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, 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 a 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