Samrah Ahmed UDK 81'42:616.89
St George’s, University of London*
Peter Garrard
St George’s, University of London**
SPOKEN DISCOURSE IN ALZHEIMER’S DISEASE: 
A REVIEW
1 INTRODUCTION: ALZHEIMER’S DISEASE – TYPICAL AND ATYPICAL 
Alzheimer’s disease (AD) is the most common cause of late life cognitive deterio-
ration and dementia. It is a progressive, neurodegenerative disease with a character-
istic pathological signature, which shows an early predilection for brain structures
(mesial temporal regions and limbic circuit) that are intimately involved in memory.
A probable clinical diagnosis of AD can be made during life on the basis of symptoms
and neuropsychological features (McKhann et al. 1984), and an updated set of diag-
nostic criteria have recently been proposed (Dubois et al. 2007). A definitive diagnosis
of AD, on the other hand, requires demonstration of a distinctive pattern of patho-
logical abnormalities in brain tissue (Mirra 1997; Mirra et al. 1991), so a distinction
is required between the clinical syndrome of probable AD (pAD), and the pathological
diagnosis of definite AD, which is not usually made until after death. In much of the
literature relating to the cognitive profile of AD, this distinction is blurred, but will
be repeatedly emphasised in the course of this review. 
A series of key publications from the 1980s and 90s (Butters et al. 1987; Christensen
et al. 1998; Greene/Hodges 1996; Hodges/Patterson 1995; Kopelman 1985; Welsh et
al. 1992) delineated a typical cognitive profile in patients suffering from pAD. All em-
phasised the profound deficit in episodic memory in the early stages of the condition,
showing that these patients suffered from impairments in the encoding and storage 
of new information, and were insensitive to retrieval cues or structure inherent in the
learned material. The impairment has therefore been interpreted as one of new learning,
rather than either the accelerated forgetting typical of epilepsy (Blake et al. 2000), 
or the disrupted retrieval that is seen in some patients with frontal brain lesions (Bondi
et al. 1994).
As pAD progresses, additional deficits become apparent in other cognitive abilities.
These include: the cognitive process of planning, initiation and regulation of behav-
iour (executive function); the ability to process visual and spatial information; the ex-
9
* 
Author’s address: Stroke and Dementia Research Centre, St George’s, University of London, Cran-
mer Terrace, London SW17 0RE, UK. Email: sahmed-a@sgul.ac.uk
** 
Author’s address: Stroke and Dementia Research Centre, St George’s, University of London, Lon-
don SW17 0RE, UK. Email: pgarrard@sgul.ac.uk

ecution of complex goal directed movements of the hands (dyspraxia); and language-
related abilities, dominated by a decline in long term memory of concept knowledge
(semantic memory) (Garrard et al. 2005a; Greene et al. 1995; Perry/Hodges 1999;
Welsh et al. 1991; Welsh et al. 1992). The accumulation of cognitive deficits is consis-
tent with the increase and spread of the disease burden in the brain, with selective in-
volvement of mesial temporal regions in mildly affected patients, and of more
widespread cortical regions in more advanced cases (Braak/Braak 1991).
Deficits in memory and (to a lesser extent) other cognitive abilities can be identi-
fied in individuals with mild cognitive impairment (MCI), who do not meet formal
criteria for a diagnosis of pAD, but are at an increased risk of developing the syndrome
over the ensuing months and years (Petersen et al. 1999; Petersen et al. 2001). If one
considers the individual diagnostic criteria for MCI in parallel with those for pAD, it
can be seen that the difference is quantitative, and relates to the threshold at which
cognitive difficulty translates into functional impairment and dementia.
The symptoms described above are characteristic of a majority of patients with pAD,
but in addition, a number of variant clinical presentations are recognised, due to an
atypical distribution of pathology at onset. Some individuals present with predominant
and progressive impairments in spatial ability, and show striking atrophy in visual as-
sociation pathways in the brain (Hof et al. 1997). A frontal variant of pAD is also recog-
nised, leading to disproportionate impairment in executive functioning (Johnson et
al. 1999). Finally, and most relevant to this review, a minority of patients presenting
with a slowly progressive language impairment (Alladi et al. 2007; Galton et al. 2000).
