The document discusses various memory disorders, focusing on age-associated memory impairment (AAMI) and dementia, particularly Alzheimer's disease. It outlines the characteristics, symptoms, and diagnostic criteria for these conditions, along with differences between organic and psychogenic amnesias. Additionally, it highlights the implications of HIV-related cognitive disorders and the importance of management strategies, including the use of highly active antiretroviral therapy (HAART).

1. MEMORY DISODERS

2.  Age appropriate Memory Impairment
 Organic Amnesias: Dementia
 Psychogenic Amnesias
Memory Impairment

3.  This demonstrable loss of memory with increasing
age has been termed Age-associated memory
impairment (AAMI).
 It is not uncommon for older adults to complain of
declining memory:
◦ Forgetting names and appointments and
◦ misplacing everyday items, such as keys
Age-Associated Memory Impairment

4.  Studies comparing the objective memory
performance in people between the ages of 35
and 44 years and those between the ages of 70
and 74 years has shown:
◦ Younger age group had scores up to 50% higher than
those in the older group.
◦ Memory for non-verbal material seems to be more
affected by aging than memory for verbal material,
and
◦ Delayed recall is affected more than immediate recall.
Age-Associated Memory Impairment

5.  Perception by the subject of memory loss (e.g.
misplacing articles such as keys, spectacles, etc.).
 Objective evidence of impairment of memory on
standardized tests of delayed recall for verbal
information.
 A score of one standard deviation below that of a
young adult on tests of memory.
 Absence of other conditions that may affect
memory, including depression and dementia.
Criteria for age associated memory impairme

6.  Approximately 40% of individuals aged 65 and
over show AAMI.
 A common bedside test is to give a list of 20 words
to the subject to study and then ask him or her to
recall as many as possible 20 minutes later
(delayed recall).
 The score is compared with standardized scores
for the given age.
 There is considerable individual variation and a
subgroup of elderly individuals have memory and
cognitive functions are well preserved.
Other features of aami

7.  The term dementia has been used in two different
ways.
 It has been used to describe a symptom, the
gradual, and usually progressive, decline in
memory.
 In the second usage the term dementia is employed
to describe a clinical syndrome (as defined in DSM-
IV and ICD-10)
 Dementia is characterized by:
◦ marked loss of memory,
◦ deterioration in adaptive functioning and,
◦ at least one other additional sign of major cognitive deficit
(aphasia, agnosia or loss of executive functions).
Dementia

8.  Dementia consists of a collection of symptoms
that imply widespread cerebral damage.
 The most common cause of this syndrome in
individuals over 65 is Alzheimer’s disease (AD),
which accounts for approximately two-thirds of
all cases of dementia.
dementia

9.  Agnosia: Inability to understand the
importance or significance of sensory stimuli;
 Aphasia: Any disturbance in the
comprehension or expression of language
caused by a brain lesion
 Executive functions:
definitions

10.  Episodic memory refers to a long term memory which is
specific, personally experienced events or episodes
from the individuals' past.
 Procedural memory is a type of implicit memory for
sequences/procedures (cycling, skating etc.).
 Implicit memory is a behavioral, emotional, and
perceptual form of memory devoid of the subjective
internal experience of recalling, of self, or of past.
 Semantic memory refers to retrieval of facts from the
organized knowledge about the world.
 Echoic memory refers to sensory auditory memory
lasting 3-4 seconds.
definitions

11.  The earliest sign of AD is loss of memory and the
major memory system affected is episodic memory.
 Storage of information regarding our past
experiences, is known as episodic memory.
 The impairment of episodic memory is evident early
in the course of AD and is best demonstrated by
tests of delayed recall such as remembering a name
and address after 5 to 10 minutes.
 Loss of remote memory becomes evident next.
 It begins with difficulties in recall of recent events
and proceeds, according to Ribot’s law, to extend to
more distant memories.
Alzheimer's dementia

