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|Case Study - Page 2|
Because memory treatment doesn't often follow a reimbursable diagnostic scheme, and because many older adults feel stigmatized by employing insurance benefits requiring a psychiatric diagnosis, many of my older clients choose to pay privately for memory-remediation therapy and prefer to think of it as educational assistance, or even expert coaching. My academic affiliation often makes it easier for me to engage with clients who have these concerns.
I told Steve I'd be glad to consult with him about his memory issues and explained what the ground rules would be if he were to come see me. He'd have to commit to at least seven, 50-minute, weekly sessions. In the first, I'd take a history of his memory lapses and administer a screening assessment. If I was concerned that he might have a memory disease, I'd refer him to a medical expert for follow-up. Either way, after the assessment, he and I would set up a six-session training schedule. Steve asserted that this was doable.
The website www.positiveager.com/pa Resources.htm includes an assessment toolkit for clients with memory concerns, which are free downloads from the public domain. Using an assessment kit of this type can help you decide whether your client needs a referral to a specialist to rule out a memory disease, or whether memory counseling alone might meet his or her needs. Even if tests indicate the presence of Alzheimer's or some other form of dementia, good therapists will stay engaged with their clients. As therapists, we can provide educational materials, apply strategies to improve or maintain memory when possible, help them manage the consequences of memory disease, help clients plan for the future, and train current (or future) caregivers in skills that address the client's issues.
Even though no pills or diets or physical exercises can return memory to its youthful proficiency, people actually have more control over memory loss than they think. The key to preserving memory in your later years is in knowing how to engage your existing resources to offset deficits. I call this active compensation. Persons who are best at compensating work at it the hardest. As therapists, we need to keep reminding our older clients that, even in the face of memory decline, they often have what much younger people don't: a fund of life experience, acquired wisdom, intellectual discipline, problem-solving abilities, and hard-earned realism about the world. Our older clients can bring these resources to bear on age-related memory loss. So while we aren't in the business of giving them back the steel-trap memories they had at 25 (any more than we can get our own memory capacity back), we can help our aging clients draw on their other cognitive skills and learn how to use these gifts to compensate for what they've lost.
When we met for the first time, I learned from Steve that much of his work involved free (or unsupported) recall tasks—the most challenging domain for learning and retrieving of information from memory. In free recall, the environment offers few, if any, cues to aid in information retrieval. For example, though he kept notes about the content of his sermons, he spoke mostly from memory, quoting the Bible, recalling a storyline, recollecting a date or a name quickly, and at times—spontaneously and without notes—answering questions from individuals in his congregation. This kind of recall is exceedingly common for all of us and is often embedded in mundane, but difficult, everyday tasks, like punching in a personal identification number at an automatic teller machine, dialing a phone number you just looked up in the telephone book, or entering a computer password that, for security purposes, you just changed. The only cue or assistance Steve had to aid his recall was to conjure up a reminder, such as linking his mother's birthday to the location of a newly memorized Bible verse (June 14, 1926, to John 14:26)—something hard to do consistently on the fly.
During our first session, I compiled a history of his memory issues, including strategies he used to remember all kinds of information: where he put things (keys, glasses, sermons, bills); important dates and phone numbers; his schedule for the day, week, month, and long-term projects; and, of course, the names and faces of his friends, acquaintances, and members of his congregation. The following week, we reviewed Steve's assessment, and the good news was that I found no indication of a memory disease. This information always greatly relieves clients: just knowing you don't have a disease makes the time and money spent on therapy seem like a good investment. Since clients are still uncertain about what the performance threshold on these tests really measures, I go through specific test items to show the errors a person with dementia typically makes. This gives clients a better idea of what kinds of cognitive deficits characterize a disease state. My foremost goals for Steve were to help him understand his weaknesses, appreciate his relative memory strengths, and do what he could to sustain and buttress the latter.
Steve's performance on the screening tests was in the normal range overall, but he did have trouble on the "free" information-recall section. Because he didn't take the time to learn information—or deeply encode it, as the process is called in the memory-training literature—he didn't have the internal reminders (or cues) at the ready to aid him in information retrieval. When he was asked on the memory test to learn five words—pen, tie, house, car, apple—for later recall, he repeated the words a few times, and then was ready to move on to the next question. Using a deeper encoding strategy instead, he could make up a quick sentence using these words: "My father wears a pen clipped to his tie when he walks from the house to the car that he drives to buy an apple. " This latter strategy would ensure that Steve remembered these words at a later time. His lack of strategy in this instance wasn't because he was lazy, but because he wasn't practiced in using memory techniques to help his day-to-day routine. Also, my testing revealed that when he got anxious or fatigued, his memory performance worsened.