Alterations and perseverance of the firm in Alzheimer's

In PsicologíaOnline we present the results of the work on the impaired writing in people with Alzheimer's, work carried out in the Department of Neurophysiology of the Faculty of Medicine of Salamanca, directed by Doctor Javier Yajeya Pérez and with the collaboration of all the members of the Department. This work in its original sense presents a very extensive section dedicated to the Neurophysiology of writing and its mechanisms. Section that is not included due to the shortness of time, and considering that the explanation of the method developed, the data of interest and results, can be very beneficial to help the specialist in the neuropsychological evaluation of the elderly through their products graphics.

Writing is something common in our daily lives, but if such an activity we analyze it from the point of view of its execution neuromotor we find a complex system that requires a perfect synchrony of all the muscles located in the different joints hand, forearm, arm, shoulder, maintaining posture, balance, and very fine muscle control to maintain control viso-spatial. The motor regulation required for learning to write takes years to acquire and is subject to many variables; In image 1 we see the tracing of a four-year-old boy learning to write, it is easy to observe the clumsiness of movements, lack of firmness, polygonal ovals, incorrect morphology and other traits. Beside him we see the signature of a mature person, a spontaneous, agile and automated line. Keep reading this article to find out all about

Index

1. Neuromotor bases of the automaticity of writing
2. The prefrontal cortex and its relationship with the signature
3. Alzheimer's and signature decline
4. The dysgraphic features scale
5. The dysgraphic features of impairment scale
6. Factors and variables to take into account about the signature during Alzheimer's
7. A practical case of the alterations and perseverance of the firm in Alzheimer's
8. Continuation of the case study
9. Results of the case study
10. Conclusions of the case study

The facility we have to make our signature in a quick and spontaneous gesture It derives from a continuous exercise that promotes a corrective modulation by our nervous system until the desired result is obtained. The signature is a graphic behavior that we design on numerous occasions throughout our lives. The neurophysiological basis of the automation of the firm (as well as other activities) lies in a substantial increase in the interneural communication promoted by continuous exercise. By performing a certain sequence of motor acts over and over again, these tend to be facilitated because the effector neurons establish synaptic links stronger and new intercellular junctions, so that the activity is facilitated and improved both from the point of view of its duration and its results (Hebb D. OR. 1949. Kandel E. and Schwartz, 1982. Bliss T. and Lomo T. 1973). This process of synaptic plasticity, which materially constitutes the basis of learning, is called Activity-dependent Synaptic Facilitation.

From a more neuroanatomical perspective, another very important mechanism is a Process of undercorticalization of graphic behavior. Certain subcortical structures are responsible for modulating certain automatic movements performed without the contribution of conscious cortical areas. A fundamental center in scriptural automatism is the cerebellum. This structure receives instantaneous proprioceptive inputs from the muscles and inputs from the premotor cortex that indicate the movement required at this precise moment. In a sequence of precise movements, continuously perform a corrective activity adjusting the duration and intensity of contraction of the required muscle, and planning a priori (Serratrice, Habbib, 1993) the successive rapid movements so that they are knit together in a coherent sequence in their motor execution and their results concrete.

In close association with the cerebellum, and in practice receiving signals from all the areas that regulate the motor system, are the ganglia basal (image 2), located in the external part of the thalamus and occupying a large portion of the deeper structures of the hemispheres cerebral. The basal ganglia play a major role in the execution of capacities that encompass many different muscles in activities intricate, they plan multiple parallel and sequential patterns of movement that the mind must associate to accomplish a task with a purpose. It has been shown that when there is severe damage to the basal ganglia, writing becomes rough and rudimentary, as if we were learning to write again. (Guyton, 1997)

It can be said, in an easy to understand expression, that the basal ganglia, together with the cerebellum, are the most responsible for the speed and agility in the execution of writing and signing, which is considered a pattern of motor activity that unifies a sequence of very diverse movements, from the intrinsic characteristics of the same signature for each of the scribes, and of its correct execution as we can visualize it in most of the schooled people.

A very important brain area for our work would be the area of ​​the prefrontal cortex located in the anterior half of the frontal lobe (image 3), this constitutes the highest expression of brain development in the human species and is the area most directly related to the processes of cognition. The decision to sign a Document with discernment rests largely in the prefrontal cortex. Once the mental analytical processes determine the convenience of signing, this center triggers the entire sequence that leads to the execution of the signature graphic movement. However, by itself, and despite being directly responsible for originating volitional motor activities, the prefrontal area does not participate directly in their performance. Even receiving various projections from the thalamic nuclei, it does not have direct communication with the brain stem or the spinal cord. Therefore, he decides when to make the move, but has no immediate influence on it (Portellano, 2205).

