Fortunately, a variety of pharmacological and ... internal (e.g., mnemonics and visual imagery) to external (e.g., electronic: PDAs and paging systems ...
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Therapy Techniques for Mild Cognitive Impairment Michelle S. Bourgeois The Ohio State University Columbus, OH Disclosure: Michelle S. Bourgeois is employed by the Ohio State University, which supports the program described in this article. There is increasing concern among people in late middle age about cognitive changes they experience for everyday memory tasks. They are especially fearful that these memory lapses signal the beginning stages of Alzheimer’s disease (AD). For some, the diagnosis of mild cognitive impairment (MCI) represents a transitional state between normal aging and early dementia that precipitates a search for therapies to prevent conversion to AD. The purpose of this article is to describe a continuum of therapeutic approaches for the cognitive challenges experienced by persons with MCI, discuss the growing evidence for promising techniques to address these challenges, and outline a university-based memory strategies intervention program that incorporates several effective strategies. Cognitive changes, including memory retrieval problems and slower speed of information processing, begin to be evident in the language of persons in late middle age (48– 62 years; Hummert, Garstka, & Shaner, 1995). Fear of becoming old and losing competence can affect one’s self-perception, increase anxiety, affect performance on objective memory measures, and lead to a diagnosis of mild cognitive impairment (MCI; Petersen et al., 1999). Diagnostic uncertainty early in the disease process often makes it difficult to identify the transition from an asymptomatic phase to a symptomatic pre-dementia phase, but it is undeniable that a gradually progressive cognitive decline may lead to a diagnosis of Alzheimer’s disease (AD; Gauthier et al., 2006). Fortunately, a variety of pharmacological and nonpharmacological treatments for delaying disease progression or conversion to AD have been evaluated in the past decade. Systematic reviews of studies evaluating the effectiveness of cholinesterase inhibitors have yielded disappointing results (Raschetti, Albanese, Vanacore, & Maggini, 2007), including increased risks associated with the treatments and few long-term benefits for MCI patients (Aisen, 2008). Reviews of nonpharmacological cognitive interventions, in contrast, are more promising (Belleville, 2008; Jean, Bergeron, Thivierge, & Simard, 2010; Simon, Yokomizo, & Bottino, 2012; Stott & Spector, 2011). Cognitive intervention has been conceptualized as cognitive stimulation, cognitive training, or cognitive rehabilitation, and can involve restorative strategies or compensatory strategies (Clare, Woods, Moniz-Cook, Orrell, & Spector, 2003; Sitzer, Twamley, & Jeste, 2006). Cognitive stimulation approaches typically involve individual- or group-delivered generic cognitive and social activities (e.g., reality orientation, newspaper review, cognitive exercises, computer-assisted attention training, relaxation training, etc.). Cognitive training is designed to improve an individual’s specific cognitive functions through strategy-based skills training (e.g., errorless learning, spaced retrieval, visual imagery, mind mapping, external aids, etc.) and guided practice. Cognitive rehabilitation approaches typically aim to achieve client- and familyidentified goals for improved daily functioning using individualized and tailored training programs (e.g., multicomponent training, computerized training, etc.), but not necessarily to
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improve performance on specific cognitive tasks. These approaches typically incorporate strategies that aim either to restore specific cognitive functions (restorative strategies) or to teach alternative ways of performing desired tasks (compensatory strategies). The evaluation of cognitive interventions for improving memory performance and related cognitive functioning was first undertaken with healthy adults with memory complaints. Heightened awareness of diseases of cognition, such as AD, in the media has increased the popularity of self-help “memory improvement” programs. Ascribing to the “use it or lose it” philosophy, adults of all ages have incorporated crossword puzzles or Sudoku into their daily routines as a way to prevent dementia. Experimental studies of the effectiveness of these cognitive “stimulation” approaches for preventing dementia have been equivocal at best (Pillai et al., 2011; Salthouse, 2006). It is interesting to note that many middle-aged adults complain about needing to use external aids (e.g., writing notes, making lists) and perceive these supports negatively, a sign of impending “dementia.” Yet, in the past 15 years, several memory interventions for healthy adults have been evaluated with promising results, such as the maintenance of memory performance (e.g., Willis & Nesselroade, 1990) and the continued use of memory strategies in everyday life as measured at the 5-year