The A’s of Dementia Part II: Agnosia & Apraxia

Agnosia: Inability to Recognize Common Objects of People

Agnosia takes place as the frontal, occipital and temporal lobes of the brain become damaged. Behaviors associated with this “A” mean the brain develops an inability to recognize and use common everyday objects.

One example that illustrates the confusion between common objects is mistaking a toothbrush for a hairbrush. The brain may become confused because both items are brushes, or because both brushes are found in the bathroom. Maybe it is because both have handles and bristles and they are used for something around the head area.

Think about pens and pencils. These are easily confused too. Each instrument is held in the hand and each leaves marks on paper. Although this may not seem like much of a problem, the difference between signing a check with a pen and signing a check with a pencil can be costly.

Every day, without even thinking about it, we use a variety of objects to accomplish everything from cleaning and grooming to cooking and eating and more. Gradually, the ability of how to use these tools is lost by changes in the brain. The files are destroyed.

Take eating utensils, for instance. As an infant and then young child, you were fed liquids and then pureed food. As your coordination got better and your chewing skills developed, you were given finger foods or began to learn how to use a spoon. After the spoon, you began to use a fork, and finally a fork and knife.

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As dementia progresses, your loved one will take this journey again, but in the reverse order. She will go from knowing how to use a fork and knife to knowing only how to use a fork. She will then use a spoon, but eventually she will forget how to use utensils completely and will start eating with her hands. Near the end of the disease, she will have to be fed by a caregiver.

As dementia progresses, she will become lost in familiar places. When this occurs, she will have difficulty recognizing rooms in her home, such as a bathroom, or the purpose of these rooms. She may not be able to find her way from her home to the store. She may get lost in the town where she has lived for decades.

She will probably have difficulty recognizing family members and other people she once knew. What we are talking about here goes beyond the memory lapses of amnesia.

With agnosia, the Alzheimer’s brain has lost its ability to translate what the eyes see or to find the file that contains information about a person, making it impossible to determine if someone is familiar. In the later stages, many dementia patients do not recognize any family members or even themselves.

If you follow my blog or read my articles on LinkedIn, you might remember Martha who didn’t remember getting married or having a daughter. When she looked in the mirror, she became alarmed about the old lady in her bathroom. In actuality, the old lady was Martha. However, because her brain was using files from when she was only 24 years old, she no longer recognizes herself. It is not unusual for an affected person to refuse to go into the bathroom because “someone” is already there. Or you may witness her having a conversation with the person in the mirror or getting annoyed with the stranger in the window who refuses to talk to her.

How Would You Feel?

The problems caused by the A’s can cause extreme anxiety for those who suffer from dementia. Imagine how frightening the world would be if you could not recognize food items, a toothbrush or toilet, clothing, a vacuum or stove, or rooms in your own home.

Imagine how frightening the world would be if you suddenly realized when out on a walk or drive that you had no idea where you were or how to get home safely. Can you imagine how scary the world would be if people you no longer recognized regularly appeared in your house and tried to make you eat food or take a bath or change your clothes?

As difficult as it is, you must understand when someone doesn’t recognize an object such as a toilet, or a person as important as her own husband or child, that person is not pretending or being stubborn. Instead of getting frustrated or mad, you’ll need to try and find a way around the problem. For objects and rooms, you might try putting labels on them, though this will only work for a while.

Dealing with the inability to recognize people, however, is more complicated. If someone you didn’t know suddenly appeared in your house, you would be frightened. You might try to fight off the stranger or you might scream for help. Chances are you would want the police to assist you. 

It is not uncommon to hear reports about physical altercations between spouses when a wife doesn’t recognize her husband and starts beating the so-called home invader with a broom, or when a husband physically pushes his wife out of the house because he didn’t recognize the person in his bedroom as the woman he has been married to for many years.

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Interestingly, while a woman has been trained throughout life to call out for help or protect herself physically when discovering a stranger in her home, a man faced with the discovery of a strange woman in his house usually has a different response.

Often times he will remember being married, but doesn’t recognize this woman as his wife. What he does know is he had better get this new woman out of his house before his “real” wife gets home or he’ll have “hell to pay.” This socialization of sexes means wives can be at risk to be physically hurt by husbands and vice versa. In addition to the physical pain, it is also very difficult to have your spouse not recognize you. It can be heartbreaking.

