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)
- Are they having trouble finding words? Are they losing/forgetting things? Are they getting lost?
- 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
- Particularly- any triggers such as adverse life events
- 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
- Onset
- 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
- Detailed medical and drug history (including compliance) are very important, particularly in identifying an iatrogenic cause (drug induced problems)
- 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
Notes on Medicine/Surgery 