Abstract
We investigated whether an external memory aid (i.e., Google Calendar) would alleviate prospective memory compromise in a patient with mild Alzheimer’s disease. The patient was asked in the baseline phase to perform three prospective targeted events (e.g., attending her weekly bridge game at the community club) and three prospective control events (e.g., buying her weekly magazine). The same six prospective events were assessed in the intervention phase but the targeted-events were cued by Google Calendar while the control-events were not. Results showed less omission of the targeted events in the training phase than in the baseline phase, suggesting a positive effect of Google Calendar. This case report offers a unique view into how smartphone calendars may alleviate prospective memory compromise in patients with mild Alzheimer’s disease.
INTRODUCTION
Prospective memory refers to the ability to remember to do things in the future (e.g., I have to submit the manuscript by April, I have to take my medication at lunch) [1–3]. It allows us to plan future scenarios and to act on them at the appropriate time [4]. Prospective memory has been found to be particularly sensitive to neurological and psychiatric disorders [1, 5–9]. The vulnerability of prospective memory can be attributed to the fact that it relies on a complex set of cognitive processes such as attention, executive functioning [10, 11], and retrospective memory, as one needs to remember the intention to be carried out [12]. The cognitive complexity of prospective memory can be illustrated by the model of Sohlberg and Mateer [13], according to which a successful prospective task requires planning of a future scenario, keeping the steps required to accomplish this scenario in mind, remembering the targeted task, and taking the action at the appropriate moment. In a similar vein, Zogg et al. [14] suggest that a successful prospective task requires 1) intention formation where one must form or encode the intention and link it to a given cue (time- or event-related); 2) retention interval, i.e., the delay between the intention and execution, 3) cue detection and intention retrieval, where one must detect the relevant cue and initiate the retrieval of intention, 4) intention recall, i.e., the successful retrieval of the initial intention from retrospective memory, and 5) execution of the intention.
Prospective memory has been found to be compromised in Alzheimer’s disease (AD) [15, 16], not surprisingly as the cognitive hallmark of AD is memory compromise [17–21]. Prospective memory compromise in AD has been observed in laboratory tasks [22–26]. A typical laboratory study is that of Maylor et al. [27] who asked AD patients to say “animal” when an animal appeared in the film (event-based prospective memory task) or to stop a clock every three min (time-based prospective memory task). They observed compromise of prospective memory in both tasks. Compromise of prospective memory in AD has also been observed in naturalistic tasks. In one study, Kinsella et al. [28] asked AD patients to read aloud a short story (ongoing task) within which a target word (prospective remembering cue) was embedded on many occasions. Patients had to make a word substitution (prospective remembering) whenever the target word was encountered. The authors observed significant impairment of prospective memory in AD patients. The difficulties encountered by AD patients on prospective memory tasks mirror studies demonstrating difficulties in these patients to project themselves into the future to imagine a specific event [29–32]. AD has also been found to compromise prospective memory more than retrospective memory (i.e., memory for information encountered in the past) [22, 33]. AD-related prospective memory compromise has also been associated with a negative impact on instrumental activities of daily living in patients, as well as with an increase in caregivers’ burden [34].
Considering the consequences of prospective memory compromise on instrumental activities in AD patients, we investigated whether external memory aids would alleviate it. More specifically, we investigated the effectiveness of Google Calendar, a calendar that incorporates active reminders, in a patient with AD. Google Calendar (https://calendar.google.com) is a free online calendar that allows events to be entered for a specific time and date. The calendar synchronizes with the user’s mobile phone to send her/him SMS text alerts about the events. For each event, a maximum of five SMS alerts can be set. Its efficiency was evaluated by Baldwin and Powell [35] who used it as a memory aid in a 43-year-old subject with severe memory problems due to a traumatic brain injury. The authors investigated three target events and three control events. Results showed a reduction in omissions of the three target events and no change in two of the three control events. Furthermore, the patient reported high satisfaction with the calendar. McDonald et al. [36] also compared Google Calendar with a paper-based diary in 12 people with acquired brain injuries. Although both tools enhanced prospective memory, Google Calendar was significantly more effective than the paper diary. Together, these findings show that Google Calendar may be used as an effective memory aid in amnesia.
To summarize, we implemented Google Calendar as a tool to rehabilitate prospective memory in a patient with mild AD. To this end, we implemented a baseline phase in which the patient performed prospective events (e.g., attending her weekly bridge game in the community club) without cues by Google Calendar, as well as an intervention phase in which the prospective events were cued by it.
