View of The Effect of a Cognitive Rehabilitation Intervention on Cognitive Functions in Older adults Patients with Stroke

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The Effect of a Cognitive Rehabilitation Intervention on Cognitive Functions in Older adults Patients with Stroke

Eman Shokry Abd Allah¹, Safia Gomaa Mohmmed², Hanaa Hamdy Ali El-Zeiny³, Noha Mohamed Abdelsalam⁴

1Professor and Head of Gerontological Nursing Department, Faculty of Nursing, Zagazig University, Egypt, Email: [email protected]

2Assistant lecturer of Gerontological Nursing, Faculty of Nursing, Zagazig University, Egypt, Email: [email protected]

3Assistant Professor of psychiatric health nursing, Faculty of nursing, Zagazig University, Egypt, Email: Dr.hanaa_elzeiny@hotmail

4Assistant Professor of Public Health and Community Medicine, Faculty of medicine, Zagazig University, Egypt, Email: [email protected]

Corresponding Author: Safia Gomaa Mohammed, Email: [email protected]

Abstract

Studypurpose:Improving cognitive functions inolder adults patients with stroke.

Methodology: Quasi-experimental research was conducted in X University Hospitals. The research groupconsisted of 60 deliberatelyselected older adultspatients. The X version of the modified Mini-mental state test, digital span, and logical memorywere used toassess cognitive functions. By analyzing the relationship of cognitive functions with demographic as well as clinical variables, the contributing factors were established. Major results: There was a statistically significant difference in the total score of cognitive abilities domains [spatial orientation, similarities, and three stage commands] among the studied older adults’ patients with stroke after rehabilitation intervention.Clinical implications: Training program implementation has a direct impact on the cognitive performance of older adult’s patients with stroke.

Keywords: Rehabilitation intervention, Cognitive functions, olderadultspatient, Stroke

Introduction

The frequency of strokes is estimated of 795,000 annually, with first-time strokes 610,000 and a recurrence related to 185,000. The American Heart Association also estimated the approximate stroke rate of 6.8 million Americans aged 20 years, which is 2.8 percent of the population (Vincent et al., 2014). Older adults’ people experience memory loss and cognitive slowdown, which may interfere with their everyday life activities, leading to cognitive impairmentas well as reduced intellectual ability (Coco et al., 2016).Mostolder adults patients experience some cognitive function disruption after stroke and many have recurrent issues in particular cognitive areas, such as focus and concentration; memory; spatial awareness;

perception; practice; and executive functioning. Strokes can be avoided by introducing some nursing strategies directed to minimize their risk factors, such as obesity and hypertension. The main preventive methods include diet and food control, exercise, and weight loss (Gillespie et al., 2015).With regard to the capacity to think, judgment, and make choices, cognitive therapy provides retraining. In addition to speech therapy, occupational therapy, physical therapy, psychotherapy, and medication, stroke survivors will benefit greatly from cognitive rehabilitation (CR) care in order to minimize their cognitive deficits, the emphasis is on correcting deficits in memory, concentration and attention, perception, understanding, planning, sequencing, as well as judgment (Abd-Elaziz et al., 2015).

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Literature review

Neurocognitive disorders (NCD) with highly variable incidence have been identified post- stroke. The hospital-based studies published between January 1990 and September 2015 were selected based on a systematic literature review in France as they documented the prevalence of absolute, mild and major post-stroke NCD diagnosed using defined criteria.Using meta- regression analysis, factors influencing prevalence were evaluated. More than half of stroke survivors undergo post-stroke NCD, two-thirds of cases developed moderate post-stroke NCD and one-third of cases experienced major post-stroke NCD(Barbay et al., 2018).In addition, many survivors of strokes complain of cognitive impairment, such as struggling with concentration, diminished focus, and mental slowness. However, the benefits of cognitive therapy in improving these impairments remainundetermined. In a meta-analysis review byLoetscher et al. (2019) who found no statistically significant impact of cognitive therapy on persisting effects on global attention scales andstandardized attention assessment.

On the contrary, a statistically significant impact was observed in favor of cognitive rehabilitation; hence this study was conducted to measure the effect of a cognitive rehabilitation intervention on cognitive functions among older adults’ patients with stroke at x university hospitals.

