Assessing a patient with memory problems

History

  • NB It is vital to get a corroborative history from a relative close friend, particularly where it is them that are more concerned about memory problems than the patient themselves.
    • It may be useful to interview them separately
    • If the patient comes alone worried about memory problems, it is often a sign that lessens the likelihood of dementia
  • In general, consider the age of the patient
  • Assess what the patient means by memory problems
    • Are they having trouble finding words?  Are they losing/forgetting things?  Are they getting lost?
      • i.e. is it a problem with working memory? (immediate memory)
      • is it a problem with episodic memory? (short term/anterograde or old/retrograde)
      • is it a problem with semantic memory? (word meaning and general knowledge)
      • is it a problem with implicit memory? (learned/automatic responses- can be complex tasks e.g. driving, or more simple ones e.g. dressing)
    • What sort of problems is this causing? (impact on life)
  • Take a history of PC
    • Onset
      • Particularly- any triggers such as adverse life events
        • Depression is not an uncommon cause of memory problems- important to ask about mood and other associated symptoms e.g. sleep
    • Tempo/progression
      • Have things been deteriorating?  Are the problems constant or are there particular times of day when things are worse (sunset- ‘sundowning’)
      • Is there a step-wise progression?
    • Impact on work/family and any issues about safety e.g. driving/cooking, or self-care/hygiene e.g. shopping
    • Ask about associated symptoms/features
      • Mood, enjoyment in activities, personality changes, psychotic symptoms etc
      • Appetite and sleep changes
      • Walking or balance problems
      • Anorexia, weight loss, incontinence, change in bowel habits
      • Any changes in consciousness
  • Past medical history
    • Detailed medical and drug history (including compliance) are very important, particularly in identifying an iatrogenic cause (drug induced problems)
      • Vascular disease e.g. TIA/stroke, hypertension, ischaemic heart disease
    • Past psychiatric history
  • Family history
    • e.g. Alzheimer’s disease
  • Social history
    • Are they living alone (in own home or another residence)?
    • Do they have any routine?
    • Alcohol consumption (past and present)?

Examination

  • Cognitive testing (most commonly tested using Mini-mental state examination ©– good screening tool)
    • Orientation (time, place, person)
    • Attention
    • Memory
    • language
    • executive function
    • praxis e.g. hand movement/coordination
    • visuaspatial function
  • If there is concern over whether the memory problems are associated with delirium, the patient can be screened for features (e.g. 4AT score)
  • For a thorough assessment, the Addenbrookes cognitive assessment (ACE) is a more in depth assessment used for the formal diagnosis of dementia
    • see here for ACE example along with other forms of cognitive tests
  • Perform a routine physical exam to note any signs which may suggest a treatable underlying cause

Investigations

  • Imaging
    • CT scan of the brain is usually done in all patients to rule out an organic cause of confusion/dementia
    • SPECT/PET/MRI imaging is becoming more useful at diagnosing different types of dementias e.g. fronto-temoral
  • Blood tests
    • B12, TFTs

Differential Diagnosis

  • Dementia (of which there are differentials within this)
  • Delirium
  • IMPORTANT TO RULE OUT OTHER POTENTIALLY TREATABLE CAUSES OF COGNITIVE IMPAIRMENT
  • aki
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