MEMORY
Dimensions of behavior• COGNITION :  information handling aspect of the behavior.• EMOTIONALITY :  concerns feelings and e...
••CharacteristicSx.                            Characteristic Sx.Cognition                  ••Measureable..               ...
• What is memory ?• Types of memory• Understanding memory – anatomical  and physiological basis• How to evaluate memory ?•...
Definition of memory“Mental process that allows the individual to store information for later recall.”
Three temporal stages of memoryi. Immediate memory – secondsii.Recent memory – minutes to daysiii.Remote memory – yearsMem...
• What is memory ?• Types of memory• Understanding memory – anatomical  and physiological basis• How to evaluate memory ?•...
Long term memory
••Emotionalresponse                                                  Emotional response     Habituation                   ...
Explict memory                Implict memory                ( non              ( declarativedeclarative memory )          ...
• What is memory ?• Types of memory• Understanding memory – anatomical  and physiological basis• How to evaluate memory ?•...
H.M patient ( Henry molaison)• Case of temporal lobe epilepsy        Medial temporal lobes , hippocampus and  amygdyla wer...
Understanding memory        Three basic questions• How does information get into  memory?• How is information maintained i...
Stages of memory process :1.Reception and registration2.Storage and retention3.Recall and retrival
Anatomical basis
Memory process
• Information is first acquired through  unimodal and polymodal association  areas – prefrontal,limbic and parieto-  occip...
Memory process
• Therefore entorhinal cortex have dual  functions – both input and output.        # damage causes severe memory loss  and...
Anatomical basis
• Hippocampus is only a temporary way  station for LTM.• Unimodal and polymodal association areas  of cortex are concerned...
Association areas are the ‘ultimate repositories’Association areas are the ‘ultimate repositories’
• In hippocampus , it takes days-wks to  facilitate storage of information about the  face initially processed by ass. are...
Implict memory• Introduction• Different forms of implict memory are  aquired through different forms of  learning and invo...
Types of learning1. Non associative learning : learns   about properties of single stimulus Habituation – dec response to...
2. Associative learning : Operant conditioning (Skinner) – involves   relationship b/w behavior and   consequence of that...
Learning driving     Involves conscious execution (explict) of specific seq of motor acts necessary to drive .with experie...
• What is memory ?• Types of memory• Understanding memory – anatomical  and physiological basis• How to evaluate memory ?•...
EVALUATION OF           MEMORY• Assess type of memory deficit.• Degree of memory loss.• Impact of memory loss on patients ...
• Historic events are commonly used by the  examiners to screen both recent and  remote memory .       But it requires pt....
• Hinders to the test are –        > inattention .        > disturbances of basic sensory,  motor and language functions.•...
• “Valid memory testing presumes that the  patient is reasonably attentive , can relate  to and cooperate with the examine...
IMMEDIATE RECALL / STMTested by digit repetition.• Repeat digits at rate of one per second.    3-7                    *Nor...
RECENT MEMORY              (ORIENTATION)• Ask the Q. in sequence.   1. PERSON          Name          Age               3. ...
• Normal people usually perform well ,  some time with less scores in ‘time  orientation’           failed items are usual...
REMOTE MEMORY• Evaluated by pts ability to recall personal  events and historic events. PERSONAL                     Norma...
HISTORIC FACTS    Four CM s during your lifetime    Last elections• Normal person tells with out difficulty• If pt has no ...
NEW LEARNING ABILITY• This is to assess pts ability to actively  learn new material ( to acquire new  memories)• All stage...
FOUR UNRELATED WORDS• Tell that “I am going to tell u 4 words that u  have to remember.  In a few minutes, u have to recal...
• Ex) Fun – carrot – knee – honesty      Red – happiness – brush – grapes• Normal pt < 60 yrs accurately recalls three  or...
• If he cannot recall ,     1. cues – semantic (‘one word is color’)               phonemic (‘hap… for happy’)     2. ask ...
