2. ▪ Process of memory has following steps
▪ Reception from sensory inputs
▪ Registration of received information
▪ Temporarily held information (short term memory)
▪ Storing of information in a more permanent form (long term memory)
--- storage is achieved through effort of practice and rehearsal
--- enhanced by repetition or association with other information
▪ Final step is recall or retrieval of stored information
3. ▪ Memory is subdivided based on time span between stimulus presentation and memory retrieval
▪ Terms are descriptive, time span is not well defined
▪ Immediate memory -recall of trace memory after few seconds
▪ Recent memory remember- day-to-day events(doctor name too) which involves learning new
material.
▪ Remote memory- recollection of memory that occurred many yrs back
▪ Amnesia is commonly used to label pts with severe and relatively isolated memory deficits
4. EVALUATION
▪ Each aspect of memory should be assessed in some detail
▪ Distinguish type of memory deficit(if any), degree of memory loss, impact or
impairment of memory deficit on pt’s ability to function in a vocational or social
role.
▪ Depending on the nature of disorder pt will show variable performance in different
tests.
▪ For accurate assessment of memory requires any questions asked by the
examiner be verifiable
--Confabulated answers seem appropriate if not verified.
5. ▪ Personal information question must be verified
▪ Basic knowledge about any historic facts is closely related to pt’s basic premorbid intellectual
level, education and general social exposure
▪ Historic facts must be tailored to pt’s background.
▪ Most sensitive and valid tests of recent memory are those that require the pt to learn new
material and recall it over time .
▪ Eliminates error of unverified answers and unknown social background
6. ▪ New learning is an active memory process that requires more expenditure of effort on pt’s
part than does mere recall of personal or historic facts.
▪ When evaluating memory examiner must be aware of more basic processes that can
result in impaired performance even without an organic memory deficit.
▪ Eg conditions effecting attention, consciousness, mood, sensory, motor or language can
effect memory performance.
7. Immediate recall (Short Term Memory)
▪ Tested by digit repetition as in testing for attention
▪ Backward digit repetition requires several neuropsychological processes in
addition to memory, usually used as general screening test for brain
dysfunction.
▪ Not a test for memory in isolation.
8. Orientation
▪ Orientation to place and time are actually measure of recent memory, as they
test patient’s ability to learn continuing changes.
▪ Therefore first thing to ask before memory is orientation
▪ If a person is not fully oriented this alone suggests significant recent memory
deficits.
Directions :
▪ Ask in sequence
▪ Can paraphrase if necessary
▪ If fails tell the answer and test again after several minutes and have the pt recall.
failure at this level verifies very poor new learning ability and will predict deficient
performance on any subsequent memory tasks.
9. ▪ Following questions to ask in a sequence
▪ 1. Person
a) Name
b) Age
c) DOB
▪ 2. PLACE
a)Location Where are we right now
What is the name of this place
What kind of place are we in now
What floor did you come to
b) City location What city
State
c) Address What is your home address
10. ▪ 3. TIME
a) Date
b) Day of the week
c) Time of the day
d) Season of the year
11. ▪ Normal people perform adequately
▪ Although there may be small lapses in time orientation, date and day of the week
▪ May miss by one day
▪ Illiterate might miss by 2 or even 3 days
12. Remote memory
▪ Tests recall events of personal and historic nature.
▪ Test must be interpreted in light of pt’s intelligence, education and social
experience.
1. Personal information
a) Where were you born
b) School information Where did you go to school (eg Delhi)
When did you attend school(eg 1947)
Where is your school located(eg 10 Janpath)
13. c) Vocation history What do you do for work (eg Teaching)
Where have you worked (eg DPS)
When did you work at those places (eg 2015-2020)
d) Family information What is your wife’s name
How old is your wife/children
What is your mother’s maiden name?
14. 2. Historic facts
- Name four people people who have been president during pt’s life time
Slightly more difficult is asking in reverse order last 5 presidents.
- Any last national event/war in life time, which is very significant eg: kargil war
Depends on gk of the pt according to his background.
15. New Learning Ability
▪ Assess pt’s ability to actively learn new material(to acquire new memories)
▪ Requires total integrity of memory system:
Recognize and registration of initial sensory input
Retention and storage of the information
Recall and retrieval of stored information
Any interruption in any of these stages impairs new learning ability
16. ▪ A careful clinical examination of how the pt fails a particular task may often
provide valuable information of the impaired process
▪ Pts with impaired memory, confuse learning of subsequent items with items
presented earlier(proactive interference)
▪ In such situations, pt may provide answers from earlier test items in later testing.
