New Title FUHHGEDDABOUTIT! The book that will help you stop worrying about your memory - and Alzheim

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Mix things up a bit so it is fun and not boring. Same with getting out of a chair. If you have a neurologist do they have a movement disorder specialist in their office for a consult? Usually, movement disorder specialists are in a group or specialty clinic. Your neurologist may not recommend a movement disorder specialist, especially if you live in a rural area.

She is also a cannabis researcher and organic grower. Her talk focuses on the active compounds in cannabis, medicinal uses of those compounds, and how the compounds might be helpful in PD and might harm those with low blood pressure. She also discusses the pros and cons of different administration methods.

The minute lecture was recorded and is available online: Medical marijuana is legal now in California, and recreational marijuana will be legal as of January 1, This minute lecture will prepare you for that discussion. Other biologically active compounds are: Used in medicine for thousands of years, worldwide, even in the US into the s when there were 23 pharmaceutical companies making cannabis preparations.

It became illegal in the US in At the time, the AMA opposed the ban and supported cannabis as medicine. Russo and Grotenerman, Why do people with PD use cannabis? For some it may help pain and sleep, but not movement at all. Ease of pain and sleep is common in all user of cannabis, not just for those with PD, so it is likely cannabis will help with these PD symptoms. Others find relief with movement symptoms, but it is less common than relief from pain and sleep symptoms.

Russo and Guy, — Adverse reactions are rare and include headaches. Russo and Guy , Fernandex-Ruiz et al. CBD from Hemp — Hemp is an agricultural form of cannabis use to produce fiber, oil, and seed. CBD ratio is best? These people do well on a 1: CBD ratio, a person can customize e medicine to fill their needs. Then at night they can switch to a higher THC variety that may be more effective for pain or sleep. THC medicine is a great place to start: Harder to find, but available in WA. Russo and Guy, Terpenes — Essential oils found in all plants and used in body care products and foods, as fragrances and flavors — Cannabis is high in these — They create unique flavors and contribute to effects of different strains — Contains hundreds of different terpenes and profile varies by cultivar — Common terpenes found in cannabis: Myrcene, Pinene, Linalool, etc.

Terpenes take away… — look for cannabis that is high in terpenes — will have better flavor and is better medicine — some companies test their flower and concentrates for terpenes so look for tested products — flower should test over. The Entourage Effect — the collective action of all the active constituents — involving both synergy and antagonism — the whole medicine is greater than its parts — a review by McPartland and Russo in cite research that whole plant cannabis extracts produce an effect times greater than expected based on its THC content alone.

Sativa vs Indica — Different cultivars based on their genetic origin, growth patterns and perceived effects — Little scientific backing for this distinction, but a commonly used marketing strategy by dispensers and growers — Does not often correlate with chemical composition — The variation in effects is now known to be a result of terrine and cannabinoid profiles — Dispensaries often ask if you want saliva or indica, BUT the CBD: THC ratio and terpene profile are much more relevant. Suggestions Specific to PD Symptoms: Cannabis Actions that may be of benefit in PD — analgesic — soporific sleep inducing — neuroprotective Hampson et all , and Kluger et all — anti-oxidant — anti-inflammatory — stimulate neurogenesis test-tube evidence — anti-depressant — antiolytic anti-anxiety [Approved for PTSD treatment] — anti-spasmotic: CBD can reduce dyskinesia.

CBD ratios, as well as different cultivars with varying terpene profiles. A good choice for sleep. Russo — Pinene is a terpene known to be stimulating so avoid it for sleep, but use during the day. Mischley study at Bastyr Univ. Chagas et all Dystonia Muscle Cramping — e. Dyskinesia — due to too much supplemental dopamine — multiple studies show benefit and some show no effect — possible differences in formulations used in studies so experiment.

Possibly higher ratio of THC as it helps cramping. Anxiety — common in PD — cannabis can cause anxiety as a side effect. This is caused by THC and certain terpenes. To avoid anxiety, add CBD to your formula. Increase ratio of CBD until anxiety symptoms subside. Cannabis users experience less stress. Cortisol levels do not rise as easily Cuttler, C.

