Transcript Slide 1

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
MEMORY
(Explicit/conscious)
(Implicit/unconscious)
NONDECLARATIVE
DECLARATIVE
Semantic
Episodic
Facts
Events
Skills
Priming
Dispositions
Nonassociative
Motor
Perceptual
Cognitive
Perceptual
Semantic
Simple classical
conditioning
Habituation
Sensitization
(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
1
2
3
4
5
6
7
8
9
10
Age
52
23
44
18
49
45
36
43
55
51
Sex
F
F
F
F
M
M
M
F
F
M
Educ
15
16
14
12
15
15
18
15
14
15
Etiology
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
A1
B1
Percent Correct
Intervention
A2
B2
Training
100
90
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
1
10
S1
20
S2
30
S3
40
S4
50
S5
60
S6
70
S7
80
S8
Session number
Pre-tx
Skill
Acquisition
Immediately
Post-tx
Return to
Baseline
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
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Set Time
:
Date dd/mmm/yr
AM
PM
Event Time
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AM
PM
Observations:
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AM
PM
AM
PM
Observations:
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:
AM
PM
AM
PM
Observations:
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AM
PM
AM
PM
Observations:
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AM
PM
Observations:
*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
AM
PM
Event Title
*Response
Task
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
Between
Sunday June 17th:
7:00 PM - 9:00 PM
Monday June 18th:
10:00 AM - 12:00 PM
Tuesday June 19th:
9:30 AM - 11:30 AM
Thursday June 21st:
10:30 AM - 12:30 PM
Thursday June 21st:
4:00 PM - 6:00 PM
Week 2
Tuesday June 26th:
11:00 AM - 1:00 PM
Wednesday June 27th:
10:30 AM - 12:30 PM
Wednesday June 27th:
2:30 PM - 4:30 PM
Friday June 29th:
2:00 PM - 4:00 PM
Friday June 29th:
5:30 PM - 7:30 PM
Study Design
A1
B1
Percent Correct
Intervention
A2
B2
Training
100
90
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
1
10
S1
20
S2
30
S3
40
S4
50
S5
60
S6
70
S7
80
S8
Session number
Pre-tx
Skill
Acquisition
Immediately
Post-tx
Return to
Baseline
3-8 m
Post-tx
Case 9
Percent Correct
Training
100
90
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
1
10
S1
20
S2
30
S3
40
S4
50
S5
Session number
60
S6
70
S7
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
Memory Mistakes
(MMQ, Troyer & Rich, 2001)
30
Memory mistakes
25
**
Pre-Tx
Post-Tx immediate
Post-Tx 3-months
20
15
**
**
10
5
0
PM
Other
Confidence Ratings
(MASS)
**
Confidence rating
30
25
**
*
**
*
20
15
10
5
0
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
Percent Completed
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
5
Effort Rating
RR:
outcome
Baseline
PostIntervention
Return to
Baseline
4-months
4
5
4
3
2
1
3
2
1
0
Baseline
PostIntervention
Return to
Baseline
Very effortful
Effortful
Somewhat effortful
Not that effortful
Not effortful at all
3-months
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.
Study Design
A1
B1
Percent Correct
Intervention
A2
B2
Training
100
90
80
70
60
50
40
30
20
10
0
Stage 1
Stage 2
Stage 3
1
10
S1
20
S2
30
S3
40
S4
50
S5
60
S6
70
S7
80
S8
Session number
Pre-tx/
CONTROL
Skill
Acquisition
Post-tx
Return to
baseline
Post-tx
No iPhone (A)
With iPhone (B)
Route Efficiency
100%
80%
60%
40%
20%
0%
Control
A1
B1
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