Pauses in Speech: Normal or Abnormal From Ronald Reagan to Atal Ji

Pauses in Speech: Normal or Abnormal

From Ronald Reagan to Atal Ji

Dr KK Aggarwal

President CMAAO and Past National President IMA

Bharat Ratna Awardee Sh Atal Bihari Vajpayee, the former Prime Minister of India was known for his oratory as well as his pauses.

Pauses in your senses can be very powerful way of communication and can be the sign of early dementia.

Silence does have a sound. And the effective use of silence in communication, often speaks louder than words. In Vedic description the word AUM has a silence after M.

As a public speaker, one must incorporate pauses at the right places, in the right moments to connect with the audience. Pauses help the audience understand & absorb the right message. Pauses add meaning & power to the spoken words.

Type of pauses

1.     The pregnant dramatic pause suggests more than what is expressed in words. It is pregnant with unexpected possibilities and longer than the other pauses. It adds a dramatic impact to what one is about to say. It is often used in comedy, suspense and by experienced & polished speakers to heighten anticipation in the listener.

2.      The meaningful pauses: are the essential pauses in communication meant for clarity. They are the commas & full-stops of spoken communication.

3.      The emotional pauses: are used by leaders using the art in similar sounding, repetitive phrases, to arouse emotions in the audience.

4.      The physiological pauses: are the pauses needed to replenish the breath. Breath training helps to speak long phrases and deliver a powerful & emotional message.

5.      The pathological pauses: More pauses (specifically when you want to name the person, place or the event) and filler words ( in place of the name of the person or the place) might be an early sign of mental decline and Alzheimer's disease.

Lots of people say “um” and have trouble quickly recalling names as they age. They used more pronouns such as “it” or “they” instead of specific names for things, spoke in shorter sentences and took longer to convey what they have to say.

A study in 2015 analysed dozens of press conferences by former US President Ronald Reagan and found evidence of speech changes more than a decade before he was diagnosed with Alzheimer's. Similar changes can be seen when you follow the sequential speeches over last two decades of late Sh Atal Ji: a changed from normal pauses to pauses with fillers.

I also saw a change in the speeches of Advani ji over last two decades, often speaking repetitive sentences.

Leaders are our role models and their illnesses and early illness signs help in public education. Remember Atal Ji knee replacement surgery created a wave of knee surgeries in India.

Why retire at any age?

Why retire at any age?

Dr KK Aggarwal

President CMAAO and HCFI

It has been a practice in India to retire people after the age of 58. In some cases, the age has been 60, 62, 65 or 70. Let us understand the science behind this retirement.

Retirement is based on the fact that after the age of 50 one starts developing age related minimal cognitive impairment. One start losing memory for immediate recall, recent memory, starts losing the names of common people and common places.

 Quite often when one is speaking on a phone and his attention is diverted by someone, the person forgets what he was speaking.

In this age most people start entering the name of a person in the phone book by linking it to his profession, relation, JOB ETC.

Most politicians will start relying on the PPT presentations or start reading their speech.

Very few will continue oral extempore presentations. The situation is worse with vegetarians due to Vitamin B 1w2 deficiency which further impairs memory.

Premature atherosclerosis, diabetes, hypertension, recurrent mini strokes also add to this insult.

Therefore, the age of retirement should not be decided by chronological age but by the degree of age related cognitive impairment present.

All patients with age related cognitive dysfunction should be evaluated and treated for reversible causes of cognitive impairment, including medication side effects, sleep disturbances, depression, vitamin B12 deficiency, and hypothyroidism.

Both low and high levels of hemoglobin linked to increased risk of dementia

A new study has linked both low and high hemoglobin levels to an increased risk of developing dementia in the future.

The study involved 12,305 people with an average age of 65 who did not have dementia. Overall, 745 (6%) of the study subjects were found to have anemia. The participants were followed for an average of 12 years. During that time, 1,520 people developed dementia. Of those, 1,194 had Alzheimer’s disease.

Subjects who had anemia were 41% more likely to develop Alzheimer’s disease and 34% more likely to develop any type of dementia compared to those who did not have anemia. Of the 745 people with anemia, 128 developed dementia, vs 1392 of the 11,560 people who did not have anemia.

Similarly, participants with high hemoglobin levels were also more likely to develop dementia.

The study participants were divided into five groups based on their hemoglobin levels.

·         Compared to the middle group, the group with the highest hemoglobin levels was 20% more likely to develop dementia.

·         Those in the lowest group were 29% more likely to develop dementia than those in the middle group.

These findings reported in the July 31, 2019 online issue of Neurology may have important public health implications for the developing countries where the prevalence of anemia is high. These findings should ring a warning bell for these countries including India.

(Source: American Academy of Neurology, July 31, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

LATE, a new type of dementia

National Institutes of Health scientists have identified a new type of dementia and have named it LATE or Limbic-predominant Age-related TDP-43 Encephalopathy as reported April 30, 2019, in the journal Brain.

LATE is an under-recognized condition and the “oldest-old” (80 years and older) are at greatest risk of developing it.

LATE affects multiple areas of cognition, ultimately impairing activities of daily life. It mimics the clinical features of Alzheimer’s disease, but is more slowly progressing. But, LATE combined with Alzheimer’s causes a more rapid decline than either condition alone would.

Now there is rising appreciation that a variety of diseases and disease processes contribute to dementia. Each condition appears differently when a brain sample is examined at autopsy. However, it has been increasingly clear that in advanced age, a large number of people had symptoms of dementia without the telltale signs in their brain at autopsy. Emerging research seems to indicate that the protein TDP-43 may contribute to that phenomenon.

