“Bless you!”

These are the only words I ever heard Mrs. P say, even though I had sat with her on several occasions, and continued to do so on many more. Mrs. P lives in an assisted care-facility in a unit for people with profound dementia. She spends her days in a common room along with the other residents. Mrs P needs to be spoon-fed by an aide. Until her “Bless you!” I had no evidence that she was at all aware of her surroundings.

This “Bless you” was a clear sign that she was still in some important sense responsive to her environment. She heard a sneeze and responded. But what did her response mean? Did she say “Bless you!” from a sense of social decorum? Out of concern for the sneezer’s health? Or was it just a Pavlovian reflex, imprinted by decades of conditioning?

Each of those possibilities has left me wondering: why this response from an otherwise silent person? What do we have to learn from it?
Many residents of a memory-care floor in a nursing home have lost the ability to say what they want. These residents actually have a lot that they want and need – and cannot express. Even in the best-staffed dementia-care units, the staff are overworked and don’t always have the time to intuit unvoiced, unmet needs. Unmet needs ferment, and when they find their means of expression, whether verbal or physical, it’s usually not pretty.

If you could muster only one utterance per day, would you always come out with a compliment? A polite socially-conditioned expression? A blessing?

Parents teach their children to say “Please,” “Thank you,” and “Bless you” because they hope manners will become second nature, words and actions to be practiced not just to get a cookie but because treating others in a mannerly fashion is the right thing to do. So even if Mrs. P’s polite “Bless you” can be reduced to a mere habit, it’s still a pretty remarkable habit to be in, given her circumstances.

Maybe Mrs. P’s dementia is so far advanced that it has worn away all former capacity for meaningful thought  and all that’s left is instinct and habit. But I’d like to think that Mrs. P is someone so committed to being decent and mannerly that she remains so even when she has forgotten everything else.

It should go without saying that people with dementia who don’t say “Please,” “Thank you,” and “Bless you!” are not necessarily practiced in habits of incivility. They may simply be having trouble having their needs understood and met. Not to mention the unpredictable ways in which amyloid plaques or Lewy bodies are slowly vandalizing their brains.

Dementia changes people in unpredictable ways. Except when it doesn’t. The inculcation of good habits like Mrs. P’s “Bless you” comes from a lifetime of hard work. God willing, those habits will be some of the last things to go.