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The film is based on the short book by Alice Munro, “The bear came over the mountain”, and is set in Canada. It observes the emotions of a couple who have been married for 50 years when the wife goes into a care home.

The first few scenes paint the picture of Fiona’s (Julie Christie) ailing memory. She is seen to put a frying pan away into the freezer and in doing so has a slightly bewildered look about her. Her husband, Grant (Gordon Pinsent) says nothing, lets her leave the room, and then puts it away in the correct kitchen cabinet. There is a clear sense this type of event has happened on many an occasion. After this we see aide memoirs have been put on the kitchen cabinets and drawers by Fiona herself. Soon after, whilst entertaining friends at dinner, she is shown to experience some word-finding difficulty when she can’t find the word ‘wine’.

One of the strengths of the movie (and I suspect the book) is the dialogue. Early on in the movie Fiona and Grant are seen walking in the local countryside. She admires the natural beauty of a bright yellow flower and is clearly familiar with it visually but is not able to recall its actual name (skunk lily). She eloquently describes this situation when she says “Sometimes there’s something delicious in oblivion”. Later, when her memory problems have become subjectively troublesome, she comments that, “I think I’m beginning to disappear”. She also describes one of the classic core symptoms of the dementias – “half the time I wander around looking for something pertinent but I can’t remember what”.

Once it has been shown that Fiona has troublesome memory problems she undergoes a medical assessment. The memory assessment seen in the film is mainly testing abstract thinking but she tries to cover up her deficits with her very good and preserved social skills. On leaving the doctor’s room there is a hint of some frontal lobe loosening when she unsubtly comments upon the “ugly baby” in the waiting room!
At this point in the film the ‘A’ word hasn’t yet been mentioned but following their visit to the doctor Fiona and Grant are seen reading books – ‘The 36 hour day’ and ‘The Forgetting’, which cover many aspects of Alzheimer’s dementia. Fiona reads out loud to Grant about what carers can expect in the later stages of the disease.

Soon afterwards, Fiona gets lost (but avoids frostbite!) whilst cross country skiing (the Canadian equivalent of older people going walkabout in the UK!). She’s found by her husband and she announces that “we’re at that stage”, implying it is time to look at a care home placement. This I found difficult to believe the character of Fiona looked so physically well (Julie Christie herself is still beautiful!) and clearly still having many preserved ADLs (more-or-less fully independent). Compared to the usual reality of older people resisting going into a care home or being ‘put away’, Fiona positively embraces the idea, leads the move and comforts her husband (again a little reverse of the norm). I don’t think it was quite credible that she had deteriorated to an extent that placement was needed.

The husband persuaded by her decision then visits a local care home – Meadowlakes (makes a change from a tree-related care home name, I suppose!). On entering the new, spacious and very pleasant building he is greeted by a row of several zimmerframes neatly lined up in a corridor (nothing quite smacks of a care home than a wall of such frames!). He meets the administrator who shows him around in the style of an estate agent – “there’s plenty of natural light” and “we aim to maintain social functioning” being part of her sales patter. During the introduction lap of the home he has pleasantries with an older lady who delightfully, albeit a little ectopically, uses a profanity completely out of the blue! He is also informed of the policy to move residents upstairs to the extended care floor once “they have become more progressed”, an idea he totally dismisses would ever happen to his wife. During the visit to the extended care floor he hears pop music blaring out and he asks, “who chooses the music – I’m assuming it’s not the residents?” I must admit this phenomena has not gone unnoticed by myself on visits to care homes as I experience it quite regularly – only recently I pondered who of a group of older ladies having lunch had a particular penchant for Madonna as the song ‘Like a virgin’ was blaring out!

He is told of a further ‘policy’ whereby the new resident receives no visitors or phone calls for the first 30 days, to help with settling in. When he informs Fiona of this, again, it is she trying to reassure him – “all we can aspire to in this situation is a bit of grace”. However once again she looks far too beautiful and elegant and there’s no sense of any significant impairment (indeed it’s her grossly preserved ADLs which means she is able to pack her bags herself!). Grant makes a final plea for her not to go into the home and there’s no suggestion of any community support being an option. Whilst it is great there is a mainstream Oscar nominated movie depicting Alzheimer dementia, which can only help raise the profile, it is slightly annoying that issues like community care aren’t even mentioned and the stereotype of being ‘put away’ continues to be propagated. However, Fiona remains adamant, purposeful and dignified the move and she and Grant have a poignant drive to the home with a sentimental love song escorting them on the car radio. He continues to be wracked with guilt.

On their arrival they are met by the home administrator who seamlessly switches into her estate agent mode and again remarks “so you can see we get plenty of light!” Again it is Fiona who is in control of the situation but we get an insight into what may be driving her into this course of action. We begin to wonder if she’s actually punishing her husband for previous infidelities in their marriage when he was a university professor. She asks him to “make love and for you to then go” which duly happens. On hurriedly leaving the hotel-like room he briefly stops to do up his trousers in the hallway outside her room, only to receive a withering look from a nurse who is passing by!

On his return home he reads from ‘The Forgetting’, a beautifully descriptive passage describing the disease. I think the particular strength of this film is in observing the emotional turmoil and helplessness of the carer letting go of someone, going into care, rather than gaining any insights into a dementia sufferer.

