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The Role of Working Memory in Adult Aphasic Reading Comprehension

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30 April 2023

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30 April 2023

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Abstract
(1) Background: Many processes play a key role in how language functions, and these processes are strongly related to reading. The aim of our research was to explore the relationship between reading impairment associated with adult acquired cognitive-linguistic impairment (aphasia) and the components of verbal working memory involved in language functioning. (2) Methods: We measured the reading abilities of a total of twenty-two adults diagnosed with aphasia using the Adult Acquired Reading Assessment. To assess working memory, we applied the measurement procedures available in Hungarian for measuring verbal working memory. Correlation analyses were performed to investigate the relationship between reading and the components of working memory involved in processing verbal information. In order to explore this relationship as comprehensively as possible, the results were analysed quantitatively through group-level analyses and qualitatively through case studies. (3) Results: The results suggest that the functioning of phonological short-term memory and verbal working memory is crucial for the reading of vowels, for certain word reading sub-processes such as reading complex words and pseudowords, and for text comprehension tasks, in particular for the processing of implicit text-level infor-mation. (4) Conclusions: The data support a strong relationship between reading and working memory, but not all mechanisms are related with the same weighting. The data will contribute to the understanding of the relationship between reading and working memory, which is important in order to see which cognitive components are dominant in reading instruction and which other cognitive mechanisms are affected in poor readers.
Keywords: 
Subject: Social Sciences  -   Cognitive Science

1. Introduction

There are many approaches to defining intelligence, but generally it is mainly a general mental ability responsible for problem solving, reasoning and learning functions. Intelligence is a high-level function that allows the integration of cognitive functions such as perception, attention, memory, language, reasoning, and communication. There are individual differences in its functioning, which may result from differences in the functioning of cognitive processes such as the speed of information processing, the operation of executive functions, the capacity of short term memory, working memory, executive functions, etc. (Colom et al, 2010; Frischkorn and Schubert, 2018; Kovacs and Conway, 2019; Varga, Pásztor and Steklács, 2022). One of the most influential theories on this concept is that of psychologist Gardner, which is widely used and still forms the basis of much theoretical and empirical work. According to Gardner’s theory of multiple intelligences, eight or more intelligences can be distinguished, which are applied separately but also together in cognitive functions such as learning or problem solving. One of the eight types of intelligence identified is linguistic intelligence, which includes the ability to analyse information and to generate information through oral and written language (Gardner, 2000; Davis et al., 2011). One of the most comprehensive theories of cognitive abilities has been described to date is the Cattell-Horn-Carroll (CHC) model, which has been supported by a number of empirical studies. It is widely used to define and interpret intelligence and cognitive abilities. According to this model, language abilities such as grammatical sensitivity, language development, reading and writing, and working memory are all cognitive abilities (Flanagan and Dixon, 2014; Varga, Pásztor and Steklács, 2022)
Worldwide, cerebrovascular accidents are the leading cause of mortality and long-term disability, and weaker, inadequate cognitive functioning, which are associated with intelligence, as mentioned above. Half of all people receiving neurological hospital care are diagnosed with cerebral vascular dysfunction (Bereczki, 2021; Mina et al., 2022). Impairments affecting the cognitive-linguistic systems are common in everyday neurological practice and are caused by some degree of damage to the central nervous system, i.e. they can be caused by stroke, traumatic brain injury or neurodegenerative processes (O’Sullivan, Brownsett and Copland, 2019).
In diseases of neurological etiology, the involvement of language processes is common, but a comprehensive exploration of symptoms is essential for their accurate recognition and description (Guttsaw-Rothenberg, 2007). In diseases that also affect cognition, there is often impairment in reading processes. Acquired reading disorders are typically diagnosed in the context of other language and cognitive disorders in patients (Lambon Ralph and Patterson, 2005). Approximately one third of stroke survivors have acquired cognitive-linguistic impairment, or aphasia. The aphasic population is heterogeneous in its symptom profile, and therefore the individual profile of cognitive-linguistic impairment may vary in terms of the severity of involvement of different modalities and symptom patterns. The severity and symptom patterns of aphasia may vary over time, as one aspect of cognitive-linguistic processes may improve while others remain impaired (Brady et al., 2016). However, the identification and treatment of communication impairments is important for a person’s ability to communicate and quality of life (Guttsaw-Rothenberg, 2007).
The networked organization of the cognitive architecture leads to memory processes playing a prominent role in language processes. It is primarily the influence of working memory that is prominent in the functioning of reading (Arrington et al., 2014; Cain, 2006; Németh, 2008; Meteyard, Bruce, Edmundson and Oakhill, 2014; Potagas, Kasselimis and Evdokimidis; 2010; Sung et al., 2009). In our research, we sought to explore the strength and direction of the relationships between the main processes of reading. On the other hand, we investigated what relationships can be detected between the main components of verbal working memory and reading processes in Hungarian native speakers diagnosed with acquired cognitive-linguistic impairment. The relevance of all this is that a comprehensive insight into aphasia-related symptoms contributes to the selection of more accurate diagnostic tools and facilitates the appropriate, individualized and syndrome-specific planning of therapeutic work, thus improving the patient’s quality of life.