This third group of patients will be described in greater detail in section 3.
2 LANGUAGE PROCESSING IN TYPICAL ALZHEIMER’S DISEASE
2.1 Standardised neuropsychological examination
A number of standardized tests have been used to examine language impairment
in pAD. The majority of studies have reached the conclusion that language abnormal-
ities in pAD are dominated by profound anomia, diminished vocabulary, and word
finding difficulties, highlighting an early lexico-semantic processing deficit. For exam-
ple, the widely-used verbal fluency task (in which a patient is given one minute to ge -
nerate as many words as they can think of beginning with a particular letter, or
belonging to a given category) has shown that pAD patients are consistently more im-
paired in the latter (semantic) than in the former (phonemic) condition (Garrard et
al. 2001; Rosser/Hodges 1994; Salmon et al. 1999). The diagnostic utility of semantic
fluency tests is well established (e.g. Monsch et al. 1992; Salmon et al. 1999), and can
be used as a marker of disease progression (Perry et al. 2000; Small/Backman 1998).
Impairments in confrontation naming (production of a verbal label when presented
with a pictured concept) are also well documented in pAD. Significant differences be-
tween patients with early pAD and controls have been demonstrated using instruments
such as the Graded Naming Test (GNT) (McKenna/Warrington 1980), which contains
30-items of progressively decreasing lexical frequency and familiarity (Ahmed et al.
10

2008; Grundman et al. 2004; Petersen et al. 1999; Thompson et al. 2002). Low fre-
quency/familiarity items prove particularly likely to result in incorrect responses. 
In addition to the lexico-semantic impairment in typical pAD, there is mixed evi-
dence for impairment in syntactic abilities. Measures of syntax comprehension include
the Token Test (De Renzi/Vignolo 1962) or the Test for the Reception of Grammar
(TROG; Bishop 1989). In the Token Test, patients are required to carry out a series of
instructions of increasing complexity based on a high frequency vocabulary relating
to simple objects such as shapes (e.g. put the red square under the red circle). The
TROG entails matching one of four pictures to a series of spoken sentences of progres-
sive grammatical complexity, ranging from simple propositions (e.g. “the boy runs after
the dog” to sentences with passive constructions and embedded clauses, such as “the
elephant that is being pushed by the boy is large”). A number of studies have revealed
little or no effect of syntactic complexity on either comprehension or production (De
Jager et al. 2003; Hodges et al. 1996). Lambon Ralph et al. (2003) found that MCI pa-
tients performed normally on a battery of language tests, with the single exception of
the Token Test. Since patients were unimpaired on the TROG, the authors interpreted
the finding as implicating a deficit in the memory and/or attention-related processes
that are required to hold sequences of words in short-term (“working”) memory 
(Baddeley et al. 1986), rather than in syntactic processing abilities per se.
Language deterioration in combination with the hallmark memory deficit in MCI
has been found to be of increased diagnostic sensitivity and prognostic value. Studying
a group of patients with this diagnosis, Ribeiro et al. (2006) reported that around one
third were impaired in semantic fluency and a similar proportion on the Token Test.
In a separate study, Bozoki et al. (2001) found that patients with impairments in me -
mory coupled with difficulties in one other cognitive domain, including naming and
letter fluency tests, carried an eight-fold higher risk of progressing to pAD after 2 years.
De Jager and Budge (2005), also found naming difficulty in MCI to be predictive of
later conversion to pAD.
2.2 Connected speech analysis
There has been limited work examining connected speech production in pAD. The
available data suggest that the impairments discussed above may be more extensive
and of earlier onset when employing the more detailed examination of language abil-
ity that is provided by this approach. This may be because the production of connected
speech is a naturalistic activity, and/or because of the large number of descriptive di-
mensions that can be obtained from the data. The latter may be especially relevant
when considering the impact of neurodegenerative conditions on language ability, as
the brain regions involved are widely distributed (Price 2010), while degenerative
pathologies are by definition diffuse and (as illustrated) can show considerable neu-
roanatomical variability.