12.  Semantic memory deals with organized
knowledge about the world
 Shows deterioration early in the course of AD
but may not be apparent to the subject or the
clinician unless specific tests are carried out.
 In comparison with marked deficits in LTM,
working memory remains remarkably intact
even in the later stages of the disease; implicit
memory is spared until very late stages of the
disease.
Alzheimer's dementia

13.  In addition to AD, various other disorders can give rise
to the syndrome of dementia, most notably vascular
and other degenerative pathologies.
 The mini-mental state examination (MMSE) is a popular
screening and rating tool for dementia. In addition to
memory it assesses orientation, praxis and other
functions.
 The Cambridge cognitive function examination (CAMCOG)
is a well-established research instrument for the
assessment of dementia in elderly people. It assesses
a wider range of cognitive functions than memory
(attention, abstraction, language, and so on). It is part
of a standardized psychiatric assessment sched
Alzheimer's dementia

14.  The amnesic syndrome has been defined as ‘an
abnormal mental state in which memory and
learning are affected whereas all other
cognitive functions are intact.
 Cause: herpes encephalitis, severe cerebral
hypoxia and thiamine deficiency
Amnesic Syndromes

15.  Intact short term memory
 Anterograde amnesia
 Retrograde amnesia
 Preserved global intellectual abilities
 Preserved implicit memory
Clinical features

16.  Intact short-term memory. Immediate memory is
unimpaired.
 Thus performances on digit span test and other
measures of primary memory (requiring the recall of
information within a few seconds) are remarkably
intact and within normal range.
 However, performances on these short-term memory
tests are sensitive to proactive interference.
 If, for example, patients are given a second distractive
exercise (such as repeating three digits backwards)
before recalling the test items, the patients are
unable to recall the original items.
Clinical features

17.  Anterograde amnesia (AA). This refers to the
inability to acquire new information.
 The classical pattern of Anterograde amnesia
consists of normal immediate recall as indicated
above (e.g. digit span) and impaired delayed recall
(e.g. recall three items or an address after five
minutes.
 Because of the inability to learn and retain new
information, most patients experience difficulties in
remembering recent events such as the ingredients
of their last meal, the name of the hospital or, even,
the date.
Anterograde amnesia

18.  Retrograde amnesia (RA). Retrograde amnesia is
the inability to retrieve information that had been
stored prior to the onset of amnesia.
 While in amnesic syndrome AA is typical and
characteristic and invariably present, RA shows
considerable variability both in extent and
severity.
 The degree of RA depends to a large extent on the
locus of damage and the past events are better
remembered than more recent events (Ribot’s
law).
Retrograde amnesia

19.  This is a specific form of the amnesic syndrome
resulting from nutritional depletion, notably
thiamine deficiency.
 The most common cause of the syndrome is
alcohol abuse.
 The pattern of memory deficit in Korsakoff’s
syndrome involves a severe impairment of new
learning (Anterograde amnesia) and extensive
retrograde loss.
Korsakoff’s syndrome.

20.  This retrograde memory loss extends back at
least 25 to 30 years and includes loss of
memory for remote information and
autobiographic memory for incidents or events
from the patient’s past.
 These aspects of retrograde memory show a
temporal gradient, with relative sparing of the
most distant memories
 Working memory, priming and procedural
memory are well preserved.
Korsakoff’s syndrome

21.  Immediately following head injury many patients
(after recovering consciousness) show an impairment
of memory for events that occurred previously.
 The amnesic gap is known as post-traumatic amnesia
(PTA) or post-concussion amnesia.
 PTA is the time between the injury and recovery of
normal continuous memory.
 The length of PTA is considered to be more accurate
than the length of coma in predicting recovery of
function.
 The longer the period of PTA the more severe the
brain damage and poorer the prognosis for the
recovery of functions.
Memory Loss in Head Injuries

22.  A typical PTA grading system is as follows:
◦ PTA less than 1 hour – mild head injury
◦ PTA from 1 to 24 hours – moderate head injury
◦ PTA longer than 24 hours – severe injury
Pta grading system

