LANGUAGE IN INDIA

A STRANGER IN THE FAMILY: ALZHEIMER'S DISEASE AND LANGUAGE

M. S. Thirumalai, Ph.D.

1. OLD AGE AND THE ALZHEIMER'S DISEASE

Old age creeps in slowly for the young adult. Sudden changes may take place for the old, however. The old person becomes forgetful. At first it becomes a matter for laughter and joke in the family. Soon one notices that the old person is more confused than ever. He has more frequent mood changes, and begins to act in strange ways. He forgets the names of people around him, names of his own children and grandchildren whom he loved deeply. He begins to suspect your motives and wants to avoid you. Soon the old person becomes a different person altogether. He does not know his name, does not recognize his environment, and does not recognize his family. He is a stranger in his own family. He leaves home at his will and does not know where he goes or how he could return home. Family members are greatly worried and do not know what to do. The disease progresses rather slowly. Only when the disease shows some severity, the family members often begin to seek medical consultation and attention for the patient.

2. DR. ALZHEIMER

The Alzheimer's disease was not recognized as a devastating one until the 1980s. But, since then, we read about it almost daily, and come across people and families that have been affected by it. The German doctor Alois Alzheimer described the disease somewhat definitively in 1912, I think. The disease is named after him.

3. INDIAN CULTURAL TRADITIONS AND THE ALZHEIMER'S DISEASE

In India and South Asian nations, cultural traditions took the onset of senility as a natural process of aging. Since life expectancy was rather short in these nations until a few decades ago, the Alzheimer's disease was assumed to be an occurrence or the phenomenon of the Western materialistic nations. There is a greater recurrence of this disease now noticed in India, especially among the people of middle classes.

Sadly, the belief that the Alzheimer's disease is a Western phenomenon is not really true. Indian family traditions make us suffer from within, mourn our fate, and feel sorry for our dear old person who is now a stranger in his own family. We do not publicize our "fate," and we are trained to put up with what we are faced with. Our public caregiving or medical systems are not prepared to handle such cases. I know of several cases of suspected Alzheimer's disease in India and my heart breaks when I think of such cases.

In the country where I am now settled, I have come across several Alzheimer's patients. These men and women were good friends of mine a few years ago, but with the onset of the disease I became a stranger to them. I could watch these developments and recognized certain linguistic characteristics of these persons. With a heavy heart I present here some of my observations on language use in Alzheimer's patients.

4. LANGUAGE DISCONNECT

One of the important characteristics of the disease is the strange disconnect in language use noticed in the patient. This calls for the special attention of the students of linguistics in India.

5. SOCIAL VERSUS BIOLOGICAL WORLDVIEWS

There is an interesting short poem in Tamil, written perhaps nearly two thousand years ago. The poet Picira:ntaiya:r writes in this poem that he was once asked as to how he had not turned gray yet. Actually, he begins his poem saying, "If you ask me why I have not turned gray in spite of many years of life …" He answers his own question with the following argument: He has a honorable wife and children; all his servants or attendants knew what he wanted and were always willing and ready to fulfill his commands; the king or the ruler was just, and everything around him generated a peaceful and conducive condition. In other words, his health, life expectancy, and enthusiasm for continued living, etc., all depended upon the social conditions around him. The emphasis was on the social factors.

While such an emphasis on the social factors continued to be an important characteristic of modern science, there appears to be a definite turn in our thinking that seeks explanations in biology. This biological turn has become rather very strong in the second half of the twentieth century. In linguistics, the biological foundation of linguistic competence is currently accepted widely. For everything we seek some biological reason. For example, some scientists seek to establish that homosexuality is a biological endowment in some individuals.

(The implications of the theology of Karma is another area that we need to look into. Sometimes, it appears that the theology of karma and biological bases of life and characteristics may depend on each other in some strange ways.)

6. SOME HYPOTHESES RELATING TO THE ALZHEIMER'S DISEASE

There are at least four major hypotheses relating to the causes of Alzheimer's disease.