A further advantage of the study of connected speech is that it can be carried out
retrospectively. A number of landmark studies have suggested that language abilities
may be vulnerable very early in the disease process. In the narrative samples obtained
11

from the Nun study – a longitudinal study of autobiographical data and diary entries
collected from convent archives for 678 catholic sisters – Snowdon et al. (1996) showed
that, in writings produced as early as the second decade of life, low idea density (num-
ber of ideas expressed in a given number of words) was associated with low cognitive
performance in later life. Perhaps more remarkably the measure also emerged as a
reliable predictor of AD at post mortem. Garrard et al. (2005b) showed that the last
novel of Iris Murdoch, written a year before she was diagnosed with pAD (later con-
firmed as AD) in her mid seventies, contained a more restricted, and higher frequency
vocabulary than her earlier works, pointing to a lexico-semantic processing deficit. A
later study of a similarly prolific and likewise afflicted Dutch novelist (Gerard Reve)
showed that the lexical variety effect was detectable in non-English texts (van
Velzen/Garrard 2008). More recently, Garrard put forward the hypothesis that char-
acteristics of the spoken language used by Harold Wilson (a prominent British Prime
Minister during the 1960s and 70s) in parliamentary debates shortly before retirement
from office, may have been influenced by the early stages of a neurodegenerative ill-
ness (anecdotally pAD) that would not emerge until several years later. 
Specific deficits have also been observed in tasks based on picture description, such
as the Cookie Theft from the Boston Diagnostic Aphasic Examination, (Goodglass/
Kaplan 1983). In this test, the subject is presented with a line drawing depicting a do-
mestic scene: a young boy is standing on a stool reaching for a jar of cookies from a
cupboard; the stool is about to topple over; his sister is encouraging the boy to steal
the cookie and hand it down to her; the unfolding disaster goes unnoticed by their
mother, who is also unaware that the sink at which she is washing dishes is overflowing
on to the floor. Participants are simply asked to “describe what is happening in the pic-
ture”. Samples of open-ended discourse can also be used as samples for analysis. 
Hier et al. (1985) reported fewer words and less relevant information, character-
istic of reduced lexical diversity in the picture descriptions of patients with pAD.
Nicholas et al. (1985) found that pAD patients produced fewer content words and
phrases, but significantly more semantic errors, repetitions and empty phrases, and
de Lira et al. (2010) reported more lexical errors in the discourse of pAD patients.
Ehrlich (1997) found that pAD patients were reduced in the efficiency of their spoken
language and required more words to convey target propositions in a narrative task.
Similarly, Tomoeda et al. (1996) found that the efficiency and conciseness of picture
descriptions provided by patients with pAD compared unfavourably with those of
age-matched normal controls.
Analysis of discourse also appears to show syntactic change in pAD. Croisile et al.
(1996) found “simplified but relatively correct syntax” in a picture description task
provided by patients with pAD compared to controls, though the effect was more pro-
nounced in written than oral descriptions. Hier et al. (1985) studied oral descriptions
obtained from a mixed group, consisting of patients with pAD and dementia due to
vascular brain damage. They found all samples to be less complex than those of con-
trols, and the mean clause length to be shorter in the pAD than the vascular group.
On the other hand, Kempler et al. (1987) reported an absence of syntactic errors in
12

single written sentences produced by patients in the early stages of pAD. Formal analy-
sis of syntactic complexity was not performed, however, and the text samples were
necessarily shorter than transcripts of connected speech.
Inconsistencies may be explained by the use of different methods to elicit discourse
(conversational speech vs. picture description). The latter affords a number of benefits:
the Cookie Theft picture description is a robust, widely used, and simply administered
method for eliciting discourse. It allows composite examination of information con-
tent, and affords the ability to examine differences between different themes (e.g. per-
sons vs. actions vs. objects). Description draws on a constrained subset of nouns and
verbs that are highly frequent and familiar and, for the most part, acquired early in
life (Hirsch/Ellis 1994).
3 ATYPICAL VARIANTS OF ALZHEIMER’S DISEASE
So far, we have considered the types of language impairment that are evident in
patients with typical onset pAD. The atypical presentations with salient language im-
pairments, will now be discussed. These patients present with a pattern of deficits
that overlaps with those seen in primary progressive aphasia (PPA).
