Memory Intervention

Presented by: Lauren HershfieldAhuva Katzman

Shira TenenbaumMelanie Teplinsky

Presentation Outline Introduction to memory Memory interventions

Restorative approach Domain specific approach

Errorless learning External Aids

Making the most of our memory Tips for teaching memory Choosing the best intervention

Memory

Human memory can most broadly be defined as a function of the brain that gives us our ability to store and retrieve information.

(Wilson, 1991)

Processing Stages of Memory Analogous to a computer system Input stage: Information must be fed

into the system. (attention and encoding)

Storage stage: Maintaining information in memory over time.

Retrieval Stage: Recovering information from memory stores.

(Pinel, 2003, Sohlberg & Mateer, 2001)

Short Term Memory Storage of limited information for a

restricted period of time. Temporary holding information. 3-5 items, for up to a few minutes.

Long Term Memory Preserving information for anything ranging

from minutes to years.1. Declarative/Explicit Memory Conscious knowledge base: “Learning That…”

a) Semantic knowledge for the meanings of words and how to apply them.

b) Episodic memory: Unique knowledge of personal experiences, tagged in time and place.

(Sohlberg & Mateer, 2001; Reisberg, 1997)

Long Term Memory Cont’d…

2. Non Declarative Memory/Procedural

• Occurs without conscious awareness: “Learning How…”

• Memory storage of skills and procedures

• Implicit knowledge (Sohlberg & Mateer,

2001)

Memory Disorders Focal/Multi-focal:

Gun shot. Diffuse:

Hypoxia/Ischemia (stroke, cardiac/respiratory arrest)

Korsakoff syndrome Alzheimers disease Non-penetrating head injuries

(concussion-post traumatic amnesia)

Memory Interventions

Any intervention strategy or technique which enables patients/clients and their families or caregivers to live with, manage, by-pass, reduce or come to terms with cognitive deficits precipitated by injury in the brain

(Wilson, 1991)

Domains of Memory Intervention Sohlberg and Mateer (2001) classify

methods of memory intervention into two main categories Restorative/Generalized Memory Intervention Domain-Specific Memory Intervention

A third domain for memory intervention employs external aids, but this domain does not fit clearly into either of the two aforementioned domains

Types of Memory Intervention

Restorative/Generalized

1. Memory Practice Drills

2. Mnemonic Strategy Training

3. Metamemory Training

4. Prospective Memory Training

Domain-Specific1. Mnemonic Strategy

Training (for specific information)

2. Preserved Priming (i.e., Vanishing Cues)

3. Creating a Personal History

4. Expanded Rehearsal Time/Spaced Retrieval

Restorative Memory Interventions Methods that aim to

restore/improve memory across various tasks and contexts.

Memory Practice Drills Not much empirical support for this

approach Commonly used in clinical practice Visible improvements may actually be due

to increases in attention ability rather than memory ability Clients could complain of memory problems that

are actually secondary to attention deficits Attention processes respond more favorably

to drills than memory functioning

Mnemonic Strategy Training Teaching clients to use this strategy

was a focus of early memory intervention literature

Examples include Visual imagery (most popular) Verbal organization strategies (e.g.,

forming acronyms; making paired associations with target words)

Semantic elaboration (e.g., linking target words or ideas in a story)

Metamemory Training An intervention that uses the concept of

understanding ones own memory problems Used for those who are not aware of their

memory deficits One type of training method consists of

prediction exercises These involve helping clients compare predictions

with actual performance Schlund (1999) showed that provision of feedback

on accuracy of predicted recall reduced variability between self-reports and recall performance

Metamemory Training Cont’d… Another method of metamemory

training involves teaching people self-instructional or self-monitoring routines that will help them to improve memory functioning Clients are taught to regulate behaviour via

self-talk Strategies can be used to help them review

material to be remembered in a way that will increase the likelihood of recall

Metamemory Training Cont’d… Self Monitoring techniques usually involve

Providing external feedback on errors and successes, with clients recording errors

Comparing performance across trials Asking clients to verbalize their impressions

Some clients have shown great difficulty generalizing these strategies and thus more research is needed to improve these techniques (Moffat, 1992)

Prospective Memory Training Prospective Memory Process Training (PROMPT)

Clinician asks client to remember to carry out target task in specified number of minutes

Number of minutes increased after client demonstrates repeated success at particular time interval

Over course of training clinician systematically lengthens amount of time client can remember and act on assigned task

Within this particular method of training there are a number of variables that could possibly be altered

