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Chapter 2
Brain and Behaviour
Dr. John Puxty
Dr. Ken Le Clair
Dr. Marie-France Rivard
BPSD – Handbook for Family Physicians
BPSD – Handbook for Family Physicians
Chapter Index
Overview .....................................................................................................1
Key Concepts .............................................................................................1
Understanding Brain and Behaviour: A Structural/Functional
Approach .....................................................................................................2
The Frontal Lobe ............................................................................................ 3
The Temporal Lobe ........................................................................................ 5
The Parietal Lobe ........................................................................................... 6
The Occipital Lobe.......................................................................................... 7
The Cerebellum, Brain Stem and Sub-cortical Regions ................................. 8
The Limbic Region.......................................................................................... 9
The 7A’s of Dementia .............................................................................. 10
1. Anosognosia: No Knowledge of Illness or Disease .................................. 10
2. Amnesia: Loss of Memory ........................................................................ 11
3. Aphasia: Loss of Language ...................................................................... 12
4. Agnosia: Loss of Recognition ................................................................... 13
5. Apraxia: Loss of Purposeful Movement .................................................... 13
6. Altered Perception .................................................................................... 14
7. Apathy: Loss of Initiation .......................................................................... 15
Summary .................................................................................................. 16
Table: Summary of Brain Function and Behavior ......................................... 16
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Overview
This chapter explains the impairments and behaviours that are commonly seen in dementia
through a structural/functional approach; that is, by an exploration of the regions of the brain
and their functions. In addition, it introduces the “7 A’s of Dementia”, which is a handy tool for
describing the losses in dementia and the associated behaviours. A summary chart of the
brain regions, their functions and characteristic dysfunctions, appears at the end of the chapter.
Key Concepts
As a consequence of the impairments and losses caused by damage to the brain in dementia,
the individual experiences a different “reality” than others around him or her. In addition, these
deficits can precipitate a variety of negative emotional states such as frustration, fear, confusion
or anger. Subsequently, the individual may express a variety of behaviours that are known as
the “Behavioural and Psychological Symptoms of Dementia” (BPSD). Informal and formal
caregivers are often challenged by these behaviours and may misinterpret them as being
volitional or intentional. They may consequently respond in ways that are damaging to the
individual with dementia.
1. The physician can play a key role in helping caregivers to understand that these
“challenging” behaviours are not wilful or intentional, but rather occur as a result of an
“illness” or “malfunction” of the brain, and represent an individual’s adaptive response to a
negative stimulus in their physical or social environment.
2. Depending on the type and progression of dementia, different behaviours and impairments
are expressed to a greater or lesser degree. For example, individuals with fronto-temporal
dementia present with significant behavioural problems, perseverative behaviours and
language difficulties early in the course of the disease. An awareness of the prominence
and timing of the expression of certain behaviours assists the physician to:
• detect the presence of dementia
• determine the type of dementia
• guide conversations about care planning with the individual, family, and collaborative
care team.
3. A useful way to guide the understanding of common behaviour changes in dementia is to
consider the functions of the three levels of the “Developmental Brain”:
• cortex and/or forebrain (The Thinking Brain)
• midbrain (Emotional Brain)
• the lower brain or brain stem (Instinctual Brain)
In Alzheimer’s disease, as the cortex or forebrain (Thinking Brain) becomes impaired,
behaviours associated with the midbrain (Emotional Brain) and lower brain (Instinctual Brain)
become more evident. Stressful situations are therefore more likely to evoke emotional
responses such as irritability, emotional lability and sexual disinhibition or instinctual responses
such as rummaging/hoarding, fight or flight, and territoriality.
Appreciating these realities helps us to more meaningfully interpret the behaviours of a person
with dementia as responsive rather than wilful, purposeful or perhaps even vengeful. This
approach can also provide insights into predicting behaviours and exploring appropriate care
strategies to prevent, or should they occur, to support the negative consequences of these
behaviours for the person, his or her family and others.
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Understanding Brain and Behaviour: A Structural/Functional
Approach
© Copyright CSAH 2009
Figure 1: The lobes of the brain.
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The Frontal Lobe
© Copyright CSAH 2009
The frontal lobe controls “executive functions” like planning and organization,
initiation or changing activity, and insight. It also regulates emotional responses,
personality and socially appropriate behaviour, and is responsible for “expressive
language”.
