Brit.J. P.@ychiat. (zg77), 130, 131—3
Neurological
Investigation
By G. C. VICTORATOS,
Summary. first
seen
Fifty-two as
J. A. R. LENMAN
patients
neurological
of Dementia
thought
out-patients
and L. HERZBERG
to be suffering were
fully
from dementia
when
investigated.
Four of them were found to have tumours, whilst in five the dementia was due to a treatable cause. Neither a long history nor an age above sixty-five precludes a dementia being due to a treatablecause.
Tests, Urea and Electrolytes.
INTRODUCTION
PBI, T3 Index;
Patients with dementia constitute a substan tial proportion of referrals to a neurological clinic.
B12,
logist
after the air study she had not returned pre-investigation state.
Folate,
WR,
CSF;
chest
x-ray,
skull
x-ray,
EEG. Technetium Scan. Psychometry (Modi fied WAIS). The continuinginterest in some of the causes Almost all patients had a lumbar air ence of reversible dementia and the introduction of phalogram (AEG), and all patients had radio new methods of investigation in recent years has iodinated serum-albumen scan when it became prompted us to review, retrospectively, the available. No brain biopsies were performed. patientsadmitted to a Neurology Department One of our patients, a woman of 59, de veloped serious complications from her in with the diagnosis of dementia. vestigations. Before investigation she had mini :M:ETH0DS mal intellectual impairment but after an AEG Between June 1962 and December 1974, she became unconscious, responding only to 52 patients with dementia were investigated in a painful stimuli. The AEG showed cerebral neurological bed at the Dundee Royal In atrophy. She gradually improved but had to be firmary. All patients were assessed by a neuro admitted to a psychiatric hospital. Six months prior
to
admission.
The
criterion
for
inclusion in the survey was that the tentative diagnosis of dementia had been made at the time of the initial examination. To eliminate the possibility that some patients might have
to her
RESULTS
In
23 patients
(45%)
the
AEG
showed
been indexed under the heading of theirfinal evidence of cerebral afrophy. In 7 patients (14%) the AEG was normal and the rest of the in diagnosis only, the case notes of all patients
discharged with a diagnosis of a condition known to cause dementia were also reviewed. The large majority of patients had been referred by psychiatrists, and the rest by physicians or rarely directly from a general practitioner. Of
vestigations
the 52 patients,20 (@@%) were female and 23 (i@%)
male;
the
age
range
was
from
40
to
out:
Hb,
WBC.
ESR,
Liver
no basis for determining
changes on carotid angiography. Four patients (i6%) were found to have tumours, all of which were gliomas. In two cases (@%) the diagnosis of dementia was not substantiated by in-patient
73.
Forty-four patients were below the age of 65. All patients were investigated in a similar manner, the following investigations being carried
provided
the pathology underlying the dementia. Five patients (i o%) were thought to have arterio sclerotic dementia; this diagnosis was based on a previous history of strokes and hypertension. Two of these patients showed arteriosclerotic
Function
observation and investigations. Parkinsonism, 131
NEUROLOGICAL INVESTIGATION OF DEMENTIA
132
series. The diagnosis in the patients with potentially treatable causes of dementia is shown in the
with a 50% rate of improvement. Another group of patients, although initially thought to be demented are subsequently found to be suffering from other conditions, usually depres.. sion (Kiloh 1961). This depressive pseudo dementia is treatable. In others, the diagnosis of dementia is not confirmed by in-patient observa tion and pyschometry. This group constituted
Table.
14%
Creutzfeldt-Jacob
disease,
post-traumatic
de
mentia, cerebellar degeneration and dementia due to cerebral anoxia were diagnosed in 5 other patients (20%). There was only one case (2%)
of communicating
hydrocephalus
in
this
TABLE Potentially
treatable causes of dementia in a series of
fifty-two patients of
PatientAgeLength historyDiagnosisI553 yearsAlcoholism266i6
monthsSubdural haematoma366i8 aneurysm4553 monthsGiant yearsNeurosyphilis56i3
yearsCommunicating hydrocephalus DISCUSSION
In a small proportion of demented patients the underlying cause is remediable and should be sought. One group of treatable patients consists of those with space-occupying lesions. Although gliomas are the commonest, meningiomas (Hun
in
one
series
(Marsden,
1972).
