AppReminders - a pilot feasibility randomized controlled trial of a memory aid app for people with acquired brain injury.

Mobile phone reminding apps can be used by people with acquired brain injury (ABI) to compensate for memory impairments. This pilot feasibility trial aimed to establish the feasibility of a randomized controlled trial comparing reminder apps in an ABI community treatment setting. Adults with ABI and memory difficulty who completed the three-week baseline were randomized (n = 29) and allocated to Google Calendar or ApplTree app. Those who attended an intervention session (n = 21) watched a 30-minute video tutorial of the app then completed reminder setting assignments to ensure they could use the app. Guidance was given if needed from a clinician or researcher. Those who passed the app assignments (n = 19) completed a three-week follow up. Recruitment was lower than target (n = 50), retention rate was 65.5%, adherence rate was 73.7%. Qualitative feedback highlighted issues that may impact usability of reminding apps introduced within community brain injury rehabilitation. Feasibility results indicate a full trial would require 72 participants to demonstrate the minimally clinically important efficacy difference between apps, should a difference exist. Most participants (19 of 21) given an app could learn to use it with the short tutorial. Design features implemented in ApplTree have potential to improve the uptake and utility of reminding apps.

The experience and acceptability of smartphone reminder app training for people with acquired brain injury: a mixed methods study.

Smartphones are useful compensatory memory aids, yet training on how to use them is seldom offered as part of rehabilitation for acquired brain injuries (ABIs). We aimed to explore the experience and acceptability of a smartphone training intervention in 26 people with ABI who participated in a pilot randomized controlled trial comparing three skills training approaches. Participants completed questionnaire ratings and a semi-structured interview, six weeks post-training. Most participants rated the training as enjoyable (80.8%) and reasonable in duration (88.5%). Others reported that more than one training session was needed to learn the app (34.6%). Five themes were identified from qualitative data through thematic analysis: (1) Attitudes and pre-existing factors, (2) Experiencing the intervention, (3) Tailoring the intervention to the individual, (4) Facilitators and barriers to implementation and (5) Enhancing smartphone use in everyday life. These themes were juxtaposed with a theoretical framework of acceptability, which indicated that some elements (e.g., having a structured session and a supportive trainer) contributed to the acceptability of the intervention by minimizing training burden and increasing self-efficacy. Tailoring the training to the individual's technological skills and lifestyle, providing post-training resources and involving family members were identified as factors that could improve intervention acceptability.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches.

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life-but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

A Brief Period of Wakeful Rest after Learning Enhances Verbal Memory in Stroke Survivors.

OBJECTIVE: Accumulating evidence suggests that wakeful rest (a period of minimal cognitive stimulation) enhances memory in clinical populations with memory impairment. However, no study has previously examined the efficacy of this technique in stroke survivors, despite the high prevalence of post-stroke memory difficulties. We aimed to investigate whether wakeful rest enhances verbal memory in stroke survivors and healthy controls. METHOD: Twenty-four stroke survivors and 24 healthy controls were presented with two short stories; one story was followed by a 10-minute period of wakeful rest and the other was followed by a 10-minute visual interference task. A mixed factorial analysis of variance (ANOVA) with pairwise comparisons was used to compare participants' story retention at two time points. RESULTS: After 15-30 minutes, stroke survivors (p = .002, d = .73), and healthy controls (p = .001, d = .76) retained more information from the story followed by wakeful rest, compared with the story followed by an interference task. While wakeful rest remained the superior condition in healthy controls after 7 days (p = .01, d = .58), the beneficial effect was not maintained in stroke survivors (p = .35, d = .19). CONCLUSIONS: Wakeful rest is a promising technique, which significantly enhanced verbal memory after 15-30 minutes in both groups; however, no significant benefit of wakeful rest was observed after 7 days in stroke survivors. Preliminary findings suggest that wakeful rest enhances early memory consolidation processes by protecting against the effects of interference after learning in stroke survivors.

Living with global amnesia: self-established compensation strategies of a patient with severe memory impairment - a narrative report.

We report the case of C.H., a 48-year-old patient with global amnesia caused by herpes simplex encephalitis at the age of 20 and subsequent extensive bilateral temporal lobe lesions. Neuropsychological examinations performed at various intervals found persistent dense explicit memory impairment and limited vocabulary, yet intact procedural memory. Despite these limitations, C.H. self-developed and acquired a variety of effective strategies. As a result, C.H. achieved a high level of autonomy in everyday life. Her remarkable case is an encouraging and helpful example for successful implementation of creative methods and procedures to compensate and alleviate cognitive limitation, even if extensive.

