Memory Problems and Rehabilitation Research Paper

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Models of memory emphasize the distinction between declarative and procedural types of knowledge (Squire 1987). Declarative memory can be further broken down into episodic (i.e., memory for experiential information such as what one had for breakfast), and semantic (i.e., knowledge of general information such as dates in history, scientific formulas, state capitals, etc.) processes. Procedural memory refers to skills, habits, and classically conditioned behaviors (e.g., playing the piano and driving a car). These different memory processes are mediated by different brain structures; hence, they break down differentially in the context of neurological injury. In this research paper, remediation for problems in the declarative memory domain will be discussed. First, factors to consider when selecting a rehabilitation strategy will be addressed. Then, a wide variety of strategies will be described, including internal strategies, external strategies, use of augmentative technology, and pharmacological intervention.

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1. Selection of Strategy

In the clinical context disruption in various stages of memory can result in memory impairment. In order to form a new memory one must first be able to encode or analyze the information or event. The second process in memory formation is consolidation or storage. Finally, one must be able to retrieve or access the information as needed. Remediation strategies vary according to the particular stage of memory that is disrupted. Disruptions in encoding and retrieval can often be remediated with internal aids. On the other hand, disruptions in consolidation (or storage) of information are often not improved with internal strategies and therefore must rely on external aids for compensation.

Different types of memory depend on different brain structures, and therefore are differentially affected in relation to various disease processes. Injury to the hippocampus and adjacent structures may disrupt consolidation. Examples of neurological conditions that affect the hippocampus include Alzheimer’s disease, encephalitis, and anoxia (loss of oxygen to the brain resulting in death of brain cells). Other neurological conditions affect subcortical or frontal brain areas (e.g., multiple sclerosis, Parkinson’s disease, frontal lobe dementia, head injury, and stroke). In these conditions, attentionally mediated memory abilities are disrupted, rendering patients vulnerable to problems with encoding and retrieval.

In order to determine the most appropriate remediation strategy, the type of memory problem must first be characterized through a comprehensive neuropsychological assessment. In addition to memory, other cognitive domains, such as attention, language, reasoning, visuospatial abilities, and motor skills, should be assessed in order to determine which memory remediation strategies are optimal for a particular patient. It is important to note that insight into one’s medical condition and memory status is vital to the remediation process (Prigatano et al. 1986). Finally, an important aspect of a complete neuropsychological assessment includes assessment of emotional functioning, as significant depression or anxiety can adversely affect memory ability, regardless of other disease processes. Only after emotional difficulties are assessed and treated can the memory problem be accurately assessed.

2. Internal Strategies

Internal memory strategies include techniques to improve encoding and retrieval. Like other skills, these strategies must be practiced over time. Furthermore, to execute such skills, one must be able to focus attention on the task at hand.

Many internal strategies target the encoding process. Through various methods, associations between new information and old (i.e., semantic) knowledge are formed in ways that make sense to that individual. These new associations provide cues for later retrieval. Because these strategies depend upon previously stored semantic knowledge, in cases where semantic memory is impaired, internal strategies might not be effective. Three common internal strategies are imagery, verbal elaboration, and organization (West 1995). As noted earlier, internal strategies are often not successful for people with significant consolidation problems, as they will not remember to employ them when necessary (Wilson and Moffat 1984, Glisky 1995).

Imagery involves the association of interactive visual images. This method has proven especially effective in the learning of names and faces (Yesavage et al. 1983). In this instance, one would study a new person to identify a characteristic that could be linked to that person’s name. For example, when meeting a person named ‘Karen Singer,’ one could conjure up an image of the person singing. This technique can also be used to link words together, such as items from a grocery list, errands that must be done, or daily chores. For example, if one needs to pay the bills and do the vacuuming, one could create a visual image of vacuuming away the bills. A single image would therefore provide the cues for remembering both chores.

Verbal elaboration involves the creation of new words or sentences, rather than images, to link information together. These techniques are dependent upon semantic and verbal abilities. If one wanted to remember a new name, one could combine the first and last name into a new sentence. For example, the name ‘Darren Wernick’ could be remembered with the sentence ‘Darren wore a neck-tie,’ as the words ‘wore’ and ‘neck’ would provide the cue for the name. Mentally linking this sentence to a visual image, such as Darren putting on a tie, would further strengthen the elaboration and enhance later retrieval. Making up rhymes is a common method for recalling information (e.g., Thirty days hath September …). Another method is first-letter elaboration, in which one uses the first letters in words to create a new word or pseudo-word. For example, to remember emergency procedure for a hospital fire, employees are taught to remember the word ‘RACE.’ This not only reminds workers of the steps to take in case of a fire, but also the order of steps (‘Rescue’ patients, sound the ‘Alarm,’ ‘Confine’ the fire, ‘Evacuate’ the premises).

