Dementia and the Mirror People

October 13, 2023
September 29, 2022
Posted by
Bre'anna Wilson
September 29, 2022
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There's a lot of talk about whether or not mirrors are bad for people living with dementia. What I've personally found is that it really depends on the person. So what we usually see is a little bit of everything. There will be some people living with dementia that will find the mirror really distressing. For others, it can actually be a positive experience where the person will actually form a bond with the person in the mirror. For others, it may start out as a positive experience and then turn negative over time. Then for others, mirrors really have no affect — either they actually still recognize themselves as the person in the mirror or even if they don't, they just don't care.


So, what I want to do is give you some background into what's going on with this whole mirror situation. So there's actually a couple of names for it. You may hear "mirror phenomenon" "mirror agnosia or mirror image agnosia" "mirror sign" or "mirrored-self misidentification." These terms are all basically talking about the same thing though there can be slight differences in how they are sometimes used.  Now, to keep it simple. I'm just going to refer to it as mirrored-self misidentification — it's the most clear phrase that I think will keep us on the same page.

So, mirrored-self misidentification is when a person is unable to recognize their reflection in a mirror and believe that their reflection is instead another person like a stranger, relative, or friend. Basically, anybody other than themselves. Now, I want to be clear that this doesn't happen with just mirrors. It can happen with any reflective surface, which I'll share a couple of stories about this towards the end of the blog.


It is important to realize that this is not a phenomenon experienced by every person living with dementia. It's actually considered quite rare if we look at the entire dementia population. However, in my experience, it does happen quite a bit which is why I wanted to talk about it. But statistically speaking only about 2 to 10% of people with Alzheimer's disease specifically, will experience mirrored-self misidentification. However, this phenomenon is not limited to just people with Alzheimer's disease. The other type of dementia that it's often seen in is Lewy Body Dementia — not to say that it can't happen with other types of dementia. This is just where much of the research is right now, okay?


Now one of the cool, crazy things is, is that oftentimes with mirrored-self misidentification, the person typically retains the ability to recognize others' reflections in the mirror — just not their own. So for example, let's say that I had dementia and you were standing next to me in the mirror and I knew who you were. I would be able to tell that it's you I see in the mirror and I would also know that you are standing right next to me. However, I wouldn't be able to put two and two together that I'm standing next to you in real life, so the person I see standing next to you in the mirror is also me. Does that make sense?


So, we are going to talk about the role that the brain plays in all this, but I want to take it a different direction first. Okay? So, let's think about this...how do we know what we look like? How do we receive that information? I really want you to think about this for a second because when i look at myself I can see the whole front of my body, the sides, and a little bit of the back of my legs if I twist enough, but I can't see my neck, face, ears, hair — none of that. I also can't see my back. So how do I know what these parts of me look like? Well, we receive information from pictures and from the mirror, right? But, how do you know that the person you see in the mirror or photo is you? We just have to trust our visual interpretation of this information.


Now, have you ever looked at a photo of a group of babies? I mean real young babies and you know you are in the photo because your parents told you you were but then you thought, "Huh, is that me? or is that me? Idk which one is me, I'll have to ask." I've had that experience! I mean my early, early photos don't look anything like me in my opinion.  And so similarly, the opposite can happen where a person living with dementia can believe they are much younger and they don't recognize themselves as this older person that they now are.


Now interestingly enough, humans can recognize themselves in the mirror starting around 18-24 months old. So this is something we learn pretty early on. But, we actually learn how to recognize the face of other people much sooner around 2 to 4 months old. Subsequently, that very early skill seems to be retained to some degree even with dementia (at least in the sense of them being able to recognize if a face is familiar or unfamiliar in some way).


So let's talk about what researchers think is happening in the brain. Again, it's research which is like this constant process of discovery and unfolding — we think it's one thing today and find out it's potentially something else tomorrow. So, right now we think it's related to right hemisphere dysfunction. What they've found is that when the right hemisphere of the brain is damaged in anyway, a person will most likely lose the ability to recognize one's face...which of course is an important component of self-recognition. Now, knowing that it's the right hemisphere narrows it down a little bit, but not by much. They really haven't been able to identify one specific area of the brain that is being impaired that supports self-cognition and self-awareness because the patients in their studies have not had consistent neuropsychological or neuroimaging findings for a localization of lesions. So long story short, we have some ideas, but we aren't too sure exactly what specific damage causes it. But, some research, has linked to impairments of the right dorsolateral prefrontal cortex, which impacts a person's belief evaluation system. This means that a person will be unable to logically reject a delusional belief. Therefore, they would be unable to reject the belief that the person in the mirror is a thief, a stranger, a friend, a neighbor, etc.


