11/13/24, 8\:11 PM Guide | Memory impairment history

Memory impairment history

Table of contents

Opening the consultation

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Explain that you’d like to take a history from the patient.
Gain consent to proceed with history taking.
General communication skills
It is important you do not forget the general communication skills which are relevant to all patient encounters.
Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because
you’re running through a checklist in your head doesn’t mean this has to be obvious to the patient).
Some general communication skills which apply to all patient consultations include\:
Demonstrating empathy in response to patient cues\: both verbal and non-verbal.
Active listening\: through body language and your verbal responses to what the patient has said.
An appropriate level of eye contact throughout the consultation.
Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).
Making sure not to interrupt the patient throughout the consultation.
Establishing rapport (e.g. asking the patient how they are and o
Signposting\: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.
Summarising at regular intervals.

Presenting complaint

Use open questioning to explore the patient’s presenting complaint\:
" W h a t i s t h e p r o b l e m t h a t I c a n h e l p y o u w i t h t o d a y ?"
" W h a t h a s b r o u g h t y o u i n t o s e e m e t o d a y ?"
" C a n y o u t e l l m e a b o u t t h e s y m p t o m s y o u a r e e x p e r i e n c i n g ?"
Provide the patient with enough time to answer and avoid interrupting them.
Facilitate the patient to expand on their presenting complaint\:
" C o u l d y o u t e l l m e m o r e a b o u t h o w y o u r m e m o r y h a s c h a n ge d ?"
" W h a t s o r t o f t h i n g s d o y o u
Open vs closed questions
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History taking typically involves a combination of open and closed questions. Open questions are e
consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to
explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation.
Closed questions can also be used to identify relevant risk factors and narrow the di
Allow the patient to speak freely for the
builds rapport, and helps you gather vital information.

History of presenting complaint

Memory loss is often a complex topic, and targeted history taking is key in making the correct diagnosis. Therefore, it is
important to gain a detailed history to understand when the memory loss began, how it has progressed, and the risk factors.

Onset

Clarify when the memory impairment began. Understanding when and how the issues began is key to identifying whether the
cause is acute, chronic, or related to a speci
" W h e n d i d y o u
" D i d t h i s s t a r t s u d d e n l y , o r h a s i t d e v e l o p e d g r a d u a l l y ?"
" W a s t h e r e a n e v e n t , l i k e a n i l l n e s s o r p h y s i c a l i n j u r y , t h a t s e e m e d t o t r i gge r t h e s e m e m o r y p r o b l e m s ?"

Progression

It’s important to explore whether the memory impairment is worsening or
between dementia and delirium\:
" H a v e t h e m e m o r y p r o b l e m s b e e n w o r s e n i n g g r a d u a l l y o r s u d d e n l y ?"
" I s t h e r e a p a r t i c u l a r t a s k o r a c t i v i t y t h a t y o u
" D o y o u h a v e g o o d d a y s a n d b a d d a y s , o r i s i t s t e a d i l y ge t t i n g w o r s e ?"
A slowly progressive decline in memory and cognitive function is typically suggestive of Alzheimer’s disease, where
symptoms worsen gradually over months to years, primarily a
A stepwise deterioration in cognitive abilities is more characteristic of vascular dementia, where periods of sudden decline
are often linked to cerebrovascular events, such as small strokes, which cause noticeable drops in function.
Fluctuating cognition, where the patient’s attention and awareness change throughout the day, could imply delirium,
especially when acute onset and accompanied by other features like hallucinations or disorientation.

Triggers

conditions like delirium\:
Certain triggers, such as infections, medications, or stress, can precipitate or worsen memory problems, especially in acute
" H a v e y o u n o t i c e d a n y t h i n g t h a t m a y h a v e t r i g ge r e d y o u r m e m o r y p r o b l e m s ?"
" H a v e y o u r e c e n t l y h a d a n y i n f e c t i o n s , c h a n g e s i n m e d i c a t i o n , o r i n c r e a s e d s t r e s s ?"
" H a v e y o u h a d a n y p a i n , f e l t v e r y t h i r s t y o r d e h y d r a t e d , o r h a d a n y p r o b l e m s go i n g t o t h e t o i l e t r e c e n t l y ?"
PINCH ME
Delirium can be triggered by a multitude of factors. A systematic approach can be a quick way to explore and identify
reversible causes of delirium. The PINCH ME acronym is one example\:
Pain
Infection
Nutrition
Constipation
Hydration
Medications
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Environment

