Alzheimer’s Dementia From a Bilingual/Bicultural Perspective

Abstract

Alzheimer’s dementia (AD) is a progressive, degenerative disease that occurs in the cerebral cortex due to increased levels of glutamate, the proliferation of plaque-forming amyloid beta proteins, and reactive gliosis. Establishing behavioral indicators of the disease (e.g., impairments of episodic memory) and use of neuroimaging technology that can substantiate medial temporal lobe brain structure deficiencies demonstrates an important clinical neuroanatomic relationship needed for early evaluation of possible AD diagnosis. This bilingual/bicultural case study details the cognitive and language impairments associated with AD over the course of 1 year. Utilization of a bilingual/bicultural case study may elucidate the pattern of language and cognitive decline in this understudied population. Formal and informal measures, observations, and magnetic resonance imaging (MRI) results are provided. Insights into cultural and linguistic differences are presented.

Keywords

diversity cultural/linguistic cognitive impairments exceptionalities memory case studies methodology research adult age

Introduction

Alzheimer’s dementia (AD) is a progressive, degenerative disease that occurs in the cerebral cortex due to increased levels of glutamate, the proliferation of plaque-forming amyloid beta proteins, and reactive gliosis (glial scar formation). 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, Colle, Delatour, & Hauw, 1999). Despite these biological features, AD is often described based on behavioral characteristics.

A case study detailing the progression of dementia in a bilingual adult is presented. Thus, the purpose of this case study is to examine the cognitive and language abilities of a bilingual/bicultural adult diagnosed with possible AD. Additional information will be provided detailing cultural issues related to his diagnosis and cognitive decline.

Characteristics of AD

Individuals with AD demonstrate impairments in the areas of language, cognition, and behavior (Frailer, 2013; Jacobson et al., 2009; Plassman, Williams, Burke, Holsinger, & Benjamin, 2010). For example, many individuals with AD demonstrate word finding problems and difficulty following simple directions associated with language impairments. A hallmark characteristic of AD is problems with short-term memory. A progressive decline in cognition also includes deficits in executive function skills and attention. In addition, individuals may experience difficulty with problem solving, abstract thinking, cognitive flexibility, as well as attention. These impairments may result in a decline in the successful completion of activities of daily living (ADLs) such as dressing, eating, or driving a vehicle. Altered patterns of behavior, such as refusal to participate in activities that had previously been enjoyed or increased egocentricity, are also commonly observed in individuals with AD (Dubois et al., 2007; Reisberg et al., 1997).

Diagnosing AD

Current criteria for the identification of AD come from the National Institute of Neurological Disorders and Stroke–Alzheimer Disease and Related Disorders (NINCDS-ADRDA) working group (McKhann et al., 1984) and the Diagnostic and Statistical Manual of Mental Disorders (5th ed; DSM-5; American Psychiatric Association, 2013). The NINCDS-ADRDA criteria indicate that the onset of AD must not result from other systemic brain diseases (e.g., depression, hypothyroidism, diseases leading to vitamin B-12 deficiencies). In addition, the DSM-5 criteria require the occurrence of a memory disorder and deficiencies in cognitive function that interfere with ADLs and social interactions (Dubois et al., 2007). The DSM-5 criteria also include disturbance of executive functioning (i.e., planning, organizing, sequencing, and abstracting). Finally, the criteria indicate that AD must cause significant impairment in social or occupational functioning, represent a noticeably gradual decline in functioning, and occur in the absence of any other condition (nervous system or systemic) to account for the cognitive decline. 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, & Trosset, 1992; Chui et al., 2006; Collie & Maruff, 2002; de Jager, Honey, Birks, & Wilcock, 2010; Grossman & White-Devine, 1998; Marshall, Duke, & Walley, 1996).

The NINCDS-ADRDA (McKhann et al., 1984) developed four levels of diagnoses for AD: (a) Definite Alzheimer’s disease, as evidenced by neuritic plaques and neurofibrillary tangles present at autopsy; (b) Probable Alzheimer’s disease, determined through age of onset (between 40 and 90 years of age), clinical and neuropsychological testing demonstrating cognitive decline in at least two cognitive areas (i.e., memory, problem solving, attention, and/or orientation), and a progressive decline in cognitive abilities not due to any other disease/disorder; (c) Possible Alzheimer’s disease, in which the patient demonstrates atypical, progressive cognitive decline with an unknown etiology with an absence of comorbid illness; and (d) Unlikely Alzheimer’s disease, in which an acute dementia is observed with focal neurologic signs, seizures, or gait disturbances early in the course of the illness (Dubois et al., 2007).

Distinctive Markers of AD

As McKhann and colleagues (1984) initially published the NINCDS-ADRDA criteria, advancement in the diagnosis of AD has identified the need to include a phenotype not solely based on exclusionary criteria but based on the presence of distinctive markers such as cortical shrinkage, hippocampal shrinkage, or medial temporal lobe shrinkage (Ramachandran, Zachariah, & Agrawal, 2012). Other distinctive markers include hypometabolism, hypoperfusion (i.e., reduction of blood flow) in tempoparietal areas, and changes in cerebrospinal fluid biomarkers (Dubois et al., 2007). Hence, establishing behavioral indicators of the disease (e.g., impairments of episodic memory; Dubois et al., 2007) and use of neuroimaging technology that can substantiate medial temporal lobe brain structure deficiencies demonstrates an important clinical neuroanatomic correlation needed for a diagnosis of preclinical AD (i.e., a definite or probable diagnosis; Dubois et al., 2007; McKhann et al., 1984).

