Memory Intervention: From theory to clinical practice

Eva Svoboda, Ph.D., C.Psych.

Neuropsychology & Cognitive Health Program December 2, 2013

Collaborators

Baycrest Brian Richards

Nancy Posluns Gillian Rowe

Larry Leach

Kelly Murphy Sabrina Lombardi Ruth Brickman

Jeff McCarthy Ken Leung

Dmytro Rewilak Nina Dopslaff

York University Josée Rivest

Shayna Rosenbaum

Students

Narmeen Ammari

Christie Yao

Angelina Polsinelli Simon Beaulieu-Bonneau Deborah Tang Sandra Belfry Valerie Mertens

University of Toronto Morris Moscovitch

David Goldstein Morgan Barense

Sick Children’s Hospital

Sharon Guger

Outline

• Overview of related memory theory • The Memory Link program at Baycrest • Program outcome research • Intervention in a case of topographical disorientation

Memory systems

(Explicit/conscious) MEMORY DECLARATIVE (Implicit/unconscious) NONDECLARATIVE Semantic Facts Episodic Events Skills Priming Dispositions Nonassociative Motor Perceptual Simple classical Habituation Perceptual Semantic conditioning Sensitization Cognitive (Zola & Squire, 1990)

Application of multiple memory systems theory to intervention

• If one memory system is damaged, other preserved systems can be tapped to support new learning (Mateer & Sohlberg, 1989, 2001) • Development of learning techniques which capitalize on preserved memory abilities

Errorless learning

• Defining principle – learning without making mistakes (Wilson et al., 1994) • Implicit memory system is poorly designed to deal with errors (Baddeley & Wilson, 1994). • Once errors are produced amnestic individuals have a very difficult time eliminating them.

Procedural skills training

• Memory impaired individuals show robust implicit learning of new skills and procedures under conditions in which learning develops gradually across multiple trials • Sohlberg and Mateer (1989; 2001) trained individuals with severe memory impairment in the use of paper organizers with repeated trials of content questions, role-play and real-life generalization.

Memory Link Program

Short-term (12-20 wks) Clients: • Neuropsychological assessment • Real-life memory functioning assessment (behavior memory charting, questionnaires) • Individual skill training sessions on external memory aid use and application • Psychosocial/educational group for clients Family members: • Family education • Spousal support group • Kids support group

Memory Link Program

Research and Development • Basic and clinical research in collaboration with other clinicians and scientists • Development of novel intervention applications – industrial designers, programmers, participatory design groups (patients, family members).

Smartphone training example

• •

Calendar training

Event entries broken down into multiple steps (n = 24) Steps divided into 3 stages: • Stage 1 Basic steps to enter an event for today • Stage 2 Additional steps for future dates • Stage 3 Additional steps to attach a note

Errorless fading-of-cues protocol

Before smartphones …

Patient demographics

Pt Age Sex Educ Etiology

1 2 3 4 5 6 7 8 9 10 52 23 44 18 49 45 36 43 55 51 F F F F M M M F F M 15 16 14 12 15 15 18 15 14 15 ACoA Aneurysm L Medial temporal/occipital, bilat. thalamic glioma R anterior coroidal artery aneurysm Suprasellar Germinoma R temporoparietal CVA L anterior cerebral artery aneurysm + complications TBI/ski accident Heart malfunction - anoxia Colloid cyst Myocardial infarction - anoxia M = 6.32 years post-neurological event (range = 10 m - to 25.42 yrs) Svoboda, Richards, Leach & Mertens, 2012; Neuropsych Rehab

Study admission criteria

Moderate to severe memory impairment as defined by: 1.

Difficulty in day-to-day functioning due to memory impairment (e.g., ongoing supervision & /or regular assistance due to forgetting to pay bills, bathe, take medications or attend appointments); 2.

Independence in basic ADLs; 3.

At least borderline impaired to impaired memory performance on psychometric testing

Cognitive Profile: All patients

FSIQ D-S forward Boston Naming Phonemic fluency L-N Sequence Trails B WCST CVLT-II immed CVLT-II delay BVMT-R immed BVMT-R delay 1 4 7 10 13 Age-corrected scaled scores 16

Cognitive Profile: Focal impairment patients

FSIQ D-S forward Boston Naming Phonemic fluency L-N Sequence Trails B WCST CVLT-II immed CVLT-II delay BVMT-R immed BVMT-R delay 1 4 7 10 13 Age-corrected scaled scores 16 19

Cognitive Profile: Global impairment patients

FSIQ D-S forward Boston Naming Phonemic fluency L-N Sequence Trails B WCST CVLT-II immed CVLT-II delay BVMT-R immed BVMT-R delay 1 4 7 10 13 16 Age-corrected scaled scores 19

Study Design A

1

100 90 80 70 60 50 40 30 20 10 0

1

Intervention

Training

B

1

Pre-tx Stage 1 Stage 2 Stage 3

A

2

B

2

3-8 m Post-tx

Memory Log - Evaluation of everyday memory

Please record your family member's ability to independently remember to complete tasks or attend events over

2

consecutive weeks (about 5 events per week).

