Knox Goes Away – Dr Maneesh Gupta

Dementia aspects in movie “Knox goes away”

If you love murder mystery movies AND are interested in Dementia, then “Knox goes away” is a movie which works for you both ways.

The story is based on a hitman/hired killer named John “Aristole” Knox who has dementia.

Dementia is a progressive, degenerative disease of the brain that primarily manifests as forgetfulness, and progresses to behavioral changes, further deteriorating into seeing people or hearing voices of people who are not present at that time. (Hallucinations as we docs like to call them!)

In this movie, Michael Keaton playing the lead has an aggressive form of dementia due to Creutzfeldt Jakob Disease. But my interest as a psychiatrist and my recommendation to you is because of the way they have presented the manifestations of dementia, as it progresses in a period of few weeks.

Within this backdrop, the story is how Knox carries out a contract killing, botches it up and then has another murder on his hands which he chooses to ultimately take the blame for.

In terms of dementia, look at how he asks for coffee twice (having forgotten that he has already been served) and the waitress’ response “I already got you” surprises him. He walks in the parking lot to a different car than his own. Further during his assessment at the dementia clinic he spends much more time than usual in articulating the word car for a four wheeled vehicle, (indeed a car that is shown)

These are minor initial symptoms which are suggestive of dementia, but sometimes at a younger age can also be caused by other much more common and treatable syndromes, especially anxiety and depression ( termed as pseudo dementia). But the untreatable dementia that is afflicting the elderly generation across the world, forgetfulness is not only with regard to common objects but also forgetting people’s names, mis-identifying them and then having periods of lucidity where they can recall everything well, interspersed with periods of forgetting, mixing and misidentifying memories.

In the movie, the neurologist suggests “you have a thought it creates a feeling, you lose a thought you are left with feeling”! That is a concept that does not necessarily make it easy for the public to understand how dementia impacts your life. The Thought and Feeling erstwhile combination and dissonance is not even presented very clearly in the movie. What is presented though is the awareness that the person has that he or she is forgetting things, mixing up names. Backed by the knowledge of a diagnosis of dementia and an impending fast progression to death, the lead character is “cashing out”, “going away for good”! He knows that his life and memories will no more be in his control. Hence, he decides to clear out his cash, stones (diamonds) and art paintings to send money to his son and wife.

For those who are given a diagnosis of dementia, it is important to plan your end. Most cases of Alzheimer’s dementia will live five to six years after diagnosis. But in the Indian context, patients often come to us Psychiatrists at a very late stage, when dementia has reduced the brain capacity by more than half and is causing behavioral problems which the family is unable to manage. Thus, the usual lifespan which I see is about one to two years: with the last one year being a terrible burden on the family. That aspect is something this movie hasn’t touched upon. When asked about family, Keaton says “none that would” (care for him).

It has clearly presented the aspect of managing your finances, your will and your assets as fast as you can, as long as you do have an understanding and awareness and reasoning for what you are proposing should be done at later stages of your life (and beyond).

It is also important that when you make a will, you keep a Psychiatrist in the loop and keep meeting your Psychiatrist at least every month to identify what changes are happening in the disease and the impact if any, it is having on your moods, depression, anger, aggressiveness, overconfidence, stubbornness, being adamant, not being able to sleep or sleeping in the daytime and shouting at night. Hallucinations are things which we can help you with in the short term, but not really cure and your family needs to be able to learn to calmly talk you down if possible, or firmly maintain boundaries of behavior during those turbulent times when you feel out of context and your mind takes you back to the past, which seems much more real than the present, which is new, unrealistic and not understandable, often giving rise to suspiciousness and paranoia.

For a greater understanding of what later stages of dementia entails, you can watch “the father” a movie where Sir Anthony Hopkins is the lead actor having dementia. The movie makes you the audience just as confused and puzzled as the person with dementia is; about what is happening, what is real and what is not, how much is real and how much is not. It is also about the need to have medical and nursing care as soon as possible with the intent to help you maintain your independence in the familiar surroundings of your home until perhaps the need to go into a nursing home or hospital for the last stages occurs.