The Dartmouth Memory Handbook

Section 1:  Getting Started
 

Aging and Memory: 
Normal Aging, Subjective Cognitive Decline, 

Mild Cognitive Impairment, 
and Alzheimer's Disease

Nadia Paré, Ph.D.
Clinical Neuropsychologist,
Geriatric Evaluation and Management Clinic, Omaha, NE

(revised July 2016)

 
People often wonder how and to what extent normal aging should affect memory. This
seemingly simple question is a source of much controversy in the current scientific
literature. The goal of this Chapter is to characterize memory functions in normal aging
and provide insight into what constitutes abnormal memory loss suggesting that a
neurodegenerative process is taking place. Special attention is also given to the role of
cognitive concerns in otherwise healthy individuals.
 
Cognitive Changes and Normal Aging
Age is the single greatest risk factor for Alzheimer’s disease. However, this does not
imply that changes in cognitive function with normal aging lie on a continuum, the end of
which is Alzheimer’s disease or another form of dementia. The normal changes taking
place in the brain as people age are quantitatively and qualitatively different from the
changes taking place in the brain of patients suffering from Alzheimer’s disease.
Therefore, while there is a loss of neurons (brain cells) in both, the amount of neuronal
loss, the specific locations of neuronal depletion, and even the part of the cell that dies
differ in normal aging and in Alzheimer’s disease.
 
As one ages, the capacity to manipulate information in one’s mind (for example, doing
mental calculations), which is referred to as “working memory”, declines. A decline in
the capacity to strategize, organize and classify information properly and efficiently also
takes place. Therefore, in normal aging, there is a decline in “meta-memory”, or the
ability to use strategies to help encode new information in our minds in an efficient
manner, later facilitating recall. An example of such strategies is trying to remember the
name of a new acquaintance by pairing it with a physical characteristic of that person, or
trying to remember a list of errands by making a mnemonic out of the first letter of each
item on the list. Changes in the capacity to use such strategies have an impact on the
ability to remember new information and may imitate memory decline, although memory
structures (the hippocampus and surrounding areas) remain intact.
 
Mild Cognitive Impairment
In some cases, memory changes cannot only be attributed to the processes described
above. In these cases, an individual, his or her spouse, another family member, or a
friend may start noticing repetition of the same information or questions, failure to recall
recent conversations, events, or details of events, losing or misplacing everyday objects
(keys, wallet, glasses, etc.), getting confused or turned around while driving, having
difficulty keeping track of the current date or day of the week, having more difficulty
following a storyline in a movie, a TV show, or a book, etc. These memory lapses are
often accompanied by problems coming up with words and names. When individuals
with such problems are tested in a clinical setting with objective memory tests, results
may indicate memory impairments that are more severe than what would be expected
for the person’s age and level of education. However, these memory impairments may
not cause significant impairment in most daily routines. Daily activities that are more
likely to be affected at this stage are usually high level and complex activities. A first
example of this is money management, such as understanding complex financial
paperwork, balancing a checkbook, and even judgment when making financial
decisions. Another daily activity that could be affected at this stage is medication
management; in fact, even when memory changes are mild, patients are more likely to
forget to take a medication or to double-dose. Furthermore, patients and family
members may report difficulty using complex electronics, doing work-related duties, and
multitasking. However, because the ability to perform most activities of daily living is
preserved at this stage, these individuals do not meet criteria for a dementia.
 
Cognitive changes that meet the criteria above (isolated changes in memory and in
complex activities of daily living) have been termed “Mild Cognitive Impairment,
amnestic type” or MCI (or aMCI). The amnestic type specification refers to the fact that
only memory is impaired, without decline in other cognitive domains (for example,
attention and concentration, language, or visuo-spatial skills). In the last 10 years, MCI
has been widely documented as a prodromal stage to Alzheimer’s disease. Amnestic
MCI has recently been renamed “MCI due to Alzheimer’s disease” to reflect the fact that
Alzheimer’s disease is not a condition that arises spontaneously, without any warning
signs; memory disorders are in fact sometimes noticed as long as 10 years prior to the
clinical diagnosis of Alzheimer’s disease being made. New studies on biomarkers have
demonstrated that Alzheimer’s pathology starts accumulating in the brain as long as 25
to 30 years prior to diagnosis. The cumulative risk of mild cognitive impairment
progressing to dementia ranges between 30% and 50% over 5 years, depending on the
criteria used in various studies.
 
