A Song for Martin. Self-revelation on dementia - and love

(See also what the International Movie Database says about A Song for Martin.)

Please note: This article may spoil your spontaneous enjoyment of the film. A number of significant events are revealed, so if you want to watch the film without preconceptions, we advise you to read the article after watching the film.

Bille August’s prize-winning 2002 film A song for Martin is largely based on an autobiographical account from Ulla Isaksson’s The Book of E ("Boken om E"). Taut and intense throughout, it is the tale of two strong people who live in a deep and intimate loving relationship. Self-revealingly and boldly, Ulla Isaksson describes her own sorrow and anger about her husband, the author Erik Hjalmar Linder, being afflicted by dementia and their vibrant relationship of many years slowly and inexorably falling apart.

It is an important and meaningful tale, but also a magnificent love story. Her respect never fails despite his human decrepitude steadily increasing and becoming more and more difficult to live with.

Ulla Isaksson writes very openly and soul-searchingly about what she went through during this, the last, difficult shared time of their lives - what happens to love and the whole social context one lives in when one of the partners gets a disease that progressively alters their identity and breaks down the possibility of a normal relationship.

Poignant love story

Taking the novel as his starting point, Bille August has produced a free screen adaptation of this poignant love story which shows that sometimes fate can strike so hard that, no matter how you fight for your love, you are compelled to abandon it. In the end you are left alone in the gradually fading world of memory.

In the film, the main protagonist changes identity and becomes Barbara Hartmann, first violinist of a symphony orchestra, who lives in a long-term relationship. She falls hopelessly in love with the composer and conductor Martin Fischer who, like Barbara, is married and has grown-up children.

They both break out of their marriages and create a home together that is brimming with the creative urge and the joy of living. But quite suddenly Martin begins to forget things. He also shows a tendency to become confused.

Struck by disease

This innocent, easy-going middle-class existence is struck by disease. More ominously, the innocence and creative idyll they have created is torn apart and literally messed up. That is when confusion comes to the fore and feelings are put to the test, which arouses the viewer from the predictability that lies slightly heavily over the scene-setting of the first part.

To begin with they both wave the forgetfulness aside. But then one day it becomes clear that everything is not as it should be. A medical examination provides a sad answer. Martin has been stricken by an incurable disease that will make him unapproachable and change his personality.

Martin is suffering from dementia, which means that he is slowly but surely disappearing into himself, incapable of understanding the world around him or communicating with it. But Barbara will not give up the love of her life without a fight.

Children reconciled

Martin and Barbara have promised to be honest with each other for as long as they live – a promise that Barbara is forced to realise is becoming harder and harder to keep as their life together becomes ever more trying. Their children, who to begin with blamed their parents, are now reconciled with the family and brave attempts are made to celebrate birthdays and other festivities.

At the same time Martin is sinking deeper and deeper into a world of his own; Barbara finally realises that he is better off "without" her and her despair is profound and genuine.

But any revenge, whether sweet or not, is difficult to exact when the adversary is life itself and the circumstances embitter everything. What do you do when things are giving way, when life is falling apart, when disease and death are breaking down the confidence you have built up over your life?

The implacability of dementia

Life for Martin and Barbara simply becomes harder and harder and the film grows into a very powerful and authentic depiction of the implacability of dementia. She fights to keep them together. Soon he is no longer fighting, Alzheimer’s has him in its thrall. It is often known as the relatives’ disease, something that anyone who lives close to a victim knows and which, here too, becomes very apparent. It is Barbara who has to witness her loved one’s disappearance from life.

She is obliged to watch her romance wither away and perpetually tries to patch the fragments together. She cannot disappear, does not want to disappear, must reconcile herself to her loss and live on. How do you do that when what you have lost is still there? She makes demands, she screams at him, takes up the fight day after day. She loves and loves, and it is a passion she cannot let go. "You don’t need to do anything for me any more." Facing up to these words is painful and demanding but in them lies her reconciliation.

The film has received nominations for six Guldbagges (Swedish "Oscar Awards"): best film, script, director, male actor, female actor and photography. Viveka Seldahl and Sven Wollter were each awarded a Guldbagge for best performance. The film was shot in beautiful Bohuslän and Gothenburg in Western Sweden.