Early Identification of AD

Dubois and Albert (2004) stated that mild cognitive impairment (MCI) is a general dementia classification, given prior to a specific classification of an amnestic syndrome (i.e., AD). It should be noted that not all cases of MCI lead to AD. Probable AD or a possible stage of AD is “characterised by symptoms not severe enough to meet currently accepted diagnostic criteria for AD” (Dubois et al., 2007, p. 735). Early identification of AD is essential to initiating appropriate intervention and management strategies as well as providing caregivers with information concerning the disease. One area that has been widely investigated focuses on the link between communication disorders and dementia because of the close relation among language, cognition, and memory (Bayles et al., 1992).

However, concrete and widely accepted data linking a specific communication difficulty to early stages of AD remain to be determined (Balota & Duchek, 1991; Bayles, 2003; Dubois et al., 2007; Hamberger, Friedman, Ritter, & Rosen, 1995; Kempler, Almor, & MacDonald, 1998). A detailed examination of cognitive and memory decline in AD is warranted to demonstrate the relations among communication, cognitive, and memory skills. Utilization of a bilingual case study may begin to elucidate the pattern of language and cognitive decline in this understudied population. Such study offers a glimpse into bilingual cognition within and between languages unavailable through solely monolingual research.

Bilingual research related to Alzheimer’s disease has recently focused on potential protective mechanisms related to proficiency in two or multiple languages (e.g., Bialystok, Craik, & Freedman, 2007, 2010; Chertkow et al., 2010; Gollan, Salmon, Montoya, & Galasko, 2011; Ossher, Bialystok, Craik, & Troyer, 2013). Although these studies provide important information related to the connections between cognitive, language, and progressive neurodegenerative conditions such as dementia, studies that examine the cognitive decline experienced by individuals who are bilingual and multilingual are needed. Careful consideration of the language and cognitive abilities of this population is important for developing appropriate diagnostic and intervention procedures for the increasing number of bilingual and multilingual populations worldwide (Bialystok, Craik, & Luk, 2012; Gollan et al., 2011; Green & Abutalebi, 2008; Lorenzen & Murray, 2008). In addition, these studies may provide insight in approaches for addressing potential cultural differences in these populations.

Bilingual Aphasia and Bilingual Dementia

Studies of adult bilingualism have focused on localization of cognitive and language functions (Abutalebi, 2008; Abutalebi, Cappa, & Perani, 2001; Hernandez, Dapretto, Mazziotta, & Bookheimer, 2001), recovery patterns in bilingual aphasia (Green & Abutalebi, 2008; Lorenzen & Murray, 2008; Paradis, 2004), and bilingualism and onset of dementia (Bialystok et al., 2007, 2010; Bialystok et al., 2012; Chertkow et al., 2010; Gollan et al., 2011; Ossher, Bialystok, Craik, Murphy, & Troyer, 2012). Abutalebi et al. (2001) stated that two main factors exist that seem to contribute most to cerebral localization and representation in bilingual and multilingual individuals: language proficiency level and language exposure. These factors were deemed to be more important than age of second language acquisition.

A number of researchers have found that bilingual individuals share the same neurological structures and representation for their languages including when the languages are spoken independently of each other and also when code switching (i.e., alternating between the first and second language; Abutalebi, 2008; Hernandez, 2009; Hernandez et al., 2001). Shared language brain structures have included the dorsolateral prefrontal cortex (DLPFC), Broca’s area, and the superior parietal lobe during single language switching (e.g., switching from L1 to L2 and not from L1 to L2 to L3; Hernandez, 2009).

However in an earlier study, Abutalebi and colleagues (2001) found differential patterns of language recovery following a stroke (i.e., one language recovering differently from the others). This would seem to indicate differential organization of languages. Abutalebi and colleagues (2001) stated, “As mentioned above, studies of bilingual and polyglot aphasia have provided evidence that a bilingual may selectively lose one of his/her languages, while the other is spared, suggesting that the neural representation of different languages is differentially organized” (p. 181). This would follow the various recovery patterns as noted by Paradis (2004). Paradis found seven different recovery patterns in adult bilingual aphasics. Lorenzen and Murray (2008) stated that most research supports an amalgamated view (i.e., shared and separate representation). Lorenzen and Murray proposed that numerous factors following trauma may affect the recovery pattern of individuals who are bilingual. These factors may include emotional experiences regarding the languages, language use after trauma, and quantity of input from the two (or more languages) following the trauma.

Studies examining bilingualism, amnestic mild cognitive impairment (aMCI; that is, MCI affecting memory), and AD have generally focused on delays of dementia onset (Bialystok et al., 2010; Bialystok et al., 2012; Chertkow et al., 2010; Gollan et al., 2011; Ossher et al., 2012). Bialystok and colleagues (2007) found that dementia symptoms appeared 4 years later in bilinguals when compared with monolingual adults. Similarly, Ossher and colleagues (2012) found that people who are bilingual and were diagnosed with single domain aMCI were older than their monolingual counterparts. People with single domain aMCI experience only memory deficits. In contrast, people with multiple domain aMCI experience memory deficits along with difficulties in language, executive functions, or visuospatial skills. Ossher and colleagues (2013), however, found that people who are bilingual and have multiple domain deficits were slightly younger than their monolingual counterparts. Consequently, the relationship between bilingualism and dementia onset is not clearly established. Little research examines the effects of possible AD on bilingualism.

