Expert: Mary Gordon - 8/14/2010

Question
Hi Mary,  I just came from seeing my aunt in the nursing home.  It has been two weeks since I've seen her and noticed something somewhat strange today.  She seemed more talkative and somewhat animated today, however, she was blending English and Hungarian which made it difficult to understand.  She downright refused lunch and became comabative when I talked gently to her about eating, I didn't think it was a good idea to force her to eat.  She seemed to be hallucinating and kept pointing across the room telling me that "they were there" and it almost seemed that she wanted to go.  I asked her if she wanted to go there but it didn't seem to sink in.  Could this be that her dementia has escalated or am I reading too much into this?  The staff also commented that they never saw her so animated.  You have been on the money before, what do you think of this behavior as you have been through this before?

Answer
Hi Ellen, with people with later dementia, a couple of things can go on. Their perceptions are altered, and they can't make sense of what they see. They are just not living in the same reality as you - and they may well believe it's 60 years in the past, and be interpreting what they see and hear in that context.

Sometimes, they have outright visual and auditory hallucinations. For example, people with damage to frontal lobes often have extremely vivid, very detailed hallucinations - they'll see a person or animal in their house that isn't there, and they can even describe details of the hallucination, like the kind of clothing the person has on, or the kind of dog it is and what it's doing.

More common are delusions, which are essentially misinterpretations of real things or fixed ideas based on their interpretation of a situation - sometimes echos from the past they have confused with the present.   

My mother in law had lots of delusions. She thought people on TV could see and hear her and interact with her. She thought people at her table in the assisted living facility were making insults about her girlhood family - very involved conversations full of details none of these ladies could have known, much less brought up in conversation. She thought the tiny short haired ladies trying to assist her with bathing were men trying to assault her. When she stopped letting anyone put her dentures in, she told us her teeth got knocked out by bad boys throwing things at her at school. She even would relate imaginary conversations she could overhear from the "apartment" next door - when she lived at the end of a hall, and there was no one living on the side she insisted these argumentative people lived on.

Another lady I know, from Estonia, stopped speaking english as her memory regressed and got convinced that she needed to bring the cows in (she'd grown up on a farm and that had been one of her jobs). She also was always looking for her baby, which she thought she'd lost. You can imagine her poor family, watching this old lady desperately searching the house and wanting constantly to go out in all weather after phantom cows.

With all of these things, both my mother in law and the Estonian lady absolutely and completely believed their delusions, and they were sources of real agitation. And, in both cases, as their ability to communicate in any language deteriorated, so did their ability to explain what was getting them excited and what they thought was going on.   

So, who knows what your aunt saw or heard, or thought she saw or heard, or where she is in her mind. In her head, she is most likely a much younger woman, reacting to things that existed for her back then. She can't really articulate the garble her mind is making her see, and her brain is desperately trying to put perceptions in context.  If she thought something important was going on, eating lunch may not have seemed like a reasonable idea at all (Are  you crazy, how can you be thinking of food at a time like this??) If she was in Europe during the war, she may even occasionally be living in a frightening reality.

She is losing her ability to understand what is said to her in any language, so she may not even have had any idea what you were trying to tell her - that it was lunch and she should eat.

I don't think you should read too much into this, but again, if she is getting agitated in the dining hall, and distracted and delusional about what she thinks she sees, it might be a good idea to feed her in a more sheltered location where she can concentrate on eating.

Hope this helps

Mary