Remediation of Memory Disorders



Remediation of Memory Disorders


Jonathan J. Evans



Introduction

Memory problems are a feature of the majority of psychiatric and neurological conditions. Any condition that affects the physical or functional integrity of the brain is likely to have an impact on some aspect of a person’s ability to remember, as successful remembering involves many different interacting cognitive systems (see Chapter 2.5.3 on the neuropsychology of memory and Chapter 4.1.12 on the amnesic syndromes). Furthermore, mood disorders such as anxiety or depression, which impair concentration, also reduce the efficiency of memory.

Remembering difficulties disrupt the ability to participate effectively in activities of daily living, as well as social, leisure, and vocational activities. For some, memory problems will be mild and cause only minor inconvenience in everyday life. Others, such as those with the amnesic syndrome that accompanies dysfunction in limbic system structures, may be severely disabled by their memory impairment. People forget to do things (e.g. take medication, turn-off the cooker, pay bills, attend appointments, pass on messages), forget what they have been told, forget people’s names, forget where they left things (e.g. keys, the car in the car park), find it difficult to remember routes or learn new procedures, have difficulty recollecting personal experiences, and so on. Such problems lead to frustration, lowered self-confidence, and dependence on others. As such they represent an important therapeutic target.


Assessment of the nature of the memory disorder and the functional consequences for the individual should precede remediation intervention planning. As far as remediation of memory is concerned, although the future in terms of biological treatments is promising,(1) for the present time pharmacological options remain limited (see Chapter 6.2.7). The most effective treatments are cognitive rehabilitation techniques. These include use of memory aids, which function as cognitive prostheses, and methods of learning that promote more effective acquisition of knowledge or skills.


Planning memory remediation—assessment

The World Health Organization International Classification of Functioning, Disability and Health(2) provides a helpful framework for the assessment and remediation of cognitive deficits including memory impairment.(3) ICF, which complements the diagnostic approach of ICD, emphasizes that health (or illness) and functioning can be considered at the level of body structure (pathology), body function (impairment), activities, and participation. Application of this framework in relation to assessment of memory is illustrated in Box 4.1.14.1.

An assessment of memory should therefore address both the impairment and the functional consequences for the individual patient. This is important because treatment interventions will differ depending on the form and severity of the memory impairment and the nature of the everyday problems. Such an assessment will of course typically be just one part of a broader assessment of cognition—memory impairment is the focus here, but the same principles apply to all other cognitive impairments.



Box 4.1.14.1 The WHO ICF model and its relationship to assessment of memory























ICF classification

Example in relation to assessment of memory

Approaches to assessment/investigation


Body structure (Pathology)

Loss of cholinergic neurones in basal forebrain region affecting functioning of medial temporal lobe limbic system (Alzheimer’s disease)

Physical investigations (e.g. routine medical and brain imaging investigations)


Body function (Impairment)

Episodic memory deficit

Standardized neuropsychological assessment tools (e.g. Wechsler Memory Scales III; Rivermead Behavioural Memory Test)


Activities (Disability)

Failure to remember to do important tasks, failure to remember events that have happened, or things previously told

Clinical interview with patient and significant other, questionnaires, and observation


Participation (Handicap)

Inability to work; increased dependence on others; inability to participate in leisure activities

Clinical interview; quality of life measures



Assessment of memory impairment

Memory impairment is assessed through the use of standardized neuropsychological assessment tools (see Chapter 1.8.3).


Assessment of functional consequences of memory impairment

Activity limitations arising from memory disorders can be assessed through clinical interview with the patient and proxy, but it can also be helpful to use a standardized questionnaire to aid information gathering. Several questionnaires exist for this purpose. The Prospective and Retrospective Memory Questionnaire(4) is one example of a useful, brief questionnaire with self-rating and proxyrating forms that address both prospective remembering (e.g. Do you fail to do something you were supposed to do a few minutes later even though it’s there in front of you, like take a pill or turn off the kettle?) and retrospective remembering (e.g. Do you fail to recall things that have happened to you in the last few days?). This questionnaire also has normative data for self-rating and proxy-ratings.(5,6)

Awareness of the functional consequences of memory impairment may be limited on the part of the patient and the carer (see section on assessment of awareness below). It is possible that functional consequences will also be minimized (again by patient and under some circumstances the carer). In some cases there may be significant impairment of memory and associated limitations of activity, but a spouse/family may take on most or all of the remembering responsibility and hence the significant disability on the part of the patient may not represent a problem for patient or spouse/family. In this circumstance it is important to investigate whether there is adequate awareness of rehabilitation options.


Assessment of use of memory aids and strategies

Pre-morbid and current use of memory aids and strategies should also be discussed as part of the clinical interview. Given that the most effective approaches to memory rehabilitation are those that enable people with memory dysfunction to compensate for their impairment, it is important to understand what past experience of use of memory aids the patient has, and which aids/strategies are used currently. Some people will have made extensive use of memory aids and strategies throughout their life, and continue to do so in response to onset of memory problems. Others may have used aids and strategies in the past, but then do not use them despite the onset of memory problems. Others have little previous experience. Some examples of aids and strategies to investigate, drawn from a survey of use of memory aids by people with memory impairment,(7) are shown in Box 4.1.14.2.


Assessment of awareness of memory deficits

Awareness of impairment should also be examined as this will impact on the approach to remediation that will follow. To what extent is the patient aware of his or her memory (and any other cognitive) problems? Insight and awareness is a complex issue. Clare(8) presents a biopsychosocial model of the construction of awareness in Alzheimer’s disease, though the principles of the
model apply to most neurological and indeed many psychiatric conditions. Another simple model, but one that is useful in clinical practice, is the hierarchical model of Crosson and colleagues(9) which suggests that awareness may be intellectual, emergent, or anticipatory. Intellectual awareness refers to knowing that you have an impairment, but not necessarily recognizing the occurrence of problems as they occur. Emergent awareness refers to ‘online’ awareness of problems as they occur, whilst anticipatory awareness refers to using knowledge of deficits to anticipate problems and taking steps to prevent problems occurring. This tripartite model of awareness can be helpful in formulating a patient’s level of awareness of memory problems. The extent to which the patient’s reporting of problems is discrepant from their relative’s account (in interview or on questionnaires), or from what might be expected on the basis of standardized test results will give some indication of level of awareness. In addition it is useful to establish the extent to which the patient is aware of the type of memory problems that arise and the extent to which s/he makes attempt to compensate for the problems. Bear in mind that severe memory impairment may itself impact on awareness—patients may have difficulty remembering that, or what, they forget.



Box 4.1.14.2 Assessment of pre-morbid and current use of memory aids and strategies

Use of memory aids and strategies is a central component of memory rehabilitation. Investigation of prior experience, and current use, of aids and strategies is an important part of the assessment process. Below are examples of aids and strategies that are most commonly used by people with memory impairment.(3) This list is not exhaustive and it is important to ask whether any other aids/strategies are used.

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Sep 9, 2016 | Posted by in PSYCHIATRY | Comments Off on Remediation of Memory Disorders

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