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Kahneman’s Ideas Applied to Dementia: Understanding and Managing Behavior
Ian Andrew James1*, Heather Birtles2 and Katharina Reichelt3
1 Trust wide Pathway Lead for Psychological Interventions Community Care Group & Hon. Professor, University of Bradford
2 Department of Psychology, Claremont Rd Newcastle upon Tyne, UK
3 Consultant Clinical Psychologist
Submission: June 04, 2020; Published: July 16, 2020
*Corresponding author: Ian Andrew James, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Clinical Psychology Services, Campus for Ageing and Vitality, Centre for the Health of the Elderly, Westgate Road, Newcastle upon Tyne, NE4 6BE, UK
How to cite this article: Ian Andrew J, Heather B, Katharina R. Kahneman’s Ideas Applied to Dementia: Understanding and Managing Behavior. OAJ
Gerontol & Geriatric Med. 2020; 5(4): 555668. DOI: 10.19080/OAJGGM.2020.05.555668
As clinicians it is not only important to know which clinical interventions work, but also why they work. When we understand the building blocks and processes underpinning an intervention, we can improve it based on the theory. This article examines the behaviors of people with dementia using Kahneman’s (2011) notion of ‘fast and slow’ thinking. Kahneman’s ideas help explain why people with dementia can continue to perform complex activities into late stage dementia (knitting, ironing, playing a musical instrument, riding a bike, driving a car). The ‘fast and slow’ model can guide us on how to support skilled activities and to interrupt processes that might lead to illbeing (e.g. repetitive questions or acts).
Maria, a woman with dementia, has the intention to go to the shops to buy a crusty loaf. She leaves her home with this firm intention, but an hour later we find her knocking at the door of a house where she had lived 10 years earlier. She is shouting and demanding to see her child. This type of memory failure is common in people with dementia. It is important to try to understand the mechanisms underlying memory failure because they provide information about how to deal with distress and maintain wellbeing in people with dementia.
If we had observed her during this trip, we would have noticed Maria making a number of choices as she went on her journey. Her first choice point came when she arrived at the junction of her street, she should have turned left to go to the shops but instead turned right. Having turned right, she eventually came to the entrance to the park. She opted to go into the park. After a short walk she exited the gates on the far side, and then she decided to take the no. 5 bus. This took her near her son’s ‘old’ school.
She alighted from the bus but found the school closed and so progressed to the house where she had previously lived.
Ignoring the fact that Maria has dementia for a moment, her behavior reveals something important about the way humans process information. This is most eloquently described in the work of Kahneman  in his notion of ‘fast and slow’ processing. Kahneman suggests that slow thinking is conscious deliberate thought, whereas fast thinking is quick and often unconscious processing. The two features operate together whereby the slowed thinking creates the conscious goals, and ‘checks in’ every so often to ensure our plans are on track. In contrast, the fast-automatic processing enables us to carry out routine activities without using too much effort or thinking power. In other words, it allows us to ‘run in autopilot’ – see box 1.
In terms of Maria, we see her engaging in fast and slow thinking, but her poor short-term memory means she has an inability to remember and focus on her original goal (getting the crusty loaf). Therefore, instead of basing her decisions on this goal, they are based on cues that she is encountering on her journey (e.g. the no.5 bus, school, vicinity of house). She is ‘running on auto-pilot’, relying on system 1 to do a lot of fast, automatic decision-making based on her environment. During this time, her slow system 2 keeps ‘checking-in’ to see if she is ‘on track’ but cannot remember what the goal is. She is moving around like a pin-ball in a pin-ball machine, making new goals and decisions based on whatever information is available to her. A representation of Maria’s information processing is shown in (Figure 1).
The final part of Maria’s journey is particularly important because here we see evidence of her remembering a goal over a sustained period of time (i.e. the desire to see her son). This goal was cued by passing his old school. In her time-shifted state, she
thinks her son is a schoolboy and wants to collect him. However,
because the building is closed, she panics and decides to go home
(‘old’ home) to find him. This is relevant because she seems able
to retain this goal for a longer period of time than she was able
to remember that she wanted to get a crusty loaf. This is almost
certainly because of the high level of emotion attached to seeing
her son, as emotional memories are retained more easily for
people with dementia.
The above scenario, and its theoretical underpinnings,
are relevant to clinical practice. Indeed, in addition to having
explanatory power in relation to Maria’s journey, it offers guidance
in two other important areas (i) the de-escalation of challenging
behaviors (CB), and (ii) the selection of treatments in dementia.
(i) De-escalation of CBs – In a typical de-escalation situation
people with dementia have got a particular goal and their attempt
to fulfil this may put themselves, or someone else, at risk. However,
the caregiver’s attempt to intervene may be perceived by someone
with dementia as interfering or over-controlling which can further
inflame the situation and lead to aggression.
Such a situation is about to happen in Maria’s scenario because
she is now trying to find her son, and bangs on a stranger’s door;
the goal and drive to see her son is strong. The poor unsuspecting
occupant of the house, Aidan, is about to encounter a difficult
situation. If he responds to Maria in a way that further upsets her,
the situation could become problematic and he may get assaulted.
Fortunately, however, Aidan works at the local care home and is
skilled in dealing with such situations. He recognizes Maria has
a dementia and guesses correctly that she is time-shifted. Hence,
he knows that a direct confrontation of her current view would be
unhelpful. He is aware that he needs to ‘go along’ with her current
view of reality for a while and look for an opportunity to grab her
attention with a powerful topic of distraction. By doing this he
knows that he will have a chance to re-orientate her to the present
and the current reality.
