Autobiographical Memory as a Resource for Dementia Impairment Evaluation and Support: The Role of Early-Life Immigration in Identity Reconstruction

Dementia, a neurological condition that impacts more than 6 million people in the United States, disrupts cognitive functions that lead to impairments in memory, the ability to perform daily life tasks, make informed decisions, and more.^1,2 Patients may experience a fragmentation of their self-identity, resulting from the memory loss and an altered temporal awareness.³ The identity, each individual’s sense of self, relies on the autobiographical memory and is shaped by early life experiences.^4,5 Physically and mentally, childhood events and environments have lasting impacts on health, and are associated with age-related cognitive impairments such as dementia.⁶

Though how might the manifestation of dementia differ in individuals who have had life experiences that were traumatic, specifically in individuals who faced immigration at an early age? For these patients, identity development was disrupted early in life; they were required to rebuild who they were in a new country and culture, and the adversities were written into their autobiographical memories. In other words, immigrants reconstructed their identities. While the distress and social isolation that accompany immigration may increase vulnerabilities for dementia, it may also become beneficial, as immigration has been shown to be protective of certain mental health and psychotic disorders in some circumstances.^7,8 Bilingualism and language learning has also been shown to assist in cognitive flexibility, possibly delaying the effects of cognitive decline.⁹

Here we explore whether, in the absence of specific treatment modalities, immigration as an early childhood adverse event may increase the risk of dementia. We also consider the opposite: can immigration, with appropriate treatment, become a protective factor for adaptation to dementia? Do immigrants develop a resilience from their earlier identity reconstruction? If so, can immigration become a strength through recollection of memories, assisting immigrant dementia patients in restabilizing their self-identity? Through a multi-angle examination of immigration and dementia mechanisms including autobiographical memory, temporal awareness, and reminiscence therapy, this piece proposes that the experience of early-life immigration can function as both a source of vulnerability and resiliency in older patients with dementia.

Dementia and the Fragmentation of the Self

The individual experience of many dementia types is often accompanied and compounded by loss, grief, and fear. Being overwhelmed by distressing affect (negative emotional states) compounds cognitive impairments and further reduces capacity. Autobiographical memory is one of the targets of this memory loss; patients have a challenging time recalling specific points in their life or remembering parts of their identities, leading to a disruption in their self-identity. Personality changes, sometimes observed in dementia, may also reflect identity fragmentation.²

Another result of dementia is the change in temporal awareness, an internal clock that allows individuals to have a sense of self-continuity through the passage of time.³ Sequencing events in chronological order becomes a challenge for some patients with dementia, and they may even reexperience past memories as the present.³ This interrupts the patient’s ability to accurately place themselves in their own life timeline as they struggle to separate their past, present, and future self. In tandem with the autobiographical memory loss, the scrambled temporal awareness leads patients with dementia to have a destabilized sense of self that requires reconstruction.

The Self-Identity

The sense of self is constructed by the autobiographical memory, often referred to as episodic memory—it is the collection of the events in one’s own life. Without the autobiographical memory, there is no self.⁴ The autobiographical memory can be broken down into the preverbal and verbal memories: preverbal memories are events that occur in early childhood prior to language development while verbal, or narrative, memories occur afterward. As the name suggests, individuals can readily express verbal memories with words, describing and communicating past experiences. However, it is a challenge to translate preverbal memories to language.¹⁰ Together, the preverbal and verbal memories form the autobiographical memory, and with temporal awareness, is central to an individual’s identity over the course of their lifetime.

Traumatic events can impact the development of this autobiographical memory and the self. When a disruptive event occurs in the preverbal period, these memories are stored in a disorganized fashion. Unable to put the trauma into words, individuals may be unaware of the origin of their emotions or express it somatically.¹¹ Still, distressing experiences that can be verbalized also integrate into the memory in a fragmented or disorganized manner.¹² As personhood has its foundations in social interactions and culture, major disruptions such as trauma may cause a divergence in the development of self-identity.¹³ When the development of the autobiographical memory is disrupted, the sense of self also falters, requiring the individual to find ways to cope and reclaim their identity.

