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Memory Dysfunction in Neurological Practice Andrew E Budson, Bruce H Price

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Memory Dysfunction in Neurological Practice Andrew E Budson, Bruce H Price Downloaded from pn.bmj.com on 5 February 2007 42 Practical Neurology HOW TO UNDERSTAND IT Pract Neurol 2007; 7: 42–47 Memory dysfunction in neurological practice Andrew E Budson, Bruce H Price A E Budson Geriatric Research Educational Clinical Center, Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA; Boston University Alzheimer’s Disease Center, Boston University, Boston, MA; Division of Cognitive and Behavioral Neurology, Department of Neurology, Brigham and Women’s Hospital, Boston, MA; Harvard Medical School, Boston, MA, USA B H Price Department of Neurology, McLean Hospital, Belmont, MA and Harvard Medical School, Boston, MA, USA Correspondence to: Dr A E Budson Building 62, Room B30, Edith Nourse Rogers Memorial Veterans Hospital, 200 Springs Road, Bedford, MA 01730, USA; [email protected] Downloaded from pn.bmj.com on 5 February 2007 Budson, Price 43 omplaints of impaired memory are Episodic memory is the explicit and declarative among the most common symptoms reported to neurologists. Moreover, memory system that we all use to recall our C impairment of memory is one of the personal experience most disabling aspects of many neurological disorders, including neurodegenerative dis- eases, strokes, tumours, head trauma, collection of mental abilities that use hypoxia, cardiac surgery, malnutrition, atten- different systems within the brain. A memory tion deficit disorder, depression, anxiety, system is a way that the brain processes medication adverse effects, and just normal information in order to make it available for aging. This memory loss often impairs the use at a later time. Some systems are patient’s daily activities, profoundly affecting associated with conscious awareness (explicit) not just them but also their families. and can be consciously recalled (declarative), Memory research that began with neuro- whereas others are typically unconscious psychological studies of patients with focal (non-declarative) and are instead expressed brain lesions now includes new methods such by a change in behaviour (implicit). as positron emission tomography, functional Here we will describe the four systems that MRI, and event-related potentials which have are of clinical relevance: episodic memory, all provided a more refined and improved semantic memory, procedural memory, and classification system. Instead of conceptualis- working memory (table 1). Additional details ing memory as ‘‘short-term’’ versus ‘‘long- may be found in Budson and Price1 and the term’’, we now think of memory as a other references listed below.2–6 TABLE 1 Selected memory systems Length of Main anatomical Memory System Examples Awareness storage structures Episodic memory Remembering a short story, Explicit Minutes to Medial temporal lobes, what you had for dinner years anterior thalamic nucleus, last night, and what you mamillary body, fornix, did on your last birthday prefrontal cortex Semantic memory Knowing who was the first Declarative Minutes to Inferior lateral temporal President of the US, the Explicit years lobes colour of a lion, and how a fork and comb are different Procedural memory Driving a standard Declarative Minutes to Basal ganglia, cerebellum, transmission car (explicit), Implicit years supplementary motor area and learning the sequence of numbers on a touch-tone phone without trying (implicit) Working memory Phonological: keeping a phone Non-declarative Seconds to Phonological: prefrontal number ‘‘in your head’’ before Explicit minutes; cortex, Broca’s area, dialing information Wernike’s area Spatial: mentally following a Declarative actively Spatial: prefrontal cortex, route, or rotating an object in rehearsed or visual association areas your mind manipulated www.practical-neurology.com Downloaded from pn.bmj.com on 5 February 2007 44 Practical Neurology visual scenes. Distortions of memories, and false memories, may occur due to frontal lobe dysfunction, such as when information Prefrontal Thalamocingulate Cingulate gyrus becomes associated with the wrong context, cortex tract or specific details are incorrect. One way to think about how the frontal and medial temporal lobes work together is by Anterior thalamic an oversimplified but useful analogy: nucleus Fornix N the frontal lobes are the ‘‘file clerks’’ of Thalamus the episodic memory system Mammillothalamic tract N the medial temporal lobes are the ‘‘recent Mammillary body memory file cabinet’’ N other cortical regions are the ‘‘remote memory file cabinet’’. Parahippocampal Amygdala gyrus So if the frontal lobes are impaired, it is Hippocampal difficult, though not impossible, to get formation information in and out of storage. And the information may