2. Literature review

2.1. Working memory and its role in reading

Working memory plays a crucial role in the functioning of cognitive processes, is responsible for the temporary storage and manipulation of information, and is essential for complex cognitive processes (Baddeley, 2003). Several theories have emerged about working memory, the common one being that working memory refers to a system responsible for storing information in a limited amount and over a limited time (Adams, Nguyen & Cowan, 2018). In general, different models tend to define verbal working memory as a system responsible for the temporary storage of verbal information. Verbal working memory as a system that maintains and processes verbal information is distinguished from passive short-term memory (STM), which simply stores information temporarily. That is, short-term memory performs only storage, whereas verbal working memory performs storage, processing, and manipulation of information (Schwering & MacDonald, 2020).
The term working memory was first used by Galanter and Pribram (1960), who considered working memory as a system for achieving a person’s goal and subgoal, storing the information needed to accomplish it, and performing an action. Three major theories of working memory can be distinguished: the concepts of Atkinson & Shiffrin (1968), Baddeley (2000) and Cowan (1988; 1999). Atkinson and Shiffrin (1968) defined short-term memory as a simple system responsible for the temporary storage of information. In their early descriptions, they also mention the control processes responsible for switching between different memories (Adams, Nguyen & Cowan, 2018). In Cowan’s working memory model, he describes the relationships between memory and the processes that are associated with it. According to his theory, working memory has a hierarchical organization composed of three main components. One is the long-term memory itself, the second is the currently activated processes of long-term memory, and the third is the attentional and awareness processes associated with the activated memory unit. According to Cowen’s theory, memory activation, attentional and executive, and long-term retrieval mechanisms contribute together to the effective functioning of working memory (Cowan, 1999). Baddeley and Hitch (1974) defined working memory as short-term memory or immediate memory, in accordance with the views of the time. Their early results suggested that working memory does not consist of a single storage unit but functions as a multicomponent system. They theorised that one component is the phonological loop responsible for retaining verbal information, another is the visuospatial storage holding visual and spatial information, and the third is a central executive responsible for manipulating the information held in the different stores. Their most recent version of the multicomponent working memory model (Baddeley, 2000) extends it with an additional component responsible for the temporary storage of semantic information and associations, namely the episodic buffer. The episodic buffer is not a processing unit specialised for processing a specific information, its main function is to combine different types of information. The central executive has an important role in transferring information and determining its order (Adams, Nguyen & Cowan, 2018). That is, according to Baddeley (2003), working memory is a three-component system with two main subsystems, the visual and the verbal, controlled by the attentional executive. There is an interactive relationship between working memory and long-term memory. Long-term memory contains systems that can interact with subcomponents of working memory.
The capacity and functioning of working memory is crucial for the functioning of many cognitive processes. Working memory has a prominent role in language processing and production, text comprehension, as well as in language development and the nature of language disorders (Adams, Nguyen & Cowan, 2018). One of the most prominent in terms of language function is the phonological loop, when the system is impaired, it is not a general phonological processing problem that is at the root, but rather the insufficient capacity of the phonological loop. Patients with left hemisphere impairment often have problems with the functioning of the phonological loop. The phonological loop, however, seems to play an important role not only in language processing, but also in the control of action. The phonological loop plays a prominent role in native language learning. The visual-spatial sketchpad is responsible for processing visual and spatial information. The information stored is mainly spatial, mainly visually represented. The functioning of the system is primarily related to the right hemisphere. It plays a role in reading tasks, processing the spatial arrangement of text and related information, but is much less responsible for language function than the phonological loop. The cognitive capacity and the ability to retain and manipulate visual-spatial information also play a role in language comprehension, but this mechanism is not primarily responsible for language processing. Central executive involved in the attentional control of working memory, its functioning is mainly associated with the frontal lobe. Its operation can be divided into several executive sub-processes. In terms of the extent of working memory, the operation of executive processes is one of the most important. The extent of working memory is a key predictor of a wide range of complex cognitive abilities, including reading comprehension. The extent of working memory significantly influences the functioning of text comprehension skills (Baddeley, 2003).
Working memory plays an important role in reading, particularly in the simultaneous processing and storage of information being read. Therefore, it plays an important role in sentence and text processing in general. Many of the cognitive processes are related to reading, but not all of them are equally involved. In terms of working memory processes, it is the phonological loop and the central executive that play a particularly important role in reading. In children, the phonological loop plays a major role in learning words and in the acquisition of grapheme-phoneme conversion operations, while the central executive is most evident in text comprehension, specifically in the coordination and integration of information read in texts. Long-term memory is also involved in reading, as it is from long-term memory that relevant knowledge and background knowledge about the written text is retrieved during reading comprehension. This increases the functioning of working memory (Peng et al., 2018).

