“The onset of dementia is delayed by four to nine years in people who speak more than one language”

Although he studied medicine in his native Argentina, Marcelo Berthier came to Malaga 32 years ago, attracted by the city’s quality of life. Today, this university professor of neurology and researcher at IBIMA is internationally recognized as the pioneer of a combined treatment for aphasia (a language disorder that makes it difficult to communicate by speaking or writing after a brain injury) which involves medication, language rehabilitation and non-intensive brain stimulation.

– What is it in the brain that has made you devote so much of your life?

– We humans are our brains. They regulate everything, and I’ve been a specialist in this since 1980, when I started working with people who had lost their language due to some type of brain injury. My interest has always been to study the biological bases of language. It’s what makes us human, what sets us apart from other primates, and it’s a fascinating and enigmatic subject, even if society pays little attention to it.

Treatment: “In cases of chronic aphasia, the role of administration could be greatly improved”

–How can we take better care of our brain?

–A stroke is one of the most common causes of aphasia, so we need to control vascular risk factors (hypertension, diabetes, cholesterol, smoking, obesity, sedentary lifestyle, etc.), but there are also has other things that a healthy person can do. For example, someone who is bilingual has a greater cognitive reserve, more capacity in their brain than a monolingual person. In fact, symptoms of dementia are delayed by four to nine years in people who speak more than one language, so using another language, reading it and understanding what you read is fundamental. The part of the brain that regulates our language must remain active, so speaking one or more others is desirable.

– After so many years of study, what has been the most revealing?

–Historically, it was believed that there was only a remote possibility of recovering language after full or partial loss as a result of brain injury; now we know that is not the case. This has been the major challenge: finding ways for people with aphasia to be able to communicate again in one way or another and regain their quality of life.

–The announcement of Bruce Willis’ retirement after being diagnosed with aphasia drew media attention to the disorder. How likely is a healthy person to have it?

– Aphasia has multiple causes: in adults, the most frequent is a cerebrovascular accident and cardiovascular accidents in general; also neurodegenerative diseases such as Alzheimer’s disease or primary progressive aphasia, which is probably that of Bruce Willis; but also, it could be tumors or head trauma. The older you are, the higher the risk of suffering from one of these conditions, and therefore the likelihood of aphasia. It is a symptom of some neurological conditions and its clinical features and long-term course are different. With a malignant tumor, it will be worse than someone who has a stroke. In general, diseases that affect the left hemisphere of the brain, which is responsible for language, are likely to cause aphasia. The vast majority of right-handers have lateralized language in the left side of the brain. Left-handed people tend to behave similarly to right-handed people, but may have more atypical locations in both cerebral hemispheres and, exceptionally, in the right hemisphere. This also happens with those who are ambidextrous.

Statistics: “In Andalusia alone, more than 7,000 people a year suffer a stroke”

– Does this mean that the risk of suffering from aphasia is linked to whether a person is right-handed or left-handed?

– Not necessarily, because we see right-handers who recover well and left-handers or ambidextrous who do not. Aphasia is a heterogeneous disorder in which many personal characteristics are involved. If an illiterate person is affected by it, it will not be the same as a high potential person. Their ability to recover is very different. An illiterate person has a very limited vocabulary, surprisingly, he only understands 300-500 words, while a university graduate can use around 30,000 words. This means that their language is broader, richer and more distributed in the brain. The margin of recovery is greater in someone who has more vocabulary, because he has more resources, more possibilities of finding alternatives to the words he cannot pronounce.

– Can aphasia happen overnight?

-It depends. Bruce Willis had time to prepare press releases announcing his retirement, which makes us think that his illness evolved slowly, like neurodegenerative diseases. On the other hand, if someone has a stroke, they go from being able to talk to not being able to talk, just like that. It is a sudden change and it indicates what could be the cause.

–And when that happens, how do people deal with the helplessness of wanting to express themselves verbally but not being able to?

–It depends on the severity of the aphasia. About 30% of secondary aphasias are severe, although that doesn’t necessarily mean they won’t get better. However, aphasia is a devastating disorder. In a study done in Toronto, Canada, in 2010, they asked 65,000 seniors in nursing homes what affected their quality of life the most. Aphasia was number one, ahead of cancer and tetraplegia. When a person loses the ability to speak, they will lose their job, their finances will be affected, their relationships with family and friends will be different, they are more likely to suffer from depression, anxiety and frustration. They will lose their autonomy, because sometimes they will not be able to move. Aphasia is the cornerstone, but there are a number of training effects that reduce quality of life. That’s why our job is not just to treat language problems, but all the associated side effects.

– What is the darkest side of this disorder?

–The worst case is when there are a lot of side effects. There are many serious, even fatal diseases, which for a long time do not create the same disabilities. For example, a patient diagnosed with amyotrophic lateral sclerosis, which is also devastating, may live acceptably for the first few years. However, a person with aphasia loses so much from day one. The only difference with the others is that they can recover, at least partially.

–Are there any obvious signs that something is wrong?

-Yes. The first is a person’s ability to communicate as they usually do, difficulty remembering certain words, or slow communication. They also start saying words that don’t make sense, may not understand what they are reading, or be able to read aloud or write. These all indicate language impairment and are a warning sign, especially if they come on suddenly. In neurodegenerative diseases, the most common symptom is an inability to pronounce words, for example if they want to say “cup” but cannot. They know what they want to say, but cannot access the word to pronounce it.

–And do the authorities offer appropriate treatment?

–Stroke units play a vital role in early diagnosis to reverse the effects so that aphasia does not occur or, if it does occur, is less severe. Regarding chronic care, I think it could be improved. Since society does not know what aphasia is, the state does not pay much attention to it. Resources are good, but could be optimized. Remote care is one of the most used methods during the pandemic and it is more economical than in-person therapies. I hope it will continue. In fact, we have a project that aims to show that online therapy can work and is cheaper to apply. This reduces costs and does not leave patients isolated, as one of the reasons that patients with aphasia forgo their therapies is the problem of transportation.

– What role does your unit play?

–It was created in 2004 and since then the team, which is multidisciplinary, has grown in terms of researchers. There are psychologists, speech therapists, linguists, computer engineers (neuroimaging) and neurologists to treat all aspects of the disorder. We were pioneers in the drug treatment of aphasia and we use it together with intensive rehabilitation techniques and non-invasive brain stimulation. Used together, the results are more robust.

–But for the moment, your unit is still only doing research.

–This is a research unit with ongoing projects in which people who meet a certain number of criteria are invited to participate. But not all aphasics, because we are not a treatment center. We would be overwhelmed if we tried to do both: in Andalusia alone, 7,000 people a year suffer a stroke. However, as a public institution, we provide free advice and analysis.

-What happens after?

-We now know a lot about the left hemisphere and how the brain repairs itself, but one of the biggest challenges is identifying predictors. We would like to know if someone is going to be able to fully recover or not, so that we can adapt our treatment strategy with this knowledge at hand and find what will work best for them.

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