Jim and Sondra had both worked as engineers in the Columbus, Ohio, office of a multibillion-dollar construction company. Jim oversaw big commercial projects—convention centers, hospitals, ballparks. They had met twenty years earlier, playing on a local soccer team. In 2009, Jim’s brother, to whom he was very close, died of kidney cancer in his early fifties, and Sondra thought that might have triggered something in Jim, because his symptoms started soon afterward.

The first thing she noticed was his reaction time: one day she said, while they were working on the computer together, “Close that window and open another,” and she noticed that it took him time to process what she had said. She then saw that in meetings he had begun asking people to repeat things and writing down what they said. Then one day he had an appointment with a doctor he’d been seeing for twenty-five years and he couldn’t remember how to get there. Because he was so young, nobody thought of dementia. Doctors tested him for inflammation and hepatitis and mad-cow disease and autoimmune diseases; they gave him spinal taps and put him on steroids. Finally, they ordered a PET scan of his brain and diagnosed Alzheimer’s.

Jim went on disability, and Sondra bought a trained English setter to keep him company while she was at the office. The dog brought Jim’s medication to him at the sound of an alarm. When Jim was still able to drive but grew disoriented in large parking lots, he could tell the dog, “Truck,” and the dog would find his truck. If he got lost walking in the neighborhood, the dog tracked him down. The dog enabled Sondra to keep working awhile longer. But after a year it took so much out of Jim just to manage simple tasks like finding his coffee cup that he was exhausted by the end of the day, and she stopped working so that they could spend time together while he was still aware of it. They decided to check off some items on their bucket list. They took money out of Jim’s retirement account and travelled to New Zealand and Italy and Hawaii.

Sondra decided that if Jim did something weird, or said something that wasn’t true, she wouldn’t correct him. If he put on four baseball caps at once, or put a flip-flop on one foot and a sneaker on the other, she would just go with it. Then again, he had always been a pretty obstinate person, so this wasn’t a big change in their relationship. “Everyone knew if Jim says the grass is blue it’s not worth trying to talk him out of it,” she said. “And that just rolled right into when he was sick.”

Eventually, things got to the point where Sondra couldn’t manage taking care of him alone anymore, so she began looking into nursing homes. Chagrin Valley was much nicer than other places she saw—no funeral-home carpeting, no grim hallways with wall protectors and handrails—but it cost about the same. She dreaded leaving him there, but she also hoped that finding someone else to help with daily tasks would allow them to be close again. “I spent so much time taking care of him that I had no time to be his wife anymore,” she said. “By the time where I can sit down on the couch and hold his hand, I’m so completely drained mentally and physically that I can’t even go through a photo album with him. I’m hoping now I can hold his hand and go for a walk and just have that husband-wife relationship. We still have it; it’s just that we haven’t been able to really experience it in a long time.” Many people said this: that while they were taking care of their wife or their father at home they were no longer a husband or a child—just a nurse.

The staff gives residents cognitive exercises, such as puzzles, tracing, and hangman. Photograph by Philip Montgomery for The New Yorker

Jim mostly lost his ability to speak early on, but he could still recognize faces, and he could show emotion. Oddly enough, while many people with dementia grow angry and difficult, Jim was the opposite. “He got a lot nicer,” Sondra said. “Not that he was mean before, but he was always very businesslike, very serious and by the book. The disease changed his personality. People would ask, Who is this guy?—he was just so kind, and there was a softer side to him that they hadn’t seen before.” Before, when he was frustrated he would get angry; now he was more likely to cry.

In losing his language so early but remembering faces, Jim was unusual. Most people with dementia start to become confused long before they stop speaking. Many people mistake one relative for another—mistake their daughter for their mother, or their son for their husband—and many forget that their spouse or their parents are dead. It is common to imagine that you are somewhere else, such as a hotel or a prison or a ship, and to believe, therefore, that those who tell you you’re in a nursing home are trying to trick you. Some people believe that dramas on television are real. People with Lewy body dementia often experience visual and auditory hallucinations, and people with dementia of all sorts have problems with depth perception and find it difficult to distinguish dark patches on the ground from holes. Many imagine themselves to be living through an earlier time, when they had an office to go to or small children to pick up from school, or even earlier, when they themselves were small and dependent on their parents. Doctors have observed that there seems to be a “reminiscence bump”: that people whose memories are failing tend to remember the period of their late childhood and early adulthood more vividly than other stages of their life.

It is because of these characteristic confusions that dementia care has developed its characteristic lies. “I think for the most part it’s kinder to just go with the moment,” Jennifer Karp, the former acting director of nursing at Chagrin Valley, says. “Because the chances are within the next few minutes they’re not going to remember what just occurred anyway. To tell them repeatedly that their spouse has passed away, or when they’re crying out for their mother to say, ‘You’re ninety-four years old, where do you think your mother is?’ That’s just cruel. So we say, ‘Hey, maybe they’re at the store.’ Someone asked me yesterday, ‘Where do you think all the kids went?’ And instead of saying, ‘What kids?’ I said, ‘I think they’re playing—it’s a beautiful day outside.’ And she said, ‘That’s good, they can go play.’ That was all she needed to hear.”

In dementia care, everybody lies. Although some nursing homes have strict rules about being truthful, a recent survey found that close to a hundred per cent of care staff admitted to lying to patients, as did seventy per cent of doctors. In most places, as in Chagrin Valley, there is no firm policy one way or another, but the rule of thumb among the staff is that compassionate deception is often the wisest course. “I believe that deep down, they know that it is better to lie,” Barry B. Zeltzer, an elder-care administrator, wrote in the American Journal of Alzheimer’s Disease & Other Dementias. “Once the caregiver masters the art of being a good liar and understands that the act of being dishonest is an ethical way of being, he or she can control the patient’s behaviors in a way that promotes security and peace of mind.” Family members and care staff lie all the time, and can’t imagine getting through the day without doing so, but, at the same time, lying makes many of them uncomfortable. To ease this “deception guilt,” lying in dementia care has been given euphemistic names, such as “therapeutic fibbing,” or “brief reassurances,” or “stepping into their reality.”