Handwriting Changes in Alzheimer’s Disease: A Systematic Review

Article type: Systematic Review

Authors: Fernandes, Carina Pereira^{a; b; *} | Montalvo, Gemma^{b; c} | Caligiuri, Michael^d | Pertsinakis, Michael^{e; f} | Guimarães, Joana^{g; h; i}

Affiliations: [a] NCForenses Institute, Porto, Portugal | [b] Instituto Universitario de Investigación en Ciencias Policiales (IUICP), Universidad de Alcalá, Alcalá de Henares, Spain | [c] Universidad de Alcalá, Departamento de Química Analítica, Química Física e Ingeniería Química, Alcalá de Henares, Spain | [d] Department of Psychiatry, University of California San Diego, La Jolla, CA, USA | [e] Ingeniería Química, Alcalá de Henares, Spain | [f] City Unity College, Athens, Greece | [g] Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal | [h] Department of Clinical Neurosciences and Mental Health, Faculty of Medicine, University of Porto, Porto, Portugal | [i] MedInUP – Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal

Correspondence: [*] Correspondence to: Carina Fernandes, NCForenses Institute, Rua Pinto Bessa, 522, RC Esq., 4300-428 Porto, Portugal. Tel.: +351 224022684; E-mail: [email protected].

Abstract: Background: Handwriting is a complex process involving fine motor skills, kinesthetic components, and several cognitive domains, often impaired by Alzheimer’s disease (AD). Objective: Provide a systematic review of handwriting changes in AD, highlighting the effects on motor, visuospatial and linguistic features, and to identify new research topics. Methods: A search was conducted on PubMed, Scopus, and Web of Science to identify studies on AD and handwriting. The review followed PRISMA norms and analyzed 91 articles after screening and final selection. Results: Handwriting is impaired at all levels of the motor-cognitive hierarchy in AD, particularly in text, with higher preservation of signatures. Visuospatial and linguistic features were more affected. Established findings for motor features included higher variability in AD signatures, higher in-air/on-surface time ratio and longer duration in text, longer start time/reaction time, and lower fluency. There were conflicting findings for pressure and velocity in motor features, as well as size, legibility, and pen lifts in general features. For linguistic features, findings were contradictory for error patterns, as well as the association between agraphia and severity of cognitive deficits. Conclusions: Further re-evaluation studies are needed to clarify the divergent results on motor, general, and linguistic features. There is also a lack of research on the influence of AD on signatures and the effect of AD variants on handwriting. Such research would have an impact on clinical management (e.g., for early detection and patient follow-up using handwriting tasks), or forensic examination aimed at signatory identification.

Keywords: Agraphia, Alzheimer’s disease, dementia, forensic examination, kinematics, signature

DOI: 10.3233/JAD-230438

Journal: Journal of Alzheimer's Disease, vol. 96, no. 1, pp. 1-11, 2023