Cortical vs Subcortical Dementia
Neuropsychological Differences
Steven J. Huber, MA; Edwin C. Shuttleworth, MD;
Maree J. G. Bellchambers, MS; Lawrence E. Clapp
\s=b\ The distinction between cortical and
subcortical syndromes of dementia is
controversial. Clinical reports suggest
that subcortical syndromes (eg, Parkin-
son's disease) involve less severe intel-
lectual and memory dysfunction and lack
the aphasia, agnosia, and apraxia typical
of the cortical dementias (eg, dementia of
the Alzheimer type). A recent neuropsy-
chological investigation using a standard-
ized procedure failed to confirm the
distinction. We examined patients with
Alzheimer's disease, patients with Parkin-
son's disease, and normal controls by
using a neuropsychological procedure
specifically designed to quantitatively
evaluate the proposed clinical differ-
The results differentiated these
ences.
dementia syndromes, and the pattern of
performance was consistent with the cor-
tical-subcortical hypothesis.
(Arch Neurol 1986;43:392-394)
T~\ementia is classically associated
with degenerative disorders of the
cerebral cortex, and dementia of the
Alzheimer type (DAT) is the most
common example. Dementia is also
seen in neurologic disorders that
involve predominately subcortical
structures such as the basal ganglia
and brain stem; progressive supranu-
clear palsy,1 Huntington's disease
(HD),2 and Parkinson's disease (PD)3 5
are examples. The nature of the dif-
Accepted for publication Nov 6, 1985.
From the Department of Neurology, Ohio
State University College of Medicine, Colum-
bus.
Reprint requests to Department of Neurology,
439 Means Hall, 1655 Upham Dr, Columbus, OH
43210 (Mr Huber).
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George W. Paulson, MD;
ferences, if any, between cortical and
subcortical dementia syndromes is
controversial.
Cortical and subcortical dementia
syndromes have been clinically de¬
scribed as quite different.6'8 The pro¬
gressive intellectual and memory dys¬
function of DAT may be more severe
and progress more rapidly than that
of the subcortical syndromes. In addi¬
tion, the hallmarks of cortical demen¬
tia, aphasia, agnosia, and apraxia, are
typically absent in subcortical disor¬
ders. Patients with subcortical dis¬
eases are described as apathetic and
often depressed, whereas patients
with DAT often lack insight and tend
not to be depressed. Finally, subcorti-
cal disorders often are linked with
movement disorders, such as the
rigidity and bradykinesia of PD or the
chorea of HD.
Despite these well-described clini¬
cal distinctions, some researchers
question the validity of the entire
concept of a subcortical dementia. Of
the proposed subcortical dementia
syndromes, PD may be the most con¬
troversial. Recent research has sug¬
gested that the mental deterioration
seen in PD may result from cortical
degeneration superimposed on the
subcortical degeneration responsible
for the motor disturbance. Neuro-
pathologic reports have noted that the
pattern of cortical degeneration seen
in DAT (senile plaques and neurofi-
brillary tangles) can also be present in
patients with PD.910 Neuropsychologi¬
cal studies have also suggested that
the clinical aspects of dementia in
patients with DAT and PD are simi¬
lar. Mayeux and associates" compared
performance on a lengthened version
of the Mini-Mental State Examina¬
tion12 and found no systematic pattern
of deficits associated with these disor¬
ders. However, the procedure used
was designed to confirm the presence
and assess the severity of dementia
and was not intended to evaluate spe¬
cific differences between dementing
disorders. It is possible that both
groups of patients achieved low scores
on this mental status scale for differ¬
ent reasons.
We examined the possible distinc¬
tion between cortical and subcortical
dementia by using a neuropsychologi¬
cal test battery that was specifically
designed to evaluate the proposed
clinical differences. This battery
included measures of overall mental
function, memory, language, apraxia,
attention, and visuospatial skills, and
a scale for depression.
SUBJECTS AND METHODS
Subjects
Fourteen patients who met currently
accepted criteria1314 for DAT were exam¬
ined. Other possible sources of dementia
were excluded by appropriate laboratory
evaluation that included computed tomog¬
raphy and electroencephalography. The
modified Hachinski Ischemie Rating
Scale" was also used to aid in excluding
multi-infarct dementia. This patient group
had a mean age of 65.3 years and 14.9 years
of formal education. All patients met the
definition of dementia as proposed by
Cummings and Benson.'
Thirty-eight patients with idiopathic PD
were examined. All patients were receiving
some form of medication to alleviate clini¬
cal symptoms, but none had undergone
thalamotomy. This group had a mean age
of 64.9 years and 14.7 years of formal
 on these tests suggest the presence of
visual agnosia, anomia, or both.
Memory.—Immediate memory was as¬
sessed by the digit span procedure.18 Sub¬
jects were to repeat sets of numbers
increasing in length in the same order in
which they were presented. Acquisition
memory was assessed using the paired-
associate technique in which a list of ten
word pairs (six easy and four hard) were
read to the subject, and the task was to
provide the appropriate second item when
given the first. Significant failure on this
test may indicate impairment of attention
(digit span) or impairment of short-term
memory (paired associates).
Apraxia.—Subjects performed five com¬
mon motor sequences (eg, threading a nee¬
dle)." Inability to perform these actions
was considered indicative of ideomotor
apraxia.
Visuospatial Ability.—Subjects were pre¬
sented with a systematic visual array with
a blank area and with six alternatives, of

