The normal aging process does not create major deficits in the intelligibility or the appropriate organization of speech. However, those persons who are afflicted with Alzheimer’s disease are atypical because the undergo brain changes in areas that appear to be highly associated with memory and language. The mechanical components of speech production remain relatively unaffected by Alzheimer’s disease until the final stages of the disorder. It is disturbance in the meaningfulness of language that is most pronounced throughout the progression of the disease.
The major aspects of disrupted communication arising in Alzheimer’s disease are language problems that result from cognitive decline. One of. the first problems to occur involves the forgetting of appropriate words or the use of “pseudowords” in place of the forgotten item. For example. person might use the term pencicle to describe a ballpoint pen, or the term firebugs to describe matches. There is also difficulty naming objects, particularly specific names. The Alzheimer patient, for example, may be able to identify a picture as that of a dog, but not as that of a “collie,” which is a higher order name. The communication problem is not one of articulation but a deficit in generating the appropriate words with which to convey information on a symbolic level.
The Alzheimer patient is generally unaware of these communication problems; his/her speech is frequently characterized by an empty, aimless, quality. Much of this pointless vocalization is the result of verbal wandering characterized by repetitive speech with little comprehensible meaning. The spoken words are produced correctly and with appropriate fluency but with limited ability to communicate meaningfully .
As the disease progresses, problems will occur in generating words. naming objects, and recognizing meaningful relationships. For example - forks, knives, and spoons may no longer have a relationship to one another for a person experiencing the symptoms of Alzheimer’s disease. He or she may begin to engage in echolalia, repeating the same word or phrase over and over. These verbal repetitions will occur with little or no comprehension of what was said. Echolalia may progress to the point where vocalizing deteriorates to repetitious syllables that are unrecogniz able as language.
With Alzheimer’s disease there is also a decreased ability to recognize some of the pragmatic aspects of speech. Pragmatics involve the rules of speech and language as they apply to usage. Adjusting one’s rhetoric to suit the audience, not standing too close to the listener, and using body language to help convey intentions are all part of the pragmatics of communication. Other examples of pragmatics include asking questions by using the appropriate inflection, or greater emphasis being placed on certain statements by the way words are spaced and timed. Lacking awareness of the pragmatics of a certain situation, a person night not respond in the desired or appropriate manner.
In advanced stages of Alzheimer’s disease communication has progressed to such an extent that the individual is essentially mute. Spontaneous speech may all but cease, and echolalic behavior is quite common. At this point the patient may have difficulty even with the physical generation of speech sounds.
Since many Alzheimer patients have trouble communicating, it is actually quite common that problems as visual impairments go unnoticed. This is completely unnecessary, since it is relatively easy to correct, and the impairment can be quickly confirmed with an examination by an eye care practitioner.
A very common and convenient method of correcting visual impairments today is the contact lens. Contact lenses don’t fall off and break like glasses, they don’t obstruct movements, and they are very soft and comfortable to wear. Thanks to the huge market, modern contact lenses also have come down a lot in price, and are now very affordable, with many cheap lenses to choose from.
Soft lenses can be replaced daily, or worn for up to a month without taking them out, which takes away the need for care, cleaning and maintenance. They also “breathe”, or let in much oxygen to the eye, which creates less irritation, tired eyes and infections. Contact lenses correct most kinds of visual impairments, like myopia, hypermetropia, astigmatism and presbyopia, and the advanced optics give a very sharp vision. To buy contact lenses, simply make a quick internet search, and you will find a great assortment of brands and types.
It is well known that the population of the United States is rapidly aging. As greater numbers get older, there is an increase in the number of people who develop dementia. By far the most common dementia is Alzheimer’s disease and there are also the less frequently occurring dementias, such as those associated with small strokes resulting from arteriosclerosis (so-called hardening of the arteries). The treatment of dementia becomes one that must be approached from many perspectives. The patient, the patient’s family, the family doctor, other medical specialists, social workers, home health providers, and physiotherapists must work together to improve the general outlook for the patient. The goals of treatment include maintaining the physical health of the patient by treating other diseases that may worsen the dementia, alleviating dementia symptoms whenever possible, and providing a social and physical environment that will allow the highest possible level of functioning.
Although there are few specific studies of exercise programs for individuals with dementia, a number of studies have been conducted that show that a routine exercise program benefits people of all ages, particularly older individuals. Although it is optimal to start an exercise program in the younger years and to continue throughout adulthood, it is never too late to begin exercising.
A sedentary lifestyle presents a definite risk for heart and blood vessel disease. There are many areas of normal aging that are really not aging at all but due to inactivity. It has been proven that forced inactivity (illness or incapacity) has many of the same characteristics of so-called normal aging. These include increased loss of bone calcium, decrease in oxygen use, decrease in the output (the amount of blood pumped per beat) of the heart, decrease in red blood cells (anemia), and a decrease in glucose tolerance (tendency to diabetes mellitus). Decreased activity is also associated with increased blood pressure, increased body fat, and elevated cholesterol levels.
