I’ve been caring for dementia sufferers for some years now and have come to recognise something curious about the delusional symptoms of this pernicious disease.
Firstly, that the damaged brain possesses an extraordinary creative power to create entirely imaginary scenery and scenarios for the patients to inhabit. I’m sure that neurologists have studied this in more detail than me, but I suppose that these detailed delusions occur as a sort of automatic sense-making mechanism when the brain loses its ability to grasp the present and is forced to dredge the memory banks instead.
Secondly, that these detailed delusions are surprisingly unoriginal. Time and time again the same ones crop up. I’ve made a list of them………
- At Home. The patient believes they are at home, either their present home or a past one. They can clearly see their house and all their furniture. The nurses and the other patients are either invisible or intruders. Their spouses or other relatives (sometimes dead ones) are just out of sight in another room, but can’t hear them calling.
- The Holiday Camp. The patient believes they are guests in some sort of recreational camp. It is quite a regimented affair with timetabled activities, sports and music. They are unsure whether they’re supposed to make their own beds or not. They are pleased that the food is included in the price. They wait patiently to be told what to do next.
- The Prison Camp. The patient believes they have been interned for a crime they didn't commit. The other patients are criminals or fellow-victims and the nurses are guards.
- The Railway Station. The patient believes they are waiting at a railway station. They are trying to get somewhere but are unsure when the train is coming. They ask for timetable information. Sometimes they believe that they are already on the train and that the scenery beyond the window is moving slowly by them.
- The Airport. A less common variant on the above. Seen in younger patients.
- The Cruise Ship. The patient believes they are on a cruise ship. The beds are deck loungers and the nurses are stewards. They are having a nice time. They look forward to the next stopover. They worry that they may have accidentally left a book or item of clothing behind in the last port.
What’s at the root of these? The first one is perhaps easy to explain. Memories of home and family are the most deeply imprinted. The others must be partially based on experience too. Nearly everybody in Britain has travelled on a train and many of our patients would have commuted on them daily. I have a patient at the moment who alternates between the railway and airport delusions. His family tell me he spent a lot of time travelling by both modes. Other patients may have spent time on cruise ships or at holiday camps. Some might have been POWs in the war. But that isn’t always the case. My own grandfather spent years living the ‘holiday camp’ delusion though, to the best of our knowledge, he never attended any such establishment.
The mechanisms at work here are more subtle and, in some ways, impressive and beautiful. The one thing all the patients have in common is that they are placed in the same situation; an anonymous hospital ward with lines of beds, strange faces and people in uniform. Their brains are unable to process the visual information presented as ‘a hospital’, even if they are told that that’s where they are. So, they do one of two things, either they blank it entirely and mentally repaint their surroundings with the intimately familiar, or they confabulate based on present information. The process draws on certain elements of the hospital ward: its anonymity, regimentation, uniforms, an apparent leisure or lack of anything to do, and the fact that they are looked after, albeit by busy strangers; it then combines these with an understanding of transient, regimented places of leisure or clock-watching, gained either from experience or second hand. And so we see, repeatedly, delusions of organised, transient public places of enforced or enjoyed leisure; large ships, transport nodes or temporary camps.
So, I wonder how today’s youth will cope with dementia. Finding themselves on hospital wards in 40 or 50 years time how will their brains compensate? I think railway stations and airports will still feature. Maybe there will be new ones, based on common contemporary experiences. Shopping malls or Spanish hotels perhaps. We’ll see.