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. 1979 Nov 3;121(9):1175–1190.

A rational approach to dementia.

A H Ropper
PMCID: PMC1704685  PMID: 159118

Abstract

Dementia is a common problem facing all medical practitioners and it frequently results in hospitalization and death. This review provides a framework for dealing with dementia in clinical practice that is based on both traditional concepts and recent advances in the understanding of the problem. Distinguishing at the bedside between dementia and other disorders of intellect is emphasized. The main causes of dementia and their clinical characteristics are reviewed and a rational approach to definitive diagnosis is developed. Simple, effective symptomatic forms of therapy are described.

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Selected References

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  1. ADAMS R. D., FISHER C. M., HAKIM S., OJEMANN R. G., SWEET W. H. SYMPTOMATIC OCCULT HYDROCEPHALUS WITH "NORMAL" CEREBROSPINAL-FLUID PRESSURE.A TREATABLE SYNDROME. N Engl J Med. 1965 Jul 15;273:117–126. doi: 10.1056/NEJM196507152730301. [DOI] [PubMed] [Google Scholar]
  2. ADAMS R. D., VANBOGAERT L., VANDEREECKEN H. STRIATO-NIGRAL DEGENERATION. J Neuropathol Exp Neurol. 1964 Oct;23:584–608. [PubMed] [Google Scholar]
  3. ARING C. D. SUPRANUCLEAR (PSEUDOBULBAR) PALSY. Arch Intern Med. 1965 Feb;115:198–199. doi: 10.1001/archinte.1965.03860140078017. [DOI] [PubMed] [Google Scholar]
  4. Albert M. L., Feldman R. G., Willis A. L. The 'subcortical dementia' of progressive supranuclear palsy. J Neurol Neurosurg Psychiatry. 1974 Feb;37(2):121–130. doi: 10.1136/jnnp.37.2.121. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Alexander D. A. "Senile dementia": a changing perspective. Br J Psychiatry. 1972 Aug;121(561):207–214. doi: 10.1192/bjp.121.2.207. [DOI] [PubMed] [Google Scholar]
  6. Appenzeller O., Salmon J. H. Treatment of parenchymatous degeneration of the brain by ventriculo-atrial shunting of the cerebrospinal fluid. J Neurosurg. 1967 May;26(5):478–482. doi: 10.3171/jns.1967.26.5.0478. [DOI] [PubMed] [Google Scholar]
  7. BERGIN J. D. Rapidly progressing dementia in disseminated sclerosis. J Neurol Neurosurg Psychiatry. 1957 Nov;20(4):285–292. doi: 10.1136/jnnp.20.4.285. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. BLAKE J. R., Jr, KUNKLE E. C. The palmomental reflex; a physiological and clinical analysis. AMA Arch Neurol Psychiatry. 1951 Mar;65(3):337–345. doi: 10.1001/archneurpsyc.1951.02320030074008. [DOI] [PubMed] [Google Scholar]
  9. Benson D. F., LeMay M., Patten D. H., Rubens A. B. Diagnosis of normal-pressure hydrocephalus. N Engl J Med. 1970 Sep 17;283(12):609–615. doi: 10.1056/NEJM197009172831201. [DOI] [PubMed] [Google Scholar]
  10. Blass J. P., Gibson G. E. Abnormality of a thiamine-requiring enzyme in patients with Wernicke-Korsakoff syndrome. N Engl J Med. 1977 Dec 22;297(25):1367–1370. doi: 10.1056/NEJM197712222972503. [DOI] [PubMed] [Google Scholar]