METHODS
The participant
The study concerned Madame L, a 66-year-old right-handed French native-speaker. She worked as a teacher and had been retired for three years. She lived in her own home with her husband who served as her primary caregiver. Diagnosis of mild AD had been made four months before on the basis of NINCDS-ADRDA-clinical-criteria [17], and a comprehensive clinical assessment including a brain MRI scan demonstrated mild hippocampal atrophy. Immediately after the diagnosis, Madame L commenced pharmacotherapy with an acetylcholinesterase inhibitor but did not report any other significant general health comorbidities (e.g., diabetes or hypertension). She had no history of psychiatric or neurological illness, alcohol, ordrug use.
Madame L had reported memory difficulties 12 months beforehand such as trouble remembering names and groceries she wanted to purchase, as well as frequently losing her papers and keys. Sleep disturbances also gradually occurred in the previous year. At the beginning of the present study, some basic daily life activities were compromised as she needed help to take medicines and to use money. According to her husband, the main difficulties that she encountered were related to prospective memory (e.g., forgetting medical appointments or to take her medication).
Her score on the Mini-Mental State Examination [37] was 27/30, the affected cognitive areas being recall and time orientation. Verbal episodic memory was evaluated with a French adaptation [38] of the Grober and Buschke task [39]. She had to retain 16 words, and after a 20-second distraction phase during which she had to count numbers aloud, she had two minutes to recall the 16 words. She correctly remembered three words (according to the French norms of the Grober and Buschke task, her percentile was below 5%). In the working memory (digits) assessment, her span was 5 forward and 4 backward. Her depression score on the Hospital Anxiety and Depression Scale [40] was 9, although the cut-off set by Herrmann [41] is >10/21 points.
Procedures
As illustrated in Fig. 1, the study included a pre-intervention phase, a baseline phase, a training phase, and an intervention phase. In the pre-intervention phase, we tried to define with Madame L and her husband the best tool to improve her prospective memory. In this discussion, she emphasized that she had already been using her smartphone to text her children and grandchildren, as well as to send them photos. She also declared occasionally using the map on her smartphone when afraid of being lost. When asked if she preferred a paper-based calendar, she replied that such an aid would be obvious and that she preferred discrete assistance, such as that available on her smartphone. She also declared being comfortable using her smartphone. When defining the best application to be used as a memory aid on her smartphone, her husband suggested using an application to warn her that something needed to be done, and not just an alarm application. Hence we proposed Google Calendar. We then defined tasks that were important in her daily life so as to ensure the intervention was as meaningful and helpful as possible for her and her husband. A meeting was organized between Madame L, her husband, and the researcher about prospective events that were the most important to her daily life. According to Madame L and her husband, the three most important prospective omissions were: forgetting her weekly medical appointment, forgetting her weekly bridge game in the community club, and forgetting to go to weekly mass at the church. Three other prospective omissions were identified as controls: forgetting to post her weekly letter to her sister, forgetting her weekly call to her friend, and forgetting to buy her weekly magazine.
In the baseline phase lasting four weeks, her husband monitored omissions related to each of the targeted and control events. He kept a weekly record of instances of omissions and/or instances of having to remind her about an event at a point where, had he not reminded her, an important event would have been omitted. After the baseline phase, she received a week’s training. During the week, she had to undertake three prospective events: calling the researcher to confirm the time and date of their appointment, completing a demographic form, and sending an SMS to the researcher to confirm the completion of the form. For all three events, the alerts prompted by Google Calendar were sent at: 9 p.m. (the night before the event), 7 : 30 a.m., as well as 1 hour, 45 minutes, and 30 minutes before the task. The time of the alerts was defined a priori with Madame L. Because she had successfully performed the three prospective events, the training week was followed by a four-week intervention phase during which she received five alerts from Google Calendar for each of the three targeted prospective events. For all three events, the alerts time were similar to those in the baseline phase. We did not send a reminder after 30 minutes because, in the event of omissions (e.g., omitting to get ready for her medical appointment), her husband had 30 minutes to remind her and accompany her to the medical center, which was five minutes away. As in the baseline phase, omissions in the intervention phase were monitored by her husband. At the end of the intervention phase, a debriefing session was held to gather feedback from Madame L and her husband. She also answered a question (1 = terrible, 5 = very good) inquiring about her experience of using the calendar.
