Introduction

A young man with head injuries described his memory functioning in the
following words: My memory is like a tape on a tape recorder with large
chunks erased or of poor quality'. Like this young man, people often talk about
memory as though it were one particular skill or single function. We might hear
someone say, He has a photographic memory' or My memory is dreadful'. In
fact, memory comprises a number of subskills, subsystems, or subfunctions
working together. The number of these subdivisions, and their roles, depend on
the model or classification system used to interpret or explain memory
functioning. One influential model proposed by Baddeley and Hitch(1)
subdivides memory into three main categories depending on the length of time
information is stored. We can also divide memory into a number of systems for
remembering different types of information that can be labelled as semantic,
episodic, or procedural. Yet another way to conceptualize memory is by
considering the different stages involved in remembering: namely encoding,
storing, and retrieving. Other ways of regarding memory include subdividing
the kinds of remembering required into recall or recognition; or by
demonstrating that something has been remembered in terms of whether it is
explicit or implicit; or, in the case of lost memories, whether they date from
before or after a neuropsychological insult, that is whether there is retrograde or
anterograde amnesia. We shall consider all these subsystems and categories in
more detail in this chapter.
Although dementia is probably the biggest cause of organic memory
impairment, memory problems are common after many other neurological
insults including traumatic head injury, encephalitis, vascular disorders, chronic
alcohol abuse, temporal lobe epilepsy, cerebral tumour, and anoxia. Whatever
the cause, memory-impaired people tend to share certain characteristics in that
they do not lose personal identity, their immediate memory functioning is
normal or nearly normal, they have problems remembering after a delay or
distraction, they have difficulty learning new information, they usually recall
things that happened some time before the insult better than things that
happened a short time before, and they typically do not forget how to do things
they learned well before the insult such as reading, swimming, or riding a
bicycle. Of course, there are exceptions to this general pattern particularly with
certain syndromes such as semantic dementia. We shall discuss typical amnesic

patients together with some of the less common memory disorders as this
chapter progresses.
Although few people working in memory rehabilitation would claim to be able
to restore memory functioning in someone whose problems result from an
organic cause, there is nevertheless a considerable amount that can be done to
help memory-impaired people and their families or carers. We can organize the
environment to make it easier for people to cope without adequate memory
functioning; we can help memory-impaired people to learn more efficiently; we
can teach them to compensate for their impairments; and we can reduce the
anxiety or other emotional sequelae resulting from impaired cognition. Again,
these rehabilitative approaches will be discussed more fully later in this chapter.
Ways of understanding memory
Length of storage
The working memory model of Baddeley and Hitch(1) subdivides memory into
three main types depending both on time-based and conceptual differences. The
first system, sensory memory, is a brief and rather literal trace that results from
a visual, auditory, or other sensory event, probably lasting no longer than a
quarter of a second. This is the system we use to make sense of moving pictures
(visual sensory memory) or language (auditory sensory memory). Most people
with damage to this system would present with perceptual or language disorders
and we would not normally think of them as having memory problems.
The second system, working memory, is considered to have two main
components or functions. The first of these is short-term or immediate memory,
which lasts for several seconds. This period of time can be extended to several
minutes if the person is rehearsing or concentrating on the particular
information. Unlike sensory memory, information in working memory has
already undergone substantial cognitive analysis, so it is typically represented in
meaningful chunks such as words or numbers. We use this system when looking
up a new telephone number and holding on to it long enough to dial.
The second component of working memory is a central executive that can be
conceived of as an organizer, controller, or allocator of resources. This
component enables us to both drive a car and talk to our passenger at the same
time. Sufficient resources are allocated to each of these tasks, and if a
demanding or unusual situation occurs on the road we stop talking while all our
resources are required to deal with the unexpected situation.

