Visuospatial impairment
Page most recently updated 7 September 2026
This page focuses on presentations with visuospatial-predominant cognitive impairment of insidious onset and progressive course suggestive of a neurodegenerative process. Key differential diagnoses to consider include:
Posterior cortical atrophy
Dementia with Lewy bodies and Parkinson disease dementia
Corticobasal syndrome
The approach below begins with relevant features on history and neurocognitive testing, followed by the relevant differential diagnoses, with further distinctive history and examination findings provided for each diagnosis.
● History (direct and collateral)
Symptoms reported or elicited typically include difficulty with:
Spatially organizing or aligning objects
Seeing or reading, sometimes described as “blurry vision” despite apparently adequate visual acuity
Completing forms or other visually presented information
Locating objects, including items in a refrigerator or drawer or objects directly in front of the person
Judging the location of objects when reaching for them (optic ataxia), which may be particularly suggestive of posterior cortical atrophy
Reading and interpreting maps
Navigating the environment, including becoming lost in unfamiliar or familiar places, or even within their own home
Parking or positioning a car accurately, sometimes resulting in dents, or driving unusually close to other vehicles
● Neurocognitive testing
▪ Tasks that show impairment on initial screening (and are typically included in routine neurocognitive screening instruments) may include:
◦ Asking the patient to copy a geometric figure, provided that the validity of the assessment is not confounded by impaired visual acuity or other ocular pathology.
▪ Supplementary tests that may be performed to corroborate initial findings and to further characterize deficits may include:
◦ Additional figure-copying tasks, such as:
Necker cube copy
Benson complex figure copy
Rey-Osterrieth Complex Figure Test
◦ Tasks assessing visuospatial attention and neglect, which may be relevant to posterior cortical atrophy:
Visual search or cancellation tasks
Line bisection
◦ Navon hierarchical letter paradigm, in which a large letter is composed of smaller letters, assessing global versus local visual processing; impaired global processing may be suggestive of simultanagnosia, which may occur in posterior cortical atrophy.
● Differential diagnoses, including distinctive history and examination findings
▪ Posterior cortical atrophy
Patients typically initially present with visuospatial impairment. On neurological examination, there may be higher-order visual or visuospatial abnormalities, including visual field deficits, visuospatial neglect, simultanagnosia, optic ataxia, or other features of posterior cortical dysfunction. Posterior cortical atrophy is most commonly associated with Alzheimer disease pathology, although Lewy body disease, corticobasal degeneration, and other underlying pathologies may occur.
▪ Dementia with Lewy bodies and Parkinson disease dementia
Patients may initially present with executive dysfunction, visuospatial impairment, and/or slowed cognition, and may be accompanied by characteristic cognitive fluctuations. When dementia precedes or occurs within approximately one year of the onset of parkinsonism, the syndrome is classified as dementia with Lewy bodies; when dementia develops in the setting of established Parkinson disease, it is classified as Parkinson disease dementia. Neurocognitive testing typically supports the predominant cognitive deficit and may reveal additional executive, visuospatial, or other cognitive dysfunction. On neurological examination, there is typically parkinsonism, with rigidity and bradykinesia, with or without resting tremor. Gait may be slow and shuffling, with reduced stride length and other features of parkinsonian gait. Other distinctive clinical features may include recurrent visual hallucinations and REM sleep behaviour disorder.
▪ Corticobasal syndrome
Patients may initially present with language dysfunction, executive dysfunction, apraxia, visuospatial impairment, and/or slowed cognition, which may be accompanied by asymmetric motor or cortical features. Neurocognitive testing typically supports the predominant cognitive deficit and may reveal additional executive, language, visuospatial, or other cognitive dysfunction. On neurological examination, there is typically markedly asymmetric rigidity and parkinsonism, often accompanied by limb apraxia, cortical sensory abnormalities, alien-limb phenomena, dystonia, or myoclonus. Hyperreflexia or other upper motor neuron features may also occur, and gait may show a combination of parkinsonian and hemiparetic features. CBS may result from corticobasal degeneration or other underlying neurodegenerative pathologies, including Alzheimer disease and progressive supranuclear palsy.
Selected references and further reading — Cognitive lens
Tang-Wai DF, Freedman M. Bedside approach to the mental status assessment. Continuum (Minneap Minn). 2018 Jun;24:672-703.
Hodges JR. Cognitive assessment for clinicians. 3rd ed. Oxford: Oxford University Press; 2017.
Dickerson BC, Atri A, editors. Dementia: comprehensive principles and practices. Oxford: Oxford University Press; 2014.
Jankovic J, Mazziotta JC, Pomeroy SL, Newman NJ, editors. Bradley and Daroff's neurology in clinical practice. 8th ed. Philadelphia: Elsevier; 2022.
Dening T, Thomas A, editors. Oxford textbook of old age psychiatry. 3rd ed. Oxford: Oxford University Press; 2021.
Blazer DG, Steffens DC, Busse EW, editors. The American Psychiatric Publishing textbook of geriatric psychiatry. 5th ed. Washington (DC): American Psychiatric Publishing; 2015.
Arciniegas DB, Yudofsky SC, Hales RE, editors. The American Psychiatric Association Publishing textbook of neuropsychiatry and clinical neurosciences. 6th ed. Washington (DC): American Psychiatric Association Publishing; 2018.
Agrawal N, Faruqui R, Bodani M, editors. Oxford textbook of neuropsychiatry. Oxford: Oxford University Press; 2020.
Boland R, Verduin M, editors. Kaplan and Sadock's comprehensive textbook of psychiatry. 11th ed. Philadelphia: Wolters Kluwer; 2024.