The problem that arises, therefore, is that the alteration of a motor behavior does not imply a dysfunction of "higher" psychic abilities, such as rational discursive mental course and judgment critical. The nervous system involves numerous areas of neuromotor integration that can function defective and manifest executive dysgraphia unrelated to cognitive status of the subject. And vice versa, a person can suffer a significant degree of dementia and at the same time make his signature perfectly or quite acceptable.

As experts, the question we are interested in answering is the following: What scope of neuromotor and cognitive impairment, can we infer through the writings of a sick person? A pertinent question if we consider the increase in life expectancy in "developed" societies that provide non-existent medical care at the beginning of the 20th century. This favors the presence of a large number of elderly people whose medical-clinical care requires constant effort. Image 4 shows three moments of the population pyramid of Spain during the twentieth century, note that while in 1900 the percentage of people with ages superiors did not exceed 1%, currently it almost reaches 5%, with clear indications of being exceeded in the future due to advances in medicine and services social. This percentage of senility is higher in countries that began industrial development before Spain.

A typical symptom of Alzheimer's is he brain damage diffuse in its advanced stages (image 5). Correlatively to this destruction of cells there is a substantial increase in the encephalic tissue of neuritic plaques (degenerated nerve fibers interspersed with aggregates of abnormal amyloid proteins) and neurofibrillary tangles (image 6). These neurofibrillary tangles are large accumulations of the neurofilaments that constitute the supporting cytoskeleton of the neurons of the nervous system; In the autopsy of Alzheimer's patients, numerous abnormal accumulations of this material are detected in neurons, contributing decisively to the death of the cell. At present, these phenomena are considered as demonstrative physiological symptoms of Alzheimer's. They are also found in the brain of the non-demented elderly (although in much less abundance), so it can be said that they are inherent to old age.

Another more practical and clinical perspective considers an Alzheimer patient to be a person of advanced age, that without signs of other etiological pathologies, presents a specific dementia picture that prevents him from performing basic operations such as dressing, eating, taking care of himself, confusion of people and objects, significant memory problems, and lack of the intellectual abilities he enjoyed before presenting this symptomatology. In essence, presenting an insane picture that prevents you from leading an adequate existence to her environment, discriminate appropriately from stimuli, and that he can endanger his own life if left only.

The expert in writing that many times may lack the adequate background of neuropsychological or neurological knowledge, and above all, of the direct evaluation of the patient, must be very cautious when extrapolating brain or cognitive alterations from the graphic-constructive apraxiaespecially if we only have a few signatures.

It must be said clearly that sometimes we will not be able to infer the existence of Alzheimer's dementia through one or more signatures. The graphic execution of the signature, acquired in years prior to the pathology, supposes an implicit learning of character automatic or reflex, and its formation and evocation do not depend entirely on consciousness or cognitive processes. This type of memory accumulates slowly through repetition over many trials, it is basically manifested by an increase in performance or ease of execution. Examples of implicit learning can be considered learning to drive the car properly, learning a new language or one's own native language during childhood. Such learnings are automatically evoked without deliberate effort and can be preserved for a long time (Kandel E. & Hawkins D., 1996).

A fundamental symptom of Alzheimer's in its early stages is difficulty acquiring new memories and learning new things, however, patients, despite coping with a significant dementia, can preserve many skills and knowledge learned in years prior to the onset of the disease, in short: a memory or preservation of retrograde learning, in the presence of anterograde amnesia after disorder. As the disease progresses, such skills and knowledge will certainly be lost, but they can last for a while and gradually deteriorate over many years. Such is often the case with personal signature.

Currently, a hypothesis originating from many investigations assumes that the cause of Alzheimer's lies in the deficiency of the neurotransmitter acetylcholine in the hippocampus and associated areas. AC is the neurotransmitter of the neuromuscular junction as well as other interneural junctions within the central nervous system. The hippocampus is a deep structure of the temporal lobe that plays a fundamental role in the formation of memory networks in the associative cortex (image 7). Patients with lesions in the hippocampus suffer from anterograde amnesia and have severe difficulties in consolidating new ones memories and memorize new things, but they can carry out memorized learning in other parts of the brain (Milner B., 1985). The cholinergic terminals of the hippocampus are crucial for the formation of these processes, therefore it is more than likely that some cognitive defects in Alzheimer's disease are a direct result of a deficit in cholinergic neurotransmission (Wurtman, 1985).