The third system in the Baddeley and Hitch model(1) is long-term memory,
which encodes information in a reasonably robust form and can last for decades.
Although there are differences in memory for things that happened 10 minutes
ago and things that happened 10 years ago, the differences are less clear-cut
than those between sensory (quarter of a second) and immediate (a few seconds)
memory systems. Nevertheless, because long-term memory means different
things to different people, the following terms can be used to reduce ambiguity:
Delayed memory refers to memory for information presented in the last few
minutes.
Recent memory refers to knowledge accumulated in the last few days or weeks.
Remote memory refers to knowledge accumulated over several years.
All the systems described so far are connected with retrospective memory, that
is remembering information or events that have already occurred. Frequently,
however, we want to remember to do something in the future, such as take our
medicine, water the plants, or make a telephone call. The system activated for
remembering to do something is known as prospective memory. It is significant
that many of the complaints of memory-impaired people refer to failures in
prospective memory.
Type of information to be remembered
In 1972 Tulving(2) produced an influential paper distinguishing two types of
memory: semantic and episodic. Semantic memory is memory for our
knowledge about the world, for example remembering that Dublin is the capital
of Eire, or that a fox has a bushy tail. Semantic memory is also concerned with
our knowledge of social customs, the meanings of words, the colours and
textures of objects, and how things smell. Most memory-impaired patients do
not forget this kind of information, although they may have difficulty adding to
their store of semantic knowledge. Amnesic patients are often unable, for
example, to learn new words that enter the vocabulary after their neurological
insult. Thus CW, an ex-patient of mine, cannot understand the terms AIDS' or
e-mail', or mad cow disease', all of which came into widespread usage after
1985 when CW developed herpes simplex encephalitis.
Episodic memory, on the other hand, represents what most of us would think of
as memory, in that it refers to a specific episode that has been experienced and
can be recalled. Thus remembering what you ate for dinner last night, when you

last phoned your mother, or what you read a few minutes ago are all examples
of episodic memory. This system is frequently damaged in people with organic
memory impairment and episodic memory deficits are perhaps the most
noticeable characteristic of the amnesic syndrome.
A third system that operates differently from either semantic or episodic
memory is procedural memory, the system used for learning skills such as
riding a bicycle or learning to type. People get better with practice and can
demonstrate the skill even though they may not remember how they learned to
ride a bicycle or type. JC, a young amnesic patient of mine, successfully learned
to type even though he had no conscious recollection of learning. In his words,
Practical skills developed without me being aware of how this came about. I
could do things without being able to explain how'. Procedural memory is
typically normal or nearly normal in amnesic patients.
The stages involved in remembering
Typically there are three stages involved in remembering: encoding, storage,
and retrieval. Encoding refers to the registration stage or getting the information
into memory. Storage refers to the maintenance of information in the memory
store, and retrieval refers to the stage of extracting or recalling the information
when it is required. After a neurological insult to the brain each of these stages
can be affected.
The following are some suggestions for improving encoding, storage, and
retrieval:
Simplify the information you give to a memory-impaired person.
Reduce the amount of information supplied at any one time.
Ensure that there is minimal distraction.
Make sure the information is understoodby asking the person to repeat it in
his/her own words.
Encourage the person to link or associate information with material that is
already known.
Try to ensure processing at a deeper levelby encouraging the person to ask
questions.
Use the little and often' rule.

Make sure learning occurs in different contexts to avoid context specificity and
enhance generalization.
Recall and recognition
Recall and recognition are two of the main ways we remember information.
Recall involves actively finding the information to be remembered. If I asked
someone to summarize what they had read in this chapter so far they would
demonstrate this by recalling the information. In some situations, however, we
do not need to recall the information but to recognize it. Most of us at some
time have been unable to tell someone how to find a particular street but can
nevertheless take ourselves there with no trouble. We recognize which turns to
make and when but cannot actively recall the route. Most memory-impaired
people find recall harder than recognition, although both systems are usually
affected. Some people might have difficulty with both verbal and visual
information, while others might have problems in only one of these modalities.
Explicit and implicit memory
In many situations we need to consciously recall information we have received.
For example, if I asked someone where they went for their summer holidays last
year, and they could tell me, they would be using explicit memory as they could
consciously recall the information wanted. If, on the other hand, I asked
someone when and where they learned to ride a bicycle, and the steps by which
they gained expertise, they would probably find this difficult. They might
demonstrate how to ride a bicycle without much trouble, that is they would have
implicit memory of this skill, they would remember how to do it even if they
were unable to explain it with any great ease or remember when and how they
learned the skill. Like procedural memory, implicit memory is usually intact or
relatively intact in people with organic memory impairment.
Retrograde and anterograde memory
One of the questions frequently asked by relatives of memory-impaired people
is, Why can she/he remember what happened several years ago but not what
happened yesterday?' The short answer is that old memories are stored
differently in the brain from new memories. Although information acquired
before a neurological insult may be forgotten, this is usually for a specific time
periodranging from a few minutes for some head-injured people to several
decades for some people with Korsakoff' syndrome or herpes simplex viral
encephalitis. Memory loss dating from before the insult is known as retrograde