Given the continuum between aMCI and Alzheimer’s disease, the types of memory
impairments characteristic of aMCI are similar to those in Alzheimer’s disease. Memory
for new information, such as recalling personal experiences, events, and conversations,
is the first to be impaired. This type of memory is called “episodic memory”, or memory
for episodes of one’s life. When one suffers from episodic memory impairment, the
information does not get encoded in memory in the first place, and the memory trace is
not present when the person tries to bring back the memory later on. The structure of
the brain responsible for encoding new memory, called the hippocampus (more
specifically the left hippocampus), is deficient because the markers of Alzheimer’s
disease are taking place in these cells (the so-called plaques – made of beta-amyloid
proteins - and tangles – made of tau protein - and ensuing loss of neurons).
Consequently, the individual cannot access the information he or she wants to recall
because that information was not stored in the first place.
 
Other types of memory impairments happen later in progressive MCI or in the early
stage of Alzheimer’s disease. One type affects semantic memory, which refers to
recalling historical facts, grammar rules, vocabulary, and other forms of general
knowledge. In addition, as with normal aging, certain impairments in working memory
and in meta-memory are also found in MCI and Alzheimer’s disease.
On the other hand, procedural memory is a type of memory that is quite resistant to
normal aging, MCI and Alzheimer’s disease. Procedural memory refers to the set of
skills and abilities one learned through practice and repetition. Examples of procedural
memory include remembering how to ride a bicycle, play a musical instrument, or play
golf. Those abilities involve memory structures that are not impaired by normal aging,
MCI and initially in Alzheimer’s disease, but that can be impaired in other conditions,
such as Parkinson’s disease.
 
Because of the risk of conversion described above, once a diagnosis of MCI is
established, it is important for the patient to be followed closely by a physician. Medical
management of MCI may help slow down the progression to a dementia via different
interventions. In fact, research now shows that when prescribed early in the disease
process, acetylcholinesterase inhibitors (such as Aricept, or its generic donepezil, and
Exelon) can increase the size of the hippocampus, reflecting generation of new cells in
this region of the brain that is of primary importance in memory. In addition to
prescribing a memory boosting drug, the treating physician may discontinue
medications that have a negative impact on memory, specifically a class of medications
called “anticholinergic medications”, which includes most of the over-the-counter sleep
aids (such as Tylenol-PM, Benadryl, ZzzQuil, among others) and many medications
used to treat urinary incontinence. The physician can also test the patient for conditions
that may worsen memory, such as hypothyroidism, B12 deficiency, sleep apnea, and
depression.
 
Regarding sleep apnea, studies have now documented that patients suffering from
sleep apnea have smaller hippocampi but that patients that are 100% compliant with
their CPAP grow new hippocampal cells. In one particular study, this increased
hippocampal size has been associated with improved scores on neurocognitive testing
in these patients suffering from obstructive sleep apnea.
 
While depression can cause memory loss and even mimic dementia, one should not
systematically attribute cognitive decline to depression. In fact, depression is a common
symptom in aMCI due both to one’s realization that they are declining cognitively, and to
neurochemical and neuroanatomical changes taking place in regions of the brain that
are linked to emotional regulation. That being said, treating depression may improve
one’s cognition and functional status; the treating physician should remain aware for
signs of cognitive decline once the mood issues have been addressed and stabilized.
Finally, close monitoring by a physician may help prevent some of the conditions that
can contribute to cognitive decline and acute confusion, such as dehydration and poor
caloric intake, poor medication management, falls, urinary tract infection, or other type
of infections. This is especially important given that these can lead to delirium (or toxicmetabolic
encephalopathy) and that 30% of patients suffering from delirium will fail to
return to baseline and will continue to have a lower level of cognitive functioning, even
after the acute episode of delirium has resolved.
 
Subjective Cognitive Decline
A new focus of research explores the value of subjective cognitive complaints as a pre-
MCI phase. Subjective Cognitive Decline (SCD) is defined as perceived decline in
memory and other cognitive abilities, relative to a previous level of performance in the
absence of objective deficits on cognitive testing. Hence, SCD is thought to occur
before cognitive impairment can be measured on formal neuropsychological testing,
when individuals are still able to compensate for the disease process that is slowly
taking place in their brain.
 