Frontal Lobe Dysfunction
Planning and organization
Difficulties in planning and organization lead to an inability to plan and complete basic tasks
such as activities of daily living, or more complex tasks, such as planning a holiday or a dinner
party. Way-finding may be challenging for the individual, even with familiar routes.
Initiation
An inability to initiate activity may be misconstrued by caregivers as laziness,
uncooperativeness, or even depression. The person with dementia may appear uninterested in
doing anything, even previously enjoyed activities and hobbies. This lack of initiation (apathy)
can be a tremendous source of caregiver strain. Spouses or other family members may believe
that the person is unwilling to contribute to household chores (as they no longer take the
initiative to offer help) or pursue activities on his or her own (which would free the care provider
to attend to his or her own activities).
Perseveration
In contrast to the inability to initiate an activity, perseveration may occur, which is the inability to
stop an activity. Perseveration affects not only behaviour (rubbing hands together or tapping a
table), but also language (perseverating on the same story or word) and emotions (a frustrating
experience early in the day can lead to frustrated mood all day). Perseverative behaviours are
often frustrating for caregivers.
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Caregivers can be encouraged to initiate activities that incorporate perseveration into a more
appropriate or meaningful activity, such as folding laundry, flipping through a catalogue,
magazine or photo album, or sanding a small toy. Similarly, triggering positive emotions at the
beginning of the day through a pleasant demeanour (smiling caregiver), and engagement in
positive and meaningful conversation (reminding the person of previous accomplishments,
funny anecdotes, and important loved ones), will significantly increase the likelihood that this
positive mood will persist throughout the day.
Insight
The frontal lobes provide feedback and insight about how a person is performing. Incorrect
feedback may create a false belief that there is nothing wrong, and cause the individual to
refuse assistance, where assistance is actually required. Often, refusal of assistance may be
delivered in the form of a verbal outburst. Caregivers, understandably, are often hurt by these
angry exchanges, and struggle to contain these emotions while providing care. Furthermore,
apologies are usually not forthcoming since the person is unable to appreciate the impact of
their actions on others.
When the spouse is the main caregiver, he or she may have lost his or her long “confidante”
and may not be able to vent such feelings to anyone for some time. This issue needs to be
addressed with care providers. Suggestions to improve care providers’ wellness may include
stepping back and taking a “time out” to deal with their emotions before pursuing care, finding
an empathetic ear to vent those feelings on a regular basis, or using humour or relaxation
techniques to diffuse these emotions.
This lack of insight may cause an individual to be rather impulsive in thought, affect, and action.
Regulation of emotions, personality, and socially appropriate behaviour
Frontal lobe impairment can lead to socially challenging events, such as verbal outbursts or
inappropriate sexual behaviours. These behaviours tend to occur in response to a stimulus
where the individual is unable to hold back initial responses. For example, in a person with a
“normal” frontal lobe, a stimulus that causes acute intense pain (e.g. stubbing one’s toe) may
lead to an over-ride of the frontal lobe and cause use of uncharacteristic language or display of
anger. In an individual with an impaired frontal lobe, a stimulus of much lower intensity such as
discomfort or hunger may cause the same or more extreme behaviour.
Emotional lability and mood changes with swings in emotions to quite mild stimuli are often
present in frontal lobe dysfunction.
Language expression
With impairment in the frontal lobes, the individual loses vocabulary and has difficulty with
expressing language and articulating speech, finding the right word, and word order (expressive
aphasia). There is a poverty of language and it is non-fluent in flow.
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The Temporal Lobe
© Copyright CSAH 2009
The temporal lobe controls language comprehension, and memory. Impairments in
this region cause difficulties with expression and comprehension, an inability to learn
new things, and a loss of long-term memory from most to least recent.
Temporal Lobe Dysfunction
Language comprehension
Hearing is affected in temporal lobe damages, as is the ability to comprehend language and
remember words (receptive aphasia). The individual has difficulty organizing verbal information
and selectively attending to auditory and visual input. The person may forget what has been
said and may repeat things or ask the same question over and over. Often the flow of language
is fluent but it lacks meaningful content (gibberish). Persistent talking may be a behaviour
associated with temporal lobe dysfunction.
