In my previous post, I discussed some of the elements that make the caregiving of older adults diagnosed with a dementia rather unique. Another aspect to consider is the experience of time. One of the many accomplishments of childhood and adolescence is to develop a complex understanding of time: time as a set of boundaries by which we regulate behavior or allocate effort toward goals; time as an experience of duration or action taken in a timely manner; time as having a sense of history or the experience of reviewing one’s past. These aspects of time reflect some of the complexity and depth of the word. Usually, we move freely across these nuances with little thought (sometimes too little). But, when someone we care for begins to make frequent errors with time, it is rather difficult at first to understand what is happening. For example, many early stage patients can attend to their personal daily activities (shower, toilet, dress, etc.) but do so more and more slowly. In my experience, such individuals rarely experience how long it is taking them other than the self-perception of being slow. Cognitively, what seems to be occurring is that the person is struggling to recall the sequence of actions necessary to complete the task at hand (e.g. which clothes to wear or the order the clothes are put on). When executive functions (such as maintaining focus, managing time, planning and organization, self-control of behavior, and integration of past experience with present experience) and memory begin to unravel, simple tasks that must be completed in a timely manner take longer and longer.
In other words, experientially, the sense of duration is impaired. Without a sense of duration, it is harder to judge when things happened or will happen. In a way duration provides the experiential link between past and future (e.g. this happened way back when; that will happen a little later). As the use and experience of time as an integrated set of skills becomes impaired in conjunction with memory failure, the person becomes increasing forced into a present that has no past or future element. This ‘being in the moment’ isn’t the same thing as mindfulness or being present in the usual sense because there is nothing else but the present (as the disease progresses). Caregivers eventually learn to communicate with the impaired person as if only the present matters–not so easy to do at first because of our expectations of normative adult functioning and the fact that cognitive impairment doesn’t occur in a predictable manner.
Perhaps the most difficult problem related to the impairment of time sense is repetition of questions. For the patient, he or she asks questions multiple times because there was neither a memory formed of the question having been asked nor of the answer given. Hence, he or she experiences the repetition as the first time the question was asked! There is no experience of the interval between each question and answer, no experience of duration. Part of the caregiving task is to develop a view of the patient’s difficult behaviors as unmotivated– they are not asking the same question over and over again to drive you crazy (although it may feel that way). What if that behavior is viewed as an effort of adaptation that has failed, i.e. the person keeps asking because he or she wants to know where they are going, or what’s planned for the day, etc? By seeing the behavior in that light, we might have enough empathy to react in a helpful way by repeating the answer or re-directing the conversation to another topic. Re-direction feels discourteous– one is simply, and without preface, changing the subject abruptly. But, it can work, provided we do not express our frustration, weariness, or irritation that accompany such situations.
Contact Dr. Reichlin at 281-813-7202 Drreichlin@robertreichlinphd.com
