What Dementia Does to Thinking

Thinking can be divided into two types: abstract and concrete. Good thinking requires a balance of both. Children start with concrete thinking and as their brain develops, they learn to add abstract thinking.

Abstract thinking uses executive skills (judgment, reasoning, organizing, etc.) to develop concepts and ideas, and to reason. Abstract thinking expands into things that aren't material-- like time, possibilities, generalizations or comparisons. When a person becomes too abstract, they lose clarity. Politicians are good at being abstract--at saying a lot without saying much at all! Abstract thinking is about concepts, ideas built in the mind.

But as dementia progresses, executive skills are lost. This is especially true with LBD, where the loss of these skills often occurs before memory loss. When this happens, the PlwD is left with concrete thinking. Concrete thinking is based on information derived from the senses, what the person can see, hear or touch this minute.

• Is literal: Idioms and generalities don't compute. A "hot potato" is just a very warm vegetable and "man" is about a specific man, not men in general.
  Application: Be careful how you word your requests or comments. What you actually say is what the PlwD gets, not what you may mean.

• Is two-dimensional. Something either is or isn't. It is here or not here (i.e., nowhere), now or not now (i.e., never), mine or not mine (no one's).
  Application: Word your communications so that they are in the present, not the past or the future. "Let's go to the car." not "If we leave now, we can get home in time to watch your video."

• Is single-minded. Can only focus on one issue at a time. Leads to obsession.
  Application: Distraction, deflection and bribes work well. If you can get the person to change their focus, they will let go of the obsession, at least for the moment. With LBD, memory may still be intact and so they may return to an obsession however.

• Is closely connected to emotions, which aren't material, but can be felt. Unlike thinking, emotions remain.
  Application: Take careful notice of emotions, both yours and the PlwD's. Residual emotions, those left over from past events, will be the first piece of information a PlwD receives about an event.

• Is based on the FIRST information received. If a person sees a dog and experiences fear, the dog is the cause of the fear--and thus, dangerous. The fear is often residual, i.e., from a past experience, but that doesn't matter.
Application: Try to discover the residual feeling that led to the conclusion, and work with that, not the conclusion itself.

Is inflexible. Once something is decided upon, that's the way it is; there is only "what is," not "what might be."
Application: Do not try to change a PlwD's mind. This is futile. Instead, align with the residual feeling, join the person's reality and move the action from there.

Is impulsive. Without the ability to see cause and effect, there is no consideration of future consequences. If the thought arises, the action follows.
Application: Refuse to be upset by inappropriate words or actions. Distract and deflect instead.

Is about instant gratification. Without the ability to see the value of future benefits, now is all that counts. A spoonful of ice cream now is better than the promise of a whole bowlful later.
Application: This can be used a distraction or bribe. Bribes work well with PlwD. With children, bribes can backfire when the child learns to manipulate. But dementia has decreased the ability to learn and so the bribe simply serves as a distraction.

Lacks empathy. Without the ability to consider other ways of seeing an event or to oneself in the other's place, it's all about "me."
Application: Don't expect the PlwD to be able to see that their behavior or words are painful to you. They are not trying to hurt you. In their view, they are the only one affected, the only one in pain.

For information about Lewy body disorders, read our books:
A Caregivers’ Guide to Lewy Body Dementia
Managing Cognitive Issues in Parkinson's and Lewy Body Dementia

Helen and James Whitworth are not doctors. As informed caregivers, they share the information here foreducational purposes only. It should never be used instead of a physician's advice.