Memory
Short-term memory impairments lead to an inability to learn new things, and, as a result,
difficulty adjusting to new situations. For example, if the person moves to a new home or a
long-term care home, he or she may have trouble orienting to new surroundings, and may
encounter difficulties finding the correct bedroom or the bathroom.
With progressive dementia loss of long-term memory may result in a person becoming
disoriented in a setting that may have been familiar for a number of years. The individual may
look for the familiarity of previous environments such as the home he or she grew up in, thereby
asking to “go home” (to his or her parents) while in his or her own home.
The loss of long-term memory and temporal lobe damage is also associated with the loss of
ability to do familiar things (apraxia) such as use tools, the stove etc., which may present
significant safety issues. Visual memory is affected as well, as the person may no longer
recognize familiar faces (agnosia). More information on aphasia, amnesia, apraxia, and agnosia
is found in the “7 A’s of Dementia” section further in this chapter.
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The Parietal Lobe
© Copyright CSAH 2009
The parietal lobe is the analysis and perception center of the brain, integrating
sensory information in order to formulate the meaning and relationships of language,
numbers, people, objects, and places.
Parietal Lobe Dysfunction
Analysis and perception
With damage to the parietal lobes, the individual has difficulty integrating sensory information in
order to perform reading, writing, drawing, constructing, or calculating. In addition, the ability to
recognize familiar places, objects and people is impaired (agnosia) because the person has
difficulty integrating and interpreting the sensory information. The individual may be unable to
appreciate the extent or existence of their deficits (anosognosia).
Organization and sequencing of language and activities
Parietal lobe damage results in an inability to perform activities in sequence. While the person
may be able to complete individual steps, he or she may be unable to put all of the steps
together to complete an activity (apraxia). Care providers may have to give ”step-by-step”
directions to allow the person to complete tasks without direct assistance.
Calculation and manipulation of numbers
The parietal lobe is responsible for the ability to use numbers. When impaired, activities such
as using the telephone, paying bills, or calculating financial transactions become difficult.
Visuo-spatial perception and planning
Spatial perception, the ability to know how close or how far one is from an object, becomes
impaired. An abnormal “clock drawing test”, which is evidence of visuo-spatial planning
difficulties, is often used to identify the deficit which has a number of functional consequence
including affecting ability to drive safely.
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The Occipital Lobe
© Copyright CSAH 2009
The occipital lobe controls vision and depth perception. A loss of peripheral vision,
and an inability to focus or track movement results from damage to this area of the
brain.
Occipital Lobe Dysfunction
Vision
Peripheral vision may be lost leading to tunnel vision, only seeing things, objects or people that
are directly in front the individual (visual field cuts). Persons approaching from the side are not
seen until they may appear to have “jumped in front of the patient”, causing startling responses.
The person may have difficulty focusing on or tracking a moving object. He or she may no
longer be able to follow a television show or movie, “losing interest” as a result.
Difficulties with reading, writing, and recognition of objects, words, colours result from damage
to the occipital lobe.
Depth perception
The risk for falls increases due to the inability to judge distance on stairs. The individual may be
fearful stepping into bathtub, as the water may appear very deep. Also, dark tiles in carpet or
flooring may appear as holes. The individual may have frequent “spills” when pouring into cups
or containers.
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The Cerebellum, Brain Stem and Sub-cortical Regions
© Copyright CSAH 2009
In the previous discussion we have focused on functions of the cortex or outermost
layers of the cerebrum that play a key role in memory, attention, perceptual awareness,
thought, language, and consciousness. Beneath the cerebral cortex is the sub-cortex
which links the cortex to structures such as the thalamus and the basal ganglia. The
term sub-cortical dementia relates to specific clinical manifestations and neuroanatomical findings arising from lesions predominantly in the basal ganglia, brain stem
nuclei and cerebellum.
Cerebellum, Brain Stem, and Sub-cortical Dysfunction
Voluntary movement, balance and coordination
The cerebellum and brain stem control voluntary movement and balance functions; the brain
stem controls all involuntary body systems, which include the heart, lungs, and digestive
system. The cerebellum and brain stem are often not impaired until the late stages of the
dementia.
As coordination and balance functions are lost, the person often loses the ability to walk safely.
