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Why Alzheimer's Patients Behave the Way They Do
by Harry S. Lipscomb, M.D, F.A.C.P. Professor of Family and Community Medicine Texas A & M University College of Medicine Family members of Alzheimer's patients often say to me, "We just can't understand why she acts so normal sometimes and then can be so difficult at others." Or more often they ask, "Why does he ask the same questions or do the same things over and over? Why does he constantly touch things or wander aimlessly?" The answer to these questions lies in a study of how you learn and how you forget.
The Remembering and Learning Processes
To remember events that have occurred in your life, your brain requires that these events be so vivid that you reflect on them afterward. Consider how you learn a language or a mathematical formula: you repeat it until it becomes second nature to you. And if your teaching is inadequate (or your teachers unmemorable), it's likely that it lacked the vividness to attract either your attention or your memory. Also consider the really important events in your life: accidents, first love, or first school triumph or disaster. Each of these events was characterized by a "memorable" sort of afterglow because you endow them with vividness. I don't remember my first cut (or stitches afterwards), but I will always remember my first love, simply because I attached such world-shaking importance to the event. As you reflect on these things (perhaps many times as you grow older) the memories become essentially shadows of the event. Moreover, you derive from the event a whole set of secondary emotional feelings: pleasure, sadness, anger, nostalgia, affections, excitement, etc. These events (and the emotions they arouse) become stored in special areas of the brain for deeply embedded information, commonly called long-term memory. If your special brain areas for deeply embedded information remain basically intact (as they seem to do in those with Alzheimer's), you can recall not only these memories but also your emotional responses to them. It may take a little longer for older persons to resurrect the memory, but if they are allowed to ruminate a bit, the memory comes to the surface. Equally important is that these skills, events, and learned things are resurrected often as we mature and they are referred to often. This is the way you learn from experience. For example, it doesn't take many burns for a child to learn not only about fire but about heat. Of course, in early life, most of the warm things were pleasant. Perhaps the hardest part of learning for the child is to distinguish the difference between good heat and bad heat. This is the first difference in the memory disturbance of dementia. Ask a demented person who still has language skills something about his younger years, such as, "Do you remember when you had your first party dress or your father had a buggy?" it will surprise you that these deeply-buried experiences are vividly recalled. A lot of brain energy went into the storage of these experiences. So most persons with dementia have a rather good long-term memory of their early life.
Effects of Alzheimer's
Alzheimer's patients have lost the ability to recognize current life events with vividness. They cannot learn new things because they cannot reflect upon them. If they learn to make a stitch or throw a ball on Monday, they cannot remember how to duplicate the task on Tuesday. Everything is new and there is nothing left for reflection, storage, or recall. We deem this to represent loss of short-term memory. Even when you penetrate what seems to be a grim apathy in these persons, Alzheimer's patients can never again endow an event with vividness so that they'll remember it. For example, Alzheimer's patients seem to know warm from cold, but they seem to have lost their ability to resurrect from deep memory any useful, newly learned information. They will remember their first burn, but they won't be able to remember that the bathtub today (like yesterday) has hot water in it. This explanation of short-term and long-term memory is a simplified version of a complex process. There are many other things involved in this process. Alzheimer's patients not only cannot endow vividness to events but cannot reflect upon these events and learn something new. Your efforts to teach, retrain, or enable Alzheimer's patients to do for themselves are most often fruitless. This is not to say that you shouldn't try, but only up to your limit of frustration.
In dealing with family caregivers, one of my hardest tasks is to show them how to handle those behaviors that reflect this loss of vividness and learning capacity. If a loved one has died and the loss is no longer vivid, Alzheimer's patients will not remember it. Thus, they will call, endlessly, for a departed spouse. I see families attempting to impose reality with phrases such as, "Mamma, you know Papa Tom's been dead for 10 years." These delusional thoughts (mostly over money, infidelity, or jewelry) also may exhaust unimaginative caregivers. When a loved one insists that someone is under the bed, it is fruitless to attempt to argue with them. A perceptive daughter told me she had stopped saying, "Mamma, I've looked under the bed and no one's there" and replaced her answer with, "What color hair does he have?" Her mother then will give her a long and detailed description. Basically, what I'm saying is that not only have these persons lost the ability to reflect and learn, but in their world there is no reality (as we know it) and no such thing as truth or falsehood. This means it's all right for caregivers to fib and fabricate and to deflect, deceive, or distract these folks. This notion was brought home to me most poignantly by a woman whose 7-year-old son asked, "Mamma, why do you lie to Grandmama?" The mother replied, "It's easier on her and all of us." Lying is very hard for most of us who have spent our lives insisting on the truth. But Alzheimer's patients live in another world. They remember the "long time ago." live only in today, and cannot plan a future. Caregivers may find it painful, but they must enter this other world to make their life easier and to make life more comfortable for their loved one.