Memory RehabilitationinOccupational Therapy
by
Iris Lazaro, Hricha Rakshit, Eugenia Wong
What is Rehabilitation?
Cognitive rehabilitation is described as any intervention strategy or technique that enables clients and their caregivers to live with, manage, by-pass, reduce or come to terms with cognitive deficits precipitated by injury to the brain (Wilson, 1999).
RESTORATIVE STRATEGY
Memory Practice Drills
- Assumption – memory responds like a “mental muscle”
- Examples – party games (Kim’s game) and laboratory tasks (list learning)
- Ericsson, Chase, Faloon (1980) analyzed how a memory skill is acquired
- Subject without memory impairment engaged in a memory span task over a 20-month period
- Method – subject was read random digits, then recalled the sequence
- Subject categorized 3- and 4-digit groups as running times for different races
- Result – if subject was present with sequences that could be coded in terms of running times, his performance would increase
- Conclusion – it is not possible to increase capacity of short-term memory with extended practice; increase in memory span is due to use of mnemonic associations in long-term memory
INTERNAL COMPENSATORY STRATEGIES
Mnemonics
- Verbal Mnemonics
- Alphabetical Searching – To work through alphabet in the hope that a particular letter will act as a retrieval cue for the word or name to be recalled
- First-letter cueing – Uses initial letters to act as retrieval cues
- Story Method – Words are embedded in a story with each word chained on to the next
- Visual Mnemonics
- Peg-word Method – A standard peg words (bun, shoe, tree) are learned, and items to be remembered are linked to the peg words by visual imagery
- Method of Loci – Visually linking items of information to be recalled with specific locations, such as locations in a house or body parts, whereby locations trigger recall of information
- Comparison of four mnemonic strategies – first-letting cueing, method of loci, visual imagery, story method (Wilson, 1987)
- In control subjects, story method was better than other strategies in both immediate recall and delayed recall
- In subject with brain damage, none of the mnemonic strategies could help to improve memory in immediate recall; story method was the best amongst all strategies in delayed recall
- Story method combines both visual and verbal methods; it acts as efficient integration system in which previously isolated items become memorable because they are associated with one another
Method of Vanishing Cues
Is a process where a client is given cues (i.e. stem words) and the cues are systematically withdrawn as the client learns
Theory: to utilize intact ability to respond to partial cues of items presented before
•Successfully taught domain-specific skills for the work environment: word processing, data entry and database management (Glisky et al., 1988, 1989)
•Glisky, E.L. (1995): case study of acquisition and transfer of word processing skills of an amnesic client
Method:
(1) Initial Trial: client is presented with ascending amount of cues to elicit the target response
•A sequence of characters enclosed in quotation marks is called a ______. (answer: STRING)
•1st trial hints required: S, T, R, I, N
(2) Subsequent Trials: cues are withdrawn gradually (usually one less than the last time client was correct) to produce the same response
•2nd trial hints given: S T R I
•3rd trial hints given: S T R
•4th trial hints given: S T …… and so on
VC vs. SA (Hunkin and Parkin, 1995)
•SA teaching method appears to be more effective during the initial phase of training (greater learning = method effect, and faster rate of learning = method session effect). But this disappears after 12 sessions (when quick learning is not a factor anymore). However after a 6 week delay, there is greater rate of forgetting for SA.
•Correlational of “VC-SA score difference” with verbal IQ, verbal memory, attention and frontal lobe function = revealed that clients with low verbal IQ, with more severe memory deficit, and with more compromised fontal lobe functioning are those who gain benefit form VC procedure
Limitations:
(1) Takes a long time to train and learn
(2) Takes a lot of effort
(3) Hyper specific = only elicit response if the format of prompt is the same as training and can not transfer to other circumstances
(4) Errorful learning can be learned and strengthen = especially on the initial trial
(5) Implicit memory likely to occur when there is already an existing trace of association
Spaced Retrieval
It is a process where a client is taught to recall information over increasingly longer periods of time.
Theory: rely on intact ability to respond to prompted behaviours due to previous exposure and practice
Employs errorless learning
•Brush and Camp (1998a) reported the use of SR to reach clinical goals involving strategies: teaching the client to use a schedule or date book, teaching the client to use a voice amplifier and make eye contact when speaking, etc
Method:
(1)Clients are given specific information to remember.
(2)Immediate recall is solicited.
(3)If the recall attempt is successful, the next trial interval is expanded systematically (e.g., 5, 10, 20, 40, and 60 s)
(4)If the recall is wrong or no response is given, the therapist immediately gives the correct respond and ask the client for immediate recall (usually clients are instructed to not respond if they are not sure of their answer = errorless)
(5)Then the interval for the next recall will be the same as the last time the client gave the correct response
(6)Each trial must end with a correct recall
SR vs. CH (Bourgeois et al., 2003)
(1) Number of goals mastered is greater in the SR condition. No participants mastered a CH goal without mastering a SR goal, but 5 participants mastered a SR goal without mastering a CH goal. Thus, it seems that mastering a goal through SR is easier.
