Table 1

Bedside assessment of the patient with suspected dementia: a ‘walk around the cognitive brain’

Cognitive domainLeading or early symptomsAssociated symptomsExamination findingsBrain region(s)First thoughts
Behaviour (social and emotional)Loss of empathy/emotional awareness (eg, family events such as funerals, illnesses and warmth toward children/pets) and self-centrednessDisinhibition, loss of initiative, obsessionality/rituals (eg, clock watching), gluttony/sweet tooth/food faddism, altered interests/humour, loss of insight/anosognosiaImpulsive, inert, disinhibited interaction, ‘1000-yard stare’Frontal lobe (especially right), right temporal lobe, otherBehavioural variant frontotemporal dementia
Irritability, more anxious and ‘clingy’Quieter in social situationsDiffident/head turningAlzheimer’s disease*
Language output
(speech sounds, sentences and prosody)
Stumbling over words, especially public speakingMixing up ‘yes’/no’, mispronunciations, monotonous/odd accent,
grammatical/spelling slips
Effortful speech, reduced articulatory agility (repeating syllable strings, eg, ‘puh-kuh-tuh’), impaired repeating single words and following complex commandsLeft inferior frontal gyrus/peri-Sylvian†Non-fluent primary progressive aphasia
Word-finding difficulty, losing thread of sentencesReduced speech quantity, pausesReduced picture namingLeft temporoparietal junctionLogopenic aphasia
Knowledge of words (vocabulary), objects and conceptsForgetting names, circumlocutions, vague expressing thoughts and ‘going deaf’Asking meaning of words, keeping personal ‘dictionaries’ and decline in spelling/understanding written wordsReduced knowledge of specialist vocabulary,‡ reduced naming of objects/ability to identify pictures/define words named by examiner, surface dyslexia (irregular words, eg, ‘yacht’)Left anteroinferior temporal lobeSemantic primary progressive aphasia
Difficulty choosing groceries/tools, etc§Unable to describe/demonstrate use of an object§ (visual agnosia)
Reading, spelling and calculationLoss of pleasure reading
Less numerical facility (eg, change)
Losing place reading text, difficulty resolving closely spaced text and decline in spelling abilityDifficulty reading blocked text and acalculia on simple mental arithmeticLeft parietal lobePosterior cortical atrophy, logopenic aphasia and Alzheimer’s disease
Working memory (verbal)Poor ‘concentration’Difficulty holding information for example, a new phone number in mind
Losing thread of conversation
Reduced forward (passive) digit span, reduced reverse (active) digit span and reduced repetition of phrases more than wordsLeft temporoparietal junction/frontal lobeLogopenic aphasia and Alzheimer’s disease
Action (learnt/voluntary: praxis)Difficulty learning new devices, loss of facility with do-it-yourself, etcDifficulty using household gadgetsIdeomotor limb apraxia: impaired copying meaningless/sequential gestures (Luria), ideational limb apraxia: impaired pantomime of learnt actions (eg, tool, waving)Left parietal lobePosterior cortical atrophy and corticobasal syndrome
Difficulty positioning self in spaceBottom apraxia (difficulty sitting on chair)
Loss of facility whistling/singingDifficulty swallowingOrofacial apraxia: volitional cough/yawn/blow kiss, etcLeft frontal lobe†Non-fluent primary progressive aphasia
Object analysis (visual)Difficulty reading large/unusual (eg, pixelated/CAPTCHA) font;
not confident on escalators;
often multiple optician visits
Difficulty interpreting complex scenes with patterns, overlaid objects, identifying slopes/steps, etc;
difficulty recognising or misrecognising objects in suboptimal viewing conditions
Difficulty perceiving fragmented letters/pictures, distorted viewsRight parietal lobePosterior cortical atrophy and dementia with Lewy bodies
Spatial awareness (visual)Bumps/scrapes in car, difficulty parking and difficulty filling forms, etcUnable to find items in an array, placing items too close to table edgeDifficulty drawing clockface/copying design/counting dots, finding examiner’s outstretched hand (visual disorientation)Right parietal lobePosterior cortical atrophy and Alzheimer’s disease
(early sensory–visual, auditory, somatic and interoceptive)
Difficulty driving if night-time/rainingAbnormally prolonged after-images (colour ‘washes’, often red/green), visual ‘tilt’ and other distortionsImpaired colour/shape discrimination (e.g., oblong vs square)Sensory cortices/thalamus¶Posterior cortical atrophy, ‘visual’ Creutzfeldt-Jakob disease
‘Double vision’, brief misperceptionsIllusions/hallucinationsCheck visual acuityDementia with Lewy bodies
Dislikes noisy environmentsDifficulty conversing in noiseCheck peripheral hearingAlzheimer’s disease and variants
Tinnitus/hyperacusisAltered pain/temperature awarenessCheck basic sensory functionSemantic primary progressive aphasia and behavioural variant frontotemporal dementia
Face recognitionLoss of facility recognising faces‘Blanking’ familiar people and misidentification of ‘impostors’Impaired famous face recognition**Right anteroinferior temporal lobe and connectionsSemantic primary progressive aphasia and right temporal lobe atrophy††
Impaired perception of faces (age/gender)Right temporal lobe/parietal lobeAlzheimer’s disease and dementia with Lewy bodies
Executive functionDisorganised, distractible, poor planning/decision making/multitasking/prioritising, apatheticDifficulty with inference/abstraction, choosing alternatives, envisaging/learning from consequences and dealing with noveltyReduced/bizarre verbal fluency (category/letter–number of animals/‘S’ words in 1 min),‡‡ Stroop task errors, concrete proverb interpretation, inaccurate cognitive estimates (eg, ‘How many lions in Belgium?’)§§¶¶Bilateral frontal lobe and connectionsMay be behavioural variant frontotemporal dementia but depends on associated problems
Memory (episodic and topographical)More repetitive and less facility with route findingVague knowledge of current affairs and getting lostOrientation to date/time/place, details of hospital journey/stay and incidental recall of pictures from naming testHippocampi and connectionsAlzheimer’s disease (but beware)
Forgetful, absent-mindedPoor concentration, disorganisedImproves on cueing/foils; ‘Did you see a…?’)Vascular/other
  • This table presents early symptoms (‘canaries’; see also table 2) that signal difficulty in each major cognitive domain, together with associated symptoms that may be elicited on history. For each domain, we suggest bedside tests (see also box 1) and features that may be used to corroborate the historical impression and indicate major neuroanatomical associations (see also figure 2) and leading diagnostic considerations.

  • *Refers to the clinical syndrome of typical (memory-led) Alzheimer’s disease.

  • †Prosody/ singing may be additionally linked to right peri-Sylvian cortical regions

  • ‡Initial loss of knowledge of lower-frequency words reflecting patient’s interests/occupation.

  • §May indicate visual agnosia (the patient with apraxia recognises how an object is used).

  • ¶Usually conjoint ‘top-down’ abnormalities in attentional/executive/semantic functions.

  • **Ask for other biographical details if patient cannot name.

  • ††Refers to the syndrome associated with right temporal lobe atrophy, within the behavioural variant frontotemporal dementia spectrum.

  • ‡‡In non-aphasic patients.

  • §§Dependent on education and culture.

  • ¶¶The manner in which the patient approaches executive tests is also informative, for example, are they impulsive? do they produce odd items on fluency tasks? do they produce overprecise, incorrect estimates that they cannot revise? etc.