Associated symptoms

Associated symptoms such as mood disturbances, hallucinations, and behavioural changes provide insight into the underlying
cause of memory impairment.
Depression
the two\:
Depression can cause or exacerbate memory impairment, often mimicking early dementia. It’s essential to distinguish between
" H a v e y o u b e e n f e e l i n g d o w n o r l o s i n g i n t e r e s t i n t h i n g s y o u u s u a l l y e n j o y ?"
" H o w i s y o u r m o o d ?"
Patients with pseudodementia secondary to depression are aware of their memory loss, as opposed to dementia, where
limited insight is demonstrated in earlier stages.
1
Psychiatric symptoms
Hallucinations or unusual beliefs may point towards conditions like Lewy body dementia or delirium, where cognition is often
impaired\:
" H a v e y o u e v e r s e e n o r h e a r d t h i n g s t h a t o t h e r s d o n’ t s e e m t o n o t i c e ?"
" H a v e y o u h a d a n y t h o u g h t s o r i d e a s t h a t o t h e r s h a v e t o l d y o u a r e u n u s u a l o r n o t t r u e ?"
Behavioural changes
Behavioural changes, such as aggression or wandering, may indicate more advanced dementia or speci
such as frontotemporal dementia\:
" H a v e y o u n o t i c e d a n y c h a n g e s i n h o w y o u b e h a v e , l i k e f e e l i n g m o r e r e s t l e s s o r e a s i l y u p s e t ?"
" H a v e y o u b e e n w a n d e r i n g a r o u n d o r ge t t i n g l o s t i n f a m i l i a r p l a c e s ?"
Wandering, disinhibition, and calling out may indicate behavioural and psychological symptoms of dementia (BPSD), a non-
cognitive plethora of symptoms present in a range of dementias.
Sleeping patterns
Sleep disturbances, including night-time confusion (sundowning), are common in certain types of dementia and should be
assessed carefully\:
" H a v e t h e r e b e e n a n y c h a n g e s i n y o u r s l e e p , l i k e w a k i n g u p a t n i gh t o r s l e e p i n g m o r e d u r i n g t h e d a y ?"
" D o y o u f e e l m o r e c o n f u s e d o r d i s o r i e n t e d a t c e r t a i n t i m e s o f t h e d a y , l i k e i n t h e e v e n i n g?"
Night-time wakefulness is common in Alzheimer’s, while early morning waking may suggest depression.
Cognitive disturbances
Exploring cognitive changes, such as di
memory problems and guide diagnosis\:
" H a v e y o u n o t i c e d d i
" D o y o u
" H a v e y o u b e e n h a v i n g d i
Aphasia (language di
of cortical dementia (e.g. Alzheimer’s disease).
Bowel and urinary symptoms
Explore any changes in bowel or urinary habits, as these can indicate underlying issues contributing to confusion or delirium\:
" H a v e y o u n o t i c e d a n y c h a n g e s i n y o u r b o w e l s , l i k e c o n s t i p a t i o n o r i n c o n t i n e n c e ?"
" H a v e y o u h a d a n y i s s u e s p a s s i n g u r i n e , l i k e b u r n i n g o r s t i n gi n g o r n e e d i n g t o go m o r e f r e q u e n t l y ?"
Di
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Distinguishing dementia, delirium, and depression is key in OSCEs, as depression can mimic dementia but is often
reversible. Accurate diagnosis ensures correct management and demonstrates strong clinical reasoning and diagnostic
skills.
Table 1. Key features of dementia, delirium and depression and their corresponding subtleties in presentation
Onset
Course
Attention
Consciousness
Cognition
Reversibility
Dementia Delirium Depression
Gradual onset over
months to years
Slowly progressive and
irreversible
Generally preserved in
early stages
Usually clear until late
stages
Memory impairment is
gradual, a
memory
Irreversible, but
progression may be
slowed
Acute, sudden onset (hours to
days)
Fluctuating course (waxing and
waning), often reversible
Severely impaired, di
focusing and maintaining attention
Altered level of consciousness,
ranging from drowsiness to
hyperalertness
Global cognitive impairment with
acute changes in memory,
orientation, and language
Often reversible if the underlying
cause is treated
Gradual onset over weeks to
months
Variable, often episodic, with
periods of normalcy
Generally preserved but may
appear distracted
Clear consciousness
Di
processing, but memory intact on
deeper questioning
Reversible with treatment for
underlying depression

Ideas, concerns and expectations (ICE)