Depression — epidemiological studies have shown cannabis users are less depressed — other studies have shown an association with cannabis use and depression but it is not clear if the depression is due to the cannabis or other factors. Babayeva et al Euphoria as a Side Effect: Avoiding contamination pesticides and molds and understanding test results — grown your own — buy at retail in legal states — buy via medical cannabis programs — purchase on the black or gray market. How to find pesticide free cannabis: Ask for a list of pesticides they use. Clean Green Certified 2.

Department of Health DOH Certified Complaint Cannabis — WA state — tested for heavy metals, mycotoxins and pesticides — hard to source — expensive — poor product selection — availability improving as testing requirements will change — www. Coli and salmonella — mycotoxins — residual solvents — moisture content. Many products and consumption methods currently available: Hash, hash oil — Creams, oils, salves good for muscloskeletal pain and sore joints — Sublingual sprays and drops — Suppositories vaginal or rectal — Pharmaceuticals.

Inhalation, including vaporization with no combustion products into the lungs, so safer — inhalation goes directly from the lungs into the bloodstream and then to the brain and other tissues where it binds with CB1 and CB2 receptors. It acts quickly 5 minutes and wears off quickly within 2 hrs. Huestic et al a,b — fast acting, easy to control dose — pre-rolls and infused pre-rolls are available at retail stores — portable flower vaporizers vaporizes off cannabinoids and leaves carbon behind — vape pens —— avoid cartridges made of plastic hormone mimicking compounds —— glass and metal are better.

Start with 1 puff and increase until relief is noted —— available in refillable and disposable models —— cautions: These have not been tested for safety and PEG creates formaldehyde as a byproduct when vaporized. Oral consumption — enters the bloodstream through the gut where it is sent to the liver before entering other tissues. It takes up to 2 hrs. Doses must be titrated — over consumption can be uncomfortable but is not toxic. Symptoms can include nausea, panic attack, rapid heart rate and hallucinations.

Tinctures drops — traditional herbal preparation are ethanol based, but not available in WA state. You can make your own by soaking flowers in Ever Clear. Good for many, but some find them too weak. Experiment to find what works. Topicals massage oils, creams, etc. Juicing fresh cannabis leaves and sometimes flowers works well. Concentrates smoke this — resin glands which contain cannabinoids and terpenes are isolated from plant material using various methods and turned into an oil or hash product — high potency — good for symptoms that are not responding to flower — small amounts can be highly effective — can use vape pen.

It is extracted with butane and contains residue — may be sold as crumble, sugar, shatter, wax — hydrocarbon extracted products: Use low temperature to achieve vaporization under F — BHO Butane dabs are the most common and should be avoided — dabbing THC heavy products will cause a high level of intoxication quickly so it is unsafe to drive or operate machinery — avoid if you have low blood pressure as it can cause a rapid drop THC mostly — safest product to dab are: Bubble hash, CO2 oil, Rosin.

Oral ingestion of concentrates: If desired dose is mg, take mg per dose. What is the shelf life of cannabis? Cool, dark place can be years. Sunny, warm places will be really short. No need to refrigerate or freeze. DOH certified medical grade cannabis is expensive and hard to find. She likes these stores: Medical grade cannabis has been tested for pesticides and micotoxins. Dabbing compared to morphine? Cannabis can be a good way to wean off morphine. This webinar from the Michael J.

And the webinar includes a terrific discussion with two physicians about research into these disorders. What do Movement Disorders Look Like? Fox Foundation Webinar March 20, Brain Support Network uber-volunteer Denise Dagan recently listened to the recording and shared notes below. Alexander explained that he went 20 years before getting an accurate diagnosis of LBD.

One symptom was significant fatigue, misdiagnosed as Chronic Fatigue Syndrome. Another was losing his sense of smell. He discovered a neurologist as a forerunner in the field of LBD and flew to him to confirm that diagnosis. At the time he was surprised at the ignorance of neurologists about LBD.

