Neuropsychologia 48 (2010) 3884–3890

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Neuropsychologia
journal homepage: www.elsevier.com/locate/neuropsychologia

An analysis of communication in conversation in patients with dementia

Marc Rousseaux a,b,∗ , Amandine Sève a,b , Marion Vallet a,b , Florence Pasquier a,b ,
Marie Anne Mackowiak-Cordoliani a,b
a
Univ Lille Nord de la France (EA 2691 and Institut d’Orthophonie), F-59000 Lille, France
b
Centre Hospitalier Universitaire (Service de rééducation neurologique and Centre mémoire de ressource et de recherche), F-59037 Lille, France

a r t i c l e i n f o a b s t r a c t

Article history: Patients with degenerative dementia often show language disorders, but little is known about their ver-
Received 27 April 2010 bal (VC) and non-verbal communication (NVC). Our aim was to analyse VC and NVC in patients with
Received in revised form 5 July 2010 standard criteria of mild-moderately severe dementia (MMSE ≥ 14/30) resulting from Alzheimer’s dis-
Accepted 23 September 2010
ease (AD; 29 cases), behavioural variant of frontotemporal dementia (FTD; 16), or dementia with Lewy
Available online 1 October 2010
bodies (DLB; 13). We used the Lille Communication Test, which addresses three domains: participation
in communication (PC: greeting, attention, participation), VC (verbal comprehension, speech outflow,
Keywords:
intelligibility, word production, syntax, verbal pragmatics and verbal feedback), and NVC (understanding
Alzheimer’s disease
Fronto temporal dementia
gestures, affective expressivity, producing gestures, pragmatics and feedback). Patients were compared
Dementia with Lewy bodies with 47 matching control subjects. AD patients were partially impaired (p ≤ 0.01) in PC (greeting), and
Verbal communication more definitely in VC, especially by verbal comprehension and word finding difficulties and to a much
Non-verbal communication lesser degree in verbal pragmatics (responding to open questions, presenting new information), while
NVC was mostly preserved. FTD patients were severely impaired in PC. VC difficulties were related to
lexical–semantic, syntactic and more specifically pragmatic problems. NVC was impaired by difficulties
in affective expressivity, pragmatics and feedback management. DLB patients showed modest difficulties
with VC. PC, VC and NVC strongly correlated with performance in the dementia rating scale. In conclu-
sion, the profile of communication difficulties was quite different between groups. FTD patients showed
most severe difficulties in PC and verbal and non-verbal pragmatics, in relation to their frontal lesions.
AD patients had prominent impairment of lexical–semantic operations.
© 2010 Elsevier Ltd. All rights reserved.

1. Introduction
Communication refers to exchanges between individuals and
social interactions. It occupies a central place in participation
in social activities and can be severely impaired by acquired
brain lesions. Patients with Alzheimer’s disease (AD) present
with cognitive disorders that progressively worsen. Many stud-
ies have been devoted to language difficulties (Appell, Kertesz, &
Fisman, 1982; Murdoch, Chenery, Wilks, & Boyle, 1987). Even at
the early stage of the disease (mild dementia), patients exhibit
anomia, literal and neologistic errors, reduction in phrase length,
difficulties in sentence repetition, and impairment in compre-
hension, especially for written sentences (Mendez, Clark, Shapira,
& Cummings, 2003). And the severity of language and gesture
expression/comprehension is closely related to the global sever-
ity of dementia (Bayles, Tomoeda & Trosset, 1992; Bschor, Kühl
∗ Corresponding author at: Univ Lille Nord de la France (EA 2691 and Institut
d’Orthophonie), F-59000 Lille, France. Tel.: +33 320 444872; fax: +33 320 445832.
E-mail address: marc.rousseaux@chru-lille.fr (M. Rousseaux).
& Reischies, 2001). Discourse has been shown impaired during
oral and written picture description (Forbes-McKay & Venneri,
2005), especially by word finding difficulties, reduction in pictorial
themes and informative content and problems with error monitor-
ing. Other studies have shown weakness in the indices of thematic
coherence, contrasting with relative preservation of phonological
and syntactic processing (Glosser & Deser, 1990). The key factors of
discourse disorders are said to be at the lexical–semantic level by
some authors (Forbes-McKay & Venneri, 2005) or at the macrolin-
guistic supra-sentential level by others (Glosser & Deser, 1990).
Communication has been assessed first with tests requiring
responding to open questions, or setting the patient in specific
social situations. The Communicative Ability in Daily Living test
identified more severe impairment in AD than in aphasic patients,
contrasting with less severe basic language disorders (Murray,
Marquardt, Richardson, & Nalty, 1984). Other authors reported
that patients with mild dementia had difficulties when required
to account for situational context and interpret metaphors and
humour (Fromm & Holland, 1989). And those with moderate
dementia were additionally impaired in generating logical alterna-
tives from given information, untangling cause-effect relationships,