3.1 Primary progressive aphasia (PPA)
PPA is an umbrella term that encompasses a group of neurodegenerative syn-
dromes in which cognitive decline is restricted to one or more components of the lan-
guage system (Gorno-Tempini et al. 2011; Mesulam 1982). Recently proposed
consensus criteria have identified clinical, neuropsychological, and imaging charac-
teristics that describe three distinct subtypes: semantic dementia (SD) is characterized
by fluent but empty speech, impaired single-word comprehension, and a high inci-
dence of regularisation errors when reading aloud single words. This constellation of
impairments has been convincingly argued to represent disintegration of the stored
representation of concept knowledge (semantic memory). SD is associated with se-
lective atrophy in one or both anterior temporal regions, providing a unique opportu-
nity to gain insights in the way such information is stored and organised in the brain
(Hodges/Patterson 2007). Progressive non-fluent aphasia (PNFA) is the term used to
describe patients with phonologically and/or grammatically distorted speech output,
and impaired comprehension at the single word (but not grammatical) level. Atrophy
is focused on left inferior frontal and insular regions. The third variant, logopenic
aphasia (LPA) is a more recent addition to the PPA syndromes, and will be discussed
in some detail in the next section. 
PPA is considered to be a distinct clinical syndrome, in which the presenting aphasic
difficulties suggest a high likelihood of an underlying degenerative process other than
AD. The most frequent pathological associations have been found to be with the group
of diseases considered under the heading of frontotemporal lobar degeneration (Gross-
man 2010). There is, however, growing evidence that variants of AD with early and
dominant language impairment are much more common than previously recognized
13

(Alladi et al. 2007; Galton et al. 2000; Knibb et al. 2006). Retrospective studies of patho-
logically confirmed AD, in which progressive aphasia was the predominant feature,
have shown both SD and PNFA to be possible presenting syndromes of the condition.
In a detailed comparison of typical and atypical syndromes in pathologically proven
AD, Galton et al. (2000) retrospectively examined the clinical presentations of six pa-
tients who had presented with PPA. Neuropsychological assessment showed that two
cases were classified as PNFA and three others with SD, and one with a mixed aphasic
pattern, containing elements of both syndromes. In another recent study, Alladi et al.
(2007) found that AD was the primary pathological diagnosis in almost half of patients
present with PNFA, and in three quarters of those with a mixed aphasic syndrome. In
contrast, SD was associated with AD pathology in only one in ten cases. 
3.2 Logopenic aphasia (LPA)
Although it should by now be evident that AD can present with a range of progres-
sive aphasic features, and that progressive aphasia can be produced by more than one
degenerative disease, recent descriptions have emphasized a clinically homogenous
group of patients with a focal cortical syndrome that appears to be exclusively associ-
ated with AD pathology. LPA has been described as a third variant of PPA, following
the first description by Gorno-Tempini et al. (2004). Recent clinico-pathological studies
have found that AD is the most common underlying pathological process in LPA
(Mesulam et al. 2008). Retrospective analysis may, of course, show that a diagnosis of
LPA may apply to some of the patients described in earlier clinic-pathological studies
as presenting with “mixed aphasia”, but this hypothesis awaits formal examination.
Detailed clinical, neuropsychological, and imaging studies have allowed the phe-
notype of LPA to be further refined. The language of patients with this syndrome is
characterized by slow production, simplified grammar, word-finding difficulties, and
impaired picture naming, with relatively preserved semantics, and particular difficulty
with sentence repetition (Gorno-Tempini et al. 2008; Gorno-Tempini et al. 2004;
Gorno-Tempini et al. 2011). Patients make phonologic errors in speech but there is
no evidence of agrammatism. These observations have been interpreted as represent-
ing impairment in auditory verbal short term memory, which has been proposed as
a central mechanism in LPA (Gorno-Tempini et al. 2004). In addition to impaired
language, neuropsychological profiling in LPA has identified impairments on tests of
memory (Mesulam et al. 2008), calculation (Amici et al. 2006; Gorno-Tempini et al.