Purpose of This Case Study

Therefore, the purpose of this case study is to examine the cognitive and language abilities of a bilingual/bicultural adult diagnosed with possible AD. Additional information will be provided detailing cultural issues related to his diagnosis and cognitive decline.

Method

Participant

This case study described the progression of AD in an 88-year-old man (at the time of the study) who came to the United States from Cuba at the age of 37. He was a lawyer in Cuba (earning his doctorate of jurisprudence) and then eventually became a Spanish teacher (earning a master of arts) in the United States. He had taught high school before retiring. He would be considered a highly fluent bilingual if one utilized an oral proficiency rating scale in assessing his English proficiency abilities (e.g., the International Second Language Proficiency Ratings; Wylie & Ingram, 1999). His Spanish abilities were judged to be high level as he practiced law in Cuba for many years before coming to the United States. In addition, his English skills were also judged to be high level as he taught in U.S. schools for more than 20 years.

When the participant was 85 to 86 years old, he began demonstrating the following symptoms of progressive cognitive decline as evidenced by his difficulties with immediate, working and long-term memory and reduced ability to complete ADLs independently. Examples of these symptoms included (a) repeating the same stories within the same conversation, (b) getting lost while driving in the city where he had lived for 20 years, (c) decreased orientation to the day of the week, (d) wearing the same clothes several days consecutively without washing them, (e) forgetting to eat some meals or naming all meals “breakfast,” (f) frequently over drafting his bank account, (f) losing interest in reading the newspaper and novels (the participant had been an avid reader in both English and Spanish), and (f) causing a kitchen fire because of a forgotten pot placed on the stovetop on high heat. The participant’s episodes of forgetfulness continued and significantly increased after the loss of his spouse. At that time, the family became aware of the safety issues of the participant living alone. Subsequently, the participant moved to his son’s home.

Differential Diagnosis

Initial assessments were performed by the participant’s primary care physician and neurologist who are both Cuban American. Table 1 provides an overview of the participant’s diagnosis timeline. The purpose of these tests was to exclude the possibility of other causes of cognitive and behavioral symptoms (e.g., depression, thyroid disease, and vitamin B-12 deficiency) and to differentially diagnose the participant’s suspected dementia. The preceding factors were discounted as causal agents. The participant’s family members reported that the neurologist was initially hesitant to make a tentative diagnosis regarding the participant’s mental status and stated that the participant was “fine” when the participant asked about his test results. It was noted that only when prompted by the participant’s son, did the neurologist state that the symptoms might have been the result of possible AD. To aid in the differential diagnosis, the neurologist requested a magnetic resonance imaging (MRI) of the participant’s head, which was performed when the participant was 87 years of age.

Table 1.

Timeline of Diagnostic Events and Testing.

Age (years)	Date	Event/test
85	2009	Immediate and long-term memory problems evident to family members
87	February 26, 2011	Observational notes begin
87	July 25, 2011	Initial consult with primary care physician and referral to neurologist
87	July 28, 2011	Initial visit with neurologist
87	August 1, 2011	Administration of MRI
87	August 11, 2011	Initial diagnosis of MCI
87	September 15, 2011	First administration of GDS
87	October 5, 2011	First administration of MMSE and MMSE Spanish
87	October 24, 2012	Observational notes end
88	October 25, 2012	Second administration of GDS
88	October 25, 2012	Second administration of MMSE and MMSE Spanish

Note. MRI = magnetic resonance imaging; MCI = mild cognitive impairment; GDS = Global Deterioration Scale; MMSE = Mini-Mental State Examination.

Instruments

The following assessments were administered to determine the level of cognitive and language impairments: (a) Mini-Mental State Exam English (MMSE; Folstein, Folstein, & McHugh, 1975); (b) Mini-Mental State Exam Spanish adaptation (MMSE Spanish; Reyes de Beaman et al., 2004); (c) Global Deterioration Scale (GDS; Reisberg, Ferris, de Leon, & Crook, 1982); and (d) observations taken over the course of 20 months.

The MMSE is a quantitative measure of orientation, registration, attention and calculation, recall, and language abilities and yields subtest scores in each of these areas as well as a total score (Folstein et al., 1975). The Orientation Subtest provides information about knowledge of location, date, and time. Immediate and delayed recall are measured through administration of the Registration and Recall Subtests, respectively. The Language Subtest briefly assesses areas of language, including confrontation naming, repetition, as well as auditory and reading comprehension. Finally, the Attention and Calculation Subtest measures working memory through numeric calculation and spelling tasks.

