Prospective memory rehabilitation for adults with traumatic brain injury: A compensatory training programme

A review of prospective memory in individuals with acquired brain injury

OBJECTIVE

Prospective memory (PM) deficits have emerged as an important predictor of difficulty in daily life for individuals with acquired brain injury (BI). This review examines the variables that have been found to influence PM performance in this population. In addition, current methods of assessment are reviewed with a focus on clinical measures. Finally, cognitive rehabilitation therapies are reviewed, including compensatory, restorative and metacognitive approaches.

METHOD

Preferred reporting items for systematic reviews and meta-analyses guidelines were used to identify studies. Studies were added that were identified from the reference lists of these.

RESULTS

Research has begun to elucidate the contributing variables to PM deficits after BI, such as attention, executive function and retrospective memory components. Imaging studies have identified prefrontal deficits, especially in the region of BA10 as contributing to these deficits. There are now several clinical measures available with good psychometric properties. Rehabilitation techniques have mostly focused on compensatory strategies, but, in addition, some restorative and metacognitive approaches have shown preliminary promise.

CONCLUSIONS

PM deficits are a common and important deficit after BI. Clinical evaluation is recommended and further understanding of rehabilitation techniques is needed.

Retrospective and Prospective Memory Among OEF/OIF/OND Veterans With a Self-Reported History of Blast-Related mTBI

OBJECTIVES

To evaluate prospective and retrospective memory abilities in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans with and without a self-reported history of blast-related mild traumatic brain injury (mTBI).

METHODS

Sixty-one OEF/OIF/OND Veterans, including Veterans with a self-reported history of blast-related mTBI (mTBI group; n=42) and Veterans without a self-reported history of TBI (control group; n=19) completed the Memory for Intentions Test, a measure of prospective memory (PM), and two measures of retrospective memory (RM), the California Verbal Learning Test-II and the Brief Visuospatial Memory Test-Revised.

RESULTS

Veterans in the mTBI group exhibited significantly lower PM performance than the control group, but the groups did not differ in their performance on RM measures. Further analysis revealed that Veterans in the mTBI group with current PTSD (mTBI/PTSD+) demonstrated significantly lower performance on the PM measure than Veterans in the control group. PM performance by Veterans in the mTBI group without current PTSD (mTBI/PTSD-) was intermediate between the mTBI/PTSD+ and control groups, and results for the mTBI/PTSD- group were not significantly different from either of the other two groups.

CONCLUSIONS

Results suggest that PM performance may be a sensitive marker of cognitive dysfunction among OEF/OIF/OND Veterans with a history of self-reported blast-related mTBI and comorbid PTSD. Reduced PM may account, in part, for complaints of cognitive difficulties in this Veteran cohort, even years post-injury. (JINS, 2018, 24, 324-334).

Ecologically Valid Assessment of Prospective Memory for Task Planning and Execution by Adults With Acquired Brain Injury

PURPOSE

Individuals with acquired brain injury (ABI) often struggle due to inadequate planning and execution skills for completing nonroutine tasks. This study's purpose was to pilot ecologically valid procedures to assess planning for and execution of prospective daily activities.

METHOD

Participants included 9 adults with histories of severe ABI and 9 controls. Data collection included both prospective task planning and execution. First, participants created a plan for later execution of daily tasks in accordance with preestablished rules. Over the subsequent 10 days, participants independently attempted task completion. Differences within and between participant groups regarding planning and task performance were evaluated statistically and through examiner observation.

RESULTS

Participants with ABI implemented minimal planning strategies. They demonstrated highly variable performance and displayed substantially greater difficulty initiating and successfully executing tasks in adherence to rules than participants without ABI.

CONCLUSIONS

Evaluating planning strategies and execution of novel prospective tasks is a crucial but often neglected aspect of assessment following ABI. Implementing ecologically valid procedures to evaluate this aspect of functioning can reveal individual strengths and challenges and provide guidance for developing effective intervention programs. Examining potential roles played by planning and strategy execution provides critical assessment information relating to independent living.

Prospective memory in youth with perinatally-acquired HIV infection

Youth with perinatal HIV infection (PHIV) are at increased risk for neurocognitive impairment (NCI). Prospective memory (PM) is a complex neurocognitive function that has been shown to be impaired in adults with HIV disease and independently associated with poorer daily living skills, including medication nonadherence. The current study sought to determine the presence and extent of PM deficits in youth with PHIV. Participants included 173 youth with PHIV and 85 youth perinatally HIV-exposed but uninfected (PHEU), mean age 14.1 years, 75% black, 18% Hispanic. Among youth with PHIV, 26% had a past AIDS-defining condition (Centers for Disease Control and Prevention [CDC], Class C), 74% did not (non-C). Adjusted generalized estimating equation models were used to compare groups (PHIV/C, PHIV/non-C, and PHEU) on the Naturalistic Event-Based Prospective Memory Test (NEPT) and the Prospective Memory Assessment for Children & Youth (PROMACY). Secondarily, subgroups defined by HIV serostatus and global NCI were compared (PHIV/NCI, PHIV/non-NCI, PHEU). PHIV/C had significantly lower NEPT scores than PHEU, with decreases of 40% in mean scores, but did not differ from PHIV/non-C. PHIV/NCI had 11-32% lower PROMACY scores and 33% lower NEPT scores compared to PHIV/non-NCI (all p < .05); significantly, lower scores for PHIV/NCI versus PHEU also were observed for PROMACY and NEPT indices. Findings suggest a subset of youth with PHIV (those with a prior AIDS-defining diagnosis) is vulnerable to PM deficits. The extent to which PM deficits interfere with development and maintenance of independent living and health-related behaviors during transition to adulthood requires further study.

