Introduction
Old age undeniably constitutes a natural stage of life. Multifaceted and interdisciplinary research conducted on this period of human life still has not led to the development of a single definition that specifies “old age”. Researchers consider this phase of life in terms of gradual loss of physical and mental faculties associated with natural or pathological ageing of body systems [1, 2]. According to the Dictionary of Social Gerontology, compiled by Adam Zych, old age is understood as a natural and inevitable process, involving the synergetic interaction of biological, psychological, and social processes [3].
The article analysed linguistic features in a person in advanced old age, the aetiology of which was not fully understood. From the interview conducted with the caregiver of the person under study, it appeared that she underwent a nervous breakdown, after which the environment observed first a depletion in active and passive vocabulary, and then features of anomie. A puzzling issue was not only the occurrence – from a neurological perspective – of features of mixed aphasia, i.e. expressive-impressive with a dominant profile of Wernicke’s aphasia (problems at the level of understanding and perception of sensory stimuli), with amnesic symptoms in the absence of any reports of stroke, Alzheimer’s disease, or other neurological incidents, but also the fact that such peculiar features of language disorders manifested themselves after experiencing a psychological trauma. This raised the question of whether disorders at the level of the language, speech, and communication were closely related to a specific incident of purely neurological origin, such as stroke or craniocerebral trauma, or whether they were dictated solely by psychological trauma, the consequence of which was a nervous breakdown.
The progression of certain processes could not be stopped. On foreign soil, old age was treated as an involutionary process. At the same time, it was emphasised that the determination of the early phase of changes associated with the ageing process was very difficult [3–6]. In Poland, the definitional aspect was mainly concerned with the consideration of changes associated with natural age versus ongoing disease processes [7]. Stefan Klonowicz, defined old age as “one of the normal stages of personal development”, which was associated with morphological and functional changes of the organism occurring with age, which consequently leads to a reduction in its efficiency [8]. Elzbieta Trafialek said that old age was a natural phase of life, which was manifested by many changes occurring in the human body. They generate consequences that concern not only a decrease in physical fitness, associated with a decline in the body’s capacity, but also a reduction in immune forces (physiological/biological old age). In addition, a person in advanced old age had difficulty adapting to any changes, and often needed help and support from the environment [9]. Kijak and Szarota added, in their considerations, that aging was a multidimensional process, which was typically the result of internal and external factors, such as genotype and phenotype [10].
Aim of the research
The results of the present observations aimed to show the features at the level of syntax and its connectivity with meaning at the linguistic level in an elderly person with symptoms of sensory aphasia, resulting from an incident of psychological trauma. Subsequently, the aim of the study was to establish the relationship between the occurrence of these features with the psychological incident, and to verify whether the causes of these symptoms were related to typical physiological ageing of the brain or a pathological process.
Material and methods
While observing the speech and communication features of one of the wards of a social welfare home in the Świętokrzyskie voivodeship, disturbing symptoms that had not been present before were noticed. These included cognitive processing disorders, difficulties in receiving messages, emotional lability, and progressive withdrawal from daily life. This prompted research toward a neurologopaedic diagnosis. After receiving consent for the study from both the care recipient herself and her caregivers, research activities were undertaken. Initially, a motor speech disorder was suspected because the person did not exhibit verbal features. A thorough interview was conducted, which revealed that the subject had undergone a mental incident related to a traumatic random event.
The article presents the results of the study, based on the obtained linguistic-cognitive samples, to assess the receptive and perceptive levels. In the diagnosis of linguistic features, the following research procedure was included:
– Articulatory motor examination (purpose: assessments of the work of the articulatory organs);
– Assessment of functioning in a pragmatic situation (goal: assessment of coping in a communicative situation);
– Study of semantic categorisation (purpose: diagnosis of the level of understanding of thematic categories);
– Verification of performance at the level of situational comprehension and feedback (purpose: to diagnose reactions to the situation and determine the correspondence between the subject’s intentions and those of the interlocutor).
The above tests are not research tools, so they are not a set of standardised tests, but they define the direction of verification of proficiency in the process of speaking, language processing and functioning of the patient in the sphere of communication. The form of their presentation is the author’s own invention.
