I saw my barber, Ray, yesterday, and he asked me if I wanted the senior discount. "Ray," I said, "How old do you think I am?" He was polite. "I'm not sure, but if you want the senior discount, you need to ask for it." At a mere 54 years, I insisted on paying the full charge.
I'm a youngster when it comes to longevity, but my barber's misjudgment and my mildly deflated ego caused me to reconsider the markers many of us use to decide whether or not we're old. For Ray, appearance was everything. And to look at me—the not-so-subtle signs of balding, the gray beard, and the errant hairs protruding from my ears and nose—told him I was a card-carrying senior citizen.
What really concerns me, however, isn't my appearance, but the internal processes that tell me I'm old. The signs and symptoms of memory decay are hitting the radar screen of middle-agers at a higher frequency than ever before. Maybe it's because the 21st century expects us to remember more and do it faster, like the stream of computer passcodes or personal identification numbers, which keep growing in length and complexity. Maybe it's because, in an aging population, the media have discovered Alzheimer's with a vengeance, and we begin fearing its onset in every forgotten name or word.
According to the most recent 2010 Alzheimer's Disease Fact and Figures, an estimated 5.3 million Americans have Alzheimer's, including 200,000 persons under the age of 65. About 14 percent of Americans aged 71 and older have dementia, a broader label for memory diseases of aging, not specifically Alzheimer's—17 percent among women, 11 percent among men. Just because your mother or father didn't contract Alzheimer's disease doesn't mean that you're immune. The increase of average life expectancy puts even "long livers" into the high-risk category for memory impairment. The prevalence statistics increase in one's ninth decade, so if you yourself aren't afflicted with dementia when you're 80, the chances are that at least 20 percent of clients in their 80s will be seeking your help for it.
With this in mind, it isn't surprising that even "normal, age-related memory deficits" can strike dread into middle-aged hearts. Certainly, these maddening memory lapses dominate the lexicon of professional gerontology, and the proliferation of memory-disorder clinics signals a rising level of social concern, not to say panic, among the boomer-aged and older, generated by what are often euphemistically called personal memory slips.
Since our population is aging, memory decline is something middle aged and older clients are increasingly bringing to therapists. In fact, the first thing that most clients who make an appointment with me want is reassurance that they don't have brain disease. Once that issue has been addressed, we have to help them—whether or not they have a medical problem—understand that memory is like any other bodily ability: it shows the signs of natural aging. Finally, we need to engage them, gently but firmly, in a realistic program of memory training, making it clear that if they want to improve their skills at recall, they'll have to know it's important to always work at it. No therapist, no neurologist, no expert of any kind has a magic potion or intervention that'll miraculously recover for them the memory skills they had at 18 or 25, or even 35.
From Memory Slips to Alzheimer's
A few months ago, just after I'd concluded one of the positive-aging workshops I hold each summer, a tall, trim, keen-eyed, white-haired man came up to see me from the audience. He introduced himself as Steve and said he'd been pastor of his local congregation for nearly 30 years. He was on a first-name basis with his 228 regular parishioners. At age 72, in excellent physical health, he thought he could continue to lead his flock for at least another decade. However, he was deeply worried about persistent memory slips, which seemed to be worsening. He made jokes about his forgetfulness, but beneath his playfulness was an obvious fear that his problem might be an early indication of Alzheimer's or dementia.
Steve's worries were compounded by his lingering sense that his parishioners and their families were construing his intermittent forgetfulness—of their names and important dates—as a sign of lack of interest. His fear—that they might think he didn't care enough to remember their names—was so serious that he'd become less engaged with some of them. Even when I pointed out that his ministerial work made substantial demands on his memory, he remained anxious, becoming more so as we talked.
During his years as pastor, Steve had learned many coping strategies, which he artfully used to compensate for his declining memory. He'd leveraged his social skills so that he could convey interpersonal connectedness, no matter which member of his congregation he was talking to or what the topic of conversation was, even when his recall of specifics failed him. He also was becoming more dependent on his wife, since she helped him put names to faces in novel ways. During conversations at social gatherings and after church, she'd cleverly insert information to aid Steve's recollection. She might say, for example, "Steve, you remember that the Johnsons have that fishing camp out on the lake—Jake here is a champion fisherman, and Deanna is a wizard at cooking the catch." However, should he be without her when the talk veered in a direction requiring recall of personal details, he could find himself caught in a moment of forgetfulness so severe that he was forced to admit it and then apologize. It was clear that he was beginning to fear the worst.
