Differential Diagnosis

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Differential Diagnosis

• Language impairments after head injury
• Speech, reading and writing
• Pragmatics
• Language impairments in dementia
• Speech, reading and writing
• Differential diagnosis
• Summary

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Acceleration/ deceleration
Contusions haematoma
Diffuse damage
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Pre-morbid ability
Cognitive function
Plateau of recovery
trauma coma PTA 3 6 12 24 (months)
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Language impairments after traumatic brain injury

• Patients with traumatic brain injury (TBI) have a
  variety of language disorders but usually have an
  expressive aphasia (Broca's aphasia) and anomia
  (word production) and/or receptive aphasia
  (Wernickes aphasia).
• Most TBI patients can understand speech after
  emerging from Post-Traumatic Amnesia (PTA) but
  speech production impairments last longer.
• TBI patients can spontaneously recover basic
  comprehension abilities sooner than expressive
  abilities following head injury (Groher, 1990).

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Most typical language impairments following TBI

• Speech impairments
• articulation problems dysarthria
• sound substitutions phonemic paraphasias
• or word substitutions semantic paraphasias
• Word finding difficulties (anomia)
• Acquired dyslexia
• Acquired dysgraphia
• Peripheral writing problems (allographia)
• Dis-inhibition characterizing speech content
• Impairment to the indirect use of language called
  pragmatics.

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Written language impairments

• Acquired dyslexia
• Surface e.g., bury read as b?ry
• Deep e.g., bury read as grave
• Phonological e.g., jar (v) better than nar (x)
• Acquired dysgraphia
• Surface e.g., bury written as berry
• Deep e.g., bury written as grave
• Phonological e.g., jar vs nar
• Other writing problems
• These include letter case substitution errors (B
  for b) letter sequencing and graphic motor
  errors and word finding errors.

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Pragmatics of communication

• McDonald (1995) found TBI patients impaired at
  using language indirectly (metaphors, proverbs).
• The ways in which language is used socially such
  as social rules about conversations with another
  person or in groups, e.g., turn taking.
• Understanding and using words that mean one thing
  but when they are accompanied by a tone of voice
  or inflection this conveys the opposite meaning
  (e.g., innuendo, sarcasm).
• Use of indirect questions leads TBI patients to
  use the literal rather than the inferred meaning.

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Inference making

• In order to understand a sarcastic comment, the
  listener must process the literal meaning,
  compare this to information available from the
  context reject the literal meaning as patently
  unfeasible and replace it with a meaning that is
  more appropriate but is in fact the opposite.
• The listener must therefore have the skills to
  recognise that there is more to the question than
  the literal meaning and be able to infer the
  intention behind the utterance (mental model).
• Communication with patients can be difficult.

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• Jane and Billy rode together along the path. It
  was a warm and sunny day. They stopped near to
  the breaking waves and lay down a towel. Jane ate
  a sandwich and Billy drank lemonade
• What did Jane eat?
• Where are Jane and Billy?

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Dementia

• Deterioration in cognitive skills always involves
  memory, loss of time and place disorientation,
  intellectual decline and impaired judgment.
• A central feature of dementia is progressive
  deterioration of language processing as well as
  memory, praxic and visuo-spatial deficits.
• Language problems in dementia includes a
  restricted vocabulary limited to a few words and
  stereotyped automatisms e.g., How do you do?

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Folstein's Mini-Mental State Examination - MMSE

• ORIENTATION
• Ask the patient what (year) (season) (date) (day)
  (month) it is.
• Ask the patient where he/she is (province)
  (country) (town or city) (hospital) (floor).
• REGISTRATION
• Name 3 common objects (e.g., "apple", "table",
  "penny"). Take 1 second to pronounce each
• ATTENTION AND CALCULATION
• Ask the patient to substract 7 from 100 and keep
  substracting 7 until you tell him/her to stop.
• RECALL
• Ask the patient for the 3 objects repeated above.
  Give 1 point for each correct answer. (Note
• Recall cannot be tested if all 3 objects were not
  remembered during registration.)
• LANGUAGE
• Show the patient a "pencil" and a "watch" and ask
  him/her to name them.
• Ask your patient to repeat the following
• No ifs, ands or buts.
• Ask your patient to follow a 3-stage command
• Take a paper in your right hand, fold it in
  half, and put it on the floor.
• Ask the patient to read and obey the following
• Close your eyes. (1 pt)
• Write a sentence. (1 pt)

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Beck Depression Inventory - BDI

• 1)
• a) I do not feel sad 0
• b) I feel sad 1
• c) I am sad all of the time and I cannot snap out
  of it 2
• d) I am so sad or unhappy that I cannot stand
  it 3
• 2)
• a) I do not feel particularly guilty 0
• b) I feel guilty a good part of the time 1
• c) I feel guilty most of the time 2
• d) I feel guilty all of the time 3
• .
• .
• .
• .
• .

