If a progressive memory disease is suspected, but a definite diagnosis cannot be established straightaway, regular follow-up is necessary either every six or twelve months depending on the case.
The clinical assessment of a patient with memory impairment primarily includes symptom questionnaires, an assessment of memory and cognitive functions and coping with everyday activities, as well as evaluation of mood and behavioural symptoms.
The diagnosis and treatment assessment of memory diseases require specialist knowledge and experience.
Working-age patients should be referred directly to a neurological memory clinic.
Recognition of memory impairment
Symptom questionnaires
A questionnaire relating to memory to be completed by the patient
A questionnaire relating to memory to be completed by a close family member who knows the patient
Assessment of memory and cognitive function
The Mini Mental State Examination (MMSE) Mini-Mental State Examination (Mmse) for the Detection of Alzheimer's Disease and other Dementias in People with Mild Cognitive Impairment (Mci) is a brief test that measures intellectual memory and cognitive function. It is used to detect a more advanced stage of a memory disease where the ability to function normally on a day-to-day basis has deteriorated. It is not suited for screening early subtle memory losses. It should be noted, however, that the patient's level of education or linguistic problems can influence the test results.
For the evaluation of cognitive functioning, a more comprehensive neuropsychological examination is recommended Neuropsychological Disorders.
Specific indications for the examination include an evaluation of work capacity, assessment of rehabilitation needs, problems in the differential diagnosis (specific disorders, depression), as well as an assessment of legal competence in problem situations. It is often indicated in skilled patients and in patients in working age.
In mild and incipient disorders, repeating the examination in 6-12 months often helps to establish the diagnosis.
Typical earliest findings in progressive memory diseases
Alzheimer's disease: progressive impairment of episodic memory
Lewy body disease: disturbances in the regulation of attention and alertness and in executive function, visual perception disturbances, visual hallucinations and extrapyramidal findings
Frontotemporal lobar degenerations: behavioural symptoms, impaired executive function and language problems
Assessment of functional independence and coping with everyday activities
The daily activities to be assessed are washing, feeding, dressing, transferring, toileting and continence (BADL - Basic Activities of Daily Living). More complex activities (IADL - Instrumental Activities of Daily Living) include the ability to use the telephone, shopping, food preparation, housekeeping, ability to travel independently, responsibility for own medications and the ability to handle finances. Various short tests have been developed for the assessment of BADLs and IADLs Assessment of Functional Capacity in the Elderly.
An assessment of functional independence is often based on interviews with the patient and a family member as well as on reports from providers of home help services and home nursing care.
Assessment of mood and behavioural symptoms
Depression can be identified by interviewing and observing the patient. Occasionally in depression, a depressed mood is not apparent but the patient presents with a decline in memory and cognitive function or physical symptoms. In such cases, depression can be diagnosed only through trial treatment and monitoring.
Depression rating scales include, for example, the Geriatric Depression Scale (GDS) and the Cornell Scale for Depression.
In addition to depression, attention should be paid to anxiety, psychotic symptoms, restlessness and other possible forms of abnormal behaviour and personality changes. In unclear cases the patient should be sent for a psychiatric examination.
Assessment of disease severity
Tools used to assess the severity of a progressive memory disease include the Clinical Dementia Rating (CDR) and GDS-FAST staging systems.
Clinical assessment of memory impairment
General and neurological status
Normal neurological status is common at the early stages of Alzheimer's disease Alzheimer's Disease.
Unilateral symptoms (weakness on one side, abnormal pronator drift test, increased tendon reflexes), and bulbar findings (dysarthria, dysphagia, compulsive crying and laughter), as well as extrapyramidal symptoms (increased muscle tone, short-step gait) are indications of vascular dementias Vascular Cognitive Impairment (Vci).
Involuntary movements indicate Huntington's disease. These are also often seen in patients with Parkinson's disease receiving drug treatment.
Laboratory tests
Basic blood count with platelets, glucose, plasma sodium, potassium, calcium, thyroid, liver, and kidney function tests, vitamin B12 and, if considered necessary, lipids and ESR
When suspecting Alzheimer's disease, examining cerebrospinal fluid markers (beta-amyloid 42 and tau and/or phospho-tau protein) may be considered, but this is not always necessary if the diagnosis is reached otherwise.
Further tests after individual consideration: e.g. syphilis serology (Treponema pallidum antibody test or Treponema pallidum haemagglutination assay), HIV and Borrelia antibodies, drug screen.
Brain imaging
Magnetic resonance imaging (memory MRI) of the brain is the first-line investigation when features characteristic of memory diseases are to be demonstrated.
CT scanning (memory CT) can be carried out if an MRI scan is contraindicated (sometimes pacemaker, other ferromagnetic foreign bodies, claustrophobia) or imaging needs to be done urgently (e.g. a suspicion of trauma).
The most important treatable causes, such as a subdural bleed, normal-pressure hydrocephalus and tumours, can be demonstrated with a CT scan as can changes caused by a cerebrovascular disease, such as signs of infarcts and moderate to severe white matter low-density areas.
Referral for further investigations
If the cause of the memory complaint is not evident, the patient should be referred to a physician experienced in memory disorders (e.g. a neurologist, geriatrician, psychogeriatrician) as well as for further investigations according to the division of responsibilities.
A consultation is usually warranted in the following situations:
mild symptoms suggesting an incipient memory disease
atypical clinical features
the cause of the memory impairment remains unclear
assessment of driving ability if needed
assessment of legal competence if needed
behavioural symptoms refractory to treatment
any problematic situation
always when the treating physician him-/herself regards a consultation warranted.