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.
After we reviewed Steve's assessment, I told him we'd spend the remaining sessions improving skills that he already possessed. For him, as for many clients, this was surprising and not necessarily welcome. He believed he didn't have any memory skills left (the bad news), but he hoped that I'd somehow magically supply those skills to him (the good news). I acknowledged that sometimes it's hard not just to recognize your own abilities, but to do the work required to take advantage of them. In short, remembering no longer would be the automatic process it had been for Steve when he was younger, but now would require conscious effort.
I engaged him in exercises to identify and review the strategies he was currently using to remember sermons, especially sermons that involved learning new material. I challenged him, through some structured handouts, to take time during the upcoming week to jot down "the strategies that you use to remember things," and congratulated him for already taking steps to boost his memory capacity. "Steve, give yourself permission to acknowledge that you're already a memory expert; you just never realized it."
He returned to our third session having completed the assignment, and was pleased to discover that he was already employing many memory aids, like using a checklist to remember the materials he needed from home and keeping a notepad on which he wrote down parishioners' names that were more difficult to remember. We discussed external versus internal aids. Sometimes, for example, external aids are the obvious choice—a container or a place where important items, like wallet and car keys, are automatically deposited to avoid misplacing them, or a checklist as a reminder to take items needed on a trip or to work. Steve's strategy of keeping a notepad to write things down—the name of a parishioner he didn't want to forget, the time of an appointment, an important date to remember—is an excellent use of an external aid. External aids require as much skill to use as internal aids, and practice using external aids—like checklists, reminder notes, and regular locations for important objects—is essential to gain proficiency with them.
In the fourth session, we examined a class of memory device called mnemonics, which would help Steve retrieve information on demand without external aids. Mnemonics link personal or familiar information, such as an object or a location in one's home, with an unfamiliar or to-be-remembered item, such as an item needed at the grocery store. Steve was quick to point out that one way he used this method with names and faces was to remember people as a group according to where they lived (this is a mnemonic known as categorization). He'd created strong memories of the parishioners who lived on his own block by associating unique features of their houses with their first and last names. For example, Ray Leveridge lives in the small house on the corner, with the big garage that he must hand open (or RAYz) with the large handle (or LEVER) on the front of the door. Steve noted that when people came to church regularly and sat in the same pews, it gave him cues for remembering their names. I explained to him that this strategy was actually a well-known mnemonic, called "the method of loci." Mnemonics go by many names, including peg-word, number-consonant, and name-face mnemonic. (The full range of mnemonics can be found on my webpage, http:// www.positiveager.com, with detailed information, including videos on how to use them.) Indeed, Steve was discovering that what he thought were his own home-grown strategies were formally described mnemonic techniques, which we could continue to refine for his personal use.
Like my other clients, Steve found that fixed, session-by-session memory-remediation training ended with his surprised discovery that his own repertoire of skills was sufficient to meet his memory demands. The time and practice are taken up not so much by providing arcane and specialized intervention, as by helping clients consciously and diligently apply what they already know to new situations and challenges.
When people complain about "memory loss," they're probably experiencing something cognitively and emotionally more complex than a simple skills deficit. To provide good memory-remediation training requires not just knowledge of assessment and training strategies, but understanding how the brain works, where memory deficits originate, and—perhaps most important—the connections between cognitive and emotional processing. Steve's description of his problem didn't suggest a disease of the brain, but rather that his anxiety and sense of diminished self-efficacy were making his memory deficits worse. A key part of this therapy was helping him to stay calm in the face of memory slips—not to catastrophize to the worst-case scenario—and reassuring him that he was most likely doing his job well, even with some diminished memory. As often happens, the key to memory training with Steve wasn't coming up with startling new ideas and fancy techniques, but helping him recognize, actualize, and refine his existing skills.