0028-3932/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.neuropsychologia.2010.09.026
 M. Rousseaux et al. / Neuropsychologia 48 (2010) 3884–3890
reading and writing. They often produced irrelevant, vague and
incomplete responses. A paradoxical result was that AD patients
had much more modest difficulties with social conventions, role
playing and speech acts.
However, social communication is first of all supported by con-
versation and we must emphasize that we have little information
about patient behaviour during this activity. In structured inter-
views, AD patients exhibited reduced use of content words and
empty speech, and responses that did not fulfil the examiner
request (Blanken, Dittmann, Haas, & Wallesch, 1988). They were
shown less coherent and more verbose than normal elderly sub-
jects, with a breakdown in the thematic structure and an increase
in speech turns frequency (Ripich & Terrell, 1988). Speech acts
analysis showed an increase in requests and a decrease in asser-
tions (Ripich, Vertes, Whitehouse, Fulton, & Ekelman, 1991). Other
studies emphasized difficulties in topic management, especially
for changing topic and contributing to bringing new information
about the topic (Mentis, Briggs-Whittaker, & Gramigna, 1995). Fur-
thermore, selecting and maintaining a topic, changing a topic and
turn taking would be better managed by the patient in a relatively
unstructured setting (group conversation) compared with a more
formal environment of language assessment (Moss, Polignano,
White, Minichiello, & Sunderland, 2002). In referential commu-
nication, i.e. dyadic communication using the support of images,
paraphasic errors, difficulties in providing crucial information,
increase of erroneous and non-crucial information, misunderstand-
ings and poor response to feedback from the examiner requesting
reparation for an error, have been identified (Carlomagno, Santoro,
Menditti, Pandolfi, & Marini, 2005). For non-verbal communication
(NVC), the analysis of a referential communication task revealed an
increase in global gesture production and in the proportion of deic-
tic and indefinite gestures, contrasting with a relative reduction
of iconic gestures (Carlomagno, Pandolfi, Marini, Di Iasi, & Cristilli,
2005).
Communication has been much less studied in patients with
other dementias. Frontotemporal dementia (FTD) – frontal vari-
ant – results in severe behavioural disorders impairing self-control,
leading to physical neglect, mood disorders and decreased inter-
est (Lebert & Pasquier, 1995; The Lund and Manchester Groups,
1994). Basic language processing is partially impaired. Indeed, con-
frontation naming revealed word finding difficulties and semantic
paraphasias (Pasquier, Lebert, Lavenu, & Petit, 1998) and sentence
comprehension was impaired in relation with syntactic complexity
(Grossman, Rhee, & Moore, 2005). But oral production of a story pre-
sented on a sequence of images was found to be more sensitive to
general executive limitations and frontal atrophy (Ash et al., 2006).
Patients were mostly impaired by slowing, production of fewer
accurate events and more incomplete events, reduction of global
and local connectedness, and difficulties in maintaining the theme
of the story. Other studies have shown difficulties in recognis-
ing sarcasm on video recordings (Kipps, Nestor, Acosta-Cabronero,
Arnold, & Hodges, 2009) and identifying emotions (Kipps et al.,
2009; Lavenu, Pasquier, Lebert, Petit, & Van der Linden, 1999),
which is important for NVC. But in fact, nothing is known about
their behaviour in dyadic communication. Considering the impair-
ment in executive functioning (Lindau, Almkvist, Johansson, &
Wahlund, 1998; Perry and Hodges, 2000) and discourse produc-
tion (Ash et al., 2006), it can be hypothesized that pragmatics could
be severely impaired. But this has to be confirmed. Similar consid-
erations apply to dementia with Lewy bodies (DLB), which is the
source of less severe aphasic disorders, but in which VC and NVC
have never been explored.
To conclude, we need more information about social commu-
nication disorders and their main mechanisms in patients with
dementia, because human relations with the real world are mostly
through conversations with other persons. This analysis is essential
3885
for formulating the rehabilitation project adapted to each patient,
and for explaining patient difficulties to family members, neigh-
bours and health professionals. Improving communication is an
important goal of rehabilitation procedures (Ripich, 1994).
Here, we used a test of verbal and non-verbal communica-
tion (conversation-based interaction) in a relatively large cohort
of patients with AD, FTD, and DLB, in order to more precisely define