The MMSE has an overall correct classification of dementia with 89% accuracy (i.e., 0.66 sensitivity and 0.99 specificity) when using the cutoff score of 23 or below (O’Bryant et al., 2008). Spanish adaptations of the MMSE (e.g., MMSE Spanish) have demonstrated high validity (0.97 sensitivity and 0.88 specificity; Reyes de Beaman et al., 2004). Ostrosky-Solís, López-Arango, and Ardila (2000) also found high sensitivity (86.36%) and specificity (86.36%) when using the MMSE Spanish with a Spanish-speaking population when the participants had more than 5 years of schooling. Differences in test sensitivity between the English MMSE and the Spanish adaptation may have resulted from differences in sampling errors and what was considered to be the “gold standard” comparison (i.e., a benchmark available under reasonable conditions, a definitive in diagnosis; Qu & Hadgu, 1998; Valenstein, 1990). However, use of the English and adapted Spanish versions of the MMSE appeared to be adequate exams in detecting cognitive dysfunction. The researchers used the MMSE Spanish adapted by Reyes de Beaman and colleagues (2004) for this investigation.

The researchers utilized a dual language scoring combined approach to determine the Combined English and Spanish MMSE scores (Bedore, Peña, Garcia, & Cortez, 2005; Castilleja, 2012; Pearson, Fernandez, & Oller, 1993). This approach is similar to total conceptual vocabulary scoring in vocabulary studies (Pearson et al., 1993). It is the sum of all correct responses combined across languages (i.e., correct responses are counted only once regardless of which language). Consequently, a combined score tends to produce a more accurate score in cognitive and language abilities than single language administration scores (Bedore et al., 2005; Castilleja, 2012; Pearson et al., 1993).

Procedures

To quantify the progressive changes in language and cognitive abilities of the participant, two speech-language pathologists (SLPs) administered several assessments over a period of 1 year. The SLPs administered the MMSE and MMSE Spanish, as well as the GDS 1 year apart when the participant was 87 and 88 years of age, respectively. Observations (obtained by the first and third authors) were obtained during functional interactions with the participant and his family members for over a period of 20 months (the participant was between 87 and 88 years of age).

Data were gathered over extended interactions and these interactions were noted during family visits over this time period. All notations were discussed between the first and third author and 100% consensus agreement was achieved regarding the details of the events.

Results

Brain Imaging

Neuroimaging evidence suggested a strong possibility of AD. Medial temporal lobe atrophy and hippocampal atrophy are highly associated with AD (Dubois et al., 2007; Ramachandran et al., 2012). Visual inspection of the MRI when the participant was 87 years old indicated the following physiological distinctive markers of AD: (a) cortical shrinkage, axial view; (b) hippocampal shrinkage, coronal view; and (c) temporal lobes shrinkage, axial view (Dubois et al., 2007; Ramachandran et al., 2012; see Figures 1 –3).

Figure 1.

Cortical shrinkage, axial view.

Figure 2.

Hippocampal shrinkage, coronal view.

Figure 3.

Temporal lobes shrinkage, axial view.

Formal Test Scores

Results of the MMSE and MMSE Spanish highlight differences in the participant’s performance when administered in each language. The results from the English, Spanish, and Combined scores of the MMSE (administered October 2011 and 2012) are presented in Table 2.

Table 2.

English, Spanish, and Combined Scores From the Mini-Mental State Examination Subtests and Total Score.

	2011			2012
	English	Spanish	Combined	English	Spanish	Combined
Orientation	3/10 (30%)	8/10 (80%)	9/10 (90%)	1/10 (10%)	2/10 (20%)	2/10 (20%)
Registration	3/3 (100%)	3/3 (100%)	3/3 (100%)	2/3 (67%)	3/3 (100%)	3/3 (100%)
Attention and calculation	3/5 (60%)	5/5 (100%)	5/5 (100%)	0/5 (0%)	0/5 (0%)	0/5 (0%)
Recall	0/3 (0%)	0/3 (0%)	0/3 (0%)	0/3 (0%)	0/3 (0%)	0/3 (0%)
Language	7/9 (78%)	8/9 (89%)	8/9 (89%)	4/9 (44%)	7/9 (78%)	7/9 (78%)
Total	16/30 (53%)	24/30 (80%)	25/30 (83%)	7/30 (23%)	12/30 (40%)	12/30 (40%)
Interpretation	Moderate AD	Mild AD	Low normal	Severe AD	Moderate AD	Moderate AD

Note. AD = Alzheimer’s dementia.

The two administrations of the GDS were completed by the first author with input from the participant’s family members and friends. Examples of his behaviorsconsidered for first GDS included the following: (a) the participant would forget where one of his two sons lived (GDS Stage 3); (b) the participant would repeat the same story or ask the same question minutes later (GDS Stage 3); (c) the participant would repeat what was previously said by another person and he would act as if he had originally made the comment (GDS Stage 3); (d) the participant was frequently unable to orient to place, time, and context (e.g., incorrectly identifying the city he lived in and also the year; GDS Stage 4); (e) the participant would respond to a sales clerk in Spanish when the clerk only spoke English and would not self-correct by switching to English after three conversational turns (GDS Stage 4); and (f) the participant would ask in Spanish what common words meant in English (GDS stage 5). In sum, results from the GDS first administered indicated his behaviors were predominantly in Stage 4 (mild dementia). A second administration of the GDS in 2012 revealed an increased number of behaviors in Stage 5 (moderate dementia).

