Strategies for Memory Improvement in Older Adults

Jane S. Saczynski, PhD; George W. Rebok, PhD

Disclosures

Topics in Advanced Practice Nursing eJournal. 2004;4(1) 

In This Article

Management/Interventions

The following treatment plan is based on a 3-session model. This 3-session approach is based on formal intervention studies that have typically been implemented in group settings or in individualized sessions.[15,16,17,18,19,20,21] The 3-session model is modified to fit the medical visit setting. It is designed to be implemented in a shorter time period than a typical memory intervention (approximately 5 sessions), with an emphasis on practice outside of the one-to-one sessions. Group and individual memory training has been successful at improving memory performance in adults with maintenance observed over 3-month to 1-year follow-up periods.[16,22] With the additional practice built into the 3-session model presented here, we believe that extended maintenance of memory gains may be observed.

The APN can alter the treatment plan according to the specific needs of the patient, the number of sessions allotted, or the length of each session. In order to maximize the effectiveness of the intervention, at least 30 minutes should be allotted for the first session and 45 minutes for each of the 2 additional sessions, with practice at home emphasized. In fact, practice with the strategies is the most important component and should be the focus of a significant amount of the session time.

Table 1 presents an outline of the goals for each session and strategies to be presented during the 3 sessions. During the initial session, the memory impairment or worry will be assessed. Although memory strategies can be tailored to the specific memory problems of the patient, there are 2 general strategies, visualization and association, that are involved in all memory tasks and that should be presented to patients during the initial session. Environmental, physical, and emotional factors that may impact memory functioning and the use of external memory aids will also be described and discussed during the initial session. Strategies specific to the patient will be described in session 2 and practiced in the third session.

Session 1: Assessment and Discussion

The first session is essentially an assessment session with a brief discussion of external factors that may affect memory performance as well as the introduction of 2 memory strategies, visualization and association. The more formal intervention will begin in the second and third sessions. During the initial session, the APN will gain an overall picture of the emotional, physical, and mental state of the patient. There are various factors, unrelated to memory decline, that may affect memory performance.[36] These include sleep, medications, physical health, and exercise. These factors should be discussed briefly with all patients in an attempt to draw attention to the many systems affecting memory performance and to potentially highlight areas of vulnerability. Although these factors may not be entirely responsible for memory impairments, they may be significant contributors.

Sleep patterns can affect memory performance via alertness and concentration.[37] Too little sleep can lead to inattention when initially encoding the information to be remembered or the inability to concentrate during retrieval. It is important to communicate to patients that if they never heard the information in the first place, there is little chance that they will remember it when it is needed. Over-the-counter and prescription medications can also affect memory performance.[38] Finally, physical health is related to memory performance across the lifespan, but particularly in the second half of life. Research shows that there is also a positive relationship between physical activity and memory performance where greater physical activity is associated with better memory. Aerobic exercises such as walking, swimming, bicycling, or jogging for at least 15 minutes on 3 or more occasions a week particularly benefit cognitive performance, regardless of age.[39,40]

Visualization and association. After briefly discussing lifestyle, factors related to memory strategies common to all memory tasks, visualization and association, should be described to the patient. These global strategies are important to consider when approaching any memory situation and can be combined with task-specific strategies for optimal performance. Global and task-specific strategies are presented in Table 1 . Visualization is the process of seeing in the "mind's eye" the thing that you are trying to remember. Visualization puts meaning to the object to be remembered and allows the creation of a mental picture that helps with later recall. Again, one of the most important components of memory is being sure to hear or understand what needs to be remembered; visualizing an object ensures acknowledgement and creates a visual understanding of the object. Visualization is an important component to all of the task-specific strategies, so it should be mastered before moving on.

As with most mnemonics, visualization will differ by individual; therefore, there is not really one correct or incorrect way to use the strategy. Rather, there are less or more effective ways for each individual to incorporate the strategy into memory tasks. Table 2 presents a number of practice examples for visualization. Practice is what is most important to emphasize to the patient. Visualization is a powerful strategy but a difficult task to master for many people, and thus may require a significant amount of practice. If the patient is having a hard time visualizing, the APN can encourage visualization by asking the patient to give details about places that are very familiar to him/her, such as his/her home. Useful questions include, "How many windows are in the home you live in right now?" "How about the one you grew up in?" These questions require the patient to do a visual walk-through of their home. Once they have answered, ask how they counted the windows -- walking from room to room in their mind. If they can do this, then they have just visualized.

Association is the second strategy modeled for the patient. Association is the incorporation of the object to be remembered into an individual's current framework or with another item to be remembered. The strategy of association requires the individual to combine 2 or more things that he/she wants to remember in a meaningful way. For example, when reading a story or watching a movie, think of how it is similar to and different from others that may have been experienced.

Practice with association may involve simply picking 2 words, from the newspaper, a book being read, or from a grocery list, and thinking of a way to combine them visually. Associations do not need to make sense. In fact, some of the most effective associations are unintuitive and thus easier to recall. For example, to remember the words "shoe" and "tree," one can picture a shoe hanging by its lace from a tree limb. This visual association is not a scene one would typically experience, but one would be likely to remember it later, since it is so strange. Motion can also help with associations. Picturing the shoe blowing in the wind on the tree limb creates a rich memory full of movement.

Description of, and practice with, visualization and association in the first session may have to continue into the second session, but it is important to at least introduce the 2 strategies in the first session. Emphasize the importance of practicing the strategies at home prior to the next session. Additionally, it is important to explain to patients that strategies are difficult to use at first, and they may actually see a decrease in their memory performance when first using these strategies. Practice is an important component to mastering these strategies and achieving optimal performance.

