Brain and Language 94 (2005) 5460

www.elsevier.com/locate/b&l
0093-934X/$ - see front matter 2004 Elsevier Inc. All rights reserved.
doi:10.1016/j.bandl.2004.11.007
Fluent versus nonXuent primary progressive aphasia: A comparison
of clinical and functional neuroimaging features
David Glenn Clark
a,
, Anthony Charuvastra
b
, Bruce L. Miller
c
,
Jill S. Shapira
a
, Mario F. Mendez
a,b
a
David GeVen School of Medicine, Department of Neurology, University of California-Los Angeles, VA Greater Los Angeles Healthcare System,
11301 Wilshire Blvd., 3-South Neurobehavior Unit (116AF), Los Angeles, CA 90073, USA
b
David GeVen School of Medicine, Department of Psychiatry and Biobehavioral Sciences, University of California-Los Angeles, USA
c
UCSF Memory and Aging Center, University of California-San Francisco, USA
Accepted 15 November 2004
Available online 7 January 2005
Abstract
To better characterize Xuent and nonXuent variants of primary progressive aphasia (PPA). Although investigators have recog-
nized both Xuent and nonXuent patients with PPA (Mesulam, 2001), the clinical and neuroimaging features of these variants have
not been fully deWned. We present clinical and neuropsychological data on 47 PPA patients comparing the Xuent (n D21) and nonXu-
ent (n D26) subjects. We further compared language features with PET/SPECT data available on 39 of these patients. Compared to
the nonXuent PPA patients, those with Xuent PPA had greater impairment of confrontational naming and loss of single word com-
prehension. They also exhibited semantic paraphasic errors and loss of single word comprehension. Patients with nonXuent PPA
were more likely to be female, were more often dysarthric, and exhibited phonological speech errors in the absence of semantic
errors. No signiWcant diVerences were seen with regard to left hemisphere abnormalities, suggesting that both variants result from
mechanisms that overlap frontal, temporal, and parietal regions. Of the language measures, only semantic paraphasias were strongly
localized, in this case to the left temporal lobe. Fluent and nonXuent forms of PPA are clinically distinguishable by letter Xuency, sin-
gle word comprehension, object naming, and types of paraphasic errors. Nevertheless, there is a large amount of overlap between
dysfunctional anatomic regions associated with these syndromes.
2004 Elsevier Inc. All rights reserved.
Keywords: Aphasia; Primary progressive aphasia; PET; SPECT; Functional imaging; Dementia; Frontotemporal dementia; Semantic dementia;
Fluency
1. Introduction
In 1982, Mesulam introduced the term primary pro-
gressive aphasia (PPA) for a series of patients with lan-
guage impairment that began insidiously and progressed
gradually (Mesulam, 1982). Patients with PPA have iso-
lated language impairment for at least two years before
progressing to a dementia. Mesulam and others have
since developed criteria for the clinical diagnosis of PPA
(Table 1) (Mesulam, 2001; Neary, Snowden, Gustafson,
& Passant, 1998). The criteria proposed by Mesulam do
not emphasize the distinction between Xuency and non-
Xuency, since most patients eventually progress to non-
Xuency and mutism (Kertesz, Davidson, McCabe,
Takagi, & Munoz, 2003; Mesulam, 2001). Criteria pro-
posed by Neary et al. (1998), however, emphasize Xuency
as one of several key features that distinguish two dis-
tinct forms of progressive aphasia: progressive nonXuent
aphasia (PNFA) and semantic dementia (SD). It is
*
Corresponding author. Fax: +1 310 268 4181.
E-mail address: dgclark@mednet.ucla.edu (D.G. Clark).
D.G. Clark et al. / Brain and Language 94 (2005) 5460 55
unclear whether the Xuent and nonXuent forms of PPA
are distinct clinical syndromes, similar to Brocas apha-
sia and Wernickes aphasia.
PNFA resembles descriptions of Brocas aphasia
from left inferior frontal lesions. It is deWned as an insid-
ious and progressive language abnormality with reduced
phrase length, agrammatism or eVortful, and halting
speech. Studies of structural and functional imaging in
PNFA have suggested involvement of the left inferior
frontal region (Abe, Ukita, & Yanagihara, 1997; Rosen
et al., 2002b). Similar to stroke patients with nonXuent
aphasia (Bates et al., 2003; Dronkers, 1996), patients
with PNFA have atrophy (Gorno-Tempini et al., 2004)
and reduced metabolic activity in the anterior insula
(Nestor et al., 2003).
