Annals of Indian Academy of Neurology
  Users Online: 6382 Home | About the Journal | InstructionsCurrent Issue | Back IssuesLogin      Print this page Email this page  Small font size Default font size Increase font size

Table of Contents
Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 129-130

Cross-cultural differences in dementia: Indian etiquette of honorifics

Director, Pauranik Academy of Medical Education, Ex-Professor, Medicine and Neurology, M.G.M. Medical College, Indore, Madhya Pradesh, India

Date of Web Publication9-Apr-2019

Correspondence Address:
Dr. Apoorva Pauranik
4, Ahilyapuri, Near Resident Area, Zoo Road, Indore, Madhya Pradesh
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aian.AIAN_404_18

Rights and Permissions


How to cite this article:
Pauranik A. Cross-cultural differences in dementia: Indian etiquette of honorifics. Ann Indian Acad Neurol 2019;22:129-30

How to cite this URL:
Pauranik A. Cross-cultural differences in dementia: Indian etiquette of honorifics. Ann Indian Acad Neurol [serial online] 2019 [cited 2022 May 20];22:129-30. Available from:

Dr. P., a musician, has been immortalized by the poet laureate of neurology, late Dr. Oliver Sacks, in his classical book of clinical tales “The Man Who Mistook His Wife for a Hat.”[1] Dr. P. was that man, having prosopagnosia and other deficits due to posterior cortical atrophy variant of dementia. Dr. P. had preserved facility for music and conversation. He also had a strange evolution of his artistic skills in painting, changing from concrete or realistic to cubist and abstract. A few more similar case reports have speculated about the development of new networks and synapses in the face of the ongoing pathology of cellular apoptosis in dementia.[2]

A study published in this issue of the Annals tangentially touches the insight obtained from the tale of Dr. P.[3] The authors have focused on a very precise culture-specific observation about the relative preservation of familial interaction (FI), between persons with Alzheimer's dementia (PAD) and their caregivers, despite the presence of prosopagnosia and anomia.

The clinical and demographic data are at some variance from other international and national studies.[4] AD accounted for only 35% (42 out of 120), that too at a relatively young mean age of 62.83 years. Possibly other etiologies played a greater role – vascular, nutritional, and infective. The incidence of prosopagnosia (14/120, 33%) and anomia (6/120, 14.2%) is comparable to most other studies.[5]

The quality of life for PAD depends, apart from many other factors, also on interaction with close family members.[6] The ability to engage in meaningful FI is often preserved in mild-to-moderate dementia.

Deferential attrition of many cognitive skills ultimately impacts interactional competence. The authors emphasize only three factors: face recognition, naming, and language function. That may be an oversimplification. Other factors are attention (neglect), interest (apathy), memory, and executive function. It may be difficult to parse many components of F1 which is a multifaceted activity.

It has been rightly argued by authors that prosopagnosia may not come into the way of FI because the person's voice serves as an adequate cue. They could have mentioned other cues as well: clothing, jewelry, type of makeup adorned by the relative, and also the sheer high statistical probability of the interacting person being a close family relative. During FI with significant others, one does not need to name the person, and hence, anomia may not be a handicap.

The authors defined anomia as the inability to name a person or object with retained recognition. There is more to anomia testing than this,[7] for example, the ability to accept a correct answer and to reject a wrong answer from amongst multiple foils of phonemic and semantic nature. Anomia also pertains to “responsive naming” wherein a word response has to be generated without the overt presence of a person, object, or picture. Similar details about the testing of “face-recognition” could have been provided. The discussion about the relationship between more detailed and fine-grained deficits in naming and face recognition with F1 would then become more informed and nuanced.

Three PAD having prosopagnosia and one without it had a peculiar problem during, FI. The subjects addressed their close relative with a name that is usually of a person of one generation earlier (higher). While being asked to name the relation, they again erred to an earlier generation (sister instead of daughter). However, the use of an appropriate honorific (peculiar to Bengali and most Indian language) betrayed the correct identification of the person concerned. The author's observations on the use of markers of politeness are unique and underscore the importance of cross-cultural and linguistic differences in clinical features of dementia.[8]