  11. Bower H. M. Sensory stimulation and the treatment of senile dementia. Med J Aust. 1967 Jun 3;1(22):1113–1119. [PubMed] [Google Scholar]
  12. Boyd W. D., Graham-White J., Blackwood G., Glen I., McQueen J. Clinical effects of choline in Alzheimer senile dementia. Lancet. 1977 Oct 1;2(8040):711–711. doi: 10.1016/s0140-6736(77)90517-7. [DOI] [PubMed] [Google Scholar]
  13. Brown D. G., Goldensohn E. S. The electroencephalogram in normal pressure hydrocephalus. Arch Neurol. 1973 Jul;29(1):70–71. doi: 10.1001/archneur.1973.00490250088014. [DOI] [PubMed] [Google Scholar]
  14. Burger L. J., Rowan A. J., Goldensohn E. S. Creutzfeldt-Jakob disease. An electroencephalographic study. Arch Neurol. 1972 May;26(5):428–433. doi: 10.1001/archneur.1972.00490110062006. [DOI] [PubMed] [Google Scholar]
  15. Butler R. N. Psychiatric aspects of cerebrovascular disease in the aged. Res Publ Assoc Res Nerv Ment Dis. 1966;41:255–266. [PubMed] [Google Scholar]
  16. CARTER H. R., SUKAVAJANA C. Familial cerebello-olivary degeneration with late development of rigidity and dementia. Neurology. 1956 Dec;6(12):876–884. doi: 10.1212/wnl.6.12.876. [DOI] [PubMed] [Google Scholar]
  17. CHAPMAN L. F., WOLFF H. G. The cerebral hemispheres and the highest integrative functions of man. Arch Neurol. 1959 Oct;1:357–424. doi: 10.1001/archneur.1959.03840040001001. [DOI] [PubMed] [Google Scholar]
  18. Carlen P. L., Wortzman G., Holgate R. C., Wilkinson D. A., Rankin J. C. Reversible cerebral atrophy in recently abstinent chronic alcoholics measured by computed tomography scans. Science. 1978 Jun 2;200(4345):1076–1078. doi: 10.1126/science.653357. [DOI] [PubMed] [Google Scholar]
  19. Ch'ien L., Hathaway B. M., Israel C. W. Seronegative dementia paralytica: report of a case. J Neurol Neurosurg Psychiatry. 1970 Jun;33(3):376–380. doi: 10.1136/jnnp.33.3.376. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Chédru F., Geschwind N. Disorders of higher cortical functions in acute confusional states. Cortex. 1972 Dec;8(4):395–411. doi: 10.1016/s0010-9452(72)80004-2. [DOI] [PubMed] [Google Scholar]
  21. Colon E. J. The cerebral cortex in presenile dementia. A quantitative analysis. Acta Neuropathol. 1973;23(4):281–290. doi: 10.1007/BF00687457. [DOI] [PubMed] [Google Scholar]
  22. Crapper D. R., Krishnan S. S., Dalton A. J. Brain aluminum distribution in Alzheimer's disease and experimental neurofibrillary degeneration. Science. 1973 May 4;180(4085):511–513. doi: 10.1126/science.180.4085.511. [DOI] [PubMed] [Google Scholar]
  23. Dewhurst K. The neurosyphilitic psychoses today. A survey of 91 cases. Br J Psychiatry. 1969 Jan;115(518):31–38. doi: 10.1192/bjp.115.518.31. [DOI] [PubMed] [Google Scholar]
  24. Duffy P., Wolf J., Collins G., DeVoe A. G., Streeten B., Cowen D. Letter: Possible person-to-person transmission of Creutzfeldt-Jakob disease. N Engl J Med. 1974 Mar 21;290(12):692–693. [PubMed] [Google Scholar]
  25. Eisner D. A. Can hyperbaric oxygenation improve cognitive functioning in the organically impaired elderly?: a critical review. J Geriatr Psychiatry. 1975;8(2):173–188. [PubMed] [Google Scholar]
