European Journal of Neurology 2007, 14: 632–637 doi:10.1111/j.1468-1331.2007.01797.

Action and object naming in Parkinson’s disease without dementia

M. Cotellia, B. Borronib, R. Manentic, M. Zanettib, A. Arévaloc,d, S. F. Cappac and A. Padovanib
a
IRCCS S. Giovanni di Dio – Fatebenefratelli, Brescia, Italy; bDepartment of Neurology, University of Brescia, Brescia, Italy; cVita Salute
University and San Raffaele Scientific Institute, Milan, Italy; and dCenter for Research in Language, University of California at San Diego,
San Diego, CA, USA

Keywords:
language, naming,
Parkinson’s disease
Received 3 November 2006
Accepted 12 March 2007
The present study aimed to assess the ability in objects and actions naming in Par-
kinson’s disease (PD) patients. Further, we wished to assess the effect of a particular
conceptual dimension, i.e. manipulability, on the naming of object and actions.
Patients were recruited from the Department of Neurology, University of Brescia.
Thirty-two were diagnosed as PD, according to published criteria, and 15 healthy
volunteers matched in age and education to patientsÕ sample. All patients underwent a
detailed clinical and neurological evaluation. The stimuli used in the action–object
picture naming task were taken from the Center for Research in Language-Interna-
tional Picture Naming Project corpus. To assess the effect of manipulability (or the
involvement of fine hand movements) the noun–verb stimuli were re-categorized into
manipulable and non-manipulable items (i.e. objects which can or cannot be mani-
pulated and actions which do or do not involve fine hand movements). Patients
showed a deficit both in action and object naming, compared with controls. In
addition, patients with PD but not controls were significantly more impaired in action
than in object naming. The current study supports the view that action naming is
affected in patients with PD, possibly reflecting the presence of prefrontal dysfunction.

result, a functional MRI study showed that left pre-

Introduction
The prevalence, natural history and pathophysiological
mechanisms of cognitive dysfunction in Parkinson’s
disease (PD) are complex issues. Some studies indicate
that non-demented patients at an early stage of PD
already show atrophy in the hippocampus and in the
prefrontal cortex [1–4]. As it is known that patients at
an early stage of PD can show impaired executive
functions and memory abilities, a magnetic resonance
imaging (MRI) study suggested that in these patients
left hippocampal atrophy is related to impaired mem-
ory and prefrontal atrophy is associated with impaired
vigilance [5].
The neurological correlates of action naming
impairment may also be relevant for the interpretation
of the responsible cognitive mechanisms. Several pa-
tient studies highlighted the involvement of different
cerebral areas during noun and verb processing,
suggesting that left prefrontal cortex is involved in verb
processing whilst left temporal lobe is crucial for noun
processing [6]. A recent PET study underlined that the
production of verbs activated a left frontal network
whilst the production of nouns activated a greater
temporal lobe activation [7]. In agreement with this
Correspondence: Maria Cotelli, IRCCS S. Giovanni di Dio –
Fatebenefratelli, Via Piastroni, 4 Brescia, Italy (tel.: +39 0303501593;
fax: +39 0303501513; e-mail: mcotelli@fatebenefratelli.it).
frontal cortex and left parietal lobule are selectively
activated during verb production, whilst left inferior
temporal lobe is involved in noun production [8].
Moreover using repetitive transcranial magnetic
stimulation, Shapiro et al. [9] proved that left prefrontal
cortex is selectively engaged in the production of verbs,
whilst Cappa et al. [10] underlined the selective
relevance of left prefrontal cortex in action naming.
In the degenerative spectrum there are some
evidences that action and object naming is impaired in
frontal pathologies such as fronto-temporal dementia
[11] and the dissociation between action (more
impaired) and object naming performances seems to
be greater in fronto-temporal dementia than in
Alzheimer’s patients [12]. Our previous study showed
the usefulness of the investigation of action naming
abilities in distinguishing fronto-temporal dementia
from Alzheimer’s dementia and also in differentiating
the numerous clinical variants that belong to fronto-
temporal dementia [11].
The simple possibility that tasks involving verbs are
more ÔdifficultÕ than task involving nouns seems to be
refuted by the observation of a double dissociation, as
well as by the lack of correlation with the severity of
language impairment or of dementia. Other hypotheses
include the possible relationship of verb processing
impairments with grammatical disorders, typically
associated with frontal damage [13]; a link with