In our series the dementia was due to a potentially remediable cause in five patients (i o%).—one
alcoholic,
one
chronic
subdural,
one giant aneurysm, one with neurosyphilis and one with communicating hydrocephalus. We wish to emphasize that the arbitrary age of 6o (or 65) which is sometimes used to classify dementias into senile or pre-senile is potentially misleading and should be abandoned. Two of the five cases with treatable causes were above the age of 65 and one of them improved with treatment. We therefore recommend that a patient should not be denied investigation on the basis of advanced age. It is essential to consider all the circumstances of each individual patient. The length of history, although perhaps impor tant
in cases of communicating
hydrocephalus
(Messert ci a!, 1974), does not preclude success ful treatment in cases of dementia due to other causes (Strachan ci a!, 1965, Olivarious et a!, 1970).
All
our
five
patients
with
treatable
causes
had a history longer than a year, and three tereta!,1968),colloidcystsand other benign improved with treatment. tumours (Riddoch, 1936), subdural haematomas At present we feel that each case must be and giant aneurysms (Bull, 1969) can present as judged individually. The potential morbidity dementia. of the investigations, the inconvenience to the In one series (Marsden, 1972) io% of patients patient and the availability of beds must be presentingwith dementia had an underlying balanced against the possibility of discovering space-occupying lesion, a finding corresponding a treatable lesion. closely to the i i % of the Dundee series. The advent of the EMI Scanner should not A number of other treatable conditions are blind clinicians to causes of dementia which are known to cause dementia, and these include not due to space-occupying lesions. Endocrine, neurosyphilis, alcoholism, hypothyroidism (011- infective and metabolic causes in particular are varius et al, ‘¿ 97°)B12 deficiency (Strachan in danger of being overlooked. ci a!, 1965) and hypocalcaemia (Robinson eta!, 1954). In 1965,
REFERENCES
Adams
ci al, reported
successful
treatment of dementia associated with normal pressure hydrocephalus, using a CSF shunt procedure. Since then a considerable number of patients have been treated in a similar way,
,.Ai@uss,
R. D., Fissssa,
C. M.,
H@xn,
S., OJERILMQç
R. G. & SwEET,W. H. (1965)Symptomaticoccult hydrocephalus
with
‘¿ normal'CSF fluid pressure.
Xew EnglandJournal of Medicine,273, 1,7. 2. BULL,
J.
(1969)
Massive
brain. Brain, 92, 535.
aneury3ms
at the
base
of the
G. C. VICTORATOS, J. A. R. LENMAN 3.HUNTER, R., BLACKWOOD, W. & Buu@,J. (1968)
Three
cases of subarachnoid
presenting
psychiatrically.
haemorrhage
British Medical Journal,
iii, 9—15. 4.Kn@ou,L. G. (i96i)Pseudo-dementia. ActaPsychi africaScandinavica37,336—51. 5. MARSDEN, C. D. & HARRISON,M. J. G. (1972) Out
come of investigation of patients with presenile dementia. British MedicalJournal, ii@249-52.
@
6. MESSERT,B. & [email protected],B. (1974) Reappraisal of the adult occult hydrocephalus Minneap, 224—31.
syndrome.
Neurology,
‘¿ 33
AND L. HERZBERG
7. Ouv@iuus, B.DEF. & RöDER, E. (i@7o) Reversible psychosis and dementia in Psychiatrica Scandinavica, 46,1. 8. RIDDOCH, G. (1936) Progressive
myxoedema. dementia
Ada without
headaches or changes in the optic discs due to
tumours of the third ventricle. Brain, 59, 225. 9.ROBINSON, K. C., KALLBERO, M. H. & CRowuw,
M. F. (z9@) Idiopathic hypoparathyroidism presenting
as dementia.
British Medical Journal, ii,
1203.
io. Sm@cw@i,R. W. & HENDERSON,J. G. (1965)Psychia.. tric syndromes
due to avitaminosis
B12 with normal
blood and marrow. QparterlyJournal of Medicine, 303.
G. C. Victoratos, F.R.C.S. Registrar in Neurology, Dundee Teaching Hospitals
J. A. R. Lenman,M.R.C.P., Consultant Neurologist, DundeeTeaching Hospitals L. Herzberg, M.R.C.P.,Senior Registrar in Neurology, Dundee Teaching Hospitals Address for Correspondence: G. C. Victoratos, F.R.C.S.,Senior Registrar in Neurosurgery, University Hospital of Wales, Cardil@ (Received 29 March;
revised 20 July 1976)
Neurological
Investigation
By G. C. VICTORATOS,
Summary. first
seen
Fifty-two as
J. A. R. LENMAN
patients
neurological
of Dementia
thought
out-patients
and L. HERZBERG
to be suffering were
fully
from dementia
when
investigated.
