Non-pharmacological treatments to help memory loss can improve function equal to or greater than medication.
External memory aids such as calendars, lists, and whiteboards can be helpful in keeping patients functional.
It is important to keep the memory aid in the same place.
Learning habits (using procedural memory) allow patients with even moderate Alzheimer’s disease to improve their function.
Pictures are easier to remember for patients with Alzheimer’s disease.
Music can be helpful for patients at all stages of Alzheimer’s disease.
The Mediterranean diet or diets high in resveratrol (red grapes, red wine, and blueberries) or antioxidants have been suggested to reduce memory loss, although their value is currently uncertain.
Social and cognitively stimulating activities, as found in an enriched environment, have been shown to improve function.
Aerobic exercise can stimulate the development of new neurons in the hippocampus and improve cognition, in addition to its effects on cardiovascular health and mood.
Pharmacological treatment of memory loss, present or future, can only help so much when dealing with Alzheimer’s and other diseases affecting memory. Non-pharmacological treatments are invaluable, and can often help daily function as much as, if not more than, medications ( ). An entire book could be written on this important subject. In this chapter we briefly touch on a number of relevant topics.
Using a system that can become a habit is critically important when teaching a patient with memory loss new skills. Habits do not depend upon the episodic memory system—the memory system that is affected by Alzheimer’s disease and most other disorders of memory. Habits depend upon a different kind of memory, procedural memory. Procedural memory is the type of memory we use when riding a bike, touch typing, playing the violin, and dialing a phone number that we have done hundreds of times without thinking about it. It is due to procedural memory that, when we are not paying attention to where we are driving, we may make turns toward a familiar location—but not necessarily the one we had intended to go to! Procedural memory is quite well preserved in Alzheimer’s disease and other memory disorders until quite late in the disease. This preservation of procedural memory allows us to teach the patient with Alzheimer’s disease new functional skills even when their episodic memory is devastated. See Appendix C for more on the different types of memory systems in the brain.
Teaching by doing is the key to learning with procedural memory. Think again about learning to ride a bike; it is not learning verbally with words. Has anyone ever asked you for a phone number and you’ve had to say, “Hold on, let me dial it?” You have to dial it because that number is stored in your procedural memory, not your episodic memory.
Here is an example. The wife of a patient with mild Alzheimer’s disease has just bought a new wall calendar that she is keeping all of their appointments on. Although they had not previously used a wall calendar, she is very pleased with her new system, which works very well for her. She reports to us, however, that it is not working for her husband. He is continually asking her what they are doing for the day. Although she has told him a thousand times to go look at the calendar, he never goes on his own; he will go to it, however, after she tells him to. We then explained to her that she needs to actually lead him to the calendar each time he asks what they are doing for the day, so that “his feet can learn where to go.” At first it seems like no progress is being made. But over the course of a few weeks of her leading him to the calendar every time he asks, he begins to go to look at the calendar automatically.
External Memory Aids
Almost all of us use external devices to augment our memory. These include traditional simple items, such as a list, calendar, Filofax or organizer, as well as more sophisticated electronic devices including smartphones and tablets to store names, addresses, phone numbers, appointments, and other information. Prior to their illness, most patients with memory problems also used such devices to a greater or lesser extent. Not surprisingly, patients who always depended upon external devices are, in general, able to continue using them early on in the disorder to compensate for their declining memory. Patients who, by contrast, always depended upon their memory to keep themselves organized tend to suffer more swift and severe functional impairment as their memory declines, because they do not automatically reach for external devices to compensate for their impaired memory. As the illness progresses, however, almost all patients would benefit from additional use of external devices to compensate for their memory problems. What follows are some of the simple ways that a number of our patients have found functional improvement in the face of memory impairment.
Knowing the day, date, month, season, and year are important basic components of knowledge that most of us take for granted. Such knowledge is important insofar as we have appointments, meetings, lunch dates, or television shows that we want to keep, participate in, or watch. Losing track of this information is one of the first things that occurs when memory becomes impaired.
There are, of course, many different types of calendars that can be used. Early in the disease course (e.g., in mild cognitive impairment or very mild Alzheimer’s disease) any of these would be fine, as a certain amount of new learning is possible. However, the best approach—and the only approach that works as the disease progresses—is to use a calendar system that can easily become a habit to the patient as described above.
In general we recommend a large desk or wall calendar that always stays in one place. In this way it will not become lost, and the patient with memory loss will be able to get into the habit of going there to look at it. It is important that the previous days are “crossed off,” so that the patient will automatically know what the current date is.
In the same way that the patient with memory loss can get into the habit of going to look at the calendar, so can the patient get into the habit of going to other places as well. For example, shoes can be kept in a special place in the front hall so that there is never a search for them. Shopping lists can be kept on the left side of the refrigerator. Microwave dinners can be kept on the right-hand side of the freezer. Clothes for the next day can be laid out on a certain chair such that the patient never needs to ask what they should wear for the day. And even the order of the clothes, laid out in the same way each day, helps the patient to get dressed properly (e.g., underpants first, then pants).
At a more general level we discourage caregivers from rearranging closets or the kitchen drawers or any other organizational system with which the patient is familiar. We have even heard reports from caregivers that rearranging furniture can be a disorienting experience for the patient. Alzheimer’s patients can continue to function in long-standing environments because they can rely upon their intact remote memories.
Bulletin Boards and Whiteboards
Just like the calendar and special places, bulletin boards and whiteboards mounted in a special place can provide a way to help the patient with memory loss know what is happening.
Let’s return to the patient and his wife described in the section on Habits, above. Several years have passed, and he is more impaired, now in the moderate stage of Alzheimer’s disease. He is too impaired to read. And the calendar is now too complicated for him to figure out, even with the dates crossed off. But with the help of their daughter, they have found a new system that works. In place of the calendar, in the same spot in which it had hung, they have a magnetic board. Here they put up pictures that let the patient know what is going on that day. Using the camera on her cell phone, the daughter has taken pictures of many of the common friends and family members that they see, common places they visit, such as the post office, bank, grocery store, and a favorite restaurant, as well as activities such as walking and gardening. Each morning his wife puts up the people, places, and activities that they will be seeing, visiting, and doing that day. She tells us that she isn’t sure that he can remember the things on the board for more than a minute or two, but now he simply goes and looks—sometimes 10 or 20 times in an hour—rather than asking her every time.