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Beyond Denial: Strategies for Helping Older Clients Unaware of Cognitive Impairment

July 11, 2023

Diving into the vast ocean of cognitive impairment in older adults can be challenging, especially when waves of denial or lack of awareness obstruct the view. As healthcare providers, we often find ourselves caught in the current, struggling to navigate these tumultuous waters. The aging population is on the rise, and with it, an increasing number of individuals grappling with cognitive changes, particularly memory loss. But what happens when they can’t see the tide changing? 


Enter Margaret, a vivacious woman in her 80s with a knack for gardening and a passion for storytelling. Yet, beneath her lively exterior, changes were stirring. Her stories began to loop, and her prized gardening tools found new hiding places she couldn’t remember. Family pleas for medical attention were met with dismissive waves, chalked up to the forgetfulness of old age. “If I had a penny for every time I forgot something, I’d probably forget where I kept all those pennies!” she’d jest. But for those around her, and for us as healthcare providers, it wasn’t just a joke. Margaret’s obliviousness to her memory loss posed a daunting challenge: how to breach this unseen wall and provide the support she needed.


This article aims to guide you through this labyrinth, offering valuable insights into the why and how of such scenarios. It will equip you with the knowledge and skills necessary to traverse this sensitive landscape with empathy and patience, highlighting the urgency of addressing cognitive impairment to maintain our clients’ quality of life.


Prevalence of Cognitive Impairment and Memory Loss in Older Clients 


As the population ages, we will be seeing more older adults entering our mental health and therapy practices and we are bound to see more and more memory loss, cognitive impairment, and dementia disorders. In fact, the annual report of the Alzheimer’s Association estimates that 6.7 million people 65 and older are living with Alzheimer’s dementia, the most common form of dementia. 


Yet, it’s not just these more severe instances of cognitive decline we must consider. Subtle changes often emerge with aging, including lapses in memory and slower information processing speeds. These, too, require our attentive understanding and compassionate response. 


Untreated cognitive decline can result in difficulty with daily living tasks, increased risk of accidents, and a decreased sense of wellbeing. It can also lead to feelings of isolation and contribute to mood changes, such as increased anxiety and depression.


Our role involves more than just identifying the signs and symptoms of cognitive impairment. We are called to compassionately communicate these changes to our clients, to provide them with the tools and resources they need to manage their condition, and to reassure them they are not alone on this journey.


Cognitive Impairment versus Memory Loss


With a clear understanding of cognitive impairment and memory loss, we, as health providers, can offer informed, compassionate care to our older adults. Let’s delve deeper into the definitions, common symptoms, and the impact these conditions can have on our clients’ daily lives.

Cognitive impairment is a broad term that describes a decrease in cognitive function, which goes beyond what we might expect from normal aging. It encompasses a variety of conditions, including dementia and Alzheimer’s disease. 

To confuse matters, cognitive impairment is both a general term and a condition called Mild Cognitive Impairment (MCI). MCI triggers cognitive shifts that are significant enough to be recognized by the individual experiencing them, as well as their family and friends. Yet, these changes might not impair the person’s ability to manage daily tasks. It’s noteworthy that around 12% to 18% of individuals aged 60 and above are navigating life with MCI.

Here are some additional facts about MCI

  • An estimated 10% to 15% of individuals living with MCI develop dementia each year.
  • About one-third of people living with MCI due to Alzheimer’s disease develop dementia within five years.
  • 42% percent of Americans say they worry about developing MCI due to Alzheimer’s disease.
  • More than 80% of Americans know little or are not familiar with MCI, which can be an early stage of Alzheimer’s.

Memory loss, on the other hand, is one aspect of cognitive impairment, characterized by an individual’s inability to recall past events, information, or personal experiences.


In simpler terms, think of cognitive impairment as an umbrella term, under which falls memory loss, along with other issues like difficulty in decision-making, problem-solving, and language difficulties. Understanding this distinction is essential for healthcare providers to deliver targeted and effective care.


Common Causes of Cognitive Impairment and Memory Loss in Older Adulthood


Why is it important to understand the cause of cognitive impairment? 


Understanding the root cause of memory loss is crucial for several reasons. Firstly, it allows us as healthcare providers to develop an effective, personalized treatment plan. Whether the cause is Alzheimer’s disease, a medication side effect, depression, or a nutritional deficiency, each requires a different therapeutic approach. 


Secondly, some causes of memory loss, like medication side effects or nutritional deficiencies, can be reversible once identified and addressed. Even in cases where the memory loss is irreversible, as in neurodegenerative diseases, knowing the cause can help in managing symptoms, slowing the progression, and improving the quality of life. 