RESULTS
Following the procedures of McDonald et al. [36], we compared the number of forgotten control and targeted events in the baseline phase versus omissions in the intervention phase. There were 12 control events in the baseline phase (3 events×4 weeks) and 12 targeted events. This was likewise in the intervention phase. As shown in Fig. 2, Madame L forgot 7 targeted events and 6 control events in the baseline phase. In the intervention phase, she forgot only 2 targeted events and 5 control events. These findings suggest a beneficial effect of Goggle Calendar on prospective memory in Madame L. As for the satisfaction question, she rated her experience as “very good”.
DISCUSSION
We investigated whether an external memory aid (i.e., Google Calendar) would alleviate prospective memory compromise in a patient with AD. To this end, Madame L was asked in the baseline phase to perform three targeted and three control events, without any cuing by Google Calendar. The same six prospective events were assessed in the intervention phase, but the three targeted events were cued by Google Calendar while and the three control events were not. Results showed less omission of the targeted events in the intervention phase than in the baseline phase, suggesting a positive effect of Google Calendar on prospectivememory.
Prospective memory has been found to be compromised in AD [15, 25]. This compromise that has been associated with a negative impact on instrumental activities of daily living in patients, as well as with an increase in caregivers’ burden [34]. Therefore, we tried to alleviate compromise of prospective memory in a patient with AD by cuing with Google Calendar. The calendar had a positive effect that mirrored previous research using the same memory aid in patients with traumatic brain injury [35, 36]. Our patient’s satisfaction was also high, as in the study by Baldwin and Powell [35].
The positive effect of Google Calendar on prospective memory in Madame L can be attributed to her familiarity with smartphones and technology. Generally speaking, the use of smartphones is relatively frequent in older adults who tend to use them to receive and send multimedia communication from/to their children and grandchildren. Smartphones may therefore become increasingly attractive for use as memory aids in older adults. Furthermore, they are relatively easy to use, socially acceptable, and cost-effective. In the general population, the reminder functions on smartphones are widely used as they are free and can even include reminder functions that remind you to do a specific task when arriving at a certain location (event-based prospective memory). Nevertheless, individuals with moderate cognitive impairment need to be trained how to use them as an effective memory aid [42]. In our view, their effectiveness depends on the amount of benefit that the user derives, e.g., whether they would allow her/him to remember the birthday of a loved one.
Patients with amnesia have by definition an inherent difficulty in developing rehabilitation strategies, because they have difficulty remembering how to apply the compensatory techniques that they have learned. Technological aids, including Google Calendar, could be particularly useful for them because they counteract this problem, as the patient does not have to remember to use the device [43]. This reminder principle is to be found in several electronic aids, such as the NeuroPage [44, 45], an alphanumeric beeper that emits preprogrammed audio/vibration/SMS alerts at set times. Studies showed the positive effect of NeuroPage in patients with amnesia due to acquired brain injuries or encephalitis [44–46]. In one study, Fish et al. [11] found a positive effect of the NeuroPage on everyday memory problems in patients with amnesia due to acquired brain injuries or cerebral vascular accidents. Although both populations showed short-term benefits, brain-injured patients had greater long-term benefits, associated with an improvement in executive function. Unlike the NeuroPage, Google Calendar does not require a specific device and can be downloaded on most smartphones. It is also unobtrusive, thus avoiding the embarrassment that some patients may feel by carrying around a dedicated device.
The main finding of this study was that Madame L forgot fewer targeted events in the intervention phase. She also forgot one less control event in the intervention phase than in the baseline phase. This might have been due to reverse causation, i.e., the positive effect of the calendar may have prompted her to monitor the control events. However, this assumption should be interpreted with caution owing to the smallness of the effect. Furthermore, we assessed relatively few events (i.e., three control + three targeted events). Although this low number can be considered as a limitation of the study, we were careful to choose the most meaningful events in the daily life of Madame L and her husband. Another limitation could be the fact that Madame L was particularly at ease with a smartphone, thereby limiting the generalization of the results. On the other hand, smartphones are being used more and more by older adults. The use of reminder applications in smartphones will likely become a part of everyday life in the future generation of mild AD patients, at least those who regularly use smartphones prior to the onset of disease.
By demonstrating the positive effect of Google Calendar on prospective memory in a patient with AD, our study paves the way for exploring the potential of smartphone-integrated memory aids in the disease. In our view, the future generation of AD patients may be particularly sensitive to their use as a tool to alleviate their memory compromise.
Footnotes
ACKNOWLEDGMENTS
The authors would like to thank Madame L, her husband, and family for their generous participation. They would also like to thank Dr. Ray Cooke for linguistic assistance. Funding was provided by the LABEX (excellence laboratory, program investment for the future) DISTALZ (Development of Innovative Strategies for a Transdisciplinary Approach to Alzheimer’s Disease).