Research hypothesis

There will be improvement in the cognitive function and activities of daily livingfor study group after the implementation of Cognitive Rehabilitation program

Method

Study Design and Ethical Considerations

A quasi-experimental research design was used to conduct the present study from September 2019 to February 2020 at the stroke unit, physical medicine and rehabilitation departments and outpatient neurology units at X University Hospitals. The study was approved by the Research Ethics Committee (REC) and the Postgraduate Committee of the Faculty of Nursing at X University. Verbal informed consent was obtained from the studied patients.

Sample size and sample selection

A sample of 60 older adults’ cases of stroke was calculated using Version 6.04 of the Epi info software package program with a confidence interval of 95% as well as 80% power of test. A purposeful sampling technique was used for selecting subjects who fulfilled the study inclusion criteria.

Tool of data collection

The first method was created by the researcher to gather the necessary information, and it consists of three parts: Part (1): demographic data on the studied older adults, suchas gender;

marital status and education level, current occupation, residence and source of income. Nine questions were included, in addition to questions such as age and number of family members.

Part (2): The medical history of the studied older adultsand it included questions about the history of chronic illness, as well as numerous questions about diet, exercise, smoking, etc.

Part (3): included questions about stroke history, past and present, signs and symptoms, etc.

Tool II: The Mini-Mental State Test Updated (3ms) by (Ghoniem et al., 2018), which isa screening method used to test a broader range of cognitive domains. The 3(MS) expanded the spectrum of The Mini-Mental State Test (MMSE), which is a global measure of cognitive skills that tap domains such as focus, attention, orientation, time and place, long term and short-term memory, etc. Instructions are given verbally, and two of the items involve visual stimuli. Tool III: Digit Span: Forward and backward, this scale is a Wechsler memory scale

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subtest (Wechsler, 1987), which was modified and used by neuropsychological department, forward span tests basic attention, with the backward span providing a general working memory index. In the forward span, the researcher gives the patient numbers from four to eight digits and asks the patient to forward these numbers in sequence.Tool IV: Logical Memory: This measure is a sub-test of the Wechsler memory scale (Wechsler, 1987), which was modified and used by neuropsychological department. It includesimmediate recollection of two short stories; two short stories were reviewed by the researcher for older adults’

patients then asked them to recall the words of these stories. Five specialists in the field of Gerontological nursing, community health nursing, and public health medicine at X University updated the Method I 'interview questionnaire'. The panel reviewed the content of the instrument regarding significance, consistency, comprehension, clarity, and accuracy.

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Statistical analysis

The statistical software package SPSS 20.0 was used for data entry and statistical analysis.

Descriptive statistics were used to present the data in the form of frequencies and percentages of qualitative variables, and mean and standard deviations and medians for quantitative variables. To assess the reliability of the established tools through their internal consistency, the Cronbach alpha coefficient was measured. Paired Continuous quantitative data were compared using paired t-test. To decide whether there are variations in a dichotomous

dependent variable, the McNemar test was used,statistical significance at p-value < 0.05.

Results

Table 1 reveals that the age of older adults’ patients ranged between 60 and 74 years with a mean of 65.25 ± 3.5 years. In addition, 73.3%, 56.7%, and 63.3% of the studied older adultspatients were married, worked and educated respectively. The older adultspatients were living with their family (66.7%) and had three children or less (50.0%). With respect to income, 66.7% of the studied older adultspatients had sufficient income. Table 2 shows the distribution of older adults’patients with stroke according to the present condition. Based on the table, it is noted that 30.0%ofthestudiedolder adults sufferedfromischemicstrokeand46.7%of them had stroke from 1-5years. With regard to symptoms of stroke, 50.0% of the studied elderly patients had from 5-7 symptoms: blurred of vision (96.7%), numbness or paralysis on one side of the face (70.0%), pain in the face, chest or arms (66.7%) and painful severe headache (63.3%).Table 3 indicates that the older adult’s patients’ cognitive level improved steadily and significantly throughout the intervention phases. In general, 50.0% of the older adultshad severe cognitive impairment before the intervention.This decreased to 10.0% in the post-intervention phase, and 15.0% at the follow- up phase,statistically significant differences in mean total score for cognitive level among the studied older adultspatients pre, post and follow-up of the rehabilitation intervention (P<0.001). Before the rehabilitation intervention, the mean overall score of cognitive level was 60.11±14.33, which increased to 70.81±10.68 in the post phase, and declinedto70.45±10.35atthefollow-upphase.Theseimprovementswere statistically significant.Table 4 indicates that older adults patients’ digit span improved steadily and significantly throughout the intervention phases. Overall, 30.0% of the older adultshad moderate cognitive impairment prior to the intervention, and this decreased to 3.3 % at the

