The Polytrauma Experience: Best Practice Guidelines for Memory Rehabilitation

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The Polytrauma Experience Best Practice
Guidelines for Memory Rehabilitation

• Patricia Baggett, M.Ed., CCC-SLP
• Polytrauma Rehabilitation Center
• Richmond VA Medical Center
• ASHA, November 18, 2006

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Objectives

• Identify the different memory subsystems
• Discuss assessment instruments for memory
  problems
• Explore management and treatment strategies for
  memory problems

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What is Memory?

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Memory is the ability to retain information.

• Encoding processing of information
• Storage creation of a permanent record
• Retrieval/recall bringing back stored info

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Duration or length of memory storage

• Immediate
• Short term
• Long term

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Time periods of memory loss

• Post traumatic Amnesia (PTA)
• Retrograde Amnesia
• Anterograde amnesia

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Working memory and attention

• Working memory is seen as a system for temporary
  storage and manipulation of information in
  complex cognitive tasks
• Attention is strongly associated with the concept
  of working memory
• Baddley, A.D. Working Memory. Clarendon Press,
  Oxford, 1986

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Memory Deficits and Levels of Cognitive
Functioning
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• I-III - Early stages of recovery
• Looking at level of response to stimuli
• IV- Confused Agitated
• Speech begins
• Verbalizations are incoherent and/or
  inappropriate to activity or environment
• Absent short-term memory

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• V- Confused/ Inappropriate- Non-agitated
• Severe short term memory deficits
• Severe tertiary/long term memory
• impairment
• Poor orientation

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• VI Confused Appropriate
• Short term memory deficits
• Long term memory re-emerging
• Inconsistent orientation to place and time
• Orientation for person clearing

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• VII Automatic Appropriate
• Increased awareness of self and environment
• Follows routines with supervision

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• VIII- Purposeful Appropriate
• Alert and oriented
• Recalls past and integrates with recent events
• Carry-over for new learning

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Assessment of memory loss

• Orientation
• Immediate recall
• Short term memory
• Long term/remote memory
• Visual memory
• Verbal memory

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Assessment instruments

• Mini-Mental State Exam (MMSE)
• The Williams Memory Screening Test
• Galveston Orientation and Amnesia Test (GOAT)
• Memory, Orientation and Amnesia Test (MOAT)

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Assessment instruments (cont.)

• Ross Information Processing Assessment (RIPA)
• The Rivermead Behavioral Memory Test (RBMT)
• The Scales of Cognitive Abilities for Traumatic
  Brain Injury (SCATBI)

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Neuropsychological memory tests

• Wechsler Memory Scale (WMS), (WMS-R)
• Word list learning tests
• Rey Auditory Verbal Learning Test
• California Verbal Learning Test
• Buschke Selective Reminding Test
• Visual memory test
• Rey-Osterrieth Complex Figure

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Treatment

• Begin easy, then increase the load, the delay,
  and the interference
• Focus on encoding strategies (organization),
  rehearsal strategies, compensatory strategies.
• Internal/self monitoring
• External- memory aids (low tech and high tech)

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Orientation interventions

• GOAL
• Establish knowledge and understanding of
  environmental information

• PROCEDURE
• Repeat facts immediately
• Repeat facts after a brief delay
• Provide facts after interference with other
  orientation facts
• Provide facts after intervening tasks

Halper, A, Cherney, L., Burns, M.S. Clinical
Management of Cognitive-Communicative Problems in
Right Hemisphere Dysfunction. Aspen Publishers,
1996.
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• Client names pictures and audio recordings of
  significant others
• Client names familiar pictures without audio
  recordings or prompts
• Client names less familiar pictures
• Scanning the environment
• Using maps
• Route finding

• Orientation to person
• Orientation to place

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• Orientation to time

• Use of temporal aids (e.g. pocket calendar, daily
  log) to cue recognition of time factors
• Use of watch initially use alarms for
  reminders, fewer alarms as the client becomes
  more independent

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Internal memory strategies

• Self monitoring/ metamemory
• Visual imagery
• Rote rehearsal/ routines
• Concentration/sustained attention
• Wh questions
• PQRST technique
• Mnemonics/ Associations

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External memory strategies

• Use of cognitive prosthetic devices
• Low tech
• High tech

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Low Tech- external memory aids

• Memory Books
• Picture based
• Word based
• Calendars
• Planners/organizers
• Sticky notes
• Lists
• Alarms
• Color coding systems

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High tech- external memory aids

• PDAs
• Cell phones
• Programmable watches
• Computers
• Voice mates

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Considerations when choosing a memory device

• Vision
• Hearing
• Speech and language functioning
• Physical impairments (fine vs. gross motor)
• Cognitive problems
• Family support

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Compensatory features

• Vibrating alarms
• LED alarms
• Amplification
• Magnification
• Simplicity/complexity
• Voice activation
• Size of device
• Others programming info

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Memory compensation and cognition

• Match technology to patients abilities
• Analyze on a case-by-case basis
• Sometimes low tech or no tech is the best
  alternative
• Caregiver knowledge/support
• Therapist knowledge/support
• Team approach

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Sample Therapy Tasks
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Prospective memory tasks

• Assignments to be completed at a future time
• Message to deliver to another staff member
• Attend appointments on time
• Perform a specific task at a later time during
  the therapy session

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Routines in a structured environment

• Memory notebook training with increasing
  information and responsibility for independence
• ADL checklists
• Marked calendar, named photographs, written
  signs, clock
• Keeping items in the same location

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Working memory and sustained attention tasks

• Memory game using a deck of cards/ match
  increasing amount of pairs
• Field of pictures (or objects)- pt. turns away
  and objects are removed
• Auditory processing and recall of a story
• Tape recording of lectures/conversations
• Mirroring/ restating information in your own
  words
• Captains Log and other attention training

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Thank you for listeningPatricia.Baggett_at_va.gov
Source Ablelink Technologies, Colorado Springs
(Terry Jonathan).