the presence and role of verbal and non-verbal disorders in the
dyadic exchange. We also analysed the relationship of VC and NVC
disorders with dementia severity.
2. Subjects and methods
2.1. Patients
Patients were recruited in the outpatient Memory clinic of Lille, France. All
patients were assessed with a comprehensive clinical examination conducted by a
senior staff neurologist, a psychiatrist, a neuropsychologist, a speech therapist, and
a nurse (Deschaintre, Richard, Leys, & Pasquier, 2009). They had cerebral imaging
(CT or MRI). A consensual diagnosis was given for each patient according to existing
diagnostic criteria. The study received approval by the institutional review board
and conformed to the standards set by the Declaration of Helsinki. Each subject had
to agree to participation in the study and sign an informed-consent form.
We included patients (age: 50–80) suffering from mild to moderately severe
dementia (14 < Mini Mental State Examination, MMSE < 30) (Folstein, Folstein &
McHugh, 1975), using standard criteria of probable Alzheimer disease (National
Institute of Neurological and Communicative Disorders and Stroke and the
Alzheimer’s Disease and Related Disorders Association: NINCDS-ADRDA) (McKhann
et al., 1984), frontotemporal dementia – frontal variant (Neary et al., 1998; The
Lund & Manchester Groups, 1994), and dementia with Lewy bodies (probable DLB)
(McKeith et al., 1996). In AD and FTD patients, the severity of dementia was classified
as mild-moderate (MMD) or moderately severe (MSD) according to the Demen-
tia Rating Scale (DRS) (Mattis, 1976) score (115 ≤ DRS < 133; 77 < DRS < 115). In the
AD group, the classification was similar to that obtained with a cut-off score of 20
(20 ≤ MMSE ≤ 28; 15 ≤ MMSE < 20) on the MMSE.
Patients with severe and uncorrected visual or auditory deficit, illiteracy, who
had a stroke before examination, or who showed vascular lesions on MRI or CT scan
(Roman et al., 1993) were excluded from the study.
We also included normal control subjects from the community who matched
with patients in gender, age and education level.
2.2. Communication assessment
The Lille Communication Test (LCT) (Rousseaux, Delacourt, Wyrzykowski, &
Lefeuvre, 2001) is composed of three parts, participation in communication, ver-
bal communication (VC) and non-verbal communication (NVC). These are analysed
in three situations of natural interaction, a directed interview, an open discussion
about technical progress and a referential communication situation. In this latter
condition, interlocutors are sitting at a table, facing each other. Each has a similar
set of images in front of him, and one (either the patient or the investigator) has to
make the other discover one of these images using oral language or gesture. There-
fore, the patient and the investigator are alternatively speaker and listener. In fact,
the LCT is relatively ecological and only partially a patient interview. Communica-
tion did not take place with a person from the direct environment of the patient,
because of the variability of this environment, and difficulties in having a relatively
standardized discussion and in using a referential communication situation with
family members.
We carried out an audio–video recording of the patient–interlocutor interaction,
and the assessment was made during the interview and corrected using the infor-
mation provided on the record. The LCT has been validated in a population of stroke
patients (Rousseaux et al., 2001). Fair inter-rater reliability has been confirmed for
each subtest, with Cohen Kappa value always greater than 0.90. Furthermore, the
global score of motivation to communicate and VC correlated with the global score
of the Boston Diagnostic Aphasia examination and the Functional Communication
Profile. Norms have been obtained in a group of 96 normal control subjects from
the community and we found an effect of education level on the global VC score.
Its presentation time is about one hour. A time break was introduced before the
third part of the communication assessment (PACE situation), in patients showing
lack of concentration or fatigue. For each subtest, the semi-quantitative scoring is
simple (0–1, 0–1–2, 0–1–3 or 0–2–4), the higher score indicates better performance
and fair ability to manage the specific point, and absence of consequences of the
patient–investigator communication.
Participation in communication is analysed with three subtests (global score/6),
greeting behaviour (presence of verbal or non-verbal greeting;/2), attention to
interlocutor production (using adapted posture, gaze, and verbal and non-verbal
responses;/2), and engagement in the interaction (using verbal and non-verbal ini-
tiatives;/2).
3886 M. Rousseaux et al. / Neuropsychologia 48 (2010) 3884–3890