According to clinical descriptions, SD resembles Wer-
nickes aphasia in that it is associated with normal
Xuency, comprehension deWcits, and left temporal lobe
lesions (Edwards-Lee et al., 1997; Hodges, Patterson,
Oxbury, & Funnell, 1992; Hodges & Miller, 2001; Lam-
bon Ralph, McClelland, Patterson, Galton, & Hodges,
2001). As the disease progresses, patients often suVer a
breakdown of semantic knowledge that usually mani-
fests as loss of single word comprehension. Patients with
SD have a predominance of left temporal lobe atrophy
on neuroimaging (Garrard & Hodges, 2000; Gorno-
Tempini et al., 2004; Mummery et al., 2000; Rosen et al.,
2002a). The importance of the temporal lobe for lexical
and semantic knowledge is well-supported by other
lesion studies (Damasio et al., 1996; Tranel, Damasio, &
Damasio, 1997; Warrington & Shallice, 1984).
There are limitations in the analogy between these
two types of progressive aphasia and the classic syn-
dromes of Brocas and Wernickes aphasia. Some
patients do not clearly have PNFA or SD. A recent
study suggests that many PPA patients have a logope-
nic progressive aphasia (LPA) (Gorno-Tempini et al.,
2004), characterized clinically by spared articulation,
reduced phrase length despite grammatical output, and
impaired syntactic comprehension due to auditory
working memory deWcits. Atrophy in these patients was
located chieXy in the posterior superior temporal and
inferior parietal regions of the dominant hemisphere.
Another recent study found that many PNFA patients
had signiWcant phonological errors and had diYculty
with phrase repetition similar to conduction aphasia
(Mendez, Clark, Shapira, & Cummings, 2003). Further-
more, patients with SD, unlike most Wernickes apha-
sics, have intact comprehension for phrases. Despite
such limitations to this Xuent vs. nonXuent distinction,
it remains a widely used and important dichotomy in the
clinical evaluation of patients.
The aim of this study was to characterize the clinically
salient and diVerential diagnostic features between Xuent
and nonXuent PPA syndromes, and to contrast them
with the typical features of Brocas aphasia and Wer-
nickes aphasia. We were able to identify a large number
of patients with PPA. We Wrst compared the demo-
graphic, general cognitive and language functioning of
Xuent and nonXuent PPA patients. We then compared
Wndings on functional imaging between these two
groups as well as relationships between linguistic and
neuroimaging variables.
2. Subjects and methods
2.1. Subjects
Forty-seven patients from the UCLA Focal-Type
Dementia Clinic and the VA Greater Los Angeles Neu-
robehavior Clinics were identiWed as having PPA
according to criteria proposed by Mesulam (2001).
Experienced behavioral neurologists conducted assess-
ments on these patients and made the diagnosis of PPA.
All patients had the insidious onset and gradual pro-
gression of diYculty with word Wnding, object naming
or word comprehension manifesting during spontane-
ous conversation. These patients exhibited preservation
of cognition in other domains on history and neuropsy-
chological assessment. They underwent an extensive
diagnostic assessment including baseline Mini-Mental
State Examination (MMSE) (Folstein, Folstein, &
McHugh, 1975), neuropsychological testing from the
Consortium to Establish a Registry for Alzheimers
Disease (CERAD), neurological examinations, mag-
netic resonance imaging (MRI), and either single pho-
ton emission tomography (SPECT) or positron
emission tomography (PET). Patients were divided into
Table 1
Diagnostic criteria for primary progressive aphasia (Mesulam, 2001)
Insidious onset and gradual progression of word Wnding, object-
naming, or word-comprehension impairments as manifested during
spontaneous conversation or as assessed through formal
neuropsychological tests of language
All limitation of daily living activities attributable to the language
impairment, for at least 2 years after onset
Intact premorbid language function (except for developmental
dyslexia)
Absence of signiWcant apathy, disinhibition, forgetfulness for recent
events, visuospatial impairment, visual recognition deWcits or
sensory-motor dysfunction within the initial 2 years of the illness
(This criterion can be fulWlled by history, survey of daily living
activities or formal neuropsychological testing.)