He has since found they are most curious to learn about it. He believes humor is very powerful in taking some of the weight off the experience of having such a serious diagnosis with disturbing symptoms, like hallucinations. Humor is something he can still offer others. The name was coined in the late s and even in the early 90s they knew very little about it. In the late 90s, researchers discovered the protein alpha synuclein, which is a major component of Lewy bodies.

That opened the door in looking across the brain. Researchers discovered that those people who had dementia and other associated symptoms Alexander described including hallucinations had these Lewy bodies all over the brain. These Lewy bodies are hard to see unless you stain for alpha synuclein, then they are obvious.

Susan Bressman says the abnormally mis-folded, or clumping proteins are a common phenomenon of other neurodegenerative disorders MSA, PSP , as well. Alexander has participated in research at the Mayo Clinic. Bressman suggests the area of the brain affected determines what symptoms manifest so Alexander has RBD, loss of smell, hallucinations pre-motor features.

Alexander does take some Neupro, which, at a higher dose, worsened his hallucinations. He still takes a low dose. One form has a cerebellar effect with more unsteadiness and uncoordination symptoms. What helps distinguish it from PD are problems with autonomic issues like bladder and blood pressure control very early in the progression of the disease. It can take years to feel confident which diagnosis is correct. There is a lot of overlap in the pathology, but in MSA, instead of the neurons, alpha synuclein pathology is in the glia supporting cell. The glia cells in the brain have inclusions.

Treatment overlaps as well. Standaert agrees with Dr. People are working on one. As a neurologist follows a patient over years symptoms become more distinct, like when motor symptoms do not respond well to PD medications, and when there are a lot of early autonomic symptoms. In MSA there are very few cognitive problems. There is some loss of dopamine function in MSA because the Parkinsonian form does damage the substantial nigra, but the appearance on the DAT scan is somewhat different because in MSA you can see the damage is still somewhat even, whereas in PD the damage is asymmetric.

So, the DAT scan can give you a clue, but it is not a definitive test to separate the two. Bressman says there are papers suggesting an MRI can help to distinguish between the two, but there is a lot of debate about that. The definitive diagnostic method is really to follow patients over time and watch the manifestation of symptoms, responsiveness to medications, and putting all the pieces together.

Dave Iverson asked the doctors what can be learned about one of these neurodegenerative disorders as we learn about another of them. Standaert says they are all age-associated diseases. While young people do, occasionally, develop neurodegenerative diseases they develop after age 50, 60, 70 and beyond so age is a trigger. They are all also associated with the development of abnormal proteins. Each disorder is a different protein misfolding protein , but at the core there are important commonalities.

Dave Iverson asked if there is an important reason to pursue the right diagnosis. Bressman says patients really want to know what it is.

Knowledge is power, and getting the right diagnosis can affect getting the right treatment. It is important in terms of prognosis, family counseling, clinical trials, and ultimately for targeted treatments, when those become available. We think of PD as being a homogenous entity, but there are subtypes, early onset, those with more or less gait disorder. Dave Iverson asks if essential tremor can progress to PD. Standaert says sometimes doctors will diagnose essential tremor often symmetrical, runs in families, and is bilateral, so not PD and the patient will return with real PD symptoms.

People with essential tremor tend to be diagnosed with PD more frequently with PD than the general population. They thought this was due to misdiagnosis as essential tremor when it is incipient PD. DAT scan can help with this teasing out between these two conditions.

This lingering question of whether essential tremor increases risk of developing PD, or is essential so common some percentage will go on to develop PD in the same numbers of the general population, or are some number of those diagnosed with PD misdiagnosed until the PD symptoms become obvious. Bressman says it is an unlikely but now that we have different genetic subtypes, looking at ALS through a genetics lens, it is a heterogeneous disorder and some people who have motor-neuron disorder can have parkinsonism or a PSP-like picture.