Verbal communication is investigated with 14 subtests (global score/30). First,
understanding words and sentences (fair comprehension which does not require
repetition and simplification of the interlocutor production;/4), producing fluent
language (normal speech outflow of about 150–200 words in one minute;/2),
producing intelligible utterances (which do not require more attention from the
interlocutor;/2), producing words without word finding difficulties and paraphasia
(/4), and producing adapted syntax (/2). Then pragmatics (/12), with responding to
open questions (explicit and informative response to open questions), maintaining
the topic of the exchange (respect of the topic without digressions), present-
ing new information (with presentation of information new to the interlocutor),
introducing new topics (which are coherent with the previous ones, without perse-
verations), logically organising discourse (with explicit indications about the logic
or chronologic nature of the relationship between the different parts), and adapting
production to interlocutor knowledge (explicitly or implicitly). And finally, emitting
verbal feedbacks (referring to comprehension difficulty) and adapting to verbal feed-
backs from the interlocutor (readjustment of discourse when the listener reports
comprehension difficulty or shows a verbal response which is not adapted to the
patient production) (/4).
Non-verbal communication is evaluated with 19 subtests (global score/30). First,
understanding limb gestures (deictic, symbolic, miming the use of objects, miming
the shape of objects, gesture referring to physical or emotional state;/5), affective
expressivity (expression of affects using gestures, facial expressions, vocal utter-
ances, body orientations or physical contact(s);/3), and producing limb gestures
(global spontaneous production, then production of different gesture subtypes:
deictic, symbolic, pantomime, gestures miming the shape of objects, referring to
physical or emotional state, sequential;/14). Then pragmatics with adapting prosody
(both linguistic and emotional), orienting gaze (to the interlocutor), using regulatory
mimogestuality (accompanying verbal utterances and turn taking), and turn-taking
(respect of the interlocutor production, intervention during interlocutor pauses)
(/4). Lastly, emitting non-verbal feedback (gesture, facial expression, head move-
ment referring to comprehension difficulties) and adapting to non-verbal feedback
from the interlocutor (readjustment of discourse when the listener emits non-verbal
feedback) (/4).
In these subtests, the objective is both to assess the presence of specific deficits,
and to analyse their consequences on communication, i.e. to identify the main mech-
anisms of communication disorders in a given patient. An example of poor verbal
comprehension is the necessity for the listener (investigator) to repeat or simplify
his production for efficient patient understanding.
2.3. Other assessments
To assess cognitive and behavioural disorders, we first used global tests, the
MMSE (score of 0–30) and the DRS (score of 0–144), which addresses five domains
of cognition: attention (digit span forward and backward, follow successive com-
mands/37), initiation and perseveration (categorical evocation, repeating rhymes,
alternating hand movements/37), construction (/6), conceptualization (similarities,
differences, inductive reasoning/39) and memory (orientation, word and design
recall/25). We analysed language with confrontation naming (36 images from the
DO 80: score of 0–36; Deloche & Hannequin, 1997), word and sentence compre-
hension (Toulouse Montreal Test; 0–13 for each part; Nespoulous et al., 1992),
categorical (animals) and literal (letter P) evocation for two minutes, production
of 10 gestures to verbal command and imitation (0–10 for each part; Poeck, 1986),
and behavior withe the Echelle de Dysfonctionnement Frontal (EDF/26; Scale of
Frontal dysfunction) (Lebert & Pasquier, 1995).
2.4. Statistical analysis
Statistical analysis was achieved with the SPSS 16.0 system (Chicago, Illinois).
Analyses were performed after rank transformation of data. For the MMSE, DRS and
other cognitive assessments, we compared the performance of patients and control
subjects using an ANOVA of group (AD, FTD, DLB, C). Age, education level and gender
(M = 1; F = 2) were introduced as covariance factors. Post hoc comparisons used the
Tuckey correction. For each of the three parts of the LCT, we used a MANOVA of
the same factors, with the Tuckey correction in post hoc comparisons. Correlations
between communication and cognitive disorders were analysed with the Spearman
t-test. As regards the number of comparisons, the alpha risk was set at 0.01.
3. Results
3.1. Patients
Fifty eight patients and 47 control subjects were recruited.
Twenty nine patients had AD, 16 FTD, and 13 DLB (Table 1). The
group had a significant effect on age. Post hoc comparisons did
not reveal any difference between each patient group and control
subjects, but age was lower in FTD than AD patients (p = 0.003).
Education level did not differ between groups. The MMSE was
reduced in AD and DLB groups, and the DRS in AD, FTD and DLB
patients. Furthermore, the ratio of discrete-moderate/moderately
severe dementia was 16/13 in AD, 9/7 in FTD, and 9/4 in DLB
patients.
3.2. Cognitive and behavioural assessment
In the DRS, patients were more severely impaired in the concep-
tualization and memory subtests (Table 1). For language, only AD
patients showed significant disorders in confrontation naming, and
word and sentence comprehension was relatively preserved. Con-
versely, verbal fluency (categorical; literal) was severely reduced in
all groups. In gesture production, execution to verbal command was
impaired in FTD and AD patients. The EDF questionnaire identified
severe behavioural disorders in the three groups. Age, education
level and gender had no significant effects on these cognitive scores.
3.3. Communication assessment
The group effect was significant for most of PC and VC sub-
tests. Conversely, its influence was reduced for NVC (Table 2). Age