START DATE:______________________ END DATE: ___________________

(continued on next page)

Date

dd/mmm/yr

Set Time Date

dd/mmm/yr

Event Time Event Title

/ /

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AM PM / /

:

AM PM Observations:

* Response Task

/ / Observations:

:

AM PM / /

:

AM PM / / Observations:

:

AM PM / /

:

AM PM / / Observations:

:

AM PM / /

:

AM PM / / Observations:

:

AM PM / /

:

AM PM

*Response to task completion (0-1) 0

= did not independently complete the task or remember the event

1

= completed the task or remembered the event

Call Dr. Eva Svoboda at 416 785-2500 ext. 3194

[If you are unavailable during a particular time slot, you can complete your call in advance the same day]

Week 1 Sunday June 17 th : Monday June 18 th : Tuesday June 19 th : Thursday June 21 st : Thursday June 21 st : Week 2 Tuesday June 26 th : Wednesday June 27 th : Wednesday June 27 th : Friday June 29 th : Friday June 29 th : Between 7:00 PM - 9:00 PM 10:00 AM - 12:00 PM 9:30 AM - 11:30 AM 10:30 AM - 12:30 PM 4:00 PM - 6:00 PM 11:00 AM - 1:00 PM 10:30 AM - 12:30 PM 2:30 PM - 4:30 PM 2:00 PM - 4:00 PM 5:30 PM - 7:30 PM

Study Design A

1

100 90 80 70 60 50 40 30 20 10 0

1

Intervention

Training

B

1

Pre-tx Stage 1 Stage 2 Stage 3

A

2

B

2

3-8 m Post-tx

Case 9

Training

100 90 80 70 60 50 40 30 20 10 0

1 S1 10 S2 20 S3 30 40 50 S4 S5 Session number S6 60 S7 70

Stage 1 Stage 2 Stage 3

80 S8

Focal vs. global cognitive impairment

Trials to complete phase I (calendar function) • Participants required an average of 101.27 training trials to acquire all 3 training stages (range = 42 to 229) • Focal impairment -

M

= 74.50,

SD

= 29.51

• Global impairment -

M

= 173.56,

SD

= 65.69).

Phone calls/observation log

15 10 5 0 30 25 20

Memory Mistakes

( MMQ , Troyer & Rich, 2001 ) **

Pre-Tx Post-Tx immediate Post-Tx 3-months

** **

PM Other

30 25 20 15 10 5 0

**

Confidence Ratings (MASS)

** ** * * Self (n = 10) Other (n = 6)

Long-term maintenance of smartphone and PDA use in individuals with moderate to severe memory impairment Svoboda, E., Richards B., Yao, C. & Leach, L.

Paper under review

Phone calls/observation log – Long term follow-up

Hypointense rounded lesion (1.5 cm) in the third ventricle at the midline adjacent to the foramen of Munro.

Svoboda & Richards, 2009; JINS

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 5 4 3 2 1 0

Baseline Baseline Post- Intervention Return to Baseline Post- Intervention Return to Baseline 4-months 3-months

RR: outcome

5 Very effortful 4 Effortful 3 Somewhat effortful 2 Not that effortful 1 Not effortful at all Svoboda & Richards, 2009; JINS

RR: qualitative observations

• RR was creative in expanding the functional capacity of the Palm to support her individual memory needs. • •

Prospective guidance:

She attached notes to appointments or social events to remind herself of items to bring, questions to ask, messages to convey or instructions to follow. As part of her granddaughter’s birthday party event she attached a note outlining that she would be expected to baby sit, several details regarding the kids’ routines (bed time, sleeping arrangements).

RR: qualitative observations

• •

Retrospective guidance:

She attached notes to describe what happened at appointments or events, creating an autobiographical memory log. For a weekly outing event with her friend she attached a note documenting that they went clothes shopping, what they bought, what item was not in stock and what size was ordered by the store.

Caregiver Strain Index Stull, D. E. (1996). Journal of Clinical Geropsychology, 2(3), 175 –196.

Svoboda, Richards, Leach & Polsineli, 2010; Neuropsych Rehab

Smartphone intervention in a case of topographical disorientation Rivest J., Svoboda, E., McCarthy, J., Moscovitch, M., Paper in preparation

Case: FP

• Background: To date only two case studies published of intervention for topographical disorientation (Brunsdon et al., 2007; Davis & Coltheart, 1999. • Landmark agnosia - inability to recognize salient environmental stimuli (Aguirre & D’Esposito, 1999)

Case: FP

• • • • History: 65 year old right-handed gentleman 21 years education, owned environmental consulting business and travelled globally. Etiology: MVA while vacationing. Normal GCS at scene. 12 hrs post-MVA, unresponsive. Feb 2011 underwent L frontoparietal craniotomy with subdural hemorrhage evacuation.

L occipital gyriform high signal R occipital gyriform high signal Cortical laminar necrosis in cortex of bilateral posterior & medial occipital lobes & L inferomedial parietal lobe. Concl: Bilateral posterior circulation infarcts, multiple foci of parenchymal & intracranial hemorrhage secondary to trauma.

Case: FP

• • • • • • • • • Cognitive function (select findings): Did not go beyond corner store in his neighbourhood.

Took ++ effort to learn which building he now lives in.

Famous buildings – visited 28/30, visually recognized 11/30. Famous/personal faces - 6 recognized of 35 known people FP had poor colour discrimination across the entire wavelength spectrum Basic perceptual function was intact Verbal and visual memory were low average Verbal and nonverbal IQ were in the superior range.

Post-intervention cognitive status remained unchanged.

A

1

Study Design

Intervention 100 90 80 70 60 50 40 30 20 10 0

1 S1 10 S2 20 S3 Training

B

1

A

2 S7 70

Stage 1 Stage 2 Stage 3

80 S8

Return to baseline

B

2

Post-tx

No iPhone (A) 100% 80% 60% 40% 20% 0% Control A1 B1 With iPhone (B) A2 B2

Confidence in managing various navigation demands

Navigation ability

Conclusions

• Application of a theory-driven training program enables individuals with severe memory impairment to successfully use smartphones to support day-to-day memory function. • Use of map apps on smartphones offer significant promise to individuals with topographical disorientation, and possibly patients with poor way-finding secondary to other cognitive difficulties (amnesia)

Salvador Dali: Persistence of Memory