The person becomes bedridden and, with increasing immobility, the body becomes more prone
to pneumonia and pressure ulcers.
Swallowing
Swallowing difficulties may occur causing choking spells and increasing the risk for aspiration
pneumonia, which can lead to death.
Regulation of involuntary thought processes
Sub-cortical deficits are a feature of vascular dementia, Parkinson’s Disease and Huntington’s
Disease. They include slowing of thought processes (bradyphrenia), difficulty in memory
retrieval, and problems with changing cognitive strategies (mindset). Sub-cortical dementia is
also more likely to affect attention, motivation and emotionality. People with sub-cortical
dementia often show early symptoms of depression, clumsiness, irritability or apathy.
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The Limbic Region
© Copyright CSAH 2009
The limbic system connects the frontal and temporal lobes, linking behaviour with
memories. It is responsible for storing new memories, for emotional control, and control
of autoregulatory functions such as sleep-wake cycles, temperature, appetite and thirst.
It is often affected early in Alzheimer’s Disease, particularly the hippocampus, which is
responsible for storing new memories.
Limbic Dysfunction
Connection of behaviour with memory
The limbic system connects the frontal and temporal lobes, linking behaviour with memories.
When a person looks for a misplaced object, the first reaction (unfiltered by the frontal lobe) is to
assume someone else has moved or taken it, before also considering the possibility that they
may have misplaced it themselves or may have a faulty memory. Persons with dementia often
have an impaired filtering and analysis of events and are likely to accuse others of stealing the
object. As a result, poor memory leads to misinterpretations of events, anger, suspiciousness,
and blaming others.
Emotional control
Damage in the limbic system can result in emotions that are extreme and change rapidly,
including irritability, depression and anxiety. Blunting of emotions may also occur and the
person may appear uninterested or unaffected emotionally by events in his or her immediate
environment.
Auto-regulatory functions – sleep, appetite, thirst, body temperature
The limbic system also controls daily functions such as sleeping and appetite; so the person
may lose track of when he or she would normally be awake or sleeping. This may result in the
individual being awake through the night (day-night reversal).
The hypothalamus, which is responsible for control of body temperature, thirst, and appetite, is
also part of the limbic system. A person with damage in the hypothalamus may feel cold deep
in the bones or feel extremely hot. The person may also experience extreme thirst or appetite.
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The 7A’s of Dementia
The 7 A’s tool is a useful way to categorize and understand the most common losses of
dementia. The 7 A’s are:
1. Anosognosia (no knowledge of illness or disease)
2. Amnesia (loss of memory)
3. Aphasia (loss of language)
4. Agnosia (loss of recognition)
5. Apraxia (loss of purposeful movement)
6. Altered Perception (loss of visual perception)
7. Apathy (loss of initiation)
The 7 A’s is an effective tool to understand the way the person with dementia is experiencing
the world. This insight helps us shape the way we interact with the individual and with the
creation of individualized and supportive care strategies. It has been applied in P.I.E.C.E.S.
training programs throughout Ontario over the last several years, and enables us to use a
common language for dialogue and collaborative care planning.
1. Anosognosia: No Knowledge of Illness or Disease
a = no;
nosos = illness/disease;
gnosia = knowledge of
A person affected by dementia (with formerly intact functional abilities), living in the present but
only accessing their past, may lack insight into their own deficits have and have difficulty
appreciating his or her needs for assistance and may become angry with care providers. This is
particularly likely to occur if parietal lobe pathology is present.
Behaviours which may be associated with Anosognosia:
• Overestimation of abilities, poor judgment, problem-solving, planning, leading to
safety issues (e.g. attempting to self-transfer when not physically able, driving, doing
finances).
• Resistance to care which may include physical aggression (e.g. pushing away,
slapping, kicking).
• Uncharacteristic or inappropriate verbalizations or profanities (inability to control
impulses).
• Being unaware that they are in a hospital or long-term care home (they may think
they are at home, at work, at school etc.).
• Unaware of consequences of behaviour on others, i.e. “how it makes other people
feel”.
• Perseveration of thought, task, emotion, or phrase; like an “on-off” switch stuck in the
“on” position.
• Impaired attention and concentration.
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Effective care strategies for Anosognosia:
• Understand that behaviours are not wilful or intentional.