  26. FARBROT O. Electroencephalographic study in cases of cerebrovascular accidents; preliminary report. Electroencephalogr Clin Neurophysiol. 1954 Nov;6(4):678–681. doi: 10.1016/0013-4694(54)90096-6. [DOI] [PubMed] [Google Scholar]
  27. FELDMAN R. G., CHANDLER K. A., LEVY L. L., GLASER G. H. FAMILIAL ALZHEIMER'S DISEASE. Neurology. 1963 Oct;13:811–824. doi: 10.1212/wnl.13.10.811. [DOI] [PubMed] [Google Scholar]
  28. FINK M., GREEN M., BENDER M. B. The face-hand test as a diagnostic sign of organic mental syndrome. Neurology. 1952 Jan-Feb;2(1):46–58. doi: 10.1212/wnl.2.1-2.46. [DOI] [PubMed] [Google Scholar]
  29. FISHER C. M. The clinical picture in Creutzfeldt-Jakob disease. Trans Am Neurol Assoc. 1960;85:147–150. [PubMed] [Google Scholar]
  30. FISHER M. Left hemiplegia and motor impresistence. J Nerv Ment Dis. 1956 Mar;123(3):201–218. doi: 10.1097/00005053-195603000-00001. [DOI] [PubMed] [Google Scholar]
  31. Fisher C. M. Communicating hydrocephalus. Lancet. 1978 Jan 7;1(8054):37–37. doi: 10.1016/s0140-6736(78)90378-1. [DOI] [PubMed] [Google Scholar]
  32. Fisher C. M. Nonsense speech--amphigory. Trans Am Neurol Assoc. 1970;95:238–240. [PubMed] [Google Scholar]
  33. Folstein M. F., Folstein S. E., McHugh P. R. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975 Nov;12(3):189–198. doi: 10.1016/0022-3956(75)90026-6. [DOI] [PubMed] [Google Scholar]
  34. Freemon F. R. Evaluation of patients with progressive intellectual deterioration. Arch Neurol. 1976 Sep;33(9):658–659. doi: 10.1001/archneur.1976.00500090064013. [DOI] [PubMed] [Google Scholar]
  35. GOLDIN S., MACDONALD J. E. The Ganser state. J Ment Sci. 1955 Apr;101(423):267–280. doi: 10.1192/bjp.101.423.267. [DOI] [PubMed] [Google Scholar]
  36. GOODMAN L. Alzheimer's disease; a clinico-pathologic analysis of twenty-three cases with a theory on pathogenesis. J Nerv Ment Dis. 1953 Aug;118(2):97–130. [PubMed] [Google Scholar]
  37. Gado M. H., Coleman R. E., Lee K. S., Mikhael M. A., Alderson P. O., Archer C. R. Correlation between computerized transaxial tomography and radionuclide cisternography in dementia. Neurology. 1976 Jun;26(6 Pt 1):555–560. doi: 10.1212/wnl.26.6.555. [DOI] [PubMed] [Google Scholar]
  38. Gajdusek D. C., Gibbs C. J., Jr, Asher D. M., Brown P., Diwan A., Hoffman P., Nemo G., Rohwer R., White L. Precautions in medical care of, and in handling materials from, patients with transmissible virus dementia (Creutzfeldt-Jakob disease). N Engl J Med. 1977 Dec 8;297(23):1253–1258. doi: 10.1056/NEJM197712082972304. [DOI] [PubMed] [Google Scholar]
  39. Gascon G. G., Gilles F. Limbic dementia. J Neurol Neurosurg Psychiatry. 1973 Jun;36(3):421–430. doi: 10.1136/jnnp.36.3.421. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Geschwind N. Non-aphasic disorders of speech. Int J Neurol. 1964;4(3):207–214. [PubMed] [Google Scholar]
  41. Gibbs C. J., Jr, Gajdusek D. C., Asher D. M., Alpers M. P., Beck E., Daniel P. M., Matthews W. B. Creutzfeldt-Jakob disease (spongiform encephalopathy): transmission to the chimpanzee. Science. 1968 Jul 26;161(3839):388–389. doi: 10.1126/science.161.3839.388. [DOI] [PubMed] [Google Scholar]