VERBAL STORY FOR IMMEDIATE                    RECALL• Tell the pt “ I am going to read a short  story and I want u to reme...
It was july / ramu had packed up / their four children / and were off on vacation . They were taking / their yearly trip /...
• Of these 20 separate ideas, a normal  person of < 70 yrs should be expected to  produce atleast 10 items• This is a sens...
VISUAL MEMORY (Hidden objects)• Tested in all pts, but mainly useful in  aphasic pts. and also for illiterates.• Tell the ...
Assess by following Q.• Number of hidden objects found.• Number of hidden objects named, but not  found.• Number of hidden...
PAIRED ASSOCIATE            LEARNING• Another highly sensitive measure of new-  learning ability.• Tell the pt that you ar...
• Correct the incorrect responses , if any.• After 10 sec, give 2nd presentation and  recall lists.    1 ST PRESENTATION  ...
• No. of easy paired associates recalled :• No. of difficult paired associated recalled :• Normal pt < 70yrs – recalls two...
• What is memory ?• Types of memory• Understanding memory – anatomical  and physiological basis• How to evaluate memory ?•...
CLINICAL IMPLICATIONS• Limbic structures are involved in LTS  and retrieval of recent information.• Structures required fo...
IMMEDIATE RECALL• Performed by language cortex surrounded by  sylvian fissure.  (it requires registration, short term hold...
• Most common cause for failure of tests -  inattention.• Inattention may be –      organic - confusional states.         ...
Recent memory• Limbic structures –        Medial temporal lobe        Mamillary bodies        Dorsal medial nuclei of thal...
• Bilateral temporal damage  Damage to phc and entorhinal cortex  Orbitofrontal lobe damage (AcA  aneurysm rupture)       ...
ISOLATED LIMBIC SYSTEM DAMAGE –                                 organic  amnestic state. Severe anterograde amnesia Mode...
POST HEAD INJURY – Some retrograde amnesia Transient anterograde amnesiaMech. - temporal lobes are concussed againest  b...
 In head injury, ‘shrinking retrograde  amnesia’ occurs. i.e retrograde amnestic  period shortens in days following recov...
KORSAKOFF’S SYNDROME• Thalamus and mamillary body damage  occurs. Recent memory lost Good implict memory
• Deficit in retrieving the information , and  not in storage.     In cortical process memory traces  are stored without p...
TRANSIENT GLOBAL AMNESIA• Transient ischemia of both medial temporal  lobes secondary to decreased perfusion in  PCA terri...
OTHERS• Bilateral lesions of hippocampus –  infarctions – permanent memory loss.• Unilateral lesions –       dominant temp...
REMOTE MEMORY• Older memories stored in association  cortex and these doesn’t require limbic  system for retrival from sto...
ALZHEIMER’S DEMENTIA• Difficulty with STM - atrophy of basic  sensory association cortex.• Decreased recent memory acquisi...
FUNCTIONAL MEMORY               DISTRUBANCES• First and most common psychiatric  condition with memory disturbance is  DIS...
• During these states,    pts are not confused (as seen with TGA).    able to learn new material (unlike those in organic ...
• Ganser’s syndrome seen in –                        Prisoners                        Schizophrenia                       ...
TAKE HOME MESSAGE• Information must first get registered in basic  sensory cortical area and then processed through  limbi...
Thank you
Memory
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Memory

  1. 1. MEMORY
  2. 2. Dimensions of behavior• COGNITION : information handling aspect of the behavior.• EMOTIONALITY : concerns feelings and emotions• EXECUTIVE FUNCTIONS : related to ‘how behavior is expressed’
  3. 3. ••CharacteristicSx. Characteristic Sx.Cognition ••Measureable.. Measureable ••Subtlechanges can be Subtle changes can be identified. identified.1.Receptive functions – acquire new information2.Memory and learning – storage & retrieval3.Thinking – reorganize the information4.Expressive function – means through
  4. 4. • What is memory ?• Types of memory• Understanding memory – anatomical and physiological basis• How to evaluate memory ?• What are its clinical implications ?
