Picture Naming of Patients with Alzheimer' Disease, Aphasia and The Healthy Elderly

Fariba Yadegari, MSc,Speech - Language Pathologist
Instructor/ Ph.D student
Affiliation: University of Social Welfare and Rehabilitation Sciences( USWRS)

Mahshid Foroughan, MD, Psychiatrist
Title: Assistant professor, Research deputy of Iranian Research Center on Aging
Affiliation: Iranian Research Center on Aging( IRCA), University of Social Welfare and Rehabilitation Sciences( USWRS)

Azar Mehri , MSc, Speech - Language Pathologist
instructor
Affiliation: Tehran Medical University, Faculty of Rehabilitation

Peymaneh Shirinbayan, MSc, Psychometrist
Research expert
Affiliation: Iranian Research Center on Aging (IRCA), University of Social Welfare and Rehabilitation Sciences( USWRS)

Correspondence:
Dr A S Ajaj MBBCh MSc (Keele) FRCP (Lond)
Fariba Yadegari, Speech Therapy Department,
University of Social Welfare and Rehabilitation Sciences,
Kudakyar St, Daneshjoo Blvd, Evin
Zip Code: 1985713831
Tehran, Iran
Telefax: 0098 21 22180043
E-mail: faribayadegari@yahoo.com

INTRODUCTION

Confrontaton naming performance is one of the important language functioning indices which is often assessed by picture naming tests.These neuropsychological tests typically include pictures of familiar objects such as tools, fruits, animals, etc. which should be named by the subject. Anomia is one of the very early symptoms observed in patients with dementia of Alzheimer type (DAT) and, also, a universal frequent symptom in aphasic patients. However the nature of the two problems is considerably different. As Randolph et al. mentioned ," ... little work has been done... to determine how various demographic, linguistic, and disease status variables influence patterns of performance on these tests"⁽¹⁾. Anomia in patients with DAT is supposed to have a semantic nature^(2,3) resulting from deterioration of semantic memory. But some studies have stressed the role of post semantic deficits such as phonological lexicon activation in DAT patients⁽⁴⁾. A tendency is increasing among researchers to consider semantic anomia in DAT patients as a category - specific deficit^(5,6,7) but this category specificity is by no means so prominent in aphasic patients, a fact which may be confirmed by the well-known verb-noun double dissociation in aphasic patients^(8,9). Also some authors are opposed to the semantic nature of anomia in DAT patients and attribute it to visual object recognition deficits^(10,11,12). The status for local acute lesions is much different. Aphasia arising from selective local impairments has been the subject of more detailed linguistically based tasks and, also, development of useful tools for testing psycholinguistic models⁽¹³⁾. Margolin et al showed that impaired word finding reflected impaired processing of semantic information in the patients with DAT, whereas in the anomic patients impaired processing related to the lexical-phonological information⁽¹⁴⁾. Some studies have shown that phonological priming is the most effective cue in confrontational tasks for aphasic patients regardless of type and severity of their impairments^(15,16). But Stimely et al. claimed that naming accuracy of aphasic patients was facilitated by both phonemic and semantic cues⁽¹⁷⁾. Also, Butterworth et al. discussed that the incidence of semantic comprehension errors was not related to aphasic diagnostic group but to the overall severity of aphasia⁽¹⁸⁾ The present study was designed to compare visual confrontation naming performance in patients with DAT and aphasic patients and to assess the effects of semantic-phonologic priming on their performance.

METHODS

Two groups of patients participated in this study.The first group included patients with dementia of Alzheimer type (DAT) who were the clients of Iranian Alzheimer
Association, Tehran division and who had been successively presented to the attending psychiatrist of the association and met the criteria of DSM-IV-TR for the diagnosis of Alzheimer's disease and also the MMSE score < 27 at the interval of 2005-2006.

The second group consisted of aphasic patients who were referred by the speech therapy section of rehabilitation centers of Tehran and Mashhad at the interval of 2005-2006 to the researchers of the present study. They all suffered from an ischemic CVA damaging left perisylvian area which primarily included left temporoparietal region leaving them with a somewhat fluent aphasia, relatively spared oral expression skills and anomia. All the patients were literate (able to read and write) and in both bilinguals and monolinguals, Farsi was their primary language at the time of the disease.

We also used a control group consisting of healthy elderly individuals.All the controls were literate (able to read and write) and in both bilinguals and monolinguals, Farsi was their primary language at the time of the study. None of them had a history of neurological, sensory or motor problems or any complaints of memory loss in the last few months.
After clearly explaining the aim and the process of the present study to the referred persons, those who signed the consent letter entered the study. The letter was signed by the primary care-giver in the case that the patient was not able to give informed consent due to her/his cognitive impairment. This study, also, gained the approval of the Research Ethical Committee of the University of Social Welfare and Rehabilitation.

