Chapter 30

Memory deficits
BARBARA A. WILSON*
The Oliver Zangwill Centre, Princess of Wales Hospital, Cambs, UK
INTRODUCTION
Memory problems are one of the commonest conse-
quences of an insult to the brain (Hawley et al., 2004).
A number of conditions can result in impaired memory
but most people seen for rehabilitation are likely to have
sustained a traumatic brain injury (TBI), stroke, enceph-
alitis, or hypoxic brain damage. Those with progressive
conditions, particularly Alzheimer disease (AD), are in-
creasingly offered rehabilitation to help with their difficul-
ties (Clare, 2008). Although at present there is no effective
way to restore lost memory functioning, we can help
people to compensate for their problems and to learn more
efficiently. For those with very severe and widespread
cognitive difficulties it may be that the best we can do is
to modify or structure or rearrange the environment to
help them manage without a memory.
A fewof those referred for memory rehabilitation will
have the pure amnesic syndrome, the characteristics of
which are (a) a profounddifficulty inlearningand remem-
bering most kinds of new information (anterograde
amnesia), (b) difficulty remembering some information
acquiredbefore the onset of the syndrome (retrograde am-
nesia), (c) normal immediate memory as measured by for-
ward digit span, (d) normal/nearly normal learning on
implicit tasks, and (e) normal/nearly normal functioning
on other cognitive tasks (Baddeley, 2004). These patients
may well be able to compensate without too much trouble
because, apart from memory, their cognitive skills are in-
tact (see Wilson, 1999, for a report of rehabilitation for pa-
tients with the pure amnesic syndrome). The majority of
patients, however, will have more widespread problems;
in addition to their memory difficulties they are likely to
have attention and concentration difficulties, slowed
thinking and information processing, poor planning and
organizational deficits, and possibly word-finding prob-
lems. For both those with a pure amnesia and those with
additional problems, however, themaincharacteristics are:
1. Immediate memory is normal or nearly normal
2. There is difficulty remembering after a delay or
distraction
3. Patients have difficulty learning most new
information
4. Events that happened some time before the insult
are typically remembered better than those that hap-
pened a short time before.
Although some patients will have other kinds of
memory deficit such as impaired semantic memory (loss
of general knowledge) or impaired immediate memory,
these are rare and not representative of those seen for
rehabilitation. Wilson (2009) discusses the ways in which
memory can be classified and ways in which it can break
down: memory can be conceptualized in terms of time-
dependent memory, information-dependent memory,
modality-specific memory, stages in remembering, re-
call or recognition, explicit and implicit memory, and ret-
rograde or anterograde memory.
The typical person referred for memory rehabilitation
is young and most likely to be a male who has sustained
a TBI. In addition to memory, he presents with atten-
tion, planning, and organizational difficulties. He is also
likely to have emotional problems such as anxiety,
depression, and mood swings. He may have behavior
problems such as poor self-control and verbal aggres-
sion. He wants to return to work or has returned and
failed. His family needs help and, after a few months,
the young mans friends start to drift away leaving
him socially isolated. All of these problems should be
addressed in rehabilitation.
*Correspondence to: Professor Barbara A. Wilson, O.B.E., Ph.D., D.Sc., C.Psychol, F.B.Ps.S., F.med.S.C., Ac.S.S., The Oliver
Zangwill Centre, Princess of Wales Hospital, Lynn Rd., Ely, Cambs, CB6 1DN, UK. E-mail: barbara.wilson00@gmail.com
Handbook of Clinical Neurology, Vol. 110 (3rd series)
Neurological Rehabilitation
M.P. Barnes and D.C. Good, Editors
#2013 Elsevier B.V. All rights reserved
GENERAL PRINCIPLESFORHELPING
PEOPLEWITHMEMORYDEFICITS
Memory can be defined as the ability to take in, store,
and retrieve information. The taking in of information
is the encoding stage; retaining the information is the
storage stage; and accessing the information when it is
required is the retrieval stage. There are guidelines we
can follow to help with all these stages (Wilson, 2009).