It is important to note that health benefits can be shown at relatively low levels of activity. The greatest improvement demonstrated is between the least active individuals and those who are moderately active in other words, from no activity to some activity, however minor. Much less beneficial effect is apparent between the moderately active and the very active. To reach true fitness for the heart and blood vessels, the aging patient should have fifteen to twenty consecutive minutes of exercise at least three times per week. The exercise should be of an intensity that increases the heart rate to 75 percent of its maximum rate. The maximum heart rate can be calculated roughly by subtracting one’s age from 220. The goal is to reach 75 percent of this figure (or 220 - age x .75). There should always be a careful physical evaluation of any individual past the age of forty who undertakes an exercise program. This evaluation is more important as one grows older and even more important for the demented elderly. However, since this level of exercise will be difficult or impossible to attain in the patient with Alzheimer’s disease or multi-infarct dementia, a careful physical examination without a stress test would be acceptable if the patient is unable to take such a test.
Alzheimer patients sometimes act in ways that bring them into conflict with criminal authorities. Such actions as wandering the streets and forgetting to wear proper clothing may attract the attention of police and other law enforcement personnel. In the criminal law there is generally a requirement that an individual must demonstrate criminal intent and know that what he is doing is a crime. If he does not know what he is doing then his legal responsibility diminishes. The consideration of intent will not prevent the police from arresting or detaining an Alzheimer patient, however, nor will they reduce the family’s need to try to prevent such events from occurring, but they may relieve the family of some of the anxiety that such behavior may generate.
The power of attorney allows an individual to act through others; it permits the individual upon whom the power has been conferred by the court to make decisions pertaining to someone’s real and personal property as though the true owner had so decided. Some states do not allow a power of attorney to continue after an individual becomes incompetent, while other states do if there is a provision in the power of attorney that authorizes its continuance even when the person becomes incapacitated.Trusts offer another method through which an individual can permit others to assume partial or full control over financial matters. One or more persons can be named to manage their property, income-producing assets, bank accounts, and other financial matters. The use of a trust arrangement allows an individual to avoid an appointed guardian in the event that he becomes incapacitated. This is the ultimate form of preplanning for the contingency of incapacity. To initiate a trust the family will require the services of an appropriate financial institution, such as a bank or trust company, as well as an attorney.
If taste sensation has diminished, try using foods that vary in texture and temperature.
Enhancing the flavors of foods with spices can increase the acceptance of foods by those patients whose taste acuity has decreased.
The sense of different tastes (sweet, salt, bitter) are best perceived at body temperature. Patients will be more aware of different flavors if food is served at body temperature (rather than normal serving temperatures).
Serve colorful and attractive foods. Foods taste better if they are attractive.
Along with a decline in taste and smell, the Alzheimer patient may not be able to determine the temperature of food or beverages. Therefore, check the temperature (especially for beverages) before serving This practice will avoid burns.
Make use of the professionals in your community. They are there to help. Psychologists may assist you in resolving family conflict, reducing behavior problems, making difficult decisions about nursing home placement, and diagnosing and treating depression or anxiety of the caregiver. Physicians and nurses may provide answers regarding medical treatment, nutrition, and safety. Attorneys may be consulted regarding estate planning, guardianship, and living wills. Your local Area Agency on Aging will assist you in obtaining government services. Geriatric care managers, who are usually registered nurses or trained social workers, can assess the needs of elderly people, find services for them, and visit them in their homes. Your Alzheimer Association can teach you how to advocate for research and more government assistance for long-term care. Your congressmen and representatives can join you in seeking laws that protect families with catastrophic illnesses.
Not all caregivers seek out the resources that are available in the community. This may be especially true of minority groups, although the incidence of dementia is similar across cultures. In one survey, only 19 percent of minority caregivers had contacted an agency for assistance in locating and arranging services for family members with dementia. Educational materials sensitive to cultural differences and better reach out programs to minorities are needed.
Though proper nutrition will not cure Alzheimer’s disease, it is neverthe-less vital to the patient’s well-being and may help to prevent the onset of other complications including malnutrition and pneumonia. Caregivers should be aware that medications may interfere with the absorption or utilization of nutrients and, over prolonged periods of time, could lead to some nutritional deficiencies. The advice of a physician or pharmacist may be needed concerning possible drug/nutrient interactions.
We must also remember that although the patient is in a demented state, he or she may at times be perfectly lucid. The patient should always be treated with dignity, respect, and concern for individual self-worth.
