The Gospel in Memory Changes
God has made us all in His image. Yet in this fallen world, all aspects of our humanity has been affected by sin. This includes memory loss and changes to our minds as we age. As Christians, what hope does the gospel give us? How can we help others in our community and our family?
Shiyun, one of our members, is a doctor in geriatrics and she gave a talk on this issue. Here is a lightly edited version of her talk.
In my day job as a doctor in geriatrics, I have the privilege of caring for older adults. Older adults present to the geriatrics clinic with concerns of geriatric syndromes. In particular, memory issues are a significant concern for many.
Uncle Chong Tien asked if I would share on this topic, given the experiences I have had at work. As with last year, I will start off by stating that this is not a medical forum. I am also not speaking as an expert in this area. The purpose of this session is to consider the issue of memory changes from a biblical perspective, so that we can better serve one another as the body of Christ. Whether you are worried about your own forgetfulness, are personally afflicted with dementia or caregiving for someone afflicted with dementia, I hope that having some knowledge can help you live faithfully in this current season. I am not able to go into specific details, since this is a vast topic, and individuals and their caregivers can experience dementia very differently.
In this talk, we will first define what we mean by dementia and memory changes. We will then consider the world's view of humanity, compared to the Bible’s perspective. Finally, we will look at how the Bible's perspective shapes the way we live faithfully amidst memory changes as a community.
Overview of Cognitive Symptoms and Dementia
“Dementia” is derived from two Latin words – 'de' meaning without, and 'mens' meaning mind. Together, “dementia” was originally coined to mean being out of one's mind. For most people, dementia means being forgetful.
In actual fact, dementia is an umbrella term for symptoms representing the loss of brain function, otherwise known as cognitive impairment. Our brain is an extremely complex organ with different domains of activity, for example attention, executive function (or our ability to plan), learning and memory, language, and social cognition (to help us manage our social interactions). Hence, cognitive impairment may include memory loss, behavioural changes and planning difficulties. In this talk, I will use memory changes as shorthand to include other changes in brain function.
Changes in brain function that occur more commonly in older age exist on a spectrum. The challenge is in identifying changes significant enough to represent an underlying disease process. On one end, some degree of cognitive changes is typical of normal aging. For example, our thinking speed slows down, we have more difficulty sustaining attention, difficulty multitasking or holding information in our mind.
When the decline in brain function is greater than would be expected for a person's age, education or development, we move along the spectrum to an underlying neurocognitive disorder, such as mild cognitive impairment or dementia. With mild cognitive impairment, there is a modest decline in brain function compared to before, but not significant enough to affect independence in everyday activities. On the other end, a diagnosis of dementia can be made when the acquired changes in brain function have become severe enough to affect a person's ability to carry out everyday tasks. Those with mild cognitive impairment have a higher risk of progressing to dementia, but not all will eventually develop dementia.
Determining the diagnosis of dementia is significant because it identifies that there is likely an underlying disease process driving the changes in brain function. However, the terms mild cognitive impairment and dementia are only part of the story — they tell us the presence of the changes in brain function, but not the cause. While dementia can occur in all ages, the most common causes in older adults are neurodegenerative disorders, or progressive decline of the brain. The 2 most common causes of dementia in Singapore are Alzheimer’s dementia and vascular dementia.
Determining the diagnosis of dementia is significant, but it is also challenging. As I’ve shown earlier, changes in brain function occurs on a spectrum which differs for each individual. What is normal for one person may not be normal for another. Hence, it can often be difficult to determine exactly when a person should be concerned with their cognitive changes.
The Lies of the World
At this point I will highlight a few assumptions of our world. Whether or not we realize, they are shaping how we think about memory changes and dementia.
Our worth is found in our usefulness. In modern Singapore, this often means our intellect and economic productivity. We lose our value and worth when we can no longer contribute.
Our success is found in being a self-made man. Being vulnerable and dependent on others is inherently shameful.
Our wholeness is found in the health of our body and soul in this life. Being unwell physically or mentally means that we are not fully human.