To improve encoding, first simplify the information
to be remembered as it is easier to remember short words
than long words and short sentences than long sentences
even if the words and sentences are well understood by
the person trying to remember (Wilson, 1989). Second,
the person should be asked to remember only one thing
at a time so do not present three or four items, words,
names, or instructions one after the other. Third, make
sure the person has understood the information being
presented. This is usually achieved by having him or
her say it back in his or her own words. Fourth, ask
the person to link the information to something already
known; for example, when remembering a name think of
someone else with the same name or a word that rhymes
with the name. Fifth, follow the little and often rule, oth-
erwise known as distributed practice. When people are
trying to learn something they learn better when the prac-
tice trials are spread over a period of time rather than
crowded all together (Baddeley, 1992). Sixth, avoid
trial-and-error learning. In order to benefit from our
mistakes we needto be able to remember them. For people
who cannot remember their errors, the very fact of mak-
ing an incorrect response may strengthen that erroneous
response so we want to avoid mistakes occurring in the
first place (Baddeley and Wilson, 1994). Seventh, ensure
that the people who are trying to remember or learn are
not passive recipients of the information. They need to
think about the material or information and manipulate
it in some way. This is also known as levels of proces-
sing after Craik and Lockhart (1972).
Storage is the next stage; once information is regi-
stered in memory it needs to be stored there until
required. Once information is encoded and has entered
the long-termstore, rehearsal, practice, or testing can help
keep it there. One way to do this is to use the principle of
expanded rehearsal, otherwise known as spaced retrieval
(Landauer and Bjork, 1978). This involves testing the per-
son immediately after he or she has seen or heard a short
piece of newinformation such as a newtelephone number
or name or short address; then test again after a very short
delay, maybe of 2 or 3 seconds, and again after a slightly
longer delay. The retention interval is gradually built up
and can lead to better retention of information. This prin-
ciple, therefore, can help both encoding and storage.
The third stage in the memory process is to retrieve
information when it is needed. Retrieval problems are
experienced by everyone at times but are even more
likely for those with memory problems. If we can pro-
vide a hook in the form of a cue or prompt, we may
be able to help them access the correct memory. Provid-
ing the first letter of a name may well lead to the person
remembering the whole name. The principle of context
specificity should also be borne in mind. It has been
shown that recall is easier if the retrieval situation is
similar to the original learning situation (Godden and
Baddeley, 1975). So memory-impaired people may re-
member better if they are in the same room and with
the same people as they were when the learning first oc-
curred. Obviously, in most situations, we want to avoid
such context specificity so when trying to teach a person
with memory impairments new information; we should
teach that person to remember in a number of different
settings and social situations. Our aim should be to en-
courage learning in many different, everyday situations
that are likely to be encountered in daily life. Learning
should not be limited to one particular context such as
a hospital ward, classroom, or therapists office.
MODIFYINGTHEENVIRONMENT FOR
THOSEWITHSEVEREAND
WIDESPREADCOGNITIVEDEFICITS
Kapur et al. (2004) classify nonelectronic aids into envi-
ronmental and portable external aids.
Environmental aids
External aids that are not specific to a particular environ-
ment, such as notebooks, clocks, or computers, are con-
sidered later. Norman (1988) argues that knowledge
should be in the world rather than in the head. By this
he means that if we approach a door it should be obvious
whether or not we should push or pull to open the door. If
we are using a cooker it should be obvious which knob
works which burner. We should not have to remember
these things as the design should make it obvious. This
is the same principle behind the concept of environmen-
tal memory aids.
Just as people with severe physical disabilities can use
environmental control systems to enable them to open
and close doors, turn the pages of a book, answer the
telephone, and so forth, so can people with cognitive def-
icits avoid the need to use memory provided the environ-
ment is structured in a certain way. Thus, someone with
severe executive deficits may be able to function in a
structured environment, with no distractions and where
there is no need to problem-solve as the task at hand is
clear and unambiguous. Similarly, people with severe
memory problems may not be handicapped in environ-
ments where there are no demands made on memory.
Thus if doors, cupboards, drawers, and storage jars
358 B.A. WILSON
are clearly labeled, if rooms are cleared of dangerous
equipment, and if someone appears to remind or accom-
pany the memory-impaired person when it is time to go
to the dentist or to eat supper, the person may cope
reasonably well.
Kapur et al. (2004) give other examples. Items can be
left by the front door for people who forget to take
belongings with them when they leave the house; a
message can be left on the mirror in the hallway; and
a simple flow chart can be used to help people search
in likely places when they cannot find a lost belonging
(Moffat, 1989). Cars, mobile phones, and other items
may have intrinsic alarms to remind people to do things.
These can be paired with voice messages to remind
people why the alarm is ringing. Modifications can also
be made to verbal environments to avoid irritating be-
havior such as the repetition of a question, story, or joke.
