Family members are quick to tell the clinician that the person with Alzheimer's Disease (AD) does not read any longer; a once avid reader of novels is no longer interested even in the newspaper. Yet, Gail Neustadt has found a way to maintain the functional reading skills of her husband who has AD. By adjusting the size of type, reducing the distractions of multiple articles, and eventually simplifying article content, the discussion of current events through newspaper reading continues to be an enjoyable activity for this couple.
This clinical finding supports the increasing awareness that the written modality may be spared enough throughout the degenerative course of dementia to be a useful way to maintain communication with persons who are having difficulty accessing the words and thoughts they want to share with others.
Some of the early descriptive studies of the oral reading and reading comprehension abilities of persons with dementia documented effortless oral reading with reading comprehension impairments proportionate to dementia severity (see Schwartz, Saffran, & Marin). The processes involved in oral reading (grapheme to phonological processing) were thought to bypass the semantic processing system. Recent psycholinguistic theories of reading, however, suggest the interdependency of orthographic, phonologic, and semantic processes (see Patterson & Hodges).
Studies of the reading abilities of populations with documented semantic deficits (i.e., patients with AD) have produced contradictory results. In some studies, AD patients demonstrated decreased performance on a semantic task (word-picture matching task), whereas other AD patients with moderate and severe semantic deficits demonstrated virtually errorless oral reading of regular and exception words (see Raymer & Berndt).
The problem with much of this research may be related to the type of tasks patients are asked to do to demonstrate their skills. Word-picture and sentence-picture matching tasks are used widely to demonstrate the semantic deficits of persons with AD who have working memory limitations and may be distracted by multiple stimuli. They may forget the task instructions and deviate from expected procedures by pointing to and talking about each response choice. The oral reading of single words presented as lists of words does not reflect functional reading behaviors of adults with a long history of literacy. Consider that most adults read a variety of stimuli in their daily lives that are mostly presented in sentence format (or multi-word phrases). Sentences provide a multiplicity of cues beyond the orthographic-phonologic, such as grammar and context. Therefore, tests of single-word oral reading ability and reading comprehension may not reflect accurately the reading abilities of persons with AD.
Evidence of orthographic input leading to semantic activation can be found in the studies of the use of memory books to support conversational interactions and the use of orthographic cues to modify various repetitive verbalizations of persons with AD (Bourgeois, 1992; Bourgeois et al., 1997). Memory book stimuli in the form of 5-7 word sentences and related pictures, one sentence and picture per page, were found to increase the statement of facts related to the sentence and to decrease ambiguous statements by persons with AD in conversational interactions (Bourgeois, 1992).
Follow-up assessment at 24- and 36-months post-intervention revealed maintenance of improved information content in spite of significant cognitive deterioration (MMSE scores declined from 15/30 to 0/30). Similarly, sentence length stimuli in various formats that answered a specific repetitive question of the person with AD were found to decrease significantly the frequency of repeated questions (Bourgeois et al., 1997). These data suggest that orthographic input can access semantic information that is not accessible by other input modalities (i.e., auditory or verbal input).
Clinical applications, such as Gail Neustadt's, provide continuing evidence for the need for more research in this area. My work has just begun to scratch the surface. While it is still too early to answer the question, "Is reading preserved in dementia?," evidence is mounting that functional reading skills may help mediate the challenges of providing a quality life for persons with AD and their caregivers.