Of course, none of us would outrightly claim to believe these. Yet, these insidious lies often seep out in our individual struggles or in interactions with others. For example, imagine you were picking up your morning coffee at the coffee shop. Recently, the coffee shop attendant has been taking a long time to count your change. Many of us would express frustration at the situation. Why that frustration? Would you have been less frustrated if you knew that the attendant had recently started to have trouble recognising and calculating money? Should our fundamental attitude toward one another change only because we recognise an underlying disease process?
Rather than allowing the lies of the world to define our worth, we need to understand ourselves in light of God. The truth is, whether or not we can count money, we have inherent dignity as those made in the image of God.
Made in God’s image
Created in the image of God (Gen 1:26-28)
We will start where Scripture starts. On the sixth day of the Creation account, God made man, in the image and likeness of God (Gen 1:26-27). People often wonder what specific aspects of humanity make us those made in the image of God. Yet, rather than our rationality or our relational nature or our spirituality, our image-bearing nature speaks directly about our being. Not what we have, not what we do, but who we fundamentally are.
Of course, out of our being naturally flows our function. Because of who we are, we can reflect God in our character and actions. We can live out the cultural mandate in Genesis 1:28.
The fundamental reality of our being is significant. Regardless of whether our character, function or abilities truly reflect God, all humanity have inherent dignity as those made in the image of God. The coffee shop attendant may be struggling with counting your change, but she is still fully deserving of dignity as one made in the image of God. We need to ask ourselves, why would we instinctively treat her differently from our doctor, or our boss? Or why would our frustration toward her change only when we recognise that she may be struggling with dementia?
Marred, but still carrying the image of God (Gen 5:1-9)
Instead of being content with reflecting the image of God, we wanted to be like God. Ironically, when Adam and Eve grasped for their own glory, they moved further from their likeness with God. We do not reflect the image of God fully. Yet this image was diminished but not destroyed. In Genesis 5:1-3, we are reminded that even after the fall, Adam fathered his son in the likeness of Adam and of God. In our fallen nature, our character, function or abilities may be far from God, yet our inherent dignity remain.
Redeemed by Christ, the true image of God (Col 1:15; 3:9-10)
When Jesus Christ entered our world, He showed us the true display of God. He is also restoring us into His image. As Colossians 1:15 tells us, while humanity was merely made in the image of God, Jesus Christ is the true image of God.
Colosians 3:9-10 tells us that Jesus Christ is the One who redeems and remakes us into the image of God. Through His death and resurrection, we are redeemed, and through the gift of the Spirit, we can increasingly conform to His image.
Restored into the image of Christ: 1 Corinthians 15:49
And one day, as 1 Corinthians 15:49 tells us, just as we have borne the image of the man of dust, we shall also bear the image of the man of heaven. Just as Jesus was resurrected from the dead, so we can look forward to the day when we will enter into His glory. We will bear the image of God for all eternity.
Applying the Gospel to Memory Issues
You may wonder, how do these abstract truths help me with the medical realities of memory changes? Let us use the following questions and principles to guide us as we process:
How has the fall marred our ability to reflect the image of God, as we walk with one another through memory issues?
How does the redemption in Christ transform us towards truly reflecting the image of God, as we walk with one another through memory issues?
What hope does the future restoration into the image of Christ give us as we walk with one another through memory issues in this life?
We'll think about these in a few situations today. As we do so, we want to approach memory changes with a biblical worldview and seek to promote the dignity of one another, especially those afflicted with dementia. We also want to see to meet one another’s needs.
1. Normal Aging or Significant Memory Changes?
Firstly, let's consider the situation when we are noticing changes in our memory.
The Impact of the Fall
If you are noticing memory changes in yourself or in someone you care about, you are probably not alone. Many of us struggle with misplacing our things, or with our thinking slowing down, or with difficulty learning new things as we age. However, as I’ve mentioned earlier in the talk, determining whether memory changes are significant can be challenging even for doctors.
The Bible is realistic about the effects of the fall. Whether normal aging or underlying dementia, the Bible calls us to expect trials and decline as we age. Yet the Bible is also hopeful that senior saints can still trust in the Lord amidst these afflictions.
So we know, suffering is real, and yet there can be a response of faith. How does knowing Christ and His redemption shape how we respond? Firstly, we examine our hearts.