A questionnare designed to gather demographic and medical data was applied to all of the subjects. MMSE scores of patients with DAT and the normal group were obtained by using MMSE section of the Pocket Guide of Elderly Health Evaluation provided by Iranian Research Center on Aging⁽¹⁹⁾. The aphasic patients were examined by Farsi Aphasia Test⁽²⁰⁾ to provide the differential diagnoses and the whole picture of the patient's language performance. The major tool of the study was Farsi Aphasia Naming Test⁽²¹⁾ which is structurally much similar to Armstrong Naming Test⁽²²⁾. It is a picture naming test consisting of 50 pictures of familiar objects including ordinary tools, animals and fruits. Each picture is shown to the subject and (s)he is asked to name it orally. There are 4 columns in the answer sheet consisting of
1) responded without any priming,
2) responded with semantic priming,
3) responded with phonological priming and
4) the type of error.

Every noun is characterized by an underline below the first syllable used for phonological priming and a short sentence describing the name used for semantic priming. At first the participant is subjected to the picture without any help. If (s)he could not respond in 10 seconds, the semantic priming is introduced and again if (s)he could not respond, the phonological priming is given. Finally the rates and percentages of the responses in each column are converted into a profile.

RESULTS

The data analysis showed that the first group, the patients with Alzheimer's disease, consisted of 20 patients including 8 females and 12 males with the mean age of 75.85 (age range= 61-82, SD=5.32) and the mean length of education of 7.10 (SD=4.33). 3 of them were bilingual and 17 were monolingual and all were in the mild to moderate stages of the disease (mean MMSE=18.95, SD=6.18, MMSE range=12-27). The second group, aphasic patients, consisted of 17 patients and included 6 females and 11 males with the mean age of 66.82 (age range=60-78, SD=6.18) and the mean length of education of 11.52 (SD=6.49). 8 of them were bilingual and 9 were monolingual. The control group included 8 females and 12 males with the mean age of 67.25 (age range=60-82, SD=6.21) and the mean length of education of 9.30 (SD=4.31). Their mean MMSE score was 28.50 (MMSE range=25-30, SD=1.67) and 8 were bilingual and 12 were monolingual.

As it is shown in Figure 1, healthy elderly persons showed the highest and aphasic patients showed the lowest correct responses to 50 items of the test.

Figure 1 Frequency of Correct Responses without any Cues in all 3 groups

CR.NOR = the number of correct responses without any cue in normal group
CR.ALZ = the number of correct responses without any cue in DAT group
CR.APH = the number of correct responses without any cue in aphasic group

As the Kolmogorov-Smirnov test proved the normality of data, T test was used for analysis. T test revealed that there is a significant difference in the mean scores of correct responses without any cue between DAT patients and aphasic patients (p= 0.000).

Figure 2 shows the frequency of correct responses after introducing semantic or phonological priming to the subjects. T test revealed significant difference (p = 0.000) between the mean score of DAT and aphasic patients regarding their reaction to semantic priming indicating a greater effect in DAT patients (Table 1). Also it is apparent from Figure 2 that aphasic patients have shown a greater effect in phonological priming than the other group and T test revealed that the difference is significant (p = 0.000)(Table 1).

Figure 2 The Effects of Different Primings on Eliciting Correct Responses in DAT and Aphasic Patients

CRWS.ALZ = the number of correct responses with semantic priming in DAT group
CRWS.APH = the number of correct responses with semantic priming in aphasic group
CRWP.ALZ = the number of correct responses with phonological priming in DAT group
CRWP.APH = the number of correct responses with phonological priming in aphasic group

Table 1: Comparison of correct responses without and with priming between DAT and aphasic patients

CR.ALZ = correct responses without any cue in DAT group
CR.APH = correct responses without any cue in aphasic group
CRWS.ALZ = correct responses with semantic priming in DAT group
CRWS.APH = correct responses with semantic priming in aphasic group
CRWP.ALZ = correct responses with phonological priming in DAT group
CRWP.APH = correct responses with phonological priming in aphasic group

Figure 3 summarizes some of the results obtained from the naming test .The number of wrong responses in DAT patients were less than aphasics which was shown to be significant (p< 0.05) by T test (Table 2). Also aphasic patients showed more "no response" than the other group and T test revealed the significance of this difference (p = 0.000)( Table 2). As indicated in Figure 3 total correct responses the sum of correct responses without any cue, with semantic priming and with phonological priming) is higher in DAT patients than aphasics which is proved to be significantly different (p = 0.000) by T test (Table 2).