post-intervention phase, and 1.7%atthefollow-

upphase.Theseimprovementswerestatisticallyhighly significant(P<0.001),statistically significant differences in mean total score of counting forward among the studied older adultspatients pre, post and following the rehabilitation intervention (P<0.001). Before the rehabilitationintervention,the totalmeanscoreofdigitforwardwas3.31±1.70,which increased to 4.50±1.39 at the post phase and to 4.63±1.50 at the follow-up

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phase.Theseimprovementswerestatisticallysignificant,statistically significant differences in mean total score of counting backward among the studied older adults patients pre, post and following the rehabilitation intervention (P<0.001). Before the rehabilitation intervention, the

mean score of counting backward was

3.60±1.62,whichincreasedto4.51±1.43atthepostphaseandto5.63±1.07 at the follow-up phase.

These improvements were statistically highly significant.Regarding older adults logical memory table 4 reveals a statistically significant difference in the total score of logical memory among the studied older adults patients pre, post and follow the rehabilitation intervention (P<0.001),before the rehabilitation intervention, the mean total scoreoffirstshortstorywas6.06±2.57, whichincreasedto7.01±2.56atthe post phase, and to 7.10±2.37 at the follow-up phase. Concerning the second short story before the rehabilitation intervention, the mean total score was 6.66±2.57, whichincreasedto7.46±2.31atthe post phase andto7.73±2.20 at the follow-up phase. These improvements were statistically significant.

Demonstrates that a statistically significant difference in total mean scoreof logical memory amongthestudiedolder adults patientspre, post and following the rehabilitation intervention (P<0.001). Before the rehabilitation intervention, the mean total score logical memory was 6.36±2.45,whichincreasedto7.24±2.32atthe post-phase andto7.41±2.18at the follow-up phase,these improvements were statistically significant.

Discussion

Based on the results of the current research, it is clear that there is a decline in cognitive abilities among the studied older adults patients with stroke, which improved after the application of cognitive rehabilitation intervention, leading to accepting the study hypothesis.

With respect to the socio-demographic characteristics of the older adults in the research sample, the results of the current study showed that less than one third of the studied older adults were over 70 years of age, and the participants were women and married, most of them live in rural areas. In addition, a higher percentage of study participants were employees and living with family, living with family help supporting older adults, especially those with chronic diseases to adopt with disease and encourage them to conform to cognitive recovery.

In comparison, Middle Eastern cultures are known to have more collectivist ideals in which communities appear to foster interdependence and therefore tradition. Employment is an essential aspect of life that not only provides a source of livelihood, but also a source of social relations and a means of social interaction. These findings are consistent with research conducted in Nigerian by Onabajo et al. (2015), in which substantially higher social support was observed among stroke survivors who were in employment prior to their stroke.

Regarding the history and characteristics of stroke among the studied older adults, the findings of the current study showed that approximately one-third of the studied older adults suffered from hemorrhagic stroke,while 30.0% of them suffered from ischemic stroke. In a report by Heshmatollah et al. (2020) in Rotterdam, Netherlands, it was found that there were a total of 489 strokes, (74.2 percent) of them were ischemic strokes, (12.7 percent) were hemorrhagic strokes. Regarding the cognitive status of the older adults before, during and after the cognitive rehabilitation intervention (digit span & logical memory), the current research results suggest that the digit span of the older adults patients increased gradually and substantially during the intervention phases. In general, prior to the intervention, one-third of the older adults had mild cognitive disability, which decreased to 3.3 percent at the post- intervention level and 1.7 percent at the follow-up stage (table 4). There was a statistically significant difference in the mean overall logical memory score among the studied older adult’s patients before, during and after the rehabilitation intervention with respect to logical memory. Total mean logical memory score at the post-period as well as in the follow-up phase prior to the recovery intervention.These findings indicate the positive impact of

