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Dementia

What Effect Does Alzheimer’s Disease Have on Writing?

Observations on dementia's impact on creative writing and diagnostic potential.

Key points

  • Agraphia is very common in Alzheimer's disease but is of limited diagnostic value.
  • The earlier diagnosis of Alzheimer's disease has led to a new wave of writers who have movingly described what it is like to lose memory.
  • Computerized textual analysis may be able to distinguish early writing changes due to incipient dementia, especially in creative writers.

In the earliest stages of dementia, literate individuals are able to compensate for their written mistakes by double-checking what they have put down on paper and then using word processing software to further correct spelling, grammar, and punctuation. Uncharacteristic substitution of homophones such as "there" for "their" or the jumbling of syllables are sometimes early voiced concerns, but it is impossible for a neurologist to diagnose Alzheimer’s disease from a letter received from a person who is worried about their memory. On the other hand, the copious written accounts running to several pages that are often handed over during the medical consultation by people worried they might be developing dementia and by those with functional cognitive disorder (pseudodementia) can be of considerable diagnostic value.

Characteristics of Writing in Early Alzheimer's

When writing by individuals in the early stages of Alzheimer’s disease is compared with their written text from ten years earlier it may be found to have an impoverished vocabulary less grammatical complexity with fewer subjunctive clauses, and a lack of punctuation. Frequent perseverations, unnecessary gaps between letters and words and an inappropriate mixing of lower- and upper-case letters may also be present. Poorly constructed or illegible letters and omission or over-repetition of letter strokes are other characteristic findings. Written expression is more affected than spoken language in many people with dementia, but despite this many people with Alzheimer’s retain their ability to produce simplified but coherent written sentences for many years after diagnosis. Ronald Reagan's handwritten letter composed without assistance that announced he had been diagnosed with Alzheimer's disease is of interest in this regard. Although his writing had become crabbed and the strikingly uneven margins raise the possibility of new visuo-spatial difficulties, the grammar, spelling and punctuation were accurate.

Public domain
None
Source: Public domain

As the pathology of Alzheimer’s disease spreads from the hippocampus to involve the angular gyrus and Wernicke’s and Broca’s language areas, word-finding difficulties increase, and agraphia, an acquired inability to write, is inevitable. In 1906, Alois Alzheimer reported that, when attempting to write, his patient Auguste D tended to hold the paper as if she had a right-visual-field defect and that she would duplicate some letters while omitting others. Later in the course of her illness, when she was asked to write her name, she would get as far as writing "Frau" and then come to an abrupt halt because she could not remember what came next. Lynn Brophy, in her 2015 blog "Boomerang-Parents," includes a sample of her mother’s writing a few weeks before she died with Alzheimer’s disease. On the second line, Brophy deciphers an attempt by her mother to write her Christian name, Eleanor in capital letters, but which she was unable to complete with her script dilapidating into an illegible scribble ( see below)

Lynn Brophy/blog
None
Source: Lynn Brophy/blog

There are a few outstanding individuals with Alzheimer's disease who have written about their own cognitive impairments in autobiographies, newsletters, and, increasingly, on blogs. One of these, the late Thomas de Baggio, an herb farmer from the Washington, D.C., area described his difficulties writing:

With failing memory, it is difficult to write long passages without getting lost in words. Where does the story go?

Words come when I sit down to write, but they dance away seductively....

I am having trouble reading the writing I do with a pencil or pen. It used to be sharp; now it wobbles and is full of uncertainty. The words come normally but the letters are sometimes not in proper order.

The words that are lost first are those that tend to appear less frequently in everyday English, so that sentences become formulaic and infantile with a preponderance of "low-image" verbs like "come," "do," "get," and "have," and indefinite nouns like "thing."

Regular writing and reading are recommended as therapy for people with episodic memory difficulties. Lists, notebooks, diaries, calendars, and labels for items whose name and function are not reliably accessible become over time essential aide-memoires . Christine Boden, in her pathography Who Will I Be When I Die writes:

Without a shopping list, it is pointless me venturing to the shop. Without my diary, I don’t remember what day it is, what anyone is doing, where they are and so on. I don’t seem to have space in my brain for that sense of "Thursday-ness"...or "April-ness" or "1998-ness."