▪ These intrusion errors are characteristics of many organic syndromes
17. Four unrelated words
▪ Directions:
o Tell the pt “ I am going to give you four words that I would like you to remember,
in a few minutes I will ask you to recall these words”.
o To ensure that pt has heard, understood and initially retained the four words, have
him repeat the words after their presentation.
o Correct any errors made on immediate repetition.
o Older pts require several trials to learn words, but if pt must be given 4/5 trials to
repeat the words accurately, this usually forecasts significant memory problem
o To eliminate possible mental rehearsal, interference should be used between
presentation and recall.
18. o Accordingly four words can be presented before remote memory or orientation examination
o After 5 mins ask for recall of four words
o Following test words are selected because of their semantic and phonemic diversity
1. Brown 1.Fun
2. Honesty 2.Carrot
3. Tulip 3.Ankle
4. Eyedropper 4.Loyalty
19. ▪ If pt is unable to recall a word, obtain words from verbal cues indicating memory storage.
▪ Verbal cues can be – semantic cues (eg one word was a color)
phonemic cues using syllabic components (eg Hon….)
contextual cues (eg common flower in holland)
▪ If pt is unable to recall spontaneously or by verbal cues, ask to pick from the series of words
given (eg was the color red, brown green or yellow?)
▪ Recognition with cues suggests memory problem due to retrieval defect rather than acquisition
or storage deficit
scoring : normal pt under 60yrs expected to recall 3or 4 words after 10 mins delay
- there is significant variation within normal population
- clinical implication of low score must be interpreted in light of pt’s history and performance of
entire examination.
20. ▪ There is age related decline in performance on this test in normal individuals over
60years of age.
▪ Octogenarians average only two of four words retained over 5 minutes, with
substantial variance.
▪ They will improve their performance at 10 and 330 minutes after being reminded
of the correct words.
21. Verbal story for immediate recall
▪ Directions: tell the pt “ I am going to read you a short paragraph. Listen carefully
because when I finish reading, I want you to tell me everything that I told you”.
▪ In older pt read the story more slowly to give them adequate time to process the
information.
▪ After reading the story say, now tell me everything that you can remember of the
story
22. ▪ Test item:
It was July/and the rogers / had packed up / their four children / in the station wagon / and were off /
on vacation.
They were taking / their yearly trip / to the beach / at gulf shores. This year / they are making / a
special 1-day stop / at the aquarium / in New Orleans.
After a long day’s drive / they arrived / at the motel / only to discover / that in their excitement / they
had left / the twins / and their suitcases / in the front yard.
Scoring:
Story contains 26 relatively separate ideas or information bits.
Normal atleast 10 items on immediate recall in <70years
23. Visual memory (Hidden Objects)
▪ Directions: Used in all pts, especially helpful in evaluating memory of aphasic pt.
▪ Also useful for pts with reduced verbal abilities and illetrate pts
▪ Can use any small easily recognizable objects that may readily hidden in pt’s
vicinity.
▪ Commonly use pen, comb, keys, coin and spoon.
▪ Five items provide reasonable span
▪ Objects are hidden while the pt is watching.
▪ Name each item while being hidden.
▪ After hiding the objects, examiner must engage/interfere pt in another task to
prevent rehearsal. 5mins should be suffice.
▪ After this period ask the pt to name and indicate the location of each hidden
objects.
24. ▪ Scoring: <60yr old name reasonably name 4-5 objects
▪ Fewer than three objects indicates impaired usual memory.
25. Visual memory ( Visual Design Reproduction)
▪ It is not a test of visual memory alone but also tests constructional abilities.
▪ Directions:
Five simple line drawings of increased complexities.
Design is presented for 5 secs ( 5secs × 5, total 25 secs) and 10 sec delay before
beginning
Instruction: now I am gonna show you some pictures watch it carefully, after
sometime I will ask you to draw without seeing it. Don’t draw until I said so.
Scoring :
0- poor 1- recognizable but distorted/omitted
2- easily recognizable 3 – near perfect/perfect
Average pt reproduce near 2/3 scoring
26.