A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to
gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the
consultation.
The exploration of ideas, concerns and expectations should be
This will help ensure your consultation is more natural, patient-centred and not overly formulaic.
It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several
examples for each of the three areas below.
Ideas
Explore the patient’s ideas about the current issue\:
" W h a t d o y o u t h i n k m i g h t b e c a u s i n g t h e s e m e m o r y i s s u e s ?"
" H a v e y o u t h o u g h t a b o u t a n y r e a s o n s w h y t h i s i s h a p p e n i n g t o y o u ?"
Concerns
Explore the patient’s current concerns\:
" I s t h e r e a n y t h i n g i n p a r t i c u l a r t h a t y o u’ r e w o r r i e d a b o u t ?"
" H a s a n y t h i n g a b o u t t h i s s i t u a t i o n b e e n c a u s i n g y o u a l o t o f s t r e s s ?"
Expectations
Ask what the patient hopes to gain from the consultation\:
" W h a t d o y o u h o p e w e c a n d o f o r y o u t o d a y ?"
" I s t h e r e a n y t h i n g s p e c i

Summarising

Summarise what the patient has told you about their presenting complaint. This allows you to check your understanding of
the patient’s history and provides an opportunity for the patient to correct any inaccurate information. Summarising is
particularly important in memory impairment.
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Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Continue to periodically
summarise as you move through the rest of the history.

Signposting

Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to
discuss next. Signposting can be a useful tool when transitioning between di
provides the patient with time to prepare for what is coming next.
Signposting examples
Explain what you have covered so far\:
a c h i e v e t o d a y .
"
What you plan to cover next\:
h i s t o r y .
"
“ O k , s o w e’ v e t a l k e d a b o u t y o u r s y m p t o m s , y o u r c o n c e r n s a n d w h a t y o u’ r e h o p i n g w e
“ N e x t I’ d l i k e t o q u i c k l y s c r e e n f o r a n y o t h e r s y m p t o m s a n d t h e n t a l k a b o u t y o u r p a s t m e d i c a l

Systemic enquiry

A systemic enquiry helps identify additional symptoms that may be relevant to the patient's cognitive changes, especially if
these symptoms contribute to or exacerbate memory impairment.
It also provides an opportunity to uncover symptoms the patient may have forgotten to mention. The choice of symptoms to
ask about should be guided by the primary presenting complaint.
Some examples of symptoms to screen for in each system include\:
Systemic\: fevers, fatigue, unintentional weight loss (consider infection or metabolic causes)
Neurological\: headaches, dizziness, loss of balance, or tremors (consider stroke, Parkinson’s disease, or other neurological
conditions)
Cardiovascular\: palpitations, chest pain, or syncope (may indicate vascular causes of cognitive decline)
Respiratory\: cough, shortness of breath, or wheezing (potential signs of respiratory infection or hypoxia contributing to
confusion)
Gastrointestinal\: nausea, vomiting, constipation, or diarrhoea (consider metabolic disturbances or dehydration as causes of
delirium)
Genitourinary\: urinary frequency, incontinence, or dysuria (consider urinary tract infections (UTI), common in elderly patients
with delirium)
Musculoskeletal\: falls, di
mobility and increasing falls risk)
Dermatological\: rashes, bruises, or skin lesions (look for signs of injury or infection that might be related to confusion or
memory issues)

Past medical history

Ask if the patient has any medical conditions\:
“ D o y o u h a v e a n y m e d i c a l c o n d i t i o n s ?"
" A r e y o u c u r r e n t l y s e e i n g a d o c t o r o r s p e c i a l i s t r e g u l a r l y ?"
" H a v e y o u h a d a n y i n f e c t i o n s r e c e n t l y , l i k e a c h e s t o r u r i n e i n f e c t i o n ?"
" H a v e y o u e v e r h a d a h e a d i n j u r y o r c o n c u s s i o n ?"
If the patient has a medical condition, you should gather more details to assess how well-controlled the disease is and what
treatment(s) the patient receives. It is also important to ask about any complications associated with the condition,
including hospital admissions.
Ask if the patient has previously undergone any surgery or procedures\:
" H a v e y o u e v e r p r e v i o u s l y u n d e r g o n e a n y o p e r a t i o n s o r p r o c e d u r e s ?"
" W h e n w a s t h e o p e r a t i o n / p r o c e d u r e a n d w h y w a s i t p e r f o r m e d ?"
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Examples of relevant past medical history
Medical conditions relevant to memory impairment include\:
Parkinson’s disease\: this may suggest the development of Parkinson’s dementia or Lewy body dementia, both of
which are associated with motor symptoms and cognitive decline
Vascular disease and diabetes\: both are signi
blood
Head injuries\: particularly traumatic brain injuries, may contribute to cognitive decline and are associated with the
development of traumatic brain injury-related dementia
Recent or recurrent infections (e.g. UTIs or chest infections)\: these should be considered as potential causes of
delirium, particularly in elderly patients
Depression and anxiety\: mental health conditions such as depression or anxiety can either mimic or exacerbate
cognitive decline

