Counting Your Marbles
So, here's a revelation for you: as time passes, people get older. Shocking, isn't it?
A little more than four years ago, Eris Lis, M.D., began writing a series of brilliant and informative posts on RPGs through the eyes of a medical professional. Following is the sixth of them, which appeared here on January 12, 2013.
So, here's a revelation for you: as time passes, people get older. Shocking, isn't it?
Actually, in my experience, a lot of people do seem to be sort of shocked by it. Most people don't really stop to think about getting older until it happens to them. One major part of aging is cognitive decline, which fortunately doesn't happen too early for the vast majority of people. Some degree of cognitive decline is perfectly normal and not worrying; it's expected that as one ages, the memory isn't quite as sharp, for example. Sadly, a certain percentage of people develop more severe changes to memory and attention, which is then called "dementia." Dementia is a category of diagnoses, not a diagnosis in and of itself, and it includes Alzheimer's disease, vascular dementia (damage to the brain caused by recurrent small strokes), frontotemporal dementia (characterized by disinhibition and behaviour changes), Lewy body dementia (characterized by visual hallucinations), and others. How can we, as storytellers, realistically represent cognitive decline in the aging? Here are some thoughts.
To me, the best way to conceptualize realistic cognitive decline is to think about how it's measured. We test cognition in older adults with various standardized questions, and we know a lot both about how a "normal" person should function and what seems to be the expected decline at various ages. Picture an elderly NPC from one of your games, someone you imagined as being a bit senile, and imagine how they might do if they sat down with their doctor and were given one of these tests. Take a moment to consider what questions they would have the hardest time with. Like this, you can actually sort of imagine whether someone has mild memory problems or severe memory problems.
The most commonly-used test for cognition in the elderly is the mini–mental state examination (MMSE), also known as the Folstein. The MMSE is a test that gives us a score out of 30, and depending who you ask, a score of greater than 24 is usually considered "normal" no matter the age. You can view the MMSE on a number of websites, but this is a pretty good version which comes with explanations for most of the items. Basically, the person is asked:
- if they're oriented to time and place (10 points, losing a point for not knowing the year, or the date, or what building they're in)
- to repeat three words immediately and recall them a couple of minutes later (3 points immediately and 3 points later)
- to subtract 7 from 100 several times or their ability to spell the word world backwards (a test of the ability to pay attention, not of one's mathematical skill; 5 points)
- to name common objects, usually a pen and a wristwatch (2 points)
- to repeat a complicated sentence exactly (1 points)
- to follow three sequential simple commands (3 points)
- to read a simple sentence and do what it says, and then to write a simple sentence (2 points)
- and lastly, to copy a geometric drawing (1 point
All together, the test measures attention, memory, language, and what's usually called "construction." A person with fairly mild dementia might get a score of, say, 22, losing a few points for getting the date, month, and year wrong, getting two letters wrong when they try to spell "world," missing one step in a three-stage command, and not being able to recall some of the words given at the beginning.
Another test for memory is the Montreal Cognitive Assessment, or MOCA. It's less popular than the MMSE, but since it was invented in my hometown and it's very popular here, I'm obligated to mention it. The MOCA also gives a score out of 30, but it's widely considered a tougher test. A person is expected to recall five words instead of three, for example, and to do a "connect the dots" where they have to go from a number to a letter to a number. The "normal" score is about 26 or higher, but there's some very good data showing lower "normal" scores for people at different ages and with different levels of education. One thing that the MOCA offers is that the person being tested has to draw a clock (analogue, not digital), putting in all the numbers and the two hands and setting the time to "ten minutes past 11." This is a useful test because it challenges a person's ability to plan, construct, and imagine a shape in space, and according to research, it's probably the single test we have which is most predictive of, of all things, an older person's driving safety.
Personally, I like to test people using the Modified Mini Mental exam, or the 3MS. The 3MS is sort of a combination of the MMSE and the MOCA. It gives a score out of 100 for more subtle differences, and gives different weight to different tasks (for example, a person who doesn't know today's date loses one point but who doesn't know the year loses eight). The 3MS has another advantage, which are various tables that take the person's score and calculates how well they performed relative to other people of their age and education level; the actual score is of secondary importance to whether they score better than similar people or worse. It doesn't have a clock-drawing task, so I usually administer that at the same time.
How is all this useful? The next time you write a senile, two-hundred year old wizard into your campaign, he doesn't have to be just another befuddled old man (or woman). You can take a moment to think about what skills you feel he's lost and what he's maintained. He could still have a sharp memory but no longer be able to name ten four-legged animals in thirty seconds, for example. You can probably imagine how changing the cognitive losses a bit can lead to a very different NPC and a very different encounter for your players.