The authors have made a cogent attempt to understand the neuroanatomical substrate of dissociation between face recognition and naming in the context of erroneous face recognition, but a correct marker of politeness. Many types of dissociation between various aspects of cognitive function have been described, for example, between face recognition, naming, and pointing to named emotions on the one hand (which are impaired) and discriminating facial expressions of emotion (which are spared) on the other hand. The former is correlated with mini-mental status and Raven scores, while the latter is not. Such dissociations implying separate systems (networks) are consistent with the notion of modular organization of cognition.[9] It also correlates with the fact that nonverbal communication often remains preserved in the severe AD. It may be true that in PAD, naming problems may be early with preserved visual memory (including face), but exceptions are not uncommon, including the example of Dr. Oliver Sacks himself.[10]

The author's discussions about many theoretical models of memory (category specificity, modality specificity, and sensory functional theory), their deferential vulnerabilities, and the role of new wiring with increased functional connections between anatomical regions and overlapping networks, are cogent and ingenous.[11]

The study raises some questions and suggests a need for additional similar work. Among many determinants of quality of life for PAD, what role is played by FI? What is the incidence of many subtypes of prosopagnosia and anomia in Indian PAD and how do they correlate with other demographic, clinical, and imaging features? What additional types of dissociations may occur across many components of the cognitive system, while some are impaired and others not?

It would be interesting and meaningful if these observations and comments are seen in a broader context of linguistics discourse, turn taking, and facilitation by communication partners, to repair the conversational breakdowns.[12] A case series with a larger number of subjects will be welcome, wherein more PAD having more varied instances of problems during FI are described in greater detail.

   References Top

Sacks O. The Man Who Mistook His Wife for a Hat. London: Picador; 1986. p. 9-24.  Back to cited text no. 1
Erkkinen MG, Zúñiga RG, Pardo CC, Miller BL, Miller ZA. Artistic renaissance in frontotemporal dementia. JAMA 2018;319:1304-6.  Back to cited text no. 2
Pal S, Sengupta P, Ghosal M, Pal A, Acharya R, Biswas D. Storage, degradation, and new connectivity of face-related semantic memory in alzheimer's disease. Ann Indian Acad Neurol 2019;22:170-4  Back to cited text no. 3
Mathuranath PS, George A, Ranjith N, Justus S, Kumar MS, Menon R, et al. Incidence of Alzheimer's disease in India: A 10 years follow-up study. Neurol India 2012;60:625-30.  Back to cited text no. 4
[PUBMED]  [Full text]  
Li J, Wu L, Tang Y, Zhou A, Wang F, Xing Y, et al. Differentiation of neuropsychological features between posterior cortical atrophy and early onset Alzheimer's disease. BMC Neurol 2018;18:65.  Back to cited text no. 5
Banerjee S, Samsi K, Petrie CD, Alvir J, Treglia M, Schwam EM, et al. What do we know about quality of life in dementia? A review of the emerging evidence on the predictive and explanatory value of disease specific measures of health related quality of life in people with dementia. Int J Geriatr Psychiatry 2009;24:15-24.  Back to cited text no. 6
Williams BW, Mack W, Henderson VW. Boston naming test in Alzheimer's disease. Neuropsychologia 1989;27:1073-9.  Back to cited text no. 7
Chandra V. Behavioral and psychological signs and symptoms of dementia: Implications for research and treatment. Cross-cultural perspectives: India. Int Psychogeriatr 1996;8 Suppl 3:479-81.  Back to cited text no. 8
Roudier M, Marcie P, Grancher AS, Tzortzis C, Starkstein S, Boller F, et al. Discrimination of facial identity and of emotions in Alzheimer's disease. J Neurol Sci 1998;154:151-8.  Back to cited text no. 9
Sacks O. Face-blind. In: The Mind's Eye. New York: Alfred A. Knopf; 2010. p. 82-110.  Back to cited text no. 10
Salehi M, Reisi M, Ghasisin L. Lexical retrieval or semantic knowledge? Which one causes naming errors in patients with mild and moderate Alzheimer's disease? Dement Geriatr Cogn Dis Extra 2017;7:419-29.  Back to cited text no. 11
Hall K, Lind C, Young JA, Okell E, van Steenbrugge W. Familiar communication partners' facilitation of topic management in conversations with individuals with dementia. Int J Lang Commun Disord 2018;53:564-75.  Back to cited text no. 12


Print this article  Email this article


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Article in PDF (268 KB)
    Citation Manager
    Access Statistics
    Reader Comments
    Email Alert *
    Add to My List *
* Registration required (free)  


 Article Access Statistics
    PDF Downloaded125    
    Comments [Add]    

Recommend this journal