Aaron W. Haney, MD

They are an adorable elderly pair with their white hair pulled up in buns, green button-down sweaters, and long skirts, or at least that is what I imagine the hospitalized one would be wearing too if not required to wear a gown. The sister lying in bed has a deep V in her brow, like a bird frozen in flight, her eyes lost in the distance. The face of the sister sitting at the bedside is more pliable and relaxed, but still full of concern. They are siblings living out their latter days together and I get the feeling my presence is an intrusion.

The sister in bed tries to give a polite smile but only the corners of her mouth move, the rest of her face strangely unchanged. I introduce myself and wonder how I might gain access to their insular world.

On some level I feel like a child again at church camp surrounded by those sweet old ladies who in appearance and mannerisms were very much like these two. Early in the interview I notice a Bible lying on the bed and try to open things up a bit by making reference to it. The supportive sister responds positively, and the subject of God and prayer weaves its way into the mix. It feels somewhat like a ruse, but I am not a reluctant participant in thinking and talking about such things.

A small opening begins to form in the circle where I gently set my foot as a place marker. The sweatered sister mentions taking “one day at a time” in regards to the 

 facing her sister. The patient chimes in with, “It’s like that song says, ‘one day at a time, sweet Jesus,’“ and I add the next line, “That’s all I’m asking of you.”

With that little bit of gospel music knowledge from my youth, I find myself as much in the circle as can realistically be expected in so short a time. They both appear more relaxed and talkative after my unexpected lyrical intervention which makes things easier in figuring out what is at issue and how I can be of help. It is a 3-way dance in this particular psychiatric consultation and another gospel song sings its way out of the depths of my memory, “Will the circle be unbroken, by and by, Lord, by and by,” as the little boy inside taps his foot to the beat.

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On the value of drawing from past experiences to establish a relationship with an elderly patient.

The Circle

He is staring at the wall-mounted TV when I enter his hospital room and it is not clear to me that he knows I’m there.

His head slowly swivels in my direction and he nods, “Hi.”

“What brings you to the hospital, Mr Smith?”

I see many patients with cognitive deficits in my line of work, people suffering from 

, psychosis, stroke, intoxication, or withdrawal among other things. Mr Smith is typical-that is to say he is elderly with multiple medical issues and on multiple medications. He doesn’t fully hear, see, or understand what is going on around him, yet there he is, talking to me in his own limited way.

Looking at him and allowing my mind to wander a bit (he doesn’t seem to notice or care), I imagine there’s a little man inside his head. The little man sits in a little chair somewhere just back from the eyes and maybe in line with the ears. It is dark all around him but to the front some light gets in through the eye holes. Sounds come to him from a distance, muted, like in a heavy fog at night. If too much sensory information reaches the little man, he becomes overwhelmed and confused. He is tiny after all.

The scene repeats itself, but now I am able to share the little man’s perceptions as he sits there patiently in the dark.

A shadow passes the eye holes but is ignored. Then a sound comes slow and low like speech in a slow motion reel. The little man leans forward to see what is making the noise. Out of the corner of the eye hole, something is blocking the light from the window. The head rotates and he can see someone standing there. “Hi,” he says.

Now that he realizes a person is next to him, he leans towards that ear. “How are you feeling today?” the shadow person asks. His answer is automatic, socially conditioned, and short-but it still takes some time to be expressed, “Okay.”

Another question makes its way through the cognitive ether, and he prepares to give it his full attention this time. “What brings you to the hospital, Mr Smith?” When it finally gets to him sitting in his little chair it requires some sifting through recent memories. They’re jumbled and not well organized, like things accumulated pell mell over the years and stored in the attic. The lights of an ambulance flash in the darkness around him as a result of his search and he answers, unsure of what he’s found, “A stroke?”

I bring myself back into my own present reality and am relieved to find I am inhabiting my body fully. The muddle and delay are gone, my senses are sharp, and the grasp of my situation is immediate once again. I realize my mind and body may very well be burdened with these limitations in the future, but instead of becoming somber or morose, I remember my grandmother’s voice from my childhood: “How’s my little man?”

Cognitive decline feels as though a little man is inside the elderly patient's head, with darkness all around him. To the front, some light seeps in through the eyes. Sounds come from a distance, muted, like in a heavy fog.

Author | Aaron W. Haney, MD

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The Circle

The Little Man: Through the Cognitive Ether