Immigration: Psychological Vulnerability and Resilience

Immigration, regardless of whether it is forced or by choice, is inherently traumatic. This trauma may emerge long after immigration, as the individual accumulates into their autobiographical memory the grief and losses of home and self-continuity over time.¹⁴ The simultaneous culture loss and culture shock requires individuals to trade the language and habits of home for the new society and norms of the new country; their identities are broken and rebuilt as they adapt to the new languages, cultures, and mannerisms.¹⁴ When immigration occurs at a young age, this trauma leads to a disruption of the typical formation of the autobiographical memory and self.

Psychologically, immigrants have increased vulnerability to social isolation, grief, and other mental health issues. Immigration causes a break in their attachment to their home and family members; the loss of the social network and the sudden pause to that storyline of their identity can lead immigrants to question their self-identity, build up trauma, and experience depression.¹⁵ Even generally, anxiety, depression, and post-traumatic stress disorder (PTSD) increase dementia risk.¹⁶ In the United States, for immigrants that work jobs that do not require use of English or lack opportunities to join new communities, the isolation and loneliness can increase risk of dementia by 31%.⁷ Hence, the experience of early-life immigration may be a risk factor for dementia.

Paradoxically, early-life immigration may also be a protective factor. In some contexts, immigration has been associated with lowered risks of certain psychological disorders including anxiety and depression.⁸ In terms of identity, the move and the need to integrate into a new country provided immigrants with the experience of reforming their identities early in life. Not only does the trauma from immigration facilitate personal growth, but the need for immigrants to rewrite their narratives simultaneously cultivates a coping mechanism which may become useful in combating identity crises later in life.¹⁴ When immigrant patients with dementia face a similar grief and fracture in their identity, paralleling their earlier experience, the prior identity reconstruction becomes a source of resilience and a tool in restabilizing their personhood in the face of memory and temporal awareness loss.

Furthermore, increased cognitive resilience in immigrants may be a product of bilingualism. It is well-studied that language leads to neurogenesis (the production of new neurons), enhances brain function and connectivity, and increases cognitive reserve (the brain’s flexibility).⁹ As immigrants learn the language of a new place, many will strive to maintain their home language, leading them to maintain 2 parallel brain networks, increasing executive control as well as episodic memory.^17,18 Dementia impacts these same brain functions, so the enhanced cognitive performance and increased episodic memory from bilingualism may play a protective role in the impacts of aging in older adult patients. Interestingly, the younger the individual learns a second language, or becomes bilingual, the more impactful these benefits are.¹⁸ Hence, the bilingualism from early-life immigration is another mechanism in which the event may serve as a protection against cognitive decline.

Reminiscence-Based Therapy: Illustrative Case of Identity Reconstruction with Patient Suffering with Vascular Dementia

To assist patients who immigrated and have developed dementia in identity restabilization, reminiscence functions as a mechanism to reactivate the earlier life experiences in maintaining identity amidst adversity. Reminiscence is the retrieval of memories, such as the autobiographical memory, and is known to aid dementia patients in improving mood and cognitive functions.¹⁹ Since patients may struggle with recalling episodic memories, the use of art, dance, or personal photos can provide patients opportunities for self-reflection and evoke autobiographical memories.^19,20 Reminiscence has been shown successful in improving connections to past memories and increasing the sense of self.²¹

In the case of “Dana,” a patient with vascular dementia, the act of reminiscing on her earlier immigration story through photo review yielded improvements in both emotional and physical symptoms. Dana had 3 major immigrations from infancy through adolescence. At the age of 1, she was sent from Japanese-occupied Shanghai to the countryside, then her family fled Mao’s China to Taiwan when she was 3 years old. Dana and her family later immigrated to the United States when she was 11, as refugees from Taiwan where her father was in danger of being assassinated. These moves disrupted Dana’s development of the autobiographical memory and self, requiring her to adapt her identity for the new country. Now, Dana’s vascular dementia causes symptoms of memory loss, anxiety, and unstable blood pressure. During a visit with Dana, we reviewed past photographs of herself and her family. At first, she struggled to recognize faces, locations, or contexts of the images. However, after analyzing the pictures for longer or taking a break and returning, she began to recognize her parents, siblings, and locations in the photos, including the time of her life the event occurred. This exercise allowed Dana to recall and reminisce on memories where her identity may have been undergoing changes, while bridging gaps in her autobiographical and temporal memory of her identity. Following this visit, Dana showed improvements in her identity reintegration, decreased anxiety, and a more stabilized blood pressure.