amnesia. This form of amnesia is usually less of a problem and less

handicapping for the memory-impaired person than anterograde amnesia, which
refers to memory difficulties dating from the time of the neurological insult
(although see Kapur(3) for a review of retrograde amnesia).
Conditions that give rise to memory problems, and typical presentations
A variety of brain pathologies can give rise to severe memory impairment, the
most common being the following:
degenerative disorders (particularly Alzheimer' disease and Huntington'
disease);
chronic alcohol abuse giving rise to Korsakoff' syndrome;
traumatic head injury;
temporal lobe surgery;
encephalitis;
cerebral vascular disorders (including subarachnoid haemorrhage
resulting from ruptured aneurysms);
anoxic brain damage (following, for example, myocardial infarction,
carbon monoxide poisoning, or respiratory arrest);
cerebral tumours.
These conditions are described in the chapters in Section 4.1 of this book and in
more detail in a number of publications: Kapur(4) and Lishman(5) both provide
good accounts of all these pathologies as well as less common ones.
Clients referred to rehabilitation centres for memory-therapy rehabilitation are
most likely to have sustained a severe traumatic head injury, a cerebral vascular
accident (CVA), herpes simplex encephalitis, or anoxic brain damage. It should
also be remembered that these conditions are not mutually exclusive. I once saw
a man who had a CVA while driving, thus sustaining some brain damage from
the stroke; he then crashed his car because of the CVA and sustained further
brain damage from a head injury caused by the crash; following this he stopped
breathing for a while and appeared to sustain further damage from the anoxia;
then on top of everything else a haematoma developed and the man required
surgery to remove the blood clot. Thus he sustained damage from four separate
causes. He went on to respond reasonably well to rehabilitation and, although
never able to return to work as a university lecturer, he became a secretary of his
local Headway Group (The National Head Injuries Association).

Whatever the cause of the organic memory impairment, certain characteristics

tend to be seen in survivors. People with a classic amnesic syndrome show an
anterograde amnesia, that is they have great difficulty learning and
remembering most kinds of new information. Immediate memory, however, is
normal when this is assessed by forward digit span or the recency effect in free
recall. There is usually a period of retrograde amnesia. This gap or period of
retrograde amnesia is very variable in length and may range from a few minutes
to decades. Previously acquired semantic knowledge and implicit memory
(remembering without awareness or conscious recollection) are typically intact
in amnesic subjects. Other cognitive skills, apart from memory, are normal or
nearly normal. As the majority of patients with severe memory disorders present
with additional cognitive problems such as attention deficits, word-finding
problems, or slowed information processing, those with a classic amnesic
syndrome are relatively rare.
Nevertheless, people with a pure' amnesic syndrome and people with more
widespread cognitive deficits tend to share certain characteristics. In both cases
immediate memory is reasonably normal; there is difficulty remembering after a
delay or distraction; new learning is difficult, and there is a tendency to
remember things that happened a long time before the accident or illness better
than things that happened a short time before. People with organic amnesia
never seem to lose memory for personal identity, unlike those with a functional
amnesia following, say, an emotional trauma. Despite the rather exaggerated
interest in functional amnesia by the media, organic amnesia is far more
commonly encountered in clinical practice. In some cases it is not easy to
distinguish between the two, and indeed some people have memory problems
resulting from both brain injury and from an overlying or functional memory
disorder, possibly caused by a need for sympathy or some other secondary gain.
Kopelman(6) believes there is a continuum between totally organic amnesia and
totally functional problems rather than two orthogonal dimensions.
Less common manifestations of memory disorders
Despite the typical picture of organic memory impairment described above,
other manifestations are possible and are encountered every now and again.
Returning for a moment to the working memory model of Baddeley and
Hitch(1) referred to earlier, one can find patients with deficits in the short-term
or immediate (that is to say a few seconds) memory system. Baddeley and Hitch
subdivide this system into several slave' systems that aid the central executive