  5. 5. Definition of memory“Mental process that allows the individual to store information for later recall.”
  6. 6. Three temporal stages of memoryi. Immediate memory – secondsii.Recent memory – minutes to daysiii.Remote memory – yearsMemory systems Short term memory Working memory Long term memory Declarative memory Non declarative memory
  7. 7. • What is memory ?• Types of memory• Understanding memory – anatomical and physiological basis• How to evaluate memory ?• What are its clinical implications ?
  8. 8. Long term memory
  9. 9. ••Emotionalresponse Emotional response Habituation Habituation -- amygdyla -- amygdyla and and Sensitization SensitizationMedial temporal lobe & ••Skeletalmuscle Skeletal muscle reflex Neocortex Neocortex Striatum reflex hippocampus -- cerebellum -- cerebellum pathways. pathways.
  10. 10. Explict memory Implict memory ( non ( declarativedeclarative memory ) memory )• Factual knowledge of • Involved in training people, places, things reflexive motor or and meaning of facts perceptual skills.• Conscious process and • Builds up slowly recall requires conscious through repetition over search of memory. many trails• Expressed mainly in verbal form • Recalled unconsciously • Expressed mainly in1. Episodic - events and form of performance personal experience2. Semantic - memory for facts
  11. 11. • What is memory ?• Types of memory• Understanding memory – anatomical and physiological basis• How to evaluate memory ?• What are its clinical implications ?
  12. 12. H.M patient ( Henry molaison)• Case of temporal lobe epilepsy Medial temporal lobes , hippocampus and amygdyla were removed bilaterally.• He had – * normal STM * normal LTM (events before operation) * good language and IQ was normal but he was unable to retain information for > mins , mainly about people , places and objects. He lost the ability to transfer new data from STM to LTM extensive bil. lesions of limbic ass. areas of medial temporal lobe show this defect. (i.e in explict memory)
  13. 13. Understanding memory Three basic questions• How does information get into memory?• How is information maintained in memory?• How is information pulled back out of memory?
  14. 14. Stages of memory process :1.Reception and registration2.Storage and retention3.Recall and retrival
  15. 15. Anatomical basis
  16. 16. Memory process
  17. 17. • Information is first acquired through unimodal and polymodal association areas – prefrontal,limbic and parieto- occipito-temporal cortex – which synthesize visual and somatic information
  18. 18. Memory process
  19. 19. • Therefore entorhinal cortex have dual functions – both input and output. # damage causes severe memory loss and all sensory modalities involved. # earliest pathological change in AD – entorhinal cortex involvement and so explict memory lost early.• Hippocampus – right side – spatial memories stored (lesions cause defect in spatial orientation) left side – memories for words, objects and people (lesions cause defect in verbal memory)
  20. 20. Anatomical basis
  21. 21. • Hippocampus is only a temporary way station for LTM.• Unimodal and polymodal association areas of cortex are concerned with LTM storage.• Amygdyla – stores component of memory concerned with emotion. It doesnt store factual information. (damage has no effect on explict memory)
  22. 22. Association areas are the ‘ultimate repositories’Association areas are the ‘ultimate repositories’
  23. 23. • In hippocampus , it takes days-wks to facilitate storage of information about the face initially processed by ass. areas.• There is relatively slow addition of information to neocortex, which permits new data to get stored without disrupting information. Their (ie ass. areas) damage l/t impaired recall of knowledge , aquired before the damage. Ex- prosopagnosia.
  24. 24. Implict memory• Introduction• Different forms of implict memory are aquired through different forms of learning and involve different regions.Acquired through fear – amygdyla (emotional)Acquired through operant conditioning – striatum and cerebellum.Acquired through sensitisation and habituation – sensory and motor systems.
  25. 25. Types of learning1. Non associative learning : learns about properties of single stimulus Habituation – dec response to stimulus, when presented repeatedly. Ex.-crackers. Sensitization – enhanced response to any stimuli , following a first intense stimulus. this occurs through reflex pathways.