2004; Rohrer et al. 2010), and limb apraxia (Rohrer et al. 2010). 
Imaging studies have identified damage typically in the left temporoparietal junc-
tion, and a recent study showed that the severity of imaging abnormalities in this re-
gion correlated with the performance on naming and sentence repetition (Leyton et
al. 2012). Less consistent damage has been noted in the medial temporal and parietal
cortex, posterior cingulate, inferior frontal and temporo-parietal cortex (Gorno-
Tempini et al. 2008; Gorno-Tempini et al. 2004; Rohrer et al. 2010). The latter finding
is typical of pAD with language dysfunction at presentation , and in particular of early
onset AD (Migliaccio et al. 2009).
14

4 RECENT FINDINGS
The literature reviewed so far has suggested that, although language deficits in clin-
ically typical pAD may not be present to the same extent as those observed in PPA,
they may nonetheless be of clinical importance. A recent series of investigations has
therefore been carried out with the aim of characterising connected speech in patients
at different stages of clinically typical pAD, all of whom went on to have AD defini-
tively diagnosed at post-mortem. 
Discourse samples, elicited using the Cookie Theft task, had been generated by
participants in a longitudinal study of ageing: the Oxford Project to Investigate Mem-
ory and Ageing (OPTIMA). This cohort consists of community dwelling elderly per-
sons who were recruited to the study as normal controls or with varying degrees of
cognitive impairment. All participants have undergone regular physical, laboratory
and cognitive assessment at six to twelve month intervals, during which the evolution
of pre-existing cognitive problems has been documented, and the new onset of cogni-
tive impairment in previously asymptomatic individuals observed. All patients selected
for language analysis had been recruited either as controls or with a diagnosis of MCI,
ensuring that follow-up assessments included the first episode at which subjects with
AD met criteria for clinically probable disease, ensuring homogeneity of disease stage
in the sample. Pathological confirmation of control or AD status was obtained at post
mortem in all cases. 
4.1 Lexico-semantic processing in early Alzheimer’s Disease
We began by asking whether the previously noted deficit in lexico-semantic pro-
cessing (cf. section 2) could be observed at the first point of clinical diagnosis of a ty -
pical pAD syndrome that was later confirmed at post mortem to have been due to
AD. Hereinafter this group will be referred to as early AD (Ahmed et al. in press).
Our initial aim was to quantify the semantic content of discourse produced by patients
through the analysis of semantic units, defined as “a relevant, truthful and non-re-
dundant fact or plausible inference about the stimulus picture” (Bayles et al. 1989).
Production of semantic units can be quantified using a checklist of key elements re -
presented in the picture description task, an approach that has consistently revealed
differences between samples of connected speech produced by pAD patients and con-
trols (Croisile et al. 1996; Hier et al. 1985; Tomoeda/Bayles 1993; Vuorinen et al.
2000). Secondly, we aimed to establish whether semantic units were reduced globally,
or whether there was a disproportionate reduction of specific classes of information.
Discourse samples were available from 18 early AD patients and 18 matched con-
trols. Following the classification of Croisile et al. (1996) semantic unit identification
was scored overall and for four subclasses of information from the picture description
task: subjects, locations, objects (noun units) and actions (verb units). Idea density
and efficiency of language were also calculated. Early AD transcripts showed signifi-
cantly reduced units overall, particularly with reference to the persons (mother, boy,
girl) and actions (drying dishes, looking out of the window, stealing cookies, falling
off stool) in the picture. By contrast, there were no significant differences in the total
15

number of words produced or the number of words per minute, suggesting that the
early stages of AD are associated with normal fluency of speech. Efficiency was also
significantly reduced, whereas conciseness remained within the control range. 
Statistical analyses confirmed that these measures (i. e. total units, actions, subjects
and efficiency) were highly predictive of diagnosis. Moreover, in a head-to-head com-
parison between the semantic units produced using nouns and verbs, only the latter
remained predictive of group membership. This finding may have some relevance to
neurolinguistic studies suggesting that verb retrieval is more severely impaired in
agrammatic aphasia, and retrieval of nouns in anomic aphasics (McCarthy/Warring-
ton 1985), as syntactic impairment leads to difficulties in correctly inflecting verbs
and using them in appropriate contexts (Friedmann 2000). It should be pointed out,
however, that the direction of the association between grammatical category and gram-
matical abilities is by no means consistent (Berndt et al. 1997). 