Acalculia and ideomotor apraxia may be present even in the Wrst 2
years (Mild constructional deWcits and perseveration (as assessed in
the go no-go task) are also acceptable as long as neither visuospatial
deWcits nor disinhibition inXuences daily living activities.)
Other domains possibly aVected after the Wrst 2 years but with
language remaining the most impaired function throughout the
course of the illness and deteriorating faster than other aVected
domains
Absence of speciWc causes such as stroke or tumor as ascertained by
neuroimaging
56 D.G. Clark et al. / Brain and Language 94 (2005) 5460
Xuent and nonXuent groups and compared on language
measures.
Fluency was deWned as ease of word production. For
purposes of this study, behavioral neurologists classiWed
the patients as nonXuent or Xuent based on the presence
or absence of reduced phrase length (Wve words or less),
and eVortful, halting speech. Twenty-six patients were
identiWed as nonXuent and 21 as Xuent.
2.2. Methods
A language examination was undertaken consisting
of: (1) Assessment of a speech sample (obtained during
clinical interview for all subjects) for eVortful speech (hes-
itation and delay in word production), changes in articu-
lation and prosody, and the presence of reiterative speech
changes; (2) a test of phonemic repetition (pa-ta-ka) to
assess for apraxia of speech; (3) assessment of a language
sample for phrase length, agrammatism and paraphasic
errors; (4) verbal Xuency measures including categories
(animals/min) and letters (F words/min); (5) confronta-
tional naming on the mini-Boston Naming Test (BNT)
(Kaplan, Goodglass, & Weintraub, 1983); (6) assessment
of repetition on a series of utterances that ranged from
very simple (This is it) to very diYcult (No ifs ands or
buts); and (7) assessment of auditory comprehension on
a series of yesno questions and pointing commands.
Scoring methods used for the quantitative assessments of
language in dementia have been described elsewhere
(Cummings, Darkins, Mendez, Hill, & Benson, 1988;
Mendez et al., 2003). Scores on the Boston Naming Test
reXect the performance of the patient without cueing and
prior to any attempts at self-correction.
The analysis of functional imaging included scans
from 17 of the 21 Xuent patients and 22 of the 26 nonXu-
ent patients. Of the functional scans on the Xuent
patients, six were PET and 11 were SPECT. Among the
nonXuent patients eleven scans were of each type. The
nuclear medicine specialists reading the scans were
blinded to the patients diagnoses. Disturbances in
metabolism or perfusion were rated by predominant lat-
erality and lobe involved, i.e., left frontal, right frontal,
left temporal, and right temporal.
Data were analyzed using the Students t test or two-
way factorial ANOVA for continuous measurements
and
2
for categorical variables.
3. Results
Except for gender, the groups were equivalent on
demographic variables, including age of onset, duration
at the time of testing, handedness, level of education, and
MMSE score (see Table 2). The Xuent group was dispro-
portionately male and the nonXuent group was dispro-
portionately female (
2
D4.56; p <.05).
The two groups diVered in frequency of dysarthria,
confrontational naming diYculty, and single word com-
prehension (see Table 3). The nonXuent patients had
more dysarthria than the Xuent patients (77.8% vs. 9.5%;

2
D18.7; p <.001). In contrast, the Xuent patients were
more impaired on the Wfteen-item BNT (Students t test;
p <.05) and on single-word comprehension (10/18 Xuent
subjects and 1/22 nonXuent subjects;
2
D12.9; p <.01).
The nonXuent group was impaired in both repetition
(76.2%) and phrase comprehension (72%), but both of
these Wndings were common in the group of Xuent
patients, with 61.1% exhibiting repetition deWcits and
76.2% exhibiting comprehension deWcits. Expressive
agrammatism was not a common Wnding among the
nonXuent patients (3/26, 11.5%).
The two groups diVered on letter Xuency, but not on
category Xuency. Letter Xuency was more impaired in the
nonXuent group (Students t test; p<.01) than in the
Xuent group. A post hoc analysis of performance on these
two measures revealed no diVerence in z-scores for the
two tests among the Xuent patients. NonXuent patients,
however, performed signiWcantly worse on letter Xuency
(Students t test; p<.05) than on category Xuency.
Table 2
Demographic and general cognitive data on Xuent and nonXuent
groups
a
DiVerence between proportions is signiWcant (p <.05).