In 2014, an international work group published a set of criteria aimed at better defining
SCD and the characteristics that increase the likelihood of preclinical AD in those
individuals reporting it. These characteristics are: subjective decline in memory rather
than in other domains of cognition (such as language or attention); onset of SCD within
the last 5 years; age of onset of SCD≥ 60 years; worries associated with SCD; feeling of
poorer performance than others of the same age group; confirmation of cognitive
decline by an objective informant; presence of the APOE ε4 genotype (a gene that
increases the likelihood of developing AD); and biomarker evidence for AD (see below).
Research on SCD suggests that subjective memory impairment, accompanied by
worries about these changes, in addition to consistency of the SCD over time better
predicts who is at greater risk for developing Alzheimer’s disease than the presence of
perceived decline alone.
 
While the concept of SCD was initially introduced in the early 1980s, interest further
increased about 10 years ago, as structural imaging techniques allowed for better
quantification of neuroanatomical changes of the memory structures. Research has
shown that a significant proportion of individuals noticing decline in their memory but
without any measurable memory deficits on cognitive testing actually are showing both
structural and functional changes in their brain that are similar to individuals with aMCI.
This finding raised interest in determining not only how early Alzheimer’s disease starts
in the brain but also how early it starts to have clinical significance (i.e. impact daily
functioning). These findings raise important questions regarding how early Alzheimer’s
disease pathology actually begins, and at what point it begins to have clinical
significance (i.e., impact daily functioning. This interest is partly driven by the desire to
reduce the societal costs by detecting it the disease as soon as possible, allowing for
earlier intervention.
 
Several research studies currently underway recruit individuals with cognitive concerns
to test the effect of medications that could reverse the damages done by the
Alzheimer’s process in the brain. In these studies, individuals undergo tests to
determine the presence of biomarkers such as beta amyloid and tau tangles. This
testing includes PET scans with specific contrast agents that bind to beta amyloid
plaques and tau tangles in the brain, and lumbar puncture to look for abnormal levels of
tau and beta amyloid in spinal fluid. These techniques permit detection of the disease in
the pre-clinical stage, therefore allowing participants who are not yet showing clinical
signs of the disease an option to participate in treatment studies.
 
It is imperative to take subjective concerns about memory functions seriously, especially
if these concerns create significant stress in daily life and persist over time. Whenever
there is a significant concern about memory, this should be addressed with the family
physician and a referral for memory assessment should be requested. Even when
testing does not reveal areas of impairment, the pattern of concerns expressed, and the
possible presence of very early cognitive changes may reveal important clinical
information. If anything, the assessment will establish a definitive baseline to which
results could be compared in the future.
 

Definitions and Diagnostic Criteria

Robert B. Santulli, M.D.
(Revised September 2016)
 
What Is a Memory Disorder?
A memory disorder is any condition that affects thinking, recall, or other cognitive
functions in ways that are more significant than those changes simply associated of
normal aging. At times, the boundary between normal aging and a memory disorder can
be very difficult to discern.
 
Memory disorders include subjective cognitive decline (see p 11) and mild cognitive
impairment, a condition that primarily causes memory impairment, but no other
significant functional difficulties, and is often (but not always) a precursor to Alzheimer’s
disease (see p. 9). Memory disorders are also caused by a wide variety of medical,
emotional, or mood difficulties that contribute to impairments in cognitive functioning.
The most common forms of severe memory disorders are the dementias.
 
What is Dementia?
Dementia involves a significant loss of mental functioning usually associated with a
decline in memory, thinking, behavior, and judgment. Although memory impairment is a
primary symptom of most dementias, it may not be a significant component in every
case, as for example in fronto-temporal dementia, at least early in the illness (see p. 97).
In any dementia, the symptoms are sufficiently severe to interfere with daily functioning.
As noted, dementia can be caused by many different illnesses, although only a small
number are relatively common. Dementia is “acquired”, meaning that it has not been
present since birth, but developed at some point later in life, usually after the age of 65.
 
Official Diagnostic Criteria for Dementia
There are two sets of diagnostic criteria that are commonly in use at the present time.
These are: (1) The National Institute on Aging – Alzheimer’s Association criteria, which
were first published in 2011; and (2) The American Psychiatric Association’s Diagnostic
and Statistical Manual Version 5 (DSM 5), first published in 2013. Although the differing
terminology can be somewhat confusing, there is a great deal of overlap in the two sets.
 