Due to the fact that the subject had features of a nervous breakdown, the effects of which are observable in speech production and language processing, it was decided to carry out test trials with the Cognitive Activity Rating Scale (TEST MMSE – Mini Mental State Examination), in the direction of assessing the following skills: orientation in time and place, memorisation, attention and counting, recollection, language functions, following instructions, writing, and construction praxis. The results of the indicated trials are presented in the Results section.
Description of research procedure
The table below singles out activities in tongue and lip movements that may suggest other motor symptoms affecting articulatory abnormalities (Table 1) [11].
Another tool used in the process of diagnosing language and communication features was a questionnaire based on the Pragmatics Rating Scale (PRS), which, moreover, was used, among other things, in the diagnosis of pragmatic abilities in children and adults with cognitive disorders, including the autism spectrum.
Individual areas of assessment of the subject’s ways of coping in specific language situations were presented. Features, such as excessive giving of facts, confusion of context and situation, and vocabulary, were designed to check the level of coping in the communicative act. The tip-of-the-tongue phenomenon (TOT) referred to the inability to find in memory the names of objects that were related in meaning and context to the event in question. The presence of other linguistic symptoms, such as an excess of pragmatic words or, on the contrary, laconicisms in verbal and textual utterances, were aimed at verifying whether the patient is at risk of, for example, mnestic disorders, permanent pathological symptoms at the level of various subsystems of language, and whether these symptoms were temporary, whether they were identified with aphatic effects, and whether they would be partially or completely corrected in the course of ongoing neurologopaedic therapy.
The PRS questionnaire was used to observe such factors as easy establishment of the communicative act, asking questions unrelated to the subject of the speech, excessive facts, confusing the context of the speech, TOT phenomenon, use of verbal pragmatisms, social interaction, incoordination in speech, and stereotypical statements.
In the semantic categorisation test of naming (Table 2), it is about the test subject’s indication of the correct meaning of verbal and graphic material. Verbal material activates individual hippocampal areas in the brain, including associative speech. On the basis of illustrated material, dexterity was verified on the level of such processes as differentiation, object categorisation, and visual-spatial skills. The patient also saw a letter pattern of a sentence with a highlighted word on which semantic emphasis falls. The questionary was addressed in Polish language, so an English translation was provided for clarity.
Description of the course of the comprehension study
The interlocutors presented the patient with a description of the situation, asking in conditional form to elicit feedback.
Results
Based on the articulatory motor study, it was assessed that the person under examination maintained the normal characteristics of the muscular mobility of the articulatory organs. Currently, she can tighten and stretch her lips and extend them laterally with the mouth closed. The patient performs these actions, reacting only to a pattern shown by the therapist. On the other hand, commands such as ‘Please put your upper lip on top of your lower lip’ or ‘Please whistle, screech, or smack’ are not understood. The mobility of the tongue also achieves regularity. However, it should be considered that the patient performs these actions by merely mimicking the movements of the examiners. There is a poor response to comprehension of the command, and often no response at all. A lack of independence at the receptive level is perceived. The level of understanding is realised through the partially preserved ability to imitate.
The results of the PRS scale indicate a pathological symptom in terms of semantic discoordination, followed by interaction in communication and orientation in distinguishing the meanings of certain linguistic categories (Table 3).
The symptoms observed were based on the following:
– difficulty in engaging in spontaneous conversation, as well as with starting the speech act,
– asking questions out of context,
– excessive number of facts in one utterance (facts with different contexts),
– dealing with several topics at once,
– difficulties with word recall, including impoverished passive vocabulary,
– low interaction skills,
– dyscoordination in the process of speaking with features of simple fluency of speech accompanied by psychosomatic symptoms such as sweating palms, uneven breathing, nervousness,
– presentation of habitual language patterns and perseveration of words or phrases, e.g. ‘jakie są tu’, ‘jakie są tu’.