Table 1
Patient presentation. Significant differences with the control group are indicated with asterisks.

MD FTD DLB C subjects p

Patient number 29 16 13 47
Age (year) 74 (50–79) 61 (51–78) 71 (57–78) 68 (50–79) 0.005
Education level (year) 8 (6–13) 9 (8–17) 8 (7–16) 8 (6–17) 0.333
Gender M/F 10/19 8/9 8/5 25/22 0.020
MMSE/30 22 (14–28)** 27 (14–30) 24 (13–28)** 29 (25–30) 0.0001
DRS global score/144 117 (86–135)** 116 (77–139)** 123 (107–140)** 137 (129–143) 0.0001
DRS attention/37 22 (14–28) 36 (27–37) 34.5 (32–37) 34 (32–37) 0.591
DRS initiation/37 29.5 (13–37)** 32 (19–37) 31.5 (20–34) 35 (30–37) 0.0001
DRS construction/6 6 (2–6) 6 (0–6) 6 (3–6) 6 (5–6) 0.003
DRS conceptualization/39 35.5 (25–39)** 32 (20–39)* 35.5 (22–39)* 39 (36–39) 0.0001
DRS memory/25 13 (6–25)** 21 (10–22)* 17.5 (11–25)* 25 (19–25) 0.0001
Confrontation naming/36 32 (18–35)** 32.5 (28–36) 32.5 (27–35) 34 (30–36) 0.001
Oral comprehension/26 12 (7–13) 11.5 (10–13) 12 (8–13) 12 (10–13) 0.339
Categorical fluency (animals, 2 min) 14.5 (3–31)** 13 (9–18)** 18 (7–21)** 31 (22–44) 0.0001
Literal fluency (p, 2 min) 9.5 (0–22)** 9 (2–13)** 9 (1–15)** 17 (11–26) 0.0001
Gesture production to command/10 9 (5–10)* 7 (5–10)* 10 (4–10) 9 (8–10) 0.002
Gesture production on imitation/10 10 (5–10) 10 (7–10) 10 (8–10) 10 (8–10) 0.299
Behaviour (EDF questionnaire) 3 (0–4)** 4 (1–4)** 2.5 (1–4)* 0 (0–2) 0.0001
*
0.001 < p ≤ 0.01
**
p ≤ 0.001.
 M. Rousseaux et al. / Neuropsychologia 48 (2010) 3884–3890 3887

Table 2
Patient performance in each subtest of PC, VC and NVC: median value (range). Significant differences with the control group are indicated with asterisks.

AD FTD LBD Controls p

** **
Greeting/2 2 (0–2) 2 (1–2) 2 (0–2) 2 (2–2) 0.0001
Participation to
Attention/2 2 (1–2) 1.2 (0–2)** 2 (1–2) 2 (2–2) 0.0001
communication
Engagement/2 2 (1–2) 1 (0–2)** 2 (1–2) 2 (1–2) 0.0001
Understanding words and sentences/4 4 (2–4)** 4 (2–4)** 4 (2–4) 4 (4–4) 0.0001
Producing fluent language: speech outflow/2 2 (1–2) 2 (1–2) 2 (1–2)** 2 (2–2) 0.0001
Producing intelligible utterances/2 2 (1–2) 2 (1–2) 2 (1–2) 2 (1–2) 0.647
Producing words: word finding difficulties/2 1 (0–2)** 2 (0–2)** 1 (0.5–2)** 2 (1–2) 0.0001
Producing words: paraphasia/2 2 (0–2) 2 (0–2)* 2 (1–2) 2 (2–2) 0.005
Producing adapted syntax/2 2 (1–2) 2 (1–2) 2 (1–2) 2 (2–2) 0.025
Pragmatics: responding to open questions/2 1 (0–2)** 1 (0–2)** 2 (1–2) 2 (1–2) 0.0001
Verbal communication
Pragmatics: maintaining a theme/2 2 (0–2) 2 (0–2) 2 (0–2) 2 (1–2) 0.017
Pragmatics: presenting new information/2 2 (0–2)* 0.5 (0–2)** 2 (0–2) 2 (0–2) 0.0001
Pragmatics: introducing new theme/2 1 (0–2) 1 (0–2) 0 (0–2) 2 (0–2) 0.001
Pragmatics: organising discourse/2 2 (0–2) 0 (0–2)** 2 (0–2) 2 (0–2) 0.0001
Pragmatic: adapting to interlocutor knowledge/2 2 (0–2) 2 (0–2)** 2 (0–2) 2 (2–2) 0.0001
Feedback: emitting/2 2 (0–2) 2 (0–2)* 2 (0–2) 2 (0–2) 0.001
Feedback: adapting/2 2 (0–2) 2 (0–2) 2 (0–2) 2 (0–2) 0.037
Understanding gestures: deictic/1 1 (0–1) 1 (0–1) 1 (0–1) 1 (1–1) 0.054
Understanding gestures: symbolic/1 1 (0–1) 1 (0–1) 1 (1–1) 1 (1–1) 0.545
Understanding gestures: pantomime/1 1 (1–1) 1 (0–1) 1 (0–1) 1 (1–1) 0.131
Understanding gestures: object shape/1 1 (0–1) 1 (0–1)** 1 (1–1) 1 (1–1) 0.0001
Understanding gestures: physical or emotional state/1 1 (1–1) 1 (0–1) 1 (1–1) 1 (0–1) 0.329
Affective expressivity/3 3 (0–3) 0.5 (0–3)** 1 (0–3) 3 (1–3) 0.0001
Producing gestures: spontaneous using/2 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–2) 0.430
Producing gestures: deictic/2 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–2) 0.048
Producing gestures: symbolic/2 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–2) 0.811
Non-verbal communication Producing gestures: pantomime/2 2 (0–2) 0 (0–2) 0 (0–2) 0 (0–2) 0.342
Producing gestures: object shape/2 0 (0–0) 0 (0–2) 0 (0–0) 0 (0–2) 0.133
Producing gestures: physical or emotional state/2 0 (0–2) 0 (0–2) 0 (0–2) 0 (0–2) 0.211
Producing gestures: sequential/2 0 (0–2) 0 (0–2) 0 (0–0) 0 (0–2) 0.373
Pragmatics: adapting prosody/1 1 (0–1) 1 (0–1)* 1 (0–1) 1 (1–1) 0.001
Pragmatics: orienting gaze/1 1 (0–1) 1 (0–1) 1 (0–1) 1 (0–1) 0.024
Pragmatics: using regulatory mimo gestuality/1 1 (0–1)* 0 (0–1)** 1 (0–1) 1 (0–1) 0.0001
Pragmatics: turn taking/1 1 (0–1) 1 (0–1)* 1 (0–1) 1 (0–1) 0.040
Feedback: emitting/2 2 (0–2) 1 (0–2) 2 (0–2) 2 (0–2) 0.007
Feedback: adapting/2 2 (0–2) 0 (0–2)** 2 (0–2) 2 (0–2) 0.001
*
0.001 < p ≤ 0.01.
**
p ≤ 0.001.

