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Understanding Dementia: Language Difficulties - DementiaGuide.com
   
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Understanding Dementia

Language Difficulties

Language is discussed chiefly in Chapter 5 in the book Understanding Dementia. That chapter helps physicians to understand whether the person with a memory problem might have dementia. An important part of knowing whether the person has dementia is whether the patient has problems not just in memory but in other areas such as thinking, attention and calculation. Given that language will be used to inquire about all aspects of cognition (thinking), assessment of language is clearly important in establishing the extent of impaired brain function.


To be diagnosed with dementia a patient needs to have both memory impairment (identified in visit one) as well as impairment in at least one other area of cognitive function. Commonly tested areas include language, praxis (defined below), calculation, attention and concentration, psychomotor speed, and higher functions such as problem-solving, abstraction, and judgment. Some areas of cognition must be tested formally, other areas can be observed during the course of the interview. It is important to record the test results for future reference. Our aim, in answering the clinical question of whether cognitive impairment is present, is to gain an impression of the presence or absence of impairment, not to precisely define the patient's entire cognitive profile. Below we describe many tests and observations we find useful and simple to use. It is best to develop familiarity with the range of responses to a few tests, and then expand your repertoire as your comfort level increases and a need is present. We do not pretend to be neuropsychologists, and our definition of abnormal is not dependent on strict criteria, but rather on our experience with what is abnormal.

An error we commonly see, when physicians identify an abnormality, is to simply attribute it to advanced age or to low education. As far as we know, little readily obvious cognitive _decline, other than the mild degree of slowing seen in the Age-Associated Memory Impairment described above, occurs with aging, so any degree of impairment is abnormal. A useful technique to identify that cognitive impairment is important is to confirm that the current state is a change; a patient who used to speak fluently but who now stumbles over words probably has an important neurological illness, not just 'old age'. Some adjustment must be made for low education, especially in the face of illiteracy. Again, experience with local norms is invaluable and is gained chiefly through doing many MMSEs.

Language
The MMSE has many language items, including naming, repetition, following a sequence of commands and writing a sentence. In addition, language can be observed critically during the course of the interview, as many abnormalities are noticeable in spontaneous conversation (see Table 5.2). Because conversation is a social interaction, physicians sometimes fail to recognize subtle language abnormalities in their patients, particularly those whom they know well. In assessing dementia, it is important to be conscious of your own tendency to fill in words for the patient and to infer meaning from incomplete or vague sentences. These can be subtle signs of language impairment.

Does the patient have word-finding difficulties? Is their speech broken by constant round-about explanations or gestures in the place of words? Do they make errors in word-production, producing the wrong syllables or using the wrong word? Do they understand what is said to them? If language problems are suspectedseveral simple exercises can help to confirm the suspicion. Can the patient name unfamiliar objects, such as a stethoscope? Can they name parts of common objects, such as the band, face, stem (winder) and hands of a wristwatch? Abnormal answers include blank looks, don't knows, and statements such as "the part that goes around your wrist" or "the part you turn." Patients with early to mid stage dementia are often able to name the object, though not its parts. Repetition, following complex commands, and writing were briefly covered in the MMSE.

Another, more formal, test of language is to ask the patient to generate word lists. We ask for all the words they can think of that start with the letter 'f', and for all the four-legged animals they can think of, and give 30 seconds for each set of answers. Normal responses must be taken in the context of the person, but should be around 10 words in 30 seconds for either task. A typical set from a patient with dementia would start as, "well, you've got a cat, and a dog," and then trail off. (We have noticed that patients who include the indefinite article in their responses typically produce only a few items.) In Alzheimer's disease it is often the case that the list of animals is a little longer than the list of 'f' words. This is a feature known as semantic cuing, and large discrepancies between the two often raise the suspicion of other diagnoses, such as frontotemporal dementia .

Rockwood & MacKnight, 2001. p.77


Taken from Understanding Dementia: A Primer of Diagnosis and Management
Kenneth Rockwood & Chris MacKnight, 2001
Chapter 5, pp 75-78


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