Percentage deviation from control performance (100%) for patients with Parkinson's disease which only one completed the pattern.20
(solid bars) and patients with dementia of Alzheimer type (shaded bars); asterisk indicates Impairment on this test was thought to
performance not significantly different from that of controls. indicate visuospatial dysfunction.
Trail Making Task A.—Subjects were to
connect circles in ascending order (one
through 25) as quickly as possible.21 Fail¬
ure to complete this task resulted in a
Performance of Patients With PD and DAT and Controls
maximum score of 300 s. This task assessed
on Neuropsychological Measures* sequencing and visuomotor ability.
Group Zung Self-rated Depression Scale.—Sub¬
Differences jects were to complete a questionnaire that
Control, PD, DAT, quantifies level of depression.22
Measure Mean ± SD Mean ± SD Mean ± SD
Age, yr 61.65 ± 11.1 64.95 ±9.7 65.29±10.3 0.79 RESULTS
Education, yr 15±2.9 14.68±2.8 NS
Mini-Mental State 29.65±0.6t 27.16±3.8* 18.54±6.2 Performances of patient and con¬
Orientation 10±0 9.5 ±1.5* 5.9±2.8 28.73 .01 trol groups were analyzed by analysis
Registration 3±0 2.9±0.16 of variance and planned comparisons
Calculation 4.7±0.6t 3.7 ±1.4* 1.7± 1.7 (Newman-Keuls) to detect specific
Recall 3±0 2.8±0.68* 1.1 ± 1.23 group differences. Patients and con¬
Language 9±0t 8.4 ±1.0* 18.66 .01 trols were comparable in age (F
Vocabulary 10±0 9.9 ±0.39* 10.59 .01 [2,69] 0.79) and years of formal edu¬
=

Naming 9.9±0.3 9.5 ±0.86* cation (F [2,69] 0.09). Of the 16

=

Fluency 13.1 ±4.56* measures, only Registration

Digit Span 6.8± 1.6 5.7±1.9 NS (F [2,69] 2.4) and Digit Span (F
=

Paired Associates 16.1 ±3.1t 12.5±3.9* 5.6±2.9 37.56 .01 [2,69] 2.67) resulted in a nonsignifi¬
=

Apraxia 5±0 4.9±0.39* 23.39 .01 cant overall difference between

Visuospatial 5.2±0.7t 4.2 ± 1.3* groups. Since these procedures are
Trails A (s) 37.7± 15.3 65.9 ±49.9* 218.7± 1.6 basically measures of attentiveness,

Depression 30.2 ± 7.9t
*PD indicates Parkinson s disease; DAT, dementia of the Alzheimer type; NS, not significant.
\P < .05, control vs PD.
*P < .05, PD vs DAT.
education. All patients met the definition
of dementia as proposed by Cummings and
Benson.'
Twenty normal controls with no known
neurologic disorders or history of alcohol¬
ism were also examined. Many of these
subjects were spouses of patients in either
of the two patient groups. This group had a
mean age of 61.7 years and 15 years of
formal education. All subjects gave
informed consent.
Procedures
Mini-Menial State Examination.—This is
a brief evaluation of mental functioning.12
40.8 ±9.4 37.6± 10.6 8.59
Subtests include orientation, registration,
calculation, recall, and language.
Language.—Verbal fluency16 was tested
by asking subjects to generate as many
words as possible that begin with s or in
60 s. Significant impairment on this test
may indicate impaired search of verbal
(lexical) long-term memory. Vocabulary"
was assessed by presenting each subject
with ten sheets containing four outline
drawings of common objects and asking
the subject to point to the object named by
the experimenter. In the naming task, sub¬
jects were to name ten outline drawings of
common objects. Significant impairment
all further group differences are prob¬
ably not the result of the patient's
failure to attend or to concentrate on
the task at hand.
For ease of communication, the pat¬
tern of results is divided into two
categories, qualitative and quantita¬
tive differences. Qualitative differ¬
ences refer to instances where perfor¬
mance of patients with PD was not
significantly different from that of
normal controls, but both groups per¬
formed significantly better than
patients with DAT. This pattern
occurred for the following subtests:
Verbal Fluency, Naming, Vocabulary,
Orientation, Apraxia, and Trails A.
Quantitative differences ocurred
when both patient groups achieved