Finally, understanding the cause of memory loss can offer peace of mind to both patients and caregivers. It enables more informed decision-making, encourages proactive care management, and fosters an environment of empathy and understanding around the individual’s condition. 



What are the common causes of memory loss? 

  • Neurodegenerative Diseases: Conditions such as Alzheimer’s disease and other forms of dementia are common culprits behind cognitive impairment and memory loss. These diseases cause progressive damage to brain cells, leading to a steady decline in cognitive abilities.


  • Vascular Disorders: Conditions that affect the circulation of blood to the brain, such as stroke or vascular dementia, can lead to cognitive changes. These disorders deprive the brain cells of vital nutrients and oxygen, causing them to function less efficiently or die.


  • Depression: Surprisingly, depression in older adults can often manifest as cognitive impairment, particularly memory loss. This phenomenon, sometimes referred to as ‘pseudodementia,’ can be reversed with effective treatment for depression.


  • Medication Side Effects or Interactions:  Some medications can have cognitive side effects, particularly when combined or when used in high doses. Always consider the potential role of medication when assessing cognitive changes.


  • Nutritional Deficiencies: Deficiencies in key nutrients like vitamin B12 can impact cognitive functioning. These deficiencies are reversible once identified and treated.


  • Chronic Diseases: Chronic conditions like diabetes, hypertension, kidney disease, or heart disease can increase the risk of cognitive impairment and memory loss due to their impact on overall bodily functioning, including the brain.


As healthcare providers, our holistic understanding of these causes can guide us in formulating effective care strategies. Through thorough assessments and empathetic communication, we can reassure our clients that they are not alone in their journey, helping them manage their cognitive health and enjoy a good quality of life in their golden years.


What are the signs of cognitive impairment? 


Cognitive impairment and memory loss manifest in various ways, but some common symptoms stand out in older adults. These include:


  • Regularly forgetting recent events or conversations
  • Difficulty performing familiar tasks, such as cooking a well-known recipe or using a household appliance
  • Confusion about time and place
  • Trouble making decisions or solving problems
  • Difficulty finding the right words in a conversation


Depending on the cause of the cognitive impairment, in some clients, these symptoms can start subtly and gradually progress, and in other clients come on “out of the blue”. This makes it even more crucial for us to be well informed about detecting memory loss, communicating our concerns to our clients and/or their family members, and connecting them to necessary supports and resources. 


How Does Cognitive Impairment Impact Daily Functioning? 


Cognitive impairment and memory loss can significantly affect an individual’s daily life and overall functioning. They can lead to challenges in performing everyday tasks like cooking, shopping, and taking medications correctly. Over time, they can also affect a person’s ability to drive safely, manage finances, or even maintain personal hygiene.


Moreover, these conditions can take an emotional toll. Feelings of frustration, confusion, anxiety, and depression are common in individuals experiencing memory loss and cognitive impairment. It can also lead to social withdrawal, as the individual might feel embarrassed about their difficulties or fearful of making mistakes.


As healthcare providers, our role in understanding, identifying, and addressing cognitive impairment and memory loss is pivotal. These conditions, while challenging, can be managed effectively with our compassionate care, appropriate interventions, and ongoing support. With the right approach, we can help our older adults navigate these changes, ensuring they continue to enjoy a fulfilling and dignified life.


Why Do People With Dementia Appear To Be In Denial Or Unaware Of Their Memory Loss? 


What you see as “denial” may actually be anosognosia.


Anosognosia is derived from the Greek words ‘nosos,’ meaning disease, and ‘gnosis,’ meaning knowledge. It refers to a situation where a person is unaware of or denies the existence of their health condition. In the context of cognitive impairment and memory loss, anosognosia implies that an individual is unable to accurately perceive or understand the changes happening in their cognitive function.


Anosognosia is a frequent companion of cognitive impairment and memory loss conditions, especially dementia and Alzheimer’s Disease. Many people living with Alzheimer’s Disease experience some degree of anosognosia. As healthcare providers, recognizing anosognosia in our patients is crucial because it can influence their safety, their ability to engage in treatment, and the stress levels of their caregivers.


“To unravel the thread of anosognosia, we must understand that it’s more than denial—it’s a lack of awareness rooted in the brain itself.”



The Difference Between Anosognosia and Denial


An important distinction we need to make in our practice as healthcare providers is understanding the difference between anosognosia and denial. 


Anosognosia, as we have discussed, is a lack of insight or awareness into one’s own cognitive condition. It’s not that individuals with anosognosia are refusing to acknowledge their cognitive impairment or memory loss; rather, they genuinely do not perceive the changes that others observe in them. No matter how hard you try, they are not likely to gain awareness. This lack of awareness often results from changes in the brain associated with their cognitive condition. 