follow-up (Advanced Cognitive Training for Independent and Vital Elderly [ACTIVE] study, Willis et al., 2006). Valentijn et al. (2005) documented greater improvements in subjective and objective memory performance in healthy older adults who participated in a memory training group in comparison to individually trained or control participants. More stability in memory functioning and fewer feelings of anxiety and stress were reported by participants after the eight-session (2-hour per week) program. The program consisted of a weekly theme for discussion with practical applications, homework assignments, and a “reader” summarizing the weekly themes (e.g., short- and longterm memory, age-related decline in memory, internal and external memory strategies). See Rogalski and Quintana (2013, in this issue) for further information on cognitive interventions in healthy aging. Studies of memory enhancing interventions for persons with documented memory disorders (e.g., dementia, traumatic brain injury [TBI]) have explored a range of strategies, from internal (e.g., mnemonics and visual imagery) to external (e.g., electronic: PDAs and paging systems; nonelectronic: planners and notebooks) techniques. Systematic reviews of this literature underscore the effectiveness of memory strategies, especially external techniques for persons with dementia (Hopper et al., 2013) or TBI (Sohlberg et al., 2007). Applying these principles to persons with amnestic MCI (a-MCI), Troyer, Kelly, Anderson, Moscovitch, and Craik (2008) hypothesized that the impact of impairment could be moderated by training compensatory strategies and found that their participants increased knowledge and use of strategies following their training program. Similarly, Kinsella and colleagues (2009) evaluated an intervention program for persons with MCI consisting of five 90-minute sessions that included discussions of strategies, written materials, and home assignments. Their problemsolving approach to everyday memory problems began with a session explaining memory as a multifactorial construct impacted by health, lifestyle, aging, and neurological issues, followed by four sessions detailing a variety of evidence-based strategies such as external aids, organizational and attention skills, verbal categorization and elaboration, visual imagery, errorless learning, spaced retrieval, and general coping strategies (physical and mental exercise). The treatment group outperformed the waitlist control group, demonstrating improved everyday memory performance, knowledge and use of memory strategies following intervention, as well as a trend toward improved contentment with memory. Participants’ appraisal of their own everyday memory concerns, however, did not change significantly. Kinsella and colleagues suggest that it might take time for participants to experience the benefits of using memory strategies in their everyday lives and to change their self-appraisals; the use of daily memory logs to document day-to-day memory performance and improve accuracy of self-appraisal was recommended.
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These promising findings have prompted others to evaluate a continuum of cognitive intervention approaches in MCI. For example, Jean et al. (2010) conducted a systematic review of cognitive interventions that directly targeted cognition; 15 studies were evaluated, of which 8 were group-delivered treatments and 7 were delivered individually. All studies targeted memory goals using techniques such as errorless learning, spaced retrieval, mind mapping, visual imagery, face–name associations, categorization, hierarchical organization, chunking, and cueing. Some studies addressed multiple aspects of cognition including attention, processing speed, language, visuospatial abilities, executive functions, and memory using a variety of tasks; several studies included didactic education about memory, relaxation skills, and occupational and physical therapy components. Overall, most cognitive intervention programs reported some statistically significant improvements on objective or subjective measures of memory, or both, when compared to control conditions. In addition, more improvements on measures of quality of life and mood were seen than on objective measures of cognitive domains. The authors caution, however, that most of the studies had small sample sizes, few utilized randomized control designs, and a lack of long-term treatment effects, thus limiting the interpretation of the results. In an effort to improve upon the review by Jean and colleagues by excluding single-case studies and studies using only cognitive stimulation approaches, Stott and Spector (2011) conducted a systematic review of memory interventions with the aim of determining if (a) the approaches helped people with MCI to learn specific information, (b) training generalized to untrained objective measures of memory, (c) training helped to compensate for memory impairment, and (d) training improved functioning in everyday life. Of the 10 studies reviewed, 2 provided evidence that people with MCI could learn new information using