  26. 26. 2. Associative learning : Operant conditioning (Skinner) – involves relationship b/w behavior and consequence of that behavior. Ex.- Reward . Classical conditioning (Pavlov) – involves relationship b/w two stimuli.PRIMING : effect in which exposure to a stimulus influences response to a later stimulus. Ex- Table- ‘tab__’
  27. 27. Learning driving Involves conscious execution (explict) of specific seq of motor acts necessary to drive .with experience driving becomes automatic and non conscious (implict) activity
  28. 28. • What is memory ?• Types of memory• Understanding memory – anatomical and physiological basis• How to evaluate memory ?• What are its clinical implications ?
  29. 29. EVALUATION OF MEMORY• Assess type of memory deficit.• Degree of memory loss.• Impact of memory loss on patients functional ability• Accurate assessment of memory requires that any question asked by examiner be verifiable from a source, other than pt.
  30. 30. • Historic events are commonly used by the examiners to screen both recent and remote memory . But it requires pt.’s premorbid intellectual capacity & social exposure.• Most valid and sensitive test for recent memory – learning new material and recalling it over time.
  31. 31. • Hinders to the test are – > inattention . > disturbances of basic sensory, motor and language functions.• Any evidence of aphasia impairs both verbal STM and LTM. Caution to be taken while examining these pts.
  32. 32. • “Valid memory testing presumes that the patient is reasonably attentive , can relate to and cooperate with the examiner , and has no defect that impairs language comprehension and expression.”( Poor memory performance in pts who are deaf, aphasic , acute confusion, psychotic, depressed and inattentive – reflects defect caused by the process alone )
  33. 33. IMMEDIATE RECALL / STMTested by digit repetition.• Repeat digits at rate of one per second. 3-7 *Normal person repeats 2-4-9 five to seven digits. 8-5-2-7 2-9-6-8-3 5-7-1-9-4-6 *< five digits – impaired 8-1-5-9-3-6-2 repitition.
  34. 34. RECENT MEMORY (ORIENTATION)• Ask the Q. in sequence. 1. PERSON Name Age 3. TIME Birth date Date Day of the week. Time of the day 2. PLACE Season of the year Location Duration of time City with the examiner. Home address
  35. 35. • Normal people usually perform well , some time with less scores in ‘time orientation’ failed items are usually date of month and day of week .( mainly illiterates)• Orientation to time and place are actually measures of recent memory, as they test the pts ability to learn these changing facts
  36. 36. REMOTE MEMORY• Evaluated by pts ability to recall personal events and historic events. PERSONAL Normal and those INFORMATION with mild nonspecific Where were you born? brain damage do School information Vocational history with same accuracy. Family information Impaired perfor- mance is pathologic.
  37. 37. HISTORIC FACTS Four CM s during your lifetime Last elections• Normal person tells with out difficulty• If pt has no memory of these events, this implies deficient memory. ( some Q. depend on literacy level of pts )
  38. 38. NEW LEARNING ABILITY• This is to assess pts ability to actively learn new material ( to acquire new memories)• All stages of memory process __ are necessary for adequate performance. Any defect at any stage l/t loss of this ability.
  39. 39. FOUR UNRELATED WORDS• Tell that “I am going to tell u 4 words that u have to remember. In a few minutes, u have to recall these words• Ask him to repeat the words after they are presented- to ensure that he understood.• After 5 min , ask him to recall the words
  40. 40. • Ex) Fun – carrot – knee – honesty Red – happiness – brush – grapes• Normal pt < 60 yrs accurately recalls three or four words after 10 min delay. pt > 80 yrs recalls two words normally after 5 min delay.
  41. 41. • If he cannot recall , 1. cues – semantic (‘one word is color’) phonemic (‘hap… for happy’) 2. ask to select from a series of words. When 2 yeilds better than 1(recall), the problem may be due to retrieval defect, rather than storage. This indicates normal implict memory.
