Takeaway
Some people with dementia live more comfortably in the past than in the present. Consider joining them there rather than forcing orientation to current reality.
Lifelong learning in clinical excellence | May 28, 2026 | 4 min read
By Mary Woesner, MD, Albert Einstein College of Medicine
I’m a psychiatrist who worked with people with dementia and their caregivers. I’m also a spouse who cared for a husband with mixed dementia (vascular and Alzheimer’s dementia) for two decades. He remained at home, and I witnessed the transformations wrought by this grievous disease. He slowly lost orientation, memory, language, and comprehension, had delusions and hallucinations, and underwent a personality change. I thought I lost the man I knew but realized he was there, changed but there. I don’t believe that a person with dementia completely loses their “self” and becomes “an empty shell.” Rather, they transform over time, and caregivers and clinicians can adapt their care to the changing self.
When the past becomes the present
Since short-term memory is lost early in several forms of dementia, the person is left with their long-term memories and, to the outside observer, appears to be disoriented and living in another world. They may be living in a past world or identity and may be more comfortable there. The neurologist Dr. Oliver Sacks gleaned this while treating two patients with dementia. One was the former medical director of the hospital where he was a patient. The other was a janitor living in a nursing home. Sacks observed that both men were most comfortable when occupying their former roles and he allowed them to do so (in modified ways).
An aide gave me a striking example of this. She and others were caring for an older woman with Alzheimer’s who was disoriented and wandered. In her younger days, she was an avid shopper and clothes connoisseur, and her closets were filled with outfits and shoes. This gave the aide an idea. Why not turn the upper floor of the house into a clothing store and each room into a specialty department, with items to try on? Every morning, the woman put on her coat, picked up her purse, and ascended the stairs to go shopping with her aide. She spent most of the day shopping, was comfortable in a past identity, and rarely wandered.
Stepping into their reality
Staff who work in memory-care facilities join residents in these other worlds. They use terms like “compassionate deception” and “stepping into their reality.” They no longer attempt to pull the person into the present with questions like “What day is it?” or “Do you know where you are?” If a woman says her (dead) husband is coming to visit, they don’t say, “Your husband is dead,” over and over again until she agrees (and suffers and cries). They might say, “Lovely to have a visitor.”
Adapting communication as language fades
As the disease progresses, the person may have less ability to communicate and less comprehension. You can adapt to them in new ways. I have a close friend who developed Primary Progressive Logopenic Aphasia and Alzheimer’s. As she became nonverbal, her facial expressions were more pronounced, and I learned to read them. As my husband lost the ability to comprehend my words, he responded to the timbre of my voice. Dr. de la Cuesta-Benjumea studied caregivers in Columbia, where most caregiving is in the home. She describes the care of relatives with advanced dementia as a craft specific to each individual. Caregivers devise approaches for difficult situations and modify the home to meet their loved one’s needs. They use special modes of communication—gestures, touch, and tone of voice.
Clinical approaches to adapting dementia care:
1. As dementia progresses, the disease can overshadow the person who has the disease.
We might spend too much time rating their mental and social functioning with scales (MMSE, FAST, etc.) and turning the person into a number. Or—frustrated by their symptoms—we might ignore them altogether and get the history from others. Our geriatrician had the right approach. When his patient and family arrived for their appointment, he announced, “I’ll be speaking with my patient first—for as long as he needs.” Greet your person immediately and warmly.
2. Try to understand their reality—when and where do they reside in their mind?
Don’t argue with them about the correct reality. If necessary, protect them in their new reality. They may wander to find their childhood home. Join them in the world of their childhood but protect them from the dangers of wandering. Read up on treatments that validate the person’s reality at different stages, such as reminiscence, simulated presence, validation, and life review therapies.
3. Those with dementia don’t completely lose their self, as some believe. They change.
Identify the changes and how you and the family and caregivers can adapt. Ask the daily caregivers how they cope with the changes—for example, as verbal dialogue fails, how they find ways to communicate nonverbally. They can educate you. Learn from them.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.