An old woman has been admitted to an institution with a probable diagnosis of dementia and uncommunicative. She doesn’t speak nor appear to understand. However, it soon becomes clear that she can speak and understand.

Silence is, however, her way of punishing the family whom she regards as insensitive to her needs. “They are all living in my house and they treat me like a poor relation. Boss me around all the time!”

In her new home, staff members see her having a vacant, rejecting attitude on her family and visitors, only to relax and chat coherently, later in the day, with somebody who is in her favor.

This is but one example of the use of “dementia” as a strategy by some old people. The strategy may not always be as deliberate as this, nor is silence the only form it takes. The individual who is no longer in complete control of her body and environment may have only one sure response left in her own hands – the “non-response response.” Stubborn, we may complain; “demented?”

But she is making use of one of her remaining coping strategies, i.e.: the ability to divorce herself from pressure and disagreeable reality by refusing to respond as demanded.

Dementia, as a strategy, however, has its dangers. The old person, in an alien and disagreeable environment, may turn her mind into a sort of kite. She lets out the string, catches a breeze from memories of a happier past, and allows her thoughts to soar away from the drab realities of the immediate situation.

Others may recognize in her a quality of disorientation that she is not where they are, yet they do not really know where or why she has gone.

Potential caregivers may come to care less because they feel out of touch with the old person’s personality. She may be given drugs with disabling side effects. Removed from daily realities, the mind in flight may become increasingly incapable of meeting its own basic survival needs. The same downhill spiral can occur when social withdrawal is brought about by protective caution. The individual withdraws from stimulation and social interaction out of fear of being hurt physically or emotionally, humiliated or proved incompetent. They assume a guarded, no-risk position.

Again this position cannot only be mistaken for dementia, but can contribute to the actual faltering of the mind by the loss of stimulation, experience and mental exercise.

Dementia as a strategy may be subtly encouraged by others. Psychologists have observed children who have given an impression of unintelligence because they had been told repeatedly at home or at school that they were dim. When provided with an opportunity to discover their own abilities and develop them, the children often flourish.

In the same way, old people are sometimes treated as if they were unintelligent and not to be taken seriously. Any error they make, or any point at which they differ from a general opinion, is taken as evidence.

In some institutional environments, the old person is better off if she says little. Passivity seems to be what the situation requires. I must however add that in many of our nation’s facilities, openness is broadly encouraged by enlightened staff.

We should recognize that the comfort and well-being of an afflicted individual can be improved even when a progressive and debilitating brain disease exists.

Environment can also be adapted to allow for a measure of independence together with safety.

The research has repeatedly demonstrated improvements in mental and physical functioning when the impaired aged individual is moved to a socially enriched environment. Memory units are but one example! Damaged brain cells, of course, have not to date been repaired, but the person with dementia can, with encouragement, become motivated to make better use of their remaining function.

In my fifty plus years as a registered nurse, working in long-term care with the aged individual and diagnosed with dementia, I’ve witnessed, time and again, a dramatic and sustained improvement in their social and physical skills.

Even when the individual’s behavior appears bizarre and ineffective, it often has the same goals as our own behavior, i.e.: to understand and to relieve anxiety, to achieve a comfortable measure of safety, and feel emotionally and act like a person.