A Brief Overview of Memory:

ClassificationAnd Neurcognitive Testing

Craig Goodman, Ph.D.

Lev HaSharon Mental Health Center, Israel

Objectives:1. Review functional

classification of memory

2. Review evaluation of memory and Neuroconitive Testing

3. Cognitive Inpairments in Schizophrenia

Memory

Defining “Information Processing”

Also called “Cognition” or “Neurocognition Ability to recognize and process information in order to carry out complex tasks adequately Broad Term- Encompassing memory, attention, sequencing/planning, General Intelligence, visuo-motor skills Brain Structures mainly involved -frontal, temporal, basal ganglia

Types of Information Processing Deficits

GLOBAL DEFICITS General Intelligence Measured by IQ Tests-IQ does not decline with age Leads to Global Assumptions Deficit fails to prevent the individuals ability to acquire, retain or relearn new skills

Specific DeficitsMEMORY Short Term/Working Memory Verbal- Acquisition of verbal material Visual- same for visual material Poorer verbal and spatial memory Frontal lobes main modulator of WM-may be

related to reduced blood flow to this areaworking memory capacity underlies general intelligence

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What is Working Memory?

Active Memory Approach - Modern Perspective

- working memory is not static, is not a place

- working memory is information that is activated in long-term memory

- incoming information is “repackaged”- connections are made between incoming information and other information already storedActive

Processes

Long term Memory

Ability to hold information over longer time period-hrs,days,years Problems seen specifically with recalling previous events Memory deficits present in first episode and un medicated individuals

From: Tasman, Psychiatry, 1st ed.

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Executive Function

Ability to plan and carry out goal directed behavior Solving puzzles main neuropsychological assessment tool Performance does not improve after explicit instructions

Attention

One of the oldest documented problems dating back to Kraeplin 1919 Often difficulties remaining vigilant and not getting distracted

- Dopamine theory (performance on Neurocognitive Tests)

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Working Memory: Baddeley’s ModelThe Central Executive

(Supervisory Attentional System )(central pool of limited resources)

Visual-Spatial “Scratch Pad”

Control and decision processes - allocates between sensory representations

Reasoning, language comprehensionTransfer information to long-term memory

via rehearsal, recodingRecency effects

Articulatory Rehearsal Loop(“short-term buffer”)

Recycling items for immediate recallArticulatory processes

Inner Ear / Inner Voice

Visual imagery tasks

Executive’s resources are drained if imagery task is difficult

Brain areas involved in WM?

Perceptionand memory

Sensory inputs

Arousal

Selective attention

Working Memory

Associationcortex

Hippocampus

Consolidation

Storage

Thalamus

Emotionalencoding

CingulateEmotionalexperience

Amygdala

Emotion expressionEndocrine Autonomic

HypothalamusSensory inputs

Arousal

Selective attention

Working Memory

Hippocampus

Consolidation

Storage

Associationcortex

Thalamus

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What is the capacity of Working Memory?

Digit Span Test: (Verbal Working Memory)

5 7 97 1 8 38 3 4 6 90 2 5 1 9 8 0 2 5 3 2 8 18 3 1 2 7 9 0 4

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What is the capacity of working memory?

Digit Span Test Results:

Amount recalled = memory span

People on average can recall “7 plus-or-minus 2” items

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Visuospatial Scratch Pad: Summary

• Evidence shows that there is a distinct visual subcomponent to working memory.

- dual tasks- neuroimaging studies show different sites in brain activated for

verbal versus spatial tasks

• Functions to allow us to maintain and manipulate visual and spatial images.

- planning and executing spatial tasks- tracking objects in our environment

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Central Executive: Evidence Continued

3. Damage in prefrontal cortex - neuroimaging studies show prefrontal cortex is active with tasks that

make heavy use of central executive.

- people with prefrontal cortex damage are unable to plan and inhibit their impulses.

Malfunction of the WM system can be logically perceived to cause impairment of:• goal oriented behavior• disorganized cognition - cognitive

organization• failure of self-monitoring and other

manifestations cognitive dysfunction.

Examination of Memory

Short-term: 3 object registration and 3-minute recall.-warn the patient, have them repeat the words-attend them in the delay to prevent rehearsal-if dysphasic, hide 3 objects

Long-term: Name the last 5 PMs or Presidents-personal history is helpful for specific areas-present objects and ask what they are used for

2. Test immediate, short-, and long-term memory.

3. Be aware of other localizing findings.eg. personality change in Huntington’s, sensory extinction in cortical disorder, primitive reflexes, etc.

Examination of MemoryBRIEF MEMORY

TEST1. MMSE and MSE2. 5-7 forward digits3. 3 minute 3 object

recall4. 5 Prime-Ministers5. Neurocognitive

exam to localize other findings

Example of Typical Cognitive Battery

• Digit Span Test• Digit Symbol Test

• Rey-Osterrieth Complex Figure Test• Trail Making Tests

• Rey Auditory Verbal Memory Test• Beck Depression Inventory

• Finger Tapping

Digit Span - Derived from the Wechsler Adult Intelligence Scales

(Verbal Subtest)

Purpose:to evaluate ability to repeat digits

forward and backward

measure of attentiveness

immediate recall

working memory capacity

Digit Symbol Test - Derived from the Wechsler Adult Intelligence Scales

(Performance Subtest)

Purpose: visual-motor task - measures subjects ability to match symbols with numbers according to a code, assesses speed and visual perception.

