Descriptive writing abilities in Alzheimer's disease

Handwriting Changes in Alzheimer's Disease: A Systematic Review

BACKGROUND

Handwriting is a complex process involving fine motor skills, kinesthetic components, and several cognitive domains, often impaired by Alzheimer's disease (AD).

OBJECTIVE

Provide a systematic review of handwriting changes in AD, highlighting the effects on motor, visuospatial and linguistic features, and to identify new research topics.

METHODS

A search was conducted on PubMed, Scopus, and Web of Science to identify studies on AD and handwriting. The review followed PRISMA norms and analyzed 91 articles after screening and final selection.

RESULTS

Handwriting is impaired at all levels of the motor-cognitive hierarchy in AD, particularly in text, with higher preservation of signatures. Visuospatial and linguistic features were more affected. Established findings for motor features included higher variability in AD signatures, higher in-air/on-surface time ratio and longer duration in text, longer start time/reaction time, and lower fluency. There were conflicting findings for pressure and velocity in motor features, as well as size, legibility, and pen lifts in general features. For linguistic features, findings were contradictory for error patterns, as well as the association between agraphia and severity of cognitive deficits.

CONCLUSIONS

Further re-evaluation studies are needed to clarify the divergent results on motor, general, and linguistic features. There is also a lack of research on the influence of AD on signatures and the effect of AD variants on handwriting. Such research would have an impact on clinical management (e.g., for early detection and patient follow-up using handwriting tasks), or forensic examination aimed at signatory identification.

Alzheimer's Disease: Prototype of Cognitive Deterioration, Valuable Lessons to Understand Human Cognition

It is important for neurologists to become more familiar with neuropsychological evaluation for Alzheimer disease. The growth of this method in research, as an available, inexpensive, and noninvasive diagnostic approach, which can be administered even by non-specialist-trained examiners, makes this knowledge more necessary than ever. Such knowledge has a basic role in planning national programs in primary health care systems for prevention and early detection of Alzheimer disease. This is more crucial in developing countries, which have higher rates of dementia prevalence along with cardiovascular risk factors, lack of public knowledge about dementia, and limited social support. In addition compared to the neurological hard signs which are tangible and measurable, the concept of cognition seems to be more difficult for the neurologists to evaluate and for the students to understand. Dementia in general and Alzheimer's disease as the prototype of cognitive disorders specifically, play an important role to explore all domains of human cognition through its symptomatology and neuropsychological deficits.

A correlational study between signature, writing abilities and decision-making capacity among people with initial cognitive impairment

BACKGROUND

Some clinical conditions, including dementia, compromise cognitive functions involved in decision-making processes, with repercussions on the ability to subscribe a will. Because of the increasing number of aged people with cognitive impairment there is an acute and growing need for decision-making capacity evidence-based assessment.

AIMS

Our study investigates the relationship between writing abilities and cognitive integrity to see if it is possible to make inferences on decision-making capacity through handwriting analysis. We also investigated the relationship between signature ability and cognitive integrity.

METHODS

Thirty-six participants with diagnosis of MCI and 38 participants with diagnosis of initial dementia were recruited. For each subject we collected two samples of signature-an actual and a previous one-and an extract of spontaneous writing. Furthermore, we administered a neuropsychological battery to investigate cognitive functions involved in decision-making.

RESULTS

We found significant correlations between spontaneous writing indexes and neuropsychological test results. Nonetheless, the index of signature deterioration does not correlate with the level of cognitive decline.

DISCUSSION

Our results suggest that a careful analysis of spontaneous writing can be useful to make inferences on decision-making capacity, whereas great caution should be taken in attributing validity to handwritten signature of subjects with MCI or dementia.

CONCLUSIONS

The analysis of spontaneous writing can be a reliable aid in cases of retrospective evaluation of cognitive integrity. On the other side, the ability to sign is not an index of cognitive integrity.

Writing Impairments in Japanese Patients with Mild Cognitive Impairment and with Mild Alzheimer's Disease

Background/Aims

We investigated writing abilities in patients with the amnestic type of mild cognitive impairment (aMCI) and mild Alzheimer's disease (AD). To examine the earliest changes in writing function, we used writing tests for both words and sentences with different types of Japanese characters (Hiragana, Katakana, and Kanji).

Methods

A total of 25 aMCI patients, 38 AD patients, and 22 healthy controls performed writing to dictation for Kana and Kanji words, copied Kanji words, and wrote in response to a picture story task. Analysis of variance was used to test the subject group effects on the scores in the above writing tasks.

Results

For the written Kanji words, the mild AD group performed worse than the aMCI group and the controls, but there was no difference between the aMCI group and the controls. For the picture story writing task, the mild AD and aMCI groups performed worse than the controls, but the difference between the AD and the aMCI groups was not significant.

Conclusions

The mild AD group showed defects in writing Kanji characters, and the aMCI group showed impairments in narrative writing. Our study suggests that narrative writing, which demands complex integration of multiple cognitive functions, can be used to detect the subtle writing deficits in aMCI patients.

