1. CROSS LANGUAGE VARIATIONS IN LINGUISTIC DEFICITS IN DAT INDIVIDUALS Mr. SUNIL KUMAR. RAVI, 2 nd M. Sc (Speech – Language Pathology). & Prof. SHYAMALA. K. C., Dept. of SLP.

2. INTRODUCTION

3. DEMENTIA Dementia is a common clinical syndrome characterized by a decline in the cognitive function and memory from previously attained intellectual levels, which is sustained over a period of months or years. The deterioration is of such severity that it impairs the affected individual’s ability to work and to perform activities of daily living, including communication

4. Cummings and Benson (1992) state that at least three of the following five areas of mental activity must be involved: 1.Language; 2.Memory; 3.Visuospatial skills; 4.Emotion or personality; and 5.Cognition (ex: abstraction, calculation, and judgment).

5. The DSM – IV & APA, 1994 states that the essential feature in dementia is impairment in short term and long term memory. This deficit in memory may also be associated with one or more features like, aphasia, apraxia, agnosia, impairment in abstract thinking, impaired judgment, and personality changes.

6. INCIDENCE & PREVALENCE In India, approximately 3 to 4 million people had been affected by dementia (ARDSI). About 4% of the population over 65 years is afflicted with dementia; It is expected that around 10 million people will be afflicted with Alzheimer’s disease by 2010. It is expected to be 36 million by 2020 (WHO, 2001).

7. Shaji (2005) reported that Prevalence of dementia in Kerala was 33.6 per 1000 (95% CI 27.3-40.7).  Alzheimer's disease (54%)  Vascular dementia (39%), and  Other causes such as infection, tumor and trauma (7%)

8. The language disturbances in dementia long have been reported. Interest in the dementias has increased in the past decade Resulted in more systematic description of the effects of dementia on communication Since dementing illnesses are associated with the elderly, we can expect that the prevalence of dementia will increase.

9. Dementia can be caused by a variety of conditions: diseases, infections, or infarcts. Alzheimer’s disease (AD) accounting for 50 to 60% of all the patients with dementia, Vascular dementias are seen in 20% of the dementia patients. Other causes account for 20 %.

10. DEMENTIA OF ALZHEIMER’S TYPE (DAT)

11. A type of dementia which is associated or caused due to Alzheimer’s disease. AD is a degenerative disease that attacks the brain, begins gradually, and progresses at a variable rate. AD results in impaired memory, thinking, and behavior and can last from 3 to 20 years from the time of onset of symptoms.

12. Warning signs of AD are: Memory loss that affects job/home skills, Difficulty performing familiar tasks, Problems finding the right words, Disorientation to time and place, Poor or decreased judgment, Difficulty with learning and abstract thinking, Placing things in inappropriate places, Changes in mood and personality, and Marked loss of initiative.

13. With the help of standardized diagnostic criteria, physicians can now diagnose AD with an accuracy of 85-90% once symptoms occur. However, a definitive diagnosis of Alzheimer’s disease is possible only through the examination of brain tissue at autopsy. AD is a debilitating progressive disease which gradually affects all aspects of cognition and behavior, including aspects of semantic memory and semantic knowledge.

14. Most patients with confirmed Alzheimer’s disease appear to have fluent speech with poor semantic content and comprehension. Selective loss of the appropriate use and recall of word meanings and object naming and recognition occurs particularly in discourse. Phonology and syntax are usually well preserved until later stages of the disease. Affected individuals progress from mild memory loss and the capacity to live independently to intellectual devastation and total dependency.

15. Communication deficits in DAT Deterioration of quality of life of DAT patients Communication deficits Cognitive Deficits

16. Stages of AD Obvious impairments to episodic memory Ability to abstract the central message from information is affected. Early Encoding and retrieval of information are both diminished, and memory span capacity is reduced Struggle to retrieve names & Verbal output diminishes Middle Neuropathology is widespread and perception, attention, encoding, retrieval, and executive functioning are all significantly compromised The content of utterances is often nonsensical and comprehension of written text is typically impossible Late

17. DAT IN BILINGUALS

18. Using one or two languages depending on the context and interlocutor is skill healthy bilingual speakers manage with ease. They are able to select the appropriate language to speak for a particular occasion depends on a complex interaction of topic, setting, participants and so forth. Random switching between languages and mixing them together is a common occurrence

19. However, despite this apparent randomness, the types and degree of mixing and switching tolerated are highly structured. When needed, speakers can maintain strict separation between their languages for example when speaking to a monolingual speaker. Studies have suggested that bilingual speakers with AD, even in the early stages of deterioration, can have problems selecting the appropriate language, and maintaining conversations in that language once appropriately chosen

