Definition/Introduction

Dysgraphia is defined as a difficulty or inability to communicate clearly and correctly through written language. This evaluation requires adjustment to the patient's age and education. Syntax errors, ineligible handwriting, odd spelling, and inaccurate word production are common. Writing is a complex task that requires exquisite coordination of higher levels of complex cognitive domains, including expressive language and fine motor skills.

Issues of Concern

Anatomy

Dysgraphia is usually associated with multiple cortical and subcortical damage in the functional language regions. Multiple bi-hemispheric cortical networks produce written language, including the anterior cingulate, supramarginal, and frontal gyrus. The functional areas include the left supero-frontal sulcus/middle frontal gyrus, the left supero-parietal lobule, the left inferior parietal lobule, the angular gyrus, the primary motor cortex, and the somatosensory cortex. Other associated areas include the right anterior and posterior cerebellum, the left posterior nucleus of the thalamus, the left inferior frontal gyrus, the right superior frontal cortex, the right inferior parietal lobule, the left fusiform gyrus, and the left putamen. Agraphia is a complete impairment when it comes to writing correctly. Different types of agraphia can result from brain damage in multiple cortical and subcortical regions of the central nervous system.[1][2][3][4][5]

Types of Agraphia

• Deep agraphia affects orthographic memory and phonology production, leading to semantic errors. It is associated with left parietal lobe damage.[6][7]
• Peripheral agraphia is the inability to connect letters to form words and full sentences; visual misperception is another manifestation. It can be associated with temporal atrophy and temporal lobe neurodegeneration.[8][9][10]
• Lexical agraphia- inability to spell irregular words.[11][12][13]
• Alexia, with agraphia, cannot read and write, and the patient cannot retrieve orthographic memory. It is attributable to frontal lobe and thalamic damage.[14][15][16][17]
• Phonological agraphia- inability to sound out a word, difficulties with writing abstract thoughts more than concrete thoughts. It appears to be caused by left-hemispheric damage.[18][19][20][21]
• Reiterative or repetitive agraphia-affected individuals tend to repeat letters or words as they write.[18]
• Apraxic or pure agraphia-inability produces written language with preserved reading and speaking. Associated with frontoparietal, frontotemporal, and thalamic structure damage.[22][23][24][25]
• Visuospatial agraphia-inability to organize the letters of a word in a sentence correctly (spacial semantic errors), sometimes can lead to vertical writing or writing that focuses on 1 area of a page. Related to the damage to the right hemisphere (middle cerebral artery territory).[26][27]
• Dysexecutive agraphia- inability to organize planned thoughts in written language. Associated with neurodegenerative disorders (frontotemporal dementia, Parkinson disease) usually involving the frontal lobes.[27][28]
• Musical agraphia- inability to write musical language (disrupting creativity) because of traumatic brain injury.[29][30]
• Other manifestations include Gerstmann syndrome-finger agnosia (inability to recognize fingers), right-left confusion, agraphia, and acalculia (inability to perform simple math operations). It is related to the damage to the dominant left angular gyrus.[31][32][33]

Causes of Agraphia

• Head trauma[34][35][36]
• Metabolic[37]
• Vascular[24][38][39][40][41]
• Malignancy[42]
• Developmental[43][44][45]
• Seizures[46][47][48]
• Infectious[49][50][51][52]
• Inflammatory or autoimmune[53][54][55][56][57]
• Neurodegenerative[58][59][60]
• Motor neuron disease[59][60][61]

Prognosis

Prognosis is mainly dependent on etiology. Dysgraphia may improve with lifelong therapy, but many patients do not regain the ability to write at their original baseline writing ability. When caused by neurodegenerative disorders, it is expected to worsen progressively.

Treatment

• Speech/language therapy and occupational therapy are mandatory
• Treat motor disorders to control writing movements[9][62][63][64]
• Cognitive rehabilitation[65] 

  • Training exercises involved pattern association of ocular visual recognition of serial and synchronous movements of hands and fingers in producing written language
  • Conscious effort to correct deficiencies
• Behavioral change

  • Spend more time writing with pen and pencil as opposed to computer writing (journal diary)[66]
  • Concentrate on the activity
• Deep brain stimulation

  • Parkinson disease with tremors and micrographia

Clinical Significance

Agraphia or dysgraphia, in the context of other neurological symptoms, can be cognitive, motor, or visuospatial. It can be a useful anatomical diagnostic clue to a myriad of neurological disorders. Therefore, it is crucial to understand the definition, types, and potential causes of agraphia. Dysgraphia frequently presents together with other neurological communicative and learning disorders.

Nursing, Allied Health, and Interprofessional Team Interventions

An interprofessional team with an integrated approach to dysgraphia can help achieve the best possible outcomes. A neurologist, neuropsychologist, cognitive neurologist, psychiatrist, psychologist, social worker, occupational therapist, and speech therapist should be consulted to provide the best care and quality of life for a patient with dysgraphia or agraphia and its accompanying neurological symptoms. Collaboration, shared decision-making, and communication are key elements for a good outcome. The interprofessional care provided to the patient must use an integrated care pathway combined with an evidence-based approach to planning and evaluating all joint activities.

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Disclosure: Franklyn Rocha Cabrero declares no relevant financial relationships with ineligible companies.

Disclosure: Orlando De Jesus declares no relevant financial relationships with ineligible companies.