What Do Wrinkles Have to Do With Dementia?

As a culture we seem overly concerned, at least the baby boomers among us, with wrinkle prevention. We have the soft approach: creams, scrubs and lotions. We have the serious stuff: lasers, botox, fillers, surgery and some ominous sounding choices, like carboxytherapy, which might not raise eyebrows if listed among the service items of an auto repair shop. We subject ourselves to any number of "rejuvenating" technologies to fight the synergy of failing collagen, bone loss and gravity. While I'm not criticizing or holding myself aloft from this obsession, I had an insight recently about wrinkles and how they might contribute to dignity.

I was sitting with a handsome 60-something man and his wife. Had I only seen him in passing -- had we been waiting together for a table at a restaurant or standing in line at an airport -- I might have described him as intelligent, courtly, good humored, elegant. Why? Mainly because of his wrinkles. His past years are etched in amicable crow's feet, the half-amused slightly arrogant curve of his lip, the stern line between his brows. His is an interesting face, one a portrait artist might choose to paint, one that commands respect in a public space.

His face continues to tell us who he was before his mind, well hidden, failed: a corporate executive, a family man, a witty and broadly-read conversationalist, an athlete who spent many hours in the sun. Alzheimer's disease, however, has whittled away his world until now he spends most days sitting somberly in a chair with his dog by his side. He responds to questions with a single word, yes or no, or a humorless stare.

"People ask how they can help," his wife said, admitting her isolation. "I feel like saying, 'Could you spend a couple of nights here?' But I can't say that. He might walk downstairs and sit in a chair buck-naked. He might go out to get the mail that way. I can't turn that over to a friend. I want to preserve as much of his dignity as I can." I understand her point. We aren't conditioned to allow our friends a real loss of dignity. What would I do if this friend's husband appeared downstairs, naked, with the naivety of a young child? Probably race to the kitchen for the biggest dishtowel I could find, sputtering in alarm.

But my inability to reconcile those telling wrinkles with a helpless loss of inhibition is my problem, not his. His anatomy would not surprise anyone. And we've all found ourselves in compromised positions in the course of medical care, while chatting mundanely with our doctor about work, gardening or whatever. We expect our physicians to regard us as worthy people, our sordid tales of health-related misconduct and flawed bodies notwithstanding. We don't have this confidence because doctors are really smart or have had years and years of training. It is a matter of simple humanity. In such a context, we cannot help but shed the trappings of dignity -- our clothing, our privacy -- and in return, we insist upon respect.

Maybe the time has come to expect this much of ourselves in caring for friends who've lost their ability to discern between right and wrong social behavior. What if we responded to the wife's dilemma by asking, with the deadpan tone and unflappable expression of a physician who has heard and seen it all, "I can stay with him. If he does undress while I'm here, what should I do?" Imagine sitting in front of your physician in a blue paper gown, describing an embarrassing symptom, and being inexplicably grateful when she does not wince. We can all offer this same kind of compassion.

It wouldn't be hard to retrieve a choice of garments and say in a cheerful voice, "Richard, would you rather wear this robe or these shorts?" while focusing exclusively on his life-earned facial wrinkles. Then everyone's dignity would be honored. Of course not all people with more advanced dementia can be cared for by friends, but many can. By staying calm if things take off in an indelicate direction, friends could transform the odd mishap from a hand-wringing calamity to a no-big-deal bump in the road.

Begin to believe that you might handle the situation, that you can override your past conditioning and awkwardness. See in your friend's wrinkles the testimony to an adult life of good humor, thoughtfulness, determination, achievement, concern -- even if he or she cannot otherwise show these qualities anymore. There should be no loss of dignity in dementia. Challenge, perhaps heartbreak and fear, but not shame or loss of dignity. Dignity is a right you can continue to confer, even if your friend can no longer ask for it or behaves in ways that seem to contradict the need for it. And what better example of humanity?

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