The NIA – Alzheimer’s Association Criteria
According to the NIA – Alzheimer’s Association criteria for “all cause” dementia,
dementia is diagnosed when there are cognitive or behavioral (neuropsychiatric)
symptoms that:
            1. Interfere with the ability to function at work or at usual activities; and
            2. Represent a decline from previous levels of functioning and performing;
            3. Are not explained by delirium or major psychiatric disorder.
 
Cognitive impairment is detected and diagnosed through a combination of history
gathering from the patient and a knowledgeable informant and an objective cognitive
assessment, either a brief mental status examination performed by the clinician during
the initial evaluation, or a battery of neuropsychological testing. Neuropsychological
testing should be performed when the routine history and bedside mental status
examination cannot provide a confident diagnosis (see p. 37).
 
Furthermore, according to the NIA – Alzheimer’s Association criteria, the cognitive or
behavioral impairment involves a minimum of two of the following domains:
 
a. Impaired Ability to Acquire and Remember New Information
           Symptoms include: repetitive questions or conversations, misplacing
           personal belongings, forgetting events or appointments, or getting lost on a
           familiar route.

b. Impaired Reasoning and Handling of Complex Tasks, Poor Judgment
           Symptoms include: poor understanding of safety risks, inability to manage
           finances, poor decision-making ability, inability to plan complex or sequential
           activities.
     
c. Impaired Visuospatial Abilities
           Symptoms include: inability to recognize faces or common objects or to
objects in direct view despite good acuity, inability to operate simple implements,
or orient clothing to the body.

d. Impaired Language Functions (Speaking, Reading, Writing)
Symptoms include: difficulty thinking of common words while speaking,
hesitations; speech, spelling, and writing errors.
     
e. Changes in Personality, Behavior, or Comportment
Symptoms include: uncharacteristic mood fluctuations such as agitation,
impaired motivation, loss of initiative, apathy, loss of drive, social withdrawal,
decreased interest in previous activities, loss of empathy, compulsive or
obsessive behaviors, socially unacceptable behaviors.
 
The DSM 5 Criteria
In the DSM 5, dementia is now officially called “Major Neurocognitive Disorder”
According to these DSM 5 criteria, the following are necessary for a diagnosis of Major
Neurocognitive Disorder:
     
1.   There must be a decline from a previous level of performance

2.   Cognitive deficits are sufficient to interfere with independence

3.   Assistance with at least one instrumental activity of daily living (IADL) is
                 necessary
 
4.   There must be deficits in at least one of the following areas (although there are
                 typically deficits in several of them):
 i.   Complex attention
ii.   Executive ability
iii.   Learning and memory
iv.   Language
v.   Visuospatial perception
vi.   Social cognition
1.  Recognition of emotions
2.  Behavioral regulation
 
Alzheimer’s Disease Is a Type of Dementia
In addition to the above criteria for dementia, or major neurocognitive disorder, there are
specific criteria for Alzheimer’s disease, as well. The individual must first meet the
criteria for dementia (or major neurocognitive disorder, in the DSM 5 criteria). Two
additional diagnostic signs are also necessary in both sets of criteria:
(1) Insidious Onset; and
(2) Progressive Cognitive Decline
 
Alzheimer’s disease is the most common cause of dementia, by far; as noted above,
Alzheimer’s is a type of dementia, not a condition that is different from dementia, as
many people seem to believe.
 
Other Types of Dementia
Other common forms of dementia are: Vascular Dementia (see p. 75); Mixed
Dementia (A mixture of Alzheimer’s disease and usually vascular dementia – see p.
76); Dementia with Lewy Bodies (see p. 77); Fronto-temporal Dementia (see p. 97);
and others.
 
While it is very important for clinicians to try to be precise about the exact diagnosis of a
dementing illness, that is sometimes not possible, given our current knowledge and
testing technology. From the caregivers’ perspective, whether the illness is Alzheimer’s
disease or another form of dementia, many of the issues are quite similar.
 
Cognitive, Functional and Behavioral
Signs and Symptoms in
Alzheimer’s Disease and Other Dementias
Adapted from Santulli RB:
The Alzheimer’s Family: Helping Caregivers Cope
New York: WW Norton, 2011
 
Alzheimer’s specialists often talk about the “ABCs of Alzheimer’s”, referring to the areas
of impairment that typically occur in the disease: Activities, Behavior, and Cognition. Of
course, there is great variability from person to person, and no one individual will have
all of the signs or symptoms that are discussed below. In addition, different individuals
may show certain signs or symptoms prominently at one point in the illness, while others
may appear at a later point, or not at all. For example, some people with Alzheimer’s
disease may have a great deal of difficulty with language, from relatively early in the
illness, while another individual may have fluent language until very late in the disease.
 
