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Alzheimer’s disease and Parkinson’s

disease: Gomparison of speech and language alterations
J.L. Cummings, MD; A. Darkins, MD; M. Mendez, MD; M.A. Hill, PhD; and D.F. Benson, MD

Article abstract-Speech and language alterations were assessed in 51 patients with Parkinson’s disease (PD)and 10
patients with dementia of the Alzheimer type (DAT). Thirty-five of the PD patients had no evidence of intellectual
impairment on a conventional mental status questionnaire and 16 of the PD patients had dementia syndromes of
comparable severity to the DAT patients. DAT produced significantly greater language disturbances, including anomia,
decreased information content of spontaneous speech, and diminished word list generation. PD patients had significantly
decreased phrase length, impaired speech melody, dysarthria, and agraphia. The results suggest that the dementia of PD is
distinguishable from that of D A T PD patients have prominent motor speech abnormalities, whereas DAT patients exhibit
more profound language alterations.
NEUROLOGY 1988;38680-684

The nature and frequency of dementia in Parkinson’s underlying cause of these mental status deficits is
disease (PD) is an evolving area of understanding. controversial. Albert,l6Cummings and Benson,I7and
Between 25 and 55% of PD patients exhibit overt Huber et all6 suggested that PD patients exhibit a
Even those PD patients without man- subcortical dementia similar to that of patients with
ifest dementia have some degree of intellectual im- progressive supranuclear palsy and Huntington’s dis-
pairment including deficits in visuospatial abil- ease and attributable to dysfunction of basal ganglia
ities,s-ll m e m ~ r y , ~ and
* J ~ executive skills.14J5The and frontal-subcortical connections. Alternatively,

From the Neurobehavior Unit, West Lou Angeles VAMC (BrentwoodDivieion) and Department of Neurology,UCLA School of Medicine (Dra. Cummings, Darkins,
Mendez, andBenson), the Department of Research and Development, Weat Loa Angela VAMC (BrentwoodDivision) (Dr. Hill), and the Department of Psychiatry
and Biobehavioral Sciences, UCLA School of Medicine (Drs. Cumminps. Hill.and Benson), Los Angeles, CA.
Supportedby the John Doughs French Foundationof LosAngeles,Californin,the Los Angek Chapter of the Alzheimer’sDiseaaeand Related Disorders Association,
and the Veterans Administration. Dr. Darkins was supported by a Traveling Fhenrch Fellowship from the Medical Reeearch Council of the United Kingdom.
Received July 17,1987. Accepted for publication in final form September 10,1987.
Addreascorreepondenceand reprint requeatato Dr. Cummings,Neurobehavior Unit (69l/Blll), West LA VAMC (BrentwoodDivision), 11301 Wilahire Boulevard,
Lo8 Angeles, CA 90073.
680 NEUROLOGY 38 May 1988
Table. Demographic features and speech and Language alterations are a characteristic feature of
language test results of patients with dementia of the DAT. Anomia occurs early and comprehension is
Alzheimer type (DAT) and Parkinson’s disease (PD) gradually compromised, leading to an aphasic syn-
with overt dementia drome resembling transcortical sensory a p h a ~ i a . ~ ~ - ~ l
Studies of speech and language alterations in patients
PD DAT with PD might help clarify whether the dementia of
-re (SEM.1 rore (SEW P VlltM PD is a product of DAT. If DAT accounted for the
Sample characteristics dementia of PD, then similar linguistic changes
MMSE 20.25 (0.78) 17.90 (0.84) 0.0550 would be expected in PD patients with dementia. To
73.20 (3.30)
Age
Gender (MIF)
71.81 (0.96)
1610 614
0.6964
- address this question, we compared a group of pa-
Duration (ym) 4 (0.70) 3.9 (0.72) 0.9233 tients having PD and overt dementia with a group of
Distinguishing features equally demented DAT patients and with PD patients
Information content 1.18 (0.24) 2.80 (0.24) 0.0011
Animal naming 10.62 (0.91) 5.50 (1.19) 0.0030
without overt dementia using a battery of speech and
(totallmin) language tests.