SAMPLER OF DEMENTIA

The film is a sampler of the symptoms of dementia and how it affects social life from a different perspective. Martin’s cognitive symptoms creep into the tale and the first symptoms of amnesia and word loss appear when he forgets the name of his manager and misses a meeting with his pupil.

Cognitive failure

An attack of confusion at home results in a visit to the doctor but the whole thing is dismissed as burn-out. Barbara and Martin work closely with one another and it is in the actual process of composition that the cognitive failure shows up when Martin can no longer follow a discussion on notes and score. His ability to follow the score, formerly so brilliant, disintegrates and his ability to abstract fails him. What was so naturally familiar is no longer there.

However, at a family party, Martin is able to formulate a well-articulated analysis of and thoughts about his favourite operate The Magic Flute, a sign that his semantic memory is intact. His personality and emotions continue to be unaffected.

During a live broadcast of the first performance of a concerto, Martin once again has a confusion attack and is investigated by a specialist who informs him that he is suffering from Alzheimer’s disease. After the diagnosis has been made, the symptoms deteriorate and Martin’s loss of short-term memory increases to the extent that it has a detrimental effect on his life, as when the couple go to the same restaurant twice in the same evening.

Disaster area

They continue working together but Martin’s opera becomes a disaster area. He seems to have a vision of his work, but is unable to put it down on paper. He mixes things up, copies the fair copy and what makes things come apart for Barbara is when he throws the entire vocal score into the garbage. Martin has a strong feeling that he is ill but is desperately trying to finish off his opera. The scene in the bedroom when Martin retires into himself and Barbara desperately tries to get close to him is touching. Martin is tense, filled with anxiety and depressed, and the scene conveys a strong feeling of disaster.

Then follows Martin’s birthday at which Sven Wollter portrays the demented man’s uncertainty, quiet astonishment and wonder at what is going on around him. He can no longer keep up with a discussion as he once could and repeats himself when speaking.

No social control

He has no social control but approaches his birthday cake, candles and all, like a child. The subsequent game of croquet shows up his apraxia and, when his publisher has to leave the party, he simply follows him and is incapable of saying goodbye. When the guests have gone, Martin breaks down in tears in his wife’s arms, borne down by his inability.

Table 1. Definition of dementia according to DSM IV (short version)

Memory impairment (mandatory) At least one of the following: aphasia apraxia agnosia disturbance of executive function Impaired working or social ability involving a decline from a previously higher functional level. Does not occur only in connection with confusion. The condition must have existed for more than six months.

That night Martin suddenly wakes Barbara to tell her how he has resolved the conclusion of his opera. He works feverishly the whole night through. In the morning he asks Barbara to send the score to his publisher.

Barbara is happy and hopeful but in the car on the way to the post office she stops and opens the envelope; it proves to be a disaster - incomplete bars and arrows that mean nothing. The crucial point, so far as Martin’s profession is concerned, comes when Barbara tells the director of the opera that the disease has advanced so far that Martin’s working life has reached its end.

Brutality of the disease

After this scene, the situation becomes painfully obvious in the brutality of the disease. The trip to Crete is a serious failure. Martin is insecure and confused. He asks unceasingly when they will be going home and exhibits defective perception of time. He calls the sea a river as a sign of apraxia of speech.

Further symptoms of apraxia appear when he is unable to cope with making the bed or swallowing his medicine. Martin goes out of the hotel and his spatial deficiencies mean that he gets lost. Here we see how Martin’s perception of illness is declining appreciably and how his personality is breaking up.

He no longer has any feeling for Barbara as a woman or as a wife. The dramatic drowning scene may be viewed as an expression of illness but is also symbolic of Martin and Barbara both being on the point of drowning because of the disease.

Serious symptoms

After their return from Crete, Martin exhibits serious symptoms of dementia as in severe dementia with a frontal lobe element such as hyperphagia and lack of social judgement. Barbara takes Martin with her to the Opera to see the Magic Flute. On the way there she tells Martin about the work but what Martin is most interested in is a road sign with a warning about elk. Thinking entirely literally, he is unable to understand how the elk knows it should cross at exactly that point.

At the opera performance, Martin lacks all social skills. His defective judgement means that he talks loudly, sings along and is entirely outside normal bounds, and they are forced to leave. His moods become more and more unstable and aggression makes itself felt when he takes Barbara’s violin to pieces.

