Background
We were impressed by the Clinical Guidance Paper on Neuropsychological Interventions by Wong and colleagues in the most recent issue of Neuropsychology Review. This comprehensive paper, coauthored by many of Australia’s most experienced Clinical Neuropsychologists, offers a broad practice overview, as well as specific guidelines for the provision of cognitive interventions. Clearly, neuropsychologists are adopting roles in many settings and addressing a variety of cognitive deficits. Irrespective of the cognitive domain(s) being targeted, the article emphasises that interventions need to be evidence-based and offered with consideration of the patient’s biological, psychological and social issues. These issues will affect the content as well as the duration and intensity of the therapeutic approach. The use of goal setting and monitoring is advised. The authors point out that although many neuropsychologists say they would like to engage in intervention, they report that limited time and insufficient training as some of the barriers to engaging in this activity. The article has given us the opportunity to reflect on how MEMORehab fits within this landscape.
MEMORehab’s aim, evidence and target audience
As pointed out in Wong et al.’s (2023) overview, neuropsychological intervention can be applied to a wide variety of cognitive impairments and can be helpful to many types of patients. Because the most common complaint of patients presenting to neuropsychologists relates to poor memory, the first web-based platform developed by MEMORehab provides a comprehensive, clinician-led training program that targets the improvement of everyday memory. The approach utilises evidence-based information, techniques and strategies. It was developed primarily for adults with ABI, and for these patients, outcome studies have shown that the content provided is effective (see research articles on website).
More recently, MEMORehab has been trialled successfully in people with cognitive deficits in the context of mental health issues (including a group of older teenagers). Other clinicians are trying it with adults who have memory concerns, but who have no formal diagnosis. Satisfaction and engagement have been good in all these subject groups, but relevant memory outcome data has yet to be collected. Our company is working with several researchers to address this issue.
Importance of the Biopsychosocial context
Considering the influences on each patient with regard to their biological, social and psychological context is emphasized as important for directing an intervention in the Wong et al. (2023) article. In this section, we first consider the psychological, biological and social conditions that must be met to make participants appropriate for MEMORehab. Then we point out the ways in which MEMORehab can be adapted to meet the variation in participants’ needs, both in the way the intervention is run and the way in which its content can be modified.
What’s the right Biological, Psychological and Social Context for using MEMORehab?
When considering whether MEMORehab is right for your patient, several things are important.
Biological factors include perceptual abilities that allow the patient to see and hear what is presented through this computer program. They will also need adequate motor skills to speak and carry out typing movements. Age needs to be considered, but is not necessarily a limiting factor… facility with a computer is much more relevant.
Psychological or cognitive factors will also influence MEMORehab’s effectiveness. Like most interventions, MEMORehab will work best for patients who are motivated and able to pay good attention (i.e., for 30-60 min at a time). The level of memory difficulty is also important to consider; MEMORehab is aimed at those with mild to moderate memory impairments, who are capable of learning with instruction and practice. It is not likely to help those with a dense amnesia or dementia.
Social factors such as access to the internet as well as to an appropriate device (i.e., computer, laptop, tablet or iPad) must also be considered. Having had some experience with using a computer is also important (e.g., ability to log in, create a password, use email). For now, the program is only available in English, so the patient must also be able to converse in this language.
How MEMORehab can be adapted depending on the biopsychosocial context
Factors raised in the previous section will help to determine how MEMORehab should be run.
Neuropsychologists have generally found it rewarding to run participants in small groups. This reduces the amount of time involved and is more cost-effective. Also, for the patients, participating in groups usually fosters peer support and motivation. If the referral base is sufficient, matching participants within a group by etiology, age range and/or general memory ability level tends to work best.
Of course, patients with problems related to impulse control or communication might not thrive in group settings. MEMORehab can also be used to run one-on-one interventions for patients who are not appropriate for group participation or by clinicians in smaller practices (where it may be difficult to accumulate enough patients to run a group).
Clinicians can also choose whether the interactive sessions between clinician and patient are run via the inbuilt videoconferencing software or in person. Thus far, if given the option, the majority of clinicians and patients would still seem to prefer to meet in person, but having the videoconferencing option means that no-one need miss out because of mobility issues or distance. Furthermore, it has been observed that excellent group bonding occurs even if the sessions take place over the internet.
Depending on the patient’s ability level and stamina, scheduling of the interactive sessions is flexible and depends on the desired intensity and duration. Although MEMORehab is most often run as a six-week program involving one-hour sessions between the patient(s) and clinician each week, this schedule can easily be altered, and meetings can be broken up into shorter segments if necessary. The patient chooses the pace at which to engage in the out-of-session material (i.e., educational videos, quizzes, homework and computer-based exercises).
How MEMORehab’s content addresses biopsychosocial factors that affect memory
MEMORehab’s content helps participants understand the ways in which memory is affected by psychosocial, emotional and biological issues (e.g., organisation of home environment, noise levels, mood, stress levels, sleep, diet and exercise). Tips are also offered to improve all these factors. The clinician can choose the extent to which each of these is emphasised, based on the participant(s) profile.
Goal Setting
The Wong et al. (2023) review paper strongly recommends person-centred goal setting and monitoring as part of an intervention. At present, this is not an integral component of MEMORehab, though it is on the list for inclusion in future developments. For now, the clinician could consider adding sessions with each participant to set goals initially and then regularly monitor/discuss how aspects of the program are helping the participant to achieve these goals. The ability to set “Instant Meetings” using the videoconferencing software in the app could support this type of interaction.
Supporting Neuropsychologists’ strong interest in intervention
As said by Wong et al. (2023) “Delivery of neuropsychological interventions … is increasingly recognised as an important, if not essential, skill set for clinical neuropsychologists. It has the potential to add substantial value and impact to our role across clinical settings”. MEMORehab is keen to be part of this future. The program we have created provides material that is easy for clinicians to use and it supplies practice materials for participants to access throughout the weeks between and after the clinician-led sessions. In turn, progress on these activities is fed back to clinicians so that they can modify their approach. With the ability to co-facilitate groups and the fully annotated slides for the group-based sessions, even students and those new to intervention will feel extremely well supported.
Summary
Many neuropsychologists are turning to the provision of intervention to enhance the services they provide. There are many ways that this can be delivered and many patients that can benefit. MEMORehab provides the first digital tool of its kind to support a neuropsychological intervention to improve memory. Numerous aspects of the program fit the criteria considered important in the recent review article by Wong et al. (2023). We hope to continue to hone the current program in light of the ideas put forward in the article and to be able to offer additional programs for the purpose of facilitating intervention in the future.