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Memory Intervention: From theory to clinical practice Eva Svoboda, Ph.D., C.Psych. Neuropsychology & Cognitive Health Program December 2, 2013.

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Presentation on theme: "Memory Intervention: From theory to clinical practice Eva Svoboda, Ph.D., C.Psych. Neuropsychology & Cognitive Health Program December 2, 2013."— Presentation transcript:

1 Memory Intervention: From theory to clinical practice Eva Svoboda, Ph.D., C.Psych. Neuropsychology & Cognitive Health Program December 2, 2013

2 Collaborators Baycrest Brian Richards Nancy Posluns Gillian Rowe Larry Leach Kelly Murphy Sabrina Lombardi Ruth Brickman Jeff McCarthy Ken Leung Dmytro Rewilak Nina Dopslaff Sick Children’s Hospital Sharon Guger University of Toronto Morris Moscovitch David Goldstein Morgan Barense York University Josée Rivest Shayna Rosenbaum Students Narmeen Ammari Christie Yao Angelina Polsinelli Simon Beaulieu-Bonneau Deborah Tang Sandra Belfry Valerie Mertens

3 Outline Overview of related memory theory The Memory Link program at Baycrest Program outcome research Intervention in a case of topographical disorientation

4 Memory systems MEMORY DECLARATIVE NONDECLARATIVE SemanticEpisodic FactsEvents Skills Priming Dispositions Nonassociative Motor Perceptual Simple classical Habituation Perceptual Semantic conditioning Sensitization Cognitive (Explicit/conscious) (Implicit/unconscious) (Zola & Squire, 1990)

5 Application of multiple memory systems theory to intervention If one memory system is damaged, other preserved systems can be tapped to support new learning (Mateer & Sohlberg, 1989, 2001) Development of learning techniques which capitalize on preserved memory abilities

6 Errorless learning Defining principle – learning without making mistakes (Wilson et al., 1994) Implicit memory system is poorly designed to deal with errors (Baddeley & Wilson, 1994). Once errors are produced amnestic individuals have a very difficult time eliminating them.

7 Procedural skills training Memory impaired individuals show robust implicit learning of new skills and procedures under conditions in which learning develops gradually across multiple trials Sohlberg and Mateer (1989; 2001) trained individuals with severe memory impairment in the use of paper organizers with repeated trials of content questions, role-play and real-life generalization.

8 Short-term (12-20 wks) Clients: Neuropsychological assessment Real-life memory functioning assessment (behavior memory charting, questionnaires) Individual skill training sessions on external memory aid use and application Psychosocial/educational group for clients Family members: Family education Spousal support group Kids support group Memory Link Program

9 Research and Development Basic and clinical research in collaboration with other clinicians and scientists Development of novel intervention applications –industrial designers, programmers, participatory design groups (patients, family members). Memory Link Program


11 Smartphone training example Calendar training Event entries broken down into multiple steps (n = 24) Steps divided into 3 stages: Stage 1 Basic steps to enter an event for today Stage 2 Additional steps for future dates Stage 3 Additional steps to attach a note

12 Errorless fading-of-cues protocol

13 Before smartphones …


15 Patient demographics Pt Age Sex Educ Etiology M = 6.32 years post-neurological event (range = 10 m - to 25.42 yrs) Svoboda, Richards, Leach & Mertens, 2012; Neuropsych Rehab

16 Study admission criteria Moderate to severe memory impairment as defined by: 1.Difficulty in day-to-day functioning due to memory impairment (e.g., ongoing supervision & /or regular assistance due to forgetting to pay bills, bathe, take medications or attend appointments); 2.Independence in basic ADLs; 3.At least borderline impaired to impaired memory performance on psychometric testing

17 Cognitive Profile: All patients Age-corrected scaled scores

18 Cognitive Profile: Focal impairment patients Age-corrected scaled scores

19 Cognitive Profile: Global impairment patients Age-corrected scaled scores

20 Study Design A 1 B 1 A 2 B 2 Pre-tx Skill Immediately Return to 3-8 m Acquisition Post-tx Baseline Post-tx Intervention



23 Study Design A 1 B 1 A 2 B 2 Pre-tx Skill Immediately Return to 3-8 m Acquisition Post-tx Baseline Post-tx Intervention

24 Case 9

25 Focal vs. global cognitive impairment Trials to complete phase I (calendar function) Participants required an average of 101.27 training trials to acquire all 3 training stages (range = 42 to 229) Focal impairment - M = 74.50, SD = 29.51 Global impairment -M = 173.56, SD = 65.69).