Naming 0.43 (0.20) 2.10 (0.54) 0.0152
Phrase length 2.31 (0.31) 0.40 (0.16) 0.00005
Melody 2.56 (0.15) 0.40 (0.16) 0.00005 Methods. Sixteen patients with idiopathic PD and overt
Writing mechanics 3.62 (0.37) 0.60 (0.40) O.lWO05 dementia were compared with 35 PD patients without overt
Grammatical 1.06 (0.28) 0.20 (0.13) 0.0115 dementia and with 10 DAT patienta. All patients had a mini-
complexity mum of 8 years of formal education and were native English
Dyaarthria
Loudncas 3.81 (0.29) 0.50 (0.22) 0.00005 speakers. DAT patients and PD patients with overt dementia
Pitch 2.18 (0.31) 0.20 (0.13) 0.00005 scoredbetween 12 and 24 on the Mini-Mental State Examina-
Articulation 2.75 (0.32) 0.50 (0.22) 0.00005 tion (MMSE)32;PD patients without overt dementia ecored
Rate
Intelligibility
2.81 (0.27)
2.62 (0.28)
0.30 (0.15)
0.30 (0.15)
O.ooOo5
0.00005
above 24. The PD patients were all in stage 11,111,or N of the
Writing Severity Rating Scale33and were outpatients attending a Par-
Narrative 3.25 (0.54) 3.70 (0.63) 0.5957 kinson’s disease clinic. All PD patients were men 64 to 78
Dictation 2.43 (0.49) 1.50 (0.45) 0.1740 years old. There were six men dnd four women with DAT;
Auditory comprehension
Sequential commands 0.37 (0.12) 0.70 (0.47) 0.5208
their ages ranged from 52 ta 89 years.
Word discrimination 0.06 (0.06) 0.80 (0.38) 0.0923 DAT patients met Diagnostic and Statistical Manual of
YesfNo 0.18 (0.10) 0.90 (0.37) 0.0982 Mental Disorders34criteria for primary degenerative demen-
Complex commands 1.00 (0.39) 1.30 (0.42) 0.6106 tia and National Institute of Neurological and Commu-
Automatic apeech
Nursery rhyme 0.86 (0.41) 2.00 (0.55) 0.1196
nicative Disorders and Stroke-Alzheimer’s Disease and
completion Related Disorders Association (NINCDS-ADRDA)35criteria
Sentence completion 0.00 (0.00) 0.40 (0.30) 0.2229 for probable DAT and had Hachinski Ischemia Scale scores36
Counting (1-20) 0.25 (0.25) 0.00 (0.00) 0.3332 of four or less to help exclude a vascular contribution to their
Alphabet recitation 0.87 (0.3I ) 1.00 (0.47) 0.8281
Paraphaaia
dementia. They were outpatients attending a dementia clinic
Verbal 0.18 (0.13) 0.80 (0.35) 0.1375 or inpatients of neurology or neurobehavior services. All pa-
Literal 0.12 (0.12) 0.40 (0.22) 0.2963 tients underwent extensive diagnostic evaluations including
Neologistic 0.00 (0.00) 0.10 (0.10) 0.3434 appropriate laboratory and neuroimaging procedures to ex-
Repetition
Phrases 0.50(0.22) 1.10 (0.31) 0.1377
clude alternative diagnoses.
Numbers 0.12 (0.12) 0.00 (0.00) 0.3332 The speech and language battery (table) consisted of ques-
Reading comprehension tions derived from the Boston Diagnostic Aphasia Examina-
Sentences 0.37 (0.25) 1.20 (0.68) 0.2791 tiorP7 and the Western Aphasia Battery38 modified for use
Commands 0.56 (0.18) 1.30 (0.70) 0.3314
Worda 0.00 (0.00) 0.70 (0.70)
with a dementia population and augmented by a dyaarthria
0.3434
Reading aloud scale and scales aseessing reiterative speech disturbances. The
Sentences 0.25 (0.14) 0.60(0.341 0.3615 battery was used previously in a study comparing 30 DAT
words 0.00 (0.00) 0.00 (0.00) 1.ooOo patients with 70 normal control subjects; controls performed
* Standard error of measurement.
nearly perfectly on the test battery.30 A total of 37 subscales
measured elements of spontaneous speech, auditory com-
prehenaion, repetition, naming, paraphasia, reading aloud,
reading comprehension, writing, automatic speech, word list
generation (number of animals named in 1 minute), dys-
identification of Alzheimer-type histopathologic arthria, and reiterative speech abnormalities (echolalia,pali-
changes in the brains of some patients with PD led Mia, logoclonia, stuttering). Each subtest was assigned a scale
Boller et a l l 9 and Hakim and Mathiesonm to suggest score between 0 (normal)and 6 (most abnormal). Scale scores
corresponded to the number of e m r e of the subtest (six ques-
that the dementia of PD was due to concomitant tions per subtest) or had defined anchor points to guide stan-
dementia of the Alzheimer type (DAT). This hypoth- dardized scoring.
