In my practice as a geriatrician, no syndrome is as interesting, intellectually stimulating, and simultaneously frustrating and rewarding as dementia. Ethical sensitivity, integrative neurology, a critical approach to neurobiology, and a kind but dogged inquisitiveness underpin the knife-edge act of supporting the patient within the complex web of family and insufficient social and societal supports.
Transmitting this intellectual and professional ferment to students and trainees is not easy. Affected by the nihilism and reductionist views of the general public towards Alzheimer’s disease, they are often daunted by a condition where laboratory tests and neuro-imaging are so markedly subsidiary to clinical skills and a collaborative approach to diagnosis and management.
Tangles, a graphic novel from Canada, provides a fresh perspective that should spark enthusiasm to do better in understanding and managing this illness. With a title that economically evokes Alzheimer neuropathology, complex family dynamics, and entrapment by circumstances, it chronicles the impact of early onset Alzheimer’s disease on Sarah Leavitt’s mother and family.
The art form, undervalued in Anglophone academia, made a breakthrough just over 25 years ago with Art Spiegelmann’s magisterial Maus. By recasting those enmeshed in the Holocaust as animals, Spiegelmann provided an engaging and innovative common space whereby we could all question our own roles and responsibilities should we have found ourselves in central Europe at the time.
In her own way, Leavitt also guides us into challenging territories that we would negotiate much less easily with the written word alone and at a self-regulated pace that film would not allow. The fusion of graphics and text provides a striking fluidity of thought, emotion, and memory, while the spidery, delicate drawings radiate fragility and trepidation.
We come to know this secular Jewish family whose liberal and educated background is typified by a television free childhood and organic food. Close, articulate, and loving, we track their bewilderment at the early subclinical changes, and agonise that there are still neurologists who interview en masse rather than seeing the patient on her own first.
As the illness progresses, we are struck by the waxing and waning sparks of communication and love alongside the shocks of dealing with personal hygiene, body hair, and evolving faecal incontinence. Life continues for all, as the episodic salience of the author’s lesbian relationships demonstrates, and we share the tensions and warmth of sharing care, first with family, then progressively with paid carers and a nursing home.
Death, grief, and the unexpected solace of bereavement rituals round off a journey that fulfills its promise of being both novel and graphic. The experience of Alzheimer’s disease is simultaneously common and extraordinary: this illuminated and illuminating manuscript may assist in motivating new generations of physicians to afford it more priority in their hearts and their heads.
Desmond O’Neill is a consultant physician in geriatric and stroke medicine in Dublin, and is a member of the external advisory panel of the age friendly university initiative.