While individuals with different forms of dementia may show differences in the pattern of
signs and symptoms, compared to those with Alzheimer’s disease, the impairments
described below occur in nearly all types of dementia.
 
With these caveats, here is a description of some of the most common signs and
symptoms that occur in dementia.
 
Activities
“Activities” refers to the so-called instrumental activities of daily living (IADLs) and the
basic activities of daily living (ADLs).
 
Instrumental activities of daily living (IADLs) are higher-level functions, requiring a
greater degree of cognitive acuity, and tend to become impaired earlier in the disease
process. IADLs include such things as balancing a checkbook, paying bills, cooking,
shopping, using electronics (microwave, cell phone, ATM, and the like), and driving. Of
course, these don’t decline all at once. Nor is it the case that one day a person is
capable of performing a task and the next day is completely unable to do so. IADLs, like
everything else in Alzheimer’s disease and most other dementias, decline gradually,
although the impairment in a particular activity—driving, for example—may reach a
tipping point that alerts others to the problem. While behaviors are declining, the
individual is often unaware of it and may be quite resistant to the notion that something
is wrong. But when the tipping point is reached—an accident or getting lost while driving,
or having the power turned off because of neglecting to pay the electric bill, for
example—the individual is no longer able to hide his or her difficulties, and the family
may become aware, for the first time, that there are functional problems, along with
memory issues.
 
Driving is one of the more critical IADLs, as it involves vital issues of personal autonomy
and independence, personal safety, and the safety of others. Please see p. 211 for more
information.
 
Basic Activities of Daily Living (ADLs) include dressing, feeding oneself, using the
toilet, bathing and general hygiene, and walking. Usually these activities become
impaired later in the disease process, after the IADLs are already significantly
compromised. Dressing is frequently the first ADL to become impaired. Individuals with
moderate Alzheimer’s disease may have difficulties with choosing correct clothing; they
may, for example, put on summer shorts when it is snowing, put on two or three shirts
(“layering”), or put on a bra outside the shirt. If clothing is laid out, the individual may be
able to dress correctly, or may need some cueing (e.g., “Put on your socks before you
put on your shoes,” or “Let me help you with those pants” which are going on
backwards). As the disease progresses, the person may need assistance with tying
shoes or buttoning buttons. Later, it may become necessary for the care partner to take
over the task of dressing completely.
 
Problems with eating usually begin with the person becoming very messy at the table,
and progress to no longer recognizing the correct utensil for a particular food (e.g.,
attempting to eat soup with a fork), spitting food out onto the plate or the floor, and using
fingers to eat items that are not finger food (e.g., mashed potatoes).
 
Difficulty with toileting is, of course, a challenging issue for caregivers to handle. Males,
in particular, may urinate in inappropriate locations, such as the garbage pail, the sink, a
potted plant, or on the floor, because the toilet is no longer recognized or remembered.
Urinary incontinence often begins during the night, in bed, for both sexes, although this
can be variable. Urinary continence tends to be lost before bowel continence, but bowel
accidents may occur intermittently prior to losing continence entirely. Once people with
dementia completely lose bowel continence, caregivers frequently feel they can no
longer care for the individual at home; bowel incontinence is one of the chief precipitants
of nursing home placement, along with behavioral problems.
 
Usually, the final ADL to become impaired is the ability to walk, unless of course there
are physical reasons why this has already become difficult. Persons in the later stages of
dementia may literally become too cognitively impaired to know how to put one foot
safely in front of the other. They suffer frequent falls as a result, which of course can
lead to serious injury. If a person who falls is living at home with an aged caregiver, it
may not be possible for the caregiver to pick the person up, and 911 must be called.
Again, this scenario frequently leads to placement in a long-term care facility. Falls
occur, of course, in nursing homes as well, and can lead to serious injury; but at least
there are staff present who can get someone off the floor and immediately attend to any
injuries that may have occurred.
 