Prospective memory impairment in multiple sclerosis: a review

OBJECTIVE

Multiple sclerosis (MS) is a progressive disease of the central nervous system affecting information processing speed, episodic memory, attention, and executive functions. MS patients also often report prospective memory (PM) failures that directly impact their functional autonomy, including professional and social life. The purpose of this paper was to review the literature concerning the assessment and remediation of PM deficits in MS.

METHOD

The literature pertaining to PM impairment in MS was carefully reviewed using PubMed, PsyINFO, and Google Scholar, as well as cross-references from the articles published on this topic. Since PM rehabilitation in MS patients is still in its infancy, this review mainly focuses on studies that have directly assessed PM through various measures including questionnaires, standardized clinical tests, and experimental procedures.

CONCLUSION

This literature review confirms the presence of PM deficits in MS patients, even in the early stages of the disease. A further need for controlled studies on PM assessment and PM interventions in patients with MS is stressed.

Cognitive impairment and clinical characteristics in patients with chronic obstructive pulmonary disease

We aimed to investigate (1) the relationship between cognitive impairment (CI) and disease severity and (2) the potential differences in exercise performance, daily activities, health status, and psychological well-being between patients with and without CI. Clinically stable chronic obstructive pulmonary disease (COPD) patients, referred for pulmonary rehabilitation, underwent a neuropsychological examination. Functional exercise capacity (6-minute walk test [6MWT]), daily activities (Canadian Occupational Performance Measure [COPM]), health status (COPD Assessment Test [CAT]) and St George’s Respiratory Questionnaire-COPD specific [SGRQ-C]), and psychological well-being (Hospital Anxiety and Depression Scale [HADS], Beck Depression Inventory [BDI], and Symptom Checklist 90 [SCL-90]) were compared between patients with and without CI. Of 183 COPD patients (mean age 63.6 (9.4) years, FEV₁ 54.8 (23.0%) predicted), 76 (41.5%) patients had CI. The prevalence was comparable across Global Initiative for Chronic Obstructive Lung Disease (GOLD) grades 1–4 (44.8%, 40.0%, 41.0%, 43.5%, respectively, p = 0.97) and GOLD groups A–D (50.0%, 44.7%, 33.3%, 40.2%, respectively, p = 0.91). Patients with and without CI were comparable for demographics, smoking status, FEV₁% predicted, mMRC, 6MWT, COPM, CAT, HADS, BDI, and SCL-90 scores. Clinical characteristics of COPD patients with and without CI are comparable. Assessment of CI in COPD, thus, requires an active case-finding approach.

A randomized controlled trial to treat impaired learning and memory in multiple sclerosis: The self-GEN trial

Background:

Difficulties in learning and memory are among the most persistent and frequently reported cognitive symptoms in individuals with multiple sclerosis (MS).

Objective:

To examine the efficacy of the self-generation learning program ( self-GEN trial) that consist of behavioral intervention sessions, teaching self-generation technique while using metacognitive strategies to improve learning and memory abilities in persons with MS. Additionally, the treatment aimed to address generalization of the treatment to activities of daily living.

Methods:

This double-blind, placebo-controlled, randomized clinical trial included 35 participants with clinically definite MS, 19 in the treatment group and 16 in the placebo control group. Participants completed a baseline neuropsychological assessment, including questionnaires assessing everyday memory and a repeat assessment immediately post-treatment.

Results:

The treatment group showed significantly improved learning and memory, self-regulation, and metacognition relative to the placebo post-treatment. Similar results were noted on measures of depression, functional status, and quality of life (QOL).

Conclusion:

This study provides initial Class I evidence that the self-GEN behavioral intervention improves memory, self-regulation, functional status, affective symptomatology, and QOL in patients with MS.

A meta-analysis of task-related influences in prospective memory in traumatic brain injury

Prospective memory is the ability to remember to do something in the future and it is essential to every-day functional independence. Traumatic brain injury is associated with frequent and persistent prospective memory deficits. This study presents a review and meta-analysis investigating the effects of task parameters on prospective memory performance of individuals with TBI. Individual studies using continuous behavioural measures of prospective memory with a sample of adults with TBI and matched controls were included. Consistent with previous research, a random effects meta-analysis indicated that TBI groups demonstrated lower prospective memory performance than control groups (d = 1.10, SE = 0.12, 95% CI = 0.86-1.34). In addition, we found that type of prospective memory cue, saliency of cues, and complexity of the ongoing task significantly moderated the difference in prospective memory performance between TBI and control groups. These findings suggest that prospective memory task parameters should be considered in the assessment of prospective memory in individuals with cognitive impairment. In addition, considering the influence of these task parameters would be useful to develop effective compensatory strategies to reduce prospective memory failures.

