Summary: The Fear You Treat in Others

Dr. Miriam Goldstein is 68 and has been a geriatric psychiatrist in Denver for thirty-one years. She has sat across from more than four thousand patients in the specific chair she bought in 1997 because it puts her at eye level with whoever is sitting across from her. She has said the words “cognitive decline” more times than she can count. She has held the silence that follows.

Three months ago, she forgot the name of a medication she has prescribed for twenty years. Not a momentary lapse. A blank. She stood in the hallway outside the exam room, prescription pad in hand, and the name was not there. It came back ninety seconds later. Donepezil. She has not told anyone. She is a geriatric psychiatrist who is afraid she is becoming one of her own patients, and she knows exactly what she would tell someone in her chair with this fear. She is not sure the advice holds when the person in the chair is her.

Before there is a diagnosis, before a screening test, there is a feeling. Miriam’s patients describe it in language she has heard a thousand times: “I’m probably just being paranoid.” The hedge. The minimization. She has spent three decades moving people past the hedge. She cannot move herself past it. Clinical vocabulary does not help at 2 AM.

The fear before the fear is the most common psychological experience among adults over 60 and the least treated. It is the ambient dread that accompanies aging in a culture that has taught everyone what Alzheimer’s looks like and taught almost no one what normal aging looks like.

Miriam knows that subjective cognitive complaints in educated professionals are poorly correlated with objective decline. She knows the people most likely to notice changes are often those least likely to have dementia, because noticing requires intact self-monitoring. She knows anxiety about cognition can itself produce the lapses that feed the worry. She has explained this to patients hundreds of times. None of this helps her at 2 AM, because statistics about populations do not answer questions about individual brains.

The psychological experience of cognitive worry includes shame, isolation, anticipatory grief, and a specific loneliness Miriam recognizes from the inside: the loneliness of a person who knows exactly what to tell others and cannot tell herself. Professional knowledge does not confer personal immunity. It confers a particular kind of suffering: knowing exactly what you should do and finding that the knowing does not make the doing easier.

Depression affects 30 to 50 percent of people with early-stage dementia and is underdiagnosed because symptoms overlap with cognitive symptoms. Anxiety takes specific forms: anticipation of future decline, fear of public exposure, exhaustion from performing normalcy. These are treatable conditions. Adapted psychotherapy and carefully selected medication produce better outcomes than either alone. The person with dementia has a psychological life, and that life deserves clinical attention.

Miriam makes two appointments. The first with a neurologist she has referred patients to for fifteen years but never seen herself. She wants the full baseline, not the screening she could self-administer. She wants the data. She is tired of the 2 AM ceiling. The second with a colleague, a geriatric psychologist. She calls and says: “I need to see you, not as a colleague. As a patient.” Her colleague says yes without asking why.

She sits in a chair that is not her chair. She says what she has heard four thousand times: “I’m afraid something is changing, and I don’t know if it’s real.” Her colleague holds the silence. The silence is the right length. The advice she has given for thirty-one years holds, even when the person taking it is her.

Read the full article on BlueMirror.life.