Wakeful rest during storage and consolidation enhances priming effects for those with acquired memory impairment.

A period of rest after learning results in better explicit memory for the material than a period of unrelated mental activity. This study investigated whether the same applies to priming. Thirty-four people with memory impairments due to acquired brain injury took part. In a repeated measures design, participants studied word lists; then either engaged in a relaxation technique (wakeful rest condition) or completed visuo-spatial tasks (control condition); and finally completed two priming tasks. Priming effects were significantly larger in the wakeful rest condition. This result is difficult to explain in terms of some of the explanations used to account for the benefits of wakeful rest on explicit memory, and alternative explanations are considered. One possibility is that the attentional demands of the control task resulted in inhibition of activity in neocortical areas associated with perception that contributed to the priming effect. The findings have implications for memory rehabilitation. Acquired memory impairments typically impact on explicit memory, and implicit memory is often relatively intact. It is important to find ways of enabling those with more severe explicit impairments to make best use of their implicit memory as a way of compensating for the deficits in their explicit memory.

Therapist competence and clinical outcome in the rehabilitation of memory following traumatic brain injury trial.

Objectives: Therapist competencies when delivering an intervention can impact clinical outcomes. However, the relationship between competence and outcome in the context of memory rehabilitation has not previously been investigated. We aimed to evaluate whether therapist competencies in delivering a group-based memory rehabilitation intervention, as part of a randomized-controlled trial, was associated with changes in clinical outcome in the participants with traumatic brain injury.Method: Outcome data on the Everyday Memory Questionnaire (EMQ) and Goal Attainment Scaling (GAS) were obtained for 24 participants of the memory rehabilitation trial. Video recordings of intervention sessions delivered by six therapists were coded using a checklist designed to evaluate therapist competence in group facilitation.Results: Therapists demonstrated consistently high levels of competency in facilitating the memory group. Correlational analyses showed that there was a non-significant weak association between EMQ and therapist competence (r = .28, p = .18), and between GAS and therapist competence for short- and long-term goals (r = -.33, p = .12 and r = -.24, p = .25, respectively).Conclusions: We found no significant association between competence and outcome in this memory rehabilitation trial. This may reflect insufficient variability in therapist competence and/or the nature of the clinical outcome measures used. Further research is needed to understand competence-outcome relationships in cognitive rehabilitation.

Memory Compensation Strategies in Older People with Mild Cognitive Impairment.

OBJECTIVES: With the rapid growth of the older population worldwide, understanding how older adults with mild cognitive impairment (MCI) use memory strategies to mitigate cognitive decline is important. This study investigates differences between amnestic and nonamnestic MCI subtypes in memory strategy use in daily life, and how factors associated with cognition, general health, and psychological well-being might relate to strategy use. METHODS: One hundred forty-eight participants with MCI (mean age = 67.9 years, SD = 8.9) completed comprehensive neuropsychological, medical, and psychological assessments, and the self-report 'Memory Compensation Questionnaire'. Correlational and linear regression analyses were used to explore relationships between memory strategy use and cognition, general health, and psychological well-being. RESULTS: Memory strategy use does not differ between MCI subtypes (p > .007) despite higher subjective everyday memory complaints in those with amnestic MCI (p = .03). The most marked finding showed that increased reliance-type strategy use was significantly correlated with more subjective memory complaints and poorer verbal learning and memory (p < .01) in individuals with MCI. Moreover, fewer subjective memory complaints and better working memory significantly predicted (p < .05) less reliance strategy use, respectively, accounting for 10.6% and 5.3% of the variance in the model. CONCLUSIONS: In general, the type of strategy use in older adults with MCI is related to cognitive functioning. By examining an individual's profile of cognitive dysfunction, a clinician can provide more personalized clinical recommendations regarding strategy use to individuals with MCI, with the aim of maintaining their day-to-day functioning and self-efficacy in daily life.

Feasibility and effectiveness of computerised cognitive training for memory dysfunction following stroke: A series of single case studies.