Prospective memory intervention using visual imagery in individuals with brain injury

Prospective memory deficits are common after brain injury and can create impediments to independent living. Most approaches to management of such deficits are compensatory, such as the use of notebooks or electronic devices. While these can be effective, a restorative approach, in theory, could lead to greater generalisation of treatment. In the current study a metacognitive technique, using visual imagery, was employed under conditions of rote repetition and spaced retrieval. Treatment was provided in an AB-BA crossover design with A as the active treatment and B as a no-treatment attention control to 20 individuals with brain injury. A group of 20 healthy participants served to control for effects of re-testing. Individuals with brain injury demonstrated improvement on the main outcome measure of prospective memory, the Memory for Intentions Screening Test, only after the active treatment condition. In addition, some generalisation of treatment was measured in daily life. Moreover, treatment gains were maintained for one year after treatment was completed.

The efficacy of prospective memory rehabilitation plus metacognitive skills training for adults with traumatic brain injury: study protocol for a randomized controlled trial

BACKGROUND

Impairment of prospective memory (PM) is common following traumatic brain injury (TBI) and negatively impacts on independent living. Compensatory approaches to PM rehabilitation have been found to minimize the impact of PM impairment in adults with TBI; however, poor self-awareness after TBI poses a major barrier to the generalization of compensatory strategies in daily life. Metacognitive skills training (MST) is a cognitive rehabilitation approach that aims to facilitate the development of self-awareness in adults with TBI. This paper describes the protocol of a study that aims to evaluate the efficacy of a MST approach to compensatory PM rehabilitation for improving everyday PM performance and psychosocial outcomes after TBI.

METHODS/DESIGN

This randomized controlled trial has three treatment groups: compensatory training plus metacognitive skills training (COMP-MST), compensatory training only (COMP), and waitlist control. Participants in the COMP-MST and COMP groups will complete a 6-week intervention consisting of six 2-h weekly training sessions. Each 1.5-h session will involve compensatory strategy training and 0.5 h will incorporate either MST (COMP-MST group) or filler activity as an active control (COMP group). Participants in the waitlist group receive care as usual for 6 weeks, followed by the COMP-MST intervention. Based on the sample size estimate, 90 participants with moderate to severe TBI will be randomized into the three groups using a stratified sampling approach. The primary outcomes include measures of PM performance in everyday life and level of psychosocial reintegration. Secondary outcomes include measures of PM function on psychometric testing, strategy use, self-awareness, and level of support needs following TBI. Blinded assessments will be conducted pre and post intervention, and at 3-month and 6-month follow-ups.

DISCUSSION

This study seeks to determine the efficacy of COMP-MST for improving and maintaining everyday PM performance and level of psychosocial integration in adults with moderate to severe TBI. The findings will advance theoretical understanding of the role of self-awareness in compensatory PM rehabilitation and skills generalization. COMP-MST has the potential to reduce the cost of rehabilitation and lifestyle support following TBI because the intervention could enhance generalization success and lifelong application of PM compensatory strategies.

TRIAL REGISTRATION

New Zealand Clinical Trials Registry, ACTRN12615000996561 . Registered on 23 September 2015; retrospectively registered 2 months after commencement.

Domain-specific cognitive impairment in patients with COPD and control subjects

Impaired cognitive function is increasingly recognized in COPD. Yet, the prevalence of cognitive impairment in specific cognitive domains in COPD has been poorly studied. The aim of this cross-sectional observational study was to compare the prevalence of domain-specific cognitive impairment between patients with COPD and non-COPD controls. A neuropsychological assessment was administered in 90 stable COPD patients and 90 non-COPD controls with comparable smoking status, age, and level of education. Six core tests from the Maastricht Aging Study were used to assess general cognitive impairment. By using Z-scores, compound scores were constructed for the following domains: psychomotor speed, planning, working memory, verbal memory, and cognitive flexibility. General cognitive impairment and domain-specific cognitive impairment were compared between COPD patients and controls after correction for comorbidities using multivariate linear and logistic regression models. General cognitive impairment was found in 56.7% of patients with COPD and in 13.3% of controls. Deficits in the following domains were more often present in patients with COPD after correction for comorbidities: psychomotor speed (17.8% vs 3.3%; P<0.001), planning (17.8% vs 1.1%; P<0.001), and cognitive flexibility (43.3% vs 12.2%; P<0.001). General cognitive impairment and impairments in the domains psychomotor speed, planning, and cognitive flexibility affect the COPD patients more than their matched controls.