The TOT phenomenon, which consists of the patient’s inability to recall a given phrase, word, context, or further part of a sentence, in the case of the respondent refers to difficulties in recalling a given lexeme that does not always fit the context of the utterance. This phenomenon accompanies both healthy people and those presenting cognitive deficits, e.g. in dementia diseases.
An example of spontaneous speech in which the TOT phenomenon is present, in addition to semantic inconsistency, repetition (perseveration), is as follows:
Mam dziś mam duże takie owoce… i one są moje, w mojej misce, w tej no… dużej. Chcę pokazać bardzo dobre owoce. Chcę… chcę pokazać to, że dzieci przyjdą.
In the study of semantic categorisation, 4 misidentifications of the verbal pattern were characteristic, while the subject made 5 accurate identifications based on the pictorial material. Finding the correct concept in the lexical resource was difficult in examples 2–5. The respondent became confused when searching for words related to linguistic categories such as: ‘furniture’, failing to identify ‘fridge’ as a piece of equipment that does not fit with furniture, such as ‘chair’, ‘table’, and ‘bed’ (Table 2, example 2). In instruction 3, the respondent associated only ‘pen’ with the term ‘student’, as well as ‘bench’, which did not appear in the example at all. Another difficulty was the formal-meaning identification in terms of the infinitive form of the verbs ‘cook’, ‘paint’, ‘read’, and the noun ‘book’. There was no response to the command in example 5. The correct response was indicated by the respondent only in example 1, identifying the term ‘banana’ with the category ‘fruit’.
In terms of illustrated associations, an inverse proportion was noted; 4 results were correct (examples 1–4). The subject was able to recognise the designator and correlate it with the object in the picture. Occasionally, she gave several matching names to one designator.
The study of situational comprehension and feedback showed a partial incompatibility of the subject’s operational knowledge with that of the observation interlocutors. The linguistic categories were inadequate for a common chain of thought.
The following feedback emerged in response to question 1:
‘Call them’, ‘meet them’ instead of, e.g., notifying the relevant services about the incident and doing the appropriate thing, including trying to help or seeking help from others – the police or the emergency room.
Using question 2 as an example, one semantic category – ‘buying a gift’ – dominated the responses. The respondent reacted appropriately to the event presented in the description of the situation by giving the possibility of compensation in an intangible form, e.g. buying something else, such as ‘another gift’, ‘a trip’, etc. However, when asked by the interlocutor to elaborate on the category ‘buying a gift’, she was unable to give a concrete thing. For example, ‘going out for ice cream’, ‘extra pocket money’, or ‘a trip to a specific place’.
In response to question 3, the respondent did not find a practical solution to the situation, such as calling or going to the pharmacy and asking for advice from a specialist.
The situations initiated in questions 4 and 5 referred to the problem of elderly people being exploited in common methods, such as “playing policeman” or “sales representative”. The respondent did not show vigilance here either, showing no doubt in the credibility of the situation and its protagonists.
Assessment of cognitive activity with the Mini-Mental Scale
Results of the test conducted after the patient signed consent for the study (Figure 1).
The study of the cognitive activity results:
The patient was unable to point out the date on the day of the test (time orientation), and failed to refer to answer the question “on which floor are we currently located” (place orientation).
In terms of memorising the words BYK, MUR, LAS – she repeated all the lexemes.
There was a problem with command 3. In 5 attempts to subtract the number 7 from 100, she got 3 correct results.
In terms of the deferred test, i.e. words previously memorised, the patient reproduced only 2 words, i.e. BYK and MUR. On the other hand, she replaced the word LAS with LIS.
The range of naming words (command No. 5) was within the norm, while there were difficulties with the literal reproduction of the sequence “neither yes, nor no, nor but”.
The respondent understood the directed commands. She took a piece of paper in her hand, sequentially folding it in half with both hands, and then placed it on her lap. However, there was a slight issue with interpreting the request to follow the command in the correct order, i.e. read the command “please close your eyes” and follow it.
The writing activity was successful, and the reproduction of the construction on the paper showed half correctness. In our opinion, the patient is able to reproduce a figure with 5 sides, thus preserving the praxis movements. She only confused the direction of the mapping, i.e. vertical instead of horizontal. This may indicate an unspecified deficit in cognitive orientation in space or include the effects of visual dyslexia.