A useful way to remember nutritional support for Alzheimer patients is “Mealtimes”:
M- Maintain a routine
E- Eat well-balanced meals
A- Alertness to any nutritional problems
L- Light and frequent meals
T- Teach the caregiver how to deal with the patient
Virtually all behavioral methods for improving patient functioning derive from two traditional behavioral paradigms. The first is called the classical or respondent model of learning, and is most associated with Ivan Pavlov, a Russian psychologist active in the 1920s. This paradigm focuses on behaviors that are largely involuntary and controlled by the body’s autonomic nervous system, Examples of such behaviors include salivation, heartrate, and emotional states.The second behavioral paradigm is called the operant model, and is usually associated with B. F. Skinner, an American psychologist active from the late 1930s to the 1980s. This paradigm focuses on behaviors that are conscious, voluntary, and purposeful, and are controlled especially by the cerebral cortex. Speech and all observable motor behaviors (except reflexes and involuntary movements) would be included.
This model reasons that all voluntary behavior is influenced by its context. That is, through experience, individuals learn that observable environmental conditions make it possible to guess pretty accurately whether a particular behavior by the organism will bring to it a pleasant or unpleasant consequence. This idea is summarized as “SORC,” which stands for Stimulus (also called discriminative stimulus, antecedents, cues, or prompts) Organism (the abilities and limitations created for an individual by its genetic, physiological, historical, and social characteristics) Response (the behavior itself ) Consequence (also called reinforcement, reward, punishment, and the like).
Examples of such operant learning pervade our lives. We all recognize the discriminative stimulus of a phone ring. We respond by picking up the phone and saying hello because we have so often been reinforced for such behavior by hearing the caller’s voice. Experiencing the sight, sounds, and smells (cues) of a ball game in a ballpark elicits specific behaviors (like cheering) that may be considered strange in other contexts. Many common situations become cues for us to choose to act in specific ways, and then reward us for so acting.
Most instances of voluntary, inappropriate, learned behavior by dementia victims involve the patient responding to whatever cue is most noticeable and subjectively relevant at the moment. So, for example, seeing a door, especially a glass door or open door, will attract any patient who is restless and enjoys walking, or who feels lost and wants to go home. The door is a cue that elicits exiting behavior because, in previous experience, walking-through-door behavior has led to gratification in the form of strolling or getting home.
Learning becomes random when caregivers allow the links (also called contingencies) between desired patient behaviors and pleasant consequences to weaken or dissolve. If caregivers do not carefully insure that pleasant consequences follow most acceptable actions, random environmental events will establish haphazard, even dangerous, new rules for patients to live by. For example, when the patient’s dementia causes a decreased sense of social propriety, and caregivers do not provide the patient with structured activities, several behaviors are likely to emerge because they are available on the patient’s own body, and because they feel good. Some are often unacceptable, such as skin scratching, nose-picking, anal digging, and masturbation. Others are sometimes acceptable, unless their frequency is very high, such as patting, rubbing, rocking, walking, and tapping. These self-stimulatory behaviors are self-reinforcing, and usually indicate inadequate environmental stimulation .
Much undesired patient behavior is inadvertently reinforced by caregiver attention. Speech-such as questions, statements, or moans-that is disruptively loud or repetitive almost always results in increased caregiver attention. Contrary to common sense, waiting longer to respond to the patient for such behavior may actually strengthen, rather than weaken, the behavior. This is because it trains the patient that extensive responding is simply required to gain the attention reward.
It is crucial to realize that these two behavioral paradigms, the classical and the operant, are useful in understanding the development of both appropriate, desirable behaviors, and inappropriate, undesirable, even self-destructive behaviors. By applying these concepts to the secondary symptoms shown by dementia victims, in what is called a fimctiol1al analysis of behavior, it is possible to both understand the behavior better and design interventions that may improve the patient’s behavior.
In dementia sufferers, learning is, by definition, very inefficient. Therefore, it is vital that caregivers continually enable, prompt, and reward appropriate behavior.
Before we can attempt to “improve” memory functioning, we must first understand the different processes involved in forming memories. The ability to retain information from previous experience is one of our most important abilities on which our capacity to adapt and function effectively in different situations depends. Most people tend to think of memory as a single mental function, when in fact many mental processes are involved. First, we must attend to something before we can acquire information about it. Depending on the complexity of the information, some rehearsal may be required before it can be retained. Once acquired, this information is stored in what scientists have called immediate or short-term memory, where information we have just been exposed to is retained. Beyond this is a process of storage, where information in immediate memory is consolidated and finally retained in remote or long-term memory. When in the future we are exposed to familiar circumstances, we may retrieve certain information, such as the last meal ordered at a certain restaurant, or the like. Thus, memory involves attending, acquisition, rehearsal and finally, retrieval. Disruption of anyone aspect and memory will be impaired to some degree.