1. The Genetic Hypothesis suggests that if in a family the Alzheimer's disease occurs at the age of forty in a person, there is at least a forty percent chance or risk for the family members. This is not a very strong genetic disorder.
2. The Unconventional Virus Hypothesis suggests that the disease may have been caused by a slow virus infection. The virus has not been identified, and is considered to be an unconventional virus.
3. The Aluminum Hypothesis claims that the person with the Alzheimer's disease has an increased amount of aluminum in his brain.
4. The Autoimmune Hypothesis claims that the immune system of the patient declines with age.

There are other hypotheses as well.

7. LINGUISTIC CHARACTERISTICS OF THE ALZHEIMER'S DISEASE

In this paper our focus is not on explaining why the Alzheimer's disease occurs but on how we can cope with the Alzheimer's patient in so far as language use is concerned.

Scholars consider that language and communication problems faced by the Alzheimer's patient are "hallmarks" of the disease. The language and communication deficiencies in the Alzheimer's patient develop during the progress of the disease. There is actually no way that would help us easily separate the normal deficiencies in hearing and speech associated with the aging process from the onset of the Alzheimer's disease. It appears that there are no clear-cut diagnostic linguistic elements that would distinguish the Alzheimer's disease at the onset level. For example, in the study of aphasia or autism, use or non-use of certain speech and grammatical elements may signal the presence of the disorder. Such a diagnostic help is not available for the Alzheimer's disease patient at the onset level.

The Alzheimer's patient continues to use the speech mechanism for the major part of his life as an Alzheimer's patient. In other words, he is able to produce appropriate sounds and their combinations, able to generate words and sentences, and use these sentences in a discourse. But the relevance of the discourse to the context is slowly lost. Towards the end of his life, he may even lose his speech and language totally. Meaningfulness of the utterances is slowly lost, and when the disease is in its peak, contextual relevance is totally lost. He is not able to take turns in his conversations, and he does not recognize the addressee, nor is he interested in communication to be relevant or directed to the addressee. Towards the end, the patient's speech becomes more repetitive and the meaning conveyed by him more incomprehensible as to its meaning. We can say that the speech of the Alzheimer's patient may be intact, but there is decline in his language as to its relevance in all aspects of language use: social, psychological, internal speech, and the link between the utterance and the act.

8. INDIAN LANGUAGES AND THE ALZHEIMER'S PATIENT

In terms of Indian languages, the pronominal usage is much affected, at variance with what the person would have done if he were not an Alzheimer's patient. The verb inflection with appropriate pronoun endings is also affected. He has problems with number and person attached to the main verb, but his problem with the gender is not as intense as his problem with the number and person of his addressee.

The most significant early process (and this continues to deteriorate further) is the patient's frequent substitution of one word for another. This begins with the confusion between related items such as ripe fruit and unripe fruit in Indian languages. The substitution process takes place between the similar items in some sense. Similarity is usually related to the similarity in meaning and appearance of the object or quality or action referred to. However, as the disease progresses, the patient may not restrict himself to the substitution of one word by another from a related field only. Some of his substituted words may come from the related fields and some others from totally unrelated fields. Perhaps the intensity and frequency of failure relating to the transfer of words from the unrelated fields may be used as a diagnostic tool to assess the deterioration of the condition.

9. WORD AND SEMANTIC DOMAINS IN ALZHEIMER'S DISEASE

Use of pseudo-words in place of real words is an important characteristic of the language of the Alzheimer's patient. First of all, he forgets the words, and then he tries to use some pseudo-words in place of the proper word that he has forgotten. Then at the next level, he may identify an object or person or animal, using a generic word, but he may not be able to relate that object, person, or animal to their specific proper name. He recognized his daughter as a human being, a person, a woman, etc., but he fails to use her given name. The link between the person and the specific proper name is a very important tool to build and maintain our social or inter-personal relations. The Alzheimer's patient loses this important link and thus evicts himself from the society of which he was a part until recently. I would say that the language loss that an Alzheimer's patient undergoes reveals that he is no more part of the social set up and that he has lost his membership of the human social environment.

