Editor’s Note: As you know, PediaStaff typically features only articles on pediatric topics. Alejendro’s story is such a moving and deeply personal one, however, that we have made an exception to share this article with you this month.
Alzheimer’s Dementia. A Cuban-American Story.
By: Alejandro Brice, Ph.D, CCC-SLP, Roanne Brice, Ph.D., CCC-SLP, and Ellen Kester, Ph.D., CCC-SLP
Introduction
Alzheimer’s dementia (AD) is a progressive, degenerative disease that occurs in the cerebral cortex due to increased levels of glutamate and the proliferation of plaque-forming amyloid beta proteins. Neuronal transmissions are reduced and slowed due to the presence of neurofibrillary tangles and neuritic plaques, which are the by-products of high glutamate and protein levels (Duyckaerts, Cole, Delatour, & Hauw, 1999). Individuals presenting with progressive, degenerative cognitive ability and memory skills following the pattern and behaviors of Alzheimer’s dementia are given the AD label.
Memory impairment and disturbance of executive functioning contribute to language, behaviors, and cognitive deficits commonly seen in individuals with AD across several areas of functioning: (a) progressive deterioration of language skills such as word finding difficulties or following simple directions ; (b) decline in two or more areas of cognition, such as memory, problem solving, attention, and/or orientation; © decline in successfully completing activities of daily living such as dressing, eating or driving a vehicle; and (d) other difficulties such as confusion, paranoia, or anxiety. Exclusion criteria are utilized to ensure that the suspected dementia is not the result of other illness, such as malnutrition, dehydration, depression or other emotional issues, or cognitive changes following a cerebral vascular accident (Bayles, Tomoeda, & Trossett, 1992; Grossman & White-Devine, 1998; Marshall, Duke, & Walley, 1996).
A Personal Tale
My father is 87 years of age and came to the United States in 1961. He was a lawyer in Cuba and then eventually became a school Spanish teacher here in the U.S. He would be considered a high fluent bilingual. Several years ago, he began demonstrating immediate and working memory difficulties when he was in his mid-eighties. He would repeat the same stories in conversation. His dementia progressed to a level where he began asking the same questions no more than five minutes apart. He also began forgetting long term memory events (e.g., what his grandson was studying when A. was in medical school). Within the last year these episodes of forgetfulness increased. He began getting lost in the city where he had lived for twenty years; he would only talk of past events; or he would constantly ask the day of the week. His bank account was frequently overdrawn. His ability to process information decreased significantly. He became frequently agitated and angry. In addition, his orientation skills of place, time, and context seriously declined.
As a speech- language pathologist with experience in working with adult geriatric populations, I became very aware of his cognitive decline. I administered the Global Deterioration Scale (Reisberg, Ferris, de Leon, & Crook, 1982). This consists of a seven point scale describing behaviors documenting cognitive decline. In addition, I began documenting
observations that were atypical (e.g., he would look at me and call me by my brother’s name).
He recently came to visit my house for a period of three weeks. During this time he called his sister to ask for my phone number so that he could call me. Apparently, he thought that I was my brother. Also, during this time he would say that he was in Miami (when he was actually in St. Petersburg). He could not find the local store a few blocks away when we had driven to this store numerous times.
The Diagnosis and The Cuban Perspective
Brice and Brice (2009) noted that the concept of disability varies by culture. Personally, I have observed that the Latino culture, and particularly, the Cuban-American culture defines “normal” in a broader range and “disability” in a narrower range than North American culture. When my father was told that he was experiencing “confusion”; he perceived it as being “crazy”. He associated his memory losses with normal aging.
My father was recently seen by his Cuban primary care physician and then a Cuban neurologist over a period of three visits. Prior to the second visit with the neurologist he underwent a MRI. The neurologist diagnosed my father as having a mild cognitive impairment; something which seemed obvious from observations. The neurologist had also seen the MRI. From the MRI, it is evident that cortex shriveling had occurred; shrinkage had occurred in the hippocampus, and that the ventricles had grown larger (all features of AD).