esis was supported by the discovery that both DAT Data were analyzed using BMDP Statistical Software.39
and PD patients have atrophy of the nucleus basalis Because multiple t testa were computed, only conservative
of Meynert, the source of cholinergic innervation of levels of significance (p = 0.01 or 0.001), suggesting marked
the cerebral c ~ r t e x . Recently,
~ ~ - ~ ~ more complex ex- differences, are emphasized.
planations for the dementia of PD have been pro-
posed, suggesting a progression from dopaminergic to Results. There was no significant difference between
combined neurochemical deficits and the occurrence the PD-dementia and DAT patients in age, duration of
of superimposed subcortical and cortical pathologies illness, or dementia severity as reflected in MMSE
in some patient~.~4--26 scores (table). There were more women in the DAT
May 1988 NEUROLOGY 38 681
sample. The PD patients with dementia were somewhat guished by auditory comprehension,automatic speech,
older than those without dementia (PD without demen- reading comprehension, repetition, paraphasia, or
tia, mean age 67.3; PD with dementia, mean age 71.8; reading aloud. There was a consistent tendency for
p = 0.03). DAT patients to be more impaired than PD-dementia
Parkinson’s disease without ooert dementia. We patients on nearly all components of the language ex-
performed one-sample t tests to determine if speech amination. There was also a nonsignificant trend for
and language performances of PD patients without PD patients to exhibit more reiterative speech distur-
overt dementia had scale scores different from 0 (nor- bances of all types (stuttering, echolalia, palilalia, log-
mal). They exhibited marked changes in the mechan- oclonia).
ical aspects of speech and writing and few linguistic Stepwise discriminant analysis using a jackknifed
alterations. There were significant abnormalities of classification revealed that 100% of PD-dementia pa-
p h r m length, grammatical complexity, speech mel- tients and DAT patients were correctly classified on the
ody, writing mechanics, writing to dictation, nar- basis of four variables-loudness, mechanical aspects of
rative writing, word list generation, loudness, pitch, writing, narrative writing, and comprehension of writ-
articulation, speech rate, and overall speech intel- ten sentences. When the analysis was performed after
ligibility (all p < 0.001). Information content of spon- elimination of the dysarthria elements,96% of patients
-
taneous speech and Comprehension of complex
commands were diminished (p 0.01 and p = 0.04,
respectively), but were not as markedly abnormal as
were correctly classified on the basis of information
content of spontaneous speech and speech melody.
With these two variables, all DAT patients were cor-
speech and writing mechanics. There were no other rectly recognized, one PD patient was misclassified as
abnormalities of comprehension, repetition, naming, DAT.
reading, or automatic speech. Pearson correlation coefficientswere used to explore
Parkinson’s disease with overt dementia We com- the relationship between declining intellectual function
pared PD patients with dementia and PD patients (decreasing MMSE) and speech and language altera-
without overt dementia using two-sample t tests. The tions. Within the range of dementia severityincluded in
former were more abnormal in phrase length, speech the study, no correlations were found for the DAT
melody, information content of spontaneous speech, patients. PD-dementia patients, on the other hand,
phrase repetition, comprehension of written and spo- exhibited significant correlations between dementia se-
ken commands, naming, writing mechanics, writing to verity and decreasing phrase length (r = -0.563; p =
dictation, narrative writing, alphabet recitation, word 0.022), diminishing information content of spon-
list generation, loudness, pitch, articulation, speech taneous speech (r = -0.598; p = 0.013), anomia (r =
rate, and intelligibility (allp < 0.01). There was a trend -0.565; p = 0.021), and impaired comprehension of
for the demented PD patients to be more impaired on written sentences (r = -5.626; p = 0.035).
tests of sentence reading and completion of nursery
rhymes (p < 0.05). Discussion. The results of this study suggest that
Test performances by PD patients revealed that (1)DAT patients exhibit more language disturbances
language-related errors tended to occur in a limited than equally demented PD-dementia patients on the
number of patients. Only 6 of 16 PD patients with current assessment battery; (2) PD patients with and
overt dementia made naming errors and, of these six, without overt dementia have more prominent speech
four also had comprehension disturbances. Thus, and writing abnormalities than DAT; (3) PD patients
one-fourth of the PD patients accounted for a sub- with overt dementia have more prominent abnormali-
stantial proportion of all language abnormalities ties of the motor aspects of speech and writing as well as
found in the PD group. some aspects of language function than PD patients
Parkinson’s disease with overt dementia and Alz- without dementia; and (4) PD patients with dementia
heimer’s disease. PD with dementia and DAT were may be distinguished from DAT on the basis of speech
compared, using two-sample t tests. The most strik- and language characteristics.