632  2007 EFNS


executive dysfunction [14]; and the relationship between
verbs and action content [15,16].
The aim of the present study was to systematically
investigate action and object naming in a sample of
patients with a clinical diagnosis of PD [17]. Further-
more, a study on non-demented PD patients showed
that these patients were more impaired in verb
generation tasks than in noun generation tasks. In the
same study, the authors showed a negative correlation
between error rate in verb generation task and the
performance in the memory subtest of the Dementia
Rating Scale [18]. PD disease affects prefrontal areas, as
well as other cortical and subcortical structures in-
volved in action organization and motor control: the
presence of a verb deficit would support theories which
predicate a relationship between action representation
and verb processing [19,20].
Given that both phonemic and semantic fluency are
impaired in PD patients [17], there is the possibility that
the difficulty of the task may have differentially affected
noun and verb generation. The present study investi-
gates action and object naming abilities in PD patients.
In particular, the prediction was a greater impairment
of action naming compared with object naming in the
case of non-demented PD.
The role of specific semantic factors in action naming
has not been frequently investigated. We thus tested the
impact of a semantic variable, i.e. manipulation, on
naming performance by re-categorizing the action
stimuli into stimuli which do or do not involve fine
hand movements.
Finally, we investigated the relationship between
naming performance and other cognitive functions.
Methods
Subjects
Thirty-two PD patients were recruited from the Center
for Movement Disorders, Department of Neurology,
University of Brescia. Clinical diagnoses were estab-
lished by experienced neurologists on the basis of aki-
nesia associated with one of the other two cardinal signs
(tremor, rigidity) and responsiveness to levodopa ther-
apy. All patients fulfilled the UK Parkinson’s Disease
Brain Bank criteria for the diagnosis of idiopathic PD
[21].
All patients underwent a detailed clinical and neu-
rological evaluation. A structural brain imaging study
was performed in each patient.
The motor disability was evaluated using the motor
examination section of the Unified Parkinson’s Dis-
ease Rating Scale (UPDRS-III) [22] and using Hoehn
and Yahr Scale (mean 1.66). Patients who had end-of-
 2007 EFNS European Journal of Neurology 14, 632–637
Naming in PD 633
dose motor fluctuations were always tested in the on
phase.
Patients with potentially confounding neurological
and psychiatric disorders, clinically known hearing or
vision impairment, a past history of alcohol abuse,
psychosis, or major depression, were excluded. Patients
with clinical presentations suggestive of progressive
supranuclear palsy (PSP), multiple systemic atrophy or
vascular Parkinsonism were also excluded. The use of
medication that could interfere with test performance
or diagnosis was considered as a further exclusion cri-
terion. The use of psychopharmacological agents that
could interfere with test performance (antipsychotics,
benzodiazepines) was considered as a further exclusion
criterion. Only patients without dementia were included
in the study (Clinical Dementia Rating ¼ 0).
The study also included a control group of 15 healthy
volunteers, matched in age and education to our patient
sample. All healthy volunteers performed a clinical and
neurological examination, and the same patientsÕ
exclusion criteria were considered.
All participants were made fully aware about the
aims of the research and the signature of an informed
consent was sought from all subjects. The work was
conducted in accordance with local clinical research
regulations and conformed to the Helsinki
Declaration.
Neuropsychological assessment
Baseline cognitive assessment included screening tests
for global cognitive decline [Mini-Mental State Exam-
ination (MMSE)], tests of non-verbal reasoning (Ra-
ven’s Colored Matrices), verbal fluency with phonemic
and semantic cues, memory for prose (logical memory),
constructional abilities and visuo spatial recall (Rey’s
Complex figure), and attention and executive function
(Trail Making A and B) [22].
Experimental evaluation: action–object naming
The stimuli used in the action–object picture naming
(PN) task were taken from the Center for Research in
Language-International Picture Naming Project corpus
CRL-IPNP [23], which contains 795 black and white 2-
D line drawings representing actions and objects. These
items have been tested and normed in healthy and pa-
tient populations across seven different international
sites and languages. Items are coded for a number of
variables known to influence naming difficulty.
Amongst others, these are initial word frequency, age of
acquisition, and picture imageability scores, which were
tested to see whether they significantly influenced par-
ticipantsÕ naming performance.
634 M. Cotelli et al.