Fluent (ND21) NonXuent (ND26)
Age of onset 62.2 (8.9) 64.8 (7.8)
Duration at test 3.4 (1.7) 3.68 (2.1)
Sex (M:F)
a
13:8 8:18
% Right handed 88.9 91.3
Level of education 15.1 (2.7) 14.2 (2.1)
MMSE score 21.7 (8.4) 22.4 (8.1)
Table 3
Clinical and neuropsychological data from Xuent and nonXuent
groups
*
DiVerence between proportions is signiWcant (p <.01).
**
DiVerence between proportions is signiWcant (p 6.001).
9
DiVerence between means is signiWcant (p <.01).
99
DiVerence between means is signiWcant (p <.05).

DiVerence between mean animal score and mean letter Xuency

score is signiWcant (p <.01) within the subset of nonXuent patients that
underwent both tests.
Fluent NonXuent
BNT-15
99
6.6 (4.6) 10.4 (5.5)
Semantic anomia
**
10/18 (55.6%) 1/22 (4.5%)
Semantic paraph.
*
12/16 (75%) 4/16 (25%)
Phonemic paraph.
**
11/17 (64.7%) 17/18 (94.4%)
Only phonemic paraph.
**
2/16 (12.5%) 11/16 (68.8%)
Repetition 11/18 (61.1%) 16/21 (76.2%)
Comprehension 17/21 (81%) 18/25 (72%)
Dysarthria
**
2/21 (9.5%) 14/18 (77.8%)
Animal Xuency 8.1 (5.8) 9.7 (6.4)
Letter Xuency
9
9.1 (5.9) 3.6 (2.7)

D.G. Clark et al. / Brain and Language 94 (2005) 5460 57

The two groups exhibited diVerent patterns of speech
error production. Semantic paraphasic errors were more
common in the Xuent group (12/16 subjects) than in the
nonXuent group (4/16 subjects) (
2
D8.00; p <.05) and
phonological errors were more common in the nonXuent
group (94.4% vs. 64.7%) (
2
D13.6; p D.001). The
patients in the Xuent group nearly always produced a
mixture of both types (87.5% of patients), whereas the
nonXuent group more often produced exclusively phone-
mic errors (68.8% of patients) (
2
D17.3; p <.001).
A comparison of Wndings on PET or SPECT scans
revealed predominant hypoperfusion or hypometabo-
lism in the left hemisphere in both groups of patients
(
2
D7.92; p <.05) (see Table 4). Although in some cases
abnormalities were restricted to the left hemisphere, in
no case were they restricted to the right hemisphere, and
whenever a lobe of the right hemisphere was involved,
the corresponding lobe of the left hemisphere was also
involved. The proportion of patients with left frontal
Wndings was slightly higher in the nonXuent group than
in the Xuent group, and the proportion of patients with
left temporal Wndings was slightly higher in the Xuent
group than in the nonXuent group, however, these diVer-
ences did not reach statistical signiWcance.
Except for semantic paraphasias, the language vari-
ables did not correlate with frontal or temporal localiza-
tion on functional neuroimaging. Considering the entire
cohort of 39 patients with available neuroimaging data,
semantic paraphasic errors were associated with abnor-
malities of the left temporal lobe on functional imaging
(
2
D8.4; df D3; p <.05). Phonological errors were not
associated with abnormalities in a speciWc region. No
signiWcant associations were found between abnormali-
ties on functional imaging and dysarthria, Xuency, pho-
nological errors, phrase comprehension, or the mini-
BNT.
4. Discussion
This study identiWed distinct diVerences between non-
Xuent and Xuent groups. The nonXuent patients were
more likely than the Xuent patients to be women, to have
impaired initial letter Xuency, and to be dysarthric. The
Xuent patients, on the other hand, had worse confronta-
tional naming and single word comprehension. The two
groups exhibited diVerent patterns of paraphasic error
production and performed diVerently on verbal Xuency
measures.
Although males are more likely than females to
develop progressive aphasia (Westbury & Bub, 1997),
females signiWcantly outnumbered males in our nonXu-
ent group. This diVerence may be due to the presence of
AD. Patients with the syndrome of logopenic progres-
sive aphasia (LPA) were classiWed as nonXuent in this
study. LPA patients have an increased proportion of apo
4 alleles and exhibit atrophy in the left superior tempo-
ral and parietal regions (Gorno-Tempini et al., 2004).