Another characteristic that we notice is the patient's inability to recognize the relationship between the words as members of semantic domains. In other words, his sense of the semantic field or the collocation of the words is slowly lost. He is not able to recognize the relationship of a set of connected objects such as, for example, the plate, the tumbler, the spoon, dining table, curry-pot, ladle, etc. The relationship between pen, pencil, writing paper, eraser, notebook, etc. may be lost for him. The individual objects begin to exist for him as individual objects. They may be divorced from the function they perform and the inherent or imposed relations that may exist between them as a group of words referring to a group of related objects.

10. THE RETURN OF THE CHILDHOOD ECHOLALIA

Echolalia is another characteristic noticed in the language of the Alzheimer's patient. As I already mentioned, an Alzheimer's patient may begin to repeat words in the beginning, perhaps as an emphasis. Soon the frequency and quality of repetition changes. He is no more repeating meaningful words from the adult language around him. He begins to repeat syllables, and true echolalia is the result.

11. NONVERBAL BEHAVIOR IN ALZHEIMER'S DISEASE

The Alzheimer's patient's pragmatic nonverbal behavior also deteriorates along with his verbal behavior. I have already mentioned about his inability to take turns in conversations. He is not concerned about the addressee. He is not fully aware of the topic of conversation between him and others. His reason and arguments do not go with the context and topic of conversation. His body language and his proxemic behavior have no relevance to the conversation he has with the people around him. His paralinguistic speech loses its value. In addition, he is soon unable to use the paralinguistic features at all. If he uses these features, such usage is faulty. He is not able to transform his statements into appropriate questions, positive statements into negative statements, etc. In other words, the patient is unable to deliberately manipulate transformations to generate effective sentences for communication purposes. However, I've noticed that his nominalized constructions are still in use. He does not respond to the questions raised in an appropriate manner.

12. THE WHEEL OF ALZHEIMER'S DISEASE

Cognition leads an infant who begins his articulation of language, and cognition diminishes in the adult Alzheimer's patient long before the articulation of language begins to deteriorate. The loss of language is saddening and dramatic. Even as its quality begins to deteriorate mainly at the word level, the problems with semantics come to influence the use of syntactic constructions as well. And with the deterioration of syntactic abilities, phonetic articulation is affected. At the end, the Alzheimer's patient begins to have less and less spontaneous speech. Linguistic silence sets in. The deterioration of cognition and consequent linguistic competence are at stake in the progress of the disease, but ultimately the speech is also affected or lost.

13. SPEECH AND LANGUAGE THERAPY FOR THE ALZHEIMER'S PATIENT

How do we help the Alzheimer's patient to maintain his communication ability and to understand what is being communicated to him? The usual speech and language therapy may not help much in such cases. It is important for the caregivers to work out strategies that suit individual patients. For example, the conversation between the caregivers and the patient should be carried out in quieter atmosphere to avoid problems of hearing faced by the Alzheimer's patient. Let the caregivers speak with less speed, and even repeat slowly several times what they say to the Alzheimer's patient. Perhaps the caregivers may make use of gestures more frequently to communicate with the patient. The basic features of memory loss, difficulty in recalling names of persons, objects, and places, etc., and semantic confusion may have to be attended to in short and repetitive steps.

The goal of therapy in this case is not really the improvement of the linguistic behavior, but simple and basic communication between the caregiver and the patient. It is recognized that the Alzheimer's patient can still learn some skills. It is an amazing grace of God, and we should take advantage of this remnant ability even in the midst of deteriorating memory, cognition, and language competence. The good old repetition exercise comes very handy to impart some skills of survival to the Alzheimer's patient. But let us not expect great and spectacular results. The fact that the person is engaged in some task itself is a great success story. We should not expect the patient to perform any complex task. Every task should be broken into simpler and self-contained units. Reduce the stimulation around the patient. Redundancy should be kept to the minimum. Redundancy of words and actions are important for others, but not for the Alzheimer's patient.

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