27. Paired Associate Learning
▪ PAL used in standard memory battles
▪ Highly sensitive measure of new learning ability
▪ A pair of words presented and asked for recall by presenting the words
associated in a pair
▪ Instruction :
▪ I am gonna present to you pair of words, listen carefully, after sometime I will give
a word among them and you have to remember word asso
28. TEST ITEMS
presentation lists
FIRST PRESENTATION SECOND PRESENTATION
Weather- box House – income
High - low Weather –box
House - income Book – page
Book - page High – low
29. RECALL LISTS
First recall Second recall
House - Book -
High - House-
Weather - High -
Book - Weather -
30. ▪ Scoring :
▪ Normal person(pt)<70 yrs expected to recall the two “easy” paired associates and
atleast one of the hard associates of first recall trial, and to recall all paired
associates on second trial.
▪ In pts greater than 70, performance is slightly less adequate.
▪ Some pts will be able to learn paired words with strong natural associations, but
unable to learn new material if that associations are not there are unable to
establish.
▪ This shows dependency on association with semantic cues with old memories in
storage
31. CLINICAL IMPLICATIONS
▪ Immediate recall:
Has registration, temporary holding and repetition/expression involves language cortex
surrounding sylvian fissure.
Short term memory is a distinctive property of sensory and motor cortex and its
associative areas necessary to register, recall and produce the original stimulus.
It doesnot require limbic system that is necessary for long term storage and permanent
memory formation
So if immediate memory needs cortex any cortical damage will show impairement of
immediate recall.
Information is coded in brain in form of “language”, so any disruption in language will
affect immediate memory also
32. ▪ Most common cause of short term memory tasks is inattention.
▪ Inattention can be caused by dementia/delirium/anxiety/depression.
▪ Anything that prevent registration will affect short term memory (read as
immediate recall) is impaired.
33. ▪ Recent memory
▪ In general ability to store and retrieve new material (recent memory, new learning or
memorizing) presumes intact registration, retention and short term storage.
▪ If the material is familiar with past information already in long term storage, process relies
less on short term storage or kind of bypass?
▪ Memory which is stored relatively for longer duration involves some limbic structures, to
ensure storage and retrieval
▪ Limbic structures hippocampi, mammillary bodies and the dorsal medial nuclei of thalami
form the essential subcortical “links” for storage and retrieval.
34. Recent memory:
▪ Actual memories are probably not stored in these structures, but limbic system seems to
act as the mechanism to store and retrieve memories from the cortex.
▪ When these subcortical structures are damaged involved new material cannot be
learned/retained (anterograde amnesia) or (?recent)past memories cannot be
retrieved(retrograde amnesia)
▪ Person is literally fixed in time and cannot record passing of events.
35. ▪ In some clinical situations damage of these structures in isolation develop profound
organic amnesic state
▪ Characterized by
1. Severe anterograde amnesia
2. Mod to severe retrograde amnesia
3. Confabulation during acute stage
But intact immediate memory
No change in premorbid intelligence
Conversations appear intelligent, if areas that needs usage of memory are not touched
Because cannot remember changed place, date and recent events they, appear
confused.
36. ▪ This dramatic organic amnesia state has been secondary to bilateral temporal lobectomy,
herpes simplex encephalitis and bilateral hippocampal infarction.
▪ In these hippocampus has been destroyed completely bilaterally
▪ In korasakoff’s syndrome similar memory deficit is seen, lesion involves bilateral mammillary
body and dorso medial nuclei of thalami.
▪ During the onset of memory difficulty, pt frequently goes through acute encephalopathy
(wernickes encephalopathy)
▪ Infarction of dorsal medial thalamus also cause severe organic amnesic syndrome
37. ▪ In Alzheimer’s dementia points to remember are
1. Its “gradual” degeneration of hippocampus along with other parts of brain which gives
2.Compounded/ complex picture rather than dramatic organic amnesias
38. ▪ Pts with moderate to severe closed head injury almost always have some degree of
retrograde amnesia for the time immediately preceding the injury(ie moments before) and
they usually have short lived (transient) difficulty in learning new material(anterograde
amnesia).
▪ In head trauma the temporal lobes are commonly concussed against bony confines of the
middle fossa.
▪ Trauma leads to physiologic disruption of hippocampal function causing disturbance in
memory storage and retrieval.
▪ Retrograde amnesia is usually reversible, but in case of significant temporal lobe damage
memory loss can be permanent
39. ▪ Recovery of retrograde amnesia is seen as shrinking in duration of retrograde amnesia,
gradually remembering, this verifies that memories were temporary irretrievable, rather than
lost.
▪ Memory disturbances in various organic amnesias is similar (ie cannot recall recent
information)
▪ On experimental tasks its been shown that pts with koraskoff’s syndrome whose damage is
in the thalamus and mamillary body have actually retained considerable amount of material
presented to them, but unaware of this(memory is implicit but not explicit)
▪ The deficit is with retrieving the information and realizing that it has been presented
rather than with storage process.
