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ily may mistakenly date an abrupt onset of dementia to the time of the intercurrent illness Loss of social graces and indifference to social customs occur, but usually later in the course of illness Judgment becomes impaired, early in some, late in others At certain phases of the illness, suspiciousness or frank paranoia may develop Although more typical of advanced cases, on occasion the rst indication of an oncoming dementia is the expression of paranoia for example, relating to being robbed by cleaning help or to the in delity of a spouse When the patient s condition is probed by an examination, there are no signs of depression, hallucinations, or illogical ideas, but memory and problem solving are found to be de cient The troublesome ideas then persist throughout the illness Also more typical of late disease but an early feature of certain degenerative dementias, visual and auditory hallucinations, sometimes quite vivid in nature, may be added Wandering, pacing, and other aimless activities are common in the intermediate stage of the illness, while other patients sit placidly for hours As a rule, these patients have little or no realization of the changes occurring within themselves; ie, they lack insight As the condition progresses, all intellectual faculties are impaired; but in the most common degenerative diseases, memory is most affected Up to a certain point in the illness, memories of the distant past are relatively well retained at a time when more recently acquired information has been lost (Ribot s law) Eventually patients also fail to retain remote memories, to recognize their relatives, and even to recall the names of their children Apraxias and agnosias are early and prominent in certain degenerative conditions, occurring only later in Alzheimer disease, and these defects may alter the performance of the simplest tasks, such as preparing a meal, setting the table, or even using the telephone or a knife and fork, dressing, or walking Or, language functions may be impaired almost from the beginning of certain forms of dementia Lost is the capacity to understand nuances of the spoken and written word, as are the suppleness and spontaneity of verbal expression Vocabulary becomes restricted and conversation is rambling and repetitious The patient gropes for proper names and common nouns and no longer formulates ideas with well-constructed phrases or sentences Instead, there is a tendency to resort to cliches, stereotyped phrases, and exclamations, which may hide the underlying defect during conversation Paraphasias and dif culty in comprehending complex conversations are almost universal abnormalities Subsequently, more severe degrees of aphasia, dysarthria, palilalia, and echolalia may be added to the clinical picture As pointed out by Chapman and Wolff, there is loss also of the capacity to express feelings, to suppress impulses, and to tolerate frustration and restrictions If the patient is restrained, disagreeable behavior, petulance, agitation, shouting, and whining may occur Well known to physicians is nighttime confusion and inversion of the normal sleep pattern, as well as increased confusion and restlessness in the early evening ( sundowning ), as described in Chap 20 Any febrile illness, drug intoxication, surgery, or metabolic upset is poorly tolerated, leading to severe confusion and even stupor an indication of the precarious state of cerebral compensation (see Beclouded Dementia, page 363) It would be an error to think that the abnormalities in the atrophic-degenerative dementing diseases are con ned to the intellectual sphere The patient s appearance and the physical examination yield highly informative data The rst impression is often revealing; the patient may be unkempt and unbathed He may. birt ean 13 BIRT Barcode Plugin for eclipse BIRT versions 2.x, 3.x and 4.x
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