Improving Memory In Epilepsy - Dr. Laurie Miller, MEMORehab, NSW, Australia
Memory problems are one of the most common and frustrating symptoms experienced by people with an epilepsy - but what actually causes them? And how can we "treat" them? Dr. Laurie Miller explains how different types of memory work, why memory difficulties are often linked to the underlying brain pathology rather than just seizures, and what evidence-based strategies and techniquest may help improve everyday functioning.
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Episode Highlights
Why memory problems in epilepsy are not always caused by seizures
How different brain regions affect different types of memory
What memory rehabilitation and neuropsychological testing actually involve
Practical evidence-based strategies to support everyday memory function
About Laurie Miller
Laurie’s work has focussed mainly on the effects of focal brain lesions on memory as well as memory rehabilitation. She is currently working as a cofounder and content director of MEMORehab (an Australian company that has created a digital memory training program), and both an affiliate of the Medical School at the University of Sydney and the University of Technology of Sydney (UTS) Materialising Memories Lab.
Full profile: Laurie-Miller
Topics mentioned
cognition
memory
neuropsychology
executive function
attention
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Trailer & intro
00:00 Laurie Miller
“The main thing that drives a memory problem is the same thing that's causing the seizure disorder. So I look before the seizures in a sense. What is causing someone to have seizures? Because that's really a symptom of an abnormality in the brain. And that basic abnormality or pathology is probably also the root of a memory problem.”
00:22 Torie Robinson
Welcome to Epilepsy Sparks Insights! I’m your host, Torie Robinson, and today I’m joined by clinical neuropsychologist Dr. Laurie Miller from MEMORehab, a digital memory training program. Laurie is going to be sharing why memory problems in the epilepsies are often far more complex than people realise! Indeed, memory problems are one of the most common and frustrating experiences reported by people with an epilepsy. But what are they caused by? Seizures, mood, medications, surgery, sleep disruption - or the underlying brain pathology itself? Laurie is going to share with us the different types of memory, how memory functions are assessed, and the evidence behind practical memory rehabilitation strategies that may help improve everyday functioning and quality of life. If you’re new here, please subscribe so you don’t miss future conversations - and let’s get into today’s episode!
Types of memory
01:12 Laurie Miller
There are so many types of memory and we tend to divide them up as neuropsychologists we think of them in different boxes, probably because different parts of the brain are responsible for different types of memory. So let me describe some of the main types. One is motor or procedural memory. It's the stuff that helps you learn. it's the way that you learn to walk or play the piano or even formulate speech by learning to modulate your tongue and your lips and everything.
01:42 Torie Robinson
Oh, yeah
01:42 Laurie Miller
So, it's very important kind of learning for children. And it's basically the job of the cerebellum; which is the part of the brain at the back and underneath. It's a little tennis ball that sits under the main part of the brain. Well, that's for the early motor learning. Later we have retrograde memory is a component where it's memory for the past, basically. So, if you have something happen to your brain, like you have a sudden head injury or you have a stroke, retrograde memory counts everything that has come before that time. So, your ability to think about your past. And even that can be divided into autobiographical memory versus semantic memory. So semantic memory is knowledge of the world, your vocabulary, your knowledge of the state capitals, you know, things like that that you've learned that's a bit separate from your autobiographical memory. Then there's anterograde memory. So, everything that has come after maybe that onset of a head injury. Anterograde memory means you're putting something into the brain and you're seeing how well the person can remember it later on. So, it's kind of going forward. That can be divided by modality and we might talk more about that. And then finally, the last one I would mention is prospective memory. That's when you're given something or you want to remember something in the future. So, you have to recall it down the line.
03:06 Torie Robinson
So, we need to make it more complex, I guess! You know, what you've just said reminds me of, like, for instance, when people can have different issues with memory depending upon what part of their brain they injure or what part of the brain they have resected, for instance. It really depends, doesn't it?
03:20 Laurie Miller
It surely does. And that's really one of the big roles of a neuropsychologist in an epilepsy centre is to try and assess various types of memory in the context of other skills to see what part of the brain is not working quite as well as the other parts. And that's often where the seizures start.
