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MEMORY LOSS
LEARNING OBJECTIVES:

At the end of this tutorial, you should be able to:


1. Define memory loss
2. Form a differential diagnosis for memory loss.
3. Differentiate between the different types of memory loss.
4. Take a history from patients with memory loss, and take a collateral
history, looking for features which may assist in narrowing the
differential.
5. Examine patients with memory loss to elicit features suggestive of
underlying aetiology.
6. Choosing and justifying appropriate investigations of the patient with
memory loss.

DEFINITION: Memory loss, also referred to as amnesia, is an abnormal degree of


forgetfulness and/or inability to recall past events. Depending on the cause,
memory loss may have either a sudden or gradual onset, and memory loss may
be permanent or temporary. Memory loss may be limited to the inability to
recall recent events, events from the distant past, or a combination of both.
Although the normal aging process can result in difficulty in learning and
retaining new material, normal aging itself is not a cause of significant memory
loss unless there is accompanying disease that is responsible for the memory
loss. In older people, dementia is the main cause of progressive memory loss
and will form the main focus of these lecture notes.

Types of memory loss:


1. Transient Global Amnesia: Transient global amnesia is a rare,
temporary, complete loss of all memory.
2. Anterograde Amnesia: Anterograde amnesia refers to the inability to
remember recent events in the aftermath of a trauma, but recollection of
events in the distant past in unaltered.
3. Retrograde Amnesia: Retrograde amnesia is the inability to remember
events preceding a trauma, but recall of events afterwards is possible.

PATHOPHYSIOLOGY:
In the case of memory loss caused by Alzheimer's disease, it is characterised by
loss of neurons and synapses in the cerebral cortex and certain subcortical
regions. This loss results in gross atrophy f the affected regions, including
degeneration in the temporal lobe and parietal lobe. Both amyloid plaques and
neurofibrillary tangles are clearly visible by microscopy in brains of those
afflicted by AD.
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Differential Diagnosis: Mnemonic = VINDICATE

V Vascular 1. Cerebral arteriosclerosis


2. Cerebral thromboembolism
3. Cerebral haemorrhage
I Inflammatory 1. Syphilis
2. Chronic encephalitis (inclusion body encephalitis
and CJD).
3. Cerebral abscess
N Neoplasms 1. Primary
2. Secondary
Neoplasms of the brain and meninges
D Degenerative 1. Alzheimer's disease
2. Vascular dementia
3. Pick disease
4. Advanced Parkinson's disease
5. Wernicke's Encephalopathy
6. Pellegra
7. Pernicious anaemia
I Intoxication/Idiopa 1. Alcoholism
thic 2. Bromism
3. Lead poisoning
4. Toxic induced encephalopathies
I may stand for idiopathic and suggest normal-pressure
hydrocephalus.
C Congenital 1. Encephalopathies
2. Tay-Sachs disease
3. Cerebral palsy
4. Down Syndrome
5. Wilson's Disease
6. Huntington's Chorea
7. Congenital hydrocephalus
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8. Porphyria (often forgotten in differential diagnosis)


A Autoimmune 1. Systemic lupus erythematosus
2. Multiple sclerosis
T Trauma 1. Epidural haematoma
2. Subdural haematoma
3. Intra-cerebral haematoma
4. Dissociative reaction of psychoneurosis may be
precipitated by trauma.
E Endocrine 1. Myxoedema
2. Insulinoma (chronic hypoglycaemia)
3. Pituitary tumour (invading the hypothalamus)
4. Addison's disease (aldosteronism may affect
memory by the associated potassium disturbance).

HISTORY:
Important questions to ask include:
1. Can the patient remember recent events, and/or remote events
(events further back in time)?
2. When did the memory problems start?
3. How did the memory problems evolve?
4. Were there any factors which may have caused the memory loss, such
as a head injury, surgery, or stroke?
5. Is there a family history of any neurological or psychiatric diseases or
conditions?
6. Details about the patient's alcohol intake.
7. Is the patient currently on any medication?
8. Has the patient taken illegal drugs, such as cocaine, marijuana, etc.?
9. Are the patient's symptoms undermining his/her ability to look after
himself/herself?
10. Does the patient have a history of depression? Elderly patients with
depressed mood, hopelessness, and suicidality may be suffering from
"pseudodementia" ( false dementia). When the depression is alleviated
with treatment, the dementia-like condition fully resolves.
11. Has the patient ever had cancer? (possibility of brain metastases)
12. Does the patient have a history of seizures?