Prospective Memory Training Cont’d… Task variables that may be altered include

Type of prospective memory task (e.g., one-step motor command vs. multistep)

Time delay (i.e., number of minutes between task administration and execution)

Distracter task during time delay (e.g., sit quietly vs. math sheet)

Associated prompts to initiate task (e.g., alarm vs. requirement to monitor time independently)

Prospective Memory Training Cont’d… To effectively employ PROMPT it is

important to follow these stages Alter only one task variable at a time Observe the effects, and then Wait for stable improvement before altering

another variable Overall goal is to increase intervening

delay systematically as client’s prospective memory lengthens

Prospective Memory Training Cont’d… Most common method is to teach people

to use appointment books Initial experiments suggest effects appear

to generalize across contexts and tasks This technique is beneficial for clients with

severe memory disturbances who can encode information but do not hold on to it, and who have preserved procedural learning

Critical Review of Prospective Memory Training Schmidt I. W., Berg I. J. and Deelman B. G. (2001).

Prospective Memory Training in Older Adults. Study evaluates the results of a training

program for prospective remembering. The goal of the study was to improve

prospective memory by associating cues from the retrieval situation with the to be remembered information

At three month interval, control group had reached same level of trained group

As well, training effects did not generalize to other memory tasks or control measures.

Critical Review of Prospective Memory Training

Furst (1986); Sohlberg, White, Evans & Mateer, (1992)

Found that effects of prospective memory training were generalizable to real-world tasks and related neuropsychological tests.

Controversy in the literature: Does prospective memory training simply teach a behavior or skill or is there is improvement in the underlying processes that mediate acting on future intentions?

Domain-Specific Memory Intervention Also referred to as compensatory

strategies Goal – to reduce problems associated

with memory impairment rather than restore memory processes

Information learned has practical value Purpose – to teach clients procedures

so they can access information independently

Examples of Domain Specific Tasks Procedures for operating computer Names of people or objects Operating a wheelchair Medication schedule

Types of Memory Intervention

Restorative/Generalized

1. Memory Practice Drills

2. Mnemonic Strategy Training

3. Metamemory Training

4. Prospective Memory Training

Domain-Specific1. Mnemonic Strategy

Training (for specific information)

2. Preserved Priming (i.e., Vanishing Cues)

3. Creating a Personal History

4. Expanded Rehearsal Time (i.e., Spaced Retrieval)

Preserved Priming Cues that prompt accurate recallExample: 500 University Ave all of this

information is initially presented 5_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 1st

letter presented (if fail to produce response, next letter added)

50_ _ _ _ _ _ _ _ _ _ _ _ _ _

Preserved Priming Cont’d… An example of priming includes the

“method of vanishing cues” Can be used to teach

knowledge/behaviours that might be used in everyday life

Client is provided with enough information to give correct response and then parts of information are gradually withdrawn

PRINT PRIN PRI PR P

Creation of Personal History Used for clients with retrograde

amnesia (loss of events prior to injury) Creation of autobiography using items

such as Written life history Video composite of important people Photographic life essay

Helps clients to relearn aspects of their personal history

Expanded Rehearsal/Spaced Retrieval Client practices recalling

information over increasingly longer periods of time

Spaced retrieval (SR) has been used to teach clients to remember names of common objects, to remember to perform a future action, etc.

Advantages of SR (Camp & Stevens 1996)

Easily used by professionals and caregivers

Intervals between trials can easily be incorporated into treatment sessions

Intervals between trials can be filled with conversation or other tasks enjoyed by client

Participant receives a high degree of success during each session

Errorless Learning Method of instruction that reduces errors in

the acquisition phase Been suggested that if clients prevented from

committing errors during initial process, they will learn more quickly and less likely to repeat their errors

For example people with amnesia often remember their own mistakes better than they remember the corrections to their mistakes

The theory is that if the person is not given the opportunity to make a mistake then there are no mistakes to be remembered

Errorless Learning Controversy Baddeley and Wilson (1994)

suggested that EL enhances implicit memory

Tailby and Haslam (2003) showed that it may actually employ explicit learning

Making Use of Compensatory Strategies (Oddy & Cogan, 2004)

1) Nature of original injury2) Confabulation3) Awareness of deficit and mood4) Premorbid characteristics5) The strategies6) The family

Critical Appraisal of Compensatory Training Jennetta & Lincoln (1991) argue that

teaching memory compensation strategies is time consuming and benefits minimally compared with the effort

In contrast, Wilson (1991) found evidence of increased use of memory aids and compensations by patients 5-10 years post cerebral insult.