Qualitative exploration of the benefits of group-based memory rehabilitation for people with neurological disabilities: implications for rehabilitation delivery and evaluation

OBJECTIVE

To identify patient-perceived benefits of memory rehabilitation and draw transferrable lessons for the delivery and evaluation of similar interventions for people with neurological disabilities.

METHODS

A qualitative study was conducted as part of a pragmatic randomised controlled trial comparing 2 memory rehabilitation approaches with a self-help control group. Postintervention interviews were conducted with 20 participants with a diagnosis of traumatic brain injury, multiple sclerosis or stroke. Data were analysed using a qualitative content analysis approach.

RESULTS

Participants receiving memory rehabilitation reported that the sessions responded to previously unmet needs for information on brain injury and memory function and developed their insight along with a sense of self-efficacy and control over the management of their memory problems. Although they did not experience major improvements in their memory function per se, they reported that rehabilitation gave them the skills to effectively cope with the residual deficits. Respondents in the control groups did not report similar benefits. The opportunities for interaction offered by the group setting were greatly valued by all respondents. Mixed aetiology groups were received positively; however, marked differences in cognitive performance were frustrating for some participants.

CONCLUSIONS

The study highlighted important patient-perceived outcomes that should be considered by researchers and rehabilitation professionals when evaluating the effects of memory rehabilitation. The use of domain-specific outcome measures which reflect these areas is recommended. Qualitative changes in the use of memory aids may be achieved which cannot be captured by frequency indices alone. The benefits of the group-based rehabilitation approach were stressed by participants, suggesting that a combination of group and individual sessions might be a good practice.

TRIAL REGISTRATION NUMBER

ISRCTN92582254; Results.

Do memory aids help everyday memory? A controlled trial of a Memory Aids Service

There is a growing body of knowledge about the use of compensatory memory aids in memory rehabilitation, but relatively few controlled trials on how to train the use of such aids. This study investigated the effects of systematic training in the use of compensatory memory aids on everyday memory functioning within a Memory Aids Service. In a controlled clinical trial, a comparison was made between treatment participants and waiting list controls. Participants had everyday memory problems secondary to progressive or non-progressive neurological conditions. Following baseline assessment and goal setting, treatment participants underwent three training sessions, in which memory aids were matched to goals, across a six week period, with a follow-up assessment 12 weeks later. Outcome was measured by a goal attainment diary, neuropsychological test performance, psychosocial questionnaires and a problem solving inventory. There was a significant treatment effect of training on the goal attainment diary but only at 12 weeks follow-up. A post-hoc analysis indicated that treatment was effective for participants with a non-progressive condition but not for participants with a progressive condition. We conclude that a Memory Aids Service can be beneficial for patients with a non-progressive neurological condition, and make suggestions that might inform future applications of memory aids with those who have a progressive neurological disorder.

Cognitive and neural plasticity in older adults' prospective memory following training with the Virtual Week computer game

Prospective memory (PM) – the ability to remember and successfully execute our intentions and planned activities – is critical for functional independence and declines with age, yet few studies have attempted to train PM in older adults. We developed a PM training program using the Virtual Week computer game. Trained participants played the game in 12, 1-h sessions over 1 month. Measures of neuropsychological functions, lab-based PM, event-related potentials (ERPs) during performance on a lab-based PM task, instrumental activities of daily living, and real-world PM were assessed before and after training. Performance was compared to both no-contact and active (music training) control groups. PM on the Virtual Week game dramatically improved following training relative to controls, suggesting PM plasticity is preserved in older adults. Relative to control participants, training did not produce reliable transfer to laboratory-based tasks, but was associated with a reduction of an ERP component (sustained negativity over occipito-parietal cortex) associated with processing PM cues, indicative of more automatic PM retrieval. Most importantly, training produced far transfer to real-world outcomes including improvements in performance on real-world PM and activities of daily living. Real-world gains were not observed in either control group. Our findings demonstrate that short-term training with the Virtual Week game produces cognitive and neural plasticity that may result in real-world benefits to supporting functional independence in older adulthood.

Development of Neuropsychological Measures: Personal Experience and Lessons Learnt

This paper briefly reviews the history and purposes of neuropsychological assessment, as well as advancements in this area, and discusses the development of neuropsychological tests, using examples developed by the author and his colleagues to measure different aspects of human memory. These include the Shum Visual Learning Test, the Australian Retrograde Memory Test, the Comprehensive Assessment of Prospective Memory and the Virtual Reality Prospective Memory Task. The intended uses and psychometric properties of these tests, as well as examples of their use in research and clinical settings, will also be discussed. The paper will conclude with recommendations and advice on the development of neuropsychological tests based on the author's own experience.