Causes of memory problems in epilepsy
03:38 Torie Robinson
So, from a neuropsych perspective then, what are the main drivers of memory problems in people with an epilepsy? Is it the seizures? Cause some people think, it's just the seizures that does that. Or is it the medication? Is it the whole disruption created by the seizures and other functions? Or is it something completely different?
03:54 Laurie Miller
From my opinion is that the main thing that drives a memory problem is the same thing that's causing the seizure disorder. So, I look before the seizures in a sense. What is causing someone to have seizures? Because that's really a symptom of an abnormality in the brain. And that basic abnormality or pathology is probably also the root of a memory problem. Often there might be hippocampal sclerosis, so a bit of pathology in the hippocampus that's going to lead to a seizure disorder. It also affects that really important structure in the brain for storing new memories. Again, like yes, as you said, if you have a stroke or you have a head injury, clearly there's a pathology established that may lead to seizures. It's also likely the cause of the memory disorder. There can be additional effects. You mentioned surgery. So yes, surgery can cause some additional problems depending on what has removed and the condition of the person's function before the surgery. So if their verbal memory was strikingly good and it was very strong skill for them and they're right-handed and then they have part of their left temporal lobe and part of the hippocampus removed, they will likely notice a drop in their verbal memory because that's the part of the brain that's really important for that.
05:11 Torie Robinson
Medications can also cause other symptoms such as sleepiness, which then can affect cognition and word finding as well. So, it's not always the direct effect of some of these things.
05:20 Laurie Miller
I think over the lifespan, there's evidence that it causes cognitive decline if people go on having seizures quite regularly. If you have a seizure or significant discharges between the time of an event or an encoding, like when you learn the material and when you're trying to recall it, if you have a seizure in the middle, that's very likely to affect your memory. And if you have discharges in your hippocampus, even if you don't have seizures, you can have trouble later on. That is linked with longer term memory problems. So, it's really important to try to control those discharges and seizures.
Ways to assess people’s memory
05:55 Torie Robinson
So, when you assess memory in people, what does that involve? know, so you're not saying “By the way, can you remember, I don't know, where you went shopping this morning?”. What is what does it involve…
06:06 Laurie Miller
You'd be surprised, sometimes we do! Hahahaha!
06:07 Torie Robinson
Oh really! Oh, okay, okay, hahaha! So, so, but what do you usually do, do you have a sort of standard set of questions? And how do you identify what, you know, what regular people, say, a friend or family might miss?
06:22 Laurie Miller
So the job of a neuropsychologist is to assess memory but also assess a variety of cognitive functions in a standard fashion. As in, we have a quiet environment, we're one-on-one, you know, the conditions are optimal for storage of memory, right? Like, we're really focused. And it usually takes a couple of hours. So, there's usually some breaks, but we're not just assessing memory. We want to know how good is the person's attention. What is their problem solving? Like, are they okay at flexible thinking? Because we want to see how the memory fits into the rest of the picture. But with regard to assessing memory, there are standardised measures where you give them, in a certain fashion, and then ask for the recall or the recognition later. One test would be to tell you a story and see how much you remember immediately and then later ask you for that story again. And more recently we are starting to do really long-term memory - so might call you up out of the blue a week later and say what do you remember of that story. Because what we found was that we were missing some memory deficits in people. Sometimes people performed quite well at half an hour later and yet were still complaining “There's something wrong with my memory.”; well you call them in a week later and they can't even remember their appointment, you know, so there was something changing over a longer period of time. So, we would tell stories, would get you… not just any stories(!), they are specific stories, and there's ways of scoring them for the details. There are lists of words we would give you and get your recall. Sometimes you get some repetition; you might hear the word list several times and try to learn it and then recall it later. And there are pictures that we would show you, get you to copy them, see how much you can recall of those. And that's sort of the pictures versus the words is sort of testing the right side of the brain versus the left. Sometimes we do prospective memory too. That's again a fairly recent addition, but it's important to give some tasks to the person to try to recall during their assessment session and perhaps even recall during the next several days. So that's, yeah, sometimes prospective memory is introduced.