External Aids Favored mode of compensation

across non-disabled and disabled population

Means to reduce load on memory or executive functioning so person can carry out a task and get around cognitive impairment

Involves teaching sets of behaviours rather than retraining a process

Selecting an External Aid

1. Clinician, client and other involved parties must perform a needs assessment which usually focuses on

Organic Factors Personal Factors Situational Factors

2. Clinician should have an appreciation of available options for external aids

External Aid OptionsGeneric Aids Written

Electronic Computer Systems

Task Specific Aids

Key findersCar memo padsRefrigerator pads, grocery listsPill box reminders

Written Memory Aids Day Planners Notebook divided into sections Calendars Appointment books Memory books

Memory Books Facts about a person’s life they can share with

others and use to remember important events Includes information on client history, family,

appointments, schedules, medications, daily meal planners, telephone numbers.

Can reduce caregiver burden, as it provides a source for individuals to obtain answers to questions

Andrews-Salvia, Roy, and Cameron (2003) study supports the use of memory books for individuals with dementia.

Electronic Memory Aids Watches Dictaphone Voice Organizer Mobile Phones Palm Pilots “Blackberry”

Computerized Memory Aid Word processor Telephone dialing software Timex Data Link Watch

Uses USB link and custom software Schedule, phone/address, contacts

(and it also tells the time!) Approx. $130

What do People use Currently? Evans, Wilson, Needham and Brentnall (2003) Survey of 94 people with memory impairment. Most commonly used:

Wall Calendar (72%) Notebook (63.8%) Lists (62%) Diary (54.3%) Asking others to remind (48.9%)

Only 7 out of 94 were using an electronic device.

External AidsBenefits

Non Technological aids Easy to use and

teach Technological Aids

Alerting function Storage space

Limitations Non Technological

aids Lack alerting

function Only work when

looking at them Technological Aids

Complex and may be unfamiliar so learning demands are high

Making the Most of Our Memory (CAOT)

Keep a date book or calendar. Write down everything that you have to remember to do.

Give yourself a visual cue to remember things whenever possible

Use written “to do lists”. Keep the list in the same spot all the time, and check it every day.

Keep your home organized and uncluttered Have a routine way of doing certain activities

to help you remember everything that needs to be done

THE REALITY

INTERVENTIONS ARE NOT INTERVENTIONS ARE NOT

CURE ALL!!CURE ALL!!

Tips for Teaching Memory Strategies Teaching should be done one step at a time It is better to draw images then to rely on

mental images. Materials to be learned should be realistic

and relevant to the needs of the patient. Therapists should also recognize that

individual patients have individual styles and preferences when it comes to learning.

(Wilson, 1992)

Tips for Teaching Memory Strategies Cont’d… Goals should be small and specific: ex: “

To teach Mrs. A to check her notebook every half hour.”

Measure the deficit in order to obtain a satisfactory baseline

SIMPLIFY information REDUCE amount of information LINK new information to existing

information or schemas.

Case Study – A.B. (Adapted from Kime, Lamb, & Wilson, 1996)

24 year old woman with orthopaedic injuries following MVA Requires assistance for clothing selection,cues to carry out

personal hygiene tasks, and direct supervision to assure compliance with medication regime

Entered day hospital with goal of improving ability to independently complete self-care and home-management tasks

Upon admission tests showed borderline range of ability on immediate recall of narrative passages and simple designs

Ability to learn list of 16 words severely impaired Showing signs of amnesia Unable to remember where toilets located, names of

various therapists, purposes of different sessions, or having participated in programme activities from day to day

Treatment Strategies Employed by Kime, Lamb, and Wilson (1996)

1) Mnemonic Cues Associated with photos of staff and patients

She linked PT with her job (“Heather is healthy”) Sometimes rhymed names (“Dennis plays

tennis”) Each cue was written on cue card that

included her own associate drawings Practiced linking cues with names and was

tested daily

Treatment Strategies Employed by Kime, Lamb, and Wilson (1996)

2) Creation of Personal History Collected photos in an album and

labeled them to mark events in which she participated since her accident

Treatment Strategies Employed by Kime, Lamb, and Wilson (1996)

3) External Aids Purchase of date-book and watch

alarm that chimed hourly to remind her to refer to the date-book

Written procedures were developed for every multi-step task

An eraser board with information for tracking self-care and home duties

Questions and Discussion