LESIONS

A Guide to Localisation in Neurology

Case 19 - Memory problems

Case

A 66 year old woman presented with memory problems. Her family were concerned and brought her to her doctor and gave most of the history.

Until 3 weeks previously she was cognitively normal, with a good memory. Then she began displaying problems with her memory. They couldn’t recall an exact onset point, but said the problem was quickly becoming more evident as the days passed.

She was frequently repeating questions and not remembering the answers a few minutes later. This was evident even within the same conversation - 'like a loop'. She struggled to remember conversations she'd had earlier in the day. She misplaced items frequently, such as her phone, keys and glasses.

She had no problem remembering longer-term facts, such as historical events or her own autobiographical background, and she knew who she was and who her relatives were. The problem seemed to be with remembering new information or events. She remained orientated overall, bar a few periods at night when she would wake up thinking it was daytime, and her sleep had become disrupted, with a tendency to stay awake later at night and sometimes nap during the day – which was unusual for her.

There was no major personality changes such as becoming angry, insensitive or showing disinhibited behaviour, although she sometimes became frustrated and anxious after repeatedly asking questions and finding out she had already asked them. She was still able to communicate fluently, work household appliances, and think logically. She could navigate the house and familiar environments without difficulty. She had no difficulty with things like getting dressed and knew how to cook, but had at one point gone to answer the door while cooking and left the food in the oven, which she then forgot about and it burned.

There were no hallucinations or delusional thoughts apparent.

She was systemically well. She had not complained of headaches nor any issues with coordination, gait, strength or sensation.

She had a history of breast cancer treated 7 years earlier with excision and adjuvant chemotherapy. Surveillance testing showed no signs of recurrence in the interval years.

She was retired, and lived with family. She had smoked her entire adult life and occasionally drank alcohol but not to excess.

On examination :

• She was pleasant and cooperative but had little insight into the recent problems
• She frequent repeated things she'd already said, including questions and observations
• She could repeat 6 items immediately back, but after a delay of 2 minutes could not remember any of them or that there had even been a memory task minutes before
• Testing other cognitive domains including attention, verbal fluency, language (speech, writing, comprehension), visuospatial function, abstraction and executive function was completely normal
• Long-term memory was completely normal - for example naming historical famous figures, or talking about her own life events (her husband confirmed the accuracy of her statements)
• Physical examination was unremarkable

Observations were normal and she was afebrile.

Her doctor ran basic tests including checking electrolytes, renal, liver and thyroid functions, which were all normal. They then referred her for an urgent neurology opinion.