errorless learning techniques (Akhtar, Moulin, & Bowle, 2006) or visual imagery (Hampstead, Sathian, Moore, Nalisnick, & Stringer, 2008). Three studies of computerized general cognitive training packages produced inconclusive results relative to improvements in memory as a result of the training; poor methodological quality of these studies also compromised interpretation of the results. Another three studies evaluated the impact of a group-based memory training intervention. Rapp, Brenes, and Marsh (2002) reported no changes in objective memory performance, but there were self-perceived improvements in memory after intervention and at the 6-month follow-up for the treatment group compared with the control group. Belleville et al. (2006) found medium to large effect size changes in face–name associations and list-learning following group-based memory training, as did Troyer et al. (2008), who also found improvements in well-being and self-perceived memory. Evidence of training helping to compensate for memory impairment was provided by studies that trained in the use of external memory aids (Greenaway, Hanna, Lepore, & Smith, 2008; Rapp et al., 2002; Troyer et al., 2008). Memory interventions were found to have variable effects on improving everyday functioning; Londos et al. (2008) reported increased performance and satisfaction with performance of everyday activities that maintained for 6 months, but three other studies reported few effects (Belleville et al., 2006; Rapp et al., 2002; Troyer et al., 2008), even when taking caregiver reports into account. In studies that measured the effects of intervention on secondary effects, such as mood, improvements were found in all cases (Belleville et al., 2006; Londos et al., 2008; Rozzini et al., 2007; Talassi et al., 2007), suggesting that training may give people some sense of control and self-efficacy over their memory complaints. Future research should measure these constructs. Li and colleagues (2011) conducted a meta-analysis of 17 cognitive intervention studies (cognitive stimulation/training and cognitive rehabilitation approaches) designed to improve specific cognitive functions (e.g., memory, executive function, attention/processing speed, visuospatial ability) in persons with MCI. There were improvements in overall cognitive functioning in most studies, but small effect sizes characterized the changes in specific cognitive skills in the treatment groups relative to the control groups. Modest improvements in memory self-ratings, quality of life, activities of daily living, and self-rated depression were also demonstrated when compared to control groups.
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In a systematic review of 20 cognitive intervention studies for persons with MCI, Simon et al. (2012) found that persons with a-MCI benefited from approaches that involved learning strategies such as visual imagery, errorless learning, spaced retrieval, and the use of external aids (i.e., calendars); researchers also documented improvements in daily life activities, selfperception of their own memory, mood, emotions, and quality of life. These improvements were shown to last from several months to up to 2 years following intervention (Unverzagt et al., 2007). In summary, despite the limitations in the quality of the studies reviewed, there is promising evidence accumulating that cognitive interventions including memory strategies can improve memory and cognitive functioning (Olchik, Farina, Maineri, & Yassuda, 2008); increase positive memory self-efficacy (Valentijn et al., 2005); and have collateral effects on a variety of other outcomes, including affective and quality of life measures. It should be equally apparent that some approaches to cognitive intervention (i.e., those that focus on restoring underlying cognitive processes) may not result in outcomes that generalize to related everyday functions or maintain for very long. Two critical aspects of designing effective interventions are (a) selecting appropriate training targets and training methods and (b) selecting sensitive and meaningful outcome measures that will reveal changes as a result of training. The evidence from the systematic reviews seems to suggest that client and/or family goal-oriented treatment targets and group training interventions yielded stronger outcomes on subjective appraisals of cognitive and memory performance. Perceived self-efficacy (memory beliefs and confidence) has been shown to predict memory performance in studies of memory interventions (Best, Hamlett, & Davis, 1992; Lachman, Weaver, Dandura, Elliott, & Lewkowic, 1992) and has been proposed to be as important as teaching specific strategies. In their metaanalyses of memory training studies for healthy adults, Floyd and Scogin (1997) and Verhaeghen, Marcoen, and Goosens (1992) suggest that enhanced intervention effects could be attained by increasing participants’ awareness and knowledge (metamemory), decreasing negative beliefs (memory self-efficacy), and decreasing negative memory-related affect (anxiety). Many of the reviewed studies reported changes in self-perceptions