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cognitive therapy intervention on studied older adults by providing memory-enhancing images for older adults patients, repeating these images for two weeks, and training the elderly on a computerized programmed. In addition, the cognitive therapy intervention was viewed as a starting point and encouragement for the older adults to perform cognitive activity with or without the aid of their caregiver. These findings are in line with research conducted by Ajtahed et al. (2019) in Tehran, Iran, which found that one group of patients used a computerized cognitive therapy programmed that resulted in enhanced cognitive functions in terms of sustained, selective, divided attention and working memory. This result, using a larger sample size, is regarded as an extension of previous research by de Tournay- Jette et al. (2012). In this research, patients who underwent computerized cognitive rehabilitation therapy (CCRT) within two months outperformed the other two classes in multiple concentration and working memory measures. This means that the implemented curriculum was an appropriate cognitive training that could help them engage properly and disengage their focus in the sense of real life.Moreover, a significant improvement was found regarding the sustained attention for those studied older adults. There have been statistically substantial changes in cognitive performance following the introduction of the new cognitive therapy intervention trial, in which the average mean cognitive level score improved from 60.11±14.33 to 70.81±10.68 in the post-phase phase (table 3).This has demonstrated the efficacy of the current program in developing cognitive skills.The implementation of the new study program showed marked significant differences in all aspects of the cognitive capacity of the elderly. Nonetheless, There was a significant decreases in the follow-up process. This demonstrates the effectiveness of the present program, and consequently leads to acceptance of the hypothesis of this study. The current results are consistent with those of Pashang et al.

(2020) in Tehran, Iran, which showed that cognitive therapy training enhanced attention- related cognitive functions in stroke patients. Furthermore, the study in Tehran, Iran by Oskoei et al. (2013) showed that cognitive therapy can be effective in improving cognitive function in people with mild cognitive disability.

Limitations of the Study

The limitations of the current research were that the authors did not have data prior to the initiation of the cognitive rehabilitation intervention on the cognitive state and behaviors of the studied patients. In addition to the purposeful sampling technique as a restriction, that can be considered a limitation.

Conclusion

It can be assumed that stroke is a major health concern, based on the findings of the present research, which sometimes results in chronic and pervasive cognitive difficulties. These cognitive deficits,however, these cognitive deficiencies are an important contributor to long- term impairment. Older adults patients with post-stroke cognitive disability have a substantial effect on the patient's physical status. The implementation of a cognitive disability training program in patients with stroke has a profound impact on cognitive performance and everyday life activities.

Recommendation

The routine use of the cognitive impairment screening assessment for early detection in any stroke patient. The extent of the disorder should be determined and its impact on operation and engagement should be illustrated to patients and caregivers. Proper and revised early cognitive compromise neurorehabilitation and all cognitive recovery activities should concentrate on enhancing the functioning of daily life. Nursing and counseling sessions should employ strategies that take advantage of retained skills, e.g. teach compensatory

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techniques to alleviate their limitations, such as the use of journals, diaries, audiotapes and electronic organizers to assess their profile of disabled and preserved memory skills. When triggering intervention, such as taking medicine, auditory alarms can be particularly helpful.

To find out the main aspects of these issues, there is a need to repeat the analysis on a wider probability sample from various geographical areas in order to generalize the findings. The stroke patient's family/caregiver will participate in decision making and recovery planning as early as possible, if available, and during the rehabilitation process. In addition to increasing understanding of the value of routine check-up to identify early health deviation in order to perform early management and avoid complications. Health education for older adult patients and caregivers regarding potential ways to avoid chronic stroke and ways to manage diabetes and hypertension. Older adults people and their families should be familiar with various community-based programmed that help them meet their physical, social, psychological needs.

