What is Agraphia?
Agraphia is a condition where a person loses the ability to write. This can happen on its own or along with other neurological problems like alexia, apraxia or hemispatial neglect. Essentially, agraphia falls into two categories: central agraphia, which is commonly tied to a language disorder known as aphasia, and peripheral agraphia, which is not related to aphasia.
Writing involves generating a series of symbols to communicate information. In English, these symbols are the letters of the Latin alphabet. To write correctly, a person must understand the letters individually and then how to organise them into real words and grammatically sound sentences. Any damage to this process leads to central agraphia. The writer also needs to know how to properly make these letters, keep the letters in mind to form a word, control hand-eye coordination to write, and finally, manage the physical act of writing. Trouble with these steps can result in peripheral agraphia.
There are specific medical categories for various types of agraphia. For instance, pure agraphia refers to a writing problem that is not connected to a language disorder or other impairment. Some experts link pure agraphia with apraxic agraphia, while others differentiate between pure linguistic agraphia (relating to language) and pure apraxic agraphia (relating to motor skills).
Patients who suffer from agraphia can often type on a keyboard or use a mobile phone, indicating that these might be separate issues. It’s also important to distinguish agraphia from illiteracy, meaning the skill to write was never learned by the person. Dysgraphia is a term usually used for writing problems that are part of a learning disability, while paragraphia refers to a specific error in writing that’s similar to speech errors.
Agraphia can be categorized based on the language or motor skills disorder that it is associated with. For instance:
– Agraphia with non-fluent Aphasia: Here, the person’s written and spoken language abilities could have different levels of capabilities.
– Agraphia with fluent Aphasia: The individual writes smoothly, but the content can be meaningless.
– Agraphia with conduction aphasia: This rare form is characterized by a repeating pattern until the right word is written.
– Alexia with agraphia: Here, both the ability to read and write are impaired.
There are also Pure linguistic agraphia and Pure apraxic agraphia, which are impairments in writing that are not associated with any other language or motor skill impairment. To be clear, experts are looking at features such as the writing quality, spelling, and the ability to copy written text, to discern between the different types of agraphia.
Functional agraphia can also occur as a manifestation of a psychological disorder called conversion syndrome. Diagnosing functional agraphia using traditional ways can be challenging.
What Causes Agraphia?
Agraphia, the difficulty or inability to write, can be triggered by any harm or disorder affecting the language centers of the brain – areas involved in understanding and producing speech. This is often observed in individuals who have experienced a stroke – a leading cause of language impairment. Other factors like injuries, tumour growths, infections, and even certain symptoms related to diseases such as COVID-19 can also potentially lead to this predicament termed as central agraphia.
Additionally, conditions that gradually deteriorate the brain’s health, like Alzheimer’s disease or frontotemporal dementia, can result in central agraphia. This is typically a slow and progressive process, wherein language skills keep eroding over time. This form of language impairment is often seen in primary progressive aphasia, a clinical syndrome characterized by the gradual loss of language skills. Alzheimer’s disease and frontotemporal degeneration are commonly connected with most of these cases. Moreover, agraphia is frequently reported in people suffering from a state of confusion called delirium. But since delirium can be caused by a variety of reasons, its association with agraphia is not unique.
Like central agraphia, peripheral agraphia, which impairs the physical act of writing, can also be caused by a range of factors. Any damage from the outer layer of the brain down to the peripheral nerves and muscles involved in writing can trigger this condition. Essentially, peripheral agraphia occurs when these injuries impede the planning or execution of the writing process.
Risk Factors and Frequency for Agraphia
Information about the frequency of neurological language disorders like agraphia, which are acquired after birth, is quite limited. A stroke is known to be the most common cause of these types of disorders.
- A study done in Switzerland found that every year, 47 out of every 100,000 people develop a language disorder after suffering their first stroke.
- Among those who experienced a stroke, about 30% developed aphasia, a condition that impacts their ability to communicate effectively.
- This study also included patients suffering from agraphia – another language disorder – but the exact number of people with this condition wasn’t specified.
Signs and Symptoms of Agraphia
As part of examining potential issues with a patient’s language skills, a doctor must look into various aspects, including how a patient writes. These assessments are crucial for identifying the cause of written language difficulties, also known as agraphia.
To test a patient’s writing, medical professionals usually give the patient something to write with and on, and then ask them to write a complete and grammatically correct sentence. To get a more comprehensive picture, doctors may prompt the patient with open-ended questions such as “What did you do today?” or “Why are you here?”. They’ll also remind the patient to maintain legibility in their handwriting.
When the patient starts writing, doctors will observe a number of factors:
- Their orientation of the page and the writing instrument
- The overall ease and speed with which they write
- The uniformity of their handwriting (size, spacing, stroke quality)
- Any mistakes they make
- The content they produce (sentence length, word choice, spelling, grammar)
Doctors may also compare the patient’s current writing to past samples to spot any significant changes. They’ll as well consider any other neurological exam results that could help determine the cause of the writing issues.