40. ▪ Total four structures to remember Thalamus
Temporal lobe
Mammilary body
Hippocampus
▪ Pts with hippocampal and temporal damage have both a storage and a retrieval defect
Hippo temppo
41. Transient global amnesia
Decreased perfusion in post cerebral artery territory with transient ischemia of of
both medial temporal lobes
Characterized by acute, temporary confusional state with amnesia
Pts seem disoriented to time place and significant difficulty in imbibing new material
it is reversible but amnesia for the time period of decreased perfusion is
permanent, if the brain circulation is regained and there is no permanent tissue
hypoxic injury.
42. Case vignette
▪ DrJL was a robust 68year old educator who was addressing a teacher’s
convention. In the middle of his speech he stopped suddenly became dazed, and
began to ask where he was. He repeatedly asked what I am doing, and where am
i? on initial neurologic examination he was distraught and very confused. He was
unable to learn new material. He did not remember arriving new orleans, but he
did know he that he was scheduled to attend convention. One day later his
mental function was essentially normal except he was amnesic for the day prior to
and the day of his amnesic episode.
43. ▪ Unilateral lesions have distinct features
▪ Unilateral dominant temporal lobe lobectomy produce relative decrease in verbal
learning.
▪ Unilateral non dominant temporal lobectomies demonstrate a decrease in visual
memory
44. ▪ Net banking username and passwords, debit/ credit card pins are products of
recent memory which after repeated use goes into longterm storage
▪ OTPs seems product of immediate memory, which are discarded after transaction
is over.
45. ▪ Remote memory
▪ Memory that remain in persons’ repertoire for no of years becomes an old/ remote
memory (through rehearsal and repeatetion)
▪ These memories are stored in appropriate association cortex(? Probably different
place in cortex to that of recent memory)
▪ In contrast to recent memory, remote memory doesnot require limbic system for retrieval
from storage
▪ Pts with Korsakoff syndrome or bilateral temporal lobectomy can accurately discuss
personal and historic events that occurred years previously
46. ▪ Yet they are unable to remember what they had for breakfast that morning(recent memory)
▪ These memories can only be lost by damage to the storage device(cortex)
▪ Loss of remote or old memories is seen in pts with atrophic dementias(alzheimers and picks)
▪ The memory disturbance in demented pt is complex, initial stages there is recent and short
term memory disturbances due to atrophy of primary cortices like temporal parietal and frontal
and basilar nucleus of meynert and hippocampal system later defects in remote memory with
widespread atrophy of cortex
47. Functional Memory Disturbance
▪ Not all memory disturbances are organic origin
▪ Most common dissociative state/psychogenic amnesia
▪ Seen with new identity, working as normal as anyone else, no confusion related to
place unlike in TIA/ no difficulties related to learning new information unlike in
organic amnesia
▪ Don’t have memory related to new identity or activities.
▪ Brief testing using the four unrelated words task or paired associate words task should
suffice
48. ▪ Another condition is pseudomemory disturbance: Ganser’s syndrome or syndrome of
approximate answers
these pts will routinely give approximate answer to all questions
Eg today is Tuesday(actually it is Wednesday)
the month is march(actually it is April)
because their answers are so consistently close to the correct answer it is obvious that they
have more knowledge of the subject in question than what is being indicated
The nature and inconsistency of their mental status findings strongly suggest a significant
component of either hysteria or malingering
Have some motivating reason to appear legally insane, incompetent, or cognitively incompetent
49. ▪ On examination, these pts may give approximate answers or very bizzare answers.
▪ Memory loss is usually inconsistent, in that they may fail all memory testing but remember a
football score from the previous weekend.
▪ Also claim patches of remote memory loss and at times claim not to remember their own
name
▪ Usually observed to have a very specific well recognized reason for their malingering
50. Summary
▪ Memory is hierarchic process
▪ Information must first be registered in basic sensory cortical area
▪ Then processed through limbic system for new learning
▪ Finally material is permanently established in appropriate association cortex
▪ At this point limbic retrieval is no longer required in the recall process.
▪ Immediate recall system is disturbed by damage to primary sensory or motor cortex or
by inattention
▪ Learning is prevented by damage to the hippocampi or dorsal medial thalamic nuclei
▪ Old remote memories are resistant to limbic damage but will be lost when widespread
cortical damage occurs