It is typical in the Latino medical profession not to tell the patient or sometimes family members the diagnosis. This occurred when the Cuban neurologist told my father that he was “fine”. Only upon my prodding did he say that my father presented with some memory difficulties and mild cognitive impairment (MCI).
Conclusion
Recognizing the diverse perspectives of the North-American culture and the Cuban or Latino culture, an SLP must acknowledge and accommodate both perspectives. I acknowledged what the neurologist had said and supported his comments. I also explained to my father in simple terms what was occurring (i.e., that he was physically fine, but that he was having memory difficulties that were going to continue and also get worse over time). As speech-language pathologists and audiologists, we must recognize different cultural perspectives and change North-American speech-language pathology and audiology practices to fit other cultures. The same practice cannot be given to all. It is our job to accommodate and modify our means of intervention.
References
Bayles, K., Tomoeda, C., & Trosset, M. (1992). Relation of linguistic communication abilities of Alzheimer’s patients to stage of disease. Brain and Language, 42, 454– 472.
Brice, A. & Brice, R. (2009). (Ed.s). Language development: Monolingual and bilingual acquisition. Old Tappan, NJ: Merrill/Prentice Hall.
Duyckaerts, C., Colle, M. A., Delatour, B. & Hauw, J. (1999). Alzheimer’s disease: Lesions and their progression. Review of Neurolology, Paris, 155, 17–27.
Grossman, M., & White-Devine, T. (1998). Sentence comprehension in Alzheimer’s disease. Brain and Language, 62, 186-201.
Marshal, N. B., Duke, L. W., & Walley, A. C. (1996). Effects of age and Alzheimer’s disease on recognition of gated spoken words. Journal of Speech and Hearing Research, (39), 724-733.
Reisberg, B., Ferris, S.H., de Leon, M.J., & Crook, T. (1982). The Global Deterioration Scale. American Journal of Psychiatry, 139, 1136-1139.
This Month’s Featured Authors:
Alejandro Brice, Ph.D., CCC-SLP University of South Florida St. Petersburg
Roanne Brice, Ph.D., CCC-SLP University of Central Florida
Ellen Kester, Ph.D., CCC-SLP Bilinguistics, Inc.
Many thanks to Dr. Alejandro E. Brice for providing this article for this months newsletter
Dr. Alejandro E. Brice is an Associate Professor at the University of South Florida St. Petersburg in Secondary/ESOL Education. His research has focused on issues of transference or interference between two languages in the areas of phonetics, phonology, semantics, and pragmatics related to speech-language pathology. In addition, his clinical expertise relates to the appropriate assessment and treatment of Spanish-English speaking students and clients. Please visit his website at http://scholar.google.com/citations?user=LkQG42oAAAAJ&hl=en or reach him by email at [email protected]
Dr. Roanne G. Brice is the Assistant to the Chair for the Department of Child, Family and Community Sciences at the University of Central Florida. Her research interests have focused on language and beginning literacy skills in bilingual children and students with disorders/disabilities. In addition to teaching at the university level, Dr. Brice has been an itinerant and self-contained classroom speech-language pathologist as well as a general education classroom teacher. She may be reached at [email protected]
Dr. Ellen Kester is a Founder and President of Bilinquistics, Inc. http://www.bilinguistics.com. She earned her Ph.D. in Communication Sciences and Disorders from The University of Texas at Austin. She earned her Master’s degree in Speech-Language Pathology and her Bachelor’s degree in Spanish at The University of Texas at Austin. She has provided bilingual Spanish/English speech-language services in schools, hospitals, and early intervention settings. Her research focus is on the acquisition of semantic language skills in bilingual children, with emphasis on assessment practices for the bilingual population. She has performed workshops and training seminars, and has presented at conferences both nationally and internationally. Dr. Kester teaches courses in language development, assessment and intervention of language disorders, early childhood intervention, and measurement at The University of Texas at Austin. She can be reached at [email protected]