Discussion
The recognition of disorders with a neurological, psychological, or cognitive basis includes several criteria: anatomical, physiological, psychological, linguistic, and logopaedic. The differences between aphatic features – seen as specific language disorders following neurological incidents [12], and dementia features – increasing psychopathological symptoms in the course of neurodegenerative diseases [12, 13], are not always clear-cut. The juxtaposition of aphatic, dementia, and vacillating features of mental function is due to the treatment of these disorders as consequences of neurological conditions, on the one hand, and as mixed, i.e. and/or with a background of impaired mental function, on the other. The cause of these issues is not fully understood.
In medical science, aphasia is one of the symptoms of brain damage, occurring alongside symptoms such as plegia, paraesthesia, ataxia, apraxia, hemianopsia, agnosia, and others [14]. As a symptom, it is the result of neurological disease [14]. The term phasia (Gr. fazis, Latin phasia ‘speech’) denotes a set of neurophysiological activities taking place in the central nervous system (CNS) that enable speaking and comprehending speech. Disruption of these activities as a result of damage to the central nervous system is referred to by the terms aphasia or dysphasia [15–18].
The term dementia is derived from Latin. Dementia means heedlessness, folly, madness, insanity, from: demens- stupid, mad, insane. In Polish literature and clinical practice, the term is used interchangeably with dementia. By definition, dementia is ‘a syndrome of behavioural disorders caused by cerebral dysfunction of known or unknown aetiology, leading to a general breakdown of cognitive functions, emotions, personality, and social functioning of a person’ [19, 20].
The ageing process manifests itself through muscle weakness, reduced coordination of movements and gestures, impaired activity of purposeful actions, inability to perform often even the simplest daily activities, e.g. preparing and eating meals, taking care of the toilet and personal hygiene [21]. Apraxia refers to a disturbance in the execution of movements, which can be caused by a weakness of muscle strength. Apraxia of speech is a speech disorder that results from realisation difficulties in the planning and programming of muscular movements of the articulatory organs involved in the speech distribution process [22]. Apraxia is characterised by the occurrence of articulatory errors, e.g. phonetic paraphrases, vowel distortions, substitutions, slowed speech rate, and prosody specific to this disorder (slow speech rate, verbal fluency disorders, disturbed accentuation characterised by uniformity of speech) [23]. The causes of realisation difficulties may include flaccidity and atrophy of masticatory muscle fibres, loss of neuromuscular coordination, dysfunction of the temporomandibular joints, loss of teeth, use of dentures [24], and slowing and decreased precision of articulatory organ movements [25].
Older people also experience changes in the rate of speech, which depends on several factors. Among these are the age of the patient, the presence of diseases, and the functioning of the central nervous system. In addition to physiological factors, there is an index of sociophonetic facts (region of origin, degree of mastery of a foreign language if the utterance is produced in that language, type of relationship with the interlocutor), stylistic (dialogue vs. monologue, spoken vs. read text, length of utterance), and psychological (emotional state of the speaker) [26]. The ageing of the nervous system affects the slowing down of the neurodevelopmental system, emerging attention deficits, and disorders in the programming of utterances [27].
According to the American Psychiatric Association’s DSM-IV definition, dementia primarily refers to disorders of memory, both short-term (inability to remember new information) and long-term (inability to reproduce existing information/memories/facts in memory). In addition, speech disorders in aphasia, agnostic disorders, apraxia, and executive function disorders also appear. All these factors lead to difficulties in every sphere of functioning for the individual, who, over time, requires support and assistance from others in performing activities of daily living [28]. From a linguistic perspective, the patient gradually loses syntactic and semantic skills, and communication skills become impaired.
The symptoms presented so far may occur in a homogeneous form, e.g. only mental dysfunction, nervous breakdown, or mental state with a poor prognosis, which may affect the mental functioning of the individual. They can also become heterogeneous disorders, with one dominant symptom or several that are exacerbated to a similar degree. As a result, this can generate mixed symptoms – dementia and depression, with a concomitant impact on the deterioration of motor and language and communication functions as well [6, 8, 25, 29].
