Compensatory memory strategy
Brief description of strategy
Memory notebook
A place where all important information to be remembered is written down. A memory notebook can be divided into different sections (e.g., daily calendar; things to do; addresses and phone numbers) based on individual needs. It can also be referred to as a planner or organizer
Cell phone or smart phone
Blackberry, iPhone, and other mobile phones have alarms that can be set to sound at a particular time and date as a reminder of appointments, things to do, etc. Some phones also have calendars and a place for notes
Computer
Like a memory notebook, a computer can be a place where all important information is kept. A calendar program on a computer can be used to keep track of important appointments or tasks to accomplish (e.g., paying bills, submitting paperwork)
Checklist
A list of items that need to be purchased, tasks that need to be completed, steps in a task or procedure, or anything else that needs to be remembered and can be formatted like a checklist (i.e., each step or item can be checked off as it is completed)
Memory station
A specific place in the home where frequently used items are kept or where belongings are kept that need to be taken when the person leaves home
Pill box
A box with separate compartments that can hold medications to be taken and that can be labeled as to day and time of dosage
Digital voice recorder
Can be used to keep track of information when writing it down is too difficult or not preferred. For example, when parking your car at the grocery store, you can read your car’s location into the voice recorder and after grocery shopping, play back what you recorded to quickly locate your car
Step 3: Setting Up the Strategy
Once a strategy has been agreed upon, the therapist should help the client and caregiver to set up the strategy in a way that will maximize success. Even if a client is already using a strategy, it may need to be set up differently or reorganized. A good example is use of a pill box to keep track of medications. Many pill boxes are set up by day, with all the medications for one day placed in the same compartment (e.g., “Monday” compartment). This can be problematic if there is more than one dose of the same medication per day, or if there are multiple medications being taken in one day, but at different times. Persons with impaired memory may forget which of the medications to take at which time or may become confused and take medications twice. The pill box should be set up according to dosage times. For example, all of the medications for the Monday a.m. time slot should be in one compartment, the noon time slot in another, and the p.m. dosage in yet a different compartment. This strategy may also need to be supplemented by use of an alarm to cue the person with TBI to go to the pill box to take the medication. This is just one example of how traditional strategies may need to be altered to fit the needs of individual clients. Setting up strategies in the context in which they will be used (e.g., home, community) can be very beneficial.
Step 4: Demonstrating the Strategy
Simply explaining strategy use to a person with TBI and/or their caregiver is not usually sufficient. Even the most well-established and easy-to-follow verbal and written instructions can be difficult to implement once the individual with injury has left the rehabilitation treatment setting and returned to his or her home or community. The clinician should teach the memory compensation strategy to the client in short, discrete steps and provide reinforcing feedback. It is imperative to know that the person with injury adequately understands how the memory compensation strategy is implemented and when to use it. This can best be done by breaking the strategy down and showing the person with injury in a “hands-on,” ecologically valid manner (i.e., working with materials that will be used by the individual with injury and in situations that resemble the real-world situations as closely as possible). This can allow the clinician to identify obstacles to successful strategy implementation and address the problems immediately. It is important to provide reinforcing feedback as the person with injury implements the strategy. People often become discouraged when the strategy does not work right away, but successful use of strategies requires repeated practice. Providing verbal reinforcement and encouragement can help to build a client’s confidence that he or she can master the strategy.
Step 5: Simulated and Real-World Practice
Guided practice of compensatory memory strategies is important for clients to acquire the skills necessary to use them independently. Initially, this practice can occur through role-played situations with the therapist; however, much of the meaningful practice must occur in real-world situations, such as in the client’s home or community. Assigned practice of strategies in these real-world environments is crucial to success. The therapist should help the person with injury to identify specific opportunities for practice in their real-world environments. The strategies should be practiced a minimum of once per day, but optimally more frequently. Providing clients with a written reminder to practice (e.g., calendar, list) can be beneficial, but involving caregivers to prompt them is also helpful. If naturally occurring opportunities for daily practice are not readily available during the course of a client’s day, the clinician should assist with development of role-plays that can be used to practice strategies. In our clinical practice and experience, daily and repeated practice of the memory compensation strategy is necessary for the strategy to become a habit. Once use of the memory strategy becomes a habit, the memory problem that it is designed to address will have less of an impact on the person’s daily functioning. This is the ultimate objective of memory rehabilitation.
