Confabulations, No Celebrations

Confabulation. Sounds like a hybrid word, doesn’t it, like “fantabulous” or “ginormous”? And indeed it is a hybrid – of fact and fiction. If you haven’t heard of it as a term, you’re not alone; but if you care for someone with dementia, you may recognise it in action.

I’m not a medic or scientist, so I’ll describe as a layman how I understand the difference between three related symptoms of some types of dementia: hallucination, delusion, and confabulation. 

We may be more familiar with the first two:

Hallucination – seeing, hearing, or smelling things that are not there.

Delusion – believing things that are not true or misinterpreting information.

While these two states can be very disturbing for both the person with dementia and those around them, they are reasonably straightforward to grasp. Others can tell at once if there is, or is not, “a man in clerical robes” or “a big fat bottom!” at the end of the bed, or a woman whispering in the wall. 

Delusions, such as a belief that a dead relative is still alive, can be harder to handle, but the factual truth can be determined. 

Confabulation, however, is a complex amalgam of fact and fantasy, in which a false narrative may involuntarily be created by a person’s belief that an imagined scenario is memory. 

This imagined scenario will usually be woven around a kernel of truth: an event that actually happened, transposed to a different time and place, or involving a different set of characters; or an emotional trauma that was real, but misremembered in a different context.

And because there is an element of veracity at the heart of it and it may contain mundane, inconsequential detail as well as major incident, such a hybrid narrative may be very hard for the carer or other friends and relatives to unravel. 

For instance, my mum was a professional singer in her youth. I know that on several occasions she studied at the famous International Summer School of Music at Dartington Hall in Devon. This is her treasured photograph of the composer Stravinsky (right), a souvenir of one of those sojourns (probably taken by Dartington's official photographer, Catharine Scudamore).

At around that time, she also attended the International Eisteddfod at Llangollen in North Wales. That’s a fact. But in latter years, she began to tell me that she had been present to see the tenor Pavarotti “make his name” there. Now Pavarotti did perform at Llangollen in 1955 – in a choir with his father. The choir won first prize in competition. Pavarotti later gave many interviews in which he credited this as a formative experience that inspired him to pursue a singing career. 

But he was only 19 at that time and had yet to make his professional operatic debut; he would not have been noted individually. Yet my mum was adamant that she had not only been aware of him as a soloist, but that the performance had made him a star; and she had seen it happen.

Then in 2007 a cousin of mine, whom neither of us had previously met, came from abroad to stay with me for a few days on the way to a friend’s wedding. I had planned to take her to visit mum too and see the countryside around my hometown; but in the event there were terrible floods, and the water supply at mum’s was cut off for nearly two weeks. I couldn’t take my cousin there after all. Mum, however, would later talk about this visit as if she had not only met my cousin herself, but had hosted the entire stay. Her “memory” of this was based solely on what I had told her of things I had done with my relative.

Another time, I went into hospital for major surgery and was anxious about mum in my absence; the surgeon kindly called her from the recovery room to let her know I was all right. Mum was subsequently convinced that she had actually met the surgeon, describing in great detail what she had looked like and where they had met (“on the stairs”), despite this being a complete fantasy. 

Mum, in her singing days

She also told a friend that she had “been up to Ming’s; I didn’t go in, I just stood outside and looked up at her flat” – an account which greatly alarmed the friend, as mum was by then too frail to make such a long journey on her own and I was in any case not at home. Yet mum’s tale had sounded so plausible that her worried friend had called me to check whether it might indeed have been true. It was not; but another friend had brought mum to visit me at the hospital a few days after the operation. The surgeon had been in to check on me earlier that morning (long before mum had arrived) and I had mentioned this. So you can see where the seeds of mum’s hybrid story were sown...

Now you may say, what’s the problem? These are all fairly innocuous confusions; it doesn’t matter if they’re not true. 

And with examples like this, I agree that there’s no gain in trying to point out anomalies or assert the factual version; contradiction will only provoke distress. 

But other confabulations may not be so benign. I have detailed in an earlier post a particularly traumatic incident where mum believed that a tradesman had broken into her house and was holding me hostage. It was of course a terrible delusion, but those to whom she told this story had no way of knowing at first that it was wholly imagined. 

Similarly, she once told me, when she herself was in hospital after a fall, that she had been down the stairs (the ward was on the 11^th or 12^th floor and mum is lift phobic) and had sat in the foyer, where an orchestra had been playing; and that she had been taken from “the bus station” (which I later recognised from her description as the ambulance bay) to a nurse’s house, where she had been abused. 

Logically, I knew these things were all highly unlikely, if not impossible; but she believed them so completely and vehemently that I did wonder if there might be some grain of very confused truth.

Such threads of confabulation can be impossible to disentangle. The question then for carers is how should we respond? 

That’s something I’ll discuss in my next post, "Truth" or "Lies"?…