Dementia patients may believe they are still working because their brains are experiencing changes that affect memory, perception, and reality testing, leading to persistent delusions or false beliefs about their current status and activities. This phenomenon is often rooted in the way dementia alters brain function, causing patients to hold onto fixed beliefs that do not align with reality, such as the idea that they are still employed or actively engaged in their former jobs.
At the core of this experience is the disruption of brain regions responsible for belief formation and evaluation. Dementia, including Alzheimer’s disease, Lewy body dementia, and frontotemporal dementia, damages areas like the prefrontal cortex and hippocampus, which are crucial for processing new information, distinguishing fact from fiction, and updating one’s understanding of the world. When these areas malfunction, patients may develop delusions—firmly held false beliefs that resist correction—even when presented with clear evidence to the contrary. For example, a person might insist they need to go to work despite being retired or physically unable to do so.
This belief that they are still working can also be a form of psychological coping. Work often represents identity, purpose, and routine. When dementia erodes memory and cognitive function, patients may cling to familiar roles and routines from their past as a way to maintain a sense of normalcy and self-worth. The brain’s impaired ability to reconcile current reality with past experiences can cause the individual to live in a mental time frame where they are still active in their job.
Additionally, dementia-related behavioral and psychological symptoms, such as agitation, anxiety, and hallucinations, can contribute to these false beliefs. The brain may assign excessive importance to irrelevant stimuli or memories, a process known as aberrant salience, which fuels delusions. For instance, seeing a briefcase or hearing a phone ring might trigger the belief that it’s time to work, reinforcing the delusion.
In some cases, specific types of dementia produce characteristic delusions. Frontotemporal dementia, for example, can cause delusions involving mistaken identity or false beliefs about one’s environment, which might include the conviction that one is still employed. Lewy body dementia often involves vivid hallucinations and delusions that fluctuate in intensity, further complicating the patient’s grasp on reality.
The persistence of these beliefs is also linked to the brain’s reduced capacity for conflict monitoring and error correction. Normally, the prefrontal cortex helps us recognize when our beliefs conflict with reality and adjust accordingly. Damage to this area in dementia patients impairs this function, making it difficult for them to update or abandon false beliefs about their work status.
Caregivers often observe that when dementia patients express that they are still working, it is not simply confusion but a deeply held conviction. Attempts to correct or argue against these beliefs can cause distress or agitation. Instead, understanding that these beliefs stem from brain changes and serve emotional or psychological needs can guide more compassionate and effective care approaches.
In essence, dementia patients may believe they are still working because their brains are no longer able to accurately process and update their understanding of their current life situation. This leads to fixed, false beliefs that preserve a sense of identity and purpose, even if those beliefs no longer reflect reality. The combination of neurological damage, psychological coping mechanisms, and behavioral symptoms creates a complex picture where the patient’s experience of reality diverges significantly from the present moment.
