Behind the [MASK]: Disentangling Representation and Faithfulness in DAPF-Based Dementia Detection

Early detection of dementia enables timely intervention, and reflecting cognitive impairment, spontaneous speech offers a non-invasive screening modality. Conventional approaches often focus on a single representational dimension -- such as acoustic descriptors, pause modeling, automatic speech recognition (ASR) transcripts, or multimodal fusion -- limiting integrative reasoning across heterogeneous cognitive symptoms. We propose a low-rank adaptation (LoRA)-tuned large language model (LLM) that performs structured multi-view reasoning over four complementary speech-derived signals: ASR transcripts with pause markers, discourse-level topic cues, temporal fluency statistics, and phonological sequences. These cues are encoded within a unified prompt, enabling a single LLM to learn a coherent decision function without modality-specific encoders or late-stage fusion. On ADReSSo, our best model achieves an F1-score of 90.14%, and ablation confirms the complementary contribution of each view.

Dementia detection from spontaneous speech offers a scalable approach to cognitive screening, yet NLP systems remain predominantly English-centric. This limitation is especially acute in the Philippines, where Filipino-English code-switching is pervasive and no prior work has addressed NLP-based dementia detection. We present the first systematic evaluation of transformer-based dementia detection in Filipino speech and the first assessment of NeoBERT in a clinical NLP setting. To separate language from domain effects, we construct a parallel bilingual dataset of 4,000 DementiaBank-derived transcripts, with Filipino translations produced manually to preserve discourse-level markers of cognitive decline. We evaluate five model families, TF-IDF + LogReg, BERT, NeoBERT, XLM-R, and RoBERTa-Tagalog, under monolingual, zero-shot cross-lingual, and bilingual fine-tuning settings. We find that in-domain performance does not transfer across languages, with English-trained BERT dropping to Macro-F1 = 0.455 on Filipino, and that architectural modernization alone does not improve robustness. Bilingual fine-tuning, however, eliminates cross-lingual degradation across all transformer models, converging to Macro-F1 = 0.969-0.973. These results suggest that multilingual clinical NLP performance is driven primarily by linguistic coverage during training rather than model scale or architecture.

Speech-based cognitive impairment detection offers a noninvasive, accessible alternative to costly biomarker assays, yet transformer-based models remain clinically uninterpretable. We propose a multi-stage explainability framework that translates black-box transformer predictions into clinically grounded narratives by integrating SHapley Additive exPlanations (SHAP)-based token attribution, theory-informed linguistic features, and a four-stage LLM reasoning pipeline using LLaMA-3.1-70B-Instruct. Built on the SpeechCARE-Adaptive Gating Network multimodal screening model (F1 = 72.11% on the NIA PREPARE benchmark), the framework maps model outputs to four cognitive-linguistic dimensions, including lexical richness, syntactic complexity, and semantic coherence. Physician evaluation on 70 stratified English samples demonstrated strong alignment with patient-level cognitive profiles, and a System Usability Scale score of 82/100 indicated high potential for clinical workflow integration.