Prospective memory performance in traumatic brain injury patients: a study of implementation intentions

Traumatic brain injury (TBI) patients often present with prospective memory (PM) dysfunction. Forgetting to complete tasks may result in a loss of independence, limited employment prospects and anxiety, therefore, it is important to develop programs to improve PM performance in TBI patients. A strategy which may improve PM performance is implementation intentions. It involves making explicit plans specifying when, where and how one will perform a task in the future. In the present study, a group of 36 TBI patients and a group of 34 controls performed Virtual Week using either implementation intentions or no strategy. The results showed that the PM performance of TBI patients was less accurate than controls, in particular when the PM cue was time-based. No effect of implementation intentions was observed for TBI patients, however, controls improved their PM performance when the task was time-based. The findings suggest that strategies to improve PM in this clinical group are likely to be more complex than those that benefit healthy adults and may involve targeting phases of the PM process other than, or in addition to, the intention formation phase.

Validation of the Cambridge Prospective Memory Test (Hong Kong Chinese version) for people with stroke

This study aimed to develop and evaluate a Hong Kong Chinese version of the Cambridge Prospective Memory Test (CAMPROMPT-HKCV). Thirty-three subjects at least one year post-stroke participated in the study. They were simultaneously rated on version A of the CAMPROMPT-HKCV by two testers to establish its internal consistency and inter-rater reliability. Raters used the parallel versions of the test (A and B), in rating 10 patients within 2 weeks to establish the parallel form reliability. Another 10 were also assessed on the same day using both version A of the CAMPROMPT-HKCV and the Rivermead Behavioural Memory Test-Chinese version (RBMT-CV) to establish concurrent validity. A new group of 40 stroke patients and 44 healthy controls was recruited to establish its sensitivity and specificity. Results indicated that test-retest reliability on time-based, event-based and total scores, and inter-rater reliability for versions A and B of the test were high. Cronbach's alpha of the event-based score was higher than that of the time-based score. The reliability and concurrent validity of the parallel forms were established. There was a significant difference in performance on CAMPROMPT-HKCV (version A) between the stroke group and the healthy control group. ROC analysis showed that the ability of the cut-off CAMPROMPT-HKCV (total score) to differentiate PM problems was 20.5 (out of 36) with sensitivity at 95.5% and specificity at 55.9%. Further study in developing stratified norms across different age groups in Chinese-speaking stroke patients is recommended.

An occupation-based video feedback intervention for improving self-awareness: Protocol and rationale

Background.

Impaired self-awareness can limit rehabilitation outcomes for people with traumatic brain injury (TBI). Video feedback on occupational performance has been found to improve self-awareness after TBI when delivered according to specific principles.

Purpose.

The purpose of this article is to describe an occupation-based video feedback intervention found to be effective in a randomized controlled trial to assist with translation into clinical practice.

Key Issues.

The intervention uses therapist-mediated video feedback on clients’ occupational performance, aiming to facilitate self-reflection on performance and improve self-awareness. This paper describes the theoretical background, intervention principles, and protocol of the intervention.

Implications.

Therapists can use video feedback intervention, incorporating the principles in this article, to improve people’s intellectual awareness and ability to recognize and correct errors during task performance after TBI without a negative impact on emotional status.

Google Calendar: A single case experimental design study of a man with severe memory problems

A single case experimental design across behaviours was utilised to explore the effectiveness of Google Calendar text alerts delivered to a mobile phone as a memory aid. The participant was a 43-year-old man (JA) with severe memory problems and executive difficulties caused by a traumatic brain injury (TBI). JA was initially very unwilling to use any memory aid and so a detailed assessment of his beliefs about memory aids, his cognitive difficulties and his social context was performed and a set of specifications for an aid was produced collaboratively. Six weeks of baseline data and six weeks of intervention data were collected for three target memory behaviours and three control memory behaviours. Results were analysed using nonoverlap of all pairs (NAP) analysis which showed a reduction in forgetting in the three target behaviours and no change in two of the three control behaviours. A subjective measure (the revised Everyday Memory Questionnaire) also suggested improvement. This study illustrates that Google Calendar is a highly effective memory aid and emphasises the importance of choosing a memory aid to suit the person's lifestyle and beliefs.

Construct validity of the Memory for Intentions Screening Test (MIST) in healthy older adults

The Memory for Intentions Screening Test (MIST) is a clinical measure of prospective memory. There is emerging support for the sensitivity and ecological relevance of the MIST in clinical populations. In the present study, the construct validity of the MIST was evaluated in 40 younger (18-30 years), 24 young-old (60-69 years), and 37 old-old (70+ years) healthy adults. Consistent with expectations derived from the prospective memory and aging literature, older adults demonstrated lower scores on the MIST's primary scale scores (particularly on the time-based scale), but slightly better performance on the seminaturalistic 24-hour trial. Among the healthy older adults, the MIST showed evidence of both convergent (e.g., verbal fluency) and divergent (e.g., visuoperception) correlations with standard clinical tests, although the magnitude of those correlations were comparable across the time- and event-based scales. Together, these results support the discriminant and convergent validity of the MIST as a measure of prospective memory in healthy older adults.