Declaration of Conflicting Interests

The Author(s) declare(s) that there is no conflict of interest.

Funding

This research did not receive a specific grant from any funding agency in the public, commercial, or non-profit sectors.

Table 1: Demographic characteristics of the studied older adults(N=60)

Demographic characteristics (n=60)

frequency percent Age group: /year

Mean ± SD (range) 65.25 ± 3.5

(60 –74) Gender:

Male Female 26

34

43.3 56.7 Marital status:

Married

Unmarried (divorced, widow and single)

44 16

73.3 26.7 Education:

Educated Uneducated 38

22

63.3 36.7 Current occupation:

Work Notwork 34

26

56.7 43.3 Number of children: No children

≤ 3

> 3

6 30 24

10.0 50.0 40.0 Living with whom:

Alone With family

20 40

33.3 66.7 Income:

Sufficient Insufficient 40

20

66.7 33.3

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Table (2): History of stroke among the studied older adults (N=60)

@ Not mutually exclusive

Table (3): The total cognitive level of the older adults people pre, post and following the cognitive rehabilitation intervention (3Ms) (N=60)

Cognitive level

Pre (n=60) Post (n=60) Follow up (n=60)

McNemarTest (p- value)

No % No % No %

Mild cognitive impairment

8 13.3 16 26.7 16 26.7

37.292

39.382 .000*1 .000*2 Moderate cognitive

Impairment

22 36.7 38 63.3 35 58.3

Sever cognitive impairment

30 50.0 6 10.0 9 15.0

Total mean score

Mean ± SD 60.11±14.33 70.81±10.68 70.45±10.35

709.729#

642.128# .000*1 .000*2

# Paired test*: Significant P1: Perverse PostP2: Pre versus Follow-up

Table (4): Older adults digit span and logical memory pre, post and following the cognitive History of stroke

(n=60)

Frequency Percent Suffering of stroke since:

3 months to one year 24 40.0

1-5 years 28 46.7

More than 5 years 8 13.3

Type of stroke :

Ischemic 16 26.7

Hemorrhagic 18 30.0

Small infraction 2 3.3

Don’t know 24 40.0

Symptoms of stroke@:

Blurred vision 58 96.7

Difficulty speaking 34 56.7

Weakness in the legs 34 56.7

Numbness or paralysis on one side of the face 42 70.0

Pain in the face, chest or arms 40 66.7

Confusion or difficulty understanding what 34 56.7 others are saying

Painful and severe headache 38 63.3

Dizziness 32 53.3

Nausea 30 50.0

Vomiting 16 26.7

Total no. of stroke symptoms:

2-4 5- 7 8-10

14 23.3

30 50.0

16 26.7

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rehabilitation intervention (N=60)

Digit span

McNemar test

(p-value)

No % No % No %

Normal

cognitive status

18 30.0 40 66.7 49 81.7

79.576

47.554 .000*1 .000*2 Mild cognitive

impairment

22 36.7 18 30.0 9 15.0

Moderate cognitive Impairment

18 30.0 2 3.3 1 1.7

Sever cognitive impairment

2 3.3 0 0.0 1 1.7

Total mean score Mean ± SD

Digit forward 3.31±1.70 4.50±1.39 4.63±1.50

123.561#

99.374 .000*1 .000*² Digit backward 3.60±1.62 4.51±1.43 5.63±1.07 116.885#

70.516 .000*1 .000*2

logical memory

Paired t test

(p-value) Mean ± SD Mean ± SD Mean ± SD

First short story

(A) 6.06 ± 2.57

7.01± 2.56 7.10 ± 2.37 208.951

190.537 .000*1 .000*2 Second short

story (B)

6.66 ± 2.57 7.46 ± 2.31 7.73 ± 2.20 206.595 175.299

.000*¹ .000*2 Total mean

score Logical memory

6.36 ± 2.45 7.24 ± 2.32 7.41 ± 2.18

401.933

353.981 .000*1 .000*2

*: Significant P1: PreversusPostP2: Pre versus Follow-up References

1. Abd-Elaziz, S.A., Khedr, E.M., Ahmed, H.A.& Ibrahim, H.D.(2015). Effect of Cognitive Rehabilitation on Improving Cognitive Function and Activities of Daily Living among Elderly Patients With Stroke at Assiut University Hospital. Journal of Education and Practice; 6(24),44-56.