In times of trouble, our instinctive response is to leap to action. Instead, slow down and consider our hearts. Engage our hearts with the Lord. Consider the following questions for yourself, whether you are observing memory changes in yourself or your loved ones:
How am I responding to noticing my (or my loved one's) forgetfulness? What fears or anxieties do my observations bring up for me?
What do my fears or anxieties about my forgetfulness tell me about who, or what, is important to me?
Who is God, and how is He (and His gospel) relevant to my forgetfulness?
As you examine your heart, your situation might not change. But you may gain clarity on how to approach your situation while walking with the Lord.
Here are a few particular truths that might be helpful for you as you engage the Lord in your fears and anxieties.
The Lord Jesus himself suffered unto death, so we can turn to the Lord amidst our afflictions.
Consider the example of the Psalmist in Psalm 71. He was in extreme distress, facing the wicked as well as the weaknesses of older age. Yet he confidently called the Lord his strong refuge. He was unafraid to tell of the trouble and calamities in his life. Yet he was equally unafraid to plead with the Lord. He boldly asked the Lord not to cast him off in the time of old age, and to forsake him not when his strength is spent.
We can have that same confidence now, because the Lord Jesus himself suffered to the point of death. Through death He has destroyed the one who has the power of death, the devil. In our fears of worthlessness or vulnerability, He is our merciful and faithful high priest. He speaks for us, and He helps us. What comfort it can bring us, when we see that the Lord Jesus is with us in our suffering!The Lord Jesus himself has opened a new and living way through his death, so we can have hope of future glory amidst our afflictions.
Jesus won victory over death when He was raised to life again. In 2 Corinthians 4:16, Paul reminds us not to lose hope. Though our outer self is wasting away, our inner self is being renewed day by day. In our affliction, we are being prepared for an eternal weight of glory.
When we struggle with feeling useless, can we trust that our experiences are not pointless? When we are weary of needing help from others, can we see that this suffering is producing character, endurance and hope which will not disappoint us? The Lord tells us that all of these will matter for all of eternity. How we respond in our suffering is getting us ready for the rest of our days in the New Creation!
Secondly, we promote the dignity of one another. If we are grappling with memory changes ourselves, can we rejoice that we are those made in the image of God?
For those of us who are caregivers or part of the community, how can we respect the dignity of our brother or sister as they experience memory changes? How do we treat them as people made in the image of God, with their own quirks, gifts and struggles?
There are no clear rules for what this looks like. But we can learn from the Lord Jesus, who was personal with everyone He met. He draws near and invites us into knowing and being known by Him. Likewise, we can do the same with our brother or sister.
One concrete way of doing this is to slow down. Getting to know someone in their need takes time. It takes us loosening our grip on our own agendas and tasks, and focusing on the person before us. Are we willing to slow down to relate to one another in our neediness? For example, can we speak slowly when our brother or sister are struggling to understand? After all, we speak not to make ourselves heard, but to communicate to another in order to build up.
Lastly, how might we meet the changing needs of our brother or sister? It is humbling to even recognise that we have needs. If we are the ones grappling with memory changes, are we willing to make our changing needs known?
For those of us in the community, how could we meet these needs practically? For example, in a healthcare system increasingly bent towards electronic apps, we recognise that older adults might not be comfortable learning new apps. Our clinic advocates strongly for printed materials to continue to be made available to older adults.
Another example: when we notice changes to older adults' lifestyles, such as stopping driving, or becoming less willing to leave the house, are we curious in understanding their struggles? As we understand their changing needs, we can provide practical help such as providing rides, or accompanying them on journeys to unfamiliar places. We can also help them to process their emotions as they navigate these changes in their body in real time.
Seeking help from medical professionals
A practical way of meeting the needs of older adults facing these struggles is helping them figure out when, and where to seek help from medical professionals.
Firstly, how can we assess whether these memory changes might be significant? I have printed off a few copies of a screening questionnaire, also available on the website of Dementia Singapore. You can come forward and look at these after the talk. This is a self checklist, a guide on whether to seek further help. Importantly, none of these changes alone is sufficient to raise concerns for dementia. However, when one or more changes truly impacts quality of life, further evaluation should be considered.