Language disorders, impaired cognitive processes, deteriorating precision of movement, or impaired mental functions are among the first signs of neurodegenerative processes occurring in the affected brain. Amnestic syndromes are other features of the brain in which the pathological process develops. This is a very characteristic group of disorders concerning the loss by the said organ of the ability to acquire new information (sequential amnesia) and to reproduce information that was acquired before the brain damage (retrograde amnesia) [30]. A phenomenon called temporal gradient is often observed, whereby the older the memory trace, the more resistant it is to the degradative and pathological processes occurring in the human brain. Fresh memory traces are degraded first, then episodic memory traces. Eventually there is a loss of the ability to perceive, recognise, and identify specific objects, places, events, people, and situations.
Conclusions
The analysis of linguistic elements in a person with indeterminate cerebral symptoms leads one to reflect on the recognition of mixed symptoms, i.e. aphatic, dementia and psychiatric symptoms, as factors that may cause symptoms of nervous breakdown. On the other hand, the nervous breakdown may in this case be the result of an ongoing pathological process.
Language symptoms take a heterogeneous form. They include performance difficulties with preserved muscle mobility of the articulatory organs, which are caused by problems at the level of comprehension rather than deficits in the speech apparatus. Hence, articulatory and semantic fluency appear. At the level of linguistic-communicative proficiency, the inability to program a response fully in line with the topic being addressed is characteristic. Attempts to enter a communicative act initiated by the interlocutors are unsuccessful because the deficits occurring at the level of comprehension prevent a normative response to the messages.
The feedback instructions were intended to show whether the elderly person logically seeks a way out of situations that are among the occasional ones. What was observed in this case was not only an inability to deal with a pragmatic problem, but also a lack of emotional expression. A response was attempted, but ongoing pathological processes in the brain result in impaired cognitive function.
A consequence of the psychological trauma experienced may be a lack of verbal response, resulting in a closure to experiencing a communicative, dialogical situation, to expressing oneself in spontaneous and narrative speech. The result is a depletion of the passive lexicon, i.e. the vocabulary at the level of conceptual understanding, which generates a mixed nature of language disorders with a complex aetiology.
After differential diagnosis with the Cognitive Activity Rating Scale, mild cognitive deficits were found, which, according to the examination, fall within the range of mild dementia. Given that the patient did not have clinically diagnosed Alzheimer’s disease, we believe that this condition may be the result of a traumatic experience, and the patient should be under the constant care of a psychotraumatologist. In the case of disturbances in the emotional-volitional sphere, effects also are observed at the level of speech, language, and communication.
Acknowledgments
We would like to thank one of the social care homes in the Świętokrzyskie Voivodeship for the opportunity to conduct language observations. It is a very valuable experience for us of the knowledge and skills displayed by older people and their caregivers.
Funding
No external funding.
Ethical approval
Bioethics committee no. 1/2023.
Conflict of interest
The authors declare no conflict of interest.
References
1. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med. 1980; 303: 130-135.
2.
Lane NA. Unifying view of ageing and disease: the double agent theory. J Theor Biol. 2023; 225: 531-540.
3.
Baltes B. The aging mind: potential and limits. Gerontologist. 1993; 33: 580-594.
4.
Anderson S, Brenner BM. Effect of aging on the renal glomerulus. Am J Med. 1986; 80: 435-442.
5.
Cohen G. Language comprehension in old age. Cogn Psychol. 1979; 11: 412-429.
6.
Birren JE, Fisher LM. Aging and speed of behavior: possible consequences for psychological functioning. Rev Psychol. 1995; 46: 329-353.
7.
Zych AA. Słownik gerontologii społecznej. Wydawnictwo Akademickie “Żak”, Warszawa 2001; 202.
8.
Klonowicz S. Oblicza starości: wybrane zagadnienia gerontologii społecznej. Wiedza Powszechna, Warszawa 1979; 10.
9.
Trafiałek E. Starzenie się i starość. Wybór tekstów z gerontologii społecznej. Wydawnictwo Uczelniane Wszechnica Świętokrzyska, Kielce 2006; 269.
