FOXcast PT: Improving Memory In Patients With Cognitive Disorders

Welcome to FOXcast Physical Therapy. A podcast for clinicians made by clinicians. It’s brought to you by Fox rehabilitation. Find out more at FOXRehab.org.

Jimmy McKay, PT, DPT: All right welcome to the show. My name is Jimmy McKay. And joining us this afternoon is Rob Whittingham. Rob welcome to the program.

Rob Winningham, PhD: Well thank you Jimmy. Glad to be here.

Jimmy: Describe your background. You know one word a cocktail party that’s always like the first or second question we get right is what do you do. How do you answer that question?

Rob: I’m a neuropsychologist by training got my start in the world of psychology by implanting false childhood memories into college students in the 1990s. But after that work was done I kind of focused on older adults and started working on older adults in memory how they remember crime scenes things like that. About 20 years ago I started working in an assisted living community. I was collecting data there for a project and we just came to realize that the people in those communities weren’t doing a lot. It seemed as if they were being warehoused and we got a large grant and we wanted to see could we change their ability to make new memories, their executive functioning the quality of life if we introduced high quality intensive brain exercises. And as far as I know we had the first randomised controlled publication of cognitive stimulation exercises relative to a control group nearly 20 years ago and then just been extrapolating that work ever since.

Jimmy: I don’t think that I’ve ever had quite an introduction to a guest like that one. I feel like we can spend a half hour in any of those topics. The first one of course grab my attention now implanting false memories in college students. But I guess I’ll stay on the people with that with cognitive impairment for this show just because the audience are clinicians that work with older adults who many times have cognitive impairments. Why do people have memory failures? We learn neuroscience throughout our curriculum before we become PTs or OTs or SLPs piece but just give us that overview on the memory process.

Rob: It’s a great question. Why do we have memory failures? In every memory of failure is related to a failure of one of three processes. Either we never encoded the memory in the first place we never saved the memory in the first place. And that’s probably the most common reason we have a memory failure we don’t pay attention to it enough we don’t rehearse it enough. It falls out of working memory before it gets encoded into long term storage. And a lot of the work we do is related to that particularly with therapists trying to help them give them tools so they can help their clients encode new memories memories of compensatory strategies and whatnot. The other reason we can have a memory failure is just a storage failure. We haven’t used it for a period of time. Maybe it wasn’t. It wasn’t deeply encoded and it’s gone. That probably some changes in the cell maybe some dendrites pulled back maybe some changes in some ion channels but it just isn’t there anymore. I mean we’ve all experienced that. I’m talking to a family member and they remember something from 20 years ago and they have so many details and their memory is so vivid that you believe them but you just have no memory of that. So you probably knew it at some point but then you lost it through decay and then the third reason is a retrieval failure and a great example of this is when you have something encoded it’s there and you often know it’s there. A common example of that is a proper noun and name you know the name you know you know the name but you just can’t retrieve it. And that is so common we even have a name for that called the tip of the tongue state. And that’s a retrieval failure. And it’s interesting that we often when we stop trying to retrieve it that’s when it comes to mind.

Jimmy: Yeah. I love how you laid those out really really simply. Either you didn’t save it properly right. I mean you know you can you can almost apply this to like something a letter that you’re writing or a paper you’re working you didn’t save it properly you did save it but it decayed a little bit over time. Now you’re not getting that memory at all are you getting pieces of it and then that third stage of retrieval it’s there and that tip of the tongue I like that someone actually went ahead and put that on there because we’ve all been there. You’ve got it and you know it’s there. And as you mentioned it’s usually when you kind of give up and let the universe kind of bring it to you instead of you trying to get it. That’s when you wind up finding it.

Rob: Exactly.

Jimmy: When working with individuals with cognitive impairment what’s the best way to maximize these abilities how do you what are the best strategies we can employ?