Treating memory problems
08:30 Torie Robinson
Do you think that we underestimate how treatable memory problems can in epilepsy can actually be? Because I think sometimes, we'll think “Okay, you've got a memory problem, because, for instance, you know, temporal lobe section, there's not a lot we can do. Good luck with that.”. Is that the case? And what's the biggest mismatch that you see between how people describe their memory problems and what your objective testing shows?
08:56 Laurie Miller
I would say along with a neurologist, get your seizures controlled as best you can. So, you know, reduce the discharges, reduce the seizures. Use the best medication and the level of medication that's adjusted, you know, to keep you from being too sleepy. If you want to try to improve your memory, you got to keep your brain healthy. So, observe things like good eating, getting exercise, getting good sleep. Then you have to change your lifestyle. If your memory is not very good, you might need to become more organised. You might need to set up better routines for yourself. And thirdly, you can also try to learn some memory strategies. So, encoding with more elaboration at the time that you're learning something new, preparing to learn. So, getting your brain in a good state and thinking about planning on learning.
Memory rehabilitation
09:46 Torie Robinson
What is memory rehabilitation? Is it what you've just described? Is that the same thing? What does it involve?
09:55 Laurie Miller
It's largely that. A neuropsychologist would normally give you feedback at the end of your assessment to give you a few strategies, few points that might help your memory. I used to like to send a feedback letter so that you didn't just hear it, but you had it in writing because obviously if you have a memory problem.
10:10 Torie Robinson
Yeah.
10:10 Laurie Miller
Then I started to develop some more intensive memory training where people got instruction on why a strategy works, how you can apply it, and then get to practice it. So, I think all those steps are really important in putting strategies into place. You can't just tell someone “You should use visualisation” or “You should use elaboration.”. How do you do that, you know, so you need to train them. That's what memory training is.
10:33 Torie Robinson
No, that's great. And what evidence do you have that what you do works?
10:36 Laurie Miller
We sort of have about 15 years’ worth of evidence where we ran group-based studies. We would have, say, 10 to 15 people come together for six weeks where they got two hours’ worth of training on these strategies, also improving their lifestyle and their nutritional levels. And we started to publish those in about 2011.
10:55 Torie Robinson
How do you measure how good somebody's doing though?
10:58 Laurie Miller
Well, we would do outcome studies. So, we would measure some things in a standard way. Like, we would look at anterior grade and prospective memory, sometimes with our objective tests where we're again giving stories or giving items that they have to recall later. Or we're giving questionnaires about their everyday life. So, again, there's standardised measures where either they, or a carer, or both, fill in how well they remember things in everyday life and then reassess after they've done the training.
Simple ways to improve memory
11:25 Torie Robinson
What are things that can be done easily in everyday life and that you've seen evidence as to why they can be beneficial for improving one's memory?
11:34 Laurie Miller
Learning to use your phone well is a very good external aid. So it's really good for prospective memory, obviously, you put things in - and you remember to keep your phone with you! And it's also… it's common. So, it's not just people with epilepsy that are using their phones! So that's a really good external strategy. Keep a journal at night. If you're having trouble remembering life events, it's a good way to rehearse what's happened in the day. Just note a few key points and then you'll have that, you know, for years, you can look back. That's a really good way of rehearsing and recording. And then I would say try to look at your organisation and routine, you know, stick to routine, de-stress, de-clutter. Keep it simple.
12:18 Torie Robinson
Yeah, would say that's for anybody and everybody actually. Stress we know is something that really does impact memory negatively.
12:25 Laurie Miller
Yeah, it's the same kind of things that work for everyone. You can do specific strategies, which require a little more time to explain, but just spending more time when you are encoding someone's name. So repeating it, talking to them about their name, you know, often people complain they can't remember names, but if you spend a little more time with the person asking them how to spell their name, those things can help you recall it later.
Improving memory conversation
12:49 Torie Robinson
Go on, give us a little insight into what you just said.
12:51 Laurie Miller
Okay, so “Hi Torie. That's an interesting name. Is it a nickname for Victoria?”.
12:56 Torie Robinson
It is and no affiliation with any political party at all.
13:00 Laurie Miller
No? You weren’t named after the Queen or anything?
13:03 Torie Robinson
No, no, although my friends do call me the Queen sometimes if I put on a posh voice, darling.
