Independent representations for cursive and print style: Evidence from dysgraphia 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.

Progressive macrographia for block letter writing: A case study

"Macrographia", a relatively rare symptom generally following cerebellar diseases, consists of an abnormally large handwriting. The case reported in the present investigation shows several outstanding features. First, it is of the progressive variety, letters increase in size as one goes through the word towards the lower-right portion of space. Moreover, it is limited to one allographic variety, that is, block letters. This phenomenon is previously unreported, all allographic varieties being usually equally affected. Finally, no prominent cerebellar or basal ganglia abnormality could be demonstrated with structural MRI or PET. From a cognitive point of view, a peculiar combination of spatial attention, executive function and working memory deficits is proposed to account for the progressive misalignment and elongation of individual letters when specifically writing in block prints. From an anatomical perspective, the pattern of multifocal lesions, encompassing multiple cortical areas in both hemispheres and the corpus callosum, may support this multi-componential interpretation of the reported phenomenon.

Neural correlates of spelling difficulties in Alzheimer's disease

Alzheimer's disease (AD) is associated with a general cognitive decline that affects the memory and language domains. Thus, an oral production deficit with a lexical-semantic origin has been widely observed in these patients. Their written production capacities, however, have been much less studied. We assessed the spelling abilities of 22 AD patients and a group of matched healthy controls with a test battery including written picture naming and word and pseudoword dictation tests, as well as text dictation and spontaneous writing tasks. The results of the AD patients in the discriminative tasks were then entered into voxel-based morphometry analyses along with their grey matter volumes. The patient group presented a selective impairment for word dictation, which contrasted with a spared capacity to spell pseudowords, and showed more difficulties for words with arbitrary and rule-based orthography. Moreover, they also produced less complete syntactic units in the spontaneous writing task. These results point out the lexical-semantic, as opposed to sublexical, nature of the spelling deficit associated to AD. In addition, we recognized a mainly left-lateralized cortical network, including areas in the posterior inferior temporal lobe and the superior region of the parietal cortex, which might be responsible for this impairment. Other regions, such as the putamen, were also associated to the deficit. The results of this study, hence, improve our understanding of the neuropsychological and neuroanatomical mechanisms that underlie the cognitive symptoms associated to AD.

Dyscravia: voicing substitution dysgraphia

We report a new type of dysgraphia, which we term dyscravia. The main error type in dyscravia is substitution of the target letter with a letter that differs only with respect to the voicing feature, such as writing "coat" for "goat", and "vagd" for "fact". Two Hebrew-speaking individuals with acquired dyscravia are reported, TG, a man aged 31, and BG, a woman aged 66. Both had surface dysgraphia in addition to their dyscravia. To describe dyscravia in detail, and to explore the rate and types of errors made in spelling, we administered tests of writing to dictation, written naming, and oral spelling. In writing to dictation, TG made voicing errors on 38% of the words, and BG made 17% voicing errors. Voicing errors also occurred in nonword writing (43% for TG, 56% for BG). The writing performance and the variables that influenced the participants' spelling, as well as the results of the auditory discrimination and repetition tasks indicated that their dyscravia did not result from a deficit in auditory processing, the graphemic buffer, the phonological output lexicon, the phonological output buffer, or the allographic stage. The locus of the deficit is the phoneme-to-grapheme conversion, in a function specialized in the conversion of phonemes' voicing feature into graphemes. Because these participants had surface dysgraphia and were forced to write via the sublexical route, the deficit in voicing was evident in their writing of both words and nonwords. We further examined whether the participants also evinced parallel errors in reading. TG had a selective voicing deficit in writing, and did not show any voicing errors in reading, whereas BG had voicing errors also in the reading of nonwords (i.e., she had dyslegzia in addition to dyscravia). The dissociation TG demonstrated indicated that the voicing feature conversion is separate for reading and writing, and can be impaired selectively in writing. BG's dyslegzia indicates that the grapheme-to-phoneme conversion also includes a function that is sensitive to phonological features such as voicing. Thus the main conclusion of this study is that a separate function of voicing feature conversion exists in the phoneme-to-grapheme conversion route, which may be selectively impaired without deficits in other functions of the conversion route, and without a parallel deficit in reading.