For instance, patients with agraphia often struggle with other language abilities (aphasia). Some patients may have muscle weakness (paresis) in their arms. They may also have difficulty performing familiar tasks, like miming brushing their teeth or hammering a nail. In some cases, these patients may wrestle even to draw a simple spiral, which can be a sign of various movement disorders like Parkinson’s disease.
A specialist would require further tests to ensure an accurate diagnosis. One of these tests, for example, could test the patient’s ability to recreate a complex figure. This can help rule out any issues with visual-spatial processing.
Testing for Agraphia
If a person is having trouble writing, doctors initially examine this at the bedside, which gives them a basic understanding of the problem. If it’s not clear what’s causing the writing difficulties, more detailed evaluations can be very helpful. Specific assessments, like the Western Aphasia Battery or Boston Diagnostic Aphasia exam, can provide a deeper view of the issue. These tests are typically done by speech and language specialists, but psychologists may also conduct them as part of a broader psychological examination.
After writing problems are identified, doctors will then try to understand where in the brain the issue is happening. This can determine what’s causing the problem and helps map out future diagnoses. In some cases, a careful review and physical examination can give enough information to make a diagnosis, like writer’s cramp. Brain scans, like CT or MRI, are often used to pinpoint or identify brain abnormalities that could be causing the writing problems, particularly if a stroke has occurred. If dementia is suspected, specialists might use specific types of MRI or psychological tests. To distinguish between Parkinson’s disease that’s either caused naturally or by medication, or to rule out conditions like essential tremor, a specialized scan called “dopamine transporter single-photon emission computed tomography” could be used along with an injection of a substance called ioflupane I-123.
Treatment Options for Agraphia
Identifying the type of agraphia, a condition causing difficulty with writing, is crucial for deciding the best course of action, since treatments can vary significantly. Generally, therapies involving speech, language, and occupation are the backbone of treating both central and peripheral agraphia. Usually, a mixed treatment method, including therapy, medicine, and sometimes surgery, is necessary for successfully treating agraphia. For example, someone with Parkinson’s disease might need deep brain stimulation, medication, occupational therapy, or special equipment to help improve their writing.
It’s also vital to tackle the root cause of agraphia, not just the symptoms, in order to prevent their writing skills from worsening. For instance, if a person’s agraphia is due to a tumor, they should be offered suitable chemotherapy, radiation, or surgical treatments.
Regarding central agraphia caused by strokes, speech and language therapy have proven effective, with evidence indicating that intensive therapy can enhance writing ability more than less intensive therapy. A small study found targeted, task-specific training for reading or writing may be beneficial, suggesting that treatment plans may gain from a broader focus on various writing issues.
Though evidence is limited, the drug piracetam might be useful for acute stroke-induced agraphia. Memantine has also proven effective for language difficulties after a stroke; however, its impact on writing impairments has not yet been explored. Transcranial magnetic stimulation, a non-invasive procedure that stimulates brain cells, may also have potential benefits for writing impairment after strokes, although more extensive studies are required.
Treatment for peripheral agraphia is a bit more versatile than for central agraphia and relies on the type of agraphia. For instance, peripheral agraphia caused by neglect of one side of the visual field might benefit from prism lenses. Writer’s cramp, a condition causing painful hand contractions while writing, could be treated with injections of botulinum toxin. Occupational therapy, relaxing techniques, and special equipment can also help with symptoms of writer’s cramp.
What else can Agraphia be?
Agraphia, or the loss of ability to write, isn’t just one condition but a symptom related to a variety of neurological causes. When examining a patient who may have agraphia, doctors must also consider the following:
- Illiteracy: This is when the person has never learned how to write in the first place.
- Abulia: This condition involves overall decreased functionality and a lack of motivation.
These possibilities need to be differentiated from agraphia to ensure an accurate diagnosis.
What to expect with Agraphia
The outcome of agraphia, a condition that affects a person’s ability to write, can vary greatly depending on the underlying cause. If a stroke causes language impairment, recovery typically reaches its peak around three months after the event, before eventually stabilizing.
However, agraphia caused by neurodegenerative diseases, like Parkinson’s or Alzheimer’s, is likely to progressively worsen over time. Peripheral agraphias, a form of the condition with various causes, also carry different outcomes.
Possible Complications When Diagnosed with Agraphia
Agraphia can cause several problems for a person. For instance, it can make community integration difficult since being able to communicate effectively is important for independent daily living. Dealing with language issues can be frustrating and can lead to depression, especially for individuals who have suffered a stroke. It’s important to remember that agraphia isn’t a disease in itself, but a symptom, so there could be complications related to the actual cause of the agraphia.
Preventing Agraphia
It’s vital to educate patients and their families about acquired language impairments and their characteristics. Even if one’s overall cognitive ability is intact, isolated language impairment can be confused with more widespread cognitive issues. Tailoring communication strategies to each patient’s specific impairment is also crucial.
Surprisingly, even in cases where reading language abilities are affected, offering written educational material can still be beneficial. Regularly providing these resources to patients with language impairments can help their understanding over time.