2. Ajtahed ,S.S., Rezapou,T., Etemadi,S., Moradi,H.&Asgarabad ,M.H.(2019). Efficacy of Neurocognitive Rehabilitation After Coronary Artery Bypass Graft Surgery in Improving Quality of Life: An Interventional Trial,Front Psychol, 10(1759). doi: 10.3389/fpsyg.2019.01759

3. Barbay,M., Diouf,M., Rousse,M.&Godefroy,O. (2018).Systematic Review and Meta- Analysis of Prevalence in Post-Stroke Neurocognitive Disorders in Hospital-Based Studies.Dement GeriatrCognDisord ,2018(46),322-334. DOI: 10.1159/000492920 4. Coco, D.L., lopez , G. &Corrao,S. (2016). Cognitive impairment and stroke in elderly

patients.Vascular health and risk management; 12(5), 105-116.

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5. deTournay-Jette, E., Dupuis, G., Denault, A., Cartier, R., &Bherer, L. (2012). The benefits of cognitive training after a coronary artery bypass graft surgery, J. Behav.

Med, 35, 557–568. doi: 10.1007/s10865-011-9384-y

6. Ghoniem, N.E., Abdallah, E.S. & Ahmed, F.M. (2018). Cognitive Abilities And Social Isolation Among Elderly With Hearing Impairment Attending Zagazig University Hospitals. Published thesis, faculty of nursing, Zagazig University. P.p 51- 54.

7. Gillespie, D.C., Bowen, A., Chung, C.S., Cockburn, J., Knapp, P. & Pollock, A.

(2015). Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence. Clinical Rehabilitation; 29(2), 1-9.DOI:10.1177/0269215514538982Source:

PubMedhttp://www.who.int/cardiovascular_diseases/en/cvd_atlas_08_physical_inacti vity.

8. Heshmatollah, A.,Mutlu, U.,Koudstaal ,P. J. , Ikram ,M. A. & Ikram ,M. K.(2020).

Cognitive and physical impairment and the risk of stroke – A prospective cohort ,study,Scientific Reports ,10(6274) ,1-8. doi.org/10.1007/s13760-020-01288-4

9. Loetscher, T., Potter, K.J., Wong, D.and&das Nair, R. (2019).Cognitive rehabilitation for attention deficits following stroke.Cochrane Database Syst Rev, 2019(11), 1-15. doi: 10.1002/14651858.CD002842.pub3

10. Onabajo, G.V., Muhammad,M.M., Ali,M.U. &Masta,M.A.(2015). Influence of Sociodemographicand Stroke-related Factors on Availability of Social Support among Nigerian Stroke Survivors.Ann Med Health Sci Res,5(5), 353–357.

doi: 10.4103/2141-9248.165258

11. Oskoei ,A.S., Shomali ,A.&Ajilchi,B.(2013). The Effectiveness of Cognitive Rehabilitation on Improving the Selective Attention in Patients with Mild Cognitive Impairment.International Journal of Alzheimer’s Disease,2011(10),1-6.

doi:10.4061/2011/27673

12. Pashang, S.H.,· Zare, H., Alipour,A., Sharif,M.&Alhoseini.(2020).The effectiveness of cognitive rehabilitation in improving visual and auditory attention in ischemic stroke patients,ActaNeurologica Belgica,1-9. Doi.org/10.1007/s13760-020-01288-4 13. Vincent, Y.,Chan ,L.&Carruthers, K.J. (2014). The Incidence, Prevalence, Costs and

Impact on Disability of Common Conditions Requiring Rehabilitation in the US:

Stroke, Spinal Cord Injury, Traumatic Brain Injury, Multiple Sclerosis, Osteoarthritis, Rheumatoid Arthritis, Limb Loss, and Back Pain. Journal ofArch Phys Med Rehabil. ,95(5), 986–995.

14. Wechsler, D. (1987).Manual for the Wechsler Memory Scale-Revised, The Psychological Corporation, San Antonio, TX.