Step 6: Follow-up Support
Use of compensatory memory strategies often must evolve over time to meet changing needs in real-world environments. Follow-up support is important for helping to maintain the skills learned during therapy. This support can be provided by telephone or in person. During these support sessions, the therapist can determine if the client is using the memory compensation strategy on an ongoing basis, if he or she is encountering any problems, and if the strategy needs to be adapted to meet the demands of a new situation. The therapist can assist with problem-solving and tweaking of the memory strategy. Whenever possible, the person with injury and their caregiver should be engaged in the problem-solving process. As noted in the section on emphasizing process, this can help them learn how to generalize the memory compensation strategy to fit other needs or needs that have not yet emerged. In some situations, development of a new strategy may be necessary.
Case Examples
We will now present two case examples that illustrate in detail how to apply the principles and concepts discussed in this chapter. These case examples are based on our clinical experiences in working with individuals with TBI in both a post-acute rehabilitation setting and in an ongoing clinical trial investigating contextualized memory compensation training in participants’ homes.
Case Example No. 1: Remembering to Take Medications
Bob was a 24-year-old male who sustained a severe TBI as a result of a motor vehicle accident. At the time of initial clinical assessment with Bob, he was 6 months post-injury and had not returned to productive work outside the home. He was safe to stay home alone, but had moved in with his girlfriend for continued support and assistance with meeting his needs. During clinical interview, Bob expressed several concerns related to his memory; chief among them was his ability to remember to take his medications as directed. He was taking numerous medications at multiple times throughout the day and was not using a pill box. Because his girlfriend and family recognized the potential for Bob to miss a medication dose or take the wrong medication, his girlfriend and brother were actively involved in monitoring his medications. His brother, who was responsible for his daytime medications, frequently called him or stopped by his apartment to ensure that his medications were taken as prescribed. This was creating a strain for both Bob and his brother. Bob felt that he was being treated like a child and his brother was having difficulty meeting his demands at work because of his involvement in his brother’s care. At the end of the initial clinical interview and assessment, it was agreed that the first treatment goal would be for Bob to become independent with his medications.
Information Gathering
To figure out how to best intervene in Bob’s difficulty with remembering to take his medications as directed, in-depth information was needed. Questions, like those shown in Table 2 below, were asked of Bob and his brother during his first in-home appointment:
Table 2
Information gathering for Case No. 1
Specifics about the memory activity |
• How many medications is Bob taking? |
• At what times must each of the medications be taken (including multiple times for some medications)? |
• Where does Bob keep his medications? |
• How does Bob keep track of whether or not he has taken his medications (including whether a caregiver prompts him)? |
• Where is he when he needs to take his medications (e.g., at home, out in the community) |
Previous compensation efforts |
• What, if any, previous compensation efforts have been tried by Bob and his family to help with medication management? |
– Were these attempts successful, and why or why not? |
– Are there elements of these previous strategies that they would like to incorporate into development of a new strategy? Can the existing strategy be modified to be more effective? |
• What, if any, strategies did Bob use to help with memory prior to his injury? |
Reactions to potential compensatory strategy |
• Is Bob open to using a pill box to manage his medications? If not, what are his concerns? |
• Would Bob prefer to use an electronic device or paper-and-pencil-based tools to help him remember to take medications? |
• Is Bob open to involving his family in helping him to learn a compensatory memory strategy? |
Available resources |
• Does Bob already own a pill box? |
• Does Bob have a cell phone? |
– Does the phone have text messaging or an alarm feature? |
– Does Bob or his family have access to the Internet to program text reminders to be sent to his phone? |
– Does Bob have an alarm clock or other device (e.g., digital watch with an alarm feature) that could be used to alert him that it is time to take medications? |
–What types of paper-and-pencil materials does he have that could be used to develop a strategy? |
Family member/caregiver support |
• How do Bob’s brother and girlfriend ensure that he is taking his medications as prescribed? |
• Does Bob need help getting refills on his medications? |
• Does Bob’s family believe that he would need supervision to fill his pill box? |