These Wndings may indicate that AD is the underlying
cause of progressive aphasia in many LPA patients, as
AD is implicated in 1620% of autopsied cases of PPA
(Mesulam, 2001; Turner, Kenyon, Trojanowski, Gona-
tos, & Grossman, 1996). Since the tendency for AD to
aVect women preferentially is well established, this may
explain the increased number of women as opposed to
men with nonXuent PPA (Pace-Savitsky et al., 2004).
Histopathological evidence of AD, however, has been
associated with both Xuent and nonXuent forms of PPA
(Clark, Mendez, Farag, & Vinters, 2003; Galton, Patter-
son, Xuereb, & Hodges, 2000; Greene, Patterson,
Xuereb, & Hodges, 1996).
Patients with nonXuent PPA develop dysarthria,
impaired letter Xuency and a high proportion of phono-
logical errors more commonly than patients with Xuent
PPA. Dysarthria and impaired letter Xuency would be
consistent with a left frontal nonXuent syndrome. Non-
Xuent patients perform abnormally on both initial letter
and category verbal Xuency tasks, but performance is sig-
niWcantly worse with initial letter Xuency. In addition,
they have a greater tendency to produce phonological
errors than Xuent patients, and they commonly produce
exclusively phonemic errors. Although most of the non-
Xuent PPA patients had evidence of a left frontal ori-
gin for their clinical presentation, an abundance of
phonemic paraphasic errors could indicate involvement
of the superior temporal gyrus (Hickok, 2001; Hickok &
Poeppel, 2004; Kreisler et al., 2000). The occurrence of
damage to temporal-lobe lexical-semantic networks can-
not be excluded, however, the pattern of performance on
Xuency tests (i.e., letter worse than category Xuency) sug-
gests greater frontal dysfunction (Kitabayashi, Ueda,
Tsuchida, & Iizumi, 2001; Mummery, Patterson, Hodges,
& Wise, 1996). Further psycholinguistic assessments of
comprehension in this group will be necessary to deter-
mine whether the comprehension diYculties arise from
disruption of acousticphonetic processing, short-term
auditory memory, or the phonological input lexicon.
NonXuent PPA diVers from descriptions of classic
Brocas aphasia. Although agrammatism is considered a
Table 4
Abnormalities on functional imaging, by brain region
a
No signiWcant diVerence between groups in any region.
Fluent
a
NonXuent
a
Left cortical 14/17 (82.45%) 19/22 (86.4%)
Left frontal 8/17 (47.1%) 12/22 (54.5%)
Left temporal 11/17 (64.7%) 13/22 (59.1%)
Left parietal 10/17 (58.8%) 14/22 (63.6%)
Right cortical 8/17 (47.1%) 13/22 (59.1%)
Right frontal 6/17 (35.3%) 8/22 (36.4%)
Right temporal 4/17 (23.5%) 8/22 (36.4%)
Right parietal 6/17 (35.3%) 9/22 (40.9%)
58 D.G. Clark et al. / Brain and Language 94 (2005) 5460
common feature of Brocas aphasia, we found little
agrammatism among our nonXuent subjects (3/21,
14.3%). We did not include subjects who exhibited
agrammatic writing in the absence of verbal output, but
this was the case in only three subjects. However, the
number of agrammatic patients in our study population
(3/47, 6.4%) is similar to the number identiWed in another
generous sample of PPA patients, in which only 4/38
(10.5%) were agrammatic (Kertesz et al., 2003). This
raises the question of whether the nonXuency of PPA
results more from articulatory disturbances, such as
apraxia of speech, than does that of Brocas aphasia. In
addition, while patients with Brocas aphasia may
exhibit comprehension deWcits at the phrasal level, the
prevalence of severe comprehension deWcits in our non-
Xuent group sets nonXuent PPA further apart from the
syndrome of classic Brocas. A prospective, blinded com-
parison of these two syndromes will be necessary to
ascertain the validity of these observations.
The Xuent PPA patients performed worse with con-
frontational naming of objects (mini-BNT) than nonXu-
ent PPA patients and exhibited higher proportions of
semantic anomia and semantic paraphasic errors. Taken
together, these three Wndings suggest that the Xuent PPA
syndrome is largely the result of a semantic deWcit.