of memory performance due to learning and using new strategies; others have shown similar results with participants with a-MCI when using a small group training format in which participants benefit from listening to others’ problem-solving examples and improve their metacognitive skills (Moro et al., 2012). The reviewed literature underscores the necessity of selecting meaningful and sensitive outcome measures to document training effects; objective, standardized measures of cognitive constructs may yield less robust outcomes than subjective, self-report measures. Clinicians and researchers may need to develop new instruments or adapt existing tools in order to capture the relevant outcomes. For example, Kinsella and colleagues (2009) chose measures of memory in everyday activities—such as the Reminding Task (appointment card) from the Rivermead Behavioral Memory Test and an Envelope Task (remember to write name and initials, seal envelope)—to measure objective prospective memory performance, but, to document knowledge of strategies, created nine hypothetical memory situations and scored the generated list of strategies for effectiveness and specificity. Troyer and Rich (2002) created the Multifactorial Metamemory Questionnaire (MMQ) with three subscales (Ability subscale: frequency of self-rated memory failures; Strategy Use subscale: frequency of self-rated use; and Contentment subscale: emotions and perceptions linked to memory performance) to measure self-perception and self-efficacy constructs related to their training. These measures appear to have good face validity and should be considered for use in other studies designed to improve objective and subjective memory performance. More research is needed to strengthen the evidence for the effectiveness of cognitive interventions for persons with MCI, as well as other neurological conditions. The following description of a memory strategies training program in a university clinic is presented as an example of designing a treatment program based on the available literature and gathering more evidence for the effects of cognitive rehabilitation for persons with MCI.
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Application of Memory Strategy Training in a University Training Program Due to the promising effects of memory strategies training programs reported in the literature, clinical training programs have begun to consider the pros and cons of including memory strategies training services to their adult clientele, and training student clinicians to provide these services. Clinicians are addressing questions about the need for this service: Will clients enroll in a university-based memory strategies training program? Will participants demonstrate improvements in memory, knowledge, and use of strategies as a result of the program? Will participants (and family members) report satisfaction with memory and strategy use after training? What will be the effects of program on student clinician competencies? Faculty and staff at the Ohio State University (OSU) are evaluating such a program—the OSU Memory Strategies course, a 10-week, 90-minute per week program of group-delivered didactic and activity-based training about a variety of evidence-based memory strategies. After obtaining Institutional Review Board (IRB) approval to recruit, assess, and evaluate individuals with documented memory impairments due to MCI or early AD, faculty recruited participants via descriptive flyers distributed at the OSU Memory Disorders Clinic and the local Alzheimer’s Association chapter support groups. To date, the program has been offered over three consecutive academic terms (Autumn, Winter, and Spring). For each term, eight persons with memory impairment and their family member were recruited; each memory strategies group had a maximum of eight participants and the concurrent family support group had eight persons. In addition, five student clinicians were assigned to lead and facilitate the groups (memory group: 3; family group: 2). After completion of the 10-week course, participants “graduated” to the alumni group, which mets once a month to socialize and review memory strategies in a separate room; there were 8 alumni participants during Winter term, and 16 during Spring term. To date, 22 participants with MCI, 22 family members, and 15 student clinicians have participated in a 10week course; one faculty member and one clinical instructor have supervised the program. An overview of the 10-week memory strategies program (for clients) is presented in Table 1. During the concurrent family group meeting, student clinicians elicited from family members their problems and concerns and desired information on resources, coping strategies, and behavior management ideas; they also provided information requested from the prior week. At the end of the session, one of the student clinicians from the client group reviewed the day’s memory strategy, practice activity, and home activity with the family group, encouraging them to review the client’s notebook with them during the week and to assist with the home activity completion.
