Procedural Memory and Emotional Attachment in Alzheimer Disease: Implications for Meaningful and Engaging Activities

David E. Vance, PhD MGS MS BS; Barbara S. Moore, DSN RN NHA; Tom Struzick, MSW/ACSW LCSW MEd


J Neurosci Nurs. 2008;40(2):96-102. 

In This Article

Procedural and Emotional Religious Activity Therapy

According to the Progressively Lowered Stress Threshold Model, agitation and related cognitive problems in adults with AD emerge when environmental stimuli exceed their level of tolerance (Hall & Buckwalter, 1987; Stolley, Koenig, & Buckwalter, 1999). In other words, adults will become agitated when the activities in which they are engaging exceed their cognitive abilities. For example, a 1,000-piece puzzle may be too difficult for those in the early stages of the disease, but a 100-piece puzzle may be just challenging enough without being overwhelming. Finding activities that match patients' cognitive ability levels should result in reduced agitation and more adaptive behavior. Studies indicate that spiritual and religious activities also can assuage agitation and improve quality of life in adults with AD (Abramowitz, 1993; Khouzam, Smith, & Bissett, 1994).

PERAT builds on the above model and posits that activities emphasizing procedural memory and emotional attachment are fundamental requirements to create or target activities that will be salient, meaningful, and engaging for adults with AD. In fact, such carefully targeted activities have the potential for improving quality of life and ameliorating behavioral difficulties. Furthermore, PERAT recognizes religious activities that are meaningful and emotionally salient, especially those that have been repeated over the course of one's life, have the greatest probability of being engaging for adults with AD. This engagement rests on the fact that such religious activities require cognitive and emotional components that remain robust in adults with this condition.

During the early stages of AD, short-term memory is one of the first cognitive abilities to be impaired, although long-term memory still can be accessed to facilitate participation in religious activities (Heyman et al., 1999; Kuzis et al., 1999; Nebes, 1992). This pattern of memory loss is obvious as one observes that people with AD may not be able to tell you with whom they were just talking (i.e., short-term memory), but they can recall in vivid detail precious childhood memories (i.e., long-term memory). It is the dependence on such long-term memory on which much of PERAT relies.

Religious and spiritual activities assimilated and engrained early in life (including the associated behaviors and emotional attachments), paired with lifelong devotion and practice, suggest such activities will hold salience, even during the later stages of the disease. Studying religious texts may be difficult for those with compromised short-term memory and executive ability; however, recalling familiar stories from childhood (e.g., Noah's Ark) is more likely to be appreciated. A simple story time including the telling of such an event would facilitate long-term memory and be engaging.

Procedural memory is more robust against the neurological insults of AD than explicit memory (Farina et al., 2002; Nebes, 1992). Tasks that do not rely on conscious recollection are more likely to be performed effortlessly. Religious and spiritual activities that are well-rehearsed call upon procedural memory and are more likely to be engaged in with success. Singing a familiar hymn, clutching a religious icon (e.g., prayer beads, a Star of David, the Koran, or a cross), or modeling a religious gesture (e.g., facing and praying to Mecca) all are examples of such tasks. In fact, due to the overrehearsed nature of some of these behaviors, they can be practiced into the later stages of this disease.


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