Imagine you forget…
…how to cook your favourite meal, what the name of your best friend is, or what bus you have to take to get home. In our everyday lives, we take memory and language for granted. Our everyday communication has become highly automatised and also routinised. We can think about our last school trip, about our last birthday party, and about our last holiday vacation. Usually, we don’t have any problems to tell other about these experiences in detail without being aware of how complex the interconnection between language and the brain actually is. This is a good thing. We don’t have to worry about it at all and are able to enjoy thinking back to these days and share these memories with our family and friends. This is the case with a healthy brain.
Unfortunately, it can also happen that the brain partially loses its functions through accidents and diseases or even through dysfunctions present at birth. For example, a person becomes unable to speak fluently or write correctly anymore and has to learn it again. In fact, the brain is a very sensitive system and even small impairments can lead to serious damages in the overall brain functions. Therefore, it is a real privilege to have a healthy brain and being able to speak as we think. Memory and language are two of the most important tools that we, as human beings, are equipped with and these are vital for living our lives independently.
However, even at young age we are not immune to damage caused for example by strokes, heart attacks, and dementia which have a deep impact on our mental and physical abilities. The brain is a very complex system that makes us the way we are and any harm can have serious implications. We use it to produce language, so to form sentences such as questions, answers, compliments, and even insults (when we are really angry at someone). Being able to produce sentences makes it necessary to comprehend sentences we hear from others or which we read in a book. Two areas in the brain, namely Broca’s and Wernicke’s area (see picture below), play an important role when language is comprehended and produced. Consequently, any harm to the brain in these areas can lead to difficulties in the comprehension and production of language. Broca’s area is important for producing and Wernicke’s area is important for comprehending language.
When working in the field of Clinical Linguistics, you encounter the terms Broca’s and Wernicke’s area regularly and therefore, it could be useful for you to have heard of them. A term you also encounter quite often in Clinical Linguistics is Dementia of Alzheimer’s type or Alzheimer’s disease. You will learn more about Alzheimer’s disease in this post, but before we get to this topic, here is a quick crash course in Clinical Linguistics:
The term ‘Clinical Linguistics’ started to become widely known during the 1970s and was used as the title of a particularly influential book by David Crystal, which mapped out the territory of the new discipline. Crystal defined it as ‘the application of linguistic science to the study of communication disability, as encountered in clinical situations’ (p. 1). Clinical Linguistics is concerned with the diagnosis and treatment of language disorders and also aims at developing guidelines for attending doctors, patients and those who care for the patients. Thus, it gives a straight and concise overview of this field the study of Alzheimer’s disease is embedded in.
Many people get confused when hearing of Alzheimer’s disease and dementia because they don’t know the difference between these two terms. Dementia is the cover term and describes a group of diseases that affect the general functions of the brain. There are more than 50 different kinds of dementia. The most frequent one is dementia of Alzheimer’s type, which accounts for 60% of the reported cases of dementia. Other forms of dementia are, for example, Parkinson’s disease or vascular dementia. In 1907, a German psychiatrist named Alois Alzheimer described another type of dementia that is named after him for the first time. Auguste Deter was 51 year old when she was put into psychiatric care. She was mentally confused, had only limited memories of her life and was not able to correctly answer questions. At 51 years her mental state was unusual. Usually, the same mental state is found in 70-year-olds. Alzheimer presented his findings on the disease in his famous paper Über eine eigenartige Erkrankung der Hirnrinde.
Up to now, it has not been discovered why some people develop Alzheimer’s disease. It often occurs in patients who are age 65 and older. The probability of developing Alzheimer’s disease increases with age. It causes nerve cells in the brain to die off, which, as a consequence leads to a decrease in the cognitive and communicative abilities and physical abilities of the patient. While the disease can not be entirely cured there is medication that can slow down its progress. Before we tell you about the symptoms that occur in Alzheimer’s, we would like to show you how the brain is affected by the disease.
On the picture below you can see a neural pathway. The activity of the human brain is based on networks of neuron cells. Billions of neurons are highly interconnected in the brain, where each neuron is connected to thousands of others. Here, all the information is being processed (this can be a thought, a motion, sensory input etc.). A neuron basically works like a switch, which, once activated, sends an electric signal to other neurons. In a patient who has developed Alzheimer’s, the connection between neurons can be destroyed and the signal cannot be transmitted any further.
