New Technologies for Improving New Technologies for Improving MemoryMemory

Stella Karantzoulis, Ph.D.Clinical NeuropsychologistAssistant Professor of NeurologyAssistant Professor of Neurology

New York University School of MedicineNew York University School of Medicine

December 2, 2011

Outline

• Cognitive Intervention Goals• Strategies: Compensatory, Restorative• Cognitive Intervention in Epilepsy, Examples• New Technologies• Our Memory Training Study• Key Points

Has This Happened to You?

Goals of Cognitive Training Programs

• To enable people to function as independently as possible in their own most appropriate environment

• No standardized cognitive training program for use among individuals with epilepsy

If only it were that easy….

Cognitive Intervention Strategies

Compensatory Strategies– Learn to 'work around' one’s cognitive deficits– Emphasizes the use of strategies (e.g., visual imagery,

organization) & external (e.g., electronic memory aids) strategies

Restorative Strategies– ‘Working on’ the actual problem– To enhance functioning in specific cognitive domains, with the

goal of returning cognitive function to premorbid levels

Compensatory Cognitive Strategies

• Combination of compensatory and restorative may be most effective for improving memory among individuals with epilepsy

• Restorative strategies may be better choice for patients with mild-to-moderate Alzheimer’s disease than compensatory approaches

Factors to Consider

• Age• Educational history• General intellectual functioning• Cognitive strengths and weaknesses (attention skills)• Diagnosis (time since injury)• Medical history • Psychological factors• Aids used premorbidly• Social support system

External Memory Aids

• One of the most efficient ways to compensate

• Most people without neurological memory deficits use aids

Memory Aids: People with Acquired Brain Injury

• Wall calendar 72%• Notebook 64%• Lists 63%• Appointment diary 54%• Asking others 49% • Mental retracing 48%• Alarm clock 41%• Notes in special places 34%• Repetitive Practice 30%

• Writing on hand 24%• Watch with date 18%• Daily routine 18%• Personal organizer 17%• Journal 16%• Daily timetable 16%

Evans et al. JINS, 9, 925-935. 2003.

Current age; time since injury; number of aids used premorbidly,; measure of attentional functioning best predicted use of memory aids

More is Not Always Better

Internal Strategies: Mnemonics

• Systems that enable us to remember things more easily

• Mainly refers to internal strategies that are consciously learned and require considerable effort to put into practice

First-Letter Mnemonics

Memory tools

Attention

Writing

Organization

Repetition

Meaningfulness

Repetition

• At first, repeat the information over short intervals

• Eventually, repeat the information over long intervals

Spaced Repetition

Meaningfulness

• Think of what something means• Visualize a picture

– Image-name method

• Associate it with something else– make a meaningful connection or relationship

between things

Meaningfulness

Preview: preview the material

Question: ask key questions about the text

Read: read the material carefully to answer questions

State: state the answers

Test: test regularly for retention of the information

Restorative Approaches: Prevent Errors

• Errorless learning– prevent mistakes – avoid trial and error– provide written instructions, guide someone through

a task, model the steps of a procedure

•Two groups of post-surgical patients (N = 55 treatment group, N = 57 controls, 27-46 yrs), mixed left and right cases•Broad training program - compensation + psychoeducation, counseling, occupational therapy sessions•Short program, Mean = 29 days•78% seizure-free postoperatively, seizure outcome did not affect scores on memory tests•Significant positive effect on verbal learning and memory, greater for right-sided surgical cases

Cognitive Interventions: Temporal Lobe Epilepsy Surgery

Helmstaedter et al. Epilepsy & Behavior. 12, 402-409 (2008).

Memory Rehabilitation + Brain Training: Left Temporal Lobe Epilepsy Surgery

• 20 Left TLE patients (25-37 yrs); 10 pre-op; 10 post-op (3-6 months); 22 Healthy Controls

• 10 training sessions + 4 booster sessions• 4 hours over three sessions• psychoeduation + use of external aids + memory

strategies + homework• computer training for half of sample; 40 sessions of

Lumosity, at least 15 mins/day – memory, concentration, mental flexibility, processing speed

• Subjective ratings of memory skills, moodKoorenhof et al. Seizure 21, 178-182 (2012) .

Memory Rehabilitation + Brain Training: Left Temporal Lobe Epilepsy Surgery

• Improvements in verbal memory for both groups• Pre-operative training not more effective than post-

operative training• LTLE group showed significant reduction in memory

nuisance ratings and overall mood ratings• Computer training associated with gains in verbal

learning; no effect on verbal recall

Koorenhof et al. Seizure 21, 178-182 (2012) .

Sample case: Mild to Moderate AD

• Individual having difficulty recalling names of individuals in his social club

• Decreased confidence, at risk for social isolation

• Goal: learn names of 11 individuals • Training at home with photos, later

generalized to club

Clare et al. Neurocase, 5, 37ff. 1999

• Identified individual item for training: Caroline• Discussed semantic association: Caroline with the

curl on her forehead• Learned with vanishing cues

– CAROLIN_– CAROLI_ _– CAROL_ _ _– etc.

• Consolidated using spaced retrieval– Tested after 30s, 1m, 2m, 5m, 10m

• Tested with all face/name pairs

Clare et al. Neurocase, 5, 37ff. 1999.

Baseline Intervention Post-Intervention

Clare et al. Neurocase, 5, 37ff. 1999.

Computer Technology

Improvement in Memory with Adaptive Plasticity-based Cognitive Training

The IMPACT Study• Largest clinical trial to examine a computerized cognitive

training program• Multi-center: Mayo Clinic, USC, and Posit Science

• N = 242 Computer Training • N = 245 Auditory Training • Age M = 75 yrs.; Education M = 16 yrs.; Male: 47%• 8-week program

Smith et. al., J. of Amer. Ger. Soc. 2009

The IMPACT Study: Results

• Improvement on the exercise tasks• Improvements “generalized” (or extended) to

multiple standard memory tests• People who used the program reported

positive changes in their everyday lives– remembering a shopping list – hearing conversations in noisy restaurants more

clearly– feeling more self-confident

Smith et. al., J. of Amer. Ger. Soc. 2009

Key Points

• Evidence to support use of cognitive interventions in epilepsy

• Program goals can vary – no standardized programs yet available

• Several ways to compensate for memory difficulties – some require considerable effort and practice

• Combination of compensatory and restorative approaches may be best for epilepsy patients

• Goals should be appropriate• Not a one-size fits all approach

Any Questions?