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Table 1. Program Overview: Memory Strategies Group (Clients) Week 1
Group: Overview of study and consent forms Individually: Clinicians administer assessment battery
Week 2
Group topic: What is memory? (sensory, short-term, long-term); What are memory strategies? (internal vs. external)
Week 3
Group topic, strategy 1: Organization (calendars, special places)
Week 4
Group topic, strategy 2: Routine (daily routines)
Week 5
Group topic, strategy 3: Verbal elaboration (association)
Week 6
Group topic, strategy 4: Active observation (attention to visual cues)
Week 7
Group topic, strategy 5: Written strategies (notes, lists, memory books)
Week 8
Group topic, strategy 6: Verbal strategies (spaced rehearsal/retrieval)
Week 9
Group topic, strategy 7: Other strategies (music, art); review
Week 10
Clinicians administer post-assessment battery to individual clients
To assess the effects of the program on the participants, objective measures of memory functioning and subjective measures of memory performance were administered to the participants pre- and post-training. The clients were administered the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005) and the MMQ (Troyer & Rich, 2002). Family members were asked to complete the Modified Caregiver Strain Index (Thornton & Travis, 2003) and the Multifactorial Memory Questionnaire-Family version (Troyer & Rich, 2002) to obtain their impression of the client’s memory ability (frequency of observed client memory failures), client’s strategy use, and client’s perceptions of memory performance. All 90-minute client group sessions followed the following format: introductions and greetings, review of last week’s memory strategy and home activity completion, introduction of new memory strategy (with handout for notebook), completion of an activity demonstrating the new memory strategy, and explanation of a home activity to practice the new strategy (with handout for notebook). During the concurrent 90-minute family group meeting, the student clinician prompted the group in greeting each other; sharing problems and concerns; reviewing requested information on resources, coping strategies, and behavior management ideas; and planning for the following week. At the end of the session, one of the student clinicians from the client group reviewed the day’s memory strategy, practice activity, and home activity with the family group, encouraging them to review the client’s notebook with them during the week and to assist with the home activity completion. Sample memory strategy and home activity handouts are shown in Figures 1 and 2.
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Figure 1. Example of Memory Strategies Handout: Routines (print in large font; 20+ pitch)
Figure 2. Example of Memory Strategies Home Practice: Routines (print in large font; 20+ pitch)
Student clinicians and faculty supervisors met for 1 hour prior to each session to discuss client goals for the session, finalize plans for the day, make copies of the handouts,
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and prepare the rooms, including snacks and beverages. During the session, the designated student group leader followed the session sequence of activities, delivered the didactic presentation of the new strategy, facilitated the practice activity, and explained the home practice activity. The other two or three student clinicians sat interspersed among the clients in order to provide prompts and cues to participate in group activities and take data on the frequency of initiation/response behaviors of the individual clients during the session. After the session, students and faculty met for 30 minutes to discuss their observations of the session (both client group and family group activities); report on the data collected during the session; share positive aspects of their own and the clients’ participation, as well as areas in need of improvement; and plan for the next week’s session. Students facilitating the family group shared insights and concerns of the family members and used that information to plan future sessions and resource materials for the family. Afterwards, the student clinicians wrote SOAP notes in each of the client files to document their session participation and progress toward their individual goals. During the week, the designated student group leader for the next week prepared a detailed lesson plan, activities for group and home practice, and handouts; these files were shared with the other student clinicians and faculty via e-mail for suggestions, discussion, and faculty approval. Student clinicians met with the supervising faculty at regular intervals throughout the term to develop long-term goals and short-term objectives for each client, produce summary reports about the client’s and family member’s participation and progress toward goals, and discuss the student clinician’s progress in learning clinical skills. Some typical long-term goals and short-term objectives for clients are as follows: Long-term goal: •
Client will utilize memory strategies on a daily basis in the home to maintain independent functioning Short term objectives: •
Client will use calendar daily with minimal prompts
•
Client will complete weekly home activity with minimal assistance
•
Client will maintain participation and engagement in group activities with minimal assistance
•
Client will respond to direct questions 4/5 times with minimal assistance in group setting
Preliminary Results Preliminary analysis of the client data (N = 22) revealed that clients attending the 10week memory strategies class maintained or showed some decreases on objective memory, as measured by the MoCA. On the MMQ, they reported maintenance or decreased memory abilities, increased strategy use, but overall decreased contentment with their memory functioning. There were mixed results from the family members’ pre-post Caregiver Strain Index scores. An open-ended satisfaction survey was collected from each family member; reports showed the most valuable/effective strategies taught during the program were calendars, routines, visual cues, and written reminders. Their only suggestion for improving the class was to schedule for more time. They wrote: •
“Class made my husband more confident and comfortable talking about memory loss.”
