The Four A’s of Alzheimer’s Disease

Families and friends dealing with a loved one’s dementia often see the Four A’s of Alzheimer’s disease during their interactions. The behaviors presented through the Four A’s can at first, appear very confusing to us. But once we understand what is happening in our loved one’s brain that is causing these behaviors, we can begin to track and stage the disease process.
For most persons with any type of dementia, these are the order in which the A’s will present themselves.

Amnesia – the inability to use or retain memory, including short term and long term memory.

The person may constantly repeat questions such as “Where am I?” and “Who are you?” and “When are we going to eat?” or accuse the caregiver of stealing or being an imposter. This type of behavior can continue for hours at a time. This process occurs from damage to the Frontal lobes and the Hippocampus. The Frontal lobes store memory, personality, cognition, impulse control, speech, attention, rational thought, imagination and judgment. The Hippocampus allows us to learn any new information, such as being able to remember the answer to the question “Where are we going.”
This is usually the first area of change noticed by families and the “A” which has most likely caused verbal or physical abuse within the family structure. In this beginning level of Amnesia, the person with dementia does not look ill, so the confusion and inability to remember can appear to be purposeful and is often interpreted by us as just “annoying” behavior.

Aphasia – the inability to use or understand language.

The person will use the wrong word, or complete a story with phrases from another story, or provide a lengthy description of an item because he/she cannot find the right word. He/she may call family members by the wrong name, which increases the family’s anxiety and concern. This word finding difficulty will increase until all language use is lost. This is associated with damage to the Temporal lobes and the Frontal lobes. The Temporal lobes control hearing, language and smell. The left lobe holds formal language and the right lobe controls automatic speech (yes and no), singing and cursing. The left lobe is generally destroyed first leaving the person with dementia the ability to communicate with swearing and singing.

Agnosia — the inability to recognize or use common objects or people.

The person may become lost in a familiar place because he/she doesn’t recognize the items that alert us to our surroundings. He/she may confuse a fork with a spoon, a toothbrush with a hairbrush or toothpaste with denture cream. Eventually the ability to recognize objects is lost completely. The person may also confuse a son with a husband or a father or an uncle, or a daughter may be confused with a mother or an aunt or a grandmother. This process is associated with increased damage to the Frontal lobes, the Occipital lobes (visual association, distance and depth perception) and the Temporal lobes.

Apraxia – the inability to use or coordinate purposeful muscle movement or coordination.

In the early stages the person may reach for an item and miss it. He/she may have difficulty catching a ball or clapping his/her hands. The floor may appear to be moving to this person and balance becomes affected, increasing the risk for falls and injury. In time, this loss of ability to move affects the Activities of Daily Living (sleeping, ambulating, toileting, grooming, hygiene, dressing and eating). In the end stage, the person is not able to properly chew or swallow food, increasing the risk of choking or aspiration. This is linked to damage to Parietal lobes (pain, touch, temperature and pressure, sensory perception) and the Cortex (skilled movement) and the Occipital lobes.

Article provided by:
Tam Cummings, M.S.