She has had patients with motor-neuron disease and parkinsonism who have turned out to have one of these genetic subtypes. They are separate disorders but in some subtypes you can have the two together. So there were other forms of neurodegenerative disease in those families. Researchers wonder about LRRK2 — does something happen far upstream, modulating the response of the brain to these mis-folded proteins, perhaps modulating the inflammatory response that follows them. So, is it a general kind of gene that can enable a number of different pathologies?

Family members who are gene carriers are either normal healthy or have PD, although it is classic PD. Some have a classic rest tremor. This seems to lead to a connection between a link between the gene and some upstream event, or some sort of exposure to lead to PD. Standaert says most disease process are a combination between genetics and environment. Dave Iverson asked Alexander if he has autonomic symptoms bladder, constipation, blood pressure, etc. Then he knew all his symptoms were related. Dave Iverson asked Dr. Bressman if these autonomic symptoms cut across all these disorders?

She says certainly PD and MSA and can be the most debilitating feature like low blood pressure, and bladder issues. Alexander comments and the doctors both agree that proper diagnosis is important, especially for those with LBD, because word needs to get out to doctors, patients and families to prevent patients being given neuroleptics such as Haldol which are powerful blockers of the dopamine receptors in the brain.

These types of drugs are used widely in medicine when someone has hallucinations common in LBD. Dave Iverson asked what is the difference in prognosis between these different disorders. Alexander says his doctor says, in his experience, the rate at which the initial condition unfolds is similar to the rate at which it further progresses. If symptoms come on gradually, it is likely to continue to progress just as slowly and is unlikely to make sharp downturns.

That is good news for him as his took so long to diagnose. Standaert agrees, although no two cases are exactly the same. These neurodegenerative disorders progress at different rates from each other, ALS tends to progress much more rapidly than others. Bressman to talk about dystonia. She says dystonia is on the list separately because a not insignificant percentage of PD, particularly with early onset, can be caused by the disease itself or medication induced. How you treat it depends on what you think is the cause peak dose, end of dose, early morning so you may adjust the timing, Amantadine, or Entacapone.

Ultimately, the best treatment will be better dopaminergic meds, DBS or a cure. Dave Iverson asked if exercise helps in all of these disorders as it does for PD. Standaert thinks exercise is helpful in all of them, but in PSP there is a tremendous issue with balance and falling. MS is worsened by overheating, so be careful with that. Apply the right kind of exercise for safety to each disorder.

Alexander says he only recently realized exercise is helpful for him. Standaert says both have abnormal proteins, but the part of the brain attacked is different. MS is quite different as it is an immune attack upon the brain, but the commonality is the recent recognition of the inflammation response between all these disorders. Otherwise, the cause, diagnosis, and management is quite different. Bressman says that is true. If they are feeling faint they should tell their doctor and have regular blood pressure checks to discuss how to manage it.

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Its dangerous because it can lead to falling, but there are a lot of treatment options. Dave Iverson asks Dr. Bressman if she is hopeful that connections between research will lead to treatments across all these disorders. She is quite hopeful and the research is broad and applicable to not only insight into PD, but other disorders with respect to the search for a cure or better uses of the treatments they already have. Standaert if he things that is encouraging for pharmaceutical companies. He says the more they learn about these diseases the more they realized there are shared commonalities of attack to research treatments.

Success in one will really open the door to success in others. The rare disorders may not get the funding for research, but will benefit from those getting funding. PD may not be just one condition because there are more than one gene that can trigger it, and a multitude of symptoms.

Dave Iverson asks Alexander to close the conversation. Alexander says he has found with respect to his hallucinations is to use them as creative prompts for writing poetry and other creative works. That is always potentially possible and there is more attention to this in the dementia care community. Amanda Herges, PhD, clinical neurologist. It is related to some of the pathways related to psychosis, and is a typical PD symptom.

It is more common in those who had mood issues before their PD diagnosis. Herges recommends tracking these symptoms, like you do your PD symptoms time, situation, when were last medications, etc.