Prospective memory training in older adults and its relevance for successful aging

In research on cognitive plasticity, two training approaches have been established: (1) training of strategies to improve performance in a given task (e.g., encoding strategies to improve episodic memory performance) and (2) training of basic cognitive processes (e.g., working memory, inhibition) that underlie a range of more complex cognitive tasks (e.g., planning) to improve both the training target and the complex transfer tasks. Strategy training aims to compensate or circumvent limitations in underlying processes, while process training attempts to augment or to restore these processes. Although research on both approaches has produced some promising findings, results are still heterogeneous and the impact of most training regimes for everyday life is unknown. We, therefore, discuss recent proposals of training regimes aiming to improve prospective memory (i.e., forming and realizing delayed intentions) as this type of complex cognition is highly relevant for independent living. Furthermore, prospective memory is associated with working memory and executive functions and age-related decline is widely reported. We review initial evidence suggesting that both training regimes (i.e., strategy and/or process training) can successfully be applied to improve prospective memory. Conceptual and methodological implications of the findings for research on age-related prospective memory and for training research in general are discussed.

Testing the effectiveness of group-based memory rehabilitation in chronic stroke patients

Memory complaints are common after stroke, yet there have been very few studies of the outcome of memory rehabilitation in these patients. The present study evaluated the effectiveness of a new manualised, group-based memory training programme. Forty outpatients with a single-stroke history and ongoing memory complaints were enrolled. The six-week course involved education and strategy training and was evaluated using a wait-list crossover design, with three assessments conducted 12 weeks apart. Outcome measures included: tests of anterograde memory (Rey Auditory Verbal Learning Test: RAVLT; Complex Figure Test) and prospective memory (Royal Prince Alfred Prospective Memory Test); the Comprehensive Assessment of Prospective Memory (CAPM) questionnaire and self-report of number of strategies used. Significant training-related gains were found on RAVLT learning and delayed recall and on CAPM informant report. Lower baseline scores predicted greater gains for several outcome measures. Patients with higher IQ or level of education showed more gains in number of strategies used. Shorter time since onset was related to gains in prospective memory, but no other stroke-related variables influenced outcome. Our study provides evidence that a relatively brief, group-based training intervention can improve memory functioning in chronic stroke patients and clarified some of the baseline factors that influence outcome.

A randomized controlled trial of the effectiveness of handheld computers for improving everyday memory functioning in patients with memory impairments after acquired brain injury

Objective:

To determine the effectiveness of personal digital assistant devices on achievement of memory and organization goals in patients with poor memory after acquired brain injury.

Design:

Assessor blinded randomized controlled trial.

Setting:

Specialist brain injury rehabilitation hospital (inpatients and outpatients).

Participants:

Adults with acquired brain impairments (85% traumatic brain injury; aged ≥17 years) who were assessed as having functional memory impairment on the Rivermead Behavioural Memory Test (General Memory Index).

Interventions:

Training and support to use a personal digital assistant for eight weeks to compensate for memory failures by an occupational therapist. The control intervention was standard rehabilitation, including use of non-electronic memory aids.

Main outcome measures:

Goal Attainment Scale which assessed achievement of participants’ daily memory functioning goals and caregiver perception of memory functioning; and General Frequency of Forgetting subscale of the Memory Functioning Questionnaire administered at baseline (pre-randomization) and post intervention (eight weeks later).

Results:

Forty-two participants with memory impairment were recruited. Use of a personal digital assistant led to greater achievement of functional memory goals (mean difference 1.6 (95% confidence interval (CI) 1.0 to 2.2), P = 0.0001) and improvement on the General Frequency of Forgetting subscale (mean difference 12.5 (95% CI 2.0 to 22.9), P = 0.021).

Conclusions:

Occupational therapy training in the use of a handheld computer improved patients’ daily memory function more than standard rehabilitation.

Effects of video modelling on emerging speech in an adult with traumatic brain injury: preliminary findings

PRIMARY OBJECTIVE

Research has shown that traumatic brain injury (TBI) can affect a person's ability to perform previously learned skills. Dysexecutive syndrome and inattention, for example, alongside a number of other cognitive and behavioural impairments such as memory loss and lack of motivation, significantly affect day-to-day functioning following TBI. This study examined the efficacy of video modelling in emerging speech in an adult male with TBI caused by an assault.

RESEARCH DESIGN

In an effort to identify functional relations between this novice intervention and the target behaviour, experimental control was achieved by using within-system research methodology, overcoming difficulties of forming groups for such an highly non-homogeneous population.

METHODS AND PROCEDURES

Across a number of conditions, the participant watched a videotape in which another adult modelled a selection of 19 spoken words. When this modelled behaviour was performed in vivo, then generalization across 76 other words in the absence of a videotape took place.

MAIN OUTCOMES AND RESULTS

It was revealed that video modelling can promote the performance of previously learned behaviours related to speech, but more significantly it can facilitate the generalization of this verbal behaviour across untrained words.

CONCLUSIONS

Video modelling could well be added within the rehabilitation programmes for this population.

