Language Preferences In Bilingual Education For People With Dementia

Life expectancies have increased significantly during the past century which has resulted in more elderly people in the social spectrum with improved health systems. Effective communication is central to an older person’s wellbeing. It involves the adequate production and reception of a message, congruity between the message sent and the message received in the environment in which his/her interactions are valued and reinforced. On the other hand, as people age, there exists a difficulty in understanding as well as remembering spoken and written language. Hence it is a prerequisite to the understanding of the cognitive processing involved in language production and comprehension. In using language one has to draw on the abilities to encode information, to store information over short or long periods of time, and to retrieve the information at the time of speaking. If older individuals have difficulty in one or more of these stages, it would be reflected as changes in their ability to use language, either as a listener or as a speaker [1].

While some of these difficulties can be due to sensory impairments (such as hearing and vision), and others could be because of deficits in cognitive processes (such as memory, attention & concentration, abstract reasoning, judgment, etc.).

A range of cognitive processes reportedly slows down with age. Changes occur in the ability to coordinate language abilities with cognitive skills. This is because language depends on cognitive components such as perception, attention, reasoning, and memory. Memory is considered to be the core of cognition. When healthy elderly face deficits of cognitive-linguistic skills it is likely to be exaggerated in adults with neurogenic communication disorders which encompass a variety of specific abnormalities all caused by nervous system pathology. Their features, severity, and outcome reflect the location, magnitude, and nature of the abnormality. And these deficits emerge as dynamic and range from subtle to severe. The present study is primarily based on dementia.

Dementia is a debilitating condition that causes chronic and progressive deterioration in intellect, personality, and communication functioning. There are many varied causes of dementia, among them, are infections, anoxia, intracranial masses, trauma, toxicity, hearing and visual disorders, vitamin deficiencies, endocrine, and metabolic disorders, arteriosclerotic complications, and Alzheimer’s, and other disorders [2].

The early stage of dementia lasts from two to four years. The symptoms observed during the early stage include difficulty in handling finances, memory problems, reduced competence in cognitive tasks, and decreased awareness of recent events[3]. Early noticed symptoms of dementia are a problem with episodic memory and working memory which deteriorate with the progression of the disease. This will in turn reduce the efficiency of encoding and decoding information. Individuals have difficulty in attention [4, 5] and memory which is attenuated in some individuals.

It is mentioned by several authors that persons with mild to moderate dementia exhibit intact phonology, syntax, and semantic knowledge while semantic and pragmatic knowledge may be significantly impaired[6,7]. Apart from this linguistic analysis in dementia, some studies assessed the pattern of reduction in the language in a bilingual context [8-11]. Communication abilities and the pattern of this reduction in bilingual persons affected with dementia are rarely documented and have not been of interest to authors. However few suggest that the ability to maintain fluency in many languages reduces with increasing age.

An evaluation of elderly individuals revealed that those who spoke two languages had been diagnosed with Alzheimer’s 4.3 years later and reported the start of symptoms five years later than those who spoke only one language [12]. [13]Reported that multilingualism acts as a protection against the development of Alzheimer’s but no significant benefit for those who spoke two languages [14] stated that, bilingualism may not eradicate dementia but may help retain the cognitive reserve of the individuals.

Procedures commonly assessment procedures for dementia may not be employed for the bilingual situation.[10]Demonstrated that potential contribution related to the assessment carried out in the language of choice during L2 setting.

Deterioration of language during normal aging has been reported by several authors and has been compared with certain aphasic disorders. [9]Examined the advantage of using the Bilingual Aphasia Test (BAT) for typical bilingual people to examine the preserved and declined linguistic abilities in both languages. Results show that bilingual elderly participants exhibited deterioration in both languages equally.

[15]Demonstrated impaired naming ability in both languages known in bilingual persons with dementia. However, the oral reading ability was most impaired in one language followed by irregular words in another language. The patients could recognize one language and exhibited disturbances of lexical comprehension and lexical decision in another language. These results may reflect different patterns in language deterioration as AD progresses.

[16]Reported research investigated the influence of bilingualism cognitive and linguistic performance across the life span. According to them, bilingualism shows both advantages and disadvantages. Bilingual individuals show reduced formal language proficiency than monolinguals however they exhibited heightened executive control in nonverbal tasks requiring conflict resolution[17]. Inferred that potential differences between bilinguals and monolinguals in age-associated cognitive decline during normal and abnormal aging. [18]Hypothesized that implicit language processing is more impaired than explicit language processing in Parkinson’s disease.

The present study aimed at assessing the effectiveness of the use of two languages by bilingual (Kannada/English) elderly people with dementia using the Bilingual Aphasia Test (BAT). The study also examined performance in each language condition for similar task difficulty.

