Working with Memory Problems Presented by Dr Nigel George Clinical Psychologist

Growing Older  “Growing old… what is the opposite of ‘growing’? I ask myself. Withering perhaps? It is, I assume, quite easy to wither into old age, and hard to grow into it” (Mary Sarton).

Why has the person got memory problems? Any physical health issues: Any physical health issues: Infections Infections Bloods Bloods Falls Falls Concussion Concussion CT scan CT scan Depression Depression Anxiety Anxiety Mild Cognitive Impairment Mild Cognitive Impairment Dementia Dementia

Quick revision of memory How memory made? How memory made? Absorbing (encoding) Absorbing (encoding) Storing Storing Recalling Recalling

Process of making memories Working memory Working memory STM STM LTM – autobiographical, procedural, faces, words etc LTM – autobiographical, procedural, faces, words etc Different areas of the brain involved and difficulties can occur in one or many areas Different areas of the brain involved and difficulties can occur in one or many areas Most common difficulty with emerging Alzheimer dementia is ‘absorbing’ new verbal information Most common difficulty with emerging Alzheimer dementia is ‘absorbing’ new verbal information

MCI Mild Cognitive Impairment (MCI) – what is it? Mild Cognitive Impairment (MCI) – what is it? Still can function, neuro psych have only memory problems or other subtle changes; MMSE not specific enough to pick it up Still can function, neuro psych have only memory problems or other subtle changes; MMSE not specific enough to pick it up How many convert to dementia? How many convert to dementia? 6-25% of people presenting with MCI will convert to Dementia each following year 6-25% of people presenting with MCI will convert to Dementia each following year Approximately 10% remain stable in fact some become normal again over time Approximately 10% remain stable in fact some become normal again over time Diagnosis of increased risk rather than of degeneration Diagnosis of increased risk rather than of degeneration

Working with Memory Problems Treatments: Treatments: Physical - body Physical - body Medication Medication Social – the carer Social – the carer Environmental Environmental Psychological Psychological Holistic is best! Holistic is best!

Journey of Increasing Memory Issues MCI MCI Clearer Forgetfulness Clearer Forgetfulness Early Dementia Early Dementia Mild Mild Moderate Moderate Severe Severe ‘Treatments in each area build on not move on’ ‘Treatments in each area build on not move on’

Strategies for Working with Memory Problems 1. Absent minded – normally more of an attention problem Improve concentration: Improve concentration: Make sure awake!! Make sure awake!! Focus attention and avoid distractions Focus attention and avoid distractions Don’t divide attention – do one thing at a time Don’t divide attention – do one thing at a time Short activities Short activities Frequent breaks Frequent breaks Give information in slow, absorbable form Give information in slow, absorbable form

Absent minded - continued Hydrated Hydrated Blood sugar Blood sugar Time of the day Time of the day Physical activity – good for lowering risk of a developing vascular dementia in particular Physical activity – good for lowering risk of a developing vascular dementia in particular Pain? – very distracting Pain? – very distracting Other meds and side effects e.g. Valium Other meds and side effects e.g. Valium Cognitive stimulation Cognitive stimulation Maintenance of social network Maintenance of social network

2. Early memory problem – forgetfulness – aware of issues – still motivate self to do these tasks External aides to memory: External aides to memory: Note books Note books Memory station Memory station Dictaphone Dictaphone Calendar Calendar Clocks at right time Clocks at right time Diary Diary Associate new information with older information Associate new information with older information Conscious of use of mnemonic Conscious of use of mnemonic Repeat information – verbal Repeat information – verbal Chunk information – telephone numbers Chunk information – telephone numbers Organise information – post it notes Organise information – post it notes Bleepers for medication Bleepers for medication Begin to use more visual cues and prompts Begin to use more visual cues and prompts

3. Memory problem (Dementia) – can’t remember verbal information just given – repeated asking, a little disorientated at times Reality orientation: Reality orientation: Verbal prompts and cues Verbal prompts and cues External cues – signs in rooms, clocks, calendars, etc External cues – signs in rooms, clocks, calendars, etc Structure/routine Structure/routine Medication (dementia) Medication (dementia)

4. Moderate memory problems: Can’t remember much of what is said to them. Can’t remember much of what is said to them. Begin to not remember faces. Begin to not remember faces. Disorientated – place and time of day. Disorientated – place and time of day. Might be getting some other problem behaviours emerging – disinhibited/agitation etc. Might be getting some other problem behaviours emerging – disinhibited/agitation etc. Reality orientation/validation: Reality orientation/validation: More obvious cues (signs) and reminders around home More obvious cues (signs) and reminders around home Begin validation techniques Begin validation techniques Start to rely more on autobio memory – reminiscence therapy Start to rely more on autobio memory – reminiscence therapy Rely more on visual memory – use photos as prompts to life Rely more on visual memory – use photos as prompts to life Use of routine Use of routine Carer starts to more clearly become ‘the environment’ Carer starts to more clearly become ‘the environment’

5. Severe memory problems – appears confused a lot of the time, can’t remember significant people, places, where they are etc. Maybe some behavioural problems – aggressive, disinhibited etc Person centred care: Person centred care: Environment more important Environment more important ABC charts ABC charts Comforters, manipulators, distracters Comforters, manipulators, distracters Life books Life books

Dementia with severe behavioural and psychological symptoms (BPSD) BPSD behaviours might include: BPSD behaviours might include: Wandering Wandering Yelling Yelling Disorientated Disorientated Disinhibited Disinhibited Personality changes Personality changes Sun downing Sun downing Apathy Apathy

Dementia Dementia – multiple cognitive (thinking) deficits – memory, language, frontal (organization, planning, inhibiting) Dementia – multiple cognitive (thinking) deficits – memory, language, frontal (organization, planning, inhibiting) Types: Types: Alzheimer's Alzheimer's Vascular Vascular Frontal temporal and others Frontal temporal and others Treatments: Treatments: Environmental (nursing/psychological/activity) Environmental (nursing/psychological/activity) Medication Medication

Approaches to dementia care Reliance on care environment most important - ‘rementing’ – environmentally driven behaviours Reliance on care environment most important - ‘rementing’ – environmentally driven behaviours Behaviour modification – ABC – knowing the person’s history Behaviour modification – ABC – knowing the person’s history Reality Orientation - 24hr/individual Reality Orientation - 24hr/individual Reminiscence - life review/reminiscence Reminiscence - life review/reminiscence Validation therapy Validation therapy Stimulation - OT/exercise/Music/Dogs/Snoezelen Stimulation - OT/exercise/Music/Dogs/Snoezelen Working with care givers - family therapy/elder abuse/nurses Working with care givers - family therapy/elder abuse/nurses

How understand? THE CARER 1. Care practices 2. Attitudes of carers 3. Relationships

How understand? THE ENVIRONMENT 1. Architecture 2. Interior decoration 3. Layout

How understand? BIOLOGY 1. Dementia 2. Sensory Changes 3. Physical Changes 4. Ill Health Pain

How understand? THE PERSON 1. Life History 2. Attributes 3. Beliefs and Expectations 4. Habits and Needs

How understand? THE CARER 1. Care practices 2. Attitudes of carers 3. Relationships THE ENVIRONMENT 1. Architecture 2. Interior decoration 3. Layout BIOLOGY 1. Dementia 2. Sensory Changes 3. Physical Changes 4. Ill Health Pain THE PERSON 1. Life History 2. Attributes 3. Beliefs 4. Habits THE BEHAVIOUR Behaviour (ie. mood, thought, speech and action)