Through the bibliographic review on dysgraphic alterations and the detailed study of specific cases, we have prepared a list of the graphic-scriptural alterations typical of Alzheimer's, although it is applicable to many other processes insane. More than an Alzheimer's diagnostic tool, it is used to assess the presence of dementia states in the clerk or the patient.

The scale consists of 70 symptomatic items of motor disturbances and mental-cognitive impairment. The items are divided into two sections: one for motor dysgraphia (dyssynergias, dyskinesias and dysmetria), and another for traits that primarily indicate language disturbances and character disorders psychic-cognitive. It can be objected that a language alteration does not imply a cognitive deficit, which is true, without However, in the final stages of Alzheimer's, language and communication can be altered dramatically. drastic. In the specific case of this pathology, it is admitted that a significant element that confirms a deterioration An important psychico-cognitive loss is the loss of graphic-linguistic communication skills (Junqué C. and Jurado M.A. 1994).

The scale is divided into the following sections and sub-sections:

A) GRAPHOMOTIVE SUBSCALE:

A.1) Graphic dyssynergy.

A.2) Dysmetria.

A.3) Dyskinesias.

B) COGNITIVE SUBSCALE:

B.1) Morphological alterations.

B.2) Omission of scriptural sections.

B.3) Undue inclusion of scriptural sections.

B.4) Undue reiteration of scriptural sections.

B.5) Confusion of scriptural sections (paragraphs).

C) ITEMS COMMON TO THE TWO SUBSCALES:

C.1) Drawn writing.

The ideal application requires signatures or writings prior to the pathological process in order to control the variables detailed below.

A) GRAPHOMOTIVE SUBSCALE:

A.1) GRAPHIC DYSYNERGY: SEQUENTIAL WRITING:

1. Difficulty drawing curves and abundance of angles.

2. Ovals and polygonal letters.

3. Fragmentation of the internal structure of the letters.

4. Letters detached in writing.

5. Abundance of straight lines.

6. Arrests located at changes of address.

A.2) DISMETRIES AND ALTERATIONS OF THE SPACE ORDER:

TRAIL DYSMETRY:

7. Arbitrarily placed initial and final strokes of letters and rubrics:

8. Non-calligraphic driven strokes.

9. Excessively long strokes (hypermetry).

10. Excessively short strokes.

INTERPALABRA DYSMETRY:

11. Very irregular distance between letters: very close together or very far apart.

12. Outstanding disproportion in the inter-letter size ratio.

13. Lack of baseline in the progression of the letters.

INTRALINE DYSMETRY:

14. Very irregular distance between words: very close together or very far apart.

15. Outstanding disproportion in interword size ratio.

16. Lack of baseline in the progression of words within the line.

17. Ostensible inclination inequalities not due to scriptural tonic.

INTRA-WRITTEN DYSMETRY:

18. Confusion or mixing of some lines with others.

19. Very irregular distance between lines.

EXTRA WRITTEN DYSMETRY:

20. Orientation of the anarchic and irregular lines with respect to the axes of the folio.

21. Disproportionate top margin due to excess or default.

22. Disproportionate lower margin due to excess or default.

23. Very irregular right margin.

24. Disproportionate right margin due to excess or defect.

25. Very uneven left margin.

26. Left margin disproportionate due to excess or defect.

27. Lack of spatial adaptation to the Lockers.

28. Lack of spatial adaptation to the Points or basal lines.

29. Lack of spatial adaptation to other writings, signatures or sections of the text.

A.3) DISCINESIAS:

30. Broken or interrupted strokes.

31. Heavy writing, either continuously or discontinuously.

32. Ink pastures or residues not due to the writing tool.

33. Absence of saturation due to lack of pressure when gripping the tool.

34. Superficial writing.

35. High amplitude tremors (essential) in vertical crossbars.

36. Low amplitude (physiological) tremors in vertical crossbars.

37. High amplitude tremors (essential) in horizontal beams.

38. Low amplitude (physiological) tremors in horizontal beams.

39. Torsions in vertical crossbars.

40. Torsions in horizontal crossbars.

41. Hypokinesia in vertical lines.

42. Hypokinesia in horizontal lines.

43. Micrography.

B) COGNITIVE SUBSCALE:

B.1) MORPHOLOGICAL ALTERATIONS:

