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Understanding Dementia: Important Features of a Memory Complaint - DementiaGuide.com
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Understanding Dementia

Important Features of a Memory Complaint

This section is comprised of excerpts from the book Understanding Dementia, which is meant to be a practical manual for primary care physicians and other health care professionals. Dementia exists when impairment with cognition (e.g. memory , language, calculation) is severe enough to interfere with function. The first question to be addressed therefore is whether the patient with a memory complaint actually has a memory problem. Below, in the introduction to Chapter 4, we outline how a physician might do that. The method that we suggest is set up as a single, 15-minute visit (this is only part of the visit) in a series of four such visits, at the end of which the physician can answer these four questions:

    1. Does it occur on its own or in the face of other cognitive problems? Does it interfere with function?)
    2. If yes, what type of problem is it? (Is it mild, moderate or severe? Does it occur on its own or in the face of other cognitive problems? Does it interfere with function?)
    3. What is the cause?
    4. How can we help the patient?

Ascertaining important features of the presenting complaint
This will, of course, follow the time- honoured clinical interview features of description, duration, precipitants and exacerbating or ameliorating factors. This part of the interview can also be grouped along the lines of a few questions:

1. Is the complaint one of memory?

The differential diagnosis of a memory complaint includes anxiety, depression , and less commonly, delirium and aphasia or other problems of higher cortical function. Questions about mood and neurovegetative features (e.g. "How is your mood? Do you feel sad or unhappy? Do you feel nervous or anxious? How do you sleep? Has your weight been stable? Do you find yourself crying for no reason?") provides insight into anxiety and depression. The diagnosis of aphasia is usually not difficult when it is suspected and can be detected by asking the patient to name simple objects. Often patients will answer affirmatively to the questions: "Do you find that you know what to say, but just can't get the right words to say it?" Delirium is recognized by a comparatively acute onset and fluctuating course, and by inattention out of proportion to other cognitive problems.

It is usually easy to quickly determine whether the memory complaint is about memory or about something else.

2. What is the description of the complaint?

Most patients with dementia will have a memory problem, whether or not they complain of it. Happily, most patients with a memory complaint do not have dementia. It is therefore important to have a precise understanding of the nature of the memory complaint, and to establish the extent to which this memory complaint is relieved by cuing, and most importantly, whether and how it interferes with function.

In the usual memory complaint that is seen in early dementia, patients and their families will commonly assert that the patient's "short term memory" is impaired, but that "long term memory" is well- preserved. As will be seen, this observation commonly is incorrect. In general, the history is most usefully obtained by asking the patient to tell you the last thing that he or she can remember forgetting. Patients who immediately launch into a detailed description of circumstances under which they forgot something rarely have a serious problem. More ominous is the patient who looks blankly at you in response, and then turns to face his or her spouse (this is so characteristic that it is sometimes called the "head-turning sign ").

In eliciting the description of the memory complaint, it is often useful to incorporate some memory testing. As this can be off-putting to some patients, we often introduce this part of the interview gently.

Rockwood & MacKnight, 2001. p.58

When the history establishes the presence of a memory problem, testing of memory can continue with the Mini-Mental State Examination, as detailed below, or can begin in a more conversational way. The MMSE is an extremely helpful screening test, but in comparison with those items which make up memory (Table 4.1) it only addresses a limited part of this central cognitive _function. As can be seen, those aspects of memory which are perhaps most important (the synthesis of past experiences into meaning) are not tested by the MMSE. Nevertheless, impairment on the MMSE correlates with other aspects of memory loss. We typically begin by making enquiries about recent memory , with questions such as "What did you have for supper last night?" or "How did you come here today?" Depending on the patient's circumstances, it may be appropriate to ask about recent events on the news or in the patient's life.

Rockwood & MacKnight, 2001. p.60

When discussing remote history, it is often helpful to ask about education and occupation. Thus, for example, one would ask, "How far did you get in school?" "Do you remember the names of any of the teachers or children that you went to school with?" "What was your first job after coming out of school?" "What about the next job?" etc.

As noted, patients and families commonly believe that the patient has a good long term memory because of the ability to tell over-learned stories. It is a fascinating and rewarding part of clinical practice to hear some of these over-learned stories and our practice is to usually let the patient tell their favourite story which usually can be elicited by the request to "Tell me about your life." We usually do this after having asked several direct questions which require very short answers, so that the patient is socially cued to give a limited answer to this complex, open-ended question. This they usually do to the extent that long, rambling answers often reflect anxiety, depression, or disinhibition.

Asking the patient this type of question also allows the patient to establish his or her past character and achievements, and to provide insight into how the patient has synthesized these memories into meaning. It is useful, however, to interrupt at a certain point and see if the patient can situate this anecdote in terms of the past chronology. Thus, for example, a common question that we ask is "Was that before you got married or after?" or "Was that during the war?" It can often then become apparent that though the story is detailed, it is over-learned, and the patient cannot put it into context. In our experience, it is helpful for the spouse or caregiver to hear the difficulties that the patient has, as this helps to form an understanding of the disease, but many physicians are not comfortable with this approach. Nevertheless, it is often worthwhile to at least experiment with overcoming this inhibition, as there is a great deal which can be gained by questioning patients with their carers present.

Other questions that we find particularly useful as prompts to testing remote memory include "How many children do you have?" "Are they all alive?" "Tell me who was born first?" "Is he/she married?" "What is their spouse's name?" etc. (Such questioning about long term memory makes it clear that either the physician must know the answers, or an informant must be present who can provide this type of individualized, personal detail.)

It is also important to get some feeling for duration. In our experience, this can sometimes be very difficult for patients and families, and often one only gets the sense of it at subsequent visits. The question "Now that you look back on it, when were you first aware that something was wrong?" is often a very good guide to duration, particularly where the dementia has emerged insidiously. When patients present in mid or late stages of dementia this question must be directed to the caregiver.

Another important feature of the memory complaint is to know whether or not it is helped by cuing or whether a forgotten memory returns "spontaneously." Patients with dementia who have forgotten memories (e.g. not remembering the name of a friend) do not usually find that the memories return spontaneously at a later time. This is in contrast to patients with Age-Associated Memory Impairment (AAMI ) who will complain of not being able to remember a name or an item when it is required, only to have it spontaneously return when no longer needed (Table 4.2). Cuing is often helpful in AAMI, although patients with dementias other than Alzheimer's disease can demonstrate improvement with cuing. This is particularly the case in some forms of vascular dementia.

Rockwood & MacKnight, 2001. p. 62

Asking how the patient has adapted to the memory complaint is another helpful question in establishing its nature and impact on function. Patients with AAMI, much more commonly than patients with Alzheimer's disease, will develop memory strategies which are helpful. Simple strategies include making lists, repeating the name of new acquaintances and mnestic tricks such as mnemonics. Questions about the impact of memory problems on daily life are also included in the diagnosis of dementia, as illustrated in Text Box 4.2. It is important to thoroughly explore function in patients with suspected AAMI. Slight memory loss occurring along with functional loss is likely an early dementia, and treatment at early stages may provide more benefit than treatment later in the course of the disease. The exploration of function and other cognitive domains is covered in Chapter 5.

Rockwood & MacKnight, 2001. p.63

Taken from Understanding Dementia: A Primer of Diagnosis and Management
Kenneth Rockwood & Chris MacKnight, 2001
Chapter 4, pp 57-63

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