Drug history

Ask if the patient is currently taking any prescribed medications or over-the-counter remedies\:
" A r e y o u c u r r e n t l y t a k i n g a n y p r e s c r i b e d m e d i c a t i o n s o r o v e r-t h e-c o u n t e r t r e a t m e n t s ?"
If the patient is taking prescribed or over-the-counter medications, document the medication name, dose, frequency, form,
and route.
Ask the patient if they’re currently experiencing any side e
" H a v e y o u n o t i c e d a n y s i d e e
Examples of relevant medications
Medications relevant to a memory impairment history include\:
Medications for neurological conditions (e.g. levodopa, dopamine agonists)
Metabolic disease treatments (e.g. antihypertensives, anti-diabetics)
Medications a
Recent changes to medications (e.g. new prescription, recent dose change)
Allergies
anaphylaxis).
Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance (e.g. mild rash vs

Family history

A family history of dementia or other neurodegenerative conditions can suggest a genetic predisposition\:
" I s t h e r e a f a m i l y h i s t o r y o f m e m o r y p r o b l e m s o r n e u r o l o g i c a l c o n d i t i o n s ?"
" H a s a n y o n e i n y o u r f a m i l y e v e r b e e n d i a gn o s e d w i t h A l z h e i m e r’ s o r a n o t h e r f o r m o f d e m e n t i a ?"
Alzheimer’s disease, frontotemporal dementia and Hunting's disease can all have hereditary links.

Social history

General social context
Explore the patient’s general social context including\:
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The type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them
(e.g. stairlift)
Who else the patient lives with and their personal support network. This is important when considering if there is someone at
home to observe them for signs of deterioration rather than admission for observation in hospital
What tasks they can carry out independently and what they require assistance with (e.g. self-hygiene, housework, food
shopping)
If they have any carer input (e.g. twice daily carer visits)
Smoking
Record the patient’s smoking history, including the type and amount of tobacco used.
Calculate the number of ‘pack-years‘ the patient has smoked for to determine their risk pro
pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes
Smoking is a signi
Alcohol
Record the frequency, type and volume of alcohol consumed on a weekly basis.
Alcohol excess is a common cause of cognitive impairment and dementia.
See our alcohol history taking guide for more information.
Recreational drug use
Ask the patient if they use recreational drugs, and if so, determine the type of drugs and frequency of their use.
Occupation
Ask about the patient’s current occupation to clarify their job role. The impact on patients who occupy jobs that involve manual
labour, driving or operating heavy machinery should be considered carefully, as they may face restrictions.
Inform patients about driving restrictions, particularly if they have cognitive impairment, and explain the rules set by the Driver
and Vehicle Licensing Agency (DVLA).

Risk assessment

Evaluating potential risks to the patient and others is crucial in advanced cognitive impairment, particularly in assessing safety,
behaviour, and carer strain.
To self
important\:
Patients with cognitive impairment are at risk of accidental harm, so assessing their ability to maintain personal safety is
" D o y o u e v e r
" H a v e y o u e v e r f o r g o t t e n t o t u r n t h e c o o k e r o
The 4 Fs of memory impairment
Four key components to ask in a memory impairment risk assessment include\:
Fire\:
" H a v e y o u e v e r f o r g o t t e n t o t u r n o
Floods\:
" H a v e y o u e v e r l e f t t h e t a p s r u n n i n g o r c a u s e d a n y
Famine\:
" D o y o u s o m e t i m e s f o r g e t t o e a t o r h a v e d i
Falls\:
" H a v e y o u h a d a n y f a l l s r e c e n t l y , o r d o y o u f e e l u n s t e a d y o n y o u r f e e t ?"
To others
It’s essential to determine whether the patient’s behaviour poses any risks to others, especially in more advanced dementia\:
" H a s t h e r e b e e n a n y a g g r e s s i o n o r r i s k y b e h a v i o u r ?"
" H a v e y o u b e e n m o r e i r r i t a b l e o r h a d e p i s o d e s w h e r e y o u f e l t o u t o f c o n t r o l ?"
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Frontotemporal dementia often presents with aggression, disinhibition, and risky behaviour due to early personality and
behavioural changes. In Alzheimer’s disease, aggression and risky behaviour typically occur in advanced stages, linked to
confusion and frustration.
Carer’s needs
Caring for someone with cognitive decline can be physically and emotionally taxing, so it’s important to assess the carer’s
wellbeing and support system\:
" H o w a r e y o u c o p i n g ?"
" A r e y o u r e c e i v i n g e n o u g h s u p p o r t ?"
Empathise with the demands on carers, who may experience burnout.

Closing the consultation

Summarise the key points back to the patient.
Ask the patient if they have any questions or concerns that have not been addressed.
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.

R f

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