To do that, visit your local GP or polyclinic doctor, who may refer you on to specialists such as neurologists, geriatricians or geriatric psychiatrists for evaluation. The diagnostic process usually includes a comprehensive history from you and your family about the changes you have been experiencing. They will do an objective assessment of your mental abilities. They may also arrange for blood tests and brain scans to rule out other causes of your symptoms. Other common conditions that may present as memory changes in older adults include depression and delirium, which is a sudden change in brain function due to an underlying infection or illness.
Notice I have intentionally not given everyone a copy of the screening questions. This is because the question of whether to seek diagnosis is as important to consider as what the diagnosis is. This is ultimately a personal question that can only be answered while weighing the spiritual, relational and physical needs of the individual.
For example, I have patients referred by well-meaning doctors after a positive screen, yet neither the patient nor their family members were keen on further evaluation. The person felt that his quality of life was not impacted despite his memory changes, and his family felt able to adapt to his changing needs despite a decrease in his capabilities.
Another patient led an active life, until she was diagnosed with mild cognitive impairment. Her own fears of stigma and dependence on others drove her to isolation, which ironically may have contributed to her further decline. As Christians, we need to recognise the limits of medical knowledge, and the infinite knowledge and wisdom of the Lord.
2. Dementia
Secondly, let's consider the situation when someone has received the diagnosis of dementia.
The Impact of the Fall
As mentioned earlier, dementia is undoubtedly an effect of the fall. Dementia is a disease, not part of normal aging. While older adults with dementia will continue to struggle with sin, they are also sufferers who have no control over the devastating process of dementia. It can be easy to forget that, as people living with dementia can often function normally in some aspects. Hence, it can be an invisible illness.
The experience of dementia can vary for different individuals, and for different types of dementia. So I will only share generally about what living with dementia might look like.
The severity of dementia is one way to think about this. A person with “mild” dementia is independent of self-care, but needs help with more complex community functions such as housework, finances or getting around. For example, Mr S is a 72 year-old chartered accountant. His daughter requested an evaluation for dementia, when she noticed he was struggling to keep track of his rental properties. In his assessment, he was noted to be impaired in his memory and executive function. He was diagnosed with mild dementia. He was also referred for a driving evaluation with an occupational therapist, and was certified to be safe for driving. After diagnosis, his family needed to provide supervision and put in safeguards for more complex financial tasks. However, he was able to continue working with supervision, driving independently and maintaining his daily routines.
A person with “moderate” dementia may need help with basics like dressing and eating. After 2 years, Mr S was hospitalised with pneumonia. His dementia noticeably progressed after he was discharged. He needed to be prompted, or he would forget to shower or brush his teeth. He needed help with buttoning his shirt. He was no longer able to leave the house without someone accompanying him.
Finally, a person with “severe” dementia is dependent on others for almost everything.
In any of these stages, behavioural and psychological symptoms may occur for some. For example, regulating their own emotions may become harder. They may have changes in their perception of reality, such as hallucinations and delusions. They may have difficulty sleeping. Some may even have disinhibited behaviour, when they have trouble understanding what is appropriate in a social setting.
Another helpful way of understanding the symptoms of dementia is to consider the probable cause. The cause of dementia can give us an idea of the pattern of symptoms and the expected progression in disease.
In Alzheimer's dementia, brain function is lost progressively in a predictable fashion. I often describe it to my patients as a reversal of the developmental growth that you witness in children. In contrast, vascular dementia, which is caused by circulation problems in the brain, tends to progress in steps, so the decline is not as predictable.
Redemption through Christ
Hearing about the changes expected as dementia progresses is sobering. Again, Paul tells us in 2 Corinthians 4:16 that though our outer self is wasting away, our inner self is being renewed day by day. This light momentary affliction is preparing us for an eternal weight of glory beyond all comparison.
In the daily struggles of dementia, believing this is a daily exercise of faith for both the afflicted individual, and increasingly, their caregivers. But brothers and sisters, this is a worthy fight.
Here are some ways exercising that faith could look like. As dementia progresses, some of these may become more relevant than others. Some of these may also become more applicable for caregivers to exercise on behalf of their loved ones.
Repent of our idols of "productivity" and "independence".