44. Amorphologies: Letters or calligraphy without a determined form (illegible).

45. Clumsy and very precarious execution lyrics.

46. Warps: Letters with incorrect structure.

47. Irregularity or regularity in the structure of the letters.

48. Presence of erasures or corrections.

49. Fusion of two or more letters in a single structure.

B.2) OMISSION OF SCRIPTURAL SECTIONS:

50. Omission of complete letters.

51. Omission of structural parts of the letters.

52. Omission of sections of the word.

53. Omission of whole words.

54. Omission of other scriptural sections (rubric, ornaments, lines ...).

B.3) UNDUE INCLUSION OF SCRIPTURAL SECTIONS:

55. Inclusion of complete letters.

56. Inclusion of structural parts of the letters.

57. Inclusion of word sections

58. Inclusion of whole words.

59. Nonsensical accessory strokes.

B.4) IMPROPER REITERATION OF SCRIPTURAL SECTIONS:

60. Reiteration of structural parts of the letters.

61. Reiteration of full letters.

62. Reiteration of sections of the word.

63. Reiteration of whole words.

B.5) CONFUSION OF SCRIPTURAL SECTIONS (PARAGRAPHS):

64. Improper substitution of some letters for others.

65. Undue substitution of letters or graphemes for other graphic elements.

66. Wrong placement of graphic signs: points "i", accents, commas, etc.

C) ITEMS COMMON TO THE TWO SUBSCALES:

C.1) WRITING DRAWN:

67. Graphic bradykinesia (bradygraphy).

68. Increase in size.

69. Lack of scriptural rhythm.

70. Loose or tensionless writing (hypotonia or atony).

These last 4 items are included in the two subscales, in the graphomotor subscale the items function like any of the others, since they refer to movement disorders (dyskinesias). In the cognitive subscale they are only added when they appear all together: the subject is drawing and not writing. When these four points appear together in a signature there is a high probability of cognitive impairment in the elderly.

C.2) SERIOUS IMPAIRMENT FEATURES:

71) Dyskinesia or dyssynergia in very wide movements (rubric).

72) General deterioration in all sections of the firm.

All the points of the previous scale are quantified as follows:

SCORE 0. THERE IS NO TRAIT.

SCORE 1. SLIGHT PRESENCE OF THE TRAIT.

Although the feature is found in some strokes or graphic elements, it appears incidentally or sporadically.

SCORE 2. AVERAGE PRESENCE OF THE TRAIT.

The trait is seen generally but not excessively.

SCORE 3. HIGH FEATURE PRESENCE.

The feature is observed in a recurring and constant way throughout the entire writing or a good part of it.

The writing above belongs to a woman (case 2) in a healthy state who carried out the word with agility and correct kinetic melody, something that is verified when analyzing the pressure in the absence of the pigment (image right). In the image below, he suffered a neurodegenerative process, among whose manifestations we find the presence of a pekinetic apraxia that imposes a very poor sequential writing and rudimentary.

Age

The likelihood of Alzheimer's increases with age. Although there are some quantitative differences between one and the other studies, it can be affirmed that from the age of 85 the possibility of suffering a dementia process due to Alzheimer's is 50%. On the other hand, Alzheimer's-type dementias, whether in its simple form or mixed with some type of vascular disorder, account for approximately 75% of all dementias (image 11).

Differential diagnosis

Differential diagnosis can be very complicated. Often the elderly will be affected by a myriad of pathologies that affect writing and that may seem like symptoms of cognitive dysfunction: osteoarthritis in the upper extremities or conditions in the peripheral nervous system that generate a very important graphic dysfunction, myopia, astigmatism, tremors or bradykinesia due to other causes, etc. On the other hand, the causes responsible for the appearance of a dementia are very numerous.

It is especially in the alterations that occur with specific language disorders where the diagnosis can be more complex, such as Broca, Wernicke, or conduction aphasia, resulting in significant apraxia and even agraphia complete. In this sense, having medical-clinical reports is almost essential and they will help us a lot, especially if we only have a few signatures. In many cases the differential diagnosis through writing or signing can be quite difficult if not impossible. It is always convenient to analyze which scriptural dimensions are deteriorated to a greater degree, since this specificity can often indicate some data of interest.

Structural test characteristics

The graphics of the signature is the last thing that deteriorates because its continuous testing promotes a greater degree of undercorticalization with respect to texts written according to different modalities. If we have a choice, what is relevant is that we have several signatures and some written text, and make an assessment of the following capabilities:

TO. Write a text freely without a model, free writing.