in its role as co-ordinator of temporary storage systems. Two of these slave

systems have been studied in detail. One is the phonological loop that utilizes
subvocal speech and is involved in many short-term verbal memory tasks. The
second system is the visuospatial sketchpada temporary system used in
creating and manipulating visual images. Patients with phonological loop or
verbal short-term memory difficulties have been reported,(7) and visuospatial
sketchpad or visual short-term memory deficits have also been reported.(8)
Wilson et al.(9) describe a sculptress with an autoimmune disorder, systemic
lupus erythematosus, that caused her to have an impaired visual short-term
memory (VSTM) together with image generation problems. This dramatically
affected her sculpting style; prior to the episode causing the VSTM difficulties
she produced sculptures that were full of detail, while afterwards the sculptures
were abstract and completely lacking in detail. Her style changed because she
could not hold images in her mind to see where the details should go. If she
tried looking in a mirror or using a model she lost' the visual memory in the
brief period between looking at the model and looking at the material with
which she was working.
Patients with semantic memory impairments are another group of people who
show yet another different pattern of characteristics. Semantic memory is the
system we use to store knowledge about the world. Not only knowledge such as
the meaning of the word happy' or the name of the world' largest ocean, but
knowledge about what things look like, sound like, smell like, or feel like and
knowledge about social customs such as when to shake hands. Damage to the
semantic memory store (or impaired access to this store) may be caused by
brain injury. Warrington,(10) for example, suggests that visual object agnosia
(the failure to recognize objects despite adequate eyesight, language, and
naming) is due to a deficit of the visual semantic memory system. Furthermore,
Warrington and Shallice(11) demonstrated that there are category-specific
deficits so that some patients lose the ability to recognize living things but are
still able to recognize non-living things. Hillis and Caramazza(12) describe the
reverse, that is subjects who show greater knowledge of living things than of
manufactured objects. Patients with semantic memory deficits are likely to have
problems recognizing objects in the real world, problems expressing
themselves, and may be considered intellectually disabled because of the errors
they make.

In recent years there has been considerable interest in the syndrome known as
semantic dementia, a term coined by Snowden et al.,(13) and studied in some
detail by Hodges and Patterson.(14) The essential characteristics of semantic
dementia are as follows:
selective impairment of semantic memory causing severe anomia, impaired
single-word comprehension (both spoken and written), reduced generation of
exemplars on category-fluency tests, and an impoverished fund of general
knowledge;
relative sparing of other components of speech production, notably syntax and
phonology;
unimpaired perceptual skills and non-verbal problem-solving abilities;
relatively well-preserved episodic memory.
Patients with semantic dementia show a progressive deterioration of the
semantic memory store associated with damage to the temporal neocortex.
However, semantic memory impairments may also be seen in patients with nonprogressive conditions. Wilson(15) describes four patients, two of whom had
sustained a severe head injury and two with herpes simplex viral encephalitis
(HSVE). In many ways Wilson' patients were similar to those reported by
Hodges and Patterson,(14) although younger and with more serious episodic
memory deficits (particularly the two patients with HSVE).
In this section we have looked at a few of the more atypical memory disorders.
For those readers interested in retrograde without anterograde amnesia see
Kapur,(3) and for those wanting to know how post-traumatic amnesia differs
from the amnesic syndrome and from chronic memory impairment see Wilson
et al.(16)
Management and remediation of memory difficulties
Although there is no known cure for memory impairment there are a number of
ways we can help memory-impaired people and their families or carers. The
main methods are: environmental adaptations, improving learning,
compensating for memory problems, and managing anxiety or other emotional
sequelae resulting from impaired cognition.
Environmental adaptations