26 Phone calls/observation log

27 Memory Mistakes ( MMQ, Troyer & Rich, 2001 )

28 Confidence Ratings (MASS) (n = 10) (n = 6)

29 Long-term maintenance of smartphone and PDA use in individuals with moderate to severe memory impairment Svoboda, E., Richards B., Yao, C. & Leach, L. Paper under review

30 Phone calls/observation log – Long term follow-up


32 Hypointense rounded lesion (1.5 cm) in the third ventricle at the midline adjacent to the foramen of Munro. Svoboda & Richards, 2009; JINS


34 RR: qualitative observations RR was creative in expanding the functional capacity of the Palm to support her individual memory needs. Prospective guidance: She attached notes to appointments or social events to remind herself of items to bring, questions to ask, messages to convey or instructions to follow. As part of her granddaughter’s birthday party event she attached a note outlining that she would be expected to baby-sit, several details regarding the kids’ routines (bed time, sleeping arrangements).

35 RR: qualitative observations Retrospective guidance: She attached notes to describe what happened at appointments or events, creating an autobiographical memory log. For a weekly outing event with her friend she attached a note documenting that they went clothes shopping, what they bought, what item was not in stock and what size was ordered by the store.



38 Caregiver Strain Index Stull, D. E. (1996). Journal of Clinical Geropsychology, 2(3), 175–196. Svoboda, Richards, Leach & Polsineli, 2010; Neuropsych Rehab

39 Smartphone intervention in a case of topographical disorientation Rivest J., Svoboda, E., McCarthy, J., Moscovitch, M., Paper in preparation

40 Case: FP Background: To date only two case studies published of intervention for topographical disorientation (Brunsdon et al., 2007; Davis & Coltheart, 1999. Landmark agnosia - inability to recognize salient environmental stimuli (Aguirre & D’Esposito, 1999)

41 Case: FP History: 65 year old right-handed gentleman 21 years education, owned environmental consulting business and travelled globally. Etiology: MVA while vacationing. Normal GCS at scene. 12 hrs post-MVA, unresponsive. Feb 2011 underwent L frontoparietal craniotomy with subdural hemorrhage evacuation.

42 L occipital gyriform high signal R occipital gyriform high signal Cortical laminar necrosis in cortex of bilateral posterior & medial occipital lobes & L inferomedial parietal lobe. Concl: Bilateral posterior circulation infarcts, multiple foci of parenchymal & intracranial hemorrhage secondary to trauma.

43 Case: FP Cognitive function (select findings): Did not go beyond corner store in his neighbourhood. Took ++ effort to learn which building he now lives in. Famous buildings – visited 28/30, visually recognized 11/30. Famous/personal faces - 6 recognized of 35 known people FP had poor colour discrimination across the entire wavelength spectrum Basic perceptual function was intact Verbal and visual memory were low average Verbal and nonverbal IQ were in the superior range. Post-intervention cognitive status remained unchanged.

44 Study Design A 1 B 1 A 2 B 2 Pre-tx/ Skill Post-tx Return toPost-tx CONTROL Acquisition baseline Intervention

45 No iPhone (A)With iPhone (B)

46 Confidence in managing various navigation demands

47 Navigation ability

48 Conclusions Application of a theory-driven training program enables individuals with severe memory impairment to successfully use smartphones to support day-to-day memory function. Use of map apps on smartphones offer significant promise to individuals with topographical disorientation, and possibly patients with poor way-finding secondary to other cognitive difficulties (amnesia)

49 Salvador Dali: Persistence of Memory

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