Bit by bit, Alzheimer’s disease stole Carol Kirsch’s rich and interesting life, robbing her of her ability to drive a car, work the New York Times’ crossword puzzles, travel, sing in the choir.
Once an editor at Doubleday, she no longer could digest complicated books. A former “Type A” personality who juggled work and home life with ease, she became disorganized and forgetful. She would set out for a drive to a familiar place and become lost.
As her world got smaller, her husband, Howard, devoted his days and nights to caring for Carol at their Bay Area home.
Then the disease started to change the very personality of the woman he had loved for more than three decades. She began to have disabling anxiety and fits of rage so disturbing that they warranted trips to the emergency room.
“I would try to calm her down and she would push me away, beat me on my chest,” Howard Kirsch said. “The emergency room visits were happening more and more frequently.”
So Kirsch made the painful decision to place Carol in a care facility.
“Having her at home no longer was working in terms of the health and well-being of both of us,” he said.
Aggressive behavior is not uncommon among people with dementia and is one of the primary reasons that family members consider placing loved ones in a nursing home, according to the Alzheimer’s Foundation of America. Studies estimate that as many as one in four patients with Alzheimer’s, which is the most common form of dementia, show physical aggression toward family members and caregivers.
Extreme violence by people with dementia is rare, according to medical specialists, yet in a flash of anger or disorientation it can happen. That is what Sacramento County defense attorneys suggest occurred in three recent cases in which men in their 80s believed to be suffering from dementia have been accused of attacking their spouses. Two of the women died. The other was beaten and stabbed, but survived.
“None of these men deserve to be in the positions that they are in,” said county Assistant Public Defender Norm Dawson, whose office represents all three of the defendants. “None of them have a history of violence. There is no way that, if they were in their right minds, they would have done the things they are accused of doing.”
The men are incarcerated in the medical unit of the Sacramento County jail. Now, it is up to their attorneys to convince prosecutors that they do not belong in prison.
Assistant Chief Deputy District Attorney Rod Norgaard said he is open to negotiations.
If the defendants are found to have committed the crimes but are deemed too mentally impaired to be legally responsible for them, he said, they may be allowed to serve their time in a secure mental facility and avoid prison. “My primary goal is to make sure that nobody else gets hurt,” Norgaard said. “If that can be guaranteed, it is reasonable to assume” that the two sides could agree on an alternative to incarceration.
In 2013, prosecutors in British Columbia dropped a murder charge against a 95-year-old man who killed his roommate at a nursing home, instead committing him to a psychiatric facility. Prosecutors in Massachusetts last year declined to press charges against a woman who was 98 when she was charged with strangling her roommate. She was placed in a state mental hospital.
Cases like those, and the three making their way through the Sacramento County court, may be a disturbing bellwether of the future, as the population continues to age and people live longer with diseases such as Alzheimer’s, Dawson said.
By 2030, there will be about 72.1 million people 65 and older in America, more than twice their number in 2000, according to the U.S. Department of Health and Human Services.
Since the risk of dementia increases with age, “it’s going to become a larger and larger problem for society,” Dawson predicted. The justice system, he said, likely will see more people like the three men jailed in Sacramento.
Battling personality changes
Medical specialists emphasized that, although many people with Alzheimer’s or other forms of dementia develop “behavioral symptoms,” rarely do they seriously harm anyone.
Dementia is a broad term that describes a wide range of symptoms that are caused by damage to brain cells and affect a person’s ability to perform everyday activities. Alzheimer’s accounts for 60 to 80 percent of dementia cases, according to the Alzheimer’s Association. Symptoms of dementia can vary greatly but often include problems with memory, communication and language, and reasoning and judgment.
Some forms of dementia, depending upon the part of brain affected, can cause personality changes and an inability to control impulses, said Dr. Michael Geschwind, a neurologist at the University of California, San Francisco, who works in the Memory and Aging Center. Damage to the lower limbic region of the brain, for example, has been linked to violence. The frontal lobe area controls impulses.
“When those two parts of the brain are not working right,” Geschwind said, “patients may become agitated and upset, and you can see episodic violence.”
Aggressive behavior is more common in the later stages of dementia and sometimes can be controlled with medications, said Dr. Shawn Kile, a Sutter Medical Group neurologist and co-director of its Memory Clinic. “Behavior symptoms do occur, but I would say that extreme aggression is highly unusual,” Kile said.
All three of the elderly men whose cases are pending in Sacramento have “documented dementia and mental health issues,” Dawson said, though he declined to be specific about their diagnoses or whether they were receiving treatment. Their family members, through their attorneys, declined comment for this story.
Anh Thai was 84 when he was accused of stabbing his wife, Xuan Thi Thai, 77, to death at their Laguna area home in February. A former police officer in his native Vietnam, he is “struggling both mentally and physically” in the county jail, said Dawson. Frail and slightly built, he “is not extremely mobile” and “is suffering from cognitive impairment due to dementia,” he said.
