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Table 21-3 Bedside classi cation of the dementias I Diseases in which dementia is associated with clinical and laboratory signs of other medical diseases A AIDS HIV infection B Endocrine disorders: hypothyroidism, Cushing syndrome, rarely hypopituitarism C Nutritional de ciency states: Wernicke-Korsakoff syndrome, subacute combined degeneration (vitamin B12 de ciency), pellagra D Chronic meningoencephalitis: general paresis, meningovascular syphilis, cryptococcosis E Hepatolenticular degeneration familial (Wilson disease) and acquired F Chronic drug intoxications (including CO poisoning) G Prolonged hypoglycemia or hypoxia H Paraneoplastic limbic encephalitis I Heavy metal exposure: arsenic, bismuth, gold, manganese, mercury J Dialysis dementia (now rare) II Diseases in which dementia is associated with other neurologic signs but not with other obvious medical diseases A Invariably associated with other neurologic signs 1 Huntington chorea (choreoathetosis) 2 Multiple sclerosis, Schilder disease, adrenal leukodystrophy, and related demyelinative diseases (spastic weakness, pseudobulbar palsy, blindness) 3 Lipid-storage diseases (myoclonic seizures, blindness, spasticity, cerebellar ataxia) 4 Myoclonic epilepsy (diffuse myoclonus, generalized seizures, cerebellar ataxia) 5 Subacute spongiform encephalopathy; Creutzfeldt-Jakob disease; Gerstmann-Strausler-Scheinker disease (prion, myoclonic dementias) 6 Cerebrocerebellar degeneration (cerebellar ataxia) 7 Cerebrobasal ganglionic degenerations (apraxia-rigidity) 8 Dementia with spastic paraplegia 9 Progressive supranuclear palsy (falls, vertical gaze palsy) 10 Parkinson disease 11 Amyotrophic lateral sclerosis (ALS) and ALS-Parkinson-dementia complex 12 Other rare hereditary metabolic diseases B Often associated with other neurologic signs 1 Multiple thrombotic or embolic cerebral infarctions and Binswanger disease 2 Brain tumor (primary or metastatic) or abscess 3 Brain trauma, such as cerebral contusions, midbrain hemorrhages, chronic subdural hematoma 4 Lewy-body disease (parkinsonian features) 5 Communicating, normal-pressure, or obstructive hydrocephalus (usually with ataxia of gait) 6 Progressive multifocal leukoencephalitis 7 Marchiafava-Bignami disease (often with apraxia and other frontal lobe signs) 8 Granulomatous and other vasculitides of the brain 9 Viral encephalitis (herpes simplex) III Diseases in which dementia is usually the only evidence of neurologic or medical diseases A Alzheimer disease B Pick disease C Some cases of AIDS D Progressive aphasia syndromes E Frontotemporal and frontal lobe dementias associated with tau deposition, Alzheimer change, or with no speci c pathologic alteration F Degenerative disease of unspeci ed type.

Note: The special clinical features and morbid anatomy of these many dementing diseases are discussed in appropriate chapters throughout this book, particularly Chap 39 on degenerative disorders, Chaps 37 and 41 on metabolic and nutritional disturbances, and Chap 33 on chronic infections

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seem somewhat cumbersome and not based on newer genetic and molecular models However, it is likely to be more useful to the student or physician not conversant with the many diseases that cause dementia

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Although confusion or dementia per se does not indicate a particular disease, certain combinations of symptoms and neurologic signs are more or less characteristic and may aid in diagnosis The age of the patient, the mode of onset of the dementia, its clinical course and time span, the associated neurologic signs, and the accessory laboratory data constitute the basis of differential diagnosis It must be admitted, however, that some of the rarer types of degenerative brain disease are at present recognized mainly by pathologic examination The correct diagnosis of treatable forms of dementia subdural hematoma, certain brain tumors, chronic drug intoxication, normal-pressure hydrocephalus, AIDS (reversible to some extent), neurosyphilis, cryptococcosis, pellagra, vitamin B12 and thiamine de ciency states, hypothyroidism, and other metabolic and endocrine disorders is, of course, of greater practical importance than the diagnosis of the untreatable ones Also important is the detection of a depressive illness, which may masquerade as dementia, and chronic intoxication with drugs or chemical agents, both of which are treatable The rst task in dealing with this class of patients is to verify the presence of intellectual deterioration and personality change It may be necessary to examine the patient serially before one is con dent of the clinical ndings and their chronicity A mild aphasia from a focal brain lesion must not be mistaken for dementia Aphasic patients appear uncertain of themselves, and their speech may be incoherent Careful attention to the patient s language performance will lead to the correct diagnosis in most instances Further observation will disclose that the patient s behavior, except that which is related to the language disorder, is not abnormal Similarly, aside from certain dementing diseases that begin with prominent components of apraxia alone, an apractic disorder from a stroke should not be misinterpreted as dementia It is a clinical truism that the abrupt onset of mental symptoms points to a delirium or other type of acute confusional state and occasionally to a stroke; inattention, perceptual disturbances, and often drowsiness are conjoined (Chap 20) Also, progressive deafness or loss of sight in an elderly person may sometimes be misinterpreted as dementia There is always a tendency to assume that mental function is normal if a patient complains only of nervousness, fatigue, insomnia, or vague somatic symptoms and to label the patient as anxious This will be avoided if one keeps in mind that a neurosis rarely has its onset in middle or late adult life A practical rule is to assume that all mental illnesses beginning during this period are due either to structural disease of the brain or to depression Clues to the diagnosis of depression are the presence of frequent sighing, crying, loss of energy, psychomotor underactivity or its opposite, agitation with pacing, persecutory delusions, persistent hypochondriasis, and a history of depression in the past and in the family Although depressed patients may complain of memory failure, scrutiny of their complaints will show that they can usually remember the details of their illness and that little or no qualitative change in other intellectual functions has taken place Their dif culty is either a lack of energy and interest or preoccu-.

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