Behavioral Observations

The participant’s behaviors were observed frequently for a period 20 months by the first and third authors (the participant was observed 3–5 times per week for periods from 45 min to 1 hr). Episodes of anger were noted in the early diagnostic stages (i.e., when the participant was 87 years of age). In addition, the participant experienced cognitive, memory, and orientation difficulties related to identifying place, time, and context. For example, he incorrectly stated the city in which he lived, was unaware of the year, month, date, or day of the week. When provided the correct information and a 10-s delay, he was unable to provide the correct information. His conversations always centered around only past events and he was unable to converse about current events. It should be noted that when the participant was initially tested with the MMSE, he stated that he was “not crazy” and “not stupid” potentially indicating his cultural perceptions of cognitive impairments and associated disability.

In addition to the orientation difficulties observed, the researchers noted that the participant would speak Spanish to monolingual English speakers and was unaware of this inappropriate language choice. Over the period of the 20 months of observations, the participant spoke less English and increasingly relied on his Spanish language skills. Frequently, when listening to a person talk in English, the participant responded that he could not hear what was said. However, when the speaker repeated the same comment or question in Spanish, at a similar loudness and decibel level, the participant responded without difficulty. In separate instances, the participant stated that he could hear what was said, but did not understand what was said (see Table 3).

Table 3.

Triangulation Data of Diagnostic Criteria for Alzheimer’s Dementia.

Diagnostic criteria for “MCI of Alzheimer-type” or “prodromal AD” (Dubois & Albert, 2004)	Global Deterioration Scale (2011; Reisberg, Ferris, de Leon, & Crook, 1982)	Global Deterioration Scale (2012; Reisberg et al., 1982)	Observations (July 2011–October 2012)	Other
Memory complaints by the patient or by the family	3(b) Coworkers (family members with the participant) become aware of patient’s relatively poor performance.	3(b) Coworkers become aware of patient’s relatively poor performance.	Forget where one of his two sons lived.	MMSE Recall subtest results from 2011 and 2012.
	3(c) Word of naming finding deficit become evident to intimates.	3(c) Word of naming finding deficit become evident to intimates.	Repeated the same story or question a few minutes later or immediately afterward.
	3(e) Patient may demonstrate decreased facility remembering names upon introduction to new people.	3(e) Patient may demonstrate decreased facility remembering names upon introduction to new people.	Attended a wedding and later inquired about the reason for the celebration.
	3(f) Patient may have lost or misplaced an object of value.	3(f) Patient may have lost or misplaced an object of value.	Repeated other’s comments as if it came from him, that is, he had originally made the comment.
	3(g) Concentration deficit may be evident on clinical testing.	3(g) Concentration deficit may be evident on clinical testing.
Progressive onset			Gradual onset noted in 2007.
			Progression noted from 2007 to 2012.
Normal or mildly impaired complex activities of daily living	4(d) Decreased ability to travel, handle finances, and so on.	4(d) Decreased ability to travel, handle finances, and so on.	Frequently unable to orient to place, time, and context.
	5 Patient can no longer survive without some assistance.	5 Patient can no longer survive without some assistance.	Looked for his medicine in a bread bag.
		5 Frequently some disorientation to time (date, day of the week, season, etc.) or to place.	Prepared cereal and milk on a plate instead of a bowl.
			Spit food on the floor in a restaurant.
			Had frequent anger outbursts over small matters.
			Responded in Spanish when a sales clerk had asked a question in English. He continued to respond in Spanish over three turns and did not switch to English.
			Responded that he could not hear when asked a question in English, but then responded when questioned in Spanish.
			Frequently overdrew his bank account.
			Caused a fire in the kitchen by leaving a pan on the stove.
Amnestic syndrome of the “hippocampal type” defined by:	4(a) Decreased knowledge of current and recent events.	4(a) Decreased knowledge of current and recent events.	Confused grandchildren and what they studied at the university. He frequently asked what they were studying and what was their academic year standing.	MMSE Recall subtest results from 2011 and 2012.
very poor free recall despite adequate (and controlled) encoding;	4(b) May exhibit some deficit in memory of one’s personal history.	4(b) May exhibit some deficit in memory of one’s personal history.	Confused his two sons.
decreased total recall because of insufficient effect of cueing or impaired recognition;	5(a) Patient is unable during interview to recall a major relevant aspect of their current life, for example, (a) their address or telephone number of many years;	5(a) Patient is unable during interview to recall a major relevant aspect of their current life.	Called his son (in out of state city) for daily assistance yet did not call the son who was local.
numerous intrusions	(b) the names of close members of their family (such as grandchildren).		Given evening medications and 10 min later asked for his medicines.
			Asked in Spanish what words meant in English.
Persistence of memory changes at a subsequent assessment			Progressive decline of cognitive, perception, attention, and memory skills was noted over the period from October 2011 to October 2012.	MMSE decreases from 2011 to 2012.
Absence of the fully developed syndrome of dementia			Diagnosed with Mild Cognitive Impairment Not Otherwise Specified in July 2011.
Exclusion of other disorders that may cause MCI, with adequate tests, including neuroimaging and biomarkers				Negative tests for depression, thyroid disease, and, vitamin B-12 deficiency.

Note. MCI = mild cognitive impairment; AD = Alzheimer’s dementia; MMSE = Mini-Mental State Examination.