External Memory Aid Training after Traumatic Brain Injury: ‘Making it Real’

Introduction:

A number of options exist for the rehabilitation of memory after traumatic brain injury, and research suggests that the use of external memory aids is one of the best approaches. Unfortunately, there is very little evidence to guide therapists in training clients to use external memory aids and to ensure the sustainable use of the aids long term.

Method:

Grounded theory methodology was used to explore the question of how occupational therapists train clients to use external memory aids after a traumatic brain injury. Semi-structured interviews, with eight occupational therapists working in neurological rehabilitation, were conducted until data collection reached a saturation point. The data were analysed following the constant comparative method proposed by Strauss and Corbin.

Findings:

Analysis revealed four overlapping processes: developing client insight, getting client buy-in, getting others on board and making it real. Making it real emerged as the core process that encompassed and ran through the other three. It emphasised the need for occupational therapists to use meaningful, functional activities in order to establish an aid that fitted the client's real life.

Conclusion:

The processes uncovered by this study give occupational therapists working in the field of brain injury rehabilitation guidance for clinical practice.

Improving memory in outpatients with neurological disorders using a group-based training program

Memory problems are common in patients with a range of neurological conditions, but there have been few attempts to provide and evaluate the usefulness of memory training for groups of neurological outpatients. We used a waitlist-controlled trial design to assess the effectiveness of a newly created, 6-session intervention, which involved training in the use of compensatory strategies as well as education regarding memory function, neurological damage, sleep and lifestyle factors that have an impact on memory. Fifty-six patients with neurological conditions (e.g., stroke, epilepsy) and memory complaints completed the training and assessments. Outcomes were evaluated in terms of reported strategy use as well as objective and subjective measures of anterograde and prospective memory. Training resulted in significant improvements on number of strategies used, scores on the Rey Auditory Verbal Learning Test (total learning and delayed recall) and self-report on the Comprehensive Assessment of Prospective Memory. Improvements were stable at 3-month follow-up. Better individual outcomes were related to lower baseline memory scores, fewer symptoms of depression and greater self-awareness of memory function. Overall the study provides encouraging results to indicate that patients with neurological conditions such as stroke and epilepsy can show improvements in memory after a relatively short group-based intervention.

Time-based prospective memory in severe traumatic brain injury patients: the involvement of executive functions and time perception

Prospective memory (PM) is the ability to remember to perform a future action at a specified later time, which is investigated through the use of event-based and time-based tasks. Prior investigations have found that PM is impaired following traumatic brain injury (TBI). However, there is limited information regarding the cognitive functions that mediate TBI and PM performance. Thus, this study investigated time-based PM in TBI patients, and the relationship among time-based PM, time perception, and executive functions. To accomplish this objective, 18 severe TBI patients and 18 healthy matched controls performed a time-based PM task, a time reproduction task, and two executive functions (Stroop and n-back) tasks. While both groups increased their monitoring frequency close to the target time, TBI patients monitored more and were less accurate than healthy controls at the target time confirming the time-based PM dysfunction in these patients. Importantly, executive functions, particularly inhibition and updating abilities, were strongly related to time-based PM performance; both time perception and executive functions are involved in time-based prospective memory in controls, whereas, only executive functions appear to be involved in TBI time-based prospective memory performance.

Prospective memory rehabilitation based on visual imagery techniques

Despite the frequency of prospective memory (PM) problems in the traumatic brain injury (TBI) population, there are only a few rehabilitation programmes that have been specifically designed to address this issue, other than those using external compensatory strategies. In the present study, a PM rehabilitation programme based on visual imagery techniques expected to strengthen the cue-action association was developed. Ten moderate to severe chronic TBI patients learned to create a mental image representing the association between a prospective cue and an intended action within progressively more complex and naturalistic PM tasks. We hypothesised that compared to TBI patients (n = 20) who received a short session of education (control condition), TBI patients in the rehabilitation group would exhibit a greater improvement on the event-based than on the time-based condition of a PM ecological task. Results revealed however that this programme was similarly beneficial for both conditions. TBI patients in the rehabilitation group and their relatives also reported less everyday PM failures following the programme, which suggests generalisation. The PM improvement appears to be specific since results on cognitive control tasks remained similar. Therefore, visual imagery techniques appear to improve PM functioning by strengthening the memory trace of the intentions and inducing an automatic recall of the intentions.

