Progressive supranuclear palsy: cognitive and behavioral changes

Linda A Hershey MD PhD (Dr. Hershey of the University of Oklahoma Health Sciences Center has no relevant financial relationships to disclose.)
David G Lichter MD ChB (

Dr. Lichter of SUNY University at Buffalo received honorariums from Teva for speaking engagements and from US World Meds for speaking engagements.

Martin R Farlow MD, editor. (

Dr. Farlow of Indiana University received research grant support from AbbVie, Biogen, Boehringer Ingelheim, Eisai, Eli Lilly, Genentech, Roche, Novartis, Suven Life Sciences Ltd, and vTv Therapeutics; fees from Cerecin/Accera, Allergan, Avanir, AZ Therapies, Eli Lilly, Kyowa Kirin Pharma, Longeveron, Medavante, Merck, Neurotrope Biosciences, Proclara, Takeda, and vTv Therapeutics for consultancy, or advisory board/DSMB membership; licensing fees from Elan; and consulting fees from Cortexyme, Green Valley, Regenera, Samumed, Zhejiang Hisun Pharmaceuticals, Cognition Therapeutics, Danone, Eisai, and Otsuka.

Originally released August 7, 1997; last updated April 27, 2020; expires April 27, 2023

This article includes discussion of progressive supranuclear palsy: cognitive and behavioral changes and Richardson syndrome. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.


Many patients with progressive supranuclear palsy present to neurologists with unsteady gait, postural instability, and falls, but others come with complaints of cognitive slowing, apathy, loss of verbal fluency, and loss of ability to recognize emotion in others. There are now at least seven well-defined syndromes that are subtypes of progressive supranuclear palsy. The brains of patients with classic supranuclear palsy, or “Richardson syndrome” show frontal atrophy and excessive amounts of abnormally aggregated tau protein. The apathy of supranuclear palsy is associated with atrophy of the ventromedial frontal cortex. The cognitive slowing is correlated with fronto-cerebellar gray matter atrophy and widespread changes in white matter tracts. Patients with the clinical variant of “PSP-parkinsonism” present with dysarthria, asymmetrical tremors, rigidity, and slowness that respond for one or two years to levodopa (they do not have early gaze palsy and their brains show less severe tau pathology and less severe cortical atrophy). In this update, the authors describe how the cognitive and behavioral changes in patients with progressive supranuclear palsy can be used to distinguish it from other common neurodegenerative syndromes, such as Parkinson disease, dementia with Lewy bodies, Alzheimer disease, frontotemporal dementia, multiple system atrophy, and corticobasal degeneration. New data about the use of various neuroimaging tools in the diagnosis of supranuclear palsy are described.

Key points


• Patients with progressive supranuclear palsy are more likely to progress faster if they have poorer baseline performance on cognitive tests. This is particularly true of the PSP-Richardson syndrome variant and the PSP-behavioral variant frontotemporal dementia, where mean survival is about seven years, compared to 11 years for the milder variants of supranuclear palsy (PSP-parkinsonism and PSP-pure akinesia and gait freezing).


• The most common cognitive impairment in PSP-Richardson syndrome is the frontal dysexecutive syndrome, which is manifested by difficulty with planning and organization. These patients also have problems with apathy, rigid thinking, and lack of emotional recognition in others. Midbrain atrophy is in the common imaging feature of PSP-Richardson syndrome and all other PSP syndromes.


• Apathy is the most common behavioral symptom seen in several of the main subtypes of supranuclear palsy. Apathy has significant negative predictive value for health-related quality of life and appears to be correlated with dysfunction of prefrontal subcortical white matter tracts. Survival is worse in PSP patients who have high apathy scores, compared to patients with frontotemporal dementia or primary progressive aphasia, who have lower apathy scores.


• There are two subtypes of supranuclear palsy that can imitate other neurodegenerative diseases. PSP-behavioral variant frontotemporal dementia patients present with changes in personality and socially inappropriate behaviors years before they show signs of gaze palsy, falls, or axial rigidity. Those with PSP-cortical basal syndrome manifest with signs of dementia and motor apraxia, alien limb phenomenon, or cortical sensory loss before they fall or show signs of supranuclear gaze palsy.

Historical note and terminology

In 1877, Dr. Charcot described a 40-year-old woman who had rigid-akinetic parkinsonism, neck dystonia, dysarthria, and eye-movement problems (Charcot 1877). Chavany and others reported the clinical and pathologic features of a 50-year-old man with a rigid and akinetic form of parkinsonism with postural instability, neck dystonia, dysarthria, and staring gaze (Chavany et al 1951). Richardson, Steele, and Olszewski recognized the same clinical syndrome in eight patients and described the autopsy findings in six of them (Richardson et al 1963). Progressive supranuclear palsy was not a “new” disease in 1963, as 22 well-documented case reports had been identified in the neurologic literature between 1877 and 1963 (Brusa et al 2004). The unique frontal lobe cognitive changes of progressive supranuclear palsy (apathy, loss of spontaneity, slowing of thought processes, and loss of executive functions) were first described by Albert and colleagues (Albert et al 1974).

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