For this particular set of patients we used a subset of
120 items from the original corpus. These were 60 ac-
tions and 60 objects, with half (30) of the items in each
category being ÔeasyÕ and half ÔdifficultÕ. The difficulty
was defined on the basis of native Italian participantsÕ
reaction times (RTs) in previous norming studies, using
the Italian-language adaptation of the stimuli. A subset
of these items were then assigned to difficulty bins,
where all items with mean RTs of at least 2 standard
deviations above the grand mean classed as ÔdifficultÕ,
and items with RTs at least 2 standard deviations below
the mean classed as ÔeasyÕ. All the selected stimuli were
high-imagery items.
The nouns and verbs corresponding to the set of
objects and actions were matched for word frequency
and word length [24]. The items were presented to each
participant in three pre-randomized orders. Each par-
ticipant (patients and controls) was asked to orally
name each test stimulus as it was presented.
In order to test the impact of manipulability on the
processing of nouns and verbs we re-categorized the
action stimuli into actions which do or do not involve
fine hand movements, using an objective categorization
method, based on the assessment of the gestural re-
sponses produced by a sample of normal subjects pre-
sented with the written actions [25]. For example,
actions that involve fine hand movements are Ôto
squeezeÕ or Ôto cutÕ, whilst an action that does not in-
volve fine hand movements is Ôto flyÕ (see Fig. 1). For
this further categorization participants were asked to
read the target words for the same noun–verb stimuli
and produce Ôthe first posture, movement or expressionÕ
that came to their mind when thinking about the item.
Videotaped gestures were then coded according to a
complex rating system based on the apraxia literature.
An item was considered as ÔmanipulableÕ if at least 70%
of participants who gestured to it produced obvious
fine-grained movements of the fingers (especially in a
grasping motion); all other items were classified as Ônon-
manipulableÕ. In addition, any item which also elicited
significant involvement of other major body parts (i.e.
mouth, foot and whole body) was excluded from sub-
sequent analyses, in order to avoid any obvious con-
founds [26]. Of 60 action items, 28 were classified as
Ômanipulation actionsÕ and 11 as Ônon-manipulation
actionsÕ. The patientsÕ performance was re-analyzed
after re-categorization of the action items according to
this classification.
Statistical analysis
Demographic and clinical data between patients and
controls were compared using Mann–Whitney U-test or
chi-square test. Scores were compared using analyses of
variance (ANOVA) and post-hoc planned comparisons.
Non-parametric correlation analyses were used to as-
sess between significantly impaired scores. All values
are expressed as mean ± standard deviation. The sig-
nificant level was set at P < 0.05. Analyses were con-
ducted using a statistical software (SPSS Inc., Chicago,
IL, USA).
Results
Confrontation Naming
Thirty-two PD patients and 15 controls entered the
study. Demographic and clinical characteristics are
shown in Table 1.
No differences in MMSE [26] scores between PD
patients and controls was found.
In regard to normative data, approximately one-third
(28%) of the patients showed an impairment of visuo-
spatial recall (Rey Recall), whereas one-half (56%) of
the patients showed an impairment of constructional
abilities (Rey Copy). Furthermore, one-third (31%) of
the patients showed an impaired verbal long-term
memory (Story Recall), and one-fourth (25%) showed
an impairment of attentional resources (Trail Making
section A). The incidence of more pronounced neuro-
psychological impairment as measured by abnormal

