According to the CDC in 2023, Alzheimer's disease has affected 6.7 million people, but this could be a conservative number because not everyone with SDAT has received a diagnosis. In fact, many people with incipient or mild Alzheimer's dementia can function in our society without being noticed.

How is that possible? In this article, I would like to provide several personal instances where I have directly observed these patients attempting to conceal the degree of cognitive decline they have experienced.

At one time in my career, I was fortunate enough to be the national clinical monitor for the first medication to treat Alzheimer's, Cognex. Initially, researchers used this medication at the turn of the 20th century to treat intestinal parasites.

A researcher on the West Coast of the United States found it useful in treating people with Alzheimer's, and that began several researchers probing this specific acetylcholinesterase inhibitor. The work involved touring 17 research sites across the United States to validate the administration of the particular cognitive test that was being used for everyone who had been selected for that site participation.

It was one of the most rewarding and instructive experiences of my professional life. As a result, I met hundreds of patients and researchers. I learned quite a bit from sitting in on evaluations and observing these patients as they sat and waited for testing. Even though a pharmaceutical company that was involved in the project produced a training video for me, it needed to have several errors fixed. We corrected them, and the research went on.

At first, it seemed like ordinary psychological testing. Still, I quickly learned that the patients were attempting to maintain their cognition, or at least cover their deficiencies, through at least two methods: joking or repetition.

I can recall one woman in her late 80s who was extremely pleasant and friendly and used joking as her device to maintain her sense of self. During one session with a caregiver, she used the same method repeatedly when asked questions. When asked who the President of the United States might be, she would playfully respond, "What's the matter, dear? Have you forgotten?" Her question was asked with a broad smile and an engaging manner. The woman had been a teacher all her life, and now she couldn't remember who the President of the United States might be.

Her caregiver, a kind woman in her middle 50s, prompted her to continue the testing, even as the woman asked if they could go to lunch. They assured her that they would go to lunch shortly and that they would go to a lovely restaurant. This encouraged the continuation of the testing, and upon its completion, the results revealed significant cognitive decline.

At another major research center, a former healthcare professional, answered the same thing, no matter what the question had been. It didn't matter what the question was; the line was always the same and, in fact, she grew more and more agitated as the questioning went on. We had to cancel her testing because she could not undergo any tests.

Let me say a word about cognitive testing. There are several short tests, which contain possibly 10 simple questions. The questions refer to orientation, where the testing is taking place, perhaps some simple addition or numbers remembering or numbers backward, and, in some tests, there are overlearned actions. One of these overlearned actions is folding a letter and putting it into an envelope. The sum of the scores determined the degree of dementia, and whether or not someone would be accepted into our specific clinical protocol.

At another site, I was sitting in on a test when a woman insisted I was someone she knew and that I had been to her home many times. Of course, I had never even been to the state, and we did not know each other, but she failed to recognize that and thought I was joking with her and that we were old friends.

Of course, she was very similar to another woman I saw in private practice, who had had brain surgery, and insisted that we knew each other; in fact, we frequented many places in the neighborhood where she lived. I had never seen her before her neurosurgeon referred her to me.

Even when the brain is compromised, individuals strive to maintain their sense of self and avoid the stigma of cognitive decline. One man, an accountant whose desk was situated near a wide window that permitted the sun to shine in, insisted it was the sunshine that was affecting his inability to add numbers and add any longer.

Maintaining the sense of self is so strong that it can rise to the level of anger when we refuse to agree with what they are saying. People frequently use jokes as a way of getting around the issue, and they often make it seem like you don't realize that they are joking and that it's your fault, not theirs.

Alzheimer's is no joke, but people who have been diagnosed with the disorder frequently use joking as a defense mechanism. Remember their self-esteem whenever you interact with anyone with this type of memory decrement.