Like dominos toppling over:
If we remove a single domino stone from a series of dominos, the succeeding stones cannot fall over and the motion of the toppling pieces is stopped. As a consequence, the patient can be impaired in memory and communication, but also motoric skills and orientation decrease over the course of the disease.
In the onset of the disease, the patient starts to have difficulties in finding particular words. This can range from forgetting simple words to names of people s/he is close to. For example, a patient knows what a flower is, has an idea of it in mind and recognizes one if seen, but the word to label it is missing. In the course of the development of Alzheimer’s, people suffer not only from the loss of short time memory but also from a decline of their fine motor skills. Everyday activities like writing, drawing, getting dressed and washing yourself become more and more difficult tasks in their lives. In a later stage, patients begin to lose their long-term memory, which leads to the point of a patient not being able to remember people and everyday objects. At this stage, Alzheimer’s patients are not capable of recognizing family members and friends and a mother might ask her own daughter “Who are you?”. Alzheimer’s can also lead to changes of mood and personality. A person that used to have a quiet and gentle character can become aggressive. Overall, patients are less and less able to communicate actively as the disease develops (see speech sample below). While there is a progressive decrease of language and memory capabilities they, at a later stage, start being less aware of the language problems they have. When the disease reaches a critical point, patients stop talking at all, as you can see in this speech sample:
HEIDI: Isn’t that .. Is that a nice man?
HEIDI: Who is that?
ELSIE: Mhm. (Hamilton 1994: 159)
This speech sample shows parts of a conversation between the Alzheimer’s patient Elsie and the researcher Heidi Hamilton who recorded this conversation in a care centre for Alzheimer’s patients. She talked with Elsie a lot and recorded the conversations to see how Elsie’s illness developed over time. This sample shows a late stage of the illness. To the present day, no medication has been found to cure Alzheimer’s, nor is there a medical treatment that slows down the degenerative process of the disease. Nevertheless, speech therapists work with patients of Alzheimer’s disease and have them to perform different language tasks. What this treatment can look like you will learn in the following part:
In the first part of this post, you have received information about Clinical Linguistics, a distinction between dementia and Alzheimer’s disease and different symptoms people with Alzheimer’s disease show.
Now, in the second part we want to introduce you to the important and valuable work of speech therapists, not by just listing possible treatment options that are available for patients of Alzheimer’s disease, but by telling you about the experience we gained by attending several therapy units in a small institution for speech and language therapy. The experiences are based on an internship that has been performed in the framework of a linguistic-related internship, which is a requirement of the master’s programme of Applied Linguistics, providing a profound insight in a future field of work based on our course of studies. We do not want to use the word therapy centre because it would not correctly describe the place in which the treatment of the patient took place. The speech therapist’s office can be described as comfortable because it contained a big desk, two chairs, shelves filled with books and many games for younger patients; it looked like a home office. The therapy room did not look like the ones we are used to when attending a doctor’s appointment and can best be described as “comfortable” due to the way it was furnished; this had also a relaxing effected on the patients that came to the therapy. It made the therapy units less discomforting and less sterile.
The patient was an elderly woman in her late 70’s who had dementia of Alzheimer’s type. In the following, we will refer to her as Grandma, as we do not want to use the word patient that often because it sounds too distant. Grandma was a warm-hearted person, but very insecure in terms of her self-confidence since she had forgotten “so many words” as she explained to us several times. She also told us that she had forgotten how to cook certain meals, for example, a cutlet in a pan. It was interesting to listen to her, as while she could not remember this piece of information she was fully aware of it. At the same time, it was sad because she explained to us that she felt insecure and not confident enough doing tasks all alone which were easier in the past. She was in an early stage of Alzheimer’s disease.
The speech therapist started the treatment unit with a short text (here, it was a short poem) that Grandma was supposed to read out loud in order to relax the muscles of her mouth. In an advanced stadium of Alzheimer’s disease, people talk less and less; they are not used to speak frequently anymore. Therefore, this exercise can be seen as a “warm-up” for the next exercises. Grandma showed symptoms of the early stages of Alzheimer’s disease and was therefore still communicative and able to write, but her memory was weak.
Among other exercises, Grandma had to form a new word by putting together two other words, for example, “Kinder” and “garten” → “Kindergarten” or “Schaf” and “hirte” → “Schafhirte”. Sometimes she switched two words and put them together in the wrong order and she often commented on the task with “das Wort kenne ich doch”, again showing that she was aware of her condition. As the speech therapist explained to us, this exercise served to repeat and support those words that are still familiar to Grandma in order to strengthen them in her memory as far as this is possible. Also, this exercise should train Grandma’s understanding by helping to create a “mind map” comprising all words she still can come up with.
