By Michael Castleman

When I recall my mother-in-law, Ruth Simons, I try to remember the special person she was before Alzheimer’s disease stole her away. Ruth was charming, smart, articulate, and kind. She raised four children. She loved dinner parties. She adored classical music. With my father-in-law, Gene, she attended dozens of Elderhostels around the world.

But in 1999, something changed. Ruth began using words incorrectly. One day, my sister-in-law, Vicki, noticed that Ruth couldn’t fasten her seatbelt. She seemed to have forgotten how. On trips, Gene said she seemed disoriented. Gene was a kind, patient man, but Ruth’s confusion irked him. He’d complain, “When are you going to get back to being your old self?”

Little cat feet
In retrospect, we should have suspected Alzheimer’s. Its top risk factor is age, and Ruth was 82. And it’s increasingly common. The Alzheimer’s Association says it afflicts 5 million Americans.
But Alzheimer’s develops slowly, says Deborah Halpern, of the National Family Caregiver Alliance, in Kensington, Maryland. Like the fog in Carl Sandberg’s poem, it “comes on little cat feet.” We had trouble distinguishing Ruth’s situation from normal age-related changes. But if you know what to look for, dementia is different from normal aging. Anyone can misplace their keys. People with dementia find them and have no idea what they are (see “Warning Signs of Alzheimer’s” on page TK).
We also should have suspected Alzheimer’s based on Ruth’s long history of high blood pressure, heart disease, and lack of exercise. Myth has it that Alzheimer’s strikes out of the blue, but in fact, it’s a close cousin to cardiovascular disease. In CV, arterial injury leads to cholesterol-rich plaque growth and reduced blood flow to either the heart, which leads to heart attack, or the brain, which leads to stroke. With Alzheimer’s, on the other hand, a different type of plaque forms in the brain (beta-amyloid plaques), and the brain cells get all tangled up. Although the biochemical mechanisms of Alzheimer’s and cardiovascular disease are different, Alzheimer’s prevention strategies can mimic those for warding off heart attack and stroke (see “Risk Factors and Prevention” on page TK).

Oh, my God
As Alzheimer’s develops, someone in the family starts wondering about the person and suggests medical testing. Others may think that’s alarmist, and rancor sometimes ensues. Around the time Ruth fumbled with her seat belt, my wife, Anne, who happens to be a doctor, added up her mother’s increasing forgetfulness, language problems, and lethargy, and quietly suggested the possibility of dementia. Her father dismissed it as ridiculous. He insisted that Ruth was simply fatigued, and would soon be her old self again. “Say Alzheimer’s,” explains Dolores Gallagher-Thompson, PhD, a professor in the department of psychiatry at Stanford who specializes in dementia caregiving, “and people think: memory loss. But inappropriate behavior—bizarre speech, buttons misbuttoned—is often the first sign.”
Anne e-mailed her three siblings. They didn’t know what to think. They decided to wait and see. If Gene was right, then confronting him would be energy wasted. If he was wrong, he’d realize it soon enough.
As Alzheimer’s progresses, it becomes obvious that something is amiss. For Anne and me, the oh-my-God moment occurred in 1999 at our son Jeff’s bar mitzvah. Ruth and Gene flew to San Francisco from Ohio. They loved the City by the Bay, but this time,