20. Two mechanisms underlying inappropriate language use in bilingual AD speakers 1.Language choice problem 2.Language separation problem Few studies on bilingual AD have investigated discourse management along these lines

21. Researchers set out to answer questions such as whether a given speaker has either a choice or a separation problem; 1.Whether every bilingual speaker with AD evidences these difficulties? 2.How the incidence and prevalence of a choice or separation problem relates to severity of dementia? 3.Whether the direction of mis-selection or intrusion of one language into another is bidirectional and unpredictable, or whether, for instance, is it always one language (e.g. the most proficient/ the first learned/ the most recently used) that takes precedence over the other; and so forth?

22. Conclusions indicate that not every bilingual individual with AD demonstrates inappropriate language use. There is large variability in the extent of appropriate/ inappropriate language use, with some individuals showing more language mixing than others.

23. The ability to maintain fluency in more than one language decreases with advancing age. Older people may have a tendency to retreat to a single language, even those with a lifetime of bilingualism. Bilingual dementia patients tended to have asymmetrical language impairment with preferential preservation and use of the first acquired language.

24. Need for the Study India being a multilingual country and with rapid increase in geriatric population, the incidence & prevalence of DAT is increasing. This bilingualism and multilingualism becomes an important issue during assessment and management of individuals with DAT. Question arises in terms of the language in which, speech and language therapy should be given and on what basis we should select that language, etc

25. Therefore, there is a great need to study the cross language variations in bilingual dementias to explore the nature of language deficits in each language. And this will in turn help in both assessment and management of these individuals.

26. AIM OF THE STUDY

27. The aims of the present study were 1.To explore the nature of the linguistic deficits in both the languages of bilingual DAT individuals and also 2.To study the differences in performance between bilingual DAT individuals and normal population.

29. Subjects 20 individuals who were diagnosed as DAT by a neurologist or psychiatrist in the age range of 45 to 65 years were taken for the study. Inclusion criteria for selection of DAT subjects: 1.Subjects who are diagnosed as having DAT by a neurologist or psychiatrist, 2.Subjects who have Kannada as their native language (L1) and English as their second language (L2), 3.A relatively stable clinical and metabolic state, and 4.Fair knowledge of reading and writ­ing in Kannada and English languages.

30. 20 age and gender matched normal subjects without any past neurological or psychiatric disorders were taken as control group.

31. Test material Dementia Assessment Battery (DAB) in English and Kannada

32. MemoryLinguistic Expression Linguistic Comprehension Visuospatia l skills 1Episodic Memory Object NamingComparative Questions Generative Drawing 2Working Memory Generative NamingFollowing CommandsFigure Copying 3Semantic Memory Confrontation Naming Reading Comprehension of Sentences 4Delayed Story Telling Responsive SpeechReading Commands 5Spontaneous Speech 6Repetition

33. Data Collection Data collection was done at Department of Speech – Language Pathology at All India Institute of Speech and Hearing, Mysore, India with the subjects hailing from Mysore and Bangalore cities

34. RESULTS AND DISCUSSION

35. The results of various tasks like memory, language expression and language comprehension were compared between DAT individuals in Kannada and English languages and the results were also compared with that of results of normal adults Majorly, four comparisons were made in this study to study the cross language variations in DAT individuals

36. Comparison of performance of normal adults in Kannada and English Languages Independent samples t – test to find out the significant difference between two groups across the parameters. No significant difference between two groups on memory (p>0.005, f = 0.10) and language expression (p>0.005, f = 0.08) tasks and Significant difference was found on language comprehension tasks (p<0.005, f = 0.01).

37. Mean and S.D of normal individuals in Kannada and English on different tasks TasksGroupNMean Std. Deviation Memory Nl Kan2086.55002.4810 Nl eng2081.35004.9553 ExpressionNl Kan20234.15005.0604 Nl eng20223.65009.7618 ComprehensionNl Kan20143.00004.4129 Nl eng20118.000011.4202 TOTALNl Kan20463.70006.4571 Nl eng20423.000018.2064

38. Comparison of performance of individuals with DAT in Kannada and English Languages Results showed that there is a significant difference between the performances of DAT individuals in English and Kannada on all the three tasks (p<0.005, f = 0.01).