The autopsy diagnosis has been suggested in three stages, according to where in the brain TDP-43 is detected:

·         Stage 1: amygdala only

·         Stage 2: amygdala and hippocampus

·         Stage 3: amygdala, hippocampus and middle frontal gyrus

TDP-43 (transactive response DNA binding protein of 43 kDa) is a protein that normally helps to regulate gene expression in the brain and other tissues. Recent research has shown misfolded TDP-43 protein as being very common in older adults. Around 25% of people over 85 years of age have enough misfolded TDP-43 protein to affect their memory and/or thinking abilities.

Unusually misfolded TDP-43 has a causative role in most cases of amyotrophic lateral sclerosis and frontotemporal lobar degeneration. TDP-43 pathology is also commonly associated with hippocampal sclerosis. The hippocampal region of brain plays an important role in memory and learning. Therefore, cognitive impairment as the symptoms of hippocampal sclerosis may appear to be very similar to the effects of Alzheimer’s disease.

(Source: NIH, April 30, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Exercise has no upper age limit: Moving more in old age linked to sharper memory

Older adults who move more, either with daily exercise or even simple routine physical activity like housework, may preserve more of their memory and thinking skills, even if they have brain lesions or biomarkers linked to dementia, according to a study published in the January 16, 2019, online issue of Neurology.

The study examined 454 older adults; 191 had dementia and 263 did not. All participants were given physical exams and thinking and memory tests every year for 20 years. Participants agreed to donate their brains for research upon death. The average age at death was 91. The brain tissue was examined after death for lesions and biomarkers of dementia and Alzheimer’s disease.

The study found that people who had better motor skills had better thinking and memory skills compared to those who did not move much at all. For every increase in physical activity by one standard deviation (SD), participants were 31% less likely to develop dementia. For every increase in motor ability by 1 SD, participants were 55% less likely to develop dementia. This association was consistent in people who had dementia and people who did not.

Today, most of us are less physically active even though the benefits of exercise on physical health as well as mental health are known to us all. Lack of initiative or lack of safe open spaces may have contributed to this scenario. A heavy work schedule is often a deterrent to physical activity for many of us.

Walking is the best form of exercise, which requires no investment, no special training. Walking in natural environments such as parks also reduces mental stress and fatigue and improve mood via the release of the ‘feel good’ endorphins. This proximity to nature also helps in the inward spiritual journey and shifts one from the sympathetic to parasympathetic mode manifested by lowering of blood pressure and pulse rate

(Source: American Academy of Neurology News Release, Jan. 16, 2019)

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

D KK Answers: Can dementia be a ground for bail?

Yesterday, by one of the TV channel I was asked the question whether any person whether any under trial claim relief on  the grounds that he or she is suffering from dementia.

A: It will depend upon the clinical situation.

Dementia is a disorder that is characterized by impairment of memory and at least one other cognitive function. These impairments must represent a decline from the previous level of function and should be severe enough to interfere with daily functioning and independence. Anything below that will be either age related cognitive impairment or minimal cognitive impairment.

To claim benefit from the court of law, one must show that at the time of decision making the dementia was severe enough to  interfere with daily functions and independence. A patient of dementia cannot do his normal day to day functions.

Dr KK Answers: What is the link with depression?

Screening for depression in patients with dementia is recommended because depression is a common treatable co-morbidity that may also masquerade as dementia.

Dr KK Answers: Should we do MRI in all cases?

Neuroimaging rules out patients who might have reversible causes of dementia that can be diagnosed with imaging studies (subdural hematoma, normal pressure hydrocephalus, treatable cancer). Structural neuroimaging with either a non-contrast head CT or MRI should be considered in the initial evaluation of all patients with dementia. 

Dr KK Answers: Should we screen for B12 levels?

The American Academy of Neurology recommends screening for B12 deficiency and hypothyroidism in patients with dementia.

Dr KK Answers: What are Dementia syndromes?

The major dementia syndromes include

• Alzheimer disease
• Dementia with Lewy bodies
• Frontotemporal dementia
• Vascular (multi-infarct) dementia
• Parkinson disease with dementia 

Dr KK Answers: How common is dementia?

5 percent of individuals over age 65 years and 35 to 50 percent of persons over age 85 years have dementia, the pretest probability of dementia in an older person with reported memory loss is estimated to be at least 60 percent.

Dr KK Answers: Who reports dementia?

Most patients with dementia do not present with a complaint of memory loss; it is often a spouse or other informant who brings the problem to the physician's attention.

Dr KK Answers: What is DSM-IV definition of dementia?

Evidence from the history and mental status examination that indicates major impairment in learning and memory as well as at least one of the following:

a.     Impairment in handling complex tasks (eg, balancing a checkbook)

b.     Impairment in reasoning ability (eg, unable to cope with unexpected events)

c.     Impaired spatial ability and orientation (getting lost in familiar places)

d.     Impaired language (word finding)

The cognitive symptoms must significantly interfere with the individual's work performance, usual social activities, or relationships with other people. There must be a significant decline from a previous level of functioning. The disturbances are of insidious onset and are progressive. The disturbances are not due to delirium; a major psychiatric diagnosis; systemic disease or another brain disease.

Patients with dementia may also have difficulty with

a.    Learning and retaining new information (eg, trouble remembering events)

b.   Behavior

Dr KK Answers: What is Alzheimer disease?

Ad is the most common form of dementia in the elderly, accounting for 60 to 80 percent of cases.

Dr KK Answers: What is dementia?

It’s a disorder characterized by impairment of memory and at least one other cognitive domain (aphasia, apraxia, agnosia, executive function). These must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.