  42. Hirose G., Bass N. H. Metachromatic leukodystrophy in the adult. A biochemical study. Neurology. 1972 Mar;22(3):312–320. doi: 10.1212/wnl.22.3.312. [DOI] [PubMed] [Google Scholar]
  43. Jellinger K., Seitelberger F., Heiss W. D., Holezabek W. Konjugale Form des subakuten spongiösen Enzephalopathie (Jakob-Creutzfeldt-Erkrankung. Wien Klin Wochenschr. 1972 Apr 14;84(15):245–249. [PubMed] [Google Scholar]
  44. KILOH L. G. Pseudo-dementia. Acta Psychiatr Scand. 1961;37:336–351. doi: 10.1111/j.1600-0447.1961.tb07367.x. [DOI] [PubMed] [Google Scholar]
  45. KRAL V. A. Senescent forgetfulness: benign and malignant. Can Med Assoc J. 1962 Feb 10;86:257–260. [PMC free article] [PubMed] [Google Scholar]
  46. Kahn R. L., Zarit S. H., Hilbert N. M., Niederehe G. Memory complaint and impairment in the aged. The effect of depression and altered brain function. Arch Gen Psychiatry. 1975 Dec;32(12):1569–1573. doi: 10.1001/archpsyc.1975.01760300107009. [DOI] [PubMed] [Google Scholar]
  47. Katzman R. Editorial: The prevalence and malignancy of Alzheimer disease. A major killer. Arch Neurol. 1976 Apr;33(4):217–218. doi: 10.1001/archneur.1976.00500040001001. [DOI] [PubMed] [Google Scholar]
  48. LEWIS A. Amnestic syndromes:the psychopathological aspect. Proc R Soc Med. 1961 Nov;54:955–961. [PubMed] [Google Scholar]
  49. LIDDELL D. W. Investigations of E.E.G. findings in presenile dementia. J Neurol Neurosurg Psychiatry. 1958 Aug;21(3):173–176. doi: 10.1136/jnnp.21.3.173. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Leibowitz U., Sharon D., Alter M. Geographical considerations in multiple sclerosis. Brain. 1968 Mar;91(1):37–52. doi: 10.1093/brain/91.1.37. [DOI] [PubMed] [Google Scholar]
  51. Leventhal C. M., Baringer J. R., Arnason B. G., Fisher C. M. A case of Marchiafavabignami disease with clinical recovery. Trans Am Neurol Assoc. 1965;90:87–91. [PubMed] [Google Scholar]
  52. Maher B. The language of schizophrenia: a review and interpretation. Br J Psychiatry. 1972 Jan;120(554):3–17. doi: 10.1192/bjp.120.554.3. [DOI] [PubMed] [Google Scholar]
  53. Marsden C. D., Harrison M. J. Outcome of investigation of patients with presenile dementia. Br Med J. 1972 Apr 29;2(5808):249–252. doi: 10.1136/bmj.2.5808.249. [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. May W. W., Itabashi H. H., De Jong R. N. Creutzfeldt-Jakob disease. II. Clinical, pathologic, and genetic study of a family. Arch Neurol. 1968 Aug;19(2):137–149. doi: 10.1001/archneur.1968.00480020023002. [DOI] [PubMed] [Google Scholar]
  55. Messert B., Baker N. H. Syndrome of progressive spastic ataxia and apraxia associated with occult hydrocephalus. Neurology. 1966 May;16(5):440–452. doi: 10.1212/wnl.16.5.440. [DOI] [PubMed] [Google Scholar]
  56. Mohr J. P., Watters W. C., Duncan G. W. Thalamic hemorrhage and aphasia. Brain Lang. 1975 Jan;2(1):3–17. doi: 10.1016/s0093-934x(75)80050-2. [DOI] [PubMed] [Google Scholar]