In the case of Alzheimer's disease, it is usually diagnosed clinically from the


patient history, collateral history from relatives, and clinical observations, based
on the presence of characteristic neurological and neuropsychological features
and the absence of alternative conditions.

Early symptoms of Alzheimer's disease include


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1. Problems with memory, including slight forgetfulness, most often of


recent events. There is also a slowing down of the thinking and learning
processes. These symptoms can also be a normal part of the aging
process. However, in the normal aging process, the accuracy of memory
or thoughts does not decline, just the speed.
2. An inability to complete familiar tasks or work with numbers, such as in
paying bills which impacts on daily functioning.. Symptoms also include
confusion with time and date and disorientation to place. This can lead to
wandering and getting lost in a familiar place.
3. Difficulty with reading and writing, losing items, poor judgement, social
withdrawal, difficulty speaking and communicating, and changes in
emotion.
4. People developing Alzheimer's disease may have personality changes and
may become restless, anxious, angry, and agitated.

A history (in an elderly patient) of a stuttering course, with periods of lucidity


alternating with periods of confusion may point to multi-infarct dementia, which
is caused by repeated lacunar strokes.

EXAMINATION:

In the case of acute memory loss, a full neurological exam including fundoscopy
needs to be carried out urgently.
1. Fever: Fever may point to infection, heat illness, thyroid storm, aspirin
toxicity, or the extreme adrenergic overflow of certain drug overdoses
and withdrawal syndromes (in particular, delirium tremens). Extreme
hyperthermia (with pinpoint pupils) may be seen in pontine strokes.
Temperature or neck stiffness may suggest meningitis or subarachnoid
haemorrhage
2. Respiratory Rate: In patients with a rapid respiratory rate, consider
diabetic ketoacidosis (ie, Kussmaul respiration), sepsis, stimulant drug
intoxication, and aspirin overdose.
In patients with a slow respiratory rate, consider narcotic overdose, CNS
insult, or various sedative intoxications.
3. Pulse: A rapid pulse rate is seen in patients with fever, sepsis,
dehydration, thyroid storm, and various cardiac dysrhythmias and in
overdoses of stimulants, anticholinergics, quinidine, theophylline,
tricyclic antidepressants, or aspirin. Patients with a slow pulse rate may
have elevated intracranial pressure, asphyxia, or complete heart block.
Calcium channel blockers, digoxin, and beta-blockers also may
produce altered mental status and bradycardia.
4. Fundoscopy: Papilleodema suggests raised intracranial pressure.
5. Focal Neurological Signs: Unilateral limb weakness, facial droop,
dysphasia may indicate recent CVA.

INVESTIGATIONS:
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Bloods:
1. Full blood count and ESR
2. Urea and Electrolytes(U/E), calcium, renal function tests
3. Blood glucose level
4. Liver function tests
5. Thyroid function tests
6. Blood cultures, if fever
7. Syphilis and HIV testing, if appropriate
8. Folic Acid
9. B12 assay for deficiency which may suggest subacute combined
degeneration of spinal cord which in the late stages can cause cognitive
impairment, memory loss and confusion
10. ANA antibody to detect lupus erythematosus
11. Lead levels, if suspected lead poisoning

Urine

1. Urine microscopy and culture


2. Urine drug screen (if drug ingestion suspected)

Radiological:
1. CT Brain: A CT scan without should be obtained if CNS infection,
trauma, or a cerebral vascular accident (CVA) is suspected. A CT scan is
excellent for detecting acute hematomas and most subarachnoid
hemorrhages (SAH) but is most accurate early in the course. Follow-up
lumbar puncture may be needed to rule out SAH.
2. MRI Brain: An MRI brain may be considered as part of the work up for
dementia as it helps distinguish between Alzheimer disease and vascular
causes of dementia.

Miscellaneous

1. Lumbar Puncture: May be required to diagnose multiple sclerosis,


neurosyphilis, meningitis/subarachnoid haemorrhage.
2. EEG: May be helpful in demonstrating drug intoxication and epilepsy.

Cognitive tests.

A brief bedside neurologic examination to include mental status testing, is an


essential part of the workup of organic brain syndrome and altered mental
status when a rapidly treatable cause, such as hypoglycaemia or narcotic
overdose, is not immediately apparent.

The Mini-Mental Status Examination (MMSE) is a formalized way of


documenting the severity and nature of mental status changes. The maximum
score per item is indicated in parentheses.

MMSE Below:
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