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Notes from an emergency room doctor: "Hello," the voice on the other end of the phone whispered secretively.

But I knew immediately who it was. "Hello, Mom,"

I answered.

"Your father doesn't know I'm calling," she said still softly.

"What's the matter?" I asked apprehensively.

"Your father is not thinking right," my mother went on. "He's getting senile."

My father is seventy-seven, somewhat cantankerous at times, but still active. That word "senile" switched my thoughts to nursing homes, and wheelchairs, and spoon feedings. A friend had just related the story of his own father who had recently developed Alzheimer's. One morning his father went out walking with his grandson. A few hours later, he came home without him. He just forgot he had taken the little boy along. Fortunately, that incident had an uneventful outcome. The child was found. But the "old man" was upset by his lapse. And his son was equally distressed. Knowing that your father has become as dependent as your child is an agonizing threshold event in life. Had my time come to deal with this difficult and all too common illness that transforms the lives of the elderly that suffer from it and their families?

"He's not thinking right," is often the first and only way family can describe the syndrome of dementia that has overcome a loved one. Dementia usually results from a degeneration of the cerebral cortex, the thinking part of the brain. There are some treatable forms of dementia like subdural hematomas, cancer, tuberculosis, anemias, vitamin deficiencies, thyroid disorders, chronic infections, and diabetes. But once the treatable dementias have been ruled out, the diagnosis of exclusion is called senility or Alzheimer's disease.

Alzheimer's disease (AD) is a progressive, severe atrophy of the entire brain, particularly the frontal cortex, which not only effects thinking but a patient's emotional control. AD has a relatively subtle and early onset, between the ages of 40 and 60, and then progresses steadily to total impairment usually within 5 to 15 years.

Anatomically, senile dementia is very similar to Alzheimer's. Some experts think it is just a milder form of AD with a later onset.

In its early stages, someone with dementia may exhibit little more than some anxiety or depression as they subtly try to cope with increased problems with memory or comprehension. As these deficits progress with more obvious loss of memory and defects in judgment, anxiety and depression also increase along with occasional eruptions of volatile behavior.

There is no cure for AD. Until recently, physicians could only treat its secondary symptoms. Agitation, delusions, hallucinations, and paranoia were treated with antipsychotic medications. Anxiety was treated with drugs like Xanax or Ativan. Depression was treated with a myriad of antidepressants. And there are several drugs now that help slow the progression of the disease Namenda, Aricept, Exelon, and others. But there is no cure. There is no evidence that any drug changes the underlying disease process at all.

Because senility and AD are so insidious in their progression and because they are so associated with the process of aging, many don't think of these ailments as a major health issue. But 4 million Americans have Alzheimer's. It is the nation's third most expensive disease, after heart disease and cancer, costing more than $90 billion a year. Worse still, two-thirds of the costs of caring for Alzheimer's patients are indirect, often involving round-the-clock care, and lost productivity for both the patient and the patient's caring family, costs hardly ever covered by insurance.

"How is dad not thinking right?" I asked my mother. "Does he get lost? Or forget what he's doing?"

"No," she answered. "He forgets to shut off the lights and lock the doors at night."

"My God," I laughed. "Using that criteria, I'm senile. Most everybody I know is senile."

"Well," my mother went on, "I have to stay up now until he goes to sleep. I used to go to sleep first but I can't anymore."

"Mom, even if he is a little senile, there's not much you can do about it. So, go to sleep."

"All right," my mother responded, unconvinced. "Good night."

"Mom!" I caught her before she hung up. "And don't worry." Afterall, I thought, that's my job. Then I added, "And don't forget to lock the door and shut off the lights."