Gabriel García Márquez

Eighteen years ago, the Colombian Nobel Laureate Gabriel García Márquez, best remembered for popularizing a style of writing called magical realism, wrote his last book after a long-anticipated wait of more than 10 years. Memories of My Melancholy Whores was a rather terse 115-page novella that received a mixed reception. Alberto Manguel, a literary critic for The Guardian, considered the work to be flat and conventional lacking Márquez’s characteristic color, inventiveness, and trademark quotable snippets of wisdom. In the Literary Review, Sam Leith complained that the book was seeded with odd little paradoxes that were tense, careful, deadpan, and often baffling, while Michiko Kakutani writing in the New York Times had this to say:

The fertile inventiveness that animated his masterpiece ''One Hundred Years of Solitude'' is decidedly muted in these pages, and the reverence for the mundane realities of ordinary life, showcased in more recent works, seems attenuated as well. As a result, ''Memories of My Melancholy Whores'' feels like a brittle little fable composed on automatic pilot. The trajectory of this narrative turns out to be highly predictable, leading to a banal ending to a banal story that's quite unworthy of the great Gabriel García Márquez's prodigious talents.

Five years before the book’s publication, García Márquez had been diagnosed with cancer of the lymphatic system and, despite going into remission with chemotherapy, concerns about his health continued to be raised from time to time over the next decade in the Colombian press. Finally, in 2012, Jaime García Márquez announced that his brother had been suffering with dementia and that he would be unable to complete his autobiography. Gabriel García Márquez died two years later of a chest infection in Mexico City at the age of 87.

In his masterpiece One Hundred Years of Solitude, Marquez provided a detailed description of a type of memory impairment that was eventually characterized eight years later by the clinical neuropsychologist Elizabeth Warrington and many years later became known as semantic dementia. Marquez wrote that those living in the Pueblo of Mirrors who sucked on Úrsula Iguarán's homemade sweets became unable to sleep and developed a difficulty in remembering the names and uses of everyday items. To compensate for this, the villagers started to mark the name with an inked brush on every important object. For example, one hung a sign around a cow’s neck saying, "this is the cow which must be milked every morning so that she will produce milk and the milk must then be boiled in order that it can be mixed with coffee."

It is conceivable that in the course of his work as a journalist, Márquez heard about la bobera ("the foolishness"), a pestilence known to cause amnesia in certain families who lived in and around the Andean municipality of Yarumal in North West Colombia. Before Márquez’s death, it was discovered that the cause of this familial dementia which went back for hundreds of years was a mutation in the presenilin 1 gene, a known genetic cause of early-onset Alzheimer’s disease. In his announcement to the press, Jaime García Márquez had reported that their mother and other brother had also suffered from Alzheimer’s disease.

An interrogation of the texts of the "dementia writers," like Thomas DeBaggio, Christine Boden, Greg O’Brien, and Daniel Gibbs reveals none of the recognized handwriting abnormalities reported in Alzheimer’s disease, perhaps, in part, because of editorial assistance, but it is worth at least considering whether the lukewarm reception of Márquez’s last novel might have been justified and explained by incipient Alzheimer’s disease rather than its "smutty" subject matter, the author’s general ill health and increasing age, or the lapse in time from the publication of his previous book.

Jackson’s Dilemma by Iris Murdoch was published in 1995, four years before her death. As with Memories of My Melancholy Whores, the reviews were not what she or her publisher had hoped for. The writer A.S. Byatt commented that the structure of the novel was akin to an "Indian Rope Trick" in which the characters "have no selves and therefore there is no story and no novel," and Penelope Fitzgerald noted that the economy of the writing made it appear "as though Murdoch had let her fiction wear through almost to transparency."

Computerized Language Analysis

In 2005, clinical neuroscientist Peter Garrard used a computerized textual and "word typing" program to compare the writing of Murdoch’s last book with two of her earlier novels, Under the Net, written in her 30s, and the Booker Prize-winning The Sea. Garrard’s analysis indicated that the vocabulary used in Jackson’s Dilemma was more stunted compared with her other books. A postmortem examination had confirmed clinical suspicions of Alzheimer’s disease, and a biography by Murdoch’s husband, the writer John Bayley, provided moving detail of her mental difficulties during her final years.

If computerized language analysis of the sort used by Garrard can be refined further and be made less time-consuming to perform, it might one day become a useful adjunct in the neuropsychological evaluation of people with early memory impairment. Detailed case study analyses, similar to the one carried out with Iris Murdoch’s writing, have also been attempted in the paintings of artists like Willem de Kooning and William Utermohlen, serially describing the changes in style and technique that occurred after the diagnosis of Alzheimer's disease was made.

References

Rascovsky, K., Growdon, M. E., Pardo, I.R., Grossman, S., Miller, B.L. "The quicksand of forgetfulness": semantic dementia in One Hundred Years of Solitude. Brain. 2009;132(Pt 9):2609–2616.

Garrard, P., Maloney, L. M., Hodges, J.R., Patterson, K. The effects of very early Alzheimer's disease on the characteristics of writing by a renowned author. Brain. 2005;128(Pt 2):250–260.

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