B. Write a text to dictation.

C. Copy a written text.

D. Sign multiple times.

Especially in the initial stages of senile deterioration, it is very difficult to evaluate cognitive deterioration with the mere presence of a signature and without the aid of other writings. As an important indication, and according to our professional experience as well as the bibliographic review, in a typical case of Alzheimer's the first Skill that is lost is A, the last one is D, passing through successive phases of skill loss that more or less follow the previous progression. In many cases the subjects are capable of signing but almost totally incapable of a free-form text, a dictation, or to write familiar and common names, etc. (Horner et al., 1986).

In the signature, the separate verification of each element according to the order of appearance in the graphic is pertinent. As a general rule, the proper name is better designed than the first surname, and in turn the latter better than the second surname. The proper name is heard more times, it is written more often in intimate letters, and this greater familiarity generates a greater preservation of the name to the detriment of the first surname, and this respect the second. This rule does not have to be necessary, you have to see each individual case, but it is the most common.

Control of learning acquired before the disease

The determination of the schooling, academic degree and profession of the firm's writer.

The writings of unschooled subjects can maintain characteristics very similar to those of old age and those of Alzheimer's dementia (image-12), extremely precarious, full of corrections, misspellings, slow strokes, increased size, paragraphies and confusion, as well as other features typical. It is necessary that before deciding a deterioration through writing, the academic training and the possibility that the subject has had to facilitate automatism in their professional and existential performance.

In the opposite line, in certain offices, notaries, magistrates, secretaries, it is required to be signing continuously to legally validate the documents. These subjects, as is evident, will have a better chance of preserving the intrinsic qualities of graphics for many more years due to increased exercise.

In our assessment of the general state of the patient affected by Alzheimer's it is necessary that we have signatures or other writings prior to the pathological process, we will not be able to analyze duly the state of a patient if before we have no record of how she signed and wrote, what has been altered and what has been the evolution of the dysgraphia since her state is not pathological. However, in the absence of other data, on the scale we indicated certain dysgraphic features typical of Alzheimer's.

Drugs administered to the elderly with Alzheimer's

It is difficult to verify its effects in most cases, due to:

A) Diffusion of the affected brain area in the disease.

B) Large amount of drugs administered (other diseases concomitant to old age), and their possible interactions.

C) Difficulties of elimination and absorption suffered by the elderly due to their physical condition.

Sex

According to numerous studies, and confirmed by our professional experience, women are more likely to suffer Alzheimer's disease, however these results must be evaluated with caution due to the longer life expectancy of the women.

Other variables that can be considered

• Locality, country: Rural or urban environment. Degree of industrialization or development of the country.
• Family history.: Level of academic training of parents, other cases in the family.
• Personality: There is a hypothesis that people who have exercised more memory and intellectual functions during their lives are less likely to suffer from Alzheimer's. At present these studies are premature and more data is lacking.
• Genetic inheritance: Many studies are carried out in this field but they are still insufficient to establish reliable conclusions.
• Posture, support, scriptural tool, etc. Older people often have to write with a thick-tipped black marker because they are unable to visualize the lines of the pens.

It belongs to a woman who left a series of signatures distributed over a period of 40 years, from 52 to 91 years old, age at which he died from cardio-respiratory arrest and with a diagnosis of Alzheimer's on the medical certificate of death. The first signature corresponds to the 52 years. We see in it the agility and ease with which the different curvilinear ellipses that adorn the writing, the appropriate proportionality of its components and the sustained rhythm that shows us the good neuromotor disposition of the author (image 14). There are, however, certain features that may seem indicative of a certain pathological process, but in essence this signature does not present any significant dysgraphia.

Applying the scale to the successive signatures (Im. 15) we see that the evolution of dysgraphia adjusts to the described phenomenology, a deterioration gradual over the years until reaching a general crisis in the last year of life, where neuromotor functions are very altered. This is the type of evolutionary pattern that we can find in the signatures of Alzheimer's patients. Note that the progression breaks his trajectory over the age of 85, remaining stable in the preceding years. It is not necessary to explain the influence that trauma or injury could have on steep ascents. specific injuries of a certain intensity (ischemia, hemorrhage, head trauma, etc).

The second signature we present is at 86 years of age (image 16). The most indicative feature is the difficulty in designing ellipses and curvilinear gestures, a kinetic dyssynergy that affects the correct structure of the letters. Neuromotor dyssynergia is the breakdown of a complex movement in which different muscles and joints contribute. The execution of the letters requires a very fine adjustment of the muscle contractions of the distal limb to obtain a good result. In dysnergic disorders, movements become uncoordinated and imprecise, the patient cannot unitaryly execute an action that requires the consecutive action of a series of distal and proximal muscles, instead moving each joint sequentially, acting unequivocally on the synergistic muscles and their antagonists but without keeping a succession of continuity with the previous activations muscular. The consequence of such a decomposition of complex movement when making ovals, ellipses, and other graphic structures, is that the designs do not come out curved, but polygonal.