Discussion

The results of the tests and observation indicated that this participant later presented with moderate to severe AD (from 85 years of age in 2009 to 88 years of age in 2012). This participant had a unique profile related to his language abilities and culture. Please refer to Table 1, which provides a time frame of the participant’s Alzheimer’s disease progression. Consideration of the testing results and observations, provide information that may be helpful for professionals providing services to similar patients.

Language and Cognition

As indicated by the MMSE English, Spanish, and Combined scores, the participant showed greater proficiency in Spanish over time as compared with his second language of English.

Studies examining language decline associated with dementia support these findings, in that often the people who are bilingual and have dementia show the least impairment in their first language (e.g., Mendez, Perryman, Pontón, & Cummings, 1999). For example, Mendez, Saghafi, and Clark (2004) reported two case studies in which individuals with dementia were most proficient in their first language. In contrast, other studies have found that people with dementia perform language tasks similarly in their first and second languages (Hernandez et al., 2001) or perform language tasks the worst when using their dominant language (Gollan et al., 2011). The difference in results could have been affected by different tasks eliciting the responses. However, the results do seem to suggest differential organization for language, or, at the minimum, an amalgamated representation of language (Lorenzen & Murray, 2008).

The varied results on the English and Spanish versions of the MMSE highlight the need to consider both or multiple languages when completing cognitive assessments. Assessing in only one language may not reflect the cognitive abilities of an individual who is bilingual or multilingual. One possible strategy would be to use non-verbal assessments of cognition and provide instructions in both or multiple languages. These types of assessments are often used with people with language impairments (e.g., individuals with aphasia) to reduce the effects language might have on the evaluation of cognitive performance. Examples of these tasks include design memory, symbol cancellation, and design generation (e.g., subtests from the Cognitive Linguistic Quick Test by Helms-Estabrooks, 2001).

The participant’s difficulty switching between his first and second languages, and poor recognition of the need to use the language understood by his communication partner likely reflects a decline in attention and executive function skills. The increased recruitment of attention and executive function skills in people who are multilingual or bilingual is thought to protect against cognitive decline. However, enhanced skills in these areas compared with individuals who are monolingual may also result in a delay in the recognition of symptoms (Bialystok et al., 2010).

Administration of the GDS and recording of observations supplemented results from the MMSE. These additional measures are important because no single measure is definitive of AD. The results of the GDS indicated a progressive onset, deterioration of memory, impaired ADLs, amnestic qualities, and a persistent memory decline. All of the testing, observations, and use of distinctive markers assisted with the diagnosis of probable AD, thus supporting triangulation as a strategy for evaluating cognition in individuals who are bilingual.

Cultural Considerations

Because the concept of disability varies from culture to culture (Brice & Brice, 2009), SLPs and other health professionals should note that cognitive, mental, and language ability assessments may be misunderstood by patients and their family members. Careful explanation should be provided as to the nature of the assessments and consequently the recommended treatments.

Another example of how culture may have influenced this participant’s care relates to his shared culture with his physicians. Typically individuals or families may seek medical professionals speaking the same language and from the same or similar culture to increase comfort and familiarity (Bowen, 2001; Ferguson & Candib, 2002; Ginzberg, 1991; Lipson & Meleis, 1983; Misra-Hebert, 2003). In the current study, the participant was initially seen by his primary care physician, followed by a neurologist who had a similar cultural background as well (i.e., both Cuban American). After the MRI, the neurologist required prodding by the patient’s son before he explained the extent of the difficulties with memory observed and provided a diagnosis of MCI and possibly AD. In some Latino medical professions it may be typical for physicians to refrain telling the patient and/or family members the specific diagnoses in the initial stages of the disease (Brice & Brice, 2009). This type of diagnostic behavior, while sometimes accepted in Latin cultures, may result in a delay in patients seeking the appropriate medical treatment. In addition, a misconception that dementia is the result of normal aging is common among individuals in minority cultures and may result in further delays in seeking treatment (Gauthier & Clarke, 1999). In situations such as the one presented in the current case study, SLPs or other professionals may be expected to provide detailed information about diagnosis and test results. However, in doing so, all professionals should carefully consider how to accommodate cultural norms while providing the necessary information.

Clinical Implications

The participant in this investigation is not typical of what SLPs frequently encounter, that is, the participant was highly fluent in both languages; he was seen by knowledgeable SLPs and physicians who shared his language and culture. However, please note that some cultural interference occurred with the participant’s neurologist when he initially failed to disclose a potential diagnosis. Any of these factors (language skills, SLP knowledge and skills, and physician knowledge and skills) are likely to change according to the patient, clinician, physician, and family idiosyncrasies. Second language skills may not be possible for all health care providers. However, SLPs need to be aware of cultural differences that can affect diagnosis and treatment. In addition, SLPs should educate and advocate for patients when working with other professionals.

In an effort to improve services provided to the growing population of bilingual and bicultural individuals, SLPs and other health professionals must recognize the diverse perspectives of various cultures to ensure that their practices appropriately accommodate their clients’ cultural perspectives. Due to differing cultural perceptions of disabilities, it is imperative that SLPs explain (or provide in writing) diagnostic information to the patient and family in understandable terms (e.g., memory difficulties that will continue to decline over time). Use of the AD label may confuse patients and families as to the exact diagnosis in the early stages of dementia. Use of both languages is crucial because it is not known which language may provide the best therapeutic intervention (Gollan et al., 2011; Hernandez et al., 2001; Mendez et al., 2004). Consequently, a multimodal, dual language approach to intervention is recommended along with use of interpreters as needed.