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A therapist can help you learn to live with anxiety, too. Herges suggests using electronic devices to help remember things. Do one thing at t time. Attention problems are also common in PD, so it is easy to become distracted. Keep distractions to a minimum. Taking images over time is not recommended. Clinical exam is a better assessment for physical symptoms.

Repeated neuropsychological testing will show cognitive decline. Man asks what is punding and how are its symptoms controlled. Can this behavior be modified by medication? Punding is repetitive sorting of materials. Often goes unnoticed if it is related to a long time hobby. Punding can be controlled with medication, but if the behavior is not harmful or interfering with quality of life, medication is not necessary. The more medications you take, the more the likelihood of adverse medication interactions or medication mistakes so sometimes it is better to manage behavior without medications.

Talk with your doctor about your individual situation. Early in PD if you have hallucinations or illusions peripheral fleeting impression of bugs, shadows out of the corner of your eye, etc. Recent research shows most hallucinations or illusions cannot be accounted for by medications. Depends on what you are calling cognitive decline. Most people become concerned, when they have a memory change, that it will be precipitous. Memory change can be disease progression but there are many causes of memory change, including changes in medications that cause sleepiness or fatigue which affects memory.

Illness, even just a cold, or dehydration, and loss of sleep can all cause memory loss. Thyroid issues, low vitamin B12, depression can also affect memory. Talk with your doctor whenever you have memory loss. With respect to her hallucinations, regardless of the cause, always discuss with your neurologist to determine the impact of your PD meds on the hallucinations.

An adjustment to your meds should help, but it is a process of rebalancing your medications vs symptoms control. Adding an atypical antipsychotic Seroquel, Quetiapine can help treat hallucinations. Also try changing your home environment: Prints and patterns contribute to visual discrepancies which can increase frequency of hallucinations. With respect to her delusions or serious memory impairment forgetting father died , it depends on the emotional state of the person with PD or LBD.

Challenging memory impairment can cause more stress and depression. Sometimes, it is best to ignore these types of comments. See the prior answer for living with hallucinations. Hallucinations is visual disturbance caused by changes in the chemistry and function of the brain. Usually they see nonthreatening people or animals.

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Delusions are beliefs that have no basis in fact. Sometime they are difficult to detect because they are not completely implausible. Person experiencing the delusion is often persistent in their belief. Delusions can be paranoia over finances, especially in those who have been business people, or money handlers head of household, etc. A delusion can be a belief their spouse is having an affair or that they are being persecuted trying to put me in a home.

Hyper-religeousity, compulsive spending or donating, gambling, etc. Herges recommends not trying to handle delusions on your own when they begin to affect quality of life, especially loss of trust, or finances in the family. Assessment or evaluation is performed by a PhD with training in PD. They use standardized tests to see how well you perform on memory, attention, processing speed, executive functioning against normal controls of the same age. The test determines your strengths and weaknesses on these skills and the doctor makes recommendations for functioning with your unique skills and deficits.

These assessments are required pre-DBS surgery. DBS is contra-indicated in situations where the DBS candidate already suffers severe cognitive deficits because DBS can worsen cognition and make it more difficult to function. Assessment may also include mood and depressive symptoms, hallucinations, delusions, etc. Patients fill out a questionnaire beforehand, followed by Testing could be broken into more than one day. Herges scores all tests, writes up a report of her findings and asks the patient back for a review of that report and shares recommendations for living well with deficits and suggestions for playing on strengths.

If so, make sure your neurologist, psychiatrist and pharmacist are communicating about medications prescribed for these behaviors. Stop engaging them immediately and call for help if someone becomes violent. Counseling to redevelop trust among family members may be necessary. Sometimes, the person cannot return to the same environment if safety cannot be ensured. Yes, if it is deemed medically necessary and prescribed by a doctor for memory loss or cognitive disorder it will be covered.

If your doctor orders it to determine your ability to work, for example, it will not be covered. Other insurances not Medicare are totally determined by what policy you have. Most insurances cover at least a limited number of visits and the doctor needs to fit an evaluation and treatment into that maximum number of visits covered by your policy. You should speak with your insurance carrier to see how much they cover before seeking an assessment.