2.2. Characteristics of adult reading

In sciences investigating the functioning of cognition, reading is nowadays mostly defined as the interaction of language, orthographic and cognitive abilities. The processing of the written text involves a number of mechanisms that are also used in language production and processing (Perfetti, 1999; Petfetti and Stafura, 2014; Stafura and Perfetti, 2017). Reading and language are closely related, and more precisely, reading is a part of language processing that begins with visual processing. From a psycholinguistic point of view, three main processing stages can be distinguished during reading: (1) the visual perception of the stimulus itself, (2) the processes that convert the visual input into a linguistic representation, and (3) the mechanisms that perform different operations on the converted representation itself (Perfetti, 1999). Based on the above, reading can be defined as a cognitive process that is strongly linked to language processing, since a close interaction between the two processes has been observed, and; therefore, language impairment also affects reading functions (Hallowell and Chapey, 2008; Perfetti, 1999; Papathanasiou et al, 2013; Riley and Kendall, 2013; Stafura and Perfetti, 2017). The strong relationship between language, reading and other related verbal and non-verbal cognitive processes has been confirmed by the results of research using behavioural and brain imaging (Amunts, 2008; Tsapkini and Hillis, 2015; Wollams et al., 2018; Luzatti, 2008).
Adult reading is described in Perfetti’s (1999) The Reading Systems Framework in which reading is defined in a broader context as the interaction of linguistic, cognitive and general knowledge. Processing written text involves a number of processes that are also used in oral language production and comprehension. The components of reading range from lower-level visual processing to higher-level comprehension and inference processes. There is interaction between the individual processing units. The main components of the concept include different types of knowledge, the cognitive and linguistic processes and the interactions among them. The centre of the framework is the lexicon, which is the element between the word recognition system and the comprehension system. The processes of reading comprehension are based primarily on word recognition, followed by the retrieval of the appropriate meaning for the words in context, then identifying morphemes necessary for the processing of syntactic structure, then the integration of meaning units within and between sentences, and finally the creation of a general (linguistic and non-linguistic) representation. The main reading-related mechanisms such as decoding, word identification, meaning retrieval, sentence and text constituent construction, and inference and verification mechanisms use these knowledge resources in both a limited and interactive way. These processes take place within the cognitive system and are linked to both perceptual and long-term memory systems (Perfetti, 1999; Perfetti and Stafura, 2014; Stafura and Perfetti, 2017; Perfetti and Helder, 2022).
The above shows that, according to current popular views, the process of reading cannot be defined as a single operating mechanism, but requires a combined operation of several mechanisms and their interaction. Although different disciplines have fundamentally different perspectives on this issue, there is a consensus that the process of reading itself is highly complex and that understanding its mechanisms of operation requires an understanding of the process in a broader context. The expansion of the definition over the past half century has been accompanied by a broader interpretation of the dysfunctions in reading, and by a greater consideration of the impact and consequences on social, everyday life, in addition to individual, psychological and cognitive aspects. This has led to the emergence of a number of theories and models of reading.