4.2 Profiles of connected speech in early Alzheimer’s Disease: a comprehensive 
examination
The results of our initial study confirmed the characteristic lexico-semantic deficit
in early AD, and raised the possibility of a co-existent reduction in the syntactic com-
plexity of the samples. A comprehensive examination of linguistic indices to provide
a profile, or profiles of impairment in AD, and investigate how these compare to other
language disorders was, however, lacking in the literature. The question was given
added importance by the association between LPA and the presence of AD pathology
(cf. section 3.2). We therefore set out to investigate whether typical AD patients share
the same profile of impairment as those presenting with LPA.
To do so, we utilised a detailed language analysis protocol taken from the quanti-
tative production analysis (QPA) approach (Berndt et al. 2000; Saffran et al. 1989).
This is a widely used and comprehensive approach for the analysis of normal and ab-
normal discourse, whose sensitivity and discriminatory value was recently demon-
strated in the context of the clinical variants of PPA (Wilson et al. 2010). QPA yields
a combination of indices that are sensitive to five dimensions in connected discourse:
speech production, lexical content, fluency, semantic content and syntactic complex-
ity. Owing to the limitations of the rating scale when using small language samples,
however, we excluded the semantic indices from the schedule used in our early AD
group (cf. Ahmed et al. 2012 for full details). 
Individual linguistic variables were reviewed in the same set of Cookie Theft de-
scriptions, produced by the 18 early AD patients and 18 controls (as were considered
in the semantic units study) and compared to profiles obtained in the three variants
of PPA published by Wilson et al. (2010). The results showed that a third of the early
AD group (n=6) produced language with a similar profile to that of controls, suggesting
that features of aphasia are not a universal finding in the early stages of typical AD.
Linguistic abnormalities were detected in the remainder of the samples, confirming
the findings of an earlier study of the prevalence of language deficits at the early stages
of the disease (Price et al. 1993). The abnormal samples showed a variety of patterns
16

of linguistic impairment, and contained features of all three variants of PPA to varying
degrees, with no single homogeneous profile emerging. More specifically, nine pa-
tients showed a reduction in one or more measure of syntactic complexity, indexed
by a reduction in the proportion of words in sentential contexts, and increased num-
bers of syntactic errors, coupled with a reduction in the proportion of nouns with de-
terminers and verbs with inflections. Three patients deviated from this majority
profile: isolated fluency impairment was noted in two patients, while one patient
showed a profile compatible with LPA, with a combination of reduced speech rate,
fluency errors, reduced lexical content and syntactic simplification, similar to the pro-
file observed by Wilson and colleagues (2010). 
The results suggest that connected speech in clinically typical, early AD conforms
to a range of recognised profiles and shares some features with the syndromes of PPA,
but that an isolated reduction of syntactic complexity may be specific to the disease.
LPA, despite its robust association with AD pathology, was far from ubiquitous, and
should therefore continue to be regarded as an atypical presentation of AD, rather than
a common clinical feature of clinically typical disease. The occurrence of these distinct
language profiles in early AD clearly needs to be replicated in a larger sample of well
characterised pAD patients, but suggests that, with further refinement, connected
speech analysis has potential as a diagnostic marker in typical variants of the disease. 
4.3 Connected speech in MCI
Cognitive and neuropathological changes of AD can be detected in patients with
MCI, and AD is considered to be particularly likely when a memory deficit can be ob-
jectively demonstrated (Petersen et al. 1999; Winblad et al. 2004). A group of re-
searchers at the Mayo Alzheimer’s Disease Research Centre followed 220 individuals
meeting criteria for MCI for up to 6 years, and documented 12% as progressing to de-
mentia in each year of follow-up (around 80% of the total cohort by the end of the
study). In contrast, the incident rate of dementia diagnoses in the same population is
only 1–2% per year. These sobering statistics underline the importance of identifying
other cognitive markers of progression, and we therefore asked whether the features
characterising language impairment observed at early AD had also been present when
the patients in our sample had met criteria for MCI. 