During another meeting, Dana noticed a new painting in the office and provided critique worthy of any art critic. She was able to use the critique of the artwork metaphorically, relating it to the discordance and entropy that the artist was struggling with. When she reminisced, our work included exploring the family tree, which included a great grandfather who was a painter and traveled from Southeast Asia (Vietnam) to Shanghai to study art and grandparents who were real estate developers, philanthropists, and founders of a school. Dana herself had travelled worldwide in her day job as a flight attendant and developed affordable, beautifully designed housing for students at her home base. While reminiscing on this, Dana recognized and was able to credit herself for her accomplishments, which led to additional emotional uplift in the face of the entropy that accompanies losses in aging and illness. As our work progressed, she was able to cope with the dementia-related identity impairments well enough that she built and currently maintains a dedicated team around herself to age in place.

The observed benefit of reminiscence we observed with Dana may be explained through the exercising of qualities that allow for the retrieval of autobiographical memories and successful aging such as curiosity, communication, and imagination. The relaxed environment to ponder the people and contexts of the images, engagement with the visual cues, effort to retrieve memories, and reactivation of past mechanisms resulted in a successful guided identity reconstruction and stabilization. This case highlights that reminiscence-based exercises may assist immigrant patients with dementia who dealt with identity challenges earlier in life to regain their sense of self once again.

Concluding Thoughts

Dementia patients face a myriad of challenges that impact their physical and emotional wellbeing. One of these includes autobiographical memory loss, which results in a hit to their self-identity. In patients who experienced early-life immigration, this trauma and unresolved grief may increase the patient’s vulnerability to dementia, but early-life immigration can provide protective mechanisms too. In addition to the cognitive benefits from bilingualism, identity disruption occurred earlier in life, requiring adaptation and reconstruction. This prepares patients with resiliency skills for when they encounter another identity disruption in dementia.

In short, patients who learned how to rebuild themselves earlier in life are more prepared to do so later.

In patients with dementia, these moments and memories can be accessed through reminiscence, simultaneously reminding patients of their past ability to reclaim their identities while closing gaps in their autobiographical memories. For patients who experienced early-life immigration, reminiscence may additionally remind one of past instances of successful identity reconstruction, providing both comfort and confidence. Altogether, alternative interventions such as reminiscence tailored to an individual patient’s life history may be beneficial for patient care, to restabilize identity and support personhood among aging immigrant populations.

Further work is required to fully understand the relationship between early-life immigration and its protective nature in dementia; more exploration is needed to examine how technologies, especially artificial intelligence, may assist in retrieving autobiographical memory, reminiscence-based therapies, and identity-focused care.²² From connecting patients who lack transportation to medical care to developing cues for reminiscence, there are opportunities to turn dementia risks into protective factors and increase accessibility to personalized care.

Acknowledgements

We thank both Lisa M. Cukier, Esq, partner at Rubin Rudman LLP, and Adrianna Alpaugh McGrath, MSW, CDP, geriatric care manager, for their professionalism and continuity of care for making “Dana’s” continued aging in place care possible.

Also, we thank “Dana” for her courageous perseverance in the face of dementia and her encouragement, with her guardian’s support, of this article. In her own words “I hope this publication will help other people suffering with dementia and the people who help people suffering with dementia.”

Dr Bursztajn is an associate professor of psychiatry (part-time) at Harvard Medical School. He is also the president of the American Unit of the International Chair in Bioethics.He can be reached at [email protected].

Ms Pan is a BA candidate in neuroscience at Harvard College.

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