LESIONS

A Guide to Localisation in Neurology

Case 19 - Memory problems

Case

A 66 year old man presented with memory problems. His family were concerned and brought him to his doctor and gave most of the history.

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

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

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

There was no major personality changes such as becoming angry, insensitive or showing disinhibited behaviour, although he sometimes became frustrated and anxious after repeatedly asking questions and finding out he had already asked them. He was still able to communicate fluently, work household appliances, and think logically. He could navigate the house and familiar environments without difficulty. He 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 he then forgot about and it burned.

There were no hallucinations or delusional thoughts apparent.

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

He had a history of colon cancer treated 7 years earlier with surgery and chemotherapy, which had been curative.

He was retired, and lived with his wife. He had smoked his entire adult life and occasionally drank alcohol but not to excess.

On examination :

• He was pleasant and cooperative but had little insight into the recent problems
• He frequently repeated things he'd already said, including questions and observations
• He 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 his own life events (his wife confirmed the accuracy of his statements)
• Physical examination was unremarkable

Observations were normal and he was afebrile.

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