Now, mirrored-self misidentification can happen at any stage of dementia, but it's most common in those with moderate to severe dementia.


So, what I want to do is share two quick stories of what this phenomenon can look like.


The first story is an excerpt shared by a woman name Krista back in 2019 on the Lewy Body Dementia Association website. So it reads, "It began with him talking to himself in the mirror. He made himself laugh and we thought as long as he was happy, we were good! Many mornings, when mom would call him for breakfast, he would be busy talking to the man in the mirror. She would come into the bathroom and firmly tell him it was time for breakfast and she already called him a few times. Come NOW! She would say. He would look at the man in the mirror and say stuff like “That’s the witch!” Or “She was drunk last night.” And would laugh heartily. Before long, the friend in the mirror would become his enemy. The mid afternoon would come, and the man in the mirror would tell my dad that he was going to take his car, his house, his wife. He would say “Its mine.” He would talk for hours each day to the guy in the mirror, sometimes laughing, sometimes yelling. The guy in the mirror eventually turned to friends in the back seat of the car, ghosts on the wall, robbers in the basement…anything where he saw a reflection, he would start chatting with the person he saw. He could identify that his daughter was standing next to the man in the mirror, but could not understand that his daughter was also standing next to him and that it was a reflection. There was no reasoning."


The next story is an excerpt shared by a woman named Lickety back in 2018 from the Alzheimers.org UK website. It reads, "Several times an evening, I'll see Mom in conversation with her friend. Then she’ll open the door only to find the mirror lady has disappeared, replaced by quite a nice selection of clean towels and sheets. The mirror lady shows up everywhere! We find her in department stores, restaurants, all bathrooms, anywhere there is a reflective surface. Mom always gives the mirror lady a wave and a smile as if to say, 'Hello! I'm happy to see you again!' Other people in the vicinity are perplexed or amused."


I wanted to share these two stories with you so that you can have a realistic idea of what this can look like for those who may have not yet experienced this with your partner.


Now a big question is... since people with dementia can have issues with mirrors should you always just remove any mirrors that the person would have access to? Some people will say yes, but my answer is no. This is only necessary if you notice your specific partner has issues with mirrors or their reflection.


Here are a few quick tips if your partner is someone who finds mirrors or reflections distressing: 


Remove or cover up any mirrors and reduce reflective surfaces.

With mirrors you can use something like roller shades over the mirror or short curtain — that way the mirror can be accessible to people in the household who need and like them. You can also add adhesive to fabric and cover the mirror or use adhesive contact paper, which can work really well for like reflective table tops or mirrored closet doors, but a table cloth or curtain could work too right. If it's something like a dresser with a mirror you can throw a blanket over it. It's really about design preference and what you have on hand or want to use. Just don't get too fancy with the designs because they can be confusing for people living with dementia and cause misperceptions. Keep it simple and solid if you can and try to avoid dark colors like black or navy that could be potentially perceived as a huge black hole — that can be scary okay?


Avoid surfaces that high glare and reflective.

You also want to try to avoid surfaces that are like glass, mirror, polished metals, marble, or use high gloss paints. Matte type of surfaces are typically better.


Now, the area of the house that mirrors can be most problematic is the bathroom and can sometimes be a reason why the person living with dementia doesn't feel comfortable using the bathroom or showering. Could you imagine walking into the bathroom and seeing a person looking right at you and when you ask them to leave they are just staring you down? That's pretty creepy, right? So, that's just something I want you to keep in mind okay.


So that's just a quick run down of mirrors and dementia. Hopefully, you found this blog interesting and informative.

References: 

https://www.jneuropsychiatry.org/peer-review/the-mirroredself-misidentification-delusion-neuropsychiatry.pdf

https://research-management.mq.edu.au/ws/portalfiles/portal/19434554/mq-13693-Publisher+version+%28open+access%29.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4193155/

https://www.karger.com/Article/FullText/506510


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