How would family members, if at all, be willing to help Bob to learn a strategy to remind him to take his medications? |
From these questions it was learned that Bob was taking five different medications and the dosage of one of them changed every couple of days. He took medications both in the morning and in the evening, and for two of the medications, he took them both in the morning and evening. Bob kept his medications lined up on the dining room table. Once he had taken the medication, he would turn a medication bottle around, so that the label could not be seen. He kept his medications in the dining room so that he saw them frequently, which reminded him to take them, and he preferred to take his medications with food (it should also be noted that Bob did not have small children in his home, so there were no worries about keeping medications in a spot where a child would not be able to access them). Bob’s brother called him 5 min prior to a scheduled medication time to remind him to take his medication, and his girlfriend would remind him to take his medication in the evening if she did not see him take them on his own. Bob’s brother and girlfriend would periodically count the number of pills in a bottle to ensure that Bob was taking his medication as prescribed. When his medications were close to running out, his girlfriend would call in the prescription refill and pick them up from the pharmacy.
Bob did not have a pill box, but was interested in and willing to buy one. He believed that he could fill his pill box on his own, but was willing to include his brother and girlfriend in the beginning. He was also open to his brother and girlfriend initially monitoring his use of the pill box to ensure that he took his medications, but felt that their monitoring would not be needed for very long. Bob was also interested in using his cell phone to set-up reminders of when to take his medication. He always carried his cell phone in his pants’ pocket or on a table next to him, so he did not feel that wearing a digital watch with a reminder was necessary. He also did not like to wear a watch. Bob was not interested in having written reminders posted in the home because he did not want guests to know he had a hard time remembering information. He also felt like posted reminders would lead him to feeling as if he was being treated like a child.
Prior to injury and currently, Bob felt comfortable with his knowledge of how his cell phone worked, and he believed he could independently program reminders on it. His brother had a similar phone to Bob’s and could be a resource for programming reminders, if needed. Bob’s brother was willing to be involved in Bob’s therapy in the hopes that he could become more independent and need less help from him. Bob’s girlfriend was also interested in being involved in his therapy, but did not have a work schedule that would allow for it. Bob’s brother and girlfriend frequently spoke, and he and Bob felt like they could adequately pass along information to her so that she too could help Bob with memory compensation efforts.
Before injury, Bob did not use any strategies to help him with his memory. He felt like he had been able to remember appointments, important information, and anything else without any external aids.
Strategy Development
Review of cognitive rehabilitation literature suggests that a strategy focused on the use of an external aid with direct application to a functional activity would be best for a person with a severe TBI [43–45]. Within this context and clinical experience, it was hypothesized that a pill box, in conjunction with external reminders to take medications, would be a best-fit memory compensation strategy for Bob’s goal of remembering to take his medications as prescribed. Based on Bob’s preferences, text messages or reminders sent from his cell phone would be used as external reminders of when to take his medications. This strategy was presented to Bob and his brother and met with approval. Bob felt like the use of his cell phone in the strategy was in line with his preferences, and using his cell phone helped him to feel “normal since people use their cell phones for all sorts of things.” His brother felt that he and Bob’s girlfriend could easily support Bob in the use of the strategy.
To identify the specifics of how the strategy would work, Bob and his brother wrote down a list of all Bob’s medications, their dosages, and the times the medications needed to be taken. Together, they programmed Bob’s cell phone to send him a reminder message that consisted of the instruction “take AM MEDS” or “take PM MEDS,” depending on which time of day it was. With the reminders in place, Bob and his brother filled his pill box, using the medication list they had created and paying close attention to the particular medication that changed three times during the week. Bob chose to keep his pill box on the dining room table since he had a strong memory of the pills being there and it did not pose a risk to anyone in the household to keep them there. Bob also decided he would like to keep a box of crackers next to his pill box so that he would have food to eat when it was time to take his medications.