23.  Retrograde amnesia is also common after head
injury.
 RA is the loss of memory for events occurring before
the time of injury.
 Amnesia extends backward in time for a variable
period.
 As memory is regained, RA shows shrinkage and the
most remote memories return first.
 In most cases the amnesic gap is very short, usually
lasting one minute or less.
 It is not a good indicator of prognosis.
Retrograde amnesia

24.  A specific syndrome termed transient global
amnesia (TGA) describes a condition occurring in
middle-aged or elderly men in whom there is
profound but temporary failure of memory lasting
several hours.
 During the attack the subject is unable to acquire
new lasting memories (AA) and, therefore,
continues to have a permanent memory gap for
the period of attack.
Transient Organic Amnesias

25.  Psychogenic amnesia are thought to be caused by
psychological factors, especially traumatic events,
which are unacceptable to the person.
 There is no actual brain damage and the amnesia
recovers over a period of time.
Psychogenic Amnesias

26.  In clinical practice two types of psychogenic
amnesia have been recognized: ‘global’ and
‘situation-specific’.
 In Global Amnesia, sometimes known as fugue
state, there is sudden loss of all autobiographical
memories and knowledge of self and personal
identity.
 This is usually associated with wandering, for
which there is an amnesic gap upon recovery.
Psychogenic amnesia

27.  Global amnesia usually follows exposure to some
form of psychological trauma.
 Often such patients report having made trips over
a period of hours but do not recall what happened
during that time.
Psychogenic amnesia

28.  Patients are usually unaware of the memory
disturbance. Usually memory recovery is
complete after few hours or days.
 Situation-specific amnesia may arise in states of
extreme arousal including committing an offence,
being the victim of an offence or of child sexual
abuse. It may also occur in post-traumatic
disorder.
Psychogenic amnesia

29.  Immediate or STM is tested by recall of
information seconds after its presentation.
 Digit span is the commonest test of auditory,
verbal short-term or working memory.
 In clinical practice, both the forward digit span
and the backward digit span are measured.
TESTS OF MEMORY

30.  The subject is given a string of digits beginning
with two digits and asked to repeat it
immediately. The score is the longest series
correctly repeated.
 For reverse digit span, exactly the same method is
used except that the subject is asked to repeat the
digits in the reverse order.
 The normal range of digits forwards is 6 ± 1 and
for reverse digit span it is 5 ± 1. An example is as
follows: 4-9, 6-3-2, 6-4-3-9, 7-2-6-8, 4-2-7-3-1, 7-5-8-
3-6, 6-1-9-4-7-3, 5-9-1-7-4-2-3, 5-8-1-9-2-6-4-7-8.
Digit span test

31.  Recent memory can be tested informally by
asking patients to recall very recent events
such as:
◦ how they came to the clinic or hospital,
◦ their last meal, or
◦ events that may have happened that day.
Tests of Recent Memory

32.  Recall of three items and progressing on to more
complex material.
 These are tests of Anterograde amnesia and new
learning.
 The three word learning test, where the subject is
read out (and shown) three items (e.g. watch, pen,
desk) and asked to recall them five minutes later,
is used with patients with severe memory loss.
Tests of recent memory

33.  The commonest test of recent memory is the
name and address recall test. This consists of seven
items such as “Joseph Phiri, L2021, Paseli Road,
Northmead.
 Here the subject is read a short story from the
Wechsler memory scale (WMS) containing 25
elements and both immediate and delayed recall
(after an interval of 30 minutes) is tested.
Tests of recent memory

34.  Non-verbal memory: May be tested by the
getting subjects to reproduce a geometric shape.
One such test is the Rey-Osterrieth complex figure
test.
 This consists of complex geometric figure that the
subject is first asked to copy and then to draw
from memory after an interval of 30 minutes.
Tests of non-verbal memory

35.  Recall is impaired in patients with amnesic
syndrome, selective and those with mild AD.
 Remote or retrograde memory may be assessed
from questioning the person about a variety of
past events from the preceding months, years or
decades.
 Ask about public events, news items and famous
events from various past eras.
Tests of remote memory