• When re-approaching the individual, smile, use positive words and a friendly and
relaxed tone. This approach is crucial to the success of a second attempt if a
caregiver needs to proceed with a task or activity.
• Use a non-confrontational approach to resistive or aggressive behaviours.
• Avoid punitive approaches that attempt to instil remorse, or belabour how the
person’s behaviour makes other people feel.
• Realize that negative interactions may provoke an angry or frustrated mood that
persists all day.
• If required, caregivers should “step back” and regain their composure prior to
responding to the resistive or aggressive behaviour.
2. Amnesia: Loss of Memory
The vast majority of information processing occurs outside of our conscious awareness. Only
novel information is processed at a conscious level. For the person with dementia and memory
loss, more and more information appears new and unfamiliar requiring increasing energy to
process. This can lead to feeling overwhelmed or frustrated.
Short-term memory is the most important aspect of memory, allowing information to be held
long enough to get into long-term storage. Without access to short-term memory, the person
with dementia can no longer consciously learn.
Long-term memory is divided into two areas: declarative, for all information learned or
experienced over time, and procedural for all tasks learned. Both are stored in layers. As a
person proceeds through life, memories pile on top of each other, so that the first thing a person
experienced or learned is at the bottom and the last thing learned is at the top of this pile.
Memory is lost in reverse order, i.e. the last thing learned is the first thing lost (think of it like
knitting a sweater, then beginning to unravel it row by row). A person with memory loss may not
remember what happened this morning or last week, but still has intact memory for information
that happened a long time ago.
In effect, a person with cognitive impairment lives in the present, but only has access to
information in the past. Their access to information (i.e. their reality) may be 30-40 years back,
and they will therefore act based on that information.
“The person’s reality is not our reality.”
The phenomena of reversed memory lose applies also to recognition of caregivers and family
member. If the individual has remarried later in life the spouse who is the main caregiver may
be perceived as a stranger or imposter.
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Behaviours that may be associated with Amnesia:
• Becoming anxious and overwhelmed by too much new information.
• Accusing family and caregivers of being imposters.
• Accusing others of withholding information, stealing items, not visiting, etc.
• Becomes suddenly uncooperative with familiar tasks or activities.
• Refusing assistance with care.
• Repeating questions, comments or behaviours.
• “Time Warp Delusions”, e.g. a past memory is triggered by a stimulus in the present,
which can cause extreme emotional reactions or misinterpretation of events.
Effective care strategies for Amnesia:
Use memory aides or reminders such as:
Keeping a diary or other visible written schedules for “bath days”.
Using a “signing book” for visitors.
Displaying pictures of loved ones, family and friends.
Repeat information without pointing out that the information has been provided
before and forgotten.
• Validate experiences of the past while redirecting the individual to more pleasant and
meaningful activities in the present.
• Create a “memory trail” to enable new learning by doing important tasks the same
way, every day. Routines are important.
• Rather than confronting them it may be helpful to offer to look for the missing items.
•
•
•
•
3. Aphasia: Loss of Language
The regions of the brain that control the expression and comprehension of speech are
located in different areas of the brain.
With receptive aphasia, which is usually associated with temporal lobe pathology, the person
may be able to express him or herself but cannot understand what is being said. With
expressive aphasia, which is usually associated with frontal lobe pathology, the individual may
be able to comprehend speech, but is unable to express him or herself.
Communication difficulties and misunderstandings between the person, the family, and the
health care team are common and often attributable to some degree of aphasia. Care providers
may assume that the person’s communication skills are intact because the failure to follow
directions may be episodic or situational. It may be that some care providers use more nonverbal cues within their communications, and the individual performance may vary within a 24
hour time period.
Despite impairment in the person’s expressive and receptive language functions, he or she
often remains responsive to appropriate non-verbal communications of others (e.g. smiling,
gestures and directly facing).
Behaviours associated with Aphasia:
• Difficulty following conversations, especially more than one (receptive aphasia).
• Social withdrawal.
• Word substitution, using the wrong word, leading to inappropriate statements or
requests.
• Reversion to first language (even if not used for number of years).
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Effective care strategies for Aphasia:
• Suspect the presence of expressive and receptive aphasia.