Validity of the Comprehensive Assessment of Prospective Memory (CAPM) for Use With Adults With Traumatic Brain Injury

Objective: To expand upon the existing psychometric properties of the Comprehensive Assessment of Prospective Memory (CAPM) for use with adults with traumatic brain injury by examining concurrent and criterion validity. Method: Participants were 45 adults with a traumatic brain injury. Participants and their relatives completed Section A of the CAPM and a measure of psychosocial integration. Participants were also administered two neuropsychological tests of prospective memory, the Cambridge Prospective Memory Test (CAM-PROMPT) and the Memory Intentions Screening Test (MIST). Concurrent validity was measured by comparing scores on the CAPM with scores on the CAM-PROMPT and MIST. Criterion validity was examined by correlating CAPM scores with level of psychosocial integration. Results: Participant self-reports on the CAPM were not significantly correlated with the CAM-PROMPT or MIST, but were significantly correlated with level of psychosocial integration. Relative reports on the CAPM were correlated significantly with total score on the MIST and CAM-PROMPT and level of psychological integration. Conclusions: The findings indicate that the concurrent validity of the self-report version of CAPM is low suggesting that self-reports alone do not provide an objective measure for assessing prospective memory function. The relative report version however, demonstrated reasonable concurrent and criterion validity, suggesting that the relative report version of the Section A of the CAPM is a useful means of evaluating frequency of prospective memory failure in adults with traumatic brain injury.

Prospective Memory Intervention: A Review and Evaluation of a Pilot Restorative Intervention

Prospective memory impairments continue to be among the greatest impediments to return to work for individuals following neurological illness or injury. Current approaches to prospective memory intervention are reviewed in this article. These include behavioral interventions, metacognitive strategies and restorative approaches. In addition, the summary of a study using the restorative approach is presented and discussed. Eight subjects were given a course of prospective memory training designed to increase the length of time that they are able to maintain to-be-performed tasks in mind. These subjects demonstrated improvement on neurospsychological measures, a standardised measure of prospective memory and a generalisation measure of prospective memory in daily life. These data lend support to the notion that prospective memory may be one area of cognition that is responsive to restorative intervention approaches.

The Multiple Sclerosis Work Difficulties Questionnaire

Background: A better understanding of the workplace difficulties experienced by people with multiple sclerosis (PwMS) may be critical to developing appropriate vocational and rehabilitative programs.

Objective: We aimed to assess the factor structure, internal consistency and validity of the new Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ).

Methods: Work difficulty items were developed and reviewed by a panel of experts. Using the MSWDQ, cross-sectional self-report data of work difficulties were obtained in addition to employment status and MS disease information, in a community-based sample of 189 PwMS.

Results: Exploratory Maximum Likelihood Factor Analysis on the draft questionnaire yielded 50 items measuring 12 factors. Subscale internal consistencies ranged from 0.74 to 0.92, indicating adequate to excellent internal consistency reliability. The MSWDQ explained 40% of the variance in reduced work hours since diagnosis, 40% of the variance in expectations about withdrawing from work, 34% of the variance in expectations about reducing work hours, and 39% of the variance in expectations about changing type of work due to MS.

Conclusion: The MSWDQ is a valid and internally reliable measure of workplace difficulties in PwMS. Physical difficulties, as well as cognitive and psychological difficulties were important predictors of workplace outcomes and expectations about future employment.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Prospective memory in patients with closed head injury: a review

This paper aimed to review the limited, but growing literature on prospective memory (PM) following closed head injury (CHI). Search of two commonly used databases yielded studies that could be classified as: self- or other-report of PM deficits; behavioral PM measures in adults with CHI, behavioral PM measures in children and adolescents with CHI, and treatment of PM in adults with CHI. The methodology and findings of these studies were critically reviewed and discussed. Because of the small number of studies, meta-analysis was only conducted for studies that used behavioral PM measures in adults to integrate findings. PM deficits were found to be commonly reported by patients with CHI and their significant others and they could be identified using behavioral measures in adults, children and adolescents with CHI. However, more work is needed to clarify the nature and mechanisms of these deficits. Although some promising results have been reported by studies that evaluated PM treatment, most studies lack tight experimental control and used only a small number of participants. The paper concluded with some suggestions for future research.

Patterns of agitated behaviour during acute brain injury rehabilitation

OBJECTIVE

To monitor daily shift-by-shift changes in agitated behaviour during adult brain injury rehabilitation.

DESIGN

A prospective, descriptive study.

METHODS

Eight participants were monitored daily for up to 28 days. The Agitated Behaviour Scale (ABS) evaluated behaviour during three nursing shifts (morning, afternoon, night). Severity of agitation, peak intensity and concomitant behaviours were calculated. Shift differences and patterns of behavioural changes were analysed.

RESULTS

Four hundred and seven recordings were taken with the ABS. All participants demonstrated multiple agitated behaviours (between 3-13 concomitant behaviours per person); the most common behaviours were representative of the ABS Disinhibition sub-scale. Weekly peak intensity ranged from 14-55 on the ABS. Mean ABS scores were highest during the afternoon shift and lowest at night. Improved cognition was associated with resolving agitated behaviour; while persistent agitated behaviour was associated with low levels of cognition. Minimal agitated behaviour was observed in participants who emerged from post-traumatic amnesia.

CONCLUSIONS

Agitated behaviour during acute brain injury rehabilitation has a complex clinical presentation. High levels of agitation observed during the afternoon shift may be associated with low levels of structured activities available at that time, higher levels of environmental stimuli during visiting times and increased cognitive fatigue. Lower cognitive ability was related to consistently higher levels of agitated behaviour and vice-versa.