Can We Rehabilitate Memory in Alzheimer’s Disease?
Because the cure for Alzheimer's disease remains elusive the best we are currently able to offer are ways to maximize the level of functioning. Keeping the brain ticking over has the effect of maintaining independence. In so doing it may have the effect of delaying hospitalization in cases where Alzheimer's becomes so advanced that it becomes impossible to support them at home.
Comparatively little is known about the ways we might exert a positive influence on the brain during a state of progressive decline. However, in this Sharepost I want to outline a few of the areas that show some level of promise.
The use of external aids have been around for quite some time. These tend to be cheap, easily available and familiar. Despite a general understanding that things like diaries or memory boards can be extremely effective, surprisingly little in the way of formal research into the training of patients with Alzheimer's disease with external aids has been undertaken. Despite this, objects like notebooks for use as memory aids are used broadly. Such notebooks may contain little facts about the person, their name, age address, etc and can even be organized by conversation topic.
At face value memory training may seem a counter-productive exercise for someone with Alzheimer's disease but what little research has been undertaken suggests this may have a positive if modest effect. Most attempts at improving memory with Alzheimer's disease have focused on episodic memory. This includes repetition of information and visual imagery as an aid to memory. No significant improvements have ever been reported with such techniques but it may be that their use helps to slow the progression of cognitive decline.
Making changes to a living environment is usually very easy and can have a marked effect on maintaining some level of independence. Dementia tends to correspond with a level of disorientation and confusion so anything that can reduce confusion and aid the most likely behavior of the individual is worthwhile. For example, a person may easily locate the bathroom if they are in their bedroom but get confused if they are in the kitchen. A sign in the kitchen pointing to the bathroom may be all that is required.
My final example uses a method called ‘errorless learning'. This is a form of learning that provides opportunities to learn without committing errors along the way. Let's contrast this with a form of learning we are all familiar with - trial and error. In trial and error learning we use a complex series of checks and balances to learn from our mistakes and gradually develop the knowledge and skills required for a behavior or task. Although it may seem familiar, the healthy brain has to apply a high level of resource to the solving of problems and learning from mistakes. Errors stick in the mind and they cause frustration and anxiety. Telling someone to try again and again only increases negative emotions. In the case of someone with a severe memory impairment this is both impractical and demeaning.
In trials, errorless learning has been shown to be an effective tool. Its use appears to encourage better retention of information and even some capacity for additional learning. The basic principles are these:
- Make the task achievable: For this to happen without error you must be 90 per cent certain the person has the capacity to do it.
- Model What's Required: This is a collaborative venture in which you work closely with the person. Any instructions must be clear, simple and consistent. You may need to work with the person on the task until they reach a point where they are able to do it themselves and you may need to shadow them afterwards rather than assume total independence.
- Anticipate: As the teacher, you must anticipate all the possible problems in advance. Allow the person to feel comfortable with the task or procedure by saying things like, ‘this part can be a bit tricky', so if it fails to be achieved it is because the task is problematic, not the person doing it.
- Use Cues: Provide helpful cues if you have seen the person accomplish a step once and then struggle the next time. If you can get away with subtle cues such as nodding positively if they are towards achieving part of a task, use them. Otherwise you might want to use a verbal cue such as, ‘now we need to brush our t t t ..'
- Repeat: Errorless learning is effective in tasks that are repetitive or frequently used. The more practice the person gets the easier and quicker it becomes for the information to be embedded. In Alzheimer's, memory for motor tasks (doing things like walking, brushing hair, etc) is relatively unaffected, but the cues to undertake such actions are often missing. Repetition, patience, lots of praise and support are essential ingredients in its success.