My first patient with Alzheimer’s, Sheryll, led me on a journey of questions and self-growth which I had never expected. Until meeting her, I hadn’t thought extensively about how our biology may dictate cognition and free will. While my thoughts on the matter continue to develop as I broaden my clinical experience, these considerations continue to frame my understanding of my patients, myself and the world around me.
Sheryll was a happy older woman who talked to her providers like we were distant relatives. She reported having excellent concentration skills and no difficulty in her day-to-day life, so I was caught off guard when during memory and concentration testing her happy demeanor became uncharacteristically flustered. Serial 7’s turned into a series of stops and stutters barely progressing past 93, or even 100. In her “defense,” Sheryll cited disinterest or purposeful forgetfulness of memories. She seemed happier after moving on to another task, but from the corner of my eye, I could see her husband’s downtrodden facial expressions. The juxtaposition in their attitudes made it clear that she didn’t realize her loss of capacity.
I learned that a lack of insight into one’s decline is a common presentation in patients with Alzheimer’s. She was forgetting day-to-day tasks, was unable to manage home finances and failed to perform other necessary functions for her independent survival. All the while, she believed herself to be cognitively normal, rejecting intervention from those close to her. She clearly had lost her capacity for instrumental activities of daily living, but what of her free will?
To assess the status of her free will, I find it useful to compare her “agency” to my own. My actions are influenced by prior experiences, which allow me to make decisions based on the remote and recent past. Concurrently, I need the concentration to consider my options and manipulate different scenarios within my head. As a result, I have what many consider to be sufficient free will to decide my actions. In contrast, her deficits seem to detract from free will. How could she truly be “free” without the faculties to focus on and contextualize her actions? The damaged cellular architecture from amyloid plaques and neurofibrillary tangles effectively placed a limit on her cognition. Her state made me wonder how my own biology influenced my thought processes — are we all inherently confined mentally, disease or not?
An important tool in cognition is our senses, which are critical in deciphering the world around us. For example, if my expired milk has an awful stench, I know to avoid it to prevent a stomachache. However, my senses may biologically differ from others. For example, interpretation of color is influenced by the number of cones in their retina, genetic variation, gender differences and linguistic/cultural influences. If you and I may experience something so fundamental as color differently, imagine how other small variations in cognition shape the way we interpret the world. In fact, the confluence of brain volume, genetic inheritance, environment and personality are all factors in cognition, thus no two people’s experiences can be exactly the same; the differences between us don’t have to be extreme or pathological like in Alzheimer’s to merit reflection.
The more I ponder the subject, the greater its impact on my worldview. Because there are limits to what I perceive, I find myself more open to the ideas of others and the bigger picture which I might not be able to see. In clinic, I’m now more careful in building a portrait that leads to a better informed diagnosis and treatment. When I listen to patient’s stories — their thoughts and insights, how they interact with their environments and possible exposures, as well as collateral from others — I try to remember that everyone comes from varied backgrounds with their own biases and perspectives. I’ve also found myself to be more empathetic towards my patients as I attribute more of their cognitive deficits to nonmodifiable factors like genetics, environmental exposures, etc. I have even become more aware of the emotional burden of the disease on family or friends. Sheryll’s husband carries the emotional weight of her disease, not just out of love, but necessity, considering her lack of insight. He too deserves my attention, education and help.
While I’ve learned an incredible amount about how to analyze and process my patients’ diverse situations, I have also found important insights into my own life. By reflecting on my thoughts, biases and upbringing, I have removed barriers to my own free-thinking. A new appreciation for the limits to my perception has encouraged me to slow down and critically analyze my thoughts, actions and check my biases.
This process has created a new openness to learning. For example, most actions are considered and performed in a fraction of a second, but with just a momentary pause for introspection, we can identify their root causes and make modifications. Eventually, these moments could shape higher-order beliefs — including our worldview, perception of personality and more — which can then influence our future subconscious actions.
It’s surprising where we find the triggers that change our lives. My patient with Alzheimer’s has influenced and enlightened the way I view cognizance, its variation among people and how I conceptualize free will for my patients and myself. At a larger scale, I have come to appreciate the value in learning from the broader context of our patients’ lives. Reflecting on their situations can inform not only our treatment and management plans but also provide insight into our own life — elevating us as future physicians and people.