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Stuttering, or dementia? Let's see... [1]
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Date: 2023-12-14
We have been hearing for months, no, for years, about how President Biden is showing his age and incipient dementia through his sometimes clumsy speech. Not only the MAGA faction but many left-leaning pundits point to every fumble, pause, butchered word, or circumlocution as evidence of some level of mental incompetence. Yet, Mr Biden soldiers on with victory after legislative victory, and with policies that actually work. So what’s going on here?
In a word, it’s President Biden’s lifelong stutter. As a fellow traveler on that road (and a former long time resident of Delaware), I’ve known about it for decades. There are many rather smarmy and forgettable articles around that make mention of his “lifelong battle” with stuttering, and his “victory” over it. I’m disinclined to use that kind of militaristic language, because it seems to me to be as inappropriate as talking about someone having a lifelong battle with their eye color, or seeking victory over their height. Stuttering is not an invasive entity that has attached itself to him. It’s a characteristic. Just like any other characteristic, it can assume a disproportionate place in the constellation of characteristics that make up a person, but it’s still just one characteristic among many. Its importance usually derives from the way other people react to it.
Some of you already know from another article I wrote a short time ago that I stutter. I’m also a licensed speech-language pathologist with a lot of experience working with people who have cognitive issues and/or dementia, usually resulting from strokes, chronic and progressive illnesses, substance abuse, brain injury, and plain old age. People with those conditions have formed the bulk of my patients/clients for the last fifteen years and more.
There is a clear difference between the speech of a stutterer and the speech of someone with a cognitive deficit or dementia. (Those last two are closely similar but not quite the same.) I’d like to discuss some of the most salient contrasts and places where one might be taken for the other.
Fluency
First is the concept of fluency. Fluent speech is speech that runs smoothly like a river that flows down a wide valley. The words “flow” and “fluent” are closely related.
Stuttering is first and foremost a disorder of fluency. Where in nonstuttered speech one word slides nicely into the next, sometimes with only the barest pause between them, in stuttered speech, there is often something that gets in the way of that gentle flow. It can be a repeated first sound or syllable; a strained pause that is well outside of the expected length of pause between words; a lengthened and prolonged sound; or an interjected meaningless sound or phrase. Sometimes two or more of these can occur together or in such quick succession that they appear to be one phenomenon. There are also a number of other fluency interruptors that are idiosyncratic or unusual enough to be of interest only to specialists - and to the person who has to live with them.
In cognitive deficit speech and most dementias including Alzheimer’s Dementia, speech is usually fluent even when it is significantly deficient in other ways. A relatively few conditions can produce dysfluent speech, such as Parkinson’s dementia, some cases of MS and muscular dystrophy, and nonfluent aphasia (loss of language) from stroke or brain injury. Some people with cerebral palsy also have dysfluent speech which most often is accompanied by a host of articulation issues that mark it as a horse of a very different color. But the speech of the majority of dementia patients is almost always normally fluent
In short, even the fluency interruptors in the speech of most people with cognitive and dementia issues are smoother and usually far less disruptive than the staccato machine-gun-burst dysfluencies or the achingly long and tense silent “tonic” blocks typical of the speech of a person who stutters. Of course there are lots of exceptions on both sides but I’ll bet a week’s pay that anyone who hears them side by side will hear the difference immediately.
Circumlocutions
In both stuttered speech and cognitive deficit / dementia speech, one will find word workarounds called circumlocutions. They sound alike to the listener, as people find themselves searching for a word or trying to force out a word that just won’t come. But the source of the missing word is very different for stutterers and for people with cognitive issues. Unfortunately, that is seldom evident to an uninformed listener.
A person caught in some kind of stuttering block might want to say “car” but has stuck on the “c.” Instead of putting themself in the way of yet another speech bomb (“c-c-c-c-c-c-c-car”), our stutterer will quickly run through their mental thesaurus and choose a word that is close in meaning, perhaps “automobile.” Unless they are talking about a train car for which there are few synonyms that don’t begin with “c”. Carriage, caboose, cattle car, conveyance… Not a lot of help here. So perhaps they get a little creative and say “the thing the engine pulls.” That just plain sounds weird.