  42. 42. VERBAL STORY FOR IMMEDIATE RECALL• Tell the pt “ I am going to read a short story and I want u to remember, and I want u to tell me what I have told ”• Read the story slowly and correctly without any pauses.• Ask the pt to retell the story as accurately as possible.
  43. 43. It was july / ramu had packed up / their four children / and were off on vacation . They were taking / their yearly trip / to the beach / of vizag. This year / they were making / a one day stop / at araku. After a long day drive / they came back to hotel / and found that / they had left / their suit cases / in the garden.• No. of correct memories _________• Describe confabulations , if present.
  44. 44. • Of these 20 separate ideas, a normal person of < 70 yrs should be expected to produce atleast 10 items• This is a sensitive method of assessing short term verbal recall.• Story recall discriminates b/w Normal and AD pts Brain damaged and low IQ pts
  45. 45. VISUAL MEMORY (Hidden objects)• Tested in all pts, but mainly useful in aphasic pts. and also for illiterates.• Tell the pt that you are going to hide some objects and ask him to remember where they are.• Hide 4 or 5 common objects like – keys, pen, etc in various areas of pt’s sight.• After 5 min , ask pt to find the objects.• Ask him to name the objects that he could not find.
  46. 46. Assess by following Q.• Number of hidden objects found.• Number of hidden objects named, but not found.• Number of hidden locations found, but objects not named. Normal person < 60 yrs finds 4 or 5 objects. Impaired visual memory – finds < 3 objects. Aphasic pt should find the objects , but may not be able to name them.
  47. 47. PAIRED ASSOCIATE LEARNING• Another highly sensitive measure of new- learning ability.• Tell the pt that you are going to read a list of words – two at a time .• Pt is expected to remember the two paired words. ( ex. High – Low )• Read the 1st presentation list and test for recall by saying 1st recall list . (Give the first word of pair – ask for other)
  48. 48. • Correct the incorrect responses , if any.• After 10 sec, give 2nd presentation and recall lists. 1 ST PRESENTATION 2 nd PRESENTATION LIST LIST Weather - box House - income High - low Book – page House - income Weather - box Book – page High - low 1 st RECALL LIST 2 nd RECALL LIST House - ______ High - ____ High - ____ House - ______ Weather - _______ Book - ____ Book - ____ Weather - _______
  49. 49. • No. of easy paired associates recalled :• No. of difficult paired associated recalled :• Normal pt < 70yrs – recalls two easily paired associates and atleast one hard on 1st recall and to recall all on 2nd trail.• Total PAL score is the best measure of verbal learning.
  50. 50. • What is memory ?• Types of memory• Understanding memory – anatomical and physiological basis• How to evaluate memory ?• What are its clinical implications ?
  51. 51. CLINICAL IMPLICATIONS• Limbic structures are involved in LTS and retrieval of recent information.• Structures required for immediate recall and remote memory are not yet established.
  52. 52. IMMEDIATE RECALL• Performed by language cortex surrounded by sylvian fissure. (it requires registration, short term holding and repetition, doesn’t require LTS) Mechanism is not known. May be due to ? Reverberating circuits ? Cortical after images• STM is a property of cortical sensory, motor and integrative areas. If these basic sensory – motor areas are damaged , STM is disrupted.
  53. 53. • Most common cause for failure of tests - inattention.• Inattention may be – organic - confusional states. - dementia. functional – anxiety and depression• Pt. with dementia have difficulty with immediate memory due to – > inattentiveness > cortical ( sensorimotor) atrophy > intellectual detriment.
  54. 54. Recent memory• Limbic structures – Medial temporal lobe Mamillary bodies Dorsal medial nuclei of thalamus are essential subcortical links in storage and retrieval of both verbal and non verbal memories
  55. 55. • Bilateral temporal damage Damage to phc and entorhinal cortex Orbitofrontal lobe damage (AcA aneurysm rupture) -- impair recent memory.• In damage of these structures, # anterograde amnesia & # retrograde amnesia occurs. i.e pt. is fixed in time
  56. 56. ISOLATED LIMBIC SYSTEM DAMAGE – organic amnestic state. Severe anterograde amnesia Moderate to severe retrograde amnesia Confabulation Intact immediate memory No change in premorbid levels of intellegence. They don’t remember time , place , person.Causes : bil. Hippocampal lobectomy HSV encephalitis bil. Hippocampal infarction. korsakoff syndrome.