2.3. The relationship between adult acquired cognitive-linguistic impairment and working memory

The study of the symptoms of acquired cognitive impairment can provide valuable insights into the functioning of cognition. The focus of our study is to explore the relationship between reading impairment associated with adult acquired cognitive-linguistic impairment, namely aphasia, and working memory. In the following, the definition of aphasia, the main characteristics of aphasic reading, and the relationship between aphasia and working memory will be discussed.
Defining aphasia is complicated by the many different ways it manifests itself. However, there are different perspectives on the definition of aphasia as a syndrome;- there is an agreement on the main characteristics: (1) an acquired disorder, i.e., a dysfunction in the operation of an already developed ability system; (2) a neurological impairment, i.e. a disorder that occurs as a result of damage to the central nervous system; (3) symptoms affect the production and comprehension processes of language abilities; (4) multimodal impairment, i.e., in addition to affecting production and comprehension processes, symptoms occur in several components, such as reading, writing, executive functions (Martin and Gupta, 2004; Hallowell and Chapey, 2008; McNeil, Hula and Sung, 2010; Martin and Reilly, 2012; Papathanasiou and Coppens, 2013; Cahana-Amitay and Albert, 2015; Lambon Ralph et al. 2017).
The symptoms of aphasia are also manifested in the functioning of reading processes, all of which present a varied picture. As a consequence of the damage to the central nervous system, the application of the rules of grapheme-phoneme correspondence and the execution of lexical and semantic operations (linking word form and meaning) may be affected. As a consequence of the involvement of phonological and semantic processes, paralexia (syllable and/or word substitutions) and phonological errors in reading may occur. Persons with aphasia (PWA) are often presented with semantic or visual errors as symptoms, and have a better reading of concrete words than abstract words (Denes, Cipolotti and Zorzi, 1998; Cherney, 2004; Wollams, 2015; Coslett, 2012).
In terms of text comprehension, aphasic individuals have longer reading times and make more errors compared to controls, and aphasic reading is significantly influenced by the structure of the text (DeDe, 2013a). Text coherence also has a significant effect on reading performance in aphasic individuals, who show a high sensitivity to sentences with inconsistent verb structure and sentence type (DeDe, 2013b). In addition to syntactic structure, a marked effect of word frequency, word order and verb properties on text comprehension has been demonstrated in aphasic individuals. They find it easier to process texts that are simpler in sentence structure and contain frequent words than those that are more complex in structure and contain low-frequency words (Kay and Cherney, 2016). In addition, they have a particular difficulty in tasks that require the integration of information from the text (Webster et al., 2018). It can be seen that aphasia presents a varied picture of symptoms, but that the symptoms in verbal mechanisms are often due, among other things, to impairments in closely related cognitive processes that determine the functioning of language processes, such as working memory.
Meteyard, Bruce, Edmundson and Oakhill (2014) explored the background of text-level reading difficulties in four individuals with mild aphasia. Focusing on processes closely related to text comprehension, they investigated the participants’ language and cognitive abilities in a comprehensive measure, including an analysis of their reading speed, language skills (word and sentence level), inference skills, working memory, and metacognitive skills (observation and strategy use). The results of the aphasic participants were compared with those of a control group. One person showed lower performance in inference skills and three participants showed lower performance in language and working memory. The results suggest that the functioning of verbal working memory and reasoning skills appears to be critical for text comprehension.
Potagas, Kasselimis and Evdokimidis (2010) analysed the relationship of short-term memory and working memory with the severity of language impairment in fifty-eight individuals with aphasia. Working memory functioning was measured from two modalities, the verbal and the spatial modality. Results showed that aphasic subjects scored lower on all memory tasks compared to the control group. Approximately equal correlation coefficients were found between aphasia test scores and short-term memory and working memory. The results suggest that the severity of aphasia is related to both verbal and spatial memory components, and that the primary source of the problem appears to be a deficit in information retention, resulting in reduced working memory capacity.
Sung et al. (2009) investigated sentence comprehension performance of aphasic individuals as a function of working memory capacity. They investigated the relationship between verbal working memory, sentence comprehension and aphasia severity, and analysed the performance of aphasic individuals with higher and lower verbal working memory capacity on sentence comprehension tasks. The results showed that performance on verbal working memory tasks significantly predicted sentence comprehension task performance, and that verbal working memory was significantly correlated with aphasia severity and with auditory and written sentence comprehension. The effect of working memory was most noticeable in tasks where a higher degree of memory system functioning was required.
The above shows that aphasic cognitive-linguistic impairment is related to general cognitive abilities that determine the functioning of reading and language processes, due to a common neural architecture. The results of empirical research highlight that a wide range of features of reading disorders can be identified in aphasia. Despite the fact that reading abilities of individuals with aphasia have been investigated using different methods, the results have been mostly consistent, supporting the close relationship between reading, language and related non-verbal cognitive functions. Accordingly, aphasia is now defined as a syndrome, which determines not only the complex diagnostic but also the therapeutic process.

2.4. The aim of the study

Working memory plays a crucial role in the functioning of reading processes, but not all its components are equally involved (Adams, Nguyen & Cowan, 2018; Baddeley, 2000; 2003; 2005; Józsa & Józsa, 2018; Arrington et al., 2014; Cain, 2006; Peng et al., 2018). The aim of this study was to determine which processes of reading in adult individuals diagnosed with acquired cognitive-linguistic impairment are associated with impairments in processes of working memory involved in language functioning. Data that investigate and analyse this issue from this perspective are not yet available. The results allow conclusions to be drawn about the extent and functions of the cognitive processes required for reading to be functional. This is not only relevant for adult acquired disorders, but may also help in the detection and treatment of developmental reading problems.

2.5. Research questions

According to Baddeley’s (2000; 2003) multicomponent working memory model, it is composed of the following mechanisms: verbal short-term memory for processing phonological information, visual-spatial sketchpad, central executive and episodic buffer. The verbal short-term memory, the central executive and, together, the verbal short-term memory and the central executive, i.e. verbal working memory, are involved in the linguistic production and processing processes. For this reason, the present research has focused on the relationship between these components and the main mechanisms of reading.
The literature suggests that verbal short-term memory and verbal working memory play a prominent role in text comprehension skills (Minkina, Salis & Martin, 2018). Based on this, we hypothesized that the functioning of verbal short-term memory and verbal working memory would be related to performance on text comprehension. The functioning of verbal short-term memory is crucial for language functioning. Deficits in short-term memory are mainly manifested in the processing of longer and complex sentences (Baddeley, 2003; Peng et al., 2018). Therefore, we hypothesized that verbal short-term memory will be associated with the processing of sentence- and text-level information. Among the components of working memory, the central executive is the one that still determines text comprehension abilities. We hypothesized that there will be a link between text comprehension functioning and the central executive (Baddeley, 2003).

3. Materials and Methods

3.1. Participants

In our study, a total of 22 persons with aphasia (8 women, 14 men) were investigated. The average age of the participants was 62.31 years (44-84 years). The type and severity of aphasia were determined using the Hungarian version of Western Aphasia Test (Osmanné, 1991) according to which 14 mild and 8 moderate aphasic, 1 Broca’s, 2 transcortical motor, 6 driving and 13 anomic aphasic patients were included. All subjects were right-handed, and the etiology of aphasia was consistently left ACM hemispheric stroke. After the review of the medical history and consultation with the neurologist, patients diagnosed with visual perception problems, dementia, depression, or any type of psychiatric illness were excluded. The study was carried out at the Department of Neurology, Faculty of Medicine, Szent-Györgyi Albert University of Szeged, Hungary, and participation was voluntary, with written informed consent from the subject. The research was conducted under the ethical approval of the RKEB 60/2022-SZTE.

