Chapter 1: The Facade of Cognitive Decline

Even individuals who are aware of their cognitive challenges frequently attempt to obscure their impairments, often resorting to humor or misinterpretation to downplay their condition.

According to the CDC's 2023 statistics, approximately 6.7 million people are living with Alzheimer's disease; however, this figure may be understated since not all those with mild or early-stage Alzheimer's have received a formal diagnosis. Remarkably, many individuals with incipient Alzheimer's can navigate daily life without drawing attention to their condition.

How does this happen? In this article, I will share several personal observations of patients striving to hide the extent of their cognitive decline.

During my career, I had the privilege of serving as the national clinical monitor for Cognex, the first medication approved to treat Alzheimer's. Initially, this drug was developed in the early 1900s to combat intestinal parasites. A researcher on the West Coast discovered its potential in treating Alzheimer's, which spurred further investigation into this acetylcholinesterase inhibitor.

My role involved visiting 17 research sites across the United States to ensure the consistent application of cognitive tests for participants. This experience was one of the most fulfilling of my career, allowing me to interact with numerous patients and researchers. I gained valuable insights by observing patients as they awaited evaluations. Although a training video was provided by the pharmaceutical company, it required several revisions before the research could proceed.

What initially appeared as standard psychological testing quickly revealed that patients were actively working to mask their cognitive deficits using humor and repetition.

For instance, I recall an elderly woman in her late 80s who, despite her friendly demeanor, relied on jokes to preserve her self-image. When asked about the President of the United States, she would cheerfully respond, "What's the matter, dear? Have you forgotten?" Her light-heartedness contrasted starkly with her inability to recall basic information, such as the current President.

Her caregiver, a compassionate woman in her 50s, encouraged her to continue the testing, assuring her that lunch would follow. This reassurance helped facilitate the assessment, which ultimately indicated significant cognitive decline.

At another research facility, a former healthcare worker consistently provided the same response, regardless of the question posed. Her agitation increased as the questioning progressed, ultimately leading us to halt her testing.

Let’s take a moment to discuss cognitive assessments. These typically consist of brief tests with around ten straightforward questions covering orientation, simple arithmetic, and recalling numbers. One common task involves folding a letter and placing it in an envelope. The cumulative score determines the extent of dementia and whether a participant qualifies for specific clinical trials.

During one test, a woman insisted that I was a familiar acquaintance, claiming we had visited her home multiple times. Despite having never been to her state, she believed I was teasing her about our supposed friendship.

Similarly, I encountered another woman in private practice who, following brain surgery, insisted we were well-acquainted and frequently visited the same local spots. However, I had never met her before her referral by her neurosurgeon.

Even when cognitive function falters, individuals endeavor to maintain their identity and evade the stigma associated with cognitive decline. For example, one accountant, sitting near a bright window, attributed his inability to perform simple calculations to the sunlight.

The desire to preserve one’s sense of self can elicit strong reactions, including anger, especially when others do not validate their perceptions. Humor often serves as a coping mechanism, with individuals framing their cognitive challenges as jokes, suggesting that any misunderstanding is the fault of the listener, not themselves.

While Alzheimer's is a serious condition, those diagnosed frequently resort to humor as a form of self-defense. It's essential to be mindful of their self-esteem when engaging with individuals facing memory challenges.

Understanding Denial & Lack of Insight in Dementia - YouTube

This video explores how individuals with dementia often deny their cognitive decline, showcasing the complexities of their self-awareness.

Understanding Denial and Lack of Insight in Dementia - YouTube

This video discusses the common defensive mechanisms used by dementia patients, including denial and humor.