• Maintain a high index of suspicion for pain, discomfort, or other symptoms that the
individual may not be able to express.
• Use positive, supportive non-verbal communication that conveys calmness,
reassurance and kindness, e.g. facial expressions, body postures, tone of voice, etc.
4. Agnosia: Loss of Recognition
The individual with dementia and impaired parietal lobe sensory integration function can
experience a loss of their ability to both recognize and respond appropriately to people
(including self), objects and sounds. Confusion, suspicion, and inappropriate behaviour (e.g.
sexual expression) can result from the individual’s progressively anachronistic self-perception
and from the misidentification of others. Safety and care issues are likely to arise from the
inappropriate use of objects, as a result of a loss of recognition of objects and their intended
purpose.
Behaviours associated with Agnosia:
• Loss of recognition of people in the reverse order that they came into the person’s
life (i.e. grandchildren are forgotten first).
• Thinking of themselves as much younger than in actuality; becoming confused at
having “older” spouse, adult children the same age as the individual, etc.
• Delusions that a family member or care provider is an imposter.
• “Inappropriate” sexual behaviour resulting from deluded self-perception and
misidentification of others.
• Disturbed by mirrors, especially when reflecting the person (and other caregivers) in
their most personal space (e.g. bedroom/bathroom). May not recognize self or other
caregivers, so the perception is of a stranger(s) watching him or her undress, bathe,
toilet, etc.
• Inappropriate use of objects, or forgetting what they are for (e.g. toothbrushes,
faucets, and toilet).
• Defensive reactions to care using “unfamiliar” objects (e.g. caregiver trying to brush
teeth causes resistance).
• Impaired auditory recognition (e.g. a cat meowing may be thought to be a crying
baby).
Effective care strategies for Agnosia:
• Remove or reverse mirrors.
• Mimic the use of an object (such as toothbrush or face cloth) prior to handing it to the
person or administering care.
• Provide reassurance that the person in the environment is a family member or a care
provider who is there appropriately.
5. Apraxia: Loss of Purposeful Movement
A person with cognitive impairment loses the ability to plan, sequence and execute the steps of
particular tasks. Every task has a sequence and order. Even the simplest of tasks, such as
brushing teeth or combing hair, consists of a number of steps. The individual with dementia
loses the ability to discern what step comes where in the sequence. The person also has an
impaired ability to attend to tasks, thus tending to shift from one task to another especially when
distracted.
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Behaviours associated with Apraxia:
• Dress apraxia, i.e. cannot sequence the layering of clothing or can’t coordinate
movements to put on article of clothing.
• Difficulty with push-button items, remote controls, microwaves, touch-tone phones
(last learned is first lost).
• Frustration and inappropriate behaviours if tasks are too difficult, unfamiliar, or have
multiple steps and demands that may exceed the individual’s capabilities.
• Apparent “refusal” to participate in care by saying ”no” to a suggested task or activity,
despite the fact that they may appear physically able. It may not mean he or she
does not want to do it, but rather that the person does not remember how.
Effective care strategies with Apraxia:
• Explain to care providers the impact that apraxia may have on the observed
behaviours.
• Set out clothes in the correct order, from top to bottom, to facilitate independent
dressing.
• Provide step-by-step instructions while allowing the person to proceed independently
with each step, thereby preserving privacy and dignity.
• Minimize distractions which compete for attention.
• Whenever feasible, provide visual cuing by dressing at the same time as the person
with dementia (e.g. a spousal care provider setting out clothes in the morning or a
staff member demonstratively putting on a coat to go outside).
6. Altered Perception
Depth perception may be altered during the course of dementia. Since loss of depth perception
impacts greatly on the ability to mobilize freely through the environment, it changes the way the
person walks and sits. As well, visual distortions are common and may cause misperceptions of
objects, causing fearful behaviours.
Behaviours associated with Altered Perception:
• Verbal or physical resistance to bathing (water is perceived to be much deeper than
it actually is; the individual may believe they are at risk of drowning).
• Jumping over dark thresholds (looks like a crevasse) or dark tiles in floor (looks like a
hole).
• Avoids dark flooring (appears as body of water or ditch).
• Avoids flooring with bold patterns (appears as obstacles).
• The person may misinterpret clothing on a chair, pole lamps or other objects as
people.