Grant is obviously very pensive on his first visit after the 30 days. Whilst Fiona is bright and bubbly her behaviour suggests she has dramatically declined. There is a tense period of does-she-or-doesn’t-she recognise him and then it becomes clear she thinks he is a new resident. Grant’s worst fears are thus realised. Not only that, but Fiona has struck up a close and tactile relationship with a wheel-chair bound fellow male resident, Aubrey (Michael Murphy – who gives an excellent performance of the severe end of the dementia spectrum) who suffers from an advanced almost mute dementia. Grant cuts a desolate and devastated figure, walking along a corridor on his way out.

However, he befriends a salt-of-the-earth nurse at the care home and is able to share his worries and concerns in a matter-of-fact way which is immensely helpful to him as part of his ‘living bereavement’ process. His visits essentially become exercises in watching rather than interacting with his wife as she fails to recognise him and is now very close to Aubrey, caring for him closely and attentively. I’ve seen this scenario on several occasions in care homes, which can understandably cause consternation for staff and family alike. Despite receiving no emotional feedback from her, he tries to start from the beginning, as it were, and he tries to (re)befriend his wife. Again, in the midst of his emotional turmoil he wonders if she’s putting on a charade and retains a hope that she’ll be able to remember him. In one scene he sees her wearing someone else’s pullover (again, a problem I’ve sometimes seen on wards and in care homes) – “she’d never wear that - it’s too tacky”.

As he comes to accept the situation, Grant seeks advice and comfort (including a rather impulsive yet liberating night in bed together) from Aubrey’s wife Marian (Olympia Dukakis - who has been a spokesperson for the Alzheimer’s Association in the US). Later in the movie, Marian has to take Aubrey back to live at home and Fiona falls into a depressed and distraught state due to his sudden absence. Grant by now has accepted his wife has transferred her affections to someone else and selflessly asks Marian to send Aubrey back to the home for the sake of Fiona.

Her precipitous decline, both physically and mentally (a probable depressive disorder which is often treatable in such situations and often very much under-diagnosed in this cohort of patients) means the inevitable upstairs move is needed to the extended care facility (“it’s for people who’ve really lost it” explains the salt-of-the-earth nurse), a proposition Grant never envisaged in his early denial phase.

In an effort to awaken Fiona from her almost depressive stupor, Grant persuades Marian to let him take Aubrey to visit Fiona to see if this can stimulate her. He wants time alone with Fiona before she meets Aubrey again. He is most surprised on entering her room to see her markedly improved, sitting in a chair, wearing a lovely dress (again looking far too elegant and well!), and engrossed in a book (which she was previously well acquainted with). They then have a moment of the previously lost emotional connection between them (these fleeting moments of emotional lucidity, however severe the dementia, are seemingly the moments that relatives and in particular, devoted spouses often cling on to). She says to him he could have “forsook…..forsooken me…….forsaken” and the film finishes with them embracing. The end credits are poignantly accompanied by the beautiful yet haunting melody of ‘Helpless’ by K. D. Lang.

Whilst Julie Christie puts in an Oscar nominated performance, I’m not sure it quite depicts the real essence of Alzheimer’s dementia (again the ‘gold standard’ portrayal is probably still the performance of Dame Judy Dench in the acclaimed ‘Iris’). The star of the film I thought, was that of the suffering husband, Grant – his character demonstrated the real-life emotional turmoil surrounding the issue of a loved one going into permanent care. I think carers having faced such issues would easily identify with this character, and other carers faced with the dilemma may gain an insight into the emotional processes involved.

The film also touches on an important but somewhat taboo subject of spouses starting to become emotionally and physically involved with other people when they have essentially ‘lost’ a partner who is still alive but severely demented and not able to recognise their spouse.

Following on from the recent Savages movie, it is good to see the issue of dementia as the central theme for a mainstream movie. This movie does highlight the important use of caregiver support books noted above and indeed, I think ‘The Forgetting’ should be a standard text for nursing and medical students and healthcare workers involved with geriatric care as it is a beautifully written and moving book about all aspects of Alzheimer’s dementia.

As I wrote this review, the issue of dementia in the media and particularly funding for dementia research featured large in the news of the best selling author Terry Pratchett OBE who recently donated $1,000,000 to the Alzheimer’s Research Trust after he was diagnosed with an early-onset form of the disease at the age of 59 (a diagnosis he calls “an embuggerance”!). He noted that for every person with Alzheimer's, £11 is spent each year on UK research compared with £289 for each cancer patient, even though similar numbers of people are affected. He pointedly commented that because of his ‘young’ age “the NHS kindly allows me to buy my own Aricept…a situation I’m OK with in a want-to-kick-a-politician-in-the-teeth-kind of way”. Speaking of the vagaries of science and future research, he says with heartfelt eloquence: “….personally I'd eat the arse out of a dead mole if it offered a fighting chance.”

Martin Curtice
Consultant in old age psychiatry
Hollyhill Unit
Birmingham

BGS Newsletter, May 2008
Issue 16 ISSN 1748-6343 16