Table 1 Demographic and clinical data in patients with Parkinson’s

disease (PD) and controls

Variable PD Controls P value

Number 32 15 –
Age, years 69.59 ± 7.4 63.4 ± 3.7 n.s.
Gender, female % 43% 42% n.s.
Education, years 7.06 ± 3.5 8.6 ± 2.1 n.s.
Age at onset, years 63.9 ± 9 – –
UPDRS-III 18.4 ± 14 0 0.0001
MMSE 27.5 ± 2.2 28.5 ± 0.9 n.s.

MMSE, Mini-Mental State Examination; UPDRS-III, Unified

Figure 1 Examples of manipulable and non-manipulable actions. Parkinson Disease Rating Scale.

 2007 EFNS European Journal of Neurology 14, 632–637

 Naming in PD 635

Objects Table 2 Parkinson’s disease patientsÕ performance on a general

Actions standard neuropsychological assessment
100 *
Mean SD Cut-off
90
Non-verbal reasoning
80 CPM Raven [22] 21.7 5.1 18
70 Language
Controlled association letters test [22] 24.7 10 17
60 Controlled association categories test [22] 30.1 7.3 25
Memory
50 Story recall [22] 7.17 3.2 8
Rey recall figure [36] 10.1 7.4 9.47
40
PD C Constructional abilities
Rey copy figure [36] 23.4 7.1 28.88a
Figure 2 Mean scores for oral action and object naming in each Attentional and executive functions
group. PD: Parkinson’s disease, C: control subjects. Results are Trailtest A [22] 63.5 46 93
expressed as mean of percentage of correct responses. *Action– Trail making test B [22] 145.6 89 282
object naming, P < 0.05. Trail making test B ) A [22] 94.9 50 186
a
Score below cut-off.
performance in more than two tests was of three
patients (Table 2). (a) 40 Visuo spatial long term memory
In order to compare PD patients and normal con- 35
trolsÕ performances, a 2 (PD versus controls) · 2 (ob- 30
Raw scores

ject versus action) ANOVA was performed. This analysis 25

showed a significant effect of kind of stimulus 20
[F(1,45) ¼ 36.104, P < 0.001]; group [F(1,45) ¼ 15
512.654, P < 0.001] and interaction [F(1,45) ¼ 41.763, 10
P < 0.001]. Planned comparisons underlined that PD 5
patients showed a deficit both in action and object 0
naming, compared with controls (object naming: 0 10 20 30 40 50 60

P < 0.001; action naming:, P < 0.001). In addition, Dissociation

patients with PD but not controls were significantly (b) 18 Verbal long term memory
more impaired in action naming than in object naming 16

(objects mean ¼ 89.69 ± 10.07 versus actions mean ¼ 14

Raw scores

65.26 ± 21.47; P < 0.001). Means scores on oral 12

naming of nouns and verbs are reported in Fig. 2. 10

8
The effect of manipulation was analyzed, comparing
6
errors in the naming of manipulation and non-mani-
4
pulation action stimuli (action that do or do not involve
2
fine hand movements). We performed a repeated
0
measure ANOVA with Manipulability as within-subject 0 10 20 30 40 50 60
factor and Group (PD, control subjects) as between- Dissociation
subject factor. The main effects and interaction were
not significant. Figure 3 Correlation between dissociation of action/object nam-
ing and cognitive and neuropsychological scores. (a) Visuo-spatial
In particular, the difference between manipulable
recall, R2 ¼ 0.25; (b) verbal memory, R2 ¼ 0.22.
actions score and non-manipulable actions score was
not significant for PD subjects (manipulation mean ¼
20.9 ± 14.5 versus non-manipulation mean ¼ significant correlation between dissociation scores and
24.1 ± 19.9). These data indicate that the Ômanipula- visual spatial recall task (R ¼ )0.470, P < 0.009) and
tionÕ factor does not influence picture naming in PD memory for prose (R ¼ )0.438, P < 0.013) (see
patients. Fig. 3).
Finally, the correlation between dissociation scores in
action and object naming and neuropsychological tests
Discussion
was further analyzed.
A regression analysis controlling for age and MMSE The present findings provide additional evidence that
was performed. Regression models demonstrated a verb processing is impaired in PD, using a confrontation