Especially immediately after diagnosis, emotions like grief, anger and frustration are common. These emotions are appropriate. After all, the consequences of the fall are an unwelcome intrusion into God's good world. However, as we work through our own emotions, the Lord may also reveal God-substitutes in our hearts. Whether we have trusted in our economic value or our independence, the Lord graciously invites us to repent and return to Him.Reach out to the Lord who hears.
Dementia is inherently isolating. It may feel like the world has forgotten us, or nobody understands us. That was the experience of the Psalmist in Psalm 71, which we looked at earlier. But the Lord hears and the Lord cares. He may not change our situation, but He is present with us through it. He seeks to form us toward the image of Christ through our present situations, whether as an afflicted saint, or as a caregiver.Rejoice that the Lord remembers.
As dementia progresses, as disruptive symptoms of dementia take over, the situation may feel hopeless. An afflicted saint may start to act in ways that go against their character, or their expressed beliefs. But we are not justified by our right actions, but through Jesus' perfect life and sacrificial death.
The Lord remembers. This refrain repeats throughout Scripture as a way of reminding His people that He is faithful to His covenant. He remembered Noah in Genesis 8:1 after the flood. He remembered Abraham in Genesis 19 after the destruction of Sodom and Gomorrah. He remembered His covenant with Abraham, Issac and Jacob in Exodus 2:23-25 when the Israelites were enslaved in Egypt. He told Judah that He will not forget them in their exile in Isaiah 49. In Luke 1, Zechariah, whose very name means the Lord remembers, tells us that the Lord remembered His covenant with Israel because Jesus the Messiah King was coming.
Even when we are no longer able to remember, even when our outer self exhibits behaviour contrary to our beliefs, even when we can no longer express our trust in Jesus, He remembers His covenant to His people. And so we have hope that He will one day return to restore us into our full glory as His image-bearers.Remember that God holds all our memories perfectly.
Our memories can be a great source of joy for us, so we should rightly grieve the loss of them. Our memories, even at their best, are often poor. Think about how much you remember of the happiest moment of your life so far?As afflicted saints, we may be grieving the loss of our memories as what has contributed to our personhood. As caregivers, we may be grieving the loss of our relationship (as we know it) with our loved one. However, the Lord has perfect memory, and holds all our memories perfectly.
In fact, in Psalm 139, the God who formed us, has seen our frame and knows our hearts. His sovereignty also guarantees His providence – He has a plan and purpose for His creation, and everything from the least to the greatest contributes to the achievement of that plan and purpose. In our everyday lives, His providence means He has worked and is working through every event of our lives.
So there is no doubt that these events of our lives are significant! But while these memories are lost to us in dementia, they are never lost to God. In fact, each strand of sorrow has a place within His tapestry of grace, whether or not we can remember it now. One day, that tapestry of grace will be revealed to us as a glorious display of the glory of Christ.Rehearse the truths of the gospel as long as we live.
Here is where our roles as caregivers and community grow as dementia progresses. The Christian faith is a faith of remembrance. In the unfolding story of the Bible, the Lord constantly called Israel to remember. He gave them embodied ways to remember. He knew they, just like us, would be prone to forget. And He called us to rehearse these truths, even if He knew that we would forget.
So we rehearse the gospel with our afflicted brothers and sisters, whether or not they can engage. We can rehearse with them in ways accessible for them – through hymns, home visitations and smaller groups. As we rehearse, we hold out this hope defiantly in the face of the Devil's lies. Jesus will come again to make all things new.
Here, I'm speaking more directly to caregivers and the community. As with the previous section, we need to be personal in promoting the dignity of those afflicted with dementia. What would it look like to approach them as unique individuals, still with their own needs, gifts and struggles? Consider this: the afflicted person's perception of time and reality may look different from ours. We need to be more intentional in entering their world and understanding their perspective.
Apart from slowing down, here are some other tips that might be helpful, especially as dementia progresses:
Respect their autonomy.
Though those afflicted with dementia have impaired brain function, they are often still capable of some independence. As with children, it can be easier to take control and make decisions on their behalf. But promoting their dignity means making the effort to involve them. For example, Mr S may have required more oversight from his daughter in managing his rental properties, but he was still capable of handling simple cash and credit transactions, which accorded him some independence with his daily life.Protect their dignity.