Allographic agraphia: a case study

We report the case of patient MN, diagnosed with frontotemporal dementia, who exhibited a severe impairment in writing letters and words in upper-case print in the face of accurate production of the same stimuli in lower-case cursive. In contrast to her written production difficulties, MN was unimpaired in recognizing visually presented letters and words in upper-case print. We find a modest benefit of visual form cueing in the written production of upper-case letters, despite an inability to describe or report visual features of letters in any case or font. This case increases our understanding of the allographic level of letter-shape representation in written language production. It provides strong support for previous reports indicating the neural independence of different types of case and font-specific letter-shape information; it provides evidence that letter-shape production does not require explicit access to information about the visual attributes of letter shapes and, finally, it reveals the possibility of interaction between processes involved in letter-shape production and perception.

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.

Letter processing automatically recruits a sensory–motor brain network

Behavioral, neuropsychological and neuroimaging research suggest a distributed network that is recruited when we interact with letters. For the first time, we combine several letter processing tasks in a single experiment to study why letters seem to engage such disparate processing areas. Using fMRI, we investigate how the brain responds to letters using tasks that should recruit systems for letter perception, letter writing, letter copying and letter imagery. We describe a network of five cortical regions including the left fusiform gyrus, two left pre-central areas, left cuneus and the left inferior frontal gyrus that are all selectively engaged during a 1-back matching paradigm with letters. Our results suggest involvement of these regions to different extents in different tasks. However, the regions also form an integrated network such that letter perception also engages motor regions while writing recruits letter-specific visual regions as well. We suggest that this distributed network is a direct result of our sensory-motor interactions with letters.

The evolution of dysgraphia in Alzheimer’s disease

Evidence from recent studies suggests that writing may be an aspect of cognition capable of identifying impairments specific to patients with Alzheimer's Disease (AD). The precise nature and progression of the writing disorder, however, remains unclear. The current study assessed the central and peripheral aspects of writing among a sample of minimal, mild and moderate AD patients and a group of healthy elderly controls on a narrative description task. Comparisons of the two groups indicated that AD patients suffer from a primary impairment at the semantic level. Even those in the minimal stages of the disease could be differentiated from controls on measures of word finding and information conveyed. This semantic impairment was coupled with a secondary milder impairment in phonological processing. The prevalence of phonological errors increased, but no shift in error type (plausible/implausible) was identified as the disease progressed. In addition to the central impairments, patients evinced damage at the peripheral level. In the more severe stages, patients experienced more problems with letter formation and stroke placement and tended to rely upon the more simplistic writing form of print. The writing impairment in AD is multi-componential in nature and follows the pattern of cortical deterioration reported in the brains of AD patients.

A case for case: handling letter case selection in written spelling

This study reports the unusual writing performance of a 72-year-old woman, Pp, who was unable to maintain her writing within a particular case, and made numerous case mixing errors (e.g. insTEAd). Her oral spelling was flawless, but when tested using a written spelling task (including words and non-words), a picture description task, a sentence writing task and a transcription task (from upper case to lower case, and vice versa), she showed a high proportion of case mixing errors, though spelling per se was correct. The problem, although less severe, was also present when spelling with letter cards. Despite a spared ability to select the correct letters in the stimulus, specify the correct number of letters and place them in the correct order, she had a specific problem in selecting the appropriate case. This impairment is indicative of peripheral dysgraphia. She appeared to have intact orthographic representations, but selection of the appropriate allographic codes for upper and lower case was impaired. Her longitudinal neuropsychological profile and MRI evidence suggest that Pp suffers from mild vascular dementia with more severe impairments in attentional functions. Her writing deficits may be accounted for by a model that incorporates an inhibitory mechanism, which is responsible for maintaining the appropriate case and inhibiting the inappropriate one, subsequent to case selection in writing. Failure of this mechanism would explain the pattern of case mixing shown by Pp.