In conclusion, SLPs must recognize different cultural and linguistic perspectives and ensure that their practices appropriately accommodate cultural and language differences. It is the responsibility of health professionals to accommodate and modify means of intervention to match clients’ linguistic and cultural backgrounds.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

References

Abutalebi

(2008). Neural aspects of second language representation and language control. Acta Psychologica, 126, 466–478.

Abutalebi

Cappa

Perani

(2001). The bilingual brain as revealed by functional neuroimaging. Bilingualism: Language and Cognition, 4, 179–190.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Balota

D. A.

Duchek

J. M.

(1991). Semantic priming effects, lexical repetition effects, and contextual disambiguation effects in healthy aged individuals and individuals with senile dementia of the Alzheimer’s type. Brain & Language, 40, 181–201.

Bayles

(2003). Effects of working memory deficits on the communicative functioning of Alzheimer’s dementia patients. Journal of Communication Disorders, 36, 209–219.

Bayles

Tomoeda

Trosset

(1992). Relation of linguistic communication abilities of Alzheimer’s patients to stage of disease. Brain & Language, 42, 454–472.

Bedore

Peña

Garcia

Cortez

(2005). Conceptual vs. monolingual scoring: When does it make a difference? Language, Speech, and Hearing Services in Schools, 36, 188–200.

Bialystok

Craik

F. I. M.

Freedman

(2007). Bilingualism as a protection against the onset of symptoms of dementia. Neuropsychologia, 45, 459–464.

Bialystok

Craik

F. I. M

Freedman

(2010). Delaying the onset of Alzheimer disease: Bilingualism as a form of cognitive reserve. Neurology, 75, 1726–1729.

10.

Bialystok

Craik

F. I. M.

Luk

(2012). Bilingualism: Consequences for mind and brain. Trends in Cognitive Sciences, 16, 240–250. doi:10.1016/j.tics.2012.03.001

11.

Bowen

(2001). Language barriers in access to healthcare. Ottawa, Ontario: Health Canada.

12.

Brice

(Eds.). (2009). Language development: Monolingual and bilingual acquisition. Old Tappan, NJ: Merrill.

13.

Castilleja

(2012, November). PLS-5 Spanish: Dual language administration and scoring. Available from http://www/speechpathology.com

14.

Chertkow

Whitehead

Phillips

Wolfson

Atherton

Bergman

(2010). Multilingualism (but not always bilingualism) delays the onset of Alzheimer’s disease: Evidence from a bilingual community. Alzheimer’s Disease & Associated Disorders, 24, 118–125.

15.

Chui

H. C.

Zarow

Mack

W. J.

Ellis

W. G.

Zheng

Jagust

W. J.

. . .Vinters

H. V.

(2006). Cognitive impact of subcortical vascular and Alzheimer disease pathology. Annals of Neurology, 60, 677–687.

16.

Collie

Maruff

P. M.

(2002). An analysis of systems of classifying mild cognitive impairment in older people. Australian and New Zealand Journal of Psychiatry, 36, 133–140.

17.

de Jager

Honey

T. E. M.

Birks

Wilcock

G. W.

(2010). Retrospective evaluation of revised criteria for the diagnosis of Alzheimer’s disease using a cohort with post-mortem diagnosis. International Journal of Geriatric Psychiatry, 25, 988–997.

18.

Dubois

Albert

(2004). Amnestic MCI or prodromal Alzheimer’s disease? The Lancet Neurology, 3, 246–248.

19.

Dubois

Feldman

Jacova

Dekosky

Barberger-Gateau

Cummings

. . .Scheltens

(2007). Research criteria for the diagnosis of Alzheimer’s disease: Revising the NINCDS-ADRDA criteria. The Lancet Neurology, 6, 734–746.

20.

Duyckaerts

Colle

M. A.

Delatour

Hauw

(1999). Alzheimer’s disease: Lesions and their progression. Review of Neurology, 155, 17–27.

21.

Ferguson

Candib

(2002). Culture, language, and the doctor-patient relationship. Family Medicine, 34, 353–361.

22.

Folstein

M. F.

Folstein

S. E.

McHugh

P. R.

(1975). Mini-Mental State: A practical method for grading the state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198.

23.

Frailer

(2013). State of science: Use of biomarkers and imaging in diagnosis and management of Alzheimer disease. Journal of Neuroscience Nursing, 45, 63–70.

24.

Gauthier

M. A.

Clarke

W. P.

(1999). Gaining and sustaining minority participation in longitudinal research projects. Alzheimer’s Disease & Associated Disorders, 13, S29–S33.

25.

Ginzberg

(1991). Access to health care for Hispanics. Journal of the American Medical Association, 265, 238–241.

26.

Gollan

T. H.

Salmon

D. P.

Montoya

R. I.

Galasko

D. R.

(2011). Degree of bilingualism predicts age of diagnosis of Alzheimer’s disease in low education but not in highly educated Hispanics. Neuropsychologia, 49, 3826–3830.

