In early Alzheimer’s disease, a person may misplace or hide things for safekeeping for illogical reasons. As the disease progresses, drawers and cabinets can become cluttered with random items that present to outsiders as an organizational nightmare. Toward the middle stage, hoarding and rummaging become frustrating behaviors for caregivers to deal with. But one thing to remember here is that the person with Alzheimer’s at this stage is still able to understand the concept of in and out, under and over, above and beneath- the idea that things exist in the environment that are not in plain view. Down the road, this ability will diminish.
In the later stages of Alzheimer’s, the world becomes quite one-dimensional. Unless an item is placed in plain view, he or she may not know to look inside a drawer, or behind the mirror where there is a hidden cabinet. Higher-level tasks also require a person to perform an action with an object, sometimes in conjunction with another object (squeeze the toothpaste onto a toothbrush), in order to produce a desired outcome.
(Reminder: This is not so much a discussion of apraxia or agnosia, as much as it is about the concept of spatial relations and directional concepts. Think of it as the awareness of things in the world that are not plainly visible, or that may require an action to access).
Many times discussions about directional or positional concepts in cognition relate to processing language (Ex: The towels are under the sink. Your toothbrush is in the medicine cabinet.). In Alzheimer’s disease, however, when the language centers are typically damaged early on in the disease, trying to preserve this visual perceptual skill is not effective using verbal commands.
Scavenger hunts are good way to promote visual perceptual skills related to positional concepts, if there is enough working memory to support sustained attention to the task. This is especially helpful in the person’s own environment, where the location of items can be reinforced over time and logged into long term memory via repetition.
Simpler activities may be putting coins into a piggy bank, and emptying them back out again. Or stacking nesting bowls or dolls, or putting marbles in a jar, or opening the mail and removing the contents. Opening plastic Easter eggs and finding something inside can remind a person to look beyond what is obvious. Unloading the dishwasher- even if some items are misplaced- is a good task to reinforce positional concepts.
Take home message: Preserving rummaging and hoarding skills may not be a bad thing, if the environment is controlled and positional concepts are encouraged.