only showed significant influence on NVC (p = 0.008), and education
level and gender did not influence PC, VC and NVC.
In the PC assessment, AD patients showed reduced greeting
behaviour. FTD patients were severely impaired in each subtest,
greeting behaviour, attention to the interlocutor and engagement
in the interaction. The DLB group had no definite difficulties.
In VC, AD patients were more severely affected by basic dis-
orders of word and sentence comprehension and word finding
difficulties, and less severely by pragmatic problems, especially
in responding to open questions and presenting new informa-
tion. Paraphasia and difficulties in logically organising discourse
had a discrete but non-significant influence (0.01 < p ≤ 0.05) on the
dyadic interaction. Furthermore, they were able to produce fluent
language and were not impaired in producing intelligible utter-
ances and adapted syntax. Their ability to manage topics and verbal
feedbacks was relatively preserved. The FTD patients were first
impaired by difficulties in understanding words and word find-
ing and by paraphasia. They were even more severely affected
by pragmatic disorders, especially responding to open questions,
presenting new information, logically organising discourse, adapt-
ing to interlocutor knowledge, and emitting feedback. They also
showed discrete and non significant difficulties in speech outflow,
producing syntax, maintaining the theme of the exchange, intro-
ducing a new theme and adapting to verbal feedback from the
interlocutor. Patients with DLB showed problems with speech out-
flow and word finding.
In NVC, AD patients had difficulties in using regulatory mimo-
gestuality, and were discretely but non-significantly impaired by
difficulties in understanding deictics (p = 0.044). The FTD group
showed more severe problems, which concerned comprehension
of gestures miming the shape of objects, affective expressivity, and
pragmatics, especially prosody, using regulatory mimogestuality,
turn taking and adapting to interlocutor feedback. They were par-
tially impaired in orienting gaze (p = 0.025) and emitting feedback
(p = 0.017). DLB were discretely impaired in using regulatory mimo-
gestuality (p = 0.024).
Between-group comparison revealed more severe impairment
in FTD than AD patients for attention to the interlocutor, adapting
to interlocutor knowledge, emitting feedback, and comprehension
of gestures miming the shape of objects.
3.4. Correlations
In the 58 patients, the overall PC, VC and NVC scores corre-
lated (p ≤ 0.001) with the DRS, and VC correlated (p = 0.01) with
the MMSE.
3.5. Specific analysis of AD patients
This group was relatively large in size, and it was possible to
compare patients with mild-moderate (115 ≤ MDRS) and mod-
erately severe (MDRS < 115) dementia. At the early stages, AD
patients were not significantly impaired in greeting behaviour
(p = 0.029), and presenting new verbal information (p = 0.075). Con-
versely, patients who were at the moderately severe stage were
also impaired (p ≤ 0.0001) in attention to interlocutor production,
engagement in the interaction, producing fluent language, compre-
hension of deictic gestures and mimes of shape of objects, and in
using regulatory mimogestuality (p = 0.004).
3888 M. Rousseaux et al. / Neuropsychologia 48 (2010) 3884–3890
4. Discussion
In this study, the assessment of VC and NVC in AD, FTD and
DLB patients at a mild or moderate stage of the disease showed
that most severe communication disorders resulted from FTD. Con-
versely, AD patients had more modest difficulties, especially in PC
and VC. Furthermore, the profile of verbal communication disorders
was quite different in AD and FTD patients, with more severe diffi-
culties at the lexical level in the AD and at the pragmatic level in the
FTD. In comparison, the DLB group only showed minor impairment
of communication abilities.
AD patients participated relatively well in the dyadic interac-
tion. In fact, they only showed a reduction of greeting behaviour.
This usually involves production of both conventional sentences
and gestures. Similar difficulties have already been reported
(Fromm & Holland, 1989). At the stage of moderately severe
dementia, discrete difficulties also appeared in the attention to
the interlocutor. But conversely, patients showed no difficulty in
engaging in the interaction. Thus, they were relatively fair partners
for communication, especially in the mild-moderate stage of the
disease. In verbal communication, their main problems resulted
from difficulties in understanding words and sentences and pro-
ducing words, mainly because of word finding difficulties and to
a lesser degree of paraphasia. This a priori suggests that lexical
and semantic difficulties are key factors of their communication