be distorted due to ‘‘impro- per filing’’ leading to inaccurate context or Figure 1 EPISODIC MEMORY sequence. If the medial temporal lobes are Episodic memory. The medial temporal Episodic memory is the explicit and declara- damaged, it will be difficult or impossible for lobes, including the hippocampus and parahippocampus, form the core of the tive memory system that we all use to recall recent information to be retained. Older episodic memory system. Other brain our personal experience, framed in our own information that has been ‘‘consolidated’’ regions are also necessary for episodic context, such as remembering a short story or over months to years is thought to be stored memory to function correctly. (From Budson AE, Price BH. Memory what we had for dinner last night. Episodic in other cortical regions, and will therefore be dysfunction. N Engl J Med memory loss follows a predictable pattern available even when the medial temporal 2005;352:692–9. Copyright known as Ribot’s law: recently acquired lobes are damaged. Massachusetts Medical Society. All memories are more vulnerable to loss than Alzheimer’s disease is the most common rights reserved.) longer established ones. This memory system disorder that disrupts episodic memory. Recent depends on the medial temporal lobes research suggests that these patients suffer (including the hippocampus, entorhinal and from memory distortions and false memories in perirhinal cortex). Other critical structures addition to their failure to remember informa- (some of which are associated with a circuit tion. Other common disorders that disrupt described by Papez in 1937) include the basal episodic memory are listed in table 2. forebrain with the medial septum and the If a patient presents with an inability to diagonal band of Broca’s area, the retro- remember recent information and experi- splenial cortex, the mammillothalamic tract, ences, a disorder of episodic memory should and the anterior nucleus of the thalamus. A be suspected. The evaluation should include a lesion in any one of these structures may detailed history, with emphasis on the time cause the impairment that is characteristic of course of the memory disorder. For example: dysfunction of the episodic memory system N degenerative diseases such as Alzheimer’s (fig 1). start insidiously and progressively worsen The frontal lobes are also important for N vascular dementia and other multifocal certain aspects of episodic memory, including disorders such as multiple sclerosis tend the registration, acquisition, or encoding to start suddenly and progress in a (learning) of information, retrieval of infor- stepwise manner mation without contextual and other cues, N staticdisorderssuchasstrokesand recalling the source of information, and traumatic brain injuries are typically assessing the temporal sequence and recency maximal at onset, improve, and are then of events. The left medial temporal and stable frontal lobes are most involved when learning N transient disorders of episodic memory words, whereas the right medial temporal and include those attributable to a concussion, frontal lobes are most involved when learning a seizure, and transient global amnesia. Downloaded from pn.bmj.com on 5 February 2007 Budson, Price 45 Interviewing a family member or other informant is usually necessary because the TABLE 2 Four memory systems and the common clinical disorders patient will invariably not remember impor- which disrupt them tant aspects of their history. Any history of other cognitive deficits should also be elicited, Episodic Semantic Procedural Working such as attention, language, and visuospatial Disease memory memory memory memory skills. Medical and neurological examination Alzheimer’s disease +++ ++ – ++ should be performed to look for signs of Frontotemporal dementia ++ ++ – +++ neurodegenerative disorders, focal neurologi- Semantic dementia + +++ ?– cal injury, and systemic illness. Lewy body dementia ++ ?? ++ There are many cognitive tests that can be Stroke and vascular +++ ++ used to assess a patient’s episodic memory dementia Parkinson’s disease + + +++ ++ function. But the relationships between a Huntington’s disease + + +++ +++ patient’s cognitive functions, test perfor- Progressive supranuclear + + ++ +++ mance, and their ‘‘real life’’ activities are palsy often complex. Test performance is rarely Korsakoff syndrome +++ –– ¡ pathognomonic of a specific disorder. And no Multiple sclerosis + ¡ ? ++ single test is capable of evaluating all aspects Transient global amnesia +++ ¡ –– of memory. Factors confounding test inter- Hypoxic–ischaemic injury ++ –– ¡ pretation include aphasia, dyslexia, low intel- Head trauma ++¡ ++ ¡¡¡ ¡ lectual function, alterations in mood and Tumours ¡ ¡ motivation, confusion or delirium, psychosis, Depression + ++ Anxiety + –– ¡ and medication adverse effects. Cognitive
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