Because Alzheimer’s disease can only be diagnosed by ruling out everything else, doctors often rely on the presence of related indicators. In addition to the changes that occur to memory and cognitive abilities, people with Alzheimer’s also experience significant impairment to visual (agnosia), speech (aphasia), and motor skills (apraxia).
Additional Symptoms For the purpose of ease these significant impairment indicators are known as the “A” Triad. The “A” Triad comprised of agnosia, aphasia, and apraxia, is often the most accurate clue that a person with signs of dementia actually has Alzheimer’s disease. The combined effect can lead to further emotional problems, such as anxiety, paranoia, hallucinations, frustration or irritability, anger, aggression or violence, withdrawal, pacing, restlessness and eventually to wandering. All of these behaviors are based on an unmet need or discomfort that is not being resolved.
Agnosia is the loss or reduction of the brain’s ability to interpret vision accurately. Our eyes do not actually “see”; our eyes act as a camera, which transmits information for the brain to interpret. With Alzheimer’s disease this interpretation process becomes altered. Even though the information being transmitted remains the same and the eyes and optic nerve suffer no injury, the brain will no longer process that information in the same way. Our elderly may misrecognize her grandchildren as her children. They may no longer recognize their home, car, spouse, children or beloved pet.
This is particularly important for the law enforcement officer or search and rescue worker to know. Many times a missing person with Alzheimer’s has disappeared while on a routine errand, a customary walk, or from a familiar place. It is important to realize that as agnosia develops, a person will lose the ability to record or recognize changes, even when it occurs slowly.
An Agnosia Example: Mary always walks along Fifth and Vine Street; however, road construction has begun and Mary is forced to walk on the opposite side of the street. Even though Mary walks the same route every day, she now must view the street in an entirely different manner and she may not be able to do so. When Mary is unable to do so, she is no longer able to get back home because her usual references have disappeared.
Family members will often tell the Alzheimer’s interviewer that their Alzheimer’s love one will not cross a certain street. As a result, it is quite common for the Search Commander to set up boundaries along these given barriers. It is a dangerous fallacy to believe that a person who has agnosia, who does not recognize friends or family, will somehow recognize that they should not cross a certain street.
Persons with agnosia who still drive will often drive the wrong way on a street, drive onto a highway using an exit ramp, misread street signs, brake inappropriately or drive erratically.
Important questions to ask the family members during an interview include “Has your mother ever mistaken your children for hers?”, “Has your father ever not recognized common items, such as a key to his home?”
Aphasia is the loss or reduction of the brain’s ability to use and interpret language appropriately. Aphasia may manifest in many ways. A person with aphasia may drop words during the course of conversations such as “I go store with you?” They may substitute similar words for more common terms such as Medium Aged, instead of Middle Aged.
Frequent usage of vague terms such as “thing,” “there,” “that,” or nonspecific naming, such as “he,” “she,” or “it” may also demonstrate language deterioration.
Aphasia Example: Alzheimer’s Person says, “I want that thing over there.” Caregiver replies, “What thing? The watch? Book?” Alzheimer’s: “That thing!” Caregiver: “Where? On the dresser? On the table?” Patient: “THERE!”
Aphasia may include the use of sexually explicit, profane or other socially inappropriate language that would be atypical of the patient’s past use of language.
Aphasia Example 2: an elderly white female with Alzheimer’s encounters a police officer of color. She is not likely, as her language regresses, to refer to the officer as an African American or black officer. Instead, she is more likely to use one of the several offensive terms more commonly used during the 1950s, 1960s, or 1970s. By understanding that this may simply be part of her aphasia progression, the officer is less likely to react and escalate an already tenuous situation.
Persons with Alzheimer’s may revert to a primary or native language (particularly a language from childhood); this is important to know as your Alzheimer’s love one may be completely unresponsive in English, but become quite animated and talkative in another language. Furthermore, persons with Alzheimer’s may become responsive only to certain terms or phrases.
Aphasia Example 3: Franklin will only respond to being told, “Mrs. Barnes wants to see you”, or Kathryn will only come when she hears “Here, kitty, kitty, kitty!” an apparent nickname from her childhood.
Some persons with Alzheimer’s will lose all ability to use spoken language; however, there is nothing physically wrong with their vocal cords. They may not speak at all, but sing perfectly on key with the appropriate words. Even as they are normally silent, they may scream, moan, shriek, bark like a dog, or make other sounds.
It is most important for everyone, especially search and rescue personnel or law enforcement officers to recognize that symptoms may seem mild when at home, where the person is well fed, cared for, warm and comfortable. However, when in the field, the person with Alzheimer’s may often be overly cold or hot, agitated, angry or fearful, and their symptoms will worsen. Someone who has normal or only mildly limited verbal skills in a pleasant setting may lose language entirely when out of their comfort zone.
Apraxia is the loss or reduction of fine motor skills. A person with apraxia will have difficulty with basic life skills, such as dressing themselves, making a sandwich or eating, bathing, brushing their teeth or performing other basic hygiene. The Alzheimer’s person may look disheveled and unkempt and have the appearance of a homeless person. Coupled with aphasia and/or agnosia, apraxia may cause law enforcement to misinterpret a contact with the Alzheimer’s person as just another homeless encounter and actually transport the person with Alzheimer’s to a shelter or County Mental Health. Historically, it was not uncommon for police to transport persons with Alzheimer’s to jail, having failed to recognize the disease and its manifestations.
Apraxia Example: a 75 year-old male comes to the attention of law enforcement for exposing himself to a woman in a park. The man comes out of a public bathroom with his pants unzipped and exposed. He approaches a woman and makes grunting noises at her, gesticulating at his pants. Further investigation reveals the gentleman to have Alzheimer’s disease, suffering from moderate agnosia and apraxia, with severe aphasia. He had wandered away from his home. His primary caregiver is his daughter, whose hair coloring resembles that of the woman in the park. The gentleman can take himself to the bathroom, but cannot reassemble himself after urinating. It is habit, in his home, to toilet by himself and then come to his daughter for help in re-dressing.