27.

Green

Abutalebi

(2008). Understanding the link between bilingual aphasia and language control. Journal of Neurolinguistics, 21, 558–576.

28.

Grossman

White-Devine

(1998). Sentence comprehension in Alzheimer’s disease. Brain & Language, 62, 186–201.

29.

Hamberger

Friedman

Ritter

Rosen

(1995). Event-related potential and behavioral correlates of semantic processing in Alzheimer’s patients and normal controls. Brain & Language, 48, 33–68.

30.

Helms-Estabrooks

(2001). Cognitive Linguistic Quick Test. San Antonio, TX: Pearson.

31.

Hernandez

(2009). Language switching in the bilingual brain: What’s next? Brain & Language, 109, 133–140.

32.

Hernandez

Dapretto

Mazziotta

Bookheimer

(2001). Language switching and language representation in Spanish-English bilinguals: An fMRI study. NeuroImage, 14, 510–520.

33.

Jacobson

Delis

Peavy

Wetter

Bigler

Abildskov

. . .Salmon

(2009). The emergence of cognitive discrepancies in preclinical Alzheimer’s disease: A six-year case study. Neurocase: The Neural Basis of Cognition, 15, 278–293.

34.

Kempler

Almor

MacDonald

M. C.

(1998). Teasing apart the contribution of memory and language impairments in Alzheimer’s disease: An on-line study of sentence comprehension. American Journal of Speech-Language Pathology, 7, 61–67.

35.

Lipson

Meleis

(1983). Issues in health care of Middle Eastern patients. The Western Journal of Medicine, 139, 854–861.

36.

Lorenzen

Murray

(2008). Bilingual aphasia: A theoretical and clinical review. American Journal of Speech-Language Pathology, 17, 299–317.

37.

Marshall

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.

38.

McKhann

Drachman

Folstein

Katzman

Price

Stadlan

E. M.

(1984). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology, 34, 939–944.

39.

Mendez

M. F.

Perryman

K. M.

Pontón

M. O.

Cummings

J. L.

(1999). Bilingualism and dementia. Journal of Neuropsychiatry and Clinical Neuroscience, 11, 411–412.

40.

Mendez

M. F.

Saghafi

Clark

D. G.

(2004). Semantic dementia in multilingual patients. Journal of Neuropsychiatry and Clinical Neuroscience, 16, 381.

41.

Misra-Hebert

(2003). Physician cultural competence: Cross-cultural communication improves care. Cleveland Clinic Journal of Medicine, 70, 289–303.

42.

O’Bryant

Humphreys

Smith

Ivnik

Graff-Radford

Petersen

Lucas

(2008). Detecting dementia with the Mini-Mental State Examination in highly educated individuals. Archives of Neurology, 65, 963–967.

43.

Ossher

Bialystok

Craik

F. I. M.

Murphy

K. J.

Troyer

A. K.

(2013). The effect of bilingualism on amnestic mild cognitive impairment. Journal of Gerontology: Psychological Sciences and Social Sciences, 68, 8–12. doi:10.1093/geronb/gbs038

44.

Ostrosky-Solís

López-Arango

Ardila

(2000). Sensitivity and specificity of the Mini-Mental State Examination in a Spanish speaking population. Applied Neuropsychology, 7, 25–31.

45.

Paradis

(2004). A neurolinguistic theory of bilingualism. Amsterdam, The Netherlands: John Benjamins.

46.

Pearson

Fernandez

Oller

D. K.

(1993). Lexical development in bilingual infants and toddlers: Comparison to monolingual norms. Language Learning, 43, 93–120.

47.

Plassman

Williams

Burke

Holsinger

Benjamin

(2010). Systematic review: Factors associated with risk for possible prevention of cognitive decline in later life. Annals of Internal Medicine, 153, 182–193.

48.

Hadgu

(1998). A model for evaluating sensitivity and specificity for correlated diagnostic tests in efficacy studies with an imperfect reference test. Journal of the American Statistical Association, 93, 920–928.

49.

Ramachandran

T. S.

Zachariah

S. B.

Agrawal

V. K.

(2012). Alzheimer disease imaging. Retrieved from http://emedicine.medscape.com/article/336281-overview

50.

Reisberg

Burns

Brodarty

Eastwood

Rossor

Sartorius

Winblad

(1997). Diagnosis of Alzheimer’s disease. Report of an International Psychogeriatric Association Special Work Group Meeting under the cosponsorship of Alzheimer’s Disease International, the European Federation of Neurological Societies, the World Health Organization, and the World Psychiatric Association. International Psychogeriatrics, 9, 11–38.

51.

Reisberg

Ferris

de Leon

Crook

(1982). The Global Deterioration Scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139, 1136–1139.

52.

Reyes de Beaman

Beaman

Garcia-Peña

Angel Villa

Heres

Córdova

Jagger

(2004). Validation of a modified version of the Mini-Mental State Examination in Spanish. Aging, Neuropsychology, and Cognition, 11, 1–11.

53.

Valenstein

(1990). Evaluating diagnostic tests with imperfect standards. American Journal of Clinical Pathology, 93, 252–258.

54.

Wylie

Ingram

D. E.

(1999). International second language proficiency ratings. Brisbane, Australia: Griffith University.