It is important to note in both imagery and verbal elaboration that the imaginary links created between objects or words are most effectively remembered when they make personal sense to that individual, even if they seem nonsensical to others. Often the first and most creative idea is the most salient cue for later recall.

Finally, organization of incoming information is beneficial to emphasize natural links between stimuli in order to enhance later retrieval. Organizational techniques can be particularly useful in situations where the individual has to learn information that exceeds attention span limitations (e.g., a lengthy list). One effective method of organization is ‘chunking,’ or grouping items into categories (Cermak 1975). When trying to remember items for the grocery store one could organize the list so that the five dairy items and the five vegetables are grouped together. Therefore, simply remembering the two general categories of dairy items and vegetables would enhance memory retrieval. This technique is also used to remember sequences of numbers. For example to remember a phone number, one could chunk ten individual numbers into three larger numbers.

3. External Strategies

Internal strategies enhance encoding and retrieval abilities of patients with attentionally based memory problems. However, those with impaired consolidation capacity will often not benefit from such techniques. Often consolidation problems occur as the result of damage to the hippocampus and related cortices. Because they rely less on cognitive capacity and effort, external memory strategies are often more effective than internal strategies. Wilson (1991) found that patients taught both internal and external strategies tended to utilize external aids more often and for a longer amount of time following intervention. External strategies include use of both environmental and portable cues.

Environmental memory techniques involve structuring one’s environment so that memory cues are naturally provided by the surroundings. Kapur (1995) describes three main environmental strategies that include personal, proximal, and distal cues.

Personal environmental cues involve making changes on one’s person that serve as reminders. For example a person might place a ring on an unusual finger as a prompt to remember to make a phone call. The ring would be returned to the proper finger once the task has been accomplished. The drawback to this method is that it serves as a cue to remember an event, but does not provide specific information regarding that event.

Proximal environmental cues involve manipulating the layout within a space or a room so that cues are permanently provided concerning the location of objects and procedures that should be attended to. Examples include having a desk drawer dedicated to letter-writing and bill-paying supplies, having a basket within eyesight to place unpaid bills, and having a shelf near the door for outgoing mail. In this instance, the room itself provides cues to remember an important chore (i.e., paying the bills), where to find supplies (i.e., desk drawer), and a cue to complete the last step of the task (i.e., taking bills to the mailbox). Clear labels describing contents of storage areas are also often helpful for people with severe memory problems, as they might not remember where to find things on a day-to-day basis.

Distal environmental cues provide directions to places and instructions on how to safely navigate one’s surroundings. These can include navigating a home, a building, a neighborhood, or transportation networks. Cues can include maps, visual signs pointing out how to get to certain places, labels reminding people where they are going, and warning signs about possible hazards that they may encounter (e.g., steep stairs, heavy doors, etc.). A professional assessment of the home environment is helpful in determining which proximal and distal cues are necessary best to create a supportive and safe setting.

In contrast to environmental aids, portable external memory aids are devices that people can take with them into other environments. Such devices are intended to provide cues and reminders about important information. Examples are notebooks, calendar books, and day planners. Often people with memory problems must be taught to use these devices until they become habitual and no longer require novel memory effort.

Memory books are special notebooks created by rehabilitation therapists that contain specific information to meet the needs of the person with memory problems. Such books are personally tailored for the individual, and may contain such sections as daily schedules, orientation calendars, addresses phone numbers, maps for getting around, pictures and names of people that the individual will interact with, pictures of buildings the individual should know, and detailed instructions for accomplishing certain tasks. The book must be easy for the individual to use (i.e., clearly labeled, easy to carry, self-explanatory). Often therapists spend a good deal of time teaching patients how to use memory books. Correct usage often requires practice and rehearsal until the procedure becomes automatic. Without proper instruction and cueing, individuals with significant memory problems often cannot use external aids successfully.

4. Augmentative Technology

In recent years there has been a proliferation of electronic organizers and computer programs that serve as external memory aids for normal healthy individuals as well as in the rehabilitation setting. In order for patients with memory problems to use such technology, they must retain sufficient cognitive capacity to learn complex new skills with new equipment. Factors that affect ability to utilize such technology include age, educational level, and prior familiarity with electronics or computers (Kapur 1995). Success with this approach requires careful analysis and selection of specific memory aids to compensate for the specific memory problems. Attempts should be made to avoid depending on other areas of cognition that may be compromised. Furthermore, patients often must have support in their home environment, usually by family members, as they learn to use and rely upon technology on a daily basis.

