Cover Story

Brain injury, such as that from an accident or stroke, or a memory-draining disease such as Alzheimer's, can leave people struggling with everything from cooking dinner to knowing their own children. What's more, as the number of older adults in America grows, so will the number with age-related dementia, boosting the prevalence of this frustrating and usually invisible disability.

As the need for intervention grows, U.K. neuropsychologist Barbara Wilson, PhD, an authority on memory rehabilitation at the Medical Research Council's Cognition and Brain Sciences Unit in Cambridge and the Oliver Zangwill Centre for Neuropsychological Rehabilitation in Ely, says that due to lack of specialists and insurance barriers, few are being shown how best to keep their handicap from hurting everyday functioning. Yet much more is possible. "We can help people adapt to, understand, bypass and compensate for their memory difficulties," Wilson says.

Thanks to new scientific insights, the field of memory rehabilitation made remarkable strides in its first 25 years, says Allen Heinemann, PhD, president of APA's Div. 22 (Rehabilitation) and a rehabilitation psychologist with Northwestern University and the Rehabilitation Institute of Chicago. Now, says Heinemann, "the challenge is to apply what modern imaging techniques have shown about localization of memory function."

Accordingly, psychologists are studying everything from memory-related brain-activation patterns to mobile Internet devices, searching for ways to support independent living and even help the brain repair itself.

Heinemann expects the next decade to bring more clinical trials of various behavioral interventions, a growing cadre of investigators and a greater number of high-quality outpatient services and inpatient facilities providing cognitive rehab. "Our research investment will start to bear fruit," he predicts.

From finding keys to greeting friends

Although most people think that good memory means good retrieval, good memory is actually good learning--forming a strong association when acquiring new information, say rehab experts. That's why they often advise memory-impaired people to systematically take note of things. For example, they can learn to habitually take a mental snapshot when they put down their keys--say, next to the fruit bowl on the kitchen table.

Thus, Keith Cicerone, PhD, clinical director of cognitive rehabilitation at the JFK-Johnson Rehabilitation Institute in Edison, N.J., and his clinical team teach people with early-stage dementia and similar forms of memory loss--who are still capable of learning--to pay attention to routine, actively process information, avoid being distracted and write notes.

Using a similar approach is neuropsychologist Linda Clare, PhD, of University College London and the Dementia Services Development Centre Wales. Clare and her associates help patients with early-stage dementia to set goals that are relevant to daily life, for them and their families. Sample goals include:

  • Learning names of familiar people they meet socially so that they do not feel awkward when they go out.

  • Using a memory aid such as a calendar or memory board instead of asking family members the same question over and over again.

  • Remembering family information so that it is easier to join in conversations at home.

  • Identifying different types of coins to make it easier to pay for things.

In a 2002 study reported in APA's Neuropsychology (Vol. 16, No. 4, pages 538-547), Clare found that patients with mild Alzheimer's benefit in a lasting way from simple, systematic memory training that may enlist the still-intact neocortex. Participants were able to learn people's names by using mnemonic devices, "vanishing cues" (filling in more and more letters in a name until recall kicks in) and "expanding rehearsal" (testing themselves in spaced intervals over time). This kind of training doesn't rely on faulty parts of the brain, such as the hippocampus. Clare speculated at the time that, "If other brain areas can take over some of the functions of damaged areas, then this opens up new directions for rehabilitation."

When providing rehab services, memory experts employ a powerful approach called "errorless learning," which minimizes mistakes during training. Wilson and Clare have demonstrated in, among other journals, the Journal of Clinical and Experimental Neuropsychology (Vol. 22, No. 1, pages 132-146) that people with severe deficits learn better with confidence-boosting errorless training. Fostering awareness of memory loss also appears to aid therapy.

Cognitive support is central, but living with memory loss involves the whole person, says Suzanne Corkin, PhD, a neuroscientist with the Massachusetts Institute of Technology's brain and cognitive sciences department.

"Rehabilitation [also] teaches ways to keep people's mood up by taking the memory-impaired person out for lunch, to museums, for walks, by giving them a healthy level of mental stimulation," she says.

Memory technologies

For people with mild to moderate memory loss, assistive technologies essentially take what was lost or compromised about memory on the inside and put it on the outside--in the form of everything from digital watches to computerized schedules, pagers programmed with streams of reminders and wireless personal digital assistants (PDAs), which take patients step-by-step through complex tasks.

In a controlled study published in 2001 in the Journal of Neurology, Neurosurgery and Psychiatry (Vol. 70, No. 4, pages 477-482), Barbara Wilson and her colleagues found that a paging system helped patients become significantly more successful in carrying out everyday activities. As if they were asking for a wake-up call, patients picked the messages and listed routine appointment dates and times in advance.

Things get more futuristic at the University of Michigan Health Systems in Ann Arbor, where rehabilitation psychologist Ned Kirsch, PhD, director of adult neurorehabilitation programs, is using PDAs and laptop computers with wireless Internet connections to help with complex functional tasks. For example, in one study, published in Rehabilitation Psychology (Vol. 49, No. 3, pages 200-212), Kirsch's team used a wireless PDA to help one patient who could not remember the way from one room to another in the treatment center to follow large colored circles on the walls. In this special treasure hunt, he taps the screen each time he finds a circle; progressive instructions guide him to the next one and enable him to navigate independently through his therapy day. Kirsch adds that once a home has broadband, it's cheap and easy to set up a wireless node. This type of technological approach to treatment will also become increasingly available in the community as city-wide wireless Internet installations spread, Kirsch notes.

Assistive technology has limits: For example, people with weak memories may have problems learning to use these devices, or they may lose them. And, notes Cicerone, "You have to remember to use it." People who never liked technology probably still won't; "early adopters" may be more proficient. Better interfaces should help, he notes.

Some may grow out of research projects under way at the Rehabilitation Engineering and Research Center for Advancing Cognitive Technologies, a new program established in 2004 by the National Institute on Disability and Rehabilitation Research and housed at the University of Colorado.

Cicerone says that some private companies have developed proprietary devices specifically for neurological support, but the evidence of their effectiveness is anecdotal only. There's also limited evidence that so-called memory-building software works: "People get good at playing that particular game, but it doesn't transfer," he adds.

The future of memory

Meanwhile, even though drug companies are pouring resources into memory drugs because of the huge market, pharmaceutical options for improving memory are meager. First-generation antidementia drugs called cholinesterase inhibitors haven't been shown to support significant improvement in everyday life; they may help a subset of patients in a limited way. Still, Corkin is intrigued by drugs under development that are directed at toxic forms of the amyloid protein and could limit the proliferation of amyloid plaques, which are a neuropathological hallmark of Alzheimer's disease.

On the imaging front, at the University of Illinois Medical School in Chicago, psychologist Linda Laatsch, PhD, and her colleagues in neurology and rehabilitation are using functional magnetic resonance imaging (fMRI) to gather information on normal brain-activation patterns during simple memory tasks. Conceivably, fMRI could help differentiate patients whose brains respond to cognitive rehab from those who should stick with external cues, and help follow progress via changes in brain activation. She says, "If we could reach for the stars, we'd give feedback on activation patterns during imaging"--the ultimate in biofeedback.

Rachel Adelson is a writer in Raleigh, N.C.