• Misperceptions that people on TV are in the room, causing the person to talk to the
TV or perhaps become very distressed by it.
• When sitting, the person may cautiously put a hand on the edge of the seat, brush
the edge of the seat with a lower leg, and then sit on the edge or even arm of the
chair. Although the person may be encouraged to move to the middle, he or she
may not be sure where the middle is or how far down, or how far over to go.
• When walking, the person takes a more stooped pose, feet slightly apart, shoulders
hunched, and knees bent a bit. The person ignores the peripheral visual fields
because there is only so much information the brain can handle. The person
focuses only on what is directly in front, therefore looking either straight ahead or
down (mostly down). This may be a very adaptive way of mobilizing.
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• The person may be unable to relate to space and therefore bump him or herself or
his or her wheelchair into objects and/or people.
Effective care strategies for Altered Perception:
• Identify an individual’s perceptual difficulties and understand how they may cause
the behaviours.
• Seek to minimize misperception by appropriate lighting, and use of colors.
• Problem-solve around how to maintain safety for the person and others.
7. Apathy: Loss of Initiation
Apathy occurs with damage to the medial frontal lobes. Over time, a person with cognitive
impairment does not initiate conversation or activity. This is often interpreted as a symptom of
depression.
With dementia, the difference is that the person has lost the ability to initiate, but will participate
if someone engages him or her. Conversely, someone who is depressed will not participate
even if someone tries to engage him or her. The individual feels too low to motivate him or
herself to interact socially, and will often complain of tiredness to cut activities short.
Behaviours associated with Apathy:
• A person may sit in front of a meal and not touch it until a care provider initiates the
activity.
• A person spends most of the day in silence with his or her chin on her chest,
however, if approached and called by name, will lift his or her head to make eye
contact and smile.
Further information on depression in dementia is provided in Chapter 6 of this handbook.
Effective care strategies for Apathy:
• Initiate an activity (e.g. eating) by using verbal cues or hand-over-hand technique.
This may be sufficient to enable the person to complete the task or activity
independently.
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Summary
Physicians have an important role in helping care providers understand how changes in the
brain affects behaviour in dementia. They can help to guide caregiver interactions with the
individual, and identify supportive care strategies that enable the individual’s functional
abilities/potential rather than confront their cognitive losses.
In this way, challenges related to the behavioural changes that occur in cognitive impairment will
be minimized for the individual and others.
Table: Summary of Brain Function and Behaviour
Brain area
Frontal lobes
Î
Temporal
lobes
Î
Parietal lobes
Î
Occipital
lobes
Î
Cerebellum
Brain stem
Sub-cortical
areas
Î
Limbic
Hippocampus
Î
Function
Deficiency
Behaviour
• Executive function
• Problems with
planning, initiating,
executing in a
planned, organized
manner
• Re-emergence
primitive reflexes
• Unable to initiate (may appear
lazy, uncooperative with requests)
• Impulsivity
• Can’t plan holiday, activities of the
day, dinner party, etc.
• Grabbing (Grasp reflex) and
Paratonia
• Language
• Memory
• Aphasia
• Amnesia
• Frustration with aphasia, annoying
repetitions, unsafe use of tools,
stove, disorientation.
• Language analysis
Calculations
Spatial perception,
Sequencing
• Difficulty
understanding
• Visual-spatial planning
difficulties
• Difficulty sequencing
movements
• Apraxia
• Agnosia
• Anosognosia
• Vague historian
• Unable to manage finances or
driving
• Dressing, gait or eating difficulties
may be present
• Failure recognize people/objects
• Lacks insight into disease
• Vision
• Depth perception
• May not scan or
interpret environment
properly
• Startled response
• Afraid of tub water (appears too
deep)
• Messy when pouring liquids, etc.
• Balance
• Voluntary &
• Involuntary
movements
• Abnormal gait/balance
Slowness of
movement
• Swallowing problem
• Falls
• Slow movements
• Aspiration pneumonia
• Memory retrieval
• Connects
behaviour with
memories
• Regulates sleep,
appetite
• Misinterprets events
• Emotional lability
•
•
•
•
BPSD – Handbook for Family Physicians
Blaming others
Irritability and depression
Day-night reversal
Hot/cold perception changes