36.  Human immunodeficiency virus (HIV) enters
the central nervous system (CNS) early in the
course of the infection and causes several
important CNS conditions over the course of
the disease, such as HIV encephalopathy and
AIDS dementia complex
Aids-dementia complex

37.  In 1986, the term AIDS dementia complex (ADC)
was introduced to describe a unique constellation
of neurobehavioral findings.
 Prior to the advent of highly active antiretroviral
therapy (HAART), dementia was a common source
of morbidity and mortality in HIV-infected patients.
 It was usually observed in the late stages of
acquired immunodeficiency syndrome (AIDS),
when CD4+
lymphocyte counts fall below 200
cells/mL, and was seen in up to 50% of patients
prior to their deaths
history

38.  ADC, also known as HIV-associated dementia
complex (HAD), is considered a single entity with
a broad and varied spectrum of clinical
manifestations and severit.
 ADC is characterized by cognitive, motor, and
behavioral features in adults, usually those with
advanced AIDS.
 With the advent of HAART, a less severe
dysfunction, minor cognitive motor disorder
(MCMD), has become more common than ADC.
history

39.  The risk of severe neurocognitive disorders in
patients with HIV is 1 in 1000; patients who are
not receiving highly active antiretroviral
therapy (HAART) and who have a low CD4+
lymphocyte count are at particular risk.
 In 4-15% of AIDS dementia complex (ADC)
patients, ADC is the presenting clinical
manifestation of HIV disease
epidemiology

40.  The annual incidence of HIV dementia in the
Western world prior to HAART was 7%, with a
cumulative risk of 5-20%.
 With HAART, the incidence of HIV dementia
started declining, but it has begun to increase
again
incidence

41.  In a study of patients with HIV in a Ugandan clinic,
the prevalence of ADC was 31%.
 If extrapolated to sub-Saharan Africa (26 million
people with HIV out of 40.3 million people
infected worldwide), ADC would be the most
important cause of dementia in persons younger
than 40 years.
 The incidence of AIDS dementia is low when
access to health care is good; risk factors include
non-use of HAART and low CD4+
counts.[28]
Incidence in sub saharan
africa

42.  AIDS dementia complex (ADC) has a variable
progression.
 Without treatment, the disease typically has a
rapid progression over a few months, with a mean
survival rate of 3-6 months for patients with AIDS
who have untreated ADC.
 As a result of HAART, however, the survival rate
increased from 5 months in 1993-94 to 38.5
months in the 1996-2000 period.
 Cognitive improvement is observed in patients
with ADC after the initiation of HAART
prognosis

43.  Lower educational levels
 Older age
 Lower CD4+
counts and higher HIV RNA levels
 Decreased hemoglobin level
 Reduced platelet count
 Thrush
 Low body mass index
 More constitutional symptoms
 Hepatitis C virus co-infection
Poorer prognosis

44.  Educate the patient at an early stage, and
discuss future medicolegal implications of
dementia.
 The patient should be strongly encouraged to
prepare a living will or to assign power of
attorney.
 Educate patients and families about the
persistent dangers of the transmission of HIV
management

45.  HIV dementia is a multifaceted problem, and
caregivers should know about the
complications, including psychiatric
complications.
 Often, friends and family need counseling and
support to deal with this chronic and difficult
condition
management

46.  Currently, highly active antiretroviral therapy
(HAART) is the cornerstone of treatment for HIV-
related cognitive disorders.
 Aggressive early treatment of patients with HIV
disease with antiviral medications and early
suppression of viral replication prevents most of
the devastating consequences of HIV dementia
 Early and aggressive treatment of HIV infection
decreases the rate of dementia from greater
than 50% to 10%
management

47.  Multiple studies have shown that patients on HAART
show partial reversals of neuropsychological deficits
and significant improvement, which is sustained,
whereas patients not on HAART steadily decline.
 HAART protects against and induces remission and
decreases the incidence of AIDS dementia complex
(ADC) and HIV-associated progressive
encephalopathy (HPE).
 Early and continuous viral suppression with HAART is
associated with improved performance on
neuropsychological testing.
management