I read Dr Fleminger's (Reference Fleminger2002) article with interest and in particular his description of hypoactive delirious states, which he ascribed to Lipowski in 1990. They were, in fact, first described by me (Reference Philpott and TallisPhilpott, 1989) as attenuated or negative confusional symptoms in my chapter on ‘Recurrent acute confusional states’ in The Clinical Neurology of Old Age. I emphasised that these are common, particularly when acute confusion occurs in the setting of patients with established dementia. Perhaps the fact that this is included in a textbook of neurology rather than psychiatry accounts for it being overlooked.