On the other hand, denial is a psychological defense mechanism where individuals consciously refuse to accept the reality of their condition. Even when they notice their cognitive difficulties, they may reject the idea that they have a problem out of fear, shame, or the overwhelming nature of such a diagnosis. Understanding this difference is crucial as it informs our approach in communication and intervention strategies. Providing empathy and understanding in both situations is vital, but the strategies we use might vary depending on whether we are dealing with true anosognosia or a psychological denial.


As healthcare providers, we can help manage the challenges posed by anosognosia through education, understanding, and patient-centered care. By doing so, we can better support our older adults in their journey, promoting safety, dignity, and quality of life, even in the face of cognitive change.



How to Recommend Further Assessment of Cognitive Impairment


When we observe signs suggestive of cognitive impairment, it’s essential to approach the subject delicately. Use empathetic, non-alarming language to express your concerns. For instance, “I’ve noticed some changes in our sessions that suggest we should explore your memory function a bit more. It’s a standard procedure, and it can help us ensure we’re providing the best care for you.” 


In cases where clients might not acknowledge their cognitive changes due to anosognosia or denial, consulting with their family members or caregivers can be an effective step.


Early detection of cognitive impairment and memory loss in older adults is an important aspect of promoting their overall quality of life. By utilizing effective tools and strategies, observing subtle changes, and promoting further assessments, we as healthcare providers can ensure we offer the necessary support to our clients in their cognitive health journey.


“Effective communication is key when discussing memory loss with clients—it’s a conversation that needs sensitivity, respect, and honesty.”


Effective Communication Techniques with Cognitively Impaired Older Clients


As healthcare providers, one of our most profound skills is the ability to communicate effectively, especially when serving older adults showing signs of cognitive impairment or memory loss. These interactions often require a delicate balance of sensitivity, respect, honesty, and the ability to handle resistance, denial, or anosognosia. 


Communication with older adults experiencing cognitive changes requires an approach that is patient, clear, and reassuring. Use simple, concise language and break down instructions into manageable steps. Non-verbal communication is equally important, so maintain a calm, friendly facial expression, and use gentle, reassuring touches where appropriate. Visual aids can be beneficial in explaining complex issues or instructions. Remember to allow ample time for your client to process the information and respond.


Discussing Cognitive Changes Sensitively, Respectfully, and Honestly


When addressing cognitive changes, it’s paramount to approach the conversation with sensitivity, respect, and honesty. Start by acknowledging the individual’s feelings and concerns. 


Express your observations gently, focusing on specific examples and the impact on daily life. For instance, you might say, “I’ve noticed that you’ve been having trouble remembering appointments. This must be really frustrating for you.” Make it clear that these changes are common and that there’s a range of support and resources available. Throughout the conversation, respect their dignity and reassure them of your ongoing support.


Overcoming Resistance and Denial: The Role of Motivational Interviewing


When clients resist the idea of cognitive changes or deny the observations, the technique of motivational interviewing can be invaluable. Motivational interviewing is a client-centered, directive method that enhances motivation to change by helping clients explore and resolve their ambivalence. It involves expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy. 


For instance, instead of confronting denial directly, acknowledge the difficulty of the situation, and emphasize the discrepancies between their goals and their current situation. A conversation might start with, “I can see how hard it is to consider these changes. You’ve mentioned how important it is for you to remain independent and maintain your hobbies. Let’s discuss some strategies to support these goals.”


Effective communication is a cornerstone in our role as healthcare providers serving older adults experiencing cognitive impairment. With sensitivity, respect, and the right strategies, we can navigate these challenging conversations, fostering trust and cooperation with our clients, and ensuring they feel understood, supported, and empowered throughout their cognitive health journey.


Involving Family Members and Caregivers in Client’s Care


Family members and caregivers often serve as an integral part of the care team for older adults with cognitive impairment. Involve them in discussions about the client’s condition, treatment plans, and daily care needs. Regular updates and care meetings can facilitate their active involvement. Recognize their insights about the client’s behaviors and changes that may not be evident in clinical settings. Additionally, support them in their role as caregivers, as this journey often brings its own challenges.


Educating Families about Cognitive Impairment and Memory Loss


Empowering families with knowledge about cognitive impairment and memory loss is crucial. Provide clear explanations about the nature of these conditions, their symptoms, and progression. Discuss the common challenges and practical strategies for managing them. Share credible resources for further reading and direct them to support groups or workshops where they can learn more and connect with others in similar situations. Reiterate that while these conditions are challenging, many resources and supports can assist in managing them effectively.