Aidan invites Maria into the house and says she can wait to
see if her son comes home. Despite being agitated she sits and
accepts a cup of tea. Aidan’s friendly chat calms her and reduces
her ‘emotional thinking and her drive’ somewhat. He notices
that she is taking a lot of interest in his Labrador and asks does
she like dogs. Maria is a big dog lover and she is soon talking
enthusiastically about the many dogs she’s owned. Aidan is hugely
attentive, asking lots of questions about her dogs. Five minutes
later Maria has been distracted from her son. Aiden doesn’t want
Maria to be reminded of her son again, so he asks his own children
to stay out of the room until her taxi arrives.
Aidan did something really simple here, something that many
caregivers do without recognizing the processes underpinning
it. Aidan’s choice of topic, and the enthusiastic manner he used
to engage Maria, resulted in a shift from ‘children’ to ‘dogs’. We
can see how fast and slow thinking underpins this interaction
because we can understand how the CB stems from cues in the
environment altering her goals (slow thinking) and short-term
decisions (fast thinking). In this situation, Aiden is able to use this
to his advantage by encouraging Maria to focus on different, more
helpful cues like his dogs. This redirected her slow thinking to
forget about the goal of seeing her son so that her fast processes
were anchored in the current situation rather than focused on this
outdated goal. He also removed cues which could retrigger her
distressing thoughts of her son.
In clinical practice we can use this idea to:
a) Identify what elements of the environment are triggering
the goals and thoughts behind CBs
b) Remove these cues to prevent CBs.
c) Introduce topics and cues that can redirect attention
to more situation-appropriate thoughts and goals which are
anchored in the present (or away from the distressing thoughts).
(ii) Selection of treatments in dementia – The term treatment
can be confusing because it could refer to interventions to either
reduce the rate of the dementing process or to tackle agitation or
aggression. However, in the current discussion the interventions
are designed to maintain wellbeing.
Unfortunately, the evidence base for effective wellbeing
treatments is rather inconsistent, except in case of Cognitive
Stimulation Therapy (CST) and some person-centered programs
. In part, this is due to the fact that dementia includes a wide
range of diseases which may be at many different stages, and
also that the experience of dementia is different for every person.
This means that studies which might show positive effects of
interventions in some cases are watered down by the fact they
may not be appropriate for every individual at every stage.
To deal with such variability, occupational therapist (OTs)
have produced a number of programs that attempt to match
interventions to the stage of the condition . We suggest that the
effectiveness of the OT frameworks can be further enhanced by
factoring-in Kahneman’s notion of ‘fast and slow’ processing. Let’s
look at the implication of Kahneman’s ideas with respect to people
with moderate to advanced dementia.
a) People with dementia have difficulties sustaining
activities that require the retention of long-term goals or strategies
(slow thinking). Therefore, the use of prompts at key points would
b) Activities that include overlearned activities (procedural
memories and fast thinking) can be exploited and are able to
provide a sense of accomplishment. However, to maintain the
person’s active participation he/she may require assistance at
transition points between actions which require slow thinking
(e.g. when baking a cake the person may struggle with regulating
the oven; selection of ingredients; timings).
c) If the tasks fulfil some basic emotional needs (fun, touch,
being active, sense of belonging, feeling safe) they are more likely
to be engaged initially and their interest and understanding of the
activity is more likely to be sustained .
Kahneman’s ideas lead us to promote activities that provide
positive experiences ‘in the moment’ that do not require goals
or strategies (e.g. listening to music, speaking with an attentive
listener, looking at photographs, engaging with table-top
interactive touch games). It is also helpful to choose actions
that provide immediate feedback because this facilitates the
use of ‘autopilot’ activities. It is worth noting that the above
recommendations are not new and many of them are being done
intuitively by experienced cares. However, what is different is that
the theory informs us why the approaches are effective. Further, if
we start to understand the building blocks of such interventions,
we can produce more effective treatments. Therefore, what we are
offering here is the theory underpinning the choice of intervention.
An example of this idea can be seen in a study we undertook in
2014 in which we spoke to Christian clerics about their experiences
of providing religious services to people with dementia . The
most exciting part of this project was to see people with advanced
dementia, who appeared to struggle to speak in a residential
setting, suddenly become engaged and lively during the religious
service. One person attending a Catholic mass fully participated
in the prayers, hymns and symbolic aspects of the service. She
smiled throughout, seeming to have a sense of belonging in a
community from which she had previously appeared detached.
Such projects need to be replicated across other religious groups
and across other such communal topics. However, the key point
being made is that the woman attending the service was able
to participate in the service through a mixture of fast and slow
processes. She knew the prayers and hymns once they had begun
(fast thinking) and was being guided through the transitions
by both the structural elements provided by the mass and the
behaviors of the other members of the congregation so she was
not reliant on slow thinking and retaining information about the
Before concluding the article, it is worth reflecting on the skills
required to devise activities for people with dementia. A good
activity for someone with an advanced dementia is something
that does not require a goal or strategy – this is where dominoes
is better than draughts, which is superior to chess. Further, the
actions associated with the task need to be basic and intuitive,
another reason dominoes is good (involving a simple matching
task), and why the card game ‘snap’ would be more appropriate
than either ‘whist’ or ‘poker’.
Also, it is better to use activities that can be undertaken and
enjoyed ‘in the moment’, and ones that rely on reflexes: playing
simple instruments, ‘copy-cat’ yoga, simple ball games, etc. It is
worth noting that games that are traditionally used with small
children contain features that make them ideal in late stage
dementia. Childhood brain development and brain deterioration
have overlapping phases and therefore the types of activities that
are suitable for children may be relevant for people with dementia.
It is important to remember however, that unlike children,
people with dementia have an array of skills that have been
developed in the past that can be utilized if the correct cues are
employed. This is well illustrated in the church service example.
In this case, a vast range of skills were unlocked once we had
provided the person with an environment that supported and
triggered the expression of their skills.