In terms of a procedure to follow, it was decided that after hearing and reading the reminder message, Bob would stop whatever he was doing, get a glass of water and then sit down at the dining room table, take the pills out of the appropriate place in the pill box, eat a few crackers, and then take his medications. At the end of the week, Bob would refill his pill box. For the first 2 weeks, Bob would fill the pill box with either his brother or girlfriend. After that, he would fill it on his own, with his brother or girlfriend checking his work until everyone felt confident in Bob’s ability to independently fill his pill box. A plan for Bob to take over calling in his own prescription refills was deferred initially; however, Bob indicated that once he was filling his pill box with complete independence, he believed he could make his girlfriend aware of the need to call in his prescription refills.
Teaching of Strategy and Assignment of Practice
To ensure that Bob could carry out the compensation strategy that was developed, the therapist first modeled the strategy in short, discrete, concrete steps to Bob and his brother. Sitting in a chair in his living room, the therapist made a mock cell phone alert sound and upon hearing the sound, picked up Bob’s cell phone and said, “my phone has a reminder message on it that says ‘take AM MEDS,’ I am going to get up out of this chair and get a glass of water. The therapist then walked into the kitchen, with Bob and his brother following behind her watching, and got a glass of water. The therapist then said, “I have a glass of water and I am now going to go sit at the dining room table.” She then went and sat at the dining room table and said, “I am taking the medications out of the AM slot for Monday.” She then took the medications out of the indicated spot. The therapist then said, “I am going to eat a few crackers and then I’ll take my medications.” Having gone through the entire strategy step-by-step for Bob and his brother, the therapist asked if they had any questions before helping to guide Bob through the same trial run. Without much difficulty, Bob went through the strategy and the therapist positively reinforced his efforts.
Bob needed to take medications twice a day, so the therapist did not see a need to assign him any artificial practice. Practice of the strategy was already set up through the twice daily reminders that were programmed in Bob’s phone. With Bob in agreement, Bob’s brother would call him 15 min after his morning reminder had gone off on his phone to ensure that he had taken his medications. His girlfriend would be home in the evening to observe if Bob followed through with the reminder to take his evening medications. Bob, his brother, and the therapist felt comfortable with the plan for continued use and practice of the memory compensation strategy.
Follow-up Support
During a follow-up visit, Bob and his brother reported successful use of the strategy. As a precaution, the therapist asked Bob to role-play use of the strategy. During this role-play, the therapist noticed that Bob’s pillbox was full despite it being the middle of the week. She queried Bob about this and Bob reported that he filled in the pill box each night. The therapist, Bob, and his brother discussed the pros and cons of filling the pill box each day or once a week. Together they identified that it was better to fill the pill box once a week so that Bob could immediately know where he was at with his pills during a week. Particularly due to the medication with dosage changes, the potential for confusion and inaccurate taking of medications was high. No other difficulties or problems with this strategy were identified during subsequent visits with Bob and his brother.
Case Example No. 2: Remembering Important Information, such as Details About Upcoming Events and Appointments
Bill was a 56-year-old, married male who sustained a moderate TBI as a result of a fall from a ladder. At the time of the initial clinical encounter, Bill was 3 months post-injury and very eager to go back to work. Bill was a successful regional salesperson for a major company and was worried about losing his customers in an extremely competitive market. By 3 months post-injury, Bill’s recovery had progressed quickly and the rehabilitation team had begun to discuss his return-to-work plan. One of the biggest challenges for Bill to cope with when he returned to work was going to be deficits in his short-term memory that had been observed functionally and on neuropsychological testing. Bill often forgot details about upcoming events and times of appointments and meetings. As part of Bill’s job, he would need to remember times and dates of meetings with customers, specifics about their needs as customers, and information about past and future orders. The goal of treatment with Bill was to help him learn a compensation strategy for remembering important information.
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