Computerised cognitive training (CCT) approaches to memory rehabilitation represent an attractive alternative to traditional approaches; however, there is limited empirical evidence to support their use. An AB with follow up single case design was repeated across five participants to explore the feasibility and effectiveness of CCT on subjective memory in patients with stroke. Target behaviour was subjective everyday and prospective memory failures which were assessed weekly. Following baseline (three weeks), participants completed six weeks of LumosityTM training in their homes. Data were analysed visually and statistically. The frequency of prospective memory failures decreased during intervention for one participant, while the frequency of prospective and everyday memory failures decreased significantly during the follow up period for another participant. Yet, significantly more everyday and prospective memory failures were reported following training by one study participant. No significant change in subjective memory ratings was found for remaining participants. Regarding secondary outcomes, meaningful changes on objective measures of memory were not observed, despite considerable inter-individual variability. Three participants reported improvement in individualised memory goals, while two participants described a decline. Overall, LumosityTM training appears feasible; however, no consistent evidence to support effectiveness of this CCT on subjective or objective memory was found.

Understanding the experience of compensatory and restorative memory rehabilitation: A qualitative study of stroke survivors.

Memory impairment is common following stroke. Memory skills groups (MSGs) utilising compensatory strategies and computerised cognitive training (CCT) are two rehabilitation approaches available to improve memory function; however, there is no consensus as to which is more effective following stroke. This study aimed to explore and contrast the qualitative experiences of 20 stroke survivors (Mage = 61.90, SD = 10.48, range: 34-77 years) who received six weeks' training in MSG (manualised memory skills group, n = 10) or individual-CCT (LumosityTM, n = 10). Using semi-structured interviews, data were collected and analysed thematically, adopting a critical realist approach. Six themes were identified: (1) Facilitators and barriers to intervention engagement, (2) Improving knowledge and understanding, (3) Connecting with others, (4) Perception of the intervention, (5) Impact on everyday memory and (6) Impact on emotions and sense of purpose. Encouragingly, most participants valued and enjoyed participating in the memory interventions, irrespective of rehabilitation approach. MSG participants reported learning and sharing with similar others as important to the experience and described everyday memory improvements. CCT participants described enjoyment of its game-like nature, yet reported frustration associated with game-specific characteristics, and did not report everyday memory improvements.

Clinical and cost effectiveness of memory rehabilitation following traumatic brain injury: a pragmatic cluster randomized controlled trial.

OBJECTIVE: To evaluate the clinical and cost effectiveness of a group-based memory rehabilitation programme for people with traumatic brain injury. DESIGN: Multicentre, pragmatic, observer-blinded, randomized controlled trial in England. SETTING: Community. PARTICIPANTS: People with memory problems following traumatic brain injury, aged 18-69 years, able to travel to group sessions, communicate in English, and give consent. INTERVENTIONS: A total of 10 weekly group sessions of manualized memory rehabilitation plus usual care (intervention) vs. usual care alone (control). MAIN MEASURES: The primary outcome was the patient-reported Everyday Memory Questionnaire (EMQ-p) at six months post randomization. Secondary outcomes were assessed at 6 and 12 months post randomization. RESULTS: We randomized 328 participants. There were no clinically important differences in the primary outcome between arms at six-month follow-up (mean EMQ-p score: 38.8 (SD 26.1) in intervention and 44.1 (SD 24.6) in control arms, adjusted difference in means: -2.1, 95% confidence interval (CI): -6.7 to 2.5, p = 0.37) or 12-month follow-up. Objectively assessed memory ability favoured the memory rehabilitation arm at the 6-month, but not at the 12-month outcome. There were no between-arm differences in mood, experience of brain injury, or relative/friend assessment of patient's everyday memory outcomes, but goal attainment scores favoured the memory rehabilitation arm at both outcome time points. Health economic analyses suggested that the intervention was unlikely to be cost effective. No safety concerns were raised. CONCLUSION: This memory rehabilitation programme did not lead to reduced forgetting in daily life for a heterogeneous sample of people with traumatic brain injury. Further research will need to examine who benefits most from such interventions.

Errorless (re)learning of everyday activities in patients with Korsakoff's syndrome: A feasibility study.

Errorless learning has proven to be an effective method for (re)learning tasks in several patient groups with amnesia. However, so far only a handful of studies have examined the effects of errorless learning in patients with Korsakoff's syndrome. The aims of this feasibility study were to (a) examine the effects of errorless learning training on (re)learning tasks in a patient with Korsakoff's syndrome, (b) examine the effects of the nature of the training on the execution of the tasks, and (c) examine characteristics that may mediate learning outcome. Professional caregivers, who were trained in errorless learning principles, taught 51 patients with Korsakoff's syndrome two everyday tasks. Significant improvements in the performance were found after an errorless intervention for different types of trained tasks (activities of daily living, chores, mobility, housekeeping). Moreover, the results of this study suggest that all patients, despite of age, educational level, or level of cognitive functioning, may benefit from errorless learning. The results showed that, despite severe amnesia, patients with Korsakoff's syndrome have the potential to (re)learn everyday skills. Errorless learning might be beneficial for memory rehabilitation in patients with Korsakoff's syndrome in clinical practice. The results of this study are clinically relevant, as successfully learning tasks using errorless learning principles might improve autonomy and independence in the daily lives of patients with Korsakoff's syndrome.