Behavior
It is estimated that at least 90% of people with Alzheimer’s will have one or more
significant mood or behavioral problems during the course of the illness. For other
dementias, the proportion of those with mood or behavioral problems may be similar or
even greater. The most common behavioral symptoms in Alzheimer’s disease and other
dementias are the following:
• Aggression
• Agitation
• Anxiety
• Apathy
• Delusions
• Depression
• Disinhibition
• Hallucinations
• Irritability
• Paranoia
• Restlessness
• Sleep disturbance
 
These are generally not separate psychiatric illnesses that happen to occur in persons
with dementia but are an integral component or complication of the disease itself. This is
why it is useful to think of most forms of dementia as neuropsychiatric illnesses, rather
than simply medical or neurologic ones.
 
Behavioral problems are understandably one of the most significant causes of stress for
caregivers. Dealing with behavioral problems can wear out the sturdiest caregiver. As
noted above, behavioral difficulties - particularly agitation in its various forms - and bowel
incontinence are the symptoms most likely to lead to nursing home placement. A more
detailed discussion of mood and behavioral symptoms, and approaches to managing
them, can be found beginning on page 119.
 
Cognition
Cognition refers to memory and thinking. Cognitive symptoms are the hallmark of
Alzheimer’s disease and most other dementias. The most frequent areas of impairment
are:
• Memory impairment (amnesia)
• Language disturbance (aphasia)
• Difficulty carrying out motor tasks despite intact motor abilities (apraxia)
• The inability to recognize people or places that should be familiar (agnosia)
• Difficulties with planning, initiating, or organizing, and problems in social
judgment (executive dysfunction)
 
Memory Impairment (Amnesia)
This is the memory impairment that is most characteristic of Alzheimer’s disease and
most other dementias. Recent, as opposed to long term, memory is most severely
affected. Individuals - at least until much later in the disease - are generally able to
register information, or immediately recall it. For example, a person with mild or
moderate Alzheimer’s disease can usually repeat a few words or a simple phrase
immediately afterward. But, particularly in Alzheimer’s disease, this content becomes
subject to “rapid forgetting” and after a few minutes’ delay can no longer be recalled.
This impairment in recent memory is often one of the first symptoms noted by family
members, and one of the most prominent early in the disease. It is the cause of the
repetitive comments or questions that can be so stressful for care partners. The
individual simply does not recall having recently made a particular comment or asked a
question, and/or does not remember the answer. Repetitiveness appears to increase
when the topic is one that causes anxiety. As the disease progresses, people forget
more and more rapidly, and may be unable to retain information for more than seconds.
 
Events from long ago may be remembered until quite late in the disease, particularly if
these events are especially meaningful, such as one’s wedding, graduation from college,
and so forth. For some care partners, the fact that memories from years ago are recalled
while events of the last few minutes or hours are forgotten seems counterintuitive, and
the care partner may feel that the individual is simply not trying hard enough or is using
selective memory—that is, choosing to remember certain things while forgetting the rest.
Occasionally people with Alzheimer’s who are defensive about memory impairments will
say that they forget intentionally, remembering only the things they want or need to
remember. This defensive type of comment is designed to help people feel more in
control of this frightening process, but it is not really under their control, at all.
 
As the disease progresses, more and more aspects of the past are forgotten, to the point
where a woman married for 50 years may forget her married name and only recall her
maiden name, for example. Eventually that may be lost as well, along with many of the
basic historical facts of one’s life. In this way, people with Alzheimer’s disease and other
dementias may gradually lose their sense of personal identity.
 
Language Disturbance (Aphasia)
Aphasia in dementia usually refers to a gradual decline of language abilities as the
disease progresses. Some degree of aphasia almost always occurs in Alzheimer’s
disease, and with variable frequency in other forms of dementia. Aphasia may begin
with occasional difficulty coming up with someone’s name. In fact, this is a common
symptom of aging in otherwise normal persons at midlife and beyond. In Alzheimer’s
disease, as well as in other dementias, however, the loss of names becomes more and
more pronounced, and other proper nouns are frequently lost as well. As the condition
further progresses, other common words may be lost or used incorrectly. The individual
may refer to “that thing you sit on” instead of finding the word “chair” or will refer to
wearing a “clock” or a “timer” rather than a wristwatch. Even though the language
difficulties may be quite apparent, often a care partner who knows the individual very
well will be able to discern what the person is attempting to say, although others who are
less familiar with the individual may have more difficulty. After a period of time, language
may become so disordered that it either conveys very little information (“empty speech”)
or makes little, if any, sense. This is usually a source of enormous frustration for both the
person with dementia and the care partner, although at times the person with the
disease does not seem aware that he or she is not speaking coherently. Eventually,
most afflicted individuals will have very little if any coherent speech, or speech may be
limited to a few over- learned social pleasantries (e.g., “I’m fine; how are you?”) or to
profanities, for example. Of course, as in all aspects of dementia, there is significant
variability from person to person. Some remain fairly verbal until quite late in the
disease, but others lose speech as an early manifestation of the illness.
 