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 significantly lower scores relative to
controls, but patients with DAT were
significantly more impaired relative
to patients with PD. This pattern
occurred on the following subtests:
Mini-Mental State Examination (to¬
tal), Paired-Associate Memory, and
Visuospatial performance. Finally,
patient groups with DAT and PD both
achieved higher scores on the Depres¬
sion scale relative to controls. A
graphic illustration of the pattern of
results is presented in the Figure and
the Table.
COMMENT
This research was an attempt to
evaluate dementia by using a specific
series of neuropsychological tests
designed to quantify the proposed
clinical differences between cortical
(DAT) and subcortical (PD) forms of
dementia. The results support a dis¬
tinction.
Dementia in patients with PD was
characterized by mild impairment of
memory and visuospatial function but
no impairment of language or evi¬
dence of apraxia. Significant depres¬
sion was also present. The pattern of
performance for patients with DAT
was markedly different. Overall men¬
tal functioning, memory performance,
and visuospatial skills were more
severely impaired relative to patients
with PD. There was significant dis¬
turbance on all language-related
tasks and evidence of apraxia. Depres¬
sion was also evident. In summary,
the results suggest qualitative as well
as quantitative differences in the
dementia syndromes associated with
PD and DAT.
Our findings are in conflict with
conclusions derived from previous
neuropsychological research examin¬
ing the cortical-subcortical distinc¬
tion of dementia. Mayeux and asso-
ciates11<p282) compared patients with
DAT, HD, and PD and concluded that
"the clinical aspects of dementia are
similar in patients with DAT, HD,
and PD." This conclusion is contrary
to a vast literature on the clinical
distinctions between these dementing
syndromes summarized by Ben-
son5(ppi89 wo). «it js obvious that the clin¬
ical features alone provide a clear
distinction between the two types of
dementia.... On the basis of the
striking clinical differences, accep¬
tance of the two distinct types of
dementia would appear mandatory."
Why this discrepancy? Mayeux et al11
used a lengthened version of the Mini-
Mental State Examination,12 a mea¬
sure not specifically designed to
detect differences between dementing
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syndromes. Our research evaluated
dementia in patients with PD and
DAT by a procedure designed to
examine specific clinical symptoms.
Perhaps a simpler interpretation of
the findings of Mayeux et al would be
that the Mini-Mental State Examina¬
tion is a useful bedside procedure to
assess severity of dementia but is not
sufficiently sensitive to differentiate
dementing syndromes.
There is no question that similari¬
ties do exist in the dementia of PD
and DAT. Pathologic similarities have
also been noted, such as a similar
pattern of cortical degeneration in PD
and DAT910 and evidence of subcorti-
cal degeneration in patients with both
disorders.23 In fact, some researchers
suggest that this type of evidence
argues against the cortical-subcorti-
cal distinction of dementia. However,
this distinction is a clinical and not a
precise anatomic one, and the entire
concept cannot be dismissed simply on
the basis of a literal interpretation of
a probably unfortunate choice of
terms.
Another argument raised concern¬
ing the cortical-subcortical distinc¬
tion is whether the intellectual
decline associated with PD can be
considered a true example of demen¬
tia. According to Cummings and Ben¬
son, 7(pl) dementia may be defined as
"an acquired persistent impairment
of intellectual function with compro¬
mise in at least three of the following
spheres of mental activity: language,
memory, visuospatial skills, emotion
or personality, and cognition (abstrac¬
tion, calculation, judgment, etc)." In
our study, patients with PD were
impaired relative to controls on mea¬
sures of memory, visuospatial skills,
and depression, thereby meeting the
definition of the dementia syndrome.
The primary controversy surround¬
ing the cortical-subcortical distinc¬
tion is whether the clinical manifesta¬
tions of these dementing syndromes
are quantitatively different examples
of the same syndrome, or whether
they are qualitatively unique. Our
results support the latter distinction.
Certain features of dementia are
invariant in both disorders, but these
impairments are more severe in
patients with DAT. Striking qualita¬
tive differences also exist, and these
are easily identified using procedures
specifically designed to evaluate these
symptoms. In conclusion, it would
appear there are overlapping patho¬
logic and clinical features in the
dementia of DAT and PD, but there is
no doubt these are distinct clinical
disorders.
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