Rob: Well a lot of them are related to encoding you know when we’re working with clients who have cognitive impairment that’s what we’re really trying to do we’re trying to get them so they can learn something new. How do you enhance encoding? There’s different ways of doing this but it’s all about maximizing attention maximizing focus. So there’s some really simple strategies is asking people the best time of day for a lot of our older adults. They’ll tell you that I’m great at 8:00 in the morning I’m not so good at 3:00 o’clock in the afternoon. I like to rest at that point. We should meet with them at eight o’clock in the morning. It’s interesting now in the psychological literature. You know not only will they they say how old somebody is or their gender background. We’re increasingly measuring. Are they a morning person or an evening person. Because some of these variables related to cognition seem to matter based on whether or not you’re more of a morning person or an evening person. So so that’s that’s a that’s a real simple one then a lot of it is try to get them to process the information actively. A lot of the same things we would do with students. We want them to process it actively rather than receive it passively. We’ll ask them to make predictions on how well they did. So we’re going to do timed up and go stand up walk twelve feet turn around come back and sit down. It took you 18 seconds last time. We’ve been working on this how long you think it’s going to take you this time? Also some things like that but actually some of the most effective strategies are related to retrieval. How often and when do we ask them to retrieve the information? It’s called The Space retrieval effect. And there’s even an app for that where you can download I think it’s sold by TACTIS therapy where 30 seconds after you’ve given some information to somebody maybe it’s that they’re going to put the brake on a wheelchair before doing a transfer. And we want them to remember they need to put the brake on before doing the transfer. And so we’ll tell them that and then we’ll say we’re going to test you on that. Even just telling them that they’re going to be tested on that that will what I like to say light up their frontal lobes. The frontal lobes where we a lot of our attentional resources come from the frontal lobes will light up the deficit. Test me on what? Right now they’re focused on the to be remembered information and then 30 seconds later we ask them what’s the first thing we’re going to do before a wheelchair transfer. I’m going to put the brake on. Good. And then what you do is you double the interval that’s this based retrieval effect. So to go from 30 seconds to a 1 minute interval if they get it right two minutes they get it right four minutes. The challenge is though for therapists there’s so many things that they need to pay attention to and the brain doesn’t have a timer that’s going to go off after 30 seconds or a minute. So that’s where the app is really helpful. And then make a note of it at the end of the session and then begin the next session with that. And that’s another has another little side benefit is that they’re probably going to be successful at it and having success at the beginning of the session can be really helpful.

Jimmy: It sounds a lot like strengthening a muscle. I love the fact how you address as a therapist. There’s so many things going on that’s where the app is an enhancement it doesn’t take the place of the clinician doesn’t take the place of the exercise, it really brings it to the forefront.

Rob: Because you need the therapist you know a lot of this just cannot be programmed with technology a lot of it reading the client. You know there’s another nice little technique that I’d like to share with other people when you ask people do remember what I want you to remember that is that’s free of any cues we call that free recall No I don’t remember what am I supposed to remember. And then cued recall. They don’t get a free recall give them a cue. Cued recall would be that something to a safety related to your transfer and if they don’t get that right then you give them a multiple choice test. Where are you going to put the armrest down or put the brake on? And I almost guarantee if they could verbalize what they were going to do a minute or two ago they will get the multiple choice correct. And that is just facilitating the beliefs that they can do it the belief that they’ll be successful with you. So yeah that’s not something that you can program and do a computer you need a savvy therapist to really maximize those therapeutic outcomes.

Jimmy: Like that a lot and then yeah as you were mentioning bringing that up mentioned that beforehand I’m going to test you on that so I need your reminder even when I work with co-workers without cognitive impairment when we’re in receive mode all of a sudden you hear that and people sit up straighter as you say that frontal lobe lights up.

Rob: Absolutely.

Jimmy: How about maximizing motivation? What’s something we can do with individual the cognitive impairment to maximize their motivation.