It might be possible to identify a trigger or an anteced-
ent that elicits this behavior. Thus, by eliminating the
trigger one can avoid the repetitious behavior. For ex-
ample, in response to the question How are you to-
day?, one young brain-injured man would say Just
getting over my hangover. If staff simply said Good
morning, however, he replied Good morning, so
the repetitious comments about his supposed hangover
were avoided.
Environmental aids involve the immediate environ-
ment, which requires the structuring and organization
of equipment or material to reduce the load on memory,
and the wider environment, which involves the layout of
buildings, shopping centers, streets, and towns. Smart
Houses are already in existence to help disable the
disabling environment described by Wilson and Evans
(2000). Layouts of shopping centers, office buildings,
hospitals, and residential homes differ in the ease of
getting around. In some the sign posting, color coding,
alarm systems, and warning signs are excellent in reduc-
ing the chances of getting lost or falling downstairs.
We can reduce the load on memory through improve-
ments in the organization of these wider environments.
NEWLEARNINGFORMEMORY-
IMPAIREDPEOPLE
The inability to learn new information is one of the most
handicapping aspects of memory impairment and much
of rehabilitation is concerned with this issue. Mnemon-
ics, the method of vanishing cues, spaced retrieval,
and errorless learning are the main ways we can enhance
new learning in those with memory deficits. Mnemonics
are systems that enable us to remember things more eas-
ily and usually refer to internal strategies such as reciting
a rhyme to remember how many days there are in a
month or remembering the order of the colors of the
rainbow through a sentence such as Richard of York
gives battle in vain whereby the first letter of each word
is the first letter of the color (red, orange, yellow, green,
blue, indigo, violet). Although verbal and visual
mnemonic systems have been used successfully with
memory-impaired people (Wilson, 2009), not everyone
can use them. Instead of expecting memory-impaired
people to use mnemonics spontaneously, therapists
may need to employ them to help their patients achieve
faster learning for particular pieces of information, such
as names of a fewpeople or a newaddress. It may help to
use two or three strategies. New information should be
taught one step at a time, individual preferences and
styles should be acknowledged, and we should focus
on things that the person with memory impairments
wants and needs to learn and will be useful in his or
her everyday life. Finally, generalization or the transfer
to real life must be built in to the training program.
Rote rehearsal, or simply repeating material, is widely
used by the general population but it is not a particularly
good learning strategy for people with memory deficits.
We can hear or read something many times over and still
not remember it and the information may simply go in
one ear and out the other. Other strategies are better at
enhancing learning (Ehlhardt et al., 2008). One is the
method of vanishing cues (VC) whereby prompts are
provided and then gradually faded out. For example,
someone learning a new name might be expected first
to copy the whole name, then the last letter would be de-
leted; the name would be copied again and the last letter
inserted by the memory-impaired person, then the last
two letters would be deleted and the process repeated un-
til all letters were completed by the memory-impaired
person. Glisky et al. (1986) were the first to report this
method with memory-impaired people. Several studies
have since been published with both nonprogressive
patients and those with dementia (see Wilson, 2009,
for a full discussion). The results are mixed.
Another method to improve learning is spaced
retrieval, also known as expanded or expanding
rehearsal (Landauer and Bjork, 1978). This method
involves the presentation of material to be remembered,
followed by immediate testing, then a very gradual
lengthening of the retention interval. Spaced retrieval
may work because it is a form of distributed practice,
i.e., distributing the learning trials over a period of time
rather than massing them together in one block. Distri-
buted practice is known to be more effective than
massed practice (Baddeley, 1999). The method has been
used to help people with TBI, stroke, encephalitis, and
dementia.
In order to benefit from our mistakes, such as occurs
with trial-and-error learning, we need to be able to
remember our mistakes and, of course, memory-
impaired people have difficulty with this, so the very fact
of making an erroneous response can strengthen that
MEMORY DEFICITS 359
response. This is the rationale behind errorless learning,
which is a teaching technique whereby the likelihood of
mistakes during learning is minimized as far as possible.
Errors can be avoided through the provision of spoken or
written instructions or guiding someone through a par-
ticular task or modeling the steps of a procedure little
by little. There is now considerable evidence that error-
less learning is superior to trial-and-error learning for
people with severe memory deficits. In a meta-analysis
of errorless learning, Kessels and De Haan (2003) found
a large and statistically significant effect size of this kind
of learning for those with severe memory deficits. The
combination of errorless learning and spaced retrieval
would appear to be a powerful learning strategy for peo-
ple with progressive conditions in addition to those with
nonprogressive conditions (Wilson, 2009).