In reality, and as readers will have readily seen, we are clearly dealing with apraxia. that divides and separates the graphic sequence into its units of motion, as perceived in the picture. The volume "Neuropsychology" by Peña Casanova and Barraquer (1983) makes a complete review of this type of disorders:

(…) "A well-chosen, well-placed cinema imposes a perfect synergy of agonist and antagonist muscles, an eventual kinesthetic and visual control, and in addition, its execution is not isolated, inscribing itself in a chain that constitutes the melody kinetics. A disturbance at this level constitutes motor (pekinetic) apraxia. "(…)

(Peña C. J, Barraquer B. LL. Neuropsychology. Ed. Toray, 1983)

The "cinema" is the elementary unit of simple movement, and is understood by the unit of muscular contraction and its corresponding antagonistic disinhibition. The following text, by the same authors, is very interesting:

(…) "The skilled worker - Luria comments - loses the ability to carry out the successive system of movements that he normally executed. The musician is disoriented before his instrument, losing the ability to perform the successive system of automatisms previously acquired. An instrumental amusia appears. The writing is altered and each feature of the graphemes requires a special effort. The typographer loses speed and his work is increasingly clumsy.

"The patient behaves as if he were performing for the first time the movements that form part of his usual repertoire, as if he had never realized the dynamic stereotypes acquired. "(…)

To conclude, we present the brilliant description of Serratrice-Habib, which does not require any special comment:

(…) "Lastly, motor apraxia, traditionally called melokinetic, that is to say, that affects the performance of the gesture by the extremity of the limb, is a disorder of the synergy of agonist and antagonist muscles, and the kinetic melody of the movement, according to Luria's expression, that is, the harmonious succession of the different movements that make up the gesture. Speed, finesse, and dexterity of movement are affected. His expression is one-sided. Its exact place in pathology has often been debated and is sometimes considered an intermediate disorder between apraxia and paralysis. On the other hand, it is sometimes called inervatoria. It is contralateral to the causal lesion that affects the premotor frontal area and the anterior parietal region. "(…) (G. Serratrice, M Habib. Writing and Brain, Ed. Masson, 1997).

The following signature was made when she was 91 years old (image 17), the age at which the patient died. It is evident that the automatism has degraded substantially. Apart from the various types of tremor, there are other scriptural features typical of old age that do not, by themselves, indicate a cognitive impairment, are those that affect the speed, rhythm and pressure of writing (see scale), and that we have included as Dyskinesias Which, although they are fundamental for the calligraphic comparison and identification of signatures, they are not so much to draw inferences about the Psychic functionality of the elderly due to the fact that its etiology may be more related to the nerve and spinal periphery than to the encephalic one. We are now, therefore, with an ideomotor apraxia.

Peña Casanova's book introduces this section with a text by Ajuriaguerra (1975):

(…) "It is the apraxia of the simple gesture; the ideation plan of the complex activities is preserved; such activities are only altered at the level of their fragments and not in the harmony of their totality (De Ajuriaguerra, Hecaen and Angelergues, 1960) "(…)

In another section they describe the vision of Signoret and North (1979):

(…) "Ideomotor apraxia is, for Signoret and North, a disturbance that affects the selection and combination of cinemas. The gestural realization offers an overall impression of clumsiness; the well-chosen gesture can be identified, but some of its components, the cinemas, are erroneous, displaced. For example, in the military salute, the hand is placed incorrectly and in an inappropriate place on the head. "(…)

We present the Serratrice-Habib perspective:

(…) "Ideomotor apraxia is an alteration of the elemental motor act. The concept of movement is correct, the gesture is well chosen, but it is full of spatial and temporal errors that produce the impression of clumsiness, of which the patient is aware. The words are slowly and laboriously arranged in an irregular way, and displaced, with a distortion of graphemes, which are disorganized or with a kind of literal paragraphy. In these cases, anomalies are observed both in the copy and in the dictation. Consequently, it is a poor execution of the symbolic gesture of writing, which Morlaas once interpreted as Spatial dyskinesia, an exaggerated interpretation because it is not a primary anomaly of the representation of space. " (…)

The authors delimit this type of apraxia in other ways such as graphic-constructive or merely constructive apraxia. The essential is exposed: "an alteration of the elemental motor act" (Serratrice, 1993), with a preservation of the "ideational plan" of the activity (Ajuriaguerra, 1960). And these are the two main ideas in our opinion. The cognitive functions of linguistic communication, the graphemic or lexical-semantic selection are preserved, but there is a motor dysfunction that alters the entire sequence of the activity in a substantial and relevant way, the graphical-writing distortions of this type of apraxia can be very varied depending on the area or section affected (image 17).