An older type of electronic aid is the dictating machine. These are still useful tools for recording verbal information for later use, especially if the information is abundant and given quickly, as in a classroom or lecture situation. Furthermore, dictation machines can be used by people with visual or writing impairments, and are fairly simple to use even for patients with significant memory impairment. However, they do not provide a way to organize incoming information.

Much new computer software that can facilitate the organizational skills of memory-impaired individuals is available. Computer programs can be specifically designed or altered to compensate for a particular disability. Research indicates that successful computer usage increases self-esteem in brain-injured patients (Glisky and Schacter 1987). However, the costeffectiveness of individualized computers and computer programs as compensatory tools is questionable because these techniques are narrow in application and require a great allocation of resources (Glisky 1995).

A very promising development in electronic memory aids is the personal digital assistant (electronic organizer), such as the Palm Pilot. These portable machines can be individually tailored to meet a variety of needs, serving as a notebook, daily schedule, calendar, address book, reminder list, and even auditory alarm. However, the user must be able to learn three basic operations: entering new information, reviewing stored information, and deleting obsolete information.

In several case studies, patients with memory problems were introduced to electronic organizers. Findings indicated that patients with very poor memory, lack of initiative, lack of insight into memory problems, difficulties with visual attention, poor motor control, and limited problem-solving skills had difficulty learning to utilize these aids successfully. However, patients with mild impairment in everyday memory functioning may find the electronic organizer extremely helpful in compensating for memory lapses (Kapur 1995).

5. Pharmacology

Some types of memory problems occur due to poor encoding or retrieval secondary to attentional limitations. Medications that facilitate attention, such as Ritalin and other stimulants, have the potential to increase functional memory abilities in such patients. However, many memory problems are due to consolidation problems secondary to hippocampal damage. Alzheimer’s disease (AD) is the most common type of disorder that impairs consolidation. Because AD affects a large segment of the population, considerable resources have been devoted to developing effective pharmacological intervention. Hence, most of our knowledge regarding psychopharmacological remediation of memory disorders is based on research of patients with AD. Although no medications exist for repairing brain damage once it has occurred, several medications are being developed to prevent or slow down brain degeneration associated with progressive dementia, such as AD. Other medications focus on enhancing specific neurotransmitters that may be depleted in this disorder.

Two drugs have been approved by the FDA for use in memory remediation in patients with AD: tacrine and donepezil. Both are cholinesterase inhibitors, as they prevent the breakdown of acetylcholine, a neurotransmitter needed for memory processing and thought to be diminished as a result of AD (Frautschy 1999). Both drugs have demonstrated some ability to slow down memory decline in some, but not all, AD patients in the early stages of disease (Doody 1999). However, tacrine was shown to have serious side effects in some patients and therefore is no longer commonly prescribed. As of 2001, several new cholinesterase inhibitors, such as metrifonate and eptastigmine, are undergoing clinical trials. These may prove to be promising agents in AD treatment.

Currently there are many other drugs in development, applying different strategies and theories to the slowing of AD. Many are focused upon eliminating or slowing formation of abnormalities characteristically found in Alzheimer’s brains, such as plaques and tangles. Although many pieces of the puzzle continue to fall into place with ongoing study, the cascade of events that creates these abnormalities is still not well characterized.

Other research approaches have used antioxidants, such as Vitamin E, as these compounds may help to prevent AD-induced neurotoxicity in the brain. Because AD patients’ brains often show evidence of plaque-associated inflammatory response, antiinflammatory agents may also prove to be beneficial. Multiple ongoing research trials are currently investigating beneficial effects of steroids, such as corticosteroids, estrogens, and androgens. However, extensive study of human subjects will be required before benefits of these approaches are clearly understood (Frautschy 1999).

6. Conclusions

Memory impairment can occur for many reasons, and memory can break down in different ways. Professional consultation by neuropsychological and rehabilitation specialists may help to characterize the type and extent of memory deficits, associated cognitive impairment, and emotional distress. Specific cognitive strengths and weaknesses and details regarding the particular type of memory deficit will dictate the compensatory strategies that are selected and taught to the individual. These can include both internal and external strategies. Furthermore, some patients with specific neuropsychological profiles may benefit from pharmacological intervention. In particular, patients with attentionally based memory problems may benefit from use of stimulants. Increased use of strategies, aids, and techniques has improved day-to-day memory performance in memory-impaired patients, even at long-term follow up (Wilson 1991). These findings underscore the potential effectiveness of a strong and precise program of rehabilitation.


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