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Dementia and depression
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Dementia and depression
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Dementia

• Process of diagnosis is one of elimination
• Medical history (falls, LOC, epilepsy, family
  history)
• Clinical exam (neurological signs, MMSE lt24)
• Neuropsychological testing (WAIS, WMS, PALPA)
• Neuroimaging (CT, PET, fMRI)
• Clinical features include
• problems learning new material (episodic memory)
• remembering to do things (prospective memory)
• using language correctly (semantic memory).

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Dementia poor response
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Wisconsin Card Sorting Test
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Trails A
Trails B
The time difference for completing B compared to
A is increased in patients with FL lesions.
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Semantic memory

• The memory system used for language skills.
• It is conceived of as a mental thesaurus or store
  of knowledge about the meaning of objects, words
  etc. (Tulving, 1972).
• The organised knowledge that a person has about
  words and other verbal symbols their meanings and
  the relations among them.
• Our knowledge about the rules, formulas and
  algorithms for the manipulation of symbols,
  concepts and their relations is necessary for
  linguistic and higher cognitive processing tasks.

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hat
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Pyramids and Palm Trees test
Associative Semantics
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General language features

• Dementia can result in language disturbance to
  one or more of the following domains
• spoken word comprehension and production
• written word comprehension and production
• lexical-semantic ability (concept formation)
• perseverative (repetitive) speech errors
• word finding difficulties
• object naming problems
• semantic paraphasias e.g., boy/girl up/down
• Mutisminability to speak

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Mild stage of cortical dementia

• Patient is disoriented for time and place and
  memory for recent events has begun to fail (MMSE
  24-28).
• The patient relies on over-learned situations
  such as stereotypical utterances and often is
  unable to generate a sequence of related ideas.
• Patient begins to exhibit semantic impairment
• slightly reduced vocabulary
• word finding difficulties
• increased use of automatisms and clichés.

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Mild stage of cortical dementia

• Speech production
• syntax and phonology are both intact.
• Reading and writing
• reading regular words (jump) and nonwords (finp)
  is spared although there are errors with
  irregular words (yacht) surface dyslexia.
• writing impaired with peripheral dysgraphias.
• Pragmatic impairment
• this is characterised by a loss of desire to
  communicate and disinhibitions in speech.

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Moderate stage

• Patient has a severe impairment of memory and
  orientation to time and place (MMSE lt23).
• Speech is perseverative, non-meaningful and
  errors are not self corrected (as in mild stage).
• Patient shows further semantic impairment
• significantly reduced vocabulary naming.
• errors semantically and visually related.
• verbal paraphasias evident in discourse.
• utterances are usually very concrete.

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Moderate stage of cortical dementia

• Speech production
• reduction in syntactic complexity of speech.
• phonology is generally intact though repetition
  skills begin to deteriorate.
• patient makes frequent circumlocutions
• e.g. toothbrush -gt the thing you brush your teeth
  with.
• Reading and writing
• nonword and irregular word reading both impaired.
• surface dysgraphia emerges (e.g., yacht --gt yot).
  
• Pragmatic impairment
• declining sensitivity to context, diminished eye
  contact and egocentricity in speech content.

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Advanced stage

• Patients are now very disoriented for time, place
  and person and fail to recognise family and
  friends i.e. prosopagnosic (MMSE lt17).
• Patients require extensive personal care.
• Further semantic impairment is observed.
• very reduced vocabulary
• frequent use of unrelated word meanings
• jargonaphasia and neologistic speech

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Advanced stage of cortical dementia

• Speech production
• further syntactic and phonological impairment
• many inappropriate word combinations
• paraphasias and neologisms
• Reading and writing
• reading aloud and spelling and writing of regular
  words, irregular words and nonwords is impaired.
• Pragmatic impairment
• non adherence to conversational rules (turn
  taking)
• poor eye contact
• lack of social awareness (disinhibited speech)

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Focal frontal lobe atrophy
Focal temporal lobe atrophy
Localised damage
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Focal lobar atrophy (Picks Disease)

• Progressive atrophy of the brain that is confined
  initially to either the frontal or temporal
  lobes.
• Pick's disease was considered to be a rare cause
  of dementia, that was indistinguishable from
  Alzheimer's disease but improved diagnostic tests
  have lead to an increased recognition of cases of
  focal lobar atrophy.
• It has been claimed that 10-20 percent of younger
  patients with dementia (i.e those below the age
  of 65) may have Pick's disease.

