The Little Man: Through the Cognitive Ether

March 13, 2013
Aaron W. Haney, MD

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.

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.

“Hello, Mr Smith. I’m Dr Haney."

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

“How are you feeling today?” I ask.

A pause, “Okay.”

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

A long pause, “A stroke?”

A question from a question.

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