Curiously, persons who have learned english as a second language will often revert to
their native tongue, either completely or intermingled with English, while their language
abilities are deteriorating. This can be true even in someone has spoken English
exclusively for many decades.
 
Persons with language difficulties usually maintain a greater ability to understand
language than to produce it. Occasionally, others will talk in front of someone who has
dementia as if the person is not present, particularly if he or she cannot speak very
coherently. It is important to remember that the individual may understand much more
than he or she appears to, and feelings can easily be hurt. On the other hand, it is also
important to keep in mind that the individual who has difficulty speaking may also have
difficulty understanding what is being said, particularly when multiple people are talking
at once, or talking rapidly (see the list of “Dos and Don’ts for Effective Communication”,
p.189).
 
Difficulty Carrying Out Motor Tasks Despite Intact Motor Abilities (Apraxia)!!
Apraxia involves the loss of the ability to perform a particular movement or series of
complex of movements, despite having the desire and the physical ability to do so. In
simple terms, the brain has a problem telling the muscles how to carry out a certain
action. Apraxia leads directly to impairments in ADLs and is a good example of how the
various domains of impairment - the A, B, and C’s - are intertwined. The desire and
intent to carry out the activity remain, but the cognitive ability - not the motor ability - to
do so is lacking. Apraxia may be involved in some failures of IADLs as well, such as not
being able to place a letter or a check in an envelope, seal the envelope, and put a
stamp on it. As apraxia worsens, much that has been taken for granted becomes lost,
and the individual needs increasing amounts of support with simple tasks. Care partners
sometimes do not understand how this can be a function of dementia, particularly if, for
example, yesterday or even earlier today the person could eat with his fork, but by
dinner this skill seems to have been lost. As with so many of the impairments in
Alzheimer’s disease and other dementias, there is great variability from person to
person, from one day to the next, and even from one time of day to another.
 
The Inability to Recognize People or Places that Should be Familiar (Agnosia)
Agnosia causes the person with Alzheimer’s disease or other dementia to be unable to
recognize people, places, or objects that should be familiar. This is not a visual problem
per se; it has to do with recognition and understanding of what is seen. As agnosia
worsens over time, as it usually does in Alzheimer’s disease, and many other dementias,
individuals who should be familiar - neighbors, more distant relatives - are not
recognized. Eventually, even immediate family members may not be recognized,
perhaps starting with children who live out of town and visit less frequently. Ultimately
even the spouse may not be recognized. Understandably, this is most upsetting for the
spouse, but it is also upsetting for the person with Alzheimer’s, who may feel that there
is a stranger in the house. As the process of agnosia is beginning, the individual may
have some sense that someone is familiar but cannot be exactly identified. Alternatively,
the nature of the relationship may become confused; a spouse may be seen as a mother
or father, or an adult son as a brother, for example.
 
Occasionally, the individual may be certain that the spouse, for example, is not around
but has been replaced by someone who appears quite similar, and may even have the
same name. This seems to represent an incomplete loss of recognition of the individual,
but can be very confusing to all concerned. At times the individual with Alzheimer’s may
feel that the person who lives with him is not his spouse (indeed, he may no longer recall
that he was ever married) but will feel that this person is a very good friend.
 
As these agnosias are developing, they can be transient, so that someone may not
recognize the spouse at one moment but a few minutes later will be able to identify him
or her correctly. It may be possible for an unrecognized spouse to merely leave the room
for a few moments and return, and then be immediately recognized. At other times, an
individual may not recognize his spouse visually but, when he or she speaks, will be able
to use the combination of auditory and visual stimuli to make the correct identification.
Occasionally, a person with dementia will be unable to recognize his or her own image in
a mirror or a photograph. When this happens, the person may believe that there is an
intruder in his home. If this is the case, all of the mirrors in the house may need to be
removed or covered, and it may be important to ensure that the curtains are drawn
before dark, so that the image reflected in the glass is not seen as someone prowling
around outside the home.
 