Herges hears hot weather affecting MS, not PD. She recommends monitoring your hydration in hot weather because dehydration can cause these symptoms. Tell your doctor about these symptoms and, possibly, do a medication review with the doctor. Ask yourself and discuss with your neurologist if you are getting adequate benefit vs. Try changing to another medication or different dose. Just keep trying until you find the right balance. If you really fail in finding a medication balance, you may benefit from neuropsychological counseling to learn behaviors to control the compulsive eating or other compulsive behaviors.

So this has kept me and uber-volunteer Denise Dagan very busy. Denise attended the webcast of the National Caregiving Conference in early November. She is now catching up on the notes she took from the various sessions she attended. The moderator was Diane Breslow, LCSW, social worker, with a panel of other speakers addressing personal challenges, changes and choices. Breslow itemized the physical challenges to all caregivers: Challenges, Changes, and Choices: Eventually, you will need a team neurologist, primary care physician, physical therapist, occupational therapist, speech therapist, at a minimum , emotional support support group, religious community, family, therapist.

Physical Challenges of PD on Caregiver: Diane asked each panelist to speak to a particular aspect of their caregiving experience. Karen was a stay-at-home Mom so there was anxiety due to uncertainty and unknowns, especially financial. After four years she realized they needed to move to a 1-level, less expensive home. She went back to work, and she began to drive him to work. He was laid off and began to decline quickly. They have long term care insurance which helps pay for 4 aides.

Karen finds herself doing everything finances, taxes, home repair, his health care management, insurance issues, etc. She injured herself helping him move around. His sleep disturbances interrupt her sleep. Feeding him and toileting make messes that need to be cleaned up daily. Karen feels like a hamster on a wheel that never stops. They have three kids, two of whom are supportive. She understands that caregiving is not for everyone.

She struggles to find her own identity and joy. Linda exemplifies the word proactive. Her father lives in Canada and the day after his diagnosis showed up at a speech Diane this session moderator was giving, and spoke with Diane after the speech. One of her siblings live near her parents. Linda lives in the states.

Linda knew that it is important to her father to remain self sufficient. Linda gave her father a list of organizations to contact. In that meeting they learned that not every neurologist is a movement disorder specialist. Now he sees one of the best movement disorder specialists in Canada. He has learned to advocate for himself in pursuit of his own self sufficiency. He is in a seated exercise class but finds that depressing because the other participants were all sick. Then he was hospitalized due to infection and returned to the exercise class with a different perspective.

They are now the center of their social group, real cheerleaders and the class is respite for Claire. They expanded the number of seated exercise classes and made even more friends for both Ira and Claire, eventually finding a seated dance class which Ira enjoys so much he moves more during that class. They love it and they met even more friends, added more dance classes and more friends. Now there are 8 exercise or dance classes. The physical therapist has seen no deterioration in the past year and Ira has fewer falls.

They also enjoy the opera and several theaters both live and movies. They know where all the bathrooms are and have found people are generous in offering help with carrying equipment, opening doors, etc. Some things they have had to give up, like the symphony, because the family bathroom is not convenient and it is too much of a hassle.

All the exercise means Ira can participate in the opera and theater, etc. Jean exemplifies having built a community of support over many years of caregiving. For example, he lost much of their savings due to cognitive challenges and there is a division between him and his children. Through the VA he participated in a day program which gave her respite. Catholic charities and the VA helped them decide to move him into Wesley Place, where he lives now.

She has been very happy with his care there and their emotional support for her family. Eppie remembered the men, their calloused palms scrubbed clean, holding the dainty cup handles between their thumbs and forefingers, the white linen napkins tucked under their chins. When Eppie brought the china home some fifteen years ago, we delighted in unpacking the pieces, so delicate we could almost see through them.