Physical decline creeps up when Martin becomes faecally incontinent. During a visit to a restaurant with his family he urinates in a flower pot. Barbara reacts strongly and Martin becomes offended, feels threatened and reacts with great distrust and aggression toward his nearest and dearest. After this incident Martin is put into care. He feels relieved when he has to go into a care environment and get the care for his condition that he so badly needs.

Dementia in its final stage

In the scenes that are played out while Martin is in hospital we can follow dementia in its final stage. Martin’s entire body is marked by disease. He shrinks up, becomes weak and acquires a characterless facial mimicry. Soon he is no longer able to be up and about and has no verbal communication ability left. Lying in bed, Barbara feeds him chocolate and when she has to kiss him goodbye, she is met by his primitive rooting reflex.

DEMENTIA – A RELATIVE’S DISEASE

Martin’s dementia is depicted through the eyes of his wife Barbara and her personal reaction to the progress of the disease in her husband Martin. In the film, Barbara does not exhibit only a sympathetic side but is to a large extent suffused by anger and frustration that directly affect Martin and he responds with aggression and defensiveness.

Barbara goes through an emotional struggle and it is not until the very last stage of Martin’s illness that she reconciles herself to the situation.

Throughout the course of the disease, she desperately tries to make her life and existence as normal as possible, which often fails, and her frustration leads to sheer malice with subsequent feelings of shame. Martin appreciates his shortcomings and reacts with anger and aggression.

Physical violence

The anger and frustration lead to physical violence from which both really ought to be spared. There are many examples where, if Barbara had had more support and knowledge of the symptomology and treatment of the disease, the worst outbreaks of aggression would never have occurred.

Barbara responds to Martin’s symptoms and change of personality alternately as if he were a child giving him tellings-off and as a healthy partner with demands far in excess of his ability. Not until Martin goes into the institution can they both meet again in a loving way.

Visits to family doctor and specialist

The film clearly shows that dementia is a relative’s disease. The picture one obtains of healthcare and his confinement leaves much to be desired. The film depicts visits to both Martin’s family doctor and a specialist. The specialist in the film is a neurologist, which does not accord with normal practice in Sweden where geriatrics and psychiatry are the specialities that, along with primary care, bear the main responsibility for dementia.

On the first visit to the doctor, no basic investigation, including cognitive testing and computer tomography, is carried out. Only after Martin’s second confusion attack is a CT performed and, incorrectly, the result of this provides the basis for the diagnosis of Alzheimer’s disease. When investigating dementia, computerised tomography is used to rule out causes other than dementia as reasons for the patient’s cognitive failure.

Incomplete and incorrect information

The information provided is incomplete and incorrect. Among other things, it is said that the progression of the disease can stop for many years, which is not the case with Alzheimer’s disease. One wishes that Barbara had had the information about the progressive course of the disease and how its symptoms can be aggravated and occur over the course of time so that she might have the opportunity to deal with the expected symptoms.

It is now considered that providing this information early on in the course of the disease, together with psychological and social support, should be routine.

Pure assault

The scene in the restaurant when Martin is subjected to forcible medication is perceived as a pure assault and precedes his acute admission to hospital. Martin has been suffering from dementia for several years and is in the final stage of his disease and only now is a blood flow measurement carried out, which should have been done in the initial investigation but at this stage can contribute nothing.

Barbara is also given to understand that there is no medical treatment available, which must be assumed to be because the dementia drugs that have been developed in recent years were not available.

The lack of information, support from relatives and even medical intervention right from an early stage may obviously be because at that time they did not have the ability.

Table 2 Behavioural disturbance in dementia

Depression Anxiety Delusions Hallucinations Apathy Sleep disturbances Agitation/aggression Uninhibited behaviour Motor restlessness Appetite/weight changes

POINTS FOR DISCUSSION

• Is Martin suffering from Alzheimer’s disease? Or are there signs that some other type of dementia may be involved?
• What would the situation have been like if Martin had received modern dementia drugs?
• How do you investigate a patient with suspected dementia, is this correctly depicted in the film?
• In what way should the health service/local authority have helped Martin and Barbara to avoid the crisis situation the couple lived in?