Eleven.

“Now draw a clock face, with the numbers,” the medical assistant instructed my mother. I sat motionless, feigning invisibility, taking in my surroundings. I am seated next to my mother at the neurologist’s office during a work-in appointment, which was graciously granted to us because of the severity of her symptoms and my (the adult daughter’s) observations of her behavior since Dad’s sudden death. She hasn’t been functioning well for what appears to be several years, but I would not have known. Estranged from my parents by choice, I kept in minimal contact with them as the dysfunction and mental illness could topple me. I dreaded calling. I’d set a timer, keep it to 20 minutes, only discussed light and pleasant topics. I never missed a birthday or Christmas, always sending a nice gift basket, but I kept her away from my life, my children. But now, living in the house with her (and the 24 hour a day caregiver I set up), I see her mental deterioration firsthand. I didn’t understand at first. The hate spewing forth at me, the daughter who abandoned her years ago, triggered more than one angry outburst on my part. She resents me for who I have become, well adjusted, thriving in my normal life, happy, active. I resent her for her lack of basic parenting skills and teaching me ineffective and unhealthy ways of living. I have much, much work to do to forgive and heal. But for now, there is a job to do. Regardless of who she was before dementia, she is mentally incompetent and unable to care for herself, make safe choices, or manage her finances. So the work begins and it is exhausting.

“Now draw the hands on the clock to show ten minutes after 11:00,” continued the medical assistant after my mother had drawn a circle with clock numbers. She struggled, staring at the sketch. “Hands?” she asked. The medical assistant explained the hands of a clock, what would they look like if the clock showed ten after 11:00? She drew lines, clock hands, but they didn’t show the requested time. Her poor aged demented brain did the best it could. I sat motionless, heartsick. More questions, assessing executive functioning, language abilities, attention, short term memory. Many fails. Sometimes I had to look away as she fails the answers, part protecting her dignity and part feeling the weight of the grief of losing not one parent, but the soul and heart of the other in a matter of just a few weeks. I feel the weight of the devastation ravaging her diseased brain. Damn you dementia. Damn. You.

The medical assistant completes the assessment, leaves, and the neurologist enters moments later. He talks with her and asks questions, takes his time and is patient, reserved, careful. He reviews my handwritten note about mom’s recent functioning and asks more questions. I sit silently unless directly asked. She is agitated when I answer questions. She wonders what it’s all about, unsure why she is here at the neurologist today. “You have significant memory impairment,” he tells her.

“No, my memory is good!” she defends. He discusses need for additional testing to get to the cause of the impairment, a lab draw and an MRI. He tells her that having her daughter live with her right now is a good thing, that she needs signifiant help and support. He questions me about future planning…will you take her back to where you live? She jumps in, telling him no, “It’s too cold there.” He looks straight at me and tells me that I should start looking for locked memory units, makes a plan to discuss results of MRI with me once it is completed, and said we will schedule an appointment pending results. I stare blankly, my eyes sad and soft. “What was the result, the score?” I ask.

“Eleven.”

The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. MoCA scores range between 0 and 30. A score of 26 or over is considered to be normal. In a study, people without cognitive impairment scored an average of 27.4; people with mild cognitive impairment (MCI) scored an average of 22.1; people with Alzheimer’s disease scored an average of 16.2.

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