Conversation Tips

One way to try and deal with people recognition problems is to give a person clues that may help her brain make some sort of connection. For example, you might start a conversation with your mom something along the lines of this: “Here’s a picture of dad and me from when we visited the Grand Canyon. I’m your daughter Terra, and I remember standing on the edge of the canyon while you took pictures. Wow did you yell at me to get away from the edge!”

With this type of greeting, you have given your loved one a variety of social and memory clues, such as your name, a reminder of her husband, a memory about a trip, or a laugh from how she fussed at you.

This sort of social greeting is much more appropriate than starting a conversation with “Do you know who I am?” or “What’s my name?” or any other number of questions that challenge the person with dementia.

Two things are wrong with this approach. First, the person is already burdened by trying to make sense of a confusing world. Directing questions toward someone who cannot answer them because of damage to her brain by dementia just adds to the confusion. It increases paranoia and can increase verbal or physical agitation as a result. Remember suspicion is also a part of dementia. 

Second, social skills function until late in the disease, that is, they are deep in the file cabinet. Not being able to answer questions like “Hey do you know who I am?” is embarrassing and humiliating. Those feelings can cause a person to withdraw further. Think about how you feel when you’ve bumped into someone you’ve met before but could not remember his or her name.

Chances are you were embarrassed and frustrated while you tried to pretend you knew that person. Meanwhile your brain was frantically searching for the information you needed about that person. Someone with dementia experiences these same feelings over and over, until that is lost too.

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Apraxia: Inability to Use Coordinated and Purposeful Movement

When your loved one is unable to carry out routine motor tasks, such as turning on the TV, tying her shoelaces, brushing her teeth, moving in and out of a chair, walking or standing and turning, chewing or swallowing food or controlling her bladder or bowel, in spite of the fact that she has the physical capacity and the desire, she is experiencing the effects of apraxia.

Medically speaking, apraxia is the inability of the prefrontal motor cortex and the parietal lobes of the brain to coordinate purposeful movement. In other words, both the lower and upper parts of the brain that integrate the information needed to perform movements are deteriorating and no longer able to send movement signals to the muscles. This causes a type of disconnect between the idea of a task and the execution of the task.

Signs of apraxia also signal that Alzheimer’s is completing its circular route through the brain and has left its mark in the front (frontal lobes), back (occipital lobes), bottom (temporal lobes) and top (parietal lobes) areas.

You see apraxia when someone picks up a glass of juice and is unable to move it to her mouth. Fine coordinated hand movement is lost. Instead, she may pour her drink onto the table or in her plate of food. She may even be unable to hold the glass at all. Likewise, she may grab onto something, like a caregiver’s wrist, with more intensity than needed and then be unable to let go or release her grip.

Apraxia also impacts a brain’s inability to tell the body how to stay in balance while standing, walking or sitting.

Falls and Dementia

One consequence of damage to the parts of the brain that control movement is that a person’s risk for falls (and injury from falls) becomes a real concern. When added to continuing deterioration of the occipital lobe and resulting loss of peripheral vision and depth perception, a person’s gait will begin to change. Steps become shorter and eventually she may not lift her feet from the floor at all as she moves.

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As the brain is damaged from dementia, the person cannot safely maneuver. Trying to force her to stand when she says she can’t only increases the risk of falling, except now you may get hurt as well if she falls with you. Falls are not a sign of poor care; they are an indicator of infection, delirium, or the progression of the disease.

Remember, even if a person knew how to walk this morning or just a moment ago, because her brain can’t find the right pathway of signals, she may not be able to walk in this moment. Accusing her of “faking” her abilities is cruel. People with dementia are doing the best they can every moment of the day. They don’t, in spite of how it may appear, have the ability to pretend or fake a behavior.

Falls are a part of the disease. They are scary and can cause bruising to the brain (hematoma or contusions). Falls can be deadly because of the impact of the head on the floor. Seizures, stroke activity, internal bleeds, double vision and an increase in amnesia can all result from a fall.

Remember as the disease progresses, the brain structure inside the cranium is smaller. When the head strikes the floor, for example, the whiplash effect means the brain is actually bouncing inside the cranium from the front to the back, a double blow known as contra coup trauma.

