Games

We're going to play a tapping game now, Mrs. MacDonald,” I say, but it's not true, not exactly.

The kitchen where we play this game is, according to her, not her kitchen. It is another kitchen, situated in a strange house that has replaced hers. Despite its resemblance to her home, this is only a copy, a counterfeit, a changeling dwelling. Even the ocean outside the window, rolling restlessly under the grey sky, is a different ocean than the one she listened to as a child. She doesn't know this ocean's name.

We are at the table, seated opposite each other the way arm wrestlers face off in the moment before they lock hands. My patient is 79 years old, but looks much older: white hair, deep-set grey-green eyes that glare at me with a mixture of fury and bewilderment. Her bones are thin beneath her housedress. If we were to arm wrestle, her arm would snap like a twig in winter. She has a yellowing bruise on her forehead; she can't recall when she fell. Home Care is scared she's going to break a hip.

I smile encouragingly.

“The rules of the game are as follows: when I tap once, you tap twice.” I demonstrate by tapping my index finger on the table. She taps a twisted finger, twice. We do this 3 times.

If there wasn't so much at stake, she might find this entertaining. On the coffee table is last week's newspaper, open to the crossword puzzle. She told me proudly, when I inquired, that she does the crossword puzzle every day. The squares of the crossword grid are filled out in ink. Under the newspaper, I found her pills, neatly blister-packaged by her pharmacy. The foil cells are punched out randomly and brightly coloured pills lie scattered on the table and floor.

We are 20 minutes into the assessment, and a couple of times I think she is going to cut me off. I have abandoned all attempts to get a history — it wouldn't be reliable anyway — and am devoting my efforts to getting the cognitive testing done. By all accounts, Mrs. MacDonald has always been a very bright woman and I can see she has a ferociously strong will. She commands respect. She has no children and her nieces and nephews are intimidated by her, which is why the situation has been allowed to deteriorate this far.

“Now,” I say, “When I tap twice, you tap once.”

She tries, but even this simple instruction confuses her and she taps twice. I try again, but she slams her hand down on the table.

“This is damned foolish!” she says, “I'm not doing any more.”

“Mrs. MacDonald…”

“No!” She points her finger at me her hand shaking. Her affect is slightly blunted by dementia, but you can still tell she's very, very angry. I gather we're finished the testing for today. I look down at the partially completed frontal assessment battery. She did poorly on tests of abstraction and verbal fluency, not to mention the fact that she only scored 18/30 on the Mini Mental State Examination.

She stands up. “Go. Go now.”

I remain seated. “Mrs. MacDonald, you know people are concerned about you living here alone.”

“Out!” She points at the door.

She will probably hit me if I don't leave soon, but I hate to go without trying to explain what will happen next. “I am concerned about your memory. I was asked to come here by Adult Protection…”

“No, no…”

“And I'm going to have to tell them that I don't think you should be making decisions without assistance…”

She tells me to go to hell and raises her fist. For a moment we look at each other. She's scared. I feel a heavy sadness settle on me. Not pity, exactly. More like the regret you might feel about the loss of an historic building to fire, or an ancient tree that has succumbed to internal decay. I stand up and gather my things.

As I pass through the living room, I look at the crossword puzzle on the table. All of the squares of the grid are filled, but they aren't the right answers — they aren't even real words, just combinations of letters. Her brain has conveniently filled in the empty spaces, yet there is nothing there.

As I get back in the car, I look back to see her standing on the front step, wearing an expression of grim satisfaction, and I'm glad that, for now, she's had a last opportunity to think she has won.