The use of a smartwatch as a prompting device for people with acquired brain injury: a single case experimental design study.

Prompting-based memory compensation is a potential application for smartwatches. This study investigated the usability and efficacy of a Moto360 smartwatch as a memory aid. Four community dwelling adults with memory difficulties following acquired brain injury (ABI) were included in an A-B-A single case experimental design study. Performance of everyday memory tasks was tested over six weeks with the smartwatch and software provided during weeks three and four. Participants were asked to use their usual memory aids and strategies during the control phases (weeks 1-2, 5-6). Three participants successfully used the smartwatch throughout the intervention weeks and gave positive usability ratings. A fourth participant experienced a seizure and subsequently left the study before the intervention phase. Three participants showed improved memory performance when using the smartwatch. Nonoverlap of all pairs (NAP) analysis showed a non-significant small increase in memory performance between baseline and intervention phases (mean NAP = 0.1, p = .84). There was a larger, significant decline between the intervention and return to baseline (mean NAP = 0.58, p < .01). The use of an off-the-shelf smartwatch device and software was feasible for people with ABI in the community. It was effective compared to practice as usual, although this was only apparent on withdrawal of the device.

Technological memory aid use by people with acquired brain injury.

Evans, Wilson, Needham, and Brentnall ( 2003 ) investigated memory aid use by people with acquired brain injury (ABI) and found little use of technological memory aids. The present study aims to investigate use of technological and other memory aids and strategies 10 years on, and investigate what predicts use. People with ABI and self-reported memory impairments (n = 81) completed a survey containing a memory aid checklist, demographic questions and memory questionnaires. Chi-square analysis showed that 10 of 18 memory aids and strategies were used by significantly more people in the current sample than in Evans et al. ( 2003 ). The most commonly used strategies were leaving things in noticeable places (86%) and mental retracing of steps (77%). The most commonly used memory aids were asking someone to remind you (78%), diaries (77%), lists (78%), and calendars (79%) and the most common technologies used were mobile phone reminders (38%) and alarms/timers (38%). Younger people who used more technology prior to their injury and who use more non-technological memory aids currently were more likely to use technology. Younger people who used more memory aids and strategies prior to their injury and who rated their memory as poorer were more likely to use all types of memory aids and strategies.

Descriptions of memory rehabilitation group interventions for neurological conditions: a systematic review.

OBJECTIVE: To establish what aspects of group-based cognitive rehabilitation for memory problems are reported, and to develop a checklist for authors, which may to improve reporting of these interventions in future studies. DATA SOURCES: A systematic search was conducted on Web of Knowledge, CINAHL, MEDLINE, AMED, EMBASE and PsycINFO electronic databases (last search: 01/05/2015). REVIEW METHODS: Articles were included if the sample were adults with a neurological disorder, the intervention was group-based cognitive rehabilitation for memory problems, and if the study was a randomised controlled trial. Articles were independently screened for inclusion and data extracted by two researchers, with the third researcher arbitrating any disputes. RESULTS: Fourteen studies were included in this review. The reporting of certain aspects of an intervention was found to be poor, particularly in relation to: duration of the programme (6 of 14 studies did not report), the development of the intervention (7 of 14 studies did not discuss), and the content and structure of intervention (7 of the 14 studies did not provide details). CONCLUSION: This review found that the overall reporting of memory rehabilitation content and format is poor. Refinement and adaption of pre-existing checklists to capture aspects of cognitive rehabilitation programmes may help authors when reporting complex interventions. A draft checklist is provided that could be refined and validated in further research.

An evaluation of treatment integrity in a randomised controlled trial of memory rehabilitation for people with multiple sclerosis.

OBJECTIVE: To assess the treatment integrity of a memory rehabilitation programme for people with multiple sclerosis. SUBJECTS: Data were drawn from the intervention group of a randomised controlled trial of memory rehabilitation. This comprised 24 participants with multiple sclerosis. MEASURES: Four core session components were identified from the treatment manual: recap, activities, take-home activity and other. One video-recording of each of ten intervention sessions was transcribed and amount of time spent on components recorded. RESULTS: There were no significant differences between early and late stages of the programme in time spent on the core components (recap Z= -0.87, P=0.49; activities Z = -0.29, P=0.89; take-home activity Z = -0.59, P=0.69; other Z = -0.58, P=0.69). Thus, adherence to the manual was good with no evidence of programme drift. CONCLUSIONS: Good adherence indicates the intervention was delivered as described in the manual and strengthens confidence in the findings of the randomised controlled trial.