Data from 9 AD patients and 10 matched subjects from the control group were ex-
amined. Language analysis combined the semantic processing indices with an abbre-
viated version of QPA. Group comparisons showed that there were no significant
differences between MCI and controls, but closer inspection of the data revealed a
difference between MCI and control samples in semantic content. Similarly, MCI pa-
tients scored on average one standard deviation below controls on syntactic complexity
measures (here assessed according to mean length of utterance, proportion of words
in sentences, number of embedded clauses, syntactic errors, nouns preceded by de-
terminers, and verbs with inflections). Both contrasts, however, remained below the
threshold (corrected for multiple comparisons) for statistical significance.
17

It is likely that the mild difference between controls and MCI patients reported in
this small group may achieve greater significance in a larger cohort of patients. Ne -
vertheless, the results suggest that the profile of impairment in MCI mirrors that seen
in early AD, suggesting that this same pattern of language impairment progresses
from very early in the disease process. Given these findings, further work is warranted
in order to firstly replicate these results, and secondly to consolidate suggestions for
key features of language that should be used to identify impairment in prodromal
pAD, and finally to track these impairments through the course of the disease. 
5 CONCLUDING REMARKS
The results of recent analyses exploring language impairment in autopsy confirmed
cases of AD using a simple, reproducible and ecologically valid approach to data col-
lection (i. e. connected speech sampling), support the existing literature in showing se-
lective impairment of key processes, both at and prior to formal diagnosis. The language
deficit in AD initially disturbs lexico-semantic processing and syntactic complexity of
language, and similar changes can be detected at the MCI stage of disease.
Although it is not proposed that language examination should replace memory
testing in the diagnosis of pAD, the results nonetheless have clear clinical implica-
tions. Profiles of language impairment provide information that can help to distin-
guish AD from PPA, and to predict conversion to pAD in patients with MCI. Further
clarification of the profile and nature of these impairments will contribute to the vital
goal of determining sensitive and specific markers to aid in providing accurate diag-
nostic as well as prognostic information for the benefit of the patients and to com-
mence intervention strategies, through pharmacological treatment, psychological
intervention, financial planning and other methods, as soon as possible. 
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Abstract
SPOKEN DISCOURSE IN ALZHEIMER’S DISEASE: A REVIEW
In its typical form, Alzheimer’s disease (AD) manifests with early impairment in episodic
memory. Evidence suggests that language deficits also occur early on in the disease process,
and can be detected at the preclinical stage, suggesting that language could constitute an im-
portant diagnostic marker for disease. Additionally, a number of variant clinical presentations
of AD are recognised, due to an atypical distribution of pathology at onset, including a minority
of patients presenting with a slowly progressive language impairment. We review language per-
formance in typical and atypical presentations of AD, and describe a series of recent, novel
findings examining the language phenotype of typical AD.
Keywords: Alzheimer’s disease, connected speech, primary progressive aphasia.
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Povzetek
GOVORJENI DISKURZ IN ALZHEIMERJEVA BOLEZEN
Tipična oblika Alzheimerjeve bolezni se kaže v zgodnji okvari epizodnega spomina.
Raziskave kažejo, da se v začetni stopnji bolezenskega procesa pojavljajo tudi jezikovne motnje,
ki jih je mogoče zaznati že v predklinični fazi, zaradi česar bi jezik lahko predstavljal pomemben
diagnostični marker za to bolezen. Kljub številnim in raznolikim kliničnim oblikam te bolezni,
ki so posledica atipičnih patoloških stanj v začetku obolenja, obstaja tudi manjše število bol-
nikov, pri katerih z napredkom bolezni počasi in postopno slabi tudi njihova jezikovna
zmožnost. V prispevku ponujamo pregled raziskanih stopenj jezikovne zmogljivosti v tipičnih
in atipičnih oblikah Alzheimerjeve bolezni in predstavimo vrsto nedavnih ugotovitev o spre-
membah jezikovne rabe pri tipični obliki te bolezni.
Ključne besede: Alzheimerjeva bolezen, povezani govor, primarna progresivna afazija.
25