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c h a p t e r t w o Receiving the Diagnosis In the course of our lives we are likely to have many diseases and conditions diagnosed by a physician. We develop symptoms—a nagging cough, a swollen joint, persistent pain—that suggest all is not as it should be, and we consult our physician. Sometimes, we do this reluctantly or only because a loved one nags us into doing so. The physician may offer an immediate diagnosis or refer us for various tests. At some point in the process, the disease or condition is given a name, and some form of treatment is suggested—surgery, medication, lifestyle changes— with the expectation that the disease will be cured, the condition will be healed, or, at the very least, will be managed in a manner that mitigates its impact on our quality of life. We expect our physicians to fix whatever is wrong with us. If only the process of diagnosis were as straightforward in the case of cognitive impairment. As with any other condition, concerns about possible cognitive impairment begin with a set of symptoms that raise worries, either for the affected persons or for people who care about them. Perhaps he has gotten lost several times while in familiar settings. Perhaps she has been having difficulty remembering her own phone number or is forgetting to take important medications . Maybe in conversation with long-term friends he increasingly needs to pause to search for a familiar word. Or, most commonly, she asks a question that she asked just minutes earlier, or shares a bit of news, unaware that she shared the same information twenty minutes ago. Often such symptoms of potential cognitive impairment develop gradually, so neither the person nor those around her can readily identify when “Mom’s a little forgetful, but we all are sometimes” changes to “something is not right with Mom.” We are adaptable creatures and develop work-arounds that mask minor problems with memory. The week’s medications are placed in a daily reminder container, important phone numbers are entered into speed-dial, and an index card indicates the television channel of favorite programs. Family members and friends learn to listen to a repeated story without interjecting, “You just told me that!” Sometimes it is not until there is an incident that is genuinely frightening—Dad drives to the store to pick up his morning newspaper as he does every day, but this time he does not return and is found an hour and a half Receiving the Diagnosis 33 later miles from his destination with no sense of how he got there—that someone concludes that it is time to talk to the doctor. Everyone around Dad, and likely Dad himself, has known that there was a problem greater than being a little forgetful, of course, but if many of us are prone to putting off a doctor’s visit over a physical complaint for as long as possible , we are even likelier to procrastinate in consulting the doctor about cognitive concerns. Denial takes the form of a loving conspiracy: we all pretend not to see the issue for as long as we possibly can. For family members and friends, there is a desire to protect our loved one from being given a diagnostic label that we know will bring distress, anxiety, and embarrassment. For the person himself or herself, there is the fear that a medical diagnosis will make the condition real and that he or she will cross over the line from being a little forgetful to having a dreaded disease that marks “the beginning of the end.” We know a woman in her eighties who counts backward from 100 by sevens several times each day because a friend told her that it is something people are asked to do when given “the test.” She has convinced herself that as long as she can successfully pass her self-administered test, she cannot have dementia. If we understand the diagnosis of cognitive impairment as a kind of death sentence, delaying that diagnosis as long as possible makes strategic sense, for that perspective too easily becomes a self-fulfilling prophecy. But if instead we view living with some degree of cognitive impairment as a next step in life’s journey, one that does not preclude the possibility of living in a way that continues to be rich and fulfilling, then seeking diagnosis sooner can be helpful and positive...

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