Failure to Recognize
Many people caring for individuals with Alzheimer’s or other forms of dementia notice that, as their disease progresses, their loved one lives more and more in the past. While past experiences remain intact, they are challenged in forming new memories. Over time even these memories begin to lose their clarity, and details disappear. This often results in the person failing to recognize their homes, friends, and family—and even themselves.
A woman I worked with whose husband had Alzheimer’s relayed a story of a recent family gathering. She told me that during the party a woman spoke to her husband in a familiar manner, but he didn’t know who she was and was too embarrassed to ask her. After the conversation he asked his wife who the woman was. It was his oldest daughter. He told her the woman did not look like his daughter. To him, in his moment of fatigue and confusion, his daughter was a 20-year-old college student, not the 40-year-old woman chatting with him.
This can even happen with the person closest to you, your spouse, as was the case with a woman I was coaching. Jeannie noticed that her husband was having trouble recognizing her in the early evening. Increased confusion and agitation in the late afternoon/early evening is quite common. There is even a term for it, sundowning. More on this later.
At first, Jeannie found it easy to reorient her husband: When he asked who she was, she gently replied, “Sweetheart, we have been married for over 50 years. I know we both look different.” Then with a light tone she turned his attention to a photo from a cruise 20 years prior with their adult children. She calmly and happily shared how much fun that family vacation had been, and how they had a wonderful family. Then she would redirect with the statement, “Let’s get ready for dinner.”
This strategy worked for a month or so, until one night he replied in an agitated voice, “You are not my wife. You are too old.” Shaking his fist, he shouted at her to leave the house. Jeannie sat on the porch for 10 minutes, willing herself to calm down. She walked back into the house and said in a sunny voice, “Hi, honey, I’m home.” Looking relieved, he said, “Oh, I am so glad you’re home, I was worried.”
Let’s unpack this story. When her husband was confused but calm, Jeannie began by gently reorienting him, being careful not to quiz him or otherwise make him feel uncomfortable. She briefly mentioned the family vacation, a pleasant memory, then transitioned to their dinner and nightly routine. This is a good strategy, but as we have seen, it does not always work.
As I consistently coach families: Expect to be surprised. Good dementia care requires adaptability. When Jeannie’s husband reacted so negatively to her efforts to reorient him, she switched gears. And when that didn’t work, she took the best course of action: leaving the immediate environment. Not only would it have been ineffective to continue insisting they were married, but it might also have been dangerous for her.
Often caregivers feel that if they just repeat something enough times or in different ways, their loved one will eventually get it. But the result is often more confusion, anxiety, and sometimes even aggression.
By the way, I recommend that the primary caregiver keep an extra set of keys hidden outside, in case they get locked out. If you live in an area that can be dangerously hot or cold, hide the car keys, as well.
Let’s talk for a few moments about sundowning. Sundowning is a symptom of Alzheimer’s and other forms of dementia and often occurs in late afternoon and early evening. The causes of sundowning are not fully known, but fading light and fatigue are certainly contributing factors. Some ways of managing sundowning are to create a calm environment and engage in fewer tasks later in the day. Keep a daily routine; the same time starting and ending the day is helpful. Reduce the light to promote rest, but be careful to ensure that the person can still see clearly and avoid shadows. One woman told me that when her husband started getting more confused in the evening, she would turn off the TV, turn on gentle music, and dance with him for a few minutes.
Failure to recognize familiar places, other people, and themselves often does not happen suddenly. If the person is aware that they are changing and/or family are closely observing, small slips can be detected. In my early-stage support group, a man relayed a story about planning a backyard garden. He was visualizing his backyard and where he would plant new flowers. But when he went into his yard, he was startled to find it wasn’t as he expected: He realized he was imagining the yard he had 20 years ago. He suddenly understood, in those moments, that he was living in the past, not the present—in those moments the past 20 years were gone.
His story helped us all understand how a person living with dementia can forget more recent experiences, perhaps the past several years, and coupled with confusion, this may lead to not recognizing their current home at all.
I have a client with mild dementia who is experiencing more of these moments. I was helping Sam move into a senior community. One day I picked him up for errands and lunch. When we got back to his apartment he said, “Isn’t it funny how this place looks like the other place?” I believe he was tired from our outing and didn’t fully perceive he was indeed in his own apartment. As Sam was in a good mood, I responded, “Well, it is a nice place, and I am glad you live here.”
But if he’d asked to go home, what would I have done? Here are some responses I’d consider:
Saying, “Okay, let’s go,” and taking him on a walk around the facility. As we approached his apartment I would announce, “Well, good, you’re home now.”
Or saying, “Let’s stay for dinner. I heard they’re having your favorite dish, lasagna,” then changing the subject or doing something else.
In that case, we started folding and putting away his laundry. By the time I left, Sam was calm and comfortable in his apartment.
People living with dementia may not only fail to recognize their home or people in their lives, they may also stop recognizing themselves. As more recent events fade from their memories, they may believe they are 60 or 40 or 20 years old and tell stories about working or having young children, their young adult experiences or their parents, as if they were happening right now.
If they are calm, it’s okay to go along. Make comments that show you’re engaged with the story, such as “That sounds like a wonderful trip,” or “I didn’t know you learned Russian in the army, how interesting is that!” If the storytelling is enjoyable and going well, that is a gift. If the conversation heads to a dark place, quickly and gently nudge to a more pleasant topic: “Can you tell me more about your trips to Hawaii? Did you surf?”
Sometimes the person will embrace two thoughts that don’t logically coincide, such as believing they went to school with their daughter. Again, no need to correct or challenge their version of reality. Instead, the daughter might talk about her wonderful childhood, and being so grateful to her mom. Or she might talk about the ranch where Mom grew up. Always keep it as light and pleasant as possible.
All in all, the details and facts are far less important than the positive feeling your loved one has when they are with you. This is what they will recognize, and what will ground them.
Geriatric Care Manager