Cognitive Treatment Update:
The following is a discussion about a study conducted by Drs. Daniel N. Allen, Rock Heyman, and myself at the VA Pittsburgh Healthcare System and the University of Pittsburgh. The case elucidates several valuable points in cognitive rehabilitation.
Memory failure is one of the major neuropsychological findings in MS and one of the major complaints of patients. They do not have amnesia, but rather something that you might more simply call forgetfulness or intermittent failures of memory. These are the people who forget appointments, who leave the house meaning to bring something with them and don't bring it, and so on. In that sense, they have similar traits to people who have had closed-head injuries.
In our lab, we have tried to retrain the memory of people with MS who had complaints of memory failure using a number of mnemonic methods based primarily on imagery. The techniques rely on making a picture in your mind of what you want to remember and using this picture to organize the material. There are two methods: the "story method'' and "Face-name learning.''
In the story method, you may have to remember a shopping list. You would take the words on the list and make up a story about them; then you would put the words into a story and go back and try to remember the list. The face-name method has to do with remembering the name of a person on first introduction, a common failure among us all. Here we teach patients to form an image between the name and some picture they can recall easily. For instance, if somebody's name was Harry, think of somebody who has a lot of hair. So you meet Harry. Harry has a lot of hair. You develop that image to remember the name Harry. A variation on this is to associate the name with a celebrity (e.g., person looks like Bruce Willis).
Our first work with these methods was applied to patients with closed-head injury, with good results. We then applied it to Multiple Sclerosis. Our preliminary work involved a single case study of an individual with MS who produced very encouraging results. Subsequently a sample of ten subjects was obtained, eight of whom completed the study. Their average age was 37-years old, with an average of 14 years of education, and they had an average level mean IQ. The mean score on the Mattis Dementia Rating Scale was not in the dementia range. All of these are indicators that these patients did not have clinical evidence of dementia. They were given a series of commonly used memory tests. On the Wechsler Memory Scale the scores were all in the low end of the average range, except for delayed recall, which was clearly below average. Delayed recall is recalling information after about a half an hour, during which you are doing other things. The subjects were given another test called the Rivermead Behavioral Memory Test. The Rivermead tests practical memory where, rather than learn a list of words, subjects are asked to recall practical things, such as names or costs of items. The patient is asked to hide three objects in the room and then find them after a period of time. These scores were considered to be in the "poor memory'' range.
We also gave the Beck Depression and Beck Anxiety Inventory. The Beck Depression Inventory was at a range clinically significant for depression. On average, these people had significant problems with depression. The patients were given a memory questionnaire, which asked questions such as "how often do you leave the house meaning to take something with you and you forget to take it with you?'' The answers are "every day,'' or "once a week,'' or "once a month,'' or "every few months.'' Their scores were borderline abnormal, not at the magnitude of a frank amnesia, but certainly at a level that would be disabling in every day life.
We gave the Beck and the memory questionnaire before and after the imagery training.
The patients were trained over a course of 15 sessions, about 3 times a week. They were first referred to a story on a computer screen containing words in boldface. After having read the story, they are asked to recall the words in boldface and to type them into the computer. As patients begin to understand the system, they are encouraged to provide real life lists and stories. Patients with MS responded to this learning method very quickly in contrast to patients with head injury, who ultimately succeeded, but took longer. That is, they were able to recall lengthy word lists through relating the words to their contexts in the stories.
The same learning curve was found in Face-name learning. Using a video library that can randomly associate names with faces, we were able to introduce "new faces" to patients and teach them to remember names. Learning was rapid and the patients accurately recalled increasing numbers of names across sessions.
When the training was completed, we again gave the Beck Depression Inventory and the memory questionnaire to the MS patients. They were significantly less depressed and had less complaints of memory failure. They also had numerous spontaneous comments about how positive they felt about the training and how it was helping them in their everyday life. On the memory questionnaire, episodes of forgetfulness occurring once a month previously, was now reported as occurring "once every few months.'' The Beck scores went from the depression range to outside the depression range.
These encouraging results may merit further refined study. It appears patients with MS may improve their memory loss in practical matters through imagery based methods of memory training. They appear to learn these techniques quickly, making these methods a potentially effective interim procedure for coping with the progressive cognitive loss associated with the disease.
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