"The Savages," Fox Searchlight Pictures, limited release, Nov. 28, 2007.
The premise: Wendy (Laura Linney) and Jon (Philip Seymour Hoffman) Savage are sister and brother (playwright and college professor, respectively); their father, Lenny (Philip Bosco), has been admitted to a hospital after angrily smearing the walls of his bathroom with excrement in the wake of his girlfriend's death. His children fly to Arizona to see him and discover that he has been diagnosed with progressive dementia. He undergoes an MRI brain scan, and his doctor tells the family that the dementia is not due to strokes but could well be due to Parkinson's disease. When asked about Alzheimer's disease, the doctor says, "It is too soon to tell." Lenny suffers from tremors, a shuffling gait, progressive weakness requiring a wheelchair, the inability to initiate movement, disorientation and a loss of memory. (He thinks his nursing home is a hotel, and he mistakes his daughter for an aide.) He also suffers from bowel and bladder incontinence, is frequently irritated, objects to swearing, and turns off his hearing aide when his children are arguing.
The medical questions: Are Lenny's symptoms and his condition typical of Parkinsonian dementia? Or would Alzheimer's disease or another kind of dementia be more likely? Are his frequent emotional reactions to his circumstances common? Do most patients end up confused and dysfunctional in nursing homes the way Lenny does?
The reality: Alzheimer's disease is by far the most common form of dementia in the elderly, affecting one-third of all people older than 85. Although Alzheimer's patients are frequently fearful or irritable, they are not responding directly to their environment. Lenny, in his 80s, exhibits the kind of emotional, socially inappropriate behavior that is characteristic not of Alzheimer's but of frontotemporal dementia, which affects much younger patients, generally in their 50s and 60s. And though incontinence is common among severe dementia patients, the impulse to smear excrement on the walls is far more characteristic of a psychiatric disorder such as schizophrenia than of dementia, says Dr. Jeff Cummings, director of the UCLA Alzheimer Disease Center.
Many of the details of dementia in the film are accurate, Cummings says. Lenny's physical problems -- weakness, slow movement, rigidity, tremors, mask-like face and shuffling gait -- make his diagnosis much more likely a Parkinsonian dementia such as dementia with Lewy bodies (abnormal proteins that accumulate inside nerve cells responsible for memory and movement) rather than Alzheimer's disease. "The fluctuations [that Lenny experiences] are a hallmark of this type of dementia and are distinctly different from the ongoing memory loss of Alzheimer's disease," Cummings says. He adds that patients experience periods of marked confusion or lack of alertness.
Lenny's embarrassment over his pants falling down or his purposeful movement of turning off his hearing aid to avoid listening to his children fight shows unusual, but not unheard of, awareness for a dementia patient, Cummings says. Also, types of Parkinsonian dementia characteristically cause visual hallucinations, which are not evident in the film.
With all progressive dementias, the growing confusion and loss of the ability to deal with the world lead to an inevitable disastrous outcome. "Eighty-five percent of all dementia patients die in nursing homes in a state of agitation, incontinence and fear," Cummings says.
Dr. Marc Siegel is an internist and an associate professor of medicine at New York University's School of Medicine. He is also the author of "False Alarm: The Truth About the Epidemic of Fear." In The Unreal World, he explains the medical facts behind the media fiction. He can be reached at firstname.lastname@example.org.