Confabulation vs. False Memories: Atypical Sign of Alzheimer's Disease

Alzheimer's disease (AD), is the most common form of dementia, affecting 5.2 million Americans over the age of 65. Typical signs of AD include memory loss, language difficulty, and changes in function. Someone in the early to mid-stages of AD may also have atypical signs such as false memory and confabulation.

While confabulation may seem like your loved one is lying, be aware they firmly believe what they tell you is the truth. Understanding the cause of false memories and confabulation will help you respond appropriately to your loved one.

Real-life example of confabulation

Bill — diagnosed with early AD — and his daughter sat in his apartment while the case manager conducted an assessment. He told her about how he and his family visited Pennsylvania in 1996 to buy horses. Bill acted puzzled when his daughter interrupted and told him they'd never been to Pennsylvania, let alone to purchase horses.

"How do you not remember going to the horse farm? Remember, we stayed at that Howard Johnson's on the I-95. The one with the green roof."

Bill became somewhat agitated, as he couldn’t understand why his daughter wouldn't remember such an important trip. Rather than try to convince Bill he was wrong, the case manager changed the subject and redirected Bill's attention back to the assessment.

Is Bill lying, is he delusional, or is he confabulating?

What is confabulation?

Confabulation is the unintentional creation of false memories, sometimes called “honest lying.” The person who confabulates believes the false memory to be accurate. A confabulation can range from filling memory gaps with a few points to a bizarre and detailed story.

Confabulation helps the person with AD make sense of their environment, situation, or identity. Confabulation may be a subconscious mechanism to cope with declining memory. People with AD who confabulate are not trying to be deceptive. Instead, they believe what they are telling you to be true. Their brain fills in gaps to make sense of incomplete information.

There are two types of confabulations based on the situation:

• Provoked confabulation. This occurs when someone asks a person with memory loss a question. This questioning requires a response to recall a past event. To compensate for their lack of memory details, they will “fill in” missing points with information from their false memory.
• Spontaneous confabulation. This not in response to a question, but is when a person “recalls” a story or situation in detail without knowing the information is false. An example is when a person will tell an entire experience centered on a news event they saw on television. This person will proceed to weave people they know into their recount. The news story is an example of an external cue that can trigger confabulation.

Confabulation and other brain conditions

Confabulation occurs in other conditions affecting the brain. For example, people with Wernicke-Korsakoff's Syndrome, a vitamin B1 deficiency type of dementia caused by an alcohol use disorder, often express themselves with confabulated stories. Other types of dementia that may show confabulation include frontotemporal dementia and AD. Any condition that disrupts the brain, causing damage may be prone to confabulation, including:

• Traumatic brain injury
• Encephalitis
• Schizophrenia
• Subarachnoid hemorrhage
  
• Fetal alcohol spectrum disorder (FASD)
• Post-traumatic stress disorder (PTSD)

Possible causes of confabulation in AD

There are a few possible causes of confabulation, including:

• Poor encoding. Encoding is the process where our senses take the information we see, hear, touch, or smell and transform it into data stored as memory in the brain. The hippocampus is a part of the brain responsible for encoding and consolidating episodic memories. In early AD, the characteristic tangles and plaque proteins affect nerve conduction in the hippocampus, interrupting messages. This leaves the brain vulnerable to disruption in the encoding process.
• Retrieval of “over-learned” Information. “Over-learned” information refers to a person's repetitive life habits and well-known stories told over the years that become part of their engrained, long-term memory. This information is easy to recall when needed. An example of over-learned behavior includes learning multiplication tables or the ability to drive a stick shift in a car. This memory has automatic recall even in early to mid-stage AD. The information in a person's memory will surface in a confabulation to make sense of a situation.

Confabulation vs. lying

Sometimes confabulation is mistaken for lying, but the person with AD is actually expressing an “unintended” memory distortion. In contrast, someone lying deliberately creates a story for deceptive purposes. In moderate to advanced stages of dementia, a person may not have the insight to lie intentionally and is more likely to confabulate.

Confabulation vs. delusion

It can be confusing to differentiate between confabulations and delusions. Psychiatric disorders such as schizophrenia and various types of dementia can exhibit delusional behavior. A delusion distorts a person’s belief not based on reality, whereas confabulation distorts a person's memory that originated as reality.

Response to confabulation

Often, family and friends have various emotions when it comes to their loved one confabulating. For example, they may initially believe their loved one is lying, which can cause resentment. It is essential to remind loved ones that the confabulation is not purposeful and the person confabulating honestly believes they are telling the truth.

• Please resist the urge to correct. Don't argue with the person confabulating, since they believe what they are telling you is true. It may induce a negative response if you insist they are wrong.
• Enter your loved one's reality if safely possible. This is a type of validation therapy where your loved one feels you are validating their feelings about the memory. Whether the memory is false to you, remember it is true to them. For example, if they are talking about visiting their “mother” yesterday — when their mother died 20 years ago — ask them how they felt about visiting their mother and what they did together.
• Gauge the conversation to your loved one's response. They may have some negative feelings associated with the memory. In this case, the memory may trigger anxiety or aggressive behavior. If this happens, try redirecting them to a new topic or activity.

Confabulation is the expression of false memories exhibited in someone with AD. If you see that your loved one with AD is “making up stories,” you may first believe they are lying, when they are likely confabulating due to false memories. Remember, the memories incorrectly stored in their brain are due to the disease. Validating and joining your loved one in their reality will help them feel safe and preserve a sense of well-being.