3.2. Methods

The language ability profile of the aphasic participants in the study was assessed using the Hungarian version of Western Aphasia Test (Osmánné, 1991). Based on this, information was obtained on the four main components of the language system, namely spontaneous speech fluency, auditory verbal comprehension, repetition and naming, and then these four main areas were used to determine the aphasia coefficient (AQ).
Patients were shown the tasks via a tablet. For this purpose, with the help of a software manager a program called Neurolinguistics Research 1.0 was created, available online, which measures reaction time and the accuracy of responses to tasks measuring lexical access and processing of morphosyntactic items. Reading skills of the participants were measured with the Adult Acquired Reading Assessment, which we developed. The development of the scoring system for the reading assessment and the analysis of the psychometric indicators of the test were based on a large sample (n=480). The test reliability was found to be acceptable in the analyses (Cronbach’s alpha 0.66-0.76) (Kis, Földi & Steklács, under review; Kis, 2023). The reading measurement called Adult Acquired Reading Assessment (AARS) compiled for our research consisted of four groups of tasks (phonology, lexicon, morphosyntax and text comprehension) and included a total of 10 tasks (Table 1). The stimuli were presented on a tablet using the online interface of the Neurolinguistic Research App.
Phonology was assessed by reading vowels (n=26) and consonants (n=28). Participants in the study were asked to read aloud the stimuli on the screen. Lexicon was measured using two sets of tasks, word reading and lexical access. To assess word reading, four tasks were set up, two with semantic content and two without semantic content, asking the subjects to read out pseudowords. The stimuli were selected according to word frequency, based on the word frequency list published by the Hungarian National Text Repository. The stimuli used for reading pseudowords were generated with the Neurolinguistics Research App. When measuring lexical access, access to lexical information was investigated with three tasks: picture-word matching, word-nonword lexical decision, grammatical/agrammatical sentence decision. In the picture-word pairing task, participants had to choose the word associated with the picture from three alternative answers, while in the word-nonword lexical decision task, participants had to decide whether the stimulus on the screen was a real word with a meaning in Hungarian. For the grammatical/agrammatical sentence decision task, the aim was to assess the processing of sentence-level information by showing participants morphosyntactically correct and incorrect sentences. Their task was to decide whether the presented stimulus was correct or incorrect. An open access text published by the Progress in International Reading Literacy Study (PIRLS) was selected and the task was to answer questions about the text, with the assessment analysing the processing of explicit (n=10) and implicit (n=11) information separately.
For the Adult Acquired Reading Assessment, a software developer enabled us to develop the Neurolinguistics Research App. through which the measurement procedure could be accessed. The app was accessed via a website, after entering an email address and password, the application provided an interface where the participant’s details (gender, age group, education) could be entered, and the participants could select the task to run.
Regarding the main components of working memory, as mentioned above, Baddeley’s (2000; 2005) multicomponent working memory model was used as a starting point and the study material was constructed accordingly. When assessing working memory, only those components were measured that play a key role in language production and processing (Baddeley, 2000; 2003; Minkina, Salis & Martin, 2018; Adams, Nguyen & Cowan, 2018; Peng et al., 2018; Schwering & MacDonald, 2020). Accordingly, the functioning of verbal short-term memory, central executive and verbal working memory was explored. To investigate working memory, we applied the Hungarian test procedures of Racsmány, Lukács, Németh and Pléh (2005) and Tánczos (2014) for verbal working memory. Verbal short-term memory was measured by nonword repetition and number span tests. In the former one, the participants were asked to repeat words of different lengths without meaning, and in the latter one, to repeat an increasing number of numbers. The central executive function was measured by fluency tasks. In the case of letter fluency, participants were asked to list as many words starting with the given sound as possible in one minute. For semantic fluency, subjects were asked to classify as many words of the given category as possible in one minute. Verbal working memory was measured by listening and reading span tasks. In the auditory sentence span task, participants had to judge the correctness of the sentences they heard, while memorising the last word at the end of the sentences and then recalling it. For the reading span, participants had a similar task, reading aloud different sentences, memorising the last word, and then recalling them in the order in which the sentences were read.

