Mutism in the Older Adult

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC; Gowrie Pavan, MBBS, FRAGP

Disclosures

Geriatrics and Aging. 2005;8(8):61-68. 

In This Article

Abstract and Introduction

Mutism in older adults is not uncommon. It is often confused with severe depression, locked-in syndrome, and persistent vegetative state, but it is important to distinguish among them as the management and prognosis are different. The family physician is the most consulted professional and so is the most helpful in making this distinction. Mutism is a neuropsychological disorder with marked heterogeneity among patients, raising the possibility of conditions such as advanced Alzheimer's disease, Jacob-Creutzfeldt disease, frontotemporal dementias, and certain psychiatric and psychological conditions. It is both a symptom and a syndrome, and is often associated with akinesia when the term akinetic mutism is used. Akinetic mutism has a number of causes with varied pathology and is characterized by a marked reduction in motor function, including facial expression, gestures, and speech output, with awareness being preserved. All of the disease manifestations can be explained by damage to the frontal lobe or interruption of the complex frontal subcortical circuits and the frontal diencephalic brain stem system by focal lesions or diffuse brain damage.

By definition, mutism is the state or condition of being speechless. If speech occurs it is restricted to terse responses or monosyllables. Mutism is not uncommon in the older population. Since it is often caused by brain damage, mutism is considered a neurological disorder. However, it is also a psychological disorder and so can be more accurately termed a neuropsychological disorder. Mutism can be congenital or acquired when, as a result of damage to a part of the brain, the normally functioning psychological capability is altered. In mutism there is impairment of speech function and it is an articulatory disorder as opposed to aphasia, a disorder of linguistic processing (Figure 1).

Diagnostic Algorithm for Mutism

The primary care physician must have a high degree of awareness or suspicion in patients presenting with varied clinical conditions that are often associated with mutism, and often erroneously diagnosed as depression, delirium, and locked-in-syndrome, amongst others.

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