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Frontal lobe atrophy

• A frontal dementia (loss of either executive and
  social function) and progressive nonfluent
  aphasia (loss of output grammar and phonology).
• Frontal dysfunctions such as adaptive behaviour
  abstract conceptual ability set-shifting/mental
  flexibility problem-solving planning
  sequencing of behaviour temporal order
  judgments personality, drive, motivation and
  inhibition.
• Often changes in personality and social conduct
  predominate over the loss of cognitive skills.

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Progressive Non-fluent Aphasia

• A gradual decline in language abilities affecting
  predominantly language output - disintegration of
  grammar and phonology - which in some progresses
  to a state of complete mutism.
• The language disorder resembles a Brocas type
  non-fluent aphasia with very frequent
  phonological errors in speech although use of
  simple syntax can be preserved in early stages.
• The preservation of nonverbal skills, nonverbal
  visuo-spatial memory and right hemisphere
  functions separates this from a dementia.

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Temporal lobe atrophy

• The most common presentation is fluent
  progressive aphasia because speech output is
  grammatically correct.
• The language impairment is restricted to the
  comprehension of single words together with some
  reduced vocabulary causing anomia.
• Most of the features can be explained in terms of
  a breakdown in semantic memory leading to severe
  anomia impaired performance on category fluency
  tests defective word-picture matching and a
  loss of general knowledge.

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Semantic dementia

• The term semantic dementia has been applied to
  this syndrome of fluent progressive aphasia.
• Episodic memory, visuo-spatial and frontal
  executive abilites are preserved in the early
  stages which contrasts sharply with the typical
  presenting features of Alzheimer's disease.
• As the disease progresses SD patients may develop
  Kluver-Bucy Syndrome (disturbance in eating
  behaviour with a tendency to consume inedible
  things) as a result of bilateral damage to the
  amygdala as well as visual agnosia.

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DAT or Semantic dementia (SD)?

• Episodic and semantic memory
• DAT patients can remember events from early years
  but are poor at recall of recently acquired
  episodic knowledge i.e. there is a negative
  temporal gradient whereas SD have preserved
  memory for recent events.
• Visuospatial and perceptual skills
• DAT patients are impaired on tasks such copying
  the Rey Figure but visuo-perceptual skills are
  intact in SD.
• Lesion Loci
• DAT patients have bilateral lesions in the medial
  temporal lobes whereas semantic dementia patients
  have damage to the inferior temporal cortex that
  is often worse in the left hemisphere.

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DAT, SD or Progressive Aphasia (PA)?

• 1) Spontaneous speech
• DAT present initially with normal speech SD show
  fluent and grammatical speech but devoid of
  content.
• Patients with PA have impaired spontaneous
  speech.
• 2) Comprehension of single words
• DAT present initially with normal comprehension
  of single words but SD patients are impaired
  early in the disease and generate frequent
  semantic paraphasias.
• 3) Comprehension of syntax
• DAT and SD patients present initially with normal
  comprehension of syntax but patients with PA make
  frequent phonological errors.

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Summary

• Aphasias and language impairments can be useful
  in the differential diagnosis of brain damage due
  to head injury and dementia.
• Head injured patients tend to show aphasia in the
  recovery phase but this resolves leaving longer
  term pragmatic language impairments.
• Patients with semantic dementia display early
  comprehension impairments whereas patients with
  dementia of the Alzheimers type tend to develop
  language difficulty later in the disease.

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Frontal lobe dementia
Temporal lobe dementia
Localised damage
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Pseudodementia

• The MMSE and the BDI would be the tests of choice
  for distinguishing one from the other.
• Patients who are depressed but not dementing will
  not have aphasia, apraxia or amnesia.
• Qualitatively, depressed/anxious patients are
  often inquisitive about their performance and the
  onset of symptoms is usually rapid.

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Dementia and depression

• Disorientation, self care
• Performance on tests of cognitive function
• Poor performance on
• Timed tests e.g. WAIS-R Block design subtest
• Preserved oral reading of irregular words e.g.
  NART.

• Disorientation, self care
• Performance on tests of cognitive function
• Poor performance on
• Timed tests e.g. WAIS-R Block design subtest
• Preserved oral reading of irregular words e.g.
  NART.