Alzheimer's

History and Presenting Symptom: 11/26/75: Patient of Dr. Kolsky's examined by Bob Yee. The patient is a 65 year old woman with pre-senile dementia and abnormal opticokinetic response. The history is that at the age of 60 her recent and past memory became poor and she developed a vertical and horizontal diplopia at near and occasionally at distance. She seems to miss objects in the left field. The visual symptoms progressed and the patent was unable to find the next line of type with reading. She missed food on her plate when it was on the left visual field. She developed dressing apraxia, dysnomia and topographic agnosia with difficulty in recognizing faces. Her intellect progressively deteriorates. The symptoms were quite variable. At times she is nearly normal and at others times extremely forgetful and unable to find her way while walking.P.E.G. showed increase in sulci and enlargement of ventricles consistent with diffuse loss of gray matter. Carotid angiogram and B scans have shown no abnormalities; although, the sulci were wider on the right side than on the left. The optikokinectic response is poor on rotation to the patient's right. She can name colors well and name parts of the body well. She ahs moderate finger agnosia. Her acuity is 20/50 in both eyes. There is spasticity of gaze to the right and a left hemianopia which probably comes close to the midline. EOG recording made showing poor opticokinectic response to the right with saccadic pursuit movement with no bias of the eyes in the dark. Impression: Alzheimer's disease with focal signs pointing to the right parietal lobe. 6/2/76: Re-examined patient and reviewd history. Patient was seen early in her disease by John Henderson of U of M. who was diagnosed it as organic brain disease making it difficult for her to interpret visual images rather than as an ophthalmologic difficulty as initially believed. Then saw Tom Kearn at Mayo where her number is 3-146-704. He was unable to chart fields because of difficulty in holding fixation but he thought there was difficulty on left side because of missing letters. Deep reflexes were hyperactive on the left. EEG suggested a bitemporal defect. Exam today shows 1. Difficulty in localizing objects on left side either with hand or with fixation of eyes although she perceives the movement of the hand; most especially has difficulty in eye localization (Has a good position sense in her fingers). 2. Cannot select objects the are partially covered by other objects although she identifies them adequately when they are separate from other objects; thus she could not pick out tooth paste tube which was partially covered in a group by a brush but identified it readily when it was separate from the pile; depends heavily on color mnemonic for identification of objects. 3. Has difficulty in finding her door to her room except by a large red sheet of paper which she sees and feels before opening the door to her room. 3/11/77: Visual status seems to me about the same: 1. Visual acuity approximately normal as judged by single letter recognition but patent is confused when multiple letters are simultaneously presented and is totally alexic for words. 2. Visual fields hard to evaluate but suggest a left hemianopia with splitting of the point of fixation by confrontation tests but patient does recognize movement onto objects of attention in the right field. 3. Color discrimination for gross objects is accurate, 4. Spatial localization for visual cues is profoundly abnormal as indicated by hand direction, eye movements or subjective testimony. She cannot specify where objects are as a function of distance or on a horopter. Background objects are especially confusing. Was unable to find door of room. Yet tactile recognition appears normal. 5. Visual anomia profound for wrist watch, bush, bottle, etc. but prompt recognition by touch. 6. Eye movements. Saccades seem normal and no right-left disorientation but pursuit movements are cog-wheel. We will check this by electro-oculography. Impression: Visual agnosia for object and space recognition but good color perception, tactile cognition, and sound identification. HANDWRITTEN 3/30/77: Repeat color test by Dr. Gunkel shows for both eyes a defect in blue and a tendency to call green yellow but excellent detection of red. With the AO chart she recognizes colors but no the figures (crosses and circles). With the yarns she recognizes the colors and can match them but cannot put them in a series. HANDWRITTEN 12/27/77: Brief visit. Patient appears to be more incapacitated: runs into closed doors, walks in the wrong direction, mixes up her room at home, requires help in dressing, gets spoons and plates mixed up at the table. Exam now. Definite complete left hemianopia and I cannot estimate visual acuity in right field. She certainly sees hand movements and may count fingers; is sporadic in her recognition of objects (watch, keys) but is most incapacitated in placing objects in space. She cannot find an object which she obviously "sees". Is unable to read large letters but has some, however poor, ability to write her name. Fundi normal; pupils reactive. Video repeated showing spatial disorientation. Incidentally she also has prosopagnosia but picks up other clues to by-pass this. This was apparent in the video when I tried to get her to recognize her own face. She did this only because she heard us say we were going to do this. HANDWRITTEN 2/25/78: Subjectively little change. In a 2 hour session the following were noted: conspicuous defect in looking at an object or person when directed to do so. Tends to look to the right and may then converse with the wrong person. Looks at the right side of a picture e.g in the loom at a car saw the rear o the car and was unable to find the front wh. Was on the left side. Reaches to the right of objects and below, cannot estimate their distance; consequently bumps into objects and bumps hand against edge of chair when raising it from her lab. Asked to bisect a line, draws a vertical line. Looks to the right of the horizontal line and cannot appreciate the discrepancy. Recognizes a series of objects on the table (wine glass, pen, pencil, watch, and spoon) identifies color of each; yet cannot find the 3rd pen when 3 are laid out in front of her. Nor can she tell which pen is nearest to her. When asked to arrange 3 books according to size, she becomes confused. Cannot read letters. By history from her husband she frequently fails to find the right room in her house: goes into wrong bedroom. Gets up from chair in living room to get a glass of water in kitchen and goes out the wrong door. Recalls the correct route to market and her house but cannot name any of adjacent towns. Likes to watch TV soap operas and recalls some of them but does not know how much is auditory and how much is visual. On several occasions was unable to recognize familiar persons and often goes to a person thinking erroneously that it is her husband. On one occasion failed to recognize husband who was wearing an unfamiliar polka doted shirt but recognized him immediately on feeling his beard. Has difficulty in finding door to get in car. Persistently tries to find door in front of hinge at position of side mirror (which would be on the right side of her). On the objective side the patient appears to see well hen she looks directly at an object or person. Recognized that Dr. Chu had Oriental features but acuity cannot be measured. Has dense left hemianopia and questionable relative defect in lower right field. Eyes deviate to right with closure of lids. Recognized "hearts" on optokin tape at 10 inches. Excellent auditory rapport and good insight. Identifies objects readily by touch with eyes closed. Impression: No real object agnosia but rather a difficulty in getting eyes to fix on an object of attention. Definite defect in judgment of distances and grasping objects which she sees. Eyes do not fixate object of attention. Ignores left side. HANDWRITTEN Summary notes: 1st Sx attributed to vis - environment. Seemed in disarray; missed a napkin on floor, yet could see a grain of sand. Couldn't find bookends which were on table. Went to ophthalmologists for 3-4 years before being told she had "organic brain disease". Referred by M. Kolsky to Yee and me. Eventually had PEG at University Hospital. Further Sx: Would not prepare supper until late. Difficulty in dressing. Wanted to touch everything. First video recording shows this. Wants to touch microphone instead of object. Although vision 20/30. Acts as thought blind. Good tactile recognition. Likes to talk to self. Good manual dexterity . Folds paper well. Difficulty reading. Fields full but exting. On left side. Writes well but had difficulty with triangle. Cannot directly eyes in space Later could find chair only by touch. Cannot find glasses. Disease/ Diagnosis: Alzheimer Disease