Clinical History

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Patients with memory deficits are, by definition, limited in their ability to provide information about their history, and this limitation is especially salient for patients who may be demented. Therefore, obtaining a clinical history from a patient complaining of memory disorders usually requires considerable cooperation from the patient's family or caregivers. In many cases, they are the ones who can most accurately recite the patient's problems. This fact introduces a challenge to the interpersonal skills of the examining physician because the patient must retain a feeling of central importance during the interview even though much information about the patient must come from these collateral sources.

The physician, after introductions, can elicit a general history that may be directed if the patient begins to go off-track. As the patient begins to tell the history of the present illness, the physician should be appraising the patient for a general view of affect and cognitive function, and for salient aspects of the patient's personality, educational background, and state of health. Information about the temporal onset and progression of memory impairment is useful in focusing the differential diagnosis. An acute onset of decline to a chronic level of memory dysfunction suggests a stroke or anoxic episode. An abrupt onset with a stepwise progression raises a suspicion of a vascular-based memory problem such as multi-infarct dementia. An insidious, slowly progressive, chronic decline shifts attention to the possibility of alcohol-related dementia or Alzheimer's disease. A more rapid progression of memory dysfunction over weeks to months may point to a depression-related memory loss or, especially if seizures are present also, to primary or metastatic tumors or encephalitis.

Family history should include the age and state of health or age at death and cause of death of at least the siblings, parents, grandparents, aunts, and uncles. Neurological disease in any relatives or the possibility of consanguinity should be pursued as a lead to uncovering a genetic etiology.

Occupational and intellectual achievements of the past should be elicited. A discordance between poor language or judgment relative to superior occupational and intellectual achievements in the past suggests causes that are not consonant with more pure amnesias. Further, high levels of premorbid functioning may mask the severity of current problems because such individuals can effectively compensate for memory loss. Paradoxically, individuals with high levels of premorbid functioning may be most sensitive to and concerned about memory disturbances, and they may interpret such age-associated disturbances as harbingers of Alzheimer's disease.

The past and current medical history should be thorough because memory disorders have a wide range of primary and secondary causes. Information about alcohol, drug, and dietary habits should be obtained. Substantial alcohol consumption, which should be quantified, may lead to

memory dysfunction through Wernicke-Korsakoff psychosis or hepatorenal encephalopathy. A detailed drug history should be obtained because many medications directly or indirectly (e.g., via lethargy) reduce memory performance. Commonly used prescription and nonprescription drugs that may interfere with memory and cognition include analgesic, antihypertensive, anticholinergic, psychotropic, and sedative medications.

A history of surgery, trauma, or head injury should be pursued for the possibility of cerebral anoxia or direct trauma to the brain structures. Onset and progression of seizures and headaches should be clarified to direct suspicions of tumors, aneurysms, encephalitis, or epilepsy. A cancer history should raise a suspicion of metastases to the brain or paraneoplastic disorders, and known hypertension, stroke, or transient ischemic attacks point to a vascular cause of a memory disorder.

A history of depression is particularly notable because memory loss is often seen during depressive episodes, in which anxiety, guilt, and delusions are also present. For this reason, it is useful to assess the mood of the patient and make note of any insomnia or fatigue. A primary memory disorder, however, can affect a patient's mood, sleep, work, family relations, and daily activities. Personality changes, usually reported by the family, should be pursued to determine whether they are an incidental finding, a consequence of the memory dysfunction, or a clue to the underlying etiology, such as depression or frontal lobe tumors.

Finally, social and legal issues may have to be considered, especially when the findings are inconsistent across time or do not agree with the signs of an organic disorder. Stressful family situations may color the complaints of the patient or family. Legal motivations are salient in cases of insurance claims or conservatorships.


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