Broken hips can result from a fall or may trigger the fall. Let me explain. When people with advanced dementia stand, they may turn suddenly, causing the body to twist at the hips. Frail and fragile bones can literally snap below the ball joint, resulting in a “twist and turn” fracture. The person then falls and the appearance or common belief is that the broken hip was a result of the fall. In reality, the broken hip caused the fall.

In time, apraxia affects all muscular movement. Facial features will become flatter as the brain will not be able to send signals to the face to make the subtle movements that are interpreted by professionals as “affect.” A person also slowly loses the ability to perform any of her activities of daily living, i.e., sleeping, ambulating (walking), toileting, grooming, hygiene care, dressing, and eating. This means her physical capabilities along with her mental capabilities will transition from those of an adult, to those of a child, to those of a newborn baby.

The A’s Mix Up

The A’s tend to follow the order of amnesia, aphasia, agnosia, and apraxia because of how the disease is moving through the brain. Just remember one “A” does not go away when another “A” starts.

Instead, they begin to overlap and occur together. Remember the earlier example of a misplaced purse that ended up in the freezer? Amnesia caused mom to forget where she put her purse. The reason the purse ended up in the freezer was a result of agnosia because she didn’t recognize the purse as a purse at that particular time nor did she recognize that the refrigerator as the wrong place to store a purse.

Lorraine’s Story

Lorraine became an agitated and anxious lady as dementia worked its course. She had been married to a career Air Force colonel. A widow for 20 years, she had never remarried. Her husband’s photo, a beaming young man in uniform standing next to his newly married wife, sat next to her bed. It was the first thing she looked at each morning and the last thing she touched each night. Lorraine also had been a successful clothing buyer for a large department store chain.

One day she came to my office and after several minutes and much effort on her part to speak, I figured out she was missing a pair of pants. Because I knew she had been a clothing buyer, I thought I could figure out what pair of pants she was missing by naming every type of material I could think of. Sounds like a good plan, right?

I asked her if she was missing her wool pants and she shook her head ‘No.” I asked about her corduroy, silk, and knit pants. Again she shook her head “no” each time. I asked her if she was looking for dungarees (people from Lorraine’s generation didn’t wear blue jeans; they wore dungarees).

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Her struggle to speak resulted mostly in gibberish until she finally was able to blurt out, “Army pants! My army pants!”

During World War II, the military wore khaki uniforms. Lorraine’s files in her brain were full of military information. Part of the files existed because she lived through WWII and part of her files had khaki pants because her husband was a career officer.

I opened her closet door, which required pulling the handle towards me and slightly to the left and looked in the dirty clothes hamper. There they were. Lorraine literally clapped her hands with glee when she saw the pants.

Lorraine’s story shows us how the A’s will overlap as Alzheimer’s progresses. When Lorraine couldn’t remember where her pants were, she was suffering from amnesia. When she couldn’t find the words to say she was trying to find her khaki pants, she was experiencing aphasia. When she didn’t recognize the pants must be in the dirty clothes hamper or know what the hamper was, agnosia was at work. Apraxia meant she couldn’t perform the movements required to open the closet door.

The brain’s processing of information through the course of amnesia, aphasia, agnosia and apraxia is difficult and challenging for caregivers. Think of the inability to remember a word (amnesia) and the inability to understand a word (aphasia) or the inability to recognize a fork as a fork (agnosia) and the inability to use it properly (apraxia).

Dementia Behaviors Appear Random

Another reason dementia behaviors are tough is they seemingly come and go with no particular pattern as the brain works to find – sometimes successfully – alternate pathways to process information.

For example, your mom may not recognize you for several days in a row and then, out of the blue, call you by name and ask about her grandchildren by name. Then the next day, she’s back to referring to you as her mother. This back and forth is extremely hard on families and caregivers especially because they never know exactly when the alternate pathways will succumb to the disease and the ability for their loved ones to recognize them will be gone for good.

With Alzheimer’s and other dementias, the damage taking place in the brain is not visible to us, thus making our leap to understanding behaviors all that more difficult. For this reason, try to cherish the good moments and recognize the challenging ones as the disease and not your loved one.

So let’s add one more big “A.” Anosognosia is the inability to recognize impaired function in memory, general thinking skills, emotions and body functions. This means your loved one really doesn’t remember (not denial) she has dementia. As the disease progresses she doesn’t remember that she has a brain illness.

Tam Cummings, PhD, Gerontologist

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