Four of them were found to have tumours, whilst in five the dementia was due to a treatable cause. Neither a long history nor an age above sixty-five precludes a dementia being due to a treatablecause.
Tests, Urea and Electrolytes.
INTRODUCTION
PBI, T3 Index;
Patients with dementia constitute a substan tial proportion of referrals to a neurological clinic.
B12,
logist
after the air study she had not returned pre-investigation state.
Folate,
WR,
CSF;
chest
x-ray,
skull
x-ray,
EEG. Technetium Scan. Psychometry (Modi fied WAIS). The continuinginterest in some of the causes Almost all patients had a lumbar air ence of reversible dementia and the introduction of phalogram (AEG), and all patients had radio new methods of investigation in recent years has iodinated serum-albumen scan when it became prompted us to review, retrospectively, the available. No brain biopsies were performed. patientsadmitted to a Neurology Department One of our patients, a woman of 59, de veloped serious complications from her in with the diagnosis of dementia. vestigations. Before investigation she had mini :M:ETH0DS mal intellectual impairment but after an AEG Between June 1962 and December 1974, she became unconscious, responding only to 52 patients with dementia were investigated in a painful stimuli. The AEG showed cerebral neurological bed at the Dundee Royal In atrophy. She gradually improved but had to be firmary. All patients were assessed by a neuro admitted to a psychiatric hospital. Six months prior
to
admission.
The
criterion
for
inclusion in the survey was that the tentative diagnosis of dementia had been made at the time of the initial examination. To eliminate the possibility that some patients might have
to her
RESULTS
In
23 patients
(45%)
the
AEG
showed
been indexed under the heading of theirfinal evidence of cerebral afrophy. In 7 patients (14%) the AEG was normal and the rest of the in diagnosis only, the case notes of all patients
discharged with a diagnosis of a condition known to cause dementia were also reviewed. The large majority of patients had been referred by psychiatrists, and the rest by physicians or rarely directly from a general practitioner. Of
vestigations
the 52 patients,20 (@@%) were female and 23 (i@%)
male;
the
age
range
was
from
40
to
out:
Hb,
WBC.
ESR,
Liver
no basis for determining
changes on carotid angiography. Four patients (i6%) were found to have tumours, all of which were gliomas. In two cases (@%) the diagnosis of dementia was not substantiated by in-patient
73.
Forty-four patients were below the age of 65. All patients were investigated in a similar manner, the following investigations being carried
provided
the pathology underlying the dementia. Five patients (i o%) were thought to have arterio sclerotic dementia; this diagnosis was based on a previous history of strokes and hypertension. Two of these patients showed arteriosclerotic
Function
observation and investigations. Parkinsonism, 131
NEUROLOGICAL INVESTIGATION OF DEMENTIA
132
series. The diagnosis in the patients with potentially treatable causes of dementia is shown in the
with a 50% rate of improvement. Another group of patients, although initially thought to be demented are subsequently found to be suffering from other conditions, usually depres.. sion (Kiloh 1961). This depressive pseudo dementia is treatable. In others, the diagnosis of dementia is not confirmed by in-patient observa tion and pyschometry. This group constituted
Table.
14%
Creutzfeldt-Jacob
disease,
post-traumatic
de
mentia, cerebellar degeneration and dementia due to cerebral anoxia were diagnosed in 5 other patients (20%). There was only one case (2%)
of communicating
hydrocephalus
in
this
TABLE Potentially
treatable causes of dementia in a series of
fifty-two patients of
PatientAgeLength historyDiagnosisI553 yearsAlcoholism266i6
monthsSubdural haematoma366i8 aneurysm4553 monthsGiant yearsNeurosyphilis56i3
yearsCommunicating hydrocephalus DISCUSSION
In a small proportion of demented patients the underlying cause is remediable and should be sought. One group of treatable patients consists of those with space-occupying lesions. Although gliomas are the commonest, meningiomas (Hun
in
one
series
(Marsden,
1972).