ing differences between the PD and DAT patients Sparing of linguistic abilities in PD patients with-
were those related to the motoric disability produced out overt dementia has been a consistent finding.
by PD (table). Thus, all five dysarthria measures, Bayles and TomoedaZ8found that PD patients with
writing mechanics, phrase length, and speech melody mild functional impairment scored within the normal
were more abnormal in the PD patients (p < 0.001). range on the Peabody Picture Vocabulary Test, and
Grammatical complexity was also more impaired (p Freedman e t a1N found that PD patients without
= 0.01). overt dementia scored within the normal range on the
Language characteristics distinguished DAT and Boston Naming Test.41Matison et aP2 also used the
PD-dementia and were more abnormal in the former. Boston Naming Test to explore the linguistic abilities
DAT patients had more impoverishedinformation con- of PD patients without overt dementiaand found that
tent of spontaneous speech (p = 0.001), more impaired they scored one standard deviation below normal con-
word list generation (p = 0.003), and more severe trols but within the range of normal for the test. The
anomia (p = 0.01). few investigations of language function in PD pa-
In the limited MMSE range included in the sample, tients with overt dementia also suggest that language
neither demented group exhibited marked language def- is largely spared. Huber et all2 and Pirozzolo et al,43
icits, and DAT and PD-dementia were not distin- studying patients with a broad range of MMSE
682 NEUROLOGY 38 h h y IS88
scores, found no deficits in naming or vocabulary. small group of patients. Naming errors were found in
Globus et a144found that PD patients of varying intel- only 6 of 16 with overt dementia. This subgroup of
lectual impairment were more impaired t h a n linguistically disabled PD patients might reflect the
matched controls on tests of auditory comprehension simultaneous occurrence of PD and DAT, and the
and naming but the disturbances were not severe. exploration of language deficits is a promising tool for
Pillon et alG compared PD and DAT patients with identification of such subpopulations.
equivalent dementia severity and found little lan- Results of correlation analyses assessing the rela-
guage impairment in either group on the measures tionship between dementia severity and speech and
utilized. Bayles and Tomoeda= demonstrated that language changes also suggest differences between
moderately impaired DAT patients were more im- DAT and PD-dementia. Correlations between PD-
paired than moderately disabled PD patients on a dementia severity and speech and language were
confrontation naming test. In the current study, DAT found for phrase length, information content of spon-
patients had greater disturbances of information con- taneous speech, anomia, and sentence completion.
tent of spontaneous speech, confrontation naming, Such correlations could not be demonstrated in DAT.
and word list generation than PD patients with overt This suggests that, in PD, loss of information content
dementia. The difference in total number of animals of spontaneous speech and abnormalities of naming
named in 1minute is particularly impressive in view may reflect overall cognitive decline, whereas the lan-
of the fact that DAT patients were more compro- guage deficits in DAT correlate less strongly with
mised despite the more marked slowing of verbal out- advancing dementia and may represent instrumen-
put in PD. Thus, the profile of language abnormalities tal-linguistic dysfunction associated with pathologic
in PD and DAT differ when the two disorders have changes in the primary language areas of the cor-
dementia9 of comparable severity, and DAT patients tex."*-
have significantly more linguistic disability than PD-
dementia patients.
Relative sparing of language function in PD is in
marked contrast to their abnormalities of effort- Acknowledgments
demanding rnem0ry,~2J3 difficulties in executive abil-
i t i e ~ , ' ~ and
J ~ . impairments
~ on a variety of visu- The authore are indebted to Norene Hiekel for preparing the manu-
ecript and to Linda Chdingar for data programming.The authors are
ospatial Abnormalities in these indebted to Dr. Charlea Markham and Dr. Jeffrey Metter for patient
neuropsychological domains have been identified in referrals.
patients who score normally on conventional mental
status tests as well as those with overt dementia.%
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684 NEUROLOGY 38 May 1888

 Alzheimer's disease and Parkinson's disease: Comparison of speech and
language alterations
J. L. Cummings, A. Darkins, M. Mendez, et al.
Neurology 1988;38;680
DOI 10.1212/WNL.38.5.680

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