Picture 17. Graphic idemotor apraxia. The lack of pressure and firmness is evident, the gestures are thrown but without force, the outlined forms without success, some lines are unsaturated, with numerous pastures due to an incorrect inclination of the tool on the surface of the leaf.

The last signature is also at the age of 91 (image 18) and is the closest to the date of death. This writing is much more deficient in terms of morphology, inequalities and general appearance.

This signature is not properly writing, but rather a highly deficient drawing that we can include within the so-called Scriptural Ideatoria Apraxia. Serratrice-Habib's review is very clear:

(…) "Ideational apraxia, sometimes described as a gestational alteration, is an alteration of the idea of ​​a complex gesture, the internal model of which is no longer evoked. The plan of the sequence of the action to be executed is no longer conceived. There is a disorder in the knowledge of the use of objects, which led Morlaas to interpret the ideational apraxia as an agnosia of use. The loss of the gestema alters the whole of the gesture, both symbolic - mimicking the writing - and concrete - manipulating the pencil or the pen. However, the degree of alteration is inversely proportional to the degree of automation. A simple, often repeated gesture, such as removing the cap from the pen, does not require resorting to gestation. It runs automatically. Parapraxia often occurs, that is, one gesture for another, the most common example being that of a patient who writes with a pair of keys or scissors. Baxter and Warrington described an exemplary case of ideational agraphy that "(…)" was not related to manipulation, but to the symbol of writing. These researchers interpret it as a defect in access to the storage of graphomotor engrams and the pattern of motor sequences. In reality, the alteration of the writing was isolated and independent of any other apraxic manifestation. The patient, protruding from a left parietooccipital glial tumor, was unable to write letters or words to dictation, but was able to copy them again. He also recognized and spelled letters and words. In this way, when a model was presented to him he could execute the graphic movement. However, in the absence of an external model, he did not use the internal model. This could correspond "(…)" to a defect of access to the sequences of the program of the graphomotor standards. "(…)

Regardless of the cognitive function or mechanism that is "altered", the bottom line is that "the internal model is no longer evoked." The symbolic-scriptural gestures, the sequential motor patterns of writing, the kinetic melody, the engrams motor of the letters, the graphic-motor praxia (whatever you want to call it), we no longer find it in the internal space of our mind. It may be because it is no longer recognized (functional agnosia), or because it no longer exists due to deterioration or disease. The subject can copy the letters using mechanisms similar to those of the child who is learning to write, but cannot write by dictation or make a sentence freely.

The sequential pattern of scriptural movements has an execution plan, this plan supposes a anticipation of the graphic-motor activity, in a way it can be said that it is done before being done. This previous plan has disappeared. The writing would no longer be properly so, but rather a drawing. The last stages of the deterioration of the elderly are characterized by a global destruction of writing ability, the whole game dynamic of tensions, pressures, different speeds and rhythms (all the harmony of the kinetic melody) with which the writing is designed has disappeared, instead we see a very slow layout, slowness that is necessary to avoid erring in the structural form that is intended imitate. The pressure of the stroke can now be light or heavy, as if the tool had an excessive weight, or as if the hand did not have enough force to press on the paper and saturate it with ink. It also increases the size, since the old man needs visual-motor feedback to see what he really writes. The ability to write with closed eyes is forbidden in the elderly as in the child, they need to visually follow the result of their graphic movements step by step.

Apart from the features that concern language or written expression (the essential ones ultimately instance), there are certain motor traits that may be indicative of Apraxia Ideatoria in the Alzheimer's.

• Graphic bradykinesia (bradygraphy).
• Increase in size.
• Lack of scriptural rhythm.
• Loose or tensionless writing (Dystonia or Atonia).

There are other concomitant features, but the previous four seem to us the most demonstrative and revealing.