By Terry Hargrave
As Robert Hill points out in this case study, people have a fair amount of anxiety and fear concerning memory loss. The fact that longevity is increasing in our society guarantees that memory deficits will increase as more and more of us have aging brains. There's little doubt that the prescription that Hill recommends here is on target in terms of being able to assess when a person simply needs to apply more skills and training toward the work of memory versus determining that there's a serious disease. Both assessment and training are essential in dealing with problems of memory, but my main question in this case is this: did Hill lose psychotherapeutic opportunities with Steve because of the psychoeducational process?
I have nothing against psychoeducation and memory improvement, but it seems to me that several psychotherapeutic issues are lost in this vignette. First and foremost, the primary issue that memory loss reminds us of is that we're making adjustments in response to conditions indicating that we're headed toward the end of life. We can't work ourselves out of dying or the anxiety and fear that death signals.
I'm absolutely for positive aging, and there are important and positive ways to engage these fears so as to move an older population toward being generative and connecting in relationships. The way our society and psychotherapy deal with aging is often to try and make sure that we can keep people functioning in middle age. While this is sometimes appropriate, it is also necessary to deal with the real therapeutic questions of aging and memory loss when Steve might not be able to combat the effects of his aging. Helping Steve reckon with those questions would help him in his aging adjustment if he isn't so lucky as to be able to work another 10 years.
My second point centers on Hill's statement that, if Steve had had indications of a serious disease such as Alzheimer's, he'd have suggested referral for in-depth assessment. No doubt this is needed, but serious therapeutic work is called for too, as Steve would have to face the grief and loss of a terminal disease, along with the turmoil of anticipating the loss of a sense of self and recollections and connections with others. Therapeutic work with Steve and his family would go far in easing his emotional pain, guiding the role and care structure for the family and making the most of the memory that remains. We can do much more with these families than simply to refer or train.
Finally, I'd suggest that there's a need to prepare Steve's family for an eventual care-giving role for him. Aging brings on losses, and memory loss is a signal that Steve and the family must start asking questions about care. The fear that compels him to explore his memory loss is the same fear that may keep him quiet on the subject of his eventual needs. Loss signals opportunities for these discussions, and I believe Hill would have done well to use the opportunity to begin this discussion. Steve likely won't require care until he's in his 80s, but talking about and settling these issues is much easier now, when he's 72, than when he's in immediate need of it.
Terry Hargrave has highlighted an important issue that faces all older adults: the phenomenology of irretrievable loss. Although this wasn't the focus of the case, I agree with his assertion that psychotherapy is an excellent arena in which to address this concern.
Because Steve had been a pastor for many years, he'd dealt with issues of irretrievable loss among members of his parish, including the death of family members, the disabilities brought on by chronic disease, and even profound memory deprivation resulting from Alzheimer's. Therefore, his difficulty in accepting his own losses as a consequence of age-related decline was part of our therapy, although it wasn't presented in the case.
My approach to Steve's memory issues was focused and optimistic because he had the personal resources to remediate his memory deficits. Learning strategies to adapt to memory loss lifted his mood as it helped him continue functioning well in his pastoral role.
I agree with Hargrave's viewpoint that, as psychotherapists, we have much to offer our older clientele to aid them with the realities of irreversible age-related loss. However, I'm also aware of the growing and substantial research literature indicating that the general perception that there's inevitable loss of memory and intellect as we age simply is not accurate.
In fact, the human mind is quite capable of leveraging adaptive processes to preserve intellectual function--even at an advanced age. There are many of us who'll live beyond our eighties or even nineties and will still possess cognitive resilience. This outcome depends not only on our inherited biology, but also on our ability to recruit latent resources and sustain intellectual function even in our later years.
Robert Hill, Ph.D., A.B.P.P., has studied aging internationally through a Fulbright Fellowship at Maastricht University in the Netherlands. He's the author of six books, including Seven Strategies for Positive Aging and Cognitive Rehabilitation in Old Age. Contact: email@example.com.
Terry Hargrave, Ph.D., is a professor of counseling at West Texas A & M University. He's the author of numerous articles and nine books, including Strength and Courage for Caregivers and Loving Your Parents When They No Longer Love You. Contact: firstname.lastname@example.org.
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