Impaired performance on object naming has been linked
to lesions of the left temporal lobe (Damasio & Tranel,
1993), and the performance of our Xuent PPA group
coincides with the Wnding of other investigators that
Xuent PPA patients perform worse on object naming
than nonXuent patients (Grossman, 2002; Hillis, Oh, &
Ken, 2004; Mesulam, Grossman, Hillis, Kertesz, &
Weintraub, 2003). In addition, disruption of lexical-
semantic networks in the left temporal lobe would be
consistent with the high frequency of semantic parapha-
sic errors observed among the Xuent PPA patients. Sin-
gle word comprehension could be impaired in these
patients due to a disturbance in any one of several pro-
cesses that are supported by the left temporal lobe,
including acousticphonetic processing, auditory lexical
access, or, most likely, semantic access (Hodges & Miller,
2001; Hodges et al., 1992; Lambon Ralph et al., 2001;
Mummery et al., 2000, 1999).
Fluent PPA resembles characterizations of Wer-
nickes aphasia in several respects. Both are associated
with reduced naming, comprehension and repetition in
the setting of spared Xuency. In addition, both types of
Xuent aphasia are associated with semantic and phone-
mic paraphasic errors. Some Xuent PPA patients, how-
ever, have impaired comprehension at the single word
level and not at the phrase level. Wernickes aphasia
patients often have disturbed comprehension at the
phrase level, but may have impairment at the level of
phonemes or single words. In some cases of Wernickes
aphasia, phonemic paraphasic errors vastly outnumber
semantic errors and result in neologistic, jargon speech
(Hillis, Boatman, Hart, & Gordon, 1999). As with non-
Xuent PPA and Brocas aphasia, a controlled study com-
paring Xuent aphasia to Wernickes would be of value in
more clearly deWning these clinical distinctions.
The functional scans did not clearly distinguish
between patients with nonXuent and Xuent aphasia. This
Wnding suggests a great deal of overlapping damage to
the frontal and temporal lobes. It is possible that some
regions that appeared abnormal appeared so only due to
diaschisis, and not due to actual disease within the
region. Nevertheless, left temporal lobe abnormalities on
the functional scans were associated with the production
of semantic paraphasic errors. This is consistent with the
view that networks supporting lexical-semantic knowl-
edge are located chieXy in the left temporal lobe, and
that disruption of these networks leads to noisy out-
put that ultimately results in semantic paraphasias.
Caselli and Jack (1992) made several interesting
observations regarding progressive aphasia, albeit with a
relatively small sample size. SpeciWcally, females out-
numbered males in their nonXuent group, and they
noted that naming scores were lower in their Xuent
group. Error types diVered between the two groups, with
nonXuent patients generating more phonemic and gra-
phemic errors, and Xuent patients making a combination
of phonemic and semantic errors. Westbury and Bub
(1997) found that functional imaging showed changes
that were restricted to the left hemisphere in 69% of sub-
jects, but bilateral changes in the remaining 31%. Gorno-
Tempini et al. (2004) performed clinical assessments and
MRI scans on 31 subjects with PPA. Voxel-based mor-
phometry of the entire group identiWed atrophy in the
left perisylvian and anterior temporal regions.
There are several limitations of this study. First, it was
a retrospective assessment of measures obtained on
screening language examination. Nevertheless, the
speech and language evaluation was part of a standard-
ized and comprehensive evaluation of patients with
PPA. Second, the functional neuroimaging analysis was
qualitative and not quantitative. This was necessary
since some of the patients had undergone PET imaging
while others had undergone SPECT. These images, how-
ever, were evaluated and coded by physicians blind to
the diagnosis. All variables analyzed were cross-sec-
tional. Thus, this analysis does not take into account
change in Xuency status or any of the variables of inter-
est over time.
In summary, nonXuent and Xuent forms of progres-
sive aphasia are clinically distinct from traditional lan-
guage syndromes and from one another, but generally
overlap on functional imaging. The language character-
istics of nonXuent PPA argue for greater frontal than
temporal involvement. In the case of Xuent PPA, the
clinical Wndings are supportive of left temporal localiza-
tion. Much more research is needed to clarify the Wnd-
ings of this preliminary study.
D.G. Clark et al. / Brain and Language 94 (2005) 5460 59
Acknowledgments
This research was supported in part by the National
Institute on Aging (NIA) Grant AG19724-01A1 and the
state of California. Dr. Clark is supported by the VA
Special Fellowship in Geriatric Neurology.
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