One of the simplest ways to help people with memory impairment is to arrange
the environment so that they rely less on memory. Examples include using
written labels or drawings for cupboards in the kitchen or bedroom as reminders
of where things are kept; positioning objects so that they cannot be missed or
forgotten (for instance tying a front-door key to a belt); or painting the toilet
door a distinctive colour so that it is easier to find. Sometimes changing the
wording of our questions or comments can reduce problems. For example, CW,
a former musician, became very densely amnesic following encephalitis. He
frequently thinks he has just woken up and says, This is the first time I've been
awake. I don't remember you coming into this room but now I'm awake' (or
words to that effect). Sympathizing with him, or offering explanations, seems to
increase his agitation and causes escalation of the number of repetitions he
makes about awakening. One partial solution is to distract him by introducing
another topic of conversation or asking him a question about music. Such a ploy
can also be viewed as an environmental adaptation, although in this case it is the
verbal rather than the physical environment that is being modified.
For people with severe intellectual deficits, or progressive deterioration, or
extremely dense amnesia, environmental adaptations may be the best we can
offer to enable them and their families or carers to cope, and to reduce some of
the frustration and confusion associated with their conditions.
Improving learning in memory-impaired people
One of the greatest handicaps for memory-impaired people is their inability to
learn new information. In recent years a number of studies have been carried out
to investigate errorless learning in memory rehabilitation. Errorless learning is a
teaching strategy whereby people are prevented, as far as possible, from making
mistakes while they are learning a new skill or acquiring new information.
Instead of teaching by demonstration, which may involve the learner in trial and
error, the experimenter or teacher presents the correct information or procedure
in ways that minimize the possibility of erroneous responses.
There are two theoretical backgrounds influencing errorless learning work with
cognitively impaired people. The first is errorless discrimination learning from
behavioural psychology, first developed by Terrace(17) in his work with
pigeons, and later used with mentally retarded (learning disabled) people.(18)
The second influence is from studies of implicit learning in amnesic subjects,
(19) showing that people with amnesia can learn some information normally

although they may have no conscious recollection (explicit recall) that they
have previously engaged in the task.
Building on these two strands of research we posed the question, Do amnesic
subjects learn better when prevented from making errors during the learning
process?' In one group study and several single-case studies(20) it was
demonstrated that people with severe memory disorders learn more successfully
with an errorless learning strategy. Others have adapted this strategy with nonprogressive amnesic patients,(21) and recently we have used errorless learning
procedures with patients who have Alzheimer' disease.(22) All patients
benefited to a greater or lesser degree and were able to learn some useful
everyday information.
Compensating for memory loss
Much of the work in memory rehabilitation involves teaching people to
compensate for their impairments by employing aids such as diaries, tape
recorders, organizers, computers, and other similar items. These external
memory aids are probably the most useful devices for helping memory-impaired
people and they are likely to be used more by them in the long run.(23) Despite
their value, it is not always easy to persuade patients to use compensatory
strategies. Some feel it is cheating and believe they should not rely on such aids,
others feel such devices will reduce their chances of natural recovery occurring,
and others simply forget to use them or may use them in a disorganized manner.
After all, remembering to use a compensation is in itself a memory task. Despite
these difficulties, some memory-impaired people use compensatory aids and
strategies very efficiently. Kime et al.(24) describe a young amnesic woman
who was able to get back to paid employment once she had been taught to use a
comprehensive system of external aids. Wilson et al.(25) describe the 10-year
natural history of a compensatory memory system devised by a young man who
became amnesic following the rupture of a posterior cerebral artery aneurysm.
Using results from a long-term follow-up study, Wilson and Watson(23) made
some predictions as to which people are more likely to use compensatory aids
effectively and which are not. Age, absence of additional cognitive deficits, and
scoring above floor level on a test of everyday memory were all predictors of
independence and the use of aids.
Other work looking at how to help memory-impaired people compensate
involves the use or modification of new technology.(26) One fairly recent
development that appears to help people with a wide range of conditions and

