Overview

Diagnosis and treatment for agraphia are greatly varied due to the diverse aetiology of the disease. Diagnostic methods use language tests and imaging techniques to understand the severity of agraphia while identifying the site of abnormality that is causing the disease. 

In response, appropriate surgical and medical interventions are conducted to remove or mitigate the cause, which is usually neurodegenerative diseases or cardiovascular conditions. Utilising language therapies, emotional support, and resources is also important to improve the life standards of patients who struggle with agraphia.

Understanding agraphia

Agraphia can be defined as the impairment or loss of ability to write.¹ A range of traumas, lesions, neurological diseases, and health conditions can cause agraphia. The lack of, or inaccurate, writing skills results in disrupted interpersonal communication and activities, which can ultimately induce emotional and social struggles. 

Together with aphasia and alexia, the main cause of language impairment conditions is thought to be ischemic strokes, particularly when the language centres of the brain are damaged.²

Types of agraphia

To be able to write, an individual must know the word or letter and have the physical capability to perform the skill.¹ These skills depend on a functioning nervous system, including the central nervous system (CNS) and peripheral nervous system (PNS). Disruptions in such neuronal functionality damage both components of the writing capability, resulting in agraphia. 

The type of agraphia depends on the nature of the lesion that disrupts these skills. Agraphia can be accompanied by other language impairments including alexia and aphasia, meaning the patient will have writing, reading, and speaking impairments. Language impairments that solely affect writing are known as “pure agraphia”.¹

Central (linguistic/aphasic) agraphia

Specific regions of the CNS and the brain are damaged in central agraphia. These regions are likely to be areas that are important for storing, organising, and utilising the knowledge of letters and words. 

• Phonological agraphia – A disorder in which the individual is unable to write nonwords without dictation but can write words to dictation and orally repeat those, too ³
• Lexical agraphia – Where the individual struggles to write words that are not spelt phonetically ⁴

Peripheral agraphia

As mentioned previously, brain storage of a word or letter is insufficient to write correctly – an individual must also be able to use their motor and sensory systems in their PNS to accurately write the word in question. 

In peripheral agraphia, the patient has typical knowledge of words and letters but has disrupted writing skills.

• Apraxic agraphia – Previously known as “pure motor agraphia”. The individual can spell a word orally but is unable to write it down accurately due to lesions in the motor and sensory neuronal circuits of the PNS⁵
• Spatial agraphia – Associated with orientation-related errors in writing. Individuals are typically unable to write in a horizontal line or maintain distinctive handwriting using repeated strokes and letters⁶

Causes of agraphia

Agraphia can be caused by a range of neurological and physiological problems. Strokes caused by tumours, injuries, and infections are thought to be the major cause of agraphia.² 

Although the exact pathophysiology is unexplored, COVID-19 infections can affect the brain to trigger dementia-like symptoms including agraphia.⁷ Slow but progressive symptoms are likely to be associated with neurodegenerative diseases including Alzheimer’s disease. In such conditions, damage in brain areas responsible for writing is observed.⁸ Additionally, Parkinson’s disease affects the basal ganglia which is involved in the extrapyramidal motor system, resulting in tremors that induce agraphia.⁸ 

Meanwhile, peripheral agraphia can be caused by disruptions in regions of the CNS that coordinate movement (e.g., Parkinson’s disease). Additionally, lesions and injuries in the PNS, more specifically the motor circuits that carry out or plan writing tasks, can also cause peripheral agraphia. Spatial agraphia is thought to be caused by a disruption in the right hemisphere of the brain and is usually associated with other language deficiencies such as dyslexia and apraxia.⁹ 

Diagnosis of agraphia

The patient’s writing skills are usually tested using open-ended questions such as “What did you do today?”, or “Describe yourself”, to which the patient attempts to write an answer on a blank sheet of paper.¹ 

The clinician would observe and examine the answer using the following criteria:

• Orientation of the words and letters
• Ease and speed of task completion
• Spacing or uniformity of words and letters
• Stroke strength and quality
• Any grammatical errors 
• Spelling accuracy¹

The severity of agraphia is further classified using the Western Aphasia Battery and Boston Diagnostic Aphasia Examination.¹⁰ Meanwhile, more specific evaluations are required to characterise the type and severity of agraphia. For example, physics imaging techniques including computerised tomography (CT) and magnetic resonance imaging (MRI) are useful in localising specific regions of brain damage or dementia progress.¹

Agraphia treatment

Complete treatment of agraphia usually requires a combination of language and writing therapy, surgical interventions, and medication that reverses or mitigates the lesion causing the disorder.

Therapy

Speech and language therapy (SLT) is the most common approach to treating central and peripheral agraphia. Conducted by a speech-language pathologist, SLT helps to improve the patient's fluency, language comprehension, and clarity by practising facial movements, playing word games, and reading actively. SLT is effective in alexia and aphasia, too. Earlier introduction to SLT correlates with better treatment outcomes, particularly in young children.

A strong benefit of SLT is its flexibility. The frequency and duration of treatment sessions can vary depending on the patient’s condition, age, preference, and comfortability. This high individuality allows SLT to be an accessible treatment option for agraphia.

Surgical interventions

Surgical operations that target the cause of agraphia, for example, tumours, strokes, or injuries, are thought to be effective in treating agraphia. This can target both CNS and PNS areas, depending on the nature of the cause and type of agraphia.

Medication

Similar to surgical operations, medical treatments can help to relieve the cause of agraphia. Agraphia associated with Parkinson’s disease can be treated using anti-parkinsonian drugs including dopamine receptor agonists and Levodopa.¹

Support

Patients with agraphia can receive support in a wide range of forms. Patients who have apraxic agraphia can use a keyboard instead of writing in academic and social situations. Additionally, patients who struggle with socialising and communication due to agraphia can receive emotional support, therapy, resources, and information about the condition. Although treatment of agraphia is an important goal, it is also crucial to support patients with “coping” with the disease until it can be treated.

Complications

Complications of agraphia stem from its influential role in interpersonal communication and social capabilities. Patients with agraphia usually suffer from depression and tend to cut off social interactions, resulting in loneliness and further difficulties in communication.¹¹

Furthermore, since agraphia is a secondary condition that arises from other physiological or neurological conditions, there are increased complications in understanding the precise pathophysiology of the disease. 

Summary

Diagnosis and treatment of agraphia are highly dependent on the type and cause of agraphia. It is important to talk to clinicians to receive the appropriate medical support. Agraphia is a condition that significantly impairs the patient’s social skills, therefore its treatment is crucial to improve their interpersonal capabilities. Agraphia is also detrimental to cognitive well-being, as it increases the risk of depression, loneliness, and isolation. Other than medical assistance, family members and friends could provide emotional support, alter communication methods, or consider therapy sessions to take care of the patient.

Frequently asked questions

How reversible is agraphia?

Although treatment of agraphia is unlikely to be completely successful, rehabilitation proves to be majorly successful in recovering a major part of the patient’s writing ability.¹² Early introduction of SLTs and medical/surgical intervention is important for better treatment outcomes. 

When was agraphia discovered?

Although agraphia was identified in the mid-14th century, clinical tests were introduced only during the 19th century.

How do I interact with someone who has agraphia?

Language impairments can be isolating and upsetting for the patient, and so the people around them must know the best ways to communicate with them. This can include avoiding written communication, utilising electronic audio devices, providing emotional support, and helping them whenever they need to hand-write letters or documents.