disorders, as previously reported using more formal language anal-
ysis (Appell et al., 1982; Forbes-McKay & Venneri, 2005; Mendez
et al., 2003; Murdoch et al., 1987). But they were not disturbed by
disorders of speech outflow, speech articulation or syntactic man-
agement. That phonological processing can be preserved in patients
with mild or moderate AD is in line with previous descriptions of
spontaneous speech (Romero & Kurz, 1996). Furthermore, prag-
matics was impaired moderately, especially for responding to open
questions and presenting new information and to a lesser degree
for logically organising discourse. Reduction of information content
has already been reported in aphasia tests (Mendez et al., 2003) and
is relatively similar to the impairment in the propositional develop-
ment of the topic described by other authors (Mentis et al., 1995).
Logically organizing discourse requires fair executive functioning,
which can be impaired in AD patients (Perry & Hodges, 1999).
Here, we did not find that difficulties in changing or maintaining
topics (Mentis et al., 1995) had definite consequence on con-
versation. Furthermore, no significant communication problems
resulted from difficulties in managing verbal feedback. Previous
investigation has reported that AD patients are less successful at
requesting additional information to clarify ambiguous questions
and, more rarely than normal subjects, produce an effective reme-
diation with production of accurate information in response to
feedback from their interlocutor (Carlomagno and Santoro et al.,
2005). But at the mild-moderate stages of the disease, the conse-
quences on the interaction can be relatively reduced. In comparison
with VC, NVC was relatively preserved. Patients were not dis-
turbed by disorders of gesture production nor by difficulties in
understanding gestures. Other authors have described how AD
patients may exhibit more ambiguous gestures and fewer con-
ceptually complex gestures (Glosser, Wiley & Barnoskir, 1998), as
well as increased production of deictic and reduced production
of iconic gestures (Carlomagno and Pandolfi et al., 2005). But the
consequences on the efficacy of the interaction can be relatively
modest. Our patients showed difficulties in using regulatory mimo-
gestuality, which is closely associated with language production.
Importantly, they were not significantly disturbed by NV pragmatic
disorders such as difficulties with prosody, gaze orientation, turn
taking and non-verbal feedbacks. In fact, the increase in speech
turns which has been described by others (Ripich & Terrell, 1988;
Ripich et al., 1991) may not definitely disturb communication. In
the literature, the presence and severity of NV pragmatics disorders
remains debated. Several authors have reported preservation of
body postures, facial expressions and gaze orientation (Feyereisen,
1993; Asplund, Norberg, Adolfsson, & Waxman, 1991), as well as
relative preservation of responses to NV behaviour of the inter-
locutor (Hubbard, Cook, Tester, & Downs, 2002). In conclusion,
our results showed that AD patients are especially impaired by
lexical–semantic problems, and less severely by difficulties of prag-
matic or higher levels of language processing (Blanken et al., 1988;
Glosser & Deser, 1990) That pragmatics can be relatively preserved
at the mild to moderate stages of the disease, in comparison with
lexical–semantic processing, is in line with the relative preserva-
tion in understanding non literal (metaphors and idiom) sentences
(Papagno, 2001), in recognition of emotions and sarcasms (Kipps
et al., 2009) and with the more severe impairment in basic lan-
guage compared with discourse production (Bschor et al., 2001). It
could be that pragmatics is relatively more severely affected at fur-
ther stages of the degenerative process. But we did not investigate
such patients in our series. Therefore, social conventions and social
interactions can be relatively preserved in patients with mild to
moderately severe AD (Fromm & Holland, 1989). In daily living, the
quality of social communication during conversation also depends
on the positive psychosocial qualities of the interlocutors and espe-
cially of family caregivers (Small, Perry & Lewis, 2005), and patient
behaviour is not the only variable to be taken into account.
The profile of communication disorders was quite different in
FTD – frontal variant – patients. These were severely impaired
in their participation in communication, especially in greeting
behaviour, attention to the interlocutor and engagement in the
interaction. There is no comparable information in the literature,
since dyadic communication has never been addressed in such
patients. This problem a priori results from the decrease in inter-