3.3. Data analysis

Data are presented using both quantitative and qualitative techniques in order to provide a more comprehensive picture of the relationship between reading and working memory in individuals with adult acquired cognitive-linguistic impairment. First, the relationship between reading and working memory will be investigated through correlational group analyses, and then this will be described in detail through two case studies.
Data were analysed according to two main aspects. In order to explore the relationships between the different levels of reading and the main components of working memory involved in processing verbal information, the different components of reading (vowels, consonants, syllables, two-letter words, complex words, nonwords, picture-word matching, word-nonword lexical decision, grammatical/agrammatical sentences, processing explicit and implicit information at text level) and the interrelationships between working memory (central executive, phonological loop, verbal working memory) were analyzed. Secondly, the relationships between the main mechanisms measured by the reading test (grapheme-phoneme conversion, word reading, lexical decision, text comprehension) and the main components of verbal working memory were explored (central executive, phonological loop, verbal working memory). In addition, the internal relationships between the main reading task groups were analysed (grapheme-phoneme conversion, word reading, lexical decision, text comprehension). IBM SPSS Statistics 26 was used for the analyses. First, a Shapiro-Wilk test was applied to test normality, suggesting that our data did not follow a normal distribution. Accordingly, Spearman’s non-parametric correlation test was used to explore the correlations. In all our analyses, the margin of error was 95% confidence interval.
For the analyses, the results produced on each task were summarized by the task group. For the grapheme-phoneme conversion, the results produced when reading vowels (n=26) and consonants (n=28) were included. The combined scores for syllables (n=24), two-letter words (n=24), longer words (n=50) and pseudowords (n=25) formed the word reading performance. The lexicon performance was calculated from the scores on the picture-word pairing (n=20), word-nonword lexical decision (n=50) and grammatical/agrammatical sentences (n=20) tasks. Text comprehension scores were computed in aggregate, i.e., explicit (n=10) and implicit (n=11) processing was analysed in summary. For the verbal working memory assessment, the verbal short-term memory was measured by the pseudo-word repetition and number span tasks. The central executive was calculated from the results of letter fluency and semantic fluency. Verbal working memory was calculated from the listening and reading span tasks. In the following, the results are presented on this basis.

4. Results

4.1. Group-level analyses

The relationships between the reading assessment tasks and the main components of working memory involved in processing verbal information were analysed. Significant positive correlations were found between verbal short-term memory and reading two-letter words (r(21)=0.54; p=0.009) and compound words (r(21)=0.50; p=0.017). No correlations were found between verbal short-term memory and reading vowels (r(21)=0.41; p=0.054), consonants (r(21)=0.38; p=0.075), syllables (r(21)=0.19; p=0.385), and pseudowords (r(21)=0.27; p=0.219), and picture-word matching (r(21)=0.38; p=0.076), word-nonword lexical decision (r(21)=0.26; p=0.227), grammatical/agrammatical sentences (r(21)=0.25; p=0.0245), and processing explicit (r(21)=0.38; p=0.079) and implicit (r(21)=0.122; p=0.589) text-level information. Central executive function was only correlated with vowel reading (r(21)=0.47; p=0.025). In the other cases, no relationship was found, i.e. no correlation was found with consonants (r(21)=0.34; p=0.121), syllables (r(21)=0.24; p=0.277), reading two-letter words (r(21)=0.30; p=0.170), reading compound words (r(21)=0.14; p=0.522), and reading pseudowords (r(21)=0.29; p=0.190), and picture-word matching (r(21)=0.29; p=0.183), word-nonword lexical decision tasks (r(21)=0.14; p=0.524), judging the correctness of grammatical/agrammatical sentences (r(21)=0.31; p=0.158), and processing explicit (r(21)=-0.03; p=0.89) and implicit (r(21)=0.27; p=0.212) text-level information. Verbal working memory functioning was associated with reading vowels (r(21)=0.44; p=0.040) and processing implicit text-level information (r(21)=0.56; p=0.006). Reading consonants (r(21)=0.29; p=0.181), syllables (r(21)=0.26; p=0.225), two-letter words (r(21)=0.36; p=0.098), compound words (r(21)=0.21; p=0.335), reading pseudowords (r(21)=0.29; p=0.188), picture-word matching (r(21)=0.37; p=0.083), word-nonword lexical decision (r(21)=0.24; p=0.280), grammatical/agrammatical sentence judgments (r(21)=0.35; p=0.109), and explicit (r(21)=0.34; p=0.111) text-level information processing were not related (Table 2).
The relationships between the reading task domains (grapheme-phoneme conversion, word reading, lexical decision, text comprehension) and the working memory components (verbal short-term memory, central executive, verbal working memory) were then analysed. A significant positive correlation was found between verbal short-term memory and word reading (r(21)=0.44; p=0.036). No correlations were found between verbal short-term memory and grapheme-phoneme conversion (r(21)=0.41; p=0.055), lexical access (r(21)=0.35; p=0.110) and text comprehension (r(21)=0.31; p=0.158). No correlations were found between any of the tasks measuring central executive and grapheme-phoneme conversion (r(21)=0.41; p=0.057), word reading (r(21)=0.26; p=0.261), lexical access (r(21)=0.26; p=0.241) and text comprehension (r(21)=0.17; p=0.434). Verbal working memory functioning showed a relationship with text comprehension ability (r(21)=0.60; p=0.003), but no relationship was found for the other measures, i.e., neither grapheme-phoneme conversion (r(21)=0.37; p=0.090), nor word reading (r(21)=0.31; p=0.159), nor lexical access (r(21)=0.35; p=0.105).
Correlations between the main reading task groups were also examined. A significant positive correlation was found between grapheme-phoneme conversion and all reading tasks, i.e. word reading (r(21)=0.80; p<0.001), lexical access (r(21)=0.68; p<0.001) and reading comprehension (r(21)=0.58; 0.004). Word reading was associated with grapheme-phoneme conversion (r(21)=0.80; p<0.001), lexical access (r(21)=0.68; p<0.001) and text comprehension (r(21)=0.50; p=0.004). There was a relationship between lexical access and grapheme-phoneme conversion (r(21)=0.68; p<0.001), word reading (r(21)=0.68; p<0.001) and text comprehension (r(21)=0.71; p<0.001). Text comprehension was also found to be correlated with all reading tasks, i.e., with tasks measuring grapheme-phoneme conversion (r(21)=0.58; p=0.004), word reading (r(21)=0.51; p=0.018) and lexical access (r(21)=0.71; p<0.001) (Table 3).
In the following, the relationship between reading and the main components of verbal working memory will be illustrated through two case studies using a qualitative analysis method.

