I am a primary care physician and I want to identify a PPA case

Before assessing a patient’s language level, you must know about the patient’s:

  • Pre-morbid functioning
  • Number of years of education and previous jobs
  • Strengths and weaknesses, hobbies
  • History of learning disorders (e.g. dyslexia), ADHD?

Here is an effective plan of action:

  1. Have the patient talk in order to assess spontaneous speech. If necessary, you may ask open-ended questions to help (e.g., Tell me about what you did yesterday.)

    Note if any of the following features are present:

    • Word-finding difficulty (anomia)
    • Difficulty correctly articulating/pronouncing words
    • Difficulty understanding questions
    • Production of short and incomplete or agrammatic sentences
    • Hesitations in speech
    • Phonological paraphasias (e.g., papple instead of apple) or semantic paraphasias (e.g., pear instead of apple)
  2. Question the caregiver:
    • When did the difficulties appear and in which context? Did they appear gradually vs suddenly?
    • How did the patient’s condition evolve? Is it stable, evolving gradually, etc?
    • How is the language impairment evident in the person’s life? You may use examples from everyday life to truly target the patient’s difficulties: talking on the phone, having a conversation with a relative, reading, or writing.
    • How do language deficits affect other daily activities? Examples: cooking meals, social activities, hobbies.
  3. Ask the patient about other cognitive functions such as memory, calculation, orientation, executive functioning and visuospatial abilities. Also ask for any changes in behavior. A neuropsychological assessment can be helpful in this regard.
  4. The nonfluent/agrammatic variant of PPA is often caused by tau pathology which is frequently associated with parkinsonism. Therefore, it is important to ask the patient about any motor changes such as slower walking, falls, postural abnormalities, etc.
  5. Make sure that you understand the difference between language and speech

    • Language includes the following abilities:

      • The capacity to understand words (semantic) and sentences
      • The capacity to find the right word (word retrieval)
      • The capacity to produce correct sentences (syntax and grammar)
      • The capacity to repeat words and sentences
      • The capacity to read and write

    • Verbal fluency tests, phonological (example: name as many words that begin with the letter F as you can in one minute) or semantic (example: name as many animals as you can in one minute), are not considered language tests but rather they are tests of executive functions.

    • Speech is the neuromuscular execution of language. There are two main problems that can affect a patient’s speech:

      1. Dysarthria

        This is a motor speech disorder affecting the execution of speech movements. The patient’s speech can be flaccid, spastic, ataxic, hypo/hyperkinetic or mixed. Dysarthria is not common in PPA.

      2. Apraxia of speech

        This is a motor speech disorder affecting the planning and sequencing of speech sound movements.

    A speech-language pathology assessment may be recommended.

  6. A simple test to assess the patient’s language abilities :
    • Dépistage Cognitif de Québec (DCQ) – Language Index (Available in English for free at www.dcqtest.org)

  7. Finally, these next elements can help formulate diagnostic hypotheses (Leyton et al., Brain 2011):

    Symptom = Most frequently associated PPA
    Motor speech disorder (slowed speech, distortions, dysprosody) = Nonfluent/agrammatic PPA
    Agrammatism = Nonfluent/agrammatic PPA
    Impaired repetition of sentences = Logopenic PPA
    Impaired word comprehension = Semantic PPA