Notes on The Running Grave Re-listen Part II: What is Ted's Actual Diagnosis?

 I'm continuing my post of random bits I noticed in my second listen through The Running Grave. As always, spoilers ahead.  

As a neuroscientist, I was happy to see Ted's diagnosis called by its most appropriate name: dementia, and a little surprised to see Strike refer to it as Alzheimer's in Chapter 116. While Alzheimer's is the most common cause of dementia in the elderly, it is not the only potential cause. Alzheimer's disease can typically only be definitively diagnosed after autopsy, so, at least in the US, the official diagnosis, once other causes of dementia are ruled out, is usually DAT: Dementia of Alzheimer's Type. However, it was clear to me from the beginning that Ted might have something other than DAT, and some more evidence appeared later in the book.  Rather than Alzheimer's, I thingk Ted Nancarrow probably has a form of vascular dementia, specifically multiple infarct dementia (MID). 

Multiple infarct dementia is memory loss and other symptoms caused by a series of small strokes. Brain damage occurs because blocked blood vessels deprive parts of the brain of oxygen and nutrients, ultimately resulting in neuron loss in those regions,  Alzheimer's disease, in contrast, is brain damage associated with abnormal protein accumulation in the brain, causing the characteristic plaques and tangles that can give a definitive diagnosis after death,

There are several reasons to believe Ted has multi-infarct dementia rather that DAT.

• His symptoms came on suddenly: Lucy and Strike both spent considerable time with Ted during Joan's illness in 2013 to 2014 and in the two years since, and there is no indication that they noticed any memory issues or other signs of cognitive decline during that time. In TRG, Ted seemed to go from simply repeating himself to being unable to care for himself over the course of a few months, and, when Ted visits London, Strike is able to tell that he had deteriorated over a period of only a few weeks. MID can come on suddenly and have periods of sharp decline followed by intervals of stability or even improvement. DAT is more likely to come on gradually, with family members often seeing a period of mild cognitive decline for several years before things get bad enough to seek medical help.
• Ted is having mobility issues: Strike noted when he visited St. Mawes that Ted was "not too steady on his feet" and worried about him falling on the steep stairs to his house. MID patients are known to develop a shuffling gait. This is not a symptom that is associated with Alzheimers.
• A major risk factor for MID is hypertension: Ted apparently has a history of high blood pressure, as Joan said this was a concern of his doctor, back when she was showing Strike where to find the chocolate biscuits. 
• MID is associated with depression: Lucy reported when Ted visited in The Ink Black Heart that he seemed "pretty low." 
• Ted had a "funny turn."  MID is associated not only with small, silent strokes but transient ischemic attacks (TIA's): temporary blockages of blood vessels that clear themselves. These can cause stroke symptoms (such as confusion, slurred speech, partial paralysis) that last only a few minutes. These episodes are commonly called mini-strokes, although that term is better reserved for actual permanent rupture or blockage of small blood vessels. 

So, why did Strike say Ted had Alzheimer's?  I think he, like many others, is using the term generically, assuming that all dementia-related conditions in the elderly can be called that. Strike is not always precise in his scientific terminology. Other examples include 1) calling the paternity test that apparently proved Rokeby his father at age five or so a "DNA" test; that technology would not have been around until the mid-to-late 1980's and 2) referring to Lady Bristow's Valium tablets as "opiates." 

Sadly, MID is also associated with a lower lifespan than Alzheimer's, with the average patient dying five years after diagnosis, compared to ten for DAT.  TIA's are also a warning sign that a major stroke may be eminent, as was the case for Mrs. Cunliffe after her "funny turn" in The Silkworm. There is a good chance Ted will join Joan in the sea before series end. As I'll explain in a future post, there are some specific bits of information that I hope he communicates to his nephew before he crosses the veil. 

Onto some other questions that occurred to be during my re-read:

What really happened to Jacob?  

Obviously, the child was near death when Robin was caring for him, so it is possible that he did succumb to starvation or dehydration a few hours after Robin made her escape. But that seems awfully convenient for the cult leadership, who were probably panicking that she would go to the police and wondering where they were going to stash the child. It would not surprise me to learn that Papa J, having already decided the "soul-less" child could be starved to death, would order the process speeded up: no doubt justifying it by saying that Daiyu wanted him to join her in the spirit world. I think it likely that a drug injection or a pillow over Jacob's face caused his death, assuring he could be buried before the police got permission to search.  

Why didn't the police enter immediately?

Robin reported a life-threatening emergency, involving child abuse,  in the farmhouse attic.  I don't know what British law said, but in the US, the police would have been justified in entering immediately, even without a warrant. Did the police not take her seriously, assuming she was one of those UHC nutters?  Or does the cult have enough political clout in the area that the police dragged their feet and gave the group way more warning than they should have?

Is Robin's rapist also a murderer? 

We learned a potentially new detail about Robin's attack when she was explaining about her history to Prudence:

I was a nice intelligent middle-class girl with a steady boyfriend when I was raped. The only two other girls who survived him-- they weren't like that.

"The only two other girls who survived him" could mean there were some girls who did not survive his attack. Were some of the man's victims killed. Robin was "left for dead" and survived by "pretending she was already dead" so we know this criminal had no qualms about killing. Some have suggested that Robin's attacker could be released from jail soon, and she will have to cope with that trauma. If the man was actually convicted of murder as well, then it is more likely he is in for life.  

Having read the book twice, I am now re-reading Steven Hassam's book. Having been through the cult with Robin, it is clear that many elements Hassan describes from his own experience with the Unification church were incorporated into UHC practices.