(2) After a one week and 4 month delay, SR is superior to CH in maintenance of goal that had been mastered during the training.
Rules to Remember in SR training
(1) Effortless
(2) Errorless
(3) Procedure or info is concrete
(4) 1 piece of info taught at a time
(5) If clients can not recall correctly after 6 min interval after 6 sessions, this method might not be the best one
Limitations
(1) Domain Specific (transferability problem)
(2) Spontaneously use when prompt is not available
(3) Passive Learning
EXTERNAL COMPENSATORY STRATEGIES
Memory Books
Sohlberg and Mateer’s protocol includes three training phases: (Sohlberg, M. M. and Mateer, C. A, 1989)
•Acquisition: teaching patients to use the journal by outlining of the name, purpose, and use of each section of the book using a question and answer format.
•Application: phase involves teaching patients to record in the appropriate journal sections through engagement in role playing exercises.
•Adaptation: phase involves teaching patients to use the journal in naturalistic settings.
Barriers to memory book training:(Burke, J.M, Danick, J.A., Bemis, B. & Durgin, C. J., 1994)
•Physical: loss of dominant arm and/ or fine motor coordination, visual impairments, decreased mobility.
•Cognitive: linguistic and attention deficits, decreased language comprehension, reduced problem solving skills and so on.
•Emotional: fear of stigma associated with using memory aids, level of social support from family and friends.
Challenges of memory book training:
•Gaining clients’ compliance to use the memory book after therapy sessions.
•Clients are not aware of the severity of their neurological and cognitive deficits.
•Fear of stigmatization
How is the memory book training initiated?
1. Awareness training
2. Selection and design of tool:
3. Memory book training
The training procedure is comprised of four processes:
• Orientation
• Develop a system to keep the book close to client.
•
Learning to write info that is meaningful to client
• Development of consistent referral to the book
4. Generalizability of the memory book:
• Using the book at home may include recording when bills are due, repairs that need to be completed, household chores and medications.
•
At work the book may be used to record tomes of meetings, daily job tasks, assignments to be completed by specific due dates and so on.
Benefits of using memory books:
Ø(Fluharty, G. & Priddy, D., 1993).
•Helps clients in recalling important events, keeping appointments, running errands, and remembering to complete household chores.
•Effective in compensating for prospective memory deficits.
Ø(Harrel, M., Parente, F., Bellingrath,E., G. & Lisicia, K., A., 1992).
•Makes a client a more active listenerbecause you are writing info down.
•Facilitates encoding process via multisensory modalities, such as hearing the info, seeing it written down, and using motor functions to write it down
•It also avoids repetition of info, reducing boredom and potential distraction.
Limitations of using memory Books:
Glitsky, E. L., & Schacter, D. L. (1986).
•Passive cues as opposed to active
•Notebook has to be constantly referred to.
•learning or remembering to use them
(Donaughy, S. & Williams, W., 1998).
•Using memory notebooks require extensive training.
•Acquisition phase entails client having to acquire new semantic information. This is difficult for brain injury patients.
•Patients are not happy with the requirement of having to flip frequently between sections of Calendar, Things to Do, and Memory Log for each referral.
Neuropagers
B. A., Evans,J. J., Emslie, H. & Malinek, V. (1997).
•Portable paging system with a screen that is attached to the waist belt.
•Connected to an array of microcomputers that is linked to a paging company via a conventional computer memory and by telephone
•Scheduling of cues or reminders for each individual is keyed into the computer.
•At a specified date and time the reminder is transmitted to the individual.
•Purpose of pagers is to assistance to patients with prospective memory deficits. The practice of using pagers eventually builds on their procedural memory.
Benefits of using neuropagers: (Wilson,B. A., Evans,J. J., Emslie, H. &Malinek, V., 1997)
•Apart from initial programming no other commands or programs have to be computed.
•Very easy to use.
•Are small and portable and they avoid problems of existing aids such as cumbersome computers
•Possess option of an audible alarm that can be modified to vibrate coupled with a verbal message displaying on the screen.
•They are used typically when other memory interventions fail.
•Have the potential to enhance independence and employability
•Speed discharge from acute and rehabilitation services, and reduce stress.
•NeuroPage is also likely to be cost effective for health services
Things to Consider
About the Client
(1) Dimension, type, severity, and chronicity of memory impairment
(2) Age, Education
(3) Pre-morbid knowledge and skills
(4) Other difficulties (physical, behavioural, cognitive)
(5) Current daily routine
(6) Context where the client will do his/her occupations
(7) Awareness of own difficulties
As a Therapist
(1) Sensitive to client’s wishes on which memory aid to use
(2) Educate clients
(3) Caregivers need to be closely involved in the process
(4) Teach meta-memory and problem solving skills
(5) Utilize the external environment and everyday routines to anchor strategies
(6) Help make it meaningful to the client
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