The person with dementia might also get stuck on “car” but because their mind is just not finding it in their internal dictionary. That’s OK, for this person “carriage” might do. Or they might also go with the associative phrase, “the thing the engine pulls.” It is about impossible for the ordinary listener to tell the difference.
Both will fill the silences caused by the lost word with empty sounds such as um, uh, ok, y’know, Porky Pig’s “abada, abada, abada” interjection. This probably is a way to hold the floor in the conversation long enough to finish their thought. The stutterer’s interjection may start with a repeat or a block before they get to the “um,” but by no means always. The person with dementia almost never starts with a block or repeat.
My point is that circumlocutions are common enough in stuttering that they can’t fairly be taken as representing evidence of a mental decline.
Language Formulation
People who stutter usually have pretty normal language formulation skills. The message they have to get across is not usually garbled or simpler than anyone else’s. I don’t have statistics but I bet that the language scores of even severe stutterers who have no comorbidities would be higher than those of many people on the high (“Aspergers”) end of the autism spectrum. (Although I have met more than one person who has both diagnoses.) Their scores would all but certainly top those of people with dementia or cognitive deficits.
People with dementia or cognitive deficits struggle with even ordinary language. These people would have difficulty parsing a complex sentence such as “The man who was holding an umbrella spoke to the woman on a bicycle in front of the library.” I would not expect someone with noticeable dementia to even try to put so many ideas into a single sentence. A person who stutters probably would have no difficulty at all either formulating or understanding that sentence. And while they might take forever to say the sentence, they could write it easily and as rapidly as a person with no diagnoses.
The language formulation skills of people with dementia and cognitive deficits usually decline over time. While someone in early stage dementia might sound pretty normal in a casual conversation, their language a year later would show a lot more simplified grammar and vocabulary. That would not happen to someone who stutters unless that person had suffered an injury or illness.
Another characteristic of the language of people with cognitive and dementia issues is the use of empty words and partial concepts. They might say, “I put that thing over there,” meaning that they put the TV remote on the coffee table. This empty language can be highly context dependent. It is sometimes characteristic of the language of working-class people who might clarify their meaning with gesture. But just yesterday I asked a patient with early-stage dementia how to make a peanut butter and jelly sandwich. Patient said, “You get out the peanut butter and the jelly and you put it on.” I had to cue her several times to finish the thought and provide the bread.
On the other hand, someone who stutters will often try mightily to use the correct words and sentence forms for whatever they are talking about. They may pause long enough to get the mouth to liberate the words, or they may find a close simile, but they won’t usually just stop mid-sentence or leave a word out altogether.
Related to this: Donald Trump’s language, especially his spontaneous language, shows a lot of characteristics of cognitive deficit / dementia speech. It’s very fluent but the half-finished sentences and abandoned utterances, the fairly simple grammatical structure, the many non-sequiturs, the occasional jargon words (“covfefe”) and outright misstatements (“World War III”) all point to a language processing disorder that would be really fun to do a deep analysis on. Unfortunately, my favorite language analysis software tops out at 12 years 8 months so TFG is waaaay too old. It still might be fun.
Secondary Behaviors
There is a phenomenon in stuttering called “secondary behaviors” in which the person will engage in some unrelated behavior when stuck in a stuttering block, such as blinking, turning their head (me), moving a hand or a foot, whatever, all things that really have no effect on the stutter but that can distract the speaker long enough for the block to break. People with dementia rarely have any secondary behaviors at all associated with their speech.
There are a lot more possible points of comparison, and I have left out a lot of byways that could contribute to a better understanding of this topic. I hope that people who have made it this far will take a good, hard look at clips online showing President Biden struggling with speech and question whether they represent a cognitive deficit or stuttering. I’d lay money on stuttering for every one of them.
Here is a link to an excellent article about President Biden’s stutter.
Final disclaimer: I have not really researched this article the way I might have wanted to. There are few or no scholarly studies that make this kind of comparison and I don’t live in a place or have the kind of life that would allow me to compile the data that would constitute a “study’ in the formal sense. If anyone out there has that sort of information, please share it.
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