A retrospective analysis of the sentence writing component of Folstein's MMSE

Objectives: Agraphia is the loss or impairment of the ability to produce written language as a consequence of brain damage and is a well recognised feature of dementia. However there is no generally accepted classification of agraphic disorders. Our aim was to determine the influence of writing style, lettercase and sentence polarity of the writing component of Folstein's MMSE on the overall test score.

Methods: We retrospectively reviewed the ‘write a sentence’ request of Folstein's MMSE of 280 randomly selected patients attending a geriatric day hospital. We analysed four sentence characteristics: 1 Number of words, 2 Writing legibility, 3 Sentence polarity, 4 Letter case.

Results: 280 MMSE forms were examined, 165 were from female patients. Mean age was 81.7(± 6.6) years. Mean MMSE score was 21.6 (males: 21.9, females: 21.4). Significant correlation was detected between the overall MMSE score and both legibility and number of words. Legibility scores were significantly higher for females than for males (7.2 vs. 6.6, p < 0.03). The mean MMSE of females writing in lowercase was significantly higher than for those writing in uppercase (21.5 vs. 18.6, p < 0.05). The mean MMSE score of subjects writing sentences with a positive tone was significantly higher than that of those writing a neutral or negative sentence (22.6 vs. 21.0 p < 0.03).

Conclusions: We have demonstrated a relationship between the content and structure of the writing assessment aspect of the MMSE and the overall test score.

A retrospective analysis of the sentence writing component of the Mini Mental State Examination: cognitive and affective aspects

BACKGROUND

One of the components of the Mini Mental State Examination (MMSE) is the request to write a sentence. We investigated the relationship between the characteristics of the written sentence of the MMSE and the cognitive and affective status of elderly patients.

METHODS

The characteristics of the sentence were compared to the total MMSE score, sociodemographic characteristics, tests evaluating cognition and affective status, and diagnoses.

RESULTS

The number of words was significantly associated with the degree of cognitive impairment, whereas the emotional polarity of sentences and concerns about health were associated with depression.

CONCLUSIONS

Characteristics of the MMSE sentence may provide important additional information regarding both cognition and affect when assessing older people.

DYSEXECUTIVE AGRAPHIA: A MAJOR EXECUTIVE DYSFUNCTION SIGN

Different types of writing disorders associated with brain pathology have been described. Limited mention the writing disturbances associated with prefrontal pathology, however, is found. Clinical observations of patients not only with focal prefrontal pathology but also with other conditions affecting the frontal system (e.g., traumatic head injury, dementia) confirm the assumption that these patients present an overt decrease in the ability to express ideas in writing. It is proposed that complex aspects of writing, such as planning, narrative coherence, and maintained attention, are significantly disturbed in cases of impairments of executive functions. Frontal lobe patients not only have difficulties in keeping the effort required for writing, but also to organize the ideas in the written texts. The term dysexecutive agraphia is proposed to refer to this writing disorder. Three illustrative cases are presented. It is finally suggested that questions regarding the ability to write should be included in dementia questionnaires and executive functioning testing.

Language performance in Alzheimer's disease and mild cognitive impairment: a comparative review

Mild cognitive impairment (MCI) manifests as memory impairment in the absence of dementia and progresses to Alzheimer's disease (AD) at a rate of around 15% per annum, versus 1-2% in the general population. It thus constitutes a primary target for investigation of early markers of AD. Language deficits occur early in AD, and performance on verbal tasks is an important diagnostic criterion for both AD and MCI. We review language performance in MCI, compare these findings to those seen in AD, and identify the primary issues in understanding language performance in MCI and selecting tasks with diagnostic and prognostic value.

Individual differences in young and older adults' spelling: do good spellers age better than poor spellers?

Young and older adults' ability to retrieve the spellings of high- and low-frequency words was assessed via tests of spelling recognition and production. One of the spelling production tests required participants to write down the correct spellings of auditorily presented words, and accuracy was used to categorize participants in both age groups as good or poor spellers. The results showed that individual spelling ability and word frequency contributed to age differences. Older adults who were poor spellers were less accurate in recognizing and producing correct spelling than young adults who were poor spellers. In contrast, no age differences occurred for good spellers. Furthermore, low-frequency words were especially difficult for young adults and poor spellers, relative to older adults and good spellers. These results indicate that aging alone is not detrimental to the processes underlying recognition or production of spelling but instead compounds existing problems caused by poor spelling.

Dysgraphia in Alzheimer's disease: a review for clinical and research purposes

PURPOSE

This article presents a critical review of literature on dysgraphia associated with Alzheimer's disease (AD). Research presented includes discussions of central and peripheral spelling impairments as well as the impact of general, nonlinguistic cognitive functions on dysgraphia associated with AD.

METHOD

The studies critically reviewed were from a variety of disciplines, with emphasis on seminal work, recent literature, and the first author's research.