The study consisted of 20 participants, 10 persons with a diagnosis of mild dementia, and 10 healthy elderly. The age range of the participants was 71-86 years. The group of persons with dementia (PWD) comprised of bilingual (Kannada-English) persons suffering from mild dementia as measured by the Mini-Mental Status Examination[19]. A diagnosis of probable dementia was made according to DSM IV criteria. The majority of the participants attended a geriatric clinic at the National Institute of Mental Health and Neurosciences (NIMHANS) where they underwent thorough medical screening to rule out any other treatable pathology that could explain their impairment. This included neuropsychological assessment, laboratory blood testing, and Computerized Tomography (CT) scanning of the head. Few patient participants were taken from Nightingales Medical Trust, Bangalore, India. All the participants had a minimum of 12years of formal education. All of them had Kannada (Kannada is a South Indian Dravidian Language spoken in the state of Karnataka, India) as their first language (L1) and English as their second language (L2) with vision and hearing acuity corrected to normal / near normal limits. All the clinical participants were diagnosed by neurologists/ psychiatrists/neurosurgeons or geriatric specialists. Second language proficiency was assessed using Second Language Proficiency Rating Scales (ISLPR) by [20]in both Kannada and English to categorize and those who scored “three” and above were selected for the study (persons with vocational proficiency in the second language).

Healthy elderly participants were not suffering from any neurological (such as stroke, dysarthria, etc) or psychological illness (such as mental retardation, memory impairment, schizophrenia, etc) likely to impair performance and were not complaining of memory or other cognitive difficulties. A score of 25 and above in MMSE and a score of “zero” in clinical dementia rating were required for the healthy elderly group. Table 1 shows the mean age, years of education, and handedness of all the participants, and duration of illness for persons with dementia. There were no significant differences in the distribution of males and females (p> 0.05). Also, the participants in the dementia group exhibited similar cognitive decline despite having different types of dementia.

On comparing the HE with PWD, tasks involving word translation, sentence translation, and grammaticality judgment correction showed a highly significant difference between the groups. Persons with dementia were inaccurate in performing these tasks as compared to healthy elderly. Our findings support the concept that dementia affects the ability of individuals to perform proficiently in linguistics tasks for languages they are known. The effect is more pronounced for the second and third languages of the individuals. As an effect of dementia persons start losing their ability to code-switch and code mix. Hence they failed to come out with the right response. Or they may even end up with failure to attempt a particular task. This finding is supported by [24], who stated that “subjects with dementia did not make use of code-switching strategies, and there was some relationship between age of acquisition, the pattern of use and verbal fluency scores”.

The group with HE was compared for the different tasks in BAT in two language conditions (Kannada to English and English to Kannada). The main effect of language condition was significantly high for the task involving grammaticality judgment correction. That is the HE found difficulty in correcting the grammatically incorrect sentences in English. The difficulty in the task may be attributed to the fact that English being the second language, the proficiency may be deteriorating with advanced age. The general language deterioration can be related to age. The HE also had difficulty in sentence translation from English to Kannada, but there was no significant difference for language conditions. The findings support [9] who states that with the advancement of age the accuracy of maintaining language proficiency in more than one language deteriorates. The deterioration affects both languages and supports a non-modular explanation of language decline in the elderly. The results provide evidence in support of the hypothesis that all linguistic levels (phonology, morphology, syntax, lexicon, and semantics) deteriorate in the elderly even though only some linguistic skills (comprehension, repetition, lexical access, and propositioning) are impaired. The deterioration in attention could affect the most complex levels of linguistic abilities in old people. This is in agreement with two authors [25].

A similar analysis was done for the group with PWD. PWD was not able to translate words in Kannada to English as accurately as they could do with English words in Kannada. They faced difficulty in correcting the grammatically incorrect sentences in English to Kannada as well as sentences in Kannada to English. But the difference was not significantly different at the p < 0.001 level. This suggests that PWD not only had difficulty with their second language but also the primary language was deteriorating with the disease. Bilingualism affects cognitive and linguistic performance across the disease condition. Bilinguals typically have lower formal language proficiency than monolinguals. There are studies [12,14] that suggest that bilingualism acts as a protective shield against developing dementia. But to claim it as a point, proficiency in two languages is important. More the mastery in both languages, the more the protection against developing dementia. In the present scenario, PWD wanted several repetitions for the stimuli. It was true for both words as well as sentence level. And they required multiple attempts before giving the correct response or the final response initiating self-repair abilities. Although the final attempt generally was an incorrect response. Hence the language mediates not only the social relationship systems but also the control of cognitive processes.

To conclude, in bilingual persons with dementia, regression to a primary language may be associated with the development of cognitive impairment. Although the ability to use two languages was similar in both the population, they all relied on L1. Participants with dementia failed to differentiate that they were using two distinct languages at several conditions strongly indicating the retreating of bilingual competence into monolingualism. This may be explained due to reduced neural networks and synapses as a consequence of atypical aging.