Agnosia occurs not only in regard to people but for places as well. Someone with
dementia may lose the ability to recognize his or her own house, and insist on going
home. This can lead to wandering, if the person goes out the door and down the street,
looking for home. At times, these individuals seem to have in mind a home where they
lived earlier in life, but that is not always the case. Occasionally, the individual will seem
to partially recognize the home, feeling that this house looks very similar, but is not
identical to the “real” home. Sometimes, persons with this sort of partial agnosia can be
reoriented by gently pointing out that it is, indeed, their house, but perhaps it doesn’t look
quite the same “in this light” or something of the sort. Most of the time, however, people
with these mistaken beliefs due to agnosias cannot be persuaded through the force of
logic, and trying to do so will only upset them.
 
Difficulties with Planning, Initiating, or Organizing, and Problems in Social
Judgment (Executive Dysfunction)
Executive function involves two broad areas. One has to do with the ability to initiate
behaviors, to maintain them, and to terminate them when appropriate. This also includes
the ability to know how to sequence steps to accomplish a task. The other broad area
has to do with judgment: that is, knowing - and caring - what is appropriate behavior in a
given social or interpersonal context. It also involves being able to make accurate
judgments of people and situations to protect one’s own interests.
 
Initiation.
Individuals with deficits in executive function (or, as it is called, “executive
dysfunction”) often have difficulty initiating behavior. This is directly related to apathy, a
prominent feature of Alzheimer’s disease and other dementias (see p. 127 for more
information about apathy).
 
Many people who are able, perhaps with help, to initiate an activity are unable to follow
the necessary steps to its conclusion. This leads directly to impairments in functioning.
Being able to follow the correct sequence of steps to review a bill, write out a check
properly, enter the check stub information correctly, address the envelope, put a stamp
on it, and mail it is an example of a complex sequence of behaviors that requires
executive ability, and one that is frequently impaired even in early Alzheimer’s disease or
other dementia. Another breakdown of proper sequencing coming somewhat later in the
disease would involve being unable to follow the correct steps to get dressed in the
morning, even with all of the clothes laid out on the bed. This can lead to significant
frustration on the part of the individual who is trying to get dressed and can also be quite
stressful for the care partner when it becomes necessary to dress the person entirely.
 
Judgment.
The other critical area of executive functioning involves judgment, which
requires a number of high-level cognitive abilities. It is often impaired in subtle or not-sosubtle
ways early in the course of disease. Impairments in social and interpersonal
judgment lead directly to a wide range of behavioral problems and conflicts with others,
while impairments in the ability to correctly judge other people and situations can make
someone vulnerable to exploitation (see p.209).
 
A number of the behavioral problems (see p.117) may occur because of lack of social
appropriateness. Thus, someone who is unable to perform a given task might not simply
feel some sense of frustration internally, but might become quite angry, possibly verbally
abusive or aggressive, in response. Mace and Rabins, in The 36-Hour Day (2012), have
called this type of response a “catastrophic reaction”; indeed, to judge from the
individual’s behavior, it would seem that a catastrophe had occurred, when it may be no
more than a minor matter. Such emotional storms seem to come from nowhere, or in
response to even mild stressors. Individuals who react this way are unable to recognize
and carry out the socially appropriate response to a given situation; and they may also
be unable to stop their reaction due to their executive dysfunction.
 
Other examples of impaired social judgment include people who curse in settings where
they might never have done that before, or make off-color or bigoted remarks in the
presence of those who would be offended. Persons with more advanced disease in
nursing homes may walk in the halls undressed, masturbate publicly, make sexually
inappropriate comments to staff, or make unwanted sexual advances to staff or other
residents.
 
It is sometimes impossible to tell if the individual does not recognize that a given
behavior is offensive to others, or if he or she knows that others are offended, but lacks
appropriate concern about that. This lack of awareness or concern for the feelings of
others leads some to view the person with Alzheimer’s as self-centered, unkind, or even
somewhat sociopathic. These labels certainly lead to a great deal of negative feelings
toward the individual and do not help with managing the situation. It is important to
understand that these behaviors, as distasteful as they may be, are symptoms of the
illness rather than willful or morally corrupt behaviors. This awareness may help control
the anger that is often generated, and lead to more appropriate ways of dealing with the
situation.