39. Mean and S.D of individuals with DAT in Kannada and English on different tasks TasksGroupNMeanStd. Deviation MemoryDem Kan2042.65005.5562 Dem eng2060.60005.1031 ExpressionDem Kan20118.000011.4202 Dem eng2095.700012.2651 ComprehensionDem Kan2098.050011.5005 Dem eng2081.35004.9553 TOTALDem Kan20258.700015.3695 Dem eng20237.650017.1595

40. Individuals with DAT Vs normal individuals in Kannada Language Results showed that there is a significant difference between the two groups on language expression (p<0.005, f = 0.04) and language comprehension (p<0.005, f = 0.01) tasks. No significant difference was found between two groups in memory tasks (p>0.005, f = 0.06).

41. Mean and S.D of individuals with DAT and normal individuals in Kannada on different tasks. TasksGroupNMeanStd. Deviation MemoryNormal Kannada2086.55002.4810 Dementia Kannada2042.65005.5562 ExpressionNormal Kannada20234.15005.0604 Dementia Kannada20118.000011.4202 Comprehe nsion Normal Kannada20143.00004.4129 Dementia Kannada2098.050011.5005 TOTALNormal Kannada20463.70006.4571 Dementia Kannada20258.700015.3695

42. Individuals with DAT Vs normal individuals in English Language Results showed that there is a significant difference between the two groups in memory (p<0.005, f = 0.04), language expression (p<0.005, f = 0.02) and language comprehension (p<0.005, f = 0.02) tasks

43. Mean and S.D of individuals with DAT and normal individuals in English on different tasks. TasksGroupNMeanStd. Deviation MemoryNormal Kannada2081.35004.9553 Dementia Kannada2060.60005.1031 ExpressionNormal Kannada20223.65009.7618 Dementia Kannada2095.700012.2651 ComprehensionNormal Kannada20118.000011.4202 Dementia Kannada2081.35004.9553 TOTALNormal Kannada20423.000018.2064 Dementia Kannada20237.650017.1595

44. Differences in performances in all the tasks between groups

45. Differences between groups on memory task Comparison of the performance of different groups is represented in graph – 1.

46. Differences between groups on language expression task Comparison of the performance of different groups is represented in graph – 2.

47. Differences between groups on language comprehension task Comparison of the performance of different groups is represented in graph – 3.

48. Graph – 4 consists of results of the all the groups on three tasks and total of the three tasks.

49. DISCUSSION

50. The above results indicated significant differences in the performance of language and memory skills between normal and DAT individuals in both languages. The differences in performance between Kannada and English languages can be attributed to the factors like age of acquisition of English, amount of exposure, language use in daily life, etc… and these factors can influence the performance of the both groups.

51. Bilingual dementia patients tended towards asymmetrical language impairment with preferential preservation and use of the first acquired language. Studies in aphasic patients from strokes and other brain lesions show that recovering language patterns are most commonly synergistic; recovery in one language is accompanied by recovery in another.

52. Many bilingual aphasic patients, however, recover differentially in one language. In these circumstances, the language most recovered may be the earliest acquired language, or the language of greater use, or the language spoken in the patient’s environment. In dementia, due to deficits in memory, the earliest language is preserved than the new language

53. In dementia, a retreat to the original language could result from an exacerbation of the cross-language difficulties that typically increase with age. “Cross – language interference” refers to deviations from the language being spoken due to the involuntary influence of the “deactivated” language. Dementia patients tend to mix languages, and they have special problems with language separation.

54. These results are in agreement with studies by Cummings et al., 1985; Bayles et al., 1993; Luderus 1995 in that, the deficits found in this study were similar to the findings of the above studies. The cross language variations were more similar to those seen in bilingual aphasics with English – Yiddish and German – Dutch background as reviewed by Paradis, 1997.

55. CONCLUSIONS

56. This study has revealed that the individuals with DAT have language deficits in both comprehension and expression and also in memory tasks. Significant differences were found between the performances of DAT individuals in Kannada and English. This becomes an important issue in the selection of language used in speech and language management of bilingual DAT individuals

57. Individuals with DAT have better preserved language skills compared to English and thereby, suggesting continuing the speech and language therapy in the native language than in the second language. The deficits in language skills in both languages were similar to that of bilingual aphasics, but, the recovery processes may not be same in both the disorders due to variations in the site of lesion and also due to changes in histopathological changes in the central nervous system (CNS).

58. For speech – language pathologists, it becomes an important issue during selection of management programs for individuals with DAT. Several studies have been conducted on normal bilinguals and on bilingual aphasics to find out the language organization in them. Future studies are expected to determine the language organization in CNS in DAT individuals and their effect on first and second languages

59. More studies in this area in different languages can give information on differences in performances between languages. These results can be applied and are useful in both assessment and management of the individuals with DAT.

60. Dr. Vijayalakshmi Basavaraj, Director, AIISH, Mysore. Organizers of SCONLI – 3.