degrees of memory impairment is Neuro-Page,(27) which is a simple and

portable paging system with a screen that can be attached to a belt. It utilizes an
arrangement of microcomputers linked to a conventional computer memory
and, by telephone, to a paging company to produce a programmable messaging
system. The scheduling of reminders or cues for each individual is entered into
the computer and from then on no further human interfacing is required. On the
appropriate date and time NeuroPage accesses the user' data files and
transmits the appropriate information by modem to a terminal where the
reminder is converted and transmitted to the receiver corresponding to the
particular user. The reminder is graphically displayed on the screen of the
receiver. NeuroPage is easy to use and avoids many of the problems inherent
in other external aids. It is highly portable, has an audible alarm that can be
adapted to vibrate if required, together with an accompanying explanatory
message, and, rather than being embarrassing to use, it conveys a certain
amount of prestige. In a pilot study,(28) the average number of target
behaviours achieved by 15 people during a 2- to 6-week baseline was 37 per
cent. Once the pager was provided (for a 12-week period) the average number
of targets achieved rose to over 85 per cent. Preliminary analysis of the first 38
clients in a larger study of 200 people, many of whom have very severe
impairments, suggests similar (if less dramatic) results, ranging from 50 per
cent of targets achieved in the baseline to 77 per cent in the treatment stage.
Managing anxiety and other emotional sequelae resulting from impaired
cognition
Anxiety and depression are frequently seen in memory-impaired people.
Kopelman and Crawford(29) found depression in over 40 per cent of 200
consecutive referrals to a memory clinic. Evans and Wilson(30) found anxiety
to be common in attenders of a weekly memory group. Dealing with these
emotional problems should be an integral part of memory rehabilitation.
Obviously, listening, trying to understand, and providing information are key
factors in encouraging families to cope with their difficulties. Wearing(31)
provides a helpful reference on the problems faced by families of memoryimpaired people, and makes suggestions as to what can be done to help.
Providing information or explanations is one very simple and therapeutic
strategy that can help reduce the fear and anxiety accompanying memory
impairment. Written information is best, as most people, whether memory
impaired or not, are unlikely to have good recall of information at times of

stress. Memory Problems After Head Injury,(32) written for the National Head
Injuries Association; Managing Your Memory,(33) and Coping With Memory
Problem(34) are all useful publications to have available for patients and their
relatives.
In addition to providing information, it may be necessary to offer therapy for
anxiety and depression. Relaxation therapy can be helpful in reducing anxiety,
even if memory problems are severe enough to prevent a participant from
remembering the actual therapy sessions. Depression, too, may exacerbate
difficulties in people with organic memory impairment. It is possible that
cognitive behavioural therapy approaches such as those employed by Beck(35)
might be appropriate for those with depression associated with organic memory
impairment, although no studies appear to have been reported. Psycho-therapy,
on the other hand, is a well-established intervention for patients with
neurological damage. Prigatano et al.(36) firmly believe in group and individual
psychotherapy with brain-injured clients. Jackson and Gouvier(37) provide
descriptions and guidelines for group psychotherapy with brain-injured adults
and their families.
Other groups for memory-impaired people can be useful in reducing social
isolation, which is also common in people with memory problems.(31) Wilson
and Moffat(38) describe several kinds of groups for patients. Moffat(39) reports
on a relative' memory group for people with dementia, and Wearing(31) offers
suggestions for setting up self -help groups. Evans and Wilson(30) point out the
social value of memory groups as well as their effect in reducing anxiety.
Conclusions
This chapter has emphasized that memory should be regarded as a
multifunctional cognitive system that can be understood in a number of ways.
We can consider the length of time information is stored, the type of
information being stored, the stages involved in remembering, whether
information is recalled or recognized, or whether memories date from before or
after neurological insult.
The chapter has described a number of conditions that can give rise to organic
memory impairment, the most common of which are degenerative conditions,
Korsakoff' syndrome, traumatic head injury, temporal lobe surgery, encephalitis,
anoxic brain damage, and cerebral tumours.

Most memory-impaired people have difficulty in learning and remembering

new information; they have a normal or nearly normal immediate memory span
but have problems remembering after a delay or distraction, and they usually
have a period of retrograde amnesia that may range from minutes to decades.
Less common memory disorders include semantic memory impairment and
immediate verbal or visuospatial deficits.
Although restoration of memory functioning is unlikely to occur in the majority
of people whose memory impairments follow neurological insult, there is,
nevertheless, much that can be done to reduce the impact of disabling and
handicapping memory problems and foster understanding of the issues
involved. These include environmental modifications that can enable very
severely impaired people to cope in their daily lives despite the lack of adequate
memory functioning, the employment of errorless learning principles to
improve the learning ability of memory-impaired people, teaching how to use
external memory aids to help compensate for memory difficulties, and dealing
with emotional sequelae such as anxiety and depression, which are often
associated with organic memory impairment.