  57. NEUMANN M. A. Combined amyloid vascular changes and argyrophilic plaques in the central nervous system. J Neuropathol Exp Neurol. 1960 Jul;19:370–382. doi: 10.1097/00005072-196007000-00005. [DOI] [PubMed] [Google Scholar]
  58. Ojemann R. G., Fisher C. M., Adams R. D., Sweet W. H., New P. F. Further experience with the syndrome of "normal" pressure hydrocephalus. J Neurosurg. 1969 Sep;31(3):279–294. doi: 10.3171/jns.1969.31.3.0279. [DOI] [PubMed] [Google Scholar]
  59. Pearce J., Aziz H., Gallagher J. C. Primitive reflex activity in primary and symptomatic Parkinsonism. J Neurol Neurosurg Psychiatry. 1968 Oct;31(5):501–508. doi: 10.1136/jnnp.31.5.501. [DOI] [PMC free article] [PubMed] [Google Scholar]
  60. Peck A., Wolloch L., Rodstein M. Mortality of the aged with chronic brain syndrome. J Am Geriatr Soc. 1973 Jun;21(6):264–270. doi: 10.1111/j.1532-5415.1973.tb01689.x. [DOI] [PubMed] [Google Scholar]
  61. Peters B. H., Levin H. S. Memory enhancement after physostigmine treatment in the amnesic syndrome. Arch Neurol. 1977 Apr;34(4):215–219. doi: 10.1001/archneur.1977.00500160029004. [DOI] [PubMed] [Google Scholar]
  62. Pilleri G. Schippenzeichen von Darwin ("Pursing of the Lips") beim Morbus Alzheimer. Psychiatr Neurol (Basel) 1966;152(5):301–305. [PubMed] [Google Scholar]
  63. Prinsley D. M. Psychogeriatric ward for mentally disturbed elderly patients. Br Med J. 1973 Sep 15;3(5880):574–577. doi: 10.1136/bmj.3.5880.574. [DOI] [PMC free article] [PubMed] [Google Scholar]
  64. Rathbone-McCuan E. Geriatric day care: a family perspective. Gerontologist. 1976 Dec;16(6):517–521. doi: 10.1093/geront/16.6.517. [DOI] [PubMed] [Google Scholar]
  65. Reynolds E. H., Rothfeld P., Pincus J. H. Neurological disease associated with folate deficiency. Br Med J. 1973 May 19;2(5863):398–400. doi: 10.1136/bmj.2.5863.398. [DOI] [PMC free article] [PubMed] [Google Scholar]
  66. Ropper A. H., Hatten H. P., Jr, Davis K. R. Computed tomography in Wilson disease: report of 2 cases. Ann Neurol. 1979 Jan;5(1):102–103. doi: 10.1002/ana.410050118. [DOI] [PubMed] [Google Scholar]
  67. Roth M., Tomlinson B. E., Blessed G. Correlation between scores for dementia and counts of 'senile plaques' in cerebral grey matter of elderly subjects. Nature. 1966 Jan 1;209(5018):109–110. doi: 10.1038/209109a0. [DOI] [PubMed] [Google Scholar]
  68. SIM M., SUSSMAN I. Alzheimer's disease: its natural history and differential diagnosis. J Nerv Ment Dis. 1962 Dec;135:489–499. [PubMed] [Google Scholar]
  69. STEELE J. C., RICHARDSON J. C., OLSZEWSKI J. PROGRESSIVE SUPRANUCLEAR PALSY. A HETEROGENEOUS DEGENERATION INVOLVING THE BRAIN STEM, BASAL GANGLIA AND CEREBELLUM WITH VERTICAL GAZE AND PSEUDOBULBAR PALSY, NUCHAL DYSTONIA AND DEMENTIA. Arch Neurol. 1964 Apr;10:333–359. doi: 10.1001/archneur.1964.00460160003001. [DOI] [PubMed] [Google Scholar]
  70. STERNLIEB I., SCHEINBERG I. H. PENICILLAMINE THERAPY FOR HEPATOLENTICULAR DEGENERATION. JAMA. 1964 Sep 7;189:748–754. doi: 10.1001/jama.1964.03070100042008. [DOI] [PubMed] [Google Scholar]
  71. STREJILEVICH S. M. [The nocturnal restlessness of the elderly psychotic]. Encephale. 1962 May-Jun;51:238–262. [PubMed] [Google Scholar]