4.2. Case study 1

Firstly, the case of a 65-year-old female patient (BA) who received an ischaemic stroke in March 2021, with localised damage to the left ACM is discussed. The Western Aphasia Test, which determines the type and severity of aphasia, scored a total of 81.2 aphasia quotients, confirming a mild degree of anomic aphasia in this case. Her reading function was measured with the Adult Acquired Reading Assessment (Kis, Földi & Steklács, under review), which provides a comprehensive picture of the functioning of the major components involved in reading. Thanks to the developed scoring system included in the test, information is available not only on scores but also on reaction times required to perform the tasks. The main components of verbal working memory (verbal short-term memory, central executive, verbal working memory) were also tested. The results of the reading performance were compared with normatives for the age and educational level of the participant, both in terms of scores and reaction times.
Regarding the scores in the reading test, BA performed according to her age and educational level in the vowel reading and word-nonword lexical decision tasks. She showed a mild degree of impairment in the consonants, syllables, two-letter words, picture-word matching and grammatical/agrammatical sentence corrctness judgements sections. Severe impairment was confirmed in reading compound words and pseudowords, and in text comprehension skills.
In terms of reaction times, the patient performed age- and education-appropriate in the tasks of reading vowels, consonants, syllables and two-letter words, with severe impairment in reading complex words and moderate impairment in reading pseudowords. Severe differences were found in the picture-word matching, word-nonword lexical decision and grammatical/agrammatical sentence correctness sections. That is, the patient showed increased reaction times for some parts of the word reading task, specifically for the longer words and stimuli without meaning (pseudowords) and for the lexical access task.
For the measured components of working memory, severe impairments were observed in all areas. In his case, verbal short-term memory had only three items. Fluency tasks measuring central executive function performed somewhat better, with 18 items in total. In the verbal working memory tasks, however, she scored particularly low, with only 2 items.
In summary, BA showed impairments in some word reading tasks (compound words, pseudowords), with differences not only in scores but also in reaction times, and differences in processing sentence-level and text-level information. As regards working memory, impaired functioning was mainly observed in verbal short-term memory and verbal working memory.

4.3. Case study 2

The following is the case of another patient. FF is 84 years old, with intermediate education. As in the previous case, he also received a stroke of ischaemic etiology in 2021. Brain imaging stechniques also confirmed left ACM area lesions. The severity and type of aphasia showed moderate transcortical motor aphasia.
FF showed severe impairment in almost all areas of reading test scores compared to age and educational performance, with moderate impairment in grammatical/agrammatical sentence comprehension alone. That is, reading of vowels, consonants, two-letter words, compound words and pseudowords, as well as picture-word pairing, word-nonword lexical decision processes and text comprehension skills were severely impaired. In terms of reaction time, a moderate degree of reaction time increase was detected in the reading of consonants, while a severe degree of difference was detected in the reading of vowels, syllables, two-letter words, compound words, picture-word matching, word-nonword lexical decision processes and grammatical/agrammatical tasks. Such a severe impairment in the reading of pseudowords could be detected that this part of the assessment could not be scored.
Regarding working memory functioning, verbal short-term memory had only two items, central executive measured by fluency tasks had only three items, and verbal working memory was not measurable.
The results showed that FF showed severe impairments in all domains, i.e., grapheme-phoneme conversion, word reading, lexical access and text comprehension mechanisms, both in terms of scores and reaction times, and that verbal working memory functioning was also severely affected.