The results show well-defined stages in the writing impairment of Alzheimer's, at least in this case. In image 20 we see the different evolution of the graphomotor subscales: motor dyssynergia, dyskinesia and graphic drawing. Three phases or defined graphic states that are summarized below:

1) Dysynergic Phase: Predominance of dyssynergia, with abundant rectilinear lines, angular and polygonal writing, while dyskinetic features remain contained. The period covers firms between the ages of 73 and 86.

2) Dyskinetic Phase: A second period corresponds to two of the last firms located in the 91 years; tremor predominates in all its modalities, torsions, alterations in pressure and lack of muscle tone. They involve movement disorders unrelated to dyssynergic processes. Which ostensibly descend.

3) Phase of the Graphic Drawing: The third period corresponds to the last signature or Terminal phase of the patient. We call it "Graphic Drawing", and it shows abundant dyskinetic features apart from those of drawn writing, as we saw in a previous section.

Image 21 also shows the progressive evolution of motor dysgraphia in the face of stagnation of cognitive traits in a wide trajectory that covers from 50 to 85 years of age. Then, from the 90s, cognitive increases substantially in a strong trend of global deterioration. The assessment we can make is that the scriptural automatism is preserved in parallel with the increase in dysgraphic processes of neuromotor etiology. We see in the last three signatures, corresponding to 91 years, a characteristic reflection of the generalized Alzheimer's crisis.

The scale has also been applied separately to the first and last names to analyze the variable called Reinforced Learning by Family Graphics test. The results confirm its full influence. Image 22 shows how the surname suffers more directly from the deterioration progress than the signatory's own name (20.8% less on average). Note, however, how both graphics maintain a similar trend of evolution until practically the last months of the patient's life, where the degradation of the writing affects all the components of the signature equally without distinction, however, the resistance of the name to degradation is striking graph.

To finish we will say that we have verified the evolution exposed in many other cases, without this meaning that it is a fixed nor axiomatic tonic. It is convenient not to lose sight of the variables exposed in the previous section.

1. The signature is a bad indicator of the degree of deterioration in its initial and intermediate stages due to the influence of the Reinforced Learning Variable per trial. That promotes the continued performance of an acceptable signature that does not reflect neuromotor impairment. The best indicator of patient deterioration is directly related to non-dependent functions of the aforementioned variable, in this sense, a handwritten text either when dictated, copied or written free.

2. The name is more resistant to graphic degradation than the surnames. The influence Variable Learning Reinforced by essays is directly proportional to the ordinal place that the elements within the signature occupy, in this sense: 1st) Name, 2nd) First Surname, 3rd) Second surname.

3. The neurographic deterioration of the signature is concomitant with the critical deterioration of the patients in their final stages. It is reasonable to understand that at this stage there is a serious alteration of the somatic seating (subcortical, cerebellar, cortico-spinal, etc.) of the Reinforced Learning Variable per trial.

4. Three main stages of Senile Graph deterioration or Alzheimer's are detected, without this meaning that they are the only typologies (there are others), necessary or generalized. These phases are: 1st) Dysynergic (peachine apraxia), 2nd) Dyskinetic (ideomotor apraxia), and 3rd) Graphic Drawing (ideational apraxia). The prevalence of one of the phases in the evolution of the deterioration is verified in all cases. The first being dyssynergic and the last being the graphic drawing.

5. In the dyssynergic and dyskinetic neurographic stages, both scales are inversely proportional. Dysynergia predominates in the early stages (approx. 70 to 80 years), and is being displaced by dyskinetic factors as age and deterioration progress. Dyskinetic dysgraphic features predominate in the final stages, without excluding the former.

6. The significant general deterioration (motor and cognitive) coincides with the last and most dysgraphic stage: drawn writing. This stage includes a very intense ideational apraxia and drawn morphological creation. It is inferred that the Graphic drawing stage is concomitant to the cessation of the influence of the Variable "Reinforced Learning by trial". In the graphic drawing stage, all the elements of the signature deteriorate regardless of their location within the signature and their greater or lesser familiarity.

7. The Graphic drawing stage is concomitant with a decrease in dyskinetic traits and a significant increase of Cognitive Dysgraphic Traits, as well as the following Traits: Large size, Hypotonia, Arrhythmia and Bradygraphy. Likewise, it coincides with important malformations in the rubric.

The previous conclusions do not affect people with a poor level of education.

This article is merely informative, in Psychology-Online we do not have the power to make a diagnosis or recommend a treatment. We invite you to go to a psychologist to treat your particular case.

If you want to read more articles similar to Alterations and perseverance of the firm in Alzheimer's, we recommend that you enter our category of Clinical psychology.

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