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"Imagination" Helps Older People Remember to Comply with Medical Advice

A healthy dose of "imagination" helps older people remember to take medications and follow other medical advice, according to a new study supported by the National Institute on Aging (NIA), a part of the National Institutes of Health.

Researchers found older adults who spent a few minutes picturing how they would test their blood sugar were 50 percent more likely to actually do these tests on a regular basis than those who used other memory techniques. The findings by Linda Liu, Ph.D., of the University of Michigan, and Denise Park, Ph.D., of the University of Illinois at Urbana-Champaign, appear in the June 2004 issue of Psychology and Aging. The researchers are part of the CACHET Center at the University of Michigan and the Center for Healthy Minds at the University of Illinois. Both are NIA-supported Roybal Centers for Applied Gerontological Research, which focus on research of immediate clinical value.

"This is an innovative study. It presents an unusual but apparently very effective way to use imagination as a memory tool to help older adults more successfully follow medical instructions," says Jeffrey Elias, Ph.D., of the NIA's Behavioral and Social Research Program. "The best medical care in the world isn't much good if a patient can't or won't follow through. Creative approaches such as this one need to be explored further if we are to solve difficult medication adherence problems. The genius of this method is that it requires less conscious effort than other memory methods. So, it can be easily learned and applied."

For the study, Liu and Park taught 31 non-diabetic volunteers to do home blood glucose tests. The researchers chose individuals who didn't have diabetes in order to simulate the learning conditions faced by someone who is newly diagnosed with a disease. In addition, because the blood glucose monitors recorded time- and date-stamps each time a test was conducted, it allowed the researchers to collect very accurate data. The participants, ages 60 to 81, were randomly assigned to one of three groups and told to monitor their blood sugar levels four specific times daily. They were not allowed to use timers, alarms or other devices.

Those in the implementation group, defined by the investigators as an "imagination" intervention, spent one 3-minute session visualizing exactly what they would be doing and where they would be the next day when they were scheduled to test their blood sugar levels. Those in the "rehearsal" group repeatedly recited aloud the instructions for testing their blood. Finally, those in the "deliberation" group were asked to write a list of pros and cons for testing blood sugar.

Over the next 3 weeks, participants in the implementation group remembered 76 percent of the time to test their blood sugar at the right times of the day compared to an average of 46 percent in the other two groups. Those in the implementation group were far less likely to go an entire day without testing than those in the other two groups. Although the effects observed in this study were large, NIA scientists note, further studies will be need to be conducted to replicate the findings more generally.

"Getting older people to remember to take their medications and conduct self-monitoring tests is a huge issue," Dr. Park says. "Although many strategies have been tried, none appears to be as potent or as simple as using one's own imagination. This study shows it's a powerful and incredibly inexpensive technique with potentially lasting effects."

Dr. Park suspects that using imagination may be more effective than other techniques because it relies on automatic memory, a primitive component of memory that doesn't decline with age. Using this technique, you might, for example, imagine taking your pills right after you drink your morning glass of orange juice. The next day at breakfast taking a sip of orange juice will "automatically" cue you to take your medication.

"It's not an explicit thought," Dr. Park says. "It's not as if you think, `Ah, ha! I remember to take my pills now.' It's more that the orange juice provides an unconscious prompt to, 'Take your meds, take your meds.' "

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Training Improves Cognitive Abilities of Older Adults

Training sessions for 2 hours a week for 5 weeks improved the memory, concentration and problem solving skills of healthy independent adults 65 years and older who participated in the nation's largest study of cognitive training. The training not only improved participants' cognitive abilities, but the improvement persisted for 2 years after the training, according to initial findings from the multi-site trial of Advanced Cognitive Training for Independent and Vital Elderly, or ACTIVE.*

"The trial was highly successful in showing that we can, at least in the laboratory, improve certain thinking and reasoning abilities in older people," says Richard M. Suzman, Ph.D., Associate Director for the Behavioral and Social Research Program at the National Institute on Aging (NIA). "The findings here were powerful and very specific. Although they did not appear to make any real change in the actual, daily activities of the participants, I think we can build on these results to see how training ultimately might be applied to tasks that older people do everyday, such as using medication or handling finances. This intervention research, aimed at helping healthy older people maintain cognitive status as they age, is an increasingly high priority."

The study, published in the November 13, 2002, issue of the Journal of the American Medical Association, was funded by the NIA and the National Institute of Nursing Research (NINR), two components of the National Institutes of Health at the Department of Health and Human Services.

According to Dr. Patricia A. Grady, Director of the NINR, “The ACTIVE trial provides encouraging preliminary findings that we may be able to conserve or improve some cognitive abilities in older adults not currently having problems in these areas. How this training may affect those who later experience cognitive deficits is a tantalizing question waiting to be answered.”

The study looked at several types of cognitive training and then assessed, in the laboratory and in “real world” measures, whether the training was effective. At the outset, certified trainers conducted 10 sessions of 60 to 75 minutes over a 5 to 6 week period. The 2,802 participants were divided into four groups -- three groups that received either memory training, reasoning training, or speed of processing training, and a fourth group that received no training. The three types of training were chosen because they showed the most promise in small laboratory studies and were related to tasks of daily living such as telephone use, shopping, food preparation, housekeeping, laundry, transportation, medication use, and personal finances. For all three groups, the training focused on developing strategies as well as providing exercises using these new strategies. All participants were assessed prior to training, immediately after training, and again 1 and 2 years later.

Those in the memory-training group were taught strategies for remembering word lists and sequences of items, text material, and main ideas and details of stories. Participants in the reasoning group were taught how to solve problems that follow patterns. Such strategies can be used in tasks such as reading a bus schedule or filling out an order sheet. Speed of processing training focused on the ability to identify and locate visual information quickly for use in tasks such as looking up a phone number, finding information on medicine bottles, and responding appropriately to traffic signs.

Immediately following the 5-week training period, 87 percent of participants in speed training, 74 percent of participants in reasoning training, and 26 percent of participants in memory training demonstrated reliable improvement on their respective cognitive ability. The training effects continued through 24 months, particularly for the participants who received “booster” training. "The improvements in memory, problem solving, and concentration following training were sizeable,” noted Karlene Ball, Ph.D., of the University of Alabama at Birmingham, the study’s corresponding author. “These roughly counteract the degree of cognitive decline that we would expect to see over a 7- to 14- year period among older people without dementia.”

The analysis did not find, however, that participants’ improvements in thinking and reasoning also improved their ability to perform everyday tasks like preparing food or handling medications. “Since all participants were living independently, and most were functioning quite well at the outset of the study, it will be interesting to see if those who received training experience less decline in their daily living skills over time,” Ball said.

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