In our series the dementia was due to a potentially remediable cause in five patients (i o%).—one
alcoholic,
one
chronic
subdural,
one giant aneurysm, one with neurosyphilis and one with communicating hydrocephalus. We wish to emphasize that the arbitrary age of 6o (or 65) which is sometimes used to classify dementias into senile or pre-senile is potentially misleading and should be abandoned. Two of the five cases with treatable causes were above the age of 65 and one of them improved with treatment. We therefore recommend that a patient should not be denied investigation on the basis of advanced age. It is essential to consider all the circumstances of each individual patient. The length of history, although perhaps impor tant
in cases of communicating
hydrocephalus
(Messert ci a!, 1974), does not preclude success ful treatment in cases of dementia due to other causes (Strachan ci a!, 1965, Olivarious et a!, 1970).
All
our
five
patients
with
treatable
causes
had a history longer than a year, and three tereta!,1968),colloidcystsand other benign improved with treatment. tumours (Riddoch, 1936), subdural haematomas At present we feel that each case must be and giant aneurysms (Bull, 1969) can present as judged individually. The potential morbidity dementia. of the investigations, the inconvenience to the In one series (Marsden, 1972) io% of patients patient and the availability of beds must be presentingwith dementia had an underlying balanced against the possibility of discovering space-occupying lesion, a finding corresponding a treatable lesion. closely to the i i % of the Dundee series. The advent of the EMI Scanner should not A number of other treatable conditions are blind clinicians to causes of dementia which are known to cause dementia, and these include not due to space-occupying lesions. Endocrine, neurosyphilis, alcoholism, hypothyroidism (011- infective and metabolic causes in particular are varius et al, ‘¿ 97°)B12 deficiency (Strachan in danger of being overlooked. ci a!, 1965) and hypocalcaemia (Robinson eta!, 1954). In 1965,
REFERENCES
Adams
ci al, reported
successful
treatment of dementia associated with normal pressure hydrocephalus, using a CSF shunt procedure. Since then a considerable number of patients have been treated in a similar way,
,.Ai@uss,
R. D., Fissssa,
C. M.,
H@xn,
S., OJERILMQç
R. G. & SwEET,W. H. (1965)Symptomaticoccult hydrocephalus
with
‘¿ normal'CSF fluid pressure.
Xew EnglandJournal of Medicine,273, 1,7. 2. BULL,
J.
(1969)
Massive
brain. Brain, 92, 535.
aneury3ms
at the
base
of the
G. C. VICTORATOS, J. A. R. LENMAN 3.HUNTER, R., BLACKWOOD, W. & Buu@,J. (1968)
Three
cases of subarachnoid
presenting
psychiatrically.
haemorrhage
British Medical Journal,
iii, 9—15. 4.Kn@ou,L. G. (i96i)Pseudo-dementia. ActaPsychi africaScandinavica37,336—51. 5. MARSDEN, C. D. & HARRISON,M. J. G. (1972) Out
come of investigation of patients with presenile dementia. British MedicalJournal, ii@249-52.
@
6. MESSERT,B. & [email protected],B. (1974) Reappraisal of the adult occult hydrocephalus Minneap, 224—31.
syndrome.
Neurology,
‘¿ 33
AND L. HERZBERG
7. Ouv@iuus, B.DEF. & RöDER, E. (i@7o) Reversible psychosis and dementia in Psychiatrica Scandinavica, 46,1. 8. RIDDOCH, G. (1936) Progressive
myxoedema. dementia
Ada without
headaches or changes in the optic discs due to
tumours of the third ventricle. Brain, 59, 225. 9.ROBINSON, K. C., KALLBERO, M. H. & CRowuw,
M. F. (z9@) Idiopathic hypoparathyroidism presenting
as dementia.
British Medical Journal, ii,
1203.
io. Sm@cw@i,R. W. & HENDERSON,J. G. (1965)Psychia.. tric syndromes
due to avitaminosis
B12 with normal
blood and marrow. QparterlyJournal of Medicine, 303.
G. C. Victoratos, F.R.C.S. Registrar in Neurology, Dundee Teaching Hospitals
J. A. R. Lenman,M.R.C.P., Consultant Neurologist, DundeeTeaching Hospitals L. Herzberg, M.R.C.P.,Senior Registrar in Neurology, Dundee Teaching Hospitals Address for Correspondence: G. C. Victoratos, F.R.C.S.,Senior Registrar in Neurosurgery, University Hospital of Wales, Cardil@ (Received 29 March;
revised 20 July 1976)