That night Eppie served leftover potato salad on the dessert plates and ice cream in the two-handled soup bowls. I recall Eppie putting the yellow book down on a log as she rummaged around her day pack for her binoculars. For a minute I forget to breathe. Margaret rubs her hand over the cover. She takes it over to the couch and places it next to her purse. Our friend Rene is with me.

One of the aides leads us to the common area, where a dozen women and men wearing blank expressions sit in a circle tapping a giant balloon to one another. Mostly it just bounces off them as they sit and stare at nothing. When the balloon floats by Eppie, however, she punches it across the circle as though she were playing volleyball.

She hugs me and pats my face and kisses my cheeks and hugs me again. No one has ever been this happy to see me before. She shows us her room and the patio, then introduces us to a new friend. The delay is fine with me; I am in no hurry to rent it. Once the place is empty, I let myself in. Spiders have strung cobwebs everywhere, and I bat them away. The carpet smells faintly of Bramble, and dead leaves have been tracked inside.

The kitchen sink and bathtub are thick with grime. I wander through the empty rooms with a clipboard to make a list of the work that needs to be done. The quilt some friends and I made for her sixtieth birthday hung over there. Her CD player sat on a tall shelf unit in that corner by the window.

Before the CD player, it was a tape player. Before that, a stereo. That night we danced: Eppie with her eyes closed, head bobbing from side to side, hips swaying, fingers fluttering in time to the beat. One late afternoon a few months before Eppie moved out, we sat on her front porch talking. She explained that she planned to end her life when her memory got too bad. She wanted me to know since I would be the one to find her. That night I called her son, but he dismissed it. He talked to her every week on the phone, he said, and she sounded fine. He should spend an afternoon with her, I said.

Once in a while, though, she keeps talking about it, and when she does, I just listen. We turn onto the Delta Highway on our way to lunch, and, having caught sight of the sign, Eppie bursts into song: Last week, while we were waiting for a table, Eppie slid onto the bench next to an older woman. I grudgingly dole out one task at a time to him: Sam offers to hang new drape rods, but I tell him I can do it. Balancing on the ladder, I gently tap the screw with my hammer to get it started.

I pick up the hammer and slam the screw. I slam and slam and slam until the hammer busts through the sheetrock. I pull the hammer out and slam it again. I want my friend back.

Eppie has always loved her glass — or glasses — of wine. That created some hard scenes. On a Sunday afternoon we sit in the car outside the restaurant as Rene taps some marijuana into a little glass pipe. Eppie watches with all the intensity of a four-year-old waiting for her birthday cake to be sliced. Soon I forget why I ever stopped. She had recently discovered pot smoking and decided to grow her own. She proudly showed me two spindly plants hidden among the gladioluses.

But a few weeks later she ripped the plants out of the ground and hid them in her trash. After Sam has repaired the wall damage and hung drapes, I decide to hire a property manager. Taxes will be due soon and then the insurance. Eppie is never coming home. The first property manager I call comes over and tells me how much rent I should charge and what his percentage would be. He opens and closes a kitchen cabinet and runs his hand over the counter.

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He walks over to the sliding glass door and looks out at the backyard. She probably forgets my visits the minute I leave, whereas I remember them long afterward. Two years ago I learned that my father had died. The news came to me several weeks after his passing, and I was stunned that neither my sister nor my brother had contacted me. Out of habit I went straight to Eppie. Immediately I regretted it. She simply did not have the capacity anymore to understand what had happened. Soon Eppie was laughing at Bramble racing around the living room. But late that night Eppie knocked on my door.

When I answered, she was standing on my porch in her bathrobe, crying. She took my hands into hers and squeezed them hard. Subscribers get full access to the current issue and more than 40 years of archives. Give in to the temptation. We love getting mail. Of course, we reserve the right to edit. Yet the emptiness is so absolute, it feels like a presence I have to push through.

Then I notice that the rectangular Tupperware container that holds her medications is gone. Eppie suddenly seemed more interesting. But all the while she is leaving you. I sat in the rocking chair and watched with her. It was the first time Eppie had ever shouted at me. Thank you for sharing The Sun. One Free Selection Left Already a subscriber?

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