Figure 3 Comparison of overall performance of DAT and aphasic patients in naming task

WR.ALZ = the number of wrong responses in DAT group
WR.APH = the number of wrong responses in aphasic group
NO.R.ALZ = the number of no responses in DAT group
NO.R.APH = the number of no responses in aphasic group
TCR.ALZ = the number of correct responses in DAT group
TCR.APH = the number of correct responses in aphasic group

Table 2: Comparison of wrong, no response and total correct responses between DAT and aphasic patients

WR.ALZ = wrong responses in DAT group
WR.APH = wrong responses in aphasic group
NOR.ALZ = No responses in DAT group
NOR.APH = No responses in aphasic group
TCR.ALZ = Total correct responses in DAT group
TCR.APH = Total correct responses in aphasic group

DISCUSSION

Naming is a mental process requiring representations of semantic, phonologic and morphosyntactic information of our mental lexicon. Many neurologial conditions including neurodegenerative diseases such as Alzheimer's disease and acute brain lesions leading to aphasia bring about confrontational naming deficits in their victims which are much different by nature and would be a way to understand brain cognitive mechanisms in terms of language processesing. As Chiarelli mentioned , "Indeed, the peculiar pattern of linguistic and cognitive deficits in early Alzheimer's disease, whereby memory limitation and failure in semantics prevail over deficits on syntax, makes an interesting contrast with linguistic deficits in classic aphasia categories"⁽²³⁾. The results of the present study showed that there are many differences between the performance of the 3 groups, of healthy elderly individuals, patients with DAT and aphasic patients. In fact our normal aged group showed no deficit in the confrontational naming task which is consistent with the finding of Goulet, Ska, and Kahn who showed that picture-naming accuracy dose not decline with advancing age⁽²⁴⁾. There was a significant difference in correct responses without any cue between DAT and aphasic patients. The DAT group had better performance in naming compared to the other. Also, total naming performance including the total wrong responses, no responces and total correct responses showed a better status for DAT patients compared to the aphasic patients. These findings by no means indicate a good naming performance on the part of DAT patients but recognize and emphasize on anomia as a universal symptom of aphasia. The main finding of this study is the recognition of differential stimulating power of semantic and phonological priming in word retrieval abilities of these 2 groups. The DAT group benefited much by semantic cues whereas the aphasic patients responded better from phonological primings. This study confirmed the findings of the previous researchers that phonological cues are the best priming stimuli in aphasia, but the word retrieval problems of DAT patients are related to semantic memory deficits, and so they are more dependant on semantic cues for better naming performance. As Wingfield and colleagues outlined, when an aphasic person is unable to name an object, giving the patient the initial sounds of the target name will often trigger the correct response⁽²⁵⁾. Also, it has been suggested that aphasic anomia originates from a difficulty in accessing the formal lexical representation and not from a semantic problem⁽²⁶⁾. It seems that.phonological primes have a consistent facilitatory effect on aphasic picture naming⁽²⁷⁾, but word retrieval problems of DAT patients are attributed to semantic memory deficits, so that it may be a valid determinator of predementia Alzheimer's disease (AD). It has been shown that impairments on semantically related tests are common in mild AD and may exist prior to the clinical diagnosis, hence assessment of semantic memory could be relevant in the evaluation of patients with suspected AD⁽²⁸⁾. The research body investigating multilayer processes involved in naming from concept to phonems use different neurological conditions such as aphasia and progressive dementias to be able to see a slow motion, scanned picture of what happens in an extraordinary rapid mental stream called naming and has led so far to the development of lexical retrieval modules with theoretical and clinical applications.

Conflict of interest declaration

Although the present research has been funded by Iranian Research Center on Aging, there is no predetermined agreement between the researcher and the institute on the methodology and results of the study. The authors have had full control on their data , analysis and interpretation of results.

Description of authors' roles
F.Yadegari has been the main administrator of the research , proposing the topic and design, controlling data collection, reviewing literature and writing the article. M. Froughan cooperated in designing study, introducing patients and consulting on differential diagnosis procedures of Alzheimer patients, analyzing and discussing the results and organizing the paper. A. Mehri helped much in aphasic section of the study, review of literature and writing the proposal. And finally P.Shirinbayan was responsible for research methodology and statistical analysis.

Acknowledgement
This project has been benefited of the financial and scientific support of Iranian Research Center on Aging. The authors are thankful of Mrs. Soheila Hejrati, Mrs. Marzieh Amrovani, Mrs. Mitra Soltani and Dr. Lili Hayati for their help in different stages of the study. And also appreciate the help of Iranian Alzheimer Association and consider theirselves indebted to all patients, their families and also the healthy elderly who participated in this study despite all difficulties.

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