13:08 Laurie Miller
With that kind of rehearsal, I wouldn't forget your name! That's a good, like that's a number of touch points. I could maybe ask you how you spell it as well. And now we've repeated it a couple of times in conversation. And I haven't even bothered to introduce myself to you. That's something we tend to do in conversation is like, as soon as I hear your name and say, “My name's Laurie.”. Well, try not to do that, try to wait, try to talk about the other person's name a bit so that you have time to think about their name before you've changed the conversation to be talking about yourself. Do know what I mean, like, so I can ask you about Torie and is that short for Victoria and were you named after the Queen and how do you spell it? And then I can say, oh well, my name's Laurie.
Practice, practice, practice
13:48 Torie Robinson
Okay, I get it, but what would you say, so say you're going to a networking event, right, or something like that, you can't do that with everybody, it would be embarrassing apart from anything else. So, in real life, what does one do?
13:58 Laurie Miller
Yes, you don't have to remember everyone's name. Nobody remembers everyone's name. So, you don't have to use names. You can try to tell the person how you remember them. “Oh, I've seen one of your podcasts…”... you can tell them that you know them, even if you can't remember their name in conversation. You can prepare for the event. If you know that some people are going to be there by name, you could rehearse those names ahead of time. Think about who you're going to meet, what you know about them. That sort of preparation rehearsal is good. Name tags.
14:31 Torie Robinson
Do you know what I do? I get embarrassed when I go to an event and I'm just like, I feel like I'm looking at their chest…
14:38 Laurie Miller
Yeah! Hahaha!
14:38 Torie Robinson
…and say “What is your actual name?” Yeah. So, it can, I just think lots of these things that like great advice, but sometimes I think people, especially in the beginning can be quite a bit embarrassed about doing it. It's something that you're not used to doing.
14:49 Laurie Miller
Yeah, but that's why I think memory training courses can help because you actually make it a practiced thing that you get used to doing it over and over and then it becomes a little more normal.
15:00 Torie Robinson
Oh, so, is it about it is about practice just like physical exercise is that generally what we're saying here?
15:05 Laurie Miller
I would say so, yeah, because you're never going to use a strategy unless it becomes like second nature to you.
15:11 Torie Robinson
So, it's habit, really getting to the habit. Okay, so if somebody is listening, whether they be a clinician, a researcher or somebody with an epilepsy or a mum or a dad, and they want to improve their memory outcomes today, we've spoken about one thing, like looking at somebody's badge or asking them about their name, et cetera, but what are some general evidence-based strategies that they could use that would help them do this, both short and long term?
Other strategies
15:40 Laurie Miller
Well, there's an awful lot of individual strategies that have been researched. Some of them make more sense in everyday life than others. So, for example, if you have a grocery list of five items, you have to remember, you will be better at remembering it if you can take those five items and put them in some kind of ridiculous image together. Or if you can remember them in different parts of your house, like if you can imagine yourself walking around your house and you have to form a visual image, you know, the broccoli is growing out of the stove top or the, you know, whatever, you have to make a kind of unusual image. That takes quite a bit of work! What we do in our memory training courses is its sort of we can mention that strategy, but instead, like, making a list is obviously an easier kind of thing to do!
There are things that work in principle, in everyday life, they're always better. There's, you know, pick and choose amongst your strategies, which ones work the best. And making a simple list is going to probably be better in most cases, unless you don't have a pencil and paper and you have to remember something, well, making an unusual visual image is a good thing to do. So, if I was trying to remember your name and you mentioned the political party which makes me think of kind of “ra ra ra” raving towards I might try to think of you doing something like that. Being a politician.
Torie Robinson
Oh great! What a sight!
Closing thoughts & thanks
17:00 Torie Robinson
A huge thank you to Laurie for sharing her expertise with us! Memory problems are so often a challenge in the day to day life of those with an epilepsy so it’s great to hear that there are practical, evidence-based strategies that can genuinely help people improve how they function day to day.
If you found today’s conversation helpful, please give the episode a like, and subscribe for future episodes. And if there was a particular insight or strategy from today’s discussion that stood out to you, feel free to share it in the comments below. Thanks so much for joining us - and I’ll see you next time.