Posts tagged: planning

What’s Up with Mom?

Business Logo for Psychological and Neuropsychological IssuesWhat’s up with Mom?  We moved her into a new apartment over the weekend, and she is not like anything or anyone I’ve seen before.  She is so confused she has forgotten to eat; sitting and staring for hours, or up at night and wondering the hallways.  All the children take shifts supervising her, but the situation does not appear to be resolving.  It tears me up to see her like this.  What is worse, the our family is splitting down the middle; some favor keeping her in the apartment no matter what arises, and the rest believe she should be in a nursing home.  I don’t know where to turn.

This is a paraphrased narrative that I have heard literally hundreds of times.  Neurologists of old called this the “Monday Morning Disease.”  It refers to family that did not notice a loved one becoming senile until some change in their environment produced confusion.  Most families will report changes in the patient’s behavior over a one to two year period prior to an incident, only they did not ascribe them to a senile dementia of the Alzheimer’s type.

One of the earliest symptoms of Alzheimer’s to escape the notice of others is a deficit of planning.  It is not as noticeable as memory or attention deficits, yet it causes profound functional impairment.  As long as the dementia victim relies on old well-learned behavioral routines, there is minimal trouble living independently.  Once a person’s daily behaviors are upset by a move, they must develop new functional behaviors that accomplish goals necessary to live; for example, shopping for food.  In a new environment, the person lacks clues to their old behaviors, and so are at a complete loss for where to go and what to do.  Many cognitive scientists (fancy term for psychologist) conceptualize humans as planning machines.  As you read this post, you may also be thinking of what you are going to do next, and you may even formalize the steps to accomplish this goal.  Children burst with plans for what they will do after school.  Do not mistake deficient planning for a lack of energy or optimism.  Planning is a necessary cognitive skill for survival, and it is one of the earliest functions to decline in a senile dementia.

Another early cognitive deficit is a decline of mental flexibility.  This is not to be confused with someone who is easygoing and complaint with the wishes of others.  Cognitive flexibility refers to a person’s ability to switch between mental sets; for example, glancing at a drawing and putting together a model.  It is a necessary skill we all employ every day to accomplish tasks with greater efficiency and accuracy.  It is evident while doing the dishes and answering the telephone, alternating between tasks at work, and making conversation while driving.  When this skill declines, the person is noticed to be performing behaviors that are out of character with the situation.  In my residency, the team was to discharge a patient to independent living when I noticed he had taken apart his shaver and laid it across his bed.  The patient missed several physical therapy sessions due to his insistence he had to fix the shaver.  The shaver was busted, but he could not conceive of working alternately on the shaver and his ambulation.  He became obsessed (stimulus bound) to the shaver; neglecting more important goals that he had to accomplish.  While it may appear as a failure to prioritize his goals, this unfortunate man could not accomplish the main goal because he was stimulus bound to an unimportant goal.

The early deficits of a senile dementia are subtle, yet as real and damaging to an independent existence as the deficits of verbal and visual memory.  The latter deficits are well known to the average person.  Memory skills are the main determinant of Alzheimer’s Disease in most people’s minds.  Actually, verbal and visual memory may be functional well into the disease, and these “executive” deficits of planning and flexibility may be crippling at an earlier stage of the disease.  In terms of planning the future for someone with a known or suspected senile dementia, the family should take these symptoms into account.  It reduces the probability of a Monday morning surprise.  Please leave comments regarding this post in the space provided below.

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