Digit Symbol Test

Rey-Osterrieth Complex Figure TestPurpose: permits assessment of several cognitive processes including;

Visuospatial Abilities MemoryPlanning, Organizational and

Constructional Skills (executive function) Problem-Solving Strategies Perceptual Visuomotor Skills

 

 

Rey-Osterrieth Complex Figure

Trail Making Tests - Form A and Form B

Purpose: Tests of speed for attention, sequencing, mental flexibility, visual search, and motor function, and

executive functionForm A

Screens for impairment in attentional (“focused mental processing speed”), visuo-spatial sequencing, rapid visual search processes/visuo-motor scanning factor (visuomotor speed ), numeric sequencing and Identifies frontal lobe dysfunction.  Form B

Higher difficulty level of contextual and procedural memory, cognitive demands include visual scanning, visual-motor coordination and visual-spatial ability adequate enough to understand on an on-going basis the alternating pattern of numbers and letters. Test screens for an inability to execute and modify a plan of action dysfunction of dopaminergic function in the frontal lobes, and focal frontal lesions

Trail Making Form A

Trail Making Form A

Trail Making Form B

Trail Making Form B

Rey Auditory Verbal Memory Test

Purpose: immediate and delayed recall, learning rate, recognition, interference,

and primacy and recency effects.

Total Learning (Trials 1-5 ) Score = (Norm = 46)* Interference (Trials 6 and &7 ) Score = 3 (Norm = 14)*

Delayed Recall (Trial 8) Score = 2 (Norm = 9)* Recognition (Trial 9) Score = 3 (Norm = 13)*

Screens for impairment of learning, susceptibility to interference, impairment of memory and recall – may

suggest prefrontal dysfunction.  

(Norms: Ages 60-69) *

Rey Auditory Verbal Memory Test

Rey Auditory Verbal Memory Test

Beck Depression Inventory Purpose: to assess depression

Finger TappingPurpose: evaluates visual-motor coordination and

dexterity 

Performance in visuo-motoric coordination possibly indicative of damage to frontal-parietal cortical

pathways.

Schizophrenia

Are Characterized by: Related Neurocognitive Impairments Neuroanatomical and Neurochemical

Abnormalities

CognitiveWorking memorySelective attention

Positive symptomsHallucinations

DelusionsLoose associations

Negative symptomsAvolition anhedonia

anergiaasociality

alogia

Symptoms of schizophrenia

History and Current ViewsKraepelin’s Views

Emil Kraepelin , a German psychiatrist who believed defining feature of madness was a deterioration over time.

He called condition, Dementia Praecox (premature dementia), citing that it primarily affected the young, and aged them before their time.

By the 20th century, this became the prevailing theory of madness.

“Dementia praecox” (premature deterioration)

- Early onset- Deterioration- Poor prognosis

NeurocognitiveSymptoms

Poor attention

Memory impairment

Poor working memory

“Executive functions”

Poor visuo-motor coordination

Impaired perception of emotion

It has been established in the literature that: • Insight into illness and attitudes towards

medications among schizophrenia patients are important determinants of clinical outcomes (Amador et al., 1994).

• Noncompliance and poor medication adherence in schizophrenia patients is common and negatively impacts outcomes (Awad, 1993).

• Studies have reported non-adherence rates ranging from 26% (Drake et al. 1989) to as high as 73% (Razali and Yahya, 1995), using various measures of adherence.

Findings Continued:

Several studies have reported that a poor level of insight was a strong predictor of poor medication adherence (Amador et al., 1994; Awad, 1993). • Several reports have correlated

schizophrenia patients’ early subjective response to anti-psychotics with a less favorable outcome of treatment (Awad, 1993).

• Few studies examine relationships between attitudes towards their medications and cognitive impairment, and present conflicting data (Jeste et al., 2003).

Goodman C, Knoll G, Isakov V, Silver H. Insight Into Illness in Schizophrenia. Comprehensive Psychiatry. 2005 Volume 46, Issue 4,

(July-August ):284-290.

Goodman C, Knoll G, Isakov V, Silver H. Negative attitude towards medication is associated with working memory impairment in

schizophrenia patients. Int Clin Psychopharmacol. 2005 Mar;20(2):93-96.

Both patient groups were impaired in cognitive performance, consistent with widely reported cognitive dysfunction in schizophrenia

Schizophrenia patients with positive attitudes towards medication performed significantly better than those with negative attitudes on tests of:

• verbal and visual working memory (digit span forwards and backwards) • inhibition • overall mental status (Mini Mental State Exam)There were no differences in age, education, hospitalizations, or clinical symptoms between the groups.

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5

10

15

20

25

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Digit SpanForward

Digit SpanBackward

Mini MentalState Exam

ObjectMemory-

Delay

PennInhibition

Test

Differences in Neurocognitive Performance among Schizophrenia Patients with and without Negative Drug

Attitudes

Positive Attitude Negative Attitude

In agreement with our findings:

Jeste et al. (2003) reported that cognitive functions, especially working memory and attention measured by the Digit Span Task, were the strongest patient-related predictors of the ability to manage medications.

Likewise, our finding that patients with positive drug attitudes performed better on the MMSE was consistent with Patterson et al. (2002) who reported that better medication management was related to enhanced cognitive performance on the MMSE

Discussion

This suggests that:

• Negative drug attitude may be related to impaired online storage of information and hence poorer ability to learn and subsequently store information relevant to drug treatment.

• This finding is consistent with the postulated central role of working memory dysfunction in impairment of goal oriented behavior, disorganized cognition, failure of self-monitoring and other phenotypic manifestations of schizophrenia (Silver et al., 2003).

What does all this mean?

Working memory impairment may influence:

retention of relevant information

limit the ability to learn

influence knowledge about the effects or benefit of medication, as well as other illness features, and the patient’s subjective attitude towards treatment.

Conclusion Neurocognitive impairments are diverse and greatly effect a person’s daily functioning. It is important to properly diagnose any cognitive impairments to better understand and effectively treat patients. This calls for an awareness and knowledge of cognitive disorders and appropriate testing/screening.