Planning a memory rehabilitation programme

01/07/2009

By Professor Barbara A Wilson.

Introduction

Memory problems are one of the commonest consequences of an insult to the brain. A number of conditions can result in impaired memory but most people seen for rehabilitation are likely to have sustained a traumatic brain injury (TBI), stroke, encephalitis or hypoxic brain damage. Those with progressive conditions, particularly Alzheimer's Disease (AD) are increasingly offered rehabilitation to help with their difficulties (Clare 2008). Although at present, there is no effective way to restore lost memory functioning, we can help people to compensate for their problems and to learn more efficiently. For those with very severe and widespread cognitive difficulties it may be that the best we can do is to modify or structure or rearrange the environment to help them manage without a memory.

A few of those referred for memory rehabilitation will have the pure amnesic syndrome the characteristics of which are

• a profound difficulty in learning and remembering most kinds of new information (anterograde amnesia)
• difficulty remembering some information acquired before the onset of the syndrome (retrograde amnesia)
• normal immediate memory as measured by forward digit span
• normal/nearly normal learning on implicit tasks and
• normal/nearly normal functioning on other cognitive tasks (Baddeley 2004).

These patients may well be able to compensate without too much trouble because, apart from memory, their cognitive skills are intact (see Wilson 1999 for a reports of rehabilitation for patients with the pure amnesic syndrome). The majority of patients, however, will have more widespread problems; in addition to their memory difficulties they are likely to have attention and concentration difficulties, slowed thinking and information processing, poor planning and organisational deficits and possibly word finding problems. For both those with a pure amnesia and for those with additional problems, however, the main characteristics are

• Immediate memory is normal or nearly normal
• There is difficulty remembering after a delay or distraction
• Patients have difficulty learning most new information
• Events that happened some time before the insult are typically remembered better than those which happened a short time before.

Planning a memory rehabilitation programme

The first step in devising a memory rehabilitation programme is the clinical interview. We need as much background information as possible: have the memory problems occurred as a result of an illness or infection or have they developed slowly over time? What problems are most troubling for the patient and the family? What coping strategies are they using? What memory aids, if any, are being employed? What does the patient and the family expect to happen as a result of rehabilitation? Are these expectations realistic or not? Is any recovery likely to occur?

At the end of the clinical interview we may want to offer patients and families some general advice on the nature of memory, for example, that some aspects will be unaffected together with information on what environmental or situational factors might affect memory. Drugs and alcohol, for example, are likely to impair memory functioning, so, too, will anxiety, depression, poor sleep and fatigue; many people may demand too much of themselves and need to reduce their expectations.

At some point a detailed assessment should take place. This should include a formal neuropsychological assessment of all cognitive abilities including memory in order to build up a picture of a person's cognitive strengths and weaknesses. In addition, assessment of emotional and psychosocial functioning should be carried out. Standardised tests should be complemented with observations, interviews and self report measures. This will allow a proper formulation of the situation. A formulation uses theories and models to understand the development and maintenance of problems and can be used to make predictions about treatment. If other team members say, occupational and speech and language therapists, have assessed the patient then a team discussion and joint formulation is desirable.

The next stage in the memory rehabilitation programme is likely to be the goal setting stage. A goal is something the person receiving rehabilitation wants to do, something that is relevant and meaningful to him or to her and something reflecting his or her longer term aims. Rehabilitation should address personally meaningful themes, activities, settings and interactions so we should not set goals that lack meaning for the patient such as “improve performance on a memory test”. Nor should we set goals that are vague such as “improve memory functioning” or highly unlikely to be achievable such as “restore memory functioning”. Goals should be set after discussion with the patient, family members, carers and, if necessary, with other relevant support services. We need to know what the families and brain injured person perceive as their problems, what are their priorities and needs and what do they want to be able to do? Goals need to be negotiated with all concerned. If patients have an unrealistic goal such as “I want my memory back to how it was before” then we need to try to persuade them that this is probably not possible but we might (for example) be able to help them remember what they have to do each day and how would they feel about trying this as a goal first? The wording of the goals should be comfortable for patients and should allow them to feel they have ownership of the goal. Goals should follow the SMART principles. SMART is an acronym that stands for (Specific, Measurable, Achievable, Realistic and Time based). An example of a SMART memory goal might be for “Jane to remember to take her medication twice a day without prompts from her carers; at the end of six weeks she will achieve this at least 75 per cent of the time”. This is specific; it is measurable as we can count how many times Jane does this before we begin treatment; we believe it is potentially achievable; it is a realistic step in Jane's long term goal of being independent; and we have specified a time frame by which this should be achieved. The first short term goal might be to provide a pager for Jane and see if she can respond to a test message; this might be followed by giving her a checklist to complete when she carries out the test message; Jane's occupational therapist will observe to make sure Jane completes the checklist accurately and so forth. Jane will probably be working on other goals at the same time and these may well be other memory goals, other cognitive goals, emotional goals, leisure goals and so forth.

Selecting the best strategy to achieve the goal is another consideration. For prospective memory tasks such as remembering to take medication, water the plants or feed the dog, external aids are the method of choice. If we wish to teach new information we need to consider one or more of the strategies to improve learning such as spaced retrieval, vanishing cues, rehearsal strategies and mnemonics. All these are described in Wilson 2009. Teaching should follow errorless learning principles. This means we need to avoid trial-and-error learning for, in order to benefit from our mistakes, we need to be able to remember them and, this of course is impossible or very difficult for memory impaired people.

Finally, we need to evaluate the success of our treatment programmes not only at a group level but also at an individual level. For every patient we see, we want to know whether or not the patient is changing and, if so, is the change due to our intervention or would it have happened anyway? One way to do this is through single case experimental designs which allow us to separate the effects of treatment from the from the effects of spontaneous recovery.

Conclusion

Memory rehabilitation can help people to compensate for, bypass or reduce their everyday problems and thus survive more efficiently in their own most appropriate environments. Rehabilitation makes clinical and economic sense and should be widely available to all those who need it.

Baddeley, A. D. (2004). The psychology of memory. In A. D. Baddeley, M. D. Kopelman, & B. A. Wilson (Eds.), The Essential Handbook of Memory Disorders for Clinicians. Chichester: John Wiley & Sons.

Clare, L. (2008). Neuropsychological Rehabilitation and People with Dementia Hove: Psychology Press.

Wilson, B. A. (1999). Case Studies in Neuropsychological Rehabilitation New York: OUP.

Wilson, B.A (2009) Memory Rehabilitation: Integrating Theory and Practice New York The Guilford Press