Rob: I think this is the really important question and topic. You know we know how to do therapy we know how to improve people’s quality of life. But some of the clients that just seem to be unwilling to do that work therapists need to have a tool box full of ideas to help motivate people. And I like to if I was to present this simply I’d go to just two variables. This is actually comes from some work in the 1970s by Albert Bandura and it’s been a really influential theory. Albert Bandura said whether or not a human being is willing to do a behavior is determined by two factors. One the belief they can do it. We call that self efficacy. And two, the knowledge of the benefits of doing that behavior. What are the benefits? And I really try to push therapists on this. I see therapists. They ask people to do things and if you’re not a trained therapist you don’t know why we should be doing that. You know retro walking. You know why should I walk backwards? Why should I walk backwards pulling away? Or doing a chin tuck while swallowing. Why should I do that? We need to tell people the benefits of doing that behavior. And then also connected to the goals that they want in life. And I work a lot on cognitive rehabilitation. And that one’s easy in that sense. So if we’re working on maximizing executive functioning or working on improving the ability to make new memories that generalizes to almost every aspect of daily life. So you can kind of connect it to the things they want. So the benefits is a big one. And I think therapists are doing that and most of them are pretty good at that. I think I can give some helpful suggestions on the self efficacy because that’s the challenge you know. I see this happen to therapists. You know they have a new client come in. They look at them like this is great. I’m so glad you’re here I can see what’s going on. We have some exercises we have some interventions that will help improve what you need to work on here. Are you ready to get started. The therapist is just oozing enthusiasm and excitement for this opportunity and the client says Do you know how old I am? And it just must. It must be so heartbreaking because when a therapist hears that. They know that the client isn’t going to give them the attention and the effort necessary to truly maximize the outcome. So how do we max myself efficacy? One way is just just to see others succeed. If there’s an opportunity to group therapy if they can see others like them who have done the work and succeeded that can be powerful. But you can’t always set that up so an easy tool that everybody can put in their back pocket is tell the unmotivated client about about previous clients who are like them who succeeded. And you know if you’re worried about HIPPA of course change the names you know don’t give away the identity. But but say you remind me a lot of so-and-so. She had a similar problem but she worked hard. This is what she did. And these were the outcomes that she got from that work. So that can be helpful. And then the third one is success. Success begets success. So we start easy. We make it harder. We create opportunities for success and that’s kind of what I was talking about earlier. It’s a great way to begin a session to remember what we were talking about last time. If they don’t, don’t stop there. Give them a cue. And if they don’t get that give them give them two choices. And that success will be get success.

Jimmy: Love that love how you laid that out there. Really breaking it down to can the clients see the opportunity for success. Do they actually think they can do this and be successful. And what’s the reason behind breaking it down to those two things is really a great paradigm to walk into because you can now apply that to any client.

Rob: And your children and your spouse and your parents.

Jimmy: If someone wanted to reach out to you check out more of your work or ask you a question is there is there an easy way to do that.

Rob: Yeah, they can just go to my web site. RobWinningham.com, my email is on there, I have courses, my numbers from companies on the web that people can participate in and I’m always happy to help.

Jimmy: OK we have a tradition on the show. I don’t think I prepared you for this once you got to wing it. OK so what’s your FOXtale? What’s the reason that really drew you and your work to focusing on older adults?

Rob: Well you know to be honest from it from a scientific standpoint a lot of work still needed to be done. And I think a lot of work still needs to be done. If you look at the scientific literature on children and cognition that work is there. And what I noticed in graduate school when I had an entire year to study Memory and Aging it was that we still had a lot of work to do with the older adults. And I think everybody wants to do something where they can leave a legacy have an impact and and working in this area of Gerontology Clinical Gerontology. There are a lot of opportunities to change lives.

Jimmy: We appreciate the work. I love how you break those things down really simply and gave what I could call Monday morning applicable usage and things to put into play things to put in the back of your brain and you can use that. I think today’s talk really gave my pleasure.

Rob: Glad to be here Jim.

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