  57. 57. POST HEAD INJURY – Some retrograde amnesia Transient anterograde amnesiaMech. - temporal lobes are concussed againest bony confines of middle cranial fossa , which causes disruption of hippocampal function.Post traumatic amnesia is usually reversible, if significant it is permanent. In boxers (dementia pugilistica),gradual but permanent memory disturbances occur.
  58. 58.  In head injury, ‘shrinking retrograde amnesia’ occurs. i.e retrograde amnestic period shortens in days following recovery of consiousness. initially pt doesn’t recall yrs preceding RTA . With in days, pt remembers all but few minutes preceding RTA. ALZHEIMER’S DISEASE – Defect in new learning
  59. 59. KORSAKOFF’S SYNDROME• Thalamus and mamillary body damage occurs. Recent memory lost Good implict memory
  60. 60. • Deficit in retrieving the information , and not in storage. In cortical process memory traces are stored without pt awareness. Implict memory is retained which don’t need active recall. Even then it doesn’t help him – as he doesn’t realize that they are stored.(In hippocampal + temporal lobe damage, both storage and retrieval are defective.)
  61. 61. TRANSIENT GLOBAL AMNESIA• Transient ischemia of both medial temporal lobes secondary to decreased perfusion in PCA territory. Acute , but temporary confusional state. Amnesia . Disoriented to time , place. Significant defect in new learning ability.• Recovers in hrs-days, but left with permenant amnesia for the episode itself.
  62. 62. OTHERS• Bilateral lesions of hippocampus – infarctions – permanent memory loss.• Unilateral lesions – dominant temporal lobectomy – verbal learning non dominant temporal lobectomy - defective visual learning.• Drugs : Psychotropics B-blockers Prednisolone AED Medications and toxins- alcohol
  63. 63. REMOTE MEMORY• Older memories stored in association cortex and these doesn’t require limbic system for retrival from storage.• Seen in Alzheimer’s disease and Pick’s disease (atrophic dementias)• In koraskoff psychosis and bil temporal lobectomy, remote memory retained. recent memory lost.
  64. 64. ALZHEIMER’S DEMENTIA• Difficulty with STM - atrophy of basic sensory association cortex.• Decreased recent memory acquisition – degeneration of hippocampus• Defect in remote memory – widespread cortical atrophy.
  65. 65. FUNCTIONAL MEMORY DISTRUBANCES• First and most common psychiatric condition with memory disturbance is DISSOCIATIVE STATE (now, psychogenic amnesia) .1.Dissociative amnesia or fugue : pts lose their identity and travel to new location.2.Dissociative state or localized amnesia: pt have periods of hrs to days when thay carry out normal routine life and become aware that they remember nothing during this period.
  66. 66. • During these states, pts are not confused (as seen with TGA). able to learn new material (unlike those in organic amnesia).3. Ganser’s syndrome : syndrome of approximate answers. Pt routinely give approx. answers as if thay have knowledge regarding the Q. These pts have clouded consciousness , hallucinations and conversion Sx.
  67. 67. • Ganser’s syndrome seen in – Prisoners Schizophrenia Brain Disease. Malingering.4. Malingering : pts may give approx answers , memory loss is inconsistent , fail all memory tests, but remembers football score of past week.
  68. 68. TAKE HOME MESSAGE• Information must first get registered in basic sensory cortical area and then processed through limbic system for new learning to occur. Finally memory is established in appr. association cortex.• Immediate recall lost – pri. sensory / motor cortex. Learning – hippocampus / DMN of thalamus. Old remote memories – widespread cortex .• Careful testing is important for clinical and anatomical diagnosis
  69. 69. Thank you

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