The Forgetting: Understanding Alzheimer’s: A Biography of a Disease. David Shenk
it all life and thought were an unrelated succession.” While he constructed an elaborate external memory system in topical notebooks, filling thousands of pages of facts and observations that were intricately cross-referenced and indexed, Emerson was also known for his own keen internal memory. He could recite by heart all of Milton’s “Lycidas” and much of Wordsworth, and made it a regular practice to recite poetry to his children on their walks. His journal entries depict an enchantment with the memory feats of others.
He kept a list:
• Frederic the Great knew every bottle in his cellar.
• Magliabecchi wrote off his book from memory.
• Seneca could say 2,000 words in one hearing.
• L. Scipio knew the name of every man in Rome.
• Judge Parsons knew all his dockets next year.
• Themistocles knew the names of all the Athenians.
“We estimate a man by how much he remembers,” Emerson wrote.
Ronald Reagan was never particularly admired for his memory. But in the late 1980s and early ’90s, he slowly began to lose his grasp on ordinary function. In 1992, three years after leaving the White House, Reagan’s forgetting became impossible to ignore. He was eighty-one.
Both his mother and older brother had experienced senility, and he had demonstrated a mild forgetfulness in the late years of his presidency. Like many people who eventually suffer from the disease, Reagan may have had an inkling for some time of what was to come. In his stable of disarming jokes were several about memory troubles afflicting the elderly. He shared one at a 1985 dinner honoring Senator Russell Long.
An elderly couple was getting ready for bed one night, Reagan told the crowd. The wife turned to her husband and said, “I’m just so hungry for ice cream and there isn’t any in the house.”
“I’ll get you some,” her husband offered.
“You’re a dear,” she said. “Vanilla with chocolate sauce. Write it down—you’ll forget.”
“I won’t forget,” he said.
“With whipped cream on top.”
“Vanilla with chocolate sauce and whipped cream on top,” he repeated.
“And a cherry,” she said.
“And a cherry on top.”
“Please write it down,” she said. “I know you’ll forget.”
“I won’t forget,” he insisted. “Vanilla with chocolate sauce, whipped cream, and a cherry on top.”
The husband went off and returned after a while with a paper bag, which he handed to his wife in bed. She opened up the bag, and pulled out a ham sandwich.
“I told you to write it down,” she said. “You forgot the mustard.”
It seems clear enough that Reagan was increasingly bothered by personal memory lapses. In a regular White House checkup late in his second term, the President began by joking to his doctor, “I have three things that I want to tell you today. The first is that I seem to be having a little problem with my memory. I cannot remember the other two.”
Did Reagan have Alzheimer’s disease in office? Yes and no. Without a doubt, he was on his way to getting the disease, which develops over many years. But it is equally clear that there was not yet nearly enough decline in function to support even a tentative diagnosis. Reagan’s mind was well within the realm of normal functioning. Even if his doctors had been looking intently for Alzheimer’s, it is still likely that they would not have been able to detect the disease-in-progress. A slight deterioration of memory is so common among the elderly that even today it is considered to be a natural (if unwelcome) consequence of aging. About a third to a half of all human beings experience some mild decline in memory as they get older, taking longer to learn directions, for example, or having some difficulty recalling names or numbers.
Alzheimer’s disease overtakes a person very gradually, and for a while can be indistinguishable from such mild memory loss. But eventually the forgetting reaches the stage where it is quite distinct from an absentminded loss of one’s glasses or keys. Fleeting moments of almost total confusion seize a person who is otherwise entirely healthy and lucid. Suddenly, on a routine drive home from work, an intersection he has seen a thousand times is now totally unfamiliar. Or he is asking about when his son is coming back from his vacation, and his wife says: “What do you mean? We both spoke to him last night.” Or he is paying the check after a perfectly pleasant night out and it’s the strangest thing, but he just cannot calculate the 20 percent tip.
The first few slips get chalked up to anxiety or a lousy night’s sleep or a bad cold. But how to consider these incidents of disorientation and confusion when they begin to occur with some frequency? What begin as isolated incidents start to mount and soon become impossible to ignore. In fact, they are not incidents; collectively, they are signs of a degenerative condition. Your brain is under attack. Months and years go by. Now you are losing your balance. Now you can no longer make sense of an analog clock. Now you cannot find the words to complain about your food. Now your handsome young husband has disappeared and a strange elderly man has taken his place. Why is someone taking your clothes off and pouring warm water over you? How long have you been lying in this strange bed?
By 1992, the signs of Reagan’s illness were impossible to ignore. At the conclusion of a medical exam in September, as the New York Times would later report, Reagan looked up at his doctor of many years with an utterly blank face and said, “What am I supposed to do next?” This time, the doctor knew that something was very wrong.
Sixteen months later, in February 1994, Reagan flew back to Washington, D.C., from his retirement home in Bel Air, California, for what would turn out to be his final visit. The occasion was a dinner celebrating his own eighty-third birthday, attended by Margaret Thatcher and twenty-five hundred other friends and supporters.
Before the gala began, the former President had trouble recognizing a former Secret Service agent whom he had known well in the White House. This didn’t come as a total shock to his wife, Nancy, and other close friends, but it did cause them to worry that Reagan might have problems with his speech that night.
The show went on as planned. After an introduction by Thatcher, Reagan strolled to the podium. He began to speak, then stumbled, and paused. His doctor, John Hutton, feared that Reagan was about to humiliate himself. “I was holding my breath, wondering how he would get started,” Hutton later recalled, “when suddenly something switched on, his voice resounded, he paused at the right places, and he was his old self.”
Back at his hotel after the dinner, Reagan again slipped into his unsettling new self, turning to Nancy and saying, “Well, I’ve got to wait a minute. I’m not quite sure where I am.” Though the diagnosis and public announcement were both months away, Reagan was already well along the sad path already trod by his mother, his brother, and by Auguste D.
The doctors who diagnosed Reagan in 1994 knew with some specificity what was happening to his brain. Portions of his cerebral cortex, the thin layer of gray matter coating the outside of his brain, were becoming steadily clouded with two separate forms of cellular debris: clumpy brown spherical plaques floating between the neurons, and long black stringy tangles choking neurons from inside their cell membranes. As those plaques and tangles spread, some neurons were losing the ability to transmit messages to one another. Levels of glucose, the brain’s sole energy source, were falling precipitously, weakening cell function; neurotransmitters, the chemicals that facilitate messages between the neurons, were becoming obstructed. The tangles in some areas of the brain were getting to be so thick it was like trying to kick a football through a chain-link fence.
Ultimately, many of the neurons would die, and the brain would begin to shrink. Because the brain is highly specialized, the strangulation of each clump of neurons would restrict a very specific function—the ability to convert recent events into reliable memories, for example, or the ability to recall specific