10.
Kijak RJ, Szarota Z. Starość: między diagnozą a działaniem. Centrum Rozwoju Zasobów Ludzkich, Warszawa 2013; 12.
11.
Rodak H. Karta badania motoryki artykulacyjnej. In: Terapia dziecka z wadą wymowy. Wydawnictwo Uniwersytetu Warszawskiego, Warszawa 2002.
12.
Panasiuk J. Neurobiological mechanisms of emotional and volitional behaviors vis-à-vis strategies for logopedic therapy. In: Polish logopedic socjety. Logopedia 47-2. Panasiuk J (ed.). Polskie Towarzystwo Logopedyczne. Zarząd Główny, Lublin 2018; 51-70.
13.
Mesulam MM, Grossman M, Hillis A, Kertasz A, Weintraub S. The Core and Halo of Primary Progressive Aphasia and Semantic Dementia. Ann Neurol. 2003; 54, 11-14.
14.
DSM-IV. Diagnostic and Statistical Manual, APA, Washington 1993.
15.
Lindsay PH, Norman DA. Procesy przetwarzania informacji u człowieka. Wprowadzenie do psychologii. PWN, Warszawa 1991.
16.
Tesak J. Der aphasische Symptomencomplex von Carl Wernicke. Idstein, Schulz-Kirchner. Germany 2005.
17.
Graves RE. The legacy of the Wernicke-Lichtheim model. J History Neurosci. 1997; 6: 3-20.
18.
Huber W, Poeck K, Weniger D. Aphasie. In: Klinische Neuropsychologie. Poeck K (ed.). Thieme, Stuttgart 1982.
19.
Marczewska H, Osiejuk E. Nie tylko afazja... O zaburzeniach językowych w demencji Alzheimera, demencji wielozawałowej i przy uszkodzeniach prawej półkuli mózgu. Energeia, Warszawa 1994.
20.
Szepietowska EM, Daniluk B. Demencja. In: Podstawy neuropsychologii klinicznej. Domańska Ł, Borkowska AR (eds.). Wydawnictwo UMCS, Lublin 2011; 281.
21.
Marchewka A, Dąbrowski Z, Żołądz JA. Fizjologia starzenia się. PWN, Warszawa 2013.
22.
Duffy IR. Apraxia of speech in degenerative neurologic disease. Aphasiology. 2013; 20: 269-270.
23.
Duffy JR. Motor speech disorders: substrates, differential diagnosis, and management (third edition). Elsevier, St. Louis, 2013.
24.
Zapała J, Szuta M. Procesy starzenia w obrębie tkanek miękkich i kości twarzy ze szczególnym uwzględnieniem układu stomatognatycznego. In: Fizjologia starzenia się. Marchewka A, Dąbrowski Z, Żołądź JA (eds.). Warszawa 2012; 130-156.
25.
Krajewska M. Ograniczenia i możliwości językowe osób z demencją a osób starzejących się fizjologicznie – analiza porównawcza. In: Nowa Logopedia. Tom 3. Diagnoza różnicowa zaburzeń komunikacji językowej. Michalik M, Siudak A, Orłowska-Popek Z (eds.). Collegium Columbinum, Kraków 2012; 472.
26.
Wagner A. Rytm w mowie i języku w ujęciu wielowymiarowym. Elipsa, Warszawa 2017; 15.
27.
Tłokiński W. Mowa ludzi u schyłku życia. Państw Wydaw Naukowe, Warszawa 1990.
28.
American Psychiatric Association. Diagnostic and Statistical Manual Disorders, 4th ed. Washington, D.C. 1994.
29.
Honig LS, Tang MX, Albert S, Costa R, Luchsinger J, Manly J, Stern Y, Mayeux R. Stroke and the risk of Alzheimer disease. Arch Neurol. 2003; 1707-1712.
30.
Scott J, Schoenberg M. Memory and learning: the forgetful patient. In: The Black Little Book of Neuropsychology. Schoenberg MR, Scott JG (eds.). Springer, New York 2011; 179-200.
