Memory loss

Medicine > Medicine of older adult

Differential Diagnosis Schema 🧠

Degenerative Causes

Alzheimer’s Disease: Most common cause of dementia; progressive memory loss, especially recent memory, with associated cognitive decline.
Vascular Dementia: Stepwise progression of symptoms; associated with cerebrovascular disease; may have a history of stroke or transient ischemic attacks.
Lewy Body Dementia: Fluctuating cognition, visual hallucinations, and parkinsonism; often early visual-spatial impairments.
Frontotemporal Dementia: Personality and behavioral changes often precede memory loss; typically affects younger individuals (40-60 years).

Reversible Causes

Depression (Pseudodementia): Memory impairment secondary to depression; often presents with subjective memory complaints and reversible with treatment of depression.
Vitamin B12 Deficiency: May cause memory loss along with peripheral neuropathy and macrocytic anemia; reversible with supplementation.
Hypothyroidism: Slowed mental processes and memory issues; check TSH and correct with levothyroxine.
Normal Pressure Hydrocephalus: Triad of memory loss, gait disturbance, and urinary incontinence; treatable with ventriculoperitoneal shunt.
Chronic Alcohol Use: Wernicke-Korsakoff syndrome can present with memory loss, particularly short-term memory, associated with thiamine deficiency.

Other Causes

Head Trauma: Post-traumatic amnesia may result from concussion or more severe brain injury; consider in patients with a history of head injury.
Medications: Anticholinergics, benzodiazepines, and opioids can impair memory; assess medication history thoroughly.
Infections: Encephalitis, meningitis, or HIV-associated neurocognitive disorder can cause memory issues; look for associated symptoms of infection.
Epilepsy: Transient memory loss can occur in temporal lobe epilepsy; often associated with other neurological symptoms like aura or postictal confusion.

Key Points in History 🥼

Symptomatology

Onset and Duration: Gradual onset suggests degenerative causes; sudden onset may indicate vascular or traumatic etiology.
Type of Memory Affected: Recent memory loss is typical in Alzheimer’s, while remote memory is often preserved; check for specific memory lapses.
Associated Cognitive Symptoms: Look for other cognitive deficits such as language disturbances, executive dysfunction, or visuospatial impairments, which can help localize the pathology.
Behavioral and Mood Changes: Personality changes may indicate frontotemporal dementia; depressive symptoms could suggest pseudodementia.
Functional Impact: Assess impact on daily living activities; early difficulties with complex tasks can indicate mild cognitive impairment.

Background

Past Medical History: Important to identify previous neurological or psychiatric conditions; history of cerebrovascular disease is relevant.
Drug History: Review for any medications that may contribute to memory impairment, including sedatives and anticholinergics.
Family History: Inquire about family history of dementia, particularly if early-onset; also relevant for conditions like Huntington’s disease.
Social History: Alcohol use is crucial; also consider the impact of social isolation and any recent life changes or stressors.
Occupation and Education: Higher baseline cognitive reserve from advanced education or intellectually demanding occupations may mask early dementia symptoms.

Possible Investigations 🌡️

Laboratory Tests

Full Blood Count: To rule out anemia or infection that could contribute to cognitive impairment.
Thyroid Function Tests: Hypothyroidism is a reversible cause of memory loss; check TSH and free T4.
Vitamin B12 and Folate Levels: Deficiencies can cause reversible cognitive decline; essential to correct if low.
Liver Function Tests: Chronic liver disease can lead to hepatic encephalopathy; assess if there’s a history of alcohol use.
Glucose and HbA1c: Hypoglycemia and poorly controlled diabetes can cause acute and chronic cognitive symptoms.

Imaging and Specialist Tests

CT or MRI Brain: Essential to rule out structural causes such as tumors, strokes, or normal pressure hydrocephalus.
Electroencephalogram (EEG): Consider in cases where epilepsy is suspected as a cause of memory loss.
Neuropsychological Testing: Comprehensive cognitive assessment can help differentiate between types of dementia and establish a baseline.
Lumbar Puncture: Indicated if central nervous system infection or inflammatory process (e.g., multiple sclerosis) is suspected.
SPECT or PET Scanning: May be used in specialized centers to assess cerebral blood flow or metabolism, particularly in differentiating Alzheimer’s disease from frontotemporal dementia.

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