

Jennifer's amazing journey back to the old neighborhood is told in second person. She awakens the next day convinced that she is late for work at a free clinic. So off she goes by cab. She dons a white coat and starts seeing patients. In the realm of medicine, she still seems competent, though it is both appalling and funny that she can diagnose shingles while blithely forgetting to pay the cab driver. Before long, Detective Luton appears and confronts her and Fiona with new evidence of Jennifer's involvement in Amanda's death. The detective decides not to prosecute because of Jennifer's mental incompetence.

In the next circle of hell, Jennifer is sent to an understaffed state facility where she is refusing food. Narration now is third person. Increasingly lost in her visions of angels, she sings songs of praise that sound to the staff like wailing without words.

Case closed, mystery solved? Not quite. Revelations in the last few pages radically alter the understanding of all that has gone before, unless the reader picked up on carefully placed clues.

LaPlante's evocation of a mind unraveling is imaginative and heartbreaking, her pacing marvelous, her storytelling economical and assured. We come to care about the characters, who are rounded and believable, although Amanda remains inscrutable to the end. Turn of Mind takes what seems like a far-fetched premise and turns it into a fascinating tale about the complexity of truth and the ambiguity of justice.

Dr. McCammon is voluntary associate clinical professor of neurology at the University of California-San Diego and editor of the Humanities/Reflections section for Neurology

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