2. Dysnomia The forgetting of words, especially proper names, may first bring the patient to a neurologist. Later the difficulty involves common nouns and progresses to the point where fluency of speech is seriously impaired. Every sentence is broken by a pause and search for the wanted word; if the desired word is not found, a circumlocution is substituted or the sentence is left unfinished. When the patient is given a choice of words, including the one that was missed, there may be a failure of recognition. Repetition of the spoken words of others, at first flawless, later brings out a lesser degree of the same difficulty. The defect in naming is evident with even simple tests, for example, asking the patient to generate a list of farm animals or car brands—a test that may elicit only 3 or 4 responses. A more extensive examination entails asking the patient to name as many items as possible in a subject category in 1 min—for example, vegetables, tools, or clothing. Alzheimer patients fall well below 8 items in any 1 category or 25 items total if asked to give names in all 3.
3. Visuospatial disorientation Parieto-occipital functions are sometimes deranged in the course of Alzheimer disease and in a few cases may fail while other functions are relatively preserved (see Mendez et al). When it occurs in a pure form it is termed posterior cortical atrophy, as discussed in a later section (see Renner et al).
As remarked above and in Chap. 21, prosopagnosia (impaired facial recognition), losing one’s way in familiar surroundings or inability to interpret a road map, to distinguish right from left, or to park or garage a car, and difficulty in setting the table or dressing are all manifestations of a special failure to orient the schema of one’s body with that of surrounding space. Exceptionally, there is a neglect of stimuli in one visual field. In the late states, some of these patients develop the Balint syndrome or Gerstmann syndrome (Tang-Wai et al; McMonagle et al).
4. Paranoia and personality changes Occasionally, at some point in the development of Alzheimer dementia, paranoia or bizarre behavior assumes prominence. This may appear before the more obvious memory or language defects announce themselves. The patient becomes convinced that relatives are stealing his possessions or that an elderly and even infirm spouse is guilty of infidelity. He may hide his belongings, even relatively worthless ones, and go about spying on family members. Hostilities arise, and wills may be altered irrationally. Many of these patients are constantly worried, tense, and agitated. Of course, paranoid delusions may be part of a depressive psychosis and of other dementias, but most of the elderly patients in whom paranoia is the presenting problem, seem not to be depressed, and their cognitive functions are for a time relatively well preserved. Social indiscretions, rejection of old friends, embarking on imprudent financial ventures, or an amorous pursuit that is out of character are other examples of these types of behavioral change.
5. Executive dysfunction This may be the most disabling of the main aspects of the disease and when it appears early on, is not specific to Alzheimer dementia as it is a component of several other processes that affect the frontal lobes. These patients display early difficulties in coordinating and planning tasks and following complex conversations or instructions. They may become disinclined to participate in social activities and become withdrawn or quieter than usual. As the problem advances, simpler and formerly automatic actions such as driving become problematic for the patient; the degree of insight varies. Some are able to express that they feel “confused” but more often, it is the family that brings these changes to attention.