When I learned that Sir Patrick Stewart had passed away following a “brief and poignant journey” with Alzheimer’s disease and Lewy body dementia, I didn’t think of Captain Picard. Instead, I thought of the husbands and wives who sit in my exam room, worried something is wrong, even when the person next to them looks perfectly fine to me.
The phrase “brief journey” caught my attention and made me reflect. A Washington Post piece posed this question to neurologists, and one of them, Dr. Sami Barmada, said, “It’s hard to tell when a disease actually begins.” This statement reflects an office visit I know all too well.
The consultation starts with a firm handshake, eye contact, and a funny story about the patient’s knee or back. The companion sits beside the patient. Before the patient finishes, the companion corrects the date, supplies the name the patient was reaching for, and turns to me. “Doctor, my loved one has dementia. Nobody believes me.”
This scene has become increasingly familiar as my patients have grown older right alongside me. It presents me with one central challenge: How do I care for the person in front of me while their companion continues to speak for them?
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It is tempting to trust the patient in front of me. He is articulate, oriented to the visit, and socially graceful. And to be honest, quite likable. However, these are exactly the skills that early dementia can often preserve for a long time.
The literature is a powerful reminder of our limits. In an older primary care study, physicians failed to recognize dementia in two-thirds of affected patients, and recognition improved only as the disease advanced. More recently, University of Southern California researchers analyzing Medicare data found that over 99 percent of primary care clinicians underdiagnosed mild cognitive impairment, with only about 8 percent of expected cases receiving a diagnosis.
So when I catch myself thinking, “The patient seems normal to me,” I have to acknowledge that my clinical impression is a pretty blunt tool. A quick visit for a sore knee or back pain is hardly a substitute for a proper cognitive assessment.
Dr. Barmada, a neurologist at the University of Michigan, described a quality he calls resilience: the ability to function relatively well despite changes in the brain. That word has stayed with me. It means a person can keep shaking hands, telling stories, and sailing through a 10-minute visit while something is already changing underneath.
I cannot know the course of Sir Patrick’s illness, although it can explain my interactions with patients undergoing this process. But resilience can look exactly like composure, and the companion sitting beside the patient may be the only witness to what has changed at home.
I do not want to swing the other way. Informant reports are not always accurate. In a 2025 primary care study of three informant questionnaires, the tools were useful for ruling out dementia but less useful for ruling it in. Adult children tended to rate patients as more impaired than other companions did, and their specificity was the lowest. The authors also noted earlier work linking higher anxiety or depressive symptoms in companions to higher impairment ratings.
A companion who is exhausted, frightened, or grieving a changed relationship can be completely sincere and still be off. And not every cognitive complaint is dementia. Medical conditions such as drug side effects, thyroid dysfunction, vitamin B12 deficiency, and depression can all mimic it, and they need to be taken into consideration.
The right posture is neither “the patient looks fine” nor “the companion must be right.” It is “I do not know yet, and I owe both of them an answer.”
Researchers who recorded memory clinic visits found that the three-way conversation is really a series of alternating two-person exchanges, with the focus drifting from talking with the patient to talking about the patient, or ignoring the patient altogether. A systematic review of triadic consultations found that companions who provide information help, while dominating or demanding behavior does not, and it recommends agreeing on roles up front. A 2024 conversation analysis argues that patients with dementia must be given a real chance to take a turn at talking when decisions are made.
The interruptions can also tell something. A companion who finishes every sentence may be trying to clarify the patient’s current situation, may be tired of dealing with the frustration, or may have learned that the patient cannot be counted on to report their own lapses. I want to know which one it is.
Here is where I have to confess: I do not always get this right. When a companion keeps interrupting, I notice my posture stiffen, my answers get shorter, and I find myself reacting to the interruption rather than the concern behind it. The truth is, even after decades in practice, a determined companion can still turn me into the referee at a poorly managed game.
The outcome is predictable. The room grows tense, the companion feels dismissed, the patient withdraws, and I learn less in 20 minutes than I might in 10. My medical degree, as it turns out, offers no immunity to interruption or to letting my own ego get in the way. If I am being honest, the tension in that room is rarely just the companion’s fault. I have to own my share.
So, what do I usually try to do?
- Set the rules early and kindly: “I am going to start the consultation with the patient first, then I will turn to you, and you can tell me your concerns, what you think.”
- Do not react: When someone tries to take over the conversation, I pause, take a breath, and do my best not to let my ego do the talking. I thank the companion, let them know I value their observations, and gently steer the conversation back to the patient. The interruption is information, not a personal affront. I am still a work in progress here, which is a polite way of admitting I fail this test more often than I care to admit.
- Separate the two accounts: Many companions will not describe lapses in front of the person they are describing. I ask for a few minutes alone with the companion, with the patient’s knowledge and permission, never behind the patient’s back. I also give the companion the chance to write down what they have seen.
- Document both versions: I put the patient’s account and the companion’s account in the chart, and I tell them both my recommendations.
- Protect the patient’s dignity: I use their name. I don’t discuss the patient in the third person while they sit there like furniture. Even when I turn toward the companion, I keep the patient in the conversation.
A patient who looks fine deserves a real evaluation, not reassurance based on a handshake and a good story. A companion who says the patient is not fine deserves to be heard, not dismissed and not simply believed. My job is to sort out what is true, not to choose sides.
The longer I practice, the more I think my job in that room is not to judge who is more credible. It is to listen carefully to both sides and to do it in a way that leaves both people feeling respected.
Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness.
Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.
Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.