“My hope is that we don’t look to mount any defense, that the DA and my office can come to some sort of agreement short of a trial,” Dawson said. “(Thai) is not a physical threat to anyone right now.”
Four months after the tragedy involving Thai, another elderly man was arrested and charged with killing his wife, this time in south Sacramento. The suspect, Masaharu Ono, recently turned 90.
According to the legal complaint against him, Ono, who stands 5 feet, 2 inches tall and weighs 140 pounds, denied stabbing his wife Hiroko when officers arrived at their home. But Ono admitted to “cleaning up some blood off a table” where Hiroko Ono “appeared to have been stabbed,” and dragging her to the bedroom and covering her with a blanket, the complaint reads. He also had blood on his hands and watch.
Ono’s court-appointed attorney, John Perkins, called the case “the saddest one I’ve seen” in his lengthy career. He said his client, who is Japanese and has few relatives in America, remembers “hardly anything about a lot of things,” including details of what happened at his home on June 5, the day his wife died.
A few days after Hiroko Ono’s death, Citrus Heights police arrested 87-year-old David Wolff, accused of stabbing and beating up his wife of 30 years. He was found naked in a wooded area and taken into custody after a lengthy standoff with officers.
Police have withheld the name of Wolff’s spouse, who they said is in her 60s. She suffered stab wounds on her torso, arms and hands and has been released from the hospital.
Wolff was a licensed, practicing psychologist and family therapist for more than 40 years, Dawson said. Friends and family members have described him as “kind, gentle and caring,” he said. “They have no explanation whatsoever for what happened here” other than mental issues.
Pain becomes violence
Geschwind of UCSF said pinpointing why dementia patients become aggressive can be difficult. Sometimes, he said, they may simply be responding to pain or discomfort.
“They may be reacting to noises in a crowded room during a meal, or the way they are being touched when someone is trying to care for them. They may simply be very frustrated because of their deficits, but they are unable to express those feelings. It’s very important to determine why they are agitated, and see if you can avoid the activity or modify it in a way that doesn’t upset them.”
Mood stabilizers and other medications can stem symptoms, Kile said, but sometimes “just understanding how to interact with that person in a different way can be very helpful.”
In the later stages of the illnesses, however, people who are physically aggressive often require a higher level of care than a friend or relative can provide.
“Most patients do want to stay at home, and their families want to care for them,” Kile said. “But in some instances, it’s just not safe.”
Kirsch said he never feared that his wife, Carol, would seriously harm him. But after a while, he said, her behavior became too difficult and unpredictable to manage on his own.
More than four years after his wife’s death, memories of her decline remain painful.
Carol and Howard Kirsch met in New York in 1973 and fell in love immediately. “We were both ready to get married and thought we would make a good couple,” he recalled. “And we did, for 36 years.”
Howard worked in news media, and Carol edited books and magazines. “She was outgoing, very smart, well read,” he recalled. “She studied Chinese. She was an editor at Doubleday. She was just every accomplished in everything she did, including being a parent.” The couple had two daughters, Rebecca and Shana, and moved to the Bay Area in 1986.
At age 55, Carol was diagnosed with early onset Alzheimer’s. She became forgetful and disorganized to the point that people at work took notice. Eventually, she lost her driver’s license, her job and much of her freedom.
During the last 18 months or so of her life, Carol began showing signs of aggression. She would get out of bed at night, agitated about nonsensical things. “It was pure frustration, disorientation, anger and fear,” Howard Kirsch said. “She would get up at 2 or 3 in the morning and rant, and I couldn’t calm her down.”
Sometimes, during his attempts to comfort her, Carol would lash out at him physically. Unable to control her, he would take her to the emergency room. But the medications she got in the ER either “gave her more anxiety, or turned her into a zombie,” Kirsch said.
He felt he had no choice, he said, but to find a new place for her to live.
In Sacramento, the elderly men accused of attacking their spouses spend their days under the strict, regimented supervision of deputies at the downtown jail. The process has begun to determine whether they will remain behind bars for the rest of their days.
Defense lawyers could argue that their clients are not guilty by reason of insanity. The insanity defense allows a mentally ill person to avoid being imprisoned for a crime on the assumption that he or she was not capable of distinguishing right from wrong. Often, the sentence will substitute psychiatric treatment in place of jail time. Or defense attorneys could argue that the men lacked the required level of intent to commit the crimes of which they are accused.
“Our choices in cases like these are to keep people locked up in jail or prison, send them to a care facility that might not be equipped to care for them, or find a hospital to place them for the long term,” Dawson said. Should they be found not guilty by reason of insanity, they likely would get treatment at the Napa State Hospital, which houses the criminally insane.
Dawson said he wished the system offered better choices for people such as Thai, Ono and Wolff.
“It’s sad,” Dawson said. “Sending any of these guys off to prison or to the Napa State Hospital for the rest of their lives is not a rational option.”
For more information about anger and aggression in dementia patients, go to www.alz.org or call the Alzheimer’s Association’s 24-hour hotline at 1-800-272-3900.
Other resources include the Family Caregiver Alliance at caregiver.org