Experts often refer to a distinction between semantic and episodic memory. Semantic memory involves information that is based on language, word knowledge, verbal concepts, and is independent of references to time or place. Episodic memory, in contrast, has to do with personally experienced events labeled in terms of time and place, such as a baseball game, a doctor’s appointment, or a day at the office. Scientists who have studied memory in different age groups have noted that younger individuals rely more on episodic memory, whereas older persons use semantic memory more heavily. It is also known that there are different brain centers for verbal, or language-based, information, and for nonverbal, or visuospatial information (forms, objects, geometric shapes, and directions). As we grow older our ability to deal with and recall nonverbal types of information declines, and with it our memory for shapes, forms, directions, and the like.
One can also distinguish between recent or remote memory. Recent memory refers to our ability to recall or recognize information or events within minutes, hours, or days, whereas events that occurred or information gained years ago are considered examples of remote memory. Unless some special area of the brain is damaged, our remote memories stay with us, even in the face of brain injury or neurological disease of the central nervous system. In contrast, our ability to retain recent information typically declines with age and with most diseases affecting the brain. In addition, depression can cause reversible impairments in recent memory.
Finally, whereas conscious memory for events and visual or language-based information (scientists call this declarative memory) declines with Alzheimer’s disease, the ability to learn how to do things involving habits and simple routines, is preserved. An example of this noncoscious procedural memory would be dressing, doing physical therapy exercises, or grooming sequences. However, while an Alzheimer’s patient could learn new motor behaviors of these kinds, he or she very well might not have any recollection of where or with whom the learning took place.
Memory Aids
Studies of the “normal” aging process suggest that, as we age, we may lose as much as 20 to 40 percent of our ability to deal with novel, unfamiliar situations and problems, spatial information, and recall of recent events. It also appears that older individuals stop using certain kinds of strategies for learning and recalling information that those with excellent or younger memories may use extensively. In recognition of this, psychologists specializing in the study of memory have developed some techniques for improving and enhancing memory functioning. Most of these techniques involve increasing the number of associations around the information we desire to retain. For example, making up a silly rhyme in connection with a certain word we need to remember may help us recall that word. The phrase Every good boy does fine helps us to remember the full notes E, G, B, D, F on the musical scale. Conjuring up an image that in turn is connected with some other kind of information (e.g., noting a resemblance between a certain person’s face and features of a particular animal) may facilitate memory for that information. For caregivers it is crucial to keep in mind that Alzheimer’s disease may keep the patient from generating helpful associations of either a verbal or nonverbal kind. In short, any memory improvement technique that depends upon new learning or novel experience should be regarded with caution, as the value of the approach will be quite limited.
In the case of Alzheimer’s disease, memory is progressively impaired in a generally predictable order. Recent memory, especially for unfamiliar visuospatial information will be the first to deteriorate. Whereas the Alzheimer patient will seem to have a good memory for events that occurred in childhood or in earlier adulthood, he or she may get lost repeatedly, ask the same question, or never recall phone conversations or messages. As the condition worsens, gaps in remote memory may occur, even to the point that family members may not be recognized. Ultimately, even habits such as dressing and eating are disrupted and eventually lost.
Physical Aids
The order in which memory deteriorates, from the most unfamiliar and novel to the most repetitive experiences and behaviors, gives us a strategy for dealing with the Alzheimer patient. First, any enhancement technique that depends on new learning and recent memory is likely to fail, which may only frustrate and aggravate the problem. Where new things have to be learned, use of external aids, such as taking notes, will work best. For recall of time-related events, such as appointments, a calendar and even a digital alarm (some of which can be programmed to specify the information to be remembered), can help substitute for missing functions in the Alzheimer patient.
Association Aids
For the Alzheimer patient, making new bits of information part of old, well-known, and frequently repeated routine may help cue (elicit) recall of important new information. For example, having the patient take a new prescription at a time that had originally been set aside for administering a vitamins (for example, at breakfast), or when teeth are to be brushed (which places the patient in proximity to the medicine cabinet), would make it more likely that the medicine would be taken.
Backward Chaining
Learning new locations can be particularly difficult, or even beyond the capabilities of an Alzheimer sufferer, but a method called backward chaining has been helpful with some demented patients. Normally we learn to get from one place to another by learning various cues in a forward progression, from point of origin to destination. Backward chaining involves the opposite process, where the patient is taken first to the destination on repeated occasions, then familiarized with prominent locations increasingly distant from the destination and closer to the starting point. In a hospital setting, this initially might involve taking a patient from the bed, directly under supervision to the destination-say, the occupational therapy area. Subsequently, the patient would be taken to the closest landmark along the way, which might be the nurse’s station, from which point the patient would try to get to the occupational therapy area. This backward progression or “chaining” would be continued until the patient could walk from his or her room to various destination points with minimal or no supervision.
February 5, 2008 
Posted in Alzheimer's Disease Disorder 
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