4. Discussion

Different memory processes are linked to different aspects of language and reading mechanisms. Online cognitive-linguistic processes are mainly influenced by the functioning of working memory. Verbal working memory and verbal short-term memory play a key role in language processing and comprehension (Baddeley, 2000; 2005; Arrington et al., 2014; Cain, 2006; Józsa and Józsa, 2018; Mikina, Salis & Martin, 2018). In our study, we aimed to explore the relationship between reading and verbal working memory in adult individuals diagnosed with acquired cognitive-linguistic impairment. We investigated the main components of reading that co-occur with verbal working memory, and analysed the relationships within reading process. The main question was which components of working memory and reading in adult neurogenic acquired cognitive-linguistic disorders are interrelated in order to identify which components should be focused on in the diagnostic and therapeutic process. To explore all these, we developed and used the Adult Acquired Reading Assessment (Kis, Földi & Steklács, under review, Kis, 2023), as well as Hungarian language measures for verbal working memory (Racsmány, Lukács, Németh and Pléh; 2005; Tánczos, 2014).
The analysis involved exploring the relationships between the four main task groups of the reading test - grapheme-phoneme conversion, word reading, lexical access and text comprehension - and the main components of working memory most involved in language operations - verbal short-term memory, central executive, verbal working memory. In order to gain a deeper insight into the functioning of reading processes, both group-level quantitative analyses and qualitative case studies were conducted. Correlational analysis was used to investigate the relationships between each mechanism.
First, the components of working memory that play a main role in reading and the components of the reading tasks were analysed, followed by the relationships between working memory and the reading measurement task groups. These showed a correlation between verbal short-term memory and reading two-letter words and compound words. In terms of task groups, word reading showed a correlation. All this suggests that the better the functioning of verbal short-term memory, the better word reading skills can be expected. The operation of the central executive was only correlated with the reading of vowels. There was a significant positive correlation between verbal working memory and vowel reading, implicit text-level information, and text comprehension. The results suggest that the better the central executive functions, the better the reading of vowels, and the better the verbal working memory functions, the better the operation of the mechanisms involved in vowel reading and text comprehension.
The relationship between working memory and reading was also analysed qualitatively through case studies. For this purpose, the cognitive-linguistic profiles of two individuals diagnosed with cognitive-linguistic impairment of different severity were presented. The results showed that the person with mild cognitive-linguistic impairment was mainly impaired in the most language-related processes of working memory, i.e. phonological short-term memory and complex verbal working memory. In reading, certain word reading processes and the processing of text-level information were impaired. In the other case report of a person with moderate cognitive-linguistic impairment, severe deficits were detected in all functions, i.e. both reading processes and working memory mechanisms were severely affected. The results showed that the damage of certain working memory processes was most strongly associated with the reading of vowels, the reading of more complex words with and without extended meanings in word reading, and the processing of implicit text-level information. Lexical access operations showed no correlation with any working memory component.
Based on the literature, we hypothesized that there would be a correlation between text comprehension and verbal short-term memory and verbal working memory (Minkina, Salis & Martin, 2018). This hypothesis was partially proven, as verbal short-term memory performance did not show a correlation with text comprehension, but it did with word reading. However, verbal working memory showed a correlation with text comprehension skills, including the processing of implicit text-level information. We hypothesized that verbal working memory would be related not only to processing text-level information, but also to processing sentence-level information (Baddeley, 2003; Peng et al., 2018). Our hypothesis was also partially confirmed, as our data showed no relationship between verbal working memory and processing sentence-level information, but a relationship between text comprehension and verbal working memory. Based on literature, we hypothesized that central executive function would be related to text comprehension performance (Baddeley, 2003). This hypothesis was not confirmed, but surprisingly, we found a correlation between central executive and performance on vowel reading.
The networked functioning of the cognitive architecture means that memory and reading processes interact with each other, but not all mechanisms are linked with the same weightings. Some processes are more closely interrelated and, as a result, poorer or inappropriate functioning in one process can lead to different functioning in another closely related process. The results could contribute to a more accurate diagnosis and a more comprehensive understanding of acquired cognitive impairment.
The results will not only contribute to a deeper understanding of adult acquired cognitive-linguistic disorders, but also to a more comprehensive understanding of the mechanisms of reading. From a pedagogical point of view, the understanding of the interrelationship of cognitive processes may help not only in neurological diagnosis and therapeutic planning, but also in the identification of developmental reading disorders and may provide input for reading pedagogy.

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper” if applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Table 1. Structure of the Adult Acquired Reading Assessment (AARA).
Table 1. Structure of the Adult Acquired Reading Assessment (AARA).
Adult Acquired Reading Assessment
Grapheme-to-phoneme conversion vowels (26)
consonants (28)
Word reading syllables (24)
two-letter words (24)
compound words (50)
pseudowords (25)
Lexicon picture-word matching (20) 10 noun, 10 verb
word-nonword lexical decision (50)
grammatical/agrammatical sentences (20)
Text comprehension text comprehension (21) – explicit (10) and implicit (11) information processing
Table 2. Correlations between each reading task and working memory components.
Table 2. Correlations between each reading task and working memory components.
Reading tasks Verbal short-term memory Central executive Verbal working memory
vowel .42 .48* .44*
consonant .39 .34 .30
syllables .19 .24 .27
two-letter words .55** .30 .36
compound words .50* .14 .22
pseudowords .27 .29 .29
picture-word matching .39 .29 .38
word-nonword decision .27 .14 .24
grammatical/agrammatical sentences .26 .31 .35
explicit text-level information processing .38 -.03 .35
implicit text-level information processing .12 .28 .56**
Note: *p<.05;**p<.01.
Table 3. Correlations between the reading assessment task groups and the main components of verbal working memory.
Table 3. Correlations between the reading assessment task groups and the main components of verbal working memory.
verbal short-term memory central executive verbal working memory grapheme-phoneme conversion word reading lexical access
verbal short-term memory
central executive .13
verbal working memory .26 .39
grapheme-phoneme conversion .41 .41 .37
word reading .45* .26 .31 .80**
lexical access .35 .26 .35 .69** .68**
text comprehension .31 .18 .60** .59** .50* .71**
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