Navigating Family Members’ Emotions: Fear, Frustration, and Denial


Family members of individuals with cognitive impairment often grapple with a range of emotions, including fear, frustration, and denial. Acknowledge these emotions and provide a supportive space for them to express their feelings. Validate their experiences and remind them that these emotions are a natural response to a challenging situation.


For family members struggling with fear or anxiety, offer reassurances about the support and resources available. Discuss concrete steps they can take to manage the situation effectively, which can help provide a sense of control.


When dealing with frustration, encourage self-care and stress management strategies. Remind them of the importance of taking time for themselves and seeking support from others.


If family members are in denial, be patient. Allow them time to process the situation. Continue to provide clear, compassionate information about the client’s condition and gently challenge any misconceptions.


Partnering with families is a key component in the holistic care of older adults with cognitive impairment. By involving them in care, providing education, and offering emotional support, we can foster a more supportive and effective care environment. Through these collaborative efforts, we not only enhance the quality of care provided to our clients but also support families in their important role as caregivers.


The Importance of Professional Consultation in Geriatric Care: Ensuring Optimal Outcomes and Preventing Burnout 


Caring for older adults, particularly those with cognitive impairment or memory loss, calls for an in-depth understanding of the aging process, cognitive disorders, geriatric syndromes, and the psychosocial aspects of aging. While broad clinical expertise provides a valuable foundation, consultation with professionals who specialize in geriatrics can enrich our knowledge, expand our perspective, and refine our intervention strategies. By harnessing the specialized insights and experience of these professionals, we can ensure a more nuanced, effective approach to geriatric care. 


Enhancing Client Outcomes Through Specialized Consultation 


Seeking consultation from geriatric specialists can significantly enhance the care we provide to our older clients. Through their specialized knowledge and experience, we can gain a deeper understanding of the unique challenges our clients face and the best strategies to address them. Whether it’s refining our diagnostic approach, optimizing our treatment plans, or navigating complex ethical dilemmas, these consultations can contribute to more accurate, effective, and compassionate care. 


Preventing Professional Burnout Through Consultation 


In addition to improving client outcomes, consultation plays a critical role in preventing burnout among healthcare professionals. The emotional and intellectual demands of geriatric care can be significant, and navigating them in isolation can lead to stress, fatigue, and burnout. By seeking consultation, we create opportunities for shared problem-solving, mutual support, and professional growth. These interactions can enhance our resilience, renew our motivation, and enrich our professional satisfaction.


“Embracing consultation with specialized colleagues isn’t just about improving client care—it’s also about sustaining our professional wellbeing.”


As therapists and healthcare providers working with older adults, we are often the first line of defense in recognizing and managing cognitive impairment or memory loss. Our role is fundamental not only in identifying these changes but also in supporting our clients and their families through the often challenging journey that follows. 


Final Thoughts and Encouragement for Health Providers


The work we do is not without challenges, but the impact we can make is immense. It’s important to remember that we’re not alone in this journey – consultation with colleagues, multidisciplinary collaboration, and a community of support are vital resources. They can provide fresh perspectives, practical strategies, and a shared understanding that enriches our practice and fosters our professional wellbeing. 


Margaret’s journey, like many others, may have its ups and downs. Yet, by employing strategies we’ve discussed—compassionate communication, family involvement, holistic care planning, and a proactive approach to cognitive changes—we can empower Margaret and her family to manage her cognitive impairment in a way that maintains her dignity and enhances her quality of life.


“Remember, as healthcare providers, we don’t just manage symptoms—we enable our clients to navigate their journey with dignity, respect, and autonomy.”


Our role as healthcare providers in recognizing and managing cognitive impairment in older adults is fundamental. It may challenge us, but it also provides us with the profound opportunity to make a meaningful difference in the lives of our clients and their families. As we navigate this path, let us draw strength from our shared commitment, our collective wisdom, and the very human stories that inspire our work, like Margaret’s. In this intricate dance of care, we are not just observers but also essential participants, shaping the narrative with each step we take.




Regina Koepp, PsyD, ABPP

Dr. Regina Koepp is a board certified clinical psychologist, clinical geropsychologist, and founder and director of the Center for Mental Health & Aging: the “go to” place online for mental health and aging. She is currently the lead medical psychologist at University of Vermont Medical Center. Dr. Koepp is a sought after speaker on the topics of mental health and aging, caregiving, ageism, resilience, sexual health and aging, intimacy in the context of life altering Illness, and dementia and sexual expression. Learn more about Dr. Regina Koepp here.