The key

“Neil,” said his wife, “shake the doctor's hand.” Neil looked past my hand, through his lap to the jumble of linoleum floor tiles. “I don't think he can see.” Linda stood opposite her muddled, mumbling husband. He fiddled with the drawstrings on his sweat pants. I'd not seen him before.

“I'm Dr. Velado, from the memory clinic,” I said. “Good to meet you both.” He looked through me, now sweeping his hands through delicate wisps of hallucinated gauze.

“The aphasia is worse. I can't understand him but he understands me.” She stood at his back, elegant, tall, controlled. She'd been caring for him long enough to learn a few technical terms like “aphasia.” “He's bumping into walls and falls more. I call my son or friends; sometimes I call the ambulance. We have a system.” I glanced at the electronic record of his first visit 6 months ago. “72 year old white male… Montreal Cognitive Assessment score 3/30.” He already had severe dementia.

Neil had retired 10 years before. He was a Vietnam Veteran and a Town Veterans Service Officer. “And good at it,” said Linda, “a real fighter for his fellow vets.” I knew about this and understood the passion, commitment, and political skill Veterans' representatives needed to wade through the maze of government regulations. I'd seen them all too; prisoners of war, Veterans of Operations Enduring Freedom and Iraqi Freedom, Mai Lai, Tet, Pork Chop Hill, Normandy, and Okinawa. Many triumphed but many were terribly wounded in flesh and spirit.

Neil sat in his government-issued wheelchair. I looked straight at him. “Close your eyes.” “Stick out your tongue.” “Open your mouth.” No response. He fingered the hallucinated gauze. “I can't sloop the hasmot! Shoot!” He slumped back in the chair and resumed his tactile explorations. “Now he can't understand language either.” Melanie stood by the door, watchful, attentive the first day of her elective. I liked to demonstrate fancy clinical signs to my medical students.

“Let's check his ability to name objects.” I fished the Mazda key from my right pocket and showed it to Neil. “What's this?” He looked past it. No response. “It could be visual agnosia. He can see but what he sees is meaningless. His visual cortex is disconnected from the visual association cortex that knows what things look like. It's like a foreign language. You can hear it but the words mean nothing.” I imagined tiny gnawing vermin chewing through the myelinated cables in Neil's brain. These once connected the widely distributed neuronal networks he needed to speak, see, understand, remember, feel, love. Cables frayed, nerve cells dead and dying. Broken brain. “Hey, good morning. How ya doin'?” Neil's language circuits flashed together for a second.

“Would he know a key if he felt it?” I slipped the Mazda key into his probing hands. He caressed it with a grin of recognition. “Umm; mutour zoom go-er.” He shoved the key into his left pocket. “Hey, I'll need that thing to get home tonight, Neil.”

“Let's see you walk. It's the most important part of the neurologic examination,” I emphasized to my attentive student.

Neil did not understand the standing and walking thing. We pulled up his stiff body. He took a wobbly step and froze, hands probing and grasping everything, mail holders, rolling carts, keyboards. He gripped the office doorknob and pulled, trapping himself in a narrowing triangle of darkness between the door and wall. He squeezed the knob tightly, overloaded by a flood of useless stimuli. “Wait a minute!” he cried. “Wait a middle!” He was trembling, sweating, stuck in a contagious panic that for a moment trapped us all.

Linda pushed Neil's wheelchair into that dark triangle. She reached for her husband's anguished face. She kissed him. Their grief lines touched. He calmed, settling back into the chair, taken up again with the well-textured hallucinated gauze. “It's time to go,” she said. “Isn't it, Neil.”

Linda retrieved the key from Neil's left pocket and offered it to me. “You're so good with him, Linda. This must be so painful, so hard.” She flushed, looked away. Seconds passed. “I wish we had something better for you and Neil. This illness has taken away so much.”

I glanced over at my student. “She can still reach her husband and still finds his humanity. It makes this more bearable.”

“Julie makes it bearable. The support group, day care, the planning, the nursing home admission paperwork, all of it.”

“Neil's care manager.” I explained.

“We'll walk you down to Julie's office and …I'll call you next week, for a progress report.”

We shook hands. I said goodbye to Neil. Now released from the discovery, anguish, and tenderness of this amazing clinical moment, I moved on to the next patient.

• © 2015 American Academy of Neurology