EEG-Neurofeedback as a Potential Therapeutic Approach for Cognitive Deficits in Patients with Dementia, Multiple Sclerosis, Stroke and Traumatic Brain Injury.

Memory deficits are common in patients with dementia, such as Alzheimer's disease, but also in patients with other neurological and psychiatric disorders, such as brain injury, multiple sclerosis, ischemic stroke and schizophrenia. Memory loss affects patients' functionality and, by extension, their quality of life. Non-invasive brain training methods, such as EEG neurofeedback, are used to address cognitive deficits and behavioral changes in dementia and other neurological disorders by training patients to alter their brain activity via operant activity. In this review paper, we analyze various protocols of EEG neurofeedback in memory rehabilitation in patients with dementia, multiple sclerosis, strokes and traumatic brain injury. The results from the studies show the effectiveness of the ΕΕG-NFB method in improving at least one cognitive domain, regardless of the number of sessions or the type of protocol applied. In future research, it is important to address methodological weaknesses in the application of the method, its long-term effects as well as ethical issues.

Diencephalic versus Hippocampal Amnesia in Alzheimer's Disease: The Possible Confabulation-Misidentification Phenotype.

BACKGROUND: Alzheimer's disease (AD) is clinically heterogeneous, including the classical-amnesic (CA-) phenotype and some variants. OBJECTIVE: We aim to describe a further presentation we (re)named confabulation-misidentification (CM-) phenotype. METHODS: We performed a retrospective longitudinal case-series study of 17 AD outpatients with the possible CM-phenotype (CM-ADs). Then, in a cross-sectional study, we compared the CM-ADs to a sample of 30 AD patients with the CA-phenotype (CA-ADs). The primary outcome was the frequency of cognitive and behavioral features. Data were analyzed as differences in percentage by non-parametric Chi Square and mean differences by parametric T-test. RESULTS: Anterograde amnesia (100%) with early confabulation (88.2%), disorientation (88.2%) and non-infrequently retrograde amnesia (64.7%) associated with reduced insight (88.2%), moderate prefrontal executive impairment (94.1%) and attention deficits (82.3%) dominated the CM-phenotype. Neuropsychiatric features with striking misidentification (52.9%), other less-structured delusions (70.6%), and brief hallucinations (64.7%) were present. Marked behavioral disturbances were present early in some patients and very common at later stages. At the baseline, the CM-ADs showed more confabulation (p < 0.001), temporal disorientation (p < 0.02), misidentification (p = 0.013), other delusions (p = 0.002), and logorrhea (p = 0.004) than the CA-ADs. In addition, more social disinhibition (p = 0.018), reduction of insight (p = 0.029), and hallucination (p = 0.03) persisted at 12 months from baseline. Both the CA- and CM-ADs showed anterior and medial temporal atrophy. Compared to HCs, the CM-ADs showed more right fronto-insular atrophy, while the CA-ADs showed more dorsal parietal, precuneus, and right parietal atrophy. CONCLUSION: We described an AD phenotype resembling diencephalic rather than hippocampal amnesia and overlapping the past-century description of presbyophrenia.

VR for Cognition and Memory.

This chapter will provide a review of research into human cognition through the lens of VR-based paradigms for studying memory. Emphasis is placed on why VR increases the ecological validity of memory research and the implications of such enhancements.

Cuing Prospective Memory With Smartphone-Based Calendars in Alzheimer's Disease.

OBJECTIVES: We investigated the effect of using smartphone-based calendars (Google and Outlook Calendar) on prospective memory in Alzheimer's disease (AD). METHODS: we recruited two groups of participants with mild AD. In one group, prospective memory was cued by a paper-and-pencil calendar, whereas in the second group prospective memory was cued by a smartphone calendar application. After 2 weeks of training to familiarize the participants with calendar use, we invited participants to perform three prospective events per week (e.g., remembering to go to the grocery store) during a 3-week period. Events were cued either by the paper- or smartphone-based calendar. RESULTS: we observed fewer omissions of prospective events in the smartphone-based calendar group than in the paper-based calendar group. CONCLUSIONS: our study suggests positive effects of smartphone calendar applications on prospective memory in AD.