est in the environment and distractibility that has been reported
in their global behaviour (Lebert & Pasquier, 1995; The Lund and
Manchester Groups, 1994). Verbal communication was not sig-
nificantly impaired by phonologic or syntactic disorders. In fact,
patients were first impaired by difficulties in word comprehension
and word finding. Lexical difficulties with verbal perseverations
and stereotypes are recognized as classical diagnostic criteria (The
Lund and Manchester Groups, 1994). But in formal language tests,
impairment in producing words and understanding words and
sentences has been described (Grossman et al., 2005; Mendez
et al., 1996; Siri, Benaglio, Frigerio, Binetti, & Cappa, 2001), and
discourse production is also impaired partially by word finding dif-
ficulties (Ash et al., 2006). In our series, an important point was
that FTD patients were severely impaired by pragmatic disorders.
This was evident in VC, especially for responding to open ques-
tions, presenting new information, organizing discourse, adapting
to interlocutor knowledge and emitting feedback. But patients
also showed modest difficulties in maintaining the theme of the
exchange (Ash et al., 2006), introducing a new theme and adapting
to verbal feedback from the interlocutor. NVC analysis confirmed
the severe consequence of pragmatic difficulties, especially in
adapting prosody, using regulatory mimogestuality, and managing
speech turns and feedback. Therefore, there were definite differ-
ences with AD patients, who only showed limited problems with
verbal pragmatics. These divergences likely rely on the difference
of profile of both behavioural-cognitive disorders and brain-lesions
dysfunction. Even if several studies did not show definite differ-
ences between the two populations in a variety of cognitive tests
of language, praxis, attention and executive functioning (Mendez
et al., 1996; Siri et al., 2001), many authors have reported that
FTD patients are more severely impaired in several executive tests
(Kramer et al., 2003), especially when considering performance
characteristics and error types (Thompson, Stopford, Snowden, &
Neary, 2005). Anatomically, the main FTD lesions/dysfunction are
 M. Rousseaux et al. / Neuropsychologia 48 (2010) 3884–3890
in the anterior frontal and temporal areas, contrasting with promi-
nent involvement of temporal and parietal lobes in AD (Talbot,
Lloyd, Snowden, Neary, & Testa, 1998). In fact, the dysexecutive
syndrome and anterior brain dysfunction are critical for explain-
ing pragmatic disorders (Ash et al., 2006). It has already been
shown that FTD patients have poor ability to infer interlocutor men-
tal states, thoughts and feelings (Theory of mind) (Gregory et al.,
2002), which was confirmed here by their difficulties in adapting
to interlocutor knowledge. Patients with focussed frontal injury as a
consequence of stroke or traumatic brain injury are defective in the
interview setting, with a reduction in the number of utterances per
speaking turn, an increase in digressions, and difficulties in devel-
oping topics. They need solicitations to present information related
to a specific theme and their management of verbal and non-verbal
feedbacks from the interlocutor is poor (Bernicot & Dardier, 2001).
It can be suggested that the severe difficulties in both VC and NVC
management actively participate in their poor social interactions
and their isolation.
DLB patients did not show definite impairment of participation
in communication. But VC was impaired partially, especially by a
reduction in speech production and word finding difficulties. Using
appropriate syntax and understanding words and sentences were
relatively well preserved. There was not any difficulty either in
using verbal pragmatics. Nonverbal communication was also pre-
served, except for using regulatory mimogestuality. Therefore, DLB
patients had less severe problems in conversation than AD and
FTD patients. It has been suggested that DLB patients could present
more severe difficulties than AD patients in executive functioning
and greater attentional variability (Levy & Chelune, 2007). But here,
they were not more severely impaired in using verbal and non-
verbal pragmatics. It remains probable that this does not apply to
those with more severe dementia, which may result in more severe
behavioural disorders.
In conclusion, the profile of communication disorders was
clearly different between patients with AD, FTD, and DLB. Health
care and rehabilitation must be adapted to the profile we identi-
fied, and more specifically to the lexical–semantic impairment in
AD patients and to both the lexical and pragmatic difficulties in FTD
patients.
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