External memory aids. In addition to the mnemonic strategies modeled and practiced, a brief discussion of external memory aids that can be used in combination with mnemonic strategies should conclude the first session. External memory aids include habits such as writing notes to remember to do something or using a calendar to keep appointments and dates. External memory aids can be used in conjunction with the mnemonics for maximal memory performance. As always, it is important to stress practice with the external and mnemonic memory strategies.

Session 2: Review and Task-Specific Strategies

The second session will consist of a review of the 2 strategies covered in the first session, as well as task-specific strategy instruction for individualized memory concerns raised by the patient. Table 2 describes task-specific memory strategies and gives examples of how and when to use and practice these strategies. The case vignettes below also provide a few typical memory problems and a description of how to approach treatment.

Briefly, there are 5 main mnemonic strategies included in Table 2 . Visualization and association are strategies applicable to all memory tasks. Method of Loci (the location method) is useful for list learning tasks. Name/face association can be utilized in social or business situations when names need to be remembered. Finally, the chunking strategy can be used for remembering numbers. Each of these is described in detail.

The Method of Loci. This is a very powerful mnemonic that relies heavily on visualization and uses a route so familiar to the patient that it is almost automatic, along which items to be remembered are "placed". The first task when learning the Method of Loci is to choose a route familiar to the patient and select areas on the route to place objects. Any travel or time-of-day routine that is very familiar can be the Method of Loci route. For example, the route to the grocery store or somewhere the patient goes often, their morning routine, or their routine when they come home in the evening can all be used.

Using the morning routine, the patient would describe his/her morning routine and choose places to locate items. For instance: turning off the alarm (alarm clock is a place to put an item to be remembered); turning on the coffee maker (coffee maker is a place to put an item); turning on the sink to brush teeth (sink is a place to put an item); the patient should visualize him/herself going through the routine and be able to describe where the objects will be placed. Start with 5-7 locations (more if the patient seems able, fewer if this is straining) and walk through the route a number of times, having the patient name the locations where items will be placed. It is important that the APN not select the locations for the patient. Personal meaningfulness is what makes this strategy so effective, and only the patient can identify meaningful locations. The APN can ask the patient to describe his/her routine and suggest locations that seem appropriate. However, the patient should ultimately choose the locations and be able to name them all in sequence.

Once the route is learned to the point of automation, choose words and walk the patient through the route, placing the items on the route in the locations chosen by the patient. Visual associations between the locations and items should be created by the patient. The combination of visualization and association will solidify the object in the patient's mind. The APN may have to assist the patient in forming rich visualization associations, especially when there is no logical connection between the item and location. It is useful for the APN to remember that often the most effective associations are either illogical ones or those that involve movement.

Name/face association. Loss of memory for names and faces is one of the most common memory complaints from adults. The name/face association strategy involves associating a prominent feature of a person's face (the shape, a large nose, hair, eyes, smile, etc.) with their name. The name/face association strategy is effective for use in both social and business situations. This strategy can be practiced by taking a magazine and picking out people in the pictures whose names are mentioned in captions. The patient can practice associating names and faces with any picture. There are many variations of this strategy. Associations with names can also be made to people the patient is familiar with, such as family members or celebrities. For instance, if the name of the person is the same as the name of the patient's sister-in-law, the patient would associate a feature of the new face with one similar to his/her sister-in-law.

Chunking. The chunking strategy is used to remember long strings of numbers by breaking them up into smaller, more manageable "chunks." The chunking method relies heavily on association, as the smaller chunks of information are remembered by making them meaningful to the patient. For instance, if the patient wants to remember a phone number such as 558-555-3469, it could be broken up into 5 chunks of 2 numbers each. Each chunk is then given meaning by associating it with something in the patient's life, such as an event that happened that year or the significance of a year of life. For example, for the chunks 55, 85, 55, 34, and 69: the patient turned 55 this year, 85 is the age of the patient's favorite aunt, 1955 was the year the patient's younger brother was born, 34 was the age the patient was when his/her youngest child started kindergarten, and 1969 was the year when an astronaut first walked on the moon. By recalling these meaningful facts associated with numbers, the patient can remember a 10-digit phone number. It is often initially difficult for the patient to create meaningful associations with the number chunks. It is important to encourage the patient, as this is what will solidify the numbers in the patient's mind. Larger chunks can be effective for learning even longer strings of numbers. If possible, encourage the patient to create chunks of 3 or 4 numbers. The fewer chunks, the less of a load on the patient's memory system.

Session 3: Review, Practice, and Troubleshooting

The third session should be scheduled within a week of the second session. Although this may be the last formal session with the APN, practice outside of the office visits will be important in continuing with memory improvement. Session 3 will involve review and practice of the strategies presented in the first 2 sessions. Additionally, the APN should attempt to integrate the use of the 2 general memory strategies with the task-specific strategy. This involves pointing out to the patient how visualization and association are involved in the task-specific memory strategies and encouraging rich visualizations and movement-filled associations. The third session may also involve troubleshooting with any of the 3 strategies presented or the integration of the 3 strategies.

The most important component of session 3 is to be sure the participant can continue to practice at home without the prompt of the APN. This will involve discussing how to obtain practice lists or name/face combinations and how to integrate practice into daily life. If possible, scheduling a follow-up session in 1 or 2 months may be helpful to answer any questions and refresh strategies.

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