21 COGNITIVEDISORDERS 521
◗ SYMPTOMS OFDEMENTIA
- Loss of memory (initial stages, recent memory
loss such as forgetting food cooking on the
stove; later stages, remote memory loss such
as forgetting names of children, occupation) - Deterioration of language function (forgetting
names of common objects such as chair or table,
palilalia (echoing sounds), and echoing words
that are heard [echolalia]) - Loss of ability to think abstractly and to plan,
initiate, sequence, monitor, or stop complex
behaviors (loss of executive function): the client
loses the ability to perform self-care activities
tia affects remote memory; clients forget the names
of adult children, their life-long occupations, even
their names.
Aphasia usually begins with the inability to name
familiar objects or people then progresses to speech
that becomes vague or empty with excessive use of
terms such as “it” or “thing.” Clients may exhibit
echolalia(echoing what is heard) or palilalia(re-
peating words or sounds over and over) (APA, 2000).
Apraxia may cause clients to lose the ability to per-
form routine self-care activities such as dressing or
cooking. Agnosia is frustrating for clients: they may
look at a table and chairs but are unable to name
them. Disturbances in executive functioning are evi-
dent as clients lose the ability to learn new material,
solve problems, or carry out daily activities such as
meal planning or budgeting.
Clients with dementia also may underestimate
the risks associated with activities or overestimate
their ability to function in certain situations. For
example, while driving clients may cut in front of
other drivers, sideswipe parked cars, or fail to slow
down when they should.Onset and Clinical Course
When an underlying, treatable cause is not present,
the course of dementia is usually progressive. Demen-
tia often is described in stages:- Mild:Forgetfulness is the hallmark of
beginning, mild dementia. It exceeds the
normal, occasional forgetfulness experi-
enced as part of the aging process. The
person has difficulty finding words,
frequently loses objects, and begins to
experience anxiety about these losses.
Occupational and social settings are less
enjoyable, and the person may avoid them.
Most people remain in the community
during this stage.
Jack Smith, 74, and his wife Marion, 69, have been liv-
ing in their home and managing fairly well until lately.
The Smiths have two grown children who both live out
of town but visit about every 2 months and at holidays
and birthdays. Jack recently had a stroke and entered
a rehabilitation facility to try to learn to walk and talk
again. Marion wanted to stay at home and wait for his
return, but when the children would call to check on her,
she would often be crying and confused or frightened.
On one visit, they found her looking very tired, dressed
in a wrinkled dress that looked soiled. She looked as if
she had lost weight and couldn’t remember what she
had eaten for breakfast or lunch.
Marion’s daughter remembered that before her fa-
ther had the stroke, she noticed that Jack had taken over
several routine tasks her mother had always done such
as making the grocery list and planning and helping to
cook their meals. Her mother seemed more forgetful and
would ask the same questions over and over and often
related the same story several times during their visit.
A few weeks after Jack entered the rehab center and
Marion was living at home alone, the neighbors found
Marion wandering around the neighborhood one morn-CLINICALVIGNETTE: DEMENTIA
ing lost and confused. It was now clear to her children
that their mother could not remain in her home alone
and take care of herself. It was uncertain how long Jack
would need to remain at the rehabilitation center, and
they were not sure what his physical capabilities would
be when he did return.
Her daughter decided that Marion (and eventually
Jack) would come to live with her family. They moved
her in with them, but even after getting settled at her
daughter’s home, Marion continued to be confused and
often did not know where she was. She kept asking
where Jack was and forgot her grandchildren’s names.
At times she grew agitated and would accuse them of
stealing her purse or other possessions. Later she would
always find them. Marion would sometimes forget to go
to the bathroom and would soil her clothes. She would
forget to brush her hair and teeth and take a bath and
often needed help with these activities. When her daugh-
ter came home from work in the evening, the sandwich
she had made for her mother was often left untouched in
the refrigerator. Marion spent much of her time packing
her bags to go home and “see Jack.”