Ehlhardt et al. (2008) provides guidelines for teaching
new information to memory-impaired people:
1. Intervention targets should be clearly delineated;
2. Errors should be constrained;
3. Sufficient practice should be provided;
4. Practice should be distributed;
5. Multiple examples should be provided to avoid
hyperspecificity of learning and enhance
generalization;
6. Strategies to promote more effortful processing
should be used; and
7. New learning should focus on personally meaning-
ful targets.
COMPENSATORYEXTERNAL
MEMORYAIDS
External memory aids may provide cues to alert some-
one to the fact that something needs to be done at a par-
ticular time and place, or they may act as systems to store
information independent of a particular temporal or spa-
tial context. Alarms, timers, and pagers to help people to
remember to take medication or take a cake out of the
oven belong in the former category, while journals and
tape recorders belong in the latter category. Although ex-
ternal memory aids may well be the most efficient strat-
egies for memory-impaired people, it is not always easy
for them to use such aids. The use of such aids involves
memory, so the people who need them most typically
have greatest difficulty learning to use such aids.
Nonelectronic aids are more widely used than elec-
tronic ones (Evans et al., 2003) with wall calendars/wall
charts, notebooks, lists of things to do, and appointment
diaries being the top four strategies reported in the Evans
et al. (2003) study. This study, together with an earlier
one by Wilson (1991), found that certain characteristics
predicted which memory-impaired people were more
likely to use external aids, including: age (younger
people more likely than older ones); severity of deficit
(very severely memory-impaired people compensate less
well); premorbid use of aids which increased the likeli-
hood of use postmorbidly; and those without widespread
cognitive deficits were more likely to use aids than those
with such deficits. Scherer (2005) pointed out that, in or-
der to use external aids successfully, there needs to be
insight and motivation, past use of memory aids, certain
cognitive, emotional, and motivational characteristics,
demands on memory, support from family, school, or
work, and availability of appropriate aids. A number
of studies have looked at the efficacy of external aids
for memory-impaired people and these are summarized
in Wilson (2009).
In Cambridge in 2003, Kapur (reported in Wilson and
Kapur, 2009) set up the first Memory Aids Clinic in the
UK, and possibly in the world. In collaboration with
Kopelman and Dewar, Kapur set up a second clinic in
London in 2006. Wilson and Kapur (2009) provide a
description of how to set up a memory aids clinic or re-
source center including funding, staffing, the range of
aids and resources needed, finding and cataloging these
aids, and research and development.
EMOTIONALCONSEQUENCESOF
MEMORYIMPAIRMENT
Emotional problems are common after brain injury
(Fleminger et al., 2003; Horner et al., 2008). In addition
to their memory problems, many memory-impaired
people will have additional cognitive deficits such as im-
paired attention, word-finding problems, and difficulties
with planning, judgment, and reasoning, and they will also
suffer emotional disorders such as anxiety, depression,
mood swings, anger, or fear. When neuropsychological
rehabilitation programs address the cognitive, emo-
tional, and psychosocial consequences of brain injury,
patients experience less emotional distress, increased
self-esteem, and greater productivity (Prigatano et al.,
1994; Prigatano, 1999).
Treatment for emotional difficulties includes psycho-
logical support for individuals and for groups (Wilson
et al., 2009). Individual psychological support is mostly
derived from cognitive behavioral therapy (CBT) which
is now very much part of neuropsychological rehabilita-
tion programs, particularly in the UK (Gracey et al.,
2009). Tyerman and King (2004) provide suggestions
on how to adapt psychotherapy and CBT for those with
memory problems. Notes, audio- and videotapes of ses-
sions, frequent repetitions, mini reviews, telephone re-
minders to complete homework tasks, and use of
family members as co-therapists can all be used to help
circumvent the difficulties posed by impaired retention
of the therapeutic procedures.
360 B.A. WILSON
Group therapy can also be of great help in reducing
anxiety and other emotional difficulties. Memory-
impaired people often benefit from interaction with
others having similar problems. Those who fear they
are losing their sanity may have their fears allayed
through the observation of others with similar problems.
Groups can reduce anxiety and distress; they can instill
hope and show patients that they are not alone; it may
be easier to accept advice from peers than from thera-
pists, or easier to use strategies that peers are using
rather than strategies recommended by professional
staff (Evans, 2009; Malley et al., 2009).