CONCLUSIONS

Studies have shown that writing impairment is heterogeneous within the AD population; however, there are certain aspects of the writing process that are more vulnerable than others and may serve as diagnostic signs. Identifying patterns of writing impairment at different stages of AD may help to chart disease progression and assist in the development of appropriate interventions.

A comparison of verbal and written language in Alzheimer's disease

Few studies have examined characteristics of both verbal and written language of individuals with Alzheimer's disease (AD). This study used parallel measures (picture description, word fluency, spelling to dictation, and confrontational naming) to compare verbal and written language of individuals with mild AD, moderate AD, and normal controls (14 participants per group). Goals were to determine whether verbal/written differences would be exhibited within groups, and to identify measures sensitive to the effects of mild AD. Results showed that increasing AD severity led to decline in performance for most tasks, but only word fluency differentiated subjects with mild AD from normal controls. Confrontational naming was the only task to identify a difference in verbal and written performance for an AD group but not controls; moderate AD subjects performed worse in written naming. Similar verbal and written performance for the spelling to dictation task indicates impairment to central spelling processes in AD.

LEARNING OUTCOMES

As a result of this activity, participants will be able to: (1) identify verbal and written language measures which are sensitive to the effects of mild AD; (2) describe similarities and differences in verbal and written language performance among mild AD subjects, moderate AD subjects, and controls; (3) describe how findings may inform clinical practice for individuals with mild AD.

Perseverative writing errors in a patient with Alzheimer's disease

This study reports the writing performance of a dysgraphic patient with Alzheimer's disease and moderate dementia who frequently perseverated on strokes and letters. Letter formation errors were also frequently produced. Oral spelling was superior to written spelling. The habitual style of writing (cursive writing) was significantly more prone to perseverations than writing in uppercase letters, a form of writing less frequently used by the patient. Central (linguistic) spelling processes were relatively preserved. The pattern of preserved and impaired functions is consistent with impairment of the peripheral mechanism that generates the graphic motor patterns code. We suggest that damage to the peripheral orthographic mechanism may cause deficits in some patients with Alzheimer's disease.

Dysgraphia in mild dementia of Alzheimer's type

We assessed writing abilities in a cohort of 31 patients with a diagnosis of DAT (in two subgroups, with minimal [MMSE 24-28] and mild [MMSE 16-23] levels of dementia), and 10 matched controls. Central aspects of writing were assessed by both written and oral spelling to dictation of 72 single words varying in frequency (high or low) and predictability of sound-to-spelling correspondences (predictable, unpredictable and irregular). All subjects achieved better scores on high, as compared to low, frequency words. The performance of both patient groups was significantly affected by degree of predictability, and was equivalent in the written and oral spelling conditions. Phonologically acceptable alternative spellings (e.g. 'wade'-->WAID) constituted the majority of errors. More peripheral processes in writing were assessed by copying and cross-case transcription of single letters. Subjects were more successful at copying within case than transcribing across case. Performance was also better--substantially so for the mild DAT group--when the target response in either task was an upper- rather than a lower-case letter. There was considerable heterogeneity in performance on the spelling and the letter tasks. Some patients (even in the more affected DAT group) were unimpaired on both tasks, suggesting that dysgraphia is not a constant feature in early DAT. When writing deficits do become apparent, in the earliest stages of the disease the pattern is most likely to be one of mild surface dysgraphia, a form of central dysgraphia; impairments in more peripheral aspects of writing tend to emerge once the disease has progressed beyond the minimal stage.

Characteristics and evolution of writing impairment in Alzheimer's disease

Rapcsak et al. (Archs Neurol. 46, 65-67, 1989) proposed a hypothesis describing the evolution of agraphic impairments in dementia of the Alzheimer type (DAT): lexico-semantic disturbances at the beginning of the disease, impairments becoming more and more phonological as the dementia becomes more severe. Our study was conducted in an attempt to prove this hypothesis on the basis of an analysis of the changes observed in the agraphia impairment of patients with DAT. A writing test from dictation was proposed to 22 patients twice, with an interval of 9-12 months between the tests. The results show that within 1 year there was little change in the errors made by the patients in the writing test. The changes observed however were all found to develop within the same logical progression (as demonstrated by Correspondence Analysis). These findings made it possible to develop a general hypothesis indicating that the agraphic impairment evolves through three phases in patients with DAT. The first one is a phase of mild impairment (with a few possible phonologically plausible errors). In the second phase non-phonological spelling errors predominate, phonologically plausible errors are fewer and the errors mostly involve irregular words and non-words. The last phase involves more extreme disorders that affect all types of words. We observe many alterations due to impaired graphic motor capacity. This work would tend to confirm the hypothesis proposed by Rapcsak et al. concerning the development of agraphia, and would emphasize the importance of peripheral impairments, especially grapho-motor impairments which come in addition to the lexical and phonological impairments.