At other times, promoting their dignity might look like protecting it on their behalf. This is especially true as judgment becomes affected, and social inhibition is lost. For example, Mr A’s family had to scrap his car, when they realised he had little insight into his loss of ability to drive. Undoubtedly, caregivers will feel the weight of constantly assessing what levels of decisions afflicted saints are capable of making, and where they have to step in. But the gospel compels us to constantly seek the wellbeing of our fellow saints, in a time they are unable to do so themselves.Give the gift of time and presence.
The present moment will gradually become the only frame of reference for the afflicted saint. Resist the pull of the anxieties of the future, and have moments where we can sit with them in the present. This can be a unique area for us as a church community to participate in, as we walk alongside afflicted saints and their caregivers.Enter their world.
Part of spending time with afflicted saints will require entering their world, which may be a different reality and time. Earlier on, it may still be possible to reorient them to the present reality. But as dementia progresses, enter their world. This may look like revisiting older memories with them. It may mean being patient with them as they repeat the same stories constantly. It will look like shedding our own agendas and focusing on theirs.
Here is a call to the caregivers among us. Caregiving is a distinct calling from God, filled with significant burdens and challenges. Caregivers are uniquely able to enter the world of individuals with dementia. But it can be easy to isolate ourselves as caregivers, because the community will never be able to care for our loved ones the way we can. But we're not meant to do this alone! Allow the community and help us to enter into the world of these afflicted saints. Share your burdens and struggles with others in the church so that you can be cared for as well.Communicate differently and creatively.
In early dementia, this could mean being patient with their word-finding difficulties. In later-stage dementia, it could mean learning to understand the unmet needs beneath their challenging behaviors. For example, an afflicted saint who is repeatedly shouting to go home despite being physically at home, may be feeling insecure because they perceived themselves to be in an unsafe place. In these situations, can we practise being difficult to offend even when the communication we are receiving could be offensive? Can we learn to meet their challenging behaviours with compassion?
Finally, it goes without saying that those afflicted with dementia are needy. This is what the world pictures of a patient with dementia - vulnerable, dependent and needy. Yet the full picture is often obscured by an outsized view of physical needs. After all, afflicted individuals are often unable to communicate their needs, and physical needs are more easily observed. I hope to reorient our view to other needs. The scope is broad, so I will not be going into details.
Physical
As dementia progresses, the afflicted saints will require more assistance with daily care. Again, it can be taxing on caregivers to be sole providers for these needs. There are growing resources in the community to help caregivers. But as a church community, we can also ask ourselves how we can serve afflicted individuals and their caregivers in really practical ways.Emotional
Our emotions don’t turn off when we develop memory changes. In fact, our emotional needs can become heightened. Think of your emotional state the last time you received bad news. Our brothers and sisters with dementia will experience those challenging emotions as they grapple with their diagnosis. Increasingly, their ability to regulate their emotions, even with day to day events, may also be affected. When we notice these emotions, how can we engage with them? This may look like responding to them, or it could be distracting them from inappropriate emotions. Are we able to engage with them without responding in anger or frustration ourselves?Social
Those afflicted with dementia are still image-bearers with needs for relationship. However, their ability for social interactions may start to differ from the norm. Being in a large group might become challenging. They might also be tempted to withdraw. Having to process social cues might also become more tiring for them. How might we as a community adapt so that we might provide the gift of presence to our afflicted brothers and sisters? It may be something as simple as moving to a separate room for one on one interaction. It may be visiting them at home.Spiritual
Though we cannot see the depths of their heart, the indwelling Spirit continues to work in the lives of those who trust in Him. Just as we have heard earlier on, we can continue to rehearse the gospel with one another, in ways that are accessible to them.
Finally, this talk focuses more on the experience of individuals grappling with memory changes. I have not addressed the needs of caregivers, which are also important to consider. The scope of their needs is beyond what I can cover here. Pastor Oliver has previously done an EQUIP series on this.
We have toured the landscape of memory changes in older adults, and how the Bible speaks into these challenging situations. May God be honored and glorified as we seek to serve one another sacrificially in this area.