•
“Sharing with caregivers like me was very helpful.”
•
“We all had the same problems!”
•
“Expand the program.”
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These strong feelings for the continuation of the program resulted in establishing the monthly “alumni” group, during which clients and clinicians reviewed memory strategies and socialized. During these meetings, clients reported increased confidence in their memory abilities due to strategy use, socialization with group members outside of the university program (e.g., weekly lunch meetings), independence with activities of daily living, and engagement with lifelong hobbies. One participant reported the class gave him the confidence to try using written strategies (chord fingering patterns) to play his guitar, which he had not touched in 10 years. These anecdotal reports of the increase in life participation activities suggest the need to include a measure of change in participation as a result of group membership. Student comments about the clinical experience included: •
“Wow! What an awesome experience.”
•
“I was impressed with their rapport, friendships, honesty, sincerity, and enthusiasm for learning how to utilize strategies.”
•
“Most of all I enjoyed seeing them laugh and commiserate with one another.”
•
“Hearing them express how grateful they are for the class, how they have more confidence to do things like go on vacations, serve as leaders of organizations, how their stress levels decreased, how they try to implement at least 1 or 2 strategies a day.”
• “What an inspiration!” Several groups enjoyed the lesson on how music (an auditory cue) can trigger old memories and encode new memories; one group member composed the following song that she shared with the group, who performed it multiple times during the session and at the end of the session for their family members. “Memory Group with Dr. B.” (to be sung with gusto!) Composed by a Spring 2011 Memory Strategies Group Member (sung to the tune “Let me Call you Sweetheart”) Friday I have memory group With Dr. B I’ll see Bob and Billie, Louann, Doug, Jer-ry Marilyn and Linda, Bill are friends I’ll see Friday I have memory group With Dr. B! This program is continuing to enroll approximately eight new participants and their caregivers each term. Each new group of student clinicians expands upon and creates variations of the activities associated with the seven memory strategies that are taught each term. Due to the number of requests from persons with memory problems resulting from TBI or stroke, we have begun separate groups for these etiologies. Ongoing evaluation of the materials and the required modifications to them to address the unique problems encountered due to TBI or aphasia will result in a collection of diagnosis-specific materials to share with other clinicians.
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Final Thoughts Although MCI is an increased risk factor for AD, cognitive training interventions have the potential to improve everyday memory functioning through increased strategy use and participation in meaningful life activities. Clinical training programs can provide opportunities for clients, families, and student clinicians to gain skills and resources for dealing with the challenges of memory loss, while supporting the collection of evidence for effective clinical practices.
About the Author Michelle S. Bourgeois, PhD, CCC-SLP, ASHA Fellow, is a professor in the Department of Speech & Hearing Science, The Ohio State University. A clinical researcher, Bourgeois evaluates interventions for persons with memory impairment and their spouses designed to improve communication and quality of life. Comments/questions about this article? Visit the SIG 2 ASHA Community and join the discussion!
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