Mohammed T. Abou-Saleh

238 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYdementia, suggesting that naming difficulties may precede memoryfailure. Whether the common difficulty in finding proper namesexperienced by the over-50s 15 is related to the later onset ofdementia, or is merely a manifestation of ‘‘AAMI’’, has yet to bedetermined. Perseveration in AD is much less common thanconfabulation. Difficulties in understanding, as well as in finding,some words increase during the dementia, until finally there isalmost total incomprehension and incoherence. Difficulties inreading and writing may precede those affecting the spoken word.Loss of intellect is traditionally demonstrated by psychometrictests, which show a greater impairment of ‘‘performance’’ than‘‘verbal’’ IQ 16 . It is also exposed by difficulty in defining conceptsand explaining similarities in the course of cognitive testing. Ineveryday life it is mainly manifest in illogical thinking and ofteninconsistencies, e.g. ‘‘I live with my mother’’. ‘‘How old is she?’’‘‘Oh, in her 80s’’. ‘‘But how old are you?’’ ‘‘I’m 82’’. ‘‘Then you’reabout the same age as your mother?’’ ‘‘That’s right!’’ There is afailure to draw appropriate deductions from environmental cues:a shopping expedition is undertaken in pitch dark, or, despite theblizzard evident outside the window the season is stated to besummer. A lack of ‘‘common sense’’ contributes to the increasingdependency.Judgement and creativity are early casualties of dementia, and agood sense of humour may be the first loss. Taste in music, art,reading, clothing and decor may be coarsened, so that the patientwears a garish or incongruous garment, comes back from theshops with a tatty ornament which clashes with the fastidiouslyappointed living-room, only reads familiar books or gives up TheTimes for a tabloid newspaper. Exploitation by unscrupulouscallers, who offer a few pounds for valuable heirlooms, is all tooeasy. Wills are changed without due regard for those who mighthave expected to inherit, in favour of some parvenu opportunist,causing deep hurt, disappointment and disputation when thepatient has died. Judges and physicians become erratic andunreliable and artistic activity ceases or becomes facile, empty andrepetitive.Agnosia contributes, with amnesia, to disorientation. A failureof recognition of faces (prosopagnosia), places and objectsbewilders the patient and his/her carers. Apraxia presents asdifficulties in dressing—clothes are put on, if at all, in the wrongorder, back to front and upside down—and feeding: knife andfork may have to be replaced by a spoon, and the patient maythen use his/her hands or lap food from the plate. Apraxia mayaffect walking, when there is difficulty in judging the height ofsteps, or a change in the covering or the colour of the floor may beperceived as a step.A personality change is not inevitable in AD, neither is italways for the worse. Occasionally, those who recognize theirlimitations and the need for others’ help become less dominantand assertive and more docile, mellow and biddable. Commonly,however, as the dementia progresses the range of responsesnarrows, animation and spontaneity are subdued into apathy andindifference; the unpleasant label ‘‘vegetable-like’’ can apply.Some people become uncharacteristically coarse and disinhibited,swearing and using obscenities. There may be frequent, noisy,seemingly insatiable demands. Irritability, reproaches and angryoutbursts can devastate and mystify carers. Regression indementia facilitates the crude use of mental mechanisms, notablydenial and projection: problems are denied or blamed on others.‘‘There’s nothing wrong with my memory—why, I can rememberyears back. It’s other people who muddle me up by trying to catchme out. If they’d just leave me alone I’d be all right’’. A loss ofinsight, however, is not inevitable in AD, or not until loss oflanguage prevents its expression. Alzheimer’s original patientsometimes declared that she could not understand anything, andmany sufferers are similarly painfully aware that there is somethingterribly wrong with their health.Disordered behaviour is often the most distressing andchallenging aspect of progressive AD 17 . Behavioural andpsychological symptoms of dementia (BPSD) are strong predictorsof caregiver burden and psychiatric morbidity 18 . Someforms arise understandably from personality change and cognitivedeficits, while others might be core features of the dementia 19 .Studies based on those patients or clients referred to health andsocial services are likely to find disordered behaviour more oftenthan in those who manage or are managed without such help athome, although few epidemiological studies assess behaviour aswell as cognitive deficits. O’Connor et al. 20 found that amongcommunity residents in Cambridge, UK, such disturbed behaviouras demanding attention, repeating questions, using badlanguage, noisiness, temper outbursts, physical aggression andnocturnal wandering increased with the severity of dementia: 7%of those with mild disorder were aggressive and 42% of theseverely demented.Withdrawal and reclusiveness can have a protective function forthose who find that the complexities of their former life are nowbeyond them. Self-neglect and squalor may be the inevitableconsequence of incompetence and lack of help, often because it isrefused, although sometimes demented people who live withothers are reluctant to wash themselves or to change their clotheswhen it is time they did. Hoarding and clutter may result becauseof difficulty in taking the decision to throw rubbish away. Leavingthe gas on, carelessness with cookers and inadvertent fire-raisingare simple, although dangerous, consequences of forgetfulnessand impaired judgement. Verbal abuse and acts of aggression areconsistent (although still alarming) with explosive irritability, andthe ‘‘catastrophic reaction’’ to exposure of cognitive incompetencein those who robustly deny it makes some sense, both as a form ofprotest and as a defence. Disinhibition—social, being excessivelyoutspoken, tactless, fulsome or critical, yawning and nodding offduring a conversation or a meal and departing from a gatheringprematurely and abruptly; minor shoplifting (although this maybe partly due to dysmnesia); and, occasionally, sexual disinhibition,taking the form of stripping, exposure, open masturbationand importuning—cause carers and companions various degreesof embarrassment and shame. Noisiness may be associated withboredom, deafness, the desire for attention or depression (seebelow). Interfering with appliances and destructiveness may be aperverted form of ‘‘do-it-yourself’’! Strange actions like talking tothe reflection in the mirror as if it were another person and tophotographs as if they were real people may be partly attributableto prosopagnosia.Wandering and incontinence, two of the most troublesomebehaviour disorders, are often overdetermined. Wandering mayarise from utter boredom and underactivity; it is difficult tointerest someone who can no longer read or enjoy television orradio and who is discouraged from going out alone for a walk orto the shops, lest they should get lost. Wanderers might have beenin the habit of taking a walk with the dog or to buy cigarettes or apaper, at that time of day. They may be seeking their home even ifactually at home; it may not be recognized as such, and there is avain, vague, poorly (if at all) articulated quest for the home wherethey used to live. Wandering is sometimes a sign of agitateddepression (see below) and occasionally a wanderer may be tryingto get away from a loaded bowel! Restlessness towards nightfall(‘‘sundowning’’) and nocturnal roaming 21 by patients who haveno idea of the time and are bored as well as restless, are aparticular strain on carers 22 .Incontinence of urine may occur for other reasons thandementia—stress incontinence, the frequency of a urinary tractinfection, polyuria from diabetes or a prescribed diuretic. Theforesight to urinate when the chance arises may have been lost, thelocation of the lavatory forgotten, or a vaguely similar place (like acupboard or a storeroom) used in its stead. In advanced dementia