  72. STUTEVILLE P., WELCH K. Subdural hematoma in the elderly person. J Am Med Assoc. 1958 Nov 15;168(11):1445–1449. doi: 10.1001/jama.1958.03000110019006. [DOI] [PubMed] [Google Scholar]
  73. Scheibel M. E., Lindsay R. D., Tomiyasu U., Scheibel A. B. Progressive dendritic changes in aging human cortex. Exp Neurol. 1975 Jun;47(3):392–403. doi: 10.1016/0014-4886(75)90072-2. [DOI] [PubMed] [Google Scholar]
  74. Schneck L., Volk B. W., Saifer A. The gangliosidoses. Am J Med. 1969 Feb;46(2):245–263. doi: 10.1016/0002-9343(69)90009-6. [DOI] [PubMed] [Google Scholar]
  75. Sim M., Turner E., Smith W. T. Cerebral biopsy in the investigation of presenile dementia. I. Clinical aspects. Br J Psychiatry. 1966 Feb;112(483):119–125. doi: 10.1192/bjp.112.483.119. [DOI] [PubMed] [Google Scholar]
  76. Smith C. M., Swash M. Possible biochemical basis of memory disorder in Alzheimer disease. Ann Neurol. 1978 Jun;3(6):471–473. doi: 10.1002/ana.410030602. [DOI] [PubMed] [Google Scholar]
  77. Sternberg D. E., Jarvik M. E. Memory functions in depression. Arch Gen Psychiatry. 1976 Feb;33(2):219–224. doi: 10.1001/archpsyc.1976.01770020055009. [DOI] [PubMed] [Google Scholar]
  78. Strachan R. W., Henderson J. G. Psychiatric syndromes due to avitaminosis B 12 with normal blood and marrow. Q J Med. 1965 Jul;34(135):303–317. [PubMed] [Google Scholar]
  79. TERRY R. D., GONATAS N. K., WEISS M. ULTRASTRUCTURAL STUDIES IN ALZHEIMER'S PRESENILE DEMENTIA. Am J Pathol. 1964 Feb;44:269–297. [PMC free article] [PubMed] [Google Scholar]
  80. Terry R. D. Dementia. A brief and selective review. Arch Neurol. 1976 Jan;33(1):1–4. doi: 10.1001/archneur.1976.00500010003001. [DOI] [PubMed] [Google Scholar]
  81. Tomlinson B. E., Blessed G., Roth M. Observations on the brains of demented old people. J Neurol Sci. 1970 Sep;11(3):205–242. doi: 10.1016/0022-510x(70)90063-8. [DOI] [PubMed] [Google Scholar]
  82. Tomlinson B. E., Blessed G., Roth M. Observations on the brains of non-demented old people. J Neurol Sci. 1968 Sep-Oct;7(2):331–356. doi: 10.1016/0022-510x(68)90154-8. [DOI] [PubMed] [Google Scholar]
  83. Utz J. P. Histoplasma and cryptococcus meningitis. Res Publ Assoc Res Nerv Ment Dis. 1968;44:378–392. [PubMed] [Google Scholar]
  84. WEINSTEIN E. A., KAHN R. L. Non-aphasic misnaming (paraphasia) in organic brain disease. AMA Arch Neurol Psychiatry. 1952 Jan;67(1):72–79. doi: 10.1001/archneurpsyc.1952.02320130078008. [DOI] [PubMed] [Google Scholar]
  85. Wells C. E. Dementia reconsidered. Arch Gen Psychiatry. 1972 Apr;26(4):385–388. doi: 10.1001/archpsyc.1972.01750220095018. [DOI] [PubMed] [Google Scholar]
  86. Wiśniewski H., Terry R. D., Hirano A. Neurofibrillary pathology. J Neuropathol Exp Neurol. 1970 Apr;29(2):163–176. [PubMed] [Google Scholar]
  87. Wood J. H., Bartlet D., James A. E., Jr, Udvarhelyi G. B. Normal-pressure hydrocephalus: diagnosis and patient selection for shunt surgery. Neurology. 1974 Jun;24(6):517–526. doi: 10.1212/wnl.24.6.517. [DOI] [PubMed] [Google Scholar]

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