Although the clinically significant phase of Alzheimer’s disease is characterized as a disorder of memory, it is so much more.  There are a number of cognitive skills that become progressively compromised as it progresses.  For example, in addition to loss of memory there is a decline in attention, concentration, orientation, judgment, reasoning, visuospatial ability, executive function, and language. 

The language changes present a real challenge for caregiving as we function in the world by language abilities that we take for granted.  In the mild stages (Late Confusional to Early Dementia) there are often deficits in language such as anomia (cannot name common objects) and circumlocutions (provide functions of objects rather than names) in addition to the forgetfulness.  For example, a person may look at a clock and say it’s for telling time or point to the lights rather than saying light switch.

In the middle stages of Alzheimer’s disease there is not only greater short-term memory loss but also a progressive decline in language that is similar to those who have had a stroke that produces aphasia (difficulty putting thoughts into words).  This decline is both semantic and pragmatic.  Semantic errors manifest as paraphrasias (using the wrong word), empty speech (using ambiguous referents “that thing”), and a reduction in verbal fluency (for example when asked to name animals or grocery items quickly they cannot get many to come out).

Pragmatic errors include speaking too much, speaking at inappropriate times, talking too loudly, repetitiveness, and digressing from the topic of discussion.  Of course, these changes reflect not only language decline but also short-term memory loss, decreased concentration, and disinhibition.

Changes unfold over the course of ten years or more and need to be differentiated from Primary Progressive Aphasia, which is characterized by progressive language decline but often less memory loss in the early stages (about 25% of those diagnosed with Primary Progressive Aphasia have Alzheimer’s disease).  Of course, this distinction is more academic than practical as impaired expressive and receptive communication is the problem either way.

Even in early stages of language decline there is also an increasing loss of comprehension making it increasingly difficult to understand spoken and written language and, in later stages, increasingly difficult to make ones needs known.  This makes it difficult to explain things like why one must stop driving or why one cannot stay alone.  Furthermore, there is increased agitation, social withdrawal, loss of friendships, and passivity adding to the complexity and stress of caregiving.

Treatment involves understanding, patience, and compassion.  Activities often need to focus on doing rather than saying (e.g., art, music), past memories rather than new memories, being in smaller groups, being invited into simpler conversations, encouragement to talk even if repetitive or tangential, giving simple single step directions, and not over-explaining. The objective is to keep the language-impaired person engaged with others and interacting within their own limits.  A monumental task that best requires more than a single caregiver.