PLANNINGAMEMORY
REHABILITATIONPROGRAM
The first step in devising a memory rehabilitation program
will be the clinical interview. We need as much background
information as possible. Have the memory problems oc-
curred as a result of an illness or infection, or have they
developed slowly over time? What problems are most trou-
blingfor the patient andthe family? What copingstrategies
are they using? What memory aids, if any, are being
employed? What does the patient and the family expect
to happen as a result of rehabilitation? Are these expecta-
tions realistic or not? Is any recovery likely to occur?
At the end of the clinical interview we may want to of-
fer patients and families some general advice on the nature
of memory, for example that some aspects will be unaf-
fected, together with information on what environmental
or situational factors might affect memory. Drugs and al-
cohol, for example, are likely to impair memory function-
ing, so too will anxiety, depression, poor sleep, andfatigue;
many people may demand too much of themselves and
need to reduce their expectations. Kapur (2008) offers tips
to help people cope. These include taking it easy, being or-
ganized, concentrating better, and using memory aids.
At some point a detailed assessment should take
place. This should include a formal neuropsychological
assessment of all cognitive abilities including memory
in order to build up a picture of a persons cognitive
strengths and weaknesses. In addition, assessment of
emotional and psychosocial functioning should be car-
ried out. Standardized tests should be complemented
with observations, interviews, and self-report measures.
This will allow a proper formulation of the situation. A
formulation uses theories and models to understand the
development and maintenance of problems and can be
used to make predictions about treatment. If other team
members, say, occupational and speech and language
therapists, have assessed the patient then a team discus-
sion and joint formulation is desirable.
The next stage in the memory rehabilitation program
is likely to be the goal-setting stage. A goal is something
the person receiving rehabilitation wants to do, some-
thing that is relevant and meaningful to him or her,
and something reflecting his or her longer-term aims.
Rehabilitation should address personally meaningful
themes, activities, settings, and interactions (Ylvisaker
and Feeney, 2000), so we should not set goals that lack
meaning for the patient such as improve performance
on a memory test. Nor should we set goals that are
vague, such as improve memory functioning, or highly
unlikely to be achievable, such as restore memory func-
tioning. Goals should be set after discussion with the
patient, family members, carers, and, if necessary, other
relevant support services. We need to know what the
families and the brain-injured person perceive as their
problems, what are their priorities and needs, and what
do they want to be able to do? Goals need to be negoti-
ated with all concerned. If patients have an unrealistic
goal such as I want my memory back to how it was be-
fore then we need to try to persuade them that this is
probably not possible but we might (for example) be able
to help them remember what they have to do each day,
and how would they feel about trying this as a goal first?
The wording of the goals should be comfortable for pa-
tients and should allow them to feel they have ownership
of the goal. Goals should follow the SMART principles.
SMART is an acronym that stands for Specific, Measur-
able, Achievable, Realistic, and Time based. An example
of a SMARTmemory goal might be for Jill to remember
to take her medication twice a day without prompts from
her carers; at the end of 6 weeks she will achieve this at
least 75 per cent of the time. This is specific; it is measur-
able as we can count how many times Jill does this before
we begin treatment; we believe it is potentially achievable;
it is a realistic step in Jills long-term goal of being inde-
pendent; and we have specified a time frame by which this
should be achieved. The first short-term goal might be to
provide a pager for Jill and see if she can respond to a test
message; this might be followed by giving her a checklist
to complete when she carries out the test message; Jills
occupational therapist will observe Jill to make sure she
completes the checklist accurately and so forth. Jill will
probably be working on other goals at the same time
and these may well be other memory goals, other cogni-
tive goals, emotional goals, leisure goals, and so on.
Selecting the best strategy to achieve the goal is
another consideration. For prospective memory tasks
such as remembering to take medication, water the
plants, or feed the dog, external aids are the method
of choice. If we wish to teach new information we need
to consider spaced retrieval, vanishing cues, rehearsal
strategies, and mnemonics, and followerrorless learning
principles.
Finally, we need to evaluate the success of our treat-
ment programs not only at a group level but also at an
MEMORY DEFICITS 361
individual level. For every patient we see, we want to
know whether or not the patient is changing and, if so,
is the change due to our intervention or would it have
happened anyway? One way to do this is through single-
case experimental designs which allow us to separate the
effects of treatment from the effects of spontaneous
recovery (Barlow et al., 2008).
CONCLUSIONS
Memory rehabilitation can help people to compensate for,
bypass, or reduce their everydayproblems andthus survive
more efficiently in their own most appropriate environ-
ments. Rehabilitation makes clinical and economic sense
and should be widely available to all those who need it.
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