 2007 EFNS European Journal of Neurology 14, 632–637

636 M. Cotelli et al.
naming task rather than verbal fluency [18,27]. Non-
demented PD patients were significantly more impaired
in action naming than control subjects. We found a
significant discrepancy between actions and objects
naming in these patients, but not in control subjects.
The severe impairment in verb retrieval in PD
patients could be the consequence of dopamine deple-
tion in the striatum, disrupting the function of sub-
cortical prefrontal networks [28]. Both lesion and
imaging studies have supported the hypothesis of a
central role of the left prefrontal and parietal areas in
verb processing [29]. In particular, Perani et al. [30]
using a lexical decision task found that some left hem-
ispheric areas, including the dorsolateral frontal and
lateral temporal cortex, were activated only by verbs,
whilst there were no brain areas more active in response
to nouns. More recently, using event-related MRI,
Shapiro et al. [8] found verb-specific responses in the
left prefrontal and parietal areas, whilst noun-specific
activations involved the inferior temporal lobe. The
present finding supports the hypothesis of a central role
played by prefrontal cortex in action naming. The
underlying mechanisms are open to different interpre-
tations. In the first place, it must be pointed out that a
significant positive correlation was present between the
action naming deficit (and the degree of action–object
naming dissociation) and visual and verbal long-term
memory impairment, i.e. with the classical features of
PD neuropsychological impairment. Action naming
may be more demanding than object naming in terms of
cognitive resources: when presented with a picture, the
naming of the object may be a more automatic response
than the retrieval of the action name. It cannot thus be
excluded that the action naming disorder is a conse-
quence of initial executive impairment [31,32]. In
alternative, the defective retrieval of verbs may indicate
the presence of a specific language dysfunction. Action
naming deficit in our patients does not seem to reflect
impaired general linguistic abilities. As a matter of fact
our patients showed normal scores in verbal fluency
tasks. A similar naming deficit is present in other
movement disorders, such as corticobasal degeneration
(CBD) and PSP [11]. An action naming disorder in PSP
had originally been reported by Daniele et al. [29]; re-
cently, Bak et al. [33] reported a familiar disorder
resembling PSP which was characterized by an hered-
itary selective verb deficit. The finding of a severe verb
deficit in two conditions which are clinically charac-
terized by a prominent movement disorder, rather than
by language dysfunction, cannot but open the discus-
sion about the relationships between action language
and action representation [16,34]. Our previous report
[11] described a particularly severe impairment in the
naming of manipulation actions in the case of CBD, but
not of PSP, providing a further element supporting the
relationship between naming and action. Moreover,
Soliveri et al. [35] reported that, whilst both CBD and
PSP patients are impaired on apraxia tests, the qualit-
ative features of errors were different, with more severe
impairment of simple limb movement in CBD. It is
remarkable that a similar manipulation effect was
found in AD, in which limb apraxia can also be
observed. However, we failed to observe a manipula-
tion effect in the case of PD. It is noteworthy that PD
patients are not clinically characterized by an impair-
ment of simple limb movement. Imaging studies may
provide further insights about the relationship amongst
the location of prevalent cortical involvement, the
pattern of lexical impairment and the specific feature of
high-order motor dysfunction in these conditions.
Disclosure
The authors have reported no conflicts of interest.
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