Another exercise she did take part in was the task of finding as many words as possible that started with a particular letter. For example, she had to name all animals starting with the letter “k”. We could experience how difficult it can be to find a word of a specific category (animals) with a specific criterion (starting letter: k) when it is required. Grandma attempted to find many different words and we observed that she repeated several of the words she and we had already mentioned. For some words, she realized that she repeated them. For some, she thought she found them for the first time. The speech therapist explained that this exercise is useful to train Grandma’s “verbal fluency”. That means, to help her finding more words and to find them quicker. The way Grandma behaves in the task tells the therapist about the knowledge she has about the words.
A further exercise we want to describe to you is one that included changing the order of letters and writing them down (preferably in the right order). The words that had to be found belonged to the category of German authors, for example, “HREANNM EHSSE” had to be reordered to “HERMANN HESSE”. Some words were easy to find for Grandma and others were more difficult. When she could not find a word after trying hard the speech therapist gave hints such as pronouncing the author’s last name. After Grandma found the word she commented it with “ich bin ja so dusselig”. Here, the exercise is used to train Grandma’s “planning” of words. This involves looking at the “chaotic” words and understanding that the letters are in wrong order. It also entails making a “plan in mind” and bringing the letters back into the correct order. In this exercise, the brain has different functions to fulfill: Seeing, understanding, planning and reordering.
Getting to know Grandma and attending several therapy units showed us that healthy brain functions are essential for communication, writing, cooking…living independently. Therefore, we need to take care of us and our fellows and should treat people with respect regardless of their physical or mental condition. Just because a person cannot speak properly it does not necessarily mean that this person is less intelligent. Up to now, there is no cure for Alzheimer’s disease and therefore doctors, speech therapists, caregivers, and family members need to support patients to the best of their ability. Many of us who do not have any direct experience with this disease can help rebuilding an Alzheimer’s patient’s self-esteem by treating them respectfully.
We hope that you could get an insight into the area of Clinical Linguistics and the specific example of Alzheimer’s disease. It is of great importance to raise awareness for this disease because, compared to 100 years ago, more people get to the age where the disease might be a serious problem. An interesting movie we can recommend is the drama Still Alice which was released in 2014. It is about a 50-year-old Linguist named Dr. Alice Howland who is facing the diagnosis of early onset Alzheimer’s disease and coping with the changes it causes in her life: “I am not suffering. I am struggling. Struggling to be part of things, to stay connected to whom I was once. So, ‘live in the moment’ I tell myself. It’s really all I can do, live in the moment”.
(NOTE: If the authors have indicated their real names at the beginning or end of the post, please substitute the pseudonyms accordingly.)
Aitchison, J. (2003). A Glossary of Language and Mind. Edinburgh: Edinburgh University Press.
Hamilton, H. (1994). Conversations with an Alzheimer’s patient: An interactional sociolinguistic study. Cambridge: Cambridge University Press.
Hughes, J. C. (2011). Alzheimer’s and other dementias. Oxford: Oxford University Press.
Jucker, M., Beyreuter, K., Haass, C., Nitsch, R., & Christen, Y. (Eds.). (2006). Alzheimer: 100 years and beyond. Berlin: Springer.
Marnis, T. (2009). Syntactic Processing in Developmental and Acquired Language Disorders. In: Ball, M. J., Perkins, M. R., Müller, N., Howard, S. (Eds.). The Handbook of Clinical Linguistics. (pp. 198-211). Oxford: Blackwell.
Still Alice (2014). (2016). IMDb. Retrieved 06 December 2016, from http://www.imdb.com/title/tt3316960/quotes
Figure 1 retrieved from “Aphasia” by the National Institute on Deafness and Other Communication Disorders, 2015, NIH Publication, No. 97-4257. https://www.nidcd.nih.gov/health/aphasia [12-11-2016].
Figure 2 retrieved from “GFP expressing pyramydal cell in mouse cortex. Dynamic Remodeling of Dendritic Arbors in GABAergic Interneurons of Adult Visual Cortex” by W-C. A. Lee, H. Huang, G. Feng, J. R. Sanes, E. N. Brown, P. T. So, and E. Nevidi (PLoS), 2006, Biology, Vol. 4, No. 2, e29 DOI: 10.1371/journal.pbio.0040029 [12-11-2016].